title: Pediatric Intubation by Paramedics in a Large Emergency Medical Services System: Process, Challenges, and Outcomes.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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%.
  
  
  CONCLUSIONS
  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.
authors: Department of Emergency Medicine and Department of Medicine, Division of Pulmonary and Critical Care Medicine, Hennepin County Medical Center, Minneapolis, MN. Electronic address: matthew.prekker@hcmed.org.
authors: Matthew E
authors: ME
authors: Prekker
authors: University of Washington School of Medicine, Seattle, WA.
authors: Fernanda
authors: F
authors: Delgado
authors: Emergency Medical Services Division, Public Health-Seattle & King County, Seattle, WA.
authors: Jenny
authors: J
authors: Shin
authors: Division of Emergency Medicine, University of Washington, Seattle, WA.
authors: Heemun
authors: H
authors: Kwok
authors: Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA.
authors: Nicholas J
authors: NJ
authors: Johnson
authors: Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA.
authors: David
authors: D
authors: Carlbom
authors: Department of Anesthesiology, University of Washington, Seattle, WA.
authors: Andreas
authors: A
authors: Grabinsky
authors: Division of Pediatric Critical Care Medicine, University of Washington and Seattle Children's Hospital, Seattle, WA.
authors: Thomas V
authors: TV
authors: Brogan
authors: Division of Pediatric Critical Care Medicine, University of Washington and Seattle Children's Hospital, Seattle, WA.
authors: Mary A
authors: MA
authors: King
authors: Emergency Medical Services Division, Public Health-Seattle & King County, Seattle, WA.
authors: Thomas D
authors: TD
authors: Rea
mesh_terms: D000293:Adolescent; D000488:Allied Health Personnel / Q000706:statistics & numerical data*; D002648:Child; D002675:Child, Preschool; D004632:Emergency Medical Services / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007442:Intubation, Intratracheal / Q000706:statistics & numerical data*; D008297:Male; D010043:Outcome and Process Assessment, Health Care; D012189:Retrospective Studies