Pediatric Intubation by Paramedics in a Large Emergency Medical Services System: Process, Challenges, and Outcomes Matthew E. Prekker, MD, MPH*; Fernanda Delgado, BS; Jenny Shin, MPH; Heemun Kwok, MD; Nicholas J. Johnson, MD; David Carlbom, MD; Andreas Grabinsky, MD; Thomas V. Brogan, MD; Mary A. King, MD, MPH; Thomas D. Rea, MD, MPH *Corresponding Author. E-mail: matthew.prekker@hcmed.org. Study objective: Pediatric intubation is a core paramedic skill in some emergency medical services (EMS) systems. The literature lacks a detailed examination of the challenges and subsequent adjustments made by paramedics when intubating children in the out-of-hospital setting. We undertake a descriptive evaluation of the process of out-of-hospital pediatric intubation, focusing on challenges, adjustments, and outcomes. Methods: We performed a retrospective analysis of EMS responses between 2006 and 2012 that involved attempted intubation of children younger than 13 years by paramedics in a large, metropolitan EMS system. We calculated the incidence rate of attempted pediatric intubation with EMS and county census data. To summarize the intubation process, we linked a detailed out-of-hospital airway registry with clinical records from EMS, hospital, or autopsy encounters for each child. The main outcome measures were procedural challenges, procedural success, complications, and patient disposition. Results: Paramedics attempted intubation in 299 cases during 6.3 years, with an incidence of 1 pediatric intubation per 2,198 EMS responses. Less than half of intubations (44%) were for patients in cardiac arrest. Two thirds of patients were intubated on the first attempt (66%), and overall success was 97%. The most prevalent challenge was body fluids obscuring the laryngeal view (33%). After a failed first intubation attempt, corrective actions taken by paramedics included changing equipment (33%), suctioning (32%), and repositioning the patient (27%). Six patients (2%) experienced peri-intubation cardiac arrest and 1 patient had an iatrogenic tracheal injury. No esophageal intubations were observed. Of patients transported to the hospital, 86% were admitted to intensive care and hospital mortality was 27%. Conclusion: Pediatric intubation by paramedics was performed infrequently in this EMS system. Although overall intubation success was high, a detailed evaluation of the process of intubation revealed specific challenges and adjustments that can be anticipated by paramedics to improve first-pass success, potentially reduce complications, and ultimately improve clinical outcomes. [Ann Emerg Med. 2015;-:1-10.] Please see page XX for the Editor’s Capsule Summary of this article. 0196-0644/$-see front matter Copyright © 2015 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2015.07.021 INTRODUCTION Background Airway management is a hallmark of pediatric emergency care, given the frequent involvement of the respiratory system in acute critical illness. The optimal timing and setting for invasive airway management (ie, intubation) in critically ill children is unclear. 1,2 Intubation by paramedics, if successful, allows early, controlled oxygenation and ventilation through a patent airway that can also protect against aspiration. However, emergency care systems must weigh these potential benefits against potential complications of pediatric intubation. Challenges to achieving proficiency in pediatric intubation include inadequate training, infrequent opportunities to perform pediatric intubation, anatomic differences in the pediatric versus the adult airway, inappropriately sized equipment, unfamiliar drug dosing, and the unpredictable out-of-hospital environment. 3-5 In the largest clinical trial evaluating pediatric intubation by paramedics, bag-valve-mask ventilation resulted in comparable patient survival and neurologic outcomes compared with intubation, with attempted intubation delaying transport to a hospital in an urban EMS system. 6 Importance Many EMS systems consider pediatric intubation a core paramedic skill. 7,8 And yet substantial variability in the use of pediatric intubation exists among US EMS systems. Moreover, overall intubation success in the out-of-hospital setting has ranged from 57% to 98%, whereas unrecognized esophageal intubation has occurred in 1% to 3% of cases. 9-13 Volume -, no. - : - 2015 Annals of Emergency Medicine 1 PEDIATRICS/ORIGINAL RESEARCH