Drug-Assisted Intubation in the Prehospital Setting

Approved April 2011

Reaffirmed by the  ACEP Board of Directors  April 2011 

Originally approved by the ACEP Board of Directors January 2005 

The American College of Emergency Physicians (ACEP), American College of Surgeons Committee on Trauma (ACS-COT), and the National Association of EMS Physicians (NAEMSP) recognize that expert prehospital airway management by trained, non-physician, EMS providers is of paramount importance in the treatment of critically ill and injured patients. Endotracheal intubation (ETI) may be difficult or impossible, especially if the patient is combative or has intact airway reflexes. The scope of prehospital care may include drug-assisted intubation (DAI) to facilitate ETI.

DAI is an advanced airway procedure that should not be considered mandatory, nor is it appropriate, for many prehospital EMS systems. DAI should be utilized only by EMS systems that, in the judgment of the EMS medical director(s), have a specific need for the procedure and possess adequate resources to develop and maintain a prehospital DAI protocol. It must be understood that DAI is a powerful technique used to facilitate endotracheal intubation, which can be harmful if not performed properly. Every effort must be made to ensure that EMS providers authorized to perform DAI demonstrate ongoing competence in order to maximize patient safety and quality of care. This position statement is not an advocacy statement for or against the use of DAI.

EMS providers performing DAI should possess training, knowledge, and experience in the techniques and in the use of pharmacologic agents used to perform DAI. Confirmation of proper endotracheal tube placement is essential.

ACEP, ACS-COT and NAEMSP recommend that a prehospital DAI program should include, at a minimum, the following elements:

• Medical direction with concurrent and retrospective oversight supervision;
• Proper patient selection; to include training and continuing education designed to demonstrate initial and ongoing competence in the procedure (includes supervised DAI experience); 
• Training in airway management of patients who cannot be intubated; as well as the availability, and competence in the use, of backup rescue airway methods in the event of failed DAI;
• Standardized DAI protocols, including the use of sedation and neuromuscular blockade;
• Resources for drug storage and delivery;
• Resources for continuous monitoring and recording of heart rate and rhythm, oxygen saturation, and end-tidal carbon dioxide, before, during, and after DAI;
• Appropriate training and equipment to confirm initial and verify ongoing tube placement;
• Continuing quality assurance, quality control, performance review, and when necessary, supplemental training; and
• Research to clarify the role of DAI on improved patient outcome within EMS systems.