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Clinical Pathway for Children with Difficult/Critical Airway
Relative Contraindication Neuromuscular Blockage
- Anterior mediastinal masses
- Obstructing airway mass
- Infiltrative storage diseases (glycogen storage diseases and others)
Sugammadex can be used to reverse the paralytic effects of rocuronium and vecuronium
- Child Requiring Urgent/Emergent Intubation on Inpatient Units
- Outside ED, PICU, N/IICU, CICU, OR
- Call 4-CODE
- Code Team will activate Airway Response Team as necessary
Critical Airway Known
Difficult Airway
Known/Anticipated
Known/Anticipated
No Airway Issues Identified
- While Awaiting Airway Response Team
- Monitor, Continue O2
-
Consider the following based on airway characteristics:
- Bag Mask Ventilation
- Nasal/Oral Airways
- Laryngeal Mask (LMA)
Perform Bag Mask Ventilation
Use nasal/oral/laryngeal airways as necessary
Use nasal/oral/laryngeal airways as necessary
Routine Airway Management
by Clinical Team
by Clinical Team
Inadequate
Adequate
Failed BVM or laryngoscopy
- Consider laryngoscopy
- Most experienced practitioner
- Laryngoscopy
- Limit to 2 attempts
Failure
To Activate the Airway Response Team
- Call Medical Emergency Line, 4-CODE (4-2633)
- or
- Click 4CODE on your smartphone
- then
- State Airway Emergency and give location
Activate Airway Response Team
Consider Laryngeal Mask Airway
Airway Response Team Arrives
- Airway Team Provides Expert Support to Local Team
- Laryngeal Mask
- Indirect Laryngoscopy
- Considerations for Sedation, Neuromuscular Blockade
- Fiberoptic Laryngoscopy
- Fiberoptic Laryngoscopy through LMA
- Invasive Airway
Evidence
- ASA Practice Guidelines for Management of the Difficult Airway
- A National Emergency Airway Registry for Children: Landscape of Tracheal Intubation in 15 PICUs
- Airway Management Complications in Children with Difficult Tracheal Intubation from the Pediatric Difficult Intubation(PeDI) Registry: a Prospective Cohort Analysis
- Difficult Airway Response Team: A Novel Quality Improvement Program for Managing Hospital-wide Airway Emergencies
- Seminars in Neonatal and Fetal Medicine: The Neonatal-fetal Airway
- A Retrospective Analysis of Neuromuscular Blocking Drug Use and Ventilation Technique on Complications in the Pediatric Difficult Intubation Registry Using Propensity Score Matching
- Management of the Difficult Airway
- Premedication with Neuromuscular Blockade and Sedation During Neonatal Intubation is Associated with Fewer Adverse Events
- Neonatal Intubation Practice and Outcomes: An International Registry Study
- Airway Management in Neonates and Infants