Pediatric Fluid Resuscitation and Airway Management

"Sick or not sick?" I wondered as I walked into the room. Gillian was sick. She had a thousand-mile stare and did not exhibit any age-appropriate behaviors. Mom reported that Gillian had diarrhea every few hours and had no desire to eat. In fact, every time mom tried to give her fluids, Gillian vomited. Gillian's heart was beating so fast I could barely count the rate, and her respirations were rapid and shallow. She was hypovolemic and needed fluids.

Volume Shock
Volume, or hypovolemic, shock is a result of a lack of circulating volume. The primary cause in a pediatric patient is trauma. Either blunt or penetrating trauma to the chest or abdomen can cause rapid internal or external fluid loss.

Hypovolemia can also result from medical problems, like a ruptured appendix, that cause persistent vomiting and/or diarrhea.

Hypovolemia in children can also be triggered by environmental conditions like heat, when substantial amounts of fluid are lost through perspiration. Volume shock can be from fluid loss, lack of volume replacement or a combination of fluid loss and lack of replacement. A pediatric patient in volume shock, regardless of the cause, needs two treatments: stopping the fluid loss and fluid replacement.

Cardiogenic Shock
Cardiogenic shock is a problem with the heart. Unless the child has a history of congenital heart defects, heart problems are rare for pediatric patients. Most acute pediatric cardiac problems are initiated by respiratory problems. The primary use of an IV for a pediatric patient in cardiogenic shock is for medication delivery, like giving adenosine to treat supraventricular tachycardia.

Vascular Shock
Vascular, or distributive, shock refers to a problem with the size of the blood vessels. Causes of vascular shock include: septic or system-wide infection, spinal cord injury and anaphylaxis. In any of these situations, the size of the "container" holding circulating blood volume increases, but the amount of fluid in the container is the same, forcing the body to compensate to maintain blood pressure. IV access is used to deliver fluids to fill the "tank" and medications to restore the tank to normal size.

Anaphylaxis causes vasodilation--the blood vessels get larger as a result of histamine release from the allergen antibody response. Vasodilation increases the size of the tank. Imagine, for example, that an eight-year-old has four liters of blood volume in a four-liter tank. An anaphylactic reaction increases the tank to five liters, dropping perfusion pressure. To maintain normal blood pressure, his heart and respiratory rate increase. But, as we know, a child might not be able to maintain an elevated respiratory rate, especially if the anaphylaxis is also causing bronchoconstriction. If the child is no longer able to compensate, his blood pressure drops, leading to a decline in level of consciousness. In this case, epinephrine is a fast-acting vasoconstrictor delivered by injection or IV that restores the tank to its normal size.

Volume Replacement
After six-year-old Beth was run over in her driveway, the physical exam revealed a painful, rigid abdomen and she showed signs of shock, which made us suspect internal bleeding. Beth needed IV fluids to help maintain perfusion pressure, but more important, she needed a trauma surgeon to identify and treat the source of bleeding.

For this reason, minimize on-scene time when caring for a pediatric trauma patient. ALS providers should initiate IV or IO fluid replacement during transport; BLS providers should request an ALS intercept en route for IV access and fluid administration. An ALS intercept is especially important if you have a long transport time and/or a severely injured or extremely sick pediatric patient. Follow local protocols to request an intercept.

Sally had been missing for some time. After frantically searching their house and yard, her parents found her in their car, which was parked in the sun. The three-year-old had apparently climbed into the car, but was unable to open the door to get out. Her parents reported she was hot to the touch, had dry skin and only moaned when they shouted her name. Before calling an ambulance, they attempted to give her sips of cold water, which caused her to vomit and choke. Now, Sally had two problems: heat stroke and partial airway obstruction with aspirated vomitus. Oral fluid administration has little value for treating severely injured or extremely sick pediatric patients because of the potential to compromise the patient's airway.

Equipment Considerations
In general, equipment selection plays a critical role in pediatric patient treatment. Does your service have appropriately sized pediatric equipment? Do you know where it is? Is it easily accessible? Check to see if you carry pediatric non-rebreather masks, nebulizer masks and nasal cannulas. Do you have sizes for neonates, infants, children and adolescents?

The equipment must fit properly to be effective. Improperly sized equipment leads to poor patient outcomes. The Broselow tape is a simple and comprehensive tool used to estimate a pediatric patient’s weight, medication dosages and equipment sizes that all levels of provider should feel comfortable using. The tape colors match different sizes of equipment.

IV Insertion Techniques
Follow local protocols for starting and maintaining an IV if the patient needs fluids or IV medications. Unless the patient is stable, do not prolong on-scene time to start an IV or provide more than basic care, as you will be depriving the patient of much-needed definitive care at the hospital.

There are many techniques to start IVs successfully in pediatric patients. Some things we find useful include:

• If a tourniquet is needed for an infant, apply it around the mid-forearm.
  
• Bend the infant's hand to an almost 90-degree angle to the forearm.
  
• Take care when using AC venous access in infants and children, as children constantly flex and extend their arms.
  
• Consider using a butterfly needle for more precise control and insertion.
  
• Ask your partner or the caregiver to explain the procedure and comfort the child.
  
• After a series of successful or unsuccessful attempts, offer the infant or child a stuffed animal for good behavior.

We tell older children, "We need to start an IV. It will hurt, and you are allowed to cry, yell or scream, but do not move. It will be over in a few seconds. When we are done, there will be a small plastic tube like a straw in your arm, not a needle." Treat an adolescent patient much like an adult. Ask which hand is dominant, then explain the procedure, clean and prep the site and perform venipuncture.

An IO is indicated or preferred when a prehospital provider cannot achieve a successful IV. Protocols typically allow three peripheral IV attempts or 90 seconds before choosing an IO. Some protocols direct the providers to initiate an IO first if large amounts of fluid are required for a severely ill or injured pediatric patient.

There are several IO devices on the market, which we differentiate as simple-mechanical or technology-assisted.

Simple mechanical IO needles are guided by hand into the intraosseous space until the provider feels a "pop."

Technology-assisted IO devices "fire" or "inject" the IO device into the intraosseous space. If your service uses a technology assisted IO device, we recommend having a simple mechanical on hand in case of equipment malfunction.

When to Call for Intercept
Recognize your limits and the scope of care you can provide. BLS providers can play a critical role in pediatric patient care by calling for an ALS intercept so fluid administration can be started prehospital. It is better to request ALS early and not need it than wish you had called. Follow your instincts: Is the patient sick or not sick? A sick patient will benefit from ALS treatment.

Follow local protocols for requesting an ALS intercept. Typical reasons include:

• Compromised airway that is not responding to basic airway management, like suctioning or oral airways
• Respiratory distress that is not improving with BLS interventions
• Respiratory failure or arrest
• Severe external bleeding or suspected internal bleeding
• Abnormal pulse rate and rhythm
• Cardiac arrest
• Altered mental status
• Severely ill or injured patients
• Long transport time for a patient who is not improving with BLS care

Fluid Administration
Although fluid replacement can be a valuable treatment for a pediatric patient, a fluid bolus can be harmful if too much is given. A fluid overload can have detrimental consequences on electrolyte balances, which can cause severe heart and kidney problems.

The size of a fluid bolus is based on patient weight and age. For children and adolescents, administer a fluid bolus of 20 mL/kg up to three times before moving on to vasopressors like dopamine. For an infant, administer a fluid bolus of 10 mL/kg. Most prehospital providers administer crystalloids like normal saline to pediatric patients.

Following are a few ideas to minimize the risk of fluid-overloading a pediatric patient:

• Use a pump to administer IV fluids by entering the desired rate and volume to be infused.
  
• Use micro-drip tubing and a smaller bag of fluid.
  
• Rather than hanging a one-liter bag, choose a 100- or 250-mL bag of saline.
  
• Measure the volume to be infused into a burette chamber.
  
• Close the clamp between the fluid bag and burette chamber before opening the clamp between the patient and burette chamber.

Airway Difficulties
Pediatric airway management is difficult for many reasons. First is the emotional response to the emergency: Kids are not supposed to get sick or injured. As few as 10% of emergency calls involve a pediatric patient, of which only 1% of the 10% involve a critically ill or injured child. When they do, you need to put aside everything else and focus on doing an excellent assessment and providing appropriate treatment.

Pediatric anatomy is different from adults'. The same structures are present, but they are much smaller. This is problematic for two reasons: The pediatric airway is easier to compromise and airway structures are harder to visualize. The pediatric patient's airway is the same diameter as their little finger. An infant's lungs are no larger than two deflated balloons, so aspirated vomit can easily fill the lungs and prevent gas exchange. Overall, a pediatric patient can withstand a much smaller insult than an adult.

Pediatric airway structures are not fully developed; therefore, an infant does not have enough surfactant to maintain alveolar inflation during respiratory distress. Grunting, an abnormal breath sound, is a compensatory mechanism used to maintain inflated alveolar sacs.

The pediatric patient's tongue is larger in proportion to the upper airway than an adult patient's. The larger tongue increases airway obstruction problems and requires the provider to give effective abdominal or chest thrusts.

Remember, the primary purpose of the head tilt/chin lift or jaw thrust is to displace the tongue. A pediatric patient has a floppier epiglottis and a larger head in proportion to the rest of his body than an adult patient, which makes intubation more difficult. Incorrect alignment of the airway structures, whether using the head tilt/chin lift or modified jaw thrust, leads to airway compromise. Padding under the shoulders can help maintain an open airway.

A patient in respiratory distress can quickly become fatigued. In one memorable case, the infant's initial respiratory rate was 50-60 breaths per minute and increased to 80-90 times per minute during transport.

Upon arrival, the infant was so fatigued that advanced airway management procedures were necessary.

Pediatric Airway Management
If there is no MOI for spinal cord injury, maintain an open airway with a head tilt/chin lift. Remember, the sniffing position is best for an infant or child. Hyperextending the neck can kink the trachea, restricting the flow of air.

Be constantly vigilant to airway positioning. A jostling ambulance ride, interference from other caregivers, releasing your hands to perform another intervention or patient movement can change the airway position.

Visually monitor airway positioning and the adequacy of ventilations, and adjust the airway position as necessary.

Use a simple airway adjunct to help maintain an open airway. Use a nasopharyngeal airway for a pediatric patient with a gag reflex and an oropharyngeal airway for a pediatric patient who does not have a gag reflex. Remember that the oral airway does not need to be inverted when it is inserted into the mouth of an infant or small child. Size an OPA or NPA as you would size it for an adult. Measurement landmarks are from the corner of the mouth or nose to the earlobe.

Respiratory arrest is imminent for a pediatric patient in respiratory failure. Prepare intubation equipment and back-up airway devices like a pediatric Combitube, LMA or trach kit for a failed intubation. Follow local protocols for intubation indications, tube placement and tube confirmation. If local protocols allow, insert a nasogastric tube to prevent gastric distention and help facilitate good oxygenation and ventilation.

In some areas, protocols allow ALS providers to use rapid sequence intubation to secure the airway of a pediatric patient in respiratory failure or to control the airway from obstruction from fluids or swelling. Follow local protocols for RSI indications, medication administration and tube placement.

There is an ongoing debate among ALS providers about the use of cuffed or uncuffed endotracheal tubes for pediatric patients. Some argue that an uncuffed tube is preferred because of the anatomy of the pediatric airway distal to the glottic opening. In a pediatric patient, the level of the cricoid cartilage is the narrowest portion of the airway, thus the uncuffed tube would become lodged there and would not come out. An uncuffed tube could also cause less airway trauma if the tube were inadvertently removed.

Others argue that a cuffed tube is preferable, because the distal balloon secures the tube and prevents dislodgment. Discuss the merits of a cuffed or uncuffed tube with your medical director and service director before replacing your pediatric ET tubes.

Suctioning
Suctioning the mouth and/or nose is a simple treatment that can reverse a pediatric respiratory problem.

For infants, use a bulb syringe or soft catheter. Pre-oxygenate the patient, insert the suction device only as far as you can see, and suction as you withdraw the device.

For toddlers, children and adolescents, choose the type of suction device based on the contents to be suctioned. Soft catheters work well for fluids; rigid catheters are better for copious amounts of fluids, debris and vomitus.

Insert the suction catheter only as far as you can see, limiting suctioning time to less than 10 seconds. Since the airway opening is smaller, the suction device may stick to the wall of the upper airway or tongue. Simply remove your finger from the proximal port to interrupt the vacuum seal.

Breathing
If the patient has adequate spontaneous breathing, determine the need for supplemental oxygen and choose the appropriate oxygen delivery device. An infant or toddler who tolerates a nasal cannula or non-rebreather mask is sick. A non-rebreather mask should cover the mouth and nose, without riding up onto the patient's eyes.

If the child is intolerant of a non-rebreather mask, try the blow-by method. Use a caregiver to hold the oxygen source close to the child to increase the percentage of oxygen the patient receives. Calming and reassuring the patient has two effects: It lowers their oxygen demand and increases the oxygen they inhale.

If the patient does not have spontaneous respirations, or respirations are inadequate, begin assisted ventilations as soon as possible. Use a bag-valve mask to deliver high-flow oxygen. Bag-valve masks come in a variety of sizes for pediatric patients. While you can use any size bag, the patient only needs enough air to cause chest rise. Excessive ventilations cause gastric distention and increase the risk of a spontaneous pneumothorax.

Remember to squeeze the bag slowly. I use "squeeze-release-release" to time ventilations. The mask of the BVM should cover the mouth and nose, but not the eyes. If a larger-size BVM is the only device available, turn the mask sideways.

Respiratory Medications
In some areas, BLS providers are allowed to administer albuterol by nebulizer for reactive airway diseases like asthma, and epinephrine to treat an anaphylactic reaction. Follow local protocols to confirm the six rights before administering any medication: right patient, right dose, right medication, right time, right route and right documentation.

Consequences of Untreated Respiratory Distress
Pediatric patients compensate until they are no longer able to do so, then they crash. Little time elapses between respiratory failure and respiratory arrest. Because pediatric patients are not supposed to get sick or hurt, the caregiver often waits too long to call 9-1-1.

Case in point: One of the authors was dispatched on a call for a child choking. Our response time was four minutes, but the parent had waited more than 10 minutes before calling because it was only a partial airway obstruction. Upon our arrival, the child was already blue from the neck up, using accessory muscles and moving very little air. The caregiver reported that the patient was sucking on a latex balloon when it popped, but she did not call 9-1-1 until the airway obstruction was complete--a critical delay. The patient had deteriorated from a partial airway obstruction and respiratory distress to a full airway obstruction and respiratory failure. Unfortunately, we were not able to relieve the obstruction and the child died.

The general appearance of the child is an important sign, since agitation, retractions, cyanosis, anxiety, weak or absent cry and stridor can all be indications of an airway problem. Signs and symptoms of an airway problem can be broken down as early or late.

Early signs are: increased respiratory rate; increased heart rate; wheezing, crackles, stridor; accessory muscle use; nasal flaring; fatigue; anxious or panic-stricken look; compliant with instructions.

Late signs include: decreased respiratory rate; decreased heart rate; diminished or absent sounds; minimal movement of chest wall; nonrecognition of caregiver and noncompliance with instructions.

Summary
In summary, if the problem is volume shock, stop the loss and replace the fluid without overloading. IV fluids may be necessary to maintain perfusion pressure and administer medications. Pediatric airway anatomy requires different techniques and equipment for proper management, but all airway management starts with basic life support skills.

Bibliography
American Heart Association and American Academy of Pediatrics, eds. PALS Provider Manual. American Heart Association, 2002.
Bledsoe BE, Porter RS, Cherry RA. Essentials of Paramedic Care. Prentice Hall, 2002.
Bledsoe BE, et al. Paramedic Care: Principles & Practice, Special Considerations/Operations. Prentice Hall, 2001.
Brownstein D, Gausche-Hill M, Diekman J, eds. Pediatric Education for Prehospital Professionals. Jones and Bartlett Publishers, Inc., 2005.
Sanders MJ, et al. Mosby's Paramedic Textbook. C.V. Mosby, 2001.