Nasogastric intubation is a medical process involving the insertion of a plastic tube (nasogastric tube, NG tube) through the nose

, past thethroat, and down into the stomach.

Uses The main use of a nasogastric tube is for feeding and for administering drugs and other oral agents such as activated charcoal. For drugs and for minimal quantities of liquid, a syringe is used for injection into the tube. For continuous feeding, a gravity based system is employed, with the solution placed higher than the patient's stomach. If accrued supervision is required for the feeding, the tube is often connected to an electronic pump which can control and measure the patient's intake and signal any interruption in the feeding.

Nasogastric aspiration (suction) is the process of draining the stomach's contents via the tube. Nasogastric aspiration is mainly used to remove gastric secretions and swallowed air in patients with gastrointestinal obstructions. Nasogastric aspiration can also be used in poisoning situations when a potentially toxic liquid has been ingested, for preparation before surgery under anesthesia, and to extract samples of gastric liquid for analysis.

Technique Before an NG tube is inserted, the health care provider - most often the nurse - must measure with the tube from the tip of the patient's nose, to their ear and down to the xyphoid process. Then the tube is marked at this level to ensure that the tube has been inserted far enough into the patient's stomach. Many commercially available stomach and duodenal tubes have several standard depth markings, for example 18" (46cm), 22" (56cm), 26" (66cm) and 30" (76cm) from distal end; infant feeding tubes often come with 1 cm depth markings. The end of a plastic tube is lubricated (local anesthetic, such as 2% xylocaine gel, may be used; in addition, nasal vasoconstrictor spray may be applied before the insertion) and inserted into one of the patient's anterior nares. The tube should be directed aiming down and back as it is moved through the nasal cavity and down into the throat. When the tube enters the oropharynx and glides down the posterior pharyngeal wall, the patient may gag; in this situation the patient, if awake and alert, is asked to mimic swallowing or is given some water to sip through a straw, and the tube continues to be inserted as the patient swallows. Once the tube is past the pharynx and enters the esophagus, it is easily inserted down into the stomach. Only smaller diameter (12 Fr or less in adults) nasogastric tubes are appropriate for long-term feeding, so as to avoid irritation and erosion of the nasal mucosa. These tubes often have guidewires to facilitate insertion. If feeding is required for a longer period of time, other options, such as placement of a PEG tube, should be considered.

Contraindications he use of nasogastric intubation is contraindicated (inadvisable) in patients with base of skull fractures, severe facial fractures especially to the nose and obstructed esophagus and/or obstructed airway. The use of an NG tube is also contraindicated in patients who have had gastric bypass surgery.

Complications Minor complications include nose bleeds, sinusitis, and a sore throat. Sometimes more significant complications occur including erosion of the nose where the tube is anchored, esophageal perforation, pulmonary aspiration, a collapsed lung, or intracranial placement of the tube.

SUCTIONING NOTE: If the patient has secretions or emesis that cannot be removed quickly and easily by suctioning, the patient should be log rolled and the oropharynx should be cleared Take Body Substance Isolation precautions. Assemble and Check the equipment Assure a tight fit on all of the hoses. Measure the suction catheter Connect a rigid tip catheter to the hose, turn on the machine and check the vacuum.

Measure the catheter in the same manner as the OPA. The length of catheter that should be inserted into the patient’s mouth is equal to the distance between the corner of the patient’s mouth and their earlobe or center of the mouth to the angle of the jaw Hyperventilate the patient if necessary If the patient is being artificially ventilated and is producing “frothy” secretions as quickly as you can suction them from the airway you may alternate hyperventilation with suctioning. Alternating suctioning for 15 seconds with 2 minutes of hyperventilation. However, note that hyperventilation and/or artificial ventilations is not appropriate if vomitus or other particles are present in the airway. Remember the patient will not be receiving oxygen while you are suctioning. Open the mouth The mouth should be opened using the “crossed or scissors” finger technique.

Insert the suction tip The rigid tip catheter must be inserted following the pharyngeal curvature, with the suction OFF (usually there is a control hole on the tip, if not you will need to crimp the suction hose to initiate suctioning). Insert the catheter only as far as you properly measured it. Suction the mouth while retracting After inserting the catheter the measured distance initiate suctioning as you retract the catheter in a sweeping motion. Do not suction too long! The maximum suction time should only be 15 seconds. Oxygenate After suctioning, re-oxygenate the patient. If the patient is being artificially ventilated and needs to be suctioned again, you should continue to ventilate the patient for two minutes and then suction again, if needed, for up to 15 seconds and continue in this manner. Clean the catheter If necessary, rinse the catheter and tubing with water to prevent obstructions of the tubing and catheter. cleaning of the equipment should be done as soon as possible after you arrive at the h ospital. A thorough

Tracheotomy and tracheostomy are surgical procedures on the neck to open a direct airway through an incision in the trachea (the windpipe). They are performed by paramedics, veterinarians, emergencyphysicians, and surgeons. Both surgical and percutaneous techniques are now widely used.

ses of tracheotomy The conditions in which a tracheotomy may be used are:  Acute setting - maxillofacial injuries, large tumors of the head and neck, congenital tumors, e.g. branchial cyst,

acute inflammation of head and neck, and  Chronic / elective setting - when there is need for long term mechanical ventilation and tracheal toilet,

e.g. comatose patients, surgery to the head and neck. In emergency settings, in the context of failed endotracheal intubation or where intubation is contraindicated, cricothyroidotomy or mini-tracheostomy may be performed in preference to a tracheostomy. [edit]Tracheotomy procedure

1. 2. 3. 4. 5.

Curvilinear skin incision along relaxed skin tension lines (RSTL) between sternal notch and cricoid cartilage. Midline vertical incision dividing strap muscles. Division of thyroid isthmus between ligatures. Elevation of cricoid with cricoid hook. Placement of tracheal incision. An inferior based flap, or Björk flap, (through second and third tracheal rings) is

commonly used. The flap is then sutured to the inferior skin margin. Alternatives include a vertical tracheal incision (pediatric) or excision of an ellipse of anterior tracheal wall. 6. Insert tracheostomy tube (with concomitant withdrawal of endotracheal tube), inflate cuff, secure with tape

around neck or stay sutures. 7. Connect ventilator tubing.

It is also possible to make a simple vertical incision between tracheal rings (typically 2nd and 3rd) for the incision. Rear end flaps may produce more intratracheal granulation tissue at the site of the incisions, making it less favorable to some surgeons. Tracheostomy Care Rubbing of the trach tube and secretions can irritate the skin around the stoma. Daily care of the trach site is needed to prevent infection and skin breakdown under the tracheostomy tube and ties. Care should be done at least once a day; more often if needed. Children with new trachs or children on ventilators may need trach care more often. Tracheostomy dressings are used if there is drainage from the tracheostomy site or irritation from the tube rubbing on the skin. It may be helpful to set up a designated spot in your home for equipment and routine tracheostomy care. Equipment • • • • • • • Sterile cotton tipped applicators (Q-tips) Trach gauze and "unfilled" gauze Sterile water Hydrogen peroxide (1/2 strength with sterile water) Trach ties and scissors (if ties are to be changed) Two sterile cups or clean disposable paper cups Small blanket or towel roll

Procedure • • • • • • • Wash your hands. Explain procedure in a way appropriate for the child's age and understanding. Lay your child in a comfortable position on his/her back with a small blanket or towel roll under his/her shoulders to extend the neck and allow easier visualization and trach care. Open Q-tips, trach gauze and regular gauze. Cut the trach ties to appropriate length (if trach ties are to be changed). Pour 1/2 strength hydrogen peroxide into one cup and sterile water into the other. Clean the skin around the trach tube with Q-tips soaked in 1/2 strength hydrogen peroxide. Using a rolling motion, work from the center outward using 4 swabs, one for each quarter around the stoma and under the flange of the tube. Do not allow any liquid to get into trach tube or stoma area under the tube. Note: Some doctors recommend cleaning with just soap and water in home care, using hydrogen peroxide only to remove encrusted secretions. This is because daily use of hydrogen peroxide might irritate the skin of some children. Rinse the area with Q-tip soaked in sterile water. Pat dry with gauze pad or dry Q-tips. Change the trach ties if needed (See Changing a Tracheostomy Tube). Check the skin under the trach ties. Tuck pre-cut trach gauze around and under the trach tube flush to skin. Do not cut the gauze or use gauze containing cotton because the child may inhale small particles. Use precut tracheostomy gauze or unfilled gauze opened full length and folded into a U shape or use two gauze pads, one placed under each wing of the tube. Be sure the trach dressing does not fold over and cover the trach tube opening. Change the dressing when moist, to prevent skin irritation. Tracheostomy dressings may not be needed for older tracheostomies when the skin is in good condition and the stoma is completely healed and free from rash or redness. For tracheostomy tubes with cuffs, check with your doctor for specific cuff orders. Check cuff pressure every 4 hours (usual pressure 15 - 20 mm Hg). In general, the cuff pressure should be as low as possible while still maintaining an adequate seal for ventilation. Monitor skin for signs of infection. If the stoma area becomes red, swollen, inflamed, warm to touch or has a foul odor, call your doctor. Check with the doctor before applying any salves or ointments near the trach. If an antibiotic or antifungal ointment is ordered by the doctor, apply the ointment lightly with a cotton swab in the direction away from the trach stoma. Wash your hands after trach care.

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Care of the Inner Cannula Some older children and teens have trach tubes with an inner cannula. Some inner cannulas are disposable (DIC: Disposable Inner Cannula). These should be changed daily, discarding the old cannula. Check with your equipment vendor regarding disposable cannulas. For the reusable cannulas, the cannula should be cleaned 1 to 3 times a day and more often if needed. Do not leave the inner cannula out for more than 15 minutes.

Fluid, Electrolyte and Acid-Base Balance - Body water accounts for half of body weight and Age, gender and body fat content Intracellular Fluid (ICF) All fluid inside cells Extracellular Fluid (ECF) All fluid outside cells Body Fluid Compartments Composition of Body Fluids Water Nonelectrolytes Do not dissociate (covalent bonds) Mostly organic molecules Do not contribute to osmotic activity Electrolytes Dissociate (ionic bonds) Charged particles—electricity Responsible for osmotic activity Comparison of ECF and ICF Water (fluid) moves between ICF and ECF Exchange regulated by hydrostatic and osmotic pressure Change solute concentration in any compartment and water flow affected Exchanges Exchanges between ICF and between interstitial fluid (ECF) more complex interstitial fluid and plasma depends hydrostatic on and oncotic (osmotic) pressure Membranes impermeable to ions Water exchanges substantial Changes in ECF osmolality will cause changes in ICF osmolality ECF osmolality always equals ICF osmolality Water Balance Varies greatly from person to person Healthy people—body fluid tonicity of 285-300 moms/L Thirst driving force for water intake Water loss mechanisms • obligatory water losses unavoidable Insensible water loss Water loss in feces Minimal sensible water loss—urine • remaining water loss depends on diet, intake, and other water loss • water volume closely linked to sodium levels Influence of ADH ADH causes water reabsorption in PCT Osmoreceptors in hypothalamus monitor ECF concentration below ECF concentration inhibits ADH release—more water in urine Water Balance Disorders - Dehydration Loss exceeds intake Hemorrhage, burns, vomiting, diarrhea, sweating, water deprivation, Thirst, oliguria Confusion, shock Water Balance Disorder—Hypotonic Hydration Overhydration—renal insufficiency or rapid water ingestion (intoxication) Edema

Collection of fluid in interstitial space Increased fluid loss from blood to interstitial space • increased blood pressure • increased capillary permeability Inhibited fluid return to blood from interstitial space • imbalance of oncotic pressure • blocked lymphatics Electrolyte Balance Abundant in diet Lost through sweating, feces, urine Severe electrolyte deficiency may lead to unusual cravings Addisons disease—salt Non-food substances—pica, clay Sodium plays central role in fluid and electrolyte balance Sodium Regulation Important function of kidney 142 mEq/L Most abundant cation in ECF Only electrolyte exhibiting significant osmotic pressure Cell membrane impermeable to Na Water follows sodium Regulation—neural and hormonal Hormonal Controls Aldosterone—DCT 65% reabsorbed in PCT, 20% in Loop of Henle Cardiovascular baroreceptors Renin-angiotensin trigger for Aldosterone—blood pressure driven Influence of ANP Influence of other hormones (estrogen↑, progesterone↓, glucocorticoids↑) Regulation of Potassium 3.5-5.0 mEq/L Important in membrane potential Can be toxic Indirect regulation with sodium Actively secreted in collecting duct Regulation of Calcium and Phosphate 99% of calcium in bones as calcium phosphate salts Ionic calcium important for clotting, neuromuscular activity, and secretory activity Calcitonin and parathormone (PTH) Regulation of Chloride Major anion of ECF Maintenance of osmotic pressure Indirect regulation with sodium Acid-Base Balance Chemistry Review + Acids are proton (H ) donors + Bases are proton (H ) acceptors Ionic substances dissociate in solution Strong acids dissociate completely Weak acids dissociate incompletely pH is a measure of H+ in solution Normal blood pH necessary for normal enzyme activity 7.35-7.45 Below 7.35 = acidosis Above 7.45 = alkalosis Changes in pH due to by-products or endproducts of metabolism • phosphoric acid • lactic acid • ketones and fatty acids • bicarbonate ions Regulation of Blood pH Chemical Buffer Systems • Bicarbonate buffer system

• Phosphate buffer system • Protein buffer system Respiratory System Renal Mechanisms Chemical Buffer Systems Molecules that resist pH change Bind or release H+ to control pH Limited in ability to control pH Bicarbonate buffer system most important in ECF Phosphate and protein buffer systems important in ICF Bicarbonate Buffer System Carbonic acid ↔ Hydrogen + Bicarb ions ions H2 CO3 H+ HCO3 – Phosphate Buffer System Dihydrogen phosphate?monohydrogen phosphate H2 PO4 -3 HPO4 -2 Protein Buffer System Amino Acid NH -C-COOH 3 Some can Some can accept H+ donate H+ Weak base Weak acid Respiratory and Renal Regulation H2O + CO2 ? H2CO3 ? H+ + HCORespiratory Renal pCO2 ↑, pH ↓ Control H+ and HCO - 3 secretion pCO2 = 35-45 mmHg (Metabolic) HCO3 = 22-26 mEq/L HCO - ↓, pH ↓ Abnormalities of Acid-Base Balance Respiratory acidosis High pCO , low pH2 Pneumonia, cystic fibrosis, etc Kidneys retain bicarbonate Kidneys compensate for problem Abnormalities of Acid-Base Balance Respiratory alkalosis Low pCO , high pH2 hyperventilation kidneys secrete bicarbonate Kidneys compensate for problem Abnormalities of Acid-Base Balance Metabolic acidosis Low bicarbonate, low pH Too much alcohol, excessive loss of bicarbonate (diarrhea) Hyperventilation Lungs compensate for metabolism Abnormalities of Acid-Base Balance Metabolic alkalosis High bicarbonate, high pH Vomiting, excessive base intake Hypoventilation Lungs compensate for metabolism Acid-Base Compensation Respiratory problem— kidneys compensate Metabolic problem— lungs compensate Patient presents with pH 7.51, pCO2 40 mmHg, HCO3- 28 mEq/L. What is his problem? Check pH pH 7.51 ALKALOSIS Check pCO2 Normal Check HCO - Increased METABOLIC How will the body compensate?

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Metabolic problem LUNGS COMPENSATE To ↓ pH, ↑ pCO2 HYPOVENTILATE

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