Remember that A comes before B and C. If you haven't protected the airway, you haven't effectively cared for the patient

Remember that A comes before B and C. If you haven't protected the airway, you haven't effectively cared for the patient: Excerpt from Avoiding Common Pediatric Errors

Author: Renée Roberts, MD

What to Do - Take Action

The guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care for pediatric and neonatal patients contains recommendations designed to improve survival from sudden cardiac arrest and acute life-threatening cardiopulmonary problems. They have recently been revised, but this does not imply that the use of earlier guidelines is outdated. It is important that pediatric caregivers be familiar with these guidelines and the changes. In particular, the guidelines continue to emphasize that cardiac arrest in children is most often the end result of respiratory arrest. Thus a lone rescuer for an unresponsive child should begin with 30 compressions and two breaths, then activate the emergency medical services system. This approach is thought to optimize the chances for quick resuscitation of children with primary respiratory arrest, before complete cardiopulmonary arrest occurs. Two-rescuer CPR in children is the only situation that deviates from the 30:2 ratio recommended for compressions and breaths; for two-rescuer CPR in children, two breaths should be given after every 15 compressions. Otherwise, CPR recommendations for children closely parallel those for adults where basic life support should always be remembered as an "ABCD" approach to cardiopulmonary arrest: airway, breathing, circulation, defibrillation. Guidelines for advanced life support for children also are similar to those for adults, with a few notable exceptions: vasopressin and atropine not recommended for pulseless electrical activity; defibrillation should be dosed on weight (4 joules per kg); and the use of intraosseous (IO) access is permissible if intravenous (IV) access is not established quickly.

Changes in the guidelines include caution about use of endotracheal tubes. Confirmation of tube placement requires exhaled carbon dioxide detection and is recommended especially when a prompt increase in heart rate does not occur after intubation. Furthermore, all rescue breaths given over 1 second with sufficient volume need to produce a visible chest rise. Lastly, correct placement must be verified when the tube is inserted, during transport, and whenever the patient is moved. With an advanced airway in place, CPR is not done in cycles but rather chest compressions are performed continuously at a rate of 100 per minute without pauses for ventilation, which should be 8 to 10 breaths per minute. Remember an increase in heart rate is the primary sign of improved ventilation during resuscitation.

The unexpected difficult pediatric airway that may be encountered during resuscitation is subdivided into the nonemergency (can ventilate but cannot intubate) and emergency pathways (cannot ventilate and cannot intubate). Management for the unexpected difficult pediatric airway involves maintaining adequate oxygenation while a definitive course of action is pursued. Unfortunately, infants have an increased metabolic rate and decreased functional residual capacity, which makes the time between the loss of the airway and resultant hypoxemia with secondary neurologic injury significantly diminished compared with adults. Approximate time to zero oxygen saturation from an inspired oxygen concentration of 90% is 4 minutes in a 10-kg child, whereas the same event in a healthy adult takes 10 minutes. If there is any question of a possibility of difficulty with ventilation or intubation due to airway, face, or neck abnormalities, appropriate personnel (anesthesia) should be notified immediately. This can include facial and neck trauma, craniofacial syndromes, infectious causes (e.g., epiglottitis, large abscesses deforming the mouth head or neck), and masses encroaching on the trachea or mediastinum. A timely call for experienced airway assistance will result in the best possible outcome. Figure 81.1 is an algorithm for management of an unexpected difficult airway.

Thelaryngealmaskairwayhasproventobeanextremelyusefuldevicein the emergency pathway when used by health care providers. It is an effective device for ventilation and an effective conduit for intubation. It is easily inserted blindly and requires a relatively low level of skill. However, caution must be used because this is a supraglottic device, so if glottic or subglottic obstruction to ventilation is present it will be ineffective, and transtracheal jet ventilation via percutaneous needle cricothyrotomy must be pursued. In addition, protection against aspiration is not assured.

In the new guidelines, induced hypothermia (32–34°C for 12–24 hours) may be considered if a child remains comatose after resuscitation. Studies show that infants without signs of life after 10 minutes of resuscitation show either a high mortality rate or severe neurodevelopmental disability, thus in the child who already has conditions with unacceptable high morbidity and congenital anomalies associated with certain early death, discontinuation of resuscitation is justified.

Suggested Readings

American Heart Association. 2005 American Heart Association (AHA) guidelines for car diopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of pediatric and neonatal patients: pediatric basic life support. Pediatrics. 2006;117(5):e989–e1004.
Cayley WE. Understanding 2005 AHA Guidelines for CPR and emergency care. Am Fam Physician. 2006;73(9):1644.
Wheeler M. The difficult pediatric airway. Anesthesiol Clin North Am. 1998;16(4):743–761.

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Book Source Details

• Book Title: Avoiding Common Pediatric Errors
• Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
• Year of Publication: 2008
• Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Avoiding Common Pediatric Errors Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7489-6

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