PEGASUS Recommendations - Airway

PEGASUS Recommendations - Airway

Section of Change / Recommendation / Evidence Quality/
Strength of Reccomendation / Expected Impact
-Operational
-Educational
-Financial
Airway – Scope of Practice (1a) / There is no evidence to suggest that on scene paramedics enhance survival in pediatric airway management. Based on the algorithm and the potential need for rapid progression toward advanced airway management, however, EMS system leadership should consider dispatch of higher level providers, based on the local scope of practice. / Low/Weak / None – Currently the MEMS protocols
NO CHANGE NEEDED
Airway – QI & Training (2) / We suggest that EMS systems have hands-on airway training, have online medical control readily available, and utilize quality improvement methods to enhance airway management skills for their providers. / Low/Weak / None in Protocols – should consider encouraging system based airway QI
NO CHANGE NEEDED
Airway – Training (1b & 3) / (1b) We suggest recent pertinent airway training improves skills in successful intubation, but does not necessarily improve mortality.
(3) We suggest continuous training to mitigate airway skill degradation. / Low/Weak (1b)
Low/Strong (3) / None for the protocols – although, again, should consider this at the service or even regional level…
NO CHANGE NEEDED
Airway - Assessment / We suggest that difficulty with direct laryngoscopic visualization is a known evidence-based indicator of a difficult airway. Therefore, we suggest the following physical features should be assessed as they are associated with increased difficulty in laryngoscopy:
-Craniofacial abnormalities (maxillary/mandibular hypoplasia, infiltative disease, chronic subglottic abnormalities, limited jaw/mouth/neck mobility)
-Limited jaw thrust
-Small thyromental space
-Upper airway obstruction
-Higher Malampatti scores / Low/Strong / From ED COmm – Probably not necessary based on the educational agenda - WELL UNDERSTOOD BY PROVIDERS
NO CHANGE NEEDED
Airway – Monitoring (5b) / We recommend the routine use of waveform capnography for initial confirmation and continuous monitoring of the patient after an extraglottic device or endotracheal tube has been placed / Low/Strong / Already in the protocols
NO CHANGE NEEDED
Airway – Management / We suggest for non-traumatic, impending respiratory failure that BiPAP, CPAP or HFNC be considered as potential adjuncts to lessen the likelihood of the need for advanced airway placement. / Low/Strong / We have had the discussion re CPAP – and in the protocols already
NO CHANGE NEEDED
Airway – Management (7) / We suggest that BVM ventilation be used as the first modality used to support children in respiratory failure, and advanced airways be placed only when adequate oxygenation and ventilation cannot be safely sustained with BVM / Moderate/Strong / Already in the MEMS protocols
NO CHANGE NEEDED
Airway Management (7a2) / We suggest that extraglottic devices can successfully be placed by EMS providers / Low/Weak / Already in the MEMS Protocols
NO CHANGE NEEDED
Airway – Management (7a3) / We recommend that EGDs should be placed for respiratory failure when less invasive means (BiPAP, CPAP, HFNC, BVM) are inadequate to support oxygenation and ventilation. ETI should only be attempted when oxygenation and/or ventilation cannot be maintained successfully via EGD. / Low/Weak / ETT already in the MEMS Protocols – will maintain the current approach to the Maine EMS guidelines and allow sequence of airway management device to be determined by the provider on scene
NO CHANGE NEEDED
Airway – Management (7b) / We suggest when advanced airways are placed, that the tube be secured with either a commercial tube holder or tape, rather than being held manually by hand. / Low/Weak / Add the following Pearl – “When advanced airways are placed, that the tube be secured with either a commercial tube holder or tape, rather than being held manually by hand.”
Airway – Management (8b) / We suggest that RSI not be performed, except by specialized providers operating within a comprehensive program with ongoing training and quality assurance measures. / Low/Strong / Not an issue in MEMS protocols
Airway – Management (9a & 9b) / When patients cannot be oxygenated/ventilated effectively by previously mentioned interventions, the provider should consider cricothyroidotomy
We suggest that in children in respiratory failure who cannot be oxygenated or ventilated by other methods, there are no age-driven criteria directing which surgical airway (needle, open, or percutaneous) is indicated. / Very Low/Strong
Very Low/Weak / In the protocols already under the “Failed Intubation Algorythm” States – FOR PEDIATRIC PATIENTS REQUIRING SURGICAL AIRWAY – Considerneedle cricothyrotomyin patents <10 years old OR if physiologically young enough that surgical landmarks are NOT identifiable
NO CHANGE NEEDED
Airway – Management (10) / We suggest for patients requiring mechanical ventilation with obvious gastric distention limiting oxygenation or ventilation, that gastric decompression can improve the ability to oxygenate and ventilate. / Very Low/Strong / In the Protocols under “Pediatric Airway Management” as an option
NO CHANGE NEEDED
Airway – Management (11) / Evidence is lacking to suggest that transport time or distance should be a factor to guide the type of airway management. Therefore, we suggest that decisions to escalate care for airway management should be based on patient response to oxygenation/ventilation interventions. / Low/Strong / In the Protocols
NO CHANGE NEEDED
‘Airway – Post Airway Destination Choice / We suggest that pediatric patients with respiratory failure that cannot be managed should be transported to the closest appropriate critical care facility for airway stabilization prior to transferring the patient to a facility with pediatric critical care capability. / Very Low/Strong / Not specifically in the protocols – other than Brown 5 allowing for Regional Destination
NO CHANGE NEEDED