PREHOSPITAL AIRWAY AND OXYGENATION MANAGEMENT BY EMERGENCY MEDICAL TECHNICIANS: A SYSTEMATIC REVIEW OF SAFETY AND PATIENT OUTCOMES

Abstract Background: Emergency medical technicians (EMTs) and paramedics frequently manage airway and oxygenation in the prehospital setting. However, advanced airway techniques and liberal oxygen delivery may introduce safety risks (multiple attempts, misplacement, interruptions) while potential outcome benefits vary by patient group. Objective: To synthesize evidence on the association between EMT prehospital airway and oxygenation strategies and patient outcomes and safety events. Methods: We conducted a PRISMA aligned systematic review of original human studies available in PubMed Central. We included randomized and observational studies evaluating prehospital airway (endotracheal intubation, supraglottic airways, airway process) and oxygenation strategies delivered by EMS personnel, reporting patient outcomes and, or safety events. Outcomes of interest included survival (short term and discharge), neurologic outcome where available, ROSC, mortality, and procedure related complications. Results: Ten original studies were included, spanning out of hospital cardiac arrest, trauma, TBI, and mixed EMS airway cohorts. In a cluster crossover randomized trial of adults with out of hospital cardiac arrest, an initial laryngeal tube (LT) strategy improved 72 hour survival compared with endotracheal intubation (ETI) and had higher initial airway success, with similar key adverse events. Large observational EMS datasets consistently linked airway performance and operator experience to outcomes, with improved survival in cardiac arrest and medical non arrest when ETI was performed by more experienced rescuers. In traumatic out of hospital cardiac arrest, advanced airway management improved ROSC on hospital arrival but not survival to discharge. For severe TBI without hypoxia, low flow oxygen was associated with lower mortality while high flow oxygen in patients with high saturations showed worse associations. Conclusion: Prehospital airway and oxygenation management by EMS personnel is high impact but context dependent. Supraglottic first strategies may offer pragmatic advantages during cardiac arrest, while ETI outcomes appear sensitive to provider experience and system quality. Oxygen should be titrated to avoid both hypoxia and hyperoxia, particularly in TBI.