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The use of midazolam for prehospital rapid-sequence intubation may be associated with a dose-related increase in
D P Davis1, T A Kimbro, G M Vilke
1Department of Emergency Medicine, UCSD, San Diego, California, USA. shrimptaco@aol.com
Objective:
To investigate the incidence of hypotension associated with the use of midazolam for prehospital rapid-sequence intubation (RSI).
Methods:
A retrospective review was performed using charts from the two aeromedical agencies servicing the authors' region. The RSI protocols used by crews from the northern (north) and the southern (south) parts of the region were identical, with the exception of midazolam dosing. The north crews used 0.1 mg/kg for all patients, while the south crews used 0.1 mg/kg up to a maximum of 5 mg. All patients receiving midazolam for prehospital RSI were pooled, with multiple linear regression used to investigate the relationship between midazolam dose and both hypotension and a decrease in systolic blood pressure (SBP) following RSI. Patients weighing >50 kg and patients with traumatic brain injury (TBI) were evaluated separately to determine differences between north and south with regard to midazolam dosing and incidence of hypotension. Multivariate logistical regression was used to test for these differences and for potential confounders such as age, initial SBP, and Glasgow Coma Scale score (GCS).
Results:
A total of 219 patients were identified from the north (n = 75) and the south (n = 144). Multiple linear regression revealed a statistically significant relationship between midazolam dose and both hypotension and an SBP decrease following RSI. There was no difference between north and south with regard to age, sex, incidence of TBI, initial SBP, or GCS. In patients >50 kg, those from the north received higher doses of midazolam and had a higher incidence of hypotension than those from the south. This relationship was also present in 184 patients with TBI.
Conclusion:
The use of midazolam with prehospital RSI is associated with a dose-related incidence of hypotension.
Insights
Midazolam dosing during prehospital rapid-sequence intubation (RSI) is linked to hypotension. Higher midazolam doses increase the risk of hypotension, particularly in patients over 50 kg and those with traumatic brain injury (TBI).
Area of Science:
- Emergency Medicine
- Pharmacology
Background:
- Prehospital rapid-sequence intubation (RSI) frequently utilizes sedatives like midazolam.
- Hypotension is a known complication of RSI, but the specific dose-response relationship with midazolam in the prehospital setting requires further investigation.
Purpose of the Study:
- To determine the incidence of hypotension associated with midazolam administration during prehospital RSI.
- To explore the relationship between midazolam dosage and the occurrence of hypotension and decreased systolic blood pressure (SBP).
Main Methods:
- A retrospective chart review of 219 patients undergoing prehospital RSI with midazolam was conducted.
- Midazolam dosing protocols differed between two aeromedical agencies (northern vs. southern region).
- Statistical analyses, including multiple linear and multivariate logistical regression, were used to assess the association between midazolam dose and hypotension, controlling for confounders.
Main Results:
- A significant relationship was found between midazolam dose and both hypotension and decreased SBP post-RSI.
- Patients receiving higher midazolam doses (north region protocol) experienced a higher incidence of hypotension compared to those receiving lower doses (south region protocol).
- This dose-related hypotension was observed in the general patient population, as well as specifically in patients weighing over 50 kg and those with traumatic brain injury (TBI).
Conclusions:
- Midazolam use during prehospital RSI is associated with a dose-dependent risk of hypotension.
- Optimizing midazolam dosage may be crucial in mitigating hypotension during prehospital RSI, especially in vulnerable patient populations.