Prekker Matthew E, Delgado Fernanda, Shin Jenny, Kwok Heemun, Johnson Nicholas J, Carlbom David, Grabinsky Andreas, Brogan Thomas V, King Mary A, Rea Thomas D
Department of Emergency Medicine and Department of Medicine, Division of Pulmonary and Critical Care Medicine, Hennepin County Medical Center, Minneapolis, MN.
University of Washington School of Medicine, Seattle, WA.
Ann Emerg Med. 2016 Jan;67(1):20-29.e4. doi: 10.1016/j.annemergmed.2015.07.021. Epub 2015 Aug 29.
Pediatric intubation is a core paramedic skill in some emergency medical services (EMS) systems. The literature lacks a detailed examination of the challenges and subsequent adjustments made by paramedics when intubating children in the out-of-hospital setting. We undertake a descriptive evaluation of the process of out-of-hospital pediatric intubation, focusing on challenges, adjustments, and outcomes.
We performed a retrospective analysis of EMS responses between 2006 and 2012 that involved attempted intubation of children younger than 13 years by paramedics in a large, metropolitan EMS system. We calculated the incidence rate of attempted pediatric intubation with EMS and county census data. To summarize the intubation process, we linked a detailed out-of-hospital airway registry with clinical records from EMS, hospital, or autopsy encounters for each child. The main outcome measures were procedural challenges, procedural success, complications, and patient disposition.
Paramedics attempted intubation in 299 cases during 6.3 years, with an incidence of 1 pediatric intubation per 2,198 EMS responses. Less than half of intubations (44%) were for patients in cardiac arrest. Two thirds of patients were intubated on the first attempt (66%), and overall success was 97%. The most prevalent challenge was body fluids obscuring the laryngeal view (33%). After a failed first intubation attempt, corrective actions taken by paramedics included changing equipment (33%), suctioning (32%), and repositioning the patient (27%). Six patients (2%) experienced peri-intubation cardiac arrest and 1 patient had an iatrogenic tracheal injury. No esophageal intubations were observed. Of patients transported to the hospital, 86% were admitted to intensive care and hospital mortality was 27%.
Pediatric intubation by paramedics was performed infrequently in this EMS system. Although overall intubation success was high, a detailed evaluation of the process of intubation revealed specific challenges and adjustments that can be anticipated by paramedics to improve first-pass success, potentially reduce complications, and ultimately improve clinical outcomes.
在一些紧急医疗服务（EMS）系统中，儿科插管是护理人员的一项核心技能。文献中缺乏对护理人员在院外环境中为儿童插管时所面临的挑战及后续调整的详细研究。我们对院外儿科插管过程进行描述性评估，重点关注挑战、调整措施及结果。
我们对2006年至2012年间，在一个大型都市EMS系统中护理人员尝试为13岁以下儿童插管的EMS响应进行回顾性分析。我们利用EMS和县级人口普查数据计算儿科插管尝试的发生率。为总结插管过程，我们将详细的院外气道登记与每个儿童的EMS、医院或尸检临床记录相链接。主要结局指标包括操作挑战、操作成功、并发症及患者处置情况。
在6.3年期间，护理人员共尝试插管299例，发生率为每2198次EMS响应中有1例儿科插管。不到一半的插管（44%）是针对心脏骤停患者。三分之二的患者首次尝试插管成功（66%），总体成功率为97%。最常见的挑战是体液遮挡喉镜视野（33%）。首次插管尝试失败后，护理人员采取的纠正措施包括更换设备（33%）、吸引（32%）和重新安置患者（27%）。6例患者（2%）发生插管期间心脏骤停，1例患者发生医源性气管损伤。未观察到食管插管情况。转运至医院的患者中，86%入住重症监护病房，医院死亡率为27%。
在这个EMS系统中，护理人员进行儿科插管的情况并不常见。尽管总体插管成功率较高，但对插管过程的详细评估揭示了一些特定的挑战和调整措施，护理人员可预见到这些情况以提高首次插管成功率，潜在地减少并发症，并最终改善临床结局。
