How to Manage the Pediatric Airway

Training for these critical calls is vitally important


  • Discuss patient positioning, airway opening and suctioning
  • Review pediatric anatomy and physiology
  • Discuss prehospital airway management tools

“Medic 7 and Rescue 5, Lilly Lake Day Care, 3-year-old choking. All responding units, be advised object is dislodged, child is not breathing, prearrival being initiated.”

As you arrive on the scene, you are met by a distraught daycare provider who takes you inside. There two colleagues are desperately attempting to clear vomitus out of the 3-year-old’s mouth. “We have a pulse,” one of them tells you anxiously.

As you turn the patient onto her side, your partner prepares the battery-operated suction, and you insert a large-bore suction catheter, using gravity and suction to clear the remaining vomitus from the child’s mouth. As you roll her back, one of the EMTs grabs a nearby blanket, quickly folds it and places it under the patient’s shoulders to help with positioning. You assess the level of consciousness and find the child unresponsive to painful stimuli.

Next, while you are looking and listening for breathing, you simultaneously assesses for a carotid pulse. The child is still not breathing, but has a pulse of 70.

From the brief initial history your partner obtained, there is nothing to suggest trauma was involved. You place the bag-valve mask onto the patient’s face, pull the jaw into the mask and begin ventilating as one EMT attaches the BVM to oxygen at 15 lpm and another inserts an oral airway.

As one EMT ventilates the patient, you select and place an appropriate-size supraglottic airway, and your partner places a tibial intraosseous needle. Another EMT places cardiac electrodes. Following assessment for proper placement, you secure the SGA and then package the patient on a long spine board with a cervical collar.


Pediatric patients make up a small percentage of most EMS systems’ responses, and critical pediatric responses are even rarer.

A survey conducted by the National Registry of EMTs in 2000 found most EMS providers responded to 0–3 pediatric calls a month.1 A 2006 study from a large Canadian metropolitan area found that of 1,377 pediatric patients cared for during a six-month period, only 0.3% received BVM ventilation, and 0.1% were endotracheally intubated.2 Courses like the American Heart Association’s PALS (Pediatric Advanced Life Support) and PEARS (Pediatric Emergency, Assessment, Recognition and Stabilization), the Pediatric Education for Prehospital Providers (PEPP) course, and Pediatric International Trauma Life Support (PITLS) have helped standardize and disseminate prehospital pediatric education and training, but even with these courses and required hours for all levels of nationally registered EMS providers, many providers still describe a need for additional education and training on pediatric patients (i.e., from newborn to around 3 years old).1

The leading causes of cardiac arrest in young children are respiratory compromise/failure from sudden infant death syndrome (SIDS), trauma, a primary respiratory problem and near-drowning, and the average age of pediatric cardiac arrests is 3 months to 3 years.3–5 This supports EMS providers’ desire for additional education and training in assessment and management of pediatric patients.

Positioning, Opening and Suctioning

Whether you are a basic or advanced provider, the key elements of airway management are patient positioning, provider positioning, opening the airway and suctioning.6–8 For children 3 and under, the foundation of positioning is padding under the shoulders and/or upper torso to obtain a neutral or “sniffing” position; those over 3 may require padding under their occiput.7 Bath blankets, towels and folded sheets work well for this.

Patient location can affect patient positioning. There are times when the patient has to be managed where they are found—for example, in a vehicle with extrication required. If the patient is located in a bathroom, cramped room or small space, moving them as soon as possible will allow for better positioning and room for log-rolling and suctioning if required. It is optimal to have plenty of space to conduct all aspects of the resuscitation.

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