title: Airway emergencies presenting to the paediatric emergency department requiring advanced management techniques.
abstract: Airway emergencies presenting to the emergency department (ED) are usually managed with conventional equipment and techniques. The patient group managed urgently in the operating room (OR) has not been described.
  
  
  
  This study aims to describe a case series of children presenting to the ED with airway emergencies managed urgently in the OR, particularly the anaesthetic equipment and techniques used and airway findings.
  
  
  
  A retrospective cohort study undertaken at The Royal Children's Hospital, Melbourne, Australia. All patients presenting to the ED between 1 January 2012 and 30 July 2015 (42 months) with an airway emergency who were subsequently managed in the OR were included. Patient characteristics, anaesthetic equipment and technique and airway findings were recorded.
  
  
  
  Twenty-two airway emergencies in 21 patients were included over the study period, on average one every 2 months. Median age was 18 months and 43% were male. Inhalational induction was used in 77.3%, combined inhalational and intravenous induction in 9.1%, and intravenous induction alone in 13.6%. The most commonly used inhalational induction agent was sevoflurane, and the most commonly used intravenous induction agents were ketamine and propofol. Ten airway emergencies did not require intubation, seven for removal of inhaled foreign body, two with progressive tracheal stenosis requiring emergent dilatation and one examination under anaesthesia to rule out inhaled foreign body. Of the 12 airway emergencies that required immediate intubation, direct laryngoscopy was used in 9 and fibre-optic intubating bronchoscopy in 3. For intubations performed by direct laryngoscopy, one was difficult (Cormack and Lehane grade 3). First pass success was 83.3%. Adverse events occurred in 3/22 (13.6%) cases.
  
  
  
  Advanced airway techniques, including inhalational induction and intubation via fibre-optic intubating bronchoscope, are rarely but predictably required in the management of patients presenting to the ED. Institutions caring for children should prepare in advance where such patients should be managed, by whom, and provide equipment and training for their care.
authors.affiliation: Department of Emergency Medicine, The Royal Children's Hospital, Parkville, Victoria, Australia.
authors.forename: Leopold
authors.initials: L
authors.lastname: Simma
authors.affiliation: Department of Emergency Medicine, The Royal Children's Hospital, Parkville, Victoria, Australia.|Murdoch Children's Research Institute, Parkville, Victoria, Australia.|Department of Pediatrics, Faculty of Medicine, Dentistry, and Health Sciences,University of Melbourne, Victoria, Australia.
authors.forename: Domenic
authors.initials: D
authors.lastname: Cincotta
authors.affiliation: Murdoch Children's Research Institute, Parkville, Victoria, Australia.|Department of Anaesthesia and Pain Management, The Royal Children's Hospital, Parkville, Victoria, Australia.
authors.forename: Stefan
authors.initials: S
authors.lastname: Sabato
authors.affiliation: Department of Emergency Medicine, The Royal Children's Hospital, Parkville, Victoria, Australia.|Murdoch Children's Research Institute, Parkville, Victoria, Australia.|Department of Pediatrics, Faculty of Medicine, Dentistry, and Health Sciences,University of Melbourne, Victoria, Australia.
authors.forename: Elliot
authors.initials: E
authors.lastname: Long
mesh_terms: D058109:Airway Management / Q000379:methods*; D000402:Airway Obstruction / Q000628:therapy; D000769:Anesthesia, Inhalation / Q000379:methods; D000771:Anesthesia, Intravenous / Q000379:methods; D001999:Bronchoscopy / Q000379:methods; D002675:Child, Preschool; D004630:Emergencies; D004636:Emergency Service, Hospital; D005260:Female; D005547:Foreign Bodies / Q000628:therapy; D006776:Hospitals, Pediatric; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007442:Intubation, Intratracheal / Q000379:methods; D008297:Male; D009873:Operating Rooms; D012131:Respiratory Insufficiency / Q000628:therapy*; D012189:Retrospective Studies
keywords: airway management; anesthesia; child; difficult laryngoscopy; emergency service; intubation