Peri-Intubation Arrest in High Risk vs. Standard Risk Pediatric Trauma Patients Undergoing Endotracheal Intubation

Background: While the anatomically difficult airway has been studied in pediatric trauma patients, physiologic risk factors are poorly understood. Our objective was to evaluate if previously published high risk physiologic criteria for difficult airway in medical patients is associated with adverse outcomes in pediatric trauma patients. Methods: This was a retrospective chart review of patients ≤18 years with traumatic injuries who underwent endotracheal intubation (EI) in a pediatric emergency department (PED) between 2016 and 2021. High risk criteria evaluated included 1) hypotension, 2) concern for cardiac dysfunction, 3) persistent hypoxemia, 4) severe metabolic acidosis (pH < 7.1), 5) post–return of spontaneous circulation. Our primary outcome was peri-intubation cardiac arrest, defined as cardiac arrest within 10 minutes of EI. Secondary outcomes included in-hospital cardiac arrest and mortality and first pass EI success. Results: One third (n = 32; 36.4%) of the 88 patients analyzed had at least one high risk criteria. When compared to the standard risk group, those in the high risk group had a higher incidence of peri-intubation arrest (28.1% vs. 0%, difference: 28.1%, 95% CI: 10.1–46.2), PED/in-hospital arrest (43.8% vs. 3.4%, difference: 38.4%, 95% CI: 17.8–59.0) and in-hospital mortality (33.4% vs. 3.6%, difference: 29.8%, 95% CI: 8.4–46.9). Having multiple high risk criteria progressively increased the odds of post-intubation PED/in-hospital cardiac arrest (1 risk factor: OR = 6.7, 95% CI: 1.5–30.2; 2 risk factors: OR = 12.5, 95% CI: 2.3–70.0; ≥ 3 risk factors: OR = 56.1, 95% CI: 6.0–523.8). Conclusions: The presence of high risk physiologic criteria is associated with increased incidence of peri-intubation, in-hospital arrest, and death in pediatric trauma patients. Children with multiple risk factors are at an incremental risk of cardiac arrest.