Download Ron Brown - North Region EMS

Pediatric Airway
Management
SNOHOMISH COUNTY EMS
OBJECTIVES
 Anatomy
 Physiology
 Equipment
 Establish respiratory distress present
 Technique
 Post intubation management
 Pitfalls and Pearls
 Difficult airway
ANATOMY
 Unique <2 years old
 Approaches normal adult airway by 8 years old
 Glottic opening high and anterior
 C1, transitions to C3/4, then C5/6 by adulthood
 More soft tissue, less tone
Consider copying fig 20-2
p 270 here
ANATOMY
 Large tongue in relation to oral cavity
 Large tonsils and adenoids that can bleed (no
blind nasotracheal intubations)
 Angle of epiglottis to laryngeal opening more
acute
ANATOMY
 Large occiput/cranium flexes the neck
 Avoid further neck flexion
 Use sniffing position
 Neck flexed, head extended
ANATOMY
 Small cricothyroid membrane
 <3-4 years old almost nonexistant
 >8 similar to adults
 No surgical cricothyroidotomy <8
 Cricoid ring most narrow part of airway (below
vocal cords)
PHYSIOLOGY
 Smaller floppy upper airway more likely to
obstruct and more susceptible to swelling
 Resistance is inversely proportional to
radius
 R  1/r4th power
 Small decrease in airway size=large
increase in airway resistance
PHYSIOLOGY
 Crying increases the work of breathing 32
times
 Basal O2 requirement 2x that of adults
 FRC (functional residual capacity) 40% of
adults
 Only half the alveoli of adults
 Overall, less reserve and faster desaturations
EQUIPMENT
 Length based systems
 Decrease errors
 Eliminate remembering and completing
mathematical equations
 Organize equipment
BROSELOW SYSTEM
EQUIPMENT
 Self inflating bags smallest 450ml
 Pop off valves that may have to be closed
 Newborn equipment different than peds (0
blades, <50mm oral airways, 250ml BVM, 3-0
tubes)
RESPIRATORY
DISTRESS
 Rapid 30 second assessment





T one
I nteractive
C onsolablity
L ook/track
S peech/cry
RESPIRATORY
DISTRESS
 Altered mental status
 Nasal flaring
 Head bobbing
 Accessory muscle use
 Grunting
RESPIRATORY
DISTRESS
 You must undress the patient
 Retractions




Substernal
Intercostal
Supraclavicular
Suprasternal
RESPIRATORY
DISTRESS
 Infants are nose breathers
 Secretions can impeded air flow
 Bulb syringe nasal suction may alleviate this
RESPIRATORY FAILURE
 Impending respiratory arrest





All of the above signs diminish
Respiratory rate diminishes
Mental status diminishes
Child becomes quiet
Mottling may develop
TECHNIQUE
MEDICATIONS
 Succinylcholine
 Dose higher at 1.5mg/kg
 Etomidate
 0.3mg/kg
 Fentanyl
 1-3mcg/kg consider for age >10 and head injury
TECHNIQUE
MEDICATIONS
 Vecuronium
 0.1mg/kg
 Rocuronium
 1mg/kg
TECHNIQUE
MEDICATIONS
 Atropine
 Routine use not recommended
 Should be available and prepared in case it is
needed (more common in children <1)
 0.02mg/kg
TECHNIQUE HEAD
POSITION
 Sniffing position
 Slight anterior displacement of neck (pulling chin
up)
 Small infants may require elevation of shoulders
with a towel to counteract a large occiput flexing
head
 Older children may require a towel under the
head
 Goal is to align ear canal anterior to shoulders
 Head tilt chin lift or Jaw thrust (trauma
patients)
Picture Fig 21-1 page
284
TECHNIQUE OXYGEN
SUPPLEMTATION
 Oxygen may be delivered by
 Blow by
 Nasal cannula
 Face mask
 Forcing the child to struggle with nasal
cannula oxygen increase oxygen demand
 Blow by may suffice
TECHNIQUE BVM
 BVM alone may suffice for short
transports
 Pediatric airway obstruction usually
amenable to BVM
 The extra thoracic trachea is collapsible in
children, so with increased negative pressure
from inspiration during obstruction,
obstruction may become worse and BVM may
help
TECHNIQUE BVM
 Don’t compress submental tissue
 Hold angle of mandible
 Use C-Clamp technique (solo)
 Use 2 providers when possible
 Don’t put pressure on eyes (causes vagal
response)
TECHNIQUE BVM
 Normal tidal volume 8-10ml/kg
 Watch for adequate chest rise
 Squeeze-Release-Release to allow for
exhalation
 Only use enough force to see chest rise
 8-10 BPM code, 12-20 alive (monitor end
tidal CO2)
TECHNIQUE BVM
 Avoid gastric insufflation
 Avoid excessive peak inspiratory pressure
 Ventilate slowly and watch for chest rise
 Slight cricoid pressure (excessive will compress
trachea in peds)
TECHNIQUE BLADES
 Follow Broselow guide
 Miller straight blade better until about age 5
 Lifts disproportionately large epiglottis out of
way
TECHNIQUE CRICOID
PRESSURE
 Insufficient evidence to routinely recommend
cricoid pressure during intubation (as opposed to
BVM)
TECHNIQUE LAYNGEAL
MANIPULATION
 Use as needed
 Frequently:




B ackward
U pward
R ightward
P ressure
TECHNIQUE TUBES
 Use Broselow guide
 Be prepared with tubes 0.5mm larger and
smaller
 Narrowest part of airway is below cords
 If tight, use smaller tube
 If large air leak, use larger tube or same
size tube with cuff
 Small air leak, no worries if adequate
chest rise, O2 sat, end tidal CO2
TECHNIQUE TUBES
 Cuffed tubes
 Are OK
 Cuff pressure needs to be monitored (20-25cm
water)
 Don’t have to be inflated
 In general, go a size smaller if using cuffed
tube for size <6.0
 Too large a tube/too high cuff
pressure)=laryngeal tracheal stenosis
which can develop rapidly
TECHNIQUE TUBES
 Tube insertion depth
 Follow Broselow
 3x size of tube (4.0 ETT=12cm insertion length
at teeth)
 Secure tube, immobilize neck, as short
trachea predisposes to moving tube too
far in with neck flexion, and out with neck
extension
TECHNIQUE CONFIRM
PLACEMENT
 Tube fogging
 B/L breath sounds
 Silent epigastrum
 End Tidal CO2
 Pulse ox
TECHNIQUE END
TIDAL CO2
 Peds detectors up to 15kg (adult detectors have
too much dead space in circuit)
 Adult detectors over 15kg (peds detectors will
cause too much resistance
TECHNIQUE END
TIDAL CO2
 In cardiac arrest:
 If <10-15mmHg, focus on improving CPR and
avoid over ventilation
 An abrupt and sustained increase may signal
return of spontaneous circulation
 In non arrest:
 Titrate to clinical condition (35-45 unless head
injury/impending herniation 25-30)
POST INTUBATION
MANAGEMENT
 Adequate sedation
 Benzodiazepines
 Diazepam 0.2mg/kg (max 10mg/dose)
 Lorazepam 0.05mg/kg (max 2mg/dose)
 Midazolam 0.1mg/kg (max 2mg/dose)
 Opiates
 Fentanyl 1-3mcg/kg (max 50mcg/dose)
 Morphine 0.05-0.2mg/kg (max 5mg/dose)
 Paralytics as needed
 Rocuronium 1mg/kg
 Vecuronium 0.1mg/kg
POST INTUBATION
MANAGEMENT
 Problems




D isplacement of tube (confirm placement)
O obstruction of tube (pass suction catheter)
P neumothorax
E quipment failure (unhook from vent, check O2)
PITFALLS AND PEARLS
 Performance anxiety
 Equipment stocking and testing
 Troubleshooting
 Periodic training and practice
DIFFICULT AIRWAY
 Infectious disease causes
 Noninfectious causes including trauma
 Congenital abnormalities
DIFFICULT AIRWAY
INFECTIOUS DISEASE
 Epiglottitis
 Croup
 Retropharyngeal abscess
 Bacterial Tracheitis
 Ludwig’s angina
DIFFICULT AIRWAY
INFECTIOUS DISEASE
 Small changes in airway diameter have a large
impact on airway resistance
 Crying increases work of breathing 32 times
 Don’t “over treat”
EPIGLOTTITIS
 If stable, leave patient with parent in position of
comfort
 2 person bag valve mask ventilation can be
sufficient
 If needed, intubation can be attempted with a
smaller than predicted tube
 Push on chest to try to see bubbles coming from
airway if visualization obstructed
 One of the few indications for needle
cricothyrotomy if all else fails
CROUP
 Subglottic narrowing
 Tube may fit through cords, but then get snug
 Use smaller than expected tube
 BVM can work, but requires 2 people and possible
high pressure
DIFFICULT AIRWAY
NONINFECTIOUS DISEASE
 Foreign body
 Burns
 Anaphylaxis
 Caustic ingestion
 Trauma
FOREIGN BODY
 Conscious



Consider doing nothing if patient stable
Back blows less than age 1 year
Heimlich (age greater than 1)
 Unconscious
 BVM may work
 Direct laryngoscopy
 Removal of object
 Push it down and move the tube back to normal position
 Needle cricothyrotomy will only work if obstruction is
above the cricothyrotomy level (you should see it but
can’t remove it)
BURNS, ANAPHYLAXIS,
CAUSTIC INGESTIONS,
TRAUMA
 If condition is decompensating and/or not
responding to treatment, consider early
intervention
 Should consider medications first in anaphylaxis
CONGENITAL
ABNORMALITITES
 Don’t try unless you have to
 May be more reasonable to support until
respiratory failure/arrest has occurred
 Treat for causes of respiratory distress
CONGENITAL
ABNORMALITITES
MICROGNATHIA
 Small mandible reduces the space to which the
tongue and soft tissue can be displaced out of
your way
DIFFICULT AIRWAY
ADJUNCTS
 LMA
 Needle cricothyrotomy
 Combitube/King LT
DIFFICULT AIRWAY
LMA
 Can be used in all ages
 In small infants more complications
 Causes obstruction with relatively large
epiglottis
 Easy to lose adequate seal with movement
 Air leaks
 Recommend inserting upside down and
rotating it as advanced back
 Not for foreign bodies, caustics, burns
NEEDLE
CRICOTHYROTOMY
 For use when you cant intubate or ventilate
 For use in children <8-10 years old
 Not helpful for croup or distal foreign bodies
NEEDLE
CRICOTHYROTOMY
 Extend head, towel under shoulders
 Identify landmarks
 Insert catheter (14g) over the needle at a
30 degree angle directed toward feet
 Aspirate air
 Slide catheter off needle and remove
needle
 Attach 3mm ETT adapter and begin BV
NEEDLE
CRICOTHYROTOMY
 Will require excessive force due to small
catheter diameter
 Pop off valve should be disabled
 Does not protect airway
 Does not allow for adequate ventilation, only
oxygenation
NEEDLE
CRICOTHYROTOMY
 Complications




Inappropriate needle placement
Inadequate ventilation (hypercarbia and acidosis)
Obstruction of small catheter
Subcutaneous emphysema
NEEDLE
CRICOTHYROTOMY
 TTV
 For use >5 years
 Supraglottic patency required to allow for
exhalation (air stacking)
 Barotrauma
 Start with 20 PSI and adjust to chest rise
 Requires no more than of 1 second inspiration,
then 3 seconds to exhale
 Nasal/oral airway should be placed as well
COMBITUBE/KING LT
 Double/single lumen tube designed to be place in
esophagus
 Must be 4ft tall for small Combitube
 May not protect against aspiration
 Not for caustic ingestion or significant
esophageal pathology