Implementation of a Rapid Sequence Intubation Checklist Improves First-Pass Success and Reduces Peri-Intubation Hypoxia in Air Medical Transport.

OBJECTIVE: Rapid sequence intubation (RSI) is a critical skill commonly performed by air medical teams in the United States. To improve safety and reduce potential patient harm, checklists have been implemented by various institutions in intensive care units, emergency departments, and even prehospital air medical programs. However, the literature suggests that checklist use before RSI has not shown improvement in clinically important outcomes in the hospital. It is unclear if RSI checklist use by air medical crews in prehospital environments confers any clinically important benefit. METHODS: This institutional review board-approved project is a before-and-after observational study conducted within a large helicopter ambulance company. The RSI checklist was used by flight crewmembers (flight paramedic/nurse) for over 3 years. Data were evaluated for 8 quarters before and 8 quarters after checklist implementation, spanning December 2014 to March 2019. Data were collected, including the self-reported use of the checklist during intubation attempts, the reason for intubation, and correlation with difficult airway predictors (HEAVEN [Hypoxemia, Extremes of size, Anatomic disruption, Vomit, Exsanguination, Neck mobility/Neurologic injury] criteria), and compared with airway management before the implementation of the checklist. The primary outcome was improved first-pass success (FPS) when compared among those who received RSI before the checklist versus those who received RSI with the checklist. The secondary outcome was a definitive airway sans hypoxia improvement noted on the first pass among adult patients as measured before and after RSI checklist implementation. Post-RSI outcome scenarios were recorded to analyze and validate the effectiveness of the checklist. RESULTS: Ten thousand four hundred five intubations were attempted during the study. FPS was achieved in 90.9% of patients before RSI checklist implementation, and 93.3% achieved FPS postimplementation of the RSI checklist (P ≤ .001). In the preimplementation epoch, 36.2% of patients had no HEAVEN predictors versus 31.5% after RSI checklist implementation. These data showed that before RSI checklist implementation, airways were defined as less difficult than after implementation. CONCLUSION: The implementation of a standardized RSI checklist provided a better identification of deterring factors, affording efficient and accurate actions promoting FPS. Our data suggest that when a difficult airway is identified, using the RSI checklist improves FPS, thereby reducing adverse events.

Expired Epinephrine Maintains Chemical Concentration and Sterility.

OBJECTIVES: Epinephrine shortages affect nearly all American emergency medical services (EMS) systems. Utilization of expired epinephrine could mitigate this situation in daily EMS operations. Concerns about using expired medications include sterility, potency, and potential harmful chemical decay byproducts. There are no cross-platform analyses of sterility and chemical purity of multiple samples of expired parenteral epinephrine. We hypothesized that epinephrine injections will remain sterile and will retain their active ingredient's content for more than 30 months past expiration. METHODS: Six parenteral epinephrine prefilled syringes, 1 mg/10 mL, with an expiration date of January 1, 2012 had been stored in the climate controlled setting of a hospital inpatient pharmacy where they remained until they were taken for chemical or microbial analysis 30 months after expiration. An unexpired parenteral epinephrine prefilled syringe content was used as a control. Contents of three separate syringes with expired content from the same lot and one control underwent ultra-high pressure liquid chromatography-mass spectrometry (UHPLC-MS) and nuclear magnetic resonance (NMR) to determine epinephrine content and stability. In parallel, contents of another three expired epinephrine syringes were analyzed for sterility by plating on aerobic, anaerobic, and fungal media in a hospital microbiology laboratory. The aerobic plates were checked for growth in 3 days, the anaerobic in 5 days, and the fungal in 28 days. RESULTS: UHPLC-MS and NMR showed that content of epinephrine present in the original sample remained unchanged compared to the control. There was no statistical difference in the UHPLC-MS and NMR signal amplitudes between the control and the expired samples. No chemical degradation byproducts were detected using NMR. There was no growth of any bacteria or fungus. CONCLUSION: Recurrent epinephrine shortages impact EMS and hospital operations in the United States. Individual administrators may be hesitant to authorize use of expired pharmaceuticals due to perceived potential complications or fear of litigation. This study shows that the original parenteral epinephrine remains sterile and detectably pure more than 2.5 years after expiration. Further study of the sterility and chemical integrity of expired medications that had been subjected to the conditions of EMS vehicles may be a future research endeavor based on the aforementioned paradigm.