Pre-hospital Airway Equipment

The kit & equipment carried by pre-hospital teams must be fit for purpose, meet national guideline requirements and reflect the team’s scope of practice. In this step, Julian Wijesuriya (KSS HEMS Doctor) discusses pre-hospital airway equipment.

Introduction 

Selection of equipment for pre-hospital emergency anaesthesia (PHEA) is complex. The RSI kit dump aims to re-create the hospital anaesthetic room and this must be reflected in the equipment carried by pre-hospital teams. The AAGBI (UK) Safer Pre-Hospital Anaesthesia 2017 guideline states that “standards of equipment and monitoring used for PHEA must match those applied to in-hospital anaesthetic practice”. The minimum essential equipment required to meet these standards is outlined below:

• Monitoring equipment
• Oxygen: sufficient for PHEA and transfer to hospital, with reserve
• Drugs: adequate supply for induction and maintenance of anaesthesia
• Simple airway adjuncts
• Suction: hand or battery operated
• Ventilation equipment: self-inflating bag-valve-mask with an oxygen reservoir
• Intubation equipment: to include an intubating bougie and spare laryngoscope
• Mechanical ventilator: properly serviced and checked with appropriate pressure relief systems and alarms
• Rescue airway equipment: 2nd generation supraglottic airway devices and surgical airway equipment
• Vascular access equipment: intravenous and intra-osseous
• Procedural checklists

One of the main challenges is the fact that all kit has to be portable and carried by pre-hospital clinicians. It also has to fit in an emergency vehicle or aircraft and not exceed weight limits. This means that there may need to be a compromise between logistics and equipment that might be “nice to have”.

Fixed space & weight restrictions for equipment storage

Interactive Equipment Bag

Please click on the link below to explore an example Airway & Monitoring equipment bag.

Interactive Equipment Bag

Kit selection

Suitability for pre-hospital care

Equipment must have certain basic characteristics, such as portability (including size & weight), robustness (including weather resistance & impact protection) and appropriate battery life (where applicable). The manufacturer-specified range of working temperatures must account for those encountered in the local pre-hospital setting and equipment must be usable in the full spectrum of lighting conditions. Any warning alarms must be both audio and visual to account for noisy scene or transport conditions. Consideration should also be given to the length and complexity of any daily and pre-use checks, storage requirements and equipment sterility.

Airway equipment must be suited to the environments encountered

Organisational Considerations

From an organisational perspective there are a number of other important considerations, including:

• Costs
• Complexity & clinician training requirements
  • Initial training and competency maintenance
• Maintenance requirements
  • Servicing frequency & costs
  • Decontamination processes
• Consumables:
  • Robustness of the supply chain
  • Costs
• Environmental impact
• Potential risks/hazards to clinicians or patients

Organisations should also consider how effectively equipment will integrate with other equipment carried within the service and equipment used by local partner services and receiving hospitals.

Specific Equipment Considerations

Patient Monitoring

Patient monitoring must include heart rate, non-invasive blood pressure, oxygen saturation, continuous waveform capnography and electrocardiography (ECG) and observations should be measured and recorded at three minute intervals. Ideally observation data should be uploaded to a patient’s electronic healthcare record (EHR), rather than manually documented, as this better informs handover between clinical teams, increases the robustness of governance processes and facilitates audit & research activity.

Patient observation data in EHR

Difficult and Failed Airway Equipment

Selecting equipment to manage difficult or failed airway scenarios can be challenging, it is rarely possible to carry all the items typically found on a hospital difficult airway trolley. In particular, equipment for fibreoptic intubation is rarely carried by pre-hospital teams.

In addition, it is not practical to accommodate individual clinician preferences, by carrying multiple varieties of equipment fulfilling the same purpose, for example a range of different supraglottic airway devices (SAD), videolaryngoscopes (VL) or emergency front of neck access (eFONA) kits. Services must commit to a common approach, considering the background and competency of its clinicians and ensure that appropriate training is provided.

Equipment Resilience

While there is little capacity to carry unnecessary equipment, the isolation of the pre-hospital environment means that it is prudent to ensure some resilience. It may be necessary to carry spare batteries for powered devices or duplicates of critical items – such as a second laryngoscope handle and backup SpO2 / ETCO2 monitors in case of equipment failure.

It is sensible to carry spare equipment (eg airway modules) in case of back-to-back taskings or multiple casualty scenes. This spare equipment can be packed separately and kept on the response vehicle or aircraft until needed.

Quick, reliable restock of equipment when the team returns to base is important. This is easy to manage with pre-checked replacement bags or pouches which can be swapped for used bags. These bags can also be used as part of a service’s major incident response

Pre-checked & tagged airway modules for immediate team re-supply

Equipment Packing and Checks

The organisation and layout of equipment is often debated and there are no perfect solutions. However, in principle, equipment should be organised in a systematic manner so that items can be found easily in time-critical situations. It is also essential that bags are standardised within a service (including services with multiple operating sites or bases); there is no place for individual modification of bags or pouches based on personal preferences.

All equipment and vehicles should be subject to standardised, two-person checks for missing items, functionality and battery life at the start of every shift. Less frequent, but still regular, checks should also be conducted to ensure no equipment has expired.

Two-person challenge & response equipment checks

Summary

There are many factors to consider when selecting and procuring equipment for pre-hospital airway management. Services often need bespoke solutions based on local logistics, available resources, the clinical context and with consideration for partner organisations. Decisions are often best made by a team of experienced multi-disciplinary clinicians. In addition to carrying appropriate equipment, patient safety is bolstered by rigorous equipment-specific training, robust daily checks and regular equipment servicing and maintenance.