The Royal College of Anaesthetists recently received a coroners report where an oesophageal intubation took place and was not recognised in time to save the life of the patient. Unrecognised oesophageal intubation is preventable through adherence to published recommendations on the monitoring of exhaled carbon dioxide (capnography) and its correct interpretation. All clinicians involved in airway management should watch the College and DAS video on capnography. Always remember 'No Trace = Wrong Place' and actively seek to exclude oesophageal intubation when a flat capnograph trace is encountered.
Prevention of Future Deaths: Unrecognised oesophageal intubation (Royal College of Anaesthetists) https://www.rcoa.ac.uk/safety-standards-quality/patient-safety/prevention-future-deaths
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