Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

How Accurate are We at Rapid Sequence Intubation for Pediatric Emergency Patients – Part II


Continuing from Part I,

Do we accurately report errors and success with pediatric RSI (Rapid Sequence Intubation/Induction)?

Should we trust our memories?

The leading indications for tracheal intubation were a failure of oxygenation (22 subjects) or ventilation (20 subjects), followed by head injury (17 subjects), seizure (16 subjects), apnea caused by infection (12 subjects), and altered mental status (11 subjects). None of the 114 subjects died in the ED; 5 died during the corresponding hospitalization.[1]

There is good variety among the patients studied, so there should not be any claims that this just looked at other pediatric patients. This appears to be representative.

All but 1 subject were tracheally intubated by the fifth attempt (1 required 9 attempts) in the ED.

. . . .

No rescue methods, eg, laryngeal mask airways, were used for any subject and no surgical airways were performed.[1]

1 required 9 attempts

That is so unreasonable, that it distracts us from the rest of the sentence –

All but 1 subject were tracheally intubated by the fifth attempt

5 intubation attempts are not considered to be unreasonable.

A patient doesn’t require 9 attempts. The patient is abused by 9 attempts by doctors who refuse to manage the airway by other means.

Taking 5 attempts, without switching to other means, is similarly unreasonable. The difference appears to be that the tube coincidentally ended up in the trachea in 5 moves or less.

Original image credit.

Hold onto this nut, while I take a shot at that intubation.

But you’re bind – and a squirrel!

But nothing – I can probably intubate in fewer than 9 attempts.

Well, we don’t know about that particular patient, but we do know that 31% of patients had more than one adverse effect.

52% intubation success on the first attempt. I could almost make an argument that there are two holes, so the probability is 50-50 regardless of training, but that is not the way probability works. that is just the appearance – if we were to judge a book by its cover. Let’s not be that foolish.

In their defense, some of these unsuccessful intubations were right mainstem intubations, which are providing some oxygenation and ventilation and (if correctly identified) only need to have the tube pulled out a small distance. A mainstem intubation is significantly less of a problem than an esophageal intubation.

Seventy subjects (61%; 95% CI 52% to 70%) experienced at least 1 adverse effect during RSI, and 35 (31%; 95% CI 23% to 40%) experienced more than 1.[1]


61% at least 1 adverse effect.

31% more than 1 adverse effect.

The depth of desaturation was available for 29 of the 38 subjects with an episode identified during RSI. Among these 29 subjects, 22 (76%) had desaturation to below 80% and 10 (29%) to less than 60%.[1]


10 patients had desaturation to 59% or less.

They give this as 29%, but that is 29% of the patients who desaturated. These are actually 9% of all RSIs.

One out of every 11 patients had SpO2 drop to 59% or less.

While hypoxia alone is not harmful, these patients had other medical problems that would probably not do well in the presence of hypoxia.

I usually have to tie a patient down and place a pillow over the airway to drop their sat into the 30s, 40s, or 50s.

Did anyone hit the 20s?

We don’t know, but if we assume that they hit 60% and stopped, we are lying to ourselves. Less than 60% does not include 60%. Also, this is not a PaOO2 of less than 60 torr, which also indicates hypoxia, just a much milder hypoxia.

An SpO2 of 59% or less is an adorable little Smurf, but this is not a cartoon and I don’t like Smurfs.

Was there any other bad news?

4 patients with some hypotension, 4 patients with some bradycardia, and 2 patients with some CPR.

How much of this would have been avoided by a maximum number of intubation attempts (2?, 3?) before requiring use of an extraglottic airway?

We did not identify any occurrences of aspiration, pneumothorax, or pneumomediastinum for any subject.[1]

That is some good news.

Focused review of the written record revealed marked variation in the documentation of important aspects of the RSI process, as well as notable discrepancies with findings from video review.[1]

Is anyone surprised that the documentation of these adverse events is more optimistic than what really happened?

There is more to write about this, because this is an important paper, so there will be at least a Part III.


[1] Rapid sequence intubation for pediatric emergency patients: higher frequency of failed attempts and adverse effects found by video review.
Kerrey BT, Rinderknecht AS, Geis GL, Nigrovic LE, Mittiga MR.
Ann Emerg Med. 2012 Sep;60(3):251-9. Epub 2012 Mar 15.
PMID: 22424653 [PubMed – in process]

Free Full Text from Annals of Emergency Medicine.

There will probably be a podcast by David H. Newman, MD, and Ashley E. Shreves, MD. covering this paper, but the current issue podcasts usually do not get posted until a few weeks after the current issue. Annals Podcast page.

Kerrey BT, Rinderknecht AS, Geis GL, Nigrovic LE, & Mittiga MR (2012). Rapid sequence intubation for pediatric emergency patients: higher frequency of failed attempts and adverse effects found by video review. Annals of emergency medicine, 60 (3), 251-9 PMID: 22424653