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Recent pediatric studies in emergency medical systems with short transport times suggest that prehospital intubation provides no benefit or is even potentially harmful, compared with ventilation alone. In a prospective observational study, researchers assessed the frequency of unrecognized esophageal intubation in 132 consecutive adult patients who were transported to two New York City emergency departments and had been intubated in the field. Emergency physicians confirmed tube placement by direct visualization (71%), end-tidal carbon dioxide detection (39%), or both. Tubes were misplaced in 32 patients (24%), with 20 tubes in the right mainstem bronchus, 11 in the esophagus, and 1 in the hypopharynx. Only one patient with a prehospital esophageal intubation survived to hospital discharge. Information was not available on the training and experience of the paramedics who performed all prehospital intubations.
The researchers assessed reasons for deferred intubation in a separate group of 60 consecutive patients who were intubated within 10 minutes after arrival at the same hospitals. Prehospital intubation was not attempted in 52% and was unsuccessful in 22%. The most common reasons for not attempting prehospital intubation were short transport time and suspected difficult airway. The authors call for controlled trials to assess whether prehospital intubation of adult patients improves outcomes.
Wirtz DD et al. Unrecognized misplacement of endotracheal tubes by ground prehospital providers. Prehosp Emerg Care 2007 Apr-Jun; 11:213-8.
Comment
Adult prehospital endotracheal intubation is yet another example of a protocol that was implemented without prior scientific validation of outcomes benefit. Now that this procedure is standard care, controlled trials would be difficult to design and might face challenges from research ethics boards. However, the high rate of tube misplacement found in this study — consistent with rates reported in other systems — is unacceptable. The key prehospital intervention is oxygenation, not necessarily intubation; other airway management methods, such as use of laryngeal mask airways, may be preferable to intubation. Prehospital intubation requires mandatory confirmation of proper tube placement by end-tidal carbon dioxide monitoring, which often was not done in this study. EPs must immediately confirm proper tube placement for all patients who have been intubated in the field.