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#8Essential Emergency Airway Care-

Paediatric Considerations-Anatomic, physiological, dosing, and equipment issues

Andrew Brainard, MD, MPH, FACEM, FACEPhttp://www.thesharpend.org/

abrainard01@gmail.com

# 8 RSI of paediatric pt• Learning Objectives:

• Prep team/plan/room/equipment• Mask seal, BVM, adjuncts, suction• Pre and apnoeic oxygenation• Pt positioning

– Airway assessment and plan• MOANS/LEMON• Announce “pullout criteria”• Briefing for Plan A, B, C, & D

– Use Paed Drug Calculator– Correctly Sizes equipment – Correct RSI drugs and dosage

• Completes FINAL airway checklist– Call and response– <1 min

– Direct/Video laryngoscopy • Proper Technique• Advantages/disadvantages • Difficulties• Contraindications

– Complete Airway Audit Form

• R40: 1 y/o lethargic• 2 days of fever, cough, dyspnea• GCS 4, SaO2 88%, P 210, RR 80, BP

100/70 Temp 41, Glucose 10

– On arrival• Same as above • (SaO2 91% w/ O2 BVM)• LEMON shows:

– No blood in airway, normal 3-3-2, snoring

– Consultant suggests RSI• Patient can only be intubated using

– Sedation and Paralysis– Optimal pre and apnoeic O2 and

positioning– Suction– Properly sized equipment and

dosages

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Anatomy and physiology

• Quick to Desaturate• Large head:

– Place roll under shoulders for level ear-to-sternal notch

• Large tongue: – Jaw thrust, difficulty clearing tongue with blade

• Long flexible epiglottis: – Directly lift the epiglottis with the tip of blade

• Cricothyoid cartilage is smallest diameter: – Foreign body obstruction occurs below the

larynx• Soft tracheal cartilage

– Positive pressure ventilation can open airway, cricoid pressure in contraindicated.

• Small airways – Can quickly swell closed– Dramatic changes with oedema

• Short Trachea– Blade is frequently advanced to far– Frequent mainstem intubation

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Pharmacological and equipment• RSI Drugs: use a dosage calculator!!!,

• Sedation – Etomidate (0.3mg/kg) – Fentanyl (5-10mcg/kg) – Ketamine (0.5-2mg/kg)– Propofol (0.15-3mg/kg)

• Midazolam (0.1-0.3 mg/kg)

– Thiopental (0.15-3mg/kg)• Paralysis

– Rocuronium (1.2mg/kg) – Succinylcholine (1-2-2mg/kg for infant, 2-3mg/kg for neonate)

• Know contraindications

• Premedication:– Atropine:

• APLS recommends atropine if: <1 year (1-5y/o if using suxamethonium) and patients who receive a second dose of suxamethonium

• Routine premedication with atropine in absence of bradycardia is not evidence based and is no longer recommended.

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EquipmentSizing of equipment (use a memory aid!!!)– Straight blade under 3 y/o– Video laryngoscopy can provide a better

view– ETT tubes

• Predicted cuffed ET Tube = (Age /4) + 3.5– (either cuffed and uncuffed tubes can be used)

• Predicted uncuffed ET Tube = (Age / 4) + 4 – 1kg = 2.5, 2kg = 3.0, 3kg = 3.0-3.5, >3kg =3.5– 1y/o = 4.0

• Distance to lip = 3x ETT size• Adjuncts– NPA- nare-to-ear or size of little finger– OPA- mouth-to-ear against patient’s face

• Paediatric bougie• Mask Sizing• Nasal apnoeic oxygen at 2-10 lpm

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MMH ED Pt Age/Weight -Based Equipment Suggestions

On Resus 5 & 6 airway carts

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Major differences in airway management? • Desaturation is more rapid• Needle cricothyroidotomy is

recommended over surgical cricothyroidotomy– APLS suggests <12y/o– Some say <6y/o– Others say <3y/o (AKA: it depends)

• Manufactured needle cricothyrotomy kits are superior to improvised cric kits

Paed Intubationhttp://emupdates.com/2011/05/24/12-minute-screencast-pediatric-airway-for-emergency-physicians-who-are-not-also-pediatricians/ (12min)

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Airway briefing and checklist• We have a 1 y/o child with pneumonia and hypoxia.

• We need to intubate her to improve her ventilation.

• Based on our airway assessment, it is appropriate to intubate this 1 year old 10kg child.

• We have the correct wt based doses of 50mcg of fentanyl and 20mg of Sux.

• The team will be:•I’ll be team leader •Linda as primary airway operator •I’ll be the backup airway operator •Joyce as airway assistant•James also push the drugs

• Our plan is:•A- #1 Straight blade/#4 uncuffed tube w/ sylet•B- #2 straight blade/bougie/#3.5 uncuffed tube•C- LMA size “2”•D- Needle Cric for Sats <80% and dropping

• We will pullout if SaO2 drops below 93% or if we can’t see anything after 1 minute and re-oxygenate

• Everyone understand their roles?

• Questions or suggestions?

• Is everyone ready to complete the checklist in less than a minute?

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AndyLindaAndy

Andy

JoyceJoyce- Bimanual

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Brief Paediatric References:• Reuben Strayer. Emergency Medicine Updates (http://emupdates.com). 12 minute

screencast: pediatric airway for emergency physicians who are not also pediatricians http://emupdates.com/2011/05/24/12-minute-screencast-pediatric-airway-for-emergency-physicians-who-are-not-also-pediatricians/

• Eric R Schmitt, Marianne Gausche-Hill, Advanced Pediatric Airway Management—Updates and Controversies. Emergency Medicine & Critical Care , 2011;5:21-27 (Accessed on 18/03/2013)

• Nagler J, Bachur RG. Advanced airway management. Curr Opin Pediatr. 2009 Jun;21(3):299-305.

• Ching KY, Baum CR: Newer agents for rapid sequence intubation. Pediatr Emerg Care 2009;25:200-210.

• The Difficult Airway Society Paeditric Guidelines:

http://www.das.uk.com/content/paediatric-difficult-airway-guidelines (Accessed on 20/03/2013)