 • The pediatric airway has known unique challenges. Prepare yourself physically and cognitively!
• Maintain spontaneous ventilation if there is any doubt about obtaining successful advanced airway. • Practice using airway equipment when you don't need it, so you are ready when you do need it.
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Bariatric Patients
Aortic DIssection
 • Acute treatment: bronchodilator and steroids
– Consider antibiotics with sputum changes • Use NIV early for increasing WOB • Disposition guide: – Sa02, treatment response, COPD severity • Discharge meds: SABA, steroids – Consider antibiotics and LABA/ICS  - Early recognition and treatment is critical.... give epinephrine EARLY and OFTEN
- Treat anaphylaxis as a spectrum... as short as 2 hour observation up to admission - Steroid duration depends on who you ask. No good evidence to support or refute their use. - Vasopression for anaphylatic shock with suboptimal epi response. - Consider glucagon for those patients on beta-blockers.
Case 2 - Ludwig's Angina- Ludwig’s angina is infection within the sublingual/submandibular potential space, isolated by superficial fascia. Infection demonstrates rapid progression with posterior deflection of the tongue, obstructing the airway. - Airway management, ENT consultation and IV antibiotics (penicillin + metronidazole, clindamycin or ampicillin/sulbactam) are the necessary steps for management of Ludwig’s angina. Severe Mucositis- Mucositis is a common side effect of most chemotherapy and head/neck radiation regimens that is associated with significant morbidity. - Severe mucositis carries 75% risk of serious co-infection and 9% risk of associated mortality. Ehler's-Danlos and Aortic DIssection- Ehler’s-Danlos Syndrome, an inheritable collagen vascular disease, is associated with hyperextensible skin and hyperflexible joints; many subtypes are at risk for arterial aneurysm, dissection or rupture at young ages.
- Management of acute aortic dissection or perforation includes vascular surgery consult (for emergent intervention) and decreased BP/sheer stress with IV nicardipine or esmolol. Core Concepts 
The stakes are high!
Stepwise Assessment Goals
Anticipate Trouble!! Always ask yourself:
 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  Timing Matters
1. Single episode - concerning for impending airway compromise - get help! a. Febrile? - tonsills, abscess, mono, croup, tracheitis, epiglottitis, bronchiolitis b. Afebrile? - airway foreign body 2. Recurrent a. Inspiration - obstruction is above the level of the vocal cords; - Ex, laryngomalacia - from bith; worse with supine. eating or upset b. Expiration - below the vocal cords; - Ex, tracheomalacia in hypotonic kids; vascular anomalies c. Biphasic - at the level of the cords (or just below) - Ex, subglottic stenosis/ hemangioma (get bigger over the first year of life before they start to shrink); vocal cord dyfunction; esophageal foreign body  Pneumococcal Meningitis with HUS Usually serotypes outside of 13-valent vaccine If you suspect, initial treatment with: - Cefotaxime 300 mg/kg/day IV (max 12g/day) in 3 doses OR - Ceftriaxone 100mg/kg/day IV (max 4g/day) in 2 doses PLUS - Vancomycin 60mg/kg/day IV (max 4g/day) in 4 doses Pneumococcal HUS Recognize classic triad: - Microangiopathic hemolytic anemia - Thrombocytopenia - Acute Kidney Injury Sources: - PNA - 70% - Meningitis - 20-30% - Others - Otitis, sinusitis, bacteremia - Not like STEC-HUS - Needs Tx with Abx - Pneumococcal leads to higher M&M Hemoptysis from 5-yr old retained GSW Delayed Pulmonary Hemorrhage from FB - Up to 30 yrs latency reported - Present with intermittent hemoptysis Complications: - Pulm Art or Aortic Pseudoaneurysm - AVMs with R -> L shunts - Embolization - arterial or venous Massive Hemoptysis No universal definition - "Is this life threatening?" Initial ED Management - ID bleeding lung and position dependently - A - Establish airway (8-0 ETT or bigger for bronchoscope) - B - Ensure good gas exchange on vent - C - Stop bleeding! Restore volume, give PRBCs, reverse coagulopathy,etc... Regular Wide Complex Tachycardia
- Consider VT until proven otherwise!!! - 80% is VT by numbers - Algorithms to differentiate SVT are difficult to remember - If you treat for VT, won't harm SVT - Nodal blockers for SVT can send VT into VF -- PLACE PADS with Adenosine! A great analysis of EP and Cardiologist failure in applying Brugada to electrophysiologically proven VT. Two fantastic talks from the ever-salient @amalmattu - VT vs SVT with Aberrancy - Adenosine Sensitive VT  Case 1 - Is that Tube in the Right Place?
Case 2 - Locked-In
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