The Combitube as a salvage airway device for paramedic rapid sequence intubation.
OBJECTIVE
The safety of out-of-hospital rapid sequence intubation depends on a reliable strategy when orotracheal intubation is unsuccessful. Here we describe our experience with the Combitube (esophageal-tracheal twin-lumen airway device) as a salvage airway device for paramedic rapid sequence intubation.


METHODS
The San Diego Paramedic Rapid Sequence Intubation Trial was performed to assess the effect of paramedic rapid sequence intubation on outcome in severely head-injured patients. Adults with severe head trauma (Glasgow Coma Scale score 3 to 8) who were unable to be intubated without medications were enrolled. Midazolam and succinylcholine were administered, and paramedics were allowed a maximum of 3 attempts at orotracheal intubation. If the attempts were unsuccessful, Combitube insertion was mandated. After confirmation of tube position, rocuronium was given and standard ventilation protocols were used. The primary outcome measure for this analysis was the success rate for Combitube insertion after unsuccessful orotracheal intubation. In addition, Combitube insertion and orotracheal intubation patients were compared with regard to demographic, clinical, and outcome data.


RESULTS
A total of 426 patients were enrolled in the trial, with 420 meeting inclusion criteria for this analysis. Orotracheal intubation was successful in 355 (84.5%) of 420; Combitube insertion was successful in 58 (95.1%) of 61 attempts, with no reported complications. Patients undergoing Combitube insertion had higher Face Abbreviated Injury Scale scores and were more likely to have oropharyngeal blood or vomitus. Arrival Pco(2) values were higher, and arrival Po(2) values were lower but still supranormal in patients undergoing Combitube insertion. There were no mortality differences between patients undergoing Combitube insertion and those undergoing orotracheal intubation.


CONCLUSIONS
The Combitube can be an effective salvage airway device for paramedic rapid sequence intubation in an urban/suburban, high-volume emergency medical services system with paramedics who are experienced in Combitube placement and with stringent protocols for its use. The device should be tested in other sizes and types of systems and under less medical scrutiny than was used in this study.
Department of Emergency Medicine, University of California-San Diego, San Diego, CA 92103-8676, USA. davismd@cox.net
Daniel P
DP
Davis
Carla
C
Valentine
Mel
M
Ochs
Gary M
GM
Vilke
David B
DB
Hoyt
D015998:Abbreviated Injury Scale; D000328:Adult; D000732:Androstanols / Q000627:therapeutic use; D018686:Anesthetics, Intravenous / Q000627:therapeutic use; D001784:Blood Gas Analysis; D002140:California / Q000453:epidemiology; D002983:Clinical Competence / Q000592:standards; D002985:Clinical Protocols; D006259:Craniocerebral Trauma / Q000097:blood / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D004634:Emergency Medical Technicians / Q000193:education / Q000592:standards; D004638:Emergency Treatment / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods; D004867:Equipment Design; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D007441:Intubation, Gastrointestinal / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods; D007442:Intubation, Intratracheal / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods; D008297:Male; D008874:Midazolam / Q000627:therapeutic use; D009467:Neuromuscular Depolarizing Agents / Q000627:therapeutic use; D003473:Neuromuscular Nondepolarizing Agents / Q000627:therapeutic use; D011446:Prospective Studies; D000077123:Rocuronium; D016879:Salvage Therapy / Q000295:instrumentation / Q000379:methods; D013390:Succinylcholine / Q000627:therapeutic use; D013997:Time Factors; D016896:Treatment Outcome
D000732:Androstanols; D018686:Anesthetics, Intravenous; D009467:Neuromuscular Depolarizing Agents; D003473:Neuromuscular Nondepolarizing Agents; D013390:Succinylcholine; D008874:Midazolam; D000077123:Rocuronium