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Back of the Bus – Should Paramedics Intubate Kids?

Brian Moore MD and Darren Braude, MD
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18:31
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Nurses Edition Commentary

Mizuho Spangler, DO, Lisa Chavez, RN, and Kathy Garvin, RN
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03:30

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EM:RAP 2015 May Written Summary 1 MB - PDF

We think that intubation is the gold standard for airway management. That may not always be the case for kids

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Mike J., M.D. -

While the point is probably moot, I remain disappointed in the continued reliance on the San Diego study as support for the theory that Paramedics shouldn't intubate children. I ageee that we have better supraglottic techniques to use, but that doesn't excuse us from examining the San Diego study and it's lack of applicability to the real world. Mean transport time of 6 minutes? Maximum IQR of 9 minutes? I would argue that NO ONE should be intubated 6 minutes fromthe hospital! This study cannot be extrapolated to the real world. In my world, average transport times are closer to 20-30 minutes. And while Dr. Moore quotes a 20 minute time, no such data is available in the original article. I am glad that we live in a time whrere alternate airways exist for children and shudder to think how many children were harmed by the inappropriate application of the findings od the San Diego study.

Andrew B. -

Firstly, I agree with Mike J, with transport times being so short, the appropriateness of the decision to intubate has to be questioned in some pt cohorts.

The article cited by Gausche et al is not good evidence that paediatric intubation should not be performed by paramedics. It is however, evidence that poorly trained paramedics with resultant (and likely expected) high complication rates will result in detrimental effects in a paediatric population.

Good results could not be expected in a study where only 77% of intubations had CO2 detection (but weren't uniformly maintained throughout transport) and there was such a high rate of ETT dislodgement, where suspicion being the pt was oesophageally intubated initially, but only recognised at hospital.

If there was a study done with high success rates and no unrecognised oesophageal intubations or ETT dislodgment issues, with there still being a difference in outcome, then a discussion about paed intubation by paramedics should be had.

The Gausche article should not change practice.

Erik G., EMT-P -

What other manuscripts were considered in the journal club referenced during this segment? Although I'm all for transitioning most medics to a rescue airway device, if for no other reason then maintenance of an extremely low volume/high risk skill, the other logic presented for removal of pediatric intubation is concerning. If we have unrecognized esophageal intubations, regardless of whether it was from a bad initial placement or displacement during transport, would it not make more sense to also mandate continuous waveform EtCO2 on all intubated patients?

Darren B., M.D. -

Sorry for the delay. Here is a response from Dr. Moore:

First is was LA/Orange County not San Diego, but that's not relevant. Mike is correct in the transport times but I completely disagree with his opinion on "how many children were harmed by the inappropriate application of the findings". The data would support that there was no increased harm in the the BVM group, but rather the opposite- they did better.
The last two comments by Andrew and Erik can be addressed by Marianne's slides from one of her talks. Many of those articles were used as supporting articles for the changes:
http://gatheringofeagles.us/2013/Friday/Gausche-Hill-PrehospitalPediIntubation.pdf

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A Totally Mental Month of Education! Full episode audio for MD edition 285:23 min - 332 MB - M4AEM:RAP 2015 May Canadian Edition Canadian 17:44 min - 24 MB - MP3EM:RAP 2015 Peut Résumé en Francais Français 59:38 min - 82 MB - MP3EM:RAP 2015 Mayo Resumen Español Español 74:07 min - 85 MB - MP3EM:RAP 2015 May Aussie Edition Australian 62:22 min - 86 MB - MP3EM:RAP 2015 May MP3 329 MB - ZIPEM:RAP 2015 May Written Summary 1 MB - PDFEM:RAP 2015 May Board Review Answers 415 KB - PDFEM:RAP 2015 May Board Review Questions 416 KB - PDFEM:RAP Español Mayo 2015 1 MB - PDF

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