430 Emergency Medicine
387.The answer is c.(Fleischer and Ludwig, pp 7-16.)This patient has
become apneic and requires assisted ventilation.The correct approach is
to do a jaw thrust and chin liftin order to provide optimal airway position-
ing and begin bag-valve-mask ventilation. This is the most important skill to
learn in pediatric resuscitation. In many cases, providing oxygen appropri-
ately is all that is needed to resolve the bradycardia and circulatory issues.
The most common cause of arrest in children is respiratory.This is a clas-
sic case of respiratory arrest causing cyanosis and subsequent bradycardia.
Epinephrine(a)is certainly in the algorithm for bradycardia, but the
first step in resuscitation is always addressing the airway. Oxygen should be
administered to this patient and a non-rebreather facemask (b)can provide
high oxygen delivery. However, the patient is not respiring so this method
is ineffective. Endotracheal intubation (d)may be necessary to establish a
definitive airway in this patient. However, it will take time to set up per-
form. The simplest and quickest intervention is jaw thrust or chin lift with
bag-valve-mask ventilation. Chest compressions (e)are soon to follow in
this patient’s resuscitation, but the initial intervention is attention to airway
and breathing.
388.The answer is e.(Fleischer and Ludwig, pp 19-20,)This patient is in
shock.Attempts at peripheral IV access are acceptable, but should be lim-
ited to two attempts within 60 seconds and then intraosseous (IO) inser-
tion should be attempted. IO lines can be performed quickly and
reliably.The preferred sites for insertion are the proximal tibia, followed
by the distal tibiaandproximal femur.In adults, there is a sternal IO sys-
tem that has gained popularity for its ease of placement and use of flexible
tubing once in place. All medications can be administered through the IO
line and onset of action is similar to venous administration.
Internal jugular central line (a), femoral vein central line (b), and saphe-
nous cutdown (c)are all very good methods of establishing quick IV access
in many critically ill adults and some pediatric patients. However, IO access
is proven to be quick and reliable in the pediatric population and should be
utilized in when peripheral access is difficult to obtain in an unstable patient.
A large-bore IV in the antecubital fossa (d)is also a good method of vascular
access, but peripheral access was not obtained in this individual.
389.The answer is a.(Fleischer and Ludwig, pp 805-808.)Epiglottitisis
a life-threatening inflammatory condition of the epiglottis, aryepiglottic,
and paraglottic folds. The etiology is usually infectious, with Haemophilus