Written by Clay Smith
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Rapid sequence intubation (RSI) in the prehospital setting was associated with an increase in mortality for stroke patients.
Why does this matter?
A while back, we wrote a summary of some important articles on prehospital airway management. Generally, there is concern that it may actually cause harm to try to intubate prehospital. Specific to stroke patients, GOLIATH did not find a difference between sedation without intubation and general anesthesia with RSI prior to a stent retriever procedure for stroke, but it was not looking at prehospital RSI.
No RSI for CVA by EMS
This was a retrospective review of paramedic RSI for stroke patients in the prehospital setting in Australia over ten years. They used propensity score matching to help account for confounders. They found 38,352 patients with stroke transported by EMS, of which 727 had RSI. They chose 727 patients who did not have RSI but were otherwise well matched on propensity score analysis. Using this statistical technique, they determined that RSI was associated with a 39% lower odds of survival; OR 0.61 (95%CI, 0.45 to 0.82). This was true of both ischemic and hemorrhagic strokes. Why might this be? Patients with RSI were more likely to have a drop in BP, which may have exacerbated already ischemic brain. Bear in mind, this was a retrospective study, designed to reduce confounding, but not immune to it. I think the results are believable and consistent with prior studies. Only a RCT can answer this, but in the meantime, it seems best to not intubate stroke patients in the prehospital setting.
Source
The association of paramedic rapid sequence intubation and survival in out-of-hospital stroke. Emerg Med J. 2019 May 30. pii: emermed-2019-208613. doi: 10.1136/emermed-2019-208613. [Epub ahead of print]
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Reviewed by Thomas Davis
Thank you for yet another good review. Very helpful and relevant. Perhaps the conclusion might be slightly reworded to say, "best not to RSI stroke patients." If paramedics are careful to practice good DSI with safety stops to prevent hypotension and hypoxia, then we might see better results. Might.
Please keep up the wonderful posts!