Pediatric Basic Airway Management (Emergency Medicine)

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SAMPLE EXCERPT
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PRE-PROCEDURE
INDICATIONS
  • Airway obstruction
  • Hypoxia—documented or suspected
  • Increased metabolic demand for oxygen
  • Pneumothorax
CONTRAINDICATIONS
  • Cervical spine injury is a contraindication for head tilt–chin lift maneuver.
  • Severe facial injuries are contraindications for the jaw-thrust maneuver.
  • Oropharyngeal airways (OPAs) are contraindicated in responsive patients with a gag reflex.
  • Nasopharyngeal airways (NPAs) are contraindicated in patients with basilar skull fracture. The benefit of providing airway support must be weighed against the risk of this extremely rare potential complication.
  • Fully correcting oxygenation in patients with chronic respiratory disease and carbon dioxide retention may compromise respiratory effort.
  • In some congenital heart diseases, supplemental oxygen may cause pulmonary vascular vasodilation and may disrupt the balance between pulmonary and systemic blood flow.
  • Use of nasal cannulas may be limited in infants with mucosal edema, rhinorrhea, or altered nasal anatomy.
EQUIPMENT
  • Equipment required to establish airway patency:
    • Oropharyngeal airway, appropriately sized.
    • Nasopharyngeal airway, one or two appropriately sized.
    • Water-soluble lubricants or anesthetic lubricants are required.
    • Topical vasoconstrictor (e.g., neosynephrine) is optional.
  • Equipment required to deliver supplemental oxygen (choose one of the following systems):
    • Oxygen tubing
    • Blow-by oxygen delivery devices (e.g., corrugated tubing, funnel, face shovel)
    • Oxygen hood
    • Oxygen tent
    • Nasal cannula
    • Simple mask
    • Partial rebreather mask
    • Non-rebreather mask
  • Other equipment required for basic airway management:
    • Suction and suction catheter, appropriately sized, in case of secretions and/or emesis
    • Bag mask in case of further airway compromise
    • Supplies for universal precautions, including gloves, mask, eye protection **UNIVERSAL PRECAUTIONS**
    • Cardiorespiratory monitor
    • Pulse oximeter
    • Capnography device

Airway Patency Devices

  • Oropharyngeal airway
  • Nasopharyngeal airway (NPA)

Supplemental Oxygen Delivery Systems

  • Blow-by (wafting) oxygen devices
  • Oxygen hood
  • Oxygen tent
  • Nasal cannula
  • Simple mask
  • Partial non-rebreather mask
  • Non-rebreather mask
ANATOMY

Pediatric Anatomic Considerations

  • The occiput in neonates, infants, and toddlers is large. In the supine position, the cervical spine is flexed, and the airway tends to buckle. A roll under the child's shoulders and airway positioning may allow more favorable anatomic airway alignment.
  • Neonates and infants up to 4 months of age are obligate nose breathers.
  • The tongue is disproportionately large in children and tends to fall back into the oropharynx. Airway positioning and airway adjuncts, such as OPA, NPA, and an intubation tube may be necessary to establish and maintain airway patency.
  • The narrower pediatric airway is vulnerable to obstruction due to edema, foreign body, secretions, and/or vomitus.
  • Infants are obligate nasal breathers until approximately 6 months of age, necessitating patency of the nasopharynx to allow for effective spontaneous respirations in this age-group.

PROCEDURE
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The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

POST-PROCEDURE
CARE
  • Patients who require basic airway maneuvers or adjuncts will (1) improve to the point of no longer requiring these devices/techniques, or (2) require definitive airway management with endotracheal intubation.
  • Supplemental oxygen can be delivered acutely or for prolonged periods, as indicated.
  • Frequent reassessment with continuous or spot oxygen saturation monitoring is crucial.
COMPLICATIONS
  • Complications of oropharyngeal airways
    • Worsening airway obstruction due to the following:
      • Pushing the tongue posteriorly
      • Use of an incorrectly sized device
    • Soft tissue trauma
    • Vomiting
    • Laryngospasm
  • Complications of NPAs
    • Inadequate ventilation due to use of an incorrectly sized device
    • Soft tissue trauma
    • Intracranial NPA placement
    • Prolonged use of NPAs is associated with ulceration of the nasal mucosa and sinusitis
  • Complications of oxygen delivery devices
    • Hypoxia from inadequate oxygen delivery
    • Suffocation
    • Aspiration
    • Nasal mucosal irritation
    • Inadvertent positive pressure
    • Cutaneous fungal infection
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