time critical procedures part 2
DESCRIPTION
Part 2 of talk on Time Critical Procedures for the Emergency NurseTRANSCRIPT
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Time Critical Procedures Part II
Kane Guthrie
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Last Talk
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This Talk
•Emergency Resuscitative Thoracotomy
•Pericardial Tamponade
•Tension Pneumothorax
•Peri-Mortem C section
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Case 1
•22 male
•Fight over girl
•Stabbed to L chest
•Goes into PEA
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6 Killer Chest Trauma
•ATOM-FC
•Air obstruction - disruption
•Tension pneumothorax
•Open pneumothorax
•Massive haemothorax
•Flail chest
•Cardiac tamponade
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Emergency Resuscitative Thoracotomy
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Indications•Penetrating thoracic injury
•Traumatic arrest - previously SOL
•Unresponsive hypotension (BP <70)
•Blunt thoracic injury
•Unresponsive hypotension (BP <70)
•Chest tube output >1500ml
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Allows us to
•Evacuation pericardial tamponade
•Direct control intrathoracic haemorrhage
•Control massive air embolism
•Open cardiac massage
•Cross clamp aorta
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Relative Indications
•Traumatic arrest without witnessed cardiac activity!
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Contraindications
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Survival Rates
•Penetrating > 9-12%
•Some institutions achieved >38%
•Blunt trauma > 1-2%
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Risky Business
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Factors associated with survivors!
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Equipment
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Opening the Chest
•Left anterolateral incision
•Scissor through muscle, periosteum, pleura
•Rib spreaders 6th ribs
•May need to move the lung
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Once Inside
•Relieve tamponade
•Look for bleeding source
•Suture
•Cross clamp
•IDC
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Internal Cardiac Compressions
•2 handed technique
•Compress heart between:
•2 flat hands
•Hinged clapping motion
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Defib the Cracked Chest
•Internal paddles
•Paddles each side of heart
•Low joules 15-30
•No internal paddles?
•Close chest- standard defib!
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Case 2
•60 male
•Hx lung ca on chemo
•Progressive SOB
•Now:
•Hypotensive/shocked
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Pericardial Tamponade
•is defined as the critical compression of the heart by accumulation of blood in the pericardial space.
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Beck’s Triad!
•Distended neck veins
•Hypotension
•Muffled heart sounds
•Only occurs 40% of time!
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Use the Probe!
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Pericardiocentesis
•
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Handy Hints
•Pericardial blood doesn’t clot
•Intracardial blood does clot
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Some Pearls
•Only 100ml of blood can cause it
•Early Dx is key -ECHO
•Best manage in OT
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Complications
•Myocardial perforation
•Bleeding
•Pneumothorax
•Arrhythmia
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Pericardiocentesis Fails!
•Open thoracotomy
•Pericardio window
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Case 3
•24 male
•Fell from roof
•SOB, hypotensive, agitated
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Signs of Tension PTX
•Anxiety, agitation, distress
•Tachycardia-hypotension
•Neck vein distention
•Decreased chest movement
•Tracheal deviation
•Decreased breath sounds
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Should be found clinically!
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Managing Tension PTX
•Give high flow O2
•Immediate:
•Needle thoracentesis
•Finger thoracostomy
•Proceed to:
•Intercostal catheter
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Needle Thoracentesis
•14g inserted
•2nd ICS
•Aim relive Tension PTX!
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Needles Don’t Work
•Don’t reach target in 65% cases
•Prone to:
•Kinking
•Occluded
•Compress
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A better spot
•5th ICS in AAL
•Less failure rate (16%)
• Caution on the L side!
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Finger Thoracostomy
•Chest tube insertion w/o chest tube
•Use prehospital- arrest situations
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Indications
•PTX in PT undergoing ventilation
•Actual/near traumatic cardiac arrest
•Shocked state - no apparent cause
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Advantages
•The lung can be felt/seen to re-expand
•Pt deteriorates lung can be “re-fingered”
•Avoids blockage/kinging chest drain system
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Trouble getting ICC in?
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Case 4
•29 Female
•MVA -cardiac arrest
•Bun in the oven!
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Determining Gestation
•Hard to do!
•No magic number >20weeks
•If fundal height above umbilicus great
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Peri-mortem C-section
•Ability for 200% mortality
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Timing
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Get as much help as possible
•Obstetrician
•Paediatrician
•Midwife
•NICU
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Remember
•PMCS is a resuscitative intervention for the mother!
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Equipment - Mum
•Scalpel
•Surgical scissors
•Towels
•Cord clamps
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Equipment -Baby
•Baby warmer
•Neonatal BVM
•Intubation kit
•IO
•First line drugs
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Procedure
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Neonatal Resuscitation
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Questions
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Take Home Points
•These are once in a career cases!
•Your own adrenaline is the enemy
•Be cognitive ready
•Know your equipment
•Hardest part is making the decision to do it
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Thankyou