title: The incidence and risk factors for cardiac arrest during emergency tracheal intubation: a justification for incorporating the ASA Guidelines in the remote location.
abstract: OBJECTIVE
  To determine the incidence and etiology of cardiopulmonary arrest during emergency intubation in the remote location by comparing two periods (1990-1995 vs. 1995-2002) at the same institution to assess whether immediate access to advanced airway devices and endotracheal tube-verifying devices altered the incidence of hypoxemia-driven cardiac arrest.
  
  
  METHODS
  Retrospective review of a quality improvement (QI) database for emergency intubation outside the operating room (OR).
  
  
  METHODS
  765-bed tertiary care, level 1 trauma center.
  
  
  METHODS
  3035 critically ill patients suffering from cardiopulmonary, traumatic, septic, metabolic, or neurological-based deterioration and requiring emergency airway management.
  
  
  METHODS
  Rate of cardiac arrest, as defined as asystole, bradycardia, or ventricular dysrhythmia with non-measurable blood pressure during or within 5 minutes of intubation, requiring cardiopulmonary resuscitation (CPR), were measured.
  
  
  RESULTS
  60 cardiac arrests were documented (2%, or one per 50 cases), 83% of which were associated with profound hypoxemia (oxygen saturation <70%) during the airway procedure. Esophageal intubation was a frequent complication (n = 38; 63%), often leading to hypoxemia (97%) and regurgitation (67%). The overall rate of cardiac arrest was reduced 50% between the two time periods (2.8%: 1990-1995 period and 1.4%: 1995-2002 period). The relative risk estimate for complications in a match cohort contributing to the etiology of cardiac arrest included hypoxemia (4X), regurgitation (28X), aspiration (22X), bradycardia (23X) (all P < 0.003), and esophageal intubation (7X), P < 0.04). A total of 34% patients survived less than 24 hours and 31% survived to be discharged.
  
  
  CONCLUSIONS
  Cardiac arrest during emergency tracheal intubation outside the OR is relatively common compared with the OR environment. Airway-related complications played a prominent role, either singly or in combination with the patient's underlying physiological state. Immediate access to advanced airway devices and endotracheal tube-verifying devices appear to have a significant impact on the incidence of hypoxemia-driven cardiac arrest.
authors.affiliation: Department of Anesthesiology, Hartford Hospital, Hartford, CT 06015, USA. TMORT@harthosp.org
authors.forename: Thomas C
authors.initials: TC
authors.lastname: Mort
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000402:Airway Obstruction / Q000150:complications; D016638:Critical Illness; D004638:Emergency Treatment; D005260:Female; D006323:Heart Arrest / Q000453:epidemiology* / Q000209:etiology; D006439:Hemodynamics; D006801:Humans; D007442:Intubation, Intratracheal / Q000009:adverse effects*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D012307:Risk Factors; D011795:Surveys and Questionnaires