Ease and difficulty of pre-hospital airway management in 425 paediatric patients treated by a helicopter emergency medical service: a retrospective analysis

Abstract

BackgroundPre-hospital paediatric airway management is complex. A variety of pitfalls need prompt response to establish and maintain adequate ventilation and oxygenation. Anatomical disparity render laryngoscopy different compared to the adult. The correct choice of endotracheal tube size and depth of insertion is not trivial and often challenged due to the initially unknown age of child.MethodsData from 425 paediatric patients (<17 years of age) with any airway manipulation treated by a Swiss Air-Ambulance crew between June 2010 and December 2013 were retrospectively analysed. Endpoints were: 1) Endotracheal intubation success rate and incidence of difficult airway management in primary missions. 2) Correlation of endotracheal tube size and depth of insertion with patient’s age in all (primary and secondary) missions.ResultsIn primary missions, the first laryngoscopy-guided endotracheal intubation attempt was successful in 95.3% of cases, with an overall success rate of 98.6%. Difficult airway management was reported in 10 (4.7%) patients. Endotracheal tube size was frequently chosen inadequately large (overall 50 of 343 patients: 14.6%), especially and statistically significant in the age group below 1 year (19 of 33 patients; p < 0.001). Tubes were frequently and distinctively more deeply inserted (38.9%) than recommended by current formulae.ConclusionDifficult airway management, including cannot intubate and cannot ventilate situations during pre-hospital paediatric emergency treatment was rare. In contrast, the success rate of endotracheal intubation at the first attempt was very high. High numbers of inadequate endotracheal tube size and deep placement according to patient age require further analysis. Practical algorithms need to be found to prevent potentially harmful treatment.

Radiological evaluation of tube depth and complications of prehospital endotracheal intubation in pediatric trauma: a descriptive study

“…In a recent Swiss HEMS study, tube depth was also found to be deeper than recommended by the Weiss formula in 38.9% of patients despite a 15% tolerance [21].…”

Success and complications by team composition for prehospital paediatric intubation: a systematic review and meta-analysis

“…1). The characteristics of 40 included studies involving 11,567 children are shown in Table 1 [1,3,[5][6][7][8][9][10]. Fifteen studies (8201 participants) were published from 2015 onwards.…”

“…Traditionally, ground EMS systems have intubated children without muscle relaxants, but many systems are introducing relaxants into their clinical protocols with the expectation that overall success rates would improve and that intubation could be offered for a wider range of pathologies. There are also recent reports that physician staffed helicopter EMS (PS-HEMS) may produce particularly high procedural success with low complication rates [7][8][9][10].…”

Specialist advice may improve patient selection for decompression therapy following diving accidents: a retrospective observational study

“…As described by Schmidt et al [ 15 ], Rega is a non-profit HEMS that performs more than 11.000 emergency missions per year from 12 bases and one partner-base in Switzerland (except for the Canton Valais). Operation profiles comprise primary (scene to hospital) and secondary (inter-hospital transport) missions with all type of emergencies (medical, trauma, evacuations) and patient characteristics.…”

“…These movements are linked to mandatory information on mission and patient characteristics limiting the influence of selection bias. The analysed HEMS protocols were completed directly at the end of every mission by the responsible emergency physician, narrowing the effect of a recall bias [ 15 ]. Data was available for patients transported by Rega HEMS only.…”