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Out-of-hospital rapid-sequence induction for intubation of the pediatric patient
R F Sing1, P M Reilly, M F Rotondo
1Division of Trauma/Surgical Critical Care, University of Pennsylvania Medical Center, Philadelphia, USA.
Insights
Out-of-hospital rapid-sequence induction (RSI) effectively secures airways in critically ill pediatric patients. While intubation mishaps were common, they did not increase pulmonary complications, but atropine omission was linked to bradycardia.
Area of Science:
- Emergency Medicine
- Pediatric Critical Care
- Airway Management
Background:
- Out-of-hospital endotracheal intubation (ETI) in pediatric patients presents unique challenges.
- Rapid-sequence induction (RSI) is a common technique for airway management.
Purpose of the Study:
- To evaluate the effectiveness and morbidity of out-of-hospital RSI for ETI in pediatric patients.
- To identify complications associated with out-of-hospital pediatric RSI.
Main Methods:
- Retrospective review of medical records for pediatric patients undergoing out-of-hospital RSI by flight paramedics.
- Data abstracted included patient demographics, medications, blood gas results, and complications.
Main Results:
- Out-of-hospital RSI was performed on 40 pediatric patients (mean age 8.1 years).
- Intubation success rate was 97.5%, with 33% experiencing mishaps (e.g., aspiration, multiple attempts).
- Pulmonary complications occurred in 13 patients; bradycardia was linked to a lack of atropine pretreatment.
Conclusions:
- Out-of-hospital RSI is an effective method for airway control in critically ill pediatric patients.
- Intubation mishaps did not correlate with an increased rate of pulmonary complications.
- Failure to administer atropine prior to RSI was associated with bradycardia in pediatric patients.
Objective:
To determine the effectiveness and morbidity of out-of-hospital rapid-sequence induction (RSI) for endotracheal intubation (ETI) in the pediatric population.
Methods:
The medical records were retrospectively reviewed for a consecutive series of pediatric patients undergoing out-of-hospital RSI by flight paramedics from July 1990 through July 1994. Patient demographics, pharmacologic agents, ED arterial blood gas data, pulmonary complications, and RSI-related complications were abstracted.
Results:
Forty patients (31 injured, 9 medical) with a mean age of 8.1 years (range 0.5-17 years) underwent out-of-hospital RSI. Indications for intubation included hyperventilation (n = 20), combativeness (n = 16), apnea (n = 5), and unknown (n = 5). Intubation mishaps occurred in 13 patients (33%); these included multiple attempts (n = 9), aspiration (n = 8), and esophageal intubation (n = 1). The success rate of ETI was 97.5% (one failed attempt). Hemodynamic side effects occurred in three patients (8%); all three had bradycardia, with one developing hypotension. Bradycardia was associated with failure to pretreat with atropine (p < 0.05). Sixteen pulmonary complications, seven pneumonia (18%) and nine atelectasis (22.5%), occurred in 13 patients within the first ten hospital days. Intubation mishaps were not associated with pulmonary complications. There were six deaths, none associated with RSI.
Conclusions:
1) Rapid-sequence induction is an effective method for obtaining airway control in the critically ill pediatric patient. 2) Intubation mishaps did not influence the rate of pulmonary complications. 3) Omission of atropine was associated with bradycardia during RSI in pediatric patients.