mouth, and switch to a 3 Miller. Over three more attempts they note significant swelling in the airway, have difficulty identifying structures, and cannot clearly visualize the vocal cords. They place an endotracheal tube but quickly remove it when it does not return EtCO2. They are forced to abandon the attempts when the patient’s oxygen saturation falls to 60% and he becomes bradycardic. They place a SGA and are able ventilate and to recover the patient’s oxygen saturation.
The medical director reviews the case and re‐educates the crew on the following points. 1) Given the patient’s ability to protect his own airway it may have been better to manage the patient conservatively, keeping him upright with humidified oxygen and suction (know when not to intubate). 2) When it is clear that there will be a difficult airway, ask for additional resources including, perhaps, a second unit, supervisor, EMS physician, or critical care team (call for help). 3) Intubation attempts should be discontinued if they are not likely to be successful. The conditions of the intubation (positioning, equipment, or clinician) should be changed after a failed attempt. 4) The backup plan should be discussed prior to the attempt and prepared for implementation. The crew recreated this scenario in a high‐fidelity simulation to review alternative actions that could have resulted in a better outcome. The simulation included multiple iterations of the scenario and debriefing to discuss the points noted above. The scenario was then used to build a simulation demonstrating and evaluating decision making for all the paramedics in the service during the following year’s education sessions.
References
1 1 Thomas JB, Abo BN, Wang HE. Paramedic perceptions of challenges in out‐of‐hospital endotracheal intubation. Prehosp Emerg Care. 2007; 11:219–23.
2 2 Pollock MJ, Brown LH, Dunn KA. The perceived importance of paramedic skills and the emphasis they receive during EMS education programs. Prehosp Emerg Care. 1997; 1:263–8.
3 3 Stewart RD, Paris PM, Winter PM, Pelton GH, Cannon GM. Field endotracheal intubation by paramedical personnel. Success rates and complications. Chest. 1984; 85:341–5.
4 4 Jacobs LM, Berrizbeitia LD, Bennett B, Madigan C. Endotracheal intubation in the prehospital phase of emergency medical care. JAMA. 1983; 250:2175–7.
5 5 Guss DA, Posluszny M. Paramedic orotracheal intubation: a feasibility study. Am J Emerg Med. 1984; 2:399–401.
6 6 DeLeo BC. Endotracheal intubation by rescue squad personnel. Heart Lung. 1977; 6:851–4.
7 7 Carlson JN, Quintero J, Guyette FX, Callaway CW, Menegazzi JJ. Variables associated with successful intubation attempts using video laryngoscopy: a preliminary report in a helicopter emergency medical service. Prehosp Emerg Care. 2012; 16:293–8.
8 8 Wang HE, Yealy DM. Out‐of‐hospital endotracheal intubation: where are we? Ann Emerg Med. 2006; 47:532–41.
9 9 Wang HE, Peitzman AB, Cassidy LD, Adelson PD, Yealy DM. Out‐of‐hospital endotracheal intubation and outcome after traumatic brain injury. Ann Emerg Med. 2004; 44:439–50.
10 10 Gausche M, Lewis RJ, Stratton SJ, et al. Effect of out‐of‐hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial. JAMA. 2000; 283:783–90.
11 11 Jabre P, Penaloza A, Pinero D, et al. Effect of bag‐mask ventilation vs endotracheal intubation during cardiopulmonary resuscitation on neurological outcome after out‐of‐hospital cardiorespiratory arrest: a randomized clinical trial. JAMA. 2018; 319:779–87.
12 12 Benger JR, Kirby K, Black S, et al. Effect of a strategy of a supraglottic airway device vs tracheal intubation during out‐of‐hospital cardiac arrest on functional outcome: the AIRWAYS‐2 randomized clinical trial. JAMA. 2018; 320:779–91.
13 13 Wang HE, Schmicker RH, Daya MR, et al. Effect of a strategy of initial laryngeal tube insertion vs endotracheal intubation on 72‐hour survival in adults with out‐of‐hospital cardiac arrest: a randomized clinical trial. JAMA. 2018; 320:769–78.
14 14 Katz SH, Falk JL. Misplaced endotracheal tubes by paramedics in an urban emergency medical services system. Ann Emerg Med. 2001; 37:32–37.
15 15 Jemmett ME, Kendal KM, Fourre MW, Burton JH. Unrecognized misplacement of endotracheal tubes in a mixed urban to rural emergency medical services setting. Acad Emerg Med. 2003; 10:961–5.
16 16 Jones JH, Murphy MP, Dickson RL, Somerville GG, Brizendine EJ. Emergency physician‐verified out‐of‐hospital intubation: miss rates by paramedics. Acad Emerg Med. 2004; 11:707–9.
17 17 Wang HE, Kupas DF, Paris PM, Bates RR, Yealy DM. Preliminary experience with a prospective, multi‐centered evaluation of out‐of‐hospital endotracheal intubation. Resuscitation. 2003; 58:49–58.
18 18 Aufderheide TP, Lurie KG. Death by hyperventilation: a common and life‐threatening problem during cardiopulmonary resuscitation. Crit Care Med. 2004; 32:S345–51.
19 19 Aufderheide TP, Sigurdsson G, Pirrallo RG, et al. Hyperventilation‐induced hypotension during cardiopulmonary resuscitation. Circulation. 2004; 109:1960–65.
20 20 Wang HE, Simeone SJ, Weaver MD, Callaway CW. Interruptions in cardiopulmonary resuscitation from paramedic endotracheal intubation. Ann Emerg Med. 2009; 54:645–52e1.
21 21 Sunde GA, Sandberg M, Lyon R, et al. Hypoxia and hypotension in patients intubated by physician staffed helicopter emergency medical services ‐ a prospective observational multi‐centre study. BMC Emerg Med. 2017; 17:22.
22 22 Davis DP, Koprowicz KM, Newgard CD, et al. The relationship between out‐of‐hospital airway management and outcome among trauma patients with Glasgow Coma Scale Scores of 8 or less. Prehosp Emerg Care, 2011; 15:184–92.
23 23 Dunford JV, Davis DP, Ochs M, Doney M, Hoyt DB. Incidence of transient hypoxia and pulse rate reactivity during paramedic rapid sequence intubation. Ann Emerg Med. 2003; 42:721–8.
24 24 Elmer J, Brown F, Martin‐Gill C, Guyette FX. Prevalence and predictors of post‐intubation hypotension in prehospital trauma care. Prehosp Emerg Care. 2020; 24:461–9.
25 25 Pavlov I, Medrano S, Weingart S. Apneic oxygenation reduces the incidence of hypoxemia during emergency intubation: a systematic review and meta‐analysis. Am J Emerg Med. 2017; 35:1184–9.
26 26 Wimalasena YH, Corfield AR, Hearns S. Comparison of factors associated with desaturation in prehospital emergency anaesthesia in primary and secondary retrievals. Emerg Med J. 2015; 32:642–6.
27 27 United States Department of Transportation National Standard Curricula. 2007. https://www.nhtsa.gov/people/injury/ems/pub/emtbnsc.pdf. Accessed December 23, 2020.
28 28 Bradley JS, Billows GL, Olinger ML, Boha SP, Cordell WH, Nelson DR. Prehospital oral endotracheal intubation by rural basic emergency medical technicians. Ann Emerg Med. 1998; 32:26–32.
29 29 Sayre MR, Sakles JC, Mistler AF, Evans JL, Kramer AT, Pancioli AM. Field trial of endotracheal intubation by basic EMTs. Ann Emerg Med. 1998; 31:228–33.
30 30 Ochs M, Vilke GM, Chan TC, Moats T, Buchanan J. Successful prehospital airway management by EMT‐Ds using the Combitube. Prehosp Emerg Care. 2000; 4:333–7.
31 31 Lefrancois DP, Dufour DG. Use of the esophageal tracheal Combitube by basic emergency medical technicians. Resuscitation. 2002; 52:77–83.
32 32
