Read this tutorial on the use of point of care ultrasonography (POCUS) for confirmation of endotracheal tube (ETT) placement in pediatric patients. Then test your skills on the ALiEMU course page to receive your PEM POCUS badge worth 2 hours of ALiEMU course credit.
- List indications for performing airway/lung POCUS to confirm ETT placement
- Describe the technique of performing airway and focused lung POCUS
- Distinguish between normal and abnormal airway and lung POCUS findings
- Distinguish between tracheal, endobronchial, and esophageal placement of ETT
- List the limitations of airway and lung POCUS
Case Introduction: The Postictal Toddler
Joey is a 2-year-old male with a history of epilepsy who presents to a community hospital emergency department with generalized tonic-clonic seizures of more than 45 minutes duration. After receiving 2 doses of IV midazolam, he stopped seizing. He has very shallow breathing and oxygen saturations as low as 90 percent on 2 liters of supplemental oxygen via nasal cannula. The pediatric transport team arrives to transport him to another hospital for admission and note that he is somnolent with poor respiratory effort. His current vital signs:
|Heart Rate||115 bpm|
|Oxygen Saturation (room air)||92% on 2 L via nasal cannula|
An end tidal carbon dioxide (ETCO2) monitor shows a ETCO2 level in the high 70s mmHg. The decision is made to intubate the patient given disordered breathing, hypercapnia, and hypoxia following medical management of seizures. The transport team would like to use POCUS to evaluate ETT placement at the outside hospital and during transport.
For simplicity, this module will focus on 3 modes of using POCUS for ETT confirmation. Collectively, these techniques can help improve evaluation.
After administration of fentanyl, midazolam, and rocuronium, the patient was intubated with a 4.0 cuffed ETT by direct laryngoscopy with a Macintosh blade.
POCUS was used to confirm ETT placement by the transport team in the community hospital ED. Specifically, the provider directly visualized the in the anterior neck (with a single air-mucosa interface), the presence of bilateral lung sliding, and movement of the diaphragm towards the abdomen with PPV. End tidal CO2 further confirmed accurate placement. Once loaded into the ambulance, the ETT was again confirmed to be in the trachea.
Video 11: POCUS showing bilateral lung sliding
Video 12. POCUS showing diaphragmatic movement down to the abdomen with breathing.
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