Postintubation confirmation and evaluation of hemodynamic response in patients undergoing rapid sequence intubation in the emergency department

ABSTRACT Postintubation Confirmation and Evaluation of Hemodynamic Response in Patients Undergoing Rapid Sequence Intubation in the Emergency Department Introduction and Aim: Today, many critical patients admit to emergency services and it is our priority to ensure airway safety at the first evaluation of patients. Many patients with insufficient oxygenation and ventilation are performed endotracheal intubation procedures by emergency medicine physicians in emergency departments. It has been reported that giving the patient a sniffing position while performing endotracheal intubation can facilitate the procedure. Many drugs such as midazolam, diazepam, ketamine, propofol, etc. are used as induction agents in endotracheal intubation. These drugs have complications such as hypotension, apnea, bradycardia, respiratory arrest, and many more. In addition, the endotracheal intubation procedure has various complications too. These complications are seen starting from dental damage and simple arrhythmias, to aspiration after esophageal intubation and even cardiac arrest as serious complications. To minimize these complications, early confirmation of endotracheal intubation and evaluation of the patient's hemodynamic response to postintubation is required. Today, besides the accepted methods for the confirmation of endotracheal intubation, bedside transtracheal ultrasonography has started to be used in emergency services and intensive care units as a new method. In this study, we aimed to evaluate the success of the sniffing position given to the patient, the place of bedside transtracheal ultrasonography in the confirmation of the intubation site as soon as possible, and the effects of drugs and procedures used in rapid sequence intubation on the hemodynamic response in patients who underwent intubation in the emergency department. Material and Method: This study was performed as a prospective and cross-sectionally between March 8, 2019 - June 30, 2020, in the Department of Emergency Medicine at Balcalı Hospital with the approval of Çukurova University Faculty of Medicine Ethics Committee. This study was performed as a prospective and cross- sectionally between March 8, 2019 - June 30, 2020, in the Department of Emergency Medicine at Balcalı Hospital with the approval of Çukurova University Faculty of Medicine Ethics Committee. 50 patients, aged 18 and over, who admitted to the Adult Emergency Medicine Service within the specified time period, who underwent endotracheal intubation, and who had the inclusion criteria, were included in the study. Patients who admitted to the emergency department as previously intubated and patients younger than 18 years were excluded from the study. Sociodemographic data, vital signs, laboratory findings, study parameters and procedure data of the patients and data related research assistants who made central vein catheterization were recorded in the previously prepared study sheet. Research data was uploaded and analyzed on computer via "SPSS for Windows 23.0 (SPSS Inc, Chicago, IL)". Results: A total of 50 patients were included in the study. The average age of all patients was 67.1±16.92 years and 56.0% (n = 28) of the patients were male. The most common causes of endotracheal intubation in the study were low GCS (62.0%) and hypoxic respiratory failure (60.0%). The most common reason for patients admitting to the emergency service was dyspnea (48.0%). There was no statistically significant difference between the patient groups in terms of sociodemographic data. In the cases included in the study, the median intubation confirmation time of the physicians was found to be 22.34±41.96 seconds. It was observed that whether the sniffing position was given or not before intubation in the cases included in the study had no statistically significant effect on the number of intubation attempts and the successful intubation time (p:0.621; p:0.858). As a statistically significant, it was shown that decrease of systolic blood pressure (p <0.001) and diastolic blood pressure (p = 0.002) values after intubation in patients who used "Midazolam + Fentanyl" as induction agent (p <0.05). Discussion and Conclusions: In our study, it was observed that the combination of "Midazolam + Fentanyl" used as an induction agent significantly decreased systolic and diastolic blood pressure compared to the other groups. In addition, it has been determined whether or not the patients are given the Sniffing position before intubation may have no effect on the success of intubation and the number of intubation attempts. It was observed that as the years of seniority of physicians increased, it was observed that they used multiple verification methods together with transtracheal USG and it was concluded that shorter transtracheal USG verification time would improve the outcome of patients. However, the effectiveness of the transtracheal USG technique in confirming endotracheal intubation and the effects of the induction agents used on the hemodynamic response can be more clearly demonstrated by further studies with more patients. Keywords: RSI, intubation, induction, rapid sequence intubation, ultrasonography, transtracheal USG