Advanced Trauma Life Support ATLS Student Course Manual 2018

194
CHAPTER 10 n Pediatric Trauma
bradycardia with direct laryngeal stimulation. Bradycardia
in infants is much more likely to be due to
hypoxia. Atropine sulfate pretreatment should be
considered for infants requiring drug-assisted intubation,
but it is not required for children. Atropine
also dries oral secretions, enabling visualization of
landmarks for intubation.
After inserting the endotracheal tube, ensure that
its position is assessed clinically (see below) and, if
correct, the tube carefully secured. If it is not possible to
place the ETT after the patient is chemically paralyzed,
ventilate the child with 100% oxygen administered
with a self-inflating bag-mask device until a definitive
airway is secured.
Orotracheal intubation under direct vision with
restriction of cervical motion is the preferred method
of obtaining definitive airway control. Do not perform
nasotracheal intubation in children, as it requires
blind passage around a relatively acute angle in the
nasopharynx toward the anterosuperiorly located
glottis, making intubation by this route difficult.
The potential for penetrating the child’s cranial vault
or damaging the more prominent nasopharyngeal
(adenoidal) soft tissues and causing hemorrhage also
discourages the use of the nasotracheal route for
airway control.
Once the ETT is past the glottic opening, position it 2
to 3 cm below the level of the vocal cords and carefully
secure in place. Next, conduct primary confirmation
techniques, such as auscultation of both hemithoraces
in the axillae, to ensure that right mainstem bronchial
intubation has not occurred and that both sides of
the chest are being adequately ventilated. Then use
a secondary confirmation device, such as a real-time
waveform capnograph, a colorimetric end-tidal carbon
dioxide detector, or an esophageal detector device, to
document tracheal intubation, and obtain a chest x-ray
to accurately identify ETT position.
Because young children have short tracheas, any
movement of the head can result in displacement of the
ETT, inadvertent extubation, right mainstem bronchial
intubation, or vigorous coughing due to irritation of the
carina by the tip of the tube. These conditions may not
be recognized clinically until significant deterioration
has occurred. Thus, clinicians should evaluate breath
sounds periodically to ensure that the tube remains in
the appropriate position and identify the possibility of
evolving ventilatory dysfunction.
If there is any doubt about correct placement of the
ETT that cannot be resolved expeditiously, remove the
tube and replace it immediately. The mnemonic, “Don’t
be a DOPE” (D for dislodgment, O for obstruction, P
for pneumothorax, E for equipment failure) may be a
useful reminder of the common causes of deterioration
in intubated patients.
Cricothyroidotomy
When airway maintenance and control cannot be
accomplished by bag-mask ventilation or orotracheal
intubation, a rescue airway with either laryngeal
mask airway (LMA), intubating LMA, or needle
cricothyroidotomy is necessary. Needle-jet insufflation
via the cricothyroid membrane is an appropriate,
temporizing technique for oxygenation, but it does
not provide adequate ventilation, and progressive
hypercarbia will occur. LMAs are appropriate adjunct
airways for infants and children, but their placement
requires experience, and ventilation may distend the
patient’s stomach if it is overly vigorous.
Surgical cricothyroidotomy is rarely indicated for
infants or small children. It can be performed in older
children in whom the cricothyroid membrane is easily
palpable (usually by the age of 12 years).
Pitfall
Patient’s oxygen
saturation
decreases
prevention
Use the “Don’t be a DOPE”
mnemonic as a reminder of the
common causes of deterioration in
intubated patients:
• D—Dislodgment can easily occur,
as the trachea of an infant or child
is short. Secure the tube well and
recognize the situation early if it
occurs. Use monitoring equipment,
especially during transport, to help
alert the provider of this problem.
• O—Obstruction with secretions or
secondary to kinking can occur, as
the diameter of the tubes is small.
Suctioning can clear secretions,
but tube replacement may
be necessary.
• P—Pneumothorax. Tension
pneumothorax can develop with
positive pressure in patients with
underlying pneumothorax from
traumatic injury or barotrauma
related to mechanical ventilation.
This conditions warrants
decompression.
• E—Equipment failure. Ventilators,
pulse oximeters, and oxygen
delivery devices can malfunction.
Ensure that equipment is
well maintained and properly
functioning, and use backup
equipment when necessary.
n BACK TO TABLE OF CONTENTS