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 I

ResearchBlogging.org

Which patients cause most of us the most anxiety?

Kids.

Which patients do most of us least want to injure?

Kids.

What skill do we tend to brag about as if we are much better than our actual success rates?

IVs, 12 lead ECG interpretation, and even driving are up there for EMS, but the biggest exaggeration is probably for intubation.

Combine all of these and move to the ED (Emergency Department) and the skill most inaccurately represented as positive may be pediatric intubation.

Is this because we unintentionally remember only some of our errors in managing pediatric airways?

An article in the current Annals of Emergency Medicine suggests that the errors reported are much lower than the actual number of errors during pediatric RSI (Rapid Sequence Intubation/Induction).

These studies likely underreport the frequency of both first-attempt failure and adverse effects because of voluntary self-reporting or the limitations of chart review. Our clinical experience and quality assurance efforts suggested that failed first attempts and adverse effects occur more commonly than reported for pediatric emergency patients undergoing RSI.[1]

Are they right?

The goal of our study was to accurately and thoroughly describe the process, success, and safety of RSI for patients in a busy pediatric ED. Using video review, we specifically sought to determine the frequencies of first-attempt success and adverse effects for patients undergoing RSI in a pediatric ED.[1]

The video does not lie – at least it is less motivated to lie.

Video review was the primary source for all study data; if a data point was unavailable or unclear from the video, it was obtained from the medical record or consensus review. If not recorded in the medical record, the data element was considered missing for that subject.[1]

None of the doctors reviewed their own patients.

In this ED, critically ill or injured patients are managed in one of 4 resuscitation bays by a designated team, which includes emergency physician and nurse team leaders, a pediatric or emergency medicine resident, several bedside nurses, and a respiratory therapist. The physician team leader is either board certified in pediatric emergency medicine or a second- or third-year fellow in pediatric emergency medicine. For critically injured patients, the team also includes a general surgery resident, a surgical fellow or attending surgeon, and providers from anesthesiology and critical care. During the study period, no standard protocol for the practice of RSI was in place and video-assisted laryngoscopy was not routinely performed.[1]

These should be the calmest, coolest, most collected of the people intubating children, so the tendency to unintentionally under-report errors may be least with these doctors.

In other words, we should expect that other hospitals, and especially EMS, should be much more stressed out and much less accurate in their reporting of errors.

The primary outcome was success of intubation with the first attempt, which included all insertions of the laryngoscope blade with the intent to intubate, even when there was no insertion of the tube, but they do not explain how they determined intent.

If I place the laryngoscope in the airway, how does anyone know what my intent is?

If I am holding the tube in my hand, this may just be a reasonable way to be prepared for an unexpectedly easy intubation, even though I had not been intending to place the tube. This is much more likely to be the case when the patient has not received RSI medications. The best reason for taking a look without the intent of intubating is before the RSI drugs are given, because the main reason to look first is to see if there is something that would make RSI especially dangerous in this patient.

If I take a look in the airway and decide that intubation with RSI is not the best way to manage this patient’s airway, is that a failed attempt. According to this study – only if I have pushed RSI drugs.

However, suppose that I have pushed RSI drugs and notice something I had not noticed earlier. If I take a look after pushing the RSI drugs, but place an extraglottic airway, that is a failed attempt. If I never use the laryngoscope, that is not a failed attempt, but it is also not an intubation. This does not appear to have been the case for any patients, but it is a good idea to be prepared to use Rapid Sequence Airway.[2],[3]

Our secondary outcome was the occurrence of adverse effects, measured as the number of patients with video evidence of 1 or more adverse effects during RSI.2, 16 [1]

Unfortunately, they had to rely on statements about the adverse events, except for the obvious (such as CPR), in order to recognize adverse events, because they did not have continuous records of the information on the monitors.

If the patient has an adverse event, but nobody notices or it is corrected without comment, the adverse event did not happen, at least as far as this study is concerned. RSI-related adverse events are unlikely to resolve spontaneously, so that should not affect the outcome, but a nurse, or doctor, could easily correct something and not state it out loud, especially if the people working together are accustomed to communicating without stating the obvious.

Here is the way they dealt with these limitations –

We attempted to identify the following adverse effects with only video review: nonairway intubation, inadequate paralysis (vocalization, biting, or general movement at the first attempt), vomiting, and endotracheal tube obstruction. The following adverse effects were identified with the aid of the medical record: mainstem bronchial intubation (confirmatory chest radiograph), aspiration (foreign material visualized in the airway or a combination of vomiting and new infiltrate on chest radiograph), pneumomediastinum, pneumothorax, and dental/oral injury.[1]

In Part II I will discuss the results. Some are good. Some are not so good.

Footnotes:

[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.

[2] Rapid Sequence Airway (RSA)–a novel approach to prehospital airway management.
Braude D, Richards M.
Prehosp Emerg Care. 2007 Apr-Jun;11(2):250-2.
PMID: 17454819 [PubMed – indexed for MEDLINE]

[3] Rapid sequence airway vs rapid sequence intubation in a simulated trauma airway by flight crew.
Southard A, Braude D, Crandall C.
Resuscitation. 2010 May;81(5):576-8. Epub 2010 Feb 18.
PMID: 20171002 [PubMed – indexed for MEDLINE]

Average time to secure the airway was 145 s shorter in the RSA group (95% CI: 100.4-189.7). Lowest oxygen saturation was 4.8% higher (95% CI: 2.8-6.8) in the RSA group. During RSI, FC placed a back-up airway 47% of the time.

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

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