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④ Equipment ⑧ Indication
Emergency airway Mx
- .

1.
Stylets -

Cardiac arrest
Acute airway insulting
laryngoscope
-

2.
et.

3. EndotrachealTube

4. Suction source $ Yankauer Suction catheter

E.
Syringe to me
⑧ ContraIndication
6. Co2 detector Total
upper airway obstruction
-

-
Me oft Trauma Burns ,

f- Ambu bag Mask oropharyngeal landmark

and -
loss of

8. Pulse Oximeter

9. Ventilator ⑧ Complication : -

Aspiration of Gastric
contentlaryngeal edma
, .
Postintubation
10 .

Oxygen Source Pneumonia

A Nasal Cannula

12 . lubricant $ Tape /attachment to fix the ET

 t

⑧ Opent Pt.

Mouth c- Right hand

laryngoscope in left hand
Inflate cuff approx
-
10 1020mL .
T.t #-En-KoN@E-qu-ip-ment-
1. Bvm device c- cushioned Rim
⑦ Indication
-

Insufficient Ventilation
2.
Tongue Blade -

Airway obstruction
3. Pulse oxymeter

_Undergonechemi
4-
Oxygen Source ⑧ Contraindication
"
Nasopharyngeal /Oropharyngeal airway Upper airway obstruction
-

6. Water based lubricant

Paralyzed
-

f. Gloves
paralysis
④ Aument for Ventilation/Intubation -
"

Mallampati Airway classification

"

class I Soft palate

-

.
Fauces Uvula and pillars
. are Visible

class II -

Soft palate fauces

, § a portion of the Uvula are

visible

class -
Soft palate $ base of the Uvula Visible

Class II -

Only hard palate is Visible

⑧ Thyromental distance (distance btw the tip of the jaw and the thyroid cartilage )
Approx -

7cm

④ TWO Technique -

1) Single hand
2) Two hand
?⃝
Procedure : -

/
,
 T
H0RAC0É
INDIAMEN :- For Dx and Therapeutic purpose

C /1 : -
Memo thorax .
Bleeding disorder
Equipment :-
dare : -
1. Monitor the patient's vital signs.
2. Ensure the drainage system is properly connected to
the suction source.
3. Position the patient in either a supine or a semirecum-
bent position. Abduct the patient's ipsilateral arm and
flex the elbow to position the hand comfortably over
the patient's head.
4. Use ultrasonography to examine the fourth and fifth
intercostal spaces at the midaxillary or anterior axillary
line for selecting a safe insertion site.
5. Locate the fourth and fifth intercostal spaces in the an-
terior axillary line at the horizontal level of the nipple.
This area is one boundary of the "triangle of safety" and
is the site of incision; the incision site is one intercostal
space below the actual chest tube insertion site. Use a
surgical marker to mark the spot for incision.
6. Prepare the skin around the area of insertion with anti-
septic solution.
7. Drape the patient appropriately, exposing only the
marked area.
8. Administer a local anesthetic (lidocaine 1% to 2%) to
anesthetize a 2- to 3-cm area of skin and subcutaneous
tissue at the site of incision.
9. Continue to anesthetize deeper subcutaneous tissues
and intercostal muscles. Identify the rib inferior to the
intercostal space where the tube will be inserted and an-
esthetize the periosteal surface. When anesthetizing the
rib, identify the superior aspect of the rib and use this to
help guide the needle at an angle on top of the rib.
10. Stop advancing the syringe needle when a flash of pleu-
ral fluid enters the syringe. 'This will confirm entry into
the pleural space; in the case of pneumothorax, air will
fill the syringe. Inject any remaining anesthetic to fully
anesthetize the parietal pleura and completely with-
draw the syringe.
11. Use a scalpel to make a 1- to 2-cm skin incision parallel
to the rib.
12. Use a Kelly clamp to dissect a tract through the subcu-
taneous tissue and intercostal muscles by intermittently
advancing the closed instrument and opening it.
13. Close the Kelly clamp and carefully pass through the
intercostal muscles and parietal pleura, gently entering
the pleural space.
14. Open the Kelly clamp while inside the pleural space and
then withdraw it so that its jaws enlarge the dissected
tract through all the layers of the chest wall.
15. Insert a finger into the pleural space and rotate it 360
degrees to feel for adhesions.
16. Use a Kelly clamp to grasp the fenestrated portion of
the tube and introduce it through the incision and in-
sertion sites. To advance the chest tube into the tho-
racic cavity, release the Kelly clamp. For the evacuation
of air, aim the tube apically; for evacuation of fluid, aim
the tube basally.
17. Use mattress or interrupted sutures on both sides of the
incision to close the ends. Secure the chest tube to the
chest wall using the suture's loose ends to wrap around
the tube and tie them off.
18. Wrap petroleum-based gauze around the tube and
cov-
er it with several pieces of regular gauze. Secure the site
with multiple layers of dressings, using adhesive tape to
secure them to the chest.
19. Connect the chest tube to the drainage device.
20. Obtain an anteroposterior chest radiograph to
confirm
proper chest tube placement. A radiopaque line should
be seen along the tube. If the drainage hole is outside
the pleural space, drainage may be ineffective and leak-
age of air may result. If this occurs, remove the tube and
insert a new chest tube.
oftroracentesis :-

Pleural effusion is the excess accumulation of

fluid between the lung and chest wall. The
severity of the effu- sion depends on the
underlying cause and degree of respi- ratory
symptoms. Thoracocentesis is a procedure in
which a needle is inserted to remove the excess
fluid accumulated in the pleural space.
Pleural effusions occur as a result of many
disease pro- cesses, including cancer,
pneumonia, congestive heart failure, pulmonary
embolism, and liver cirrhosis. Depending on the
-

cause, the accumulated fluid can be classified as

an exudate (protein rich) or transudate (watery).
Furthermore, effusions can be distinguished by
the specific type of fluid found in the pleural
space: hemothorax (blood), empyema (pus),
chylo- thorax (lymph), hydrothorax (serous fluid),
and urinothorax (urine). Analysis of the fluid
allows the diagnosis of the cause of the pleural
effusion.
 Clinical Anatomy : -

⑧ Boundaries
The thoracic cage is bounded superiorly by the thoracic inlet
and inferiorly by the thoracic outlet, and is surrounded by the
rib cage. The thoracic inlet is defined by the body of the first
thoracic vertebra, first pair of ribs and their costal cartilages,
and jugular notch of the sternum. It communicates with the
neck and the upper extremities (Fig. 5.1). The thoracic out-
let is defined by the twelfth thoracic vertebra, eleventh and
twelfth pairs of ribs, costal cartilages of ribs 7 to 10 (costal
margin), and xiphisternal joint. This outlet is closed by the
diaphragm, a musculotendinous partition that serves as a
septum between the thoracic and abdominal cavities and
functions as the major muscle of respiration.
Viscera
Within the framework of the thoracic cage are the lungs and
pleural cavities and interposed mediastinum. Important
structures within the mediastinum include the heart, great
vessels, trachea, and esophagus.
Pleurae and Pleural Cavity
The pleura is a double-layer serous membrane made up of
the visceral pleura that adheres to and covers the lung and
the parietal pleura that covers the internal surface of the
thoracic wall. The visceral pleura is insensitive to pain,
whereas the parietal pleura is sensitive to pain and is
innervated by the intercostal (costal and cervical pleura),
phrenic (mediastinal and central diaphragmatic pleura), and
lower fifth to sixth intercostal nerves (peripheral
diaphragmatic pleura). Between the parietal and visceral
pleurae is a potential space known as the pleural cavity. It
normally contains a thin film of serous fluid but can
accumulate fluid in pathological conditions.
Grinned
Sterile field preparation
Skin cleaning antiseptic solution:
chlorhexidine or povidone-
iodine solution
Sterile gauze
Sterile gloves
Sterile fenestrated drape (24 × 30 inches)
with adhesive
strip Anesthesia
Lidocaine (1% to 2%), 10-mL ampule
Syringe, 10 mL
22-gauge needle, 1.5 inches 25-gauge
needle, 1 inch
Hemostat (optional) Fluid collection
Prepackaged thoracocentesis kit; if a kit is
unavailable, the following components
should be collected:
• Over-the-needle catheter, 18 or 20 gauge
• Syringe, 60 mL
• Three-way stopcock
• Drainage tubing
• Large evacuated container
Scalpel, No. 11 blade Specimen tubes
Sterile occlusive dressing Adhesive
dressing
Ultrasound (if available)
Prcaedure : -
Tracheotomy
Skin marker
No. 15 scalpel
blade Cricoid hook

"
Kitner sponge
'

Tracheostomy tube
Bag-valve-mask
device Oxygen
source

Cricotnyroidolomy
Bag-valve-mask device
Oxygen source
No. 15 scalpel blade
Hemostats
Tracheal hook
Scissors
Trousseau dilator
Tracheostomy tube
 Contraindications
Tracheotomy -
^
.
-
children
younger than
12yr .

Active infection over the bite

Thyroid mass or
goiter

Cricolhyroidotomy :- ① Needle
coicothyroidotomy
②
Surgical Cricothyroidotomy
-
-

① Needle Coicotnyroidotomy :-

① Position Supine
Neck
hyperextended
locate crico
thyroid membrane located 2cm to 3cm below
laryngeal
prominence .

②
Inject lidocaine
CH )
③ Standing at the head of the
patient and the non dominant
.
Using -

hand insert a 12 14 needle attached to a 5or to me

or
gauge
- .

syringe containing 2to 3 me of Normal beeline to a

30 to 46 degree
angle caudally towards the buprasternal notch
⑨ Pay close attention
for bubbles seen in syringe to indicate entry
into the trachea .

⑧ Holdthe needle in place and advance the catheter to the

hub .

⑥ withdraw the needle when the catheter is in place

⑦ Confirm proper placement by withdrawing
approximately of the 10 me air into catheter and
Expel it into the airway of resistance .
is
felt
the catheter is located subcutaneously , the air
will expand the skin .

Adjust the catheter accordingly .

⑧ Remove
connect it to
the syringe
a
q secure
jet Ventilation
the catheter
apparatus which
,

consist
ofa
flow regulator connected to on Oz source.

② Surgical Cñcothyroidolomy
1. Position the patient and identify the cricothyroid mem-
brane as described for the needle cricothyroidotomy.
2. Inject lidocaine (usually 1%) into the skin and
subcutane- ous tissue where the incision will be placed.
3. Prepare the neck and upper chest with povidone-iodine
solution and drape the surgical site.
4. Standing at the head of the patient, stabilize the larynx with
the nondominant hand.
5. Use the No. 15 scalpel to make a single 3- to 5-cm vertical
incision through the skin and subcutaneous tissue in the
midline over the thyroid cartilage, extending to below the
inferior border of the cricoid cartilage.
6. Expose the cricothyroid membrane. Use the scalpel to make
a horizontal incision perforating the membrane in its inferior
half, nearer to the cricoid cartilage. This re- duces the chance
of damage to the vocal cords and crico- thyroid vessels.
7. Use a Trousseau dilator to penetrate and widen the mem-
brane entry site. A Kelly clamp, curved hemostat, right angle
instrument, or the handle of the scalpel may be used as an
alternative to the dilator.
 8. Insert a tracheostomy or endotracheal tube and connect to a
bag-valve-mask device for ventilation. If an endotra- cheal tube
is used, the end should be placed no more than 2 to 3 cm into
the trachea to avoid placement into the right main stem
bronchus.
9. Confirm that bilateral breath sounds are present.
10. Secure the tube in place with a tracheal tie, suture, or ad-
hesive tape.
If the airway is needed for more than 48 hours, the surgical
cricothyroidotomy should be converted to a tracheostomy. If a
needle cricothyroidotomy was performed, the patient should
have a formal tracheostomy as soon as possible be- cause
ventilation through the catheter is suboptimal and there is a risk
of catheter dislodgment.

④ Open Tracheotomy

1. Place the patient supine with a bolster underneath the

shoulders to extend the neck and expose the laryngotracheal
landmarks. (This maneuver is con- traindicated in patients with
cervical spine injuries or atlantoaxial instability because of the
risk of spinal cord compression.)
2. Palpate the major landmarks of the neck, including the
thyroid cartilage, cricoid cartilage, and suprasternal notch. Use
a skin marker or pen to indicate the position of each landmark.
3. Inject lidocaine (usually 1%) into the skin and subcuta-
neous tissue where the incision will be placed.
4. Prepare the neck and upper chest with povidone-iodine
solution and drape the surgical site.
5. Make a 2- to 3-cm incision in the vertical or horizontal plane.
A horizontal incision yields a more cosmetically pleasing
postoperative scar, as it will follow the relaxed skin tension
lines. In the case of emergency tracheoto- my, a vertical
incision should be used to avoid bleeding from the anterior
jugular venous system.
6. Incisions
a. A vertical incision starts just below the cricoid
cartilage.
b. A horizontal incision is placed approximately two fin-
ger breadths below the cricoid cartilage or halfway be- tween
the cricoid cartilage and the suprasternal notch, corresponding
to the second or third tracheal ring.
7. Divide the subcutaneous tissue using either a No. 15 blade
or electrical cautery to the level of the strap mus- cles. Avoid
damage to the anterior jugular vein. When identified, it should
be ligated or lateralized to avoid bleeding.
8. Identify the strap muscles and dissect them laterally through
the midline raphe, separating right and left sides, until the
thyroid isthmus is exposed.
9. Retract the thyroid isthmus either superiorly or inferiorly or
divide and ligate it to expose the second and third tra- cheal
rings, allowing for creation of a tracheal window.
10. With a cricoid hook, place traction on the cricoid car- tilage
to move it superiorly and superficially to allow easier access into
the trachea.
11. With a Kitner sponge, dissect the pretracheal fascia off the
proximal trachea.
12. Enter the trachea by making a window by using one of the
following techniques:
a. Single horizontal intercartilaginous incision
b. H-type incision
c. Removing 1-cm-wide portion of the anterior aspect of the
second or third tracheal ring with a scalpel, Metzenbaum
scissors, or a tracheal punch
13. After entering the trachea, use a tracheotomy dilator to open
the tracheal lumen further, taking care to prevent excessive
trauma to the cartilaginous framework. Stay sutures can be
placed superiorly and inferiorly to the stoma.
14. Upon visualization of the endotracheal tube within the
tracheal lumen, ask the anesthesiologist to withdraw the tube
until the posterior tracheal wall is visualized.
15. Place the tracheostomy tube (#8 for men or #6 for women)
into the tracheal lumen under direct visualization.
16. Confirm proper placement by connecting the tube to
the ventilator, inflating the cuff, and observing end- tidal CO2.
Once placement is established and chest auscultation reveals
bilateral breath sounds, remove the cricoid hook.
17. Close the fascia and skin and suture the tracheostomy tube
collar in place using nonabsorbable sutures placed through the
flanges of the tube. Place the tracheostomy ties around the
patient’s neck.
18. Perform a posttracheostomy chest radiograph to as- sess
tube positioning and to look for pneumothorax or
pneumomediastinum.
③ Central Venus Catheterization
⑧ Indications :-
tlypovolemie /critically ill