Journal Entry Essay Example
Journal Entry 6
Case Study 2
Differences in Airway Management in Pediatrics
Physicians apply similar airway management techniques in both adults and children including the Hudson mask, laryngeal mask, fiberoptic-assisted intubation, and endotracheal intibution. However, application of the airway management techniques differs significantly when dealing with children due to several anatomical differences (Holm-Knudsen & Rasmussen 2009). Children are predisposed to increased airway obstruction risks because of their relatively larger tongue, higher larynx, floppy, long, U-shaped epiglottis, and larger occiput among other anatomical differences that influence the airway management interventions (Holm-Knudsen & Rasmussen 2009). During mask ventilation in children practitioners, seldom use nasal airways as a way of preventing the sensitive epistaxis and injury to the adenoidal tonsils. In this case, oral airways and tight-fitting masks, along with appropriate hand position on the mask and jaw play a critical role in preventing the problem of airway obstruction.
Another difference in airway management in children involves the use of uncuffed tubes in tracheal intubation. This helps in preventing possible mucosal injury with edema, which arises from the narrow nature of the cricoid cartilage and tight seals of pediatric airway. Nurses should also ensure performance of 100% oxygen bag and mask ventilation before tracheal intubation among the children.
Some of the challenges experienced when performing tracheal intubation in children compared to adults relate to large head size relative to neck, small mandibular size, and relatively large tongue (Sims & von Ungern-Sternberg 2012). Therefore, nurses must respond to the various anatomical differences between adults and children during airway management in order to achieve the desired outcomes through the common airway management techniques. For example, repositioning of the airway with a triple airway maneuver, which includes jaw thrust, chin lift and head tilt play a critical role in minimizing airway obstruction among the infants and children undergoing emergency airway management.
Emergency Nurse Interventions to Improve the Child’s Situation
In the case study provided, Emma a 2-year-old indigenous girl presented to the emergency department with bronchiolitis shows airway management deterioration even with a Hudson mask on at 12lt/min. The child’s situation may be attributed to significant airway obstruction, which is common in children of her age during mask ventilation. Signs such as decline in oxygen saturation despite administration of artificial oxygen show limitations in airflow through the child’s airways. In this case, the emergency nurse can improve the child’s situation by enhancing the effectiveness of the airway management techniques (Holm-Knudsen & Rasmussen 2009).. In order to overcome potential airway obstruction as a contributing factor to the child’s situation, the emergency nurse should ensure the Hudson mask is tightly fitted and administration of the oxygen via the oral airways instead of the nasal airways. In addition, the nurse should ensure proper hand position on the mask as well as position of the patient to open up the airways (Sims & von Ungern-Sternberg 2012).
The nurse should apply appropriate jaw thrust, lift the child’s chin, and tilt the head to allow maximum airflow through the patient’s airways (Holm-Knudsen & Rasmussen 2009).. This would enhance the effectiveness of mask ventilation leading to restoration and maintenance of normal oxygen saturation. If these interventions fail to improve the patient’s response to the mask ventilation, a small dose of succinylcholine would enhance the effectiveness of mask ventilation by triggering significant muscle relaxation.
Patient’s Report (ISBAR Approach)
Role: Emergency Nurse
To: Concerned physician within the emergency department
Bec, 15 years has been admitted to the emergence ward with the possibility of a sustained a head injury following a fall and subsequent hitting of a tree with her head while riding her horse. Although she was wearing a helmet, it is reported that the helmet broke into pieces once she struck a tree with her head. She had initially lost consciousness before resulting into vomiting and drowsiness and reported no neck pain. On arrival to the emergency department, she presented a GCS of 8, RR of 24 rpms, and a heart rate of 62 beats /min. She also has no indications for injuries on any other part of her body.
As indicated, the Bec could have sustained a head injury following fall from a horse in which she struck a tree with a head leading to subsequent short-term loss of consciousness. She took sometime before arriving at the emergency department because the accident took place about 60km from the town. Her companion reported that, she had vomited and become drowsy after gaining her consciousness. She also did not indicate any neck pain or injury on any of her other body parts.
Clinical assessments including the Glasgow Coma Scale (GCS) indicated a score of 8 suggesting the possibility of severe head injury sustained from the accident (Zuercher, Ummenhofer, Baltussen & Walder 2009). Assessment of her respiratory rate indicated an increase in her respiratory rate of 24 rpms, depicting significant difficulties in her breathing. Her heart rate was found to be 62 beats per minutes, which is within the resting heart rate for persons of her age. Determination of her oxygen saturation level (SaO2) indicated a slight drop from the normal 90-95% to 86% (Zuercher, Ummenhofer, Baltussen & Walder 2009). Her blood pressure was found to be 110/77 mmHg which is within the normal range for her age. The drop in oxygen saturation shows that she risks possible brain cell damage not supplied with sufficient oxygen.
Following these findings, Bec condition has been categorized under the red triage category indicating that her condition requires immediate attention and treatment to avert any life-threatening risks from her injury.
Bec should be administered with 100 percent oxygen through a facemask to restore her blood oxygen saturation to normal as well as lower her respiratory rate to normal to allow for further examination and surgery. Urgent computer tomography (CT) imaging to be performed with 1 hour to establish the extent of the head injury (Park et al. 2009. The patient should be examined by a neurosurgeon based on the CT results to determine the appropriate steps to avert possible complications from the head injury. In case, the hospital does not have a neuroscience unit, the hospital should arrange for immediate transfer to a hospital with necessary equipments and specialists. Appropriate nursing interventions and care should be implemented to ensure stability of the patient throughout the entire treatment process and patient care.
Holm-Knudsen, R & Rasmussen, L 2009, ‘Paediatric airways management: basic aspects’, Acta Anaesthesiologica Scandinavica, Vol. 53, pp. 1-9.
Park, H et al. 2009, ‘The clinical efficacy of repeat brain computed tomography in patients with traumatic intracranial haemorrhage with 24 hours after blunt head injury’, British Journal of Neurosurgery, Vol. 23, no. 6, pp. 617-621.
Sims, C & von Ungern-Sternberg, B 2012, ‘The normal and the challenging pediatric airway’, Pediatric Anesthesia, Vol. 22, pp. 521-526.
Zuercher, M, Ummenhofer, W, Baltussen, A & Walder, B 2009, ‘The use of Glasgow Coma Scale in injury assessment: a critical review’, Brain Injury, Vol. 23, no. 5, pp. 371-384.
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