Intubation of the Pediatric Patient

imagesInadequate oxygenation or ventilation


imagesAirway obstruction


imagesLoss of protective airway reflexes (e.g., depressed cough and gag reflexes)


imagesExcess work of breathing


imagesNonresponsive and apneic


CONTRAINDICATIONS



imagesAbsolute Contraindications


   imagesNone for unstable patients (i.e., “crash” airway)


imagesRelative Contraindications


   imagesIn these circumstances one should consider consultation with anesthesiologist/intensivist, alternative techniques, and/or sedation without paralysis


      imagesInfectious: Epiglottitis, croup, retropharyngeal abscess, bacterial tracheitis


      imagesNoninfectious: Anaphylaxis/angioedema, foreign body, trauma, burns


      imagesCongenital anomalies (e.g., cleft palate, micrognathia)


      imagesUnanticipated difficult airway (e.g., multiple failed attempts)


RISKS/CONSENT ISSUES



imagesAirway trauma


imagesArrhythmia (e.g., bradyarrhythmia)


imagesAspiration of stomach contents


imagesEsophageal intubation


imagesIncrease in blood pressure and intracranial pressure (ICP)


imagesHypoxemia


imagesPain


LANDMARKS



imagesAnatomical differences in children (FIGURE 89.1):


   imagesLarger tongue


   imagesLarger and floppy epiglottis


   imagesNarrower cricoid ring


   imagesLarger occiput


   imagesThe glottic opening is more cranial and anterior in children and is located at:


      imagesC1 in infancy


      imagesC3–C5 at age 7


      imagesC4–C6 in the adult (Figure 89.1)


   imagesDifferences are most pronounced under 2 years, transition from 2 to 8 years, then approach small adult anatomy by 8 years



images


FIGURE 89.1 The anatomic differences particular to children are (a) higher, more anterior position of the glottic opening (note the relationship of the vocal cords to the chin/neck junction); (b) relatively larger tongue in the infant, which lies between the mouth and the glottic opening; (c) relatively larger and more floppy epiglottis in the child; (d) the cricoid ring is the narrowest portion of the pediatric airway versus the vocal cords in the adult; (e) position and size of the cricothyroid membrane in the infant; (f) sharper, more difficult angle for blind nasotracheal intubation; (g) larger relative size of the occiput in the infant.



imagesGeneral Basic Steps


   imagesPreparation


   imagesPreoxygenation


   imagesPretreatment


   imagesProtection and positioning


   imagesParalysis and induction


   imagesPlacement of tube and proof of tube placement


   imagesPostintubation management


TECHNIQUE



If crash airway and difficult airway algorithms are not indicated, then rapid sequence intubation (RSI) is the preferred approach. This approach is summarized in seven discrete steps, each beginning with the letter “P.”


imagesPreparation: Directed history, physical examination, indications/contraindications for RSI


   imagesAssemble equipment using the “SOAP ME” mnemonic (TABLE 89.1)


   imagesSize is best estimated using Broselow tape or centimeter measuring tape


      imagesOral airway


        imagesSize using Broselow tape or distance from the angle of the mouth to the ear tragus


      imagesNasopharyngeal airway


        imagesSize using Broselow tape, distance from the tip of the nose to the ear tragus, or largest comfortable size that does not produce skin blanching


      imagesLaryngoscope blade


        imagesStraight/Miller blade traditionally has been preferred to the curved blade for infants and young children. However, either blade can be used in any age group depending on availability and operator comfort.


      imagesEndotracheal tube (ETT) size based on Broselow tape or calculated as follows:


        imagesUncuffed: (Age in years/4) + 4 (subtract 0.5−1 for cuffed tube)










TABLE 89.1.


EQUIPMENT FOR RSI—“SOAP ME” MNEMONIC






























S


Suction


Yankaur device (children/adolescents) and/or flexible catheters (infants), suction tubing, wall-mounted suction


O


Oxygen


Face mask (preferably nonrebreather), oxygen tubing, high-flow oxygen source, Bag/Valve device (with positive-pressure valve)


A


Airway


Laryngoscope handle with functional light source and blades, endotracheal tubes, airway tape, stylets, oral/nasopharyngeal airways of varying sizes. Rescue equipment (e.g., Bougie, GlideScope, LMA, cricothyrotomy kit, etc.) should be available in case RSI fails.


P


Pharmacology


Weight-based medications should be prepared in advanced. Agent selection will depend on circumstances and may include sedatives, induction agents, neuromuscular-blocking agents, lidocaine, and atropine.


ME


Monitoring equipment


Cardiorespiratory monitoring with pulse oximetry and frequent blood pressure checks through postintubation monitoring phase. Following endotracheal tube placement, secondary confirmation with end-tidal CO2 calorimeter (qualitative/semiquantitative) and/or capnography (quantitative)


LMA, laryngeal mask airway; RSI, rapid sequence intubation.


        imagesHistorically, uncuffed tubes were preferred in infants and young children due to high rates of subglottic stenosis. Currently, either tube may be used in any age group if leak pressures are monitored.


        imagesPrepare extra tubes, both 0.5 size smaller and larger than estimated


      imagesA stylet can be used to provide rigidity (TABLE 89.2)


      imagesETT depth by Broselow tape or calculated (if age >1 year)


        imagesFormula (in cm): (Age in years/2) + 10 or Tube size × 3


      imagesEnd-tidal CO2 monitor


        imagesIf weight <15 kg, use pediatric calorimeter to avoid false negative readings


      imagesHave airway alternatives available (e.g., GlideScope, Airtraq, laryngeal mask airway [LMA], Bougie, needle cricothyrotomy equipment)


imagesPreoxygenation


   imagesTheoretically, deliver 100% oxygen for 3 minutes. Practically, use nonrebreather facemask (with positive end-expiratory pressure [PEEP] valve) and high-flow nasal cannula once RSI is considered.


   imagesIf child becomes apneic, use bag valve mask (BVM) ventilation prior to intubation


      imagesPerform neck extension and E-C clamp technique with bag-mask ventilation (BMV) if C-spine injury is not suspected


      imagesIf two providers are available, one person maintains mask seal while the other compresses the bag


      imagesUse the rhythm “squeeze, release, release” to allow time for exhalation


      imagesInsert an oral airway in an unconscious patient who is difficult to ventilate


imagesPretreatment: Refers to the administration of medications to attenuate the potential adverse effects of intubation (TABLE 89.3)


   imagesPrior recommendations summarized by “LOAD” (Lidocaine, Opioid, Atropine, Defasciculating agent)


   imagesNo pretreatment agent is recommended routinely for pediatric RSI


   imagesLidocaine: May limit further rise in ICP in cases of head trauma or elevated ICP


      imagesNo data to suggest or refute use to prevent reflex bronchospasm


   imagesFentanyl: Analgesic effects may decrease the reflex sympathetic response


      imagesMay cause hypotension or respiratory depression with other sedatives


   imagesAtropine: Used for its anticholinergic effects to prevent or treat bradyarrhythmias


      imagesAntisialogogue effect is delayed, limiting its use in RSI


      imagesInterferes with pupillary response of the neurologic examination after paralysis


   imagesDefasciculating agent: “Defasciculating” and “Priming” doses are no longer recommended










TABLE 89.2.


 



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Aug 9, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Intubation of the Pediatric Patient
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