APPENDIX H: PEDIATRIC CONSIDERATIONS

Pediatric Considerations for MSMAID & Airway Management

MSMAID:

Similar to adult patients, the same preparatory steps should be followed prior to pediatric airway intervention. There are, however, significant differences with respect to equipment requirements and provider skill level. The core principles of MSMAID remain the same, with the following considerations:

- Machine – Continuous ventilation requires specific rate and volume based on the patient’s age/size. Ensure your equipment (ventilator) and/or BVM can provide the required rate and volume prior to intubating or performing advanced procedures.1,2
- Suction – Similar to adults, ideally you can provide in-line suction, but you also will at a minimum need the correct size tubes to be able to provide suction
- Monitor – having pediatric sized equipment is essential as well as being able to adapt to pediatric sizes using adult monitors
- Airway – Multiple sizes of tubes are essential and proper pre-mission logistic planning includes pediatric supplies
- Intravenous access – Ensure you have pediatric sized needles with 24, 22, 20 and 18g as the primary access based on age of the patient. Pediatric intraosseous needles may be required.
- Drugs – Ensure you have a drug estimation guide, but always double check pediatric weight-based doses and measurements.

Additional Equipment

1. Broselow Tape or similar height-based treatment aids.3
2. Video Laryngoscopy (VL) –VL has been shown in studies to out-perform direct laryngoscopy in pedatric airways.4-7
3. Pediatric Kit – Pediatric airway equipment should be pre-packaged and set apart to allow for a rapid inclusion or addition to baseline airway kits.

Essential Measurements and Formulas

Unlike adult airways that are narrowest at the level of the vocal cords (and therefore visible during DL or VL) pediatric tracheas are narrowest at the infraglottic level (19). In consideration of this, the following formulas and treatment aids are presented to best estimate tube sizes and measurements:

1. ETT size: age/4 +3.5. 8
2. ETT insertion depth (for children over 1 year of age) in centimeters: age/2 + 13
3. ETT insertion depth (for children under 1 year of age) in centimeters: weight/2 + 8
4. Tidal volume: 5-8 cc/kg, rate concordant with pre-arrest breathing or rate prior to intervention. PALS recommends initial rate of at least 10-12 breaths/minute.1,2
5. Use caution with BVM, especially if improvising with adult BVM. Inflate gently only until the chest begins to rise. Surgical Airway Management

LMAs should be the first choice in all children prior to consideration of surgical intervention. Surgical airways should NOT be attempted on children younger than 12 years of age given the maturity of the thyroid cartilage and the cricothyroid membrane. It should never be attempted in children where the thyroid cartilage cannot be palpated. For children needing advanced airway intervention younger than 12 years of age, a combination of bag-valve-mask ventilation or placement of a supraglottic airway is recommended.9,1

References

1. Eastridge BJ, Mabry RL, Sequin P, et al. Death on the battlefield (2001-2011): implications for the future of combat casualty care. J Trauma Acute Care Surg. 2012;73(6 Suppl 5):S431-7.
2. Hudson I, Blackburn MB, Mannsalinas EA, et al. Analysis of casualties that underwent airway management before reaching role 2 facilities in the Afghanistan conflict 2008-2014. Mil Med. 2020;185(Suppl 1):10-18.
3. Blackburn MB, April MD, Brown DJ, et al. Prehospital airway procedures performed in trauma patients by ground forces in Afghanistan. J Trauma Acute Care Surg 2018;85(1S Suppl 2):S154-S160.
4. Mabry RL. An analysis of battlefield cricothyrotomy in Iraq and Afghanistan. J Spec Oper Med. 2012;12:17-23.
5. Adams BD, Cuniowski PA, Muck A, De Lorenzo RA. Registry of emergency airways arriving at combat hospitals (REACH). J Trauma 2008;64(6):1548-54.
6. Tao B, Liu K, Zhao P, et al. Comparison of GlideScope video laryngoscopy and direct laryngoscopy for tracheal intubation in neonates. Anesth Analg. 2019 Aug;129(2):482-486.
7. Prekker ME, Driver BE, Trent SA, et al. DEVICE Investigators and the Pragmatic Critical Care Research Group. Video versus direct laryngoscopy for tracheal intubation of critically ill adults. N Engl J Med. 2023 Aug 3;389(5):418-429
8. Acosta P, Santisbon E, Varon J. The use of positive end-expiratory pressure in mechanical ventilation. Critical Care Clin, 2007 Apr;23(2):251-61.
9. Loos PE, Glassman E, Doerr D, et al. Documentation in prolonged field care. J Spec Oper Med. 2018; 18(1): 126-32.