A two year old child presents with fever, stridor and a harsh cough. His condition deteriorates and he requires intubation. Outline how you would do this.
Call for help
This should be in context –
a) If the child becomes hypoxic/has a respiratory arrest etc – proceed with attempt bag mask ventilation 100% oxygen immediately – attempt intubation.
b) If there is time – aim to have the person with the best paediatric airway management expertise – intubate child
Optimise medical management
a) High flow oxygen
b) if child hypoxic – can discuss avoiding distressing the child by holding mask away from face and with child on parents lap (unless really sick)
c) IV steroids – adequate dose (` 0.6mg/kg dexamethasone d) NEB adrenaline 5mg (repeated doses)
e) Oxygen/Helium mixture if tolerates
Adequate discussion of preparation for intubation
a) range of ETT’s (size 4.0, 4.5. 5.0, 5.5)
b) two laryngoscopes with range of blade sizes – straight/curved c) small diam “bougie”
d) cannula for percutaneous needle cricothyroidotomy + method for oxygen delivery
Intubation: One of 2 approaches
(1) Inhalational induction of anaesthesia with maintenance of spontaneous ventilation until adequate depth of anaesthesia achieved to allow intubation (or to assess ability to ventilate – then proceed to paralyse child)
Or (2) IV induction – with paralysis
There must be some discussion regarding risks of either technique. Mere mention of IV approach will not be enough to gain marks. There must be some discussion regarding risks of either technique
However, if not trained in inhalational anaesthetic techniques – reasonable to proceed with
IV induction of anaesthesia + muscle paralysis – with risk of being unable to ventilate
Alternate strategies if unable to intubate Ventilate with LMA/face mask until help arrives Rarely need to proceed to needle cricothyroidotomy
Ohs Manual has a whole chapter on pediatric airway managemnt, and the child with stridor receives some attention (page 1099). I will paraphrase their suggestion regarding the management of such a problem.
Heard, A. M. B., R. J. Green, and P. Eakins. "The formulation and introduction of a ‘can't intubate, can't ventilate’algorithm into clinical practice." Anaesthesia64.6 (2009): 601-608.
Stacey, Jonathan, et al. "The ‘Can't Intubate Can't Oxygenate’scenario in Pediatric Anesthesia: a comparison of different devices for needle cricothyroidotomy." Pediatric Anesthesia 22.12 (2012): 1155-1158.
Weathers E., "The Anatomy of the Pediatric Airway" 2010 -RC EDUCATIONAL CONSULTING SERVICES, INC.
Santillanes, Genevieve, and Marianne Gausche-Hill. "Pediatric airway management." Emergency medicine clinics of North America 26.4 (2008): 961-975.
HOLM‐KNUDSEN, R. J., and L. S. Rasmussen. "Paediatric airway management: basic aspects." Acta Anaesthesiologica Scandinavica 53.1 (2009): 1-9.
Cardwell, Mary, and Robert WM Walker. "Management of the difficult paediatric airway." BJA CEPD Reviews 3.6 (2003): 167-170.