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Emergency airway management

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    Key points

    1. Specific measures to avoid hypoxia and hypotension should be undertaken prior to every emergency intubation.
    2. Every emergency intubation should include early consideration of the need for help, clear team member role allocation, a clear plan for unsuccessful intubation, and strategies to help avoid fixation.
    3. Emergency intubation checklist and other cognitive aids should be used during emergency airway management.
    4. Continuous wave-form end-tidal CO2 should be used to confirm correct ETT position.


    Emergency airway management is an uncommon procedure performed on unwell children. Adverse events are common, resulting in cardiac arrest in 1.5-2%. In emergencies, problems with airway management are rarely due to anatomically difficult airways, but commonly due to physiologically or situationally difficult airways. The strongest predictors of adverse events are multiple intubation attempts, and respiratory or cardiovascular failure as the indication for intubation.



      • Assess the patient’s physiology.
        • An extremely ill patient with cardiac and respiratory failure is a physiologically difficult airway. Physiology must be optimised prior to the induction of anaesthesia (table 1).

      Table 1: Strategies to avoid hypoxia and hypotension    
      • Elevate head of bed
      • Pre-oxygenation with positive airway pressure / PEEP
      • Apnoeic oxygenation with nasal cannula oxygen 2L/kg/min (15 L/min maximum)
      • Abort intubation attempt when saturations <93%
      • Fluid resuscitation
      • Inotrope infusion
      • Bolus dose ino-pressor drawn up*
      • Induction agent dose titration

      *Bolus dose inopressor: first line – adrenaline 1 mcg/kg (resuscitation dose of adrenaline drawn up to a total volume of 10ml with 0.9% saline. 1ml = 1/10th of a resuscitation dose =1 mcg/kg) . Alternatives – metaraminol 5-10 mcg/kg, phenylephrine 5 -10 mcg/kg. Atropine 20mcg/kg may be used for vagal bradycardia.

      • Asses the patient airway
        • Identify risk factors for difficulty in bag mask ventilation, laryngoscopy, intubation, and rescue techniques (LMA, cricothyroidotomy and tracheostomy).
        • Congenital syndromes (table 2) )and acquired conditions (table 3) are often associated with difficult airways.
        Table 2: Congenital syndromes   
        Micrognathia  Pierre Robin sequence
        Treacher Collins 
        Goldenhaar syndrome 
        Midface Hypoplasia  Apert syndrome
        Crouzon syndrome
        Pfeiffer syndrome 
        Macroglossia  Down’s syndrome
        Beckwith-Wiedemann syndrome
        Mucopolysaccharidoses (Hurler’s/Hunter’s syndrome) 

        **Airway of children may change as they grow. Pierre Robin airway generally improves as the mandible grows. Mucopolysaccharidoses airway may worsen with time. 

        Table 3: Acquired conditions 
        Pre-surgical  Airway burns / trauma 
        Airway infections 
        Airway tumours 
        Tonsillar hypertrophy 
        Tracheal anomalies (subglottic stenosis) 
        Sleep Apnoea 
        Foreign body aspiration 
        Post-surgical  Cervical spine fixation 
        Maxillofacial surgery 
        ENT surgery 

        • Assess the situation
          • do you need help? If your assessment of the patient’s airway, physiological condition, or your situation makes you feel uncomfortable then call for help before administering any drugs (table 4). 

        Table 4: Your help at RCH  


        In Business Hours

        After hours (Consultant Staff not available or not in hospital)



        Ext 52000

        Ext 52327
        Ext 52169
        Ext 52211
        Ext 777

        Consultant Anaesthetist
        ICU Outreach Doctor
        ED Consultant
        Nurse unit manager
        ICU Outreach registrar

        Senior anaesthetic doctor in hospital
        ICU registrar on duty
        Senior ED doctor in hospital
        Nurse unit manager
        ICU Outreach registrar

        Equipment preparation / monitoring / drugs

        • Standardised equipment should be laid out on the airway equipment template prior to emergency intubation. Equipment not on the template should be at the bedside and confirmed as functioning (T-piece, suction, video laryngoscope).  

        Emergency Airway Management

        • Monitoring should include: saturations, heart rate, respiratory rate, blood pressure (2 minute cycle), and end-tidal CO2 monitoring prepared.
        • Induction agent and muscle relaxant should be chosen and drawn up (the final dose administered may be titrated to the patients condition) (table 5). Post intubation sedation should be prepared.

        Table 5: Drug dosing 

        Induction agent

        • All induction agents can precipitate acute hypotension if used at “normal” doses in unwell children; significant dose titration is required.
        • Ketamine (0.5-2mg/kg) is the preferred default induction agent for emergency intubation at RCH.

        Muscle relaxant

        • Higher dose may be required in unwell children to achieve normal onset of action.
        • Rocuronium (1.2-1.6mg/kg) is the preferred default muscle relaxant for emergency intubation at RCH.

        Pre-intubation checklist

        • The emergency intubation checklist should be read aloud in a challenge-response format by the Team Leader prior to every emergency intubation.

          Emergency intubation checklist


        Emergency Intubation (pdf)

        Post intubation care

        • The endotracheal tube should be secured with tape / Hollister.
        • Endotracheal tube position should be confirmed with a chest x-ray.
        • Ongoing sedation should be commenced.

        For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.

        Table 6: Cricoid force (pressure)

        • Cricoid force (application of pressure to the cricoid cartilage to compress the oesophagus and prevent passive regurgitation of gastric contents) is different from external laryngeal manipulation (movement of the trachea to help glottic exposure)
        • Cricoid force in children compresses the trachea, making oxygenation and intubation more difficult, results in oesophageal displacement and not compression, and decreases lower oesophageal sphincter tone, making regurgitation more likely.
        • Cricoid force is therefore not routinely used for emergency intubation at RCH.

        Post Intubation Debriefing

        • Post intubation debriefing for team members should routinely occur.This should be short (5-10 mins ) and conducted as soon as possible after the event.
        • This identifies technical and human factors that can be addressed to improve the safety of future intubations.
        • The attached debrief form may be used as a cognitive aid.
        • Emergency Airway Management Debrief Form 

        Last revised 01/09/2016