Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors
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The unique challenges of pediatric respiratory and airway emergencies require the development and maintenance of a prehospital quality management program that includes pediatric-focused medical oversight and clinical care expertise, data collection, operational considerations, focused education, and clinician competency evaluation. NAEMSP recommends:Medical director oversight must include a focus on pediatric airway and respiratory management and integrate pediatric-specific elements in guideline development, competency assessment, and skills maintenance efforts. ⋯ EMS agencies should implement both quantitative (objective) and qualitative (subjective) measures of performance to assess competency in pediatric respiratory distress and airway management. EMS agencies choosing to incorporate pediatric endotracheal intubation or supraglottic airway insertion must use pediatric-specific quality management benchmarks and perform focused review of advanced airway management.
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Prehospital airway management encompasses a multitude of complex decision-making processes, techniques, and interventions. Quality management (encompassing quality assurance and quality improvement activities) in EMS is dynamic, evidence-based, and most of all, patient-centric. Long a mainstay of the EMS clinician skillset, airway management deserves specific focus and attention and dedicated quality management processes to ensure the delivery of high-quality clinical care. ⋯ Hospital outcome information should be shared with agencies and the involved EMS clinicians. Findings from quality management programs should be used to guide and develop initial education and continued training. Quality improvement programs must continually undergo evaluation and assessment to identify strengths and shortcomings with a focus on continuous improvement.
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Airway management is a critical component of out-of-hospital cardiac arrest (OHCA) resuscitation. Multiple cardiac arrest airway management techniques are available to EMS clinicians including bag-valve-mask (BVM) ventilation, supraglottic airways (SGAs), and endotracheal intubation (ETI). Important goals include achieving optimal oxygenation and ventilation while minimizing negative effects on physiology and interference with other resuscitation interventions. ⋯ Airway management should not interfere with other key resuscitation interventions such as high-quality chest compressions, rapid defibrillation, and treatment of reversible causes of the cardiac arrest. EMS clinicians should take measures to avoid hyperventilation during cardiac arrest resuscitation. Where available for clinician use, capnography should be used to guide ventilation and chest compressions, confirm and monitor advanced airway placement, identify return of spontaneous circulation (ROSC), and assist in the decision to terminate resuscitation.
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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.