Anesthesiology

BURNS
 Causal Conditions
• Thermal
• Chemical
• Radiation
• Electrical

• Most common aetiology:

– Children: scald burns
– Adults: flame
Pathophysiology
• Amount of tissue
destruction is based on:
– Temperature
– Time of exposure
– Specific heat of the
causative agent
• Zones of Thermal Injury
– Zone of hyperemia
– Zone of stasis (oedema)
– Zone of coagulation
(ischaemia)
 Diagnosis and Prognosis
• Depends on:
– Burn size
• % of total body surface area (TBSA) burned
– Rule of 9s for 2 ° and 3 ° burns only
– For patchy burns, surface area covered by patient’s palm (fingers closed) = ~1%
– Children <10 years use Lund-Browder chart
– Age
– Depth
– Location
– Inhalation injury
– Associated injuries
– Co-morbid factors
Burn Size: Lund-Browder Chart
Burn Size: Rule of 9s
Burn Depth
Layers of the Skin
 Burn Depth
• Superficial (1 °)
– Limited to the epidermal layers
– Equivalent to a superficial sunburn without blister
formation

• Partial Thickness (2 °)
– Also called dermal burns
– Can be:
• Superficial partial thickness
• Deep partial thickness
 2 ° : Superficial Partial
• Involve the superficial
papillary dermal
elements
• Pink and moist
• Painful
• Blister formation
• Expected to heal within
several weeks without
skin grafting
 2 ° : Deep Partial
• Involves the deeper reticular
dermis
• Can have variable appearance
– From pink to white with a dry
surface
• Sensation may be present but
is usually somewhat
diminished
• Capillary refill is sluggish or
absent
• Routinely require excision and
grafting
 3 ° : Full Thickness
• Extend into the
subcutaneous tissue
• Firm, leathery texture
• Complete anaesthesia
upon examination
• Clotted vessels can be
observed through
eschar
 4 ° : Devastating Full Thickness
• Full thickness burns
that extend into muscle
and bone
 Respiratory Problems
• Three major causes
– Burn eschar encircling chest
– Carbon monoxide poisoning
• Signs
– Headache
– Confusion
– Coma
– Arrhythmias
– Smoke inhalation leading to pulmonary injury
Inhalation
Injury
Inhalation
Injury
 Inhalation Injury
• Diagnosis
– Best made in the Emergency Department by direct
visualization of the airway with fibreoptic
laryngoscopy and bronchoscopy
• Note bronchoscopy cannot exclude parenchymal injury
– Findings
• Presence of soot
• Charring and mucosal inflammation
• Oedema
Inhalation Injury
 Inhalation Injury: Management
• Pulse Ox and CO
• ABG
• Carboxyhaemoglobin level
• Lactate
• CBC
• Chest radiography
• ECG
• Pulmonary function testing
• Direct Laryngoscopy and fiberoptic bronchoscopy
 Inhalation Injury: Management
• Treatment of suspected inhalation injury
– Humidified 100% oxygen
– Intubation and ventilation
– Bronchodilators
– Pulmonary toilet
– Hyperbaric oxygen for severe carbon monoxoide poisoning
• Indication for endotracheal intubation and mechanical ventilation
– Inability to handle secretions
– Hypoxaemia despite 100% oxygen
– Patient obtundation
– Muscle fatigue suggested by a high or low respiratory rate
– Hypoventilation (a PCO2 > 50mmHg and a pH less than 7.2)
 Burns Management
• Pre-hospital care:
– Stop the burning process
– Establish the airway
– Initiate fluid resuscitation
– Relieve pain
– Protect the burn wound
• Emergency Department resuscitation and stabilization
– Approach in a systematic manner – ABCDEF
– History
– Look for evidence of airway compromise (or impending)
• Swelling of the neck
• Burns inside the mouth
• Wheezing
– Secure the airway with an ETT until the swelling has subsided which is usually
after about 48 hours
 Acute Care of Burn Patients
• Adhere to ATLS protocol
• Resuscitation using Parkland formula
• Monitor resuscitation, parameters used:
– Pulse
– BP
– Urine output - >0.5cc/kg/h (adults), >1.0cc/kg/h (children)
• Burn specific care
• Tetanus prophylaxis if needed
• Baseline laboratory tests and investigations
• Cleanse, debride, and treat the burn injury (antimicrobial dressings)
• Early excision and grafting important for outcome
 Resuscitation
Burn Shock Resuscitation Parkland Formula
Hour 0-24 4ml x %TBSA x Weight (kg) with ½ of total 0-8h and ½ of total 8-24h
Hour 24-30 0.35 – 0.5ml plasma/kg/%TBSA
> Hour 30 D5W at rate to maintain normal serum sodium
 Indications for Admission
• Total 2° and 3° burn > 10% TBSA in patients <10 or >50 years of age
• Total 2° and 3° burns > 20% TBSA in patients any age
• 3 ° burns/full thickness >5% TBSA in patients in any age
• 2 °, 3 ° or chemical burns posing a serious threat of functional or
cosmetic impairment
– Circumferential burns, burns to face, hands, feet, genitalia, perineum,
major joints
• Inhalation injury (may lead to respiratory distress)
• Electrical burns, including lightning (internal injury underestimated
by TBSA)
• Burns associated with major trauma/serious illness
 Burn Wound Healing
First Degree •No scarring
•Complete healing
Second degree •Spontaneously re-epithelialize in 7-14 days from retained epidermal
(Superficial Partial) structures
•+/- residual skin discoloration
•Hypertrophic scarring uncommon
•Grafting rarely required
Deep Second degree •Re-epithelialize in 14-35 days from retained epidermal structures
(Deep Partial) •Hypertrophic scarring frequent
•Grafting recommended to expedite healing
Third degree •Re-epithelialize from wound edge
(Full thickness) •Grafting necessary to replace dermal integrity, limit hypertrophic
scarring
Fourth degree •Re-epithelialize from wound edge
•Grafting necessary to replace dermal integrity
•Must ensure viable bed to graft onto
 Burns: Treatment
• Three stages:
– Assessment – depth determined
– Management – specific to depth of burn
– Rehabilitation
• Important to obtain early wound closure
• Initial dressing should decrease bacterial proliferation
• Indication for skin graft: deep 2nd or 3rd degree burn that is
> size of a quarter
• Prevention of wound contractures: pressure dressings, joint
splints, early physiotherapy
 Burns: Treatment
First Degree:
– Treatment aimed at comfort
• Topical creams
– Pain control
– Keep skin moist
• +/- aloe
• Oral NSAIDs (pain control)
 Burns: Treatment
Superficial second degree
– Daily dressing changes with topical antimicrobials,
polysporin, may use a temporary biological or
synthetic covering to close the wound
– Leave blisters intact unless circulation impaired
 Burns: Treatment
Deep second degree and third degree
– Prevent infection and sepsis
• Most common organisms: S.aureus, P. aeruginosa & C. albicans
– Day 1-3: gram +ve
– Day 3-5: gram –ve (Proteus, Klebsiella)
• Topical antimicrobials: prevent bacterial infection and secondary sepsis
– Remove dead tissue
• Tangential excision of necrotic tissue, excise to viable (bleeding) tissue
• Escharotomy
• Skin graft
 Topical Antimicrobial Therapy for Burns
Antibiotic Pain with Penetration Adverse Effects
Application
Silver nitrate None Minimal May cause methemoglobinemia,
(0.5% solution) stains (black), leaches sodium
from wounds

Silver sulfadiazine Minimal Medium, does not Slowed healing, leukopenia, mild
(cream) penetrate eschar inhibition of epthelialization

Mafenide acetate Moderate Well, penetrates Mild inhibition of epithelilization,

(solution/cream) eschar may cause metabolic acidosis
with wide application
 Burns: Other Considerations in
Management
• Nutrition
• Immunosuppression and sepsis
• GI bleed may occur with burns >40% TBSA
(usually subclinical) – CURLINGS ULCER
• Renal failure secondary to under resuscitation,
drugs, myoglobin, etc.
• Progressive pulmonary insufficiency
• Wound contracture and hypertrophic scarring
OSCE PICTURES: BURNS
 Burns
Male with deep partial thickness/2nd degree
burns to the face

• Examples of causative agents:

– Hot liquid, steam, grease, flame

• Concern in this patient is inhalation injury

 Burns
Female with superficial partial thickness/2nd
degree burns to the face

• Example of causative agent:

– Hot water scald

• Concern in this patient is inhalation injury

 Burns
Patient with full thickness/3rd degree burns
involving the face, chest, and both arms

• Apply the Rule of 9s to calculate fluid needed

for resuscitation using Parklands formula

• Concern in this patient is inhalation injury

DIFFICULT AIRWAY
 Difficult Airway
• Pre-op assessment
– History of previous difficult airway
– Airway examination
• If difficult airway expected consider:
– Awake intubation
– Intubating with bronchoscope, trachlight (lighted
stylet), fibre optic laryngoscope, glidescope
Airway Examination
 Modified Cormack-Lehane Classification
Grade Description Approximate Likelihood of
frequency difficult intubation
1 Full view of glottis 68% <1%
2a Partial view of glottis 24% 4.3%
2b Only posterior extremity of glottis 6.5% 67.4%
seen or only arytenoid cartilages
3 Only epiglottis seen, none of glottis 1.2% 87.5%
seen
4 Neither glottis nor epiglottis seen Very rare Very likely
Airway Examination
• Thyromental distance:
– The distance of the lower
mandible in the midline
from the mentum to the
thyroid notch
– With adult patient’s neck
fully extended, <3 finger
breadths (<6cm) is
associated with difficult
intubation
 Rapid Sequence Induction
To secure the airway as quick as possible to minimize the risk
of aspiration
• Pre-oxygenate – 4 vital capacity breaths
• Assistant performs Sellick’s maneuver
• Administer induction agent immediately followed by fast
acting muscle relaxant
• Intubate shortly after administration of muscle relaxant with
no bag mask ventilation between induction and intubation
• Must use cuffed ETT
• Inflate cuff
• Verify correct placement of ETT, release cricoid pressure
• Ventilate
 Difficult Airway
• If intubation unsuccessful after induction:
– Call for help
– Ventilate with 100% oxygen via bag and mask
– Consider returning to spontaneous ventilation and/or waking
patient
• If bag and mask inadequate:
– Call for help
– Attempt ventilation with oral airway
– Consider/attempt LMA
– Emergency invasive airway access
• E.g. rigid bronchoscope, cricothyrotomy or tracheostomy
OSCE PICTURE: DIFFICULT AIRWAY
Patient with severe facial oedema

• Secondary to ACEi use

• Approach to patient with a difficult airway

FLUIDS
 Replacement of Fluid Loss
• Takes into consideration:
– Normal losses (Maintenance)
– Pre-existing deficits
– Ongoing losses
 Replacement: Maintenance
• 100 mls/kg/d for the first 10kg
• 50 mls/kg/d for the next 10kg
• 20 mls/kg/d for the rest of the total body weight
OR
• 4 mls/kg/hr for the first 10kg
• 2 mls/kg/hr for the second 10kg
• 1 ml/kg/hr for the rest of the body weight
 Replacement: Deficit
• Replacement should be done preoperatively
to prevent marked hypotension at the
induction of anaesthesia
• Assessment:
– Clinical
– Laboratory investigations
– Invasive methods
 Replacement: Ongoing/Intra-op
• Clinical clues intra-operatively include:
– Tachycardia
– Hypotension
– Decreased urine output
– Marked sensitivity to sedation/analgesia or
muscle relaxation
• Invasive monitoring may be required
 What fluids should be used?
• Consideration in selection
– Oxygen carrying capacity
– Coagulation factors
– Colloid oncotic pressure
– Tissue oedema
– Electrolyte balance
– Nutrition/glucose metabolism
– Cerebral abnormalities
 Crystalloids
• Crystalloids are fluid substances which are able to cross
a semi-permeable membrane.
• Usually composed of at least one solute in water.
• Used for fluid and electrolyte resuscitation in:
– Trauma or shocked patient
– Burns
– Dehydration secondary to diarrhea/vomiting/ or reduced
intake
– For maintenance fluids in patients being kept NPO
– As a medium to give drugs which must be diluted
 Crystalloids
• In hemorrhagic shock, for each mL of blood loss,
3-5mL of crystalloid is given for replacement.
• If the patient is elderly or has cardiac disease,
then replacement is 3ml per 1mL of blood loss.
• 30-40% of the crystalloid infusion stays in the
intravascular space
 Crystalloids
• Complications of administration of crystalloids
include:
– Volume overload
– Shock from administration of cold fluid
– DIC secondary to dilution of clotting factors
– Electrolyte disturbances
 Crystalloids
• Classification
– Hypertonic
• 5% Dextrose in Normal Saline (5% D/S)
• 50% Dextrose Water (50% D/W)
– Isotonic
• Lactated Ringer (L/R)
• Normal Saline (N/S)
– Hypotonic
• 5% Dextrose in Water
 Colloids
• Colloids are fluid substances which are used for fluid
replacement therapy.
• Used especially in patients who are hypotensive or are
hypovolemic.
• They do not cross semi-permeable membranes easily
because their molecules are large.
• Colloid are given after 2-3L of crystalloid is given, in
order to avoid the complications of giving too much fluid.
 Colloids
• Complications include:
– Allergic reactions with Dextran
– Hexastarch interferes with cross-matching of
blood
– Introduction of infection
– Thrombophlebitis
 Colloids
• Classification
– Natural
• Blood
• Packed cells
• Albumin
• Plasma
– Synthetic
• Gelafusin
• Dextran 40:70
• Heta Starch
 Lactated Ringer’s
• Crystalloid
• Isotonic
• 1000mL bag composed of:
– Sodium – 130 mEq
– Potassium – 4 mEq
– Calcium – 3 mEq
– Chloride – 109 mEq
– Lactate – 28 mEq
– 272 mOsmol/Liter
– pH 6.6 (6.0-7.5)
 Isolyte P in 5% dextrose (Multi-
electrolyte injection)
• Crystalloid
• Hypertonic
• This solution is indicated for use in adults as a source
of electrolytes, calories and water for hydration, and as
an alkalinizing age

• Each 1000ml bag contains:

– Sodium – 140 mEq
– Potassium – 5 mEq
– Acetate – 27 mEq
– Gluconate – 23 mEq
– pH – 5.0 (4.0-6.0)
– Osmolarity – 550 mOsmol/Litre
 Sterile Water for Injection
• Hypotonic and hemolytic
• pH: 5.5 (5.0 – 7.0)
• Uses:
– A diluent or solvent
– Irrigation
– Inflate bulb on Foley catheter
– Suspending dry medications
 5% Dextrose injection
• Crystalloid
• Hypotonic
• Composition
– Each 100 mL contains 5g dextrose hydrous USP
– pH 4.0 (3.2-6.5)
– Osmolarity – 252 mOsmol/L
 5% Dextrose and Electrolyte No. 48
• Crystalloid
• Components:
– 5g Dextrose Hydrous
– pH – 5.0 (4.0 – 6.5)
– Sodium – 25 mEq/L
– Potassium – 20 mEq/L
– Magnesium – 3 mEq/L
– Chloride – 24 mEq/L
– Lactate – 23 mEq/L
– Phosphate (as HPO4) – 3 mEq/L
– Osmolarity – 348 mOsM/L
 HESPAN - 6% Hetastarch in 0.9%
Sodium Chloride
• Colloid
• Synthetic
• Components:
– Hetastarch 6g/100mL
– Sodium 154 mEq/L
– Chloride 154 mEq/L
– In water for injection
– pH - ~ 5.9 with negligible
buffering capacity
– Oslolarity - ~ 309 mOsM
 0.9% Sodium Chloride Injection
• Crystalloid
• Isotonic
• Contains:
– 154 mEq/l Na
– 154 mEq/l Cl
– pH 5.5 (4.5-7.0)
– Osmolarity – 308 mOsmol/L
• Expands the intravascular
compartment without affecting
tonicity
 20% Mannitol
• Colloid
• Osmotic diuretic, free radical scavenger property
• Contents:
– Each 100mL contains 20g Mannitol
– Water for injection
– pH – 5.3 (4.5-7.0)
– Osmolarity – 1100 mOsmol/L
• Uses
– Increased ICP
– Increased IOP
– Bowel prep
– Hepatorenal syndrome
– Vascular surgery – post revascularization
– Renal transplant
– Decreases amount of reperfusion injury
– Bowel surgery – large bowel
INSTRUMENTS
LINES
 Swanz-Ganz Catheter
• A pulmonary arterial catheter
• Used for measurement of:
– Central venous pressure
– Pulmonary artery pressure
– Pulmonary capillary wedge pressure
– Cardiac output
– Pulmonary vascular resistance
– Systemic vascular resistance.
 Swanz Ganz Catheter
Indications
• Patients with severe
cardiopulmonary derangement (eg
Heart Failure, MI)
• Hypovolemic shock not responding
readily to volume replacement
• Sepsis with oliguria or hypotenstion
• Lung disorders at risk for
associated myocardial dysfunction.
• Failure of 2 or more organs
• Procedures in which large volumes
are required or large fluid shifts e.g.
abdominal aortic surgery
Complications
• Same as for central venous catheter
• Complications unique to Swan-
Ganz:
– Ventricular arrhythmias
– Ventricular rupture
– Valvular damage on the right side of
the heart
– Intra-cardiac knotting of catheter
– Pulmonary infarction induced by
permanent wedging of the catheter
in the distal pulmonary vasculature
– Perforation of the pulmonary artery
(rare)
 Central Venous Catheters
• Double lumen and Triple lumen
 Central Venous Catheters
• Indications
– Diagnostic – measure CVP
– Therapeutic
• Total parenteral nutrition
• Hypertonic infusion
• Chemotherapeutic administration
• Medications - inotropes
• Haemodialysis
• Infusion- Intravascular infusion of large amounts of fluid rapidly,
especially in resuscitating hypotensive and/or hypovolemic patients
• Inadequate peripheral venous access
• Central venous and pulmonary artery pressure monitoring
 Central Venous Catheters
• Contraindications
– Thrombolysis of central veins
– Coagulopathy- a relative contraindication.
– Bullous emphysema
 Central Venous Catheters
• Immediate
– Pneumothorax (except for femoral
lines)
– Haemothorax (except for femoral
lines)
– Hemorrhage- venous or arterial
– Air embolism
– Catheter tip embolism or loss of
guide wire
– Brachial plexus injury
– Chylothorax
– Hydrothorax
– Catheter misplacement-
– Arterial puncture
– Diaphragmatic paralysis (from
phrenic nerve injury)
– Arrhythmias (atrial or ventricular)
• Late
– Infection
• Cellulitis at puncture site
• Bacteremia from catheter
colonization (catheter sepsis)
• Increased incidence with use of
multilumen catheters
– Haemorrhage
– Thrombosis
– AV malformation
– Erosion of catheter through SVC
after successful placement
 Central Venous Catheters
– Complications of the – Complications of things
Catheter Itself: put thru it:
• Infection • Hydrothorax
• Thromboembolism • Hydromediastinum
• Obstruction • Hydropericardium
• Displacement • Obstruction
 Central Venous Catheters
• Seldinger Technique (catheter over a guidewire):
– First localize the vessel is using a small gauge needle.
– Introduce a thin walled percutaneous entry needle into the
vessel.
– Pass a guide wire through the needle; advance a portion of the
wire guide length into the vessel
– Leaving the wire guide in place, advance the needle.
– Enlarge the puncture site with a number 11 scalpel blade
– With a twisting motion, advance the catheter over the wire
guide and into the vessel.
– After the catheter is in position, remove the guide wire.
• The main landmarks are shown - the
sternocleidomastoid muscle (SCM), its sternal
and clavicular heads, external jugular vein, the
clavicle and jugular notch. Numbers are for
several routinely used approaches: 1 - anterior; 2
- central; 3 - posterior; 4 - supraclavicular.
Variations are possible, one may want to find a
point between 2 and 4; some guidelines refer it
to as a central inferior approach and so on (about
3 more puncture points can be found in
guidelines). Note, if you feel distinct carotid
pulsation and even are able to move the artery
medially, you will not necessarily succeed with
IJV puncture but surely will avoid that of carotid
artery (ICA). Recall the course of the IJV relatively
to ICA - in the upper neck behind the ICA, in the
middle neck laterally and in the lower third - in
front of ICA joining the ipsilateral subclavian vein.
 Central Venous Catheters
• Other forms of central venous catheters
include:
– Shiley Catheter for dialysis
– Port-a-Cath for chemoRx
– Perma-Cath for dialysis
– Hickman Cath for dialysis
Hickman
Shiley catheter
Or
Peripherally inserted catheter
DRAINS
 Nasogastric Tubes
• Closed active or passive drain
 Nasogastric Tubes
Diagnostic Indications
• Diagnosing the presence and
amount of blood in the
stomach.
• Colour of aspirate (coffee
ground)
• Monitor fluid volume from
stomach
• Quality of gastric contents
• Pentagastrin MAO/ BAO test*
• Poisoning
Therapeutic Indications
• Decompression of the stomach
– PRE-OP – Empty for anesthesia
– POST-OP
• Paralytic ileus
•
•
Bowel obs.
Cholecystitis
• Pancreatitis
• Lavage for ingestion poisoning
• Removal of activated charcoal given to
children in acute poisoning
• Nutritional (administration of enteral
feeds – coma, very ill, premature
infants)
• Administration of drugs
• Prevent further vomiting
• Treatment of acute gastric dilatation
secondary to burns
 Nasogastric Tubes
• Contraindications:
– Basal skull fracture
– Facial fractures.
– Fracture of the Cribiform plate
– Oesophageal anastomosis
 Nasogastric Tubes
• Complications
– Malplacement into the trachea which may result in
pulmonary aspiration and abscess.
– Pressure necrosis of ala, nasal septa, palate, pharynx and
oesophagus
– Blockage of sinuses – sinusitis
– Blockage of Eustachian tube – otitis media
– Increased risk of aspiration as it passes the GE junction
 Nasogastric Tubes
• Placement
– Gain informed consent
– Gather equipment
– Don non-sterile gloves
– Sit patient upright
– Examine nostrils
– Measure tubing and mark measured length
– Lubricate distal end of tube
 Nasogastric Tubes
• Placement cont’d
– Pass tube posteriorly horizontal to the floor
– Instruct patient to swallow when you encounter
resistance and advance the tube as the patient
swallows
– Advance until tube mark is reached
– Check for correct placement
– Secure with tape
 Nasogastric Tubes
• Identification of correct placement:
– Hear gush of air over stomach with steth
– Withdrawal of gastric contents
– pH of contents is acidic (<6)
– When proximal end submerged in water it does
not bubble
• Bubbling indicated that tube is in lung
 Suction Catheter
• Structure :
– Cylindrical, transparent tube
– Prox. End: 2 parts
• 1 part: Attachment for suction apparatus
• Other part: occlusion with finger to control suction
– Distal end: Bevelled with 2 holes
AIRWAY
 Laryngoscope & Blade
• Classification
– Curved
• Macintosh
– Straight
• Miller
• Magill (used in neonates or children because of the anatomy of
the pharynx)
• Each laryngoscope consists of:
– Handle (contains grip and power handle source
– Blade (light source and groove)
 Tracheal Intubation
• Equipment
– Monitors
– Drugs
– Suction
– Oxygen source
– Laryngoscope
– Endotracheal tubes
– Stylet, Syringe
 Tracheal Intubation
• Ensure equipment is available
• Pre-oxygenate
• Proper positioning
– ‘Sniffing position”: flexion of lower C-spine (C5,6) and
extension of upper C-spine at atlanto-occipital joint
• Pass tube
– The tip should be located at the midpoint of the trachea at
least 2cm above the carina
– https://www.youtube.com/watch?v=0VGiBwyfuNI
 Tracheal Intubation
• Confirmation of placement
– Direct visualization of tube passing through cords
– Misting of the tube
– Capnography
– Auscultation for equal breath sounds bilaterally and absent
sounds over epigastrium
– Bilateral chest movement
– Refilling of reservoir bag during exhalation
– C-xray (rarely done) – lateral more sensitive and specific
 Laryngoscope & Blade
• Positioning
– Moderate head elevation
– Extension of atlanto-occipital joint
– Clear mouth of dentures, foreign objects with gloved hand.
• Prevention of the HTN Response to Laryngoscopy:
– Give deep anesthesia
– Give 50-100 mcg of fentanyl 2 minutes prior to laryngoscopy
– Give 50-100 mg of lidocaine 2 minutes prior to laryngoscopy
– Give a small dose of a short acting beta blocker eg. Esmolol 5-10
mg, immediately before intubation (Avoid in irritable airways)
 Laryngeal Mask Airway
• A mask that fits over the larynx
• Made of non-latex material
• Allows provision of positive pressure ventilation without
visualization of the vocal cords – supraglottic airway
• Does not protect the airway against regurgitation and
pulmonary aspiration
• Requires anesthesia for placement (topical, regional or
general)
• It comes in 4 sizes (1-2 for Peds, 3-4 for Adults)
• https://www.youtube.com/watch?v=vNvymbRD5b4
 Laryngeal Mask Airway
• Indications:
– Surgeries lasting < 30 minutes in which an established airway is
needed
– Difficult intubation
– To guide ET tube placement
• It is inserted into the hypopharynx in its anatomical
position and then passed onward behind the larynx, sealing
the glottic opening, and enabling ventilation after inflation
of the cuff.
• A slight bulging of the tissues over the larynx indicates the
mask is properly positioned.
 Laryngeal Mask Airway
• Complications: • Contraindications:
– Laryngospasm in a lightly – Full stomach patients
anesthetized airway – Procedures lasting >30
– Mal-placement mins
– Injury to surrounding – Allergy to the material
structures
– Infection
– Aspiration
• Nasotracheal tubes
• Nasopharyngeal tube/airway
• Tracheostomy tube
 Nasopharyngeal Airway
• Also called the “trumpet”
• It is a flexible, soft rubber airway which is placed
in the more patent nostril.
• It can be used without anesthesia
• It is better tolerated than the oropharyngeal
airway
• Complications
– Epistaxis
 Endotracheal Tubes
• Classification
– Cuffed
• Inflated cuff:
– Prevents leakage of
anaesthetic agent (gas).
– Prevents aspiration of
secretions.
– Maintains positive pressure
(some don’t agree on this one)
– Uncuffed
• Required in children:
– the subglottic region is the
narrowest portion of larynx
– the tube can fit snugly
– If a cuffed tube is passed there
is risk of damage to the
cartilage
 Endotracheal Tubes
Endotracheal tube sizes and approximate depths

Group ETT size (mm ID) ETT depth (cm from alveolar ridge
Children (4 +age)/4 (12 + age)/2

Adult women 7.0 – 8.0 20 – 22

Pregnant women 6.5 – 7.5 20 – 22

Adult men 8.0 – 9.0 22 - 24

 Endotracheal Tubes
• Indications
– Patients at risk for aspiration
– For GA
– Respiratory Support (Note: NOT SUITABLE for long term use)
– Administration of medication
– Any operation lasting >30 mins
– All prone position surgeries.
– Unconscious patients (for airway protection)
– Evidence of burns to the airway.
– To provide positive pressure ventilation and PEEP.
– To free the anesthetist’s hands.
 Endotracheal Tubes
• Signs of Correct Placement
– See slide #
• Signs of incorrect placement
– Tachycardia
– Hypertension
– Abdominal distension
– Desaturation
 Endotracheal Tubes
• Complications
– During Insertion:
• Airway trauma
– Lips, teeth, tongue, throat
– dislocated mandible
– hemorrhage
• Failed intubation (adequate oxygenation may be maintained by face-mask).
• Malposition
– Oesophageal intubation (must be recognized rapidly, otherwise à fatal)
– Endobronchial intubation,
» Recognized by:
• Unequal chest movements
• Lack of breath sounds on the left side of chest
• Low blood oxygen saturations.
» This is easily remedied by withdrawing the ETT a short distance
• Pressure necrosis. (Adults do not have a narrowing of larynx)
 Endotracheal Tubes
• Complications
– Late
• Irritate Vocal Cord
• Fistula formation
• Sore throat (more in patients with irritable airways eg.
smokers, asthmatics)
 Cuffed Endotracheal Tubes
• Internal diameter is in millimeters
• E.g Type Portex ETT
– Parts consist of the
– Curved tube of internal diameter x mm. Need  diameter of little finger.
– Inflatable cuff – to provide an air-tight seal.
– Pilot balloon attached to ETT by an inflating tube (valve prevents air loss). The
pilot cuff is used to monitor the cuff, if the pilot is flat, then the cuff has no air
in it.
– Bevelled tip aids direct visualization and insertion through vocal cords.
– Murphy’s eye to  risk of complete tubal occlusion, maintains patency of the
airway if the main lumen is obstructed.
– Bulb, for inflation of the cuff
– A universal adaptor or Connector for attachment to the breathing circuit
(connects to ventilator or airbag)
– Radio-opaque line to allow direct visualization on CXR.
Uncuffed Endotracheal Tube With
Stylet
– Pediatric ETT
– Size 2.0 (premature age)
– Size 3.0 (newborns up to 2 yrs)
– Uncuffed because the airways of a child are small, and provide
an adequate seal; A cuff can cause irritation à edema à
narrowing of the trachea à respiratory embarrassment.
– The tube is lubricated with sterile water because KY Jelly can
also à edema and swelling.
– Rx for broncho-oedema is racemic epinephrine (aerosolized
epinephrine)
– Because there is no cuff, a leak may be audible.
 Stylet
• This is an instrument used to facilitate proper
placement of the ETT
• It is placed near the tip, but not past it, otherwise
perforation of trachea on insertion is possible.
• It ensures that the tip is rigid so that the tube can be
easily placed without wavering along its course.
• Complications:
– Perforation of the trachea with hemorrhage
– Perforation of the esophagus
Uncuffed Endotracheal/Nasotracheal
Tubes
 Magills Forceps
• Long curved handle - continuous angle & obtuse
angle.
• Used to introduce:
– Introduce endotracheal tube for visualization for passage
of endotracheal tube.
– Introduce orogastric tube
– Grasps tongue to remove tongue away e.g. tonsillectomy.
– Removal of foreign bodies.
– https://www.youtube.com/watch?v=l-ZfMa2-ykc
 Oropharyngeal Airways
• A device that is placed into the oral cavity to prevent the
tongue from falling back and obstructing the airway.
• Creates a patent air passage between tongue and post.
Pharyngeal wall. It is used in persons who don’t have a gag
reflex
• Description
– It is made of plastic
– It has a flange at the external end to keep it from disappearing
beyond the lips.
– It functions as a bite block, preventing the comatose patient
from biting down on the ET tube
– It has a port for allowing suctioning
 Oropharyngeal Airways
• Length Estimation
– Distance between tip of nose and ear- lobe - nasopharyngeal
– Distance between mouth and ear lobe - oropharyngeal
• Insertion:
– Placed in mouth (after removal of dentures if present)
– It is inserted upside down with the concavity facing cephalad and then turned
180º when it is well within the oral cavity.
• Complications:
– Can precipitate vomiting in persons with a gag reflex
– May cause cervical movement  spinal damage in a person with c-spine
trauma
– Can cause elevation of ICP.
– Injury to oral mucosa or teeth
 Cuffed Face Mask
• Structure
– RIM- Contoured + Conforming to variety of facial features
– BODY - ?transparent: observe exhaled humidified gas + immediate recognition of vomiting.
– ORIFICE:- 22mm
– Attaches to O2 /Breathing circuit direct through right angle connector.
– Breathing hooks- can attach to head stirrup so that mask need not be continually held.
• Aim
– Delivery of O2 / anaesthetic gas from breathing circuit by creating an airtight seal (along
patent airway essential for effective ventilation)
• Procedure
– Usually oropharyngeal airway is in- situ
– Hold mask in left hand : right hand to squeeze back (+ve Pressure)
– Mask held with downward pressure via thumb and index finger
– Other finger grasps the mandible- extend atlanto-occipital joint ( it prevents tongue from
slipping backwards)
Facemask With Nonrebreather Bag &
O2 Tube
 Oxygen Delivery Methods
• The choice of delivery devices depends on the patient’s oxygen requirement, efficacy of the device, reliability, ease of therapeutic
application and patient acceptance. An arterial blood gas (ABG) or oximetry is advised upon switching delivery devices. Frequent
monitoring is highly advisable in the unstable patient [2-5].
• First-Line Options
Standard nasal cannula
• The standard nasal cannula delivers an inspiratory oxygen fraction (FI,O2) of 24-40% at supply flows ranging from 1-5 L·min-1. The
formula is FI,O2 = 20% + (4 × oxygen litre flow). The FI,O2 is influenced by breath rate, tidal volume and pathophysiology. The slower
the inspiratory flow the higher the FI,O2 [6].
Venturi mask
• A Venturi mask mixes oxygen with room air, creating high-flow enriched oxygen of a settable concentration. It provides an accurate
and constant FI,O2. Typical FI,O2 delivery settings are 24, 28, 31, 35 and 40% oxygen. The Venturi mask is often employed when the
clinician has a concern about CO2 retention

• Second-Line Options
Simple face mask
• The volume of the face mask is 100-300 mL. It delivers an FI,O2 of 40-60% at 5-10 L·min-1. The FI,O2 is influenced by breath rate,
tidal volume and pathology. The face mask is indicated in patients with nasal irritation or epistaxis. It is also useful for patients who
are strictly mouth breathers. However, the face mask is obtrusive, uncomfortable and confining. It muffles communication, obstructs
coughing and impedes eating .
Nonrebreathing face mask with reservoir and one-way valve
• The nonrebreathing face mask is indicated when an FI,O2 >40% is required. It may deliver FI,O2 up to 90% at high flow settings.
Oxygen flows into the reservoir at 8-10 L·min-1, washing the patient with a high concentration of oxygen. Its major drawback is that
the mask must be tightly sealed on the face, which is uncomfortable. There is also a risk of CO2 retention
Tracheostomy Tube
 Tracheostomy Tube
• Plastic Cuffed Tracheostomy Tube
– Cannula - can be outer and inner
– Obturator is used to clear anything that obstructs the
tube. Eg.
• Crusted blood
• Mucous plug
• Secretions
– Inflatable cuff - enough air put in to prevent a leak.
– Flange - for suturing to skin.
– Strap/Tape - to secure around neck
 Tracheostomy Tube
• Indications:
– Prolonged intubation > 2/52
– Respiratory Toilet (easier suctioning with tracheostomy
than ETT)
– Trauma to facial bones
– During failed oro/naso-tracheal intubation.
– Prophylactically in ENT surgery or head surgery.
– Upper airway obstruction (esp mechanical obstruction,
because oedema can be treated with epinephrine before
doing a tracheostomy)
 Tracheostomy Tube
The patient is made to lie down on their back with the neck & head extended by keeping a pillow under the shoulder and neck.

Local anaesthesia or general anaesthesia is used for the procedure.

A horizontal cut is made across the neck above the 'sternal notch' using a knife.

The skin is separated and surrounding tissues are dissected to expose the trachea.

The 2nd or 3rd of the tracheal ring is incised for the tracheostomy tube to be placed.

A suitable size tracheostomy tube is then introduced inside. While choosing the tube, the smallest feasible tube should be used. A
general rule is that the tube should be three fourths of the diameter of the trachea.

The cuff of the tube is inflated by using 2-5 ml of air and it is held in place by using a necktie.

The incision is closed using skin sutures by the side of the tracheostomy tube.

Dressing is applied for the wound to heal.

Read more: Tracheostomy - Procedure http://www.medindia.net/surgicalprocedures/tracheostomy-procedure.htm#ixzz3W0dmfWUR

 Tracheostomy Tube
• Advantages
– ETT facilitâtes positive pressure ventilation.
– Can be left in for long periods- life
– More oxygen can be delivered & quicker.
– It reduces the dead space by half. (Normally dead space = 150 ml)
– Can be used in procedures with upper airway obstruction
• Laryngeal obstruction
• Impaired laryngeal reflex.
• http://medicalvideos.org/videos/5889/tracheosto
my-procedure
• https://www.youtube.com/watch?v=d_5eKkwnIRs
 Tracheostomy Tube
• Complications:
– Early
• Hemorrhage
• False passage
• Pneumothorax
– Late:
• Fistula formation
 Tracheostomy Tube
• Care of the tube:
– Intermittent suction & proper humidification & relieving pressure of cuff i.e. inflate 1 cuff &
deflate other cuff I ETT.
– Dressing - change every 2 hrs or more frequently if it becomes saturated. (NB moist dressings
act as a breeding ground for bacteria)
– Note the type of drainage from drainage from tracheostomy
– Incision site must be inspected and cleaned with hydrogen peroxide and sterile water with
each dressing change.
– Nitrofurazone ointment is applied if there is any sign of local infection.
– If the tracheostomy tube has an inner & outer cannula, the inner cannula should be removed
every 2-4 hrs for the first 24 hrs, cleaned with a tracheostomy brush, hydrogen peroxide, and
sterile water.
– NB Always keep a spare tracheostomy tube handy in case the need for it arises.
– Frequent suctioning (Based on volume & character of patient’s secretions). Suctioning orders
should be written as prn orders. Some patients need constant suctioning initially; eg.
Fulminant pulmonary edema. However, unnecessary suctioning may lead to undue irritation
of the tracheobronchial mucosa and actually cause extensive production of mucus.
– Tracheostomy tubes should be changed on a regular basis (eg. q7 days). This allows for total
inspection of the tracheal stoma and the tube itself.
 34 a & b
• Blood tubes
 Grey Top Tube
• Contains:
– Fluoride: prevents enzymes in the blood from
working by preventing glycolysis therefore glucose
will not be gradually used up during storage
– Oxalate: an anticoagulant
 Blue top tube
• Contains:
– Citrate – a reversible anticoagulant
• Used for coagulation assays
 Purple top tube
• Contains EDTA (potassium salt)
– A strong anticoagulant
• Used for complete blood counts and blood
films
 Red Top Tube
• Contains a clot activator and is used when
serum is needed
IV Catheters
 IV Catheters
Size Flow Rate
14 315 mL/min
16 220 mL/min (GREY)
18 105 mL/min (GREEN)
20 60 mL/min (PINK)
22 38 mL/min (BLUE)
24 24 mL/min (YELLOW)
Radial Artery Catheter Set
Sprotte Cannula
 Intraosseous Infusion Needle
• In children may be used to instill fluid into the bone
marrow cavity.
• The site selected is 2-3 cm below the tibial tuberosity.
– Tibia is used because its plate has not closed as yet.
• The needle is driven into the bone marrow cavity in a
screwing motion.
• Bone marrow is aspirated back, and 10cc of saline is
instilled. If this flows easily, then the IV fluid is
connected.
 Intraosseous Infusion Needle
• Complications of intraosseous infusions:
– Osteomyelitis
– Cellulitis
– Damage to the epiphyseal plate if placed in the
wrong location.
– Injury to muscle
– Injury to nerves
Chest Tube/Straight Thoracic Catheter
• Closed active or passive drain
• Used to drain:
– Haemothorax
– Pneumothorax
– Hydrothorax
– Chylothorax
– Pleural effusion
– Empyema
• Restores the negative pressure in the thoracic cavity
Chest Tube/Straight Thoracic Catheter
• The chest tube is removed when it drains
<1ml/kg/24hrs or when it stops draining.

• Thoracotomy is indicated for:

– Initial chest drainage of >1500 ml or
– 3 consecutive hours of >200 ml per hour blood
loss.
Chest Tube/Straight Thoracic Catheter
• Complications:
– Hemorrhage from intercostal vessel injury
– Subcutaneous emphysema
– Malpositioning into the lung parenchyma, liver, heart.
– Re-expansion pulmonary edema
– Obstruction from kinking, clots, tissue debris
– Dislodgement
– Infection
Lubricating Jelly
Corrugated Drain
X-RAYS
Foreign Body in Stomach
Pneumothorax

Normal
Lines
DRUGS