Resuscitation equipments

DEBOJYOTI MUKHERJEE
PGT, ANESTHESIOLOGY
R.G.KAR MCH ; KOLKATA

Resuscitation
A process to restore
consciousness or other signs
of life ofoneapparentlydead
or dying
orwhoserespirations
hadceased.

CARDIO PULMONARY
RESUSCITATION
Cardiopulmonary resuscitation
commonly known as CPR is an
technique of basic life support for
oxygenating the brain and heart until
appropriate definitive medical
treatment can restore spontaneous
blood circulation and breathing with
intact neurological function in a
person who is in cardiac arrest.

 The Royal College of Anesthetists, Royal

College of Physicians of London, Intensive
Care Society and Resuscitation Council
(UK) (2013) have made recommendations
on the resuscitation equipment and
medications that should be immediately
available for the management of an adult
cardiac arrest. These equipment and
medications are normally stored in a
cardiac arrest trolley, the contents of which
should be standardized throughout a
hospital (Resuscitation Council (UK), 2013)

Basic Airway Maneuvers

ALWAYS REMEMBER THE BASICS
These skills should be used prior to
initiating any advanced airway
technique
Head-tilt/chin lift
Jaw thrust
Modified jaw thrust (for trauma patients)
Sellicks maneuver

Dr. Arthur Guedel

1883-1956

Oropharyngeal Airway
Guedel airway

a curved plastic tube with a flanged end.

Help maintain the airway in patients who
are unconscious.
Size is measured from the corner of the
mouth to the angle of the jaw OR vertical
distance between the patients incisors and
the angle of the jaw (Resuscitation Council
UK, 2011).
Sizes range from 0-6
It holds the tongue away from the posterior
pharynx, but does not isolate the trachea

OPA
The oral airway is
inserted with the
curve towards the
side of the mouth
Then rotated 180
degree once past
soft palate so that
the curve of the
airway matches the
curve of the tongue.
helps to ensure the
tongue is not
pushed back during
airway insertion

Nasopharyngeal Airway
Soft plastic or rubber tube that is designed to pass just inferior to
the base of the tongue.

can be used with patients who are not deeply unconscious

but still have some level of airway obstruction or impairment,
such as those with trismus (lockjaw) or maxillofacial trauma.
Passed through one of the nares and can be used in patients with
an intact gag reflex.

ensuring the patients nasal passage is patent and free from

solid obstructions.
CONTRAINDICATED in cases of suspected or possible basilar skull
fracture

Nasopharyngeal Airway
Sizes range from 17-26 cm in length
and 6-9 mm internal diameter
Measured from tip of the nose to the
corner of the patients ear.
The size of these airways correlates to
the internal diameter (in millimeters)
of the tube and the length, which
increases with the diameter size. Sizes
of 6-7mm are suitable for most adults

NPA
The nasal airway is
lubricated with a water
soluble lubricant
The beveled tip is
inserted directed
towards the septum,
with the airway
directed perpendicular
to the face
If resistance is met,
rotating the airway
may help or the other
nare may be used

Blind Insertion Airways

Combi-tube
LMA (Laryngeal
Mask Airway)
King Airway

Blind insertion
airways considered
an alternative
airway control
device to be used
when intubation is
unsuccessful
They do not require
visualization of the
vocal cords

Supraglottic Airway Devices

provide an airway intermediate
between the facemask and tracheal
tube in terms of anatomic position,
invasiveness, and security.
designed to form a seal in the
pharynx between the respiratory and
digestive tracts to protect the airway
and facilitate gas exchange.

Dr. Archie Brain

LMA : 1983 as modification of
Goldman dental mask.
1989 : LMA classic

Which ones qualify ?

Should satisfy the following conditions:
1. Placed above the vocal cord level

2. Those devices which allow hands-free

maintenance of an open airway
3. Allows spontaneous or assisted
ventilation

SAD
Ability to be placed without direct
visualization
Better cardio vascular stability both
during insertion and removal
Minimal IOP and ICP changes
Provide little protection against
aspiration

 Provides hands free maintenance

of airway
Can be used for both spontaneous
and controlled ventilation
Useful in
Routine anaesthesia
emergency airway
management
Aid to intubation

Laryngeal Mask Airway

Sits over the glottic
opening
Available in different
sizes
Has a drain tube to
aid in gastric
suctioning
With some versions
an endotracheal tube
may be passed
through to aid in
intubation

Preparation Prior to Insertion

Examine surface for cuts, tears, or
scratches.
Examine 15 mm connector.
Deflate pilot balloon until cuff walls tightly
flattened. Ensure the remain flattened.
Over inflate: look for leak
. Deflate against flat surface: ensure spoon
shape.
Lubricate post surface with water soluble

Technique of LMA insertion

Position: Neck flexed and head extended.
Use non-inserting hand to stabilize occiput. Jaw should be pulled down
by assistant. LMA tube be grasped like a pen with index finger pressing
the point where tube joins mask.
Aperture facing forward, the tip pressed upwards against the hard
palate. Middle finger may be used to push lower jaw downward.
Mask is advanced into pharynx to ensure that tip remains flattened and
avoids the tongue.
Neck is kept flexed and head extended. By withdrawing the other
fingers and with a slight pronation of the forearm, it is usually possible to
push the mask fully into position in one fluid movement
The laryngeal mask is grasped with the other hand and the index finger
withdrawn.
The hand that is holding the tube presses gently downward until
resistance is encountered.

LMA Positioning

Advancements
New generation LMAs
I gel
Laryngeal Tube/ King LTS/ LTD
Cobra plus tube

Proseal & LMA Supreme

Has two separate
tubes
Three dimensional
inflation of cuff
Holds a better cuff
seal pressure

Flexible & Ambu LMA

Flexometallic tube
Preformed angle
Better placement
Less incidence of
dislodgement once
placed
More useful in head and
neck surgery

ILMA & LMA C Trach

Allows intubation with

minimal head and
neck manipulation
Recommended in both
difficult airway and
Resuscitation
algorithm
C Trach allows
intubation under
direct vision

 Single use, cuffless

Integral gastric
channel
Epiglottic blocking
ridge
Moulding feature

Cobra plus tube

Distal end has softened
openings
Used for both
spontaneous and
controlled ventilation
Serves as a rescue
airway

Streamlined liner of Pharyngeal airway

- SILPA
Cuffless
Lines the pharynx
Large internal volume
Allows collection of
secretion, minimize
aspiration

3. Combitube

Combi-tube
This is a multi-lumen airway that works
whether it is inserted into the esophagus or
the trachea
It either blocks the esophagus above and
below the glottic opening or by directly
ventilating the trachea
Contraindicated in patients under 5 foot tall
or those under 14 years old, in patients who
have ingested caustic substances, patients
with esophageal trauma or disease, and in
patients with an intact gag reflex

Advanced Airways

Orotracheal Intubation
Nasotracheal Intubation
Digital Intubation
Surgical Airways

Endotracheal tubes
optimal device for airway
management.
A correctly inserted ETT provides a
seal, preventing foreign bodies or
secretions from contaminating the
airway, and enable enables
ventilation directly to the trachea.
> Most commonly made up of
polyvinyl chloride.

 Types of endotracheal tube include

oral or nasal, cuffed or uncuffed,
preformed (e.g. RAE (Ring, Adair, and
Elwyntube), reinforced tubes, and
double-lumen endobronchial tubes.
The "armored" endotracheal tubes
are cuffed, wire-reinforced, silicone
rubber tubes which are quite flexible
but yet difficult to compress or kink

PARTS OF ETT
It consists of the
following parts :

BEVELED TIP
MURPHY EYE
CUFF
CONNECTOR
PILOT BALLOON

A Carlens double-lumen Endotracheal

tube, commonly used
forthoracosurgicaloperations such
asVATS lobectomy. Provides single lung

"armored"

Endotracheal
tubes

 The BEVELED TIP aid

visualization and insertion
through the vocal cords.
MURPHY EYE is a hole to
decrease the risk of occlusion.
CUFF reduces the likelihood
of aspiration, provide better
ventilation
The PILOT BALLOON provides
the gross indication of cuff
inflation.

ORAL TRACHEAL TUBE SIZE

GUIDELINES

FULL TERM INFANT : 3.5 mm

CHILD : 4+age /4 (mm)
ADULT :
FEMALE : 7.0-7.5 (mm)
MALE : 7.5-9.0 (mm)

gum elastic bougie

.

stylet
A stylet can be inserted inside an Endotracheal tube to
make it more rigid, or to change the shape of the tube.
For example, the tip of the Endotracheal tube can be
bent slightly to facilitate passage through the cords. It
is recommended that the stylet be used in all
emergency intubations. In this way, if the shape of the
tube needs to be modified, the stylet is already in
place. The stylet should be lubricated prior to insertion
into the Endotracheal tube, so that it is easy to
remove.

ETT insertion requiress:

A laryngoscope
A syringe for cuff inflation
Suction to clear secretions
Tape or bandage to secure the
airway;
A stethoscope and capnometer to
confirm correct placement.

Laryngoscope
A laryngoscope is an
instrument used to
examine the larynx and
to facilitate intubation of
the trachea.
The laryngoscope
provides a physical
means to view the glottis
and vocal cords using an
attached illumination
source to improve the
picture for the operator.

PARTS OF LARYNGOSCOPES
The parts of
laryngoscopes
are as follows:
HANDLE
ELECTRICAL
CONTACT
FLANGE
BLADE
BULB

TYPES OF BLADES USED IN

LARYNGOSCOPE
MACINTOSH
MILLER
WISCONSIN
The choice of the
blade depends
on the personal
preference .

The Macintosh blade is

positioned in thevallecula ,
anterior to theepiglottis, lifting
it out of the visual pathway
the Miller blade is positioned
posterior to the epiglottis,
trapping it while exposing the
glottis and vocal fold.

Two basic styles of laryngoscope blade are

currently commercially available: the curved
blade and the straight blade. TheMacintosh
blade is the most widely used of the curved
laryngoscope blades, while the Miller bladeis the
most popular style of straight blade . Both Miller
and Macintosh laryngoscope blades are available
in sizes 0 (neonatal) through 4 (large adult)

Here are many other styles of curved and

straight blades (e.g., Phillips, Robertshaw,
Sykes, Wisconsin, Wis-Hipple, etc.) with
accessories such as mirrors for enlarging
the field of view and even ports for the
administration ofoxygen.

Syringe:
Endotracheal tubes used in adults have an inflatable
cuff near the tip. The cuff, once inflated, is intended
to seal the airway from aspiration of Oropharyngeal
contents, and to prevent air leaks during positive
pressure ventilation. A 10 cc syringe should be
included on the aspiration tray to inflate the cuff of
the tube with 5-10 cc's of air.

Suctions
A portable suction device
should be available as cardiac
arrest can and does occur in
areas where wall-mounted
suction is not available. A rigid,
oral suction device (the
Yankaeur) and a selection of
flexible suction tubes for use
with Endotracheal suction must
be available on the trolley.

rigid oral suction device

Magills forceps
Magills forceps are long-bladed,
curved forceps that a practitioner can
operate with one hand to remove
foreign
objects or assist with swabbing or ET
intubation.

Lubrication:
The tip of the Endotracheal tube should be
lubricated prior to insertion. Lignocaine jelly
is a good lubricant because it reduces
irritation due to its local anesthetic effect.

Tape:
Once in place, the ET tube must be
secured to avoid inadvertent extubation
or migration of the tube down the airway.
It is usually taped in place following
confirmation of correct ET tube position.

Stethoscope:
The position of the ET tube is confirmed by
listening over the lung fields and the epigastrium
with a stethoscope. The worst possible outcome of
an attempt at endotracheal intubation is
unrecognized esophageal intubation. It is
absolutely essential that a stethoscope be used to
confirm tube positioning by listening over both lung
fields and the epigastrium.

Capnomete
r
Capnography
is the measurement of

carbon dioxide, which is an exhaled waste

product of respiration. A capnometer
can measure the presence and, in
some cases, the amount of carbon dioxide
in exhaled air, thereby providing a useful
indicator that an endotracheal device is in
the correct position.
A basic colorimetric capnometer fits
between the airway device and the
ventilation
equipment and provides a colourchange
reference to show the presence of
carbon dioxide in the airway; more
sophisticated
monitoring equipment can provide

Nasotracheal Intubation
Can be done blind or with the aid of a
laryngoscope.
If done blind, the patient must be
breathing.

Cannot be performed on patients

with a suspected basilar skull
fracture.
Can be performed on patients with
an intact gag reflex.

Surgical airways

TRACHEOSTOMY
Cricothyrotomy

cricothyrotomy
temporizing

measure

an incision made through

theskinandcricothyroid membraneto
establish a patent airwayduring certain lifethreatening situations, such as airway
obstruction by aforeign body,angioedema, or
massivefacial trauma.
Last resort in cases where orotracheal and
nasotracheal intubationare impossible or
contraindicated.
easier

and quicker to perform

thantracheotomy, does not require
manipulation of thecervical spine, and is
associated with fewer complications.

Find the indentation between the

Adam's apple and the Cricoid
cartilage.

Make a half-inch horizontal incision

about one half inch deep.

Pinch the incision or insert your

finger inside the slit to open it.

Insert your tube into the incision,

roughly one-half to one inch deep.

EQUIPMENTS
FOR
BREATHING

NASAL CANULA

SIMPLE FACE MASK

Non- rebreather mask

Anon- rebreather mask, orNRB, is a device

used inmedical emergenciesthat
requiresoxygen therapy. An NRB requires that
the patient can breathe unassisted, but unlike
low flownasal cannula, the NRB allows for the
delivery of higher concentrations ofoxygen.
Exhaled air is directed through aone-way
valvein the mask, which prevents the inhalation
of room air and the re-inhalation of exhaled air.
The valve, along with a sufficient seal around
the patient's nose and mouth, allows for the
administration of high concentrations of oxygen,
approximately 60% - 80% OXygen

venturi mask
venturi mask, also
known as an airentrainment mask (and
sometimes by the
brand name
Ventimask), is
amedical deviceto
deliver a knownoxygen
concentration to
patients on
controlledoxygen
therapy

self inflating Bag Valve Mask

bag valve mask, abbreviated toBVMand
sometimes known by the proprietary
nameAmbu bagor generically as a manual
resuscitatoror self-inflating bag, is a
hand-held device commonly used to
providepositive pressure ventilationto
patients who are not breathing or not
breathing adequately.. The device can be
used without attaching oxygen; however, it
is most effective when attached to high-flow
oxygen, which is delivered to the patient
when the bag is squeezed.

Self inflating BMV

The interface between the bag and
patient is provided by a clear face
mask; a range of mask should be on the
cardiac arrest trolley to accommodate
different sizes.
the operator should ensure the patients
chest is rising adequately with the
minimum of air escaping around the
mask on every inflation of the BVM.
used to ventilate via an endotracheal
tube or Supraglottic airway device

mouth-to-mouth resuscitation, caused more

problems than they solved. The problems
of abdominal distention, vomiting,
aspiration and poor ventilation carried a
poor prognosis. The success of the Ambu
bag in rescue breathing improved
emergency services in rural and urban
communities

"Ambu" came from the word ambulance and the reference to

"bagging" was coined by rescue workers.
Hesse and Ruben named the company "Ambu," and it still was in
operation

Uses Of Manual
resuscitators
During resuscitation and other
critical situation
Transport
Stand by
Out side OT

Manual resuscitator : type

Laerdal resuscitator bag

The AMBU bag
Cardiff infant bag
Samson Blease bag
Sanjivani adult resuscitator
The air viva resuscitator

AMBU
Artificial Mandatory Breathing Unit
Or
Air Mask Bag Unit

Resuscitators: diff size

Adult (> 30 kg)
Child ( 7 to 30 kg)
Neonatal

Self inflating bag

Laerdal resuscitator bag

Ambu bag.. parts

What is self inflating bag ventilation

An essential emergency skill
Basic airway management
techniques.
Allow oxygenation and ventilation of
the patient until a more definitive
airway can be established &/or in
cases where ET intubation or other
definitive control of airway is not
possible

Contraindications
BVM ventilation is absolutely contraindicated
in the presence of complete upper airway
obstruction.
BVM ventilation is relatively contraindicated
after paralysis and induction (because of the
increased risk of aspiration).

Positioning
Place towels under the patients head to
position the ear level with the sternal
notch.
Extend the patients head slightly.

Technique

Open the airway (head-tilt chin-lift maneuver or the jaw thrust).

In patients with suspected cervical spine injury, do not perform a head-tilt;
rather, only perform a chin-lift maneuver.
Use an airway adjunct.
Place an OPA in unresponsive patients without a gag reflex. 6
If the patient is awake, place one or two NPA ( because of the risk of intracranial
placement, avoid the use of a NPA in patients with significantheadandfacial trauma).6

Place the mask on the patients face before attaching the bag. 4
Cover the nose and the mouth with the mask without extending it over the
chin.
Change the size of the mask, as appropriate, to create a good seal.
Hold the mask in place using the one-hand E-C technique, as shown below.

Contd.
Use the non dominant hand.
Create a C-shape with the thumb
and index finger over the top of
the mask and apply gentle
downward pressure.

Hook the remaining fingers

around the mandible and lift it
upward toward the mask, creating
the E.

Alternate one-hand
technique.

Two-hand technique
If a second person is available to provide ventilations by compressing the bag

Create two opposing semicircles with the

thumb and index finger of each hand to form a
ring around the mask connector, and hold the
mask on the patients face. Then, lift up on the
mandible with the remaining digits.

Alternatively, place both thumbs

opposing the mask connector, using
the thenar eminences to hold the
mask on the patients face, while
lifting up the mandible with the
fingers.
No matter which technique is being used, avoid
applying pressure on the soft tissues of the

Ventilation

volume of 6-7 mL/kg per breath (approximately 500 mL for an average adult). 6

Ventilate at a rate of 10-12 breaths per minute. (for a patient with perfusing
rhythm)
During cardiopulmonary resuscitation (CPR), give 2 breaths after each series of
30 chest compressions until an advanced airway is placed. Then ventilate at a
rate of 8-10 breaths per minute.
Give each breath over 1 second.
If the patient has intrinsic respiratory drive, assist the patients breaths. In a
patient with tachypnea, assist every few breaths.
Ventilate with low pressure and low volume to decrease gastric distension.

Cont..
Maintain cricoid pressure consistently .
to compress the esophagus and reduce the risk of aspiration.
However, it does not completely protect against regurgitation,
especially in cases of prolonged ventilation or poor technique. 1
Care must be taken to avoid excessive pressure, which can result
in compression of the trachea.

Assess the adequacy of ventilation.

- Observe for chest rise, improving color, and oxygen saturation.
- Monitor for air leak.
- Be cognizant of increasing gastric distention .

Pearls
Lift the mandible up to the mask rather than pushing the mask down onto
the face.
An adequate seal can more easily be made with a mask that is too big than
one that is too small.
Leave dentures in place, when possible, to improve mask seal.
If the patient's facial hair makes a seal difficult to obtain, apply a watersoluble lubricant over the beard to improve the contact between the face and
the mask.
If the one-handed mask ventilation is not effective, switch to the two-handed
technique.

Cont..
The best way to prevent aspiration is with good technique,
including low-pressure, low-volume ventilation with slow
insufflation. Newer bags have built-in pressure valves. The green
zone includes pressures up to 20 cm of water and corresponds to
the lowest risk of gastric distention.
Note the type of bag being used. Bags with one-way expiratory
valves allow greater than 90% oxygen delivery during both
positive pressure and spontaneous ventilation, while bags
lacking this feature only deliver about 30% oxygen during
spontaneous breaths.

Complications

Aspiration
Hypoventilation
Hyperventilation
barotrauma

Defibrillation
The waveform of the shock can be mono- or
biphasic.

Defibrillators
Monophasic

Biphasic

Defibrillator types
External

Electrodes

Positioning of electrodes for

automated external defibrillator

Defibrillation
Precautions:

1. Defibrillation should not be

performed on a patient who has a
pulse or is alert, as this could cause a
lethal heart rhythm disturbance or
cardiac arrest.
2. The paddles used in the procedure
should
not be placed on a woman's breasts
or over
a pacemaker
11/19/15

hqubeilat@ksu.edu.sa

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