Medication-Facilitated Advanced Airway Management with First-Line Use of a Supraglottic Device - A One-Year Quality Assurance Review.

INTRODUCTION: Airway management is a controversial topic in modern Emergency Medical Services (EMS) systems. Among many concerns regarding endotracheal intubation (ETI), unrecognized esophageal intubation and observations of unfavorable neurologic outcomes in some studies raise the question of whether alternative airway techniques should be first-line in EMS airway management protocols. Supraglottic airway devices (SADs) are simpler to use, provide reliable oxygenation and ventilation, and may thus be an alternative first-line airway device for paramedics. In 2019, Alachua County Fire Rescue (ACFR; Alachua, Florida USA) introduced a novel protocol for advanced airway management emphasizing first-line use of a second-generation SAD (i-gel) for patients requiring medication-facilitated airway management (referred to as "rapid sequence airway" [RSA] protocol). STUDY OBJECTIVE: This was a one-year quality assurance review of care provided under the RSA protocol looking at compliance and first-pass success rate of first-line SAD use. METHODS: Records were obtained from the agency's electronic medical record (EMR), searching for the use of the RSA protocol, advanced airway devices, or either ketamine or rocuronium. If available, hospital follow-up data regarding patient condition and emergency department (ED) airway exchange were obtained. RESULTS: During the first year, 33 advanced airway attempts were made under the protocol by 23 paramedics. Overall, compliance with the airway device sequence as specified in the protocol was 72.7%. When ETI was non-compliantly used as first-line airway device, the first-pass success rate was 44.4% compared to 87.5% with adherence to first-line SAD use. All prehospital SADs were exchanged in the ED in a delayed fashion and almost exclusively per physician preference alone. In no case was the SAD exchanged for suspected dislodgement evidenced by lack of capnography. CONCLUSION: First-line use of a SAD was associated with a high first-pass attempt success rate in a real-life cohort of prehospital advanced airway encounters. No SAD required emergent exchange upon hospital arrival.

Unrecognized cardiac arrests: A one-year review of audio from emergency medical dispatch calls.

OBJECTIVES: Immediate recognition of out-of-hospital cardiac arrest (OHCA) by Emergency Medical Dispatch (EMD) operators is crucial to facilitate timely initiation of telephone cardiopulmonary resuscitation (T-CPR) and to enable the appropriate level of Emergency Medical Services (EMS) response. The goal of this study was to identify patterns that can increase EMD-level recognition of cardiac arrests prior to EMS arrival. METHODS: The Combined Communications Center in Alachua County, Florida provided audio recordings of all emergency calls from January 1, 2018 to November 16, 2018 dispatched as a chief complaint other than OHCA, but later identified as cardiac arrest. A multi-disciplinary medical team transcribed and analyzed the calls to determine common themes and trends. RESULTS: Out of an initial 81 calls meeting inclusion criteria, 69 were immediately recognized as OHCA by EMDs, leaving 12 calls of unrecognized OHCA. In 11 of 12 calls respiratory issues were described to EMD. In 10 of 12 calls the subject was described as unconscious, and in the other 2 calls, the subject lost consciousness during the call. CONCLUSIONS: Lack of recognition of OHCA by EMD occurred in most calls due to difficulty communicating the subject's respiratory status. Further emphasis should be placed on identifying non-viable respirations in unconscious patients in EMD training and algorithms to increase recognition of OHCA and initiation of T-CPR. A multi-year review of a comparable dataset from geographically and socioeconomically diverse regions in the United States can validate and expand these preliminary trends.

Paramedic determination of appropriate emergency department destination.

BACKGROUND: Freestanding emergency departments (FSED) are equipped to care for most emergencies, but do not have all the resources that hospital-based emergency departments (ED) offer. As the number of FSEDs grows rapidly, emergency medical services (EMS) must routinely determine whether a FSED is an appropriate destination. Inappropriate triage may delay definitive care, potentially increasing morbidity, mortality, and resource utilization. We sought to evaluate paramedics' ability in determining whether a FSED is the most appropriate destination. METHODS: We conducted a retrospective study of two county EMS agencies and two FSEDs over a 25-month period in Alachua and Levy County, Florida, USA. Both EMS agencies allow paramedic discretion in determining transport destination. To determine whether paramedics can correctly identify patients that can be cared for fully at a FSED, our primary outcome was the percentage of patients transported to FSEDs by EMS that were discharged without additional hospital-based resources. RESULTS: We identified 1247 EMS patients that had a selected destination of FSED. We excluded patients that did not arrive at their selected FSED destination, left before FSED disposition, or were transferred from the FSED to unaffiliated hospitals. A total of 1184 patients were included for analysis, and 885 (74.7%) did not require additional hospital resources. Comparing the two EMS agencies yielded similar results. CONCLUSION: In this study, involving two EMS agencies over a 25-month period, we found that 3 out of 4 patients deemed appropriate for transport to a FSED by a paramedic did not require additional hospital-based services.