Presentation is loading. Please wait.

Presentation is loading. Please wait.

Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Similar presentations


Presentation on theme: "Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments."— Presentation transcript:

1 Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments

2 Goals Decision-making Decision-making Basics Basics Intubation Intubation Rescue devices Rescue devices Medications Medications Ventilators Ventilators Broselow Broselow

3 Decision-making What do I need to accomplish (why ETT)? What do I need to accomplish (why ETT)? How aggressive should I be (BLS vs. ALS)? How aggressive should I be (BLS vs. ALS)? What is my back-up plan? What is my back-up plan? What is the long-term picture? What is the long-term picture?

4 Reasons to Manage Airway Inadequate oxygenation Inadequate oxygenation Low O 2 Low O 2 Pneumonia Pneumonia CHF CHF Inadequate ventilation Inadequate ventilation High CO 2 High CO 2 Asthma/COPD Asthma/COPD Inadequate protection Inadequate protection AMS Airway trauma Anticipated course Anticipated course Hematomas Long transports

5 BLS vs. ALS We think intubation is easy We think intubation is easy We are not good at it We are not good at it Prehospital success rate as low as 70% Prehospital success rate as low as 70% We can manage many patients with BLS We can manage many patients with BLS RSI can kill people RSI can kill people

6 Who Should Be Intubated? AHA recommends prehospital intubation AHA recommends prehospital intubation De-emphasized under new ACLS/PALS guidelines De-emphasized under new ACLS/PALS guidelines AAP developed PEPP course AAP developed PEPP course Teaches intubation but not the focus Teaches intubation but not the focus What does the literature say? What does the literature say?

7 Who Should Be Intubated? Gausche, et al in Los Angeles, 2000 Gausche, et al in Los Angeles, 2000 Randomized trial comparing BVM, intubation Randomized trial comparing BVM, intubation 830 patients under 12 years 830 patients under 12 years No difference in survival or neurologic outcome No difference in survival or neurologic outcome No difference in complication rate No difference in complication rate 2% esophageal intubation all died 2% esophageal intubation all died 14% tube dislodged (6% unrecognized) 14% tube dislodged (6% unrecognized) 24% wrong sized tube 24% wrong sized tube

8 Should we be intubating ANY pediatric patients?!?! Jury is still out, but some states already forbid it.

9 Predicting the Difficult Airway Difficulty ventilating Difficulty ventilating Facial trauma Facial trauma Obesity Obesity Obstructions Obstructions Stiff lungs (asthma) Stiff lungs (asthma) Difficulty intubating Difficulty intubating External factors (obesity) Evaluate mouth opening Obstruction Smaller airways Neck mobility (trauma)

10 Easy or Hard?

11

12

13 The Debate on Prehospital Pediatric Intubation Continues…

14 Back-up Plan Can’t ventilate or basics not working Can’t ventilate or basics not working Consider adjuncts (OPA/NPA/positioning) Consider adjuncts (OPA/NPA/positioning) Intubation? Intubation? Can’t intubate Can’t intubate Rescue devices Rescue devices Can’t rescue Can’t rescue Surgical procedure Surgical procedure Okay to stick with basics if working Okay to stick with basics if working

15 It’s Not Okay to Continue with Failed Techniques

16 Long-Term Issues Securing the tube Securing the tube Tape vs. ties Tape vs. ties Commercial devices Commercial devices Restraints Restraints

17 Long-Term Issues Sedation Sedation Agent and administration (drip vs. bolus) Agent and administration (drip vs. bolus) Paralytics? Paralytics? Ventilator management Ventilator management What if the tube comes out? What if the tube comes out?

18 Basics Positioning Positioning Adjuncts Adjuncts OPA - good choice if tolerated OPA - good choice if tolerated NPA - easy to tear mucosa NPA - easy to tear mucosa Effective BVM use is most important skill Effective BVM use is most important skill Get a good seal (two person better) Get a good seal (two person better) Don’t over ventilate Don’t over ventilate Don’t forget the suction Don’t forget the suction

19 Intubation - Preparation Preoxygenate Preoxygenate Monitors - ECG, pulse ox Monitors - ECG, pulse ox Sellick’s Sellick’s Good basics Good basics Equipment selection Equipment selection Miller vs. Mac Miller vs. Mac Cuffed vs. uncuffed Cuffed vs. uncuffed ETT size ETT size Positioning Positioning

20 Airway Equipment Straight blade to age 4? Straight blade to age 4? Better able to control epiglottis? Better able to control epiglottis? Choose for comfort Choose for comfort Smaller tubes Smaller tubes Less stability Less stability More resistance More resistance Uncuffed tubes < 8 years of age Uncuffed tubes < 8 years of age

21 Airway Equipment Suction Suction Magill forceps Magill forceps Stylet Stylet Tube check and securing devices Tube check and securing devices

22 Tube Size ETT size ETT size (Age in years/4) + 4 (Age in years/4) + 4 Diameter of nare Diameter of nare Diameter of pinky Diameter of pinky Broselow tape Broselow tape Have one size smaller and larger Have one size smaller and larger

23 Tube Placement ETT depth – use the black line ETT depth – use the black line (Age in years/2) + 12 (Age in years/2) + 12 ETT internal diameter x 3 ETT internal diameter x 3

24 Intubation - Positioning Goal is to align three axes Goal is to align three axes OA/PA/LA OA/PA/LA Medical positioning Medical positioning Head tilt chin lift Head tilt chin lift Towels (older = head, younger = shoulders) Towels (older = head, younger = shoulders) Trauma positioning Trauma positioning Manual in-line stabilization Manual in-line stabilization

25 Positioning- Medical vs. Trauma Adapted from Walls et al. Manual of Emergency Airway Management. 2 nd Ed

26 Positioning Adapted from Walls et al. Manual of Emergency Airway Management. 2 nd Ed

27 Intubation - Approach Remember, much different than adults Remember, much different than adults Externally Externally Larger head/occiput Larger head/occiput Head flexes forward and can obstruct Head flexes forward and can obstruct Internally Internally Larger tongue Larger tongue Friable tissues Friable tissues Different angles and shapes Different angles and shapes

28 Airway Differences Nose Tongue Trachea Cricoid Airway

29 Adapted from Walls et al. Manual of Emergency Airway Management. 2 nd Ed

30 Airway Shape Adapted from Walls et al. Manual of Emergency Airway Management. 2 nd Ed

31 Intubation - Approach Further differences Further differences “Pinker” vocal cords worsen visualization “Pinker” vocal cords worsen visualization Different location of narrowest point Different location of narrowest point More precise ETT choice More precise ETT choice Air leak vs. trauma/stenosis Air leak vs. trauma/stenosis Peds cuffed tubes? Peds cuffed tubes? Smaller cricothyroid membrane Smaller cricothyroid membrane No surgical crics in children No surgical crics in children Needle crics difficult Needle crics difficult

32 Other Considerations More gastric insufflation with BVM More gastric insufflation with BVM Different oxygenation abilities Different oxygenation abilities Higher basal usage Higher basal usage Less residual lung capacity Less residual lung capacity Quicker desats during intubation Quicker desats during intubation 10 kg to 90% in <4 minutes (vs. 8 for adult) 10 kg to 90% in <4 minutes (vs. 8 for adult) More likely to have vagal response More likely to have vagal response

33 Intubation - Techniques Always enter from the right corner Always enter from the right corner Tongue control is critical Tongue control is critical Lift the epiglottis with the Miller Lift the epiglottis with the Miller Slide the Mac into the vallecula Slide the Mac into the vallecula Can lift the epiglottis if needed Can lift the epiglottis if needed

34 Adapted from Walls et al. Manual of Emergency Airway Management. 2 nd Ed

35 Intubation - Trouble-shooting Can’t see the cords Can’t see the cords Look for landmarks Look for landmarks Control the tongue Control the tongue BURP maneuver if epiglottis seen BURP maneuver if epiglottis seen Another attempt needed (limit number) Another attempt needed (limit number) Reposition Reposition Change something (blade, tube) Change something (blade, tube) Avoid hypoxia Avoid hypoxia

36 Blind Techniques Exist but need practice for proficiency Exist but need practice for proficiency Digital intubation Digital intubation Small work area Small work area Blind nasotracheal intubation Blind nasotracheal intubation Tough angles for tube placement Tough angles for tube placement Remember anatomic differences Remember anatomic differences Contraindicated until >10 years old Contraindicated until >10 years old

37 In general, blind techniques not useful in children

38 Intubation - Confirmation Visualize tube passing through cords Visualize tube passing through cords Breath sounds and epigastric sounds Breath sounds and epigastric sounds End Tidal CO 2 (ETCO 2 ) End Tidal CO 2 (ETCO 2 ) Commercial devices Commercial devices Not effective on uncuffed tubes Not effective on uncuffed tubes Be careful if used in children Be careful if used in children

39 REMINDER: It’s Not Okay to Continue with Failed Techniques

40 Rescue Devices LMAs (laryngeal mask airway) LMAs (laryngeal mask airway) I-LMAs (intubating LMA) I-LMAs (intubating LMA) Combitube Combitube Bougie Bougie Pick one or two and practice Pick one or two and practice Need to be comfortable before crisis Need to be comfortable before crisis

41 LMA Used in any age Used in any age Easy to place Easy to place Few complications Few complications Contraindications: Contraindications: Gag reflex Gag reflex FBs FBs Airway obstruction Airway obstruction High ventilation pressure High ventilation pressure Does not secure airway Does not secure airway

42 LMA Sizing LMA Size Patient Size 1 Neonate / Infants < 5 kg 1 ½ Infants 5-10 kg 2 Infants / Children kg 2 ½ Children kg 3 Children/Small adults kg 4 Adults kg 5 Large adult >70 kg

43

44 I-LMA Only sizes 3, 4, 5 Only sizes 3, 4, 5 Same rules and sizing as LMA Same rules and sizing as LMA Need special armored tube for intubation Need special armored tube for intubation New similar devices exist New similar devices exist Leave LMA portion in place in field Leave LMA portion in place in field

45 Combitube Two sizes Two sizes Small (4 to 5.5 feet tall) Small (4 to 5.5 feet tall) Regular (over 5.5 feet tall) Regular (over 5.5 feet tall) Not useful in most kids Not useful in most kids Easy to place Easy to place Contraindications Contraindications Gag reflex Gag reflex Esophageal disease Esophageal disease Caustic ingestions Caustic ingestions FBs/Airway obstruction FBs/Airway obstruction

46 Bougie Replaces stylet Replaces stylet Able to use with poor view Able to use with poor view Feel tracheal rings Feel tracheal rings Feel carina Feel carina Intubate over it Intubate over it Keep blade in place Keep blade in place Two person technique Two person technique Need to practice Need to practice

47 Other Toys Lighted stylet Lighted stylet Flexible fiberoptic scopes Flexible fiberoptic scopes Rigid fiberoptic scopes Rigid fiberoptic scopes Bullard Bullard Shikani Shikani Video laryngoscopy Video laryngoscopy

48 Surgical Airways - Cricothyrotomy Indications (only if >10 years old) Indications (only if >10 years old) Failed airway Failed airway Failed ventilation Failed ventilation Predictors of difficulty Predictors of difficulty Previous neck surgery Previous neck surgery Obesity Obesity Hematoma or infection Hematoma or infection

49 Cricothyrotomy - Techniques Open Locate CTM Locate CTM Stabilize larynx/prep Stabilize larynx/prep Incise skin Incise skin Vertical Vertical Horizontal through CTM Horizontal through CTM Insert spacer/dilator Insert spacer/dilator Insert cuffed tube Insert cuffed tube Check breath sounds Check breath soundsClosed Locate CTM Locate CTM Stabilize larynx/prep Stabilize larynx/prep Insert needle Insert needle Direct inferiorly Insert guidewire Remove needle Small skin incision Small skin incision Insert dilators/UC tube Insert dilators/UC tube Check breath sounds Check breath sounds

50 Cricothyrotomy - Complications Bleeding Bleeding Laryngeal or tracheal injury Laryngeal or tracheal injury Infection Infection Pneumomediastinum Pneumomediastinum Subglottic stenosis Subglottic stenosis

51 Surgical Airways - Needle Cric Same indications (all ages, tougher if young) Same indications (all ages, tougher if young) Must use with TTJV (jet ventilator) Must use with TTJV (jet ventilator) Cannot use with superior airway obstruction Cannot use with superior airway obstruction Similarly difficult patients Similarly difficult patients

52 Needle Cricothyrotomy - Procedure Identify CTM and stabilize/prep larynx Identify CTM and stabilize/prep larynx Insert needle on syringe, direct inferiorly Insert needle on syringe, direct inferiorly Large bore needle (12-16 gauge) Large bore needle (12-16 gauge) Catheter over needle Catheter over needle Advance catheter Advance catheter Connect to TTJV (BVM for infants ETT) Connect to TTJV (BVM for infants ETT) Oxygen pressure (20-30 psi) Oxygen pressure (20-30 psi) 1 second on/2-3 seconds off 1 second on/2-3 seconds off

53 Needle Cricothyrotomy - Complications Similar complications to other crics Similar complications to other crics Pneumothorax/subcutaneous emphysema Pneumothorax/subcutaneous emphysema Barotrauma Barotrauma Esophageal injury Esophageal injury Obstruction Obstruction

54 TTJV

55 What About RSI?

56 Rapid Sequence Intubation Does increase intubation success Does increase intubation success You stop intrinsic breathing You stop intrinsic breathing You can kill them You can kill them Little place for peds in prehospital setting Little place for peds in prehospital setting

57 RSI Medications Same as adults Same as adults Lidocaine Lidocaine Etomidate Etomidate Succinylcholine Succinylcholine Vecuronium Vecuronium Remember atropine Remember atropine Consider ketamine Consider ketamine

58 Pretreatment - Lidocaine Mechanism: Decrease ICP, bronchospasm Mechanism: Decrease ICP, bronchospasm Indications: Asthma, head injury Indications: Asthma, head injury Contraindications: Allergy Contraindications: Allergy Dosage: 1.5 mg/kg 3 minutes before ETT Dosage: 1.5 mg/kg 3 minutes before ETT

59 Pretreatment - Atropine Mechanism: Blunt vagal response Mechanism: Blunt vagal response Prevent bradycardia from intubation Prevent bradycardia from intubation More prevalent in children More prevalent in children Indications: All children <10 years old Indications: All children <10 years old Contraindications: Allergy Contraindications: Allergy Dosage: 0.02 mg/kg 3 minutes before ETT Dosage: 0.02 mg/kg 3 minutes before ETT

60 Induction - Etomidate Mechanism: Hypnotic, not analgesic Mechanism: Hypnotic, not analgesic Most hemodynamically stable Most hemodynamically stable Inhibits excitation Inhibits excitation Indications: All inductions Indications: All inductions Less protection from bronchospasm Less protection from bronchospasm No ICP issues No ICP issues Contraindications: None (careful in shock) Contraindications: None (careful in shock) Dosage: 0.3 mg/kg for induction (15-45 sec) Dosage: 0.3 mg/kg for induction (15-45 sec)

61 Induction - Ketamine Mechanism: PCP derivative Mechanism: PCP derivative Analgesia, anesthesia, amnesia Analgesia, anesthesia, amnesia Little respiratory or hemodynamic effect Little respiratory or hemodynamic effect Increases cerebral oxygen demand Increases cerebral oxygen demand Indications: RAD, children?, hemodynamics Indications: RAD, children?, hemodynamics Contraindications: Contraindications: Elevated ICP (worsens) Elevated ICP (worsens) Re-emergence in adults (hallucinations) Re-emergence in adults (hallucinations) Dosage: 1-2 mg/kg for induction (45-60 sec) Dosage: 1-2 mg/kg for induction (45-60 sec)

62 Paralysis - Succinylcholine Mechanism: Depolarizing agent Mechanism: Depolarizing agent Binds to NMJ and fires Binds to NMJ and fires Indications: Paralysis w/ fasciculation Indications: Paralysis w/ fasciculation Contraindications/Complications: Contraindications/Complications: Hyperkalemia (Burns, crush, renal failure) Hyperkalemia (Burns, crush, renal failure) Increased ICP, globe injury Increased ICP, globe injury Prolonged blockade, MH Prolonged blockade, MH Dosage: mg/kg (2 for younger) Dosage: mg/kg (2 for younger) Rapid onset, brief duration (30 secs – 4 min) Rapid onset, brief duration (30 secs – 4 min)

63 Paralysis - Vecuronium Mechanism: Nondepolarizing agent Mechanism: Nondepolarizing agent Competitive blockade at NMJ Competitive blockade at NMJ Indications: Indications: Pretreatment before SCh (no fasciculations) Pretreatment before SCh (no fasciculations) Paralysis Paralysis Contraindications: None (difficult airway) Contraindications: None (difficult airway) Dosage: mg/kg in secs Dosage: mg/kg in secs Lasts 60 minutes Lasts 60 minutes 1/10 th dose for pretreatment 1/10 th dose for pretreatment

64 Ventilator Management Pressure vs. volume control Pressure vs. volume control Depends on patient Depends on patient Need to reassess Need to reassess Tidal volumes 8-10 mL/kg Tidal volumes 8-10 mL/kg Similar to adult Similar to adult Again, adjust according to patient Again, adjust according to patient Titrate other settings Titrate other settings Last resorts: HFOV, ECMO Last resorts: HFOV, ECMO

65 Ventilator Management Volume control (constant volume) Volume control (constant volume) Set Rate and Tidal Volume Set Rate and Tidal Volume Set PEEP (~5) & Pressure Support Set PEEP (~5) & Pressure Support Pressure control (constant pressure) Pressure control (constant pressure) Set Rate and PIP (20-25) Set Rate and PIP (20-25) Set PEEP Set PEEP All settings require FIO 2 All settings require FIO 2

66 Ventilator Management To alter O 2 To alter O 2 Change FIO 2 Change FIO 2 Change PEEP Change PEEP Change I:E ratio Change I:E ratio To alter CO 2 To alter CO 2 Change rate Change rate Change tidal volume (or PIP) Change tidal volume (or PIP)

67 Ventilator Management CPAP and BiPAP CPAP and BiPAP Not much use in younger children Not much use in younger children Need to be able to comply with treatment Need to be able to comply with treatment Good modalities in some settings Good modalities in some settings Rarely (if ever) useful in prehospital setting Rarely (if ever) useful in prehospital setting

68 Last but not least…

69 Broselow Tape Lubitz, et al. (1998) Lubitz, et al. (1998) Most accurate kg Most accurate kg More accurate than RN or MD More accurate than RN or MD 94% vs 63% 94% vs 63%

70 Broselow Tape Rowe, et al. (1998) Rowe, et al. (1998) Calculation error rate 3% Calculation error rate 3% Recheck increases to 10% Recheck increases to 10% Under stress, up to 25% Under stress, up to 25%

71 Broselow Tape Equipment sizes Equipment sizes Airway adjuncts Airway adjuncts Intubation equip Intubation equip Oxygen delivery Oxygen delivery Vascular access Vascular access Defibrillation Defibrillation NGT, suction caths NGT, suction caths BP cuff BP cuff Chest tubes Chest tubes Foley Foley Medications Medications Antiarrhythmics Arrest medications Anticonvulsants Overdose meds Increased ICP meds Induction agents Paralytics Vasopressors IV drips

72 Broselow Tape

73 8 color codes (6-36 kg) 8 color codes (6-36 kg) Broselow-Luten Emergency System Broselow-Luten Emergency System Color-coded bags with equip Color-coded bags with equip Quicker, more efficient Quicker, more efficient

74 Summary Think carefully about your goals Think carefully about your goals Assess your options Assess your options Good BLS is the most important skill Good BLS is the most important skill Intubate or not? Intubate or not? Have a back-up plan Have a back-up plan Use your Broselow Use your Broselow

75 Questions?

76 References Gausche M, et al. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurologic outcome. JAMA (6): Gausche M, et al. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurologic outcome. JAMA (6): Gilligan BP, et al. Pediatric Resuscitation. In Rosen’s Emergency Medicine: Concepts and Clinical Practice, 6 th Ed. Mosby, Gilligan BP, et al. Pediatric Resuscitation. In Rosen’s Emergency Medicine: Concepts and Clinical Practice, 6 th Ed. Mosby, Hazinski MF, et al (Ed). PALS provider manual. AHA, Hazinski MF, et al (Ed). PALS provider manual. AHA, Lee BS, et al. Pediatric airway management. Clin Ped Emerg Med (2): Lee BS, et al. Pediatric airway management. Clin Ped Emerg Med (2): Lubitz DS. A rapid method of estimating weight and resuscitation drug doses from length in the pediatric age group. Ann Emerg Med (6): Lubitz DS. A rapid method of estimating weight and resuscitation drug doses from length in the pediatric age group. Ann Emerg Med (6): Luten R. Error and time delay in pediatric trauma resuscitation: Addressing the problem with color-coded resuscitation aids. Surg Clin of N Amer (2). Luten R. Error and time delay in pediatric trauma resuscitation: Addressing the problem with color-coded resuscitation aids. Surg Clin of N Amer (2). Luten RC. The pediatric patient. In Manual of Emergency Airway Management, 2 nd Ed. Lippincott, Luten RC. The pediatric patient. In Manual of Emergency Airway Management, 2 nd Ed. Lippincott, Tobias JD. Airway management for pediatric emergencies. Pediatric Annals. 1996; 25: Tobias JD. Airway management for pediatric emergencies. Pediatric Annals. 1996; 25:317-28


Download ppt "Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments."

Similar presentations


Ads by Google