Transcript Airway Management

Airway Management
Sarah McPherson
Gord McNeil
July 17, 2003
What are the indications to
intubate?
• Failure to protect airway
• Failure to oxygenate or ventilate
• Anticipated course
Basic Airway Approach
Needs intubation
Unresponsive?
Near death?
no
Predict difficult
airway?
no
RSI
yes
Crash Airway
yes
Difficult Ariway
Basic Airway Approach
Attempt Oral
Intubation
yes
Successful?
no
BMV maintains
SpO2 > 90%?
yes
no
>3 Attempts at
OTI by attending
MD?
yes
Post-intubation
Management
Failed Airway
Airway Anatomy
Epiglottis
Aryepiglottic folds
Arytenoid cartilage
False vocal cords
True vocal cords
Anatomy
• Pediatric Airway Differences
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Larger tongue
Large occiput
Anterior larynx
Larger epiglottis/floppier
Subglottic area narrowest
Less musculature
Shorter trachea
Narrower airway
8 Steps to a Successful RSI
• RSI 8 p’s:
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Preparation
Peruse
Preoxygenate
Pretreatment
Paralysis
Protection
Placement
Post intubation management
Basic Airway Management - 8 P’s
“Prepare” – SIGMA D
What do you need for intubation?
• SIGMA D
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S = Suction
I = Intravenous
G= Gas
M = Mask/Bag
A =airway equipment (oral airway, laryngoscope,
tubes, alternative)
– D= Drugs
“Peruse” - LEMON LAW
• L = Look: face, neck, chest
• E = Examine: mouth, thyromental, floor of mouth
to thyroid
• M = Mallampatti: huge tongue?, back of throat?
• O = Obstruction: tumor, epiglottitis
• N = Neck mobility: OA, RA, syndromic
LEMON - Look
• Look
– Evaluate the pt.
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Obesity
Micrognathia
High arched palate
Narrow face
Short or thick neck
Neck trauma
Large tongue
Presence of facial hair
Dentures
Large teeth
LEMON –Evaluate 3-3-2
• Evaluate 3-3-2
– Evaluate the anatomy
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3 fingerbreadths of mouth opening
3 fingerbreadths between front of chin and hyoid
2 fingerbreadths from mandible to thyroid cartilage
CAN I DISPLACE TISSUE SUB-MENTALLY?
LEMON – Mallampati score
• Mallampati score
– Grade 1: entire post.
Pharynx, visualized to
tonsillar pillars
• No difficulty
– Grade 2: hard palate, soft
palate and top of uvula only
• No difficulty
– Grade 3: hard and soft
palate only
• Moderate difficulty
– Grade 4: no visualization
post pharynx or uvula (hard
palate only
• Severe difficulty
LEMON -Obstruction
• Obstruction
– Look for upper and lower airway obstruction
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foreign body aspiration
Epiglottitis
croup
Abscesses
others: surgery,tumors, radiation
LEMON –Neck Mobility
• Neck Mobility
– Collar, RA, degenerative arthritis, history of
surgery
– Note: get significant movement with BVM
ventilation also!!
“Pre-oxygenate” - no bagging
• Preoxygenate (nitrogen washout)
– Saturate O2 reservoir, tissues and blood
– 100% NRB (70%)
• 5 min healthy adult
• 2.5 min children
• 8 VC breaths
How much time do I have?
• 70kg adult maintains O2 sat >90% for 8 min
– From 90% - 0% = < 120 seconds
• Obese adult (>120kg) desaturate to 0% in
less than 3 min
• 10kg child desaturate <90 in 4 min
– From 90% to 0% in 45 seconds
• Walls graph
“Pre- medicate” - LOAD
• Lidocaine: tight heads, tight lungs
• Opioid: for blunting sympathetic response (ICP,
IOP, aortic dissection, aneurysm, IHD)
• Atropine: children <= 10
• Defasiculate: for increased ICP
Lidocaine ?
• Premise
– Laryngoscopy and Intubation
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afferent stim. in post pharynx/ larynx
increased central stim
increased ICP
stim of autonomic system
– increased HR / BP
– upper and lower resp. tract leading to increased airway
resistance
Lidocaine ?
• Literature (supports)
– suppresses cough reflex
– attenuates increase in airway resistance (from
ET tube irritation)
– prevents increased ICP (normal increase with
ETT is 22mmHg)
– prevents increased IOP
– decreases dysrhythmias by 30-40%
Lidocaine ?
• Literature (?doesn’t support)
– use to attenuate sympathetic response to
laryngoscopy
• Use: tight lungs / tight brains
– 1.5mg/kg 3 min prior
• Topical 4% lidocaine and ICP ????
Drugs to Decrease Sympathetic
Response to Intubation (LOAD)
• Fentanyl
– high dose 5-10 ug/kg (will unequivocally block
sympathetic response - hypotension, apnea ,
chest wall rigidity)
– 1.5-3ug/kg (2 min prior) blocks increase BP but
no effect on HR
• Beta-blockers
– will decrease sympathetic response
– prob: neg ionotrope, bronchoconstriction
Drugs to Decrease Sympathetic
Response to Intubation
• Helfman et al
– compared 200 lido, 200 fentanyl, 150 esmolol
– esmolol only reliably agent in preventing rise in
HR and BP
• Chung et al
– combination esmolol and fentanyl (2ug/kg and
2mg/kg) best combo with limited side-effects
LOAD - Atropine
• Use with SUX in children under the age of
8 and when giving repeat doses to adults
– Sinus brady, junctional, sinus arrest usually
after a second dose
– Reason: Sch mimicks action of Ach at the
cardic muscarinic receptors
– Dose 0.02mg/kg (no less than 0.1mg), 3 min
prior to induction
LOAD - Atropine
• Literature
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Prevents brady in children
Reduces BUT doesn’t eliminate them in infants
No effect on older children
Anesthesia literature: volatile anesthetics in
combination with atropine - increased risk of
arrhythmias
– Bottomline: Use atropine on children in the ED
Defasiculation
• Decrease the rise in ICP from Sch induced
fasciculation (animal data, limited human)
• Does not attenuate the sympathetic response to
intubation
• Does not attenuate the increase in airway
resistance with intubation
• 1/10 intubating dose
RSI in Adults With Elevated Intracranial
Pressure: A Survey of Emergency
Medicine Residency Programs
• Am J Emerg Med :1995
– 100 programs surveyed
– 67 responses, 65 used RSI in their programs!!!
– Top NMB agents – Sux and vecuronium
– Top induction agents - midazolam and thiopental
– Lidocaine - was routine
– Fentanyl - other pretreatment agent
– Defasciculating dose used by most programs
Paralysis with induction
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Rapid sequence - “intubation before aspiration”
Do not titrate
Midazolam, ketamine, thiopental or etomidate
Succinylcholine or rocuronium
Induction
• Used to produce anesthesia and
unconsciousness
• Many options
• Best choice depends on clinical and
pharmacokinetic factors
Etomidate
• Ultrashort acting non-barbiturate hypnotic agent
(no analgesic effects)
• Adv:
– rapid onset and rapid recovery
– hemodynamic stability
– minimal resp depression
– cerebral protection
• Induction Dose: 0.3 mg/kg (decrease to 0.15
mg/kg if hemodynamic instability)
Etomidate
• Onset : one arm-brain circulation (within 1 min)
• Duration : 3-5 min
• Cerebral
– decreases CBF by 35% - decr ICP
– no change MAP
– CPP increases (increased cerebral
oxygen/demand ratio) - decr ICP
Etomidate
• Resp
– minimal effects
– doesn’t release histamine
• CV
– no change in HR/ MAP/ CI/ PAWP
• Endocrine
– concern re: steroid depression
Etomidate
• Dose dependant reversible inhibition of 11-betahydroxylase (converts 11-deoxycortisol to
cortisol)
• Studies:
– transient drop in cortisol levels with induction
of anesthesia (6hrs), back to normal in 20 hrs
– no reported adverse outcomes
Etomidate
• Contraindications: age < 10, known seizure
disorder, pregnant
• Adverse effects
– nausea and vomiting (30-40%)
– pain on injection (similar to propofol)
– myoclonic movement, may cause trismus
• Pregnancy category C
– embryocidal in rats
Ketamine
• Phencyclidine derivative (similar to Angel Dust)
• Dissociative anesthetic (dissociation between the
thalmus and limbic system)
• Sympathomimetic (increased HR and BP)
• Increases cerebral blood flow by 60%
potentially elevating ICP!
• Reduces airway resistance
• Dose 1-2mg/kg IV, 4-5mg/kg IM
• Onset: within 60s
Thiopental
• Barbituate, potentiates GABA
• Cerebroprotective
• Dose related potent venodilator and
myocardial and resp depressant
• Adult 1-4 mg/kg, child 1- 6 mg/kg
• Onset 15 - 30 secs, duration 3- 5 min
• Do not use in hypotension
Benzos and Narcotics
• Benzos:
– Midazolam
• Dose: 0.5-2 mg/kg depending on hemodynamics and
age of patient
• often will cause hypotension
• Narcotics
– Fentanyl
• Dose: 1-3 ug/kg
• less hemodynamic effects than midaz but in high
doses will cause hypotension
• not great anestethic when used alone
Succinylcholine
• Depolarizing NM agent
– Onset:
– Duration:
30-45s
5-10 min
• Dosage (IV):
– 1-1.5mg/kg adult
– 2mg/kg child
– 3mg/kg neonate
• Can give IM at twice the dose
Succinylcholine
• Side-effects?
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Incr IOP, ICP
Bradycardia
Trismus-masseter muscle spasm
Fasciculations
Malignant Hyperthermia
Hyperkalemia (mean increase < 0.4mmol/L)
Prolonged blockade
Succinylcholine Contraindications
• History of MH
• Burns > 24 hrs old until healed
• Muscle damage (crush) > 7 days - completely
healed
• Spinal cord injury, stroke (denervation UMN,
LMN) > 7 days - 6 months
• Neuromuscular disease, myopathies: indefinately
as long as disease is active
• Intra-abdominal sepsis > 7 days - resolution of
infection
• hyperkalemia
Sux - Hyperkalemia
• Literature
– Case reports since 1960’s
– No case reports of hyperkalemia in the ED (multiple
trauma, burns, neurological disease)
– Literature poor with chronic renal failure
• Zink et al
– 100 pts (no risk factors)
– Max increase 1.0 meq/L (K increased in 46pts, dropped
in 46 pts and unchanged in 8)
– 1 pt found to be in a wheelchair!, K dropped from 4.6
to 4.1
Sux - Hyperkalemia
• Conclusion
– Non high risk pts
• No problems with administration
– High risk pts
• CRF probably okay
• Others : literature is not great but we have good
NDNM blockers, therefore no point to take risk
Sux – Raised IOP
• Thought to be a contraindication to an open globe
injury!
• Pressure elevations do occur, are transient,
maximal for 2-4 min post administration
– Pressure elevations of 3-8mmHg (never been shown to
worsen globe injury
– Comparison: normal blink – increases IOP by 1015mmHg, forceful closure of the eyelid >70 mmHg
– Anesthesia continues to use Sux in OR with globe
injuries
– Chiu et al:
• if you want to prevent increase in IOP, can give
defasciculating dose of a NDNM blocker (rocuronium 2 min
pre RSI)
Sux – Prolonged blockade
• Pseudocholinesterase Deficiency
– Congenital
• Heterozygous : up to 25 min, homozygous up to 5 hrs after a
single dose
• Homozygous : 1 in 3000 pts
– Acquired
• Organophosphate poisoning
• Cocaine use
• CRF, severe liver disease, hypothyroidism,malnutrition,
pregnancy, cytotoxic drugs, metoclopramide, bambuturol(long
acting beta 2 anonist)
– Note: above none have prolonged blockade over 20-25 min
Sux – Trismus/Masseter muscle
Spasm
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Occasionally can get spasm
Especially in children
Transient
If prolonged, severe and other muscle involved
should think of MH
Malignant Hyperthermia
• Genetic skeletal muscle membrane abnormality never been an ED case reported
• Onset acute or delayed - 60% mortality
• Clinically
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Muscle rigidity
Autonomic instability
Hypoxia
Hypotension
Hyperkalemia
Lactic acidosis
Temp. elevation is a late sign
• treat with dantrolene (2mg/kg iv q 5min to max
10mg/kg)
Rocuronium
• Aminosteroid, non-depolarizing neuromuscular
blocker
• Agent of choice when sux is CI
• Onset: 1.2-1.8 min (sux 0.8-1.2)
• Dose: 0.6 mg/kg
• Duration of action: 30 -45min
Rocuronium
• Cannot depend on neostigmine in failed
intubation - time to recovery will be too
long
• Histamine related hypotension
• Primary use of non-depolarizing agents is
for defasiculation and paralytic maintenance
post-intubation
Paralytics (table)
Agent
Class
Dose(mg/kg)
Onset
Duration
Vecuronium
Intem.
0.1
3-5
30-45
Atracurium
Intem.
0.5
3-5
30-45
Pancuronium
Long
0.1
3-5
60-90
Rocuronium
Intem.
0.6
1-2
30-45
Mivacurium
Short
0.15
2.5-4
10-20
Rapacuronium
Short
1.5
1-2
10-15
Timing
• 10 minutes out:
– Prepare (SIGMA D) Peruse (LEMON)
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5 minutes out: Pre-oxygenate
3 minutes out: Pre-treat (LOAD)
Zero: Paralysis with induction
Zero +30 sec: Pressure and position
Zero +45 sec: Pass tube - jaw flaccidity
Zero +1 minute: Post-tube mngmt
RSI Sequence
• Video clip here
Pressure and position
• Sellicks maneuver “BURP”
• Sniffing position - cervical extension and atlantooccipital flexion
BURP
• The Efficacy of the "BURP" Maneuver
During a Difficult Laryngoscopy. Takahata
O Anesth Analg - 1997 Feb; 84(2): 419-21
[The difficult intubation. The value of BURP and 3 predictive tests of difficult intubation] Ulrich B - Anaesthesist - 1998 Jan; 47(1): 45-50
Basic Airway Management
Positioning
Pass tube with proof
How do you know it is in????
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Thru cords
Misting
Chest rising and falling
ETCO2
Esophageal detector
Pass tube with proof
Position of Tube During Intubation
End Tidal CO2
• Qualitative
– Colorimetric
• When color change (yellow = yes) virtually 100% specific
• False negative with cardiac arrest
• Quantitative
– Capnography
• Measures amount of CO2 in the expired air (direct indicator of
CO2 elimination by the lungs)
• Again false negative with cardiac arrest
Esophageal Detection Devices
(EDD)
• Premise
– Esophagus will collapse with suction
– Trachea rigid structure with lots of air (no
collapse
• Not as reliable as end tidal CO2 therfore should be
used as a 2nd line device to confirm tube
placement
Bulb Aspiration
• “Turkey baster”
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Round compressible ball
Deflate the bulb and attach to end of ETT
Esophagus: delayed or sluggish inflation
Trachea: expands rapidly (within 2 seconds)
Syringe Technique
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Same principle
Use larger volume of air
Withdraws 30 cc of air
Use rapid aspiration os syringe
“Post-intubation”
• Use a one third therapeutic dose of benzo and nondepolarizing paralytic when any signs of patient
awareness detected
• Appropriate vent settings: PEEP, rate, volume
• Post-intubation bradycardia is an esophageal
intubation until absolutely proven otherwise.
Postintubation Hypotension
• Tension pneumothorax:
– Incr PIP, difficulty bagging, decr B/S, poor sats
– Rx: Chest tube
• Induction agents:
– Exclude other causes
– Rx: Fluid bolus, expectant
Postintubation Hypotension
• Decreased venous return:
– High PIPS secondary to high intrathoracic pressure
– Rx: Fluid bolus, bronchodilator, incr exp time, decr
tidal volume and rate
• Cardiogenic:
– Usually in compromised patient; EKG: exclude other
causes
– Rx: cautious fluid bolus. pressors
Post-tube complication
• A patient becomes hypoxemic 2 minutes
after you intubate him. What is your
differential?
Post-intubation Hypoxia
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D: Dislodged
O: Obstruction
P: PTX
E: Equipment failure
Difficult Airway
• Emergency Physicians
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National Emergency Airway Registry
6294 intubations
85% successful on first attempt
99% ultimately successful
1% failed airway requiring rescue
maneuvers
Difficult Airway
• Sakles Jc et al Ann Emergency Med 1998
• Intubations over 1 yr in their ED (N=610)
– 569 (93%)by staff/residents
– 515(84%) used RSI
– 98.9% intubated successfully
Difficult Airway
• Paralytics and Aeromedical Transport
– Program A (RSI) success rate: 93.5%
– Program B (no RSI) : 66.7%
• Same program after institution if RSI
• Success: 90.5%
Difficult Airway – BARF
• B(5): Best view, Best person, Bougie, Blade
change, BURP manueuver
• Alternative airway: LMA, lighted stylet
• Rescue: BMV
• Failed airway: TTJV if <8 years old, crich if >8
Best View
• Cormack-Lehane
laryngoscopy grading
system
• Grade 1 & 2 low
failure rates
• Grade 3 & 4 high
failure rates
Blade Change
• Macintosh (curved)
– McCoy – articulating tip
• Miller (straight)
– Use with children younger than 8y/o, and
people with anterior larynx (short mentalhyoid distance)
– Wisconsin and Guedel blades
• Larger more rounded barrel
Blade Change
• Laryngoscopy and Intubation
– “the single greatest obstacle to successful
intubation is the tongue… the tongue is the
enemy”
– Paraglossal technique
• Step 1 (blind) insert blade blindly into the esophagus
• Step 2 (visual) withdraw blade until you visualize
the cords /epiglottis
Alternative Airway technique
• LMA
• Orotracheal or nasotracheal
• Lighted stylet
• Digital
• Retrograde
• Fibreoptic
Alternative Airway - Laryngeal
Mask
• Does not constitute
definitive airway
management
• Temporizing measure
in the ED
• Size :
– #3 teenagers and small
female adults
– #4 average size adult
– #5 large adults
Alternative Airway-Laryngeal
Mask
• Inflate cuff
– #3 – 20cc
– #4 – 30cc
– #5 – 40cc
– Or until no leak
Note: no literature
describing the
success rate in the
ED(OR success >95%)
Alternative Airway - LMA
Zideman D - Ann Emerg Med - 01-Apr-2001; 37(4 Suppl): S126-36
• Not studied in infant/child resuscitation
• Complications more frequent in peds
• Correct size
– 1 = smallest; 3-4 = adult female; 4-5 = adult male
• May be dislodged during transport/CPR
• Aspiration – little protection
Alternative Airway Nasotracheal
Intubation
• Indication
– A potentially difficult intubation who is spontaneously
breathing - epiglottitis
– Pt you do not want to paralyze
• Contraindicated
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Combative pts
Anatomically deranged airway
Neck hematomas
Raised ICP
Severe facial trauma
Coagulopathy
Alternative Airway Nasotracheal
Intubation
• Pearls
– Sniffing position
– Pull tongue forward by grasping with gauze
– Only 60-70% successful on first attempt (1020% of NTI’s are simply not possible
Alternative Airway
Lighted Stylet
• Use if cannot directly
visualize the larynx with
laryngoscopy
• Relies on
transillumination of the
soft tissues of the neck
• Trachea: well defined
glow
• Esophagus: diffuse light
glow
Alternative Airway
Lighted Stylet
• Success rates consistent with or exceed that of
conventional laryngoscopy
Rescue Airway
• BVM
BONES - predicts difficult mask ventilation
• B: Beard
• O: Obese
• N: No teeth
• E: Elderly (>55 y/o), or cachectic (sunken cheeks)
• S: Snores
• 3rd trimester pregnancy
• obstructive lung disease
Failed Airway
Retrograde Intubation
• Puncture the cricothyroid membrane then thread a
wire retrograde to the mouth, the tube is then
inserted over the wire
• Use as rescue technique
• used for failed airway and you have TIME
• Do not use if infection at the site of the needle
puncture
• Note: does take time to do
Failed Airway
Fiberoptics
• will take time (~ 15 min or longer)
• Indications:
– predicted difficult airway
– C-spine immobility
– failed intubation “can’t intubate, CAN
oxygenate”
• Contraindications
– excessive blood or secretions
– upper airway obstruction
– can’t oxygenate patient
Failed Airway
Surgical:
• Needle crich & TTJV, cricothyrotomy
• used for failed airway that needs IMMEDIATE
management
Difficult crich: SHORT
S: Surgery
H: Hematoma
O: Obese
R: Radiation
T: Tumor
Failed Airway
• Cricothyroidodomy not recomm. age <8
– crichoid cartilage space is VERY small and
high larynx
– complication rate 10-40%
– Retrograde?
• Transtracheal jet ventilation
– surgical method of choice in emergency
– allows ventilation for 45-60 mins
– risk – aspiration, subcutaneous emphysema,
barotrauma, bleeding, catheter dislodgment,
CO2 retention
Failed Airway
Surgical Airway
• Cricothyrotomy
– NEAR Study
• Only 1% of 4000 Ed intubations required cric.
• 20% complication rate (mostly minor)
– 4 step process
– Pediatrics age >8 y/o
– #4 Shiley cuffed tube
• Needle cricothyrotomy (age <8)
Crich’s
• Indications
– failure of nasal or OTI
– immediate need for
airway management
• Contraindications
– age < 8-12
– preexisting laryngeal
pathology (tumor)
– hematoma over site
– destruction of
landmarks
– infection of abscess
over site
– coagulopathy
– lack of procedural
knowlege
Complications of surgical airway
management
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Major hemorrhage
pneumomediastinum
infection
voice change
subglottic stenosis
laryngeal/tracheal injury
Steps for crichothyrotomy
• Identify landmarks
– identify laryngeal prominence then feel one
finger breadth below
– four fingers breadth above the sternal notch
• Prepare the neck
– antiseptic solution
– local anesthesia if awake patient and enough
time
Steps for crich
• Immobilize Larynx
– place thumb and 3rd finger on opposite sides of
the superior laryngeal horns
• Incise the skin
– 2 cm
– through skin but not through deep structures
• Reidentify the membrane
Steps for crich
• Incise the membrane
– horizontal incision
– 1 cm
– incise lower half of membrane because less
vascular
• insert tracheal hook
– hook inferior aspect of thyroid cartilage and
apply light anterior traction
Steps for crich
• Insert dilator
• insert the tracheostomy tube
• inflate cuff and ensure tube position
Failed Airway
Surgical Airway
• Needle cricothyrotomy/ TTJV
– Temporizing measure
– Surgical airway of choice for age <8 y/o
– Need supraglottic patency (exhalation)
– No airway protection
Needle crich - the steps
• Identify landmarks
• immobilize larynx
• transtracheal needle insertion
– large-bore catheter (12-16)
– attach 10-20cc syringe
– direct needle caudally at 30 degree angle
through crichoid membrane
– when the needle enters the trachea the syringe
will easily fill with air
Needle crich - steps
• Catheter advancement
– DO NOT advance the needle with the catheter
– connect to jet ventilator
– What if no jet ventilator???
• Connect to 3cc syringe and ETT connector of an 8.0
ETT then to a bagging unit
Failed Airway
Surgical Airway
• Needle cricothyrotomy/ TTJV
– 12-16G needle
– <5 y/o ventilation only by bag
– 5-12 y/o 30 psi
– 12 – adult 30-50 psi
Awake intubation
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Lidocaine spray
5cc 4% lido neb
4% lidocaine on pledgets
Titrated dose of midazolam and fentanyl
Take a look - can turn into a formal RSI
Pediatric Pointers
• Broselow tape
• Avoid 2nd dose of sux
– infants/children exquisitely sensitive 
intractable brady/arrest
• Pierre Robin and Treacher Collins’ syndrome
– Small mandibles and posteriorly fixed tongues
• Down syndrome - large tongue
Positioning the Peds patient
• NB-6 months
– neutral or elevation of the shoulders
• 6 mo-5yr
– elevate head, no to minimal head extension
• 5-10 yrs
– elevate and extend head
Peds airways
• BVM
– be careful not to put pressure on the
submandibular tissues because you may cause
obstruction
– use an oral airway whenever possible
– be careful not to put pressure over the eyes
• children will desat faster so preoxygenation
phase to intubation must be shorter
• decompress the stomach with an NG tube
• under age of 8 use uncuffed tubes
Case #1
• 30 yo male brought to ED after MBA. He
has blood coming from his ears, GCS 5 and
is ina C-collar. His vitals are HR = 110, BP
120-50, RR 25, O2 Sat 94%
• What would you do????
Case #2
• A five yo girl with known asthma presents
with worsening dyspnea. On arrival to the
ED she has a RR of 40, O2 Sat 88%,
extensive accessory muscle use BP 80-35,
HR 110
• After 2 hours of cont vent nebs, iv
salbuatmol, steroids she now looks worse
RR = 15, O2 Sat 83%, altered LOC
• What would you do???
Case #3
• 22 yo male has a known nut allergy. He
was eating at Dairy Queen and thought he
was only eating peanuts when his lips
became tingly. His sister brings him to the
ED. He is stridorous on arrival, not able to
speak in full sentences and has a BP of
100/60, HR 120
• What would you do????
Case #4
• A 55 year old women collapsed in the
shower. Her husband states that she had
been complaining of a severe headache. On
arrival to the ED she is unresponsive, GCS
= 5, HR 110, BP 150/60
• What would you do?????