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The Process of Prehospital Airway Management: Challenges and Solutions During Paramedic Endotracheal Intubation*

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The Process of Prehospital Airway Management: Challenges and Solutions During Paramedic Endotracheal Intubation* The Process of Prehospital Airway Management: Challenges and Solutions During Paramedic Endotracheal Intubation* Matthew E. Prekker, MD, MPH1,2; Heemun Kwok, MD, MS1,3; Jenny Shin, MPH4; David Carlbom, MD1,2; Andreas Grabinsky, MD5; Thomas D. Rea, MD, MPH1,4 Objectives: Endotracheal intubation success rates in the pre- Interventions: None. hospital setting are variable. Our objective was to describe the Measurements and Main Results: An intubation attempt was challenges encountered and corrective actions taken during the defined as the introduction of the laryngoscope into the patient’s process of endotracheal intubation by paramedics. mouth, and the attempt concluded when the laryngoscope was Design: Analysis of prehospital airway management using a pro- removed from the mouth. Endotracheal intubation was success- spective registry that was linked to an emergency medical ser- ful on the first attempt in 77% and ultimately successful in 99% vices administrative database. of patients (7,433 of 7,523). Paramedics used a rapid sequence Setting: Emergency medical services system serving King County, intubation strategy on 54% of first attempts. Among the subset Washington, 2006–2011. Paramedics in this system have the with a failed first attempt (n = 1,715), bodily fluids obstructing the capability to administer neuromuscular blocking agents to facili- laryngeal view (50%), obesity (28%), patient positioning (17%), tate intubation (i.e., rapid sequence intubation). and facial or spinal trauma (6%) were identified as challenges to Patients: A total of 7,523 patients more than 12 years old in whom intubation. A variety of adjustments were made to achieve intu- paramedics attempted prehospital endotracheal intubation. bation 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 *See also p. 1543. rapid sequence intubation (6%). Surgical cricothyrotomy (0.4%, 1 Department of Medicine, University of Washington School of Medicine, n = 27) and bag-valve-mask ventilation (0.8%, n = 60) were rarely Seattle, WA. performed by paramedics as final rescue airway strategies. 2Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, Seattle, WA. Conclusions: Airway management in the prehospital setting has 3Division of Emergency Medicine, University of Washington School of substantial challenges. Success can require a collection of adjust- Medicine, Seattle, WA. ments that involve equipment, personnel, and medication often in 4Emergency Medical Services Division, Public Health–Seattle and King a simultaneous fashion. (Crit Care Med 2014; 42:1372–1378) County, Seattle, WA. Key Words: airway management; intubation; paramedics; 5Department of Anesthesiology, University of Washington School of Medi- cine, Seattle, WA. prehospital emergency care; registries Supplemental digital content is available for this article. Direct URL cita- tions appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ ccmjournal). ndotracheal intubation is performed to optimally oxygen- Dr. Prekker received support for article research from the National Insti- ate, ventilate, and protect critically ill patients from aspira- tutes of Health (NIH). His institution received grant support from NIH T32 Institutional Training Grant: Pulmonary and Critical Care Medicine Division Etion. Its use in the prehospital setting has been questioned at the University of Washington (salary support for his work as a senior due to concerns regarding both safety and efficacy (1–6), and research fellow). Dr. Rea’s institution received grant support from the some advocate abandoning this procedure in favor of alternative Laerdal Foundation (general grant to improve community-based programs directed toward emergency prehospital care) and Life Sciences Discovery methods of invasive or noninvasive respiratory support (7, 8). In Fund (grant supporting innovative use of technology to improve prehospi- the context of this ongoing controversy, endotracheal intubation tal care for emergency conditions). The remaining authors have disclosed that they do not have any potential conflicts of interest. remains an established practice worldwide in many emergency For information regarding this article, E-mail: [email protected] medical services (EMS) systems. These systems have committed Copyright © 2014 by the Society of Critical Care Medicine and Lippincott to training ground-based paramedics (9), flight nurses (10), or Williams & Wilkins prehospital physicians (11–13) to perform endotracheal intuba- DOI: 10.1097/CCM.0000000000000213 tion in austere environments and face the inherent challenges of 1372 www.ccmjournal.org June 2014 • Volume 42 • Number 6 Clinical Investigations acquisition and retention of airway decision making and techni- training is included in the supplemental data (Supplemental cal skills. Therefore, improvement in intubation proficiency is Digital Content 1, http://links.lww.com/CCM/A849). As part an important and shared goal. of regional certification requirements, paramedics must suc- There is wide variability in the overall rate of intubation cessfully intubate at least 12 times annually or return to the success across EMS systems (14–16), and while this metric is a operating suite to obtain the necessary count of intubations. commonly used measure of intubation proficiency, it does not provide insight into specific challenges or potential opportuni- Measurements ties for improvement. The quality of care provided by an EMS Data from paramedic encounters involving invasive airway system may be considered a function of three components: management have been prospectively collected in a registry structure, process, and outcome (17). This conceptual frame- since 2006. Following an attempt at endotracheal intubation, work has been used to enact improvements in hospital-based regardless of outcome, the paramedic operator completes an critical care, including emergency endotracheal intubation by online form in order to fulfill requirements for continuous critical care trainees (18, 19). Application of this quality-of-care practice improvement. This form captures patient and encoun- model has the potential to improve prehospital advanced air- ter characteristics detailing the process of airway management. way management, but studies that detail the process of prehos- Operators report the best glottic view obtained during direct pital intubation in a quantitative manner are lacking. laryngoscopy as one of four grades, where a grade 1 view is Our primary objective is to describe the process of pre- optimal (full visualization of the vocal cords) and a grade 4 hospital advanced airway management. In doing so, we high- view indicates no visualization of the epiglottis (22). Follow- light the challenges and corresponding corrective actions that ing an unsuccessful intubation attempt, paramedics report any enable paramedic endotracheal intubation. The goal is to pro- specific challenges encountered during the attempt and specific vide context for additional quality improvement among EMS corrective actions taken with each subsequent attempt (upper systems performing this complex procedure and ultimately airway suctioning, patient repositioning, change of operator, improve early care for critically ill patients. equipment change, rescue RSI, and use of the bougie). An intubation attempt is defined as the introduction of the METHODS laryngoscope into the patient’s mouth. The attempt concludes We evaluated advanced prehospital airway management when the laryngoscope is removed from the mouth, regardless performed by paramedics from September 2006 to Novem- of whether or not the trachea was intubated. We defined RSI as ber 2011 in a large metropolitan EMS system. We excluded an intubation attempt in conjunction with the administration encounters with children less than 12 years old. The study of a paralytic agent (succinylcholine). We defined an intubation community includes urban, suburban, and rural areas with a attempt as successful if correct endotracheal tube position was size of approximately 2,000 square miles and a population of confirmed by capnography. Additional measures used to help con- 1.3 million people. The EMS system employs a two-tier emer- firm tube placement included visualization of the tube between the gency response: firefighter-emergency medical technicians vocal cords and the presence of bilateral breath sounds plus chest provide basic life support, and paramedics, working in teams rise. We confirmed successful endotracheal intubation in 200 ran- of two, provide advanced life support including advanced air- domly selected patients through review of hospital records. way management. The EMS system has approximately 150 paramedics who serve this population of 1.3 million persons. Data Analysis Paramedics are permitted to intubate patients in cardiac arrest The airway registry data were linked to administrative EMS prior to physician consultation, with or without the use of para- data using a composite of variables including the EMS incident lytic agents. For patients not in arrest, paramedics consult with a number, age, gender, date, time, survival to hospital admission, physician providing online medical direction prior to attempt- and receiving hospital. This linkage enabled the calculation of ing endotracheal intubation. Rapid sequence intubation (RSI)
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