General Approach to All Pediatric Patients

Airway Emergencies – Pediatric Dyspnea

Dyspnea

Basic Life Support

  • Supplemental 100% oxygen
  • If foreign body obstruction is suspected refer to foreign body protocol

Advanced Life Support

  • Full Pediatric ALS Assessment and Treatment
  • For bronchospasm:
    • Albuterol (Proventil) 2.5mg/3ml and Ipratropium Bromide 0.02% (Atrovent) 0.5mg/2.5ml via nebulizer over 10-15 minutes
      • Repeat Albuterol (Proventil)/Ipratropium Bromide (Atrovent) X 2 for continued wheezing
    • If patient shows signs of worsening respiratory distress, inadequate ventilation or respiratory failure in the setting of bronchospasm or a history of asthma:
      • Epinephrine 1:1,000 at 0.01 mg/kg (max 0.3 mg) IM
        • May repeat Epinephrine every 15 minutes X 2 additional doses (3 total) if severe symptoms persist
        • May administer at same time nebulizer is being administered
      • Methylprednisolone (Solumedrol) 2 mg/kg IV or IM (Maximum individual dose 60 mg)
      • Magnesium Sulfate 50 mg/kg IV over 10-15 minutes; contraindicated if history of renal failure
  • If partial upper airway obstruction or stridor without severe respiratory distress:
    • Do nothing to upset the child
    • Perform critical assessments only
    • Have parent administer blow by supplemental oxygen
    • Place patient in position of comfort
    • Do not obtain vascular access
    • Expedite transport
  • If complete airway obstruction, or severe respiratory distress, failure, or arrest:
    • Advanced airway/ventilatory management as needed

Drowning

  • Spinal immobilization if pool related event or circumstances uncertain
  • Protect from heat loss
  • Patients may develop delayed onset respiratory symptoms
    • Consider CPAP for patients with significant dyspnea or hypoxia if size allows
  • Refer to appropriate protocol if cardiac arrest present

Basic Life Support

  • If suspicion of trauma, maintain C-spine immobilization
  • Suction all debris, secretions from airway
  • Bag valve mask ventilate; use only sufficient volume and force to just make chest rise visibly
  • Ventilate at a rate of 12-20 breaths/minute, using the higher rate for younger ages
  • Supplemental 100% oxygen

Advanced Life Support

  • Have assistant apply cardiac monitor as soon as possible
  • Address cardiac rhythm abnormalities per appropriate protocol
  • Monitor end-tidal CO2 and oxygen saturation continuously
  • BVM ventilate at least 2 minutes with 100% oxygen to achieve O2 saturation >90%
  • Follow sequence listed below (use weight/length based tape to select appropriate equipment)

Bag Mask Ventilate (BVM)

  • At every step of airway algorithm, effective bag valve mask ventilation is an acceptable level of airway management
  • Components of effective ventilation include oxygenation, chest rise and fall, adequate lung sounds, and the presence of an alveolar waveform on capnography
  • Monitor ETCO2, oxygen saturation and assess for effective ventilation continuously

Confirmation of Placement and Effectiveness of Ventilation (ETT or LTA)

Capnography/ETCO2 Monitoring:

  • Digital capnography (waveform) is the system standard for ETCO2 monitoring and continuous ETCO2 monitoring is a mandatory component of invasive airway management
  • Immediately after placing an ETT or LTA capnography shall be applied to confirm proper placement
    • Proper placement is indicated by the presence of a continuous alveolar waveform on capnography
    • If an alveolar waveform is not initially present, or disappears after 3-5 breaths (i.e. flat-line), remove the ETT or LTA and proceed to the next step in the algorithm
  • With the exception of on-scene equipment failure, patients should not be switched from digital capnography to a colorimetric device for monitoring end-tidal C02
  • If capnography is not available due to serious on-scene equipment failure, apply a colorimetric ETCO2 detector capable of continuous ETCO2 monitoring (much less reliable)
  • If ETCO2 monitoring cannot be accomplished by either of the above methods, the invasive airway device must be removed, and the airway managed noninvasively

Additional Measures

  • Assess epigastric sounds, breath sounds, and chest rise and fall
  • Record tube depth and secure in place using a commercial tube holder
  • Utilize head restraint devices or rigid cervical collar and long spine board immobilization as needed to help secure airway device in place

Foreign Body Airway Obstruction

  • If unresponsive, open airway using a head tilt/chin lift (if no trauma)
  • If < 1 year old, administer up to 5 back blows and 5 chest compressions
  • If ≥ 1 to 8 years, administer abdominal thrusts until foreign body dislodged
  • If ventilation is unsuccessful (O2 saturations cannot be kept > 90) perform the following in order:
    • Reposition airway and attempt bag valve mask assisted ventilation again
    • If unsuccessful, establish direct view of object and attempt to remove it with Magill forceps
    • If unable to visualize a foreign body using laryngoscope, and vocal cords are clearly seen, attempt intubation only once
    • If unsuccessful, re-attempt BVM ventilation; if oxygen saturation > 90 with BVM proceed no further and expedite transport
  • If patient cannot be ventilated/oxygenated with the above measures, perform needle cricothyrotomy and needle jet insufflation as a last resort
  • Expedite transport to nearest emergency department