74 Pediatric Cardiac Arrest is Associated With Increased Number of Intubation Attempts in the Emergency Department

Abstract

Advanced airway management is central to pediatric resuscitation, especially since respiratory failure is a leading cause of pediatric cardiac arrest. There is limited evidence regarding airway management for pediatric patients who arrive in the emergency department (ED) in cardiac arrest. The purpose of this study was to compare the number of intubations attempts in the emergency department (ED) for pediatric patients in cardiac arrest to those that were not in arrest. This was an analysis of pediatric intubations prospectively recorded into a Continuous Quality Improvement (CQI) database in an academic pediatric ED over a 10-year period. Between July 1, 2007 and June 30, 2017, emergency physicians recorded all consecutive intubations performed in the pediatric ED. The database included patient demographics and detailed information about each intubation such as age of the patient, reason for intubation, number of intubations attempts and outcome of each attempt. All patients <18 years of age that underwent intubation by an emergency and emergency-pediatric physicians were included in the study. The primary outcome was number of intubations attempts for pediatric patients in cardiac arrest compared to those not in cardiac arrest. The secondary outcomes were rates of failed prehospital intubation attempts and their effect on ED success. A total of 472 pediatric intubations were attempted during the study period. 88 pediatric patients arrived in the ED in cardiac arrest while 384 pediatric patients were intubated for reasons other than cardiac arrest. Pediatric cardiac arrest is associated with an increased number of failed first intubation attempts as well as a higher rate of multiple intubation attempts compared to non-arrested patients. This is likely multifactorial and is likely due to limited time for airway assessment and procedure preparation, increased difficulty in directing a tracheal tube during active compressions and limited time for each attempt. This high intubation failure rate suggests that airway management in this cohort should focus on effective face mask ventilation or supraglottic ventilation.Tabled 1Arrest (95% CI)Non-Arrest (95% CI)First Pass Success48.8% (38.2-59.1%)76.3% (71.2-80.3%)Second Pass Success35.2% (26.0-45.6%)14.6% (11.4-18.5%)Third Pass Success15.9% (9.6-25.1%)0.5% (0.02-2.0%)Failed Prehospital Intubations36.4% (27.1-46.8%)6.3% (4.2-9.2%)Failed Prehospital Intubations – First Pass Success in ED56.3% (39.3-71.8%)75% (54.8-88.3%)Failed Prehospital Intubations – Second Pass Success in ED28% (15.4-45.5%)12.5% (3.5-31.8%)Failed Prehospital Intubations – Third Pass Success in ED15.6% (6.4-32.2%)12.5% (3.5-31.8%) Open table in a new tab