1. Airway Management Aric Storck PGY-5 Dr. Mike Betzner July 20, 2005

2. Objectives Crash course in ED airway management: Crash course in ED airway management: Indications Indications Who do you intubate Who do you intubate Who do you not intubate Who do you not intubate What type of airway is it What type of airway is it easy, difficult, failed, crash easy, difficult, failed, crash RSI RSI Pediatric Airways Pediatric Airways Hands on procedural skills station Hands on procedural skills station

3. Practical skill stations Practical skill stations Gum elastic bougie Gum elastic bougie LMA & I-LMA LMA & I-LMA Trachlight Trachlight Needle cricothyrotomy / surgical cricothyrotomy Needle cricothyrotomy / surgical cricothyrotomy

4. Case 78F 78F Acutely SOB Acutely SOB Alert Alert Talking one word sentences Talking one word sentences JVP up JVP up Diffuse wheeze Diffuse wheeze Sats 84% Sats 84% ABG 7.25 / 60 / 50 / 19 ABG 7.25 / 60 / 50 / 19 Does she need intubation? Does she need intubation?

5. Step 1 Who needs intubation?

6. Indications for Intubation ABCDE ABCDE A - Airway protection A - Airway protection aspiration, obstruction aspiration, obstruction B – Breathing B – Breathing Failure to oxygenate Failure to oxygenate Failure to ventilate Failure to ventilate C – Circulation (Shock) C – Circulation (Shock) D – Disability / neuro (GCS <9 or drop by 2) D – Disability / neuro (GCS <9 or drop by 2) E - Expected clinical course E - Expected clinical course

7. Does our patient have a reason to intubate? Airway – not a concern right now Airway – not a concern right now Breathing Breathing Failure to oxygenate Failure to oxygenate Failure to ventilate Failure to ventilate Circulation – not a concern right now Circulation – not a concern right now Disability – not a concern right now Disability – not a concern right now Expected Course – likely to get worse Expected Course – likely to get worse

8. Does our patient need to be intubated immediately? Crash Airway

9. APPROACH TO THE AIRWAY

10. THE CRASH AIRWAY

11. You have decided to intubate. How do you assess her airway?

12. Predicting a Difficult Airway the LEMON law L = Look L = Look E = Examine E = Examine M = Mallampatti M = Mallampatti O = Obstruction O = Obstruction N = Neck mobility N = Neck mobility

13. LEMON - Look Obesity Obesity Micrognathia Micrognathia High arched palate High arched palate Narrow face Narrow face Short or thick neck Short or thick neck Neck trauma Neck trauma Large tongue Large tongue Presence of facial hair Presence of facial hair Dentures Dentures Large teeth Large teeth Easy intubation Call anesthesia

14. LEMON –Evaluate 3-3-2 Evaluate 3-3-2 Evaluate 3-3-2 3 fingers of mouth opening 3 fingers of mouth opening 3 fingers between front of chin and hyoid 3 fingers between front of chin and hyoid 2 fingers from mandible to thyroid cartilage 2 fingers from mandible to thyroid cartilage

15. LEMON – Mallampati score Mallampati score Mallampati score Grade 1: entire post. Pharynx, visualized to tonsillar pillars Grade 1: entire post. Pharynx, visualized to tonsillar pillars No difficulty No difficulty Grade 2: hard palate, soft palate and top of uvula only Grade 2: hard palate, soft palate and top of uvula only No difficulty No difficulty Grade 3: hard and soft palate only Grade 3: hard and soft palate only Moderate difficulty Moderate difficulty Grade 4: no visualization post pharynx or uvula (hard palate only Grade 4: no visualization post pharynx or uvula (hard palate only Severe difficulty Severe difficulty

16. LEMON -Obstruction Upper and lower airway obstruction Upper and lower airway obstruction Foreign body aspiration Foreign body aspiration Epiglottitis Epiglottitis Croup Croup Abscesses Abscesses Trauma Trauma Others Others

17. LEMON –Neck Mobility C-spine collar C-spine collar Rheumatoid arthritis Rheumatoid arthritis Spinal surgery Spinal surgery

18. Is this likely a difficult airway?

19. RSI (Rapid Sequence Intubation) What is it? What is it? Preoxygentation + Induction agent + NMB + Sellicks maneuver Preoxygentation + Induction agent + NMB + Sellicks maneuver Why do we do it? Why do we do it? To minimize risk of aspiration in unfasted pts i.e. almost anybody in the ED To minimize risk of aspiration in unfasted pts i.e. almost anybody in the ED Whom do you do it in? Whom do you do it in? Pts w/ anticipated & no contraindications to RSI (~80% of ED intubations) Pts w/ anticipated easy airways & no contraindications to RSI (~80% of ED intubations)

20. Steps of RSI 7 P’s 7 P’s Preoxygenation-10 to -5 min Preoxygenation-10 to -5 min Preparation Preparation Premedication-3 min Premedication-3 min Paralysis & Induction0 min Paralysis & Induction0 min Protection & Positioning+20 sec Protection & Positioning+20 sec Pass the tube w/ Proof+ 45-60 sec Pass the tube w/ Proof+ 45-60 sec Post-intubation care+60 – 80 sec Post-intubation care+60 – 80 sec Sellicks maneuver = key concept in RSI

21. Preoxygenation Why do we do it? Why do we do it? Replace nitrogen portion of FRC w/ 100% O 2, creating a for delaying desaturation during apneic period Replace nitrogen portion of FRC w/ 100% O 2, creating a O 2 reservoir for delaying desaturation during apneic period How do we do it? How do we do it? Ideally 5 min of 100% O 2 via BVM or alternatively 8 VC breaths Ideally 5 min of 100% O 2 via BVM or alternatively 8 VC breaths Pearls Pearls NRB delivers only 70% O 2 – need to use BVM w/ good seal NRB delivers only 70% O 2 – need to use BVM w/ good seal Spontaneous breaths only -- DON’T BAG THE PT (unless clinically indicated) Spontaneous breaths only -- DON’T BAG THE PT (unless clinically indicated) DON’T BREAK SEAL – single RA breath sets you back to step 1 DON’T BREAK SEAL – single RA breath sets you back to step 1

23. Preparation Even SIMPLE BOB can do it… Even SIMPLE BOB can do it… S – Suction S – Suction I – IV I – IV M – Meds & Monitors M – Meds & Monitors P – Personnel P – Personnel L – Laryngoscopes L – Laryngoscopes E – ETT’s (3 sizes) E – ETT’s (3 sizes) B – BVM B – BVM O – Oxygen O – Oxygen B – Backups / alternative devices B – Backups / alternative devices

24. Pretreatment LOAFD – given 3 min before Induction LOAFD – given 3 min before Induction L – Lidocaine L – Lidocaine 1.5 mg/kg IV (tight heads, tight lungs) 1.5 mg/kg IV (tight heads, tight lungs) O – Opiates (Fentanyl) O – Opiates (Fentanyl) 2-3 ug/kg IV – blunts sympathetic response 2-3 ug/kg IV – blunts sympathetic response A – Atropine 0.02 mg/kg IV A – Atropine 0.02 mg/kg IV Kids ≤ 10 or 2 nd dose Sux Kids ≤ 10 or 2 nd dose Sux F – Fluid bolus F – Fluid bolus D – Defasiculating agent D – Defasiculating agent Rocuronium 0.1 mg/kg – blunts rise in ICP Rocuronium 0.1 mg/kg – blunts rise in ICP

25. Paralysis & Induction Induction agent Induction agent Etomidate 0.15-0.30 mg/kg IV push Etomidate 0.15-0.30 mg/kg IV push Midazolam 0.1-0.2 mg/kg IV push Midazolam 0.1-0.2 mg/kg IV push Ketamine 1-2 mg/kg IV push Ketamine 1-2 mg/kg IV push Thiopental 1-5 mg/kg IV push Thiopental 1-5 mg/kg IV push NMB NMB Succinylcholine 1.5 mg/kg IV push Succinylcholine 1.5 mg/kg IV push Rocuronium 0.6 – 1.0 mg/kg IV push Rocuronium 0.6 – 1.0 mg/kg IV push

26. Protection…. Sellicks Maneuver Sellicks Maneuver Gentle (10 lb) pressure on cricoid ring – compresses esophagus & prevents passive regurgitation Gentle (10 lb) pressure on cricoid ring – compresses esophagus & prevents passive regurgitation Initiate 10-20 sec after NMB – don’t release until cuff inflated & ETT position confirmed Initiate 10-20 sec after NMB – don’t release until cuff inflated & ETT position confirmed Release if vomiting occurs (rare once NMB in) Release if vomiting occurs (rare once NMB in) Key part of RSI but frequently done wrongly, poorly, or forgotten altogether Key part of RSI but frequently done wrongly, poorly, or forgotten altogether

27. … & Positioning Key to successful intubation – don’t neglect Key to successful intubation – don’t neglect Age & Body habitus dependent – goal is “sniffing” position Age & Body habitus dependent – goal is “sniffing” position Neonates & infants – towel under shoulders Neonates & infants – towel under shoulders Children – towel under neck Children – towel under neck Adolescents & Adults – towel under head Adolescents & Adults – towel under head Obese – towels under head, neck, & shoulders Obese – towels under head, neck, & shoulders

28. Pass the tube w/ Proof Confirmation of ETT position Confirmation of ETT position Watch it go through cords Watch it go through cords ETCO 2 monitors – gold standard ETCO 2 monitors – gold standard Colorimetric – Yellow = Yes / Purple = Poor Colorimetric – Yellow = Yes / Purple = Poor Portable digital – gives reading Portable digital – gives reading Quantitative – good waveform Quantitative – good waveform Esophageal detector devices Esophageal detector devices Bulb or syringe aspiration Bulb or syringe aspiration Clinical methods – least reliable Clinical methods – least reliable Auscultation, chest rise, misting Auscultation, chest rise, misting

29. Post-intubation Management Right insertion depth? Right insertion depth? Adults: TT = TT (tip-teeth = 22 cm) Adults: TT = TT (tip-teeth = 22 cm) Kids: ETT size x3 = cm mark at teeth Kids: ETT size x3 = cm mark at teeth Confirm w/ portable CXR Confirm w/ portable CXR Secure ETT Secure ETT Ventilator settings Ventilator settings different talk but hugely important! different talk but hugely important! Continued sedation +/- paralysis Continued sedation +/- paralysis Rule of 1/3’s – give 1/3 of intubation doses prn Rule of 1/3’s – give 1/3 of intubation doses prn

30. Contraindications to RSI Relative Relative Anticipated difficulty to intubate or BMV ventilate pt Anticipated difficulty to intubate or BMV ventilate pt Inexperience w/ RSI technique & drugs Inexperience w/ RSI technique & drugs Specific drug contraindications Specific drug contraindications Upper airway obstruction Upper airway obstruction

31. Case You have just intubated your patient You have just intubated your patient Suddenly they becomes difficult to bag Suddenly they becomes difficult to bag What is your approach to dealing with post-intubation complications? What is your approach to dealing with post-intubation complications?

32. Approach to post-intubation complications G-DOPE G-DOPE G – gastric distention (peds) G – gastric distention (peds) D – Displacement of ETT D – Displacement of ETT O – Obstruction of ETT O – Obstruction of ETT P – Pneumothorax P – Pneumothorax E – Equipment failure E – Equipment failure Pearls Pearls Bradycardia = esophageal intubation until proven otherwise Bradycardia = esophageal intubation until proven otherwise When in doubt, take it out (change everything) When in doubt, take it out (change everything)

33. Case 4 45M 45M Morbidly obese, big beard Morbidly obese, big beard Sudden collapse and grand mal seizure Sudden collapse and grand mal seizure Vomiting as EMS rolls them in Vomiting as EMS rolls them in What kind of airway is this? What kind of airway is this?

34. Difficult Airway Anesthesia literarture: Anesthesia literarture: 1-3% of intubations will be difficult 1-3% of intubations will be difficult 0.1-0.4% of anticipated “easy” intubations end up failing intubation 0.1-0.4% of anticipated “easy” intubations end up failing intubation ~1/10,000 will be “can’t intubate, can’t bag” ~1/10,000 will be “can’t intubate, can’t bag” ED airways likely more difficult ED airways likely more difficult NEAR data indicates 1% cricothyrotomy rate NEAR data indicates 1% cricothyrotomy rate Important to try and anticipate but often cannot Important to try and anticipate but often cannot

35. Approach to the Difficult Airway 1. Anticipate thorough evaluation when possible thorough evaluation when possible 2. Call for help 2 nd EP, anesthesia, ENT, surgery, etc. 2 nd EP, anesthesia, ENT, surgery, etc. 3. Evaluate ability to bag the patient 4. Make an intubation strategy Triple set-up Triple set-up Topical anesthesia / awake laryngoscopy Topical anesthesia / awake laryngoscopy Adjuncts / Alternatives / Backups Adjuncts / Alternatives / Backups

36. Predictors of the Difficult Airway COMATOSE COMATOSE C – C-Spine mobility limitations C – C-Spine mobility limitations O – Obstructed, OSA O – Obstructed, OSA M – Mallampati grade 3 or 4 M – Mallampati grade 3 or 4 A – Anatomy A – Anatomy dysmorphic features, retrognathia, short or thick neck, large incisors, facial hair dysmorphic features, retrognathia, short or thick neck, large incisors, facial hair T – Trauma (head, neck) T – Trauma (head, neck) O – Obesity O – Obesity S – “Soon to be moms” (pregnant) S – “Soon to be moms” (pregnant) E – Evaluate 3-3-2 rule E – Evaluate 3-3-2 rule

37. Predictors of Difficult BMV Age > 55 yo Age > 55 yo Obesity (BMI > 26 kg/m 2 ) Obesity (BMI > 26 kg/m 2 ) Facial Hair Facial Hair Lack of teeth Lack of teeth Hx of snoring Hx of snoring Identified as independent predictors of difficlut BMV ventilation in prospective analysis of 1502 pts Identified as independent predictors of difficlut BMV ventilation in prospective analysis of 1502 pts Anesthesiology 2000; 92:1229–36 Anesthesiology 2000; 92:1229–36

38. Difficult Airway Algorithm Anticipated Difficult Airway Time (sats OK)No Time (desats) BMV worksBMV Fails Failed Airway Anticipate easy to Bag Anticipate hard to bag Triple Set-up Awake Look +/- RSI Backups Ready 2 Cric Topical Anesthesia Mild Sedation Awake Laryngoscopy Consider: I-LMA Trachlight Fiberoptic Cricothyrotomy BNTI Failed Airway

39. Triple Set-Up 1. Awake laryngoscopy topical anaesthesia topical anaesthesia may go to RSI if looks easy may go to RSI if looks easy 2. Rapid Sequence Induction 2-3 backups immediately at hand: 2-3 backups immediately at hand: Bougie Bougie Trachlight Trachlight I-LMA I-LMA Fiberoptic Fiberoptic McCoy blade McCoy blade 3. Cricothyroidotomy preparation Neck prepped & draped, Cric kit open, 2 nd person gloved & gowned w/ scalpel in hand Neck prepped & draped, Cric kit open, 2 nd person gloved & gowned w/ scalpel in hand

40. Awake Laryngoscopy Mild sedation Mild sedation Small doses of midazolam (1-2 mg) +/- fentanyl (25-50 mcg) Small doses of midazolam (1-2 mg) +/- fentanyl (25-50 mcg) Titrate q3-5 min to effect Titrate q3-5 min to effect Want pt able to follow instructions, w/ spont resps Want pt able to follow instructions, w/ spont resps Topical anesthesia Topical anesthesia 4% viscous lidocaine on gauze to pharynx, or 4% viscous lidocaine on gauze to pharynx, or Lidocaine spray (10-20 sprays), or Lidocaine spray (10-20 sprays), or Lidocaine neb Lidocaine neb 5 cc 2% lido + 5 cc 2% lido w/ epi in nebulizer 5 cc 2% lido + 5 cc 2% lido w/ epi in nebulizer Laryngoscopy or Fiberoptic Laryngoscopy or Fiberoptic 2 options if can see cords: 2 options if can see cords: Dynamic airway (e.g. anaphylaxis)  tube right there Dynamic airway (e.g. anaphylaxis)  tube right there Stable airway (e.g. Pierre Robin)  do RSI Stable airway (e.g. Pierre Robin)  do RSI

41. Airway Pharmacology Drugs you need to know Pre-medications Pre-medications L-O-A-D L-O-A-D Lidocaine Lidocaine Fentanyl Fentanyl Atropine Atropine Defasiculation Defasiculation Neuromuscular Blockers Neuromuscular Blockers Succinylcholine Rocuronium Induction Agents Induction Agents Etomidate Midazolam Ketamine Thiopental

42. Succinylcholine Pharmacology Depolarizing NMB Depolarizing NMB Binds to Ach-R, depolarizes it (fasiculations), and stays bound preventing further depolarization Binds to Ach-R, depolarizes it (fasiculations), and stays bound preventing further depolarization Dose: Dose: Adults: 1.5 mg/kg IV, 3.0 mg/kg IM Adults: 1.5 mg/kg IV, 3.0 mg/kg IM Kids <1 yo: 3.0 mg/kg IV Kids <1 yo: 3.0 mg/kg IV Kids >1 yo: 2.0 mg/kg Kids >1 yo: 2.0 mg/kg Onset: 45-60 sec Onset: 45-60 sec Duration of Action: ~10 min Duration of Action: ~10 min

43. Succinylcholine Side Effects Bradycardia – vagotonic effect Bradycardia – vagotonic effect Kids <8 -- prevent w/ atropine Kids <8 -- prevent w/ atropine 2 nd dose – Tx w/ atropine 2 nd dose – Tx w/ atropine Fasiculations Fasiculations ↑ IOP – questionable clinical significance ↑ IOP – questionable clinical significance ↑ ICP – prevent w/ defasiculating dose of Roc ↑ ICP – prevent w/ defasiculating dose of Roc Hyperkalemic arrest in at risk pts Hyperkalemic arrest in at risk pts Pre-existing hyperK e.g. CRF Pre-existing hyperK e.g. CRF Burns: 24 hrs post – 1-2 yrs after healing Burns: 24 hrs post – 1-2 yrs after healing Crush injuries: 7d post – 2-3 months Crush injuries: 7d post – 2-3 months Denervation injuries (CVA, spinal cord): 7d – 6 mo Denervation injuries (CVA, spinal cord): 7d – 6 mo Neuromuscular Dz (MS, Muscular dystrophies, ALS etc): indefinite Neuromuscular Dz (MS, Muscular dystrophies, ALS etc): indefinite Malignant Hyperthermia – rare but 60% mortality Malignant Hyperthermia – rare but 60% mortality Trismus / masseter spasm – usually transient Trismus / masseter spasm – usually transient

44. Succinylcholine Contraindications Absolute Absolute Personal or FHx of Malignant Hyperthermia Personal or FHx of Malignant Hyperthermia Burns >24 hrs old Burns >24 hrs old Crush or denervation injuries >7d old Crush or denervation injuries >7d old Neuromuscular Dz Neuromuscular Dz Relative Relative Lack of experience w/ drug Lack of experience w/ drug Anticipated difficult airway Anticipated difficult airway

45. Rocuronium Pharmacology Non-depolarizing NMB Non-depolarizing NMB Competes with ACh & binds to ACh-R Competes with ACh & binds to ACh-R Doesn’t cause depolarization (no fasciculations) Doesn’t cause depolarization (no fasciculations) Dose: Dose: Intubation dose: 0.6-1.0 mg/kg Intubation dose: 0.6-1.0 mg/kg Defasiculation dose: 10% of intubation dose Defasiculation dose: 10% of intubation dose Onset: 60 sec Onset: 60 sec Duration of Action: 40-60 min Duration of Action: 40-60 min

46. Can you reverse it? Sort of… Sort of… Neostigmine Neostigmine Blocks Ach breakdown – thus increases [ACh] at receptor to compete with rocuronium Blocks Ach breakdown – thus increases [ACh] at receptor to compete with rocuronium Won’t work until [Roc] ↓ ’s to ~40% therefore slow onset (~30 min) making it clinically useless as such in the ED Won’t work until [Roc] ↓ ’s to ~40% therefore slow onset (~30 min) making it clinically useless as such in the ED Cholinergic side effects Cholinergic side effects

47. Induction Agents ALL induction agents can potentially cause myocardial depression & hypotension ALL induction agents can potentially cause myocardial depression & hypotension Individualize agent & dose to clinical situation Individualize agent & dose to clinical situation Inadequate induction (i.e. light pt) increases risk of laryngospasm Inadequate induction (i.e. light pt) increases risk of laryngospasm

48. Etomidate Pharmacology Imidazole derivative w/ hypnotic effects Imidazole derivative w/ hypnotic effects Appears to work at GABA receptor Appears to work at GABA receptor Trauma drug of choice Trauma drug of choice Most hemodynamically stable agent we have Most hemodynamically stable agent we have Cerebroprotective Cerebroprotective Blunts ↑ in ICP, ↓ ’s cerebral O 2 demand Blunts ↑ in ICP, ↓ ’s cerebral O 2 demand Dose Dose 0.15 – 0.3 mg/kg (use lower dose if unstable) 0.15 – 0.3 mg/kg (use lower dose if unstable) Onset: 20-30 secs Onset: 20-30 secs Duration of Action: 7-14 mins Duration of Action: 7-14 mins

49. Etomidate Side Effects Vomiting SPAM Vomiting SPAM N & V N & V occurs in 30-40% occurs in 30-40% S – Seizures S – Seizures Conflicting data, but appears to lower Sz threshold in pts w/ focal seizures Conflicting data, but appears to lower Sz threshold in pts w/ focal seizures P – Pain on injection P – Pain on injection A – Adrenal surppression A – Adrenal surppression Reversible & not associated w/ worse outcomes after single dose Reversible & not associated w/ worse outcomes after single dose M – Myoclonus M – Myoclonus Not associated w/ Sz activity on EEG Not associated w/ Sz activity on EEG Occurs in 30-65% -- can ↓ incidence w/ fentanyl pre-Tx Occurs in 30-65% -- can ↓ incidence w/ fentanyl pre-Tx

50. Etomidate Contraindications 4 p’s 4 p’s Prior Seizures Prior Seizures Pregnancy Pregnancy Category C: animal evidence of harm Category C: animal evidence of harm Poor Adrenal function Poor Adrenal function Pediatrics Pediatrics Likely to change; several studies documenting use for RSI & PSA in kids Likely to change; several studies documenting use for RSI & PSA in kids Used by 70% of US ED’s Used by 70% of US ED’s

51. Ketamine Pharmacology PCP deriviative PCP deriviative Analgesic, amnestic, anesthetic Analgesic, amnestic, anesthetic Bronchodilator Bronchodilator Drug of choice in Asthma / COPD Drug of choice in Asthma / COPD Catecholamine release  ↑ HR & BP Catecholamine release  ↑ HR & BP Good in hypovolemic, hypotensive pts Good in hypovolemic, hypotensive pts Does not supress respiratory drive Does not supress respiratory drive Dose: 1-2 mg/kg IV or 4-6 mg/kg IM Dose: 1-2 mg/kg IV or 4-6 mg/kg IM Onset: 15-30 Sec Onset: 15-30 Sec Duration: 10-15 min Duration: 10-15 min

52. Ketamine Side Effects Makes you SMILE Makes you SMILE ↑ ’s Secretions – prevent w/ atropine ↑ ’s Secretions – prevent w/ atropine Myocardial depression Myocardial depression Avoid in kids w/ CHD Avoid in kids w/ CHD Increases ICP Increases ICP Avoid in head trauma Avoid in head trauma Laryngospasm Laryngospasm Gently bag them; NMB if sats drop/unable to bag Gently bag them; NMB if sats drop/unable to bag Emergence rxns Emergence rxns Midaz does not appear to prevent this Midaz does not appear to prevent this

53. Midazolam Pharmacology Benzodiazepine Benzodiazepine Acts at GABA receptor Acts at GABA receptor Amnestic, anxiolytic, sedative, anticonvulsant properties Amnestic, anxiolytic, sedative, anticonvulsant properties Dose: 0.1 – 0.2 mg/kg IV Dose: 0.1 – 0.2 mg/kg IV Onset: 30-60 sec Onset: 30-60 sec Duration of Action 30-60 min Duration of Action 30-60 min

54. Midazolam Side Effects Hypotension Hypotension Dose-related ↓ in SVR Dose-related ↓ in SVR Direct myocardial depression Direct myocardial depression Opiates potentiate effect Opiates potentiate effect Respiratory depression Respiratory depression

55. Case 6 4 yo boy 4 yo boy Found unresponsive in pool Found unresponsive in pool Brought by EMS unintubated Brought by EMS unintubated What makes the pediatric intubation different? What makes the pediatric intubation different?

56. Pediatric Airways Large head & occiput Causes neck flexion – towel under shoulders to obtain sniffing position Large tongue, tonsils and adenoids Obstructs airway, obstructs laryngoscopy view view High anterior larynx Can be more difficult to see – may need straight blade to lift epiglottis Funnel-shaped larynx – narrowest portion below cords Use uncuffed tubes in kids <8 yo Tiny cricithyroid membrane Needle cric is difficult; surgical cric impossible in age <8 yo High basal metabolic rate & relatively smaller FRC Desat quickly (2x as fast as adults) Relatively higher H 2 O content Need larger doses of Sux Monosynaptic airway reflexes Vagal response to laryngoscopy  bradycardia; need atropine

57. Pediatric Airway Estimating Weight (Age in yrs x 2) + 8 (Age in yrs x 2) + 8 Broselow tape Broselow tape Length-based method Length-based method

58. Estimating ETT size (Age / 4) + 4 (Age / 4) + 4 Size of patient’s small finger = size of ETT Size of patient’s small finger = size of ETT Broselow tape Broselow tape Length-based method Length-based method

59. ETT Insertion Depth Size of of ETT x 3 = cm from tip-teeth Size of of ETT x 3 = cm from tip-teeth Broselow tape Broselow tape Length-based method Length-based method

60. Bottom Line In pediatric resuscitation, the Broselow tape is your friend! In pediatric resuscitation, the Broselow tape is your friend!

61. Cuffed vs uncuffed airways in kids Cuffed vs uncuffed airways in kids Does it matter? Does it matter?

62. What kind of blade should you use? Textbooks Textbooks Straight (Miller) blade Straight (Miller) blade Pediatric anesthetists: Pediatric anesthetists: Many use curved (MacIntosh) blade in age>1yo Many use curved (MacIntosh) blade in age>1yo Many use curved blade in all kids Many use curved blade in all kids Bottomline Bottomline Use what works for you Use what works for you

63. the end

64. Basic Airway Skills Pearls Pearls BVM is cornerstone of airway management BVM is cornerstone of airway management Saves lives, especially in kids Saves lives, especially in kids Gauche 2000: kids did better w/ BVM pre-hospital than w/ intubation Gauche 2000: kids did better w/ BVM pre-hospital than w/ intubation Read up on it & practice at every opportunity Read up on it & practice at every opportunity C-grip technique C-grip technique SMALL adjustments (especially in kids) SMALL adjustments (especially in kids) Use OPA’s / NPA’s Use OPA’s / NPA’s KY jelly onto beards to improve seal KY jelly onto beards to improve seal Stuff 4x4’s into cheeks Stuff 4x4’s into cheeks Keep dentures in place Keep dentures in place

65. Case 1 65 yo M presents w/ massive LGIB 65 yo M presents w/ massive LGIB PMHx: HTN, MIx2, A. fib PMHx: HTN, MIx2, A. fib GCS 15, P120, BP 85/65, RR 28, SpO2 98% on NRB GCS 15, P120, BP 85/65, RR 28, SpO2 98% on NRB What (if any) indications does he have to be intubated? What (if any) indications does he have to be intubated?

66. Case 2 22 yo F brought in after taking GHB overdose. 22 yo F brought in after taking GHB overdose. How would you specifically assess her airway? How would you specifically assess her airway?

67. Assessing an Airway Taking their last GASPS? Taking their last GASPS? G – GCS impairment G – GCS impairment A – Artificial airway (OPA) tolerated A – Artificial airway (OPA) tolerated S – Swallowing impaired / inability to handle secretions S – Swallowing impaired / inability to handle secretions P – Pathological process involving airway e.g. stab wound, anaphylaxis P – Pathological process involving airway e.g. stab wound, anaphylaxis S – Speech (quality, quantity) S – Speech (quality, quantity)

68. Case 3 55 yo M brought in by EMS for chest pain – suddenly becomes unresponsive 55 yo M brought in by EMS for chest pain – suddenly becomes unresponsive Apneic, pulseless on quick exam Apneic, pulseless on quick exam Does he need intubation? Does he need intubation? What kind of airway is he? What kind of airway is he?

69. Approach to Airway Mangement 1) Are indications for intubation present? Contraindications? 1) Are indications for intubation present? Contraindications? 2) Define the type of airway: 2) Define the type of airway: Easy Easy Difficult Difficult Failed Failed Crash Crash 3) Choose strategieS best suited to airway & clinical situation 3) Choose strategieS best suited to airway & clinical situation 4) Anticipate & plan for post-intubation complications 4) Anticipate & plan for post-intubation complications

70. Step 2: Type of Airway Requires Intubation Easy Airway No anticipated difficulty w/ ETI or BVM Crash Airway Unresponsive Apneic / Arrested Near-death Difficult Airway Anatomy Pathology Failed Airway Can’t intubate Can’t bag RSI No Drugs or SCh alone Difficult Airway Algorithm Failed Airway Algorithm

71. Do Kids really need Atropine? Retrospective review of 163 pediatric ED pts Fastle & Roback. Ped Emerg Care 2004; 10:651-655