2007/02/15 by Arnd Timmermann, A. Timmermann, Sebastian G. Russo +8 · 26 citations
Medicine · #Airway Management and Intubation Techniques #Tracheal and airway disorders #Restraint-Related Deaths
paper · doi:10.1213/01.ane.0000253523.80050.e9
In Brief BACKGROUND: Rapid establishment of a patent airway in ill or injured patients is a priority for prehospital rescue personnel. Out-of-hospital tracheal intubation can be challenging. Unrecognized esophageal intubation is a clinical disaster. METHODS: We performed an observational, prospective study of consecutive patients requiring transport by air and out-of-hospital tracheal intubation, performed by primary emergency physicians to quantify the number of unrecognized esophageal and endobronchial intubations. Tracheal tube placement was verified on scene by a study physician using a combination of direct visualization, end-tidal carbon dioxide detection, esophageal detection device, and physical examination. RESULTS: During the 5-yr study period 149 consecutive out-of-hospital tracheal intubations were performed by primary emergency physicians and subsequently evaluated by the study physicians. The mean patient age was 57.0 (±22.7) yr and 99 patients (66.4%) were men. The tracheal tube was determined by the study physician to have been placed in the right mainstem bronchus or esophagus in 16 (10.7%) and 10 (6.7%) patients, respectively. All esophageal intubations were detected and corrected by the study physician at the scene, but 7 of these 10 patients died within the first 24 h of treatment. CONCLUSION: The incidence of unrecognized esophageal intubation is frequent and is associated with a high mortality rate. Esophageal intubation can be detected with end-tidal carbon dioxide monitoring and an esophageal detection device. Out-of-hospital care providers should receive continuing training in airway management, and should be provided additional confirmatory adjuncts to aid in the determination of tracheal tube placement. IMPLICATIONS: The incidence of unrecognized out-of-hospital esophageal intubation is frequent when end-tidal CO2 monitoring and esophageal detection devices are not used for tube placement confirmation by emergency medical service physicians with basic training. Unrecognized esophageal intubation is associated with a high mortality rate.