Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors
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Airway management is a critical component of resuscitation but also carries the potential to disrupt perfusion, oxygenation, and ventilation as a consequence of airway insertion efforts, the use of medications, and the conversion to positive-pressure ventilation. NAEMSP recommends:Airway management should be approached as an organized system of care, incorporating principles of teamwork and operational awareness. EMS clinicians should prevent or correct hypoxemia and hypotension prior to advanced airway insertion attempts. ⋯ To mitigate aspiration after advanced airway insertion, EMS clinicians should consider placing a patient in a semi-upright position. When appropriate, patients undergoing advanced airway placement should receive suitable pharmacologic anxiolysis, amnesia, and analgesia. In select cases, the use of neuromuscular blocking agents may be appropriate.
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Bag-valve-mask ventilation and endotracheal intubation have been the mainstay of prehospital airway management for over four decades. Recently, supraglottic device use has risen due to various factors. The combination of bag-valve-mask ventilation, endotracheal intubation, and supraglottic devices allows for successful airway management in a majority of patients. ⋯ A surgical airway is not a substitute for other airway management tools and techniques. It should not be the only rescue option available. Success of an open surgical approach using a scalpel is higher than that of percutaneous Seldinger techniques or needle-jet ventilation in the emergency setting.
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Airway emergencies and respiratory failure frequently occur in the prehospital setting. Patients undergoing advanced airway management customarily receive manual ventilations. However, manual ventilation is associated with hypo- and hyperventilation, variable tidal volumes, and barotrauma, among other potential complications. ⋯ Prehospital mechanical ventilation techniques, strategies, and parameters should be disease-specific and should mirror in-hospital best practices. EMS clinicians must receive training in the general principles of mechanical ventilation as well as detailed training in the operation of the specific system(s) used by the EMS agency. Patients undergoing mechanical ventilation must receive appropriate sedation and analgesia.
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Definitive management of trauma is not possible in the out-of-hospital environment. Rapid treatment and transport of trauma casualties to a trauma center are vital to improve survival and outcomes. Prioritization and management of airway, oxygenation, ventilation, protection from gross aspiration, and physiologic optimization must be balanced against timely patient delivery to definitive care. ⋯ Management of immediately life-threatening injuries should take priority over advanced airway insertion. Drug-assisted airway management should be considered within a comprehensive algorithm incorporating failed airway options and balanced management of pain, agitation, and delirium. EMS medical directors must be highly engaged in assuring clinician competence in trauma airway assessment, management, and interventions.
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Supraglottic airway (SGA) devices provide effective conduits for oxygenation and ventilation and may offer protection from gastric aspiration. SGA devices are widely used by EMS clinicians as both rescue and primary airway management devices. While in common use for more than four decades, major developments in SGA education, science, and technology have influenced clinical strategies of SGA insertion and use in prehospital airway management for patients of all ages. ⋯ Confirmation of initial and continuous SGA placement using waveform capnography is strongly encouraged as a best practice. When it is functioning properly, EMS clinicians should refrain from converting an SGA to an endotracheal tube. The decision to convert an SGA to an endotracheal tube must consider the patient's condition, the effectiveness of SGA ventilations, and the clinical context and course of initial SGA insertionSGA training, competency, and clinical use must be continuously evaluated by EMS agencies using focused quality management programs.