A two year old child presents with fever, stridor and a harsh cough. His condition deteriorates and he requires intubation. Outline how you would do this.
Answer and interpretation
Call for help
This should be in context –
- If the child becomes hypoxic/has a respiratory arrest etc – proceed with attempt bag mask ventilation 100% oxygen immediately – attempt intubation.
- If there is time – aim to have the person with the best paediatric airway management expertise – intubate child
Optimise medical management
- High flow oxygen
- if child hypoxic – can discuss avoiding distressing the child by holding mask away from face and with child on parents lap (unless really sick)
- IV steroids – adequate dose (0.6mg/kg dexamethasone)
- NEB adrenaline 5mg (repeated doses)
- Oxygen/Helium mixture if tolerates
Adequate discussion of preparation for intubation
- range of ETT’s (size 4.0, 4.5. 5.0, 5.5)
- two laryngoscopes with range of blade sizes – straight/curved
- small diameter “bougie”
- cannula for percutaneous needle cricothyroidotomy + method for oxygen delivery
Intubation: One of 2 approaches
- Inhalational induction of anaesthesia with maintenance of spontaneous ventilation until adequate depth of anaesthesia achieved to allow intubation (or to assess ability to ventilate – then proceed to paralyse child), or
- IV induction – with paralysis
There must be some discussion regarding risks of either technique. Mere mention of IV approach will not be enough to gain marks. There must be some discussion regarding risks of either technique. However, if not trained in inhalational anaesthetic techniques – reasonable to proceed with IV induction of anaesthesia + muscle paralysis – with risk of being unable to ventilate.
Alternate strategies if unable to intubate
- Ventilate with LMA/face mask until help arrives
- Rarely need to proceed to needle cricothyroidotomy
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.