Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Capnography Use Saves Lives AND Money – Part IV

Continuing from Capnography Use Saves Lives AND Money – Part I and from Capnography Use Saves Lives AND Money – Part II as well as from Capnography Use Saves Lives AND Money – Part III.
 

Here are some recent case examples:
•In Ohio, a medical malpractice suit was filed against an EMS agency after the death of a 2-year-old boy. The patient died following a hospital transfer during which his ET tube became dislodged but wasn’t detected. The final settlement wasn’t made public.
•In Texas, a 41-year-old female suffered severe brain damage and died following an undetected esophageal intubation. Capnography wasn’t in use. The case settled out of court for $500,000.
•A Florida-based air ambulance service was sued when a 58-year-old female suffered severe brain damage and died when an ET tube became dislodged and was undetected. Capnography wasn’t in use. The case was settled out of court for an undisclosed sum.
[1]

 

This just shows how rare unrecognized esophageal intubations really are!

Not really.
 

(12%) had unrecognized esophageal intubations discovered upon the initial airway assessment performed on arrival. We found no difference in mortality between those patients who were properly intubated and those who were not.[2]

 

There is good news and bad news in this.
 

The bad news is that unrecognized esophageal intubations are not at all rare, even though they should never happen.

The good news is that the outcome for these patients was not worse than the outcome for the patients successfully intubated.

I wouldn’t look at either of these as typical. They are indications of possible outcomes.

Unrecognized esophageal intubations are not at all rare, but I certainly hope that most organizations do not have this big of a problem.

1 out of every 8 1/2 intubations in the wrong hole?

Imagine if an airline’s planes crashed on 1 out of every 8 1/2 flights, but the outcome for the passengers on the flights that crashed was not clearly worse than the outcome on the flights that did not crash.

Would anyone fly that airline?
 

The good news is that the unrecognized esophageal intubations seem to be happening to spontaneously breathing patients, because that is the most reasonable explanation for these patients surviving in spite of EMS trying to remove the patient’s airway.

We cannot rely on this to protect us from bad airway management. Quite the opposite.

We are probably too aggressive with intubation, since so many patients survive in spite of treatment expected to kill any patient in need of intubation.

Those medics worst at intubation are the ones most likely to intubate patients who would be better off without intubation.

That these patients survive in spite of aggressive attempts by incompetent medics to kill these patients is not a reason to ignore the problem.
 

And then there are the patients who are the most dead and the easiest to intubate –
 

Continuous waveform capnography is recommended in addition to clinical assessment as the most reliable method of confirming and monitoring correct placement of an endotracheal tube (Class I, LOE A). Providers should observe a persistent capnographic waveform with ventilation to confirm and monitor endotracheal tube placement in the field, in the transport vehicle, on arrival at the hospital, and after any patient transfer to reduce the risk of unrecognized tube misplacement or displacement.[3]

 

According to the AHA (American Heart Association) and plenty of other organizations –

Assessment is not good enough.

The evidence for this is Class I, LOE A.[4]

Evidence does not get much better than this.

To be continued in –

Capnography Use Saves Lives AND Money – Part V

An excellent source of information about waveform capnography can be found at Capnography for Paramedics.

Footnotes:

[1] Capnography Use Saves Lives & Money
By Patricia A. Brandt, RN, BSN, MHR
JEMS.com
Article

[2] 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]

Free Full Text Article from Anesth Analg. with links to Free Full Text PDF download

[3] Advanced Airways
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Part 8: Adult Advanced Cardiovascular Life Support
Part 8.1: Adjuncts for Airway Control and Ventilation
Free Full Text Article with links to Free Full Text PDF download

[4] Ethics, Research, and IRBs – Part II
Rogue Medic
Article
.

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