Prehospital endotracheal intubations in vitally comprised children in The Netherlands

Introduction

The reason for the study was to evaluate prehospital endotracheal intubations of vitally compromised children. The data studied were collected by a Dutch Helicopter-transported Medical Team (HMT) that provides advanced medical care in the eastern part of The Netherlands. The HMT consists of a specially trained physician and paramedic transported to the incident location by helicopter in day-time. The Dutch HMT is activated together with the emergency medical service (EMS) by the dispatch centre, or by the EMS paramedics from the incident location. Activation of the HMT is according to a structured list of incident situations and/or the medical condition of the patient.

Design

Retrospective analysis of 297 HMT calls for prehospital vitally comprised children (<16 years) from 2001 to 2005 by the HMT-Netherlands-East. Registered data included age, sex, physiological parameters, prehospital treatment given, and survival until hospital discharge.

Endotracheal intubation was performed by either the EMS paramedic or the HMT physician. Intubation was confirmed by the HMT physician with auscultation and capnography. For descriptive analysis, the Fischer exact test and relative risk were used on SPSS. P ≤ 0.05 was considered significant.

Results

The EMS on scene cancelled the paediatric HMT calls before the landing of the helicopter in 36% (n = 107) – reasons: no serious injury 82% (n = 88), deceased 10% (n = 11), other 8% (n = 8). The HMT examined and treated 190 children on scene. The EMS paramedic attempted an endotracheal intubation in 33 patients before the arrival of the HMT, and the HMT physician performed 89 endotracheal intubations. The success rate of endotracheal intubation for EMS paramedics was 70% (n = 23) and for the HMT physician 100% (n = 89) (P < 0.001).

The HMT physician checked the endotracheal intubation and ventilation on arrival by auscultation and capnography; an emergency correction had to be performed by the HMT physician in 10 out of 33 patients. Four patients had an oesophageal intubation, four patients had an inappropriate sized endotracheal tube making ventilation impossible, and two patients had lethal ventilator settings. Two of these 10 patients were discharged from the hospital in good condition, the others died at the incident scene or in the hospital.

Thirty-three per cent (n = 65) of all patients had an initial prehospital Glasgow Coma Scale (GCS) of 3 or 4. The overall survival rate until hospital discharge with an initial GCS of 3 or 4 was 23% (n = 14). The survival rate until hospital discharge with a GCS of 3 or 4 was 6.5% (n = 2) for the EMS-intubated group, and 40% (n = 12) for the HMT-intubated group (Fischer exact P = 0.007).

Conclusion

Successful endotracheal intubation is a difficult task for EMS paramedics; 30% of all recorded endotracheal intubations resulted in potentially lethal complications. Mask-balloon ventilation is to be preferred to a failed intubation effort; prehospital endotracheal intubation of children calls for an experienced physician.