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 induction (DSI) has been proposed as an alternative to rapid sequence induction (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.
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 allocated to 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-severity characteristics were comparable between groups. Baseline SBP was 109.46±12.62 mmHg (RSI) versus 107.4±13.72 mmHg (DSI; p=0.394), and did not differ significantly at 1 minute (109.89±11.77 vs. 109.2±11.12; p=0.742), 2 minutes (110.97±12.05 vs. 109.4±10.45; p=0.447), 3 minutes (112.49±11.42 vs. 112.0±10.05; p=0.803) or post-intubation (121.49±5.94 vs. 119.83±6.08; p=0.133). DBP and HR followed similarly comparable trajectories at every time point (all p>0.05). Hypotension occurred in 7 (11.7%) RSI patients versus 3 (5.0%) DSI patients (p=0.322), and bradycardia in 2 (3.3%) versus 1 (1.7%) patient (p=1.000); any adverse event occurred in 11 (18.3%) versus 4 (6.7%) patients (p=0.095). First-pass intubation success was identical between groups (96.7% each).
Conclusion: Peri-intubation SBP, DBP and HR response were statistically comparable between ketamine-facilitated DSI and RSI in critically injured trauma patients, and hypotension, bradycardia and composite adverse events were numerically — though not significantly — less frequent with DSI. These findings support the haemodynamic safety of both airway strategies and suggest DSI does not compromise cardiovascular stability while facilitating oxygenation in agitated trauma patients.
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