[Recommendations of the new S1 guidelines on airway management]. / Empfehlungen zur neuen S1-Leitlinie Atemwegsmanagement.

The German guidelines for airway management aim to optimize the care of patients undergoing anesthesia or intensive care. The preanesthesia evaluation is an important component for detection of anatomical and physiological indications for difficult mask ventilation and intubation. If predictors for a difficult or impossible mask ventilation and/or endotracheal intubation are present the airway should be secured while maintaining spontaneous breathing. In an unexpectedly difficult intubation, attempts to secure the airway should be limited to two with each method used. A video laryngoscope is recommended after an unsuccessful direct laryngoscopy. Therefore, a video laryngoscope should be available at every anesthesiology workspace throughout the hospital. Securing the airway should primarily be performed with a video laryngoscope in critically ill patients and patients at risk of pulmonary aspiration. Experienced personnel should perform or supervise airway management in the intensive care unit.

Laryngeal mask airway indications: new frontiers for second-generation supraglottic airways.

PURPOSE OF REVIEW: Because of the many advantages of supraglottic airways (SGA) compared to mask ventilation and endotracheal intubation, their areas of application are constantly expanding. The development of second-generation SGAs in particular has led to a widening of the indications for use thanks to the improved oropharyngeal leak pressure and the possibility of inserting a gastric tube. The identification of possible malpositions and any increased ventilation requirements using simple clinical tests must be given particular emphasis. The question of patient safety for expanded indications has to be evaluated. RECENT FINDINGS: The review describes the evolution of these devices in detail with an analysis of the increased range of possible uses for prolonged application periods, minor laparoscopic procedures, obese patients, surgery in the prone position, and caesarean sections. SUMMARY: The use of second-generation SGA for expanded indications seems useful and safe, provided the contraindications are heeded, the placement and performance tests are successfully completed and there is adequate clinical expertise.

[Retrograde intubation in an emergency situation - indication, technical performance, risks and pitfalls]. / Die retrograde Intubation in Notfallsituationen - Indikation, technische Durchführung, Risiken und Fehlerquellen.

Retrograde intubation is an alternative technique to endotracheal intubation. It is used for the management of expected or unexpected difficult intubation. The indication for use of this technique is, above all, a situation in which a flexible bronchoscope, a video laryngoscope or other alternative devices are not available or, respectively, when their use is - or appears to be - not possible due to bleeding and secretions or other particular anatomic pathological conditions. Although the necessary equipment for a retrograde intubation is frequently available, the technique is rarely used, especially in the German-speaking regions.The present article describes the technical steps of retrograde intubation and discusses its possible risks and pitfalls. Furthermore, modifications that facilitate the technical procedure are presented. This contribution is intended to promote the acceptance and use of this less invasive technique in order to avoid possible injury to the patient due to hypoxia, trauma of the airways, and surgical emergency procedures or tracheotomies during the management of difficult airway conditions.

Impact of physical fitness and biometric data on the quality of external chest compression: a randomised, crossover trial.

BACKGROUND: During circulatory arrest, effective external chest compression (ECC) is a key element for patient survival. In 2005, international emergency medical organisations changed their recommended compression-ventilation ratio (CVR) from 15:2 to 30:2 to acknowledge the vital importance of ECC. We hypothesised that physical fitness, biometric data and gender can influence the quality of ECC. Furthermore, we aimed to determine objective parameters of physical fitness that can reliably predict the quality of ECC. METHODS: The physical fitness of 30 male and 10 female healthcare professionals was assessed by cycling and rowing ergometry (focussing on lower and upper body, respectively). During ergometry, continuous breath-by-breath ergospirometric measurements and heart rate (HR) were recorded. All participants performed two nine-minute sequences of ECC on a manikin using CVRs of 30:2 and 15:2. We measured the compression and decompression depths, compression rates and assessed the participants' perception of exhaustion and comfort. The median body mass index (BMI; male 25.4 kg/m2 and female 20.4 kg/m2) was used as the threshold for subgroup analyses of participants with higher and lower BMI. RESULTS: HR during rowing ergometry at 75 watts (HR75) correlated best with the quality of ECC (r = -0.57, p < 0.05). Participants with a higher BMI and better physical fitness performed better and showed less fatigue during ECC. These results are valid for the entire cohort, as well as for the gender-based subgroups. The compressions of female participants were too shallow and more rapid (mean compression depth was 32 mm and rate was 117/min with a CVR of 30:2). For participants with a lower BMI and higher HR75, the compression depth decreased over time, beginning after four minutes for the 15:2 CVR and after three minutes for the 30:2 CVR. Although found to be more exhausting, a CVR of 30:2 was rated as being more comfortable. CONCLUSION: The quality of the ECC and fatigue can both be predicted by BMI and physical fitness. An evaluation focussing on the upper body may be a more valid predictor of ECC quality than cycling based tests. Our data strongly support the recommendation to relieve ECC providers after two minutes.

Positive impact of crisis resource management training on no-flow time and team member verbalisations during simulated cardiopulmonary resuscitation: a randomised controlled trial.

OBJECTIVES: To evaluate the impact of video-based interactive crisis resource management (CRM) training on no-flow time (NFT) and on proportions of team member verbalisations (TMV) during simulated cardiopulmonary resuscitation (CPR). Further, to investigate the link between team leader verbalisation accuracy and NFT. METHODS: The randomised controlled study was embedded in the obligatory advanced life support (ALS) course for final-year medical students. Students (176; 25.35±1.03 years, 63% female) were alphabetically assigned to 44 four-person teams that were then randomly (computer-generated) assigned to either CRM intervention (n=26), receiving interactive video-based CRM-training, or to control intervention (n=18), receiving an additional ALS-training. Primary outcomes were NFT and proportions of TMV, which were subdivided into eight categories: four team leader verbalisations (TLV) with different accuracy levels and four follower verbalisation categories (FV). Measurements were made of all groups administering simulated adult CPR. RESULTS: NFT rates were significantly lower in the CRM-training group (31.4±6.1% vs. 36.3±6.6%, p=0.014). Proportions of all TLV categories were higher in the CRM-training group (p<0.001). Differences in FV were only found for one category (unsolicited information) (p=0.012). The highest correlation with NFT was found for high accuracy TLV (direct orders) (p=0.06). CONCLUSIONS: The inclusion of CRM training in undergraduate medical education reduces NFT in simulated CPR and improves TLV proportions during simulated CPR. Further research will test how these results translate into clinical performance and patient outcome.

Characteristics and outcome of prehospital paediatric tracheal intubation attended by anaesthesia-trained emergency physicians.

AIM: To collect data regarding prehospital paediatric tracheal intubation by emergency physicians skilled in advanced airway management. METHODS: A prospective 8-year observational study of a single emergency physician-staffed emergency medical service. Self-reporting by emergency physicians of all children aged 0-14 years who had prehospital tracheal intubation and were attended by either anaesthesia-trained emergency physicians (group 1) or by a mixture of anaesthesia and non-anaesthesia-trained emergency physicians (group 2). RESULTS: Eighty-two out of 2040 children (4.0%) had prehospital tracheal intubation (58 in group 1). The most common diagnoses were trauma (50%; in school children, 73.0%), convulsions (13.4%) and SIDS (12.2%; in infants, 58.8%). The overall tracheal intubation success rate was 57 out of 58 attempts (98.3%). Compared to older children, infants had a higher number of Cormack-Lehane scores of 3 or 4, "difficult to intubate" status (both 3 out of 13; 23.1%) and a lower first attempt success rate for tracheal intubation (p=0.04). Among all 82 children 71 (86.6%) survived to hospital admission and 63 (76.8%) to discharge. Of the 63 survivors, 54 (85.7%) demonstrated a favourable or unchanged neurological outcome (PCPC 1-3). The survival and neurological outcomes of infants were inferior compared to older children (p<0.001). On average an emergency physician performed one prehospital tracheal intubation in 3 years in a child and one in 13 years in an infant. CONCLUSIONS: Anaesthesia-trained emergency physicians working in our system report high success rates for prehospital tracheal intubation in children. Survival and neurological outcomes were considerably better than reported in previous studies.

LMA-ProSeal for elective postoperative care on the intensive care unit: a prospective, randomized trial.

BACKGROUND: Compared to an endotracheal tube, laryngeal mask airways are known to cause less hemodynamic alteration during the extubation phase of routine perioperative airway management. This study aims to examine the hypothesis that the LMA-ProSeal (PLMA, The Laryngeal Mask Company Limited, St. Helier, Jersey, Channel Islands) is an adequate tool for elective postoperative care in the intensive care unit (ICU) and potentially associated with less hemodynamic alteration during extubation in the ICU environment compared to an endotracheal tube. METHODS: Forty-eight patients were enrolled for this prospective randomized, controlled trial and were allocated to either control (ICU-T) or study group (ICU-P). In the ICU-P group, the endotracheal tube was replaced by a PLMA at the end of surgery. RESULTS: Forty-patients completed the study. Cardiovascular parameters increased significantly less in the ICU-P group: systolic blood pressure increased by 18.10 +/- 5.57 mmHg versus 34.65 +/- 5.63 mmHg (P < 0.05), mean arterial blood pressure increased by 11.23 +/- 3.25 mmHg versus 22.65 +/- 3.36 mmHg (P < 0.05), and heart rate increased by 9.3 +/- 2.9 versus 12.9 +/- 2.2 min (P < 0.05). Ventilation via the PLMA during transfer from the operation room to the ICU as well as during ICU stay was successful and without any adverse events. CONCLUSIONS: Removal of the PLMA after recovery from anesthesia was associated with less cardiovascular change compared to the endotracheal tube. Ventilation was possible without reported adverse events during the entire trial. Elective endotracheal tube replacement by the PLMA may be a useful procedure in selected patients.

Characteristics of out-of-hospital paediatric emergencies attended by ambulance- and helicopter-based emergency physicians.

BACKGROUND: In Germany, as in many other countries, for the vast majority of cases, critical out-of-hospital (OOH) paediatric emergencies are attended by non-specialised emergency physicians (EPs). As it is assumed that this may lead to deficient service we aimed to gather robust data on the characteristics of OOH paediatric emergencies. METHODS: We retrospectively evaluated all OOH paediatric emergencies (0-14 years) within a 9-year period and attended by physician-staffed ground- or helicopter-based emergency medical service (EMS or HEMS) teams from our centre. RESULTS: We identified 2271 paediatric emergencies, making up 6.3% of all cases (HEMS 8.5%). NACA scores IV-VII were assigned in 27.3% (HEMS 32.0%). The leading diagnosis groups were age dependent: respiratory disorders (infants 34.5%, toddlers 21.8%, school children 15.0%), convulsions (17.2%, 43.2%, and 16.0%, respectively), and trauma (16.0%, 19.5%, and 44.4%, respectively). Endotracheal intubation was performed in 4.2% (HEMS 7.6%) and intraosseous canulation in 0.7% (HEMS 1.0%) of children. Cardiopulmonary resuscitation (CPR) was commenced in 2.3% (HEMS 3.4%). Thoracocentesis, chest drain insertion and defibrillation were rarities. HEMS physicians attended a particularly high fraction of drowning (80.0%), head injury (73.9%) and SIDS (60.0%) cases, whereas 75.6% of all respiratory emergencies were attended by ground-based EPs. CONCLUSIONS: Our data suggest that EPs need to be particularly confident with the care of children suffering respiratory disorders, convulsions, and trauma. The incidence of severe paediatric OOH emergencies requiring advanced interventions is higher in HEMS-attended cases. However, well-developed skills in airway management, CPR, and intraosseous canulation in children are essential for all EPs.

Undergraduate medical education in emergency medical care: a nationwide survey at German medical schools.

BACKGROUND: Since June 2002, revised regulations in Germany have required "Emergency Medical Care" as an interdisciplinary subject, and state that emergency treatment should be of increasing importance within the curriculum. A survey of the current status of undergraduate medical education in emergency medical care establishes the basis for further committee work. METHODS: Using a standardized questionnaire, all medical faculties in Germany were asked to answer questions concerning the structure of their curriculum, representation of disciplines, instructors' qualifications, teaching and assessment methods, as well as evaluation procedures. RESULTS: Data from 35 of the 38 medical schools in Germany were analysed. In 32 of 35 medical faculties, the local Department of Anaesthesiology is responsible for the teaching of emergency medical care; in two faculties, emergency medicine is taught mainly by the Department of Surgery and in another by Internal Medicine. Lectures, seminars and practical training units are scheduled in varying composition at 97% of the locations. Simulation technology is integrated at 60% (n = 21); problem-based learning at 29% (n = 10), e-learning at 3% (n = 1), and internship in ambulance service is mandatory at 11% (n = 4). In terms of assessment methods, multiple-choice exams (15 to 70 questions) are favoured (89%, n = 31), partially supplemented by open questions (31%, n = 11). Some faculties also perform single practical tests (43%, n = 15), objective structured clinical examination (OSCE; 29%, n = 10) or oral examinations (17%, n = 6). CONCLUSION: Emergency Medical Care in undergraduate medical education in Germany has a practical orientation, but is very inconsistently structured. The innovative options of simulation technology or state-of-the-art assessment methods are not consistently utilized. Therefore, an exchange of experiences and concepts between faculties and disciplines should be promoted to guarantee a standard level of education in emergency medical care.

[Modern airway management--current concepts for more patient safety]. / Modernes Atemwegsmanagement--Aktuelle Konzepte für mehr Patientensicherheit.

Effective and safe airway management is one of the core skills among anaesthesiologists and all physicians involved in acute care medicine. However, failure in airway management is still the most frequent single incidence with the highest impact on patient's morbidity and mortality known from closed claims analyses. The anaesthesiologist has to manage the airway in elective patients providing a high level of safety with as little airway injury and interference with the cardio-vascular system as possible. Clinical competence also includes the management of the expected and unexpected difficult airway in different clinical environments. Therefore, it is the anaesthesiologist's responsibility not only to educate and train younger residents, but also all kinds of medical personnel involved in airway management, e.g. emergency physicians, intensive care therapists or paramedics. Modern airway devices, strategies and educational considerations must fulfill these sometimes diverse and large range requirements. Supraglottic airway devices will be used more often in the daily clinical routine. This is not only due the multiple advantages of these devices compared to the tracheal tube, but also because of the new features of some supraglottic airways, which separate the airway from the gastric track and give information of the pharyngeal position. For the event of a difficult airway, new airway devices and concepts should be trained and applied in daily practice.

Prospective clinical and fiberoptic evaluation of the Supreme laryngeal mask airway.

BACKGROUND: In March 2007, a new disposable laryngeal mask airway (LMA) became available. The LMA Supreme (The Laryngeal Mask Company Limited, St. Helier, Jersey, Channel Islands) aims to combine the LMA Fastrach feature of easy insertion with the gastric access and high oropharyngeal leak pressures of the LMA ProSeal. METHODS: The authors performed an evaluative study with the LMA Supreme, size 4, on 100 women to measure the ease of insertion, determinate the laryngeal fit by fiberoptic classification, evaluate the oropharyngeal leak pressure, and report adverse events. RESULTS: Insertion of the LMA Supreme was possible in 94 patients (94%) during the first attempt, and in 5 patients (5%) during the second attempt. In one small patient, the LMA Supreme could not be inserted because of limited pharyngeal space. This patient was excluded from further analysis. Insertion of a gastric tube was possible in all patients at the first attempt. The median time for LMA Supreme insertion was 10.0 s (+/-4.7 s; range, 8-30 s). Laryngeal fit, evaluated by fiberscopic view, was rated as optimal in all patients, both immediately after insertion of the LMA Supreme and at the end of surgery. After equalization to room pressure, the mean cuff volume needed to achieve 60 cm H2O cuff pressure was 18.4 ml (+/-3.8 ml; range, 8-31 ml). The mean oropharyngeal leak pressure at the level of 60 cm H2O cuff pressure was 28.1 cm H2O (+/-3.8 cm H2O, range, 21-35 cm H2O). Eight patients (8.1%) complained of a mild sore throat. No patient reported dysphagia or dysphonia. CONCLUSIONS: Clinical evaluation of the LMA Supreme showed easy insertion, optimal laryngeal fit, and low airway morbidity. Oropharyngeal leak pressure results were comparable to earlier data from the LMA ProSeal.

Out-of-hospital airway management with the LMA CTrach--a prospective evaluation.

AIM OF THE STUDY: Airway management in an out-of-hospital setting is a critical and demanding skill. Previous studies evaluated the intubating laryngeal mask airway (ILMA) as a valuable tool in this area. The LMA CTrach Laryngeal Mask Airway (CTrach) may increase intubation success. Therefore, we evaluated the CTrach as the primary tool for airway management in the out-of-hospital setting in adult patients. METHODS: From October 2006 until September 2007 EAN and SGR included all patients who needed advanced airway management during out-of-hospital emergency medicine service. Ventilation and intubation has been performed via the CTrach as the primary choice. Before intubation, visualization of the vocal cords was optimized under continuous ventilation via the CTrach. The time needed, manoeuvres to optimize vision, grades of vision and success rates have been documented. RESULTS: 16 patients have been included. Ventilation and intubation via the CTrach was possible in all patients. Ventilation was mostly established in less than 15s and was established in 15 of 16 (94%) patients at the first attempt. Intubation was successful in 15 of 16 (94%) patients on the first attempt. Visualization of the laryngeal structures was achieved in 69% of patients, while intubation without sight was performed in 31%, respectively. CONCLUSION: In this study, ventilation and intubation via the CTrach was successful and could be rapidly established in all patients. Our data suggest that the use of the CTrach may be suitable for the out-of-hospital setting as it provides ventilation and facilitates intubation with a very high success rate.

Paramedic versus emergency physician emergency medical service: role of the anaesthesiologist and the European versus the Anglo-American concept.

PURPOSE OF REVIEW: Much controversy exists about who can provide the best medical care for critically ill patients in the prehospital setting. The Anglo-American concept is on the whole to provide well trained paramedics to fulfil this task, whereas in some European countries emergency medical service physicians, particularly anaesthesiologists, are responsible for the safety of these patients. RECENT FINDINGS: Currently there are no convincing level I studies showing that an emergency physician-based emergency medical service leads to a decrease in overall mortality or morbidity of prehospital treated patients, but many methodical, legal and ethical issues make such studies difficult. Looking at specific aspects of prehospital care, differences in short-term survival and outcome have been reported when patients require cardiopulmonary resuscitation, advanced airway management or other invasive procedures, well directed fluid management and pharmacotherapy as well as fast diagnostic-based decisions. SUMMARY: Evidence suggests that some critically ill patients benefit from the care provided by an emergency physician-based emergency medical service, but further studies are needed to identify the characteristics and early recognition of these patients.

Self-reported changes in attitude and behavior after attending a simulation-aided airway management course.

STUDY OBJECTIVE: To evaluate the influence of a simulator-aided course for airway management on participants' daily clinical airway management practice. DESIGN: Survey instrument. SETTING: University hospital. PARTICIPANTS: 88 participants who attended a simulator-aided course for airway management. INTERVENTION: Six mo after 4 consecutive courses with identical structure and content, participants were mailed a standardized questionnaire to answer. MEASUREMENTS AND MAIN RESULTS: Of 88 participants queried, 48 completed the questionnaire. Ninety-two percent had experienced a difficult airway situation in the 6 mo after the course. Fourteen (29%) evaluated predictors for a difficult airway more carefully. Fourteen (29%) established structural changes within their departments. Ten (21%) participants acquired new technical airway devices. The mean estimated impact on the participants' rating for lectures, skill stations, and scenarios on a scale from 1 (very helpful) to 6 (not at all helpful) was 2.8 for lectures, 1.6 for skill stations, and 1.4 for scenarios. CONCLUSIONS: Attendance at a simulator-aided airway management course has a significant impact on self-reported accuracy and confidence in evaluation of airways, use of alternative airway devices, and changes in the practitioner's clinical practice toward difficult airway situations.

Which airway should I use?

PURPOSE OF REVIEW: To summarize recent findings for the optimal airway device for patients in the operating room and for medical personnel with limited experience in out-of-hospital airway management. RECENT FINDINGS: Extraglottic airway devices, like the laryngeal mask airway, are increasingly used for airway management in patients undergoing elective surgery. New devices with separate gastric access reduce the risk of aspiration, providing higher airway seal pressure and extending the range of clinical use (e.g., for patients with surgical procedures in the prone position). The major advantages are reduced airway morbidity and less significant cardiovascular responses. Extraglottic airway devices insertion is easier to learn, and the skill is better retained. Failure to secure the airway in critically ill emergency patients can drastically increase the likelihood of poor or fatal outcome. Recently published studies recommend a shift in the curriculum for medical students and other healthcare providers from conventional laryngoscopic tracheal intubation towards the use of extraglottic airway devices. The intubating laryngeal mask might play a major role because it facilitates both ventilation and tracheal intubation. SUMMARY: Extraglottic airway devices are increasingly used for airway management not only in patients for elective surgery, but also in out-of-hospital settings, when less experienced personnel have to secure the airway.

Novices ventilate and intubate quicker and safer via intubating laryngeal mask than by conventional bag-mask ventilation and laryngoscopy.

BACKGROUND: Because airway management plays a key role in emergency medical care, methods other than laryngoscopic tracheal intubation (LG-TI) are being sought for inadequately experienced personnel. This study compares success rates for ventilation and intubation via the intubating laryngeal mask (ILMA-V/ILMA-TI) with those via bag-mask ventilation and laryngoscopic intubation (BM-V/LG-TI). METHODS: In a prospective, randomized, crossover study, 30 final-year medical students, all with no experience in airway management, were requested to manage anesthetized patients who seemed normal on routine airway examination. Each participant was asked to intubate a total of six patients, three with each technique, in a randomly assigned order. A task not completed after two 60-s attempts was recorded as a failure, and the technique was switched. RESULTS: The success rate with ILMA-V was significantly higher (97.8% vs. 85.6%; P < 0.05), and ventilation was established more rapidly with ILMA-V (35.6 +/- 8.0 vs. 44.3 +/- 10.8 s; P < 0.01). Intubation was successful more often with ILMA-TI (92.2% vs. 40.0%; P < 0.01). The time needed to achieve tracheal intubation was significantly shorter with ILMA-TI (45.7 +/- 14.8 vs. 89.1 +/- 23.3 s; P < 0.01). After failed LG-TI, ILMA-V was successful in all patients, and ILMA-TI was successful in 28 of 33 patients. Conversely, after failed ILMA-TI, BM-V was possible in all patients, and LG-TI was possible in 1 of 5 patients. CONCLUSION: Medical students were more successful with ILMA-V/ILMA-TI than with BM-V/LG-TI. ILMA-TI can be successfully used when LG-TI has failed, but not vice versa. These results suggest that training programs should extend the ILMA to conventional airway management techniques for paramedical and medical personnel with little experience in airway management.

Outcome of 12 drowned children with attempted resuscitation on cardiopulmonary bypass: an analysis of variables based on the "Utstein Style for Drowning".

BACKGROUND: In 2003, the International Liaison Committee on Resuscitation (ILCOR) published the "Utstein Style for Drowning" (USFD) to advance knowledge on the epidemiology, treatment, and outcome prediction after drowning. Applying the USFD and evaluating its data template for outcome analysis, we report here on the largest study published thus far of drowned children (age 0-14) who underwent attempted resuscitation on cardiopulmonary bypass (CPB). METHODS: We conducted a retrospective review of all drowned children admitted to Göttingen University Hospital between 1/1987 and 12/2005 in sustained cardiopulmonary arrest and resuscitation with CPB. We correlated eight outcome-affecting USFD variables and four additional variables not included in the USFD with potential impact on outcome to four outcome groups: survival, non-survival, survival with full recovery, and failed resuscitation. RESULTS: Out of 12 children (aged 22 months to 7.5 years), 5 survived to hospital discharge and 7 died in hospital. Two survivors recovered fully and three remained in a vegetative state. In two patients, resuscitation on CPB failed. Both children who fully recovered, compared to the 10 others, had relatively low serum K+ concentrations (2.6 and 3.7 mmol/l versus 5.8+/-3.8 mmol/l [mean+/-S.D.; n=10]), a relatively slow rewarming speed (1.9 and 1.2 degrees C/h versus 3.4+/-1.8 degrees C/h), were female (all three girls survived), received early basic life support (BLS) and showed idioventricular bradycardia. Both children with failed resuscitation had severe hyperkalaemia (11.7 and 13.3 mmol/l versus 10 others, 4.0+/-1.5 mmol/l), were relatively rapidly rewarmed (6.9 and 4.0 degrees C/h versus 10 others, 2.61+/-1.32 degrees C/h), male, and in asystole. We identified no outcome trends for age, pH, or water and core temperatures. CONCLUSIONS: Most variables relevant for outcome in drowned children can be documented with the use of the USFD. Additional variables not included in the USFD that have emerged from this study and may predict outcome include serum K+ concentration, rewarming speed, and initial cardiac rhythm.

The out-of-hospital esophageal and endobronchial intubations performed by emergency physicians.

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.