Transcript Pediatric Airway Management

Vascular Access
o A 2-month-old girl arrives at the
Emergency Department in cardiac
arrest. Other providers promptly
begin ventilation and perform chest
compression. You need to establish
vascular access to administer fluids
and medications
I.S.
MD
o What is the optimal site for
immediate vascular access for this
infant?
o If resuscitative efforts are
successful, what is the optimal site
for vascular access during the post
resuscitation period?
I.S.
MD
Objectives
o Prioritize sites of vascular access for
different clinical circumstances
o Describe the risks and benefits of
peripheral venous, central venous, and
intraosseous vascular access
o Describe the IO access technique
I.S.
MD
Selection of site and priorities of vascular
access 1
For CPR and treatment of
decompensated shock the one that is
o most readily accessible
o not require interruption
I.S.
MD
Selection of site and priorities of vascular
access 2
o Compensated shock… large bore
peripheral IV catheter
o Post resuscitation phase… central
venous catheter
o Intracardiac administration of drugs
during closed chest compression
o Arterial cannulation
I.S.
MD
Priorities of Vascular Access
o During pediatric CPR or treatment of
decompensated shock.. IO access
o One practical approach: IO or
peripheral or central access
simultaneously
o During attempted resuscitation..
Transtracheal …LEAN
I.S.
MD
Intraosseous Access
o Provides access to a noncollapsible marrow
venous plexus which serves as a rapid ,
safe and reliable route of administration
o Often can be achieved in 30-60 seconds by
using a rigid needle(specially designed or
Jamshidi-type)
I.S.
MD
Intraosseous Access
o A rapid, safe, & effective route
for the administration of
medications & fluids, & may be
used for obtaining an initial blood
sample for type & crossmatch &
for chemical & blood gas analysis
even during resuscitation (Class
IIa; LOE 3).
o Acid-base analysis is inaccurate
after sodium bicarbonate
administration via the IO cannula.
I.S.
MD
Intraosseous Access
o Epinephrine, adenosine, fluids, blood
products, & catecholamines can safely be
administered.
o Onset of action & drug levels achieved are
comparable to venous administration.
o Use manual pressure or an infusion pump to
administer viscous drugs or rapid fluid
boluses, & follow each medication with a
saline flush to promote entry into the
central circulation.
I.S.
MD
Intraosseous Access
I.S.
MD
Intraosseous Access
I.S.
MD
Intraosseous Access
I.S.
MD
Intraosseous Access
I.S.
MD
Complications
o
o
o
o
o
Complications reported in fewer than 1%
Fracture of Tibia
Lower extremity compartment syndrome
Osteomyelitis
Extravasation of Drugs
I.S.
MD
Central V/S Peripheral
Venous Access
o More secure long-term access
o Not higher drug levels or a substantially
more rapid response
o Administration of drugs could injure
tissues(vasopressors ,calcium ,sodium
bicarbonate)
I.S.
MD
Complications of central venous cannulation
o Local and systemic infection,venous or
arterial bleeding, arterial cannulation,
Thrombosis,plebitis, pulmonary
thromboembolism,hydro pneumo hemo
chylo thorax, cardiac tamponade,
arrhythmias, air embolism, catheter
fragment embolism
I.S.
MD
Peripheral Venous Access Devices
o Over-the-needle catheters
o Catheter-over-wire devices
o Catheter-through-introducing sheath
devices
o Butterfly needles
I.S.
MD
Peripheral Venous Access
I.S.
MD
Peripheral Venous Access
A tourniquet is
placed around the
infant's head & the
needle inserted 0.5
cm from the
intended puncture
site in the direction
of blood flow.
I.S.
MD
Peripheral Venous Access
I.S.
MD
peripheral Venous Access
I.S.
MD
Peripheral Venous Access
I.S.
MD
Peripheral Venous Access
I.S.
MD
Central Venous Access
I.S.
MD
External Jugular cannulation
I.S.
MD
Subclavian approach to central
vein
I.S.
MD
Central Venous Access
Approach to Femoral Vein
I.S.
MD
Venous Cutdown
I.S.
MD
Venous Cutdown
I.S.
MD
Venous Cutdown
I.S.
MD
Venous Cutdown
I.S.
MD
Mini-cutdown
oThe vessel is
elevated with a
hemostat & occluded
with gentle traction
from a distal tie.
oThe needle is
inserted & the sheath
is advanced into the
vessel.
oThe vessel should
not be tied off with
this technique.
I.S.
MD
Arterial Lines
I.S.
MD
Arterial Lines
I.S.
MD
Summary points
o Intravascular or intraosseous
access is the preferred route for
medication and drug delivery in
cardiopulmonary emergencies.
I.S.
MD
2
o Immediate intraosseous access is
recommended in cases of
decompensated shock and
cardiopulmonary arrest, particularly if
the provider lacks experience in
pediatric central venous access
techniques
I.S.
MD
3
o Central venous catheterization
can be used in children in
emergencies. But it requires
significant expertise. Many
complications and delays may
occur in expert hands
I.S.
MD
QUESTIONS???
I.S.
MD