Introduction to EMS Airway Management

THE CLINICAL CHALLENGE

The prehospital setting presents unique challenges to all patient care, not the least of which is airway management. The patient’s disease process is often undifferentiated, resources and equipment may be more limited than in the hospital setting, and there may be issues of patient access, lighting, adverse weather, confined space, turbulence or road vibration, and safety of the provider among others. When these factors are taken in aggregate, it is unreasonable to expect that out-of-hospital airway management will look identical to in-hospital airway management. Furthermore, airway management will not look the same in any two emergency medical services (EMS) systems owing to differences in provider levels of training, scope of practice, medical direction, treatment guidelines, transport times, equipment, and availability of backup, including air medical transport.

Despite these challenges, the core concepts of emergency airway management are the same in the prehospital and hospital environments: maintaining oxygenation and ventilation while mitigating complications. The airway algorithms are fundamentally equivalent; however, as we will discuss in the following chapters, accommodations need to be made when specific equipment or skills are not available. If oxygenation cannot be maintained via bag-mask ventilation (BMV) and the patient cannot be intubated, it does not matter whether it is because rapid sequence intubation (RSI) is not within the scope of practice or because RSI was attempted and unsuccessful; the airway has failed, and urgent placement of an extraglottic device (EGD) or cricothyrotomy is indicated regardless of the environment.

The prehospital setting is often unforgiving and may even be considered “error prone.” These risks may be offset by careful planning, continuing education, use of algorithms and checklists, quality oversight, and strong medical director involvement. System administrators, medical directors, educators, and providers must all be committed to rigorous evaluation of the care delivered, patient outcomes, and the latest literature and how it applies to that system’s practice.

APPROACH TO THE AIRWAY

EMS airway management must focus on rapid assessment and simultaneous interventions. The goals are optimization of oxygenation and ventilation with minimization of complications such as aspiration, while facilitating extrication and transport, and performing any other critical treatments that may be indicated. In general, the least-invasive and time-consuming interventions that achieve the stated goals are preferable. Given the inherent limitations of the prehospital environment, the goals are not necessarily to achieve definitive airway management. For example:

• A 55-year-old presents for an exacerbation of left-sided congestive heart failure with pulmonary edema, resulting in respiratory distress and hypoxemia to 75%. The primary issue is oxygenation. If supplemental oxygen delivery in a position of comfort does not rapidly correct the problem, then administration of sublingual nitroglycerin and titration of continuous positive airway pressure (CPAP) along with initiation of transport are appropriate in most EMS systems. Administration of diuretics, nitroglycerin infusions, and intubation, if necessary, may usually be deferred to the hospital unless transport times are prolonged.

• A 14-year-old female thrown from a horse initially presents with a Glasgow Coma Scale (GCS) of 13, and a flight crew is dispatched. While transporting the patient, her mental status deteriorates with a noted rise in blood pressure and drop in respirations. Because of the confined space of the aircraft, the flight crew elects to perform a Rapid Sequence Airway (RSA) procedure with placement of an EGD rather than RSI. The patient receives analgesia, the ventilator is placed and titrated to maintain normal ETCO₂, a gastric tube is inserted and attached to suction, and oxygen is titrated down until the saturation just falls below 100%. On arrival to the ED, the patient is taken directly to the CT scanner, an epidural hematoma is detected, and the EGD is exchanged for an endotracheal tube using a flexible endoscope while awaiting arrival of the neurosurgeon. The best possible outcome for the patient has been ensured without definitive airway management in the field.

• A 27-year-old male with multisystem blunt trauma presents with GCS of 11, a systolic blood pressure of 90, and a saturation of 85%. The first actions are to maintain spinal motion restriction, roll the patient to clear the airway, apply supplemental oxygen, assess for tension pneumothorax, and start an IV for fluid administration, all while moving towards the hospital. As long as the provider addresses hypotension and hypoxemia, avoids hyperventilation, and makes reasonable attempts to prevent aspiration (or further aspiration), the goals have been met even though the airway has not been secured. If the provider has time, the airway is not predicted to be anatomically difficult outside of cervical precautions, and medication-facilitated airway management (MFAM) is available, then it should be considered. However, as discussed later, the evidence of benefit is limited while the potential for harm is real if the patient is allowed to become hypoxemic, hypotensive, hypocarbic, or hyperoxic.

In each of these cases, the providers focused on the most efficient means of establishing oxygenation and ventilation, and minimizing complications, not on any particular procedure. Invasive airway management, including MFAM, has a role in prehospital care as long as it is done carefully and judiciously with close supervision and medical oversight. It is our belief that care for each patient should be individualized based on the presenting clinical condition and anticipated clinical course, transport time, predicted difficulties, and the provider’s experience and scope of practice. It is critical to keep in mind that many studies and reviews have failed to demonstrate improved patient outcome from prehospital endotracheal intubation, and several have demonstrated worse outcomes (see Evidence section).

The indications for prehospital intubation are the same as for hospital-based care, with appropriate consideration of resource constraints, transport mode and time, and the option to provide less-invasive, temporizing care while transporting to the hospital. The Universal and Main Emergency Airway Algorithms are applicable for prehospital providers recognizing that those providers not performing MFAM will primarily function in the Crash and Failed Airway Algorithms. In addition, the primary question for EMS providers is not whether the patient “needs intubation” but whether they need any form of invasive airway management before arrival at the hospital. The application of the Difficult and Failed Airway Algorithms to prehospital care is discussed in Chapter 30.

LEVELS OF TRAINING AND SCOPE OF AIRWAY PRACTICE

Generally speaking, the different levels of training and scope of practice for prehospital providers in the United States are defined by the National Highway Traffic Safety Administration (NHTSA) in both their National EMS Scope of Practice Model (February 2007) and National Emergency Medical Services Education Standards (January 2009) documents. These provide the scope of practice and individual psychomotor skills for each level of prehospital provider. Both the scope of practice document and the education standards outline the individual credential levels as follows:

• Emergency Medical Responder (EMR)

• Emergency Medical Technician (EMT)

• Advanced Emergency Medical Technician (AEMT)

• Paramedic

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