The most important step in trauma care for children is airway intervention. Many preventable traumatic deaths among children are due to loss of an adequate airway or due to hypoxia. Proficient training in airway skills and aggressive airway management leads to a reduction in the number of pediatric deaths. Often, only airway opening and support are needed to prevent death. However, because pediatric trauma patients infrequently require intubation, many health care providers have inexperience with more advanced methods.6 Proficient management of a child's airway requires an understanding of the anatomy of children (see Chap 11, "Pediatric

Airway Management").

OXYGEN High-flow oxygen should be applied to all trauma patients. Patients who are not hypoxemic initially may become so as their condition changes if they are not given supplemental oxygen. A non-rebreathing mask is the usual method of delivery, but blow-by oxygen is acceptable in a child who fights having the face mask. Continuous-pulse oximetry should be monitored.

BASIC AIRWAY MANEUVERS Basic airway techniques are covered in detail in Chap 11, "Pediatric Airway Management." In the trauma patient, care must also be taken to avoid injuries to the head or neck while managing the child's airway. The cervical spine should be protected by stabilization, not traction, with one provider dedicated to this task. The airway should be opened by using the jaw-thrust technique. This technique minimizes movement of the cervical spine, yet still easily opens the airway. Prolonged maintenance of the jaw-thrust can be tiring. Thus, in an unconscious child, placement of an oral airway can be considered, whereas, if the child is conscious or has an intact gag reflex, a nasopharyngeal airway should be used instead. Constant reassessment of the airway status is necessary, as airway adjuncts can become occluded by blood, vomit, or tissue swelling.

ENDOTRACHEAL INTUBATION If the airway cannot be maintained by basic maneuvers, the child requires hyperventilation, or access is needed for medication administration, then the child should be intubated by the oral route. The most experienced airway provider should perform the intubation. A trauma patient who is a child requires several considerations beyond the normal concerns. First, cervical spine stabilization must be maintained throughout the procedure. Excessive cervical spine movement can occur during endotracheal intubation. Thus, at least two persons will be needed to perform the intubation: one for cervical spine stabilization and one to intubate. Secondly, selection of the induction agents requires consideration of the patient's hemodynamic state, risks, and likelihood of cerebral injury. For example, the use of ketamine must be avoided in head-injured patients. The propensity for thiopental to cause hypotension minimizes its utility in trauma patients. Frequently used agents include fentanyl and etomidate. The choice of a paralytic agent is less dependent on a child's condition. Succinylcholine or vecuronium are commonly used. Third, some patients will require pretreatment with pharmacologic agents prior to intubation. Lidocaine should be considered in head-injured patients, although the importance of using it has not been firmly established. Atropine should be given to all patients younger than age 6, especially if succinylcholine will be used as the paralyzing agent.7 These issues are covered in detail in Chap 10, "Pediatric Cardiopulmonary Resuscitation" and in Chap 11, "Pediatric Airway


SURGICAL AIRWAY Rarely will the emergency physician or emergency medical service provider need to perform a surgical airway on a child. However, the difficulty with performing this technique has perpetuated the need for preparation and training. Because of the relative small size of a child's airway, needle cricothyroidotomy is the preferred first attempt at securing a surgical airway. A 14- to 16-gauge catheter is placed through the cricothyroid membrane and is attached to a jet insufflator. A bag-valve mask can be used for a short time, but high pressures are needed to ventilate through the small catheter. Although ventilation will be limited, oxygenation is achievable for up to 2 h, or until a more definitive airway can be established by additional oral attempts or more advanced techniques. 8 (See Chap 11, "Pediatric

Airway Management.")

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