Andy Sloas - Are we Masters of the Paediatric Airway?
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A D U LT & P E D I AT R I C A I RWAY Andrew Sloas, DO, RDMS RDMS,FACEP,FAAEM,FAAP
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Transcript of Andy Sloas - Are we Masters of the Paediatric Airway?
A D U L T & P E D I A T R I C
A I R W A Y
A n d r e w S l o a s , D O , R D M SR D M S , F A C E P , F A A E M , F A A P
T O O R
T h a t i s n o t t h e q u e s t i o n . . . . .
A R E W E M A S T E R S
O F T H E P E D I A T R I C
A I R W A Y
• Understand the differences between adult and pediatric airway
• Develop an algorithmic approach to the difficult pediatric airway
• Understand advanced airway techniques for intubation
• Be aware as to when a patient requires a surgical airway
OBJECTIVES
http://usnews.nbcnews.com/_news/2013/05/12/18210934-oj-simpson-seeks-to-have-robbery-conviction-thrown-out?litehttp://www.hemisfair.org/ai1ec_event/san-antonio-living-history-presentations-dawn-at-the-alamo/?instance_id=
http://www.forbes.com/fdc/welcome_mjx.shtml
http://www.clipartof.com/images/purchased/210376_MDPNG_20130824135353864.png
TO N G U E I N C H E E K
TO N G U E I N A I RWAY
THE CONGENITAL DIFFICULT AIRWAY
http://en.wikipedia.org/wiki/Klippel–Feil_syndrome http://webhome.idirect.com/~brainology/brainology/devpath_271_lysosomal.html
POSITION IS EVERYTHING
Collins JS, Lemmens HJ, Brodsky JB, Brock-Utne JG, Levitan RM. Laryngoscopy and morbid obesity: a comparison of the "sniff" and "ramped" positions. Obes Surg. 2004 Oct;14(9):1171-5. PubMed PMID: 15527629.
Levitan RM, Mechem CC, Ochroch EA, Shofer FS, Hollander JE. Head-elevated laryngoscopy position: improving laryngeal exposure during laryngoscopy by increasing head elevation. Ann Emerg Med. 2003 Mar;41(3):322-30. PubMed PMID: 12605198.
Schmitt HJ, Mang H. Head and neck elevation beyond the sniffing position improves laryngeal view in cases of difficult direct laryngoscopy. J Clin Anesth. 2002 Aug;14(5):335-8. PubMed PMID: 12208436.
http://www.ncsrc.org/2_newsletters_2008_2.shtml
A N YO N E F O R R O C K E T S L E D D I N G ?
APNEIC OXYGENATION
P E E P I N G R ATN A M E D T O M
http://goo.gl/1CTCJU
http://goo.gl/oJA6xK
http://goo.gl/Mf0TW0
Bronchiolitis or Croup ?Stridor and Wheeze
CRASHDL()(ET(
Placed?CAN(BAG?
2nd(try(
with(
paraly?cs
ET(Placed? FAILED
LMA/Combitue
Cannot(Intubate/
Can(Ven?ilate
CAN(BAG?
Can(Intubate/
Cannot(Ven?late
Cannot(Intubate/
Cannot(Ven?late
If(surgical(airway(ready;(
one(shot(quick(look
*Surgical(Airway
DIFFICULT**LEMON((Laws)(
BAT(MOANS,(SAT(>90%
Bag,(Oral(Airway,(
Jaw(Thrust(=(
SAT>90?
NOW(SAT(
>90%
Intuba?on(
Predicted((
Successful?
AWAKE(SEDATED(
INTUBATION
Hypercapnia,(Severe(
Sepsis,(Acidosis,(
Aspirin(OD
DELAYED(SEQUENCE(
INTUBATION
Bougie,(Video(Assist(
Intuba?on((LMA,(Flexible/
Rigid(Bronch,(Retrograde(
Intuba?on
RSI
INTUBATION
PREPARE(
PRETREAT
PLACEMENT
POSTERIOR((BURP)
PARALYSIS
PLACE(TUBE
POST/CONFIRMATION
Direct(Laryngoscopy(
Successful?
Can(
BAG?
Aaempted(DL(3(?mes(
by(most(experienced(
operator(=(no(ETT
START
Failed Failed
NO
NO((( NO
YES
Failed
Failed
NO
NO
YES
YES
YES
YESNO
YES
NO
NO
YES
NO YES
YES NO
NO
Failed
*(Surgical%Airway:• Surgical(Cric(if(>(12(yrs(or(MD(feels(
appropriate(size(neck
• Needle(Cric(<(12(with(jet(ven?la?on
(
Needle%Cric%and%Jet%Ven/la/on:!!this!only!buys!you!30!minutes!of!oxygena4on!–!call!a!SURGEON!•((Cric(with(a(14(or(16(g(angiocath•((aaach(BVM(adapter((plas?c(piece(b/w(ET(and(BVM)(from
((((a(3.0(ET(tube(to(angiocath(and(then(to(the(BVM
•(aaach(3cc(syringe(to(the(angiocath,(then(aaach(BVM((((adapter(from(6.5/7.0(ET(tube(to(a(BVM
•(Give(20(gentle(bags(q(minute(and(call(for(a(surgeon!
EMERGENCY(MEDICINE(AIRWAY(ALGORITHM
**(BAT%MOANS%and%LEMON:L()(• BAT(=(Blood/Anaphylaxis/Trauma.((These(have(a(physiologic((blood/
edema)(or(severe(anatomic(barrier((trauma)(and(will(most(likely(need(
surgical(airways(in(failed(algorithm.
• MOANS(=(Mask(fit/obeise/adv(age/no(teeth/s?ff(neck.((These(are(
physiologic(barriers(that(do(beaer(with(secondary(airway(devices.((
E((()((3(3(2(rule.
M()((Mallampa?(score(3((loss(of(tonsil(pillars)(or(greater(is(predicted(
diffiicult
O(()((Obstruc?ons
N(()((Neck(s?ffness
(
NO
NO
YES
Thursday, August 2, 12
DELAYED SEQUENCE INTUBATION
iLMAPreoxygenation
http://www.youtube.com/watch?v=yvcDEbGOw0A
Peds Anesth 2004
http://www.zastavki.com/eng/Creative_Wallpaper/wallpaper-14000.htmhttp://www.foro.fullaventura.com/viewtopic.php?f=1&t=32021
http://www.espntimes.com/tag/horseshoes
Cincinnati Mar 2013
CHOP, Mar 2013
G L I D E S C O P E P E D I A T R I C
http://www.youtube.com/watch?v=_zXI_pN39AI
SURGICAL AIRWAYS
Stay cool.....
This is going to get bloody.....
Scalpel, finger, bougie
Practice on a trainer
Wide range of “contraindications”
< 5 yo
< 8 yo
< 10 yo
< 12 yo
C R I C ’ N K I D S
https://wiki.uiowa.edu/display/protocols/Tracheotomy+(epithelial+lined+tracheostomy)+with+laryngeal+suspension+for+ankylosing+
http://medical-diagonosis.wonderhowto.com/how-to/perform-cricothyrotomy-emergency-room-220545/
http://www.bestpediatricsurgeon.com/cystic-hygroma/
http://medical-diagonosis.wonderhowto.com/how-to/perform-cricothyrotomy-emergency-room-220545/
https://wiki.uiowa.edu/display/protocols/Tracheotomy+(epithelial+lined+tracheostomy)+with+laryngeal+suspension+for+ankylosing
S U M M A R Y
DL Success = 99%
VL Success = 98%
