Prehospital Tracheal Intubation Research Articles

Pharmacologically assisted laryngeal mask insertion: a consensus statement

Management of the pre-hospital airway can be challenging.1 A range of techniques and adjuncts are available to the pre-hospital clinician to aid in their efforts to maximise oxygenation and support ventilation. When measures fail, management is escalated through a series of increasingly complex and invasive procedures (‘the airway management ladder’) with the aim of establishing a definitive airway secured with an endotracheal tube or other surgical airway. In the non-arrested patient the gold standard for definitive pre-hospital airway management is pre-hospital rapid sequence induction and tracheal intubation (RSI) delivered by a competent clinical team. There may, however, be circumstances in which a pre-hospital RSI cannot be delivered, whether due to lack of clinical capability or lack of access to the patient. Some of these patients may benefit from advanced airway management, with the aim of promoting oxygenation, through the technique of pharmacologically assisted laryngeal mask (PALM) insertion. This technique involves sedating the trauma patient and inserting a supraglottic airway device (SAD) with the aim of improving their oxygenation and providing a degree of protection from ongoing airway contamination. This article reports the conclusions of a consensus meeting held in April 2012. The meeting followed a full literature search which was presented to the meeting, to which there was an open invitation to all relevant stakeholders. The meeting examined the PALM technique and its indications and outlined the competencies required of practitioners performing the procedure. Representatives from across the pre-hospital community and emergency care who contributed to the meeting are listed in box 1. A draft document was produced reflecting the conclusions from the meeting; this document was then reviewed by the attendees prior to a final review by the key colleges, faculties and other organisations within pre-hospital care. The Royal College of Anaesthetists, although represented at the initial …

The relationship between head injury severity and hemodynamic response to tracheal intubation

The acutely injured brain is sensitive to fluctuations in blood pressure. During tracheal intubation, airway stimulation provokes acute surges in blood pressure that have the potential to cause further harm in patients with intracranial pathology. Although reduced consciousness is thought to suppress airway reflexes, its influence on these hemodynamic reflexes is unknown.We aimed to investigate the relationship between head injury severity and hemodynamic response to laryngoscopy and intubation. This retrospective observational study included 97 consecutive patients with head injuries who underwent prehospital tracheal intubation by a physician-led helicopter emergency medical service. The primary outcome was the acute hemodynamic response to the procedure. Secondary outcomes included the incidence of serious intracranial pathology and mortality. A hypertensive response to laryngoscopy and tracheal intubation occurred in 80% of patients. In 11% of patients, blood pressure increased by ≥100%. The hemodynamic response was attenuated with increasing head injury severity but unpredictably and not to clinically acceptable levels. The incidence of serious intracranial bleeding (61%) and raised intracranial pressure (22%) was high in patients with head injuries, requiring tracheal intubation. A clinically significant hemodynamic response to laryngoscopy and intubation is common in patients with head injuries and is not effectively attenuated by increasing head injury severity. The need to attenuate the hemodynamic response should be assessed independently of head injury severity. Therapeutic study, level III.

Outcomes in Seriously Head-Injured Patients Undergoing Pre-Hospital Tracheal Intubation vs. Emergency Department Tracheal Intubation

Background: The optimal treatment of major head injuries in the resuscitative phase of care post-injury has yet to be determined. This study measured the effect on mortality of pre-hospital intubation (PHI) vs. emergency department in tubation (EDI) of patients suffering serious head injury. Methods: In the single emergency medical services system for this Canadian province, we used a population-based trauma database, conventional logistic regression (with and without the use of a propensity score to control for selection effect bias) to evaluate the effect of PHI vs. EDI on in-hospital mortality. Inclusion criteria were age ≥ 16 years, serious head injury (Abbreviated Injury Score ≥ 3, non-penetrating trauma) and resuscitative intubation (PHI or EDI). Results: Over 5 years, 283 patients (2000-2005) met inclusion crite ria. Conventional unconditional logistic regression modelled on mortality with “PHI vs. EDI” as the intervention of interest showed an odds ratio of 2.015 (95% CI 1.062 3.825) for improved survival if these patients were intubated in the emergency department rather than in the pre-hospital phase of care. A propensity score adjustment demonstrated a similar but more conservative point estimate (OR 1.727, 95% CI: 0.993 3.004). Conclusions: This observational study demonstrated a survival advantage with EDI (versus PHI) in seriously head-injured patients in a mature, province-wide emergency medical services system.

Incidence of transient hypoxia during pre‐hospital rapid sequence intubation by anaesthesiologists

Pre-hospital tracheal intubation (TI) is an important but difficult procedure with the potential to produce hypoxaemia. The aim of this study was to determine the incidence of desaturation episodes during out-of-hospital rapid sequence induction (RSI) and TI by the medical team of a German Helicopter Emergency Medical Service (HEMS). We performed a prospective study at HEMS 'CHRISTOPH 22'. TI was performed as RSI according to a standard protocol. Desaturation was defined as a reduction in SpO(2) below 90% or a reduction of more than 10% from baseline SpO(2) when initial values were less than 90%. The RSI/TI manoeuvre was attempted in 150 patients [107 male (71.3%); median age 40 years (IQR 21-61); overall success rate 100%]. The incidence of desaturation episodes was 13.3% with a median duration of 50 sec. (IQR 30-92) and a median SpO(2) decrease of 24 ± 10%. Upon hospital admission, all patients had SpO(2) values ≥ 96%. In the desaturation group the duration of successful TI was significantly longer [median 85 sec. (IQR 60-119) vs. median 63 sec. (IQR 48-70); P < 0.01], and the number of patients with a baseline SpO(2) ≥ 90% was significantly lower (65.0% vs. 88.5%; P < 0.01). Among patients with difficult to manage airway, those with desaturation were significantly younger, and technical problems were significantly more frequent. The incidence of episodes of desaturation during pre-hospital RSI/TI at HEMS Ulm is relatively low, and the duration of such episodes is short.

Patient safety in pre-hospital emergency tracheal intubation: a comprehensive meta-analysis of the intubation success rates of EMS providers

IntroductionPre-hospital airway management is a controversial subject, but there is general agreement that a small number of seriously ill or injured patients require urgent emergency tracheal intubation (ETI) and ventilation. Many European emergency medical services (EMS) systems provide physicians to care for these patients while other systems rely on paramedics (or, rarely, nurses). The ETI success rate is an important measure of provider and EMS system success and a marker of patient safety.MethodsWe conducted a systematic search of Medline and EMBASE to identify all of the published original English-language articles reporting pre-hospital ETI in adult patients. We selected all of the studies that reported ETI success rates and extracted information on the number of attempted and successful ETIs, type of provider, level of ETI training and the availability of drugs on scene. We calculated the overall success rate using meta-analysis and assessed the relationships between the ETI success rate and type of provider and between the ETI success rate and the types of drugs available on the scene.ResultsFrom 1,070 studies initially retrieved, we identified 58 original studies meeting the selection criteria. Sixty-four per cent of the non-physician-manned services and 54% of the physician-manned services reported ETI success rates but the success rate reporting was incomplete in three studies from non-physician-manned services. Median success rate was 0.905 (0.491, 1.000). In a weighted linear regression analysis, physicians as providers were significantly associated with increased success rates, 0.092 (P = 0.0345). In the non-physician group, the use of drug-assisted intubation significantly increased the success rates. All physicians had access to traditional rapid sequence induction (RSI) and, comparing these to non-physicians using muscle paralytics or a traditional RSI, there still was a significant difference in success rate in favour of physicians, 0.991 and 0.955, respectively (P = 0.047).ConclusionsThis comprehensive meta-analysis suggests that physicians have significantly fewer pre-hospital ETI failures overall than non-physicians. This finding, which remains true when the non-physicians administer muscle paralytics or RSI, raises significant patient safety issues. In the absence of pre-hospital physicians, conducting basic or advanced airway techniques other than ETI should be strongly considered.

Chapter 3. Indications for intracranial pressure monitoring

Chapter 3. Indications for intracranial pressure monitoring

The Association Between Obesity and Difficult Prehospital Tracheal Intubation

Holmberg, Timothy J.*; Bowman, Stephen M.†; Warner, Keir J.‡; Vavilala, Monica S.*; Bulger, Eileen M.‡; Copass, Michae K.§; Sharar, Sam R.* Author Information

Morbid Obesity Is Associated with Difficult Prehospital Tracheal Intubation

Obesity is associated with difficult tracheal intubation in patients undergoing elective anesthesia. To determine whether this association exists also

Telemedicine and Telepresence for Prehospital and Remote Hospital Tracheal Intubation Using a GlideScope™ Videolaryngoscope: A Model for Tele-Intubation

The inability to secure a patient's airway in the prehospital setting is a major cause of potentially preventable death in the field of trauma and emergency medicine. The University of Arizona in Tucson has established two telepresence programs, the Southern Arizona Teletrauma and Telepresence Program and Tucson Emergency Room (ER)-Link for assisting with trauma and emergency medicine patients in remote hospitals and prehospital system. Most recently, we have added videolaryngoscopes to our telepresence programs to assist with patients whose airway is difficult to manage. We describe the first reported case of using a videolaryngoscope (GlideScope™) and a telemedicine network to assist a healthcare provider performing tracheal intubation in a remote hospital. Videolaryngoscopes allows for assistance with remote tracheal intubation and should be strongly considered as a component of teletrauma and telepresence programs to assist with difficult airway management.

The Association Between Obesity and Difficult Prehospital Tracheal Intubation

Nonphysician advanced life support (ALS) providers often perform tracheal intubation (TI) for cardiac arrest or other life-threatening indications in the prehospital setting, where airway assessment and airway management tools are limited. However, the frequency of difficult TI in obese patients in this setting is unclear. In this study we determined factors associated with TI success, and determined TI difficulty as a function of body mass index (BMI) in a system of ALS providers experienced in TI, to guide future prehospital education efforts. A retrospective review was performed of all patients ≥15 years of age who underwent prehospital TI by paramedics in the Seattle Medic One system over a 4-year period, and were transported to the regional level 1 trauma center (Harborview Medical Center). Data were abstracted from a prospectively collected prehospital airway management database and from the hospital medical records, including demographic information, number of TI attempts, TI success or failure, and body weight/height (BMI). Descriptive statistics and multivariable logistic regression were calculated, with the primary end point being difficult TI (defined as ≥4 TI attempts or the need to use an alternative airway management technique). Of 80,501 patient contacts in whom 4114 TIs were attempted during the 4-year study period, 823 met study entry criteria (including a calculable BMI). The overall TI success rate in the study population was 98.5% (811 out of 823), with 6.8% (56 out of 823) meeting the predetermined definition for difficult TI. There was no significant association between difficult TI and patient age, gender, use of succinylcholine, or medical diagnosis (trauma vs. nontrauma). In comparison with the lean patient subgroup (BMI <30 kg/m(2)), patients with class III obesity (BMI >40 kg/m(2)) had a significant association with difficult TI (odds ratio 3.68; confidence interval [CI] 1.27-10.59), whereas those with class I/II obesity (BMI ≥30 kg/m(2) and <40 kg/m(2)) did not (odds ratio 0.98; CI 0.46 -2.07). Among prehospital ALS providers with previously documented and published successful TI performance, increased difficulty with TI was observed in patients with extreme obesity, but not in patients with lesser degrees of obesity. Because extreme obesity is an easily identifiable patient characteristic, didactic and clinical (e.g., operating room) airway management education for such providers should emphasize airway management challenges and strategies associated with obesity, including specific equipment, patient positioning, and practice recommendations that may facilitate both TI and alternative airway management techniques in this population.

Revisiting the value of pre-hospital tracheal intubation: an all time systematic literature review extracting the Utstein airway core variables

IntroductionAlthough tracheal intubation (TI) in the pre-hospital setting is regularly carried out by emergency medical service (EMS) providers throughout the world, its value is widely debated. Heterogeneity in procedures, providers, patients, systems and stated outcomes, and inconsistency in data reporting make scientific reports difficult to interpret and compare, and the majority are of limited quality. To hunt down what is really known about the value of pre-hospital TI, we determined the rate of reported Utstein airway variables (28 core variables and 12 fixed-system variables) found in current scientific publications on pre-hospital TI.MethodsWe performed an all time systematic search according to the PRISMA guidelines of Medline and EMBASE to identify original research pertaining to pre-hospital TI in adult patients.ResultsFrom 1,076 identified records, 73 original papers were selected. Information was extracted according to an Utstein template for data reporting from in-the-field advanced airway management. Fifty-nine studies were from North American EMS systems. Of these, 46 (78%) described services in which non-physicians conducted TI. In 12 of the 13 non-North American EMS systems, physicians performed the pre-hospital TI. Overall, two were randomised controlled trials (RCTs), and 65 were observational studies. None of the studies presented the complete set of recommended Utstein airway variables. The median number of core variables reported was 10 (max 21, min 2, IQR 8-12), and the median number of fixed system variables was 5 (max 11, min 0, IQR 4-8). Among the most frequently reported variables were "patient category" and "service mission type", reported in 86% and 71% of the studies, respectively. Among the least-reported variables were "co-morbidity" and "type of available ventilator", both reported in 2% and 1% of the studies, respectively.ConclusionsCore data required for proper interpretation of results were frequently not recorded and reported in studies investigating TI in adults. This makes it difficult to compare scientific reports, assess their validity, and extrapolate to other EMS systems. Pre-hospital TI is a complex intervention, and terminology and study design must be improved to substantiate future evidence based clinical practice.

Failed Prehospital Tracheal Intubation

Failed Prehospital Tracheal Intubation

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...

If You’ve Seen One EMS System, You’ve Seen One EMS System…

If You’ve Seen One EMS System, You’ve Seen One EMS System…

Characteristics and outcome of prehospital paediatric tracheal intubation attended by anaesthesia-trained emergency physicians

Aim To collect data regarding prehospital paediatric tracheal intubation by emergency physicians skilled in advanced airway management. Methods A prospective 8-year observational study of a single emergency physician-staffed emergency medical service. Self-reporting by emergency physicians of all children aged 0–14 years who had prehospital tracheal intubation and were attended by either anaesthesia-trained emergency physicians (group 1) or by a mixture of anaesthesia and non-anaesthesia-trained emergency physicians (group 2). Results Eighty-two out of 2040 children (4.0%) had prehospital tracheal intubation (58 in group 1). The most common diagnoses were trauma (50%; in school children, 73.0%), convulsions (13.4%) and SIDS (12.2%; in infants, 58.8%). The overall tracheal intubation success rate was 57 out of 58 attempts (98.3%). Compared to older children, infants had a higher number of Cormack–Lehane scores of 3 or 4, “difficult to intubate” status (both 3 out of 13; 23.1%) and a lower first attempt success rate for tracheal intubation ( p = 0.04). Among all 82 children 71 (86.6%) survived to hospital admission and 63 (76.8%) to discharge. Of the 63 survivors, 54 (85.7%) demonstrated a favourable or unchanged neurological outcome (PCPC 1–3). The survival and neurological outcomes of infants were inferior compared to older children ( p < 0.001). On average an emergency physician performed one prehospital tracheal intubation in 3 years in a child and one in 13 years in an infant. Conclusions Anaesthesia-trained emergency physicians working in our system report high success rates for prehospital tracheal intubation in children. Survival and neurological outcomes were considerably better than reported in previous studies.

Pre-hospital tracheal intubation in patients with traumatic brain injury: systematic review of current evidence

We reviewed the current evidence on the benefit and harm of pre-hospital tracheal intubation and mechanical ventilation after traumatic brain injury (TBI). We conducted a systematic literature search up to December 2007 without language restriction to identify interventional and observational studies comparing pre-hospital intubation with other airway management (e.g. bag-valve-mask or oxygen administration) in patients with TBI. Information on study design, population, interventions, and outcomes was abstracted by two investigators and cross-checked by two others. Seventeen studies were included with data for 15,335 patients collected from 1985 to 2004. There were 12 retrospective analyses of trauma registries or hospital databases, three cohort studies, one case-control study, and one controlled trial. Using Brain Trauma Foundation classification of evidence, there were 14 class 3 studies, three class 2 studies, and no class 1 study. Six studies were of adults, five of children, and three of both; age groups were unclear in three studies. Maximum follow-up was up to 6 months or hospital discharge. In 13 studies, the unadjusted odds ratios (ORs) for an effect of pre-hospital intubation on in-hospital mortality ranged from 0.17 (favouring control interventions) to 2.43 (favouring pre-hospital intubation); adjusted ORs ranged from 0.24 to 1.42. Estimates for functional outcomes after TBI were equivocal. Three studies indicated higher risk of pneumonia associated with pre-hospital (when compared with in-hospital) intubation. Overall, the available evidence did not support any benefit from pre-hospital intubation and mechanical ventilation after TBI. Additional arguments need to be taken into account, including medical and procedural aspects.

Trauma: we care. More for discussion

I read with interest the recent letter by Zafar et al. [1] and felt that some of the issues raised required clarification. Firstly, there seems to be some confusion in the letter between transfer/retrieval medicine and pre-hospital medicine. Transfer and retrieval in civilian practice in the United Kingdom is concerned with delivery of patients between hospitals, i.e. patients who have already been admitted to a medical care facility. Pre-hospital medicine may include this role, but more commonly refers to ‘the provision of skilled healthcare at the site of a trauma incident or medical emergency’ [2]. Secondly, the authors also make reference to pre-hospital tracheal intubation, implying that paramedics intubate trauma patients. Paramedics in the United Kingdom currently do intubate patients, but only those who do not require pharmacological agents to assist intubation. This group of patients, in the context of trauma, have a near 100% mortality rate [3]. Rapid sequence induction of anaesthesia is only performed currently by pre-hospital doctors. This seems unlikely to change in light of a Joint Royal Colleges Ambulance Liaison Committee report of June 2008, which states ‘paramedic tracheal intubation cannot be recommended as a mandatory component of paramedic practice and should not be continued to be practiced in its current format’ [4]. The authors seem to suggest a retrieval system based on the military model, presumably referring to Medical Emergency Response Teams, currently operating in Afghanistan. A typical Medical Emergency Response Team setup will include a consultant or senior trainee anaesthetist. As the authors rightly state, medical treatment is started en route to base, in the back of the helicopter. Cramped as it may be, a CH-47 helicopter is still a great deal larger than the majority of civilian air ambulances. There are also restrictions on when civilian air ambulances may fly without an instrument rating; some may not carry passengers after dusk. Most are not based at the site of tertiary referral or trauma centres, necessitating a crew waiting at the airfield and removed from other clinical work. In particular, I find the suggestion regarding a Physician’s Assistant being utilised in retrieval particularly worrying. The Royal College of Anaesthetists explicitly states that Physician’s Assistants must not undertake initial airway assessment and management of acutely ill or injured patients and cannot work without a named consultant being both within the theatre suite and being immediately available [5]. The authors summarise by calling for raised standards for transfer training, which appears to be a perfectly reasonable aim. There are already many in the pre-hospital community who are working tirelessly towards raising standards in the field of pre-hospital care. It is important however that we don’t lose sight of the issues surrounding each speciality by confusing transfer/retrieval medicine with pre-hospital care.

The gum elastic bougie: One of anaesthesia's best-kept secrets

Recent guidelines for paramedic intubation have been published by the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) (2008). One important recommendation for paramedic intubation is that: ‘When prehospital tracheal intubation is undertaken, a gum elastic bougie should be available routinely’. Despite this, the bougie has not been universally available among ambulance services in the UK—up to a third do not include the bougie as part of their airway management strategy. We aim to introduce the bougie, provide information on its use, advantages and pitfalls, and provide some tips as to how to get the most out of this invaluable device in clinical practice.

Pre‐hospital airway management – time to provide the same standard of care as in the hospital

PRE-HOSPITAL care has used Utstein guidelines for years to document results in cardiac arrest and trauma care. One of the latest Utstein meetings dealt with the formula of survival (Fig. 1). If there is good medical science, great educational efficiency, and the local organization implements it all in an effective way, then the formula will be 1 1 151. This is rarely true. There can be good medical evidence, but usually we are not able to implement it in our daily practice. The formula in real life could be 0.9 0.2 0.25 0.04. Therefore, it is time to focus on education and the local organization. There is considerable research about tracheal intubation, also in the pre-hospital setting. We know that insufficient breathing and obstructed airways are bad. We also know that securing the airway by tracheal intubation in that situation is good. However, is it good or bad to intubate in the pre-hospital environment? Tracheal intubation improves survival in major blunt trauma (1), but it does not seem to be better than bag-valve-mask ventilation (2). If you look more closely at these articles, you can see that using proper medication to facilitate intubation performed by highly trained professionals improved survival (1), but survival was not improved when intubation was performed without medication by less trained persons (2). This is usually what the results are about. Not the tracheal intubation itself, but how it is performed. Besides, when have you last seen an article asking whether tracheal intubation inside a hospital is good or bad? Pre-hospital tracheal intubation is not an intervention performed daily by every unit in any emergency medical system. Tracheal intubation is used only when it is really needed, and that is fairly seldom. In Finland, in the busiest of systems, the individual paramedic intubates once or twice a year or less. You can hardly think that anyone can maintain skills and competence in tracheal intubation in this way. Some time ago, I read that 60 intubations are needed to reach a good level on the training curve. I am sure it did not mean that those 60 intubations are performed during 30–60 years. Intubating a manikin gives you good practice, but it can never fully mimic the real situations. The prehospital environment is very different from the inhospital one. It can be very cold, dark, and wet. The patient can be entrapped and in anything but a supine position. This can be a major challenge even for a very skilled and competent physician working constantly with the airways. Nowadays, anaesthesia does not necessarily comprise general anaesthesia with tracheal intubation. This means that it can be hard to offer the pre-hospital personnel the possibility to train in the operating room. In addition, elective surgical patients in the operating room environment are very different from those in the pre-hospital setting. We know that an open airway and adequate ventilation is beneficial. The next question should be, which method should we use to give the best possible care? The golden standard is still tracheal intubation, but there are also many supraglottic devices available. If we believe that tracheal Survival x x Medical Science Educational Effiency Local Organization =

Prehospital airway management: A prospective evaluation of anaesthesia trained emergency physicians

To determine the characteristics of prehospital tracheal intubation and the incidence of difficult-to-manage airways in out-of-hospital patients managed by emergency medicine physicians with anaesthesia training. In a prospective study, conducted over a 4-year period, we evaluated all airway interventions performed by anaesthesia-trained emergency physicians. One thousand, one hundred and six out of 16,559 patients (6.8%) required tracheal intubation. Orotracheal intubation was attempted in 982, laryngoscopic aided nasotracheal intubation in 64 and blind nasotracheal intubation in 90 of the cases. Two techniques were used in 30 patients. Failure rates were 2.4, 8.1 and 25.6%, respectively. A Combitube or LMA was used in 2.0%. In one case of failed Combitube insertion successful needle cricothyrotomy was performed. In patients undergoing direct laryngoscopy, Cormack-Lehane laryngeal grade views I-IV were seen in 52.0, 28.8, 12.6 and 6.6% of cases, respectively. A difficult to manage airway (DMA) was reported in 14.8%, multiple intubation attempts in 4.3% and failed intubation in 2.0% of all cases. Grouping patients based on clinical presentation revealed a significantly higher incidence of DMA in trauma patients (18.6%) and during cardiopulmonary resuscitation (16.7%) than in the remaining patient group (9.8%). Intubation failed significantly more often in trauma (3.9%) than in the remaining patient group (1.1%). When compared to studies on laryngoscopy performed in the operating room, this study demonstrated a higher incidence of difficult and failed laryngoscopy, DAM, and high laryngeal grade views when patients were managed in a prehospital setting by anaesthesia trained physicians.