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Managing The Pediatric Airway In The ED

January 2006

Abstract

The agitated or unconscious child or infant with a compromised airway is a challenging, anxiety-provoking clinical problem that may be faced by everyone from basic life support (BLS) providers to emergency physicians.

The management of the child’s airway is arguably the most important lifesaving skill any EMS provider possesses. A systematic approach, combined with adequate preplanning, serves to calm everyone down and offers the greatest likelihood of an optimal outcome. Over the years, many (if not most) emergency physicians have become experts in adult airway management.

Unfortunately, adult intubation techniques, tools, and skills may not easily transfer to infants and young children. This does not mean that intubation of the pediatric airway is more difficult — just that different skills and tools are required to maximize the likelihood of success. Far fewer children than adults require prehospital or emergent intubation, even in designated “children’s” EDs.1 Fortunately, children account for only about 10% of all ambulance transports — and only 1% of critically ill ambulance transports.2 Unfor tunately, this means that few practitioners have much experience intubating infants. Emergency physicians are not alone in this regard. Anesthesiologists who do not regularly perform pediatric intubations also lose the skills gained in training. Complicating matters is the fact that adult airway rescue techniques that may be appropriate for older children and adolescents may be very difficult or even dangerous for infants and younger children.

In this article, we will highlight the unique features of pediatric airway management and make recommendations on approaching the pediatric airway. There is an old adage about pediatric resuscitation — the 3 most important concepts to master are: 1. Airway, 2. Airway, and 3. Airway.

Abbreviations Used In This Article
ACLS          —        Advanced Cardiac Life Support
AIS             —        Abbreviated Injury Scale
AMPLE        —        Allergies, medications, past medical history, last meal, events leading to the need for intubation
BLS             —       Basic life support
BVM            —       Bag-valve-mask
CPAP          —       Continuous positive airway pressure
EDD            —       Esophageal detector device
EMS            —       Emergency Medical Services
ET               —       Endotracheal
ETI              —       Endotracheal intubation
ETT              —      Endotracheal tube
GCS             —      Glasgow Coma Scale
ICP              —      Intracranial pressure
ID                —      Inner diameter
LMA             —      Laryngeal mask airway
NG               —      Nasogastric
NPTR  -3       —      National Pediatric Trauma Registry phase 3
OD               —       Outer diameter
PALS            —      Pediatric Advanced Life Support
PEEP            —      Positive end-expiratory pressure
RCT              —      Randomized controlled trial
RSI               —      Rapid sequence intubation
TBI               —      Traumatic brain injury
 
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