Carolinas Core Concepts Core Concepts in EM; a repository for Carolinas lecture summaries.

2Dec/11Off

Pediatric Textbook Review – Lower Extremity Fractures and Upper Airway Management

Lee Garvey, MD

  • Toddler’s fractures may be missed on the normal two views. Consider getting an oblique view.
  • Pediatrics upper airway management requires significant forethought. Have your second and third backups ready.
  • For suspected epiglottitis, do NOT agitate the child until ENT/anesthesia available. NO IVs, NO meds, just transfer.
  • Proper documentation for likely viral URI
    • Position of uvula
    • Erythema of tonsillar pillars
    • Symmetry of tonsils
    • No pain on external manipulation of larynx
    • No trismus
15Jul/11Off

The Airway Course

  • Rapid sequence intubation with both sedative and paralytic is superior to sedative or paralytic alone.
  • Failure rate requiring surgical airway for RSI is 1% for all comers (0.5% for medical, and 2% for trauma cases)
  • Failed airway is defined as 3 attempts by the most experienced provider in the room.
  • When preoxygenating, remember: holding an ambu bag over the face doesn't deliver oxygen unless actively bagging.  Use an NRB mask instead or the end of the corrugated tubing on the ambu.
  • Preoxygenation for 5 minutes causes nitrogen washout and gives 5-8 minutes of 100% sats in the healthy adult.
  • Sellick's maneuver has been called into question.  It is now recommended you guide your assistant's hand with pressure on the cricoid as needed.
  • Pretreatment data is sketchy at best.  Consider lidocaine in the asthmatic or TBI, and fentanyl in TBI or dissection, but don't hold up your intubation for it.
  • "Best" paralytic depends on the circumstance.  Succinylcholine always paralyzes faster than rocuronium by 15-20 seconds and wears off within 5-8 minutes.  It brings the risk of hyperkalemia, though.
  • Data shows that succinylcholine may be used in renal failure patients as long as they have a normal EKG.
  • Reflex time! A new arrhythmia in the setting of succinylcholine administration is hyperkalemia.  Administer calcium, insulin, bicarb, glucose.
  • There is poor data saying ketamine should never be used in ICH.  Similarly, there are no prospective, powered trials proving etomidate worsens sepsis.
  • Direct laryngoscopy provides a grade I view of the vocal cords only 87% of the time.  Video laryngoscopy provides a grade I view 97-98% of the time.
  • A true grade IV view of the vocal cords occurs only 5% of the time.
  • Trismus in Ludwig's angina is related to muscle belly inflammation and will NOT respond to paralytics.  Be prepared with advanced airways.
  • Hurricaine spray, while helpful with topical anesthesia for awake looks, may cause methemoglobinemia.
  • Using an atomizer to deliver 4% lidocaine to the oropharynx should cause anesthesia within 15 minutes, allowing for an awake look.
  • Jet ventilation in the pediatric population should be performed at 20-30 psi with 1:4 second ratio for partial obstructions, 1:9 for complete.
  • The "sniffing" position is best obtained by placing the tragus of the ear in-line with the anterior axillary line.
  • Propofol is a more potent bronchodilator than ketamine and useful for intubating asthmatics, however it requires a second physician to push the propofol.
  • There have been case reports of undiagnosed muscular dystrophy in children causing death after succinylcholine administration.  Use rocuronium in peds.