Intubation

Paediatric “tube” sizes

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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.

  • 1 x ETT = (age/4) + 4 (formula for uncuffed tubes)
  • 2 x ETT = NG/ OG/ foley size
  • 3 x ETT = depth of ETT insertion
  • 4 x ETT = chest tube size (max, e.g. hemothorax)

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

Rapid Sequence Intubation Medications

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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

 

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Intubating the child

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intubating-the-child

Endotracheal Tube Depth: Estimate

  • 3 x Internal Diameter of Endotracheal Tube (ETT) e.g. 4.0 ETT => Depth = 12 cm. Only used for ETT 3.0 or greater

Anticipate and Estimate, but Confirm with CXR!!!

 

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What you should see during intubation…

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When intubation fails…

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Intubation

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!

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How to Master Tracheal Intubation

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How do I shape the stylet

  1. Preparation
    a. Select the right blade size.
    b. Shape the stylet and ETT straight to the cuff, then bend at a 30-35 degree angle.
    c. Properly position the patient Ear-to-Sternal-Notch with face plane parallel to ceiling.
  2. Epiglottoscopy
    a. Progressively and methodically advance the tip of the blade midline and gently seat in the vallecula.
  3. Laryngeal Exposure
    a. If the view is still not optimal, consider trying ELM, or HELP to improve visualization.
  4. Tube Delivery
    a. Using straight-to-cuff shaping, insert near the right corner of the mouth and advance upward.
    b. Pass the tip anterior to the interarytenoid notch.
    c. Ensure the cuff of the tracheal tube is below the level of the cords.
  5. Tube Confirmation and Maintenance
    a. Direct visualization
    b. Absent sounds over the epigastrium
    c. Equal bilateral breath sounds
    d. Good compliance with the BVM
    e. Tube fogging (never primary)
    f. Continuous waveform capnography (for confirmation and maintenance)
    g. Rising SpO2 (for patients with a pulse)

Apneic Preoxygenation

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Use of ApOx during RSI in adult patients in the ED, is low cost, low complexity, and not proven to cause harm while also reducing incidence of hypoxemia and increasing first pass attempt intubation. It is time for a RCT evaluating this modality.