Airway Transport
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Transcript Airway Transport
Airway Management in
Transport
Objectives
Overview
of the differences between
the pediatric and adult airway
Intubation of the pediatric patient
The Basics
The airway in any patient can be:
Physiologic
• maintained easily or with effort by the
patient
Maintainable
• with some assistance/positioning
Invasive
Intervention
• oral airway, nasal trumpet, or intubation
The Basics
To assist patient’s in maintaining an
airway:
Clear mouth
Position head
Consider Airway adjuncts
Proper Positioning
A jaw thrust or head tilt
maneuver will position the
tongue so that it will not
obstruct the airway
Remember that a child has a
relatively large tongue
compared to an adult
In infants it is possible to
hyperextend the neck too much
and cause the soft tissue to
obstruct the airway
Nasal Trumpet
A nasal trumpet can
be a useful adjunct
possible for the
trumpet to be too long
or too short
Oral Airway
An appropriately placed
oral airway will pull the
tongue forward and
provide an unobstructed
airway
If the oral airway is too
long, it will stimulate a
gag. If it’s too short, it
will not lift the tongue.
Airway Adjuncts
The use of airway adjuncts, such as the nasal
trumpet and oral airway, will only provide an
adequate airway.
The patient must have reasonable respiratory
effort.
If the patient is unable to maintain adequate
ventilation, he/she should be bagged or
proceed to endotracheal intubation.
Indications for Intubation
1. Unable to protect airway
2. Inadequate ventilation
3. Hypoxemic respiratory failure requiring
positive pressure
4. Therapeutic (e.g. Hyperventilation in
head injury)
Difficult Airway Considerations
Short,
muscular neck
Receding mandible
Protruding incisors
Uvula not visualized
Limited TMJ mobility
Limited C-spine mobility
What do you need?
Monitors -- cardiac and pulse oximetry
Suction -- Yankauer or catheter
Machine -- ventilator or bag/mask
Airway -- Endotracheal tube
Intravenous -- peripheral or central line
Drugs -sedation/analgesia/paralysis/atropine
Laryngoscopes
Straight
Curved
Fiberoptic
Proper visualization
The laryngoscope
should be used to lift
“up and out”. Do not
rock back on upper
teeth.
Curved blade tip is
placed in vallecula and
will lift epiglottis away
from airway.
Straight blade tip is
used to hold the
epiglottis from beneath.
Proper ETT Size
Newborn - 6 months
6 months - 1 year
> 1 year
3.5
4.0
4 + age
4
Intubation Procedure
Prepare Equipment
Position patient
• Table height
• “Sniffing” position
Pre-oxygenate
• 4 max breath in 30 sec
• 100% O2 for 3-5 min
Induction agent
• sedative/analgesic
Neuromuscular
blocker
Intubation
• Laryngoscope in L hand
• Insert on R of mouth and
sweep tongue to L
• Advance in midline until
epiglottis visualized
• Advance tip of blade
– into vallecula (curved
blade)
– beneath epiglottis
(straight blade)
• Lift towards feet
– “up and out”, “Never
Lever”
Rapid Sequence Intubation
Done when immediate airway stabilization is
required or the patient has a “full stomach”
• has eaten
-- pregnancy
• trauma
-- abdominal mass
• GER
-- misc
• bowel obstruction
Expedited with rapid acting drugs and
avoidance of bag mask ventilation
Rapid Sequence Intubation
Procedure
• Pre-oxygenate
• Rapid Induction Agents
• Rapid Acting Neuromuscular Blocker
• Sellick’s Maneuver
• Intubate
• Check breath sounds, inflate cuff (if
applicable)
• Release cricoid pressure
Sellicks’ Maneuver
Cricoid
Pressure
Closes esophagus against the vertebral
column
protects against passive regurgitation
DO NOT release until airway is secure !
Intubation Medications
Goals:
Provide adequate intubation conditions
• airway easily visualized
• patient comfort (not fighting procedure)
Avoid
complications
• hemodynamic instability
• ICP in head injury
Atropine
Blunts
vagal response that can cause
bradycardia and dries oral secretions
Dose = 0.02 mg/kg (min 0.1 mg)
Adverse effects
•
•
•
•
tachycardia
mydriasis
atropine flush
disorientation
Benzodiazepines
Effective
in providing anxiolysis and
amnesia
Onset and duration vary between
midazolam, lorazepam, and diazepam
Dose = 0.1 mg/kg
Adverse Effects include: hypotension
and myocardial depression
Fentanyl
Sedative/Analgesic
Dose
2-5 mcg/kg
Rapid Onset and short duration -- thus
an excellent intubation med
Virtually no CV side effects
Ketamine
PCP
Derivative, Dissociative Hypnotic
Rapid Onset and short duration
Dose = 1-2 mg/kg IV or 2-4 mg/kg IM
Increases HR, and BP and thus may be
ideal for the patient with shock.
Increases cerebral metabolic rate and
ICP and thus not a good choice in head
injury or seizure
Thiopental (Pentothal)
Dose
= 2-5 mg/kg
Max Effect in 60 seconds
Sedative Hypnotic that decreases
cerebral metabolic rate and ICP
Hypotension and Myocardial Depression
are possible adverse effects
Etomidate
Ultra
short-acting non-barbiturate
hypnotic
rapid induction of anesthesia with
minimal cardiovascular effects
0.2-0.6 mg/kg over 30-60 seconds
Peak effect: 1 minute
Duration of action: 3-5 minutes
Can cause adrenal suppression
Neuromuscular Blockers
Recommend
•
•
•
•
•
only rapid acting agents:
Succinylcholine - dose = 1 mg/kg IV
Rocuronium - dose = 0.6-1.2 mg/kg IV
Vecuronium - dose = 0.1-0.3 mg/kg IV
Mivacurium - dose = 0.2 mg/kg IV
Atracurium - dose = 0.2 mg/kg IV
Recommended Intubation
“Cocktails”
Controlled Intubation
•
•
•
•
Fentanyl & Lorazepam or
Etomidate
Vecuronium/Rocuronium
+ Atropine
Head Injury
•
•
•
•
Pentothal or Etomidate
Lidocaine 1 mg/kg IV
Vecuronium
Atropine
Septic Shock
• Atropine
• Ketamine
• Rocuronium/Vecuronium
Status Asthmaticus
•
•
•
•
Atropine
Ketamine
Lorazepam
Rocuronium/Vecuronium
Physiologic Response to
Intubation
Airway
Reflexes
• Laryngospasm
• Cough
• Gag
Cardiovascular
Reflexes
•
•
•
•
Sinus bradycardia
Tachycardia
Hypertension
Dysrhythmias
Assessing ETT placement
Direct
visualization
ETCO2 (digital readout or color
paper)
Chest rise
Auscultation (be certain to confirm
absence of gastric breath sounds)
ETT vapor (unreliable)
Chest X-ray
Monitoring on Transport
Physical
Exam
EKG monitor
Pulse oximeter
ETCO2 Monitor
Reevaluate Frequently
Capnograms
Normal
Zero baseline
Rapid, sharp up rise
Alveolar plateau
Well-defined end-tidal
Rapid, sharp down stroke
A—B
B—C
C—D
D
D—E
Deadspace
Dead space and alveolar gas
Mostly alveolar gas
End-tidal point
Inhalation of CO2 free gas
Capnography
Sudden loss of waveform
Esophageal intubation
Ventilator disconnect
Ventilator malfunction
Obstructed / kinked ETT
Capnography
Decrease in waveform
Sudden hypotension
Massive blood loss
Cardiac arrest
Hypothermia
PE
CPB
Capnography
Gradual increase in waveform
Increased
body temp
Hypoventilation
Partial airway obstruction
Exogenous CO2 source (w/laparoscopy/CO2
inflation)
Capnography
Sudden drop – not to zero
Leak
in system
Partial disconnect of system
Partial airway obstruction
ETT in hypopharynx
Capnography
Sustained low EtCO2
Asthma
PE
Pneumonia
Hypovolemia
Hyperventilation
Low ETCO2, but good plateau
40
30
Capnography
Cleft in alveolar plateau
Partial
recovery from neuromuscular
blockade
40
Capnography
Transient rise in ETCO2
Injection
of bicarbonate
Release of limb tourniquet
40
Capnography
Sudden rise in baseline
Contamination
of the optical bench –
need to recalibrate
40
Questions
1.
Which drug is not used in the
intubation of a head injury patient?
•
•
•
•
A. Ketamine
B. Thiopental
C. Lidocaine
D. Etomidate
Question
2.Capnograph
represents
A. Esophageal
intubation
B. Ventilator
disconnect
C. Obstructed /
kinked ETT
D. All of the above
Question
3.
Appropriate ETT size for a 6 year old
calculated by formula is?
•
•
•
•
A. 6.0
B. 4.5
C. 5.0
D. 5.5
Question
4.
True or False:
• Curved blade tip is placed in vallecula and
will lift epiglottis away from airway
Question
5.
All of the following are indications for
intubation except:
• A. Unable to protect airway
• B. Inadequate ventilation
• C. Hypoxemic respiratory failure requiring
positive pressure
• D. GCS 10