11. • Externally
– Larger head/occiput
– Head flexes forward and can obstruct
• Internally
– Intra-oral tongue
– Large, floppy epiglottis
12. • Further differences
– “Pinker” vocal cords worsen visualization
– Different location of narrowest point
• Peds cuffed tubes?
– Smaller cricothyroid membrane
• No surgical crics in children
13. Other Considerations
• More gastric insufflation with BVM
• Quicker desats during intubation Different
• 10 kg will drop to 90% in <4 minutes (vs. 8 for adult)
• Vagal response (not significant)
• Consider Pre-treatment with Atropine
(though not literature supported and not the standard of care)
47. 3 Emergent Indications
for Intubation
• Can’t Protect Airway
• Can’t Maintain Ventilation / Oxygenation
• Expected Decline in Clinical Status
48. Can’t Protect Airway
Gag reflex is absent in up to 37% of population, and
is a poor predictor of airway protection
• Can they talk?
• Can they swallow and manage secretions?
49. Can’t Maintain Ventilation
or Oxygenation
• SaO2 <90% on High Flow O2 or PaO2<60 on FiO2>40%
• PaCO2 >55 if baseline is normal, or >10 increase from
baseline
• Respiratory Rate
50. Expected Decline
in Clinical Status
• Deterioration/Impending Compromise Transport
• Airway protection during procedures
(ie. endoscopy)
52. DEFINITIONS
Delayed Sequence Intubation (DSI)
DSI consists of the administration
of specific sedative agents, which
do not blunt spontaneous
ventilations or airway reflexes;
followed by a period of
preoxygenation before the
administration of a paralytic agent.
62. The 7 “P’s”of RSI
t – 10 minutes
PREPARATION
PREOXYGENATION
PRETREATMENT
TIME ZERO
PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
t + 90 seconds
POST-INTUBATION MANAGEMENT
63.
64. PREPARATION
t – 10 minutes
1. EQUIPMENT PRESENT AND
WORKING
INCLUDING EQUIPMENT
FOR PLAN “B”
65. PREPARATION
t – 10 minutes
2.
Ask yourself:
CAN I…
BAG THE PATIENT
TUBE THE PATIENT
CRIC THE PATIENT
82. DEFense Readiness CONdition
Maximum readiness
Armed Forces ready to deploy and
engage in less than 6 hours
Air Force ready to mobilize
in 15 minutes
Above normal readiness
Normal readiness
83. Perform Cric
Make Skin Cut
& Find Membrane
Inject / Prep / Open & Set Kit
Scalpel in Hand
Mark / Kit Bedside
Discuss / Feel / See Kit
94. Summary of LOAD
PRETREATMENT
L idocaine
à optional
O piates
à optional
A tropine
à for infants
consider for kids < 8
D efasciculating
à optional
dose
95. DEFASCICULATING DOSE
1/10 th the RSI dose
Traditional Indications
1. Blunt rise in ICP
2. Decrease risk of aspiration
3. Prevent muscular pain
96. PRETREATMENT
t – 3 minutes
If you’re going to give these drugs:
…at least give them some time to
circulate (3 minutes)
97. PARALYSIS WITH
INDUCTION
Time “0”
PARALYTIC AGENTS
INDUCTION AGENTS
Etomidate
Ketamine
Propafol
Midazolam
+
DEPOLARIZING
Succinylcholine
NON-DEPOLARIZING
Vecuronium
Rocuronium