Airway Airway ManagementManagement

Aric Storck PGY-5Aric Storck PGY-5

Dr. Mike BetznerDr. Mike Betzner

July 20, 2005July 20, 2005

ObjectivesObjectives Crash course in ED airway Crash course in ED airway

management:management: IndicationsIndications

Who do you intubateWho do you intubate Who do you not intubateWho do you not intubate

What type of airway is itWhat type of airway is it easy, difficult, failed, crasheasy, difficult, failed, crash

RSIRSI Pediatric AirwaysPediatric Airways Hands on procedural skills stationHands on procedural skills station

Practical skill stationsPractical skill stations Gum elastic bougieGum elastic bougie LMA & I-LMALMA & I-LMA TrachlightTrachlight Needle cricothyrotomy / surgical Needle cricothyrotomy / surgical

cricothyrotomycricothyrotomy

CaseCase 78F78F

Acutely SOBAcutely SOB AlertAlert Talking one word sentencesTalking one word sentences JVP upJVP up Diffuse wheezeDiffuse wheeze Sats 84%Sats 84% ABG 7.25 / 60 / 50 / 19ABG 7.25 / 60 / 50 / 19

Does she need intubation?Does she need intubation?

Step 1Step 1

Who needs Who needs intubation?intubation?

Indications for IntubationIndications for Intubation ABCDEABCDE

A - Airway protectionA - Airway protection aspiration, obstructionaspiration, obstruction

B – BreathingB – Breathing Failure to oxygenate Failure to oxygenate Failure to ventilateFailure to ventilate

C – Circulation (Shock)C – Circulation (Shock) D – Disability / neuro (GCS <9 or drop by D – Disability / neuro (GCS <9 or drop by

2)2) E - Expected clinical courseE - Expected clinical course

Does our patient have a reason Does our patient have a reason to intubate?to intubate?

Airway – not a concern right nowAirway – not a concern right now BreathingBreathing

Failure to oxygenateFailure to oxygenate Failure to ventilateFailure to ventilate

Circulation – not a concern right nowCirculation – not a concern right now Disability – not a concern right nowDisability – not a concern right now Expected Course – likely to get worseExpected Course – likely to get worse

Does our patient need to Does our patient need to be intubated immediately?be intubated immediately?

Crash Airway

APPROACH TO THE AIRWAYAPPROACH TO THE AIRWAY

D oes th e p a tien t n eed to b e in tu b a ted ? A B C D E s

C ard iac a rres tA p n e ic

N ear d ea th

C R A S H A IR W A Y

N ot a c rash a irw ayN o an tic ip a ted d ifficu lty

E A S Y A IR W A Y

D ifficu lt an a tom yD ifficu lt p a th o log y

D IF F IC U L T A IR W A Y

Q u ck ly eva lu a te th e s itu a tion an d th e p a tien t?W h at typ e o f a irw ay?

THE CRASH AIRWAYTHE CRASH AIRWAY

G o to fa iled a irw ay a lg orith m

R ep eat a ttem p ts (u p to 3 )A d d su cc in ylch o lin e p rn

TIM E(can b ag , sa ts ok )

G o to fa iled a irw ay a lg orith m

N O TIM E(can 't b ag , sa ts d rop p in g )

U n su ccess fu l

JU S T D O IT !D irec t la ryn g oscop y w ith n o d ru g s

You have decided to intubate. You have decided to intubate.

How do you assess her How do you assess her airway?airway?

Predicting a Difficult AirwayPredicting a Difficult Airwaythe LEMON lawthe LEMON law

LL = Look = Look EE = Examine = Examine MM = Mallampatti = Mallampatti OO = Obstruction = Obstruction NN = Neck mobility = Neck mobility

LLEMON - LookEMON - Look ObesityObesity MicrognathiaMicrognathia High arched palateHigh arched palate Narrow faceNarrow face Short or thick neckShort or thick neck

Neck traumaNeck trauma Large tongueLarge tongue Presence of facial Presence of facial

hairhair DenturesDentures Large teethLarge teeth

Easy intubation

Call anesthesia

LLEEMON –Evaluate 3-3-2MON –Evaluate 3-3-2

Evaluate 3-3-2Evaluate 3-3-2

3 fingers of mouth opening3 fingers of mouth opening 3 fingers between front of chin and 3 fingers between front of chin and

hyoidhyoid 2 fingers from mandible to thyroid 2 fingers from mandible to thyroid

cartilagecartilage

LELEMMON – Mallampati scoreON – Mallampati score Mallampati scoreMallampati score

Grade 1Grade 1: entire post. : entire post. Pharynx, visualized to Pharynx, visualized to tonsillar pillarstonsillar pillars

No difficultyNo difficulty Grade 2Grade 2: hard palate, soft : hard palate, soft

palate and top of uvula palate and top of uvula onlyonly

No difficultyNo difficulty Grade 3Grade 3: hard and soft : hard and soft

palate onlypalate only Moderate difficultyModerate difficulty

Grade 4:Grade 4: no visualization no visualization post pharynx or uvula post pharynx or uvula (hard palate only(hard palate only

Severe difficultySevere difficulty

LEMLEMOON -ObstructionN -Obstruction

Upper and lower airway obstruction Upper and lower airway obstruction Foreign body aspirationForeign body aspiration EpiglottitisEpiglottitis Croup Croup AbscessesAbscesses TraumaTrauma OthersOthers

LEMOLEMONN –Neck Mobility –Neck Mobility

C-spine collarC-spine collar Rheumatoid arthritisRheumatoid arthritis Spinal surgerySpinal surgery

Is this likely a difficult Is this likely a difficult airway?airway?

RSIRSI(Rapid Sequence Intubation)(Rapid Sequence Intubation)

What is it?What is it? Preoxygentation + Induction agent + NMB + Preoxygentation + Induction agent + NMB +

Sellicks maneuverSellicks maneuver Why do we do it?Why do we do it?

To To minimize risk of aspirationminimize risk of aspiration in unfasted pts in unfasted pts i.e. almost anybody in the EDi.e. almost anybody in the ED

Whom do you do it in?Whom do you do it in? Pts w/ anticipated Pts w/ anticipated easy airways & no & no

contraindications to RSI (~80% of ED contraindications to RSI (~80% of ED intubations)intubations)

Steps of RSISteps of RSI

7 7 P’sP’s PPreoxygenationreoxygenation -10 to -5 min-10 to -5 min PPreparationreparation PPremedicationremedication -3 min-3 min PParalysis & Inductionaralysis & Induction 0 min0 min PProtection & rotection & PPositioningositioning +20 sec+20 sec PPass the tube w/ ass the tube w/ PProofroof + 45-60 sec+ 45-60 sec PPost-intubation careost-intubation care +60 – 80 sec+60 – 80 sec

Sellicks maneuver = key concept in RSI

PreoxygenationPreoxygenation

Why do we do it?Why do we do it? Replace nitrogen portion of FRC w/ 100% OReplace nitrogen portion of FRC w/ 100% O22, creating a , creating a O2

reservoir for delaying desaturation during apneic period for delaying desaturation during apneic period How do we do it?How do we do it?

Ideally 5 min of 100% OIdeally 5 min of 100% O22 via BVM or alternatively 8 VC via BVM or alternatively 8 VC breathsbreaths

PearlsPearls NRB delivers only 70% ONRB delivers only 70% O22 – need to use BVM w/ good seal – need to use BVM w/ good seal Spontaneous breaths only -- DON’T BAG THE PT (unless Spontaneous breaths only -- DON’T BAG THE PT (unless

clinically indicated)clinically indicated) DON’T BREAK SEAL – single RA breath sets you back to DON’T BREAK SEAL – single RA breath sets you back to

step 1step 1

PreparationPreparation

Even Even SIMPLE BOBSIMPLE BOB can do it… can do it… SS – Suction – Suction II – IV – IV M M – Meds & Monitors– Meds & Monitors PP – Personnel – Personnel LL – Laryngoscopes – Laryngoscopes EE – ETT’s (3 sizes) – ETT’s (3 sizes) BB – BVM – BVM OO – Oxygen – Oxygen B B – Backups / alternative devices– Backups / alternative devices

PretreatmentPretreatment

LOAFDLOAFD – given 3 min before Induction – given 3 min before Induction LL – Lidocaine – Lidocaine

1.5 mg/kg IV (tight heads, tight lungs)1.5 mg/kg IV (tight heads, tight lungs) OO – Opiates (Fentanyl) – Opiates (Fentanyl)

2-3 ug/kg IV – blunts sympathetic response2-3 ug/kg IV – blunts sympathetic response AA – Atropine 0.02 mg/kg IV – Atropine 0.02 mg/kg IV

Kids Kids ≤ 10 or 2≤ 10 or 2ndnd dose Sux dose Sux F F – Fluid bolus– Fluid bolus DD – Defasiculating agent – Defasiculating agent

Rocuronium 0.1 mg/kg – blunts rise in ICP Rocuronium 0.1 mg/kg – blunts rise in ICP

Paralysis & InductionParalysis & Induction

Induction agentInduction agent Etomidate 0.15-0.30 mg/kg IV pushEtomidate 0.15-0.30 mg/kg IV push Midazolam 0.1-0.2 mg/kg IV pushMidazolam 0.1-0.2 mg/kg IV push Ketamine 1-2 mg/kg IV pushKetamine 1-2 mg/kg IV push Thiopental 1-5 mg/kg IV pushThiopental 1-5 mg/kg IV push

NMBNMB Succinylcholine 1.5 mg/kg IV pushSuccinylcholine 1.5 mg/kg IV push Rocuronium 0.6 – 1.0 mg/kg IV pushRocuronium 0.6 – 1.0 mg/kg IV push

Protection….Protection….

Sellicks ManeuverSellicks Maneuver Gentle (10 lb) pressure on cricoid ring – Gentle (10 lb) pressure on cricoid ring –

compresses esophagus & prevents passive compresses esophagus & prevents passive regurgitationregurgitation

Initiate 10-20 sec after NMB – don’t release Initiate 10-20 sec after NMB – don’t release until cuff inflated & ETT position confirmeduntil cuff inflated & ETT position confirmed

Release if vomiting occurs (rare once NMB Release if vomiting occurs (rare once NMB in)in)

Key part of RSI but frequently done wrongly, Key part of RSI but frequently done wrongly, poorly, or forgotten altogetherpoorly, or forgotten altogether

… … & Positioning& Positioning

Key to successful intubation – don’t Key to successful intubation – don’t neglectneglect

Age & Body habitus dependent – goal is Age & Body habitus dependent – goal is “sniffing” position“sniffing” position Neonates & infants – towel under shouldersNeonates & infants – towel under shoulders Children – towel under neckChildren – towel under neck Adolescents & Adults – towel under headAdolescents & Adults – towel under head Obese – towels under head, neck, & Obese – towels under head, neck, &

shouldersshoulders

Pass the tube w/ ProofPass the tube w/ Proof

Confirmation of ETT positionConfirmation of ETT position Watch it go through cordsWatch it go through cords ETCOETCO22 monitors – gold standard monitors – gold standard

Colorimetric – Colorimetric – Yellow = YesYellow = Yes / / Purple = PoorPurple = Poor Portable digital – gives readingPortable digital – gives reading Quantitative – good waveformQuantitative – good waveform

Esophageal detector devicesEsophageal detector devices Bulb or syringe aspirationBulb or syringe aspiration

Clinical methods – least reliableClinical methods – least reliable Auscultation, chest rise, mistingAuscultation, chest rise, misting

Post-intubation Post-intubation ManagementManagement

Right insertion depth?Right insertion depth? Adults: TT = TT (tip-teeth = 22 cm)Adults: TT = TT (tip-teeth = 22 cm) Kids: ETT size x3 = cm mark at teethKids: ETT size x3 = cm mark at teeth Confirm w/ portable CXRConfirm w/ portable CXR

Secure ETTSecure ETT Ventilator settings Ventilator settings

different talk but hugely important!different talk but hugely important! Continued sedation +/- paralysisContinued sedation +/- paralysis

Rule of 1/3’s – give 1/3 of intubation doses prnRule of 1/3’s – give 1/3 of intubation doses prn

CaseCase

You have just intubated your patientYou have just intubated your patient

Suddenly they becomes difficult to Suddenly they becomes difficult to bagbag

What is your approach to dealing What is your approach to dealing with post-intubation complications?with post-intubation complications?

Approach to post-intubation Approach to post-intubation complicationscomplications

G-DOPEG-DOPE GG – gastric distention (peds) – gastric distention (peds) DD – Displacement of ETT – Displacement of ETT OO – Obstruction of ETT – Obstruction of ETT PP – Pneumothorax – Pneumothorax EE – Equipment failure – Equipment failure

PearlsPearls Bradycardia = esophageal intubation until Bradycardia = esophageal intubation until

proven otherwiseproven otherwise When in doubt, take it out (change everything)When in doubt, take it out (change everything)

Case 4Case 4

45M45M Morbidly obese, big beardMorbidly obese, big beard Sudden collapse and grand mal seizureSudden collapse and grand mal seizure Vomiting as EMS rolls them inVomiting as EMS rolls them in

What kind of airway is this?What kind of airway is this?

Difficult AirwayDifficult Airway Anesthesia literarture: Anesthesia literarture:

1-3% of intubations will be difficult1-3% of intubations will be difficult 0.1-0.4% of anticipated “easy” intubations 0.1-0.4% of anticipated “easy” intubations

end up failing intubationend up failing intubation ~1/10,000 will be “can’t intubate, can’t ~1/10,000 will be “can’t intubate, can’t

bag”bag”

ED airways likely more difficultED airways likely more difficult NEAR data indicates 1% cricothyrotomy rate NEAR data indicates 1% cricothyrotomy rate

Important to Important to trytry and anticipate but and anticipate but often cannotoften cannot

Approach to the Difficult Approach to the Difficult AirwayAirway

1.1. AnticipateAnticipate thorough evaluation when possiblethorough evaluation when possible

2.2. Call for helpCall for help 22ndnd EP, anesthesia, ENT, surgery, etc. EP, anesthesia, ENT, surgery, etc.

3.3. Evaluate ability to bag the patientEvaluate ability to bag the patient4.4. Make an intubation strategyMake an intubation strategy

Triple set-upTriple set-up Topical anesthesia / awake Topical anesthesia / awake

laryngoscopylaryngoscopy Adjuncts / Alternatives / BackupsAdjuncts / Alternatives / Backups

Predictors of the Difficult Predictors of the Difficult AirwayAirway

COMATOSECOMATOSE CC – C-Spine mobility limitations – C-Spine mobility limitations OO – Obstructed, OSA – Obstructed, OSA MM – Mallampati grade 3 or 4 – Mallampati grade 3 or 4 AA – Anatomy – Anatomy

dysmorphic features, retrognathia, short or thick dysmorphic features, retrognathia, short or thick neck, large incisors, facial hairneck, large incisors, facial hair

TT – Trauma (head, neck) – Trauma (head, neck) OO – Obesity – Obesity SS – “Soon to be moms” (pregnant) – “Soon to be moms” (pregnant) E E – Evaluate 3-3-2 rule– Evaluate 3-3-2 rule

Predictors of Difficult BMVPredictors of Difficult BMV

Age > 55 yoAge > 55 yo Obesity (BMI > 26 kg/mObesity (BMI > 26 kg/m22)) Facial HairFacial Hair Lack of teethLack of teeth Hx of snoringHx of snoring

Identified as independent predictors of difficlut Identified as independent predictors of difficlut BMV ventilation in prospective analysis of 1502 BMV ventilation in prospective analysis of 1502 ptspts

Anesthesiology 2000; 92:1229–36Anesthesiology 2000; 92:1229–36

Difficult Airway AlgorithmDifficult Airway AlgorithmAnticipated Difficult Airway

Time (sats OK) No Time (desats)

BMV works BMV Fails

Failed Airway

Anticipate easy to Bag

Anticipate hard to bag

Triple Set-upAwake Look +/- RSI

BackupsReady 2 Cric

Topical AnesthesiaMild Sedation

Awake Laryngoscopy

Consider:I-LMA

TrachlightFiberoptic

Cricothyrotomy

BNTI

Failed Airway

Triple Set-UpTriple Set-Up1.1. Awake laryngoscopyAwake laryngoscopy

topical anaesthesiatopical anaesthesia may go to RSI if looks easymay go to RSI if looks easy

2.2. Rapid Sequence InductionRapid Sequence Induction 2-3 backups immediately at hand:2-3 backups immediately at hand:

BougieBougie TrachlightTrachlight I-LMAI-LMA FiberopticFiberoptic McCoy bladeMcCoy blade

3.3. Cricothyroidotomy preparationCricothyroidotomy preparation Neck prepped & draped, Cric kit open, 2Neck prepped & draped, Cric kit open, 2ndnd person person

gloved & gowned w/ scalpel in handgloved & gowned w/ scalpel in hand

Awake LaryngoscopyAwake Laryngoscopy Mild sedationMild sedation

Small doses of midazolam (1-2 mg) +/- fentanyl (25-50 Small doses of midazolam (1-2 mg) +/- fentanyl (25-50 mcg)mcg)

Titrate q3-5 min to effectTitrate q3-5 min to effect Want pt able to follow instructions, w/ spont respsWant pt able to follow instructions, w/ spont resps

Topical anesthesiaTopical anesthesia 4% viscous lidocaine on gauze to pharynx, or4% viscous lidocaine on gauze to pharynx, or Lidocaine spray (10-20 sprays), orLidocaine spray (10-20 sprays), or Lidocaine nebLidocaine neb

5 cc 2% lido + 5 cc 2% lido w/ epi in nebulizer5 cc 2% lido + 5 cc 2% lido w/ epi in nebulizer Laryngoscopy or FiberopticLaryngoscopy or Fiberoptic

2 options if can see cords:2 options if can see cords: Dynamic airway (e.g. anaphylaxis) Dynamic airway (e.g. anaphylaxis) tube right there tube right there Stable airway (e.g. Pierre Robin) Stable airway (e.g. Pierre Robin) do RSI do RSI

Airway PharmacologyAirway Pharmacology

Drugs you need to knowDrugs you need to know Pre-medicationsPre-medications

L-O-A-DL-O-A-D LidocaineLidocaine FentanylFentanyl AtropineAtropine DefasiculationDefasiculation

Neuromuscular Neuromuscular BlockersBlockers SuccinylcholineSuccinylcholine RocuroniumRocuronium

Induction AgentsInduction Agents EtomidateEtomidate MidazolamMidazolam KetamineKetamine ThiopentalThiopental

SuccinylcholineSuccinylcholinePharmacologyPharmacology

Depolarizing NMBDepolarizing NMB Binds to Ach-R, depolarizes it (fasiculations), and Binds to Ach-R, depolarizes it (fasiculations), and

stays bound preventing further depolarizationstays bound preventing further depolarization Dose:Dose:

Adults: 1.5 mg/kg IV, 3.0 mg/kg IMAdults: 1.5 mg/kg IV, 3.0 mg/kg IM Kids <1 yo: 3.0 mg/kg IVKids <1 yo: 3.0 mg/kg IV Kids >1 yo: 2.0 mg/kgKids >1 yo: 2.0 mg/kg

Onset: 45-60 secOnset: 45-60 sec Duration of Action: ~10 minDuration of Action: ~10 min

SuccinylcholineSuccinylcholineSide EffectsSide Effects

Bradycardia – vagotonic effectBradycardia – vagotonic effect Kids <8 -- prevent w/ atropineKids <8 -- prevent w/ atropine 22ndnd dose – Tx w/ atropine dose – Tx w/ atropine

FasiculationsFasiculations ↑ ↑ IOP – questionable clinical significanceIOP – questionable clinical significance ↑ ↑ ICP – prevent w/ defasiculating dose of RocICP – prevent w/ defasiculating dose of Roc

Hyperkalemic arrest in at risk ptsHyperkalemic arrest in at risk pts Pre-existing hyperK e.g. CRFPre-existing hyperK e.g. CRF Burns: 24 hrs post – 1-2 yrs after healingBurns: 24 hrs post – 1-2 yrs after healing Crush injuries: 7d post – 2-3 monthsCrush injuries: 7d post – 2-3 months Denervation injuries (CVA, spinal cord): 7d – 6 moDenervation injuries (CVA, spinal cord): 7d – 6 mo Neuromuscular Dz (MS, Muscular dystrophies, ALS etc): Neuromuscular Dz (MS, Muscular dystrophies, ALS etc):

indefiniteindefinite Malignant Hyperthermia – rare but 60% mortalityMalignant Hyperthermia – rare but 60% mortality Trismus / masseter spasm – usually transientTrismus / masseter spasm – usually transient

SuccinylcholineSuccinylcholineContraindicationsContraindications

AbsoluteAbsolute Personal or FHx of Malignant HyperthermiaPersonal or FHx of Malignant Hyperthermia Burns >24 hrs oldBurns >24 hrs old Crush or denervation injuries >7d oldCrush or denervation injuries >7d old Neuromuscular DzNeuromuscular Dz

RelativeRelative Lack of experience w/ drugLack of experience w/ drug Anticipated difficult airwayAnticipated difficult airway

RocuroniumRocuroniumPharmacologyPharmacology

Non-depolarizing NMBNon-depolarizing NMB Competes with ACh & binds to ACh-RCompetes with ACh & binds to ACh-R Doesn’t cause depolarization (no Doesn’t cause depolarization (no

fasciculations)fasciculations) Dose: Dose:

Intubation dose: 0.6-1.0 mg/kgIntubation dose: 0.6-1.0 mg/kg Defasiculation dose: 10% of intubation doseDefasiculation dose: 10% of intubation dose

Onset: 60 secOnset: 60 sec Duration of Action: 40-60 minDuration of Action: 40-60 min

Can you reverse it?Can you reverse it?

Sort of…Sort of… NeostigmineNeostigmine

Blocks Ach breakdown – thus increases Blocks Ach breakdown – thus increases [ACh] at receptor to compete with [ACh] at receptor to compete with rocuroniumrocuronium

Won’t work until [Roc] Won’t work until [Roc] ↓’s to ~40% ↓’s to ~40% therefore slow onset (~30 min) making it therefore slow onset (~30 min) making it clinically useless as such in the EDclinically useless as such in the ED

Cholinergic side effectsCholinergic side effects

Induction AgentsInduction Agents

ALL induction agents can potentially ALL induction agents can potentially cause myocardial depression & cause myocardial depression & hypotensionhypotension

Individualize agent & dose to clinical Individualize agent & dose to clinical situationsituation

Inadequate induction (i.e. light pt) Inadequate induction (i.e. light pt) increases risk of laryngospasmincreases risk of laryngospasm

EtomidateEtomidatePharmacologyPharmacology

Imidazole derivative w/ hypnotic effectsImidazole derivative w/ hypnotic effects Appears to work at GABA receptorAppears to work at GABA receptor

Trauma drug of choiceTrauma drug of choice Most hemodynamically stable agent we haveMost hemodynamically stable agent we have

CerebroprotectiveCerebroprotective Blunts Blunts ↑ in ICP, ↓’s cerebral O↑ in ICP, ↓’s cerebral O22 demand demand

DoseDose 0.15 – 0.3 mg/kg (use lower dose if unstable)0.15 – 0.3 mg/kg (use lower dose if unstable)

Onset: 20-30 secsOnset: 20-30 secs Duration of Action: 7-14 minsDuration of Action: 7-14 mins

EtomidateEtomidateSide EffectsSide Effects

Vomiting Vomiting SPAMSPAM N & VN & V

occurs in 30-40%occurs in 30-40% S – SeizuresS – Seizures

Conflicting data, but appears to lower Sz threshold in pts w/ Conflicting data, but appears to lower Sz threshold in pts w/ focal seizuresfocal seizures

P – Pain on injectionP – Pain on injection A – Adrenal surppressionA – Adrenal surppression

Reversible & not associated w/ worse outcomes after single Reversible & not associated w/ worse outcomes after single dosedose

M – MyoclonusM – Myoclonus Not associated w/ Sz activity on EEGNot associated w/ Sz activity on EEG Occurs in 30-65% -- can Occurs in 30-65% -- can ↓ incidence w/ fentanyl pre-Tx↓ incidence w/ fentanyl pre-Tx

EtomidateEtomidateContraindicationsContraindications

4 p’s4 p’s Prior Seizures Prior Seizures PregnancyPregnancy

Category C: animal evidence of harmCategory C: animal evidence of harm Poor Adrenal functionPoor Adrenal function PediatricsPediatrics

Likely to change; several studies Likely to change; several studies documenting use for RSI & PSA in kids documenting use for RSI & PSA in kids

Used by 70% of US ED’sUsed by 70% of US ED’s

KetamineKetaminePharmacologyPharmacology

PCP deriviative PCP deriviative Analgesic, amnestic, anestheticAnalgesic, amnestic, anesthetic

BronchodilatorBronchodilator Drug of choice in Asthma / COPDDrug of choice in Asthma / COPD

Catecholamine release Catecholamine release ↑ HR & BP↑ HR & BP Good in hypovolemic, hypotensive ptsGood in hypovolemic, hypotensive pts

Does not supress respiratory driveDoes not supress respiratory drive Dose: 1-2 mg/kg IV or 4-6 mg/kg IMDose: 1-2 mg/kg IV or 4-6 mg/kg IM Onset: 15-30 SecOnset: 15-30 Sec Duration: 10-15 minDuration: 10-15 min

KetamineKetamineSide EffectsSide Effects

Makes you Makes you SMILESMILE ↑ ’↑ ’s s SSecretionsecretions – prevent w/ atropine – prevent w/ atropine MMyocardialyocardial depression depression

Avoid in kids w/ CHDAvoid in kids w/ CHD IIncreases ncreases IICPCP

Avoid in head traumaAvoid in head trauma LLaryngospasmaryngospasm

Gently bag them; NMB if sats drop/unable to bagGently bag them; NMB if sats drop/unable to bag EEmergencemergence rxns rxns

Midaz does not appear to prevent thisMidaz does not appear to prevent this

MidazolamMidazolamPharmacologyPharmacology

BenzodiazepineBenzodiazepine Acts at GABA receptorActs at GABA receptor Amnestic, anxiolytic, sedative, Amnestic, anxiolytic, sedative,

anticonvulsant propertiesanticonvulsant properties Dose: 0.1 – 0.2 mg/kg IVDose: 0.1 – 0.2 mg/kg IV Onset: 30-60 secOnset: 30-60 sec Duration of Action 30-60 minDuration of Action 30-60 min

MidazolamMidazolamSide EffectsSide Effects

HypotensionHypotension Dose-related Dose-related ↓ in SVR ↓ in SVR Direct myocardial depressionDirect myocardial depression

Opiates potentiate effectOpiates potentiate effect

Respiratory depressionRespiratory depression

Case 6Case 6

4 yo boy4 yo boy Found unresponsive in poolFound unresponsive in pool Brought by EMS unintubatedBrought by EMS unintubated

What makes the pediatric intubation What makes the pediatric intubation different?different?

Pediatric AirwaysPediatric AirwaysLarge head & occiputLarge head & occiput Causes neck flexion – towel Causes neck flexion – towel

under shoulders to obtain under shoulders to obtain sniffing positionsniffing position

Large tongue, tonsils and Large tongue, tonsils and adenoidsadenoids

Obstructs airway, obstructs Obstructs airway, obstructs laryngoscopy view viewlaryngoscopy view view

High anterior larynxHigh anterior larynx Can be more difficult to see – Can be more difficult to see – may need straight blade to lift may need straight blade to lift

epiglottisepiglottis

Funnel-shaped larynx – Funnel-shaped larynx – narrowest portion below cordsnarrowest portion below cords

Use uncuffed tubes in kids <8 Use uncuffed tubes in kids <8 yoyo

Tiny cricithyroid membraneTiny cricithyroid membrane Needle cric is difficult; surgical Needle cric is difficult; surgical cric impossible in age <8 yocric impossible in age <8 yo

High basal metabolic rate & High basal metabolic rate & relatively smaller FRCrelatively smaller FRC

Desat quickly (2x as fast as Desat quickly (2x as fast as adults)adults)

Relatively higher HRelatively higher H22O contentO content Need larger doses of SuxNeed larger doses of Sux

Monosynaptic airway reflexesMonosynaptic airway reflexes Vagal response to laryngoscopy Vagal response to laryngoscopy bradycardia; need atropine bradycardia; need atropine

Pediatric AirwayPediatric AirwayEstimating WeightEstimating Weight

(Age in yrs x 2) + 8(Age in yrs x 2) + 8

Broselow tapeBroselow tape Length-based methodLength-based method

Estimating ETT sizeEstimating ETT size

(Age / 4) + 4(Age / 4) + 4

Size of patient’s small finger = size Size of patient’s small finger = size of ETTof ETT

Broselow tapeBroselow tape Length-based methodLength-based method

ETT Insertion DepthETT Insertion Depth

Size of of ETT x 3 = cm from tip-Size of of ETT x 3 = cm from tip-teethteeth

Broselow tapeBroselow tape Length-based methodLength-based method

Bottom LineBottom Line

In pediatric resuscitation, the In pediatric resuscitation, the Broselow tape is your friend!Broselow tape is your friend!

Cuffed vs uncuffed airways in kidsCuffed vs uncuffed airways in kids Does it matter?Does it matter?

What kind of blade should you What kind of blade should you use?use?

TextbooksTextbooks Straight (Miller) bladeStraight (Miller) blade

Pediatric anesthetists:Pediatric anesthetists: Many use curved (MacIntosh) blade in age>1yoMany use curved (MacIntosh) blade in age>1yo Many use curved blade in all kidsMany use curved blade in all kids

BottomlineBottomline Use what works for youUse what works for you

the endthe end

Basic Airway SkillsBasic Airway Skills

PearlsPearls BVM is cornerstone of airway managementBVM is cornerstone of airway management

Saves lives, especially in kidsSaves lives, especially in kids Gauche 2000: kids did better w/ BVM pre-hospital than Gauche 2000: kids did better w/ BVM pre-hospital than

w/ intubationw/ intubation Read up on it & practice at every opportunityRead up on it & practice at every opportunity

C-grip techniqueC-grip technique SMALL adjustments (especially in kids)SMALL adjustments (especially in kids)

Use OPA’s / NPA’sUse OPA’s / NPA’s KY jelly onto beards to improve sealKY jelly onto beards to improve seal Stuff 4x4’s into cheeksStuff 4x4’s into cheeks Keep dentures in placeKeep dentures in place

Case 1Case 1

65 yo M presents w/ massive LGIB65 yo M presents w/ massive LGIB PMHx: HTN, MIx2, A. fibPMHx: HTN, MIx2, A. fib GCS 15, P120, BP 85/65, RR 28, SpO2 GCS 15, P120, BP 85/65, RR 28, SpO2

98% on NRB98% on NRB What (if any) indications does he What (if any) indications does he

have to be intubated?have to be intubated?

Case 2 Case 2

22 yo F brought in after taking GHB 22 yo F brought in after taking GHB overdose.overdose.

How would you specifically assess How would you specifically assess her airway?her airway?

Assessing an AirwayAssessing an Airway

Taking their last Taking their last GASPSGASPS?? GG – – GCSGCS impairment impairment AA – – Artificial airwayArtificial airway (OPA) tolerated (OPA) tolerated SS – – SwallowingSwallowing impaired / inability to impaired / inability to

handle secretionshandle secretions PP – – PathologicalPathological processprocess involving involving

airway e.g. stab wound, anaphylaxisairway e.g. stab wound, anaphylaxis SS – – SpeechSpeech (quality, quantity) (quality, quantity)

Case 3Case 3

55 yo M brought in by EMS for chest 55 yo M brought in by EMS for chest pain – suddenly becomes pain – suddenly becomes unresponsiveunresponsive

Apneic, pulseless on quick examApneic, pulseless on quick exam Does he need intubation?Does he need intubation? What kind of airway is he?What kind of airway is he?

Approach to Airway Approach to Airway MangementMangement

1) Are indications for intubation present? 1) Are indications for intubation present? Contraindications?Contraindications?

2) Define the type of airway:2) Define the type of airway: EasyEasy DifficultDifficult FailedFailed CrashCrash

3) Choose strategie3) Choose strategieSS best suited to airway & best suited to airway & clinical situationclinical situation

4) Anticipate & plan for post-intubation 4) Anticipate & plan for post-intubation complicationscomplications

Step 2: Type of AirwayStep 2: Type of AirwayRequires Intubation

Easy AirwayNo anticipated difficulty

w/ ETI or BVM

Crash AirwayUnresponsive

Apneic / ArrestedNear-death

Difficult AirwayAnatomyPathology

Failed AirwayCan’t intubate

Can’t bag

RSI

No Drugs orSCh alone

Difficult Airway Algorithm

Failed AirwayAlgorithm

Do Kids really need Do Kids really need Atropine?Atropine?

Retrospective review of163 pediatric ED pts

Fastle & Roback. Ped Emerg Care 2004; 10:651-655