Pediatric emergency medicine trisk 351

Maneuvers

Indications

Heimlich maneuver Relieve upper airway
(abdominal
obstruction caused by
thrusts) for age ≥1
foreign body
yr
Back/chest blows for
age <1 yr
Manual foreignbody extraction
Head tilt/chin lift,
Relieve oropharyngeal
jaw thrust
obstruction
Nasopharyngeal
airway

Oropharyngeal
airway
Suction

Relieve nasopharyngeal
obstruction

Relieve obstruction by the
tongue
Remove excess secretions,
mucous plug

Bag-mask
Provide mechanical
ventilation
ventilation, deliver highconcentration oxygen
Noninvasive
Decreases work of
positive pressure
breathing, increases
ventilation (CPAP,
oxygenation and
BPAP)
ventilation
Endotracheal
Control ventilation for
intubation/assisted
depressed central nervous
ventilation
system
Absent pharyngeal reflexes
Mechanical support for
weak chest wall

Comments
Contraindicated if
conscious patient able to
phonate
Remove visible foreign
body in the oropharynx,
blind sweep
contraindicated

Head tilt/chin lift
contraindicated if neck
trauma
Conscious or unconscious
patient
Contraindicated if bleeding
diathesis, cerebrospinal
fluid leak, nasal
deformity
Unconscious patient
Nose, mouth, and, if
intubated, trachea
Self-inflating or anesthesia
bag
Contraindicated if
decreased level of
consciousness, apnea,
increased secretions
Relatively contraindicated
if severe midface trauma
If epiglottitis, consider
intubation in operating
room
Avoid intubation in severe
asthma if possible


Artificial airway for
obstructed airway
Supplemental oxygen for

damaged alveoli
Control intracranial
pressure by
hyperventilation
Provide tracheopulmonary
toilet
Provide positive endexpiratory pressure to
increase lung volume
Needle
Emergent artificial airway
cricothyroidotomy
required to sustain life,
upper airway obstruction
cannot otherwise be
relieved, tracheostomy
cannot be immediately
performed
Tracheostomy
Emergent artificial airway
required to sustain life,
upper airway obstruction
cannot be relieved by
endotracheal intubation
Thoracentesis
Evacuation pneumothorax,
tension pneumothorax,
hemothorax, drainage
pleural effusion,
empyema
Thoracostomy

Evacuate, prevent
reaccumulation
pneumothorax, tension
pneumothorax,
hemothorax, effusion,
empyema
Pericardiocentesis
Relieve tamponade:
effusion,

Temporizing measure,
tracheostomy to follow
immediately

Should be performed in
operating room by
experienced physician

Pigtail or chest tube
placement to follow
immediately or
performed instead
Thoracentesis first if
pigtail/chest tube cannot
be placed immediately in
life-threatening situation

Improve cardiac output

Bronchoscopy

hemopericardium,
pneumopericardium
Foreign-body removal

Requires ultrasound or
ECHO guidance
Do not agitate the child
before the procedure
Esophagoscopy for
esophageal foreign body

Physical Examination
The physical examination should assess the degree and likely etiology of
respiratory distress ( Fig. 71.1A,B ). Continuous cardiopulmonary monitoring and
frequent reassessment are important because respiratory status can change
quickly. General appearance, level of consciousness, work of breathing, and vital
signs, including respiratory rate and adequacy of oxygenation and ventilation help
identify the severity of respiratory distress and possible etiologies. Heightened
level of consciousness, manifesting as restlessness, anxiety, or combativeness, is
more likely an early sign of hypoxia, whereas diminished level of consciousness,
manifesting as somnolence, lethargy, stupor, obtundation, or coma, tends to result
from hypercarbia or severe hypoxia. The child’s posture may provide clues
regarding the source of the respiratory compromise. Children with upper airway
obstruction tend to assume a sniffing position, an upright sitting posture with
neck slightly flexed and head extended. For lower airway obstruction, a tripod
position, in which the child is sitting up and leaning forward, may be preferred.
Dysphagia and/or drooling are concerning for oropharyngeal or laryngeal
obstruction. Pallor suggests possible anemia, structural heart disease, arrhythmia,

sepsis, or hemorrhage. Peripheral cyanosis is caused by local vascular changes of
the extremities that result in inadequate perfusion or vascular stasis.