Overview of EMS Airway Management in Adverse Conditions
Keeping the airways open and ensuring regular breathing are vital to keep oxygen flowing in the body. This allows our normal body functions to continue without any complications. These factors become even more important when a person is suffering from a severe illness or injury, which can increase the body’s demands. For this reason, the capability to manage airways effectively is a crucial skill for healthcare professionals working in emergency medical services (EMS) outside of a hospital.
The unpredictable and often challenging conditions outside of the hospital set-up can create unique problems not usually found in hospital-based emergency care. For instance, a patient could be in a hard-to-reach position. Additionally, there could be limited support, a shortage of necessary supplies, or insufficient lighting. All these factors can make it hard for EMS professionals to manage a patient’s airways. They may need to change their usual methods and decisions based on the situation. This document talks about some specific examples of these technical and non-technical challenges that may arise. It also provides overall principles for managing a patient’s airway under difficult outside-hospital conditions.
Anatomy and Physiology of EMS Airway Management in Adverse Conditions
Your airway is the path that air follows to get from your nose and mouth down into your lungs. This pathway includes your nose, mouth, throat (pharynx), voice box (larynx), windpipe (trachea), and the tubes that branch off the trachea to carry air to the lungs (bronchi). All these areas are lined with a special layer called mucous membrane.
Your nose is divided into two parts: the outer nose that you see, and the nasal cavity inside. The nasal cavity is split into two sections by a wall in the middle, called a septum. The walls of the nasal cavity are made up of various bones. The nose can be used to deliver oxygen to the patient through a tube known as a nasal cannula. Alternatively, tubes can be passed through the nose to help with breathing.
Your mouth, on the other hand, contains a space surrounded by your upper and lower jaws (maxilla and mandible) and your teeth. The roof of your mouth is made up of two parts: the hard and soft palate. The space behind your mouth is known as the oropharyngeal isthmus.
Your throat is divided into three parts, from top to bottom: the nasopharynx, behind the nasal cavity and contains adenoids; the oropharynx, behind your mouth and has tonsils at the sides; and the laryngopharynx, from the epiglottis (a flap that prevents food from entering your windpipe) to the sixth vertebrae in your neck. The walls of your throat are made up of multiple muscle layers.
The voice box, or larynx, is made up of cartilages, ligaments, and muscles. The biggest structure in the front is the thyroid cartilage, commonly known as the Adam’s apple. Beneath it is the ring-shaped cricoid cartilage. Between these two structures, there is a small space with the cricothyroid ligament. Behind the thyroid cartilage is the laryngeal cavity, which houses the upper (false) and lower (true) vocal cords.
Lastly, airway management, when needed, involves the passing of an airway device below the level of the vocal cords. This device helps protect the lower airways from debris while allowing controlled oxygen delivery and support for breathing, when required.
Why do People Need EMS Airway Management in Adverse Conditions
Managing a patient’s breathing is often necessary in emergency medical situations, such as when a person has difficulty getting enough oxygen or making the effort to breathe, or when they can’t keep their airway clear because of an illness or injury.
In these situations, it’s important to choose the best way to ensure the patient can breathe safely and easily. This method should be chosen carefully, keeping in mind the need to see clearly, clean the passage with a suction device, and insert the required device gently. It’s important that this doesn’t cause low oxygen levels in the patient’s blood. To prevent this, techniques such as apneic oxygenation (adding oxygen while the patient is not breathing) and nitrogen washout (removing nitrogen from the lungs to improve the efficiency of oxygen uptake) can be used.
If the first method chosen is not successful, a backup method should quickly be used to secure the patient’s ability to breathe. However, this might have to be done without being able to prevent a temporary drop in oxygen levels. Backup methods can include using a video or a tool called a bougie to view and access the throat, or using a laryngeal mask airway (LMA), which helps the patient breathe by covering the entrance to their windpipe.
If these methods fail, or if the patient is too unwell to wait, an emergency method must be chosen and applied quickly. This method should be one that allows for fast implementation and is familiar to the medical professional.
When a Person Should Avoid EMS Airway Management in Adverse Conditions
Getting enough oxygen is critical for survival. So, there are no conditions in which supplying oxygen is completely off-limits. However, certain treatments may not be the best choice depending on the patient’s situation. For example, intubation, which involves inserting a tube down the throat to help with breathing, should be done only by trained medical professionals and only when its potential benefits outweigh potential risks.
In some cases, doctors may need to limit how much they interfere with a patient’s breathing process. For example, for children suspected to have a condition called epiglottitis, which is a severe throat infection, intensive out-of-hospital procedures could make the situation worse. Equally, if a patient has factors that could make intubation difficult and less invasive methods are working well enough, it may be better to steer clear of intubation.
Equipment used for EMS Airway Management in Adverse Conditions
There are numerous techniques used by medical professionals to manage and control your airway during different medical situations. They require different levels of expertise and each has its own benefits and potential risks depending on the situation. Here are some examples:
1) Manual airway management movements – these include the head-tilt-chin-lift method and the jaw-thrust method.
2) Oxygen devices – these deliver oxygen in high amounts directly into your nose.
3) Insertion of oropharyngeal or nasopharyngeal airways – these are small tubes inserted into the nose or mouth to keep your airway open.
4) Bag-valve-mask device – a device that helps to push air into your lungs when you cannot breathe on your own.
5) Supraglottic airways – devices put into your throat to help you breathe.
6) Continuous positive airway pressure (CPAP) devices – machines that help those who have trouble breathing, especially during sleep.
7) Direct laryngoscopy with endotracheal intubation – a procedure in which a tube is inserted into your windpipe via your mouth or nose to help you breathe.
8) Nasal intubation – a special technique where a tube is inserted into your windpipe via your nose.
9) Rapid sequence intubation (RSI) – a fast process that uses sedatives and muscle-relaxing drugs to put a breathing tube into your windpipe.
10) Drug-assisted or facilitated intubation without muscle relaxants – similar to RSI but without using muscle-relaxing drugs.
11) Airway intubation adjuncts – other devices like bougies, styles, or video laryngoscopes that help in inserting a breathing tube into your windpipe.
In emergency situations when there’s difficulty accessing the airway through mouth or nose, medical professionals may have to access the airway through the front of the neck, such as needle cricothyrotomy or surgical cricothyrotomy.
Who is needed to perform EMS Airway Management in Adverse Conditions?
Everyone who works in emergency medical services (EMS – these are the people who respond to emergency situations like a car accident) should have a basic understanding of and training in airway management. Airway management is about making sure that patients can breathe properly. Sometimes, when a person has had a major injury, they cannot breathe on their own. So, EMS providers may need to step in and help.
Some EMS providers may need to do advanced procedures such as intubation. Intubation is when a tube is inserted into the patient’s throat to help them breathe. To do this, they should have enough training, experience and continuous mentoring to keep their skills fresh. Intubation and other advanced techniques usually need more than one trained person. That’s because a patient might need different types of help at the same time. It’s best not to do these tasks alone, if possible.
Preparing for EMS Airway Management in Adverse Conditions
Before doctors can treat a patient, they need to make a detailed plan that takes many factors into consideration. These factors can be grouped into three categories: patient-related, staff-related, and environment-related.
Patient-related factors include things that might make it harder for doctors to help the patient breathe, such as facial injuries or vomit. The plan should also take into account how the patient is positioned, as well as their physical and mental health. If possible, the doctors will try to improve these factors before treatment begins.
Staff-related factors are about the healthcare professionals that are present. This includes things like their level of training and experience, whether there are enough people to help, how tired or stressed they are, and how familiar they are with the equipment they will be using.
Environment-related factors can vary a lot. They could include the time of the day, how much light is available, the temperature, how high above sea level the patient is, weather conditions, how far away the nearest hospital is, and whether the environment is safe (especially in military settings). During a flight, doctors need to keep an eye on the air pressure in the breathing aid. This is because the air pressure can change during the flight. Also, the tools they use to help them see the patient’s throat (video laryngoscope) may not work properly if it is too hot or too cold, so they should always have a backup plan ready.
How is EMS Airway Management in Adverse Conditions performed
If you are in an environment with very poor light, either too little or too much, it can be a problem when preparing for a medical procedure. This is particularly problematic during procedures that require an open airway, such as intubation (inserting a tube down the throat to help with breathing), which needs to be precisely placed. In cases where the light is too bright and causing a glare, people around can help by using a sheet or other object to reduce harshness. In dimly lit situations, additional light can be provided by using artificial sources or head-mounted lamps. In emergencies, if there’s no light source, the provider can insert an intubation tube guided by feel only, but this is risky and not frequently done.
Patients in emergencies outdoors are often found on the ground, making it more difficult for the medical team to reach them. This can also make it harder to place the patient in the best position for certain procedures, like having them lie down flat on their back. During these situations, people can perform simple techniques, like tilting the patient’s head or inserting an airway device manually to help with breathing while more medical help arrives.
If a patient is overweight, it can make it harder to manage their airways due to the increased soft tissue around the neck and breathing areas. When lying flat on their back, breathing can be more difficult due to their weight and size, leading to lower oxygen levels and making breathing assistance harder. It’s important therefore to make sure their airways are as open as possible by aligning the patient’s earlobe with the breastbone.
In emergency situations outside a hospital, there may be fewer medical professionals to help, and sometimes the equipment available might be limited. It’s necessary to be resourceful during these circumstances and utilize basic techniques to maintain the patient’s oxygen levels and ensure they can breathe while waiting for more assistance.
Possible Complications of EMS Airway Management in Adverse Conditions
Most people don’t have any physical difficulties with their airways, which are the passages that carry air from our nose and mouth to our lungs. However, in emergencies, especially outside of hospital settings, some people might have what doctors call “physiologically difficult” or “situationally difficult” airways.
“Physiologically difficult” means that even though the airways look normal, they are not working properly. This might be because the patient hasn’t been able to breathe in enough oxygen, or they may have other serious illnesses at the same time. “Situationally difficult” means the environment or setting is causing difficulties. For example, there might not be enough skilled help, the patient’s position may not be right, there may not be enough time, or other unfavorable conditions could be present.
When dealing with airway problems, there can be complications like accidentally getting food or vomit in the lungs (“aspiration”), inserting a tube into the esophagus by mistake instead of the windpipe (“esophageal intubation”), a lack of oxygen (“hypoxia”), or other major health problems (“physiological derangement”).
Before doing complex procedures like putting a tube down the patient’s throat to help them breathe (“intubation”), emergency medical service (EMS) clinicians need to prepare a plan for dealing with any immediate complications. These plans might include removing the device and replacing it with another or deciding on a series of steps for when a first approach to manage a difficult airway fails, possibly even needing to make an opening at the front of the neck (“front of neck access”).
What Else Should I Know About EMS Airway Management in Adverse Conditions?
Managing your airway, or making sure you can breathe properly, isn’t a simple process. Past research has found that when putting a tube into a patient’s windpipe, a process called tracheal intubation, is challenging, complications can occur more frequently. Over recent years, it’s become less clear whether doing this procedure outside the hospital provides a significant benefit for many health conditions, when you consider the potential problems that can arise.
The decision to use advanced techniques to manage the airway may need to be limited in cases where a patient’s health condition or underlying illnesses could make the procedure more risky. Making these careful decisions may be linked with a lower chance of negative outcomes.