Prehospital Airway Management Examined at Two Pediatric Emergency Centers

Abstract

IntroductionRoutine advanced airway usage by Emergency Medical Services (EMS) has had conflicting reports of being the secure airway of choice in pediatric patients.Hypothesis/ProblemThe primary objective was to describe a pediatric cohort requiring airway management upon their arrival directly from the scene to two pediatric emergency departments (PEDs). A secondary objective included assessing for associations in EMS airway management and patient outcomes.MethodsRetrospective data from the health record were reviewed, including EMS reports, for all arrivals less than 18 years old to two PEDs who required airway support between May 2015 and July 2016. The EMS management was classified as basic (oxygen, continuous positive airway pressure [CPAP], or bag-valve-mask [BVM]) or advanced (supraglottic or endotracheal intubation [ETI]) based on EMS documentation. Outcomes included oxygenation as documented by receiving PED and hospital mortality.ResultsIn total, 104 patients with an average age 5.9 (SD=5.1) years and median EMS Glasgow Coma Scale (GCS) of nine (IQR 3-14) were enrolled. Basic management was utilized in 70% of patients (passive: n=49; CPAP: n=2; BVM: n=22). Advanced management was utilized in 30% of patients (supraglottic: n=4; ETI: n=27). Proper ETI placement was achieved in 48% of attempted patients, with 41% of patients undergoing multiple attempts. Inadequate oxygenation occurred in 18% of patients, including four percent of ETI attempts, nine percent of BVM patients, and 32% of passively managed patients. Adjusted for EMS GCS, medical patients undergoing advanced airway management experienced higher risk of mortality (risk-ratio [RR] 2.98; 95% CI, 1.18-7.56; P=.021).ConclusionWith exception to instances where ETI is clearly indicated, BVM management is effective in pediatric patients who required airway support, with ETI providing no definitive protective factors. Most of the patients who exhibited inadequate oxygenation upon arrival to the PED received only passive oxygenation by EMS.TweedJ, GeorgeT, GreenwellC, VinsonL.Prehospital airway management examined at two pediatric emergency centers. Prehosp Disaster Med. 2018;33(5):532–538.

Meta-Analysis of Failure of Prehospital Endotracheal Intubation in Pediatric Patients

“…is study shows wide variability in the frequency of failed intubation in pediatric patients ranging from 0.4% (Cooper) [18] to 52.6% (Boswell) [21]. According to Tweed et al [23], a main factor contributing to successful intubation by prehospital care providers is being consistently exposed to the performance of the procedure, both in the field and in simulated conditions, and this aspect is more relevant than the inherent risk factors of patients. In pediatric population, intubation requirements are approximately 4 per year, and in many places, training demands are minimal in terms of exposure, which may not be sufficient for prehospital staff to provide an adequate service when required [11,15,21,23,24].…”

“…Despite all the available techniques, OTI remains the gold standard for airway management because its utility and safety mainly depend on nonpatient-related factors, such as consistent [29] 8.0 (1.0-26.0) SpO2 < 90% after intubation, hypotension, aspiration Hansen et al [25] 1.2 (0.8-1.5) Bleeding, bradycardia, hypotension, hypoxia, trauma, sickness Bankole et al [22] 2.6 (0.1-13.5) ND Eich et al [39] 1.7 (0.0-9.2) Misplaced tube Ehrlich et al [11] 3.4 (0.4-11.7) Body intubation, aspiration, barotrauma, extubation Vilke et al [41] 0.9 (0.2-2.7) ND Pointer [43] 2.8 (0.1-14.5) ND Aijian et al [44] 3.6 (0. Emergency Medicine International training of prehospital staff and sufficient pediatric intubation opportunities, which may reach only up to 4 or 5 per year, as stated previously [11,15,21,23,24]. Nowadays, there are 2 prehospital care models: the Anglo-American model, whose aim is for patients to arrive at the hospital and receive treatment there, and the French-German model, which focuses on the hospital arriving where the patient is.…”

Endotracheal intubation to reduce aspiration events in acutely comatose patients: a systematic review

“…Seven studies involved non-traumatic unconscious patients (poisoned or intoxicated patients) [6,8,[16][17][18][19][20], 4 studies enlisted traumatic brain injury (TBI) patients [11,[21][22][23]. A study enrolled adult patients who required intubation for traumatic and non-traumatic cases [24]; a study enrolled pediatric mixed traumatic and non-traumatic cases [12].…”

“…All studies were observational: 4 enrolled patients prospectively [8,16,18,21], while the remaining 9 were retrospective [6,11,12,17,19,20,[22][23][24]. Only one study, among those prospective, specified the consecutive enrollment of patients [8].…”

“…Other studies observed an increased risk of hospitalization [8]. In addition, pre-hospital intubation can encounter complications related to the operator's experience [9,10] and the environment in which it takes place [11][12][13].…”