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CRITICAL CARE AND TRAUMA

The Out-of-Hospital Esophageal and Endobronchial Intubations Performed by Emergency Physicians

Arnd Timmermann, MD, DEAA^*, Sebastian G. Russo, MD^*, Christoph Eich, MD, DEAA^*, Markus Roessler, MD, DEAA^*, Ulrich Braun, MD, PhD^*, William H. Rosenblatt, MD, PhD, and Micheal Quintel, MD, PhD^*

From the *Department of Anesthesiology, Emergency and Intensive Care Medicine, Georg-August University, Goettingen, Germany; and Department of Anesthesiology, School of Medicine, Yale University, New Haven, Connecticut.

Address correspondence to Arnd Timmermann, Department of Anesthesiology, Emergency and Intensive Care Medicine, Georg-August University, Robert-Koch-St. 40, 37085 Goettingen, Germany. Address e-mail to atimmer{at}zari.de.

BACKGROUND: Rapid establishment of a patent airway in ill or injured patients is a priority for prehospital rescue personnel. Out-of-hospital tracheal intubation can be challenging. Unrecognized esophageal intubation is a clinical disaster.

METHODS: We performed an observational, prospective study of consecutive patients requiring transport by air and out-of-hospital tracheal intubation, performed by primary emergency physicians to quantify the number of unrecognized esophageal and endobronchial intubations. Tracheal tube placement was verified on scene by a study physician using a combination of direct visualization, end-tidal carbon dioxide detection, esophageal detection device, and physical examination.

RESULTS: During the 5-yr study period 149 consecutive out-of-hospital tracheal intubations were performed by primary emergency physicians and subsequently evaluated by the study physicians. The mean patient age was 57.0 (±22.7) yr and 99 patients (66.4%) were men. The tracheal tube was determined by the study physician to have been placed in the right mainstem bronchus or esophagus in 16 (10.7%) and 10 (6.7%) patients, respectively. All esophageal intubations were detected and corrected by the study physician at the scene, but 7 of these 10 patients died within the first 24 h of treatment.

CONCLUSION: The incidence of unrecognized esophageal intubation is frequent and is associated with a high mortality rate. Esophageal intubation can be detected with end-tidal carbon dioxide monitoring and an esophageal detection device. Out-of-hospital care providers should receive continuing training in airway management, and should be provided additional confirmatory adjuncts to aid in the determination of tracheal tube placement.

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