British Journal of Anaesthesia 113 (2): 21119 (2014)

doi:10.1093/bja/aeu205

REVIEW ARTICLES

Pre-hospital anaesthesia: the same but different

D. J. Lockey 1,2*, K. Crewdson2 and H. M. Lossius 3,4
1
North Bristol NHS Trust, Bristol BS16 1LE, UK
2
Londons Air Ambulance, Barts Health NHS Trust, London E1 1BB, UK
3
Department of Research and Development, The Norwegian Air Ambulance Foundation, Holterveien 24, PO Box 94, N-1441 Drbak, Norway
4
Field of Pre-hospital Critical Care, Network for Medical Sciences, University of Stavanger, Kjell Arholmsgate 41, Stavanger 4036, Norway
* Corresponding author. E-mail: David.Lockey@nbt.nhs.uk

Advanced airway management is one of the most controversial areas of pre-hospital

Editors key points
Pre-hospital anaesthesia is
indicated in a small
proportion of major trauma
patients.
Pre-hospital advanced
airway management should
be delivered to the same
standard as in-hospital care.
Inexperienced providers
have increased
complication rates when
delivering
pre-hospital advanced
airway care.
Where pre-hospital airway
care cannot be delivered to
a consistently high standard
basic airway management
should be the mainstay
of treatment.
trauma care and is carried out by different providers using different techniques in different
Emergency Medical Services systems. Pre-hospital anaesthesia is the standard of care for
trauma patients arriving in the emergency department with airway compromise. A small
proportion of severely injured patients who cannot be managed with basic airway
management require pre-hospital anaesthesia to avoid death or hypoxic brain injury. The
evidence base for advanced airway management is inconsistent, contradictory and rarely
reports all key data. There is evidence that poorly performed advanced airway
management is harmful and that less-experienced providers have higher intubation
failure rates and complication rates. International guidelines carry many common
messages about the system requirements for the practice of advanced airway
management. Pre-hospital rapid sequence induction (RSI) should be practiced to the
same standard as emergency department RSI. Many in-hospital standards such as
monitoring, equipment, and provider competence can be achieved. Pre-hospital and
emergency in-hospital RSI has been modified from standard RSI techniques to
improve patient safety, physiological disturbance, and practicality. Examples include
the use of opioids and long-acting neuromuscular blocking agents, ventilation before
intubation, and the early release of cricoid pressure to improve laryngoscopic view.
Pre-hospital RSI is indicated in a small proportion of trauma patients. Where pre-
hospital anaesthesia cannot be carried out to a high standard by competent providers,
excellent quality basic airway management should be the mainstay of management.
Keywords: anaesthesia; emergency care, pre-hospital; management,
airway
Accepted for publication: 29 March
2014

Pre-hospital trauma care source into advanced pre-hospital services and others are
still rudimentary even in 2014.
The organization of pre-hospital trauma care can have a
major influence on outcome. It determines how quickly help
is deliv- ered to scene, the type and quality of early care
received, how quickly the patient is delivered to hospital and
which hospital they are delivered to. The importance of
the pre-hospital element of trauma care has been
acknowledged in the develop-
ment of trauma systems1 3 and recently developed UK
trauma
networks have been encouraged to take responsibility
for injured patients from point of injury to
rehabilitation.4 In quality terms, a pre-hospital postcode
lottery exists on a large scale even in countries with similar
income and infrastructure.5
The international development of Emergency Medical Services
(EMS) and trauma care has produced almost every variation
possible. Some countries have put significant effort and re-
 In the UK, pre- and in-hospital trauma care has been
the subject of several adverse reports in the last 20 yr.
Inter- nationally, the UK has been seen to move to an
Anglo- American paramedic-led model of pre-hospital care
in con- trast to the Franco-German physician-led model
of care seen in many other European countries.8 In the UK,
paramedic training commenced in the 1970s and the first
national train- ing course commenced in 1985. Paramedic
training then became more uniform and they have provided
the bulk of clin- ical pre-hospital care in the UK for many years.
6 7 Their advanced skills have included advanced airway
managementup to and including intubation without drugs
and the administration of i.v. fluid and drugs. Unfortunately,
the benefit of nearly every paramedic extended skill used in
trauma has been questioned.
The administration of i.v. fluid has been limited to the most
9
severely hypovolemic for many years, the value of tracheal
in- tubation without drugs is questionable10 11 and few drugs
are

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loa
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20
16
BJA
Pre-hospital anaesthesia: the same but different BJA
Lockey et al.

indicated in the early phases of trauma (although tranexamic ation has been seriously questioned.25 27 Despite many
12
acid is now administered by some UK ambulance services).
It is perhaps unfair that effectiveness is usually judged on
the basis of i.v. rather than the more difficult to measure
safe and effective scene management which may result from
ex- perience. What is clear is that most UK paramedics only
rarely encounter major trauma6 and that enhanced care
teams (doctor paramedic or air ambulance) treat trauma
patients more frequently. Doctors have been active in UK
pre-hospital care for many years, but recently there has
been a move to ensure that the care delivered is of a high
standard and the UK is the first country in Europe to recognize
Pre-hospital Emer- gency Medicine as a medical sub-specialty
(of anaesthesia and emergency medicine).

Pre-hospital airway management

Airway compromise has been identified as a preventable
cause of poor outcome and death in trauma and cardiac
13 14 loa
arrest patients for many years. The influential American
de
College of Surgeons Advanced Trauma Life Support Course
d
(ATLSTM )15 has propagated the ABC approach to trauma fro
care which makes the airway management the highest m
htt
priority. As un- corrected airway compromise can lead to p:/
preventable death or hypoxic brain injury, this concept is /bj
generally accepted. However, the means by which effective a.o
airway management should be achieved before arrival in xf
or
hospital is not straightfor- ward and highly controversial. dj
Where rapid sequence induction (RSI) is required after arrival ou
in the emergency department, it is usually carried out by rn
als
appropriately trained physicians. In most countries, these .or
physicians are trained anaesthetists or emer- gency g/
physicians with anaesthesia training.
16 17
In-hospital RSI by
gu
allows the administration of drugs to optimize the con- est
ditions for tracheal tube insertion and minimize physiological on
M
derangement.17 It is generally accepted as the technique of
arc
choice for securing the airway in seriously ill or injured pati- h
17 18 17,
ents and has also become a key component of advanced
20
pre-hospital care. It is one of the more complex i.v. that can 16
be carried out on scene and is seen by many as critical in
defin- ing the skill set of advanced providers, the acuity of the
patient case mix and for quality indicator measurement in
advanced EMS systems. All three elements of RSI such as
sedation, anal- gesia, and muscle relaxation are necessary
for a safe and ef- fective anaesthetic. The drugs used to
perform RSI produce apnoea, can induce hypotension and
increase the risk of regur- gitation and aspiration.
Unsuccessful or poorly conducted RSI can be life threatening
and may result in significant compli- cations, such as
oesophageal intubation,19 hypoxaemia,20 or post-induction
21
cardiac arrest. The intervention therefore requires a high
level of competence and the ability to manage any
complications. In hospital settings, these requirements
usually assume the educational level of a specialized
physician.
In the pre-hospital setting, the situation is somewhat
different. The first Medline- or Embase-indexed reports on
pre-hospital intubation were published in the mid-to-late
1960s.22 24 In the last 10 yr, the value of pre-hospital intub-
212 212
 BJA
Pre-hospital anaesthesia: the same but different
published studies, the benefits of this practice in specific
patient groups, the skill levels required by providers, the
effect of different techniques, and the alternatives to intub-
ation are less clear now than ever before. The majority of the
published papers are based on retrospective trauma
database methodologies and are considered to be low-
quality evi- dence.28 Despite the publication of guidelines
from Europe and the USA that recognize the need for
29 31
appropriately con- ducted pre-hospital RSI in a limited
number of patients, the practice is still widely variable
between and within coun- tries. In many European countries
in which specially trained physicians have participated in
pre-hospital EMS services since the late 1950s, RSI is a core
component of pre-hospital advanced life support.32 34 In
contrast, some pre-hospital EMS systems in developed
countries base their advanced life support entirely on
paramedics, nurses, or both and their intub- ation protocols
35 37
and procedures depend far less on drug admin- istration.
A systematic review was carried out in 2011 which
attempted to examine the frequency of reporting of 29 key
variables, previously determined by an expert panel, in
studies reporting on pre-hospital intubation.38 The majority
of the included studies were from North American EMS
(59 studies). Of these, 46 (78%) described services in
which intubation was conducted by non-physicians. In con-
trast, physicians performed the pre-hospital intubations in
13 (87%) of the 15 non-North American EMS systems. Of
the 46 non-physician-manned systems, 25 (53%) performed
drug-assisted intubation. An average of only 10 out of the 29
key variables was reported in the included studies. The
under- reporting of key variables and considerable
213
BJA
Lockey et al.
heterogeneity of published studies makes it extremely
difficult to generalize findings. This heterogeneity stems
from a number of areas. The professional group from which
the providers come are usually documented, but there are
considerable differences between training and skill levels
within professional groups. The term paramedic can
describe a very different provider in different EMS systems.
The term physician is even more ill- defined. In some
countries, the term relates to a senior doctor with
extensive experience and, in European systems, is often a
consultant anaesthetist. In other systems, the phys- ician
might be a relatively junior trainee or a general practition- er
with a lower level of advanced airway management skill.
Case mix also varies in different studies. It is often difficult to
separate trauma and non-trauma patients, cardiac arrest
and non-cardiac arrest, adults and children. The use of
drugs is also pivotal to intubation success but in a review of
pre-hospital
airway management in 200339 which involved 263
publications
and 9534 patients it was unclear in 21 studies (involving
2887 patients) whether or not drugs had been administered
to facili- tate intubation. Similarly, a Cochrane review on the
value of pre- hospital tracheal intubation40 failed to separate
paramedic and physician intubation or drug-assisted
intubation and intubation without drugs or medical and
trauma patients.
In the UK, paramedics have the full range of basic airway
management skills (oxygen administration, chin lift/jaw
thrust, bag-valve-mask ventilation, nasal/oral airway). In add-
ition, intubation without drugs has been carried out for more
213
than 20 yr. The benefits of intubation without drugs have not ambu- lance service care. Advanced airway management was
been demonstrated. One study did demonstrate benefit,41 likely to be a key factor in any difference demonstrated. The
but authors from the same EMS system have subsequently study ran
reported contradictory results.42 In 2001, a large series of
trauma patients who were intubated without drugs was
reported in the UK.10 Mortality was almost 100%, which sug-
gested that the group of trauma patients who could be easily
intubated by paramedics were either in cardiac arrest, peri-
arrest, or in very severely injured. Other publications have
sup- ported the view that this intervention does not confer
any benefit and also that success rates are relatively
low between 49 and 63% without drugs.43 45 As a result
of this and recognition that the development of supraglottic
airway devices has provided a less invasive but more
effective option, the Joint Royal College Ambulance Liaison
Committee in the UK made recommendations in 2008 that
tracheal intub- ation should not be mandatory training for
UK paramedics.46
Paramedics do not carry out RSI in the UK although there
are advocates for this development. Two studies in this area loa
de
have drawn particular attention. In 2003, Davis and
d
colleagues42 published a prospective study of 209 patients fro
who were uncon- scious and could not be intubated without m
htt
drugs. They were intubated with midazolam and p:/
succinylcholine. Mortality and neurological outcome were /bj
then compared with 627 historical controls. Outcome in the a.o
xf
RSI group was significantly worse. After sub-group analysis, or
it was suggested that this may have been because of poor dj
training or poor technique resulting in in- ou
rn
appropriate ventilation or hypoxaemia. A more recent study als
was unusual in that a randomized controlled study was .or
achieved in unconsented critically unwell patients.21 A total g/
by
of 310 patients with head injury were randomized to gu
paramedic RSI or transport to hospital for RSI in the est
emergency depart- ment. Although no survival benefit was on
M
demonstrated, there was an improvement in functional arc
neurological outcome in h
the pre-hospital RSI group. However, there were a 17,
20
significant number of reported unexpected cardiac arrests 16
after induction in the pre-hospital RSI group, which is of
concern. There are other studies that record very high rates
of complication after paramedic RSI. A study of 203 trauma
patients received in an emergency department in Florida
after paramedic RSI reported that 31% had failed intubation.
Eighteen percentage could not be intubated after
administration of succinylcholine and 12% had unrecognized
47
oesophageal intubation on arrival. On the basis of the
available literature, it is unclear whether reported
sub-optimal results are because of the fact that the
intervention of RSI is performed or because it is being
performed badly.
Only a handful of randomized controlled studies have
been performed in pre-hospital trauma patients and the
barriers to the conduct of studies in unconsented critically
unwell patients have been formidable.48 49 The most recent
attempt to perform a large randomized controlled study in
pre-hospital care was the Head Injury Retrieval Trial (HIRT)
in Sydney, Australia.50
The study was designed to measure neurological outcome in
head-injured patients who were randomized to treatment by
a physician paramedic aeromedical team or standard
into problems with recruitment and crossover in the two
arms of the study because the ambulance service dispatched
a physician response to some patients randomized to
standard care. This study clearly demonstrates some of the
difficulties of carrying out even well-funded high-quality
research in the pre- hospital environment.
Is there real need for pre-
hospital anaesthesia?
One of the key questions in the provision of pre-hospital
anaes- thesia for trauma patients is whether there is genuine
demand for the intervention. If airway management which
stops short of pre-hospital anaesthesia is adequate for
victims of major trauma, then the provision of pre-hospital
anaesthesia may be unnecessary. Unfortunately, the
39
published literature does not support this concept. The
National Confidential Enquiry into patient outcome and
6
deathTrauma Who Cares? Pub- lished in 2007 reported a
significant number of patients who arrived in the emergency
department after suffering traumatic injury with airway
compromise after on-scene management by ambulance
paramedics. In the USA, an examination of trauma patients
arriving in hospital demonstrated that 10% required
18
intubation in the emergency department. Around half of the
patients who required intubation had immediate indications
such as airway obstruction, ventilatory failure, or cardiac
arrest, which are highly unlikely to have developed on arrival
in the emergency department. Similarly in a Norwegian
EMS, Sollid and colleagues demonstrated that a
substantial number of trauma patients were only intubated
on arrival in the emergency department despite having clear
51 52
indications for RSI before arrival in hospital. The exact
demand for pre- hospital anaesthesia in trauma patients is
difficult to quantify. Ideally, it would be useful to understand
what proportion of major trauma patients meet the criteria
for immediate intub- ation on scene and also to establish
what proportion of these can be safely managed with more
basic airway management. When poor performance is
reported in systems where pre- hospital anaesthesia is not
6
available, it is difficult to establish whether this is because the
available, more basic interventions are inadequate or were
not carried out properly.
The discussions about the potential advantages and draw-
backs of pre-hospital anaesthesia (and other pre-hospital
interventions) are often related to time. There is little doubt
that pre-hospital interventions increase time on scene. This
is often only by a small margin53 and increased scene time
is not necessarily associated with increased mortality.
54
What is clear is that, regardless of the interventions
carried out, total pre-hospital times are quite consistent in
different EMS systems55 56 and the scoop and run concept
rarely results in trauma patients arriving in the emergency
department min- utes after injury. In the small proportion of
trauma patients who have airway compromise on scene,
there may be a consid- erable interval before in hospital RSI is
possible. In addition, the actual time of RSI might well be
some time after arrival in the emergency department. In
patients who require immediate in- tubation in the
emergency department delay is unacceptable
and is one of the quality indicators of trauma care measured
in the UK Trauma Audit and Research Network.57 The
patients outside hospital are the same patients earlier in the
patient pathway and the concept of Critical care without
walls58 could be applied to the critically ill with airway
compromise outside hospital in the same way as the
critically unwell patient on the general hospital ward.
Less immediate indications are also used for pre-hospital
anaesthesiahumanitarian in severe injury or perhaps
severe agitation without airway compromise. In these
situations, the risk benefit ratio is different and, as survival
or disability is unlikely to be prevented by immediate RSI, the
provider must be confident that the intervention can be
delivered with minimal risk. This is likely to require an
experienced provider working with established clinical
governance processes.
The practical delivery of pre-hospital
anaesthesia
RSI of anaesthesia is a technique to provide anaesthesia
and intubation in non-starved patients for emergency
procedures. It has been widely applied to the management
of trauma patients both in and outside hospital. Early
59 60
descriptions of the technique describe the administration
of an induction agent and succinylcholine followed by rapid
intubation. Cricoid pressure and head up positioning were
used to help prevent regurgitation of stomach contents.
Although the aims of RSIrapid, safe induction of
anaesthesia, and securing the airway with a definitive
airwayare still as important as they
were when the technique was first described, many adapta-
tions have been trialled to improve safety, intubation
success, or physiological disturbance. This has also been the
case in the pre-hospital environment. Anaesthesia is only
one complex intervention carried out in the pre-hospital
phase of care. Training and technological advances have,
with enough resource, made it possible to perform almost
any diagnostic or medical intervention on-scene. Recent
examples include diagnostic ultrasound,61 diagnostic com-
62
puted tomography for stroke thrombolysis,
63
resuscitative thoracotomy for traumatic cardiac arrest. The
challenge of pre-hospital medicine is to determine which
interventions translate to improved outcome. Changes to the
delivery of pre- hospital RSI have been inconsistent. In some
EMS systems, the simple use of an induction agent and
succinylcholine still dom- inate and may deliver high
intubation success rates. Other
systems, usually with more experienced providers deliver the
option of a more complex anaesthetic altered to meet the
requirements of particular patients. It is well established that
the experience of the provider influences intubation success.
A meta-analysis carried out in 2012 compared paramedic
64
and physician intubation success. This crude comparison
was followed by analysis of intubation success of both groups
after administration of neuromuscular blocking agents and
also with paramedics with very high levels of training. Overall
intubation success rates in 15 398 patients were 92.7%. The
median success rate for physicians was 99.1% and 84.9% for
paramedics. Paramedics intubating without drugs had overall
median success rates of 67.5%, using sedatives 81%, and
with neuromuscular blocking agents 96.7%. Weighted linear
regression analysis demonstrated a statistically significant
increased success rate with physician providers in all groups.
This difference persisted when comparing physicians with
highly trained paramedics using neuromuscular blocking
agents. Neuromuscular blocking agents increase the success
rates of intubation but also increase the magnitude of
potential complications in failed intubation.
The training advantage is not only seen between
paramedics and physicians. It has also been demonstrated
between physi- cians with different levels of experience.
Breckwoldt65 defines a model of competent and expert
intubators defined by the number of intubations carried out in
routine practice by different physicians. This definition
approximates to emergency physicians and anaesthetists in
the UK system of pre-hospital practice. Other
studies have demonstrated that even experienced
physician anaesthetists require regular structured training to
maintain their pre-hospital RSI skills66 and that quality loa
de
control measures are required to ensure non-procedural skills d
such as equipment familiarity and standard operating fro
67
procedures. m
htt
The use of portable monitoring systems means that all p:/
man- datory in-hospital standards of monitoring can be met /bj
in the conduct of pre-hospital anaesthesia. Even new modes a.o
of mon- itoring and near patient testing can be brought to the xf
or
68
patient where advantage is anticipated. Capnography is dj
also easily transferable to pre-hospital care and mandatory in ou
an environ- ment with high failed and oesophageal rn
30
als
intubation rates. In .or
2005, a study from Florida demonstrated the importance of g/
by
pre-hospital capnography reducing a 9% misplaced tracheal gu
tube rate on arrival in hospital to zero with the introduction est
of continuous CO2 monitoring.69 on
M
Improving airway management may be achieved by arc
altering process. The development of algorithms and h
standard operating procedures are as important in pre- 17,
70 71 20
hospital anaes- thesia as in the emergency department 16
and have been demonstrated to change practice. Where
72
and less-experienced anaesthetic practitioners are delivering
pre-hospital anaes- thesia, the process may be simplified and
choices limited to prevent cognitive overload during the
73
procedure. Some pro- cesses used in elective anaesthesia
are impractical in the emergency or pre-hospital situation.
Drugs
The majority of pre-hospital trauma anaesthetics are adminis-
tered to patients with airway compromise or unconscious-
ness73 so the option of waking up a patient is rarely used. If
waking the patient up is not an option, the importance of
using short-acting neuromuscular blocking agents or short-
acting opioids is reduced.
In experienced hands, most combinations of induction
agents, analgesics, and neuromuscular blocking agents are
possible to safely anaesthetize trauma patients in the pre-
hospital environment. For less-experienced providers, some
EMS systems provide limited options to improve reliability
and familiarity with a reproducible technique. Ketamine is an
increasingly popular induction agent for pre-hospital and to pre-hospital cricoid pressure might be to use it routinely for
emergency department induction and analgesia. oesophageal compression and for the manipulation of laryn-
Reservations about the use of ketamine in head-injured goscopic view but to release early if the view is poor.
patients because of the risks of increased intracranial
pressure have largely dec- lined,74 provided that adequate Equipment
ventilation and CO2 control is possible. Neuromuscular
64 Most devices used in in-hospital emergency airway manage-
blocking agents increase the success of intubation, but the ment have been successfully taken into the pre-hospital envir-
consequences of failed intubation after rendering patients
47
onment. Selection of particular devices for pre-hospital use
apnoeic are potentially catastrophic. Suc- cinylcholine has may be influenced by practical factors such as battery life,
been the main agent used for pre-hospital RSI, but long- port- ability, weight, and robustness. The use of the gum
acting agents particularly rocuronium have been in-
75 76
elastic bougie is familiar to all UK anaesthetists and has been
creasingly introduced into pre-hospital practice. It has demon- strated to be effective in unanticipated difficult
been suggested that the use of this agent should be intubation in
combined 84
77
with sugammadex for reversal in pre-hospital anaesthesia. the pre-hospital environment and is used routinely in some
With limited numbers of skilled providers on scene and the
con- services.73 A number of videolaryngoscopes have been trialled
siderable preparation time for this agent, it is questionable in pre-hospital intubation85 and although data are limited
whether the timely use of a reversal agent is practical in the some devices have performed disappointingly86 particularly
cant intubate, cant ventilate trauma patient. The common in the presence of blood in the airway.87 Airway rescue devices loa
use of pre-induction opioids in emergency anaesthetic should be available wherever pre-hospital anaesthesia is de
78 d
practice is another difference between current practice and carried out. Most of the features determining the choice of spe-
fro
the ori- ginal descriptions of RSI. The pre-hospital cific supraglottic rescue devices are similar in the pre-hospital m
haemodynamic re- sponse to intubation can be impressive79 environment and hospital environment and therefore a htt
and is of potential risk in those with head injury and unstable variety of different devices are used in different EMS systems. p:/
The per- formance of a surgical airway is included at the end /bj
blood clots. Opioid use is therefore common but risks a.o
depression of respiration during induction and recovery from of every failed intubation algorithm. The technique is more xf
short-acting neuromuscu- lar blocking agents. likely to be required in pre-hospital care,36 either as a primary or
procedure in trapped patients, severe burns or maxillo-facial dj
ou
Patient assessment trauma, or as a rescue technique after failed intubation. rn
Although many commercial kits are available, there is no als
Airway assessment is standard practice in elective .or
good evidence in real patients to indicate that any technique
anaesthesia but of less value in pre-hospital anaesthesia. As g/
is more successful than a standard surgical technique (in or by
emergency an- aesthesia should not be contemplated
out of hospital).88 gu
unless absolutely ne- cessary the assessment of the airway est
and risk stratification for difficult intubation is unlikely to on
influence management. Also there is evidence that the Pre-hospital advanced airway guidelines M
arc
elements of airway assessment In recognition that poorly performed tracheal intubation has h
that include, for example, patient co-operation and neck 89 90 17,
mo- 20
bility may be impractical in the compromised trauma lar- yngoscopic view particularly when applied by less- 16
patient.80 experienced assistants in the pre-hospital environment.82
The evidence base for benefit has been questioned.83 A
Pre-oxygenation strategies pragmatic approach
Pre-hospital trauma patients may be children or present with
obesity, and rarely pregnancy all of which are established risk
factors for rapid desaturation after the induction of ana-
esthesia. They may also have the additional risk factors of
hypovolaemia and respiratory compromise. Pre-oxygenation
is important in pre-hospital anaesthesia and gentle bag-
valvemask ventilation may be indicated after
neuromuscu- lar blocking agent administration. Although this
is contrary to standard RSI descriptions because of the risk of
gastric insuffla- tion and aspiration, it has been
demonstrated to reduce
oxygen desaturation in children after pre-hospital
81
induction.

Cricoid pressure
The use of cricoid pressure is well established in the UK
anaesthetic practice and is frequently used in pre-hospital
emergency anaesthesia. It has been associated with a poor
been shown to worsen patient outcome in any setting,
and that pre-hospital advanced airway management can
be particularly challenging, a number of countries have pro-
duced guidelines to direct and standardize practice in their
pre-hospital services in an effort to improve safety and effect-
iveness. The guidelines produced do reflect the different infra-
structure of the services operating within the various countries
but are remarkably consistent in their key messages.
In the UK, The Association of Anaesthetists of Great Britain
and Ireland (AAGBI) produced a pre-hospital anaesthesia
safety guideline in 2009, which was endorsed by all of the key
training providers including the Royal College of
Anaesthetists, College of Emergency Medicine, and Faculty
of Pre-hospital Care of The Royal College of Surgeons of
Edinburgh.30 The guidelines place strong emphasis on
performing anaesthesia in the pre-hospital setting to the
same standard as in the hos- pital emergency department.
All providers should be compe- tent in emergency
anaesthesia, and the equipment and
monitoring used should meet AAGBI in-hospital guidelines.
In addition, individual pre-hospital services should have a
robust structure in place for clinical governance that provides
a regular review of clinical practice, guidelines for the
management of difficult airways and failed intubations, and
a lead clinician
with overall responsibility for the practice of anaesthesia of patients earlier in the patient pathway in the pre-
within the pre-hospital service. hospital phase of care. Al- though the benefits of early
31
Comprehensive guidelines from Scandinavia contain airway control, oxygenation, and controlled ventilation are
similar principles to those from the UK. In Scandinavia, pre- attractive, there is a great deal of
hospital airway management is often performed by
anaesthe- tists with specific pre-hospital training. The
guidelines place emphasis on the skill level of the healthcare
provider, recom- mending very different airway techniques
for anaesthetists and non-anaesthetists. Tracheal intubation
is recommended only for anaesthetists and more basic airway
management com- bined with the lateral trauma position for
all other providers. The Scandinavian guidelines also consider
end-tidal carbon dioxide (E CO2 ) monitoring to be mandatory in
advanced airway manage-
ment, in recognition that misplaced tracheal tubes are
well
described and potentially fatal. Both the UK and
Scandinavian sets of guidelines recommend capnography as
the suggested method of E CO2 monitoring; colorimetry alone
has been demon- loa
strated to 91 be unreliable in some de
circumstances. d
The USA has a variable EMS model but paramedic-led fro
systems dominate, sometimes using physicians for telephone m
htt
support. Much controversy exists around paramedic p:/
intubation with several studies showing higher rates of poor /bj
outcome, failed intubation, misplaced tracheal tubes, and a.o
xf
other signifi- cant airway complications.36 42 47 64 92 or
A joint position statement on drug-assisted pre-hospital in- dj
tubation was produced by the National Association of EMS ou
93 rn
Phy- sicians, the American College of Emergency Physicians, als
and the American College of Surgeons Committee on .or
Trauma in g/
by
2006. Despite key system differences the guidelines are in gu
many respects similar to the UK and Scandinavian guidelines. est
Standards of the equipment and monitoring used, the use of on
M
well-rehearsed failed intubation drills, and a robust clinical arc
governance system are all common. One major difference h
is the direction on the exact level of training that should 17,
20
be given to providers of drug-assisted intubation. Unlike the 16
US guidelines, the UK and Scandinavian guidelines make it
quite clear that providers of pre-hospital anaesthesia
should have the same level of competence as in-hospital
anaesthesia providers. The lateral trauma position described
in the Scandi-
navian guidelines and the European Resuscitation
guidelines94
to reduce the incidence of airway obstruction and contamin-
ation is also rarely mentioned in US practice. Routine
positioning of trauma patients in the supine position with in
line stabilization provided for potential spinal cord injury, as
traditionally taught on Advanced Trauma Life Support and
Pre-hospital Trauma Life Support courses appears to be
standard US practice.

Conclusions
There is a clear need for immediate RSI in a small proportion
of trauma patients. After arrival in the emergency
department, the time in which this intervention is achieved is
a quality indi- cator of performance.57 Anaesthesia is
currently delivered in many EMS systems to the same group
evidence to suggest that poorly performed RSI can be
harmful. Straightforward guidelines are available with advice
on provider competence, equipment, monitoring, and system
governance and the use of these principles may have the po-
tential to improve patient safety and give pre-hospital and
emergency department anaesthesia a similar safety profile.
There are many unanswered questions in pre-hospital
advanced airway management. They include: which sub-
group of trauma patients really benefit from pre-hospital
RSI? What are viable alternatives to RSI in systems unable
to deliver the intervention? When making the decision to
perform pre- hospital anaesthesia, which factors in the risk
benefit analysis should influence the decision? Do less-
experienced providers perform the procedure and post-
intubation interventions less well and have worse results or
do they anaesthetize a different group of patients to more
experienced providers?
Unfortunately, there is a lack of data in which to search
for answers to these questions. Studies are rarely easily
transfer- able to other EMS systems and key data are
38
frequently missing. Reporting key data in pre-hospital
airway studies are an important step forward in
unravelling the complex picture which currently exists.95
An international template for pre-hospital airway
reporting has been developed and has the potential to
96
achieve this objective. Pre-hospital an- aesthesia is an
intervention which has the potential to improve trauma
patient outcome. Current evidence suggests that when
performed badly or by less-experienced providers it can be
detrimental. In systems where it is provided, it should
meet the same standards as emergency department
anaesthetic management. In systems that cannot provide
this level of care, efforts should be made to achieve excellent
standards of basic airway management and ventilation.
Declaration of interest
None declared.
References
1 Lendrum RA, Lockey DJ. Trauma system development.
Anaesthesia
2013; 68(Suppl. 1): 30 9
2 Btker MT, Bakke SA, Christensen EF. A systematic review of
con- trolled studies: do physicians increase survival with
prehospital treatment? Scand J Trauma Resusc Emerg Med 2009;
17: 12
3 Celso B, Tepas J, Langland-Orban B, et al. A systematic review and
meta-analysis comparing outcome of severely injured patients
treated in trauma centers following the establishment of trauma
systems. J Trauma 2006; 60: 371 8
4 Regional Networks for Major Trauma NHS Clinical Advisory Groups
Report September 2010. Available from www.excellence.eastmid
lands.nhs.uk/welcome/improving-care/emergency-urgent-care/
major-trauma/nhs-clinical-advisory-group/ (accessed 14 February
2014)
5 Lockey D. International EMS systems: geographical lottery and di-
versity but many common challenges. Resuscitation 2009; 80: 722
6 NCEPOD. Trauma: Who Cares? Report of national confidential
enquiry into patient outcome and death (NCEPOD). Available
from www.ncepod.org.uk/2007report2/Downloads/SIP_report.pdf
(accessed 14 February 2014)
7 Lockey D. Improving UK trauma care: the NCEPOD trauma report.
Anaesthesia 2008; 63: 455 7
8 Dick WF. Anglo-American vs. Franco-German emergency
medical services system. Prehosp Disaster Med 2003; 18: 29 35
9 National Institute for Health and Care Excellence. Available from
www.nice.org.uk (accessed 14 February 2014)
10 Lockey D, Davies G, Coats T. Survival of trauma patients who
have prehospital tracheal intubation without anaesthesia or
muscle relaxants: observational study. Br Med J 2001; 323: 141
11 Christensen EF. Prehospital tracheal intubation in severely in-
jured patients: a Danish observational study. Br Med J 2003;
327: 533 4
12 CRASH-2 trial collaborators, Shakur H, Roberts I, et al. Effects of
tran- examic acid on death, vascular occlusive events, and blood
transfu- sion in trauma patients with significant haemorrhage
(CRASH-2): a randomised, placebo-controlled trial. Lancet 2010;
376: 23 32
13 Anderson ID, Woodford M, de Dombal FT, Irving M.
Retrospective study of 1000 deaths from injury in England and
Wales. Br Med J (Clin Res Ed) 1988; 296: 1305 8
14 ESPOSITO TJ, Sanddal ND, Hansen JD, Reynolds S. Analysis of pre-
ventable trauma deaths and inappropriate trauma care in a
rural state. J Trauma 1995; 39: 955 62
15 American College of Surgeons Committee on Trauma. Advanced
Trauma Life Support Course for Doctors, 8th Edn. Chicago:
American College of Surgeons, 2008
16 Lockey DJ, Black JJM. Emergency physicians: additional providers
of emergency anaesthesia? Anaesthesia 2002; 57: 629 31
17 Jensen AG, Callesen T, Hagemo JS, et al. Scandinavian clinical
prac- tice guidelines on general anaesthesia for emergency
situations. Acta Anaesthesiol Scand 2010; 54: 922 50
18 Sise MJ, Shackford SR, Sise CB, et al. Early intubation in the
manage- ment of trauma patients: indications and outcomes in
1,000 con- secutive patients. J Trauma 2009; 66: 32 9
19 Wirtz DD, Ortiz C, Newman DH, Zhitomirsky I. Unrecognized mis-
placement of endotracheal tubes by ground prehospital
providers. Prehosp Emerg Care 2007; 11: 213 8
20 Davis DP, Dunford JV, Poste JC, et al. The impact of hypoxia and
hyperventilation on outcome after paramedic rapid sequence in-
tubation of severely head-injured patients. J Trauma 2004; 57: 1
8 survival in patients with severe head injury. Trauma Research
21 Bernard SA, Nguyen V, Cameron P, et al. Prehospital rapid
sequence intubation improves functional outcome for patients
with severe traumatic brain injury: a randomized controlled
trial. Ann Surg
2010; 252: 959 65
22 Fischer G. [Intubation or tracheotomy at the place of accident
(at the same time a contribution to the equipment of the
physicians emergency kit).] Z Arztl Fortbild (Jena) 1965; 59: 1314
6 of trauma patients: complications, indications, and outcomes.
23 Lick RF. [Medical first aid in accidents.] Munch Med Wochenschr
1969; 111: 340 5
24 Baskett PJ, Zorab JS. Priorities in the immediate care of roadside
and other traumatic casualties. Anaesthesia 1975; 30: 80 7
25 Spaite DW, Criss EA. Out-of-hospital rapid sequence intubation:
are we helping or hurting our patients? Ann Emerg Med 2003;
42:
729 30
26 Bernard SA. Paramedic intubation of patients with severe head
injury: a review of current Australian practice and recommenda-
tions for change. Emerg Med Australas 2006; 18: 221 8
27 Stiell IG, Nesbitt LP, Pickett W, et al. The OPALS Major Trauma
Study: impact of advanced life-support on survival and morbidity.
Can Med Assoc J 2008; 178: 1141 52
28 Jaeschke R, Guyatt GH, Dellinger P, et al. Use of GRADE grid to
reach decisions on clinical practice guidelines when consensus is
elusive. Br Med J 2008; 337: a744
29 Wang HE, OConnor RE, Domeier RM, National Association of
EMS Physicians Standards and Clinical Practice Committee.
Prehospital rapid-sequence intubation. Prehosp Emerg Care 2001;
5: 40 8
30 The Association of Anaesthetists of Great Britain and Ireland.
Guidelines for Pre-hospital Anaesthesia. Available from
http://www. aagbi.org/sites/default/files/prehospital_glossy09.pdf
(accessed 14
February 2014)
31 Berlac P, Hyldmo PK, Kongstad P, et al. Pre-hospital airway
manage- ment: guidelines from a task force from the
Scandinavian Society for Anaesthesiology and Intensive Care
Medicine. Acta Anaesthe- siol Scand 2008; 52: 897 907
32 Adnet F, Lapostolle F. International EMS systems: France.
Resuscita- tion 2004; 63: 7 9
33 Roessler M, Zuzan O. EMS systems in Germany. Resuscitation 2006;
68: 45 9
34 Langhelle A, Lossius HM, Silfvast T, et al. International EMS
Systems:
the Nordic countries. Resuscitation 2004; 61: 9 21
35 Timmermann A, Russo SG, Hollmann MW. Paramedic versus emer-
gency physician emergency medical service: role of the anaesthe- loa
siologist and the European versus the Anglo-American concept. de
Curr Opin Anaesthesiol 2008; 21: 222 7 d
fro
36 Hubble MW, Brown L, Wilfong DA, Hertelendy A, Benner RW, m
Richards ME. A meta-analysis of prehospital airway control techni- htt
ques part I: orotracheal and nasotracheal intubation success p:/
rates. Prehosp Emerg Care 2010; 14: 377 401 /bj
a.o
37 Black JJM, Davies GD. International EMS systems: United Kingdom. xf
Resuscitation 2005; 64: 21 9 or
38 Lossius HM, Sollid SJM, Rehn M, Lockey DJ. Revisiting the value of dj
pre-hospital tracheal intubation: an all time systematic literature ou
review extracting the Utstein airway core variables. Crit Care rn
als
2011; 15: R26 .or
39 Dunham CM, Barraco RD, Clark DE, et al. Guidelines for emergency g/
tracheal intubation immediately after traumatic injury. J Trauma by
2003; 55: 162 79 gu
est
40 Cochrane database of systematic reviews. Available from www. on
cochrane.org (accessed 14 February 2014) M
41 Winchell RJ, Hoyt DB. Endotracheal intubation in the field improves arc
h
and Education Foundation of San Diego. Arch Surg 1997; 132: 17,
20
592 7
16
42 Davis DP, Hoyt DB, Ochs M, et al. The effect of paramedic rapid se-
quence intubation on outcome in patients with severe traumatic
brain injury. J Trauma 2003; 54: 444 53
43 Murray JA, Demetriades D, Berne TV, et al. Prehospital intubation
in patients with severe head injury. J Trauma 2000; 49: 1065 70
44 Karch SB, Lewis T, Young S, Hales D, Ho CH. Field intubation
Am J Emerg Med 1996; 14: 617 9
45 Gausche M, Lewis RJ, Stratton SJ, et al. Effect of out-of-hospital
pediatric endotracheal intubation on survival and neurological
outcome: a controlled clinical trial. J Am Med Assoc 2000; 283:
783 90
46 Deakin CD, Clarke T, Nolan J, et al. A critical reassessment of ambu-
lance service airway management in prehospital care: Joint Royal
Colleges Ambulance Liaison Committee Airway Working Group,
June 2008. Emerg Med J 2010; 27: 226 33
47 Cobas MA, la Pen a De MA, Manning R, Candiotti K, Varon AJ.
Prehos- pital intubations and mortality: a level 1 trauma center
perspective. Anesth Analg 2009; 109: 489 93
48 Jones J, Hunter D. Using the Delphi and Nominal Group Technique
in Health Services Research, 2nd Edn. London: BMJ Books, BMJ
Publish- ing Group, 1999
49 Coats TJ, Goodacre S. Consent in emergency and resuscitation re-
search. Eur J Emerg Med 2009; 16: 242 3
50 Garner AA, Fearnside M, Gebski V. The study protocol for the Head
Injury Retrieval Trial (HIRT): a single centre randomised
controlled trial of physician prehospital management of severe
blunt head injury compared with management by
paramedics. Scand J Trauma Resusc Emerg Med 2013; 21: 69
51 Sollid SJM, Lossius HM, Sreide E. Pre-hospital intubation by
anaes- thesiologists in patients with severe trauma: an audit of a
Norwe- gian helicopter emergency medical service. Scand J
Trauma Resusc Emerg Med 2010; 18: 30
52 Sollid SJM, Lossius HM, Nakstad AR, Aven T, Sreide E. Risk
assess- ment of pre-hospital trauma airway management by
anaesthesiol- ogists using the predictive Bayesian approach.
Scand J Trauma Resusc Emerg Med 2010; 18: 22
53 Cudnik MT, Newgard CD, Wang H, Bangs C, Herringtion R. Endo-
tracheal intubation increases out-of-hospital time in trauma
patients. Prehosp Emerg Care 2007; 11: 224 9
54 Lerner EB, Billittier AJ, Dorn JM, Wu Y-WB. Is total out-of-hospital
time a significant predictor of trauma patient mortality?
Acad Emerg Med 2003; 10: 949 54
55 Carr BG, Caplan JM, Pryor JP, Branas CC. A meta-analysis of
prehos- pital care times for trauma. Prehosp Emerg Care 2006; 10:
198 206
56 van der Velden MWA, Ringburg AN, Bergs EA, Steyerberg EW,
Patka P, Schipper IB. Prehospital interventions: time wasted or
time saved? An observational cohort study of management in
initial trauma care. Emerg Med J 2008; 25: 444 9
57 Trauma Audit & Research Network (TARN). August 2006.
Available from www.tarn.org.uk (accessed 2 July 2014).
58 Hillman K. Critical care without walls. Curr Opin Crit Care 2002; 8:
594 9
59 Stept WJ, Safar P. Rapid induction-intubation for prevention of
gastric-content aspiration. Anesth Analg 1970; 49: 633 6
60 Snow RG, Nunn JF. Induction of anaesthesia in the foot-down
pos- ition for patients with a full stomach. Br J Anaesth 1959; 31:
493 7
61 Stawicki SP, Howard JM, Pryor JP, Bahner DP, Whitmill ML, Dean AJ.
Portable ultrasonography in mass casualty incidents: The CAVEAT
examination. World J Orthop 2010; 1: 10 9
62 Walter S, Kostopoulos P, Haass A, et al. Diagnosis and treatment
of patients with stroke in a mobile stroke unit versus in hospital: a
ran- domised controlled trial. Lancet Neurol 2012; 11: 397 404
63 Davies GE, Lockey DJ. Thirteen survivors of prehospital
thoracotomy for penetrating trauma: a pre-hospital physician-
performed resus- citation procedure that can yield good results. J
Trauma 2011; 70: E75 8
64 Lossius HM, Rislien J, Lockey DJ. Patient safety in pre-
hospital emergency tracheal intubation: a comprehensive
meta-analysis of the intubation success rates of EMS providers.
Crit Care 2012;
16: R24
65 Breckwoldt J, Klemstein S, Brunne B, Schnitzer L, Arntz H-R,
Mochmann H-C. Expertise in prehospital endotracheal intubation
by emergency medicine physicians-Comparing proficient perfor-
mers and experts. Resuscitation 2012; 83: 434 9
66 Sollid SJM, Heltne JK, Sreide E, Lossius HM. Pre-hospital
advanced airway management by anaesthesiologists: is there
still room for improvement? Scand J Trauma Resusc Emerg Med
2008; 16: 2
67 Rogna s LK, Hansen TM. EMS-physicians self reported airway
man- agement training and expertise; a descriptive study
from the Central Region of Denmark. Scand J Trauma Resusc
Emerg Med
2011; 19: 10
68 Guyette FX, Gomez H, Suffoletto B, et al. Prehospital dynamic
tissue oxygen saturation response predicts in-hospital lifesaving
interventions in trauma patients. J Trauma Acute Care Surg 2012;
72: 930 5
69 Silvestri S, Ralls GA, Krauss B, et al. The effectiveness of
out-of-hospital use of continuous end-tidal carbon dioxide moni-
toring on the rate of unrecognized misplaced intubation within a
re- gional emergency medical services system. Ann Emerg Med
2005;
45: 497 503
70 Wang HE, Kupas DF, Greenwood MJ, et al. An algorithmic
approach to prehospital airway management. Prehosp Emerg
Care 2005; 9:
145 55
71 Ballow SL, Kaups KL, Anderson S, Chang M. A standardized rapid
sequence intubation protocol facilitates airway management in
critically injured patients. J Trauma Acute Care Surg 2012; 73:
1401 5
72 Rogna s L, Hansen TM, Kirkegaard H, Tnnesen E. Standard
operat- ing procedure changed pre-hospital critical care
anaesthesiolo- gists behaviour: a quality control study. Scand J
Trauma Resusc Emerg Med 2013; 21: 84
73 Lockey DJ, Avery P, Harris T, Davies GE, Lossius HM. A prospective
study of physician pre-hospital anaesthesia in trauma patients: loa
oe- sophageal intubation, gross airway contamination and the de
quick look airway assessment. BMC Anesthesiol 2013; 13: 21 d
fro
74 Morris C, Perris A, Klein J, Mahoney P. Anaesthesia in haemo- m
dynamically compromised emergency patients: does ketamine htt
represent the best choice of induction agent? Anaesthesia 2009; p:/
64: 532 9 /bj
a.o
75 Hiestand B, Cudnik MT, Thomson D, Werman HA. Rocuronium
xf
versus succinylcholine in air medical rapid-sequence intubation. or
Prehosp Emerg Care 2011; 15: 457 63 dj
76 Smith CE, Kovach B, Polk JD, Hagen JF, Fallon WF. Prehospital ou
tra- cheal intubating conditions during rapid sequence rn
intubation: rocuronium versus vecuronium. Air Med J 2002; 21: 26 als
.or
32 g/
77 Paal P, Herff H, Mitterlechner T, et al. Anaesthesia in prehospital by
emergencies and in the emergency room. Resuscitation 2010; 81: gu
148 54 est
on
78 Morris J, Cook TM. Rapid sequence induction: a national survey of
M
practice. Anaesthesia 2001; 56: 1090 7 arc
79 Perkins ZB, Gunning M, Crilly J, Lockey D, OBrien B. The haemo- h
dynamic response to pre-hospital RSI in injured patients. Injury 17,
2013; 44: 618 23 20
16
80 Reed MJ, Rennie LM, Dunn MJG, Gray AJ, Robertson
CE, McKeown DW. Is the LEMON method an easily applied
emergency airway assessment tool? Eur J Emerg Med 2004; 11:
154 7
81 Eich C, Timmermann A, Russo SG, et al. A controlled rapid-
sequence induction technique for infants may reduce unsafe
actions and stress. Acta Anaesthesiol Scand 2009; 53: 1167 72
82 Harris T, Ellis DY, Foster L, Lockey D. Cricoid pressure and
laryngeal manipulation in 402 pre-hospital emergency
anaesthetics: essen- tial safety measure or a hindrance to rapid
safe intubation? Resus- citation 2010; 81: 810 6
83 Ellis DY, Harris T, Zideman D. Cricoid pressure in emergency
depart- ment rapid sequence tracheal intubations: a risk-benefit
analysis. Ann Emerg Med 2007; 50: 653 65
84 Combes X, Jabre P, Margenet A, et al. Unanticipated difficult
airway management in the prehospital emergency setting:
prospective validation of an algorithm. Anesthesiology 2011; 114:
105 10
85 Cavus E, Callies A, Doerges V, et al. The C-MAC videolaryngoscope
for prehospital emergency intubation: a prospective, multicentre,
ob- servational study. Emerg Med J 2011; 28: 650 3
86 Gellerfors M, Larsson A, Svense n CH, Gryth D. Use of the
Airtraq(R) device for airway management in the prehospital
settinga retro- spective study. Scand J Trauma Resusc Emerg
Med 2014; 22: 10
87 Trimmel H, Kreutziger J, Fertsak G, Fitzka R, Dittrich M, Voelckel 92 Karamanos E, Talving P, Skiada D, et al. Is prehospital endo-
WG. tracheal intubation associated with improved outcomes in iso-
Use of the Airtraq laryngoscope for emergency intubation in the lated severe head injury? A matched cohort analysis. Prehosp
prehospital setting: a randomized controlled trial. Crit Care Disaster Med 2014; 29: 32 6
Med
93 National Association of EMS Physicians. Drug-assisted intubation
2011; 39: 489 93
in the prehospital setting position statement of the National
88 Crewdson K, Lockey DJ. Needle, knife, or devicewhich choice in Asso- ciation of Emergency Physicians. Prehosp Emerg Care
an airway crisis? Scand J Trauma Resusc Emerg Med 2013; 21: 49 2006; 10:
89 Peterson GN, Domino KB, Caplan RA, Posner KL, Lee LA, Cheney 260
FW.
94 Nolan JP, Soar J, Zideman DA, et al. European Resuscitation
Management of the difficult airway: a closed claims analysis.
Council Guidelines for Resuscitation 2010 Section 1. Executive
Anes- thesiology 2005; 103: 33 9 summary. Resuscitation 2010; 81: 1219 76
90 Cook TM, Woodall N, Frerk C, Fourth National Audit Project. 95 Davis DP. The need for standardized data reporting for prehospital
Major complications of airway management in the UK: results airway management. Crit Care 2011; 15: 133
of the Fourth National Audit Project of the Royal College of
96 Sollid SJM, Lockey D, Lossius HM. Pre-hospital advanced
Anaesthetists and the Difficult Airway Society. Part 1:
airway management expert group. A consensus-based
Anaesthesia. Br J Anaesth
template for uniform reporting of data from pre-hospital
2011; 106: 617 31
advanced airway man- agement. Scand J Trauma Resusc Emerg
91 Puntervoll SA, Sreide E, Jacewicz W, Bjelland E. Rapid detection Med 2009; 17: 58
of oesophageal intubation: take care when using colorimetric
capno- metry. Acta Anaesthesiol Scand 2002; 46: 455 7
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