An institutional approach to the management of the ‘Can't Intubate, Can't Oxygenate’ emergency in children

Abstract

The 'Can't Intubate Can't Oxygenate' emergency is rare in children. Nevertheless, airway clinicians involved in pediatric airway management must be able to rescue the airway percutaneously through the front of the neck should this situation be encountered. Little evidence exists in children to guide rescue techniques, and extrapolation of adult evidence may be problematic due to anatomical differences. This document reviews the currently available evidence, and presents a practical approach to standardizing equipment, techniques, and training for managing the 'Can't Intubate Can't Oxygenate' emergency in children.

Management of pediatric ‘cannot intubate, cannot oxygenate’

“…Neonates and infants generally have short fat necks. Thus, when performing a PCC, the steeper the angle of approach to the cricothyroid membrane, the greater the likelihood of a posterior tracheal puncture, which is a severe complication 2. In our case, full extension of the head and neck still did not allow a sufficient flattening to undertake PCC safely during the resuscitation (Fig.…”

“…The incision of the tracheostomy should be made below the cricoid cartilage more proximal than is common in tracheostomies in adults. Because the distal anatomy may be more difficult to define than the proximal anatomy, the more distal attempts to obtain a clear airway along the trachea in pediatric patients may lower the success rates for both cannula and scalpel techniques 2. Moreover, we should select the scalpel–finger–bougie technique, which is recommended in the guideline for cricothyroidotomy in adults if the cricothyroid membrane is impalpable or if other techniques have failed 1.…”

“…Moreover, we should select the scalpel–finger–bougie technique, which is recommended in the guideline for cricothyroidotomy in adults if the cricothyroid membrane is impalpable or if other techniques have failed 1. An emergent tracheostomy can also be carried out in pediatric patients2 as follows: a midline vertical incision is made with a scalpel from thyroid cartilage to the upper edge of sternum, soft tissue is dissected bluntly by finger. A transverse stab incision of the trachea is made, the bougie introducer is inserted into the trachea, and the tube is inserted into the trachea.…”

“…In pediatric CICO, the Difficult Airway Society (DAS) guideline suggests some airway rescue techniques 2, 3. However, pediatric CICO is very rare, and this suggestion is mostly based on animal experimental results and expert opinions;3 therefore, further reports are necessary to consider the best strategy for pediatric CICO.…”

Postępowanie w niespodziewanych trudnych drogach oddechowych u dzieci — stanowisko Sekcji Anestezjologii i Intensywnej Terapii Dziecięcej, Sekcji Przyrządowego Udrażniania Dróg Oddechowych Polskiego Towarzystwa Anestezjologii i Intensywnej Terapii oraz Po

“…Of note is fact that the actual occurrence of problems arising from difficult airways may be greater than it is reported in the official reports [24]. The risks related to difficult airways may be minimised by the use of the approriate equipment and training that includes simulation techniques [25][26][27].…”