A 3-year-old involved in an RTC has a significant head injury and suspected abdominal injury. They are cardio vascularly unstable, has a fluctuating GCS, and requires intubation. The child is in the resus room and you are planning for intubation…. Who do you need? What do you need? What might go wrong? Is this the right place to do this?
Intubation in the paediatric emergency department is scary stuff. For critically ill children who require intubation, it is rarely practised outside of the critical care unit. With the centralisation of services there are reduced opportunities for these skills to be practised. Those working in DGHs may have fewer chances to practice these skills – and when they do it may be in an emergency situation.
This can be aided by collaboration with paediatric retrieval teams who can provide distanced advice for those in a non-tertiary setting until the retrieval team arrives. However, the overall management can be still on the local team. A recent article by Kanaris et al. aims to give tips on how to provide a safe, rapid successful intubation along with some of the common pitfalls and how to overcome them (which has formed the basis of this post).
Kanaris C, Murphy PCFifteen-minute consultation: Intubation of the critically ill child presenting to the emergency departmentArchives of Disease in Childhood – Education and Practice Published Online First: 19 August 2021. doi: 10.1136/archdischild-2021-322520
The 3Ps- Planning | Preparation | Procedure
It is important that the right planning takes place even in an emergency situation. A lot of things need to happen quickly. Take a look at a rough timeline of the intubation process…
The first step should focus on training and simulation of these procedures – ideally in any of the locations mentioned above.
Resuscitate before you intubate
Intubating the critically ill child is a risky procedure. Induction has a very real chance of causing cardiac arrest on induction. This is even more likely if the child has not been properly resuscitated.
Administration of fluids (10mls/kg aliquots – up to 40-60mls/kg) in children who are hypotensive and tachycardic, or blood in children who have had blood loss is important. As per the new resus council guidance balanced isotonic crystalloids, e.g, Plasmalyte, are now the first choice. Peripheral inotropic support may also be required with adrenaline/noradrenaline.
A summary of the new resus council guidance can be found here.
In the child who is shocked gaining IV access is likely to be tricky – IO access can be a quick, easy and effective alternative. This can be seen as a temporary ‘central access’ which can be particularly useful in ED resus. Central line placement in this environment can take time and may distract the team from other priority actions.
What drugs should you use?
Like many things in paediatrics, there isn’t a ‘perfect’ drug or combination of drugs for anaesthesia in an emergency setting.
The combination that is advocated and relied upon by critical care teams is Ketamine (1-2mg/kg) (+/- Fentanyl 1.5 microgram/kg) and Rocuronium (1mg/kg).
Anaesthetists who may be more familiar with adults might be used to using drugs like propofol or thiopentone. These both have significant vasodilatory effects and should really only be reserved for children WITHOUT any signs of SHOCK.
Adult colleagues may also be more at home with using suxamethonium than rocuronium. Suxamethonium works rapidly providing paralysis in 30-60 seconds. It works fast but does not last long (2-6mins), it can also cause bradycardia and potassium release.
Rocuronium, when used in the right dose, can have a fairly similar onset of action (40-60 seconds) without the unwanted side effects. Rocuronium can also be reversed if required with sugammadex if needed.
Having emergency drugs ready prior to intubation in the event of deterioration should be part of your preparation.
Location, location, location
The move from the ED to theatres to facilitate intubation can be a daunting one. This may be preferable due to familiarity with equipment and space of the intubating team, potentially more space, and the ability to use anaesthetic gases in the case of a difficult airway. Some equipment e.g. video laryngoscope may also be more readily available in CCU/ Theatres.
However, there is always the risk of potential deterioration on the journey from resus to somewhere else. Having been stuck in a lift with a critically unstable child, it is not a desirable position to be in. If, as a team, the decision is made to transfer the patient, careful planning about who and what you may need in terms of personnel and equipment is essential. Ensuring monitoring: pulse oximetry, ECG, cycling NIBP and of course as per the new resus council guidance capnography in place prior to moving is crucial.
A reminder on capnography….
A poor workman blames their tools… But you need to make sure you have the right ones.
In a time-critical emergency situation, with a newly-put-together team, having the right equipment is vital. An intubation checklist allows individuals to gather the appropriate equipment without an individual needing to take this on as a cognitive load. There are lots of examples of intubation equipment checklists. Take a look in the references for some examples.
In addition to having an intubation checklist, it is a good idea to have a checklist that acts as a sort of WHO sign-in/out sheet which may incorporate the equipment needed.
What size endotracheal tube?
Cuffed tubes are the gold standard in critically unwell children >3kg.
It’s not one size fits all…
Oxygenation, oxygenation and more oxygenation.
When it comes to oxygenating the patient before or between intubation attempts, a standard bag-valve-mask or anaesthetic circuit can be used. Something to consider may be placing the child on high flow humidified oxygen (100%) via HFNC to improve oxygenation before and between attempts. If this takes too long or the nasal apparatus affects the seal of the face mask, then don’t do it. The aim is for 3 minutes of pre-oxygenation prior to intubation – in younger/ sicker children the chance of apnoeic desaturation is high as they hover on the critical cliff off of the oxygen-haemoglobin dissociation curve.
It’s important to have an NGT that can be aspirated frequently is important to reduce a full stomach (either of stomach content or air) and prevent splinting the diaphragm, as well as reducing the risk of aspiration.
‘Oxygenation’ not ‘intubation’ is the ultimate goal
Always remember the primary goal – to oxygenate the patient. Take a step back, if necessary to remind yourself and the team of the ultimate goal. You may be able to oxygenate via simpler methods and thus avoid multiple intubation attempts.
‘The Vortex technique’ can be useful as a visual aid to remind the team to take a step back. You can maintain an airway with adjuncts and bagging a patient can be done until more help arrives.
Teamwork makes the dream work
Having a well drilled and skilled team is the dream. In reality, we know this may not always be the case. Brief introductions with clarification of roles and a brief action plan (including a plan B, C and even D) if things don’t go exactly as planned are useful. Make it clear who is leading and transfer leadership briefly during the intubation itself if required. Allocate a member of the team to keep an eye on the clock during intubation. This can prevent the intubator from becoming too ‘task focused’. Again ‘oxygenation’, not ‘intubation’ is the ultimate goal here.
As with any high-risk procedure, simulation is essential, coupled with a debrief after the event itself has occurred to see what bits worked well and what learning points can be made.
Selected references
Some free Intubation Checklist resources are as follows. Thanks to the DFTB community for signposting to these useful checklists:
https://kids.bwc.nhs.uk/wp-content/uploads/2021/02/Pre-Intubation-Checklist-V25Final.pdf
Paediatric resuscitation tools | Queensland Paediatric Emergency Care (health.qld.gov.au)
Airway Plan & Kit Dump – KI Doc (kidocs.org)
Anandi Singh, Jilly Boden and Vicki Currie. 2021 Resuscitation Council UK Guidance: What’s new in paediatrics?, Don’t Forget the Bubbles, 2021. Available at: https://doi.org/10.31440/DFTB.33450
The Vortex Method: http://vortexapproach.org/downloads– Lots of really useful information/ printouts that could be used on a resus trolley!
Thank you for sharing this insightful article on the challenges of intubating critically unwell children in the emergency department. As a concerned reader, I appreciate the recognition of the scarcity of opportunities to practice this crucial skill outside of critical care units due to the centralization of services. It’s indeed a daunting task that requires expertise and precision.”
Love the infographics. Atropine dose needs to be amended from 600->20mcg/kg
Great work here.
Congratulations to this article.