2012 airway management


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  • The major differences btwn a ped and adult airway are size, shape and position IN THE NECK The differences in adult anatomy are particularly marked when compared to infantsThe form and position of the pediatric airway is more like an adults as early as 8yrs of ageSo now well talk about the differences and their clinical implications
  • Larynx is generally higher (cephalad) and more forward (anterior) in the neck than adults. This is more evident as you appreciate its position in relation to the C spine (GLOTTIS at C3-C4 in newborns, C4-C5 by 2 years of age, C5-C6 in adults) Epiglottis is:longer, floppier and more U-shapedbecomes more adult-like after 3 yoTongue:Relatively large tongue
  • Larger adenoidal tissues: can contribute to airway obstruction and bleed if traumatized complicating airway managementGreater Raw bc R is inversely proportional to the fourth power of the radius (Poiseuille’s law). Thus even the slightest compromise in radius can cause significant Raw and increased WOB (when flow is laminar, ie at rest, fifth power when turbulent, ie agitation)
  • Larynx higher and anterior:Shortens thyromental distance  “Bunching” of the tongue in the oropharynxGlottis opening at base of the tongue therefore more acute angle btwn tracheal opening and epiglottisEpiglottisDifficult to move out of the way during ETIInfluences laryngoscope blade type TongueCan cause obstruction due to close proximity to soft palateOcciput protuberant thus making the head flex on the C spine and thereby obstructing the airway
  • Compliant & distensible large airways:Can be susceptible to collapse/obstruction esp with cricoid pressureAdd. sublglottic airway is smaller and more compliant, and supporting cartilage is not well developed compared to adultsUpper airway obstruction can cause tracheal collapse and stridorNarrow/shorter trachea:Greater Raw bc R is inversely proportional to the fourth power of the radius (Poiseuille’s law). Thus even the slightest compromise in radius can cause significant Raw and increased WOB (when flow is laminar, ie at rest, fifth power when turbulent, ie agitation)Larger adenoidal tissues: can contribute to airway obstruction and bleed if traumatized complicating airway managementIMPLICATION: All these things together make the pediatric patient very susceptible to airway obstruction esp when loss of muscle tone/supine position. Additionally, can make visualization of airway difficult and thus ETI is challengingJaw thrust opens both the pharynx and oropharynx. The jaw-thrust maneuver can be a potent arousal stimulus, also improvingrespiratory effort
  • Lower percentage of type 1 or slow-twitch skeletal muscle fibers in their intercostal muscles and diaphragm. Type 1 muscle fibers are less prone to fatigue. Infants also have lower stores of glycogen and fat in their respiratory muscles. These differences predispose infants to respiratory muscle fatigue.During oral breathing, must use soft palate muscles to maintain an open oral airway.Reduced FRC (40% that of adults in AWAKE infants)Bullets 4 & 5: they hold their respiratory muscles in a slightly inspiratory position.infants have less reserve and are more susceptible to respiratory failure.Additionally, infants have less and immature alveoli
  • Faster falls in PaO2 during periods of apnea, i.e. for ETI, and/or resp compromise
  • Before performing any invasive airway procedure, the provider MUST assess for a potentially difficult airwayFIRST THINGS FIRST:2 extremes in time:Elective (i.e. MAC) you have time to do full BAAEmergent you don’t have the time, therefore, If emergent quickly perform a basic airway assessment (BAA) BEFORE intubation
  • Combination predicts adult difficult airway but no ped data
  • Class 1laryngoscopy yields adequate laryngeal exposure in >99% of adultsClass 3 is 7% adultsNot validated in children and has a high-false positive rate (50%) in identifying difficult pediatric airways
  • Mandibular space is of importance because the tongue and soft tissues must be displaced and compressed into this spacePotential displacement area is adequate when the distance between the anterior ramus of the mandible and the hyoid bone is…If this space is small it will make laryngoscopy more difficult bc cannot align axes (laryngeal and pharyngeal axes make a more acute angle
  • i.e. Respiratory failure (or impending)/arrestHead traumaPneumonia, bronchiolitis, etcShock
  • DEPENDING UPON EMERGENCY of the procedure; consider informing parents/guardians of risks/benefits/alternative. May even delegate someone to do so on your behalf.GET YOUR TEAM READY!Prepare your:TeamYourselfPatientequipmentAnatomy INFLUENCES your choice of equipment
  • PositioningAdjust the bed, if possible, so pt’s head is level with lower sternumSniffing positionShoulder/head rollAirway patencyAligns all 3 axes to gain a line of vision from the mouth to the glottisIN ALL AGES, axes are correctly aligned for ETI if external auditory canal is anterior to the front edge of the patients shouldersPreoxygenate for at least 3 minSuction: for less than 10 sec and if use soft catheter, suction on the way out
  • Insert laryngoscope: Hold laryngoscope with left hand, insert blade into right side of pts mouthDisplace tongue to left Position blade tip: Mac vs. MillerLift: Cricoid vs. BURP, 2nd person hold right side of mouth openInsert ETT/Remove stylet: using right hand, insert to predetermined depth, ensure cuff passes through VC/lines on tube at VC, (CAREFUL NOT TO OVER DO IT AS CHILDREN SUSCEPTIBLE TO RIGHT MAINSTEM INTUBATION BC OF SHORTER TRACHEAL LENGTHInflate cuff: A pressure of 20cm H2O is sufficient to provide a seal, but does not compromise mucosal blood flow. Tracheal mucosal blood flow is compromised at 30 cm water pressure, and mucosal blood flow is completely obstructed at pressures of 45 cm water
  • CO2 detector: color change from purple to yellow. Bag for 6 breathsAuscultation: listen over stomach first then B/L mid axillary lung fields. Esophageal intubation if gurgling sounds heard, BS can be transmitted. Give time for oxygenation to improveConfirm ETT depth and secure with tape/holder, sedation/analgesia, hook up to ventilator
  • Immediate complications of ETI
  • Suction should beWorking ANDable to generate at least -80 to -120 but wall-suction able to generate -300mm Hg is preferableIf using flexible suction catheter for nasopharynx. If so, DON’T place it further than approximated
  • NOT SENSITIVE WITH NON PERFUSING RHYTHM!!!If ped used in adults take out after 6 breaths due to RawIf adults used in peds take out after 6 breaths bc of dead space
  • Check functionality of laryngoscope/blade apparatus including light bulbChoice of bladeMacIntosh: curved blade is placed in the vallecula, at the base of the tongue, and used to indirectly lift the epiglottis from above.Miller:Infant/child epiglottis is floppy and elusive so straight blade may be safer for child <5yo but curve may also be used if > 2yoblade to be positioned below the epiglottis, which is lifted directly. ****Although this provides an improved view of the larynx, it may stimulate the vagus nerve, which innervates the underside of the epiglottis, resulting in bradycardia.
  • Full or presumed full stomachRisk of regurgitation and aspiration is high
  • Bradycardia from airway manipulation and meds can reduce DO2PALS and ACEP recommend atropine for RSI in children <1 yr, 1-5y receiving succinylcholine and for adolescents receiving a second dose of succinylcholineAtropine causes pupillary dilation, Glycopyrrolate an alternative Lido-Suppress autonomic and airway responses to laryngoscopy esp with elevated ICP. However, proof of efficacy in ped. Lit. limited
  • Benzos blunt endogenous catecholamines therefore can have negative hemodynamic effectsRigid chest with fentanyl >5mcg/kg and high doses can effect hemodynamicsKetamine with increased secretions
  • Volume load also!!!
  • Before performing any invasive airway procedure, the provider MUST assess for a potentially difficult airwayFIRST THINGS FIRST:2 extremes in time:Elective (i.e. MAC) you have time to do full BAAEmergent you don’t have the time, therefore, If emergent quickly perform a basic airway assessment (BAA) BEFORE intubation
  • Easy to insert but dependent on operator experience Malpoitioning/insertion difficulty more common in younger children
  • Combined width of index/middle/ring fingers can be used to estimate size
  • 2012 airway management

    1. 1. AirwayManagement Pediatrics
    2. 2. Overview •REFLECTION •Advanced airway management •Pediatric airway anatomy & physiology •PRACTICE •O2 delivery devices •Rapid sequence intubation (RSI) •Basic airway management •The Difficult Airway •PRACTICE •PRACTICE Page 1Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    3. 3. Pediatric AirwayAnatomy &Physiology Pediatrics
    4. 4. Objectives By the end of this workshop, the learner will: ‐List 5 anatomical differences between a pediatric and adult airway ‐Describe in your own words at least 3 physiologic factors that make pediatric patients more susceptible to hypoxemia Page 3Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    5. 5. Children are NOT small adults!!! •Major differences between pediatric and adult airway are: ‐Size ‐Shape ‐Position •Pediatric airway similar to adult at approx. 8-14 years of age Page 4Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    6. 6. Pediatric vs. Adult Airway Page 5Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    7. 7. Pediatric vs. Adult Airway •Conical larynx •Narrowest point @ cricoid ring •Larger occiput •Compliant and distensible large airways Page 6Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    8. 8. Pediatric vs. Adult Airway •Larger adenoidal tissues •Narrower tracheal diameter and shorter tracheal length •Narrower larger airways Page 7Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    9. 9. So what is the relevance? Larynx more superior and anterior •Shortens thyromental distance •“Bunching” of the tongue in the oropharynx •More acute angle between tracheal opening & epiglottis Relatively large tongue •Difficult to move out of the way Large, floppy epiglottis •Can cause obstruction •Influences choice of laryngoscope blade Conical larynx •Narrowest point is cricoid •Influences ETT size Page 8Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    10. 10. So what is the relevance? Large occiput •Obstructs airway •Influences patient positioning Compliant & distensible large •Susceptible to collapse & airways obstruction Narrower tracheal diameter, •Alters airway resistance large airways & shorter tracheal •Can influence WOB length Larger adenoidal/tonsillar •Can cause obstruction tissue •Susceptible to bleeding Page 9Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    11. 11. Physiologic Differences •Lower %age of slow twitch muscle fibers •Preferentially nose-breathers •Compliant chest wall •Ribs in a horizontal position •Flatter diaphragm •Higher oxygen consumption •Higher MV:FRC Page 11Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    12. 12. Physiologic Differences •Lower %age of slow twitch muscle fibers •Preferentially nose-breathers •Compliant chest wall •Ribs in a horizontal position •Flatter diaphragm •Higher oxygen consumption •Higher MV:FRC Page 12Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    13. 13. Oxygen DeliveryDevices &Basic AirwayManagement Pediatrics
    14. 14. Objectives By the end of this workshop, the learner will: ‐Decide which O2 delivery device would be most appropriate given a case-based example ‐Recall at least: •5 complications associated with the use of airway adjuncts •3 complications associated with BVM ‐Practice the placement of airway adjuncts using an airway task trainer ‐Perform proper bag-valve mask ventilation using an airway task trainer Page 14Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    15. 15. Oxygen delivery devices •Nasal Cannula •Non rebreather mask •Heated high flow Nasal •Cpap/Bipap Cannula •Tent/hoods •Simple Face mask •Bag mask •Venturi mask Page 15Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    16. 16. •Nasal Cannula ‐ up to 4 lpm (adults 6 lpm) ‐Approximately 24-45% Fio2 Page 16Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    17. 17. Heated High Flow Nasal Cannula •Uses Optimal heated humidified O2 •Higher flow which causes a “splinting” effect to the airways •Reduces WOB •Flow rates exceed patients inspiratory flow rate Page 17Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    18. 18. Heated High Flow Nasal Cannula •Infant/ Pediatric cannula ‐up to 8 lpm •Adult Cannula ‐ 10 to 60 lpm Page 18Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    19. 19. Simple Face Mask •Flow Rates 6-10 lpm •Approximately 35%-55% Page 19Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    20. 20. Venturi Masks •Allow for a set O2 concentration •Entrain Room Air •Liter flow depends on Set Fio2 •Can deliver up to 100% Page 20Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    21. 21. Non rebreather mask •Has a one way valve •Can deliver close to 100% Fio2 •Liter flow enough to keep the bag inflated Page 21Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    22. 22. Bipap/Cpap •BiPAP- delivers a higher pressure on inspiration, helping the patient obtain a full breath, and a low pressure on expiration, allowing the patient to exhale easily. •CPAP-delivers a steady pressure of air, which assists the patients inspiration (breathing in) and resists expiration (breathing out). Page 22Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    23. 23. Page 23Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    24. 24. Bag/Mask •Used to ventilate •Delivers 100% Fio2 •Describe technique for bagging Page 24Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    25. 25. Page 25Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    26. 26. Intro to Ambu Bag Page 26Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    27. 27. Page 27Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    28. 28. Positioning and opening the airway Page 28Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    29. 29. Oropharyngeal Airway •Prevents upper airway obstruction •May be used as a bite block •May make Bag-valve-mask ventilation more effective •Should not be used in semi comatose of alert patients Page 29Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    30. 30. Complications of Oropharyngeal Airways •Vomiting and aspiration •Obstruction can occur if the tube is to Large or to small •Dental damage •Oral damage •Laryngospasm Page 30Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    31. 31. Oropharyngeal Airway Page 31Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    32. 32. Nasopharyngeal Airway •May be used to bypass an upper airway obstruction •Reduce trauma caused by nasotracheal suctioning •To determine proper size measure from the tip of the nose to the tragus of the ear plus 2 cm. Page 32Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    33. 33. Complications of Nasopharyngeal Airways •Laryngospasm and coughing (too long) •Nosebleeds •Do not use of patients undergoing anticoagulation therapy. •Sinus infection Page 33Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    34. 34. Nasopharyngeal Airway Page 34Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    35. 35. What would you do??? •Intervention •Why •Liter flow Page 36Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    36. 36. •14 y/o male with end-stage CF and recent sinus surgery is admitted to your service. His blood gas is as followed pH 7.35 Pco2 60 Pao2 85, HCO3 26 Vital signs O2 sat 88%, RR 30 HR 95 BP 130/90 What would you do? Page 37Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    37. 37. •16 year old soccer player is admitted to the ICU, following an acute onset of SOB after a coughing spell. His recent chest x-ray shows a moderate right sided pneumothorax. Pt is hemodynamically stable. •What would you recommend? Page 38Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    38. 38. •A 6 month old RSV+ is admitted to the ICU with increase WOB. His vital signs are as followed HR 180 RR 80 Sat 90 What would you recommend? Page 39Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    39. 39. Advanced AirwayManagement:OrotrachealIntubation Pediatrics
    40. 40. Objectives By the end of this workshop, the learner will: ‐Identify 5 laryngeal anatomic landmarks seen during laryngoscopy ‐Recall at least 3 indications and 5 complications associated with orotracheal intubation ‐Choose the appropriate sized ETT and laryngoscopy blade according to the patient‟s age/weight ‐Decide on an appropriate combination and dosage of medications required for intubation ‐Carry out the proper sequence of events involved in tracheal intubation Page 41Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    41. 41. General Anatomic Overview Anatomical Pop Quiz EPIGLOTTIS ARYEPIGLOTTIC FOLD CUNEIFORM TUBERCLE INTERARYTENOID ARCH CORNICULATE TUBERCLE Page 42Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    42. 42. Anatomical Pop Quiz INNERVATION •Sensation ‐Supraglottic ‐Infraglottic •Motor ‐Exception Page 43Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    43. 43. 1st Commandment Page 44Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    44. 44. 3 Basic Components •Most difficult airways can be recognized by 3 maneuvers: ‐Examination of the oropharynx ‐Evaluation of the range of motion at the atlanto-occipital joint ‐Measurement of the mandibular displacement area Page 45Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    45. 45. Examination of the oropharynx •With mouth open to the fullest extent and tongue maximally protruding you can assess: ‐ROM at TMJ ‐Size of tongue ‐Palate (highly arch palate increases difficulty) Page 46Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    46. 46. Examination of the oropharynx •Mallampati Classification: degree of airway difficulty based on ability to visualize ‐Soft palate ‐Faucial pillars ‐Uvula. Page 47Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    47. 47. Range of motion at the AO joint•Reduced ROM does not allow alignment of airway axes Page 48Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    48. 48. Mandibular Displacement Area •Tongue & soft tissues must be displaced and compressed into this space •Adequate when distance between the anterior ramus of the mandible and the hyoid bone is: ‐3 cm (2 finger breadths) in a child ‐1.5 cm in an infant Page 49Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    49. 49. Indications •Actual or anticipated compromise in airway patency, ventilation and/or oxygenation •Altered mentation/Compromised airway reflexes •Airway or parenchymal lung disease •Hemodynamic compromise •Cardiopulmonary arrest •Neuromuscular weakness Page 50Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    50. 50. Equipment/Preparation •Monitors •ETT, stylet and syringe •Gloves •Laryngoscope and blade •Suctioning equipment •Tape/tube holder ‐Test suction •Obtain/verify IV access ‐Ensure within reach •Medications •CO2 detector Page 51Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    51. 51. Ready… •Positioning •Preoxygenate •Suction Set… •Check vitals •Administer medications Page 52Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    52. 52. Intubate! •Insert laryngoscope blade •Displace tongue •Position blade tip •Lift •Insert ETT/Remove stylet •Inflate cuff Page 53Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    53. 53. Confirmation •Condensation in ETT •CO2 detector •Auscultation •CXR Secure ETT Page 54Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    54. 54. Complications •Physiologic ‐Vomiting/Aspiration ‐Cardiovascular instability/arrest •Malposition ‐Esophageal intubation ‐Mainstem bronchus intubation •Traumatic ‐Airway trauma Page 55Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    55. 55. Page 56Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    56. 56. Rapid SequenceIntubationSlides courtesy of Dr. Fong Lam Pediatrics
    57. 57. Objectives By the end of this workshop, the learner will: ‐Assess the need for Rapid Sequence Intubation (RSI) given case-based examples ‐Summarize the steps for RSI using case-based examples Page 64Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    58. 58. What is Rapid Sequence Intubation (RSI)? •Intubating quickly •Intubating efficiently •Intubating without bag-mask ventilation ‐ AVOID bag-mask ventilation ‐ AVOID bag-mask ventilation ‐ AVOID bag-mask ventilation •BUT… do what you have to do. If you can‟t intubate, then bag-mask ventilate Page 65Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    59. 59. When Should I Use RSI? •Any acute/sudden respiratory decompensation ‐Acute traumas ‐Code Reds •When risk of aspiration of gastric contents is high Page 66Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    60. 60. How Do I Perform RSI? •Prepare •Preoxygenate •Premedicate •Paralyze •Place ETT Page 67Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    61. 61. Prepare •Let the RN and RT know that RSI will be done ‐ That way, they are also ready ‐ Minimize bag-mask ventilation ‐ Cricoid pressure AFTER sedation, although care should be taken to avoid deforming/moving the airway from view ‐ Once medications are given, give in succession as quickly as possible •Talk to the patient, if possible ‐ Spontaneously ventilating, even minimally will help prior to induction •Get in the best position possible ‐ Stand at head of bed & position the patient ‐ Get all equipment ready Page 68Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    62. 62. Preoxygenate •Supply 100% oxygen at the highest flow rate ‐Goal is to fill FRC ‐~3-5 minutes, if possible ‐Avoid BMV, if possible ‐This allows for longer apnea time prior to desaturation ‐Patient will still become hypercarbic Page 69Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    63. 63. Premedicate •Atropine (0.02 mg/kg IV) ‐Blunt vagal effects of laryngoscopy (especially in infants) ‐Dries secretions •Lidocaine (1mg/kg IV) ‐Blunts ICP spike from laryngoscopy Page 70Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    64. 64. Premedication •Midazolam (0.1-0.2 mg/kg IV/IM/IN) ‐Hemodynamically neutral •Fentanyl (2-4 mcg/kg IV) ‐Beware of rigid chest when infused quickly ‐Hemodynamically neutral •Ketamine (1-3 mg/kg IV) ‐Raises BP and HR ‐Useful if hypotensive or with asthma ‐Avoid in head trauma/increased ICP/IOP Page 71Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    65. 65. Premedicate •Thiopental (3-5 mg/kg IV) ‐Negative inotrope ‐Decreases CMR & CBF  ICP •Etomidate (0.25 mg/kg IV) ‐Causes adrenal suppression ‐Avoid in septic shock, if possible Page 72Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    66. 66. Paralyze • Rocuronium (1.2-1.5 mg/kg IV) ‐ Onset ~60-90 seconds ‐ Duration ~30-45 minutes OR • Vecuronium (0.15-0.2 mg/kg IV) ‐ Onset ~3-5 minutes ‐ Duration ~34-60 minutes OR • Succinylcholine (1-2 mg/kg IV) ‐ Causes bradycardia with rapid injection in infants ‐ Avoid in burns, crush, neuromuscular disease, renal failure ‐ Causes hyperkalemia due to fasciculations ‐ Onset ~30-60 seconds ‐ Duration ~2-3 minutes Page 73Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    67. 67. Place ETT •Use cricoid pressure, if possible ‐Some helpers get overanxious and give too much pressure ‐It may be useful for you to find the best location and then have someone hold the position •Place the tube •Be prepared for difficult airways!!! Page 74Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    68. 68. REMEMBER: •Prepare ‐ Good communication •Preoxygenate ‐ Avoid bag-mask ventilation •Premedicate ‐ Based on the disease •Paralyze ‐ Safer to use non-depolarizing if history unknown •Place ETT ‐ Be prepared for difficult airways Page 75Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    69. 69. Vignette 1 3 mos. old previously healthy infant presents with bronchiolitis and requires intubation for impending respiratory failure. Last fed breast milk 5 hrs ago. ‐What medications are you going to administer? ‐Why? ‐Requires RSI?? Page 76Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    70. 70. Premedicate (typical) •Atropine (0.02 mg/kg IV) •Midazolam (0.1-0.2 mg/kg IV/IM/IN) •Fentanyl (2-4 mcg/kg IV) •Rocuronium (1.2-1.5 mg/kg IV) Page 77Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    71. 71. Vignette 2 8 year old with ALL who presents with septic shock and respiratory failure. HR = 150 and BP 80/35. Drank a coke 3 hrs ago. ‐What medications are you going to administer? ‐Why? ‐What medications would you NOT give? ‐Requires RSI?? Page 78Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    72. 72. Premedication (alternative/sepsis) •+/- Atropine (0.02 mg/kg IV) •Ketamine (1-3 mg/kg IV) •Rocuronium (1.2-1.5 mg/kg IV) Page 79Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    73. 73. Vignette 3 18 year old previously healthy male presents S/P MVA. He acutely becomes altered with a GCS=7. His HR is 120 and BP is 120/80. ‐What medications are you going to administer? ‐Why? ‐What medications would you NOT give? ‐Requires RSI?? Page 80Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    74. 74. Premedicate (risk of increased ICP) •+/-Atropine (0.02 mg/kg IV) •Lidocaine (1mg/kg IV) •Thiopental (3-5 mg/kg IV) – if hemodynamically intact OR •Etomidate (0.25 mg/kg IV) – if hypotensive Page 81Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    75. 75. TheDifficult Airway Pediatrics
    76. 76. Objectives By the end of this workshop, the learner will: ‐Be aware of the institutional protocol for a “Known/Suspected Critical Airway” ‐List at least 3 complications associated with LMA insertion ‐Choose the appropriate sized LMA according to the patient‟s weight ‐Practice the placement of LMA „s using an airway task trainer Page 83Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    77. 77. 1st Commandment Page 84Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    78. 78. 2nd CommandmentThe intubator should always have asecond strategy to provideoxygenation and ventilation if theinitial airway approach fails. Page 86Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    79. 79. Remember… Anticipate & Plan Page 87Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    80. 80. Laryngeal Mask Airway •Supraglottic device •Indications: ‐ Failed BVM or endotracheal •Easy to insert intubation •Low complication rate •Contraindications: ‐ Awake patients or patients ‐Malpositioning with a gag reflex ‐Increased insertion difficulty ‐ Those requiring high ‐Laryngosapsm pressures to ventilate ‐Bronchospasm Page 88Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM
    81. 81. Laryngeal Mask Airway •It is important to choose the correct size ‐ Too large  will be difficult to place ‐ Too small  will not maitain an adequate sea **Combined width of index/middle/ring fingers can be used to estimate size Page 90Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM