LaSt wEEk-Endotracheal Intubation and Intravenous cannulation

·   Endotracheal intubation

·       Indicated in cardiac arrest, serious head injury, certain acute respiratory and trauma settings, and prior to many surgical operations

• Effective bag and mask ventilation is better than multiple attempts at endotracheal intubation in the arrest setting.
• Except in a dire emergency endotracheal intubation should not be performed without expert supervision.

Equipment:

• 10mL syringe.

• Endotracheal tube (ET; size 8-9 for females and 9-11 for         males).

• Laryngoscope.

• Ribbon to secure tube; lubricating jelly

Steps:

• Pre-oxygenate the patient.

• Ensure that the laryngoscope and ET cuff are        functioning.

• Remove any dentures, and suction excess saliva and secretions.

• Extend the neck.

• Insert the laryngoscope pushing the tongue to the left.

• Advance the scope anterior to the epiglottis and pull gently but firmly upwards to expose the        vocal cords. Take care not to lever on the upper teeth with the  scope.

• Insert the lubricated ET tube between the cords into the trachea.

• Confirm correct positioning of the tube by observing chest movements, and listening over lung    bases and stomach.

• Progressively inflate the cuff and attach ventilation equipment.

• Confirm correct cuff inflation by listening for whistling or bubbling in the larynx suggesting air  leak and secure the tube in place with ribbon.

• * Patients not in cardiac arrest or who maintain a gag reflex will need anesthetizing prior to  oropharyngeal intubation, i.e. administration of inducing agent plus muscle relaxant.

• * The best setting to learn intubation is preoperatively in the anesthetic room of a theater with  good supervision in controlled conditions.

                                                

and .....

Intravenous cannulation

A similar skill to that of simple venepuncture but needs plenty of practice to become competent. If having difficulty, observe a few experts in action.

Indications

Venous access for administration of IV fluids, blood, or IV drugs.

Equipment

• Tourniquet.

• Cannula: 20G or 18G.

• Adhesive dressing/tape.

• Alcohol swabs.

• 5mL syringe containing 0.9% saline or heparinized      saline.

• IV fluid bag with giving set, if necessary.

Preparation

Apply tourniquet above or below the elbow and inspect the arm for suitable engorged veins.

Method

• Clean the skin thoroughly at the site of access.

• Identify a suitable vein.

• Tether the skin distal to the proposed site of puncture.

• Pass the cannula obliquely through the skin at a point approximately 1cm distal to the point at which you wish to enter the vein.

• Advance the cannula smoothly until the vein is entered: a flashback  seen in the hub of the cannula.

• Hold the hub of the needle with one hand and advance the cannula into the vein, while maintaining skin fixation until the cannula is well into the vein.

• Remove the tourniquet and press on the vein proximal to the cannula as the needle is removed. Apply the screw cap to the end of the cannula.

• Secure the cannula in place with a dressing.

• If the cannula is not going to be used immediately, flush with heparinized saline

Tips 

• Poor veins. If the patient is cold and the samples non-urgent, place the arm in warm water and this may aid venous dilatation. Veins on the dorsum of the hand may be the only ones readily available-try using a smaller or butterfly needle to obtain samples.
• Obese patients. Try the dorsum of the hand or the radial aspect of the wrist; access may be easier here.
• Failed attempts. Repeated failed attempts will distress the patient and demoralize the doctor! Ask someone to help. If the samples are extremely urgent, a femoral stab may be the best option for obtaining blood samples, e.g. during cardiac arrest.
• IV cannulae. If blood samples and IV access are needed, a sample can be taken immediately after inserting the cannula. However, do not use a peripheral cannula for routine samples; they can be haemolysed, contaminated by IV fluids, and unreliable.

• Agitated or fitting patients. Try not to place the cannula over a joint, as these tend to become easily dislodged
• Secure the cannula. Cannulas are all too easily dislodged because of poor fixation to the skin. Use of two cannula dressings (one placed above and one below) and a bandage is often needed.
• Hairy arm. Shaving the skin at the planned cannula site seems tedious but will allow the cannula to be secured adequately.
• Non-dominant hand. Placing the cannula in the non-dominant hand, if possible, will allow the patient a little bit more freedom and may prevent the cannula becoming dislodged easily.
• Fragile veins. This tends to be a problem in elderly or debilitated patients. Try using a smaller cannula: the dorsum of the hand is often an ideal site.
• Poor peripheral access. In some patients with multiple collapsed or damaged veins alternative cannula sites may have to be considered, e.g. feet. If peripheral cannulation becomes impossible, a central line will have to be considered.
• Blood transfusion. If blood is being given IV then an 18G or 16G cannula will be needed.

Size and function of different cannulae

Colour Size   Flow mL/min Use Blue 22G 31 Small fragile veins, paediatrics Pink 20G 55 IV drugs and fluid/slow transfusion Green 18G 90 IV fluids, drugs White 17G 135 Grey 16G 170 Rapid IV fluids, in emergencies Brown 14G 265

before I end this post..
Last Week:

Wonder how this happen.(.it is a button)

This made to go back that day..

 missing them..

during free time..

by Lakdhes..