Special Considerations for Pediatric Patients: Endotracheal Intubation

As an EMS provider, providing your patient with a secured airway is one of the most important skills you will perform in the field. Let’s face it, without a viable airway you won’t have a viable patient.

Prehospital endotracheal intubation is always a topic of discussion and research. If you google “prehospital endotracheal intubation success,” you will find a myriad of articles and research. Some are very good in terms of findings, some not so much. It’s on all of us to assure that prehospital airway management, which includes endotracheal intubation, remains a high priority in our training schedule. Endotracheal intubation is a skill that should be constantly practiced, whether you are a new paramedic or a veteran. Much like every skill in life, the more we practice, the better we become.

As you move through your career, you will discover that adult intubations happen fairly frequently. Luckily, the necessity to intubate a pediatric patient occurs much less frequently. While that is good news, it can be detrimental to the skillset of the paramedic that doesn’t practice enough. In fact, a JEMS article published in 2017 found that only 7-13% of EMS calls involve pediatric patients. The number of those requiring airway management is much smaller. The article also discusses a study in which the authors looked at success rates of pediatric intubation. Paramedics in this study had a 97% success rate; however, first-pass success rates were around 66%.

Challenges Intubating a Pediatric Patient

Pediatric intubations bring a different set of challenges. To begin, the mindset of the provider is different. Anxiety rises and adrenaline flows just a little heavier when treating a critically ill pediatric patient. Sometimes this can be a detriment to the prehospital provider. It’s important to find ways to keep your mind in check in these high-stress environments. Although it may seem cliche, we have to remember to take a deep breath, stay focused, and remember our protocols.

Another challenging factor for the prehospital provider is anatomy. While the actual “pieces” of the pediatric airway are the same as an adult, the anatomy is far different. We must remember that the tongue is proportionally larger than that of an adult. The trachea is much more pliable and can be likened to that of a straw. If it is positioned incorrectly, it will occlude. It’s important that we position our pediatric patient correctly. Padding under the shoulders is a must when managing a pediatric airway because of the proportionally larger head, and we want our patient in a “sniffing” position.

As you prepare for the intubation, remember to do certain things to make it easier on yourself:

• Use a Broselow tape, pediatric wheel, Handtevy system, etc. These are extremely valuable tools that will quickly guide you throughout the process.
• Communication is essential. Use effective communication techniques with your team so that everyone understands what their role will be during the process. When everyone knows their job duties, the task will be accomplished with efficiency.
• Have all of your equipment ready BEFORE you begin—this includes your intubation equipment, your suction equipment, and your monitoring equipment.
• Remember to always have a plan B in mind. If this intubation attempt fails, you and your team will know exactly what the next step will be.

References

• An Overview of EMS Pediatric Airway Management. JEMS. https://www.jems.com/2017/02/28/an-overview-of-ems-pediatric-airway-management/. Published 2017. Accessed March 31, 2021.
• Garza A, Gratton M, Coontz D, Noble E, Ma O. Effect of paramedic experience on orotracheal intubation success rates. J Emerg Med. 2003;25(3):251-256. doi:10.1016/s0736-4679(03)00198-7

Chris Troxell is a paramedic with 16 years of experience in EMS. Currently, Chris serves as the Emergency Department Director, Safety Officer, and Emergency Preparedness Coordinator for Critical Access Hospital in central Illinois.