Prehopsital Cricothyrotomy

1. Dr. Andy Anton: Prehopsital Cricothyrotomy Resident Rounds: Critical Concepts in Emergency medical Services Andy R. Anton MD, FRCP(C) Medical Director, City of Calgary EMS and Fire Departments

2. The Issue • A decision has been made to move EMS from a municipally based system to a regionally based system • As a newly hired emergency physician you have just been “volunteered” to sit on a steering committee for the CHR aimed at completely redesigning the EMS system to best meet the current needs of the community

3. Where do we begin ?? • Establish a leadership structure and recruit a leadership team • Experience and understanding of both emergency services as well as the health care system is crucial • Top down approach to recruitment

4. Leadership Recruitment • Medical Director • Practicing Emergency physician • Experience in EMS and knowledge of EMS system design • Experience in quality assurance • Experience in research

5. The History of EMS • Has evolved from and continues to be a subspecialty within Emergency Medicine • Needs to be consistent with local Emerg med practice • Many systems utilize a medical advisory board to ensure medical control consistent with local practice

6. Leadership Recruitment • Operations Director/Chief • Oversees operational aspects of system • Management experience • Experience in labor relations • Experience in finance • Knowledge of EMS system design

7. Leadership Recruitment • Director of Quality and research • Experience in research design and quality methodology • Measures performance benchmarks and recommends change as needed • Response times • Chute times • Dispatch times • Cardiac arrest survival • Intibation success rates

8. Leadership Recruitment • Director of Staff Development/training • Experience in education and curriculum design • Experience in computers and IT • Experience in patient simulation

9. Leadership Recruitment • Operations Director • Oversees day to day operations and ensures equipment and resources are adequate

10. So we have a management team… Whats next ?? • Dispatch Center • Must be coordinated with Fire and Police dispatch • Must have adequate staffing (?paramedics) • IT equipment and support • Dispatch system (MPDS) • Must record and report response times • Coordinates communication with area hospitals

11. Medical Directors Office • Responsible for Medical Control • Direct • indirect • Protocols • Evidence based • Integrate local practice and policy • Take into account resources, experience and training capacity

12. What type of system ? • ALS or BLS ? • Single Tiered or Dual Tiered ?

13. ALS… pros and cons • Pros • High level of care theoretically available for every call • Advantage of using paramedics in nontraditional roles (hallway medicine) • Cons • Lack of exposure to high risk low frequency procedures • Lack of outcome evidence to support ALS care

14. Medical Control Guidelines • Wide spectrum ranging from very conservative to very progressive • Some allow ++ autonomy for medics • Local versus regional/provincial protocols • Best protocols are evidence based • Prehospital research is limited, particularly with respect to outcome studies

15. Medical Control Guidelines • Current desire from AB health is to develop provincial protocols • Highly specific local protocols • STEMI • RSI • Tx and release (hypoglycemia and SVT) • Stroke • Specialty teams (TEMS, Air Med, IRP etc)

16. Controversies in Prehospital Care • RSI/ETT • System response benchmarks • Treat and release • Hallway care

17. Discussion

18. The Patient • 25 year old male laying prone on roadway • Unresponsive, Pulseless, Apneic • Trismus with vomitus in airway • Distended abdomen • Unstable pelvis • Left testicle injury • Rectal bleeding • Left leg injuries

19. Details of the Call • Spinal precautions • Begin transport to foothills • Airway (decision to cric.) • CPR • Cardiac monitor (PEA) • IV access • Patch

20. Time Components • 1140 AM – 911 initiated, EMS dispatched • 1142 AM – Medic One arrives on scene • 1145 AM – Transport of patient initiated to foothills ER • Total time from “Bumper to Bed” – 14 min. • ER staff successfully resuscitates patient

21. Discussion

22. The million dollar question...

23. Can prehospital Rapid Sequence Intubation (RSI) be done safely and effectively and does it decrease the need for surgical airway management ?

24. Literature Review

26. Neuromuscular blockade in aeromedical airway management • Murphy-Macabobby et al, Annals Emerg Med 21:6 pg 664 (1992) • 119 pts requiring airway management in aeromedical program (nurse/paramedic); 115 successfully intubated, 4 required cricothyrotomy due to conditions prohibiting oral intubation • no significant complications attributed to neuromuscular blockade

27. Rapid sequence induction for intubation by an aeromedical transport team: A critical analysis • Sing et al, Am J Emerg Med 1998(6):598-602 • looked at relationship between intubation mishaps and pulmonary complications in trauma pts in a system using RSI • concluded that pulmonary complications related to severity of injuries, not intubation problems

28. Rapid Sequence Induction Intubation of trauma pts in the prehospital vs hospital setting • Abstract-1996 ACEP meeting • retrospective review and comparison of air medical vs ED RSIs from 1988 to 1995 • found no difference in success rates or complications other than pneumonia which was more common in the prehospital group (28% vs 6%)

29. Intubation success rates improve for an air medical program after implementing the use of neuromuscular blocking agents • Ma et al, Am J Emerg Med 16(2):125-127, Mar 1998 • 5 yr retrospective review of 1 air medical program using paralytics and another which implemented RSI 2 yrs into the study • intubation success rates in program that implemented RSI went from 69.6% to 97.5% overall which was comparable to the program that had the RSI throughout the study period

30. Emergency scene endotracheal intubation before and after the introduction of a rapid sequence induction protocol • Retrospectively studied consecutive patients requiring intubation before (114 pts) and after(95 pts) RSI implementation in an air medical system • groups did not differ in rate of successful intubations or cricothyrotomys but RSI group had scene time increased by mean of 4.4 minutes

31. The effect of a rapid sequence induction protocol on intubation success rate in an air medical program • Lowe et al, Air Med J-1998 Jul-Sep 17(3): 101-4 • retrospectively reviewed intubation success rates before(100 pts) and after (98 pts) • success rate pre was 79% vs 84.7% post

32. Prehospital Use of neuromuscular blocking agents in a helicopter ambulance program • Prospectively examined use of paralytics by nurse/paramedic teams in pts intubated at sending hospital vs at accident scene (nurse/paramedic doing intubation in all cases) • intubation success rates were 96% in pts who received paralytics vs 54% prior to admin of paralytics

33. Out of hospital use of neuromuscular blocking agents in the United States • Mcdonald et al, Prehosp Emerg Care 1998 Jan-Mar 2(1):29-32 • National survey to determine usage of neuromuscular blockade in prehospital care • found 29/50 states used paralytics, 11 of these use it in aeromedical program only • conclude that there is steady trend toward services launching paralytic use and that paralytic drug use by paramedics is becoming standard of care in many out of hospital systems

34. Out of hospital rapid sequence induction for intubation of the pediatric patient • Sing et al, Acad Emerg Med 1996 Jan 3(1) 41-5 • retrospectively reviewed 40 consecutive prehospital RSIs performed by flight medics, mean age 8.1 yrs • 3 pts developed bradycardia of which 1 became hypotensive, seven pts developed pneumonia but no pulmonary complications were attributable to RSI • concluded that RSI is safe and not associated with any intubation mishaps in this study

35. Effect of Out of Hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial • Gausche et al, JAMA, Feb 9 2000 283(6) 783-90 • randomized trial compared survival and outcomes of ped.pts who received BVM alone or followed by ETI • conclude that ETI does not improve survival or neurological outcome

36. Limitations in Our Knowledge • Limited information reporting prehospital cricothyrotomy rates in urban EMS systems • it’s unclear whether RSI decreases surgical airway rates in the prehospital setting

37. Prehospital Paralytics in Alberta

38. RSI In Alberta Survey • Telephone survey • Of 18 EMS services contacted in Alberta, 11 currently have RSI protocols, 4 have RSS and are implementing RSI. The standard protocol (8) uses, Midazalam, Fentanyl and Succinylcholine. 2 use Vecuronium, 1 uses Etomidate.

40. Calgary EMS Airway Data

41. Calgary Data (Retrospective) • Total number prehospital intubations performed by Calgary EMS • (1998) = 337 • (1999,1st Qtr.) = 64 • ??%intubation success rate * • limited experience makes maintenance of competence a major issue * based on Calgary Intubation study Dr. P Gant

42. Calgary EMS Surgical Airway Data

43. Calgary Data (Retrospective • Total number ofCricothyrotomys Performed

44. Indications for Prehospital Cricothyrotomy • 30 total • trismus 12 • blood or vomitus in airway 3 • airway burn injury 1 • oropharyngeal trauma 3 • airway foreign body 2 • inability to intubate 7 • not documented 1

45. Indications for Cricothyrotomy • 19/30 (63.3%) cricothyrotomys performed for trismus or inability to intubate • a significant percentage of this patient subset would be appropriate for prehospital neuromuscular blockade

46. Inability to intubate • Inability to intubate may be related to: • patient factors (trauma, burns, anatomy, etc) • equipment and medication deficiencies • lack of training (especially hands on) • lack of ongoing experience (Calgary is an all ALS system)

47. Data Analysis • Data set: total number patients transported by Calgary EMS with GCS< or = 6, where an OPA, BVM or O2 was used without intubation. • N = 130 calls

48. # of unsuccessful intubations 1999 1st Quarter • N= 13 Based on calls where Paramedics attempted to intubate and were unsuccessful

49. The Protocol

50. Calgary EMS RSI Protocol