Time Critical Procedures Part 1
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Transcript of Time Critical Procedures Part 1
Time Critical Procedures
Kane Guthrie
Time Critical Procedures
•Often performed in frequently
•Life saving
•You must be prepared for these
•Cognitive hurdle
The Batterfield
Being Ready
•This is the sharpest end of what we do
•Need to be ready:
•Cognitively
•Materially
Metacognition
•Cognitively
•Invisible simulation
•Develop/prepare plans-scenarios in your mind
•Knowing what you need to know
•Leads = metacompetence
Human Factors
•Manage your catecholamines
Cognitive Hurdle
•Hardest part of doing most of these procedures is making the decision to do it!
Dominating the Resus Room
•Know your environment
•Know your equipment
•Know your drugs
•Know your algorithms
Getting the Most out of the Team
•Be Nice
•Be authoritative
•Stay patient focused
•Ask for help
•Use the group
•Push the right buttons
•Craft your language
Resus Room Law
Cliff Reid. www.Resus.Me.com
Cliff Reid. www.Resus.Me.com
Checklist Help
Always Ensure Safety
Time Critical Procedures
Warning
Case 1
•44 female
•Rigid abdomen
•Septic shock
•IVDU
Difficult Vascular Access
•Your options:
•Ultrasound guided PIVC
•CVC
•IO
Intraosseous Access
•Needle inserted into bone
•Non-collapsible vein
•Infuse into systemic circulation
•97% first pass success rate
•Insertion in under 30secs
Intraosseous Access
•Equal predictable drug delivery
•Equal pharmacological effect
•Flow rates 125-250mls/min
•Pain comparable to PIVC
•Dwell time 24hours
Case 1
•No luck PIVC
•IO - humeral head
•Given 2litres CSL
•RSI- Ketamine-Roc
•Given 2g ceftriaxone
•2/24 later CVC inserted
Case 2
http://lifeinthefastlane.com/ortho-library/2010/07/bone-and-joint-bamboozler-002/
Compartment Syndrome
•Limb threatening condition
•Increased pressure with muscle compartment
•Compression of - nerves, muscles & vessels within compartment
Causes
•Fractures - 75%
•Crush injury
•Snake bite
•Excessive exertion/imobilisation
•Constrictive -POP, tourniquet
•Soft tissue infection/burns
Pearl
•Patients with a coagulopathy are at particular risk of compartment syndrome.
History & Physical•Pain (especially on passive
stretching)
•Pallor
•Perishingly cold
•Pulselessness
•Paralysis
•Paraesthesia
Fasciotomy
•Surgical procedure where the fascia is cut to relieve tension/pressure resulting in loss of circulation to tissue or muscle.
Indications
•Delta pressure <20mmHG definite
•<30mmHg relative
•Clinical signs suggesting
Pearl
•Palpable distal pulses & normal CRT does not exclude compartment syndrome!
Preparing
•Best done in theater with orthopod!
•May be done in ED
•Scalpel & sterile area
Pearls & Pitfalls
•Give analgesia
•Keep these patient hydrated
•Monitor urine output
•Hopefully prevents rhabdomyolysis
Case 3
•24 male
•Drunk
•Baseball bat vs head
http://lifeinthefastlane.com/ophthalmology-
befuddler-033-2/
Case 3
•Unable to detect light
•Afferent pupil defect R eye
•Reduced extraocular movement
•Tonmetry reveals IOP 45mmHg
The Bulging Eye
•Retrobulbar haemorrhage result in orbital compartment syndrome.
Acute Orbital Compartment
Syndrome
•Cause - trauma, operatively
•Haemorrhage into orbital space
•Transmits pressure onto optic nerve
•Results- swelling, visual loss.
History
•Symptoms:
•pain
•decreased vision
•inability to ope eyelids
•proptosis
Physical Exam
•Decreased visual acuity
•Swelling
•Limited extraocular movements
•Tonometry - raised IOP
•Funduscopy - papilloedema
Treatment Options
•Conservative
•Topical timolol
•Acetazolamide
•Mannitol
•Lateral Canthotomy
Lateral Canthotomy
•Sight saving procedure
Indications
Lateral Canthotomy
The Procedure
Case 4
•29 male
•Meth lab explosion
•Severe Burns
•Struggling on the vent!
http://lifeinthefastlane.com/trauma-tribulation-005/
Escharotomy
Indications
•Circumferential burns to chest - impair ventilation
•Constrictive circumferential neck burns - impair airway
•Circumferential burns extremities
Preparing
•Best done in theater
•Need scalpel, diathermy, artery ties, topical haemostatics
•Good anaesthesia - Ketamine
Completed Escharotomy
Escharotomy Complications
•Bleeding
•Infection
•Damage to underlying structures
Take Home Points
•These procedures are uncommon
•You need to be cognitively prepared
•Know your equipment
•Avoid failure to act
Questions