Andrew Brainard, MD, MPH, FACEM, FACEP thesharpend/ abrainard01@gmail

1. #8Essential Emergency Airway Care-Paediatric Considerations-Anatomic, physiological, dosing, and equipment issues Andrew Brainard, MD, MPH, FACEM, FACEP http://www.thesharpend.org/ abrainard01@gmail.com

2. # 8RSI of paediatric pt • Learning Objectives: • Prep team/plan/room/equipment • Mask seal, BVM, adjuncts, suction • Pre and apnoeic oxygenation • Pt positioning • Airway assessment and plan • MOANS/LEMON • Announce “pullout criteria” • Briefing for Plan A, B, C, & D • Use Paed Drug Calculator • Correctly Sizes equipment • Correct RSI drugs and dosage • Completes FINAL airway checklist • Call and response • <1 min • Direct/Videolaryngoscopy • Proper Technique • Advantages/disadvantages • Difficulties • Contraindications • Complete Airway Audit Form • R40: 1 y/o lethargic • 2 days of fever, cough, dyspnea • GCS 4, SaO2 88%, P 210, RR 80, BP 100/70 Temp 41, Glucose 10 • On arrival • Same as above • (SaO2 91% w/ O2 BVM) • LEMON shows: • No blood in airway, normal 3-3-2, snoring • Consultant suggests RSI • Patient can only be intubated using • Sedation and Paralysis • Optimal pre and apnoeic O2 and positioning • Suction • Properly sized equipment and dosages

3. Anatomy and physiology • Quick to Desaturate • Large head: • Place roll under shoulders for level ear-to-sternal notch • Large tongue: • Jaw thrust, difficulty clearing tongue with blade • Long flexible epiglottis: • Directly lift the epiglottis with the tip of blade • Cricothyoidcartilage is smallest diameter: • Foreign body obstruction occurs below the larynx • Soft tracheal cartilage • Positive pressure ventilation can open airway, cricoid pressure in contraindicated. • Small airways • Can quickly swell closed • Dramatic changes with oedema • Short Trachea • Blade is frequently advanced to far • Frequent mainstemintubation

4. Pharmacological and equipment • RSI Drugs: use a dosage calculator!!!, • Sedation • Etomidate (0.3mg/kg) • Fentanyl (5-10mcg/kg) • Ketamine (0.5-2mg/kg) • Propofol (0.15-3mg/kg) • Midazolam (0.1-0.3 mg/kg) • Thiopental (0.15-3mg/kg) • Paralysis • Rocuronium (1.2mg/kg) • Succinylcholine (1-2-2mg/kg for infant, 2-3mg/kg for neonate) • Know contraindications • Premedication: • Atropine: • APLS recommends atropine if: <1 year (1-5y/o if using suxamethonium) and patients who receive a second dose of suxamethonium • Routine premedication with atropine in absence of bradycardia is not evidence based and is no longer recommended.

5. Equipment Sizing of equipment (use a memory aid!!!) • Straight blade under 3 y/o • Video laryngoscopy can provide a better view • ETT tubes • Predicted cuffed ET Tube = (Age /4) + 3.5 • (either cuffed and uncuffed tubes can be used) • Predicted uncuffed ET Tube = (Age / 4) + 4 • 1kg = 2.5, 2kg = 3.0, 3kg = 3.0-3.5, >3kg =3.5 • 1y/o = 4.0 • Distance to lip = 3x ETT size • Adjuncts • NPA- nare-to-ear or size of little finger • OPA- mouth-to-ear against patient’s face • Paediatric bougie • Mask Sizing • Nasal apnoeic oxygen at 2-10 lpm

6. MMH ED Pt Age/Weight -Based Equipment Suggestions On Resus 5 & 6 airway carts

7. Major differences in airway management? • Desaturation is more rapid • Needle cricothyroidotomy is recommended over surgical cricothyroidotomy • APLS suggests <12y/o • Some say <6y/o • Others say <3y/o (AKA: it depends) • Manufactured needle cricothyrotomy kits are superior to improvised cric kits Paed Intubation http://emupdates.com/2011/05/24/12-minute-screencast-pediatric-airway-for-emergency-physicians-who-are-not-also-pediatricians/ (12min)

9. Airway briefing and checklist Andy Linda Andy Joyce Joyce- Bimanual • We have a 1 y/o child with pneumonia and hypoxia. • We need to intubate her to improve her ventilation. • Based on our airway assessment,it is appropriate to intubate this 1 year old 10kg child. • We have the correct wt based doses of 50mcg of fentanyl and 20mg of Sux. • The team will be: • I’ll be team leader • Linda as primary airway operator • I’ll be the backup airway operator • Joyce as airway assistant • James also push the drugs • Our plan is: • A- #1 Straight blade/#4 uncuffedtube w/ sylet • B- #2 straight blade/bougie/#3.5 uncuffed tube • C- LMA size “2” • D- Needle Cric for Sats <80% and dropping • We will pullout if SaO2 drops below 93% or if we can’t see anything after 1 minuteand re-oxygenate • Everyone understand their roles? • Questions or suggestions? • Is everyone ready to complete the checklist in less than a minute? Andy 9 9

10. Brief Paediatric References: • Reuben Strayer. Emergency Medicine Updates (http://emupdates.com). 12 minute screencast: pediatric airway for emergency physicians who are not also pediatricians http://emupdates.com/2011/05/24/12-minute-screencast-pediatric-airway-for-emergency-physicians-who-are-not-also-pediatricians/ • Eric R Schmitt, Marianne Gausche-Hill, Advanced Pediatric Airway Management—Updates and Controversies. Emergency Medicine & Critical Care , 2011;5:21-27 (Accessed on 18/03/2013) • Nagler J, Bachur RG. Advanced airway management. Curr Opin Pediatr. 2009 Jun;21(3):299-305. • ChingKY, Baum CR: Newer agents for rapid sequence intubation. PediatrEmerg Care 2009;25:200-210. • The Difficult Airway Society Paeditric Guidelines: http://www.das.uk.com/content/paediatric-difficult-airway-guidelines (Accessed on 20/03/2013)