M&M - Dr. Kiefer

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.

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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