The neonatal/pediatric specialist has made two unsuccessful attempts at endotracheal intubation for a 9-year-old child who survived a near-drowning. After providing ventilation with a manual resuscitation bag and mask the specialist should

• A. request the assistance of a physician
• B. attempt endotracheal intubation
• C. perform a cricothyrotomy
• D. prepare for emergency tracheostomy

Answer: (B)

Securing a definitive airway remains the priority when a child who has near-drowned is being resuscitated. If bag-mask ventilation is maintaining oxygenation, you should continue efforts to establish an endotracheal tube, optimizing technique with the next attempt (adjusting head position, suctioning clean airway, trying a different blade, using a stylet or bougie, or a video-assisted device if available) and calling for help if needed. Procedures like cricothyrotomy or emergency tracheostomy are invasive options reserved for when all less invasive airway maneuvers have failed in a pediatric patient. While enlisting additional help is important, the immediate best step is to persist in securing a definitive airway with endotracheal intubation.