14 Critical Care Emergencies
ACUTE UPPER AIRWAY OBSTRUCTION(ii) Perform up to five abdominal thrusts if back blows fail
(Heimlich’s manoeuvre) in adults and children over 1 year:
(a) stand behind the patient, place your arms around the upper
abdomen with your hands clasped between the umbilicus and
xiphisternum
(b) give thrusts sharply inwards and upwards to expel the
obstruction.
(iii) Continue alternating five back blows with five abdominal thrusts
if the obstruction is still not relieved.
(iv) Hold babies and infants up to 1 year head-down, and deliver up
to five back blows with the heel of the free hand.
(v) Perform up to five chest thrusts if this fails, using the same
landmark as for cardiac compression, to dislodge foreign material
in the airway.
(vi) Attempt removal under direct vision if the foreign body is still
present, using a laryngoscope and a pair of long-handled Magill
forceps.
(vii) Cricothyrotomy
Perform a cricothyrotomy if the patient is in extremis, and all else has
failed (see p. 469):
(a) achieve rapid access by inserting a large-bore 14-gauge i.v.
cannula through the cricothyroid membrane
(b) alternatively, make an incision through the cricothyroid
membrane with a scalpel blade, and insert a 4–6 mm
endotracheal tube (or small tracheostomy tube) and connect
this to an Ambu or Laerdal bag and the oxygen supply (see
p. 469).
3 Epiglottitis (see p. 353)
Inflammation of the epiglottis presents with sudden onset of fever, difficulty
in breathing, soft inspiratory stridor, dysphagia and drooling. The child looks
pale, toxic and unwell.
(i) Do not examine further, i.e. no temperature, blood pressure, or
X-ray. Do not attempt to visualize the throat.
(ii) Leave the parent holding the child upright with an oxygen mask
held near the child’s face.
(iii) Call for senior ED, paediatric, anaesthetic and ENT assistance
immediately.
4 Croup (see p. 352)
A child with croup will have a barking cough, harsh stridor and hoarseness,
and will be frightened and miserable but not systemically ill.
(i) Give dexamethasone 0.15–0.3 mg/kg orally or i.m., nebulized
budesonide 2 mg or prednisolone 1 mg/kg orally.
(ii) Refer to the paediatric team.