Study objective We sought to determine, using video review, the frequencies of first attempt success and adverse effects during rapid sequence intubation (RSI) in a large, tertiary care pediatric emergency department (ED). Methods We conducted a retrospective study of children undergoing RSI in the ED of a pediatric institution. Data were collected from pre-existing video and written records of care provided. The primary outcome was successful intubation on the first attempt at laryngoscopy. The secondary outcome was the occurrence of any adverse effect during RSI, including episodes of physiologic deterioration. We collected time data from the RSI process using video review. We explored the association between physician type and first attempt success. Results We obtained complete records for 114 of 123 (93%) children who underwent RSI in the ED over 12 months. Median age was 2.4 years and 89 (78%) were medical resuscitations. Of the 114 subjects, 59 (52%) were successfully intubated on the first attempt. Seventy subjects (61%) had one or more adverse effects during RSI; 38 (33%) suffered oxyhemoglobin desaturation and two required cardiopulmonary resuscitation after physiologic deterioration. Fewer adverse effects were documented in the written records than were noted on video review. The median time from induction through final endotracheal tube placement was 3 minutes. After adjusting for patient characteristics and illness severity, attending level providers were 10 times more likely to be successful on the first attempt than all trainees combined. Conclusions Video review of RSI revealed that first attempt failure and adverse effects were much more common than previously reported for children in an ED.

Following the simultaneous introduction of four interventions in a paediatric ED, RSI was performed more reliably, successfully and safely.

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Pediatric residents working in one of the busiest pediatric EDs in the country and working 1 month more than the ACGME-recommended minimum did not achieve the ACGME requirement for emergency and acute illness experience through direct patient care.