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Emergency tracheal intubation of severely head-injured children: Changing daily practice after implementation of national guidelines*

Martinon, Claire MD; Duracher, Caroline MD; Blanot, Stéphane MD; Escolano, Sylvie PhD; De Agostini, Maria PhD; Périé-Vintras, Anne Catherine MD; Orliaguet, Gilles MD, PhD; Carli, Pierre A. MD; Meyer, Philippe G. MD

Pediatric Critical Care Medicine: January 2011 - Volume 12 - Issue 1 - p 65-70
doi: 10.1097/PCC.0b013e3181e2a244
Neurocritical Care

Objective: To report daily practice of scene emergency tracheal intubation performed by physicians and changes induced by implementation of national guidelines, with special attention to rapid sequence induction (RSI) and control of assisted ventilation.

Design: Observational study.

Setting: Pediatric intensive care unit of a university hospital.

Patients: A total of 296 children (age, 2–15 yrs old) referred to our center for severe traumatic brain injury (Glasgow Coma Scale score of ≤8), with spontaneous cardiac rhythm.

Interventions: Scene RSI practice by field physicians was compared before (n = 188), and after (n = 108) publication of national guidelines. Emergency tracheal intubation conditions, RSI use, immediate complications, assisted ventilation efficiency on blood gases measurements upon arrival, and, in the later period, physician's knowledge, and observance to published guidelines were analyzed.

Measurements and Main Results: After publication of guidelines, tracheal intubation was performed at the scene in 100% of the cases (vs. 88%, p = .05); RSI practice was more standardized, with an increased use of succinylcholine (10% to 80%, p = .0001), and a concomitant decreased use of nondepolarizing muscle relaxant (20% vs. 0%, p = .005), and opioids (70% vs. 36%, p = .05). Recommended RSI protocol (etomidate and succinylcholine) was effectively used by 64% of the physicians (vs. 2.8%, p = .001), and rate of immediate complications upon tube insertion (mainly cough reflex) decreased to 8% (vs. 25%, p = .0015). Scene emergency tracheal intubation, when ordered, resulted in a 100% success rate and adequate oxygenation within the two groups. Despite increasing the use of portable capnograph in the later period, Paco2 was measured outside the tight target range (35–40 torr, 4.6–5.3 kPa) in 70% of the cases upon arrival.

Conclusions: Scene emergency tracheal intubation was effectively performed by trained careproviders in children with traumatic brain injury. Implementation of guidelines led to a more standardized practice of RSI, decreased rate of immediate complications, but insufficient control of Paco2 during transport.

From the Pediatric Surgical Critical Care Unit (CM, CD, SB, ACP-V, GO, PAC, PGM), Department of Pediatric Anesthesiology and SAMU de Paris, Centre Hospitalier Universitaire Necker Enfants Malades, Faculté de Médecine Descartes-Paris 5; Institut National de la Santé et de la Recherche Médicale (INSERM) Unité 780 (SE, MDA), Villejuif, France.

This study was supported, in part, by Grant PHRC 2003/AOM-03018 from the “Direction Régionale de la Recherche Clinique (DRCC)-Assistance Publique Hôpitaux de Paris” (PGM).

The authors have not disclosed any potential conflicts of interest.

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©2011The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies