This secondary analysis of emergency department RSI found no association between drug order and apnea time but is not generalizable to sedatives other than etomidate. During rapid sequence intubation (RSI), a paralytic and a sedative agent are successively administered to facilitate laryngoscopy with minimal apneic time. The decision about which medication to administer first is rooted in theoretical advantages, such as minimizing time without spontaneous respirations, optimal paralysis, and ensuring adequate sedation. To study the association between the order of RSI medications and apneic time, researchers conducted a secondary analysis of a randomized, controlled trial comparing a bougie versus endotracheal tube and stylet for first intubation attempt. The analysis included 562 adult patients who were successfully intubated in the emergency department (ED) on the first attempt. Essentially all patients (>99%) received etomidate and 61% received succinylcholine. Providers administered the paralytic agent first in 73% of cases. The apneic time, defined as the time from administration of the first RSI medication to successful laryngoscopy, was not significantly different between groups. |
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This study offers no guidance on the ordering of RSI medications in the ED, particularly in situations where a sedative other than etomidate is used. For example, the onset of action of ketamine is longer than that of etomidate, which may allow a patient to breathe spontaneously longer, thereby minimizing actual apnea time; however, delayed administration could result in paralysis without sedation. Lastly, the outcome of interest is hypoxemia, not time from RSI medication administration to successful laryngoscopy, so even if this study had found a statistically significant difference in apneic time, it’s doubtful that would have any clinical meaning.