Major trauma patients frequently require advanced airway control.
Endotracheal intubation is the preferred advanced airway intervention in major trauma patients.
Intubated trauma patients also need significant post-intubation pharmacological support.
Specifically, these patients require analgesia and sedation. This is particularly true when transfer to another facility is required, during which ICU level support is not available unless transfer occurs via Air Ambulance.
In New Brunswick, there is significant variation in the approach to both advanced airway control and post-intubation analgesia and sedation practices for major trauma patients.
Physicians in smaller centres in particular have asked for standardized, evidence-based guidance for both Rapid Sequence Intubation (RSI) and post-intubation pharmacological support in preparation for (and during) ground-based interfacility transfer.
Rapid Sequence Intubation (RSI) is a method to achieve airway control that involves rapid administration of sedative and paralytic agents, followed by endotracheal intubation.
The purpose of RSI is to affect a state of unconsciousness and neuromuscular blockade, allowing for increased first pass success of endotracheal intubation.
Post-intubation analgesia and sedation is a method of controlling pain, agitation and medically induced amnesia for major trauma patients.
Consensus Statements:
A provincially standardized, evidence-based guideline for Rapid Sequence Intubation should be available in all NB Trauma Centres (Appendix A).
Similarly, a provincially standardized, evidence-based guideline for Post-Intubation Analgesia and Sedation should be available in the Emergency Department of all NB Trauma Centres (Appendix B).
In addition to standardized, evidence-based guidelines, a provincially standardized equipment layout is recommended to optimize the preparation for RSI (Appendix C).
Ambulance New Brunswick should ensure consistency with the provincially standardized guidelines for RSI and Post-Intubation Sedation and Analgesia in procedures for Ambulance New Brunswick’s Air Medical Crew.
RSI should not be considered or applied for trauma patients who are in cardiac arrest or who are apneic.
RSI should not be considered in patients with a predicted difficult airway.
RSI should be considered for all trauma patients meeting the following:
GCS < 8, quickly deteriorating GCS or loss of airway protection
Facial trauma with poor airway control
Burns with suspected inhalation injury
Respiratory failure
Hypoxia
Persistent or uncompensated shock (reduction of respiratory efforts)
Agitation with possible injury to self or others
Potential for eventual respiratory compromise
Possible respiratory and/or neurological deterioration during prolonged transport
Transport in a confined space with limited resources
In addition to the above, RSI Guidelines should include
Assessment of the possibility of a difficult intubation
Troubleshooting
Immediate reference to post-intubation analgesia and sedation
In addition to standardized, evidence-based guidelines, a provincially standardized pre-induction checklist is recommended to optimize the preparation for RSI (Appendix D)
