Crewdson et al.

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

(2018) 26:89
https://doi.org/10.1186/s13049-018-0556-4

REVIEW Open Access

Airway management in pre-hospital critical

care: a review of the evidence for a ‘top
five’ research priority
K. Crewdson1* , M. Rehn2,3,4 and D. Lockey1,2,5

Abstract
The conduct and benefit of pre-hospital advanced airway management and pre-hospital emergency anaesthesia
have been widely debated for many years. In 2011, prehospital advanced airway management was identified as a
‘top five’ in physician-provided pre-hospital critical care. This article summarises the evidence for and against this
intervention since 2011 and attempts to address some of the more controversial areas of this topic.
Keywords: Airway management, Emergency medical services, Intubation

Background reported only 127 intubation attempts by physicians up

Pre-hospital emergency anaesthesia (PHEA) and ad- to and including 2009 [8], compared with 23,738 intub-
vanced airway management remains a controversial sub- ation attempts by physicians between 2006 and 2016 [9].
ject. There are mixed views about whether advanced The recent interest in pre-hospital advanced airway
interventions are beneficial or detrimental [1–4]. What management has generated more research in this area
is clear however, is that there is a small but identifiable but the majority of studies are single centre retrospective
group of patients with recognised indications for intub- database reviews, with significant heterogeneity in the
ation, in whom basic airway manoeuvers are not suffi- design, methodology and endpoints, making interpret-
cient to maintain adequate oxygenation, and advanced ation and the generation of meaningful conclusions diffi-
airway interventions are warranted at an early stage [5]. cult [10, 11]. Randomised controlled trials are difficult to
The quality of pre-hospital emergency airway manage- conduct in a pre-hospital or major trauma setting due to
ment has progressed significantly. For many years intub- issues around consent and inclusion criteria [12, 13].
ation was usually only performed for patients in cardiac In 2011, an expert consensus process identified ad-
arrest or in those with an absent gag reflex, and was vanced airway management as one of the top five re-
associated with a poor outcome [6, 7]. The number of search priorities in pre-hospital critical care [10]. Some
advanced airway interventions performed in the pre-hos- of the most important questions remain the most diffi-
pital setting has increased significantly over recent years. cult to answer, for example, what are the indications for
A meta-analysis published in 2010 reported a total of pre-hospital advanced airway management, does it
54,933 intubation attempts [8]. In a subsequent confer a survival benefit, which patients should receive
meta-analysis from 2006 to 2016, 125,177 intubation it, who should deliver it? [10]. The aim of this article is
attempts were reported [9]. It is likely that one of the to present the arguments for and against the practice of
major factors contributing to these findings is the in- advanced pre-hospital airway management and PHEA
creasing number of physicians involved in pre-hospital and attempt to address some of the controversy sur-
care, particularly in European practice. This observation rounding this topic.
is borne out by further data from meta-analyses which
Is pre-hospital advanced airway management necessary?
* Correspondence: kate.crewdson@nbt.nhs.uk One method of addressing whether advanced airway
1
Department of Anaesthesia, North Bristol NHS Trust, Southmead Hospital,
Southmead Way, Bristol BS10 5NB, UK interventions performed in the pre-hospital setting are
Full list of author information is available at the end of the article actually necessary is to assess whether there is an unmet
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Crewdson et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:89 Page 2 of 6

need for pre-hospital intubation. This can be determined reporting data on 2327 intubations from multiple cen-
by identifying the number of patients who arrive in the tres. In this study, 55% of patients were intubated for
emergency department (ED) with indications for urgent medical reasons, of whom 62% were in cardiac arrest.
tracheal intubation. Relatively few studies directly ad- The remaining 45% of patients are intubated following
dress this issue and those that do suggest that there is traumatic injury, of who 56% are in cardiac arrest [21].
an unmet demand for urgent tracheal intubation for a There are circumstances in which early intubation
proportion of trauma patients in whom basic airway ma- may not be in the patient’s best interests. There is data
noeuvres are inadequate. One study from a pre-hospital to suggest that patients with significant hypovolaemia
physician-led service based in the United Kingdom (UK) following traumatic injury may have a higher mortality if
investigated trauma patients who required any airway anaesthetised in the pre-hospital setting, and that
interventions. Despite the presence of ambulance shorter scene times and waiting until arrival at hospital
personnel, 57% of patients still had airway compromise with direct access to definitive surgical intervention may
on arrival of the physician-led trauma team. All patients be preferable for this patient group [22, 23].
required emergency intubation on scene [5]. Unpub-
lished data obtained by the author (KC) from the UK How should it be done?
trauma audit and research network also suggests an The question of the optimal techniques for pre-hospital
unmet demand in the delivery of pre-hospital ad- airway management remain much debated. The majority
vanced airway management. In the United States, of studies in this area focus on out-of-hospital cardiac
approximately 10% of trauma admissions require ad- arrest and only a small number describe techniques used
vanced airway intervention within the first 5 hours of for trauma patients. Some studies which compare the
hospital arrival; over half of the patients had indica- use of bag-valve mask (BVM) ventilation with advanced
tions for urgent intubation including reduced level of airway management techniques found no benefit of ad-
consciousness, hypoventilation or hypoxaemia, or air- vanced airway techniques over BVM ventilation [3, 24]
way obstruction [14, 15]. but other studies do suggest a morbidity and mortality
benefit associated with the use of advanced airway tech-
Which patients need it? niques for all severely-injured patients [25–27] and for
Emergency airway management in any setting has a sig- those patients with traumatic brain injury if performed
nificant risk of complications; [16] complication rates of by personnel with appropriate training and experience
up to 13% have been reported [17], and careful selection [4, 28, 29]. Those studies that focus on out-of-hospital
of the correct patients is part of improving the overall cardiac arrest also do not conclusively show a benefit of
success of the procedure. There are some indications advanced techniques over basic techniques but the in-
which require immediate airway intervention, including ability to adjust for confounders is widely acknowledged
complete airway obstruction, failure to oxygenate or [30–32]. A UK-based study assessing the use of supra-
ventilate adequately, cardiac arrest or a Glasgow Coma glottic airway devices for non-traumatic out-of-hospital
Scale (GCS) less than 9 [18]. In some circumstances, cardiac arrest failed to demonstrate superiority when
basic airway techniques may provide temporary manage- compared with tracheal intubation [33]. In contrast, data
ment of oxygenation and ventilation but advanced air- from the United States suggested improved 72-h survival
way techniques are usually required to provide definitive using supraglottic airway devices when compared to
airway control. There is considerable variation in the in- tracheal intubation [34]. Data published in 2018 from a
dications for pre-hospital emergency airway manage- trial comparing bag-valve-mask ventilation with tracheal
ment. Datasets produced from analysis of United States intubation for initial airway management was inconclu-
(US) airway registries are often difficult to interpret but, sive [35].
of the two largest published recently, one study from PHEA is usually performed using an induction agent,
2011 reports 10,356 intubation attempts [19] and one often ketamine, a neuromuscular blocker and a sedative
from 2014 reports 74,993 intubation attempts [20]. The agent. As with in-hospital practice, the majority of
2011 data from Wang et al. suggest that the major indi- agents can be safely used in a pre-hospital setting as
cation for intubation is cardiac arrest and this is sup- long as careful attention is given to the dose of drug
ported by the 2014 data from Diggs et al., with the administered, to reflect the deranged physiology of
studies reporting that 53 and 52% of patients respect- severely-injured patients. The use of ketamine as an in-
ively are intubated following a cardiac arrest. The fre- duction agent has historically been associated with an
quency of intubation following trauma is also similar increase in intracranial pressure [36]. More recent stud-
between the two studies - 6 and 8% [19, 20]. Outside the ies suggest these concerns are not associated with any
US, one of the largest pre-hospital emergency airway clinical significance and ketamine is now considered a
studies of the last 5 years comes from Sunde et al. safe and effective drug for use in the pre-hospital setting
Crewdson et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:89 Page 3 of 6

[37], particularly in haemodynamically unstable patients Recommendations in recent UK guidelines suggest that
[38]. Rocuronium is the neuromuscular blocking agent the standard of care delivered in the pre-hospital setting
of choice for many and a combination of fentanyl, should be the same as that delivered in-hospital and doc-
ketamine, and rocuronium has been shown to pro- tors providing emergency anaesthesia should be able to do
duce more favourable intubating conditions in the so competently, and unsupervised, in the emergency de-
pre-hospital setting [39]. partment [50, 52]. Recognition of Pre-hospital Emergency
All efforts should be focused on making the first at- Medicine (PHEM) as a subspecialty in the UK has helped
tempt at laryngoscopy successful, as repeated attempts structure and formalise training programmes in pre-hos-
have been shown to be detrimental both in terms of pital care to improve the care delivered to patients. In
morbidity and mortality [40, 41]. Multiple attempts at Europe, pre-hospital emergency care is increasingly deliv-
laryngoscopy can cause bleeding or swelling in the air- ered by physicians [53]. There is evidence to suggest
way and may result in significant desaturation and hyp- higher success rates and shorter on scene times for PHEA
oxic episodes [42]. Laryngoscopy is highly stimulating when this technique is delivered by physicians [54]. A me-
for patients and causes a sympathetic surge. Perkins et dian intubation success rate of 98.8% (range 78.1–100%)
al. demonstrated a hypertensive response to pre-hospital has been reported for physicians performing intubations
laryngoscopy and intubation in 79% of severely injured in the pre-hospital setting. The reported median success
patients, and 9% of patients experienced a greater than rate for non-physicians is 91.7% (range 61.6 to 100%) [9].
100% increase in mean arterial pressure and/or systolic As expected, success rates are generally higher for anaes-
blood pressure [43]. Impairment of cerebral autoregula- thetists when compared with non-anaesthetists [53, 55],
tion following traumatic brain injury leaves the brain emphasising the importance of increased clinical exposure
vulnerable to surges in blood pressure and intracranial in the preservation of skills, and avoidance of skill fade
pressure, with a subsequent worsening of cerebral [56]. In recognition of the fact that intubation without the
oedema and haematoma expansion, which can be detri- use of drugs is generally futile [6], the Joint Royal Colleges
mental to patient outcome [43–45]. The hypertensive Ambulance Liaison Committee no longer train para-
response to laryngoscopy is arguably more common in medics in tracheal intubation but recommend the use of
emergency settings, where the dose of induction agent supraglottic airway devices for advanced airway manage-
may be modified if there are significant concerns about ment [57].
the severity of injury and the likely physiological re-
sponse to anaesthesia. Opioids which suppress the How can practice be improved?
hypertensive response, may be given in low doses or Standards and safety
omitted altogether. PHEA has become increasingly formalised and guide-
A robust failed intubation plan should be well-embed- lines exist at local and national levels to standardise the
ded into all services delivering PHEA. This plan should procedure and improve patient safety [50, 52, 58]. The
be verbalised to the attending team before starting pre-hospital infrastructure in the United States differs
PHEA. Videolaryngoscopy may be considered as part of significantly from that in Europe and Australasia and al-
a failed intubation plan or may at times be used for the though the guidelines reflect those differences, the gen-
first attempt at laryngoscopy. The benefit of videolaryn- eral messages delivered are similar in all the guidelines.
goscopy for emergency airway management remains There is a strong focus on patient safety, the guidelines
widely debated but recent evidence does not strongly suggest that advanced airway management should only
support a positive benefit of this intervention [46–48]. be delivered when appropriately skilled pre-hospital
Emergency cricothyroidotomy is generally the endpoint of personnel are available. Otherwise meticulous attention
failed intubation guidelines [49, 50]. The evidence-base for should be paid to performing high-quality basic airway
this technique remains small and no clear benefit of a interventions [50, 52, 58, 59]. Studies which have
surgical technique has been demonstrated over needle reviewed the implementation and effectiveness of these
technique however the increased number of complications tools within pre-hospital services have been able to
associated with needle cricothyroidotomy and the require- demonstrate uncomplicated introduction process [60]
ment for conversion to a surgical technique means that a and improvement in compliance with guideline stan-
surgical technique is recommended by major airway dards [61, 62].
guidelines [49, 51].
Apnoeic oxygenation
Who should deliver it? Severely injured patients with significant physiological
There is ongoing debate about who should deliver pre- and anatomical derangement, are more susceptible to
hospital advanced airway management and the amount of adverse events during emergency anaesthesia. Anatom-
training required and consensus has not been reached. ical distortion of the head and neck from injury may
Crewdson et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:89 Page 4 of 6

impede intubation, and chest injury may cause ventilation- Reporting data
perfusion mismatch. Hypoxia is one of the most commonly The standardised reporting of data for pre-hospital ad-
occurring adverse event during emergency intubation and vanced airway management remains poor despite recent
is reported to occur in over one quarter of emergency intu- major guidelines promoting the use of key performance
bations [63, 64]. Whilst any given reduction in the partial indicators [52]. In 2009, Sollid et al. developed an
pressure of arterial oxygen will reduce arterial oxygen satur- Utstein-style template for documenting and reporting
ation, the magnitude of this fall increases once SaO2 falls pre-hospital airway management [11], but to date its use
below 93% [65]. Increasing the time to desaturation during remains limited with relatively few studies reporting data
prolonged or difficult intubation using apnoeic oxygenation in accordance with the template. The template has been
has been demonstrated to increase peri-intubation oxygen recently revised [74] and improvements in data collec-
saturation and reduce the incidence of hypoxaemia. The tion and reporting will make the evidence-base for
technique, though simple to perform, remains rela- pre-hospital advanced airway management more robust
tively underused in the pre-hospital setting. One and provide better indications of the benefits and pitfalls
retrospective study reported a 6% reduction in episodes of of this intervention.
desaturation associated with emergency intubations [66].
Further studies are being conducted to evaluate its use in Conclusion
the pre-hospital environment. PHEA remains a controversial area with a limited
evidence-base but current data suggests an unmet de-
mand for PHEA in a small but identifiable group of pa-
Post intubation care tients. Where necessary, the intervention should be
In line with in-hospital practice, there is an increasing delivered by personnel with the appropriate skills and
focus on post-intubation care. If possible, post intub- training. Careful attention should be given to optimising
ation care should begin in the pre-hospital phase. the first attempt at laryngoscopy and the intervention
Patients should be appropriately sedated using an anaes- should be delivered to the same standards as those
thetic agent following intubation, the dose of which is achieved in hospital. The increasing numbers of physi-
titrated to their haemodynamic physiology. Further cians in Pre-hospital Emergency Medicine should help
doses of neuromuscular blocking agents may also be re- improve the delivery of PHEA, which will hopefully
quired to enable mandatory ventilation and avoid any translate into improvement in morbidity and mortality.
ventilatory compromise. The use of end-tidal carbon di-
oxide monitoring, has become mandatory in any intu- Abbreviations
BVM: Bag-valve-mask; GCS: Glasgow Coma Scale; PaO2: Arterial partial pressure
bated patient and careful attention should be paid to the of oxygen; PHEA: Pre-hospital Emergency Anaesthesia; PHEM: Pre-hospital
provision of appropriate ventilation strategies, incorpor- Emergency Medicine
ating lung protective ventilation if possible. Emerging
Availability of data and materials
evidence about the harmful effects of hyperoxia may Data sharing is not applicable to this article as no datasets were generated
guide future practice, particularly in patients with or analysed during the current study.
traumatic brain injury where a PaO2 greater than 65 kPa
Authors’ contributions
(or 487 mmHg) has been shown to worsen patient out- KC reviewed the evidence and authored the first draft. MR and DL reviewed
come [67]. Ventilation should be carefully managed to and constructively criticised the first draft and co-authored subsequent drafts.
avoid hypocarbia and hypercarbia, both of which have All authors read and approved the final manuscript.
been demonstrated to be detrimental, particularly in
Ethics approval and consent to participate
traumatic brain injury [68–70]. Mechanical ventilation is Not applicable
generally considered to be superior to hand ventilation
when targeting a specific range for end-tidal carbon Consent for publication
Not applicable
dioxide [71]. One Scandinavian service demonstrated
increased use of mechanical ventilation following the Competing interests
introduction of an standard operating procedure [62]. The authors declare that they have no competing interests.
Body temperature should be maintained in the
pre-hospital setting. Recent data has demonstrated a Publisher’s Note
higher rate of hypothermia in patients who are anaesthe- Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
tised outside hospital [62]. Previously cooling patients
with traumatic brain injury or post cardiac arrest was Author details
1
considered to be beneficial to outcome but subsequent Department of Anaesthesia, North Bristol NHS Trust, Southmead Hospital,
Southmead Way, Bristol BS10 5NB, UK. 2Department of Research, Norwegian
studies have questioned this theory and it is no longer Air Ambulance Foundation, Drøbak, Norway. 3Pre-hospital Division, Air
recommended practice [72, 73]. Ambulance Department, Oslo University Hospital, Oslo, Norway. 4Faculty of
Crewdson et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:89 Page 5 of 6

Health Sciences, University of Stavanger, Stavanger, Norway. 5Bristol 22. Crewdson K, Rehn M, BROHI K, Lockey DJ. Pre-hospital emergency anaesthesia
University, Bristol, UK. in awake hypotensive trauma patients: beneficial or detrimental? Acta
Anaesthesiol Scand. 2018;62:504–14.
Received: 23 July 2018 Accepted: 4 October 2018 23. Chou D, Harada MY, Barmparas G, Ko A, Ley EJ, Margulies DR, et al. Field
intubation in civilian patients with hemorrhagic shock is associated with
higher mortality. Journal Trauma Acute Care Surg. 2016;80:278–82.
24. Bochicchio GV, Ilahi O, Joshi M, Bochicchio K, Scalea TM. Endotracheal
References intubation in the field does not improve outcome in trauma patients
1. Hussmann B, Lefering R, Waydhas C, Ruchholtz S, Wafaisade A, Kauther MD, who present without an acutely lethal traumatic brain injury. J Trauma.
et al. Prehospital intubation of the moderately injured patient: a cause of 2003;54:307–11.
morbidity? A matched-pairs analysis of 1,200 patients from the DGU trauma
25. Winchell RJ, Hoyt DB. Endotracheal intubation in the field improves survival
registry. Crit Care. 2011;15:R207.
in patients with severe head injury. Trauma research and Education Foundation
2. Pepe PE. Prehospital endotracheal intubation: elemental or detrimental? Crit
of san Diego. Arch Surg. 1997;132:592–7.
Care. 2015;19:121.
26. Meizoso JP, Valle EJ, Allen CJ, Ray JJ, Jouria JM, Teisch LF, et al. Decreased
3. Stockinger ZT, McSwain NE Jr. Prehospital endotracheal intubation for trauma
mortality after prehospital interventions in severely injured trauma patients.
does not improve survival over bag-valve-mask ventilation. J Trauma. 2004;56:
J Trauma Acute Care Surg. 2015;79:227–31.
531–6.
27. Hartog Den D, Romeo J, Ringburg AN, Verhofstad MHJ, Van Lieshout EMM.
4. Bossers SM, Schwarte LA, Loer SA, Twisk JWR, Boer C, Schober P. Experience
Survival benefit of physician-staffed helicopter emergency medical services
in prehospital endotracheal intubation significantly influences mortality of
(HEMS) assistance for severely injured patients. Injury. 2015;46:1281–6.
patients with severe traumatic brain injury: a systematic review and meta-
28. Bernard SA, Nguyen V, Cameron P, Masci K, Fitzgerald M, Cooper DJ, et al.
analysis. PLoS One. 2015;10:e0141034–26.
Prehospital rapid sequence intubation improves functional outcome for
5. Lockey DJ, Healey B, Crewdson K, Chalk G, Weaver AE, Davies GE. Advanced
patients with severe traumatic brain injury: a randomized controlled trial.
airway management is necessary in prehospital trauma patients. Br J Anaesth.
Ann Surg. 2010;252:959–65.
2015;114:657–62.
29. Davis DP, Peay J, Sise MJ, Kennedy F, Simon F, Tominaga G, et al. Prehospital
6. Lockey D, Davies G, Coats T. Survival of trauma patients who have
airway and ventilation management: a trauma score and injury severity score-
prehospital tracheal intubation without anaesthesia or muscle relaxants:
based analysis. J Trauma. 2010;69:294–301.
observational study. BMJ. 2001;323:141.
7. Christensen EF, Høyer CCS. Prehospital tracheal intubation in severely injured 30. Fouche PF, Simpson PM, Bendall J, Thomas RE, Cone DC, SAR D. Airways in
patients: a Danish observational study. BMJ. 2003;327:533. out-of-hospital cardiac arrest: systematic review and meta-analysis. Prehosp
8. Hubble MW, Brown L, Wilfong DA, Hertelendy A, Benner RW, Richards ME. A Emerg Care. 2014;18:244–56.
meta-analysis of prehospital airway control techniques part I: Orotracheal and 31. Carlson JN, Reynolds JC. Does advanced airway management improve
Nasotracheal intubation success rates. Prehosp Emerg Care. 2010;14:377–401. outcomes in adult out-of-hospital cardiac arrest? Ann Emerg Med. 2014;
9. Crewdson K, Lockey DJ, Røislien J, Lossius HM, Rehn M. The success of pre- 64(2):163–4.
hospital tracheal intubation by different pre-hospital providers: a systematic 32. Hasegawa K, Hiraide A, Chang Y, Brown DFM. Association of prehospital
literature review and meta-analysis. Crit Care. 2017;21:1–10. advanced airway management with neurologic outcome and survival in
10. Fevang E, Lockey D, Thompson J, Lossius HM, Collaboration TTR. The top patients with out-of-hospital cardiac arrest. JAMA 2013;309:257–66.
five research priorities in physician-provided pre-hospital critical care: a 33. Benger JR, Kirby K, Black S, Brett SJ, Clout M, Lazaroo MJ, Nolan JP, Reeves BC,
consensus report from a European research collaboration. Scand J Trauma Robinson M, Scott LJ, Smartt H. Effect of a strategy of a Supraglottic airway
Resusc Emerg Med. 2011;19:57. device vs tracheal intubation during out-of-hospital cardiac arrest on functional
11. Sollid SJM, Lockey D, Lossius HM. Pre-hospital advanced airway management outcome: the AIRWAYS-2 randomized clinical trial. JAMA. 320(8):779–91.
expert group. A consensus-based template for uniform reporting of data from 34. Wang HE, Schmicker RH, Daya MR, Stephens SW, Idris AH, Carlson JN,
pre-hospital advanced airway management. Scand J Trauma Resusc Emerg Colella MR, Herren H, Hansen M, Richmond NJ, Puyana JC. Effect of a
Med. 2009;17:58. strategy of initial laryngeal tube insertion vs endotracheal intubation on
12. Lockey DJ. Research questions in pre-hospital trauma care. PLoS Med. 2017; 72-hour survival in adults with out-of-hospital cardiac arrest: a randomized
14:e1002345–4. clinical trial. JAMA. 2018;320(8):769–78.
13. Swain SA, Stiff G. Issues and challenges for research in major trauma. Emerg 35. Jabre P, Penaloza A, Pinero D, Duchateau FX, Borron SW, Javaudin F, Richard
Med J. 2018;35:267–9. O, de Longueville D, Bouilleau G, Devaud ML, Heidet M. Effect of bag-mask
14. Stephens CT, Kahntroff S, Dutton RP. The success of emergency endotracheal ventilation vs endotracheal intubation during cardiopulmonary resuscitation
intubation in trauma patients: a 10-year experience at a major adult trauma on neurological outcome after out-of-hospital cardiorespiratory arrest: a
referral center. Anesth Analg. 2009;109:866–72. randomized clinical trial. JAMA;319(8):779–87.
15. Sise MJ, Shackford SR, Sise CB, Sack DI, Paci GM, Yale RS, et al. Early 36. Schwedler M, Miletich DJ, Albrecht RF. Cerebral blood flow and metabolism
intubation in the Management of Trauma Patients: indications and following ketamine administration. Can Anaesth Soc J. 1982;29:222–6.
outcomes in 1,000 consecutive patients. J Trauma. 2009;66:32–40. 37. Zeiler FA, Teitelbaum J, West M, Gillman LM. The ketamine effect on ICP in
16. Cook TM, Woodall N, Harper J, Benger J. Major complications of airway traumatic brain injury. Neurocrit Care. 2014;21:163–73.
management in the UK: results of the fourth National Audit Project of the 38. Paal P, Herff H, Mitterlechner T, Goedecke Von A, Brugger H, Lindner KH, et
Royal College of Anaesthetists and the difficult airway society. Part 2: al. Anaesthesia in prehospital emergencies and in the emergency room.
intensive care and emergency departments. Br J Anaesth. 2011;106:632–42. Resuscitation. 2010;81:148–54.
17. Struck MF, Fakler JKM, Bernhard M, Busch T, Stumpp P, Hempel G, et al. 39. Lyon RM, Perkins ZB, Chatterjee D, Lockey DJ, Russell MQ, Kent S, Sussex Air
Mechanical complications and outcomes following invasive emergency Ambulance Trust. Significant modification of traditional rapid sequence
procedures in severely injured trauma patients. Nat Sci Rep. 2018:1–10. induction improves safety and effectiveness of pre-hospital trauma anaesthesia.
18. Mayglothling J, Duane TM, Gibbs M, McCunn M, Legome E, Eastman AL, et Crit Care. 2015;19:134.
al. Emergency tracheal intubation immediately following traumatic injury: 40. Mort TC. Emergency tracheal intubation: complications associated with
Eastern Association for the Surgery of Trauma practice management guideline. repeated laryngoscopic attempts. Anaes Analg. 2004;99:607–13.
J Trauma Acute Care Surg. 2012:S333–40. 41. Hasegawa K, Shigemitsu K, Hagiwara Y, Chiba T, Watase H, Brown CA, et al.
19. Wang HE, Mann NC, Mears G, Jacobson K, Yealy DM. Out-of-hospital airway Association between repeated intubation attempts and adverse events in
management in the United States. Resuscitation. 2011;82:378–85. emergency departments: an analysis of a multicenter prospective observational
20. Diggs LA, Yusuf J-EW, De Leo G. An update on out-of-hospital airway study. Ann Emerg Med. 2012;60:749–754.e2.
management practices in the United States. Resuscitation. 2014;85:885–92. 42. Bernhard M, Becker TK, Gries A, Knapp J, Wenzel V. The first shot is often the
21. Sunde GA, Heltne JK, Lockey D, Burns B, Sandberg M, Fredriksen K, et al. best shot: first-pass intubation success in emergency airway management.
Airway management by physician-staffed helicopter emergency medical Anesth Analg. 2015;121:1389–93.
services – a prospective, multicentre, observational study of 2,327 patients. 43. Perkins ZB, Gunning M, Crilly J, Lockey D, O'Brien B. The haemodynamic
Scand J Trauma Resusc Emerg Med. 2015;23:57. response to pre-hospital RSI in injured patients. Injury. 2012;44:618–23.
Crewdson et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:89 Page 6 of 6

44. Chesnut RM, Marshall LF, Klauber MR, Blunt BA, Baldwin N, Eisenberg HM, 66. Wimalasena Y, Burns B, Reid C, Ware S, Habig K. Apneic oxygenation was
et al. The role of secondary brain injury in determining outcome from associated with decreased desaturation rates during rapid sequence
severe head injury. J Trauma. 1993;34:216–22. intubation by an Australian helicopter emergency medicine service.
45. Perel P, Roberts I, Bouamra O, Woodford M, Mooney J, Lecky F. Intracranial Ann Emerg Med. 2015;65:371–6.
bleeding in patients with traumatic brain injury: a prognostic study. BMC 67. Vincent J-L, Taccone FS, He X. Harmful effects of Hyperoxia in Postcardiac
Emerg Med. 2009;9:1321–8. arrest, Sepsis, traumatic brain injury, or stroke: the importance of individualized
46. Savino PB, Reichelderfer S, Mercer MP, Wang RC, Sporer KA. Direct versus oxygen therapy in critically ill patients. Can Respir J. 2017;2017:1–7.
video laryngoscopy for prehospital intubation: a systematic review and 68. Davis DP, Idris AH, Sise MJ, Kennedy F, Eastman AB, Velky T, et al. Early
meta-analysis. Acad Emerg Med. 2017;24:1018–26. ventilation and outcome in patients with moderate to severe traumatic
47. Jiang J, Ma D, Li B, Yue Y, Xue F. Video laryngoscopy does not improve the brain injury. Crit Care Med. 2006;34:1202–8.
intubation outcomes in emergency and critical patients – a systematic review 69. Warner KJ, Cuschieri J, Copass MK, Jurkovich GJ, Bulger EM. The impact of
and meta-analysis of randomized controlled trials. Crit Care. 2017;21:288. prehospital ventilation on outcome after severe traumatic brain injury.
48. Lascarrou JB, Boisrame-Helms J, Bailly A, Le Thuaut A, Kamel T, Mercier E, J Trauma. 2007;62:1330–8.
et al. Video laryngoscopy vs direct laryngoscopy on successful first-pass 70. Deakin CD, Sado DM, Coats TJ, Davies G. Prehospital end-tidal carbon dioxide
Orotracheal intubation among ICU patients. JAMA. 2017;317:483–11. concentration and outcome in major trauma. J Trauma. 2004;57:65–8.
49. Higgs A, McGrath BA, Goddard C, Rangasami J, Suntharalingam G, Gale R, 71. DP, De Cosmo D, Bossi A. Comparison of manual and mechanical
et al. Guidelines for the management of tracheal intubation in critically ill ventilation during transport of patients to the intensive care unit after
adults. Br J Anaesth. 2018;120:323–52. cardiac surgery. Eur J Anaesthesiol. 2006;38:1–47.
50. Rehn M, Hyldmo PK, Magnusson V, Kurola J, Kongstad P, Rognås L, et al. 72. Langhelle A, Lockey D, Harris T, Davies G. Body temperature of trauma patients
Scandinavian SSAI clinical practice guideline on pre-hospital airway management. on admission to hospital: a comparison of anaesthetised and non-
Acta Anaesthesiol Scand. 2016;60:852–64. anaesthetised patients. Emerg Med J. 2012;29:239–42.
51. Truhlář A, Deakin CD, Soar J, Khalifa GEA, Alfonzo A, Bierens JJLM, et al. 73. Lindsay PJ, Buell D, Scales DC. The efficacy and safety of pre-hospital
European resuscitation council guidelines for resuscitation 2015: section 4. cooling after out-of-hospital cardiac arrest: a systematic review and meta-
Cardiac arrest in special circumstances. Resuscitation. 2015;95:148–201. analysis. Crit Care. 2018;22:66.
52. Lockey DJ, Crewdson K, Davies G, Jenkins B, Klein J, Laird C, et al. AAGBI: 74. Carney N, Totten AM, O'Reilly C, Ullman JS, Hawryluk GWJ, Bell MJ, et al.
safer pre-hospital anaesthesia 2017. Anaesthesia. 2017;72:379–90. Guidelines for the Management of Severe Traumatic Brain Injury. Neurosurgery.
53. Sollid SJM, Rehn M. The role of the anaesthesiologist in air ambulance 2017;80:6–15.
medicine. Curr Opin Anaesthesiol. 2017;30:513–7.
54. Gellerfors M, Fevang E, Bäckman A, Krüger A, Mikkelsen S, Nurmi J, et al.
Pre-hospital advanced airway management by anaesthetist and nurse
anaesthetist critical care teams: a prospective observational study of 2028
pre-hospital tracheal intubations. Br J Anaesth. 2018;120:1103–9.
55. Lockey D, Crewdson K, Weaver A, Davies G. Observational study of the
success rates of intubation and failed intubation airway rescue techniques
in 7256 attempted intubations of trauma patients by pre-hospital physicians.
Br J Anaesth. 2014;113:220–5.
56. Breckwoldt J, Klemstein S, Brunne B, Schnitzer L, Arntz H-R, Mochmann H-C.
Expertise in prehospital endotracheal intubation by emergency medicine
physicians—comparing ‘proficient performers’ and ‘experts’. Resuscitation.
2012;83:434–9.
57. Deakin CD, Clarke T, Nolan J, Zideman DA, Gwinnutt C, Moore F, et al. A
critical reassessment of ambulance service airway management in prehospital
care: joint Royal Colleges Ambulance Liaison Committee Airway Working
Group, June 2008. Emerg Med J. 2010;27:226–33.
58. Hossfeld B, Bein B, Boettiger BW, Bohn A, Fischer M, Graesner J-T, et al.
Recommended practice for out-of-hospital emergency anaesthesia in adults:
statement from the out-of-hospital emergency Anaesthesia working Group
of the Emergency Medicine Research Group of the German Society of
Anaesthesiology and Intensive Care. Eur J Anaesthesiol. 2016;33:881–97.
59. O'Connor RE. Drug-assisted intubation in the prehospital setting position
statement of the National Association of emergency physicians. Prehosp
Emerg Care. 2006;10:260–0.
60. Chesters A, Keefe N, Mauger J, Lockey D. Prehospital anaesthesia performed
in a rural and suburban air ambulance service staffed by a physician and
paramedic: a 16-month review of practice. Emerg Med J. 2014;31:65–8.
61. Chen C, Kan T, Li S, Qiu C, Gui L. Use and implementation of standard
operating procedures and checklists in prehospital emergency medicine: a
literature review. Am J Emerg Med. 2016;34:2432–9.
62. Rognås L, Hansen TM, Kirkegaard H, Tønnesen E. Standard operating procedure
changed pre-hospital critical care anaesthesiologists’ behaviour: a quality control
study. Scand J Trauma Resusc Emerg Med. 2013;21(1):84.
63. Jaber S, Amraoui J, Lefrant J-Y, Arich C, Cohendy R, Landreau L, et al. Clinical
practice and risk factors for immediate complications of endotracheal
intubation in the intensive care unit: a prospective, multiple-center
study. Crit Care Med. 2006;34:2355–61.
64. Griesdale DEG, Bosma TL, Kurth T, Isac G, Chittock DR. Complications of
endotracheal intubation in the critically ill. Intensive Care Med. 2008;34:
1835–42.
65. Davis DP, Hwang JQ, Dunford JV. Rate of decline in oxygen saturation at
various pulse oximetry values with prehospital rapid sequence intubation.
Prehosp Emerg Care. 2008;12:46–51.