Pediatric emergency medicine trisk 0168 0168
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where a difficult airway is predicted, and maintaining spontaneous respiration and
airway patency is deemed prudent ( Fig. 8.1 ).
RSI is generally considered to be a controlled series of steps starting with
preparing for the procedure and ending with management following placement.
The steps are often described as the 7 Ps: preparation, preoxygnenation,
pretreatment/preoptimization (i.e., adjunctive therapies), paralysis with induction,
positioning, placement of the endotracheal tube, and finally postintubation
management. The key components of RSI are reviewed in the sections that
follow.
EQUIPMENT
Anticipating the need for increasing airway support and having necessary
advanced airway equipment available are critical. An oxygen supply source,
devices for passive oxygen delivery, and a resuscitation bag and mask are needed
for preparation as well as during advanced airway management procedures.
Monitoring equipment including capnography should be available. For advanced
airway management, oral and nasal airways, endotracheal tubes (ETTs), stylets,
and traditional laryngoscope blades and handles and/or a videolaryngoscope in
the appropriate size for the patient should be available. To facilitate preparation,
the mnemonic “SOAP ME” (suction, oxygen, airway equipment, positioning,
monitors and meds, end-tidal CO2 monitor and equipment) can be used.
Alternatively, centers are increasingly using preintubation checklists to assure
appropriate equipment, personnel resources, and medications are available.
Endotracheal Tubes
Both cuffed and uncuffed ETTs are available for use in pediatrics. Historically,
uncuffed tubes were preferentially used in young children to allow use of the
maximal tube size that would be accommodated by the anatomic narrowing at the
level of the subglottis. More recent bronchoscopic and radiolographic data
(airway CT and MRI) suggest that the pediatric airway may by more elliptically
shaped at this level rather than circumferentially narrowed. In addition, newly
designed cuffed pediatric ETTs are manufactured with balloons that are low
profile and moved distally on the tube to avoid laryngeal structures when
appropriately positioned. Use of these new cuffed tubes has been shown to
decrease the need for tube exchange secondary to inappropriate sizing, with no
increase in postextubation stridor, need for racemic epinephrine, or long-term
complications. Pediatric Advanced Life Support (PALS) guidelines as well as the
anesthesia literature now support that, beyond the newborn period, cuffed ETTs
are equally as safe as uncuffed tubes. In addition, cuffed tubes are favored in
