Field airway management disasters.

Volker Wenzel, MD, MSc* A half century ago, a patient with impaired ventilation was at high risk of imminent death. Successful airway management profoundly reduces the risk of morbidity and mortality in a severely injured or ill patient. Unsuccessful airway management kills patients. Studies have questioned the usefulness of endotracheal intubation by relatively inexperienced rescuers because of its deadly complications (1,2). The impressive study from Timmermann et al. (3) reveals similarly catastrophic disasters after intubation in the field, as detected by emergency medical service (EMS) physicians arriving by helicopter and performing laryngoscopy upon arrival at the scene to verify endotracheal tube position. Although brief and rapidly detected esophageal intubation may not cause harm, seven patients with spontaneous circulation on initial examination developed asystole after esophageal intubation. This suggests iatrogenic hypoxia resulting in cardiac arrest. We can only assume that the steps required to detect esophageal intubation were either incorrectly performed or completely omitted in these cases. Unfortunately, these cases from Göttingen, Germany are not isolated incidents of bad luck. After we published eight cases of catastrophic airway management (4), another five cases quickly surfaced, suggesting that these potentially deadly problems are common. Case 1: A woman suffered multiple trauma in a car accident, but was breathing spontaneously. Because of severe head trauma, intubation was performed to prepare for helicopter transport. After intubation, her oxygen saturation decreased rapidly, and asystole developed. During continuous cardiopulmonary resuscitation (CPR), the patient was flown to the next hospital, where esophageal intubation was detected. The patient died. Case 2: A man collapsed at home after suffering myocardial infarction and was intubated by EMS staff. Advanced cardiac life support was unsuccessful and abdominal distension developed. Esophageal intubation was corrected but CPR failed and the patient died. Case 3: A child suffered multiple trauma in a car accident and was intubated by a physician. Laryngoscopy at the scene did not confirm endotracheal intubation, but as oxygen saturation was 90%, transport was performed without further measures. A computed tomography scan in the hospital revealed esophageal intubation. The child died of massive brain edema. Case 4: A man suffered cardiac arrest at a public swimming pool. EMS staff did not succeed with several intubation attempts, resulting in severely swollen tissues. An arriving anesthesiologist was subsequently unable to intubate, but performed cricothyrotomy, enabling ventilation. CPR was continued, but the patient died at the scene. A patient does not die from lack of attempted intubation, but because of the failure to ventilate the lungs. This can be caused by undiagnosed esophageal intubation or failure to ventilate with a bag and mask during multiple unsuccessful intubation attempts (5). It is unclear whether the rescuers fully understood the importance of verifying endotracheal intubation or the catastrophic risk of undetected esophageal intubation. All EMS units carry intubation equipment as part of their standard supplies. However, the tools to verify endotracheal intubation, such as end-tidal carbon dioxide detection devices, are frequently not available. A From the *Department of Anesthesiology and Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria; and the †Department of Anesthesiology and Critical Care Medicine, University of SchleswigHolstein, Campus Kiel, Germany. Accepted for publication December 7, 2006. Supported, in part, by the Science Foundation of the Austrian National Bank, Vienna, Austria grant 11448. Neither author has a conflict of interest with regards to ventilation devices discussed in this manuscript. Address correspondence and reprint requests to Achim von Goedecke, MSc, MD, Department of Anesthesiology and Critical Care Medicine, Innsbruck Medical University, Anichstrasse 35, 6020 Innsbruck, Austria. Address e-mail to [email protected]. Copyright © 2007 International Anesthesia Research Society DOI: 10.1213/01.ane.0000255964.86086.63