COMMON EMERGENCY PROCEDURES PART-II

INTERNS 24th batch IOM

PERIPHERAL IV CANNULATION

That is damn easy!That is commonplace!!what a waste of time!!!What a waste of

energy!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

A BIG NO

The commonest procedure done in ERsimplest invasive procedures, potentially life-saving intervention requires refined skills and experience

indications

intravenous drug administration, intravenous hydrationtransfusions of blood or blood

components, Emergency care, and in other situations

in which direct access to the bloodstream may be needed

What to order?

Iv cannula 20G usually (16, 18 for shock and 22, 24 for children)

Iv setNS- II

Sometimes

KVO- keep vein open

Heplock- iv set and fluid not given

Equipments

have it ready at the bedside before beginning the procedure.

1. gloves, non-sterile2. tourniquet, 3. Cotton swab; ensure it is wet4. Tape board with tape5. Containers for blood- routine (test tube, EDTA

vial); special (blood culture bottle, d/s syringe)6. Ensure the drip is ready and free of gas

bubbles

Contraindications

Only relativeLocal infection,phlebitis, sclerosed veins,Local burns or Arteriovenous fistula in an extremity e.g.

in CRF dialysis cases

Site Selection

No local contraindications upper-extremity veins preferred; more durable ,

fewer complications than that of lower-extremity veins. If upper-extremity veins inaccessible, dorsal veins of the foot or the saphenous veins of the lower extremity may be used; associated with a higher incidence of thrombosis and embolism. However, risk is lower in children and infants

the urgency of the situation; as distal as possible usually but if fluid administration required fast then proximal i.e. veins of the forearm preferred

Positioning

supine position, arm supported.The vein should be felt rather than seen;

so how to make the vein prominent?

Tie the tourniquet with a half-knot 8 to 10 cm above the targeted insertion site.

Place the tourniquet flat against the skin. Lower the arm below heart level, Gently tap on the vein, Instruct patient to open and close fist

repeatedly,

apply a warm compress to the selected site to increase vasodilatation

Gently tilt the extremity or adjust the angle of the light to reveal better the contours of the vessel.

Procedure

Swab the selected area. Allow the area to dry completely and Do not

repalpate the area. Use your nondominant hand to apply traction to

the skin distal to the venipuncture site. Pull downward to flex the wrist and use your

thumb to keep the skin taut. Always maintain a firm grip on the patient’s hand throughout the procedure.

With your dominant hand, insert the catheter with the metal needle bevel up,at a 5- to 30-degree angle through the skin and into the vein

When the catheter enters the vein lumen, watch for the initial “flashback” of blood

lower the catheter so that it is almost parallel to the skin; or hematoma

Keep the needle safely into the cover; be sure u don’t prick urself

Get blood for investigationsJoin the iv dripsecure the cannula with tapeAfter securing the cannula with tape, loop

the intravenous tubing and secure it

OCCUPATIONAL EXPOSURE TO BLOOD –BORNE PATHOGENS IN HEALTH CARE SETTINGS

Q. PUNCTUALITY IS IMPORTANT. WHO COMES FIRST IN ER?

A. HOUSE OF?B. NURSES?C. INTERNS?D. JUNIOR INTERNS?E. ON DUTY DOCTORS?

The correct answer is…………………

SAFETY!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

epidemiology

first report of a health care worker infected with HIV by a needle stick in 1984

CDC estimates that more than 380,000 needle-stick injuries occur in U.S. hospitals each year

Dec 2001, CDC received voluntary reports of 57 documented cases of HIV seroconversion temporally associated with occupational exposure to HIV among U.S. health care personnel

LET ALONE DEVELOPING WORLD

protection of health care workers does not appear on any list of health care priorities

too easy to ignore a problem about which there are few data

Ghana study; 803 schoolchildren; 61.2 % one marker of HBV infection and anti-HCV antibodies of 5.4%

70% of world’s HIV in sub-Saharan Africa, only 4% of worldwide cases of occupational HIV infection are reported from this region.

high demand for injections derives from the belief that they are more effective than other forms of treatment. In Ghana, 80-90% of the patients who visited a health center received one or more injections per visit.

A correlation has been documented between the frequency of injections and the prevalence of HBV, HCV and HIV in the population

AND OUR ER?

Don’t know exactly the data…sorry But no complacency. Incidences of accidental pricks

1. Iv cannulation……one incident

2. Drawing blood sample…….one incident

3. Suturing…………..one incident

4. Injecting local anesthesia……….one incident Do u want to be a part of similar anecdote?

why are we worried?

Each exposure is an urgent health issue for the exposed person

How does it occur commonly?

Percutaneous injury, usually inflicted by a hollow-bore needle, most common mechanism

percutaneous exposure to HIV-infected blood: 0.3% (95% CI: 0.2-0.5)

mucous-membrane exposure: 0.09% (95% CI:0.006-0.5)

transmission risk increased if:1. device causing the injury visibly contaminated with

blood, 2. device used for insertion into a vein or artery3. the device caused a deep injury

How to prevent?

Vaccination against hepatitis B virusIn ER; take into mind; WHO COMES

FIRST?

SAFETY

Universal precautions

CDC: a set of precautions designed to prevent transmission of HIV, HBV, and other blood-borne pathogens when providing first aid or health care.

Applicable to:1. blood, 2. other body fluids containing visible blood, 3. semen, and vaginal secretions. 4. tissues and 5. fluids: cerebrospinal, synovial, pleural,

peritoneal, pericardial, and amniotic fluids.

Not applicable to1. feces, 2. urine, 3. sweat, tears,4. nasal secretions, 5. Human breast milk,6. sputum and vomitus unless they contain visible

blood. 7. saliva except when visibly contaminated with blood

or in the dental setting where blood contamination of saliva is predictable

What to do?

don gloves on.Gloves be changed after contact with

each patient. Hands and other skin surfaces should be

washed immediately if contaminated with blood or body fluids requiring universal precautions.

Wear Face masks Wear protective eyewear; so lucky

people have glasses onWear apronCareful during

procedures………..practical tips at bedside, orientations and classes

Postexposure prophylaxis

Has finally found its place in noticeboard after accident

Dont’s: squeezeDo’s: wash with soap and running waterContact duty officer and follow

instructions as the notice in the board.

Hospital infection prevention policies

Regular training on infection prevention every month at the end of month

Some handbook

When to check again?

RECOMMENDATIONS

SAFETY training for ER health providers

Suggestions for improvements

Instruments: quantity and quality Stretchers- can be solved. BP cuffs- 2; sometimes out of order; place on top of counter- a

request Thermometers- 2; sometimes only celsius scale Tapeboards-2 Face mask; nasal cannula nebulizer electrical circuits and plugs Emergency drugs and iv cannula Cervical collar Blood glucometer Protocols for common emergency cases e.g. OP poisoning

Interdepartmental issues

priority emergency investigation at laboratory e.g. In MI, CPK-MB; in DKA, urine acetone, serum K, glucose

CT scan film be available On duty be available at call and not be

included in OPD or OT On duty routine obsolete; messed up Lunch for the evening shift duty house off and

interns

Thanks Emergency Department for

Golden opportunity for learningPutting knowledge into practice

THANK U