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December 9, 2004

BehindTheMedspeak: Emergency management of the airway in accidents with brain injury


For as long as I've been an anesthesiologist, it's been received knowledge, absolute fact, that the best airway in an emergency is an endotracheal tube.

It makes sense: a tube from an outside source of oxygen directly into the trachea, preventing foreign material from making its way into the lungs, seems bombproof.

But a new study, published last month in the Annals of Emergency Medicine, seems to show just the opposite.

Scientists from the University of Pittsburgh found that accident victims with brain injuries who had an endotracheal tube placed in the field had a death rate nearly four times higher than those intubated in the ER.

Moreover, pre-hospital-intubated patients were 61% more likely to have a poor neurological outcome and 92% more likely to have at least moderate functional impairment.

How can this be?


The same issue of the journal ran an editorial exploring this apparent conundrum.

The authors of the editorial were as puzzled as I was.

They concluded that the study by the Pittsburgh group was well conducted and that its results could not be dismissed.

They observed that the people inserting endotracheal tubes at accident scenes were, for the most part, paramedics working in very chaotic situations without the aid of anesthetics and specialized muscle relaxants available to emergency room physicians.

They noted that paramedics "have limited endotracheal intubation training and clinical skills and do not have access to the drugs used for Emergency Department intubations."


That has to be bottom line, in my opinion.

Intubating the trachea is deceptively simple.

Even after decades, I still occasionally misplace a tube and put it in the esophagus.

But that's no big deal - if you recognize it promptly and replace it correctly.

As my residency chairman said, more tellingly than I realized at the time, "It's never the first mistake that kills the patient."


True, truer, truest.

I can see how paramedics could fail to correctly intubate a patient, ventilate the stomach inadvertently, and end up with a brain-dead patient on arrival in the ER.

Doesn't make it right, but it makes it understandable.

But to tell them not to try to place a tube, and instead simply mask the unconscious patient, flies in the face of decades of experience, training, custom, and teaching.


It's going to be a while before the lessons of this landmark study take hold.

December 9, 2004 at 03:01 PM | Permalink


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i nominated this post for grand rounds, and it made it. hurrah!

2 mentions in grand rounds in the same day... you're on your way to your previous volume of readership ;)

Posted by: enoch choi | Dec 14, 2004 2:21:57 PM

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