Critical Procedures

chapter 26 Critical Procedures

Brent R. King, MMM, MD, FAAP, FACEP, FAAEM Christopher King, MD, FACEP Wendy C. Coates, MD, FACEP

Objectives Chapter Outline

Demonstrate the Introduction Section 10: Emergent Intubation 1 maneuvers required Section 1: Pediatric Length-Based 10.1 Endotracheal Intubation for the basic treatment Resuscitation Tape 10.2 Rapid Sequence Intubation of ill and injured Section 2: Cervical Spine Section 11: Rescue Airway children, including Stabilization Techniques oxygen administration, Section 3: Monitoring 11.1 Supraglottic Devices monitoring, and basic 3.1 ECG Monitoring 11.1A Laryngeal Mask Airway airway maneuvers. 3.2 Impedance Pneumatography 11.1B Combitube Demonstrate 3.3 Blood Pressure Monitors 11.2 Specialized Laryngoscopes 2 orotracheal intubation 3.4 Pulse Oximetry 11.2A Fiberoptic Scopes using a manikin model. 3.5 Exhaled Carbon Dioxide 11.3 Laryngoscopes With Special Monitors Blades Demonstrate 11.3A Video Laryngoscopes Section 4: Oxygen Administration placement of an 11.3B Lighted Stylet 3 4.1 Nasal Cannula intraosseous needle 11.4 Tracheal Guides 4.2 Oxygen Masks in a manikin or other 4.3 Nonrebreathing Masks Section 12: Surgical Airway model and describe 4.4 Oxygen Hoods Techniques the landmarks for 12.1 Needle Cricothyrotomy Section 5: Suction intraosseous needle 12.2 Retrograde Intubation Section 6: Opening the Airway placement in a child. 12.3 Wire-Guided Cricothyrotomy 6.1 Chin-Lift Maneuver Describe the 12.4 Surgical Cricothyrotomy 6.2 Jaw-Thrust Maneuver indications and 12.5 Tracheostomy Management 4 Section 7: Airway Adjuncts technique for needle Section 13: Cardioversion and 7.1 Oropharyngeal Airways thoracostomy. Defibrillation 7.2 Nasopharyngeal Airways 13.1 Cardioversion and Describe indications Section 8: Bag-Mask Ventilation Defibrillation and technique for 5 Section 9: Management of Upper 13.2 Automated External pericardiocentesis. Airway Foreign Bodies With Defibrillator Magill Forceps Section 14: Vascular Access 14.1 Peripheral Venous Catheter Placement 14.2 External Jugular Vein

Cannulation 17.2 Dislocations 14.3 Central Venous Catheter Placement 17.3 Shoulder Dislocation 14.4 Umbilical Vein Catheterization 17.4 Elbow Dislocation 14.5 Intraosseous Needle Placement 17.5 Knee Dislocation 14.6 Venous Cutdown 17.6 Hip Dislocation Section 15: Thoracic Procedures 17.7 Splinting 15.1 Needle Thoracostomy (Thoracentesis) 17.7A Volar Arm Splint 15.2 Tube Thoracostomy 17.7B Sugar-Tong Splint (Forearm) 15.3 Emergency Thoracotomy 17.7C Ulnar Gutter 15.4 Pericardiocentesis 17.7D Thumb Spica Section 16: Miscellaneous Procedures 17.7E Sugar-Tong Splint (Upper Extremity) 16.1 Nasogastric or Orogastric Intubation 17.7F Finger Splints 16.2 Catheterization of the Bladder 17.7G Posterior Splint (Lower Extremity) 17.7H Sugar-Tong Splint (Lower Extremity) Section 17: Orthopedic Procedures 17.8 Crutch Walking 17.1 Compartment Syndrome

Introduction chapter addresses the performance of several key Competence in emergency care is, in part, based emergency procedures. The individual practitio- on the physician’s ability to perform potentially ner must determine the extent to which each of lifesaving procedures. In many cases, perfor- these procedures is likely to be required in his mance of the procedure takes precedence over or her practice, but all physicians who care for other aspects of treatment. When a child presents children with serious illnesses and/or injuries in impending respiratory failure or in the early must possess, in addition to cognitive skills, the phases of shock, urgent therapy is warranted requisite procedural skills. All procedures should even in the absence of a specific diagnosis. This be performed with universal precautions.

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1.1 Pediatric Length-Based Resuscitation Tape Length-based resuscitation tape permits the rapid determination of size-dependent resuscitation parameters, such as drug doses, endotracheal tube (ETT) sizes, mask sizes, and vital Figure 26.1 Application of a length-based resuscitation tape. signs, which potentially speeds resuscitation efforts and reduces the likelihood of a medical error. The tape is placed at one end of the 4. Verbalize the color or letter block (on patient, and the other end of the patient aligns the edge of the tape) and the weight with a color-coded block corresponding to the estimate determined by the tape so that patient’s length-based resuscitation parameters. this information can be recorded. There might be two sets of blocks, one of which 5. Use the appropriate color or letter block corresponds to tube sizes, vital signs, etc., and to identify appropriate drug doses and the other of which indicates drug dosing. Many equipment sizes (Figure 26.2). systems include books with color-coded pag- es that provide even more information. Some length-based resuscitation systems will have Section 2: Cervical Spine corresponding color-coded bags or carts that contain the actual resuscitation devices (eg, tra- Stabilization cheal tubes and laryngoscope) and drugs (pre- calculated unit doses). 2.1 Cervical Spine Stabilization Technique Indications 1. Align the end of the tape to the patient. Although cervical spine injuries are relatively Alternatively, if the tape is secured to the rare in children, patients who have sustained gurney, adjust the patient’s position to significant blunt trauma (eg, falls from heights, align with one end of the tape. automobile-pedestrian crashes, moderate to se- 2. Identify the inferior end of the patient vere motor vehicle crashes, diving injuries) and using the heels, not the toes (Figure 26.1). those who sustain direct injury to the neck (blunt 3. If the child is larger than the tape (>36 or penetrating) are at risk, and the cervical spine kg), proceed as in the case of an adult. should be protected before complete evaluation.

Figure 26.2 The length-based resuscitation tape.

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Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians Likewise, children and adolescents with symp- a neutral position. A collar that is too tall toms of cervical cord dysfunction after trauma hyperextends the neck, whereas one that (eg, numbness and/or tingling or weakness in is too short allows for unwanted neck an extremity) should be appropriately stabilized flexion. Both hyperextension and flexion pending further evaluation, even if the symptoms can be disastrous in the face of a cervical are transient. Finally, patients who have signifi- spine injury and, therefore, should be cant alterations in mental status and who might avoided. have been injured should also be stabilized until 4. Some cervical collars require assembly they can be thoroughly evaluated. before use. If necessary, assemble the Equipment collar. • Appropriately sized rigid cervical collar 5. Open the cervical collar and carefully slide (Figure 26.3) the rear portion behind the neck while an • Long spine stabilization board assistant maintains inline stabilization of • Lateral spacing blocks or similar devicesa the patient’s head and neck. a • Straps or tape 6. Bring the front of the collar into position Required for Infants and Young Children: and then attach the front and back • Specially designed long spine stabiliza- portions together using the adhesive tion board with cutout or indentation to straps. The collar should fit snugly but accommodate the occiputa or not constrict the airway or restrict blood • Pad placed on the spine board and ex- flow to the skin (Figure 26.4B). tending from the child’s shoulders to his 7. Ensure that the head remains in a neutral a or her feet position. aThis equipment can be obtained as part of a kit specially 8. Secure the patient to a long spine board. designed for this purpose. If the patient is seated, a short spine board or extrication vest should be secured to the patient to stabilize the head and trunk as a unit. Then place a long spine board beside the patient and, keeping the knees and hips bent, pivot and lower the patient onto the long board. Lower the knees to the board. If the patient is supine, log-roll the patient onto his or her side, maintaining inline stabilization of the neck. Place the long board on edge behind the patient and roll the patient and the board as a unit back into a supine Figure 26.3 Rigid cervical collars in pediatric sizes. position (Figure 26.4C). 9. Secure the patient to the spine board. Technique Place soft lateral spacing devices on 1. Ensure that adequate personnel are either side of the patient’s head. Heavy available to assist. objects such as sandbags should be 2. Stabilize the patient’s head in place by avoided because they can place undue holding the head and keeping the neck lateral pressure on the spine if the board in a neutral position (Figure 26.4A). is inadvertently tilted (Figure 26.4D). 3. Determine the proper size for the cervical 10. Using tape or commercial straps, first collar. The ideally sized collar extends secure the forehead, then the chin, from the top of the shoulders to the shoulders, and pelvis to the board (Figure bottom of the chin, leaving the neck in 26.4E).

Section 2: Cervical Spine Stabilization 26-5

Figure 26.4A The head and neck should be aligned in a Figure 26.4D The cervical spine should be stabilized neutral cervical spine position. by using blanket rolls or blocks from a cervical immobilization device to block lateral head motion and rotation and to prevent upward motion of the shoulder. B E

Figure 26.4B An appropriately sized, rigid cervical collar should be applied. Figure 26.4E The head should be secured by using tape C directly above the patient’s eyebrows.

This can cause the child’s neck to be flexed when he or she is placed in a supine position on a flat surface. This problem can be corrected in two ways. Special spine boards designed with inden- tations or cutouts to accommodate the head can be used. Alternatively, a pad can be placed over the spine board before the patient is secured to it. The child should then be placed on the board such that his or her shoulders and body are on Figure 26.4C The patient should be transferred as a unit the pad but the head and neck are not. Eleva- onto a spine board or other immobilization device long tion of the torso allows the neck to remain in a enough to support the patient’s full length. neutral position. Some recommend that clinically stable, very young infants be stabilized in 11. Examine the patient to ensure that the a car seat (Figure 26.5). stabilization is complete and effective but Complications and Pitfalls is not causing neurovascular compromise The major risk associated with cervical spine and to ensure that neurologic injury has stabilization is unintentional injury to the spi- not occurred during stabilization. nal cord. Excessive movement of the patient’s For infants and young children, the tech- neck must be avoided because such movement nique must be modified slightly because chil- might convert a stable cervical spine fracture dren of this age have relatively large occiputs. not involving the spinal cord into a cord injury

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Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians some cases, attempted stabilization of struggling patients might place them at risk of injury. In such cases, patients can be evaluated without formal stabilization provided that they can remain calm and cooperative during the evaluation. The reasons for the decision not to stabilize should be documented. Spinal stabilization is an all-or-nothing procedure. All personnel must understand that a cervical collar alone is not adequate protection because it allows a significant amount of neck extension and rotation and does not completely eliminate flexion. The straps and lateral supports are an integral part of the system. Effective lateral supports, also called lateral spacing devices, can be made of many materials, including cardboard, foam, or air-filled bladders. Heavy objects, such as sandbags, should not be used because they can put pressure on the lateral side of the neck when the spine board is tilted to one side. Tilting of the board can occur unintentionally during movement or deliberately in the transport of a pregnant adolescent or to allow the patient to vomit without aspirating. Figure 26.5 Very young, clinically stable infants can be Stabilization can compromise circulation stabilized in a car seat. or the airway. These must be assessed after the patient is stabilized and at frequent intervals with neurologic deficits. Therefore, stabiliza- thereafter. The stabilized patient with signifi- tion should be performed carefully, avoiding cant nausea and vomiting can aspirate, and unnecessary movements. Adequate assistance treatment with antiemetics and/or nasogastric is mandatory to ensure that the uncooperative suction might be necessary. Personnel should patient does not harm himself or herself. This carefully log-roll the patient to one side (prefer- technique requires teamwork and should not be ably the left side) to allow him or her to vomit, if undertaken by one person if at all possible. In necessary. Adolescent females in the latter stages of pregnancy might require transport with the board tilted to the left side to reduce pressure KEY POINTS on the inferior vena cava. Stabilization can also make it more difficult to assess other injuries, Performing Spinal Immobilization particularly head and neck injuries. In these • Ensure clinical cervical spine clearance cases it is acceptable to remove the restraint (without radiographs) in selected patients devices to examine the patient while assistants at low risk. maintain inline stabilization. • Maintain cervical spine stabilization in Finally, it is important that the clinician nonawake patients. understand when stabilization can be discon- • Ensure proper cervical spine stabilization tinued. In some cases, cervical restraints can position for children to avoid flexion. be removed after a clinical examination of the • Avoid heavy sandbags. neck. Several studies have demonstrated that patients who do not have neurologic deficits, lack midline cervical spine tenderness, and are

Section 2: Cervical Spine Stabilization 26-7

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians able to voluntarily move their necks without spine flexion, which reduces the risk of spinal experiencing significant pain are unlikely to cord injury and the artifact pseudosubluxation have sustained a fracture of the cervical spine, on initial lateral cervical spine radiographs. provided that the patient has a normal level of consciousness, does not have a second injury causing significant pain (eg, a long bone frac- A ture), and is not intoxicated.1,2 Although the mechanism of injury is not a part of these rules, experience suggests that well-restrained patients involved in low-speed motor vehicle crashes are at even lower risk of cervical spine injury. These rules should be cautiously applied to pediatric patients; however, few very young children have been studied, and more conservative evaluation of these patients is recommended. Unfortunately, the standard three-view series of radiographs of the cervical spine is only 93% to 95% sensitive for the presence of a cervical spine fracture. Conscious patients should undergo a thorough examination of the cervical spine after radiographs have demonstrated no fractures. Computed tomography provides superior images but at the cost of increased radiation exposure. Unconscious patients with normal cervical spine radiographs should remain stabilized unless stabilization is compromising clinical care or B causing injury. Likewise, children with neurologic symptoms should remain stabilized even if their radiographs or computed tomography results are normal. Initially, it can be difficult or impossible to distinguish patients with occult cervical spine fractures from those who have spinal cord injury without radiographic abnormality.3 Children placed on standard spine boards will likely have their necks in moderate flexion. Lateral cervical spine radiographs taken in this position frequently show C2-3 pseudosubluxation (Figure 26.6A, B). This malalignment can be difficult to distinguish from a true subluxation or fracture injury. Absence of prevertebral soft tissue widening, a history of relatively benign trauma, lack of neck pain in an awake patient without other distracting injuries, and alignment of the anterior cortical margins of the spinous processes of C1, C2, and C3 all suggest (but do not guarantee) that this is a pseudosubluxation

and not a true subluxation. It would be preferable Figure 26.6 Two examples of C2-3 pseudosubluxation. to stabilize children properly to avoid cervical Note that the neck is flexed forward.

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Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians important, and each practitioner should learn THE BOTTOM LINE the configuration used in his or her institution (Figure 26.7).4,5

• Optimal cervical spine stabilization requires special positioning for children. • Children are at lower risk for cervical spine fracture and spinal cord injury compared with adults, but this does not RA LA permit clinicians to ignore this risk.

Section 3: Monitoring Monitoring of physiologic parameters is an essential component of modern emergency care. Front Advances in technology have made it possible to measure several key physiologic indicators in a noninvasive manner. There are seven essen- RL LL tial monitoring devices in current use. These are electrocardiographic (ECG) monitoring, impedance pneumographic monitoring, blood pressure Figure 26.7 Lead placement. monitoring, pulse oximetry, exhaled carbon dioxide detection, temperature, and the stethoscope. Measurement of temperature and auscultation Equipment are commonly used by most health care profes- • ECG monitor sionals; these techniques will not be described • Electrodes in this chapter. • Alcohol pads Technique 3.1 ECG Monitoring 1. Ensure that the monitor is functioning ECG monitors detect and display the electrical properly and that the electrode pads are activity produced by the cardiac conducting sys- not damaged. New electrode pads must tem. This monitor allows emergency personnel to be used for each patient to prevent the detect changes in cardiac rhythm. Because these spread of infection and to ensure that the devices measure the difference in electrical poten- adhesive substance can make adequate tial between two electrodes, several electrodes are contact with the patient’s skin. required. The standard monitor has three sensing 2. Select the sites for electrode placement leads. The two upper leads are intended to be and cleanse the patient’s skin with alcohol placed on the left and right arms, respectively, to improve contact. but in practice are usually placed on the left and 3. Allow the alcohol to dry and then attach right sides of the upper torso. Likewise, the lower the electrodes. left lead is intended for placement on the left leg but might be placed on the lower left side of the 4. Turn on the monitor. abdomen. Some monitors have a fourth lead for 5. Most monitors have different lead the right lower extremity, which is placed on the configurations (using different pairs right leg or on the right side of the lower abdo- of leads), which will give a different men. In many cases, the electrodes are labeled so waveform. Select one. Often lead II is that they can be properly placed. In other cases, selected (Figure 26.8). they are color-coded. Proper lead placement is 6. Set the monitor alarms.

Section 3: Monitoring 26-9

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians Figure 26.8 Multi-channel monitor showing lead II ECG, pulse oximetry wave form, impedance pneumatograph wave form, heart rate, blood pressure, pulse oximetry, and respiratory rate.

Complications and Pitfalls air flow. Intermittent auscultation is required to ECG monitoring is generally safe. There are, ensure that the ventilation is indeed adequate. however, a few complications that should be noted. On some monitors, the alarms must 3.3 Blood Pressure Monitors be activated before they will function. Failure Most health care professionals were previously to activate these alarms can result in a serious taught to measure blood pressure by ausculta- dysrhythmia going unrecognized. It is also tion. The modern oscillometric methods that are vital that the staff correctly interpret the data used by monitoring devices replace the sound of received from the monitor. Apparent dysrhyth- blood flowing with a measurement of the oscil- mias should be checked in a second lead con- lations in the arterial wall.5,6 figuration, and the staff must ensure that the Equipment electrodes are properly positioned and that the problem is not related to patient movement. • Properly sized blood pressure cuff (The appropriately sized cuff should cover approxi- 3.2 Impedance Pneumatography mately two-thirds of the upper arm length and should completely encircle the arm. It The impedance pneumatograph uses the ECG should fit snugly but not constrict the arm, electrodes to measure the motion of the chest as this can affect the result. If in doubt, se- wall as a surrogate marker for respiratory effort, lect a larger cuff rather than a smaller one.) which is displayed as a waveform (or square • Blood pressure monitoring device waveform) on the monitor (Figure 26.8).5 Technique Equipment and Technique 1. Place the cuff on the patient’s upper arm Uses the same leads as the ECG monitor. (or thigh). Complications and Pitfalls 2. Attach the cuff to the monitoring device. Like ECG monitoring, impedance pneumatography is subject to artifact caused by patient move- 3. Set the frequency of measurement and ment and lead placement problems. However, the set the alarms. most important potential pitfall in the use of im- Complications and Pitfalls pedance pneumatography lies in the understand- Like all monitors, blood pressure monitors ing that it is measuring chest wall movement, not are affected by patient movement. Likewise,

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Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians improperly sized cuffs and air leaks can affect the A accuracy of the result. A key issue in the measurement of blood pressure is the understanding that the presence of shock is not determined or ruled out by any specific blood pressure value. This is particularly true in early (compensated) shock. A patient with a normal or near normal blood pressure can exhibit shock symptoms.

3.4 Pulse Oximetry The pulse oximeter uses two different wavelengths of light to transcutaneously measure B the degree to which the patient’s hemoglobin molecules are bound to oxygen. The result is expressed as the percentage of oxygen saturated hemoglobin (Figure 26.8). Normally, 97% to 100% of available binding sites are saturated. o In hypoxemic states, when the Pa 2 is less than 70 mm Hg, the pulse oximeter will display an oxygen saturation value of 90% or less.7,8 There are many types of pulse oximeters available. Technological advances have made these devices small and portable. Figure 26.9 Various pulse oximeter probes wrap around Equipment or clip onto a digit or earlobe. • Pulse oximeter • Pulse oximeter probe receiving sections of the probe must be relatively • Alcohol pads well aligned for the device to function effective- Technique ly. There are rare case reports of falsely elevated 1. Choose a location for the placement of pulse oximeter readings caused by ambient light. the pulse oximeter probe. The site must It is, therefore, important to ensure that the re- allow the light waves to pass through the ceiving section of the probe is not exposed. skin to the receiver probe (Figure 26.9). Pulse oximetry is based on the light absorp- Fingers, toes, and ear lobes are often tion characteristics of hemoglobin A (ie, normal used for this purpose. In infants and very adult hemoglobin). It is inaccurate in the pres- young children, the side of the hand or ence of carboxyhemoglobin and methemoglo- foot can be used. bin. It is fairly accurate for fetal hemoglobin and 2. Clean the skin at the site if necessary. most other hemoglobinopathies. Pulse oximetry can be falsely elevated by 3. Apply the probe, making certain that the the presence of carboxyhemoglobin (ie, the transmitting and receiving portions are pulse oximeter reads 100% when the true oxy- well aligned. gen saturation is lower). When carbon mon- 4. Connect the probe to the monitor and oxide poisoning is suspected, a blood sample confirm that the heart rate measured by for co-oximetry or a carboxyhemoglobin level the device correlates with the patient’s should be tested. An arterial or venous blood actual heart rate. gas measurement will similarly be misleading o Complications and Pitfalls because it will show a high P 2 and high calcu- Like all monitoring devices, the pulse oxim- lated oxygen saturation, although it might cor- eter is subject to erroneous readings caused by rectly demonstrate a metabolic acidosis. Most patient movement. Likewise, the sending and blood gas analyzers do not automatically run

Section 3: Monitoring 26-11

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians co-oximetry, which uses four wavelengths (as The pulse oximeter does not measure the opposed to only two wavelengths for pulse ox- patient’s hemoglobin concentration, so the pa- imetry) that can accurately detect carboxyhe- tient’s oxygen-carrying capacity cannot be fully moglobin presence. A blood gas without the co- assessed. A patient with an oxygen saturation of oximetry component will have falsely elevated 95% and hemoglobin concentration of 6 mg/dL oxygen saturation because it is calculated based has a lower oxygen content than a patient with o on the P 2 and not actually measured. Thus, it is an oxygen saturation of 90% and a hemoglobin the co-oximetry portion that correctly identifies concentration of 14 mg/dL. the presence of carboxyhemoglobin and not the Finally, the pulse oximeter gives no infor- co blood gas measurement. mation regarding the Pa 2 and, therefore, no Methemoglobinemia presents a similar but information about the adequacy of ventilation. It is less misleading phenomenon. The accuracy possible for a child receiving supplemental oxygen of the pulse oximeter is directly related to the to be well oxygenated and yet be hypoventilating. amount of methemoglobin. When more than 30% of the patient’s hemoglobin exists as met- 3.5 Exhaled Carbon Dioxide Monitors hemoglobin, the oximeter will display an oxy- Capnometry devices measure and, in some gen saturation of approximately 85%. Lesser cases, quantify the exhaled carbon dioxide.9,10 degrees of methemoglobinemia are associated After endotracheal intubation, capnography with higher displayed oxygen saturations. The is used to confirm that the tube is located in displayed oxygen saturation might be in the the trachea; later it is used to ensure the tube slightly low range (eg, 93%-95%). The oxygen remains properly located. Carbon dioxide de- saturation displayed by the pulse oximeter does tectors are small plastic devices that are inserted not accurately reflect the degree of methemo- into the ventilation circuit closest to the ETT globinemia. An arterial blood gas analysis will (Figure 26.10). These devices change color as o reveal a high P 2 (especially if the patient is carbon dioxide flows through the device. The receiving supplemental oxygen), and the cal- color change visible with each respiration indi- culated oxygen saturation will be falsely high cates the presence of carbon dioxide, confirm- (usually 100%, despite the lower oxygen satu- ing endotracheal intubation. End-tidal carbon ration measured by pulse oximetry, which is a dioxide (ETCO2) monitors quantify the degree discrepancy that should lead to this diagnosis). of exhaled carbon dioxide. A sensor is inserted In addition, the patient’s blood will appear to be into the ventilation circuit closest to the ETT. chocolate brown in color (if the methemoglobin The sensor is then connected by wires to an percentage is high enough), and the patient will ETCO monitor to follow or track ventilation appear to be dusky or pale (often described as 2 (gas exchange) because the ETCO2 measure- ashen gray). In other instances where there is ment (numeric display on the monitor) usu- doubt as to the accuracy of the pulse oximeter co ally approximates the arterial P 2 (except in reading, co-oximetry should be obtained. instances described below). An arterial blood Note that methemoglobinemia pulse oximetry measurements are low, but they should be lower. This is less misleading than in carbon monoxide poisoning, where the pulse oximetry measurements are usually 99% to 100%. In addition, although methemoglobinemia patients are dusky, pale, or grayish, carbon monoxide– poisoned patients are pink and can appear to be well oxygenated. Table 26-1 describes the pulse oximetry, arterial blood gas, and co-oximetry differences among normal hemoglobin, carboxyhemoglobin, and methemoglobin. Figure 26.10 Using the carbon dioxide detector.

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Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians TABLE 26-1 Oximetry Measurement Method Differences in Patients With Carbon Monoxide Poisoning and Methemoglobinemia

Normal Hemoglobin Carboxyhemoglobin Methemoglobin 20% 20%

Room Air (Normal Lungs)

pH (ABG) 7.4 <7.4 <7.4

o 100 100 100 P 2 (ABG), mm Hg Calculated oxygen 99 99 99 saturation (ABG), %

Color of blood (ABG) Red Red Brown

Pulse oximetry oxygen 99 100 90 saturation, %

Co-oximetry oxygen 99 80 80 saturation, %

Clinical color Pink Pink Dusky/gray

io Supplemental Oxygen 50% F 2 (Normal Lungs) pH (ABG) 7.4 <7.4 <7.4

o 350 350 350 P 2 (ABG), mm Hg Calculated oxygen 100 100 100 saturation (ABG), %

Color of blood (ABG) Red Red Brown

Pulse oximetry oxygen 100 100 90 saturation, %

Co-oximetry oxygen 100 80 80 saturation, %

Clinical color Pink Pink/red Dusky/gray

io Abbreviations: ABG, arterial blood gas; F 2, fraction of inspired oxygen.

co gas analysis should be performed to confirm the exchange, exhaled P 2 will be lower than the accuracy of the ETCO measurement. co 2 arterial P 2. For example, New carbon dioxide detectors intended for • Low cardiac output, severe hypotension, use in the spontaneously breathing patient are cardiac arrest (false readings) becoming more available and can become an • Severe airway obstruction (increases essential monitoring tool for patients undergo- dead space) ing procedural sedation and those who require • Severe parenchymal lung disease (in- continuous monitoring of their ventilation. creases dead space) Complications and Pitfalls The following conditions can result in capnometry measurements that are lower than the Section 4: Oxygen arterial Pco . This occurs because capnometry 2 Administration requires the carbon dioxide to be exhaled for the device to detect or measure it. In conditions Supplemental oxygen is indicated for the treat- of reduced pulmonary blood flow or poor air ment of documented hypoxemia. Although oxy-

Section 4: Oxygen Administration 26-13

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians gen is used liberally for other indications, there is scant evidence to support this practice. There KEY POINTS are, however, several oxygen delivery devices, and each has its own indications and limitations. Use of Monitoring Devices in the Equipment Emergency Department (ED) • Oxygen source (eg, hospital gas system, • Know limitations of monitoring devices. oxygen cylinder) • Carbon monoxide poisoning and • Oxygen delivery device (eg, nasal can- methemoglobinemia can result in false nula, mask, oxygen hood) pulse oximetry readings.

• Presence of ETCO2 indicates endotracheal 4.1 Nasal Cannula intubation. • Lack of ETCO suggests esophageal This simple device consists of soft rubber tubing 2 fitted with two small prongs, or nipples, intend- intubation unless pulmonary circulation ed to direct oxygen into the patient’s nares or at is poor, in which case it is still possible that the trachea is intubated (requires least enrich the oxygen concentration around confirmation by another method such as the nares (Figure 26.11). These devices are avail- direct visualization). able in a variety of sizes and have the advantage of being better tolerated than face masks. They have several disadvantages. Obviously, they are less useful in children with nasal obstruction. Likewise, less oxygen is delivered in the child THE BOTTOM LINE who is crying excessively or mouth breathing. Finally, oxygen flow rates higher than 2 to 4 All monitoring devices can provide misleading L/min are uncomfortable and might be poorly information under certain conditions. tolerated. Some children will have oxygen requirements that cannot be met by nasal cannula. Technique 1. Choose the correct size for the patient. 4.2 Oxygen Masks 2. Insert the nasal prongs into the anterior Oxygen masks are clear plastic masks that fit over nares. the mouth and nose (Figure 26.12). They provide 3. Drape the tubing behind the ears. more oxygen than a nasal cannula because they 4. Consider securing the tubing to the create a more closed system. With oxygen flow patient’s face with tape. rates of 6 or more L/min, the patient will receive a io 5. Connect the distal end of the tubing to fraction of inspired oxygen (F 2) of 30% to 60%. the oxygen source. These masks have exhalation ports and, depend- 6. Monitor the patient’s oxygen saturation. ing on how well the mask fits, there might be spaces along the sides of the mask. These areas allow the patient to “entrain” room air with each breath and, therefore, dilute the inspired oxygen. Face masks are poorly tolerated by some children.

4.3 Nonrebreathing Masks When a child requires an even higher concentration of oxygen, this can often be provided by a nonrebreathing mask (Figure 26.13). These devices are simple face masks with two important modifications. First, the exhalation ports have Figure 26.11 Infant and pediatric nasal cannulas. one-way valves so that the patient cannot inhale

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Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians 3. Connect the distal end of the tubing to the oxygen source. 4. The oxygen flow should be at least 6 L/min. 5. The reservoir bag might need to be unfolded and manipulated to inflate. 6. Monitor the patient’s oxygen saturation.

4.4 Oxygen Hoods Oxygen hoods can deliver relatively high con- centrations of oxygen without the discomfort sometimes associated with a face mask. They are generally used only in young infants because older children can easily remove them.

Technique 1. Assemble the hood (if necessary). 2. Ensure that the patient is in the supine position. 3. Place the hood over the patient’s head. 4. Connect the device to the oxygen source. Figure 26.12 A proper size mask extends from the bridge of the nose to the cleft of the chin. 5. Monitor the patient’s oxygen saturation. Complications and Pitfalls The most significant potential complication of emergency oxygen therapy lies in its misuse. Oxygen therapy is indicated for hypoxemia, not respiratory failure. To benefit from oxygen therapy, the patient must have adequate ventilatory effort. The patient with inadequate ventilatory effort might require oxygen therapy but will also require assisted ventilation. Another common error is the use of a self-inflating ventilation bag (discussed later) to deliver blow- Figure 26.13 Pediatric nonrebreathing mask. by oxygen. This type of ventilation device has a one-way valve that prevents the delivery of room air through them. Second, and most impor- oxygen to the mask unless the bag is squeezed tant, the mask is equipped with a reservoir bag (regardless of the oxygen flow rate into the for the collection of more oxygen. This reservoir tail of the device). Hospital oxygen delivery bag provides the patient with a second source systems rarely fail, but oxygen tanks have a of oxygen. The bag must inflate with oxygen for limited capacity. This capacity must be taken this to work. With a well-fitting mask and high into consideration when planning treatment. enough oxygen flow, the patient can receive a io F 2 of well over 90%. Technique Section 5: Suction 1. Choose a mask that fits over the nose and The airway can easily become occluded by se- mouth with as few gaps as possible. cretions or foreign material, such as emesis or 2. Secure the mask to the patient’s face blood clots. The ability to clear these obstructions using the elastic strap. using the appropriate suction apparatus is criti-

Section 5: Suction 26-15

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians cal to basic and advanced airway management. • Tracheal suction catheters of various Appropriately sized equipment should be readily sizes from 5/6 Fr to 14 Fr (Figure 26.16) accessible and prepared for use before any airway • Suction source procedures. At least one functioning suction apparatus is required at the head of the patient’s bed, and the following functional attachments must be available for use if needed.11-13

5.1 Suction Indications and Equipment 1. Tonsillar tip suction tips—for the removal of solid materials, such as vomitus or blood clots, from the hypopharynx. Most stiff suction tips have several small holes at the tip that will not permit suctioning of solid debris. To suction solid material, a stiff suction tip with a large end hole must

be used. Figure 26.14 Tonsillar tip. 2. Nasogastric or orogastric tubes—for the removal of gastric secretions and air from the stomach. If not contraindicated, a nasogastric suction device should be placed in every intubated patient. 3. Tracheal suction catheters—these devices Connects to are used in combination with a saline suction source

wash to remove secretions and mucus Pigtail air vent left from ETTs or tracheostomy tubes. open to vent lumen Contraindications Cross-section of lumen Air 1. Avoid deep tonsillar tip suction in awake or lightly sedated patients to prevent Suctioned gagging, emesis, or laryngospasm. materials Suction Vent 2. Avoid nasogastric tubes in cases of facial or lumen lumen cranial trauma (use the oral route instead). Gastric contents 3. Use caution when placing orogastric tubes in patients with suspected laryngeal, penetrating neck, or esophageal injury.

4. Avoid vigorous suctioning with tracheal Figure 26.15 Double lumen sump tube. suction catheters in patients with fresh surgical tracheostomies. Equipment • Tonsillar tip (stiff) adult- and pediatric- sized suction catheters (Most of these have several small holes at the tip. Some have a single large hole at the tip.) (Figure 26.14) • Nasogastric or orogastric tubes of various sizes from 10 to 16 Fr, with connectors to suction tubing (Figure 26.15) Figure 26.16 Suction catheter.

26-16 Critical Procedures

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians Technique Complications and Pitfalls Oral suctioning with tonsillar tip: 1. If the suction device becomes completely 1. Connect suction apparatus to wall occluded, then suctioning will fail. suction or portable suction pump and Whenever possible, use the adult adjust to medium, continuous pressure Yankauer suction tip to avoid clogging the (not to exceed 300 mm Hg). If suctioning suction apparatus with large particles of vomitus, the suction strength will need debris or blood clots. A second stand-by to be increased to high and a stiff suction suction apparatus is strongly encouraged. tip with a larger hole will be necessary. Ideally, this device should be a rigid-tipped 2. Preoxygenate patients by increasing suction device for the suctioning of larger oxygen delivery or manually ventilating debris. Also remember that the suction them. tubing can be used directly without the 3. Open the mouth manually and sweep the Yankauer tip if the tip becomes clogged suction tip across the oropharynx, under with debris. direct visualization. 2. To function effectively, nasogastric 4. Limit suctioning to 10 seconds per or orogastric tubes must extend into attempt or less, depending on the the stomach. These tubes should be patient’s condition. measured before placement. 5. Reoxygenate the patient manually 3. Nasogastric or orogastric tubes can be between attempts. unintentionally inserted into the trachea. Tracheal suctioning with ETT or tracheostomy Always check placement with auscultation tube: immediately after placement. 1. Connect suction apparatus to wall 4. Tracheal suctioning can produce suction, adjust to low, continuous significant hypoxemia. The patient should pressure (not to exceed 100 mm Hg). receive supplemental oxygen before the 2. Preoxygenate the patient by increasing procedure begins and then be monitored oxygen delivery or manually providing throughout the procedure. The procedure ventilatory support to the patient. should be limited to 15 seconds. 3. Apply sterile gloves and open sterile 5. Tracheal suctioning can produce vagally suction setup. mediated cardiovascular alterations and 4. Advance the sterile catheter beyond the should be used judiciously with careful distal tip of the ETT or tracheostomy monitoring in the unstable patient. tube without applying suction. 6. All suctioning techniques can produce 5. When the catheter can no longer be mucosal irritation. Overly vigorous easily advanced, withdraw the catheter suctioning, suctioning using very in a rotating manner while intermittent high suction pressure, and excessively vacuum pressure is applied. frequent suctioning should be avoided. 6. Limit vacuum suction time to 10 to 15 seconds. 7. Reoxygenate the patient manually Section 6: Opening the Airway immediately after suctioning. Under the right (or wrong) circumstances, dif- 8. Suctioning can be repeated as necessary. ficulties in intubation and ventilation can oc- To loosen mucous plugs, inject 1 to 2 cur in almost any patient. Some patients have mL of sterile saline into the ETT between anatomical features or other limitations that attempts. should be recognized as potential impediments 9. After airway suctioning, the catheter to effective airway management before the ad- can be used to suction oropharyngeal ministration of neuromuscular blocking agents. secretions. Although some children require immediate

Section 6: Opening the Airway 26-17

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians airway management, when time permits, it is indeed unconscious and unable to bite prudent for the physician to perform a brief the rescuer. Hyperextension of the neck evaluation of the airway in an attempt to identify should be avoided in infants and young the presence of a “difficult airway.” This assess- children (Figure 26.17). ment can afford the physician an opportunity 4. Confirm adequate ventilation by looking to use an alternative method of airway man- for chest wall rise, by feeling for exhaled agement and to avoid potential disaster. The air, and by auscultation. assessment of the difficult airway is discussed thoroughly in Chapter 2, The Pediatric Airway in Health and Disease.14 Potential rescue airway devices are discussed later in this chapter. The initial step for most children requiring urgent airway intervention will be a basic maneuver designed to relieve the airway obstruction that inevitably accompanies loss of tone in the upper airway. The two techniques that are commonly used are the chin-lift maneuver and the jaw-thrust maneuver.

6.1 Chin-Lift Maneuver Figure 26.17 The chin-lift maneuver should be used to Indications place the airway in a neutral position. The chin-lift maneuver is indicated in children who have a depressed level of consciousness Complications and Pitfalls with concomitant upper airway obstruction and The chin-lift maneuver can cause or exacerbate who have not sustained any trauma.15,16 cervical spine injury and should not be used in Contraindications those who have sustained trauma. Hyperexten- Because this technique involves movement of sion of the neck in infants and young children the neck, it should not be performed in children can cause, rather than relieve, airway obstruction. who have sustained trauma, even if radiographs do not demonstrate a cervical spine fracture. 6.2 Jaw-Thrust Maneuver Technique Indications 1. Verify unresponsiveness. The jaw-thrust maneuver is indicated when the 2. Place one hand on the forehead and the movement of the patient’s neck is impossible or other on the mandible just lateral to the imprudent (Figure 26.18).15,16 chin. Contraindications 3. Gently depress the forehead with There are no contraindications to this technique; one hand to extend the neck while however, it might be ineffective in children with simultaneously lifting the chin anteriorly significant mandibular injuries. with the other. Classically, this technique is performed by placing the fingers of Technique the dominant hand beneath the patient’s 1. Without moving the neck, place both chin and then lifting the chin anteriorly hands at the mandibular angle and and caudally. In some cases, it might be push the mandible anteriorly. This is necessary to firmly grasp the chin and/ commonly done by using the maxilla/ or skin or to use the lip or teeth to gain zygoma or forehead region for leverage. the appropriate mechanical advantage. 2. Confirm adequate ventilation by looking If the latter technique is used, care must for chest wall rise, by feeling for exhaled be exercised to ensure that the patient is air, and by auscultation.

26-18 Critical Procedures

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians Indications Oropharyngeal airways are indicated for reliev- ing upper airway obstruction, serving as a “bite block” to protect the ETT, and facilitating oral and pharyngeal suctioning. Contraindications Oropharyngeal airways should not be used in conscious or semiconscious patients (including lightly sedated or anesthetized patients) who have intact protective airway reflexes. When used in these patients, oropharyngeal airways can cause Figure 26.18 The jaw-thrust maneuver should be used in a child with possible spinal injury. gagging, vomiting, or catastrophic laryngospasm or bronchospasm. Nasopharyngeal airways are generally better tolerated in awake or semicon- Complications and Pitfalls scious patients. Do not use either type of airway Movement of the neck should be avoided. in cases of suspected foreign body aspiration. Equipment Section 7: Airway Adjuncts • Properly sized oral airway (available in sizes 55 to 90 mm)—to estimate size, Oropharyngeal airways and nasopharyngeal air- place the airway on the patient’s cheek. ways provide a mechanical stent that relieves With the flange at the level of the lips, soft tissue obstruction from the mouth to the the distal pharyngeal tip should be at the glottis (oral airway) or from the nasal opening angle of the mandible (Figure 26.20). to the glottis (nasal airway). They can be used in intubated and nonintubated patients. These Technique airways are important in overcoming proximal 1. Select the appropriately sized oropharyn- airway obstruction for effective spontaneous geal airway. and bag-mask–assisted ventilations.11 2. Suction the oral cavity if indicated. 3. Open the mouth and place a tongue 7.1 Oropharyngeal Airways blade at the base of the tongue. Oropharyngeal airways are rigid, semicircular 4. Depress and pull the tongue forward tubes (or sometimes H-shaped in cross-section) with the tongue blade, lifting it off the with a central lumen (Figure 26.19). They can be posterior pharyngeal wall. used in intubated and nonintubated patients. In 5. Insert the airway, leaving 1 to 2 cm intubated patients, they serve to protect the ETT protruding beyond the incisors. from being crushed between the patient’s upper and lower jaws.

Figure 26.20 An oropharyngeal airway should be placed next to the face, with the flange at the level of the central Figure 26.19 Different sizes of oropharyngeal airways. incisors and the bite block segment parallel to the hard palate.

Section 7: Airway Adjuncts 26-19

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians 6. To complete the insertion, perform a jaw- thrust maneuver with the fingers until the flange is even with the lips. 7. Relax the jaw thrust. 8. Check that the tongue and lips are not caught between the teeth and the airway. Alternative Technique 1. Select the appropriately sized oropharyngeal airway. 2. Suction the oral cavity if indicated. 3. Open the mouth and insert the oral airway such that the curved portion of the device depresses the tongue. 4. Rotate the airway 180° into position, leaving 1 to 2 cm protruding beyond the incisors. 5. To complete the insertion, perform a jaw- thrust maneuver with the fingers until the flange is even with the lips. 6. Relax the jaw thrust. 7. Check that the tongue and the lips are not caught between the teeth and the airway. Complications and Pitfalls The oropharyngeal airway must be appropriately sized to function properly. An oral airway that Figure 26.21 Improperly sized oropharyngeal airways. An is too large can obstruct the airway and might airway device that is too large will displace the epiglottis stimulate potentially lethal laryngospasm and/ inferiorly over the glottic opening. An airway that is too or bronchospasm. Conversely, an oral airway small will impinge on the tongue, displacing it posteriorly into the hypopharynx. that is too small will push the tongue base posteriorly into the pharynx, worsening the airway Adapted from: King C, Henretig FM, eds. Textbook of Pediatric Emergency Procedures. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; obstruction (Figure 26.21). 2008:107.

7.2 Nasopharyngeal Airways A nasopharyngeal airway is a soft rubber or plastic tube that provides a mechanical stent to relieve soft tissue obstruction from the nares to the glottis (Figure 26.22).11 Indications Nasopharyngeal airways can be used in awake or lightly sedated patients when airway obstruction is not relieved with an oropharyngeal airway alone (eg, large adenoids, swollen tonsillar tissues) and in patients with trismus when placement of an oral airway device is difficult or impossible (eg, status epilepticus). Figure 26.22 Different sizes of nasopharyngeal airways.

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Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians Contraindications b. If resistance is felt in the posterior na- The following are contraindications to nasopha- sopharynx, a gentle anterior-posteri- ryngeal airway placement: or, back-and-forth motion of the nasal 1. Trauma with suspected nasal or basilar airway a few millimeters in each direc- skull trauma or midface fractures tion or a gentle rotation in a clockwise 2. Coagulopathy (epistaxis) or counterclockwise direction while 3. Prior history of nasal facial surgery (eg, advancing will help in passing the cleft palate repair) tube. c. If continued resistance is felt, remove 4. Adenoid hypertrophy the tube and attempt placement in the 5. Suspected foreign body aspiration opposite nostril. Consider the need Equipment for a smaller tube. • Properly sized nasal airway (available in 6. On the left: sizes 16 Fr through 34 Fr)—to estimate a. Insert the tube with the bevel toward size, place the nasopharyngeal airway at the septum. The nasopharyngeal air- the tip of the nose. A properly sized tube way will be pointed upward and resis- will extend to the tragus of the patient’s tance will be felt at 1 to 2 cm. ear (Figure 26.23). A shortened ETT can b. Rotate the airway 180° into position also be used as a nasal airway. with the flange resting against the base of the nostril (Figure 26.24).

Figure 26.23 The nasopharyngeal airway should be placed next to the face and measured from the tip of the Figure 26.24 For the left nostril, the nasopharyngeal nose to the tragus of the ear. airway should be initially inserted with the curvature upward until resistance is felt (approximately 2 cm), then Technique the device should be rotated 180° and advanced until the flange is against the outside of the nostril. 1. Select an appropriately sized nasopharyngeal airway. Complications and Pitfalls 2. Suction the nares if indicated. The nasal airway must be appropriately sized to 3. Lubricate the airway with water-soluble function properly. lubricant. 4. Hold the tube between the thumb and the first two fingers of the dominant hand Section 8: Bag-Mask Ventilation and insert it into the nostril with the Because resistance to gas flow through a tube in- bevel facing the patient’s nasal septum. creases to the fourth power as the lumen becomes 5. On the right: smaller, infants and children have higher baseline a. Pass the tube along the floor of the na- airway resistance than adults. They also experi- sal passage “downward” (ie, do not aim ence substantially greater increases in resistance it upward) toward the posterior phar- with the same amount of airway narrowing (ede- ynx using slow, gentle, steady pressure. ma, obstruction). Furthermore, the respiratory

Section 8: Bag-Mask Ventilation 26-21

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians muscles (intercostals and diaphragm) of infants Equipment and children have fewer fatigue-resistant fibers • Manual resuscitator (self-inflating or gas than adults and thus tire (fail) more rapidly. inflated) These characteristics, combined with the • Appropriately sized masks rarity of cardiac disease in pediatric patients, The most important difference in BMV set- account for the fact that most episodes of cardiac ups is determined by the type of resuscitation arrest in children are secondary events after (pri- bag used, that is, a self-inflating bag (manual mary) respiratory failure and arrest. In adults, resuscitator) vs a standard anesthesia bag (also cardiac arrest is usually a primary process re- known as the Rusch bag). As the name implies, sulting from ischemia. This is perhaps the most a self-inflating bag is designed to reinflate auto- fundamental difference in terms of resuscitation matically after being compressed and released between pediatric and adult patients. For this during BMV. Although this might make the reason, bag-mask ventilation (BMV) is a crucial procedure somewhat easier to perform, rapid skill in managing pediatric arrests. In addition, reexpansion of the bag with each ventilation although emergent endotracheal intubation will allows entrainment of ambient air, even when be performed in the ED by physicians, BMV an oxygen reservoir is used, thereby decreasing serves as the initial method to maintain ventila- the concentration of oxygen delivered to the tion and the method of choice if endotracheal patient. This disadvantage is also an advantage. intubation is unsuccessful. Many types of health Because self-inflating bags are not dependent care professionals (nurses, respiratory thera- on an external gas source, they will continue to pists, physician assistants) might be called on function even when the oxygen tank is depleted. to perform BMV in a pediatric resuscitation.17,18 This allows the patient to receive ventilation, albeit with room air, until the oxygen tank can 8.1 Bag-Mask Ventilation be replaced (Figure 26.25). Indications Indications for BMV include all circumstances in which assisted or controlled ventilation is required. The list of potential causes is long and involves a diversity of mechanisms, such as neurologic causes (diffuse axonal injury, herniation syndromes), infectious causes (sepsis, meningi- tis), upper airway causes (anaphylaxis, thermal injury), and lower airway causes (pneumonia, asthma, pulmonary contusion), among many others. There are few contraindications to this procedure. Relative contraindications include Figure 26.25 A self-inflating bag. conditions that make performing effective BMV extremely difficult or impossible, such as severe By contrast, an anesthesia bag will inflate facial or mandibular injuries or complete up- only if there is sufficient oxygen inflow, a closed per airway obstruction from a foreign body. If system is maintained (good mask seal), and the the patient has a known pneumothorax, BMV adjustable pressure leak valve is set appropri- should only be performed for a brief period be- ately (Figure 26.26). Although these requirements fore decompression of the affected hemithorax make BMV more complicated, failure of the bag is performed to avoid precipitating a tension to reexpand provides a valuable indication that pneumothorax. The two absolute contraindi- a significant problem exists and must be cor- cations to BMV are meconium in a depressed rected. Such problems (eg, depletion of an oxy- newly born infant and known diaphragmatic gen tank or a poor mask seal) do not prevent hernia, which both require immediate endotra- reexpansion of a self-inflating resuscitation bag cheal intubation. and might therefore go undetected.

26-22 Critical Procedures

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians If the child is not moving adequate air, position the head and neck so that the upper airway is most likely to be patent. This is generally best accomplished by flexing the neck slightly and rotating the head upward in a “sniffing position” (Figure 26.27). For patients with no risk of neck trauma, use the chin-lift maneuver to open the airway. For trauma patients, use the jaw-thrust maneuver to reduce neck movement. If necessary, place a small pad under the patient’s head to produce neck flexion. This will not usually be Figure 26.26 An anesthesia bag. required with young infants because they have a relatively large occiput, which causes neck flexion whenever they are supine on a firm, flat KEY POINTS surface. In infants it might be necessary to place a small towel under the shoulders to level the Basic Airway Management plane of the airway. • Position the head. • Open the airway using the jaw-thrust or chin-lift maneuver or by placing an oropharyngeal or nasopharyngeal airway. • Select the appropriate oxygen delivery device. • Provide assisted ventilation (BMV).

Basic airway management is especially rel- evant in the ED because BMV circuits with self- inflating bags are used by out-of-hospital and Figure 26.27 The airway should be placed in a neutral emergency personnel far more commonly than sniffing position to keep the trachea from kinking when the neck is flexed or hyperextended. anesthesia bag circuits. For this reason, only the use of self-inflating bag circuits is described here. If the patient continues to have inadequate Technique respirations after appropriate airway maneu- As with most aspects of pediatric advanced life vers, BMV should be started. support, performing BMV in an infant or child First, the smallest mask that completely begins with the ABCs (airway, breathing, circula- covers the nose and mouth should be selected. tion). First, determine whether the child requires A mask that is too large will compress the eyes, BMV using the “look, listen, and feel” method if causing injury and/or bradycardia. A mask that necessary. Look at the chest wall for any respi- is too small will make it impossible to establish ratory effort and/or signs of respiratory distress and maintain an adequate mask seal on the face. (belly breathing, retractions). Listen, with one The mask should be measured from the bridge ear close to the child’s nose and mouth, for any of the nose to the cleft of the chin. air movement. Feel, with one cheek close to the Next, a bag that is appropriately sized for child’s nose and mouth, for any air movement. the patient should be selected. It is always pos- These steps might not be necessary, as with a sible to ventilate with a bag that is too large— child in cardiac arrest, but they can be useful in and never possible with one that is too small. many circumstances. This aspect of the assess- A change to a better size bag or mask can be ment should take at most only a few seconds. made, even during the procedure, if this seems

Section 8: Bag-Mask Ventilation 26-23

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians necessary. A process of trial and error is often chest excursions approximate a normal deep required in selecting the best equipment for this inspiration. Once chest rise is visible, enough procedure. The physician should not make the volume has been delivered to the patient, so mistake of using improperly sized equipment. the bag should be slowly released. Less than The mask should be applied to the face with this will not provide an adequate tidal volume; the nondominant hand while the head and neck more will cause air entry into the stomach, in- are positioned optimally to maintain airway creasing the risk of vomiting and aspiration. The patency. The index finger and thumb gently heart rate and, if available, pulse oximetry and/ compress the mask onto the face (C-grip), and or capnometry should be monitored to ensure the 3rd, 4th, and 5th fingers are placed on the that the procedure is being properly performed. angle of the jaw, forming an “E.” The entire hand Bradycardia, hypoxia, and hypercapnia are all placement for BMV is called the EC clamp. The possible indications of poor technique. fingers on the jaw should pull the patient’s chin Complications and Pitfalls into the mask, creating a good mask seal. The most common serious complication that The resuscitation bag should be compressed occurs with BMV is aspiration pneumonitis. Pa- with the dominant hand at an age-appropriate tients who require BMV often have diminished rate (Figure 26.28). It is helpful to control the or absent protective airway reflexes and, in the rate and volume by saying, “Squeeze, release, out-of-hospital and ED settings, a full stomach. release.” Squeeze the bag just until chest rise is Unlike endotracheal intubation, BMV does not initiated and then release. provide protection against aspiration of gastric contents into the lungs. The risk of this complication can be reduced by minimizing air entry into the stomach. This is best accomplished by providing ventilatory support to the patient with an appropriate tidal volume (ie, monitoring chest excursions) and can also be aided by applying cricoid pressure, although the use of cricoid pressure can increase airway resistance and consequently decrease the efficiency of BMV ventilation. The other serious complication associated with BMV (or any other method of positive pressure ventilation) is barotrauma, resulting in a pneumothorax and, potentially, a Figure 26.28 The resuscitation bag should be compressed with the dominant hand. It might be preferable to use a two-person THE BOTTOM LINE technique in which one person uses both hands to apply the mask using the EC clamp and the • Airway management is crucial for all other person compresses the bag. If two individ- resuscitations. uals perform BMV, the more experienced person • Recognize the patient with a difficult should generally apply the mask and maintain airway and get help. the airway while the other person compresses • The chest should rise with spontaneous the resuscitation bag. Optionally, an available or assisted ventilation. assistant can apply cricoid pressure (Sellick ma- • Basic airway maneuvers can improve the neuver), taking care not to use excessive force condition of the patient such that more that can cause airway obstruction. invasive and risky procedures are not The patient should be carefully moni- needed. tored at all times while performing BMV. The bag should be compressed so that the patient’s

26-24 Critical Procedures

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians tension pneumothorax. The likelihood of this complication can be reduced by carefully monitoring chest wall excursions to avoid administering excessive tidal volumes. Finally, minor and generally self-limited complications include eye injury due to compression with the mask, facial nerve neurapraxia caused by excessive pressure on the mask, and allergic reactions resulting from contact with the materials used to manufacture the mask. Figure 26.29 Magill forceps, adult and pediatric sizes. Section 9: Management of Upper Airway Foreign Bodies With Magill Forceps tenacula so that oddly shaped or slippery objects can be grasped.) Treatment of the patient with a foreign object • Equipment for airway management, in- occluding, or partially obstructing, the upper cluding ETTs airway is dependent on several factors. If the • Equipment for surgical airway child is awake and has evidence of partial airway obstruction (eg, stridor), then the best course Technique of action will almost certainly be to administer 1. Open the mouth and insert the laryn- high-flow oxygen or a helium-oxygen mixture, goscope as described for endotracheal allow the patient to find a comfortable position, intubation. and transport the child to a location where the 2. Using the light from the laryngoscope, object can be removed by those with the most attempt to visualize the foreign object. expertise under controlled circumstances. On 3. If the object cannot be seen, have an the other hand, the child with impending re- assistant administer abdominal thrusts spiratory failure or complete airway obstruction in an attempt to bring the object into view. must be treated immediately. 4. Once the object is visualized, grasp it with Depending on age, such children should the forceps and remove it from the upper be treated with back blows and chest thrusts airway. Some objects can be difficult to for infants (<12 months of age) or the Heimlich grasp. In such cases, consider a different maneuver or abdominal thrusts for children (>1 tool or a suction device (Figure 26.30). year of age). When these techniques have failed 5. If the patient does not begin breathing and the patient has lost consciousness, the next spontaneously, proceed with appropriate step in the treatment algorithm is attempted re- airway management. moval of the object using direct laryngoscopy 6. If the object cannot be visualized or and Magill (or other) forceps. removed, the clinician has further options: 9.1 Management of Upper Airway a. Attempt to pass an ETT and, in so do- ing, force the object further into the Foreign Bodies With Magill Forceps airway so that it enters one mainstem Equipment bronchus, leaving the other open. • Laryngoscope b. Perform a surgical airway, bypassing • Magill forceps (Figure 26.29) (If Magill for- the occlusion, or ceps are not available, other forceps or c. Perform repeated basic maneuvers to clamps can be substituted. In fact, it is dislodge a foreign body in the esopha- wise to have a variety of tools available, gus or one below the level of the vocal including suction devices and gynecologic cords.

Section 9: Management of Upper Airway Foreign Bodies With Magill Forceps 26-25

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians hospital settings, patients are usually acutely ill and often rapidly deteriorating. They must always be presumed to have a full stomach, put- ting them at much greater risk for vomiting and aspiration of stomach contents. The clinician is rarely afforded a prior opportunity to carefully assess the patient’s airway anatomy to identify possible impediments to intubation. Many clinicians who perform emergent intubations in adult patients with great confidence and expertise become extremely anxious when the same procedure must be performed in a child. Figure 26.30 The Magill forceps should be inserted into Although there are important differences the mouth. between adults and children that must be Complications and Pitfalls understood when performing this procedure, This technique should generally be reserved the similarities far outnumber the differences. for unconscious patients with complete airway Some of the most problematic characteristics of obstruction. Attempted removal of objects in adults are rarely if ever present in children (mor- awake patients with partial airway obstruction bid obesity, beards, arthritic cervical vertebrae, can dislodge the object and cause complete oc- false teeth). With proper training and experience, clusion of the airway. Blind attempts to grasp emergency personnel can develop a high level of objects can damage the vocal cords and cause skill and proficiency in performing this proce- bleeding, which makes further efforts to visual- dure, using the same careful, systematic approach ize objects more difficult.19 used for other complex emergency procedures.

10.1 Endotracheal Intubation Section 10: Emergent Indications Intubation Indications for this procedure are similar to There is perhaps no procedure more important those for BMV. As such, the list of potential in- in pediatric resuscitation than endotracheal indications for emergent endotracheal intubation tubation. For the child who is not adequately in children is a long one, encompassing virtu- breathing, the most immediate priority is always ally all causes of acute respiratory compromise establishing a stable airway, and the definitive that affect the pediatric population. However, method of accomplishing this is endotracheal it is useful to consider how the indications and intubation. The methods involved with perform- contraindications for these two procedures dif- ing this procedure can be broadly divided into fer to better understand the unique aspects of two categories depending on the clinical circum- endotracheal intubation. stances: emergent and nonemergent (elective). For example, unlike BMV, which delivers Although the goal in both situations is the same positive pressure ventilation to the entire upper (successful insertion of a tube into the trachea), airway, endotracheal intubation also protects the the challenges that the clinician will confront airway so that entry of secretions and stomach differ substantially. Elective intubations, such as contents into the lungs is minimized. This is one those for scheduled procedures in the operating reason why tracheal suctioning is indicated and room, are performed in patients who are hemo- BMV is contraindicated for the treatment of the dynamically stable, have an empty stomach, and depressed, newly born infant after meconium have previously been evaluated for any potential delivery—the presence of a properly positioned airway problems. ETT prevents further soilage of the lungs. With emergent intubations, which are most Another major difference between BMV commonly performed in the ED and out-of- and endotracheal intubation is that an ETT

26-26 Critical Procedures

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians delivers air only to the lungs, whereas BMV al- as with a patient who has greatly diminished most always causes air entry into the lungs and lung compliance (eg, a near-drowning). With the stomach. This is why patients with respirato- higher pressures, a large air leak will often oc- ry distress resulting from a diaphragmatic hernia cur despite having an uncuffed tube that fits should undergo immediate endotracheal intuba- properly. Use of a cuffed tube in such situations tion and should not receive BMV. If the stomach should only be a temporizing measure because herniates into the chest cavity, a “ball valve” effect excessive pressure on the wall of the trachea for can occur, allowing air to enter but not escape. As prolonged periods can lead to the development the stomach progressively expands and displaces of subglottic stenosis. the lung, respiratory distress worsens, and the patient can develop tension physiology (similar to a tension pneumothorax). Bag-mask ventilation, which forces more air down the esophagus and into the stomach, exacerbates this effect. In children requiring ventilatory support for other reasons, excessive air entry into the stomach increases the likelihood of vomiting and aspiration and can impede expansion of the chest wall. Thus, although BMV can be effectively used Figure 26.31 Uncuffed tracheal tubes in pediatric sizes as a temporizing measure, emergent endotracheal 2.5, 3.0, 3.5, 4.0, 4.5, and 5.0. intubation is indicated for any child requiring assisted or controlled ventilation for a more pro- Another important decision regarding longed period. In addition, emergent intubation equipment when performing an emergent endo- is indicated for airway protection (eg, depressed tracheal intubation involves choosing a laryngo- mental status) and to provide direct access to scope blade (Figure 26.32). For both children and the trachea to facilitate pulmonary hygiene and adults, selecting the correct laryngoscope blade clearance of secretions. involves asking whether a straight or curved Equipment blade should be used and which size is right In children younger than 8 years, the narrowest for the patient. With adults, curved (Macintosh) point along the trachea is not at the vocal cords laryngoscope blades are preferred by most cli- (as with adults) but at the cricoid ring. With nicians because these blades are comparatively adults, the largest ETT that can pass through easy to use. Except in rare cases, visualization of the cords is still small relative to the subglot- the vocal cords is readily accomplished by sim- tic diameter of the trachea. For this reason, a ply inserting the blade tip into the vallecula and balloon (cuff) is needed to fill the surrounding pulling upward on the laryngoscope handle. space. This prevents a large air leak (air flowing This approach causes tension in the hyoepiglot- out into the hypopharynx instead of into the tic ligament, which in turn retracts the epiglottis lungs), which would significantly limit effec- and thereby reveals the cords. Use of a straight tive administration of positive pressure venti- blade for an adult is generally reserved for the lation. By contrast, a properly sized tube for patient who is anticipated to have an especially a younger child will pass through the cords difficult airway or when laryngoscopy with a and then wedge in position at the cricoid ring, curved blade has failed. preventing any significant air leak without the Conversely, a curved laryngoscope blade is use of a cuff. For this reason, uncuffed ETTs not recommended for use in children younger are generally used in emergency settings for than 8 years because of two important char- younger patients (usually 8 years and younger) acteristics of the immature airway: greatly in- (Figure 26.31). However, cuffed tubes might be creased laxity of the hyoepiglottic ligament appropriate even for children younger than 8 and a relatively large, floppy epiglottis. In these years if high inspiratory pressures are required, younger patients, inserting the tip of a curved

Section 10: Emergent Intubation 26-27

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians tion. There are three major advantages of RSI as follows: • Rapid sequence intubation creates a controlled clinical environment to facilitate endotracheal intubation in pediatric patients who are frightened, anxious, and uncooperative. It also provides rapid onset of unconsciousness and muscle relaxation. • The combination of anesthetic agents and neuromuscular blockade used in RSI decreases the stimulation of potentially harmful autonomic reflexes associated Figure 26.32 Pediatric laryngoscope blades: straight with endotracheal intubation and their blades (0, 1, 2, 3, 4) and curved blades (2, 3, 4). associated adverse effects (eg, elevated intracranial pressure, hypertension, bra- laryngoscope blade into the vallecula and pulling dycardia). up might not adequately retract the epiglottis. In • Rapid sequence intubation with optional fact, the epiglottis might not move at all. Conse- cricoid pressure minimizes risks for pul- quently, straight (Miller) blades should be used monary aspiration during intubation. The for such patients because they allow the clinician effectiveness of RSI depends on the rapid to directly lift the epiglottis using the blade tip intravenous administration of two drugs— so that the vocal cords can then be visualized. an anesthetic and a neuromuscular block- Guidelines for selecting the proper laryngoscope ing agent administered sequentially.21,22 blade are listed in Table 26-6. Although the airway Indications of a child is considered to become more “adult- Rapid sequence intubation is indicated for most like” at approximately 8 years of age, significant patients who will undergo emergent endotra- variability can be seen in this regard among in- cheal intubation. dividual patients. For this reason, many sources recommend the use of a straight laryngoscope Contraindications blade for emergent intubation of any pediatric Rapid sequence intubation should be attempted patient who is not yet adult-sized.20 with caution, if at all, in patients who might Although the difference between straight have difficult airways. Once the neuromuscular and curved blades for pediatric endotracheal blocking agent has been administered, the patient intubation is traditionally taught in the manner will be irreversibly paralyzed for at least a few described herein, some clinicians use curved minutes. In addition, RSI should be used with blades for young children, and many initially caution in children who have a history or a fam- direct the tip of a straight blade into the vallecula ily history of untoward reactions to anesthetic and attempt to retract the epiglottis as with a agents. Although not contraindicated, RSI might curved blade. In the latter case, the tip of the be unnecessary in patients who are unconscious. straight blade is used subsequently to directly Equipment lift the epiglottis only if this initial maneuver Making sure you have all essential equipment in fails to adequately retract the epiglottis. place can best be aided by the mnemonic SOAP- ME (suction, oxygen, airway equipment, pharma- 10.2 Rapid Sequence Intubation cology, and monitoring equipment). The essen- Rapid sequence intubation (RSI, also known tial airway equipment is listed in Table 26-2. This as rapid sequence induction) is the process of equipment must be immediately available and administering a sedative and muscle relaxant known to be functioning properly before the RSI (inducing pharmacologic flaccid paralysis) to agents are administered. All equipment must be facilitate the process of endotracheal intuba- available in the appropriate size(s) for the patient.

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Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians used by an individual physician will likely be TABLE 26-2 Airway Equipment for dictated by availability, institutional policy, fa- Rapid Sequence Intubation miliarity, and clinical advantages and disadvan- • Ventilation face masks tages of each agent with respect to the clinical • Ventilation bags requirements of the patient. • Oropharyngeal airways (with tongue blades) • Nasopharyngeal airways (with lubrication gel) • Endotracheal tubes (with syringes for the cuff) KEY POINTS • Stylets

• Laryngoscope handles Performing RSI • Laryngoscope blades • Select patient who will benefit from the • Magill forceps procedure. Difficult Airway Equipment • Prepare equipment (SOAP-ME). • Laryngeal mask airway • Monitor the patient. • Combitube (16 years or older) • Administer appropriate sedation based on • Gum elastic bougie (or other airway guide 14 the patient’s clinical status: years or older) – hypotension—etomidate • Specialized laryngoscopes – status asthmaticus—ketamine • Lighted stylet – head injury—thiopental or etomidate Surgical Airway Equipment • Administer appropriate neuromuscular • Transtracheal ventilation equipment blocking agent—succinylcholine vs rocuronium. • Perform endotracheal intubation. Pharmacologic Agents • Perform clinical assessment and use Many pharmacologic agents are useful in the ETCO2 monitor or detector to confirm performance of RSI. Tables 26-3 through 26-5 endotracheal intubation. provide information about the advantages and disadvantages of each agent. The actual agents

TABLE 26-3 Sedative Agents

Agent Dose Onset Duration Benefits Caution

Etomidate 0.3 mg/kg <1 min 10-20 min Lowers ICP, lowers Myoclonic IOP, supports BP excitation, vomiting

Ketamine 1-2 mg/kg 1 min 5 min Bronchodilator, Increases dissociative secretions, amnesia increases ICP, possible emergence reactions

Midazolam 0.1 mg/kg 1-2 min 20-30 min Reversible, Apnea, variable amnestic, dose anticonvulsant

Thiopental 3-5 mg/kg 30-40 s 10-30 min Lowers ICP Hypotension, (no longer available in U.S., Canada, and most countries) laryngospasm

Abbreviations: BP, blood pressure; ICP, intracranial pressure; IOP, intraocular pressure.

Section 10: Emergent Intubation 26-29

Adult Dose Infant/Child Onset Duration Benefits Dose

1-1.5 mg/kg 1.5-2 mg/kg 30-60 s 3-8 min Rapid onset, short duration

Complications of succinylcholine Bradyarrhythmias Increased intragastric, intraocular, and intracranial pressure Hyperkalemia Fasciculation induced musculoskeletal trauma Masseter spasm Malignant hyperthermia Prolonged apnea with pseudocholinesterase deficiency Histamine release Cardiac arrest

Atropine, 0.01-0.02 mg/kg (minimum, 0.1 mg; maximum, 0.4 mg) (child)—use prior to succinylcholine if younger than 5 years to prevent bradycardia.

TABLE 26-5 Neuromuscular Blocking Agents—Nondepolarizing Agents

Agent Dose Onset Duration Complications

Rocuronium 0.6-1 mg/kg 1-3 min Intermediate, 30- Tachycardia 45 min

Vecuronium 0.08-0.15 mg/kg or 2-4 min Intermediate/ Prolonged recovery 0.15-0.28 mg/kg long, 25-40 min or in obese patients (high dose) 60-120 min (high and those with dose) hepatorenal dysfunction

Atracurium 0.4-0.6 mg/kg 2-3 min Intermediate, 25- Histamine release, 45 min hypotension, bronchospasm

Mivacurium 0.15-0.2 mg/kg 2-3 min Short, 10-20 min Histamine release

Adjunctive Medications Atropine, 0.4-0.6 mg (adolescent), to reduce secretions. Atropine, 0.01-0.02 mg/kg (minimum, 0.1 mg; maximum, 0.4 mg) (child)—optional use if younger than 5 years to prevent bradycardia. Lidocaine (lignocaine), 1.5 mg/kg intravenously—can be beneficial in head trauma patients to reduce intracranial pressure.

Management compromise blood pressure in the hemodynam- The discussion regarding selection of sedatives, ically compromised patient. (However, consider neuromuscular blocking agents, and adjunc- that no sedative might be preferable if the degree tive agents can be rather involved, but it can be of hemodynamic compromise is severe.) broken down into three basic categories: head The choice of neuromuscular blocking injury without hemodynamic compromise, sta- agent comes down to physician preferences for tus asthmaticus, and any condition with hemo- onset time, duration, and adverse effects. When dynamic compromise. By examining the benefits comparing the nondepolarizing neuromuscular and cautions of each sedative, the following can blocking agents, rocuronium is the most useful. be determined: etomidate is useful for head injury Succinylcholine (suxamethonium) has the fast- without hemodynamic compromise; ketamine est onset and shortest duration. Rocuronium has is useful for status asthmaticus; and etomidate, a slower onset and a longer duration but it has ketamine, and midazolam are the least likely to a lower risk of adverse effects.

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Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians TABLE 26-6 Rapid Sequence Intubation Drugs, Doses (mg), Sizes, and Distances Age 2 m 6 m 1 y 3 y 5 y 7 y 9 y 11 y 12 y 14 y 16 y Adult

Average weight, kg 5 8 10 15 19 23 29 36 44 50 58 65

Preoxygenation

Adjunctive agents (optional):

Atropine 0.1 0.15 0.2 0.3 0.3 0.4 0.5 0.5 0.5 0.5 0.5 0.5 (0.01-0.02 mg/kg) Use in all children or with ketamine.

Lidocaine 8 12 15 22 28 35 44 54 66 75 90 100 (lignocaine) (1.5 mg/kg) Lowers ICP

Sellick maneuver

Sedative

Hypotension or head trauma

Etomidate (mg) 1.5 2.4 3.0 4.5 6 7 9 11 13 15 17 20 (0.3 mg/kg)

Status asthmaticus:

Ketamine (mg) 5–7 8–16 10–20 15–30 19–38 23–46 29–58 36–72 44–88 50–100 58–100 65–100 (1-2 mg/kg)

Paralyzing agent:

Succinylcholine (mg) 8 12 15 25 30 40 50 55 60 65 70 80 (suxamethonium) (1.0-1.5 mg/kg)

Rocuronium (mg) 4 6 9 12 15 20 25 30 40 45 50 60 (0.6-1.0 mg/kg)

Intubate (tube size) 3.5 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0 7.0 female, 8.0 male

Tube depth at lip, cm 11 12 13 14 15 16 18 19 20 22 22 22

Laryngoscope blade 1 1 1 2 2 2 2 2 3 3 3 3–4 size

Abbreviation: ICP, intracranial pressure.

Section 10: Emergent Intubation 26-31

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians Technique should be readily available. To determine the 1. While personnel, equipment, and appropriate ETT size, Table 26-6, the formula pharmacologic agents are being assembled (age/4) + 4, or a length-based system such as the and intravenous access is being obtained, Broselow tape should be used.20,23,24 the patient should receive high-flow The laryngoscope blade should be attached oxygen through a nonrebreather mask. to the handle and snapped into position to verify The objective is to completely saturate that the light on the blade is working and bright. all available hemoglobin binding sites so If a cuffed tube is to be used, the balloon should that the patient can tolerate a protracted be checked for easy inflation and lack of air period of apnea if necessary. leaks. Any drugs that might be needed to be 2. Briefly assess the patient for a potentially drawn up in syringes should be asked for and difficult airway (see Chapter 2, The the appropriate dosages confirmed. A stylet (if Pediatric Airway in Health and Disease). used) should be inserted into the ETT. 3. Prepare all equipment. Atropine should be administered if indicated. Atropine is considered optional in adoles- 4. Secure vascular access and monitor the patient. cents but is recommended in younger children who are more susceptible to bradycardia with 5. Administer atropine if indicated. laryngoscopy. Atropine is also beneficial if suc- 6. Administer the sedative agent. cinylcholine (reduces the risk of bradycardia) or 7. Administer any adjunctive agents (eg, ketamine (reduces the risk of excessive secre- lidocaine [lignocaine]) if indicated. tions) is to be used. 8. Administer the neuromuscular blocking Next, any other adjunctive agents, then the agent while an assistant holds optional selected sedative and neuromuscular blocking cricoid pressure (Sellick maneuver). agent, should be administered. Which of these 9. Proceed with endotracheal intubation. should go first or second is controversial, but The first aspect of preparing the patient is the sedative and neuromuscular blocking agent usually preoxygenation. When time and cir- should be given in rapid sequence regardless cumstances permit, the patient should always of order. It might be preferable to give some be preoxygenated using 100% oxygen, either sedatives slowly, which argues in favor of giving by having the patient breathe spontaneously the neuromuscular blocking agent first so that through a nonrebreather face mask or, if nec- its time of onset coincides with the completion essary, by administering assisted or controlled of sedative administration. However, others BMV. Effective preoxygenation allows the recommend that the sedative be given first to longest period of “safe” apnea (ie, the patient ensure unconsciousness before paralyzing the does not develop hypoxemia), which provides patient. the greatest amount of time for the clinician Once the sedative or neuromuscular block- to perform laryngoscopy and tube insertion. ing agent is administered, continued cricoid pres- The patient should be confirmed to have a reli- sure sufficient to gently occlude the esophageal able means of intravenous access so that RSI lumen (Sellick maneuver) potentially reduces the medications can be administered if needed. The risk of passive regurgitation (Figure 26.33). Cricoid patient should be positioned close to the head of pressure is currently considered optional. the bed and the bed raised or lowered to a com- Although achieving a successful emergent fortable height for performing the procedure. endotracheal intubation involves several coor- Next all the necessary equipment should be dinated actions, the procedure itself essentially ensured to be easily accessible and functioning consists of two steps—direct laryngoscopy and properly. The ETT most likely to be the cor- tube insertion. Once the patient is fully paralyzed rect size for the patient should be selected, and (usually 60-90 seconds after the administra- because this is only an estimate, two additional tion of the neuromuscular blocking agent), the tubes (one size smaller and one size larger) patient’s mouth should be opened and the

26-32 Critical Procedures

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians it should be advanced under direct visualization (by retracting the tongue) until the epiglottis is seen. If desired, one attempt should be made to retract the epiglottis with the technique used with a curved blade (ie, by inserting the blade tip into the vallecula and lifting upward). If this reveals the cords, then the tube can be inserted. However, if the epiglottis continues to obscure the glottic opening (as will happen in most instances), the blade should be withdrawn slightly and a scooping motion used to directly lift the epiglottis from view with the blade tip. This might take more than one attempt because the epiglottis will sometimes slip off the tip of the blade with even the slightest movement of the Figure 26.33 Cricoid pressure occludes the esophagus to laryngoscope handle. prevent gastric reflux. laryngoscope blade inserted, taking care not to injure the lips, teeth, or tongue (Figure 26.34). Most sources recommend inserting the blade on the right side of the patient’s mouth and “sweep- ing” the tongue to the left, especially when using a curved blade. However, in most cases it is also acceptable to insert the blade along the midline and slide it over the tongue into the proper position. If a curved blade is used, it should be inserted into the hypopharynx until the tip of the blade meets resistance at the vallecula and then the handle pulled upward at a 45° angle to retract the epiglottis and reveal the vocal Figure 26.35 Gentle traction should be placed upward along the axis of the laryngoscope handle at 45°. cords (Figure 26.35). If a straight blade is used, Next, the ETT should be inserted without Laryngoscope losing sight of the glottic opening and vocal cords blade (Figure 26.36). This is greatly facilitated by having an assistant retract the right cheek slightly by pulling it laterally and holding the tube close by and providing it when needed. Retracting the cheek allows the tube to be inserted from the right side of the hypopharynx so that it does not obscure the cords (Figure 26.37). This also makes it possible to watch the tip of the tube as it enters the glottis, which is the best way to confirm a successful intubation. Remember to always keep both eyes open during this step of the procedure to preserve depth perception. As with threading a needle, maintaining depth perception makes inserting the tube between the vocal cords Figure 26.34 The pediatric straight laryngoscope blade and into the trachea much easier. Confirm should be inserted into the patient’s mouth.

Section 10: Emergent Intubation 26-33

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians intratracheal placement of the tube (and exclude example, a child who is intubated with a 4-mm any possibility of an esophageal intubation) by ETT should have the depth of placement measur- listening for breath sounds in both lungs, by lis- ing about 12 cm at the lip. Correct depth can also tening over the stomach, and, most importantly, be found on the length-based resuscitation tape. by seeing good color change on a colorimetric Table 26-6 provides the expected tube length that carbon dioxide detector and/or good waveforms should be at the patient’s lips for each age group.

on a capnograph (ETCO2 monitor). Although these methods are highly reliable, a chest radiograph should be performed after the tube is secured to verify correct placement. Finally, secure the tube using adhesive tape and/or cloth tape or, if preferred, a commercial- ly produced device designed for this purpose. There are a variety of methods advocated for taping an ETT, but in general the tube should be anchored well enough that even an inadvertent yank will not dislodge it. Unexpected tube dislodgement often results in a frantic scramble for equipment to provide ventilatory support pending reintubation. Unrecognized tube dislodgement can be fatal; thus, carefully securing the ETT will usually prevent undoing the good Figure 26.36 View of normal anatomical landmarks for advancing the endotracheal tube using a straight blade. work of a successful intubation. Complications and Pitfalls Whenever possible, equipment and devices should be tested to ensure that they will function properly during the procedure (eg, the light in the laryngoscope blade, the balloon of a cuffed ETT, wall suction, oxygen source). Several potentially serious complications can be associated with performing an emergent endotracheal intubation. The most common of these include adverse physiologic effects of the procedure, inadequate oxygenation, barotrauma, mechanical trauma, and aspiration pneumonitis. Adverse physiologic effects are normally only a significant problem with patients who have severe cardiovascular compromise. For example, direct laryngoscopy is a potent in- Figure 26.37 The endotracheal tube should be advanced ducer of vagal stimulation, especially in infants from the right corner of the mouth past the vocal cords and into the trachea. and younger children. In a healthy child, this is unlikely to produce any deleterious effects; in Once the ETT has been properly inserted, a child with unstable hemodynamics, however, it should be positioned so that the tip lies at an profound bradycardia (even asystole) can occur, appropriate distance from the carina to achieve resulting in an abrupt cardiovascular collapse. midtracheal placement (1-2 cm in younger In addition, direct laryngoscopy is suspected to children and 2-3 cm in older children). The increase intracranial pressure in children. depth of tube placement can be estimated by The most serious complication of RSI is multiplying three times the ETT size; this value failure of the intubation attempted in a patient will be the appropriate depth in centimeters. For who cannot receive adequate ventilation (the

26-34 Critical Procedures

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians so-called cannot intubate or cannot ventilate cavity (through the rupture in the lung) but can- situation). In such patients, a rescue airway not escape. With each positive pressure ventila- technique must be used immediately to avoid tion, more air is forced into the thoracic cavity, significant hypoxemic injury. In addition, each increasing the pressure in the affected hemitho- of the pharmacologic agents is associated with rax and eventually causing the mediastinum to one or more potential complications. Agents shift away from the affected side. As this shift must be chosen with the clinical situation and increases, deformation of the vena cava prevents patient factors (eg, allergies) in mind. adequate venous return to the heart, producing a Inadequate oxygenation, typically caused rapid decrease in blood pressure. This significant by an esophageal intubation, is generally the and rapid decompensation takes place within, at most disastrous complication of this procedure. most, a few minutes and must be treated imme- Two ways that esophageal intubation most com- diately with needle decompression of the chest. monly occurs are by inserting the tube into the Because of this potential cascade of events, any esophagus during intubation and by dislodging pneumothorax identified in a patient who will the tube from the trachea into the esophagus continue to receive positive pressure ventilation after intubation. Everyone who performs this must be treated early with tube thoracostomy. procedure enough times encounters an esopha- Mechanical trauma during an emergent intu- geal intubation. It is the failure to recognize an bation occurs when injury to the tissues is caused esophageal intubation that must be avoided at by improper manipulation of the laryngoscope all costs. Consequently, whenever a child who and/or ETT. Great care must be taken during di- has recently been intubated has sudden and un- rect laryngoscopy to avoid using the upper teeth expected hemodynamic decompensation, the (or in infants, the upper gingival ridges) as a le- prudent clinician will take immediate measures veraging fulcrum, which can avulse a tooth or to exclude any possibility of an unrecognized lacerate the gingiva. The lips and tongue can also esophageal intubation or dislodgement of the be contused or lacerated during laryngoscopy. ETT from the trachea. Aside from the obvious detriment of harming the Barotrauma, as the name implies, occurs as patient, excessive bleeding from such an injury a complication of endotracheal intubation when can make intubation much more difficult. Im- excessive pressure causes injury to the patient. proper insertion of the tube can cause permanent The most common type of pressure-related com- damage to the vocal cords, resulting in lifelong plication is a pneumothorax resulting from the abnormalities of the voice. Therefore, the tube administration of excessive tidal volume during must never be forced. positive pressure ventilation. The high level of Aspiration pneumonitis is another serious intrapulmonary pressure induced overcomes the potential complication of emergent intubation. normal elastic properties of the tissues and pro- Any patient with a full stomach and diminished duces a rupture in the lung. This problem can or absent upper airway reflexes (either from a normally be avoided by carefully observing the depressed mental status or administration of a patient while performing positive pressure venti- paralytic agent) is at risk for aspiration of stom- lation to ensure that only tidal volumes sufficient ach contents into the lungs. This is precisely the to cause chest rise are administered. type of situation encountered (or induced) with Although a significant injury, a simple pneu- many patients who require emergent endotra- mothorax rarely causes the patient major harm as cheal intubation. Measures must be taken to long as it is recognized and treated appropriately. prevent aspiration whenever possible. This risk However, if the problem is not recognized and is potentially minimized by having an assistant the patient continues to receive positive pressure apply optional cricoid pressure (Sellick maneu- ventilation, a much more serious (and potentially ver) from the time that a patient first receives fatal) tension pneumothorax can develop. This assisted or controlled ventilation with a BMV complication occurs when the “ball valve” effect setup until the time that the ETT is inserted into is created, in which air can enter the thoracic the trachea. When performed properly, cricoid

Section 10: Emergent Intubation 26-35

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians pressure potentially minimizes air entry into plete discussion of these techniques is beyond the stomach during BMV, greatly reducing the the scope of this chapter. However, several of the likelihood of vomiting, and can limit reflux of more commonly used approaches are addressed. stomach contents into the hypopharynx during direct laryngoscopy and tube insertion. 11.1 Supraglottic Devices Indication These devices can be used to manage the airway THE BOTTOM LINE in a child who cannot be intubated or effectively ventilated and who does not have upper airway • Although the task of performing an obstruction. emergent endotracheal intubation in Contraindications a pediatric patient is one of the more challenging undertakings a clinician can These devices are generally ineffective in patients face, there are few accomplishments in with upper (extrathoracic) airway obstruction medicine more rewarding than saving because they do not form a tight seal against the the life of a child in severe respiratory airway. Other contraindications include grossly distress. distorted upper airway anatomy and significant • Because it will be a relatively rare oropharyngeal trauma. Most supraglottic air- occurrence in the lifetime of most way devices do not provide adequate protection clinicians, the value of preparation (reading, conducting in-service meetings, against aspiration of stomach contents. How- assembling a pediatric airway tray) and ever, when intubation has failed, the benefit of practice (airway workshops, animal labs, effective ventilation generally outweighs the risk mock codes) cannot be overstated. of aspiration. • In the end, it is our duty as emergency care professionals to do whatever we 11.1A Laryngeal Mask Airway can to ensure that any young patient who requires an emergent endotracheal The laryngeal mask airway (LMA) was originally intubation will undergo this procedure designed for elective surgery. However, it is an in the safest and most effective manner easy-to-use rescue airway device available in a 20,21,25 possible. variety of sizes (Figure 26.38).

Section 11: Rescue Airway Techniques Most children who require urgent or emergent airway management will respond to standard techniques, such as BMV and endotracheal intubation. However, if an experienced intubator has made three unsuccessful attempts despite Figure 26.38 Different sizes of laryngeal mask airways.

changing the laryngoscope blade length and Courtesy of LMA North America. type, then the intubation has failed.25 When standard techniques fail and a patient Technique can neither be intubated nor mask ventilated, 1. Choose the correct size LMA based on an alternative approach is indicated. These al- the child’s weight in kilograms. The size ternative approaches can be categorized as fol- for weight and the milliliters needed to lows: supraglottic devices, special laryngoscopes, inflate the LMA cuff are printed on the airway guides, and surgical techniques. A com- side of the device (Figure 26.39).

26-36 Critical Procedures

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians 2. Remove the LMA from its package and alternative device is the intubating LMA (LMA- inspect the cuff for damage. Fastrach; Laryngeal Mask Co Ltd, Henley on 3. Completely deflate the cuff. The Thames Oxon, United Kingdom). This device manufacturer has developed a special can be used like a standard LMA but is also deflator for this purpose. Alternatively, designed to serve as a conduit for the insertion the LMA can be placed with the of a special flexible ETT (Figure 26.40). Although ventilating port against a flat surface the Fastrach device is somewhat different in ap- (eg, a countertop). The index and middle pearance, it is inserted in the same manner as fingers of one hand are placed on either the standard LMA and can be used to provide side of the device and over the cuff to ventilatory support to the patient in the same deflate the cuff. Lubricate the cuff with way. Then, the flexible ETT can be passed into water-soluble lubricant. the device. 4. Insert the LMA into the mouth with the ventilating port facing down (onto the tongue). Guide the cuff against the palate

with one or two fingers. Inflation Line 5. When the device cannot be advanced any

further, inflate the cuff. The LMA should Pilot inflation Balloon LMA-FastrachTM seat itself over the glottis. ETT 6. Connect the manual resuscitator and Valve begin ventilation.

15 mm Connector Handle Epiglottic Elevating Bar Cuff

Airway Tube

Figure 26.40 The intubating laryngeal mask airway Figure 26.39 The correct size of the laryngeal mask (LMA-Fastrach). airway should be chosen based on the child’s weight in kilograms. Courtesy of LMA North America.

When the tip of the ETT reaches the laryn- Alternative Technique: The Reverse geal mask, it lifts a special lever designed to lift Rotation Technique the epiglottis and allow the tube unrestricted Steps 1 and 2 are identical to those described access to the airway. An indicator mark can be for LMA use. found on the side of the ETT. When this mark 3. Insert the LMA into the mouth with the reaches the proximal portion of the ventilation ventilating port facing the hard palate port, the tip of the tube will be about to pass instead of the tongue; the black line of into the airway. A rubber stabilizing rod is then the LMA will be facing the patient’s feet. attached to the proximal end of the tube and 4. Advance the LMA and rotate the the ETT is advanced into the airway. The LMA ventilating port 180° into position is removed over the trachea tube and stabiliz- simultaneously. ing rod, the stabilizing rod is removed, and the 5. Inflate the cuff and begin ventilation. adapter is placed on the proximal end of the

The LMA comes in two styles. The standard ETT. An ETCO2 detector should be used to LMA is designed to serve as a supraglottic venti- demonstrate that the ETT is in the airway. Then lation tool, although some have described ways ventilation can begin in the standard manner to use this device as a “bridge” to intubation. An (Figure 26.41A–I).

Section 11: Rescue Airway Techniques 26-37

ETT depth marker

D E F

Stabilizer rod removed

G H I

Figure 26.41 A. The cuff of the mask should be deflated and a water-soluble lubricant applied to the posterior surface. The lubricant should be rubbed over the anterior hard palate. B. The curved metal tube should be in contact with the chin and the mask tip should be flat against the palate before rotation. C. A circular motion should be used to swing the mask into place, maintaining pressure against the palate and posterior pharynx. D. The endotracheal tube (ETT) should be visually inspected and inflated to verify cuff integrity and symmetry. The cuff should be deflated, the ETT lubricated, and the intubating laryngeal mask airway (LMA-Fastrach) tube passed through (rotate with up/down movement) to distribute lubricant. The ETT should be passed to the 15-cm depth marker or the transverse line on the LMA-Fastrach ETT, which corresponds to passage of tube tip through the epiglottic elevating bar. E. The handle should be used to gently lift the device 2 to 5 cm as the endotracheal tube (ETT) is advanced until intubation is complete. The ETT should not be forced. The ETT cuff should then be inflated and intubation confirmed. F. The connector should be removed and the intubating laryngeal mask airway (LMA-Fastrach) gently eased out over the endotracheal tube (ETT) into the oral cavity. A stabilizer rod should be used to hold the ETT in position as the LMA-Fastrach is withdrawn over the tube. G. The stabilizer rod should be removed and the endotracheal tube held onto at the level of the incisors. H. The intubating laryngeal mask airway (LMA-Fastrach) should be completely removed by gently unthreading the inflation line and pilot balloon of the endotracheal tube. I. The endotracheal tube connector should be replaced.

26-38 Critical Procedures

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians 11.1B Combitube located in the esophagus. The small bal- The Combitube is a true rescue airway (Figure loon occludes the esophagus and the 26.42) designed specifically as an airway man- larger balloon occludes the oral cavity. agement tool for office-based practitioners. It When this is the case, oxygen or air from is available in two sizes and is appropriate for the esophageal port can only enter the adolescents who are at least 1.2 m (4 ft) tall. It trachea. The chest should rise, and breath is not available for smaller children. The larger sounds should be heard over the lung balloon is made of latex so this device should fields. The arterial oxygen saturation will not be used in latex-sensitive individuals. be maintained in the normal range. Then ETCO2 detection can be used to confirm endotracheal ventilation. 6. If ventilation via the esophageal port is ineffective, the tube might have been inserted into the trachea. Disconnect the bag-mask device from the esophageal port and attempt to ventilate via the tracheal port (clear, shorter tube, labeled number 2). If ventilation through this port is effective, the large balloon can be deflated and the Combitube can function as a

standard ETT. Then ETCO2 detection can be used to confirm tracheal ventilation.26,27

11.2 Specialized Laryngoscopes Indications These devices can be used on children who cannot be successfully intubated using a standard laryngoscope. Contraindications There are no absolute contraindications. Those devices that rely on fiberoptic technology can Figure 26.42 Combitube. be difficult to use in cases of significant oral or oropharyngeal trauma. The presence of secre- Technique tions and blood can obscure the viewing port. 1. Remove the Combitube from its package An extremely small mouth opening can also be and inspect the balloons for damage. a contraindication. When a surgical airway is 2. Ensure that both balloons are deflated. urgently required, these devices cannot serve 3. Insert the Combitube blindly into the as a substitute. oropharynx and advance it until the central incisors lie between the black 11.2A Fiberoptic Scopes marks on the proximal portion of the A variety of fiberoptic scopes are available. Cli- tube. nicians should familiarize themselves with the 4. Inflate the smaller balloon (5-15 mL of device to ensure proper use. The key issue is air) and then inflate the larger balloon the relationship between the viewing port and (85-100 mL of air). the ETT. If the viewing port is at the tip of the 5. Attempt to ventilate via the esophageal stylet onto which the tube is placed, the vocal port (blue, labeled number 1). In more cords should be seen in the center of the field than 90% of cases, the Combitube is of vision. If the tube is mounted to the right of

Section 11: Rescue Airway Techniques 26-39

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians the viewing port, the cords should be placed in The use of the videolarygoscope is other- the right side of the visual field so that they are wise similar to the use of the standard laryngo- aligned with the position of the tube. scope. Like fiberoptic scopes, these devices are Technique relatively expensive and subject to fogging of the 1. Prepare the patient for intubation in the camera lens unless antifog fluid is applied be- standard manner. fore insertion of the laryngoscope. In addition, 2. Assemble the laryngoscope and connect like all alternative airway techniques, practice the fiberoptic light source. is required to fully master video laryngoscopy. 3. Place the tube in the proper location on the scope. 11.3B Lighted Stylet 4. Clean the distal fiberoptic port with The lighted stylet is a device that does not de- defogging solution. pend on an adequate laryngoscopic view of the airway (Figure 26.43).20,27,28 5. Suction the oropharynx. 6. Insert the laryngoscope and align the vocal cords as described. 7. Pass the tube into the cords under direct vision. 8. Remove the fiberoptic scope from the ETT (similar to removing a stylet). 9. Confirm proper ETT location using

ETCO2 and secure the tube.

11.3 Laryngoscopes With Special Blades A complete discussion of even a few of these devices would be beyond the scope of this chapter. Most commonly, these blades allow extra Figure 26.43 Lighted stylet. manipulation (eg, a flexible tip) for better visualization. In general, they are used exactly like Indications standard laryngoscopes except that, if an ad- The lighted stylet works very well in circum- equate laryngoscopic view is not obtained, the stances in which the laryngoscopic view might tip or blade of the laryngoscope can be moved be obscured by blood or secretions. It also re- (by depressing a lever or by some other means) quires little or no movement of the neck. to improve the view. Contraindications 11.3A Video Laryngoscopes The lighted stylet should not be used in circumstances in which the normal airway anatomy is A variety of video laryngoscopes are available. likely to be significantly distorted or in cases of These devices use special laryngoscope blades partial or complete tracheal transection. that house small, high-resolution cameras. Rather than placing the tracheal tube under Technique direct vision, the operator of a video laryngo- 1. Choose a properly sized stylet for the scope is able to see an enlarged image of the patient. airway on a video screen. In addition, because 2. Connect the stylet to the light handle the image seen is less dependent on the patient’s and check to make sure that the light is position, the video laryngoscope can be used in functioning properly. circumstance in which it is difficult to move the 3. Lubricate the stylet and place the ETT patient’s neck. over the stylet so that the light source

26-40 Critical Procedures

ETTs have a small hole in the side wall of ETCO2 and secure the tube. the tube. This hole is sometimes referred to as the Murphy eye. When using these 11.4 Tracheal Guides tubes, the light source should be aligned Tracheal guides are devices designed to facilitate with the Murphy eye of the tube. placement of the ETT in the same way that a 4. Bend the distal portion of the stylet (many guidewire is used in the Seldinger technique.29,30 of these devices have a label indicating A variety of these devices can be used. Some are where to bend the stylet) at about a 90° to semirigid tubes that allow oxygenation, ventila- 110° angle with respect to the proximal tion, and ETCO2 detection, whereas others are portion of the stylet. solid flexible guides. 5. Prepare the patient for intubation. Airway guides can be used in a variety of 6. Open the patient’s mouth and lift the ways, as follows: mandible using the nondominant hand. • A guide can be passed through a properly 7. Have an assistant dim the lights. located ETT that is damaged or is too 8. With the dominant hand, place the tube small and then used as a guide for tube and stylet into the patient’s mouth so that replacement. it is aligned with the midline of the tongue. • A guide can be passed through an LMA and 9. Following the tongue in the midline, into the trachea. Tracheal position is sug- advance the tube and stylet toward gested by the feel as the guide crosses the the airway. Initially, the handle of the tracheal rings. If the guide is hollow, tra- lighted stylet will be nearly parallel to cheal location can be confirmed by ETCO2 the patient’s body, and the distal portion detection. Once the guide is in place, the of the tube and stylet will be parallel and LMA can be removed and an ETT passed adjacent to the middle of the tongue. As below the cords and into the trachea. the tube is advanced, the handle of the • If laryngoscopy affords only a partial view lighted stylet is gently pulled upward to of the airway, the guide can be passed between 45° and 90° with respect to the below the epiglottis and into the trachea patient’s body. This motion, coupled with and confirmed as described earlier. the proper bend in the tube, pushes the Contraindications tube anteriorly into the trachea. Airway guides are contraindicated in cases of 10. Tracheal location of the tube is indicated tracheal injury. by a concentrated uniform glow seen in the patient’s anterior neck in the region of the thyroid cartilage. A more diffuse glow Section 12: Surgical Airway or a glow that is seen laterally suggests Techniques that the tube is not located in the trachea. 11. When the location of the light suggests Surgical airway techniques are the final option that the tube is within the trachea, for management of the difficult airway. These advance the tube and stylet approximately techniques are the most invasive form of airway 2 to 5 cm. Some types of lighted stylet management and are associated with the most are designed to allow the rigid portion complications. to be withdrawn while the light source remains in the ETT. If this is the case, 12.1 Needle Cricothyrotomy withdraw the rigid stylet slightly as the Needle cricothyrotomy is the simplest form of tube is advanced. Correct location is surgical airway management. This technique indicated by a glow at the sternal notch. involves the passage of a needle through the 12. Remove the stylet and advance the tube cricothyroid membrane. The needle is then used into the trachea. as a conduit for ventilation.31-33

Section 12: Surgical Airway Techniques 26-41

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians Indications trachea is preferable to the alternative; the clini- Needle cricothyrotomy is indicated in the pa- cian should proceed with the procedure even if tient who cannot be intubated and who cannot he or she is not completely confident that the be ventilated by less invasive means. It is often cricothyroid membrane has been identified. considered in cases of significant facial trauma 3. Prepare the neck in standard manner. and life-threatening upper airway obstruction 4. Insert the catheter with the needle (eg, epiglottitis, foreign body at the level of the directed inferiorly and aspirate while vocal cords). advancing. Tracheal location is indicated Contraindications by aspiration of air. Given that this technique is intended for use in 5. Remove the needle, advance the catheter, children who might otherwise die, there are no and attach the adapter from the 3.0-mm true contraindications. Significant injury to the ETT into the hub of the catheter. neck might make the procedure difficult or im- 6. Attach the ventilation bag to the adapter possible to perform. If the needle is placed for and begin ventilation, taking care not to transtracheal jet ventilation (beyond the scope of kink the catheter. Ideally, a designated this chapter), it should be understood that the role team member should hold the catheter of transtracheal ventilation in cases of complete hub securely to prevent it from kinking. upper airway obstruction remains controversial.31 There will be significant resistance to bag Equipment ventilation, but adequate ventilation can • Sterile gloves and mask usually be provided (ie, the bag must be • Sterile preparation solution squeezed very hard to deliver a sufficient • 18- to 14-gauge (depending on the size tidal volume to make the chest rise). of the child) plastic over-the-needle in- Complications and Pitfalls travenous catheter Tracheal puncture can lead to subcutaneous em- • 10-mL syringe physema. Likewise, vascular structures can be • Adapter from a 3.0-mm ETT injured, with resultant bleeding. If the puncture • Ventilation bag site is infected or if sterile technique is not used, Technique the patient can develop an airway infection. 1. Attach the syringe to the needle. 2. Identify the cricothyroid membrane 12.2 Retrograde Intubation (Figure 26.44). Retrograde intubation involves the passage of In older children (and adults), the mem- a guidewire into the airway through the crico- brane is identified by locating the laryngeal thyroid membrane and then using this guide to 20,32,33 prominence. This is the thyroid cartilage. The direct an ETT into the trachea. inferior border of the thyroid cartilage is the Indications superior border of the cricothyroid membrane. Retrograde intubation is most useful in an In younger children, identification of the mem- awake, sedated patient with a predicted diffi- brane is difficult. It might be possible to follow cult airway. It can be used to secure the airway the trachea superiorly until the cricoid cartilage is in the “cannot intubate and can ventilate” situ- palpated. The membrane lies just superior to the ation; however, it is fairly time-consuming, so cartilage. It is also wise to palpate the area above it would be difficult to use this procedure in the thyroid cartilage and attempt to identify the such a situation. hyoid bone. The thyroid membrane is between Contraindications these two structures. This membrane lies above This technique should not be used when the the vocal cords and is not an appropriate site anatomy of the neck is severely distorted, when for insertion. Knowing the location of the thy- there is a known obstruction that will prevent roid membrane might prevent this complication. passage of the ETT, or when the skin overlying In the dying child, inadvertent puncture of the the cricothyroid membrane is infected.

26-42 Critical Procedures

Cricothyroid membrane Cricoid cartilage

Hyoid bone Laryngeal prominence B Infant of thyroid cartilage Cricoid cartilage

Superior thyroid artery

Cricothyroid artery Cricothyroid membrane Cricothyroid membrane Tracheal rings Thyroid gland A Median colli vein

Infrathyroid vein C

Figure 26.44 Cricothyroid membrane.

Adapted from: King C, Henretig FM, eds. Textbook of Pediatric Emergency Procedures. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:238.

Equipment Technique All or most of the necessary equipment can be 1. Prepare for and perform the procedure found in a commercial retrograde intubation kit. as described for needle cricothyrotomy. If such a kit is unavailable, the following equip- 2. Once the catheter is located within the ment is required: trachea, it should be directed superiorly • Sterile gloves and drapes (Figure 26.45A). • Sterile preparation solution 3. Insert the flexible tip of the guidewire • 18- to 14-gauge over-the-needle catheter into the hub of the catheter and advance • Syringe it superiorly until the wire can be • Guidewire—must have a flexible tip and visualized in the hypopharynx or mouth. be of sufficient length 4. Grasp the wire with clamps or Magill • Kelly clamp or needle drivers (at least forceps and bring it out of the oral cavity, two) then continue to advance the guidewire • Magill forceps until sufficient wire extends from the oral • ETT cavity to allow for ETT placement (Figure • Introducer (optional) 26.45B).

Section 12: Surgical Airway Techniques 26-43

Air bubbles Guide confirm wire tracheal placement

Crico- thyroid membrane

Guide wire removed through mouth

Guide wire threaded through catheter

Figure 26.45A Guidewire threaded through the catheter. Adapted from: King C, Henretig FM, eds. Textbook of Pediatric Emergency Procedures. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:231.

Figure 26.45B Guidewire advanced. Adapted from: King C, Henretig FM, eds. Textbook of Pediatric Emergency Procedures. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:232.

5. Pass the ETT over the wire or introducer from the oral cavity. Others recommend and down the airway. Some experts simply pulling the wire out from either recommend passing the wire through the end. There are arguments in favor of Murphy eye of the ETT (in an outside-to- either of these approaches. However, inside manner) rather than through the all agree that gentle downward pressure lumen of the tube. should be maintained on the ETT to 6. The tube might encounter resistance at avoid inadvertent dislodgement of the the level of the arytenoids or epiglottis. In ETT during wire removal. this circumstance, it can be manipulated 8. Advance the ETT into the airway and into position by repositioning or with secure it in the usual manner. Magill forceps. 7. Once the ETT has reached the level of the cricothyroid membrane, the wire can be Complications and Pitfalls removed. Some authorities recommend Injury to the trachea or vocal cords, airway infec- cutting the wire and then removing it tion, and injury to nearby structures are possible.

26-44 Critical Procedures

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians 12.3 Wire-Guided Cricothyrotomy • Scalpel (No. 11 blade recommended, No. This technique is identical to retrograde intuba- 15 blade optional) tion except that the (much shorter) wire is passed • Trousseau dilator (not for use in the distally into the airway. An incision is then made smaller child) into the membrane immediately adjacent to the • Tracheal hook guidewire (to enlarge the cricothyroid membrane • Curved hemostats (two sets) opening around the guidewire), and a small tra- • Small Mayo scissors cheostomy tube resting over a special introducer is • Appropriately sized tracheostomy tube passed distally into the airway over the guidewire. (Shiley 0 to 4) Once the tube is in position, the introducer and • Appropriately sized ETT (4-6 mm, cuffed guidewire are removed and the patient receives if available) ventilation through the ventilating port of the tra- • Tape or sutures to secure the tracheos- cheostomy tube.32,33 tomy tube or ETT Technique 12.4 Surgical Cricothyrotomy Note that several variations on this technique In the older child or adolescent who can be nei- are described. A complete description of each ther intubated nor ventilated, the procedure of of these is beyond the scope of this chapter. The choice is cricothyrotomy.32-34 method presented below is a standard approach to the procedure. Indications 1. Prepare the skin in the usual manner. Surgical cricothyrotomy is indicated under two 2. Apply sterile drapes. circumstances. Most commonly it will be used in patients who can be neither intubated nor 3. Identify the cricothyroid membrane as ventilated and in whom less invasive alterna- described above. tive techniques cannot be used. It might also 4. In the awake patient, if time permits, be chosen as the primary means of airway man- lidocaine (lignocaine) should be agement when the anatomy of the face and oral infiltrated into the incision site. cavity have been very distorted such that other 5. Using the thumb and middle finger of the airway management techniques are likely to fail. nondominant hand, stabilize the larynx. Contraindications 6. Taking care to incise only the skin and There is some debate regarding the age at which subcutaneous tissue, make a vertical surgical cricothyrotomy replaces needle crico- incision approximately 2 cm in length thyrotomy as the management technique of in the midline over the cricothyroid choice. Given the small size of the cricothy- membrane (Figure 26.46A). roid membrane in young children, most au- 7. An assistant should be assigned to provide thorities agree that this technique should not retraction of the skin and subcutaneous be performed in patients younger than 5 or 6 tissue using standard retractors (eg, years. Some recommend that this technique be Army or Navy retractor or Weitlaner). used only in those older than 8 years and those 8. Palpate the cricothyroid membrane with younger children with the body habitus of an the index finger of the nondominant older child. This technique can be very difficult hand to confirm that the incision has to perform when the anatomy of the neck is dis- been made in the appropriate location torted. In a life-or-death situation, however, this (Figure 26.46B). should not be considered a contraindication. 9. Bluntly dissect through the sternohyoid Equipment muscle to visualize the cricothyroid • Sterile gloves and drapes membrane (Figure 26.46C). • Local anesthetic and syringe (for awake 10. Using the scalpel, make a 1-cm horizontal patients) incision into the membrane. Incision in • Sterile preparation solution the lower half of the membrane helps to

Section 12: Surgical Airway Techniques 26-45

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians avoid inadvertent ligation of the superior 3. Draw 2 mL of normal saline into a 3-mL cricothyroid artery (Figure 26.46D). syringe. Remove the needle (if present) 11. Insert the tracheal hook into the superior from the syringe and discard the needle. portion of the incision and gently lift the 4. Open glove and catheter package(s). thyroid cartilage. Once placed, the hook Apply a glove to the hand that will hold should be passed to an assistant. the suction catheter. With the gloved 12. Place the Trousseau dilator a short distance hand holding the suction catheter, into the anterior portion of the wound with connect the catheter to the suction device the blades oriented so that the incision is (connecting tubing). Maintain aseptic dilated in a cephalad to caudad manner. technique throughout the procedure. Alternatively, curved hemostats can be 5. Place a ventilation bag on the end of used for this purpose. These should be in- the tracheostomy tube and attempt to serted “upside down” in a caudal direction ventilate. If a mechanical ventilator is with the tip of the jaws directed anteriorly used, disconnect the ventilator and assist (Figure 26.46E).The jaws should be placed ventilation with a ventilation bag device. to dilate the lateral wound margins. 6. If there is no chest rise, remove 13. Insert the tracheostomy tube or tracheal the ventilation bag device from the tube into the incision, confirm proper tracheostomy tube. Instill 2 mL of normal position, and secure the tube in place saline into the tracheostomy tube. Insert (Figure 26.46F). a sterile suction catheter through the Complications and Pitfalls tracheostomy tube until resistance is met. There are many potential complications of this Suction up to a maximum of 10 seconds procedure. The reported incidence of these while withdrawing the catheter proximally. complications is approximately 20%, with most 7. Attempt to ventilate. being minor. However, major hemorrhage and 8. Repeat the procedure. serious injury to the airway or esophagus can 9. If assisted ventilation with a ventilation occur. Nonetheless, this technique is intended bag does not result in chest rise after suc- to be used in situations in which the alternative tioning, remove the entire tracheostomy is death or severe hypoxemic injury. In such cas- device. es, the benefits of the procedure far outweigh its potential complications. Electrocautery should 10. Begin BMV over the mouth with an be avoided because high-flow oxygen is gener- assistant holding a gauze sponge over the ally in use during such an emergency procedure, tracheostomy stoma to prevent air leakage. which might result in explosive combustion. 11. If no chest rise is achieved with BMV, insert the appropriately sized replacement 12.5 Tracheostomy Management35 tracheostomy tube or ETT (if available) Tracheostomy care is described in more detail in into the tracheostomy stoma. Chapter 13, Children With Special Health Care a. ETT size is determined by using a Needs. The most common complication of tra- length-based resuscitation tape, width cheostomy placement in a child is obstruction of of child’s little fingernail, or the for- the tube by hardened secretions. The following mula (age/4) + 4. technique describes steps to assess and manage b. If using an ETT, advance it approxi- the tracheostomy for obstruction. mately half the distance of that used Technique for orotracheal insertion. 1. Ensure that the ventilation bag device is 12. Attach the BMV device and begin to connected to an oxygen source. ventilate. 2. Ensure that the suction device is func- 13. Assess for chest rise and fall. Repeat tioning. assessment and management as needed.

26-46 Critical Procedures

A Thyroid cartilage

Cricothyroid membrane Cricoid 90 cartilage Thyroid gland

Endotracheal D tube placed through cricothyroid membrane

E F

Figure 26.46

A. A vertical incision should be made approximately 2 cm in length in the midline over the cricothyroid membrane. B. The cricothyroid membrane should be palpated with the index finger of the nondominant hand to confirm the appropriate location. C. Dissection should be performed through the sternohyoid muscle to visualize the cricothyroid membrane. D. A 1 cm horizontal incision should be made into the membrane. E. A Trousseau dilator or curved hemostats should be placed into the wound to dilate the opening to receive a tracheostomy or endotracheal tube. F. The tracheostomy or endotracheal tube should be inserted into the incision and secured in place.

Adapted from: King C, Henretig FM, eds. Textbook of Pediatric Emergency Procedures. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:334.

Section 12: Surgical Airway Techniques 26-47

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians • Appropriately sized paddles or appro- THE BOTTOM LINE priately sized contact pads—for children weighing less than 10 kg, the American Heart Association recommends paddles • Preparation (equipment availability and practice) is crucial. 4.5 cm in diameter; for those weighing • Determine a set of rescue methods before more than 10 kg, the American Heart they are actually needed. Association recommends paddles 8 cm • The skills to perform a rescue airway in diameter. cannot be learned in an emergency. • Conductive gel for use with the paddles. Technique Synchronized Cardioversion: 1. If the patient is conscious, administer sedation. Section 13: Cardioversion and 2. Attach monitor leads to the patient. Defibrillation 3. Turn on the defibrillator and select the lead displaying the tallest R waves. 4. Set the defibrillator to synchronized 13.1 Cardioversion and Defibrillation mode. The R waves shown on the monitor Indications should appear to be tagged with an extra The indications for defibrillation are the presence thick stripe in the center of the wave. of ventricular fibrillation or pulseless ventricular 5. If paddles are being used, apply conduc- tachycardia. The indications for cardioversion in- tive gel to them. If contact pads are used, clude the presence of a dysrhythmia that might there is no need to apply gel because the respond to cardioversion (eg, supraventricular pads have a conductive material within tachycardia, perfusing ventricular tachycardia) them. accompanied by circulatory compromise or when 6. Place the paddles or pads into contact chemical cardioversion has failed. Overall, life- with the patient’s chest. Two positions threatening dysrhythmias are unusual in children, are acceptable. and ventricular tachycardia and ventricular fibril- a. One paddle or pad can be placed on lation are especially rare. These facts, although reassuring, are a mixed blessing. On one hand, the sternum and the other at the cardiac healthy children are unlikely to require cardio- apex (located in the anterior axillary line version or defibrillation. On the other hand, just below the nipple) (Figure 26.47). physicians, nurses, and other health care pro- b. One paddle is placed on the anterior fessionals who primarily treat children are less aspect of the chest over the heart and familiar with these procedures than are their the other on the posterior aspect of counterparts who care for adults. Furthermore, the chest and aligned with the first health care professionals should become familiar (Figure 26.48). with the operation of the automated external de- 7. Ensure that the pads are not touching fibrillator (AED), although it is less likely to be of each other and are not connected by benefit. The staff must also learn to recognize and conductive material. treat the most common pediatric rhythm distur- 8. Charge the unit. For cardioversion, the bances, especially supraventricular tachycardia. A initial charge selected is 0.5-1.0 J/kg. If growing population of children have had cardiac unsuccessful, increase to 2 J/kg, then surgery. These children are at greater risk for sig- thereafter the dose remains constant at this nificant dysrhythmias than their normal peers. level for each subsequent attempt. Equipment 9. Ensure that the patient is not touching • Standard defibrillator or monitor or AED. any metal parts of the bed.

26-48 Critical Procedures

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians c. “Three. Everyone clear.” The operator should check to make sure that everyone is indeed clear. 11. If paddles are used, press them firmly against the chest. 12. Press the discharge buttons and hold them until the shock is delivered. In synchronized cardioversion, there can be a delay of a few seconds before the dose of electricity is delivered. 13. After the cardioversion attempt, check the patient’s rhythm to determine the need, if any, for further treatment. 14. If necessary, double the energy level, recharge the unit, and make another attempt.

Figure 26.47 Site for paddles on anterior aspect of the KEY POINTS chest.

Performing Defibrillation or Cardioversion • Defibrillation is indicated for ventricular fibrillation and pulseless ventricular tachycardia. • The most common indication for cardioversion in children is for unstable paroxysmal supraventricular tachycardia or for paroxysmal supraventricular tachycardia refractory to drug conversion. • AEDs are more likely to be available in a nonhospital setting. • Practice the “clearing chant.”

Figure 26.48 Site for paddles with child on side and paddles placed in the anterior position. 13.2 Automated External 10. Initiate a “clearing chant.” Say, “I am Defibrillator36,37 going to shock on three.” The AED represents a significant advance in a. “One. I am clear.” The operator the care of patients with ventricular fibrilla- should make certain that he or she is tion and pulseless ventricular tachycardia. The not touching the patient or the bed. 2010 resuscitation guidelines published in Pe- b. “Two. You are clear.” The operator diatrics (2010:126;e1361-e1399) recommend should ensure that all other person- that AEDs can be used in children of all ages nel are not in contact with the bed or who have no signs of circulation. Ideally, the patient. device should deliver a pediatric attenuator to

Section 13: Cardioversion and Defibrillation 26-49

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians reduce the energy dose in children up to 25 kg 2. Select appropriately sized paddles or (approximately 8 years of age), but if a pediatric pads as described for cardioversion. attenuator is not available, the adult system can 3. If the patient is not on a monitor, the be used. In addition, the arrhythmia detection paddles or pads can be used for a “quick algorithm used in the device should demon- look” rhythm interpretation by placing strate high specificity for pediatric shockable them as described for synchronized rhythms (ie, it will not recommend delivery of cardioversion and turning the selector a shock for nonshockable rhythms). switch to the setting that allows the Technique paddles to be used as sensing leads. As 1. Remove the AED from its storage described in cardioversion, if paddles container. are used, they should be prepared with 2. If not already done by the manufacturer, conductive gel before use. attach the pads to the cables and the 4. If the rhythm is either ventricular cables to the unit. fibrillation or pulseless ventricular 3. Attach the pads to the patient as described tachycardia, then charge the machine. for cardioversion. For defibrillation, the correct energy dose 4. Power on the AED. is 2 J/kg for the first attempt, 4 J/kg for 5. Many newer units will “talk” the operator defibrillation, the correct energy dose is through the rest of the process. 2 J/kg for the first attempt, 4 J/kg for the next attempt, and higher energy levels 6. If the unit is fully automated, it should begin analyzing the rhythm right away. may be considered (up to 10 J/kg or the If the unit is not fully automated, press adult maximum dose) for subsequent the “analyze” button. The AED will attempts. analyze the rhythm. This can take up to 5. As with cardioversion, ensure that the patient is not touching metal parts of the 15 seconds. During the time the unit is bed and perform the clearing chant as analyzing the rhythm, there is a small described previously. theoretical possibility that other devices 6. If paddles are used, press them firmly producing an electromagnetic field against the chest and discharge the might interfere with the unit. Therefore, device to deliver the shock. cellular telephones and radios should not 7. After the shock is delivered, immediately be used while the unit is analyzing. If resume cardiopulmonary resuscitation such devices must be used, they should for two minutes, then check the be kept well away from the patient. rhythm. If the patient remains in 7. If ventricular fibrillation or pulseless ven- ventricular fibrillation or pulseless tricular tachycardia is present, the unit ventricular tachycardia, follow the will recommend a shock. Fully automat- current algorithm. ed units can perform the clearing chant and deliver the shock without human assistance, but most AEDs will instruct the user to press the shock button. 8. The machine will reanalyze the rhythm THE BOTTOM LINE and give further instructions. For children weighing less than 25 kg (approximately Children are not likely to need defibrillation 8 years of age), a pediatric dose attenuator or cardioversion, but when it is necessary, should be used. But if it is not available, practice and familiarization with defibrillation and cardioversion equipment are essential. the adult system can be used. Standard Defibrillator 1. Turn on the defibrillator.

26-50 Critical Procedures

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians Section 14: Vascular Access Intravenous fluids and medications are often required in the treatment of ill and injured children. In most cases, catheters placed into peripheral veins are sufficient. However, sometimes central venous access is required. Central venous catheters can be used to monitor central venous pressure, pulmonary artery wedge pressure, and central venous oxygen saturation. On occasion, a central venous catheter will be placed after several attempts to place a peripheral venous catheter have failed. Figure 26.49 Dorsum of the hand. 14.1 Peripheral Venous Catheter Placement Equipment • Catheters—the catheter size chosen should be appropriate for the vein selected. If a standard over-the-needle intravenous catheter is unavailable, a butterfly or similar needle can be used as a temporary alternative. • Rubber or elastic tourniquet • Antiseptic soap or wipes Figure 26.50 Antecubital sites. • Syringes • Flush solution 1. Select the vein into which the catheter • Tape will be placed. When time permits, local • Dressing material anesthetic cream can be applied to the • Clear dressing material (optional) site. This can reduce the discomfort • Local anesthetic cream (optional) associated with intravenous catheter • Local anesthetic injection (optional) placement but takes approximately 30 • 18- to 20-gauge needle (optional) minutes to 1 hour for the medication to have a significant anesthetic effect. Technique Alternatively, a small amount of local Easily accessible peripheral veins are located in anesthetic can be injected at the several anatomical areas. The most commonly insertion site immediately before the cannulated veins are located on the dorsum of the needlestick. This method of anesthesia is, hand (branches of the cephalic and basilic veins) unfortunately, associated with a second (Figure 26.49), the antecubital fossa (cephalic vein, needlestick. basilic vein, medial cubital vein) (Figure 26.50), the forearm (cephalic vein), the dorsum of the 2. Apply a tourniquet (exception: external foot (dorsal arch veins), the medial side of the jugular vein—see below) proximal to foot (saphenous vein, medial marginal vein), and the site. A rubber band around the head the lateral side of the foot (small saphenous vein, makes a good tourniquet for scalp vein lateral marginal vein) (Figure 26.51a, b). Less com- access. monly, the external jugular veins (Figure 26.52) or 3. Clean the site with alcohol or sterile the scalp veins are used. preparation liquid. When peripheral veins are difficult to iden- 4. Visualize and/or palpate the vein to be tify, ultrasound can be used to locate them. cannulated, if possible. Some veins (eg,

Section 14: Vascular Access 26-51

Figure 26.52 The external jugular veins can also be used.

the saphenous vein) are reliably located near anatomical landmarks, and these veins can be accessed blindly, if need be. 5. Some physicians choose to make a hole in the dermis with a larger gauge needle before catheter insertion. They argue that this technique avoids damage to the plastic catheter as it passes through the skin. This step is optional. B 6. Insert the catheter through the skin at a shallow angle parallel to the vein. Some authorities recommend inserting the catheter with the bevel facing down in very small or collapsed veins. This technique is intended to prevent unintentional penetration of the posterior wall of the vein. 7. Advance the catheter until blood return is seen in the hub and then advance 1 to 3 mm further to ensure that both the needle and the catheter are located within the vein. 8. Using the index finger of the dominant hand or the thumb and index finger of the nondominant hand, gently advance the catheter into the vein. Blood should flow freely from the catheter, but lack of blood flow does not necessarily mean that the catheter has not been properly placed. This is especially true in the case of external jugular veins. 9. If blood is needed for laboratory studies, Figure 26.51A, B Intravenous sites on the foot. it might be possible to obtain it from

26-52 Critical Procedures

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians the catheter before infusion of flush or access the vein. In addition, the position of the intravenous fluid. mandible can interfere with placement, and the 10. The catheter should be flushed with insertion needle might need to be bent slightly normal saline. During this process, it is for the catheter to pass below it. To stabilize the important to observe the surrounding vein, the skin should be taut at the insertion site. tissues for evidence of infiltration of Furthermore, it might be useful to make a small fluid into the surrounding tissues. This is hole in the skin before insertion of the catheter. particularly critical for intravenous lines It is not unusual to have little or no spontaneous that will be used to administer certain blood return from the catheter even when it is in medications that might cause significant the correct location. However, on aspiration with tissue injury if they are extravasated. a syringe, blood should return relatively easily.38 11. Secure the line with tape or a clear plastic Complications and Pitfalls dressing. In younger children, it might Peripheral intravenous cannulation is safely ac- be necessary to wrap the site in gauze or complished hundreds of times each day by medi- to restrain the child’s upper extremities cal professionals of all types. It is relatively free so that he or she cannot remove the of serious complications. The most common and intravenous catheter.34 important complications are as follows: • Injury to a contiguous structure (eg, an 14.2 External Jugular Vein Cannulation artery or a nerve) The technique for placing a catheter in the ex- • Extravasation of fluid into the tissues ternal jugular vein varies slightly from that used leading to compartment syndrome or, in cannulating other veins. The external jugular in the case of certain toxic medications, veins are located in the lateral aspect of the neck leading to damage to the tissues (Figure 26.53). They are most prominent when • Infection the patient is supine (in the Trendelenburg posi- • Phlebitis or thrombophlebitis tion) or when intrathoracic pressure is high (eg, Almost all of these complications can be vigorous crying). It might be necessary to place a avoided with attention to proper technique. small towel roll under the child’s neck and turn However, the most serious problem with pe- his or her head away from the insertion site to ripheral intravenous catheterization is failure to recognize when the technique has failed. Repeated attempts to obtain peripheral access in a critically ill child are not warranted. Once three or four skilled nurses and/or physicians have failed to place a peripheral catheter, an alternative method of vascular access should be chosen. When a child is in shock, it is not appropriate to delay vascular access via intraosse- External jugular vein ous access or central venous catheter placement. 14.3 Central Venous Catheter Placement Indications Central venous access is required for central venous and pulmonary artery wedge pressure monitoring and for the placement of a transvenous cardiac pacing device. It might also

Figure 26.53 The external jugular veins are good be necessary for fluid infusion or blood transfu- intravenous sites in toddlers and older children. sion if peripheral access cannot be established.39,40

Section 14: Vascular Access 26-53

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians Equipment course of the vein and at a 45° angle • Sterile gloves to the skin.39 • Sterile gown and mask (optional) b. Internal jugular vein: the internal jugu- • Sterile preparation solution lar vein is located in the anterior aspect • Local anesthetic of the neck. The more cephalad por- • Central venous catheter kit—a number tions of the vein are located somewhat of different types of kits are available. All deep within the neck, but the caudal have the use of the Seldinger over the portions are more superficial. The lo- wire technique for placement. Likewise, cation of the vein is best understood the type of catheter inserted varies with in relation to the sternocleidomastoid its intended purpose. A multiple lumen muscle. For much of its course, the catheter might be needed to infuse several vein runs directly beneath the muscle. different types of vasoactive medications, However, its more cephalad section whereas a large-bore catheter is better for lies just medial to the sternal head of infusing a large volume of fluid or as a port the muscle. Its medial portion courses for inserting a Swan-Ganz catheter. through a triangle formed by the sternal • Syringes and clavicular heads of the sternoclei- • Sterile flush solution domastoid muscle. As the vein pro- • Suture material (might be included in gresses caudally, it is found medial to the kit) the clavicular head of the muscle. The • Dressing material internal jugular veins ultimately join Technique the subclavian veins to become the in- The three central veins most commonly used nominate veins, which in turn empty for catheter insertion are the femoral vein, the into the superior vena cava (SVC). On internal jugular vein, and the subclavian vein. the right side, the internal jugular forms The insertion technique is as follows: a nearly straight pathway into the SVC; 1. Determine the vein into which the therefore, the right internal jugular is catheter will be inserted and identify the preferred when possible. The carotid external landmarks. artery lies medial to and slightly pos- a. Femoral vein: the femoral vein lies terior to the vein. Several approaches in the medial portion of the anterior to cannulation of the internal jugular aspect of the thigh (groin). The por- have been described. Of these, the most tion of the vein distal to the inguinal popular is the “median” approach. The ligament is most commonly used as key landmark is the apex of the triangle a site for catheter insertion (Figure formed by the sternal and clavicular 26.54). This section of the vein is me- heads of the sternocleidomastoid mus- dial to and slightly posterior to the cle. When the patient’s head is turned femoral artery, and both the vein and away from the insertion site, this trian- the artery are somewhat superficial. gle becomes relatively easily identified. To identify the correct site for inser- The needle is inserted at the apex at an tion, identify the arterial pulse 1 to approximately 30° angle with the skin 2 cm distal to the inguinal ligament. and is directed toward the ipsilateral A towel roll placed beneath the ip- nipple (Figure 26.55).39 silateral buttock can improve expo- c. Subclavian vein: the subclavian veins sure. The correct site for insertion is lie just beneath the clavicles. They variable (depending on the size of the are less often chosen as an insertion patient), but in the range of 0.5 to site because attempted cannulation 2 cm medial to the femoral arterial of the subclavian veins is associated pulse. The needle is directed along the with many potentially serious com-

26-54 Critical Procedures

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians plications. The most commonly used above and advance the needle while aspi- approach to the subclavian is the so- rating continuously. called infraclavicular approach. The in- 5. The easy aspiration of dark-colored venous sertion site is the junction of the distal blood indicates that the needle is in the and middle thirds of the clavicle. This correct location. If the blood is bright red, site should be approximately 1 cm lat- the syringe should be removed from the eral to the lateral border of the clavicular needle. Pulsatile blood return suggests head of the sternocleidomastoid. The that the needle has entered the arterial needle is inserted into the skin, and the lumen. If this occurs, the needle should tip is directed toward the sternal notch. be removed and pressure held on the site. The needle is then guided beneath the 6. Once the clinician is reasonably certain clavicle but is continually directed to- that the needle is within the lumen of 39 ward the notch (Figure 26.56). the vein, the syringe is removed and the Note that ultrasonography using a high- guidewire inserted into the needle. The frequency vascular probe is a valuable adjunct flexible, or “soft,” end of the guidewire in the identification of central veins, especially should be inserted into the vein first. the femoral vein and the internal jugular vein. The guidewire should then be advanced The clavicle makes identification of the subcla- well into the vein. If the needle and vian vein more difficult. wire are in the proper location, there The technique for ultrasound identification should be almost no resistance to wire is as follows: advancement. Significant resistance • Under sterile conditions, place an ample indicates that the needle and wire are volume of ultrasound gel into a sterile improperly located. In such cases, the glove or sterile probe cover. wire should be removed and the needle • Prepare the site as described in number repositioned or removed and reinserted. 2 below. 7. When the wire is positioned, withdraw • Place sterile ultrasound gel over the site the needle. Keep one hand firmly holding to be visualized (the anatomical land- the wire at all times. marks described above can be used to determine the most appropriate site). 8. Using a No. 11 scalpel blade (often • Using a sterile glove to hold the probe or supplied in the kit), make a small nick with the assistance of an operator, move in the skin over the guidewire. Take care the probe until the vein in question can not to injure the underlying vessel. be identified. In addition to being found 9. Pass the dilating device down the wire in their known anatomical locations, and insert it fully into the vessel lumen. veins are readily compressible, whereas As previously described, one hand must arteries are not. be firmly holding the wire. • The target site on the skin can be marked 10. Remove the dilating device and insert and the probe removed or the probe can the central venous catheter by passing it be used to visualize cannulation of the down the guidewire and into the vessel. vessel. A slight twisting motion can facilitate 2. Prepare the area with sterile preparation placement. solution and apply sterile drapes. 11. Remove the guidewire and confirm 3. Recheck landmarks and administer a small proper location by aspirating blood from amount of local anesthetic medication the catheter. into the skin and subcutaneous tissue 12. Infuse fluids into the catheter to keep without puncturing the vein. the lumen patent and secure the catheter 4. Attach a 5- to 10-mL syringe to the nee- in place with sutures. Apply a sterile dle. Insert the needle using the landmarks dressing to the site.

Section 14: Vascular Access 26-55

Inguinal ligament

Femoral pulse

Femoral vein Ischial tuberosity

1–2 cm distal to inguinal ligament

Advance needle 45º angle to skin towards ischial tuberosity

Figure 26.54 Femoral vein.

Adapted from: King C, Henretig FM, eds. Textbook of Pediatric Emergency Procedures. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:263.

30º angle to skin

Internal jugular vein Suprasternal notch

Infraclavicular approach to subclavian vein

Figure 26.55 Internal jugular vein. Figure 26.56 Subclavian vein.

Adapted from: King C, Henretig FM, eds. Textbook of Pediatric Emergency Adapted from: King C, Henretig FM, eds. Textbook of Pediatric Emergency Procedures. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; Procedures. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:265. 2008:267.

26-56 Critical Procedures

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians 14.4 Umbilical Vein Catheterization35 in the portal vein or the ductus venosus. Umbilical vein catheterization should be con- The catheter should be pulled back until sidered as a potential intravenous access site blood can be withdrawn smoothly. in infants up to 2 weeks old. The procedure is 10. Remove the catheter when resuscitation indicated for neonates with shock or cardiopul- is complete and peripheral vascular monary failure. access has been obtained. Equipment Complications and Pitfalls • 5F or 8F catheter or a 5F feeding tube Central venous catheterization is an invasive • 10-mL syringe form of vascular access, and many potential • Umbilical cord tape or suture to tie the complications are associated with this tech- base of the cord nique. Some of these potential complications • Flush solution are common to all sites of insertion, whereas Technique others are site specific. The complications com- 1. Place the infant beneath a radiant warmer mon to all insertion sites are as follows: and restrain the extremities. • Arterial injury: the most common complication of this technique is 2. Prepare the abdomen and umbilicus with antiseptic solution (surgical preparation). 3. Drape the umbilical area in a sterile manner. The infant’s head is exposed for observation. 4. To anchor the catheter after placement, place a constricting loop of umbilical tape at the base of the cord. Using a scalpel blade, trim the umbilical cord to Umbilical vein 1 to 2 cm above skin surface. Umbilical arteries 5. Identify the umbilical vessels. The umbilical vein is a single, thin-walled, large-diameter lumen, usually located at 12 o’clock. The arteries are paired and Head Feet have thicker walls with a small-diameter lumen (Figure 26.57). 6. Obtain an umbilical vascular catheter (5F). Flush the catheter with heparinized saline (1 U/mL) and attach it to a three- way stopcock. 7. Measure and mark 5 cm from the tip of the catheter. 8. Close the ends of a pair of smooth forceps, To then insert the end into the lumen of portal the umbilical vein. Dilate the opening vein by allowing the ends of the forceps to separate, then insert the catheter into the lumen of the umbilical vein and advance it gently toward the liver for 4 to 5 cm or until blood return is noted. 9. If resistance to advancement of the catheter is encountered, the tip might be Figure 26.57 Umbilical vein catheterization.

Section 14: Vascular Access 26-57

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians unintentional puncture and/or cannula- • Guidewire misplacement: in rare in- tion of the adjacent artery. In most cases, stances, the guidewire enters the central this results in a minor injury to the artery venous circulation and must be retrieved that can be easily managed with direct by an angiographer or a surgeon. This pressure at the insertion site or by appli- complication can be avoided by ensuring cation of a pressure dressing. Obviously, that one hand remains in firm contact it is much harder to control significant with the wire at all times. bleeding of one of the carotid arteries, • Air embolus: allowing a bolus of air to but fingertip pressure applied directly to enter the catheter can result in an air the site might be sufficient. Use of the embolus when the end of the needle or vein dilator or a mishap with the scalpel catheter is open to the air and the ve- can result in more serious injury to the nous pressure is low. This complication artery, necessitating the involvement of is most likely to occur when the catheter a vascular surgeon. If possible, it is best is placed into the internal jugular vein to avoid injuring the artery. or the subclavian vein. An air embolus • Infection: central venous catheters are can be avoided by covering the open end foreign bodies and can, like any such ob- of the catheter with the thumb after the ject, become colonized by bacteria. Cen- guidewire has been removed, before con- tral venous catheter infections can have necting the intravenous fluids, and by devastating consequences, particularly in positioning the patient with the insertion critically ill children. Furthermore, the site slightly dependent. Such positioning emergence of multiple-resistant bacteria has the added benefit of aiding catheter in many hospitals increases the risks sub- placement because it dilates the veins. stantially. Attention to sterile technique Aspirating the catheter before flushing is critical. When time permits, those will remove air within the catheter. Older involved in the placement should don patients can be asked to perform a Valsal- sterile gowns and wear masks and hats. va maneuver during internal jugular and Large sterile drapes can prevent inadver- subclavian cannulation to avoid negative tent contamination of the guidewire and pressure within the vein. catheter before insertion. Site-Specific Complications39,40 • Thrombosis: just as any foreign object • Femoral vein: few significant complica- can become infected, almost any foreign tions are associated with femoral vein object can become a nidus for throm- cannulation. The most potentially seri- bus formation. The risk is highest with ous complication is inadvertent penetra- polyvinylchloride catheters and when tion of the peritoneal cavity or rectum. the rate of infusion through the catheter This complication can be avoided by en- is less than 3 mL per hour. Flushing the suring the site of insertion is below the catheter with heparin when it is not in inguinal ligament and the needle is not use and using heparinized fluid when directed too posteriorly or inserted too the rate of infusion is less than 3 mL per deeply. hour might prevent thrombus formation. • Internal jugular vein: cannulation of the Catheters made of Teflon have surface internal jugular vein is also relatively safe characteristics that are not conducive to but less so than femoral vein cannula- the thrombus formation. Unfortunately, tion. As previously described, inadver- these catheters are also stiff and can in- tent puncture of the carotid artery can be jure vascular structures. Likewise, cath- problematic. Unintentional injury to the eters that are impregnated with heparin brachial plexus has also been described. are less often associated with thrombus The most important potential complica- formation. tion is unintentional pneumothorax.

26-58 Critical Procedures

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians • Subclavian vein: the location of the subclavian vein is such that it is possible for the needle to inadvertently penetrate the pleural space and create a pneumothorax. This complication occurs in up to 5% of attempted subclavian catheter placements. More skilled operators have a lower incidence of this complication, so subclavian cannulation is recommended only for those Figure 26.58 Intraosseous needles. who have experience with this technique. • Umbilical vein catheterization: this proximal tibia, and distal tibia (medial malleo- should be used for temporary vascular lus). Of the three sites, the proximal tibia is most access only, and the catheter should be commonly used. The technique is as follows: removed once the patient is stable and 1. Select the location for insertion and vascular access has been secured via other identify the landmarks: sites. Umbilical vein catheterization can a. Proximal tibia (Figure 26.59)—the cause hepatic thrombosis, infection, and landmark is on the medial side of the hemorrhage due to vessel perforation. tibia, 1 to 2 cm below and avoiding the tibial tuberosity, approximately 14.5 Intraosseous Needle Placement half the distance between the prominent anterior ridge of the tibia and its Indications medial edge. Intraosseous access is indicated under two cir- b. Distal femur—the femur is a trian- cumstances. In the moribund child, it might be gular bone with the point of the tri- wise to first insert an intraosseous needle for the angle on its anterior aspect. Its shape immediate infusion of fluids and medications makes needle insertion somewhat and then attempt to insert an intravenous or challenging. The site of needle inser- central venous catheter. Alternatively, intraosse- tion should be 1 to 2 cm proximal ous access might be required in the treatment of to the superior border of the patella a child who requires urgent vascular access and and slightly medial or lateral to the when attempts to place standard intravenous anterior ridge. The bone is flatter in catheters have failed. these locations, and access is easier. Equipment c. Distal tibia—the insertion site is locat- • Antiseptic preparation solution ed approximately 1 to 2 cm proximal • Local anesthetic (optional in the mori- to the medial malleolus in the center bund patient) of the bone. • Intraosseous needles (Figure 26.58)— 2. Prepare the area. In the alert child, 1 to intraosseous needles and bone marrow 3 mL of lidocaine (lignocaine) can be aspiration needles are made by several infiltrated into the skin and down to the different manufacturers; an 18- to 20-gauge periosteum before proceeding. When spinal needle can be used as an alternative. time is of the essence, however, this step • Syringe can be omitted. • Flush solution (saline or sterile water) 3. Grasp the needle in the dominant hand • Gauze pads and tape (optional) and place it on the insertion site with the Technique—Manual point angled slightly away from the joint Several bones contain active marrow. In theory, space. When possible, pinch the needle any of these can be used as a site for IO infu- itself with the thumb and forefinger of the sion. In practice, three locations are most com- dominant hand and allow the hub of the monly used. The three sites are the distal femur, needle to rest against the palm or the hy-

Section 14: Vascular Access 26-59

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians pothenar area. Do not allow the patient’s When the device is determined to be in limb to rest in your nondominant hand, the correct position, it can be used to because an unintentional slip or penetra- infuse medications or fluids. tion of both cortices of the bone can result 6. There is some debate about the best way in a needlestick injury with its attendant to secure an intraosseous catheter. The risk of acquiring a blood-borne disease. needle is in a bone, and when placed in 4. Use firm downward pressure and a child who is not moving, it is unlikely rotate the needle back and forth. It will to become dislodged. One option for gradually penetrate the cortex of the securing the intraosseous needle that bone. A sudden decrease in resistance allows visualization of the site is taping the can often be felt as the needle penetrates needle in a “goal-post” manner (similar to the cortex. This decrease in resistance an umbilical vessel catheter).41,42 might be immediately preceded by or Technique—Drill accompanied by a popping sound. At this 1. Select a needle appropriate to the size of point, the needle can be advanced a few the patient: millimeters more to ensure placement a. 3–39 kg: 15 mm into the marrow cavity. b. 40 kg or greater: 25 mm 5. Remove the trochar (or stylet) and, if c. Obese: 45 mm possible, attempt to confirm that the 2. After sterile preparation as described needle is in the marrow space. This can be above, insert the needle into the skin done by aspirating marrow or by infusing over the proposed insertion site such a sufficient volume of fluid to determine that at least 5 mm of the needle is visible that fluid flows easily into the space and above the skin surface. there is no extravasation of fluid into 3. Attach the electric driver to the needle the soft tissues around the insertion site. hub as per the manufacturer’s directions.

Figure 26.59 An intraosseous needle in the proximal tibia, distal to the tibial tuberosity.

26-60 Critical Procedures

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians 4. Depress the trigger of the driver and cephalic vein, or basilic vein. Of these, the two advance the needle with gentle downward saphenous vein techniques are the most com- pressure until either a sudden decrease monly used and are described here.43–46 This in resistance is noted or the needle is procedure has largely been replaced by intraos- inserted to the correct depth. seous vascular access. 5. Attempt to confirm the needle’s position Indications and secure it as described in steps 5 and Venous cutdown is indicated when the pa- 6 above. tient requires resuscitative fluids or drugs and Complications and Pitfalls other methods of venous access are impossible or Intraosseous catheter placement is often suc- contraindicated. Situations in which venous cut- cessful and is relatively free of complications. down might be considered include hypovolemic The most significant potential problems associ- shock, trauma, thermal burns, and cardiac arrest. ated with this procedure are as follows: Contraindications • Failure to place the needle into the marrow Potential contraindications to venous cutdown space. This technique occasionally fails. include the following: When this occurs, it is generally best to • Known vascular or orthopedic injury move to another bone rather than attempt proximal to cutdown site to place the needle into the same bone. • Major blunt or penetrating trauma to • Fracture—there is some risk of fracture. groin or abdomen This is especially true in infants and • Infection at the proposed site of cutdown young children. In theory, the most sig- • Availability of standard venous access nificant potential complication of frac- Equipment ture is damage to the growth plate. In • Sterile preparation solution, local anes- practice, this has not been reported. thetic, syringes, needles • Infection—improper attention to sterile • Scalpels (No. 10 and 11 blades) technique can result in a variety of infec- • Curved Kelly hemostats, straight mos- tious complications, ranging from cellu- quito hemostats, Iris scissors, needle litis to osteomyelitis. In addition, the risk holder, fine tooth forceps of osteomyelitis increases when the nee- • Suture material: 3-0 and 4-0 silk, 4-0 dle is left in place for more than 24 hours. nylon; for infants, 5-0 silk and 6-0 nylon This complication can be minimized by • Intravenous needle and catheters (22 to establishing intravenous access once the 14 gauge), intravenous extension tubing, child is adequately resuscitated and then saline flush removing the intraosseous needle. • Resuscitative fluids or medications • Compartment syndrome—compartment • Sterile 434 gauze, antibiotic ointment syndrome can result from extravasation of Technique: Distal Saphenous Vein fluid into the soft tissues or possibly from Cutdown a fracture at the insertion site. The area 1. Stabilize the extremity with an armboard of greatest potential risk is the proximal if the patient is awake. tibia. Insertion sites, even sites of failed insertions, should be examined periodi- 2. Prepare the medial ankle with sterile cally in the hours after the procedure for preparation solution. significant edema or tension.41,43,44 3. Identify landmarks: the saphenous vein lies 1 to 2 cm superior and anterior to 14.6 Venous Cutdown the medial malleolus (Figure 26.60). When it is impossible to secure venous access 4. Anesthetize the skin in an awake patient. by standard methods, a venous cutdown can (Omit in cardiac or traumatic arrest.) be considered. The most common sites are the 5. With a No. 10 blade, make a 2-cm (in- greater saphenous vein (at the ankle or groin), fant) to 4-cm (adolescent) transverse

Section 14: Vascular Access 26-61

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians superficial incision superior and anterior vein transversely with an upward motion to the medial malleolus. of the scalpel. Do not transect the vein. 6. With the curved hemostat (tip pointing The venotomy must include the lumen downward), bluntly dissect subcutaneous of the vein for successful venous access. tissue down to the tibia. Once the lumen is entered, bleeding can 7. Locate the saphenous vein against the be controlled by upward tension on the periosteum and bluntly dissect surrounding proximal suture, which will pinch the adventitious tissue to isolate it. vein and prevent further bleeding. 8. Elevate the vein with the hemostat, grasp 12. Insert a catheter (angiocatheter or intrave- the silk suture in the middle with the he- nous tubing) into the venotomy site. Ad- mostat, and pull it under the vein. Cut the vance the catheter by reducing tension on suture material in half, leaving two strands the proximal suture. Aspirate the catheter perpendicularly under the vein. Bluntly to confirm blood return, and then flush dissect a space under the vein so that the the catheter with intravenous fluid. two sutures are separated by at least 1 cm. 13. Tie the proximal suture around the vein 9. Tie off the distal suture (ligating the vein), with the catheter in place to secure it. leaving long ends to use as a handle to 14. Attach intravenous tubing and fluids. elevate the vein. Medications can also be administered 10. Leave the proximal suture untied, and via this route. use it as a handle to elevate and isolate 15. Close the incision with fine sutures. the vein. 16. Apply antibiotic ointment and a dressing. 11. Using a No. 11 blade, perform a 17. Perform routine wound care and remove venotomy (small nick) on the superficial sutures in 7 to 10 days. Bleeding from surface of the vein. Hold both ends of the catheter removal can be controlled with vein by the suture material and nick the sustained direct pressure.

Incision site

Great saphenous vein

Saphenous nerve

Medial malleolus of tibia

Figure 26.60 Distal saphenous vein cutdown site.

Adapted from: King C, Henretig FM, eds. Textbook of Pediatric Emergency Procedures. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:274.

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Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians Technique: Saphenofemoral Venous vein (steps 8 to 17 above). Larger Cutdown diameter catheters can be used in the The saphenous vein remains superficial until it proximal location. joins the femoral vein in the groin. A cutdown in Complications and Pitfalls this region enables more aggressive fluid resus- Complications of venous cutdown procedures citation. Once access is secured, the procedure include hematoma formation, infection, throm- is identical to the distal saphenous procedure bophlebitis, hemorrhage, injury to adjacent described earlier. structures, failure to identify the vein, and fail- 1. Thoroughly cleanse the groin area with ure to cannulate the true lumen. Therefore, ve- a sterile preparation solution. nous cutdown procedures should be reserved 2. Identify the landmarks. The saphenous for critical patients in whom it is impossible vein at the groin is located medial to to secure access by more conventional means. the femoral artery and vein, 2 to 4 cm The distal end of the vein is ligated, so its future inferior to the inguinal ligament, and functionality is doubtful.43–46 near the junction of the thigh crease and the scrotal or labial folds (Figure 26.61). 3. Anesthetize the area if indicated. THE BOTTOM LINE 4. Make a 4- to 6-cm superficial transverse incision. Vascular Access in Infants and 5. Using a curved hemostat, bluntly dissect Children through the adventitious tissue and • Immediate vascular access is best isolate the saphenous vein. The vein is obtained via peripheral intravenous or located just below the Scarpa fascia. intraosseous catheters. 6. Secure vascular access in a manner • Central venous and peripheral vein identical to that for the distal saphenous cutdowns require more time but have other advantages and disadvantages.

Femoral vein exiting fossa ovalis

Section 15: Thoracic Procedures Pubic tubercle 15.1 Needle Thoracostomy Great Incision site saphenous (Thoracentesis) vein When intrapleural pressure exceeds atmospher- ic pressure, an existing pneumothorax can prog- ress to a tension pneumothorax. The patient is unable to receive ventilation because of the increased intrathoracic pressure. Cardiac function can be compromised. Absence of breath sounds, tracheal deviation, and jugular venous Great saphenous distention are often noted. After the insertion vein of a needle to relieve pressure, a chest tube is usually inserted to maintain stability.

Figure 26.61 Proximal saphenous vein cutdown site. Indications There are several indications for the perfor- Adapted from: King C, Henretig FM, eds. Textbook of Pediatric mance of a needle thoracostomy. In some Emergency Procedures. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:275. circumstances, this technique can be used to

Section 15: Thoracic Procedures 26-63

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians definitively or temporarily treat a pneumotho- A rush of air denotes entrance into the rax. However, the emergency practitioner is pleural space and partial or nearly total most likely to use this technique when he or relief of the pneumothorax. However, she suspects a tension pneumothorax based on for a tension pneumothorax, continued the patient’s clinical findings.47–49 repeated aspiration might be required to Equipment improve heart rate, blood pressure, and • Sterile preparation solution oxygenation. Stopcock closure between • 14-gauge angiocatheter (a smaller cath- syringe aspiration cycles is generally not eter or a butterfly needle can be used in necessary when evacuating a tension infants) pneumothorax. • Syringe (use a large syringe for a tension 6. Listen for the return of breath sounds. pneumothorax) 7. Perform the tube thoracostomy procedure • Optional stopcock once the patient has stabilized. Technique Complications and Pitfalls 1. Elevate the head of the bed to 30° if The major complication associated with this possible. procedure is the failure to recognize the pres- 2. Identify the second intercostal space ence of a tension pneumothorax. This diagnosis in the midclavicular line (alternative should be made clinically and not with radio- location—fourth intercostal space in the graphs. If the needle is inserted near the lower anterior axillary line) (Figure 26.62). margin of the second rib, vascular structures can 3. Cleanse the site with sterile preparation be damaged. It can be difficult or impossible solution in the usual manner. to perform this procedure in large, muscular 4. Attach the syringe to the angiocatheter adolescents.47 or needle and insert it perpendicular to the chest wall. To avoid injury to vascular 15.2 Tube Thoracostomy structures (which lie under the rib), The purpose of a chest tube is to drain an abnor- insert the needle at the superior margin mal collection of air, blood, or other fluid from of the third rib (Figure 26.63). the pleural space and permit full reexpansion 5. Apply negative pressure (aspirate) to of the affected lung tissue.47,48 the syringe as the needle is advanced. Indications The following are indications for placement of a chest tube: 1. The presence of a pneumothorax (air collection in the pleural space) resulting from chest trauma or occurring spontaneously (If a tension pneumothorax is suspected clinically and if the patient is symptomatic, a needle Needle at 60-degree thoracostomy should be performed first, angle followed by the insertion of the chest tube.) 2. The presence of a hemothorax (blood Fourth intercostal Second collection in the pleural space), usually space, anterior Nipple intercostal space, resulting from trauma axillary line midclavicular line 3. Tube thoracostomy, which is sometimes

Figure 26.62 The child should be positioned and entry used in the treatment of pleural effusion, sites identified. empyema, or chylothorax

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PectoralisPectoralis muscle muscle Fourth rib Intercostal muscle intercostalFourth rib Intercostal muscle intercostal space space Fifth rib rib

Neurovascular bundle

Lung 90¡90º angleangle Parietal pleura pleura Visceral pleura pleura Sixth rib rib

Figure 26.63 The needle should be inserted over the top of the rib margin in the fourth intercostal space (pictured) at the anterior axillary line or in the second intercostal space at the midclavicular line.

Contraindications Technique The following are potential contraindications 1. Place the patient in the supine position. to this procedure: Elevate the head of bed 30°, if possible. 1. The presence of a coagulopathy 2. Have the patient place his or her 2. The presence of massive hemothorax ipsilateral arm behind his or her head. before fluid resuscitation 3. Provide adequate analgesia and/or 3. The patient with a recognized need for sedation. open thoracotomy 4. Prepare the area in the usual manner. 4. The presence of pulmonary adhesions or 5. Anesthetize the skin at the site of the blebs planned incision (usually the fourth Equipment intercostal space) (Figure 26.64). Many centers have a prepared tray for chest tube 6. Anesthetize the subcutaneous tissues (ie, placement. muscle, periosteum of rib, pleura) with a • Sterile preparation solution, sterile longer needle. Direct the needle along the gloves, drapes, face shields top surface of the rib to prevent injury to • Local anesthetic, syringes, needles the neurovascular bundle. Aspirate while • Scalpel, curved Kelly hemostats (two or advancing the needle. more), suture scissors • Chest tube of appropriate size 7. Make an incision 1 cm (infant) to 4 cm • Water-sealed drainage apparatus (adolescent) over the fifth rib at the • Needle holder, forceps anterior axillary line through the skin to • Suture material, 3-0 and 4-0 silk, 4-0 the muscle layer. nylon 8. Using firm pressure, advance and dissect • Sterile petroleum jelly gauze, sterile 4 3 4 over the fifth rib with a curved hemostat. gauze, antibiotic ointment, adhesive tape The tips should be pointed toward the

Section 15: Thoracic Procedures 26-65

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians thoracic cavity, using small opening and closing motions. 9. When the Kelly hemostat reaches the pleura, guide it over the rib until it passes through the pleura. This is heralded by loss of resistance and a rush of air or fluid. 10. Enlarge the opening by spreading the tips of the hemostat. 11. In a large child, place a gloved finger into the hole that was just created and attempt to palpate lung tissue and/or the * inner chest wall. Assure yourself that this is the proper location. (Avoid placement into solid organ.) 12. Discard the trochar from the chest tube and place a closed curved hemostat into a distal side hole of the chest tube. 3rd, 4th, or 5th intercostal space 13. With the tip pointing toward the thoracic anterior midaxillary line cavity, advance the chest tube through the incision, over the rib, and into the Figure 26.64 Possible sites for chest tube placement. thoracic cavity. Adapted from: King C, Henretig FM, eds. Textbook of Pediatric 14. Guide the chest tube posteriorly and Emergency Procedures. 2nd ed. Philadelphia, PA: Lippincott Williams & superiorly until all drainage holes are Wilkins; 2008:373. within the pleural space. Posterior Complications and Pitfalls placement can be facilitated by rotating The following are potential complications of the hemostat, holding the chest tube 90° tube thoracostomy: so that the points are directed posteriorly, 1. Damage to the thoracic neurovascular and then opening the clamp and bundle that lies beneath the superior rib advancing the tube. Posterior placement 2. Tamponade by the hemothorax of a is not always required. For example, if bleeding vessel, with removal resulting the lung is severely collapsed, the lung in severe hemorrhage (Clamp the chest will reexpand when negative pressure is tube to reinstate the tamponade, pending applied to the chest tube. Only then can definitive surgical care.) it be determined whether the chest tube 3. Infection at the site or resultant empyema is posterior or anterior to the lung. 4. Penetration of solid organs, stomach, 15. Connect the proximal end of the tube to diaphragm, or mediastinal structures the water seal. 5. Subcutaneous emphysema resulting 16. Confirm proper placement by observing from incorrect placement of the tube bubbles in the pleural drainage system dissecting subcutaneously instead of in when the patient coughs (if possible). the pleural space 17. Consider using an autotransfusion device for patients with brisk bleeding. 15.3 Emergency Thoracotomy 18. Secure the chest tube to the skin using a This lifesaving procedure requires technical purse string suture. expertise and proper judgment as to when it 19. Wrap the tube with petroleum jelly gauze should be performed. Although survival rates to prevent leakage of air. for patients undergoing emergency thoracotomy 20. Cover with a dressing. are low, those whose underlying conditions are

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Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians detected and repaired early have a chance of Equipment survival to hospital discharge.50–52 Patients with A prepared tray with all necessary equipment penetrating trauma who arrest in transit or in should be available. the ED have the greatest likelihood of survival • Sterile preparation solution, sterile and are the best candidates for this procedure. gloves, drapes, face shields and masks Patients who incur blunt trauma have little, if • Scalpel (No. 10 blade) any, chance of benefiting from this procedure. • Chest wall retractor (child and adult sizes The physician should have a clear understand- available) ing of the sequence of events that will be per- • Mayo and Metzenbaum scissors, forceps, formed after the chest is opened. Necessary curved hemostats, right-angle clamps, equipment should be readily available, and a Lebsche knife or sternal saw surgeon should be available to provide defini- • Foley catheters (various sizes), sutures, tive care if the patient is resuscitated. Opening pledgets, needle holder the chest of a pediatric patient is an extreme • Chest tubes procedure that is rarely successful. In the patient • Vascular clamps, aortic cross-clamp in- with penetrating chest trauma who sustains strument circulatory arrest in the ED, thoracotomy can Technique provide one last opportunity to save his or her 1. With the patient supine, rapidly sterilize life. Preparation and teamwork are the keys to the entire thorax with a sterile preparation successful performance of this procedure. solution. Indications 2. Locate the left fifth intercostal space An ED thoracotomy should be considered in (under nipple). the following types of patients: 3. Make an incision extending from the 1. The child or adolescent who incurs sternum to the posterior axillary line, penetrating chest trauma and who following the natural curve of the rib. sustains a circulatory arrest a few minutes Incise through the skin and chest wall before arrival or while present in the ED muscles. 2. The patient with penetrating chest 4. Using Mayo scissors, cut the intercostal trauma who is in shock and who fails to tissues and pleura. respond to aggressive fluid resuscitation 5. Insert rib spreaders with the ratchet side 3. The patient who incurs blunt trauma down and the handle pointing toward and sustains a circulatory arrest in the the head. ED during the resuscitation 6. Spread the chest open. Contraindications 7. Use suction to remove any blood that This procedure is contraindicated in those with might obstruct the view of the heart blunt trauma who sustain a circulatory arrest in (consider autotransfusion). the field, in patients who have clearly lethal in- 8. Identify and repair sources of bleeding, juries (eg, decapitation), and in those who have if possible, then proceed. less severe injuries and can be treated by more 9. Identify and carefully open the conservative means or can be safely transferred pericardium widely with Metzenbaum to the operating room. Lack of a surgeon who scissors to relieve tamponade, and can provide definitive management after the remove clots and/or identify cardiac emergency thoracotomy should be considered injury. Remember to keep the heart a relative contraindication. Likewise, this proce- warm by bathing it in warm saline. dure should not be performed in mass casualty 10. Repair ventricular injury by inserting situations because the physicians should devote a Foley catheter into the opening and their efforts to the care of patients who are likely inflating the balloon. The lumen can be to survive. used to infuse fluids, if necessary.

Section 15: Thoracic Procedures 26-67

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians 11. Other methods for cardiac repair include patients, the potential benefits outweigh the horizontal mattress sutures or application risks. The most significant complications of of sutures with Teflon pledgets. thoracotomy are as follows: 12. Injuries to coronary arteries should be 1. Inadvertent cutting of breast tissue or managed by applying direct pressure breast bud on initial incision until definitive repair can be performed. 2. Injury to vascular tissues: intercostal, 13. Open cardiac massage and/or internal coronary, or intrathoracic vessels defibrillation can be performed. 3. Infection, postoperative pericarditis, 14. If abdominal injury is suspected, cross- dysrhythmias clamp the aorta with a vascular clamp 4. Injuries to the heart, lungs, and/or aorta by rotating the left lung anteriorly and dissecting the aorta from the fascia of the spine posteriorly and esophagus 15.4 Pericardiocentesis anteriorly. Cross-clamping the aorta is The normal pericardial sac contains 20 to 30 performed to preferentially perfuse the mL of fluid. Larger volumes of fluid are often heart and brain with available blood. The well tolerated, especially when the fluid ac- aorta can also be occluded using direct cumulates slowly. In some cases, however, the pressure or an aortic occlusion device. volume of fluid is great enough to significantly 15. If no obvious injury exists, prepare affect cardiac function. In such cases, the patient to extend the incision to the right experiences cardiac tamponade. Many patients hemithorax, using a sternal saw or with cardiac tamponade will eventually require Lebsche knife (to transect the sternum), surgery, but, as a temporizing measure, some of scalpel, and Mayo scissors. Follow the the fluid can be drained percutaneously, thus curve of the fifth rib, opening the chest restoring normal or near-normal cardiac func- in a “clam shell” manner. tion.53 16. Identify and ligate the internal mammary Indications artery. Pericardiocentesis is indicated for the emergent 17. Identify and repair the source of bleeding. correction of immediately life-threatening car- 18. If resuscitation is successful, consult with diac tamponade. The mere presence of excessive a surgeon regarding definitive care. pericardial fluid is generally not an indication for Complications and Pitfalls this procedure. Pericardiocentesis is not without Many serious complications are associated with risks and should only be performed when there this procedure. However, if the procedure suc- is evidence of circulatory compromise.53 ceeds, a child who would otherwise have died Equipment might survive. Therefore, in properly selected • Sedative agents (optional) • Local anesthetic • Sterile preparation solution • Sterile drapes THE BOTTOM LINE • Sterile gloves • Mask Emergency Thoracic Procedures • 3-mL syringe and needle (for local anes- • Immediate thoracentesis followed thetic) by tube thoracostomy for a tension • 20- to 60-mL syringes pneumothorax • Needle for procedure: • Emergency thoracotomy for penetrating – Infant: 2.5 cm (1 inch), 20-gauge trauma-related cardiac arrest needle – Older child: 3 to 5 cm (1.5 to 2 inch), 20-gauge needle

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Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians – Adolescent: 7.5 cm (3 inch), 18- to be withdrawn slightly until the ECG 20-gauge needle change disappears. If the ECG tracing • ECG monitor does not normalize, remove the needle. • Alligator clip attached to one precordial If no ECG lead is used, then assign an lead assistant to watch the cardiac monitor Technique for changes. 1. If time and the patient’s clinical condition 11. Accurate needle placement can be aided permit, administer sedation and monitor by ultrasonography or echocardiography, the patient. The patient should be in the if available. supine position. Complications and Pitfalls 2. Apply sterile preparation solution to the Pericardiocentesis is associated with several precordial area. potentially severe complications. However, in 3. Apply sterile drapes. the setting of cardiac tamponade, the risks of the procedure are outweighed by its potential 4. Administer local anesthetic (as appropriate) at a point approximately 1 benefits. The most significant complications -as cm to the left of and immediately inferior sociated with the procedure are as follows: to the xiphoid process. 1. Pneumothorax 2. Injury to coronary arteries with 5. Place the patient slightly into the reverse subsequent ischemic injury to the heart Trendelenburg position, if possible. 3. Infection 6. Attach the needle to the syringe and attach the alligator clip to the proximal 4. Injury to the heart portion of the needle. If the alligator 5. Creation of a pericardial effusion or clip is not available or if time is short, tamponade when none was initially the procedure can be performed using present53 anatomical landmarks alone. 7. Insert the needle into the skin (on the left side and just below the xyphoid) at Section 16: Miscellaneous a 45° angle to the skin surface and direct Procedures it toward the tip of the left scapula. In older children and adolescents, some 16.1 Nasogastric or Orogastric authorities prefer to insert the needle in Intubation the left fifth intercostal space, immediately adjacent to the sternum. The needle is Indications inserted perpendicular to the skin and A nasogastric or orogastric tube can be used to advanced as described below. decompress the stomach in cases of bowel obstruction or to improve the effectiveness of me- 8. Advance the needle slowly, aspirating chanical ventilation by reducing intra-abdominal continuously. pressure. Likewise, nasogastric and orogastric 9. If fluid is obtained, the pericardial space tubes can be used in gastric decontamination should be drained as completely as for unintentional poisoning and for administra- possible. tion of activated charcoal. Finally, many children 10. If an ECG lead has been attached to the will not voluntarily drink oral contrast material needle, contact with the ventricular wall for computed tomography and will require a is indicated by ECG changes. The most nasogastric or orogastric tube for administration common manifestations are ST segment of this material. Sometimes enteral rehydration changes, QRS complex widening, or and enteral nutrition using a nasogastric tube can premature ventricular contractions. If be more efficient than administering fluids and any of these are seen, the needle should nutrition parenterally.54,55

Section 16: Miscellaneous Procedures 26-69

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians The choice between orogastric and naso- • 20% Benzocaine spray (optional—nasogastric intubation will be dictated by the clinical gastric or orogastric) situation. For simple gastric decompression or • Water-soluble lubricant enteral rehydration, a small nasogastric tube is of- • An appropriately sized nasogastric or ten well tolerated. Nasogastric tubes also offer the orogastric tube advantage of being easy to secure, and they can- • Tape not be bitten. On the other hand, gastric lavage Technique after ingestion of particulate matter might require 1. Determine the correct length of tube to a large-bore tube, and such tubes often cannot be be inserted. The time-honored way to passed via the nasogastric route. Likewise, in the accomplish this is to measure along the patient with facial trauma, nasogastric intubation external surface of the body from the tip is contraindicated. Trauma to the face can disrupt of the nose along the side of the face and the cribriform plate, and attempted passage of a down to the left side of the epigastric nasogastric tube under such circumstances can area. For orogastric insertion, the result in passage of the tube into the cranium. measurement is made from the corner of Other relative contraindications to nasogastric the mouth to the left epigastric area. An intubation include bleeding disorders, severe alternative method to determine depth epistaxis, and nasal obstruction. of insertion has recently been described. Neither nasogastric nor orogastric intuba- This method involves the use of a height- tion should be attempted blindly in the patient based graph (Figure 26.65).54 with a depressed gag reflex before the airway is 2. When time permits, insertion can secure. The absence of an intact gag reflex places be made more comfortable and less the patient at risk for inadvertent endotracheal traumatic by the following: intubation. a. If not contraindicated, a small amount of phenylephrine or similar substance KEY POINTS sprayed into the nostril will minimize the risk of bleeding. b. Swabs coated with viscous lidocaine Use of Orogastric and Nasogastric Tubes in Children (lignocaine) or lidocaine (lignocaine) • Advantages: jelly can be inserted into the nostril. This process, although effective, takes – Nasogastric—smaller, easier to tolerate several minutes. – Orogastric—larger lumen for lavage and/or charcoal c. For orogastric administration, local • Disadvantages: anesthetic spray can be used to anesthetize the mouth and throat. – Nasogastric—epistaxis, can enter the cranium if the cribriform is fractured d. Alternatively, a cooperative patient – Orogastric—more noxious, patient can inhale nebulized lidocaine (lig- might bite it nocaine) in a standard nebulizer for 5 to 10 minutes. 3. Lubricate the tube well with water- soluble lubricant. Equipment 4. Using the dominant hand, insert the tube • Phenylephrine (optional—nasogastric) into the nose. The tube should be parallel • Viscous lidocaine (lignocaine) or lido- to the floor of the nostril (ie, directed caine (lignocaine) jelly (optional—na- posteriorly and not superiorly) and not sogastric) directed up toward the cribriform plate. • Nebulized lidocaine (lignocaine) For orogastric insertion, the tube is placed (optional—nasogastric or orogastric) into the mouth and directed posteriorly.

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Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians In older children, a bite block might be are several more significant complications. The required to prevent biting of the tube. tube can injure the tonsil or adenoid and cause 5. Having the patient flex his or her neck bleeding. As previously described, injury to the will facilitate gastric intubation. cribriform plate can permit the very unusual but 6. Older children can be directed to swallow, devastating complication of intracranial tube and in the case of nasogastric insertion, placement. Finally, the tube can be improperly infants can be allowed to suck a pacifier. placed, either coiled in the esophagus or, worse, placed in the trachea. This latter complication 7. Once the tube has been inserted to can be devastating if unrecognized, especially if the desired length, its position should substances, such as activated charcoal, are ad- be confirmed. Traditionally, this ministered through the tube.55 determination is made by having one member of the team inject 60 mL of air into the tube while another auscultates THE BOTTOM LINE the epigastric area. Aspiration of the tube with the return of gastric contents also indicates that the end of the tube Placement of Nasogastric and is in the stomach. Cooperative patients Orogastric Tubes should be asked to speak. The ability to • Tubes might go where they are not speak in a normal voice confirms that wanted. the tube is not between the vocal cords. • Avoid the cribriform plate: direct Similarly, infants who are crying loudly nasogastric tube back (posteriorly), not up (superiorly). are not likely to have the tube between • Use orogastric route in facial trauma. the vocal cords, but a muffled or hoarse • Avoid endotracheal placement. If the tube cry suggests endotracheal placement. is correctly placed, the patient must be 8. Nasogastric tubes can be easily secured to able to talk or cry loudly. the nose with standard tape. Orogastric tubes are more difficult to secure but can often be taped to the side of the face with standard tape. 16.2 Catheterization of the Bladder Indications Tube insertion depth (cm) Bladder catheterization is a common procedure 70 65 in most EDs. It is the most reliable method for 60 55 obtaining a sterile urine specimen in infants and 50 45 children too young for a “clean catch” specimen. 40 OG Bladder catheters are also used to monitor urine 35 NG 30 output in children with dehydration, hemor- 25 20 rhage, and other critical illnesses. In some cases, 60 70 80 90 100110120130140150160170180190 200 contrast material must be infused into the lower Height (cm) genitourinary tract for imaging studies. In fact, a urethrogram demonstrating an intact urethra Figure 26.65 Estimated length for gastric tube insertion. is mandatory before proceeding with bladder Graph of formulas, determined on the basis of height, to determine depth of gastric tube insertion by the graphic catheterization in children with lower abdominal method. and pelvic trauma. Urinary bladder catheters are used for this purpose. Lastly, urinary catheters are Complications and Pitfalls occasionally required to drain the bladder in Most complications associated with nasogastric cases of urethral obstruction (eg, posterior ure- and orogastric intubation are minor. The most thral valves) or neurogenic bladder or when common of these is epistaxis, although there medications have caused urinary retention.

Section 16: Miscellaneous Procedures 26-71

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians Equipment 3. Procedure for female patients (Figure • Sterile gloves, preparation solution, and 26.66): drapes a. Separate the labia. (The presence of • Syringes labial adhesions can make catheter- • Water-soluble lubricant ization impossible. If adhesions are • An appropriately sized catheter present, the labia should not be forced Technique apart.) 1. Determine the size of the catheter to be b. The urethra is located just anterior to placed. When a Foley catheter will be the vaginal introitus. It is best visual- used, the size can be determined by using ized by lateral and anterior traction. the standard formula of (age/4) + 4 for ETT An assistant can perform this maneu- size selection and then doubling the result. ver or the clinician can use his or her For example, a 4 year old requires a 5.0- nondominant hand. mm ETT and a 10F Foley. Alternatively, c. Insert the lubricated catheter into the an 8F catheter can be used for an infant, a urethra until urine is obtained, and 10F catheter for a young child, and a 12F then advance the catheter further to catheter for an older child. ensure that the balloon is within the 2. Apply sterile preparation solution to the bladder. genital area. If necessary, the nondominant d. Inflate the balloon and withdraw the hand can be used to manipulate the labia catheter until the balloon abuts the or penis. In uncircumcised boys, the internal wall of the bladder. nondominant hand can be used to gently 4. Procedure for male patients (Figure 22.67): retract the foreskin. The dominant hand a. Grasp the penis in the nondominant should remain sterile, and only this hand hand and apply gentle traction such should touch the catheter. Apply sterile that the shaft is straight and approxi- drapes. mately 90° from the body.

Figure 26.66 With girls, the urethra is short and generally easily catheterized with adequate visualization of the urethral meatus.

Adapted from: King C, Henretig FM, eds. Textbook of Pediatric Emergency Procedures. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:890.

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Figure 26.67 Bladder catheterization for male patients.

Adapted from: King C, Henretig FM, eds. Textbook of Pediatric Emergency Procedures. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:889.

Section 16: Miscellaneous Procedures 26-73

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians b. Insert the lubricated catheter until brought in for emergency treatment. Most of urine is obtained. Resistance at the these injuries are minor and can be managed de- external bladder sphincter can be over- finitively in an ED or a physician’s office. Some, come by application of gentle constant however, will require the involvement of an or- pressure and by having the patient re- thopedic surgeon. If one is immediately avail- lax his abdominal musculature. able, he or she should be consulted and involved c. Advance the catheter until the balloon in the patient’s care from the outset. However, is well within the bladder, inflate it, some injuries result in restricted blood flow to and withdraw the catheter until the distal extremities. Because a significant delay in balloon rests against the internal wall restoration of circulation can leave the patient of the bladder. permanently disabled, the emergency physician 5. If the catheter is not to remain in place, might need to take the necessary steps to ensure a simple bladder catheter can be used adequate blood flow before the patient is trans- instead of a Foley, and the catheter can be ferred to the care of an orthopedic surgeon. The removed once its purpose has been served. procedures described in this section are those re- Complications and Pitfalls quired to adequately assess and, if necessary, treat Bladder catheterization is generally quite safe. extremity injuries with vascular compromise. The most common potential complication is the Clinical Features introduction of bacteria into the bladder and The presence of ischemia distal to an injury can subsequent development of a urinary tract in- be subtle. The prudent physician will perform a fection. Attention to sterile technique is, there- rapid but complete evaluation of the injured ex- fore, very important. Male patients can sustain tremity before treatment. The evaluation should damage to the penile urethra if an overly large be performed as follows: catheter is inserted or excessive force is applied 1. Ensure adequate exposure of the during insertion. Likewise, it is important to en- extremity. sure that the balloon is deflated before removing 2. Pain, fear, and anxiety will make the child a Foley catheter. Failure to return the foreskin to less likely to cooperate. These should be its normal position in an uncircumcised patient addressed as follows: 56 can cause a paraphimosis. a. If possible, apply a splint that encom- passes the injury and the points above and below the injury. This step alone THE BOTTOM LINE can significantly reduce the child’s discomfort. Bladder Catheterization b. If necessary, narcotic analgesics can • Female patients: labial or vulvar be administered. The goal is to reduce adhesions are a contraindication. the child’s pain and anxiety without • Uncircumcised male patients: do not creating sedation. Morphine sulfate forcibly retract the foreskin. (0.1 mg/kg) or fentanyl (1 mcg/kg) • All patients: determine correct catheter can be titrated to achieve the desired size and do not use excessive force in effect. catheter placement. 3. Briefly examine the extremity, looking for signs of circulatory compromise. Comparing the injured extremity to the contralateral, uninjured extremity Section 17: Orthopedic is a good idea. Remember the six P’s Procedures that suggest circulatory compromise: (1) pain out of proportion to the injury Bone and soft tissue injuries are among the most or distal to the injury; (2) pallor distal to common reasons children and adolescents are the injury; (3) paresthesias distal to the

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Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians injury; (4) paresis; (5) pulselessness (or compartment syndrome as well. When the in- diminished pulses) distal to the injury; tracompartmental pressure has become high and (6) poikilothermia (coolness) of the enough to cause vascular compromise, the pa- extremity distal to the injury. Presence tient might be expected to have some of the of any one of these suggests circulatory signs of impaired circulation described above. insufficiency. Conversely, the absence However, these are late findings (often too late); of these signs does not rule out a thus, the diagnosis must be made earlier than compartment syndrome. For example, this, before irreversible injury occurs. A com- strong pulses are frequently present in mon misconception is to believe that ischemia an acute compartment syndrome. occurs when the compartment pressure exceeds 4. Perform a complete examination of both arterial pressure, but ischemia and potential in- the injured and uninjured extremities. Pay farction occur at intracompartmental pressures attention to subtle differences between well below the arterial pressure. the extremities and look for less obvious Clinical Features changes, such as diminished capillary Of the six P’s, only pain and paresthesia are refilling time and mild sensory changes. usually present during the initial presentation of a compartment syndrome. It is typical yet paradoxical that the patient will often experi- YOUR FIRST CLUE ence pain together with diminished sensation. Muscle tenderness not associated with a fracture or another injury is considered to be a sensitive The Six P’s of Circulatory Compromise early sign. Likewise, pain with passive or active to an Extremity stretching of the muscle group also suggests the • Pain possibility of a compartment syndrome. Paresis • Pallor (weakness or paralysis), together with pain and • Paresis paresthesia, is highly suggestive of acute com- • Pulselessness partment syndrome. Pulselessness and pallor • Paresthesias will occur with an arterial transection or oc- • Poikilothermia clusion (eg, embolization), but a compartment The presence of any one of these suggests syndrome is actually a venous infarction, so circulatory insufficiency. pulselessness and pallor will be absent until infarction has already occurred (ie, too late). Ex- cessive swelling of the extremity should lead the clinician to consider compartment syndrome, 17.1 Compartment Syndrome In some cases, injuries to the forearm or lower YOUR FIRST CLUE extremity (below the knee) will result in damage to muscle tissue. Because the muscles are encased within fascial sheaths, there is little Signs and Symptoms of Compartment room for the tissue to expand to compensate Syndrome for edema or hematoma formation, and the • Extremity injury or infection or presence pressures within the muscle compartment rise. of cast Over time, this elevated pressure can decrease • Excessive swelling of the extremity perfusion of the extremity distal to the injury. • Pain and paresthesia Most commonly, a compartment syndrome • Pain on passive or active motion of the occurs as a result of either blunt or penetrat- extremity ing trauma to the extremity. Rarely, however, • Paresis or weakness recurrent injury to the extremity can result in

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Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians but this sign is not always present. Splints and • A three-way stopcock casts can also cause a compartment syndrome. • Sterile saline or sterile water Diagnostic Studies • Several sterile 18-gauge needles Once a compartment syndrome is suspected, the • Local anesthetic diagnosis is made by measuring the intracom- • A sterile 20-mL syringe partmental pressure. Portable, battery-powered • 5- to 10-mL syringe devices are made exclusively for this purpose and • Sterile preparation material should be used if available. However, three other Technique methods have been described.57–60 Intracompart- 1. Attach one length of tubing to the mental pressures between 30 and 45 mm Hg manometer and then to the rear port of are high risk and can represent a compartment the three-way stopcock (Figure 26.68). syndrome. The actual numbers are controversial, but intracompartmental pressures in this 2. Attach the other length of tubing to the range or higher require an immediate surgical front port of the 3-way stopcock. consultation or surgical intervention. Failure to 3. Draw about 15 mL of air into the 20-mL diagnose a compartment syndrome or intervene syringe and attach this to the top port of in a timely manner will result in irreversible ex- the stopcock. tremity damage (contracture, paralysis, paresis, 4. Attach an 18-gauge needle to the tubing gangrene, chronic pain). Identification of a com- attached to the front port of the stopcock. partment syndrome requires immediate orthopedic consultation and surgical intervention to 5. Open the stopcock to the top and front restore perfusion. ports and insert the 18-gauge needle into the bag or bottle of saline or sterile water. 6. Use the syringe to draw saline or sterile KEY POINTS water into the system so that liquid fills about half of the length of the front tubing. Diagnosis of Compartment Syndrome • The classic six P’s of compartment 7. Close the front port of the stopcock and syndrome are a pitfall. Only the pain, exchange the needle for a new one. paresthesia, and paresis are early signs. 8. Sterilize the skin over the site of needle • Pallor, pulselessness, and poikilothermia insertion. are NOT signs of an early compartment syndrome. By the time these conditions 9. Anesthetize the site, taking care not to occur, it is too late. inject a significant amount of anesthetic • Once a compartment syndrome is into the muscle compartment, thereby suspected, the intracompartmental increasing the intracompartmental pressure must be measured and immediate pressure. orthopedic consultation must be obtained. 10. Insert the 18-gauge needle into the muscle compartment. 11. Open the stopcock to all three ports. Method 1—The Manometer Method This method is the most complex of the three 12. Apply steady pressure to the plunger of (and it might not work), but it has the advantage the 20-mL syringe. The pressure in the of requiring equipment available in most physi- mercury manometer will rise. cian’s offices and EDs. 13. The manometer reading when the Equipment saline in the front tubing just begins to • A standard mercury manometer move toward the needle represents the • Two lengths of clear intravenous line tub- intracompartmental pressure (Figure ing at least 10 to 20 cm long 26.69).

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OFF OFF OFF OFF

OFF OFF OFF

Figure 26.68 Diagram of the stopcock.

2. Attach a sterile 18-gauge needle to the distal end of the intravenous tubing. NS AIR Withdraw 3. If the pump can move up and down, it should be moved to the level of the injured extremity. Alternatively, the bed NS AIR AIR can be raised or lowered. Push in 4. Set the pump to infuse a small amount of fluid (eg, 2 mL per hour). NS AIR AIR 5.

OF F Obtain a baseline reading by pressing and Just right holding the pressure button before the needle is inserted. Ideally, this baseline Figure 26.69 Diagram of the manometer method. number will be zero, but it might not be. If the baseline number is negative, it Method 2—The Intravenous Infusion is important to know that some pumps Pump Method place a limit on the amount of negative This method is the easiest, but it requires an in- pressure that can be accurately reported. travenous infusion pump that has a manometer Lower pressures are simply reported as feature to measure pressure within the intrave- the lowest number that the pump can nous tubing. report. 6. Equipment Record the baseline pressure. • An intravenous infusion pump with an 7. Prepare and drape the area in the standard internal manometer with a digital read- manner. out 8. Anesthetize the skin with local anesthetic • A length of intravenous tubing as previously described. • Normal saline or sterile water 9. Insert the needle into the compartment • 18-gauge needles and press the start or pressure button • Sterile preparation material again. • Local anesthetic 10. Record the pressure obtained and Technique then add or subtract the baseline 1. Attach a bag of intravenous fluid to the number as appropriate to obtain the infusion pump in the standard manner. intracompartmental pressure.

Section 17: Orthopedic Procedures 26-77

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians Method 3—The Arterial Line Monitor 17.3 Shoulder Dislocation Method The shoulder joint is hypermobile and prone Equipment to dislocation with traction when the upper • A standard multichannel monitor with a extremity is raised over the head. Common module for monitoring the blood pres- motions associated with a shoulder disloca- sure using an arterial line manometer tion include forceful throwing, spiking a vol- • Sterile saline or sterile water leyball, and serving a tennis ball. Falling onto • 18-gauge needles the shoulder area when the upper extremity is • Sterile preparation solution outstretched can also cause a dislocation. Most • Local anesthetic shoulder dislocations are “anterior” disloca- Technique tions (the humerus is anterior to the glenoid). 1. Prepare and drape the area in the standard A bulge will be visible and/or palpable anterior manner. to the shoulder. This might not be obvious if 2. Anesthetize the skin with local anesthetic the patient is obese or very muscular. A fracture as previously described. can mimic a dislocation or occur in conjunction 3. Set up and zero the monitor or manometer as would be done for an arterial catheter. with a dislocation. Thus, radiographs should be 4. Attach a needle to the end of the line, obtained to rule out a fracture before a reduction prime it with fluid, and insert the needle attempt. Posterior dislocations are uncommon into the compartment. and sometimes associated with severe direct 5. Infuse a small amount of fluid (<0.5 mL) trauma or a seizure. Posterior dislocations usu- and read the pressure. ally require reduction by an orthopedic surgeon. Technique Parenteral analgesia and/or sedation is optional THE BOTTOM LINE and is based on patient preference. There are many methods to reduce an anterior shoulder Compartment Syndrome dislocation. The external rotation method is de- • Compartment syndrome must be scribed as follows: recognized early when pain and 1. Have the patient remain supine or sitting paresthesia are present. up. The affected upper arm should be • Several methods are available to measure adducted against the torso. Flex the compartment pressure. elbow to 90°. • Immediate orthopedic consultation and 2. surgical intervention are required to Grasp the patient’s hand and slowly restore perfusion. externally rotate the humerus by using the forearm as a lever (Figure 26.70). If the patient experiences pain, administer 17.2 Dislocations intravenous analgesia and/or encourage Many dislocations are minor and are easily treat- the patient to relax. Once the pain ed in an office or ED setting. However, some subsides and muscle relaxation is dislocations compromise the distal circulation achieved, continue external rotation. by compressing, stretching, or tearing major ar- 3. As the forearm approaches the coronal teries. These dislocations often require urgent plane, reduction occurs spontaneously. reduction to avoid permanent disability. This method has the advantage of not Equipment and Personnel requiring strength, traction, or weights. • Sedative medications and equipment for 4. Once reduction has occurred, check for monitoring and resuscitation light touch sensation over the lateral • Splinting materials portion of the deltoid, then place the • Assistant patient in a shoulder immobilizer.

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Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians 17.4 Elbow Dislocation Posterior elbow dislocations can occur when a child falls onto the hand of a hyperextended arm. This injury most commonly occurs in adolescent males. In more than half of reported cases, the dislocation is accompanied by a fracture of the distal humerus, the radial head, or the coronoid process. Technique 1. Administer sedation or analgesia and monitor the patient. 2. Place the patient prone on an examination table. Allow the affected arm to hang over Figure 26.70 External rotation technique for reduction of an anterior shoulder dislocation. the side of the table. 3. Slightly flex the elbow and apply gentle Complications and Pitfalls traction to the proximal forearm. If A branch of the axillary nerve can be injured necessary, an assistant can provide gentle during a shoulder dislocation. This can be as- countertraction. sessed by checking the axillary nerve dermatome 4. Place the thumb of the hand not providing over the lateral aspect of the deltoid. Fractures traction onto the patient’s olecranon can mimic a dislocation. Even minor trauma process and apply gentle forward and can cause a fracture if the bone is weak in this downward force while simultaneously area. The proximal humerus is a common area gently flexing the elbow. for bone cysts that can predispose the patient 5. Once the dislocation has been reduced, to a pathologic fracture (Figure 26.71). Shoulder maintain the elbow in 90° flexion with a dislocations are fairly common in older teens, but posterior splint (Figure 26.72). they are uncommon in younger children. Young children are more likely to have a fracture. Ob- taining radiographs before a reduction attempt is recommended (exception might be those patients who experience recurrent dislocations).

Figure 26.71 Bone cyst of the proximal humerus and Figure 26.72 Technique for reduction of elbow joint dislocation. an associated pathologic fracture sustained during minor Adapted from: King C, Henretig FM, eds. Textbook of Pediatric Emergency trauma. Procedures. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:981.

Section 17: Orthopedic Procedures 26-79

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians Complications and Pitfalls 3. To reduce an anterior dislocation, lift The brachial artery or the median or ulnar nerve the femur anteriorly or push the tibia can become entrapped during reduction. En- posteriorly. trapment is more likely if the elbow is hyper- 4. To reduce a posterior dislocation, extended or pronated during the reduction. Be- ensure that the knee is extended but not cause associated fractures are common, these hyperextended and then lift the tibia should be identified. anteriorly. 5. After reduction, an evaluation by an 17.5 Knee Dislocation orthopedic surgeon and/or a vascular Dislocation of the knee is a serious injury. The surgeon is mandatory. Most authorities popliteal artery is relatively fixed within the recommend that the patient undergo popliteal fossa, and in approximately 30% to angiography as soon as possible after the 40% of knee dislocations the artery is torn. reduction so that injuries to the popliteal Failure to restore adequate circulation to the artery can be identified and repaired. knee within 6 hours is associated with an 85% 6. The knee should be maintained in a knee incidence of limb loss. The type of dislocation immobilizer or a posterior splint after depends on the relative position of the tibia and reduction. the femur. When the tibia is positioned forward 7. If transfer to another facility is required, relative to the femur, the patient has sustained it should occur promptly. an anterior dislocation. When the tibia is posterior to the femur, the patient has sustained a Complications and Pitfalls posterior dislocation. As previously discussed, the most common complication is injury to the popliteal artery. Injury Technique to the peroneal nerve is also possible. Tibial 1. Administer sedation or analgesia and spine fractures and other fractures of the femur monitor the patient. and tibia can occur in association with this in- 2. Have an assistant apply longitudinal jury. In some cases, the dislocation is not reduc- traction to the extremity (Figure 26.73). ible. This can occur when soft tissues or bone

For posterior dislocation lift tibia to reduce

Longitudinal counter traction

For anterior dislocation lift femur to reduce

Longitudinal traction

Figure 26.73 Technique for reduction of knee joint dislocation.

Adapted from: King C, Henretig FM, eds. Textbook of Pediatric Emergency Procedures. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:983.

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Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians fragments are interposed between the bones. and knee, apply longitudinal traction to This is a true medical emergency and warrants maintain the reduction. an urgent evaluation by an orthopedic surgeon. 6. The patient should be admitted or transferred. 17.6 Hip Dislocation Complications and Pitfalls Like a knee dislocation, a hip dislocation repre- Failure of the reduction is the most frequent sents a true medical emergency. Fortunately, this complication of this procedure. Most failed injury is rare in children. In older children and reductions require reduction in the operating adolescents, hip dislocation often results from room with the patient under general anesthesia. significant trauma, and the patient can have oth- Avascular necrosis of the femoral head compli- er serious injuries. On the other hand, younger cates approximately 10% of hip dislocations. children, presumably because they have more ligamentous laxity, can sustain a hip dislocation 17.7 Splinting with less serious trauma. Hip dislocations are potentially serious be- Indications cause they place the sciatic nerve and the vascu- Splints serve to immobilize and protect injured lar structures at risk. Posterior dislocations are extremities. They can be used to stabilize fractures less often associated with neurovascular injury pending definitive management, immobilize in- than are anterior dislocations, although poste- jured joints, and protect sensitive wounds.61,62 rior dislocations can injure the sciatic nerve. Equipment Anterior dislocations are generally reduced • Cotton stocking or sleeve (cotton stock- in the operating room with the patient under ing material)—optional general anesthesia. This reduction should occur • Soft cotton cast padding roll within 6 hours, if possible, to minimize the risk • Splint materials—one of the following: of neurovascular compromise. Posterior disloca- – Commercial fiberglass or plaster splint tions can, however, be reduced in the ED. The material technique for reduction of posterior dislocations – Plaster or fiberglass casting material is discussed below. – Preformed metal or plastic splint Technique • Elastic bandage roll 1. Administer sedation or analgesia and • Sling (optional) monitor the patient. • Crutches (optional) 2. Position the patient on the stretcher Technique in either a prone or a supine position 1. Determine the length of splint material with the knee in 90° of flexion. The hip required. Measuring of the uninjured should be slightly internally rotated and extremity is usually more comfortable adducted. for the patient. Once the correct length 3. Apply anterior traction to the leg to of splint has been determined, the splint fatigue the muscle and overcome muscle material can be prepared as follows: spasm. If the patient is in the supine a. Commercial splint material can be cut position, the person providing traction to the desired length. can either stand or kneel on the stretcher b. Plaster or fiberglass casting material of- itself to gain mechanical advantage. ten comes in strips or rolls. Several lay- 4. Using a gentle external rotary motion of ers (usually 5-15) are usually required the femur, guide the femoral head laterally to make a strong splint. Roll out the and anteriorly over the posterior rim of first layer to the desired length, then the acetabulum and into proper position. fold the material and roll out a second 5. Once the dislocation is reduced, as layer in the opposite direction. Contin- evidenced by easy extension of the hip ue the process until the desired num-

Section 17: Orthopedic Procedures 26-81

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians ber of layers has been added. If one roll 8. Keep the extremity and splint in the correct is inadequate, additional rolls can be position until the splint has hardened (30- used. If the correct number of layers 60 seconds, in most cases).62 is reached using a part of a roll, then tear or cut the plaster at that point. 17.7A Volar Arm Splint c. Plastic or metal splints for arms and Indications legs are generally preformed and Indications for a volar arm splint are forearm sized; simply select the correct size fractures, Colles fractures, wrist fractures, meta- for the patient. However, some metal carpal fractures, dislocations, and lacerations. finger splints are long strips of padded metal that can be cut to the correct Technique length. To place a splint on the volar surface of the palm 2. If cotton stocking material is to be used, and forearm (Figure 26.74), proceed as follows: it should be cut to the appropriate length 1. Measure from the proximal interphalangeal and then applied like a sleeve. If the hand joint (PIP) or metacarpal-phalangeal joint is to be incorporated into the splint, cut (MCP) joint to: a thumb hole in the cotton stocking a. the midforearm for hand injuries material. Cotton stocking material b. 6 to 10 cm distal to the elbow for wrist has the advantage of protecting the injuries skin but the disadvantage of requiring c. the midhumerus for forearm injuries manipulation of the injured extremity. 2. Shape the splint with the elbow at 90° The cotton stocking material must be flexion, wrist neutral, and the MCP joint loose enough to accommodate swelling at 45° to 90° flexion. of the extremity. 3. Roll one or two layers of cast padding over the cotton stocking material or, if no cotton stocking material has been used, directly onto the skin. As is the case with cotton stocking material, the cast padding should not be so tight as to constrict the extremity. 4. Wet the splint or cast material. In general, fiberglass material requires less water than plaster. Cool or cold water should be used for two reasons. First, the chemical reaction that causes the plaster to harden releases heat, and if the splint is already warm it can seem uncomfortable to the patient as it hardens. Second, hot water can accelerate the process of hardening, which might not allow enough time for the splint to be applied and shaped. 5. Apply the splint material and shape it into the general shape needed. 6. Roll the elastic wrap over the splint material. The elastic wrap should be only Figure 26.74 Volar arm splint. tight enough to hold the splint in place. Adapted from: King C, Henretig FM, eds. Textbook of Pediatric Emergency Procedures. 2nd ed. Philadelphia, PA: Lippincott Williams & 7. Finish shaping the splint. Wilkins; 2008:927.

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Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians 17.7B Sugar-Tong Splint (Forearm) 20º flexion Indications Forearm injuries are the main indication for the 70º sugar-tong splint (forearm). This splint can be combined with an upper arm sugar-tong splint to immobilize the elbow. Thin padding Technique between fingers To place the splint on the dorsal and volar sides of the forearm, looping around the elbow, proceed as follows: 1. Measure from the palmar PIP joint to the dorsal PIP joint, looping around the elbow. 2. Shape the splint with the elbow in 90° flexion, wrist neutral, and the MCP joint in 45° to 90° flexion.

17.7C Ulnar Gutter Splint Indications Injuries to the middle, ring, and/or small finger and ulnar styloid fractures are indications for ulnar gutter splints. Technique To place a splint on the ulnar side of forearm, proceed as follows: 1. Measure from the tip of the longest finger included (often the ring finger) to 7 to 10 cm distal to the antecubital fossa (Figure 26.75). … 2. Shape the splint with the wrist neutral Ace and the MCP joint in 50° to 80° flexion. overwrap

17.7D Thumb Spica Splint Gutter splint Indications Injuries to the thumb, scaphoid fracture, and de Quervain tenosynovitis are indications for the thumb spica splint. Technique To place a splint on the radial side of the forearm and hand, incorporating the thumb but no other digits (Figure 26.76), proceed as follows: Webril over 1. Measure from the tip of the thumb to 7 stockinette to 10 cm distal to the antecubital fossa. 2. Shape the splint with the wrist neutral, Figure 26.75 Ulnar gutter splint. thumb slightly abducted and flexed. The thumb end of the splint should partially Adapted from: King C, Henretig FM, eds. Textbook of Pediatric Emergency Procedures. 2nd ed. Philadelphia, PA: Lippincott Williams & encircle the thumb to immobilize it. Wilkins; 2008:925.

Section 17: Orthopedic Procedures 26-83

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians 17.7E Posterior Long-Arm Splint (Upper Extremity) Indications The posterior long arm splint is most commonly applied for fractures of the elbow (eg, supracondylar fractures of the distal humerus and radial head fractures). Technique To place a long arm splint from the proximal humerus passing posterior to the elbow, then into the palm, proceed as follows: 1. Measure the distance from the proximal humerus to the palm with the elbow flexed at 90°. 2. Thumb It won’t be possible to wrap the humerus spica portion above the axilla so the proximal splint end can be moved more distally. 3. Pass the splint material over the elbow, then along the forearm into the palm. The extra length of splint into the palm can be rolled or folded. Ace overwrap 17.7F Finger Splints Indications Finger injuries are the major indication for finger splints. Technique To place a splint on the palmar and/or dorsal sides of the finger, proceed as follows: 1. Measuring depends on the injury. If the

Webril over MCP joint is involved, the splint should stockinette extend from the finger tip to 2 to 5 cm proximal to the wrist. 2. Shape the splint with the wrist neutral, MCP joint neutral, and PIP and distal interphalangeal joint joints in slight flexion. Small finger fractures can usually be splinted with padded malleable aluminum or metal splints by curving the splint to a position of comfort and applying an elastic bandage starting at the wrist, encompassing the hand, then Figure 26.76 Thumb spica splint. the injured finger with a neighboring Adapted from: King C, Henretig FM, eds. Textbook of Pediatric finger, then back to the hand and wrist Emergency Procedures. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:926. to finish.

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Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians 17.7G Posterior Splint (Lower sugar-tong splint (also called stirrup splint) can Extremity) be used for more serious injuries (Figure 26.78). Indications Lower limb injuries are the major indication for posterior splints (lower extremity). if the splint Stirrup splint is extended above the knee, it can make a “poor over posterior leg splint man’s” knee immobilizer. Technique To place a splint on the plantar surface of the foot and posterior leg: (Figure 26.77), proceed as follows: 1. Measuring depends on the injury. For ankle, foot, and distal tibia or fibula, the splint should extend from the great toe B to 7 to 10 cm distal to the popliteal fossa. For distal femur, knee, and proximal Figure 26.78 Sugar-tong splint, applied over a posterior splint, lower extremity. tibia or fibula, it should extend above the knee to a point approximately half Adapted from: King C, Henretig FM, eds. Textbook of Pediatric Emergency Procedures. 2nd ed. Philadelphia, PA: Lippincott Williams & the distance from the popliteal fossa and Wilkins; 2008:930. the lower gluteal fold. 2. Shape the splint with the ankle neutral. If Technique the knee is incorporated into the splint, To place a splint on the lateral and medial as- it should be slightly flexed to allow for pects of the lower leg, looping under the foot, crutch walking. proceed as follows: 1. Measure about 6 to 9 cm distal to the popliteal fossa on either side of the leg.

Stockinette 2. Shape the splint with the ankle neutral. Webril roll Complications and Pitfalls Posterior leg splint The most serious complication associated with splinting is ischemic injury to the extremity secondary to constriction by the splint. This can

KEY POINTS A

Figure 26.77 Posterior splint, lower extremity. Splinting

Adapted from: King C, Henretig FM, eds. Textbook of Pediatric • Perform emergent reduction procedures Emergency Procedures. 2nd ed. Philadelphia, PA: Lippincott Williams & before splinting. Wilkins; 2008:930. • Knee dislocation is a true emergency to restore blood flow. 17.7H Sugar-Tong Splint (Lower • Obtain orthopedic consultation on Extremity) dislocations and fractures that might result in neurovascular compromise. Indications Ankle injuries (including sprains) are the major • Review and practice splinting methods. indication for sugar-tong splints (lower extremity). When combined with a posterior splint, the

Section 17: Orthopedic Procedures 26-85

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians occur because the cotton stocking material, cast Fitting padding, or elastic wrap is put on too tightly or • Determine the height of the patient. because it is too tight to allow for limb edema. • Choose child, youth, or adult size—each Other complications include mechanical in- has the range of appropriate patient jury to the underlying skin associated with an height written on it. improperly padded splint and (usually minor) • Adjust the top of the crutch to a height thermal injury when the splint is hardening. two fingerbreadths below the axilla. Teaching Use to the Patient • Grasp handles with both hands simulta- THE BOTTOM LINE neously and place crutches a comfortable distance in front (approximately 15-30 cm [6-12 inches]) and to the sides of the Splinting planted foot. • Splinting an injured extremity reduces • Shift weight to the arms, swinging lower pain, swelling, and complications of the injury. body forward while stepping ahead with uninjured leg. Keep injured leg or foot • Splinting is a temporizing measure before definitive orthopedic care. off the ground by flexing the knee. • Do not allow the top of the crutch to come in contact with the axilla. Points to Emphasize to the Patient • The purpose of crutches is to protect and 17.8 Crutch Walking rest the injured limb. When a fracture of an extremity is suspected, • Climb stairs only with assistance. put the extremity to rest and splint it in the • Avoid slippery surfaces. anatomical position of function to include the • Wear nonslip footwear. Do not wear flip- joints above and below the area of injury. Im- flops or sandals. mobilization will reduce pain and reduce the • Support body weight with the handgrips. likelihood of further injury to soft tissues as a Do not press the crutches into the arm- result of fracture fragment movement. The use pits. Hold the elbows straight, with the of crutches can help rest lower extremity in- tops of the crutches pressed against the juries. sides of the upper chest.

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Check Your Knowledge B. Muscle tenderness not associated with an underlying fracture or other 1. All of the following statements regarding severe injury is an important sign of impedance pneumonography are true compartment syndrome EXCEPT: C. Pulselessness is a late finding (too late) A. display can be affected by patient D. Untreated compartment syndrome movement. can result in permanent damage to the B. measures chest wall movement. extremity C. measures respiratory effort. E. All of the above D. measures ventilation. E. uses the electrocardiographic (ECG) monitor leads. References 2. Which of the following statements 1. Viccellio P, Simon H, Pressman BD, et al. A prospective regarding basic airway management is multicenter study of cervical spine injury in children. Pediatrics. correct? 2001;108:e20. 2. Hoffman JR, Mower WR, Wolfson AB, et al, for the National A. Chin-lift maneuver is acceptable for Emergency X-Radiography Utilization Study Group. Validity of most trauma patients a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med. 2000;343:94-99. B. Chin-lift maneuver is acceptable for 3. Woodward GA, Dudley NC. Cervical spine immobilization and unconscious trauma patients as long imaging. In: King C, Henretig FM, eds.. Textbook of Pediatric Emergency Procedures. 2nd ed. Philadelphia, PA: Lippincott as cervical spine films are normal Williams & Wilkins; 2008:313-324. C. Jaw-thrust maneuver is preferred for 4. Nobel JJ. ECG monitors. Pediatr Emerg Care. 1993;9:52. trauma patients 5. Yen, K, Gorelick MH. Use of monitoring devices. In: King C, Henretig FM, eds. Textbook of Pediatric Emergency Procedures. 2nd D. Nasal airways can only be used in ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:32-37. conscious patients 6. Ramsey M. Knowing your monitoring equipment: blood pressure monitoring: automated oscillometric devices. J Clin Monit. E. Oral airways work best in conscious 1991;7:56. patients 7. Fuerst RS. Use of pulse oximetry. In: King C, Henretig FM, eds. Textbook of Pediatric Emergency Procedures. 2nd ed. Philadelphia, 3. Which of the following statements PA: Lippincott Williams & Wilkins; 2008:749-754. regarding pericardiocentesis is correct? 8. Sinex JE. Pulse oximetry: principles and limitations. Am J Emerg A. Any pericardial effusion requires Med. 1999;17:59. 9. Jones BR, Dorsey MJ. Disposable end tidal CO2 detector: minimal

emergency drainage CO2 requirements. Anesthesiology. 1989;71:A358. 10. Gonzalez del Rey JA. End tidal CO . In: King C, Henretig B. ECG changes, including ST segment 2 FM, eds. Textbook of Pediatric Emergency Procedures. 2nd ed. changes and premature ventricular Philadelphia, PA: Lippincott Williams & Wilkins; 2008:755-762. contractions, suggest that the needle is 11. Scarfone RJ. Airway adjuncts, oxygen delivery, and suctioning the upper airway. In: King C, Henretig FM, eds. Textbook of Pediatric in contact with the heart muscle Emergency Procedures. 2nd ed. Philadelphia, PA: Lippincott C. Injury to the coronary arteries during Williams & Wilkins; 2008:93-108. 12. Lacher ME. Suctioning the trachea. In: King C, Henretig FM, pericardiocentesis has never been eds. Textbook of Pediatric Emergency Procedures. 2nd ed. described Philadelphia, PA: Lippincott Williams & Wilkins; 2008:785-791. D. 13. Barnes CA, Kirchhoff KT. Minimizing hypoxemia due to Normal pericardial space contains less endotracheal suctioning: a review of the literature. Heart Lung. than 5 mL of fluid 1986;15:164. E. Not possible for a pneumothorax to be 14. American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guideline for management of the created during pericardiocentesis difficult airway.Anesthesiology . 1993;78:597-602. 4. Which of the following statements 15. The American Heart Association in Collaboration with the International Liaison Committee on Resuscitation. Pediatric basic regarding compartment syndrome is life support. Circulation. 2000;102(suppl I):I253. correct? 16. McAneny CM. Basic life support. In: King C, Henretig FM, eds. Textbook of Pediatric Emergency Procedures. 2nd ed. Philadelphia, A. Most patients with compartment PA: Lippincott Williams & Wilkins; 2008:79-92. syndrome experience pain out of 17. Finer NN, Barrington KJ, Al-Fadley F, Peters KL. Limitations of proportion to their clinical findings self-inflating resuscitators.Pediatrics . 1986;77:1.

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18. King C, Reynolds SL. Bag-valve-mask ventilation. In: King C, 38. Bhende MS, Manole MD. Venipuncture and peripheral venous Henretig FM, eds. Textbook of Pediatric Emergency Procedures. 2nd ed. access. In: King C, Henretig FM. eds. Textbook of Pediatric Philadelphia, PA: Lippincott Williams & Wilkins; 2008:109-126. Emergency Procedures. 2nd ed. Philadelphia, PA: Lippincott 19. Poirier MP, Ruddy RM. Acute upper airway foreign body Williams & Wilkins; 2008:726-737. removal—the choking child. In: Henretig FM, King CC, eds. 39. Lavelle J, Costarino AT. Central venous cannulation. In: King C, Textbook of Pediatric Emergency Procedures. Baltimore, MD: Henretig FM, eds. Textbook of Pediatric Emergency Procedures. 2nd ed. Williams & Wilkins; 1997:621-629. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:247-272. 20. King C, Rappaport LD. Emergent endotracheal intubation. 40. Goutail-Flaud MF, Sfez M, Berg A, et al. Central venous catheter- In: King C, Henretig FM, eds. Textbook of Pediatric Emergency related complications in newborns and infants: a 587-case Procedures. 2nd ed. Philadelphia, PA: Lippincott Williams & survey. J Pediatr Surg. 1991;26:645. Wilkins; 2008:146-190. 41. Hodge D. Intraosseous infusion. In: King C, Henretig FM, eds. 21. Zuckerbraun N, Pitetti RD. Rapid sequence induction. In: King Textbook of Pediatric Emergency Procedures. 2nd ed. Philadelphia, C, Henretig FM, eds. Textbook of Pediatric Emergency Procedures. PA: Lippincott Williams & Wilkins; 2008:281-287. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 42. Miner WF, Corneli HM, Bolte RG, et al. Prehospital use of 2008:127-145. intraosseous infusion by paramedics. Pediatr Emerg Care. 22. Gerardi MJ, Sacchetti AD, Cantor RM, et al, Pediatric Emergency 1989;5:5. Medicine Committee of the American College of Emergency 43. Kirkham JH. Infusion into the internal saphenous vein at the Physicians. Rapid sequence induction of the pediatric patient. ankle. Lancet. 1945;2:815. Ann Emerg Med. 1996;28:55. 44. Gauderer MWL. Vascular access techniques and devices in the 23. King BR, Baker MD, Braitman LE, et al. Endotracheal tube size pediatric patient. Surg Clin North Am. 1992;72:1267. selection in children: a comparison of four methods. Ann Emerg 45. McIntosh BB, Dulchavsky SA. Peripheral vascular cutdown. Crit Med. 1993;22:530. Care Clin. 1992;8:807. 24. Luten RC, Wears RL, Broselow J, et al. Length-based 46. Vinci RJ. Venous cutdown catheterization. In: King C, Henretig endotracheal tube and emergency equipment in pediatrics. Ann FM, eds. Textbook of Pediatric Emergency Procedures. 2nd ed. Emerg Med. 1992;21:900. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:273-280. 25. The American Heart Association in Collaboration with the 47. Baldwin S, Terndrup TE. Thoracostomy and related procedures. International Liaison Committee on Resuscitation. Pediatric In: King C, Henretig FM, eds. Textbook of Pediatric Emergency advanced life support. Circulation. 2000;102(suppl I):I291. Procedures. 2nd ed. Philadelphia, PA: Lippincott Williams & 26. Minkowitz HS. Laryngeal mask airway and esophageal tracheal Wilkins; 2008:355-390. Combitube. In: Hagberg C, ed. Handbook of Difficult Airway 48. Miller KS, Sahn SA. Chest tubes: indications, technique, Management. Philadelphia, PA: Churchill Livingstone; 2000;171-183. management, and complications. Chest. 1987;91:258. 27. Pollack CV. The laryngeal mask airway: a comprehensive review 49. Hamilton AD, Archer GJ. Treatment of pneumoThorax by simple for the emergency physician. J Emerg Med. 2001;20:53-66. aspiration. Thorax. 1983;38:934. 28. Davis L, Cook-Sather SD, Schreiner MS. Lighted stylet tracheal 50. Rothenberg SS, Moore EE, Moore FA, et al. Emergency intubation: a review. Anesth Analg. 2000;90:745-756. department thoracotomy in children: a critical analysis. J Trauma. 29. Minkowitz HS. Airway gadgets. In: Hagberg C, ed. Handbook 1989;29:1322. of Difficult Airway Management. Philadelphia, PA: Churchill 51. Sheika AA, Culbertson CB. Emergency department thoracotomy Livingstone; 2000:171-183. in children: rationale for selective application. J Trauma. 30. Nitahara K, Watanabe R, Katori K, Yamasato M, Matsunaga 1993;34;323. M, Dan K. Intubation of a child with a difficult airway using 52. Koerner CE, King BR. Emergency thoracotomy. In: King C, Henretig a laryngeal mask airway and a guidewire and jet stylet. FM, eds. Textbook of Pediatric Emergency Procedures. 2nd ed. Anesthesiology. 1999;91:330-331. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:396-408. 31. Mittal M, Baren JM. Percutaneous transtracheal ventilation. 53. Reeves SD. Pericardiocentesis. In: King C, Henretig FM, eds. In: King C, Henretig FM, eds. Textbook of Pediatric Emergency Textbook of Pediatric Emergency Procedures. 2nd ed. Philadelphia, Procedures. 2nd ed. Philadelphia, PA: Lippincott Williams & PA: Lippincott Williams & Wilkins; 2008:709-714. Wilkins; 2008:237-246. 54. Klasner AE, Luke DA, Scalzo AJ. Pediatric orogastric and 32. Wong MEK, Bradrick JP. Surgical approaches to airway nasogastric tubes: a new formula evaluated. Ann Emerg Med. management for anesthesia practitioners. In: Hagberg C, ed. 2002;39:268. Handbook of Difficult Airway Management.Philadelphia, PA: 55. Simon HK, Rutman MS, Lewander W. Gastric intubation. In: Churchill Livingstone; 2000:185-218. King C, Henretig FM, eds. Textbook of Pediatric Emergency 33. Walls RM, Vissers RJ. Surgical airway techniques. In: Walls RM, Procedures. 2nd ed. Philadelphia, PA: Lippincott Williams & ed. Manual of Emergency Airway Management. Baltimore, MD: Wilkins; 2008:822-827. Lippincott Williams & Wilkins; 2000:89-104. 56. Beno S, Schwab S. Bladder catheterization. In: King C, Henretig 34. Niederman LG, Strange GR. Surgical cricothyrotomy. In: King C, FM, eds. Textbook of Pediatric Emergency Procedures. 2nd ed. Henretig FM, eds. Textbook of Pediatric Emergency Procedures. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:888-894. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:331-338. 57. Allen MJ, Stirling AJ, Crawshaw CV, Barnes MR. 35. Gausche M, ed. APLS: The Pediatric Emergency Medicine Course Intracompartmental pressure monitoring of leg injuries. J Bone Instructor Manual. Dallas, TX: American College of Emergency Joint Surg Br. 1985;67:53. Physicians; and Elk Grove Village, IL: American Academy of 58. Mubarak SJ, Hargens AR, Owen CA, et al. The wick catheter Pediatrics; 1998. technique for measurement of intramuscular pressure. J Bone 36. Tang W, Weil MH, Jorgenson D, et al. Fixed energy biphasic Joint Surg Am. 1976;58:1016. waveform defibrillation in a pediatric model of cardiac arrest and 59. Freedman SH, King BR. Approach to fractures with resuscitation. Crit Care Med. 2002;30:2736. neurovascular compromise. In: King C, Henretig FM, eds. 37. VF treated with CPR and automated external defibrillation. In: Textbook of Pediatric Emergency Procedures. 2nd ed. Philadelphia, Cummins RO, ed. ACLS Provider Manual, 2001. Dallas, TX: The PA: Lippincott Williams & Wilkins; 2008:991-1004. American Heart Association; 2001:63-73.

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60. Uliasz A, Ishida JT, Fleming JK, Yamamoto LG. Comparing the methods of measuring compartment pressures in acute compartment syndrome. Am J Emerg Med. 2003;21:143-145. 61. Johnson FC, Okada PJ. Reduction of common joint dislocations and subluxations. In: King C, Henretig FM, eds. Textbook of Pediatric Emergency Procedures. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:962-990. 62. Klig JE. Splinting procedures. In: King C, Henretig FM, eds. Textbook of Pediatric Emergency Procedures. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:919-931.

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Chapter Review 26-89