Critical Care and Trauma Section Editor: Jukka Takala Prehospital Intubations and Mortality: A Level 1 Trauma Center Perspective Miguel A. Cobas, MD* Maria Alejandra De la Pen ˜a, MD* Ronald Manning, RN, MSPH† Keith Candiotti, MD* Albert J. Varon, MD* BACKGROUND: Ryder Trauma Center is a Level 1 trauma center with approximately 3800 emergency admissions per year. In this study, we sought to determine the incidence of failed prehospital intubations (PHI), its correlation with hospital mortality, and possible risk factors associated with PHI. METHODS: A prospective observational study was conducted evaluating trauma patients who had emergency prehospital airway management and were admitted during the period between August 2003 and June 2006. The PHI was considered a failure if the initial assessment determined improper placement of the endotracheal tube or if alternative airway management devices were used as a rescue measure after intubation was attempted. RESULTS: One-thousand-three-hundred-twenty patients had emergency airway in- terventions performed by an anesthesiologist upon arrival at the trauma center. Of those, 203 had been initially intubated in the field by emergency medical services personnel, with 74 of 203 (36%) surviving to discharge. When evaluating the success of the intubation, 63 of 203 (31%) met the criteria for failed PHI, all of them requiring intubation, with only 18 of 63 (29%) surviving to discharge. These patients had rescue airway management provided either via Combitube (n = 28), Laryngeal Mask Airway (n = 6), or a cricothyroidotomy (n = 4). An additional 25 of 63 patients (12%) had unrecognized esophageal intubations discovered upon the initial airway assessment performed on arrival. We found no difference in mortality between those patients who were properly intubated and those who were not. Several other variables, including age, gender, weight, mechanism of injury, presence of facial injuries, and emergency medical services were not correlated with an increased incidence of failed intubations. CONCLUSION: This prospective study showed a 31% incidence of failed PHI in a large metropolitan trauma center. We found no difference in mortality between patients who were properly intubated and those who were not, supporting the use of bag-valve-mask as an adequate method of airway management for critically ill trauma patients in whom intubation cannot be achieved promptly in the prehos- pital setting. (Anesth Analg 2009;109:489 –93) Control of the airway is the first priority for the management of critically ill patients and is prioritized in established patient-management algorithms, such as Advanced Cardiac Life Support and Advanced Trauma Life Support. Although tracheal intubation is recommended as a definitive airway management, prehospital medical personnel perform this procedure infrequently in the United States and abroad, 1,2 and the effects of prehospital intubation (PHI) on patient mortality remain poorly defined. There is a continuing debate regarding PHI and its effect on patient outcomes. Data in trauma patients are inconclusive. Several studies suggest that this proce- dure is beneficial, especially in patients with impend- ing respiratory compromise. 3–6 Other recent trials suggest that there is an increased risk of adverse outcomes in trauma patients intubated in the field when compared with those managed with bag-valve- mask (BVM) ventilation followed by intubation in the emergency department. PHI may unnecessarily pro- long the time spent at the scene, 7–9 and some of the controversy lies in the fact that multiple failed at- tempts before conversion to alternative devices for airway management increase the odds for complica- tions, such as esophageal and bronchial intubation. 10 The placement of the airway devices also has been associated with complications, 11 including aspiration of gastric contents, laryngospasm, esophageal trauma, lacerations, and hematomas. 12 The aim of this study was to determine the incidence of failed PHI and its correlation with hospital mortality From the *Department of Anesthesiology, Perioperative Medi- cine, and Pain Management, and †DeWitt Daughtry Family Depart- ment of Surgery, Miller School of Medicine, University of Miami, Miami, Florida. Accepted for publication February 25, 2009. Address correspondence and reprint requests to Miguel Cobas, MD, Department of Anesthesiology, University of Miami, 1400 NW 12th Ave., Suite 3155, Miami, FL 33136. Address e-mail to mcobas@med.miami.edu. Copyright © 2009 International Anesthesia Research Society DOI: 10.1213/ane.0b013e3181aa3063 Vol. 109, No. 2, August 2009 489