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Physician-based on-scene airway management in severely injured patients and in-hospital consequences: is the misplaced intubation an underestimated danger in trauma management?
BACKGROUND: Endotracheal intubation (ETI) is the gold standard for the out-of-hospital emergency airway management in severely injured patients. Due to time-critical circumstances, poor patient presentation and hostile environments, it may be prone for mechanical complications and failure.
METHODS: In a retrospective study (January 2011 to December 2013), all patients who underwent out-of-hospital ETI before admittance to a level 1 trauma center were analyzed consecutively. Patients with supraglottic airways, being under cardiopulmonary resuscitation and interfacility transports were excluded. The main study endpoint was the incidence of unrecognized tube malposition; secondary endpoints were Glasgow Outcome Scale (GOS) and in-hospital mortality adjusted to on-scene Glasgow Coma Scale (GCS), Injury Severity Score (ISS), Abbreviated Injury Scale head (AIS head), and on-scene time.
RESULTS: Out of 1176 patients, 151 underwent out-of-hospital ETI. At hospital admission, tube malpositions were recognized in nine patients (5.9%). Accidental and unrecognized esophageal intubation was detected in five patients (3.3%) and bronchial intubation in four patients (2.7%). Although ISS (p=0.053), AIS head (p=0.469), on-scene GCS (p=0.151), on-scene time (p=0.530), GOS (p=0.748) and in-hospital mortality (p=0.431) were similar compared with correctly positioned ETI tubes, three esophageal intubation patients died due to hypoxemic complications.
DISCUSSION: In our study sample, out-of-hospital emergency ETI in severely injured patients was associated with a considerable tube misplacement rate. For safety, increased compliance to consequently use available technologies (eg, capnography, video laryngoscopy) for emergency ETI should be warranted.
LEVEL OF EVIDENCE: Level of Evidence IIA.
METHODS: In a retrospective study (January 2011 to December 2013), all patients who underwent out-of-hospital ETI before admittance to a level 1 trauma center were analyzed consecutively. Patients with supraglottic airways, being under cardiopulmonary resuscitation and interfacility transports were excluded. The main study endpoint was the incidence of unrecognized tube malposition; secondary endpoints were Glasgow Outcome Scale (GOS) and in-hospital mortality adjusted to on-scene Glasgow Coma Scale (GCS), Injury Severity Score (ISS), Abbreviated Injury Scale head (AIS head), and on-scene time.
RESULTS: Out of 1176 patients, 151 underwent out-of-hospital ETI. At hospital admission, tube malpositions were recognized in nine patients (5.9%). Accidental and unrecognized esophageal intubation was detected in five patients (3.3%) and bronchial intubation in four patients (2.7%). Although ISS (p=0.053), AIS head (p=0.469), on-scene GCS (p=0.151), on-scene time (p=0.530), GOS (p=0.748) and in-hospital mortality (p=0.431) were similar compared with correctly positioned ETI tubes, three esophageal intubation patients died due to hypoxemic complications.
DISCUSSION: In our study sample, out-of-hospital emergency ETI in severely injured patients was associated with a considerable tube misplacement rate. For safety, increased compliance to consequently use available technologies (eg, capnography, video laryngoscopy) for emergency ETI should be warranted.
LEVEL OF EVIDENCE: Level of Evidence IIA.
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