ED, Inpatient and ICU KOPH Clinical Pathway
for Unanticipated 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
- Admission screening
- Prioritize admitting children with known difficult/critical airways and without stable tracheostomies to
the PHL campus
- Prioritize admitting children with known difficult/critical airways and without stable tracheostomies to
- Child Requiring Urgent/Emergent Intubation on Inpatient Units
- Outside ED, PICU, N/IICU, OR
- Call 4-CODE
Child Stabilized, Difficult/Critical
Airway Suspected
Arrange transfer to PHL campus, direct to OR if necessary
Airway Suspected
Arrange transfer to PHL campus, direct to OR if necessary
Critical Airway Known
Difficult Airway
Known/Anticipated
Known/Anticipated
No Airway Issues Identified
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 or LMA
- Most experienced practitioner
- Laryngoscopy
- Limit to 2 attempts
Activate Resources and
Continue Medical Management
Continue Medical Management
Activate Resources and Continue Medical Management
Activate Resources
ED Location: Call PICU, N/IICU Tier 1
Continue Medical Management
- Consider placement of laryngeal mask airway
- If unable to intubate but able to ventilate with LMA – arrange transport to PHL OR for ENT/Anesthesia
- Consider reversal of neuromuscular blockade
- If cannot intubate or oxygenate
- Consider front of neck access (FONA) by trained provider
- FONA in infants < 1 yr is known to be extremely difficult
- Consider front of neck access (FONA) by trained provider
ICU to Activate Additional Resources as Needed
| 7 a.m. - 5 p.m. |
|
|---|---|
| 5 p.m. - 7 a.m. |
|
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