Paramedics and Intubation - Literature review Example

Running Head: Paramedics and Intubation Paramedics and Intubation [Institute’s Paramedics and Intubation Introduction In clinical care, experts have given the highest significance to airway management, which plays a crucial role in the success of nearly all circumstances related to clinical care. One of the critical reasons of such importance to airway management is its relation with blood circulation, as well as, oxygenation in the human body. In other words, all clinical treatments and processes require continuous flow of oxygen in patient’s body, which is ensured by effective airway management through provision of an open corridor to lungs for perfect flow of oxygen in the body. (Murray, pp. 23-25, 2001) Thus, a number of clinical aspects like paramedics, intensive care units, emergency services, anaesthesia, etc give significant importance to airway management. It is observed that a number of methodologies are available that are used to manage the abovementioned process in an efficient manner, such as mask ventilation, light wand, combitude, oral airway, laryngeal mask insertion, endotracheal intubation, etc. (Morris, pp. 930-960, 1994). Studies have indicated that endotracheal intubation is considered one of the most effective and commonly used methods for effective airway management in particularly paramedics. Moreover, intubation has remained as a gold standard in airway management since twenty years, (JRCALC Airway Group, 2004) and has played a vital role in ensuring the effective management of airway pathways in different clinical circumstances. However, it has recently been suggested by the Joint Royal Colleges Ambulance Liaison Committee that UK Paramedics should no longer be using intubation as the gold standard of airway management. A number of factors are responsible for such suggestion and this paper will discuss and analyze some of the significant characteristics and aspects of intubation, in order to understand the effects and complications associated with this methodology of airway management. The paper will discuss some of the characteristics of intubation, which will allow a better understanding of complications associated with it. In clinical terms, an external or internal jaw of a human body is considered for placing a tube for ensuring effective airway management, and such method is referred as intubation in medical terms. (Wang, pp. 1245, 2005) Although a number of endoscopic processes have been referred with intubation, tracheal intubation is mostly indicated with this term. (Nolan, pp. 413-421, 2001) In this regard, airway paths of patients are protected by the utilization of an elastic plastic tube, and insertion of such tube in trachea is referred as endotracheal intubation. In other words, artificial platform is provided to the patient for allowing ventilation in a mechanical manner. A number of techniques are used by the experts to perform this process of airway management, and different techniques pose various complications, which will be discussed later in this paper. Negation of intubation as gold standard of airway management has been often related with inefficiency of medical experts. Usually, a paramedic carries out the procedure of intubation for airway management, and it is noted that a number of paramedics are unable to carry out the procedure effectively, which results in a number of complications, and often results in death in extreme circumstances. (Karren, pp. 39-47, 1995) The abovementioned suggestion for discontinuing the utilization of intubation as a gold standard for airway management by Joint Royal Colleges Ambulance Liaison Committee is one of the consequences of risks associated with the procedure. In this regard, it is very important that paramedics should be aware of all the aspects and consequences of intubation, in order to achieve the objective of saving patients’ lives in clinical circumstances. In terms of indications, different medical circumstances require the procedure of intubation, such as hypoxemic respiratory failure, which often considers the utilization of intubation. In some circumstances, patients confront upper airway impediment, and airway is protected by intubation. (Weber, pp. 256-274, 2002) Moreover, elective intubation is indicated in cases of deterioration of central nervous system aspiration, as aspiration becomes an essential process for the patients, which is performed through elective intubation. Additionally, computer tomographic scan utilizes the endotracheal intubation for effective operating of procedures involved in the diagnosis as well. (Mort, pp. 607-613, 2004) Furthermore, acute intracranial hypertension is another cause that results in the requirement of intubation that facilitates reduction of intracranial pressure in such patients. In this regard, intubation and particularly, endotracheal intubation plays an imperative and crucial role in effective airway management in various clinical circumstances; however, it has been doubted as a proficient procedure, which requires a comprehensive investigation of other aspects of this methodology. (Crosby, pp. 164-167, 2000) In specific, Joint Royal Colleges Ambulance Liaison Committee carried out an assessment on the airway management by ambulance service in pre-hospital care on July 09, 2008. Different aspects of intubation procedure were analyzed and examined to acquire a strong perspective related to its consequences and complications. In the report, it was suggested that current methodology of intubation was not effective enough to treat it as a gold standard for airway management in paramedics. On the other hand, utilization of a supraglottic device has now been preferred by the committee. The paper will now discuss some of the complications associated with the procedure that are available in different literature. Until the commencement of recent decade, intubation enjoyed its golden status in airway management; however, ambulance services were associated with empirical practices that resulted in a number of queries related to the procedure. (JRCALC, 2004) Literature review has indicated that delivery of inefficient training of intubation has been the major factor of its negation in present era, as it requires an experienced medical expert and specialist, and absence of such specialization may result in complications for patients. Studies have indicated that tracheal intubation has been considered as a significant factor for saving patients from cardiac arrest. (Irish, pp. 953-969, 2002) However, such belief was dismissed by recent statistics that showed harmful consequences of intubation in such cases. Again, individual paramedics have been the depending factors of success of intubation procedure, and thus, less than 45% of success rate is observed in cases that were dealt with intubation due to higher frequency of inexperienced personnel in paramedics. (Sayre, pp. 228-233, 1998) (Bradley, pp. 26-32, 1998) One of the risks associated with intubation is physiological stress that results in failure of tracheal intubation. (Hickman, pp. 169-177, 2006) It is observed that patients become stressful due to prolonged period of the procedure, especially in the case of laryngoscopy. (Gal, pp. 1617-52, 2005) Hypoxaemia is another significant factor that has supported the suggestion of Joint Royal Colleges Ambulance Liaison Committee. In such, hypoxemia is confronted due to absence of oxygen supply for an extended and delayed period, and it is considered as one of the adverse risks associated with tracheal intubation. (Anaesthesia UK, 2004) During the procedure, it is observed that chest compressions interrupt the process that often results in bleeding, if not handled adequately. (Gatward, pp. 351-356, 2008) Due to inadequacy, oro-pharyngeal tissues confront trauma during the procedure, which is another risk that has been indicated by the committee in its report. (JRCALC, pp. 9, 2008) Training has remained the major factor of discontinuation of tracheal intubation as a gold standard for airway management, as gradually, various problems and complications are observed in the delivery of training of tracheal intubation to paramedics. According to a study, (Konrad, pp. 635-639, 1998) more than fifty attempts of intubation were required to achieve the success rate of ninety percent in the procedure of tracheal intubation in anaesthesia patients. (Kapadia, pp. 659-664, 2000) Another complication associated with intubation is unrecognized oesophageal intubation, which has reduced the success rate of the procedure. Some of the experts have suggested the utilization of monitoring of end-tidal carbon dioxide, which may facilitate the occurrence of abovementioned risk in intubation; (Karch, pp. 617-619, 1996) however, it is argued that detection of carbon dioxide will not be possible in case of cardiac arrests, and thus, may be detrimental for the patients. (Sanchi, pp. 604-605, 1999) Although a number of benefits have been related with tracheal intubation; however, scarcity of such elements have resulted in the domination of supraglottic devices for airway management. In one study, results indicated that intubation without drug was able to save only one patient out of more than 490 trauma patients in pre-hospital circumstances. (Lockey, pp. 1097-1098, 1999) One of the studies that showed positive results of intubation reported efficiency in cases of head injuries (Suominen, pp. 3-7, 2000); however, such reports have not focused specifically on details like attempts, failures, etc, which are essential for decision-making process. In this regard, a number of studies have showed inefficient results related to the failure of intubation attempts on patients. In one study, higher percentage of mortality was indicated, as compared with clinical circumstances that did not consider the intubation procedure. (Davis, pp. 444-453, 2003) In this regard, number of reports showing harmful effects of intubation has superseded the number of reports that have shown positive outcomes on patients treated with tracheal intubation. Another major factor that has resulted in the negation of tracheal intubation is the continued improvement and innovation of alternative devices available for airway management. For instance, problems of oxygenation and hypoxemia will now be able to prevent by devices, such as supraglottic device, which has now become the mandatory element in the training of paramedics in the United Kingdom. (Brimacombe, pp. 313-355, 2005) (Cook, pp. 371-387, 2006) Moreover, skill fade is another factor that has argued the compatibility of paramedics in carrying out the procedure of tracheal intubation. In specific, it is reported that only 3-4 intubation procedures are carried out by a paramedic every year in real clinical circumstances. In this regard, lack of practical experience results in inefficiency of paramedics that result in less success rate. (Divatia, pp. 308-318, 2005) In a study, some medical students were trained and assessed, after a period of six months, they were reassessed to investigate efficiency in their performance, and a significant decline was observed in the performance of these students, which proved that practical experience affects the effectiveness of paramedics in an adverse manner. (Maharaj, pp. 272-278, 2007) Studies related to airway management have indicated that one of the factors that decide the success of airway procedures is the first step of insertion. It is observed that a number of experienced and qualified paramedics are unable to insert the intubation tube adequately, which often results in bleeding, as well as, failure and trauma for patients. In order to understand the effectiveness of tracheal intubation, different other devices were compared in a study. (Abo, pp. 234-239, 2007) It was observed that Combitude procedure took less time for insertion of the device, as compared with tracheal tube, and thus, prolonged period of tracheal insertion resulted in a number of other risks. In another study, tracheal intubation was compared with laryngeal mask airway insertion, and results indicated that tracheal intubation showed only 20% success rate and LMA insertion dominated the comparison by eighty percent success rate. (Deakin, pp. 64-67, 2005) Conclusion In this regard, it is very imperative that sufficient training related to tracheal intubation should be given to paramedics, which should be accompanied by continuous practical experience, which is lacking currently due to a number of risks associated with the method of airway management. It is specified by discussed studies that it is very essential that at least fifty intubation attempts should be performed by paramedics to complete training successfully, and requirement of 25 intubation attempts is not enough in light of identified risks associated with the procedure. Moreover, steps should be taken by the ambulance services to ensure continuous practical experience of paramedics, which is essential for higher success rate of the intubation. Furthermore, it is suggested in light of identified risks that the practice of tracheal intubation should be confined to only specialists and paramedics that have specialized in this method of airway management, as even a little mistake and inadequacy in the procedure may be detrimental for patients and cost them their lives. As literature has specified that benefits of tracheal intubation exist; however, they have not accompany any evidence that is necessary for their endorsement. In this regard, it is very imperative that further research should be carried to identify the risks and its solution, which may allow the experts to prevent the harmful effects and acquire benefits from its characteristics. Else, supraglottic device is now being emphasized by medical associations and committees to be placed as the gold standard of effective management in place of tracheal intubation, which remained the gold standard for twenty years in the United Kingdom. However, supraglottic devices have their benefits, as well as, risks, and thus, comprehensive research should be carried to decide the preferred method for effective airway management. Conclusively, the paper has discussed and analyzed different aspects related to the tracheal intubation, which has played a vital role in airway management; however, recently, it has been suggested that such method should no longer be considered as gold standard for airway management. It is hoped that the paper will beneficial for students, teachers, and professionals in better understanding of the topic. References Anaesthesia UK. (2004). Complications of endotracheal Intubation. Anaesthesia UK. Retrieved on October 20, 2008; http://www.frca.co.uk/article.aspx?articleid=100165 B. N. Abo. (2007). Does the type of Out-of-hospital Airway Interfere with other Cardiopulmonary Resuscitation Tasks? Resuscitation. Volume 72, pp. 234-239. Brimacombe. (2005). Laryngeal Mask. Anesthesia. Second Edition, pp. 313-355. C. D. Deakin. (2005). Securing the Prehospital Airway: a Comparison of Laryngeal Mask Insertion and Endotracheal Intubation by UK Paramedics. Southampton University Hospital Trust. Volume 22, pp. 64-67. C. H. Maharaj. (2007). Retention of Tracheal Intubation Skills by Novice Personnel. Anesthesia. Volume 62, pp. 272-278. C. Konrad. (1998). Learning Manual Skills in Anesthesiology. Anesthesia & Analgesia. Volume 86, pp. 635-639. D. J. Lockey. (1999). 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Emergency Tracheal Intubation: Complications Associated with Repeated Laryngoscopic Attempts. Anesthesia & Analgesia. Volume 99, pp. 607-613. Total Words: 2171 Words Read More