Introduction
Airway management in the prehospital setting presents unique challenges. Patients are undifferentiated and may be critically ill. Resources, including equipment and medications, are limited compared to a resuscitation bay in an emergency department. Personnel have less training and may be task saturated with competing clinical care priorities. A patient with a compromised airway may be in a challenging position, such as sitting in an entrapped motor vehicle or lying flat on the ground. The environment and lighting pose obstacles to the ideal intubation setup. Airway equipment, medications, and protocols can vary significantly among emergency medical service (EMS) agencies. Does the team carry equipment for direct laryngoscopy? Or do they have video-assisted devices? What about airway adjuncts and backup airway devices? Which patients will the protocol allow intubation versus supraglottic airway? Can the crew perform rapid sequence intubation, or must the airway be managed without drugs? The frequency of prehospital endotracheal intubation is decreasing (possibly due to increasingly common availability of supraglottic devices and the clinical equipoise of bag-valve-mask ventilation), whereas the number of paramedics is increasing; the result may be decreased opportunities for EMS providers to have fewer actual patient scenarios to utilize this skill.1
Despite these challenges and differences between prehospital and in-hospital airway management, one critical tenet remains constant: Unrecognized esophageal intubation must be a “never event.”
Whereas some single prehospital systems reported high rates of esophageal intubation before capnography,2,3 technology advancements have made this a very rare occurrence. Summary data from a recent Agency for Healthcare Research and Quality systematic review on prehospital airway management found very few cases …
Correspondence: Jason T McMullan MD, 321 Albert Sabin Way, ML0769 Cincinnati, OH 45267-0769. E-mail: Jason.McMullan{at}uc.edu
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