Chapter 1: Emergency Management

I. Airway

Section references: [^2–5]

1. Assessment
   1. Is airway patent? Think about obstruction: Head tilt/chin lift (or jaw thrust if injury suspected) to open airway
   2. Is the child breathing spontaneously? If not, must immediately begin ventilating via rescue breaths, bag-mask, or endotracheal tube
   3. Are respirations adequate?
      1. Look for chest rise
      2. Recognize signs of distress (stridor, tachypnea, flaring, retractions, accessory muscle use, wheezes)
2. Management^2–10
   1. Equipment
      1. Use oral or nasopharyngeal airway in patients with altered mental status
         1. Oral: Unconscious patients—measure with flange at teeth and tip at mandibular angle
         2. Nasal: Conscious patients—measure tip of nose to tragus of ear
      2. Laryngeal mask airway (LMA): Simple way to secure an airway (no laryngoscopy needed), especially in difficult airways; does not prevent aspiration
      3. Bag and mask ventilation with cricoid pressure may be used indefinitely if ventilating effectively (look at chest rise)
   2. Intubation: Indicated for (impending) respiratory failure, obstruction, airway protection, pharmacotherapy, or need for likely prolonged support
      1. Equipment (see page i): SOAP (Suction, Oxygen, Airway Supplies, Pharmacology)
         1. Laryngoscope blade: Straight (or Miller) blade typically used in children
            1. Size: #00-1 for premie–2 month, #1 for 3 month–1 year, #2 for >2 years, #3 for >8 years
            2. Curved (or Mac) blade may be helpful in patients >2 years
         2. Endotracheal tube (ETT):
            1. Size determination: Internal diameter of ETT (mm) = (Age/4) + 4, or use length-based resuscitation tape to estimate
            2. Approximate depth of insertion in cm = ETT size × 3
            3. Uncuffed ETT for patients <9 years of age
            4. Mind the stylet; it should not extend beyond the distal end of the ETT
            5. Attach end-tidal CO₂ monitor as confirmation of placement and effectiveness of chest compressions if applicable
         3. Nasogastric tube (NGT): To decompress the stomach; measure from nose to angle of jaw to xiphoid for depth of insertion
      2. Rapid sequence intubation (RSI) recommended unless patient is newborn or unconscious, and results in higher success rates with lower aspiration risk
         1. Preoxygenate with non-rebreather at 100% O₂ for minimum of 3 minutes
            1. Do not use positive pressure ventilation (PPV) unless patient effort is inadequate
            2. Children have less oxygen/respiratory reserve than adults due to higher oxygen consumption and lower functional residual capacity
         2. See Figure 1-1 and Table 1-1 for drugs used for RSI: (Adjunct, sedative, paralytic) important considerations in choosing appropriate agents include clinical scenario (e.g., bronchospasm, increased intracranial pressure, neurologic status, hyperkalemia), allergies, presence of neuromuscular disease or anatomic abnormalities, hemodynamic status
         3. For patients difficult to bag or with difficult airways, may consider sedation without paralysis and the assistance of subspecialists (anesthesia and otolaryngology)
      3. Procedure: Attempts should not exceed 30 seconds
         1. Preoxygenate with 100% O₂ as above
         2. Administer intubation medications (Fig. 1-1 and Table 1-1)
         3. Apply cricoid pressure to prevent aspiration (Sellick maneuver) during bag-valve-mask ventilation and intubation
         4. Use scissoring technique to open mouth
         5. Hold laryngoscope blade in left hand. Insert blade into right side of mouth, sweeping tongue to the left out of line of vision
         6. Advance blade to epiglottis. With straight blade, lift laryngoscope straight up, directly lifting the epiglottis to view cords. With curved blade, place tip in vallecula and lift straight up to elevate the epiglottis and visualize the vocal cords
         7. If possible, have another person hand over the tube, maintaining direct visualization, and pass through cords until black marker reaches the level of the cords
         8. Hold firmly against the lip until tube is securely taped
         9. Verify ETT placement: observe chest wall movement, auscultation in both axillae and epigastrium, end-tidal CO₂ detection (there will be a false-negative response if there is no effective pulmonary circulation), improvement in oxygen saturation, chest radiograph, repeat direct laryngoscopy to visualize ETT


FIGURE 1-1 A, Treatment algorithm for intubation. B, Sedation options.

(Modified from Nichols DG, Yaster M, Lappe DG, et al [eds]: Golden hour: The handbook of advanced pediatric life support. St. Louis, Mosby, 1996, p. 29.)