Background
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▪ Impending or actual hypoxia
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▪ Impending or actual acute hypercapnia
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▪ Threatened or actual loss of airway control
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▪ Severe agitation associated with head injury
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▪ Reduced level of consciousness
Training
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▪ Physicians entering pre-hospital practice should have a minimum of 12 months experience of in-hospital anaesthetic practice and a minimum of 12 months experience in emergency medicine and acute medicine, before undertaking PHEA.
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▪ Pre-hospital emergency care services should have a written standard operating procedure (SOP) for the conduct of PHEA. All relevant personnel must be fully conversant with this document.
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▪ Pre-hospital emergency care services should provide appropriate training and competency assessment for all providers on an annual basis.
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▪ All providers of PHEA should be competent in paediatric advanced airway management.
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▪ The provider performing advanced airway management should be assisted by another member of the HEMS team with appropriate training for the safe delivery of PHEA, at all times.
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▪ PHEA should be withheld if the HEMS team do not have the correct skillmix required to ensure safe and effective delivery of the procedure.
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▪ Consultants in pre-hospital emergency medicine should be available for telephone advice at all times.
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▪ All practitioners delivering PHEA should maintain a logbook of individual cases.
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◦ Further considerations:
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▪ A relevant PHEA course or thorough induction training should be undertaken prior to starting clinical practice.
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EHAC MWG statement
Planning
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▪ Environmental factors such as ambient light, noise and adverse weather conditions should be considered when deciding where and when to intubate the patient.
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▪ Factors that may influence intubation success should be optimised prior to the first intubation attempt. These include good access to the patient (360-degree access where possible), and optimal positioning of the patient on an ambulance trolley placed at the correct height for the operator.
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▪ Intubation should be performed prior to loading onto the aircraft unless adverse weather conditions prevent safe conduct. Intubation should only be performed in the aircraft provided there is no increased risk of an adverse event during the intubation procedure.
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▪ Intubation must not be planned for, or performed in, the flight phase of aeromedical transfers.
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▪ The triage decision and distance to destination hospital should be considered prior to intubation and discussed with the HEMS team.
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Further considerations:
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▪ Aviation regulations must be observed at all times.
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EHAC MWG statement
Equipment
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▪ Nasopharyngeal and oropharyngeal airways
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▪ Two working laryngoscope handles with two different sized Macintosh blades
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▪ Intubating bougie
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▪ Cuffed tracheal tubes in appropriate sizes
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▪ Spare tracheal tube (one size smaller)
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▪ 10 or 20 ml syringe for cuff inflation (cuff checked prior to intubation)
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▪ Tube tie or tube holder
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▪ Bag-valve-mask with oxygen reservoir connected to oxygen
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▪ Carbon dioxide monitoring (colorimetric and / or quantitative)
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▪ Spare oxygen cylinder
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▪ Suction
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▪ Second generation supraglottic airway device (for failed intubation)
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▪ Surgical airway equipment (e.g. scalpel / tracheal dilators / 6.0 tracheal tube / tube tie)
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▪ Paediatric laryngoscopes with appropriately sized laryngoscope blades (size 1 and 2 Macintosh blades, and size 0 and 1 Miller blades are recommended)
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▪ Uncuffed and cuffed tracheal tubes in appropriate size range for paediatric intubation
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Further considerations:
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▪ Videolaryngoscopy
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EHAC MWG statement
Conduct of the RSI
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▪ PHEA should be performed using methods described in the standard operating procedure (SOP) for each individual service. Compliance with, or reasons for deviation from, the SOP should be formally documented.
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▪ A formal checklist for PHEA should be carried out and include confirmation of monitoring, equipment, drugs, and failed intubation management.
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▪ All required equipment should be assembled and checked prior to intubation.
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▪ Drug doses should be calculated prior to intubation and confirmed with the anaesthetic assistant.
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▪ Preoxygenation should be performed for at least 3 min before laryngoscopy.
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▪ Each service should have, and be familiar with, a robust failed intubation plan.
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Further considerations:
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▪ Apnoeic oxygenation.
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EHAC MWG statement
Post RSI care and ventilation
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▪ Effective ventilation should be established and confirmed immediately following placement of the tracheal tube. Where available, a mechanical ventilator should be used in preference to hand ventilation, especially for longer transfers.
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▪ The presence of an end-tidal carbon dioxide trace should be confirmed immediately after tube placement.
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▪ The rate of ventilation should be titrated to end-tidal carbon dioxide.
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▪ The position of tracheal tube should be confirmed and documented.
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▪ The patient should be reassessed after each intervention or change of position, and before loading onto aircraft.
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▪ The HEMS crew member(s) should have access to the patient during flight
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▪ Intubation equipment and airway rescue equipment should be immediately available during flight.
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▪ Normoxia and normocapnia should be achieved for each patient. Low to normocapnia should be considered for patients with traumatic brain injury (4.0–4.5 kPa; 30–35 mmHg).
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▪ Ensure the patient is appropriately packaged with consideration given to clot stabilisation if bleeding, fracture immobilisation and maintenance of normothermia.
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▪ Anaesthesia should be adequately maintained.
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▪ The requirement for chest decompression should be considered.
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Further considerations:
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▪ Use of arterial blood gas monitoring.
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EHAC MWG statement
Monitoring
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▪ Pulse oximetry.
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▪ Noninvasive blood pressure.
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▪ Heart rate.
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▪ Continuous waveform and quantitative capnography.
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▪ Continuous temperature monitoring.
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▪ Lactate
EHAC MWG statement
Special circumstances
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▪ Night operations
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▪ Adverse weather or environmental conditions
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▪ Psychiatric patients
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▪ Pregnant patients
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▪ Children
Key performance indicators
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Highest level of EMS provider on scene
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Airway equipment available
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Anaesthetic agents available
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Method of transportation
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Response time
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Provision of adequate governance structure
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Age
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Gender
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Co morbidity
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Patient category
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Indication for airway intervention
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Vital signs pre induction of anaesthesia (Heart rate, respiratory rate, GCS, systolic blood pressure, oxygen saturation)
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Post intervention ventilation
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Vital signs post induction of anaesthesia (End tidal carbon dioxide, heart rate, systolic blood pressure, oxygen saturation)
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Survival status
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Number of attempts at airway intervention
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Complications (hypoxia, hypotension, arrhythmias / bradycardia, aspiration, misplaced tracheal tube, oesophageal intubation (recognised / unrecognised), cardiac arrest)
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Drugs used to facilitate procedure
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Overall intubation success rate
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Devices used in successful airway management
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Intubation success rate at first attempt
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Management of failed intubation