Overview of EMS Field Intubation
Putting a special breathing tube into someone’s airway when they’re outside the hospital is called field intubation. This important task is often performed by emergency medical professionals. There are several ways they can ensure a patient can breathe and get enough oxygen, even in tricky situations. Some of these methods include direct intubation, which involves directly placing a tube through the mouth and into the windpipe; using certain airway devices; and using machines that help push air into the lungs.
While the direct tube placement method has been frequently used and is well-known among medical professionals, it does have some challenges and risks. Because of this, some people have questioned whether it should be the main method used outside the hospital.
Yet, it can be crucial to control someone’s breathing in certain situations, and being able to put the breathing tube in correctly is an important skill that emergency medical professionals need to have. They need to understand when and how to use this skill, and local rules and procedures can guide them.
Before deciding to intubate someone, the situation needs to be carefully assessed since this procedure can be quite challenging and could lead to other issues. If a medical professional isn’t comfortable with or used to performing field intubation, it might be better to use another method if possible. This could include using an airway device or a mask that helps push air into the lungs.
A patient might need to be intubated if they lose control of their airway or if they are not getting enough oxygen using other methods. Training and practice, picking the right patients, and being ready for complicated situations are all important to successfully perform field intubation.
Even though doctors have been managing patients’ airways outside the hospital for a long time, it’s not clear if field intubation actually improves patient survival rates or reduces complications. Most research has mainly focused on tracking if the procedure is done correctly, along with its complication rates. More studies are needed in the future to improve these procedures, such as finding new techniques, technologies, and training methods.
Anatomy and Physiology of EMS Field Intubation
Field intubation is a process where a tube is placed into a person’s throat to help them breathe. This is typically done outside of a healthcare facility, usually in emergency situations. Understanding the patient’s anatomy is crucial for the process, as certain key landmarks in the throat and upper airway need to be identified for the procedure to be successful.
When performing this procedure, healthcare providers use an instrument to clearly view parts of the throat, like the epiglottis and vocal cords. They do this to guide the breathing tube correctly into the windpipe. However, factors like the position of the epiglottis and vocal cords, or the size of the airway, can differ from person to person, making the process tougher in some cases.
To predict potential challenges, healthcare providers often use a strategy called LEMON, where each letter stands for a different factor to evaluate. Here’s what they check:
- L: Look – They examine the person’s physical traits (like neck size or dental conditions) to predict difficulties.
- E: Evaluate the 3-3-2 rule – This rule uses finger-width measurements of different parts of the person’s throat to assess the potential challenge of intubation.
- M: Mallampati score – This score rates throat visibility on a scale of I to IV, with I being the most ideal scenario and IV being the most difficult.
- O: Obstruction – This refers to any blockage (like trauma or swelling) that might interfere with the process.
- N: Neck Mobility – They check how flexible the person’s neck is; limited neck mobility can make intubation harder.
Studies have identified several factors that can make field intubation more difficult, including throat swelling, facial trauma, large tongue, short neck, vomit, obesity, and a short jaw. A combination of these factors tends to make the process considerably more challenging. Thus, procedures, like LEMON or similar strategies (for example, BE FAST), are crucial for providers to quickly identify any hurdles before performing field intubation.
Why do People Need EMS Field Intubation
Sometimes, a person might need a special medical procedure to help them breathe properly. This is called an advanced airway procedure and is needed in two main situations. Firstly, when a person can’t keep their airway open due to a condition called ‘failure to maintain a patent airway’. Secondly, when a person can’t breathe or absorb oxygen properly, which is called the ‘inability to oxygenate and ventilate the patient adequately’. There could be a number of reasons for these health conditions, like:
– Being very unconscious or weak that they can’t control their breathing (this is measured using the Glasgow coma scale – a scale used by doctors to measure consciousness. If the score is less than 8, it could be a cause for concern)
– Failing to breathe due to lack of oxygen (hypoxemic) or too much carbon dioxide (hypercarbic)
– Cardiac arrest – when the heart suddenly stops beating
– Being at risk of inhaling vomit, blood or body secretions into the lungs (aspiration)
– Blockage in the airway, making it hard to breathe
Medical providers like paramedics or emergency medical technicians follow local guidelines that tell them when and how to perform an advanced airway procedure in the field (e.g., at a person’s home, on the street, etc.). They can also get real-time advice from an online medical expert to help them perform the procedure in the best possible way. This helps to significantly improve the health outcomes for the patient.
When a Person Should Avoid EMS Field Intubation
Intubation in an emergency or “field intubation,” is a complex procedure and cannot be performed under certain conditions. These situations are divided into absolute and relative conditions.
Absolute conditions refer to situations where performing intubation would be unsafe for both the patient and the healthcare provider. These could include dangerous environments or lack of a trained professional or necessary equipment. For example, if you’re in a hazardous area, or if there’s no one around who knows how to do the procedure safely or the tools needed are not available, in these situations, intubation should not be attempted.
Relative conditions are more dependent on the specific conditions of the patient. These include instances where the healthcare provider might not have the technical skills required to perform the procedure given the patient’s unique circumstances. For instance, severe injuries or conditions preventing the opening of the mouth, or too much secretions, vomit, or blood obstructing the visualization of the airway (the tube that leads to your lungs) might make the procedure more challenging. Also, if certain medicines used for intubation are not suitable for the patient’s health issues, these instances could be relative conditions.
It’s important to note that intubation should never be used as a form of punishment. Patients who are uncooperative due to intoxication but have no other medical need for the procedure should not be intubated. Sedating or immobilizing the patient is sometimes necessary, though these instances should be rare. “Social intubations,” which are not medically necessary, should not be considered.
Another relative condition can be the time factor. If the medical facility is nearby, especially in city areas, it might be safer to transport the patient while managing his breathing, for instance, with a Bag Valve Mask (BVM) or Continuous Positive Airway Pressure (CPAP) which helps to support breathing. In this case, the time spent preparing for and doing the procedure could be better spent getting the patient to a hospital where they have more support and a safer environment. However, in rural areas where medical help is distant, or for air medical staff, it may be more prudent to start the procedure on-site, since there may be higher risks of the patient’s condition worsening or difficulties in doing the procedure while in transit.
Equipment used for EMS Field Intubation
When a medical professional needs to insert a breathing tube in the field (outside a hospital), they will use the tools that they are most familiar with. This choice often depends on personal preference and the resources their medical team has access to. However, there are some equipments they must have:
- A suitable laryngoscope blade. This is like a small flashlight with a blade attached to it that helps the healthcare provider see inside the throat and place the breathing tube. The type of blade (MAC, Miller, or combination) depends on the patient’s size and age.
- A suitable endotracheal tube (ET) based on the patient’s size and age. This is the actual breathing tube that gets inserted into the windpipe.
- A suitable stylet. This is a firm but flexible wire placed into the ET tube to give it shape, which makes the tube easier to place into the windpipe.
- A 10 mL syringe to blow up the balloon after putting in the tube. This balloon helps the tube stay in place.
- Medicine to help the patient relax (sedation) if Single Attempt Intubation (SAI), or exposure to relaxing and paralyzing medicines for those performing a Rapid Sequence Intubation (RSI), as permitted by their local medical team guidelines.
- An intravenous (IV) catheter, which may be used during SAI or RSI, or for delivering necessary medications.
- An age-appropriate bag-valve-mask (BVM) with a reservoir and the necessary attachments for delivering oxygen to the patient before and after inserting the breathing tube.
- Suction systems to get rid of any vomit or other secretions.
They should also have backup tools ready, like a gum elastic bougie (a device to help guide the breathing tube into the windpipe), different sized tubes to accommodate variations in patients’ throats, supraglottic airway devices (an alternate way to get oxygen into the lungs if the breathing tube can’t be placed), or video laryngoscopy equipment, if they have it. They may also have tools prepared for a surgical airway, in case of a major airway issue, as permitted by their local medical team guidelines. They should also have a method for confirming that the tube is in the right place, such as end-tidal carbon dioxide (CO2) monitoring equipment, waveform capnography (a way to visually monitor the patient’s breathing), or color change CO2 detectors. Lastly, they will need things like tape or special holders to help keep the ET tube in the right position and personal protective equipment like gloves, mask, and goggles.
Who is needed to perform EMS Field Intubation?
Everyone involved in field intubation, a process of putting a tube into a person’s airway, must have the right training and be skilled at doing it. If possible, this procedure should not be done alone because it’s pretty challenging to prepare for it and safely carry it out, and also handle other vital tasks all at the same time without assistance. Other qualified persons can help with tasks such as assisting with bag-valve-mask (BVM) respirations, which is a device used to help a person breathe, setting up and managing equipment, positioning the patient, and adjusting the position of the airway.
Having more than one person available who can perform the procedure can boost the overall success rate. If the first person trying the procedure doesn’t succeed, another trained professional can step in to try it. This teamwork approach ensures your safety and increases the chances of a successful intubation.
Preparing for EMS Field Intubation
Healthcare professionals should make sure that the patient is in a stable, controlled environment before starting any medical procedures. Ideally, the patient should be lying flat on their back, with the head slightly raised in a ‘sniffing’ position unless this is not suitable due to injury or existing health issues. To help position the patient better, pads may be placed under the back, aligning the patient more effectively.
This arrangement aligns the oral (mouth), pharyngeal (throat), and tracheal (windpipe) areas of the patient’s airway, making it easier for the healthcare provider to see the airway properly. Also, it’s essential to adjust the patient’s height to give the healthcare provider the best possible view of the patient’s airway. However, achieving these ideal conditions may not always be possible, especially in emergency settings or critical situations.
There are some instances where patients have been placed in a sitting or reclining position during entrapment scenarios. But there’s not much evidence to support these methods, and they could even pose a risk to both the patient and healthcare provider.
To be well-prepared, healthcare providers should always be ready for difficult situations and have all the necessary equipment at hand. Attempting the procedure, especially an intubation (inserting a tube into a patient’s windpipe to help them breathe), should be done in a stable environment that’s safe for patients and providers. All vital equipment, including backup options for solving issues with the airway, should be ready before starting the procedure to avoid delays in providing necessary treatment.
How is EMS Field Intubation performed
Intubation is a procedure that involves inserting a tube down a person’s throat to help them breathe. Although the way it’s performed may change a little based on who is doing it and the tools they use, generally, there are a few key steps that all healthcare providers follow:
1. Plan: All the necessary steps and precautions should be carefully thought out prior to starting the process. Both the medical staff and the location must be well-prepared to safeguard the health of the patient and medical team.
2. Preparation: The patient is positioned properly, and all the instruments, protective equipment, and medications are gathered. In pediatric cases, a Broselow Tape (a special measuring tape) is used to help ensure the correct size of equipment and medication doses.
3. Protect: A medic will support the patient’s neck to avoid any accidental damage during a traumatic event.
4. Preoxygenation: Prior to intubation, patients are given high flow oxygen to avert any sudden worsening of their conditions while undergoing laryngoscopy (the examination of the larynx, a part of the throat) and to improve oxygen availability during the procedure.
5. Pretreatment: Lidocaine or atropine may be used helping calm the patient’s physiological response to the procedure. However, the benefits of such premedications can depend on the setting and locality regulations. Frequently, the preferred medications are ones which can effectively sedate the patient, and have a quick onset and short duration.
6. Placement with proof: An endotracheal tube, a specific type of breathing tube, is inserted into the patient’s airway. ETCO2 detection, chest movement, and auscultation (listening to the sounds of your body) are all used to make sure the tube is in the right place.
7. Postintubation management: After the tube is in place, the patient needs to be closely monitored to avoid situations such as low oxygen levels and abnormal breathing rate, which can negatively impact their health. A device called a waveform capnography is used to check the ventilation and continues to verify the tube placement.
This process improves the chances of a successful first attempt, which is crucial to reduce complications. If intubation is attempted more than three times without success, it is generally deemed a failure, and other methods may need to be explored. Regardless of the exact technique used, the provider’s knowledge and skill in managing a patient’s airway and their familiarity with the required anatomical structures are key.
For the actual intubation procedure, the provider holds a laryngoscope in their left hand and pushes the patient’s tongue to the left. The laryngoscope is used to see and control the epiglottis, a flap of cartilage located in the throat behind the tongue, depending on whether a Miller or a MAC blade is used. After getting a clear view of the vocal cords, a tube is inserted past the vocal cords. The provider then makes sure that the tube is in the right place by using a color-change CO2 detector or continuous CO2 monitoring, watching the chest rise, and listening to all lung fields. The provider needs to be cautious while performing all these steps to avoid undoing any harm to the patient.
Now, there might be some instances where the provider is unable to insert the tube successfully on the first try due to not being able to see the required anatomical structures, needing to switch equipment, or inserting the tube in the wrong place. After three unsuccessful attempts, the likelihood of successfully intubating the patient decreases. In such cases, other methods like using airway aids and rescue devices are considered. Ultimately, good training, experience, and regular practice are the best defenses against a failed intubation.
Many suggestions have been made concerning the best practices for becoming proficient in intubation and maintaining that proficiency. NAEMSP (National Association of EMS Physicians) suggests that good intubation competency includes proper formal didactic training, learning with hands-on experience, and continued practicing of the skills. However, it does not mention the minimum number of procedures required to gain and maintain competency but emphasizes the importance of education and regular practice. According to some studies, healthcare providers need to perform around 50 endotracheal intubations to achieve a 90% success rate. On the other hand, prehospital providers require around 4 to 12 endotracheal intubations per year to maintain competency. This is usually challenging for most prehospital providers due to limited resources.
Possible Complications of EMS Field Intubation
Although a method called field intubation, which is done outside of the hospital, has been executed by medical practitioners for a while now, it tends to have more complications than the one carried out within the hospital premises. The most severe problem that could arise from this is misplacement of what is called ET tubes, that can result in a lack of oxygen supply leading to a potentially fatal result.
In a research conducted by Katz and Falk, it was found, surprising as it might be, that these tubes were placed wrongly approximately 25% of the time, out of 108 instances of field intubation studied. This is a significant deviation from other research which said errors in the placement of tubes were less frequent, probably between 0.4% to 12%, though the researchers suspect that the true incidence of misplacement might be higher than what is generally expected. It’s worth noting that most of these studies look back upon reported complications, and can be influenced by biases such as handlers not wanting to admit to errors, which might lead to lower reporting rates of incidents.
There are other complications arising from field intubation, besides misplaced tubes, which include injury to various parts of the nose and throat, creation of false passages, vomiting, pneumonia, overinflation of the lung, autonomic instability (a broad term that refers to changes in blood pressure, heart rate, and body temperature), and hypoxia.
Dunford and his colleagues studied a set of patients and found that over half of the patients experienced a temporary decrease in the oxygen level in their blood, accompanied by a slow heartbeat in around 19% of cases. This happened even when there was standardized training given to paramedics to better prepare patients with lots of oxygen before the intubation procedure, suggesting the need for even better strategies. Protocols should be consistently scrutinized to improve the services of the emergency medical systems.
Post intubation, complications may occur, many of which are due to improper ventilation. In the flurry of events, sometimes a medical professional might pump too much air into the patient through an equipment called a resuscitator bag, which can lead to problems such as injury from overinflation of the lungs, especially in children. To avoid this, it is always helpful to remain calm, count the time between breaths to at least six seconds, use a device called a waveform capnography to continuously monitor breathing, and give only enough air until the patient’s chest can be seen rising.
What Else Should I Know About EMS Field Intubation?
Field intubation is a critical procedure that is often necessary in emergency health situations when it’s crucial to ensure a patient can breathe. It involves inserting a tube into the trachea to provide an open airway. This procedure is usually performed by first responders and other healthcare professionals in the field, such as paramedics or mobile intensive care providers.
Field intubation, however, is quite a complex procedure and can be quite risky. There’s research suggesting that this procedure might even lead to worse patient outcomes compared to simple airway management, mainly because of high failure rates and other complications. Moreover, in emergency scenarios, healthcare professionals may need to manage other critical aspects of patient care, which can be challenging to balance with the complexity of field intubation.
Despite these challenges and risks, there is a recognition that field intubation plays a crucial role in emergency healthcare. Although there is a higher mortality rate in pre-hospital intubations compared to those done in hospitals, this doesn’t lessen the importance of the procedure, as it often gravely needed in emergency situations. It’s just vital that we continue to study and understand how to make it as safe and effective as possible.
The success rates for field intubation procedures have been improving over time, likely due to increased attention and attempts to enhance safety. Also, the discovery of discrepancies in success rates across different emergency medical services (EMS) has allowed for further investigation into the factors affecting such outcomes. We can expect to see more improvements as we continue to focus on understanding and overcoming the challenges associated with field intubation and investing in technology and tools, like waveform capnography and video laryngoscopy, to increase success rates.