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CASE PRESENTATION

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On a stormy night in the countryside, a 72-year-old male driver falls asleep at the wheel and strays into on-coming traffic. A transport truck trying to avoid him strikes his small car. The car is crushed and the driver is trapped inside. Emergency Medical Services (EMS) are activated. Basic life support (BLS) medics and fire fighters arrive on scene within 10 minutes. The patient is conscious with a Glasgow Coma Score of 13, BP 80/40 mm Hg, HR 100 bpm, RR 26 breaths per minute, and O2 saturations of 82% prior to oxygen therapy.

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UNIQUE PRE-HOSPITAL ISSUES

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What Level of Airway Management Can We Expect From Pre-Hospital Care Providers?

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“A” is the cornerstone in the ABCs, which form the foundation of BLS training for all pre-hospital care providers. The type of training and skill sets varies significantly from country to country and the provider mix may be different from one jurisdiction to another within a country. For clarity, we will define four discrete levels of airway management provided in an EMS system. Each level assumes proficiency in the skills of the previous:

  • First aid providers or “First Responders”—trained to apply supplemental O2 by face mask and perform artificial ventilation, typically bag-mask-ventilation (BMV), although in some jurisdictions extraglottic devices (EGDs) may be preferred at this level as first-line devices in place of BMV. Airway adjuncts at this level may include oral- and naso-pharyngeal airways.

  • BLS providers—more experienced with BMV, and these providers use EGDs, particularly Combitube™, King LT™, and Laryngeal Mask Airways (LMA) in some systems.

  • Advanced life support (ALS) providers—typically perform laryngoscopy (direct or indirect) and endotracheal intubation, with or without the use of facilitating drugs, such as sedative-hypnotics and neuromuscular blocking agents. Emergency cricothyrotomy training is often included at this level.

  • Critical care providers (e.g., typically Air Medical Transport or Critical Care Transport team members)—are permitted to perform rapid sequence intubation (RSI) using direct laryngoscope and usually other advanced airway techniques such as indirect laryngoscopy (e.g., video-laryngoscopy) and cricothyrotomy. In some jurisdictions (most notably Europe and Australia), teams include other health care professionals, including registered nurses and physicians, as members of these multidisciplinary teams.

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How Are Airway Management Protocols and Equipment Determined in Pre-Hospital Care Systems?

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In most North American systems, pre-hospital care providers perform delegated medical acts based on standardized medical protocols. In many European systems, physicians may be the usual pre-hospital care providers and, therefore, are less likely dependent on protocols. While protocols ought to reflect best clinical evidence, from a practical perspective they are often limited by cost, training, competency maintenance, and space constraints. Over the past several years, there has been a movement in some jurisdictions away from protocols, and more toward treatment guidelines, allowing advanced pre-hospital care providers to exercise clinical judgment when managing airways. These guidelines allow for more flexibility to achieve predefined physiologic ...

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