Quality statement 1: Airway management

Quality statement

People with major trauma who cannot maintain their airway and/or ventilation have drug‑assisted rapid sequence induction (RSI) of anaesthesia and intubation within 45 minutes of the initial call to the emergency services.

Rationale

Failure to provide an adequate airway for people who cannot maintain one can result in brain injury, with long-term implications for function and quality of life, or death. Performing drug‑assisted RSI of anaesthesia and intubation quickly, and preferably at the scene of the incident rather than by diverting to an emergency department, improves ventilation, increasing the probability of survival and reducing long-term morbidity.

Quality measures

Structure

a) Evidence of the availability of healthcare professionals trained to perform drug‑assisted RSI of anaesthesia and intubation at the scene, or of systems to transport people to the nearest emergency department where it can be performed.

Data source: Local data collection, for example from local protocols.

b) Evidence of local arrangements to support decision‑making about whether to dispatch trained healthcare professionals to the scene to deliver drug‑assisted RSI of anaesthesia and intubation, or transport the person to the nearest emergency department where it can be performed.

Data source: Local data collection, for example from local protocols.

Process

a) Proportion of people with major trauma who cannot maintain their airway and/or ventilation who have drug‑assisted RSI of anaesthesia and intubation.

Numerator – the number in the denominator who have drug‑assisted RSI of anaesthesia and intubation.

Denominator – the number of people with major trauma who cannot maintain their airway and/or ventilation.

Data source: Local data collection, for example, audit of patient records. The Trauma Audit and Research Network collects data on intubation ventilation and use of drugs at the scene and in the emergency department.

b) Proportion of people with major trauma who cannot maintain their airway and/or ventilation who have drug‑assisted RSI of anaesthesia and intubation within 45 minutes of the initial call to the emergency services.

Numerator – the number in the denominator who have drug‑assisted RSI of anaesthesia and intubation within 45 minutes of the initial call to the emergency services.

Denominator – the number of people with major trauma who cannot maintain their airway and/or ventilation and have drug‑assisted RSI of anaesthesia and intubation.

Data source: Local data collection, for example, audit of patient records. The Trauma Audit and Research Network collects data on intubation ventilation and use of drugs at the scene and in the emergency department.

Outcomes

a) Mortality rates from major trauma.

Data source: Local data collection, for example using the Office for National Statistics mortality database. The Trauma Audit and Research Network also collects data on deaths of trauma patients.

b) Rates of brain injury resulting from lack of oxygen caused by major trauma.

Data source: Local data collection, for example local audit of patient records.

What the quality statement means for different audiences

Service providers (ambulance services, major trauma centres and trauma units) ensure that there are protocols operating in ambulance control to identify people with major trauma who need drug‑assisted RSI of anaesthesia and intubation and deliver it at the scene, or transport people to the nearest emergency department if this is not possible, so that it is received within 45 minutes of the initial call to the emergency services.

Healthcare professionals (paramedics, advanced pre-hospital doctors and anaesthetists) trained in RSI deliver drug‑assisted RSI of anaesthesia and intubation at the scene of the major trauma within 45 minutes of the initial call to the emergency services. If a trained professional is not available at the scene, healthcare professionals decide whether to call out someone trained in RSI to the scene, or transport the person to the nearest emergency department. They maintain the person's airway using a suitable technique until trained healthcare professionals arrive at the scene, or until the person arrives at the emergency department. Drug‑assisted RSI of anaesthesia and intubation is performed by anaesthetists or other doctors in emergency departments within 45 minutes of the initial call to the emergency services if it cannot be performed at the scene.

Commissioners (clinical commissioning groups and NHS England) ensure that they commission services that have local protocols on performing drug‑assisted RSI of anaesthesia and intubation at the scene of the major trauma, or, if this is not possible, at the nearest emergency department within 45 minutes of the initial call to the emergency services. They monitor contracts and seek evidence that service providers have this in place.

People who have had a major injury and are not able to breathe on their own are given a general anaesthetic (a drug that puts a person to sleep) by a doctor at the scene of the injury. A breathing tube is then placed into their mouth and down into their windpipe to help them breathe. If a doctor is not available at the scene of the injury, or if the breathing tube doesn't work well enough, the ambulance team should use other methods to help the person breathe until they can be taken to a major trauma centre or a trauma unit.

Source guidance

Definitions of terms used in this quality statement

People with major trauma who cannot maintain their airway and/or ventilation

Major trauma describes serious and often multiple injuries that may require lifesaving interventions. People might not be able to maintain their airway and/or ventilation if they are in a coma (Glasgow Coma Score less than 9), if they are not breathing adequately or their mouth is obstructed, for example by vomit, their tongue or debris.

[Expert opinion and NICE's full guideline on major trauma: assessment and initial management]

Rapid sequence induction (RSI) of anaesthesia and intubation

A medical procedure involving prompt administration of general anaesthesia and subsequent intubation of the trachea. The procedure results in rapid unconsciousness (induction) and neuromuscular blockade (paralysis) and is used to maintain a patient's airway following a traumatic incident.

[NICE's full guideline on major trauma: assessment and initial management, glossary]