Prehospital intubation: the right tools in the right hands at the right time.

David Lockey, FRCA, FIMC, RCS (Ed)† In this issue of the journal, Cobas et al. report that paramedics in the metropolitan area of Miami, Florida, had problems in 31% of all intubation attempts on trauma patients. It is highly likely that there are similar results in other emergency medical service (EMS) systems, but many may be reluctant to publish negative results. These clinicians in Miami, Florida, are therefore to be congratulated for placing these serious problems into the public spotlight. The observations from Miami, Florida, are in strong contrast to a previous prehospital study in Bordeaux, France, where senior emergency physicians had intubation problems in only 3% of the cases. This suggests that a significant factor in successful out-of-hospital advanced airway management may be the experience and training of the individual providers. The helicopter EMS paramedics in the study by Cobas et al. had greater success in airway management than their paramedic colleagues working in ground EMS units. This is not surprising because helicopter EMS personnel usually respond to more major trauma cases than their ground EMS colleagues and perform advanced airway management more often. Accordingly, they may also have more experience with alternative airway devices. For example, in Bordeaux, France, experienced emergency physicians used the intubating laryngeal mask airway device in 3% of patients with intubation difficulties (45 of 2082); of these, 96% could be ventilated with the rescue device (43 of 45). Thus, combining tracheal intubation with one single alternative airway device resulted in nearly 100% success rate in advanced airway management (2080 of 2082). In contrast, the patients in Miami, Florida, were managed in a rescue strategy with a laryngeal tube as an alternative airway device; interestingly, this group had the worst outcome. It may well be that, rather than demonstrating the different success rates of alternative airway devices, these results may simply be the surrogate marker for an extremely difficult airway situation, with a corresponding poor outcome. In general, the less experienced a rescuer is in advanced airway management, the more likely he or she is to need to use alternative airway devices. However, he or she is less likely to be successful using these devices. The question of which specific airway device should be used at which time has not been answered. Hypoxia in the field may develop rapidly, and the use of airway rescue techniques may again merely be a surrogate marker for bad outcome in patients with difficult airways, decreased physiological reserve, and more severe injury. There is reason to believe that hypoxia may develop more quickly in the field than during the administration of routine anesthesia in the operating room. This is due to hypoventilation, shock, and increased oxygen consumption. For example, although 4 min of oxygen administration increased Pao2 from 80 to 400 mm Hg during scheduled anesthesia, the corresponding increase in unstable emergency patients was only from 67 to 104 mm Hg Pao2. 4