Correspondence
Funding and support: By Annals policy, all authors are required to
disclose any and all commercial, financial, and other relationships
in any way related to the subject of this article as per ICMJE
conflict of interest guidelines (see www.icmje.org). The authors
received funding from the Centers for Disease Control for this
work.
1. Lindberg DM, Shapiro RA, Blood EA, et al. Utility of hepatic
transaminases in children with concern for abuse. Pediatrics.
2013;131:268-275.
2. Holmes JF, Sokolove PE, Brant WE, et al. Identification of children
with intra-abdominal injuries after blunt trauma. Ann Emerg Med.
2002;39:500-509.
3. Holmes JF, Gladman A, Chang CH. Performance of abdominal
ultrasonography in pediatric blunt trauma patients: a metaanalysis. J Pediatr Surg. 2007;42:1588-1594.
4. Cotton BA, Beckert BW, Smith MK, et al. The utility of clinical
and laboratory data for predicting intraabdominal injury
among children. J Trauma. 2004;56:1068-1074; discussion
1074 –1075.
5. Isaacman DJ, Scarfone RJ, Kost SI, et al. Utility of routine
laboratory testing for detecting intra-abdominal injury in the
pediatric trauma patient. Pediatrics. 1993;92:691-694.
A Case of Delayed Sequence Intubation in a
Pediatric Patient With Respiratory Syncytial
Virus
To the Editor:
Recent studies and reports have focused on improving
safety during intubation by improving preoxygenation.1 A
technique referred to as delayed sequence intubation has
been described in which procedural sedation is used to
facilitate preoxygenation in patients who resist initial
attempts.2 This procedure involves dissociation with
ketamine as the agent of choice to maintain both
hemodynamics and the respiratory drive. Here, to our
knowledge, we describe the first case of this technique
being applied to the pediatric patient.
A 16-month-old Hispanic girl with no significant medical
history presented to the emergency department with 1 day
of fever, nasal congestion, and cough. She was tachycardic
to 160 beats/min and febrile to 39.4°C, had a normal
respiratory rate, and had an oxygen saturation of 95% on
room air. The respiratory examination result was benign,
with no wheezing, distress, or use of accessory musculature.
She had a positive respiratory syncytial virus antigen. Her
breathing status remained good, and she was deemed stable
for outpatient management with antipyretics and a course
of steroids, and return precautions appropriate to her
respiratory condition. Rapid streptococcal testing was also
ordered, and the culture came back positive. On a follow-up
call, the patient seemed stable and received a prescription for
amoxicillin.
278 Annals of Emergency Medicine
Two days later, the parents brought the patient back in
for difficulty breathing. She was severely dyspneic on
examination, retracting suprasternally and intercostally, and
grunting, with nasal flaring. Her color was ashen, and oxygen
saturation was 90% on room air. She was febrile, tachycardic
to about 170 beats/min, and tachypneic to about 60 breaths/
min. She had minimal response to needle pokes but was
distressed at even the placement of nasal cannula oxygen.
With nasal cannula, oxygen saturation improved to 93%,
but after a nebulizer treatment with albuterol, there was no
change in her work of breathing. Her blood gas result
showed slight respiratory alkalosis and pCO2 of 28 mmHg.
It seemed unlikely that the disease process was going to
resolve in the coming hours, so the decision was made that
she needed to be intubated for oxygenation and to decrease
the work of breathing.
Because she was still nearly hypoxemic, we focused on
preoxygenation. She was agitated by attempted application of a
nonrebreather facemask. We proceeded with delayed sequence
intubation, with a dose of ketamine at 2 mg/kg. She rapidly
dissociated, and we applied a facemask over her nasal
cannula. Oxygen saturations improved during 2 minutes to
99%. With her rate of breathing, it was clear that she had
appropriately denitrogenated as well. Rocuronium, 1 mg/kg,
was injected and breathing efforts rapidly ceased. We
maintained nasal cannula oxygen for apneic oxygenation
during the next 60 seconds. She was intubated on first pass
of direct laryngoscopy with a Cormac/Lehane grade 1 view
of the cords. Postintubation, the patient desaturated to 93%
and required titration of positive end expiratory pressure and
oxygen concentration. She was transferred to the Children’s
Hospital and lost to follow-up.
We present this case as a use of delayed sequence
intubation to show that the technique is beneficial not only
in agitated or combative adults but also in agitated and
fearful pediatric patients who may not tolerate facemasks.
This procedure may significantly benefit the patient and
intubator in terms of preoxygenation and denitrogenation,
allowing greater time during intubation without using a
bag-valve-mask device and risking aspiration.
Eric D. Schneider, MD
Department of Emergency Medicine, Mercy Hospital
Alegent-Creighton Health
Council Bluffs, IA
Scott D. Weingart, MD
Division of Emergency Critical Care
Department of Emergency Medicine
Mount Sinai School of Medicine
New York, NY
http://dx.doi.org/10.1016/j.annemergmed.2013.03.027
Volume , .  : September 
Correspondence
Funding and support: By Annals policy, all authors are required to
disclose any and all commercial, financial, and other relationships
in any way related to the subject of this article as per ICMJE
conflict of interest guidelines (see www.icmje.org). The authors
have stated that no such relationships exist.
1. Weingart SD, Levitan RM. Preoxygenation and prevention of
desaturation during emergency airway management. Ann Emerg
Med. 2012;59:165-175.
2. Weingart SD. Preoxygenation, reoxygenation, and delayed
sequence intubation in the emergency department. J Emerg Med.
2011;40:661-667.
IMAGES IN EMERGENCY MEDICINE
(continued from p. 275)
DIAGNOSIS:
Cutaneous tattoo reaction. Tattoo reactions are most commonly associated with red ink but can be seen in any
color.1 Relatively little regulation of tattoo ink composition exists, and a single color can contain varying amounts
of dyes and metals.2 Mercury is a known irritant, but reactions to ink lacking mercury are not uncommon.3,4
Tattoo reactions are most commonly allergic, inflammatory, and infectious, with estimated complication rates
of 2% to 3%.5 Symptoms of cutaneous reactions may range from itching and edema to an exfoliative dermatitis,
and lesion biopsy may be needed to differentiate the true underlying cause.6 Treatment of tattoo reactions and
other complications differs with the underlying cause. Systemic or topical steroids are often prescribed for
noninfectious cutaneous reactions, with variable success. Severe skin reactions may require excision of the tattoo
and underlying tissue.
Author affiliations: From the Department of Emergency Medicine, Staten Island University Hospital, Staten
Island, NY.
REFERENCES
1. Rudolf V, Engel E, Konig B, et al. Health risks of tattoo colors. Anal Bioanal Chem. 2008;391:9-12.
2. Food and Drug Administration. Maryland. Think before you ink: are tattoos safe? Available at: http://www.fda.gov/
ForConsumers/ConsumerUpdates/ucm048919.htm. Updated August 9, 2012. Accessed November 27, 2012.
3. Mortimer NJ, Chave TA, Johnston GA. Red tattoo reactions. Clin Exp Dermatol. 2003;28:508-510.
4. Yazdiantehrani H, Shibu M, Carver N. Reaction in a red tattoo in the absence of mercury. Br J Plast Surg. 2001;54:555556.
5. Urdang M, Mallek JT, Mallon WK. Tattoos and piercing: a review for the emergency department physician. West J Emerg
Med. 2011;12:393-398.
6. Kaur RR, Kirby W, Maibach H. Cutaneous allergic reactions to tattoo ink. J Cosmet Dermatol. 2009;8:295-300.
Volume , .  : September 
Annals of Emergency Medicine 279