ASSESSMENT OF AIRWAY, BREATHING AND CIRCULATION

ASSESSMENT  OF AIRWAY, BREATHING AND CIRCULATION

Open airway: Establish an open airway with the head-tilt/chin-lift maneuver.

If neck injury is suspected, jaw thrust with cervical-spine (C-spine) immobilization should be used.

Obstruction: Rule out foreign body, anatomic, or other obstruction.

MANAGEMENT

Equipment

Oral airway

Poorly tolerated in conscious patient.

Size: With flange at teeth, tip reaches angle of jaw.

Length ranges from 4 to 10 cm.

Nasopharyngeal airway

Relatively well tolerated in conscious patient. Rarely provokes vomiting or laryngospasm.

Size: Length equals tip of nose to angle of jaw.

Diameter: 12 to 36 French (F).

Laryngeal mask airway is an option for a secure airway that does not require laryngoscopy or tracheal intubation. It allows spontaneous or assisted respiration, but does not prevent aspiration.

Intubation: Sedation and paralysis are recommended for intubation unless the patient is unconscious or is a newborn.

Indications: Obstruction (functional or anatomic), prolonged ventilatory assistance or control, respiratory insufficiency, loss of protective airway reflexes, or route for approved medications.

Equipment

Endotracheal tube (ETT):

An uncuffed ETT should be used in patients <8 years old.

The depth of insertion (in cm; at the teeth or lips) is approximately three times the ETT size.

Laryngoscope blade: Generally, a straight blade can be used in all patients. A curved blade may be easier to use in patients >2 years old.

Bag and mask should be attached to 100% oxygen.

ETT stylets should not extend beyond the distal end of the ETT.

Suction: Use a large-bore suction catheter or 14 to 18F suction catheter.

Nasogastric (or orogastric) tube: Size from nose to angle of jaw to xyphoid process.

Monitoring equipment: Electrocardiography (ECG), pulse oximetry, blood pressure (BP) monitoring, capnometry (end-tidal CO2 monitoring).

Procedure

100% O2 via bag and mask.

Administer intubation medications

Apply cricoid pressure to prevent aspiration (Sellick maneuver).

With patient lying supine on a firm surface, head midline and slightly extended, open mouth with right thumb and index finger.

Hold laryngoscope blade in left hand.

Insert blade into right side of mouth, sweeping tongue to the left out of line of vision.

Advance blade to epiglottis. With straight blade, lift laryngoscope straight up, directly lifting the epiglottis until vocal cords are visible. With curved blade, the tip of blade rests in the vallecula (between the base of the tongue and epiglottis). Lift straight up to elevate the epiglottis and visualize the vocal cords.

While maintaining direct visualization, pass the ETT from the right corner of the mouth through the cords.

Verify ETT placement by end-tidal CO2 detection (there will be a false negative if there is no effective pulmonary circulation), auscultation in both axillae and epigastrium, chest rise, and chest radiograph.

Securely tape ETT in place, noting depth of insertion (cm) at teeth or lips.

 

ASSESSMENT OF BREATHING 

Once the airway is established, evaluate air exchange.

Examine for evidence of abnormal chest-wall dynamics, such as tension pneumothorax, or central problems such as apnea.

MANAGEMENT

Positive pressure ventilation (application of 100% oxygen is never contraindicated in resuscitation situations).

Bag-mask ventilation is used at a rate of 20 breaths/min (30 breaths/min in infants). Assess chest expansion and breath sounds. Decompress stomach with orogastric (OG) or nasogastric (NG) tube with prolonged bag mask ventilation (BMV).

 

 

ASSESSMENT OF CIRCULATION

Rate:

Assess for bradycardia, tachycardia, or absent heart rate.

bradycardia is <100 beats/min in a newborn and <60 beats/min in an infant or child; tachycardia of >240 beats/min suggests primary cardiac disease.

Assess pulse (central and peripheral) and capillary refill (assuming extremity is warm): <2 sec is normal, 2 to 5 sec is delayed, and >5 sec is markedly delayed, suggesting shock. Decreased or altered mental status may be a sign of inadequate perfusion.

Blood pressure (BP): Measuring blood pressure is one of the least sensitive measures of adequate circulation in children.

MANAGEMENT

Chest compressions

Fluid resuscitation

If peripheral intravenous (IV) access is not obtained in 90 sec or three attempts, and the patient is <8 years old, then place an intraosseous (IO) needle

If still unsuccessful, consider central venous access.

Initial fluid should be lactated Ringer’s (LR) or normal saline (NS).

Administer a bolus with 20 mL/kg over 5 to 15 minutes. Reassess. If there is no improvement, consider a repeat bolus with 20 mL/kg of the same fluid.

Reassess. If replacement requires more than 40 mL/kg, or if there is acute blood loss, consider 5% albumin, plasma, or packed red blood cells (RBCs) at 10 mL/kg.

If cardiogenic etiology is suspected, fluid resuscitation may worsen clinical status.

Pharmacotherapy: See inside front and back covers for guidelines for drugs to be considered in cardiac arrest.

Note: Consider early administration of antibiotics or corticosteroids if clinically indicated.

MANAGEMENT OF CIRCULATION

 Location *                                           Rate (per min) Compressions:   Ventilation

Infants                                       >100                                                    5:1

1 finger-breadth below intermammary line

Children (<8 yr)                                    100                                                      5:1

2 finger-breadths below intermammary line    

Older children                           100                                                      15:2

(>8 yr Lower half of sternum  

*Depth of compressions should be one third to one half anteroposterior (AP) diameter of the chest and should produce palpable pulses.