Laryngoscopy

Definition:
Its a medical procedure that use in the intubation of Endotracheal tube, to see the vocal cord or glottis, It is performed by an anesthetic to give a general anesthesia, during resuscitate the patient by cardiopulmonary Resuscitation.
Types of Methods:
There are following types that use for intubation;

1. Direct Laryngoscopy
2. Indirect Laryngoscopy
3. Fiber optic Laryngoscopy
4. Conventional Laryngoscopy

1. Direct Laryngoscopy:

It is performed on that patients who laying on his or her back in supine position.
It is inserted to the right side of tongue and slip it toward left side to move the tongue to out of sight.
Laryngoscope push upward and forward away from you and towards the roof.
Now you can seen epiglottis and glottis.
Perform the procedure and secure airway.
It can only perform in unconscious patients because it is slightly intact with gag reflexes.

2. Indirect Laryngoscopy:
It is performed by direct line of sight of tongue to see the vocal cord.
It is mostly performed by Fiber optic bronchoscope and video Laryngoscope etc.

3. Fiber optic Laryngoscopy:
These are the alternatives of Conventional Laryngoscope.
These are performed in the way of indirect Laryngoscope e.g; flexible fiber optic bronchoscope.

4.Conventional Laryngoscopy:
These are most popular devices use for the purpose of intubation and other anesthetic techniques.
Nowadays, Conventional Laryngoscope consists of handle that have batteries, light source, Sets of blades.

Sizes & Types of Blades:
There are two types of blades;

• Miller's Blades
• Macintosh Blades

 Miller's Blades; large adult (males:4), small adults (male/female:3), Peads (children:2), Infants ( 1 or 2).

Macintosh Blades;  large adult (males:4), small adults (male/female:3), Peads (children:2), Infants ( 1 or 2).

Applications:

• Administration of General anesthesia.
• For Invasive mechanical Ventilation.
• To check the voice problems i.e; week voice, breathing voice and horse voice.
• To check the causes of sore throat and ear pain.
• To check the throat injuries and airway obstructions.

Complications:

• Inexperience person can cause the severe injury.
• Soft tissues can  damage in minatory during the procedure.
• Injuries of pharynx and larynx can cause scars, ulceration and obsession.

Transcutaneous Pacing Device

Definition:

Transcutaneous pacing device also refers as External pacing device.
Some pacing devices only provide as a pacemaker.
But some of them use as a defibrillators and also as rhythm monitoring as well as pacing device.
Indications of TPM;

• Its is indicated as Temporary pacemaker (TPM).
• It is used in the treatment of Sinus bradycardia, Symptomatic bradycardia and in AV blocks mainly.
• Other than it, used in hemodynamically unstable bradycardia (i.e; reduced BP, decreased consciousness, CHF and shock etc).
• In AMI (Acute Myocardial Infarction) with symptomatic sinus bradycardia (If it have irreversible signs), II degree of heart blocks (Mobitz type II), Complete heart block (ventricular escape rhythm).
• In treatment of Tachycardia as DC (Cardiovert).

*It can beared by 90% of patients for 10 to 15mins.
*It can provide 140 to 200 mA current tolerably.

Medications:
There are some drugs that used during pacing;
To sedate the patient who are conscious and hemodynamically stable.

•  Midazolam (Benzodiazepine).
• Anxiolytics Are.

*These drugs have also amnesic effect.

These drugs necessary to use because External pacing causes;

1. Burning sensation of the skin.
2. Skeletal muscles contraction.

Electrocardiography (ECG)

Definition:
The electrical activity of heart on a graph paper is called ECG.
How to study the ECG?
1-Heart rate
2-Rhythm
3-Axis
4-Chamber Hypertrophy
5-Infarction
6-Ischemia
7-P-R Interval
8-Block bundle branch or AV blocks
9-Q Wave
10-Q-T Interval

1-Heart Rate:
QRS complex occurring once per large square is occurring at the rate of 300/min.
QRS complex occurring once per small square is occurring at the rate of 1500/min.
Heart rate may be;
a- Regular
b- Irregular
a-Regular heart rate:
Same or equal distance/difference between R-R interval represents the regular heart rate.
How to calculate;
There are two methods to calculate the Sinus heart rate by;

1. By large boxes 
2. By small boxes 

1. By large boxes:
Account the large boxes between R-R interval e.g; 5 large boxes.
One large square heart rate at the rate of 300/min.
Use the formula;
300/large boxes=300/05=60 per min heart rate (HR).
2. By small boxes:
Account the small boxes between R-R interval e.g; 18 small boxes.
One small square heart rate at the rate of 1500/min.
Use the formula;
1500/small square=1500/18=83 per min HR.

*Here 60/min is normal/ Rough HR.
*And 83/min is sinus/ Accurate HR.

b- Irregular heart rate:
They have no Equidistant between R-R interval of whole ECG, represents the Irregular heart rate.
How to calculate;
There are two methods to calculate the irregular heart rate by;

1. QRS-complex take between 30 big boxes on regular ECG (Red in color) 
2. QRS-complex take between 06 sec strip to check HR (Green in color) 

1. QRS-complex take between 30 big boxes on regular ECG (Red in color):
Account 30 big boxes in an ECG starting from a QRS-complex.
Account the QRS-complex between the big 30 boxes e.g; 10 QRS-complex
Now use the formula;
QRS-complex X 10= 10 X 10= 100/min.

2. QRS-complex take between 06 sec strip to check HR (Green in color):
Account the 6 sec line on ECG paper starting from QRS-complex.
Account QRS-complex Between the 6 sec strip.
Now use the formula;
QRS-complex X 10= 6 X 10= 60/min.

* Here both methods are accurate.

2-Rhythm or Sinus Rhythm:
When the depolarization begins in the SA node of the heart, is said to be sinus Rhythm.
Arrhythmia:
When the depolarization begins in the other places of the heart like Atria and ventricular the Rhythm is named after the part of the heart where the depolarization sequence originate and an Arrhythmia is said to be present.
Sinus Arrhythmia:
Change in the HR associated with respiration, are normally seen in young peoples, and this is called Sinus arrhythmia.

* The rate of discharge of the SA node is influenced by he vagus nerves and reflexes originate in the lungs.

There are the six types of Rhythm:

• Normal sinus rhythm 
• Junctional rhythm 
• Atrial Fibrillation 
• Extra-systole 
• Supra-ventricular tachycardia 
• Ventricular tachycardia

Normal Sinus Rhythm:
It contains P wave, QRS-complex and T wave with same rhythm or rate.
Junctional Rhythm/Nodular:
If no P wave found its called Junctional rhythm, it is due to dysfunction of SA node and AV node that take part in depolarization.
Atrial Fibrillation:
Fibrillation in the right atrium due to not proper contraction of atrium is result of many P waves found like fibrillation of right atrium.
Extra-systole:
Other parts of the heart take part in depolarization like, Atrial muscles, Junctional region(AV Node) and ventricular muscles that show the ectopic beat and ectopic rhythm.

* Atrial ES have abnormal P wave shows AF.
* Junctional ES there is no P wave shows JR.
Supra-ventricular tachycardia:
There is QRS-complex and P & T waves emerge in each other.
Ventricular tachycardia:
It shows only QRS-complex No P waves and No T waves found.

3-Axis:
The average direction of the spread of depolarization wave through the ventricular as seen from the front is called "Cardiac Axis" Its useful to decide whether this axis can derived (direction) easily from the QRS-complex in lead I, II and III.

                         Lead AVF                                                       Lead I
QRS-complex    Upward                                                         Upward             (Normal)
                         Upward                                                         Downward       (Right axis)
                         Downward                                                    Upward            (Left axis)
                         Downward                                                    Downward       (Extreme right axis)

4-Chamber Hypertrophy:

There are four type of hypertrophy:

• Right Ventricular Hypertrophy
• Left Ventricular Hypertrophy
• Left Atrial Hypertrophy
• Right Atrial Hypertrophy

Right Ventricular Hypertrophy (RVH):

Right axis deviation on ECG.

Tall R wave in lead V1.

Deep S wave in lead V6.

* Sometime is said to be right bundle branch block (RBBB).

Left Ventricular Hypertrophy (LVH):

Tall R wave in lead V5 or V6 more than 25mm.

R wave in V5 or V6 plus S wave in lead V1 or V2 more than 35mm.

* Sometime is said to be Left bundle branch block (LBBB).

Left Atrial Hypertrophy (LAH):

P wave in duration more than 12 sec or 3 small square.

Its said to be P-mitral or left atrial enlargement (LAH).

Right Atrial Hypertrophy (RAH):

P wave in amplitude more than 0.3mv or 3 small square.

Its said to be P-pulmonary or right atrial enlargement (RAH).

5- Myocardial Infarction (MI):
Sequence of ECG changes:
Normal ECG__Raised ST segment__ Appearance of Q waves__Normalization of ST segment__Inversion of T waves.
Site of Infarction:
ECG findings on graph paper in different leads shows different diagnosis.

V1-V6                              Anterior wall MI
II,III & AVF                       Inferior wall MI
I, AVL, V5,V6                   Lateral wall MI
I, AVL                              High lateral wall MI
V5-V6                              Lower lateral wall MI
V1-V4                              Antroseptal wall MI

6-Ischemic Heart Disease (IHD):
Digoxin: ST segment slopes downward.
Ischemia: Flat ST segment depression.
T wave Inversion:

• Normal in leads III, AVR, V1, V2 & V3 in black peoples (Negro).
• Ventricular Rhythm.
• Bundle branch block.
• MI.
• RVH & LVH.
• WPW syndrome.

Site of Ischemia:


V1-V6                              Anterior wall Ischemia
II,III & AVF                       Inferior wall Ischemia
I, AVL, V5,V6                   Lateral wall Ischemia
I, AVL                              High lateral wall Ischemia
V5-V6                              Lower lateral wall Ischemia
V1-V4                              Antroseptal wall Ischemia

7-P-R Interval:
(AV delay)
Current or impulse stops at this point.
Normal: 0.12 sec- 0.2 sec i.e; 3 to 5 small square or 120ms to 200ms.
Prolonged: If P-R interval more than 5 small square, then AV node delay increases and called AV block and heart block.

8-Block bundle branch or AV blocks:
There are three types of heart block;

I degree AV block
II degree AV block

• Mobitz type I
• Mobitz type II

III degree AV block

I degree AV block:
P-R interval fix prolonged e.g; 7 small square.
No beat drops i.e; no drops of QRS-complex.
No any pathology rather than it.
Its called 1 degree of heart block.

II degree AV block:
There are two type of it;
Mobitz type I
Mobitz type II

• Mobitz type I:

P-R interval progressively prolonged e.g; more than 5,6,7,8 and so on.
Beat drops i.e; drops QRS-complex.
Pulse is irregular clinically.
Its also known is Wenchebach's phenomenon.

• Mobitz type II:

P-R interval fix prolonged e.g; 7 small square.
Beat drops i.e; drops QRS-complex, e.g; more P waves than QRS-complex.
Its not due to lengthening of AV conduction time, its usually due to block within bundle of His.
Its mostly due to organic heart disease.
Its lead to complete heart block.

III degree AV block:
Its also known as complete heart block, i.e; no impulse from atria to ventricular reaches.
Its only maintained by escape Rhythm, i.e; arising from bundle of His (narrow QRS-complex at the rate of 50 to 60 bpm),  Below the bundle of His (make broad complexes at the rate of 15 to 40 bpm)
Exertion or Exercise does not increase the heart rate.

9-Q Wave:
-Small septal Q wave are normal in lead I, AVL and V6.
-Its can also seen in lead III but in AVF is not a normal variant.
-Probably indicates infarction, If MI present in more than one lead i.e; more than 2 or more leads, longer than 40 ms in duration and deeper than 2 mm in amplitude.
-Q wave in lead III (but not in AVF) pulse Right axis deviation may indicates "Pulmonary embolism".
-Leads showing Q waves indicates the site of infarction.
i.e;

V1-V6                              Anterior wall Old MI
II,III & AVF                       Inferior wall Old MI
I, AVL, V5,V6                   Lateral wall Old MI
I, AVL                              High lateral wall Old MI
V5-V6                              Lower lateral wall Old MI
V1-V4                              Antroseptal wall Old MI

10-Q-T Interval:

Uses of Conventional Defibrillator

Definition:
A Conventional Defibrillator (DC) is used as a Defibrillator that use in Hospitals to treat the cardiac arrhythmia, cardiac arrest, Ventricular tachycardia (pulse-less) or Ventricular fibrillation.

Method:How to use the DC?
1-It can only use by that person who have experience in ECG monitoring and Recognition.
2-Remove the patient from metallic body or bed
3-Make the patient position, it can be supine or decubitus.
4-Expose the patient chest, Remove contaminated things like; wet, metal etc
5-Prepare the DC, attach the batteries, attach the paddle with DC.

6-Place the paddle on patient chest; in supine or decubitus position.

• In Supine; one paddle place to the right side just below to the clavicular bone and above nipple line, second place to the left side at anterior axillary line.
• In decubitus; one paddle place to the left side just below the clavicular bone, second place to the back below shoulder blade in right lateral position.

7-Now check again DC connection, Make sure that all wires are attached.

8-Provide the Electric shock to the patient when needed, otherwise continue CPR.

Important:
DC can be Monophasic and Biphasic.

In Biphasic shock can be 150 joule.

In Monophasic shock can be 200, 300 and 360 joule.

Uses of Automated External Defibrillator

Definition:
Automated External Defibrillator is a portable or easy to use device that checks the heart rhythm. In use it can send an electrical shock to the heart to treat the cardiac arrest and normalize the heart rate.
Uses of AED:
Conditions in which an Automated external Defibrillator is used;

1- Cardiac Arrest or Asystol
2- Pulse-less Tachycardia
3-Ventricular Fibrillation
Protocol:
Scene Secure
Personal Safety
Patient safety
Approach to the patient
Check the response (Alert, Verbal, Painful Stimuli)

* If unresponsive
Call to EMS
Check ABC (Airway, Breathing, Circulation)
Start CPR
Use AED
Method:
How to use an Automated External Defibrillator?
1-An untrained person can easily use an automated external defibrillator.
2-Remove the patient from contaminated area make sure patient's and your safety.
3-Expose the patient chest, remove all contaminated things from the chest like; jewelry, metals, wet, heavy hair etc
4-Prepare the AED as turn on it, attach the sticky electrodes with AED machine, make the patient's position as supine, apply the pads as;

a) place one pad on right side just below to the clavicular bone and above to the nipple.
b) place second pad on left side in anterior axillary line at the apex beat position.

5-Make sure patient have not any medication bracelet or neck-less that alert the patient disease.
6-If patient is on PPM (permanent pace maker) then you should need to place pads 1 inch away from its wires.
7-Make Sure that no one touching ti the patient.
8-Recheck again AED preparation, then follow these steps;

• Press "Analyze" button ___ AED will check the rhythm of patient's heart.
• If needed shock ___ It will provide the shock
• If shock is not needed ___ Start CPR.

Important:
AED are mostly Biphasic.

It provide the mostly 120, 150 and 200 Joule Shock.