Prehospital Airway Management Examined at Two Pediatric Emergency Centers

Abstract

IntroductionRoutine advanced airway usage by Emergency Medical Services (EMS) has had conflicting reports of being the secure airway of choice in pediatric patients.Hypothesis/ProblemThe primary objective was to describe a pediatric cohort requiring airway management upon their arrival directly from the scene to two pediatric emergency departments (PEDs). A secondary objective included assessing for associations in EMS airway management and patient outcomes.

Methods: Retrospective data from the health record were reviewed, including EMS reports, for all arrivals less than 18 years old to two PEDs who required airway support between May 2015 and July 2016. The EMS management was classified as basic (oxygen, continuous positive airway pressure [CPAP], or bag-valve-mask [BVM]) or advanced (supraglottic or endotracheal intubation [ETI]) based on EMS documentation. Outcomes included oxygenation as documented by receiving PED and hospital mortality.

Results: In total, 104 patients with an average age 5.9 (SD=5.1) years and median EMS Glasgow Coma Scale (GCS) of nine (IQR 3-14) were enrolled. Basic management was utilized in 70% of patients (passive: n=49; CPAP: n=2; BVM: n=22). Advanced management was utilized in 30% of patients (supraglottic: n=4; ETI: n=27). Proper ETI placement was achieved in 48% of attempted patients, with 41% of patients undergoing multiple attempts. Inadequate oxygenation occurred in 18% of patients, including four percent of ETI attempts, nine percent of BVM patients, and 32% of passively managed patients. Adjusted for EMS GCS, medical patients undergoing advanced airway management experienced higher risk of mortality (risk-ratio [RR] 2.98; 95% CI, 1.18-7.56; P=.021).

Conclusion: With exception to instances where ETI is clearly indicated, BVM management is effective in pediatric patients who required airway support, with ETI providing no definitive protective factors. Most of the patients who exhibited inadequate oxygenation upon arrival to the PED received only passive oxygenation by EMS. TweedJ, GeorgeT, GreenwellC, VinsonL. Prehospital airway management examined at two pediatric emergency centers. Prehosp Disaster Med. 2018;33(5):532-538.

Keywords: BVM bag-valve-mask; CPAP continuous positive airway pressure; EMR electronic medical record; EMS Emergency Medical Services; ETI endotracheal intubation; ETT endotracheal tube; GCS Glasgow Coma Scale; NPA nasopharyngeal airway; OPA oropharyngeal airway; PCR patient care report; PED pediatric emergency department; Emergency Medical Services; airway management; intubation/intra-tracheal; pediatric emergency medicine; treatment outcomes.