Pediatric emergency medicine trisk 0163 0163
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where their directors thought exposure was insufficient (five cases per faculty per
year) and those where their directors thought exposure was sufficient (seven cases
per faculty per year). Data from tertiary PEDs have similarly shown lowfrequency exposure to TI for PED faculty, with fewer than half of PED faculty
performing TI during a year of typical clinical experience, and supervising TI
performance a median of four times per year.
Published data on exposure to pediatric TI among trainees in pediatrics and
pediatric EM also show scant—and possibly diminishing—experience. Multiple
studies have shown that pediatric residents are exposed to opportunities for
attempting TI less often. A study of video-recorded TI attempts from a tertiary
PED demonstrated success rates of 33% for residents and 50% for PEM fellows.
Multihospital registry data on pediatric TI in the ICU have shown a significant
positive association between residents attempting TI and the occurrence of
adverse events. In 2013, the Accreditation Council for Graduate Medical
Education removed nonneonatal TI from the core competencies for house staff
training in pediatrics.
Finally, while historically reported as uncommon, physiologic deterioration
during intubation may be more common than previously appreciated in children.
In the previously mentioned study of video-recorded cases of pediatric emergency
intubation, oxyhemoglobin desaturation (defined as pulse oximetry of <90%)
occurred in up to one-third of cases of emergency TI in the PED. Cardiovascular
instability (bradycardia, hypotension) has been noted to occur in up to 8% of
patients, with cardiac arrest from asphyxia occurring in 2%. This combination of
high clinical risk, infrequent occurrence, and dwindling exposure among trainees
has led to widespread reconsideration of what operators are appropriate to
perform TI in the PED. Careful attention should be paid to training exposure and
cumulative clinical experience among personnel in the PED who may be required
to perform TI on children.
Bridging the gap between the infrequent nature of TI and the need for ongoing
skill maintenance is a challenge to be met as PEM moves forward. Multiple novel
approaches to this challenge have been reported in published literature. The use
of retrospective review of TI data from individual centers and multicenter
databases, both from medical records and from video-recorded patient
encounters, has been reported as a technique to identify areas for improvement.
Simulation education is well suited to this uncommon, high-stakes procedure;
data on the effectiveness of simulation in educational and affective outcomes
(e.g., learner satisfaction) have been promising, but additional research is
