Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center...

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Pediatric Airway Pediatric Airway Management Management Dave French, MD, NREMT-P Dave French, MD, NREMT-P Attending ED Physician, Attending ED Physician, Albany Medical Center Albany Medical Center Medical Director, Medical Director, Albany & Schenectady Fire Departments Albany & Schenectady Fire Departments

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Transcript of Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center...

Page 1: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Pediatric Airway ManagementPediatric Airway Management

Dave French, MD, NREMT-PDave French, MD, NREMT-P

Attending ED Physician,Attending ED Physician,

Albany Medical CenterAlbany Medical Center

Medical Director,Medical Director,

Albany & Schenectady Fire DepartmentsAlbany & Schenectady Fire Departments

Page 2: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

GoalsGoals

Decision-makingDecision-makingBasicsBasics IntubationIntubationRescue devicesRescue devicesMedicationsMedicationsVentilatorsVentilatorsBroselowBroselow

Page 3: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Decision-makingDecision-making

What do I need to accomplish (why ETT)?What do I need to accomplish (why ETT)?How aggressive should I be (BLS vs. ALS)?How aggressive should I be (BLS vs. ALS)?What is my back-up plan?What is my back-up plan?What is the long-term picture?What is the long-term picture?

Page 4: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Reasons to Manage AirwayReasons to Manage Airway

Inadequate oxygenationInadequate oxygenation Low OLow O22

PneumoniaPneumonia CHFCHF

Inadequate ventilationInadequate ventilation High COHigh CO22

Asthma/COPDAsthma/COPD

Inadequate protectionInadequate protection AMSAMS Airway traumaAirway trauma

Anticipated courseAnticipated course HematomasHematomas Long transportsLong transports

Page 5: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

BLS vs. ALSBLS vs. ALS

We think intubation is easyWe think intubation is easyWe are not good at itWe are not good at it

Prehospital success rate as low as 70%Prehospital success rate as low as 70%We can manage many patients with BLSWe can manage many patients with BLSRSI can kill peopleRSI can kill people

Page 6: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Who Should Be Intubated?Who Should Be Intubated?

AHA recommends prehospital intubationAHA recommends prehospital intubation De-emphasized under new ACLS/PALS guidelinesDe-emphasized under new ACLS/PALS guidelines

AAP developed PEPP courseAAP developed PEPP course Teaches intubation but not the focusTeaches intubation but not the focus

What does the literature say?What does the literature say?

Page 7: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Who Should Be Intubated?Who Should Be Intubated?

Gausche, et al in Los Angeles, 2000Gausche, et al in Los Angeles, 2000 Randomized trial comparing BVM, intubationRandomized trial comparing BVM, intubation 830 patients under 12 years830 patients under 12 years

No difference in survival or neurologic outcomeNo difference in survival or neurologic outcome No difference in complication rateNo difference in complication rate

2% esophageal intubation all died2% esophageal intubation all died 14% tube dislodged (6% unrecognized)14% tube dislodged (6% unrecognized) 24% wrong sized tube24% wrong sized tube

Page 8: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Should we be intubating Should we be intubating ANY pediatric patients?!?!ANY pediatric patients?!?!

Jury is still out, but some states Jury is still out, but some states already forbid it.already forbid it.

Page 9: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Predicting the Difficult AirwayPredicting the Difficult Airway

Difficulty ventilatingDifficulty ventilating Facial traumaFacial trauma ObesityObesity ObstructionsObstructions Stiff lungs (asthma)Stiff lungs (asthma)

Difficulty intubatingDifficulty intubating External factors (obesity)External factors (obesity) Evaluate mouth openingEvaluate mouth opening ObstructionObstruction

Smaller airwaysSmaller airways

Neck mobility (trauma)Neck mobility (trauma)

Page 10: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Easy or Hard?Easy or Hard?

Page 11: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Easy or Hard?Easy or Hard?

Page 12: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Easy or Hard?Easy or Hard?

Page 13: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

The Debate on Prehospital The Debate on Prehospital Pediatric Intubation Continues…Pediatric Intubation Continues…

Page 14: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Back-up PlanBack-up Plan

Can’t ventilate or basics not workingCan’t ventilate or basics not workingConsider adjuncts (OPA/NPA/positioning)Consider adjuncts (OPA/NPA/positioning) Intubation?Intubation?

Can’t intubateCan’t intubateRescue devicesRescue devices

Can’t rescueCan’t rescueSurgical procedureSurgical procedure

Okay to stick with basics if workingOkay to stick with basics if working

Page 15: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

It’s Not Okay to Continue It’s Not Okay to Continue with Failed Techniqueswith Failed Techniques

Page 16: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Long-Term IssuesLong-Term Issues

Securing the tubeSecuring the tubeTape vs. tiesTape vs. tiesCommercial devicesCommercial devicesRestraintsRestraints

Page 17: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Long-Term IssuesLong-Term Issues

SedationSedationAgent and administration (drip vs. bolus)Agent and administration (drip vs. bolus)Paralytics?Paralytics?

Ventilator managementVentilator managementWhat if the tube comes out?What if the tube comes out?

Page 18: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

BasicsBasics

PositioningPositioningAdjunctsAdjuncts

OPA - good choice if toleratedOPA - good choice if toleratedNPA - easy to tear mucosaNPA - easy to tear mucosa

Effective BVM use is most important skillEffective BVM use is most important skillGet a good seal (two person better)Get a good seal (two person better)Don’t over ventilateDon’t over ventilate

Don’t forget the suctionDon’t forget the suction

Page 19: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Intubation -Intubation -PreparationPreparation

PreoxygenatePreoxygenateMonitors - ECG, pulse oxMonitors - ECG, pulse oxSellick’sSellick’sGood basicsGood basics

Equipment selectionEquipment selectionMiller vs. MacMiller vs. MacCuffed vs. uncuffedCuffed vs. uncuffedETT sizeETT size

PositioningPositioning

Page 20: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Airway EquipmentAirway Equipment

Straight blade to age 4?Straight blade to age 4?Better able to control epiglottis?Better able to control epiglottis?Choose for comfortChoose for comfort

Smaller tubesSmaller tubesLess stabilityLess stabilityMore resistanceMore resistance

Uncuffed tubes < 8 years of ageUncuffed tubes < 8 years of age

Page 21: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Airway EquipmentAirway Equipment

SuctionSuctionMagill forcepsMagill forcepsStyletStyletTube check and securing devicesTube check and securing devices

Page 22: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Tube SizeTube Size

ETT sizeETT size (Age in years/4) + 4(Age in years/4) + 4Diameter of nareDiameter of nareDiameter of pinkyDiameter of pinkyBroselow tapeBroselow tapeHave one size smaller and largerHave one size smaller and larger

Page 23: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Tube PlacementTube Placement

ETT depth – use the black lineETT depth – use the black line (Age in years/2) + 12(Age in years/2) + 12ETT internal diameter x 3ETT internal diameter x 3

Page 24: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Intubation -Intubation -PositioningPositioning

Goal is to align three axesGoal is to align three axesOA/PA/LAOA/PA/LA

Medical positioningMedical positioningHead tilt chin liftHead tilt chin liftTowels (older = head, younger = shoulders)Towels (older = head, younger = shoulders)

Trauma positioningTrauma positioningManual in-line stabilizationManual in-line stabilization

Page 25: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Positioning-Positioning-MedicalMedical

vs.vs.TraumaTrauma

Adapted from Walls et al. Manual of

Emergency Airway Management.

2nd Ed. 2004.

Page 26: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

PositioningPositioning

Adapted from Walls et al. Manual of

Emergency Airway Management.

2nd Ed. 2004.

Page 27: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Intubation -Intubation -ApproachApproach

Remember, much different than adultsRemember, much different than adultsExternallyExternally

Larger head/occiputLarger head/occiputHead flexes forward and can obstructHead flexes forward and can obstruct

InternallyInternallyLarger tongueLarger tongueFriable tissuesFriable tissuesDifferent angles and shapesDifferent angles and shapes

Page 28: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Airway DifferencesAirway Differences

Nose

Tongue

TracheaCricoidAirway

Page 29: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Adapted from Walls et al. Manual of

Emergency Airway Management.

2nd Ed. 2004.

Page 30: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Airway ShapeAirway Shape

Adapted from Walls et al. Manual of

Emergency Airway Management.

2nd Ed. 2004.

Page 31: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Intubation -Intubation -ApproachApproach

Further differencesFurther differences ““Pinker” vocal cords worsen visualizationPinker” vocal cords worsen visualizationDifferent location of narrowest pointDifferent location of narrowest point

More precise ETT choiceMore precise ETT choiceAir leak vs. trauma/stenosisAir leak vs. trauma/stenosisPeds cuffed tubes?Peds cuffed tubes?

Smaller cricothyroid membraneSmaller cricothyroid membraneNo surgical crics in childrenNo surgical crics in childrenNeedle crics difficultNeedle crics difficult

Page 32: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Other ConsiderationsOther Considerations

More gastric insufflation with BVMMore gastric insufflation with BVMDifferent oxygenation abilitiesDifferent oxygenation abilities

Higher basal usageHigher basal usageLess residual lung capacityLess residual lung capacityQuicker desats during intubationQuicker desats during intubation

10 kg to 90% in <4 minutes (vs. 8 for adult)10 kg to 90% in <4 minutes (vs. 8 for adult)

More likely to have vagal responseMore likely to have vagal response

Page 33: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Intubation -Intubation -TechniquesTechniques

Always enter from the right cornerAlways enter from the right cornerTongue control is criticalTongue control is criticalLift the epiglottis with the MillerLift the epiglottis with the MillerSlide the Mac into the valleculaSlide the Mac into the vallecula

Can lift the epiglottis if neededCan lift the epiglottis if needed

Page 34: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Adapted from Walls et al. Manual of

Emergency Airway Management.

2nd Ed. 2004.

Page 35: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Intubation -Intubation -Trouble-shootingTrouble-shooting

Can’t see the cordsCan’t see the cordsLook for landmarksLook for landmarksControl the tongueControl the tongueBURP maneuver if epiglottis seenBURP maneuver if epiglottis seen

Another attempt needed (limit number)Another attempt needed (limit number)RepositionRepositionChange something (blade, tube)Change something (blade, tube)

Avoid hypoxia Avoid hypoxia

Page 36: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Blind TechniquesBlind Techniques

Exist but need practice for proficiencyExist but need practice for proficiencyDigital intubationDigital intubation

Small work areaSmall work areaBlind nasotracheal intubationBlind nasotracheal intubation

Tough angles for tube placementTough angles for tube placementRemember anatomic differencesRemember anatomic differencesContraindicated until >10 years oldContraindicated until >10 years old

Page 37: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

In general, blind techniques In general, blind techniques not useful in childrennot useful in children

Page 38: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Intubation -Intubation -ConfirmationConfirmation

Visualize tube passing through cordsVisualize tube passing through cordsBreath sounds and epigastric soundsBreath sounds and epigastric soundsEnd Tidal COEnd Tidal CO22 (ETCO (ETCO22))Commercial devicesCommercial devices

Not effective on uncuffed tubesNot effective on uncuffed tubesBe careful if used in childrenBe careful if used in children

Page 39: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

REMINDER: REMINDER: It’s Not Okay to Continue It’s Not Okay to Continue with Failed Techniqueswith Failed Techniques

Page 40: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Rescue DevicesRescue Devices

LMAs (laryngeal mask airway)LMAs (laryngeal mask airway) I-LMAs (intubating LMA)I-LMAs (intubating LMA)CombitubeCombitubeBougieBougiePick one or two and practicePick one or two and practice

Need to be comfortable before crisisNeed to be comfortable before crisis

Page 41: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

LMALMA

Used in any ageUsed in any age Easy to place Easy to place Few complicationsFew complications Contraindications: Contraindications:

Gag reflexGag reflex FBsFBs Airway obstructionAirway obstruction High ventilation pressureHigh ventilation pressure

Does not secure airwayDoes not secure airway

Page 42: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

LMA SizingLMA Sizing

LMA SizeLMA Size Patient SizePatient Size

11 Neonate / Infants < 5 kgNeonate / Infants < 5 kg

1 ½ 1 ½ Infants 5-10 kgInfants 5-10 kg

22 Infants / Children 10-20 kgInfants / Children 10-20 kg

2 ½ 2 ½ Children 20-30 kgChildren 20-30 kg

33 Children/Small adults 30-50 kgChildren/Small adults 30-50 kg

44 Adults 50-70 kgAdults 50-70 kg

55 Large adult >70 kgLarge adult >70 kg

Page 43: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.
Page 44: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

I-LMAI-LMA

Only sizes 3, 4, 5Only sizes 3, 4, 5 Same rules and sizing Same rules and sizing

as LMAas LMA Need special armored Need special armored

tube for intubationtube for intubation New similar devices New similar devices

existexist Leave LMA portion in Leave LMA portion in

place in fieldplace in field

Page 45: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

CombitubeCombitube

Two sizesTwo sizes Small (4 to 5.5 feet tall)Small (4 to 5.5 feet tall) Regular (over 5.5 feet tall)Regular (over 5.5 feet tall) Not useful in most kidsNot useful in most kids

Easy to placeEasy to place ContraindicationsContraindications

Gag reflexGag reflex Esophageal diseaseEsophageal disease Caustic ingestionsCaustic ingestions FBs/Airway obstructionFBs/Airway obstruction

Page 46: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

BougieBougie

Replaces styletReplaces stylet Able to use with poor Able to use with poor

viewview Feel tracheal ringsFeel tracheal rings Feel carinaFeel carina

Intubate over itIntubate over it Keep blade in placeKeep blade in place Two person techniqueTwo person technique

Need to practiceNeed to practice

Page 47: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Other ToysOther Toys

Lighted styletLighted stylet Flexible fiberoptic Flexible fiberoptic

scopesscopes Rigid fiberoptic Rigid fiberoptic

scopesscopes BullardBullard ShikaniShikani

Video laryngoscopyVideo laryngoscopy

Page 48: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Surgical Airways -Surgical Airways -CricothyrotomyCricothyrotomy

Indications (only if >10 years old)Indications (only if >10 years old)Failed airwayFailed airwayFailed ventilationFailed ventilation

Predictors of difficultyPredictors of difficultyPrevious neck surgeryPrevious neck surgeryObesityObesityHematoma or infectionHematoma or infection

Page 49: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Cricothyrotomy -Cricothyrotomy -TechniquesTechniques

OpenOpen Locate CTMLocate CTM Stabilize larynx/prepStabilize larynx/prep Incise skinIncise skin

VerticalVertical Horizontal through CTMHorizontal through CTM

Insert spacer/dilatorInsert spacer/dilator Insert cuffed tubeInsert cuffed tube Check breath soundsCheck breath sounds

ClosedClosed Locate CTMLocate CTM Stabilize larynx/prepStabilize larynx/prep Insert needleInsert needle

Direct inferiorlyDirect inferiorly Insert guidewireInsert guidewire Remove needleRemove needle

Small skin incisionSmall skin incision Insert dilators/UC tubeInsert dilators/UC tube Check breath soundsCheck breath sounds

Page 50: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Cricothyrotomy -Cricothyrotomy -ComplicationsComplications

BleedingBleedingLaryngeal or tracheal injuryLaryngeal or tracheal injury InfectionInfectionPneumomediastinumPneumomediastinumSubglottic stenosisSubglottic stenosis

Page 51: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Surgical Airways -Surgical Airways -Needle CricNeedle Cric

Same indications (all ages, tougher if young)Same indications (all ages, tougher if young)Must use with TTJV (jet ventilator)Must use with TTJV (jet ventilator)

Cannot use with superior airway obstructionCannot use with superior airway obstructionSimilarly difficult patientsSimilarly difficult patients

Page 52: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Needle Cricothyrotomy -Needle Cricothyrotomy -ProcedureProcedure

Identify CTM and stabilize/prep larynxIdentify CTM and stabilize/prep larynx Insert needle on syringe, direct inferiorlyInsert needle on syringe, direct inferiorly

Large bore needle (12-16 gauge)Large bore needle (12-16 gauge)Catheter over needleCatheter over needle

Advance catheterAdvance catheter Connect to TTJV (BVM for infants - 3.0 ETT)Connect to TTJV (BVM for infants - 3.0 ETT)

Oxygen pressure (20-30 psi)Oxygen pressure (20-30 psi)1 second on/2-3 seconds off1 second on/2-3 seconds off

Page 53: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Needle Cricothyrotomy -Needle Cricothyrotomy -ComplicationsComplications

Similar complications to other cricsSimilar complications to other cricsPneumothorax/subcutaneous emphysemaPneumothorax/subcutaneous emphysemaBarotraumaBarotraumaEsophageal injuryEsophageal injuryObstructionObstruction

Page 54: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

TTJVTTJV

Page 55: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

What About RSI?What About RSI?

Page 56: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Rapid Sequence IntubationRapid Sequence Intubation

Does increase intubation successDoes increase intubation successYou stop intrinsic breathingYou stop intrinsic breathing

You can kill themYou can kill themLittle place for peds in prehospital settingLittle place for peds in prehospital setting

Page 57: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

RSI MedicationsRSI Medications

Same as adultsSame as adultsLidocaine Lidocaine EtomidateEtomidateSuccinylcholineSuccinylcholineVecuroniumVecuronium

Remember atropineRemember atropineConsider ketamineConsider ketamine

Page 58: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Pretreatment - Pretreatment - LidocaineLidocaine

Mechanism: Decrease ICP, bronchospasmMechanism: Decrease ICP, bronchospasm Indications: Asthma, head injuryIndications: Asthma, head injuryContraindications: AllergyContraindications: AllergyDosage: 1.5 mg/kg 3 minutes before ETTDosage: 1.5 mg/kg 3 minutes before ETT

Page 59: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Pretreatment -Pretreatment -AtropineAtropine

Mechanism: Blunt vagal responseMechanism: Blunt vagal responsePrevent bradycardia from intubationPrevent bradycardia from intubationMore prevalent in childrenMore prevalent in children

Indications: All children <10 years oldIndications: All children <10 years oldContraindications: AllergyContraindications: AllergyDosage: 0.02 mg/kg 3 minutes before ETTDosage: 0.02 mg/kg 3 minutes before ETT

Page 60: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Induction -Induction -EtomidateEtomidate

Mechanism: Hypnotic, not analgesicMechanism: Hypnotic, not analgesicMost hemodynamically stableMost hemodynamically stable Inhibits excitationInhibits excitation

Indications: All inductionsIndications: All inductionsLess protection from bronchospasmLess protection from bronchospasmNo ICP issuesNo ICP issues

Contraindications: None (careful in shock)Contraindications: None (careful in shock)Dosage: 0.3 mg/kg for induction (15-45 sec)Dosage: 0.3 mg/kg for induction (15-45 sec)

Page 61: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Induction -Induction -KetamineKetamine

Mechanism: PCP derivativeMechanism: PCP derivativeAnalgesia, anesthesia, amnesiaAnalgesia, anesthesia, amnesiaLittle respiratory or hemodynamic effectLittle respiratory or hemodynamic effect Increases cerebral oxygen demandIncreases cerebral oxygen demand

Indications: RAD, children?, hemodynamicsIndications: RAD, children?, hemodynamicsContraindications: Contraindications:

Elevated ICP (worsens)Elevated ICP (worsens)Re-emergence in adults (hallucinations)Re-emergence in adults (hallucinations)

Dosage: 1-2 mg/kg for induction (45-60 sec)Dosage: 1-2 mg/kg for induction (45-60 sec)

Page 62: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Paralysis -Paralysis -SuccinylcholineSuccinylcholine

Mechanism: Depolarizing agentMechanism: Depolarizing agentBinds to NMJ and firesBinds to NMJ and fires

Indications: Paralysis w/ fasciculationIndications: Paralysis w/ fasciculationContraindications/Complications: Contraindications/Complications:

Hyperkalemia (Burns, crush, renal failure)Hyperkalemia (Burns, crush, renal failure) Increased ICP, globe injuryIncreased ICP, globe injuryProlonged blockade, MHProlonged blockade, MH

Dosage: 1.5-2 mg/kg (2 for younger)Dosage: 1.5-2 mg/kg (2 for younger)Rapid onset, brief duration (30 secs – 4 min)Rapid onset, brief duration (30 secs – 4 min)

Page 63: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Paralysis -Paralysis -VecuroniumVecuronium

Mechanism: Nondepolarizing agentMechanism: Nondepolarizing agentCompetitive blockade at NMJCompetitive blockade at NMJ

Indications: Indications: Pretreatment before SCh (no fasciculations)Pretreatment before SCh (no fasciculations)ParalysisParalysis

Contraindications: None (difficult airway)Contraindications: None (difficult airway)Dosage: 0.1-0.15 mg/kg in 90-120 secsDosage: 0.1-0.15 mg/kg in 90-120 secs

Lasts 60 minutesLasts 60 minutes1/101/10thth dose for pretreatment dose for pretreatment

Page 64: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Ventilator ManagementVentilator Management

Pressure vs. volume controlPressure vs. volume controlDepends on patientDepends on patientNeed to reassessNeed to reassess

Tidal volumes 8-10 mL/kgTidal volumes 8-10 mL/kgSimilar to adultSimilar to adultAgain, adjust according to patientAgain, adjust according to patient

Titrate other settingsTitrate other settingsLast resorts: HFOV, ECMOLast resorts: HFOV, ECMO

Page 65: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Ventilator ManagementVentilator Management

Volume control (constant volume)Volume control (constant volume)Set Rate and Tidal VolumeSet Rate and Tidal VolumeSet PEEP (Set PEEP (~~5) & Pressure Support5) & Pressure Support

Pressure control (constant pressure)Pressure control (constant pressure)Set Rate and PIP (20-25)Set Rate and PIP (20-25)Set PEEPSet PEEP

All settings require FIOAll settings require FIO22

Page 66: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Ventilator ManagementVentilator Management

To alter OTo alter O22

Change FIOChange FIO22

Change PEEPChange PEEPChange I:E ratioChange I:E ratio

To alter COTo alter CO22

Change rateChange rateChange tidal volume (or PIP)Change tidal volume (or PIP)

Page 67: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Ventilator ManagementVentilator Management

CPAP and BiPAPCPAP and BiPAPNot much use in younger childrenNot much use in younger childrenNeed to be able to comply with treatmentNeed to be able to comply with treatmentGood modalities in some settingsGood modalities in some settingsRarely (if ever) useful in prehospital settingRarely (if ever) useful in prehospital setting

Page 68: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Last but not least…Last but not least…

Page 69: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Broselow TapeBroselow Tape

Lubitz, et al. (1998)Lubitz, et al. (1998) Most accurate 3.5 - 25 kgMost accurate 3.5 - 25 kg More accurate than RN or MDMore accurate than RN or MD 94% vs 63%94% vs 63%

Page 70: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Broselow TapeBroselow Tape

Rowe, et al. (1998)Rowe, et al. (1998) Calculation error rate 3%Calculation error rate 3% Recheck increases to 10%Recheck increases to 10% Under stress, up to 25%Under stress, up to 25%

Page 71: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Broselow TapeBroselow Tape

Equipment sizesEquipment sizes Airway adjunctsAirway adjuncts Intubation equipIntubation equip Oxygen deliveryOxygen delivery Vascular accessVascular access DefibrillationDefibrillation NGT, suction cathsNGT, suction caths BP cuffBP cuff Chest tubesChest tubes FoleyFoley

MedicationsMedications AntiarrhythmicsAntiarrhythmics Arrest medicationsArrest medications AnticonvulsantsAnticonvulsants Overdose medsOverdose meds Increased ICP medsIncreased ICP meds Induction agentsInduction agents ParalyticsParalytics VasopressorsVasopressors IV dripsIV drips

Page 72: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Broselow TapeBroselow Tape

Page 73: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Broselow TapeBroselow Tape

8 color codes (6-36 kg)8 color codes (6-36 kg) Broselow-Luten Emergency Broselow-Luten Emergency

SystemSystem Color-coded bags with equipColor-coded bags with equip Quicker, more efficientQuicker, more efficient

Page 74: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

SummarySummary

Think carefully about your goalsThink carefully about your goalsAssess your optionsAssess your optionsGood BLS is the most important skillGood BLS is the most important skill Intubate or not?Intubate or not?Have a back-up planHave a back-up planUse your BroselowUse your Broselow

Page 75: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

Questions?Questions?

Page 76: Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments.

ReferencesReferences Gausche M, et al. Effect of out-of-hospital pediatric endotracheal intubation Gausche M, et al. Effect of out-of-hospital pediatric endotracheal intubation

on survival and neurologic outcome. on survival and neurologic outcome. JAMAJAMA. 2000. 283(6): 783-790.. 2000. 283(6): 783-790. Gilligan BP, et al. Pediatric Resuscitation. In Gilligan BP, et al. Pediatric Resuscitation. In Rosen’s Emergency Medicine: Rosen’s Emergency Medicine:

Concepts and Clinical PracticeConcepts and Clinical Practice, 6, 6thth Ed Ed. Mosby, 2006.. Mosby, 2006. Hazinski MF, et al (Ed). Hazinski MF, et al (Ed). PALS provider manualPALS provider manual. AHA, 2005. . AHA, 2005. Lee BS, et al. Pediatric airway management. Lee BS, et al. Pediatric airway management. Clin Ped Emerg MedClin Ped Emerg Med. 2001. . 2001.

2(2): 91-106.2(2): 91-106. Lubitz DS. A rapid method of estimating weight and resuscitation drug Lubitz DS. A rapid method of estimating weight and resuscitation drug

doses from length in the pediatric age group. doses from length in the pediatric age group. Ann Emerg MedAnn Emerg Med.. 1998. 1998. 17(6):576-581.17(6):576-581.

Luten R. Error and time delay in pediatric trauma resuscitation: Addressing Luten R. Error and time delay in pediatric trauma resuscitation: Addressing the problem with color-coded resuscitation aids. the problem with color-coded resuscitation aids. Surg Clin of N AmerSurg Clin of N Amer. 2002. . 2002. 82(2).82(2).

Luten RC. The pediatric patient. In Luten RC. The pediatric patient. In Manual of Emergency Airway Manual of Emergency Airway Management, 2Management, 2ndnd Ed Ed. Lippincott, 2004.. Lippincott, 2004.

Tobias JD. Airway management for pediatric emergencies. Tobias JD. Airway management for pediatric emergencies. Pediatric AnnalsPediatric Annals. . 1996; 25:317-281996; 25:317-28


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