Pediatric Prehospital Airway Management By: Aaron Mills 11/26/07

The Pediatric Airway  Introduction  Anatomy / Physiology  Positioning  Adjuncts  Intubation

Introduction Almost all pediatric “codes” are of respiratory origin As few as 10% of emergency calls involve a peds patient, of which only 1% involve a critically ill or injured child.

Reasons Why These Airways Are Difficult  Emotional Response  Different Anatomy  Structures not fully developed  Large tongue

Pediatric Cardiopulmonary Arrests

Anatomy Children are much harder to intubate than adults

Anatomy: Larynx Narrowest point = cricoid cartilage

Airway Difference

Airway Positioning “Sniffing Position” Towel is placed under the head

Airway positioning for children <2yrs

Adjuncts  Nasal airway  Oral airway

Nasopharyngeal Airway  Contraindications:  Basilar skull fracture  CSF leak

Adjuncts: Oral Airway Wrong size: Too Long

Adjuncts: Oral Airway Wrong size: Too Short

Adjuncts: Oral Airway Correct size

Adjuncts: Oral Airway The importance of proper size

Signs of Respiratory Distress  Tachypnea  Tachycardia  Grunting  Stridor  Head bobbing  Flaring  Inability to lie down  Agitation  Retractions  Access muscles  Wheezing  Sweating  Prolonged expiration  Apnea  Cyanosis

Intubation

Intubation: Indications  Failure to oxygenate  Failure to remove CO 2  Neuromuscular weakness  CNS failure  Cardiovascular failure

Laryngoscope Blades Macintosh Miller

Using The Miller Blade Better in younger children with a floppy epiglottis Straight Laryngoscope Blade – used to pick up the epiglottis

ET Tube sizes  AgekgETT Length (lip)  Newborn  3 mos  1 yr  2 yrs  Children > 2 years:  ETT size: Age/4 + 4  ETT depth (lip): Age/2 + 12

Predicting the Difficult Airway  Difficulty ventilating  Facial trauma  Obesity  Obstructions  Stiff lungs (asthma)  Difficulty intubating  External factors (obesity)  Evaluate mouth opening  Obstruction  Smaller airways  Neck mobility (trauma)

Easy or Hard?

Back-up Plan  Can’t ventilate or basics not working  Consider adjuncts (OPA/NPA/positioning)  Intubation?  Can’t intubate  Rescue devices  Can’t rescue  Surgical procedure  Okay to stick with basics if working

Overview  Anatomy / Physiology  Positioning  Adjuncts  Intubation

Questions?

References  Hazinski MF, et al (Ed). PALS provider manual. AHA,  Lee BS, et al. Pediatric airway management. Clin Ped Emerg Med (2):  Lubitz DS. A rapid method of estimating weight and resuscitation drug doses from length in the pediatric age group. Ann Emerg Med (6): 