Routine advanced airway usage by Emergency Medical Services (EMS) has had conflicting reports of being the secure airway of choice in pediatric patients.

The primary objective was to describe a pediatric cohort requiring airway management upon their arrival directly from the scene to two pediatric emergency departments (PEDs). A secondary objective included assessing for associations in EMS airway management and patient outcomes.

Retrospective data from the health record were reviewed, including EMS reports, for all arrivals less than 18 years old to two PEDs who required airway support between May 2015 and July 2016. The EMS management was classified as basic (oxygen, continuous positive airway pressure [CPAP], or bag-valve-mask [BVM]) or advanced (supraglottic or endotracheal intubation [ETI]) based on EMS documentation. Outcomes included oxygenation as documented by receiving PED and hospital mortality.

In total, 104 patients with an average age 5.9 (SD=5.1) years and median EMS Glasgow Coma Scale (GCS) of nine (IQR 3-14) were enrolled. Basic management was utilized in 70% of patients (passive: n=49; CPAP: n=2; BVM: n=22). Advanced management was utilized in 30% of patients (supraglottic: n=4; ETI: n=27). Proper ETI placement was achieved in 48% of attempted patients, with 41% of patients undergoing multiple attempts. Inadequate oxygenation occurred in 18% of patients, including four percent of ETI attempts, nine percent of BVM patients, and 32% of passively managed patients. Adjusted for EMS GCS, medical patients undergoing advanced airway management experienced higher risk of mortality (risk-ratio [RR] 2.98; 95% CI, 1.18-7.56; P=.021).

With exception to instances where ETI is clearly indicated, BVM management is effective in pediatric patients who required airway support, with ETI providing no definitive protective factors. Most of the patients who exhibited inadequate oxygenation upon arrival to the PED received only passive oxygenation by EMS.

TweedJ, GeorgeT, GreenwellC, VinsonL.Prehospital Airway Management Examined at Two Pediatric Emergency Centers. Prehosp Disaster Med. 2018;33(5):532–538.

The purpose of this study was to determine the complication rates associated with the use of the endotracheal tube (ET) a the use of the esophageal obturator airway/esophageal gastric tube airway (EOA/EGT during the treatment of patients with prehospital cardiac arrest.

A descriptive, quasi-experimental study of 509 consecutive adults, cardiac arrest patients was conducted. Patients were examined prospectively for airway intervention type and complications. Some patients were examined at their final destinations (field, morgue, funeral home), while other patients were examined by EMS providers in the field when airway adjuncts were switched. Also, airways were evaluated for complications by emergency physicians at destination emergency departments.

The airway in use at the time of examination was the esophageal obturator airway (EOA) or esophageal gas lube airway (EGTA) in 208 patients (40.1%); the ET (endotracheal tube) in 232 patients (45.6%); and an oral or nasopha ryngeal airway in 47 patients (9.2%). Twenty-two patients (4.3%) had both an EOA/EGTA and an ET tube in place at the time of the examination. The survival rates were similar between the EOA/EGTA and the ET groups (28% and 32%, respectively). The complication rates overall also were similar, but the serious or potentially lethal complication rate was 3.3 times more common with the use of the EOA/EGTA than with the ET tube (8.7% versus 2.6%, respectively).

The complication rate for the EOA/EGTA is unacceptably high, and careful thought must be given to its continued use. Serious questions also arise concerning the complication rates associated with the use of the ET: is the complication rate of 2.5% acceptable or should other airway alternative be considered for use in prehospital care?