Emergency Intubations in a High-Volume Pediatric Emergency Department

Pek, Jen Heng; Ong, Yong-Kwang Gene

doi:10.1097/pec.0000000000001355

Cited by 14 publications

(17 citation statements)

References 19 publications

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“…As intubation for children is a rare event (e.g., 2–33/10,000 ED visits), emergency physicians are likely unfamiliar with airway management in children. Additionally, the highly stressed clinical situation within limited resources might further contribute to low success rates and errors, such as miscalculation for medication doses .…”

Section: Special Circumstance: Childrenmentioning

confidence: 99%

Advancing emergency airway management practice and research

Goto

Hagiwara

et al. 2019

Acute Medicine & Surgery

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Emergency airway management is one of the vital resuscitative procedures undertaken in the emergency department (ED). Despite its clinical and research importance in the care of critically ill and injured patients, earlier studies have documented suboptimal intubation performance and high adverse event rates with a wide variation across the EDs. The optimal emergency airway management strategies remain to be established and their dissemination to the entire nation is a challenging task. This article reviews the current published works on emergency airway management with a focus on the use of airway management algorithms as well as the importance of first‐pass success and systematic use of rescue intubation strategies. Additionally, the review summarizes the current evidence for each of the important airway management processes, such as assessment of the difficult airway, preparation (e.g., positioning and oxygenation), intubation methods (e.g., rapid sequence intubation), medications (e.g., premedications, sedatives, and neuromuscular blockades), devices (e.g., direct and video laryngoscopy and supraglottic devises), and rescue intubation strategies (e.g., airway adjuncts and rescue intubators), as well as the airway management in distinct patient populations (i.e., trauma, cardiac arrest, and pediatric patients). Well‐designed, rigorously conducted, multicenter studies that prospectively and comprehensively characterize emergency airway management should provide clinicians with important opportunities for improving the quality and safety of airway management practice. Such data will not only advance research into the determination of optimal airway management strategies but also facilitate the development of clinical guidelines, which will, in turn, improve the outcomes of critically ill and injured patients in the ED.

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Section: Special Circumstance: Childrenmentioning

confidence: 99%

Advancing emergency airway management practice and research

Goto

Hagiwara

et al. 2019

Acute Medicine & Surgery

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“…Matettore et al 3 had reported adverse tracheal intubation‐associated events to be more common in pediatric patients presenting to non‐specialist centers. However, this finding was not replicated and may be explained by the lower frequency of intubation among pediatric patients as compared to adult patients 12‐14 . Consequentially, emergency physicians in general EDs would be more experienced with emergency airway management even though they may be less familiar with intubation in pediatric patients.…”

Section: Discussionmentioning

confidence: 89%

“…However, this finding was not replicated and may be explained by the lower frequency of intubation among pediatric patients as compared to adult patients. [12][13][14] Consequentially, emergency physicians in general EDs would be more experienced with emergency airway management even though they may be less familiar with intubation in pediatric patients. They were thus able to apply principles and techniques to facilitate intubation in these critically ill pediatric patients, leading to a similar success rate with a lower rate of adverse tracheal intubation-associated events as compared to the pediatric ED.…”

Section: Discussionmentioning

confidence: 99%

Differences in intubation outcomes for pediatric patients between pediatric and general Emergency Departments

Ong

Chong

et al. 2021

Pediatric Anesthesia

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Background: Intubation is a life-saving intervention at the Emergency Department (ED). However, general and pediatric EDs may vary in their preparedness to manage children with airway emergencies. Aims:We aimed to compare rates of first-pass intubation and adverse tracheal intubation-associated events between general and pediatric EDs.Methods: A retrospective review of medical records was conducted at a pediatric ED and three general EDs from January 1, 2015, to December 31, 2018. Information about the intubation process involving pediatric patients (less than 16 years old), as well as eventual outcomes of first-pass intubation and adverse tracheal intubationassociated events were collected and analyzed.Results: There were 180 pediatric intubations, of which 115 (63.9%) were performed in pediatric ED. The median age was 2 years old (interquartile range 0-6). Intubation was most commonly performed for patients with cardiac arrest (88, 48.9%). Direct laryngoscopy was used in 178 (98.9%) cases and uncuffed tube was used in 135 (75.0%) cases. Apneic oxygenation was performed in 26 (14.4%) cases-all in pediatric ED.Intubation was predominantly performed by senior clinicians (162, 90.0%). Overall, intubation was performed successfully in 175 (97.2%) cases, with a first-pass intubation rate of 82.2% which was similar between pediatric (96, 83.5%) and general EDs (52, 80%) (Odds ratio [OR] 1.26, 95% confidence interval [CI] 0.58 to 2.76, p = .558).There were 68 adverse tracheal intubation-associated events with right mainstem intubation being the most common (23, 12.8%). Pediatric EDs (44, 38.3%) had a higher rate of adverse tracheal intubation-associated events than general EDs (15, 23.1%) (OR 2.07, 95% CI 1.04 to 4.11; p = .037). Conclusions: Differences exist in intubation outcomes between pediatric and generalEDs. Quality improvement efforts should focus on standardizing intubation practices across both pediatric and general EDs.

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“…Pediatric endotracheal intubations in the ED are relatively infrequent compared to adult intubations. 2 , 3 A recent study of 43 EDs in Australia and New Zealand showed that pediatric intubations accounted only for 4.94% (270/5463) of all total intubations. 2 This presents a problem to practitioners who manage pediatric patients, as they have fewer opportunities to “practice” real‐life pediatric intubations.…”

Section: Introductionmentioning

confidence: 99%

The adjuncts for endotracheal tube passage in simulated pediatric airways (AET‐SPA) study

Gan

Shepherd

2022

JACEP Open

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Objectives To investigate whether the use of adjuncts such as stylet, railroaded bougie, and preloaded bougie increases first‐pass success rate and decreases time to successful intubation when intubating simulated infant airways using direct laryngoscopy. Methods A crossover study using experienced practitioners (who were required to carry out emergency pediatric intubations as part of their usual practice) was completed. Participants completed a random sequence of 4 intubations in simulated “easy” airways and 4 intubations in simulated “difficult” airways, using naked endotracheal tube, stylet, railroaded bougie, and preloaded bougie on standardized infant airway manikins. First‐pass success rates and times to successful intubations were measured. Results From June 1 to December 30, 2019, 109 participants performed a total of 872 intubation attempts. In the easy airway, both naked endotracheal tube (mean 96.3% [95% confidence interval 90.9%–99.0%]) and stylet (mean 98.2% [95% confidence interval 93.5%–99.8%]) had higher first‐pass success rates than railroaded bougie and preloaded bougie. In the difficult airway, stylet (mean 76.1% [95% confidence interval 67.0%–83.8%]) had the highest first‐pass success rate, followed by the naked endotracheal tube, and then both the railroaded bougie and preloaded bougie. Differences in first‐pass success rates were independent of the participants’ numbers of previous pediatric intubations. Conclusion Results of this simulation‐based study suggest that stylet should be used as the first attempt technique for infant intubations regardless of the presence or absence of predicted airway difficulty. This finding needs further validation using alternative models and in non‐simulation settings.

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Emergency Intubations in a High-Volume Pediatric Emergency Department

Abstract: All tracheal intubations performed were successful. Variance still exists in tracheal intubation practice. Further elucidation of patient, practice, and provider factors will aid development of a bundle quality improvement intervention directed at addressing these factors.

Cited by 14 publications

References 19 publications

Advancing emergency airway management practice and research

Advancing emergency airway management practice and research

Differences in intubation outcomes for pediatric patients between pediatric and general Emergency Departments

The adjuncts for endotracheal tube passage in simulated pediatric airways (AET‐SPA) study

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