Pediatric Airway Basic 2.1
SFA FMR Standard Approach and Ongoing Assessment EMR PCP
SFA Administer oxygen if SpO2 Is less than Infection Prevention and Control FMR 94% on room air (RA) (IP&C) Considerations EMR Reposition and/or suction prn • N95 respirator is mandatory with PCP Ventilate with BVM and OPA airway management, including EMR Reposition and/or suction prn BVM ventilation PCP Ventilate with BVM and OPA/NPA • Providers directly involved in patient care must be wearing PCP Monitor EtCO2 appropriate PPE
Refer to Pediatric Foreign Body Airway Adequate **Signs of effective ventilation and No Obstruction air entry? oxygenation: Protocol • Increased Sp02 • Improved skin colour Yes • Improved HR • Improved LOC Impending airway Yes obstruction?
No
SFA FMR Ventilate for 2 minutes EMR PCP
Pre-oxygenate with NRB and 15 Ventilation LPM oxygen via nasal cannula Patient and oxygenation No No PCP Prepare all airway equipment unresponsive? effective?** Assess patient for airway intervention (see notes)
Yes
SFA Administer 15 LPM oxygen via FMR nasal cannula Refer to MFR EMR SFA Continue to ventilate with BVM and OPA Dispatch and PCP FMR Communication EMR Continue to ventilate with BVM and Process for OLMC PCP PCP OPA/NPA contact
Yes Consider LMA if symptomatic critical hypoxia (SpO2 85% or less) refractory PCP to 15 LPM oxygen with BVM ventilation (2-person BVM when resources are available) and OPA/NPA
SFA FMR Continue treatment and assessment until EMR transfer of care to EMS PCP
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Pediatric Airway Basic 2.1
Definition
Basic airway management is known to improve patient survival rates in the prehospital field. Once the need for airway intervention has been identified, basic maneuvers and equipment must be used before proceeding with more advanced techniques.
Pediatric Considerations
Problems with oxygenation and ventilation are the major cause of cardiac arrest in infants and children. Respiratory failure can occur quickly and without warning. The first priority in managing any seriously ill or injured child is evaluating and treating airway and breathing. You must anticipate and recognize respiratory distress / failure and initiate treatment immediately.
Initial airway management of the pediatric patient is focused on positioning and effective bag valve mask (BVM) ventilations. Proper BVM ventilation must be attempted prior to considering the Pediatric Airway – Advanced Protocol. When resources permit, 2 -person BVM ventilation should be used.
Interventions
Positioning the patient is the key first step in airway management:
1. Ensure there is adequate padding behind the shoulders, if required, to maintain an open airway
Bag Valve Mask (BVM) Ventilations:
1. If the patient’s intrinsic ventilations are adequate, do not intervene
2. Use an appropriate sized BVM to deliver adequate chest rise without hyperinflating the lungs
3. Placing the mask tightly on the face without opening the airway (e.g. head-tilt / chin-lift, modified jaw thrust) can cause an airway obstruction because of improper positioning
4. An OPA/NPA should be used, if tolerated, whenever a BVM is utilized
Airway Management
Most pediatric airways can be effectively managed with proper positioning and an OPA/NPA and BVM with high flow 15 LPM nasal cannula and often will not require further airway interventions. The gold standard for airway management is the patient maintaining their own airway, not advanced airway placement. Both the International Liaison Committee on Resuscitation (ILCOR) and American Heart Association (AHA) recommend BVM as the preferred technique for airway management in pediatric resuscitation.
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Pediatric Airway Basic 2.1
Airway management in pediatric patients follows a stepwise approach:
1. OPA/NPA and BVM with oxygen 15 LPM via nasal cannula The majority of pediatric airways can be effectively managed by this route and will not require further intervention
2. LMA LMA use is indicated in patients who you are having difficulty effectively ventilating with an OPA/NPA and BVM with oxygen 15 LPM via nasal cannula. Repositioning, suction and BVM (2-person BVM when resources are available) should be attempted first
1. Routine confirmation of airway placement with EtCO2 monitoring is required. It is the presence of a waveform, not the absolute value, which confirms airway placement
2. Continuous EtCO2 monitoring provides valuable information on airway placement and effectiveness of ventilation (OPA/NPA, BVM) a. A flat or absent EtCO2 tracing likely indicates a misplaced or dislodged airway b. Waveform and numerical value can be used to monitor hyper and hypoventilation
Possible Causes of Increased EtCO2 Pulmonary CO2 Output Alveolar Ventilation Technical Errors Perfusion Faulty valves Fever Increased BP Hypoventilation
Malignant Increased cardiac Inadequate fresh gas Bronchial intubation Hyperthermia output flows Partial airway NaHCO3 obstruction Tourniquet release Rebreathing
Venous CO2
embolism
Possible Causes of Decreased EtCO2
CO2 Output Pulmonary Perfusion Alveolar Ventilation Technical Errors Reduced cardiac Accidental tracheal Malfunction of Hypothermia output extubation ventilator Hypotension Hyperventilation Circuit disconnect
Hypovolemia Apnea Sampling tube leak
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Pediatric Airway Basic 2.1
Total airway Pulmonary embolism obstruction Partial airway Cardiac arrest obstruction
Pharmacology
Not applicable
Special Circumstances
Not applicable
Infection Prevention and Control (IP&C) Considerations Many Therapies for respiratory conditions and airway management techniques are known as aerosol generating medical procedures (AGMPs). These often produce splashes of oral secretions, as well as blood, and emesis when they are present. In the presence of an infectious state, oral secretion can transmit harmful pathogens. Personal protective equipment (PPE) that protects the pre-hospital care provider's eyes, nose and mouth as a minimum is mandatory.
Appropriate PPE must be worn while caring for all suspected ILI patients. Refer to AHS Interim Guidance for PPE requirements.
AGMPs should be avoided when possible, and only performed in consultation with OLMC. Common AGMPs Performed by pre-hospital care providers:
• Airway management e.g. intubation or BVM ventilation • Suctioning • Nebulization of medication • CPAP
The patient should wear a procedure mask, if tolerated. Oxygen can be administered while the patient is wearing the procedure mask via a nasal cannula. If the patient requires additional oxygen, a NRB can be used without the accompanying procedure mask
Pre-notification of the receiving facility is mandatory and must be done as soon as
possible
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