The Pediatric Airway 2.pdf

7/30/2019 The Pediatric Airway 2.pdf

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The Pediatric Airway

Andrew Wackett, MD


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Objectives1) Demonstrate understanding of the indications for

intubation2) Perform rapid sequence intubation

3) Learn the pharmacology behind emergency airwaymanagement

4) Demonstrate the ability to manage the pediatric airway5) Demonstrate the ability to identify the difficult and

failed airway

6) Demonstrate working knowledge of the emergencyairway algorithms

7) Practice the various techniques of airway mangement


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Objectives1) Demonstrate understanding of the indications for

intubation2) Perform rapid sequence intubation

3) Learn the pharmacology behind emergency airwaymanagement

4) Demonstrate the ability to manage the pediatric airway5) Demonstrate the ability to identify the difficult and

failed airway

6) Demonstrate working knowledge of the emergencyairway algorithms

7) Practice the various techniques of airway mangement


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Are children little adults?


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Are the managementprinciples different?


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NO, they are not! 95% of the principles are exactlythe

same

Hypoxia is bad!

Indications for intubation are the same Universal algorithm is the same

RSI, Crash, Difficult and Failedalgorithms are the same

Back up devices (LMA) are the same


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The Differences. . . Anatomical and physiological variation

which evolves as development proceedsfrom infancy to adolescence

Age and weight related differences in drugdosing and equipment sizing

Increased performance anxiety which

accompanies the resuscitation of thecritically ill child


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Anatomical andPhysiological Differences


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Infant Small Child Older child/Adult

Key to optimal individual patient position-Line traversing

external auditory canal crossing anterior to the shoulders

Support for the occiput in the older child/adult and the

shoulders in the infant

Extension of the head in the infant and small child

Hyperextension of the head in the older child or adult


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4 yr3 yr

1 yr8 mo6 mo


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Normal Anatomy

Vocal Cords

Extra-thoracic trachea

Pleural space

Lung


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Vocal Cords

Extra-thoracic trachea

Pleural space

Lung

Normal InspirationPrinciples


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Respiratory arrest is precipitated

without complete obstruction

Obstructed Inspiration

Obstruction

Principles


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2 Skills required:

1) Starting an IV2) BMV ventilation

Needle Cricothyrotomy


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Physiological Differences


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Drug Dosing and EquipmentSelection


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ADULT

CHILD

IMPLEMENTATION TIME

Pediatric Resuscitation associated with error and timedelay and a great dealof discomfort!


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The Cognitive Load of

Pediatric Resuscitation

Logistical timeAutomatic

Non-automatic activities

Critical thinking time


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Calculating the correct drug volume

Rechecking the drug volume calculation

Administering the dose correctly,

Administering the dose to the correct patient

Documenting accurately

Patientreceivesintended medication

Communication of dosage (verbal orders, handwritten)

Obtaining a the correct concentration

Estimation of weight

Recall of dose

Calculation of dosage

Decideon a medication

Vs. Automatic Activitynon-automaticactivities


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Equipment selection equally confusing:

10 different ET tube sizesSuction catheters ET tube size specificVarious types and sizes of Laryngoscope blades

Various BVM, oral and NP airways

Vs. Automatic Activity

non-automaticactivities


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1) Weight estimation2) Equipment Selection

3) Recall/referencing doses

4) Calculation of doses5) Calculation of drug volumes

6) Calculation of fluid volumes

7) Calculation of ventilatoryvolumes

Sources of non-automaticactivities,

particular to children:


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The Broselow Tape


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Resuscitation Aids

Transform non-automaticactivities, the age/size

related variables particular to children, into

automaticactivities, thereby accelerating time to

treatment and reducing potential for error.

CHILD

ADULT

ADULT

ADULT

CHILD

NON-AUTOMATIC TIME

CHILD

Time Saved

IMPLM

TIME

Time Eliminated

CHILD


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Some Specifics ETT size = (16 + age in years)/4

*Cannot be used if < 1 year

Insertion Distance = ETT size x 3

The smallest bag mask is 450 cc*Dont use the 250cc bag

Succinylcholine dose is 2mg/kg


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RSI Sequence Preparation use the Broselow tape

Preoxygenation be meticulous Pretreatment none necessary

Paralysis with induction

SCh 2 mg/kg or rocuronium 1 mg/kg

Etomidate 0.3 mg/kg or ketamine 1.5 mg/kg

Positioning EAM anterior shoulder

Placement and Proof

Postintubation Management


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Follow the nose

PostintubationManagement


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1o

2o

Postintubation

Management


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Pediatric Induced Anxiety


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Summary The indications and algorithms are the same

Use the Broselow tape to select your medicationdoses and equipment sizes

Be prepared to BMV

Intubation is different, but always in the sameway

Secure the tube and the neck

Needle cricothyrotomy is the solution to thefailed airway


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Documents

The Pediatric Airway 2.pdf