Pediatric rapid sequence intubation: incidence of reflex bradycardia and effects of pretreatment with atropine

Prevalence of Bradycardia After Induction of General Anesthesia and Associated Factors Among Surgical Pediatric Patients. A Prospective Observational Study

Background

Heart rate is the main determinant factor of the child's cardiac output in the first year of life. Thus, bradycardia decreases cardiac output leading to fatal cardiac arrhythmias, cardiac arrest, and even death. The objective of this study is to determine the prevalence of bradycardia and its associated factors after induction of general anesthesia among pediatric patients operated at Hawassa University Comprehensive Specialized Hospital (HUCSH).

Methods

Prospective observational study was employed at HUCSH by using a systematic random sampling technique. Pediatric surgical patients less than 6 years old were included in the study. Data were entered into Epi data statistical software (version 4.6.0.) and exported to SPSS (version 25.0). Categorical data were analyzed using chi-square statistics, and continuous data were analyzed using Student's t-test. Bivariable logistic regression was used to select candidate variables for multivariable logistic regression.

Results

The prevalence of bradycardia among 205 pediatric patients included in this study was 19.5%. Preoperative risk of hypoxia, opioids premedication, inhalational induction (halothane), difficult intubation, intraoperative complications, and significant surgical blood loss were independently associated with bradycardia.

Conclusion

The prevalence of bradycardia after induction of general anesthesia was 19.5%. Preoperative risk of hypoxia, opioids premedication, inhalational induction (particularly with halothane), difficult intubation, intraoperative complications such as hypoxia, and significant blood loss were significantly associated with bradycardia.

Atropine does not prevent hypoxemia and bradycardia in tracheal intubation in the pediatric emergency department: observational study

OBJECTIVE

The benefit of atropine in pediatric tracheal intubation is not well established. The objective of this study was to evaluate the effect of atropine on the incidence of hypoxemia and bradycardia during tracheal intubations in the pediatric emergency department.

METHODS

This is a single-center observational study in a tertiary pediatric emergency department. Data were collected on all tracheal intubations in patients from 31 days to incomplete 20 years old, performed between January 2016 and September 2020. Procedures were divided into two groups according to the use or not of atropine as a premedication during intubation. Records with missing data, patients with cardiorespiratory arrest, cyanotic congenital heart diseases, and those with chronic lung diseases with baseline hypoxemia were excluded. The primary outcome was hypoxemia (peripheral oxygen saturation ≤88%), while the secondary outcomes were bradycardia (decrease in heart rate >20% between the maximum and minimum values) and critical bradycardia (heart rate <60 bpm) during intubation procedure.

RESULTS

A total of 151 tracheal intubations were identified during the study period, of which 126 were eligible. Of those, 77% had complex, chronic underlying diseases. Atropine was administered to 43 (34.1%) patients and was associated with greater odds of hypoxemia in univariable analysis (OR: 2.62; 95%CI 1.15-6.16; p=0.027) but not in multivariable analysis (OR: 2.07; 95%CI 0.42-10.32; p=0.37). Critical bradycardia occurred in only three patients, being two in the atropine group (p=0.26). Bradycardia was analyzed in only 42 procedures. Atropine use was associated with higher odds of bradycardia in multivariable analysis (OR: 11.00; 95%CI 1.3-92.8; p=0.028).

CONCLUSIONS

Atropine as a premedication in tracheal intubation did not prevent the occurrence of hypoxemia or bradycardia during intubation procedures in pediatric emergency.

Rapid Sequence Intubation Experiences in the Pediatric Emergency Department

Aim: Patient selection and management of rapid sequence intubation application in the emergency department can be challenging for clinicians. In this study, we aimed to describe the demographic information, clinical characteristics and medical conditions of the patients who underwent rapid sequence intubation in the children's emergency department of our hospital and to present patient management strategies. Methods: Cases under the age of 18 who underwent rapid sequence intubation in the emergency department between January 2021 and January 2022 were retrospectively analyzed. Results: 11 patients were included in the study. The median age of the patients was 6 years (min-max 2-15), 7 of them were girls (63,6%). The median time from symptom onset to presentation was 120 minutes (min-max 15 minutes-2 weeks). RSI indications were trauma (n=5), mass (n=4), ventriculoperitoneal shunt dysfunction (n=1), refractory status epilepticus (n=1). All patients had focal neurological deficits on examination. The median value of Glasgow coma scale scores of the patients was 8 (min-max 4-15). The first neuroimaging method was cranial tomography in ten (90.9%) patients. Intracranial hemorrhage was present in 45.4% (5 patients) of the patients. No complications were observed in any of the patients during rapid sequence intubation application. One patient each died due to intracranial hemorrhage and shunt dysfunction. Neurological deficits (dysarthria, gait disturbance, hemiparesis, visual impairment) were detected in five patients during their first month follow-up. Conclusion: This retrospective study identified critically ill children who were admitted to the emergency department with acute neurological symptoms and underwent RSI to prevent increased intracranial pressure and further brain damage.

Factors Associated with the Underuse of Sedatives and Neuromuscular Blocking Agents for Pediatric Emergency Endotracheal Intubation in Korea

PURPOSE

Rapid sequence intubation (RSI) using sedatives and neuromuscular blocking agents (NMBAs) is recommended for pediatric emergency endotracheal intubation (ETI), but is not frequently performed in Korea. This study aimed to verify factors associated with the underuse of RSI medications.

MATERIALS AND METHODS

This multicenter retrospective study reviewed patients aged under 18 years who underwent an ETI within 24 hours of arrival at the emergency department between 2016 and 2019. Any cases of ETI during cardiopulmonary resuscitation were excluded. We investigated the characteristics of the patients, intubators, RSI medications, and outcomes. The study cases were classified into no-medication, sedative-only, and sedative-with-NMBA groups. Multivariable logistic regression analysis of RSI medication use was conducted.

RESULTS

A total of 334 cases with a median age of 3.4 years were included in this study. Sedatives and NMBAs were used in 63.8% and 32.9%, respectively. In comparing the no-medication (n=121), sedative-only (n=103), and sedative-with-NMBA (n=110) groups, patient age (median; 1.0 year vs. 2.8 years vs. 11.3 years; p<0.001), underlying medical conditions (77.7% vs. 56.3% vs. 36.4%; p<0.001), and pediatricians as intubators (76.9% vs. 54.4% vs. 17.3%; p<0.001) were different. The factors that influenced sedatives with NMBA use were patient age [for a year increment; adjusted odds ratio (aOR), 1.182; 95% confidence interval (CI), 1.120-1.249], no underlying medical conditions (aOR, 2.109; 95% CI, 1.093-4.070), and intubators other than pediatricians (aOR, 5.123; 95% CI, 2.257-11.626).

CONCLUSION

RSI accounted for 32.9% of pediatric emergency ETI in Korea. The underuse of RSI medications is associated with younger patient age, underlying medical conditions, and pediatricians as intubators.

Incidence of Bradycardia and the Use of Atropine in Pediatric Rapid Sequence Intubation in the Emergency Department

OBJECTIVE

Bradycardia during rapid sequence intubation (RSI) is an uncommon but serious adverse effect encountered in pediatric intubations. Atropine has historically been used in the pediatric population as RSI premedication to prevent bradycardia, especially when using succinylcholine as an induction agent. The objective of this analysis was to identify the incidence of bradycardia with or without atropine use.

METHODS

This single-center, retrospective, observational case series reviewed pediatric patients up to 18 years old requiring intubation from January 1, 2015, to December 31, 2018. Bradycardia was determined by analyzing heart rates associated with time during and up to 5 minutes after intubation.

RESULTS

A total of 62 patients were included. Three (4.8%) patients experienced a bradycardic event during intubation. A total of 15 (24.2%) patients received atropine for pretreatment of RSI. Incidence of bradycardia was similar between those who received atropine and those who did not. An increasing trend in atropine use was shown throughout the assessment period, yet only 18 (29%) patients met criteria for atropine pretreatment based on the 2015 Pediatric Advanced Life Support guideline recommendations for RSI.

CONCLUSION

Bradycardia incidence was low in pediatric patients undergoing RSI in our emergency department. Use of atropine or succinylcholine did not affect the incidence of bradycardia during pediatric intubation over this study period. Our results show a low incidence of bradycardia and support the 2015 Pediatric Advanced Life Support Guideline recommendation of limiting the use of atropine premedication in pediatric intubations.

Asystole during Suspension Laryngoscopy: Case Report, Literature Review, and Prophylactic Strategies

Transoral laryngeal procedures are considered minimally invasive but may trigger important complications such as severe bradycardia and even asystole mediated by vagal reflex. The literature on this subject is rare. This article aims to review the literature, explain associated mechanisms, establish prophylactic strategies, and highlight the importance of intraoperative safety protocols.

Process conformance is associated with successful first intubation attempt and lower odds of adverse events in a paediatric emergency setting

BACKGROUND

Intubation is an essential, life-saving skill but associated with a high risk for adverse outcomes. Intubation protocols have been implemented to increase success and reduce complications, but the impact of protocol conformance is not known. Our study aimed to determine association between conformance with an intubation process model and outcomes.

METHODS

An interdisciplinary expert panel developed a process model of tasks and sequencing deemed necessary for successful intubation. The model was then retrospectively used to review videos of intubations from 1 February, 2014, to 31 January, 2016, in a paediatric emergency department at a time when no process model or protocol was in existence.

RESULTS

We evaluated 113 patients, 77 (68%) were successfully intubated on first attempt. Model conformance was associated with a higher likelihood of first attempt success when using direct laryngoscopy (OR 1.09, 95% CI 1.01 to 1.18). The use of video laryngoscopy was associated with an overall higher likelihood of success on first attempt (OR 2.54, 95% CI 1.10 to 5.88). Thirty-seven patients (33%) experienced adverse events. Model conformance was the only factor associated with a lower odds of adverse events (OR 0.94, 95% CI 0.88 to 0.99).

CONCLUSIONS

Conformance with a task-based expert-derived process model for emergency intubation was associated with a higher rate of success on first intubation attempt when using direct laryngoscopy and a lower odds of associated adverse events. Further evaluation of the impact of human factors, such as teamwork and decision-making, on intubation process conformance and success and outcomes is needed.

Pediatric Life Support Update: 2015 American Heart Association Highlights

Despite improving survival rates for pediatric cardiac arrest victims, they remain strikingly low. Evidence for pediatric cardiopulmonary resuscitation is limited with many areas of ongoing controversy. The American Heart Association provides updated guidelines for life support based on comprehensive reviews of evidence-based recommendations and expert opinions. This facilitates the translation of scientific discoveries into daily patient care, and familiarization with these guidelines by health care providers and educators will facilitate the widespread, consistent, and effective care for patients.

Singapore Paediatric Resuscitation Guidelines 2016

We present the revised 2016 Singapore paediatric resuscitation guidelines. The International Liaison Committee on Resuscitation's Pediatric Taskforce Consensus Statements on Science and Treatment Recommendations, as well as the updated resuscitation guidelines from the American Heart Association and European Resuscitation Council released in October 2015, were debated and discussed by the workgroup. The final recommendations for the Singapore Paediatric Resuscitation Guidelines 2016 were derived after carefully reviewing the current available evidence in the literature and balancing it with local clinical practice.

Studying the Safety and Performance of Rapid Sequence Intubation: Data Collection Method Matters

OBJECTIVE

We sought to describe and compare chart and video review as data collection sources for the study of emergency department (ED) rapid sequence intubation (RSI).

METHODS

This retrospective cohort study compares the availability and content of key RSI outcome and process data from two sources: chart and video data from 12 months of pediatric ED RSI. Key outcomes included adverse effects (oxyhemoglobin desaturation, physiologic changes, inadequate paralysis, vomiting), process components (number of laryngoscopy attempts, end-tidal CO₂ detection), and timing data (duration of preoxygenation and laryngoscopy attempts).

RESULTS

We reviewed 566 documents from 114 cases with video data. Video review detected higher rates of adverse effects (67%) than did chart review (46%, p < 0.0001), identifying almost twice the rate of desaturation noted in the chart (34% vs. 18%, p = 0.0002). The performance and timing of key RSI processes were significantly more reliably available via video review (timing and duration of preoxygenation, as well as timing, duration, and number of laryngoscopy attempts, all p < 0.05). Video review identified 221 laryngoscopy attempts, whereas chart review only identified 187.

CONCLUSIONS

When compared with video review for retrospective study of RSI in a pediatric ED, chart review significantly underestimated adverse effects, inconsistently contained data on important RSI process elements, rarely provided time data, and often conflicted with observations made on video review. Interpretation of and design of future studies of RSI should take into consideration the quality of the data source.

Current medication practice and tracheal intubation safety outcomes from a prospective multicenter observational cohort study

OBJECTIVES

Tracheal intubation in PICUs is often associated with adverse tracheal intubation-associated events. There is a paucity of data regarding medication selection for safe tracheal intubations in PICUs. Our primary objective was to evaluate the association of medication selection on specific tracheal intubation-associated events across PICUs.

DESIGN

Prospective observational cohort study.

SETTING

Nineteen PICUs in North America.

SUBJECTS

Critically ill children requiring tracheal intubation.

INTERVENTIONS

None.

MEASUREMENT AND MAIN RESULTS

Using the National Emergency Airway Registry for Children, tracheal intubation quality improvement data were prospectively collected from July 2010 to March 2013. Patient, provider, and practice characteristics including medications and dosages were collected. Adverse tracheal intubation-associated events were defined a priori. A total of 3,366 primary tracheal intubations were reported. Adverse tracheal intubation-associated events occurred in 593 tracheal intubations (18%). Fentanyl and midazolam were the most commonly used induction medications (64% and 58%, respectively). Neuromuscular blockade was used in 92% of tracheal intubation with the majority using rocuronium (64%) followed by vecuronium (20%). Etomidate and succinylcholine were rarely used (1.6% and 0.7%, respectively). Vagolytics were administered in 37% of tracheal intubations (51% in infants; 28% in > 1 yr old; p < 0.001). Ketamine was used in 27% of tracheal intubations but more often for tracheal intubations in patients with unstable hemodynamics (39% vs 25%; p < 0.001). However, ketamine use was not associated with lower prevalence of new hypotension (ketamine 8% vs no ketamine 14%; p = 0.08).

CONCLUSIONS

In this large, pediatric multicenter registry, fentanyl, midazolam, and ketamine were the most commonly used induction agents, and the majority of tracheal intubations involved neuromuscular blockade. Ketamine use was not associated with lower prevalence of hypotension.

Pediatric critical care

Care of the ill and injured child requires knowledge of unique pediatric anatomic and physiologic differences. Subtleties in presentation and pathophysiologic differences impact management. This article discusses pediatric resuscitation, the presentation and management of common childhood illness, pediatric trauma, and common procedures required in the critically ill child.

Remifentanil for endotracheal intubation in premature infants: A randomized controlled trial

Objective:

Endotracheal intubation is a common procedure in neonatal care. The objective of this study was to determine whether the premedication with remifentanil before intubation has analgesic effects in newborn infants.

Methods:

A total of 40 premature infants who needed endotracheal intubation for intubation-surfactant-extubation method were randomly assigned in two groups of an equal number at two university hospitals. The control group was given 10 μg/kg atropine IV infusions in 1 min and then 2 ml normal saline. In the case group, the atropine was given with the same method and then remifentanil was administered 2 μg/kg IV infusions in 2 min.

Findings:

For remifentanil and control groups, the mean birth weight were 1761 ± 64 and 1447 ± 63 grams (P = 0.29), and the mean gestational ages were 31.69 ± 3.5 and 30.56 ± 2.8 weeks (P = 0.28), respectively. Using premature infant pain profile score, infants who received remifentanil felt significantly less pain than the control group (15.1 ± 1.6 vs. 7.5 ± 1.4; P < 0.001). There were no significant differences in the duration of endotracheal intubation procedure (20.8 ± 6 vs. 22.8 ± 7.3 s; P = 0.33), the number of attempts for successful intubation and oxygen desaturation between groups.

Conclusion:

Premedication with remifentanil has good analgesic effects for endotracheal intubation in premature infants without significant derangements in mean blood pressure and oxygen saturation.

Estimating 'lost heart beats' rather than reductions in heart rate during the intubation of critically-ill children

Purpose

Reductions in heart rate occur frequently in children during critical care intubation and are currently considered the gold standard for haemodynamic instability. Our objective was to estimate loss of heart beats during intubation and compare this to reduction in heart rate alone whilst testing the impact of atropine pre-medication.

Methods

Data were extracted from a prospective 2-year cohort study of intubation ECGs from critically ill children in PICU/Paediatric Transport. A three step algorithm was established to exclude variation in pre-intubation heart rate (using a 95%CI limit derived from pre-intubation heart rate variation of the children included), measure the heart rate over time and finally the estimate the numbers of lost beats.

Results

333 intubations in children were eligible for inclusion of which 245 were available for analysis (74%). Intubations where the fall in heart rate was less than 50 bpm were accompanied almost exclusively by less than 25 lost beats (n = 175, median 0 [0–1]). When there was a reduction of >50 bpm there was a poor correlation with numbers of lost beats (n = 70, median 42 [15–83]). During intubation the median number of lost beats was 8 [1]–[32] when atropine was not used compared to 0 [0–0] when atropine was used (p<0.001).

Conclusions

A reduction in heart rate during intubation of <50 bpm reliably predicted a minimal loss of beats. When the reduction in heart rate was >50 bpm the heart rate was poorly predictive of lost beats. A study looking at the relationship between lost beats and cardiac output needs to be performed. Atropine reduces both fall in heart rate and loss of beats. Similar area-under-the-curve methodology may be useful for estimating risk when biological parameters deviate outside normal range.

Drug utilization pattern in critical care unit in a tertiary care teaching hospital in India

Aims:

The aim of this study is to evaluate the drug utilization pattern and pharmacoeconomic analysis in critical care unit (CCU).

Materials and Methods:

Indoor case papers of patients admitted in CCU between January 2008 and December 2010 were analyzed for demographic variables; indications; duration of CCU stay; proportion of common drugs used. Use of antimicrobials was evaluated based on the culture report and empirical regimen used. Defined daily dose (DDD)/100 bed-days were calculated. Various World Health Organization prescribing indicators were evaluated. Cost of drugs was calculated from Indian Drug Review (2010).

Results:

A total of 397 cases were evaluated with a mean age of 44.62 years (95% confidence interval [CI]: 42.56-46.69). Average duration of CCU stay was 4.15 days (95% CI: 3.79-4.51). The average number of drugs prescribed per patient was 13.54 (95% CI: 13.05-14.04). Total drug utilization in terms of DDD/100 bed-days was 226.27. Metronidazole, cefotaxime, atropine, adrenaline, dopamine, dobutamine, deriphyllin, ranitidine, metoclopramide and furosemide were prescribed in more than 30% cases. Number of antimicrobials prescribed per patient was 2.50 (95% CI: 2.37-2.66). Cefotaxime + metronidazole (26.70%) were the most common empirical regimen used. Average cost of treatment per patient was Rs 3225.70 (95% CI: 2749.8-3701.6). Higher economic burden was noted among expired patients and admitted due to medical + surgical indication (P < 0.05).

Conclusion:

Poly-pharmacy and use of antimicrobials without culture report is a common problem in CCU.

Pathology influences blood pressure change following vagal stimulation in an animal intubation model

Purpose

The haemodynamic response to critical care intubation is influenced by the use of sedation and relaxant drugs and the activation of the vagal reflex. It has been hypothesized that different disease states may have a contrasting effect on the cardiovascular response to vagal stimulation. Our objective was to determine whether the blood pressure response to vagal stimulation was modified by endotoxaemia or hypovolaemia.

Methods

New Zealand White rabbits were anaesthetised with urethane before tracheotomy. The exposed left Vagus nerve of randomised groups of control (n = 11), endotoxin (n = 11, 1 mg/kg), hypovolaemia 40% (n = 8) and hypovolaemia 20% (n = 8) rabbits were subjected to 10 Hz pulsed electrical stimulations of 25 s duration every 15 min. Haemodynamic parameters were recorded from a catheter in the right carotid artery connected to an iWorx monitor. Serum catecholamines were measured every 30 min using reverse-phase ion-pairing liquid chromatography. The change in blood pressure after vagal stimulation was compared to controls for one hour after the first death in the experimental groups.

Results

29% of the rabbits died in the hypovolaemia 40% group and 27% in the endotoxin group. One rabbit died in the hypovolaemia 40% group before vagal stimulation and was excluded. Following electrical stimulation of the Vagus nerve there was a fall in blood pressure in control rabbits. Blood pressure was conserved in the hypovolaemic rabbits compared to controls (p<0.01). For the endotoxaemic rabbits, there was a non-significant trend for the mean blood pressure to decrease more than the controls. Serum catecholamines were significantly raised in both the hypovolaemic and endotoxaemic rabbits.

Conclusions

Pathology may contribute to modifications in blood pressure when vagal activation occurs. Patients who are either already vasoconstricted, or not vasoplegic, may be less at risk from intubation-related vagally mediated reductions in blood pressure than those with vasodilatory pathologies.

The effect of atropine on rhythm and conduction disturbances during 322 critical care intubations

OBJECTIVES

Our objectives were to describe the prevalence of arrhythmia and conduction abnormalities before critical care intubation and to test the hypothesis that atropine had no effect on their prevalence during intubation.

DESIGN

Prospective, observational study.

SETTING

PICU and pediatric/neonatal intensive care transport.

SUBJECTS

All children of age less than 8 years intubated September 2007-2009. Subgroups of intubations with and without atropine were analyzed.

INTERVENTION

None.

MEASUREMENT AND MAIN RESULTS

A total of 414 intubations were performed in the study period of which 327 were available for analysis (79%). Five children (1.5%) had arrhythmias prior to intubation and were excluded from the atropine analysis. Atropine was used in 47% (152/322) of intubations and resulted in significant acceleration of heart rate without provoking ventricular arrhythmias. New arrhythmias during intubation were related to bradycardia and were less common with atropine use (odds ratio, 0.14 [95% CI, 0.06-0.35], p < 0.001). The most common new arrhythmia was junctional rhythm. Acute bundle branch block was observed during three intubations; one Mobitz type 2 rhythm and five ventricular escape rhythms occurred in the no-atropine group (n = 170). Only one ventricular escape rhythm occurred in the atropine group (n = 152) in a child with an abnormal heart. One child died during intubation who had not received atropine.

CONCLUSIONS

Atropine significantly reduced the prevalence of new arrhythmias during intubation particularly for children over 1 month of age, did not convert sinus tachycardia to ventricular tachycardia or fibrillation, and may contribute to the safety of intubation.

Atropine for critical care intubation in a cohort of 264 children and reduced mortality unrelated to effects on bradycardia

Background

Atropine has is currently recommended to facilitate haemodynamic stability during critical care intubation. Our objective was to determine whether atropine use at induction influences ICU mortality.

Methodology/Principal Findings

A 2-year prospective, observational study of all first non-planned intubations, September 2007–9 in PICU and Intensive Care Transport team of Hôpital Robert Debré, Paris, 4 other PICUs and 5 NICUs in the Paris Region, France. Follow-up was from intubation to ICU discharge. A propensity score was used to adjust for patient specific characteristics influencing atropine prescription. 264/333 (79%) intubations were included. The unadjusted ICU mortality was 7.2% (9/124) for those who received atropine compared to 15.7% (22/140) for those who did not (OR 0.42, 95%CI 0.19–0.95, p = 0.04). One child died during intubation (1/264, 0.4%). Two age sub-groups of neonates (≤28 days) and older children (>28 days, <8 years) were examined. This difference in mortality arose from the higher mortality in children aged over one month when atropine was not used (propensity score adjusted OR 0.22, 95%CI 0.06–0.85, p = 0.028). No effect was seen in neonates (propensity score adjusted OR 1.3, 95%CI 0.31–5.1 p = 0.74). Using the propensity score, atropine maintained the mean heart rate 45.9 bpm above that observed when no atropine was used in neonates (95%CI 34.3–57.5, p<0.001) and 43.5 bpm for older children (95%CI 25.5–61.5 bpm, p<0.001).

Conclusions/Significance

Atropine use during induction was associated with a reduction in ICU mortality in children over one month. This effect is independent of atropine’s capacity to attenuate bradycardia during intubation which occurred similarly in neonates and older children. This result needs to be confirmed in a study using randomised methodology.

Critical airway skills and procedures

Airway management is a critical procedure and essential skill necessary for all physicians working in the emergency department. Optimal resuscitative treatment of medical and trauma patients often revolves around timely and effective airway interventions that can be challenging in the acute setting, especially in critical patients. Time-honored airway techniques and procedures combined with recent advances in rapid sequence intubation, video laryngoscopy, and further advanced airway techniques now offer emergency clinicians a wide range of exciting new options for improving this crucial component of acute care and management.

Asystole following Reintubation during Suspension Laryngoscopy

Transient increase in heart rate and mean arterial pressure commonly occur during manipulation of the airway via direct laryngoscopy. This phenomenon is understood to be due to a sympathetic nervous system reflex causing an increase in plasma catecholamines. Rarely, severe bradycardia and possible asystole can occur following laryngoscopy. One previous report described asystole during suspension laryngoscopy after uneventful direct laryngoscopy. Here we report a case of asystole occurring at the time of reinsertion and cuff inflation of an endotracheal tube in a patient who had been hemodynamically stable during initial direct laryngoscopy and the ensuing suspension laryngoscopy. The asystole was immediately recognized and successful cardiopulmonary resuscitation was performed with the patient returning to baseline sinus rhythm. Cardiac arrest following laryngoscopy is rare. This case highlights the importance of continued vigilance even after the initial manipulations of the airway by both direct laryngoscopy and suspension laryngoscopy are to be performed. Identifying patients who may benefit from premedication with a vagolytic drug may prevent adversity. Preoperative heart rate analysis can identify patients with strong vagal tone.

Rapid sequence intubation for pediatric emergency patients: higher frequency of failed attempts and adverse effects found by video review

STUDY OBJECTIVE

Using video review, we seek to determine the frequencies of first-attempt success and adverse effects during rapid sequence intubation (RSI) in a large, tertiary care, pediatric emergency department (ED).

METHODS

We conducted a retrospective study of children undergoing RSI in the ED of a pediatric institution. Data were collected from preexisting video and written records of care provided. The primary outcome was successful tracheal intubation on the first attempt at laryngoscopy. The secondary outcome was the occurrence of any adverse effect during RSI, including episodes of physiologic deterioration. We collected time data from the RSI process by using video review. We explored the association between physician type and first-attempt success.

RESULTS

We obtained complete records for 114 of 123 (93%) children who underwent RSI in the ED during 12 months. Median age was 2.4 years, and 89 (78%) were medical resuscitations. Of the 114 subjects, 59 (52%) were tracheally intubated on the first attempt. Seventy subjects (61%) had 1 or more adverse effects during RSI; 38 (33%) experienced oxyhemoglobin desaturation and 2 required cardiopulmonary resuscitation after physiologic deterioration. Fewer adverse effects were documented in the written records than were observed on video review. The median time from induction through final endotracheal tube placement was 3 minutes. After adjusting for patient characteristics and illness severity, attending-level providers were 10 times more likely to be successful on the first attempt than all trainees combined.

CONCLUSION

Video review of RSI revealed that first-attempt failure and adverse effects were much more common than previously reported for children in an ED.

The role of the emergency pharmacist in trauma resuscitation

The clinical pharmacist in the emergency department is now commonly incorporated as a member of the emergency department trauma team. As such, the emergency pharmacist needs to have detailed knowledge of the pharmacotherapy of resuscitation and be able to apply the skills needed to function as a valuable member of this team. In addition to the traditional skills of the discipline of clinical pharmacy, the emergency pharmacist must be familiar with the intricacies of treating life-threatening injuries in an emergent setting and be able to anticipate the direction of the patient's care. The ability to provide valuable pharmacological interventions throughout the resuscitation and stabilization process requires familiarity with the process of resuscitation, including rapid sequence induction, analgesia and sedation, seizure prophylaxis, appropriate antibiotic and tetanus prophylaxis, intracranial pressure control, hemodynamic stabilization, and any other specific drug therapy that the clinical situation demands. This article discusses the aforementioned pharmacotherapeutic topics and describes the role of the Emergency Pharmacist on the ED trauma team.

Rapid sequence intubation in the neonate

Rapid sequence intubation (RSI) is premedication prior to intubation that includes atropine, a sedative, and a neuromuscular blockage. Rapid sequence intubation is infrequently performed in neonates despite evidence that it is safe and effective. Neonates that experience endotracheal intubation often display apnea and cardiac arrhythmias, decreased or obstructed nasal airflow, increased systolic blood pressure, and decreased heart rate and transcutaneous oxygen tension. Infants can also experience increased anterior fontanel pressure, which can place them at greater risk for intraventricular hemorrhage. Rapid sequence intubation has been shown to facilitate better intubation conditions including no movement from the infant and better visualization of the airway. Infants receiving RSI were successfully intubated twice as fast as infants who were not premedicated. Infants with premedication also had fewer changes in baseline heart rate. Neonatal RSI can be easily and safely performed in the neonate. Knowledge and skill allow for the best conditions when intubating the infant. Future research must focus on the best combination of medications for RSI in the neonate.

Challenges and advances in intubation: airway evaluation and controversies with intubation

Management of the airway is the first priority in any patient. Dealing with a difficult airway can be a challenge, whether or not it involves facemask ventilation, an intermediate airway device, laryngoscopy and intubation, or a surgical airway. Various scales predict which patient is likely to have a difficult airway. The goal of rapid sequence intubation (RSI) is to eliminate or mitigate untoward reflex responses to intubation. Although controversy has arisen regarding the various steps in RSI, it remains an essential component of emergency medicine practice.

Controversies in rapid sequence intubation in children

PURPOSE OF REVIEW

Rapid sequence intubation is the method of choice for intubation of the emergency department patient. The purpose of the present review is to address several controversies pertaining to emergency department rapid sequence intubation of children.

RECENT FINDINGS

The topics covered in this review include the determination of the appropriate clinician to perform emergency department intubation, the use of atropine and lidocaine as premedications, the choice of sedative agents depending upon the clinical scenario, and the choice of neuromuscular blockade agent. Concerning these topics: The literature supports that emergency department physicians, with appropriate training, successfully perform intubation in most patients. Limited data exist to determine the appropriate use of atropine and lidocaine for rapid sequence intubation. Etomidate has clearly become a preferred sedative for rapid sequence intubation with a low risk of cardiovascular side effects. Thiopental and propofol may more readily provide adequate sedation as compared with etomidate but both have the potential to reduce blood pressure. Succinylcholine arguably remains the preferred neuromuscular blockade agent for rapid sequence intubation in most children. The side effects of succinylcholine occur in relatively predictable circumstances. Rocuronium is a commonly used nondepolarizing paralytic agent but its prolonged duration of action must be weighed against the risk of side effects associated with succinylcholine.

SUMMARY

Though more research is needed, the available data allow for the development of protocols that will result in a rational, scenario-based approach to rapid sequence intubation in children.