Feasibility of laryngeal mask airway use by prehospital personnel in simulated pediatric respiratory arrest.

INTRODUCTION: Pediatric respiratory arrest is a technically challenging scenario infrequently faced by prehospital providers. Prehospital endotracheal intubation (ETI) is a complex procedure, and one study showed that it may result in worse neurological outcome in these patients. Alternatives to ETI include bag-valve-mask (BVM) ventilation and the laryngeal mask airway (LMA). Although the LMA has been used successfully for pediatric resuscitation in the hospital setting, there is no data describing its use in the prehospital setting. HYPOTHESIS: Prehospital providers can successfully place and ventilate the pediatric LMA in a simulated pediatric respiratory arrest. METHODS: Paramedic students received a 1-hour training session covering the use of the pediatric LMA. Subjects performed airway management of a simulator manikin using both the LMA and the BVM. Rate of successful LMA placement, time to first ventilation, tidal volume by weight, and ventilations per minute were recorded. A generalized estimating equation analysis was completed to determine the effects of time and ventilation technique. RESULTS: All 13 subjects (100%) successfully ventilated the mannequin with both techniques. The median number of attempts required to successfully place the LMA was one. Median time from the start of the scenario to BVM ventilation was 4 seconds (IQR 3, 5), and the median for LMA ventilation was 30 seconds (IQR 25, 52). Tidal volumes were significantly greater with BVM ventilation (5.07 mL/kg [IQR 4.47, 5.43]) than with LMA ventilation (2.88 mL/kg [IQR 2.17, 4.04]). An obvious air leak was present in all LMA cases, potentially resulting in reduced tidal volume delivery. Excessive ventilatory rates were noted in both BVM (42 ventilations per minute [IQR 33, 46]) and LMA (37 ventilations per minute [IQR 31, 39]) groups. CONCLUSIONS: Prehospital providers were able to place and ventilate a simulated pediatric respiratory arrest patient using the LMA after a brief educational intervention. Obvious air leakage was noted when ventilating with the LMA and likely represents one technical limitation of using a simulator.

Use of etomidate as an induction agent for rapid sequence intubation in a pediatric emergency department.

OBJECTIVES: Although etomidate is widely used for rapid sequence intubation (RSI), there is no consensus on the optimal induction agent and no prospective pediatric emergency department (ED) study exists. The objective of this study was to assess the effectiveness and safety of etomidate as an induction agent for RSI in the pediatric ED. METHODS: Data on RSI conditions and complications were collected prospectively on patients undergoing RSI in a tertiary pediatric ED from January 2003 to December 2003. ED hemodynamic data and inpatient data were collected retrospectively via chart review. RESULTS: Seventy-seven of 101 patients requiring intubation underwent RSI with etomidate. The mean (+/- SD) age was 8.2 (+/- 6.2) years. All 77 patients were successfully intubated. Intubation condition data were available for 69 of 77 patients (89.6%). Conditions were good in 68 of 69 (99%; 95% confidence interval = 92.2% to 99.9%). The mean (+/- SD) maximal percent decrease in systolic blood pressure was 10% (+/- 13.6%). A greater than 20% maximal percent decrease in systolic blood pressure occurred in 12 of 69 patients (17.4%; 95% confidence interval = 9.3% to 28.4%). There was no relationship between seizures after etomidate administration and prior seizure history (p = 0.25). Corticosteroids were given to 29 of 77 patients post-RSI for varying diagnoses. All eight patients given corticosteroids for shock were in shock at the time of intubation. CONCLUSIONS: In the pediatric ED setting, etomidate as an induction agent provided successful RSI conditions and resulted in varied hemodynamic changes that were especially favorable in those patients presenting in decompensated shock. Hypotension and seizures were uncommon and occurred in patients with confounding diagnoses. Until the significance of a single dose of etomidate on adrenal dysfunction is further clarified, caution should be used in those patients at risk for adrenal insufficiency.