Emergencies Tracheal intubation

laryngoscopes prepared emergency anaesthesia

rapid sequence induction , intubation (rsi) particular method of induction of general anesthesia, commonly employed in emergency operations , other situations patients assumed have full stomach . objective of rsi minimize possibility of regurgitation , pulmonary aspiration of gastric contents during induction of general anesthesia , subsequent tracheal intubation. rsi traditionally involves preoxygenating lungs tightly fitting oxygen mask, followed sequential administration of intravenous sleep-inducing agent , rapidly acting neuromuscular-blocking drug, such rocuronium, succinylcholine, or cisatracurium besilate, before intubation of trachea.

one important difference between rsi , routine tracheal intubation practitioner not manually assist ventilation of lungs after onset of general anesthesia , cessation of breathing, until trachea has been intubated , cuff has been inflated. key feature of rsi application of manual cricoid pressure cricoid cartilage, referred sellick maneuver , prior instrumentation of airway , intubation of trachea.

since introduction of rsi, there has been controversy regarding virtually every aspect of technique, including:

choice of induction drug, dose , method of administration.
avoidance of manual ventilation before tracheal intubation.
optimal position , whether head-up, head-down, or horizontal supine position safest induction of anesthesia in full-stomach patients.
application of cricoid pressure (the sellick maneuver).

named british anesthetist brian arthur sellick (1918–1996) first described procedure in 1961, goal of cricoid pressure minimize possibility of regurgitation , pulmonary aspiration of gastric contents. cricoid pressure has been used during rsi fifty years, despite lack of compelling evidence support practice. initial article sellick based on small sample size @ time when high tidal volumes, head-down positioning , barbiturate anesthesia rule. beginning around 2000, significant body of evidence has accumulated questions effectiveness of cricoid pressure. application of cricoid pressure may in fact displace esophagus laterally instead of compressing described sellick. cricoid pressure may compress glottis, can obstruct view of laryngoscopist , cause delay in securing airway.

cricoid pressure confused burp (backwards upwards rightwards pressure) maneuver. while both of these involve digital pressure anterior aspect (front) of laryngeal apparatus, purpose of latter improve view of glottis during laryngoscopy , tracheal intubation, rather prevent regurgitation. both cricoid pressure , burp maneuver have potential worsen laryngoscopy.

rsi may used in prehospital emergency situations when patient conscious respiratory failure imminent (such in extreme trauma). procedure commonly performed flight paramedics. flight paramedics use rsi intubate before transport because intubation in moving fixed-wing or rotary-wing aircraft extremely difficult perform due environmental factors. patient paralyzed , intubated on ground before transport aircraft.

cricothyrotomy


in cricothyrotomy, incision or puncture made through cricothyroid membrane in between thyroid cartilage , cricoid cartilage



cricothyrotomy kit

a cricothyrotomy incision made through skin , cricothyroid membrane establish patent airway during life-threatening situations, such airway obstruction foreign body, angioedema, or massive facial trauma. cricothyrotomy performed last resort in cases orotracheal , nasotracheal intubation impossible or contraindicated. cricothyrotomy easier , quicker perform tracheotomy, not require manipulation of cervical spine , associated fewer complications.

the easiest method perform technique needle cricothyrotomy (also referred percutaneous dilational cricothyrotomy), in large-bore (12–14 gauge) intravenous catheter used puncture cricothyroid membrane. oxygen can administered through catheter via jet insufflation. however, while needle cricothyrotomy may life-saving in extreme circumstances, technique intended temporizing measure until definitive airway can established. while needle cricothyrotomy can provide adequate oxygenation, small diameter of cricothyrotomy catheter insufficient elimination of carbon dioxide (ventilation). after 1 hour of apneic oxygenation through needle cricothyrotomy, 1 can expect paco2 of greater 250 mm hg , arterial ph of less 6.72, despite oxygen saturation of 98% or greater. more definitive airway can established performing surgical cricothyrotomy, in 5 6 mm (0.20 0.24 in) endotracheal tube or tracheostomy tube can inserted through larger incision.

several manufacturers market prepackaged cricothyrotomy kits, enable 1 use either wire-guided percutaneous dilational (seldinger) technique, or classic surgical technique insert polyvinylchloride catheter through cricothyroid membrane. kits may stocked in hospital emergency departments , operating suites, ambulances , other selected pre-hospital settings.