Seated Position Does Not Change Lumbar Dimensions Compared With Lateral Position.

OBJECTIVE: The infant lumbar puncture (LP) can be a technically challenging procedure. Understanding the anatomical lumbar dimensions may optimize LP conditions. Data from preterm neonates, older children, and adults indicate measurements of the lumbar spine in the seated LP position may be superior when compared with the lateral position. We use point-of-care ultrasound (US) to determine if the seated position, when compared with the lateral decubitus position, significantly affected the lumbar dimensions of infants 12 months or younger presenting to the pediatric emergency department. METHODS: We conducted a prospective observational study of a convenience sample of patients 12 months or younger. We used US to obtain 3 still images oriented longitudinally in the midline over the L3 to L4 interspace in the lateral decubitus and seated positions. A US fellowship-trained emergency physician, blinded to patient position, measured interspinous space, subarachnoid space width, and spinal canal depth. We then compared the means of all 3 dimensions in the lateral and seated positions. RESULTS: From 50 subjects, 49 subjects provided 46 evaluable sets of images for each measure. Interspinous space, spinal canal depth, and subarachnoid space width did not differ significantly between positions. Mean differences did not exceed 0.02 cm for any of the measured dimensions. We report no significant differences in the 3 lumbar dimensions at the seated position when compared with the lateral decubitus position. CONCLUSIONS: For infants younger than 12 months, sonographic measurements of lumbar dimensions did not differ between the positions commonly used for LP.

Bottle Tongue Entrapment: Increasingly Popular Soda Becomes Airway Emergency.

Tongue entrapments within bottles are very rare childhood mishaps. The most immediate hazard in a tongue entrapment is airway obstruction. Tongue entrapment is an airway emergency; contingency planning to maintain airway patency, oxygenation, and ventilation is critical. Here, we report the case of a 5-year-old girl presenting to a pediatric emergency department with an increasingly popular novelty soda bottle, featuring a unique and dangerous design, entrapped on her tongue. Operative removal was anticipated. Although initially stable, she became agitated and developed retching while awaiting transfer to the operating room. Symptoms were managed medically after careful consideration of the risks and benefits of drug adverse effects while airway contingencies were planned. Fortunately, airway interventions were not necessary in the emergency department. The child was transferred to and intubated in the operating room where the bottle was removed uneventfully. This case demonstrates our approach to an evolving difficult airway in our pediatric emergency department. We review the available literature on similar presentations.

Changes in Pediatric-Sized Endotracheal Tube Cuff Pressure With Elevation Gain: Observations in Ex Vivo Simulations and In Vivo Air Medical Transport.

OBJECTIVES: Prolonged excessive endotracheal cuff pressure greater than 30 cmH2O is thought to cause ischemic airway injury. Excessive cuff pressure with altitude gain during air medical transport has been previously described in adult patients. It is poorly understood how pediatric-sized endotracheal tube (ETT) cuffs behave with atmospheric pressure change during flight. METHODS: In ex vivo models 4.0, 6.0, and 8.0, ETTs restricted within scaled syringe tubing were inflated to 20 cmH2O. Pressure was measured against 1500 ft elevation gain in ground and flight models. In an in vivo observation of pediatric patient transport, change in cuff pressure was measured between takeoff and helicopter peak flight altitudes. RESULTS: In the ex vivo ground model, endotracheal cuff pressure increased linearly with altitude and exceeded 40 cmH2O in all tube sizes. Comparable pressure change was demonstrated in the flight model. No difference was demonstrated in the degree of pressure change between ETT sizes. In the in vivo observations during patient transport, pressure increase was consistent with that seen in the ex vivo models. CONCLUSIONS: Children who are intubated with cuffed ETTs for air medical transport are subject to excessive endotracheal cuff pressure at even low flight altitudes. Endotracheal tube size did not affect the degree of cuff pressure change, contrary to previous study. These findings need to be validated and correlated to patient clinical outcomes. The implications of these data need to be considered clinically particularly for prolonged transport of intubated pediatric patients at elevation.