needle cricothyrotomy

Pediatric Medical Resuscitation Pearls and Pitfalls:  The Airway Author: Geoff Jara-Almonte, MD // Editor: Alex Koyfman, MD (@EMHighAK)  Featured on #FOAMED REVIEW 39TH EDITION – Thank you to Michael Macias from emCurious (@EMedCurious) for the shout out! You are one hour into your overnight shift at a single-coverage semi-rural emergency department when you are paged overhead to the resuscitation room. As you come in you see your triage nurse rushing back with a young couple holding a boy who looks to be about two years old. He is in severe respiratory distress. You place him on the monitor, his vital signs are HR 145, SpO2 95%, tympanic temperature 36.7, he is breathing 32 times a minute. You place him in his father’s lap on the stretcher and examine him. His neck is flexed and head extended. He has supraclavicular retractions and nasal flaring. His lungs are clear, there is soft inspiratory stridor. No trismus, the oropharynx looks normal, neck is supple with no adenopathy or masses. You try and decide what is causing his respiratory distress . . .   In children the combination of history and exam is often sufficient to determine the cause of respiratory distress as well as assess the degree of severity. Particularly helpful findings include:   Stridor- suggestive of upper airway obstruction; respiratory phase may help localize lesion: Inspiratory – obstruction in supraglottic area or immediately at the level of the glottis Biphasic – obstruction in the trachea Expiratory – carina or below Retractions may be subtle, require careful observation of unclothed child, indicate increased work of breathing. Tend to progress from inferior to superior with increasing distress. Tachypnea – may be the only sign of significant respiratory distress, especially in young infants. Prolonged observation is necessary, as periodic breathing can lead to under- or overestimation. Position – sniffing position indicates airway obstruction, tripoding usually with lower airway pathology. Nasal Congestion – can precipitate significant respiratory distress in neonates and infants under 4 months of age who are obligate nasal breathers Grunting – creates PEEP usually indicates alveolar pathology Nasal Flaring – reflexive activity, usually with upper airway obstruction. Paradoxical or see-saw breathing – chest collapse and abdominal protrusion during inspiration is an ominous sign of respiratory muscle fatigue.[i] Head Nodding – associated with impending respiratory failure and mortality[ii]   You decide he likely has an upper airway obstruction of some sort. You get a bit more history from the parents – they tell you he has no medical problems, and was in his usual state of health until tonight. He was playing with his older sister in her room unsupervised for about ten minutes when they heard crying. They rushed in and found him in distress. You quickly run over the differential of acquired upper airway obstruction in children . . .   Epiglottitis – Usually febrile and toxic-appearing. Rapid onset, present after <24 hr of symptoms. Drooling, trismus, odynophagia, and respiratory distress are common presentations. Retropharyngeal and parapharyngeal abscesses – Often polymicrobial, associated with sore throat, high fever, muffled voice, trismus, and neck stiffness, usually less than 3y/o Croup – Most common cause of obstruction, peak at 2yr. Harsh barking cough, inspiratory stridor, preceded by URI. Usually worse at night and improves in cold air Bacterial tracheitis – usually viral prodrome, may have acute onset of respiratory distress. Febrile, sometimes toxic appearing. Difficult to differentiate from croup and epiglottitis. Aspirated foreign body – Sudden in onset, no associated infectious symptoms. Peak age in toddler years. Variable history of choking episode.[iii]   Based on this history you suspect an aspirated foreign body. As you are trying to decide what to do next you place him on a non-rebreather. He gets upset with the mask on his face and fights to take it off. As he is crying and becoming more distressed, you hear his stridor worsening. He begins to have severe retractions, and you notice some perioral cyanosis. His pulse ox drops to the 80s. You try and decide if it’s more important that he have the O2 mask on, or that he be comfortable . . .   Agitation and crying can precipitate worsening respiratory distress and decompensation of a tenuous patient. Crying and hyperventilation lead to increased minute ventilation, which in turn leads to increased airflow velocity across the site of obstruction. As airflow velocity increases, there is increasingly negative intraluminal pressure (Bernoulli’s principle). As intraluminal pressure drops, there is worsened dynamic inspiratory collapse of the pliable airway soft tissues, which leads to worsened obstruction and increasing distress. [iv] Keeping your patient as calm as possible can reduce the possibility of sudden decompensation. Allow the child to maintain a position of comfort. Allow him to sit in a parent’s lap or be near a parent if at all possible. Minimize noxious stimuli such as blood-pressure cuffs, rectal thermometers, phlebotomy, and oxygen masks or nasal cannula as much as possible. Try alternatives like blow-by oxygen or nebs. Consider inhaled steroids for croup. Try to limit the number of caregivers in the room. Remember that children take their behavioral cues from their parents, and the parent will take them from you. Be as calm and reassuring as possible. Allow the child access to a favorite toy, video game, or phone.   You decide to allow him to take off the mask. You have the father hold it and give blow-by oxygen. Over the next few minutes he stops crying. His stridor and retractions improve a little. But he remains distressed, and seems worse than when he came in. You consider trying the Heimlich maneuver or looking in the mouth to see if there is a foreign body you could remove, but then you wonder if that would be a good idea . . .   The preferable treatment for a child with a partially obstructing foreign body is endoscopic or surgical removal in the OR under controlled circumstances. So long as it remains a partial obstruction – the child is breathing, crying, or phonating and