On a stormy night in the countryside, a 72-year-old male driver falls asleep at the wheel and strays into oncoming traffic. A transport truck trying to avoid him strikes his small car. The car is crushed with the driver trapped inside. Emergency medical services (EMS) are activated. Basic life support (BLS) medics and firefighters 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.
14.2.1 What Level of Airway Management Can We Expect from Prehospital Care Providers?
"A" is the cornerstone in the ABCs, which form the foundation of BLS training for all prehospital care providers. The type of training and skill sets vary significantly from country to country and the provider mix varies from one jurisdiction to the next in any 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 one:
- 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.
- 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 and endotracheal intubation with or without the use of facilitating drugs, such as sedative-hypnotics and neuromuscular blocking agents.
- Critical care providers (eg, typically air medical transport or critical care transport team members)—are permitted to perform rapid sequence intubation (RSI) using a laryngoscope and, usually, other advanced airway techniques such as cricothyrotomy. In some jurisdictions (most notably Europe and Australia), physicians are often members of these teams.
14.2.2 How Are Airway Management Protocols and Equipment Determined in Prehospital Care Systems?
In most North American systems, prehospital care providers perform delegated medical acts based on standardized medical protocols. In many European systems, physicians may be the usual prehospital care providers and, therefore, are less likely to be 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.
Protocols approved by the medical director of the EMS system determine the equipment necessary in prehospital care practice. The type and range of equipment available for managing the difficult airway in the prehospital setting are typically limited when compared to emergency department (ED) and operating room settings. Even the availability of basic equipment such as the endotracheal tube introducer (ETI; eg, the intubating stylet or the Eschmann tracheal introducer, also know as the gum-elastic bougie),1 laryngoscope blades, and endotracheal tubes (ETT) in an ...