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Avoid the Goose! Paramedic Identification of Esophageal Intubation by Ultrasound.
Prehosp Disaster Med. 2018 Aug; 33(4):406-410.PD

Abstract

OBJECTIVES

Rapid identification of esophageal intubations is critical to avoid patient morbidity and mortality. Continuous waveform capnography remains the gold standard for endotracheal tube (ETT) confirmation, but it has limitations. Point-of-care ultrasound (POCUS) may be a useful alternative for confirming ETT placement. The objective of this study was to determine the accuracy of paramedic-performed POCUS identification of esophageal intubations with and without ETT manipulation.

METHODS

A prospective, observational study using a cadaver model was conducted. Local paramedics were recruited as subjects and each completed a survey of their demographics, employment history, intubation experience, and prior POCUS training. Subjects participated in a didactic session in which they learned POCUS identification of ETT location. During each study session, investigators randomly placed an ETT in either the trachea or esophagus of four cadavers, confirmed with direct laryngoscopy. Subjects then attempted to determine position using POCUS both without and with manipulation of the ETT. Manipulation of the tube was performed by twisting the tube. Descriptive statistics and logistic regression were used to assess the results and the effects of previous paramedic experience.

RESULTS

During 12 study sessions, from March 2014 through December 2015, 57 subjects participated, evaluating a total of 228 intubations: 113 tracheal and 115 esophageal. Subjects were 84.0% male, mean age of 39 years (range: 22 - 62 years), with median experience of seven years (range: 0.6 - 39 years). Paramedics correctly identified ETT location in 158 (69.3%) cases without and 194 (85.1%) with ETT manipulation. The sensitivity and specificity of identifying esophageal location without ETT manipulation increased from 52.2% (95% confidence interval [CI], 43.0-61.0) and 86.7% (95% CI, 81.0-93.0) to 87.0% (95% CI, 81.0-93.0) and 83.2% (95% CI, 0.76-0.90) after manipulation (P<.0001), without affecting specificity (P=.45). Subjects correctly identified 41 previously incorrectly identified esophageal intubations. Paramedic experience, previous intubations, and POCUS experience did not correlate with ability to identify tube location.

CONCLUSION

Paramedics can accurately identify esophageal intubations with POCUS, and manipulation improves identification. Further studies of paramedic use of dynamic POCUS to identify inadvertent esophageal intubations are needed. LemaPC, O'BrienM, WilsonJ, St. JamesE, LindstromH, DeAngelisJ, CaldwellJ, MayP, ClemencyB. Avoid the goose! Paramedic identification of esophageal intubation by ultrasound. Prehosp Disaster Med. 2018;33(4):406-410.

Authors+Show Affiliations

1University at Buffalo Jacobs School of Medicine and Biomedical Sciences,Department of Emergency Medicine,Buffalo,New YorkUSA.1University at Buffalo Jacobs School of Medicine and Biomedical Sciences,Department of Emergency Medicine,Buffalo,New YorkUSA.2University of Colorado School of Medicine,University of Colorado Hospital Department of Emergency Medicine,Aurora,ColoradoUSA.1University at Buffalo Jacobs School of Medicine and Biomedical Sciences,Department of Emergency Medicine,Buffalo,New YorkUSA.1University at Buffalo Jacobs School of Medicine and Biomedical Sciences,Department of Emergency Medicine,Buffalo,New YorkUSA.3Cambridge Hospital Department of Emergency Medicine,Cambridge,MassachusettsUSA.1University at Buffalo Jacobs School of Medicine and Biomedical Sciences,Department of Emergency Medicine,Buffalo,New YorkUSA.4Roswell Park Cancer Institute,Applied Technology Laboratory for Advanced Surgery (ATLAS) Team,Buffalo,New YorkUSA.1University at Buffalo Jacobs School of Medicine and Biomedical Sciences,Department of Emergency Medicine,Buffalo,New YorkUSA.

Pub Type(s)

Journal Article
Observational Study

Language

eng

PubMed ID

30129915

Citation

Lema, Penelope C., et al. "Avoid the Goose! Paramedic Identification of Esophageal Intubation By Ultrasound." Prehospital and Disaster Medicine, vol. 33, no. 4, 2018, pp. 406-410.
Lema PC, O'Brien M, Wilson J, et al. Avoid the Goose! Paramedic Identification of Esophageal Intubation by Ultrasound. Prehosp Disaster Med. 2018;33(4):406-410.
Lema, P. C., O'Brien, M., Wilson, J., James, E. S., Lindstrom, H., DeAngelis, J., Caldwell, J., May, P., & Clemency, B. (2018). Avoid the Goose! Paramedic Identification of Esophageal Intubation by Ultrasound. Prehospital and Disaster Medicine, 33(4), 406-410. https://doi.org/10.1017/S1049023X18000651
Lema PC, et al. Avoid the Goose! Paramedic Identification of Esophageal Intubation By Ultrasound. Prehosp Disaster Med. 2018;33(4):406-410. PubMed PMID: 30129915.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Avoid the Goose! Paramedic Identification of Esophageal Intubation by Ultrasound. AU - Lema,Penelope C, AU - O'Brien,Michael, AU - Wilson,Juliana, AU - James,Erika St, AU - Lindstrom,Heather, AU - DeAngelis,John, AU - Caldwell,Jennifer, AU - May,Paul, AU - Clemency,Brian, PY - 2018/8/22/entrez PY - 2018/8/22/pubmed PY - 2018/12/12/medline KW - ACLS Advanced Cardiovascular Life Support KW - ED emergency department KW - ETT endotracheal tube KW - FAST focused assessment with sonography for trauma KW - NPV negative predictive value KW - OR operating room KW - POCUS point-of-care ultrasound KW - PPV positive predictive value KW - US ultrasound KW - emergency ultrasound KW - endotracheal tube KW - esophageal intubation KW - paramedic KW - prehospital SP - 406 EP - 410 JF - Prehospital and disaster medicine JO - Prehosp Disaster Med VL - 33 IS - 4 N2 - OBJECTIVES: Rapid identification of esophageal intubations is critical to avoid patient morbidity and mortality. Continuous waveform capnography remains the gold standard for endotracheal tube (ETT) confirmation, but it has limitations. Point-of-care ultrasound (POCUS) may be a useful alternative for confirming ETT placement. The objective of this study was to determine the accuracy of paramedic-performed POCUS identification of esophageal intubations with and without ETT manipulation. METHODS: A prospective, observational study using a cadaver model was conducted. Local paramedics were recruited as subjects and each completed a survey of their demographics, employment history, intubation experience, and prior POCUS training. Subjects participated in a didactic session in which they learned POCUS identification of ETT location. During each study session, investigators randomly placed an ETT in either the trachea or esophagus of four cadavers, confirmed with direct laryngoscopy. Subjects then attempted to determine position using POCUS both without and with manipulation of the ETT. Manipulation of the tube was performed by twisting the tube. Descriptive statistics and logistic regression were used to assess the results and the effects of previous paramedic experience. RESULTS: During 12 study sessions, from March 2014 through December 2015, 57 subjects participated, evaluating a total of 228 intubations: 113 tracheal and 115 esophageal. Subjects were 84.0% male, mean age of 39 years (range: 22 - 62 years), with median experience of seven years (range: 0.6 - 39 years). Paramedics correctly identified ETT location in 158 (69.3%) cases without and 194 (85.1%) with ETT manipulation. The sensitivity and specificity of identifying esophageal location without ETT manipulation increased from 52.2% (95% confidence interval [CI], 43.0-61.0) and 86.7% (95% CI, 81.0-93.0) to 87.0% (95% CI, 81.0-93.0) and 83.2% (95% CI, 0.76-0.90) after manipulation (P<.0001), without affecting specificity (P=.45). Subjects correctly identified 41 previously incorrectly identified esophageal intubations. Paramedic experience, previous intubations, and POCUS experience did not correlate with ability to identify tube location. CONCLUSION: Paramedics can accurately identify esophageal intubations with POCUS, and manipulation improves identification. Further studies of paramedic use of dynamic POCUS to identify inadvertent esophageal intubations are needed. LemaPC, O'BrienM, WilsonJ, St. JamesE, LindstromH, DeAngelisJ, CaldwellJ, MayP, ClemencyB. Avoid the goose! Paramedic identification of esophageal intubation by ultrasound. Prehosp Disaster Med. 2018;33(4):406-410. SN - 1945-1938 UR - https://www.unboundmedicine.com/medline/citation/30129915/Avoid_the_Goose_Paramedic_Identification_of_Esophageal_Intubation_by_Ultrasound_ L2 - https://www.cambridge.org/core/product/identifier/S1049023X18000651/type/journal_article DB - PRIME DP - Unbound Medicine ER -