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More Disturbing News About Prehospital Trauma Intubation

Prehospital intubation failed in 31% of trauma patients in a large urban trauma system.

Prehospital intubation (PHI) has come under fire as studies have reported high rates of failure and complications (JW Emerg Med Mar 30 2007 and Apr 1 2000). To determine the effectiveness of PHI in a single urban trauma system, researchers in Miami reviewed the records of all 203 patients who received PHI during a 34-month period.

PHI, defined as endotracheal intubation, use of a laryngeal mask airway (LMA) or Combitube, or cricothyrotomy before ED arrival, was successful in 69% of patients. Intubation failure, defined as improper location of the endotracheal tube or the need for a rescue device after failed intubation attempts, occurred in 31% of all patients and included unrecognized esophageal intubation (12%), Combitube use (14%), LMA use (3%), and cricothyrotomy (2%). Overall, 64% of patients who received PHI died. In-hospital mortality did not differ significantly between patients with failed and successful PHI (71% and 60%), but the percentage of patients who were dead on arrival was significantly higher in the failed-intubation group (48% vs. 26%). Significantly more patients transported by air than by ground were successfully intubated (82% vs. 52%).

Comment: In this trauma system, air paramedics received more training and performed more intubations than their ground counterparts, and only air crews were permitted to use succinylcholine. These factors likely account for the superior performance of air crews in this study. The 12% incidence of esophageal intubation is unacceptably high, consistent with prior study findings, and, therefore, profoundly disturbing. As editorialists remind us, this study, despite its flaws, provides further impetus to reexamine how we manage airways for trauma patients in the prehospital setting.

— Ron M. Walls, MD, FRCPC, FAAEM

Published in Journal Watch Emergency Medicine September 18, 2009

Citation(s):

Cobas MA et al. Prehospital intubations and mortality: A level 1 trauma center perspective. Anesth Analg 2009 Aug; 109:489.

• Original article (Subscription may be required)
• Medline abstract (Free)

Herff H et al. Prehospital intubation: The right tools in the right hands at the right time. Anesth Analg 2009 Aug; 109:303.

• Original article (Subscription may be required)
• Medline abstract (Free)

Reader Remarks:

Review and add to remarks on this article

• Dependence on System Quality?
  Bill T Jenkins MD, MSMC, 11 Jan 2010 10:54 AM EST
  A comparison of different systems, i.e. locations in the country would be valuable. Miami pays paramedics poorly and is less... [more]

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