1. Pediatric Prehospital Airway Management By: Aaron Mills 11/26/07

2. The Pediatric Airway  Introduction  Anatomy / Physiology  Positioning  Adjuncts  Intubation

3. Introduction Almost all pediatric “codes” are of respiratory origin As few as 10% of emergency calls involve a peds patient, of which only 1% involve a critically ill or injured child.

4. Reasons Why These Airways Are Difficult  Emotional Response  Different Anatomy  Structures not fully developed  Large tongue

5. Pediatric Cardiopulmonary Arrests

6. Anatomy Children are much harder to intubate than adults

7. Anatomy: Larynx Narrowest point = cricoid cartilage

8. Airway Difference

9. Airway Positioning “Sniffing Position” Towel is placed under the head

11. Airway positioning for children <2yrs

12. Adjuncts  Nasal airway  Oral airway

13. Nasopharyngeal Airway  Contraindications:  Basilar skull fracture  CSF leak

14. Adjuncts: Oral Airway Wrong size: Too Long

15. Adjuncts: Oral Airway Wrong size: Too Short

16. Adjuncts: Oral Airway Correct size

17. Adjuncts: Oral Airway The importance of proper size

18. Signs of Respiratory Distress  Tachypnea  Tachycardia  Grunting  Stridor  Head bobbing  Flaring  Inability to lie down  Agitation  Retractions  Access muscles  Wheezing  Sweating  Prolonged expiration  Apnea  Cyanosis

19. Intubation

20. Intubation: Indications  Failure to oxygenate  Failure to remove CO 2  Neuromuscular weakness  CNS failure  Cardiovascular failure

21. Laryngoscope Blades Macintosh Miller

22. Using The Miller Blade Better in younger children with a floppy epiglottis Straight Laryngoscope Blade – used to pick up the epiglottis

23. ET Tube sizes  AgekgETT Length (lip)  Newborn 3.53.59  3 mos6.03.510  1 yr 104.011  2 yrs124.512  Children > 2 years:  ETT size: Age/4 + 4  ETT depth (lip): Age/2 + 12

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

25. Easy or Hard?

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

29. Overview  Anatomy / Physiology  Positioning  Adjuncts  Intubation

30. Questions?

31. References  Hazinski MF, et al (Ed). PALS provider manual. AHA, 2005.  Lee BS, et al. Pediatric airway management. Clin Ped Emerg Med. 2001. 2(2): 91-106.  Lubitz DS. A rapid method of estimating weight and resuscitation drug doses from length in the pediatric age group. Ann Emerg Med. 1998. 17(6):576-581.  www.emsresponder.com