Pediatric Difficult Airway

This case is written by Dr. Jonathan Pirie. He is a staff physician in the Division of Pediatric Emergency Medicine and Associate Professor at the University of Toronto. Dr. Pirie is also the Director of Simulation for Pediatric Emergency Medicine and the Simulation Fellowship program. His simulation interests include development of core curricula for postgraduate training programs, in-situ team training, and mastery learning with competency based simulation for trainees and faculty in pediatric technical skills and resuscitation.

Why it Matters

While croup makes stridor a relatively common presentation in the Pediatric ED, today it is quite rare to have a child with stridor who requires definitive airway management. It is exceedingly rare for an Emergency physician to need to proceed to cricothyroidotomy on a child. This case highlights the following:

  • The initial management steps for a child with undifferentiated, severe stridor
  • The need to call for help early
  • The steps required for a needle cricothyroidotomy and the equipment necessary to ventilate a child after this procedure is performed

Clinical Vignette

You are working in the ED, and your team has been called urgently to see a 2-year-old old boy with difficulty breathing. The patient was brought in by his mother, who states he’s had a 2-day history of runny nose. Today he developed a barking cough with fever, and is “breathing with a funny noise.”

Case Summary

The ED team is called to manage a 2-year-old boy in severe respiratory distress with stridor and hypoxia. Initial management steps (humidified O2, nebulized epinephrine and dexamethasone) fail to improve the patient’s respiratory status, and the team must prepare for a difficult intubation. They will encounter difficulties with both bagging and passing the endotracheal tube due to airway edema, which will necessitate an emergency needle cricothyroidotomy.

Download the case here: Pediatric Difficult Airway

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