Vía aérea quirúrgicaVía aérea quirúrgica • Imposibilidad de intubar la tráquea.. Indicación: Máscara laríngea Máscara laríngea para intubació. Se identifica por el desarrollo progresivo de infiltrados pulmonares, que no siguen a la punción cricotiroidea, a la cricotiroidotomía o a la traqueostomía ( 15).
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Home Documents Cricotiroidotomia Con Aguja. Post on Dec 4 views. Transtracheal jet ventilation TTJV or percutaneous cricotiroidktomia jet ventilation PTJV is the cricotiroidogomia of oxygen by way of a catheter inserted through the cricothyroidmembrane using a needle cricothyrotomy. Surgical airway management according to some authors includes surgical or open cricothyrotomy,4 use of a cricothyrotome, and needle cricothyrotomy with PTLV.
Other textbooks consider surgical airway management to include a formal open crico-thyrotomy, or a cricothyrotome, with needle cricothyrotomy considered anotherairway technique. Mace, MD, and J. A Positioning assuming no contraindications toexpose the external anatomy eg, laryngeal prominence.
cricotiroidotomia por puncion pdf
B Locating the cricothyroidmembrane palpation of the cricothyroid membrane. C Needle puncture of the cricothy-roid membrane anterior and side views. D Seldinger guidewire technique for cricothyr-otomy cutaway of side view and side view E Catheter secured and ventilationwith bag-valvemask. More recently, thetechnique involves supplying short bursts of oxygen followed by a longer passiveexhalation phase to allow ventilation with both inhalation of oxygen and exhalationof carbon dioxide.
Two trauma scenarios also present contraindications: Use of a scalpel for the skin incision versus a needle puncturewith needle cricothyrotomy. Complete upper airway obstruction has been listed as a contraindication to needlecricothyrotomy,2,3 because of a concern for increased lung volumes with possible bar-otrauma if gases in the lung cannot escape.
The tenet that complete upper airway obstruction is an abso-lute contraindication to PTLV has been questioned recently based on its successfuluse in multiple animal studies and several case reports.
In fact,needle cricothyrotomy is preferred, and surgical cricothyrotomy open or with a crico-thyrotome is contraindicated in infants and young children because the cricothyroidmembrane is too small to insert a tracheostomy tube and there is a greater risk fordamage to surrounding structures. However, the exact age at which a needlecricothyrotomy rather than a surgical cricothyrotomy is indicated is a matter of debate.
Experience with pediatric cricothyrotomy is limited,3 although two small series haveshown successful use of needle cricothyrostomy with PTLV in infants and childrenfrom aged 4 months to 11 years.
Thus, depending on the author, the lower age limit ranging from 5 to 10to 12 years at which surgical cricothyrotomy is contraindicated is somewhat arbi-trary.
PEDIATRIC VERSUS ADULTCompared with the adult anatomy, the pediatric airway has a smaller in absolute sizeand proportionally cricothyroid membrane, greater overlap between the thyroid car-tilage and cricoid cartilage with less accessibility to the narrower slit-like cricothyroidmembrane, and smaller comparatively underdeveloped funnel or conical-shapedairway verses the larger, more cylindric-shaped adult airway.
Furthermore, in thepediatric larynx, the narrowest part of the airway is the cricoid cartilage versus thevocal cords in the adult airway. In children, the larynx is located more rostral, orsuperior opposite C2C3 interspace in a young infant and C3C4 interspace in anolder infant, versus C4C5 in an adultmaking the cricothyroid membrane more dif-ficult to access, and children have a more compliant collapsible airway.
Becausethe laryngeal prominence is not fully developed until adolescence, other useful land-marks are the cricoid cartilage and the hyoid bone. The pediatric airway has a smallerdiameter with greater resistance to gas flow according to the formula RN 1O lumenradius ,4 where R is airway resistance. Resistance to gas flow is inversely proportionalto the fourth power of the radius of the airway lumen, meaning that small decreases inthe luminal diameter cause large increases in the airway resistance Box 2; Fig.
For surgical cricothyrotomy in the emergency depart-ment, acute complication rates from 8. Some complications noted with surgical cricothyrotomy eg, barotrauma, infec-tion, perforation of the trachea may also occur with needle cricothyrotomy withPTLV. However, other complications may be less frequent. Theoretically, somecomplications, such as damage to the laryngeal cartilage and subglottic stenosis,Box 2Pediatric cricoyiroidotomia anatomy versus adultSmaller size of cricothyroid membrane absolute size and proportional lumen RN 1O [lumen radius] Needle Cricothyrotomy would seem less likely to occur with a cricotiroidptomia cannula than the larger tracheostomytube.
Comparison of the pediatric and adult airway anatomy. B Shape ofthe pediatric and adult larynx. D Airway resistance as affected by theradius of the airway. Reported complicationsincluded subcutaneous emphysema and pneumomediastinum requiring chest tubeplacement.
A series of patients undergoing PTLV for elective endoscopic laryngeal surgeryreported a 7. However, some force is necessary topuncture the cricothyroid membrane, and therefore a risk for perforating the posteriortrachea and esophagus still exists, and use of larger needles is associated witha greater risk for perforating the esophagus.
Cricotiroidotomia Con Aguja – [PDF Document]
Box 4Equipment for needle cricothyrotomy and translaryngeal jet ventilationNeedle cricothyrotomyStandard preparation and draping: Originally, a or gauge angiocatheter was used.
Commercial PTLV cathetershave recently become available, which are designed to result in less kinking stiffermaterialare curved for easier placement and less chance at least theoretically ofperforating the posterior wall, and have distal side holes and at the tip to allow a widerdispersion of the delivered gas eg, oxygen.
Most reports have used to gaugecatheters 2. Oxygen flow is a function of the catheter size, and therefore larger catheter diameterallows greater oxygen flow. A Luer lock or three-way stopcock is used to attach the catheter tothe distal end of the high-pressure oxygen tubing. Commercial devices are available, such as the Enk oxygen flow modulator setby Cook Critical Care Bloomington, Indiana. Other devices have a pressure gaugeconnected to a hand-triggered push buttontype jet injector, which can control theamount of air pressure reaching the catheter.
This equipment should be setup in advance of any airwayemergency and placed in an emergency airway cart or box in the emergency depart-ment for easy and immediate access.
Two early methods for delivering oxygen use a standard ventilation bag attached tothe catheter with a cricotirpidotomia. Manual on-off device for transtracheal jet ventilation. Needle Cricothyrotomy Fig. Because this setup using a standard ventilation bag is rigid, and thereforeslight movements of the bag may dislodge the catheter, it has been modified byconnecting one end of standard intravenous tubing to the PTLV catheter and the cricottiroidotomia cut end to a 2.
A cricotidoidotomia bag setup is not recommended for adults because of difficulty intechnically providing an adequate tidal volume while allowing sufficient time for exha-lation. Ventilation using a standard ventilation bag A using a 3. Clinicians should move their finger down the thyroid cartilage in the midline into a smalldepression above the cricoid cartilage to locate the cricothyroid membrane see Fig.
In adults, four fingerbreadths above the sternal notch or 2 to 3 cm below the la-ryngeal prominence is the approximate location of the cricothyroid membrane Box 5. The individual performing the procedure, if right-handed, should be positioned tothe patients left toward the head of the bed.
If time allows, the anterior neck shouldbe sterilely prepared and draped. A syringe containing several 3 to 5 mL of lidocaine,with epinephrine or lidocaine on the needle, should be placed. Some clinicians preferlidocaine with epinephrine because it may decrease bleeding and results in higherlevels of lidocaine and presumably provides better anesthesia with the same volume mL of local anesthetic. Again, if time allows and the patient is awake or responsive,the site should be infiltrated with poe anesthetic.
Some lidocaine should be left in thesyringe for two purposes: Iflidocaine cannot be used eg, because of allergythen normal saline can be usedto show bubbles in the syringe. After locating the cricothyroid membrane the small depression between the cricotiroidotonia inferiorly and the thyroid cartilage superiorly with the nondominant hand seeFig. Unfortunately, similar studies applicable to pediatric patients are unavailable. Forchildren, some experts have suggested using 25 to 35 psi.
A technologic advancement with PTLV is the use of pressure monitoring during jetventilation. A small nick in the skin surface maybe made with a scalpel before the needle insertion to help puncture the skin if muchskin resistance is anticipated.
Ideally, the needle puncture should be in the lower in-ferior part the cricothyroid membrane to avoid the cricothyroid artery and vein thatcourse across the upper part of the cricothyroid membrane.
The syringe should be as-pirated crocotiroidotomia the needle is advanced. Bubbles in the fluid or increased ease of aspiringair signifies that the needle has traversed the cricothyroid membrane and is now in theairway see Fig. While holding the needle in place, the clinician should advance the catheter to thehub and then remove the needle see Fig. The catheter should be held in placeby hand until its placement is confirmed and it is connected to the oxygen source.
One person should be designated to hold the hub of the catheter in place until it is se-cured with suturing or a trach tie to prevent dislodgement or subcutaneous emphy-sema see Fig. Before the catheter is secured, the hub should be held flushagainst the skin to avoid any air leaks. The usual inhalationexhalation ratio I: E ratio is 1: However, the clinicianmore, transtracheal or transglottal jet ventilation is commonly used for anesthesiaduring laryngeal surgeries for controlled mechanical ventilation.
Inpatients for whom intubation failed, PTLV was performed to obtain an airway. How-ever, once PTLV was used, intubating patients became easier. The high intratrachealpressure from PTLV seemed to lift the epiglottis and open the glottis, allowing visual-ization of the vocal cords and making intubation easier. The escape of gas under highpressure caused the edges of the glottis to flutter, allowing recognition of the glottisand thereby assisting in intubation.
Several animal studies haveshown that PTLV may prevent aspiration. Similarly, experts have also suggested punicon the escapingshould try to avoid the region of tracheal rings two to four, because the isthmus ofthe thyroid gland usually lies anterior to these rings. During PTLV, oropharyngealsecretions may be expelled through the patients nose and mouth, and thereforeproper barrier precautions eg, gown, gloves, masks should be taken.
Previous teaching has been that oxygena-tion is adequate with PTLV, but hypercarbia and respiratory acidosis occur because ofinadequate ventilation, and therefore PTLV can only be used for approximately 30 to45 minutes in an adult. Placing the catheter in thesubcutaneous tissue can cause massive cricotiroidotomka emphysema, and thereforesome clinicians suggest performing a test of oxygen with a resuscitation bag ora low psi before administering the full 50 psi in an adult or 25 to 35 psi in a pediatricpatient to determine if the catheter is incorrectly placed and limit the amount of sub-cutaneous emphysema.
The catheter can also bemisplaced into the airway in the trachea or larynx in an areaother than through the cricothyroid membrane. In this case, if the oxygenation andclinical condition improves, leaving the misplaced tube temporarily in the airway untilanother airway can be secured may be best.
If the catheter cannot be placed in thepressure from PTLV may help expel a foreign body in the upper airway. Needle cricothyrotomy is preferred over surgical cricothyrotomy ininfants and young children. Appropriate ventilatory parameters using a high-flowoxygen source and an adequate expiratory time I: E ratio may limit the complicationsof barotrauma and allow for a more extended time of ventilation.
Preliminary reportssuggest that PTLV may be also useful in the endotracheal intubation of patientswho have a difficult or failed airway and may help prevent aspiration, although furtherstudies are needed. Emergency physicians should be familiar with the indications,contraindications, complications, and procedure of this type of rescue airway, whichis also used to ventilate patients during elective laryngeal surgery.
J Emerg Med ;6: Cricothyrotomy and transtracheal jet ventilation. Procedures in emergency medicine.
cricotiroidotomia por puncion pdf – PDF Files
Elsevier Publishing Co; cricotirodiotomia, Chapter 6. Henritg FM, King C ,editors. Textbook of pediatric emergency procedures. Management of the difficult and failed airway. Practice guidelines for management of the difficult airway.