Page 70 - Journal of Special Operations Medicine - Spring 2017

compensatory mechanisms are exhausted. Critically in- cognizant of hand placement, because the adult hand
jured children can decompensate in a matter of minutes is much larger than most children’s faces. Improperly
if vital interventions are not implemented quickly. placed hands can easily become a source of obstruction
to their airway or a mechanism of injury to a child’s eyes.
Management The gastroesophageal sphincter in pediatric patients is
Airway management is of paramount importance in easily overcome by small changes in pressure. Overly
injured children; their anatomic and physiologic differ- vigorous use of the BVM can contribute to aerophagia
ences dictate an even more careful approach than usual. and eventual aspiration if the child is ventilated at high
When available, all pediatric trauma patients with seri- pressures. Providers should only provide the minimum
ous injury should receive 100% oxygen. Many of these bagging pressures necessary to allow for equal rise and
children will eventually require a definitive airway, but fall of the chest. A simplified tool for ventilation rate
endotracheal intubation is a specialized skill that many based on patient age can be used. For a child younger
prehospital providers have seldom performed. Intuba- than 1 year old, bag at a rate of 20 breaths per minute
tion can be difficult even in ideal circumstances; the (bpm); if older than 1 year, bag at a rate of 15 bpm; and
suboptimal conditions commonly found in prehospital if an adolescent, then bag at a rate 10 bpm. Of note,
environments make this procedure fraught with poten- a pneumothorax will be worsened by positive pressure
tial complications. For this reason, prehospital intuba- ventilation via a BVM and may potentially cause ten-
tion has not been shown to improve outcomes when sion physiology. If there is evidence of a tension pneu-
compared with ventilation via bag-mask ventilation. 10,11 mothorax, then immediate needle decompression with
A more practical and recommended approach is ventila- a 16–18 gauge 2-inch catheter at the second intercostal
tion via BVM and/or the use of airway adjuncts until space in the midclavicular line should occur. If there is
the patient can be transported to a safer environment evidence of an open pneumothorax, an occlusive dress-
where the necessary equipment and experienced person- ing will need to be applied until definitive placement
nel are available to ensure a safe and effective endotra- of a thoracostomy tube can be implemented. Note that
cheal intubation. chest tube sizes vary by patient age and, if a thoracos-
tomy tube is not available, an endotracheal tube may
Some minor procedural modifications are necessary for be used as a temporizing measure. In general, the outer
the effective use of the BVM in the pediatric popula- and inner diameters of the endotracheal tube should be
tion. Pediatric BVM reservoir bags come in different compared with a given-sized chest tube. There are no
volumes depending on the age of the child and often randomized trials to date assessing efficacy or inferiority
have pop-off pressure valves. If equipment is available, of the use of endotracheal tubes in place of thoracotomy
neonates should be bagged with a 250mL reservoir bag, tubes. Most of the available literature comes from case
infants should be bagged with a 500mL reservoir bag, reports.
and children should be bagged with a reservoir bag of
1–2L. Pop-off valves usually go off when pressures are If a pediatric patient cannot be ventilated via BVM
greater than 40cmH O; therefore, to enable ventilation, because of facial trauma, burns, or upper airway ob-
2
children with increased airway pressure should have struction, an emergent needle cricothyroidotomy is indi-
the pop-off valve disabled on the BVM reservoir bag. cated. Needle cricothyroidotomy is the preferred type of
When equipment is limited, ventilation via BVM should emergent surgical airway for children younger than 10
be achieved with only the minimum pressure and rate years. Equipment necessary to perform the procedure
4
necessary to maintain oxygen saturations above 95%. include a 14- or 12-gauge sheathed needle catheter, a
When a provider is unable to monitor oxygen satura- 3mL syringe with Luer-Lok tip, the adapter from the end
tions, a good rule of thumb is to provide enough pres- of a 6.5mm endotracheal tube, and a self-inflating bag
sure to allow equal rise and fall of the chest. (e.g., Ambu bag; Ambu A/S; http://www.ambu.com/;
®
Figures 1A–1E).
Patient positioning is extremely important for success-
ful ventilation via BVM. As previously mentioned, the With the patient in sniffing position, locate the cricothy-
large pediatric occiput causes increased lower cervical roid membrane. Take the 3mL syringe and attach it to
spine flexion. In general, placing the patient in the sniff- the 14- or 12-gauge catheter. While aspirating the pa-
ing position should allow enough cervical extension for tient, introduce the catheter into the subcutaneous tissue
proper ventilation. If the true sniffing position is per- at a 90° angle to the skin. When the cricothyroid mem-
formed and there continues to be difficulty ventilating, brane has been disrupted, there should be a return of air
the provider should place a towel underneath the pa- that indicates entry into the airway. Note that when a
tient’s neck between the head and shoulders. This should patient is in extremis, accessing any portion of the air-
overcome most of the lower cervical spine flexion and way is sufficient. The angle of the catheter should be
allow for better ventilation. The provider should also be changed to 45° and caudal at this point. Advance the

48 Journal of Special Operations Medicine Volume 17, Edition 1/Spring 2017