UMEM Educational Pearls - By Cathya Olivas Michels

Several studies have described factors associated with peri-intubation cardiac arrest in the adult population. Factors such as pre-intubation hypotension, elevated BMI, and elevated shock index (HR/SBP) have been associated with cardiac arrest following intubation in adult ED patients. Given the differences in anatomy and physiology in children, one may expect risk factors for peri-intubation cardiac arrest to differ in children.

A number of studies have examined factors associated with peri-intubation cardiac arrest in the pediatric population, but these have remained limited to the inpatient setting. These studies have found that, in hospitalized and PICU patients, the factors of hemodynamic instability, hypoxemia, history of difficult airway, pre-existing cardiac disease, and higher number of intubation attempts are associated with peri-intubation cardiac arrest. A paucity of literature exists on this airway complication in pediatric ED patients.

Pokrajac et al. provide the first study on risk factors for peri-intubation cardiac arrest in pediatric ED patients. These authors conducted a retrospective nested case-control study of pediatric patients (ages <18 years) who presented to a tertiary children’s hospital in San Diego from 2009-2017. Cases included patients who had a cardiac arrest within 20 minutes after the start of endotracheal intubation. Authors selected a number of predictors to examine, including age-adjusted hemodynamic variables, capillary refill, pulse oximetry, patient characteristics, intubation-related factors, and pre-intubation interventions.

The authors found the following:

-       Demographic characteristics:

o   Patients with peri-intubation cardiac arrest were significantly younger (<1 year of age), shorter, and more likely to have history of preexisting pulmonary disease.

-       Incident characteristics:

o   Patients with peri-intubation cardiac arrest were more likely to have:

       -Low or unobtainable SBP or DBP

       -Delayed capillary refill time

       -Low (<92%) or unobtainable pre-intubation SpO2

        -More than 1 intubation attempt than controls

        -No paralytic or sedative agent prior to intubation

o   Patients with peri-intubation cardiac arrest were NOT more likely to have increases in age-adjusted HR or pediatric shock index in comparison to controls.

o   The strongest clinical predictor for peri-intubation cardiac arrest was pre-intubation hypoxia or unobtainable SpO2. This fact is supported by children’s increased metabolic rate and thus increased oxygen consumption. This physiologic finding explains the shorter amount of time it takes children to develop acute hypoxia, particularly in the peri-intubation setting.

Bottom line: If planning to intubate a pediatric patient in the ED, keep in mind that pre-intubation systolic or diastolic hypotension, delayed capillary refill time, multiple intubation attempts, and hypoxia in particular may increase the risk for peri-intubation cardiac arrest. Consider providing apneic oxygenation to minimize hypoxemia prior to intubation.

Show References

Acute appendicitis is the most common etiology requiring urgent abdominal surgery in children in the United States. Peak incidence occurs in the second decade of life, with male patients being more commonly affected than female patients. Classic manifestations of appendicitis occur in school-aged children and adolescents, but are often absent in younger children. Infants and young children <5 years are more likely to present with nonspecific or atypical findings, resulting in delays in diagnosis and higher rates of perforation.

Diagnosis is aided by clinical factors, lab findings, and ultrasound (+/- CT or MRI if ultrasound is equivocal).

Historically, the standard of care for acute appendicitis has been urgent operative management. However, in the past several years, there has been increasing literature supporting nonoperative management (antibiotics only) in adult patients with acute uncomplicated appendicitis. Additionally, there is a growing body of evidence demonstrating the safety and efficacy of nonoperative management for uncomplicated appendicitis in children.

Hartford and Woodward provide a review of the current literature on the nonoperative management of uncomplicated appendicitis in children. They conclude:

-       The majority of recent prospective studies demonstrate early treatment success (0-30 days) of approximately 90% in pediatric patients undergoing nonoperative management.

-       Factors associated with failure of nonoperative management in pediatric appendicitis: longer duration of symptoms (>48 hours), younger age (<5 years), and presence of appendicolith.

-       Nonoperative management has been associated with

o   Lower healthcare costs at 1 year

o   Fewer disability days at 1 year

o   No significantly different rate of complicated appendicitis

-       Most trials to date involve a 24-48 hour initial course of broad spectrum IV antibiotics followed by oral antibiotics for a total of >/= 7 days as nonoperative management. Currently, there is no consensus on antibiotic regimen.

Bottom Line: Given the current evidence, nonoperative management may be a viable treatment option for low risk pediatric patients with uncomplicated appendicitis. The literature is not conclusive, thus we as medical providers in conjunction with our surgical colleagues, should consider numerous factors when discussing treatment options for acute appendicitis with patients and their families.

Show References


Every year, numerous children die of non-exertional heatstroke after being left in motor vehicles in the United States. Per data obtained from the national nonprofit, the average number of pediatric vehicular heatstroke deaths is 39 per year since 1990. In 2018, this number peaked at 54 pediatric deaths. Prior studies show that the interior temperature of a closed vehicle rises quickly within minutes of closing the doors and windows. This rapid change occurs even on days with cooler ambient temperatures (20s °C/70s °F): the interior temperature of a car may still reach 117F within an hour.

Children, particularly infants and toddlers, are at increased risk for heat illness due to several physiologic and developmental factors:

-       Unable to escape hot environments or to self-hydrate

-       Lack mature thermoregulatory systems

o   Have lower rate of sweat production than adults

-       Have higher basal metabolic rates than adults

-       Have higher body surface area:mass ratio --> absorb heat faster in hot environments

Bottom line:  ED providers can be instrumental in giving anticipatory guidance on vehicular heatstroke in children during the warmer seasons:

-        Educate caregivers to “Look before you Lock”

-       Suggest that the caregiver place a valuable object (phone, employee badge, handbag) in the back seat when traveling with a child

-       Remind caregiver of the dangers of intentionally leaving a child in the car for any reason, even during cooler spring/summer days.

Show More In-Depth Information

Show References


Hammett._Pediatric_Heatstroke_Fatalities_Caused_by_Being_Left_in_Cars.pdf (581 Kb)