success rates in the prehospital setting are variable. Our objective was to describe the challenges encountered and corrective actions taken during the process of endotracheal intubation
Analysis of prehospital airway management
using a prospective registry that was linked to an emergency medical services administrative database.
Emergency medical services system serving King County, Washington, 2006–2011. Paramedics
in this system have the capability to administer neuromuscular blocking agents to facilitate intubation
(i.e., rapid sequence intubation
A total of 7,523 patients more than 12 years old in whom paramedics
attempted prehospital endotracheal intubation
Measurements and Main Results:
attempt was defined as the introduction of the laryngoscope into the patient’s mouth, and the attempt concluded when the laryngoscope was removed from the mouth. Endotracheal intubation
was successful on the first attempt in 77% and ultimately successful in 99% of patients (7,433 of 7,523). Paramedics
used a rapid sequence intubation
strategy on 54% of first attempts. Among the subset with a failed first attempt (n
= 1,715), bodily fluids obstructing the laryngeal view (50%), obesity (28%), patient positioning (17%), and facial or spinal trauma (6%) were identified as challenges to intubation
. A variety of adjustments were made to achieve intubation
success, including upper airway suctioning (used in 43% of attempts resulting in success), patient repositioning (38%), rescue bougie use (19%), operator change (16%), and rescue rapid sequence intubation
(6%). Surgical cricothyrotomy (0.4%, n
= 27) and bag-valve-mask ventilation (0.8%, n
= 60) were rarely performed by paramedics
as final rescue airway strategies.
Conclusions: Airway management
in the prehospital setting has substantial challenges. Success can require a collection of adjustments that involve equipment, personnel, and medication often in a simultaneous fashion.