What is the best next step in managing a pediatric patient who experienced a witnessed cardiac arrest and is currently receiving bag-mask ventilation by Emergency Medical Services (EMS) personnel prior to transport to the Emergency Department (ED)?

Best Next Step in Pediatric Cardiac Arrest Airway Management

Continue bag-mask ventilation during transport to the ED is the recommended approach for this pediatric cardiac arrest patient who is already receiving effective bag-mask ventilation from EMS personnel.

Rationale for Continuing Bag-Mask Ventilation

The 2020 American Heart Association guidelines explicitly state that bag-mask ventilation should be initiated and continued during pediatric cardiac arrest, with advanced airway placement (either endotracheal intubation or supraglottic airway) listed as an option rather than a requirement 1. The key principle is to minimize interruptions in chest compressions, with any interruption for airway management ideally limited to less than 10 seconds 1.

• Bag-mask ventilation is effective when performed correctly and provides adequate oxygenation and ventilation during the initial resuscitation phase 1, 2.
• Recent evidence demonstrates that bag-mask ventilation during out-of-hospital cardiac arrest is associated with improved survival to discharge and neurologically intact survival compared to advanced airway management 3.
• The compression-to-ventilation ratio should be 15:2 when two rescuers are present (as is the case with EMS personnel), with each breath delivered over 1 second to achieve visible chest rise 1, 2.

Why Not Place an Advanced Airway Immediately

Attempting endotracheal intubation or supraglottic airway placement in the prehospital setting risks prolonged interruptions in chest compressions, which directly impacts survival 1. The guidelines emphasize that:

• Advanced airway placement should not interrupt ongoing high-quality CPR 1, 2.
• If bag-mask ventilation is effective, there is no urgent need to place an advanced airway during transport 1.
• In pediatric patients, a nationwide study found no significant difference in one-month survival between endotracheal intubation and supraglottic airway insertion by EMS personnel, suggesting that the choice of airway strategy is less critical than maintaining effective ventilation and compressions 4.

When to Consider Advanced Airway Placement

Advanced airway placement (endotracheal tube or supraglottic airway) should be considered only if bag-mask ventilation is inadequate or if trained personnel can place it without interrupting chest compressions 1. The guidelines state:

• Endotracheal intubation or supraglottic advanced airway are acceptable options when providers have appropriate training and can minimize interruptions 1.
• Once an advanced airway is placed, continuous chest compressions should be provided with one breath every 2-3 seconds (20-30 breaths per minute) 1, 2.
• Waveform capnography or capnometry must be used to confirm and monitor endotracheal tube placement 1, 2.

Why Needle Cricothyrotomy is Not Indicated

Needle cricothyrotomy is not indicated in this scenario because:

• The patient is already receiving effective bag-mask ventilation 1.
• Cricothyrotomy is reserved for "cannot intubate, cannot ventilate" situations, which is not the case here 1.
• This invasive procedure would cause significant delays and interruptions in ongoing resuscitation efforts 1.

Critical Pitfalls to Avoid

• Do not delay transport to place an advanced airway if bag-mask ventilation is effective 1.
• Avoid prolonged intubation attempts that interrupt chest compressions for more than 10 seconds 1.
• Do not hyperventilate the patient, as excessive ventilation increases intrathoracic pressure and decreases cardiac output 2, 5.
• Ensure proper bag-mask technique with adequate seal, appropriate tidal volume (visible chest rise), and coordination with chest compressions 1, 2.

Optimal Transport Strategy

During transport to the ED, EMS should:

• Continue high-quality CPR with 15:2 compression-to-ventilation ratio 1, 6.
• Maintain compression depth of at least one-third of the anteroposterior diameter of the chest at a rate of 100-120 per minute 1, 2.
• Establish IV or IO access for medication administration during transport 1, 2.
• Administer epinephrine 0.01 mg/kg (0.1 mL/kg of 0.1 mg/mL concentration) IV/IO every 3-5 minutes, with a maximum dose of 1 mg 1, 2, 6.
• Attach a monitor/defibrillator to identify and treat shockable rhythms 1, 2.