Pediatric emergency medicine trisk 0178 0178
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Continuous pulse oximetry should be used to detect adequate oxygenation.
Developing or persistent hypoxia after intubation may suggest incorrect tube
placement, if equipment issues or underlying disease do not provide an alternative
explanation. In most cases, desaturation in children will develop quickly;
however, studies have shown that in some cases, there is a significant lag time
before hypoxia develops. This potential delay precludes relying on pulse
oximetry as a means for early detection of a missed intubation.
Postintubation imaging with a chest radiograph is considered standard of care
to confirm ETT placement. Newer data suggest that bedside ultrasound may play
a role in rapidly detecting ETT position. Small studies in children and adults have
shown that ultrasound imaging can allow direct visualization of the tube in the
trachea, or can be used to evaluate for lung sliding and/or diaphragmatic
excursion bilaterally as an indirect measure of lung inflation. In addition, the
ability to evaluate each hemithorax independently allows for the detection of
asymmetry, suggesting right or left mainstem bronchus intubation which would
not be recognized by end-tidal detection alone.
Maintenance of Sedation Following Tracheal Intubation
TI is a high-stress procedure and following ETT placement confirmation, the
clinician must move rapidly to the maintenance of sedation. Since rocuronium has
a long duration of action, the patient will be paralyzed for a period that exceeds
the duration of the initial sedative, which might be very short. Additional sedative
doses must be administered as small boluses or as a continuous infusion to
maintain the unconscious state.
RESCUE DEVICES IN PEDIATRIC AIRWAY MANAGEMENT
When to Use
Protocols for airway management set forth by the American Society of
Anesthesia include rescue devices as an option for sustaining effective assisted
ventilation in the “can’t intubate, can’t ventilate” scenario, when a face mask is
ineffective (see Fig. 8.1 ). Importantly, rescue devices are not definitive airways.
That is, they do not isolate the trachea from the esophagus; thus, the risk of
gastric contents being regurgitated and aspirated remains significant when these
devices are used. In most emergent situations, a rescue device is used to avert
life-threatening desaturation while at the same time as mobilizing appropriate
support (personnel and/or equipment) for subsequent attempts at securing a
definitive airway.
