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The Process of Prehospital Airway Management: Challenges and Solutions During Paramedic Endotracheal Intubation*

Prekker, Matthew E. MD, MPH1,2; Kwok, Heemun MD, MS1,3; Shin, Jenny MPH4; Carlbom, David MD1,2; Grabinsky, Andreas MD5; Rea, Thomas D. MD, MPH1,4

doi: 10.1097/CCM.0000000000000213
Clinical Investigations

Objectives: Endotracheal intubation 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 by paramedics.

Design: Analysis of prehospital airway management using a prospective registry that was linked to an emergency medical services administrative database.

Setting: 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).

Patients: A total of 7,523 patients more than 12 years old in whom paramedics attempted prehospital endotracheal intubation.

Interventions: None.

Measurements and Main Results: An intubation 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.

Supplemental Digital Content is available in the text.

1Department of Medicine, University of Washington School of Medicine, Seattle, WA.

2Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, Seattle, WA.

3Division of Emergency Medicine, University of Washington School of Medicine, Seattle, WA.

4Emergency Medical Services Division, Public Health–Seattle and King County, Seattle, WA.

5Department of Anesthesiology, University of Washington School of Medicine, Seattle, WA.

* See also p. 1543.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (

Dr. Prekker received support for article research from the National Institutes of Health (NIH). His institution received grant support from NIH T32 Institutional Training Grant: Pulmonary and Critical Care Medicine Division at the University of Washington (salary support for his work as a senior research fellow). Dr. Rea’s institution received grant support from the Laerdal Foundation (general grant to improve community-based programs directed toward emergency prehospital care) and Life Sciences Discovery Fund (grant supporting innovative use of technology to improve prehospital care for emergency conditions). The remaining authors have disclosed that they do not have any potential conflicts of interest.

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© 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins