Airway Management

Question 1

What is the most frequent indication for intubation in pediatrics?

Answer 1

neurologic failure - brain injury, cardiac arrest, status epilepticus

Question 2

What are the anatomic features in children that are pertinent to laryngoscopy and intubation?

Answer 2

Smaller airway structures
Smaller field of vision
Common adenoidal hypertrophy
Developing teeth & primary teeth
Large tongue relative to oropharynx size
Superior larynx
Hyoepiglottic ligament - less strong
Epiglottis - narrow and angled acutely, covering tracheal opening more
Narrowest point at level of cricoid cartilage

Question 3

Where does the larynx sit in infants? in adults?

Answer 3

Infants: C3-C4
Adults: C4-C5

Question 4

What are the physiologic features in children that are relevant for intubation?

Answer 4

Lung - smaller and fewer alveoli, decreased gas exchange surface area, absent collateral channels of ventilation
Cartilagenous chest wall (poor recoil, increased compliance). greater tendency for atelectasis and collapse.
Increased O2 consumption in infants
High vagal tone - greater tendency for bradycardia with hypoxia

Question 5

What is the maximum rate at which high-flow nasal cannula delivers O2?

Answer 5

60L/min (adults)

Question 6

What are the minimum and maximum flow rates suggested for children <5kg?

Answer 6

6-8L/min

Question 7

What are the minimum and maximum flow rates suggested for children 5-10kg

Answer 7

8-15L/min

Question 8

What are the minimum and maximum flow rates suggested for children 10-20kg

Answer 8

15-20L/min

Question 9

What are the minimum and maximum flow rates suggested for children 20-40kg?

Answer 9

25-40L/min

Question 10

What are the minimum and maximum flow rates suggested for children > 40kg

Answer 10

25-60L/min

Question 11

What are the absolute contraindications to using non-invasive ventilation?

Answer 11

Patient requires immediate intubation
Impaired mental status
Patient requires airway protection

Question 12

What are the relative contraindications to to non-invasive ventilation?

Answer 12

Facial injury
Upper GI bleeding
Untreated pneumothorax
Significant or escalating vasopressor support

Question 13

What are the significant complications of non-invasive ventilation?

Answer 13

barotrauma
aspiration
hemodynamic instability due to decreased venous return

Question 14

What are the 7 Ps of RSI?

Answer 14

Preparation
Preoxygenation
Pretreatment/preoptimization
Paralysis with induction
Positioning
Placement of the tube
Postintubation management

Question 15

How do you calculate the appropriate size of uncuffed ETT?

Answer 15

4+ (age in years / 4)

Question 16

How do you calculate the appropriate sized of cuffed ETT?

Answer 16

3.5 + (age in years / 4)

Question 17

What size of laryngoscope blade is used for children <2 y/o?

Answer 17

Size 1

Question 18

What size of laryngoscope blade is used for children 2-10 y?

Answer 18

Size 2

Question 19

What size of laryngoscope blade is used for children 10+ y/o?

Answer 19

Size 3

Question 20

How can you approximate the size of laryngoscope needed when age not known?

Answer 20

Laryngoscope blade that approximates the distance between the upper incisors and the angle of the mandible

Question 21

What are the sedative options for intubation?

Answer 21

Benzos
Narcotics (fentanyl)
Ketamine
Etomidate
Propofol

Question 22

Sedative dose of benzos for intubation

Answer 22

0.2-0.3mg/kg

Question 23

Sedative dose of fentanyl for intubation

Answer 23

1-2mcg/kg

Question 24

Sedative dose of ketamine for intubation

Answer 24

1-3mg/kg

Question 25

Sedative dose of etomidate for intubation

Answer 25

0.3mg/kg

Question 26

Sedative dose of propofol for intubation

Answer 26

1-4mg/kg

Question 27

What are the benefits of Ketamine for sedation for intubation?

Answer 27

- dissociative - rapid onset - augments hemodynamics - preserves airway reflexes and respiratory drive - bronchodilator

Question 28

What are the disadvantages of Ketamine?

Answer 28

- vomiting - laryngospasm - emergence delirium - increases oral secretions (sialogogue) - possibly increases ICP

Question 29

What are the advantages of Etomidate for procedural sedation?

Answer 29

- rapid onset - cardiovascular stability - no effect on ICP

Question 30

What are the disadvantages of Etomidate for procedural sedation?

Answer 30

- increased risk of hypotension in sepsis - increased risk of ARDS - increased risk of multi-organ dysfunction in severely injured trauma patients - longer ventilator courses and hospital stays * *adrenal suppression

Question 31

What are the disadvantages of Propofol for procedural sedation?

Answer 31

- vasodilator - myocardial depressant therefore increased risk of hypotension

Question 32

What medication can be used as an antidote for benzodiazepines?

Answer 32

Flumazenil

Question 33

What are the advantages of benzodiazepines for procedural sedation?

Answer 33

- amnestic - anticonvulsant - minimal cardiovascular depression

Question 34

What are the disadvantages of Benzodiazepines for procedural sedation?

Answer 34

higher doses required for induction | slower onset

Question 35

What is the time of onset of Succinylcholine? duration of action?

Answer 35

30-60 seconds | 3-8 minutes

Question 36

How does succinylcholine work?

Answer 36

depolarizing

Question 37

What are the disadvantages of succinylcholine?

Answer 37

causes muscle fasciculations - muscle pain - myoglobinuria - hyperkalemia - histamine release INCREASED RISK of malignant hyperthermia - transient bradycardia

Question 38

What is the dose of succinylcholine for RSI?

Answer 38

1-2mg/kg

Question 39

What is the dose of rocuronium for RsI?

Answer 39

0.6-1.2mg/kg

Question 40

What is an example of a non-depolarizing paralytic?

Answer 40

Rocuronium

Question 41

What is the duration of action of rocuronium?

Answer 41

30-45 mins

Question 42

What is the antidote for rocuronium?

Answer 42

sugammadex

Question 43

What are the advantages of rocuronium over succinylcholine?

Answer 43

longer action - good for multiple intubation attempts or need to go to imaging no muscle fasciculations

Question 44

How can lidocaine be used as an adjunctive agent in intubation?

Answer 44

- blunts autonomic effects of laryngoscopy on hemodynamics and ICP - recommended for intubation secondary to TBI NOT routinely recommended

Question 45

Why do needle instead of surgical cricothyroidotomy in children?

Answer 45

i. Risque élevé de dommage au cartilage cricoïde qui est le seul support circonférentiel de la trachée supérieure ii. C’est l’endroit le plus petit de la trachée, et donc risque de passer au travers iii. Le cartilage cricoïde est peu palpable avant l’âge de 12 ans

Question 46

Signs of possible laryngeal or tracheal fracture

Answer 46

crepitus over larynx laryngeal or tracheal tenderness flattened thyroid prominence anterior neck deformity severe resp distress abnormal neck radiography

Question 47

Rescue devices/techniques

Answer 47

- LMA - Video laryngoscopy - Tube that has both ETT + one in esophagus – combitube - Laryngeal tube - Cricothyrotomy - More experienced provider - Flexible fiberoptic intubation

Question 48

Adverse effects of ketamine

Answer 48

hypoxia emesis laryngospasm recogery agitation (hyperactivity, hallucinations, euphoria, unpleasant sensations, dreams, flashbacks)