Guideline on Treatment of Patients with Severe and Multiple ... - AWMF

S3 <strong>Guideline</strong> on Treatment of Patients with Severe and Multiple Injuries
Explanation:
In the prehospital and in-hospital phases, capnometry/capnography must always be used during
endotracheal intubation for monitoring the placement of the tube and then to reduce incidence of
dislocation and monitor ventilation. Capnography is an essential component here in monitoring
the intubated and ventilated patient [74]. Normoventilation should be carried out in
endotracheally intubated and anesthetized trauma patients. From emergency room treatment
onwards, ventilation must be monitored and controlled by frequent arterial blood gas analyses.
Capnography for monitoring tube placement and dislocation
The most serious complication in endotracheal intubation is an unrecognized esophageal
intubation, which can lead to the death of the patient. This is why, both prehospital and inhospital,
all methods must be applied to recognize esophageal intubation and remedy it
immediately.
The percentage of esophageal intubations reported in the literature starts at less than 1% [100,
106] spanning 2% [40], 6% [75], and reaching almost 17% [53]. Moreover, a high case fatality
rate was shown as a result of tube misplacement in the hypopharynx (33%) or in the esophagus
(56%) [53]. Esophageal intubation is thus not a rare event and, particularly in recent years,
various studies have examined this catastrophic complication of endotracheal intubation in
Germany as well. In a prospective observational study, helicopter emergency physicians trained
in anesthesiology identified an esophageal tube placement in 6 out of 84 (7.1%) trauma patients,
who had been intubated by land-based emergency physicians before arrival of the helicopter, and
an endobronchial tube placement in 11 (13.1%) [95]. The case fatality rate of esophageally
intubated patients was 80% in this study. In another prospective study with 598 patients in a
German emergency physician system, the rate of esophageal intubations by non-medical
personnel or physicians before arrival of the actual emergency physician system was 3.2% [92].
Another prospective observational study revealed esophageal intubation in 5.1% of 58 patients,
who had been intubated by the land-based emergency service or emergency physician before
arrival of the helicopter emergency physician trained in anesthesiology [43]. In a study focusing
on the admitting emergency room team, esophageal intubation was found in 4 out of 375
prehospital intubated and ventilated patients (1.1%) [41].
In a prospective observational study of 153 patients, evidence showed that none of the patients
who had been monitored by capnography had an unrecognized misplaced intubation, but 14 out
of the 60 patients (23.3%) not monitored by capnography had [83]. Capnography therefore
belongs in the standard equipment of the anesthesiology workplace and has dramatically
increased the safety of anesthesia.
In a prospective observational study with 81 patients (n = 58 severe traumatic brain injury [TBI],
n = 6 maxillofacial trauma, n = 17 multiple injuries), markedly greater sensitivity and specificity
was demonstrated by monitoring tube placement by capnography compared to auscultation only
(sensitivity: 100 versus 94%; specificity: 100 versus 66%, p < 0.01) [44]. These data prove that
capnography must always be used for monitoring tube placement.
Prehospital – Airway management, ventilation and emergency anesthesia 29