Instruments Flashcards
Endotracheal tube
ET tube is used to provide a definitive airway to ventilate a patient when the airway is compromised or when there is extreme hypoxemia. E.g. Where GCS is <8, in general anaesthetic (elderly, obese), in complicated upper airway surgeries, in patients with neuromuscular diseases. It is connected to oxygen and ensures adequate gas exchange.
After inserting the tube, a balloon at the end of the tube is inflated through the blue side port which maintains the position and prevents aspiration.
Can confirm location in a few ways:
A) (best) end-tidal CO2 concentration
B) symm rising of the chest, bilateral breath sounds and no gurgling over the epigastrium
C) moisture in the tube
D) visualising the tube passing through the cords
E) CXR for positioning *blue radio-opaque line
Short term complications include inappropriate placing (oesophageal), dental trauma, injury to larynx, airway spasm, pneumothorax and haemodynamic compromise. Longer term complications include infection, granuloma formation, vocal cord damage and tracheal stenosis.
A laryngoscope (handle, curved blade, light source) is used to aid intubation, visualisation of larynx to aid diagnosis of vocal problems and strictures. There are multiple different forms of blades – curved (Macintosh) as seen in the picture. Straight blades (Miller) are also used. They can cause severe harm to the patient including mild soft tissue injury, laryngeal and pharyngeal scarring, ulceration and abscess formation.
Supraglottic airway devices
LMA - good for elective procedures, cardiac arrests and prehospital airway management. Can be inserted blindly – since it doesn’t enter the trachea, lower risk of bronchospasm. NOT definitive = risk of aspiration. Risk of nerve/vocal cord damage on inflation, dislodgement, pressure necrosis and aspiration.
iGel - supraglottic airway device made of flexible material and a moulded cuff, sized according to patient weight. Has its own gastric channel to allow the passing of NG tube into the stomach for gastric emptying. The iGel also seals off the oropharyngeal opening from the larynx, reducing the risk of aspiration.
To insert - lubricate cuff, insert with cuff opening facing the chin, patient’s head tilted back slightly, advance until resistance felt
Airway adjuncts
OPA – Rigid, curved plastic tube. This is used to provide a patent airway for a patient where there is an impaired level of consciousness, sized from the angle of the mouth to the angle of the jaw. Inserted by upside down, and then rotated within the oral cavity (normal way up in children).
NPA – similar indication, inserted into the nose using a rotational action, sized from tip of nose to the earlobe. A safety pin is placed in the end of the tube to prevent it being inhaled. Comps - trauma. CI - facial injuries, ?basal skull # (racoon eyes, Battles mastoid bruising, hemotympanum, CSF -orrhoea)
Narrow bore NG
Narrow-bore NG tube - used following SALT ad dietician review for supported enteral nutrition in patients with an unsafe swallow i.e. Post stroke, decreased consciousness, following surgery to the upper GI or respiratory tract. The NG is measured from the tip of the nose, around the ear and to below the xiphisterum.
After explaining to the patient what you are about to do the tube is inserted into the nostril after it has been lubricated, give the patient some water and you advance the tube as the patient swallows. These tubes come with a wire inside them to aid their introduction and to check position on xray.
Absolute contraindications:
Mid face trauma + base of skulls fractures
Recent nasal surgery
Oesophageal strictures
Complications include trauma to the nasophyrynx or oesophagus on the way down, infection, blockage, and misplacement into the trachea causing a masive aspiration pneumonia.
Wide bore NG
Initial and continued gastric decompression in the endotracheal intubated patients
Symptom relief and bowel rest in bowel obstruction (the “drip and suck” conservative management – aspiration of stomach contents in conjunction with intravenous fluid administration)
Aspirating ingested toxic material
Upper GI bleed - mediastinitis
Checking NG position
Correct position of the tube is checked by x-raying for the wire. Should descend down the midline to the level of the diaphragm, intersecting the carina, and the tip should be visible at least 10cm beyond the gastro-oes junction. When you are happy with the position of the tube the wire is removed and the feed attached in a sterile manner.
ABG
This is a ABG needle consisting of a needle tip and syringe containing heparin.
Arterial Blood Gas samples are a useful adjunct in the acute environment. I’ve seen this used for acutely unwell patients in A&E and when titrating O2 therapy for COPD patients on the wards. They are a example of point-of-care testing (POCT).
Parameters tested with the blood test include:
pH – acidosis/alkalosis
pO2 and pCO2 – identification of respiratory failure (arterial sample)
Bicarbonate – renal and compensation of acidosis/alkalosis
Lactate – poor perfusion
Hb – anaemia
Na+/K+ quick testing of electrolytes – handy in monitoring and treatment of hyperkalaemia.
Blood culture bottles
Indications: Investigate a patient with pyrexia.
Features:
• Blue (like the sky): aerobic culture medium.
• Red: anaerobic culture medium.
Method:
• Take blood using ANTT.
• Replace needle with a clean one.
• Wipe top of bottles with alcohol.
• Fill aerobic (blue) bottle first then anaerobic (red).
• Fill in patient details and send to pathology lab.
Central lines
Central venous catheter is inserted into the internal jugular vein or subclavian vein under ultrasound guidance. Blood tests and central venous pressures can also be obtained.
Short term venous catheter - ~ 2 wks
Key indications include: parenteral nutrition, emergency venous access, fluid resuscitation, infusion of irritant drugs, vasopressors, inotropes, allows longer term access.
Complications include misplacement, pneumothorax, bleeding - infection, haematoma - thrombosis, blockage - do CXR after insertion
This is a Hickman line. The way it differs from a CVC is that there is a portion of it that’s tunnelled under the skin, and there’s a Dacron cuff that theoretically prevents infections from tracking up the catheter. It is therefore suitable for longer term use.
PICC is put in a peripheral vein (usually cephalic vein) ends up in the superior vena cava. I’ve seen this used in my medicine placement for long term antibiotics for infective endocarditis.
Sigmoidoscope and proctoscope
This is a rigid sigmoidoscope, which is used for the endoscopic examination of the rectum and lower sigmoid, with a possibility for biopsy. I’ve seen this used in colorectal clinic.
After explaining to the patient, you attach a light source and a air pumping device. The patient is placed in the left lateral position and a digital rectal examination is performed. The sigmoidoscope is then lubricated and inserted, pointing towards the umbilicus. Air is pumped into the rectum to help visualisation.
Biopsies can also be taken of rectal mucosa through the sigmoidoscope e.g. in a case of ulcerative colitis.
This is a proctoscope, it is used to visualise the anal canal and lower rectum, it is also used when injecting (shouldered syringe with phenol in oil) or banding haemorrhoids (above the dentate line - less sensitive). After explaining the procedure to the patient, the patient is placed in the left lateral position and a digital rectal examination is performed. The proctoscope is then attached to a light source and lubricated prior to its insertion into the rectum.
Urine dip
Urine dipstick testing is very useful in the acute clinical environment and in primary care. Key elements assessed in urine dipstick testing are blood (microscopic/macroscopic haematuria), protein (renal disease), nitrites (active infection), and leukocytes (inflammatory processes), glucose (diabetes), ketones (DKA), bilirubin and urobilinogen (haemolysis and liver pathology).
- Positive tests for Nitrites and Leukocytes should be sent for urine MCS.
Positive blood and protein should be sent for Urine Protein:Creatinine Ratio.
Catheters
Useful as a therapeutic measure in urinary retention, for immobile patients or those that need irrigation, also useful for measuring urine output and you can take urine samples from a catheter as well.
Inserted with an ANTT, insert lubricating anaesthetic gel and advance catheter until urine is draining, fill balloon.
Comps - false tract, urethral damage, paraphimosis –> infection, blockage
Two-way catheter – typically start 10-12 Fr for females, and 12 – 16 Fr for males. One port for drainage, one for filling balloon with sterile water.
Short-term catheters should only last 2 weeks, max 28 days. At this point, they should be changed or removed altogether if possible.
Long-term catheters can last up to 3 months, and are sometimes coated in silver alloys to provide anti-microbial action. Usually use in patients with chronic issues, such as chronic bladder outlet obstruction (e.g. prostatic enlargement), neurological bladder, or ulcers in incontinent patients
You would use a three-way catheter if a person was at risk of clot retention and needed bladder washout and irrigation.
The urometer drainage bag allows monitoring of urine collection as it is designed with a clear graduation scheme. It reflects the accurate amount of urinary output per hour. It is used during surgery, postoperatively and to monitor fluid status.
Tracheostomy tube
This is a temporary tracheostomy; it is an example of a definitive airway as it protects the patients lungs from aspiration, can be temporary or permanent. Placed between the 2nd and 4th tracheal rings under GA.
Indications:
Long term intubation i.e. >2wks, a patient being ventilated on the intensive care unit.
Severe maxillofacial injury, post laryngeal surgery
Respiratory failure, upper airway obstruction
A tracheostomy allows more efficient ventilation of the patient with a decreased dead space and also allows more effective suctioning of the airways.
Comps: stenosis, infection, blockage, tracheoesophageal fistula
Nasal cannulae
Nasal cannula are commonly used mode of oxygen delivery both in hospital and in the community.
It is widely used to carry 1-3L of oxygen per minute (can be upto 5L/min). This delivers between 28-44% of oxygen.
These cannulae differ from high-flow nasal oxygen therapy (optiflow). better seal between the nostrils and the cannula, and the air is humidified and warmed, therefore allowing you to take in MORE air at higher flow rate (can be up to 60L/min)
Common issues are nasal sores and epistaxis, therefore patients are encouraged to apply water-based creams to moisturise.
Venturi mask
Venturi masks are used when an accurate FiO2 is needed, for example in type 2 respiratory failure in COPD. It delivers 24-60% oxygen depending on the colour shown on the mask. The vents at the bottom of the mask allow controlled mixing of atmospheric air.
Types:
–BLUE = 2-4L/min = 24% O2 –WHITE = 4-6L/min = 28% O2 –YELLOW = 8-10L/min = 35% O2 –RED = 10-12L/min = 40% O2 –GREEN = 12-15L/min = 60% O2
