Pediatric emergency medicine trisk 0173 0173
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the one-way valve in self-inflating devices. Newer approaches include the use of
apneic oxygenation to increase safe apnea time. Data are currently limited,
particularly in children; however, many PEM clinicians are currently employing
this technique. The optimal flow rate in children has not been established, but
rates of 2 to 5 L/min in infants, 5 to 15 L/min in school-age children, and 15+
L/min in adolescents are likely beneficial with minimal risk of harm. Much
higher rates have been utilized in fasted patients in the OR setting.
PATIENT POSITIONING
Bag-valve-mask (BVM) ventilation and TI are generally performed with the
patient in the supine position. There are instances in which upright or prone
positioning has theoretical anatomic airway structure advantages for BVM
ventilation. Some newer studies conclude that intubation success rates are higher
when using head-elevated positioning, also called ramping. Here, the upper body
is included and the head extended, similar to sniffing position. Much of this data
come from adult literature, however limited pediatric experience is supportive.
The optimal intubation patient position in pediatrics might continue to evolve
with further study and dissemination of this information.
MEDICATIONS
Sedatives
Sedatives used for intubation should render the patient rapidly unconscious (
Table 8.3 ). They should ideally have minimal adverse effects on hemodynamics
or intracranial pressure (ICP); however, all sedatives have the potential for
adverse effects and efficacy limitations. The optimal sedative depends on the
clinical situation and appropriately weighs benefits against risks.
TABLE 8.3
SEDATIVES
Medication
Dose
Benzodiazepines (midazolam, lorazepam)
Narcotics (fentanyl)
Ketamine
Etomidate
Propofol
0.2–0.3 mg/kg
1–2 mcg/kg
1–3 mg/kg
0.3 mg/kg
1–4 mg/kg
