Transcript Pediatric Advanced Airway - Teaching Portfolio Alicia Kleinhans

Developed By Alicia Kleinhans BSN RN CEN CCRN
Objectives

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List 3 unique features of pediatric airway which are
necessary to recognize for airway management
Describe the main difference between ventilation
and perfusion and list 2 ways this can cause
hypoxemia
Name at least 4 clinical signs of respiratory distress
and respiratory failure
List at least 3 causes of respiratory distress in
pediatric patients and describe 2 methods of
treatment
Name at least 3 indicators for intubation
Describe the 6 steps necessary for intubating a
pediatric patient
List 5 steps in a systematic approach to xray
interpretation
Airway is the key to success
Normal Anatomy

Normal Chest
Anatomy
 Some things the
same with adult vs
Peds ie Tidal Volume
4.5-7ml/kg
 Most things different
How does Pediatric airway differ
from adults
Narrowing of airway
Anatomical Differences
o Tongue proportionally larger
o Epiglottis floppy, U shaped
o Larynx more anterior and high – C2 in
neonate, C3-4 in child, C5-6 in adult
o Shorter - newborn trachea 5cm; 18 month
old 7cm
o Narrower – narrowest point at cricoid ring,
uncuffed tubes <8 yrs functional seal
Anatomical differences
o Chest wall of infant weak and unstable
o Heart muscle less contractile
o Alveoli not fully developed until 2 years
Pediatric vs Adult
Physiologic Differences
Infants <2 months obligate nose
breathers
 Immune system immature
 Developmental – put everything in their
mouths
 Compensate better than adults but
crash faster

 Increase HR and RR
Ventilation
Defined as movement of air into and out
of lungs
 Inspiration and Expiration
 Control via pons
 Chemoreceptors
 Hypoxic Drive – default control

Inspiration





Stimulus via pons
Transmitted via phrenic nerve to diaphragm
Diaphragm flattens, intercostal muscles
contract, ribs elevate and expand
Results in decreased intrapulmonic
pressure (pressure gradient)
Air is passively drawn into the lungs and
alveoli expand
Expiration
Stretch receptors in lungs signal
respiratory center via vagus nerve to
inhibit inspiration (Hering-Breuer Reflex)
 In non-diseased lungs, natural elasticity
passively expels air

Chemoreceptors
Located in carotids and aortic arch
 Stimulated by decreased PaO2,
increased PaCO2 or decreased Ph
 Increased PaCO2 considered normal
neuroregulatory control of ventilations

Hypoxic Drive
Default regulatory control of ventilations
 When changes are sensed in PaO2

Stimulants & Depressants
Body temp – increase RR with fever,
decreased with hypothermia
 Drugs/Meds – decrease
 Pain – usually increases RR
 Emotion ie Anxiety – Increases
 Acidosis – Increases
 Sleep - Decreases

Perfusion
Defined as process of nutritive delivery
of arterial blood to a capillary bed in the
biological tissue
 Need blood flow to alveoli for gas
exchange to occur
 Many things can affect it – scar tissue,
fluid, trauma, etc.

Hypoxia vs Hypoxemia
Hypoxemia is an inadequate supply of
oxygen in the blood
 Hypoxia is inadequate supply of oxygen
to the cells and tissues of the body

 Caused by reduction in partial pressure of
oxygen (PaO2), inadequate oxygen
transport, inability of tissues to use oxygen
Hypoxic Hypoxia

A reduction of oxygen entering the blood
 Reduced oxygen pressure in the lungs
 Reduced gas exchange area
 Lung disease
Hypemic Hypoxia

A reduction in the capacity of blood to
carry oxygen
 Reduced hemoglobin
○ Drugs, Chemicals, Smoking, or Carbon
Monoxide exposure
 Reduced number of red blood cells
○ Decreased production or hemorrhage
 Improperly formed red blood cells
○ Sickle cell
Stagnant Hypoxia

A deficiency in oxygen due to poor blood
circulation
 Sitting or hanging for long periods
 Exposure to cold temperatures
 Shock states
Histotoxic Hypoxia

An inability of the tissues to use oxygen
 Carbon monoxide or Cyanide poisoning
 Certain narcotics
 Chewing tobacco and alcohol
Respiratory Distress
May stem from anywhere in the
tracheobronchial tree, lungs/alveoli,
pleura, or chest wall
 Body begins compensation
 Signs and Symptoms

 Tachypnea, increase WOB/retractions, nasal
flaring, grunting (generates PEEP),
tachycardia, tripod or sniffing position,
cyanosis, AMS, stridor, wheezing, crackles
Respiratory Failure
Occurs when compensating
mechanisms fail
 Signs and Symptoms

 Agonal respirations, bradycardia (imminent
arrest), flaccid muscle tone, stuporous
ALI and ARDS

Acute Lung Injury
 Defined by PaO2:FiO2 ratio
<300 with bilateral
infiltrates
 Precursor to ARDS

Acute Respiratory
Distress Syndrome
 PaO2:FiO2 ratio<200 and
bilateral infiltrates
 Diagram
you take the PaO2 value from the Arterial Blood gas (let's
say it's 100) and you take the FiO2 from the ventilator (let's
say it's 30%) and then you divide the PaO2 by FiO2. Now,
30%=0.3
So PaO2/FiO2 ratio would be 100/0.3 = 333 mmHg.
If it is 200 or below, you would think of ARDS
ARDS
Physical
damage to lungs
Pulmonary
edema and
alveolar
collapse
Endothelial
dysfunction, fluid
extravation from
capillaries,
impaired drainage
from lungs
Inflammation of
lung
parenchyma
Impaired gas
exchange and
release of
inflammatory
mediators
Hypoxia/Hypoxemia
ARDS
Ground glass appearance on CXR
ARDS
Mechanical ventilation necessary but
also detrimental
 High FiO2 and positive pressure cause
barotrauma and scarring of tissue
 May lead to SIRS (Systemic
Inflammatory Response Syndrome) if
not treated properly

Break?
Common Pediatric Upper Airway
Emergencies
Croup
 Epiglottitis
 Foreign Body Aspiration
 Trauma

Croup
Viral, cold symptoms
and fever, edema of
vocal cords
 S&S – stridor, barking
cough, symptoms
worse at night,
increased work of
breathing, steeple
sign
 Management – Cool
mist, racemic epi
Epiglottitis

Bacterial (haemophilus influenza B),
edema of epiglottis and surrounding
structures, rapid progression
 S&S – fever, sore throat, drooling,
retractions, sniffing position
 Management – keep child calm, O2 as
tolerated, racemic epi, rocephin IV,
intubation by anesthesiologist (one shot),
cricothyroidotomy if unsuccessful intubation
Epiglotittis
Foreign Body Aspiration

Highest risk from 6 months to 5 years,
object can be lodged anywhere in
respiratory tract
 S&S – coughing, stridor in upper, wheezing
in lower, increased work of breathing
 Management – remove foreign body only if
you can see it, intubation?, bronchoscopy
Trauma
Trauma

Many types and causes
 Facial fractures – most involve lower




jaw(most vulnerable),falls, MVA, sports
Choking – choking game, abuse
Hanging – second most common method of
suicide, if death not immediate, delayed
airway obstruction from edema and/or
trauma, intubation difficult
Smoke inhalation - high temperature burns
airway, edema can close airway within 30
minutes
Management – maintain patent airway
Common Pediatric Lower Airway
Emergencies
Asthma/ RAD
 RSV pneumonia
 BPD
 Toxins – Hydrocarbons
 Trauma

Asthma

Hyper-reactive airways (RAD), various
triggers produce bronchial edema,
constriction and increased mucous
production
 S&S – wheeze (expiratory, inspiratory, or
none),tachypnea, retractions
 Management – O2, bronchodilators/beta2agonist, methylprednisone 1-2mg/kg,
magnesium 25-50mg/kg, *terbutaline,
theophylline, mechanical ventilation
Respiratory Syncytial Virus (RSV)

Premature babies and infants more
susceptible, can be life threatening
 S&S – cold-like symptoms, copious, thick
upper airway secretions, may present with
apnea
 Management – Supplemental O2, good
pulmonary toilet, nasal suctioning
Bronchopulmonary Dysplasia
(BPD)
Premature baby
born with 10%
of adult alveoli
requires
mechanical
ventilation
Prolonged
exposure to
high FiO2 and
PPV causes
barotrauma and
scarring of
existing alveoli
Baby becomes
more difficult to
ventilate,
provider
increases
pressure and/or
FiO2 and new
forming alveoli
are scarred as
well
BPD

Abnormal development of lung tissue,
children continue to grow more alveoli
until around two years of age
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
Lungs less compliant
BPD fits
low to no functional reserve
common tracheostomy (2/3 of resistance in
upper airway)
Very important to use lung protective
strategies
Toxins
Toxins

Hydrocarbon aspiration
 Toxic hydrocarbons, CHAMP – Camphorated,
Halogenated, Aromatic, heavy Metals and
Pesticides
 Found in lamp oil, gasoline, turpentine, furniture
polish, propellants, glue, freon, liquid paper
 Penetrates deep into tracheobronchial tree
causing inflammation, bronchospasm and air
leak syndrome
 Rapidly progresses to pulmonary edema and
respiratory failure, CNS and cardiovascular
complications
Hydrocarbon Aspiration

Air leak syndrome
 Pneumothorax
 Tension
pneumothorax
 Pneumomediastinum
 Pneumopericardium

Management
 No antidote
 NO gastric emptying
 Lung protective
strategies
Trauma


Pulmonary
Contusions
Hemothorax/pneumot
horax
 Management – chest
tubes, FOCA

Tension
Pneumothorax
 Needle decompression

Steam Inhalation
burns
 HFOV
Others to consider




Cystic Fibrosis – hereditary, mucous glands of
lungs, liver, pancreas and intestines + weak
immune system; hypoxic hypoxia
Sickle Cell anemia – genetic, red blood cells
sickled; hypemic hypoxia
Carbon monoxide poisoning –
carboxyhemoglobin has higher affinity to
RBC’s; histotoxic hypoxia
Apnea of Prematurity – brain not developed
babies <35 weeks gestation, begins after 2
days and continues for 2-3 months


Tracheomalacia –
floppy airway,
stridor, positional,
supportive care
Tracheoesophageal
fistula (TEF)commonly
associated with
esophageal atresia,
VACTER syndrome,
surgical repair

Diaphragmatic
hernia – stomach
and/or bowel in
thoracic cavity,
defects depend on
when formed,
ECMO,surgical
repair
Break Time
Congenital Defects
Fetal Circulation

Fetal Circulation
 The placenta
provides oxygenated
blood from the mother
to the fetus.
 Instead of perfusing
the lungs, blood is
shunted from the
pulmonary artery to
the aorta by way of
ductus arteriosus
At birth
The fluid that filled the alveoli is expelled
during delivery or absorbed by lung tissue,
the alveoli expand with the first breath
 An increase in systolic blood pressure
occurs when the umbilical cord is clamped,
PVR falls to ½ SVR
 With exposure to oxygen, SVR increases,
thus decreasing blood flow through ductus
and increasing blood flow to lungs

Problems with transition
Insufficient breathing – fails to force fluid
from lungs and increase oxygen
 Systemic hypotension – excessive blood
loss, poor cardiac contractility, or
bradycardia
 Failure of blood vessels in lungs to dilate

Persistent Pulmonary
Hypertension (PPHN)

Hypoxemia secondary to increased
pulmonary vascular resistance
 When transition does not occur as it should,
the body shunts blood through fetal
structures
 Blood flow through foramen ovale or ductus
arteriosus occurs with unoxygenated blood
entering system, can also cause right sided
heart failure
 Present with cyanosis and SOB, treat with
indomethacin, long term with viagra
Why am I telling you this?
High risk for altered respiratory function
 Presents to you as respiratory problem
 Categories:

 Acyanotic=left-to-right shunts, CHF
 Obstructive=restrictive blood flow
 Cyanotic=right-to-left shunts, pt is purple

Oxygen will either do nothing or be bad
5 Most common
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Ventricular Septal
Defect
Hypoplastic Left
Ventricle
Coarctation of the
Aorta
Tetralogy of Fallot
Complete
Transposition of the
Great Arteries
Patent Ductus Arteriosus – PDA
(acyanotic)

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

Oxygen sensitive
Stays anatomically
patent with
hypoxemia for
weeks to months
after birth
Normally begins
closing 24-36 hours
after birth
Ductal dependent
lesion
Ventricular Septal Defect

Usually benign
Hypoplastic Left Ventricle
(obstructive/mixed)

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



Left Ventricle did not
develop
Blood flows from left
atrium to right atrium
Right to left across PDA
Signs & symptoms –
CHF, tachypnea,
increased WOB,
grunting
Management –
Prostaglandin, Oxygen
can be bad
Surgical repair
Coarctation of the aorta
(obstructive)
Narrowing of the aorta
 Usually infants > 1 week
 Pre or Post ductal – important
 S&S – cyanosis, tachypnea,
tachycardia, CHF
 Management –

 Prostaglandin
 O2 can be Bad
 surgical repair
Coarctation of the aorta
Tetralogy of Fallot (cyanotic)

Signs & Symptoms





Low O2 Sats
TET spells
“Boot” shaped heart
Right to Left shunt
Management
 Prostaglandin
 O2 won’t help
 2 staged surgical
repair – BlalockTaussig shunt and
total repair
TET Spells
Transposition of Great Arteries
(cyanotic)

Signs & Symptoms
 Cyanosis, Tachypnea,
Retractions
 Poor feeding/FTT
 With VSD, not
recognized until CHF

Management
 Prostaglandin
 O2 won’t help
 Atrial septostomy
 Arterial switch
Airway adjuncts

Conscious patient

Conscious


Nasopharyngeal
Airway/Nasal Trumpet
Length=distance from
nares to meatus of ears
Unconscious patient
 Oropharyngeal
Unconscious
Airway/OPA
 Holds tongue out of
the way
 Length=distance from
corner of mouth to
meatus of ears
Oxygen delivery




Nasal Cannula
Venturi Mask
Non rebreather
(NRB)
High flow Nasal
Cannula
Positive Pressure Delivery
Basics – BVM
 BiPAP/ CPAP
 Definitive Airways

 LMA
 King Tube
 ETT: nasal, oral, retrograde,
cricothyroidotomy
 Transtracheal Jet Insufflation
Indicators for Intubation

Ventilatory Support
 Tachypnea and increased WOB
 Inadequate rate, depth

Protection/Patency of Airway
 GCS <8
 Edema due to burns, trauma, infectious
process

Positive Pressure Delivery
 Pneumonia
 Pulmonary Edema
Ventilatory Support

Can't Maintain Ventilation/Oxygenation
 SaO2 <90% on High Flow O2 or PaO2<60 on
FiO2>40%
 PaCO2 >55 if baseline is normal, or >10
increase from baseline
 Respiratory Rate

Expected decline in Clinical Status
 Deterioration/Impending Compromise
 Transport
 Airway protection during procedures (ie.
endoscopy)
Protection patency of airway
Can't Protect Airway
 Gag reflex is absent in up to 37% of
population, so a poor predictor of airway
protection
 Can they talk?
 Can they swallow and manage
secretions

Other Reasons:
Supply/Demand imbalance of
perfusion.
 Mechanical Obstruction, or need for
Core Rewarming,
 Inadequate respiratory compensation for
met acidosis CO2 should=(1.5 [HCO3-]
+ 8) ± 2

LMA


Cuff device provides
sufficient seal for
PPV
Indication for Use:
 Endotracheal
intubation not desired
 Emergent mask
ventilation not
possible/adequate
 Intubation fails
King Tube





Supraglottic airway
Proximal cuff seals
nasopharynx and
oropharynx
Distal cuff seals
esophagus
Smallest tube for
12kg patient
Indication for Use:
 Same as LMA
 Suspected c-spine
Endotracheal Tube
Made from polyvinyl chloride with
radiopaque line from top to bottom
 Cuffed vs Uncuffed
 Hole at beveled, distal end Murphy’s
Eye
 External insertion depth marks
 Sizes range 2.5-8, estimate pinky finger
or (age/4) +4

Stylette/ Bougie
Stylette
Bougie
Nasotracheal Intubation

Indications
 Conscious patient

Complications
 Esophageal
 Status epilepticus

 Anaphylaxis

 Anatomy

Contraindications

 Apnea
 Basilar skull fracture/
facial trauma
 Bleeding disorders

placement
Epistaxis
Vagal stimulation
Trauma to vocal
cords/paralysis
Injury to nasal
turbinates
How do you intubate this guy?
Orotracheal Intubation


Indications

Complications
 Definitive airway –
 Esophageal
protect airway
 GCS<8
placement
 Right mainstem
 Vagal stimulation
 Trauma to vocal
cords/paralysis
Contraindications
 Semi-conscious/gag
 Unstable c-spine
 trauma
Assessing airway for difficulty




ASA classification
Malampati scores
History
Obvious trauma or
deformities
Position patient
Look for landmarks
Retrograde Intubation

Indications
Complications
 Conscious patient
 False passage of
 Difficult/Unable to
guidewire
 Bleeding/ hemoptysis
 larygospasm
intubate
 Suspected c-spine


Contraindications
 Laryngotracheal
disease
 Anatomy
 Coagulopathy
Retograde intubation
Fiberoptic and Glidescope
Trachlight
Cricoidectomy – Not typically
used in pediatrics

Indications
Complications
 Unable to intubate
 Subglottic stenosis
 Airway obstruction
 Laceration of
 Trauma to face/upper
esophagus
 Injury to laryngeal
structures
 Air leak syndrome
airway
 Unstable c-spine


Contraindications
 Coagulopathy
 Anatomy
 Lack of practitioner
skill
Transtracheal Jet Insufflation

Indications
 Unable to intubate

Contraindications
 Anatomy

Complications
 Perforation of





esophagus
Bleeding
Subcutaneous
emphysema
Air leak syndrome
Hypoventilation
Expiratory obstruction
Tracheostomies – This is your
airway
To RSI or Not To RSI, that
is the question.
6 P’s of RSI
Preparation
 Preoxygenation
 Pretreatment
 Paralysis
 Placement
 Post-intubation

Preparation




Assess for difficulty
Prepare drugs
Patent IV
Prepare Equipment
 ETT
 Miller blade/light
 Oxygen and Suction
(on and working)
 Co2 detector

Position patient (roll)
Difficulty?
Preoxygenate and Pretreat



100% O2 for 5
minutes
Non-rebreather vs
BVM
Want sats of 100%


Use of atropine?
(hypoxia bradycardia, masking)
Give analgesic
 Morphine 0.1mg/kg– not
with asthma
 Fentanyl 1mcg/kg

Give sedative
 Versed 0.1mg/kg
 Ketamine 0.5-2mg/kg
 Propofol 0.5-1mg/kg
Paralysis
Non-depolarizing neuromuscular
blockade only!
 Vecuronium 0.1mg/kg
 Rocuronium 1mg/kg (Sugammadex)
 Gantacurium – new shorter duration
 Emesis cannot occur
 Wait until no movement


Depolarizing
Neuromuscular
Blockade

Non-Depolarizing
Neuromuscular
Blockade
 Persistent agonist at
 Competitive
nicotinic receptor
sites
 Fasciculations
 Short duration of
paralysis (5-10min)
 Side effects are many
antagonist at nicotinic
receptors
 Longer duration of
paralysis (30-40min)
 Virtually no side
effects
Depolarizing

Problems associated with depolarizing
neuromuscular blockade include




Myalgia (muscle soreness),
Hyperkalemia
Increased ICP
Atypical interactions in some individuals
Depolarization will induce the release of
potassium from skeletal muscle
Malignant hyperthermia is rare but lethal
Recovery cannot be accelerated by
administering medications
Non-depolarizing


Recovery from paralysis with non-depolarizing
neuromuscular blockers can be accelerated by
administration of a cholinesterase inhibitor (ie
Pyridostygmine).
These agents cause muscle paralysis in a
predicted sequence (and recovery in the
opposite sequence):





muscle of fine movement (eye, jaw, larynx)
limbs
trunk
intercostals
diaphragm
Placement
Hold all ventilations unless sats fall
below 90%
 Watch for bradycardia
 Using Miller/straight blade, sweep
tongue to left, go past the epiglottis and
lift without rocking
 Sellick’s maneuver aka cricoid pressure
 Visualize cords and pass through
 Confirm placement

Post intubation management




Secure the tube
Initiate mechanical
ventilation
Insert naso- or
orogastric tube
Monitor patient
continuously
Gold Standard: Clinical Exam
Look for symmetrical chest
rise and misting in tube
Auscultation of epigastrum
Auscultation of bilateral lung
fields including axillae
Change in Skin
Color/Improvement in patient
Oxygen Saturations

Oxygen
Saturation
PaO2
90%
60
 movement
75%
40
 perfusion
50%
27
Sensitive to
 light
CO2 Detectors – Depend on
perfusion

Capnography
 Many EMS have in
Ambulances
 Useful for trending
over periods of time
 Can lose reading
 Studies finds 70%
accuracy in
determining
placement in post
cardiac arrest pt

Colorimetric CO2
detector
 Yellow=Yes
 Purple=Problem
 May take 4-6
ventilations before
color change
Esophageal Detector




Bulb shape
Squeeze then place
on end of ETT
If self-inflates,
tracheal intubation
due to rigid cricoid
cartilage
Studies finds 99100% accurate,
more accurate than
ETCO2 (70-86%)
Chest xray

Placement- tip of
ETT should be
 no lower than 1-2 cm
above the carina
 No higher than 1st rib

Remember 1cm of
movement in adult
ok, 1cm of
movement in infant
or child=extubated
Break for Lunch
Remember in each case
Proper technique- ability to see
important landmarks
 Orientation of the film- left or right
marked
 Good inspiratory effort
 Recognize film artifacts
 Systematic Approach
 Pertinent clinical history

Top to bottom







Determine orientation- clavicles
Airway
Inspiratory vs Expiratory- count ribs (10
above diaphragm)
Heart – shape, size 50% or less, aortic
knob
Clear costo-phrenic angle/ cardiophrenic
angle
Pulmonary vasculature, Fluid or Air
Fractures/Trauma
Mnemonic
A. Airway and adenopathy
 B. Bones and breast shadows
 C. Cardiac silhouette.
 D. Diaphgram
 E. Everything else
 F. Fields
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Normal Chest
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Trachea Midline
Thymus- water dense mass in superior mediastinum.
Usually wavy contour. Bilobed but not always
symmetrical.
Heart- water dense with apex to left. Occupies about
50% of chest at widest point. Aortic knob seen
through thymus on left
Pulmonary vessels- seen best on lateral view.
Extend to mid lung tapering gradually
Lungs- uniformly aerated. Appear black
Bony structures- ribs, upper thoracic vertebral
bodies, scapulae and clavicles
Diaphragm- right and left equal
Normal Chest
Group Activity
Tension Pneumothorax
Pleural Effusion
Pneumopericardium vs
Pericardial Effusion
Pneumomediastinum
Hydrocarbon Aspiration vs
Pneumonia
4 month old premature infant
More history
Ex 33 weeker. Required BVM
resuscitation at birth. 48 hours of
ventilator and two weeks total in NICU
until feedings were adequate
 Hospitalized at 2 months for severe
bronchiolitis
 Lives with mother who smokes and 4
year old sibling who attends day care
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Physical exam
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What do you want to know??
Which is the most likely
diagnosis?
Asthma/ RAD
 Bronchiolitis

Bronchiolitis
Although this is his second episode of
wheezing, a diagnosis of asthma in a
child this young is unlikely
 Most likely Viral bronchilotis
 Why is this most likely?
 What treatment?
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15 month old
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Wheezing in
morning and
worsened
throughout the day
Not taking fluids or
eating
Physical Exam
General
 Vitals
 Head to toe

What is going on?
Possible diagnosis
 What do you need to do?
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References
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Fojt, Diane F. (2008) The Advanced Airway Course. Tampa, FL: MECA
Gaedeke, M.K. (1996) Pediatric and Neonatal Critical Care Certification
Review. St. Louis, MO: Mosby
Emergency Nurses Association (2007) Trauma Nursing Core Course
(6th ed.). Des Plaines, IL: ENA
Emergency Nurses Association (2004) Emergency Nurse Pediatric
Course (3rd ed.). Des Plaines , IL: ENA
Slota, Margaret C. (1998) Core Curriculum for Pediatric Critical Care
Nursing (1st ed.). Philadelphia, PA: W.B. Saunders
Waldrop, Julee (2008) Basics of Xray Interpretation in Infants and
Children. www.unc.edu/courses
Whitethorn, Deborah (2000) Pediatric Airway Management and
Respiratory Distress. Alaska EMSC website www.ems-c.org
Washington State Emergency Medical Services for Children (1990)
Alaska Pediatric Prehospital Emergency Course. Seattle, WA
www.ems-c.org
Emergency Medicine & ED Critical Care EMCrit.org
Canadian Journal of Anesthesia Cja-jca.org
Center for Pediatric Emergency Medicine at NYU TRIPP (Teaching
Resource for Instructors in Prehospital Pediatrics) cpem.med.nyu.edu
C.S. Mott Children’s Hospital med.umich.edu/mott/chc
J Trauma 2004;57(5):993-997
J Accid Emerg Med 1999:16(6):444
Lancet. 1995 Feb 25;345(8948):487-8
Clin Otolaryngol. 1993 Aug;18(4):303-7
Bozeman WP, Hexter D, Liang HK, Kelen GD: Esophageal
detector device versus detection of end-tidal carbon dioxide
level in emergency intubation. Ann Emerg Med. 1996
May;27(5):595-9
 Takeda T, Tanigawa K, Tanaka H, Hayashi Y, Goto E, Tanaka K:
The assessment of three methods to verify tracheal tube
placement in the emergency setting.Resuscitation. 2003
Feb;56(2):153-7.
 Schaller RJ, Huff JS, Zahn A: Comparison of a colorimetric
end-tidal CO2 detector and an esophageal aspiration
device for verifying endotracheal tube placement in the
prehospital setting: a six-month experience.Prehosp
Disaster Med. 1997 Jan-Mar;12(1):57-63.
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