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

To determine the incidence of unrecognized, misplaced endotracheal tubes inserted by paramedics in a large urban, decentralized emergency medical services (EMS) system.

We conducted a prospective, observational study of patients intubated in the field by paramedics before emergency department arrival. During an 8-month period, emergency physicians assessed tube position at ED arrival using a combination of auscultation, end-tidal carbon dioxide (ETCO(2)) monitoring, and direct laryngoscopy.

A total of 108 intubated patients were studied. On arrival in the ED, 25% (27/108) of patients were found to have improperly placed endotracheal tubes. Of the misplaced tubes, 67% (18/27) were found to be in the esophagus, whereas in 33% (9/27), the tip of the tube was found to be in the hypopharynx, above the vocal cords. Of the patients with misplaced tubes noted in the hypopharynx, 33% (3/9) died while in the ED. For the patients found to have tubes in the hypopharynx, 56% (5/9) had evidence of ETCO(2) on ED arrival. For the patients found to have esophageal tube placement on ED arrival, 56% (10/18) died in the ED. Esophageal intubation was associated with an absence of expired CO(2) (17/18, 94%) on ED arrival. The single patient in this subset with a recordable ETCO(2) had been nasotracheally intubated with the tip of the endotracheal tube noted in the esophagus while spontaneous respirations were present. On patient arrival to the ED, 63% (68/108) of the patients had direct laryngoscopy in addition to ETCO(2) determination. All patients had ETCO(2) evaluation performed on arrival. All patients in whom an absence of ETCO(2) was demonstrated on patient arrival underwent direct laryngoscopy. In cases in which direct laryngoscopy was not performed, the attending physician documented the ETCO(2) in conjunction with the presence of bilateral breath sounds.

The incidence of out-of-hospital, unrecognized, misplaced endotracheal 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.