Emergency Procedures ( Important in OSCE) v) Placement and Proof - Visualization of ETT entry into trachea - Chest movt1) Rapid Sequence Intubation - Misting of ETT2) Chest tube insertion - 5 point auscultation – bilat apex and bases (listen for increased A/E over Rt3) Femoral Line insertion side indicating one sided intubation) and epigastrium4) CVP Line insertion - Confirm with CXR vi) Post-intubation1) Rapid Sequence Intubation - Secure ETT at 3X size of ETT tube (male 22-24cm, female 20-22cm) - meant for intubation of PTs at risk of gastric aspiration - Check for hypotension/ other complicationsIndications of intubation i) Failure of airway maintenance or protection (eg LOC) 2) Chest tube insertion ii) Failure of ventilation or oxygenation (eg status asthmaticus, APO) Preparation iii) Anticipated deterioration (eg SAH, airway burns, laryngoedema) - stitch set + chlorhexidine + gauzeSteps - chest tube (size 22) + underwater seal i) Preparation - LA + needle + syringe - Equipment: ETT, syringe (check cuff is intact), stylet, laryngoscope (check light), - sterile gloves BVM, drugs, Yankauer sucker - scalpel - Monitoring: ECG, BP, PR, SpO2 – ensure all are optimal before RSI - suture - Prolene 2-0 and Mersilk 3-0 - Assess PT with LEMON: - Pressure bandage Look externally for maxillofacial and neck abnormalities, obesity Steps Evaluate 2-3 Rule: 2 finger mouth opening, 3 finger thyromental distance 1) Position PT Mallampati score 2) Surface mark Obstruction of airway – FB, trauma - mid axillary line Neck – optimize positioning in the ‘sniffing morning air’ position - ant axillary line ii) Preoxygenation - 4th/5th intercostal space (superior to rib) iii) Paralysis with induction and paralytic agent 3) Clean & drape - Induction agents 4) Insert LA needle - aspirate while going in until air/effusion is drawn (ie pleural cavity entered) Dose Special Indications Disadvantage/ContraIndication 5) Withdraw LA needle, injecting LA along track while withdrawing Midazolam 0.1mg/kg - First line agent - Hypotension 6) 2cm incision with scalpel - Resp depression 7) Blunt dissection with artery forceps in 2 directions until pleura is breached Etiomidate 0.3mg/kg - Hypotension - Myoclonus 8) Clear thoracic cavity with finger - ensure no lung/liver/spleen - ↑ICP / Head injury 9) Insert chest tube with trocar slightly withdrawn Ketamine 1-2mg/kg - Bronchoconstrictive dz - Raises ICP – CI in head - point up for PTx, down for fluid. – COPD / asthma injury/ ↑ICP - Insert up to 12 cm on Rt, 10cm on Lt - Hypotension - Dissociative amnesia 10) Clamp chest tube 11) Fix chest tube free end to underwater seal - Paralytic agents - need to cut off plastic seal at end of underwater seal tube connector first Dose Special Indications Disadvantage/ContraIndication 12) Anchor with Mersilk 3-0 Succinyl- 1.0- - First line agent - bradycardia / cardiac arrest 13) Purse string with prolene 2-0 choline 1.5mg/kg - rapid onset - hyperkalaemia (check ECG) 14) Pressure bandage - short duration - ↑ ICP and IOP 15) CXR - check position of chest tube - histamine release - malign hyperthermia Invx to order for pleural effusion Rocuronium 0.6mg/kg - rapid onset - tachycardia - Pleural fluid - cell count/cytospin, adenosine deaminase, glucose, protein, LDH, specific gravity, +/- cytology Atracurium 0.3- - hypotension - 0.6mg/kg - bronchospasm - Serum glucose, total protein & LFT (for LDH) iv) Protection and Positioning - Sellick’s manoeuvre – BURP (Backward, Upward, Rightward, Presure)
3) Femoral line 4) CVP linePreparation Preparation - Seldinger femoral line set (length 19.5cm for femoral line, 14cm for IJ line) - Seldinger CVP line set - 21G green needle - 21G green needle - Syringe + saline flush - Syringe + saline flush - Stitch set - Syringe for taking blood if required - LA + needle + syringe - Stitch set - Sterile gloves - LA + needle + syringe - Scalpel - Sterile gloves - Suture – prolene - Scalpel - Bandage - Suture – proleneSteps - Opsite dressing1) Landmark - locate femoral pulse along inguinal fold, 2-3cm inf & 1cm medial to pubic tubercle Steps2) Prepare Seldinger set 1) Surface mark - flush catheter ports x2 - Position PT - Trendelenberg position w head rotated to left - free guidewire - apex btwn med & lat heads of Rt SCM towards Rt nipple / Medial corner of triangle - attach green needle (21G) to searching syringe, half-fill syringe with sterile water formed by heads of SCM towards Lt nipple - prepare scalpel, stitch set and sutures for anchoring stitch 2) Prepare CVP line set - prepare bandage - Flush & lock all 3 ports - prepare LA and needle - Withdraw hooked tip of guide wire just into cap - additional syringe and saline for aspiration of catheter ports - Withdraw 2ml N/S into locating syringe & affix needle3) Clean & drape 3) Clean & drape4) Apply LA 4) LA at apex of triangle of SCM heads5) Search for femoral vein with induction syringe provided in Seldinger set (just medial to femoral 5) Insert locating needle while applying suction at 45degrees. Aim for Rt nipple. Carotid arteryartery) should be medial to IJV. - insert at 45degree angle along course of femoral vein while aspirating until flash back 6) Stop when flashback occurs. occurs when needle hits vein - Stop suction & watch. Ensure no arterial pulsation of blood into syringe.6) Ensure flash back is NON-PULSATILE 7) Remove Syringe, block needle w thumb - if so, femoral artery was entered. Remove and apply pressure. 8) Insert guide wire7) Remove syringe and cover needle with thumb 9) Remove needle8) Insert guide wire 10) Small incision w scalpel at point of CVP insertion - always ensure a good length of wire is left externally. Consider applying artery forceps 11) Insert dilator over wire & remove to wire end to prevent loss of wire. 12) Insert CVP line over wire up to 10-12cm.9) Remove induction needle over wire 13) Check backflow is good10) Make small incision in the skin at the base of the wire with scalpel 14) Check CVP (normal 8-16cmH2O) – assistant to attach manometer device to 3 way tap and11) Thread dilators over guide wire in succession, starting from smallest to biggest saline drip12) Thread femoral catheter over guide wire 15) Flush ports13) Remove guide wire 16) Anchor CVP line w suture14) Check each port for flash back 17) Opsite dressing over CVP line - attach syringe to port, release clamp, aspirate for good easy flow of venous blood, 18) CXR - tip of CVP line should be at level of carina. Ensure no PTx flush with saline, then clamp and seal15) Anchor with sutures16) Cover catheter ports with sterile gauze, bandage17) Document
5) Peritoneal TapStepsSurface mark - LIF / RIF, percuss for fluid level and ensure no organomegaly1) Clean & Drape2) LA - blue needle, insert with suction until peritoneal fluid is drawn, then withdraw needle andgive lignocaine along track3) Prepare Saldinger set - unhook J tip4) Insert 20 ml syringe with introducing needle until peritoneal fluid is withdrawn freely - draw20mls for investigations5) Remove syringe from needle and cover needle with fingertip6) Insert guidewire and ensure no resistance is met7) Remove needle over guide wire8) Nick skin with scalpel9) Progressively dilate track with introducers over guide wire10) Insert pigtail over guidewire11) Remove guidewire12) Fix tap on end of pigtail, ensuring tap is closed13) Place plastic flange around pigtail and secure with cable tie14) Connect urine bag to tap15) Tape down with elastic bandages16) Document17) Drain up to 6L/Day with IV alb cover Digitally signed by DR WANA HLA SHWE DN: cn=DR WANA HLA SHWE, c=MY, o=UCSI University, School of Medicine, KT-Campus, Terengganu, ou=Internal Medicine Group, email=wunna. email@example.com Reason: This document is for UCSI year 4 students. Date: 2009.02.24 10:00:43 +0800
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