Journal of Emergencies, Trauma, and Shock
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EMERGENCY AIRWAY ENCOUNTERS Table of Contents   
Year : 2010  |  Volume : 3  |  Issue : 2  |  Page : 185-186
Accidental oxygen disconnection in the emergency department


1 Department of Emergency Medicine, Brooke Army Medical Center, El Paso, TX, USA
2 Department of Emergency Medicine, William Beaumont Army Medical Center, El Paso, TX, USA

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Date of Submission27-Sep-2008
Date of Acceptance22-Jan-2009
Date of Web Publication31-Mar-2010
 

   Abstract 

Accidental oxygen disconnection during rapid sequence intubation (RSI) in the emergency department is a potentially catastrophic yet avoidable event. We report three cases of inadvertent oxygen disconnection during RSI, which resulted in significant oxygen desaturation. This error can potentially be prevented by thorough preparation, focusing on teamwork training, ensuring an ergonomic environment, and by making simple modifications to existing equipment.

Keywords: Airway management, bag-valve mask, breathing, hypoxia, intubation, oxygen, safety, training

How to cite this article:
Hill GJ, Adams BD. Accidental oxygen disconnection in the emergency department. J Emerg Trauma Shock 2010;3:185-6

How to cite this URL:
Hill GJ, Adams BD. Accidental oxygen disconnection in the emergency department. J Emerg Trauma Shock [serial online] 2010 [cited 2019 Jun 20];3:185-6. Available from: http://www.onlinejets.org/text.asp?2010/3/2/185/62123



   Introduction Top


Rapid sequence intubation (RSI) is necessary for resuscitating critically ill patients in the emergency department (ED). The process of emergency intubation, however, is fraught with the potential for life-threatening errors that include equipment failure, medication errors, procedural complications, and teamwork mishaps. [1],[2],[3]

The specific complication of oxygen desaturation is the most common complication during RSI and it has multiple causes. [4] While accidental disconnection of the oxygen circuit has been reported for stabilized patients on ventilators in both intensive care units and operating rooms, this complication has not previously been reported during RSI or in the ED. Historically, the majority of adverse outcomes relating to these types of errors have been death or permanent brain damage. In one study investigating the reasons for these adverse outcomes, misconnection or disconnection of the breathing circuit was the greatest reason for adverse outcomes (35%). [5] Other studies have shown that disconnection of the breathing circuit was the most common form of human error resulting in avoidable patient injury. [6],[7] One of these studies also concluded that up to one-third of disconnections were caused by interference in the breathing circuit by a third party. We present a series of accidental oxygen desaturation events caused by inadvertent oxygen circuit disconnections in the ED.


   Case Reports Top


Case 1

A 46-year-old female arrived by ambulance for acute respiratory failure with a respiratory rate of 40-50 respirations per minute. The medical emergency team prepared for RSI by preoxygenating the patient with a nonrebreather mask at 100% FiO 2 . The first attempt at intubation was unsuccessful, but the respiratory therapist had also switched the oxygen source to the ventilator without the physician's knowledge. The oxygen saturation declined to around 70% during several attempts at RSI, despite the use of a rescue bag-valve mask (BVM) and a nasopharyngeal airway. The physician then discovered that the BVM was attached to the air outlet instead of the oxygen outlet. The physician reconnected the patient's BVM to the oxygen supply and the patient's oxygen saturation recovered to 100%. No permanent injury was noted as a result of the hypoxic event.

Case 2

A 13-month-old male was intubated for respiratory distress secondary to pneumonia. Following successful RSI and placement on a ventilator, the ED physicians briefly left the bedside. The respiratory therapist ventilated the patient using a BVM while making adjustments to the ventilator. Several minutes later, the oxygen saturation plummeted to approximately 30% with a pulse rate of 30-40 beats per minute. The medical emergency team leader quickly discovered that the BVM had been inadvertently disconnected from high-flow oxygen. Upon reconnection to supplemental oxygen, the patient's oxygen saturation and heart rate rapidly returned to normal and the patient suffered no adverse outcome.

Case 3

A 55-year-old patient was brought to the ED after suffering burns and smoke inhalation following a house fire. Despite accurate confirmation of endotracheal tube placement with end tidal CO 2 and auscultation, the patient rapidly desaturated to 83%. It was noted at that time that the BVM had been disconnected from oxygen during the RSI process. The BVM was connected to oxygen and the patient's oxygen saturation improved immediately. The patient suffered no ill effects from the period of hypoxia.


   Discussion Top


The cases presented here were caused by either a disconnection of supplemental oxygen or attaching a device to the wrong connection during the RSI process. Teamwork and provider errors far exceed equipment failure as contributors to preventable patient morbidity and mortality. [1],[2],[3] Indeed, more than half of the death and disability that occurs in the ED may be a result of team errors. [1],[2],[8] Airway management is particularly susceptible to team errors. [4],[9] One retrospective analysis to investigate the role of human error in airway management showed that 82% of adverse patient outcomes were from human error, while equipment failure was only responsible for 14% of incidents. [6]

Standardizing tasks and clear communication can reduce error. For example, to prevent the communication error seen in Case 1, one should assign the task of switching the solitary oxygen source from the nonrebreather mask to the ventilator once the endotracheal tube is in place. Training in airway skills usually focuses on individuals, although real-time airway management is seldom, if ever performed in isolation. There may also be students of varying types present as well as residents of differing skill levels and experience. Minimizing the interference of third parties not directly involved with the patient can also reduce the possibility of interference with the oxygen source.

Ergonomic improvements in airway equipment may also lessen the likelihood of desaturation. Many hospitals have only one oxygen source or possibly less for each bed. As seen in these cases, this setup can result in accidental desaturation. Ensuring one outlet for each device that supplies oxygen during RSI will minimize the risk of disconnection. These connections should be as secure as possible or permanent. All oxygen outlets should remain visible to the resuscitation team leader and should not be obscured during RSI by people or equipment. Direct visualization of the oxygen circuit could have prevented the desaturation that occurred in all cases. Vigilance must be maintained during RSI due to the addition of care providers and materials. In some instances, the installation of dual oxygen flow devices may be beneficial. These allow for multiple airway devices to be attached to a single wall source. This allows for the nonrebreather mask and the BVM to be attached simultaneously during the preparation stage. This will minimize the opportunity of not connecting (or double switching) the devices during the procedure.


   Conclusion Top


Many preventable errors that occur during a patient's hospital stay may occur during airway management. Improvements in the functioning of the airway team can improve patient safety and decrease the likelihood of significant adverse events. Changes in the environment in which airway management takes place may also help to decrease accidental oxygen desaturation. Direct visualization of the entire airway circuit, adequate and secure outlets and attachments, and oxygen flow splitting devices can all be beneficial.

 
   References Top

1.Wears R, Leape LL. Human error in emergency medicine. Ann Emerg Med 1999;34:370-2.  Back to cited text no. 1  [PUBMED]    
2.Risser DT, Rice MM, Salisbury ML, Simon R, Jay GD, Berns SD. The potential for improved teamwork to reduce medical errors in the emergency department. The MedTeams Research Consortium. Ann Emerg Med 1999;34:373-83.  Back to cited text no. 2  [PUBMED]    
3.Croskerry P, Shapiro M, Campbell S, LeBlanc C, Sinclair D, Wren P, et al. Profiles in patient safety: Medication errors in the emergency department. Acad Emerg Med 2004;11:289-99.  Back to cited text no. 3  [PUBMED]    
4.Simpson J, Munro PT, Graham CA. Rapid sequence intubation in the emergency department: 5 year trends. Emerg Med J 2006;23:54-6.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]  
5.Caplan RA, Vistica MF, Posner KL, Cheney FW. Adverse anesthetic outcomes arising from gas delivery equipment: A closed claims analysis. Anesthesiology 1997;87:741-8.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]  
6.Cooper JB, Newbower RS, Long CD, McPeek B. Preventable anesthesia mishaps: A study of human factors. Anesthesiology 1978;49:399-406.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]  
7.Russell WJ, Webb RK, van der Walt JH, Runciman WB. The Australian Incident Monitoring Study. Problems with ventilation: An analysis of 2000 incident reports. Anaesth Intensive Care 1993;21:617-20.  Back to cited text no. 7  [PUBMED]    
8.Morey JC, Simon R, Jay GD, Wears RL, Salisbury M, Dukes KA, et al. Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the MedTeams project. Health Serv Res 2002;37:1553-81.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]  
9.Kapadia FN, Bajan KB, Raje KV. Airway accidents in intubated intensive care unit patients: an epidemiological study. Crit Care Med 2000;28:659-64.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]  

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Correspondence Address:
Guyon J Hill
Department of Emergency Medicine, Brooke Army Medical Center, El Paso, TX
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-2700.62123

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    Abstract
    Introduction
    Case Reports
    Discussion
    Conclusion
    References

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