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Pre-hospital airway management: guidelines from a task force from the scandinavian society for anaesthesiology and intensive care medicine

Acta Anaesthesiol Scand 2008; 52: 897–907 r 2008 The Authors Printed in Singapore. All rights reserved Journal compilation r 2008 The Acta Anaesthesiologica Scandinavica Foundation ACTA ANAESTHESIOLOGICA SCANDINAVICA Pre-hospital airway management: guidelines from a taskforce from the Scandinavian Society for Anaesthesiologyand Intensive Care Medicine ERLAC , P. K. HYLDMO , P. KONGSTAD , J. KUROLA , A. R. NAKSTAD and M. SANDBERG 1Copenhagen Mobile Intensive Care Unit, Rigshospitalet, Capital Region of Denmark, Copenhagen, Denmark, 2Division of Anaesthesia andEmergency Medicine, Sørlandet Hospital, Kristiansand, Norway, 3Department of Prehospital Care and Disaster Medicine in Region of Ska˚ne,Sweden, 4Department of Anaesthesiology and Intensive Care, Kuopio University Hospital, Kuopio, Finland, 5Department of Anaesthesiology,Ulleva˚l University Hospital, Oslo, Norway and 6The Air Ambulance Department, Ulleva˚l University Hospital, Lørenskog, Norway This article is intended as a generic guide to evidence- as paramedics and other EMS personnel, are recom- based airway management for all categories of pre-hospital mended the lateral trauma recovery position as a basic personnel. It is based on a review of relevant literature intervention combined with assisted mask-ventilation in but the majority of the studies have not been performed trauma patients. When performing advanced cardiopul- under realistic, pre-hospital conditions and the recommen- monary resuscitation, we recommend that non-anaesthe- dations are therefore based on a low level of evidence (D).
The advice given depends on the qualifications of the A supraglottic device such as the laryngeal tube or the personnel available in a given emergency medical service intubation laryngeal mask should also be available as a (EMS). Anaesthetic training and routine in anaesthesia and backup device for anaesthesiologists in failed ETI.
neuromuscular blockade is necessary for the use of mosttechniques Accepted for publication 25 February 2008 reflexes. For anaesthesiologists, the Task Force commis-sioned by the Scandinavian Society of Anaesthesia and Key words: Pre-hospital; airway management; endotra- Intensive Care Medicine recommends endotracheal intu- cheal intubation; laryngeal mask airway; laryngeal tube bation (ETI) following rapid sequence induction when airway; combitube; emergency medical systems.
securing the pre-hospital airway, although repeated un-successful intubation attempts should be avoided inde- r 2008 The Authors pendent of formal qualifications. Other physicians, as well Journal compilation r 2008 The Acta Anaesthesiologica Scandinavica Foundation EMS. Our baseline assumption is that a certainlevel of education and training is necessary for the THIS article is intended as a guide to evidence- safeuseofaspecifictechnique.Distinctionmustbe based pre-hospital airway management. The made between personnel trained and experienced available litterature on pre-hospital airway man- in providing and monitoring anaesthesia and other agement reflects vast differences in pre-hospital groups of personnel with limited or no anaesthetic emergency medicine service (EMS) organisation, skills. This distinction dictates which drugs and qualification levels, training programmes and even equipment that should be available in the pre- terminology. These differences make comparisons hospital setting.
between systems and treatment protocols difficultat best. The conduct of clinical trials in pre-hospitalairway management is hampered by the 2001/20/ Differences between regions and EC directive of the European Parliament concern- ing informed consent.
This paper describes selected equipment and Paramedic-based systems are the rule in the United techniques available for pre-hospital airway man- States, whereas physician-based pre-hospital sys- agement. Advice given differs, depending on tems are common in Europe. Ideally, the best which category of personnel is available in a given person to manage the pre-hospital airway should P. Berlac et al.
be a dedicated specialist, trained for the pre-hospi- Weaknesses of this system have been pointed out tal environment, experienced in medical emergen- and a new system for grading recommendations in cies and critical care, with daily routine in the evidence-based guidelines has been published (3).
induction of anaesthesia and advanced airway In the latter system, the level of evidence is graded management. The pre-hospital environment in from 111 (high-quality meta-analyses, systematic Scandinavia is unique, with consultants or senior reviews of randomised clinical trials or randomised trainee anaesthetists providing advanced emer- clinical trials with a very low risk of bias) via gency care as well as support for paramedics in several levels to level 4 (expert opinion). Based on the field. A review of the similarities and differ- the level of evidence, a grade of recommendation is ences between the Nordic EMS systems, as well as assigned, where A is the highest level (at least one their main problems and challenges, has pre- meta-analysis, systematic review or randomised viously been published (1). Emergency medicine clinical trial rated as 111 and directly applicable is a cornerstone of Scandinavian anaesthesiology, to the target population or a systematic review of and anaesthesiologists predominate as pre-hospital randomised clinical trials or a body of evidence emergency physicians. Advanced pre-hospital air- consisting principally of studies rated as 11 di- way management is almost exclusively performed rectly applicable to the target population and by anaesthesiologists, although in some countries demonstrating overall consistency of results) and paramedics have authorisation to intubate the D is the lowest level (extrapolated evidence rated trachea under certain conditions. Paramedic train- as 211 or 21 or evidence level 3 or 4).
ing requirements and qualifications vary between However, in many areas of medical practise, the five Nordic countries.
randomised trials may not be practical or ethical In recognition of the central role anaesthesiolo- to undertake, and for many questions other types gists play in the pre-hospital setting, the Scandina- of study design may provide the best evidence.
vian Society of Anaesthesiology and Intensive Care Pre-hospital airway management is an example of Medicine (SSAI) commissioned a Task Force to such an area. Many of the references referred to in formulate guidelines for pre-hospital airway man- this paper are actually well-performed studies on agement, specifically taking into account the pro- airway management performed in a laboratory fessional culture and level of pre-hospital expertise setting on manikins or anaesthetised patients by available in the Nordic countries. The Task Force personnel usually working pre-hospitally. The stu- aimed at providing one combined, but not too dies are well performed and the level of evidence is detailed, set of practice guidelines for pre-hospital 11 or 111 and can be used to predict for instance airway management, applicable to pre-hospital whether paramedics should use the bag-valve- health care providers at all levels. The guidelines mask (BVM) technique or use a laryngeal mask to are based on a comprehensive review of the litera- secure the airway in anaesthetised patients in the ture (ultimo 2007) supported by the Task Force's operating theatre. But can the results – and evi- clinical experience. Systematic searches in Medline, dence level – from such laboratory studies be used EMBASE and Cochrane Library were performed to develop recommendations about pre-hospital with the search terms ‘airway device', ‘airway airway management? Yes, they can for lack of management' ‘airway success rate', ‘pre-hospital better studies performed in the pre-hospital setting, airway', ‘resuscitation airway' and ‘trauma air- but subjective judgment must be applied by the way'. The resulting literature and related articles group developing the recommendations. The were manually scanned to identify relevant litera- grades of recommendations presented in this paper ture. The guidelines provide a differentiated ap- will be on D level because the evidence is extra- proach to airway management, acknowledging polated and the majority of the studies have that level of training and experience influence out- not been performed under realistic, pre-hospital come, and that ‘the right tool in the wrong hands' may be harmful to the patient. The Task Force'soverall goal is to ensure patients the same standardof care in the pre-hospital environment as in the Lateral recovery position and cervical hospital setting.
In evidence-based medicine, the hierarchy of study types described by the Agency for Health The dogma in Prehospital Trauma Life Support Care Policy and Research is widely used (2).
(PHTLS) (National Association of Emergency Pre-hospital airway management Medical Technicians, Clinton, MS) (4) and Ad- support. The major disadvantages of BVMV in- vanced Trauma Life Support (ATLS) (Committee clude increased risk of gastric inflation and of on Trauma, American College of Surgeons, Chicago, aspiration of gastric content (12). The optimal tidal IL) (5) is to always secure the patient's airways first.
and minute volume during BVMV will depend In addition, much emphasis in pre-hospital emer- upon the clinical setting. During CPR, a tidal gency care in the last decade has been put on volume of 10 ml/kg has been suggested to achieve protecting a possible or suspected spinal injury as normocapnia (13). It seems likely that high tidal reflected in the manuals of the aforementioned volumes will increase the risk of gastric inflation.
courses. Personnel not qualified in performing en-dotracheal intubation (ETI) may therefore choose to Supraglottic airway devices (SADs) transport the unconscious patient strapped in thesupine position. However, the International Liaison SADs are not inserted past the vocal cords into the Committee on Resuscitation (ILCOR) states that it is trachea and an attractive feature is that laryngo- reasonable to position an unconscious adult with scopy or direct visualisation of the cords is not normal breathing on the side (6), which is also in necessary for their insertion. These devices may be accordance with the current European Resuscitation easier to insert and suitable for users with limited Council (ERC) guidelines regarding paediatric and experience. A number of such devices have been adult patients (7–9). These two treatment modalities introduced, including the oesophago-tracheal com- can be combined if, after checking the airways and bitube (ETC), the laryngeal tube (LT) and various applying a stiff neck collar, the patient is log-rolled kinds of laryngeal masks [laryngeal mask airway with manual inline stabilisation to a position similar (LMA)]. This paper will focus on the three most to the recovery position. Caution must be taken to commonly described of these devices because they maintain normal alignment of the spine at all times, have been used quite extensively in the pre-hospital and the head is supported in a neutral position. The setting. Many other SADs are available commer- patient can be strapped to the stretcher with a cially, such as the Airway Management Device modification of the standard three-belt technique.
(AMD), Pharyngeal Airway xpress (PAx), Cobra This enables the health care provider to sit and Perilaryngeal Airway (CobraPLA), Streamlined observe at the patient's head, supporting it while Liner of the Pharynx Airway (SLIPA), iGel and administering oxygen and performing suction when the Elisha Airway Device, (14–19) and new SADs are introduced regularly. Comparably few pre-hospital studies employing these devices havebeen performed until now, and they will therefore BVM ventilation (BVMV) not be discussed further in this paper.
Primarily designed for use in conjunction with This basic skill, using a self-inflating bag and a non- elective anaesthesia, SADs have in recent years return valve attached to a mask, is the platform for received increasing interest from the pre-hospital all other airway procedures. Several studies have area. SADs have mainly been used as alternative been performed to evaluate the skill of use of this devices for airway management during resuscita- technique in various groups of health care provi- tion, but they have also been used as backup ders (8, 10, 11). This skill is mandatory for all health measures in the treatment of trauma patients care professionals and must be subjected to re- when intubation has proven difficult. The ETC peated training. Studies show, however, that was originally designed as a simpler primary alter- BVMV – even in conjunction with jaw thrust and native to ETI in emergencies, but has mainly been chin lift – is demanding and that the use of alter- employed as a backup device. The LT was intended native airways such as the laryngeal mask and the as both a primary and secondary airway device for laryngeal tube result in significantly higher tidal emergency situations, and its variants LT-D and LT- volumes than BVMV. The self-inflating bag may Sonda II with a suction channel have been used pre- provide a false sense of security, in so much as the hospitally. The LMA and its variants have become a bag always expands independent of the amount of very popular airway management device for anaes- lung (or gastric) inflation. The complexity of per- thesia [see (20) and references therein].
forming adequate BVMV may necessitate the use With the exception of the ETC, the available of adjunct devices in order to ensure sufficient ventilation in patients in need of ventilatory they are not inserted into the trachea. This makes P. Berlac et al.
inadvertent oesophageal intubation impossible.
complexity and potential for injury, makes the ETC The ETC can be blindly inserted to the trachea, unsuitable as first choice as SAD for EMS care which should be noted. Furthermore, it seems that providers in Scandinavia.
SADs have a shorter learning curve and better skillmaintenance when compared with ETI. Althoughsome of these devices require minimal practice, training is still essential for safe use. Whether The LMA is probably the most widespread and manikin training alone is sufficient has not been commonly used SAD. It has three major variants: the classic LMA (cLMA), the intubating LMA The major concern regarding SADs is the fact (ILMA) and the ProSealt LMA (PLMA) [see (20) that the trachea is not sealed from the GI-tract and and references therein]. Although originally de- aspiration of stomach contents may occur. In emer- signed for elective anaesthesia, it has rapidly gency cases, patients must be assumed to have a gained success in emergency care. Successful in- full stomach and thus an increased risk of regur- sertion rates ranging from 64% to 100% (30, 31) gitation (21). SADs also do not fully seal the lower have been demonstrated among inexperienced airways from blood and debris associated with EMS care providers, nurses and respiratory thera- pists. Training in the placement and use of cLMA Each SAD has its own special features, described seems to be simpler than ETI (32–35). Inexper- in the text below.
ienced health care workers provide more secureand reliable ventilation in cardiac arrest cases withLMA than with BVMV (11, 36). The cLMA is recommended for ventilation in cardiac arrest by The ETC is a double lumen airway allowing venti- the ERC in the resuscitation guidelines (24, 37). The lation in either the oesophageal or tracheal posi- ILMA has been proposed for emergency airway tion. One lumen resembles an endotracheal airway management because its insertion technique is with an open distal end. The second lumen resem- somewhat simpler than that for the cLMA with bles an oesophageal obturator type airway, with a no need for digital manoeuvres. Insertion success blocked distal end and perforations for air passage rates up to 97% on manikins have been reported at pharyngeal level. The ETC is inserted blindly and it seems that users prefer the ILMA to the along the surface of the tongue with a gentle cLMA (15). ILMA provides a feature for blind downward, caudal movement until the printed intubation, but limited data regarding intubation marking lies between teeth. After insertion, the by inexperienced users is available and this proce- proximal and distal cuffs are inflated with air. Blind dure can therefore not be recommended.
insertion places the ETC in the oesophagus in more The use of ILMA and cLMA as primary devices than 95% of cases (22). The ETC has been studied should be reserved for anaesthetised patients and extensively among inexperienced pre-hospital care patients in cardiac arrest because limited data is providers. The success rate for insertion and suc- available about their use in patients with airway cessful ventilation varies from 79% to 82.4% reflexes. The use of PLMA is not recommended by (23, 24). The ERC has included the ETC as an the Task Force because there is some evidence that alternative airway in advanced cardiovascular life its insertion is more difficult than with cLMA.
support (6).
A major concern regarding the ETC is the fact that it has a double lumen, and the user must verify the correct lumen through which ventilation is The LT is a single-lumen, silicon tube with two possible. This problem has been described in a cuffs. The distal cuff lies at the end of the tube and study involving EMS personnel (25). Another po- is somewhat cone shaped. The second cuff is larger tential cause for concern is trauma of the upper and formed to fit the patient's oropharynx. Both oesophagus inflicted by the large distal balloon.
cuffs are low-pressure cuffs and inflated via the Several reports describe such injuries (26–29).
same pilot balloon–valve system. Two ventilation The ETC has never gained widespread use outlets are located between the cuffs, and the distal among anaesthetists and pre-hospital systems in opening is large enough to allow suction of the Scandinavia. It is the view of the Task Force that airway. The LT is inserted with the patient's head in this lack of popularity, combined with its relative the neutral position. The tube is inserted along the Pre-hospital airway management hard palate with a curved, downward motion, until or deeply comatose patients lacking protective air- a distinct resistance is felt at the recommended way reflexes.
ETI is traditionally regarded as the preferred The new laryngeal tube-Sonda (LTS-II) has a method of airway management, because a cuffed suction channel posterior to the airway tube and tracheal tube protects the lungs from aspiration of offers the advantage of gastric suctioning, but blood and gastric contents (43).
limited data is available regarding the modifiedLTS-II model.
Anaesthesiologists have inserted LT in anaesthe- tised patients with a success rate of up to 100% (38– In many countries, paramedics are taught how to 40). Inexperienced pre-hospital care providers in- perform ETI on the assumption that pre-hospital sertion success rates on anaesthetised patients vary ETI improves outcome for comatose patients. Sev- from 78% to 100% (8, 36). Pre-hospital care provi- eral recent studies contradict this assumption, ders have demonstrated an insertion success rate of however, showing worse outcomes for patients 83% in cardiac arrest cases (41).
intubated in the field compared with patients A steep learning curve, easy insertion and mini- intubated in the hospital (44–48). Most of these mal harmful effects are advocated, although pro- studies are from the United States, where the spective studies regarding the use of LT are missing.
majority of pre-hospital ETIs are performed by The LTS-II is an option as a pre-hospital SAD and is paramedics from the ground ambulance system.
increasingly used in Scandinavia for airway man- In similar studies from the air ambulance system, agement during resuscitation performed by para- where ETI is performed by flight nurses, the medics. There is no literature describing its use in difference between field and hospital outcome is patients retaining some degree of airway reflexes, less pronounced (49). A recent article reports de- but insertion will most likely increase the risk of creased mortality in trauma patients offered ad- gagging, vomiting and aspiration.
vanced life support with rapid sequence intubationby emergency physicians (50).
ComplicationsIn the absence of neuromuscular blockers, ETI ETI has for decades been regarded as the gold success rates in emergency settings are generally standard in airway management in both the hospi- poor. Some studies report success rates varying tal and pre-hospital setting. The support in the from 53% to 63% when paramedics attempt intuba- literature for this notion is weak, however, because tion of traumatised patients without neuromuscu- two major points frequently are not taken into lar blocking agents (51–53). Not surprisingly, consideration: the education and experience level success rates are much better for patients in car- of the personnel performing the procedure, and dio-respiratory arrest (54).
whether or not neuromuscular blocking agents are Intubation attempts – whether they are success- being used (42). ETI is a potentially harmful pro- ful or not – may delay transfer of the patient from cedure and undetected oesophageal intubation is the scene of the accident to the hospital. Intubation disastrous for the patient. A severe disadvantage attempts without sufficient sedation may result in a for the ETI is that the patient often has to be moved detrimental increase of intracranial pressure in several times pre-hospitally, which could change patients with closed head injury. Unrecognised the position of the tube in trachea so that disloca- oesophageal intubation is by far the most harmful tion occurs during pre-hospital rescuing or trans- potential complication of ETI. The incidence of unrecognised oesophageal intubation is dependent especially in children and also more often for on whether neuromuscular blocking agents have patients with cardiac arrest. Health care providers been used or not. In two studies of drug-assisted lacking expertise and day-to-day routine in drug- field intubation performed by paramedics, the assisted ETI should use alternative methods to reported rate was as low as 0.4% (55, 56). Con- secure the airways of critically ill or injured pa- versely, in other studies of paramedic field intuba- tients, independent of their formal education. A tion where drugs were not used, the rate of possible exception may be patients in cardiac arrest unrecognised oesophageal intubation was 6% (57) P. Berlac et al.
and 16.7% (58), respectively. In the latter study, 37% the learning curve for residents in anaesthesiology of trauma patients had a misplaced endotracheal for various skills was studied (64). For ETI, a 90% tube (ET) (the majority in the oesophagus, the success rate was achieved after a mean of 57 remainder in the hypopharynx above the vocal attempts. There is no reason to believe that para- medics or other pre-hospital personnel shouldhave a steeper learning curve, especially consider-ing the harsher working conditions compared with Use of neuromuscular blocking agents the operating theatre. The annual requirement of Paramedics in the Nordic countries are tradition- intubations to maintain the skills of ETI is not well ally not permitted to use neuromuscular blocking documented, but the number 10 is often cited.
agents in connection with ETI, because of concerns In-hospital ETI rates are declining because of the regarding unrecognised oesophageal intubation development and success of alternative SADs and and ‘cannot intubate–cannot ventilate' situations regional anaesthesia for patients undergoing elec- in the paralysed patient. Reports from the State of tive surgery. Consequently, fewer patients are Washington, however, where paramedics have un- available for paramedic ETI training, rendering it dertaken succinylcholine-assisted intubations for at more or less impossible to achieve and maintain least two decades, are encouraging with a success skill levels acceptable for pre-hospital use.
rate of 95.5% (55). Another group has reported a It is important to take note of differences in success rate of 92% (59). In EMS systems where the terminology in the literature. ‘Advanced' airway paramedics are permitted to use sedatives, but not skills for the paramedic are basic core skills for the neuromuscular blocking agents, the reported suc- experienced anaesthetist. The abbreviation RSI re- cess rates are lower (62.5–85%) (60, 61). Unfortu- fers in the literature both to rapid sequence intuba- nately, almost all studies of field ETI performed by tion and to rapid sequence induction, a subtle but paramedics are retrospective in nature.
important distinction. The knowledge and ability Most pre-hospital ETIs in traumatised patients in to correct changes in cardiopulmonary function the Nordic countries are performed by anaesthe- after the use of sedatives and muscle relaxants is tists using sedatives and/or neuromuscular block- rarely commented on in studies.
ing agents when necessary. The reported success Advanced airway management is potentially rates are significantly higher. In a French study, 685 harmful in unskilled hands. Based on recent litera- of 691 (99.1%) consecutive pre-hospital intubations ture, the SSAI Task Force recommends that pre- were successful (62). Approximately half of these hospital ETI in traumatised patients or medical ETIs were non-cardiac arrests, but neuromuscular patients is restricted to anaesthesiologists routined blocking agents were used only in 8.8% of the in drug-assisted ETI. Experienced EMS personnel cases, while sedation was performed in 2/3 of the may attempt ETI during cardiopulmonary resusci- patients not suffering from cardiac arrest. In a tation but repeated attempts should be avoided.
study from Paris, 147 children were intubated byphysicians in the field (63). No failures were re-ported in sharp contrast to the 57% success rate in a Pre-hospital end-tidal carbon dioxide study where paramedics were responsible for the monitoring for the ETI airway management (44).
Detailed information about choice of drugs, Unrecognised misplacement or dislodgement of an doses and side effects falls outside the scope of ET can be fatal. Primary methods of confirmation of this paper and has not been included.
ET placement – direct visualisation of the ETpassing through the vocal cords, inspection of chestexcursions and auscultation of the epigastrium and Training and simulation techniques anterior and lateral chest walls – can be unreliable The low success rates among paramedics may also in the pre-hospital environment.
reflect inadequate training. Studies indicate that End-tidal carbon dioxide (ETCO2) monitoring is training in the operating theatre is essential to a standard, obligatory adjunct in the modern acquire the necessary skills (8). Manikin training anaesthetic and critical care setting. ETCO2 mon- alone is not sufficient. There is no consensus itoring provides non-invasive information regard- regarding the number of ETIs required for achiev- ing CO2 production, pulmonary perfusion, alveolar ing and retaining intubation skills. In a Swiss study, ventilation and respiratory patterns. The absence of Pre-hospital airway management ETCO2 indicates either a misplaced or dislodged by the waveform alone (e.g. tube disconnection, ET (oesophageal intubation or accidental extuba- cardiac arrest, bronchospasm). In situations with tion) or absent/decreased CO2 production as in CO2-rich gastric contents (carbonated beverages, cardiac arrest. ETCO2 can be detected or measured mouth-to-mouth resuscitation attempts), confusion by the following methods – colorimetry, capnome- may arise after oesophageal intubation. The trend try and capnography (65). None of the methods can and waveform of the capnogram aids in differen- distinguish between tracheal or main-stem bron- tiating ET placement under these circumstances.
chial intubation.
Capnography is also of value in the monitoring ofnon-intubated patients but have a risk of false-negative interpretation for patients with low car- diac output, similar to the colorimetric method The colorimetric, single-use device consists of a pH-sensitive chemical indicator enclosed in a plas-tic housing that may be attached between the ETand the ventilation device. The indicator changes colour when exposed to CO Colorimetric devices are unreliable in certain clin- 2. The colour varies according to breath-to-breath changes in ETCO ical settings and have potentially serious functional levels, providing an estimate within a range of CO drawbacks, which limit their use in the pre-hospi- concentrations. As such, the device only functions tal environment. For this reason, colorimetric CO2 as a qualitative detector and not a monitor. The detectors are not recommended by the Task Force device is unreliable in confirming ET placement in for pre-hospital use in Scandinavia. Capnography, situations with absent or minimal levels of expired with the advantages stated above, also fulfils the criterium of providing the same level of care in the 2 (cardiac arrest, pulmonary oedema, extremely low cardiac output). Several breaths are recom- pre-hospital setting as in hospital. Verification of mended before interpreting a colour change. This correct ET placement is only one of several benefits may not be feasible in an emergency situation, provided by capnography. The Task Force recom- especially when rapid differentiation between oe- mends that the use of capnography should be sophageal intubation and profound shock or car- mandatory in connection with pre-hospital ad- diac arrest is vital (66). Colorimetric devices vanced airway management.
provide false-positive readings when exposed toacidic substances such as gastric contents, lidocaine or epinephrine, which are not uncommon in theresuscitation setting. The device is vulnerable to Many guidelines for airway management have clogging by secretions and subsequently unable to been published, but none to our knowledge en- provide a reading. The device has no audible alarm compassing all skill levels of pre-hospital health or backlighting, limiting its value in hostile pre- care providers [see (70) and references therein]. In hospital settings (67).
recognition of the organisational culture of pre-hospital emergency medicine common to the Nor-dic countries, SSAI felt the need for the develop- ment of common guidelines and appointed a Task Capnography combines a quantitative measure- Force with representatives from all Nordic coun- ment of exhaled CO2, displayed as a numeric tries. Health care providers with vastly different ETCO2 value (capnometry), with a graphic display skill levels and educational backgrounds made it of ETCO2 over time (capnogram). Capnographs necessary to design an algorithm that accordingly display the respiratory rate and are equipped differentiates between recommended actions (Fig. 1).
with audible alarms and illuminated displays.
Whether health care providers belong in the basic The method enables tight control of ventilation, or intermediate group will vary across Scandina- reducing the risk of inadvertant hypo- or hyper- via, but in the foreseeable future, advanced airway ventilation (68). The dynamic waveform of the management in the field will universally be pro- capnogram provides invaluable information re- vided by anaesthesiologists. Specially trained garding ventilation and circulatory status as well anaesthetic nurses can employ advanced techni- as monitoring airway and breathing-circuit integ- ques, but consultation with the anaesthesiologist in rity. Critical situations may be diagnosed or alerted charge is mandatory in each case.
P. Berlac et al.
Insufficient airway Need for airway management Advanced training Oropharyngeal airway Insufficient airway after basic actions Assess for difficult airway Manual in-line stabilization when Verify correct position Start ventilation with pocket mask/ If necessary start Surgical or cannula Fig. 1. Flow chart for pre-hospital airway management. The recommended actions depend on the skill level of the health care provider. Threelevels are indicated: basic, intermediate and advanced. See text for details.
It must be emphasised that arrows in the algo- with scattered populations – to implement more rithm may point in both directions, because an advanced airway devices, but in these EMS it is all improvement in the patient's condition after an the more important to be focused on drilling the action has successfully been performed may be basic skills instead.
temporary in nature, forcing new actions to be Anaesthesiologists have anaesthetic training warranting a wider instrumental and pharmacolo- Based on current literature and clinical and gical repertoire. This group could primarily secure educational experience, the Task Force recom- the patient's airway with ETI – drug assisted when mends that pre-hospital airway management per- necessary – or secondarily with a SAD if intubation formed by EMTs and paramedics is based on the proves difficult. However, even for maximally lateral recovery position and assisted BVMV in all skilled personnel, it should always be considered patients retaining some degree of airway reflexes.
whether intubation attempts should be performed During cardio-pulmonary resuscitation, this group pre-hospitally or be postponed till more advanced of personnel may try ETI if locally authorised, but in-hospital techniques are available. The clinical repeated attempts should be avoided. A SAD situation as well as the distance from the hospital should then be used if BVMV does not result in will decide the correct treatment in a given case.
adequate oxygenation. Actions more complex than For all groups of health care providers, the skill necessary should generally be avoided.
and training of the individual as well as local The Task Force acknowledges the fact that it is protocols must govern which SAD is to be em- unrealistic for many EMS – especially in rural areas ployed. No literature is available comparing the Pre-hospital airway management use of LMA and LT in anaesthetised trauma or external defibrillators. Resuscitation 2005; 67 (Suppl. 1): medical patients; thus preference of SAD depends on the skill and training of the individual health 10. Doerges V, Sauer C, Ocker H et al. Airway management during cardiopulmonary resuscitation – a comparative care provider as well as the local organisation. The study of bag-valve-mask, laryngeal mask airway and com- use of emergency airway techniques is rare and no bitube in a bench model. Resuscitation 1999; 41: 63–9.
literature supports recommendations on what kind 11. Alexander R, Hodgson P, Lomax D et al. A comparison of of technique or equipment is superior. However, the laryngeal mask airway and Guedel airway, bag andfacemask for manual ventilation following formal training.
for health care providers without prior experience Anaesthesia 1993; 48: 231–4.
with SADs, it seems reasonable to recommend the 12. Stone BJ, Chantler PJ, Baskett PJ. The incidence of regur- LT because studies indicate that the insertion of this gitation during cardiopulmonary resuscitation: a compar-ison between the bag valve mask and laryngeal mask device is easiest to learn and to maintain skill with airway. Resuscitation 1998; 38: 3–6.
suitable realistic training in hospital.
13. Dorph E, Wik L, Steen PA. Arterial blood gases with 700 ml These guidelines for pre-hospital airway man- tidal volumes during out-of-hospital CPR. Resuscitation agement must be updated on a regular and fre- 2004; 61: 23–7.
14. Cook TM, Gupta K, Gabbott DA et al. An evaluation of the quent basis in order to keep abreast with the rapid airway management device. Anaesthesia 2001; 56: 660–4.
development in this field. Anaesthesiological com- 15. Kurola J, Pere P, Niemi-Murola L et al. Comparison of petencies are needed in the pre-hospital setting and airway management with the intubating laryngeal mask, it is the health authorities' responsibility to ensure laryngeal tube and CobraPLA by paramedical studentsin anaesthetized patients. Acta Anaesthesiol Scand 2006; 50: public access to this expertise when the need arises.
SSAI is taking its part of the responsibility by 16. Cook TM, Rudd P, McCormick B et al. An evaluation of the providing Nordic anaesthesiologists with a course PAxpress pharyngeal airway. Anaesthesia 2003; 58: 191–2.
in advanced airway management. In addition, a 17. Hein C, Plummer J, Owen H. Evaluation of the SLIPA (streamlined liner of the pharynx airway), a single use 2-year SSAI post-specialist training programme in supraglottic airway device, in 60 anaesthetized patients advanced emergency medicine is to be launched undergoing minor surgical procedures. Anaesth Intensive Care 2005; 33: 756–61.
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