One of the many things that we, as intensivists or emergency physicians, do better than anyone in the business is obtain the emergent airway. We are usually introduced to our patients on the worst days of their lives and even though we may sometimes wish for it, we do not have the option to reschedule our intubations. Smashed, bloody, distorted, edematous airways secondary to trauma, anaphylaxis, and GI bleeds are the commonality not the exception. We manage those airways routinely with nary a complaint or even a hither for a better look at the glottis than what we can obtain. We often feel lucky to even get a glimpse of the arytenoids much less something that actually resembles normal laryngeal anatomy. Personally, if I knew that I would need to be intubated today, that my airway would be a bloody, edematous, traumatic mess and there was only chance for one person to take a shot at placing the tube, then I would pray to God that the last face I saw before the Roc and Ketamine pushed me asunder was the familiar grill of one of my EM/critical care colleagues. Who better to bet all my chips on then someone who deals with the most difficult airways on the face of the planet as part of their daily routine? The EM doc or critical care provider can not only get that airway, but is so relaxed about it that they will often casually check on the patient in the next bed before and after the intubation. That’s the confidence I’m looking for when it comes to the fast-paced life and death world of emergency airway. Now put a child’s life on the line. Are you ready to intubate what was a perfectly healthy three year old two hours before trauma threatened their life and placed their airway in your hands? You will be... Andrew Sloas DO, RDMS, FACEP, FAAEM, FAAP Editor-in-Chief: The PEM ED Podcast www.pemed.org

1. A D U L T &
P E D I A T R I C
A I R W A Y
A n d r e w S l o a s , D O , R D M S
R D M S , F A C E P , F A A E M , F A A P

2. T O O R
T h a t i s n o t t h e q u e s t i o n . . . . .
A R E W E M A S T E R S
O F T H E P E D I A T R I C
A I R W A Y

3. • Understand the differences between adult and pediatric
airway
• Develop an algorithmic approach to the difficult pediatric
airway
• Understand advanced airway techniques for intubation
• Be aware as to when a patient requires a surgical airway
OBJECTIVES

6. http://usnews.nbcnews.com/_news/2013/05/12/18210934-oj-simpson-seeks-to-have-robbery-conviction-thrown-out?lite
http://www.hemisfair.org/ai1ec_event/san-antonio-living-history-presentations-dawn-at-the-alamo/?instance_id=
http://www.forbes.com/fdc/welcome_mjx.shtml

7. ER, Nov 2001,“Flight of Fancy”

8. http://www.clipartof.com/images/purchased/210376_MDPNG_20130824135353864.png

9. G O R O S T R A L
http://aaronbagwell.wordpress.com

10. TO N G U E I N C H E E K

11. TO N G U E I N A I RWAY

12. THE CONGENITAL DIFFICULT
AIRWAY
http://en.wikipedia.org/wiki/Klippel–Feil_syndrome http://webhome.idirect.com/~brainology/brainology/devpath_271_lysosomal.html

13. POSITION IS EVERYTHING
Collins JS, Lemmens HJ, Brodsky JB, Brock-Utne JG, Levitan RM. Laryngoscopy and morbid obesity: a
comparison of the "sniff" and "ramped" positions. Obes Surg. 2004 Oct;14(9):1171-5. PubMed PMID: 15527629.
Levitan RM, Mechem CC, Ochroch EA, Shofer FS, Hollander JE. Head-elevated laryngoscopy position: improving
laryngeal exposure during laryngoscopy by increasing head elevation. Ann Emerg Med. 2003 Mar;41(3):322-30.
PubMed PMID: 12605198.
Schmitt HJ, Mang H. Head and neck elevation beyond the sniffing position improves laryngeal view in cases of
difficult direct laryngoscopy. J Clin Anesth. 2002 Aug;14(5):335-8. PubMed PMID: 12208436.

14. http://www.ncsrc.org/2_newsletters_2008_2.shtml
A N YO N E F O R R O C K E T
S L E D D I N G ?

15. APNEIC OXYGENATION

16. P E E P I N G R AT
N A M E D T O M
http://goo.gl/1CTCJU
http://goo.gl/oJA6xK
http://goo.gl/Mf0TW0

17. Bronchiolitis or Croup ?
Stridor and Wheeze

18. CRASH DL()(ET(
Placed?
CAN(BAG?
2nd(try(
with(
paraly?cs
ET(Placed? FAILED
LMA/Combitue
Cannot(Intubate/
Can(Ven?ilate
CAN(BAG?
Can(Intubate/
Cannot(Ven?late
Cannot(Intubate/
Cannot(Ven?late
If(surgical(airway(ready;(
one(shot(quick(look
*Surgical(Airway
DIFFICULT
**LEMON((Laws)(
BAT(MOANS,( SAT(>90%
Bag,(Oral(Airway,(
Jaw(Thrust(=(
SAT>90?
NOW(SAT(
>90%
Intuba?on(
Predicted((
Successful?
AWAKE(SEDATED(
INTUBATION
Hypercapnia,(Severe(
Sepsis,(Acidosis,(
Aspirin(OD
DELAYED(SEQUENCE(
INTUBATION
Bougie,(Video(Assist(
Intuba?on((LMA,(Flexible/
Rigid(Bronch,(Retrograde(
Intuba?on
RSI
INTUBATION
PREPARE(
PRETREAT
PLACEMENT
POSTERIOR((BURP)
PARALYSIS
PLACE(TUBE
POST/CONFIRMATION
Direct(Laryngoscopy(
Successful?
Can(
BAG?
Aaempted(DL(3(?mes(
by(most(experienced(
operator(=(no(ETT
START
Failed Failed
NO
NO((( NO
YES
Failed
Failed
NO
NO
YES
YES
YES
YESNO
YES
NO
NO
YES
NO YES
YES NO
NO
Failed
*(Surgical%Airway:
• Surgical(Cric(if(>(12(yrs(or(MD(feels(
appropriate(size(neck
• Needle(Cric(<(12(with(jet(ven?la?on
(
Needle%Cric%and%Jet%Ven/la/on:
!!this!only!buys!you!30!minutes!of!oxygena4on!–!call!a!SURGEON!
•((Cric(with(a(14(or(16(g(angiocath
•((aaach(BVM(adapter((plas?c(piece(b/w(ET(and(BVM)(from
((((a(3.0(ET(tube(to(angiocath(and(then(to(the(BVM
•(aaach(3cc(syringe(to(the(angiocath,(then(aaach(BVM
((((adapter(from(6.5/7.0(ET(tube(to(a(BVM
•(Give(20(gentle(bags(q(minute(and(call(for(a(surgeon!
EMERGENCY(MEDICINE(AIRWAY(ALGORITHM
**(BAT%MOANS%and%LEMON:
L()(
• BAT(=(Blood/Anaphylaxis/Trauma.((These(have(a(physiologic((blood/
edema)(or(severe(anatomic(barrier((trauma)(and(will(most(likely(need(
surgical(airways(in(failed(algorithm.
• MOANS(=(Mask(fit/obeise/adv(age/no(teeth/s?ff(neck.((These(are(
physiologic(barriers(that(do(beaer(with(secondary(airway(devices.((
E((()((3(3(2(rule.
M()((Mallampa?(score(3((loss(of(tonsil(pillars)(or(greater(is(predicted(
diffiicult
O(()((Obstruc?ons
N(()((Neck(s?ffness
(
NO
NO
YES

19. DELAYED SEQUENCE
INTUBATION

20. iLMA
Preoxygenation
http://www.youtube.com/watch?v=yvcDEbGOw0A

21. Peds Anesth 2004

23. http://www.zastavki.com/eng/Creative_Wallpaper/wallpaper-14000.htm
http://www.foro.fullaventura.com/viewtopic.php?f=1&t=32021
http://www.espntimes.com/tag/horseshoes

24. Cincinnati Mar 2013

25. CHOP, Mar 2013

27. G L I D E S C O P E
P E D I A T R I C
http://www.youtube.com/watch?v=_zXI_pN39AI

28. SURGICAL AIRWAYS
Stay cool.....
This is going to get bloody.....
Scalpel, finger, bougie
Practice on a trainer

29. Wide range of “contraindications”
< 5 yo
< 8 yo
< 10 yo
< 12 yo
C R I C ’ N K I D S

30. https://wiki.uiowa.edu/display/protocols/Tracheotomy+(epithelial+lined+tracheostomy)+with+laryngeal+suspension+for+ankylosing+

31. http://medical-diagonosis.wonderhowto.com/how-to/perform-cricothyrotomy-emergency-room-220545/
http://www.bestpediatricsurgeon.com/cystic-hygroma/

32. http://medical-diagonosis.wonderhowto.com/how-to/perform-cricothyrotomy-emergency-room-220545/
https://wiki.uiowa.edu/display/protocols/Tracheotomy+(epithelial+lined+tracheostomy)+with+laryngeal+suspension+for+ankylosing

34. S U M M A R Y
DL Success = 99%
VL Success = 98%

35. andrew@pemed.org
@pemedpodcast
www.pemed.org

36. andrew@pemed.org
@pemedpodcast
www.pemed.org