Can We Predict Which Children Will Arrest Soon After Intubation in the ED?

Carolyn K. Holland, MD, Med, FACEP, FAAP


Hypoxia prior to intubation strongly predicts post-intubation cardiac arrest in pediatric patients.


To identify risk factors for postintubation cardiac arrest in children, these authors retrospectively examined 543 endotracheal intubations performed at a single pediatric emergency department over 9 years. They conducted a nested case-control study of the 21 patients (3.9%) who had a cardiac arrest within 20 minutes after intubation and 84 randomly selected controls without cardiac arrest.


Reason for intubation, intubator’s specialty or level of training, medications used to facilitate intubation, and time of day did not differ between the two groups. Infants aged 1 to 12 months accounted for 38% of the cardiac arrest cases. Median time to cardiac arrest was 5 minutes. Return of spontaneous circulation was achieved in 16 patients (76%), 12 of whom survived to hospital discharge. Children who arrested were significantly younger and more likely to have existing lung disease, but there were no significant differences in sex, weight, or cardiac, genetic, or congenital diseases.


Factors significantly associated with peri-intubation cardiac arrest included abnormal or unobtainable pulse oximetry (odds ratio, 66.6), delayed capillary refill (OR, 20.5), abnormally low or unobtainable systolic (OR, 17.3) or diastolic blood pressure (OR 14.3), and more than one attempt at intubation (OR, 5.3).


We always prepare for an arrest when intubating a patient. Being able to identify children at higher risk will allow physicians to plan for and potentially prevent an arrest. I am going to be especially wary of infants with preexisting lung disease or who are hypoxic, making sure to maximize oxygenation in all patients prior to intubation (via noninvasive positive pressure ventilation, bag-valve-mask, or passive oxygenation via nasal cannula). Finally, consider having code medications out and drawn up in these high-risk intubations; trying to calculate weight-based epinephrine dosing can be difficult in the stress of a resuscitation.


Pokrajac N et al. Risk factors for peri-intubation cardiac arrest in a pediatric emergency department. Pediatr Emerg Care 2020 Jun 22; [e-pub].



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