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Hanlin ER, Chan HK, Covert H, Hansen M, Wendelberger B, Shah MI, Bosson N, Gausche-Hill M, VanBuren JM, Schulz K, Huebinger R, Wang HE. The Epidemiology of Out-of-Hospital Pediatric Airway Management in the 2019 ESO Data Collaborative. PREHOSP EMERG CARE 2024:1-6. [PMID: 39132933 DOI: 10.1080/10903127.2024.2383967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 05/16/2024] [Accepted: 06/20/2024] [Indexed: 08/13/2024]
Abstract
OBJECTIVES Airway management is a fundamental skill that Emergency Medical Services (EMS) clinicians must be prepared to perform on patients of any age. We performed one of the first epidemiological studies of out-of-hospital pediatric airway management utilizing the ESO data set. METHODS We used the 2019 ESO Data Collaborative public release research data set. We performed a descriptive analysis of all patients <18 years receiving at least one of the following airway management interventions: nasopharyngeal airway, oropharyngeal airway, noninvasive positive pressure ventilation (NIPPV), airway suctioning, bag-valve-mask ventilation (BVM), tracheal intubation (TI), supraglottic airway (SGA) or surgical airway placement. We determined the success rates for BVM, TI and SGA. RESULTS Among 7,422,710 911 EMS activations, there were 346,912 pediatric encounters that resulted in patient care. Airway management occurred in 27,071 encounters (7,803 per 100,000 pediatric EMS patient care events). Use of BVM, intubation or supraglottic airway insertion occurred in 3,496 encounters (1,007 per 100,000 pediatric EMS patient care events). Ventilation with BVM occurred in 2,226 encounters (642 per 100,000 pediatric EMS patient care events), TI in 935 pediatric EMS patient care encounters (270 per 100,000 patient care encounters), and supraglottic airway insertion in 335 patient encounters (97 per 100,000 patient care encounters). Overall TI success was 71.4%, rapid sequence intubation success was 86.3%, and SGA success was 87.2%. Overall TI first pass success rate was 63.1%. CONCLUSIONS In the ESO cohort, advanced airway management of children occurred in only 5.9 in 10,000 911 emergency encounters. Overall and first pass success rates for TI were low. These data provide contemporary perspectives of pediatric prehospital airway management in the United States.
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Affiliation(s)
- Erin R Hanlin
- Department of Emergency Medicine, Duke University, Durham, North Carolina
- Durham County Emergency Medical Services, Durham, North Carolina
| | - Hei Kit Chan
- Department of Emergency Medicine, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Harold Covert
- Department of Emergency Medicine, Duke University, Durham, North Carolina
| | - Matthew Hansen
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | | | - Manish I Shah
- Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Nichole Bosson
- Los Angeles County Emergency Medical Services Agency, Los Angeles, California
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Marianne Gausche-Hill
- Los Angeles County Emergency Medical Services Agency, Los Angeles, California
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
- David Geffen School of Medicine at UCLA, Los Angeles, California
- Department of Pediatrics, Harbor-UCLA Medical Center, Torrance, California
| | - John M VanBuren
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Kevin Schulz
- Department of Emergency Medicine, The University of Texas Health Science Center at Houston, Houston, Texas
- Houston Fire Department, Houston, Texas
| | - Ryan Huebinger
- Department of Emergency Medicine, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Henry E Wang
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio
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AlGhamdi FA, AlJoaib NA, Saati AM, Abu Melha MA, Alkhofi MA. Paramedics' Success and Complications in Prehospital Pediatric Intubation: A Meta-Analysis. Prehosp Disaster Med 2024; 39:184-194. [PMID: 38531631 DOI: 10.1017/s1049023x24000244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024]
Abstract
BACKGROUND Prehospital pediatric intubation is a potentially life-saving procedure in which paramedics are relied upon. However, due to the anatomical nature of pediatrics and associated adverse events, it is more challenging compared to adult intubation. In this study, the knowledge and attitude of paramedics was assessed by measuring their overall success rate and associated complications. METHODS An online search using PubMed, Scopus, Web of Science, and Cochrane CENTRAL was conducted using relevant keywords to include studies that assess success rates and associated complications. Studies for eligibility were screened. Data were extracted from eligible studies and pooled as risk ratio (RR) with a 95% confidence interval (CI). RESULTS Thirty-eight studies involving 14,207 pediatrics undergoing intubation by paramedics were included in this study. The prevalence of success rate was 82.5% (95% CI, 0.745-0.832) for overall trials and 77.2% (95% CI, 0.713-0.832) success rate after the first attempt. By subgrouping the patients according to using muscle relaxants during intubation, the group that used muscle relaxants showed a high overall successful rate of 92.5% (95% CI, 0.877-0.973) and 79.9% (95% CI, 0.715-0.994) success rate after the first attempt, more than the group without muscle relaxant which represent 78.9% (95% CI, 0.745-0.832) overall success rate and 73.3% (95% CI, 0.616-0.950) success rate after first attempt. CONCLUSION Paramedics have a good overall successful rate of pediatric intubation with a lower complication rate, especially when using muscle relaxants.
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Affiliation(s)
- Faisal A AlGhamdi
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Nasser A AlJoaib
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Abdulaziz M Saati
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Mishal A Abu Melha
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Mohammad A Alkhofi
- Department of Pediatrics, King Fahad University Hospital, Imam Abdulrahman bin Faisal's University, Khobar, Saudi Arabia
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Ramgopal S, Jaeger L, Cercone A, Martin-Gill C, Fishe J. The Child Opportunity Index and Pediatric Emergency Medical Services Utilization. PREHOSP EMERG CARE 2023; 27:238-245. [PMID: 35536226 DOI: 10.1080/10903127.2022.2076268] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Background: The delivery of emergency medical services (EMS) is a resource-intensive process, and prior studies suggest that EMS utilization in children may vary by socioeconomic status. The Child Opportunity Index (COI) provides a multidimensional measure of neighborhood-level resources and conditions that affect the health of children. We evaluated EMS utilization and measures of acuity among children by COI.Methods: We performed a cross-sectional study using encounters for patients less than 18 years of age from 10,067 EMS agencies in 47 US states and territories contributing to the National Emergency Medical Services Information System 2019 dataset. We compared patient demographics, EMS encounter characteristics, and care provided to children stratified by ZIP code using the COI 2.0.Results: We included 1,293,038 EMS encounters (median age 10 years, IQR 3-15 years). The distributions of encounters in the five tiers of COI were 30.6%, 20.1%, 18.0%, 16.3% and 15.1%, (from Very Low to Very High, respectively). The distribution of diagnoses between groups was similar. Most measures of EMS acuity/resource use were similar between groups, including non-transport status, cardiac arrest, vital sign abnormalities, and EMS-administered procedures and medications. Among children with respiratory-related encounters, children in the Very Low group had a greater need for nebulized medications (26.4% vs 18.3% in Very High COI children). Among children with trauma, a lower proportion in the Very Low group were given analgesia (4.0% vs 7.4% in the Very High group), though pain scores were similar in all groups.Conclusion: Pediatric EMS encounters from lower COI neighborhoods occur more frequently relative to encounters from higher COI neighborhoods. Despite these differences, children from lower COI strata generally have similar encounter characteristics to those in other COI strata, suggestive of a greater number of true out-of-hospital emergencies among children from these areas. Notable differences in care included use of respiratory medication to children with respiratory diagnoses, and administration of pain medication to children with trauma.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lindsay Jaeger
- Department of Pediatrics, Section of Emergency Medicine, University of Chicago School of Medicine, Chicago, Illinois
| | - Angelica Cercone
- Division of Emergency Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jennifer Fishe
- Division of Pediatric Emergency Medicine, Dept of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida
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Stuby L, Mühlemann E, Jampen L, Thurre D, Siebert JN, Suppan L. Effect of Intermediate Airway Management on Ventilation Parameters in Simulated Pediatric Out-of-Hospital Cardiac Arrest: Protocol for a Multicenter, Randomized, Crossover Trial. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10010148. [PMID: 36670698 PMCID: PMC9856669 DOI: 10.3390/children10010148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/02/2023] [Accepted: 01/10/2023] [Indexed: 01/13/2023]
Abstract
Most pediatric out-of-hospital cardiac arrests (OHCAs) are caused by hypoxia, which is generally consecutive to respiratory failure. To restore oxygenation, prehospital providers usually first use basic airway management techniques, i.e., bag-valve-mask (BVM) devices. These devices present several drawbacks, most of which could be avoided using supraglottic airway devices. These intermediate airway management (IAM) devices also present significant advantages over tracheal intubation: they are associated with higher success and lower complication rates in the prehospital setting. There are, however, few data regarding the effect of early IAM in pediatric OHCA. This paper details the protocol of a trial designed to evaluate the impact of this airway management strategy on ventilation parameters through a simulated, multicenter, randomized, crossover trial. The hypothesis underlying this study protocol is that early IAM without prior BVM ventilations could improve the ventilation parameters in comparison with the standard approach, which consists in BVM ventilations only.
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Affiliation(s)
- Loric Stuby
- Genève TEAM Ambulances, Emergency Medical Services, CH-1201 Geneva, Switzerland
- Correspondence:
| | - Elisa Mühlemann
- ESAMB-École Supérieure de Soins Ambulanciers, College of Higher Education in Ambulance Care, CH-1231 Conches, Switzerland
| | - Laurent Jampen
- ESAMB-École Supérieure de Soins Ambulanciers, College of Higher Education in Ambulance Care, CH-1231 Conches, Switzerland
| | - David Thurre
- Ambulances de la Ville de Sion, Emergency Medical Services, CH-1950 Sion, Switzerland
| | - Johan N. Siebert
- Division of Pediatric Emergency Medicine, Geneva Children’s Hospital, Geneva University Hospitals, CH-1205 Geneva, Switzerland
| | - Laurent Suppan
- Division of Emergency Medicine, Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, CH-1211 Geneva, Switzerland
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Arnim V, Dumbarton T, Vlatten D, Law JA. The authors respond: Prehospital airway support and provider training. Am J Emerg Med 2022; 60:181-182. [PMID: 36050133 DOI: 10.1016/j.ajem.2022.08.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 08/14/2022] [Indexed: 11/29/2022] Open
Affiliation(s)
- Vlatten Arnim
- Department of Pediatric Anesthesia, IWK Health Centre, Halifax, Canada; Department of Anesthesia, Pain Management and Perioperative Management, Dalhousie University, Halifax, Canada.
| | - Tristan Dumbarton
- Department of Pediatric Anesthesia, IWK Health Centre, Halifax, Canada; Department of Anesthesia, Pain Management and Perioperative Management, Dalhousie University, Halifax, Canada
| | - David Vlatten
- Department of Anesthesia, Pain Management and Perioperative Management, Dalhousie University, Halifax, Canada
| | - John Adam Law
- Department of Anesthesia, Pain Management and Perioperative Management, Dalhousie University, Halifax, Canada
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McCans K, Varma S, Ramgopal S, Martin-Gill C, Owusu-Ansah S. Variation in Prehospital Protocols for Pediatric Respiratory Distress Management in the United States. Pediatr Emerg Care 2022; 38:e1355-e1361. [PMID: 35267248 DOI: 10.1097/pec.0000000000002620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study aimed to compare statewide emergency medical services protocols for the management of pediatric respiratory distress. METHODS We performed a descriptive study of emergency medical services protocols for the management of pediatric respiratory distress in the United States, excluding those without model or mandatory protocols. We compared medication recommendations for specific disease processes, including asthma, croup, epiglottitis, anaphylaxis, generalized respiratory distress, intubation, and drug assisted intubation. RESULTS Thirty-four state protocols were included. All had protocols to address the management of pediatric respiratory distress. There was high agreement in albuterol use for bronchospasm and epinephrine use in anaphylaxis. Epinephrine was recommended in all anaphylaxis protocols, 27 croup protocols (79%), and 3 epiglottitis protocols (9%). Six states (18%) called for albuterol in patients with generalized respiratory distress. Steroid recommendations and indications had variance among states; 26 states (76%) allowed steroid use in patients with asthma, 19 states (56%) recommended steroid use in anaphylaxis, and 11 (32%) recommended steroid use in croup protocols. The route for steroid administration also varied among protocols. Five states (15%) allowed continuous positive airway pressure application in pediatric patients, whereas endotracheal intubation and rapid sequence intubations had varying requirements as well as recommendations for use. Twelve (35%) listed impending or current respiratory failure as an indication, whereas other states had specific markers, such as Glasgow Coma Scale or oxygen saturation, as indications. CONCLUSIONS All included states had specific recommendations for the management of pediatric respiratory distress. There was consistency in recommendations for albuterol use for wheezing and epinephrine use for anaphylaxis. However, there was wide variability in other uses for epinephrine, steroid administration, continuous positive airway pressure use, and specific treatments for croup and epiglottitis. The findings of this study provide a base for important future evidence-based protocol developments and changes in prehospital pediatric respiratory distress treatment.
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Affiliation(s)
- Kerry McCans
- From the University of Pittsburgh, Pittsburgh, PA
| | - Selina Varma
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Sriram Ramgopal
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Sylvia Owusu-Ansah
- Division of Pediatric Emergency Medicine, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
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7
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Tracheal Tube Misplacement after Emergency Intubation in Pediatric Trauma Patients: A Retrospective, Exploratory Study. CHILDREN 2022; 9:children9020289. [PMID: 35205009 PMCID: PMC8870798 DOI: 10.3390/children9020289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 02/14/2022] [Accepted: 02/16/2022] [Indexed: 02/07/2023]
Abstract
Inadvertent tracheal tube misplacement and particularly endobronchial intubation are well-known complications of emergency endotracheal intubation (ETI) in pediatric trauma patients, which require repositioning of the tube to avoid impairment of gas exchange. The main aim of study was to identify the frequency of tube misplacement and associated factors of pediatric trauma patients who received ETI either by prehospital physician-staffed emergency medical service (EMS), or at emergency department (ED) admission to a single level-1 trauma center. Sixty-five patients (median age 14 years and median injury severity score 29) were included. Of these, 30 underwent helicopter EMS ETI, 29 ground EMS ETI, and 6 ED ETI. Seventeen cases (26%) of tracheal tube misplacement were recognized. After multivariable analysis, tracheal tube misplacement was independently negatively associated with body weight (OR 0.86; 95% CI, 0.76–0.99; p = 0.032) and helicopter EMS ETI (OR 0.20; 95% CI, 0.04–0.97; p = 0.036). Two of nineteen patients received tube thoracostomy due to endobronchial intubation. Mortality and length of stay were comparable in patients with misplaced tubes and correctly placed tubes. The results suggest that particularly small children require attention to avoid tracheal tube misplacement, which emphasizes the need for special training. Helicopter EMS physicians’ expertise might be beneficial in prehospital pediatric trauma patients requiring advanced airway management.
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Harris M, Lyng JW, Mandt M, Moore B, Gross T, Gausche-Hill M, Donofrio-Odmann JJ. Prehospital Pediatric Respiratory Distress and Airway Management Interventions: An NAEMSP Position Statement and Resource Document. PREHOSP EMERG CARE 2022; 26:118-128. [PMID: 35001823 DOI: 10.1080/10903127.2021.1994675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Devices and techniques such as bag-valve-mask ventilation, endotracheal intubation, supraglottic airway devices, and noninvasive ventilation offer important tools for airway management in critically ill EMS patients. Over the past decade the tools, technology, and strategies used to assess and manage pediatric respiratory and airway emergencies have evolved, and evidence regarding their use continues to grow.NAEMSP recommends:Methods and tools used to properly size pediatric equipment for ages ranging from newborns to adolescents should be available to all EMS clinicians. All pediatric equipment should be routinely checked and clearly identifiable in EMS equipment supply bags and vehicles.EMS agencies should train and equip their clinicians with age-appropriate pulse oximetry and capnography equipment to aid in the assessment and management of pediatric respiratory distress and airway emergencies.EMS agencies should emphasize noninvasive positive pressure ventilation and effective bag-valve-mask ventilation strategies in children.Supraglottic airways can be used as primary or secondary airway management interventions for pediatric respiratory failure and cardiac arrest in the EMS setting.Pediatric endotracheal intubation has unclear benefit in the EMS setting. Advanced approaches to pediatric ETI including drug-assisted airway management, apneic oxygenation, and use of direct and video laryngoscopy require further research to more clearly define their risks and benefits prior to widespread implementation.If considering the use of pediatric endotracheal intubation, the EMS medical director must ensure the program provides pediatric-specific initial training and ongoing competency and quality management activities to ensure that EMS clinicians attain and maintain mastery of the intervention.Paramedic use of direct laryngoscopy paired with Magill forceps to facilitate foreign body removal in the pediatric patient should be maintained even when pediatric endotracheal intubation is not approved as a local clinical intervention.
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9
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Mandt M, Harris M, Lyng J, Moore B, Gross T, Gausche-Hill M, Donofrio-Odmann JJ. Quality Management of Prehospital Pediatric Respiratory Distress and Airway Programs: An NAEMSP Position Statement and Resource Document. PREHOSP EMERG CARE 2022; 26:111-117. [PMID: 35001832 DOI: 10.1080/10903127.2021.1986184] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The unique challenges of pediatric respiratory and airway emergencies require the development and maintenance of a prehospital quality management program that includes pediatric-focused medical oversight and clinical care expertise, data collection, operational considerations, focused education, and clinician competency evaluation.NAEMSP recommends:Medical director oversight must include a focus on pediatric airway and respiratory management and integrate pediatric-specific elements in guideline development, competency assessment, and skills maintenance efforts.EMS agencies are encouraged to collaborate with medical professionals who have expertise in pediatric emergency care to provide support for quality management initiatives in pediatric respiratory distress and airway management.EMS agencies should define quality indicators for pediatric-specific elements in respiratory distress and airway management and benchmark performance based on regional and national standards.EMS agencies should implement both quantitative (objective) and qualitative (subjective) measures of performance to assess competency in pediatric respiratory distress and airway management.EMS agencies choosing to incorporate pediatric endotracheal intubation or supraglottic airway insertion must use pediatric-specific quality management benchmarks and perform focused review of advanced airway management.
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10
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Findlay S, Swanson M, Junker C, Kinkor M, Harland KK, Buresh C. Adapted Helping Babies Breathe approach to neonatal resuscitation in Haiti: a retrospective cohort study. BMC Pediatr 2022; 22:7. [PMID: 34980010 PMCID: PMC8722303 DOI: 10.1186/s12887-021-02987-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 10/26/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Helping Babies Breathe (HBB) is an American Academy of Pediatrics neonatal resuscitation program designed to reduce neonatal mortality in low resource settings. The 2017 neonatal mortality rate in Haiti was 28 per 1000 live births and an estimated 85 % of Haitian women deliver at home. Given this, the Community Health Initiative implemented an adapted HBB (aHBB) in Haiti to evaluate neonatal mortality. METHODS Community Health Workers taught an aHBB program to laypeople, which didn't include bag-valve-mask ventilation. Follow-up after delivery assessed for maternal and neonatal mortality and health. RESULTS Analysis included 536 births of which 84.3 % (n=452) were attended by someone trained in aHBB. The odds of neonatal mortality was not significantly different among the two groups (aOR=0.48 [0.16-1.44]). Composite outcome of neonatal health as reported by the mother (subjective morbidity and mortality) was significantly lower in aHBB attended births (aOR=0.31 [0.14-0.70]). CONCLUSION This analysis of the aHBB program indicates that community training to laypersons in low resource settings may reduce neonatal ill-health but not neonatal mortality. This study is likely underpowered to find a difference in neonatal mortality. Further work is needed to evaluate which components of the aHBB program are instrumental in improving neonatal health.
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Affiliation(s)
- Shannon Findlay
- Department of Emergency Medicine, University of Iowa, Roy J. and Lucille A. Carver College of Medicine, 200 Hawkins Drive, IA, 52242, Iowa City, USA
| | - Morgan Swanson
- Department of Emergency Medicine, University of Iowa, Roy J. and Lucille A. Carver College of Medicine, 200 Hawkins Drive, IA, 52242, Iowa City, USA
| | - Christian Junker
- Department of Emergency Medicine, University of Iowa, Roy J. and Lucille A. Carver College of Medicine, 200 Hawkins Drive, IA, 52242, Iowa City, USA
| | - Mitchell Kinkor
- Department of Emergency Medicine, University of Iowa, Roy J. and Lucille A. Carver College of Medicine, 200 Hawkins Drive, IA, 52242, Iowa City, USA
| | - Karisa K Harland
- Department of Emergency Medicine, University of Iowa, Roy J. and Lucille A. Carver College of Medicine, 200 Hawkins Drive, IA, 52242, Iowa City, USA
| | - Christopher Buresh
- Department of Emergency Medicine, University of Washington, Harborview Medical Center, Box 359702, 325 Ninth Avenue, WA, 98104, Seattle, USA.
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Hanlin ER, Kit Chan H, Hansen M, Wendelberger B, Shah MI, Bosson N, Gausche-Hill M, VanBuren JM, Wang HE. Epidemiology of Out-of-Hospital Pediatric Airway Management in the 2019 National Emergency Medical Services Information System Data Set. Resuscitation 2022; 173:124-133. [DOI: 10.1016/j.resuscitation.2022.01.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 01/08/2022] [Accepted: 01/11/2022] [Indexed: 11/26/2022]
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12
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Elonheimo L, Ljungqvist H, Harve‐Rytsälä H, Jäntti H, Nurmi J. Frequency, indications and success of out-of-hospital intubations in Finnish children. Acta Anaesthesiol Scand 2022; 66:125-131. [PMID: 34514584 DOI: 10.1111/aas.13980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 08/19/2021] [Accepted: 08/23/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Earlier studies have shown variable results regarding the success of paediatric emergency endotracheal intubation between different settings and operators. We aimed to describe the paediatric population intubated by physician-staffed helicopter emergency medical service (HEMS) and evaluate the factors associated with overall and first-pass success (FPS). METHODS We conducted a retrospective observational cohort study in Finland including all children less than 16 years old who required endotracheal intubation by a HEMS physician from January 2014 to August 2019. Utilising a national HEMS database, we analysed the incidence, indications, overall and first-pass success rates of endotracheal intubation. RESULTS A total of 2731 children were encountered by HEMS, and intubation was attempted in 245 (9%); of these, 22 were younger than 1 year, 103 were aged 1-5 years and 120 were aged 6-15 years. The most common indications for airway management were cardiac arrest for the youngest age group, neurological reasons (e.g., seizures) for those aged 1-5 years and trauma for those aged 6-15. The HEMS physicians had an overall success rate of 100% (95% CI: 98-100) and an FPS rate of 86% (95% CI: 82-90). The FPS rate was lower in the youngest age group (p = .002) and for patients in cardiac arrest (p < .001). CONCLUSIONS Emergency endotracheal intubation of children is successfully performed by a physician staffed HEMS unit even though these procedures are rare. To improve the care, emphasis should be on airway management of infants and patients in cardiac arrest.
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Affiliation(s)
- Lauri Elonheimo
- Emergency Medicine and Services Helsinki University Hospital Helsinki Finland
| | | | - Heini Harve‐Rytsälä
- Emergency Medicine and Services Helsinki University Hospital Helsinki Finland
- University of Helsinki Helsinki Finland
| | - Helena Jäntti
- Center for Prehospital Emergency Care Kuopio University Hospital Kuopio Finland
| | - Jouni Nurmi
- Emergency Medicine and Services Helsinki University Hospital Helsinki Finland
- University of Helsinki Helsinki Finland
- FinnHEMS Research and Development Unit Vantaa Finland
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13
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Bosson N, Hansen M, Gausche-Hill M, Lewis RJ, Wendelberger B, Shah MI, VanBuren JM, Wang HE. Design of a novel clinical trial of prehospital pediatric airway management. Clin Trials 2021; 19:62-70. [PMID: 34875893 DOI: 10.1177/17407745211059855] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Emergency Medical Services personnel are often the first to intervene in the care of critically ill children. Airway management is a fundamental step in prehospital resuscitation, yet there is significant variation in current prehospital airway management practices. Our objective is to present a methodologic approach to determine the optimal strategy for prehospital pediatric airway management. We describe the conceptual premise for the Pediatric Prehospital Airway Resuscitation Trial, a novel Bayesian adaptive sequential platform trial. We developed an innovative design to enable comparison of the three predominant prehospital pediatric airway techniques (bag-mask-ventilation, supraglottic airway insertion, and endotracheal intubation) in three distinct disease groups (cardiac arrest, major trauma, and other respiratory failure). We used a Bayesian statistical approach to provide flexible modeling that can adapt based on prespecified rules according to accumulating trial data with patient enrollment continuing until stopping rules are met. The approach also allows the comparison of multiple interventions in sequence across the different disease states. This Bayesian hierarchical model will be the primary analysis method for the Pediatric Prehospital Airway Resuscitation Trial. The model integrates information across subgroups, a technique known as "borrowing" to generate accurate global and subgroup-specific estimates of treatment effects and enables comparisons of airway intervention arms within the overarching trial. We will use this Bayesian hierarchical linear model that adjusts for subgroup to estimate treatment effects within each subgroup. The model will predict a patient-centered score of 30-day intensive care unit-free survival using arm, subgroup, and emergency medical services agency as predictors. The novel approach of Pediatric Prehospital Airway Resuscitation Trial will provide a feasible method to determine the optimal strategy for prehospital pediatric airway management and may transform the design of future prehospital resuscitation trials.
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Affiliation(s)
- Nichole Bosson
- Los Angeles County Emergency Medical Services Agency, Santa Fe Springs, CA, USA.,David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Matthew Hansen
- Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Marianne Gausche-Hill
- Los Angeles County Emergency Medical Services Agency, Santa Fe Springs, CA, USA.,David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA.,Department of Pediatrics, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Roger J Lewis
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA.,Berry Consultants, LLC, Austin, TX, USA
| | | | - Manish I Shah
- Department of Pediatrics, Section of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA
| | - John M VanBuren
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Henry E Wang
- Department of Emergency Medicine, The Ohio State University, Columbus, OH, USA
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Weihing VK, Crowe EH, Wang HE, Ugalde IT. Prehospital airway management in the pediatric patient: A systematic review. Acad Emerg Med 2021; 29:765-771. [PMID: 34807481 DOI: 10.1111/acem.14410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 10/25/2021] [Accepted: 11/02/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Critically ill children may require airway management to optimize delivery of oxygen and ventilation during resuscitation. We performed a systematic review of studies comparing the use of bag-valve-mask ventilation (BVM), supraglottic airway devices (SGA), and endotracheal intubation (ETI) in pediatric patients requiring prehospital airway management. METHODS We searched Ovid MEDLINE, EMBASE, and Cochrane databases for papers that compared SGA or ETI to BVM use in children, including studies that reported survival outcomes. We followed the Preferred Reporting Items in Systematic Reviews and Meta-Analyses (PRISMA) guidelines and assessed study quality using the Newcastle-Ottawa Scale. We compared key characteristics of the candidate papers, including inclusion criteria, definitions of airway interventions, and association with outcomes. RESULTS Of 773 studies, eight met criteria for inclusion. Only one study was a randomized controlled trial; the other seven studies were observational. Four studies compared ETI to BVM, two studies compared SGA to BVM, one study compared ETI to SGA, and two studies compared advanced airway management (AAM) to BVM. Primary outcomes varied, ranging from overall mortality and 24-h mortality to 1-month survival, hospital survival, and neurologically favorable survival. Four of the studies found no difference in survival with the use of ETI, and four found increased mortality with the use of ETI. Associations with outcomes could not be assessed by meta-analysis due to limited number of studies and the wide variation in the design, population, interventions, and outcome measures of the included studies. CONCLUSIONS In this systematic review, studies of prehospital pediatric airway management varied in scope, design, and conclusions. There was insufficient evidence to evaluate efficacy of pediatric prehospital airway management; however, the current research suggests that there are equal or worse outcomes with the use of ETI compared to other airway techniques. Additional clinical trials are needed to assess the merits of this practice.
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Affiliation(s)
- Veronica K. Weihing
- McGovern Medical School The University of Texas Health Science Center at Houston Houston Texas USA
| | - Ellen H. Crowe
- McGovern Medical School The University of Texas Health Science Center at Houston Houston Texas USA
| | - Henry E. Wang
- Department of Emergency Medicine The Ohio State University Columbus Ohio USA
| | - Irma T. Ugalde
- Department of Emergency Medicine McGovern Medical School The University of Texas Health Science Center at Houston Houston Texas USA
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Van de Voorde P, Turner NM, Djakow J, de Lucas N, Martinez-Mejias A, Biarent D, Bingham R, Brissaud O, Hoffmann F, Johannesdottir GB, Lauritsen T, Maconochie I. [Paediatric Life Support]. Notf Rett Med 2021; 24:650-719. [PMID: 34093080 PMCID: PMC8170638 DOI: 10.1007/s10049-021-00887-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 12/11/2022]
Abstract
The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.
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Affiliation(s)
- Patrick Van de Voorde
- Department of Emergency Medicine, Faculty of Medicine UG, Ghent University Hospital, Gent, Belgien
- Federal Department of Health, EMS Dispatch Center, East & West Flanders, Brüssel, Belgien
| | - Nigel M. Turner
- Paediatric Cardiac Anesthesiology, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, Niederlande
| | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, Hořovice, Tschechien
- Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Medical Faculty of Masaryk University, Brno, Tschechien
| | | | - Abel Martinez-Mejias
- Department of Paediatrics and Emergency Medicine, Hospital de Terassa, Consorci Sanitari de Terrassa, Barcelona, Spanien
| | - Dominique Biarent
- Paediatric Intensive Care & Emergency Department, Hôpital Universitaire des Enfants, Université Libre de Bruxelles, Brüssel, Belgien
| | - Robert Bingham
- Hon. Consultant Paediatric Anaesthetist, Great Ormond Street Hospital for Children, London, Großbritannien
| | - Olivier Brissaud
- Réanimation et Surveillance Continue Pédiatriques et Néonatales, CHU Pellegrin – Hôpital des Enfants de Bordeaux, Université de Bordeaux, Bordeaux, Frankreich
| | - Florian Hoffmann
- Pädiatrische Intensiv- und Notfallmedizin, Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Ludwig-Maximilians-Universität, München, Deutschland
| | | | - Torsten Lauritsen
- Paediatric Anaesthesia, The Juliane Marie Centre, University Hospital of Copenhagen, Kopenhagen, Dänemark
| | - Ian Maconochie
- Paediatric Emergency Medicine, Faculty of Medicine Imperial College, Imperial College Healthcare Trust NHS, London, Großbritannien
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16
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Hansen M, Bosson N, Gausche-Hill M, Shah MI, VanBuren JM, Wendelberger B, Wang H. Critical Factors in Planning a Pediatric Prehospital Airway Trial. PREHOSP EMERG CARE 2021; 26:476-483. [PMID: 33886422 DOI: 10.1080/10903127.2021.1918808] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Objective: The objective of this study was to assess factors influencing the design of a pediatric prehospital airway management trial, including minimum clinically significant differences for three clinical subgroups. Methods: We conducted a virtual consensus-conference among U.S. emergency medical services (EMS) agency medical directors and researchers in the Fall of 2020. This included (1) a preconference survey, (2) an interactive live videoconference, and (3) a postconference survey. Participants were identified through co-investigator relationships and by surveying "The Eagles," a consortium of medical directors from large urban EMS systems and, subsequently, through follow up email contact based on survey responses. Results: Twenty-seven of the 34 (80%) EMS agencies we invited responded to the prewebinar survey. Of the 27 agencies, 27 (100%) use BMV, 19 (70%) use endotracheal intubation (ETI), 21 (78%) use supraglottic airways (SGA). SGA use included 14 (52%) who use the iGel, 8 (30%) who use the King laryngeal tube (LT), and 2 (7%) who use a laryngeal mask airway (LMA). Three agencies use more than one of the available SGAs. Twenty (74%) of the EMS agencies indicated they had access to an SGA suitable for pediatric patients, and 9 (33%) agencies have access to pediatric video laryngoscopy. The majority of agencies indicated that the minimum clinically significant difference for survival to change practice was 1% for cardiac arrest patients with a baseline survival assumption of 7%, 4% for respiratory failure with a baseline survival assumption of 73%, and 3% for trauma with a baseline survival assumption of 42%. Overall, these agencies responded that BVM vs. SGA is the most important comparison that would change their practice. Conclusions: This virtual consensus conference provided a new perspective on current airway management practice and identified specific factors likely to drive change in pediatric prehospital airway management. This information will be leveraged in future trial design to ensure impactful clinical trials.
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Van de Voorde P, Turner NM, Djakow J, de Lucas N, Martinez-Mejias A, Biarent D, Bingham R, Brissaud O, Hoffmann F, Johannesdottir GB, Lauritsen T, Maconochie I. European Resuscitation Council Guidelines 2021: Paediatric Life Support. Resuscitation 2021; 161:327-387. [PMID: 33773830 DOI: 10.1016/j.resuscitation.2021.02.015] [Citation(s) in RCA: 173] [Impact Index Per Article: 57.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.
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Affiliation(s)
- Patrick Van de Voorde
- Department of Emergency Medicine Ghent University Hospital, Faculty of Medicine UG, Ghent, Belgium; EMS Dispatch Center, East & West Flanders, Federal Department of Health, Belgium.
| | - Nigel M Turner
- Paediatric Cardiac Anesthesiology, Wilhelmina Children's Hospital, University Medical Center, Utrecht, Netherlands
| | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, Hořovice, Czech Republic; Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Medical Faculty of Masaryk University, Brno, Czech Republic
| | | | - Abel Martinez-Mejias
- Department of Paediatrics and Emergency Medicine, Hospital de Terassa, Consorci Sanitari de Terrassa, Barcelona, Spain
| | - Dominique Biarent
- Paediatric Intensive Care & Emergency Department, Hôpital Universitaire des Enfants, Université Libre de Bruxelles, Brussels, Belgium
| | - Robert Bingham
- Hon. Consultant Paediatric Anaesthetist, Great Ormond Street Hospital for Children, London, UK
| | - Olivier Brissaud
- Réanimation et Surveillance Continue Pédiatriques et Néonatales, CHU Pellegrin - Hôpital des Enfants de Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Florian Hoffmann
- Paediatric Intensive Care and Emergency Medicine, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | | | - Torsten Lauritsen
- Paediatric Anaesthesia, The Juliane Marie Centre, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Ian Maconochie
- Paediatric Emergency Medicine, Imperial College Healthcare Trust NHS, Faculty of Medicine Imperial College, London, UK
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Richards CT, Fishe JN, Cash RE, Rivard MK, Brown KM, Martin-Gill C, Panchal AR. Priorities for Prehospital Evidence-Based Guideline Development: A Modified Delphi Analysis. PREHOSP EMERG CARE 2021; 26:286-304. [PMID: 33625309 DOI: 10.1080/10903127.2021.1894276] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Objective: Few areas of prehospital care are supported by evidence-based guidelines (EBGs). We aimed to identify gaps in clinical and operational prehospital EBGs to prioritize future EBG development and research funding. Methods: Using modified Delphi methodology, we sought consensus among experts in prehospital care and EBG development. Five rounds of surveys were administered between October 2019 and February 2020. Round 1 asked participants to list the top three gaps in prehospital clinical guidelines and top three gaps in operational guidelines that should be prioritized for guideline development and research funding. Based on responses, 3 reviewers performed thematic analysis to develop a list of prehospital EBG gaps, with participant feedback in Round 2. In Round 3, participants rated each gap's importance using a 5-point Likert scale, and participants' responses were averaged. In Round 4, participants rank-ordered 10 gaps with the highest mean scores identified in Round 3. In Round 5, participants indicated their agreement with sets of the highest ranked gaps. Results: Of 23 invited participants, 14 completed all 5 rounds. In Rounds 1 and 2, participants submitted 65 clinical and 58 operational gaps, and thematic analysis identified 23 unique clinical gaps and 28 unique operational gaps. The final prioritized list of clinical EBG gaps was: 1) airway management in adult and pediatric patients, 2) care of the pediatric patient, and 3) management of prehospital behavioral health emergencies, with 79% of participants agreeing. The final prioritized list of operational EBG gaps was: 1) define and measure the impact of EMS care on patient outcomes, 2) practitioner wellness, and 3) practitioner safety in the out-of-hospital environment, with 86% of participants agreeing. Conclusions: This modified Delphi study identifies gaps in prehospital EBGs that, if prioritized for development and research funding, would be expected to have the greatest impact on prehospital clinical care and operations.
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Präklinisches Management von Atemwegs- und Atmungsproblemen im Kindesalter. Notf Rett Med 2021. [DOI: 10.1007/s10049-020-00836-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Prospective evaluation of airway management in pediatric out-of-hospital cardiac arrest. Resuscitation 2020; 156:53-60. [DOI: 10.1016/j.resuscitation.2020.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 07/24/2020] [Accepted: 08/03/2020] [Indexed: 11/22/2022]
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21
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Hansen ML, Wagner A, Schnapp A, Lin A, Le N, Deverman S, Pedigo E, Johnson A, Cusick J, Gries H, Kato M. Cluster cross-over randomised trial of paediatric airway management devices in the simulation lab and operating room among paramedic students. Emerg Med J 2020; 38:27-32. [PMID: 33046528 DOI: 10.1136/emermed-2020-209929] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 08/18/2020] [Accepted: 08/24/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVES The objective of this study was to compare paediatric emergency airway management strategies in the simulation lab and operating room environments. METHODS This was a two-part cluster cross-over randomised trial including simulation lab and operating room environments conducted between January 2017 and June 2018 in Portland, Oregon, USA. In simulated infant cardiac arrests, paramedic students placed an endotracheal tube, an i-gel or a laryngeal mask airway in random order. In the operating room, paramedic students placed a laryngeal mask airway or i-gel device in random order in sequential patients. The primary outcome for both portions of the study was time to ventilation. In the operating room portion, we also evaluated leak pressures and average initial tidal volumes. RESULTS There were 58 paramedic students who participated in the simulation lab and 22 who participated in the operating room study. The mean time to airway placement in the simulation lab was 48.5 s for the i-gel, 68.9 s for the laryngeal mask and 129.5 s for the endotracheal tube. In the operating room, mean time to i-gel placement was 34.3 s with 45.2 s for the laryngeal mask. In multivariable analysis of the simulation study, the laryngeal mask and i-gel were significantly faster than the endotracheal tube, and the i-gel was faster than the laryngeal mask. In the operating room, there was no significant difference in time to placement, leak pressure and average volume of the first five breaths between the i-gel and laryngeal mask. CONCLUSIONS We found that paramedic students were able to place supraglottic devices rapidly with high success rates in simulation lab and operating room environments. Supraglottic devices, particularly the i-gel, were rated as easy to use. The i-gel may be easiest to use since it lacks an inflable cuff and requires fewer steps to place.
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Affiliation(s)
- Matthew Lee Hansen
- Emergency Medicine, Oregon Health & Science University School of Medicine, Portland, Oregon, USA
| | - Adam Wagner
- Oregon Institute of Technology, Wilsonville, Oregon, US
| | - Ashley Schnapp
- Emergency Medicine, Oregon Health & Science University School of Medicine, Portland, Oregon, USA
| | - Amber Lin
- Emergency Medicine, Oregon Health & Science University School of Medicine, Portland, Oregon, USA
| | - Nancy Le
- Emergency Medicine, Oregon Health & Science University School of Medicine, Portland, Oregon, USA
| | - Sarah Deverman
- Anesthesiology and Peri-operative Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Elizabeth Pedigo
- Anesthesiology and Peri-operative Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Andrea Johnson
- Anesthesiology and Peri-operative Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Jordan Cusick
- Anesthesiology and Peri-operative Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Heike Gries
- Anesthesiology and Peri-operative Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Meredith Kato
- Anesthesiology and Peri-operative Medicine, Oregon Health & Science University, Portland, Oregon, USA
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Shaw MR, Lindsay D, Figueroa A. Beyond Tools: Continuous High-Fidelity Training at the Center of Successful First-Pass Intubation in Ground Emergency Medical Services. Air Med J 2020; 39:364-368. [PMID: 33012473 DOI: 10.1016/j.amj.2020.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 06/01/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Increased emphasis on the use of video laryngoscopy in emergency medical services has potentially caused providers to forfeit the skills required to perform direct laryngoscopy. The purpose of this study was to determine if the introduction of a continuous high-fidelity training program improves first-pass intubation success in a non-rapid sequence induction ground-based emergency medical services agency with an established video laryngoscopy program. METHODS This is a retrospective analysis of quality improvement data of advanced airway management performed by an ambulance service between 2012 and 2019. A mandatory biannual high-fidelity simulation training curriculum was introduced at the beginning of 2017. RESULTS A total of 459 patients underwent intubation attempts during the 7-year study period. First-pass intubation success improved from 57.6% to 81.4%, an improvement of 23.8% (95% confidence interval [CI], 15.4-31.5; P < .001), and overall intubation success improved from 77% to 91%, an improvement of 14.1% (95% CI, 7.3-20.3; P < .001). The average number of intubation attempts per patient decreased by 0.19 (95% CI, 0.09-0.29; P < .0003). The mean time of arrival to intubation time increased by 2.21 minutes (95% CI, 0.84-3.58; P = .0016). CONCLUSION Implementation of a high-fidelity airway training program is associated with improvements in overall endotracheal intubation and first-pass endotracheal intubation success rates in all adult patient categories.
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Affiliation(s)
| | - Daniel Lindsay
- Department of Public Health and Tropical Medicine, James Cook University, Townsville, Australia
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Koslow EA, Borgman MA, April MD, Schauer SG. Pediatric Prehospital Airway Management by U.S. Forces in Iraq and Afghanistan. Mil Med 2020; 185:e1435-e1439. [PMID: 32754753 DOI: 10.1093/milmed/usaa173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/07/2020] [Accepted: 06/11/2020] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Airway obstruction is a treatable cause of potentially preventable death on the battlefield. Emergency cricothyrotomies are rarely performed in developed countries, but are a common prehospital procedure in recent conflicts in Iraq and Afghanistan. We describe prehospital airway interventions performed on pediatric casualties with a focus on cricothyrotomy during these recent conflicts. MATERIALS AND METHODS This is a secondary analysis of previously published dataset from the Department of Defense Trauma Registry for pediatric encounters from January 2007 to January 2017. Within our dataset we searched for all instances of airway interventions in the prehospital setting. RESULTS During this time, there were 3,439 pediatric casualties in the registry with a total of 18 prehospital cricothyrotomies and 211 prehospital intubations. For cricothyrotomies, the median age was 10 years, most (72.2%) were male, median composite injury score was 25, most were injured by explosive (44.4%), more commonly located in Afghanistan (77.8%), and approximately half survived to hospital discharge (44.4%). The head was most frequently injured (44.4%). Of those undergoing endotracheal intubation, the median age was 10 years, most (75.8%) were male, median injury score was 17, most were injured by explosives (53.5%), most were in Afghanistan (85.7%), and most survived to hospital discharge (66.8%). The head/neck most frequently had a serious injury (56.8%). CONCLUSIONS In this dataset, 6.8% of children underwent prehospital intubation and 0.5% underwent prehospital cricothyrotomy. Airway interventions were frequently associated with head injuries. This highlights the importance of training and equipping prehospital medical personnel for pediatric trauma care in accordance with military clinical practice guidelines.
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Affiliation(s)
| | - Matthew A Borgman
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA.,Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Michael D April
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA.,Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Steven G Schauer
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA.,Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, USA
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Talbert S, Detrick CW, Emery K, Middleton A, Abomoelak B, Deb C, Mehta DI, Sole ML. Intubation Setting, Aspiration, and Ventilator-Associated Conditions. Am J Crit Care 2020; 29:371-378. [PMID: 32869069 DOI: 10.4037/ajcc2020129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Patients experience endotracheal intubation in various settings with wide-ranging risks for postintubation complications such as aspiration and ventilator-associated conditions. OBJECTIVES To evaluate associations between intubation setting, presence of aspiration biomarkers, and clinical outcomes. METHODS This study is a subanalysis of data from the NO-ASPIRATE single-blinded randomized clinical trial. Data were prospectively collected for 513 adult patients intubated within 24 hours of enrollment. Patients with documented aspiration events at intubation were excluded. In the NO-ASPIRATE trial, intervention patients received enhanced oropharyngeal suctioning every 4 hours and control patients received sham suctioning. Tracheal specimens for α-amylase and pepsin tests were collected upon enrollment. Primary outcomes were ventilator hours, lengths of stay, and rates of ventilator-associated conditions. RESULTS Of the baseline tracheal specimens, 76.4% were positive for α-amylase and 33.1% were positive for pepsin. Proportions of positive tracheal α-amylase and pepsin tests did not differ significantly between intubation locations (study hospital, transfer from other hospital, or field intubation). No differences were found for ventilator hours or lengths of stay. Patients intubated at another hospital and transferred had significantly higher ventilator-associated condition rates than did those intubated at the study hospital (P = .02). Ventilator-associated condition rates did not differ significantly between patients intubated in the field and patients in other groups. CONCLUSIONS Higher ventilator-associated condition rates associated with interhospital transfer may be related to movement from bed, vehicle loading and unloading, and transport vehicle vibrations. Airway assessment and care may also be suboptimal in the transport environment.
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Affiliation(s)
- Steven Talbert
- Steven Talbert is an assistant clinical professor, Christine Wargo Detrick is a doctoral student, and Kimberly Emery is a doctoral candidate, University of Central Florida College of Nursing, Orlando, Florida
| | - Christine Wargo Detrick
- Steven Talbert is an assistant clinical professor, Christine Wargo Detrick is a doctoral student, and Kimberly Emery is a doctoral candidate, University of Central Florida College of Nursing, Orlando, Florida
| | - Kimberly Emery
- Steven Talbert is an assistant clinical professor, Christine Wargo Detrick is a doctoral student, and Kimberly Emery is a doctoral candidate, University of Central Florida College of Nursing, Orlando, Florida
| | - Aurea Middleton
- Aurea Middleton is a clinical research coordinator, Orlando Regional Medical Center, Orlando, Florida
| | - Bassam Abomoelak
- Bassam Abomoelak is a senior research associate and Chirajyoti Deb is a senior research scientist, Gastrointestinal Translational Laboratory, Arnold Palmer Hospital, Orlando Health, Orlando
| | - Chirajyoti Deb
- Chirajyoti Deb is a senior research scientist, Gastrointestinal Translational Laboratory, Arnold Palmer Hospital, Orlando Health, Orlando
| | - Devendra I. Mehta
- Devendra I. Mehta is an associate professor at Florida State University and director of the Gastrointestinal Translational Laboratory, Arnold Palmer Hospital for Children, Orlando Health
| | - Mary Lou Sole
- Mary Lou Sole is dean, Orlando Health Endowed Chair in Nursing, and University of Central Florida Pegasus Professor, University of Central Florida College of Nursing
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Meta-Analysis of Failure of Prehospital Endotracheal Intubation in Pediatric Patients. Emerg Med Int 2020; 2020:7012508. [PMID: 32455022 PMCID: PMC7212286 DOI: 10.1155/2020/7012508] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 04/07/2020] [Indexed: 11/17/2022] Open
Abstract
Prehospital care is essential for airway preservation in pediatric patients who require early endotracheal intubation to improve oxygenation and prevent aspiration. However, high frequencies of failure of endotracheal intubation have been reported for this age group. We aimed to analyze the frequency of failure of endotracheal intubation in pediatric patients within a prehospital context and compare it with adult patients. Thus, a systematic revision of literature with a meta-analysis was performed using a study search and selection strategy ensuring extensiveness, sensitivity, and reproducibility. Meta-analyses were performed for odds ratio, DerSimonian and Laird's Q test was used to assess heterogeneity, and Egger and Begg's test was used to assess publication bias. Overall, 17 papers and 8772 patients were included, and the main cause of prehospital care was assessed to be trauma. Failed endotracheal intubation frequency was 0.4%–52.6% in pediatric patients. The most frequent complication was with esophageal intubation. Forest plot suggests that risk of failure during intubation of pediatric patients is 3.54 fold higher than that observed for adults. It was concluded that airway management in pediatric patients within a prehospital context is a challenge for prehospital care providers because it entails clear physiological and anatomical differences and a low frequency of exposure to this kind of events as opposed to adults. These differences support a widely higher risk of failure of intubation, suggesting the necessity of consistently trained prehospital care providers to ensure proficiency in technique as well as availability of the required equipment.
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Type of advanced airway and survival after pediatric out-of-hospital cardiac arrest. Resuscitation 2020; 150:145-153. [DOI: 10.1016/j.resuscitation.2020.02.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 01/29/2020] [Accepted: 02/06/2020] [Indexed: 01/24/2023]
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Lee-Jayaram JJ, Kunimune M, Hara KM, Barnes LC, Berg BW. Pediatric Simulation Training for Emergency Pre-Hospital Providers in Hawai'i: An Inter-Professional Curriculum Collaboration and Update. HAWAI'I JOURNAL OF HEALTH & SOCIAL WELFARE 2020; 79:13-18. [PMID: 32490380 PMCID: PMC7260876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Experience with pediatric transport and pediatric-specific training for paramedic students and practicing paramedics is lacking nationally. Kapi'olani Community College (KCC) conducts the only paramedic training program in the state and has recently expanded its pediatric training section. KCC and the John A. Burns School of Medicine (JABSOM) collaborated on a simulation-based pediatric pre-hospital provider training course titled PediSTEPPs-H (Pediatric Simulation Training for Emergency Pre-hospital Providers in Hawai'i), which was developed and piloted in 2019, to supplement the students' didactic and clinical experiences. The program was developed using Kern's 6-step approach to curriculum development in medical education. The PediSTEPPs-H pilot course was co-facilitated by faculty from both campuses and enrolled 12 students in the first cohort. Program evaluation demonstrated high student satisfaction and included feedback regarding curriculum elements for further refinement. The PediSTEPPs-H pilot program evaluation provided direction that the course be offered annually for all KCC paramedic students and as continuing professional development program for practicing paramedics in Hawai'i.
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Affiliation(s)
- Jannet J. Lee-Jayaram
- Correspondence to: Jannet Lee-Jayaram MD; 651 Ilalo Street, MEN 212, Honolulu, HI 96813;
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Garner AA, Bennett N, Weatherall A, Lee A. Success and complications by team composition for prehospital paediatric intubation: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:149. [PMID: 32295610 PMCID: PMC7161251 DOI: 10.1186/s13054-020-02865-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Accepted: 03/31/2020] [Indexed: 12/18/2022]
Abstract
Background Clinical team composition for prehospital paediatric intubation may affect success and complication rates. We performed a systematic review and meta-analysis to determine the success and complication rates by type of clinical team. Methods We searched MEDLINE, EMBASE, and CINAHL for interventional and observational studies describing prehospital intubation attempts in children with overall success, first-pass success, and complication rates. Eligible studies, data extraction, and assessment of risk of bias were assessed independently by two reviewers. We performed a random-effects meta-analysis of proportions. Results Forty studies (1989 to 2019) described three types of clinical teams: non-physician teams with no relaxants (22 studies, n = 7602), non-physician teams with relaxants (12 studies, n = 2185), and physician teams with relaxants (12 studies, n = 1780). Twenty-two (n = 3747) and 18 (n = 7820) studies were at low and moderate risk of bias, respectively. Non-physician teams without relaxants had lower overall intubation success rate (72%, 95% CI 67–76%) than non-physician teams with relaxants (95%, 95% CI 93–98%) and physician teams (99%, 95% CI 97–100%). Physician teams had higher first-pass success rate (91%, 95% CI 86–95%) than non-physicians with (75%, 95% CI 69–81%) and without (55%, 95% CI 48–63%) relaxants. Overall airway complication rate was lower in physician teams (10%, 95% CI 3–22%) than non-physicians with (30%, 95% CI 23–38%) and without (39%, 95% CI 28–51%) relaxants. Conclusion Physician teams had higher rates of intubation success and lower rates of overall airway complications than other team types. Physician prehospital teams should be utilised wherever practicable for critically ill children requiring prehospital intubation.
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Affiliation(s)
- Alan A Garner
- CareFlight Australia, 4 Barden St, Northmead, NSW, 2152, Australia. .,The University of Sydney, Sydney, Australia.
| | | | - Andrew Weatherall
- CareFlight Australia, 4 Barden St, Northmead, NSW, 2152, Australia.,Division of Paediatrics and Child Health, The University of Sydney, Sydney, Australia
| | - Anna Lee
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong.,Hong Kong Branch of The Chinese Cochrane Centre, The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong
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Ramgopal S, Button SE, Owusu-Ansah S, Manole MD, Saladino RA, Guyette FX, Martin-Gill C. Success of Pediatric Intubations Performed by a Critical Care Transport Service. PREHOSP EMERG CARE 2020; 24:683-692. [PMID: 31800336 DOI: 10.1080/10903127.2019.1699212] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: Prehospital pediatric endotracheal intubation (ETI) is rarely performed. Previous research has suggested that pediatric prehospital ETI, when performed by ground advanced life support crews, is associated with poor outcomes. In this study, we aim to evaluate the first-attempt success rate, overall success rate and complications of pediatric prehospital ETI performed by critical care transport (CCT) personnel.Methods: We conducted a retrospective observational study in a multi-state CCT service performing rotor wing, ground, and fixed wing missions. We included pediatric patients (<18 years) for whom ETI was performed by CCT personnel (flight nurse or flight paramedic).Our primary outcome of interest was rate of first-attempt ETI. Secondary outcomes were overall rates of successful ETI, complications encountered, and outcomes of patients with unsuccessful intubation.Results: 993 patients were included (63.2% male, median age 12 years, IQR 4-16 years). 807/993 (81.3%) patients were intubated on the first attempt. Lower rates of successful first-attempt intubation were seen in younger ages (42.9% in infants ≤30 days of age). In multivariable logistic regression, lower odds (adjusted odds ratio, 95% confidence interval) of successful first-attempt ETI were associated with ages >30 days to <1 year (0.33, 0.18-0.61) and 2 to <6 years (0.60, 0.39-0.94) compared to patients 12 to <18 years. Patients given an induction agent and neuromuscular blockade (NMB) had a higher odds of first-attempt ETI success (1.53, 1.06-2.15). 13 (1.3%) had immediately recognized esophageal intubation and 33 (3.3%) had vomiting. No episodes of pneumothorax were reported. 962/993 (96.9%) patients were successfully intubated after all attempts. In patients without successful ETI (n = 31), supraglottic airways were used in 24, bag-valve mask ventilation in 5, and surgical cricothyroidotomy in 2, with an overall advanced airway success rate of 988/993 (99.5%).Conclusion: Critical care flight nurses and paramedics performed successful intubations in pediatric patients at a high rate of success. Younger age was associated with lower success rates. Improved ETI training for younger patients and use of an induction agent and NMB may improve airway management in critically ill children.
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Abstract
OBJECTIVE The aim of this study was to compare demographic and clinical features of children (0-14 years old) who arrived at general emergency departments (EDs) by emergency medical services (EMS) to those who arrived by private vehicles and other means in a rural, 3-county region of northern California. METHODS We reviewed 507 ED records of children who arrived at EDs by EMS and those who arrived by other means in 2013. We also analyzed prehospital procedures performed on all children transported to an area hospital by EMS. RESULTS Children arriving by EMS were older (9.0 vs 6.0 years; P < 0.001), more ill (mean Severity Classification Score, 2.9 vs 2.4; P < 0.001), and had longer lengths of stay (3.6 vs 2.1 hours; P < 0.001) compared with children who were transported to the EDs by other means. Children transported by EMS received more subspecialty consultations (18.7% vs 6.9%; P < 0.05) and had more diagnostic testing, including laboratory testing (22.9% vs 10.6%; P < 0.001), radiography (39.7% vs 20.8%; P < 0.001), and computed tomography scans (16.8% vs 2.9%; P < 0.001). Children arriving by EMS were transferred more frequently (8.8% vs 1.6%; P < 0.001) and had higher mean Severity Classification Scores compared with children arriving by other transportation even after adjusting for age and sex (β = 0.48; 95% confidence interval, 0.35-0.61; P < 0.001). Older children received more prehospital procedures compared with younger children, and these were of greater complexity and a wider spectrum. CONCLUSIONS Children transported to rural EDs via EMS are more ill and use more medical resources compared with those who arrive to the ED by other means of transportation.
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Nwanne T, Jarvis J, Barton D, Donnelly JP, Wang HE. Advanced airway management success rates in a national cohort of emergency medical services agencies. Resuscitation 2019; 146:43-49. [PMID: 31756361 DOI: 10.1016/j.resuscitation.2019.11.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 11/06/2019] [Accepted: 11/11/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Despite its important role in care of the critically ill, there have been few large-scale descriptions of the epidemiology of Emergency Medical Services (EMS) advanced airway management (AAM) and the variations in care with different patient subsets. We sought to characterize AAM performance in a national cohort of EMS agencies. METHODS We used data from ESO Solutions, Inc., a national EMS electronic health record system. We analyzed EMS emergency patient encounters during 2011-2015 with attempted AAM. We categorized AAM techniques as conventional endotracheal intubation (cETI), neuromuscular blockade assisted intubation (NMBA-ETI), supraglottic airway (SGA), and cricothyroidotomy (needle and open). Determination of successful AAM was based on EMS provider report. We analyzed the data using descriptive statistics, determining the incidence and clinical characteristics of AAM cases. We determined success rates for each AAM technique, stratifying by the subsets cardiac arrest, medical non-arrest, trauma, and pediatrics (age ≤12 years). RESULTS AAM occurred in 57,209 patients. Overall AAM success was 89.1% (95% CI: 88.8-89.3%) across all patients and techniques. Intubation success rates varied by technique; cETI (n = 38,004; 76.9%, 95% CI: 76.5-77.3%), NMBA-ETI (n = 6768; 89.7%, 88.9-90.4%). SGAs were used both for initial (n = 9461, 90.1% success, 95% CI: 89.5-90.7%) and rescue (n = 5994, 87.3% success, 95% CI: 86.4-88.1%) AAM. Cricothyroidotomy success rates were low: initial cricothyroidotomy (n = 202, 17.3% success, 95% CI: 12.4-23.3%), rescue cricothyroidotomy (n = 85, 52.9% success, 95% CI: 41.8-88%). AAM success rates varied by patient subset: cardiac arrest (n = 35,782; 91.7%, 95% CI: 91.4-92.0), medical non-arrest (n = 17,086; 84.7%, 84.2-85.2%); trauma (n = 4341; 84.3%, 83.1-85.3%); pediatric (n = 1223; 73.7%, 71.2-76.2%). CONCLUSION AAM success rates varied by airway technique and patient subset. In this national cohort, these results offer perspectives of EMS AAM practices.
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Affiliation(s)
- Tracy Nwanne
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Jeffrey Jarvis
- Williamson County Emergency Medical Services, Georgetown, TX, United States; Texas A&M Health Science Center, Temple, TX, United States
| | | | - John P Donnelly
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, United States; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, United States
| | - Henry E Wang
- Department of Emergency Medicine, The University of Texas Health Science Center at Houston, Houston, TX, United States.
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Ostermayer DG, Camp EA, Langabeer JR, Brown CA, Mondragon J, Persse DE, Shah MI. Impact of an Extraglottic Device on Pediatric Airway Management in an Urban Prehospital System. West J Emerg Med 2019; 20:962-969. [PMID: 31738725 PMCID: PMC6860396 DOI: 10.5811/westjem.2019.8.44464] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 08/25/2019] [Indexed: 11/30/2022] Open
Abstract
Introduction Prehospital pediatric endotracheal intubation has lower first-pass success rates compared to adult intubations and in general may not offer a survival benefit. Increasingly, emergency medical services (EMS) systems are deploying prehospital extraglottic airways (EGA) for primary pediatric airway management, yet little is known about their efficacy. We evaluated the impact of a pediatric prehospital airway management protocol change, inclusive of EGAs, on airway management and patient outcomes in children in cardiac arrest or respiratory failure. Methods Using data from a large, metropolitan, fire-based EMS service, we performed an observational study of pediatric patients with respiratory failure or cardiac arrest who were transported by EMS before and after implementation of an evidence-based airway management protocol inclusive of the addition of the EGA. The primary outcome was change in frequency of intubation attempts when paired with an initial EGA. Secondary outcomes included EGA and intubation success rates and patient survival to hospitalization and discharge. Results We included 265 patients age <16 years old, with 142 pre- and 123 post-protocol change. Patient demographics and event characteristics were similar between groups. Intubation attempts declined from 79.6% pre- to 44.7% (p<0.01) post-protocol change. In patients with an intubation attempt, overall intubation success declined from 81.4% to 63.6% (p<0.01). Post-protocol change, an EGA was attempted in 52.8% of patients with 95.4% success. Conclusion Implementation of an evidenced-based airway management algorithm for pediatric patients, inclusive of an EGA device for all age groups, was associated with fewer prehospital intubations. Intubation success may be negatively impacted due to decreases in procedural frequency.
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Affiliation(s)
- Daniel G Ostermayer
- McGovern Medical School, University of Texas Health Sciences Center, Department of Emergency Medicine, Houston, Texas.,Houston Fire Department, Houston, Texas
| | - Elizabeth A Camp
- Baylor College of Medicine, Texas Children's Hospital, Department of Pediatrics, Section of Emergency Medicine, Houston, Texas
| | - James R Langabeer
- McGovern Medical School, University of Texas Health Sciences Center, Department of Emergency Medicine, Houston, Texas
| | - Charles A Brown
- University of Michigan Medical School, Department of Emergency Medicine, Ann Arbor, Michigan
| | - Juan Mondragon
- Baylor College of Medicine, Texas Children's Hospital, Department of Pediatrics, Section of Emergency Medicine, Houston, Texas
| | | | - Manish I Shah
- Baylor College of Medicine, Texas Children's Hospital, Department of Pediatrics, Section of Emergency Medicine, Houston, Texas
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Moors XRJ, Van Lieshout EMM, Verhofstad MHJ, Stolker RJ, Den Hartog D. A Physician-Based Helicopter Emergency Medical Services Was Associated With an Additional 2.5 Lives Saved per 100 Dispatches of Severely Injured Pediatric Patients. Air Med J 2019; 38:289-293. [PMID: 31248540 DOI: 10.1016/j.amj.2019.04.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 02/18/2019] [Accepted: 04/24/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Physician-based helicopter emergency medical services (HEMS) provide specialist medical care to the accident scene in order to improve the survival of severely injured patients. Studies that focus on the role of physician-based HEMS in pediatric trauma are scarce. The aim of this retrospective, observational study was to determine the effect of physician-based HEMS assistance on the survival of severely injured pediatric patients. METHODS All consecutive severely injured pediatric patients (age < 18 years and Injury Severity Score > 15) treated between October 1, 2000, and February 28, 2013, were included. The survival of patients who received medical care of physician-based HEMS was compared with the survival of patients treated by an ambulance paramedic crew (ie, emergency medical services group) only. A regression model was developed for calculating the survival benefit in the physician-based HEMS group. RESULTS A total of 308 patients were included; 112 (36%) were primarily treated by emergency medical services, and 196 (64%) patients received additional physician-based HEMS assistance on scene. The model with the best diagnostic properties and fit contained physician-based HEMS assistance, 3 components of the Glasgow Coma Scale (eye, motor, and verbal) scored prehospitally (before intubation), ordinal values for the Injury Severity Scale, systolic blood pressure, and respiratory rate. This model predicted that 5 additional patients survived because of physician-based HEMS assistance. This corresponds with 2.5 additional lives saved per 100 physician-based HEMS dispatches for severely injured pediatric patients. CONCLUSION The data suggest that an additional 2.5 lives might be saved per 100 physician-based HEMS dispatches for severely injured pediatric patients.
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Affiliation(s)
- Xavier R J Moors
- Department of Anesthesiology, Erasmus MC, University Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands.
| | - Esther M M Van Lieshout
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Michael H J Verhofstad
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Robert Jan Stolker
- Department of Anesthesiology, Erasmus MC, University Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Dennis Den Hartog
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
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Amagasa S, Kashiura M, Moriya T, Uematsu S, Shimizu N, Sakurai A, Kitamura N, Tagami T, Takeda M, Miyake Y. Relationship between institutional case volume and one-month survival among cases of paediatric out-of-hospital cardiac arrest. Resuscitation 2019; 137:161-167. [PMID: 30802557 DOI: 10.1016/j.resuscitation.2019.02.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 02/11/2019] [Accepted: 02/12/2019] [Indexed: 10/27/2022]
Abstract
AIM To evaluate volume-outcome relationship in paediatric out-of-hospital cardiac arrest (OHCA). METHODS This post hoc analysis of the SOS-KANTO 2012 study included data of paediatric OHCA patients <18 years old who were transported to the 53 emergency hospitals in the Kanto region of Japan between January 2012 and March 2013. Based on the paediatric OHCA case volume, the higher one-third of institutions (more than 10 paediatric OHCA cases during the study period) were defined as high-volume centres, the middle one-third institutions (6-10 cases) were defined as middle-volume centres and the lower one-third of institutions (less than 6 cases) were defined as low-volume centres. The primary outcome measurement was survival at 1 month after cardiac arrest. Multivariate logistic regression analysis for 1-month survival and paediatric OHCA case volume were performed after adjusting for multiple propensity scores. To estimate the multiple propensity score, we fitted a multinomial logistic regression model, which fell into one of the three groups as patient demographics and prehospital factors. RESULTS Among the eligible 282 children, 112, 82 and 88 patients were transported to the low-volume (36 institutions), middle-volume (11 institutions) and high-volume (6 institutions) centres, respectively. Transport to a high-volume centre was significantly associated with a better 1-month survival after adjusting for multiple propensity score (adjusted odds ratio, 2.55; 95% confidence interval, 1.05-6.17). CONCLUSION There may be a relationship between institutional case volume and survival outcomes in paediatric OHCA.
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Affiliation(s)
- Shunsuke Amagasa
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, 1-847, Amanuma-cho, Omiya-ku, Saitama City, Saitama, 330-8503, Japan; Division of Emergency and Transport Services, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, Japan.
| | - Masahiro Kashiura
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, 1-847, Amanuma-cho, Omiya-ku, Saitama City, Saitama, 330-8503, Japan
| | - Takashi Moriya
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, 1-847, Amanuma-cho, Omiya-ku, Saitama City, Saitama, 330-8503, Japan
| | - Satoko Uematsu
- Division of Emergency and Transport Services, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Naoki Shimizu
- Department of Critical Care and Emergency Medicine, Tokyo Metropolitan Children's Medical Center, 2-8-29, Musashidai, Fuchu, Tokyo, 183-8561, Japan
| | - Atsushi Sakurai
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, 30-1, Oyagutikamichou, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Nobuya Kitamura
- Department of Emergency and Critical Care Medicine, Kimitsu Chuo Hospital, 1010, Sakurai, Kisarazushi, Chiba, 292-8535, Japan
| | - Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, 1-7-1, Nagayama, Tama-shi, Tokyo, 206-8512, Japan
| | - Munekazu Takeda
- Department of Critical Care and Emergency Medicine, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Yasufumi Miyake
- Department of Emergency Medicine, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-Ku, Tokyo, 173-8606, Japan
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White L, Melhuish T, Holyoak R, Ryan T, Kempton H, Vlok R. Advanced airway management in out of hospital cardiac arrest: A systematic review and meta-analysis. Am J Emerg Med 2018; 36:2298-2306. [PMID: 30293843 DOI: 10.1016/j.ajem.2018.09.045] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 09/16/2018] [Accepted: 09/25/2018] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES To assess the difference in survival and neurological outcomes between endotracheal tube (ETT) intubation and supraglottic airway (SGA) devices used during out-of-hospital cardiac arrest (OHCA). METHODS A systematic search of five databases was performed by two independent reviewers until September 2018. Included studies reported on (1) OHCA or cardiopulmonary resuscitation, and (2) endotracheal intubation versus supraglottic airway device intubation. Exclusion criteria (1) stimulation studies, (2) selectively included/excluded patients, (3) in-hospital cardiac arrest. Odds Ratios (OR) with random effect modelling was used. Primary outcomes: (1) return of spontaneous circulation (ROSC), (2) survival to hospital admission, (3) survival to hospital discharge, (4) discharge with a neurologically intact state. RESULTS Twenty-nine studies (n = 539,146) showed that overall, ETT use resulted in a heterogeneous, but significant increase in ROSC (OR = 1.44; 95%CI = 1.27 to 1.63; I2 = 91%; p < 0.00001) and survival to admission (OR = 1.36; 95%CI = 1.12 to 1.66; I2 = 91%; p = 0.002). There was no significant difference in survival to discharge or neurological outcome (p > 0.0125). On sensitivity analysis of RCTs, there was no significant difference in ROSC, survival to admission, survival to discharge or neurological outcome (p > 0.0125). On analysis of automated chest compression, without heterogeneity, ETT provided a significant increase in ROSC (OR = 1.55; 95%CI = 1.20 to 2.00; I2 = 0%; p = 0.0009) and survival to admission (OR = 2.16; 95%CI = 1.54 to 3.02; I2 = 0%; p < 0.00001). CONCLUSIONS The overall heterogeneous benefit in survival with ETT was not replicated in the low risk RCTs, with no significant difference in survival or neurological outcome. In the presence of automated chest compressions, ETT intubation may result in survival benefits.
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Affiliation(s)
- Leigh White
- School of Medicine, University of Queensland, Brisbane, QLD, Australia; Department of Anaesthesia and Perioperative Medicine, Sunshine Coast University Hospital, Sunshine Coast, QLD, Australia.
| | - Thomas Melhuish
- Intensive Care Service, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Rhys Holyoak
- Graduate School of Medicine, University of Wollongong, Wollongong, NSW, Australia
| | - Thomas Ryan
- Department of Orthopaedics, John Hunter Hospital, Newcastle, NSW, Australia; Sydney Clinical School, University of Notre Dame, Sydney, NSW, Australia
| | - Hannah Kempton
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia; Department of Medicine, St Vincent's Hospital, Sydney, NSW, Australia
| | - Ruan Vlok
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia; Sydney Clinical School, University of Notre Dame, Sydney, NSW, Australia; Wagga Wagga Rural Referral Hospital, Wagga Wagga, NSW, Australia
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Improving Prehospital Management of Children With Respiratory Distress. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2018. [DOI: 10.1016/j.cpem.2018.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Hernandez MC, Antiel RM, Balakrishnan K, Zielinski MD, Klinkner DB. Definitive airway management after prehospital supraglottic rescue airway in pediatric trauma. J Pediatr Surg 2018; 53:352-356. [PMID: 29096887 DOI: 10.1016/j.jpedsurg.2017.10.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 10/04/2017] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Supraglottic airway (SGA) use and outcomes in pediatric trauma are poorly understood. We compared outcomes between patients receiving prehospital SGA versus bag mask ventilation (BVM). METHODS We reviewed pediatric multisystem trauma patients (2005-2016), comparing SGA and BVM. Primary outcome was adequacy of oxygenation and ventilation. Additional measures included tracheostomy, mortality and abbreviated injury scores (AIS). RESULTS Ninety patients were included (SGA, n=17 and BVM, n=73). SGA patients displayed increased median head AIS (5 [4-5] vs 2 [0-4], p=0.001) and facial AIS (1 [0-2] vs 0 [0-0], p=0.03). SGA indications were multiple failed intubation attempts (n=12) and multiple failed attempts with poor visualization (n=5). Median intubation attempts were 2 [1-3] whereas BVM patients had none. Compared to BVM, SGA patients demonstrated inadequate oxygenation/ventilation (75% vs 41%), increased tracheostomy rates (31% vs 8.1%), and increased 24-h (38% vs 10.8%) and overall mortality (75% vs 14%) (all p<0.05). CONCLUSIONS Escalating intubation attempts and severe facial AIS were associated with tracheostomy. Inadequacy of oxygenation/ventilation was more frequent in SGA compared to BVM patients. SGA patients demonstrate poor clinical outcomes; however, SGAs may be necessary in increased craniofacial injury patterns. These factors may be incorporated into a management algorithm to improve definitive airway management after SGA.
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Affiliation(s)
- Matthew C Hernandez
- Department of Trauma, Critical Care and General Surgery, Mayo Clinic, Rochester, MN.
| | - Ryan M Antiel
- Department of Pediatric Surgery, Mayo Clinic, Rochester, MN.
| | | | - Martin D Zielinski
- Department of Trauma, Critical Care and General Surgery, Mayo Clinic, Rochester, MN.
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Meckler G, Hansen M, Lambert W, O'Brien K, Dickinson C, Dickinson K, Van Otterloo J, Guise JM. Out-of-Hospital Pediatric Patient Safety Events: Results of the CSI Chart Review. PREHOSP EMERG CARE 2017; 22:290-299. [PMID: 29023218 DOI: 10.1080/10903127.2017.1371261] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Studies of adult hospital patients have identified medical errors as a significant cause of morbidity and mortality. Little is known about the frequency and nature of pediatric patient safety events in the out-of-hospital setting. We sought to quantify pediatric patient safety events in EMS and identify patient, call, and care characteristics associated with potentially severe events. METHODS As part of the Children's Safety Initiative -EMS, expert panels independently reviewed charts of pediatric critical ambulance transports in a metropolitan area over a three-year period. Regression models were used to identify factors associated with increased risk of potentially severe safety events. Patient safety events were categorized as: Unintended injury; Near miss; Suboptimal action; Error; or Management complication ("UNSEMs") and their severity and potential preventability were assessed. RESULTS Overall, 265 of 378 (70.1%) unique charts contained at least one UNSEM, including 146 (32.8%) errors and 199 (44.7%) suboptimal actions. Sixty-one UNSEMs were categorized as potentially severe (23.3% of UNSEMs) and nearly half (45.3%) were rated entirely preventable. Two factors were associated with heightened risk for a severe UNSEM: (1) age 29 days to 11 months (OR 3.3, 95% CI 1.25-8.68); (2) cases requiring resuscitation (OR 3.1, 95% CI 1.16-8.28). Severe UNSEMs were disproportionately higher among cardiopulmonary arrests (8.5% of cases, 34.4% of severe UNSEMs). CONCLUSIONS During high-risk out-of-hospital care of pediatric patients, safety events are common, potentially severe, and largely preventable. Infants and those requiring resuscitation are important areas of focus to reduce out-of-hospital pediatric patient safety events.
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Hansen ML, Lin A, Eriksson C, Daya M, McNally B, Fu R, Yanez D, Zive D, Newgard C. A comparison of pediatric airway management techniques during out-of-hospital cardiac arrest using the CARES database. Resuscitation 2017; 120:51-56. [PMID: 28838781 DOI: 10.1016/j.resuscitation.2017.08.015] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 08/08/2017] [Accepted: 08/15/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare odds of survival to hospital discharge among pediatric out-of-hospital cardiac arrest (OHCA) patients receiving either bag-valve-mask ventilation (BVM), supraglottic airway (SGA) or endotracheal intubation (ETI), after adjusting for the propensity to receive a given airway intervention. METHODS Retrospective cohort study using the Cardiac Arrest Registry to Enhance Survival (CARES) database from January 1 201-December 31, 2015. The CARES registry includes data on cardiac arrests from 17 statewide registries and approximately 55 additional US cities. We included patients less than18 years of age who suffered a non-traumatic OHCA and received a resuscitation attempt by Emergency Medical Services (EMS). The key exposure was the airway management strategy (BVM, ETI, or SGA). The primary outcome was survival to hospital discharge. RESULTS Of the 3793 OHCA cases included from 405 EMS agencies, 1724 cases were analyzed after limiting the analysis to EMS agencies that used all 3 devices. Of the 1724, 781 (45.3%) were treated with BVM only, 727 (42.2%) ETI, and 215 (12.5%) SGA. Overall, 20.7% had ROSC and 10.9% survived to hospital discharge. After using a propensity score analysis, the odds ratio for survival to hospital discharge for ETI compared to BVM was 0.39 (95%CI 0.26-0.59) and for SGA compared to BVM was 0.32 (95% CI 0.12-0.84). These relationships were robust to the sensitivity analyses including complete case, EMS-agency matched, and age-stratified. CONCLUSIONS BVM was associated with higher survival to hospital discharge compared to ETI and SGA. A large randomized clinical trial is needed to confirm these findings.
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Affiliation(s)
- Matthew L Hansen
- Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, United States.
| | - Amber Lin
- Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, United States
| | - Carl Eriksson
- Department of Pediatrics, Oregon Health & Science University, United States
| | - Mohamud Daya
- Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, United States
| | - Bryan McNally
- Department of Emergency Medicine, Emory University, Atlanta, Georgia
| | - Rongwei Fu
- Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, United States; School of Public Health, Oregon Heath & Science University, United States
| | - David Yanez
- Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, United States; School of Public Health, Oregon Heath & Science University, United States
| | - Dana Zive
- Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, United States
| | - Craig Newgard
- Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, United States
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Hansen M, Eriksson C, Skarica B, Meckler G, Guise JM. Safety events in pediatric out-of-hospital cardiac arrest. Am J Emerg Med 2017; 36:380-383. [PMID: 28821366 DOI: 10.1016/j.ajem.2017.08.028] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 08/08/2017] [Accepted: 08/12/2017] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE The objective of this study was to explore the types of patient safety events that take place during pediatric out-of-hospital cardiac arrest resuscitation. METHODS Retrospective medical record review from a single large urban EMS system of EMS-treated pediatric (<18years of age) out-of-hospital cardiac arrests (OHCA) occurring between 2008 and 2011. A chart review tool was developed for this project and each chart was reviewed by a multidisciplinary review panel. Safety events were identified in the following clinical domains: resuscitation; assessment, impression/diagnosis, and clinical decision making; airway/breathing; fluids and medications; procedures; equipment; environment; and system. RESULTS From a total of 497 critical transports during the study period, we identified 35 OHCA cases (7%). A total of 87% of OHCA cases had a safety event identified. Epinephrine overdoses were identified in 31% of the OHCA cases, most of which were 10-fold overdoses. Other medication errors included failure to administer epinephrine when indicated and administration of atropine when not indicated. In 20% of OHCA cases, 3 or more intubation attempts took place or intubation attempts were ultimately not successful. Lack of end-tidal C02 use for tube confirmation was also common. The most common arrest algorithm errors were placing an advanced airway too early (before administration of epinephrine) and giving a medication not included in the algorithm, primarily atropine, both occurring in almost 1/3 of cases. CONCLUSIONS Safety events were common during pediatric OHCA resuscitation especially in the domains of medications, airway/breathing, and arrest algorithms.
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Affiliation(s)
- Matt Hansen
- Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, United States.
| | - Carl Eriksson
- Department of Pediatrics, Oregon Health & Science University, United States
| | - Barbara Skarica
- Department of Pediatrics, University of British Columbia, Canada
| | - Garth Meckler
- Department of Obstetrics & Gynecology, Oregon Health & Science University, United States
| | - Jeanne-Marie Guise
- Department of Obstetrics & Gynecology, Oregon Health & Science University, United States
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Stopyra JP, Wright JL, Fitch MT, Mitchell MS. Pediatric Needle Cricothyrotomy: A Case for Simulation in Prehospital Medicine. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2017; 13:10589. [PMID: 30800791 PMCID: PMC6338176 DOI: 10.15766/mep_2374-8265.10589] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 05/11/2017] [Indexed: 06/09/2023]
Abstract
INTRODUCTION A patient that cannot be oxygenated or ventilated requires immediate and effective assessment, treatment, and transportation. Pediatric needle cricothyrotomy is used infrequently, therefore providers have a tendency to lose proficiency. Simulation training and evaluation are valuable tools to improve provider experience and skill. METHODS A case was designed involving a 3-year-old male with a peanut allergy that presents with rash, swelling, and severe respiratory distress. The patient's respiratory distress and swelling worsens despite treatment with epinephrine and other allergic reaction medications. The patient then becomes unresponsive and impossible to oxygenate or ventilate. The primary objective of this case is airway management with needle cricothyrotomy in the pediatric population. A secondary objective is appropriate postprocedure management including appropriate ventilation rates and emergency medical transportation methods. RESULTS This case was initially presented to 45 paramedics. Provider comfort with managing airway emergencies in young children improved from 47% to 89%. Confidence in performing pediatric needle cricothyrotomy improved from 16% to 87%. All providers felt the exercise was valuable and 98% felt the simulation provided appropriate realism. DISCUSSION This scenario provides an outstanding opportunity for paramedic evaluation and training in pediatric needle cricothyrotomy and significantly improved the comfort level of providers' management of a failed pediatric airway. As we reflected on the use of this module, it was apparent that this was a very beneficial opportunity to spend one-on-one time between participants and their medical director. The training staff also benefited from the repeated emphasis of good assessment and treatment of a complex patient scenario.
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Affiliation(s)
- Jason P. Stopyra
- Assistant Professor, Departments of Emergency Medicine and Pediatric Emergency Medicine, Wake Forest School of Medicine of Wake Forest Baptist Medical Center
| | - Jamie L. Wright
- Resident Physician, Departments of Emergency Medicine and Pediatric Emergency Medicine, Wake Forest School of Medicine of Wake Forest Baptist Medical Center
| | - Michael T. Fitch
- Professor, Departments of Emergency Medicine and Pediatric Emergency Medicine, Wake Forest School of Medicine of Wake Forest Baptist Medical Center
| | - Michael S. Mitchell
- Assistant Professor, Departments of Emergency Medicine and Pediatric Emergency Medicine, Wake Forest School of Medicine of Wake Forest Baptist Medical Center
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Hansen M, Meckler G, Lambert W, Dickinson C, Dickinson K, Van Otterloo J, Guise JM. Patient safety events in out-of-hospital paediatric airway management: a medical record review by the CSI-EMS. BMJ Open 2016; 6:e012259. [PMID: 27836871 PMCID: PMC5128842 DOI: 10.1136/bmjopen-2016-012259] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To describe the frequency and characterise the nature of patient safety events in paediatric out-of-hospital airway management. METHODS We conducted a retrospective cross-sectional medical record review of all 'lights and sirens' emergency medicine services transports from 2008 to 2011 in patients <18 years of age in the Portland Oregon metropolitan area. A chart review tool (see online supplementary appendix) was adapted from landmark patient safety studies and revised after pilot testing. Expert panels of physicians and paramedics performed blinded reviews of each chart, identified safety events and described their nature. The primary outcomes were presence and severity of patient safety events related to airway management including oxygen administration, bag-valve-mask ventilation (BVM), airway adjuncts and endotracheal intubation (ETI).DC1SM110.1136/bmjopen-2016-012259.supp1supplementary appendix RESULTS: From the 11 328 paediatric transports during the study period, there were 497 'lights and sirens' (code 3) transports (4.4%). 7 transports were excluded due to missing data. Of the 490 transports included in the analysis, 329 had a total of 338 airway management procedures (some had more than 1 procedure): 61.6% were treated with oxygen, 15.3% with BVM, 8.6% with ETI and 2% with airway adjuncts. The frequency of errors was: 21% (71/338) related to oxygen use, 9.8% (33/338) related to BVM, 9.5% (32/338) related to intubation and 0.9% (3/338) related to airway adjunct use. 58% of intubations required 3 or more attempts or failed altogether. Cardiac arrest was associated with higher odds of a severe error. CONCLUSIONS Errors in paediatric out-of-hospital airway management are common, especially in the context of intubations and during cardiac arrest.
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Affiliation(s)
- Matthew Hansen
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Garth Meckler
- Division of Pediatric Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - William Lambert
- Department of Public Health & Preventive Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Caitlin Dickinson
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, Oregon, USA
| | - Kathryn Dickinson
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, Oregon, USA
| | - Joshua Van Otterloo
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, Oregon, USA
| | - Jeanne-Marie Guise
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA
- Department of Public Health & Preventive Medicine, Oregon Health & Science University, Portland, Oregon, USA
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, Oregon, USA
- Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon, USA
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Schmidt AR, Ulrich L, Seifert B, Albrecht R, Spahn DR, Stein P. Ease and difficulty of pre-hospital airway management in 425 paediatric patients treated by a helicopter emergency medical service: a retrospective analysis. Scand J Trauma Resusc Emerg Med 2016; 24:22. [PMID: 26944389 PMCID: PMC4779199 DOI: 10.1186/s13049-016-0212-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Accepted: 02/20/2016] [Indexed: 12/18/2022] Open
Abstract
Background Pre-hospital paediatric airway management is complex. A variety of pitfalls need prompt response to establish and maintain adequate ventilation and oxygenation. Anatomical disparity render laryngoscopy different compared to the adult. The correct choice of endotracheal tube size and depth of insertion is not trivial and often challenged due to the initially unknown age of child. Methods Data from 425 paediatric patients (<17 years of age) with any airway manipulation treated by a Swiss Air-Ambulance crew between June 2010 and December 2013 were retrospectively analysed. Endpoints were: 1) Endotracheal intubation success rate and incidence of difficult airway management in primary missions. 2) Correlation of endotracheal tube size and depth of insertion with patient’s age in all (primary and secondary) missions. Results In primary missions, the first laryngoscopy-guided endotracheal intubation attempt was successful in 95.3% of cases, with an overall success rate of 98.6%. Difficult airway management was reported in 10 (4.7%) patients. Endotracheal tube size was frequently chosen inadequately large (overall 50 of 343 patients: 14.6%), especially and statistically significant in the age group below 1 year (19 of 33 patients; p < 0.001). Tubes were frequently and distinctively more deeply inserted (38.9%) than recommended by current formulae. Conclusion Difficult airway management, including cannot intubate and cannot ventilate situations during pre-hospital paediatric emergency treatment was rare. In contrast, the success rate of endotracheal intubation at the first attempt was very high. High numbers of inadequate endotracheal tube size and deep placement according to patient age require further analysis. Practical algorithms need to be found to prevent potentially harmful treatment.
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Affiliation(s)
- Alexander R Schmidt
- Department of Anaesthesiology, University Children's Hospital, Zurich, Switzerland
| | - Lea Ulrich
- Institute of Anaesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Burkhardt Seifert
- Department of Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Roland Albrecht
- Swiss Air-Ambulance, Rega (Rettungsflugwacht/Guarde Aérienne), Zurich, Switzerland
| | - Donat R Spahn
- Institute of Anaesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Philipp Stein
- Institute of Anaesthesiology, University and University Hospital Zurich, Zurich, Switzerland. .,Swiss Air-Ambulance, Rega (Rettungsflugwacht/Guarde Aérienne), Zurich, Switzerland.
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