Airway & Resuscitation Flashcards
Procedural Sedation/Threatened airway
obese patient undergoing procedural sedation ? reflux causing laryngospam
2022.1 Case based discussion
Sedation in obese patients
Situational awareness
Airway assessment
- History
- Examination
Fasting status
Informed consent
Laryngospasm management
*Is the procedure necessary? - is the patient going to OT anyway?
*Is there a safer alternative? - nerve block/nitrous oxide
*is the ED the safest place to perform sedation
- patient factors (anticipated difficult airway, haemodynamic instability)
- departmental factors (busy department, adequate staffing)
*resources
- resuscitation room
- monitoring
- staffing and expertise
DIFFICULT AIRWAY ASSESSMENT:
HISTORY:
“AMPLE”
Allergies
Medications
Past medical history/Family history - malignant hyperthermia
Last ate/drank
Events - leading to presentation
EXAMINATION:
General:
Obesity, Pregnancy, OSA
Facial hair (unable to get a good seal with BVM ventilation)
Others:
- facial trauma
- airway burns
- angioedema
- masses
- ludwigs angina
Mouth:
- small mouth, large tongue, high arched pallate
- large protruding teeth, large overbite
- receding mandible and chin
- mallampati 3 (only see base of uvula)
- mallampati 4 (only see hard palate)
Jaw opening <6cm
Thyromental distance <6cm
Neck:
- short thick neck circumference >40cm
- inability to extend (trauma, c-spine collar, arthritis, spinal fusion)
*Ensure FASTING for at least 4hrs if non-emergent procedure
*Always mentally prepare for SURGICAL AIRWAY
- assess FON and mark landmarks
*Obese patients are at risk of ASPIRATION
- have Ducanto or Yankauer suction catheters ready to suction posterior pharynx
INFORMED CONSENT
OPTIMIZE:
Prevent hypotension
- fluid resuscitate (optimise fluid status before sedation)
- push dose vasopressors on stand by
Prevent hypoxia:
Pre-oxygenate
- sit up right
- HFNP 100% oxygen 60L/min + NRBM 15L/min for at least 5min
POSITION:
- RAMPED
- Reverse trendelenburg
improves respiratory mechanics
moves weight of off chest to allow expansion
- ear to sternal notch
- face plane parallel to the ceiling
MONITORING:
- level of consciousness
- continuous cardiac monitoring
- continuous pulse oximetry
- BP monitoring q5min
- ETCO2 capnography - continuous
SEDATION:
- ketamine 1-2mg/kg
- administer slowly
LARYNGOSPASM MANAGEMENT:
stop the procedure
call for more help
suction posterior pharynx if vomiting
Positive pressure ventilation with 100% oxygen:
2 person BVM ventilation, tight seal, high PEEP 20cm H2O
LARSONS MANOUVER + jaw thrust:
- firm pressure on posterior rami of mandible
DEEPEN SEDATION:
- propofol 1-2mg/kg IV
PARALYSE:
- suxemethonium 2mg/kg IV
INTUBATE:
- CHEST THRUST before passing the ETT through the cords
Paediatric Procedural Sedation
EM Cases Podcast “paediatric procedural sedation”
IV Ketamine
1.5mg/kg (max 50mg)
subsequent incremental doses 0.5mg/kg (max 25mg)
slow IV push over 1-2min. rapid push associated with respiratory depression.
Advantage - ease of repeat dosing, faster recovery
Clinical onset - 1 min
Effective sedation - 10-20min
Time to discharge - 90-120min
IM Ketamine
3-4mg/kg
a repeat dose of 2-4mg/kg can be given after 10min
ketamine can be safely used without IV access
Advantage - no IV necessary
Clinical onset - 3-4mins
Effective sedation 15-30min
Time to dischage - 100-140min
SIDE EFFECTS:
Transient tachycardia and hypertension
Laryngospasm (0.3%)
Emergence phenomena - recover in quiet low stimulus environment
Vomiting - prophylactic antiemetics
Hypersalivation
Nystagmus
Apnoea and respiratory depression
Muscle twitching and purposeless movements
CONTRAINDICATIONS:
Absolute:
allergy
< 3months
schizophrenia
Relative:
current respiratory illness
known difficult airway
procedures that will stimulate oropharynx
age 3-6 months
bowel obstruction
glaucoma or globe injury
VOMITING & LARYNGOSPASM:
1) Stop the procedure.
2) Call for help. Children become hypoxic quickly.
Gentle suction of vomitus under direct vision
3) 100% oxygen BVM maximum PEEP and tight seal
- Attempt manual two persons BVM ventilation
4) try to break the laryngospasm with Larsons manouvre + jaw thrust.
(firm pressure on posterior ramus of mandible)
5) If not able to adequately manually ventilate –> Deepen anaesthesia with propofol 1-2mg/kg IV
–> give suxamethonium 1-2mg/kg and intubate
(IM suxamethonium 3-4mg/kg if no IV)
atropine 20mcg/kg for bradycardia
RATIONALE FOR FASTING
1) Most guidelines state that patients should be fasted for 4-6 hours prior to procedural sedation.
2) Aspiration is not impossible with ketamine, if it is not an emergency procedure - best to wait until fasted
RATIONALE FOR PROCEEDING WITHOUT FASTING
1) Medical emergency e.g. neurovascular compromise of a displaced fracture outweighs the risk of aspiration
2) there is no relationship between adverse respiratory events and fasting times in any studies thus far
3) Maintain airway reflexes with ketamine
Difficult Airway - The Obese Patient
drug dosing is challenging
propofol & succinylcholine (lipophilic) - total deal body weight
ketamine (hydrophilic) - ideal body weight
awake fibreoptic intubation
Blood pressure cuff can’t fit. BP is over estimated. early arterial line to get accurate BP before induction.
Awake fibre-optic intubation
flexible endoscopic laryngoscopy
oral or nasal approach
- preoxygenate with HFNP
- dry mucosal secretions with glycopyrolate 200mcg 5min prior to procedure
- anaesthetise the airway with co-pheynylcaine
- bite block
- light sedation with ketamine 10-20mg slow IV push
- ETT is preloaded onto flexible endoscope
- advance endoscopic until vocal cords seen
- spray vocal cords with local anaesthetic
- advance endoscope to carina
- rail road ETT into trachea
- remove endosope
- attached to BVM and confirm etCO2
- provide sedation
Physiological changes:
SHORT TIME TO DESATURATE “safe apnoea time” is reduced
- Reduced FRC
- more fatty tissue = higher metabolic requirements
REQUIRE HIGHER AIRWAY PRESSURES TO VENTILATE
- reduced chest wall and pulmonary compliance
INCREASED RISK OF ASPIRATION:
- high intra-abdominal pressure
DRUG METABOLISM & PHARMAKOKINETICS ARE ALTERED IN OBESITY
- Lipophilic drugs (eg. Propofol & suxamethonium) have a larger Vd since Vd is dependent on the amount of adipose tissue. Lipophilic drugs need to be dosed based on TOTAL BODY WEIGHT. Therefore these doses will be much higher than in average adults.
- Hydrophilic drugs (eg. Ketamine) are dosed based on IDEAL BODY WEIGHT
AIRWAY MANAGEMENT:
Place arterial line for accurate BP readings (BP cuffs often don’t fit properly and overestimate BP which is dangerous on induction)
PREOXYGENATE with the patient sitting upright for at least 5min.
HFNP 60L/min + 15L NRBM
If not achieving adequate tidal volumes 7-8ml/kg –> preoxygenate with BiPAP
Two person BVM with thenar grip technique + bilateral Nasopharyngeal + Oropharyngeal airways
Obese patients are at an increased risk for ASPIRATION
- have decanto or yankauer suction catheters ready
POSITION:
- RAMPED position
- tragus in line with sternal notch
- face parallel with the ceiling
- Reverse trendelenburg
(Improves respiratory mechanics and glottic view)
PLAN FOR SURGICAL AIRWAY - identify landmarks and mark front of neck incase of CICO
SEDATION with ketamine 1-2mg/kg ideal body weight
PARALYSIS with succinylcholine 2-3mg/kg IV (increases tone in lower oesophageal sphinchter to help prevent aspiration)
INTUBATION PLAN:
Plan A - most experienced operator, video laryngoscope, bougie
Plan B - 2 person BVM ventilation
oxygenation with bilateral NPA and OPA
Plan C - attempt oxygenation with LMA
Plan D is officially declaring “cannot intubate, cannot oxygenate” and proceeding with a surgical airway
CRICOTHYROTOMY:
Immobilise the larynx with the non-dominant hand
Identify the cricothyroid membrane (cricoid cartilage below, thyroid cartilage above). It’s 1cm in height and 2-3cm wide)
Prep the skin with chlorhexidine
Infiltrate the skin with 2ml xylocaine with adrenaline
Make a 1.5 cm transverse incision (avoid injury to anterior jugular veins) through skin, subcutaneous tissue and the cricothyroid membrane
A rush of air will be heard and bubbling seen
pass bougie through trachea
rail road size 6 ETT over bougie
BVM ventilate
Confirm placement
- auscultate bilateral lungs
- symmetrical chest wall rise and fall
- ETCO2 trace
VENTILATOR SETTINGS:
TV should be adjusted to IBW not TBW - 8ml/kg
RR - increased to accommodate higher metabolic demands (from 12-14 to 18-20).
PEEP should be increased (can be up to 20)
- increase FRC
- alveolar recruitment
FiO2 100% and titrate down to achieve SaO2 >90%
Peak pressure limit - try to keep the Pplat under 35 cmH2O
Non Invasive Ventilation
2023.2 Interaction with registrar
Interpret ABG
Adjust NIV to meet patient needs
Teach registrar
INDICATIONS:
- T1RF
- T2RF
- respiratory distress and exhaustion
- preoxygenation prior to intubation
ADVANTAGES:
- reduces work of breathing
- improves pulmonary compliance
- reduces atelectasis / alveoli recruitment, corrects VQ mismatch
- shorter hospital stays
- reduced mortality in COPD
- decreased rate of intubation
CONTRAINDICATIONS:
- intractable vomiting (bowel obstruction)
- GCS <8 need intubation
- untreated pneumothorax
- hypotension
- copious secretions + inability to clear
- cranio-facial trauma/base of skull fractures
COMPLICATIONS:
- Hypotension (increase in intrathoracic pressure will reduce venous return to the heart)
- barotrauma
- patient intolerance, claustrophobia, anxiety
- aspiration
- facial pressure sores
- abdominal compartment syndrome
PROCEDURE:
Select the correct size mask to create a tight seal while preserving patient comfort - check for air leaks
SETTINGS FOR COPD:
Start with low pressures (better tolerated by patient)
Set FiO2
Degree of hypoxia – will determine initial FiO2 setting
Patient tolerance/anxiety – may choose to start with lower settings for tolerance
Set EPAP 1cm H2O for every 10kg body weight (70kg = 7cmH2O)
Start IPAP at 10cm H20
Increase IPAP to decrease work of breathing
Increase EPAP to recruit alveoli, improve VQ mismatch and improve oxygenation
Increase pressure support to increase tidal volume and minute ventilation to blow off CO2
(achieve tidal volumes of 8ml/kg)
Pressure suppor = IPAP-EPAP differential
Maximum pressure support IPAP 20cm/EPAP 5cm
ensure mask has tight seal / no air leak - while preserving patient comfort
increase FiO2 to 0.6 - aiming for SaO2 88-92% or PaO2 70-80mmHg)
MONITOR:
- GCS
- Work of breathing
- SaO2
- assess for barotrauma
- VBG’s
- haemodynamics (HR & BP)
CAN’T TOLERATE BIPAP??
Sedation with low dose ketamine 10-20mg IV for the agitated patient
- maintain airway reflexes
- maintain respiratory drive
- bronchodilator properties
- less likely to cause hypotension
High flow nasal prongs (2nd line)
- reduce anatomic dead space
- improve ventilation
- reduce work of breathing
set flow at 50-60L/min
titrate FiO2 to SaO2 88-92%
Anaphylaxis
vasodilatory shock
bronchospasm
upper airway oedema
7 Maximum Medications to consider in Crashing Anaphylaxis: Epinephrine, Rocuronium, Ketamine, Bronchodilators, Magnesium Sulphate, Vasopressors, Steroids
1.Push dose epinephrine 1mcg/kg IV push then 1mL/kg/min and titrate
Adrenaline formulations:
Adrenaline 1:1000 (1 mg/mL) Adrenaline 1:10,000 (1 mg/10 mL)
0.5ml of 1:10,1000 = 50mcg
2.Rocuronium 1.2mg/kg IV push paralytic if patient is maintaining muscle tone
3.Ketamine 1-2mg/kg IV induction
ketamine infusion 1-10 mg/kg/hr for it’s bronchodilator properties
4.Continuous bronchodilators in circuit (salbutamol 15 mg/h) + ipatropium 3 x 500 mcg for a 1-hour continuous nebulization)
IV Salbutamol 10mcg/kg loading then 5mcg/min
5.IV Magnesium sulphate 2g (40 mg/kg) over 20
- Adrenaline infusion 0.05mcg/kg/min
7.IV steroids:
- Methylprednisolone 2mg/kg (max 80mg) or Hydrocortisone 5mg/kg (max 400 mg)]
For persistent hypotension/shock
* give normal saline (maximum 50 mL/kg in the first 30 min)
For upper airway obstruction
* nebulised adrenaline (5 mL, i.e. 5 ampoules of 1:1000)
* intubation if skills and equipment are available
Need intubation
only cuffed ETT can withstand the high airway pressures required to ventilate the severe asthmatic/anaphylaxis
Paediatric Asthma
2023.2 Case based discussion
discuss with an examiner, the management of a paediatric patient with critical asthma in a rural hospital setting
Medical Expertise: Initial Management and Ongoing Assessment – 40%
- Identify risks of deterioration in this patient.
- Correctly choose time critical interventions based on assessment (or utilise a range of medical
therapies to provide initial targeted management)
Medical Expertise: Further Management – 30%
- Initiate treatments specific to identified abnormalities in airway and/or ventilation.
- Outline an overall plan for ongoing treatment of a patient.
Prioritisation and Decision Making – 30%
- Prioritise the essential tasks in a high complexity patient.
- Prioritise chosen treatment options to create an appropriate escalating treatment plan.
- Provide a rationale to explain and justify decisions about ongoing treatment.
Candidates were required to interact with the examiner and to:
- Outline their further management of this child.
- Answer further questions from the examiner.
ASSESSMENT:
Cardiac monitoring
Pulse oximetry
BP monitoring cycle Q5min
respiratory distress
tachypnoea
hypoxia
cyanosis
tripod stance
altered mental status
expiratory wheeze
retractions
tracheal tug
POCUS - pneumothorax
VBG - hypercapnoeic respiratory failure
MEDICAL MANAGMENT:
Escalate oxygen therapy - High flow nasal prongs, flow rate 2ml/kg, FiO2 100% target SaO2 >95%
Continuous nebulised salbutamol 2x 5mg undiluted vials
add nebulised ipratropium 500mcg every 20min (3 doses)
IV access or early IO access
- VBG
Methylprednisone 1-2mg/kg IV OR hydrocortisone 4mg/kg IV
Magnesium 40mg/kg (max 2g) IV over 20min
Adrenaline not supported by high quality evidence
- adrenaline 10mcg/kg 1:1000 IM repeat Q5 min x3
- adrenaline infusion 0.01mcg/kg/min - titrate to effect
Aminophylline 10mg/kg IV over 1hr
IV Salbutamol 10mcg/kg loading then 5mcg/min
FAMILY PRESENCE:
- reduce stress and anxiety
- parents can provide collateral history
- assign staff member to accompanry
INTUBATION:
Preoxygenation sitting upright
HFNP 2L/Kg, FiO2 100%, minimum 3min target SaO2 >95%
Optimize
- if severe acidosis - bicarbonate bolus 2ml/kg IV on induction
- adequate fluid resuscitation 20ml/kg IV
Delayed sequence induction
Ketamine 2mg/kg IV
- haemodynamically stable
- bronchodilator properties
- maintain airway reflexes and respiratory drive
Rocuronium 1.2mg/kg IV
- longer duration of action 30min
Most experienced operator
Video laryngoscope + bougie
Use the largest tube possible.
- reduce airflow resistance
- aid bronchoscopy
ETT = age/4 + 3.5
Apnoeic bag valve ventilation - low RR 5/min - avoid gas trapping and auto PEEP causing pneumothorax and hypotension
VENTILATION STRATEGY:
PERMISSIVE HYPERCAPNOEA
*FiO2 100% - titrate down target SaO2 92%
*Use a small tidal volume, 5-7ml/kg
*Use a slow respiratory rate, 8 breaths per minute
*Use a long expiratory time, with I:E ratio 1:4
*Increase inspiratory flow rate to maximum 60-80L/min
Reset the pressure limits (i.e. ignore high peak airway pressures).
*Use minimal PEEP 0cmH2O
Keep the Pplat below 25cmH2o to prevent dynamic hyperinflation.
Use heavy sedation
- ketamine infusion 1-10 mg/kg/hr
Use neuromuscular blockade
- rocuronium 50mg IV
Place NG tube
Post intubation CXR
- confirm ETT placement
- confirm NGT
Consider transfer to theatre for heliox
Invasive BP monitoring with arterial line
COMPLICATIONS:
- tension pneumothorax
TRANSFER TO TERTIARY LEVEL CARE:
- liase with major referral hospital paediatric ICU
- liase with retrieval team
UPDATE FAMILY
PREPARATION FOR TRANSPORT:
Identify and address all life threats
Secure ETT
Drugs - sedation, paralytic, vasopressors, bronchodilators, magnesium,
IV access - minimum 2x large bore
Chest drain equipment
IDC
Invasive BP monitoring
Asthma - Post Intubation Deterioration
POST INTUBATION DETERIORATION
1) Disconnect the ETT from the ventilator and decompress the chest
- breath stacking causes dynamic hyperinflation, decreased venous return causing hypotension
2) Use BVM with CO2 capnography to ventilate. Slow ventilation RR 5/min, TV 5-7ml/kg. Can feel lung compliance. This can also rule out EQUIPMENT FAILURE.
3) Assess for TENSION PNEUMOTHORAX
trachea deviated to one side?
chest asymmetry?
auscultation and percussion findings?
proceed to needle decompression and chest tube placement.
Hypovolemia - fluid bolus 20ml/kg 0.9%
Anaphylaxis to induction agents/sedation - adrenaline infusion 0.05-1mcg/kg/min
Excess sedation - especially propofol and fentanyl - reduce sedation infusion rate, consider changing sedation or add a adrenaline infusion
Sepsis - vasopressors + antibiotics
Bronchospasm
Paediatric Hypoxia and Shock
2021.2 modified simulation
Differential diagnoses:
- status asthmaticus
- tension pneumothorax
- anaphylaxis
- pneumoniae with sepsis
- cardiomyopathy with pulmonary oedema
- myopericarditis with tamponade
Trauma - non-accidental injury
Haemorrhagic shock
Toxicological -
Child deteriorates and requires intubation:
- outline intubation plan
Weight = (Age + 4) x2
ETT = (Age/4) + 3.5 cuffed
High risk features on assessment:
- tachycardia
- hypotension is a late sign
- peripherally shut down, cool peripheries, slow capillary return
- altered mentation
Causes of difficult ventilation:
- tube displacement (check correct placement - ET CO2, CXR
- obstruction (suction tube)
- bronchospasm (salbutamol3x 5mg nebs, ipratropium 3x 250mcg nebs, IV magnesium 40mg/kg IV over 20min)
CAUSES:
ETT displaced/cuff not inflated
Obstruction of ETT/Bronchospasm
Pneumothorax
Equipment malfunction (disconnection of the ventilator, incorrect vent settings, etc.)
Stacking (breath stacking)
STATEGIES:
Disconnect from ventilator, BV tube and feel resistance as you bag
Suction ETT, check for kinks, inadvertent extubation
Treat brochospasm
- salbutamol 15mg/hr nebs
- ipratropium 250mcg nebs q20min
- magnesium 40mg/kg IV over 20min
Check ventilation settings
POCUS - pneumothorax
- absent lung sliding
- absent comet tails
- lung point
MANAGEMENT:
Statement that child is critically unwell in a shocked state
Transfer to resuscitation room and call for senior help
Oxygen:
Respiratory support with HFNP 2ml/kg FiO2 100% target
(positive pressure ventilation will worsen hypotension)
IV access, early IO if no access in 2min
2x tibial IO lines - one line for fluids, one line for antibiotics
Aggressive fluid resuscitation - 3 X 20ml/kg 0.9% NS IV within the first hour of resuscitation
Urgent antibiotics:
Antibiotics for pneumoniae
ceftriaxone 50mg/kg + flucloxacillin 50mg/kg (to cover for staph aureus pneumoniae)
Vasopressors for fluid refractory shock:
adrenaline infusion
- 6mg 1 in 1000 in 1L 0.9% NS
1ml = 0.1mcg
start infusion at 1ml/kg/hr and titrate up to 10ml/kg/hr
target MAP 70
ASSESSMENT:
- assessment will be happening concurrently with resuscitation
Involve parents - collateral history
Bloods:
- VBG
- FBC (leukocytosis, leukopenia)
- UEC & LFT’s (end organ perfusion)
- CRP
- Blood cultures
Place IDC and obtain urine sample for microscopy and culture
Portable CXR
POCUS
- pneumothorax
- pericardial effusion
- pulmonary oedema
- abdominal free fluid
- guide fluid resuscitation with regular assessment of IVC
- may aid in securing IV line
INTUBATION:
- high risk of cardiac arrest in children with septic shock
- most of the medications for induction will worsen hypotension
- even ketamine will cause hypotension in children who are catecholamine depleted
- need to assess whether intubation is truly indicated
- need to optimise and prepare for safe and controlled intubation
Pre-oxygenated
Fluid resuscitated
Vasopressors infusing
Induction with ketamine 1mg/kg IV
Paralysis with rocuronium 0.6-1.2mg/kg IV
post intubation sedation with ketamine 5-20mcg/kg/min
NGT placement
central venous catheter placement for ongoing inotropic and vasopressors
Post intubation, CVC and NGT CXR to check correct placement
IDC to monitor UO aim 30ml/kg/hr
Q1h VBG - lactate, glucose
consider hydrocortisone 2mg/kg IV in fluid and vasopressor resistant shock
EARLY INVOLVEMENT PAEDIATRICS/ICU/RETRIEVAL SERVICES
Consider ECMO
Update the family
Departmental paediatric sepsis protocols and algorithms
Pre-treatment with atropine for paediatric intubation is not routine. Useful in children < 1yr.
Post Tonsillectomy Bleeding
2021.1 Case based discussion
discuss with an examiner, the management of a
paediatric patient presenting with a post-tonsillectomy haemorrhage.
Most commonly seen between day 5 & 10 post-op, when the fibrin clot sloughs off
Manage in resus
PPE including eye protection
Sit patient upright, and forward to keep blood from soiling airway.
give them vomit bag to spit blood into
Decanto suction
IV access or IO
- fbc, coags, group and screen
Inspect and locate site of bleeding - left or right, inferior or superior pole
- Hydrogen peroxide gargles if bleeding not profuse
- Apply direct pressure using tonsillar packing on a long clamp soaked in tranexamic acid/adrenaline
- co-phenylcaine spray and then cauterize with silver nitrate
- Nebulized adrenaline 5mg
- Nebulized tranexamic acid 500mg
- IV tranexamic acid 15mg/kg (up to 1g) IV
- Given benzylpenicillin IV
Keep NBM
- Urgent ENT for return to theatre and haemorrhage control
RESUSCITATION:
- Apply HFNP 2ml/kg FiO2 100% encase of deterioration and need for intubation
- give un-crossmatched blood 10ml/kg IV
- Difficult intubation due to oedema from the surgery and obstruction of view from blood
- Prepare for emergent cricothyroidotomy
Paediatric Cardiac Arrest
2021.1 Case based discussion
Assessment and management of a 1 year old child with cardiac arrest that occurred soon after intubation by a registrar.
Child becomes bradycardia and then goes into cardiac arrest.
chest compressions:
- rate 100-120/min
- depth 1/3 AP diameter of chest
- allow full recoil
- minimise interruptions to chest compressions (<10sec at pulse check)
COACHED
C - continue chest compressions
O - oxygen away
A - all others away
C - charging
H - hands off
E - evaluate rhythm and pulse
D - discharge or dump
Atropine pre-treatment for RSI: Not routine.
When it comes to pretreatment drugs for RSI in critically ill children,
atropine at 0.02mg/kg 3-5 minutes prior to sedative and paralytic drugs
for RSI should not be given routinely.
Observational data comparing the use of atropine vs. no atropine
in the intubation of critically ill children suggests that there might be some benefit to using atropine.
Consider the use Atropine (0.02mg/kg) prior to RSI for patients at risk of severe bradycardia:
1. <1 year of age
2. Succinylcholine
3. If the patient is already bradycardic
4H’s & 4T’s
hypoxia
hypovolemia
hypo/hyperkalemia
hypo/hyperthermia
hypo/hyperkalemia
hypocalcemia
hypoglycemia
severe acidosis
pericardial tamponade
tension pneumothorax
toxins
PE
Start timer
HR <60
Start chest compressions
rate 100-120/min
Remove from the ventilator
*bag valve tube ventilation
*10 breaths per minute
*tidal volumes 8ml/kg (80mls)
*100% oxygen
Connect to defib
Place pads in AP position
Pulse oximetry
eTCO2 attached to BVT
Check tube for obstruction - easy to bag
Check tube placement
- oesophageal intubation?
- Right bronchus intubation?
- did they see tip of ETT pass through cords
- is there bilateral chest wall rise and fall
- breath sounds auscultating bilateral axillae
- improvement in SaO2
- eTCO2 detection?
Place NGT to deflate the stomach - this may improve oxygenation
If in doubt - change to size 1.5-2 LMA
check for tension pneumothorax
- unilateral hemithorax expansion, hyperresonant, no breath sounds
- distended neck veins
- tracheal deviation to the contralateral side
POCUS assessment IVC
- Fluid bolus - 20ml/kg NS IV
- Adrenaline infusion 6mg in 1L 0.9% NS start at 0.5ml/kg/hr (=0.05mcg/kg/min)
POCUS to exclude pericardial tamponade
Check temperature
BSL <2.6 give 2ml/kg 10% dextrose target 7-11mmol/L
VBG - acidosis, K+, ionised calcium, glucose
Hyperkalemia:
- 0.2ml/kg calcium chloride
- 0.5ml/kg of calcium gluconate
- sodium bicarbonate 1mmol/kg (1ml/kg)
- actrapid 0.1unit/kg + 5ml/kg 10% dextrose
Hypokalemia:
- KCl 0.05mmol/kg IV over 10ming
- give magnesium 40mg/kg IV
Place arterial line
Induction Agents:
Ketamine:
- haemodynamically stable
- quick onset (30sec)
- long duration of action (20min) gives you time to set up post intubation sedation
- analgesic properties
- may have neuroprotective properties
Propofol:
- causes vasodilation and cardiac depression
- quick onset, quick offset (good post intubation and sedation choice)
- no analgesic properties
- suppresses seizure activity (status epilepticus)
Paediatric Compromised Airway
Upper airway obstruction
2023.1 Case Based Discussion
discuss with an examiner, the airway management plan for a child with airway compromise
DIFFERENTIAL DIAGNOSIS:
Croup
Anaphylaxis
Ludwigs angina
Retropharyngeal abscess
Peritonsillar abscess
Bacterial tracheitis
Epiglottitis
Inhaled foreign body
Trauma - neck swelling, subcutaneous emphysema
ETT size = age/4 + 3.5 (but will use 1 size smaller)
Sedative: Ketamine 1-2mg/kg IV
Paralytic: Rocuronium 1.2mg/kg IV
ASSESSMENT:
Keep the child calm.
Let the child sit on parents lap.
Minimal handling. Limited examination.
Red flags for impending obstruction:
- Persistant stridor
- Hypoxia
- Tachypnoea and chest wall retractions
- Tripodding
- Altered mental status (drowsy or agitated)
complete obstruction leads to cardiorespiratory arrest
MANAGEMENT:
“difficult airway” call for senior help (anaesthetics, ENT)
Gas induction (sevoflurane) in theatre by anaesthetist and ENT surgeon ready to do tracheostomy is preferred
Cardiac monitoring
Pulse oximetry
High flow oxygen 15L NRBM targeting SaO2 100%
Nebulised adrenaline 5mg
IV access - use distraction techniques
Dexamethasone 0.6mg/kg IV
Use smaller ETT (1 size smaller)
Use videolaryngoscope and bougie
Prepare for failed intubation
Needle cricothyroidotomy
Needle Cricothyroidotomy
2022.2 Teaching station
Teach a registrar needle cricothyroidotomy in a paediatric patient
Learning resource - free app called emergency procedures
INDICATIONS:
- can’t intubate, can’t oxygenate by BVM or LMA
- age under 10yrs
CONTRAINDICATIONS:
- tracheal rupture/transection
- laryngeal fracture
COMPLICATIONS:
- failed procedure
- damage to surrounding structures
- bleeding and aspiration of blood
- barotrauma
- hypercapnoea
- infection
EQUIPMENT:
- 5ml syringe with 2ml saline
- 5ml syringe
- 16 or 18G non-safety cannulae
- Leroy oxygen tubing
- Tape to secure
POSITION:
- patient supine with neck extended
- if you are right handed you stand on the patients left side
LANDMARK:
In children, the thyroid cartilage is not developed.
Palpate the trachea above the sternal notch and move superiorly until the cricoid cartilage is felt. The cricothyroid membrane is superior to this and this is where your needle will go.
Brief the team - tell them that you are performing emergency needle cric
prep the anterior neck with chlorhexidine
anesthetise infiltrate 2ml 1% lignocaine with adrenaline (skip this step in an emergency)
stabilise the larynx with the non-dominant hand
Insert cannula at a 45-degree angle
Aspirate gently while advancing the needle
When air suddenly returns (indicating entry into the airway), advance the catheter over the needle.
remove the needle and aspirate to ensure ongoing free air aspiration
attach leroy tubing to wall oxygen
1L/min/year of age Max 10L/min
e.g. 3L for 3yr old
Insufflate for 2-4s and release for 8s
allocate someone to hold the cannula in place until definitive airway is placed
place OPA and NPA to aid exhalation
Transfer to theatre for definitive airway
POST PROCEDURE:
- Anaesthetics/ENT for definitive airway
- sedation and paralysis
- OPA/NPA/jaw thrust to allow exhalation of gasses
- insufflation I:E ratio 1:4, 1:8 in complete upper airway obstruction
- monitor for barotrauma (pneumothorax)
- monitor for failure (blocking, kinking, dislodgement)
- allocate staff to maintain the airway
Ludwigs Angina
2023.1 case based discussion
interpret CT scan
outline assessment and management
Rapidly progressing necrotizing cellulitis of the mouth floor leading to airway obstruction
Polymicrobial:
Benzylpenicillin 2.4g IV (clindamycin 600mg IV if allergic to penicillin)
PLUS
Metronidazole
CLINICAL FEATURES:
- dental infection, recent tongue piercing
- Immune compromise (diabetes)
- fever
- difficulty swallowing
- hot potato voice
- drooling
- trismus
- neck swelling
- tripod stance
- tongue elevation
- stridor and respiratory distress
MANAGEMENT:
Difficult airway (anatomically challenging airway)
- severe trismus
- large elevated tongue
- limited neck extension
- upper airway swelling and oedema
Securing airway early is critical
Call for help - ENT and anaesthetics to secure airway in theatre
Sit up right
High flow oxygen and nebulised adrenaline 5mg
IV access
Dexamethasone 10mg IV
Antibiotics:
Benzylpenicillin 2.4g IV
+ Metronidazole 500mg IV
Awake fibreoptics nasotracheal intubation or surgical airway
Small size 6.0 ETT
Prepare for FONA/cricothyroidotomy
Tracheostomy
Surgical management - resection of necrotic tissue, drain abscesses
Disposition ICU
Consider hyperbaric oxygen
MALIGNANT HYPERTHERMIA
- inhaled anaesthetics (sevoflurane) and suxamethonium
- uncontrolled increase in intracellular calcium in skeletal muscle –> sustained muscle contraction
- masseter muscle rigidity, tachycardia, rising eTCO2, tachypnoea, hyperthermia, rhabdomyolysis and myoglobinuria (dark urine)
VBG - mixed metabolic acidosis and respiratory acidosis
High CK and LDH
Renal failure, myoglobinuria
DIC
Hepatic failure
Cerebral oedema with seizures
MANAGEMENT:
Discontinue succinylcholine - remove tubing or IVC in which it was given.
Call for help.
Hyperventilate RR22-25 aim for eTCO2 40
Increase FiO2 100% (metabolic demand rapidly increases)
DANTROLENE:
Ryanodex 250mg powder mixed with 5ml sterile water
Revonto 20mg powder mixed with 60ml sterile water
Administer 2.5mg/kg IV every 5min for 4 doses
Can cause phlebitis so should be given through central line
AGGREIVE COOLING:
- ice water immersion
- cold IV crystalloid 4 degrees
- bladder, peritoneal, pleural cavity lavage
- consider ECMO
- oesophageal temperature probe
TREAT METABOLIC ACIDOSIS:
- fluid resuscitation
- sodium bicarbonate 50ml IV, repeat
TREAT HYPERKALEMIA:
- 10units actrapid + 50ml 50% dextrose
PLACE IDC:
- monitor UO aim for 1-2ml/kg/hr
MONITOR FOR COMPLICATIONS:
- eTCO2 monitoring
- VBG (metabolic and respiratory acidosis)
- Rhabdomyolysis
- Hyperkalemia
- DIC
- Core temperature with oesophageal probe
- Renal failure, urine output, myoglobinuria
- Continuous cardiac monitoring (arrythmias)
- Cerebral oedema and seizures
