Emergency Resuscitation Equipment PDF

Section 5 Emergency Resuscitation Equipment 1  Upper Airway Obstruction Causes: – Soft tissue obstruction – Laryngeal obstruction – Central nervous system depression – Drug OD – Anesthesia – Cardiac arrest – Loss of consciousness...

Section 5 Emergency Resuscitation Equipment 1  Upper Airway Obstruction Causes: – Soft tissue obstruction – Laryngeal obstruction – Central nervous system depression – Drug OD – Anesthesia – Cardiac arrest – Loss of consciousness – Space-occupying lesion – Edema – Foreign body aspiration 2 Upper AW Obstruction (cont’d.) Indications for pulmonary resuscitation/relieving obstruction: (see figure 5.6) Contraindications: – Patient’s desire not to be resuscitated has been clearly expressed & documented Positional Maneuvers to Open the Airway – Focus: reposition the AW so that tongue is moved anteriorly away from posterior pharynx, thereby opening the upper AW – Methods: Head tilt Anterior mandibular displacement 3  Head Tilt Performed by tilting head backward, slightly hyperextending the neck – “Sniffing position” One hand on forehead & head is tilted backward – Do not use w/ suspected cervical spine injury! 4 Head Tilt 5  Anterior Mandibular Displacement Opens AW sans spinal cord manipulation Also called “jaw thrust” Mandible is advanced anteriorly by grabbing both sides of ramus – Tongue is displaced anteriorly, opening the AW 6 Anterior Mandibular Displacement 7 Comparison of Head-Tilt vs. Jaw-Thrust 8 C/E Technique “ BAG THEM UNTIL WE GET THERE!!!” 9  Artificial Airways Designed to maintain a patent AW – Oropharyngeal Airway – Nasopharyngeal Airway – Laryngeal Mask Airway – Combitube Airway – Mouth-to-Mask Ventilation Devices 10  Oropharyngeal Airway Designed to relieve obstructions in the unconscious pt caused by tongue or other soft tissue When properly placed, it separates the tongue from the posterior wall of the pharynx Size matters! – Too small = continued obstruction – Too large = epiglottis held shut – Just right = posterior tip of AW @ base of tongue 11 Oropharyngeal AW 12 Oropharyngeal AW 13  Nasopharyngeal Airway Separates tongue from soft palate Use largest size possible – Tragus of ear to tip of nose Tip should rest b/t tongue & soft palate – Too small = continued obstruction – Too big = epiglottis held shut 14 Nasopharyngeal AW 15 Nasopharyngeal AW 16  Laryngeal Mask Airway Designed so the tip rests against upper esophageal sphincter & sides face the pyriform fossae, lying just under base of tongue Seals off the esophagus Black line should always face the upper lip! Confirm placement w/ BS, ETCO2, and CXR 17 LMA 18  LMA Insertion Video http://www.youtube.com/wa tch?v=96e46PyARaU  Manual Resuscitators Flow-Inflating Manual Resuscitators Permanent, Self-Inflating Manual Resuscitators Disposable, Self-Inflating Manual Resuscitators 20  Manual Resuscitators Portable (make sure you know if you need flow!) Handheld Provide a means of delivering positive-pressure ventilation to a patient's airway – Ventilate bradypneic or apneic patients Most Common! – Hyperinflate patients with oxygen before and after suctioning procedures (hyperoxygenation) – Generate airway pressures and large tidal volumes to expand atelectatic lung segments Allow for the addition of positive end-expiratory pressure (PEEP) valves 21  Flow-Inflating Manual Resuscitators Rely on gas flow to inflate them (a.k.a. “anesthesia bag”) Mostly disposable May deliver 100% O2 Or ANY FiO2 if set on a blender Little “built-in” resistance – You can “feel” the lung compliance. – Harder to bag= worsening lung compliance 22 Flow-Inflating Manual Resuscitator 23  Permanent, Self-Inflating Manual Resuscitators Designed to be cleaned & reused Hopefully, you will never, ever see one. 24  Disposable, Self-Inflating Manual Resuscitators May be used to deliver 21% in the absence of supplemental O2 Inherent “stiffness” of device makes it harder to feel lung compliance May deliver up to 100% O2, depending on flow rate of supplemental gas 25 Self-Inflating Manual Resuscitators (Neo, Peds, Adult) 26  Resuscitator Valve Types Diaphragm (leaf) type – Made of flexible plastic that will distort as P is applied & allow flow through to pt Spring & disk/spring & ball type – Spring is compressed as bag is squeezed, allowing flow to pt. Duck bill valve – Made of flexible plastic that distorts w/ P (similar to diaphragm type) 27 Diaphragm-Type Resuscitator Valve 28 Spring & Disc/Ball Resuscitator Valve 29 Duck-Bill Resuscitator Valve 30 Ambu SPUR 31 BagEasy 32 Pulmanex Resuscitation Bag 33  Positive End Expiratory Pressure Valves (PEEP) PEEP may be necessary in critically ill pts. PEEP valves use spring tension to maintain a set P in the lungs, even at end- exhalation Need to confirm w/ a manometer to avoid barotrauma May use a manometer alone to try and maintain PEEP w/o a valve – Flow inflating 34 Manual Resuscitator w/ PEEP Valve & Maonometer Attached 35  Mouth-to-Mask Ventilation Devices Soft-seal mask + one-way valve (and/or filter) to separate pt & practitioner May have valve for supplemental O2 – If not, YOU wear a NC! – Supplemental O2 can FiO2 to 70% Secure mask w/ both hands – A tight seal is very important! 36 Mouth-To-Mask Devices 37  Intubation Equipment Laryngoscopes and Blades – Miller laryngoscope blade Designed to directly lift epiglottis – Macintosh laryngoscope blade Designed to slip into vallecula (indirectly lift epiglottis) Equipment Used to Assist in Intubation – Magill forceps – Stylet – Yankauer suction (tonsil tip) – End tidal CO2 detection 38 Conventional Laryngoscope w/ Miller Blade Attached 39 Miller Blades 40 View of AW Using A Miller Blade 41 Macintosh Blades 42 McGill Forceps 43 Stylets 44 Yankauer Suction Device 45 Easy Cap End-Tidal CO2 Detector 46  Intubation Equipment (continued) Endotracheal Tubes – Cuffed and uncuffed tubes – Mallinckrodt Hi-Lo® Evac endotracheal tube Suction lumen just above the cuff – Wire reinforced endotracheal tubes Used to prevent kinking – Oral and Nasal RAE® tubes Have a bend to move circuit from AW – Endobronchial endotracheal tubes Carlens tube (2 cuffs, intubate L mainstem) Robertshaw tube (2 cuffs, intubate R or L mainstem) 47  The Importance of Poiseuille’s Law Smaller AW = WOB As radius by ½, R by 16x This imposed WOB can be significant – Small artificial AW’s can make weaning from mechanical ventilation more difficult due to WOB! – Adults: height dependant Female: 6.5 - 7.5 Male: 7.0 - 8.0 – These are just normal ranges, not hard and fast rules! – Formula for Pediatrics: (age in yrs. + 16)/4 = approximate size of ETT – Does not take into account abnormal AW’s 48  Larger inner diameter = less resistance Smaller inner diameter = more resistance 49 Take A Closer Look: ETT 50 How A Balloon Seals the Trachea 51  Forces Exerted by Artificial Airway Cuffs P = F/A High-volume, low-pressure cuffs – ETT – Trachs volume = more surface area = less P to seal tube against tracheal wall – Less pressure on tracheal mucosa – Age cutoff for cuffs is 8 yrs. (not absolute) 52  Cuff Pressure Measurement Techniques – Minimal occlusion volume – Minimal leak Cuff Pressure Manometers – Mechanical manometer and three-way stopcock – Posey cufflator – DHD Cuff-Mate2 Measured/filled via pilot balloon 53  MLV vs MOV Minimal leak volume vs. minimal occlusive volume – Minimal Leak Volume Auscultate upper airway Add air to cuff until leak disappears Remove a small amount until leak is just heard again – Minimal Occlusive Volume Auscultate upper airway Add air to cuff until leak just disappears Also call minimal leak/occlusive technique (MLT/MOT) 54  Cuff Pressure Manometers Measure P in cuff used to seal trachea – 20-30 cm h2o Calibrated to atmospheric P 55 Cross-section of a Mechanical Posey Cufflator Manometer 56 Schematic of a AG CuffFill Strain-Gauge Cuff Manometer 57 Mechanical Manometer & 3-way Stopcock 58 Cuff Pressure Measurement (continued) Respironics PressureEasy – Helps with tubes having a “leaky” cuff – Adds P to cuff during inspiration, when it is needed most Utilizes positive pressure from ventilator – Cuff P is reduced during exhalation 59 Respironics Pressure Easy 60 Murphy Eye 61 Hi-Lo Evac Endotracheal Tube 62 Wire-Wrapped Reinforced ETT 63 Right Angle Endotracheal Tube (RAE) 64 Carlens Endobronchial ETT for independent lung ventilation 65 Robertshaw Endobronchial ETT 66  Combitube Airway Double lumen – Esophageal gastric AW – ETT Designed for blind insertion 2 cuffs---inflate both – Ventilate through either port, confirming which produces chest rise & adequate ventilation 67 Combitube AW 68 Combitube AW 69 Combitube Insertion Video http://www.youtube.com/wa tch?v=MhRj6MLEVoE  Intubation Equipment (continued) Endotracheal Tube Exchanger – Facilitates removal and replacement of an endotracheal tube – Tube change sometime necessary Blown cuff Upsizing Damaged – Threaded through old tube, remains in place when tube removed, new tube is fed over it. Guaranteed to go through vocal cords if old tube was properly in place 71 Tube Exchanger 72  Tracheostomy Tubes Bypass the entire upper AW Incision usually made b/t 2nd & 3rd tracheal rings 73  Tracheostomy Tubes Cuffed, Disposable Tracheostomy Tube Cuffed Tracheostomy Tube with a Disposable Inner Cannula Fenestrated Tracheostomy Tube Silver Jackson Tracheostomy Tube Communi-Trach http://youtu.be/wp5JnVcInPo TRACH VIDEO 74  Cuffed, Disposable Tracheostomy Tube Contain cuff & pilot balloon No disposable inner cannula; entire trach is changed periodically Usually made of PVC 75 Disposable Adult Tracheostomy Tube 76 Cuffed Tracheostomy Tube with a Disposable Inner Cannula Most common now Inner cannula is removable No need to change entire trach unless patency of cuff is in question – Many hospitals will change weekly 77 Adult Trach w/ a Disposable Inner Cannula 78  Fenestrated Tracheostomy Tube Contains a removable inner cannula When inner cannula is removed & balloon is deflated, patient may breath through upper AW Often used for weaning purposed With cuff inflated & inner cannula inserted, mechanical ventilation is possible 79 Fenestrated Tracheostomy Tube 80  Silver Jackson Tracheostomy Tube May be used as a permanent trach Cuffless & made from sterling silver – Silver is more durable & easier to clean Not very common these days 81 Silver Jackson Trach 82  Communi-Trach a.k.a. Pitt Speaking Tube Facilitates speech w/ an inflated cuff Blows O2 by vocal chords via fenestration Patient may speak without using their own expiratory gas flow – Often difficult for patient to coordinate – Speech is not “normal” sounding 83 Communi-Trach 84  Specialized Weaning Devices Maintain patency of stoma during weaning – Olympic Trach-TalkTM – Passy-Muir Tracheostomy Valve – Trach Button – Kistner Button 85  Olympic Trach-TalkTM A Briggs adapter w/ a spring-loaded valve Allows patient to inspire through trach, but must expire through upper AW Trach cuff must be deflated! – Otherwise, patient could not exhale! 86 Olympic Trach-Talk 87 Passy-Muir Tracheostomy Valve Small one-way valve that facilitates speech Once again, cuff must be deflated or patient cannot exhale! Very common…some consider it the gold standard of speaking valves 88  Passy-Muir Valve https://www.youtube.com/watch?v=9yn5ek GJ0Qw 89  Things to Remember… Making the switch to a speaking or weaning device can be very difficult for some patients due to fear, anxiety, or muscular weakness Often we must start small, coaxing the patient to use the device a few minutes a day & then build up 90  Trach Button Used to maintain the stoma after tracheostomy has been removed Consists of: inner cannula, plug, IPPB adapter, spacers – Plug closes the stoma so patient can breathe through upper AW – IPPB adapter allows mechanical ventilation (no cuff) – Spacers adapt to varying neck thickness 91 Trach Button 92 Placement of a Trach Button 93  Kistner Button Trach button w/ one way valve Cannot be used w/ mechanical ventilation One-way valve forces patient to exhale through upper AW – Facilitates for speech – Allows for a more effective cough 94 Kistner Button 95  Secretion Evacuation Devices Suction Regulators Suction Catheters AARC Clinical Practice Guideline: Endotracheal Suctioning of Mechanically Ventilated Adults and Children with Artificial Airways 96  Suction Regulators Use a single-stage regulator to reduce the high negative P’s from the supply line to safe physiological levels Generally, we don’t need to go > 120mmHg Must occlude to accurately read pressure! 97 Puritan Bennett Suction Regulator 98 Allied Healthcare Suction Regulator 99  Suction Catheters Long, narrow catheters designed to remove secretions, blood, or vomit from a patient’s AW Never use a catheter that has a diameter > ½ the diameter of the patients AW (either anatomical or artificial) Insert the catheter & apply suction as catheter is being withdrawn – No more than 10 seconds Pre-hyperoxygenate always…hyperventilate if necessary 100 Whistle Tip Sxn. Catheter 101 Argyle Aeroflow Catheter 102 Coude Tip Sxn. Catheter 103 Ballard Closed Suction System 104 Lukens Trap (attached to suction catheter) 105