ABSTRACTS
Prehospital Paralytic-Only Intubation: A Descriptive AnalysisAuthor: Elizabeth Blizzard BA, EMT-P, CCP-C, FP-C` | Paramedic | Rutgers New Jersey Medical School Associate Authors: Jarvis, Sydney E., MS Grawey, Tom E., DO Hayes, Alisa K., MD Dreyer, Mason Jarvis, Jeffrey L., MD, MS, EMT-P
Introduction Up to 3% of patients receiving medication-facilitated intubation remain aware while paralyzed, which is associated with psychological trauma. Concerns exist about the potential for hypotension when sedation is used during intubation of patients with shock states. These concerns may lead to the practice of paralytic-only intubation despite the competing concern of awareness. Little is known about the practice of EMS paralytic-only intubations (POI), therefore we sought to determine the prevalence of prehospital POI and describe the practice. Methods Using the 2022 ESO Collaborative dataset, we conducted an analysis of patients 10 or older encountered during a 911 activation with a suspected POI. Patients in cardiac arrest were excluded. We defined POI as one in which a paralytic medication but no sedative agent was administered prior to the first intubation attempt. We performed a narrative review of records meeting inclusion criteria. Two authors reviewed each narrative using a templated abstraction form. Authors were a mix of EMS physicians, EMS clinicians, and academics. Conflicts were resolved by the senior author. We characterized the dataset using descriptive statistics as well as themes found in narrative review. Results Of the 12,803,160 records, there were 12,713 unique patients receiving prehospital airway management. 173 (1.4%) were suspected POI. Of the 173 narratives reviewed, 31 were excluded as cardiac arrests and 30 were excluded as charting errors. The remaining 112 (65%) cases met our POI definition. Commonly identified reasons for POI included decreased mental status (86%), hypotension (3.6%), and both hypotension and altered mental status (3.6%). Other reasons for POI intubation included physician order and apparent medication error. While 153 (88%) of POI patients were completely unresponsive prior to paralytic administration, 11 (9.8%) were described as having only a diminished LOC and 9 (8.1%) were described as completely awake. Conclusion Up to 1% of prehospital non-cardiac arrest intubations may involve the use of a paralytic without prior sedation. Common reasons include hypotension or decreased mental status. This practice is rare but requires additional study to carefully balance the potential risks of sedation, such as hypotension, and awareness during paralysis.
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