O1113: Basic Is Better? An Assessment of Outcomes in Pre-hospital Airway Management in Pediatric Trauma Across the United States

Background: Pediatric pre-hospital airway management in trauma is challenging with varying recommendations across the US. Pre-hospital orotracheal intubation in children is not recommended by the National Association of Emergency Medical Services (EMS) Physicians with failure rates up to 50%. The purpose of this study was to compare prehospital basic airway procedures (Basic-AP) versus advanced airway procedures (Advanced-AP), hypothesizing a difference in time at scene and rates of improvement in acuity from the scene to the Emergency Department (ED).

Methods: A retrospective study using 2020 National Emergency Medical Services Information System dataset was performed. Trauma patients aged 1-18 years who underwent pre-hospital airway procedures were included. Advanced-AP (esophageal combi- or dual-lumen tube, laryngeal mask airway (LMA), orotracheal intubation) were compared with Basic-AP (jaw thrust, chin lift, bag-mask ventilation, naso- or oropharyngeal airway). Outcomes were improvement in patient acuity (critical, emergent, low emergent) from EMS assessment at the scene to ED arrival and time from scene to ED arrival. Multivariable logistic regression models were used to examine change in acuity, adjusting for initial acuity, provider type, region and sociodemographic variables. Linear regression was used to assess time at scene, adjusting for age, race, gender, insurance status, initial acuity, urbanicity, and provider type.

Results: 5894 cases were identified (1859 A-AP vs 4035 B-AP), with 66 esophageal combi- or dual lumen tubes, 91 LMA, and 1702 orotracheal intubations (7.3% procedure failure rate overall). B-AP had an increased associated risk of improved patient acuity from scene to ED (OR 1.19, 95% CI 1.11-1.27; p< 0.001) after adjusting for acuity, provider type, urbanicity, time spent at scene, and demographic variables. Specifically, orotracheal intubation was associated with decreased odds of improvement in acuity (OR 0.82, 95% CI 0.76-0.89; p< 0.0001) compared to B-AP. Results of a linear regression model identified a 7-minute reduction in time at the scene in patients receiving B-AP compared to patients receiving A-AP (estimate: 7 minutes 6 seconds, 95% CI 9 minutes 36 seconds - 4 minutes 36 seconds; p< 0.001). When subgroup analysis of the region with the highest rate of A-AP utilization (Pacific, 70.8%) was performed, no significant associations between procedure type, time at scene, and improved acuity were detected. This region also had the lowest rate (4.9%) of procedure failure and the highest rate of improved patient acuity (65.7%) (p < 0.0001).

Conclusion: Pediatric trauma patient airway management is a challenge for pre-hospital providers. This national analysis demonstrates that when compared to A-AP, B-AP were associated with increased improvement even when adjusting for acuity and other factors. Furthermore, orotracheal intubation was associated with decreased odds of improving patient acuity when performed in the prehospital setting. Variability in airway management practices across US regions is high, leaving room for improvement in standardization of care and training.