California — Targeted Issue

Author(s)/Presenter(s)

M Gausche, R J Lewis, S J Stratton, B E Haynes, C S Gunter, S M Goodrich, P D Poore, M D McCollough, D P Henderson, F D Pratt, J S Seidel

Abstract/Description

Context: Endotracheal intubation (ETI) is widely used for airway management of children in the out-of-hospital setting, despite a lack of controlled trials demonstrating a positive effect on survival or neurological outcome.

Objective: To compare the survival and neurological outcomes of pediatric patients treated with bag-valve-mask ventilation (BVM) with those of patients treated with BVM followed by ETI.

Design: Controlled clinical trial, in which patients were assigned to interventions by calendar day from March 15, 1994, through January 1, 1997.

Setting: Two large, urban, rapid-transport emergency medical services (EMS) systems.

Participants: A total of 830 consecutive patients aged 12 years or younger or estimated to weigh less than 40 kg who required airway management; 820 were available for follow-up.

Interventions: Patients were assigned to receive either BVM (odd days; n = 410) or BVM followed by ETI (even days; n = 420).

Main outcome measures: Survival to hospital discharge and neurological status at discharge from an acute care hospital compared by treatment group.

Results: There was no significant difference in survival between the BVM group (123/404 [30%]) and the ETI group (110/416 [26%]) (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.61-1.11) or in the rate of achieving a good neurological outcome (BVM, 92/404 [23%] vs ETI, 85/416 [20%]) (OR, 0.87; 95% CI, 0.62-1.22).

Conclusion: These results indicate that the addition of out-of-hospital ETI to a paramedic scope of practice that already includes BVM did not improve survival or neurological outcome of pediatric patients treated in an urban EMS system.

Author(s)/Presenter(s)

Gausche M

Abstract/Description

No abstract available

Author(s)/Presenter(s)

Marianne Gausche, Deborah Parkman Henderson, Dena Brownstein, George L. Foltin

Abstract/Description

In the last ten years there has been considerable interest in the development of curricula in pediatric emergency care for out-of-hospital emergency medical personnel.1-4 At the same time, there has been notable controversy in regard to the design and content of the curricula. Traditionally paramedic instruction has been diagnosis-driven: emergency medical services (EMS) educators had instructed out-of-hospital providers by modifying the “medical school” approach and incorporating information based on the scope of practice of the out-of-hospital provider. Although there are few data evaluating current educational methods, many instructors and students have found the diagnosis-based approach impractical for providers in the out-of-hospital setting when implemented in the field setting. The reasons for this are multifactorial and may include the following: 1) establishing a diagnosis in the field is problematic because physical assessment may be hampered by the unpredictable ambient conditions (poor lighting, increased noise, and inclement weather) and safety issues (gunfire or criminal activity); 2) few cost-effective, portable diagnostic resources are available for field use; and 3) the provider spends a limited time with the patient. The solution to this educational dilemma has been the development of the educational strategy that is assessment-based with management schemes driven by the clinical presentation of the patient. The advantages of the assessment-based approach are 1) it is a simple, easy-to-teach method that can be taught to basic and advanced levels of providers and 2) it allows for subsequent management strategies to be based on patient assessments and not a list of possible diagnoses. The disadvantage is that some educators believe it may be too simple and that by deemphasizing diagnoses, this educational method will decease the ability of the out-of-hospital and in-hospital-based providers to communicate information about the patient quickly.