Not All Airway Emergencies Need Intubation

An emergency department physician I met the other day shared with me an experience from her hospital  that offers a good example of the fact that there are many different ways of managing an airway emergency in a child that don’t involve intubation. Medical management can sometimes avoid some of the risks of losing the airway that intubation might impose.

The Case

The child was an 18 month old girl whose older brother had been playing with laundry detergent pods. He had offered a pod to his little sister, who promptly put it in her mouth and chewed it, releasing the liquid. Her mother had brought her to the emergency room with respiratory distress. The child had severe stridor and was breathing at 40 times a minute. Oxygen saturation was 92%. She was awake and alert but anxious.

The ED doctor recognized significant airway obstruction and was concerned that the obstruction could worsen if the edema got worse. She immediately called for an anesthesiologist and a Head and Neck surgeon to come to the Emergency Department to evaluate the child. While waiting, she gave 10 mg of IM decadron and treated the child with nebulized racemic epinephrine. She attached a pulse oximeter and left the child sitting on her mother’s lap and otherwise did not disturb the child, trying to avoid making her cry. By the time the anesthesiologist and surgeon arrived the stridor, although still present, sounded better.

The question was what to do now? Continue reading