The process of prehospital airway management: challenges and solutions during paramedic endotracheal intubation

Abstract

Objectives: Endotracheal intubation success rates in the prehospital setting are variable. Our objective was to describe the challenges encountered and corrective actions taken during the process of endotracheal intubation by paramedics.

Design: Analysis of prehospital airway management using a prospective registry that was linked to an emergency medical services administrative database.

Setting: Emergency medical services system serving King County, Washington, 2006-2011. Paramedics in this system have the capability to administer neuromuscular blocking agents to facilitate intubation (i.e., rapid sequence intubation).

Patients: A total of 7,523 patients more than 12 years old in whom paramedics attempted prehospital endotracheal intubation.

Interventions: None.

Measurements and main results: An intubation attempt was defined as the introduction of the laryngoscope into the patient's mouth, and the attempt concluded when the laryngoscope was removed from the mouth. Endotracheal intubation was successful on the first attempt in 77% and ultimately successful in 99% of patients (7,433 of 7,523). Paramedics used a rapid sequence intubation strategy on 54% of first attempts. Among the subset with a failed first attempt (n = 1,715), bodily fluids obstructing the laryngeal view (50%), obesity (28%), patient positioning (17%), and facial or spinal trauma (6%) were identified as challenges to intubation. A variety of adjustments were made to achieve intubation success, including upper airway suctioning (used in 43% of attempts resulting in success), patient repositioning (38%), rescue bougie use (19%), operator change (16%), and rescue rapid sequence intubation (6%). Surgical cricothyrotomy (0.4%, n = 27) and bag-valve-mask ventilation (0.8%, n = 60) were rarely performed by paramedics as final rescue airway strategies.

Conclusions: Airway management in the prehospital setting has substantial challenges. Success can require a collection of adjustments that involve equipment, personnel, and medication often in a simultaneous fashion.

Conflict of interest statement

Conflicts of interest: No authors have conflicts of interest to report.

Figures

Figure 1

Flowchart detailing the process of paramedic airway management in 7,523 prehospital encounters. ‘Rescue RSI’ refers to the use of a rapid sequence intubation strategy (i.e. neuromuscular blockade) to rescue a failed intubation attempt, in cases where RSI had not been used during previous attempts. *In this single case, a patient with distorted anatomy due to head & neck cancer suffered a witnessed, out-of-hospital cardiac arrest (full code status). Paramedics performed a surgical cricothyrotomy without attempts at endotracheal intubation.

Figure 2

Mosaic plot of first attempt intubation success for prehospital patients grouped by paramedic-assigned diagnostic category. The height of the dark bars represents the proportion of patients intubated on the first attempt; the width of each bar on the x-axis is proportional to the frequency of that diagnosis in the cohort.