Prehospital emergent intubations are messy affairs. There are the risks inherent to intubating a critically ill patient where vomit, blood and secretions risk blocking your laryngoscopy view or risk contaminating the patients airway. The fact that you are performing an invasive procedure outdoors or at least outside a hospital should increase the risk of contamination even more.
Once during an outdoors RSI, the paramedic I worked with had to ask a fireman to stop standing on our endotracheal tube. Suxx had just been given and it was the only tube we had readily available. All the paramedic could do was to wipe the tube against his uniform before successfully intubating. Surely the risk of airway infections secondary to contamination must be higher in patients who were intubated in the field?
Retrospective study that identified 75 patients who were admitted to an ICU after having a prehospital intubation and ventilation. The authors looked at how many of these developed Ventilator Associated Pneumonia (VAP).
15 out of the 75 patients developed VAP. A prevalence of 20 %. This should be compared to overall VAP prevalence in intubated patients reported to be in the range of 9-27%. Prior prehospital studies have reported a VAP incidence of 20-25%. Intubations after cardiac arrest were especially prone to VAP.
In accordance with ICU-litterature patients who developed VAP had longer ICU-stays. ICU stay was extended by about a week.
My recommendation to firemen and cops to refrain from standing on my ETTs is now evidence based. VAP prevention guidelines, that can reduce VAP prevalence in the ICU by 50 %, should probably be used prehospitally too.
Eur J Emerg Med. 2013 Feb;20(1):61-3. doi: 10.1097/MEJ.0b013e3283501677.
Ventilation-associated pneumonia after intubation in the prehospital or the emergency unit. Decelle L, Thys F, Zech F, Verschuren F.