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Avoid the Goose! Paramedic Identification of Esophageal Intubation by Ultrasound

Published online by Cambridge University Press:  21 August 2018

Penelope C. Lema Open the ORCID record for Penelope C. Lema [Opens in a new window] ,
Michael O’Brien ,
Juliana Wilson ,
Erika St. James ,
Heather Lindstrom ,
John DeAngelis ,
Jennifer Caldwell ,
Paul May  and
Brian Clemency
Penelope C. Lema*
Affiliation:
University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Department of Emergency Medicine, Buffalo, New YorkUSA
Michael O’Brien
Affiliation:
University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Department of Emergency Medicine, Buffalo, New YorkUSA
Juliana Wilson
Affiliation:
University of Colorado School of Medicine, University of Colorado Hospital Department of Emergency Medicine, Aurora, ColoradoUSA
Erika St. James
Affiliation:
University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Department of Emergency Medicine, Buffalo, New YorkUSA
Heather Lindstrom
Affiliation:
University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Department of Emergency Medicine, Buffalo, New YorkUSA
John DeAngelis
Affiliation:
Cambridge Hospital Department of Emergency Medicine, Cambridge, MassachusettsUSA
Jennifer Caldwell
Affiliation:
University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Department of Emergency Medicine, Buffalo, New YorkUSA
Paul May
Affiliation:
Roswell Park Cancer Institute, Applied Technology Laboratory for Advanced Surgery (ATLAS) Team, Buffalo, New York USA
Brian Clemency
Affiliation:
University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Department of Emergency Medicine, Buffalo, New YorkUSA
*
Correspondence: Penelope C. Lema, MD Buffalo General HospitalDepartment of Emergency Medicine 100 High Street, D-6 Buffalo, New York 14203 USA E-mail: Plema@kaleidahealth.org
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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

Keywords

emergency ultrasoundendotracheal tubeesophageal intubationparamedicprehospital
Type
Original Research
Information
Prehospital and Disaster Medicine , Volume 33 , Issue 4 , August 2018 , pp. 406 - 410
Copyright
© World Association for Disaster and Emergency Medicine 2018 

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Footnotes

Conflicts of interest: The authors have no conflicts of interest to disclose. The authors are responsible for the content and writing of this manuscript. This paper was presented at American College of Emergency Physicians (ACEP; Irving, Texas USA) Scientific Assembly Research Forum, Chicago, Illinois USA on October 26, 2014 and New York ACEP Scientific Assembly Research Forum, Bolton Landing, New York USA on July 6, 2016.

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