FIGURE 9.2 Signs and symptoms of lack of substrate delivery to vital organ systems CNS, central nervous system FIGURE 9.3 Management sequence for pediatric life support CNS, central nervous system; ECG, electrocardiogram; BP, blood pressure; BUN, blood urea nitrogen; Ca++ , calcium AIRWAY Evaluation Recognition and treatment of airway obstruction and respiratory failure is crucial as asphyxia is the most common cause of pediatric arrest Evidence has demonstrated that prehospital intubation in children does not improve outcomes over BVM ventilation in areas without prolonged transit time, yet many children are still intubated in the field When a child arrives in the ED with an ETT in place, verify position immediately For stable patients, continuously measured end-tidal CO2 (ETCO2 ) is optimal Chest radiograph confirms placement In arrested patients, interpretation of ETCO2 and breath sounds may be unreliable; confirm tube placement by laryngoscopy in addition to ETCO2 and CXR All patients should be monitored continuously with pulse oximetry, ETCO2 , and cardiorespiratory monitors MANAGEMENT Airway Positioning If cervical trauma is suspected, the head and cervical spine must be stabilized during all airway maneuvers Airway obstruction is most often related to relaxation of the jaw and neck muscles causing the tongue and mandibular tissues to fall posteriorly against the posterior wall of the hypopharynx Airway positioning maneuvers, such as the head tilt–chin lift and the jaw thrust, are used first to relieve obstruction ( Fig 9.4 ) Jaw thrust alone is used if cervical stabilization is needed Artificial Airways If airway positioning fails to relieve obstruction, oropharyngeal (OPA) or nasopharyngeal artificial airways (NPA) may be used Oropharyngeal Airways Estimate OPA size by placing it against the side of the child’s face; with the flange at the corner of the mouth assuring that the tip ends just proximal to the angle of the mandible; use a tongue depressor to insert, or insert sideways and rotate into place to avoid damage to the soft tissues ( Fig 9.5 ) OPAs are used in unconscious patients only If the OPA is too short, it may push the tongue backward into the posterior pharynx aggravating airway obstruction If the OPA is too long, it may touch the larynx and stimulate vomiting or laryngospasm Nasopharyngeal Airways The correct NPA size covers the distance from the nares to the tragus of the ear ( Fig 9.6 ) The NPA can be used in conscious patients The NPA may lacerate the vascular adenoidal tissue, thus adenoidal hypertrophy and bleeding diatheses are relative contraindications to the use of these airways Endotracheal Tubes Endotracheal (ET) tubes are used to overcome upper airway obstruction, isolate the larynx from the pharynx, allow mechanical aspiration of secretions from the tracheal bronchial tree, and facilitate mechanical ventilation or end-expiratory pressure delivery (see Chapter Airway ) FIGURE 9.4 A: Upper airway obstruction related to hypotonia B: Partial relief of airway obstruction by means of head extension (danger of cervical spine injury in cases of trauma) C: Extreme hyperextension causing upper airway obstruction D: Fully open airway through use of jaw thrust or jaw lift E: Oropharyngeal airway stenting mandibular block off of posterior pharyngeal wall ...FIGURE 9.3 Management sequence for pediatric life support CNS, central nervous system; ECG, electrocardiogram; BP, blood pressure;... of airway obstruction and respiratory failure is crucial as asphyxia is the most common cause of pediatric arrest Evidence has demonstrated that prehospital intubation in children does not improve