Emergency Intubations in a High-Volume Pediatric Emergency Department

Resuscitation of critically ill children can be chaotic, and emergency airway management is often fraught with difficulties. This study aimed to characterize the Singaporean landscape of tracheal intubation in a pediatric emergency unit, placing emphasis on safety outcomes, procedural process of care, and provider training.

A retrospective review of all cases presented to the KK Women's and Children's Hospital from January 2009 to December 2013 with intubation carried out within the pediatric emergency unit was done. Medical records were accessed for data collection, and the information was subsequently used for analysis.

A total of 207 intubations were carried out in the pediatric emergency unit. The median age was 4 years (interquartile range, 11 months to 8 years). Oral tracheal intubation with the combination of sedation and paralysis was the main approach. Atropine was used for pretreatment in 156 cases (75.4%). Midazolam was the most commonly used induction agent, and succinylcholine was the most commonly used the paralytic agent. Intubation was achieved on the first attempt in 175 cases (84.5%). Postintubation sedation was initiated in 94 cases (45.4%). Postintubation paralysis was initiated in 50 cases (24.2%). Postintubation analgesia was initiated in 13 cases (6.3%). Twenty emergency intubations (9.7%) were associated with at least 1 tracheal intubation adverse event, with 7 cases (3.4%) having severe tracheal intubation adverse events. In 1 case (0.5%), the patient died within the pediatric emergency unit, and 27 patients (13.0%) did not survive to discharge from the hospital.

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.