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.
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Air Medical JournalAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Pre-hospital anaesthesia: the same but different.Br J Anaesth. 2014; 113: 211-219
- Rapid sequence induction: where did the consensus go?.Scand J Trauma Resusc Emerg Med. 2021; 29: 64
- Significant modification of traditional rapid sequence induction improves safety and effectiveness of pre-hospital trauma anaesthesia.Crit Care. 2015; 19: 134
- 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
- AAGBI: safer pre-hospital anaesthesia 2017: Association of Anaesthetists of Great Britain and Ireland.Anaesthesia. 2017; 72: 379-390
- Pre-hospital advanced airway management by experienced anaesthesiologists: a prospective descriptive study.Scand J Trauma Resusc Emerg Med. 2013; 21: 58
- 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
- Guidelines for the management of tracheal intubation in critically ill adults.Br J Anaesth. 2018; 120: 323-352
- 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
- Best practice advice on pre-hospital emergency anaesthesia & advanced airway management.Scand J Trauma Resusc Emerg Med. 2019; 27: 6
- When life gives you lemons...Assessment of difficult laryngoscopy in emergency airway management.EMS World. 2011; 40: 37-39
- 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
- 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
- Preoxygenation reduces desaturation events and improves intubation success.Air Med J. 2015; 34: 82-85
- Preoxygenation and prevention of desaturation during emergency airway management.Ann Emerg Med. 2012; 59: 165-175
- Oxygenation strategies prior to and during prehospital emergency anaesthesia in UK HEMS practice (PREOXY survey).Scand J Trauma Resusc Emerg Med. 2020; 28: 99
- A prospective, randomised trial of pre-oxygenation strategies available in the pre-hospital environment.Anaesthesia. 2017; 72: 580-584
- Evaluation of the self-inflating bag-valve-mask and non-rebreather mask as preoxygenation devices in volunteers.BMJ Open. 2012; 2e001785
- Preoxygenation with flush rate oxygen: comparing the nonrebreather mask with the bag-valve mask.Ann Emerg Med. 2018; 71: 381-386
- Flush rate oxygen for emergency airway preoxygenation.Ann Emerg Med. 2017; 69: 1-6
- Alternatives to rapid sequence intubation: contemporary airway management with ketamine.West J Emerg Med. 2019; 20: 466-471
- The effect of combined out-of-hospital hypotension and hypoxia on mortality in major traumatic brain injury.Ann Emerg Med. 2017; 69: 62-72
- Pre-hospital aspiration is associated with increased pulmonary complications.Surg Infect (Larchmt). 2015; 16: 159-164
- Difficult prehospital endotracheal intubation - predisposing factors in a physician based EMS.Resuscitation. 2011; 82: 1519-1524
- The effect of exposure to high noise levels on the performance and rate of error in manual activities.Electron Physician. 2016; 8: 2088-2093
- The effect of noise on human performance: a clinical trial.Int J Occup Environ Med. 2013; 4: 87-95
- Positive pressure ventilation: what is the real cost?.Br J Anaesth. 2008; 101: 446-457
- 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
- Unanticipated difficult airway management in the prehospital emergency setting: prospective validation of an algorithm.Anesthesiology. 2011; 114: 105-110
- Video laryngoscopy in the prehospital setting.Prehosp Disaster Med. 2009; 24: 265-270
- 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
- Video laryngoscopy vs. direct laryngoscopy.Acad Emerg Med. 2019; 26: 259-260
- The C-MAC videolaryngoscope for prehospital emergency intubation: a prospective, multicentre, observational study.Emerg Med J. 2011; 28: 650-653
- Impact of videolaryngoscopy introduction into prehospital emergency medicine practice: a quality improvement project.Emerg Med J. 2021; 38: 549-555
- Increased first pass success with C-MAC videolaryngoscopy in prehospital endotracheal intubation-a randomized controlled trial.J Clin Med. 2020; 9: 2719
- Use of polarized sunglasses during video laryngoscopy: a cause of difficult prehospital intubation.Prehosp Disaster Med. 2019; 34: 104-107
- Describing the challenges of prehospital rapid sequence intubation by macintosh blade video laryngoscopy recordings.Prehosp Disaster Med. 2022; 37: 485-491
- 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
- 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
- Risk factors of relative adrenocortical deficiency in intensive care patients needing mechanical ventilation.Intensive Care Med. 2005; 31: 388-392
- The ketamine effect on ICP in traumatic brain injury.Neurocrit Care. 2014; 21: 163-173
- 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
- Current practice of rapid sequence induction of anaesthesia in the UK - a national survey.Br J Anaesth. 2016; 117: i69-i74
- 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
- Rocuronium versus suxamethonium: a survey of first-line muscle relaxant use in UK prehospital rapid sequence induction.Prehosp Disaster Med. 2015; 30: 184-186
- Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults.Br J Anaesth. 2015; 115: 827-848
- The association of rocuronium dosing and first-attempt intubation success in adult emergency department patients.CJEM. 2021; 23: 518-527
- Drug dosing in the critically ill obese patient-a focus on sedation, analgesia, and delirium.Crit Care. 2020; 24: 315
- Obstetric Anaesthetists' Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics.Anaesthesia. 2015; 70: 1286-1306
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.
- 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
- Anaesthesia for non-obstetric procedures during pregnancy.BJA Educ. 2012; 12: 203-206
- Place of rapid sequence induction in paediatric anaesthesia.BJA Educ. 2015; 16: 120-123
- Anaesthesia and morbid obesity.BJA Educ. 2008; 8: 151-156
- Atropine: re-evaluating its use during paediatric RSI.Emerg Med J. 2007; 24: 361-362
- 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
- Prehospital surgical airway management: an NAEMSP position statement and resource document.Prehosp Emerg Care. 2022; 26: 96-101
- Emergency scalpel cricothyroidotomy use in a prehospital trauma service: a 20-year review.Emerg Med J. 2021; 38: 349-354
Article Info
Publication History
Published online: September 22, 2022
Publication stage
In Press Corrected ProofIdentification
Copyright
© 2022 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.
