Airway Management of Trauma Patient of Paediatric Age Group

The airway and ventilation management in trauma patient both adult and paediatric is most critical step . Airway management in paediatric age group requires clear-cut understanding of anatomical and physiological variations as the need of each individual case may require various degree of interventions through equipment support. It is essential to arrange the range of equipment suited for each age group and varied anatomy and readily available to combat the arising emergent situation . The trauma patient with spinal and facial injuries pose a challenge in proper ventilator support and delayed or inadequate airway management may result in devastating consequences. In this review article an attempt has made to evaluate the process of quick assessment of respiratory status, paediatric anatomical variation and physiological functional status and an overview of definitive airway management methods, various airway equipments and emergency intubation practices will be elucidated. Key-wordsAirway management, Trauma, Paediatric, Intubation -------------------------------------------------IJLSSR----------------------------------------------INTRODUCTION It is most critical in Trauma to immediately restore the airway and quickly establish the life threatening conditions. Any delay may be devastating and lapse of each moments need to be accounted in priority. In trauma patient carrying out quick primary survey and treating the life threatening conditions according to ABCDE is vital. Delayed and inadequate airway management results in devastating consequences. Access this article online Quick Response Code: Website: www.ijlssr.com DOI: 10.21276/ijlssr.2016. 2.6. 1 The airway management of paediatric trauma patient requires a lot of practice/training, thorough understanding of anatomy and Physiology, knowledge and practice of various methods and equipment of airway management, complete and rapid assessment of injuries. Ineffective management of airway will lead to respiratory failure which in turn may leads to failure of resuscitation. It has been emphasized in various literatures that in-pediatric patient, most cardiac arrest begins as respiratory failure . Pediatric patient in contrast to adults have different airway anatomy and physiology which are both unique and challenging. To complicate the situation traumatized kids poses a great challenge to emergency team. It is well documented that lack of proper training in managing the trauma in Paediatric in under developed countries is a major cause of fatality. The complexity of the airway management is schematically given in Fig. 1. Review Article (Open access) Int. J. Life. Sci. Scienti. Res., VOL 2, ISSUE 6 http://ijlssr.com Copyright © 2015-2016 International Journal of Life-Sciences Scientific Research Page 645 Fig 1: Challenges in airway management in emergency There are marked difference between Kids are adults, hence it is imperative to analyses the various aspect for better facilitation of trauma care Anatomical difference It is cleary understood that kids are not small adult (2) and have unique anatomical variation from adult. From birth to adult hood in due course of development of skull, oral cavity, larynx and trachea they have considerable changes in airway anatomy (3). They have large head (3-4) and prominent occiput so when kids lye on flat surface there neck had the tendency to be in flex position (4-5) causing airway obstruction. In order to rectify this variation it is important that shoulder roll should be use to keep head in neutral position . Kids have large tongue (4-5,8-10) and adenoids in comparison to their small oral cavity which causes easy obstruction of airway and difficult laryngoscopy and stabilization of tongue . This results into less intra oral visibility and causes suboptimal view of vocal cord. Children Up to the age of five month have obligate nasal breather (4,9) so when there is nasal injury their airway gets compromise. Epiglottis of child is large and omega shape (3) (use of straight blade laryngoscope is advocated), larynx is more rostral/cephaloid (5,10) (anterior placed larynx is misnomer), Vocal cords are more obliquely placed these all causes difficulty in optimum view of vocal card during laryngoscopy. The larynx of kids are of funnel shaped in contrast to cylindrical shaped in adult . Recently in vivo measurement by bronchoscopy and MRI images it was consistently found that glottis opening are smaller than cricoid but dispensability of glottis tissue and relative non dispensability of cricoid cartilage make cricoid cartilage functionally narrowest part of airway in child . Physiological difference Due to high metabolic demand (child have 6 ml/kg oxygen demand verses 3 ml/kg in adult) and low Functional residual capacity (FRC) , when there is compromised state of oxygenation and ventilation, demand and supply mismatch occurs faster in kinds, which leads to early de-saturation (7) and respiratory failure. In children hypoxia leads to bradycardia and hypotension which may leads to cardiac arrest, therefore this sequence of events be broken and prevented as early as possible by preventing hypoxia. Further child airway passage are smaller in diameter, hence slight edema or narrowing of airway causes exponential rise in airway resistance and increases in work of breathing (4,9) causes exponential rise of airway. Assessment of patient There are certain clinical sign, symptoms and scenario which should alarm us about compromised airway and ventilation in traumatized patients (Table 1-2), a careful evaluation and urgent action plan is life saving. Int. J. Life. Sci. Scienti. Res., VOL 2, ISSUE 6 http://ijlssr.com Copyright © 2015-2016 International Journal of Life-Sciences Scientific Research Page 646 Preparation Pediatric age group patients have varying shape and size and are of different age’s group. Each developing age encounters rapid alterations in anatomy, it thus become imperative to note that one size of equipment does not fit in all. Immediate availability of appropriate size of equipment (Table 3-5) is most essential must otherwise the resuscitation attempts and procedure is bound to fail (5) (for example, Suction, Oxygen, Airway, Pharmaceuticals, Monitor Equipment (SOAP, ME). It is very critical to attach monitor for assessment of all vital parameters and secure a good IV line. The estimation of fluid requirement and drug dose in growing age is very crucial. A length based resuscitation tape such as the Brose low pediatric emergency tape, is an ideal adjunct for the rapid determination of weight based on length for appropriate fluid volume, drug doses and equipment size. (6) Basic airway management Most pediatric airway in emergency setting can be handled best with basic airway maneuvers without any further loss of time. First and foremost basic maneuvers are to correct the positioning of patient to clear the airway. It is imperative to follow the cardinal principle and rule of thumb that every trauma patient should be considered to have cervical spine (c-spine) injury (10) unless proved otherwise. The position of head could be maintained in neutral position by placing a roll beneath the shoulder in small children. The obstructed airway could be immediately be opened by performing triple maneuver (head tilt, chin lift and jaw thrust). In suspected c-spine injury head tilt maneuver maybe avoided and patient be placed on spine board with MILS . Oropharyngeal (OPA) and nasopharyngeal (NPA) airway These adjuncts are used to keep airway patent by displacing tongue or soft palate. OPA is used in unconscious patient who do not have gag reflex . Selection of appropriate and precise size of OPA alone is supportive as small size may push the base of tongue further in airway while the large one may obstruct the airway. Oral airway should be gently inserted direct in oropharynx. Insertion of airway backward and rotating 180 degree is not recommended in children as it may cause trauma. NPA could be used in children who do have intact gag reflex with due assessment. Gentle suctioning with appropriately selected suction Table 1(10)  Tachypnea  Tachycardia  Apnea/hypoventilationChest Indrawing  Use of Accessory muscles  Wheezing  Cyanosis/hypoxia/hypercarbia   Level of consciousness/agitation  Grunting /stridor  Head bobbing