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Pediatric Airway Management Sunsiree Santana MD Pediatric Critical Care

Airway management

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Page 1: Airway management

Pediatric Airway Management

Sunsiree Santana MD

Pediatric Critical Care

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Epidemiology of cardiac arrest in children

Approximately 16,000 American children suffer cardiac arrest each year

Incidence of 20/100,000 children One half younger than 1 year of age 76% younger than 4 years Male predominance

Ann Energ Med .1999 Ann Energ Med .1999

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Etiologies

SIDS

Trauma

Submersion

Cardiac diagnosis

Sepsis

Asphyxia

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Almost all pediatric “codes” are of respiratory origin

Internal Data. B.C. Children’s Hospital, Vancouver. 1989.Internal Data. B.C. Children’s Hospital, Vancouver. 1989.

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Pediatric cardiac arrest

Most often secondary to evolving respiratory failure, with cardiac arrest resulting from lack of cellular substrate rather than from a sudden cardiac event.

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The ABC’s of CPR

Asses responsiveness

If no response open the airway: look, listen and feel for breathing

If no breathing: give 2 rescue breaths

Asses for signs of circulation

If no signs of circulation begin chest compressions

Continue “pump and blow” for 1 min

911

PALS Provider Manual. AHA .2002

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Airway

• Stabilization of airway is of primary importance during the initial resuscitation of the critically or injured child.

• No matter the cause or underlying condition, further attempts at resuscitation or treatment will fail without proper control of the airway.

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Goals of airway management

• Relieve anatomic obstruction

• Prevent aspiration of gastric contents

• Promote adequate gas exchange

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Airway management

1. Proper positioning of the head

– Protection of cervical spine

– The most common cause of airway obstruction in children: collapse of the tongue and soft tissues

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Proper head positioning

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Head positioning

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““Sniffing Position”Sniffing Position”

In the child older than 2 In the child older than 2 yearsyears

Towel is placed under the Towel is placed under the headhead

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Airway adjuncts

• Nasopharyngeal airway– Used if the patient is semiconscious

• Oral airway

• Relieve obstruction by lifting the tongue from the soft tissues of the posterior pharynx

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Nasopharyngeal Airway

Contraindications:Contraindications: Basilar skull Basilar skull

fracturefracture CSF leakCSF leak CoagulopathyCoagulopathy

Length: Nostril to TragusLength: Nostril to TragusLength: Nostril to TragusLength: Nostril to Tragus

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Oral Airways

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Adjuncts: Oral Airway

Correct sizeCorrect size

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Adjuncts: Oral Airway

Wrong size: Too ShortWrong size: Too Short

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Adjuncts: Oral Airway

Wrong size: Too LongWrong size: Too Long

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Tracheal intubation

• Indications– Respiratory failure– Upper airway obstruction– Shock or hemodynamic instability– Neuromuscular weakness– Absent protective airway reflexes– Cardiac arrest (drugs administration)

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Signs of Respiratory Failure

• Tachypnea• Tachycardia• Grunting • Stridor• Head bobbing• Flaring• Inability to lie

down• Agitation

• RetractionsRetractions• Access musclesAccess muscles• WheezingWheezing• SweatingSweating• Prolonged Prolonged

expirationexpiration• ApneaApnea• CyanosisCyanosis

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Anatomy

Children are very different than adults !!!Children are very different than adults !!!

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Anatomy

• Tongue

• Larynx• High position

• Infants : C2-C3• Adults: C4-C5

• Anterior position

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• Tracheal intubation requires the alignment of 3 axes:– Oral axis– Pharyngeal axis– Laryngeal axis

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Anatomy : Epiglottis

• Relatively large size in children– Short, narrow

• Floppy – not much cartilage

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Laryngoscope Blades

Macintosh

Miller

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Intubation Technique

Straight Laryngoscope Blade – used to Straight Laryngoscope Blade – used to pick up the epiglottispick up the epiglottis

Better in Better in younger children younger children with a floppy with a floppy epiglottisepiglottis

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Intubation Technique

Curved Laryngoscope Blade – placed in the Curved Laryngoscope Blade – placed in the valleculavallecula

Better in Better in older children older children who have a who have a stiff epiglottisstiff epiglottis

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Anatomy : Larynx

Narrowest point = cricoid cartilage in the child

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Intubation

• Larynx cephalad and anterior in children

– Practitioner may need to be lower than patient and look up

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Intubation

AgeAge kgkg ETTETT Length (lip) Length (lip)

NewbornNewborn 3.53.5 3.53.5 993 mos3 mos 6.06.0 3.53.5 10101 yr1 yr 1010 4.04.0 11112 yrs2 yrs 1212 4.54.5 1212

Children > 2 years:Children > 2 years:ETT size: ETT size: Age/4 + 4Age/4 + 4ETT depth (lip): ETT depth (lip): Age/2 + 12Age/2 + 12

Children > 2 years:Children > 2 years:ETT size: ETT size: Age/4 + 4Age/4 + 4ETT depth (lip): ETT depth (lip): Age/2 + 12Age/2 + 12

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Technique: Intubation

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Critically ill or injured child should be assumed to have a full stomach and are at risk for

regurgitation and aspiration of gastric content.

Rapid sequence intubation

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Rapid sequence intubation

• Keys

1. Pre-oxygenation

2. Sellick’s maneuver

3. Medications

Rapid-acting neuromuscular blocker

Sedation

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Medications

Benzodiazepines

Midazolam (Versed): 0.1-0.2mg/kg

Narcotics

Fentanyl : 1-2 mg/kg

Morphine: 0.1mg/kg

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Medications

Ketamine: 1mg/kgBronchodilatorIncreases BP, cerebral blood flow & ICP

EtomidateThiopentalNeuromuscular blocking agents

Vecuronium(Norcuron): 0.1mg/kg

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Deterioration after intubation

• Displaced tube

• Obstructed tube

• Pneumothorax

• Equipment

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Thanks!