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:
The correct answer is #3, the common miss here is #2. Optimize oxygenation first.
Why This Question Is Often Missed
What the Distractors Indicate
| Option | What It Tests / Implies | Why It’s Wrong Here |
|---|---|---|
| Chest x‑ray | Checking ETT placement or diagnosing pathology | Patient is critically hypoxic—imaging must wait until ventilated. |
| Endotracheal Intubation | Desire to secure definitive airway | Initial intubation just failed; need to optimize oxygenation first. |
| Initiate 2‑person mask ventilation | Team‑based BVM to improve seal and tidal volumes | — |
| IV rocuronium | Paralysis to facilitate intubation | Paralysis without assured ventilation risks complete apnea. |
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
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
Try for free and save. Ace your exams and meet your CME/MOC requirements.
No matter your program, no matter the size, Med-Challenger for Groups and Institutions can better prepare your program or group, fulfill industry requirements, and increase test scores.