- Email: [email protected]
Flight team management of in-place endotracheal tubes
Flight Team Management of In-place Endotracheal Tubes Michael A. Frakes, RN, BSN, CFRN, CCRN, EMTP, FP-C
ABSTRACT Introduction: Unintended misplacement or removal of the endotracheal tube (ETT) complicates the care of up to 18% of intubated patients. This project analyzed the incidence of such complications in patients transported by a flight program. Methods: 9-month analysis of all intubated patients transported by the flight team. Results: 340/926 patients transported were intubated. One extubation was unplanned and no patients were delivered to the receiving hospital with an esophageal or endobronchial ETT placement. After initial examination, 19/241 ETTs placed before flight team arrival were repositioned. Rates of misplacement on arrival at the receiving hospital and of unplanned extubation were significantly lower than those reported in the EMS or critical care literature. Conclusion: Flight teams have very low rates of unplanned extubation or undetected ETT misplacement when transporting intubated patients.
Introduction Endotracheal tube (ETT) events are common enough to merit special discussion in the current revision of the American Heart Association guidelines.1 An unplanned extubation causes airway trauma, leaves the airway unprotected, interrupts oxygenation and ventilation, and exposes the patient to the risks associated with intubation, including potential procedure failure. Bronchial intubation is not immediately lifethreatening but is associated with increased mortality and can lead to hypoxemia, atelectasis, pneumothorax, and, rarely, unnecessary chest tube placement.2,3 An undetected esophageal intubation can cause hypoxic injury and death.4 Adverse airway events can be a source of litigation expense. A closed claims analysis of anesthesia incidents from 1990 described a median payout of $200,000 (more than $254,000 in current dollars) for all adverse respiratory events, including esophageal intubation, endobronchial intubation, hypoventilation, and unplanned extubation. There is no more current report.4,5 The incidence of ETT misplacement is reported in anesthesia, critical care, and emergency medicine literature, but there is little information examining these complications in the unique environment in which helicopter flight teams operate. Patient movement is associated with ETT misplacement and removal, so the risk for complication might be higher for transport providers.1 This study was developed to determine the incidence of unplanned ETT removal at any time during transport and of endobronchial or nontracheal ETT placement
LIFE STAR/Hartford Hospital, Hartford, Conn. Address for correspondence: Michael A. Frakes, RN, BSN, CFRN, CCRN, EMTP, FP-C, LIFE STAR/Hartford Hospital, 80 Seymour St., P.O. Box 5037, Hartford, CT 06102-5037 Copyright 2002 by Air Medical Journal Associates 1067-991X/2002/$35.00 + 0 Reprint no. 74/1/129347 doi:10.1067/mmj.2002.129347
November-December 2002
29
on arrival at the receiving hospital. The data gathered also revealed the incidence of existing endobronchial or non-tracheal placements discovered and remedied by the flight team.
Methods The program operates 2 BK-117-A4 aircraft out of 2 bases, the tertiary care sponsor hospital and a Level II trauma center partner hospital. The fully integrated flight team includes a BSN prepared registered nurse, also licensed as a paramedic, partnered with a registered respiratory therapist who is dual licensed as an emergency medical technician - intermediate. For 9 months, dispatch records identified each flight in which the flight team reached the point of origin, and the transport chart for each of those flights was reviewed. A data collection tool was completed for every patient who was intubated for any portion of the transport, capturing descriptive information (adult vs pediatric, scene vs interhospital, intubated before arrival vs intubated by flight team), initial assessment of ETT position (tracheal, endobronchial, extra-tracheal), ETT position upon patient release at the receiving hospital, and unplanned extubation. Dispatch records and patient charts were produced with AeroMed v. 5.2a (1996-98 by Innovative Engineering, Lebanon, NH). Flight team practice standards require that ETT placement be evaluated and documented on initial examination for patients already intubated or immediately after intubation if the airway is captured after the flight team arrives. Auscultation of bilateral lung sounds and epigastric sounds, ETT depth, and continuous waveform capnography determine placement. ETT position also is confirmed by the flight team after each patient movement—on or off a stretcher, in or out of the aircraft, and onto the receiving hospital stretcher—and these confirmations are noted in the transport chart. ETT placement information for the study was taken from those entries. For this survey, endobronchial intubation was clinically defined as unequal lung sounds that improved with partial withdrawal of the ETT and esophageal intubation as inappropriate findings from auscultation of lungs and epigastrum, capnography, or direct visualization, followed by reintubation with resolution of those abnormal findings. The same methods and definitions were used to evaluate repositioned ETTs as for initial and ongoing assessments.
Results A total of 926 patients were transported in the study period, with 340 (36.7%) patients intubated for some period during their contact with the flight team. Of the intubated patients, 99 (29.1%) were intubated by the flight team and 241 (70.9%) by some other medical provider. Scene flights accounted for 112 (32.9%) of the intubated patients; 228 (67.1%) were transported between medical facilities. Patients with medical diagnoses were 176 (51.8%) of intubated patients, with a trauma diagnosis for 164 (48.2%). Sixty-five (19.1%) of the intubated patients transported during the study were 16 years old or older. No patient was delivered to the receiving hospital with an esophageal, hypopharyngeal, or endobronchial ETT placement. One unplanned extubation (0.3%), resulted from the 30
collapse of a sending hospital stretcher being used to transport the helicopter litter and patient. The flight nurse successfully reintubated the patient. In the 241 patients intubated before flight team arrival, the flight team repositioned 19 (7.9%) ETTs found in place: 16 for endobronchial placement and 1 each for esophageal placement, hypopharyngeal placement, and overwhelming air leak. Neither scene (3/33 = 9.1%) versus hospital origin (13/208 = 6.3%) nor pediatric (6/56 = 10.7%) versus adult (10/185 = 5.4%) age had a significant association with endobronchial placement of an in-place ETT. Intubation by scene providers (2/33 = 6.1%), as opposed to in-hospital providers (0/208), was associated with nontracheal ETT placement (P < 0.05).
Discussion The flight team had no esophageal, pharyngeal, or endobronchial ETT misplacements on arrival at the receiving hospital and had a very low rate of unplanned extubation. There is a limited body of literature available for comparison and none from the air medical environment. Unplanned extubation is reported at rates between 11.4% and 17.1% in the intensive care unit and may be as high as 14.5% for out-of hospital patients.6-8 Katz and Falk9 report an 8.3% hypopharyngeal ETT placement rate on ED arrival of EMS patients, which could be interpreted as an 8.3% rate of unplanned extubation. The 0.3% incidence in this series was significantly lower than even that report (P < 0.001). Bronchial ETT placement accounts for 3.7% of reported anesthesia incidents.2 Out-of-hospital incidence is reported between 7% and 18%. 8,10 The absence of endobronchial placement on arrival at the receiving hospital in this series was significantly lower than the available out-of-hospital reports (P < 0.001). Undetected esophageal intubation represents 15% of catastrophic anesthesia incidents.2 For EMS patients, the incidence is reported between 0.4% and 16.7%.8,9,11-16 The absence of undetected esophageal intubation on arrival at the receiving hospital in this series was significantly lower than that of the pooled incidence (1.8%) from all of the EMS reports (P < 0.03). The reasons for the lower incidence of misplacements found in this series can only be speculative and need to be borne out by other studies. Important factors might include critical care transport experience, a high frequency of transporting intubated patients, and the presence of strict standards for continuous monitoring and frequent reassessment. Staffing factors that may be of import are the 2:1 provider:patient ratio in the aircraft and the relatively unique presence on every flight of a Registered Respiratory Therapist with particular expertise and sensitivity for airway issues. Continuous waveform capnography does not prevent unplanned extubation or detect endobronchial placement, but it does help rapidly detect extrabronchial placement. It would be interesting to compare these results with those from programs with other crew configurations, patient mixes, and volumes. The incidence of patients with detected and corrected ETT Air Medical Journal 21:6
misplacements emphasizes the need for a careful initial examination by the flight team when assuming care for patients at either scenes or sending hospitals. The low complication rates and number of patients in which ETT position was improved suggest that a number of complications may have been prevented by flight team involvement in transport. It is, of course, impossible to determine the frequency, sequelae, or cost of those complications had the flight team not become involved. There are a number of limitations to this study. First, the operational definitions for endobronchial and esophageal intubations are imperfect. Chest radiograph is the gold standard for detecting ETT placement, but it is not available for out-ofhospital intubations and is time consuming in the hospital. Auscultation of the epigastrum and both lungs may be 100% reliable in excluding esophageal ETT placement, while capnography is 93% sensitive overall for esophageal ETT placement and 100% for patients with a pulse.19,20 Direct visualization of the glottic opening, when possible, is also 100% sensitive for correct placement. With all of these options available, the ability to determine esophageal placement without radiology seems satisfactory. It is more difficult to rule out endobronchial placement without radiology. Capnometry is not helpful, so auscultation and observation of the chest wall are the only tools available out of the hospital, and they are not completely reliable. 17-19 Our operational definition of improved lung sounds with partial withdrawal of the ETT clinically correlates with an improved endobronchial placement and closely parallels the guidelines for detection and management of endobronchial ETT placement articulated in the standards for the Neonatal Resuscitation Program.21 The definition also indicates aeration of both lungs, implying placement no lower than just below the carina. Accordingly, although this clinical determination of endobronchial placement may underrepresent imperfect ETT placement, it should exclude frank endobronchial placement. We deliver patients to a large number of receiving hospitals and to a number of units in each of those hospitals, so radiological confirmation of final ETT placement was not possible. For those patients who were delivered to the ED of either sponsor hospital and had an immediate chest radiograph there, none were found with bronchial intubation. A second limitation is that the small n for repositioned ETTs limits the power of those results. The 7.9% incidence of ETTs found misplaced was not expected when the survey was designed and analysis of repositioning events was a post-hoc addition to the project, so the data collection period limited opportunities for discovering those events. A larger, focused study of these events would be useful. Additionally, the comparisons of our results with inpatient units, anesthesia reports, and emergency medicine settings are not necessarily direct. Similarly, the duration of patient care for the flight team is generally shorter than in other settings and may decrease the opportunities for unintended position change. This report seems to be the first from the air medical environment, so the comparisons used are the best available. November-December 2002
Conclusion Flight teams have very low rates of unplanned extubation or undetected ETT misplacement when transporting intubated patients. These teams also may have a role in improving the placement of previously placed ETTs. Additional evaluation of the factors that contribute to the low rates of complication would be useful, as would a more comprehensive analysis of the number of misplaced existing ETTs discovered by the flight team.
References 1. Hazinski MF, Cummins RO, Field JM, eds. Handbook of emergency cardiovascular care for healthcare providers. Dallas: American Heart Association; 2001. 2. McCoy EP, Russell WJ, Webb RK. Accidental bronchial intubation: an analysis of AIMS incident reports from 1988 to 1994. Anesthesia 1997;52:714-5. 3. Perez L, Klofas E. Unrecognized right endobronchial intubation causing total lung collapse in a pediatric trauma patient. Am J Emerg Med 2000;18:355-6. 4. Caplan RA, Posner KL, Ward RJ, et al. Adverse respiratory events in anesthesia. Anesthesiology 1990;72:828-33. 5. U.S. Department of Labor, Bureau of Labor Statistics. Consumer price indexes. Available at: www.bls.gov/cpi/home.htm. Accessed February 14, 2002. 6. Chevron V. Unplanned extubation. Crit Care Med 1998;26:1049-53. 7. Carrion MI. Accidental removal of endotracheal and nasogastric tubes and intravascular catheters. Crit Care Med 2000;28:63-6. 8. Gausche M, Lewis RJ, Stratton SJ, et al. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome. JAMA 2000;283:783-90. 9. Katz SH, Falk JL. Misplaced endotracheal tubes by paramedics in an urban emergency medical services system. Ann Emerg Med 2001;37:32-7. 10. Bissinger U, Lenz G, Kuhn W. Unrecognized endobronchial intubation of emergency patients. Ann Emerg Med 1989;18(8):853-5. 11. Jenkins WA, Verdile VP, Paris PM. The syringe aspiration technique to verify endotracheal tube position. Am J Emerg Med 1994;12:413-6. 12. Bozeman WP, Hexter D, Liang HK, et al. Esophageal detector device versus detection of end-tidal carbon dioxide level in emergency intubation. Ann Emerg Med 1996;27:595-9. 13. Steward RD, Paris PM, Winter PM, et al. Field endotracheal intubation by paramedical personnel. Chest 1984;85:341-5. 14. Sayre MR, Sackles JC, Mistler AF, et al. Field trial of intubation by basic EMT’s. Ann Emerg Med 1998;31:228-31. 15. Pointer JE. Clinical characteristics of paramedic performance of endotracheal intubation. J Emerg Med 1988;6:505-9. 16. Vilke GM, Steen PJ, Smith AM, et al. Out-of-hospital pediatric intubation by paramedics: The San Diego experience. J Emerg Med 2002;22(1):71-4. 17. Owen RL, Cheney FW. Endobronchial intubation: a preventable complication. Anesthesiology 1987;67:255-7. 18. Brunel W, Coleman DL, Schwartz DE, et al. Assessment of routine chest roentgenograms and the physical examination to confirm endotracheal tube position. Chest 1989;96:1043-5. 19. Frakes MA. Measuring end-tidal carbon dioxide: clinical applications and usefulness. Crit Care Nurse 2001;21(5):23-37. 20. Andersen KH. Assessing the position of the tracheal tube. The reliability of different methods. Anesthesiology 1989;44:984-5. 21. Kattwinkel J, ed. Textbook of neonatal resuscitation. 4th ed. Dallas: American Heart Association/American Academy of Pediatrics; 2000.
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ABSTRACT Introduction: Unintended misplacement or removal of the endotracheal tube (ETT) complicates the care of up to 18% of intubated patients. This project analyzed the incidence of such complications in patients transported by a flight program. Methods: 9-month analysis of all intubated patients transported by the flight team. Results: 340/926 patients transported were intubated. One extubation was unplanned and no patients were delivered to the receiving hospital with an esophageal or endobronchial ETT placement. After initial examination, 19/241 ETTs placed before flight team arrival were repositioned. Rates of misplacement on arrival at the receiving hospital and of unplanned extubation were significantly lower than those reported in the EMS or critical care literature. Conclusion: Flight teams have very low rates of unplanned extubation or undetected ETT misplacement when transporting intubated patients.
Introduction Endotracheal tube (ETT) events are common enough to merit special discussion in the current revision of the American Heart Association guidelines.1 An unplanned extubation causes airway trauma, leaves the airway unprotected, interrupts oxygenation and ventilation, and exposes the patient to the risks associated with intubation, including potential procedure failure. Bronchial intubation is not immediately lifethreatening but is associated with increased mortality and can lead to hypoxemia, atelectasis, pneumothorax, and, rarely, unnecessary chest tube placement.2,3 An undetected esophageal intubation can cause hypoxic injury and death.4 Adverse airway events can be a source of litigation expense. A closed claims analysis of anesthesia incidents from 1990 described a median payout of $200,000 (more than $254,000 in current dollars) for all adverse respiratory events, including esophageal intubation, endobronchial intubation, hypoventilation, and unplanned extubation. There is no more current report.4,5 The incidence of ETT misplacement is reported in anesthesia, critical care, and emergency medicine literature, but there is little information examining these complications in the unique environment in which helicopter flight teams operate. Patient movement is associated with ETT misplacement and removal, so the risk for complication might be higher for transport providers.1 This study was developed to determine the incidence of unplanned ETT removal at any time during transport and of endobronchial or nontracheal ETT placement
LIFE STAR/Hartford Hospital, Hartford, Conn. Address for correspondence: Michael A. Frakes, RN, BSN, CFRN, CCRN, EMTP, FP-C, LIFE STAR/Hartford Hospital, 80 Seymour St., P.O. Box 5037, Hartford, CT 06102-5037 Copyright 2002 by Air Medical Journal Associates 1067-991X/2002/$35.00 + 0 Reprint no. 74/1/129347 doi:10.1067/mmj.2002.129347
November-December 2002
29
on arrival at the receiving hospital. The data gathered also revealed the incidence of existing endobronchial or non-tracheal placements discovered and remedied by the flight team.
Methods The program operates 2 BK-117-A4 aircraft out of 2 bases, the tertiary care sponsor hospital and a Level II trauma center partner hospital. The fully integrated flight team includes a BSN prepared registered nurse, also licensed as a paramedic, partnered with a registered respiratory therapist who is dual licensed as an emergency medical technician - intermediate. For 9 months, dispatch records identified each flight in which the flight team reached the point of origin, and the transport chart for each of those flights was reviewed. A data collection tool was completed for every patient who was intubated for any portion of the transport, capturing descriptive information (adult vs pediatric, scene vs interhospital, intubated before arrival vs intubated by flight team), initial assessment of ETT position (tracheal, endobronchial, extra-tracheal), ETT position upon patient release at the receiving hospital, and unplanned extubation. Dispatch records and patient charts were produced with AeroMed v. 5.2a (1996-98 by Innovative Engineering, Lebanon, NH). Flight team practice standards require that ETT placement be evaluated and documented on initial examination for patients already intubated or immediately after intubation if the airway is captured after the flight team arrives. Auscultation of bilateral lung sounds and epigastric sounds, ETT depth, and continuous waveform capnography determine placement. ETT position also is confirmed by the flight team after each patient movement—on or off a stretcher, in or out of the aircraft, and onto the receiving hospital stretcher—and these confirmations are noted in the transport chart. ETT placement information for the study was taken from those entries. For this survey, endobronchial intubation was clinically defined as unequal lung sounds that improved with partial withdrawal of the ETT and esophageal intubation as inappropriate findings from auscultation of lungs and epigastrum, capnography, or direct visualization, followed by reintubation with resolution of those abnormal findings. The same methods and definitions were used to evaluate repositioned ETTs as for initial and ongoing assessments.
Results A total of 926 patients were transported in the study period, with 340 (36.7%) patients intubated for some period during their contact with the flight team. Of the intubated patients, 99 (29.1%) were intubated by the flight team and 241 (70.9%) by some other medical provider. Scene flights accounted for 112 (32.9%) of the intubated patients; 228 (67.1%) were transported between medical facilities. Patients with medical diagnoses were 176 (51.8%) of intubated patients, with a trauma diagnosis for 164 (48.2%). Sixty-five (19.1%) of the intubated patients transported during the study were 16 years old or older. No patient was delivered to the receiving hospital with an esophageal, hypopharyngeal, or endobronchial ETT placement. One unplanned extubation (0.3%), resulted from the 30
collapse of a sending hospital stretcher being used to transport the helicopter litter and patient. The flight nurse successfully reintubated the patient. In the 241 patients intubated before flight team arrival, the flight team repositioned 19 (7.9%) ETTs found in place: 16 for endobronchial placement and 1 each for esophageal placement, hypopharyngeal placement, and overwhelming air leak. Neither scene (3/33 = 9.1%) versus hospital origin (13/208 = 6.3%) nor pediatric (6/56 = 10.7%) versus adult (10/185 = 5.4%) age had a significant association with endobronchial placement of an in-place ETT. Intubation by scene providers (2/33 = 6.1%), as opposed to in-hospital providers (0/208), was associated with nontracheal ETT placement (P < 0.05).
Discussion The flight team had no esophageal, pharyngeal, or endobronchial ETT misplacements on arrival at the receiving hospital and had a very low rate of unplanned extubation. There is a limited body of literature available for comparison and none from the air medical environment. Unplanned extubation is reported at rates between 11.4% and 17.1% in the intensive care unit and may be as high as 14.5% for out-of hospital patients.6-8 Katz and Falk9 report an 8.3% hypopharyngeal ETT placement rate on ED arrival of EMS patients, which could be interpreted as an 8.3% rate of unplanned extubation. The 0.3% incidence in this series was significantly lower than even that report (P < 0.001). Bronchial ETT placement accounts for 3.7% of reported anesthesia incidents.2 Out-of-hospital incidence is reported between 7% and 18%. 8,10 The absence of endobronchial placement on arrival at the receiving hospital in this series was significantly lower than the available out-of-hospital reports (P < 0.001). Undetected esophageal intubation represents 15% of catastrophic anesthesia incidents.2 For EMS patients, the incidence is reported between 0.4% and 16.7%.8,9,11-16 The absence of undetected esophageal intubation on arrival at the receiving hospital in this series was significantly lower than that of the pooled incidence (1.8%) from all of the EMS reports (P < 0.03). The reasons for the lower incidence of misplacements found in this series can only be speculative and need to be borne out by other studies. Important factors might include critical care transport experience, a high frequency of transporting intubated patients, and the presence of strict standards for continuous monitoring and frequent reassessment. Staffing factors that may be of import are the 2:1 provider:patient ratio in the aircraft and the relatively unique presence on every flight of a Registered Respiratory Therapist with particular expertise and sensitivity for airway issues. Continuous waveform capnography does not prevent unplanned extubation or detect endobronchial placement, but it does help rapidly detect extrabronchial placement. It would be interesting to compare these results with those from programs with other crew configurations, patient mixes, and volumes. The incidence of patients with detected and corrected ETT Air Medical Journal 21:6
misplacements emphasizes the need for a careful initial examination by the flight team when assuming care for patients at either scenes or sending hospitals. The low complication rates and number of patients in which ETT position was improved suggest that a number of complications may have been prevented by flight team involvement in transport. It is, of course, impossible to determine the frequency, sequelae, or cost of those complications had the flight team not become involved. There are a number of limitations to this study. First, the operational definitions for endobronchial and esophageal intubations are imperfect. Chest radiograph is the gold standard for detecting ETT placement, but it is not available for out-ofhospital intubations and is time consuming in the hospital. Auscultation of the epigastrum and both lungs may be 100% reliable in excluding esophageal ETT placement, while capnography is 93% sensitive overall for esophageal ETT placement and 100% for patients with a pulse.19,20 Direct visualization of the glottic opening, when possible, is also 100% sensitive for correct placement. With all of these options available, the ability to determine esophageal placement without radiology seems satisfactory. It is more difficult to rule out endobronchial placement without radiology. Capnometry is not helpful, so auscultation and observation of the chest wall are the only tools available out of the hospital, and they are not completely reliable. 17-19 Our operational definition of improved lung sounds with partial withdrawal of the ETT clinically correlates with an improved endobronchial placement and closely parallels the guidelines for detection and management of endobronchial ETT placement articulated in the standards for the Neonatal Resuscitation Program.21 The definition also indicates aeration of both lungs, implying placement no lower than just below the carina. Accordingly, although this clinical determination of endobronchial placement may underrepresent imperfect ETT placement, it should exclude frank endobronchial placement. We deliver patients to a large number of receiving hospitals and to a number of units in each of those hospitals, so radiological confirmation of final ETT placement was not possible. For those patients who were delivered to the ED of either sponsor hospital and had an immediate chest radiograph there, none were found with bronchial intubation. A second limitation is that the small n for repositioned ETTs limits the power of those results. The 7.9% incidence of ETTs found misplaced was not expected when the survey was designed and analysis of repositioning events was a post-hoc addition to the project, so the data collection period limited opportunities for discovering those events. A larger, focused study of these events would be useful. Additionally, the comparisons of our results with inpatient units, anesthesia reports, and emergency medicine settings are not necessarily direct. Similarly, the duration of patient care for the flight team is generally shorter than in other settings and may decrease the opportunities for unintended position change. This report seems to be the first from the air medical environment, so the comparisons used are the best available. November-December 2002
Conclusion Flight teams have very low rates of unplanned extubation or undetected ETT misplacement when transporting intubated patients. These teams also may have a role in improving the placement of previously placed ETTs. Additional evaluation of the factors that contribute to the low rates of complication would be useful, as would a more comprehensive analysis of the number of misplaced existing ETTs discovered by the flight team.
References 1. Hazinski MF, Cummins RO, Field JM, eds. Handbook of emergency cardiovascular care for healthcare providers. Dallas: American Heart Association; 2001. 2. McCoy EP, Russell WJ, Webb RK. Accidental bronchial intubation: an analysis of AIMS incident reports from 1988 to 1994. Anesthesia 1997;52:714-5. 3. Perez L, Klofas E. Unrecognized right endobronchial intubation causing total lung collapse in a pediatric trauma patient. Am J Emerg Med 2000;18:355-6. 4. Caplan RA, Posner KL, Ward RJ, et al. Adverse respiratory events in anesthesia. Anesthesiology 1990;72:828-33. 5. U.S. Department of Labor, Bureau of Labor Statistics. Consumer price indexes. Available at: www.bls.gov/cpi/home.htm. Accessed February 14, 2002. 6. Chevron V. Unplanned extubation. Crit Care Med 1998;26:1049-53. 7. Carrion MI. Accidental removal of endotracheal and nasogastric tubes and intravascular catheters. Crit Care Med 2000;28:63-6. 8. Gausche M, Lewis RJ, Stratton SJ, et al. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome. JAMA 2000;283:783-90. 9. Katz SH, Falk JL. Misplaced endotracheal tubes by paramedics in an urban emergency medical services system. Ann Emerg Med 2001;37:32-7. 10. Bissinger U, Lenz G, Kuhn W. Unrecognized endobronchial intubation of emergency patients. Ann Emerg Med 1989;18(8):853-5. 11. Jenkins WA, Verdile VP, Paris PM. The syringe aspiration technique to verify endotracheal tube position. Am J Emerg Med 1994;12:413-6. 12. Bozeman WP, Hexter D, Liang HK, et al. Esophageal detector device versus detection of end-tidal carbon dioxide level in emergency intubation. Ann Emerg Med 1996;27:595-9. 13. Steward RD, Paris PM, Winter PM, et al. Field endotracheal intubation by paramedical personnel. Chest 1984;85:341-5. 14. Sayre MR, Sackles JC, Mistler AF, et al. Field trial of intubation by basic EMT’s. Ann Emerg Med 1998;31:228-31. 15. Pointer JE. Clinical characteristics of paramedic performance of endotracheal intubation. J Emerg Med 1988;6:505-9. 16. Vilke GM, Steen PJ, Smith AM, et al. Out-of-hospital pediatric intubation by paramedics: The San Diego experience. J Emerg Med 2002;22(1):71-4. 17. Owen RL, Cheney FW. Endobronchial intubation: a preventable complication. Anesthesiology 1987;67:255-7. 18. Brunel W, Coleman DL, Schwartz DE, et al. Assessment of routine chest roentgenograms and the physical examination to confirm endotracheal tube position. Chest 1989;96:1043-5. 19. Frakes MA. Measuring end-tidal carbon dioxide: clinical applications and usefulness. Crit Care Nurse 2001;21(5):23-37. 20. Andersen KH. Assessing the position of the tracheal tube. The reliability of different methods. Anesthesiology 1989;44:984-5. 21. Kattwinkel J, ed. Textbook of neonatal resuscitation. 4th ed. Dallas: American Heart Association/American Academy of Pediatrics; 2000.
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