Pediatric intubation

[sportygirl]

Ok at my job people have started getting upset about this and i wanted to know what others think.In the county I work in there about to take away pediatric intubation. I think it sounds very dumb so what do you all think? and why would you think this is ok?

[fireflymedic]

Hey sporty,

There has been a definite emphasis away from intubation in pediatrics. The reason most peds go downhill is respiratory failure first - if you get aggressive and start treating them early great, however, current practice trends say tube them only if you must. The reasoning behind this is you are not given adequate opportunities to maintain pediatric intubation skills (or intubation skills in general) which is why intubation is generally falling out of favor. Also, there is a higher outcome of complications such as failure to recognize a failed intubation, incorrect tube size, or right mainstem intubation. General rule of thumb for peds is O2, bag them if you have to, only tube them if you must. Studies have shown that effective bagging of a pediatric patients is just as effective as intubation in many cases. Reference http://www.caep.ca/CMS/temp/pg207.pdf This study was based in california, so it is quite pertinent to your question directly sporty. There are very few opportunities to tube pediatrics (I would say lucky if there is one a year per person in an average service). Unless you are running with a neonate/peds specialty team you are unlikely to use the skill often, and I didn't even utilize it much even when running specialty. Most were already intubated prior to arrival for transfer. Not to say there won't be the occasional patient that will need it, but on average, effective bagging will take care of the job just fine. Overall, if intubation is going to be kept across the board, greater skill maintenance needs to be kept, more so than is required now and especially the case for pediatrics as their airway is much different from the adult and in general a tougher intubation. Truthfully, I wouldn't be suprised for more services to follow suit. Just some things to think over.

[Katiebug]

Overall, if intubation is going to be kept across the board, greater skill maintenance needs to be kept, more so than is required now and especially the case for pediatrics as their airway is much different from the adult and in general a tougher intubation.

And there it is. What needs to be done is raise the competency level of the skill, not take the skill away.

It's the same thing that keeps getting preached over and over. More education- more training.

The more interventions we have at our disposal the better. As long as they are (as much as can be expected) done rationally and appropriately.

[sportygirl]

So if I under sand this right your saying that it is ok that we cant intubate because if medics do it and miss it dose more harm? If this is the case are you saying you would just put in an OPA or an NPA and it will do just as good? If it is a skill issue then wouldn't more piratic help?

Edited April 6, 2009 by sportygirl

[fireflymedic]

Yes, with the lack of successful pediatric intubations, yes most likely, especially if you are a newer medic you would benefit the child just as much to do an OPA and bag (provided no gag reflex is present). Now for long periods of time in extended transport, you may have to deal with the issue of gastric insufflation which is bound to happen over a longer period - so one point to consider. You are correct in the fact that additional training with pediatric patients would be beneficial, however, few services are willing to committ to maintaining the skills we have currently it may require medics to travel outside of their area to a pediatric specialty hospital in order to get a reasonable number of successful peds intubations of various ages. In some areas that may be quite a distance. Currently, that's not a popular thought - it is difficult enough for medic students to get live OR intubations in adults, much less pediatrics. It's a tough line. It can be beneficial if done properly, but across the board I think most people would say the risk out weigh benefits to most.

[crotchitymedic1986]

I agree with taking it away. An uncuffed tube does not protect the airway from aspiration, and I have seen too many medics (and flightmedics) spend too much time on the scene trying to complete a hard intubation.

Patients do not die because you fail to intubate them, they die because you fail to ventilate them

Next time you try to intubate a paitent, hold your breath the whole time the patient is not being bagged; which should clue you in when it is time to stop digging in their throat and give them a little ventilation.

[cdcmj]

crotchity, though I agree leaving your pt. hypoxic is hurting your pt., the whole hold your breath during intubation attempts bears no weight. It is shown that with proper pre-oxygenation, which unfortunately rarely happens in EMS , a pt. can maintain spo2 in the high 90's for a few minutes if left apneic. This is not to say wait a few minutes between attempts, but nonetheless, it should at least alert us to the positives that come from proper pre-oxygenation prior to ETI (less likelihood of transient hypoxia).

[VentMedic]

I agree with taking it away. An uncuffed tube does not protect the airway from aspiration, and I have seen too many medics (and flightmedics) spend too much time on the scene trying to complete a hard intubation.

A cuffed tube does not prevent aspiration either since the cuff is below the cords.

What is missing here is the basic concept of airway management. Too many want to do ETI but forget a few basic principles about maintaining an airway. This should be reinforced in EMT-B but again the education is lacking there also. In Paramedic school the "skill" of ETI is jumped into without a good basis.

The ones who usually complain the loudest about losing ETI are viewing it as just a "skill" that they can claim. It they had an actual understanding of the airway management concept and how ETI fits into the concept, they would also understand the rationale behind the need for proficiency and continued competency. They may have had neither to begin with in this "skill" but just had it in their scope of practice or protocols. You might ask those pondering the loss of pedi ETI how many times they reviewed their procedure manual and at least made an attempt to stay familar with the many sizes and shapes of children. Playing with an intubation head in PALS once every two years to impress the new nurses doesn't count.

Edited April 6, 2009 by VentMedic

[fireflymedic]

+5 for the explanation Vent !

[WelshMedic]

The decision to take away pediatric intubation, whilst being emotive, does appear to be evidence based. Pediatric intubations are thankfully rare, but the flipside is that maintaining the skill level required is difficult. Even with the best CE programs and OR rotations it is still very different to the actual practice. I consider myself to be reasonably well-educated, not to mention regularly trained. However, I still managed to miss a right stem intubation in a pediatric trauma a few years ago. We are not superheroes, we are just ordinary folk doing the best we can. OOH pediatric ETI may just be a little too much to ask of an EMS provider

WM