• Audrey VanDeWall, Sarah Harris-Kober, Ahmad Farooqi, and Nirupama Kannikeswaran.
• Pediatric Emergency Medicine Fellow, Division of Emergency Medicine, Children's Hospital of Michigan, 3901 Beaubien Blvd, Detroit, MI 48201, United States of America. Electronic address: avandewa@dmc.org.
• Am J Emerg Med. 2023 May 1; 67: 798379-83.

BackgroundWhile the anatomically difficult airway has been studied in pediatric trauma patients, physiologic risk factors are poorly understood. Our objective was to evaluate if previously published high risk physiologic criteria for difficult airway in medical patients is associated with adverse outcomes in pediatric trauma patients.MethodsThis was a retrospective chart review of patients ≤18 years with traumatic injuries who underwent endotracheal intubation (EI) in a pediatric emergency department (PED) between 2016 and 2021. High risk criteria evaluated included 1) hypotension, 2) concern for cardiac dysfunction, 3) persistent hypoxemia, 4) severe metabolic acidosis (pH < 7.1), 5) post-return of spontaneous circulation. Our primary outcome was peri-intubation cardiac arrest, defined as cardiac arrest within 10  minutes of EI. Secondary outcomes included in-hospital cardiac arrest and mortality and first pass EI success.ResultsOne third (n = 32; 36.4%) of the 88 patients analyzed had at least one high risk criteria. When compared to the standard risk group, those in the high risk group had a higher incidence of peri-intubation arrest (28.1% vs. 0%, difference: 28.1%, 95% CI: 10.1-46.2), PED/in-hospital arrest (43.8% vs. 3.4%, difference: 38.4%, 95% CI: 17.8-59.0) and in-hospital mortality (33.4% vs. 3.6%, difference: 29.8%, 95% CI: 8.4-46.9). Having multiple high risk criteria progressively increased the odds of post-intubation PED/in-hospital cardiac arrest (1 risk factor: OR = 6.7, 95% CI: 1.5-30.2; 2 risk factors: OR = 12.5, 95% CI: 2.3-70.0; ≥ 3 risk factors: OR = 56.1, 95% CI: 6.0-523.8).ConclusionsThe presence of high risk physiologic criteria is associated with increased incidence of peri-intubation, in-hospital arrest, and death in pediatric trauma patients. Children with multiple risk factors are at an incremental risk of cardiac arrest.Copyright © 2023 Elsevier Inc. All rights reserved.

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