An Overview of EMS Pediatric Airway

Management

oleh
SYAHYUNI SALEH 10542054213
 Pediatric Peril
• Pediatric patients are responsible for approximately
7–13% of EMS calls.1 The Pediatric Emergency Care
Applied Research Network found the most common
chief complaints were traumatic injury (29%), pain
(combining abdominal and others) (10.5%), general
illness (10%), respiratory distress (9%), behavioral
disorder (8.6%), seizure (7.45%), and asthma
(3.9%).2 Regardless of the chief complaint of the call,
early and appropriate airway management is a very
important first step.
ANATOMY & PHYSIOLOGY
upper airway
 ANATOMY & PHYSIOLOGY
upper airway
• Head In the supine position, a young child’s head will cause a natural flexion of the neck due to its large
size. This neck flexion can create a potential airway obstruction. Patients usually benefit from a towel to
elevate the shoulders as well as someone to assist to help hold the head, as it can be floppy.
• Tongue A child’s tongue is proportionally larger in the oropharynx when compared to adults, and it may
obstruct the airway due to this size.
• Larynx Located opposite C2–C3, a child’s larynx is higher up than in an adult, creating a more anterior
location that often results in difficulty when a provider attempts to visualize a child’s airway.
• Epiglottis  The adult epiglottis is flat and flexible, while a child’s is U-shaped, shorter and stiffer. This
makes it more difficult to manipulate and is a common reason providers can’t visualize an airway with a
curved blade in a pediatric patient.
• Vocal cords The anterior attachment of a pediatric patient’s vocal cords is lower than the posterior
attachment, which creates an upward slant, whereas in adults, the vocal cords are horizontal. This concave
shape may affect ventilation, and it’s important for providers to use a jaw-lift maneuver to open the
arytenoids.
• TracheaThe trachea is shorter in pediatric patients, which increases the likelihood of right mainstem
intubation.
• Airway diameter  A child’s airway is narrowest at the cricoid ring. As a result, secretions can easily
obstruct the airway, due to its small size, and even a small amount of cricoid pressure can cause complete
airway obstruction.
• Residual lung capacity Smaller lung capacity in pediatric patients means that a child can become hypoxic
more quickly than an adult. Providers should make sure to closely monitor oxygen saturation and avoid
prolonged periods without ventilation.
 Pediatric Airway Positioning
Neutral supine position showing Proper positioning of a towel under a
flexion of the neck due to a child’s child’s shoulders to counter neck
proportionally large head. flexion.
 Pediatric Airway Positioning

Improper positioning of a towel to counter neck flexion.

Another way to think of this is aligning the ear canal with the sternal
notch. This position isn’t only optimal for intubation, it’s also ideal
when you’re ventilating with a bag-valve mask (BVM).
 Airway Opening & Suction

• Start with the basics, and make sure the patient has an open airway. If your
pediatric patient is hypoxemic, use the head-tilt chin-lift if you don’t need to
take C-spine precautions. If there’s concern for C-spine injury, use a simple jaw
thrust.
• If a child is drooling or can’t handle secretions due to obstruction, help them
use gravity to expel secretions by placing them upright in a position of comfort
or on their side. Laying them down could be detrimental rather than helpful.
• Though the tongue can be an obstruction in any airway, you may find it
particularly hindering in pediatric airway management. Thus, inserting an oral
or nasal airway can be extremely helpful.
• Remember that an oral airway is contraindicated if the patient is alert or has an
intact gag reflex, and that a nasal airway adjunct is contraindicated in severe
central face trauma. If needed, two nasal airways and one oral can all be
placed in order to facilitate a patent airway.
 Ventilation

• Proper ventilation technique using a BVM is critical—potentially far more important than any invasive
airway procedures such as an extraglottic airway device or endotracheal intubation. Ideally, this procedure
is performed with two providers: one to ensure a good mask seal and the other for bag squeezing.
• The first focus should be on creating a good mask seal. This starts with selecting the correct mask size
based on the patient’s weight and ensuring it covers the mouth and nose. Be mindful that in younger
patients without teeth, it can be difficult to create a good seal because there’s no platform for the mask to
rest on.
• Next, properly place your hands using an E-C grip if you’re the only one providing ventilation support, or
the T-E grip if there another provider is available. The T-E grip is helpful because it keeps four fingers free
to help keep the patient’s airway open using the jaw lift.
• During bagging, be mindful of not pressing the mask to the face but actually lifting the patient’s face into
the mask.
• Lastly, focus on your target respiratory rate as well as the amount of compression on the bag. Barotrauma
can result due to excessive pressure being applied to the airway and this can often occur due to provider
stress and distraction.
• Another pitfall that often results from provider stress is hyperventilating the patient, so remember to focus
on the rate you’re squeezing the bag during each ventilation. The ideal respiratory rate for an infant up to
3 years is 20–30 breaths per minute. For older children (ages 3 and up), the target respiratory rate is 16–20
breaths per minute.
 Invasive Techniques

• Extraglottic airway devices (EGDs): EGDs are inserted blindly into the airway
and have very high success rates of providing oxygenation and ventilation with
a minimum of initial and ongoing training. EGDs bypass common challenges for
achieving a tight mask seal, free providers from performing two-person BVM
ventilation, may be placed easily despite ongoing CPR, and decrease the risk
for gastric insufflation and aspiration as compared to BVM.
• There are a variety of EGDs now available on the market, some of which offer
pediatric sizes. A number of them also have a channel to facilitate gastric tube
placement. The two major categories are: 1) supraglottic devices (e.g.,
laryngeal mask airways) that effectively move the facemask from the BVM
inside the patient so that it sits over the glottis; and 2) retroglottic devices that
sit within the proximal esophagus and have two balloons—one in the pharynx
to keep air from exiting the mouth and one in the esophagus to keep air from
entering the stomach, directing gases into the airway by default
 Case Conclusion

• Place the child supine and position a towel behind her

shoulders such that she’s in good sniffing position.
• shallow respirations that she has breath sounds
bilaterally  Supplemental oxygen and two-person
BVM ventilation is started and the patient is loaded
into the ambulance.
• En route, respirations continue to be adequately
supported by BVM. You arrive safely at the destination
and transfer care to the ED team, who continues
resuscitative efforts.
Removing Pediatric ETI from Scope of Practice?

• Research suggests that prehospital ETI in pediatric patients doesn’t

improve survival when compared to bag-valve mask (BVM). In one
study, pediatric patients had no difference in survival to discharge nor
neurological outcome when airway emergencies were managed with
a BVM vs. ETI. This included patients with medical and traumatic
cardiac arrests, respiratory arrest and distress, head trauma with poor
neurological response, and provider assessment that the patient
required ventilatory support.15
• Given that the rare occurrence of pediatric ETI results in poorer first
pass success rates, which thereby increases the chances for
complications, additional EMS systems may begin to reconsider
allowing pediatric ETI within the scope of practice for prehospital
providers.