The incidence and risk factors for cardiac arrest during emergency tracheal intubation: A justification for incorporating the ASA Guidelines in the remote location

Abstract

Study 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. Design Retrospective review of a quality improvement (QI) database for emergency intubation outside the operating room (OR). Setting 765-bed tertiary care, level 1 trauma center. Patients 3035 critically ill patients suffering from cardiopulmonary, traumatic, septic, metabolic, or neurological-based deterioration and requiring emergency airway management. Measurements 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. Main 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. Conclusion 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.