Prehospital Pediatric Airway Management
EMS providers should be aware of alternative airway devices that can be used to effectively manage pediatric airways.
We are fortunate to live in a time of ongoing research, open discussion and technological advances in prehospital care. EMS providers are dealing with spinal immobilization, "load-and-go" vs. "stay-and-play" situations, medications for rapid sequence airways (RSA) or intubation (RSI), and ways to manage that very first element of patient assessment--the airway.
As Shakespeare's Hamlet pondered his future with the famous words "To be or not to be," he had choices; but only one path seemed correct. In that great tragedy, Hamlet chose a path that led to deception and eventually death. All too often, in the world of prehospital pediatric emergencies, we also face an uncomfortable choice: "to tube or not to tube." Do we attempt a relatively unpracticed procedure that is fraught with danger and potential complications, or do we embrace the future and move forward, toward improved safety for our smallest patients? In this article, we will look at prehospital pediatric airway management, past, present and future. We believe the future of prehospital pediatric airway management for both ALS and BLS providers goes back to basics, back to the past and back to the nonvisualized airways of the future.
"Airway equipment, including one supraglottic alternative for patients of all ages, should be available on every ambulance."1
Research shows that, on average, only 13% of prehospital patients are children.2 We start IV lines on adults every day, and running a full arrest is not an uncommon event. But we don't often experience a need for invasive procedures on kids. A 2001 study of an urban EMS system found that ALS providers only attempted pediatric IV placement 3.7 times a year, and pediatric intubation was only attempted once every 3 years.3 With such limited actual experience, it is easy to see how real-life proficiency in these procedures is difficult, if not nearly impossible, to maintain.
"Tracheal intubation (ETI) is considered the method of choice for securing the airway and for providing effective ventilation during cardiac arrest. However, ETI requires skills that are difficult to maintain, especially if practiced infrequently."4
Intubation with an endotracheal tube properly placed in the trachea, effectively secured, and with placement confirmed and monitored with capnography is the gold standard for airway management. It allows for continuous assisted ventilation, minimizes the risk of aspiration, and, though not a preferred route, provides a means for delivery of certain emergency medications.5,6 However, intubation is not without risks and potential complications that are generally considered more significant in the uncontrolled and unpredictable prehospital environment. Several studies describe unsuccessful adult intubation rates ranging from 8%-30% and time to intubation ranging from 5-17 minutes.7-11 For our pediatric patients, data from separate studies reveal successful endotracheal intubations in only 50% of the attempts for children under 1 year of age, 54% in children younger than 18 months, and only 57% in those under 12 years.12-14
"...the addition of out-of-hospital ETI to a paramedic scope of practice that already includes BVM (bag-valve mask) did not improve survival or neurological outcome of pediatric patients treated in an urban EMS system."14
A study that opened the eyes of many prehospital providers was conducted in the Los Angeles area.14 The study was developed to evaluate outcome differences between using a bag-valve-mask procedure and intubating children. The methodology used was simple and straightforward. The study population was made up of seriously ill or injured children who were determined to need airway and/or respiratory support. EMS personnel were instructed to intubate children on Mondays, Wednesdays and Fridays, and to use only the bag and mask on other days of the week. Researchers found that pediatric patients who were only bag-mask ventilated did just as well (survival 30%; good neurologic outcome 23%) as those who were intubated (survival 26%; good neurologic outcome 20%).
