Endotracheal intubations in rural pediatric trauma patients

Abstract

Background/purpose: Evidence from urban trauma centers questions the efficacy of pediatric field endotracheal intubations (ETIs). It is recognized that in the rural environment, discovery, transport delays, and a paucity of pediatric expertise contribute to higher pediatric trauma mortality rates compared with urban environments. The purpose of our study was to determine the effectiveness of field ETI in rural pediatric trauma patients.

Methods: ETI attempts (field, referring hospital, trauma center [TC]) in trauma patients less than 19 years old were included. Prehospital and TC charts, including demographics, injury mechanism, indication, location, person performing, number of attempts, Glascow Coma Scale (GCS), complications from ETI, and outcome, were assessed.

Results: Between 1991 and 2000, 105 of 2,907 patients met study criteria. Paramedics, trauma flight nurses (field ETIs), emergency physicians, surgeons, and anesthesiologists performed the ETI. One hundred fifty-five ETIs (1 to 6 per patient) were attempted in 105 children. Fifty-seven percent of the ETIs were attempted in the field, 22% in transferring hospital, and 21% at the TC. Successful intubation on first attempt was 67% (field), 69% (referring hospital), and 95% (TC). Subsequent ETI attempts had failure rates of 50% (field) and 0% (referring hospital, TC). Indication for ETI included fear of losing airway control (37%), closed head injury (36.1%), respiratory rate less than 10 or greater than 40 (11.2%), cardiopulmonary arrest (6.5%), respiratory arrest (4.6%), and airway obstruction 4.6%. Only 9.3% of children could not be oxygenated or ventilated by bag valve mask (BVM) before ETI. Twenty-three percent had complications directly related to ETI (eg, aspiration). The relative risk of an airway complication was 2.5x higher with more then one ETI attempt (P <.05). Four percent of the airway complications occurred in TC, 29% (transferring hospital) and 66% (field, P <.05), respectively. Airway complications and multiple ETIs were associated with transport delay, lower GCS, longer hospital stay, and lower discharge GCS (P <.001) but independent of injury severity score, sex, age, and survival (P >.05).

Conclusions: Multiple ETI attempts are associated with significant complications and may offer limited advantage over BVM and possibly may affect outcome. Indications for field intubations may require review especially in rural pediatric trauma.