Variation in the type, rate, and selection of patients for out-of-hospital airway procedures among injured children and adults

Objectives: The objective was to compare the type, rate, and selection of injured patients for out-of-hospital airway procedures among emergency medical services (EMS) agencies in 10 sites across North America. Methods: The authors analyzed a consecutive patient, prospective cohort registry of injured adults and children with an out-of-hospital advanced airway attempt, collected from December 1, 2005, through February 28, 2007, by 181 EMS agencies in 10 sites across the United States and Canada. Advanced airway procedures were defined as orotracheal intubation, nasotracheal intubation, supraglottic airway, or cricothyrotomy. Airway procedure rates were calculated based on age-specific population values for the 10 sites and the number of injured patients with field physiologic abnormality (systolic blood pressure of ≤90 mm Hg, respiratory rate of <10 or >29 breaths/min, Glasgow Coma Scale [GCS] score of ≤12). Descriptive measures were used to compare patients between sites. Results: A total 1,738 patients had at least one advanced airway attempt and were included in the analysis. There was wide variation between sites in the types of airway procedures performed, including orotracheal intubation (63% to 99%), supraglottic airways (0 to 27%), nasotracheal intubation (0 to 21%), and cricothyrotomy (0 to 2%). Use of rapid sequence intubation (RSI) varied from 0% to 65%. The population-adjusted rates of field airway intervention (by site) ranged from 1.2 to 22.8 per 100,000 adults and 0.2 to 4.0 per 100,000 children. Among trauma patients with physiologic abnormality, some sites performed airway procedures in almost 50% of patients, while other sites used these procedures in fewer than 10%. There was also large variation in demographic characteristics, physiologic measures, mechanism of injury, mode of transport, field cardiopulmonary resuscitation, and unadjusted mortality among airway patients. Conclusions: Among 10 sites across North America, there was wide variation in the types of out-of-hospital airway procedures performed, population-based rates of airway intervention, and the selection of injured patients for such procedures.