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Acta Pediátrica Costarricense

Print version ISSN 1409-0090

Acta pediátr. costarric vol.13 n.supl San José Jan. 1999


 Airway management in traumatized pediatric patients
John H. Fugate, MD

The number one cause of death and morbidity in traumatized patients after the effects of the injury itself is hypoxemia related to inadequate airway control and ventilation. Protection of the airway with adequate ventilation and oxygenation must take priority over ah other conditions.

ll. Airway

The pediatric airway may be comprgmised totally and suddenly or more frequentiy partially and insidiously. The child with an altered level of consciousness is at particular risk for airway compromise. Maintaining oxygenation and preventing hypercarbia are cdtical lo patient outcome, especially in head injured patients. The physician should anticipase and be prepared for vomiting in all injured patients.

Children with maxillofacial trauma, penetrating neck trauma and laryngeal trauma demand aggressive airway management. With maxillofacial trauma hemorrhage, dislocations of fractures may occlude or cause lack of support to airway structures especially in the supine position. Clues to laryngeal injury include subcutaneous emphysema, or palpable fracture. A definitive airway must be established quickly in these type of injuries.

Signs of airway obstruction include:

agitation, hypoxia, head injury, intubation, obtundation, hypercarbia, cyanosis, hypoxia, retractions, accessory muscle use      airway, compromise /V/Q mismatch, stridor, gurgling, partial occlusion pharynx, larynx, dysphoria hoarseness, functional laryngeal
obstruction (feel for fractures) trachea evidence of obstruction.

The pediatric airway, anatomically, has some differences compared to the adult. The smaller the child, the greater is the disproportion between the cranium and the midface. Soft tissues are relatively larger and more floppy compared with oral area. The larynx generally lles higher and more anterior in The neck along with a shorter trachea. This implies The need for The sniffing position to maintain The airway and aiding intubation. Use of oral airways and jaw lift are important adjustments when intubating, and is important to avoid intubating right mainstem bronchus.
lll. Managing the Airway
Assessment of a good airway and adequate ventilation must be done accurately and quickly. There are severas airway maintenance techniques which are weli known and include chin lift, jaw thrust, oropharyngeal and nasopharyngeal airways. A definitive airway includes intubation or establishment of a surgical airway. lndications for a definitive airway include: 1) unconsciousness, (Glasgow coma score of < 8); 2) several maxillofacial fractures; 3) risk for aspiration (vomiting ¡bleeding); 4) risk of obstruction and; 5) inadequate respiratory effort ¡ ventilation including apnea.
lV. Providing a Definitive Airway

Providing a definitivo airway in The pediatric patient  usually means intubation. On rare occasions
provision of a surgical airway is necessary. There are several areas of discussion in providing a definitive airway, including: a) sedation / muscle relaxation; b) cervical spine injuries; c) new modalities and d) surgical airway placement.

Unless a child is profoundly comatose (Glasgow 3) or in cardiopulmonary arrest; sedation and muscle relaxation are needed. An oral endotracheal tube is The preferred route with rapid sequence intubation (RSI) as The technique. The steps inciude:

Preparation to perform surgical airway. if unable to intubate

Pre-oxygenate with 100% 02 and / or with bag mask ventilation (use cricoid pressure)

Cricoid pressure

1-2 mg/kg succinylchohine
Orotracheal intubation

lnflate cuff in order children

Release cricoid pressure and ventilate patient.

lf The patient is stable hemodynamically and has head injury then 3-5 mg/kg of pentothal is recommended as sedation, and some advocate 1 mg/kg of lidocaine. II The patient has no head injury then 0.5-1.0 mg versed may be used for sedation. In hemodynamically unstable patients who need sedation, ketamine 1.0 mg/kg may be used. Rapacuronium, which is a fast acting non-polarizing muscle refaxant and avoids some of the unsatisfactory side effects of succinylcholine may be substituted if available. Ongoing or intermitent muscle relaxation after intubation is frequently initially needed.

lf The patient needs airway control there are several new modalities besides tradicional laryngoscopic intubation that may be useful - both in The trauma room and occasionally in The field. These include fiberoptic intubation, Ballard laryngoscope, lighted stylet (right wand) and laryngeal mask airway. In older children the combitube may also be considered. All of these modalities will be discussed in further detail.

Special consideration is needed in The child with cervical spine injury. In The non-urgent case flexible fiberoptic intubation is safe, fast and reliable providing that a skilled operator and appropriate equipment are available. Surface airway anesthesia and light sedation frequently is all that is needed. In urgent cases laryngoscopy is generally used with RSI. With midline axial stabilization this technique has been shown not to increase the risk of cervical spinal injuries. External laryngeal manipulation backwards, upwards, rightwards (BURP) often improves The view, and styletted tubes are frequently needed.

Surgical airway is needed when intubation cannot be performed. A needle cricothyrotomy may be used in infants as a temporary measure until a surgical tracheostomy can be performed.

In order children an emergency cricothyrotomy may be performed. These will also be discussed in further detail.

V. Post Airway Evaluation

Once The airway has been secured lt is imperative to provide optimal oxygenation and ventilation With appropriate monitoring. Once oxygenation and ventilation have been secured the rest of The trauma survey and management may occur but frequent reassessment of these parameters is necessary.