Time Critical Procedures Part 2
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Part 2 of talk on Time Critical Procedures for the Emergency Nurse
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Time Critical Procedures Part 2
- 1. Time Critical Procedures Part II Kane Guthrie
- 2. Last Talk
- 3. This Talk • Emergency Resuscitative Thoracotomy • Pericardial Tamponade • Tension Pneumothorax • Peri-Mortem C section
- 5. Case 1 • 22 male • Fight over girl • Stabbed to L chest • Goes into PEA
- 6. 6 Killer Chest Trauma • ATOM-FC • Air obstruction - disruption • Tension pneumothorax • Open pneumothorax • Massive haemothorax • Flail chest • Cardiac tamponade
- 8. Indications • Penetrating thoracic injury • Traumatic arrest - previously SOL • Unresponsive hypotension (BP <70) • Blunt thoracic injury • Unresponsive hypotension (BP <70) • Chest tube output >1500ml
- 9. Allows us to • Evacuation pericardial tamponade • Direct control intrathoracic haemorrhage • Control massive air embolism • Open cardiac massage • Cross clamp aorta
- 10. Relative Indications • Traumatic arrest without witnessed cardiac activity!
- 12. Survival Rates • Penetrating > 9-12% • Some institutions achieved >38% • Blunt trauma > 1-2%
- 13. Risky Business
- 15. Equipment
- 16. Opening the Chest • Left anterolateral incision • Scissor through muscle, periosteum, pleura • Rib spreaders 6th ribs • May need to move the lung
- 18. Once Inside • Relieve tamponade • Look for bleeding source • Suture • Cross clamp • IDC
- 19. Internal Cardiac Compressions • 2 handed technique • Compress heart between: • 2 flat hands • Hinged clapping motion
- 20. Defib the Cracked Chest • Internal paddles • Paddles each side of heart • Low joules 15-30 • No internal paddles? • Close chest- standard defib!
- 23. Case 2 • 60 male • Hx lung ca on chemo • Progressive SOB • Now: • Hypotensive/shocked
- 24. Pericardial Tamponade • is defined as the critical compression of the heart by accumulation of blood in the pericardial space.
- 25. Beck’s Triad! • Distended neck veins • Hypotension • Muffled heart sounds • Only occurs 40% of time!
- 26. Use the Probe!
- 28. Handy Hints • Pericardial blood doesn’t clot • Intracardial blood does clot
- 29. Some Pearls • Only 100ml of blood can cause it • Early Dx is key -ECHO • Best manage in OT
- 30. Complications • Myocardial perforation • Bleeding • Pneumothorax • Arrhythmia
- 31. Pericardiocentesis Fails! • Open thoracotomy • Pericardio window
- 32. Case 3 • 24 male • Fell from roof • SOB, hypotensive, agitated
- 33. Signs of Tension PTX • Anxiety, agitation, distress • Tachycardia-hypotension • Neck vein distention • Decreased chest movement • Tracheal deviation • Decreased breath sounds
- 35. Managing Tension PTX • Give high flow O2 • Immediate: • Needle thoracentesis • Finger thoracostomy • Proceed to: • Intercostal catheter
- 36. Needle Thoracentesis • 14g inserted • 2nd ICS • Aim relive Tension PTX!
- 37. Needles Don’t Work • Don’t reach target in 65% cases • Prone to: • Kinking • Occluded • Compress
- 38. A better spot • 5th ICS in AAL • Less failure rate (16%) • Caution on the L side!
- 39. Finger Thoracostomy • Chest tube insertion w/o chest tube • Use prehospital- arrest situations
- 40. Indications • PTX in PT undergoing ventilation • Actual/near traumatic cardiac arrest • Shocked state - no apparent cause
- 41. Advantages • The lung can be felt/seen to re-expand • Pt deteriorates lung can be “re-fingered” • Avoids blockage/kinging chest drain system
- 51. Case 4 • 29 Female • MVA -cardiac arrest • Bun in the oven!
- 52. Determining Gestation • Hard to do! • No magic number >20weeks • If fundal height above umbilicus great
- 53. Peri-mortem Csection • Ability for 200% mortality
- 54. Timing
- 55. Get as much help as possible • Obstetrician • Paediatrician • Midwife • NICU
- 56. Remember •PMCS is a resuscitative intervention for the mother!
- 57. Equipment - Mum • Scalpel • Surgical scissors • Towels • Cord clamps
- 58. Equipment -Baby • Baby warmer • Neonatal BVM • Intubation kit • IO • First line drugs
- 59. Procedure
- 62. Questions
- 63. 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
- 64. Thankyou