Just like in so many other instances, recent studies have indicated that needle-based techniques fail for pediatric front of neck access. So you need to pick up a knife and use surgical techniques. In children <8 years old, you can’t access their airway through the cricothyroid, so you need to be able to perform a pediatric tracheotomy. I bring on my friend, Cliff Reid, to discuss his systems-based approach to this critical procedure.
Cliff Reid
My friend Cliff Reid is a brilliant ED resus doc and Sydney HEMS retrieval doc
Needles Fail, Use a Knife
Pediatric Tracheotomy
In children up to about 8 years of age, their cricothyroid is not large enough or well-developed enough to perform a cric, you must perform a trach.
Cliff’s Quick Reference Guide
PDF Version of the Pediatric Surgical Airway Quick Reference
Step 0 – Gather Equipment
Step 1 – Position Patient – Neck Extension
Bolsters to keep the head from turning, shoulder roll to allow extension but not hyper-extension
Step 2 – Identify and Mark the Midline
Mark nose, chin, sternal notch, xiphoid. Draw line on midline of neck
Step 3 – Vertical Skin Incision
If you divided neck into 4 quarters, incision would be the entire middle two quarters
Step 4 – Assistant Provides Bilateral Retraction
Cliff’s method uses right-angle retractors. Assistant stands at the head of the bed and makes sure retraction keeps the midline intact by applying equal force to both lateral retractors
Step 5 – Cut Down to the Trachea
Step 6 – Cut 1-2 Anterior Tracheal Rings
Step 7 – Insert Bougie and then Tracheal Tube
Step 8 – Ventilate and Check ETCO2
Pediatric Foreign Body Management
PDF Version of the Pediatric Foreign Body Airway Obstruction Quick Reference
The Training Manikin for Pediatric Tracheotomy
Videos
Composite Video of Nat May, Cliff Reid, and Berger-Estilita
Cliff’s Sydney HEMS Grand Rounds
Papers
- Berger-Estilita, Joana, Vivian Wenzel, Markus M. Luedi, and Thomas Riva. “A Primer for Pediatric Emergency Front-of-the-Neck Access.” A&A Practice 15, no. 4 (April 6, 2021): e01444. https://doi.org/10.1213/XAA.0000000000001444.
- Cook, T.M., N. Woodall, and C. Frerk. “Major Complications of Airway Management in the UK: Results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: Anaesthesia.” British Journal of Anaesthesia 106, no. 5 (May 2011): 617–31. https://doi.org/10.1093/bja/aer058.
- Dare, Tim, Paul A. Baker, and Sarah M. Anderson. “Paediatric Emergency Front-of-Neck Airway: Issues of Ethics, Law, and Philosophy.” British Journal of Anaesthesia 132, no. 4 (April 2024): 631–34. https://doi.org/10.1016/j.bja.2023.12.009.
- Disma, Nicola, Takashi Asai, Evelien Cools, Alexandria Cronin, Thomas Engelhardt, John Fiadjoe, Alexander Fuchs, et al. “Airway Management in Neonates and Infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia Joint Guidelines.” British Journal of Anaesthesia 132, no. 1 (January 2024): 124–44. https://doi.org/10.1016/j.bja.2023.08.040.
- Haag, Anna-Katharina, Alberto Tredese, Martina Bordini, Alexander Fuchs, Robert Greif, Clyde Matava, Thomas Riva, Tommaso Scquizzato, and Nicola Disma. “Emergency Front-of-Neck Access in Pediatric Anesthesia: A Narrative Review.” Paediatric Anaesthesia 34, no. 6 (June 2024): 495–506. https://doi.org/10.1111/pan.14875.
- Holm‐Knudsen, Rolf J., Lars S. Rasmussen, Birgitte Charabi, Morten Bøttger, and Michael S. Kristensen. “Emergency Airway Access in Children – Transtracheal Cannulas and Tracheotomy Assessed in a Porcine Model.” Edited by Charles Cote. Pediatric Anesthesia 22, no. 12 (December 2012): 1159–65. https://doi.org/10.1111/pan.12045.
- Prunty, Sarah L., Alberto Aranda‐Palacios, Andy M. Heard, Gordon Chapman, Anoop Ramgolam, Mary Hegarty, Shyan Vijayasekaran, and Britta S. Von Ungern‐Sternberg. “The ‘Can’t Intubate Can’t Oxygenate’ Scenario in Pediatric Anesthesia: A Comparison of the Melker Cricothyroidotomy Kit with a Scalpel Bougie Technique.” Edited by Charles Cote. Pediatric Anesthesia 25, no. 4 (April 2015): 400–404. https://doi.org/10.1111/pan.12565.
- Reid, Cliff, Natalie May, Emma Laird, and Sebastian Ranguis. “EMERGENCY INFANT FRONT OF NECK ACCESS: MEETING THE CHALLENGE OF PREPARATION,” n.d.
- Reid, Cliff, Natalie May, Emma Laird, Jacob Tant, and Sebastian Ranguis. “Emergency Infant Front of Neck Access: Meeting the Challenge of Preparation,” n.d.
- Riva, Thomas, Simon Goerge, Alexander Fuchs, Robert Greif, Markus Huber, Andrea C. Lusardi, Thomas Riedel, Francis F. Ulmer, and Nicola Disma. “Emergency Front-of-Neck Access in Infants: A Pragmatic Crossover Randomized Control Trial Comparing Two Approaches on a Simulated Rabbit Model.” Paediatric Anaesthesia 34, no. 3 (March 2024): 225–34. https://doi.org/10.1111/pan.14796.
-
Simpson, Nicholas S., Kelsey M. Spaur, Ashley M. Strobel, Evan J. Kirschner, Brian E. Driver, and Robert F. Reardon. “Novel Technique for Open Surgical Tracheostomy in Small Children.” The Western Journal of Emergency Medicine 23, no. 2 (February 23, 2022): 235–37. https://doi.org/10.5811/westjem.2021.11.53296.
Use of Stay Suture
Additional Stuff
More on EMCrit
You Need an EMCrit Membership to see this content. Login here if you already have one.
Editor-in-Chief, at EMCrit.org
An ED Intensivist from NY.
Professor
Nassau University Medical Center
No conflicts of interest (coi).
