Pediatric emergency medicine trisk 0177 0177
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Lidocaine
Lidocaine has been suggested to blunt the autonomic effects of laryngoscopy on
hemodynamics and ICP during laryngoscopy. Historically, it has been
recommended for patients undergoing intubation as a result of traumatic brain
injury. Meta-analyses in adults have failed to demonstrate a benefit of lidocaine
premedication during intubation, although data in pediatric patients are lacking.
Therefore, routine use of lidocaine as an adjunctive agent is not recommended.
POSTPROCEDURE MANAGEMENT
Immediately following intubation, correct placement of the ETT within the
trachea must be confirmed. Studies have shown that intubation attempts in
emergent settings can result in esophageal tube placement, with higher rates
reported when performed on children or in the prehospital setting.
End-tidal carbon dioxide detection, either colorimetric or capnographic, is the
most rapid and reliable method to confirm TI. Continuous capnography has the
advantage of confirming the correct square wave form and quantitative
assessment of the exhaled pCO2 ( e-Fig. 8.1 ).
Direct or video-assisted visualization of the ETT passing through the vocal
cords, or above the posterior cartilages in cases of suboptimal view is
fundamental to success, and is included in national emergency medicine
guidelines. However, the laryngoscopic view may be compromised by blood,
vomitus or secretions in the airway, or when swelling, habitus, or anatomic
anomalies prevent visualization of the glottic aperture. In addition, even when the
view is adequate, less experienced providers may misidentify anatomic structures.
Finally, even after successful placement, the ETT may become dislodged.
Therefore, it is recommended that tube position be verified by secondary means,
even in circumstances where it has been witnessed to pass successfully through
the cords.
Expected clinical findings when the position of the tube is within the
tracheobronchial tree include visible rise of the chest wall, auscultation of breath
sounds in both hemithoraces, absence of air movement over the stomach, and
condensation within the ETT. However, clinical evaluation is not always accurate.
Auscultation can be challenging amidst the extraneous noises that are common in
critical resuscitations. In addition, practical experience and case reports suggest
that localizing sounds can be difficult, with providers interpreting breath sounds
in cases of esophageal intubation. Therefore, confirmatory devices should also be
used.
