ER Procedures For Non-ER Docs - Amazon S3 · ER Procedures For Non-ER Docs ... sat monitor •Pt...
Transcript of ER Procedures For Non-ER Docs - Amazon S3 · ER Procedures For Non-ER Docs ... sat monitor •Pt...
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H. Mitchell Shulman MDCM FRCPC CSPQ
Assistant Professor, Dept. of Surgery
Attending Physician, Emergency Dept.
ER Procedures For Non-ER DocsTricks to Manage the Airway
Place a Chest Tube
Get Into the Circulation
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Copyright © 2017 by
Sea Courses Inc.
All rights reserved. No part of this document may be reproduced,
copied, stored, or transmitted in any form or by any means –
graphic, electronic, or mechanical, including photocopying,
recording, or information storage and retrieval systems without
prior written permission of Sea Courses Inc. except where
permitted by law.
Sea Courses is not responsible for any speaker or participant’s
statements, materials, acts or omissions.
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Dr. Mitch Shulman has no affiliation with the manufacturer
of any commercial product or provider of any commercial
service discussed in this CME activity.
CME FACULTY DISCLOSURE
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Objectives
• Manage the airway
proper positioning
tricks of the trade
surgical airway
• Chest tube placement
avoid common pitfalls
• Gaining access to the circulation
venous cutdown
IO
• Wound repair using glue
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Technology
will let you
down!
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Airway ManagementBasic Principle
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Cricothyroidotomy
• Indications:
Inability to intubate the tracheais the primary indication for creating a
surgical airway !!!
i.e. Oral / nasal endotracheal
intubation contraindicated / impossible
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CricothyroidotomyDefinition
• Establishment of an opening to the
airway at the level of the cricothyroid
membrane
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• Age
• Pre-existing laryngeal pathology
• Inexperience
• Anatomic distortion
• Coagulopathy
CricothyroidotomyContraindications
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CricothyroidotomyAnatomy
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CricothyroidotomyAnatomy
Epiglottis
Hyoid bone
Thyroid cartilage
Cricoid cartilage
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CricothyroidotomyComplications
Total 6.1 – 8.6 %
• Subglottic stenosis 1.4
• Voice change 1.4
• Local hemorrhage 2.7
• Wound infection
• Misplaced tube
• Pneumo-thorax / mediastinum
• Esophageal injury
• Subcutaneous emphysema
• Mediastinal infection
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CricothyroidotomyTools
Shiley 4 Tracheostomy TubeInternal Diameter: 5 mm
External Diameter: 8.5 mm
Be Prepared !
Saline filled syringe
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Why ???
Needle Cricothyroidotomy
Be Prepared !
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Needle CricothyroidotomyTools Be Prepared !
Oxygen:15 L / min
40 – 50 Psi
Syringe: 3 cc
Connector: 7 ETT
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Needle CricothyroidotomyTools
Be Prepared !
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Needle CricothyroidotomyTools
One second on
Four seconds off
Alternative:
Ctn O2 6 L / min 14 -16 *
Ctn O2 15 L / min 18 **
* Cat study
** 4.6 – 12.3 kg
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Chest Tubes
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Chest Tubes
Indications:
• Pneumothorax
• Hemothorax
• Empyema
• Pleural effusion
• Chylothorax
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Chest Tubes
• Bleedingrapid
300 ml 1st hr
continued200 ml / hr (3 hrs)
increasing
• Persistent hemothorax
• Large air leak
• Bronchial / esophageal / diaphragmatic injury
Contraindications:
• Need for immediate
open thoracostomy
• Massive hemothorax
1000 ml
• Clotting disorder
• Multiple pleural
adhesions / scarring
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Chest TubesProcedure
• Apical route rarely used
• Oxygen, IV, EKG, O2
sat monitor
• Pt semi-erect 30 – 600
• Chest tube size:trauma 36 – 42 Frpneumo 18 – 22 Fr
• Measure tube length
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Chest TubesProcedure
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Chest TubesComplications
• Lacerated intercostal artery
• Non-functioning tube
• Slippage
• Crossing mediastinum
• In soft tissue of neck
• Lung laceration
• Pain
• Re-expansion pulmonary edema
• Infection
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Needle Thoracentesis
Indications
• Rapid deterioration
• Tension
pneumothorax
No air or no relief……
Pericardial tamponade
Myocardial contusion / infarct
Air embolus
Complications:
infection
hemorrhage
pneumo / hemo thorax
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Venous Access
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Venous Cutdowns
• Shock
• No other access
• Site:
distal saphenous vein
• Contraindications
previous use of vein
phlebitis
cellulitis
trauma to the leg Medial & superior to the
medial maleolus
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Venous CutdownsProcedure
Skin incision perpendicular to the course of
the vein
Complications 15 %
wound infection 4
phlebitis 4
embolization
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Intraosseous
Infusions
SitesChildren:
Prox tibia anteromedial surface below
and medial to tibial tuberosity
Dist femur 2 – 3 cm above epichondyles
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Intraosseous
Infusions
Sites
Adults:
Distal tibia 1 cm above superior margin
of medial maleolus
Alternate Sites
Sternum
Proximal humerus
Proximal tibia 2 cm medial and 1
cm above tibial tuberosity
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IntraOsseous (IO) Devices
F.A.S.T.1 system (Sternal) Pyng Medical
Corp
Cook-type IO
Jamshidi IO needle
Illinois sternal iliac IO needle
EZ10 IO
Bone Injection Gun (B.I.G.) spring-loaded IO
insertion device
Pink=Pediatric
Yellow=Fat
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Intraosseous Infusions
Contraindications
Fracture / previously penetrated bone
Vascular interruption (trauma, cutdown)
Cellulitis, burns, osteomyelitis (at site)
Osteogenesis imperfecta, osteopetrosis
Right to left intracardiac shunt (ie tetralogy of Fallot): inc risk
cerebral emboli
Analgesia: slow 0.5 mg/kg (max 40mg) preservative free
2% lidocaine
Flush before and after each medication
Pressure infusion rate / resistance like a 21 gauge IV
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Interosseous InfusionsWhat’s Wrong with these Pictures ?
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Wound Repair
Dermabond
Pressure at ampule midpoint
Crush inner glass
Applicator tip up, away from pt
Histoacryl
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“I’ve Done the Best I Can”