Evaluation and Management of the Difficult PreHos

Authors: Janis P Tupesis Nathan Van Dyk

Publish Date: 2013

Volume: , Issue: , Pages: 253-270

PDF Link

Abstract

Airway management in the prehospital setting poses a unique set of challenges While elective management of a patient’s airway is typically performed in a controlled environment by experienced clinicians circumstances in the prehospital setting are often much different than that in the operating room or even the Emergency Department As seen in Figs 151 and 152 patient care happens in a wide variety of surroundings including accident scenes private residences and in Emergency Medical Service vehicles Often there are challenges to the rapid establishment of an adequate airway in ill or injured patients This can include entrapped or difficult to access patients unsafe or hostile settings and psychomotor challenges such as having to perform procedures in the back of a moving ambulance or helicopter In addition prehospital airway management often happens in the setting of an acute decompensated medical condition coupled with an increased risk of regurgitation with impaired protective reflexes In contrast to the controlled inpatient location patients are frequently in a state of cardiovascular collapse respiratory distress or suffering from polytrauma It is estimated that difficult intubating conditions are encountered in approximately 7–10 of patients requiring airway management in the prehospital setting 1 2 It is unclear whether these numbers are truly reflective of the dimension of the problem In recent studies evaluating the incidence of adverse events during prehospital airway management by paramedics in patients with severe head injuries it was noted that complications frequently occur In one study 31 57 of 54 patients demonstrated desaturation during rapid sequence intubation RSI Six 19 patients experienced marked bradycardia HR 50 beats/min during these desaturation events 3 It is in this context that we wish to discuss the evaluation approach and management of the difficult airway

Keywords: