1) The document discusses various methods for verifying proper endotracheal tube placement, including direct visualization, chest movement observation, auscultation, end-tidal carbon dioxide (ETCO2) detection, and esophageal detector devices.
2) ETCO2 detection is recommended as the most reliable and objective method for verification, especially in patients with adequate circulation. A CO2 level >2% strongly indicates proper tracheal placement.
3) No single method is completely reliable so a secondary method should be used to confirm placement if CO2 is not detected. Continuous ETCO2 monitoring can help ensure the tube remains properly placed.
mapleson circuits used in anesthesia practice, are in their way out but it is as important to know the mechanism with which the gases flow to and fro through them.
Endocuff-Assisted Colonoscopy Demonstrates High Ileal Intubation and Adenoma ...JohnJulie1
The Endocuff (EC) significantly improves the Adenoma Detection Rate (ADR). Whereas cecal intubation and cost-effectiveness using the EC have been studied repeatedly, evidence regarding the Ileum Intubation Rate (IIR) remains scarce. This study investigates the IRR and ADR in EC-assisted colonoscopy compared with standard colonoscopy in patients undergoing screening and/or surveillance colonoscopy.
mapleson circuits used in anesthesia practice, are in their way out but it is as important to know the mechanism with which the gases flow to and fro through them.
Endocuff-Assisted Colonoscopy Demonstrates High Ileal Intubation and Adenoma ...JohnJulie1
The Endocuff (EC) significantly improves the Adenoma Detection Rate (ADR). Whereas cecal intubation and cost-effectiveness using the EC have been studied repeatedly, evidence regarding the Ileum Intubation Rate (IIR) remains scarce. This study investigates the IRR and ADR in EC-assisted colonoscopy compared with standard colonoscopy in patients undergoing screening and/or surveillance colonoscopy.
Post ERCP duodenal perforation is rare –but do occur in risky pts; and expertise is needed to know tricks and tips –of Ercp procedure --Best is to detect and confirm it but it is rare to detect it endoscopically .; recently post ERCp,prerforations can be treated during ERCP through endoccopically by hemoclip-endoloopd stents etc ;pts with signs of hemodynamic instability and peritonoits can be taken to Or after resuscitation and expected preparation ;–otherwise CT can with oral, contrast is mandatory to exclude or establish the disease; and also determine the type of management –when to observe when to operate-algorithm approach is there -More than 70 % can be managed non operatively--; Elderly pts carry high mortality for surgical intervention—also delay of more than 24 hours for surgical intervention carry high mortality so non operative treatment possibility with ct guided aspiration or endoscopic stenting’ laparoscopic closure ; and minimally invasive options as should be explored- best treatment is prevention; early detection; appropriate management and knowledge =update your knowledge periodically and hope for best
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Transesophageal echocardiography complications and probe insertion techniqueskp gourav
It deals with TEE probe insertion techniques in both awake and sedated patients. it also deals with various TEE probe related complications while inserting probe and also while handling.
The effects of laryngeal mask airway versus endotracheal tube on atelectasis in patients undergoing general anesthesia assessed by lung ultrasound: A protocol for a prospective, randomized controlled trial
Anatomical difficult airway has been emphasised immensely in poly trauma management . But we very often forgot to look into the correctable physiological airway difficulties ...this presentation is exploring this aspect of airway management .
This session was done in Nepal emergency medicine conference in October 2023 at Kathmandu
This session was done in 2 nd EMS and Industrial Emergency Medicine conference in Ahammadabad in Feb 2020. The presentation explores how to asses the Key Performance in EMS and Ambulance Scenario.
Airway manipulations and intubation are the potential to cause a high level of aerosolization in the emergency department. This presentation is giving an overview of how to perform protected intubation in the emergency department. It has prepared by using the available latest data on COVID 19 protected Intubation
Evidence-based medicine is the cornerstone of quality clinical practice. It is very important that a critical appraisal of a scientific article. This presentation covers a primary survey & Secondary survey approach to select, read and appraise the article
The presentation covers various aspects of DM like the type of disasters, scientific approach, disaster cycle, zones, Incident command, triage, Hospital plan, communication, statutory structure, and support organizations
Prehospital care in trauma is as important as in hospital care. The presentation addresses simple and basic approach to care a polytrauma victim in platinum 10 minutes based on BTLS.
The presentation covers basics of pharmacotherapy involves in advanced life support scenario including peri-arrest situations which have been updated 2019
The presentation covers an easy method to manage acute poisoning in Ed. It elaborates the tox presentations through four toxidromes and an algorithmic approach to solve the puzzle
The presentation covers definitions, identification, Treatment goals, Special situations, Practice points, and cardinal pharmacotherapy. Session presented in NBE learning session
This presentation covers various aspects of OHCA scenarios, including incidence, outcome, challenges, solutions, hen to initiate CPR, protocols, Termination, ECPR, and other issues are covering in details. Explore regional experiences in training and OHCA results as well.
This presentation covers various aspects of OHCA scenarios, including incidence, outcome, challenges, solutions, hen to initiate CPR, protocols, Termination, ECPR, and other issues are covering in details. Explore regional experiences in training and OHCA results as well.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
CDSCO and Phamacovigilance {Regulatory body in India}NEHA GUPTA
The Central Drugs Standard Control Organization (CDSCO) is India's national regulatory body for pharmaceuticals and medical devices. Operating under the Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, the CDSCO is responsible for approving new drugs, conducting clinical trials, setting standards for drugs, controlling the quality of imported drugs, and coordinating the activities of State Drug Control Organizations by providing expert advice.
Pharmacovigilance, on the other hand, is the science and activities related to the detection, assessment, understanding, and prevention of adverse effects or any other drug-related problems. The primary aim of pharmacovigilance is to ensure the safety and efficacy of medicines, thereby protecting public health.
In India, pharmacovigilance activities are monitored by the Pharmacovigilance Programme of India (PvPI), which works closely with CDSCO to collect, analyze, and act upon data regarding adverse drug reactions (ADRs). Together, they play a critical role in ensuring that the benefits of drugs outweigh their risks, maintaining high standards of patient safety, and promoting the rational use of medicines.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
Follow us on: Pinterest
Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Top 10 Best Ayurvedic Kidney Stone Syrups in India
Detecting methods of endotracheal tube positions
1. GUEST SPEAKER – LECTURE NOTES
DETECTING METHODS OF ENDOTRACHEAL
TUBE POSITION
[1st
Eurasian International Congress on Emergency Medicine
5th
– 9th
November, 2008 at Antalya Turkey]
Venugopalan P.P. DA, DNB, MNAMS, Chief of Emergency Medicine,
Malabar Institute of Medical Sciences Ltd., Calicut, India
Endotracheal intubation is a potential minefield for disaster. Errors in its performance can be
associated with high morbidity and mortality for the patient and legal liability for the
practitioner. Verification of Endo Tracheal Tube (ETT) placement is of vital importance since
unrecognized esophageal intubation can prove rapidly fatal or result in hypoxic brain damage in
survivors.
There are numerous methods and devices utilized for verifying endotracheal tube placement.
However none has been shown to be 100% reliable. Even the universally taught clinical signs of
esophageal intubation are often misleading. Verification of placement in the out of hospital
setting is not always straight forward since the procedure is typically performed under adverse
conditions after a cardiac arrest.
Verification methods
Although direct visualization of ETT passing through vocal cords is generally considered to be a
reliable indicator of tracheal intubation, such clinical anatomic observations are fallible and so
additional means are required to ensure correct placement of tube within the trachea.
1
2. Traditional methods, such as chest auscultation, gastric auscultation, bag resistance, exhaled
volume, visualization of condensation within ETT and Chest radiography, all are prone to failure
as means of confirming tracheal intubation [1].
Methods available to confirm ETT Placement
I. Observational verification
1. Direct visualization
2. Observation of chest movement
3. Five point auscultation
4. Presence of exhaled tidal volume
5. Reservoir bag compliance
6. Absence of air escape
7. Tube condensation with exhalation
8. Absence of gastric contents within the ETT
These methods are amenable to subjective variations.
II. Measured verifications
1. End-tidal Carbon dioxide (ETCO2)
2. Pulse Oximeter
These methods are more objective type
III. Anatomical verification
1. Chest radiograph
2. Esophageal Detector Device (EDD)
3. Lighted stylet
2
3. 4. Ultra-sonography (USG)
5. Fibro optic Bronchoscope / Laryngoscope
Merits and demerits of conventional verification methods
METHODS OF VERIFICATION DEMERITS
Direct visualization is usually used before
all other methods and the visualization of
cuff inflation distal to cords is thought to
be offer additional evidences of proper
placement [2]
• Non visualization of cords
• Dislodged tube (before / after
securing)
• Inadvertent esophageal intubation
after direct vision intubation [3]
Chest Movement There should be
adequate chest rise in a properly placed
ETT with bag ventilation
• Obesity - decreased or absent chest
excursion
• Lung diseases - decreased or absent
chest excursion
• Esophageal intubation does produce
some degree of chest movement [4,5]
Auscultation – Axilla
Breath sounds may be heard in both
axillae but may result in misdiagnosis
in up to 15 % of all esophageal
intubations. [6]
Epigastic Auscultation
May prove accuracy
• Not 100% reliable
• Gastric distention is gradual due to
previous bag mask ventilation
Exhaled tidal volume and reservoir bag
compliance
• Highly variable and respirator bag
compliance with either esophageal
or endotracheal tube insertions
inconsistent [7,8]
Endotracheal tube cuff maneuvers
Hearing high pitched sounds during cuff
deflation in tracheal placements and
palpation of ETT cuff in the neck by
• Techniques are unreliable in
distinguishing tracheal from
esophageal tube placements.
3
4. compressing external reservoir.
Tube condensation • Extremely unreliable
Gastric Content in tracheal tube • Considered unreliable [9]
End tidal CO2 detection
CO2 detection in exhaled air using devices (colorimetric CO2 detector, Capnograph - Digital or
wave form) after six manual ventilations through ET tube is used to confirm tube placement. End
tidal CO2 detection is highly reliable in identification of tracheal and esophageal intubation in
patients with spontaneous circulation [10]
.
Detection of exhaled CO2 is one of the several independent methods of confirming endotracheal
tube position and it can be used as the initial method for detecting correct tube placement even in
the victims of cardiac arrest (Class IIa) [11]
. In cardiac arrest a CO2 level > 2 % should be
considered definitive evidence of correct ETT placement, but the absence of such CO2 cannot be
used reliably as an indicator of esophageal intubation. [37]
One meta analysis in adult (LOE 1) [13]
, one prospective controlled cohort study (LOE 3) [14]
, and
several case series and reports (LOE 5] [15, 22]
, indicate that CO2 detection (wave form,
colorimetry, or digital) may be useful as an adjunct to confirm ET tube placement during cardiac
arrest.
Sensitivity – (Percentage of correct ET tube Placement detected when CO2 is detected) –
33 to 100 %)
Specificity – (Percentage of in correct esophageal placement detected when no CO2 is detected)
– 97 to 100 %
Positive predictive value (Probability of ET tube placement if CO2 is detected) 100 %
Negative predictive value (Probability of esophageal placement if no CO2 is detected) 20-100%
The threshold to detect exhaled CO2 is approximately 15 mmHg for the colorimetric
capnometer, where as a detectable waveform may be seen at much lower levels of CO2 with
capnography [23]
. Capnography is the most reliable method for detecting tube position,
independent of user’s experience [24]
. When exhaled CO2 is detected (Positive reading) in
4
5. Cardiac arrest, it is a reliable indicator of tube position in trachea. Consumption of large amount
of carbonated liquids before cardiac arrest may cause false positive reading in esophageal
intubation [25]
.
False negative reading (Failure to detect CO2 when tube is in the trachea) may be due to
1) Low Blood flow and CO2 delivery to lung (CPR)
2) Pulmonary embolism – decreased pulmonary blood flow
3) Contaminated detector – gastric content and acidic drugs like epinephrine when
administered through trachea.
4) IV epinephrine will reduce elimination and detection of CO2 [26]
5) Severe airway obstruction
6) Status Asthmatics
7) Pulmonary Edema
So if CO2 is not detected, a second method should be used to confirm endotracheal tube
placement, such as direct visualization or esophageal detection device [11]
. Digital or waveform
capnography is very useful to monitor tube position continuously.
Esophageal detector devices (EDD)
Principle : This is based on the anatomical differences between the trachea and esophagus.
Esophagus is a muscular structure with no support within its wall. Trachea is held patent by
cartilaginous rings. Vigorous aspiration of air through ETT with deflated cuffs result in occlusion
of ETT orifices by soft walls of the esophagus, where as aspiration is rapid and easy if the tube is
in trachea.
The EDD consists of a bulb that is compressed and attached to ET tube or a syringe that is
attached to ETT. The suction created by the EDD will collapse lumen of the esophagus and the
bulb will not re expand. If the rescuer attempts to pull the barrel of the syringe, it will not be
possible to pull the barrel, if tube is in esophagus.
5
6. Eight studies of at least fair quality evaluated the accuracy of EDD (LOE 3 [20, 28, 29]
, LOE 5 [30]
,
LOE 7 [non cardiac arrest setting] [31-34]
. EDD was highly sensitive for detection of esophageal
intubation in 5 case series (LOE 5 [30]
, LOE 7 [31-34]
.) and it had poor specificity for tracheal tube
placement in 2 studies (LOE 3 [20, 29]
in Operation Theatre setting. EDD had poor sensitivity and
specificity in children < 1 year of age (LOE 2) [35]
So EDD should be considered as just one of the several independent methods for confirmation of
tube placement. EDD is more specific to confirm esophageal tube placement than Tracheal Tube
placement. EDD is not accurate for continuous monitoring of ET Tube placement.
EDD will be misleading in the following situations.
1) Morbid obesity
2) Late pregnancy
3) Status Asthmaticus
4) Copious ET Secretions
5) Tracheal collapse
Pulse oximetry
Oximetry is useful in detecting esophageal intubation. But it may not show a decreasing Oxygen
(O2) saturation for several minutes after failed intubation because of the O2 reserve (Pre
oxygenation) created in the patient before intubation [36]
. Oximetry may be misleading in
spontaneously breathing patient who has had an inadvertent esophageal intubation. The
catastrophe ensues if the patient is later paralyzed or heavily sedated in the mistaken belief that
the tube is in the trachea.
Chest Radiography
Although chest radiography is universally recommended after ETT placement, its primary
purpose is to ensure its position below the cords and above the carina [37]
. An antero- posterior
film will not rule out an esophageal tube placement.
Other methods
6
7. Lighted stylet: Is not accurate and there is as yet no evidence to support its use to confirm
tracheal tube placement. Few studies show the usage of USG, to confirm tube placement [38-42]
Bed side ultrasonographic images proved to be invaluable when the colorimetric end-tidal CO2
detector yielded false negative or equivocal reading [43]
but required more evidence to
recommend it as a confirmation method for ET tube placement. In doubtful cases a fiber-optic
scope can be passed though ETT to identify tracheal rings, a gold standard for confirmation of
tracheal placement [37]
.
International recommendation
1) Emergency Medicine Journal March 2001 [44]
Independent confirmation of correct tube placement by the use of devices that detect
end-tidal CO2 is mandatory for every endotracheal intubation performed in the
emergency department and as part of the assessment of all patients who arrive at the
emergency department already intubated.
2) American College of Emergency Physicians (ACEP) October 2001 [45, 46]
During intubation, direct visualization of the endotracheal tube passing through the
vocal cords into the tracheal constitutes firm evidence of correct tube placement, but
should be verified with additional techniques.
End-tidal CO2 detection, either qualitative, quantitative, or continuous, is the most
accurate and easily available method to monitor correct endotracheal tube position
in patients who have adequate tissue perfusion.
3)
National Association of EMS Physicians (NAEMPS) – Position statement 1999
[47]
In the patient with a perfusing rhythm, end-tidal CO2 detection is the best method for
verification.
4) American Heart Association (AHA) Protocol for advanced cardiac life support.
2002 and 2005 [48]
7
8. Expired CO2 detectors are very reliable in patients with perfusing rhythm and are
recommended to confirm tube position in these patients (Class IIa).
5) Association of Anesthetists of Great Britain and Ireland and American Society
for Anesthesiologists (ASA) [12, 48]
Capnography is essential to the safe conduct of anesthesia
Continual monitoring for the presence of expired carbon dioxide shall be performed
unless invalidated by the nature of the patient, procedure or equipment
6) NRP (Neonatal Resuscitation Protocol) Guidelines 2006. Consensuses on
sciences;
Exhaled CO2 detection is reliable indicator of ETT placement in infants and it
identifies esophageal intubation faster than clinical assessment. (Aziz J perinatol
1999, Bhende, Pediatrics 1995, Repetto, J Perinatol 2001, Roberts, Pediatric
Pulmonl 1995)
NRP recommends using exhaled CO2 detection to confirm tracheal tube placement.
An “eye opening” survey was conducted among Emergency Physicians and NEAR centers
(Institutes committed to monitoring current airway practices) shows that, despite the
recommendations issued by various National organizations that endorse continues monitoring of
ET CO2 for confirming ET tube placement, it is neither widely available nor consistently
applied [49]
8
9. AN ALGORITHM TO CONFIRM TUBE POSITION
Conclusion
Confirmation of proper tracheal tube placement is as important as successful intubation. Exhaled
CO2 detection is reliable and should be considered the standard for confirmation of tracheal
placement of an ETT and for early detection of accidental esophageal intubation. Aspiration
9
10. devices have at best a secondary role. The Emergency physician should make sure the
availability of ET CO2 detection in ER and with EMS team when they are in the field. They
should also ensure usage of confirmation devices by the concerned persons.
10
11. References:
1. Knapp S : The assessment of four different methods to verify tracheal tube placement in the
critical care setting, Anesth. Analg 88 : 766, 1999
2. Metera P. Endo tracheal tube movement (letter). Acad Emerge Med 1997; 4; 929
3. White SJ, Slovis CM. Inadvertent esophageal intubation in the field: Reliance on a fool’s
“gold standard”. Acad Emerg Med 1997; 4: 89-91
4. Cundy J. Accidental Intubation of Esophagus (letter) Anesth Intensive Care 1981; 9:76
5. Ogden PN. Endotracheal Tube misplacement (letter) Anesth Intensive Care 1983; 11: 273-4
6. Linko K. Capnography for detection of accidental esophageal intubation. Acta Anesthsiol
Scand 1983; 27: 199-202
7. Stirt JA. Endotracheal Tube misplacement. Anesth Intensive Care 1982; 10: 274-76
8. Robinson JS. Respiratory recording fro the esophagus (letter) Br. Med J 1974; 4:225
9. Birmingham P.K. Esophageal intubation: a review of detection techniques Anesth Analg
1996; 65: 886-91
10. Takeda T. The assessment of three different methods to verify tracheal tube placement in the
emergency setting. Resuscitation 56; 153, 2003.
11. American Heart Association Resuscitation guidelines 2005, Circulation 2005; 112: IV-51-IV
57)
12. Recommendation for standard of monitoring during Anesthesia and recovery. 3rd
Edition,
December 2000. The Association of Anesthetists of Great Britain and Ireland.
www.aagbi.org/guidelines.html
13. Li.J Capanography alone is imperfect for endotracheal tube placement confirmation during
emergency intubation. J. Emerg Med. 2001; 20: 223-229.
14. Germec S. Comparison of three different methods to confirm tracheal tube placement in
emergency intubation. Intensive Care Med 2002; 28:701-704
15. Anton WR, Gordon RW, Jordan TM, Posner KL, Cheney FW, A disposable end-tidal CO2
detector to verify endotracheal intubation. Ann Emerg Med. 1991; 20: 271-275
16. Bhende MS. Thomspon AE, Cook DR, Saville AL, Validity of a disposable end-tidal CO2
detector in veryging endotracheal tube placement in infants and children. Ann Emerg Med
1992; 21: 142-145
17. Hayden SR, Colorimetric end-tidal CO2 detector for verification of endotracheal tube
placement in out-of-hospital cardiac arrest. Acad Emerg Med 1995; 2:499-502.
18. MacLeod BA, Verification of endotracheal tube placement with colorimetric end-tidal CO2
detection. Ann Emerg Med. 1991; 20:267-270
19. Ornato JP. Multicenter study of a portable, hand-size, colorimetric end-tidal carbon dioxide
detection device. Ann Emerg Med 1992; 21:518-523.
20. Takeda T. The assessment of three methods to verify tracheal tube placement in emergency
setting. Resuscitation 2003; 56:153-157
21. Tanigawa K. The efficacy of esophageal detector devices in verifying tracheal tube placement
a randomized cross-over study of out of hospital cardiac arrest patients. Anesth Analg. 2001;
92:375-378
22. Varon AJ. Clincal utlity of a colorimetric end-tidal CO2 detector in Cardiopulmonary
resuscitation and emergency intubation. J.Clin Monit, 1991: 7:289-293.
11
12. 23. Nellcor.Easy Cap ET CO2 detector product information Hayward, CA: Nellcor, Inc 1992
24. Sylvia K. Assessment of for deferent methods to verify tracheal tube placement in critical
care setting Anesth. Analg 1999; 88: 766-70
25. Sum Ping ST. Accuracy of the FEF CO2 detectors in the assessment of endotracheal tube
placement. Anesth Analg 1992; 74: 415 – 419.
26. Cantineau JP; Effect of epinephrine on end-tidal carbon dioxide pressure during pre hospital
cardio pulmonary resuscitation. AmJ Emerg Med 1998; 5: 637-646
27. American Heart Association Guidelines 2000 for cardiopulmonary resuscitation and
emergency cardiovascular care. Circulation 2000; 102 (8 Supl): 186-189
28. Pelucio M. Out-of-hospital experience with the syringe esophageal detector device Acad
Emerg Med 1997; 4: 563-68
29. Tanigwa K. Accuracy and reliability of the self-inflating bulb to verify tracheal intubation in
out-of-hospital cardiac arrest patient Anesthesiology 2000; 93: 1432-1446
30. Bozeman WP. Esophageal detector device versus detection of end-tidal carbon dioxide level
in emergency intubation Ann Emerg Med. 1996; 27: 595-99.
31. Sherieff GQ. The self –inflating bulb as an airway adjunct: is it reliable in children weighing
less than 20 kilograms ? Acad Emerg. Med 2003; 10:303-308
32. Wee MY. The esophageal detector device: and assessment with uncuffed tubes in children
Anesthesia. 1991; 46: 869-871.
33. Williams KN. The esophageal detector deices: a prospective trial on 100 patients.
Anaesthesia 1989; 44:412-424.
34. Zalesi L. The esophageal detector device. Does it work? Anesthesiology 1993; 79: 244-247
35. Haynes SR. Use of esophageal detector device in children under one year of age Anesthesia
1990; 45:1067-1069.
36. Benumof J. Critical Hemoglobin desaturation will occurs before return to un paralyzed state
following 1mg/kg intravenous succinyl choline. Anesthesiology 87, 979, 1997
37. Ron M W. Airway, Rosen’s Emergency Medicine Concepts and Clinical Practice, Vol 1,
Sixth Edition 2006, MOSBY ELSEVIER
38. Yael W. Ultrasound Provides Secondary confirmation of Endotracheal Tube placement: Crit.
Care Med 2004; 32: S374-377
39. Ma G. The sensitivity and specificity of transcricothyroid ultrasonography to confirm
endotracheal tube placement in a cadaver model. J Emerg Med. 2007 May; 32(4):405-7
40. Werner SL. Pilot study to evaluate the accuracy of ultrasonography in confirming
endotracheal tube placement. Ann Emerg Med.2007 Jan;49(1):75-80
41. Chun R. Where’s the tube? Evaluation of hand-held ultrasound in confirming endotracheal
tube placement. Prehosp Disaster Med.2004 Oct-Dec19(4):366-9
42. Weaver B, Confirmation of endotracheal tube placement after intubation using the ultrasound
sliding lung sign Acad Emerg Med 2006 Mar; 13(3):239-44
43. Galicinao J, Use of bedside ultrasonography for endotracheal tube placement in pediatric
patients: a feasibility study. Pediatrics 2007 Dec;120(6)1297-303
44. Position statement number 1.Confirmation of endotracheal tube placement with end tidal
CO2 detection. Emerg Med J 2001:18 :329, review March, 2003
45. Verification of endotracheal tube placement; policy statement. American College of
Emergency Physicians. Www.acep.org /1,4923,0.html
12
13. 46. Verification of endotracheal intubation; policy resource and education papers. American
College of Emergency Physicians. www.acep.org/1,4924,0.html.
47. O’Connor RE. Verification of endotracheal tube placement following intubation. National
Association of EMS Physicians Standards and Clinical Practice committee, Pre hosp Emerg
Care 1999; 3:248-50
48. The American Society of Anesthesiologists. Standard for Basic Anesthetic Monitoring.
Approved by House of Delegates, October 1986, amended 1998.
http://www.asahq.org/publicationsAndServices/standards/02.pdf#2
49. Delorio NM, Continuous and-tidal carbon dioxide monitoring for confirmation of
endotracheal tube placement is neither widely available nor consistently applied by
emergency physicians, Emerg Med J 2005; 22:490-493
13