Monday 23 November 2015

A lot of people always suffer from yellowing and accumulated tartar buildup, any accumulation of tartar on the teeth, and this is what causes them concern, quick to go to the dentist, also omits a lot of people about the presence of some natural and healthy mixtures for bleaching teeth, without the trouble or go to the doctor .

First, you have to deal with vegetables on a regular basis, because the vegetables are working on the teeth cleaning is fast, you also must exchange old toothbrush one new purchase, with the knowledge that you should switch the old toothbrush with a new one all the time.

There are medical yarns are sold in pharmacies to clean teeth, purchase it and use it daily, and also buy sage leaves, this leaves the material reacts with the teeth and Telemann on a regular basis.

There is also an alternative natural way to clean teeth using a lemon you can rub lemon peel on the teeth, then use the water to rinse, and there are a lot of recipes will remind them of the different articles.
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Thursday 5 November 2015



Is considered to have lung cancer are two types:

The first type is the lung cancer is non-small cell: This is kind of the most common types among people with lung cancer, because it grows slowly, it does not spread very quickly among the other member.

In front of the second type it is a small lung cancer cells: considered this kind of least common species among the injured, and this type grow too quickly and reach other organs in a very short time.

You can also read: the symptoms of cancer and should see a doctor immediately

One of the main causes of lung cancer is exposure to cigarette smoke caused by smoking and other breathing this smoke out of them and this is the main cause of lung cancer, and is the cigarette smoke contains a lot of chemicals that cause cancer.



Symptoms of lung cancer:

Permanent cough cough or extruded Bbulgm and also withdrawn Bbulgm blood.
Sound "hoarseness" change.
Feeling short of breath, and difficulty in the air inhalation.
Loss of appetite, lack of Zen significantly.
There are some other symptoms:

Swelling of the face and neck.
Chronic fever.
Weakness in the interval.
Author of articles:

Shocking video call directly on the air in the life and religion program

Sherif Mounir incident illustrates Mina in Makkah

Urgent astronomical phenomenon given the Egyptians a 10-day vacation

Video imaging to detect involved in the incident defend "me."

Urgent Naguib Sawiris of the press mocked the yo-yo "yo-yo wad seared his blood."

Egypt will witness the phenomenon of today will not occur again until after 18 years

Video is very impressive for a cow cry before slaughter and escape from death

Photos Sylvie cause to terminate the ceremony Amr Diab

See pictures applies Fouda insults Reham Saeed and you reply to it

See the photos that Ibrahim Said strongly criticized because of it
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Wednesday 14 October 2015

INDICATION
          Cardiac tampon

EQUIPMENT
  • local unaesthetic
  • # 16 (orange) or # 18 (green) intravenous over the needle catheter, connected to a 20 ml syringe
  • a three way stopcock
SITE OF PLACEMENT
          1-2 cm to the left of the sternum in the left hypochondriac


PROCEDURE
  • surgically prepare and drape the puncture site and infiltrate with local anesthetic
  • insert the needle through the skin at the puncture site and advance the needle forward aiming towards the lower tip of the left scapula, while pulling out the plunger of the syringe to apply suction.
  • Aspirate as much blood as possible from the pericardia sac
  • Remove the needle and syringe leaving the catheter in sit and securing it to the skin with plaster.
  • Connect the 3 way stopcock (in the closed position) to the catheter for respiration purposes, in case cardiac tampon develops again.
POSSIBLE COMPLICATIONS
  • Local cellulitis / stomachache
  • Puncturing of :
  • myocardium leading to possible ventricular fibrillation; ECG monitoring is advised
  • coronary artery or vein, possibly leading to a new pericardium
  • lung with possible chemotherapy
  • intercontinental or great medicinal vessels with possible chemotherapy
  • esophagus with possible tendinitis
  • peritoneum with possible peritonitis

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Saturday 22 August 2015



RESPIRATORY RATE

There is considerable variation of this parameter e.g. the "normal" respiratory rate for a neonate is significantly different to that of a 60-year old adult.

HYPNOSIS

This is an unreliable sign of asphyxia and varies with:
  • skin pigmentation
  • level of haemoglobin
  • ambient light
  • skin perfusion

OXYGEN SATURATION

This is assessed by pulse optometry and has become an integral part of the assessment of respiratory status and indeed is considered an additional vital sign. Like the other vital signs it must be assessed in context and its limitations understood. 

The pulse taximeter will display:
  • oxygen saturation
  • pulse rate
  • pulse volume

The last parameter is displayed as a ethnographically waveform and is subject to more error than the oxygen saturation reading. Alarms are usually present for low saturation and for pulse rates at upper and lower limits. The accuracy for oxygen saturation is +/- 2% only between 70-90% range.

It must be remembered that saturation is not the same as the partial pressure of oxygen and there is not a linear relationship between the two. The relationship is described by the hemoglobin-oxygen dissociation curve and this in turn is not a constant as it is affected by temperature, pH and PC O 2.

Rough correlations would be :

     75% sat = Pa O 2 40 mm.Hg
     90% sat = Pa O 2 60 mm.Hg

Factors influencing pulse optometry readings :
  • Signal interference - shivering, movement, high intensity light from another source
  • Decreased light transmission - dirty skin, dark nail polish
  • Decreased signal volume - poor peripheral perfusion
  • Abnormal hemoglobin - car boxy hemoglobin (causes an overestimation of saturation)

               Anemia (especially at levels < 5 g % also affect the signal)
  • Others e.g. intravenous dyes
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Friday 21 August 2015



This requires assessment of
  • the presence of respiratory effort
  • the pattern of respiration (e.g. paradoxical movement, flail chest)
  • the adequacy of the respiratory effort :
               respiratory rate
               signs of asphyxia e.g hypnosis, mental clouding
               signs of hypercritical e.g warm dilated peripheries, sweating, mental clouding
  • auscultate findings of the chest
  • the pulse optometry reading
These clinical signs must be taken in the context of the clinical picture. The signs can be non-specific and must be interpreted as a package, rather than individually.
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A broad spectrum of medical and traumatic breathing disorders present themselves to the emergency department. As for any other patient presentation, focus your attention on the presenting complaint, and do a directed history and clinical examination. However, because disorders of many systems can lead to respiratory symptoms, it is important not to be too narrow in your approach. Good examples include severe anemia presenting as fatigue and shortness of breath, or heart failure presenting as wheezing.

We are going to concentrate on the identification and management of injuries compromising the airway and breathing - for practical and self explanatory reasons airway and breathing can be considered together, rather than as separate entities. We are however going to concentrate on chest injuries in this section.

Many medical disorders such as asthma, chronic obstructive airways disease (CO PD), pulmonary embolism, pulmonary o edema, and lower respiratory infections such as acute bronchitis and pneumonia also present to the emergency doctor. These are not going to be presented in this module, but it is necessary for you to do further reading on these conditions, and be able to competently assess and manage these medical conditions.
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INITIAL STABILIZATION
1. Position Patient
     - allow to self posture when able, to maintain airway potency. Hard collar if cervical spine injury is suspected.

2. Airway
Complete Obstruction
  • Summon help from the doctor most experienced in airway management
  • Use basic airway opening man oeuvres
  • Attempt incubation without use of muscle relaxants initially
  • If unsuccessful, proceed to emergency surgical airway
Partial Obstruction
     Based on presence of stride, hoarse voice and or respiratory distress.
  • Humidified oxygen
  • Notify anesthetist / surgeon
  • Transfer to operating theater accompanied by skilled staff for examination under anesthetic / incubation / tracheotomy
  • Do not transfer patient to another facility until incubation has occurred
Potential Obstruction
     Based on the presence of sore throat, swollen face, swollen tongue, external neck trauma. Consider incubation by a doctor experienced in airway management, especially prior to transfer. Consult with a retrieval service if necessary.
  • Mandibular fractures : where the tongue cannot be cleared by special techniques a towel clip or large suture can be used to retract and anchor it.
  • Foreign bodies penetrating the face and mouth should not be removed and the wound not explored until the patient is in the operating theater.
  • In laryngeal fracture resulting in airway obstruction, needle hypothyroidism is the procedure of choice. Formal hypothyroidism should not be performed as this may further disrupt the anatomical structures.
  • The trachea can be incubated directly through the neck in a penetrating wound.
3. Breathing
  • Measure respiratory rate. If inadequate, assist ventilation with bag valve mask attached to oxygen
  • Measure SA O 2. If <95% and not requiring assisted ventilation, administer high flow oxygen via mask.
  • Examine for associated pneumonia or other chest injury.
4. Circulation
  • Measure PR, BP, and capillary refill
  • Attach to cardiac monitor and assess rhythm
  • Insert IV annular
  • Take blood for F B C, biochemistry, crosspatch
  • If shock is present, give crystallized rapidly
5. Hemorrhage Control
  • Reduce fractures immediately, especially if mid third of face is involved
  • Pack pharynx if necessary
  • Pack or suture other wounds
6. Monitor
     - SA O2, BP, ECG

7. Summon
     a doctor with airway skills

DIRECTED HISTORY AND EXAMINATION
     Ask about :
        Event
  • mechanism of injury
Symptoms
  • voice changes
  • painful swallowing
  • noisy breathing/dyspepsia
Past History
  • medications
  • allergies
  • medical problems
Look for :
  • stride
  • swelling of the neck, palate, tongue
  • subcutaneous emphysema in the neck or face
  • laryngeal deformity or tenderness
  • middle third of face mobility
  • significant hemorrhage especially pharyngeal
Tests
     None per - stabilization
     Once stable, consider :
  • facial X rays/CT
  • C X R
  • cervical spine X ray
  • CT neck and larynx if possible
SPECIFIC TREATMENT
Laryngeal trauma - where there is no clinical evidence of airway compromise, but there is subcutaneous emphysema due to blunt neck trauma, administer humidified oxygen and commence IV antibiotics for possible salivary contamination of the deep tissues of the neck.

DISPOSITION
     For complete obstruction with surgical airway in place, or partial obstruction:
1. Notify anesthetist/NET or local equivalents
2. Notify operating theater
3. When all resources are assembled transfer to operating theater accompanied by skilled staff, oxygen, suction, bag valve mask system, difficult incubation tray and surgical airway setup.

IMPORTANT POINTS
1. Always maintain a well prepared crash trolley.
2. Ensure that before incubation the staff, equipment and patient are prepared as much as time allows.
3. Check all equipment before commencing.
4. If asphyxia occurs, assume tube malfunction or positional first. If in doubt, extenuate, ventilate, re-oxygenate and re- incubate with a fresh tube.
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DEFINITION

Blunt or penetrating traumas to the neck or face involving elements of the upper airway.

CAUSES
  1. Motor vehicle accidents
  2. Assaults
  3. Falls
  4. Hanging
  5. Penetrating injuries
CLINICAL FEATURES
1- Airway obstruction is the greatest concern and can be due to :
  •  collapse of anatomical structures (GE mid face, mandible, larynx)
  • foreign bodies
  • hemorrhage
  • swelling
Complete Obstruction
  • no air movement present
  • until the patient loses consciousness there will be
              - grabbing at throat
              - paradoxical breathing IE abdomen moves inwards while chest expands during attempted inspiration
              - extensive use of accessory muscles of respiration
              - hypnosis
              - agitation

Partial Obstruction
  • still some air movement present
  • stride, cough, self posturing (GE sitting upright and leaning forward)
  • use of accessory muscles of respiration
  • hypnosis while breathing room air is a late sign of partial upper airway obstruction
Potential Obstruction
  • normal air movement
  • none of the above features, but
  • swollen face, swollen tongue, sore throat, external neck trauma
IMPORTANT POINTS

1. Fractures of the mandible can disrupt the attachments of the tongue to the mandible, preventing effective basic airway man oeuvres.
2. Evidence of airway injury in blunt trauma may be very subtle initially, especially laryngeal tracheal injuries. Voice changes or dyspepsia may be early signs.
3. Cervical spine injuries have a higher incidence in this setting and must be excluded.
4. There is often significant hemorrhage associated with these injuries.
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INITIAL STABILISATION
1. Airway

  • Complete Obstruction
  • summon help from the doctor most experienced in airway management.
  • Use basic airway opening techniques (GE suction , head position, pharyngeal airway, pharyngeal airway) and attempt ventilation via bag valve mask attached to oxygen
  • Attempt incubation without the use of muscle relaxants initially
  • If unsuccessful, proceed to emergency surgical airway

  • Partial Obstruction

          Diagnosis based on the presence of stride, hoarse voice and/or respiratory distress.

  • Humidified oxygen
  • Notify anesthetist / surgeon
  • Transfer to operating thereat accompanied by skilled staff for examination under an aesthetic / incubation or tracheotomy
  • Do not transfer the patient to another institution until incubated

  • Potential Obstruction
          Diagnosis based on the presence of sore throat, circumferential neck burns, sooty sputum, burnt mouth/tongue/nasal hairs or history of fire or explosion in confined space. Consider incubation.

2. Breathing

  • Measure respiratory rate, and if inadequate, assist ventilation with bag valve mask attached to oxygen.
  • Measure SA O2. If <95% and not requiring assisted ventilation, administer high flow oxygen ( 100% O2 via non re breather mask if carbon monoxide poisoning is a possibility)
3. Circulation

  • Measure pulse rate, PB and capillary refill
  • Attach to a cardiac monitor and assess the rhythm
  • Insert IV annular
  • Take blood for FBC, biochemistry
4. Disability
          Record a G CS and pupil response. Consider incubation (if this has not already been done), if G CS 8 or below, to protect the airway.

5. Monitor
          - PB, ECG, SA O2

6. Summon
          senior doctor with airway skills

DIRECTED HISTORY AND EXAMINATION
     Ask about
      Event

  • Circumstances of the burn(GE enclosed area, explosion, steam)
  • Associated trauma if explosion was involved
  • Episodes of loss of consciousness (possibly associated carbon monoxide poisoning or head injury)
     Symptoms

  • stride / dyspepsia
  • cough
  • sore mouth/throat
  • hoarse voice
Past History

  • associated respiratory illnesses (GE asthma)
  • medications
  • allergies
  • medical problems
Look for
Stride, voice changes, oral or nasal burns, facial or circumferential neck burns, nature of cough

Tests
Blood gases, Carboy Hb

DISPOSITION
For complete obstruction with surgical airway in place or partial obstruction:

  • Notify anesthetist, NET surgeon
  • Notify operating theaters
  • When all resources are assembled transfer to the operating theatres accompanied by skilled staff, oxygen, Am bu bag, difficult incubation tray and surgical airway equipment
For potential obstruction, admit to an Intensive Care Unit

If patient transfer is to occur, consider incubation prior to transfer

IMPORTANT POINTS
1. Incubate early if signs or history suggesting airway involvement in burns.
2. Be prepared for a difficult incubation.
3. Involve the available doctor most experienced in airway management.
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Thursday 20 August 2015



DEFINITION
     Thermal or caustic burns to the pharynx, larynx or trachea.

1. Thermal Burns
  • Heated gases
  • pharyngeal, laryngeal, and tracheal burns are usually the worse affected area

  • Direct Flame
  • injuries usually confined to the face and lips


2. Caustic Burns
  • acid / alkali
  • intentional or accidental

CLINICAL FEATURES
1. Thermal Burns
  • The initial physical findings are notoriously unreliable at ruling out burns to the airway.
  • Suggestive findings are :
  • history of burns in an enclosed space
  • sore throat, painful swallowing
  • facial, nasal or oral burns
  • cough, stride or voice changes
  • carbonaceous sputum or respiratory distress

2. Caustic Burns
  • associated with mucous ulceration and massive o edema
  • drooling
  • cough, stride
  • ulceration of the mouth, tongue or pharynx (may appear as white plaques)
  • respiratory distress

IMPORTANT POINTS
  1. The initial physical findings can be unreliable in ruling out thermal burns to the upper airway.
  2. History of the circumstances of the burn is important to assess the possibility of airway burns (GE confined space, explosion, flame, steam)
  3. If thermal upper airway burns are present, also consider carbon monoxide, cyanide or hydrogen sulfide poisoning from smoke inhalation.
  4. If caustic burns are present, consider other ingest ants as well
  5. Airway compromise can be delayed but dramatic in onset.

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INITIAL STABILIZATION
1. Airway
     - have a difficult airway tray at hand
  • Complete Obstruction
            In the emergency Department setting manual man oeuvres (GE Heimlich man oeuvre) to relieve obstruction are not indicated as more definitive measures exist.
            Initially, use basic airway opening measures and attempt ventilation via bag valve mask attached to oxygen
            Then attempt indirect clouds cape and removal of obstructing agent with a Ma gill's forceps or suction
            If unable to remove the obstruction mechanically GE when due to swelling, proceed to emergency surgical airway IE trans tracheal jet insulation or hypothyroidism
            Then proceed as per "Specific Treatment" below.
  • Partial Obstruction
            Encourage self posturing GE in epiglottis the patient will prefer to sit upright and lean forwards
            Unless there is an obviously visible foreign body and the patient is cooperative DO NOT perform any airway clearing man oeuvres, such as the Heimlich man oeuvre. This may convert a partial obstruction into a complete one.
  • Potential Obstruction
            No immediate intervention is required

Then, for partial obstruction or potential obstruction :

2. Breathing
  • Measure respiratory rate. If inadequate, assist ventilation with bag valve mask attached to oxygen.
  • Measure SA O2. If < 95% and not requiring ventilation, administer high flow oxygen by mask.
3. Circulation
In partial obstruction great care must be taken to avoid agitating the patient and precipitating a complete obstruction GE measuring the PB or inserting a annular in a child with epiglottis may cause agitation and precipitate a complete airway obstruction.

4. Disability
Record a G CS and pupil response. Consider incubation (if this has not already occurred), if G CS is 8 or less to protect the airway.

5. Monitor
ECG, SA O2, PB (if this will not agitate the patient)

6. Summon
- a senior doctor with airway skills.

DIRECTED HISTORY AND EXAMINATION
Ask About :
Event

  • precipitating factors, likelihood of foreign body aspiration
Symptoms

  • of possible precipitants GE epiglottis, croup
Past History

  • drug allergies
  • medications
  • medical problems
Look For :

  • stride, hypnosis
  • signs suggestive of particular clinical syndromes GE epiglottis, croup, angina-o oedema
Measure :

  • reassess SA O2, respiratory rate, level of consciousness
Tests

  • in the airway control phase there is no test of any use and tests may delay definitive management and worsen the condition.
SPECIFIC TREATMENT
     If partial obstruction, potential obstruction or complete obstruction with temporary surgical airway in place :

1. Notify anesthetist / NET surgeon or local equivalents
2. Notify the operating heater
3. When all resources are assembled transfer to the operating heaters accompanied by skilled staff, oxygen, suction, bag valve mask system, difficult incubation tray and surgical airway setup.

DISPOSITION
     Depends on the cause, but in most cases would require admission to an Intensive Care Unit after definitive treatment in the operating heater.
Airway must be stabilize before any inter-hospital transfer is attempted

IMPORTANT POINTS
1. Heimlich man oeuvre is generally not indicated in the Emergency Department setting.
2. If partial airway obstruction is present then intervention in the Emergency Department should be minimal and the patient should be transferred to the operating theater accompanied by appropriate staff and equipment.
3. Do not attempt to remove penetrating foreign bodies of the neck in the Emergency Department.
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DEFINITION
     A life threatening condition where there is complete, partial or potential obstruction of the airway at some point between the teeth and the Carina. The degree of obstruction and the speed of onset will vary depending on the cause.

CAUSES
1. The Patent's Tongue - this occurs in unconscious patients who are unable to maintain airway potency
2. Foreign Body - usually occurs in one of three clinical situations
  • Patients with a decreased level of consciousness and a diminished cough reflex who inhale a foreign body
  • Young children inhaling objects / material that they have put into their mouths
  • Older patients with dentures who lack the ability to sense the size of the food bolus they are about to swallow
3. Upper Airways Swelling - due to infection /burns / trauma / o edema

CLINICAL FEATURES
     Complete Obstruction
  • no air movement present
  • until the patient loses consciousness there will be :
                  grabbing at throat

                  paradoxical breathing with extreme respiratory distress
                  hypnosis
                  agitation

Partial Obstruction
  • still some air movement present
  • stride, cough, self posturing if the patient is conscious (GE sitting up, leaning forwards)
  • use of accessory muscles of respiration
  • hypnosis while breathing room air is a late sign of partial upper airway obstruction

Potential Obstruction
  • normal air movement
  • none of the above features
  • swollen face, swollen tongue, sore throat, external neck trauma, circumferential neck burns, sooty sputum, burnt mouth / tongue / nasal hairs, history of fire or explosion in an enclosed space.

IMPORTANT POINTS

1. Hypnosis while breathing room air is a late sign of upper airway obstruction
2. Early upper airway swelling can be very subtle and initially have no clinical evidence of obstruction, yet dramatically obstruct later.
3. Skilled assistance is vital and the doctor most experienced in airway management should be summoned immediately.
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Wednesday 19 August 2015



TECHNIQUE
  • Identify the caricatured membrane as above
  • Infiltrate with local anesthetic using 1% linking with adrenaline
  • Using the scalpel make a vertical incision through the skin and down to the membrane
  • Make a horizontal incision through the caricatured membrane at its junction with the cricked cartilage
  • Use the forceps and scissors to open the aperture and pass the tube into the trachea
  • Remove the forceps, inflate the cuff and anchor the tube
  • Arrange a CXR
COMPLICATIONS
  • Mal position
              subcutaneous emphysema
              injury to nearby structures (as above)
  • Hemorrhage
  • Failure and resultant asphyxia
  • Infection
ADVANTAGES
  • Provides a definitive and stable airway
  • Simpler and safer than a tracheotomy
  • Rapid
DISADVANTAGES
  • Landmarks are often difficult in the clinical settings in which it is needed
  • Needs some surgical skill
  • Is not recommended in a child <12 years
  • Sliding sets are expensive

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Several commercial sets exist. Many are based on the Gelding guide wire principle :
  • Identify the hypothyroid membrane by placing the index finger and thumb on the thyroid cartilages and running them caudally until they fall into a groove. The floor of this groove is the hypothyroid membrane.
  • Local anesthesia, using 1% Novocaine with adrenaline, is infiltrated down to the caudal limit of the hypothyroid membrane.
  • A needle with syringe attached is inserted in the midlife through the caudal edge of the membrane while aspirating. Free aspiration of air indicates penetration into the trachea.
  • The syringe is disconnected from the needle and a guide wire passed caudally into the trachea.
  • A dilator is then passed over the wire and used to create a passage for the tube.
  • The dilator is then removed leaving the wire in suit.
  • A trochaic with tube is then inserted over the wire and once in place, the wire and trochaic are removed leaving the tube in suit.
  • The tube is then tied in place.
  • Arrange a CXR
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This is a technique for achieving oxygenation. It does not provide adequate ventilation. It is the emergency surgical airway of choice in children <12 years old. It can be useful in severe axiomatically trauma, but can also be used in the setting of an upper airway obstruction from any cause

TECHNIQUE
  • Inform the patient/parents if possible.
  • Local anesthesia using 1% Novocaine with adrenaline. This is infiltrated into the skin overlying the hypothyroid membrane and on to the membrane itself. Aspiration of air will confirm the needle's passage beyond the membrane and into the trachea.
  • With a 5 ml syringe attached to the annular and aspirating as you go, advance the annular tip through the inferior part of the hypothyroid membrane aiming caudally.
  • When air is aspirated freely, advance 1-2 mm further, stop and slide the annular sheath of the needle while holding the needle still. Remove the needle, leaving the cannula sheath in place.
  • Now connect :
                  the 3 way stopcock to the annular
                  the oxygen tubing to the 3 way stop cock
  • Commence the oxygen flow at 15 l/min and use the stop cock to control ventilation IE on to the patient on inspiration / off to the patient for expiration.
  • Expiatory phase 2 seconds, or until the chest rises.
  • Expiratory phase 4 seconds.
  • If expiration is incomplete, insert another cannula next to the first to act as a vent.
  • The procedure will provide adequate oxygenation for up to 45-60 minutes.
Alternative :
A 2ml syringe can be connected to the cannula after insertion. The plunger is removed from the syringe and the connector from a size 7 ET is inserted in its place. A bag and valve attached to oxygen can then be connected and the patient oxygenated.

COMPLICATIONS
  • Mal position
                subcutaneous emphysema
                hemorrhage
  • Injury to nearby structures
               vocal cords
               cricked cartilage
               trachea
               carotid arteries
               vague / recurrent laryngeal nerves
               jugular veins
               esophagus
  • Bertram

               especially in infants or in patients with complete upper airway obstruction
  • Infection

ADVANTAGES
  • Less complications than surgical airways
  • Easier than other surgical airways
  • Requires minimal surgical skills
  • Can be used in young children

DISADVANTAGES
  • Does not provide a definitive airway
  • Does not provide adequate ventilation
  • Exposes the lungs to potentially high pressures
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This is an extension of the concept of the introduce. A long piece of elastic material which is semi-rigid can be directed into the trachea when it is impossible to achieve direct incubation because of an inability to see the cords or because of difficulty in directing the end o tracheal tube between the cords.

TECHNIQUE
  • Under direct vision using the arthroscope the Boogie is passed between the cords as to where the cords are estimated to be.
  • An appropriate sized interracial tube is then passed over the Boogie and into the trachea using the Boogie to guide the tube
  • If the tube appears to catch at the cords its advancement may be facilitated by twisting the tube through 180 degrees.
  • The Biggie is then removed, leaving the tube in place.

COMPLICATIONS
  • Failed incubation
  • Trauma to the airway
  • Esophageal incubation

ADVANTAGES
  • Technically simple
  • Avoids surgical procedures

DISADVANTAGES
Can be awkward, particularly if interracial tube gets snagged at the cords.
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B.U.R.P.
This applies to a technique to aid visualization of the larynx when the larynx lies caudal and anterior. It refers to the application :
     Backward - to push the larynx backwards
     Upward - to push the larynx as superiority as possible
     Rightward - no more than 2 cm
     Pressure - to the thyroid cartilage (NB. not the Crisco)

LARYNGEAL MASK

This airway is the ideal emergency airway for use by unskilled practitioners. It however does not provide airway protection and therefore in emergency situations should only be seen as a temporary measure. In emergency situations it can be used as an airway in its own right or as a track for the introduction of an airway bogie or, in adults, for the insertion of a size 6 tracheal tube.

TECHNIQUE
  • Select the appropriate size laryngeal mask
  • Partially inflate the cuff (this will make insertion easier)
  • Insert the mask into the pharynx with the distal aperture directed caudally until no resistance to further progression is felt.
  • Fully inflate the cuff with air (10 ml)
  • Attempt ventilation
  • If insertion fails ie if the patient cannot be ventilated, deflate the cuff and withdraw the mask. Re-attempt the procedure with the distal aperture initially directed cranial, then, once in the pharynx, rotate through 180 degrees as for an pharyngeal tube.

If desired, an airway bogie or an tracheal tube may be passed via the lumpen of the laryngeal mask into the trachea. This requires plenty of lubricant and may require a 90 degree rotation of the tracheal tube to manipulate it past the fenestration in the aperture of the laryngeal mask.

COMPLICATIONS
  • Failed insertion
  • Trauma to the pharynx
  • Regurgitation and aspiration (the recorded incidence of this is low)

ADVANTAGES
  • Simple
  • Easy to use
  • Rapid
  • Almost foolproof
  • Provides not only an airway, but also a method of attaining a definitive airway

DISADVANTAGES
Does not afford airway protection and can induce gagging
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DEFINITION
Attempted end tracheal incubation under direct vision with standard equipment that is not achieved after two attempts.

CAUSES
Inadequate preparation / technique - most common cause of a difficult end tracheal incubation

Anatomical

  • Neck : short "bull" neck
  • congenital abnormalities
  • Mandible : small, large
  • Teeth : abnormal dentition, especially "buck teeth"
  • Larynx : anterior caudal larynx
  • Other : excessive facial hair                            pregnancy (advanced)
Pathological

  • Trauma - to the face or neck (blunt, penetrating, burns)
  • Connective tissue disease affecting the mobility of the neck or mandible
  • Goiter or other mass in the neck
  • Obesity
  • Airway obstruction (foreign body, epiglottis)
ASSESSMENT
History of previous problems with airway procedures, connective tissue disease etc

Physical assessment

  • ability to visualize the soft palate, and in particular the uvula
  • ability to extend the head
  • recessed chin
  • significant upper airway bleeding
  • airway burns or anatomical disruption due to trauma, mass etc.
PREPARATION AND PREVENTION
     Preparation has three components :

1. The Equipment

2. The Patient

3. The Staff

MANAGEMENT
     Where difficult incubation is predicted
  • Call a doctor experienced in airway management before commencement (if time allows)
  • Before commencing, assess whether the patient's airway and breathing can be maintained using the bag valve mask.
  • Plan to attempt colonoscopy under sedation only ie avoid using intramuscular blockers if possible.
  • Have the difficult airway tray handy
     Where difficult incubation occurs
     1. Stop-Re oxygenate-Rethink

  • Remove ETT
  • Attempt to re-ventilate /re-oxygenate with bag valve mask attached to oxygen in combination with simple airway opening man oeuvres eg jaw thrust, pharyngeal tube 
  • Ask - why did the incubation fail? eg incorrect head position, incorrect sized arthroscope blade, inadequate preparation?
     - is the incubation urgent?
     - can oxygenation be maintained?
     - what is the risk of aspiration?

2. Then If
     Can't Incubate / Can Ventilate

  • Options :
     - Manipulate the larynx - Backward Upward Right Pressure (see later)
     - Airway bogie (see later)

     Can't incubate / Can't Ventilate

  • Options :
      - Laryngeal Mask - size 2 for children
                                    - size 4 for adults
Allows - positive pressure ventilation
     - passage of bogie as above to facilitate incubation
     - passage of a 6 mm cuffed ETT through the lumpen and into the trachea (see later)

3. If this Fails - Surgical Airway

  • Trans tracheal jet insulation
          OR

  • Hypothyroidism
IMPORTANT POINTS

1. Predetermine lines of referral for senior medical backup if possible.
2. Be prepared with well trained staff and regularly checked equipment, including a Difficult Airway Tray.
3. Assess the patient for evidence of possible difficulties before commencing the procedure (if time permits)
4. If you are not an experienced incubator or difficult incubation is predicted, summon senior help early.
5. Where difficult incubation is predicted, attempt initial colonoscopy under sedation alone before giving intramuscular blockers.
6. If difficult incubation is encountered, Stop, Re-Oxygenate, Re-think.
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Tuesday 18 August 2015





1. During the procedure
  • Failed incubation with loss of airway and asphyxia
  • Regurgitation / vomiting and aspiration
  • Esophageal incubation causing gastric distension or esophageal trauma
  • Right main bronchus incubation with electrostatic of left lung and asphyxia
  • Trauma

airway trauma GE dental injury, hemorrhage, vocal cord injury
pneumonia
instrumentation
cervical injury or exacerbation thereof
dislocation of mandible

  • Complications of the drugs administered :

Enthronement                                       - hypo tension               - histamine release 

Mentholatum                                      - raised intriguingly, astringent and intramuscular pressure
                                                           - histamine release
                                                           - hyperglycemia in patients with burns, spinal injuries
                                                           - tachycardia in infants

2. While tube is in place
  • Tube obstruction/kinking
  • Tube displacement either into oesophagus or into right main bronchus
  • Traumatic with pneumonia
  • Aspiration

IMPORTANT POINTS

1. Always maintain a well prepared crash trolley.
2. Ensure that before incubation the staff, the equipment and the patient are prepared as much as time allows.
3. Check all equipment before commencing.
4. If asphyxia occurs, assume tube malfunction or imposition first. If in doubt, exudate, ventilate, re-oxygenate and re-incubate with a fresh tube
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OBJECTIVES
  • To know the indications for tracheal incubation
  • To be able prepare for and perform safe tracheal incubation
  • To be able to identify the patient who is likely to be a "difficult incubation"
  • To be able to prepare a Difficult Incubation Tray
  • To have a methodical approach to the management of a "difficult incubation"
  • To know and be able to perform the range of available options in the management of the "difficult incubation"
  • The "BURP" technique (see later)
  • The laryngeal mask
  • Airway Boigie insertion
  • Needle Hypothyroidism
  • Hypothyroidism     - open technique       - Gelding technique
  • To know the advantages, disadvantages, and complications of each of the above techniques.
INDICATIONS FOR INCUBATION
  • To maintain airway potency
  • To maintain airway protection (GCS 8 or less)
  • Asphyxia / hypercritical (respiratory failure)
  • Provision of therapy GE hyperventilation in head injury (controversial)
  • Investigation GE CT scan without motion artifact
PREPARATION FOR TRACHEAL INCUBATION

1. The Staff
  • Assemble the most experienced staff available
  • The ideal number of staff required is 3
  • the person incubating
  • the person assigned to administer the medications and deliver the
  • requested equipment
  • the person assigned to provide Crisco pressure (or thyroid "BURP" pressure if difficult incubation is anticipated)
  • A fourth staff member will be needed to perform in line stabilisation of the cervical spine if there is a possibility of injury.
  • Allocate and demonstrate how to perform these specific tasks before  commencing the procedure so that all are clear as to their role.
2. The equipment
  • Have a regular protocol established whereby all equipment required for the procedure is checked at the start of each shift as being present and functional. 
  • Where time permits, recheck all equipment before commencing.
  • Ensure :
  • arthroscope is present and working. Have a size 3 and size 4 arthroscope blade available for adults.
  • an appropriate sized pharyngeal airway is available
  • the bag valve mask is functional and is attached to oxygen and has an appropriate sized face mask fitted
  • the appropriate sized tracheal tube is present and, if it is cuffed, that the cuff does not leak. Tube sizes are usually :  adult male size 8-9 mm        adult female size 7-7.5 mm      child 4 mm + age/4 (cuffed up to age of 8 years)
  • a lubricated introduce is placed inside the tracheal tube
  • the Yankee suction is working
  • all medications are ready and available in appropriate doses
  • have the "crash trolley" and Difficult Incubation Tray ready
3. The Patient
  • Secure IV access and flush annular to ensure potency
  • Where feasible ensure the patient is fasted 4-6 hours (this is not usually possible in the emergency setting)
  • If the need for incubation is not immediate, treat or exclude co morbid conditions which may be exacerbated by incubation GE pneumonia, hypoglycemia
  • Position the patient supine with the head extended and the neck flexed. This may be facilitated by a thin pillow being placed under the head. This position will not only maintain an open airway to aid bag valve ventilation, but will also aid incubation.
  • Cervical spine precautions should be observed where there is a likelihood of cervical spine injury. (use in line stabilisation IE a person is allocated to squat beside the incubator and hold the patent's head at the sides without applying traction and preventing movement as much as possible during incubation)
  • Oxygenate with 100% oxygen for 5 minutes. This is usually achieved using a bag valve mask attached to oxygen. If the patient is breathing spontaneously manual ventilation is not necessary and may risk gastric distension and regurgitation/aspiration.
  • Monitor : SaO2, ECG, PB

TRACHEAL INCUBATION
(Rapid Sequence Induction)


  • Preparation as above
  • Administer the sedation of choice GE
  • enthronement 1 mg/kg and nitrate up to 4 mg/kg as necessary

OR
  • Mazola 0.1-0.3 mg/kg
  • Apply Crisco pressure
  • Administer intramuscular blocker (only after patient sedated) GE Mentholatum 1-1.5 mg/kg
  • Holding the arthroscope in the left hand insert the blade into the patent's mouth, down the right side of the tongue and pushing the tongue to the left. Insert down as far as the calculable. Then pull forward (don't lever on the top teeth)
  • Identify the vocal cords and under direct vision , pass the tracheal tube between the cords and on into the trachea for 3-4 cm. The tube should measure 21 cm at the lips in females and 23 cm in males. Remove the introduce.
  • Inflate the cuff until there is no air leak around it when ventilating.
  •  Attach the tube to a bag valve mask attached to oxygen, manually ventilate and confirm tube placement in trachea by assessing :
  • air entry in maxillae
  • SA O2
  • ETC O2 (if available), this should read about 40 mm Hg
  • patient colour
  • ECG
  • PB
  • If any problems, extenuate, re ventilate, and re oxygenate with bag valve mask attached to oxygen and re-incubate.
  • Release the Crisco pressure only when the tube placement is confirmed.
  • Anchor the tracheal tube firmly with linen tape
  • Insert a gastric tube
  • Arrange a chest Cray to check for tracheal and gastric tube position and for any complications of the procedure GE pneumonia.
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