Purpose or Case Report: Accurate placement of lines and tubes is essential in pre-hospital emergent care of pediatric patients, to ensure that lifesaving measuring can be initiated in an effective and timely manner. Malpositioned pediatric tubes can lead to failed resuscitation efforts. The purpose of this study is to determine the prevalence of misplaced endotracheal tubes (ETT), nasogastric tubes (NGT) and intraosseous trocars (IOT) in the pediatric acute care setting using post-mortem imaging.
Methods & Materials: The post-mortem imaging for 87 patients under the purview of the Medical Examiner Office performed between June 2007-May 2017 was retrospectively reviewed by a Pediatric Radiologist as part of a quality review in conjunction with the Nova Scotia Medical Examiner Service and Emergency Health Services (EHS). Of these 87 patients, 27 patients were excluded as no tubes were placed. For the remaining patients (N=61), ETT, NGT and IOT placement was assessed using a combination of radiographs and multiplanar CT, and characterized as “satisfactory position” or “malpositioned”. For the malpostioned devices, the exact location was also documented.
Results: Of the 45 patients with an ETT, the tube was in satisfactory position in 9 (20%) patients and malpositioned in 36 (80%) patients. Of the malpositioned tubes, 5 were at the carina, 20 in the right main bronchus, 9 in the esophagus and 5 in other locations (at T2, T4, nasopharynx, etc.). The NGT was in satisfactory position in 13 (76%) patients and malpositioned in 4 (24%) patients, with tubes in the pharynx (two cases) and distal esophagus (2 cases). Of the 58 IOTs inserted, 15 (26%) were in satisfactory position and 43 (74%) were malpositioned, including 10 that had been completely removed but with CT evidence of prior incorrect positioning, 8 were through and through bone and 6 in the superficial soft tissues.
Conclusions: Malpositioning of the ETT, NGT and IOTs in this study is likely multifactorial. Tube placement is less common in the pediatric emergency setting compared to adult medicine, possibly resulting in decreased experience and comfort level among pediatric EHS teams. There may be a role for further specialized training, with more frequent recertification. Use of a laryngeal airway mask could also be considered as an alternative to ETT in pediatric patients with difficult airways. The results of study will help to inform future training of pediatric EHS teams at our institution, with ongoing review of post-mortem imaging as a means of quality assurance.