Introduction & Challenges of Pre-Hospital Airway Management

In this article Julian Wijesuriya (KSS HEMS Doctor) describes what pre-hospital care is, who provides it and what challenges can be encountered.

What is pre-hospital care?

Pre-hospital care is emergency medical care that is provided to patients outside the hospital setting. Patients may present with the full spectrum of conditions from minor ailments requiring simple first aid to life-threatening illness or injury requiring advanced organ support.

Healthcare professionals working in the pre-hospital setting provide the initial assessment of patients, medical management and, if necessary, facilitate the safe transfer of patients to an appropriate secondary healthcare setting.

The “pre-hospital arena” is not a discreet setting with a single set of conditions or circumstances. Patients of all ages and co-morbidities may present in any urban or rural setting; they may be outdoors or within buildings and vehicles, in some cases they may be physically trapped. The scene itself may be hazardous and further influenced by the time of day, the weather and the availability of resources.

Who provides pre-hospital care?

Pre-hospital care is usually overseen by regional ambulance services, supported by charitable organisations, volunteer services and enhanced care teams.

Pre-hospital care is delivered by a range of providers including:

• Volunteer services
  • First-aiders
  • Community first-responders
  • Charitable ambulance services (eg British Red Cross & St John’s Ambulance)
  • British Association for Immediate Care (BASICs) schemes
• NHS Ambulance Trusts
  • Ground EMS services (eg bicycle, car, ambulance & motorcycle paramedics)
  • Specialised services (eg hazardous area response teams, tactical medical teams & critical care paramedics)
  • Enhanced care teams (typically comprising a specialist paramedic / physician team)
• Air Ambulance Services
  • HEMS teams (typically a paramedic / physician team)
• “In-house” Services
  • Police medics
  • Fire & Rescue Service medics
  • Mountain rescue / HM coastguard / RNLI services
  • Military combat medical technicians

The spectrum of pre-hospital clinicians

The scope of practice for individual pre-hospital care providers depends on their clinical background, training and organisational protocols. (This course does not mitigate deviation from national standards or professional scopes of practice.)

Pre-hospital airway management

Patients can present in the pre-hospital setting requiring emergent airway management as a result of critical illness, traumatic injury or cardiac arrest. Many of the techniques discussed earlier in the MOOC may be required to open and secure the airway – from basic airway opening manoeuvres and simple adjuncts through to rapid sequence induction of anaesthesia and intubation. However, processes need to be adapted to be effective and safe in the pre-hospital setting. Above all, patient monitoring, optimisation and airway management must be delivered to the same standards as they are in-hospital.

Challenges:

When thinking about the challenges of pre-hospital airway management it can be helpful to consider and compare with the ideal setting – the hospital anaesthetic room. Here clinicians are comfortable, working in a warm, quiet, well-lit environment; the patient is fully monitored, positioned at an appropriate height; all potential equipment and drugs are neatly organised and immediately available; and teams working together have met in advance, introduced themselves and discussed the case.

Environment – anaesthetic room

This is in stark contrast to the pre-hospital setting, where clinicians may be faced with unstable patients, with hyper-acute pathology and multiple management priorities who are on the floor or trapped in a confined space. Patients may have limited monitoring applied and specialist equipment may not be immediately available. The environment may be uncomfortably hot or cold, dark and lacking any protection from wind and rain. The scene may present serious hazards and be further complicated by aggressive or emotional bystanders. To make matters worse, teams working together are unlikely to know each other; they may have different operating procedures or priorities for the scene and communication can be further hindered by noise or PPE.

Environment – prehospital scene

Unlike in the hospital setting, pre-hospital clinicians are not simply required to manage a critically ill patient, they have to simultaneously manage the environment, the scene and the team. They also have to manage themselves – controlling their emotions and stress in response to upsetting circumstances or complex cases. With so many time-critical responsibilities and tasks, it is very easy for individuals to become cognitively overloaded and for the whole situation to spiral out of control.

Summary of pre-hospital challenges and management priorities

Making Pre-hospital Airway Management Safe

Because of the challenges presented in the pre-hospital setting, airway management has the potential to be both difficult and high-risk. Meeting these challenges and mitigating risk requires consideration and process – before, during and after patient care. Clinicians delivering pre-hospital airway management need to be selected (for both clinical and non-technical skill) and receive dedicated training. They must also be subject to robust governance and comply with national guidance. Teams should have access to appropriate drugs and equipment and follow a standardised processes for delivering advanced airway interventions.

Through these strategies it is possible to manage chaotic scenes and complex patients in a structured manner and safely deliver pre-hospital anaesthesia and advanced airway management.

Overview of safe pre-hospital airway management strategies

Over the course of the next week we will look at these areas in more detail, in order to provide an overview of safe and effective pre-hospital airway management. In the next step, Dr Duncan Bootland will discuss clinician selection, training and clinical governance.