Airway Procedures

Face masks Ideally, facemasks should be clear to allow you to see :

• The child's colour.
  
• The possible presence of vomit.
• Some masks conform to the anatomy of the child's face and make providing a good seal relatively easy. These masks also have a relatively low dead space.
• Circular soft plastic masks also give an excellent seal and are available across a range of sizes - from those designed to fit small neonates through to masks for large adults.
• The correct size mask is one which fits over the mouth and nose but does not press on the eyes.

Jaw Thrust

Jaw thrust is achieved by placing two or three fingers under the angle of the mandible bilaterally, and lifting the jaw upwards, ensuring the maintenance of in-line immobilisation.Jaw thrust acts to lift the tongue off the back of the pharynx and so clear the airway.This technique may be easier if the rescuer's elbows are resting on the bed or surface the child is lying on.

Oropharyngeal Airway Insertion (OPA)

• An OPA is indicated if the jaw thrust manoeuvre has failed to correct airway obstruction.
• An OPA acts by establishing an opening between the tongue and the posterior pharyngeal wall and can make a difficult airway much easier to manage.
• OPAs may not be tolerated by semi-conscious patients

Guedel Airways

Oropharyngeal Airway sizing measure from the centre of the incisors to the angle of the mandible, when laid on the face concave side up.

• Correction of obstruction
  
• Improved ventilation

If ventilation is still insufficient, the patient may require more advanced airway procedures, such as intubation

Endotracheal tubeintubation is required in case of failure to obtain an airway by simple airway opening maneuvers (eg: OPA insertion), for airway protection (eg: from blood, broken teeth, vomitus), to provide a secure airway for transport and to control ventilation in the unconscious/head injured patient. Uncuffed tubes are preferable in children up to eight years of age, to avoid oedema at the cricoid ring.Finding the right-sized tube is important, to avoid large leaks around the tube. Nasotracheal intubation whilst more secure is contra-indicated in patients with possible base of skull fracture

Curved or straight blades can be used although the straight blade laryngoscope is recommended in young children, because it is designed to lift the epiglottis, which is comparitavely large and floppy in children, under the tip of the blade, allowing a better view of the vocal cords.

Needle Cricothyroidotomy

If the airway is completely inadequate, consider:

• Surgical cricothyroidotomy (> 12 years)
  
• Needle cricothyroidotomy (any age; may be used to gain time during surgical cricothyroidotomy)

This is preferable to surgical airway in children under 12 years of age and is useful for obstruction in the larynx or above; not if the obstruction is in the trachea or bronchi.It improves oxygenation slightly, buying 10-15 minutes' time for help to arrive and for a definitive airway to be established.

Complications to be aware of : Asphyxia, Aspiration, Cellulitis, Oesophageal perforation, Haemorrhage, Haematoma, Posterior tracheal wall perforation, Subcutaneous and/or mediastinal emphysema, Thyroid perforation and Inadequate ventilation leading to hypoxia and death.

Breathing Procedures :Breathing Procedures :

• Self-inflating bags (LAERDEL AIR VIVA CIRCUITS) are available in three sizes:
• 250ml: Newborn or small neonates ONLY
  
• 500ml: Neonates - infants
• 1500ml: Infants-adults
• The two smaller sizes generally have a pressure-limiting valve, set at 4.41 kPa (45cmH20). This may (rarely) need to be over- ridden for high resistance/low compliance lungs, but it protects normal lungs from inadvertent barotrauma.
• The patient end of the bag connects to a one-way valve of a fish-mouth or leaf-flap design.
• The opposite end has a connection to the oxygen supply, and to a reservoir attachment.
• The reservoir enables high oxygen concentrations (up to 98% FiO2) to be delivered.
• Without it, it is difficult to give the patient more than 50% FiO2, whatever the fresh gas flow.

A significant amount of pressure is required by the patient to be able to open the "one way" valve.

Therefore, using these circuits without squeezing the bag should be avoided in spontaneously breathing children, to avoid asphyxiation.

In the breathing child who displays poor respiratory effort, assistance to breathe can be given by squeezing the bag with each breath. The squeezing action of the bag is what opens the one-way valve to release the high FiO2.

These bags must only be used to assist ventilation and not in the spontaneous ventilating child who is not being assisted.

Needle Thoracocentesis

Fluid or air that accumulates in the pleural space will reduce lung expansion and lead to respiratory compromise and hypoxia.

Insertion of an I.C.C. enables drainage of air or fluid from the pleural space, allowing negative intra-thoracic pressures to be re-established leading to lung re-expansion.

Circulation procedures :Circulation procedures :

Intra Osseous (IO) Access :

Venous Access may be difficult in children, sometimes more so in the critically ill child.It is indicated in a child following two failed attempts at cannulation (90 seconds) when IMMEDIATE access is required. The preferred site is the anterior tuberosity, 2-3 cm below the tibial tuberosity (the anteromedial flat part of the tibia).If the Tibia is fractured, an alternate site is the inferior part of the femur, 3 cm above the external condyle.

Venous Cutdown :

Venous cutdown should be performed only as a last resort for venous access.The advantage is that with IV cutdown, a large-bore cannula can be inserted under direct vision. Usually using the long saphenous the procedure may be carried out away from and therefore not interfering with the on-going resuscitation. The distal saphenous vein in the ankle is the most common site for a venous cutdown. The saphenous vein is just anterior to the medial malleolus.

Cervical Spine Assessment :

All children under 16 years of age with major trauma (including confirmed or highly suspected spinal cord injury) should have ongoing management at KIMS.

Traumatic injuries of the cervical spine are uncommon in children. However in many circumstances it is prudent to assume there is a cervical spine injury until examination and radiological investigation prove otherwise. It is often challenging to assess and immobilise children when a cervical spine injury is suspected.

• Constant reassurance is required to help keep the child still and reduce their anxiety levels.
  
• If the child is anxious or uncooperative and a thorough examination is not possible, try and maintain in line C-spine immobilisation with or without a collar.