Prehospital Intubations and Mortality: A Level 1 Trauma Center Perspective I

A new study looking at EMS intubation appears to show that prehospital intubation is a bad thing.

I do not agree.

Let me point out the ways that I think this study demonstrates where the problems are. And there are big problems. The problems are with the medical oversight, more than with the paramedics. This does not absolve the paramedics of responsibility for their lack of skill.

Control of the airway is the first priority for the management of critically ill patients and is prioritized in established patient-management algorithms, such as Advanced Cardiac Life Support and Advanced Trauma Life Support.^[1]

From the first sentence, we disagree. Control of the airway is the wrong way to think about airway management. We never have control of the airway. Even a properly placed endotracheal tube does not mean control. Control suggests that something does what you want it to do.

Having a properly placed endotracheal tube does not mean that you can get the airway to do what you want it to do.

Having a properly placed endotracheal tube does not even mean that you can get the endotracheal tube to do what you want it to do.

What do we want it to do?

Little things, like remaining properly placed, not kinking, not becoming obstructed with mucus, not separating at the adapter, not separating from the BVM (Bag Valve Mask), not having the cuff deflate, having the cuff be properly inflated, et cetera.

As you can see, control is a foolishly optimistic description of what an endotracheal tube provides.

But that is just an unimportant semantic distinction.

Our choice of words is important. We should use words that mean what we intend them to mean. The meaning of the words we use should match what we mean. Otherwise how do the speaker and the listener understand each other?

They don't?

Exactly.

Tell people that an endotracheal tube provides control. Plenty of them will ignore the many possible ways that a properly placed endotracheal tube does not mean control.

Maybe, but you keep asking for evidence. Where is your evidence?

Look at all the research on prehospital intubation. Thousands of intubations and attempted intubations have been studied. Some research demonstrates that intubation can be performed excellently in the prehospital setting.^[2]

Then we have this new study, and plenty of others with similarly pathetic results, that show that if you do not take intubation seriously, you your patient will not do well.

I believe, but cannot prove, that a part of the reason for the bad intubation results is from not using terminology correctly. For example, if I state that the tube is in the airway, I do not mean that the tube passes through the airway on the way to the esophagus. This is technically accurate, but not what one wants to know when asking if the tube is in the airway, is it?

No, but control is a different term.

Yes, but it appears to be similarly misunderstood. Elsewhere in this study . . .

Oh good, we're going to move beyond the first sentence.

Elsewhere in this study, there is a breakdown of the method of airway management. This gives you more of an idea of the way that they misunderstand airway management. PHI = PreHospital Intubation.





The esophageal tubes are not really viewed differently from the use of the LMA^[3] or the CombiTube^[4] or crichothyrotomy.^[5]

This approach demonstrates a complete misunderstanding of airway management.

The use of an alternative airway should not be seen as a failure. While it is true that it is not a successful intubation, that does not mean that it is not successful airway management. Airway management should be viewed as a continuum.^[6] Airway management is not a choice between intubation is good vs. any other form of airway management is bad.


Also, teaching that airway takes priority over everything else is finally being recognized as a mistake.


Footnotes:


^ ¹ Prehospital intubations and mortality: a level 1 trauma center perspective.
Cobas MA, De la Peña MA, Manning R, Candiotti K, Varon AJ.
Anesth Analg. 2009 Aug;109(2):489-93.
PMID: 19608824 [PubMed - indexed for MEDLINE]

PubMed states that the full text article is free at the journal site, but it is not. This seems to have been posted on all of the Anesthesia & Analgesia abstracts at PubMed.


^ ² Prehospital use of succinylcholine: a 20-year review.
Wayne MA, Friedland E.
Prehosp Emerg Care. 1999 Apr-Jun;3(2):107-9.
PMID: 10225641 [PubMed - indexed for MEDLINE]

Paramedics successfully intubated 95.5% (1,582) of all patients receiving succinylcholine, 94% (1,045) of trauma patients, and 98% (538) of medical patients. They were unable to intubate 4.5% (74) of the patients. All of these were successfully managed by alternative methods. Unrecognized esophageal intubation occurred in six (0.3%) patients. The addition of capnography and a tube aspiration device, in 1990, decreased the incidence of esophageal intubations.

^ ³ Laryngeal Mask Airway
Wikipedia
Article


^ ⁴ Combitube
Wikipedia
Article


^ ⁵ Cricothyrotomy
Wikipedia
Article


^ ⁶ The Airway Continuum
by Kelly Grayson
EMS1.com
Article


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