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• Pre-hospital airway management: not just for anaethetists
  Keith Roberts
  Published on: 29 April 2016
• Airway management in the emergency department
  Matthew Williams
  Published on: 29 April 2016

• Published on: 29 April 2016

  Pre-hospital airway management: not just for anaethetists

  • Keith Roberts, Surgical SHO
  • Other Contributors:
    • Tony Bleetman and Nick Sherwood

  Dear Editor

  We were interested to read the review of airway management in the emergency department by Clancy and Nolan.[1] Immediate airway care is in the corner stone of patient management - its importance is exemplified by the 'A' of the ABC mantra. We do not wish to go over the issues already raised but to introduce another aspect to the discussion.

  We are members of a local pre-hospital care group. Our...

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  Dear Editor

  We were interested to read the review of airway management in the emergency department by Clancy and Nolan.[1] Immediate airway care is in the corner stone of patient management - its importance is exemplified by the 'A' of the ABC mantra. We do not wish to go over the issues already raised but to introduce another aspect to the discussion.

  We are members of a local pre-hospital care group. Our 'day jobs' are various and therefore the level of anaesthetic experience varies between us. The discussion over how we should manage the pre-hospital airway wanes and waxes but is never resolved. There are many advantages of definitive pre-hospital airway care, ensuring the delivery of high concentrations of oxygen to the lungs, protecting the airway against contamination, lowering intracranial pressure when practiced correctly, to mention a few. The main disadvantages include lack of practical experience and the potential adverse pharmacological effects of anaesthetic drugs. Currently, advanced airway care is one skill that pre-hospital doctors can offer over paramedics who remain constrained by protocol to intubate only comatose or dead patients.

  We would like to see the education of advanced airway care extended to include pre-hospital carers. Courses similar to the three day National Emergency Airway Management course could offer excellent coverage of core techniques and the use of a few key drugs. Failed intubation protocols would ensure that no patient would be left anaesthetised without an adequate airway.

  Intubating patients can be daunting, especially when away from controlled environment of the hospital and when unassisted. Should endotracheal intubation fail there are alternatives including the laryngeal mask and new intubating laryngeal mask airways, the combitube and so on.

  We also recommend the maintenance an anaesthetic logbook as evidence of training and experience. Data on equipment, drugs, techniques, problems encountered and their corrective measures should be compiled. This should provide proof of knowledge, experience and skill for the non-anaesthetist. Most BASICS (British Association for Immediate Care) members are GPs. Anaesthetists form a minority. In pre-hospital care successful advanced airway management cannot just be the remit of anaesthetists. Education followed by relevant experience and revalidation must be the way forward.

  K Roberts
  SHO Surgical Rotation
  Birmingham Heartlands and Solihull NHS Trust

  N Sherwood
  Consultant Anaesthetist
  City Hospital NHS Trust
  Birmingham

  A Bleetman
  Consultant in Emergency Medicine
  Birmingham Heartlands and Solihull NHS Trust

  Reference

  (1) Clancy M, Nolan J. Airway management in the emergency department. Emerg Med J 2002;19:2-3.

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  Conflict of Interest:
  None declared.

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• Published on: 29 April 2016

  Airway management in the emergency department

  • Matthew Williams, Specialist Registrar anaesthesia/Intensive Care Medicine
  • Other Contributors:
    • Leilah Dare, Malcolm Watters

  Dear Editor

  We would like to congratulate Nolan and Clancy on their editorial addressing a controversial area.[1] We would like to comment on some of their points and add a few thoughts of our own.

  Notwithstanding our experience that there is rarely a significant delay in attendance to the emergency department (ED) by anaesthetists/intensivists, we agree that there is likely to be an increase in emer...

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  Dear Editor

  We would like to congratulate Nolan and Clancy on their editorial addressing a controversial area.[1] We would like to comment on some of their points and add a few thoughts of our own.

  Notwithstanding our experience that there is rarely a significant delay in attendance to the emergency department (ED) by anaesthetists/intensivists, we agree that there is likely to be an increase in emergency physicians in the United Kingdom performing endotracheal intubations using anaesthetic drugs. However, we believe that the care of critically ill patients must become more “fluid”, meaning that it should be performed by those competent to do so regardless of their speciality. Whilst some emergency physicians will feel uncomfortable managing difficult airways, attending trainee anaesthetists may conversely be less experienced in airway management than the referring emergency physician. A recent paper has suggested that there is no difference in success of airway management or complications in trauma patients whether management is led by emergency physicians or anaesthetists.[2] As alluded to in the editorial, sick patients are more frequently seen earlier by senior doctors in all fields of medicine, and rightly so. However, if the experienced emergency physician gets into difficulty managing an airway, he must have quick access to someone who can help him, whilst following agreed difficult airway management strategies.

  From our experience, we believe gaining the required skills would normally require a placement of about a year. This should include anaesthesia as well as intensive care medicine (ICM) – most first-year SHO anaesthetic posts will now include a 3 months block of ICM. There is often too much to take in from ICM alone to acquire the ability to intubate, but there is a need to appreciate the difficulties of intubating and then managing critically ill patients, especially the pharmacology and physiology. Exposure to ICM also gives a better understanding of which patients are likely to benefit from intensive care. In the paper referred to earlier, the emergency department residents have a more structured training and greater exposure to airway management in the emergency department than their UK counterparts.[2]

  The most difficult part to address is how to maintain these acquired skills. Everyday clinical practice is unlikely to provide enough intubation experience, especially in some smaller units. Whilst intermittent secondments to anaesthesia are likely to be helpful, allocating time will be a major challenge. Simulators have not yet been validated as a training tool – intuitively, they seem likely to complement other approaches.

  Finally, the most important point to take away from the editorial in considering these issues is who makes the decision to induce anaesthesia and intubate. These decisions have an enormous impact on the patient and their family, as well as having major resource implications. What happens, for example, if a patient is intubated in the emergency department by the attending emergency physician and then refers the case to the intensivist who feels it is inappropriate to admit him/her to the intensive care unit. The decision should be collaborative involving senior doctors experienced in the care of the critically ill. The management of these patients should be multidisciplinary both in decision making and at the bedside. With changes in the structure of units both physically and logistically (e.g. acute medical units, critical care units), these changes to the development of these core competencies will lead to improvement in interfacing between departments.

  Dr Matthew Williams
  Specialist Registrar in Anaesthesia

  Miss Leilah Dare
  Clinical Fellow in Emergency Medicine

  Dr Malcolm Watters
  Consultant in Anaesthesia & Intensive Care Medicine

  References

  (1) Nolan J, Clancy M. Airway management in the emergency department. British Journal of Anaesthesia 2002;88:9-11.

  (2) Omert L, Yeaney W, Mizikowski S, Protetch J. Role of the Emergency Medicine Physician in airway management of the trauma patient. Trauma 2001;51:1065-8.

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  Conflict of Interest:
  None declared.

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