Misplaced endotracheal tubes by paramedics in an urban emergency medical services system

Study objective: To determine the incidence of unrecognized, misplaced endo tracheal tubes inserted by paramedics in a large urban, decentralized emerg ency medical services (EMS) system. Methods: We conducted a prospective, observational study of patients intuba ted in the field by paramedics before emergency department arrival. During an 8-month period, emergency physicians assessed tube position at ED arriva l using a combination of auscultation, end-tidal carbon dioxide (ETCO2) mon itoring, and direct laryngoscopy. Results: A total of 108 intubated patients were studied. On arrival in the ED, 25% (27/108) of patients were found to have improperly placed endotrach eal tubes. Of the misplaced tubes, 67% (18/27) were found to be in the esop hagus, whereas in 33% (9/27), the tip of the tube was found to be in the hy popharynx, above the vocal cords. Of the patients with misplaced tubes note d in the hypopharynx, 33% (3/9) died while in the ED. Far the patients foun d to have tubes in the hypopharynx, 56% (5/9) had evidence of ETCO2 on ED a rrival. For the patients found to have esophageal tube placement on ED arri val, 56% (10/18) died in the ED. Esophageal intubation was associated with an absence of expired CO2 (17/18, 94%) on ED arrival. The sings patient in this subset with a recordable ETCO2 had been nasotracheally intubated with the tip of the endotracheal tube noted in the esophagus while spontaneous r espirations were present. On patient arrival to the ED, 63% (68/108) of the patients had direct laryngoscopy in addition to ETCO2 determination. All p atients had ETCO2 evaluation performed on arrival. All patients in whom an absence of ETCO2 was demonstrated on patient arrival underwent direct laryn goscopy. In cases in which direct laryngoscopy was not performed, the atten ding physician documented the ETCO2 in conjunction with the presence of bil ateral breath sounds. Conclusion: The incidence of out-of-hospital, unrecognized, misplaced endot racheal tubes in our community is excessively high and may be reflective of the incidence occurring in other communities. Data from other communities are needed to clarify the scope of this alarming issue.