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The Prehospital Emergency Anaesthetic in 2022

Published:September 22, 2022DOI:https://doi.org/10.1016/j.amj.2022.08.003

      Abstract

      Prehospital emergency anesthesia (PHEA) is a commonly performed prehospital procedure with inherent risks. The processes and drug regimens behind PHEA are continually updated by prehospital teams across the country as part of their governance structure. Essex & Herts Air Ambulance has recently updated this practice by reviewing the entire process of performing PHEA. Through experiential learning in a high-volume service, audit, and a contemporary literature review, a new standard operating procedure has been developed to combat common problems, such as hypotension, associated with the more traditional methods of performing PHEA. The aim of this article was to summarize the literature behind this new standard operating procedure, systematically breaking down the core components of performing a PHEA and the rationale behind them. The key components identified in the review are indications for PHEA, airway assessment, peri-intubation oxygenation, preparation for PHEA, drug dosing, special circumstances, and failed intubation. One significant change is the drug dosage regimen; 1 μg/kg fentanyl, 2 mg/kg ketamine, and 2 mg/kg rocuronium is recommended as the main drug dosing regimen for both medical and trauma patients. Other changes include preoxygenation with a nasal cannula in addition to the nonrebreather mask, optimizing patients in the preparation phase by considering inopressors or fluid bolus and ensuring a “sterile cockpit” to control the surrounding environment to ensure the first intubation attempt is the best attempt.
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      References

        • Lockey DJ
        • Crewdson K
        • Lossius HM.
        Pre-hospital anaesthesia: the same but different.
        Br J Anaesth. 2014; 113: 211-219
        • Avery P
        • Morton S
        • Raitt J
        • et al.
        Rapid sequence induction: where did the consensus go?.
        Scand J Trauma Resusc Emerg Med. 2021; 29: 64
        • Lyon RM
        • Perkins ZB
        • Chatterjee D
        • et al.
        Significant modification of traditional rapid sequence induction improves safety and effectiveness of pre-hospital trauma anaesthesia.
        Crit Care. 2015; 19: 134
        • Sivilotti ML
        • Ducharme J
        Randomized, double-blind study on sedatives and hemodynamics during rapid-sequence intubation in the emergency department: the SHRED Study.
        Ann Emerg Med. 1998; 31: 313-324
        • Lockey DJ
        • Crewdson K
        • Davies G
        • et al.
        AAGBI: safer pre-hospital anaesthesia 2017: Association of Anaesthetists of Great Britain and Ireland.
        Anaesthesia. 2017; 72: 379-390
        • Rognås L
        • Hansen TM
        • Kirkegaard H
        • et al.
        Pre-hospital advanced airway management by experienced anaesthesiologists: a prospective descriptive study.
        Scand J Trauma Resusc Emerg Med. 2013; 21: 58
        • Özkurtul O
        • Struck MF
        • Fakler J
        • et al.
        Physician-based on-scene airway management in severely injured patients and in-hospital consequences: is the misplaced intubation an underestimated danger in trauma management?.
        Trauma Surg Acute Care Open. 2019; 4e000271
        • Higgs A
        • McGrath BA
        • Goddard C
        • et al.
        Guidelines for the management of tracheal intubation in critically ill adults.
        Br J Anaesth. 2018; 120: 323-352
        • King C
        • Lewinsohn A
        • Keeliher C
        • et al.
        Cardiovascular complications of prehospital emergency anaesthesia in patients with return of spontaneous circulation following medical cardiac arrest: a retrospective comparison of ketamine-based and midazolam-based induction protocols.
        Emerg Med J. 2022; 39: 672-678
        • Crewdson K
        • Lockey D
        • Voelckel W
        • et al.
        Best practice advice on pre-hospital emergency anaesthesia & advanced airway management.
        Scand J Trauma Resusc Emerg Med. 2019; 27: 6
        • Dowdy B.
        When life gives you lemons...Assessment of difficult laryngoscopy in emergency airway management.
        EMS World. 2011; 40: 37-39
        • De Jong A
        • Molinari N
        • Terzi N
        • et al.
        Early identification of patients at risk for difficult intubation in the intensive care unit: development and validation of the MACOCHA score in a multicenter cohort study.
        Am J Respir Crit Care Med. 2013; 187: 832-839
        • Lockey DJ
        • Avery P
        • Harris T
        • et al.
        A prospective study of physician pre-hospital anaesthesia in trauma patients: oesophageal intubation, gross airway contamination and the 'quick look' airway assessment.
        BMC Anesthesiol. 2013; 13: 21
        • Davis DP
        • Lemieux J
        • Serra J
        • et al.
        Preoxygenation reduces desaturation events and improves intubation success.
        Air Med J. 2015; 34: 82-85
        • Weingart SD
        • Levitan RM.
        Preoxygenation and prevention of desaturation during emergency airway management.
        Ann Emerg Med. 2012; 59: 165-175
        • Boulton AJ
        • Mashru A
        • Lyon R.
        Oxygenation strategies prior to and during prehospital emergency anaesthesia in UK HEMS practice (PREOXY survey).
        Scand J Trauma Resusc Emerg Med. 2020; 28: 99
        • Groombridge CJ
        • Ley E
        • Miller M
        • et al.
        A prospective, randomised trial of pre-oxygenation strategies available in the pre-hospital environment.
        Anaesthesia. 2017; 72: 580-584
        • Robinson A
        • Ercole A
        Evaluation of the self-inflating bag-valve-mask and non-rebreather mask as preoxygenation devices in volunteers.
        BMJ Open. 2012; 2e001785
        • Driver BE
        • Klein LR
        • Carlson K
        • et al.
        Preoxygenation with flush rate oxygen: comparing the nonrebreather mask with the bag-valve mask.
        Ann Emerg Med. 2018; 71: 381-386
        • Driver BE
        • Prekker ME
        • Kornas RL
        • et al.
        Flush rate oxygen for emergency airway preoxygenation.
        Ann Emerg Med. 2017; 69: 1-6
        • Merelman AH
        • Perlmutter MC
        • Strayer RJ.
        Alternatives to rapid sequence intubation: contemporary airway management with ketamine.
        West J Emerg Med. 2019; 20: 466-471
        • Spaite DW
        • Hu C
        • Bobrow BJ
        • et al.
        The effect of combined out-of-hospital hypotension and hypoxia on mortality in major traumatic brain injury.
        Ann Emerg Med. 2017; 69: 62-72
        • Fawcett VJ
        • Warner KJ
        • Cuschieri J
        • et al.
        Pre-hospital aspiration is associated with increased pulmonary complications.
        Surg Infect (Larchmt). 2015; 16: 159-164
        • Breckwoldt J
        • Klemstein S
        • Brunne B
        • et al.
        Difficult prehospital endotracheal intubation - predisposing factors in a physician based EMS.
        Resuscitation. 2011; 82: 1519-1524
        • Khajenasiri F
        • Zamanian A
        • Zamanian Z.
        The effect of exposure to high noise levels on the performance and rate of error in manual activities.
        Electron Physician. 2016; 8: 2088-2093
        • Nassiri P
        • Monazam M
        • Fouladi Dehaghi B
        • et al.
        The effect of noise on human performance: a clinical trial.
        Int J Occup Environ Med. 2013; 4: 87-95
        • Soni N
        • Williams P.
        Positive pressure ventilation: what is the real cost?.
        Br J Anaesth. 2008; 101: 446-457
        • Hung RK
        • Lewinsohn A
        • Jovaisa T
        • et al.
        Does the use of a bougie reduce the force of laryngoscopy in a difficult airway with manual in-line stabilisation?: A randomised crossover simulation study.
        Eur J Anaesthesiol. 2013; 30: 563-566
        • Combes X
        • Jabre P
        • Margenet A
        • et al.
        Unanticipated difficult airway management in the prehospital emergency setting: prospective validation of an algorithm.
        Anesthesiology. 2011; 114: 105-110
        • Bjoernsen LP
        • Lindsay B.
        Video laryngoscopy in the prehospital setting.
        Prehosp Disaster Med. 2009; 24: 265-270
        • Vargas M
        • Servillo G
        • Buonanno P
        • et al.
        Video vs. direct laryngoscopy for adult surgical and intensive care unit patients requiring tracheal intubation: a systematic review and meta-analysis of randomized controlled trials.
        Eur Rev Med Pharmacol Sci. 2021; 25: 7734-7749
        • Bakhsh A
        • Ritchie M.
        Video laryngoscopy vs. direct laryngoscopy.
        Acad Emerg Med. 2019; 26: 259-260
        • Cavus E
        • Callies A
        • Doerges V
        • et al.
        The C-MAC videolaryngoscope for prehospital emergency intubation: a prospective, multicentre, observational study.
        Emerg Med J. 2011; 28: 650-653
        • Steel A
        • Haldane C
        • Cody D.
        Impact of videolaryngoscopy introduction into prehospital emergency medicine practice: a quality improvement project.
        Emerg Med J. 2021; 38: 549-555
        • Macke C
        • Gralla F
        • Winkelmann M
        • et al.
        Increased first pass success with C-MAC videolaryngoscopy in prehospital endotracheal intubation-a randomized controlled trial.
        J Clin Med. 2020; 9: 2719
        • Smith AJ
        • Jackimczyk K
        • Horwood B
        • Christenson D.
        Use of polarized sunglasses during video laryngoscopy: a cause of difficult prehospital intubation.
        Prehosp Disaster Med. 2019; 34: 104-107
        • Hayes-Bradley C
        • Gemal H
        • Miller M
        • Ware S.
        Describing the challenges of prehospital rapid sequence intubation by macintosh blade video laryngoscopy recordings.
        Prehosp Disaster Med. 2022; 37: 485-491
        • Cook TM
        • Boniface NJ
        • Seller C
        • et al.
        Universal videolaryngoscopy: a structured approach to conversion to videolaryngoscopy for all intubations in an anaesthetic and intensive care department.
        Br J Anaesth. 2018; 120: 173-180
        • Zed PJ
        • Abu-Laban RB
        • Harrison DW.
        Intubating conditions and hemodynamic effects of etomidate for rapid sequence intubation in the emergency department: an observational cohort study.
        Acad Emerg Med. 2006; 13: 378-383
        • Malerba G
        • Romano-Girard F
        • Cravoisy A
        • et al.
        Risk factors of relative adrenocortical deficiency in intensive care patients needing mechanical ventilation.
        Intensive Care Med. 2005; 31: 388-392
        • Zeiler FA
        • Teitelbaum J
        • West M
        • Gillman LM.
        The ketamine effect on ICP in traumatic brain injury.
        Neurocrit Care. 2014; 21: 163-173
        • Miller M
        • Kruit N
        • Heldreich C
        • et al.
        Hemodynamic response after rapid sequence induction with ketamine in out-of-hospital patients at risk of shock as defined by the shock index.
        Ann Emerg Med. 2016; 68 (e2): 181-188
        • Sajayan A
        • Wicker J
        • Ungureanu N
        • et al.
        Current practice of rapid sequence induction of anaesthesia in the UK - a national survey.
        Br J Anaesth. 2016; 117: i69-i74
        • Miller M
        • Groombridge CJ
        • Lyon R.
        Haemodynamic changes to a midazolam-fentanyl-rocuronium protocol for pre-hospital anaesthesia following return of spontaneous circulation after cardiac arrest.
        Anaesthesia. 2017; 72: 585-591
        • Hartley EL
        • Alcock R.
        Rocuronium versus suxamethonium: a survey of first-line muscle relaxant use in UK prehospital rapid sequence induction.
        Prehosp Disaster Med. 2015; 30: 184-186
        • Frerk C
        • Mitchell VS
        • McNarry AF
        • et al.
        Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults.
        Br J Anaesth. 2015; 115: 827-848
        • Levin NM
        • Fix ML
        • April MD
        • et al.
        The association of rocuronium dosing and first-attempt intubation success in adult emergency department patients.
        CJEM. 2021; 23: 518-527
        • Erstad BL
        • Barletta JF.
        Drug dosing in the critically ill obese patient-a focus on sedation, analgesia, and delirium.
        Crit Care. 2020; 24: 315
        • Mushambi MC
        • Kinsella SM
        • Popat M
        • et al.
        Obstetric Anaesthetists' Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics.
        Anaesthesia. 2015; 70: 1286-1306
      1. Difficult Airway Society. Unanticipated difficult tracheal intubation - during routine induction of anaesthesia in a child aged 1 to 8 years. 2015. Available at: https://das.uk.com/files/APA2-UnantDiffTracInt-FINAL.pdf. Accessed October 25, 2021.

        • Nightingale CE
        • Margarson MP
        • Shearer E
        • et al.
        Peri-operative management of the obese surgical patient 2015: Association of Anaesthetists of Great Britain and Ireland Society for Obesity and Bariatric Anaesthesia.
        Anaesthesia. 2015; 70: 859-876
        • Nejdlova M
        • Johnson T.
        Anaesthesia for non-obstetric procedures during pregnancy.
        BJA Educ. 2012; 12: 203-206
        • Newton R
        • Hack H.
        Place of rapid sequence induction in paediatric anaesthesia.
        BJA Educ. 2015; 16: 120-123
        • Lotia S
        • Bellamy MC.
        Anaesthesia and morbid obesity.
        BJA Educ. 2008; 8: 151-156
        • Bean A
        • Jones J.
        Atropine: re-evaluating its use during paediatric RSI.
        Emerg Med J. 2007; 24: 361-362
        • Price J
        • Lachowycz K
        • Steel A
        • et al.
        Intubation success in prehospital emergency anaesthesia: a retrospective observational analysis of the Inter-Changeable Operator Model (ICOM).
        Scand J Trauma Resusc Emerg Med. 2022; 30: 44
        • Reardon RF
        • Robinson AE
        • Kornas R
        • et al.
        Prehospital surgical airway management: an NAEMSP position statement and resource document.
        Prehosp Emerg Care. 2022; 26: 96-101
        • Aziz S
        • Foster E
        • Lockey DJ
        • Christian MD.
        Emergency scalpel cricothyroidotomy use in a prehospital trauma service: a 20-year review.
        Emerg Med J. 2021; 38: 349-354