Endotracheal intubation by paramedics during in-hospital CPR

To examine whether well-trained paramedics can perform emergent, successful, uncomplicated, endotracheal intubations during in-hospital cardiopulmonary resuscitation (CPR).

Retrospective review of medical records of in-patients undergoing emergent, endotracheal intubations during in-hospital, CPR over 8 months, with comparison of the performance of the paramedics against that of other hospital-based personnel.

A 437-bed Midwestern community teaching hospital.

Adult in-patients in general medical/surgical wards.

The rapidity of response of paramedics and other medical personnel to a cardiorespiratory arrest (code 4) announcement, and reported difficulties, success rate, rapidity, and complications of endotracheal intubation.

In the 47 cardiorespiratory arrests requiring intubation that we analyzed, the median response times (with values in parentheses representing interquartile range [IQR]) for paramedics, nurse anesthetists (CRNAs), anesthesiologists, and other physicians respectively, were 2.00 (4.25), 4.00 (2.0), 4.00 (15.0), and 7.00 (8.0) min, requiring a median of 1.0 attempt for all groups (mean values, 1.4, 1.125, 1.0, and 1.4 respectively) to place an endotracheal tube. The paramedics were successful in 13 of 15 instances. Median times (seconds) required for intubation by various groups (same order as response times, with IQR given in parentheses) were 60 (30), 150 (270), 45 (30), and 60 (30). Difficulties were reported by all groups, including patients' resistance to intubation, airway obstruction by extraneous material, and difficulty in visualizing the glottis. Reported complications (4%) were confined to groups other than the paramedics.

Paramedics can successfully, and without undue difficulty or complications, place endotracheal tubes during in-hospital CPR. Appropriately trained paramedics may be incorporated into hospital-based CPR teams in two contexts: (1) to provide an acceptable, long-term solution to the scarcity of personnel highly skilled in endotracheal tube placement during in-hospital CPR, and (2) to fulfill the need for hospitals to have on-site, qualified professionals to perform emergent endotracheal intubation during CPR. In the latter situation, personnel skilled in airway management could supplement the paramedics on demand. Further investigation in this area could be fruitful in view of the small sample size covered in this study.