INSTRUMENTS

Dr. Saher Gul Ahdi

SR Peads
DEFINITION OF AFP
• Sudden onset of weakness or paralysis in a previously normal limb
over a period of 15 days in a patient aged less than 15 years age.
• It is a Lower motor neuron lesion
DIFFERENTIAL DIAGNOSIS OF AFP
Lesions at the level of
• SPINAL CORD
• Anterior horn cell disease
• PERIPHERAL NERVE
• Disorders of neuromuscular transmission
• MUSCLE
• Systemic disease
• SPINAL CORD
• transverse myelitis
• Cord compression ( tumour • trauma • paraspinal abscess • haematoma •
vascular malformation with thrombosis/bleeding)
• Ischaemic cord damage
• spinal cord stroke
• ANTERIOR HORN CELL DISEASE
• Acute poliomyelitis
• Vaccine-associated paralytic polio
• PERIPHERAL NERVE
• Guillain Barré syndrome
• local trauma
• Focal mononeuropathy
• Neuropathies of infectious diseases
• DISORDERS OF NEUROMUSCULAR TRANSMISSION
• Myasthenia gravis
• Botulism
• Insecticide
• Tick bite paralysis
• Snake bite
• MUSCLE
• Polymyositis
• post viral myositis
• periodic paralysis
• toxic myositis
• Mitochondrial diseases
• Systemic disease
• Acute porphyrias
• Critical illness neuropathy
butterfly needle
• A butterfly needle is a device used to draw blood from a vein or
deliver intravenous (IV) therapy to a vein.
• Also called a winged infusion set or scalp vein set
• a butterfly needle consists of
• a very thin hypodermic needle
• two flexible wings
• a flexible transparent tubing
• a connector.
• The connector can be attached to a vacuum tube or collection bag to
draw blood or to tubing from an infusion pump or IV bag to deliver
fluids or medications.
• Medications can also be delivered directly to the connector via a
syringe
USES
• to obtain blood samples for complete blood counts (CBC), cholesterol
tests, diabetes monitoring, STD screens, and other blood-based tests.
• Commonly used at blood banks for people wanting to donate blood.
• to deliver intravenous fluids.
• They are also useful for delivering medications (such as pain
medications) straight into a vein or gradually infusing IV therapies
(such as chemotherapy or antibiotics) intravenously.
SIZES
• range in size from 18-gauge to 27-gauge.
• The higher the gauge, the smaller the needle.
• a 27-gauge needle is the size commonly used for insulin injections.
• Smaller gauge needles are used if an injectable fluid is thick or if
blood is being collected for transfusion.
BENIFITS
• less likely to cause profuse bleeding, nerve injury, or a vein
collapse once the needle is removed.
• can access superficial veins
DISADVANTAGES
• blood collection tends to be slower.
• Even for a routine blood draw, the wrong needle size can result in
blockage and the need for a second draw if a large quantity of blood
is needed.
• can damage a vein if the unit is suddenly yanked. Even if the right size
needle is used, the needle can become blocked during treatment if
not correctly placed
• should only be used for IV infusions of five hours or less.
• Laryngoscope handles comes with an assortment of Miller blades and
Macintosh blades (Adult, Paediatric, Infant and Neonatal)
• The basic style of blades available is straight and curved.
LARYNGOSCOPE
• INDICATIONS
• In Infants prior to endotracheal intubation in:
• Neonatal asphyxia
• Meconium aspiration
• Respiratory distress syndrome
• Tracheo oesophageal fistula
• Mechanical ventilation
• In older children prior to endotracheal intubation:
• Resuscitation
• During administration of general anesthesia
• Epiglottitis
• Kerosene poisoning
• Direct Laryngoscopy
• In cord palsy
• Anatomical lesions
• Foreign body
Contraindications
• Diseases or injuries of cervical spine.
• Moderate or marked upper respiratory obstruction.
PARTS OF LARYNGOSCOPE
• Following structures are examined serially:
• 1. Base of tongue
• 2. Right and left valleculae
• 3. Epiglottis
• 4. Right and left pyriform sinuses
• 5. Arypeiglottic folds
• 6. Arytenoids
• 7. Post cricoid region
• 8. False cords
• 9. Anterior and posterior commissure
• [Link] and vocal cords
• [Link] area
BMV
• Allows for oxygenation and ventilation of patients until a more
definitive airway can be established.
• Also used in cases where endotracheal intubation or other definitive
control of the airway is not possible.
• Always the first response to inadequate oxygenation and ventilation
• The first “bail-out” maneuver to a failed intubation attempt
• Attenuates the urgency to intubate In the pediatric population, BVM
may be the
• best option for prehospital airway support.
• BVM ventilation is also appropriate for elective ventilation in the
operation theatre when intubation is not required
AMBU BAG
• Provide a volume of 6 -7 mL/kg per breath (approximately 500 mL for
an average adult).
• For a patient with a perfusing rhythm, ventilate at a rate of 10-12
breaths per minute.
• Adult size: 2 lit
• Paediatric size: 500 ml
PARTS OF BMV
• The BMV consists of
• 1. The bag : a flexible air chamber , attached to a face mask via a
shutter valve which is squeezed to expel air to the patient.
• 2. Mask: a flexible mask to seal over the patients face,
• 3. Filter and valve : a filter & valve prevent backflow into the bag itself
(prevents patient deprivation and bag contamination)
• 4. Oxygen Reservoir:
• 5. Pressure Gauge
• 6. Oxygen Connecting tube
Self inflating bag (AMBU Bag)
• Fill spontaneously after they are squeezed, pulling oxygen or air into
the bag
• Remain inflated at all times
• Can deliver positive-pressure ventilation without a compressed gas
source.
• Require attachment of an oxygen reservoir to deliver 100% oxygen
• BVM DURING CPR
• During cardiopulmonary resuscitation (CPR), give 2 breaths after
each series of 30 chest compressions until an advanced airway is
placed.
• BVM VENTILATION: ASSESSMENT OF ADEQUACY
• Observe the chest rise and fall
• Good bilateral air entry
• Improving colour
• Lack of air entering the stomach
• Feeling the bag
• Pulse oximetry (oxygen saturation)
INDICATIONS

• Respiratory failure
• Failure of ventilation
• Failure of oxygenation
• Failed intubation
• Elective ventilation in the operating room
CONTRAINDICATIONS
• BVM ventilation is not possible in the case of complete upper airway
obstruction.
• BVM ventilation is relatively contraindicated after paralysis and
induction (because of the increased risk of aspiration).
• Caution is advised in patients with severe facial trauma and eye
injuries.
• In addition, foreign material (e.g. gastric contents) in the airway may
lead to aspiration pneumonitis. In these circumstances, alternative
approaches, including endotracheal intubation, may be necessary.
COMPLICATIONS
• Hypoventilation/ Hyperventilation
• Inflated air in the stomach (called gastric insufflation)
• Lung injury from over-stretching (called volutrauma)
• Lung injury from over-pressurization (called barotrauma)
• Aspiration
• Undesirable CV effects such as hypotension, secondary to caval
compression.
OROPHARYNGEAL AIRWAY
• Curved, Hard Plastic device that is designed to go over the back of the
tongue
• Prevents tongue from occluding airway
• Range in Size from 00 to 6
• Aids in Airway Suctioning
Indications
• OP Airways are indicated in unconscious patients without a gag reflex
• An Oral Airway will prevent the tongue, which is the most common
airway obstruction, from blocking the airway when properly inserted.
Contraindications
• OP Airways should NOT be used in responsive patients
• Or in patients with a Gag Reflex.
COMPLICATIONS
• Airway obstruction
• Epistaxis
• Ulceration & Necrosis
• Dental Damage
• CNS trauma
• Laryngospasm & Coughing
• Aspiration or Swallowing of part or all of the airway
• Latex Allergy
• Gastric distension
Face mask
• It is the device which allows administration of gases to the patient
from breathing system without introducing any apparatus to the
patients mouth.
• A face mask can be made up of black rubber, clear plastics,
elastomeric material or combination of these
• Parts of the face mask:
• Body: constitutes the main part of the mask . Transparent body
allows observation of moisture, vomitus , secretions etc
• Seal : Comes in contact with the face. Two types are available
• Pad or cushion – inflated with air
• Flap – flexible extension of the body
• Connector ( orifice/ collar )
• Opposite to the seal
• Thickened fitting of 22 mm ID
• Ring with hooks helps in strapping the mask
• Techniques of use:The face mask should
form tight seal on the pts face while fitting
comfortably in the user`s hand.
The smallest mask is most desirable
because it will cause least increase
in dead space, easy to hold & less
likely to result in pressure on eyes.
Advantages
• Lower incidence of sore throat
• requires less anaesthetic depth than tracheal tube or supraglottic
device.
• No need of muscle relaxants.
• The face mask may be the most cost efficient method for short cases.
Disadvantages
• Anesthesiologist`s hands are tied up
• higher fresh gas flows are often needed.
• During remote anesthesia, airway access is difficult ( CT & MRI).
• Often more episodes of oxygen desaturation & require more
intraoperative airway manipulations
Complications
• Skin problems- dermatitis, pressure necrosis.
• Nerve injury.
• Eye injury – conjunctival chemosis, eyelid edema & corneal injuries.
• Gastric Inflation
• Latex allergy
• Lack of co-relation between arterial & end tidal CO2.
• Jaw Pain & User fatigue.
ETT
• Endotracheal tubes are curved tubes used for intubation
• Tubes were previously made up of latex (indian rubber) and those still
available
• plastic tubes (PVC) are preferred because of following advantages :
• Disposable (less chances of infection)
• Hypoallergenic
• Transparent (easy visualization of blockage ETT due to blood , pus
, secretions
PARTS
• PROXIMAL END
• 15mm adapter (connector) which fits to ventilator or ambu bag
• CENTRAL PORTION
• 1. A vocal cord guide
• 2. A radio-opaque marker
• 3. The distance indicator (marked in centimeters) which facilitates placement
of ET tube.
• 4. A cuff- incase of cuff ET tube
• DISTAL END
• has Murphy’s eye (opening in the lateral wall ) which prevents complete
blockage of ET tube incase the distal end is impacted with secretion , blood ,
etc.
• ET tubes can be :
• Cuffed ET tubes are used in children > 8 years• The cuff when
inflated maintains the ET tube in proper position and prevents
aspiration of contents from GI tract into respiratory tract
• In children < 8 uncuffed ET tubes are used because the narrow
subglottic area performs the function of a cuff and prevents the ET
tube from slipping.
• SIZE
• From 2mm to 16 mms (internal diameter )
• age group size of tube
• premature babies 2 to 2.5
• full term babies upto 2 3 to 3.5
• 2 weeks to 24 weeks 4 to 4.5
• 6 months to 12 4.5 to 5 monthsthen
• increase the size of the et tube by 0.5cms for every 6 months rise in age so
that approximately 6 years of age size of the ett tube to be used is
approximately 8 mms
USES
• For Mechanical Ventilation
• For Intermittent Postive Pressure Ventilation (IPPV)
• During resuscitation
• Direct suctioning of trachea in meconium aspiration
• In Epiglottits &life threatening croup
• In tetanus (however for long term bases, tracheostomy is preferable)
In diphtheria
• In angioneurotic edema
COMPLICATIONS
• Mechanical trauma to tongue, teeth , palate , pharynx & larynx during
intubation procedure
• Stimulation of posterior of posterior pharyngeal wall leading to
coughing , vomiting or vasovagal episode with resultant hypoxia ,
bradycardia.
• Prolonged intubation may cause pressure necrosis of laryngeal
structures leading to persistant hoarseness ( hence tracheostomy) is
indicated in patients requiring long-term mechanical ventilation)
• Pneumothorax
incubator
• Incubator is an apparatus for maintaining an infant, especially a
premature infant, in an environment of controlled temperature,
humidity, and oxygen concentration.
• The incubator is a closed system with a heating element underneath
and a transparent hood or canopy around the baby tray.
• Air or air-oxygen mixture is sucked in through a micro filter and
streamed over the heating element humidifier using a quiet fan.
• The warm humidified air is then circulated through the hood to attain
a uniform temperature within.
PRINCIPLE OF INCUBATOR
• Infant incubator is in the form of trolley normally with mattress on
the top covered by plastic cover. This chamber provides a clean
environment and helps to protect the baby from noise, infection, and
excessive handling.
• A low rate of air circulation, ideally not more than 20-30 litre per
minute, minimizes convective heat losses due to fast currents around
the baby. Noise level within the incubator is kept low.
• A temperature sensor is tapped into the baby’s skin and the incubator
heater adjusts to maintain the baby at a constant temperature or the
temperature is controlled by thermostat in the heated air stream.
• Additional optional features which may be attached to the incubator
include an intra-venous stand, weighing scale, timer, tilt facility,
battery back up, oxygen analyser, resuscitator, vital signs monitor,
phototherapy unit, oxygen flow meter, suction, ventilator etc.
USES

• Generally all premature babies, babies with low birth weight(<1000g)

may be stable, hypothermic child (<32˚c), Sick children need
incubator and its care.
• Frequently incubator is used to transport babies from one place to
another, like referral to another hospital, within the hospital for
various investigations e.g. CT scan & MRI.
• Neonates who need close observation are also kept in the incubators.
ventilator
A ventilator is a machine which is designed to mechanically move
breathable air into and out of the lungs, to provide the mechanism of
breathing for a patient who is physically not able to breathe sufficiently.
Indications
• 1. Acute lung injury.
• 2. Acute severe asthma, requiring intubation.
• 3. Chronic Obstructive Pulmonary Disease.
• 4. Apnea with respiratory arrest.
• 5. Hypoxemia.
• 6. Acute respiratory acidosis.
• 7. Respiratory distress addressing increased work of breathing.
• 8. Hypotension including sepsis, shock, CHF.
• 9. Neurological conditions such as Muscular Dystrophy, Amyotropic
Lateral Sclerosis, etc.
Indications for Neonatal Ventilator
• Respiratory Distress Syndrome.
• Sepsis.
• Birth asphyxia.
• Meningitis.
• Pneumonia.
• Meconium Aspiration Syndrome.
ADVANTAGES OF VENTILATOR
• Better gas distribution.
• Lower mean airway pressure.
• Less Hemodynamic disturbance.
• Less sedation is required.
COMPLICATIONS OF VENTILATOR
• Barotrauma (pneumothorax, pneumomediastinum and subcut
emphysema)
• Ventilator associated lung injury.
• Ventilator associated pneumonia.
• Oxygen toxicity.
• Atrophy of Diaphragm or all respiratory muscles.
• Aspiration.
• Decreased Cardiac Output.
Less common complications are
• Fluid retention.
• Aspiration.
• Laryngeal or tracheal stenosis.
• GI bleeding due to stress ulcers
• Thick secretions.
• Hepatic congestion.
• Decreased renal perfusion.
• Respiratory acidosis or alkalosis.
• Anxiety or fear.
• Patient’s discomfort
Ng
Purpose
• To feed the patient with fluids when oral intake is not possible
• To dilute and remove consumed poison
• To instill ice cold solution to control gastric bleeding
• To prevent stress on operated site by decompressing
• To relive vomiting and distension
• To collect gastric juice for diagnostic purposes
• Patient who cannot eat (GIT functioning normally) – Comatose
patient – Mechanically ventilated
• Patient who will not eat – Patients who refuse to eat
• Elderly
• Disoriented patients – Patients who cannot maintain adequate oral
nutrition
• Patients with infection, trauma, cancer etc. – Surgery
Contraindications
• • Gastric surgery
• • Ulcers
• • Tracheoesophageal fistula
• • Oesophageal surgery
• • Polyps in nose , recent nasal surgery, facial surgery
• • Deviated nasal septum
• • Patient on anticoagulant therapy
Ryle’s tube Parts
• – Tip
• Drainage port / lateral eyes
• Radio opacity ……..radio opaque line/strip
• – Body
• Markings:
• – Base
Polyurethane NG tube (Viasys Corflo), 8 Fr × 36 in (91 cm).
Method to confirm NG tube in the stomach
• • Aspirate:
• attach the syringe to the end of NG tube and aspirate small amount of gastric
content • Immerse distal end of tube into bowl of water and check for air
bubbles • Auscultate : attach syringe to free end of the tube, place diaphragm
of stethescope over left hypochondrium .inject 10 ml of air and auscultate
abdomen for gushing sound.
• • X ray
folleys
• A urinary catheter is a small, flexible tube that can be inserted
through the urethra and into the bladder, allowing urine to drain.
• The urethra is the tube that carries urine from the bladder out of the
body
INDICATIONS
• The inability to control urine
• Dysuria : painful urination or difficult urination
• Retention of urine leading to urinary hesitancy
• Obstruction of the urethra by an anatomical condition that makes it
difficult to urinate
• Urine output monitoring in a critically ill or injured person
• Collection of a sterile urine specimen for diagnostic purposes
• Imaging study of the lower urinary tract
• After surgery to monitor urine output
• URINARY CATHETER SIZES
• Number 8 Fr. and 10 Fr. are used for children.
TYPES OF URINARY CATHETERS
• a. Intermittent Catheter.
• An intermittent catheter is used to drain the bladder for short
periods (5-10 minutes). It may be inserted by the patient.
• b. Retention/Indwelling Catheter.
• This type of catheter is placed into the bladder and secured there
for a period of time.
• c. Supra Pubic Catheter.
• This type of catheter is inserted into the bladder through a small
incision above the pubic area. It is used for continuous drainage.
Complications
• Incontinence
• Infection
• Sepsis
• Urethral injury
Contraindications
• Trauma like Pelvic fractures
• Scrotal hematoma
• High riding prostate break down
• Hematuria
• Bladder cancer.
• Spinal needle or lumber puncture needle
• IV lines, branula
• Intra osseous needle
• Suction catheter
• Chest drain
• Tracheostomy tube
• Phototherapy lamp.