California Pediatric Intubation

Qulevrius said:
Or instead, the medics could be rotated with anesthesiologists the same way RTs are.
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I don’t think that is a very plausible option. In my county alone you are talking about 500 medics who are currently in the field.
 
I thought this happened quite a while back? Thought I remember hearing maybe 10 years ago that medics in CA were no longer able to tube peds.

This is surprising to me. I'm as critical of prehospital intubation as anyone, but to be honest, kids are usually the easiest airways because they rarely have the co-morbidities that adults do.

Do the stats demonstrate worse outcomes when peds (as compared to adults) are intubated prehospital?
 
Remi said:
Do the stats demonstrate worse outcomes when peds (as compared to adults) are intubated prehospital?
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A controlled trial from 2000 demonstrated no survival advantage of introducing ETI to a system where BVM was the only other method (and it looks like BVM might be superior to ETI for a couple of etiologies, besides reducing scene time). In summary..."For ETI in this [prehospital] setting, scene time was prolonged and fatal complications were frequent."

Color me suspicious if ETI is a good idea for peds prehospitally...assuming you don't have the best (i.e. regularly intubating successfully on the first pass) medics. Heck, EMS providers don't really feel comfortable with pediatric airway management.

Here's a nice retrospective study. They note: "Our study shows out-of-hospital ETI, the most commonly used advanced technique, has significantly lower success rates compared to in the hospital and alarmingly low rates of C02-based confirmation of placement. Despite the findings of the Gauche-Hill study 15 years ago that showed no benefit and trend towards harm with pediatric ETI, it continues to be the most commonly practiced advanced airway management technique. It is unclear why the current practice is not consistent with the best available evidence."
 
Remi said:
I thought this happened quite a while back? Thought I remember hearing maybe 10 years ago that medics in CA were no longer able to tube peds.

This is surprising to me. I'm as critical of prehospital intubation as anyone, but to be honest, kids are usually the easiest airways because they rarely have the co-morbidities that adults do.

Do the stats demonstrate worse outcomes when peds (as compared to adults) are intubated prehospital?
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Some areas remove pediatric intubation but not all areas and it was still listed on the state scope of practice.

We still have areas in CA where there are no skill tests or training. Once you get hired you only have to have BLS CPR, ACLS, and enough CE hours but that’s it. The only training they actually have is when they went to medic school. I’d imagine that our first time pass rate for adult is also very low.

Also if I remember correctly we still have a couple of isolated areas without EtCO2 capability.
 
You modern medics amaze me. You applaud doing away with a skill, that might be rare, but is still lifesaving. This is horse hockey. Peds are difficult, but deserve the best treatment possible regardlessly. ETI is the best treatment for an airway in most circumstances. Butchering an airway? How so? Proper technique will prevent that. My worst intubation was a 6yo female in status eplipecticus and vomiting. I got her tubed without chipping teeth and damaging any soft tissue. She made it. Without the tube, she probably would have aspirated. Where is your collective heads at?
 
MackTheKnife said:
My worst intubation
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Hold on, though. I would say you probably don't consider yourself a poor medic, right? (Or even an average one?) We need to worry about the least common denominator.
 
MackTheKnife said:
You modern medics amaze me. You applaud doing away with a skill, that might be rare, but is still lifesaving. This is horse hockey. Peds are difficult, but deserve the best treatment possible regardlessly. ETI is the best treatment for an airway in most circumstances. Butchering an airway? How so? Proper technique will prevent that. My worst intubation was a 6yo female in status eplipecticus and vomiting. I got her tubed without chipping teeth and damaging any soft tissue. She made it. Without the tube, she probably would have aspirated. Where is your collective heads at?
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So you reject the research that this decision is based on? On what grounds?
 
EpiEMS said:
Hold on, though. I would say you probably don't consider yourself a poor medic, right? (Or even an average one?) We need to worry about the least common denominator.
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No, we need to worry about what's best for the patient. The LCD is just that, the Least. If we dumb down the standards because of the few, the patient loses and we lose. My problem with tubing kids is the lack of a cuff on the tube.
 
Remi said:
So you reject the research that this decision is based on? On what grounds?
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Remi, as I have been pursuing my BSN, I have been focused on evidenced-based practice (EBP). I can find EBP representing both sides of an argument when doing research. I am not swayed by purported studies saying this is good or bad. Our hospital, and many others, require IV sites to be rotated every 96 hours due to EBP. Problem is, there is EBP that states the exact opposite.
 
MackTheKnife said:
No, we need to worry about what's best for the patient. The LCD is just that, the Least. If we dumb down the standards because of the few, the patient loses and we lose.
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You're not worried about iatrogenic events? What about that there is no demonstrable survival advantage to ETI over BVM? If you really want something better than a BVM, why not an LMA? At least the LCD can't mess up an LMA...

I can't see any good evidence that an ETI is better than a BVM in pediatric out of hospital care...of course, I could be wrong, and there isn't a ton of research out there. But what we do have - and it is large - shows that BVM is preferable.
 
http://gatheringofeagles.us/2013/Friday/Gausche-Hill-PrehospitalPediIntubation.pdf

Pre-hospital pediatric patients whom received BVM vs ETI had better overall survival and significant better neurological outcomes. But if intubating makes you feel like you are doing something for the patient then by all means....

Would ETI be better for a vomiting status patient? Maybe, maybe not. Assuming you successfully intubate the patient with the correct size ETT without multiple attempts and hypoxic events. Which may have happened in your particular situation but frequently is not the case.
 
EpiEMS said:
Wait, wait...to recertify you don't need to pass a skills exam?
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In some areas that is correct. The state does not require it but some counties do. All the state requires are: the CE hours, ACLS, and BLS CPR.
 
Iatrogenic? Please tell me the incidence rates of these events? Survival advantage? Demonstrably ETI over BVM. BVM does NOT control the integrity of the airway. I've seen the studies of cardiac arrest patients surviving not neurologically intact with ETI, but ETI is not the only factor. Length of arrest, length of apnea/anoxia, comorbidities, etc., all factor in. Yet ETI is disdained these days. I said, IMHO, we are looking for an excuse to dumb down the standards and reduce skill sets.
 
MackTheKnife said:
Demonstrably ETI over BVM.
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I have yet to see anything showing that this is the case. I cited the preeminent study on this topic earlier (on pediatric intubation, specifically). I suggest you review it before stating this. Of course, it is an imperfect study, but is corroborated by the fact that EMS providers say they don't know what they are doing with kids!

MackTheKnife said:
've seen the studies of cardiac arrest patients surviving not neurologically intact with ETI, but ETI is not the only factor. Length of arrest, length of apnea/anoxia, comorbidities, etc., all factor in.
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ETI is a risk factor for anoxic time upon EMS arrival, no? ETI uses people who should otherwise be doing the two things that matter - CPR & defibrillation...

DesertMedic66 said:
In some areas that is correct. The state does not require it but some counties do. All the state requires are: the CE hours, ACLS, and BLS CPR.
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That's crazy...how can they do that?
 
MackTheKnife said:
Iatrogenic? Please tell me the incidence rates of these events? Survival advantage? Demonstrably ETI over BVM. BVM does NOT control the integrity of the airway. I've seen the studies of cardiac arrest patients surviving not neurologically intact with ETI, but ETI is not the only factor. Length of arrest, length of apnea/anoxia, comorbidities, etc., all factor in. Yet ETI is disdained these days. I said, IMHO, we are looking for an excuse to dumb down the standards and reduce skill sets.
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Reference the above PowerPoint. Multiple studies have shown no increase in survival or even worse survival with ETI in pediatrics. This was not exclusively in cardiac arrest patients, the majority were TBI. 3/4 of the time the ETT tube was the wrong size. Most are not cuffed. Not sure you can argue it controls the integrity of the airway in most prehospital intubations. You have zero evidence to support your claim other than it feels like the right thing to do.

ETI Complications (n=186):
Tube size incorrect 44 (24%)
Main stem intubation 33 (18%)
Recognized dislodgement 15 (8%)
Unrecognized dislodgement 12 (6%)
Esophageal intubation 3 (2%)

Results:
Of 420 ETI patients:
305 attempted intubation (73%)
174 successful (57%)
3 esophageal intubations

Treatment received:
survival - BVM (33%) vs ETI (14%), OR
0.32, 95% CI [0.20-0.50];
neurologic outcome - BVM (26%) vs. ETI
(8%), OR 0.26, 95% CI[0.15-0.45].
 
EpiEMS said:
I have yet to see anything showing that this is the case. I cited the preeminent study on this topic earlier (on pediatric intubation, specifically). I suggest you review it before stating this. Of course, it is an imperfect study, but is corroborated by the fact that EMS providers say they don't know what they are doing with kids!



ETI is a risk factor for anoxic time upon EMS arrival, no? ETI uses people who should otherwise be doing the two things that matter - CPR & defibrillation...



That's crazy...how can they do that?
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This is insane! Don't know what they're doing with kids? The anatomy is smaller and trickier, but it is the same. Patience, preoxygenation, eye-hand coordination gets the job done.
 
MackTheKnife said:
You modern medics amaze me. You applaud doing away with a skill, that might be rare, but is still lifesaving. This is horse hockey. Peds are difficult, but deserve the best treatment possible regardlessly. ETI is the best treatment for an airway in most circumstances. Butchering an airway? How so? Proper technique will prevent that. My worst intubation was a 6yo female in status eplipecticus and vomiting. I got her tubed without chipping teeth and damaging any soft tissue. She made it. Without the tube, she probably would have aspirated. Where is your collective heads at?
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We applaud doing away with a skill that is very low frequency and high risk because as a whole we suck at it and since we suck at it we found out we were killing patients. CA pulled information on all the pediatric patients in the state who were tubed or at least it was attempted and compared it to patients who were not and found the latter had better survival rates.

Yes there will always be that one patient who may die because we are unable to tube but it will save the other 9 kids from dying at our hands because we took too long to get the tube, spent too much time on scene, cause too much airway trauma, didn’t realize improper tube placement, or failed to reassess tube placement.

If the intial education, clinical rotations, continued skills verifications, mandatory ongoing training was better then we maybe able to keep these skills but once again as a whole we don’t have that.

I am all for increased survival rates over skills.
 
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