Editor,—We were disturbed to note from the survey of Florance et al that fewer than 50% of “major” accident and emergency departments in East Anglia report having any facilities for end tidal carbon dioxide (ETCO₂) monitoring available for trauma patients.¹

All emergency departments in North America that manage trauma patients routinely keep in their trauma rooms at least a calorimetric device for ETCO₂ detection—not to do so would be considered indefensible in the event of an adverse airway event (R N Walls, personal communication).

Relying on having seen the endotracheal tube “pass through the cords” and depending on clinical signs is hazardous in the multiply injured patient. Capnography should be considered mandatory in any patient requiring intubation, especially as an emergency. The endotracheal tube must be replaced immediately in any patient not in cardiac arrest in whom ETCO₂ is not detected.²

Endotracheal intubation continues to remain the “gold standard” for airway management for patients in cardiac arrest. The standard clinical signs widely used to confirm endotracheal intubation are again potentially unreliable and capnography is unhelpful. The use of a lit tracheal stylet (for example Trachlight Stylet and Tracheal Lightwand, Rusch Inc, Duluth, GA, USA), inserted through the endotracheal tube after intubation, can very simply provide indirect and rapid confirmation of correct tracheal placement by transillumination of the soft tissues of the neck. This simple technique may help to reduce the tragedy of failure to recognise oesophageal intubation in critically ill patients.