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Pediatric Airway
ManagementDr. Shapiro I., PICU
Dec 2003
I.S.
MD
EarlyEarly
DefibrillatiDefibrillationon
Adult Chain of Survival
CPRCPR ALSALSEMSEMS
I.S.
MD
Pediatric Chain of Survival
PreventiPreventionon
ALSALSCPRCPR EMSEMS
I.S.
MD
Out-of-Hospital Cardiac Arrest
SIDSTraumaSubmersionPoisoning
ChokingSevere AsthmaPneumonia
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MD
In-Hospital Cardiac Arrest
SepsisRespiratory
FailureDrug Toxicity
Metabolic Disorder
Arrhythmias
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MD
Pediatric Cardiorespiratory
Arrests
Pediatric Cardiorespiratory
Arrests
Respiratory
Shock
Cardiac
Respiratory
Shock
Cardiac
10%10%
80%
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MD
Hypoxia and Hypercarbia
Bradycardia
Pediatric Cardiorespiratory
Arrests
Pediatric Cardiorespiratory
Arrests
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MD
Schindler M, et al. Outcome of out-of-hospital cardiac or respiratory arrest in children. N Engl J Med 1996;335:1473-1479
Arrive in ER in Arrive in ER in cardiac arrestcardiac arrest
(N = 80)(N = 80)
Admit PICU(N=43) 54 %
Died in ER(N=37) 46%
Mod Deficit(N=3)
PVS at 12 mos(N=2)
Dead at 12 mos(N=1)
Died in ICU(N=37) 46%
Outcome of cardiac arrest in
children
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Survival from Respiratory Arrest
Respiratory Arrest Alone – more than 50% neurologically intact survival rate
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MD
Pediatric Chain of Survival
PreventiPreventionon
ALSALSCPRCPR EMSEMS
I.S.
MD
To Simplifythe Message…
EarlyEarly
DefibrillatioDefibrillationn
With exceptions…
(submersion, trauma, drug overdose)
With exceptions…
(sudden collapse, cardiac history)
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MD
PREVENTION
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Respiratory DistressRespiratory Failure
andRespiratory Arrest
BLS
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Evaluation of Respiratory Performance
Respiratory Rate and RegularityLevel of ConsciousnessColor of the Skin and Mucous
MembranesRespiratory Mechanics
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Respiratory Mechanics
Head BobbingNasal FlaringRetractionsGruntingStridorWheezing or Prolonged Exhalation
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Upper Airway Obstruction
turbulence
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Lower Airway Obstruction
turbulence & wheezing
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Anatomy
Children are very different than adults !!!
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Anatomy :
AirwayNose
TongueEpiglottis
Vocal CordsLarynx
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Anatomy: Larynx
Narrowest point = cricoid cartilage
INFANTADULT
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Physiology
Tongue - Posterior DisplacementTongue – Difficult to ControlEpiglottis – Difficult to ControlVocal Cords – Difficult IntubationTube size relative to Cricoid DiameterSmall Airway Edema causes High
Resistance
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Effect Of Edema
Poiseuille’s lawPoiseuille’s law
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Basic Life Support
A+B
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Two Steps Before…
1. Ensure the Safety of Rescuer and Victim ( the scene, gloves, barrier devices)
“Partial” CPR: Is Something Better than Nothing?
2. Stimulate and Check Responsiveness
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Airway
Head Tilt-Chin Lift
Jaw Thrust
+ Tongue-Jaw Lift Maneuver (FBAO)
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Breathing Check Breathing
Look
Listen
Feel
Recovery Position
Rescue Breathing
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Ventilation withOxygen
Mouth-to-Mouth ventilation provides only 17% O2
Indicated to all seriously ill or injured patients even if pCO2 is high
If Possible – humidify Oxygen Use of reduced FiO2 is uncommon
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Devices to Monitor Respiratory Function
Pulse OxymetryEnd-Tidal CO2
Arterial Blood Gas Analysis
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Oxygen Delivery Systems
Oxygen MaskFace TentOxygen HoodOxygen TentNasal Canula
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Oropharyngeal Airway
SIZE PROPER POSITION
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Nasopharyngeal Airway
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Nasopharyngeal Airway
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Bag-Mask Ventilation
Proper area for mask application
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Bag-Mask Ventilation
Sellick Maneuver
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Laryngeal Mask
Contraindicated if gag-reflex is intact
Higher success rate
Does NOT protect from aspiration
Difficult to maintain during transport
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Intubation
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Intubation: Indications
Failure to oxygenateFailure to remove CO2
Increased WOBNeuromuscular weaknessCNS failureCardiovascular failure
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Tracheal Tube
Children > 2 years:Children > 2 years:ETT size: ETT size: (Age+16)/4(Age+16)/4ETT depth (lip): ETT depth (lip): ETTsize x 3ETTsize x 3
Children > 2 years:Children > 2 years:ETT size: ETT size: (Age+16)/4(Age+16)/4ETT depth (lip): ETT depth (lip): ETTsize x 3ETTsize x 3
Age kg ETT Length
Newborn 3.5 3.5 93 mos 6.0 3.5 101 yr 10 4.0 112 yrs 12 4.5 12
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Better in younger children with a floppy epiglottis
Straight
Laryngoscope Blades
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Laryngoscope Blades
Better in older children who have a stiff epiglottis
Curved
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Intubation Technique
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Confirmation of ETT Placement
NO single technique is 100% reliable
Clinical ConfirmationChest X-rayCO2 DetectionEsophageal Detector Devices
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Clinical Confirmation
Chest riseWater vapor seen inside tubeBreath sounds - lungBreath sounds – epigastriumO2 Saturation
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Acute Deterioration after Intubation
Acute Deterioration after Intubation
D.O.P.ED.O.P.E:: DDisplacementisplacement
OObstructionbstruction
PPneumothoraxneumothorax
EEquipment failurequipment failure
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Inadequate Improvement after
Intubation Inadequate Tidal VolumeExcessive Leak Around The TubeAir Trapping and Impaired Cardiac
OutputLeak or Disconnection in Ventilator
System Inadequate PEEP Inadequate O2 Flow from Gas Source
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Percutaneous CricothyrotomyPercutaneous Cricothyrotomy
Complete UA Obstruction:FBAO
Severe Orofacial Injuries
Upper Airway Infections
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See You at Next Week’s Workshop
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