vascular access and others essentail procedures
TRANSCRIPT
![Page 1: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/1.jpg)
VASCULAR ACCESS AND OTHER ESSENTIAL
EMERGENCY PROCEDURE
2nd SP-ER day: Emergency Conference " Emergency Medicine Update “8 August 2009
Borwon Wittayachamnankul MD.
![Page 2: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/2.jpg)
VASCULAR ACCESSES
![Page 3: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/3.jpg)
Indication
Peripheral
Blood example
Drugs
fluid
Central
Central venous pressure
Inotropics
TPN
Cannot access peripheral line
![Page 4: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/4.jpg)
Alternative
Intraosseouss
Endotracheal (Drugs only)
![Page 5: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/5.jpg)
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
![Page 6: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/6.jpg)
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
![Page 7: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/7.jpg)
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
![Page 8: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/8.jpg)
Anatomy
![Page 9: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/9.jpg)
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
![Page 10: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/10.jpg)
Venous access site
Deep femoral vein
Proximal great saphenous vein in the thigh
Superficial saphenous vein at the ankle
![Page 11: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/11.jpg)
Venous access site
External jugular vein
Internal jugular vein
Subclavian
![Page 12: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/12.jpg)
APPROACH
![Page 13: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/13.jpg)
Subclavian :Infraclavicular approach
![Page 14: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/14.jpg)
Subclavian : Supraclavicular approach
![Page 15: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/15.jpg)
Contraindications
Infections
Fractures of ipsilateral ribs and clavicles
Coagulopathy
Thrombosis
![Page 16: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/16.jpg)
Internal jugular :Central approach
![Page 17: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/17.jpg)
Internal jugular : Posterior approach
![Page 18: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/18.jpg)
Internal jugular :anterior approach
![Page 19: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/19.jpg)
Contraindications
Infections
Thrombosis
Coagulopathy “
![Page 20: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/20.jpg)
Femoral vein catheterization
![Page 21: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/21.jpg)
Equipment and general technique for central venous catheterization
![Page 22: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/22.jpg)
TEACHNIQUE
![Page 23: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/23.jpg)
Catheter-over-needle
![Page 24: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/24.jpg)
Catheter-through-needle
![Page 25: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/25.jpg)
Seldinger technique
![Page 26: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/26.jpg)
Seldinger technique
Subclavian Infraclavicular approach
![Page 27: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/27.jpg)
Identify the anatomic landmarks
![Page 28: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/28.jpg)
Anesthetize skin & subcutaneous tissue with 1% lidocaine.
![Page 29: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/29.jpg)
Insert the introducer needle while gently aspirating for blood.
![Page 30: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/30.jpg)
Once venous blood is being withdrawn easily, remove the syringe.
![Page 31: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/31.jpg)
Pass the flexible guidewire through the needle into the vessel.
![Page 32: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/32.jpg)
Remove the needle over the wire.
![Page 33: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/33.jpg)
Make a small skin incision at the site of the guidewire.
![Page 34: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/34.jpg)
Pass the dilator over the wire to make a tunnel through the subcutaneous tissue.
![Page 35: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/35.jpg)
Remove the dilator, keeping the guidewire in place.
![Page 36: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/36.jpg)
Pass the central venous catheter over the guidewire into the vessel.
![Page 37: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/37.jpg)
Remove the guidewire.
![Page 38: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/38.jpg)
Withdraw blood from each catheter port.
![Page 39: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/39.jpg)
Flush each catheter port with sterile saline and cover each port with a Luer-Lok cap.
![Page 40: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/40.jpg)
Attach the catheter to the IV tubing.
![Page 41: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/41.jpg)
Suture the catheter into place, using the blue & white skin attachment collars.
![Page 42: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/42.jpg)
Pitfalls
NEJM 357;9 august 30, 2007
![Page 43: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/43.jpg)
Pitfalls
NEJM 357;24 december 13, 2007
![Page 44: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/44.jpg)
Complications
![Page 45: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/45.jpg)
Intraosseous line placement
![Page 46: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/46.jpg)
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
![Page 47: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/47.jpg)
Contraindications
fracture at proximal insertion site
Skin infection at proposed insertion site
![Page 48: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/48.jpg)
Equipment
![Page 49: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/49.jpg)
Identify the anteromedial surface of the proximal tibia & palpate the tibial tuberosity.
![Page 50: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/50.jpg)
The entry site is 1-2 cm distal to the tibial plateau & halfway between the anterior & posterior border of the tibia.
![Page 51: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/51.jpg)
Support the patient’s leg from underneath with a small towel roll.
![Page 52: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/52.jpg)
Using a twisting rather than rocking motion, advance the needle until a decrease in resistance is felt.
![Page 53: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/53.jpg)
Remove the troca.
![Page 54: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/54.jpg)
Aspirate bone marrow to confirm placement.
![Page 55: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/55.jpg)
Inject 2-3 cc of sterile saline as a flush.
![Page 56: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/56.jpg)
Attach IV tubing.
![Page 57: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/57.jpg)
Saphenous vein cut down
![Page 58: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/58.jpg)
Complications
Local hematoma or cellulitis
RARELY osteomyelitis
![Page 59: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/59.jpg)
![Page 60: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/60.jpg)
Alternative Insertion sites
![Page 61: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/61.jpg)
Peripheral Insertion of Central Catheter (PICC)
![Page 62: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/62.jpg)
![Page 63: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/63.jpg)
Ultrasound guide cannulation
![Page 64: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/64.jpg)
Issue of flow dynamics
Rate of flow
Internal catheter diameter
Temperature
Pressure
Viscosity
Catheter length
![Page 65: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/65.jpg)
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
![Page 66: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/66.jpg)
OTHER ESSENTIAL PROCEDURE
![Page 67: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/67.jpg)
CARDIAC TAMPONADE
![Page 68: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/68.jpg)
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
![Page 69: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/69.jpg)
Pericardiocentesis
If hemodynamic instability observed,
Emergently performed underfluoroscopy or echocardiographic guided
With/without comfirmatory testing with agitated saline injection
Dramatical improvement is necessary
![Page 70: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/70.jpg)
N Engl J Med 2003;349:684-90
![Page 71: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/71.jpg)
Contra-indication
Diagnosis is indoubt
Rupture true or false aneurysm
Rupture ventricular aneurysm
Severe local infection
![Page 72: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/72.jpg)
Post drainage monitoring
Symptoms
Physical findings of decompensation Blood pressure changes
Evidence of hypoperfusion
Pulsus paradoxus
Imaging Chest X ray
Echocardiography
![Page 73: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/73.jpg)
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
![Page 74: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/74.jpg)
Indwelling catheter drainage
Instillation of diluted heparin required
Heparin 0.5 mL in PSS 9.5 mL
Except with hemopericardium e.g. dissection
![Page 75: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/75.jpg)
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
![Page 76: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/76.jpg)
Essential
Indications
Contraindications
Methods
Anatomy
Materials
Aftercare
Complications
![Page 77: Vascular Access And Others Essentail Procedures](https://reader034.vdocuments.us/reader034/viewer/2022052504/554b6407b4c905030a8b46c3/html5/thumbnails/77.jpg)