Paramedic intubation training in a pediatric operating room.

The authors conducted a prospective study to assess the performance of paramedics with prior adult endotracheal intubation experience in pediatric intubation in the operating room of a teaching hospital. Nineteen paramedic students were observed attempting endotracheal intubation on a total of 57 anesthetized pediatric patients undergoing scheduled surgical procedures. The average age of patients was 5.1 years (range, 6 months to 15.2 years). Average duration of intubation attempts was 22.7 +/- 10.7 seconds, with a success rate on first attempt of 74%. Only minor complications occurred, and were limited to intubation attempts of greater than 45 seconds duration in four cases (6%), and patient oxygen saturation less than 90% in one case (2%). The study suggests that paramedics may be successfully incorporated into a hospital's clinical training program, and can receive closely supervised experience in pediatric endotracheal intubation without compromising patient care. Such training may increase the willingness of paramedics to attempt emergent prehospital endotracheal intubation of children, as well as increase their success with this potentially life-saving procedure.

Predictive value of oropharyngeal cultures for identifying lower airway bacteria in cystic fibrosis patients.

Identifying lower respiratory pathogens in young, non expectorating cystic fibrosis (CF) patients has been problematic. Bronchial secretions are difficult to obtain, and little is known about lower airway flora in these patients. We collected simultaneous bronchial and oropharyngeal specimens in 43 CF patients in optimal respiratory status, including both expectorating (17) and nonexpectorating (26) patients, to determine the predictive value of oropharyngeal cultures for identifying lower airway pathogens. An additional goal was to characterize the lower respiratory flora of these patients. Predictive values were defined as the proportion of oropharyngeal culture results that accurately reflected the results of bronchial cultures. Predictive values of positive oropharyngeal cultures in nonexpectorating patients were 83% (95% confidence interval 36 to 100%) for Pseudomonas aeruginosa and 91% (59 to 100%) for Staphylococcus aureus. Predictive values of negative oropharyngeal cultures were lower: 70% (48 to 86%) for R aeruginosa and 80% (52 to 96%) for S. aureus. A relatively high proportion of nonexpectorating CF patients less than 10 yr old had R aerusginosa (11 of 24, 46%) or Klebsiella species (5 of 24, 21%) in their lower airways. The isolation of Klebsiella was associated with younger age (p = 0.03) and recent administration of antistaphylococcal antibiotics (p = 0.05). Our results suggest that oropharyngeal cultures yielding R aeruginosa or S. aureus are highly predictive, but such cultures lacking these organisms do not rule out the presence of these pathogens in the lower airways of CF patients.

Diphtheria-tetanus-pertussis vaccine and serious neurologic illness: an updated review of the epidemiologic evidence.

A widespread impression that DTP vaccine does cause brain damage has been based first on historical precedent--smallpox and rabies vaccines were recognized as sometimes causing devastating neurologic illness; analogy to pertussis--the disease can cause encephalopathy; and more recently on anecdotal evidence, particularly case series. A noncausal relationship--coincidence--could explain the temporal relation between DTP vaccine and neurologic illness, inasmuch as DTP vaccine is given at the age of emergence of idiopathic neurologic disease. The relationship between DTP vaccine and neurologic illness lacks specificity. Case series have had an impact on both physicians' and the lay public's impression of the safety of pertussis vaccine greatly out of proportion to their scientific importance. Case series can be useful for generating hypotheses but cannot provide evidence that pertussis vaccine is causally related to acute neurologic illness or brain damage. Observational studies using cohort and ecologic designs did not find an association between DTP vaccine and serious neurologic illness, but they were not powerful enough to detect an association as rare as that observed by the NCES investigators. The case-control design offers the best chance of providing causal evidence regarding DTP vaccine and serious neurologic illness. The NCES is the only published case-control study of this issue. This study found a rare association between DTP vaccine and some types of acute neurologic illness. Bias and chance are unlikely to account entirely for the association demonstrated by the NCES. However, the association has not yet been replicated by other case-control studies. The NCES does not demonstrate that DTP vaccine causes permanent brain damage.

The NCES reconsidered: summary of a 1989 workshop. National Childhood Encephalopathy Study.

A 1989 workshop provided a forum for independent review of the National Childhood Encephalopathy Study (NCES). No official summary will be published. Workshop panelists noted: firstly, that the magnitude of the reported association between acute neurological illness and pertussis vaccine might have been overestimated because of bias, but bias was believed unlikely to account for all of the excess risk; and secondly that because of problems with study design and methodology, the NCES is not informative with regard to long-term outcome of acute neurological illness associated with recent diphtheria-tetanus-pertussis (DTP) vaccination. The workshop panel discouraged use of the NCES estimate of the attributable risk of persistent neurological damage.

Outcome and predictors of outcome in pediatric submersion victims receiving prehospital care in King County, Washington.

Predictors of outcome in pediatric submersion victims treated by Seattle and King County's prehospital emergency services were studied. Victims less than 20 years old were identified from hospital admissions and paramedic and medical examiners' reports. The proportion of fatal or severe outcomes in patients were compared with various risk factors. Of 135 patients, 45 died and 5 had severe neurologic impairment. A subset of 38 victims found in cardiopulmonary arrest had a 32% survival rate, with 67% of survivors unimpaired or only mildly impaired. The two risk factors that occurred most commonly in victims who died or were severely impaired were submersion duration greater than 9 minutes (28 patients) and cardiopulmonary resuscitation duration longer than 25 minutes (20 patients). Both factors were ascertained in the prehospital phase of care. Submersion duration was associated with a steadily increasing risk of severe or fatal outcomes: 10% risk (7/67) for 0 to 5 minutes, 56% risk (5/9) for 6 to 9 minutes, 88% risk (21/25) for 10 to 25 minutes, 100% risk (4/4) for greater than 25 minutes. None of 20 children receiving greater than 25 minutes of cardiopulmonary resuscitation escaped death or severe neurologic impairment. Our rates for saving all victims, particularly victims in cardiopulmonary arrest, are considerably higher than has been reported before the children. Prompt prehospital advanced cardiac life support is the most effective means of medical intervention for the pediatric submersion victim. Prehospital information provided the most valuable predictors of outcome.