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  • Project: Ghana Emergency Medicine Collaborative

    Document Title: Rapid Sequence Intubation & Emergency Airway Support

    in the Pediatric Emergency Department

    Author(s): Michele Nypaver (University of Michigan), MD, 2009

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    1

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    2

  • Rapid Sequence Intubation

    & Emergency Airway Support

    in the Pediatric Emergency Dept.

    Michele M. Nypaver, MD

    UMHS Pediatric Emergency Medicine

    Fellowship Lecture Series

    July 2009

    3

  • Objectives

     Basics Review

     The 7 P’s of RSI

     RSI Pharmacology

     Procedure

     Indications/Complications of RSI

     Advanced Airway options

     Resources for skill maintenance and help

    A is for

    airway!

    4

  • Definitions

    Rapid Sequence Intubation:

    • Describes a sequential process of preparation,

    sedation, and paralysis to facilitate safe, emergent

    tracheal intubation.

    • Pharmacologic sedation and paralysis are induced in

    rapid succession to quickly and effectively perform

    laryngoscopy and tracheal intubation.

    • At the same time, careful preparation (including pre-

    oxygenation) and the use of specific techniques (such

    as applying cricoid pressure and avoiding positive

    pressure ventilation) minimize the risks of hypoxia and

    aspiration.

    • Assuming a patient with full stomach. 5

  • The Evidence for RSI “NEAR” data: n=156 pediatric intubations

    Success Rates for intubation

    Sagarin et. al., 2002

    METHOD FREQ.

    (%)

    FIRST

    ATTEMP

    T (%) *

    FIRST

    PERSON

    (%)

    OVERAL

    L

    SUCCES

    S

    (%)

    COMPLI

    C-ATION

    (%)

    RSI 81 78 85 99 1

    NO MEDS 13 47 75 97 5

    SED, NO

    NMBA 6 44 89 97 0

    * May be due to size and age

    6

  • Basic Pediatric Anatomy: Size

    Take home point: Small changes in pediatric airways cause

    large incremental increases in airway resistance

    4 mm

    8 mm

    2 mm

    6 mm

    NORMAL EDEMA

    1mm

    RESISTANCE

    (R proportional to

    1/(radius^4)

    X-SECT AREA

    INFANT

    ADULT

    Increase 16x

    Increase 3x

    Decrease 75%

    Decrease 44%

    7

  • 23) In this picture taken during DL, the arrow is pointing to which

    of the following anatomic structure(s)?

    a) Arytenoid cartilages

    b) Epiglottis

    c) Vallecula

    d) Vocal cords

    e) Aryepiglottic fold

    PEM BOARD QUESTION!

    True Vocal Cords

    Pearson Scott

    Foresman, Wikimedia

    Commons

    8

    http://commons.wikimedia.org/wiki/File:Tonsil_(PSF).png http://commons.wikimedia.org/wiki/File:Tonsil_(PSF).png

  • Physical Assessment to identify signs of a real/potential difficult airway in children

     Prominent or misshapen occiput

     short neck

     poor neck mobility

     Facial trauma (including burns)

     Facial anomalies:

     Small mouth

     Small mandible/recessed chin

     Abnormal palate

     Large tongue

     Loose teeth

     Signs of upper airway obstruction

     hoarseness, stridor, drooling, upright position of comfort

    9

  • Airway Assessment: Malampati & ASA Classification

    Malampati Score

    UMHS / CES requires documentation of these on all procedural sedation consents 10

    Hard palate

    Pillar

    Uvula Soft palate

    Jmarchn, Wikimedia

    Commons

    Source Undetermined

    http://commons.wikimedia.org/wiki/File:Mallampati.svg http://commons.wikimedia.org/wiki/File:Mallampati.svg

  • The Lemon

    Pneumonic

    TheCulinaryGeek, Flick

    11

    Mouth opening > 3 cm

    Chin to neck distance > 3 finger breadths

    http://archive.ispub.com/journal/the-internet-journal-of-

    anesthesiology/volume-10-number-1/the-dilemma-of-airway-

    assessment-and-evaluation.html#sthash.TmMgasnc.dpbs

    http://www.flickr.com/photos/preppybyday/5076302395/

  • RSI Procedures

    The 7 “P”s of RSI

    Preparation

    Pre-oxygenation/Positioning

    Pre-treatment

    Protection (Pressure)

    Pharmacology

    Placement of the tube

    Post intubation management

    12

  • RSI Timeline/Protocol

     Preparation: Zero-10 Min

     Monitors, Patient position, Assess for difficulty

     Equipment and Meds

     Pre oxygenate: Zero-5 Min

     Pre treat: Zero-3 Min

     Time Zero: Inject Paralytic with induction

     Protection: Zero-30 seconds

     Placement: Zero-45 seconds

     Post intubation management: Zero-90 seconds

    13

  • 14

    http://www.ijciis.org/vie

    wimage.asp?img=IntJC

    ritIllnInjSci_2012_2_3_1

    43_100891_u2.jpg

  • Preparation for RSI:  Equipment

     Type/Size Specific

     Airway/Difficult Airway Cart

     Monitors

     Pulse Oximetry

     CR monitoring

     CO2 monitoring

     References: Broslow Tape, Harriet Lane

     Doses

     Sizing

     Personnel

     Nurses/Tech’s/Housestaff: Assign roles

     Walk thru

    Prepare for rain!

    Molly DG, flickr

    15

    http://www.flickr.com/photos/54400117@N03/5069142436/in/photolist-8HWFrw-8vnrL8-9Gsp7h-bED5hV-bECZ2P-bED4xT-bED5Ux-7BxUop-dToRjV-ehzNRf-8ZiR2V-aj82xT-aw2Vpo-99qhVj-7SJXcP-brJ8oJ-bED3M8-7UtKxZ-angVzg-ehu2AD-ehu3z4-ehu56z-81EbXt-8viyMD-8zL369-9F2NJ6-bvXdzY-evx5JC-7L4qjg-azMHST-8TB8wZ-9c6RY6-dsq87A-8ojQYf-aCYYkW-dtdBKF-9Quuf1-9QrE5r-9QrESD-9QutP1-9QrDXV-9QutHw-9Qutu9-9QutVj-9QutC5-9QrEL4-ciDu8q-9eZyn9-dpiimD-akgqqH-7VRM6v

  • RSI Preparation: Airway equipment for Pediatric patients

    Supplemental oxygen Nasal cannula (infant, child, and adult)

    Clear oxygen masks (non-re-breathing - infant, child, and adult)

    Suction Suction catheters (6 through 16 French)Yankauer suction tip (two sizes)

    Bag-mask ventilation Masks (neonate, infant, child, adult)

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