endotracheal intubation by junaedi student post graduate of nursing brawijaya university- indonesian

of 31 /31
Endotracheal Intubation BY JUNAEDI STUDENT POST GRADUATE OF NURSING BRAWIJAYA UNIVERSITY- INDONESIAN

Upload: marilyn-shaw

Post on 31-Dec-2015

229 views

Category:

Documents


0 download

TRANSCRIPT

Page 1: Endotracheal Intubation BY JUNAEDI STUDENT POST GRADUATE OF NURSING BRAWIJAYA UNIVERSITY- INDONESIAN

Endotracheal IntubationBY

JUNAEDI

STUDENT POST GRADUATE OF NURSING

BRAWIJAYA UNIVERSITY- INDONESIAN

Page 2: Endotracheal Intubation BY JUNAEDI STUDENT POST GRADUATE OF NURSING BRAWIJAYA UNIVERSITY- INDONESIAN

Definition:Introducing a tube through the mouth (or nose) into the trachea to secure open airways.

Advantages:Cuffed E.T tubes protect the airway from aspiration.E.T tube provides access to the tracheobronchial tree for

suctioning of secretions.E.T tube does not cause gastric distention and associated

danger of regurgitation.E.T tube maintains a patent airway and assists in avoiding

further obstruction.E.T tube enables delivery of aerosolized medication.the mouth (or nose) into the trachea to secure open airways.

Page 3: Endotracheal Intubation BY JUNAEDI STUDENT POST GRADUATE OF NURSING BRAWIJAYA UNIVERSITY- INDONESIAN

Indication Endotracheal Intubation:Respiratory Failure: Hypoxia, Hypercapnia,

tachypnea, or apnea ; ie. ARDS, asthma, pulmonary edema, infection, COPD exacerbation

Inability to ventilate unconscious patientMaintenance or protection of an intact airwayCardiac ArrestMedication administration

Page 4: Endotracheal Intubation BY JUNAEDI STUDENT POST GRADUATE OF NURSING BRAWIJAYA UNIVERSITY- INDONESIAN

Contraindication :

Inability of patient to extend headModerate to severe trauma to the cervical spine or

anterior neckInfection in the epiglottal areaMandibular fracture or trismusMild hypoxiaUncontrolled oropharyngeal hemorrhageIntact tracheostomyBasilar skull fracture (during nasal intubation)

Page 5: Endotracheal Intubation BY JUNAEDI STUDENT POST GRADUATE OF NURSING BRAWIJAYA UNIVERSITY- INDONESIAN

Complications: Hypoxia (Long duration of procedure, Intubation of a bronchus ( right

more common,Failure to recognize misplacement of tube, Aspiration) Pneumothorax (resulting from over ventilating with a BVM without a

pressure release valve) Trauma (to the teeth, vocal cords, soft tissues of the larynx and

related structures) Hypertension and tachycardia (can occur from the intense

stimulation of intubation. This is potentially life-threatening in the cardiac patien)

Gastric distention and regurgitasi (Failure to secure the placement into esophagus).

Cardiac arrhythmias (related to vagal stimulation or sympathetic nerve stimulation may occur)

Page 6: Endotracheal Intubation BY JUNAEDI STUDENT POST GRADUATE OF NURSING BRAWIJAYA UNIVERSITY- INDONESIAN

Difficult to intubation:

1. Difficult to bag (MOANS) :

Mask Seal : Small Hands, Wrong Mask Size, Oddly Shaped Face, Bushy Beard, Blood/Vomit, and Facial Trauma

Obesity or Obstruction: Heavy chest, Abdominal contents inhibit movement of the diaphragm, Increased supra glottic airway resistance, Billowing cheeks, Difficult mask seal, Quicker desaturation

Age > 55: Associated with BVM difficulty, possibly due to loss of tone in the upper airway

No Teeth: Face tends to “cave in”, Consider leaving dentures in for BVM and remove for intubation.

Stiff : Refers to Poor Compliance, Reactive Airway Disease, COPD, Pulmonary Edema/Advance Pneumonia, History of Snoring/Sleep Apnea, Also predicts a higher Mallampati score

Page 7: Endotracheal Intubation BY JUNAEDI STUDENT POST GRADUATE OF NURSING BRAWIJAYA UNIVERSITY- INDONESIAN

Difficult to Laringoscopy and intubation:

1. LEMONS:

Look Externally : Beards or facial hair, Short, fat neck, Morbidly obese patients, Facial or neck trauma, Broken teeth (can lacerate balloons), Dentures (should be removed), Large teeth, Protruding tongue, A narrow or abnormally shaped face.

Evaluate 3-3-2 : Bottom of Jaw/Chin to Neck > 3 fingers, Jaw/Palate > 3 fingers wide, Mouth opens > 2 fingers wide.

Page 8: Endotracheal Intubation BY JUNAEDI STUDENT POST GRADUATE OF NURSING BRAWIJAYA UNIVERSITY- INDONESIAN

Mallampati Score :

Obstruction : Anatomy, Trauma, Foreign body obstruction, Edema (burns).

Best view grade 1

Grade 1

Page 9: Endotracheal Intubation BY JUNAEDI STUDENT POST GRADUATE OF NURSING BRAWIJAYA UNIVERSITY- INDONESIAN

Neck Mobility : Ideally the neck should be able to extend back approximately 35°

Problems: Cervical Spine Immobilization, Ankylosing Spondylitis, Rheumatoid Arthritis, Halo fixation

Scene and Situation : Scene safety and Environment

Do you have a reasonable chance to get the tube?Space, positioning, access

Egress

Will you be able to ventilate during egress?A respiratory rate of 4 is better than a rate of 0!Enough meds for a long extrication?

Page 10: Endotracheal Intubation BY JUNAEDI STUDENT POST GRADUATE OF NURSING BRAWIJAYA UNIVERSITY- INDONESIAN

Oral Intubation With local anesthesia: It is also practical to apply surface anesthesia: vagal excitation is

less, the patient may tolerate the tube better, arrhytmias and laryngospasm after extubation are rare. Apply 10% Lidocain spray (2 or 3 spurts - 1 spurt=4.8 mg)

If the distal end of tube is also sprayed with Lidocain before intubation, the patient will also tolerate the tube after recovering consciousness.

Except : Reserved for the completely unconscious, unresponsive, and apneic, and Arrest situations only (without drug).

Page 11: Endotracheal Intubation BY JUNAEDI STUDENT POST GRADUATE OF NURSING BRAWIJAYA UNIVERSITY- INDONESIAN

Equipment

Page 12: Endotracheal Intubation BY JUNAEDI STUDENT POST GRADUATE OF NURSING BRAWIJAYA UNIVERSITY- INDONESIAN

Equipment Endotracheal Intubation:Laryngoscope

Blades: curved (MacIntosh) and straight (Miller)

Endotracheal tubes of various sizes: Neonates and full term infants: no. 0 and 1, Adult women: 7.0 mm i.d., Adult men: 7.0 to 8.5 mm i.d. Pediatric size: (age in years/4) + 4 or width of

fingernail of the fifth digit

Page 13: Endotracheal Intubation BY JUNAEDI STUDENT POST GRADUATE OF NURSING BRAWIJAYA UNIVERSITY- INDONESIAN

Lubricant, Malleable stylet10-ml syringe (to inflate ET cuff)Oxygen and manual bag valve maskSuction apparatusStethoscopeSterile gloves and gogglesOropharyngeal airwayCO2 Detector

Page 14: Endotracheal Intubation BY JUNAEDI STUDENT POST GRADUATE OF NURSING BRAWIJAYA UNIVERSITY- INDONESIAN
Page 15: Endotracheal Intubation BY JUNAEDI STUDENT POST GRADUATE OF NURSING BRAWIJAYA UNIVERSITY- INDONESIAN

Handle and Blade (Laryngoscope)

Blade tipe Macintosh (curve blade)

Blade tipe Miller (straight blade)

Page 16: Endotracheal Intubation BY JUNAEDI STUDENT POST GRADUATE OF NURSING BRAWIJAYA UNIVERSITY- INDONESIAN

Engaging laryngoscope blade and handle

Page 17: Endotracheal Intubation BY JUNAEDI STUDENT POST GRADUATE OF NURSING BRAWIJAYA UNIVERSITY- INDONESIAN

ETT, Stylet, and Syringe

Page 18: Endotracheal Intubation BY JUNAEDI STUDENT POST GRADUATE OF NURSING BRAWIJAYA UNIVERSITY- INDONESIAN

High volume Low pressure cuff

Low volume High pressure cuff

Page 19: Endotracheal Intubation BY JUNAEDI STUDENT POST GRADUATE OF NURSING BRAWIJAYA UNIVERSITY- INDONESIAN

Magil Forceps, sterile gloves and goggle

Page 20: Endotracheal Intubation BY JUNAEDI STUDENT POST GRADUATE OF NURSING BRAWIJAYA UNIVERSITY- INDONESIAN

Procedure

Page 21: Endotracheal Intubation BY JUNAEDI STUDENT POST GRADUATE OF NURSING BRAWIJAYA UNIVERSITY- INDONESIAN

Position patien’s head

- Position yourself at the patient’s head- Inspect the oral cavity for secretions or foreign

material.- Suction if necessary

Page 22: Endotracheal Intubation BY JUNAEDI STUDENT POST GRADUATE OF NURSING BRAWIJAYA UNIVERSITY- INDONESIAN

Hiper ventilate with 100 % oxygen for approximately 1 min (prior 2 minutes)

Page 23: Endotracheal Intubation BY JUNAEDI STUDENT POST GRADUATE OF NURSING BRAWIJAYA UNIVERSITY- INDONESIAN
Page 24: Endotracheal Intubation BY JUNAEDI STUDENT POST GRADUATE OF NURSING BRAWIJAYA UNIVERSITY- INDONESIAN

Intubation Technique22 cm

Page 25: Endotracheal Intubation BY JUNAEDI STUDENT POST GRADUATE OF NURSING BRAWIJAYA UNIVERSITY- INDONESIAN

Sellick Manuver Helps prevent regurgitation and

reduces gastric distention. Locate the cricoid cartilage by

palpating the thyroid cartilage and the feel the depression just below it (cricothyroid membrane).

Using your thumb and index finger of one hand, apply pressure to the anterior and lateral aspects of the cricoid cartilage just next to the midline.

Page 26: Endotracheal Intubation BY JUNAEDI STUDENT POST GRADUATE OF NURSING BRAWIJAYA UNIVERSITY- INDONESIAN

Laringoscopic View

Page 27: Endotracheal Intubation BY JUNAEDI STUDENT POST GRADUATE OF NURSING BRAWIJAYA UNIVERSITY- INDONESIAN

CO2 exhaled from the lungs: color change to MELLO YELLOW

Page 28: Endotracheal Intubation BY JUNAEDI STUDENT POST GRADUATE OF NURSING BRAWIJAYA UNIVERSITY- INDONESIAN

NEVER let go of the tube until secured (Tape, Commercial tube holder), ETT easily displaced so requires ongoing assessment

Oro Pharyngeal Airways (OPA)

Page 30: Endotracheal Intubation BY JUNAEDI STUDENT POST GRADUATE OF NURSING BRAWIJAYA UNIVERSITY- INDONESIAN

Documentation ET Tube Placement

On patient care report:

ET (size)___depth___cm

Post ET lung sounds

ET Attempt (x___)

Capnography Checked

Suction

Boxes used to indicate crew member activity

30

Page 31: Endotracheal Intubation BY JUNAEDI STUDENT POST GRADUATE OF NURSING BRAWIJAYA UNIVERSITY- INDONESIAN

Thank you