Intubation, Venous Access

L.Dadák ARK FNUSA

Maintaining airway


Noninvasive •airway •laryngeal mask •combitube invasive •OTI, NTI •coniotomy •tracheotomy



vocal cords

First Aid - repetition
• FBAO

First Aid - repetition

Monitoring of breathing
• • • • Auscultation lung + neck SpO2 capnography / capnometry (arterial) blood gasses = Astrup

SpO2 > 90%

CO2

CO2

Kapnograf

Ventilace obličejovou maskou
I: zástava dechu, dechová nedostatečnost  dýchání pozitivním přetlakem dechový objem 6ml/kg = pohyb hrudníku f 10.. 30 /min 100% O2 1 ruka:  palec, ukazováček.  3 prsty za čelist 2 rukama, 3 rukama

OroPharyngealAirway
I: unconsciousness + airway obstruction with tongue Correct size OPA: distance angle of mouth --- ear Risk in mild unconsciousness: vomitus + aspiration

LM

LM placed against glottis (radix of tongue, recessus piriformis, esophageal superior sphincter) I: instead face mask, OTI, difficult airway KI:  full stomach  gastro-esophageal reflux,  high inspiratory pressure  longer operation

Combitube
  

emergency situations instead OTI I: difficult airway KI: stenosing process in pharynx / trachea

Tracheal intubation Def: Placing tube to trachea through mouth/nose and larynx. I:  maintain open airway (GCS < 8)  toilet (no cough)  maintain ventilation (shock, hypoventilation) narrowest place in airway – vocal cords – subglotic space (<8let)

OTI, NTI - aids:
    

laryngoscope Magill tongs tracheal tubes syringe lead

How to:
• prepare all aids, (ventilate) • position of pat. • LA, GA, coma • direct laryngoscopy • placing tube • inflate cuff • ensure position

Laryngoscope:




crooked spoon Macintosh straight spoon - Miller

Laryngoscopic view: radix of tongue epiglottis vocal cords trachea

Always easy? (Cormac & Lehane)

Verify placing of the tube
  

auscultation End tidal CO2 fibroskopic view

Complications of TI - early:




 

 

trauma of teeth, soft tissue placed to esophagus / endobronchialy aspiration cardiovascular ↑ΒP, ↑f, arrhythmia ↑ ICP laryngospasmus, bronchospasmus

Complication of TI - later:
   

damage of vocal cords, trachea sinusitis, otitis, decubitus – lip, nose obturation of tracheal tube by secret, blood

How to do NTI:
1. LA anemisation of nose 2. tube through nose 3. placing tube under visual control CAVE: deviation of septum nasi

Check your neck


Mallanpati



3-3-2

Tracheotomy
 

surgical access to trachea punction TS I: maintain AW long time  artificial ventilation  limitation of dead space



Coniotomy
 

urgent access to airway lig. cricothyreoideum (lig. conicum)

Coniotomy
  

First try OTI find the ligament DO it.

Peripheral venous access - indication:
   

acute drugs repeated blood samples infusion th (crystaloid, colloid, blood) anesthesia

Peripheral venous access – where
    

hand (wide, well filled) 2./3 antebrachium cubit wrist v. jugularis externa, v. femoralis



head

How to

How to
       

place turniket disinfection of skin fix skin and vein punction of vein pull out metal needle, pull in flexible part displace turniket, fixation by plaster next attempt proximally

Complication of canylation of peripheral vein:

 

punction a. brachialis, n.medianus thrombosis

insufficient blood filling

Central vein: I:
    

concentrated fluid, KA, chemotherapy CVP parenteral nutrition continual elimination temporary cardiostimulation unable maintain other vein access



Contraindications:
   

wrong coagulation thrombocytopenia tumor nearby troubles with placing head

Where:
   

v. jugularis interna v. subclavia v. femoralis v. brachiocephalica

Aids for canylation central vein
   

steril table skalpel pean set  catheter-through-needle  catheter-over-needle  Seldinger technik

After canylation
 

sterile cover control RTG  exclude PNO  check placeing of catether

Complications:
       

arythmias PNO bleeding punction of arteria damage of plexus brachialis air emboly thrombosis (v.femoralis) infection, sepsis

Alternatives to vein access




intraossal access  children – tuberositas tibiae  adult:  maleolus medialis  caput humeri  distal radius intratracheal access – CPR:  adrenalin  atropine  Mesocain (trimecain)