Emergency intubation of children outside of the operating room.

Intubation of children outside of the operating room is performed infrequently and is often associated with life-threatening adverse events. This review aims to clarify the contributors to adverse events encountered during intubations outside of the operating room and provide preventative strategies. The primary contributors to adverse events during non-operating room intubations are physiologically and situationally difficult airways; anatomically difficult airways are rare. Systems-based changes, including a shared mental model, standardization in equipment and its location, checklist use, physiological resuscitation prior to resuscitation, dose titration of induction agent, multi-disciplinary team training in the technical and nontechnical aspects of non-operating room intubation, debrief post-real and simulated events, and regular audit of performance all reduce life-threatening intubation-related adverse events in children. Intubation of children outside of the operating room may be performed safely through engagement of all critical care specialties, shared learning, and focus on patient-centered care delivery.

Early experience in use of videolaryngoscopy by a neonatal pre-hospital and retrieval service.

OBJECTIVE: To describe initial experience with use of the Glidescope Go videolaryngoscope by an Australian neonatal pre-hospital and retrieval service. METHODS: We conducted a 31-month retrospective review of an airway registry for neonates intubated by MedSTAR Kids clinicians. RESULTS: Twenty-two patients were intubated using the Glidescope Go, compared with 50 using direct laryngoscopy. First-pass success was 17/22 (77.3%) with the Glidescope Go and 38/50 (76%) with direct laryngoscopy. Complications occurred in 7/22 (32%) and 8/50 (16%), respectively. CONCLUSIONS: On initial review of this practice change, videolaryngoscopy allows neonatal tracheal intubation with a comparable success rate to direct laryngoscopy in a pre-hospital and retrieval setting.

Defining normal ranges and centiles for heart and respiratory rates in infants and children: a cross-sectional study of patients attending an Australian tertiary hospital paediatric emergency department.

OBJECTIVE: Key components in the assessment of a child in the emergency department (ED) are their heart and respiratory rates. In order to interpret these signs, practitioners must know what is normal for a particular age. The aim of this paper is to develop age-specific centiles for these parameters and to compare centiles with the previously published work of Fleming and Bonafide, and the Advanced Paediatric Life Support (APLS) reference ranges. DESIGN: A retrospective cross-sectional study. SETTING: The ED of the Children's Hospital at Westmead, Australia. PATIENTS: Afebrile, Triage Category 5 (low priority) patients aged 0-15 years attending the ED. INTERVENTIONS: Centiles were developed using quantile regression analysis, with cubic B-splines to model the centiles. MAIN OUTCOME MEASURES: Centile charts were compared with previous studies by concurrently plotting the estimates. RESULTS: 668 616 records were retrieved for ED attendances from 1995 to 2011, and 111 696 heart and respiratory rates were extracted for inclusion in the analysis. Graphical comparison demonstrates that with heart rate, our 50th centile agrees with the results of Bonafide, is considerably higher than the Fleming centiles and fits well between the APLS reference ranges. With respiratory rate, our 50th centile was considerably lower than the comparison centiles in infants, becomes higher with increasing age and crosses the lower APLS range in infants and upper range in teenagers. CONCLUSIONS: Clinicians should consider adopting these centiles when assessing acutely unwell children. APLS should review their normal values for respiratory rate in infants and teenagers.

Identifying incidents of suboptimal care during paediatric emergencies-an observational study utilising in situ and simulation centre scenarios.

AIM: Life threatening paediatric emergencies are relatively uncommon events. When they do occur staff caring for these children must have the ability to recognise the deterioration, evaluate and simultaneously treat these patients. The aim of this study was to identify suboptimal care during standardised simulated scenarios and to identify the potential causation factors. METHODS: Participants were emergency department and operating theatre staff in Sydney, Australia. Incidents of suboptimal care were identified during scenarios and were analysed by thematic qualitative assessment methods. Potential causation factors were elicited both during and immediately after the scenarios and during facilitated debriefings. Causation factors were attributed to any of seven pre-defined categories. RESULTS: Seventy-three simulations occurred over 9 month period in 2011. 270 doctors, 235 nurses and 11 students participated. 194 incidents of suboptimal care were observed and attributed to 325 causation factors. There were 76 knowledge deficits, 39 clinical skill deficits, 36 leadership problems, 84 communication failures, 20 poor resource utilisations, 23 preparation and planning failures and 47 incidents of a loss of situational awareness. Clinically important themes were: paediatric life support, drug choice and doses, advanced airway and ventilation, intravenous fluids and recognition of the deteriorating patient. Recurring incidents included the failure to recognise a cardiac arrest, inadequate fluid resuscitation and incorrect medication dose administration. CONCLUSIONS: During standardised paediatric simulations multiple incidents of suboptimal care have been identified and multiple causation factors attributed to these. Educators should use this information to adapt current training programs to encompass these factors.

Triggers for head computed tomography following paediatric head injury: Comparison of physicians' reported practice and clinical decision rules.

OBJECTIVE: To compare head computed tomography (CT) triggers for paediatric head injury as reported by senior paediatric emergency physicians in Australia and New Zealand with triggers in published evidence-based clinical decision rules (CDRs). METHODS: A survey of CT triggers after head injury was distributed to senior emergency physicians at PREDICT (Paediatric Research in Emergency Departments International Collaborative) sites in Australia and New Zealand. Results were compared with recommendations for CT scans in CATCH, CHALICE and PECARN CDRs. Clinical practice guidelines (CPGs) from each site were also reviewed. RESULTS: The response rate was 93% (130/140). No published trigger for head CT was identified by 100% of survey participants and each CDR included several triggers not identified by many respondents. Abnormal examination findings, including depressed skull fracture and base of skull fracture, were most likely to prompt respondents to order a head CT (>90%). A concerning mechanism of injury, such as a fall greater than 3 feet or five stairs, triggered a CT response only in approximately 10% of respondents. Eight different head injury CPGs were used across the 13 PREDICT sites. These were highly variable between sites and CPGs were not explicitly based on published CDRs. CONCLUSION: High-quality, published CDRs exist for head CT use after paediatric head injury. Physician-reported CT triggers differ from CDR-recommended triggers. The major published head injury CDRs should be prospectively validated in the Australasian setting before incorporating them into local practice and CPGs.