Pediatric Airway Management Dave French MD NREMTP Attending

  • Slides: 76
Download presentation
Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical

Pediatric Airway Management Dave French, MD, NREMT-P Attending ED Physician, Albany Medical Center Medical Director, Albany & Schenectady Fire Departments

Goals Decision-making l Basics l Intubation l Rescue devices l Medications l Ventilators l

Goals Decision-making l Basics l Intubation l Rescue devices l Medications l Ventilators l Broselow l

Decision-making What do I need to accomplish (why ETT)? l How aggressive should I

Decision-making What do I need to accomplish (why ETT)? l How aggressive should I be (BLS vs. ALS)? l What is my back-up plan? l What is the long-term picture? l

Reasons to Manage Airway l Inadequate oxygenation l l Low O 2 Pneumonia CHF

Reasons to Manage Airway l Inadequate oxygenation l l Low O 2 Pneumonia CHF Inadequate ventilation l l High CO 2 Asthma/COPD l Inadequate protection l l l AMS Airway trauma Anticipated course l l Hematomas Long transports

BLS vs. ALS We think intubation is easy l We are not good at

BLS vs. ALS We think intubation is easy l We are not good at it l l Prehospital success rate as low as 70% We can manage many patients with BLS l RSI can kill people l

Who Should Be Intubated? l AHA recommends prehospital intubation l l AAP developed PEPP

Who Should Be Intubated? l AHA recommends prehospital intubation l l AAP developed PEPP course l l De-emphasized under new ACLS/PALS guidelines Teaches intubation but not the focus What does the literature say?

Who Should Be Intubated? l Gausche, et al in Los Angeles, 2000 l l

Who Should Be Intubated? l Gausche, et al in Los Angeles, 2000 l l Randomized trial comparing BVM, intubation 830 patients under 12 years No difference in survival or neurologic outcome No difference in complication rate l l l 2% esophageal intubation all died 14% tube dislodged (6% unrecognized) 24% wrong sized tube

Should we be intubating ANY pediatric patients? !? ! Jury is still out, but

Should we be intubating ANY pediatric patients? !? ! Jury is still out, but some states already forbid it.

Predicting the Difficult Airway l Difficulty ventilating l l Facial trauma Obesity Obstructions Stiff

Predicting the Difficult Airway l Difficulty ventilating l l Facial trauma Obesity Obstructions Stiff lungs (asthma) l Difficulty intubating l l l External factors (obesity) Evaluate mouth opening Obstruction l l Smaller airways Neck mobility (trauma)

Easy or Hard?

Easy or Hard?

Easy or Hard?

Easy or Hard?

Easy or Hard?

Easy or Hard?

The Debate on Prehospital Pediatric Intubation Continues…

The Debate on Prehospital Pediatric Intubation Continues…

Back-up Plan l Can’t ventilate or basics not working l Consider adjuncts (OPA/NPA/positioning) l

Back-up Plan l Can’t ventilate or basics not working l Consider adjuncts (OPA/NPA/positioning) l Intubation? l Can’t intubate l Rescue l Can’t rescue l Surgical l devices procedure Okay to stick with basics if working

It’s Not Okay to Continue with Failed Techniques

It’s Not Okay to Continue with Failed Techniques

Long-Term Issues l Securing the tube l Tape vs. ties l Commercial devices l

Long-Term Issues l Securing the tube l Tape vs. ties l Commercial devices l Restraints

Long-Term Issues l Sedation l Agent and administration (drip vs. bolus) l Paralytics? Ventilator

Long-Term Issues l Sedation l Agent and administration (drip vs. bolus) l Paralytics? Ventilator management l What if the tube comes out? l

Basics Positioning l Adjuncts l l OPA - good choice if tolerated l NPA

Basics Positioning l Adjuncts l l OPA - good choice if tolerated l NPA - easy to tear mucosa l Effective BVM use is most important skill l Get a good seal (two person better) l Don’t over ventilate l Don’t forget the suction

Intubation Preparation l Preoxygenate l Monitors - ECG, pulse ox l Sellick’s l Good

Intubation Preparation l Preoxygenate l Monitors - ECG, pulse ox l Sellick’s l Good l basics Equipment selection l Miller vs. Mac l Cuffed vs. uncuffed l ETT size l Positioning

Airway Equipment l Straight blade to age 4? l Better able to control epiglottis?

Airway Equipment l Straight blade to age 4? l Better able to control epiglottis? l Choose for comfort l Smaller tubes l Less stability l More resistance l Uncuffed tubes < 8 years of age

Airway Equipment Suction l Magill forceps l Stylet l Tube check and securing devices

Airway Equipment Suction l Magill forceps l Stylet l Tube check and securing devices l

Tube Size l ETT size (Age in years/4) + 4 l Diameter of nare

Tube Size l ETT size (Age in years/4) + 4 l Diameter of nare l Diameter of pinky l Broselow tape l Have one size smaller and larger l

Tube Placement l ETT depth – use the black line (Age in years/2) +

Tube Placement l ETT depth – use the black line (Age in years/2) + 12 l ETT internal diameter x 3 l

Intubation Positioning l Goal is to align three axes l OA/PA/LA l Medical positioning

Intubation Positioning l Goal is to align three axes l OA/PA/LA l Medical positioning l Head tilt chin lift l Towels (older = head, younger = shoulders) l Trauma positioning l Manual in-line stabilization

Positioning. Medical vs. Trauma Adapted from Walls et al. Manual of Emergency Airway Management.

Positioning. Medical vs. Trauma Adapted from Walls et al. Manual of Emergency Airway Management. 2 nd Ed. 2004.

Positioning Adapted from Walls et al. Manual of Emergency Airway Management. 2 nd Ed.

Positioning Adapted from Walls et al. Manual of Emergency Airway Management. 2 nd Ed. 2004.

Intubation Approach Remember, much different than adults l Externally l l Larger head/occiput l

Intubation Approach Remember, much different than adults l Externally l l Larger head/occiput l Head flexes forward and can obstruct l Internally l Larger tongue l Friable tissues l Different angles and shapes

Airway Differences Nose Tongue Trachea Cricoid Airway

Airway Differences Nose Tongue Trachea Cricoid Airway

Adapted from Walls et al. Manual of Emergency Airway Management. 2 nd Ed. 2004.

Adapted from Walls et al. Manual of Emergency Airway Management. 2 nd Ed. 2004.

Airway Shape Adapted from Walls et al. Manual of Emergency Airway Management. 2 nd

Airway Shape Adapted from Walls et al. Manual of Emergency Airway Management. 2 nd Ed. 2004.

Intubation Approach l Further differences l “Pinker” vocal cords worsen visualization l Different location

Intubation Approach l Further differences l “Pinker” vocal cords worsen visualization l Different location of narrowest point l More precise ETT choice l Air leak vs. trauma/stenosis l Peds cuffed tubes? l Smaller l No cricothyroid membrane surgical crics in children l Needle crics difficult

Other Considerations More gastric insufflation with BVM l Different oxygenation abilities l l Higher

Other Considerations More gastric insufflation with BVM l Different oxygenation abilities l l Higher basal usage l Less residual lung capacity l Quicker desats during intubation l 10 l kg to 90% in <4 minutes (vs. 8 for adult) More likely to have vagal response

Intubation Techniques Always enter from the right corner l Tongue control is critical l

Intubation Techniques Always enter from the right corner l Tongue control is critical l Lift the epiglottis with the Miller l Slide the Mac into the vallecula l l Can lift the epiglottis if needed

Adapted from Walls et al. Manual of Emergency Airway Management. 2 nd Ed. 2004.

Adapted from Walls et al. Manual of Emergency Airway Management. 2 nd Ed. 2004.

Intubation Trouble-shooting l Can’t see the cords l Look for landmarks l Control the

Intubation Trouble-shooting l Can’t see the cords l Look for landmarks l Control the tongue l BURP maneuver if epiglottis seen l Another attempt needed (limit number) l Reposition l Change l something (blade, tube) Avoid hypoxia

Blind Techniques Exist but need practice for proficiency l Digital intubation l l Small

Blind Techniques Exist but need practice for proficiency l Digital intubation l l Small l work area Blind nasotracheal intubation l Tough angles for tube placement l Remember anatomic differences l Contraindicated until >10 years old

In general, blind techniques not useful in children

In general, blind techniques not useful in children

Intubation Confirmation Visualize tube passing through cords l Breath sounds and epigastric sounds l

Intubation Confirmation Visualize tube passing through cords l Breath sounds and epigastric sounds l End Tidal CO 2 (ETCO 2) l Commercial devices l l Not effective on uncuffed tubes l Be careful if used in children

REMINDER: It’s Not Okay to Continue with Failed Techniques

REMINDER: It’s Not Okay to Continue with Failed Techniques

Rescue Devices LMAs (laryngeal mask airway) l I-LMAs (intubating LMA) l Combitube l Bougie

Rescue Devices LMAs (laryngeal mask airway) l I-LMAs (intubating LMA) l Combitube l Bougie l Pick one or two and practice l l Need to be comfortable before crisis

LMA l l Used in any age Easy to place Few complications Contraindications: l

LMA l l Used in any age Easy to place Few complications Contraindications: l l l Gag reflex FBs Airway obstruction High ventilation pressure Does not secure airway

LMA Sizing LMA Size Patient Size 1 Neonate / Infants < 5 kg 1½

LMA Sizing LMA Size Patient Size 1 Neonate / Infants < 5 kg 1½ Infants 5 -10 kg 2 Infants / Children 10 -20 kg 2½ Children 20 -30 kg 3 Children/Small adults 30 -50 kg 4 Adults 50 -70 kg 5 Large adult >70 kg

I-LMA l l l Only sizes 3, 4, 5 Same rules and sizing as

I-LMA l l l Only sizes 3, 4, 5 Same rules and sizing as LMA Need special armored tube for intubation New similar devices exist Leave LMA portion in place in field

Combitube l Two sizes l l l Small (4 to 5. 5 feet tall)

Combitube l Two sizes l l l Small (4 to 5. 5 feet tall) Regular (over 5. 5 feet tall) Not useful in most kids Easy to place Contraindications l l Gag reflex Esophageal disease Caustic ingestions FBs/Airway obstruction

Bougie l l Replaces stylet Able to use with poor view l l l

Bougie l l Replaces stylet Able to use with poor view l l l Intubate over it l l l Feel tracheal rings Feel carina Keep blade in place Two person technique Need to practice

Other Toys l l l Lighted stylet Flexible fiberoptic scopes Rigid fiberoptic scopes l

Other Toys l l l Lighted stylet Flexible fiberoptic scopes Rigid fiberoptic scopes l l l Bullard Shikani Video laryngoscopy

Surgical Airways Cricothyrotomy l Indications (only if >10 years old) l Failed airway l

Surgical Airways Cricothyrotomy l Indications (only if >10 years old) l Failed airway l Failed ventilation l Predictors of difficulty l Previous neck surgery l Obesity l Hematoma or infection

Cricothyrotomy Techniques l l l Open Locate CTM Stabilize larynx/prep Incise skin l l

Cricothyrotomy Techniques l l l Open Locate CTM Stabilize larynx/prep Incise skin l l l l Vertical Horizontal through CTM Insert spacer/dilator Insert cuffed tube Check breath sounds Closed Locate CTM Stabilize larynx/prep Insert needle l l l Direct inferiorly Insert guidewire Remove needle Small skin incision Insert dilators/UC tube Check breath sounds

Cricothyrotomy Complications Bleeding l Laryngeal or tracheal injury l Infection l Pneumomediastinum l Subglottic

Cricothyrotomy Complications Bleeding l Laryngeal or tracheal injury l Infection l Pneumomediastinum l Subglottic stenosis l

Surgical Airways Needle Cric Same indications (all ages, tougher if young) l Must use

Surgical Airways Needle Cric Same indications (all ages, tougher if young) l Must use with TTJV (jet ventilator) l l Cannot l use with superior airway obstruction Similarly difficult patients

Needle Cricothyrotomy Procedure Identify CTM and stabilize/prep larynx l Insert needle on syringe, direct

Needle Cricothyrotomy Procedure Identify CTM and stabilize/prep larynx l Insert needle on syringe, direct inferiorly l l Large bore needle (12 -16 gauge) l Catheter over needle Advance catheter l Connect to TTJV (BVM for infants - 3. 0 ETT) l l Oxygen pressure (20 -30 psi) l 1 second on/2 -3 seconds off

Needle Cricothyrotomy Complications l Similar complications to other crics l Pneumothorax/subcutaneous l Barotrauma l

Needle Cricothyrotomy Complications l Similar complications to other crics l Pneumothorax/subcutaneous l Barotrauma l Esophageal l Obstruction injury emphysema

TTJV

TTJV

What About RSI?

What About RSI?

Rapid Sequence Intubation Does increase intubation success l You stop intrinsic breathing l l

Rapid Sequence Intubation Does increase intubation success l You stop intrinsic breathing l l You l can kill them Little place for peds in prehospital setting

RSI Medications l Same as adults l Lidocaine l Etomidate l Succinylcholine l Vecuronium

RSI Medications l Same as adults l Lidocaine l Etomidate l Succinylcholine l Vecuronium Remember atropine l Consider ketamine l

Pretreatment Lidocaine Mechanism: Decrease ICP, bronchospasm l Indications: Asthma, head injury l Contraindications: Allergy

Pretreatment Lidocaine Mechanism: Decrease ICP, bronchospasm l Indications: Asthma, head injury l Contraindications: Allergy l Dosage: 1. 5 mg/kg 3 minutes before ETT l

Pretreatment Atropine l Mechanism: Blunt vagal response l Prevent bradycardia from intubation l More

Pretreatment Atropine l Mechanism: Blunt vagal response l Prevent bradycardia from intubation l More prevalent in children Indications: All children <10 years old l Contraindications: Allergy l Dosage: 0. 02 mg/kg 3 minutes before ETT l

Induction Etomidate l Mechanism: Hypnotic, not analgesic l Most hemodynamically stable l Inhibits excitation

Induction Etomidate l Mechanism: Hypnotic, not analgesic l Most hemodynamically stable l Inhibits excitation l Indications: All inductions l Less protection from bronchospasm l No ICP issues Contraindications: None (careful in shock) l Dosage: 0. 3 mg/kg for induction (15 -45 sec) l

Induction Ketamine l Mechanism: PCP derivative l Analgesia, anesthesia, amnesia l Little respiratory or

Induction Ketamine l Mechanism: PCP derivative l Analgesia, anesthesia, amnesia l Little respiratory or hemodynamic effect l Increases cerebral oxygen demand Indications: RAD, children? , hemodynamics l Contraindications: l l Elevated ICP (worsens) l Re-emergence in adults (hallucinations) l Dosage: 1 -2 mg/kg for induction (45 -60 sec)

Paralysis Succinylcholine l Mechanism: Depolarizing agent l Binds to NMJ and fires Indications: Paralysis

Paralysis Succinylcholine l Mechanism: Depolarizing agent l Binds to NMJ and fires Indications: Paralysis w/ fasciculation l Contraindications/Complications: l l Hyperkalemia (Burns, crush, renal failure) l Increased ICP, globe injury l Prolonged blockade, MH l Dosage: 1. 5 -2 mg/kg (2 for younger) l Rapid onset, brief duration (30 secs – 4 min)

Paralysis Vecuronium l Mechanism: Nondepolarizing agent l Competitive l blockade at NMJ Indications: l

Paralysis Vecuronium l Mechanism: Nondepolarizing agent l Competitive l blockade at NMJ Indications: l Pretreatment before SCh (no fasciculations) l Paralysis Contraindications: None (difficult airway) l Dosage: 0. 1 -0. 15 mg/kg in 90 -120 secs l l Lasts 60 minutes l 1/10 th dose for pretreatment

Ventilator Management l Pressure vs. volume control l Depends on patient l Need to

Ventilator Management l Pressure vs. volume control l Depends on patient l Need to reassess l Tidal volumes 8 -10 m. L/kg l Similar to adult l Again, adjust according to patient Titrate other settings l Last resorts: HFOV, ECMO l

Ventilator Management l Volume control (constant volume) l Set Rate and Tidal Volume l

Ventilator Management l Volume control (constant volume) l Set Rate and Tidal Volume l Set PEEP (~5) & Pressure Support l Pressure control (constant pressure) l Set Rate and PIP (20 -25) l Set PEEP l All settings require FIO 2

Ventilator Management l To alter O 2 l Change FIO 2 l Change PEEP

Ventilator Management l To alter O 2 l Change FIO 2 l Change PEEP l Change I: E ratio l To alter CO 2 l Change rate l Change tidal volume (or PIP)

Ventilator Management l CPAP and Bi. PAP l Not much use in younger children

Ventilator Management l CPAP and Bi. PAP l Not much use in younger children l Need to be able to comply with treatment l Good modalities in some settings l Rarely (if ever) useful in prehospital setting

Last but not least…

Last but not least…

Broselow Tape l l Lubitz, et al. (1998) Most accurate 3. 5 - 25

Broselow Tape l l Lubitz, et al. (1998) Most accurate 3. 5 - 25 kg More accurate than RN or MD 94% vs 63%

Broselow Tape l l Rowe, et al. (1998) Calculation error rate 3% Recheck increases

Broselow Tape l l Rowe, et al. (1998) Calculation error rate 3% Recheck increases to 10% Under stress, up to 25%

Broselow Tape l Equipment sizes l l l l l Airway adjuncts Intubation equip

Broselow Tape l Equipment sizes l l l l l Airway adjuncts Intubation equip Oxygen delivery Vascular access Defibrillation NGT, suction caths BP cuff Chest tubes Foley l Medications l l l l l Antiarrhythmics Arrest medications Anticonvulsants Overdose meds Increased ICP meds Induction agents Paralytics Vasopressors IV drips

Broselow Tape

Broselow Tape

Broselow Tape l l 8 color codes (6 -36 kg) Broselow-Luten Emergency System l

Broselow Tape l l 8 color codes (6 -36 kg) Broselow-Luten Emergency System l l Color-coded bags with equip Quicker, more efficient

Summary Think carefully about your goals l Assess your options l Good BLS is

Summary Think carefully about your goals l Assess your options l Good BLS is the most important skill l Intubate or not? l Have a back-up plan l Use your Broselow l

Questions?

Questions?

References l l l l Gausche M, et al. Effect of out-of-hospital pediatric endotracheal

References l l l l Gausche M, et al. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurologic outcome. JAMA. 2000. 283(6): 783 -790. Gilligan BP, et al. Pediatric Resuscitation. In Rosen’s Emergency Medicine: Concepts and Clinical Practice, 6 th Ed. Mosby, 2006. Hazinski MF, et al (Ed). PALS provider manual. AHA, 2005. Lee BS, et al. Pediatric airway management. Clin Ped Emerg Med. 2001. 2(2): 91 -106. Lubitz DS. A rapid method of estimating weight and resuscitation drug doses from length in the pediatric age group. Ann Emerg Med. 1998. 17(6): 576 -581. Luten R. Error and time delay in pediatric trauma resuscitation: Addressing the problem with color-coded resuscitation aids. Surg Clin of N Amer. 2002. 82(2). Luten RC. The pediatric patient. In Manual of Emergency Airway Management, 2 nd Ed. Lippincott, 2004. Tobias JD. Airway management for pediatric emergencies. Pediatric Annals. 1996; 25: 317 -28