5-year-old child involved in a motor vehicle crash (MVC) presents with altered mental status and a Glasgow Coma Scale (GCS) of 8. Her vital signs are: 76 over 43, heart rate of 170, respiratory rate of 6. Her breathing is irregular. What is the most appropriate treatment at this time?
Explore This Issue
ACEP Now: Vol 43 – No 10 – October 2024
Introduction
Pediatric intubations in the emergency department (ED) occur at only a tenth the frequency of adult intubations.1 Pediatric rapid sequence intubation (RSI) in the ED is associated with a higher frequency of failed first attempts and adverse effects than in adult patients.2 One study found that up to two thirds of pediatric patients experienced at least one adverse event during RSI.3 This is due to difficult airways, a lack of physician trainee experience with tracheal intubations, and the general lower acuity of pediatric patients, providing fewer opportunities for physicians to practice and hone their craft in RSI.2,4,5 Given these issues, it is imperative that emergency physicians anticipate the unique challenges of RSI in this patient population.
Preparation
If possible, AMPLE (allergies and airway history, medications, past medical history, last oral intake, and events leading up to the intubation) history should be obtained, as well as a physical exam.6 Before any pediatric RSI is initiated, the proper equipment should be prepared.
Medications
Emergency physicians should be familiar with the pediatric dosing of induction and paralytic agents, as well as their various indications. Induction agents include etomidate, typically dosed at 0.2–0.4 mg/kg IV, ketamine at 1.5–2 mg/kg IV, and propofol at 1.5–3 mg/kg IV. Paralytic agents include rocuronium at 1 mg/kg IV and succinylcholine at 1-2 mg/kg IV.6
Unique Pediatric Airway Challenges
Young pediatric patients have a larger head, larger tongue, and shorter mandible; they are obligate nasal breathers until 5 months of age and have a higher larynx and vocal cords angled in an anterior–inferior setting, among other differences.8 In addition, physicians may experience increased stress when dealing with critical illness in very young patients. However, many of these differences can be compensated for with proper preparation.8
Patient Positioning
Pediatric patients have a larger head relative to their body size than adults, which leads to a flexed airway when the patient is laid on a flat surface. Emergency physicians may fold a towel underneath the patient’s shoulders to allow extension of their head and adjust their airway into a neutral position.8 The patient should be positioned so that their external auditory meatus is in line with the anterior border of the shoulder, in a “sniffing” position.8
Pages: 1 2 3 4 | Single Page
No Responses to “The Pediatric Airway: Considerations and Challenges”