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Airway Management in Transport. Toni Petrillo-Albarano, MD Pediatric Critical Care Medicine Children’s Healthcare of Atlanta at Egleston Children’s Hospital. Objectives. Overview of the differences between the pediatric and adult airway Intubation of the pediatric patient. - PowerPoint PPT Presentation
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Airway Management in Airway Management in TransportTransport
Toni Petrillo-Albarano, MDPediatric Critical Care MedicineChildren’s Healthcare of Atlanta at Egleston Children’s Hospital
ObjectivesObjectives
Overview of the differences Overview of the differences between the pediatric and adult between the pediatric and adult airwayairway
Intubation of the pediatric patientIntubation of the pediatric patient
Anatomic Considerations Anatomic Considerations in Pediatricsin Pediatrics
Relatively Large Occiput Large Tongue Larynx is anterior and superior Epiglottis may be floppy with acute
angle Narrowest portion is cricoid cartilage
The BasicsThe Basics
The airway in any patient can be: Physiologic
• maintained easily or with effort by the patient
Maintainable• with some assistance/positioning
Invasive Intervention• oral airway, nasal trumpet, or intubation
The BasicsThe Basics
To assist patient’s in maintaining an airway:
Clear mouth Position head Consider Airway adjuncts
Proper PositioningProper Positioning
A jaw thrust or head tilt maneuver will position the tongue so that it will not obstruct the airway
Remember that a child has a relatively large tongue compared to an adult
In infants it is possible to hyperextend the neck too much and cause the soft tissue to obstruct the airway
Nasal TrumpetNasal Trumpet
A nasal trumpet can be a useful adjunct
possible for the trumpet to be too long or too short
Oral AirwayOral Airway
An appropriately placed oral airway will pull the tongue forward and provide an unobstructed airway
If the oral airway is too long, it will stimulate a gag. If it’s too short, it will not lift the tongue.
Airway AdjunctsAirway Adjuncts
The use of airway adjuncts, such as the nasal trumpet and oral airway, will only provide an adequate airway.
The patient must have reasonable respiratory effort.
If the patient is unable to maintain adequate ventilation, he/she should be bagged or proceed to endotracheal intubation.
Indications for IntubationIndications for Intubation
1. 1. Unable to protect airway2. Inadequate ventilation3. Hypoxemic respiratory failure
requiring positive pressure4. Therapeutic (e.g.
Hyperventilation in head injury)
Difficult Airway Difficult Airway ConsiderationsConsiderations
Short, muscular neck Receding mandible Protruding incisors Uvula not visualized Limited TMJ mobility Limited C-spine
mobility
What do you need?What do you need?
Monitors -- cardiac and pulse oximetrySuction -- Yankauer or catheterMachine -- ventilator or bag/maskAirway -- Endotracheal tubeIntravenous -- peripheral or central lineDrugs --
sedation/analgesia/paralysis/atropine
LaryngoscopesLaryngoscopes
Straight Curved Fiberoptic
Proper visualizationProper visualization
The laryngoscope should be used to lift “up and out”. Do not rock back on upper teeth.
Curved blade tip is placed in vallecula and will lift epiglottis away from airway.
Straight blade tip is used to hold the epiglottis from beneath.
Proper ETT SizeProper ETT Size
Newborn - 6 months 3.5
6 months - 1 year 4.0
> 1 year 4 + age 4
Intubation ProcedureIntubation Procedure
Prepare Equipment Position patient
• Table height• “Sniffing” position
Pre-oxygenate• 4 max breath in 30
sec• 100% O2 for 3-5 min
Induction agent• sedative/analgesic
Neuromuscular blocker
Intubation• Laryngoscope in L hand• Insert on R of mouth and
sweep tongue to L• Advance in midline until
epiglottis visualized• Advance tip of blade
– into vallecula (curved blade)
– beneath epiglottis (straight blade)
• Lift towards feet– “up and out”, “Never
Lever”
Rapid Sequence IntubationRapid Sequence Intubation
Done when immediate airway stabilization is required or the patient has a “full stomach” • has eaten -- pregnancy• trauma -- abdominal mass• GER -- misc• bowel obstruction
Expedited with rapid acting drugs and avoidance of bag mask ventilation
Rapid Sequence IntubationRapid Sequence Intubation
Procedure• Pre-oxygenate• Rapid Induction Agents• Rapid Acting Neuromuscular Blocker• Sellick’s Maneuver• Intubate• Check breath sounds, inflate cuff (if
applicable)• Release cricoid pressure
Sellicks’ ManeuverSellicks’ Maneuver
Cricoid Pressure Closes esophagus against the
vertebral column protects against passive
regurgitation DO NOT release until airway is
secure !
Intubation MedicationsIntubation Medications
Goals: Provide adequate intubation
conditions• airway easily visualized• patient comfort (not fighting procedure)
Avoid complications• hemodynamic instability• ICP in head injury
AtropineAtropine
Blunts vagal response that can cause bradycardia and dries oral secretions
Dose = 0.02 mg/kg (min 0.1 mg) Adverse effects
• tachycardia• mydriasis• atropine flush• disorientation
BenzodiazepinesBenzodiazepines
Effective in providing anxiolysis and amnesia
Onset and duration vary between midazolam, lorazepam, and diazepam
Dose = 0.1 mg/kg Adverse Effects include: hypotension
and myocardial depression
FentanylFentanyl
Sedative/Analgesic Dose 2-5 mcg/kg Rapid Onset and short duration --
thus an excellent intubation med Virtually no CV side effects
KetamineKetamine
PCP Derivative, Dissociative Hypnotic Rapid Onset and short duration Dose = 1-2 mg/kg IV or 2-4 mg/kg IM Increases HR, and BP and thus may
be ideal for the patient with shock. Increases cerebral metabolic rate and
ICP and thus not a good choice in head injury or seizure
Thiopental (Pentothal)Thiopental (Pentothal)
Dose = 2-5 mg/kg Max Effect in 60 seconds Sedative Hypnotic that decreases
cerebral metabolic rate and ICP Hypotension and Myocardial
Depression are possible adverse effects
EtomidateEtomidate
Ultra short-acting non-barbiturate Ultra short-acting non-barbiturate hypnotic hypnotic
rapid induction of anesthesia with rapid induction of anesthesia with minimal cardiovascular effectsminimal cardiovascular effects
0.2-0.6 mg/kg over 30-60 seconds 0.2-0.6 mg/kg over 30-60 seconds Peak effect: 1 minute Peak effect: 1 minute Duration of action: 3-5 minutesDuration of action: 3-5 minutes Can cause adrenal suppressionCan cause adrenal suppression
Neuromuscular BlockersNeuromuscular Blockers
Recommend only rapid acting agents:• Succinylcholine - dose = 1 mg/kg IV• Rocuronium - dose = 0.6-1.2 mg/kg IV• Vecuronium - dose = 0.1-0.3 mg/kg IV• Mivacurium - dose = 0.2 mg/kg IV• Atracurium - dose = 0.2 mg/kg IV
Recommended Recommended Intubation “Cocktails”Intubation “Cocktails”
Controlled Intubation• Fentanyl & Lorazepam
or• Etomidate• Vecuronium/Rocuronium• + Atropine
Head Injury• Pentothal or Etomidate• Lidocaine 1 mg/kg IV• Vecuronium• Atropine
Septic Shock• Atropine• Ketamine• Rocuronium/
Vecuronium
Status Asthmaticus• Atropine• Ketamine• Lorazepam• Rocuronium/
Vecuronium
Physiologic Response Physiologic Response to Intubationto Intubation
Airway Airway ReflexesReflexes• LaryngospasmLaryngospasm• CoughCough• GagGag
Cardiovascular Cardiovascular ReflexesReflexes• Sinus bradycardiaSinus bradycardia• TachycardiaTachycardia• HypertensionHypertension• DysrhythmiasDysrhythmias
Assessing ETT placementAssessing ETT placement
Direct visualizationDirect visualization ETCOETCO22 (digital readout or color paper) (digital readout or color paper) Chest riseChest rise Auscultation (be certain to confirm Auscultation (be certain to confirm
absence of gastric breath sounds)absence of gastric breath sounds) ETT vapor (unreliable)ETT vapor (unreliable) Chest X-rayChest X-ray
Monitoring on TransportMonitoring on Transport
Physical ExamPhysical Exam EKG monitorEKG monitor Pulse oximeterPulse oximeter EETTCOCO22 Monitor Monitor
Reevaluate Reevaluate FrequentlyFrequently
CapnogramsCapnogramsNormalNormal
Zero baselineZero baseline Rapid, sharp up riseRapid, sharp up rise Alveolar plateauAlveolar plateau Well-defined end-tidal Well-defined end-tidal Rapid, sharp down strokeRapid, sharp down stroke
A—B DeadspaceB—C Dead space and alveolar gasC—D Mostly alveolar gasD End-tidal pointD—E Inhalation of CO2 free gas
CapnographyCapnographySudden loss of waveformSudden loss of waveform
Esophageal intubationEsophageal intubation Ventilator disconnectVentilator disconnect Ventilator malfunctionVentilator malfunction Obstructed / kinked ETTObstructed / kinked ETT
CapnographyCapnographyDecrease in waveformDecrease in waveform
Sudden Sudden hypotensionhypotension
Massive blood Massive blood lossloss
Cardiac arrestCardiac arrest
HypothermiaHypothermia PEPE CPBCPB
CapnographyCapnographyGradual increase in waveformGradual increase in waveform
Increased body tempIncreased body temp HypoventilationHypoventilation Partial airway obstructionPartial airway obstruction Exogenous COExogenous CO22 source source
(w/laparoscopy/CO(w/laparoscopy/CO22 inflation) inflation)
CapnographyCapnographySudden drop – not to zeroSudden drop – not to zero
Leak in systemLeak in system Partial disconnect of systemPartial disconnect of system Partial airway obstructionPartial airway obstruction ETT in hypopharynxETT in hypopharynx
CapnographyCapnographySustained low EtCOSustained low EtCO22
AsthmaAsthma PEPE PneumoniaPneumonia
HypovolemiaHypovolemia HyperventilationHyperventilation
40
30
Low ETCO2, but good plateau
CapnographyCapnographyCleft in alveolar plateauCleft in alveolar plateau
Partial recovery from Partial recovery from neuromuscular blockadeneuromuscular blockade
40
CapnographyCapnographyTransient rise in ETCOTransient rise in ETCO22
Injection of bicarbonateInjection of bicarbonate Release of limb tourniquetRelease of limb tourniquet
40
CapnographyCapnographySudden rise in baselineSudden rise in baseline
Contamination of the optical bench Contamination of the optical bench – need to recalibrate– need to recalibrate
40
QuestionsQuestions
1. Which drug is not used in the 1. Which drug is not used in the intubation of a head injury patient?intubation of a head injury patient?• A. KetamineA. Ketamine• B. ThiopentalB. Thiopental• C. LidocaineC. Lidocaine• D. EtomidateD. Etomidate
QuestionQuestion
2.Capnograph 2.Capnograph representsrepresents
A. Esophageal A. Esophageal intubationintubation
B. Ventilator B. Ventilator disconnectdisconnect
C. Obstructed / C. Obstructed / kinked ETTkinked ETT
D. All of the D. All of the aboveabove
QuestionQuestion
3. Appropriate ETT size for a 6 year 3. Appropriate ETT size for a 6 year old calculated by formula is?old calculated by formula is?• A. 6.0A. 6.0• B. 4.5B. 4.5• C. 5.0C. 5.0• D. 5.5D. 5.5
QuestionQuestion
4. True or False:4. True or False:• Curved blade tip is placed in vallecula
and will lift epiglottis away from airway
QuestionQuestion
5. All of the following are 5. All of the following are indications for intubation except:indications for intubation except:• A. A. Unable to protect airway• B. B. Inadequate ventilation• C. C. Hypoxemic respiratory failure
requiring positive pressure• D. GCS 10D. GCS 10
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