Airway Management in the Emergency Department: A One-Year Study of 610 Tracheal Intubations

doi:10.1016/S0196-0644(98)70342-7

Annals of Emergency Medicine

Volume 31, Issue 3, March 1998, Pages 325-332

Presented in part at the Society for Academic Emergency Medicine Scientific Assembly, Washington, DC, May 1997.

https://doi.org/10.1016/S0196-0644(98)70342-7 Get rights and content

Abstract

Study objective: To describe the methods, success rates, and immediate complications of tracheal intubations performed in the emergency department of an urban teaching hospital. Methods: This was an observational, consecutive series undertaken in an urban university hospital with an emergency medicine residency training program and an annual ED census of 60,000 patients. The study population included all patients for whom intubation was attempted in the ED during a 1-year period (July 1, 1995 through June 30, 1996). At the time of each intubation, the intubator filled out an intubation data collection form. If an intubation was performed in the ED but no form was filled out, the data were obtained from the medical record. Results: A total of 610 patients required airway control in the ED; 569 (93%) were intubated by emergency medicine residents or attending physicians. Rapid-sequence intubation (RSI) was used in 515 (84%). A total of 603 patients (98.9%) were successfully intubated; 7 patients could not be intubated and underwent cricothyrotomy. In 33 patients, inadvertent placement into the esophagus occurred; all such situations were rapidly recognized and corrected. Eight (24%) of the 33 esophageal intubations resulted in a reported immediate complication. Overall, 49 patients (8.0%; 95% confidence interval [CI], 6% to 11%) experienced a total of 57 immediate complications (9.3%; 95% CI, 7% to 12%). Three patients sustained a cardiac arrest after intubation; two of these patients had agonal rhythms before intubation, and one probably had a succinylcholine-induced hyperkalemic cardiac arrest. Conclusion: At this institution, the majority of ED intubations were performed by emergency physicians and RSI was the most common method used. Emergency physicians intubated critically ill and injured ED patients with a very high success rate and a low rate of serious complications. [Sakles JC, Laurin EG, Rantapaa AA, Panacek EA: Airway management in the emergency department: A one-year study of 610 tracheal intubations. Ann Emerg Med March 1998;31:325-332.]

Section snippets

INTRODUCTION

Rapid and safe control of the airway is paramount to the successful management of critically ill and injured patients in the emergency department. An early study on ED intubations reported an alarmingly high complication rate for endotracheal intubations.¹ The authors suggested that complications could be minimized if house officers performing endotracheal intubations received “formalized training” in airway management. They also speculated that complications could be reduced with the “more

MATERIALS AND METHODS

The University of California-Davis, Medical Center is a Level I trauma center with an annual ED census of approximately 60,000 patients. There is a fully accredited, 3-year emergency medicine residency program with 8 to 10 residents in each year. The ED is staffed full-time with emergency medicine residents and attending physicians. Approximately 30% of all patients brought to the ED arrive by ground ambulance or aeromedical transport. About 300 patients per year arrive in the ED intubated by

RESULTS

During the 1-year study period approximately 61,000 patients were seen in the ED, and endotracheal intubation was attempted in 610 patients (1.0%). A total of 538 data collection forms were filled out prospectively by the intubators (88.2% compliance). The data for the remaining 72 intubations (11.8%) were retrospectively obtained by one of the authors from the medical record. Dictated procedure notes were obtained for 217 (35.6%) of the patients intubated and were compared with the information

DISCUSSION

With the development of emergency medicine as a recognized medical specialty, emergency airway management has become an essential skill for emergency physicians. There has been remarkably little literature describing the airway management skills of emergency physicians in an ED setting. We undertook this study to determine airway management practices in a busy urban ED staffed full-time with emergency medicine residents and attending physicians. We sought to determine the methods of intubation

Acknowledgements

The authors would like to express their gratitude to the emergency medicine residents at the University of California, Davis, Medical Center for their cooperation in filling out the intubation data collection forms for this study.

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A retrospective cohort study was conducted on a database of 469 patients having undergone emergent intubation with either etomidate or ketamine induction at a large academic health system. Patients were identified by automatic query of the electronic health records from 1/1/2016–6/30/2019. Exclusion criteria were patients <18-years-old, tracheal intubation performed outside of the ED, incomplete peri-intubation vital signs, or cardiac arrest prior to intubation. Patients at high risk for hemodynamic collapse in the post-intubation period were identified by a pre-intubation SI > 0.9. The primary outcome was the incidence of post-intubation hypotension (systolic blood pressure < 90 mmHg or mean arterial pressure < 65 mmHg). Secondary outcomes included post-intubation vasopressor use and mortality. These analyses were performed on the full cohort and an exploratory analysis in patients with SI > 0.9. We also report adjusted odds ratios (aOR) from a multivariable logistic regression model of the entire cohort controlling for plausible confounding variables to determine independent factors associated with post-intubation hypotension.
A total of 358 patients were included (etomidate: 272; ketamine: 86). The mean pre-intubation SI was higher in the group that received ketamine than etomidate, (0.97 vs. 0.83, difference: −0.14 (95%, CI -0.2 to −0.1). The incidence of post-intubation hypotension was greater in the ketamine group prior to SI stratification (difference: −10%, 95% CI −20.9% to −0.1%). Emergency physicians were more likely to use ketamine in patients with SI > 0.9. In our multivariate logistic regression analysis, choice of induction agent was not associated with post-intubation hypotension (aOR 1.45, 95% CI 0.79 to 2.65). We found that pre-intubation shock index was the strongest predictor of post-intubation hypotension.
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^☆: From the Division of Emergency Medicine, University of California, Davis, Medical Center University of California, Davis, School of Medicine Sacramento, CA.

^☆☆: Reprint no. 47/1/88183

^★: Address for reprints: John C Sakles, MD, Division of Emergency Medicine, University of California, Davis, Medical Center, PSSB, Suite 2100, 2315 Stockton Boulevard Sacramento, California 95817, 916-734-8574, Fax 916-734-7950, E-mail [email protected]

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Airway Management in the Emergency Department: A One-Year Study of 610 Tracheal Intubations☆,☆☆,★

Abstract

Section snippets

INTRODUCTION

MATERIALS AND METHODS

RESULTS

DISCUSSION

Acknowledgements

Chest

Am J Emerg Med

J Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

J Emerg Med

J Emerg Med

Ann Emerg Med

J Emerg Med

Complication rate of emergency department intubations: First report of the National Emergency Airway Registry (NEAR) [abstract]

Acad Emerg Med

Comparison of rapid-sequence intubation with conscious sedation or awake intubation in the ED [abstract]

Acad Emerg Med