Airway management for pediatric emergencies.

Several factors increase the difficulty and urgency of airway management in children in the emergency setting. Early and appropriate airway management are of prime importance in improving the outcome of such patients. The major decision points of airway management include one's assessment of the airway and ability to perform endotracheal intubation. If the airway is judged to be normal, oral endotracheal intubation following sedation and neuromuscular blockade is suggested. Rapid sequence intubation to prevent acid aspiration should be used. While the medications for airway management generally are administered intravenously, it should be kept in mind that intraosseous access is an acceptable alternative for the administration of several different agents, including those used for endotracheal intubation. If the airway cannot be secured following the administration of anesthetic and neuromuscular blocking agents, the ASA algorithm for the "cannot intubate/cannot ventilate" scenario should be followed (Figure). When the airway is judged to be abnormal, one of the above described awake techniques may be used. While there is ample literature concerning these techniques in adults, their use in children has been limited. Most importantly, considerable practice may be required to become and stay facile with many of these "alternative techniques" of airway management. In certain circumstances, surgical cricothyrotomy should be considered as an alternative to airway management. Regardless of the technique chosen, appropriate personnel and preparation are mandatory to ensure the safe and effective management of the airway in the pediatric trauma patient. Due to the various skills and expertise of different subspecialists, a multidisciplinary approach to such patients is recommended. Such an approach may include pediatricians, emergency room physicians, surgical subspecialists, anesthesiologists, and critical care physicians.