Overview of EMS Field Intubation
Field intubation is when emergency medical personnel place a special kind of tube, known as an endotracheal tube, in a person’s airway outside of a hospital setting. This is usually done to help control the patient’s breathing and supply them with oxygen. There are also other ways of making sure a person can breathe properly such as nasotracheal intubation, supraglottic airway devices, continuous positive airway pressure (CPAP), and bilevel positive airway pressure (BPAP) machines. However, this article focuses on endotracheal intubation, which has been the preferred option in emergency situations outside the hospital.
While endotracheal intubation has been used for a long time, there has been some debate over its effectiveness. This is because there have been cases where the procedure failed or caused complications, especially when compared to intubations done inside a hospital.
However, in some cases, controlling a person’s airway becomes extremely crucial, such as when the patient has lost the ability to breathe on their own. In these instances, being able to perform field intubation is an important skill for emergency medical responders. This is why it’s important that they understand the correct technique and when to use it. Their decision to do intubation should also be guided by local rules and guidelines.
The decision to do such a procedure should be carefully considered. It is a difficult procedure and can lead to additional problems. Whether or not intubation is done can also depend on the individual provider’s comfort level with the procedure. If they aren’t familiar or comfortable with field intubation, they might choose another option like using a supraglottic airway or a CPAP and BPAP machine. These can be better and safer alternatives in some situations.
Field intubation should be used when a patient has lost or is about to lose their ability to breathe on their own, or when they need more ventilation support than can be provided with a bag-valve-mask (BVM) and other breathing aids. To be successful at field intubation, training, practice, and preparation are needed along with the right patient evaluation and selection.
Even with its long history in emergency medical response, there isn’t enough evidence to confirm if it helps in reducing illness or death rates. Current research is more focused on the success and complication rates of this procedure. Future research should work on identifying new techniques, technologies, and training methods to improve the results of field intubation.
Anatomy and Physiology of EMS Field Intubation
The areas that healthcare providers need to know about for tube insertion via mouth into the airway (field intubation) include the back of the throat (oropharynx), the voice box (larynx), the food pipe (esophagus), and the beginning of the airway. It’s crucial for providers to identify certain features in these areas to perform the procedure successfully. During this procedure (called direct laryngoscopy), they should locate parts of the mouth and throat like the epiglottis (a flap that covers the windpipe during swallowing), arytenoids (cartilages which help open and close the voice box), and vocal cords.
Differences in patient anatomy, such as where the epiglottis and vocal cords are located in relation to the front or back of the mouth and throat, or the airway size for different body forms and ages, can make tube insertion difficult. Several tools, like mneumonics, acronyms, and scoring systems can help identify challenging airway characteristics. A commonly used acronym for predicting difficult airways is LEMON, which stands for:
- Look externally
- Evaluate the 3-3-2 rule
- Mallampati score
- Obstruction
- Neck Mobility
When looking at the patient externally, the healthcare provider should check for any signs that could make the procedure more challenging. Physical features such as short or thick necks, being overweight, dental conditions like underbites and overbites, missing teeth, or face injuries making the airway unstable, can make the procedure more difficult.
The 3-3-2 rule comprises three anatomical measurements: a patient should be able to open their mouth three finger widths; there should be three finger widths from the chin to the hyoid bone (found in the neck) along the lower jaw, and two finger widths from the hyoid bone to the thyroid notch (in the neck). Changes in these measurements can indicate a patient with tricky anatomy for intubation.
The Mallampati score is another useful way to help identify challenging airways. It is a score from I to IV given to a patient based on what could be seen inside their mouth when it’s open. The score ranges from I indicating an ideal airway where all structures at the back the throat are fully visible, to IV indicating the most challenging cases where no structures at the back are visible.
Obstruction refers to any condition that could obstruct the visualization and insertion of the tube into the windpipe, like injuries, swelling, or masses in the mouth or neck. Limited neck mobility due to neck braces, injuries, or existing health conditions can make it hard for the provider to position the airway for a successful procedure.
In a study, factors predicting the difficulty of airway tube insertion included– airway swelling, blood, facial trauma, large tongue, short neck, C-spine (neck) immobility, vomit, obesity and a short lower jaw. The presence of more than one of these factors significantly increased the likelihood of unsuccessful tube insertion. The researchers suggested the BE FAST (Blood, Emesis/Vomit, Facial trauma, Airway edema/Swelling, Spinal immobilization or short neck, and large Tongue) acronym to identify the most common factors predicting difficult airways. These predictors can also be identified using the LEMON method mentioned above.
Why do People Need EMS Field Intubation
Doctors may need to perform a specialized procedure to help a patient breathe (this procedure is called “an advanced airway” procedure) if the patient faces challenges in two broad situations: when they can’t keep their airway open or when they are unable to sufficiently take in oxygen and expel carbon dioxide on their own.
The reasons behind these challenges can vary and be quite diverse. They might happen due to:
- Decreased consciousness levels worrying doctors about the patient losing their airway control (this decrease in consciousness is often measured using something called a Glasgow coma scale, and a score less than 8 can be an issue)
- Failure to breathe in enough oxygen or breathe out enough carbon dioxide
- Heart stoppage
- Risk of choking on vomit, bodily fluids, or blood
- Blockage of the airway
Each medical provider’s protocols will clarify exactly when performing an airway procedure in a non-hospital setting is necessary. These protocols help guide doctors to take the best course of action. In addition, real-time guidance from a team of doctors, typically provided online, can also provide valuable instructions to doctors on scene, all in an effort to improve patient outcomes.
When a Person Should Avoid EMS Field Intubation
There are some situations where doing a field intubation, which is a procedure where a tube is placed into the windpipe through the mouth to help a person breathe, might be a bad idea. This is a complex procedure that doesn’t always go as planned. If it’s not possible to do this procedure safely for the person involved and the medical professional doing the procedure, then it shouldn’t be done.
Examples of such situations include a chaotic or dangerous environment, or if the medical professional on-site isn’t trained to do a procedure called endotracheal intubation, a type of breathing assistance, or if the correct equipment isn’t available. There are also special cases where the condition of the patient can increase the difficulty of the procedure. For instance, if the person has been seriously injured or has a disease that prevents them from opening their mouth, or if they have too much mucus, vomit, or blood in their mouth that may prevent the medical professional from seeing the windpipe clearly.
Additionally, if the person has health issues that can impact the use of certain drugs that can be used to sedate or assist in intubation, then it might not be safe to do a field intubation. It’s also vital that this procedure should never be done to people who are drunk or uncooperative unless there’s a medical reason to do so. If the patient needs to be sedated or paralyzed for their safety or provider’s safety, it should only be done rarely.
Another reason not to do a field intubation is if the patient can quickly be taken to a medical facility. In such cases, especially in city environments, it may be more practical to help the patient breath with a Bag Valve Mask (BVM) or stabilize them with a Continuous Positive Airway Pressure (CPAP) device until they reach the hospital. The time spent preparing for and doing the procedure in the field might be better used by getting the patient to a hospital. However, in rural areas where it might take longer to reach a hospital, or for air medical personnel, it’s usually more practical to control the patient’s airway in the field as the patient can decompensate, or get worse, or the procedure might be more challenging to perform while in transit.
Equipment used for EMS Field Intubation
When a medical professional is providing emergency breathing help (known as intubation) out in the field, they typically use the tools and equipment they’re most familiar with. Which tools they choose can depend on their personal preference and the guidelines of their organization. At the bare minimum, they need the following:
* A laryngoscope blade of an appropriate size – this is a special tool with a light source that allows them to see the patient’s vocal cords.
* An Endotracheal (ET) tube that fits the patient’s anatomy and age – this is a plastic tube inserted into the patient’s windpipe to help them breathe.
* An appropriate size wire-like tool (stylet) to help place the ET tube.
* A 10-mL syringe used to inflate a small balloon to secure the tube after it’s been inserted.
* Medications for controlling pain and possibly causing temporary paralysis as per local guidelines. These medications help the patient tolerate the tube.
* A device (known as an IV) to provide access to the patient’s bloodstream if these medications need to be given, or if other emergency medications are required.
* A Bag Valve Mask (BVM) that fits the patient’s size – this device is used to manually help the patient breathe before and after the tube is placed.
* Suction equipment to clear the trachea of vomit or secretions.
They may also need rescue equipment in case the first attempt doesn’t go as planned. This can include a thin tube called a gum elastic bougie to help insert the ET tube, multiple tube sizes due to narrow windpipe or individual differences, devices to keep the airway open at the throat area, or a video laryngoscopy equipment. In very rare circumstances where an airway can’t be secured with regular tools, a surgical airway device may be required as per local protocols. To confirm the ET tube is in the right place, they may use monitoring equipment for carbon dioxide levels, or visual indicators revealing changes in carbon dioxide levels. The ET tube is then secured in place using tapes or specifically designed tube holders. For safety, they will also use gloves, masks, and goggles to protect themselves.
Who is needed to perform EMS Field Intubation?
In order for someone to perform an emergency on-the-spot breathing tube insertion (also known as field intubation), they need to have the right training and skills. This is a critical procedure and it’s best not to do it alone if you can avoid it. It’s very tricky to get ready for this procedure and do it correctly while also managing other tasks related to resuscitation without someone else there to help you.
Extra help can be useful for things like manual breathing support (BVM respirations), setting up and controlling the equipment, getting the patient in the right position, and handling the external throat area (laryngeal positioning). The process of putting a breathing tube in is more likely to be successful if there are multiple skilled healthcare providers available who can attempt the procedure. This way, if the first person isn’t successful, another provider can give it a try.
Preparing for EMS Field Intubation
When doctors need to place a breathing tube, or intubate, a patient, it is ideal to control the surroundings as much as possible. If possible, the patient should lie on their back with their head tilted slightly upwards, unless this could potentially harm the patient due to any existing injuries or medical conditions. To help correctly align the patient and their airway, doctors may use pads underneath the patient’s back. This correct alignment provides a clear view and direct access to the patient’s mouth, throat, and windpipe; these are known as the oral, pharyngeal and tracheal planes.
The patient’s height should be adjusted so that the doctor performing the procedure can have an optimal view of the patient’s airway. However, these ideal conditions may not always be feasible out in the field or in difficult circumstances. There have been cases where patients have been intubated while seated or in a reclining position when they were trapped or unable to lie down, but there isn’t much solid evidence to show that these methods work well and they could potentially be risky to both the patient and the health care provider.
The best preparation is always to anticipate a challenging situation when intubating, and to have all the necessary tools at hand. All efforts should be made to perform the procedure in a stable and safe environment for both patients and doctors. This also includes having all essential tools and backup support ready to go before starting the procedure, in case any problems arise and immediate help is needed.
How is EMS Field Intubation performed
Intubation, the process of inserting a tube into the trachea (the windpipe), can be performed differently depending on the person conducting the procedure and the equipment available. Here, we will go over the main principles that should be followed when intubating a patient.
The guidelines we use to make sure that we perform the procedure correctly and safely are called the ‘P’s’ of airway control and intubation. This simple acronym helps healthcare providers remember the steps.
1. Plan: The healthcare provider must have a strategy in place before starting the intubation process. They need to check the surroundings to ensure the safety of everyone involved.
2. Preparation: The patient must be positioned correctly and all necessary medications, protective gear, instruments should be available. Everyone involved must understand the process and the care plan following the intubation. In case of a child patient, a tool called a Broselow Tape is useful to ensure the right equipment size and medication dosage.
3. Protect: In case of a traumatic injury, another healthcare provider should hold the patient’s neck (cervical spine) still to avoid injury. Oxygen is provided, normally through a mask or ventilator, to prevent a drop in oxygen levels during the procedure.
4. Pretreatment: Sometimes, certain medications are given to the patient before intubation. These medicines help to reduce certain bodily responses to intubation. However, whether these are necessary may depend on local healthcare rules and the specific situation.
5. Paralysis and Induction: The patient is sedated or paralyzed to allow for the procedure. Medications with rapid effects and short durations are typically used in case there’s a need to quickly reverse their effects.
6. Placement with Proof: The endotracheal tube (tube going into the trachea) is inserted while the procedure is directly observed. The placement of the tube is then confirmed with multiple methods. Afterward, the patient is sedated according to local protocols, and their breathing is closely monitored to avoid any adverse effects.
7. Postintubation Management: Following the procedure, the patient’s comfort and safety are ensured by carefully managing their breathing to avoid hazards that could affect their recovery.
The person performing the intubation needs a clear understanding of the throat anatomy to do the procedure correctly. They also need to be cautious while handling the tools, especially the laryngoscope (the instrument used to view the vocal cords) to avoid causing damage to the patient’s mouth and throat. The tube is inserted carefully past the vocal cords and is then confirmed in place by multiple methods.
It’s important to note that intubation may not always be successful on the first attempt. Providers typically get three tries before classifying the procedure as unsuccessful. Depending on the situation, alternative measures may then be taken, such as a rescue device. The best way to prevent failed intubation is to have good training and experience.
Tips on improving and maintaining airway procedure skills have been suggested, but nothing beats experience. A healthcare professional generally needs to perform 50 intubations to achieve a 90% success rate. To maintain proficiency, a prehospital provider (someone providing emergency medical care before arriving at the hospital) usually needs to perform 4 to 12 endotracheal intubations a year.
Possible Complications of EMS Field Intubation
While emergency medical professionals have been trained to insert a breathing tube, or intubate, patients outside a hospital setting, this process can sometimes run into complications. The most dangerous of these is when the breathing tube isn’t put in the correct place, which can lead to a lack of oxygen reaching the brain and in worst cases, death.
One study found that 25% of 108 intubations done outside of a hospital ended up with the tube placed wrong, a rate much higher than what other researchers have found. However, it’s important to know that these kinds of studies may not provide an accurate picture since they usually rely on healthcare providers to report their errors, which can often be underreported.
Most wrongfully placed tubes were found in the esophagus (food pipe), while the rest were in the back of the throat. Another large study found that overall, the rate of improperly placed tubes was around 3.1%, but that total errors, which included things like needing four or more tries to intubate or failure to intubate, occurred 22% of the time.
Besides misplaced tubes, patients can also suffer from additional problems after intubation, including damage to teeth, vocal cords, the windpipe, and the creation of a false passage, or an incorrect path for the tube. Patients may also experience vomiting, pneumonia, injury due to high pressure (barotrauma), disruption of autonomic functions (automatic body processes like heart rate and digestion), and a deficiency of oxygen (hypoxia).
It’s important to watch for problems that can arise during or after intubation, such as a low oxygen level and slow heart rate, which can cause serious issues for patients with traumatic brain injuries. One study found that over half of patients experienced a short-term lack of oxygen after intubation. Healthcare providers should be ready to examine their techniques and protocols to pinpoint the causes of such complications and improve patient safety.
Post-intubation complications are often linked to improper ventilation, or the process of moving oxygen into and out of the lungs. Overly aggressive ventilation can lead to increased pressure on the airway, causing trauma and a higher risk of death, especially in brain injury patients. For best results, healthcare providers should remain calm during this high-stress procedure, space out breaths to once every six seconds or more, and monitor the effectiveness of the ventilation.
What Else Should I Know About EMS Field Intubation?
Intubation in the field can save lives and should be a critical part of training for all paramedics and other emergency medical teams. This procedure involves inserting a tube through the mouth to control airflow and lung ability. However, it’s very important to understand this isn’t a simple or risk-free procedure. It is technically challenging and can have complications. There’s even debate in the medical community about how often it should be attempted outside the hospital as it can lead to worsened outcomes compared to simpler ways of managing a patient’s airway.
Adding to the complexity, critical tasks like chest compressions, giving medication, and using a defibrillator may all need to be done at the same time as intubation. Managing all these tasks with a typical two-person paramedic team is a daunting task. Furthermore, doctors in a hospital tend to have better results with intubation than medical professionals in the field.
However, just because field intubation has been associated with higher mortality rates than hospital intubation, it doesn’t necessarily mean we should disregard its importance. There are many other factors and variables to consider before deciding if this procedure should be applied in the field.
Over time, research shows field intubation success rates are improving and getting closer to the success rates in hospitals. This is probably due to increased attention and continuous efforts to improve its safety and the outcomes for patients. The use of new technologies and techniques, like waveform capnography and video laryngoscopy in the field, are also showing promising results.
Overall, with deeper understanding and research into what limits the success of field intubation, there are opportunities to improve its success rates to be closer to those achieved inside hospitals.
