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Pediatric Rapid Sequence Intubation

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									           Pediatric Rapid Sequence Intubation

                        February 26, 2004
                                    Case
A    4-yo child is an unrestrained front seat passenger in a motor vehicle
    crash.

 Child   was alert and talking coherently at the scene.

 On     arrival to ER the child is unresponsive. RR is 12 with pauses in
    breathing. SaO2 is 100% on 5 L O2. Air entry is normal bilaterally. HR is
    90. BP is 130/84. Central and peripheral pulses are strong with a cap
    refill of 2 seconds and warm pink extremities.


                                    Case
 He    has no purposeful movements. He exhibits flexion posturing
    in response to pain. He has no gag. His pupils are 3 mm and
    briskly respond to light. He has a large scalp contusion but no
    obvious midfacial or mouth injuries.

 His   abdomen is soft; there are no deformities and no obvious
    external bleeding.

                                 Definition
 Rapid      sequence induction of anaesthesia in order to

    – eliminate or attenuate the physiological reflexes to
      laryngoscopy and intubation

    – prevent pulmonary aspiration

    Physiological consequences of laryngoscopy and
                       intubation
   Afferent pathways activated by

    –   Physiological insults: hypoxia, hypercarbia
    –   Anatomical insults: oral airway, laryngoscopy, ETT

   Efferent response

    –   CNS: raised ICP, raised IOP

    –   CVS: bradycardia (parasympathetic)
             tachycardia, hypertension (sympathetic)

    –   Resp: apnea, gag, cough, sneeze, swallow,
         laryngospasm, bronchospasm



                 Pulmonary Aspiration Syndrome
 Always    assume a full stomach in RSI

 Incidence    of vomiting 36-44% (aspiration 2-4%)

 Higher    risk in children:
    – aerophagia during crying
    – strenuous diaphragmatic activity
    – shorter esophagus

 Complications     include:
    – Bronchospasm
    – Pneumonitis

              Pediatric Anatomical Considerations

 Large head

 Small nares

 Small mouth

 Large tongue
                                       Larynx
 Adult
    – Opposite C4 - C6
 Child
    – Opposite C2 - C3


                                       Larynx
 Adult
    – Cylindrical

 Child
    – Funnel-shaped


                                     Vocal Cords
 Adult
    – Horizontal
 Child
    – Sits in a slant

                                      Epiglottis
 Adult
    – Relatively smaller
    – Stiffer cartilage
 Child
    – Relatively larger & longer
    – Floppy

                                      Trachea
   Adult
     – Longer
   Child
     – Shorter
                                   Airway diameter
   Adult
     – Smallest diameter between vocal cords
   Child
     – Smallest diameter at cricoid ring (just below vocal cords)
           Pediatric Physiological Consideration
 FRC   smaller

                       Airway Resistance

 Airway    smaller and floppier


 Resistance      exponentially higher

                     Oxygen Consumption
 Oxygen  consumption is higher:
  – 6-8 ml/kg in infants
  – 3-4 ml/kg in adults

More     prone to hypoxia
                 Chest Wall Compliance

 Compliance      higher

 Retractions     are common

                      RSI - preparation
                           Brief Hx and PE
 AMPLE
  – e.g. NMD
  – e.g. previous meal
  – e.g. Hx of HI

 Exam:
  – e.g. anatomic challenges to intubation
                             Personnel
 (1)   Airway

 (2)   Medications
 (3)    Monitoring and Cricoid Pressure
                             Equipment
SOAP ME
 Suction


 Oxygen


 Airway


 Pharmacology


 Monitoring   Equipment
                                Suction

 YANKAUER        tip

 Tracheal     suction catheter

                                Oxygen

 high-flowmeter connected to a functioning bag-valve-
  mask devise

  – self-inflating bag

  – anaesthesia bag


                                Airway
 Oral   airway

 Face    masks with cushion seal

 ETT

  – size: 4 + (age/4)

  – uncuffed for < 8 year olds: 3 + (age/4)
                                          Airway
 Stylet


 Magill    forceps

 Laryngoscopes
  – Handle
  – Blade
      straight   (Miller) for infants
      curved    (Macintosh) for > 1 yr


                                   Pharmacology

 Premedication - anticholinergics

  – Atropine IV 0.02 mg/kg (min 0.1mg; max 1.0mg)

      Indications:
           – < 1 yr
           – 1-5 yo receiving Sux
           – > 5 yp receiving 2nd dose of Sux

      Consider      for:
           – Bradycardic child
           – Ketamine use



                                   Pharmacology

 Premedication - analgesia

  – Fentanyl IV 2-4 ug/kg

      S/E:
           – Chest wall rigidity
           – Raised ICP
           – Hypotension
                              Pharmacology

 Sedatives

  – Ketamine IV 2 mg/kg
     Onset w/i 1 min & anaesthesia for 10 to 15 min
     Pulmonary vasodilator
     Contraindicated in head injury


  – Thiopental IV 2-4 mg/kg
     Onset w/i 1 min & anaesthesia for 5-10 min
     Cerebral vasoconstrictor
     Contraindicated in asthma



                              Pharmacology
 Muscle     relaxation

  – Succinylcholine IV 2 mg/kg
     fastonset of action (30 s)
     recovery w/i 5-10 min
     S/E: fasciculations, hyperkalemia, raised ICP, etc.
     only NMB agent approved for IM use (4 mg/kg)


  – Rocuronium IV 1 mg/kg
     fastonset of action (30 sec)
     recovery w/i 40 min



                       Monitoring Equipment
 Continuous      cardiorespiratory monitoring

 noninvasive      blood pressure

 pulse   oximetry

 end-tidal     CO2
                       RSI - technique
                         Airway patency

 opened     by chin lift & jaw thrust
  – ONLY JAW THRUST IN TRAUMA


 oral   pharynx suctioned +/- oral airway inserted
                        Pre-oxygenation

 100%      oxygen for 2-5 min

 Creates     an oxygen reservoir in the lungs

 Avoid     BMV to prevent gastric distention

 If no effective ventilation spontaneously, may BMV +
  cricoid (if sedate)

                             Medication
 Premedications
  – Anticholinergics
  – Analgesics

 Sedatives


 Cricoid   pressure +/- BMV

 NMB

                       Tracheal Intubation

 Intubation

  – blade insertion

  – depth of ETT insertion
         ( AGE/2 ) + 12
                       OR
                  internal di. Of ETT x 3.5

                               Tracheal Intubation
   confirmation of tracheal intubation
    – Primary
           Chest rise
           Equal A/E
    – Secondary
           SaO2 & EtCO2
    – Definitive
           CXR

   secure the tube

   ng placement
    – OG IN HI

   ongoing sedation +/- paralysis



                                      Conclusion

 consider  the differences between the child and the adult
    in anatomy, physiology, drug metabolism, and
    emotional response to injury

 standardize              & simplify the procedure


                                     Reference
 Lee  BS. Pediatric Airway Management. Clinical Pediatric
    Emergency Medicine. 2001 Jun; 2(2); 91-106.

								
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