Success of Pediatric Intubations Performed by a Critical Care Transport Service

Predictive and protective factors for failing first pass intubation in prehospital rapid sequence intubation: an aetiology and risk systematic review with meta-analysis

BACKGROUND

Prehospital rapid sequence intubation first pass success rates vary between 59% and 98%. Patient morbidity is associated with repeat intubation attempts. Understanding what influences first pass success can guide improvements in practice. We performed an aetiology and risk systematic review to answer the research question 'what factors are associated with success or failure at first attempt laryngoscopy in prehospital rapid sequence intubation?'.

METHODS

MEDLINE, EMBASE, CINAHL, and Cochrane Library were searched on March 3, 2023 for studies examining first pass success rates for rapid sequence intubation of prehospital live patients. Screening was performed via Covidence, and data synthesised by meta-analysis. The review was registered with PROSPERO and performed and reported as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Reasonable evidence was discovered for predictive and protective factors for failure of first pass intubation. Predictive factors included age younger than 1 yr, the presence of blood or fluid in the airway, restricted jaw or neck movement, trauma patients, nighttime procedures, chronic or acute distortions of normal face/upper airway anatomy, and equipment issues. Protective factors included an experienced intubator, adequate training, use of certain videolaryngoscopes, elevating the patient on a stretcher in an inclined position, use of a bougie, and laryngeal manoeuvres.

CONCLUSIONS

Managing bloody airways, positioning well, using videolaryngoscopes with bougies, and appropriate training should be further explored as opportunities for prehospital services to increase first pass success. Heterogeneity of studies limits stronger conclusions.

SYSTEMATIC REVIEW PROTOCOL

PROSPERO (CRD42022353609).

Paramedics' Success and Complications in Prehospital Pediatric Intubation: A Meta-Analysis

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.

Pediatric Intubations in a Semiurban Helicopter Emergency Medicine Service: A Retrospective Review

OBJECTIVE

Although a small proportion of helicopter emergency medical service (HEMS) missions are for pediatric patients, it is recognized that children do present unique challenges. This case series aims to evaluate the intubation first-pass success rate in HEMS pediatric patients for both medical and trauma patients in a UK semiurban environment.

METHODS

A retrospective review of the computerized records system was performed from January 1, 2015, to July 31, 2022, at 1 UK HEMS. Anonymous data relating to advanced airway interventions in patients < 16 years of age were extracted. Primary analysis related to the first-pass success rate was performed; secondary analysis relating to the initial Glasgow Coma Scale (GCS) of the pediatric patients requiring prehospital anesthesia (rapid sequence induction with drugs) and first-pass success rates by clinician group was also performed.

RESULTS

Of the pediatric patients, 15.8% required intubation. The overall first-pass success rate for intubation (including in cardiac arrest) was 83.5%; for prehospital anesthesia (drugs administered), it was 98.4%. First-pass success rates were lowest for those under 2 years of age (45.2% without drugs and 87.5% with drugs). There was no difference between physician background in the first-pass success rate. The median GCS for pediatric prehospital anesthesia was 7 versus 5 for adults (P = .012). No children with an initial GCS of 15 had prehospital anesthesia.

CONCLUSION

The overall intubation first-pass success rates for pediatric patients is high at 83.5% and higher still for prehospital anesthesia (98.4%). However, it remains a rare intervention for clinicians, and children under 2 years of age require special consideration.

Factors Associated With Early Discharge in Pediatric Trauma Patients Transported by Rotor: A Retrospective Analysis

OBJECTIVE

Helicopter emergency medical services (HEMS) play a crucial role in providing timely transport for pediatric trauma patients. This service carries the highest risk of any mode of medical transport and a high financial burden, and patient outcomes are seldom investigated. This study evaluated the characteristics of pediatric trauma patients discharged within 24 hours after transport by HEMS.

METHODS

This was a single-center, retrospective analysis on pediatric trauma patients transported by HEMS from 2019 to 2022. Analyses were performed to identify factors associated with discharge within 24 hours. Factors analyzed included vital signs, Shock Index, Pediatric Age-Adjusted scores, management details, and clinical outcomes.

RESULTS

A total of 466 pediatric trauma patients were transported by HEMS, including 171 patients (36.7%) who were discharged within 24 hours. There were no differences in the rates of blunt and penetrating injury (P = .583). Patients discharged within 24 hours were more likely to have a higher Glasgow Coma Scale score (14 vs. 11, P < .001) and a lower Injury Severity Score (4.9 vs. 14.7, P < .001), required less prehospital fluid resuscitation (5.5 vs. 11.7 mL/kg, P = .039), and had higher levels of serum calcium (9.3 vs. 8.9 mg/dL, P < .001). They were also less likely to meet criteria for level 1 trauma activation (13.0% vs. 40%, P < .001) or to require prehospital respiratory support of any kind (4.1% vs. 31.1%, P < .001). After arrival at the hospital, they were less likely to require blood transfusions (2.9% vs. 29.8%, P < .001) or tranexamic acid (2.9% vs. 11.5%, P = .001).

CONCLUSION

Trauma patients with a high Glasgow Coma Scale score and a low Injury Severity Score who do not require critical care or meet the criteria for high-level trauma activation may be suitable for transportation with lower acuity. Further studies aimed at improving triage and implementing improved criteria for the use of HEMS are paramount.

A randomized crossover comparison of the bébé VieScope and direct laryngoscope for pediatric airway management by nurses in medical simulation settings

BACKGROUND

Airway management in life-threatening emergencies is essential for children, and endotracheal intubation is the gold standard. It protects against regurgitation and enables mechanical ventilation. New types of airway management equipment are being developed and implemented to meet the needs of medical personnel.

RESEARCH DESIGN AND METHODS

This prospective, randomized, cross-over simulation trial evaluated the success of endotracheal intubation in three scenarios: normal airway (scenario-A), tongue edema (scenario-B), and continuous chest compression (scenario-C), using the bébé Vie Scope™ laryngoscope (VieScope) and the Macintosh blade laryngoscope (MAC) as a comparative tool performed by nurses with limited tracheal intubation experience.

RESULTS

The results of the study showed that in scenario-A, there were no significant differences in the first attempt success rate or endotracheal intubation time between VieScope and MAC. However, VieScope was associated with better visualization of the glottis. In scenarios B and C, VieScope was significantly more effective than MAC in terms of first-pass success rate, time to intubate, Cormack-Lehane grade, POGO score, and ease of endotracheal intubation.

CONCLUSIONS

Bébé VieScope may be useful for endotracheal intubation in pediatric patients, particularly in cases of tongue edema and ongoing chest compression, providing a higher first-pass success rate than conventional laryngoscopes.

Success rate of prehospital emergency front-of-neck access (FONA): a systematic review and meta-analysis

BACKGROUND

Front-of-neck access (FONA) is an emergency procedure used as a last resort to achieve a patent airway in the prehospital environment. In this systematic review with meta-analysis, we aimed to evaluate the number and success rate of FONA procedures in the prehospital setting, including changes since 2017, when a surgical technique was outlined as the first-line prehospital method.

METHODS

A systematic literature search (PROSPERO CRD42022348975) was performed from inception of databases to July 2022 to identify studies in patients of any age undergoing prehospital FONA, followed by data extraction. Meta-analysis was used to derive pooled success rates. Methodological quality of included studies was interpreted using the Cochrane risk of bias tool, and rated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.

RESULTS

From 909 studies, 69 studies were included (33 low quality; 36 very low quality) with 3292 prehospital FONA attempts described (1229 available for analysis). The crude median success rate increased from 99.2% before 2017 to 100.0% after 2017. Meta-analysis revealed a pooled overall FONA success rate of 88.0% (95% confidence interval [CI], 85.0-91.0%). Surgical techniques had the highest success rate at a median of 100.0% (pooled rate=92.0%; 95% CI, 88.0-95.0%) vs 50.0% for needle techniques (pooled rate=52.0%; 95% CI, 28.0-76.0%).

CONCLUSIONS

Despite being a relatively rare procedure in the prehospital setting, the success rate for FONA is high. A surgical technique for FONA appears more successful than needle techniques, and supports existing UK prehospital guidelines.

SYSTEMATIC REVIEW PROTOCOL

PROSPERO CRD42022348975.

Variation in Prehospital Protocols for Pediatric Respiratory Distress Management in the United States

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.

[Paediatric Life Support]

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.

European Resuscitation Council Guidelines 2021: Paediatric Life Support

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.

The Impact of Videolaryngoscopy on Endotracheal Intubation Success by a Pediatric/Neonatal Critical Care Transport Team

INTRODUCTION

Endotracheal intubation may be required for the transport of critically ill neonates and children. Data suggest that first pass success (FPS) is associated with lower rates of complications. Thus, understanding factors associated with FPS can have important implications for clinical outcomes. We aimed to determine the impact of videolaryngoscopy (VL) on FPS by a pediatric critical care transport team (CCTT). Methods: We performed a retrospective cross-sectional study on pediatric patients (≤ 18 years of age) requiring endotracheal intubation by a tertiary care-based pediatric CCTT between 2011 and 2019. Patients were categorized as neonatal (≤ 28 days of age, either preterm or term) or pediatric (> 28 days of age). All intubation attempts using VL were performed with the C-MAC videolaryngoscope. Our primary outcome was rate of FPS. Descriptive statistics of patient, provider, and procedure characteristics were calculated. Multivariate regression was used to test the association between FPS and type of laryngoscope (video versus direct) adjusting for significant clinical predictors. Results: Over the study period, 135 patients were intubated by the CCTT. Sixty percent of these patients were neonates, and 40% were pediatric. The overall FPS rate was 61%, with lower rates in neonates (54%) and higher rates in pediatric patients (70%). Use of videolaryngoscopy increased over the study period. First pass success rate using the C-MAC videolaryngoscope was 72% compared to 42% for direct laryngoscopy across the whole study population. In adjusted analyses, FPS using VL was significantly higher in the pediatric patient population (aOR 12.42 [95%CI 3.33, 46.29]), but not in neonates (aOR 1.08 [0.44, 2.63]). Use of VL increased significantly over the study period. Conclusion: We found use of a C-MAC videolaryngoscope by a critical care transport team was associated with improved FPS during endotracheal intubation of pediatric patients but not neonates, after controlling for other patient and provider characteristics. In addition to the impact on FPS, use of VL may offer additional educational and quality benefits.