1. #8 Essential Emergency Airway Care- Paediatric Considerations- Anatomic, physiological, dosing, and equipment issues 1 Andrew Brainard, MD, MPH, FACEM, FACEP http://www.thesharpend.org/ abrainard01@gmail.com

2. # 8 RSI of paediatric pt Learning Objectives: Prep team/plan/room/equipment Mask seal, BVM, adjuncts, suction Pre and apnoeic oxygenation Pt positioning – Airway assessment and plan MOANS/LEMON Announce “pullout criteria” Briefing for Plan A, B, C, & D – Use Paed Drug Calculator – Correctly Sizes equipment – Correct RSI drugs and dosage Completes FINAL airway checklist – Call and response – <1 min – Direct/Video laryngoscopy Proper Technique Advantages/disadvantages Difficulties Contraindications – Complete Airway Audit Form R40: 1 y/o lethargic 2 days of fever, cough, dyspnea GCS 4, SaO2 88%, P 210, RR 80, BP 100/70 Temp 41, Glucose 10 – On arrival Same as above (SaO2 91% w/ O 2 BVM) LEMON shows: – No blood in airway, normal 3-3-2, snoring – Consultant suggests RSI Patient can only be intubated using – Sedation and Paralysis – Optimal pre and apnoeic O 2 and positioning – Suction – Properly sized equipment and dosages

3. Anatomy and physiology Quick to Desaturate Large head: – Place roll under shoulders for level ear-to- sternal notch Large tongue: – Jaw thrust, difficulty clearing tongue with blade Long flexible epiglottis: – Directly lift the epiglottis with the tip of blade Cricothyoid cartilage is smallest diameter: – Foreign body obstruction occurs below the larynx Soft tracheal cartilage – Positive pressure ventilation can open airway, cricoid pressure in contraindicated. Small airways – Can quickly swell closed – Dramatic changes with oedema Short Trachea – Blade is frequently advanced to far – Frequent mainstem intubation 3

4. Pharmacological and equipment RSI Drugs: use a dosage calculator!!!, Sedation – Etomidate (0.3mg/kg) – Fentanyl (5-10mcg/kg) – Ketamine (0.5-2mg/kg) – Propofol (0.15-3mg/kg) Midazolam (0.1-0.3 mg/kg) – Thiopental (0.15-3mg/kg) Paralysis – Rocuronium (1.2mg/kg) – Succinylcholine (1-2-2mg/kg for infant, 2-3mg/kg for neonate) Know contraindications Premedication: – Atropine: APLS recommends atropine if: <1 year (1-5y/o if using suxamethonium) and patients who receive a second dose of suxamethonium Routine premedication with atropine in absence of bradycardia is not evidence based and is no longer recommended. 4

5. Equipment Sizing of equipment (use a memory aid!!!) – Straight blade under 3 y/o – Video laryngoscopy can provide a better view – ETT tubes Predicted cuffed ET Tube = (Age /4) + 3.5 – (either cuffed and uncuffed tubes can be used) Predicted uncuffed ET Tube = (Age / 4) + 4 – 1kg = 2.5, 2kg = 3.0, 3kg = 3.0-3.5, >3kg =3.5 – 1y/o = 4.0 Distance to lip = 3x ETT size Adjuncts – NPA- nare-to-ear or size of little finger – OPA- mouth-to-ear against patient’s face Paediatric bougie Mask Sizing Nasal apnoeic oxygen at 2-10 lpm 5

6. MMH ED Pt Age/Weight -Based Equipment Suggestions On Resus 5 & 6 airway carts 6

7. Major differences in airway management? Desaturation is more rapid Needle cricothyroidotomy is recommended over surgical cricothyroidotomy – APLS suggests <12y/o – Some say <6y/o – Others say <3y/o (AKA: it depends) Manufactured needle cricothyrotomy kits are superior to improvised cric kits 7 Paed Intubation http://emupdates.com/2011/05/24/12-minute-screencast-pediatric-airway-for-emergency-physicians-who-are-not-also- pediatricians/http://emupdates.com/2011/05/24/12-minute-screencast-pediatric-airway-for-emergency-physicians-who-are-not-also- pediatricians/ (12min)

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9. Airway briefing and checklist We have a 1 y/o child with pneumonia and hypoxia. We need to intubate her to improve her ventilation. Based on our airway assessment, it is appropriate to intubate this 1 year old 10kg child. We have the correct wt based doses of 50mcg of fentanyl and 20mg of Sux. The team will be: I’ll be team leader Linda as primary airway operator I’ll be the backup airway operator Joyce as airway assistant James also push the drugs Our plan is: A- #1 Straight blade/#4 uncuffed tube w/ sylet B- #2 straight blade/bougie/#3.5 uncuffed tube C- LMA size “2” D- Needle Cric for Sats <80% and dropping We will pullout if SaO2 drops below 93% or if we can’t see anything after 1 minute and re-oxygenate Everyone understand their roles? Questions or suggestions? Is everyone ready to complete the checklist in less than a minute? 999 Andy Linda Andy Joyce Joyce- Bimanual

10. Brief Paediatric References: 10 Reuben Strayer. Emergency Medicine Updates (http://emupdates.com). 12 minute screencast: pediatric airway for emergency physicians who are not also pediatricians http://emupdates.com/2011/05/24/12-minute-screencast-pediatric-airway-for- emergency-physicians-who-are-not-also-pediatricians/http://emupdates.com http://emupdates.com/2011/05/24/12-minute-screencast-pediatric-airway-for- emergency-physicians-who-are-not-also-pediatricians/ Eric R Schmitt, Marianne Gausche-Hill, Advanced Pediatric Airway Management— Updates and Controversies. Emergency Medicine & Critical Care, 2011;5:21-27 (Accessed on 18/03/2013) Eric R SchmittMarianne Gausche-HillAdvanced Pediatric Airway Management— Updates and Controversies Nagler J, Bachur RG. Advanced airway management. Curr Opin Pediatr. 2009 Jun;21(3):299-305. Nagler JBachur RGCurr Opin Pediatr. Ching KY, Baum CR: Newer agents for rapid sequence intubation. Pediatr Emerg Care 2009;25:200-210. The Difficult Airway Society Paeditric Guidelines: http://www.das.uk.com/content/paediatric-difficult-airway-guidelines (Accessed on 20/03/2013) http://www.das.uk.com/content/paediatric-difficult-airway-guidelines