Paediatric intubation in Scottish emergency departments

Characteristics of paediatric pre-hospital intubation by Intensive Care Paramedics

OBJECTIVES

Emergency intubation in children is an infrequent procedure both in the pre-hospital and hospital setting. The anatomical, physiological and situational challenges together with limited clinician exposure can make this a difficult procedure with high risk of adverse events. The aim of this collaborative study between a state-wide ambulance service and a tertiary children's hospital was to describe the characteristics of pre-hospital paediatric intubations by Intensive Care Paramedics.

METHODS

We conducted a retrospective review of state-wide ambulance service electronic patient care records (ePCRs) in Victoria, Australia, population: 6.5 million. Children aged 0-18 years who were attended by paramedics over a 12-month period that required advanced airway management were analysed for demographics and first-pass success rate.

RESULTS

Paramedics attended 2674 cases aged 0-18 years over the 12-month study period who received basic or advanced airway management. A total of 78 cases required advanced airway management. The median age of patients was 12 years (interquartile range 3-16) and most were male (60.2%). Sixty-eight patients (87.5%) were intubated successfully on the first attempt, first-pass success was lowest in children <1 year of age. The most common indications for pre-hospital intubation were closed head injury and cardiac arrest. It was not possible to report complication rates because of incomplete documentation.

CONCLUSION

Pre-hospital intubation in children is performed infrequently in an extremely unwell patient group. Continued high-level paramedic training is required to prevent adverse events and ensure patient safety.

Mixed-methods pilot study exploring the influence of the novel Paediatric Anaesthetic Drug Solution tool on clinician cognitive load during simulated paediatric rapid sequence intubation in the emergency department

AIM

Rapid sequence intubation (RSI) in children is a low-incidence, high-risk event associated with cognitive overload and potential errors producing unfavourable outcomes. Cognitive aids, such as charts, algorithms and flow diagrams, are prompts that externalise and structure mental processes to reduce cognitive load, thereby reducing errors. The Paediatric Anaesthetic Emergency Drug Solution (PAEDS) approach combines a colour-coded chart and medication box with a simplified mathematical system of volume-based dosing; the effect of which on cognitive load during a simulated RSI has not previously been described.

METHODS

A randomised, cross-over trial was conducted with 26 multi-disciplinary emergency medicine clinicians (doctors and nurses) allocated to four groups, performing four high-fidelity RSI simulations, two mandating the use of the PAEDS approach. This mixed methods study followed the pragmatic ontology using grounded theory methodology. Qualitative data were collected from nine individual interviews by a process of thematic analysis via an inductive approach, to allow for appropriate open and axial coding to occur. Quantitative data collected included cognitive loading using the raw NASA-Task Load Index as well as time to intubation and drug dosage details to assess for safety.

RESULTS

Qualitative results showed that the PAEDS approach reduced cognitive loading through the use of both the labelled medication box and colour-coded medication charts. The PAEDS approach also showed improved perceived time pressure without feeling rushed, and with no recorded drug errors. Differences in the quantitative data for total cognitive load, error and time were not statistically significant, likely due to sample size.

CONCLUSION

The PAEDS approach is a multifaceted system which is not inferior to current practice, with some components described as an improvement. Further research on a larger sample size needs to be conducted to assess the aspects of the PAEDS approach both collectively and independently.

Factors Associated with the Underuse of Sedatives and Neuromuscular Blocking Agents for Pediatric Emergency Endotracheal Intubation in Korea

PURPOSE

Rapid sequence intubation (RSI) using sedatives and neuromuscular blocking agents (NMBAs) is recommended for pediatric emergency endotracheal intubation (ETI), but is not frequently performed in Korea. This study aimed to verify factors associated with the underuse of RSI medications.

MATERIALS AND METHODS

This multicenter retrospective study reviewed patients aged under 18 years who underwent an ETI within 24 hours of arrival at the emergency department between 2016 and 2019. Any cases of ETI during cardiopulmonary resuscitation were excluded. We investigated the characteristics of the patients, intubators, RSI medications, and outcomes. The study cases were classified into no-medication, sedative-only, and sedative-with-NMBA groups. Multivariable logistic regression analysis of RSI medication use was conducted.

RESULTS

A total of 334 cases with a median age of 3.4 years were included in this study. Sedatives and NMBAs were used in 63.8% and 32.9%, respectively. In comparing the no-medication (n=121), sedative-only (n=103), and sedative-with-NMBA (n=110) groups, patient age (median; 1.0 year vs. 2.8 years vs. 11.3 years; p<0.001), underlying medical conditions (77.7% vs. 56.3% vs. 36.4%; p<0.001), and pediatricians as intubators (76.9% vs. 54.4% vs. 17.3%; p<0.001) were different. The factors that influenced sedatives with NMBA use were patient age [for a year increment; adjusted odds ratio (aOR), 1.182; 95% confidence interval (CI), 1.120-1.249], no underlying medical conditions (aOR, 2.109; 95% CI, 1.093-4.070), and intubators other than pediatricians (aOR, 5.123; 95% CI, 2.257-11.626).

CONCLUSION

RSI accounted for 32.9% of pediatric emergency ETI in Korea. The underuse of RSI medications is associated with younger patient age, underlying medical conditions, and pediatricians as intubators.

Differences in intubation outcomes for pediatric patients between pediatric and general Emergency Departments

BACKGROUND

Intubation is a life-saving intervention at the Emergency Department (ED). However, general and pediatric EDs may vary in their preparedness to manage children with airway emergencies.

AIMS

We aimed to compare rates of first-pass intubation and adverse tracheal intubation-associated events between general and pediatric EDs.

METHODS

A retrospective review of medical records was conducted at a pediatric ED and three general EDs from January 1, 2015, to December 31, 2018. Information about the intubation process involving pediatric patients (less than 16 years old), as well as eventual outcomes of first-pass intubation and adverse tracheal intubation-associated events were collected and analyzed.

RESULTS

There were 180 pediatric intubations, of which 115 (63.9%) were performed in pediatric ED. The median age was 2 years old (interquartile range 0-6). Intubation was most commonly performed for patients with cardiac arrest (88, 48.9%). Direct laryngoscopy was used in 178 (98.9%) cases and uncuffed tube was used in 135 (75.0%) cases. Apneic oxygenation was performed in 26 (14.4%) cases-all in pediatric ED. Intubation was predominantly performed by senior clinicians (162, 90.0%). Overall, intubation was performed successfully in 175 (97.2%) cases, with a first-pass intubation rate of 82.2% which was similar between pediatric (96, 83.5%) and general EDs (52, 80%) (Odds ratio [OR] 1.26, 95% confidence interval [CI] 0.58 to 2.76, p = .558). There were 68 adverse tracheal intubation-associated events with right mainstem intubation being the most common (23, 12.8%). Pediatric EDs (44, 38.3%) had a higher rate of adverse tracheal intubation-associated events than general EDs (15, 23.1%) (OR 2.07, 95% CI 1.04 to 4.11; p = .037).

CONCLUSIONS

Differences exist in intubation outcomes between pediatric and general EDs. Quality improvement efforts should focus on standardizing intubation practices across both pediatric and general EDs.

Exposure and confidence across critical airway procedures in pediatric emergency medicine: An international survey study

BACKGROUND

Airway management procedures are critical for emergency medicine (EM) physicians, but rarely performed skills in pediatric patients. Worldwide experience with respect to frequency and confidence in performing airway management skills has not been previously described.

OBJECTIVES

Our aims were 1) to determine the frequency with which emergency medicine physicians perform airway procedures including: bag-mask ventilation (BMV), endotracheal intubation (ETI), laryngeal mask airway (LMA) insertion, tracheostomy tube change (TTC), and surgical airways, and 2) to investigate predictors of procedural confidence regarding advanced airway management in children.

METHODS

A web-based survey of senior emergency physicians was distributed through the six research networks associated with Pediatric Emergency Research Network (PERN). Senior physician was defined as anyone working without direct supervision at any point in a 24-h cycle. Physicians were queried regarding their most recent clinical experience performing or supervising airway procedures, as well as with hands on practice time or procedural teaching. Reponses were dichotomized to within the last year, or ≥ 1 year. Confidence was assessed using a Likert scale for each procedure, with results for ETI and LMA stratified by age. Response levels were dichotomized to "not confident" or "confident." Multivariate regression models were used to assess relevant associations.

RESULTS

1602 of 2446 (65%) eligible clinicians at 96 PERN sites responded. In the previous year, 1297 (85%) physicians reported having performed bag-mask ventilation, 900 (59%) had performed intubation, 248 (17%) had placed a laryngeal mask airway, 348 (23%) had changed a tracheostomy tube, and 18 (1%) had performed a surgical airway. Of respondents, 13% of physicians reported the opportunity to supervise but not provide ETI, 5% for LMA and 5% for BMV. The percentage of physicians reporting "confidence" in performing each procedure was: BMV (95%) TTC (43%), and surgical airway (16%). Clinician confidence in ETT and LMA varied by patient age. Supervision of an airway procedure was the strongest predictor of procedural confidence across airway procedures.

CONCLUSION

BMV and ETI were the most commonly performed pediatric airway procedures by emergency medicine physicians, and surgical airways are very infrequent. Supervising airway procedures may serve to maintain procedural confidence for physicians despite infrequent opportunities as the primary proceduralist.

Adverse events and risk factors during emergency intubation in a tertiary paediatric emergency department

BACKGROUND

Rapid sequence intubation and emergency intubation in the emergency department (ED) can be life-saving procedures, but require the appropriate skills, experience and preparation to avoid complications ranging from simple trauma to life-threatening desaturation. Only scarce data exist in the published literature on complications following emergency intubation in children and most guidelines are extrapolated from the adult population.

PATIENTS AND METHODS

We reviewed all emergency intubations of patients in our tertiary paediatric ED within a 2-year period to estimate the incidence of complications and to analyse the risk factors associated with this procedure.

RESULTS

Seventy-two children were intubated; complications occurred in one in four and repeated attempts at intubation in 17/23 children. The median age of the children was 2 years (range: 0 days-6 years). The most common reason for intubation was altered level of consciousness and the most frequent diagnosis at the time of intubation was seizure/status epilepticus. Complications were related to desaturation (n=7), equipment failure (n=3), intravenous access (n=2) and hypotension (n=2), erroneous or insufficient drug preparation (n=1) and other reasons (n=3). There was no significant association of complications with the child's age or weight, time of arrival to ED, preintubation hypotension or combination of drugs used.

CONCLUSION

Complications of rapid sequence intubation, a relatively low-frequency procedure in the paediatric ED, occurred in one of four children and repeat attempts at intubation were made in another 24%. We suggest that the use of an intubation checklist including the preparation of equipment and recommendations for drug use would minimize the occurrence of adverse events of intubation in children.

Adolescent tracheal intubation in an adult urban emergency department: a retrospective, observational study

OBJECTIVES

Tracheal intubation is the cornerstone of advanced emergency airway management in children and adults and there is good-quality data characterizing intubation in both groups. There are, however, few published studies on emergency tracheal intubation in adolescents. We carried out an observational study to characterize tracheal intubation in adolescents.

METHODS

We analysed data from a previously collected Emergency Department Intubation Registry. We included all attempts at tracheal intubation performed in our adult emergency department between 1999 and 2011. We recorded the indication for intubation, the staff involved, the technique and drugs used, and the rates of successful intubation and adverse events. We classified patients into three age groups: 13-16 years (adolescent), 17-24 years (young adult) and at least 25 years (older adult).

RESULTS

Trauma was the most common indication for intubation in adolescents, and rapid sequence induction was used in 88% of cases. Ninety-nine percent of tracheal intubations in adolescent patients were successful on the first or the second attempt, no adolescent underwent more than three attempts and none required a surgical airway. The initial intubation attempt in adolescents was more likely to be performed by an anaesthetist (P<0.005). The first attempt success rate was higher (P<0.01) and adverse event rate was lower (P<0.05) in adolescents than in adults. Hypotension was the only adverse event recorded in adolescents; this occurred in three patients (4.5%).

CONCLUSION

Our findings suggest that the airway in adolescent patients can be managed successfully and safely in an adult emergency department where there is close collaboration between anaesthetists and emergency physicians.

Pediatric Facial Fractures: An Assessment of Airway Management

Pediatric facial fractures present unique and challenging management considerations, especially with regards to airway management. Anatomical differences in children increase both airway resistance and the difficulty of intubation. A surgical airway may be required if intubation is unable to be performed. The purpose of this study was to examine a single center's experience with pediatric facial fractures to determine the frequency of advanced airway use, as well as the risk factors that may predispose a patient to requiring an advanced airway. A retrospective review of all facial fractures at a level 1 trauma center was performed from 2000 to 2012. Patients age 18 years and younger were included. Patient demographics were collected, as well as location of fractures, concomitant injuries, services consulted, and surgical management strategies. Information was collected regarding the need for an advanced airway, including intubation and the need for a surgical airway. A total of 285 patients met inclusion criteria. Of these, 57 patients (20%) required emergency intubation and 5 (1.8%) required a surgical airway. Intubation was significantly related to fractures of the midface, frontal sinuses, spine, skull, and pelvis, as well as depressed Glasgow coma scores and traumatic brain injury. The need for a surgical airway is extremely uncommon (1.8%), and tracheostomy was only needed in the setting of penetrating head trauma. Both emergent intubation and tracheostomy are associated with complications, but these complications must be weighed against the potentially life-saving measure of securing an airway.

Airway emergencies presenting to the paediatric emergency department requiring advanced management techniques

BACKGROUND

Airway emergencies presenting to the emergency department (ED) are usually managed with conventional equipment and techniques. The patient group managed urgently in the operating room (OR) has not been described.

AIMS

This study aims to describe a case series of children presenting to the ED with airway emergencies managed urgently in the OR, particularly the anaesthetic equipment and techniques used and airway findings.

METHODS

A retrospective cohort study undertaken at The Royal Children's Hospital, Melbourne, Australia. All patients presenting to the ED between 1 January 2012 and 30 July 2015 (42 months) with an airway emergency who were subsequently managed in the OR were included. Patient characteristics, anaesthetic equipment and technique and airway findings were recorded.

RESULTS

Twenty-two airway emergencies in 21 patients were included over the study period, on average one every 2 months. Median age was 18 months and 43% were male. Inhalational induction was used in 77.3%, combined inhalational and intravenous induction in 9.1%, and intravenous induction alone in 13.6%. The most commonly used inhalational induction agent was sevoflurane, and the most commonly used intravenous induction agents were ketamine and propofol. Ten airway emergencies did not require intubation, seven for removal of inhaled foreign body, two with progressive tracheal stenosis requiring emergent dilatation and one examination under anaesthesia to rule out inhaled foreign body. Of the 12 airway emergencies that required immediate intubation, direct laryngoscopy was used in 9 and fibre-optic intubating bronchoscopy in 3. For intubations performed by direct laryngoscopy, one was difficult (Cormack and Lehane grade 3). First pass success was 83.3%. Adverse events occurred in 3/22 (13.6%) cases.

CONCLUSION

Advanced airway techniques, including inhalational induction and intubation via fibre-optic intubating bronchoscope, are rarely but predictably required in the management of patients presenting to the ED. Institutions caring for children should prepare in advance where such patients should be managed, by whom, and provide equipment and training for their care.

Effects of an elevated position on time to tracheal intubation by novice intubators using Macintosh laryngoscopy or videolaryngoscopy: randomized crossover trial

Objective

To investigate the time to tracheal intubation using Glidescope videolaryngoscopy (GVL) compared to that of standard laryngoscopy, by using a Macintosh blade (SLM) in a human patient simulator in supine and elevated (ramped) positions.

Methods

In this randomized crossover design, novice intubators (first-year medical students), using both laryngoscopic techniques, attempted tracheal intubation on a human patient simulator with a “normal airway” anatomy (Cormack-Lehane grade I). The simulator was placed in both supine and ramped positions using a commercial mattress system. The mean time to intubation and complications were compared between GVL and SLM in both positions. The percentage of glottic opening (POGO, GVL only) was estimated during intubation in the ramped and supine positions. The primary outcome was time to intubation, and the secondary outcomes included complication rates such as esophageal intubation and dental trauma.

Results

There was no difference in the mean time to intubation in either position (P=0.33). The SLM intubation was significantly faster than GVL (mean difference, 1.5 minutes; P<0.001). The mean POGO score for GVL improved by 8% in the ramped position compared to that in supine position (P=0.018). The esophageal intubation rate for SLM was 15% to 17% compared to 1.3% for GVL; dental trauma occurred in 53% to 56% of GVL, compared to 2% to 6% for SLM (P<0.001, respectively).

Conclusion

Novices had shorter intubation times using standard laryngoscopy with a SLM compared to GVL in both supine and ramped positions. GVL resulted in fewer esophageal intubations, but more dental trauma than standard laryngoscopy.

A randomised controlled trial of cognitive aids for emergency airway equipment preparation in a Paediatric Emergency Department

BACKGROUND

Safety of emergency intubation may be improved by standardising equipment preparation; the efficacy of cognitive aids is unknown.

METHODS

This randomised controlled trial compared no cognitive aid (control) with the use of a checklist or picture template for emergency airway equipment preparation in the Emergency Department of The Royal Children's Hospital, Melbourne.

RESULTS

Sixty-three participants were recruited, 21 randomised to each group. Equal numbers of nursing, junior medical, and senior medical staff were included in each group. Compared to controls, the checklist or template group had significantly lower equipment omission rates (median 30% IQR 20-40% control, median 10% IQR 5-10 % checklist, median 10% IQR 5-20% template; p < 0.05). The combined omission rate and sizing error rate was lower using a checklist or template (median 35 % IQR 30-45 % control, median 15% IQR 10-20% checklist, median 15% IQR 10-30% template; p < 0.05). The template group had less variation in equipment location compared to checklist or controls. There was no significant difference in preparation time in controls (mean 3 min 14 s sd 56 s) compared to checklist (mean 3 min 46 s sd 1 min 15 s) or template (mean 3 min 6 s sd 49 s; p = 0.06).

DISCUSSION

Template use reduces variation in airway equipment location during preparation foremergency intubation, with an equivalent reduction in equipment omission rate to the use of a checklist. The use of a template for equipment preparation and a checklist for team, patient, and monitoring preparation may provide the best combination of both cognitive aids.

CONCLUSIONS

The use of a cognitive aid for emergency airway equipment preparation reduces errors of omission. Template utilisation reduces variation in equipment location.

TRIAL REGISTRATION

Australian and New Zealand Trials Registry (ACTRN12615000541505).

Endotracheal intubation in the pediatric emergency department

BACKGROUND AND OBJECTIVES

Prospective safety data on emergency department (ED) intubation in children are limited. We aimed to describe the practice and adverse events associated with endotracheal intubation in a large urban pediatric ED.

METHODS

Prospective observational study at a tertiary pediatric ED with an annual census of 82,000. The primary outcome measure was the adverse event rate. Secondary outcome measures were incidence of difficult laryngoscopy and first pass success rate without desaturation or hypotension.

RESULTS

Over a 12-month period in 2013, there were 71 intubations in 66 patients (9/10,000 ED visits). Median age was 3 years, with 25% in infants <1 year of age. Indications were as follows: trauma (21%) and medical conditions (79%); most frequently status epileptics (31%). Forty-four percent had cardiovascular compromise, 87% had respiratory compromise, and 70% had a GCS <9 prior to intubation. Adverse events occurred in 39%, the most common being hypotension (21%) and desaturation (14%). One anticipated and one unanticipated difficult laryngoscopy were encountered (both Cormack and Lehane grade 3). Overall first pass success rate was 78%, although first pass success without desaturation or hypotension was only 49%. Seven percent required more than two attempts for successful intubation.

CONCLUSION

Intubation of children in the ED is a low-frequency, high-risk procedure. The incidence of adverse events, particularly desaturation and hypotension, is high. The incidence of difficult laryngoscopy is low. First pass success rate without desaturation or hypotension is low. Strategies to avoid desaturation and hypotension in the peri-intubation setting should be prioritized.

Pediatric endotracheal intubations for airway management in the emergency department

OBJECTIVE

The objective of this study was to determine indications, type of medications used, and immediate complications of pediatric endotracheal intubations in the emergency department.

METHODS

A retrospective chart review was done on all pediatric patients (0-14 years old) who required endotracheal (ET) intubation for airway management in the Department of Emergency Medicine at Aga Khan University Hospital from January to December 2009. Data were collected on a preformed questionnaire for age, sex, indications, drugs used, and complications of pediatric ET intubations done in the emergency department. Dead-on-arrival patients and those intubated elsewhere were excluded.

RESULTS

A total of 83 pediatric intubations were done during the study period. Indications for ET intubations were respiratory failure in 51 (61%), unresponsiveness in 18 (22%), cardiac arrest in 8 (10%), and trauma in 6 cases (7%). Comorbid conditions were present in 28 (34%). Of 83 ET intubations, drugs were used in 48 cases (58%). Both sedation and neuromuscular blockade were used in 42 cases (51%), 4 cases (5%) received sedation only, and 2 cases (2%) received relaxation without sedation, and in 35 cases (42%), intubation was done without drugs. Drugs used for sedation/induction were ketamine in 22 (26%), midazolam in 14 (17%), propofol in 7 (8%), and etomidate in 3 cases (4%). Neuromuscular blockades used were rocuronium in 27 cases (32%), succinylcholine in 11 cases (13.5%), and atracurium in 5 cases (6%). Complications were noted in 16 cases (19%).

CONCLUSIONS

Respiratory failure was found to be the main presenting complaint. Drugs for sedation and relaxation to facilitate ET intubation were underused.

Tracheal intubation in the emergency department: the Scottish district hospital perspective

BACKGROUND

Tracheal intubation is the accepted gold standard for emergency department (ED) airway management. It may be performed by both anaesthetists and emergency physicians (EPs), with or without drugs.

OBJECTIVE

To characterise intubation practice in a busy district general hospital ED in Scotland over 40 months between 2003 and 2006.

SETTING

Crosshouse Hospital, a 450-bed district general hospital serving a mixed urban and rural population; annual ED census 58,000 patients.

METHODS

Prospective observational study using data collection sheets prepared by the Scottish Trauma Audit Group. Proformas were completed at the time of intubation and checked by investigators. Rapid-sequence induction (RSI) was defined as the co-administration of an induction agent and suxamethonium.

RESULTS

234 intubations over 40 months, with a mean of 6 per month. EPs attempted 108 intubations (46%). Six patients in cardiac arrest on arrival were intubated without drugs. 29 patients were intubated after a gas induction or non-RSI drug administration. RSI was performed on 199 patients. Patients with trauma constituted 75 (38%) of the RSI group. 29 RSIs (15%) were immediate (required on arrival at the ED) and 154 (77%) were urgent (required within 30 min of arrival at the ED). EPs attempted RSI in 88 (44%) patients and successfully intubated 85 (97%). Anaesthetists attempted RSI in 111 (56%) patients and successfully intubated 108 (97%). Anaesthetists had a higher proportion of good views at first laryngoscopy and there was a trend to a higher rate of successful intubation at the first attempt for anaesthetists. Complication rates were comparable for the two specialties.

CONCLUSIONS

Tracheal intubations using RSI in the ED are performed by EPs almost as often as by anaesthetists in this district hospital. Overall success and complication rates are comparable for the two specialties. Laryngoscopy training and the need to achieve intubation at the first (optimum) attempt needs to be emphasised in EP airway training.

Sala de emergência em pediatria: casuística de um hospital universitário

OBJETIVO: Descrever a casuística de pacientes pediátricos atendidos em sala de emergência pediátrica de um hospital universitário. MÉTODOS: Estudo retrospectivo descritivo de 1º de janeiro até 31 de dezembro de 2004, com crianças de zero a 14 anos, avaliadas quanto a dados epidemiológicos, hipótese diagnóstica, intubação orotraqueal, óbito, destino e duração da internação. Os pacientes foram divididos em quatro grupos: Não Óbitos; Óbitos <24 horas, Óbitos >24 horas e transferidos para outros hospitais. RESULTADOS: Foram atendidas 203 crianças; 59,1% meninos; média de idade 3,4 anos; 65% previamente hígidos. O diagnóstico mais freqüente foi insuficiência respiratória (31,1%). Dentre os 22 óbitos, 3,5% ocorreram nas primeiras 24 horas e 7,4% após estas primeiras 24 horas; 172 crianças (84,7%) evoluíram para alta após período médio de internação de 19,2 dias. Nove (4,4%) foram transferidas para outros hospitais. Das 203 crianças atendidas, 50 (24,6%) foram intubadas à admissão e 86 (42,4%) necessitaram internação em unidade de terapia intensiva pediátrica. CONCLUSÕES: Os pacientes que evoluíram para óbito precoce eram mais jovens e com diagnóstico de choque. Nos pacientes que evoluíram para óbito após 24 horas do atendimento inicial, predominaram meninas, com doenças prévias e insuficiência respiratória. Aqueles que sobreviveram ao atendimento de emergência eram, em maior freqüência, meninos mais velhos e com doenças respiratórias. Houve necessidade significativa de procedimento invasivo (intubação orotraqueal) e internação subseqüente em unidade de terapia intensiva, o que reforça a necessidade de equipamentos adequados e profissionais especializados no setor.

Advanced airway management in the emergency department: what are the training and skills maintenance needs for UK emergency physicians?

This article reviews the evidence for the training of emergency physicians in advanced airway management.