Prehospital Advanced Airway Management Research Articles

The search and rescue helicopter paramedic: an emerging role

The search and rescue helicopter paramedic: an emerging role

Advanced airway management is necessary in prehospital trauma patients

Treatment of airway compromise in trauma patients is a priority. Basic airway management is provided by all emergency personnel, but the requirement for on-scene advanced airway management is controversial. We attempted to establish the demand for on-scene advanced airway interventions. Trauma patients managed with standard UK paramedic airway interventions were assessed to determine whether airway compromise had been effectively treated or whether more advanced airway management was required. A prospective observational study was conducted to identify trauma patients requiring prehospital advanced airway management attended by a doctor-paramedic team. The team assessed and documented airway compromise on arrival, interventions performed before and after their arrival, and their impact on airway compromise. Four hundred and seventy-two patients required advanced airway intervention and received 925 airway interventions by ground-based paramedics. Two hundred and sixty-nine patients (57%) still had airway compromise on arrival of the enhanced care team; no oxygen had been administered to 52 patients (11%). There were 45 attempted intubations by ground paramedics with a 64% success rate and 11% unrecognized oesophageal intubation rate. Doctor-paramedic teams delivering prehospital anaesthesia achieved definitive airway management for all patients. A significant proportion of severely injured trauma patients required advanced airway interventions to effectively treat airway compromise. Standard ambulance service interventions were only effective for a proportion of patients, but might not have always been applied appropriately. Complications of advanced airway management occurred in both provider groups, but failed intubation and unrecognized oesophageal intubation were a particular problem in the paramedic intubation group.

Implementing new advanced airway management standards in the Hungarian physician staffed Helicopter Emergency Medical Service.

In 2011 the Hungarian Air Ambulance Nonprofit Limited Company introduced a new Rapid Sequence Intubation standard operating procedure using a template from London’s Air Ambulance. This replaced a previous ad-hoc and unsafe prehospital advanced airway management practice. It was hoped that this would increase clinical standards including internationally comparable results. All Rapid Sequence Intubations performed by the units of the Hungarian Air Ambulance under the new procedure between June 2011 and November 2013 were reviewed in a retrospective database analysis. During this period the air ambulance units completed 4880 missions with 433 intubations performed according to the new procedure. The rate of intubations that were successful on first attempt was 95.4% (413), while intubation was successful overall in 99.1% (429) of the cases; there was no failed airway. 90 complications were noted with 73 (16.9%) patients. Average on scene time was 49 minutes (ranging between: 15–110 minutes). This data shows that it is possible to effectively change a system that was in place for decades by implementing a new robust system that is based on a good template.

Anaesthesiologist-provided prehospital airway management in patients with traumatic brain injury

BackgroundGuidelines recommend that patients with brain trauma with a Glasgow Coma Scale (GCS) score of less than 9 should have an airway established. Hypoxia, hypotension and hypertension as well as hypoventilation and hyperventilation may worsen outcome in these patients.ObjectivesThe objectives were to investigate guideline adherence, reasons for nonadherence and the incidences of complications related to prehospital advanced airway management in patients with traumatic brain injury.Materials and methodsWe prospectively collected data from eight anaesthesiologist-staffed prehospital critical care teams in the Central Denmark Region according to the Utstein-style template.ResultsAmong 1081 consecutive prehospital advanced airway management patients, we identified 54 with a traumatic brain injury and an initial GCS score of less than 9. Guideline adherence in terms of airway management was 92.6%. The reasons for nonadherence were the patient’s condition, anticipated difficult airway management and short distance to the emergency department. Following rapid sequence intubation (RSI), 11.4% developed oxygen saturation below 90%, 9.1% had a first post-RSI systolic blood pressure below 90 mmHg and 48.9% had a first post-RSI systolic blood pressure below 120 mmHg. The incidence of hypertension following prehospital RSI was 4.5%. The incidence of postendotracheal intubation hyperventilation was as high as 71.1%.ConclusionThe guideline adherence was high. The incidences of post-RSI hypoxia and systolic blood pressure below 90 compare with the results reported from other physician-staffed prehospital services. The incidence of systolic blood pressure below 120 as well as that of hyperventilation following prehospital endotracheal intubation in patients with traumatic brain injury call for a change in our current practice.

Effective Pre-hospital Care for Out-of-hospital Cardiac Arrest Caused by Respiratory Disease

The relationship between pre-hospital care and the prognosis of out-of-hospital cardiac arrest (OHCA) caused by respiratory disease is unclear. This study aimed to assess the impact of pre-hospital care on the prognosis of OHCA caused by respiratory disease. In a nationwide, population-based, observational study, we enrolled 121,081 adults aged ≥18 years who experienced OHCA from January 1, 2010, to December 31, 2010. The primary endpoint was favourable neurological outcomes. Of the 120,256 eligible adult OHCA patients, 7,071 (5.9%) experienced OHCA caused by respiratory disease. Of these 7,071 patients, 3,911 (55.3%) received no cardiopulmonary resuscitation (CPR), 2,403 (34.0%) received chest-compression-only CPR, and 757 (10.7%) received conventional CPR by a bystander. There was no significant difference between the three types of bystander CPR with regard to the neurological outcome (no CPR: OR 0.68, 95%CI 0.39-1.24, p=0.1951; chest-compression-only CPR: OR 0.68, 95%CI 0.37-1.29, p=0.2295; and conventional CPR: as a reference). Pre-hospital administration of epinephrine (OR 0.37, 95%CI 0.13-0.85, p=0.0170) and the implementation of advanced airway management (OR 0.32, 95%CI 0.19-0.52, p<0.0001) were associated with poor neurological outcomes. Even in OHCA caused by respiratory disease, not only pre-hospital epinephrine administration but also pre-hospital advanced airway management and rescue breathing in bystander CPR may not be critical.

Pre-hospital critical care anaesthesiologists and traumatic brain injury-guideline adherence

Background Guidelines recommend that brain trauma patients with a Glasgow Coma Scale score 90%, systolic blood pressure >90 mmHg and end-tidal CO2 between 4.5 and 5.3 kPa is advised [1]. The objectives were to investigate guideline adherence, reasons for non-adherence and the incidences of complications related to pre-hospital advanced airway management in traumatic brain injury patients.

Failed Intubation in the ED Might Delay Return of Spontaneous Circulation

Although prehospital advanced airway management is standard in the U.S., it has not been proven effective and is not performed in some countries.

Evidence-based Prehospital Management of Severe Traumatic Brain Injury: A Comparative Analysis of Current Clinical Practice Guidelines

Objective. This study appraised the completeness and level of evidence behind prehospital recommendations in clinical practice guidelines (CPGs) for management of severe traumatic brain injury (TBI). Differences and similarities in key recommendations for prehospital emergency care were assessed between current CPGs. Methods. A systematic search identified current evidence-based CPGs for the management of severe TBI. The identified CPGs were screened for prehospital recommendations. Finally, an evaluation of the completeness and level of evidence for each of the identified recommendations was carried out. A review of the literature identified additional evidence. Designs of the retrieved publications were considered and classified according to the GRADE levels of evidence. Results. This study identified 12 current CPGs for the management of patients after traumatic brain injury. Of these, twenty-one prehospital recommendations were selected. Only a few CPGs made recommendations on temperature management and ventilation patterns. Statements on prehospital transport and advanced airway management were common to all of the guidelines. Statements on initial treatment demonstrated the greatest variability. The literature review identified several relevant publications not included in the CPGs even after we controlled for the indicated time-intervals of their literature search. In addition, evidence from more recent trials published outside the search-interval of the clinical practice guidelines was found. Conclusions. The use of current guidelines on traumatic brain injury will not always facilitate decisions about best or most appropriate practice for prehospital practitioners. The amount of recommended prehospital interventions varied considerably, and there was large content variation in prehospital recommendations in these guidelines. Not all evidence was taken into account and not all CPGs were up-to-date.

Predicting the lack of ROSC during pre-hospital CPR: Should an end-tidal CO2 of 1.3 kPa be used as a cut-off value?

AimThe aim of this study was to investigate if an initial ETCO2 value at or below 1.3kPa can be used as a cut-off value for whether return of spontaneous circulation during pre-hospital cardio-pulmonary resuscitation is achievable or not. Materials and methodsWe prospectively registered data according to the Utstein-style template for reporting data from pre-hospital advanced airway management from February 1st 2011 to October 31st 2012. Included were consecutive patients at all ages with pre-hospital cardiac arrest treated by eight anaesthesiologist-staffed pre-hospital critical care teams in the Central Denmark Region. ResultsWe registered data from 595 cardiac arrest patients; in 60.2% (n=358) of these cases the pre-hospital critical care teams performed pre-hospital advanced airway management beyond bag-mask ventilation. An initial end-tidal CO2 measurement following pre-hospital advanced airway management were available in 75.7% (n=271) of these 358 cases. We identified 22 patients, who had an initial end-tidal CO2 at or below 1.3kPa. Four of these patients achieved return of spontaneous circulation. ConclusionOur results indicates that an initial end-tidal CO2 at or below 1.3kPa during pre-hospital CPR should not be used as a cut-off value for the achievability of return of spontaneous circulation.

Abstract 276: Prehospital Advanced Airway Management Without Intravenous Access May Negatively Affect Favorable Neurological Outcome in Children With Out-of-Hospital Cardiac Arrest

Background: Although advanced airway management and intravenous (IV) access for patients with out-of-hospital cardiac arrest (OHCA) are thought to be lifesaving procedures at prehospital settings, recent data suggested that these procedures might lead to poorer neurological outcome for adult population. This association needs to be studied further for pediatric population as well. Methods: Data were collected through a Japanese nationwide, population-based registration form for OHCA from 2005 to 2011 involving 13,159 consecutive children aged less than 18 years old. Data regarding OHCA patients such as age, etiology, bystander CPR, and others were collected. Main outcome measure was favorable neurological outcome at one month from OHCA event, which was defined as cerebral performance category 1 or 2. OHCA patients who did not receive any resuscitative intervention by prehospital personnel were excluded from the analysis. Results: 12,510 OHCA pediatric patients were eligible to the analysis. Among these, 465 (3.7%) patients had both IV access and advanced airway (IV+/AA+), 328 (2.6%) patients had only IV access (IV+/AA-), 1,685 (13.5%) patients had only advanced airway (IV-/AA+), and 10,032 (80.2%) patients had neither of them (IV-/AA-). Devices of advanced airway management were esophageal obturator airway (60%), laryngeal mask (30%), and endotracheal tube (10%). Favorable neurological outcome at one month from OHCA event for IV-/AA- group (4.2% [412/10,032]) was compared with other groups. IV-/AA+ group had the worst outcome (1.9% [32/1685]; OR 0.45, 95% CI; 0.31 - 0.64) followed by IV+/AA+ group (3.4% [16/465]; OR 0.82, 95%CI; 0.49 - 1.37) and IV+/AA- group (3.7% [12/328]; OR 0.88, 95% CI; 0.49 - 1.57). Baseline characteristics for these groups were not significantly different except for age distribution as IV-/AA- group were younger than others. There was no statistical difference in neurological outcome between IV-/AA+ group and IV+/AA+ group. Conclusion: Advanced airway management without IV access seems to negatively affect pediatric OHCA patients. Obtaining IV access and further intervention by prehosital personnel may compensate this effect.

Refraining from pre-hospital advanced airway management: a prospective observational study of critical decision making in an anaesthesiologist-staffed pre-hospital critical care service

IntroductionWe report prospectively recorded observational data from consecutive cases in which the attending pre-hospital critical care anaesthesiologist considered performing pre-hospital advanced airway management but decided to withhold such interventions.Materials and methodsAnaesthesiologists from eight pre-hospital critical care teams in the Central Denmark Region (a mixed rural and urban region with 1.27 million inhabitants) registered data from February 1st 2011 to October 31st 2012. Included were patients of all ages for whom pre-hospital advanced airway management were considered but not performed. The main objectives were to investigate (1) the pre-hospital critical care anaesthesiologists’ reasons for considering performing pre-hospital advanced airway management in this group of patients (2) the pre-hospital critical care anaesthesiologists’ reasons for not performing pre-hospital advanced airway management (3) the methods used to treat these patients (4) the incidence of complications related to pre-hospital advanced airway management not being performed.ResultsWe registered data from 1081 cases in which the pre-hospital critical care anaesthesiologists’ considered performing pre-hospital advanced airway management. The anaesthesiologists decided to withhold pre-hospital advanced airway management in 32.1% of these cases (n = 347). In 75.1% of these cases (n = 257) pre-hospital advanced airway management were withheld because of the patient’s condition and in 30.8% (n = 107) because of patient co-morbidity. The most frequently used alternative treatment was bag-mask ventilation, used in 82.7% of the cases (n = 287). Immediate complications related to the decision of not performing pre-hospital advanced airway management occurred in 0.6% of the cases (n = 2).ConclusionWe have illustrated the complexity of the critical decision-making associated with pre-hospital advanced airway management. This study is the first to identify the most common reasons why pre-hospital critical care anaesthesiologists sometimes choose to abstain from pre-hospital advanced airway management as well as the alternative treatment methods used.

Prehospital Advanced Airway Management by Anesthesiologists

Controversy persists regarding prehospital airway management, with positions ranging from abandoning intubation to staffing emergency medical services

Pre-hospital advanced airway management by experienced anaesthesiologists: a prospective descriptive study

IntroductionWe report data from the first Utstein-style study of physician-provided pre-hospital advanced airway management.Materials and methodsAnaesthesiologists from eight pre-hospital critical care teams in the Central Denmark Region (a mixed rural and urban region with 1.27 million inhabitants) prospectively registered data according to the template for reporting data from pre-hospital advanced airway management. Data collection took place from February 1st 2011 to October 31st 2012. Included were patients of all ages on whom pre-hospital advanced airway management was performed. The objective was to estimate the incidences of failed and difficult pre-hospital endotracheal intubation, and complications related to pre-hospital advanced airway management.ResultsThe overall incidence of successful pre-hospital endotracheal intubation among 636 intubation attempts was 99.7%, even though 22.4% of pre-hospital endotracheal intubations required more than one intubation attempt. The overall incidence of complications related to pre-hospital advanced airway management was 7.9%. Following rapid sequence intubation, the incidence of first pass success was 85.8%, the overall incidence of complications was 22.0%, the incidence of hypotension 7.3% and that of hypoxia 5.3%. Multiple endotracheal intubation attempts were associated with an increased overall incidence of complications. No airway management related deaths occurred.DiscussionThe overall incidence of successful pre-hospital endotracheal intubations compares to those found in other physician-staffed pre-hospital systems. The incidence of pre-hospital endotracheal intubations requiring more than one attempt is higher than suspected. The incidence of hypotension or hypoxia after pre-hospital rapid sequence intubation compares to those found in UK emergency departments.ConclusionPre-hospital advanced airway management including pre-hospital endotracheal intubation performed by experienced anaesthesiologists is associated with high success rates and relatively low incidences of complications. An increased first pass success rate following pre-hospital endotracheal intubation may further reduce the incidence of complications and enhance patient safety in our system.

Association of Prehospital Advanced Airway Management With Neurologic Outcome and Survival in Patients With Out-of-Hospital Cardiac Arrest

Results Of the eligible 649359 patients with OHCA, 367837 (57%) underwent bagvalve-mask ventilation and 281522 (43%) advanced airway management, including 41972 (6%) with endotracheal intubation and 239550 (37%) with use of supraglottic airways. In the full cohort, the advanced airway group incurred a lower rate of favorable neurological outcome compared with the bag-valve-mask group (1.1% vs 2.9%; odds ratio [OR], 0.38; 95% CI, 0.36-0.39). In multivariable logistic regression, advanced airway management had an OR for favorable neurological outcome of 0.38 (95% CI, 0.37-0.40) after adjusting for age, sex, etiology of arrest, first documented rhythm, witnessed status, type of bystander cardiopulmonary resuscitation, use of public access automated external defibrillator, epinephrine administration, and time intervals. Similarly, the odds of neurologically favorable survival were significantly lower both for endotracheal intubation (adjusted OR, 0.41; 95% CI, 0.37-0.45) and for supraglottic airways (adjusted OR, 0.38; 95% CI, 0.36-0.40). In a propensity score– matched cohort (357228 patients), the adjusted odds of neurologically favorable survival were significantly lower both for endotracheal intubation (adjusted OR, 0.45; 95% CI, 0.37-0.55) and for use of supraglottic airways (adjusted OR, 0.36; 95% CI, 0.33-0.39). Both endotracheal intubation and use of supraglottic airways were similarly associated with decreased odds of neurologically favorable survival. Conclusion and Relevance Among adult patients with OHCA, any type of advanced airway management was independently associated with decreased odds of neurologically favorable survival compared with conventional bag-valve-mask ventilation.

Association of Prehospital Advanced Airway Management With Neurologic Outcome and Survival in Patients With Out-of-Hospital Cardiac Arrest

It is unclear whether advanced airway management such as endotracheal intubation or use of supraglottic airway devices in the prehospital setting improves outcomes following out-of-hospital cardiac arrest (OHCA) compared with conventional bag-valve-mask ventilation. To test the hypothesis that prehospital advanced airway management is associated with favorable outcome after adult OHCA. Prospective, nationwide, population-based study (All-Japan Utstein Registry) involving 649,654 consecutive adult patients in Japan who had an OHCA and in whom resuscitation was attempted by emergency responders with subsequent transport to medical institutions from January 2005 through December 2010. Favorable neurological outcome 1 month after an OHCA, defined as cerebral performance category 1 or 2. Of the eligible 649,359 patients with OHCA, 367,837 (57%) underwent bag-valve-mask ventilation and 281,522 (43%) advanced airway management, including 41,972 (6%) with endotracheal intubation and 239,550 (37%) with use of supraglottic airways. In the full cohort, the advanced airway group incurred a lower rate of favorable neurological outcome compared with the bag-valve-mask group (1.1% vs 2.9%; odds ratio [OR], 0.38; 95% CI, 0.36-0.39). In multivariable logistic regression, advanced airway management had an OR for favorable neurological outcome of 0.38 (95% CI, 0.37-0.40) after adjusting for age, sex, etiology of arrest, first documented rhythm, witnessed status, type of bystander cardiopulmonary resuscitation, use of public access automated external defibrillator, epinephrine administration, and time intervals. Similarly, the odds of neurologically favorable survival were significantly lower both for endotracheal intubation (adjusted OR, 0.41; 95% CI, 0.37-0.45) and for supraglottic airways (adjusted OR, 0.38; 95% CI, 0.36-0.40). In a propensity score-matched cohort (357,228 patients), the adjusted odds of neurologically favorable survival were significantly lower both for endotracheal intubation (adjusted OR, 0.45; 95% CI, 0.37-0.55) and for use of supraglottic airways (adjusted OR, 0.36; 95% CI, 0.33-0.39). Both endotracheal intubation and use of supraglottic airways were similarly associated with decreased odds of neurologically favorable survival. Among adult patients with OHCA, any type of advanced airway management was independently associated with decreased odds of neurologically favorable survival compared with conventional bag-valve-mask ventilation.

EMS-physicians' self reported airway management training and expertise; a descriptive study from the Central Region of Denmark

BackgroundPrehospital advanced airway management, including prehospital endotracheal intubation is challenging and recent papers have addressed the need for proper training, skill maintenance and quality control for emergency medical service personnel. The aim of this study was to provide data regarding airway management-training and expertise from the regional physician-staffed emergency medical service (EMS).MethodsThe EMS in this part of The Central Region of Denmark is a two tiered system. The second tier comprises physician staffed Mobile Emergency Care Units. The medical directors of the programs supplied system data. A questionnaire addressing airway management experience, training and knowledge was sent to the EMS-physicians.ResultsThere are no specific guidelines, standard operating procedures or standardised program for obtaining and maintaining skills regarding prehospital advanced airway management in the schemes covered by this study. 53/67 physicians responded; 98,1% were specialists in anesthesiology, with an average of 17,6 years of experience in anesthesiology, and 7,2 years experience as EMS-physicians. 84,9% reported having attended life support course(s), 64,2% an advanced airway management course. 24,5% fulfilled the curriculum suggested for Danish EMS physicians. 47,2% had encountered a difficult or impossible PHETI, most commonly in a patient in cardiac arrest or a trauma patient. Only 20,8% of the physicians were completely familiar with what back-up devices were available for airway management.ConclusionsIn this, the first Danish study of prehospital advanced airway management, we found a high degree of experience, education and training among the EMS-physicians, but their equipment awareness was limited. Check-outs, guidelines, standard operating procedures and other quality control measures may be needed.

Field intubation of cardiac arrest patients: a dying art?

IntroductionThe most appropriate advanced airway intervention in out-of-hospital cardiac arrest (OHCA) is unproven. This study reviews prehospital advanced airway management and its complications in OHCA patients.MethodsA 4-year, observational, retrospective case...

Should EMS-Paramedics Perform Pediatric Tracheal Intubation in the Field?: Gerritse BM, Draaisma JM, Schalkwijk A, van Grunsven PM, Scheffer GJ. Resuscitation 2008;79:225–9

Pre-hospital airway management has long been controversial. This prospective observational study from the Netherlands compares success and survival rates between bag-valve mask ventilation (BVMV) and tracheal intubation (TI) performed by Emergency Medical Services (EMS) paramedics. The population was limited to pediatric patients (< 16 years old) with a Glasgow Coma Scale score (GCS) of 3–4. The Dutch paramedic curriculum provides a 4-h session about pediatric airway management. Patients initially seen by EMS paramedics were eventually transported by a helicopter-transported medical team (HMT) consisting of a pilot, nurse, and physician specially trained in pre-hospital care and advanced pediatric airway management (> 6 months in-hospital training).

A consensus-based template for uniform reporting of data from pre-hospital advanced airway management

BackgroundAdvanced airway management is a critical intervention that can harm the patient if performed poorly. The available literature on this subject is rich, but it is difficult to interpret due to a huge variability and poor definitions. Several initiatives from large organisations concerned with airway management have recently propagated the need for guidelines and standards in pre-hospital airway management. Following the path of other initiatives to establish templates for uniform data reporting, like the many Utstein-style templates, we initiated and carried out a structured consensus process with international experts to establish a set of core data points to be documented and reported in cases of advanced pre-hospital airway management.MethodsA four-step modified nominal group technique process was employed.ResultsThe inclusion criterion for the template was defined as any patient for whom the insertion of an advanced airway device or ventilation was attempted. The data points were divided into three groups based on their relationship to the intervention, including system-, patient-, and post-intervention variables, and the expert group agreed on a total of 23 core data points. Additionally, the group defined 19 optional variables for which a consensus could not be achieved or the data were considered as valuable but not essential.ConclusionWe successfully developed an Utstein-style template for documenting and reporting pre-hospital airway management. The core dataset for this template should be included in future studies on pre-hospital airway management to produce comparable data across systems and patient populations and will be implemented in systems that are influenced by the expert panel.

Prehospital airway management: the patient needs oxygen!

Clinical commentary on Sollid SJM et al., Pre-hospital advanced airway management by anaesthesiologists - still room for improvement?