little airways, big challenges · another pitfall that often results from pro-vider stress is...
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26 JEMS | MARCH 2017 www.jeMs.CoM
Proper mask size selection is critical when assisting pedi-
atric patients with ventilation or administering oxygen.
Photos courtesy Chelsea White/Dorothy A. Habrat
1703JEMS_26 26 2/13/17 2:37 PM
www.jems.com mARcH 2017 | JEMS 27
An overview of pediatric airway management
By Dorothy A. Habrat, DO; Daniel R. Shocket, MD, MPH&TM
& Darren Braude, MD, EMT-P
1703JEMS_27 27 2/13/17 2:37 PM
Child Adult
Tongue: Child’s is larger
in proportion
to mouth
Larynx:
More anterior
and superior
in child
Epiglottis:
Floppier, U-shaped
in child; shorter
in adult
Vocal cords:
Upward slant in child,
horizontal in adult
Cricoid: Narrowest part of child’s airway
Trachea: Narrow and less rigid in child
Lungs: Less capacity in child
28 JEMS | MARCH 2017 www.jeMs.CoM
You arrive on scene, walk into the home and find
a mother sitting on the couch with a 1-year-
old child on her lap. She explains her daughter
has been sick for several days, but today it was
much harder than usual to wake her up from
a nap and, “She just isn’t acting like herself.”
The girl appears limp in her mother’s
arms and doesn’t look up at you. She appears
diaphoretic and her respiratory rate is approx-
imately 8 breaths per minute. You look at your
partner, who appears just as worried about
the patient as you are, and quickly begin tak-
ing action.
Your partner hooks up the small patient
to the monitor while you continue to assess
her. She barely wakes up from the feel of the
blood pressure cuff and is lethargic. Her sys-
tolic blood pressure is 90 mmHg, oxygen sat-
uration is 84%, temperature is 101 degrees F,
and heart rate is 160. Her respiratory rate is very
slow at 8 breaths per minute, and so you imme-
diately jump into airway and respiratory support.
PEDIATRIC PERIL
It doesn’t matter whether you’re a seasoned
professional or on your first EMS call: Being
dispatched to a scene with a sick pediatric
patient evokes feelings of fear in even the most
seasoned provider. Sick pediatric patients are a
low-volume, high-acuity call, and those who’ve
treated sick children know how fast they can
deteriorate and how quickly one must act.
It’s never a bad idea to brush up on pediatric
care, and where better to start than the airway?
Although pediatric airways may seem intim-
idating, arming yourself with knowledge and
clinical experience make them manageable.
Pediatric patients are responsible for approx-
imately 7–13% of EMS calls.1 The Pediatric
Emergency Care Applied Research Network
found the most common chief complaints
were traumatic injury (29%), pain (combining
abdominal and others) (10.5%), general illness
(10%), respiratory distress (9%), behavioral
disorder (8.6%), seizure (7.45%), and asthma
(3.9%).2 Regardless of the chief complaint of
the call, early and appropriate airway manage-
ment is a very important first step.
ANATOMY & PHYSIOLOGY
The statement, “children are just little adults,”
is a long-dispelled myth. In fact, pediatric air-
ways can be vastly different from the adult
airways EMS providers more commonly
Figure 1: Pediatric vs. adult upper airway anatomy
It’s a beautiful Saturday afternoon and you and your partner
are discussing how slow the day has been. Your conversation is
interrupted by dispatch informing you of your next call, “a 1-year-
old female with high fever, not alert.” It’s been a while since you
and your partner have had to manage a pediatric airway, and you
both begin to mentally prepare for the call.
LITTLE AIRWAYS, BIG CHALLENGES
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30 JEMS | MARCH 2017 www.jeMs.CoM
LITTLE AIRWAYS, BIG CHALLENGES
Neutral supine position showing flexion of the neck due to a child’s proportion-
ally large head.
Figure 2: Proper and improper pediatric positioning
Proper positioning of a towel under a child’s shoulders to counter neck flexion.
Improper positioning of a towel to counter neck flexion.
encounter. These differences are due to anatomical differences that
amount to physiologic changes that predispose the patient to airway
obstructions.3 (See Figure 1.)
Head: In the supine position, a young child’s head will cause a
natural flexion of the neck due to its large size. This neck flexion can
create a potential airway obstruction. Patients usually benefit from
a towel to elevate the shoulders as well as someone to assist to help
hold the head, as it can be floppy.
Tongue: A child’s tongue is proportionally larger in the orophar-
ynx when compared to adults, and it may obstruct the airway due
to this size.
Larynx: Located opposite C2–C3, a child’s larynx is higher up
than in an adult, creating a more anterior location that often results
in difficulty when a provider attempts to visualize a child’s airway.
Epiglottis: The adult epiglottis is flat and flexible, while a child’s is
U-shaped, shorter and stiffer. This makes it more difficult to manip-
ulate and is a common reason providers can’t visualize an airway with
a curved blade in a pediatric patient.
Vocal cords: The anterior attachment of a pediatric patient’s
vocal cords is lower than the posterior attachment, which cre-
ates an upward slant, whereas in adults, the vocal cords are hor-
izontal. This concave shape may affect ventilation, and it ’s
important for providers to use a jaw-lift maneuver to open
the arytenoids.
Trachea: The trachea is shorter in pediatric patients, which
increases the likelihood of right mainstem intubation.
Airway diameter: A child’s airway is narrowest at the cricoid ring.
As a result, secretions can easily obstruct the airway, due to its small
size, and even a small amount of cricoid pressure can cause com-
plete airway obstruction.
Residual lung capacity: Smaller lung capacity in pediatric patients
means that a child can become hypoxic more quickly than an adult.
Providers should make sure to closely monitor oxygen saturation and
avoid prolonged periods without ventilation.
PEDIATRIC AIRWAY POSITIONING
The best way to set yourself up for airway success is by placing the
pediatric patient in the proper position. (See Figure 2.)
Taking into account anatomical considerations, start by placing
the patient in the position of comfort. Should you need to assist the
child’s ventilation, lay them supine. You can counter the flexion of the
neck due to a child’s large head by placing a towel under the shoul-
ders. Remember, the goal is to place the patient in a “sniffing position.”
Another way to think of this is aligning the ear canal with the ster-
nal notch. This position isn’t only optimal for intubation, it’s also ideal
when you’re ventilating with a bag-valve mask (BVM).
AIRWAY OPENING & SUCTION
Start with the basics, and make sure the patient has an open airway.
For any airway management case, pediatrics included, remember that
the least invasive maneuvers are often the most beneficial. If your pedi-
atric patient is hypoxemic, use the head-tilt chin-lift if you don’t need
to take C-spine precautions.
If there’s concern for C-spine injury, use a simple jaw thrust. Sup-
plemental oxygen can be applied if you believe the patient may ben-
efit from it.
Taking these actions quickly and correctly is sometimes all you have
to do to assist a pediatric patient with oxygenation and ventilation.
These simple airway opening techniques can have a dramatic effect,
so don’t underestimate them.
If a child is drooling or can’t handle secretions due to obstruction,
help them use gravity to expel secretions by placing them upright in
a position of comfort or on their side. Laying them down could be
detrimental rather than helpful.
1703JEMS_30 30 2/13/17 2:37 PM
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32 JEMS | MARCH 2017 www.jeMs.CoM
LITTLE AIRWAYS, BIG CHALLENGES
Remember, infants preferentially breathe
through their nose and can have significant
respiratory distress from nasal secretions alone.
Thus, suctioning these secretions can decrease
the work of breathing dramatically.4
If you continue to see minimal chest rise
or low oxygen saturation readings after per-
forming basic positioning and suction maneu-
vers, airway reinforcements will help provide
additional assistance.
Though the tongue can be an obstruction
in any airway, you may find it particularly
hindering in pediatric airway management.
Thus, inserting an oral or nasal airway can
be extremely helpful.
Remember that an oral airway is contrain-
dicated if the patient is alert or has an intact
gag reflex, and that a nasal airway adjunct is
contraindicated in severe central face trauma. If
needed, two nasal airways and one oral can all
be placed in order to facilitate a patent airway.
VENTILATION
Proper ventilation technique using a BVM
is critical—potentially far more important
than any invasive airway procedures such as
an extraglottic airway device or endotracheal
intubation. Ideally, this procedure is performed
with two providers: one to ensure a good mask
seal and the other for bag squeezing.
The first focus should be on creating a good
mask seal. This starts with selecting the cor-
rect mask size based on the patient’s weight
and ensuring it covers the mouth and nose. Be
mindful that in younger patients without teeth,
it can be difficult to create a good seal because
there’s no platform for the mask to rest on.
Next, properly place your hands using an
E-C grip if you’re the only one providing venti-
lation support, or the T-E grip if there another
provider is available. The T-E grip is helpful
because it keeps four fingers free to help keep
the patient’s airway open using the jaw lift.
During bagging, be mindful of not press-
ing the mask to the face but actually lifting
the patient’s face into the mask.
Lastly, focus on your target respiratory rate
as well as the amount of compression on the
bag. Barotrauma can result due to excessive
pressure being applied to the airway and this
can often occur due to provider stress and
distraction.
Another pitfall that often results from pro-
vider stress is hyperventilating the patient, so
remember to focus on the rate you’re squeez-
ing the bag during each ventilation. The ideal
respiratory rate for an infant up to 3 years is
20–30 breaths per minute. For older children
(ages 3 and up), the target respiratory rate is
16–20 breaths per minute.
INVASIVE TECHNIQUES
Positioning and BVM-assisted ventilations
will suffice for the great majority of situa-
tions requiring airway management of pedi-
atric patients; however, it may occasionally
be necessary or helpful to incorporate more
advanced airway techniques requiring place-
ment of a tool into the airway itself.
Extraglottic airway devices (EGDs): EGDs
are inserted blindly into the airway and have
very high success rates of providing oxygen-
ation and ventilation with a minimum of initial
and ongoing training. EGDs bypass common
challenges for achieving a tight mask seal,
free providers from performing two-person
BVM ventilation, may be placed easily despite
ongoing CPR, and decrease the risk for gas-
tric insufflation and aspiration as compared
to BVM.
Although these devices are being widely
incorporated by EMS systems for all these
reasons, there’s still little data on their use for
prehospital pediatric patients.
In adults, there are mixed results from pre-
hospital studies on the risks and benefits of
EGDs compared to intubation in cardiac
arrest,5,6 with larger studies now ongoing.7,8
There are a variety of EGDs now available
on the market, some of which offer pediatric
sizes. A number of them also have a channel
to facilitate gastric tube placement. The two
major categories are: 1) supraglottic devices
(e.g., laryngeal mask airways) that effectively
move the facemask from the BVM inside the
patient so that it sits over the glottis; and 2)
retroglottic devices that sit within the prox-
imal esophagus and have two balloons—one
in the pharynx to keep air from exiting the
mouth and one in the esophagus to keep air
from entering the stomach, directing gases
into the airway by default. (See Table 1, p. 34.)
Endotracheal intubation (ETI): ETI is ideal
for airway protection because the occluded tra-
chea mostly prevents aspiration of saliva, blood
and gastric contents into the lungs.
Though it’s an excellent means of oxygen-
ation and ventilation, it’s not the only way to
do so and basic maneuvers should be attempted
first before invasive procedures are performed.
Due to the success of non-invasive air-
way management, recent data has called into
question the utility and safety of ETI in all
prehospital patient populations and is a par-
ticularly hot debate in pediatrics.9
As a result, some large EMS systems have
chosen to remove this skill from the para-
medic scope of practice, including Los Ange-
les County and Orange County, Calif., and
the entire state of New Mexico. (See sidebar,
“Removing Pediatric ETI from Scope of Prac-
tice?” on p. 37.)
Despite the controversies, there are still
many prehospital providers who are perform-
ing ETIs and this skill should be reviewed
often. Anatomical differences in pediatric
patients require adjustments to your approach.
This starts with choosing your equipment.
When picking equipment, you should keep
in mind that pediatric patients generally have
a more U-shaped and stiffer epiglottis, mak-
ing a Miller blade preferable.
The potential variation in the size of your
patient is considerable, which can make ET
tube selection a challenge. Use of a Broslow
tape or the Handtevy System can help pro-
viders more quickly identify the blade and
ET tube size.
When choosing your ET tube, there’s a
choice between cuffed or uncuffed. It’s been
the school of thought for several years that
cuffed ET tubes resulted in mucosal injury in
pediatric patients. However, newer ET tube cuff
designs and monitoring of ET tube pressures
have minimized this risk. Some research has
shown no difference in post-extubation stridor
rates between uncuffed vs. modern cuffed ET
tubes in pediatric patients.10 However, long-
term consequences haven’t been studied.
Lastly, inexperience in the management of
Infants preferentially breathe through their nose
and can have significant respiratory distress from
nasal secretions alone.
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1703JEMS_33 33 2/13/17 2:37 PM
34 JEMS | MARCH 2017 www.jeMs.CoM
LITTLE AIRWAYS, BIG CHALLENGES
pediatric airways often leads to higher stress
resulting in increased difficulty. Pediatric EMS
calls account for only 7–13% of all calls. Of
these, only 0.3% required intubation.1 Sim-
ulation training and keeping up to date on
pediatric airway skills are one way to reduce
the high stress of pediatric intubation and may
result in increased proficiency.
Video laryngoscopy (VL): Several VL
devices have been introduced over the last
decade to assist with ETI, and they’re generally
considered to improve intubation success and
aid in teaching ETI technique. By projecting
the intubation view onto a screen, VL allows
for others to provide real-time assistance and
the option to record the experience for qual-
ity improvement.
Larger VL devices have generally been used
in the hospital, but small, portable options
geared toward prehospital providers are now
readily available and have been shown to aid in
more successful first pass intubation attempts
in adults.11–13 (See Table 2, pp. 35–36, for an
overview of currently available devices.) Direct
sunlight can make screen visualization difficult
with some VL devices and this is important
to keep in mind when using them in the pre-
hospital setting.
Surgical vs. needle cricothyrotomy: In
the rare instance where you can’t oxygenate a
patient via less invasive methods, a cricothy-
rotomy may be indicated (but performed only
if it is within your scope of practice).
There are two broad categories of cricothy-
rotomy: surgical and needle. For many pediat-
ric patients a surgical airway is contraindicated
because smaller cricothyroid membranes and a
funnel-shaped, more compliant pediatric lar-
ynx can lead to an inadvertent incision of the
larynx as well as post-surgical complications
such as subglottic stenosis.3
Textbooks vary considerably regarding
the age cutoff for surgical cricothyrotomy,
but most agree that it is not indicated for
patients less than 8 years of age.3 On the
other hand, for patients over 12 years old,
the anatomy will generally permit surgical
cricothyrotomy—keep in mind it may not
be included in your scope of practice. Nee-
dle cricothyrotomy usually allows for oxygen-
ation, but ventilation will be less than ideal.
This procedure is generally utilized to keep
the patient alive until a more definitive air-
way can be obtained.
The decision to perform a cricothyrot-
omy—either needle or surgical—is often the
most difficult part of the procedure. Regular
practice helps to allay fears, as does planning
ahead of time whenever you anticipate a diffi-
cult airway by finding the anatomic landmarks,
marking the site and having the necessary
equipment ready.
CASE CONCLUSION
After you recognize the need to intervene
in the patient’s airway, you place the child
Table 1: Overview of extraglottic devices with pediatric sizes available
De
vic
e
Laryngeal mask airways King Laryngeal Tube (King LT) CombiTube
Ty
pe
Supraglottic Retroglottic Retroglottic
Ch
ara
cte
rist
ics
Most require air to inflate the cuff.
Usually have a port for a gastric tube,
allowing for less gastric distension,
which faciliatates more effective BVM
ventilation.
Some are designed for an ET tube to
be passed into the trachea.
Single inflation port inflates both
upper and lower balloons.
Recent models have a port for a
gastric tube, allowing for less gastric
distension. which faciliatates more
effective BVM ventilation.
Two separate ports for inflation of the
balloons and separate attachments
for the BVM.
Providers must assess if the distal end
is in the stomach or trachea prior to
using the BVM. (This is difficult and
increases the chance of error.)
Siz
es Usually come in pediatric and
neonate sizes.Comes in pediatric and neonate sizes.
Smaller-size 37F is available to use in
patients ≥ 4 feet. (No sizes available
for patients < 4 feet.)
1703JEMS_34 34 2/13/17 2:37 PM
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Table 2: Overview of VL devices with pediatric sizes available
De
vic
e
Glidescope C-MAC PM McGrath MAC EMS
Sty
le Hyper-angulated blade ideal for
anterior airwaysMiller and Macintosh blades Macintosh-style angle curvature
Op
tio
ns
Reusable or disposable plastic covers. Reusable or disposable plastic covers. Reusable or disposable plastic covers.
Siz
es
No Glidescope rigid stylet available for
pediatric-sized ET tubes. Use the thick-
est, most rigid stylet possible to aid
tube placement.
Pediatric/neonate blades: Miller 0 and
1, Mac 0 and 2, and hyper-angulated
D-Blade Ped for difficult airways.
Pediatric size 2 blade available with
neonate size 1 coming soon.
1703JEMS_35 35 2/13/17 2:37 PM
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36 JEMS | MARCH 2017 www.jeMs.CoM
LITTLE AIRWAYS, BIG CHALLENGES
supine and position a towel behind her shoulders such that she’s in
good sniffing position.
You confirm with her shallow respirations that she has breath sounds
bilaterally. Supplemental oxygen and two-person BVM ventilation is
started and the patient is loaded into the ambulance.
En route, respirations continue to be adequately supported by BVM.
You arrive safely at the destination and transfer care to the ED team,
who continues resuscitative efforts.
You and your partner debrief while cleaning your ambulance and
prepare for the next call. Turns out it wasn’t such a quiet Saturday
afternoon after all. JEMS
Dorothy A. Habrat, DO, is an EMS fellow and an emergency medicine physician at the Uni-
versity of New Mexico Health Sciences Center. She’s also a flight physician with Lifeguard Air
Medical Services in Albuquerque. Contact her at dhabrat@gmail.com.
Daniel R. Shocket, MD, MPH&TM, is an EMS fellow and an emergency medicine physi-
cian at the University of New Mexico Health Sciences Center. He’s also a flight physician with
Lifeguard Air Medical Services in Albuquerque.
Darren Braude, MD, EMT-P, is a professor of emergency medicine and anesthesiology at
the University of New Mexico (UNM) School of Medicine. He’s the director of the UNM EMS Fel-
lowship Program and EMS Academy, the medical director of three EMS/police organizations,
and is the medical director and national course director for The Difficult Airway Course: EMS.
REFERENCES
1. Hansen M, Lambert W, Guise JM, et al. Out-of-hospital pediatric airway management in the
United States. Resuscitation. 2015;90:104–110.
2. Lerner EB, Dayan PS, Brown K, et al. Characteristics of the pediatric patients treated by the Pediatric
Emergency Care Applied Networks affiliate EMS agencies. Prehosp Emerg Care.2014;18(1):52–59.
3. Roberts JR, Custalow CB, Thomsen TW, et al., editors: Roberts and Hedges’ clinical procedures in
Table 2 (continued): Overview of VL devices with pediatric sizes available
De
vic
e
Rusch Airtraq SP VividTrac KingVision
Sty
le
Macintosh-style angle curvature Macintosh-style angle curvature Macintosh-style angle curvature
Op
tio
ns
Single-use channel-loading device. Single-use channel loading device.Single-use channeled and traditional
blades available.
Siz
es Size 1 supports ET tube sizes
4.0–5.5 mm (pediatric); size 0 supports
ET tube sizes 2.5–3.5 mm (infant).
Pediatric blade supports ET tube sizes
4.0–6.0 mm.
Pediatric aBlades with adapter, sizes
1, 2 and 2C.
1703JEMS_36 36 2/13/17 2:37 PM
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emergency medicine, 6th ed. Saunders: Philadelphia, 2013.
4. Marx JA, Hockberger RS, Walls RM, et al., editors. Rosen’s
emergency medicine: concepts and clinical practice. Mosby:
Philadelphia, 2010.
5. Tiah L, Kajino K, Alsakaf O, et al. Does pre-hospital endotra-
cheal intubation improve survival in adults with non-trau-
matic out-of-hospital cardiac arrest? A systematic review.
West J Emerg Med. 2014;15(7):749–757.
6. Hasegawa K, Hiraide A, Chang Y, et al. Association of prehos-
pital advanced airway management with neurologic outcome
and survival in patients with out-of-hospital cardiac arrest.
JAMA. 2013;309(3):257–266.
7. Benger JR, Voss S, Coates D, et al. Randomised comparison
of the effectiveness of the laryngeal mask airway supreme,
i-gel and current practice in the initial airway management
of prehospital cardiac arrest (REVIVE-Airways): A feasibility
study research protocol. BMJ Open. 2013;3(2).
8. Wang HE, Prince DK, Stephens SW, et al. Design and implemen-
tation of the Resuscitation Outcomes Consortium Pragmatic Air-
way Resuscitation Trial (PART). Resuscitation. 2016;101:57–64.
9. Prekker ME, Delgado F, Shin J, et al. Pediatric intuba-
tion by paramedics in a large emergency medical services
system: Process, challenges and outcomes. Ann Emerg Med.
2016;67(1):20–29.
10. Weiss M, Dullenkopf A, Fischer JE, et al. Prospective randomized
controlled multi-centre trial of cuffed or uncuffed endotracheal
tubes in small children. Br J Anaesth. 2009;103(6):867–873.
11. Wayne MA, McDonnell M. Comparison of traditional versus
video laryngoscopy in out-of-hospital tracheal intubation.
Prehosp Emerg Care. 2010;14(2):278–282.
12. Jarvis JL, McClure SF, Johns D. EMS intubation improves
with King Vision video laryngoscopy. Prehosp Emerg Care.
2015;19(4):482–489.
13. Boehringer B, Choate M, Hurwitz S, et al. Impact of video
laryngoscopy on advanced airway management by critical
care transport paramedics and nurses using the CMAC pocket
monitor. Biomed Res Int. 2015;2015:821302.
14. Sakles JC, Chiu S, Mosier J, et al. The importance of first pass
success when performing orotracheal intubation in the emer-
gency department. Acad Emerg Med. 2013;20(1):71–78.
15. Gausche M, Lewis RJ, Stratton SJ, et al. Effect of out-of-
hospital pediatric endotracheal intubation on survival and
neurological outcome: A controlled clinical trial. JAMA.
2000;283(6):783–790.
REMOVING PEDIATRIC ETI FROM SCOPE OF PRACTICE?
Endotracheal intubation (ETI) is a skill that requires repetition to reinforce proficiency,
and depending on the structure of your local EMS system and makeup of the patient
population, intubation rates per paramedic vary considerably.
A study conducted in King County, Wash., showed that pediatric intubation attempts
occurred in 1 out of 2,198 EMS calls.9 Moreover, with the improvements made on
modern extraglottic devices, it’s likely that prehospital ETI will continue to occur
with less frequency.
Although eventual successful intubation was achieved in 97% of pediatric intubation
cases studied in King County—a high-functioning EMS system—only 66% achieved
first pass success (53% in infants).9 King County paramedics had an average of six live
pediatric intubations during initial training and annual pediatric intubation simulations,
which is considerably more experience than the average paramedic. It’s likely that ser-
vices with less pediatric ETI experience will have even lower rates of first pass success,
resulting in higher complication rates.
A first pass success rate is important because complications increase as the number
of intubation attempts increase. One study showed adverse event rates increasing from
14.2% (for cases with successful intubation on the first attempt) to 47.2% (in cases
with second pass success) and to 63.6% (in cases with successful intubation on the third
pass).14 Although this study only included adult patients, it’s likely that similar results
would hold true for pediatric patients.
Research suggests that prehospital ETI in pediatric patients doesn’t improve sur-
vival when compared to bag-valve mask (BVM). In one study, pediatric patients had no
difference in survival to discharge nor neurological outcome when airway emergencies
were managed with a BVM vs. ETI. This included patients with medical and trau-
matic cardiac arrests, respiratory arrest and distress, head trauma with poor neurolog-
ical response, and provider assessment that the patient required ventilatory support.15
Given that the rare occurrence of pediatric ETI results in poorer first pass success
rates, which thereby increases the chances for complications, additional EMS systems
may begin to reconsider allowing pediatric ETI within the scope of practice for pre-
hospital providers.
1703JEMS_37 37 2/13/17 2:37 PM
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