Association Between Repeated Tracheal Intubation Attempts and Adverse Events in Children in the Emergency Department.

STUDY OBJECTIVES: Studies have shown that multiple intubation attempts are associated with a higher risk of intubation-related adverse events. However, little is known about the relationship in children in the emergency department (ED). METHODS: This is an analysis of the data from 2 prospective, observational, multicenter registries of emergency airway management. The data were collected from consecutive patients who underwent emergency airway management in 19 EDs across Japan from March 2010 to November 2017. We included children 18 years or younger who underwent tracheal intubation in the ED. The primary exposure was the number of intubation attempts (1 vs ≥2). The primary outcome was an adverse event during or immediately after the intubation. RESULTS: A total of 439 children were eligible for the analysis. Of 279 children with first-pass success, 24 children (9%) had an adverse event. By contrast, of 160 children with ≥2 intubation attempts, 50 children patients (31%) had an adverse event. In the unadjusted model, multiple intubation attempts were significantly associated with a higher rate of adverse events (unadjusted odds ratio, 4.83; 95% confidence interval, 2.57-9.06; P < 0.001). This association remained significant after adjusting for 7 potential confounders and patient clustering within the hospital (adjusted odds ratio, 4.49; 95% confidence interval, 2.36-8.53; P < 0.001). Similar associations were found across different age groups and among children without cardiac arrest (all, P < 0.05). CONCLUSIONS: In this analysis of large prospective multicenter data, multiple intubation attempts were associated with a significantly higher rate of intubation-related adverse events in children in the ED.

Extrapleural hematoma that was not detectable on initial CT in a patient with pneumonia.

Extrapleural hematoma (EH) is an uncommon and occasionally life-threatening condition. Huge EH can cause potentially fatal respiratory and circulatory disturbances. The usual causes of EH are chest trauma, iatrogenic injury, and rupture of a thoracic aortic aneurysm. There have been few reports of EH as a complication of pneumonia. Here we describe a case of EH that was not detectable on initial computed tomography (CT) in a patient with pneumonia despite symptoms suggestive of hemorrhage. A 70-year-old man who had been diagnosed with pneumonia the previous day visited our hospital after developing right upper abdominal pain of sudden onset. Initial noncontrast-enhanced computed tomography (CT) showed consolidation of the right lower lobe of the lung but no hematoma. He was discharged from hospital. When the pain recurred the following day, he was transported by ambulance back to our hospital and admitted. Contrast-enhanced CT showed an EH that had not been apparent on the initial CT scan taken 33 h earlier. Coagulation tests were within normal limits. He was treated conservatively and monitored closely. His symptoms improved, and he was discharged 4 days after admission. The EH did not enlarge and had almost disappeared by 56 days after admission. The pathophysiology of the relationship between pneumonia and EH is unclear. This case suggests that EH cannot be ruled out by initial CT findings soon after an episode suggestive of hemorrhage and can occur as a complication of pneumonia. Therefore, patients in whom EH is suspected should be followed up closely.