S4C29 - Pediatric Airway Management

Question 1

Pediatric Airway Physiology

Answer 1

• higher oxygen consumption, increased CO, increased minute ventilation
• lower FRC –> decreased ability to pre-oxygenate
• more likely to need bag mask while waiting for sedation/paralytic
• children desat rapidly if O2 sat falls below 90%
• larger ECF compartment = quicker onset and shorter duraitno of drugs

Question 2

Pediatric Airway Anatomy

Answer 2

-infants- large forehead and occiput, large tongue, small mandible, larynx more superior and anterior

• therefore more difficult to line up airway
• straight airway blade helps with large tongue
• when tension put on esophagus the sides can turn white and appear like the cords
• narrowest point of airway: cricoid ring (also where croup swelling occurs)
• blind nasotracheal intubation not recommended in children <10yo b/c of prominent adenoid tissue and risk of bleeding
• surgical cricothyrotomy is contraindicated in children <10yo b/c membrane too small, needle cricothyrotomy is the choice of surgical airway

Question 3

Pediatric Airway Eqpt

Answer 3

-blade

• determine size by placing handle joint at child’s upper incisors and tip at the angle fo the mandible (should be w/in 1cm)
• use #0 or 1 for small or premature newborns
• 1-2yo = 1-2
• 2-10= 2
• >10 = 3

ETT

• size is (childs age)/4 + 4

Question 4

Pediatric Intubation

Answer 4

• prep:
• consider fluid bolus to prevent hypotension with intubation
• ventilation parameters:
• tidal volume: 8-12cc/kg
• sniffing position: external auditory canal should lie just anterior to the shoulder
• use miller straight blade to pick epiglottis up
• ETT depth: tube ID x 3 = depth at the lips
  eg. a 4mm ID tube should be 12cm length at the lips
• use of atropine to prevent reflex brady is unnecessary, however if bradycardia occurs then give it

Question 5

Succinylcholine: complications and contraindications

Answer 5

• hyperkalemia
• bruns >5d old
• denervation injury >5d old
• crush injury >5d old
• sever infxn >5d
• neuromuscular dz, myopathy
• preexisting hyperkalemia
• masseter spasm
• increased intragastric, intraocular, intracranial pressure
• malignant hyperthermia
• bradycardia
• fasciculations
• prolonged apnea with pseudocholinesterase deficiency

Question 6

Induction agents

Answer 6

-Etomidate 0.3mg/kg

• prevents hypotension
• may suppress adrenal axis
• requires concomitant analgesia

-Ketamine 1-2mg/kg

• bronchodilator, preserves respiratory drive
• cardiovascular stimulant
• good for asthma

-Propofol 1-2mg/kg

• causes hypotension
• requires analgesia/anxiolysis

Question 7

Paralytics

Answer 7

• Rocuronium 1mg/kg
• nondepolarizing agent
• Succinylcholine
• <10kg = 1.5-2mg/kg
• >10kg = 1-1.5mg/kg
• short duration
• may worsen hyperkalemia

Question 8

Sedatives

Answer 8

-Midazolam 0.1mg/kg

Question 9

Fentanyl

Answer 9

1-2mcg/kg

preserves hemodynamic stability

Question 10

Pediatric Difficult Airway

Answer 10

• upper airway infection: consider use of LMA, Bag-mask ventilation often successful b/c pos pressure stents open mobile soft tissues
• FB obstruction
• if child becomes unconscious perform direct larnygoscopcy, if FB visualized use magill’s to remove
• if obstruction subglottic insert ETT, this may push the FB into a mainstem bronchus and allow for temporizing of the other lung until bronchoscopy can be done
• surgical approaches rarely help with FB v/c obstruction is usually below the level of the cricothyroid membrane
• congenital anomalies (micragnathia)
• bag-mask ventilation and LMA usually still work well

Question 11

Needle Cricothyrotomy

Answer 11

• attach 10cc syringe to a 3.0 internal diameter endotrachel tube adapter which is attached to 14g needle with a catheter
• insert through cricothyroid membrane withdrawing on syringe until you get air back, inserter catheter, remove needle and syrnge, ventilate the catheter using the 3.0 ET tube adapter