Complications of emergency tracheal intubation in severely head‐injured children

Abstract

A high incidence of unsuccessful attempts and complications has been reported when emergency tracheal intubation (ETI) is performed outside the hospital in severely injured children. The aim of this prospective series was to analyse the incidence and related risk factors of complications of emergency tracheal intubation. The time to complete successful ETI and occurrence of incidents, e.g. cough reflex, hypoxia or spasm were related to the experience of the physician performing intubation and the use of drugs to facilitate ETI. The incidence of hypoxia, hypercarbia, postintubation complications such as extubation stridor and long-term sequelae were noted. Of the 188 children, 78% were successfully intubated at the site of the accident, 10% upon arrival at a local hospital from where they were secondarily transferred and 12% upon admission to our trauma centre. The most severely injured children were intubated in the field in 98% of cases without failure, nor life-threatening complications related to ETI. The experience of the operator influenced the number of attempts and the time to complete successful intubation. Immediate incidents were noted in 25% of children, e.g. cough in 18%. The regimen of drugs, but not level of consciousness, influenced the incidence of immediate incidents; without drugs, more than 67% experienced incidents. Early tracheal intubation and controlled ventilation resulted in adequate ventilation upon arrival (mean PaO2 of 35.8+/-24 kPa, mean PaCO2 of 4.35+/-1 kPa). Long-term complications, including transient stridor upon extubation in 33% of the cases, and laryngeal granuloma or tracheal stenosis, were comparable to those in other series. ETI in shocked patients and pulmonary infection in hospital, but not the technique of ETI, increased the risks of long-term complications. Emergency tracheal intubation can be performed safely in the field, and results in adequate ventilation during transportation of severely injured children, provided that it can be performed by trained physicians using adequate drugs to facilitate intubation.

Emergency tracheal intubation of severely head-injured children: Changing daily practice after implementation of national guidelines*

“…Although transient, these events could be particularly deleterious and result in abrupt and sustained intracranial hypertension. Except for children with no vital signs, ETI without previous administration of drugs is inadequate and could result in a 67% frequency of immediate, sometimes lifethreatening, complications (4,8). In our earlier experience, ETI, although successful when ordered at the scene, was deferred in 22% of the children with a scene GCS of Յ8.…”

“…In emergency medical systems (EMS) involving paramedics, outof-hospital endotracheal intubation (ETI) is not considered superior to bag mask ventilation, because it could result in severe complications without increasing, by itself, survival (3). In EMS where physicians are directly involved in scene management, ETI is a standard practice, resulting in a low prevalence of severe complications (4,5). Whatever the qualification of the personnel performing ETI, rapid sequence intubation (RSI) could be the key issue for improving ETI conditions and increasing success rate (5).…”

Prehospital and Early Clinical Care of Infants, Children, and Teenagers Compared to an Adult Cohort

“…From our viewpoint, this result reflects the need for more education and regular training of EMS staff and emergency physicians regarding the distinct physiological findings and procedures such as endotracheal intubation in children. This is underlined by the results of Meyer et al, who found that emergency intubation can be performed safely in the field, provided it is carried out by trained physicians and adequate drugs are used [24,25].…”

Pre‐hospital airway management: guidelines from a task force from the Scandinavian Society for Anaesthesiology and Intensive Care Medicine

“…Approximately half of these ETIs were non-cardiac arrests, but neuromuscular blocking agents were used only in 8.8% of the cases, while sedation was performed in 2/3 of the patients not suffering from cardiac arrest. In a study from Paris, 147 children were intubated by physicians in the field (63). No failures were reported in sharp contrast to the 57% success rate in a study where paramedics were responsible for the airway management (44).…”