Your agency is dispatched to a cardiac arrest. First responders have started CPR and defibrillated the patient. Upon EMS arrival, the patient is still unconscious, unresponsive with agonal respirations and poor oxygenation.
The crew decides to intubate the patient in hopes of improving oxygenation and managing the airway. The paramedic places the endotracheal tube and confirms placement with auscultation of equal breath sounds, fogging of the tube and visualization of the chest rising and falling.
The patient is then moved from the home to the ambulance for transport. While in the back of the ambulance, the crew notices an expanding abdomen, no breath sounds and poor oxygenation. The endotracheal tube has become dislodged. The decision is made to extubate the patient and reintubate.
EMS providers manage difficult and often complex airways every day. As pointed out in this example, esophageal intubations can occur and ET tubes can become displaced during the packaging and moving of a patient. This is one reason why capnography should be used to confirm and monitor placement of the endotracheal tube.
Airway adverse events
The Center for Patient Safety’s Patient Safety Organization receives regular reports of airway-related events. Some of these events reflect the complicated range of patients that EMS encounters, from trauma patients that require surgical airways, to respiratory distress patients requiring endotracheal intubation.
Regardless, EMS must often act quickly as patients frequently present in acute distress. To take immediate action, the provider must have the skills and experience to manage many types of airways. Because of the wide range of risks and airway complications, such as esophageal intubation, ET tube dislodgement, aspiration and failed attempt, CPS is including airway management as part of this report.
Lee Varner, BSEMS, EMT-P, Project Manager for the Center for Patient Safety’s EMS services states, “Provider experience and critical thinking skills are an important part in developing the best plan for airway management. These skills are often developed over time in the clinical setting. Experience will help the provider to know when to take action or monitor a suspicious airway. Every patient is different, therefore, managing an airway requires many skills and a strong degree of experience. This is even more important as EMS encounters patients often in the least desirable surroundings or situations.”
CPS issued a Safety Watch “Cricothyrotomy, are you ready?” as analysis from PSO data raised concerns about this low frequency, high risk procedure. The Safety Watch was a reminder that having multiple types of cricothyrotomy kits can lead to confusion during an airway emergency. Specifically, this means know your equipment so the procedure can be performed with whatever kit your agency stocks. Utilize only one type of kit and remove older or other freelanced kits. It was also recommended that a regular skills refresher for this critical procedure occur on a frequent basis.
Furthermore, it was recommended that this training be performed with the equipment you would use on a daily basis. Your EMS medical director should have oversight of selecting the equipment as various kits are widely available from vendors. Your agency may also prepare a specialty cricothyrotomy kit under direct supervision of your medical director.
From complex ventilators to long distance transfers, medical transport teams are frequently dispatched to handle patients with some of the most difficult airways that require advanced airway management. These can be inter-facility transports or scene calls. Whatever the scenario, there is always risk. This creates the need for the best system design or processes as well as safety behaviors.
Discuss endotracheal intubation with your EMS medical director and explore options, alternatives and backup plans for airway management. One alternative is a supraglottic airway. It can be used as either a backup rescue device or a primary means for airway management. Implementing a review of the skill, simulation training and clinical time with actual patient placement will help improve proficiency.
