#8 Essential Emergency Airway Care- Paediatric Considerations- Anatomic, physiological, dosing, and equipment issues 1 Andrew Brainard, MD, MPH, FACEM, FACEP http://www.thesharpend.org/ [email protected]
Jan 22, 2016
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#8Essential Emergency Airway Care-
Paediatric Considerations-Anatomic, physiological, dosing, and equipment issues
Andrew Brainard, MD, MPH, FACEM, FACEPhttp://www.thesharpend.org/
# 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/ O2 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 O2 and
positioning– Suction– Properly sized equipment and
dosages
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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
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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.
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EquipmentSizing 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
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MMH ED Pt Age/Weight -Based Equipment Suggestions
On Resus 5 & 6 airway carts
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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
Paed Intubationhttp://emupdates.com/2011/05/24/12-minute-screencast-pediatric-airway-for-emergency-physicians-who-are-not-also-pediatricians/ (12min)
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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?
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AndyLindaAndy
Andy
JoyceJoyce- Bimanual
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Brief Paediatric References:• 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/
• 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)
• Nagler J, Bachur RG. Advanced airway management. Curr Opin Pediatr. 2009 Jun;21(3):299-305.
• 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)