Pediatric Airway Management

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1 Pediatric Airway Management Dec 2003 Dr. Shapiro I., PICU

2 Adult Chain of Survival EMS CPR ALS Early Defibrillation

3 Pediatric Chain of Survival Prevention CPR EMS ALS

4 Out-of-Hospital Cardiac Arrest SIDS Trauma Submersion Poisoning Choking Severe Asthma Pneumonia

5 In-Hospital Cardiac Arrest Sepsis Respiratory Failure Drug Toxicity Metabolic Disorder Arrhythmias

6 Pediatric Cardiorespiratory Arrests 10% 10% Respiratory 80% Shock Cardiac

7 Pediatric Cardiorespiratory Arrests Hypoxia and Hypercarbia Bradycardia

8 Outcome of cardiac arrest in children Arrive in ER in cardiac arrest (N = 80) Admit PICU (N=43) 54 % Died in ER (N=37) 46% Mod Deficit (N=3) PVS at 12 mos (N=2) Dead at 12 mos (N=1) Died in ICU (N=37) 46% Schindler M, et al. Outcome of out-of-hospital cardiac or respiratory arrest in children. N Engl J Med 1996;335:

9 Survival from Respiratory Arrest Respiratory Arrest Alone more than 50% neurologically intact survival rate

10 Pediatric Chain of Survival Prevention CPR EMS ALS

11 To Simplify the Message Early Defibrillation With exceptions (sudden collapse, cardiac history) With exceptions (submersion, trauma, drug overdose)

12 PREVENTION

13 BLS Respiratory Distress Respiratory Failure and Respiratory Arrest

14 Evaluation of Respiratory Performance Respiratory Rate and Regularity Level of Consciousness Color of the Skin and Mucous Membranes Respiratory Mechanics

15 Respiratory Mechanics Head Bobbing Nasal Flaring Retractions Grunting Stridor Wheezing or Prolonged Exhalation

16 Upper Airway Obstruction turbulence

17 Lower Airway Obstruction turbulence & wheezing

18 Anatomy Children are very different than adults!!!

19 Anatomy : Airway Nose Tongue Epiglottis Vocal Cords Larynx

20 Anatomy: Larynx Narrowest point = cricoid cartilage ADULT INFANT

21 Physiology Tongue - Posterior Displacement Tongue Difficult to Control Epiglottis Difficult to Control Vocal Cords Difficult Intubation Tube size relative to Cricoid Diameter Small Airway Edema causes High Resistance

22 Effect Of Edema Poiseuille s s law

23 Basic Life Support A+B

24 Two Steps Before 1. Ensure the Safety of Rescuer and Victim ( the scene, gloves, barrier devices) Partial CPR: Is Something Better than Nothing? 2. Stimulate and Check Responsiveness

25 Airway Head Tilt-Chin Lift Jaw Thrust + Tongue-Jaw Lift Maneuver (FBAO)

26 Breathing Check Breathing Look Listen Feel Recovery Position Rescue Breathing

27 Ventilation with Oxygen Mouth-to-Mouth ventilation provides only 17% O 2 Indicated to all seriously ill or injured patients even if pco 2 is high If Possible humidify Oxygen Use of reduced FiO 2 is uncommon

28 Devices to Monitor Respiratory Function Pulse Oxymetry End-Tidal CO 2 Arterial Blood Gas Analysis

29 Oxygen Delivery Systems Oxygen Mask Face Tent Oxygen Hood Oxygen Tent Nasal Canula

30 Oropharyngeal Airway SIZE PROPER POSITION

31 Nasopharyngeal Airway

32 Nasopharyngeal Airway

33 Bag-Mask Ventilation Proper area for mask application

34 Bag-Mask Ventilation Sellick Maneuver

35 Laryngeal Mask Contraindicated if gag-reflex is intact Higher success rate Does NOT protect from aspiration Difficult to maintain during transport

36 Intubation

37 Intubation: Indications Failure to oxygenate Failure to remove CO 2 Increased WOB Neuromuscular weakness CNS failure Cardiovascular failure

38 Tracheal Tube Age kg ETT Length Newborn mos yr yrs Children > 2 years: ETT size: (Age+16)/4 ETT depth (lip): ETTsize x 3

39 Laryngoscope Blades Straight Better in younger children with a floppy epiglottis

40 Laryngoscope Blades Curved Better in older children who have a stiff epiglottis

41 Intubation Technique

42 Confirmation of ETT Placement NO single technique is 100% reliable Clinical Confirmation Chest X-ray CO2 Detection Esophageal Detector Devices

43 Clinical Confirmation Chest rise Water vapor seen inside tube Breath sounds - lung Breath sounds epigastrium O 2 Saturation

44 Acute Deterioration after Intubation D.O.P.E: Displacement Obstruction Pneumothorax Equipment failure

45 Inadequate Improvement after Intubation Inadequate Tidal Volume Excessive Leak Around The Tube Air Trapping and Impaired Cardiac Output Leak or Disconnection in Ventilator System Inadequate PEEP Inadequate O 2 Flow from Gas Source

46 Percutaneous Cricothyrotomy Complete UA Obstruction: FBAO Severe Orofacial Injuries Upper Airway Infections

47 See You at Next Week s Workshop Happy Khanukka

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