Tubes, Lines, and Vents in the ICU: Endotracheal Intubation Mechanical Ventilation Central Venous Catheterization Arterial Catheterization Swan Ganz Catheterization Curt Sessler, MD Professor of Medicine Medical Director of Critical Care Virginia Commonwealth University Health System May 4, 2004
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Tubes, Lines, and Vents in the ICU:Endotracheal IntubationMechanical Ventilation
Central Venous CatheterizationArterial Catheterization
Swan Ganz Catheterization
Curt Sessler, MDProfessor of Medicine
Medical Director of Critical CareVirginia Commonwealth University Health System
Suction equipmentOxygenBag and maskPulse oximetryET CO2 detectorTape / benzoinCardiac monitorDefibrillatorMedications
Patient Preparation
Open airway by placing patient in sniffing positionLift at chin or angles of jaw
Patient Preparation
Towel / blanket beneath head / upper shouldersProvide effective mask ventilation with 100% O2» May need oral airway» May need PEEP valve
Apply pressure to cricoid cartilage
Visualize Vocal CordsAlign axes of pharynx, larynx, mouthPlace towels beneath head to align larynx & pharynxUsing laryngoscope, hyperextend at C1-C2 vertebra
Orotracheal Intubation
Position patient in sniffing position, hyper-extend at C1-C2Laryngoscope blade is inserted into the right corner of the mouth and advanced halfway as
moved to the midline» Tongue swept out of the way» Epiglottis visualized
Orotracheal Intubation
Curved blade: tip of blade advanced above epiglottisStraight blade: tip of blade advanced under epiglottisLaryngoscope lifted to visualize cords
Orotracheal Intubation
ET tube tip is passed between cords until cuff is beyond cords
How to Hold the Endotracheal Tube?
Steps in OrotrachealIntubation
Insert bladeVisualize epiglottisReposition blade and visualize vocal cordsInsert ET tube
Rapid Sequence Intubation(RSI)
Short acting sedatives and neuromuscular blocking agent to facilitate immediate intubation in unstable patientFeatures» Adequate sedation and amnesia» Rapid muscle relaxation» Reduced risk of aspiration» Reduced rise in ICP
Induction Agents
Smooth rapid amnesticShort duration of actionStable hemodynamicsFew side effects
With patient sitting upright, ET tube is inserted and advanced towards the back of the head above the hard palletET tube advanced toward cords while listening for breath sounds
Nasotracheal Intubation: Technique
Endotracheal position confirmed by breath sounds through ET tube, cough.Methods to improve successful placement» head in sniffing position» protrude tongue» cricoid pressure» maintain slight downward pressure if meeting
resistance and patient cannot speak: tip likely is against cords and will pass when pt breathes
Endotracheal Intubation: Complications
Trauma: teeth, mouth, pharynx, nasopharynx, tracheaEsophageal intubation» Avoid by measuring
exhaled CO2 (bag for 5-10 breaths to confirm)
Endotracheal Intubation: Complications
Bronchial intubation» Confirm bilateral = BS » Confirm ET tube position
Reflex response to airway stimulation:» Tachycardia, hypertension,
increased ICP resulting in MI, Aspiration of gastric contentsHypotension: dehydration, poor LV function
22 cm
27 cm
Difficult Airway:Esophageal Tracheal Tube
Manually (blindly) inserted. Double lumen tube with 2 cuffs. One tube (arrow) opens to multiple holes between cuffs and is used to ventilate if tip is in esophagus. Other lumen opens beyond distal cuff and is used to ventilate if tip is placed in trachea.
Blanda. J Crit Illness 2000
Difficult Airway:Laryngeal Mask
Manually (blindly) inserted. Slightly inflate cuff and insert to fit over the larynx. Inflate tube and bag.
Cricothyroidotomy / Transtracheal Ventilation
Endotracheal Intubation: Summary
Preparation for intubation» Patient assessment» Equipment» Intubation