[The authors respond:]

Letters

CJEM 2006;8(4):243-244

We thank Drs. Kovacs, MacQuarrie and Campbell for their response on behalf of the AIME Instructors to our study evaluating the use of pretreatment for neuroprotective rapid sequence intubation (RSI) in the emergency department (ED).1 We agree that every attempt should be made to avoid hypoxia and hypotension in all patients undergoing intubation in the ED, and agree that in some scenarios the simplest approach is the best. However, we were disappointed to hear the opinion that pretreatment is contraindicated, and were further disappointed to hear that the findings of our study that pretreatment drugs were not being routinely used were welcomed by the AIME group.

Clearly there is a lack of evidence involving hard end points demonstrating improved clinical outcomes when pretreatment is administered, and further research is necessary in this area. That said, we disagree with the conclusion of the AIME Instructors that pretreatment is therefore contraindicated in patients undergoing neuroprotective RSI in the ED. Although the issue requires further study we suspect that this opinion is not shared by the majority of emergency medicine clinicians who, rather than discard the use of potentially beneficial treatment agents, carefully consider the selective use of pretreatment in patients who may benefit from this intervention. The 2006 edition of Rosen's Emergency Medicine textbook makes the following statement regarding this issue:

There is evidence supporting the physiologic benefits of these agents, but outcome data are lacking, so individualization is necessary, and critical time should not be lost administering pretreatment drugs if the patient requires immediate intubation. Despite the lack of outcome studies, there is considerable inferential evidence supporting this approach, and these agents probably provide protection for vulnerable patients against the adverse hemodynamic and intracranial effects of laryngoscopy and intubation.2

Research done at our centre has provided evidence supporting the physiologic benefit of pretreatment agents.3 In addition, we recently published a study of 522 intubations using etomidate, many of which also involved the use of pretreatment agents. This study demonstrated that our approach was associated with hemodynamic stability in a heterogeneous group of patients undergoing RSI in the ED.4 Our conclusion from the existing literature remains unchanged; premedication should be considered in selected patients undergoing neuroprotective RSI in the ED. The appropriate selection and dosing of medications in such cases provides the best opportunity to minimize post-intubation hypotension and other complications of intubation.

Peter J. Zed, BSc, BSc(Pharm),

PharmD, FCSHP

David W. Harrison, MD

Nick Kuzak, MD

CSU Pharmaceutical Sciences and

Department of Emergency Medicine

Vancouver General Hospital

Faculty of Pharmaceutical Sciences

and Faculty of Medicine

University of British Columbia

Vancouver, BC

References

1. Kuzak N, Harrison DW, Zed PJ. Use of lidocaine and fentanyl premedication for neuroprotective rapid sequence intubation in the emergency department. Can J Emerg Med 2006;8(2):80-4.
2. Walls RM. Airway. In: Marx JA, Hockberger RS, Walls RM, et al, editors. Emergency medicine: concepts and clinical practice. 6th ed. Missouri: Mosby; 2006. p. 2-26.
3. Zed PJ, Abu-Laban RB, Harrison DW. Effect of fentanyl pretreatment on sympathetic response in patients with cerebrovascular accident undergoing rapid sequence intubation in the emergency department [abstract]. Can J Emerg Med 2004;6(3):197.
4. Zed PJ, Abu-Laban RB, Harrison DW. Intubating conditions and hemodynamic effects of etomidate for rapid sequence intubation in the emergency department: an observational cohort study. Acad Emerg Med 2006;13:378-83.