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“A-OK”: Chest Radiograph during Primary Survey Facilitates Faster, More Accurate Endotracheal Tube Position in Injured Children

The Advanced Trauma Life Support algorithm recommends bedside confirmatory techniques to confirm correct endotracheal tube (ETT) depth, a critical component in the care of pediatric trauma patients. We hypothesized that bedside confirmatory techniques are inaccurate and that early chest X-ray (CXR) would overcome such inaccuracies, allowing for faster intervention of malpositioned ETTs. An “A-OK” algorithm of immediate CXR following intubation in injured children aged <16 years was implemented. Eligible patients the years before and after implementation were identified. The accuracy of bedside confirmatory techniques (use of length-based depths and auscultation of breath sounds) was assessed. Post-“A-OK” patients were compared with pre-“A-OK” controls regarding the speed of malpositioned ETTrepositioning. Twenty-eight post-“A-OK” cases and 23 pre-“A-OK” controls were identified. The groups did not differ in baseline characteristics. Bedside confirmatory techniques were accurate in only 61 per cent (length-based depth) and 58 per cent (auscultation of breath sounds) of patients. Time to ETT repositioning was significantly longer in pre-“A-OK” controls than in post-“A-OK” cases (35.2 ± 15.9 minutes vs 21.1 ± 11.8 minutes, P = 0.03). Bedside confirmatory techniques to determine ETT positioning are inaccurate in children. Inclusion of CXR in the primary survey is safe and allows for more rapid repositioning of malpositioned ETTs.