Out-of-hospital Rapid-sequence Induction for Intubation of the Pediatric Patient

Objective: To determine the effectiveness and morbidity of out-of-hospital rapid-sequence induction (RSI) for endotracheal intubation (ETI) in the pediatric population.
Methods: The medical records were retrospectively reviewed for a consecutive series of pediatric patients undergoing out-of-hospital RSI by flight paramedics from July 1990 through July 1994. Patient demographics, pharmacologic agents, ED arterial blood gas data, pulmonary complications, and RSI-related complications were abstracted.
Results: Forty patients (31 injured, 9 medical) with a mean age of 8.1 years (range 0.5–17 years) underwent out-of-hospital RSI. Indications for intubation included hyperventilation ( n = 20), combativeness ( n = 16), apnea ( n = 5), and unknown ( n = 5). Intubation mishaps occurred in 13 patients (33%); these included multiple attempts ( n = 9), aspiration ( n = 8), and esophageal intubation ( n = 1). The success rate of ETI was 97.5% (one failed attempt). Hemodynamic side effects occurred in three patients (8%); all three had bradycardia, with one developing hypotension. Bradycardia was associated with failure to pretreat with atropine (p < 0.05). Sixteen pulmonary complications, seven pneumonia (18%) and nine atelectasis (22.5%), occurred in 13 patients within the first ten hospital days. Intubation mishaps were not associated with pulmonary complications. There were six deaths, none associated with RSI.
Conclusions: 1) Rapid-sequence induction is an effective method for obtaining airway control in the critically ill pediatric patient. 2) Intubation mishaps did not influence the rate of pulmonary complications. 3) Omission of atropine was associated with bradycardia during RSI in pediatric patients.