title: Radiological evaluation of tube depth and complications of prehospital endotracheal intubation in pediatric trauma: a descriptive study.
abstract: OBJECTIVE
  Pediatric prehospital endotracheal intubation (PHETI) is a difficult and rarely performed procedure that remains the gold standard for prehospital airway management when ventilation and/or anesthesia is required, but high complications rates, including malposition continue to concern. We reviewed the experience in our institution of pediatric intubations with particular emphasis on the position of the endotracheal tube (ETT) tip within the trachea and related complications.
  
  
  METHODS
  Intubated pediatric patients presenting directly from the scene to our level 1 trauma center, between 2006 and 2014, were included in our study. Patient records and radiographs were retrospectively reviewed to identify the ETT tip-to-carina distance and possible intubation-related complications. ETT tips identified beyond the carina on radiographs or by clinical diagnosis were defined as misplaced. Because head movement causes a significant ETT movement within the trachea, which is age related, we also defined ETT tip placement (1) less than 2 cm above the carina in children younger than 8 and (2) less than 3 cm above the carina in children 8 years or older as "near miss" intubations.
  
  
  RESULTS
  From a total of 34 cases, ETT misplacement was identified in seven cases. Diagnosis was made radiologically in five cases and clinically in two cases. Four of these patients had left lung atelectasis due to tube misplacement. Tube thoracotomy was performed in two of these patients without concurrent evidence of chest injury. "Near miss" intubations accounted for 7/9 and 9/25 in children <8 years and ≥8 years old, respectively, totaling 16/34, with two of these leading to late displacements.
  
  
  CONCLUSIONS
  Pediatric endotracheal tube intubation carries a high rate of tube malposition and left lung atelectasis in our experience of pediatric trauma patients, with less than a third of ETTs placed in a safe position.
authors.affiliation: Department of Orthopedics and Traumatology, Helsinki University Central Hospital and University of Helsinki, Topeliuksenkatu 5, 00260, Helsinki, Finland. tomi.simons@hus.fi.
authors.forename: T
authors.initials: T
authors.lastname: Simons
authors.affiliation: Department of Orthopedics and Traumatology, Helsinki University Central Hospital and University of Helsinki, Topeliuksenkatu 5, 00260, Helsinki, Finland.
authors.forename: T
authors.initials: T
authors.lastname: Söderlund
authors.affiliation: Department of Orthopedics and Traumatology, Helsinki University Central Hospital and University of Helsinki, Topeliuksenkatu 5, 00260, Helsinki, Finland.
authors.forename: L
authors.initials: L
authors.lastname: Handolin
mesh_terms: D000367:Age Factors; D002648:Child; D004632:Emergency Medical Services; D005260:Female; D005387:Finland; D006801:Humans; D007442:Intubation, Intratracheal / Q000009:adverse effects / Q000295:instrumentation*; D008297:Male; D009104:Multiple Trauma; D017063:Outcome Assessment, Health Care; D012189:Retrospective Studies; D014132:Trachea / Q000000981:diagnostic imaging*; D014193:Trauma Centers
keywords: Complication; Near miss intubation; Pediatric intubation; Pediatric prehospital endotracheal intubation; Safe zone; Tip-to-carina distance