Skip to main content
Log in

Emergent endotracheal intubation associated cardiac arrest, risks, and emergency implications

  • Review Article
  • Published:
Journal of Anesthesia Aims and scope Submit manuscript

Abstract

Emergent endotracheal intubation (ETI)-related cardiac arrest (CA) is a life-threatening complication that is poorly documented. Definitions and risk factors for CA during or directly after emergent ETI have not been clearly established and may represent modifiable means of improving patient outcomes. We conducted a review of the literature to assess the incidence and risk factors associated with ETI-related CA in the Emergency Department (ED) as well as in the inpatient setting outside of the operating room. Retrospective studies demonstrated that ETI-related CA incidence was between 1.7% and 23% in both the ED and the inpatient setting. Pre-intubation hypoxemia, hypotension, Shock Index (SI), Body Mass Index, and age were most associated with CA. Medications used for induction and number of attempts were identified as risk factors. Definitions of ETI-related CA also varied considerably ranging from within 5 min to within 60 min of intubation; however, the majority of ETI-related CA cases occurred within 10 min. Hemodynamic factors such as SI, hypotension, and hypoxemia were associated with increased rates of CA. ETI-related CA may represent a potentially modifiable complication that can improve patient outcomes in critically ill patients presenting in the ED.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Schwab TD, Greaves TH. Cardiac arrest as a possible sequela of critical airway management and intubation. Am J Emerg Med. 1998;16(6):609–12.

    Article  CAS  PubMed  Google Scholar 

  2. Walls RM, Brown CA, Bair AE, Pallin DJ. Emergency airway management: a multi center report of 8937 emergency department intubations. J Emerg Med. 2011;41(4):347–54.

    Article  PubMed  Google Scholar 

  3. Graham CA, Beard D, Oglesby AJ, Thakore SB, Beale JP, Brittliff J, Johnston MA, McKeown DW, Parke TR. Rapid sequence intubation in scottish urban emergency departments. Emerg Med J. 2003;20(1):3–5.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  4. De Jong A, Rolle A, Molinari N, Paugam-Burtz C, Constantin JM, Lefrant JY, Asehnoune K, Jung B, Futier E, Chanques G, Azoulay E, Jaber S. Cardiac arrest and mortality related to intubation procedure in critically Ill adult patients: a multicenter cohort study. Crit Care Med. 2018;46(4):532–9.

    Article  PubMed  Google Scholar 

  5. Ko BS, Ahn R, Ryoo SM, Ahn S, Sohn CH, Seo DW, Lim KS, Kim WY. Incidence and outcomes of endotracheal intubation-related cardiac arrest in the ED. Am J Emerg Med. 2011;33(11):1642–5.

    Article  Google Scholar 

  6. Heffner AC, Swords DS, Neale MN, Jones AE. Incidence and factors associated with cardiac arrest complicating emergency airway management. Resuscitation. 2013;84(11):1500–4.

    Article  PubMed  Google Scholar 

  7. Kim WY, Kwak MK, Ko BS, Yoon JC, Sohn CH, Lim KS, Andersen LW, Donnino MW. Factors associated with the occurrence of cardiac arrest after emergency tracheal intubation in the emergency department. PLoS One. 2014;9(11):e112779.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Wardi G, Villar J, Nguyen T, Vyas A, Pokrajac N, Minokadeh A, Lasoff D, Tainter C, Beitler JR, Sell RE. Factors and outcomes associated with inpatient cardiac arrest following emergent endotracheal intubation. Resuscitation. 2017;121:76–80.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Mort TC. Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts. Anesth Analg. 2004;99:607–13.

    Article  PubMed  Google Scholar 

  10. Sakles JC, Javedani PP, Chase E, Garst-Orozco J, Gullen-Rodriguez J, Stolz U. The use of a video laryngoscope by emergency medicine residents is associated with a reduction in esophageal intubations in the emergency department. Acad Emerg Med. 2015;22:700–7.

    Article  PubMed  Google Scholar 

  11. Zuercher M, Ummenhofer W. Cardiac arrest during anesthesia. Curr Opin Crit Care. 2008;14:269–74.

    Article  PubMed  Google Scholar 

  12. Wallmuller G, Meron G, Kurkciyan I, Schober A, Stratil P, Sterz F. Causes of in-hospital cardiac arrest and influence on outcome. Resuscitation. 2012;83:1206–11.

    Article  PubMed  Google Scholar 

  13. Mort TC. The incidence and risk factors for cardiac arrest during emergency tracheal intubation: a justification for incorporating the ASA guidelines in the remote location. J Clin Anesth. 2004;16(7):508–16.

    Article  PubMed  Google Scholar 

  14. Mort TC. Complications of emergency tracheal intubation: hemodynamic alterations—part I. J Intensive Care Med. 2007;22:157–65.

    Article  PubMed  Google Scholar 

  15. Low JM, Harvey JT, Prys-Roberts C, Dagnino J. Studies of anaesthesia in relation to hypertension VII: adrenergic responses to laryngoscopy. Br J Anaesth. 1986;58:471–7.

    Article  CAS  PubMed  Google Scholar 

  16. Masato K, Makoto F, Shino T, Masafumi T, Masahiko M, Koji S. Hemodynamic and catecholamine responses during tracheal intubation using a lightwand device (trachlight) in elderly patients with hypertension. J Anesth. 2003;17:161–5.

    Article  Google Scholar 

  17. Shafi S, Gentilello L. Pre-hospital endotracheal intubation and positive pressure ventilation is associated with hypotension and decreased survival in hypovolemic trauma patients: an analysis of the National Trauma Data Bank. J Trauma. 2005;59:1140–5.

    Article  PubMed  Google Scholar 

  18. Heffner AC, Swords DS, Nussbaum ML, Kline JA, Jones AE. Predictors of the complication of postintubation hypotension during emergency airway. J Crit Care. 2012;27:587–93.

    Article  PubMed  Google Scholar 

  19. Heffner AC, Swords D, Kline JA, Jones AE. The frequency and significance of postintubation hypotension during emergency airway management. J Crit Care. 2012;417:419–413.

    Google Scholar 

  20. Franklin C, Samuel J, Hu TC. Life-threatening hypotension associated with emergency intubation and the initiation of mechanical ventilation. Am J Emerg Med. 1994;12:425–8.

    Article  CAS  PubMed  Google Scholar 

  21. Reich DL, Hossain S, Krol M, Baez B, Patel P, Bernstein A, Bodian CA. Predictors of hypotension after induction of general anesthesia. Anesth Analg. 2005;101:622–8.

    Article  PubMed  Google Scholar 

  22. Kim JM, Shin TG, Hwang SY, Yoon H, Cha WC, Sim MS, Jo IJ, Song KJ, Rhee JE, Jeong YK. Sedative dose and patient variable impacts on postintubation hypotension in emergency airwaymanagement. Am J Emerg Med. 2018;. https://doi.org/10.1016/j.ajem.2018.09.015.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Sutera PT, Smith CE. Asystole during direct laryngoscopy and tracheal intubation. J Cardiothorac Vasc Anesth. 1994;8:79–80.

    Article  CAS  PubMed  Google Scholar 

  24. Jones P, Dauger S, Peters MJ. Bradycardia during critical care intubation: mechanisms, significance and atropine. Arch Dis Child. 2012;97(2):139–44.

    Article  PubMed  Google Scholar 

  25. Jaber S, Jung B, Corne P, Sebbane M, Muller L, Chanques G, Verzilli D, Jonquet O, Eledjam JJ, Lefrant JY. An intervention to decrease complications related to endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Intensive Care Med. 2010;36(2):248–55.

    Article  PubMed  Google Scholar 

  26. Rose DK, Cohen MM. The incidence of airway complications depends on the definition used. Can J Anaesth. 1996;43(1):30–4.

    Article  CAS  PubMed  Google Scholar 

  27. Uribe AA, Zvara DA, Puente EG, Otey AJ, Zhang J, Bergese SD. BMI as a predictor for potential difficult tracheal intubation in males. Front Med 2015;2(38).

  28. Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, Hagberg CA, Caplan RA, Benumof JL, Berry FA, Blitt CD, Bode RH, Cheney FW, Connis RT, Guidry OF, Nickinovich DG, Ovassapian A. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on management of the difficult airway. Anesthesiology. 2013;118(2):251–70.

    Article  PubMed  Google Scholar 

  29. Saasouh W, Laffey K, Turan A, Avitsian R, Zura A, Et. al. Degree of obesity is not associated with more than one intubation attempt: a large centre experience. Br J Anaesth. 2018;120(5):1110–6.

    Article  CAS  PubMed  Google Scholar 

  30. Brodsky JB, Lemmens HJ, Brock-Utne JG, Vierra M, Saidman LJ. Morbid obesity and tracheal intubation. Anesth Analg. 2002;94:732–6.

    Article  PubMed  Google Scholar 

  31. Juvin P, Lavaut E, Dupont H, Lefevre P, Demetriou M, Dumoulin JL, Desmonts JM. Difficult tracheal intubation is more common in obese than in lean patients. Anesth Analg. 2003;97:595–600.

    Article  PubMed  Google Scholar 

  32. Shiga T, Wajima Z, Inoue T, Sakamoto A. Predicting difficult intubation in apparently normal patients: a meta-analysis of bedside screening test performance. Anesthesiology. 2005;103:429–37.

    Article  PubMed  Google Scholar 

  33. Martin LD, Mhyre JM, Shanks AM, Tremper KK, Kheterpal S. 3423 emergent tracheal intubations at a university hospital: airway outcomes and complications. Anesthesiology. 2011;114(1):42–8.

    Article  PubMed  Google Scholar 

  34. Collins JS, Lemmens HJM, Brodsky JB, Brock-Utne JG, Levitan RM. Laryngoscopy and morbid obesity: a comparison of the “Sniff” and “Ramped” positions. Obes Surg. 2004;14:1171–5.

    Article  PubMed  Google Scholar 

  35. Derbyshire DR, Chmielewski D, Fell M, Vater K, Smith A, Smith G. Plasma catecholamine responses to endotracheal intubation. Br J Anaesth. 1983;5(9):855–60.

    Article  Google Scholar 

  36. Imamura T, Brown CA, Ofuchi H, Yamagami H, Branch J, Hagiwara Y. Emergency airway management in geriatric and younger patients: analysis of a multicenter prospective observational study. Am J Emerg Med. 2013;31:190–6.

    Article  PubMed  Google Scholar 

  37. Kurnaz MM, Sarıtaş A. Comparison of the effects of truview PCD™ video laryngoscopy and macintosh blade direct laryngoscopy in geriatric patients. J Clin Anesth. 2016;35:268–73.

    Article  PubMed  Google Scholar 

  38. Johnson KN, Botros DB, Groban L, Bryan Y. Anatomic and physiopathologic changes affecting the airway of the elderly patient: implications for geriatric-focused airway management. Clin Interv Aging. 2015;10:1925–34.

    PubMed  PubMed Central  Google Scholar 

  39. Esler MD, Thompson JM, Kaye DM, Turner AG, Jennings GL, Cox HS, Lambert GW, Seals DR. Effects of Aging on the responsiveness of the human cardiac sympathetic nerves to stressors. Circulation. 1995;91(2):351–8.

    Article  CAS  PubMed  Google Scholar 

  40. Habib AS, Parker JL, Maguire AM, Rowbotham DJ, Thompson JP. Effects of remifentanil and alfentanil on the cardiovascular responses to induction of anaesthesia and tracheal intubation in the elderly. Br J Anaesth. 2002;88(3):430–3.

    Article  CAS  PubMed  Google Scholar 

  41. Zaugg M, Tagliente T, Lucchinetti E, Jacobs E, Krol M, Bodian C, Reich DL, Silverstein JH. Beneficial effects from beta-adrenergic blockade in elderly patients undergoing noncardiac surgery. Anesthesiology. 1999;91(6):1674–86.

    Article  CAS  PubMed  Google Scholar 

  42. Blanie´ A, Ract C, Leblanc PE, Cheisson GI, Huet O, Laplace C. The limits of succinylcholine for critically Ill patients. Anesth Analg. 2012;115:873–9.

    Article  CAS  PubMed  Google Scholar 

  43. Mort TC. Complications of emergency tracheal intubation: hemodynamic alterations—part II. J Intensive Care Med. 2007;22:208–15.

    Article  PubMed  Google Scholar 

  44. Hasegawa K, Shigemitsu K, Hagiwara Y, Chiba T, Watase H, Brown CA 3rd, Brown DF. Association between repeated intubation attempts and adverse events in emergency departments: an analysis of a multicenter prospective observational study. Ann Emerg Med. 2012;60:749–54.

    Article  PubMed  Google Scholar 

Download references

Funding

This study was not funded.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Ali Pourmand.

Ethics declarations

Conflict of interest

No competing financial interests exist.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Marin, J., Davison, D. & Pourmand, A. Emergent endotracheal intubation associated cardiac arrest, risks, and emergency implications. J Anesth 33, 454–462 (2019). https://doi.org/10.1007/s00540-019-02631-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00540-019-02631-7

Keywords

Navigation