AAGBI: Safer pre-hospital anaesthesia 2017
2017; Wiley; Volume: 72; Issue: 3 Linguagem: Inglês
10.1111/anae.13779
ISSN1365-2044
AutoresDavid Lockey, Kate Crewdson, Gareth E. Davies, B. Jenkins, A. A. Klein, C Laird, Peter F. Mahoney, Jerry P. Nolan, A. Pountney, Salil Prakash Shinde, S. Q. M. Tighe, M. Q. Russell, James H. Price, Cassandra J. C. Wright,
Tópico(s)Anesthesia and Sedative Agents
ResumoAnaesthesiaVolume 72, Issue 3 p. 379-390 GuidelinesOpen Access AAGBI: Safer pre-hospital anaesthesia 2017 Association of Anaesthetists of Great Britain and Ireland D. J. Lockey, Corresponding Author D. J. Lockey Consultant in Anaesthesia and Intensive Care Medicine, Honorary Professor, Chair David.Lockey@nbt.nhs.uk North Bristol NHS Trust, AAGBI Working Party, Bristol University, Bristol, UK Correspondence to: D. J. Lockey Email: David.Lockey@nbt.nhs.ukSearch for more papers by this authorK. Crewdson, K. Crewdson Senior Speciality Trainee Anaesthetics and Intensive Care Medicine, Severn Deanery, UKSearch for more papers by this authorG. Davies, G. Davies Consultant in Emergency Medicine Royal London Hospital/Royal College of Emergency Medicine, London, UKSearch for more papers by this authorB. Jenkins, B. Jenkins Senior Lecturer in Anaesthetics and Intensive Care Medicine Cardiff University, Cardiff, UKSearch for more papers by this authorJ. Klein, J. Klein Consultant in Anaesthesia and Intensive Care Medicine Derby Hospitals NHS Foundation Trust, Faculty of Pre-hospital Care, Royal College of Surgeons of Edinburgh, Edinburgh, UKSearch for more papers by this authorC. Laird, C. Laird General Practitioner British Association for Immediate Care, Auchterarder, Perthshire, UKSearch for more papers by this authorP. F. Mahoney, P. F. Mahoney Consultant in Anaesthesia, Honorary Emeritus Professor Royal Centre for Defence Medicine, Imperial College, London, UKSearch for more papers by this authorJ. Nolan, J. Nolan Consultant in Anaesthesia and Intensive Care Medicine, Honorary Professor Royal United Hospital, Bath, Anaesthesia and Intensive Care Medicine/Resuscitation Medicine at Bristol University, Royal College of Anaesthetists, Bristol, UKSearch for more papers by this authorA. Pountney, A. Pountney Consultant in Emergency Medicine Mid-Yorkshire NHS Trust, British Association for Immediate Care, Ipswich, Suffolk, UKSearch for more papers by this authorS. Shinde, S. Shinde Consultant in Anaesthesia North Bristol NHS Trust, AAGBI Board, Bristol, UKSearch for more papers by this authorS. Tighe, S. Tighe Consultant in Anaesthesia Countess of Chester Hospital, AAGBI Board, Chester, UKSearch for more papers by this authorM. Q. Russell, M. Q. Russell General Practitioner, Medical Director Kent, Surrey, Sussex Air Ambulance Trust, Royal College of General Practitioners, Tonbridge, UKSearch for more papers by this authorJ. Price, J. Price Consultant Royal United Hospital Bath, Group of Anaesthetists in Training, AAGBI, Avon, UKSearch for more papers by this authorC. Wright, C. Wright Consultant St Mary's Major Trauma Centre, Imperial College, Military Pre-hospital Emergency Medicine, London, UKSearch for more papers by this author D. J. Lockey, Corresponding Author D. J. Lockey Consultant in Anaesthesia and Intensive Care Medicine, Honorary Professor, Chair David.Lockey@nbt.nhs.uk North Bristol NHS Trust, AAGBI Working Party, Bristol University, Bristol, UK Correspondence to: D. J. Lockey Email: David.Lockey@nbt.nhs.ukSearch for more papers by this authorK. Crewdson, K. Crewdson Senior Speciality Trainee Anaesthetics and Intensive Care Medicine, Severn Deanery, UKSearch for more papers by this authorG. Davies, G. Davies Consultant in Emergency Medicine Royal London Hospital/Royal College of Emergency Medicine, London, UKSearch for more papers by this authorB. Jenkins, B. Jenkins Senior Lecturer in Anaesthetics and Intensive Care Medicine Cardiff University, Cardiff, UKSearch for more papers by this authorJ. Klein, J. Klein Consultant in Anaesthesia and Intensive Care Medicine Derby Hospitals NHS Foundation Trust, Faculty of Pre-hospital Care, Royal College of Surgeons of Edinburgh, Edinburgh, UKSearch for more papers by this authorC. Laird, C. Laird General Practitioner British Association for Immediate Care, Auchterarder, Perthshire, UKSearch for more papers by this authorP. F. Mahoney, P. F. Mahoney Consultant in Anaesthesia, Honorary Emeritus Professor Royal Centre for Defence Medicine, Imperial College, London, UKSearch for more papers by this authorJ. Nolan, J. Nolan Consultant in Anaesthesia and Intensive Care Medicine, Honorary Professor Royal United Hospital, Bath, Anaesthesia and Intensive Care Medicine/Resuscitation Medicine at Bristol University, Royal College of Anaesthetists, Bristol, UKSearch for more papers by this authorA. Pountney, A. Pountney Consultant in Emergency Medicine Mid-Yorkshire NHS Trust, British Association for Immediate Care, Ipswich, Suffolk, UKSearch for more papers by this authorS. Shinde, S. Shinde Consultant in Anaesthesia North Bristol NHS Trust, AAGBI Board, Bristol, UKSearch for more papers by this authorS. Tighe, S. Tighe Consultant in Anaesthesia Countess of Chester Hospital, AAGBI Board, Chester, UKSearch for more papers by this authorM. Q. Russell, M. Q. Russell General Practitioner, Medical Director Kent, Surrey, Sussex Air Ambulance Trust, Royal College of General Practitioners, Tonbridge, UKSearch for more papers by this authorJ. Price, J. Price Consultant Royal United Hospital Bath, Group of Anaesthetists in Training, AAGBI, Avon, UKSearch for more papers by this authorC. Wright, C. Wright Consultant St Mary's Major Trauma Centre, Imperial College, Military Pre-hospital Emergency Medicine, London, UKSearch for more papers by this author First published: 03 January 2017 https://doi.org/10.1111/anae.13779Citations: 71 You can respond to this article at http://www.anaesthesiacorrespondence.com This is a consensus document produced by expert members of a Working Party established by the Association of Anaesthetists of Great Britain and Ireland. It has been seen and approved by the AAGBI Board of Directors. It has been endorsed by: the Royal College of Emergency Medicine; the Royal College of Anaesthetists; the Faculty of Pre-hospital Care the Royal College of Surgeons of Edinburgh; BASICS and BASICS Scotland; the Department of Military Anaesthesia; the Department of Military Pre-hospital Emergency Medicine; and the Royal College of General Practitioners. Date of review: 2022. AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Summary Pre-hospital emergency anaesthesia with oral tracheal intubation is the technique of choice for trauma patients who cannot maintain their airway or achieve adequate ventilation. It should be carried out as soon as safely possible, and performed to the same standards as in-hospital emergency anaesthesia. It should only be conducted within organisations with comprehensive clinical governance arrangements. Techniques should be straightforward, reproducible, as simple as possible and supported by the use of checklists. Monitoring and equipment should meet in-hospital anaesthesia standards. Practitioners need to be competent in the provision of in-hospital emergency anaesthesia and have supervised pre-hospital experience before carrying out pre-hospital emergency anaesthesia. Training programmes allowing the safe delivery of pre-hospital emergency anaesthesia by non-physicians do not currently exist in the UK. Where pre-hospital emergency anaesthesia skills are not available, oxygenation and ventilation should be maintained with the use of second-generation supraglottic airways in patients without airway reflexes, or basic airway manoeuvres and basic airway adjuncts in patients with intact airway reflexes. What other guideline statements are available on this topic? The Association of Anaesthetists of Great Britain and Ireland (AAGBI) first produced guidelines on this area of practice in 2009 1. Other related guidelines have been produced in Scandinavia 2 and in the USA 3. Why were these guidelines developed? The guidelines were first developed because pre-hospital anaesthesia is carried out on a daily basis in the UK, and standards of care were ill defined. They set achievable standards which were endorsed by key organisations. This version updates these guidelines, taking into account changes in clinical practice, pre-hospital infrastructure and new related guidelines that have impacted on the practice of pre-hospital anaesthesia. How and why does this statement differ from existing guidelines? This updated guideline emphasises the core material produced in the initial guideline, but is updated to reflect changes in UK pre-hospital infrastructure and recent guidelines on airway management, trauma management and emergency in-hospital anaesthesia and monitoring. There are significant differences to Scandinavian and US guidelines, mostly related to differences in emergency medical services (EMS) infrastructure and providers. Introduction There are existing local and national guidelines for pre-hospital emergency anaesthesia (PHEA) and airway management 2, 4. Since the first version of these UK guidelines was produced 1, significant developments have taken place in UK pre-hospital care. The number of air ambulances staffed with doctor–paramedic teams in the UK has increased, and with this the frequency of PHEA. Pre-hospital emergency medicine (PHEM) has been recognised by the General Medical Council as a subspecialty, and pre-hospital training organisations are required to demonstrate clear evidence of a clinical governance structure. Although the evidence base for pre-hospital care and PHEA is still of relatively low quality, much has been published recently. For example, available data on pre-hospital tracheal intubation failure rates have more than tripled, and have been used as one indicator to confirm the importance of experience and training in successful pre-hospital anaesthesia 5-7. In 2007, the ‘Trauma: who cares?’ National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report documented poor pre-hospital airway management 8. A significant proportion of seriously injured patients were delivered to emergency departments with airway compromise, and this is not unique to the UK 9. More recently, it has been demonstrated that, in a significant number of trauma patients, basic and advanced airway management without PHEA does not reliably correct airway compromise 10. The majority of severely ill and injured patients have intact airway reflexes, and require drugs to facilitate tracheal intubation. In contrast, tracheal intubation has not been shown to improve outcome in patients with cardiac arrest 11, and drugs are not usually required to facilitate tracheal intubation in this patient group. Many UK pre-hospital services have aspired to achieve the key message of the AAGBI 2009 Pre-hospital anaesthesia guidelines – that, despite variable pre-hospital conditions, the standard of care delivered should be the same as that for in-hospital emergency anaesthesia 1. Recent evidence has shown that anaesthesia in the Emergency Department is not without problems 12, and the standardisation of technique, along with safety adjuncts such as pre-induction checklists are probably essential in both the pre-hospital and Emergency Department environments. This guideline outlines safety considerations in the key areas of pre-hospital anaesthetic practice: training and clinical governance; conduct and technique; monitoring; environmental considerations; and minimum data collection for performance and incident reporting. It does not consider local and regional anaesthetic techniques. Although there are many options for the safe delivery of PHEA, the principles of simplicity and standardisation are used in this document to provide a framework for safe delivery of emergency anaesthesia by experienced pre-hospital doctors from anaesthetic or non-anaesthetic training backgrounds. It is recognised that pre-hospital practitioners without PHEA competency provide the majority of pre-hospital care in the UK, and make an essential contribution to pre-hospital airway management. It is essential that pre-hospital personnel not trained in the delivery of PHEA ensure that basic airway manoeuvres are applied immediately and effectively for any patient with airway compromise 4. This may be facilitated by managing the patient in the lateral trauma position where appropriate 2, 13. Local organisation All pre-hospital organisations (immediate care schemes, hospital-related schemes, Medical Emergency Response Incident Teams (MERIT), air ambulance providers and NHS Ambulance Service Trusts) must provide appropriate, easily accessible and ongoing support to practitioners who undertake PHEA. Pre-hospital emergency medicine trainees undertaking PHEA without direct supervision must have immediate access to advice from a senior PHEM clinician who is fully competent in PHEA and pre-hospital critical care. Non-trainees who undertake PHEA should also ideally have reliable access to senior telephone support. Key organisational components for safe PHEA are: A named, responsible lead clinician with extensive PHEM experience, who ensures delivery of competency-based initial and refresher training specific for PHEA, including: simulation practice; regular review of PHEAs undertaken and constructive feedback to individual providers; and regular appraisal of practitioners undertaking PHEA. A robust clinical governance structure that will: ensure each practitioner is competent; ensure collection of key data on PHEA performed to enable quality benchmarking of pre-hospital advanced airway management 14; provide regular case reviews, audit and an adverse event reporting system feeding into a risk register database; and provide regular reviews of guidelines and standard operating procedures in the light of emerging evidence. Pre-hospital anaesthesia for children It is increasingly recognised that anaesthesia for children aged 8 years or under is a sub-specialist area of in-hospital anaesthesia. Young children with severe injuries are uncommon, but can present pre-hospital practitioners with significant challenges. All pre-hospital organisations must have written guidelines for the treatment of children that reflect the skills of their practitioners. In general terms, the threshold for anaesthesia and tracheal intubation in young children is high. The majority can be adequately managed with simple airway techniques 15. Pre-hospital emergency anaesthesia is considered only after careful risk–benefit analysis. This will usually mean that a skilled anaesthetic practitioner with appropriate equipment is present, and that simple airway manoeuvres combined with oxygen therapy have failed to provide a patent airway or adequate oxygenation. However, where PHEA is necessary, it is usually straightforward with high intubation success rates 16. In difficult circumstances, rapid transfer to the nearest hospital to enable advanced airway management may be appropriate, even if definitive care needs to be undertaken at a different hospital. Personnel and training Individual competence Pre-hospital emergency anaesthesia carries more risk than in-hospital anaesthesia. Skilled anaesthetic assistance may not be available, and both environmental and patient factors increase risk. Pre-hospital emergency anaesthesia should not be undertaken in professional isolation. Providers should have the same level of training and competence that would enable them to perform unsupervised emergency anaesthesia and tracheal intubation in the emergency department 17, 18. Since PHEA is potentially hazardous 12, and considerable resource is spent to ensure that anaesthetists who perform rapid sequence induction (RSI) in hospitals can do so safely, pre-hospital care standards should at least match these standards. Some studies have demonstrated low success rates and significant complications when RSI and tracheal intubation are undertaken by individuals with relatively little training 19. The 2007 NCEPOD ‘Trauma: Who Cares?’ report concluded that “if pre-hospital intubation is to be part of pre-hospital trauma management, then it needs to be in the context of a physician-based pre-hospital care system” 8. The training required for undertaking pre-hospital anaesthesia safely and competently has been described by the Intercollegiate Board for Training in Pre-hospital Emergency Medicine (IBTPHEM) 17. Skills in both anaesthesia and the ability to work safely in the pre-hospital environment are required. Competence should be defined by these skills, rather than by the primary specialty of the individual. The Royal College of Anaesthetists requires that all anaesthetists in training complete an Initial Assessment of Competence before giving anaesthesia without direct supervision. This assessment is completed by the trainee after about 3 months of anaesthesia training, and includes the ability to perform RSI and a failed intubation routine. The Initial Assessment of Competence confirms that the individual has the essential skills to undertake anaesthesia in ASA 1 or 2 patients in hospital. However, the achievement of this standard does not imply competence to induce anaesthesia in a severely injured patient in any setting. The two-year acute care common stem (ACCS) training programme provides individuals with 6 months of training in emergency and acute medicine and a year in anaesthesia and intensive care medicine. However, doctors completing ACCS training are inexperienced in managing the airway of complex patients, and will need further training before undertaking unsupervised pre-hospital RSI and tracheal intubation. The ACCS programme (or equivalent training) is considered the absolute minimum required for an individual entering a training programme in pre-hospital emergency medicine. Specific training for working in the pre-hospital environment is also essential. The IBTPHEM and the Faculty of Pre-Hospital Care of the Royal College of Surgeons of Edinburgh are currently the lead organisations setting standards for physician pre-hospital working, qualification and competence. Ideally, doctors likely to be undertaking PHEA should, in the future, successfully complete the IBTPHEM subspecialty training in pre-hospital emergency medicine 17. Anaesthetic assistance should be provided by an appropriately trained healthcare professional who has been signed off for extended pre-hospital care practice, or assessed to provide specific pre-hospital critical care skills. Rarely, it may be appropriate to proceed without trained assistance on the basis of an individual case risk–benefit analysis. Working under the close supervision of experienced practitioners is an essential step towards independent pre-hospital practice. Having achieved PHEA competence, skills need to be maintained by undertaking the procedure regularly. The precise number of PHEAs required to maintain competence is not defined. An average of one a month has been previously suggested as a minimum. There is a significant difference in the reported incidence of difficult tracheal intubation between clinicians considered either ‘competent’ or ‘expert’ (based on the number of intubations performed per year) 20. Unless an individual is working in a very busy pre-hospital programme, it is likely that competence in RSI and tracheal intubation will be achieved only with regular in-hospital experience of RSI and tracheal intubation, supplemented with simulation experience where necessary. Assessment of competence in PHEA should always involve direct pre-hospital observation by experienced senior clinicians. Simulator practice may usefully supplement clinical experience. Practitioners undertaking PHEA must keep a log of procedures to be included in a clinical governance structure. Crew resource management techniques are of particular importance in the pre-hospital environment, and it is critical that teams have the opportunity to train and practice regularly in order to ensure the best possible delivery of care. Pre-hospital care teams need to be adaptable to changes in their environment to ensure scene and patient safety. Appendix 1 discusses safe PHEA in challenging environments. The Working Party is aware of variable international practice with regard to non-physician delivered drug-assisted intubation. Although non-physician delivered PHEA is relatively uncommon, the administration of sedation to facilitate intubation is reported in some healthcare systems. Working Party members are aware of published evidence that has highlighted major safety concerns, particularly where non-physicians have administered neuromuscular blocking drugs 21, 22, and do not believe that existing training programmes enable safe unsupervised administration of anaesthesia by non-physicians outside physician-led teams in the UK. A similar position is stated in recent NICE trauma guidelines 4. The Working Party believes that all practitioners providing PHEA should have adequate in-hospital emergency anaesthetic training and experience, and be able to demonstrate the necessary competencies before adapting in-hospital practice for pre-hospital practice. Equipment and monitoring Standards of equipment and monitoring used for PHEA should match those applied to in-hospital anaesthetic practice 23. To prevent cross-infection, most pre-hospital providers have to use ambulance or hospital sterilisation facilities, or rely on disposable equipment. Equipment Pre-hospital equipment must be portable, robust and weather-resistant, and be effective under varying lighting conditions. Electrical equipment must have an adequate battery reserve. Equipment for very adverse conditions (e.g. extreme temperature environments) needs careful selection and confirmation of suitability before use. The equipment required for pre-hospital anaesthesia is shown in Table 1. Table 1. Equipment for pre-hospital emergency anaesthesia (PHEA) Monitoring equipment Oxygen (sufficient for PHEA and transfer to hospital, with reserve) An adequate supply of drugs (ideally pre-prepared and drawn up into labelled syringes) for induction and maintenance of anaesthesia. Intubation equipment, to include an intubating bougie and spare laryngoscope Simple airway adjuncts: Suction: hand or battery operated; Ventilation equipment: self-inflating bag-mask with an oxygen reservoir (as a minimum); Mechanical ventilators: properly serviced and checked with appropriate pressure relief systems and alarms; Rescue airway equipment: second generation supraglottic airway device and surgical airway equipment. Vascular access equipment: intravenous and intra-osseous Lighting where appropriate Procedural checklists Monitoring Clinical assessment, combined with monitoring, is used to record the patient's condition from the preparation phase, through induction and maintenance, and into the postintubation and transfer phase. Measured values can be recorded manually or electronically during the whole period, although it is recognised that manual recording is difficult in the emergency setting. Clinical measurement and observation should include: the presence or absence of a pulse, its location and rate; respiratory rate; pupil size and reactivity, lacrimation if present; and the presence or absence of muscular activity and limb movements. Invasive monitoring is possible, but can be difficult in the pre-hospital phase, and is mainly used for interhospital transfer. Non-invasive monitoring includes, as a minimum: heart rate; non-invasive blood pressure; oxygen saturation; continuous waveform capnography; and electrocardiography 23. Vital signs should be measured and recorded at least every 3 min. As oxygen or an oxygen–air mix are the only commonly used gases during PHEA, anaesthetic gas monitoring is rarely used in the pre-hospital environment. Gas supply failure alarms should be present on mechanical ventilators. Nerve stimulation devices are also rarely used in the pre-hospital environment. With these exceptions, monitoring in the pre-hospital environment should aim to meet the current AAGBI guidelines on anaesthetic monitoring 23. Monitoring of end-tidal CO2 is mandatory during PHEA. Although qualitative capnography can be used to help confirm intubation, quantitative waveform capnography is required to prevent hyper- or hypoventilation. It is important to ensure that the circuit and equipment is connected and functional before induction. Temperature monitoring should be considered particularly for vulnerable patient groups (e.g. children or those with significant burns). Audiovisual alarms on monitoring equipment should be set so that they can be detected in the noisy pre-hospital environment. Monitoring may need to be temporarily suspended during difficult extrication. Appendix 2 discusses minimum data collection and key performance indicators. Technique (general principles) The principles of PHEA are similar to those for in-hospital emergency anaesthesia. Techniques should be simple, reproducible and well-practised. A primary aim is to secure first-pass tracheal intubation with minimal cardiorespiratory compromise. The most commonly used induction drugs and neuromuscular blocking drugs can be used in pre-hospital care with appropriate considerations. Drug choice depends on the physiological state of the patient, and operator familiarity with the drug. The balance between optimising clinical condition before transfer and getting the patient to definitive care without delay will determine which interventions are undertaken before transport to hospital. Although PHEA increases ‘scene time’, time in the Emergency Department and time to definitive surgical intervention may still be reduced. Performing the intervention must still be weighed against the advantages of earlier transport to hospital, and every effort must be made to keep pre-hospital time to a minimum. Preparation Careful preparation of the patient and equipment will decrease the frequency of complications. The patient should ideally be positioned to allow 360° access at a comfortable height for airway intervention (e.g. on an ambulance trolley), in adequate but not bright light, to optimise the view at intubation. A standardised ‘kit dump’ is prepared so that the drugs and equipment necessary for safe anaesthesia are immediately available. The pre-hospital team should be thoroughly familiar with all medical equipment. A verbal challenge–response pre-induction checklist is an effective method of confirming availability of equipment, doses of drugs to be administered and the failed intubation management plan. The pre-hospital team should be fully briefed. Ideally, four people are required: PHEA physician; anaesthetic assistant; provider of manual in-line stabilisation; and provider of cricoid pressure and/or laryngeal manipulation (sometimes combined with role two). Genuine entrapment is rare, and most trapped patients can be rapidly extricated to facilitate airway management. Simple airway manoeuvres and adjuncts may be used to avoid airway obstruction before rapid extrication. If these measures fail, insertion of a supraglottic device, tracheal intubation or a primary surgical airway may be necessary. Pre-oxygenation All patients should be pre-oxygenated. A head-elevated position can improve oxygenation and reduce the risk of aspiration. A reverse Trendelenburg position can be used if spinal injury is suspected. Pre-oxygenation in spontaneously breathing patients may be achieved using high-flow oxygen delivered through a facemask with a reservoir bag. Hypoxaemic patients (SaO2 < 90%) or patients with poor respiratory effort usually require gentle support of ventilation with a bag-mask to facilitate pre-oxygenation. The risk of gastric distension and subsequent aspiration can be reduced if ventilation pressures are kept at less than 25 cmH2O 24. The provision of apnoeic oxygenation with oxygen via standard nasal cannulae may, where the airway is patent, may prolong the time to postinduction desaturation. Although this intervention has been demonstrated to decrease the incidence of desaturation in PHEA 25, the evidence base for these techniques is currently limited 26-30. Induction Hard collars limit jaw opening and restrict the view at laryngoscopy. Once manual in-line stabilisation is established, the front of the collar and head blocks should be removed before induction of anaesthesia, and replaced after induction. The dose of induction drug should be selected based on the usual considerations, for example, modified for hypotensive or head-injured patients. Simple techniques should minimise the risk of error. Cricoid pressure should be applied during induction of anaesthesia to reduce the risk of aspiration. This may make bag-mask ventilation and insertion of supraglottic devices difficult, and may improve or worsen the view at laryngoscopy 30, 31. If it is difficult to view the larynx, there should be a low threshold for removal of cricoid pressure. However, cricoid pressure may also be used to facilitate laryngeal manipulation to improve the view for the operator. Intubation Patients with airway compromise in the pre-hospital environment may be challenging, and difficult intubation should be anticipated. Every effort should be made to ensure successful first-pass intubation, and in critically ill patients, the practitioner with most anaesthetic experience should usually be the first to attempt intubation. Routine use of an intubating bougie is recommended. Pre-hospital organisations may approve other ‘di
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