Pediatric airway..Clinical pearls

When using Pediatric bougie there is concern about tracheal rupture and used when ETT size >3 mm.

To avoid bleeding from large adenoids, do not place nasal airway in child <1 yr of age

Always during transport apply cervical collar in child with ETT, even if just moving from one bed to another, to avoid displacement of ETT

Cuffed ETTs —now considered beneficial due to lower pressures.

Children highly dependent on diaphragm; once airway secured, insert nasogastric tube (NGT) or orogastric tube (OGT) as soon as possible to decompress stomach (NGT or OGT should be twice ETT size)

Proper bag-valve mask (BVM) technique — if attempting to use BVM on child with low O2 saturation, first action to place oral airway.

straight blade 0 used only in just-born newborn or premature infant, otherwise straight blade 1 used and shift to blade 2 at 2(years)..

2 times ETT size for NGT, OGT, and Foley catheter
3 times ETT size for tubes at lips
4 times ETT size biggest chest tube possibly needed for patient with

trauma

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The pressure volume loop...

In the pressure-volume loop below, cardiac work is best represented by: the area of the curve the slope of the line from points C to D the distance of the line from points C to D the slope of a line from points A to D .. .. ... .... ... .... .... .... In the pressure-volume loop below, cardiac work is best represented by: the area of the curve Cardiac work is the product of pressure and volume and is linearly related to myocardial oxygen consumption. Cardiac work is best represented by the area of the curve of a pressure-volume loop.

Driving Pressure in ARDS: A new concept!

Driving Pressure and Survival in the Acute Respiratory Distress Syndrome Marcelo B.P. Amato, M.D., Maureen O. Meade, M.D., Arthur S. Slutsky, M.D., Laurent Brochard, M.D., Eduardo L.V. Costa, M.D., David A. Schoenfeld, Ph.D., Thomas E. Stewart, M.D., Matthias Briel, M.D., Daniel Talmor, M.D., M.P.H., Alain Mercat, M.D., Jean-Christophe M. Richard, M.D., Carlos R.R. Carvalho, M.D., and Roy G. Brower, M.D. N Engl J Med 2015; 372:747-755 February 19, 2015 DOI: 10.1056/NEJMsa1410639 BACKGROUND Mechanical-ventilation strategies that use lower end-inspiratory (plateau) airway pressures, lower tidal volumes (V T ), and higher positive end-expiratory pressures (PEEPs) can improve survival in patients with the acute respiratory distress syndrome (ARDS), but the relative importance of each of these components is uncertain. Because respiratory-system compliance (C RS ) is strongly related to the volume of aerated remaining functional lung during disease (termed functional lung size)...

Anaphylaxis updates part 2- Empty Ventricle Syndrome

Patients with anaphylaxis should not suddenly sit, stand, or be placed in the upright position. Instead, they should be placed on the back with their lower extremities elevated or, if they are experiencing respiratory distress or vomiting, they should be placed in a position of comfort with their lower extremities elevated. This accomplishes 2 therapeutic goals: 1) preservation of fluid in the circulation (the central vascular compartment), an important step in managing distributive shock; and 2) prevention of the empty vena cava/empty ventricle syndrome, which can occur within seconds when patients with anaphylaxis suddenly assume or are placed in an upright position. Patients with this syndrome are at high risk for sudden death. They are unlikely to respond to epinephrine regardless of route of administration, because it does not reach the heart and therefore cannot be circulated throughout the body

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