Do our kids deserve the best ? Luke Regan on what pre-hospital care can teach us about paediatric intubation.

1. GETTING IT RIGHT
FIRST TIME
or
“IntubatingKiddies in Helicopters” LukeRegan
@lukeandrewregan

2. “60% of the time....it works every time!”
WHO is referring to WHAT here?
Let’s start with a groovy MCQ

3. A) Noted airway expert Dr Minh le Cong describing use
of cricoid pressure
B) Noted gaseous induction expert Brian Fantana
describing use of “Sex Panther”
C) Noted oral sedation expert Dr John Glasheen
describing use of Guinness in fracture manipulations
D) Dr Hyuk Joong Choi (et al) describing the alarming
baseline rate of first pass success intubating
children across 13 Korean Emergency Departments
from 2006-2010

4. D) Dr Hyuk Joong Choi (et al) describing the alarming
baseline rate of first pass success intubating
children across 13 Korean Emergency Departments
from 2006-2010

5. Improving first pass success
in emergency paediatric
intubation

6. 1 - WHY THIS MATTERS
2 – WE ARE ALL LIARS
3 – GET OUT YOUR SHOTGUNS
TAKE HOME POINTS

7. WHY FIRST PASS SUCCESS
MATTERS

8. “Airways are like
willies - the more
you fiddle the
harder they get....”
Dr Minh Le Cong

9. Sakles et al January 2013
1828 oral intubations
WHY FIRST PASS SUCCESS
MATTERS

10. Intubation
success at....
1st
2nd
3rd
or 4th attempt
14%
47%
63%
and 71%!
= complication
rates of =

11. Even a single failed attempt resulted in
over 3 times the rate of adverse events

12. So that’s all well and good
in hospital...what about
prehospital?
My hero

13. Göttingen
Emergency
Medical
Service
Oh there’s Gottingen...
Eich et al 2009

14. FPS = 84.5%
OK numbers but....
Note the enthusiasm for
nasal intubation!

15. WE ARE ALL LIARS

16. 59 of the 114 patients
(52%) were intubated
on the first attempt.
Kerrey et al September 2012

17. Can we even be trusted
to report accurately?

18. GSA HEMS
Study
All recorded intubations on
patients under the age of 16
years between 2009 and 2013.

19. 53 patients identified
Successful intubation rate of 100%.
But as we’ve discovered, that’s not the whole story....

20. Overall First Pass Success = 94.3%
on all paediatric intubations
*Please note the word
‘Guarantee’ does not represent
an actual guarantee

28. Intubation
success at....
1st
2nd
3rd
or 4th attempt
14%
47%
63%
and 71%!
= complication
rates of =

29. Intubation
success at....
1st 14%= complication
rates of =

30. Thoughts

31. AIRWAY MARKSMAN? AIRWAY SHOTGUN!
vs

32. The literature has yet to comment on what happens
when you force paramedics and doctors to:

33. AIRWAY MARKSMAN? AIRWAY SHOTGUN!
vs

34. The End
questions?

35. REFERENCES
(1) Harris T, Lockey D. Success in physician prehospital rapid sequence intubation: what is the effect of base
speciality and length of anaesthetic training? Emerg Med J 2011 Mar;28(3):225-229.
(2) Lossius HM, Roislien J, Lockey DJ. Patient safety in pre-hospital emergency tracheal intubation: a
comprehensive meta-analysis of the intubation success rates of EMS providers. Crit Care 2012 Feb
11;16(1):R24.
(3) Rognas L, Hansen TM, Kirkegaard H, Tonnesen E. Pre-hospital advanced airway management by
experienced anaesthesiologists: a prospective descriptive study. Scand J Trauma Resusc Emerg Med 2013
Jul 25;21:58-7241-21-58.
(4) Bano S, Akhtar S, Zia N, Khan UR, Haq AU. Pediatric endotracheal intubations for airway management in
the emergency department. Pediatr Emerg Care 2012 Nov;28(11):1129-1131.
(5) Choi HJ, Je SM, Kim JH, Kim E, Korean Emergency Airway Registry Investigators. The factors associated
with successful paediatric endotracheal intubation on the first attempt in emergency departments: a 13-
emergency-department registry study. Resuscitation 2012 Nov;83(11):1363-1368.
(6) Green SM. A is for airway: a pediatric emergency department challenge. Ann Emerg Med 2012
Sep;60(3):261-263.
(7) Heinrich S, Birkholz T, Ihmsen H, Irouschek A, Ackermann A, Schmidt J. Incidence and predictors of
difficult laryngoscopy in 11,219 pediatric anesthesia procedures. Paediatr Anaesth 2012 Aug;22(8):729-736.

36. REFERENCES
(8) Kerrey BT, Rinderknecht AS, Geis GL, Nigrovic LE, Mittiga MR. Rapid sequence intubation for pediatric
emergency patients: higher frequency of failed attempts and adverse effects found by video review. Ann
Emerg Med 2012 Sep;60(3):251-259.
(9) Nishisaki A, Turner DA, Brown CA,3rd, Walls RM, Nadkarni VM, National Emergency Airway Registry for
Children (NEAR4KIDS), et al. A National Emergency Airway Registry for children: landscape of tracheal
intubation in 15 PICUs. Crit Care Med 2013 Mar;41(3):874-885.
(10) Sakles JC, Chiu S, Mosier J, Walker C, Stolz U. The importance of first pass success when performing
orotracheal intubation in the emergency department. Acad Emerg Med 2013 Jan;20(1):71-78.
(11) Sukys GA, Schvartsman C, Reis AG. Evaluation of rapid sequence intubation in the pediatric
emergency department. J Pediatr (Rio J) 2011 Jul-Aug;87(4):343-349.
(12) Gerritse BM, Draaisma JM, Schalkwijk A, van Grunsven PM, Scheffer GJ. Should EMS-paramedics
perform paediatric tracheal intubation in the field? Resuscitation 2008 Nov;79(2):225-229.
(13) Eich C, Roessler M, Nemeth M, Russo SG, Heuer JF, Timmermann A. Characteristics and outcome of
prehospital paediatric tracheal intubation attended by anaesthesia-trained emergency physicians.
Resuscitation 2009 Dec;80(12):1371-1377.
(14) Sanders RC,Jr, Giuliano JS,Jr, Sullivan JE, Brown CA,3rd, Walls RM, Nadkarni V, et al. Level of trainee
and tracheal intubation outcomes. Pediatrics 2013 Mar;131(3):e821-8.
(15) R.Bloomer,B.Burns,S.Ware,K.Habig. Improving documentation in pre-hospital rapid sequence
intubation. Emerg Med J. 2012 Apr 13