Emergency Medical Services
Misplaced endotracheal tubes by paramedics in an urban emergency medical services system*

Presented in part at the Society for Academic Emergency Medicine annual meeting, Boston, MA, May 1999.
https://doi.org/10.1067/mem.2001.112098Get rights and content

Abstract

Study Objective: To determine the incidence of unrecognized, misplaced endotracheal tubes inserted by paramedics in a large urban, decentralized emergency medical services (EMS) system. Methods: We conducted a prospective, observational study of patients intubated in the field by paramedics before emergency department arrival. During an 8-month period, emergency physicians assessed tube position at ED arrival using a combination of auscultation, end-tidal carbon dioxide (ETCO2) monitoring, and direct laryngoscopy. Results: A total of 108 intubated patients were studied. On arrival in the ED, 25% (27/108) of patients were found to have improperly placed endotracheal tubes. Of the misplaced tubes, 67% (18/27) were found to be in the esophagus, whereas in 33% (9/27), the tip of the tube was found to be in the hypopharynx, above the vocal cords. Of the patients with misplaced tubes noted in the hypopharynx, 33% (3/9) died while in the ED. For the patients found to have tubes in the hypopharynx, 56% (5/9) had evidence of ETCO2 on ED arrival. For the patients found to have esophageal tube placement on ED arrival, 56% (10/18) died in the ED. Esophageal intubation was associated with an absence of expired CO2 (17/18, 94%) on ED arrival. The singe patient in this subset with a recordable ETCO2 had been nasotracheally intubated with the tip of the endotracheal tube noted in the esophagus while spontaneous respirations were present. On patient arrival to the ED, 63% (68/108) of the patients had direct laryngoscopy in addition to ETCO2 determination. All patients had ETCO2 evaluation performed on arrival. All patients in whom an absence of ETCO2 was demonstrated on patient arrival underwent direct laryngoscopy. In cases in which direct laryngoscopy was not performed, the attending physician documented the ETCO2 in conjunction with the presence of bilateral breath sounds. Conclusion: The incidence of out-of-hospital, unrecognized, misplaced endotracheal tubes in our community is excessively high and may be reflective of the incidence occurring in other communities. Data from other communities are needed to clarify the scope of this alarming issue. [Katz SH, Falk JL. Misplaced endotracheal tubes by paramedics in an urban emergency medical services system. Ann Emerg Med. January 2001;37:32-37.]

Introduction

Placement of endotracheal tubes (ETTs) in the field by paramedics is a well-accepted out-of-hospital procedure used to obtain definitive airway control. Several studies have reported the incidence of unrecognized, misplaced endotracheal intubations in the field to be low, typically 1% to 5%1, 2, 3, 4, 5 (Table 1).In the majority of these studies, verification of tube placement was performed in the field. It was our clinical impression before conducting our study that the incidence of patients with misplaced ETTs on arrival to our emergency department was substantially higher than that reported in the literature. To our knowledge, no study had investigated the actual incidence of misplaced ETTs on patient arrival to an ED.

The literature has addressed the utility of confirmatory devices to verify ETT position.6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33 Although well accepted as the standard of care by anesthesiologists in the operating room,10 the role of end-tidal carbon dioxide (ETCO2) devices has not gained universal acceptance in the out-of-hospital setting.6, 7, 8, 9 The purpose of our study was to determine the incidence of unrecognized misplaced ETTs that had been inserted in the field, in an emergency medical services (EMS) community in which ETCO2 monitoring was not consistently used.

Section snippets

Materials and methods

This study was conducted at an urban, Level I trauma center teaching hospital between May 1, 1997, and December 31, 1997. Our purpose was to assess the incidence of unrecognized, misplaced ETTs inserted by paramedics in an urban, decentralized EMS system. The institutional review committee determined that patient consent was unnecessary because of the observational and quality assurance nature of the project.

The county EMS system used a 2-tiered response with multiple providers (Table 2).

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Results

The study patients included the 108 intubated patients who were brought by paramedics to the ED during the 8-month study period. On 2 occasions, study forms were completed the next day after review of the ED patient log by the research nurse revealed the absence of completed study forms. Direct laryngoscopy was used to evaluate 63% (68/108) of the tubes. In 43% (35/81) of the cases, tubes were deemed to be endotracheally placed by virtue of the presence of bilateral breath sounds, appropriate

Discussion

The incidence of unrecognized, misplaced endotracheal intubations in the present study is alarming, and substantially higher than in previously reported series. We believe there may be several explanations for this discrepancy. All of the previously published series1, 2, 3, 4, 5 were conducted in EMS systems directed by academic EMS directors with tightly controlled oversight of paramedic training and practice. Evaluation occurred in the field with researchers present during the procedures.

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    *

    Address for reprints: Jay L. Falk, MD, Department of Emergency Medicine, Orlando Regional Medical Center, 86 West Underwood, Suite 200, Orlando, FL 32806; 407-237-6324, fax 407-649-3083; E-mail [email protected].

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