Emergency Room Intubations-Complications and Survival

doi:10.1378/chest.75.5.541

Chest

Volume 75, Issue 5, May 1979, Pages 541-543

https://doi.org/10.1378/chest.75.5.541 Get rights and content

Forty-three consecutive patients requiring endotracheal intubation in an emergency room were studied prospectively to define the complications associated with intubation and the survival of these patients, and to evaluate emergency room policies. The indications for intubation were acute respiratory failure (ARF) in 22 patients and cardiopulmonary arrest (CPA) in 21 patients. Thirty-eight complications occurred in 24 of the 43 patients. The department or level of training of the intubator did not affect the rate of complications. Furthermore, specific complications did not influence survival. Seventeen patients survived, all in the ARF group. Age < 40 years and admission PaO₂ > 40 mm Hg also were associated with increased survival. We conclude that the complication rate of emergency room intubations is high and would not appear to be lowered by limiting intubations to physicians from specific departments or with certain levels of training. The underlying diagnosis and condition on admission to the emergency room appear to be more important factors relating to survival than complications during intubation.

Section snippets

Methods

The study group consisted of all patients intubated while in the emergency department (ED) of a university hospital over a seven-month period, during the middle of the academic year. Table 1 lists the physicians involved in performing the intubations. Note that physicians are classified according to their assigned department at the time they performed the intubation. All physicians had some previous experience with endotracheal intubation.

The general policy of the ED was to page anesthesiology

Results

Forty-three patients were intubated in the ED during the study period. The indication for intubation and underlying problems are shown in Table 3. Mean age in the 22 patients with ARF was 46 ± 5 years (mean ± SEM) and 53 ± 4 years in the 21 patients with CPA (P < 0.01). The initial attempt at intubation was by ED physicians in 23 patients (ARF 12, CPA 11) and by Anesthesiology in 20 (ARF 10, CPA 10). Grouped by level of training, junior residents attempted 20 intubations, senior residents 16,

Discussion

In this study, we investigated the acute complications of endotracheal intubation performed in a university hospital emergency room. Problems developing from the tube being in place or from extubation were not included. We also examined the survival and factors influencing prognosis in these patients. The middle of the academic year was chosen to insure that most house officers would have had time to receive instruction in endotracheal intubation. The ED staff physicians were board-certified

References (3)

RN Lewis et al.
Hazards of endotracheal anesthesia
Br J Anes
(1964)

There are more references available in the full text version of this article.

Cited by (95)

Tooth aspiration following emergency endotracheal intubation
2016, Respiratory Medicine Case Reports
Citation Excerpt :
The patient tolerated the procedure very well despite being on temporary pacemaker and compromised cardiac function. In particular, emergency endotracheal intubations face increased risk of intubations related complications as opposed to non-emergent intubations [4,6,8]. Among few possible complications, rarely tooth aspiration in bronchial tree can occur in cases where enough care is not taken while intubating the patient.
Tooth aspiration in adults during endotracheal intubation is very rare. There are several risk factors for this rare event such as old age, loose teeth, difficult intubation etc. which predispose patients for tooth aspiration in tracheobronchial tree in emergent endotracheal intubation. Although extraction of aspirated tooth with flexible bronchoscopy is a difficult and complex intervention, it is still preferred over rigid scopes due to number of advantages.
This case underlines that appropriate precautions should be taken to prevent a potentially serious medico-legal complication during airway management in emergent circumstances. Also it shows how flexible broncoscope can be used effectively for extraction of foreign body without major complications.
Critical Airway Skills and Procedures
2013, Emergency Medicine Clinics of North America
Citation Excerpt :
ET intubation is not without risk. Commonly reported adverse events surrounding intubation include trauma to the upper airway structures, ET tube–induced tissue necrosis, loss of protective anatomic barriers to infection and the resulting nosocomial pneumonias, patient discomfort and agitation, as well as increased intensive care use and associated costs.11–13 Noninvasive ventilation (NIV) is delivered via positive pressure applied through either a face mask or nose mask to spontaneously breathing patients.
Challenges and Advances in Intubation: Rapid Sequence Intubation
2008, Emergency Medicine Clinics of North America
Citation Excerpt :
Rapid sequence intubation (RSI) is a process whereby pharmacologic agents, specifically a sedative (eg, induction agent) and a neuromuscular blocking agent are administered in rapid succession to facilitate endotracheal intubation.1 RSI in the emergency department (ED) usually is conducted under less than optimal conditions and should be differentiated from rapid sequence induction (also often abbreviated RSI) as practiced by anesthesiologists in a more controlled environment in the operating room to induce anesthesia in patients requiring intubation.2–6 RSI used to secure a definitive airway in the ED frequently involves uncooperative, nonfasted, unstable, critically ill patients.
Rapid sequence intubation is the process involving administration of a sedative (eg, induction agent) followed almost immediately by a neuromuscular blocking agent to facilitate endotracheal intubation The purpose of emergency RSI is to make emergent intubation easier and safer, thereby increasing the success rate of intubation while decreasing the complications. Possible disadvantages are complications from the additional drugs, prolonged intubation with hypoxia, and precipitating an emergent or crash airway. Controversy has arisen regarding various steps in RSI; however, RSI remains the standard of care in emergency medicine airway management.
Cricoid Pressure in Emergency Department Rapid Sequence Tracheal Intubations: A Risk-Benefit Analysis
2007, Annals of Emergency Medicine
Citation Excerpt :
Given the dynamic nature of emergency airways, the fact that many critical patients aspirate before tracheal intubation or ED arrival, and differences in definition, the rate of clinically significant aspiration associated with the procedure itself is unknown. It has been reported in anywhere from 0% of ED-performed rapid sequence tracheal intubations to as high as 22%.10,42-53 Some of the reported variation may also result from an increasing incidence of aspiration associated with repetitive attempts.
Cricoid pressure is considered an integral part of patient safety in rapid sequence tracheal intubation and emergency airway management. Cricoid pressure is applied to prevent the regurgitation of gastric contents into the pharynx and subsequent aspiration into the pulmonary tree. This review analyzes the published evidence supporting cricoid pressure, along with potential problems, including increased difficulty with tracheal intubation and ventilation. According to the evidence available, the universal and continuous application of cricoid pressure during emergency airway management is questioned. An awareness of the benefits and potential problems with technique allows the practitioner to better judge when cricoid pressure should be used and instances in which it should be removed.
Urgent tracheal intubation in general hospital units: an observational study
2007, Journal of Clinical Anesthesia
Citation Excerpt :
Urgent intubation of these patients is commonly thought to be associated with a high complication rate and poor outcome. Complications of urgent intubation range from dental trauma to cardiac arrest [1,2]. However, to date, only a few studies have investigated complications of urgent airway management outside the emergency department.
To determine the frequency of complications and outcomes of urgent intubations in general hospital units.
Prospective, observational, cohort study.
University-affiliated hospital.
150 patients who underwent tracheal intubation in the general care units.
A standardized data collection form was used prospectively to record events at the time of intubation. Patient outcomes were extracted from the medical record.
The complication rate was 27%. The most common complications were multiple attempts (9% required >2 intubations) and esophageal intubation (9%). The complication rate for elective intubation (22%) was similar to the complication rate for emergent intubations (27%). Of patients intubated in the general care units, 52% survived and 33% of these were discharged. There was no significant difference (P = 0.46) in survival between the patients intubated electively (59%) and emergently (50%). There was no significant difference (P = 0.63) in survival between patients with (48%) and without complications (54%).
Endotracheal intubation in general hospital units carries a high rate of complications, and patients who are intubated in general hospital units have a high mortality.
Subcutaneous emphysema and pneumomediastinum after translaryngeal intubation: Tracheal perforation due to unsuccessful fiberoptic tracheal intubation
2006, Journal of Clinical Anesthesia
A 77-year-old man was scheduled to undergo a cervical lymph node biopsy under general anesthesia. Although awake, nasotracheal fiberoptic intubation was initially planned because of an anticipated difficult airway, the attempt was unsuccessful. Orotracheal intubation was subsequently performed under direct laryngoscopy without difficulty. After initiating positive pressure mechanical ventilation, subcutaneous and mediastinal emphysema developed. The cause of this emphysema was considered to be tracheal perforation after an unsuccessful attempt at fiberoptic tracheal intubation.

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For editorial comment, see page 535

This work was supported in part by NHLBI Training Grant No. HL 07085.

Presented in part before the American Federation for Clinical Research, Western Section, Carmel, CA, February 3, 1978, and the American Thoracic Society, Boston, May 15, 1978.

Manuscript received June 23; revision accepted October 9.

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Chest

Clinical InvestigationsEmergency Room Intubations-Complications and Survival

Section snippets

Methods

Results

Discussion

Br J Anes

Clinical Investigations
Emergency Room Intubations-Complications and Survival