prehopsital cricothyrotomy

“Caring for the Community”

Emergency Medical Services Department

Prehopsital Cricothyrotomy



The IssueThe Issue

• A decision has been made to move EMS from a municipally based system to a regionally based system

• As a newly hired emergency physician you have just been “volunteered” to sit on a steering committee for the CHR aimed at completely redesigning the EMS system to best meet the current needs of the community



Where do we begin ??

• Establish a leadership structure and recruit a leadership team

• Experience and understanding of both emergency services as well as the health care system is crucial

• Top down approach to recruitment



Leadership Recruitment

• Medical Director– Practicing Emergency physician– Experience in EMS and knowledge of EMS

system design– Experience in quality assurance – Experience in research



The History of EMS

• Has evolved from and continues to be a subspecialty within Emergency Medicine

• Needs to be consistent with local Emerg med practice

• Many systems utilize a medical advisory board to ensure medical control consistent with local practice




• Operations Director/Chief– Oversees operational aspects of system– Management experience– Experience in labor relations– Experience in finance– Knowledge of EMS system design




• Director of Quality and research– Experience in research design and quality methodology

– Measures performance benchmarks and recommends change as needed

• Response times

• Chute times

• Dispatch times

• Cardiac arrest survival

• Intibation success rates




• Director of Staff Development/training– Experience in education and curriculum

design– Experience in computers and IT– Experience in patient simulation




• Operations Director– Oversees day to day operations and ensures

equipment and resources are adequate



So we have a management team… Whats next ??• Dispatch Center

– Must be coordinated with Fire and Police dispatch

– Must have adequate staffing (?paramedics)

– IT equipment and support

– Dispatch system (MPDS)

– Must record and report response times

– Coordinates communication with area hospitals



Medical Directors Office

• Responsible for Medical Control– Direct– indirect

• Protocols– Evidence based– Integrate local practice and policy– Take into account resources, experience and

training capacity



What type of system ?

• ALS or BLS ?

• Single Tiered or Dual Tiered ?



ALS… pros and cons

• Pros– High level of care theoretically available for every

call– Advantage of using paramedics in nontraditional

roles (hallway medicine)• Cons

– Lack of exposure to high risk low frequency procedures

– Lack of outcome evidence to support ALS care



Medical Control Guidelines

• Wide spectrum ranging from very conservative to very progressive

• Some allow ++ autonomy for medics• Local versus regional/provincial protocols • Best protocols are evidence based

– Prehospital research is limited, particularly with respect to outcome studies



Medical Control Guidelines

• Current desire from AB health is to develop provincial protocols

• Highly specific local protocols– STEMI– RSI– Tx and release (hypoglycemia and SVT)– Stroke– Specialty teams (TEMS, Air Med, IRP etc)



Controversies in Prehospital Care

• RSI/ETT

• System response benchmarks

• Treat and release

• Hallway care



The PatientThe Patient

• 25 year old male laying prone on roadway• Unresponsive, Pulseless, Apneic• Trismus with vomitus in airway• Distended abdomen• Unstable pelvis• Left testicle injury• Rectal bleeding• Left leg injuries



Details of the CallDetails of the Call

• Spinal precautions

• Begin transport to foothills

• Airway (decision to cric.)

• CPR

• Cardiac monitor (PEA)

• IV access

• Patch



Time ComponentsTime Components

• 1140 AM – 911 initiated, EMS dispatched

• 1142 AM – Medic One arrives on scene

• 1145 AM – Transport of patient initiated to foothills ER

• Total time from “Bumper to Bed” – 14 min.

• ER staff successfully resuscitates patient



DiscussionDiscussion



The million dollar question...



Can prehospital Rapid Sequence Intubation (RSI) be done safely and effectively and does it decrease the need for surgical airway management ?



Literature Review



Neuromuscular blockade in aeromedical airway management• Murphy-Macabobby et al, Annals Emerg Med 21:6

pg 664 (1992)• 119 pts requiring airway management in

aeromedical program (nurse/paramedic); 115 successfully intubated, 4 required cricothyrotomy due to conditions prohibiting oral intubation

• no significant complications attributed to neuromuscular blockade



Rapid sequence induction for intubation by an aeromedical transport team: A critical analysis

• Sing et al, Am J Emerg Med 1998(6):598-602• looked at relationship between intubation

mishaps and pulmonary complications in trauma pts in a system using RSI

• concluded that pulmonary complications related to severity of injuries, not intubation problems



Rapid Sequence Induction Intubation of trauma pts in the prehospital vs hospital setting• Abstract-1996 ACEP meeting• retrospective review and comparison of

air medical vs ED RSIs from 1988 to 1995• found no difference in success rates or

complications other than pneumonia which was more common in the prehospital group (28% vs 6%)



Intubation success rates improve for an air medical program after implementing the use of neuromuscular blocking agents

• Ma et al, Am J Emerg Med 16(2):125-127, Mar 1998• 5 yr retrospective review of 1 air medical program

using paralytics and another which implemented RSI 2 yrs into the study

• intubation success rates in program that implemented RSI went from 69.6% to 97.5% overall which was comparable to the program that

had the RSI throughout the study period



Emergency scene endotracheal intubation before and after the introduction of a rapid sequence induction protocol

• Retrospectively studied consecutive patients requiring intubation before (114 pts) and after(95 pts) RSI implementation in an air medical system

• groups did not differ in rate of successful intubations or cricothyrotomys but RSI group had scene time increased by mean of 4.4 minutes



The effect of a rapid sequence induction protocol on intubation success rate in an air medical program

• Lowe et al, Air Med J-1998 Jul-Sep 17(3): 101-4

• retrospectively reviewed intubation success rates before(100 pts) and after (98 pts)

• success rate pre was 79% vs 84.7% post



Prehospital Use of neuromuscular blocking agents in a helicopter ambulance program • Prospectively examined use of paralytics by

nurse/paramedic teams in pts intubated at sending hospital vs at accident scene (nurse/paramedic doing intubation in all cases)

• intubation success rates were 96% in pts who received paralytics vs 54% prior to admin of paralytics



Out of hospital use of neuromuscular blocking agents in the United States• Mcdonald et al, Prehosp Emerg Care 1998 Jan-Mar 2(1):29-

32• National survey to determine usage of neuromuscular

blockade in prehospital care• found 29/50 states used paralytics, 11 of these use it in

aeromedical program only• conclude that there is steady trend toward services

launching paralytic use and that paralytic drug use by paramedics is becoming standard of care in many out of hospital systems



Out of hospital rapid sequence induction for intubation of the pediatric patient• Sing et al, Acad Emerg Med 1996 Jan 3(1) 41-5• retrospectively reviewed 40 consecutive prehospital

RSIs performed by flight medics, mean age 8.1 yrs• 3 pts developed bradycardia of which 1 became

hypotensive, seven pts developed pneumonia but no pulmonary complications were attributable to RSI

• concluded that RSI is safe and not associated with

any intubation mishaps in this study



Effect of Out of Hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial

• Gausche et al, JAMA, Feb 9 2000 283(6) 783-90

• randomized trial compared survival and outcomes of ped.pts who received BVM alone or followed by ETI

• conclude that ETI does not improve survival or neurological outcome



Limitations in Our Knowledge

• Limited information reporting prehospital cricothyrotomy rates in urban EMS systems

• it’s unclear whether RSI decreases surgical airway rates in the prehospital setting



Prehospital Paralytics in Alberta



RSI In Alberta Survey

• Telephone survey• Of 18 EMS services contacted in

Alberta, 11 currently have RSI protocols, 4 have RSS and are implementing RSI. The standard protocol (8) uses, Midazalam, Fentanyl and Succinylcholine. 2 use Vecuronium, 1 uses Etomidate.



Calgary EMS Airway Data



Calgary Data (Retrospective)

• Total number prehospital intubations performed by Calgary EMS

• (1998) = 337• (1999,1st Qtr.) = 64• ??%intubation success rate *• limited experience makes maintenance of

competence a major issue

* based on Calgary Intubation studyDr. P Gant



Calgary EMS Surgical Airway Data



Calgary Data (Retrospective• Total number of

Cricothyrotomys Performed

10

6

16

6

4

10

3

1

4

0

2

4

6

8

10

12

14

16

1998 1999 2000

Trauma Medical Total



Indications for Prehospital Cricothyrotomy• 30 total

– trismus 12– blood or vomitus in airway 3– airway burn injury 1– oropharyngeal trauma 3– airway foreign body 2– inability to intubate 7– not documented 1



Indications for Cricothyrotomy

• 19/30 (63.3%) cricothyrotomys performed for trismus or inability to intubate

• a significant percentage of this patient subset would be appropriate for prehospital neuromuscular blockade



Inability to intubate

• Inability to intubate may be related to:– patient factors (trauma, burns, anatomy, etc)– equipment and medication deficiencies– lack of training (especially hands on)– lack of ongoing experience (Calgary is an all

ALS system)



Data Analysis

• Data set: total number patients transported by Calgary EMS with GCS< or = 6, where an OPA, BVM or O2 was used without intubation.

• N = 130 calls



• # of unsuccessful intubations 1999 1st Quarter• N= 13 Based on calls where Paramedics attempted to intubate and were unsuccessful

11

2

0

2

4

6

8

10

12

1999 1st

Medical Trauma



The Protocol



Calgary EMS RSI Protocol



The Ten Minute Guideline



The Ten Minute Guideline

• RSI has been shown to significantly increase scene times

• RSI should be avoided in cases where the patient can be oxygenated and ventilated using a BVM and transport time to a tertiary care center less than 10 minutes



Training



Training• No chemical adjunct for airway management can

replace proper training and assessment of technical skills and appropriate judgement !!

• Regular training and assessment becomes even more critical when neuromuscular blockade is used

• Hands on sessions impractical for 300+ field staff



Quality Assurance



Quality Assurance Process

• All cases using RSI will be reviewed by the EMS Medical Director

• Annual RSI recertification will be performed

• A prospective research project is underway (Drs. C. Hall, A. Anton)



Rapid Sequence Intubation QA

• Key data items:– success rates for intubation (first vs

subsequent attempts)– incidence of unsecured airways on arrival to

E.D.– incidence of esophageal intubations– incidence of surgical airways*



Pediatric RSI

• Some evidence suggests prehospital RSI may be detrimental in pediatrics

• Calgary EMS will utilize sedation agents alone in pediatrics… paralytics are used only in adult patients (15 yrs and over)



Conclusions

-RSI, as an adjunct to prehospital airway management, has tremendous potential to increase the intubation success and decrease the necessity for surgical airways-although the safety of neuromuscular blockade can only be determined after prospective review, there is evidence, both locally and in the literature to support it’s safety



Conclusions

• RSI is a potentially dangerous intervention which must be monitored with stringent quality assurance

• RSI is only one component of airway management and paramedics would benefit from increased hands on training such as OR rotations etc



Calgary EMS Quality Assurance Program



Quality Asurance

• QA can be broken down into two components; prearrival (indirectly related to patient care) and on scene (directly related to patient care)



Quality Assurance

• Pre arrival QA– is what most programs are traditionally based on– includes response times (and compliance with

accepted standards ie-Delta less than 8 minutes), chute times, dispatch compliance etc

– is related to patient care but does not provide info regarding appropriateness of care provided



Onscene QA

• Provides information regarding appropriateness and efficacy of care provided– more subjective anddifficult to study– can be subdivided into macro QA and micro

QA



Micro QA versus Macro QA

• Micro QA– PCR and Case review by superintendants,

SDOs and medical director– does not necessarily provide information

regarding quality of EMS system as a whole– may not be as effective at improving system

quality as Macro QA



Macro QA

• Examines overall system function as it relates to patient care– focused audits– ethics issues have arisen– constitutes research

prehopsital cricothyrotomy

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