Vascular Access And Others Essentail Procedures
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Transcript of Vascular Access And Others Essentail Procedures
VASCULAR ACCESS AND OTHER ESSENTIAL
EMERGENCY PROCEDURE
2nd SP-ER day: Emergency Conference " Emergency Medicine Update “8 August 2009
Borwon Wittayachamnankul MD.
VASCULAR ACCESSES
Indication
Peripheral
Blood example
Drugs
fluid
Central
Central venous pressure
Inotropics
TPN
Cannot access peripheral line
Alternative
Intraosseouss
Endotracheal (Drugs only)
Central venous pressure catheterization and monitoring Performed when
Necessary for procedure such as pulmonary artery catheter or pacemaker placement
Peripheral vein cannot be cannulated
Desired for measurement of central venous pressure
Central venous pressure catheterization and monitoring Not performed in hypovolemic shock except
Massive volume repletion to elderly patients or heart disease
Fluid administration monitored in patients with visceral trauma & severe head injury
Central venous pressure catheterization and monitoring Sites
Most common: placed in the superior vena cava via internal jugular or subclavian vein
Less common: via external jugular vein or femoral vein
Peripheral veins: brachial-basilic system
Anatomy
Venous access site
Cephalic vein
Superficial radial vein at the wrist
Veins of the hand
Veins in the anticubital fossa
The large basilic vein in the upper arm
Venous access site
Deep femoral vein
Proximal great saphenous vein in the thigh
Superficial saphenous vein at the ankle
Venous access site
External jugular vein
Internal jugular vein
Subclavian
APPROACH
Subclavian :Infraclavicular approach
Subclavian : Supraclavicular approach
Contraindications
Infections
Fractures of ipsilateral ribs and clavicles
Coagulopathy
Thrombosis
Internal jugular :Central approach
Internal jugular : Posterior approach
Internal jugular :anterior approach
Contraindications
Infections
Thrombosis
Coagulopathy “
Femoral vein catheterization
Equipment and general technique for central venous catheterization
TEACHNIQUE
Catheter-over-needle
Catheter-through-needle
Seldinger technique
Seldinger technique
Subclavian Infraclavicular approach
Identify the anatomic landmarks
Anesthetize skin & subcutaneous tissue with 1% lidocaine.
Insert the introducer needle while gently aspirating for blood.
Once venous blood is being withdrawn easily, remove the syringe.
Pass the flexible guidewire through the needle into the vessel.
Remove the needle over the wire.
Make a small skin incision at the site of the guidewire.
Pass the dilator over the wire to make a tunnel through the subcutaneous tissue.
Remove the dilator, keeping the guidewire in place.
Pass the central venous catheter over the guidewire into the vessel.
Remove the guidewire.
Withdraw blood from each catheter port.
Flush each catheter port with sterile saline and cover each port with a Luer-Lok cap.
Attach the catheter to the IV tubing.
Suture the catheter into place, using the blue & white skin attachment collars.
Pitfalls
NEJM 357;9 august 30, 2007
Pitfalls
NEJM 357;24 december 13, 2007
Complications
Intraosseous line placement
Indications
•Immediate venous access for delivery of fluids, drugs or
blood products in patients cannot find out other site
• Recommended In PALS, ACLS • CPR more than 2 mins or more than 2 attempt
Contraindications
fracture at proximal insertion site
Skin infection at proposed insertion site
Equipment
Identify the anteromedial surface of the proximal tibia & palpate the tibial tuberosity.
The entry site is 1-2 cm distal to the tibial plateau & halfway between the anterior & posterior border of the tibia.
Support the patient’s leg from underneath with a small towel roll.
Using a twisting rather than rocking motion, advance the needle until a decrease in resistance is felt.
Remove the troca.
Aspirate bone marrow to confirm placement.
Inject 2-3 cc of sterile saline as a flush.
Attach IV tubing.
Saphenous vein cut down
Complications
Local hematoma or cellulitis
RARELY osteomyelitis
Alternative Insertion sites
Peripheral Insertion of Central Catheter (PICC)
Ultrasound guide cannulation
Issue of flow dynamics
Rate of flow
Internal catheter diameter
Temperature
Pressure
Viscosity
Catheter length
Stable adult trauma patients 2 large-bore 16-gauge or greater
Exsanquination 8.5-F catheter with Manually operated pressure bag or
Wall-mounted external pneumatic device
2nd catheter for drug infusion
Volume repletion & measurement of CVP Y arm catheter sheath
OTHER ESSENTIAL PROCEDURE
CARDIAC TAMPONADE
Treatment
Venous access
Rapid volume infusion
To less volume changes during respiration
And increase RV pressure to counter with pericardial pressure
These may prevent requirement for pericardiocentesis
Pericardiocentesis
If hemodynamic instability observed,
Emergently performed underfluoroscopy or echocardiographic guided
With/without comfirmatory testing with agitated saline injection
Dramatical improvement is necessary
N Engl J Med 2003;349:684-90
Contra-indication
Diagnosis is indoubt
Rupture true or false aneurysm
Rupture ventricular aneurysm
Severe local infection
Post drainage monitoring
Symptoms
Physical findings of decompensation Blood pressure changes
Evidence of hypoperfusion
Pulsus paradoxus
Imaging Chest X ray
Echocardiography
Indwelling catheter drainage
Catheter placement for 2-3 days
Could prevent recurrent even in idiopathic effusion from 23% to 6% in 3 years
Immediately drainage for subsequent decompensation
Indwelling catheter drainage
Instillation of diluted heparin required
Heparin 0.5 mL in PSS 9.5 mL
Except with hemopericardium e.g. dissection
Others Emergency procedure
Airway RSI Difficult airway management
Breathing Needle thoracocenthesis Tube thoracostomy
Circulation Venous access Pericardiocenthesis Emergency thoracotomy
Others Nasal pack DPL Ultrasound : diagnostic, Therapeutic
Essential
Indications
Contraindications
Methods
Anatomy
Materials
Aftercare
Complications