In this section
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
(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:
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.
The life threat to identify and manage when assessing the airway is actual or impending airway obstruction
The airway doctor should assess the upper airway and the anterior neck looking for 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:
Immobilise the cervical spine - manual in-line stabilisation
(see cervial spine assessement clinical practice quideline)
Sizing of OPA
If you are unable to intubate the
child whose airway is inadequate:
(see also Emergency airway management CPG)
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 Tubes of the size calculated above, plus tube 0.5 mm ID smaller and 0.5 mm ID larger, should all be available on the child's bed.
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.
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
Drugs: Drawn up and labeled:
1. 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).
Up to 1year: Straight blade (Miller or
More than 1 year: Curved blade (MacIntosh 2 or
4. Insert the endotracheal tube
5. Insert an orogastric tube on free
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)
If the event of a CICO event you will need to progress to either a:
(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.
If the lungs do not inflate easily, possible reasons are:
The main problems of needle and surgical cricothyroidotomy are:
Be suspicious in the following injuries:
For definitive burns management see burns / management of burn wounds clinical practice guideline
Airway management is a
Airway obstruction occurs secondary to:
Upper airway obstruction can occur due
to inhaled smoke even in the absence of burn to the face.
If the child is exposed to fire or smoke in an enclosed space e.g.
a building or car, consider inhalation injury until proven
Signs of a respiratory burn injury: