Peri-Intubation Haemodynamic Response in Critically Injured Trauma Patients: Delayed Sequence versus Rapid Sequence Induction
RSI Versus DSI
Abstract
Background: Peri-intubation haemodynamic instability — hypotension, bradycardia and abrupt pressor surges — is a recognised hazard of emergency airway management in critically injured trauma patients. Ketamine-facilitated delayed sequence intubation (DSI) has been proposed as an alternative to rapid sequence intubation (RSI) in agitated patients, but its haemodynamic profile relative to RSI is not well characterised. This study compared peri-intubation systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR) response, together with the incidence of hypotension and bradycardia, between DSI and RSI in critically injured trauma patients.
The primary objective was to compare peri-intubation haemodynamic response (systolic blood pressure [SBP], diastolic blood pressure [DBP] and heart rate [HR]) between DSI and RSI. Secondary outcomes included hypotension, bradycardia, composite haemodynamic adverse events, number of intubation attempts and first-pass intubation success.
Methods: This prospective observational study was conducted in the trauma triage unit of a tertiary-care centre from June 2025 to April 2026. Critically injured patients with a low Glasgow Coma Scale score requiring emergency tracheal intubation were managed with RSI (n=60) or DSI (n=60) according to the treating physician's chosen airway strategy. SBP, DBP and HR were recorded at baseline and at 1, 2 and 3 minutes after induction and immediately post-intubation. Hypotension was defined as SBP <90 mmHg and bradycardia as HR <60 beats/min.
Results: Of 138 patients screened, 120 were enrolled (60 RSI, 60 DSI); baseline demographic, mechanism-of-injury and agitation characteristics were comparable between groups. SBP, DBP and HR did not differ significantly between groups at any measured time point. Hypotension occurred in 7 (11.7%) RSI patients versus 3 (5.0%) DSI patients, and bradycardia in 2 (3.3%) versus 1 (1.7%), respectively. The composite adverse-event rate was 18.3% versus 6.7% (p=0.095; risk difference 11.7 percentage points, 95% CI −0.4 to 23.9). First-pass intubation success was identical between groups (96.7% each).
Conclusion: This exploratory, non-randomised analysis did not demonstrate a statistically significant difference in peri-intubation SBP, DBP or HR between DSI and RSI. Haemodynamic adverse events were numerically less frequent with DSI, but the estimates were imprecise and the study was not powered for these outcomes. Larger, adequately powered studies are needed to determine whether this numerical signal represents a clinically meaningful difference.
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