Critical Care Techniques

Front 1

What is Critical Care?

Back 1

The specialized care of pts whose conditions are life threatening and who require comprehensive care and constant monitoring, usually in ICU's. AKA= intensive care.

Front 2

The Upper Airway

Back 2

AKA= The larynx

Front 3

The Sellick maneuver

Back 3

A method of preventing regurgitation of an anesthetized patient during endotracheal intubation by applying pressure to the cricoid cartilage. Use backwards and upwards pressure and DO NOT RELEASE until ETT cuff is inflated.

Front 4

Artificial airways

Back 4

1. Nasopharyngeal (AKA trunpet):

2. Oropharyngeal: most commonly used, **NOT TOLERATED IN CONCIOUS PTS***

3. Laryngeal mask airway (LMA): used by anesthiologists, usually for simple surgeries. ***DOES NOT ABSOULTELY PROTECT THE AIRWAY***

4. Esophageal obturator airway (EOA): used by untrained personnell who fail attempted intubation on unconscious apneic pt, for short term only.

5. Esophageal gastric tube airway (EGTA): EOA w gastric tube.

6. Combitube: double lumen tube with 2 inflatable balloons, can be used to ventilate eitherr trachea or esophagus. ***CANOT RELIABLLY KEEP AIRWAY OPEN**

7. ETT: **THE KING OF AIRWAYS, BEST EMERGENCY DEVICE FOR SECURING AIRWAY**

Front 5

The ETT

Back 5

* Murphy eye just proximal to beveled tip for safety if occluded.

* Inflatable cuff to seal airway (high V- low P)

* Pilot tube w balloon (10cc's to fill)

*Radio opaque stripe for CXR (blue)

Front 6

What size ETT?

Back 6

* Avg female: 7.0-8.0

* Avg male: 8.0-8.5

*If possible: 9.0-10 (largest)

**THE BIGGER DIAMETER THE BETTER FOR VENT PRESSURES**

Front 7

Nasal intubation

Back 7

** USE MAGILL FORCEPS**

*Pro's:
1. less gag reflex
2. oral care easier
3. ETT more stable

*Con's:
1. must be smaller diameter tube (bad for vent P)
2. necrosis of nasl mucosa

Front 8

Oral intubation

Back 8

**BEST< MOST COMMONLY USED**

*Pro's:
1. fastest, more directe
2. use larger diameter tube (P)
3. minimal trauma

* Con's:
1. Oral care more fifficult
2. ETT > gag reflex
3. less stable/ secure

Front 9

Types of intubation Laryngoscopes

Back 9

Y1. Fiberoptic:
- used in bronchoscopys/ difficult intubations

2. Conventional/ battery operated:
- metal/ plastic
- blade and handle

3. New fiberoptic:
- i.e. Gliderscope
- make intubations safe & easy, though expensive
- blade: flange, spatula, light & tip

Front 10

Types of laryngoscope blades

Back 10

1. Macintosh:
- curved blade. Inserted into vallecula notch and lifted to expose epiglottis and cords.

2. Miller:
- straight blade. Used to directly lift epiglottis.

Front 11

Possible complications of intubation

Back 11

*Early:
1. esophageal intubation
2. mouth, nose, teeth trauma
3. mainstem bronchus intubation
4. kinked ETT
5. vomiting/ aspiration

* Late:
1. vocal cord damaged
2. tracheal stenosis (cuff inflated too high)
3. infection (dirty equip)

Front 12

Indications for intubation

Back 12

1. unable to maintain patent airway
2. need for repeated deep Sx (not necessarily vented)
3. need for mechanical ventilation
4. protection of airway

Front 13

Intubation drugs- Paralytic

Back 13

***MUST ALWAYS ADMINISTER W SEDATIVE***

1. SUCCINYLCHOLINE, aka "SUCCS":
- stimulates nicotinic, muscarinic cholinergic receptors
- "GOLD STANDARD FOR 50 YEARS"
- FAST ONSET: 45 SECS
- SHORT DURATION: 8-10 MIN

2. PAVULON
- SLOWER ONSET: 1-5 MIN
- LONGER DURATION: 45-90 MIN (combative pt)
- renal excretion
- vagolytic (tachyarrythmias common)

Front 14

Intubation Drugs- Sedative

Back 14

1. ETOMIDATE (AMIDATE):
- non-barbiturate hypnotic
- DECREASED ICP/IOP
- RAPID ONSET
- SHORT DURATION
- non hemodynamic effects

2. DIPROVAN (PROPOFOL):
-general anesthesia, IV anesthesia, ICU sedation

3. MIDAZOLAM (VERSED, Hypnovel, Dormicum):
- slower onset: 3-5 MINS
- considered short acting: 30-60 MINS
- DOES NOT INCREASE ICP
- CAUSES RESPIRATORY & CV DEPRESSION

4. ATIVAN: BENZODIAZEPINE
- uses:
*relief of anxiety disorders
*short term (up to 4 mos)

Front 15

Intubation Equipment

Back 15

* ETT &stylet
* laryngoscope
* sterile H2O
* syringe (inflate cuff)
* adhesive tape/ tube fixation device
* bite block
* Sx eqip
* BVM
* O2
* local ap
* ventilator (set up)
* stethoscope

Front 16

27 Steps of Intubation

Back 16

1. Verify order, wash hands, don gloves and gown
2. Remove O2 device
3. Place oral airway properly
4. Position head in sniffing position w towel
5. Hyperoxygenate w bag, verify proper ventilation
6. Have assistant continue ventilations
7. Check larygoscope
8. Check ETT balloon for leaks
9. Insert stylet into ETT
10. Obtain 10cc syringe
11. Sx equipment ready
12. Capnometer ready
13. Prepare adhesive tape to secure ETT
14. Ask RN to deliver anesthesia
15. Check pt for awareness
16. Holds laryngoscope in left hand
17. Insert laryngoscope in mouth, visualise vocal cords, have assistant appy cricoid pressure
18. LIMITS ATTEMPT TO 30 SECS
19. HYPEROXYGENATES BETWEEN ATTEMPTS PRN
20. When ETT placed- ask for cuff to be inflated & remove stylet
21. Bag & observe for bilateral chest rise
22. Withdraw ETT if RT mainstem intubation- deflate & reinflate balloon
23. Ascultate BS: stomach, rt mainstem, then lt
24. Confirm w EZ Cap
25. Secure ETT, attach to vent
26. Call for STAT CXR
27. Ask Dr. for ABG order & Vent settings

Front 17

16 Steps to Extubation

Back 17

1. Verify extubation order
2. Wash hands, don gloves
3. Assemble O2 device as ordered, towel, scissors, Sx equipment, syringe
4. Identify yourself and explain procedure to pt
5. Put pt in semi-fowlers position & cover with towel
6. Preoxygenate, Sx ETT
7. Remove tape Ett & attach syringe
8. Sx orally/ above ETT
9. Instruct pt to take deep breath on count of three
10. Instruct assistant to Sx throat as soon as ETT is removed
11. On count of three, deflate ballon and w McGowan grip, immediately remove ETT
12. After assistant Sx, apply O2 device
13. Ausculate for stridor, check O2 stats
- if stridor present: order STAT racemic epi breathing Tx
14. Instruct pt to limit speaking for a few days and to immediately get nurse if problems arise and advise them of possible sore throat.

Front 18

Laryngoscope blade sizes

Back 18

* 0-1: infant
* 2: 2-8 yrs
* 3: 10- ADULT***
* 4: LARGE ADULT***