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Chapter 11 Rescue Technique

Chapter 11 Rescue Technique

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Chapter 11 Rescue Technique

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  1. Chapter 11Rescue Technique He xueying

  2. Section 1Endotracheal Intubation & Tracheotomy

  3. I. Endotracheal Intubation • Endotracheal intubation (ETI) refers to the procedure of inserting a tube directly into the trachea through the mouth or the nose by way of vocal cord.

  4. Key terms • Vallecula 会厌谷 • Gastric contents 胃内容物 • Saliva 唾液 • Upper jaw 上颌 • Cervical 颈部

  5. Purpose 1.To maintain an adequate, patent airway: 2. To provide an airway for mechanical ventilation: 3. To allow direct access to the tracheal for removal or suctioning of secretion: 4.To protect the trachea and lungs from aspiration of gastric contents, saliva(唾液), or blood and secretion into upper airway. 5. To provide a route for tracheal administration of emergency medications for a patient in cardiac arrest.

  6. Respiratory failure or respiratory distress syndrome Indication Sudden arrest of heart and breath There is secretion in respiratory tract

  7. Indication General or balanced anesthesia Major operation in upper jaw or cervical part The recovery of the newborns shock Allocation(定位) before incision of trachea

  8. Laryngeal edema/Acute laryngitis 1 Blood tumor under throat mucous 2 Cauterization of throat(喉咙烧灼伤) 3 Tumor or corpus alienum(肿瘤或异物存留) 4 Contraindication (喉头水肿) (喉头粘膜下血肿)

  9. Aortic aneurysm that oppress trachea主动脉瘤压迫气管 5 Excretion of lower respiratorytract cause dyspnea下呼吸道分泌物 6 Cervical spine fracture or dearticulation颈椎骨折或脱位 7

  10. Items 物品准备 Laryngoscopes (喉镜) There are three standard of it : adult children infant

  11. trachea cannula with cuff 有套囊气管插管 trachea cannula 无套囊气管插管 2. Trachea cannula (气管插管) man------36-40type woman--32-36type

  12. 3. Catheter(导管管心) (金属导丝) Other: bite block (牙垫) aspirator(吸引器) sprayer(喷雾器) stethoscope(听诊器)

  13. endotracheal catheter bite block pharyngealtube laryngoscopes

  14. Operating Lie the patient on his back (the standard decubitus卧姿 ) Add a bolster if the throat reveal bad.

  15. Operating Use the right thumb and index finger to open the mouth. The left hand hold laryngoscope Insert the laryngoscope to right side of the tongue

  16. Uvula (悬雍垂) Operating Push the tongue to the left side, move the lens to the middle to see the uvula Take the lens forward slightly, then you can see the epiglottis

  17. Operating • Uplift the • laryngoscope, • elevate the • epiglottis • to expose the • glottis.

  18. Operating After that, to hold the tube by your right hand Insert it into the glottis at the latter of the patient’s inspiration

  19. adult 4cm children 2cm Operating Remove the catheter rapidly after insert glottis 1cm Continue to push the tube up and in Confirmed the soundof breathing be normal.

  20. Operating Insert bite block, remove the laryngoscope, connect to ventilator.

  21. Vallecula 线沟,果谷 • Vocal cords 声带 • Arytenoids 杓状软骨 • Cartilages 软骨 • Piriform sinuses 梨状窦,梨状窝

  22. Attention ! Give the artificial breathing and O2 before cannula. Check the tube of endotracheal and the aerocyst Select catheter according to age, sex, statue and route

  23. Attention ! The depth of pipe is from apex nasi to ear lobe , and add 4--5cm Expose the throat plenty, and Operate it swiftly Sterile operation & Humidity Check the breathing sound to prevent the pulmonary atelectasis

  24. Attention ! Don’t put the tube in the trachea beyond 72 hours Volume of air inject into cuff is about 3-- 5ml , and deflation every 3--5 hours Nursing and recheck blood gas after extubate(拔管)

  25. http://www.56.com/u63/v_Mzg4MDM5MTY.html • http://you.video.sina.com.cn/b/14246953-1394159417.html • http://www.zhiyangji.org/news/20071015203459.htm • http://jpkc.gzhtcm.edu.cn/zyjzx/video-qiguanchaguanshu.htm

  26. Section 2.Tracheotomy二、气管切开置管术

  27. Preface • Tracheostomy/tracheotomy is a surgical incision into the trachea for the purpose of establishing an airway, also known as surgical airway, or “trach”. • Tracheotomy is a highly complicated, time-consuming surgical procedure and is not appropriate for emergencies.

  28. Bypass an upper airway obstruction: Laryngeal obstruction(喉梗阻) To facilitate removal of secretion: Block of excreta in lower respiratory. Using the ventilator for a long time. Indication

  29. Prophylactic (预防性的) incision of trachea: Sever laryngotracheal trauma or laryngeal fracture Others: Not appropriate to perform endotracheal intuba- tion or thyrocricotomy: epiglottitis, neoplasm, space abscess, foreign body in the pharynx, etc. Indication

  30. 2. Contraindication Hemorrhagic diseases 出血性疾病 Respiratory obstruction because of occupying lesion. 占位性病变

  31. 3. Equipment • bag of incision of trachea气管切开包 • sterile gloves无菌手套 • 1%procaine普鲁卡因 • sputum aspirator 吸痰器 • NS 生理盐水 • light 照明灯 • Syringe 注射器

  32. 4. Match with operator • 1. Place the patient in a supine position. Unless there is a potential cervical spine injury, locate the head at the centric position, and make the mandible(下颌), thyroid eminence(喉结) and incisure of the chest bone(胸骨切迹) in a line, so as to expose the neck.(to provide support under the shoulders by using a blanket or small pillow 病人双肩下垫毛毯或小枕)

  33. Match with operator 2.Clean the skin from the mandible to sub clavicles(锁骨) with antiseptic solution. 3.Drape the chest and the neck.遮盖病人的 胸部和颈部 4.Rinse the operator’s gloves with sterile saline. 生理盐水冲洗操作者的双手

  34. Match with operator 5.Infiltrate the skin with a local anesthetic(局部浸润麻醉) (optional,eg. lidocaine) 6.Prepare and regulate the light. 调节好光源

  35. Match with operator 7. Prepare the tracheal and pharyngeal suction equipment and ensure immediate availability. 准备好气管和喉部的吸引装置 并保证随时能用 8. When incise the 3-4 or 4-5 annulus cartilaginous of air tube, (切开气管的3-4 或4-5环状软骨) suction the secretions.

  36. Match with operator 9. Tie the tracheostomy tube in place around the neck with tape. Clean and dress the insertion site. (将气管外套管的系带固定于颈周, 清洁、并用无菌敷料包扎插管处) 10. Deliver humidified oxygen as soon as possible. 尽快提供湿化的氧气

  37. 5. Cautions 1.Don’t carry out tracheotomy under the following conditions: • There in seriously bleed or hemorrhagic tendency有严重出血倾向者. • The obstruction of respiratory tract is lower than the position of tracheotomy. 低于气管切开部位以下的呼吸道梗阻

  38. 2. Don’t give excessive calmative before operate in case of respiratory depression. • 操作前不可使用过量镇静剂以防引起呼吸抑制。

  39. 3. Skinincision should be maintained in the median line,in case of injuring vessel and thyroid gland。 • 皮肤切口要保持在正中线上,以防止损伤颈部两侧大血管和甲状腺.

  40. 4. Don’t cut or injure the first cartilage of air tube or annular cartilage in case of laryngeal stenosis. • 严禁切断或损伤气管第1软骨和环状软骨以免后遗喉狭窄症.

  41. 5. Trachea cannula should be located firmly. But the tie can’t be too tight or too loose. As common, it should be insert 1 finger. • 气管套管应固定牢固.

  42. 6. Keep the air tube moist and smooth. Taking the endothecia tube out every 4 hours and washing, boiling it for disinfection. • 保持气道湿化和通畅,每4小时取出内套管清洗、煮沸消毒

  43. 7. If situation is improved, we can try to extubate. • 情况改善可以试着拔管 8. After extubated, degermate the skin around the incision, and put asepsis on the wound. Use petrolatum gauze sealing the wound. • 拔管后,消毒伤口周围皮肤(用凡士林纱布封盖)并无菌处理伤口

  44. Section 3.Thyrocricocentesis环甲膜穿刺Thyrocricotomy环甲膜切开术

  45. (一)Thyrocricocentesis indication环甲膜穿刺适应症 1. Complete or incomplete block of upper airway上呼吸道完全或不完全阻塞. 2. gnathospasmus and fail to nasal intubation牙关紧闭和经鼻插管失败. 3. laryngeal edemaor surgical trauma of cervical part and faciomaxillary喉头水肿或颈部和颌面部外伤. 4. Children under 3 years old that don’t fit to thyrocricotomy 3岁以下儿童不适宜行环甲膜切开术者.

  46. Thyrocricotomy indication(一)环甲膜切开置管术适应症之一 1. Obstruction because of extraneous material,因异物梗阻injuries of larynx喉头损伤, chondritis of cartilage epiglottica会厌软骨炎, hyperkinesis larynges喉痉挛or tumor.肿瘤 2. Cataphora昏迷or cerebral trauma脑外伤lead to cough reflex disappear致咳嗽反射消失, which caused the tracheal blocked by the secretion

  47. Thyrocricotomy indication(一)环甲膜切开置管术适应症之二 3. gnathospasmus牙关紧闭or fail of nasal intubation.经鼻插管失败 4. cervical spine fracture颈脊髓骨折or cervical vertebra degeneration颈椎退化(退行性病变). 5. cardiac operation under direct vision心脏直视手术need to medisect(胸骨)正中切开in case of cross contamination以防交叉感染.

  48. (二)Attention 注意事项 • 1. Avoid to damage annular in case of laryngeal stenosis and dysarthria. 避免损伤环状软骨以防喉头狭窄和构音困难 • 2. The operation is only used of emergency. It’s better to find the reason of obstruct and alter to incision of trachea. 本手术只适用于急救。最好能找出梗阻原因改行气管切开

  49. The Clinical Application of Ventilator 呼吸机的临床应用