Endotracheal Intubation in a Pediatric Emergency Department - Which Specialist Has the Skills to Manage the Airway?

Abstract 462 Poster Session III, Monday, 5/3 (poster 187)

Background: Models of adult learning state that proficiency in procedural skills requires both a strong cognitive background as well as repetition of the learned skill. Objective: To examine differences in success and complication rates of endotracheal intubations by specialty in a pediatric emergency department (PED). Methods: Observational, consecutive series of patients intubated from 6/96-11/98 in a PED that trains pediatric emergency medicine (PEM) fellows, pediatric residents and emergency medicine (EM) residents. There are 50,000 annual ED visits, 24 hour in department PEM attending and 24 hour in hospital anesthesia back-up coverage. All PEM fellows and attendings have formal training in airway management. Results: 91 patients were intubated during the 30-month period. 75/91 (82%) patients were successfully intubated on the first attempt. Table 1 lists the first attempt success rates by specialty. There was a significant difference in first attempt success rates between pediatric residents and the remainder of the group (61.5% vs 85.9%, P=0.05) and between pediatric residents and PEM (61.5% vs 86.8%, P=0.04). There was no significant difference between the other specialties. PEM attendings accounted for only 6/68 PEM attempts and had a 100% first attempt success rate. Of the 16 missed first time attempts, 10 patients (62.5%) were successfully intubated on the second attempt, 4 (25%) required 3 attempts and 2 (12.5%) were intubated on the fourth attempt. All patients were ultimately successfully intubated in the ED. Complications included right main stem intubation (n=3), laryngospasm requiring muscle relaxant (2) and aspiration (1). There was no significant association between these complications and specialty training. There were no long-term sequelae from any complication during intubation. Conclusions: (1) Formal education in airway management may improve success rates of endotracheal intubation. (2) Teaching hospitals may need to institute programs to ensure that attending staff are able to maintain their technical skills.

Table 1 Success rate of endotracheal intubation by specialty