title: The process of prehospital airway management: challenges and solutions during paramedic endotracheal intubation.
abstract: OBJECTIVE
  Endotracheal intubation success rates in the prehospital setting are variable. Our objective was to describe the challenges encountered and corrective actions taken during the process of endotracheal intubation by paramedics.
  
  
  METHODS
  Analysis of prehospital airway management using a prospective registry that was linked to an emergency medical services administrative database.
  
  
  METHODS
  Emergency medical services system serving King County, Washington, 2006-2011. Paramedics in this system have the capability to administer neuromuscular blocking agents to facilitate intubation (i.e., rapid sequence intubation).
  
  
  METHODS
  A total of 7,523 patients more than 12 years old in whom paramedics attempted prehospital endotracheal intubation.
  
  
  METHODS
  None.
  
  
  RESULTS
  An intubation attempt was defined as the introduction of the laryngoscope into the patient's mouth, and the attempt concluded when the laryngoscope was removed from the mouth. Endotracheal intubation was successful on the first attempt in 77% and ultimately successful in 99% of patients (7,433 of 7,523). Paramedics used a rapid sequence intubation strategy on 54% of first attempts. Among the subset with a failed first attempt (n = 1,715), bodily fluids obstructing the laryngeal view (50%), obesity (28%), patient positioning (17%), and facial or spinal trauma (6%) were identified as challenges to intubation. A variety of adjustments were made to achieve intubation success, including upper airway suctioning (used in 43% of attempts resulting in success), patient repositioning (38%), rescue bougie use (19%), operator change (16%), and rescue rapid sequence intubation (6%). Surgical cricothyrotomy (0.4%, n = 27) and bag-valve-mask ventilation (0.8%, n = 60) were rarely performed by paramedics as final rescue airway strategies.
  
  
  CONCLUSIONS
  Airway management in the prehospital setting has substantial challenges. Success can require a collection of adjustments that involve equipment, personnel, and medication often in a simultaneous fashion.
authors.affiliation: 1Department of Medicine, University of Washington School of Medicine, Seattle, WA. 2Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, Seattle, WA. 3Division of Emergency Medicine, University of Washington School of Medicine, Seattle, WA. 4Emergency Medical Services Division, Public Health-Seattle and King County, Seattle, WA. 5Department of Anesthesiology, University of Washington School of Medicine, Seattle, WA.
authors.forename: Matthew E
authors.initials: ME
authors.lastname: Prekker
authors.forename: Heemun
authors.initials: H
authors.lastname: Kwok
authors.forename: Jenny
authors.initials: J
authors.lastname: Shin
authors.forename: David
authors.initials: D
authors.lastname: Carlbom
authors.forename: Andreas
authors.initials: A
authors.lastname: Grabinsky
authors.forename: Thomas D
authors.initials: TD
authors.lastname: Rea
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002983:Clinical Competence; D004632:Emergency Medical Services / Q000379:methods* / Q000592:standards / Q000706:statistics & numerical data; D004634:Emergency Medical Technicians; D006801:Humans; D007442:Intubation, Intratracheal / Q000295:instrumentation / Q000379:methods* / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D009466:Neuromuscular Blocking Agents / Q000627:therapeutic use; D011446:Prospective Studies; D011787:Quality of Health Care / Q000706:statistics & numerical data; D014861:Washington
chemical_list: D009466:Neuromuscular Blocking Agents