Tracheal intubation is a high-risk intervention for exposure to airborne infective pathogens, including the novel coronavirus disease 2019 (COVID-19). During the recent pandemic, personal protective equipment (PPE) was essential to protect staff during intubation but is recognized to make the practical conduct of anesthesia and intubation more difficult. In the early phase of the coronavirus pandemic, some simple alterations were made to the emergency anesthesia standard operating procedure (SOP) of a prehospital critical care service to attempt to maintain high intubation success rates despite the challenges posed by wearing PPE. This retrospective observational cohort study aims to compare first-pass intubation success rates before and after the introduction of PPE and an altered SOP.

A retrospective observational cohort study was conducted from January 1, 2019 through August 30, 2021. The retrospective analysis used prospectively collected data using prehospital electronic patient records. Anonymized data were held in Excel (v16.54) and analyzed using IBM SPSS Statistics (v28). Patient inclusion criteria were those of all ages who received a primary tracheal intubation attempt outside the hospital by critical care teams. March 27, 2020 was the date from which the SOP changed to mandatory COVID-19 SOP including Level 3 PPE – this date is used to separate the cohort groups.

Data were analyzed from 1,266 patients who received primary intubations by the service. The overall first-pass intubation success rate was 89.7% and the overall intubation success rate was 99.9%. There was no statistically significant difference in first-pass success rate between the two groups: 90.3% in the pre-COVID-19 group (n = 546) and 89.3% in the COVID-19 group (n = 720); Pearson chi-square 0.329; P = .566. In addition, there was no statistical difference in overall intubation success rate between groups: 99.8% in the pre-COVID-19 group and 100.0% in the COVID-19 group; Pearson chi-square 1.32; P = .251.

Non-drug-assisted intubations were more than twice as likely to require multiple attempts in both the pre-COVID-19 group (n = 546; OR = 2.15; 95% CI, 1.19-3.90; P = .01) and in the COVID-19 group (n = 720; OR = 2.5; 95% CI, 1.5-4.1; P = <.001).

This study presents simple changes to a prehospital intubation SOP in response to COVID-19 which included mandatory use of PPE, the first intubator always being the most experienced clinician, and routine first use of video laryngoscopy (VL). These changes allowed protection of the clinical team while successfully maintaining the first-pass and overall success rates for prehospital tracheal intubation.

Cricothyroidotomy is an advanced airway procedure for critically ill or injured patients. In Victoria, Australia, intensive care paramedics (ICPs) perform needle cricothyroidotomy utilizing the proprietary QuickTrach II (QTII) device. Recently, an Ambulance Victoria (AV) institutional change in workflow included pre-puncture surgical incision to assist in successful placement. This review aims to explore whether a surgical pre-incision prior to the insertion of the device improved overall procedural success rates of needle cricothyroidotomy using the QTII.

This was a retrospective review of all patients who received a needle cricothyroidotomy by ICPs from May 1, 2015 through September 15, 2020. Data and patient care records were sourced from the AV data warehouse.

A total of 27 patients underwent a needle cricothyroidotomy with the mean age of patients being 50.2 years. Most cricothyroidotomies were performed using the QuickTrach II kit (92.6%). Prior to modification of the QTII procedure, front-of-neck access (FONA) success was 50.0%; however, this improved to 82.4% after the procedures recent update. The overall success rate of all paramedic-performed needle cricothyroidotomy during the study period was 74.1% (n = 20).

This review demonstrates that propriety devices such as the QTII device achieve a low success rate for a FONA intervention. Despite the low frequency of this procedure, ICPs with extensive training and regular maintenance can perform needle cricothyroidotomy using scalpel assistance with a reasonable success rate. But when compared to the broader literature, success rate using a more straightforward technique such as a surgical cricothyroidotomy technique is likely going to be higher.

Prehospital pediatric tracheal intubation (TI) is a possible life-saving intervention that requires adequate experience to mitigate associated complications. The pediatric airway and respiratory physiology present challenges in addition to a relatively rare incidence of prehospital pediatric TI.

The aim of this study was to describe characteristics and outcomes of prehospital TI in pediatric patients treated by critical care teams.

This is a sub-group analysis of all pediatric (<16 years old) patients from a prospective, observational, multi-center study on prehospital advanced airway management in the Nordic countries from May 2015 through November 2016. The TIs were performed by anesthesiologists and nurse anesthetists staffing six helicopter and six Rapid Response Car (RRC) prehospital critical care teams.

In the study, 74 children were tracheal intubated, which corresponds to 3.7% (74/2,027) of the total number of patients. The pediatric patients were intubated by very experienced providers, of which 80% had performed ≥2,500 TIs. The overall TI success rate, first pass success rate, and airway complication rate were in all children (<16 years) 98%, 82%, and 12%. The corresponding rates among infants (<2 years) were 94%, 67%, and 11%. The median time on scene was 30 minutes.

This study observed a high overall prehospital TI success rate in children with relatively few associated complications and short time on scene, despite the challenges presented by the pediatric prehospital TI.

Prehospital anaesthesia in the United Kingdom (UK) is provided by Helicopter Emergency Medical Service (HEMS) and British Association for Immediate Care (BASICS), a road-based service. Muscle relaxation in rapid sequence induction (RSI) has been traditionally undertaken with the use of suxamethonium; however, rocuronium at higher doses has comparable intubating conditions with fewer side effects.

The aim of this survey was to establish how many prehospital services in the UK are now using rocuronium as first line in RSI.

An online survey was constructed identifying choice of first-line muscle relaxant for RSI and emailed to lead clinicians for BASICS and HEMS services across the UK. If rocuronium was used, further questions regarding optimal dose, sugammadex, contraindications, and difference in intubating conditions were asked.

A total of 29 full responses (93.5%) were obtained from 31 services contacted. Suxamethonium was used first line by 17 prehospital services (58.6%) and rocuronium by 12 (41.4%). In 11 services (91.7%), a dose of 1 mg/kg of rocuronium was used, and in one service, 1.2 mg/kg (8.3%) was used. No services using rocuronium carried sugammadex. In five services, slower relaxation time was found using rocuronium (41.7%), and in seven services, no difference in intubation conditions were noted (58.3%). Contraindications to rocuronium use included high probability of difficult airway and anaphylaxis.

Use of rocuronium as first-line muscle relaxant in prehospital RSI is increasing. Continued auditing of practice will ascertain which services have adopted change and identify if complications of failed intubation increase as a result.

HartleyEL , AlcockR . Rocuronium Versus Suxamethonium: A Survey of First-line Muscle Relaxant Use in UK Prehospital Rapid Sequence Induction. Prehosp Disaster Med. 2015;30(2):1-3.