Paediatric Acute care Guidelines PMH Emergency Department

Pre-Procedure

  • Bag and mask with an oropharyngeal (Guedel) airway is a life saving manoeuvre – the first approach to airway management
  • Anticipate the difficult airway and plan accordingly (get experienced help early)
  • Remember cervical spine injury – immobilise the spine!
  • Always have a backup plan for failed intubation
  • Do not spend more than 30 secs on an intubation attempt (return to oxygenating with a bag and mask)
  • Good team communication is vital in an intubation

Intubation Flowchart

 

General

Oral intubation is the preferred approach in the emergency setting

Difficult Airways:

  • Anatomically difficult airways (e.g. hypoplastic mandible, large tongue)
  • Upper airway obstruction (e.g. swelling, foreign body)
  • Difficult visualisation (e.g. post tonsillectomy haemorrhage, trauma to neck)
  • Chemical aspiration/inhalation (e.g. burns)
  • Difficult bag and mask ventilation

Indications

  • Cardiorespiratory arrest
  • Respiratory or ventilatory failure (manage hypoxia or hypercarbia)
  • Upper airway obstruction (actual or imminent)
  • Absent protective airway reflexes (e.g. decreased level of consciousness)
  • Neuromuscular weakness
  • Severe haemodynamic instability (e.g. shock, critically ill patients)

Contraindications

  • Operator inexperience
  • Be careful in patients with raised intracranial pressure (e.g. head trauma) – laryngoscopy and intubation is likely to worsen (or precipitate) intracranial hypertension – seek expert advice

Preparation

Staff

  • Doctor to perform intubation
  • Doctor to administer medications
  • Airway assistant (nursing staff)
  • Assistant to perform cricoid pressure

Equipment

Bag and Mask:

  • Appropriate size bag for patient
  • Appropriate size mask for patient
  • Connect bag to oxygen supply
  • Check bag is working
  • See ED Guideline: Airway Equipment – Bag and Mask

Oropharyngeal (Guedel) +/- Nasopharygeal Airway:

Suction:

  • Attach Yankauer catheter
  • Have Y suction catheter available (to suction down the ETT if required)
  • Check suction is working
  • Place within hands reach of airway doctor

Laryngoscopes:

Endotracheal Tubes (ETT):

Other Equipment:

  • Laryngeal mask airways (LMA) – have appropriate size ready in case of failed intubation (See ED Guideline: Laryngeal Mask Airway)
  • Bougie
  • Magill’s forceps – to remove a foreign body from upper airway or direct the ETT through the vocal cords if necessary
  • Equipment to secure the ETT to the patient’s face
  • Medications

Monitoring

  • Ensure patient is attached to cardiorespiratory monitoring including continuous ECG, oxygen saturations
  • Ensure end tidal CO2 monitoring is connected (if available)

Procedure

Medications

Intubation drugs should only be used in the presence of an experienced airway doctor because of the potential for serious side effects. The choice of drug for induction and maintenance of sedation, and muscle relaxation should be decided by an experienced doctor as well.

Anticholinergics:

  • Limit bradycardia, limit upper airway secretions
  • Used especially in babies and young children
  • e.g. atropine

Induction Agents:

  • Create the conditions of anaesthesia and unconsciousness
  • e.g. thiopentone, ketamine, midazolam, morphine

Muscle Relaxants:

  • Facilitate visualisation of the airway and insertion of the ETT
  • e.g. suxamethonium, pancuronium, vecuronium, atracurium

Intubation Medications:

  Drug Dose Route Onset & Duration Comments and Adverse Effects
Anticholinergic
  Atropine 20microgram/kg IV Onset 1 min
Duration 5-10 mins

Tachycardia
Minimum dose 100 micrograms, maximum dose 600 micrograms

Anaesthetic – Induction
  Thiopentone 3-5mg/kg IV Onset 30 secs
Duration 5-10 mins
Respiratory depression, apnoea, hypotension, potent myocardial depression, decreased intracranial pressure, decreased intraocular pressure. Can cause laryngospasm and bronchospasm.
Consider decreasing dose to 1-2mg/kg in unwell, shocked children.
  Ketamine 1-2mg/kg IV Onset 5mins
Duration 15 -20 mins
Analgesia, dissociative anaesthesia.
Increased HR, increased BP, increased intracranial pressure, increased intraocular pressure, bronchodilation. Increased salivation, vomiting, increased muscle tone, tonic-clonic reactions, vomiting, emergence reactions.
Usually maintain spontaneous respiration and protective airway reflexes.
Agent of choice in haemodynamically unstable patients, good choice for asthmatics.
  Fentanyl 1-2 micrograms/kg IV Onset 2 mins
Duration 30-60 mins
Bradycardia, hypotension, respiratory depression, apnoea, laryngospasm.
  Midazolam 0.15mg/kg IV Onset 2 mins
Duration 1-2 hrs
Amnesia, sedation, euphoria, hypotension, respiratory depression, apnoea.
  Propofol 2-4mg/kg IV Onset 1 min
Duration 30 mins
Respiratory depression, apnoea, bradycardia, hypotension.
May need lower dose if had opiates.
Anaesthetic – Ongoing
Boluses Midazolam  0.1-0.3mg/kg IV Onset 2 mins
Duration 1-2 hrs
Amnesia, sedation, euphoria, hypotension, respiratory depression, apnoea.
Morphine 0.1-0.3mg/kg IV Onset 5 mins
Duration 1-2 hrs
Analgesia, respiratory depression, systemic vasodilation, hypotension, vomiting.
Infusion Midazolam 2.5mg/kg
Made up to 50mL with 5% glucose
IV Start at 1mL/hr Amnesia, sedation, euphoria, hypotension, respiratory depression, apnoea.
Morphine 1mg/kg
Made up to 50mL with 5% glucose
IV Start at 1mL/hr Analgesia, respiratory depression, systemic vasodilation, hyptoension, vomiting.
Muscle Relaxant 
For Intubation Suxamethonium 1-2mg/kg IV Onset 30-60 secs
Duration 5-10 mins
Bradycardia or tachycardia, malignant hyperthermia, increased intracranial pressure, increased intraocular pressure, hypotension or hypertension.
Massive potassium release in neuromuscular disease, burns and major trauma – can cause hyperkalaemia, arrhythmias, systole.
Contraindicated after the first 24 hrs of a major burn or trauma.
Contraindicated in all spinal injuries and neuromuscular disease.
Rocuronium 0.6-1.2mg/kg IV Onset 1 min
Duration 45 mins
Tachycardia.
Ongoing Pancuronium 0.1mg/kg IV Onset 2 mins
Duration 45-60 mins
Tachycardia, hypertension.
Vecuronium 0.1mg/kg IV Onset 2 mins
Duration 35-75 mins
Cardiovascular stability.

Positioning and technique

Positioning:

  • Patient should be lying supine on a flat surface
  • May need to place a rolled/folded towel underneath shoulders in infants and young children
  • May use a head ring
  • Continue cervical spine precautions if relevant – avoid flexion or extension of the neck, usually done by in-line manual stabilisation (rather than a collar)

Rapid Sequence Intubation (RSI):

  • Commonly used in the emergency setting
  • Use a fast acting induction agent (e.g. thiopentone) and then a fast acting muscle relaxant (e.g. suxamethonium)
  • Used for intubation of conscious patients with a high risk of regurgitation and aspiration of stomach contents
  • Indications: food intake within 4 -6 hours, acute trauma, bowel obstruction or ileus, tense abdominal distension, upper airway bleeding
  • Contraindications: use RSI with extreme caution in patients with a predicted difficult airway – failure to intubate would leave the patient without spontaneous respiration. Inability to then ventilate with a bag and mask would be fatal.

Intubation Technique:

  • Pre-oxygenate with a bag and mask and 100% oxygen for at least 3 mins
  • Give the medications: induction agent then muscle relaxant
  • Apply cricoid pressure as the patient loses consciousness
  • Hold the laryngoscope blade in your left hand, insert into the right hand side of the mouth, pushing the tongue to the left and to the floor of the mouth
  • Straight blade (in infants): insert slowly so that the tip of the blade is beneath the epiglottis and lift it up and forward to see the vocal cords
  • Curved blade (in children): insert slowly, visualise the epiglottis and insert the tip of the blade above the epiglottis in the valeculla, then pull the epiglottis forward to visualise the vocal cords
  • Lift and pull the laryngoscope blade towards the ceiling on the far side of the room, do not lever, be careful of teeth
  • If you have inserted the blade too far (e.g. in the oesophagus), slowly withdraw until you see the vocal cords
  • Once you have a view of the vocal cords, insert the ETT (angle it horizontally so you don’t obstruct your view)
  • Insert the ETT until the black line is just below the vocal cords
  • Confirm ETT position clinically: fogging of the ETT, bilateral and symmetrical rise and fall of the chest wall (as you squeeze the bag), auscultation in both axillae for breath sounds and in the epigastrium
  • Confirm successful oxygenation (oxygen saturations) and ventilation (capnography or end tidal CO2 monitoring)
  • Remove cricoid pressure
  • Secure ETT to the patient’s face
  • Do not spend more than 30 secs attempting to intubate – return to oxygenating with the bag and mask before a re-attempt
  • After intubation insert an orogastric or nasogastric tube to decompress the stomach (enabling better ventilation)

Post-Procedure

Confirm success

  • To confirm correct ETT placement, look at the tip position on a chest X-Ray
  • The ETT tip should sit between the sternal angle and the carina (bifurcation of the trachea)

Complications

  • Failure to intubate
  • Failure to ventilate
  • Oesophageal intubation
  • Aspiration of gastric contents
  • Hypoxia
  • Hypercarbia
  • Injury to upper airway structures
  • Hypertension or hypotension
  • Tachyarrhythmia or bradyarrhythmia
  • Cervical spinal cord injury in trauma patients

Aftercare

  • Patients will need ongoing sedation and muscle relaxation medications whilst intubated
  • The patient can be bagged by the airway doctor for transfer or connected to a ventilator

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