Systematic Review of Prehospital Airway Management

[NomadicMedic]

I got this email this morning... thought I'd share. Seeing the beating RI Cardiacs are taking, it seemed apropos.

​

​ Public Input Requested as NHTSA and AHRQ Kick Off Systematic Review of Prehospital Airway Management

​ Key questions will drive the review of published research and help shape an evidence-based guideline for prehospital airway management​

​ The Agency for Healthcare Research and Quality (AHRQ), in partnership with the NHTSA Office of EMS, has released draft questions that will guide a subsequent review related to prehospital airway management. This is the first step in the process of examining the scientific literature regarding prehospital airway management and then developing an evidence-based guideline (EBG). Find more information and provide feedback on the key questions here. The public comment period on these key questions is open until December 20, 2019. Prehospital airway management is critical to patient survival. The purpose of this systematic review and EBG development is to establish a uniform and standardized approach to airway management in the prehospital setting when administering artificial ventilation through the use of bag valve mask or through advanced airway techniques. Evidence-based guidelines are a key component of the vision of a people-centered EMS system described in EMS Agenda 2050. To find out more about EBGs, visit the new EBG page on ems.gov and check out the recent EMS Focus webinar on the naloxone EBG and the future of evidence-based guidelines.

 

[Tigger]

I wonder if this will generate the same level of fervor that the NAEMSO call for public input regarding paramedic scope of practice did. A change.org petition to save intubation! Angry blog posts! But as one astute blogger pointed out, PEEP was also on the chopping block. Guess how long the petition was to save PEEP was...

 

[RocketMedic]

So I’m going to go with something unpopular to consider: how many intubation systems (both prehospital, in the ED, OR) are there, and why do we in EMS/ED make excuses for a lack of quality?

 

[Phillyrube]

A good medic can quickly evaluate a patient and determine whether he can be intubated quickly. Many codes I ran were resuscitated to Rosc and subsequently discharged after BLS airway in the field. I look back and wonder how many patients we killed trying to get a tube.
One anecdote is a friend of mine, former Chief of my department who coded at home. Wife is an Emt and started CPR. I was working the PD side as precinct sergeant and responded. Officer arrived on scene and applied AED, wife ventilated. One shock. Engine company arrived and started ALS. Airway by NP and BVM. Guy is like a mallinpotti 6, and there were problems intubating for surgery in the padt. BLS transport and ALS zone car arrived. First thing the medic wanted to do was intubate. N O! Engine captain said it was his scene, I was ranking medic on scene. ED 4 minutes away. 2 rounds of episode and two shocks, got a rhythm. Transport successful, the usual problems intubating but that was done, and Bill came home a week later with a new pacemaker.
Most anesthesiology students perform 100 tubes in the ED, how many do medic students get? King and Glidescopes are great and a welcome change, but things break.
40 years in the business, intubations should be reserved for a cadre of medics who routinely practice in a clinical setting, like CC or flight medics. More emphasis on supraglottic devices.
Ok, let me put my beskar on and stand by for heavy rolls.

 

[SandpitMedic]

Interesting takes here.
We shall see how this plays out.

 

[Carlos Danger]

I hate to be Negative Nelly.....but don’t waste your time.

In EMS, the only research anyone cares about is that which can be interpreted to support the practices that folks want to keep (or put) in place. Any research findings that conflict with current or desired practice will simply be ignored.

This is especially true about anything that concerns airway management.

 

[FiremanMike]

I hate to be Negative Nelly.....but don’t waste your time.

In EMS, the only research anyone cares about is that which can be interpreted to support the practices that folks want to keep (or put) in place. Any research findings that conflict with current or desired practice will simply be ignored.

This is especially true about anything that concerns airway management.

Wouldn't you say that's true of medicine in general? Hell, society in general?

 

[Peak]

Wouldn't you say that's true of medicine in general? Hell, society in general?

While I think there is some truth for this everywhere in society, among health care workers EMS is especially true.

 

[NomadicMedic]

Intubation is the one skill that is inexolerably tied to paramedic prowess. I'd be happy to see it go.

 

[Tigger]

I know I sound like a broken record regarding AUS/NZ EMS, but again...providers with three year educational programs with waaay more clinical time and US paramedics do not intubate. Why do we think we are better?

I think I'm pretty good with the McGrath. I get to the OR twice a year. We have "good" airway mannequins. I think I have a pretty good idea of who is appropriate to intubate. And yet, that's hardly what can be called a "standard" and I can't imagine how many paramedics get one, maybe two attempts a year and that's it.

 

[VentMonkey]

I think that removal of ETI from the standard paramedic formulary will remain a pipe dream given the reasons stated above.

 

[RocketMedic]

Intubation is the one skill that is inexolerably tied to paramedic prowess. I'd be happy to see it go.

...until it’s needed. Taking away intubation is like taking guns away from police. Sounds solid and amazing and prevents so many tragedies, right until reality happens and you really need a gun.

Proper training and system design can safely field ETI.

 

[Bullets]

It all comes down to attempt and this should be used to support that. If medics arent getting 30 attempts a year, then they probably shouldnt be intubating.

 

[VentMonkey]

If medics arent getting 30 attempts a year, then they probably shouldnt be intubating.

Curious where you got this number from. Is it arbitrary, or is there hard evidence to support this?

I’d say each of the flight paramedics at my base averages somewhere in the teens/ year. I’m not saying that this is a magic number to remain proficient.

That said induction meds in general, along with requisite knowledge of them and the procedure assume—at least to some degree—more proficiency with the laryngoscopists at hand.*

So are we talking all paramedics? Ground paramedics with/ without RSI? Just throwing some factors in there for discussions-sake.

*Pun not intended, but well taken.

 

[KingCountyMedic]

Our yearly requirement is 12 tubes a year. Harborview, UW Medical, and Seattle Children's Hospital Anesthesiologists oversee our airway training and the golden number they came up with was a minimum of 12 a year to remain proficient. Most of the providers in the south end get far more on average. Many folks in the nicer parts of King County see less, they go to the OR every year if they are under 12.

Airway management by Paramedics will always be debated and argued over. The number one problem in the USA is a combination of $$$ and too many Paramedics. The vast majority of patients are BLS and only need BLS transport. Private ambulance suffers from greed and puts IV's in everyone to jack up the billing. The fire department (Union) suffers from greed and wants everyone to be a paramedic to jack up union dues and also to put IV's in everyone and jack up the billing.

I think if you are going to intubate you should have RSI, ETCO2, and all the candy in your kit that goes with it, you should do it often enough that you are good at it and you should have every back up there is from SGA to surgical, video, and a paramedic partner that can take a shot if you miss. (so dual medic units) If you can't do that then you should trade in all your gear for iGels and diesel.

 

[NomadicMedic]

Sussex was the same. If you didn’t get 12 per year, you want to the OR.
The initial number for baseline competency is north of 40, if I recall correctly. There is a lot of research on determining competency.

We have medics who get 2 or 3 a year here and think they are the cat’s azz. I’ve been here in PA for 2 years and performed 3 human intubations in that time. Unlike many of my contemporaries, I KNOW I’ve been lucky and there is no way 3 times makes me competent.

IGels. That’s what we need to place. IGels.

 

[Bullets]

Curious where you got this number from. Is it arbitrary, or is there hard evidence to support this?

I’d say each of the flight paramedics at my base averages somewhere in the teens/ year. I’m not saying that this is a magic number to remain proficient.

That said induction meds in general, along with requisite knowledge of them and the procedure assume—at least to some degree—more proficiency with the laryngoscopists at hand.*

So are we talking all paramedics? Ground paramedics with/ without RSI? Just throwing some factors in there for discussions-sake.

*Pun not intended, but well taken.

Sort of, my service has a 95% 1st pass success rate and our medics average 20 live tubes per year so i thought that was a decent ballpark. We are an dual medic, intercept agency with RSI, VL and surgical crics, we do an annual RSI class as well as 2 yearly competencies that include a surgical cric station and 2 intubation scenarios. Our agency also runs the Difficult Airway class annually and pays for staff to go to it.

I do believe there is a baseline level of training that is obtainable to keep everyone proficient and I do recall there being an actual number in some study done a while back. In an all ALS or a FD ALS service where every apparatus has a medic that may not be obtainable, but in a tiered system like i work in or a place that has APPs its very possible.

 

[DrParasite]

The vast majority of patients are BLS and only need BLS transport.

say it a little louder for the people in the back who aren't listening and insist that every patient deserves a paramedic....

40 years in the business, intubations should be reserved for a cadre of medics who routinely practice in a clinical setting, like CC or flight medics.

I've never been a flight or CC medic, but I have to ask: how often do they actually intubate? I could imagine CC medics receive patients who are already intubated, while flight medics receive sick patients who were intubated by field personnel prior to their arrival.

So how many live intubations do they actually perform in a shift? in a month? in a year?

 

[akflightmedic]

One of the many reasons I enjoyed working in Florida...easily 3 tubes a month. Most times more. Old people everywhere, croaking left and right with tons of trauma sprinkled in.

 

[FiremanMike]

I realize that it is a wildly unpopular view, but I have never felt that the psychomotor skill of intubation to be that difficult, especially since the advent of field video laryngoscopy end tidal capnography.

I will agree that airway management as a package is somewhat more complicated and deserves probably a bit more standardized education than it is currently given.