Prehospital Endotracheal Intubation of Children by Paramedics

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1 PEDIATRICS/ORIGINAL CONTRIBUTION Prehospital Endotracheal Intubation of Children by Paramedics From the Department of Pediatrics*, Epidemiology ~, and Medicine ~, University of Washington; the Children's Hospital and Medical Center [I, Harborview Medical Center,I, and Harborview Injury Prevention and Research Center, Seattle, Washington. # Received for publication Jane 26, Revision received November 22, Accepted for publication February 23, I996. Presented at the Ambulatory Pediatric Association Regon IX, X Annual Meeting, Carmel, CaI~ornia, February Copyright by the American College of Emergency Physicians. Dena Brownstein, MD*" Richard Shugerman, MD*" Peter Cummings, MD, MPH *"# Frederick Rivara, MD, MPH *~# Michael Copass, MD ql Study objective: To describe the experience of an emergency medical services system with the use of liberal indications for prehospital pediatric endotracheal intubation. Methods: We performed a retrospective review of prehospital and hospital patient records in an urban and suburban prehospital care system. The study included all children aged 15 years or younger who were intubated in the prehospital setting by King County paramedics from January I, 1984, to December 31, Results: During the 7-year study period, 654 children were intubated, of which 355 (54%) were study patients. The median age of the patients was 3 years; 60% had an injury diagnosis. On arrival of the paramedics, 60% of the patients were in sinus rhythm, 62% had a systolic blood pressure of 70 mm Hg or greater, and 56% had a respiratory rate of 10 breaths per minute or greater. The Glasgow Coma Scale score was 8 or lower in 83% of the patients. Succinylcholine was used to facilitate intubation in 47% of patients. On arrival at the emergency department, 79% of the patients were in sinus rhythm; 75% had an adequate blood pressure (70 mm Hg or greater); 86% had a Pao 2 value of 100 mm Hg or greater; and 74% had a Pace 2 value of 45 mm Hg or lower. Complications of intubation, more than half of which were classified as minor, were noted in 22.6% of patients. We were unable to determine the number of failed intubation attempts. Most of the patients (58%) survived to hospital discharge. Among cardiac arrest victims, only 12% survived. Conclusion: In a setting where paramedics practice with close medical direction, applying liberal indications for pediatric intubation and permitting the use of succinylcholine allowed paramedics to intubate children of different ages and diagnoses. [Brownstein D, Shugerman R, Cummings P, Rivara F, Copass M: Prehospital endotracheal intubation of children by paramedics. Ann Emerg Med July 1996;28:34-39.] 3 4 ANNALS OF EMERGENCY MEDICINE 28:1 JULY 1996

2 INTRODUCTION Endotracheal intubation is an important advanced life support skill for paramedics. Although the technique is widely accepted for the stabilization of adult patients in the prehospital setting, many emergency medical services (EMS) systems do not permit its use in children >3, or have only recently introduced the skill. Even when permitted, field endotracheal intubations are used less often in critically ill children, with a lower proportion of successes and a higher proportion of complications, than in aduhs. 4-s Reasons for these practice patterns include the lack of evidence demonstrating improved clinical outcomes from field intubation of children, low incidence of critical pediatric cases, and difficulty in obtaining adequate clinical experience for both initial training and skill maintenance. In general, the EMS systems that do permit paramedics to perform pediatric endotracheal intubations use the technique primarily for children who are apneic and pulseless on field evaluation. 5,<s This restriction of a potentially lifesaving technique to a population known to have a dismal prognosis, regardless of any interventions undertaken, is likely to minimize its apparent benefit The purpose of this study is to describe the experience of an EMS system that uses more liberal indications for the prehospital intubation of pediatric patients. These indications include severe respiratory distress, inability to protect the airway, serious closed head injury, or physiologic instability with significant risk of deterioration in transport. Paramedics are permitted to use paralytic agents when needed to facilitate intubation of children with intact airway reflexes. We report the characteristics of patients successfully intubated in the field, subsequent emergency department course and disposition, and final patient outcome. MATERIALS AND METHODS This was a retrospective study of pediatric patients aged 15 years or younger who were successfully intubated in the field by paramedics in King County, Washington, from January 1, 1984, to December 31, King County contains 31% of the population of Washington state, and is served by two public sector EMS agencies, King County Emergency Medical Services and Seattle Medic One. King County Emergency Medical Services serves a mixed urban, suburban, and rural population of 991,060 residents outside Seattle city limits, of which 230,906 (23.3%) are children 15 years or younger. 13 Seattle Medic One serves a population base of 516,259 residents, of which 76,970 (14.9%) are 15 years or younger. Depending on the location of the caller within the county, a paramedic unit from one of these two agencies is dispatched to answer all 911 calls requiring advanced life support services. Most acutely ill, intubated pediatric patients in King County are transported to either Children's Hospital and Medical Center or to Harborview Medical Center in Seattle. All children transported to either of these hospitals by paramedics after prehospital endotracheal intubation were eligible for inclusion in this study. A smaller group of intubated children was initially transported to one of 15 local community hospitals. Two community hospitals received 91 intubated children, whose records we sought. An additional 23 children were transported to one of 13 other community hospitals. These 23 children were excluded from analysis to reduce the burden of record retrieval. All paramedics employed by King County Emergency Medical Services or Seattle Medic One have completed the 2,500-hour paramedic training program at the University of Washington. Intubation training comprises a 4.5-hour didactic session on airway management, including 1.5 hours on pediatrics; a 4-hour adult and pediatric mannikin practical session; and a cat intubation practical session. Paramedic students also participate in a 16-hour seminar on pediatric prehospital care, which includes skill stations on airway management and intubation and case scenarios involving intnbation. After successful completion of written and practical examinations, students perform a minimum of three adult intubations in the operating room under the direct supervision of an anesthesiologist and spend 6 hours performing supervised intubations in a pediatric operating room. Field intubations are then supervised by a senior paramedic. Once certified, paramedics must have documentation of 12 human intubations in each 2-year recertification cycle. Paramedics are permitted to intubate patients in cardiac arrest on the basis of a patient care protocol. In all other cases, they must first seek telephone or radio approval from an EMS base-station physician. Paramedics complete a Medical Incident Report form to document every patient encounter. King County Emergency Medical Services abstracts these forms into a computerized database. We searched this database to identify all patients for whom the procedure code "intubation" was recorded and then searched the EMS archives for the original paper Medical Incident Report form of each patient. Seattle Medic One maintains a file of all pediatric Medical Incident Report forms, and this was JULY :1 ANNALS OE EMER6ENCY MEDICINE 3 5

3 searched for all patients for whom the procedure field '~intubation" was recorded. Paramedic compliance with recording procedures on Medical Incident Report forms is believed to be good because this documentation is used for skill recertification. Information abstracted from the Medical Incident Report forms included the name, age, transport destination, vital signs, and treatment of each patient. Hospital records of patients whose Medical Incident Report forms could be retrieved were abstracted for data including initial ED vital signs, initial blood gas values, the position of the endotracheal tube on arrival, the presence or absence of intubation-associated complications, final discharge diagnoses, and survival. For patients declared dead in the field, King County Medical Examiner reports were reviewed for position of the endotracheal tube, intubation-associated complications, and final diagnoses. Minor complications of intubation were defined as mainstem bronchus intubation, which was determined by auscultation or radiography, and oral or dental trauma. Major complications were defined as esophageal intubation, pneumothorax, and aspiration of stomach contents, which was determined by chest radiography. Because of our method of case identification, failure to intubate could not be evaluated as a complication. Appropriate endotracheal tube size was calculated by the equation: Table 1. Characteristics of 335 pediatric prehospital intubation patients. Characteristic No. (%) Age (years) [N=342] <1 103 (29.6) (29.6) (17.5) (23.9) Sex (N=272 male) 168 (612) Diagnosis (N=344) Injury 173 (50.3) Motor vehicle 59 (17.1) Drowning 35 (10.2) Poison/overdose 19 (5.5) Falls 17 (4.9) Bicycle 16 (4.7) Strangulation 12 (3.5) Other 15 (4.4) Medical 171 (49.7) Neurologic/seizure 55 (16.0) SIDS 54 (15.7) Respiratory 37 (10.7) Other 25 (7.3) SlDS, sudden infant death syndrome. Endotracheal tube internal diameter (millimeters) = (age in years/4) This study was approved by the institutional review boards of Children's Hospital and Medical Center, the University of Washington, Overlake Hospital and Medical Center, and Valley Medical Center. To measure the statistical significance of differences in continuous variables, we used the Mann-Whitney U test and for proportions of categorical variables the Z 2 test. 15 Multiple logistic regression was used to estimate adjusted odds ratios. 16 Two-sided p values are presented. RESULTS We identified 654 intubated children aged 15 years or younger from the EMS agency records. The EMS medical incident report form could not be located for 153 cases, hospital (115) or medical examiner records (8) could not be found for an additional 123 children, and records were not sought for an additional 23 children transported to community hospitals. We obtained matched prehospital and hospital records for the 355 patients (54.3%) who make up the study population. We compared the study patients with patients who were excluded from analysis. No significant difference was found in presence of cardiac arrest (44.2% versus 43.8%, P=.9), an injury diagnosis (53.7% versus 56.6%, P=.5), placement of an IV line in the field (83.4% versus 88.3%, P=.07), or year of encounter (P=.5). The study patients were younger than the excluded patients (median age 3 versus 6 years, P<.01). This age difference may reflect the fact that older patients were more likely to be transported Table 2. Prehospital assessment of prehospital pediatric intubation patients. Parameters No. (%) Initial heart rhythm (N=330) Sinus 197 (59.7) Asystole 107 (32.4) Idioventricular 7 (2.1) Ventricular fibrillation 5 (1.5) Bradycardia 3 (.9) Ventricular tachycardia 2 (.6) Supraventricular tachycardia 1 (.3) Other 8 (2.4) Heart rate >_60 (N=118) 68 (57.6) Systolic blood pressure >_70 mm Hg (N=166) 103 (62.0) Respiratory rate >_10 (N=172) 97 (56.4) Glasgow Coma Scale score <_8 (N=2O0) 165 (82.5) 3 6 ANNALS OF EMERGENCY MEDICINE 28:1 JULY 1996

4 Brownstein et ai to Harborview Medical Center, and most of the missing charts were from this hospital. Of the 355 study patients, 19.2% were transported by Seattle Medic One, and 80.8% by King County Emergency Medical Services. Infants younger than 1 year comprised 29.0% of all patients, and 58.6% of all patients were younger than 5 years. Almost two thirds of the patients were male. Primary medical diagnoses predominated in infants, whereas injuries were more prevalent in children aged more than 1 year (Table 1). On arrival of the paramedics, 59.7% of children were found to be in sinus rhythm (Table 2). Of those patients who had initial vital signs recorded before intubation, more than half had a heart rate of 60 or greater, a systolic blood pressure of 70 mm Hg or greater, and a respiratory rate of 10 or greater. The Glasgow Coma Scale score was 8 or lower in more than 80% of patients. Other procedures performed in the field included peripheral placement of an IV line in 72.8% of the patients, central line placement in 9.6%, and intraosseous line placement in 1.5%. At least one medication was administered in 85.9% of the patients. Paramedics transported 74.6% of the intubated children to Harborview Medical Center or to Children's Hospital and Medical Center. The remaining patients were transported to community hospitals for initial stabilization (12.4%), or to the morgue (13.0%). On arrival at the ED, 79% of the patients had a heart rate of 60 or greater, 75% had a systolic blood pressure of 70 mm Hg or greater, 87% had an initial blood gas profile showing a Pao 2 value of 100 mm Hg or greater, and 74% had a Paco 2 value of 45 mm Hg or lower (Table 3). Paramedics chose an endotracheal tube that was within.5 mm of the size predicted appropriate for age in 61.1% Table 3, ED assessment of pediatric prehospital intubation patients. Parameters No. (%) Initial heart rate _>60(N=295) 233 (79.0) Initial systolic blood pressure _>70 mm Hg (N=291) 220 (75.6) First arterial blood gas reading (N=247) ph _> (87.8) Pao 2 ->10O mm Hg 214 (86.6) Paco2_<45 mm Hg 183 (74.1) Endotracheal tube size (N=301) Correct 184 (61.1) Too small 98 (32.5) Too large 19 (6.3) Endotracheal tube position (N=270) Trachea 231 (85.5) Mainstem bronchus 34 (12.6) Esophagus 5 (1.8) of the study patients. ED assessment of endotracheal tube position by chest radiography, auscultation, or both confirmed endotracheal placement in 85.6% of children (Table 3). Sixty-five complications related to intubation were noted in the ED records of 61 patients (22.6%), of which 36 were classified as minor (Table 4). Complications occurred in 32.1% (26 of 81) of cardiac arrest patients, in contrast with 18.5% (35 of 189) of children not in cardiac arrest (P=.01). Failure of attempted intubation was not included in the analysis of complications. Succinylcholine was used to facilitate intubation in 47.0% of all study patients (Table 5). The drug was used more frequently in older children and in patients for whom an injury diagnosis was recorded. Bradycardia (heart rate less than 50) did not develop m any patient after administration of the drug. Patients who received succinylcholine were less likely to have major complications of intubation compared with other patients, even after adjustment for age, medical versus injury diagnosis, and presence or absence of cardiac arrest: adjusted odds ratio.27 (95% confidence interval:.09 to.81). Of the patients who were transported to a hospital, 18.4% died in the ED, 7.7% were transferred to another institution, 14.4% went directly to the operating room, 47.2% were admitted to an ICU, 10.4% were admitted to a ward bed, and 2.0% were discharged home from the ED. Of the 56 patients extubated in the ED, 58.6% had a diagnosis of seizure. Most of the study patients (57.5%) survived to hospital discharge. The survival rate of the cardiac arrest victims was 11.5% (18/156). DISCUSSION This retrospective study design has several potential limitations. Only approximately half of the eligible patients could be enrolled. Because this was primarily a function Table 4. Complications of prehospital pediatric intubation (N=269). Complication Complexity No. (%) Major Aspiration 15 (5.6) Pneumothorax 9 (3.3) Esophageal intubation 5 (1.9) Minor Mainstem bronchus intubation 34 (12,6} Oral/dental trauma 2 (.7) JULY :1 ANNALS OF EMERGENCY MEDICINE 3 7

5 of problems with record retrieval, we do not believe our study sample was biased in any systematic manner. In addition, we were not able to determine the accuracy of the data recorded by the paramedics or ED staff. The method of case identification did not permit us to examine the proportion of intubation attempts that failed or the number of intubations that were medically necessau. We cannot determine the number of children who could not be intubated and who subsequently were transported with bag-valve-mask ventilation, or who died at the scene because of failure of the paramedics to intubate. Finally, the retrospective design and the complexity of both prehospital and hospital care for these very sick patients does not permit us to comment on the impact of prehospital intubation on patient outcome. This study comprises the largest reported series of children who underwent prehospital intubation. The population of pediatric patients intubated by paramedics in King County is quite different from that previously reported. Although most of the patients we describe were in coma, most had a perfusing rhythm and spontaneous respiratory effort on initial field assessment. Intubation of half of these patients was facilitated by the use of succinylcholine for neuromuscular blockade. On arrival at an ED, most patients were well oxygenated and ventilated. Not surprisingly, the proportion who survived to hospital discharge was far greater than the reported 6% to 10% survivors in studies in which intubation was confined to apneic and Table 5. Use of succiwlcholine for intubation of pediatric prehospital patients. Saccinylcholine Given Succinylcholine Not Given Characteristics No. (%) [N=167] No. (%) [N=188] P* Age (years) [N=342] <1 9 (5.6} 88 (47.8) < (32.2) 49 (26.6) (25.3) 20 (10.9) (36.7) 27 (14.7) Cardiac arrest (N=355) Absent 155 (92.8) 44 (23.4) <.001 Present 12 (7.2) 144 (76.6) Diagnosis (N=348) Medical 42 (25.8) 111 (60.0) <.001 Injury 121 (74.2) 74 (40.0) Complications (N=269) Present 29 (18.1) 32 (29.3).03 Absent 131 (81.9) 77 (70.6).%z test for difference in proportions. pulseless patientss,6; the outcome of such patients appears to be dismal regardless of interventions undertaken. Given the variable definition of intubation complications in the literature, it is difficult to compare the frequency of complications in this series with that reported in prior studies. The overall complication rate of 22.6% m this study, however, appears to be as low as or lower than that described in other reports of paramedic field intubation of children. <<8 In a study of the emergency intubation of 63 injured children, Nakayama 4 reported complications in 4 of 8 patients intubated by paramedics in the field. Half of the intubated children were suboptimally oxygenated on arrival at the hospital, and the authors felt that field intubation was unnecessary in 2 patients. Aijian 6 reported a series of 19 children in nontraumatic cardiac arrest who apparently were successfully intubated by paramedics. Complications (esophageal intubation, accidental extubation, mainstem bronchus intubation0 or oral trauma) were reported in 36.8% of patients. Pointer 8 reported experience with field intubation of 33 children, of whom 64% were in cardiac arrest. Complications (esophageal intubation, accidental extubation, mainstem bronchus intubation, and equipment failure) were noted in 15.1% of patients. Serious complications of intubation were found in 10.7% of our patients. This analysis, however, may have overestimated the prevalence of major complications. In some cases, patients may have aspirated before intubation. Similarly, two thirds of the children with pneumothorax had trauma as a principal diagnosis, and the presence of the pneumothorax may have been related to the underlying injury. The use of rapid sequence intubation has gained increasing acceptance for ED intubation of conscious patients or those with blunted sensorium but intact airway reflexes. Few reports on the use of succinylcholine in the prehospital setting have been published.it-2 Hedges 17 reported a series of 95 patients with a mean Glasgow Coma Scale score of 8.8 who underwent succinylcholine-facilitated intubation by paramedics during ground transport. Intubation was successful in 96% of cases, and 78% of patients survived to hospital admission. Three additional studies discuss the use of succinylcholine by air ambulance services, variably staffed by physicians, nurses, and paramedics, with intubation success rates ranging from 75.8% to 96%. 1s-2o Whereas several of these case series included pediatric patients, none separately analyzed use in children. In our series, paramedics used succinylcholine to facilitate intubation in half of all patients and in three quarters 3 8 ANNALS OF EMERGENCY MEDICINE 28:1 JULY 1996

6 of the children not in cardiac arrest. The use of succinylcholine was associated with a reduced prevalence of complications compared with children intubated without neuromuscular blockade, and no patient experienced bradycardia in association with its administration. None of the cases of unrecognized esophageal intubation, the most catastrophic complication, involved children who were intubated with the aid of succinylcholine. Although the use of succinylcholine may not be responsible for the lower likelihood of complications among patients who received this drug, these data suggest that the use of succinylcholine in this setting is not harmful and may be beneficial. Given the broad indications for intubation in King County, one might ask whether paramedics are performing unnecessary intubations. The disposition of the patients in this series reflects the severity of their illness: 13% of patients were declared dead at the scene, and of those who were transported to a hospital, 87.7% either died in the ED, required interfacility transport, went directly from the ED to surgery, or were admitted to intensive care. The diagnosis of seizure predominated in patients who were extubated in the ED (33 of 56 patients). This study demonstrates that paramedics can intubate children and use paralytic agents when necessary. The use of succinylcholine was associated with complication rates that were as low as or lower than those described in previous studies. This study design did not evaluate failure to intubate as a complication, or determine the frequency with which paramedics could not intubate after administering succinylcholine. The benefit of advanced prehospital airway management in children must be evaluated in a prospective study that specifically measures complications and outcomes. 8. Pointer JE: Clinical characteristics of paramedics' performance of pediatric endotracheal intubation. Am J Emerg Mad 1989;7: Eisenbarg M, Bergner L, Hallstrom A: Epidemiology of cardiac arrest and resuscitation in children, Ann Emerg Mad1983;12: O'Rourke PP: Outcome of children who are apneic and pulseless in the emergency room. Crit Care Mad 1986;14: Torphy DE, Minter MG, Thompson 8M: Cardiopulmonary arrest and resuscitation of chinren. Am J Dis Child 1984;138: Lewis JK, Minter MG, Eshelman S J, et ah Outcome of pediatric resuscitation. Ann Emerg Mad 1983;12: Census of Population, General Population Characteristics, Washington. Washington DC: Bureau of the Census: US Government Printing Office, 1992:(1990 CP-1-49). 14. Chamaides L, Hazinski MF (eds): Textbook of Pediatric Advaneed Life Support. Dallas, American Heart Association, 1994: Altman DG: PracticalStatistics for Medical Research. London, Chapman and Hall, Breslow NE, Day NE: Statistical Methods in Cancer Research, VoL 1: The Analysis of Case- Control Studies. Lyon, France, International Agency for Research on Cancer, 1980: Hedges JR, Dronen SC, Feere S, et al: Succinylcholine-assisted intubations in prehospital care. Ann Emerg Mad 1988;17: Rhea K J, O'Melley R J: Neuromuscular blockade-assisted oral intubation versus nasotracheal intubation in the prehospital care of injured patients. Ann Emerg Med1994;23: Murphy-Macabobby M, Marshall W J, Schneider C, et ah Neuromuscular blockade in aeromedical airway management. Ann Emerg Mad 1992;21: Syverud SA, Barren SW, Starer DL, et ah Prehospital use of neuromuscular blocking agents in a helicopter ambulance program. Ann Emerg Marl 1988;17: Reprint no. 47/1/73346 Address for reprints: Dena Brownstein, MD Emergency Services Children's Hospital and Medical Center 4800 Sand Point Way NE Seattle, Washington Fax REFERENCES 1. Seidel JS, Henderson DH, Ward P, etal: Pediatric prehospita] care in urban and rural areas. Pediatrics 1991 ;88: Foltin G, Salomen MS, Tun& M, et al: Developing prehospital advanced life support for children: The New York City experience. PediatrEmerg Care 1990;6: Graham C J, Stuemky J, Lera TA: Emergency medical services preparedness for pediatric emergencies. Pediatr Emerg Care 1993;9:329-33I. 4. Nakayama OK, Gardner M J, Rowe MI: Emergency endotracheal intubation in pediatric trauma. Ann Surf/1990;211: Losek JD, Hennes H, Glaeser P, et al: Prehospital care of the pulseless, non-breathing pediatric patient. Am J Emerg Mad 1987;5: Aijian P, Tsai A, Knopp R, et al: Endotracheal intubation of pediatric patients by paramedics. Ann Emerg Mad 1989;18: Stratton S J, Unde~ood LA, Whalen S, et al: Prehospital pediatric endotracheal intubation: A survey of the United States. Prehospital and Disaster Medicine 1993;8: JULY :1 ANNALS OF EMERGENCY MEDICINE 3 9

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