5.11 PEDIATRIC UPPER AIRWAY OBSTRUCTION

This emergency can vary in severity from mild to life threatening and the child's condition may change suddenly. Common mechanical causes include: tongue obstructed airway, foreign bodies in the oropharynx, trachea, or esophagus; allergic swelling of upper airway structures ("angioedema"), chemical burns, inhalation injuries; altered mental status and congenital abnormalities (patients with small jaws or large tongues). Infectious causes are common with croup and epiglottitis being the most prevalent. Although epiglottitis is becoming less common due to immunization against Hemophilus Influenza B, it still occurs.

Children, especially 1 to 3 years of age, are at greatest risk for aspirating foreign objects, particularly when running and/or falling. The most common objects aspirated resulting in airway obstruction in children include coins, buttons, beads, pins, candy, nuts, hot dogs, chewing gum, grapes and sausages.

 

 

ASSESSMENT / TREATMENT PRIORITIES

1. Maintain appropriate body substance isolation precautions.

2. Determine presence of upper airway obstruction (stridor):

a. If the obstruction due to a foreign body is complete or is partial with inadequate air exchange: follow the American Heart Association (AHA) or American Red Cross (ARC) BCLS age appropriate guidelines for foreign body obstruction. Maintain an open airway, remove secretions, vomitus and assist ventilations as needed.

b. If partial obstruction due to a foreign body is suspected and the child has adequate air exchange: transport to appropriate medical facility. Do not attempt to remove foreign body in the field.

c. If suspected croup (barking cough, no drooling) or epiglottitis (stridor, drooling) maintain an open airway, place child in position of comfort and avoid upper airway stimulation.

3. Administer high concentration oxygen by non-rebreather mask or blow-by method, as tolerated.

4. Determine patient's hemodynamic stability and symptoms. Continually assess using O-P-Q-R-S-T method, including Level of consciousness, ABCs and Vital Signs. Determine capillary refill status and if BLOOD PRESSURE is appropriate for age.

5. Obtain appropriate S-A-M-P-L-E history related to event, including recent infectious history (fever, cough, etc.) or exposure to allergens.

 

6. Monitor and record vital signs and ECG.

7. Prevent / treat for shock.

 

TREATMENT

BASIC PROCEDURES

1. Maintain appropriate body substance isolation precautions.

BASIC PROCEDURES (continued)

2. Determine presence of upper airway obstruction (stridor):

a. If the obstruction due to a foreign body is complete or is partial with inadequate air exchange: follow the American Heart Association (AHA) or American Red Cross (ARC) BCLS age appropriate guidelines for foreign body obstruction. Maintain an open airway, remove secretions, vomitus and assist ventilations as needed.

b. If partial obstruction due to a foreign body is suspected and the child has adequate air exchange: transport to appropriate medical facility. Do not attempt to remove foreign body in the field.

c. If suspected croup (barking cough, no drooling) or epiglottitis (stridor, drooling) maintain an open airway, place child in position of comfort and avoid upper airway stimulation.

d. If tracheostomy tube exists and there is evidence of obstruction resulting in inadequate air exchange; CONTACT Medical Control for further instructions. Medical control may provide instructions for emergent removal of the tracheostomy tube to establish an airway.*

3. Administer high concentration oxygen by non-rebreather mask or blow-by method, as tolerated.

4. Activate ALS intercept, if deemed necessary and if available.

5. Initiate transport as soon as possible with or without ALS.

6. Monitor and record vital signs every 5 minutes at a minimum if unstable, or every 15 minutes if stable.

7. If patient’s BLOOD PRESSURE drops below age appropriate systolic pressure (see Appendix M), treat for shock.

8. Notify receiving hospital.

 

* See Tracheostomy Tube Obstruction Management in this Protocol.

INTERMEDIATE PROCEDURES

1. Maintain appropriate body substance isolation precautions.

2. Determine presence of upper airway obstruction (stridor):

a. If the obstruction due to a foreign body is complete or is partial with inadequate air exchange: follow the American Heart Association (AHA) or American Red Cross (ARC) BCLS guidelines for foreign body obstruction. Maintain an open airway, remove secretions, vomitus and assist ventilations as needed.

b. If partial obstruction due to a foreign body is suspected and the child has adequate air exchange: transport to appropriate medical facility. Do not attempt to remove foreign body in the field.

c. If suspected croup (barking cough, no drooling) or epiglottitis (stridor, drooling) maintain an open airway, place child in position of comfort and avoid upper airway stimulation.

d. If tracheostomy tube exists and there is evidence of obstruction resulting in inadequate air exchange; CONTACT Medical Control for further instructions. Medical control may provide instructions for emergent removal of the tracheostomy tube to establish an airway.*

 

* See Tracheostomy Tube Obstruction Management in this Protocol.

INTERMEDIATE PROCEDURES (continued)

3. Administer high concentration oxygen by non-rebreather mask as tolerated.

4. Activate Paramedic intercept, if deemed necessary and if available.

5. ALS STANDING ORDERS

a. Provide advanced airway management if indicated for mechanical obstruction: Perform direct laryngoscopy if foreign body suspected. If foreign body is visible and readily accessible, attempt removal with Magill forceps.

b. Provide positive pressure ventilations if needed.

6. Initiate transport as soon as possible with or without ALS.

7. Notify receiving hospital.

 

PARAMEDIC PROCEDURES

1. Maintain appropriate body substance isolation precautions.

2. Determine presence of upper airway obstruction (stridor):

a. If the obstruction due to a foreign body is complete or is partial with inadequate air exchange: follow the American Heart Association (AHA) or American Red Cross (ARC) BCLS guidelines for foreign body obstruction. Maintain an open airway, remove secretions, vomitus and assist ventilations as needed.

b. If partial obstruction due to a foreign body is suspected and the child has adequate air exchange: transport to appropriate medical facility. Do not attempt to remove foreign body in the field.

c. If suspected croup (barking cough, no drooling) or epiglottitis (stridor, drooling) maintain an open airway, place child in position of comfort and avoid upper airway stimulation.

d. If tracheostomy tube exists and there is evidence of obstruction resulting in inadequate air exchange: CONTACT Medical Control for further instructions. Medical control may provide instructions for emergent removal of the tracheostomy tube to establish an airway.*

3. Administer high concentration oxygen by non-rebreather mask as tolerated.

4. ALS STANDING ORDERS

a. Provide advanced airway management if indicated for mechanical obstruction: Perform direct laryngoscopy if foreign body suspected. If foreign body is visible and readily accessible, attempt removal with Magill forceps. If unable to remove obstructing foreign body, continue BLS airway management by providing positive pressure ventilations.

b. If foreign body is removed proceed with endotracheal intubation if necessary.

c. IV Normal Saline titrated to appropriate BLOOD PRESSURE for age en route.

5. Initiate transport as soon as possible.

6 Contact MEDICAL CONTROL. The following may be ordered:

a. Needle cricothyroidotomy if unable to clear airway obstruction, unable to intubate as needed or unable to perform positive pressure ventilations.

7. Notify receiving hospital.

 

* See Tracheostomy Tube Obstruction Management in this Protocol.

 

* Tracheostomy tube obstruction management:

Medical control may order:

	wipe neck opening with gauze.
	attempt to suction tracheostomy tube.
	remove tracheostomy tube if necessary.
	once airway is opened, begin ventilations as necessary.
	Intermediates and paramedics may attempt to intubate the patient.

 

 

NOTE: If upper airway obstruction is the result of anaphylactic reaction, refer to the Pediatric Anaphylaxis Protocol for concurrent intervention.