Prehospital intubation failure

In the Anesthesia & Analgesia study “Prehospital Intubations and Mortality: A Level 1 Trauma Center Perspective,” the authors sought to determine the incidence of failed prehospital intubations (PHI), their correlation with mortality and the possible risk factors associated with PHI. (Cobas, et al: “Prehospital Intubations and Mortality: A Level 1 Trauma Center Perspective.” Anesthesia & Analgesia. 109:489—493, 2009.)


Data were collected on patients admitted between August 2003 and June 2006 to the Level 1 Ryder Trauma Center (University of Miami Miller School of Medicine) who had emergency prehospital airway management.


An anesthesiologist performed emergency airway interventions on 1,320 patients at the trauma center. Of those, 203 were intubated in the field by EMS personnel. PHI was considered a failure if initial assessment found improper endotracheal tube placement or if other airway management devices were used after intubation was attempted. The study found a 31% incidence of failed PHI.


“We found no difference in mortality between patients who were properly intubated and those who were not, supporting the use of bag-valve-mask as an adequate method of airway management for critically ill trauma patients in whom intubation cannot be achieved promptly in the prehospital setting,” the authors wrote.


A related study published in Resuscitation evaluates the association between three out-of-hospital endotracheal intubation errors and patient outcomes. (Wang HE, et al: “Outcomes After Out-of-Hospital Endotracheal intubation errors.” Resuscitation. 80(1):50—55, 2009.)


The authors prospectively collected multicenter data on out-of-hospital ETI by EMS personnel, and then linked the data to statewide (Pennsylvania) EMS, death and hospital discharge data sets. The ETI errors included: 1) endotracheal tube misplacement or dislodgement; 2) multiple ETI attempts (four or more laryngoscopies); and 3) failed ETI.


Of 1,954 ETIs, 444 (22.7%) patients experienced one or more errors, including misplacement/dislodgement (3%), multiple ETI attempts (3%) and failed ETI (15%). Of the 1,196 (61%) of cases linked to outcomes, 73% died and 27% survived to discharge. ETI errors were not associated with early death. However, failed out-of-hospital ETI increases the odds of pneumonitis.

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