Pediatric Emergencies Airway and Ventilation Management

Anatomical Considerations Airway is much smaller Tongue is proportionately larger in child in relation to other airway structures Small amounts of edema or obstruction is more harmful in children (size!) High position of the larynx makes angle b/n the base of tongue and glottic opening more acute (for tubing..later)

General Principals Anticipate and recognize resp. complications before they arise Support, or replace, those functions that are compromised or lost My golden rule, “Airway, airway, airway!”

Gen. Principals (cont’) Conscious Pt’s: - sit in position of comfort (usually assume position most conducive) - sit w/ parents - anxiety increases O2 consumption Unconscious Pt’s: -airway becomes obstructed due to relaxation and flexion. - use noninvasive maneuvers before adjuncts

Respiratory Monitoring Pulse Oximetry is an important technique for monitoring children w/ insufficient respiration. (or even w/out) Be aware of CO poisoning! Don’t let it fool you I’m serious! End Tidal CO2 monitors for pts that are intubated (NON-arrest!)

O2 Delivery Systems Choice of delivery is determined by pt’s status and desired concentration There are low flow systems (ex…simple mask!) There are high flow systems (ex…non-rebreather masks!)

O2 Masks KIDS HATE MASKS Remember the anxiety thing! Introduce O2 via blow by or secondary device Do so in non-threatening way!

Oropharyngeal Airways Used on UNCONS only Proper sizing…who can tell me? Too big…may obstruct larynx or traumatize structures of the airway Too Small… It will push the tongue posteriorly into the pharynx Use a tongue depressor if available!

Suction Devices A suction force of 80 to 120 mm HG is generally needed…uhhh, ok… So pick wisely Flexible plastic suction caths are useful and can be placed even into an ET tube. Look for bradycardia…monitor pulse when suctioning….why?

Management of Resp. Arrest My three simple rules of quality EMS! Airway…open and keep it open Breathing…support it artificially and appropriately Circulation…access and monitor

Arrest Continued Remember…as soon as respiratory failure or inadequate respirations are noticed, rapid initiation of assisted ventilation is the only appropriate therapy. More than half (like way more) of peds arrests are due to resp. failure and not cardiac failure.

BVM Ventilation Two hands needed One to “compress” bag Other holds mask and… Can do a modified jaw thrust at same time!

BVM continued To position the head..we call it the “sniffing position” May have to move head several times to find most beneficial and effective position. Cricoid pressure anyone?

Endotracheal Intubation What I like to call, “The Meat and Potatoes”

ET Intubation Topic Headers Cuffed vs. Uncuffed Appropriate Diameter Appropriate Depth Blade Type Selection Techniques for Pediatric Intubation

Cuffed vs. Uncuffed Used for peds 8 to 10y.o. or older Cuff should be inflated until slight leak is audible Used for peds < 8 years old Should also have slight audible leak due to anatomy of pedi pt’s.

Diameter Equations Use of Broslow Tape or Pedi Wheels Tube diameter is approx. size of pt’s little finger Or the following: ET Size = age/4 + 4 Most accurate is the use of a length based tape.

Appropriate Depth For pt’s over 2 y.o.: ET Depth = age/2 + 12 But this equation can sometimes result in placement of tube just above the corina. Try this one: the ET tube size x 3!

Blade Types Macintosh Curved Tip is placed in vallecula Not the best choice for pedi pt’s Miller Straight Lifts the Epiglottis Better fit for peds due to… Does anyone remember?

Answer! The high position of the larynx makes the angle b/n the base of the tongue and glottic opening more acute!

Techniques/Considerations Monitor heart rate when intubating Slightly lubricate the stylet so that it pulls out easier…less room for movement in relation to size of peds. Pulse oximetry can help monitor hypoxemia during intubation Secure tube but auscultate lungs prior to doing so to reconfirm placement!

Conclusion Remember…the most important treatment for pedi pt’s is airway management…

Conclusion And remember to not only take care of your pt’s but yourself as well!