Airway Management Flashcards
What is the most frequent indication for intubation in pediatrics?
neurologic failure - brain injury, cardiac arrest, status epilepticus
What are the anatomic features in children that are pertinent to laryngoscopy and intubation?
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
Where does the larynx sit in infants? in adults?
Infants: C3-C4
Adults: C4-C5
What are the physiologic features in children that are relevant for intubation?
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
What is the maximum rate at which high-flow nasal cannula delivers O2?
60L/min (adults)
What are the minimum and maximum flow rates suggested for children <5kg?
6-8L/min
What are the minimum and maximum flow rates suggested for children 5-10kg
8-15L/min
What are the minimum and maximum flow rates suggested for children 10-20kg
15-20L/min
What are the minimum and maximum flow rates suggested for children 20-40kg?
25-40L/min
What are the minimum and maximum flow rates suggested for children > 40kg
25-60L/min
What are the absolute contraindications to using non-invasive ventilation?
Patient requires immediate intubation
Impaired mental status
Patient requires airway protection
What are the relative contraindications to to non-invasive ventilation?
Facial injury
Upper GI bleeding
Untreated pneumothorax
Significant or escalating vasopressor support
What are the significant complications of non-invasive ventilation?
barotrauma
aspiration
hemodynamic instability due to decreased venous return
What are the 7 Ps of RSI?
Preparation Preoxygenation Pretreatment/preoptimization Paralysis with induction Positioning Placement of the tube Postintubation management
How do you calculate the appropriate size of uncuffed ETT?
4+ (age in years / 4)
How do you calculate the appropriate sized of cuffed ETT?
3.5 + (age in years / 4)
What size of laryngoscope blade is used for children <2 y/o?
Size 1
What size of laryngoscope blade is used for children 2-10 y?
Size 2
What size of laryngoscope blade is used for children 10+ y/o?
Size 3
How can you approximate the size of laryngoscope needed when age not known?
Laryngoscope blade that approximates the distance between the upper incisors and the angle of the mandible
What are the sedative options for intubation?
Benzos Narcotics (fentanyl) Ketamine Etomidate Propofol
Sedative dose of benzos for intubation
0.2-0.3mg/kg
Sedative dose of fentanyl for intubation
1-2mcg/kg
Sedative dose of ketamine for intubation
1-3mg/kg
Sedative dose of etomidate for intubation
0.3mg/kg
Sedative dose of propofol for intubation
1-4mg/kg
What are the benefits of Ketamine for sedation for intubation?
- dissociative
- rapid onset
- augments hemodynamics
- preserves airway reflexes and respiratory drive
- bronchodilator
What are the disadvantages of Ketamine?
- vomiting
- laryngospasm
- emergence delirium
- increases oral secretions (sialogogue)
- possibly increases ICP
What are the advantages of Etomidate for procedural sedation?
- rapid onset
- cardiovascular stability
- no effect on ICP
What are the disadvantages of Etomidate for procedural sedation?
- 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
What are the disadvantages of Propofol for procedural sedation?
- vasodilator
- myocardial depressant
therefore increased risk of hypotension
What medication can be used as an antidote for benzodiazepines?
Flumazenil
What are the advantages of benzodiazepines for procedural sedation?
- amnestic
- anticonvulsant
- minimal cardiovascular depression
What are the disadvantages of Benzodiazepines for procedural sedation?
higher doses required for induction
slower onset
What is the time of onset of Succinylcholine? duration of action?
30-60 seconds
3-8 minutes
How does succinylcholine work?
depolarizing
What are the disadvantages of succinylcholine?
causes muscle fasciculations
- muscle pain
- myoglobinuria
- hyperkalemia
- histamine release
INCREASED RISK of malignant hyperthermia
- transient bradycardia
What is the dose of succinylcholine for RSI?
1-2mg/kg
What is the dose of rocuronium for RsI?
0.6-1.2mg/kg
What is an example of a non-depolarizing paralytic?
Rocuronium
What is the duration of action of rocuronium?
30-45 mins
What is the antidote for rocuronium?
sugammadex
What are the advantages of rocuronium over succinylcholine?
longer action - good for multiple intubation attempts or need to go to imaging
no muscle fasciculations
How can lidocaine be used as an adjunctive agent in intubation?
- blunts autonomic effects of laryngoscopy on hemodynamics and ICP
- recommended for intubation secondary to TBI
NOT routinely recommended
Why do needle instead of surgical cricothyroidotomy in children?
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
Signs of possible laryngeal or tracheal fracture
crepitus over larynx
laryngeal or tracheal tenderness
flattened thyroid prominence
anterior neck deformity
severe resp distress
abnormal neck radiography
Rescue devices/techniques
- LMA
- Video laryngoscopy
- Tube that has both ETT + one in esophagus – combitube
- Laryngeal tube
- Cricothyrotomy
- More experienced provider
- Flexible fiberoptic intubation
Adverse effects of ketamine
hypoxia
emesis
laryngospasm
recogery agitation (hyperactivity, hallucinations, euphoria, unpleasant sensations, dreams, flashbacks)
