title: Pre-hospital anaesthesia: the same but different.
abstract: Advanced airway management is one of the most controversial areas of pre-hospital trauma care and is carried out by different providers using different techniques in different Emergency Medical Services systems. Pre-hospital anaesthesia is the standard of care for trauma patients arriving in the emergency department with airway compromise. A small proportion of severely injured patients who cannot be managed with basic airway management require pre-hospital anaesthesia to avoid death or hypoxic brain injury. The evidence base for advanced airway management is inconsistent, contradictory and rarely reports all key data. There is evidence that poorly performed advanced airway management is harmful and that less-experienced providers have higher intubation failure rates and complication rates. International guidelines carry many common messages about the system requirements for the practice of advanced airway management. Pre-hospital rapid sequence induction (RSI) should be practiced to the same standard as emergency department RSI. Many in-hospital standards such as monitoring, equipment, and provider competence can be achieved. Pre-hospital and emergency in-hospital RSI has been modified from standard RSI techniques to improve patient safety, physiological disturbance, and practicality. Examples include the use of opioids and long-acting neuromuscular blocking agents, ventilation before intubation, and the early release of cricoid pressure to improve laryngoscopic view. Pre-hospital RSI is indicated in a small proportion of trauma patients. Where pre-hospital anaesthesia cannot be carried out to a high standard by competent providers, excellent quality basic airway management should be the mainstay of management.
authors.affiliation: North Bristol NHS Trust, Bristol BS16 1LE, UK London's Air Ambulance, Barts Health NHS Trust, London E1 1BB, UK David.Lockey@nbt.nhs.uk.
authors.forename: D J
authors.initials: DJ
authors.lastname: Lockey
authors.affiliation: London's Air Ambulance, Barts Health NHS Trust, London E1 1BB, UK.
authors.forename: K
authors.initials: K
authors.lastname: Crewdson
authors.affiliation: Department of Research and Development, The Norwegian Air Ambulance Foundation, Holterveien 24, PO Box 94, N-1441 Drøbak, Norway Field of Pre-hospital Critical Care, Network for Medical Sciences, University of Stavanger, Kjell Arholmsgate 41, Stavanger 4036, Norway.
authors.forename: H M
authors.initials: HM
authors.lastname: Lossius
mesh_terms: D058109:Airway Management / Q000295:instrumentation / Q000379:methods; D000758:Anesthesia; D000777:Anesthetics / Q000008:administration & dosage; D003413:Cricoid Cartilage; D003695:Delivery of Health Care; D004632:Emergency Medical Services / Q000379:methods*; D017408:Guidelines as Topic; D006801:Humans; D014947:Wounds and Injuries / Q000628:therapy*
chemical_list: D000777:Anesthetics
keywords: anaesthesia; emergency care, pre-hospital; management, airway