title: The effectiveness of out-of-hospital use of continuous end-tidal carbon dioxide monitoring on the rate of unrecognized misplaced intubation within a regional emergency medical services system.
abstract: OBJECTIVE
  We evaluate the association between out-of-hospital use of continuous end-tidal carbon dioxide (ETCO2) monitoring and unrecognized misplaced intubations within a regional emergency medical services (EMS) system.
  
  
  METHODS
  This was a prospective, observational study, conducted during a 10-month period, on all patients arriving at a regional Level I trauma center emergency department who underwent out-of-hospital endotracheal intubation. The regional EMS system that serves the trauma service area is composed of multiple countywide systems containing numerous EMS agencies. Some of the EMS agencies had independently implemented continuous ETCO2 monitoring before the start of the study. The main outcome measure was the unrecognized misplaced intubation rate with and without use of continuous ETCO2 monitoring.
  
  
  RESULTS
  Two hundred forty-eight patients received out-of-hospital airway management, of whom 153 received intubation. Of the 153 patients, 93 (61%) had continuous ETCO2 monitoring, and 60 (39%) did not. Forty-nine (32%) were medical patients, 104 (68%) were trauma patients, and 51 (33%) were in cardiac arrest. The overall incidence of unrecognized misplaced intubations was 9%. The rate of unrecognized misplaced intubations in the group for whom continuous ETCO2 monitoring was used was zero, and the rate in the group for whom continuous ETCO2 monitoring was not used was 23.3% (95% confidence interval 13.4% to 36.0%).
  
  
  CONCLUSIONS
  No unrecognized misplaced intubations were found in patients for whom paramedics used continuous ETCO2 monitoring. Failure to use continuous ETCO2 monitoring was associated with a 23% unrecognized misplaced intubation rate.
authors.affiliation: Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, FL, USA. ems.medicaldirector@ocfl.net
authors.forename: Salvatore
authors.initials: S
authors.lastname: Silvestri
authors.forename: George A
authors.initials: GA
authors.lastname: Ralls
authors.forename: Baruch
authors.initials: B
authors.lastname: Krauss
authors.forename: Josef
authors.initials: J
authors.lastname: Thundiyil
authors.forename: Steven G
authors.initials: SG
authors.lastname: Rothrock
authors.forename: Amy
authors.initials: A
authors.lastname: Senn
authors.forename: Eric
authors.initials: E
authors.lastname: Carter
authors.forename: Jay
authors.initials: J
authors.lastname: Falk
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D019296:Capnography; D002245:Carbon Dioxide / Q000032:analysis; D004632:Emergency Medical Services; D005260:Female; D006801:Humans; D007223:Infant; D007442:Intubation, Intratracheal; D008297:Male; D019300:Medical Errors / Q000517:prevention & control*; D008875:Middle Aged; D011446:Prospective Studies
chemical_list: D002245:Carbon Dioxide