Intubation, Venous Access L.Dadák ARK FNUSA Maintaining airway ● Noninvasive •airway •laryngeal mask •combitube ● invasive •OTI, NTI •coniotomy •tracheotomy 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 Kombitube ● 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: 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 - P, 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: • LA anemisation of nose • tube through nose • 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) 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)