More Fuel on the Intubation Fire (31% failed prehospital ETI in Miami)

July 31, 2009

Anesth Analg. 2009 Aug;109(2):489-93.

Prehospital intubations and mortality: a level 1 trauma center perspective.

Cobas MA, De la Peña MA, Manning R, Candiotti K, Varon AJ.

Department of Anesthesiology, School of Medicine, University of

Miami, Miami, Florida 33136, USA. mcobas@...

BACKGROUND: Ryder Trauma Center is a Level 1 trauma center with

approximately 3800 emergency admissions per year. In this study, we sought

to determine the incidence of failed prehospital intubations (PHI), its

correlation with hospital mortality, and possible risk factors associated

with PHI. METHODS: A prospective observational study was conducted

evaluating trauma patients who had emergency prehospital airway management

and were admitted during the period between August 2003 and June 2006. The

PHI was considered a failure if the initial assessment determined improper

placement of the endotracheal tube or if alternative airway management

devices were used as a rescue measure after intubation was attempted.

RESULTS: One-thousand-three-hundred-twenty patients had emergency airway

interventions performed by an anesthesiologist upon arrival at the trauma

center. Of those, 203 had been initially intubated in the field by emergency

medical services personnel, with 74 of 203 (36%) surviving to discharge.

When evaluating the success of the intubation, 63 of 203 (31%) met the

criteria for failed PHI, all of them requiring intubation, with only 18 of

63 (29%) surviving to discharge. These patients had rescue airway management

provided either via Combitube (n = 28), Laryngeal Mask Airway (n = 6), or a

cricothyroidotomy (n = 4). An additional 25 of 63 patients (12%) had

unrecognized esophageal intubations discovered upon the initial airway

assessment performed on arrival. We found no difference in mortality between

those patients who were properly intubated and those who were not. Several

other variables, including age, gender, weight, mechanism of injury,

presence of facial injuries, and emergency medical services were not

correlated with an increased incidence of failed intubations. CONCLUSION:

This prospective study showed a 31% incidence of failed PHI in a large

metropolitan trauma center. 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.

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