Neuromuscular blockade in aeromedical airway management

Induction of paralysis before intubation is controversial in the aeromedical setting. We reviewed our experience using neuromuscular blockade with nurse/paramedic aeromedical teams to determine effectiveness and outcome.

In 670 flights during a 16-month period, 119 patients required endotracheal intubation aided by muscle relaxant administration. Age ranged from two months to 83 years, with a mean of 33 years. All patients were hyperventilated with 100% oxygen before intubation. Sedation was given if presenting systolic blood pressure was greater than 100 mm Hg. A short-acting depolarizing agent was then given in a 1-mg/kg dose. Once the airway was secure, a longer-acting, nondepolarizing agent and/or sedation was given.

Of the 119 patients, 115 (96.6%) were orally intubated. Four (3.4%) required surgical airway intervention because of injuries and conditions prohibiting oral intubation. Of 115 oral intubations, 99 (86%) were achieved on the first attempt. Eight patients (7%) were intubated on a second attempt, and another eight were intubated on a third attempt. There was no change in operator. Sixty-eight percent of patients requiring airway management were multiple trauma victims with associated head injuries. There were no laryngeal injuries, detected cardiac rhythm changes, bleeding episodes, or neurologic complications despite incomplete cervical-spine evaluation.

Neuromuscular blockade can be used safely and effectively in the field by experienced nurse/paramedic teams. Although problematic intubation was not eliminated, the difficulties encountered were manageable and the overall risk/benefit ratio was acceptable.