Indication of intubation 1. Failure of airways maintenance of airways protection 2. Failure of ventilation/ oxygenation 3. What is the anticipated clinical course?

Airway adjunct a) Oropharyngeal tube- absent gag reflex+unconcious Measurements: angle of the mouth to the tragus Yellow -3 Green-2 White 1 paeds Cx: trauma to the soft tissue of the mouth Damage to the teeth Vomiting Gagging Laryngospasm

Oropharyngeal tube

Nasopharyngeal tube

b) Nasopharyngeal tube- present gag reflex Measurements: nasal flare to the tragus Normal tidal volume=500 ml in 70kg men Calculate: 6-8ml/kg Each

Resuscitator bag/ ambu bag/ bag valve mask

Size of face mask: From nasal bridge to Nasal prog : 3-5L (21-28%) Face mask: 10L/min (60%) High flow mask : 15 L/min (90%)

Facial mask with reservoir/ High flow mask

Nebulizer mask Top: blade Bottom: handle Position: between base of the tongue and vocal cord Technique: insert to the right, push to the left and forward...

Laryngoscope

Endotracheal tube

Indication of ETT a) GCS less than 8 b) Respiratory distress c) Prolong seizure d) Stroke pt e) Maxillofacial injury Confirmation ETT position a) 100% see it go throught the vocal cord b) Presence of water vapour c) Chest expansion/ movement d) Auscultate 5 places: epigatric, 2 upper zone, 2 middle zone Length of ETT insertion: size of tube X 3. The length of tube up to incisor teeth Do not intubate if cant see the vocal cord as 99% of the air will go to the stomach Inflate the ETT, LMA

Syringe

Supraglottic airways device When use?

Prehospital OT Failed intubate a) Laryngeal trachea tube/Combitube

b) Laryngomask airways & laryngo mask supreme

c) Rapid sequence intubation (RSI): administration of a potent induction agent followed immediately by a rapidly acting neuromuscular blocking agent to induce unconsciousness and motor paralysisi for tracheal 1. Sedative- Midazolam (0.1mg/kg) 2. Non-depolarizing muscle relaxantsuccinylcholine 3. Opiod (Fentanyl)- blocks sympathetic response 4. Atropine (0.02mg/kg)- to prevent succinylcholine induced bradycardia

Chest tube insertion Indication 1) Pneumothorax 2) Massive pleural effusion 3) Empyema 4) Traumatic Haemopneumothorax 5) Post operative procedure. Preparation 1) Trolley with dressing pack, chest tube set and suture set. 2) 20mL 1% lidocaine 3) Scalpel (N15) 4) Chest drain (10-14 F, 0r 28-30F for trauma case) 5) Underwater drainage bottle 6) Connecting tubes 7) Suture materials. Location (Safety triangle)

1) lateral border of the pectoralis major muscle 2) anterior border of the latissimus dorsi 3) Imaginary horizontal level of the nipple Simply put, area of inserton; 4th to 6th intercostals space Anterior to mid axillary line

Aisya : stage of healing, instrumen2,respi resus yg dorang ajar time SKILL ari tu, intraoseous infusion, pastu dy ad gak ajar guna defib machine-function dy selain ntok defib ape,chest tube. =yani Ecg : vt, vf, svt, af, a flutter, heart block Management utk svt n brady

Equipment defibrillator

site : 1. anterior (apex and sternum) @ 2. ant n postii. function : 1. monitor heart rate 2. defibrillator 3. synchronizing the rhythm

type : 1. needle 2. gun with needle ( blue colour for adult, pink colour for paeds) indication : 1.when unable get peripheral IV line 2.usually used in paeds (bcoz adult usually used CVL) Site : 1. tibial tuberosity, 2. medial malleolus, 3. ASIS, 4. proximal humerus 5. distal femoraliv. Contraindication; at site insertion have 1. bone infx 2. local infx how to know it is correctly inserted? 1. yes : when blood come out 2. no : when brannula fall down

chest tube

site to be inserted : 4th to 6th i/c space from ant to midaxillary line what is safe triangle consist of? lateral : lateral side to pac major post : lateral border lat dorsi base : 5th i/c space apex : axilla reason punctured at above rib? : prevent puncture vessel /nerve (to avoid neurovascular bundle under ribiv. Trocar size : 1.20-24 (adult) as air flow faster. used in mt of pneumothorax 2. 30 to prevent blockage. in mx hemothorax how to know it is correctly inserted? : 1. bubble in drainage underwater seal when ask pt to cough 2. swinging in drainage tube When to take chest tube out? 1.when lung fully expanded (shown fm CXR result in 24 hr) 2. drain no longer have bubbling How take it out? 1.give analgesia beforehand NSAID / morphine 2. During pt expire (bkn inspire tau!! dh confirm blek ngn dr as it is wrtten in clinical oxford handbook). The idea is that, lung has regain normal expansion, jd take it out during expire, to prevent puncture the lung. 3. Closed immediately wf preplace suture. Purse string suture ( jahitan cm kantung beg duit syiling) jarang gne sbb increased scarrng and pain.

suture equipment

procedure chest tube insertionpn kna tau gak! different chest tube insertion in hemothorax and pneumothorax: >site : 1. hemothorax (fluid gravity denser jd duk kt bawah)4th-6th i/c space ant to mid axillary line , more post approach 7th space posteriorly 2. apeical pneumothoax (air less dense jd duk kt atas) at 2nd i/c space in midclavicular line type with site suture thread : 1.degradable (organ kt dlm, tak yah bkak, leh terurai sendiri) 2.non degradable (kena bkak bile sampai maseny.Catgut [ 3, 2, 1] silk [0] [2/0, 3/0, 4/0, 5/0, 6/0]brilon where to used : 1. 3 to 1 used in chest tube insertion 2. 3/0 @ 4/0 used in other site skin 3 .5/0 @ 6/0 used at face smaller the size, less scar iv. longer the suture, risk of infx v. usually 3-5daysheal take out a week later,.. but it depend at which site, and in what operation and size suture

5. ecg:

1.svt 2.heart block 3.VT 4.VF others:anaphylaxis 1.burns 2.fracture (estimated blood loss) 3.wound healin CXR exam Question : 1.hemopneumothorax 2.rib fracture intracranial bleed snake bite compartment syndrome