The Use of Endotracheal Tubes in Prehospital Care

Ben Savage

Objectives Why Endotracheal Tubes Paramedic training and remit Positives & Negatives Other methods Evidence Conclusion

Why this topic Observed difficulty of endotracheal

tube insertion

Wondered level of training that paramedics receive.

Is there a better way of maintain an airway

Prehospital airway management Mainly done by paramedics

HEMS etc

Military

Endotracheal Tubes (ETT) A flexible cuffed plastic tube placed into

the trachea Gold standard for securing an

unprotected airway

Paramedics Remit (Karen Gubbins 2007) (JRCALC, 2008) Use of ETT to manage a patient with a difficult

or complicated airway where basic airway management has failed or leaves the airway unprotected

Are not able to administer drug to assist with ETT insertion

Patient must be unconscious or have an absent gag reflex.

If they are unable to tolerate a ETT then there is little that can be done past basic airway management

How Much training (JRCALC, 2008) Paramedics have to :“achieve 25 intubations

during hospital training, of which five must be unassisted”

These are usually on patients who are in for elective surgery undergoing general anaesthesia

After this training they will often only have to perform 2-7 a year. This gives very little time to consolidate and practise these skills

How Much training The numbers of intubation that a paramedic

completes is not evidence based.

Positives & Negatives of ETT (JRCALC, 2008)

Positives: Gold standard airway

Enabling effective ventilation, particularly when lung and/or chest compliance is poor.

Minimising gastric inflation and therefore the risk of regurgitation

Positives & Negatives of ETT

Protection against pulmonary aspiration of gastric contents (and blood in trauma cases) (JRCALC, 2008)

In CPR allows continuous chest compression (ECC Committee, 2005)

Positives & Negatives of ETT (JRCALC, 2008)

Negatives: Hypoxemia, especially if poorly pre-

oxygenated and prolonged intubation attempt

Lack of CPR whilst intubation occurs

Trauma

Positives & Negatives of ETT (JRCALC, 2008)

Incorrect placement e.g mainstem bronchial, oesphagus

Unrecognised dislodgement

Is an ETT the best away to secure an airway Time/ failure rates

Specialist skills

Other airway devices (LMA)

Laryngeal Mask Airways (LMA) ET tube with elliptical mask on the

end that is designed to fit over the supraglottic structure and isolate the trachea (Nichole Bosson et al, 2009)

Much easier to insert and are very

difficult to misplace.

Laryngeal Mask Airways More advanced version

designed to protect against reflux- Proseal LMA

Are seen as an acceptable alternative to intubation in a cardiac arrest patient (EEC committee, 2005)

Evidence

Deakin CD et al 2005 LMA and ET tube insertion on same patient

In 80% of failed ETT insertion LMA was successful

Joint Royal Colleges Ambulance Liaison Committee (JRCALC, 2008)

It concluded that tracheal intubation without the use of drugs has little value in prehospital practice.

It stated there was inadequate training and that improving training to a reasonable standard is unfeasible.

Joint Royal Colleges Ambulance Liaison Committee (JRCALC, 2008)

It said that supraglotic airways are a very good alternative to ET tubes.

When pre-hospital tracheal intubation is undertaken, the following should apply: 1. A gum elastic bougie should be available

routinely.

2. Correct position of the tracheal tube must be verified using both a stethoscope and carbon dioxide detector

Conclusion Good airway management in

patients can be crucial to survival.

LMA represent a good alternative to ETT.

If ETT used then confirmation of correct placement crucial

References Deakin CD, Peters R, Tomlinson P, Cassidy M. Securing the prehospital

airway: a comparison of laryngeal mask insertion and endotracheal intubation by UK paramedics. Emerg Med J 2005;22(1):64-7.

ECC Committee; Subcommittees and Task Forces of the American Heart Association. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. Dec 13 2005;112(24 Suppl):IV1-203

Handley AJ, Koster R, Monsieurs K, Perkins GD, Davies S, Bossaert L. European Resuscitation Council guidelines for resuscitation 2005. Section 2. Adult basic life support and use of automated external defibrillators. Resuscitation 2005;67 Suppl 1:S7-23

Ignis http://commons.wikimedia.org/wiki/File:ProSeal_Laryngeal_Mask_Airway_inflated_001.jpg 2006

JRCALC Airway Working Group. A Critical Reassessment of Ambulance Service Airway Management in Pre-Hospital Care, JOINT ROYAL COLLEGES AMBULANCE LIAISON COMMITTEE. 2008

References Karen Gubbins, UK Paramedic Rapid Sequence Intubation …is

it viable? 2007 Konrad et al, Anesth Analg 1998;86;635-9 PhilppN

http://commons.wikimedia.org/wiki/Image:Endotracheal_tube_inserted.png 2008

Dr Mark Moore http://www.drmarkmoore.com/Photos/laryngescope_and_endotracheal_tube_sm.htm 2009

Nichole Bosson et al Tracheal Intubation, Laryngeal Mask Airways http://emedicine.medscape.com/article/82527-overview 2009

PhilppN http://commons.wikimedia.org/wiki/Image:Endotracheal_tube_inserted.png 2008

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