A prospective multicenter evaluation of prehospital airway management performance in a large metropolitan region

Prehospital Pediatric Respiratory Distress and Airway Management Interventions: An NAEMSP Position Statement and Resource Document

Devices and techniques such as bag-valve-mask ventilation, endotracheal intubation, supraglottic airway devices, and noninvasive ventilation offer important tools for airway management in critically ill EMS patients. Over the past decade the tools, technology, and strategies used to assess and manage pediatric respiratory and airway emergencies have evolved, and evidence regarding their use continues to grow.NAEMSP recommends:Methods and tools used to properly size pediatric equipment for ages ranging from newborns to adolescents should be available to all EMS clinicians. All pediatric equipment should be routinely checked and clearly identifiable in EMS equipment supply bags and vehicles.EMS agencies should train and equip their clinicians with age-appropriate pulse oximetry and capnography equipment to aid in the assessment and management of pediatric respiratory distress and airway emergencies.EMS agencies should emphasize noninvasive positive pressure ventilation and effective bag-valve-mask ventilation strategies in children.Supraglottic airways can be used as primary or secondary airway management interventions for pediatric respiratory failure and cardiac arrest in the EMS setting.Pediatric endotracheal intubation has unclear benefit in the EMS setting. Advanced approaches to pediatric ETI including drug-assisted airway management, apneic oxygenation, and use of direct and video laryngoscopy require further research to more clearly define their risks and benefits prior to widespread implementation.If considering the use of pediatric endotracheal intubation, the EMS medical director must ensure the program provides pediatric-specific initial training and ongoing competency and quality management activities to ensure that EMS clinicians attain and maintain mastery of the intervention.Paramedic use of direct laryngoscopy paired with Magill forceps to facilitate foreign body removal in the pediatric patient should be maintained even when pediatric endotracheal intubation is not approved as a local clinical intervention.

Quality Management of Prehospital Pediatric Respiratory Distress and Airway Programs: An NAEMSP Position Statement and Resource Document

The unique challenges of pediatric respiratory and airway emergencies require the development and maintenance of a prehospital quality management program that includes pediatric-focused medical oversight and clinical care expertise, data collection, operational considerations, focused education, and clinician competency evaluation.NAEMSP recommends:Medical director oversight must include a focus on pediatric airway and respiratory management and integrate pediatric-specific elements in guideline development, competency assessment, and skills maintenance efforts.EMS agencies are encouraged to collaborate with medical professionals who have expertise in pediatric emergency care to provide support for quality management initiatives in pediatric respiratory distress and airway management.EMS agencies should define quality indicators for pediatric-specific elements in respiratory distress and airway management and benchmark performance based on regional and national standards.EMS agencies should implement both quantitative (objective) and qualitative (subjective) measures of performance to assess competency in pediatric respiratory distress and airway management.EMS agencies choosing to incorporate pediatric endotracheal intubation or supraglottic airway insertion must use pediatric-specific quality management benchmarks and perform focused review of advanced airway management.

Procedural Sedation Intubation in a Paramedic-Staffed Helicopter Emergency Medical System in Northern Finland

OBJECTIVE

Airway management to ensure sufficient gas exchange is of major importance in emergency care. Prehospital endotracheal intubation (ETI) by paramedics is a widely debated method to ensure a patent airway. ETI is performed with procedural sedation in comatose patients because of the regulation. The use of medications increases the rate of successful airway management compared with nonmedication ETI and may also improve outcomes in patients with traumatic brain injury. In the absence of an operative emergency physician and with long distances, paramedic-induced airway management may increase the survival of patients in selected scenarios. A paramedic-staffed helicopter emergency medical system in Northern Finland operates in a rural area without an emergency physician and paralytic medications and treats critically ill patients using basic or advanced life support ground units. The aim of this study was to evaluate the success rates of ETI performed by a small, appropriately trained, and experienced group of 8 nurse paramedics in an out-of-hospital setting.

METHODS

The inclusion criterion for the study was an attempted intubation in patients with medical or traumatic indication for airway management by nurse paramedic.

RESULTS

Fifty-one patients were treated with ETI. The first-pass success rate was 72.5%, the second-pass success rate was 94.1%, and the overall success rate was 100% within 4 attempts. The median on-scene time was 54 minutes, and there were no signs of aspiration during laryngoscopy or after successful ETI. The primary mortality rate was 11.7%.

CONCLUSION

The use of a rigid standard operating procedure for paramedic rapid sequence induction, paralytics, a video laryngoscope, and a gum elastic bougie might positively affect the ETI first-pass success rate. A follow-up study after these future modifications is needed. This small study suggests that intubation might be 1 option for airway management by an experienced nonanesthesiologist in Lapland.

Video laryngoscopy for out of hospital cardiac arrest

INTRODUCTION

Endotracheal intubation is an import component of out-of-hospital cardiac arrest (OHCA) resuscitation. In this analysis, we evaluate the association of video laryngoscopy (VL) with first pass success and return of spontaneous circulation (ROSC) using a national OHCA cohort.

METHODS

We analyzed 2018 data from ESO Inc. (Austin, TX), a national prehospital electronic health record. We included all adult, non-traumatic cardiac arrests undergoing endotracheal intubation. We defined VL and direct laryngoscopy (DL) based on paramedic recorded intubation device. The primary outcomes were first pass success, ROSC, and sustained ROSC. Using multivariable, mixed models, we determined the association between VL and first pass success rate, ROSC, and sustained ROSC (survival to ED or ROSC in the field for greater than 20 min), fitting agency as a random intercept and adjusting for confounders.

RESULTS

We included 22,132 patients cared for by 914 EMS agencies, including 5702 (25.7%) VL and 16,430 (74.2%) DL. Compared to DL, VL had a lower rate of bystander CPR, but other characteristics were similar between the groups. VL exhibited higher first pass success than DL (75.1% v 69.5%, p < .001). On mixed model analysis, VL was associated with a higher first pass success (OR 1.5, CI 1.3-1.6) but not ROSC (OR 1.1, CI 0.97-1.2) or sustained ROSC (OR 1.1, CI 0.9-1.2).

CONCLUSION

While associated with higher FPS, VL was not associated with increased rate of ROSC. The role of VL in OHCA remains unclear.

Meta-Analysis of Failure of Prehospital Endotracheal Intubation in Pediatric Patients

Prehospital care is essential for airway preservation in pediatric patients who require early endotracheal intubation to improve oxygenation and prevent aspiration. However, high frequencies of failure of endotracheal intubation have been reported for this age group. We aimed to analyze the frequency of failure of endotracheal intubation in pediatric patients within a prehospital context and compare it with adult patients. Thus, a systematic revision of literature with a meta-analysis was performed using a study search and selection strategy ensuring extensiveness, sensitivity, and reproducibility. Meta-analyses were performed for odds ratio, DerSimonian and Laird's Q test was used to assess heterogeneity, and Egger and Begg's test was used to assess publication bias. Overall, 17 papers and 8772 patients were included, and the main cause of prehospital care was assessed to be trauma. Failed endotracheal intubation frequency was 0.4%–52.6% in pediatric patients. The most frequent complication was with esophageal intubation. Forest plot suggests that risk of failure during intubation of pediatric patients is 3.54 fold higher than that observed for adults. It was concluded that airway management in pediatric patients within a prehospital context is a challenge for prehospital care providers because it entails clear physiological and anatomical differences and a low frequency of exposure to this kind of events as opposed to adults. These differences support a widely higher risk of failure of intubation, suggesting the necessity of consistently trained prehospital care providers to ensure proficiency in technique as well as availability of the required equipment.

Radiological evaluation of tube depth and complications of prehospital endotracheal intubation in pediatric trauma: a descriptive study

PURPOSE

Pediatric prehospital endotracheal intubation (PHETI) is a difficult and rarely performed procedure that remains the gold standard for prehospital airway management when ventilation and/or anesthesia is required, but high complications rates, including malposition continue to concern. We reviewed the experience in our institution of pediatric intubations with particular emphasis on the position of the endotracheal tube (ETT) tip within the trachea and related complications.

METHOD

Intubated pediatric patients presenting directly from the scene to our level 1 trauma center, between 2006 and 2014, were included in our study. Patient records and radiographs were retrospectively reviewed to identify the ETT tip-to-carina distance and possible intubation-related complications. ETT tips identified beyond the carina on radiographs or by clinical diagnosis were defined as misplaced. Because head movement causes a significant ETT movement within the trachea, which is age related, we also defined ETT tip placement (1) less than 2 cm above the carina in children younger than 8 and (2) less than 3 cm above the carina in children 8 years or older as "near miss" intubations.

RESULTS

From a total of 34 cases, ETT misplacement was identified in seven cases. Diagnosis was made radiologically in five cases and clinically in two cases. Four of these patients had left lung atelectasis due to tube misplacement. Tube thoracotomy was performed in two of these patients without concurrent evidence of chest injury. "Near miss" intubations accounted for 7/9 and 9/25 in children <8 years and ≥8 years old, respectively, totaling 16/34, with two of these leading to late displacements.

CONCLUSIONS

Pediatric endotracheal tube intubation carries a high rate of tube malposition and left lung atelectasis in our experience of pediatric trauma patients, with less than a third of ETTs placed in a safe position.

The success of pre-hospital tracheal intubation by different pre-hospital providers: a systematic literature review and meta-analysis

BACKGROUND

Pre-hospital basic airway interventions can be ineffective at providing adequate oxygenation and ventilation in some severely ill or injured patients, and advanced airway interventions are then required. Controversy exists regarding the level of provider required to perform successful pre-hospital intubation. A previous meta-analysis reported pre-hospital intubation success rates of 0.849 for non-physicians versus 0.991 for physicians. The evidence base on the topic has expanded significantly in the last 10 years. This study systematically reviewed recent literature and presents comprehensive data on intubation success rates.

METHODS

A systematic search of MEDLINE and EMBASE was performed using PRISMA methodology to identify articles on pre-hospital tracheal intubation published between 2006 and 2016. Overall success rates were estimated using random effects meta-analysis. The relationship between intubation success rate and provider type was assessed in weighted linear regression analysis.

RESULTS

Of the 1838 identified studies, 38 met the study inclusion criteria. Intubation was performed by non-physicians in half of the studies and by physicians in the other half. The crude median (range) reported overall success rate was 0.969 (0.616-1.000). In random effects meta-analysis, the estimated overall intubation success rate was 0.953 (0.938-0.965). The crude median (range) reported intubation success rates for non-physicians were 0.917 (0.616-1.000) and, for physicians, were 0.988 (0.781-1.000) (p = 0.003).

DISCUSSION

The reported overall success rate of pre-hospital intubation has improved, yet there is still a significant difference between non-physician and physician providers. The finding that less-experienced personnel perform less well is not unexpected, but since there is considerable evidence that poorly performed intubation carries a significant risk of morbidity and mortality careful consideration should be given to the training and experience required to deliver this intervention safely.

Difficult Intubation Factors in Prehospital Rapid Sequence Intubation by an Australian Helicopter Emergency Medical Service

OBJECTIVE

Prehospital rapid sequence intubation (RSI) of critically ill trauma patients is a high-risk procedure that may be associated with an increased rate of severe complications such as failed intubation, failure of oxygenation, hypoxia, hypotension, or need for surgical airway. The objective of this study was to describe the factors associated with difficult intubation in prehospital RSI as defined by more than a single look at laryngoscopy to achieve tracheal intubation.

METHODS

This is an observational study using prospectively collected data.

RESULTS

Four hundred forty-three RSIs were performed. Paramedics were the initial laryngoscopist in 290 (65.5%). First-look laryngoscopy resulted in successful tracheal intubation (TI) in 372 (84.0%) (95% confidence interval, 80.3%-87.1%). Intubation was achieved on second look at laryngoscopy in 58 (13.1%). "First-pass" TI was achieved in 394 (88.9%). Overall, successful TI was achieved in 438 (98.9%) (95% confidence interval, 97.4%-99.5%). Complications occurred in 116 (26.2%), with desaturation the commonest in 77 (17.4%).

CONCLUSION

Factors associated with more than 1 look at laryngoscopy before TI included paramedic laryngoscopist and the presence of at least 1 of the following indicators: blood/vomitus in the airway, limited mouth opening, and limited neck movement. Trauma to face/neck, obese body habitus, C-spine precautions, cricoid pressure, midline stabilization, and intubation on the ground did not influence the level of difficulty encountered.

Pediatric Intubation by Paramedics in a Large Emergency Medical Services System: Process, Challenges, and Outcomes

STUDY OBJECTIVE

Pediatric intubation is a core paramedic skill in some emergency medical services (EMS) systems. The literature lacks a detailed examination of the challenges and subsequent adjustments made by paramedics when intubating children in the out-of-hospital setting. We undertake a descriptive evaluation of the process of out-of-hospital pediatric intubation, focusing on challenges, adjustments, and outcomes.

METHODS

We performed a retrospective analysis of EMS responses between 2006 and 2012 that involved attempted intubation of children younger than 13 years by paramedics in a large, metropolitan EMS system. We calculated the incidence rate of attempted pediatric intubation with EMS and county census data. To summarize the intubation process, we linked a detailed out-of-hospital airway registry with clinical records from EMS, hospital, or autopsy encounters for each child. The main outcome measures were procedural challenges, procedural success, complications, and patient disposition.

RESULTS

Paramedics attempted intubation in 299 cases during 6.3 years, with an incidence of 1 pediatric intubation per 2,198 EMS responses. Less than half of intubations (44%) were for patients in cardiac arrest. Two thirds of patients were intubated on the first attempt (66%), and overall success was 97%. The most prevalent challenge was body fluids obscuring the laryngeal view (33%). After a failed first intubation attempt, corrective actions taken by paramedics included changing equipment (33%), suctioning (32%), and repositioning the patient (27%). Six patients (2%) experienced peri-intubation cardiac arrest and 1 patient had an iatrogenic tracheal injury. No esophageal intubations were observed. Of patients transported to the hospital, 86% were admitted to intensive care and hospital mortality was 27%.

CONCLUSION

Pediatric intubation by paramedics was performed infrequently in this EMS system. Although overall intubation success was high, a detailed evaluation of the process of intubation revealed specific challenges and adjustments that can be anticipated by paramedics to improve first-pass success, potentially reduce complications, and ultimately improve clinical outcomes.

The Airtraq Optical Laryngoscope in helicopter emergency medical services: a pilot trial

OBJECTIVE

To determine the degree of success helicopter emergency medical services personnel have in placing an endotracheal tube using a relatively new device for endotracheal intubation (ETI) known as the Airtraq (AT) Optical Laryngoscope (King Systems Corp, Noblesville, IN), and to determine the frequency with which flight crews had to resort to other means for advanced airway management.

METHODS

This prospective, observational pilot trial evaluated the critical care flight team's ability to perform ETI using the AT as a first-line device in the prehospital setting. Flight crews were instructed to use the AT for any patient needing ETI. Teams completed a 30-minute training session followed by mannequin practice. They documented situations and outcomes: reason for ETI, success in placing the AT, reason for unsuccessful placement, end-tidal carbon dioxide concentration in expired air (ETCO2), and where patients were when they underwent intubation (field, ambulance, aircraft, hospital). Data were abstracted and analyzed using JMP software version 7.0 (SAS Institute, Inc, Cary, NC).

RESULTS

Fifty cases involving use of the AT were analyzed. Median patient age was 51.5 years (range, 15-90; interquartile range, 36-64.5). Most patients were male (n = 37 [74%]). The primary reasons for intubation were unresponsiveness and altered loss of consciousness (n = 23 [46%]), respiratory distress or apnea (n = 8 [16%]), cardiac arrest (n = 10 [20%]), and combative behavior (n = 7 [14%]). AT was successful (n = 31[62%]) in 1 to 2 attempts. The primary reason for AT failure was blood or vomit in the airway (n = 8 [42.1%]); 48.1% (n = 25) of patients required a different management mode.

CONCLUSIONS

HEMS crews had difficulty placing successful ET tubes with this device after minimal education with a single regular-sized device. Difficulty was pronounced when blood or vomit was present and obstructing the optical view. Further study is needed to evaluate the implementation time, training time required, and possible design advantages of the AT compared with those of traditional emergent airway management techniques.

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

Introduction

Pre-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.

Methods

We 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.

Results

From 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).

Conclusions

This 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.

[Implementation of the laryngeal tube for prehospital airway management: training of 1,069 emergency physicians and paramedics]

OBJECTIVE

The European Resuscitation Council recommends that only rescuers experienced and well-trained in airway management should perform endotracheal intubation. Less trained rescuers should use alternative airway devices instead. Therefore, a concept to train almost 1,100 emergency physicians (EP) and emergency medical technicians (EMT) in prehospital airway management using the disposable laryngeal tube suction (LTS-D) is presented.

METHODS

In five operational areas of emergency medicine services in Germany and Switzerland all EPs and EMTs were trained in the use of the LTS-D by means of a standardized curriculum in the years 2006 and 2007. The main focus of the training was on different insertion techniques and LTS-D use in children and infants. Subsequently, all prehospital LTS-D applications from 2008 to 2010'were prospectively recorded.

RESULTS

None of the 762 participating EMTs and less than 20% of the EPs had previous clinical experience with the LTS-D. After the theoretical (practical) part of the training, the participants self-assessed their personal familiarity in using the LTS-D with a median value of 8 (8) and a range of 2-10 (range 1-10) of 10 points (1: worst, 10: best). Within the 3-year follow-up period the LTS-D was used in 303 prehospital cases of which 296 were successfully managed with the device. During the first year the LTS-D was used as primary airway in more than half of the cases, i.e. without previous attempts of endotracheal intubation. In the following years such cases decreased to 40% without reaching statistical significance. However, the mean number of intubation attempts which failed before the LTS-D was used as a rescue device decreased significantly during the study period (2008: 2.2 ± 0.3; 2009: 1.6 ± 0.4; 2010: 1.7 ± 0.3).

CONCLUSION

A standardized training concept enabled almost 1,100 rescuers to be trained in the use of an alternative airway device and to successfully implement the LTS-D into the prehospital airway management algorithm. Because the LTS-D recently became an accepted alternative to endotracheal intubation in difficult airway scenarios, the number of intubation attempts before considering an alternative airway device is steadily decreasing.

Abnormal end-tidal carbon dioxide levels on emergency department arrival in adult and pediatric intubated patients

BACKGROUND

The utility of prehospital intubation is controversial, as uncontrolled studies in trauma patients suggest adverse outcomes with prehospital intubation, perhaps secondary to inappropriate ventilation once intubation is accomplished.

OBJECTIVES

The objectives were 1) to establish, immediately upon arrival to the emergency department (ED), the prevalence of abnormal end-tidal carbon dioxide (ETCO(2)) levels in patients with prehospital intubation and 2) to describe the relationship between abnormal ETCO(2) levels on ED arrival and mortality.

METHODS

This was a prospective, observational cohort study of patients with prehospital intubation. Patients were excluded if they underwent prehospital cardiopulmonary resuscitation (CPR). On ED arrival, the initial ETCO(2) measurement from the patient's endotracheal tube was immediately obtained prior to purposeful intervention in the patient's ventilation by using an Oridion Surestream Sure VentLine H Set with a Welch Allyn Propaq CS monitor. For each patient, the treating physician documented the ETCO(2) measurement, patient demographics, and details of the transport. The primary outcome was an abnormal ETCO(2) value (<30 mmHg or >45 mmHg). The secondary outcome was mortality.

RESULTS

One hundred eligible patients were enrolled, with a median age of 30 years (interquartile range [IQR] 15, 48 years). Esophageal intubations were identified in four cases, and those cases were excluded from further analysis. Mechanisms included trauma, 74; medical, 12; and burn, 10. The median ETCO(2) value was 32 mmHg (IQR 27, 38 mmHg), range 18-80 mmHg. Forty-six of 96 (48%, 95% confidence interval [CI] 38%, 58%) patients had abnormal ETCO(2) values, including 37 (39%, 95% CI 29%, 49%) with low ETCO(2) levels and nine (9%, 95% CI 4%, 17%) with high ETCO(2) levels. Death was higher in those trauma patients with abnormal ETCO(2) levels (10/33, 30%, 95% CI 16%, 49%) than in those with normal ETCO(2) levels (2/41, 5%, 95% CI 0.6%, 17%), relative risk = 6.2 (95% CI 1.5, 26.4), p = 0.004.

CONCLUSION

Nearly half of all patients transported by prehospital providers had abnormal ETCO(2) measurements on initial ED presentation, suggesting an area for potential improvement. Trauma patients with abnormal initial ETCO(2) levels were more likely to die.

A randomized controlled trial of capnography in the correction of simulated endotracheal tube dislodgement

OBJECTIVES

Unrecognized dislodgement of an endotracheal tube (ETT) during the transport of an intubated patient can have life-threatening consequences. Standard methods to monitor these patients, such as pulse oximetry and physical examination, are both subject to inaccuracies with patient movement and ambient noise. Capnography provides a continuous and objective measure of ventilation that can alert a provider immediately to an airway problem. The objective of this study was to determine through simulation if capnography decreases time to correction of dislodged ETTs during the transport of intubated patients, in comparison to standard monitoring.

METHODS

Paramedics and paramedic students were randomized as to whether or not they had capnography available to them in addition to standard monitoring during a simulated scenario. In the scenario, subjects monitored an intubated baby who subsequently experiences a dislodgement of the ETT during interfacility transport. Time to correction of the ETT dislodgement was the primary outcome. The secondary outcome was correction of dislodgement prior to decline in pulse oximetry.

RESULTS

Fifty-three subjects were enrolled in the study, with complete data on 50 subjects. Median time to correction of ETT dislodgement was 2.02 minutes (95% confidence interval [CI] = 1.22 to 4.12 minutes) for the capnography group versus 4.00 minutes (95% CI = 3.35 to 5.50 minutes) in the standard monitoring group (p = 0.05). Forty-eight percent of subjects using capnography corrected the ETT dislodgement prior to decline in pulse oximetry compared with 12% of controls (p = 0.01). There were no differences in time to correction of dislodgement based on years of experience, perceived comfort, reported adequacy of teaching, or past use of capnography.

CONCLUSIONS

The addition of capnography to standard monitoring significantly improves recognition of ETT dislodgement and reduces the time to correction of dislodged ETTs by prehospital providers in a simulated pediatric transport setting.

Airway management in the air medical setting

BACKGROUND

Airway management is a key component of air medical care for seriously ill and injured patients. This meta-analysis of the prehospital airway management literature explored the pooled air-medical placement success rates for oral endotracheal intubation (OETI), including rapid sequence intubation (RSI) and drug-facilitated intubation (DFI), nasotracheal intubation (NTI), blind insertion airway devices (BIAD), and surgical cricothyrotomy (SCRIC).

METHODS

We performed a systematic literature search for all English language articles reporting success rates for airway procedures performed in the prehospital setting. After identifying articles specific to the air-medical environment, pooled estimates of success rates for each airway technique were calculated using a random effects meta-analysis model.

RESULTS

Thirty-six unique studies, encompassing 4,574 procedures, reported airway management success rates in the air medical environment. The pooled estimates (95% CI) for intervention success across all clinicians and patients were: OETI (without RSI/DFI): 86.4% (81.2%-90.3%); DFI: 95.1% (84.1%-98.6%); RSI: 96.7% (94.8%-97.9%); NTI: 76.1% (71.9%-79.9%); BIAD: 94.0% (85.8%-97.6%); and SCRIC: 90.8% (80.6%-95.9%).

CONCLUSION

We provide pooled estimates for airway management procedural success rates in the air medical setting. These data can be used by program managers and medical directors in determining the most appropriate airway management procedures to incorporate into their services and for benchmarking in quality improvement activities.

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

Background

Prehospital 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).

Methods

The 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.

Results

There 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.

Conclusions

In 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.

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

Introduction

Although 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.

Methods

We 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.

Results

From 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.

Conclusions

Core 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.

Part 10: Pediatric basic and advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

Note From the Writing Group: Throughout this article, the reader will notice combinations of superscripted letters and numbers (eg, “Family Presence During ResuscitationPeds-003”). These callouts are hyperlinked to evidence-based worksheets, which were used in the development of this article. An appendix of worksheets, applicable to this article, is located at the end of the text. The worksheets are available in PDF format and are open access.

Airway management success and hypoxemia rates in air and ground critical care transport: a prospective multicenter study

OBJECTIVE

To assess critical care transport (CCT) crews' endotracheal intubation (ETI) attempts, success rates, and peri-ETI oxygenation.

METHODS

Participants were adult and pediatric patients undergoing attempted advanced airway management during the period from July 2007 to December 2008 by crews from 11 CCT programs varying in geography, crew configuration, and casemix; all crews had access to neuromuscular-blocking agents. Data collected included airway management variables defined per national consensus criteria. Descriptive analysis focused on ETI success rates (reported with exact binomial 95% confidence intervals [CIs]) and occurrence of new hypoxemia (oxygen saturation [SpO(2)] dropping below 90% during or after ETI); to assess categorical variables, Fisher's exact test, Pearson chi(2), and logistic regression were employed to explore associations between predictor variables and ETI failure or new hypoxemia. For all tests, p < 0.05 defined significance.

RESULTS

There were 603 total attempts at airway management, with successful oral or nasal ETI in 582 cases, or 96.5% (95% CI 94.7-97.8%). In 182 cases (30.2%, 95% CI 26.5-34.0%), there were failed ETI attempts prior to CCT crew arrival; CCT crew ETI success on these patients (96.2%, 95% CI 92.2-98.4%) was just as high as in the patients in whom there was no pre-CCT ETI attempt (p = 0.81). New hypoxemia occurred in only six cases (1.6% of the 365 cases with ongoing SpO(2) monitoring; 95% CI 0.6-3.5%); the only predictor of new hypoxemia was pre-ETI hypotension (p < 0.001). A requirement for multiple ETI attempts by CCT crews was not associated with new hypoxemia (Fisher's exact p = 0.13).

CONCLUSIONS

CCT crews' ETI success rates were very high, and even when ETI required multiple attempts, airway management was rarely associated with SpO(2) derangement. CCT crews' ETI success rates were equally high in the subset of patients in whom ground emergency medical services (EMS) ETI failed prior to arrival of transport crews.