Pediatric Airway Management Dec 2003 Dr. Shapiro I., PICU
Adult Chain of Survival EMS CPR ALS Early Defibrillation
Pediatric Chain of Survival Prevention CPR EMS ALS
Out-of-Hospital Cardiac Arrest SIDS Trauma Submersion Poisoning Choking Severe Asthma Pneumonia
In-Hospital Cardiac Arrest Sepsis Respiratory Failure Drug Toxicity Metabolic Disorder Arrhythmias
Pediatric Cardiorespiratory Arrests 10% 10% Respiratory 80% Shock Cardiac
Pediatric Cardiorespiratory Arrests Hypoxia and Hypercarbia Bradycardia
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;335:1473-1479
Survival from Respiratory Arrest Respiratory Arrest Alone more than 50% neurologically intact survival rate
Pediatric Chain of Survival Prevention CPR EMS ALS
To Simplify the Message Early Defibrillation With exceptions (sudden collapse, cardiac history) With exceptions (submersion, trauma, drug overdose)
PREVENTION
BLS Respiratory Distress Respiratory Failure and Respiratory Arrest
Evaluation of Respiratory Performance Respiratory Rate and Regularity Level of Consciousness Color of the Skin and Mucous Membranes Respiratory Mechanics
Respiratory Mechanics Head Bobbing Nasal Flaring Retractions Grunting Stridor Wheezing or Prolonged Exhalation
Upper Airway Obstruction turbulence
Lower Airway Obstruction turbulence & wheezing
Anatomy Children are very different than adults!!!
Anatomy : Airway Nose Tongue Epiglottis Vocal Cords Larynx
Anatomy: Larynx Narrowest point = cricoid cartilage ADULT INFANT
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
Effect Of Edema Poiseuille s s law
Basic Life Support A+B
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
Airway Head Tilt-Chin Lift Jaw Thrust + Tongue-Jaw Lift Maneuver (FBAO)
Breathing Check Breathing Look Listen Feel Recovery Position Rescue Breathing
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
Devices to Monitor Respiratory Function Pulse Oxymetry End-Tidal CO 2 Arterial Blood Gas Analysis
Oxygen Delivery Systems Oxygen Mask Face Tent Oxygen Hood Oxygen Tent Nasal Canula
Oropharyngeal Airway SIZE PROPER POSITION
Nasopharyngeal Airway
Nasopharyngeal Airway
Bag-Mask Ventilation Proper area for mask application
Bag-Mask Ventilation Sellick Maneuver
Laryngeal Mask Contraindicated if gag-reflex is intact Higher success rate Does NOT protect from aspiration Difficult to maintain during transport
Intubation
Intubation: Indications Failure to oxygenate Failure to remove CO 2 Increased WOB Neuromuscular weakness CNS failure Cardiovascular failure
Tracheal Tube Age kg ETT Length Newborn 3.5 3.5 9 3 mos 6.0 3.5 10 1 yr 10 4.0 11 2 yrs 12 4.5 12 Children > 2 years: ETT size: (Age+16)/4 ETT depth (lip): ETTsize x 3
Laryngoscope Blades Straight Better in younger children with a floppy epiglottis
Laryngoscope Blades Curved Better in older children who have a stiff epiglottis
Intubation Technique
Confirmation of ETT Placement NO single technique is 100% reliable Clinical Confirmation Chest X-ray CO2 Detection Esophageal Detector Devices
Clinical Confirmation Chest rise Water vapor seen inside tube Breath sounds - lung Breath sounds epigastrium O 2 Saturation
Acute Deterioration after Intubation D.O.P.E: Displacement Obstruction Pneumothorax Equipment failure
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
Percutaneous Cricothyrotomy Complete UA Obstruction: FBAO Severe Orofacial Injuries Upper Airway Infections
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