Case 1: Pediatric Airway

Remember differences in pediatric airways vs adults:
• Large Tongue, Large Head, Floppy Epiglottis
• Cricoid is narrowest (vocal cords in adult) 
    – Correct tube size is essential ( Age/4 + 3.5 )
    – Newborn (<1 kg) - 2.5;   28-34 wks (1-2 kg) - 3.0;  34-38 wks ( 2-3 kg) - 3.5;  >38 wks (3.5) - 4;  
        6 mo - 1 year -  3.5-4;  1 -2 yo - 4-5;  >2 yo - 4.0-5
    – BROSELOW TAPE!!! 

• Cuffed tube for all children >3 kg now
• Glottis (Expect a high anterior airway)
    – C-1 in infancy
    – C-3-4 by age 7

– C-5 at adulthood

• Nasal tracheal intubation more difficult due to anatomy
   - Gum Elastic Bougie for nasal intubation

• Potential technique if fiber optic equipment unavailable 
    - Load ET tube into nares and then advance to pharynx
    - Tip of GEB to protrude about 4-5 cm beyond tip of tube
    - Utilize angle of GEB to access airway or utilize Magill forceps

• Potential technique if fiber optic equipment unavailable 
    - Load ET tube into nares and then advance to pharynx
    - Tip of GEB to protrude about 4-5 cm beyond tip of tube
    - Can guide with Magill forceps through cords

TRANSTRACHEAL JET INSUFFLATION
(See Morsel and Video and another Video)

Pros:
– Quick (assuming you have your supplies available)
– Simple and Effective
– Less bleeding (than surgical cricothyroidotomy)
– No age limit 

Cons: 
– Barotrauma (Cannot use if complete obstruction. Passive exhale)
– No airway protection
– Cannot suction

• Every department will have different equipment. Know what equipment you have available and WHERE it is! If you take a job somewhere and there isn’t a kit ready, make one.

• Jet insufflation is effective at oxygenation. All patients become hypercapnic of unclear significance, but jet insufflation has effectively oxygenated patients for hours. Do not forget this important tool in your bag! 

Pearl: Keep OP and NP airways in place to facilitate passive exhalation.

CRICOTHYROIDOTOMY

• Remember Mnemonic for difficult procedure: SMART
– Surgery, Mass, Access/anatomy, Radiation, Tumor

• Cricothyroid membrane: Essentially nonexistent <4 years old, relative contraindicated in children <10 years old 

• Percutaneous vs Open vs Modified Percutaneous
– Open should be your choice with difficult anatomy. Percutaneous is effective but leads to more airway misplacement although less bleeding and less trauma to surrounding structures. Modified is a technique with an incision first followed by percutaneous approach and has been demonstrated to be effective and faster in model studies.

Case 2: Esophageal Food Impaction

• Take a good history upfront in order to save yourself headache later

– It is not “Admit vs. Street”
– Take a diagnostic pause to think about what you are forgetting. Okay to do this at bedside.

• Food impaction:
– “Steakhouse Syndrome” – Usually meats
– Acute dysphagia (92%) to the point refuse to swallow spit, chest pain, neck pain (60%), regurgitation
– Inability to swallow spit- Indicates Total Obstruction and emergent need for endoscopy.
– 90% with baseline esophageal pathology, 60% with history of food bolus obstruction

– Can trial glucagon 0.5- 1 mg IV x1. Time of action ~15 min. ~30% will resolve with this treatment (however, no different than placebo). The rest will need GI consultation for endoscopy. 

– Time to endoscopy directly related to complications

Core Concepts from Hypertensive Emergencies
Trick or Treat?
 
Definitions:
Asx HTN <220/120 without complaints
HTN urgency >220/120 w/o end organ damage
HTN emergency >220/120 + end organ damage
 
When to treat asx HTN?
If BP >165/105 + Cr >2, start two agents
or >220/>120 without any dysfunction, two agents
If  140-165: Controversial, but at the very least, tell the pt and Fast-track them
*Social intervention*
 
Rx:
No comorbidities:
black, all ages: CCB or TZD
white, <60 ACEI or ARB
white, >60, CCB or TZD
 
HTN
+ DM: ACEI or ARB
+ CKD: ACEI or ARB
+ CAD: BB + ACEI or ARB
+ CVA: ACEI or ARB
+ CHF: ACEI or ARB + BB + diuretic
 
HTN Urgency:
don't need to treat in the ED.
Do at least an EKG and check Cr. Plus fundoscopy and lytes
 
HTN Emergencies-
Aortic Dissection
Make the Dx and STOP progression
Listen for AI murmur and assess for acute heart failure
If no murmur and no failure, proceed with IV BB
Safe: morphine + nicardipine
 
Hypertensive Encephalopathy
Decrease MAP 25% in 8 hours
use comorbid appropriate therapy
Give something IV and admit
 
ICH
Let it ride unless >220/110
generally avoid nitroprusside with neurologic emergencies
Pick anything else. We like labetalol
 
Acute Ischemic Stroke
If tPA candidate, treat if BP >185/110
Otherwise, protect the penumbra
 
SAH
No good guidelines
MAP<130
Lookout for complications in the first 24 hours
 
ACS
Treat if >160/>110
No lytics if >185/>110
Use NTG (paste, SL, IV), then BB if needed
 
ACHFE
the higher the initial BP, the better chance of survival
nitro + enalaprilat +/- lasix if they have evidence of fluid overload
 
Cocaine
ASA + lorazepam
backup: NTG, CCB or phentolamine
BB dogma is lifting
 
Eclampsia
IV mag + labetalol or hydralazine

Infective Endocarditis
• Consider Infective Endocarditis in patients with multi-system organ failure and an acute embolic event
• High risk groups for developing IE: prosthetic valves, indwelling lines, HD, IV drug users, CHD
• Septic Emboli primarily involve the CNS (65%)

Immunosuppression and Sepsis
• Patients undergoing chemotherapy typically reach their ANC nadir between 7-12d
• Patients with chemotherapy induced neutropenia are at highest risk for bacterial translocation in the gut secondary to cytotoxicity to GI flora
• Sepsis management is time critical!
• Abx within 1 hour has been shown to improve mortality!