The predominant COVID‐19 illness is a viral pneumonia. Airway interventions are mainly required for tracheal intubation and establishing controlled ventilation. This consensus statement has been brought together at short notice to advise on airway management for patients with COVID‐19, drawing on published literature and immediately available information from clinicians and experts.
You decided to intubate a child and wisely remembered that you should also follow with an NG/ OG after intubation to decompress the stomach. In order to avoid the blank stare when asked “what size”? Here’s a nice mnemonic about Pediatric “tube” sizes… easy as 1-2-3-4!!! Please note ETT = endotracheal tube size.
So for example, a 4-year-old child would get intubated with a 5-0 ETT inserted to depth of 15 cm (3x ETT), a 10Fr NG/OG/foley (2x ETT), and a 20Fr chest tube (4x ETT).
Also, remember that you can use cuffed tubes in any child except neonates but the formula needs to be adjusted as follows: cuffed endotracheal tube ID (mm) = (age/4) + 3.5
Induction Agents
| Medication | Weight-Based Dosing | Time to Onset of Action | Adverse Effects/
Contraindications |
| Etomidate | 0.3 mg/kg | <1 minute | May cause clinically insignificant adrenal suppression. |
| Ketamine | 1-2 mg/kg | 1-3 minutes | May increase blood pressure. May cause hypersalivation. |
| Propofol | 2 mg/kg | <1 minute | May cause hypotension. Cardiac depressant. Contraindicated in egg/soybean allergy |
| Midazolam | 0.3 mg/kg | 1-5 minutes | May cause hypotension |
Paralytics
| Medication | Weight-Based Dosing | Time to Onset of Action | Adverse Effects/
Contraindications |
| Succinylcholine | 1.5 – 2.0 mg/kg | 45-60 seconds | Bradycardia. Malignant hyperthermia. Hyperkalemia. |
| Rocuronium | 1.2 mg/kg | 45-60 seconds | |
| Vecuronium | 0.1 mg/kg | 2-4 minutes | Questionable RSI utility when rocuronium available |
Post-Intubation Sedation
| Medication | Weight-Based Dosing | Notes |
| Midazolam | 0.04-0.2 mg/kg/hr | Short duration, but with long-term use has long half-life. Often used with fentanyl |
| Propofol | 5-80 mcg/kg/min | Propofol Infusion Syndrome with long term use: monitor TG, amylase/lipase |
| Dexmedetomidine | 0.2-0.7 mcg/kg/hr | |
| Ketamine | 0.5-1 mg/kg/hr | May decrease bronchospasm |
| Fentanyl | 1-2 mcg/kg bolus25-250 mcg/hr | |
Anticipate and Estimate, but Confirm with CXR!!!
External Laryngeal Manipulation (ELM)
1. Improves grade view
2. Facilitates tube delivery#FOAMed #FOAMcc #FOAMems pic.twitter.com/VUdP9pfGcJ— Sam Ghali, M.D. (@EM_RESUS) August 9, 2016
We should never allow more than 3 intubation attempts, and sometimes clinical conditions will dictate fewer tries. Examples that come to mind are severe brain injury patients (hypoxia is bad) and patients who do not recover from oxygen desaturation when they are bagged. Don’t lose track of time and the number of attempts!
