No. 1 recommendation: Confirm tube placement
It could be the single most important point in the American Heart Association’s (AHA’s) new guidelines for cardiopulmonary resuscitation and emergency care: You must confirm endotracheal tube placement, stresses Mary Fran Hazinski, RN, MSN, FAAN, senior science editor for the AHA’s emergency cardiovascular care programs and clinical specialist in the division of trauma in the departments of surgery and pediatrics at Vanderbilt University Medical Center in Nashville, TN.
"There is growing evidence that tracheal tube dislodgment may be occurring at a much higher rate than previously suspected,"1,2 says Hazinski. "There is a need for quality improvement programs for prehospital intubation."
Patients intubated in the prehospital setting may arrive in the ED with a tube that is actually in the esophagus or pharynx, warns Hazinski. "The tube is either misplaced originally or displaced during transport," she says. "Unrecognized tube misplacement is obviously a fatal complication."
Whenever a patient arrives with an endotracheal tube in place, you must immediately evaluate tube placement and confirm that the tube is in the correct place, stresses Hazinski.
It can be deadly’
Studies should be done by EDs to document the effectiveness and safety of prehospital intubation, Hazinski recommends. "This is a procedure that can be lifesaving, but it can also be deadly. It is critical that everyone involved in the care of these patients know that tube location must immediately be verified."
Be prepared to prove at any moment that the tube is in place, Hazinski advises. "That’s a much safer approach than simply assuming the tube is in place."
When the patient has a profusing rhythm, end-tidal capnography can be very accurate, notes Hazinski. "But when the patient is in cardiac arrest, the capnography may indicate a low CO2 that is consistent with a tube that is not in the trachea, when the tube actually is in place," she adds.
Esophageal detector devices should be used as secondary confirmation devices if the patient is in cardiac arrest, says Hazinski.
Begin with clinical assessment, then add CO2 detection or end-tidal CO2 monitoring, advises Marianne Gausche-Hill, MD, FACEP, FAAP, director of emergency medical services at Harbor-University of California at Los Angeles Medical Center in Torrance.
"If it is unclear whether the endotracheal tube is in place after using clinical assessment and CO2 detection, use an esophageal detector device for patients 5 years of age or greater [20-kg body weight]," Gausche-Hill recommends.
A recent study showed that many endotracheal tubes become dislodged in transport in children 12 years or younger, reports Gausche-Hill, the study’s principal investigator.3
Of 186 patients believed to be successfully intubated, 27 patients (14.5%) had the endotracheal tube dislodged, says Gausche-Hill. "Of these, 15 [8%] of patients had the endotracheal tube dislodged and the paramedic recognized the problem. In 12 patients [6.5%], the tube was dislodged and was unrecognized by paramedics."
Any time the patient is moved, tube position should be confirmed, Hazinski recommends. "Continuous exhaled CO2 is the best method of [evaluating] or detecting tube dislodgment," she says. "Proper head and tube immobilization is necessary during transport."
Endotracheal tubes can be easily dislodged with any movement or transfer of the patient, says Gausche-Hill. "Movement is the rule in the out-of-hospital setting. Because of a child’s short tracheal length, these tubes can be easily dislodged," she warns.
DOPE can go wrong
Deterioration of an intubated patient can indicate that the tube has become dislodged, Gausche-Hill notes. Use the mnemonic "DOPE" to remember what can go wrong, she recommends, as follows:
D = dislodgment;
O = obstruction of the tube from secretions or kinking;
P = pneumothorax may result from positive pressure ventilation;
E = equipment may be faulty. (If on a ventilator, remove and begin ventilation using the endotracheal tube and bag-valve device, recommends Gausche-Hill).
In the Gausche-Hill study, the transport interval averaged only five minutes, and paramedics were inexperienced, says Hazinski. "Only 5% of 3,000 paramedics who were trained in pediatric intubation at the beginning of the study had the opportunity to intubate a single pediatric patient in three years," she notes. "If you have a combination of a short transport interval and paramedics inexperienced in intubation, it may be better to use bag-mask ventilation, rather than have patients be intubated in inexperienced hands."
The endotracheal tube is still viewed as the "gold-standard" airway, but only when placed in experienced hands, says Hazinski. "But it’s difficult to maintain skill and experience when ill children are infrequently encountered."
It might be necessary to limit the number of people performing the intubation, Hazinski suggests. "That way, you have a smaller group of people getting a greater amount of experience, instead of a large number of people getting inadequate experience," she says.
Quality improvement will require good record keeping, says Hazinski. "If prehospital personnel are not able to perform intubation, they should have the opportunity to go back into training," she stresses. "Medical centers need to be willing to support the needs of an emergency medical services system, because that will help with the care of patients in the prehospital setting."
References
1. Berwick DM, Leape LL. Reducing errors in medicine. BMJ 1999; 319:136-137.
2. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients: Results of the Harvard Medical Practice Study I. N Engl J Med 1991; 324:370-376.
3. Gausche M, Lewis RJ, Stratton SJ, et al. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: A controlled clinical trial. JAMA 2000; 283:783-790.
Source
For more information about confirmation of tube placement, contact:
• Marianne Gausche-Hill, MD, FACEP, FAAP, Harbor-UCLA Medical Center, 1000 W. Carson St., Box 21, Torrance, CA 90509. Telephone: (310) 222-3501. Fax: (310) 782-1763. E-mail: [email protected].
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