Chapter 48

A 7-year-old boy is brought to the emergency department (ED) by ambulance following a bicycle accident. The paramedic team reports that the child was not wearing a helmet when he struck a pole while travelling at a high speed. The patient was found minimally responsive on the sidewalk, beside his bicycle. There was immediate concern for head and chest trauma. The patient was immobilized for possible C-spine injury. No other information is available.

Upon arrival at the ED, his vital signs are: temperature 36°C, heart rate 115 beats per minute (bpm), noisy breathing with a respiratory rate of 24 breaths per minute, and a blood pressure of 106/86 mm Hg. His oxygen saturation is 89% on a non-rebreather oxygen face mask. The Glasgow coma scale (GCS) score is 6. The patient is estimated to be 110 cm tall and weighs approximately 30 kg.

### 48.2.1 How Should the Airway of This Child Be Managed in the Field?

Airway management in the field is discussed in detail in Chapter 14.

Establishing and maintaining an airway in a trauma patient is the first priority of prehospital providers. Maintaining oxygenation and avoiding hypercarbia are particularly important in those in whom traumatic brain injury is suspected. Intuitively, establishing a definitive airway early in the course seems favorable. However, many studies have demonstrated increased morbidity and mortality with prehospital advanced airway management in head-injured adults.1-4 Pediatric data also fail to demonstrate benefit of prehospital intubation. A retrospective review of a large pediatric trauma registry showed no improvement in survival with prehospital endotracheal intubation over bag-mask-ventilation.5 Similarly, a prospective, randomized trial in pediatric patients found no improvement in survival for those who underwent prehospital intubation, although the subset of patients in the study with head injuries was relatively small.6 While local protocols may vary, it is generally recommended that in an urban setting head-injured children who can be adequately oxygenated and ventilated by bag-mask-ventilation be transported as rapidly as possible to the local trauma center for definitive airway management and further evaluation and care. The use of oral or nasopharyngeal airways to assist in airway patency is encouraged, when contraindications, such as severe facial injuries, do not exist.

### 48.2.2 What Are the Evaluation and Management Priorities in This Patient and Where Does Airway Fit?

Airway is the first priority in any trauma patient, as identified by the airway, breathing, and circulation (ABCs) schema. While the cervical spine is immobilized, an adequate airway must be established to allow for effective oxygenation and ventilation. When appropriate resources are available, concurrent efforts should be aimed at obtaining vascular access to address circulatory compromise, as well as recognition and stabilization of other life-threatening injuries.

Airway management is particularly urgent in patients with head trauma. Failure to maintain oxygenation has been linked to secondary brain injury. Many pediatric studies have demonstrated poor ...

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