PEM Source

Your source for all things Pediatric Emergency Medicine

All posts with tag: "airway"

Tips and Tricks

The Coach at has a great podcast on using the VBG in situations where we used to try to get an ABG (which was never fun to do in small children). From the podcast: the rule of 4’s: (note ABG values are always higher): VBG pH is 0.04 lower than ABG pH VBG pCO2 is 4 lower than ABG pCO2 VBG pO2 is approximately 40 lower than ABG pO2 The bottom line is that for most of our clinical concerns, we can use VBG to assess pH and pCO2, and O2 sat to assess oxygenation. VBG may be less reliable in shocky or hypercapneic patients (but end-tidal CO2 will be useful in hypercapneic patients). When do we really need an ABG? When we want to calculate the Aa gradient, looking for e.g. VQ mismatch, shunt, or a diffusion problem.
Two tips for intubating the obese patient:
  1. Position the patient: build a sizeable ramp to position the patient such that his/her ears are at the level of the sternal notch, and his/her face is parallel to the ceiling
  2. Position yourself: keep your back straight, your left elbow in, and lift (don't crank). If you're having difficulty summoning enough muscle, try straightening your left arm at the elbow to make use of your stronger upper arm muscles, rather than just your forearm.
Two great resources: Obese Difficult Airway Airway Jedi Step by Step (scroll down to the "How you lift matters" section)
Having trouble with bag valve mask ventilation? Don't forget to use adjunctive airways - nasopharyngeal for conscious patients, oropharyngeal for unconscious. Reuben Strayer's great video here advocates placing 2 nasal airways and an oral airway, then bagging over those, for the difficult to bag patient. You can also place an ETT adaptor (pull the adaptor off the tube) into a nasal airway and bag the nasal airway directly - see more information here. Don't forget, nasal airways are measured from the nostril to the tragus of the ear, and oral airways are measured from the center of the mouth to the angle of the jaw.
Thanks to Tim Horeczko for tube-tape-tap mnemonic Peds Sizing  
Easily remember the approximate Oxygen-Hemoglobin dissociation curve as follows: PaO2 40 corresponds to SaO2 70% PaO2 50 corresponds to SaO2 80% PaO2 60 corresponds to SaO2 90% This rule along with a lot of other handy RT knowledge can be found here Read more about PaO2 vs SaO2 at here

PEM Questions

(Click the link to comment and to vote - voting not working through email, sorry!) For which of the following patients is a laryngeal mask airway (LMA) as a temporizing measure after failure of intubation contraindicated? [yop_poll id="86"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are caring for a 4 year old child struck by a car. The child has significant maxillofacial trauma, a large parietal hematoma, and a GCS score of 7. Attempts to intubate with direct and video laryngoscopy have been unsuccessful due to blood obscuring visualization of the airway, and you are only partially able to oxygenate and ventilate the child with bag-mask ventilation, with an O2 sat on 100% FiO2 of 80%. [yop_poll id="44"]
(Click the link to comment and to vote - voting not working through email, sorry!) You receive word that the clinic is rushing over a patient with a genetic syndrome and respiratory distress. You have a few moments to look in the electronic chart of the patient and set up the resuscitation room. Which of the following syndromes would make you concerned for a potential difficult airway scenario? [yop_poll id="19"]
You are caring for a 6yo oncology patient presenting in septic shock. Although he is oxygenating and ventilating well at this time, you plan to intubate him to reduce his metabolic work. The most important pre- treatment before rapid sequence intubation (RSI) is: (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="13"]
A 36-week infant is born precipitously NSVD to a 17yo G2P1 mother in the ED after the mother presented with the chief complaint of intermittent abdominal pain. Apgars are 8 and 9 at 1 and 5 minutes, with -1 for color at both times and -1 for reflex irritability at 1 minute. The O2 sat in the left upper extremity is 82% at 5 minutes. The baby is crying intermittently, is not pale or plethoric, and is in no respiratory distress. Lung sounds are equal and clear bilaterally, and cardiac exam is normal. The next best intervention is: A. Intubate and mechanically ventilate B. Suction and apply 100% O2 C. Suction and apply nasal canula O2 at 5 L/min D. Transilluminate the chest to r/o pneumothorax E. Continue to observe the infant Check back in a few days for my answer and others' comments Also, if you're interested in the Peds ID Question of the Week, you can find it here
A 7yo patient with peanut allergy at a rice krispy treat at a birthday party and discovered afterwards that it was made with peanut butter. She presents with hives, mild swelling of her lower lip and periorbital, and some faint wheezes. O2 sat is 99% on room air. Vital signs are temp 37.6, HR 120, RR 28, BP 90/60. What is your first priority treatment? A. Diphenhydramine 1.25 mg/kg IV B. Epinephrine 0.01 mg/kg of 1mg/mL solution IM C. Methylprednisolone 2 mg/kg IV D. Normal saline 20 cc/kg IV E. RSI and prophylactic intubation Check back in a few days for my answer and others' comments Also, if you're interested in the Peds ID question of the week, go here
A 2 month old ex-30 week premie just discharged from the NICU comes in with respiratory distress and hypoxia. You determine that the patient needs to be intubated. The baby’s weight at discharge was 2.5 kg. What size ETT should you use? A. 2.5 uncuffed B. 3.0 uncuffed C. 3.0 cuffed D. 3.5 uncuffed E. 3.5 cuffed Check back in a few days for my answer and others' comments Also, if you're interested in the Peds ID question of the week, go here
A 17yo boy presents with severe sore throat for two days, and fever to 39. He has difficulty swallowing due to pain. He has no cough, congestion, nor ill contacts. His immunizations are up to date. On examination, he is alert, has no respiratory distress or stridor. His oropharynx has 2+ tonsils which are somewhat red, no exudate, no vesicles, no peritonsillar swelling. He has tender cervical lymphadenopathy and is very tender on palpation of his anterior neck at the level of the hyoid bone. The most appropriate management is: A. Obtain lateral neck X-ray in the ED and consult ENT specialist B. Consult ENT specialist to intubate the patient in the O.R. C. Give dexamethasone and penicillin-benzathine and discharge home D. Recommend supportive care for a viral URI E. Obtain a CT scan to evaluate for deep neck infection


(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! It's the day after Thanksgiving, and your patient just ate a bunch of leftovers before getting into an automobile accident. You are intubating, and hoping the patient doesn't aspirate during the procedure. A medical student asks whether he should apply cricoid pressure for you. [poll id="31"]

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