Most Missed Question in Pediatric Emergency Medicine This Week

A 14 mo boy triplet born at 29 weeks gestation with history of tetralogy of Fallot and seizures presents with concern for breakthrough seizures. He was given IN midazolam by his family. He was given a second dose of midazolam by EMS and subsequently became apneic and required bag mask ventilation. 

A pre-hospital intubation attempt with a 3.5 mm ETT after administration of IV fentanyl and rocuronium was unsuccessful. The paramedic states that intubation failed secondary to an “anterior airway”. 

Bag mask ventilation by EMS is in progress upon arrival to the ED. Temp 37.9°C HR 165 RR 20 (bagging), SpO2 76% BP 90/62. The patient has diffusely coarse, diminished breath sounds bilaterally with poor chest rise. No secretions are visible in nose or oropharynx. 

What would be the next most appropriate step in management?

Answers:

1. Chest x-ray
2. Endotracheal Intubation
3. Initiate 2-person mask ventilation
4. IV rocuronium

The correct answer is #3, the common miss here is #2. Optimize oxygenation first.

Why This Question Is Often Missed

• Clinicians fixate on “definitive airway” (intubation) rather than optimizing mask ventilation first.
• Misunderstanding that neuromuscular blockade (rocuronium) will improve intubating conditions despite ongoing hypoxia.

What the Distractors Indicate

High-Yield Pearl

In any pediatric “can’t intubate, can’t ventilate” scenario, a two‑person mask technique is the first step to restore oxygenation.

Core Learning Objectives

1. Demonstrate proper escalation from single‑ to two‑person bag‑mask ventilation in pediatric respiratory failure.
2. Recognize when neuromuscular blockade is contraindicated without a secured airway or adequate mask ventilation.

The “Test Trick” at Play

The question lures you toward a “definitive airway” (intubation or paralysis) by highlighting multiple failed attempts, but the underlying priority per PALS is restoring oxygenation via optimized bag‑mask ventilation before further invasive steps.

Additional Practice Questions and Remediation

Learning Objectives: two‑person mask ventilation; safe use of paralytics

Question 1

A 5‑year‑old with status asthmaticus becomes fatigued and hypoxic despite nebulized albuterol. Single‑person BVM yields minimal chest rise. What’s next?

A. IV succinylcholine

B. Two‑person bag‑mask ventilation

C. Rapid sequence intubation

D. Chest radiograph

Question 2

A 2‑year‑old with bronchiolitis is apneic after IV sedation. Single‑person BVM fails. Your next step is:

A. Endotracheal intubation

B. Two‑person bag‑mask ventilation

C. IV rocuronium

D. Apply CPAP mask

Question 3

During neonatal resuscitation, you note a poor mask seal. Despite repositioning, chest rise is absent. Next:

A. Nasal trumpet insertion

B. Two‑person mask ventilation

C. Open surgical airway

D. IV midazolam

Question 4

A 3‑year‑old with altered mental status receives single‑person BVM but remains hypoxic. The team should:

A. Start CPAP

B. Switch to two‑person bag‑mask ventilation

C. Give IV paralytic

D. Obtain chest x‑ray

Question 5

An intubation‑ready child develops laryngospasm post‑sedation and C‑section delivery. Single‑person BVM inadequate. Action?

A. Propofol bolus

B. Two‑person mask ventilation

C. IV rocuronium

D. Emergent tracheostomy

Mini Case Discussion Prompt

“How would your approach differ between a term infant with congenital airway anomaly versus a preterm with poor respiratory drive when initial BVM fails—what factors guide your decision to proceed to advanced airway or surgical airway?”

This question appears in Med-Challenger Pediatric Emergency Medicine 3rd Edition Exam Review with CME

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