Training Day: 3 simulation scenarios to teach unplanned extubation to paramedics

By Scott Bourn

Unplanned extubation is a common complication of endotracheal intubation. Unplanned extubation (UE) is defined as premature removal of the endotracheal tube by actions of the patient, or during care, manipulation, or movement of the patient [1-3]. Data on the occurrence of UE in EMS is not available, but in the ICU setting it occurs in 7.3% of all adult intubated patients [4]. Rates may be higher in the uncontrolled EMS setting. Consequences of UE are significant:

If not immediately recognized and resolved UE may be fatal. Even when recognized and resolved UE is associated with:

• Increase in the incidence of ventilator acquired pneumonia during hospitalization, from 13.8% to 30% [3].
• Doubling in average ICU length of stay from 9 to 18 days, increasing the risk for other ICU-related complications [3].
• Significant increase in average cost for ICU stay from $59,206 to $100,198

For specific information on the signs and symptoms, clinical presentation, and appropriate assessment and response to unplanned extubation in EMS additional information on UE in EMS [7].

Learning objectives: Unplanned extubation simulation training

Here are four learning objectives for a high-fidelity simulation training program on unplanned extubation. Upon completion of this training the ALS provider will be able to:

1. Recognize unplanned extubation. (UE)
2. Demonstrate the appropriate assessment, decision-making to determine whether the UE patient needs to be reintubated, and interventions following an unplanned extubation
3. List steps to take to prevent unplanned extubation
4. Demonstrate a hand-off report to the receiving facility for a patient who experienced an unplanned extubation during care

Simulation scenarios for unplanned extubation

Scenario 1: Cardiac arrest

Patient briefing. EMS response to a “man down.” Patient presents in full arrest in the bathroom of a single-wide mobile home.

Program the simulator with these initial parameters:

• Vitals: P 0, BP 0 and RR 0
• SpO2: no signal, no waveform
• EtCO2: no signal, no waveform

The patient remains in cardiac arrest following initial resuscitation efforts such as defibrillation or first round drugs. Presuming cardiac arrest protocols are continued and executed according to accepted procedures, including placement of an endotracheal tube or supraglottic airway, program the simulator with these parameters:

• Vitals: P 0, BP 0 and RR 0
• SpO2: 90%, waveform associated with cardiac compressions
• EtCO2: 15 mm Hg, low amplitude waveform

As the team prepares to extricate the patient from the bathroom they realize that the trailer is extremely full of furniture and clutter, with no real space in which to continue care. Due to driving rain outside the crew decided to transfer the patient directly to the ambulance for continued care. Resuscitation is continued during a difficult extrication from the trailer, and then down a narrow set of steps to the ground. The patient is transferred into the ambulance with resuscitation continuing. Upon patient placement in the ambulance:

Program the simulator with these parameters:

• Vitals: P 0, BP 0 and RR 0
• SpO2: 86%, waveform associated with cardiac compressions
• EtCO2: no signal, no waveform

Patient’s response depends upon the providers actions.

If the ET tube position is recognized to be displaced and the patient is extubated, BVM ventilations provided, and reintubated/SGA replaced, according to accepted procedures:

• Vitals: P 0, BP 0, and RR 0
• SpO2: 88%, waveform associated with cardiac compressions
• EtCO2: 12 mm Hg, low amplitude waveform

If the dislodged airway is not recognized and resuscitation is continued

• Vitals: P 0, BP 0, and RR 0
• SpO2: 78%, waveform associated with cardiac compressions
• EtCO2: no signal, no waveform

During the debrief discuss some or all of the following:

• SpO2 and EtCO2 values and waveforms in cardiac arrest, impact of adequate chest compressions on SpO2 and EtCO2, and any local protocols related to use of EtCO2 as decision support for continuing/discontinuing resuscitation.
• Potential times during the patient’s care that the unplanned extubation may have occurred.
• Strategies to prevent unplanned extubation.
• Signs and symptoms of UE.
• Appropriate steps for confirming the positioning and patency of an ET tube.
• Safe procedure for removing the ET tube and performing reintubation.
• Importance of documenting the episode to the receiving facility.

Scenario 2: Drug overdose

Patient briefing. 21 y/o male found unresponsive in his bed at home. According to his girlfriend he had injected heroin 6 hours prior. Unresponsive, circumoral cyanosis.

Program the simulator with these parameters:

• Vitals: P 62, BP 132/78 and RR 4
• SpO2: 88% normal waveform
• EtCO2: 72 mm Hg, RR 4, normal waveform

This scenario is an obvious presentation. Typical responses, depending upon local protocols, are to either begin with an administration of naloxone to reverse the overdose, or to intubate and initiate ventilations first and then administer naloxone. There are good learning opportunities with either option.

Option 1: If naloxone is given initially the patient becomes immediately conscious, agitated, and confused. Program the simulator with these parameters:

• Vitals: P 124, BP 145/30 and RR 24
• SpO2: 90% normal waveform
• EtCO2: 58 mm Hg, RR 24, normal waveform

Option 2: If the airway is secured and ventilations initiated prior to naloxone administration program the simulator with these parameters:

• Vitals: P 62, BP 132/78, and RR per team’s ventilation rate
• SpO2: 90%
• EtCO2: 55 mm Hg, RR per team’s ventilation rate, normal waveform

Following securing the airway naloxone is administered and the patient becomes immediately conscious, agitated, and confused. Program the simulator with these parameters:

• Vitals: P 124, BP 146/30, and RR 24
• SpO2: 90% normal waveform
• EtCO2: 58 mm Hg, RR 24, normal waveform

Shortly after naloxone administration, the patient’s agitation leads him to pull on both IV lines and the airway, which is pulled partially or completely out. Following restraint, program the simulator with these parameters:

• Vitals: P 124, BP 146/30, and RR 24
• SpO2: 88% normal waveform
• EtCO2: 68 mm Hg, RR 24, normal waveform

During the debrief discuss some or all of the following:

• What are the advantages and complications associated with securing the airway in this case PRIOR to administration of naloxone?
• How the case might have progressed had the team chosen to change the sequence of naloxone and air securement.
• Signs and symptoms of UE.
• Appropriate steps for confirming the positioning and patency of an ET tube.
• Safe procedure for removing the ET tube and performing reintubation.
• Importance of documenting the episode to the receiving facility.

Scenario 3: Interfacility transport

Patient briefing. Transfer of a 34 y/o female from a rural hospital to the regional Level 1 center. Patient had been in a high-speed rollover the prior night. Injuries included a fractured L femur with distal circulatory compromise and 9 fractured ribs with associated L pneumo/hemothorax and bilateral pulmonary contusions. The sending facility had stabilized the patient, surgically repaired the femur, and placed a chest tube on the left side.

Handoff assessment:

• 2 14-gauge IVs in place. Lactated ringers running at 100 mL/hr.
• Patent chest tube left 5^th intercostal space, midaxillary. Drainage system intact, 120 mL blood in the reservoir
• 7.5 endotracheal tube in place, secured with fresh twill (umbilical tape), 22 cm at the teeth
• Ventilator settings tidal volume 400 mL, rate 12, PEEP 8 cm H2O, 43% oxygen
• Patient had received 2 mg of Ativan for sedation during the transport 15 minutes prior to EMS arrival and had also received 75 mcg Fentanyl for sedation and pain, with an order for repeat dosing as needed during transport.
• Level of consciousness: sleeping but arousable and able to follow commands. Neuro exam normal.

Program the simulator with these parameters at handoff:

• Vitals: P 110, BP 108/78, and RR 12 (ventilator)
• SpO2: 90%
• EtCO2: 42 mm Hg, RR 12 per waveform

During transport, the patient awoke and became restless and her agitation increased over the next 10 minutes. When asked if she was uncomfortable, she nodded yes, and the paramedic repositioned her on the stretcher, placed padding under her lower back and femur, and administered 75 mcg of fentanyl. The patient calmed almost immediately, however, within 4-5 minutes her tachycardia and restlessness increased again.

Program the simulator with these parameters at this time:

• Vitals: P 132, BP 128/88, RR 12 (ventilator)
• SpO2: 85%
• EtCO2: 60 mm Hg, RR 16 and irregular per waveform
• Breath diminished substantially in both lungs
• ET tube position 20 cm at the teeth.

Patient’s response depends upon the providers actions.

• If the ET tube position is recognized to be displaced and the patient is extubated, reintubated, according to accepted procedures, and replaced on the ventilator the vital signs, SpO2, EtCO2 and breath sounds can return to baseline.

• If the unplanned extubation is NOT recognized and the ET tube is NOT removed and replaced the vital signs should continue to deteriorate, SpO2 should continue to drop, and the EtCO2 should continue to increase.

During the debrief, discuss some or all of the following:

• Potential times during the patient’s transport that the unplanned extubation may have occurred.
• Signs and symptoms of UE.
• Strategies for preventing unplanned extubation.
• Appropriate steps for confirming the positioning and patency of an ET tube.
• How to make the decision whether to reintubate or bag the patient for the duration of the transport.
• Safe procedure for removing the ET tube and performing reintubation.
• Importance of documenting the episode to the receiving facility.

About the Author

Scott Bourn, PhD, RN, Paramedic, FACHE is an experienced clinician, educator, researcher and clinical practice leader in the EMS, ED and ICU settings. His research, writing and lecture topics focus on defining, measuring and improving patient outcomes and experience.

Dr. Bourn has held numerous regional and national leadership positions including chair, Colorado State EMS and Trauma Advisory Council; president, National Association of EMS Educators Board; liaison to the National Association of EMS Physicians Board; and president, Advocates for EMS Board.

Dr. Bourn serves as the vice president of Clinical Quality & Impact at Securisyn Medical, senior quality consultant and research chair at ESO Solutions, and co-director of the NAEMSP Quality & Safety Course.

References

1. Ismaeil MF, E.-S.H., El-Gammal MS, Abbas, AM Unplanned versus planned extubation in respiratory intensive care unit, predictors of outcome. Egyptian Journal of Chest Diseases and Tuberculosis, 2014. 63: p. 219-231.

2. de Groot, R.I., et al., Risk factors and outcomes after unplanned extubations on the ICU: a case-control study. Crit Care, 2011. 15(1): p. R19.

3. de Lassence, A., et al., Impact of unplanned extubation and reintubation after weaning on nosocomial pneumonia risk in the intensive care unit: a prospective multicenter study. Anesthesiology, 2002. 97(1): p. 148-56.

4. da Silva, P.S. and M.C. Fonseca, Unplanned endotracheal extubations in the intensive care unit: systematic review, critical appraisal, and evidence-based recommendations. Anesth Analg, 2012. 114(5): p. 1003-14.

5. Dasta, J.F., et al., Daily cost of an intensive care unit day: the contribution of mechanical ventilation. Crit Care Med, 2005. 33(6): p. 1266-71.

6. Needham, D.M. and P.J. Pronovost, The importance of understanding the costs of critical care and mechanical ventilation. Crit Care Med, 2005. 33(6): p. 1434-5.

7. Bourn, S., Unplanned Extubation: An Underrecognized Complication. EMS World Online, 2019.