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26 JANUARY 2018 | EMSWORLD.com SPECIAL FOCUS : PEDIATRICS AND AIRWAY MANAGEMENT and Mallampati scores can be difficult to obtain if a patient is unresponsive or com- bative. And LEMON was never really built for video intubation. HEAVEN averts those mouth problems but may have even greater utility as an indi- cator for videoscopic intubation. Says Olvera: "I think HEAVEN helps guide us down a path where we can look and say, 'OK, we're going to be more successful with video in this case than direct laryngoscopy.' There just hasn't been research, prehospi- tal or in-hospital, in the emergent airway to be able to validate that one way or the other. But we've found that depending on which criteria you're falling into, one could be more successful than the other." Air Methods supplemented its HEAVEN rollout with videoscopic intubation train- ing, integrating also Dr. James DuCanto's SALAD (suction-assisted laryngoscopy and airway decontamination) technique for clearing the contaminated airway and use of an RSI checklist. The aggregate result has been improved first-pass success— as a company, Air Methods' rate is over 90%—and more comfortable, confident providers. "The flight setting's kind of interesting," Olvera says. "We'll have nurses come in who have never touched a laryngoscope blade, and then they finish orientation, and their first call may require them to intubate. Providing this HEAVEN criteria allows them to slow things down, figure out what they want to do, and develop a plan. It works well with our ground crews and our hospital crews and lets us all work well together to mitigate these potential disasters." Keys to Success A key adjunct to the HEAVEN tool is an RSI checklist Air Methods designed to help manage that process successfully. Development took several years as the company whittled three pages' worth of initial instruction down to usable form. A key aspect is that the checklist isn't actually used by the flight crew—it's given to someone else. "Our crew members don't read it to each other—they hand it to one of the other pro- viders on scene to read aloud," Olvera says. "That could be a nurse at the hospital or a member of the ground crew—it could even be a tow truck driver. As long as the person can read, that's all we need. "What that does is prevent cutting cor- ners. If you and I work together all the time, and I know you set up your suction and put it under the head of the bed and you always have it ready and it's good to go, I might skip that step on the checklist. Then the one time you don't have your suction ready, we'll have a bad outcome. So to prevent that bias, we hand it to somebody who's not part of the flight crew. And that's been named a best practice by CAMTS." Other new research examined air-med intubation success during transport vs. on scene. 3 Stationary settings yielded a first-pass success rate of 90.5%, trans- port attempts a rate of 91.1%. Transport attempts did, however, have a higher rate of oxygen desaturations (30.6% vs. 23.2%). Video intubation has helped raise that transport success rate, which likely would have been much lower a few years ago. "With the advance of videoscopic intu- bation and opportunity to intubate in dif- ferent areas, you will eventually get the airway," Olvera says. "But I think what we're finding as we analyze the data is that while our first-pass success is better in those situations, we may not properly prepare: We don't have enough sets of hands, we may not have the optimum opportunity to preoxygenate the patient, suction, do all that appropriately, and we may kind of rush into it." That's led to a preference, within Air Methods and increasingly across the indus- try, for intubating on scene, even if it takes an extra few minutes. "The trend is turning that way," Olvera adds. "It'll be a challenge to change what we've always done, but I think for the safety of patients and crews and better patient outcomes, it's what we need to do." REFERENCES 1. Davis DP, Olvera DJ. HEAVEN Criteria: Derivation of a New Dif ficult Airway Predic tion Tool. Air Med J, 2017 Jul–Aug; 36(4): 195–7. 2. Olvera DJ, Davis D, Wolfe AC, Jr. Test Charac teristics of a Novel Dif ficult Airway Predic tion Algorithm for Emergency Airway Management. World Airway Management Meeting 2015, http://www.epostersonline.com/wamm2015/ node/448. 3. Olvera DJ, Davis D, Wolfe AC, Jr., Swearingen CF. Abstrac t 1: Airway Intubation Stationar y vs. Transpor t. Air Med J, 2016 Jul–Aug; 35(4): 206–7. ABOUT THE AUTHOR John Erich is senior editor of EMS World. Reach him at john. erich@emsworld.com. HEAVEN Criteria HYPOXEMIA • DL faster if straightforward • VL may be faster with anatomic difficulty EXTREMES OF SIZE • Extremely large patient: VL (out-to-in) DL (in- to-out)if not recognized • Extremely small patient: DL with straight blade ANATOMIC DISRUPTION / OBSTRUCTION • VL (out-to-in) DL (in-to-out) if not recognized • DL if bloody VOMIT / BLOOD / FLUID • DL with strong lift EXSANGUINATION • DL faster, VL with anatomic difficulty NECK MOBILITY / NEUROLOGIC INJURY • Gentler VL Air Methods Corporation protocols are not meant to replace, amend, alter, supersede or otherwise change your agency's existing protocols. PREPARATION/PLANNING AMC monitoring equipment in place Consider fluid / blood resuscitation NRB and Passive O2 (> 10 LPM via NC), Tension Pneumothorax Consider OPA / NPA utilization HOB elevated 30-35 degrees SpO2 < 93%? BVM 2 thumbs-up w/ PEEP + ETCO2 Open C-collar if present Any HEAVEN difficult intubation indicators? INDUCTION/INTUBATION Induction agent administered Paralytic administered Suction prior to intubation attempt Intubate ETT placement confirmed via Direct visualization ETCO2 Breath sounds / No epigastric Tube secured and OG tube placed Post-intubation sedation EQUIPMENT Suction on and accessible CMAC on and warmed-up Induction agent and paralytics drawn and doses confirmed ETT, Bougie, and Alternate airways out and accessible A checklist aids crews' rapid sequence intubations. A key aspect is that the list is given to someone outside the crew to read; this helps avert any potential skipping of steps.