ACLS update 2010, and Acute Resusitation and ACLS Medications

Drug Dosage Indications/Comments Antiarrhythmic Agents Adenosine Bolus: 6 mg (initial) If no response, bolus with 12 mg after 1 “2 min For conversion of PSVT unresponsive to vagal maneuvers May repeat 12 mg once Give as rapid IV bolus over 1 “3 s followed by rapid 10 ml fluid bolus May use lower bolus dose of 3 mg if central line available Be cautious of interactions with theophylline (inhibits adenosine), dipyridamole (potentiates adenosine), other drugs that prolong QT interval Amiodarone 300 mg bolus IV 150 mg bolus IV followed by 1 mg/min for 6 h and then 0.5 mg/min for 18 h For VF or pulseless VT refractory to shock ; may repeat 150 mg bolus IV in 3 “5 min For stable wide-complex tachycardia up to a total dose 2.2 g IV per 24 h May use for narrow complex atrial arrhythmias, as adjunct to cardioversion Monitor for bradycardia and hypotension Atropine Bolus: 0.5 mg IV (maximum dose 3 mg) For either absolute (<60 beats/min) or relative symptomatic bradycardia Bolus: 1 mg IV For bradycardia manifesting with lack of pulse, PEA or for asystole unresponsive to epinephrine May repeat dose every 3 “5 min up to maximum dose 0.04 mg/kg or 3 mg ETT bolus: 2 “3 mg Dilute up to 10 ml in NS or sterile water (IV preferred) Diltiazem 0.25 mg/kg IV bolus over 2 min (typically 15 “20 mg) For control of ventricular response rate in A fib or A flutter, or other narrow complex tachycardia May repeat once Do not use in wide-complex tachycardia 0.35 mg/kg IV bolus over 2 min (typically 25 mg) Negative inotrope, so use cautiously if reduced LV function Maintenance infusion 5 “15 mg/h Epinephrine Bolus: 1 mg IV (10 ml of 1:10,000 solution) Therapy for refractory VF or pulseless VT; dose should be followed by CPR and defibrillation; may be repeated every 3 “5 min Initial therapy for PEA; may repeat every 3 “5 min Initial therapy for asystole; may repeat every 3 “5 min ETT bolus: 2 “2.5 mg Dilute up to 10 ml NS or sterile water (IV preferred) Infusion: 2 “10 µg/min For treatment of symptomatic bradycardia unresponsive to atropine and transcutaneous pacing; alternative to dopamine Ibutilide 1 mg IV infused over 10 min; may be repeated after 10 min Use 0.01 mg/kg if <60 kg For treatment of atrial arrhythmias Monitor electrolytes and EKG Increased risk for torsade de pointes if elderly, abnormal LV function (EF <35%), or electrolyte abnormalities Monitor for 4 “24 h Isoproterenol Infusion: 2 “10 µg/min May be used in torsade de pointes unresponsive to magnesium Use with extreme caution; at higher doses is considered harmful Not indicated for cardiac arrest, hypotension, or bradycardia Lidocaine Bolus: 1 “1.5 mg/kg For wide-complex tachycardia of uncertain type, stable VT, and control of PVCs May be followed by boluses of 0.5 “0.75 mg/kg every 5 “10 min up to a total of 3 mg/kg Only bolus therapy should be used in cardiac arrest Bolus: 1.5 mg/kg Initial bolus dose suggested when VF is present and defibrillation and epinephrine have failed ETT bolus: 2 “4 mg/kg Diluted in 5 “10 ml NS or sterile water (IV preferred) Infusion: 2 “4 mg/min Continuous infusion used after bolus dosing and following return of perfusion to prevent recurrent ventricular arrhythmias Because half-life of lidocaine increases after 24 “48 h, the dose should be reduced after 24 h, or levels should be monitored Therapeutic levels 1 “4 mg/L Full-loading dose but reduced infusion rate in patients with low cardiac output, hepatic dysfunction, or age over 70 years Magnesium sulfate Bolus: 1 “2 g (8 “16 mEq) Drug of choice in patients with torsade de pointes For recurrent/refractory VT or VF For hypomagnesemia For ventricular dysrhythmias, administer over 1 “2 min For magnesium deficiency, administer over 60 min Infusion: 0.5 “1 g/h (4 “8 mEq/h) Rate and duration of infusion determine clinically or by magnitude of magnesium deficiency Naloxone 0.4 mg IV is typical Onset of action 2 min IV and <5 min IM/SC May give 0.4 “2 mg IV every 2 “3 min (maximum dose is 10 mg) Duration of action ~45 min Give 0.4 mg diluted in 10 ml NS or sterile water slowly to avoid abrupt narcotic withdrawal 0.8 mg IM/SC Hypertension/hypotension, cardiac arrhythmias, pulmonary edema may occur Monitor for reoccurring respiratory depression because narcotics typically last longer than naloxone ETT: 2 mg diluted in 5 “10 ml NS or sterile water (IV preferred) Procainamide 12 “17 mg/kg; administer at rate of 20 “30 mg/min (maximum 50 mg/min) Infrequently used Recommended when lidocaine is contraindicated or has failed to suppress ventricular ectopy Use higher dose for more urgent situations (VF or pulseless VT) Maximum total dose of 17 mg/kg Continue bolus dosing until arrhythmia suppressed, hypotension, QRS complex widens by 50% of original width, or maximum total dose given Rapid infusion may cause precipitous hypotension Avoid in patients with QT prolongation (>30% above baseline) or torsade de pointes Infusion: 1 “4 mg/min Continuous maintenance infusion, after return of perfusion, to prevent recurrent arrhythmias Reduce dosage in renal failure Monitor blood levels in patients with renal failure or with >24-h infusion Therapeutic levels: procainamide 4 “10 mg/L, N-acetyl-procainamide (NAPA) 10 “20 mg/L Vasopressin 40 U IV push, one dose only As an alternative to 1st or 2nd dose epinephrine in refractory VF, asystole, or PEA resume epinephrine after 3 “5 min Verapamil Bolus: 2.5 “10 mg over 2 “3 min Only give to patients with narrow complex PSVT unresponsive to adenosine May repeat in 15 “30 min prn Max. cumulative = 20 mg Diltiazem (0.25 mg/kg) is an alternative to verapamil because it has less negative inotropy Vasopressor Agents Dopamine (For other vasopressors, Table 3.8 ) Infusion: 2 “20 µg/kg/min For treatment of symptomatic bradycardia unresponsive to atropine and transcutaneous pacing For treatment of hypotension that is unresponsive to volume Electrolyte Agents Sodium bicarbonate Bolus: 1 mEq/kg Helpful in limited clinical conditions: hyperkalemia, bicarbonate responsive acidosis, tricyclic antidepressant overdose Not recommended in the majority of arrest cases (hypoxic lactic acidosis) Guide therapy by blood gas analyses and calculated base deficit to minimize iatrogenic alkalosis A fib, atrial fibrillation; A flutter, atrial flutter; CPR, cardiopulmonary resuscitation; EF, ejection fraction; EKG, electrocardiogram; ETT, endotracheal tube; IM, intramuscular; IV, intravenous; LV, left ventricular; MI, myocardial infarction; NS, normal saline; PEA, pulseless electrical activity; PSVT, paroxysmal supraventricular tachycardia; PVC, premature ventricular contraction; SC, subcutaneous ; VF, ventricular fibrillation; VT, ventricular tachycardia

Shock General Management

Type of Shock Initial Therapy Subsequent Therapy Cardiogenic Shock Massive myocardial infarction Supplemental oxygen , aspirin, pain relief, venous access Therapy for ACS (see Table 3.1 ) Optimize volume status and ensure adequate preload Treat arrhythmias Consider RHC Determine need for inotropic agents; diuretics; vasodilators; vasopressors (see Tables 3.3 and 3.8 ) Consider mechanical ventilation Early IAB, coronary arteriography, and revascularization by PCI or bypass grafting Consider thrombolytic agent if cardiac catheterization not possible Nonischemic cardiomyopathy Therapy as above, but omit therapy for ACS Consider IAB or assist devices as bridge to transplantation Consider reversible causes (e.g., acute valvular regurgitation requiring emergent valve replacement, thyrotoxicosis ) Oligemic Shock Massive hemorrhage, severe dehydration, etc. For hemorrhage, large bore peripheral or central venous access Volume resuscitation with packed RBCs and 0.9% NaCl Consider use of blood warmer If large bleed , consider platelets, fresh frozen plasma, and supplemental calcium For dehydration, volume resuscitation with 0.9% NaCl or Ringer's lactate Monitor electrolytes and coagulation If hypotension persists despite volume resuscitation, consider: possibility of coexisting sepsis, tamponade, or ACS; RHC; inotropic and/or vasopressor agents Consult GI and surgery for massive gastrointestinal hemorrhage (see Table 7.1 ) Extracardiac Obstructive Shock Tamponade Confirm suspected diagnosis with echocardiography and/or RHC, temporize by increasing filling pressures with bolus 0.9% NaCl IV; support BP Urgent percutaneous pericardiocentesis, surgical pericardiotomy, or pericardial window Massive pulmonary embolism Correct hypoxemia; administer heparin or LMWH; thrombolytic therapy (alteplase 100 mg IV over 2 h); give inotropic support such as dobutamine for right heart strain and failure Consider percutaneous catheter suction thrombectomy or thoracotomy with embolectomy Consider IVC filter long term See Table 4.11 Tension pneumothorax Emergent needle or tube thoracostomy Tube thoracostomy Distributive Shock Septic shock Emergent broad-spectrum antibiotics IV after blood cultures; IV crystalloid; if shock persists, consider RHC If shock persists despite adequate preload, add dopamine 2 “20 µg/kg/min; or norepinephrine 2 µg/min Consider vasopressin in refractory shock Stress dose steroids hydrocortisone 100 mg IV q8h; optional fludrocortisone 50 µg po qd Consider baseline cortisol level prior to glucocorticosteroid therapy and corticotropin stimulation test Role of drotrecogin alfa is not established a Anaphylaxis Epinephrine 0.3 “0.5 mg for severe symptoms of hypotension, bronchospasm, or laryngeal edema; given as 0.3 “0.5 ml of 1:1,000 SC or 0.5 “1.0 ml of 1:10,000 solution IV; also give diphenhydramine 50 mg IV; repeat 25 “50 mg IV q4h prn; abnormal permeability causes intravascular depletion, which should be corrected with volume Cautious administration prn of additional epinephrine; give corticosteroids (Methylprednisolone 60 mg IV or equivalent) and cimetidine 300 mg IV q12; these will have delayed rather than immediate effect For persistent symptoms and patient on ²-blockers, give glucagon 1 mg IV Hypoadren-alism Administer dexamethasone 4 mg IV q6h together with fluids To confirm diagnosis, perform corticotropin stimulation test (dexamethasone will not interfere); draw baseline cortisol level, give 250 µg IV cosyntropin, and repeat cortisol level 30 min later Neurogenic Trendelenburg position; fluids If hypotension persists, consider vasopressors (e.g., phenylephrine or metaraminol) ACS, acute coronary syndrome; BP, blood pressure; GI, gastroenterology; IAB, intra- aortic balloon; IV, intravenous; IVC, inferior vena cava; LMWH, low molecular weight heparin; PCI, percutaneous coronary intervention; RBCs, red blood cells ; RHC, right heart catheterization a While some authors recommend drotrecogin alfa (recombinant activated protein C) in highly selected patients with a high risk of death (Apache score of ‰25) and a low risk of bleeding, the role of drotrecogin alfa in septic patients has not been clearly established. It has no effect or is harmful in septic patients with Apache score of <25, in surgical patients with single organ dysfunction, and in pediatric sepsis. The risk of serious bleeding including intracerebral hemorrhage is increased in patients receiving drotrecogin alfa.

Hypovolemic Shock

Mild Moderate Severe Life- threatening % loss of intravascular volume ‰10 “15% 15 “30% 30 “40% >40% Loss of intravascular volume (cc) <700 “800 800 “1500 1500 “2000 >2000 Mean arterial pressure WNL WNL Reduced Reduced Heart rate 80 “100 101 “119 120 “140 >140 Pulse pressure WNL/increased 101 “119 Reduced 120 “140 Reduced >140 Reduced Respirations (breaths/min) 15 “20 21 “29 30 “35 >35 Capillary refill test a ‰2 s >3 s >3 s >3 s Urine output (cc/h) ‰30 20 “30 5 “15 Oliguria Mental status Uneasy Mild anxiety Anxiety or confusion Confusion or lethargy Volume replacement Crystalloid Crystalloid Crystalloid or blood if indicated Crystalloid or blood if indicated a The capillary refill test is performed by pressing on the fingernail or the hypothenar eminence. The test is not valid in hypothermic patients. WNL = within normal limits.

Crystalloids and Colloids

Fluid Dosage Comments 0.9% NaCl ‰500 ml a Hyperchloremic metabolic acidosis secondary to vigorous NaCl replacement may occur Lactated Ringer's ‰500 ml a Balanced electrolyte composition (mEq/L): Na + 130, K + 4, Ca ++ 3, Cl - 110, lactate 28 Not compatible with blood products 5% albumin 0.25 “1 g/kg b Each 250 ml contains 12.5 g albumin 25% albumin 0.25 “1 g/kg b Each 100 ml contains 25 g albumin 6% hetastarch ‰500 ml a Chemically modified glucose polymer Large doses, especially >1500 ml, can lead to coagulopathies (factor VIII deficiency) and platelet abnormalities Can cause artifactual hyperamylasemia Anaphylactoid reactions have occurred Total amount should not exceed 1,500 ml/d (20 ml/kg) Cautious use in cardiac bypass and septic patients 6% hetastarch in lactated electrolyte injection 500 “1,000 ml Chemically modified glucose polymer Balanced electrolyte composition (mEq/L): Na + 143, K + 3, Ca ++ 5, Cl - 124, Mg ++ 0.9, lactate 28, dextrose 0.99 g/L A volume expander used to support oncotic pressure and provide electrolytes Doses >1,500 ml are rarely required Can cause artifactual hyperamylasemia Use with caution in anticoagulated patients a Most crystalloids are given in 500 ml aliquots as quickly as possible (i.e., over 10 “15 minutes) to increase blood pressure or perfusion. If initial aliquot is not successful in increasing blood pressure, then repeat until hemodynamic stability or the addition of a vasopressor agent occur. b Colloid has no proven outcome benefit in general ICU patients; it may have a role in hypotensive patients. Dextrans and gelatins are rarely used plasma expanders.

Universal Algorithm for Adult Emergency Cardiac Care AED, automatic external defibrillator; CPR, cardiopulmonary resuscitation; ECG, electro-cardiogram; EMS Emergency Management Service; IV, intravenous; MI, myocardial infarction

Algorithm for Ventricular Fibrillation (VF) and Pulseless Ventricular Tachycardia (VT) ABC, airway breathing circulation; CPR, cardiopulmonary resuscitation; IV, intravenous; PEA, pulseless electrical activity Give drugs typically at 3 “5 minute intervals: Vasopressin 40 U IV single dose (wait 10 minutes before giving epinephrine)

Algorithm for Pulseless Electrical Activity (PEA) CPR, cardiopulmonary resuscitation; EMD, electromechanical dissociation; IV, intravenous Class I: definitely helpful. Class IIa: acceptable, probably helpful. Class IIb: acceptable, possibly helpful. Class III: not indicated, may be harmful. *Sodium bicarbonate 1 mEq/kg: is Class I: if patient has known pre-existing hyperkalemia. Sodium bicarbonate 1 mEq/kg: Class IIa: if known pre-existing bicarbonate-responsive acidosis; if overdose with tricyclic antidepressants; to alkalinize the urine in drug overdoses. Class IIb: if intubated and long arrest interval; upon return to spontaneous circulation after long arrest interval. Class III: hypoxic lactic acidosis. (

Asystole Treatment Algorithm CPR, cardiopulmonary resuscitation; IV, intravenous; TCP, transcutaneous pacing (

Bradycardia Algorithm (Patient not in Cardiac Arrest) ABC, airway breathing circulation; AV, atrioventricular; BP, blood pressure; ECG, electrocardiogram; HF, heart failure; IV, intravenous; MI, myocardial infarction; TCP, transcutaneous pacemaker *Serious signs or symptoms must be related to the slow rate. Clinical manifestations include: symptoms (chest pain, shortness of breath , decreased level of consciousness) and signs (low BP, shock, pulmonary congestion, HF, acute MI). Do not delay TCP while awaiting IV access or for atropine to take effect if patient is symptomatic. §Atropine should be given in repeat doses in 3 “5 minutes up to total of 0.04 mg/kg. Never treat third-degree heart block plus ventricular escape beats with lidocaine. #Verify patient tolerance and mechanical capture. Use analgesia and sedation as needed. (

Tachycardia Algorithm ABC, airway breathing circulation; AV, atrioventricular; BP, blood pressure; DC, direct current; ECG, electrocardiogram; LV, left ventricular; PSVT, paroxysmal supraventricular tachycardia; VT, ventricular tachycardia

Electrical Cardioversion Algorithm (Patient not in Cardiac Arrest) IV, intravenous; VT, ventricular tachycardia *PSVT (paroxysmal supraventricular tachycardia) and atrial flutter often respond to lower energy levels (start with 50 J) Source Link can be found here- http://www.aclspro.com/links.htm

What is a Tracheostomy?........

A tracheotomy or a tracheostomy is an opening surgically created through the neck into the trachea (windpipe) to allow direct access to the breathing tube and is commonly done in an operating room under general anesthesia. A tube is usually placed through this opening to provide an airway and to remove secretions from the lungs. Breathing is done through the tracheostomy tube rather than through the nose and mouth. The term “tracheotomy” refers to the incision into the trachea (windpipe) that forms a temporary or permanent opening, which is called a “tracheostomy,” however; the terms are sometimes used interchangeably.

Reasons for a tracheostomy

A tracheotomy is usually done for one of three reasons:

1. to bypass an obstructed upper airway;
2. to clean and remove secretions from the airway;
3. to more easily, and usually more safely, deliver oxygen to the lungs.

All tracheostomies are performed due to a lack of air getting to the lungs. There are many reasons why sufficient air cannot get to the lungs.
Airway Problems That May Require a Tracheotomy

• Tumors, such as cystic hygroma
• Laryngectomy
• Infection, such as epiglottitis or croup
• Subglottic Stenosis
• Subglottic Web
• Tracheomalacia
• Vocal cord paralysis (VCP)
• Laryngeal injury or spasms
• Congenital abnormalities of the airway
• Large tongue or small jaw that blocks airway
• Treacher Collins and Pierre Robin Syndromes
• Severe neck or mouth injuries
• Airway burns from inhalation of corrosive material, smoke or steam
• Obstructive sleep apnea
• Foreign body obstruction

Lung Problems That May Require a Tracheostomy

• Need for prolonged respiratory support, such as Bronchopulmonary Dysplasia (BPD)
• Chronic pulmonary disease to reduce anatomic dead space
• Chest wall injury
• Diaphragm dysfunction

Other Reasons for a Tracheostomy

• Neuromuscular diseases paralyzing or weakening chest muscles and diaphragm
• Aspiration related to muscle or sensory problems in the throat
• Fracture of cervical vertebrae with spinal cord injury
• Long-term unconsciousness or coma
• Disorders of respiratory control such as congenital central hypoventilation or central apnea
• Facial surgery and facial burns
• Anaphylaxis (severe allergic reaction)

How a tracheostomy is performed

Surgical Anatomy

The superior thyroid notch, cricoid and suprasternal notch usually can be easily palpated through the skin. The cricothyroid space can be identified by palpating a slight indentation immediately below the inferior edge of the thyroid cartilage. Cricothyroid arteries traverse the superior aspect of this space on each side and anastomose near the midline.
The innominate artery crosses from left to right anterior to the trachea at the superior thoracic inlet. Its pulsations can be palpated and occasionally seen in the suprasternal notch especially in case of a high riding vessel, representing a contraindication for a bedside percutaneous or open tracheostomy.
The isthmus of the thyroid gland lies across the 2nd to 4th tracheal rings and must be dealt with in any procedure at or around the upper trachea.

Indications for PDT

They are the same as a routine open operative tracheostomy with particular attention to contraindications.¹

Contraindications for PDT

Absolute:
Emergent tracheostomy ( i.e., securing emergent airway) in any patient population, infants and children (<15 years)
Relative Surgical Contraindications: Poor neck landmarks, neck mass (e.g. goiter), high innominate or pulsating vessels, previous neck surgery, limited neck extension, severe coagulation (uncorrected)
Relative Anesthetic Contraindications:
High PEEP (>18 cm), high airway pressure (>45 cm), high FiO2 (80%), retrognathic mandible with a limited view of the larynx on laryngoscopy

Preparation for Tracheostomy

Once the decision to perform a tracheostomy has been made, the surgeon must determine if the patient is a good candidate for the surgery and obtain written informed consent. In addition, the range of motion of the neck needs to be assessed. The tracheostomy team, including the surgeons and anesthesiologists need to discuss the entire sequence and alternatives to the procedure. All equipment must be available and functioning properly.

Equipment

A regimented approach to preparation and performance of the procedure has been shown to significantly reduce the incidence of procedural complications⁴.
Our approach includes the following equipment and protocols:

• We routinely use Cook Blue Rhino single dilator kit and videobronchoscopy to perform the procedure.
• The following must be available:
  • An attending anesthesiologist must be present for maintenance of airway, provision of intravenous sedation and performance of bronchoscopy.
  • An intubation roll and a cricoid hook.
  • Open tracheostomy set.

Technique

Watch a tracheostomy (24 MB Windows Media file)

The technique described here is based on Seldinger’s principle ². The technique we use was first described and later modified by Ciaglia ³. The use of bronchoscopy was first introduced by Marelli et al and has subsequently been adopted by many centers ^{4, 5}.
Positioning

1. The patient’s neck is extended over a shoulder roll (unless there is a contraindication).
2. The anesthesiologist stands at the head end of the bed and under direct laryngoscopy positions the endotracheal tube (ETT) so that the cuff is midway at the vocal cord level.

Incision

1. We routinely inject the skin with 1% lidocaine with 1:100,000 epinephrine solution.
2. A horizontal or vertical incision centered on the inferior border of the cricoid cartilage may be used. We routinely use a 3-4 cm vertical incision.

Placement of Introducer Needle

1. A minimal dissection is performed onto the pretracheal tissue in order to push the thyroid isthmus downward.
2. The larynx is stabilized and pulled cephalad with the operator’s left hand.
3. A bronchoscopy is then performed and the light reflex is used to select the best site for the introducer needle.
4. Placing the needle at the inferior edge of the light reflex, the tip of the needle is directed caudad into the tracheal lumen avoiding the posterior tracheal wall at all cost.

Introduction of Guide Wire, Stylet and Initial Tract Dilatation The needle is withdrawn while keeping the cannula in the tracheal lumen. A J-tipped guide wire is then place under vision. The stylet is then placed with the safety ridge directed towards the tip of the wire. The tract is then dilated with the 8 FR dilator.
Dilatation with the Blue Rhino Dilator The Blue Rhino dilator is loaded on the stylet with the tip resting on the safety ridge. The dilator is moved in and out to optimally dilate the tissue between the skin and the tracheal lumen. The Blue Rhino dilator is never advanced beyond the point where 40 FR mark disappears below the skin level.
Placement of the Tracheostomy Tube

1. A tracheostomy tube is loaded onto the dilator
   - Females: a size 6 cuffed Shiley tracheostomy tube is loaded on to the 26 FR dilator
   - Males: a size 8 cuffed Shiley tracheostomy tube is loaded on to the 28 FR dilator
2. The dilator is then loaded on the safety ridge of the stylet and placed into the tracheal lumen under direct visualization.

Confirmation of Placement
The bronchoscope is withdrawn from the ETT and introduced via the tracheostomy tube. The placement is confirmed by visualizing the carina.
Securing the Tube
We routinely secure the tube with 2 sutures of 2-0 nylon on each side of the flange. In addition, a tracheostomy tape is used to hold the tube in place. A flexible extension tube is used to connect the tube to the ventilator circuit to avoid undue movement of the tube in the immediate postoperative period.

Postoperative Consideration

A chest X-ray is not routinely required as long as the entire procedure was done under direct visualization and there were no adverse events intraoperatively⁶. The postoperative care is same as for the open procedure.
The tract between the skin and the tracheal lumen takes a little longer (10-14 days) to mature as there is no formal layer by layer dissection involved. We, therefore, perform the first tube change on Day 10-12 postoperatively.

Bedside Percutaneous Dilational Tracheostomy (PDT)

Overview

Watch video of procedure

Percutaneous dilational tracheostomy (PDT), also referred to as bedside tracheostomy, is the placement of a tracheostomy tube without direct surgical visualization of the trachea. This is considered a minimally invasive, bedside procedure that may be easily performed in the intensive care unit or at the patient’s bedside – with continuous monitoring of the patient’s vital signs.
Two critically important preoperative criteria for PDT are:

• The ability to hyperextend the neck
• Presence of at least 1 cm distance between cricoid cartilage and suprasternal notch ensuring that the patient will be able to be reintubated in case of accidental extubation

Patients should not be considered for this procedure if they are:

• Children (younger than 12 years of age)
• Obese
• Patients with severe coagulopathies

Techniques

There are several different systems and approaches for PDT. Following are brief descriptions:

Ciaglia (method used at Hopkins)
With this technique, there is no sharp dissection involved beyond the skin incision. The patient is positioned and prepped in the same way as for the standard operative tracheostomy. General anesthesia is administered and all steps are done under bronchoscopic vision.

Procedure:

• Skin incision is made and the pretracheal tissue is cleared with blunt dissection.
• Endotracheal tube is withdrawn enough to place the cuff at the level of the glottis.
• Endoscopist places the tip of the bronchoscope such that the light from its tip shines through the surgical wound.
• Operator enters the tracheal lumen below the second tracheal ring with an introducer needle.
• The tract between the skin and the tracheal lumen is then serially dilated over a guidewire and stylet.
• A tracheostomy tube is placed under direct bronchoscopic vision over a dilator.
• Placement of the tube is confirmed again by visualizing the tracheobroncial tree through the tube.
• Tube is secured to the skin with sutures and the tracheostomy tape.
• We routinely use Ciaglia Blue Rhino Percutaneous Tracheostomy Introducer Tray.

Shachner (Rapitrac) systemAfter making a small skin incision, the surgeon passes a dilator tracheotome over the guidewire into the trachea to dilate the tract fully in one step. The tracheotome has a beveled metal core with a hole through its center that accommodates a guidewire. Once inside the trachea, the tracheotome is dilated. A conventional tracheostomy cannula, fitted with a special obturator, is passed through the tracheal opening. The dilator and obturator are then removed.

Translaryngeal tracheostomy (Fantoni’s technique)
Unlike the other techniques, the initial puncture of the trachea is carried out with the needle directed cranially and the tracheal cannula inserted with a pull-through technique along the orotracheal route in a retrograde fashion. The cannula is then rotated downward using a plastic obturator. The main advantage of Fantoni’s tracheostomy is the minimal amount of skin incision required, with practically no bleeding observed. It should be noted that the procedure can only be carried out under endoscopic guidance, and rotating the tracheal cannula downward may pose a problem – demanding that the surgeon have more experience.

Advantages of PDT

Although there is a learning curve to the technique of PDT, it is relatively easy to learn. The learning curve may be overcome by performing a number of supervised procedures. Other advantages include:

• Time required for performing bedside PDT is considerably shorter than that for an open tracheostomy
• Elimination of scheduling difficulty associated with operating room and anesthesiology teams for critical care patients
• PDT expedites the performance of the procedure because critically ill patients who would require intensive monitoring to and from the operating room need not be transported
• Cost of performing PDT is roughly half that of performing open surgical tracheostomy due to the savings in operating room charges and anesthesia fees
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Complications and Risks of Tracheostomy

As with any surgery, there are some risks associated with tracheotomies. However, serious infections are rare.
Early Complications that may arise during the tracheostomy procedure or soon thereafter include:

• Bleeding
• Air trapped around the lungs (pneumothorax)
• Air trapped in the deeper layers of the chest(pneumomediastinum)
• Air trapped underneath the skin around the tracheostomy (subcutaneous emphysema)
• Damage to the swallowing tube (esophagus)
• Injury to the nerve that moves the vocal cords (recurrent laryngeal nerve)
• Tracheostomy tube can be blocked by blood clots, mucus or pressure of the airway walls. Blockages can be prevented by suctioning, humidifying the air, and selecting the appropriate tracheostomy tube.

Many of these early complications can be avoided or dealt with appropriately with our experienced surgeons in a hospital setting.
Over time, other complications may arise from the surgery.
Later Complications that may occur while the tracheostomy tube is in place include:

• Accidental removal of the tracheostomy tube (accidental decannulation)
• Infection in the trachea and around the tracheostomy tube
• Windpipe itself may become damaged for a number of reasons, including pressure from the tube; bacteria that cause infections and form scar tissue; or friction from a tube that moves too much

These complications can usually be prevented or quickly dealt with if the caregiver has proper knowledge of how to care for the tracheostomy site.
Delayed Complications that may result after longer-term presence of a tracheostomy include:

• Thinning (erosion) of the trachea from the tube rubbing against it (tracheomalacia)
• Development of a small connection from the trachea (windpipe) to the esophagus (swallowing tube) which is called a tracheo-esophageal fistula
• Development of bumps (granulation tissue) that may need to be surgically removed before decannulation (removal of trach tube) can occur
• Narrowing or collapse of the airway above the site of the tracheostomy, possibly requiring an additional surgical procedure to repair it
• Once the tracheostomy tube is removed, the opening may not close on its own. Tubes remaining in place for 16 weeks or longer are more at risk for needing surgical closure

A clean tracheostomy site, good tracheostomy tube care and regular examination of the airway by an otolaryngologist should minimize the occurrence of any of these complications.

High-risk groups

The risks associated with tracheostomies are higher in the following groups of patients:

• children, especially newborns and infants
• smokers
• alcohol abusers
• diabetics
• immunocompromised patients
• persons with chronic diseases or respiratory infections
• persons taking steroids or cortisone

Types of Tracheostomy Tubes

A tracheotomy (trach) tube is a curved tube that is inserted into a tracheostomy stoma (the hole made in the neck and windpipe (Trachea)). There are different types of tracheostomy tubes that vary in certain features for different purposes. These are manufactured by different companies. However, a specific type of tracheostomy tube will be the same no matter which company manufactures them.
A commonly used tracheostomy tube consists of three parts: outer cannula with flange (neck plate), inner cannula, and an obturator. The outer cannula is the outer tube that holds the tracheostomy open. A neck plate extends from the sides of the outer tube and has holes to attach cloth ties or velcro strap around the neck. The inner cannula fits inside the outer cannula. It has a lock to keep it from being coughed out, and it is removed for cleaning. The obturator is used to insert a tracheostomy tube. It fits inside the tube to provide a smooth surface that guides the tracheostomy tube when it is being inserted.
There are different types of tracheostomy tubes available and the patient should be given the tube that best suits his/her needs. The frequency of these tube changes will depend on the type of tube and may possibly alter during the winter or summer months. Practitioners should refer to specialist practitioners and/or the manufacturers for advice.

Tube	Indication	Recommendations
CuffedTube with Disposable Inner Cannula
	Used to obtain a closed circuit for ventilation	Cuff should be inflated when using with ventilators. Cuff should be inflated just enough to allow minimal airleak. Cuff should be deflated if patient uses a speaking valve. Cuff pressure should be checked twice a day. Inner cannula is disposable.
Cuffed Tube with Reusable Inner Cannula
	Used to obtain a closed circuit for ventilation	Cuff should be inflated when using with ventilators. Cuff should be inflated just enough to allow minimal airleak. Cuff should be deflated if patient uses a speaking valve. Cuff pressure should be checked twice a day. Inner cannula is not disposable. You can reuse it after cleaning it thoroughly.
Cuffless Tube with Disposable Inner Cannula
	Used for patients with tracheal problems Used for patients who are ready for decannulation	Save the decannulation plug if the patient is close to getting decannulated. Patient may be able to eat and may be able to talk without a speaking valve. Inner cannula is disposable
Cuffed Tube with Reusable Inner Cannula
	Used for patients with tracheal problems Used for patients who are ready for decannulation	Save the decannulation plug if the patient is close to getting decannulated. Patient may be able to eat and may be able to speak without a speaking valve. Inner cannula is not disposable. You can reuse it after cleaning it thoroughly.
Fenestrated Cuffed Tracheostomy Tube
	Used for patients who are on the ventilator but are not able to tolerate a speaking valve to speak	There is a high risk for granuloma formation at the site of the fenestration (hole). There is a higher risk for aspirating secretions. It may be difficult to ventilate the patient adequately.
Fenestrated Cuffless Tracheostomy Tube
	Used for patients who have difficulty using a speaking valve	There is a high risk for granuloma formation at the site of the fenestration (hole).
Metal Tracheostomy Tube
	Not used as frequently anymore. Many of the patients who received a tracheostomy years ago still choose to continue using the metal tracheostomy tubes.	Patients cannot get a MRI. One needs to notify the security personnel at the airport prior to metal detection screening.

Living with a Tracheostomy

Troubleshooting a tracheostomy change
Tracheostomy care/suctioning
Stoma care
Tracheostomy equipment
Tracheostomy equipment cleaning and care
Eating with a tracheostomy
Speech with a tracheostomy
Tracheostomy as a Passey Muir Valve
Suctioning a tracheostomy
Traveling with a tracheostomy
Swimming with a tracheostomy
Tracheostomy Humidification
Decannulation

Professional Organizations
American Academy of Otolaryngology - Head and Neck Surgery
American Association for Respiratory Care
Resources for Nurses Caring for Patients with a Tracheostomy Society of Otorhinolaryngology and Head-Neck Nurses, Inc. (SOHN)
AAOHNS Conferences and Events
Support Group

Sample Chapter of Wound Care Made Incredibly Easy! 1st UK Edition

Medical proceedures....Minimally Invasive Total Hip Replacement

Total hip replacement is a common orthopedic procedure. As the population ages, it is expected to become even more common. Hip replacement surgery involves removing the head of the thighbone (femur) and replacing the ball-and-socket mechanism of the hip with artificial implants. This relieves pain and improves mobility.
Minimally invasive hip replacement allows the surgeon to perform the hip replacement through one or two small incisions. Patients usually have less pain compared with traditional hip replacement surgery, and rehabilitation is faster.

Osteoarthritis and Hip Replacement

Osteoarthritis of the hip is the most common reason for a hip replacement. Osteoarthritis is caused by the wear and tear of aging. It causes the cartilage covering the joint surfaces to wear out, resulting in pain and stiffness.
Other conditions that can cause destruction of the hip joint include loss of the blood supply to the head of the thighbone (osteonecrosis), rheumatoid arthritis, injury, infection, and developmental abnormalities of the hip. Patients with arthritis may also have brittle bones (osteoporosis), but there is no direct relationship between bone density and the development of arthritis of the hip.

Symptoms

Hip arthritis typically causes pain that is dull and aching. The pain may be constant or it may come and go. Pain may be felt in the groin, thigh, and buttock, or there may be referred pain to the knee. Walking, especially for longer distances, may cause a limp.
Some patients may need a cane, crutch, or walker to help them get around. Pain usually starts slowly and worsens with time and higher activity levels.
Patients with hip arthritis may have difficulty climbing stairs. Dressing, tying shoes, and clipping toenails can be difficult or impossible. Pain may also interfere with sleep.
See your doctor to diagnose hip arthritis. The doctor will inquire about your symptoms and perform a physical examination. X-rays may show loss of the cartilage space in the hip socket and a "bone-on-bone" appearance. Bone spurs and bone cysts are common.
Sometimes, the doctor may recommend additional tests to confirm the diagnosis, including magnetic resonance imaging (MRI) or computed tomography (CT) scans.

Treatment for Osteoarthritis

Nonsurgical Treatment

For hip arthritis, the first treatment a doctor may recommend is over-the-counter, anti-inflammatory medications, such as ibuprofen. Some nutritional supplements, including glucosamine, may also provide some relief. Short-term physical therapy may help improve strength and reduce stiffness.

For patients with more advanced arthritis, use of a cane opposite the affected hip can help transfer weight away from the painful hip and improve walking ability. A walker can also be used. Arthritis, however, is progressive. Even with treatment, it will worsen over time. Weight loss can help decrease stresses on all of the joints.

Surgical Treatment

Pain and mobility may worsen with hip osteoarthritis, even when all of the recommended nonsurgical treatments have been tried. If this happens, the doctor may recommend surgery. Surgical options include:

• Arthroscopy. Arthroscopy of the hip is a minimally invasive, outpatient procedure that is relatively uncommon. The doctor may recommend it if the hip joint shows evidence of torn cartilage or loose fragments of bone or cartilage.
• Osteotomy. Candidates for osteotomy include younger patients with early arthritis, particularly those with an abnormally shallow hip socket (dysplasia). The procedure involves cutting and realigning the bones of the hip socket and/or thighbone to decrease pressure within the joint. In some people, this may delay the need for replacement surgery for 10 to 20 years.

Types of Hip Replacement

Traditional Hip Replacement

Traditional hip replacement surgery involves making a 10- to 12-inch incision on the side of the hip. The muscles are split or detached from the hip, allowing the hip to be dislocated.

Once the joint has been opened up and the joint surfaces exposed, the surgeon removes the ball at the top of the thighbone, or femur. The hip socket is prepared by removing any remaining cartilage and some of the surrounding bone. A cup-shaped implant is then pressed into the bone of the hip socket. It may be secured with screws. A smooth plastic bearing surface is then inserted into the implant so the joint can move freely.
Next, the femur is prepared. A metal stem is placed into the femur to a depth of about 6 inches. The stem implant is either fixed with bone cement or is implanted without cement. Cement less implants have a rough, porous surface. It allows bone to adhere to the implant to hold it in place. A metallic ball is then placed on the top of the stem. The ball-and-socket joint is recreated.

Minimally Invasive Hip Replacement

Minimally invasive hip replacement surgery allows the surgeon to perform the hip replacement through one or two smaller incisions.

Candidates for minimal incision procedures are typically thinner, younger, healthier, and more motivated to have a quick recovery compared with patients who undergo the traditional surgery.
Before you decide to have a minimally invasive hip replacement, get a thorough evaluation from your surgeon. Discuss with him or her the risks and benefits. Both traditional and minimally invasive hip replacement procedures are technically demanding. They require that the surgeon and operating team have considerable experience.

Technique

The artificial implants used for the minimally invasive hip replacement procedures are the same as those used for traditional hip replacement. Specially designed instruments are needed to prepare the socket and femur and to place the implants properly.

The surgical procedure is similar, but there is less soft-tissue dissection. A single minimally invasive hip incision may measure only 3 to 6 inches. It depends on the size of the patient and the difficulty of the procedure.
The incision is usually placed over the outside of the hip. The muscles and tendons are split or detached, but to a lesser extent than in the traditional hip replacement operation. They are routinely repaired after the surgeon places the implants. This encourages healing and helps prevent dislocation of the hip.
Two-incision hip replacement involves making a 2- to 3-inch incision over the groin for placement of the socket. A 1- to 2-inch incision is made over the buttock for placement of the stem.
To perform the two-incision procedure, the surgeon may need guidance from X-rays. It may take longer to perform this surgery than it does to perform traditional hip replacement surgery.

Benefits

Reported benefits of less invasive hip replacement include:

• Less pain
• More cosmetic incisions
• Less muscle damage
• Rehabilitation is faster
• Hospital stays are shorter

For traditional hip replacement, hospital stays average 4 to 5 days. Many patients need extensive rehabilitation afterward. With less-invasive procedures, the hospital stay may be as short as 1 or 2 days. Some patients can go home the day of surgery.
Early studies suggest that minimally invasive hip replacement surgery streamlines the recovery process, but the risks and long-term benefits of less-invasive techniques have not yet been documented.