pediatric airway management l.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Pediatric Airway Management PowerPoint Presentation
Download Presentation
Pediatric Airway Management

Loading in 2 Seconds...

play fullscreen
1 / 74

Pediatric Airway Management - PowerPoint PPT Presentation


  • 311 Views
  • Uploaded on

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

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Pediatric Airway Management' - bono


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
pediatric airway management

Pediatric AirwayManagement

SNOHOMISH COUNTY EMS

objectives
OBJECTIVES
  • Anatomy
  • Physiology
  • Equipment
  • Establish respiratory distress present
  • Technique
  • Post intubation management
  • Pitfalls and Pearls
  • Difficult airway
anatomy
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
anatomy5
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
anatomy6
ANATOMY
  • Large occiput/cranium flexes the neck
    • Avoid further neck flexion
  • Use sniffing position
    • Neck flexed, head extended
anatomy8
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
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
physiology10
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
EQUIPMENT
  • Length based systems
    • Decrease errors
    • Eliminate remembering and completing mathematical equations
    • Organize equipment
equipment14
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
RESPIRATORY DISTRESS
  • Rapid 30 second assessment
    • T one
    • I nteractive
    • C onsolablity
    • L ook/track
    • S peech/cry
respiratory distress16
RESPIRATORY DISTRESS
  • Altered mental status
  • Nasal flaring
  • Head bobbing
  • Accessory muscle use
  • Grunting
respiratory distress19
RESPIRATORY DISTRESS
  • You must undress the patient
  • Retractions
    • Substernal
    • Intercostal
    • Supraclavicular
    • Suprasternal
respiratory distress20
RESPIRATORY DISTRESS
  • Infants are nose breathers
  • Secretions can impeded air flow
  • Bulb syringe nasal suction may alleviate this
respiratory failure
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
TECHNIQUEMEDICATIONS
  • Succinylcholine
    • Dose higher at 1.5mg/kg
  • Etomidate
    • 0.3mg/kg
  • Fentanyl
    • 1-3mcg/kg consider for age >10 and head injury
technique medications23
TECHNIQUEMEDICATIONS
  • Vecuronium
    • 0.1mg/kg
  • Rocuronium
    • 1mg/kg
technique medications24
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
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)
technique oxygen supplemtation
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
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 bvm29
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 bvm31
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 bvm32
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
TECHNIQUE BLADES
  • Follow Broselow guide
  • Miller straight blade better until about age 5
  • Lifts disproportionately large epiglottis out of way
technique cricoid pressure
TECHNIQUE CRICOID PRESSURE
  • Insufficient evidence to routinely recommend cricoid pressure during intubation (as opposed to BVM)
technique layngeal manipulation
TECHNIQUE LAYNGEAL MANIPULATION
  • Use as needed
  • Frequently:
    • B ackward
    • U pward
    • R ightward
    • P ressure
technique tubes
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 tubes37
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 tubes39
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
TECHNIQUE CONFIRM PLACEMENT
  • Tube fogging
  • B/L breath sounds
  • Silent epigastrum
  • End Tidal CO2
  • Pulse ox
technique end tidal co2
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 co242
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
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 management44
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
PITFALLS AND PEARLS
  • Performance anxiety
  • Equipment stocking and testing
  • Troubleshooting
  • Periodic training and practice
difficult airway
DIFFICULT AIRWAY
  • Infectious disease causes
  • Noninfectious causes including trauma
  • Congenital abnormalities
difficult airway infectious disease
DIFFICULT AIRWAY INFECTIOUS DISEASE
  • Epiglottitis
  • Croup
  • Retropharyngeal abscess
  • Bacterial Tracheitis
  • Ludwig’s angina
difficult airway infectious disease48
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
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
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
DIFFICULT AIRWAY NONINFECTIOUS DISEASE
  • Foreign body
  • Burns
  • Anaphylaxis
  • Caustic ingestion
  • Trauma
foreign body
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
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
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
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
DIFFICULT AIRWAY ADJUNCTS
  • LMA
  • Needle cricothyrotomy
  • Combitube/King LT
difficult airway lma
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
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 cricothyrotomy66
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 cricothyrotomy67
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 cricothyrotomy69
NEEDLE CRICOTHYROTOMY
  • Complications
    • Inappropriate needle placement
    • Inadequate ventilation (hypercarbia and acidosis)
    • Obstruction of small catheter
    • Subcutaneous emphysema
needle cricothyrotomy70
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
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