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IntroductionEstablishing a patent airway that allows adequate oxygenation is a key priority in the management of trauma patients. This chapter will cover how to assess and manage airway problems in the infant or child trauma patient. How are children different?(see how children are different section) Apart from their obvious smaller size and the growing process, children have important anatomical and physiological differences, relative to adults, which are significant in airway management:
Who manages the airway in paediatric trauma?At the Royal Children's Hospital, once the trauma team has been activated, a senior anaesthetist should typically be allocated the role of airway doctor. This role however, may also be filled by a PICU or ED registrar / consultant, depending on the mix of staff available, and the particular needs of the patient. The assumption is always that the person best suited to the role, and ensuring the best outcome for the patient, is allocated this role. Even in the severely injured child, intubation is rarely required immediately. The primary importance of securing the airway is to allow for oxygenation of the patient. The airway often can, and should, be opened and kept patent through appropriate positioning, simple airway manoevres (such as a jaw thrust) and adjuncts (such as an oropharyngeal airway). These techniques combined with the application of high flow oxygen will in most cases allow sufficient time for the arrival of an appropriately skilled intubator, and adherence to an intubation checklist / plan. It is recommended that only an experienced clinician should attempt to intubate a child - unless the procedure is immediately required to save a life. Primary surveyThe life threat to identify and manage when assessing the airway is actual or impending airway obstruction Mechanisms of airway obstruction
Airway AssessmentThe airway doctor should assess the upper airway and the anterior neck looking for signs of airway obstruction. Signs of airway obstruction
Examination of the anterior neck The airway doctor is also responsible for examining the anterior neck. The goal is to seek signs of impending or actual airway obstruction at the laryngeal or tracheal level, or signs of thoracic life threats such as a tension pneumothorax / cardiac tamponade. The signs to look for can be remembered using the mnemonic TWELVE-C, as below:
Airway managementImmobilise the cervical spine - manual in-line stabilisation (see cervial spine assessement clinical practice quideline) Maintain head in neutral position
Open the airway
Jaw thrust
Clear the airway
If an obstruction persists
Oropharngeal Airway (OPA)
Sizing of OPA Guedel airways
Insertion
If you are unable to intubate the child whose airway is inadequate:
IntubationIndications for Intubation
Preparation for Endotracheal intubation -(see also Emergency airway management CPG) Pre-Oxygenate:
Endotracheal tube: Where possible use a pre-printed resource to assist with drug doses and sizes of equipment such as the endotracheal tube (at RCH the standard resource is the Monash Drug Book). If this is not available, calculate the endotracheal tube (ETT) size using the below formula. Size of cuffed ETT (internal diameter in mm) =
Age/4 + 3.5 At RCH the availability of micro-cuffed ETT, and the advantage of more completely protecting the airway with the use of these ETT's makes them the first choice when intubating children who have been severely injured. e.g.: 6 year old child: 6/4 + 3.5 = 5.0mm in diameter. As such on the child's bed should be 4.5, 5.0 and 5.5 mm in diameter tubes. Endotracheal tubes
Introducer: For ET tubes 4.5 mm ID and smaller, a lightly lubricated Stiletto (PICTURE) inserted almost to the tip of the tube makes intubation easier. Oral: Always use oral, never nasal, intubation in a child with a head injury (because of the risk of meningitis, or of entering the cranial cavity if an undiagnosed fracture of the skull base is present. Laryngoscope: Have 2 available; check they are working Suction:
Drugs: Drawn up and labeled:
Induction of anaesthesia1. Pre-oxygenate the child:
2. Drugs: - Always used unless the child is in cardiac arrest
There may be a delay between administration of the anaesthetic agent and muscle relaxant at the discretion of the team lead (for example to optimise oxygenation through titrated dose of anaesthetic agent). Prioritise avoidance of hypoxia at all times. Continue gentle positive pressure ventilation with positive end- expiratory pressure during the apnoeic period. During laryngoscopy turn the flow up on nasal cannulae to 2L/kg/minute (max 15L/min). 3. Laryngoscopy.
Up to 1year: Straight blade (Miller or Robertshaw)
More than 1 year: Curved blade (MacIntosh 2 or 3)
4. Insert the endotracheal tube
5. Insert an orogastric tube on free drainage. Never use a nasogastric tube or a nasotracheal tube in a child with a head injury (because of the risk of meningitis or of entering the cranial cavity where there is undiagnosed fracture of skull base). 6. Check on an AP chest X-ray: The ET tube tip should lie at the level of the medial end of the clavicles. If not, re-position the tube and re-tape. 7. Suction the ET tube carefully each hour, and more often if needed. 8. Humidify the inspired gases using a condenser humidifier (Swedish nose) between the ETT (PICTURE) tube and the self-inflating bag. 9. Splint the child's arms if necessary. (Child should be sedated) Side effects of drugs
Can't intubate, can't oxygenate (CICO)If the event of a CICO event you will need to progress to either a:
Needle cricothyroidotomy (see airway procedures section) Useful for obstruction in the larynx or above, but not if there is obstruction in the trachea or bronchi. It improves oxygenation slightly, and buys 10-15 minutes' time for help to arrive, and for the establishment of a definitive airway.
Surgical cricothyroidotomy(see airway procedures section)
Stay in the midline
If the lungs do not inflate easily, possible reasons are:
The main problems of needle and surgical cricothyroidotomy are:
Specific airway problems in traumaAirway injuryBe suspicious in the following injuries:
BurnFor definitive burns management see burns / management of burn wounds clinical practice guideline Airway management is a priority. Airway obstruction occurs secondary to:
Upper airway obstruction can occur
due to inhaled smoke even in the absence of burn to the face. Signs of a respiratory burn injury:
Primary survey for burn
Suggested reading list
What airway maneuver should be used with a cervical spine injury?[31,32] In immobilized patients, especially for emergent intubations, direct laryngoscopy with the use of a gum elastic bougie is an excellent choice to quickly and reliably secure the airway while minimizing the force to the cervical spine.
What maneuver should be used to open a patient's airway when a spinal injury is suspected?If you think the person may have a spinal injury, place your hands on either side of their head and use your fingertips to gently lift the angle of the jaw forward and upwards, without moving the head, to open the airway. Take care not to move the person's neck.
What is the recommended treatment for suspected neck and spinal injuries?Conscious patient
Support head, neck and spine in a neutral position at all times to prevent twisting or bending movements. If the ambulance is delayed, apply a cervical collar, if trained to do so, to minimise neck movement. Ensure an ambulance has been called: triple zero (000).
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