The Importance of First Pass Success When Performing Orotracheal Intubation in the Emergency Department

Abstract

Objectives The goal of this study was to determine the association of first pass success with the incidence of adverse events (AEs) during emergency department (ED) intubations. Methods This was a retrospective analysis of prospectively collected continuous quality improvement data based on orotracheal intubations performed in an academic ED over a 4-year period. Following each intubation, the operator completed a data form regarding multiple aspects of the intubation, including patient and operator characteristics, method of intubation, device used, the number of attempts required, and AEs. Numerous AEs were tracked and included events such as witnessed aspiration, oxygen desaturation, esophageal intubation, hypotension, dysrhythmia, and cardiac arrest. Multivariable logistic regression was used to assess the relationship between the primary predictor variable of interest, first pass success, and the outcome variable, the presence of one or more AEs, after controlling for various other potential risk factors and confounders. Results Over the 4-year study period, there were 1,828 orotracheal intubations. If the intubation was successful on the first attempt, the incidence of one or more AEs was 14.2% (95% confidence interval [CI] = 12.4% to 16.2%). In cases requiring two attempts, the incidence of one or more AEs was 47.2% (95% CI = 41.8% to 52.7%); in cases requiring three attempts, the incidence of one or more AEs was 63.6% (95% CI = 53.7% to 72.6%); and in cases requiring four or more attempts, the incidence of one or more AEs was 70.6% (95% CI = 56.2.3% to 82.5%). Multivariable logistic regression showed that more than one attempt at tracheal intubation was a significant predictor of one or more AEs (adjusted odds ratio [aOR] = 7.52, 95% CI = 5.86 to 9.63). Conclusions When performing orotracheal intubation in the ED, first pass success is associated with a relatively small incidence of AEs. As the number of attempts increases, the incidence of AEs increases substantially.

Distinguishing tracheal and esophageal tissues with hyperspectral imaging and fiber-optic sensing

“…Even successful intubations, if delayed or performed poorly, can still encounter major adverse events, such as cardiac arrest, hypotension, hypoxemia, or asphyxiation due to patient aspiration. [2][3][4] Furthermore, multiple attempts at ETI have been shown to significantly increase the probability of these adverse events, jumping from 14.2% on the first attempt success to 47.2% on the second attempt, to 63.6% chance of adverse events if three attempts were made. 3 In addition to the number of attempts, the time to intubation also adds risk to patient outcomes with longer intubation times leading to extended oxygen deprivation, which has been associated with worse long-term outcomes for traumatic brain injury patients.…”

Updating our approach to the difficult and failed airway: time to “stop and think”

“…12 Further, our emergency medicine colleagues have taught that cricothyrotomy is not a surrogate measure of failure in airway management, but rather a sound and logical component of an airway strategy. 13 In competent hands, failed airways are rare, and the need for a surgical airway is rarer still. Henceforth, the clinician performing an emergency ''cric'' -after properly preparing and exhausting reasonable alternatives-should be considered to have expertly managed the situation.…”

“…12 En outre, nos collègues de médecine d'urgence ont enseigné que la cricothyrotomie n'est pas une mesure de remplacement en cas d'échec de la gestion des voies aériennes, mais plutôt un élément rationnel et logique d'une stratégie pour les voies aériennes. 13 L'échec de la maîtrise des voies aériennes est rare entre des mais compétentes et le recours à une voie aérienne chirurgicale est encore plus rare. Dorénavant, le clinicien effectuant une « trachéo » d'urgence, après une préparation adaptée et l'épuisement de toutes les alternatives raisonnables, doit être vu comme ayant géré la situation d'une main experte.…”

Notfallnarkose beim Erwachsenen

“…Dabei hat sich in den letzten Jahren ein Paradigmenwechsel vollzogen: Wäh-rend in den vergangenen Jahrzehnten die Muskelrelaxation kontrovers diskutiert wurde [4,5], insbesondere vor dem Hintergrund von "Cannot-ventilate-cannot-intubate"-Situationen, steht heute der "first-pass success", d. h. die endotracheale Intubation und damit Atemwegssicherung möglichst im ersten Intubationsversuch im Vordergrund [1,6]. Dies ist insbesondere die Konsequenz der Erkenntnis, dass bei jedem weiteren Intubationsversuch das Risiko für Komplikationen deutlich ansteigt [1,6].…”

“…Dies ist insbesondere die Konsequenz der Erkenntnis, dass bei jedem weiteren Intubationsversuch das Risiko für Komplikationen deutlich ansteigt [1,6].…”