Student paramedic rapid sequence intubation in Johannesburg, South Africa: A case series

INTRODUCTION: Pre-hospital rapid sequence intubation was introduced within paramedic scope of practice in South Africa seven years ago. Since then, little data has been published on this high-risk intervention as practiced operationally or by students learning rapid sequence intubation in the pre-hospital environment. The objective of this study was to describe a series of pre-hospital rapid sequence intubation cases, including those that South African University paramedic students had participated in. METHODS: A University clinical learning database was searched for all endotracheal intubation cases involving the use of neuromuscular blockers between 1 January 2011 and 31 December 2015. Data from selected cases were extracted and analysed descriptively. RESULTS: Data indicated that most patients were young adult trauma victims with a dominant injury mechanism of vehicle-related accidents. The majority of cases utilised ketamine and suxamethonium, with a low rate of additional paralytic medication administration. 63% and 72% of patients received post-intubation sedation and analgesia, respectively. The overall intubation success rate from complete records was 99.6%, with a first pass success rate of 87.9%. Students were successful in 92.4% of attempts with a first-pass success rate of 85.2%. Five percent of patients experienced cardiac arrest between rapid sequence intubation and hospital arrival. DISCUSSION: Students demonstrated a good intubation success and first pass-success rate. However, newly qualified paramedics require strict protocols, clinical governance, and support to gain experience and perform pre-hospital rapid sequence intubation at an acceptable level in operational practice. More research is needed to understand the low rate of post-intubation paralysis, along with non-uniform administration of post-intubation sedation and analgesia, and the 5% prevalence of cardiac arrest.