title: A prospective study of physician pre-hospital anaesthesia in trauma patients: oesophageal intubation, gross airway contamination and the 'quick look' airway assessment.
abstract: BACKGROUND
  In trauma patients intubated in a physician-led pre-hospital trauma service we prospectively examined the rate of misplaced tracheal tubes, the presence and nature of gross airway contamination, and the value of 'quick look' airway assessment to identify patients with subsequent difficult laryngoscopy.
  
  
  METHODS
  Patients requiring pre-hospital intubation in a 16 month period were included. Intubation success rate, misplaced tracheal tube rate, Cormack and Lehane grade, and the presence and nature of gross airway contamination were recorded at laryngoscopy. Tube placement was verified with carbon dioxide detection and chest x-ray. After visual assessment physicians stated whether laryngoscopy was expected to be a straightforward or 'difficult'. The assessment was compared to subsequent laryngoscopy grade.
  
  
  RESULTS
  400 patients had attempted intubation and 399 were successfully intubated. 42 were in cardiac arrest and intubated without drugs. There were no oesophageal or misplaced tracheal tubes. Gross airway contamination was reported in 177 of 400 patients (44%), of which ¾ was from the upper airway. Unconscious patients had higher contamination rates (57%) than conscious patients (34%) (p ≤ 0.0001). As a test of difficult intubation, the 'quick look' generated sensitivity 0.597 and specificity 0.763 (PPV and NPV were 0.336 and 0.904 respectively).
  
  
  CONCLUSIONS
  This study suggests that when physicians perform pre-hospital anaesthesia they have high intubation success rates and the use of ETCO2 monitoring reduces or eliminates undetected misplaced tracheal tubes. We found high rates of airway contamination; mostly blood from the upper airway. The 'quick look' airway assessment had some utility but is unreliable in isolation.
authors.affiliation: London's Air Ambulance, Department of Pre-hospital Care, Royal London Hospital, London E1 1BB, UK. David.Lockey@nbt.nhs.uk.
authors.forename: David J
authors.initials: DJ
authors.lastname: Lockey
authors.forename: Pascale
authors.initials: P
authors.lastname: Avery
authors.forename: Timothy
authors.initials: T
authors.lastname: Harris
authors.forename: Gareth E
authors.initials: GE
authors.lastname: Davies
authors.forename: Hans Morten
authors.initials: HM
authors.lastname: Lossius
references.citation: Resuscitation. 2006 Jan;68(1):45-9
references.pmid: 16401522
references.citation: Emerg Med J. 2007 May;24(5):e27
references.pmid: 17452687
references.citation: Emerg Med J. 2011 Mar;28(3):225-9
references.pmid: 21216888
references.citation: Emerg Med J. 2005 Feb;22(2):99-102
references.pmid: 15662057
references.citation: Anesth Analg. 2009 Aug;109(2):489-93
references.pmid: 19608824
references.citation: Anaesthesia. 1999 Nov;54(11):1097-8
references.pmid: 10540100
references.citation: Resuscitation. 2004 Oct;63(1):7-9
references.pmid: 15451580
references.citation: Can J Anaesth. 2002 Oct;49(8):863-6
references.pmid: 12374717
references.citation: Resuscitation. 2010 Jul;81(7):810-6
references.pmid: 20398995
references.citation: Emerg Med J. 2006 Sep;23(9):728-30
references.pmid: 16921096
references.citation: Prehosp Emerg Care. 2010 Oct-Dec;14(4):515-30
references.pmid: 20809690
references.citation: Anesth Analg. 1996 Jun;82(6):1197-204
references.pmid: 8638791
references.citation: Br J Anaesth. 2006 Jan;96(1):67-71
references.pmid: 16311285
references.citation: Ann Emerg Med. 2005 May;45(5):497-503
references.pmid: 15855946
references.citation: Scand J Trauma Resusc Emerg Med. 2009 Nov 20;17:58
references.pmid: 19925688
references.citation: Ann Emerg Med. 2004 Oct;44(4):307-13
references.pmid: 15459613
references.citation: Respir Care. 2011 Apr;56(4):503-9
references.pmid: 21255512
references.citation: Emerg Med J. 2003 Jan;20(1):3-5
references.pmid: 12533357
references.citation: Can Anaesth Soc J. 1985 Jul;32(4):429-34
references.pmid: 4027773
references.citation: Prehosp Emerg Care. 2006 Apr-Jun;10(2):260
references.pmid: 16531386
references.citation: Am J Emerg Med. 2005 May;23(3):379-82
references.pmid: 15915418
references.citation: J Trauma. 2003 Jul;55(1):162-79
references.pmid: 12855901
references.citation: Crit Care. 2012 Feb 11;16(1):R24
references.pmid: 22325973
references.citation: Resuscitation. 2006 Aug;70(2):179-85
references.pmid: 16828956
references.citation: Anaesthesia. 1984 Nov;39(11):1105-11
references.pmid: 6507827
references.citation: Resuscitation. 2011 Dec;82(12):1519-24
references.pmid: 21749908
references.citation: Resuscitation. 2004 Apr;61(1):9-21
references.pmid: 15081176
references.citation: Resuscitation. 2012 Apr;83(4):434-9
references.pmid: 22040777
references.citation: Acta Anaesthesiol Scand. 2008 Aug;52(7):897-907
references.pmid: 18702752
references.citation: Resuscitation. 2010 Oct;81(10):1305-52
references.pmid: 20956049
references.citation: Emerg Med J. 2001 Jan;18(1):20-4
references.pmid: 11310456