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?

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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

Preoxygenation

Pediatric patients are also significantly predisposed to hypoxemia, due to higher metabolic requirements and reduced functional residual capacity.⁸ According to the National Emergency Airway Registry for Children, 13 percent of all pediatric patients have desaturated prior to or during intubation, with nearly half of all difficult pediatric intubations included in that number.⁹

As soon as the team determines that RSI is required, the patient should be preoxygenated with 100 percent oxygen. If possible, the patient should be given five minutes of 100 percent oxygen on a nonrebreather mask, or eight vital capacity breaths to grant three to four additional minutes of apnea before hypoxemia sets in.⁷ In particularly difficult airways, organizations such as the Pediatric Difficult Intubation Collaborative recommend passive oxygenation via nasal cannula during the intubation attempt.¹⁰ Humidified, high-flow nasal cannula oxygenation during the patient’s apneic periods has also been shown to significantly delay the time to desaturation.⁹

Upper Airway Obstruction

Some physicians prefer using the straight Miller blade in patients younger than 4-5 years old, as it directly lifts the anteriorly shifted epiglottis to visualize the cords, while a curved Macintosh blade indirectly lifts the ligamentous connections of the epiglottis for cord visualization.⁸ In cases where ventilation with a face mask is warranted, an oral airway may be used to relieve any obstructions caused by posterior displacement of the tongue.⁸

Blade Selection

A wide range of conditions in pediatric patients, including syndromes such as Pierre Robin and Trisomy 21, can make it difficult to visualize the vocal cords.^11,12 In recent years, videolaryngoscopes (VL) designed for pediatric patients have become far more available on the market. VL blades may include options for standard direct laryngoscopy (DL) blades, such as the Miller and MacIntosh designs. Hyperangulated blades—designed specifically for VL intubation—are also growing in popularity.¹⁰ However, in infants weighing less than 5 kg, VL with a standard Macintosh or Miller blade appears to be associated with a significantly greater success rate than that achieved with hyperangulated blades.¹³

Some studies suggest there is no significant difference between these blades in the 1-24 month age group.¹⁴ However, other studies maintain that the Miller blade is significantly more effective in intubation in pediatric patients aged 2-6 years.¹⁵ In children younger than 2 years of age, the size 1 Miller may be used to lift the epiglottis, or a Macintosh blade may be used to lift the base of the tongue.¹⁶

Non-angulated VL blades have a reduced viewing angle that simultaneously makes passing an ET tube a less complex maneuver for the clinician.¹⁰ Similarly, the efficacy of VL versus DL remains controversial within the wider literature.¹⁰

In cases of severe upper airway obstruction, supraglottic airways such as the laryngeal mask airway (LMA) may be used.⁸ An LMA may temporarily secure the airway, while a bronchoscope is passed through the LMA into the patient’s trachea. Afterwards, the LMA may be removed and an endotracheal (ET) tube passed over the bronchoscope to intubate the patient.⁸

ET Tubes

ET tube insertion may be difficult due to the vocal cords being aligned in an anterior–inferior angle rather than the posterior-superior angle seen in adults. This increases the risk of the ET tube becoming obstructed or blocked by the vocal folds.⁸ The 2023 Pediatric Advanced Life Support (PALS) guidelines recommend the following formulas for ET tubes.¹⁷ Three times the tube size for ETT depth is also commonly used.¹⁸

In stressful situations in which calculations may be difficult, Broselow tape is also an effective measure to estimate ETT size.¹⁹

Cannot Intubate, Cannot Oxygenate

The most severe cases are referred to as a Cannot Intubate, Cannot Oxygenate scenario (CICO).¹⁰ If the patient cannot be intubated, mask ventilation should be optimized; then an LMA supraglottic airway should be attempted, followed by surgical airway.¹¹

For patients younger than 8 years, a surgical cricothyrotomy may be performed to create a space through which an ET tube may be inserted.⁷ Needle cricoidotomy is often difficult, due to the flexible cricoid and trachea in this population, as well as the small size of the neonatal cricothyroid membrane.^8,10 Cannula-based cricothyrotomy, is a potential alternative, particularly with products such as the Ventrain device.¹⁰

Dr. Turner originally trained at the Medical University of South Carolina, is an EM intern at Hershey Medical Center in Hershey, PA.

Dr. Glauser is professor of emergency medicine at Case Western Reserve University at MetroHealth Cleveland Clinic in Cleveland, Ohio.

References

1. Long E, Sabato S, Babl FE. Endotracheal intubation in the pediatric emergency department. Pediatr Anaesth. 2014;24(12):1204-1211.
2. Kerrey BT, Rinderknecht AS, Geis GL, et al. Rapid sequence intubation for pediatric emergency patients: higher frequency of failed attempts and adverse effects found by video review. Ann Emerg Med. 2012;60(3):251-259.
3. Rinderknecht AS, Mittiga MR, Meinzen‐Derr J, et al. Factors associated with oxyhemoglobin desaturation during rapid sequence intubation in a pediatric emergency department: findings from multivariable analyses of video review data. Acad Emerg Med. 2015;22(4):431-440.
4. Green SM, Ruben J. Emergency department children are not as sick as adults: implications for critical care skills retention in an exclusively pediatric emergency medicine practice. J Emerg Med. 2009;37(4):359-368.
5. Mittiga MR, Rinderknecht AS, Kerrey BT. A modern and practical review of rapid-sequence intubation in pediatric emergencies. Clin Pediatr Emerg Med. 2015;16(3):172-185.
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10. Stein ML, Park RS, Kovatsis PG. Emerging trends, techniques, and equipment for airway management in pediatric patients. Pediatr Anesth. 2020;30(3):269-279.
11. Sims C, von Ungern‐Sternberg BS. The normal and the challenging pediatric airway. Pediatr Anaesth. 2012;22(6):521-526.
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13. Peyton J, Park R, Staffa SJ, et al. A comparison of videolaryngoscopy using standard blades or non-standard blades in children in the Paediatric Difficult Intubation Registry. Br J Anaesth. 2021;126(1):331-339.
14. Varghese E, Kundu R. Does the Miller blade truly provide a better laryngoscopic view and intubating conditions than the Macintosh blade in small children? Pediatr Anaesth. 2014;24(8):825-829.
15. Yadav P, Kundu SB, Bhattacharjee DP. Comparison between Macintosh, Miller and McCoy laryngoscope blade size 2 in paediatric patients – a randomised controlled trial. Indian J Anaesth. 2019;63(1):15-20.
16. Passi Y, Sathyamoorthy M, Lerman J, et al. Comparison of the laryngoscopy views with the size 1 Miller and Macintosh laryngoscope blades lifting the epiglottis or the base of the tongue in infants and children <2 yr of age. Br J Anaesth. 2014;113(5):869-874.
17. United Medical Education. PALS Algorithms 2024. Updated 2024. Accessed September 15, 2024.
18. Phipps LM, Thomas NJ, Gilmore RK, et al. Prospective assessment of guidelines for determining appropriate depth of endotracheal tube placement in children. Pediatr Crit Care Med. 2005;6(5):519-522.
19. Subramanian S, Nishtala M, Ramavakoda CY, et al. Predicting endotracheal tube size from length: evaluation of the Broselow tape in Indian children. J Anaesthesiol Clin Pharmacol. 2018;34(1):73-77.