Airway assessment and basic airway management: SAQ

This unconscious child has airway obstruction from the tongue and soft tissues, signalled by snoring and minimal chest movement, and the low saturation confirms inadequate ventilation. The immediate task is to open the airway, suction the secretions, hold the airway open with an adjunct, and ventilate if needed, all within the first minute. [1]

Question 1 (10 marks)

Describe your immediate airway assessment and the basic airway management you would perform in the first minute, including the manoeuvre, the adjunct, and the positioning. [1]

Assess the airway with look, listen, and feel over about five seconds: look for chest and abdominal movement and colour, listen at the nose and mouth for the snoring that indicates tongue obstruction, and feel for air movement at the mouth. The snoring localises the obstruction to the tongue and soft palate falling back as pharyngeal tone is lost, and the minimal chest movement and low saturation confirm that ventilation is inadequate. [2]

Open the airway with a head tilt and chin lift, because there is no evidence of cervical spine injury, and suction the copious secretions under direct vision. The child is deeply unconscious with lost pharyngeal tone, so insert an oropharyngeal airway, which is the adjunct of choice when there is no gag reflex; an oropharyngeal airway in a child with a preserved gag would provoke vomiting and aspiration. [3]

Size the oropharyngeal airway from the corner of the mouth to the angle of the jaw or the earlobe, a facial-landmark method validated against magnetic resonance imaging. A device that is too long pushes the epiglottis down and worsens obstruction, and one too short is useless, so sizing matters. In the older child insert it with the curve following the roof of the mouth then rotate, but in an infant insert it directly under direct vision to avoid mouth trauma. [3]

Position matters in the young child. The large occiput flexes the neck when supine, so aim for a neutral to slightly extended position that aligns the airway, and use a small towel under the shoulders if needed to prevent over-flexion. Give high-flow oxygen by mask throughout, and be ready to ventilate with a bag-valve-mask if breathing remains inadequate once the airway is open. [1]

Question 2 (10 marks)

Breathing remains inadequate after the airway is opened. Describe your bag-valve-mask ventilation technique and the triggers that would lead you to escalate to a definitive airway. [1]

Use a two-person bag-valve-mask technique whenever a second rescuer is available. One rescuer holds the mask to the face with a two-hand E-C or thenar eminence grip, forming the seal with the thumb and index finger and lifting the jaw with the remaining fingers, while the second rescuer squeezes the bag. The two-person technique gives a far better seal and ventilation than the one-hand technique, which commonly causes gastric insufflation, regurgitation, and aspiration. [1]

Ventilate with one breath every two to three seconds, about twenty to thirty breaths per minute, using only enough volume to produce normal chest rise. Avoid excessive force and rate, because hyperventilation causes gastric distension, pneumothorax, and reduced cardiac output. Reassess continuously for chest movement, colour, and conscious level, and apply pulse oximetry and end-tidal carbon dioxide monitoring as soon as possible to track the response. [2]

Escalate when basic techniques fail or falter. The triggers are failure to achieve adequate chest rise and oxygenation despite a correct two-person technique, recurrent obstruction, exhaustion of the rescuer, or any deterioration in the child's colour, effort, or conscious level. Because difficult mask ventilation in children is strongly associated with difficult intubation, the moment basic ventilation is inadequate the responder should summon senior anaesthetic and intensive care help rather than persisting alone. [1]

While help is coming, maintain the airway, oxygenation, and ventilation, and prepare a supraglottic airway and tracheal intubation equipment, with a tube half a size smaller and larger ready. Effective bag-valve-mask ventilation is the bridge that keeps the child alive while the definitive airway is assembled, and calling for senior help early is the action most likely to determine the outcome. [2]