Hi, everyone. Welcome to primary assessment, airway.
Before we dive into the airway, I want to answer a common question the PALS instructors get, and that is CAB versus ABC. When do we do compressions first versus going to the airway first? Great question. CAB was designed and brought forth by the AHA to address the needs of the adult victim because we needed to get to chest compressions quickly. This model was carried onto the pediatric patient in PALS for the purpose of continuity of training to make it easier. The AHA recognizes the caveat is that the number one reason an infant or a child will cardiac arrest is respiratory in nature. They know that, but they still made it CAB for the pediatric patient. When would you go ABC versus CAB? When do we use CAB in the pediatric patient? If in your initial assessment this child is unresponsive, not breathing when you look at them, check a quick pulse (no more than 10 seconds). If they don’t have a pulse, start chest compressions. If in your initial assessment they’re unresponsive with gasping respirations, ineffective respirations, check a quick pulse (no more than 10 seconds). If they don’t have a pulse, begin chest compressions. It’s really the initial status of the child. If they’re unresponsive, not breathing, CAB. In all other scenarios, it’s always ABC first. Any conscious child, ABC. Any child who’s lying on the ground, not moving, but you see regular breathing, ABC. It’s only if they’re apneic and pulseless initially.
The airway: What is an airway? I think of it as a pathway. That’s all it is—airway, pathway. What we’re talking about is a pathway to get air into the child (oxygenation) and a pathway to get air out of the kid or blow CO2 off (ventilation). That’s all we’re talking about. Is this pathway open? Is it open? Is it secure? Can it be maintained? We’re assessing the airway. First thing we’re looking for is chest rise. Is the chest going up and down? Next, we’re kind of listening for sounds. We’re looking to assess for obstructions in the airway. When we talk about obstructions, some people go right to foreign body obstruction. It might not be a Lego in the back of this kid’s throat. Remember, the most common airway obstruction in any patient lying flat on their back is their tongue. That’s an obstructed airway. The tongue will obstruct the airway first. Secretions can obstruct the airway. Edema in the upper airway from, say, anaphylaxis, allergic reaction can obstruct the airway. We’re looking for chest rise, and we’re listening for clues as to what could be obstructing this airway or this pathway.
How do we open the pathway? How do we open the airway? We’re going to utilize two methods initially, either the head-tilt-chin lift or the modified jaw thrust. When do we use each of those? In any suspected traumatic cervical injury—if you suspect a neck injury in this kid—our first maneuver is the modified jaw thrust. This allows us to keep the neck in a neutral position, place our hands on the sides of the child’s head, and use our fingers to move the jaw anteriorly and get that tongue off the back of the throat. We’re going to have circumstances that suggest the use of this. If a kid fell down a flight of stairs. If we roll up on the scene and there’s a bicycle lying next to the curb and the kid’s head is next to a fire hydrant, we’re suspecting a cervical injury. We would start by using the jaw thrust maneuver. Know this, if we are unable to ventilate, oxygenate, bag this child with a jaw thrust, immediately go to a head-tilt-chin lift, because airway takes precedence over a suspected C-spine injury. Start simple, jaw thrust. If that doesn’t work, can’t get air into them, immediately go to a head-tilt-chin lift. If neither of those methods work, our next step is to employ an adjunct, either an oral or a nasal airway. If the child has no gag reflex, is unconscious, oral airway first. Remember when we’re measuring the oral airway, we’re going to go from the corner of the mouth to the angle of the jaw. The whole object of the oral airway is to get that tongue off the back of the throat and open up that pathway so we can get air in and out of the child. In airway management, we start simple. What’s the simplest thing we can do to maintain patency of that airway. It may just be the head-tilt-chin lift or head-tilt-chin lift with an oral airway. If that doesn’t work then we have to move to an advanced airway. We’re becoming more aggressive in our airway management as we need to, to maintain that airway. Never rely on just an oral airway to make sure that airway is open. If we put an oral airway in, this is done in conjunction with a head-tilt-chin lift or a modified jaw thrust. The oral airway is there just to help the previous procedure. If our pediatric patient is conscious, allow them to take the position that is easiest for them to breathe. Usually it’s going to be sitting up, sitting forward, getting the belly off the diaphragm so they can take a full breath of air. What we wouldn’t want to do is try to force a kid to lie flat on the cot or something like that. Anything that makes it more difficult for them to breathe, we’re going to avoid. Let them assume the position of comfort. If we’re unable to ventilate this child or infant—initially we couldn’t get air into them with an Ambu bag, we’re using the head-tilt-chin lift, and we tried an oral airway and still couldn’t get air into this kid—then we might start thinking foreign body obstruction. Be looking for clues. Is there food around the kid? Were they eating when this happened? Are there Legos laying all over the place, like at my house? Be thinking foreign body obstruction and then move into the appropriate therapy, which is either going to be back blows on a small child or abdominal thrusts on a larger child. The key to airway management is constant reassessment. We’re assessing. We’re evaluating. If we need to do something, do something and then reevaluate the effectiveness of whatever we just did. For instance, if we’re bagging them and it’s becoming harder, they may need an oral airway. We’re constantly reassessing that airway or that pathway. It’s paramount in a child.
This has been just a quick review of the airway, the pathway to get air in and out of this kid. I’ll see you in the breathing video, coming up next.