Page 156 - JSOM Fall 2020

APPENDIX H: PEDIATRIC CONSIDERATIONS

Pediatric Considerations for MSMAID and 1. ETT size: age/4 + 3.5. 7
Airway Management 2. ETT insertion depth (for children over 1 year of age) in
MSMAID centimeters: age/2 + 13
Similar to adult patients, the same preparatory steps should 3. ETT insertion depth (for children under 1 year of age) in
be followed prior to pediatric airway intervention. There are, centimeters: weight/2 + 8
however, significant differences with respect to equipment 4. Tidal volume: 5–8mL/kg, rate concordant with pre-arrest
requirements and provider skill level. The core principles of breathing or rate prior to intervention. PALS recommends
MSMAID remain the same, with the following considerations: initial rate of at least 10–12 breaths/minute. 1,2
• Machine – Continuous ventilation requires specific rate 5. Use caution with BVM, especially if improvising with adult
and volume based on the patient’s age/size. Ensure your BVM. Inflate gently only until the chest begins to rise.
equipment (ventilator) and/or BVM can provide the re-
quired rate and volume prior to intubating or perform- Surgical Airway Management
ing advanced procedures. 1,2 LMAs should be the first choice in all children prior to con-
• Suction – Similar to adults, ideally you can provide in- sideration of surgical intervention. Surgical airways should
line suction, but you also will at a minimum need the NOT be attempted on children younger than 12 years of age
correct size tubes to be able to provide suction. given the maturity of the thyroid cartilage and the cricothyroid
• Monitor – Having pediatric-sized equipment is essential membrane. It should never be attempted in children where
as well as being able to adapt to pediatric sizes using the thyroid cartilage cannot be palpated. For children need-
adult monitors. ing advanced airway intervention younger than 12 years, a
• Airway – Multiple sizes of tubes are essential and proper combination of bag-valve-mask ventilation or placement of a
pre-mission logistic planning includes pediatric supplies. supraglottic airway is recommended. 1,8
• Intravenous access – Ensure you have pediatric sized
needles with 24, 22, 20, and 18g as the primary access References
based on age of the patient. Pediatric intraosseous nee- 1. Eastridge BJ, Mabry RL, Sequin P, et al. Death on the battlefield
dles may be required. (2001-2011): implications for the future of combat casualty care. J
• Drugs – Ensure you have a drug estimation guide, but Trauma Acute Care Surg. 2012;73(6 suppl 5):S431–S437.
always double check pediatric weight–based doses and 2. Hudson I, Blackburn MB, Mannsalinas EA, et al. Analysis of
casualties that underwent airway management before reaching
measurements. role 2 facilities in the Afghanistan conflict 20082014. Mil Med.
2020;185(suppl 1):10–18.
ADDITIONAL EQUIPMENT 3. Blackburn MB, April MD, Brown DJ, et al. Prehospital airway
1. Broselow tape or similar height-based treatment aids. 3 procedures performed in trauma patients by ground forces in
2. Video laryngoscopy (VL) – While this is frequently an ad- Afghanistan. J Trauma Acute Care Surg. 2018;85(1S suppl 2):
S154–S160.
junctive (better/best) consideration for adult airway man- 4. Mabry RL. An analysis of battlefield cricothyrotomy in Iraq and
agement, in the case of pediatric airways, VL has been Afghanistan. J Spec Oper Med. 2012;12:17–23.
shown in studies to out-perform direct laryngoscopy. 4–6 5. Adams BD, Cuniowski PA, Muck A, De Lorenzo RA. Registry
3. Equipment should be pre-packaged and set apart to allow of Emergency Airways arriving at Combat Hospitals (REACH). J
for a rapid inclusion or addition to baseline airway kits. Trauma. 2008;64(6):1548–1554.
6. Tao B, Liu K, Zhao P, et al. Comparison of GlideScope video la-
ESSENTIAL MEASUREMENTS AND FORMULAS ryngoscopy and direct laryngoscopy for tracheal intubation in ne-
onates. Anesth Analg. 2019;129(2):482–486.
Unlike adult airways that are narrowest at the level of the vo- 7. Acosta P, Santisbon E, Varon J. The use of positive end-expiratory
cal cords (and therefore visible during DL or VL) pediatric pressure in mechanical ventilation. Crit Care Clin. 2007;23(2):
tracheas are narrowest at the infraglottic level. In consider- 251–161.
ation of this, the following formulas and treatment aids are 8. Loos PE, Glassman E, Doerr D, et al. Documentation in prolonged
presented to best estimate tube sizes and measurements: field care. J Spec Oper Med. 2018;18(1):126–132.

154 | JSOM Volume 20, Edition 3 / Fall 2020