To resuscitate out-of-hospital patients, paramedics often perform endotracheal intubation (ETI), insertion of a breathing tube into the windpipe. However, a new study found that they make three key errors when treating one-fifth of patients. The errors included tube misplacement or dislodgement, multiple ETI attempts, or failed ETI (patient arrives at the emergency department without the tube in place). Patients don't generally die due to these errors; however, they are more likely to develop pneumonitis (lung inflammation), according to the study. If untreated, pneumonitis can lead to lung scarring and permanent difficulty breathing.
A team led by Henry E. Wang, M.D., M.P.H., of the University of Pittsburgh, examined the link between these three ETI errors and patient outcomes based on multicenter data on out-of-hospital ETI attempted by emergency medical service (EMS) rescuers from 40 advanced life support EMS Pennsylvania agencies. They linked these data to statewide EMS, death, and hospital discharge data to examine the impact of ETI errors on death and outcomes ranging from esophageal perforation or injury to pneumonia and death.
EMS technicians made one or more errors while resuscitating one-fifth (22.7 percent) of patients during 1,954 out-of-hospital ETIs. Mistakes included tube misplacement or dislodgement in 3 percent of patients treated, multiple ETI attempts in 3 percent, and failed ETI in 15 percent. Of the 1,196 cases linked to patient outcomes, 73 percent died and 27 percent survived to hospital discharge. ETI errors were not associated with early or later death. Cardiac arrest was linked to early death and clinical instability upon hospital admission was associated with later death. However, failed ETI was associated with more than twice the likelihood of the patient developing pneumonitis, after adjustment for other patient clinical factors and intubation methods.
The link between failed ETI and pneumonitis may be due to aspiration of particles into the lung that occurs prior to or independent of the ETI effort, note the researchers. Their study was supported in part by the Agency for Healthcare Research and Quality (HS13628).
See "Outcomes after out-of-hospital endotracheal intubation errors," by Dr. Wang, Lawrence J. Cook, Ph.D., Chung-Chou H. Chang, Ph.D., and others, in Resuscitation 80, pp. 50-55, 2009.
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