Induction of pre-hospital emergency anaesthesia i-PHEA: a national survey of UK HEMS practice

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Abstract

Background

Pre-hospital emergency anaesthesia is a critical intervention undertaken by helicopter emergency medical teams. Previous studies informed current practice for induction regimes, using a standardized approach of fentanyl, ketamine and rocuronium. There may be a trend towards post-induction hypotension attributed to the induction regime used. Several new combinations of fentanyl, ketamine and rocuronium are emerging in clinical practice. There is currently no consensus on what induction regimes should be used.

Methods

A semi-structured survey was distributed to the medical leads of all UK air ambulance organisations between December 2022 and February 2023. Responses that were returned within the study period were included. Exclusions included missing data, declined participation and failure to return the survey within the data collection period. The survey sought to establish provision of pre-hospital emergency anaesthesia and current induction regimes for stable, unstable and post-cardiac arrest patients. Data was extracted from Microsoft Forms into Excel. Descriptive statistics were used to analyse survey response rate, provision of PHEA and induction regimes. The survey was endorsed by the National HEMS Research and Audit Forum.

Results

19 air ambulance organisations responded (response rate 86%). The majority of organisations provide over 100 pre-hospital emergency anaesthetics per annum (79%, n = 15/19). A standard combination of fentanyl, ketamine and rocuronium is used as a primary induction regime in haemodynamically stable patients by 52% of services (n = 10/19). In haemodynamically compromised patients, fentanyl was omitted or pracititioner choice emphasized by 79% of services (n = 15/19). There was variability in the dose of rocuronium from 1 mg/kg to 2 mg/kg throughout services.

Conclusion

There is variability in the approach to pre-hospital emergency anaesthesia. There is a growing dataset that would enable development of a registry to better understand induction regimes and the impact on patient physiology. Organisations are increasingly adopting a patient centered, practitioner choice model towards induction of anaesthesia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-023-00897-5.

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Most cited references 10

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European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2021: Post-resuscitation care

Jerry P Nolan, Claudio Sandroni, Bernd W Böttiger … (2021)

The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation, and organ donation.

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Significant modification of traditional rapid sequence induction improves safety and effectiveness of pre-hospital trauma anaesthesia

Richard Lyon, Zane Perkins, Debamoy Chatterjee … (2015)

Introduction Rapid Sequence Induction of anaesthesia (RSI) is the recommended method to facilitate emergency tracheal intubation in trauma patients. In emergency situations, a simple and standardised RSI protocol may improve the safety and effectiveness of the procedure. A crucial component of developing a standardised protocol is the selection of induction agents. The aim of this study is to compare the safety and effectiveness of a traditional RSI protocol using etomidate and suxamethonium with a modified RSI protocol using fentanyl, ketamine and rocuronium. Methods We performed a comparative cohort study of major trauma patients undergoing pre-hospital RSI by a physician-led Helicopter Emergency Medical Service. Group 1 underwent RSI using etomidate and suxamethonium and Group 2 underwent RSI using fentanyl, ketamine and rocuronium. Apart from the induction agents, the RSI protocol was identical in both groups. Outcomes measured included laryngoscopy view, intubation success, haemodynamic response to laryngoscopy and tracheal intubation, and mortality. Results Compared to Group 1 (n = 116), Group 2 RSI (n = 145) produced significantly better laryngoscopy views (p = 0.013) and resulted in significantly higher first-pass intubation success (95% versus 100%; p = 0.007). A hypertensive response to laryngoscopy and tracheal intubation was less frequent following Group 2 RSI (79% versus 37%; p < 0.0001). A hypotensive response was uncommon in both groups (1% versus 6%; p = 0.05). Only one patient in each group developed true hypotension (SBP < 90 mmHg) on induction. Conclusions In a comparative, cohort study, pre-hospital RSI using fentanyl, ketamine and rocuronium produced superior intubating conditions and a more favourable haemodynamic response to laryngoscopy and tracheal intubation. An RSI protocol using fixed ratios of these agents delivers effective pre-hospital trauma anaesthesia.

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Best practice advice on pre-hospital emergency anaesthesia & advanced airway management

Kate Crewdson, David J Lockey, Wolfgang G Voelckel … (2019)

Background Effective and timely airway management is a priority for sick and injured patients. The benefit and conduct of pre-hospital emergency anaesthesia (PHEA) and advanced airway management remains controversial but there are a proportion of critically ill and injured patients who require urgent advanced airway management prior to hospital arrival. This document provides current best practice advice for the provision of PHEA and advanced airway management. Method This best practice advice was developed from EHAC Medical Working Group enforced by pre-hospital critical care experts. The group used a nominal group technique to establish the current best practice for the provision of PHEA and advanced airway management. The group met on three separate occasions to discuss and develop the guideline. All members of the working party were able to access and edit the guideline online. Results This EHAC best practice advice covers all areas of PHEA and advanced airway management and provides up to date evidence of current best practice. Conclusion PHEA and advanced airway management are complex interventions that should be delivered by appropriately trained personnel using a well-rehearsed approach and standardised equipment. Where advanced airway interventions cannot be delivered, careful attention should be given to applying basic airway interventions and ensuring their effectiveness at all times.

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Author and article information

Contributors

Mark Hodkinson: mark.hodkinson@tvairambulance.org.uk

Journal

Journal ID (nlm-ta): BMC Emerg Med

Journal ID (iso-abbrev): BMC Emerg Med

Title: BMC Emergency Medicine

Publisher: BioMed Central (London )

ISSN (Electronic): 1471-227X

Publication date (Electronic): 31 October 2023

Publication date PMC-release: 31 October 2023

Publication date Collection: 2023

Volume: 23

Electronic Location Identifier: 126

Affiliations

Thames Valley Air Ambulance, Stokenchurch House, Oxford Road, Stokenchurch, HP14 3SX UK

Article

Publisher ID: 897

DOI: 10.1186/s12873-023-00897-5

PMC ID: 10617087

PubMed ID: 37904097

SO-VID: d186e46e-bee4-46d9-b0c7-56854d78e3c5

License:

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