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Esophageal tracheal intubation
indications-
contradictions-
- usually used by paramedics or EMT prior to arriving to hospital
- indications- failure to intubate or ventilate
- contradicitons- intact gag reflex, known esophageal disease, ingestion of causative substance
**usually blind intubation, just open mouth and insert, two balloons on this devise, make sure correct one is inflated, if in esophagus blow up both, if in trachea only have to blow up small one at the bottom of the tube.
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double lumen tubes ( blue tube for esophagus, and white tube for trachea) are used if
- patient has hemothorax trauma, tumor, etc..
- these are used if going to let one lung go and they will isolate and ventilate good tube.. These patients are usually dying.
** notes say not to worry much about this just know basics because we will not use these much
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Combi-tube has how many inflatable cuffs? How many cc will they hold
- two inflatable cuffs
- 1. proximal (blue)- labeled as #1 holds 100cc- tracheal
- 2. distal cuff (white)- labeled as #2 holds 15 cc- esophageal
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Insertion of combitube
- usually blind technique
- lubricate with H2O soluble lubricant
- most of the time tube is going to end up in esophagus
- advance until teeth lie between two black bands
- inflate blue (proximal cuff) first
- make sure cuff is in trachea before inflating white (distal cuff)
- ***ventilate through blue (proximal) lumen
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If you hear no breath sounds after insertion of combi tube what do you do
immediately ventilate through white (distal) tube.
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If no breath sounds or no gastric sounds with combi tube what do you do
- tube is advanced to far
- deflate #1 proximal (blue) cuff and move tube back 2-3 cm.
- reinflate #1 balloon and ventilate through the same port #1 proximal port.
- ***can pull it back and reinsert
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windex
mixture of lidocaine and prilocaine. Use suction tubing and put hole in it, and spray back of patient throat. Use prongs to spray in sections and get further down each time
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4% lidocaine
give like a neb to numb patient airway, only lasts for about 30 minutes
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Fiberoptic scope is used for
- easily recognized difficult airway
- or unrecognized difficult airway if patient is awakened or returns to sv (spontaneous ventilation???)
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options for fiberoptic scope
- nasal versus oral
- awake versus asleep- deep sedation but still breathing
- **if patient awake may give something for nerves, if patient morbidly obese use it while completely awake
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What is the most common approach for a difficult airway
awake fiberoptic- cant go wrong with keeping someone awake and breathing on their own.
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antisialogogue meds
atropine, robanol, scopolamine-- will dry out secretions
glycopyrrolate can also be given
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topicalization
local anesthetic
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vasoconstriction used in management of what, give what medication
- if using nasal approach, it helps decrease the risk of nosebleeds
- --give afrin (oxymetazoline) in pre-op if this may be a possibility when inducting patient
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adequate sedation is
- individualized when inducting patient
- may have to hold hand and reassure patient when intubating if they are not a candidate for any type of relaxant
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fiber optic intubation requires
a clear visual path
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glycopyrrolate is an_____
what is dose???
What is goal
antisialogogue and is a drying out agent
**can be given 0.2 mg IM one hour prior to surgery or 0.2 mg iv immediately prior to surgery
Goal is to dry out mucosa prior to topicalization
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Goal of sedation
what do you want to avoid
to produce a cooperative and relaxed patient
- avoid apnea!!!
- -incremental titration to achieve drowsiness or slurred speech
- -midazolam, fentanyl, and propofol are popular
- -narcotics blunt cough reflex, and this is bad because you want patient to breath
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oversedation impedes
good visualization as pharyngeal tissues relax
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how to do transtracheal block
- use 20 gauge angiocath at 90 degree angel and slightly caudad
- pierce cricothyroid membrane and confirm air aspiration
- use 4cc of 2-4% lidocaine and inject on inspiration
- **aspirate the whole time while doing this, may see a little drop of blood
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invasive types of topicalization (3)
- intraoral glossopharyngeal block- usually done by md (see other notecard for more info)
- superior laryngeal nerve blocks (see other note card for more info)
- transtracheal block (see other notecard for info)
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non-invasive techniques of topicalization
- nasal topicalization
- oral and tracheal topicalization
- **there is no single nerve that can be blocked to produce complete anesthesia of the airway
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invasive topicalization allows what??
what are risks?
- selective areas to be blocked
- use of less drug
Risks- close to thyroid so risk of damage
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non-invasive topicalization blocks what?
advantages
- more generalized areas
- advantages- there are no needles, but you have to use more drug
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how to do glossopharyngeal nerve block
What is mandatory???
- use 10% benzocaine spray to optimize exposure
- use tongue blade or miller to view tonsils
- 22g or 23g tonsilar needle used, inject at base if spinal pillar
- 5cc of 2% lidocaine into base of anterior tonsilar pillar (lower 1/3 of height) bilaterally
- ASPIRATION IS MANDATORY BEFORE INJECTING
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glossopharyngeal nerve block causes profound anesthesia to which part of tongue
posterior third of tongue
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How to do superior laryngeal nerve block
- find superior border of lateral wing of thyroid cartilage
- gently pierce thryo-hyoid membrane with 22 gauge needle
- aspirate (carotid sheath)
- inject 2-3 cc of 2% lidocaine
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what does superior laryngeal nerve block topicalize?
the internal branch of superior laryngeal nerve-provides sensory loss to both of vocal cords
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what does transtracheal block topicalize
below the vocal cords
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nebulized 4-5% lidocaine should be given over how long?
15-20 minutes
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what is nebulized lidocaine used for
- topicalization of nose and carina--but can be unpredictable
- -can loose up to 50% of solution to room air
- good for obese patients with obscure anatomy in the neck.
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topical benzocaine and cetacaine spray can be used for topicalization of what and what is the percentage used
oropharynx and 10%
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what meds do you use with atomizer
- 2-4% lidocaine
- -one should be available on every anesthesia cart
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What are the different meds you can use for nasal anesthesia
- - progressive nasal dilation with 2% lidocaine jelly
- -10% benzocaine spray (spray this in back of throat and not in nose)
- -2 cc of 4% lidocaine to each naris with 18g iv catheter (this is going to burn their nose)
- -mix 1 cc neosynephrine 1% with 4 cc viscous lidocaine and dribble down each nare while patient sniffs
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basic approach to awake fiber optic
- use mild sedation
- antisialogogue- dry out secretions
- 10% spray of cetacaine and benzocaine to posterior pharynx and side to side
- 2% viscous lidocaine to posterior tongue via tongue blade
- transtracheal block
- **if obese, use aerosolized 4% lidocaine and or spray as you go, b/c this may cover more tissue
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When using fiber optic scope you want to ensure you have a
clean and functioning light source
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to prevent humidification with FO scope
- place tip in warm water
- use anti-fog solution on distal tip
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what do you use to achieve better tongue retraction and protect FO scope
use FO airway
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Position when using FO scope
- keep scope straight
- have bed in lowest position
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mechanics for using FO scope
- keep ETT on scope
- -small changes with lever for up and sown
- slight turn of wrist for side to side changes
- distal hand should hold scope at patient mouth
- **little notch on scope is at 12:00, start at 12:00 when looking in scope
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advancement of FO scope
- after carina is visualized advance scope
- if visual field lost, pull back scope until familiar structures appear
- **often takes slight turns to advance past arytenoids
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What ports does FO scope have
- suction port
- insufflation port for 02
- auxillary port for additional topical anesthesia
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when using FO scope on anesthetized patients what should you do
jaw thrust because it opens pharyngeal space and lifts epiglottis
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Insertion of lightwand
- lubricate stylet and insert into ETT
- shape at 90 degree angle (like hockey stick)
- neutral or slight extension of the head
- turn off lights
- insert into corner of mouth
- turn to midline of mouth
- advance gently with a rocking motion along an imaginary arc
- use light glow as guide
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lightwands what are they and what are they used for
- light guided intubation
- blind displacement of lighted stylet
- trans-illumination of the soft tissue of the neck
***used for difficult airways
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when using lightwand what indicates passage through the glottis
what do you do when you get to this point
- well-defined glow at the sternal notch
- **this means you are mid trachea
slide out stylet and verify equal breath sounds and secure ETT
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advantages of using lightwand
- requires minimal cervical spine manipulation
- prevents dental and soft tissue damage
- less stimulating than direct laryngoscopy
- good for small mouth openings- because you don't have to worry about getting on teeth
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disadvantages to lightwand
- learning curve
- trauma to upper airway with blind technique
- reliance on trans illumination---may not be able to see well on obese patients and dark skinned patients
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never use lightwand with patients with
vocal cord mass- need to have direct visualization of vocal cord mass and using lightwand is a blind technique
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when is retrograde wire used
- inability to intubate
- -patient must be able to spontaneous ventilate (because this technique takes time)
- -patient can be awake or asleep
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basic technique of retrograde wire
- catheter or wire passed through the cricothryoid membrane
- -advance into oropharynx
- -acts as a guide for ETT
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specific insertion steps of retrograde wire
- -LTA lidocaine if possible
- -crycothyrotomy with 18 gauge iv catheter
- -pass guide wire up through mouth- magil forceps may be needed to grab it
- -then pass wire through murphy eye (slit on side of ETT) from outside to in and out the top of the ETT.
- - slide ETT down wire through larynx
- -ETT stops advancing approximately 2 cm below the cords
- -hold ETT securely
- -pull out guide wire from below
- -advance ETT down trachea
- -verify placment
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Blind nasal is used for difficult airways when there is inability to intubate, patient must be
breathing spontaneously with good mask airway, and can be awake or asleep (easier if awake and numb than if they are asleep)
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In blind nasal intubations nasal prep is essential use what meds??
- vasoconstrictor- afrin
- quick lubrication with nasal dilators
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As you go down on the size of ETT they also get
shorter
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when using ETT for blind nasal make sure the bevel is faced toward
nasal mucosa, the septal wall
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blind nasal diameter of ETT by
decrease calculated size by at least one half size
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warming your ETT before nasal intubation makes it
more pliable and less traumatic
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Endotrol ETT for blind nasal
- ring at proximal end
- guides distal tip anterior
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BAAM whistle (Beck Airway AirFlow Monitor) for blind nasal
- small disposable whistle attached to ETT
- -produces a whistle when near airflow
- -pitch changes with respiratory cycle
- -loud enough to hear in an ambulance or helicopter
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blind nasal contradictions
- bleeding disorder (nose bleeds)
- -basilar skull fx
- -CSF rhinorrhea
- -nasal fx
- -septal deviation or deformity
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when would you do a cricothyrotomy
- inability to venitlate
- -intubation attempts have failed
- -other conventional adjuncts have failed
- -pt continues to desaturate
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criocothryotomy is a temporary measure prior to tracheostomy to allow for ________ not _______ in the face of severe hypoxemia
oxygenation not ventilation
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non-surgical (needle) cricothyrotomy is accomplished by using what
- a small needle that is passed through the cricothryoid membrane
- -10-14 gauge angiocath is inserted at a 90 degree angle and slightly caudad
- ** technique is similar to transtracheal block
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needle cricothyrotomy set up after insertion
- connect directly to a jet ventilator (luer lock connection)
- -connect to a homemade breathing apparatus
- --7.5 ETT adapter
- --3 cc syringe
- --10-14 g IV catheter
- --use oxygen flush valve to provide oxygenation***you have to make sure patient is exhaling to avoid barotrauma. This is only temporary to oxygenate patient. Surgical intervention may be required after this.
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advantages to surgical cricothryotomy
- larger catheters/cannuli
- -ventilation is possible
- -effective with total upper airway obstruction
- -prolonged placement
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disadvantages of surgical cric
- requires an incision
- -more time consuming
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surgical pre-made kits for surgical cric
- Nu-Trake Set
- Cook Melker Kit
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complications of surgical cric
those that occur early
those that occur later
early- hemorrhage, improper tube placement, failure to gain airway, SQ emphysema, pneumothorax, vocal cord injury, aspiration, laryngeal disruption
later- tracheal and subglottic stenosis, aspiration, swallowing dysfunction, TEF, voice changes
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transtracheal jet ventilation (TTJV)
Equipment needed
- provides a mean of oxygenation following cricothyrotomy (venturi principle)
- -temporizing measure prior to surgical cricothyrotomy
- equipment needed- large bore catheter (10-14g)
- 50psi oxygen source
- non-compliant tubing
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TTJV and the anesthesia machine
- disconnect common gas outlet
- connect high pressure tubing with 15mm (7.5 ETT) adapter at one end and a luer lock at the other end
- -depress the O2 flush valve (50 psi)
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advantages to TTJV
- quick, simple, effective
- -provides emergent means of oxygenation
- -temporizing maneuver
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disadvantages of TTJV
- room air entrapment (50% of TV)
- -cant ventilate optimally
- -cant use compliant breathing circuit (this is why you use high pressure tubing)
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Precautions of TTJV
- avoid use with complete obstruction above the cords
- -gas must escape from the mouth- to avoid barotrauma
I:E ration must be increased 1:3 or 1:4, this allows time for passive exhalation
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monitor peak inspiratory pressure closely with TTJV.
what are depended factors of TTJV?
- tracheal size
- cannula size
- lung compliance
- degree of outflow obstruction
- inspiratory time (avoid stacking breaths)
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complications of TTJV
- barotrauma
- SQ emphysema
- mediastinal emphysema
- arterial perforation
- esophageal puncture
***document breath sounds, chest inflation while performing TTJV
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Rigid scopes are a combination of what
rigid scope and fiberoptic
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popular types of rigid scopes
- bullard scope
- WuScope
- upsher scope
**rigid scopes usually used by ENT on polyps of vocal cords or tonsilectomy
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advantages to rigid scopes
- allows visualization of the airway with minimal manipulation
- -sturdy and durable
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disadvantages of rigid scopes
- expensive (but can reuse)
- -steep learning curve
- -must be used routinely for practice
- -often need considerable mouth opening
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risk for cervical trauma ***KNOW****
- in-line cervical counter traction
- cervical instability
- -trauma, fx
- -rheumatoid arthritis-in children or elderly
- **some patients more at risk than others
- -downs syndrome
- -old ladies
don't crank head back**be careful***
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difficult airway algorithm is a
systematic approach to managing an airway
-developed by ASA in 1990
- -plots primary and alternative airway strategies for emergent and non emergent airways
- -begins with thorough preoperative airway evaluation
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LOOK at airway algorithms!!!!
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take home messages from this lecture
- if your suspicious of trouble, secure the airway awake
- -if you get into trouble wake the patient up immediately
- -think ahead with plan B,C,D immediately available
- -intubation choices--do what you do best!!!
- -always have a back up plan available in the room
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