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ED vs ICU: Who is Better at Intubating Kids?

December 28, 2021

Written by Aaron Lacy

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While characteristics of children requiring tracheal intubation were different between the ED and ICU, there was no difference in adverse intubation related events or first pass success rate between them.

Why does this matter?

Failure on first pass attempt during pediatric tracheal intubation is associated with increased likelihood of cardiac arrest, and 1 out of 5 pediatric intubations are associated with adverse events. Children requiring intubation in the ED and ICU often meet high-risk criteria for intubation, and identifying where we are successful and have pitfalls is a key step towards improving airway outcomes in this population. 

NEAR, but for Kids
The NEAR for Children (NEAR4KIDS) database from 2015-2018 looked at intubations of children in the ED (n = 756) and pediatric/cardiac ICU (n = 12,512). Reason for intubation varied between settings. Respiratory decompensation (52% ED vs 64% ICU), shock (26% ED vs 14% ICU) and neurologic deterioration (30% ED vs 11% ICU) were the highest reported indications. The ED was much more likely to use video laryngoscopy (64% vs 29%).

The primary outcome, severe* adverse tracheal intubation events, was not different between the ED and ICU (5.4% ED, 5.8% ICU; 95% CI -2.0, 1.3, p=0.68). There was also no difference in all** adverse tracheal intubation events between groups (15.6% ED, 14% ICU; 95% CI -1.1, 4.2, p=0.23). Oxygen desaturation was less commonly reported in the ED (13.6%) than the ICU (17%) (95% CI -5.9, -0.8, p=0.016), and there was no significant difference in first pass success rate.

Kids in the ED and ICU who need intubation are sick. Make sure to emphasize preoxygenation and have your most experienced intubator proceed with video laryngoscopy to get the best chance of success.

Intubation practice and outcomes among Pediatric Emergency Departments: A report from National Emergency Airway Registry for Children (NEAR4KIDS). Acad Emerg Med. 2021 Dec 19. doi: 10.1111/acem.14431. Online ahead of print.

*cardiac arrest, esophageal intubation with delayed recognition, aspiration, hypotension requiring treatment, dental trauma, laryngospasm, malignant hyperthermia, pneumothorax/pneumomediastinum, or direct airway injury

**above, plus: mainstem intubation, esophageal intubation with immediate recognition, emesis without aspiration, hypertension requiring therapy, epistaxis, lip trauma, medication errors, arrhythmias, and pain or agitation whose treatment delayed intubation.

What are your thoughts?