We have classified the following devices according to location in the body.
AIRWAY DEVICES
1. Endotracheal Tube
Indications: Definitive airway (a cuffed tube in the trachea). In paediatrics an uncuffed tube is used.
Position: The tip of the tube should be situated approximately 5cm above the tracheal carina,
so excursions of 2cm upward or downward (with neck extension or flexion) can be safely accommodated.
Fig 2,
3,4,5
2. Nasopharyngeal Airway Tube
Indications: The Nasopharyngeal airway (NPA) is a flexible endotracheal tube that is designed to open a channel between the nostril and the nasopharynx.
The purpose of a NPA is to bypass upper airway obstruction at the level of the nose,
nasopharynx or base of the tongue. It is widely taught that a suspected or known basal skull fracture is a contraindication to NPA placement,
however in the prehospital setting bilateral NPA are used to stabilize the midface and airway in complex facial injuries.
Position: A correctly placed NPA will sit just above the epiglottis,
having separated the soft palate from the posterior wall of the oropharynx.
Fig 6
3. Laryngeal Mask
Indications: Extraglottic airway (EGA) devices such I-Gel laryngeal mask are an option for rapid airway management in pre-hospital care and Ideal for use in emergency medicine and difficult airway management.
Position: The tip of the EGA should be located in the upper oesophageal opening and the cuff should be located against the larynx.
The incisors should be resting on the EGA bite-block.
Fig 7
4. Tracheostomy Tube
Indication: An emergency definitive surgical airway when there is an acute airway obstruction or there are difficulties with intubation (naso or orotracheal).
It is also a cuffed tube.
Cricothyrostomy is a fast and simple method for creating a surgical airway with a success rate of 88%– 100%,
especially in adult patients with trauma.
Because subglottic stenosis has long-term morbidity,
this is later converted to tracheostomy.
Position: The tip should project over the T3-T4 level and,
as with an ETT,
should project within and occupy approximately 50% or more of the tracheal lumen.
The position of the neck is not as important since tracheostomy tubes do not significantly migrate with movement of the neck.
Fig 8
5. Guedel Tube
Indications: The Guedel tube is an oropharyngeal device used to hold open the upper airway.
It is not a definitive airway.
It prevents the tongue of a patient from dropping back and blocking the airway.
It will stimulate the gag reflex therefore is only tolerated in unconscious patients.
Position: The airway is inserted into the patient's mouth upside down.
Once contact is made with the back of the throat,
the airway is rotated 180 degrees.
It is rarely seen in patients in CT as patients tolerating a Guedel are indicated for definitive airway placement prior to CT.
Fig 9
CHEST
1. Thoracostomy Drain
Indications: Used for evacuating fluid or air from the pleural space.
They vary from 10-40 F in size. Pigtail catheters are another option for standard thoracostomy tube,
most commonly used for medical rather than trauma or surgical indications.
Position: The tube is usually placed anterosuperiorly (apically) to evacuate a pneumothorax and posteroinferiorly (basal) for fluid collections.
The tube should lie on the surface of the expanded lung,
between the visceral and parietal pleurae.
Malposition of the tube occurs when it lies in the lung parenchyma,
interlobar fissure or subcutaneous tissues.
The tube can become occluded if its tip lies against the mediastinum or when the tube become kinked.
Fig 10,11,12,13
2. Russel PneumoFix
Indications: A sterile chest decompression device designed for the management of tension pneumothorax,
simple pneumothorax and pleural effusion.
Position: Traditionally the insertion site for tension pneumothorax should be just above the upper border of the third rib (i.e.
into the second intercostal space) in the anterior mid-clavicular line,
to avoid the intercostal neurovascular bundle.
Many protocols are now moving towards the insertion being place in the anterior axillary line in the fourth-fifth intercostal space (EAST guidelines)
Fig 14,15
3. Russel Chest Seal
Indications: Emergency chest seal with integrated valve for open chest wounds.
It contains 4 large peripheral apertures to allow one way drainage of air and blood as an alternative to a 3-sided dressing.
Fig 16
ABDOMINAL & PELVIC DEVICES
1. Nasogastric Tube (NG)
Indications: Temporary stomach and small intestine decompression.
They are also useful for sampling bowel contents.
NG tubes carry a significant risk of never event if inserted incorrectly in particular if used for enteral feeding in this context.
Position: The ideal position should be in the sub-diaphragmatic position within the stomach
Fig 18,19,20,21
2. Feeding Tube
Indications: To feed chronically ill patients over long periods of time.
Some are single lumen and others are dual lumen with a gastric as well as duodenal part (for feeding and also for drainage of the stomach)
Position: Should be located beyond the stomach in the distal duodenum or proximal jejunum to prevent build up of fluid within the stomach,
which could lead to aspiration.
Fig 22
3. Urinary Catheter (Foley catheter)
Indications: Decompress a distended bladder,
collect urine,
and monitor a patient urine output.
Foley catheters are used for short-time use.
Could be two ways or three ways for irrigation.
Position: Within the urinary bladder.
They have a balloon that is inflated to keep the catheter in place in the bladder.
The balloon can be inflated with sterile saline,
sterile water or air. The balloon should never be inflated in the urethra.
Fig 23
4. Rectal Thermometer
Indications: To measure accurate core temperature in hypothermic patients.
Location: within the rectum
Fig 24
5. Surgical Gauzes
Radiopaque Gauze marker provides radiographically identification of the gauze.
These gauzes may be packed into an open wound or abdominal and pelvic cavity,
as damage control surgery,
in which the packing of the area helps to control bleeding.
Haemostatic gauze,
is a type of gauze very effective for haemostasis of wounds in the pre-hospital or hospital emergency setting.
It might be administered in a single gauze roll or as a powder.
Some older variants are based on volcanic rock whereas newer versions are based on Chitin from shrimp.
Fig 25,26
6. Surgical Drains
Indications: to remove fluid collection that could otherwise lead to an infection,
abscess formation or would breakdown.
Most drains are radiopaque,
and there are 3 general types: closed-wound suction drains,
gravity drains and sump drains.
Drains may be round or flat and are of different lengths,
hole patterns,
and sizes depending on the indication.
Position: Within the fluid collection in the abdomino-pelvic cavity
Fig 27
CERVICAL SPINE ORTHOSES
1. Cervical Spine Collars
Indications: To reduce the cervical spine range of motion.
There are different types of cervical collars.
At our institutions the most used are the standard hard collar in the initial short term (within 24h) management of the patient and the Miami J collar for stabilisation longer term (Jerome Medical,
Moorestown,
NJ).
The Miami J collar is made of hard plastic,
with Velcro straps to keep it closed.
The front piece has a chin cup.
The back piece is curved and fits against the lower part of the head.
Fig 28,29
2. Head Blocks
Indications: Cervical spinal support
Position: Each block should be placed against the head and the block openings to the patient’s ears.
Then,
tape over the head blocks while centring on the patient’s forehead and secure to the back of the orthopaedic stretcher/ extrication board on the other side.
Repeat for the patient’s chin area.
Some blocks also have a pad,
which extends across the back of the head with plastics loops through which straps attach.
Fig 30
SKELETAL DEVICES
1. Pelvic Binders
Indications: Reduction and stabilisation of pelvic fractures.
Rapid immobilisation reduces haemorrhage by stabilising the bony pelvis,
reducing bleeding and stabilising clot formation. There are several versions of the binder available on the market (eg SAM,
Prometheus).
Position: The binder should be place at the level of the greater trochanters.
Traditionally it should not be placed more than 24 hours.
Fig 31,32,33,34
2.
Combat Application Tourniquet (CAT)
Indications: The CAT is a small,
lightweight one-handed tourniquet used to stop the arterial blood loss of an extremity that is not being control by simple measures (simple pressure dressing or packing of the wound).
The CAT uses a Velcro strap and buckle (plastic) to fit a wide range of extremity sizes
Position: Proximal to the wound,
but on the most distal part of the healthy tissue.
Fig 35
3.Kendrich Splint
Indications: Used to reduction and alignment of femoral shaft fractures in the prehospital setting.
Position: The Traction Splint comes complete with a pole,
which is length adjustable,
ankle hitch,
lower leg strap,
lower thigh strap (fitted to pole) and an upper thigh strap.
Fig 36
4.
Intraosseous Access
Indications: Used for emergency resuscitation If intravascular access is not readily available and should be removed within 24 hours of insertion or as soon as practical after peripheral or central intravenous access has been achieved. Intraosseous access has been recommended in paediatric advanced life support since 1988.
Position: Sites of insertion are the proximal tibia and humerus and proximal and distal tibia and humerus,
depending of the type of needle.
The sternum and iliac crest are not utilised in civilian practice.
Insertion generally requires less than 1 minute,
and flow rates up to 125 mL/min can be achieved.
Fig 37
5.
Orthopaedic Devices
Indications: External fixators (also known as ex-fix),
are usually place in open fractures,
complex injuries with severe soft tissue swelling where it is important to stabilise the injury temporarily while the swelling goes down and before a definitive open reduction and internal fixation is done.
They are also in Damage control surgery with haemodynamically unstable patients,
where you want to stabilise their bony injuries temporarily before the patient returns to theatre to complete the surgery.
Fig 38
VASCULAR DEVICES
1. Central Venous Cathether
Indications: Central venous catheters (CVCs) are cannulation devices designed to access the central venous circulation.
The wire is used in the Seldinger technique for insertion and should not be retained (never event).
Position: The tip should lie close to the junction of the SVC and right atrium to avoid contacting the pericardial reflection.
Fig 39,40
2. Arterial Line:
Indication: Invasive arterial blood pressure monitoring.
Location: Usually radial or femoral arteries
Fig 41
3. Inferior Vena Cava Filter
Indications: Prevention of thromboembolism in patients in whom anticoagulation is contraindicated,
for example trauma patients with multiple pelvic and lower limb fractures.
Position: Infrarenal location to preserve the venous drainage from the kidneys,
although they are sometimes placed higher if an IVC thrombus has extended above that level.
Fig 42,43
4. Aortic Endovascular Balloon (ER-REBOA catheter)
Indication: A temporary measure for proximal haemorrhage control.
Position: Zone 1 aorta above the celiac axis,
Zone 2 (visceral zone) between celiac axis and lowest renal artery and Zone 3 from the lowest renal and the bifurcation of the aorta.
The balloon is not inflated in Zone 2.
Fig 44