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 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 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 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 Supraglottic Airways Laryngeal mask airways (LMAs) are the most common supraglottic airways (SGAs) used as rescue devices for adults and children ( e-Fig 8.2 ) They consist of a teardrop-shaped cuff which can be inflatable or self-inflating that surrounds an aperture at the end of a tube When properly inserted, the cuff sits in the hypopharynx above and behind the glottis opening Airflow through the device is directed anteriorly through the glottis into the lungs SGAs are manufactured in a range of sizes that are suitable for patients throughout the pediatric age spectrum, including newborns and infants Multiple models are available Some SGAs allow the passage of an ETT through the aperture into the trachea Second-generation SGAs have integrated channels that allow gastric access for decompression of air following bag mask ventilation, or gastric contents in unfasted patients Numerical sizing conventions of SGAs are nonuniform among manufacturers, however most devices have information on either their packaging or the device itself displaying the correct patient size and volume of air for cuff inflation a given device requires Studies in anesthesia, emergency medicine, and pediatrics have shown that SGAs are easy to place, require very little training to use effectively, and have a very low complication rate Clinical data on SGA use on adults with cardiac arrest in the prehospital arena and depressed newborns in the delivery suite have demonstrated comparable effectiveness and equivalent or improved clinical outcomes when compared with prehospital TI and BVM ventilation, respectively Other Supraglottic Devices The following list describes several additional available options for rescue devices during emergency airway management All of these devices have in common that there are limited clinical data outside the operating room demonstrating ease of use or relative efficacy in pediatric patients Esophageal Combination Tube (Combitube) The Combitube is a dual-lumen tube with two inflatable cuffs: a larger proximal one and a smaller distal one When blindly inserted, the device usually enters the esophagus (>95% of attempts), but is designed in such a way that ventilation can be accomplished with either esophageal or tracheal placement, depending on which port is attached to the bag-valve device Combitubes only exist in sizes small enough to accommodate a patient 1.2 m in height; thus, the pediatric application of Combitubes is limited to older children Laryngeal Tube The laryngeal tube is designed for blind placement in the esophagus, with a single port that inflates a dual cuff (one above and one below the opening for airflow) which secures the device in the hypopharynx and directs airflow anteriorly into the glottis Laryngeal tubes are now made in sizes down to size 0, designed for use in infants less than kg Laryngeal tubes are increasing being used in the prehospital setting, therefore PEM clinicians should be familiar with their use, even if they are placed infrequently in emergency medicine Perilaryngeal Airway The perilaryngeal airway is a device with an inflatable cuff proximal to a widened distal end, designed to sit posterior to the larynx Randomized trials in anesthetized patients (including children) have demonstrated comparable speed and ease of placement when compared with LMAs Perilaryngeal airways are also suitable for bronchoscopy and intubation through the distal end when correctly placed Suggested Readings and Key References American College of Emergency Physicians Verification of endotracheal intubation: Policy statement Revised January, 2016 Available online at http://www.acep.org/practres.aspx?id=29846 Accessed January, 2020 April MD, Arana A, Pallin DJ, et al Emergency department intubation success with succinylcholine versus rocuronium: a National Emergency Airway Registry study Ann Emerg Med 2018;72(6):645–653 Baekgaard JS, Eskesen TG, Sillesen M, et al Ketamine as a rapid sequence induction agent in the trauma population: a systematic review Anesth Analg 2019;128(3):504–510 Balaban O, Tobias JD Videolaryngoscopy in neonates, infants, and children Pediatr Crit Care Med 2017;18(5):477–485 Berg K, Gregg V, Cosgrove P, et al The administration of postintubation sedation in the pediatric emergency department Pediatr Emerg Care 2019 doi: 10.1097/PEC.0000000000001744 [published online ahead of print, January 29, 2019] Brown CA 3rd, Kaji AH, Fantegrossi A, et al Video laryngoscopy compared to augmented direct laryngoscopy in adult emergency department tracheal intubations: a National Emergency Airway Registry (NEAR) study Acad Emerg Med 2020;27(2):100–108 Bruder EA, Ball IM, Ridi S, et al Single induction dose of etomidate versus other induction agents for endotracheal intubation in critically ill patients Cochrane ... and volume of air for cuff inflation a given device requires Studies in anesthesia, emergency medicine, and pediatrics have shown that SGAs are easy to place, require very little training to use... Arana A, Pallin DJ, et al Emergency department intubation success with succinylcholine versus rocuronium: a National Emergency Airway Registry study Ann Emerg Med 2018;72(6): 645? ??653 Baekgaard JS,... PEM clinicians should be familiar with their use, even if they are placed infrequently in emergency medicine Perilaryngeal Airway The perilaryngeal airway is a device with an inflatable cuff