Category: Pediatric

7/21/2019 1 Comment

Pediatric "Difficult" Airway Review

Republished with Permission from www.PedEMMorsels.com

Difficult Airway: Basics

Defining “Difficult Airway” is challenging, so studies are not strictly comparable (we all know it after we have dealt with it though).
Some separate “Difficult Airway” from “Difficult Intubation.” [Belanger, 2015]
- Difficult Airway – unable to provide adequate gas exchange despite BVM, airway adjuncts, or combination of the two.
- Difficult Intubation – 3 or more attempts by an experienced clinician

The incidence of difficult intubations in children vary from <0.1% to 9%[Graciano, 2014; Heinrich, 2012]
Difficult intubations is associated with higher incidence of oxygen desaturations below 80% and adverse events. [Graciano, 2014]

Difficult Airway: Important Differences
Anatomic and physiologic differences influence how the oral, pharyngeal, and tracheal axes align as well as how the respiratory mechanics function and how the child compensates to physiologic stress.
The differences are most prominent in children < 2 years of age and more adult anatomy evolves as children progress to 8 years of age.

Anatomic Differences:

Relatively larger head (particularly occiput)
- Need for shoulder roll instead of head elevation to align external auditory meatus with sternal notch (which helps align the three axes).
Smaller and compressible nasal passages
- More easily occluded by mucous
- Easily obstructed by poorly positioned facemask.
Relatively larger tongue
- More difficult to control with laryngoscope blade.
- Occupies more mouth and posterior pharyngeal space.
Larynx location is more cranial
- Adult’s larynx located around C4-5
- Child’s larynx located around C3-4, but can be even higher (C2-3).
- Makes for more of an “anterior” airway and acute angle from pharyngeal axis to tracheal axis.
Epiglottis is longer and more floppy
- Softer cartilage and more pliable tissues
- Can be more difficult to retract away from glottic opening.
Trachea is more compressible
- Softer cartilage and more pliable tissues
- Can be easily compressed by a “helpful” person performing cricoid pressure (don’t let this happen).
Ribs are horizontal
- Contribute less to the work of breathing
- Diaphragm does most of the work of breathing.
Low functional residual capacity
- Due to smaller airways and less dead space
- Smaller reservoir from which the apneic child can draw oxygen
Smaller number of alveoli
- Less oxygen absorption surface area.

Physiologic Differences:

Higher metabolic rate
- Consumes oxygen at more than twice the adult rate
- Combined with low functional residual capacity, leads to rapid desaturations.
Low glycogen stores
- High metabolic rate and low glycogen stores leads to hypoglycemia.
- Hypoglycemia is a common SYMPTOM of the critically ill child.

Difficult Airway: Predictive Factors

Adult-based tools (ex, LEMON, Mallampati, thyromental distance) are notpredictive in young children. [Belanger, 2015]
There are patient factors that are associated with difficult intubation. [Karsli, 2015; Belanger, 2015]
- History of difficult airway (duh) [Graciano, 2014]
- Less than 1 year of age
- Signs of Upper Airway Obstruction (duh) [Graciano, 2014]
- Congenital/Genetic Syndromes w/ altered anatomy
  - Down Syndrome
  - Pierre Robin Sequence
  - Treacher Collins
  - Cleft Palate
  - Mucopolysaccharidosis (ex, Hunter, Hurler)
- Physiologic stress [Graciano, 2014]
  - Hypotension, ventilation failure, etc

Difficult Airway: Assume the Worst

Most pediatric airways can be secured by experienced clinicians, but the potential for discovering a difficult airway after meds have been pushed is a perilous position to be in. [Belanger, 2015]
Absence of predictive factors for difficult airway does not mean it will be an easy airway. [Karsli, 2016; Graciano, 2014]
- One study found 1 in 5 Difficult Airway cases were NOT anticipated.[Karsli, 2016]

Moral of the Morsel

Pediatric patients are a special population and warrant special considerations.
Anatomy and Physiology matter! There are numerous differences that need to be considered… even when it is “easy.”
Anticipate the Worst! 1 out of 5 is a concerning number – All pediatric patients should be considered to have a Difficult Airway until you successfully intubate them… then you can hit the “easy” button.
There are no “easy airways” in the ED, regardless of age. Patients that require intubation in the ED have, be definition, stressed physiologic systems and, as such, should be considered difficult until proven otherwise.

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5/19/2019 1 Comment

Pediatric Non-Accidental Trauma (NAT)

Taking care of children in the ED isn't just diagnosing viruses - child abuse/neglect is more prevalent than we'd like to think:
            - 2-10% of children presenting to the ED are victims of abuse or neglect
            - children that are abused often have multiple healthcare visits before it is recognized

Child maltreatment includes neglect and abuse
Neglect
- failure to meet the most basic needs of a child (food, shelter, supervision, nurturance)
- can be educational, psychological, emotional, medical neglect, or supervisory
            - by far the most common type of maltreatment - about ⅔ of cases
            - very difficult to identify diagnose
Abuse
- includes physical abuse, sexual abuse, emotional abuse, and medical child abuse
* medical child abuse is the current term for Munchausen Syndrome by proxy
- physical abuse (also referred to as non-accidental trauma or NAT) is often the most recognizable type of abuse
- makes up 16% of maltreatment cases

Providers should be mindful of sentinel injuries - injuries without a plausible explanation
            - knowing basic developmental milestones can be helpful
                        4-5 months - rolling over
                        6 months - sitting unassisted
                        9 months - pulling to a stand and walking
                        12 months - walking

**soft tissue injuries - bruising in children who cannot cruise, or in high risk areas
            - normal childhood bruises occur on surfaces that take impact when the child falls
                        bruising on the knees and shins isn’t alarming
                        bruising on areas like the back, buttocks, thighs, abdomen is concerning
- TEN-4 FACES P can help you identify injuries that suggest potential abuse
            * bruising on the Trunk, Ears, or Neck in a child less than 4 years old
* ANYbruising on a child less than 4 months
* injuries/bruising to the Frenulum, Auricular area, Cheek, Eyes, Sclera or
* Patterned bruising is a red flag

**skeletal injuries are the second most common presentation of abuse - certain fractures should raise your suspicion for abuse
- rib fractures (make sure you check that CXR ordered to look for pneumonia)
- any fracture in a child that cannot walk
- long bone fractures in an infant or toddler

**abusive head trauma (formally known as “shaken baby syndrome”)
                  - this is the most common cause of death following abuse
                  - 30% of cases are missed initially – remember to consider it in cases of excessive fussiness or altered mental status

**chest and abdominal injuries
            - the abdomen can hide injuries and hold a lot of blood - you won’t always see bruising
            - elevated liver enzymes or lipase should raise your concern for occult intra-abdominal injury

What can you do to help prevent a missed diagnosis of abuse?

Perform a “top-toe” exam on every patient and examine their skin for bruising (this means everyone should be in a gown)
Make sure the explanation of the injury makes sense developmentally – “those who don’t cruise rarely bruise”
If you’re concerned about possible abuse, initiate a screening work up or admit the child to a service that can complete an abuse evaluation
Remember that you are a mandated reporter – involve Social Work early, even if you plan to refer the child to another hospital for evaluation.

ACEP Now. The Recognition of Child Abuse. May 1, 2012.

Colbourne M, Clarke MS. Child Abuse and Neglect. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016. http://accessmedicine.mhmedical.com.libproxy.lib.unc.edu/content.aspx?bookid=1658&sectionid=109435341. Accessed May 15, 2019.

Christian CW. The Evaluation of Suspected Child Abuse.  PEDIATRICS. 2015; 135 (5): e1337-e1354.

Glick JC, Lorand MA, and Bilka KR. Physical Abuse of Children.  Pediatrics in Review. 2016; 37(4): 146-158.

Lindberg DM, Beaty B, Juarez-Colunga E, et al. Testing for Abuse in Children With Sentinel Injuries. PEDIATRICS. 2015; 136(5): 831-838.

Petska HW and Sheets LK. Sentinel Injuries Subtle Findings of Physical Abuse. Pediatric Clinics of North America. 2014; 61(5): 923-935.

Ravichandiran N, Schuh S, Bejuk M, et al. Delayed Identification of Pediatric Abuse-Related Fractures.  PEDIATRICS. 2009; 125 (1): 60-66.

Sheets LK, Leach ME, Koszewski IJ, et al.  Sentinel Injuries in Infants Evaluate for Child Physical Abuse. PEDIATRICS. 2013; 131(4): 701-107.

Teeuw AH, Derkx BHF, Koster WA, et al. Detection of child abuse and neglect in the emergency room. European Journal of Pediatrics. 2012; 171: 877-885.

Teeuw AH, Hoytema van Konijnenburg EM, Sieswerda-Hoogendoorn T, et al.  Parents’ Opinions About a Routine Head-to-Toe Examination of Children as a Screening Instrument for Child Abuse and Neglect in Children Visiting the Emergency Department.  Journal of Emergency Nursing. 2016; 42(2): 128-138.

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