Emergency

Instruments
Dr Meera Ekka
Associate Professor
Department of Emergency Medicine
AIIMS, New Delhi
Contents
• Airway
• Breathing
• Circulation
• Disability
 Airway Equipment
• Suction catheter
• Oropharyngeal Airway
• Nasopharyngeal airway
• Supraglottic Airway
• Endotracheal tube
• Bag-valve-mask
 Suction catheter
A suction catheter is a medical device used to extract bodily
secretions, such as mucus or saliva from the upper airway
Use
• Clears secretions from the airways when the
cough reflex is impaired or absent

Indications for suctioning include:

• Audible or visual signs of secretions in the tube.
• Signs of respiratory distress.
• Suspicion of a blocked or partially blocked tube.
• Inability by the child to clear the tube by coughing
out the secretions.
• Vomiting.
• Desaturation on pulse oximetry
 Suction
catheter
Method of use
• Suction catheter is passed via an endotracheal
or tracheostomy tube or via a nasal/oral airway
to the carina
• This may stimulate a cough in a non-paralysed
patient
• Catheter is pulled back 1 cm, then suction is
applied on withdrawal
Advantages
• Stimulation of a cough when reflex is impaired
by mechanical stimulation of the larynx, trachea
or large bronchi
• Removal of secretions from central airways
when cough is ineffective or absent
 Suction catheter
Disadvantages
• Invasive procedure
• Tracheal ulceration or perforation
• Hypoxaemia
• Cardiac arrhythmias due to hypoxia
• Tracheal stimulation may produce increased SNS
activity or a vasovagal reflex producing cardiac
arrhythmias and hypotension
Contraindications
• unexplained hemoptysis
• severe coagulopathies
• severe bronchospasm
• laryngeal stridor
• base-of-skull fracture
• hemodynamic instability
 Oropharyngeal Airway

An oropharyngeal airway (oral airway, OPA) is an airway adjunct

used to maintain or open the airway by stopping the tongue from
covering the epiglottis.
Parts:
• flange to prevent over insertion
• reinforced bite section
• curved body to conform over tongue/palate
• tubular air channel
USE
Contraindications
• Lifts the tongue off the posterior pharyngeal wall to prevent airway
•conscious patient with an intact gag reflex
obstruction
• foreign body obstructing the airway
• Bite block
• nasal fractures or an actively bleeding nose
• Assist oropharyngeal suctioning
• Promotes moulding of the face of a mask for manual ventilation
COMPLICATIONS
• gagging, vomiting and aspiration
• soft tissue trauma to the tongue, palate and pharynx
• biting down on the hard surface can injure the teeth
Nasopharyngeal Airway(NPA)

• An NPA is a type of airway adjunct, a tube that is

designed to be inserted into the nasal passage way to
secure an open airway

• often used in conscious patients where an

oropharyngeal airway would trigger the gag reflex
 Nasopharyngeal Airway(NPA)

USE:
• Can provide an airway in patients with an intact gag
reflex, trismus or oral trauma COMPLICATIONS:
• Facilitate suctioning in patients with a weak cough • epistaxis and aspiration
• ulceration

Parts: • insertion through the cribriform plate into the brain

• smooth angled tip • may still stimulate gag reflex and vomiting

• curved body • sinusitis

• flanged end Contraindications:

• base of skull fractures
• Nasal fractures
• coagulopathy
 Endotracheal Tube
• An endotracheal tube is a flexible plastic tube that is placed
through the mouth into the trachea (windpipe) to help a patient
breathe
• The endotracheal tube is then connected to a ventilator, which
delivers oxygen to the lungs
• The process of inserting the tube is called endotracheal
intubation
USES:
securing of airway and provision of mechanical ventilation
Indications
• Inability to maintain airway patency
• Inability to protect the airway against aspiration
• Failure to ventilate
• Failure to oxygenate
• Anticipation of a deteriorating course that will
eventually lead to respiratory failure
 Endotracheal Tube
Safety features COMPLICATIONS
• universal 15mm connector • early: difficult/failed intubation
• clear non-toxic plastic • trauma, bleeding
• low profile, high volume, low pressure cuff -> decrease risk
• cuff perforation, endobronchial intubation
of pressure necrosis
• radio-opaque strip -> can be seen on CXR • Esophageal Intubation

• Murphy eye -> even if ETT is in too far there is a chance of • late: tracheal mucosal necrosis, stenosis
ventilating right main bronchus
• high beveled atraumatic tip Contraindications:
• latex free
Absolute contraindications include the following:
• 2cm indicator mark assists positioning of tube past vocal
• Total upper airway obstruction, which
cords
requires a surgical airway
Identifications of Tube in Trachea
• Total loss of facial/oropharyngeal
• Direct visualization of tube passing through landmarks, which requires a surgical airway
vocal cord
• Tube fogging,
• Chest rising and falling
• 5 point auscultation of chest: epigastric area first
• ETCO2 level:35-45mmHg
 Laryngeal Mask
Airway
OVERVIEW
• LMA is an acronym for Laryngeal Mask Airway Advantages
• a type of extraglottic airway device aka • provide rapid protection of airway in the field
supraglottic airway device (SAD) • technically easier to insert than ETT
• some models provide a gastric port
METHOD OF INSERTION/ USE
• blindly inserted to form a low pressure seal over Disadvantages
the laryngeal inlet
• non-definitive airway protection and patency
• difficult ventilation if high airway pressures
DESCRIPTION
Parts:
• shaft (tube)
• proximal 15 mm connector
• distal end with broad elliptical inflatable cuff —
upper smooth surface to prevent pharyngeal
secretions entering the larynx and an under
surface with an orifice with linear bars that sits
over the larynx to create a seal
• pilot balloon
Types:
• Reusable (silicon)
• Intubating LMA with endotracheal tube (e.g.
FastTrackTM) (disposable)
• LMA with gastric suction channel (e.g. ProSealTM)
(disposable)
Sizes:
• 0 (infant) to 6 (large adult)
• size 3 (females) or 4 (males) commonly used in
adults
 Laryngeal Mask
Airway
USES
COMPLICATIONS
• rescue airway in a failed intubation
• inability to achieve a seal and ventilate
• facilitate blind insertion of bougie or ETT into
trachea • gas insufflation
• facilitate blind insertion of bronchscopic assisted • partial airway obstruction (mask
airway control misplacement)
• improve oxygenation as part of rapid sequence • shaft kinking
airway approach
• malposition
• ventilation during elective anaesthesia to fasted
patients with low risks of regurgitation • dislodgement
• laryngospasm
CONTRAINDICATIONS • cough
• poor mouth opening • trauma to the upper airway (e.g. bleeding,
• potential pharyngeal/laryngeal pathology dislodgement of teeth)
• poor pulmonary compliance
• high airway resistance
 Nasogastric or Orogastric tube
• A nasogastric (NG) tube is a flexible tube of rubber or
plastic that is passed through the nose, down through the
esophagus, and into the stomach.
• It can be used to either remove substances from or add
them to the stomach.
• An NG tube is only meant to be used on a temporary basis
and is not for long-term use.
Parts:
Tip
• Drainage port/lateral eyes
• Radio opacity……..radio opaque line/strip
Body
• Markings:
.50cm-stomach
.60cm-pylorus
.70cm-duodenum
Base
 Nasogastric or
Orogastric tube
Contraindications
Indications
• Caustic ingestion or oesophageal strictures (risk of
• Gastric lavage in acute poisoning (if presented
perforation)
within 1hour of ingestion)
• aspiration of stomach contents to decompress • Hydrocarbon poisoning e.g kerosene
the stomach of fluid, air, or blood • Coagulopathy (epistaxis risk)
• detection of upper GI haemorrhage • Base of skull fracture
• enteral feeding • Severe mid-face trauma (risk of cribriform plate
• administration of drugs, contrast media or disruption with NGT entering the brain!)
activated charcoal • Consider an orogastric tube placement if
coagulopathy or facial trauma
 Nasogastric or Orogastric tube
complications
Confirmation of tube placement Insertion
• discomfort!
Key methods
• malposition (e.g. curling in the mouth or nose,
• aspiration of gastric contents endotracheal and endobronchial placement)
-inspect and check for pH <5 with pH • epistaxsis
indicator paper • vomiting and aspiration
• placement into the anterior cranial fossa (i.e. base of skull
-examining the visual characteristics fracture or cranial floor surgery)
of aspirate • oesophageal variceal hemorrhage (if varices present)
• auscultation for a gurgling sound over the • oesophageal or posterior pharyngeal perforation
During use
epigastrium or left upper quadrant of the • sinusitis
abdomen following insufflation of air • reflux and aspiration
(unreliable) • pressure areas at site of being secured
• capnography or • unplanned dislodgement or migration
colorimetric capnometry in mechanically • blockage, kinking and knotting (can even knot around
epiglottis and cause respiratory distress!)
ventilated adult patients Removal
• chest/ upper abdominal x-ray • mucosal adherence and trauma
• ultrasound • failure (e.g. kinking and knotting)
• dislodgement of endotracheal tube (e.g. if NGT is knotted
around)
 Urinary indwelling
catheter
Description
• flexible tube with central lumen that allows urine to flow from the bladder
• second lumen allows inflation of balloon to secure catheter in position
Types
• Foley = silastic or rubber, size 12 Fr to 24 Fr, usually use 14-16 Fr
• Others (PVC)
• 3-way catheter (22 Fr) has a third lumen allowing bladder irrigation

Lumen
• Single lumen—these catheters have no balloon and are
used for in/out catheterization

• Double lumen—two-way catheters have a draining lumen

and a balloon inflation lumen and are used for continuous
catheterization

• Triple lumen (or three-way catheters)—have a draining

lumen, a balloon inflation lumen and an irrigation lumen.
Size
• Catheter size refers to the circumference of the catheter,
and is recorded in French sizes (1 French (F) =0.33 mm)

• Size 12–14F is usually adequate for males and females

• Use size 16–20F if the patient has urine with debris,

mucous, blood clots or haematuria, which may occlude
smaller lumens
 Urinary indwelling
catheter
INDICATIONS
• Acute urinary retention
• urine output measurement
• clot retention and bladder irrigation
• bed bound or comatose patients
• post-operative e.g. prostate surgery
• therapeutic, e.g. clot removal
• urinary incontinence
• urine specimen collection
Other sites
• insertion in wound for balloon tamponade of bleeding
vessel
• nasal insertion for posterior epistaxis
CONTRA-INDICATIONS
• recent prostate surgery (consult urologist)
• suspected urethral injury
• patient refusal
Non-Urinary use of Urinary COMPLICATIONS
Insertion
Cathter • malposition
• trauma – false passage, urethral stricture (delayed), hemorrhage,
[Link] a torniquet for control of balloon inflation in urethra
• pain
hemorrhage from extremities • failure (e.g. meatal, urethral or prostatic stricture – may require
SPC or dilation)
[Link] epistaxis-ballon When in situ

tamponade • infection – 100% colonised at 1 week, 5% risk of septic

complication per day, 8% bacteremia, 1-3% UTI
• paraphimosis
[Link]-Tamponade effect • bladder irritation and erosion
• hemorrhage post-decompression (if >1 litre bladder)
[Link] thoracotomy- • concretion formation
tamponade effect for myocardial Removal
• traumatic removal (e.g. balloon not deflated, concretions)
rupture • unable to remove (e.g. balloon won’t deflate, concretions)
 Three-way Urinary
catheter
• Triple lumen (or three-way catheters)—have a draining
lumen, a balloon inflation lumen and an irrigation lumen

• Insert when blood, clots or debris are to be washed out of

the bladder (e.g. post TURP).
 Peripheral Intravenous
cannula
A peripheral intravenous line is a small, short plastic catheter
that is placed through the skin into a vein, usually in the hand,
elbow, or foot, but occasionally in the scalp
Description
• different devices and brands available with different
lengths and diameters.
• commonly 14–24 Gauge.
• plastic cannula (PTFE or similar material) mounted on a
smaller-diameter metal needle, the bevel of which
protrudes from the cannula.
• flashback chamber that fills with blood when the vein is
successfully cannulated.
• standard Luer-lock fitting for attaching a giving set so
fluids/drugs can be administered.
• safety features that allow the needle to be retracted inside
the cannula and be disposed of in one piece.
 Peripheral Intravenous
cannula
Method of insertion/ use
• superficial veins of the upper limbs are
preferred.
• veins are filled by use of a tourniquet and
the vein immobilized by finger traction on
the adjacent skin.
• cannula is held at ~20° to the skin and the
vein punctured
• needle is inserted far enough that the tip
of the cannula also enters the vein (i.e.
advance 1-2 mm following flashback)
• cannula is advanced and the needle pulled
back.
• needle is disposed of in a sharp container
once the cannula is advanced to the hub
• PIVC is secured with adhesive dressing
 Peripheral Intravenous cannula
COMPLICATIONS
USE
• Failed cannulation
• IV fluid administration
• Haematomas/damage to underlying structures
• blood sampling
• Extravasation of fluids/drugs
• drug administration • Thrombophlebitis
• needle thoracostomy for tension pneumothorax • Insertion site infection
• needle cricothyroidotomy • Septicaemia
Other Information • Inadvertent arterial puncture
• Flow is determined by size and diameter • operator needlestick injury
of the cannula.
• For resuscitation short, wide-bore Replacement of peripheral cannulae
cannulae provide the most rapid infusion
rate. • Many centers have a policy of routine replacement of
peripheral IV cannula at 72-96h (with the intention of
• Gauge is used to describe needles – decreasing complications such as infection)
larger Gauge corresponds to smaller • The insertion site should be inspected at each shift
needle diameter change and the cannula removed if there are signs of
inflammation, infiltration, or cannula blockage
 Central venous Catheter (CVC)

CVC is a cannula placed in a central vein (e.g.

subclavian, internal jugular or femoral)

USES/INDICATIONS

• IV access (especially if difficult peripheral access)

• CVP monitoring
• ScvO2 monitoring/sampling
• Infusions of irritant substances (e.g. vasoactive
agents, chemotherapy or TPN administration)
• Renal replacement therapy, plasmapheresis and
apheresis
• Transvenous pacing
• Large bore peripheral IV lines, RICC lines, Swan
sheaths or IO access is preferred for rapid fluid
fluid resusciation
 Central venous
Catheter
CONFIRMATION OF POSITION CONTRAINDICATIONS
• ultrasound visualization of needle insertion, • coagulopathy
guidewire placement and CVC • respiratory failure
• raised ICP (cannot tilt head down)
• pressure measurement Femoral approach can be used in all the situations
above
• assess for CVP trace • obstructed vein (e.g. thrombus, or tumour)
• overlying skin infection, burn or other disease
process
• inject agitated saline and observe rapid
appearance of bubbles on bedside echo • hemorrhage from target vessel
• uncooperative patient
• CXR
 Central venous Catheter

COMPLICATIONS Early
• haemopericardium and tamponade
• Immediate • pneumothorax
• pneumothorax (highest for SCV) • catheter blockage
• failure to locate vein • chylothorax
• accidental arterial puncture • catheter knots
• haemothorax Late
• haematoma • infection
• arrhythmia • catheter fracture
• thoracic duct injury • vascular erosion
• guide wire embolus • vessel stenosis
• air embolus • thrombosis
• osteomyelitis of clavicle
Thank you