Guidelines based on the principle 'First, do no harm'. New guidelines on tracheal tube confirmation and prevention of dislodgment.

Abstract

In summary, this editorial and the one on pulse check point out another area in which a total reliance on evidence-based guidelines amy do our patients a disservice. The debate over dropping the pulse check hinged less on the strength of the evidence and more on the widespread clinical principle of fear of false-negative errors. The discussion of secondary confirmation of tracheal tube placement also lacks a strong base of evidence that identifies the one best technique of tube confirmation for patients with a pulse versus those without a pulse. The principles of the zero-risk intervention and first, do no harm come into play in this situation. We must deal with the growing awareness of the fact that tracheal intubation is not only a potentially lethal intervention but now is also a confirmed lethal intervention, and at a much higher death rate than has ever been suspected. Factors that contribute to the transformation of the tracheal tube from a life-saving to a death-causing intervention are being identified by honest and open researchers. National societies in emergency medicine are responding appropriately. We strongly recommend shifting from making an evidence-based recommendation to instead making a principle-based recommendation--killing our patients is unacceptable; we must act on the widespread concept regarding errors in medicine. We must adopt zero-risk interventions in all possible situations.