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J Emerg Med. 2009 Apr;36(3):257-65. doi: 10.1016/j.jemermed.2007.10.058. Epub 2008 Apr 24.

Prehospital management of the difficult airway: a prospective cohort study.

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Department of Surgery, University of Washington, Harborview Medical Center, Seattle, Washington 98104, USA.


The role of prehospital endotracheal intubation (ETI) remains controversial, with significant national variability in practice. The purpose of this project was to evaluate ETI management in a system of advanced life support (ALS) providers experienced in ETI and other advanced airway techniques, and describe management and outcomes of patients with a "difficult airway." Data were collected prospectively for all ETIs performed by the fire department over a 4-year period (2001-2005), and included demographics, number of laryngoscopy attempts, airway procedures, complications, and outcomes. Of 80,501 ALS patient contacts, 4091 (5.1%) underwent attempted oral ETI, with a 96.8% success rate in four or fewer attempts. The difficult airway cohort included 130 patients (3.2%), whose airway management consisted of oral ETI after more than four attempts (46%), bag-valve-mask ventilation (33%), cricothyroidotomy (8%), retrograde ETI (5%), and digital ETI (1%). Procedural success rates ranged from 14% (digital ETI) to 91% (cricothyroidotomy). Nine patients (7%) had failed airway management, of whom 5 were found in cardiac arrest. The two most common reasons subjectively reported by ALS providers for airway difficulty were anterior trachea (39%) and small mouth (30%). Overall mortality for the difficult airway cohort was 44%. Prehospital ETI can be performed with a high success rate by experienced ALS providers, but may still require advanced airway techniques in a small subset of patients. Patient anatomy is a primary factor in failed ETI. Among the advanced procedures, cricothyroidotomy had the highest success rate and should not be delayed by other interventions.

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