Oh $#!+ It's a Baby: Preparing Your Community Emergency Department for Safe Pediatric Intubation

Pediatric intubation is a high-acuity, low-frequency procedure in both tertiary pediatric and general EDs. Physiologic and anatomic differences in pediatric airways, alongside the relative infrequency of intubation, can make pediatric intubation challenging, with lower rates of first-pass success and higher rates of complications than in adult patients. As an EM and PEM physician who practices in a tertiary pediatric ED as well as general and critical access EDs, I'd like to share a few lessons about pediatric intubation that EM physicians can apply to safely perform this critical procedure in any ED. First, I'll start with a deidentified case: a toddler with a head injury who went into cardiac arrest during what was supposed to be a routine intubation. In this case, the stress of caring for a sick child caused the team to rush intubation preparation, and not adequately preoxygenate the patient. When the attending was unable to pass the endotracheal tube after several attempts, the child became hypoxic and subsequently went into cardiac arrest. How do we avoid this? I will briefly discuss pediatric physiology and best practices for preoxygenation, apneic oxygenation, RSI medications, duration of intubation attempts, and considerations for the pediatric high-risk physiologic intubation. Next, I will outline the anatomic challenges of pediatric intubation, including patient positioning and bag-valve mask ventilation optimization. I will also briefly mention the possibility of avoiding intubation altogether - some pediatric patients with respiratory failure may only require a brief period of high-quality bag-valve mask ventilation to reverse their pathology. After that, I will discuss equipment, including video laryngscope blade considerations, the importance of cuffed endotracheal tubes, and the emergence of pediatric supraglottic airways for both primary and rescue airway management. Finally, I will show pictures that demonstrate three common challenges in pediatric endotracheal tube delivery: inability to get a view of the vocal cords, inability to reach the relatively anterior cords with the endotracheal tube, and inability to deliver the endotracheal tube due to resistance from the anterior tracheal cartilage. Each image will be accompanied by solutions to these challenges. I will conclude with the following pediatric intubation learning points: 1. Avoid it if possible 2. Don't rush your preparation 3. Know your equipment 4. Troubleshoot the common errors: can't get a view, can't reach the cords, can't pass the tube