airway management in transport

1. Airway Management in Transport Toni Petrillo-Albarano, MD Pediatric Critical Care Medicine Children’s Healthcare of Atlanta at Egleston Children’s Hospital

3. Anatomic Considerations in Pediatrics Relatively Large Occiput Large Tongue Larynx is anterior and superior Epiglottis may be floppy with acute angle Narrowest portion is cricoid cartilage

4. The Basics The airway in any patient can be: Physiologic maintained easily or with effort by the patient Maintainable with some assistance/positioning Invasive Intervention oral airway, nasal trumpet, or intubation

5. The Basics To assist patient’s in maintaining an airway: Clear mouth Position head Consider Airway adjuncts

6. Proper Positioning A jaw thrust or head tilt maneuver will position the tongue so that it will not obstruct the airway Remember that a child has a relatively large tongue compared to an adult In infants it is possible to hyperextend the neck too much and cause the soft tissue to obstruct the airway

7. Nasal Trumpet A nasal trumpet can be a useful adjunct possible for the trumpet to be too long or too short

8. Oral Airway An appropriately placed oral airway will pull the tongue forward and provide an unobstructed airway If the oral airway is too long, it will stimulate a gag. If it’s too short, it will not lift the tongue.

9. Airway Adjuncts The use of airway adjuncts, such as the nasal trumpet and oral airway, will only provide an adequate airway. The patient must have reasonable respiratory effort. If the patient is unable to maintain adequate ventilation, he/she should be bagged or proceed to endotracheal intubation.

10. Indications for Intubation 1. Unable to protect airway 2. Inadequate ventilation 3. Hypoxemic respiratory failure requiring positive pressure 4. Therapeutic (e.g. Hyperventilation in head injury)

11. Difficult Airway Considerations Short, muscular neck Receding mandible Protruding incisors Uvula not visualized Limited TMJ mobility Limited C-spine mobility

12. What do you need? Monitors -- cardiac and pulse oximetry Suction -- Yankauer or catheter Machine -- ventilator or bag/mask Airway -- Endotracheal tube Intravenous -- peripheral or central line Drugs -- sedation/analgesia/paralysis/atropine

13. Laryngoscopes Straight Curved Fiberoptic

14. Proper visualization The laryngoscope should be used to lift “up and out”. Do not rock back on upper teeth. Curved blade tip is placed in vallecula and will lift epiglottis away from airway. Straight blade tip is used to hold the epiglottis from beneath.

15. Proper ETT Size Newborn - 6 months 3.5 6 months - 1 year 4.0 > 1 year 4 + age 4

16. Intubation Procedure Prepare Equipment Position patient Table height “Sniffing” position Pre-oxygenate 4 max breath in 30 sec 100% O2 for 3-5 min Induction agent sedative/analgesic Neuromuscular blocker Intubation Laryngoscope in L hand Insert on R of mouth and sweep tongue to L Advance in midline until epiglottis visualized Advance tip of blade into vallecula (curved blade) beneath epiglottis (straight blade) Lift towards feet “up and out”, “Never Lever”

17. Rapid Sequence Intubation Done when immediate airway stabilization is required or the patient has a “full stomach” has eaten -- pregnancy trauma -- abdominal mass GER -- misc bowel obstruction Expedited with rapid acting drugs and avoidance of bag mask ventilation

18. Rapid Sequence Intubation Procedure Pre-oxygenate Rapid Induction Agents Rapid Acting Neuromuscular Blocker Sellick’s Maneuver Intubate Check breath sounds, inflate cuff (if applicable) Release cricoid pressure

19. Sellicks’ Maneuver Cricoid Pressure Closes esophagus against the vertebral column protects against passive regurgitation DO NOT release until airway is secure !

20. Intubation Medications Goals: Provide adequate intubation conditions airway easily visualized patient comfort (not fighting procedure) Avoid complications hemodynamic instability ICP in head injury

21. Atropine Blunts vagal response that can cause bradycardia and dries oral secretions Dose = 0.02 mg/kg (min 0.1 mg) Adverse effects tachycardia mydriasis atropine flush disorientation

22. Benzodiazepines Effective in providing anxiolysis and amnesia Onset and duration vary between midazolam, lorazepam, and diazepam Dose = 0.1 mg/kg Adverse Effects include: hypotension and myocardial depression

23. Fentanyl Sedative/Analgesic Dose 2-5 mcg/kg Rapid Onset and short duration -- thus an excellent intubation med Virtually no CV side effects

24. Ketamine PCP Derivative, Dissociative Hypnotic Rapid Onset and short duration Dose = 1-2 mg/kg IV or 2-4 mg/kg IM Increases HR, and BP and thus may be ideal for the patient with shock. Increases cerebral metabolic rate and ICP and thus not a good choice in head injury or seizure

25. Thiopental (Pentothal) Dose = 2-5 mg/kg Max Effect in 60 seconds Sedative Hypnotic that decreases cerebral metabolic rate and ICP Hypotension and Myocardial Depression are possible adverse effects

26. Etomidate Ultra short-acting non-barbiturate hypnotic rapid induction of anesthesia with minimal cardiovascular effects 0.2-0.6 mg/kg over 30-60 seconds Peak effect: 1 minute Duration of action: 3-5 minutes Can cause adrenal suppression

27. Neuromuscular Blockers Recommend only rapid acting agents: Succinylcholine - dose = 1 mg/kg IV Rocuronium - dose = 0.6-1.2 mg/kg IV Vecuronium - dose = 0.1-0.3 mg/kg IV Mivacurium - dose = 0.2 mg/kg IV Atracurium - dose = 0.2 mg/kg IV

28. Recommended Intubation “Cocktails” Controlled Intubation Fentanyl & Lorazepam or Etomidate Vecuronium/Rocuronium + Atropine Head Injury Pentothal or Etomidate Lidocaine 1 mg/kg IV Vecuronium Atropine Septic Shock Atropine Ketamine Rocuronium/Vecuronium Status Asthmaticus Atropine Ketamine Lorazepam Rocuronium/Vecuronium

29. Physiologic Response to Intubation Airway Reflexes Laryngospasm Cough Gag Cardiovascular Reflexes Sinus bradycardia Tachycardia Hypertension Dysrhythmias

30. Assessing ETT placement Direct visualization ETCO2 (digital readout or color paper) Chest rise Auscultation (be certain to confirm absence of gastric breath sounds) ETT vapor (unreliable) Chest X-ray

31. Monitoring on Transport Physical Exam EKG monitor Pulse oximeter ETCO2 Monitor Reevaluate Frequently

32. CapnogramsNormal Zero baseline Rapid, sharp up rise Alveolar plateau Well-defined end-tidal Rapid, sharp down stroke

33. CapnographySudden loss of waveform Esophageal intubation Ventilator disconnect Ventilator malfunction Obstructed / kinked ETT

34. CapnographyDecrease in waveform Sudden hypotension Massive blood loss Cardiac arrest Hypothermia PE CPB

35. CapnographyGradual increase in waveform Increased body temp Hypoventilation Partial airway obstruction Exogenous CO2 source (w/laparoscopy/CO2 inflation)

36. CapnographySudden drop – not to zero Leak in system Partial disconnect of system Partial airway obstruction ETT in hypopharynx

37. CapnographySustained low EtCO2 Asthma PE Pneumonia Hypovolemia Hyperventilation

38. CapnographyCleft in alveolar plateau Partial recovery from neuromuscular blockade

39. CapnographyTransient rise in ETCO2 Injection of bicarbonate Release of limb tourniquet

40. CapnographySudden rise in baseline Contamination of the optical bench – need to recalibrate

42. Questions 1. Which drug is not used in the intubation of a head injury patient? A. Ketamine B. Thiopental C. Lidocaine D. Etomidate

43. Question 2.Capnograph represents A. Esophageal intubation B. Ventilator disconnect C. Obstructed / kinked ETT D. All of the above

44. Question 3. Appropriate ETT size for a 6 year old calculated by formula is? A. 6.0 B. 4.5 C. 5.0 D. 5.5

45. Question 4. True or False: Curved blade tip is placed in vallecula and will lift epiglottis away from airway

46. Question 5. All of the following are indications for intubation except: A. Unable to protect airway B. Inadequate ventilation C. Hypoxemic respiratory failure requiring positive pressure D. GCS 10