Prehospital rapid sequence intubation.

The Professional Board for Emergency Care at the Health Professions Council of South Africa (HPCSA) has approved pre-hospital rapid sequence intubation (RSI) as part of the scope of practice for registered emergency care practitioners (ECPs). RSI is an advanced airway management process that facilitates endotracheal intubation in adults and children. Features of this technique include pre-oxygenation, rapid pharmacological induction of unconsciousness, and neuromuscular blockade to enable the placement of an endotracheal tube. RSI has become widespread as the procedure of choice for definitive airway management by pre-and in-hospital emergency care personnel worldwide. In the emergency department setting, RSI is superior to intubation with deep sedation, a technique not incorporating pharmacological paralysis as part of the intubation sequence. For this reason, the implementation of RSI in the pre-hospital environment is supported, provided that it is practised within an appropriate framework of clinical governance. Pre-hospital RSI provides improved intubating conditions compared with intubation with deep sedation only, takes less time for intubation, and uses a safer combination and dosage of drugs. RSI also has risks; using neuromuscular blocking agents has potential complications because of the removal of spontaneous respiratory effort and possibly the loss of airway patency under certain circumstances. Nonetheless, the overall benefits of this technique outweigh the risks. Although the HPCSA has communicated some minimum standards about training and system and clinical governance requirements for pre-hospital RSI, these lack the necessary detail to allow adequate preparation for its implementation. To provide pre-hospital RSI safely and effectively, the following three aspects require consideration. Pre-hospital RSI demands the application of knowledge, understanding and skill, and it requires the practitioner to reason logically, make sound clinical decisions and solve problems. The endpoint of each component of training should be demonstrated proficiency. Training and assessment should incorporate the following: Theoretical knowledge, focusing on the understanding of RSI procedures including indications, contraindications, and clinical decision-making and its influencing factors, particularly under emergency conditions. Simulated practice of RSI and related skills, including scenarios involving application of the abovementioned theoretical outcomes. These should be assessed by simulation exercises to ensure the safe application of a staged approach to airway difficulty. Clinical practice of RSI and related skills that should involve RSI performed initially in a controlled environment, under the supervision of a medical practitioner experienced in RSI, and subsequently in the pre-hospital environment. Experience should also be obtained using rescue oxygenation devices. Continuing education for RSI should …