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You are caring for a 15-month old child that fell from a second story window. The child presented with evidence of head trauma and a GCS of 6 and was intubated by you with some difficulty on the third attempt. The capnometer shows yellow color change and there is fogging in the tube. However, the pulse oximeter on her left index finger reads 87% with a good waveform. She is on 100% FiO2 and even with hand-bagging you are unable to raise her O2 sat. On exam, she has decreased breath sounds on the left. The remainder of her vital signs, exam, and her eFAST are unremarkable.
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March 5, 2026 at 4:11 pm
C) Check the tube placement with a chest radiograph or POCUS
The patient most likely has a right mainstem intubation, common in intubation of small children, especially with high-anxiety situations. ETT depth can be approximated as (3 x ETT size) in cm – measured from the central incisors. Ped EM Morsels has an excellent review here. Capnometry is consistent with the ETT being in the trachea, so complete removal especially after a difficulty intubation is not warranted. There are no other physical exam signs consistent with tension pneumothorax and the eFAST was negative. The pulse oximeter has a good waveform, so moving it is unlikely to be helpful. There is no reason to believe that bronchoconstriction is the patient’s problem, so albuterol is also unlikely to be helpful.