Esophageal intubation
We are reproducing a part of a case report of esophageal intubation for learning purpose. (You can read full case by clicking the link below).
"....A decision was made to insert a prophylactic left thoracostomy tube and intubate the patient prior to going to the OR. Rapid sequence intubation (RSI) was initiated using atropine and fentanyl followed by midazolam and succinylcholine. The ETT was perceived by the operator to have been passed into the trachea by direct vision. Auscultation of both axilla noted "good air entry," and condensation of water vapour in the tube was also noted. Neither an end tidal CO2 monitor nor an esophageal detector device were used. An arterial blood gas sample drawn during the pre-oxygenation phase of the RSI showed that the Po2 was 286 mm Hg with 99.6% oxygen saturation. Follow-up oxygen saturation was not documented. Blood was suctioned from the ETT shortly after intubation. A repeat chest/abdominal x-ray was taken, and the patient was transferred directly to the OR. The x-ray film was not viewed by the attending physician prior to sending the patient to the OR, due to the immediacy of the transfer. Upon arrival at the OR, the patient was found to have pulseless electrical activity, with a heart rate of 40 beats/min. A grossly distended abdomen was noted. Surgical emphysema was present across the abdomen, thorax and neck. Immediate assessment of the airway revealed an esophageal intubation. Airway edema and anatomic distortion secondary to surgical emphysema prevented endotracheal intubation, and a tracheostomy was performed. The patient's rhythm rapidly deteriorated to asystole and, despite all efforts, resuscitation was unsuccessful. The official x-ray reading the following day erroneously reported the ETT to be in the right main stem bronchus."
Lessons to be learned:
1. Despite your belief that you watched ETT pass through the vocal cord, there are chances that it may have went into esophageal tract.
2. Bilateral breath sounds and condensation of water vapour in ETT are not a reliable indicator of tracheal intubation.
2. All possible means available to confirm ETT in trachea should be used including CXR and end-tidal CO2 monitor. End-tidal CO2 monitor is pretty reliable but may give false positive results 1 (or false negative results in code situation). Bronchoscopy should be performed if doubt persists.
4. Followup ABG should be done to see PO2 and other values.
5. Followup CXR should be done as soon as possible and should be read by the operator despite patient is moved from the area !
6. Esophageal intubation is an emergency and need to be recognised and corrected promptly.
7. Don't wait for official CXR report !!
You can read the full case report with discussion here (reference: Canadian Association of Emergency Physicians, January 2002 Vol 4, No 1)
Reference: click to get abstract
1. Case report: a normal capnogram despite esophageal intubation - Canadian Journal of Anesthesia 48:1025-1028 (2001)
