Intubation confirmation techniques associated with unrecognized non-tracheal intubations by pre-hospital providers

This study examined pre-hospital intubations performed by paramedics, which were later determined to be non-tracheal upon arrival at an urban, academic emergency department (ED). The aim was to characterize the various confirmation techniques used among these unrecognized non-tracheal intubations. A retrospective review of the emergency medical services (EMS) quality assurance database was conducted over a period of 65 months. Paramedic patient care reports and hospital medical records were reviewed with regard to techniques used for airway evaluation. Simple descriptive statistics are used to summarize the data. During this study period, paramedics intubated 1643 patients. There were 35 (2%) intubations that were ultimately determined to be non-tracheal by receiving physicians. Among these, 20 (57%) were intubations for trauma indications. Seven patients (20%) were children (< 10 years). Fifteen patients (43%) did not have a pulse before intubation attempts. Overall, 21 (60%) had multiple confirmatory techniques employed by paramedics. The most commonly documented was 'equal lung sounds' (91%), followed by 'visualized cords' (52%). Per protocol, colorimetric end tidal CO₂ was used selectively among patients with pulses, 9/20 (45%). Aspiration techniques were not used among this study population. Based on paramedic documentation, 17 (49%) of the non-tracheal intubations were potentially recognizable. An unrecognized, non-tracheal intubation is a potentially devastating consequence of failed airway management. We report a small, but important experience with failed pre-hospital airway management. In this EMS system, more frequent use of multiple confirmatory techniques (including end tidal CO₂ detection) may help to reduce the incidence of this potentially life-threatening scenario.