Failed prehospital intubations: an analysis of emergency department courses and outcomes.

OBJECTIVE: To examine the reasons for failed prehospital endotracheal intubation (ETI) and to identify how the airway was subsequently managed in the emergency department (ED). METHODS: Data were collected from January to December 1998 for a county-wide paramedic system. Failed prehospital ETIs and perceived reasons for failure were identified. Subsequent ED airway management was reviewed. RESULTS: During the study period there were 13,112 patient contacts resulting in ETI attempts on 592 patients, of whom 536 (90.5%) were successfully intubated. Of the 56 failed field intubations, 49 (87.5%) had ED charts available for review. Endotracheal intubation failure was associated with inadequate relaxation in 24 (49%), difficult anatomy in ten (20%), and obstruction in five (10%). Successful ETI was achieved in the ED in 42 cases (86%). Twenty cases (41%) were facilitated by rapid-sequence intubation (RSI) in the ED. For those with incomplete relaxation in the field, 13 of 24 (54%) were intubated in the ED using RSI. Factors associated with the use of ED RSI include attempted prehospital nasotracheal intubation or attempted prehospital midazolam-facilitated intubation (p < 0.001). The predicted need for RSI in this prehospital system is approximately 3.9%. In eight cases, three or more ETI attempts or the use of rescue airways was required in the ED. The predicted minimum incidence of "truly difficult" intubation in this system is approximately 0.8-1.6%. CONCLUSIONS: Paramedic intubation failures result from a variety of factors. Less than half of field intubation failures were remedied in the ED by the use of neuromuscular-blocking agents. A similar number were intubated without the use of RSI. A fraction of failed field ETIs may have resulted from inadequate operator training or experience. A small percentage of field patients were "truly difficult" and required advanced resources in the ED to facilitate airway management. Medical directors should be cognizant of the numerous factors affecting intubation performance when designing and implementing approaches to difficult prehospital airways.

Subclavian central venous catheterization complicated by guidewire looping and entrapment.

The placement of central venous catheters is a technically challenging procedure with known risks and complications. We report an attempted left subclavian central venous catheterization that was complicated by looping and entrapment of the guidewire. We hypothesize that this complication occurred because the straight guidewire that was used may have perforated the wall of the vein, allowing the guidewire to loop upon itself. Although catheter looping and knotting are well known potential complications of central venous catheterization, similar complications are rarely reported with guidewires. Clinicians should be aware of these potential complications when performing or teaching central venous catheterization.

EMT defibrillation does not increase survival from sudden cardiac death in a two-tiered urban-suburban EMS system.

OBJECTIVE: The use of automatic external defibrillators (AEDs) by EMS initial responders is widely advocated. Evidence supporting the use of AEDs is based largely on the experience of one metropolitan area, with effect on survival in many systems not yet proved. We conducted this study to determine whether the addition of AEDs to an EMS system with a response time of 4 minutes for first-responder emergency medical technicians (FREMTs) and 10 minutes for paramedics would affect survival from cardiac arrest. METHODS: This prospective, controlled, crossover study (AED versus no AED) of consecutive cardiac arrests managed by 24 FREMT fire companies took place from 1992 to 1995 in Charlotte, North Carolina, a city of 455,000. Patients were stratified using the Utstein criteria. The primary endpoint was survival to hospital discharge among patients with bystander-witnessed arrests of cardiac origin. RESULTS: Of the 627 patients, 243 were bystander-witnessed arrests of cardiac origin. Survival to hospital discharge was accomplished in 5 of 110 patients (4.6%; 95% confidence interval [CI] 0.6% to 8.4%) with AED compared with 7 of 133 (5.3%, 95% CI 1.5% to 9.1%) without AED (P = .8). Both groups were comparable with regard to age, gender, history of myocardial infarction, congestive heart failure or diabetes, arrest at home, bystander CPR, and whether or not ventricular fibrillation (VF) was the initial rhythm. For arrests of any cause, witnessed by bystanders or EMS personnel, with an initial rhythm of VF or ventricular tachycardia (VT), 5 of 77 (6.5%, 95% CI 1.0% to 12.0%) with AED survived compared with 8 of 105 patients (7.6%, 95% CI 2.5% to 12.7%) without AED (P = .8). Statistically significant differences were noted in race and EMS response times between the two groups, which did not affect survival. CONCLUSION: Addition of AEDs to this EMS system did not improve survival from sudden cardiac death. The data do not support routinely equipping initial responders with AEDs as an isolated enhancement, and raise further doubt about such expenditures in similar EMS systems without first optimizing bystander CPR and EMS dispatching.

Another false alarm? apnea monitor activation in a Neonatal Intensive Care Unit graduate.

Neonatal emergencies have become more common as increasingly sophisticated Neonatal Intensive Care Units graduate lower birth-weight babies born at younger gestational ages. These patients present a number of challenges to emergency physicians. They are often discharged with apnea monitors, which generate a high number of false alarms. Neonatal Intensive Care Unit graduates, however, are predisposed to a number of conditions that can result in true episodes of apnea. We present such a case and will discuss the unusual underlying cause of apnea, the utility of apnea monitors, and the need for emergency physicians to be prepared to evaluate and treat these potentially complicated patients.

Blunt neck injury.

Emergency physicians must diagnose or exclude cervical spine trauma in daily practice. This is a complicated task, as the presentation may be subtle and the manifestations obscured, and no imaging modality is completely sensitive or specific. The research of the past two decades serves as a guide as to which types of patients require cervical radiologic evaluation and which modalities of evaluation are appropriate.

Resuscitation of cardiac arrest victims by advanced life support units in Monroe County, New York.

Four hundred sixty-three cases of cardiac arrest treated in the pre-hospital setting by advanced life support (ALS) or paramedic units in Monroe County, New York, were evaluated using Eisenberg's criteria, which define factors known to be critical for successful resuscitation. Forty-eight patients met the criteria of witnessed collapse and cardiopulmonary resuscitation (CPR) within four minutes and ALS within ten minutes, with the initial rhythm of ventricular fibrillation or pulseless ventricular tachycardia. Of these, 16 (33%) patients were discharged from the hospital. This compares to 12 of 415 (3%) patients discharged who did not meet the criteria. Of the 171 patients who suffered witnessed arrests of cardiac origin, 20 survived to be discharged. This represents a successful resuscitation rate of 12%. These percentages are within the range noted for other ALS services in the United States.