Pediatric Intubation by Paramedics in a Large Emergency Medical Services System: Process, Challenges, and Outcomes - 19/12/15

Doi : 10.1016/j.annemergmed.2015.07.021

Matthew E. Prekker, MD, MPH ^a,^⁎ , Fernanda Delgado, BS ^b, Jenny Shin, MPH ^c, Heemun Kwok, MD ^d, Nicholas J. Johnson, MD ^e, David Carlbom, MD ^e, Andreas Grabinsky, MD ^f, Thomas V. Brogan, MD ^g, Mary A. King, MD, MPH ^g, Thomas D. Rea, MD, MPH ^c
^a Department of Emergency Medicine and Department of Medicine, Division of Pulmonary and Critical Care Medicine, Hennepin County Medical Center, Minneapolis, MN
^b University of Washington School of Medicine, Seattle, WA
^c Emergency Medical Services Division, Public Health–Seattle & King County, Seattle, WA
^d Division of Emergency Medicine, University of Washington, Seattle, WA
^e Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA
^f Department of Anesthesiology, University of Washington, Seattle, WA
^g Division of Pediatric Critical Care Medicine, University of Washington and Seattle Children’s Hospital, Seattle, WA

^∗Corresponding Author.

Abstract

Study objective

Pediatric intubation is a core paramedic skill in some emergency medical services (EMS) systems. The literature lacks a detailed examination of the challenges and subsequent adjustments made by paramedics when intubating children in the out-of-hospital setting. We undertake a descriptive evaluation of the process of out-of-hospital pediatric intubation, focusing on challenges, adjustments, and outcomes.

Methods

We performed a retrospective analysis of EMS responses between 2006 and 2012 that involved attempted intubation of children younger than 13 years by paramedics in a large, metropolitan EMS system. We calculated the incidence rate of attempted pediatric intubation with EMS and county census data. To summarize the intubation process, we linked a detailed out-of-hospital airway registry with clinical records from EMS, hospital, or autopsy encounters for each child. The main outcome measures were procedural challenges, procedural success, complications, and patient disposition.

Results

Paramedics attempted intubation in 299 cases during 6.3 years, with an incidence of 1 pediatric intubation per 2,198 EMS responses. Less than half of intubations (44%) were for patients in cardiac arrest. Two thirds of patients were intubated on the first attempt (66%), and overall success was 97%. The most prevalent challenge was body fluids obscuring the laryngeal view (33%). After a failed first intubation attempt, corrective actions taken by paramedics included changing equipment (33%), suctioning (32%), and repositioning the patient (27%). Six patients (2%) experienced peri-intubation cardiac arrest and 1 patient had an iatrogenic tracheal injury. No esophageal intubations were observed. Of patients transported to the hospital, 86% were admitted to intensive care and hospital mortality was 27%.

Conclusion

Pediatric intubation by paramedics was performed infrequently in this EMS system. Although overall intubation success was high, a detailed evaluation of the process of intubation revealed specific challenges and adjustments that can be anticipated by paramedics to improve first-pass success, potentially reduce complications, and ultimately improve clinical outcomes.

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Plan

Introduction

Background

Importance

Goals of This Investigation

Materials and Methods

Study Design and Setting

Selection of Participants

Data Collection and Processing

Primary Data Analysis

Results

Characteristics of Study Subjects

Main Results

Limitations

Discussion

	Please see page 21 for the Editor’s Capsule Summary of this article.
	Supervising editor: Steven M. Green, MD
	Author contributions: MEP, HK, TVB, MAK, and TDR conceived and designed the investigation. MEP, FD, and JS supervised data collection and managed the study database. MEP analyzed the data. MEP, NJJ, and TDR drafted the article. All authors contributed substantially to article revision. MEP takes responsibility for the paper as a whole.
	Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org/). The authors have stated that no such relationships exist and provided the following details: Dr. Prekker received salary support as a senior research fellow between 2012 and 2014 from a National Institutes of Health T32 institutional training grant awarded to the University of Washington Division of Pulmonary and Critical Care Medicine.
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