Emergency endotracheal intubation in pediatric trauma

The purpose of this study was to determine the effectiveness and associated problems of emergency intubation in 605 injured infants and children admitted to the Children's Hospital of Pittsburgh in 1987. We identified 63 patients (10.4%) undergoing endotracheal intubation at the scene of injury, at a referring hospital or in our emergency department. Injuries were to the head (90.5%), abdomen (12.7%), face (11.1%), chest (6.3%), neck (3.2%); or were orthopedic (19%) or multiple (39.7%). Indications for intubation included coma (74.6%), shock (28.6%), apnea (22.2%), and airway obstruction (3.2%). Of 16 complications (25.4%), 13 were immediately life threatening: right mainstem intubation (5), massive barotrauma (2), failure of adequate preoxygenation (2), esophageal intubation (1), attempt at nasotracheal intubation in an open facial fracture (1), and extubation during transport (1). Three were late complications: vocal cord paresis (2) and subglottic stenosis (1). Airway complications led to PO2 less than 90 mm Hg in 7 of 12 on first ABG, compared to 9 of 44 in uncomplicated cases (p less than 0.05). Intubation attempts at the scene of injury were more often multiple, unsuccessful, and associated with airway complications. All four complication-associated fatalities were life-threatening scene complications. Nearly one half (44.4%, 28 of 63) had one of the following problems in respiratory management: major airway complication, PaO2 less than 90, or PaCO2 greater than 45 on either the first or second ABG after arrival at our emergency department. Head injury with coma is the most common setting for emergency intubation. Airway complications are common, and are more frequent in treatment attempt at the scene. Despite endotracheal intubation, injured children in our series remain at high risk for hypoxemia, elevated arterial PCO2, and major airway complications, all of which contribute to secondary brain injury.