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Heroic procedures you should know


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  • 1. Heroic Procedures You Should Know Said Al-Mazroui R5
  • 2. Objectives
    • Be aware of important procedures
    • Indications and Contraindications
    • Know yr limitations
  • 3. Case I
    • 31 yr old w h/o stab wound to the chest
    • suddenly in the ER became unresponsive
    • monitor is showing PEA
    • What is your action?
  • 4.  
  • 5. ER Thoracotomy
    • Indications:
    • • Penetrating chest trauma with recent loss of
    • vital signs
    • • Blunt trauma with loss of vital signs in the
    • ED??????
  • 6.
    • Survival rates were 5% for GSW and 33% for SW. Overall 18%
    Outcomes after emergency department thoracotomy for penetrating cardiac injuries: a new perspective. Molina EJ - Interact Cardiovasc Thorac Surg - 01-OCT-2008; 7(5): 845-8
  • 7.
    • The goals of the procedure are to:
    • treat pericardial tamponade
    • control hemorrhage
    • perform open cardiac massage
    • temporarily occlude the thoracic aorta.
  • 8. Contraindications
    • • Obvious signs of death
    • • Penetrating chest trauma with no vital signs in the field
    • BLUNT TRAUMA with or without vitals
  • 9. Procedure:
    • • Open the chest
    • • Deliver the heart
    • • Open the pericardium
    • • Plug the holes!
    • • Cross-clamp the aorta
    • • Open chest CPR /Defibrillation
  • 10.  
  • 11.  
  • 12. Complications
    • ( Complications are not significant when the alternative is death!!!)
    • • Iatrogenic laceration of surrounding
    • structures e.g. Lung, heart, vessels
    • • Blood-borne disease transmission
    • Infection, never done under sterile conditions
    • Care should be taken to prevent injury to any of the health care provider..
  • 13.
    • A retrospective review of EDT experience was performed. Data collected included injury mechanism and location, presence of measurable ED vital signs, initial ED cardiac rhythm, GCS, method of transportation, and survival. Ninety-four of 237 patients presented penetrating cardiac injuries after EDT. Eighty-nine patients (95%) were males. Measurable ED vital signs were present in 15 patients (16%).
    Outcomes after emergency department thoracotomy for penetrating cardiac injuries: a new perspective. Molina EJ - Interact Cardiovasc Thorac Surg - 01-OCT-2008; 7(5): 845-8
  • 14. Cont’d
    • Cardiac injuries were caused by GSW in 82 patients (87%) and SW in 12 patients (13%). Fifteen patients (16%) survived EDT and were taken to the operating room, while eight patients (8%) survived their entire hospitalization. All survivors were neurologically intact. Survival rates were 5% for GSW and 33% for SW . Mechanism of injury (SW), prehospital transportation by police, higher GCS, sinus tachycardia, and measurable ED vital signs were associated with improved survival..
  • 15.
    • An overall survival of 18% suggests that ET is a life saving procedure . It is difficult to find good predictors of survival from logistic regression analysis . It should, for a trained trauma team, be a liberal attitude toward performing the procedure on the agonal patient.
    • Emergency thoracotomy saves lives in a Scandinavian hospital setting. Pahle AS - J Trauma - 01-MAR-2010; 68(3): 599-603
  • 16.
    • Our primary study objective was to determine which patients requiring EDT for penetrating cardiac or great vessel (CGV) injury are salvageable . METHODS: All patients who underwent EDT for penetrating CGV injuries in two urban, level I trauma centers during 2000 to 2007 were retrospectively reviewed. Demographics, injury (mechanism, anatomic injury), prehospital care, and physiology (signs of life [SOL], vital signs, and cardiac rhythm) were analyzed with respect to hospital survival. RESULTS
    Emergency department thoracotomy for penetrating injuries of the heart and great vessels: an appraisal of 283 consecutive cases from two urban trauma centers. Seamon MJ - J Trauma - 01-DEC-2009; 67(6): 1250-7; discussion 1257-8
  • 17. Cont’d
    • CONCLUSION: When the cumulative impact of penetrating injury mechanism, ED SOL, and number of CGV wounds was analyzed together, we established that those sustaining multiple CGV GSWs (regardless of ED SOL) were nearly unsalvageable . These results indicate that when multiple CGV GSWs are encountered after EDT, further resuscitative efforts may be terminated without limiting the opportunity for survival
  • 18. Case II
    • 29 yo female G1P0, 34 wks pregnant, presents with chest pain.
    • As you are interviewing the patient she suddenly collapses and is found to be in PEA.
    • CPR is commenced.
  • 19.
    • What procedure should be considered at this stage?
  • 20.
    • Perimortem Cesarean Section
  • 21. Legal and Ethical Considerations
    • Permission for the operation should be obtained from the family when possible but not at the expense of delaying the procedure.
    • The emergency physician has the legal right and responsibility to provide the unborn fetus with every possible chance of survival when there is no hope of maternal survival.
  • 22.
    • What is the minimum gestational age for performing Perimortem CS??
  • 23. Infant survival
    • Most literature involves only small numbers of cases.
    • Emphasis mainly on successful cases so survival statistics difficult to ascertain.
    • Survival rates range from 11-40%.
  • 24. Indications
    • Optimize maternal CPR
    • PMCD must be considered in any woman who suffers irreversible cardiac arrest during 3 rd trimester.
    • Should be performed within 5 minutes of maternal demise.
  • 25. Contraindications
    • Prolonged CPR and fetus shows no sign of life
    • Inability to adequately resuscitate the fetus after delivery
    • Less than 24 wks of gestation
  • 26. Equipment
    • Scalpel with a No. 10 blade
    • Bandage scissors
    • Bladder retractor
    • Large retractors (2)
    • Forceps
    • Lap or gauze sponges
    • Hemostats (curved and straight)
    • Suction
    • Obstetric pack
  • 27.
    • Using the scalpel, a midline vertical incision is made through the abdominal wall extending from the symphysis pubis to the umbilicus and carried through all abdominal layers to the peritoneal cavity.
  • 28.
    • The bladder is reflected inferiorly; if full it may be aspirated to evacuate it and permit better access to the uterus
    • approximately 5-cm, vertical incision is made through the lower uterine segment until amniotic fluid is obtained or until the uterine cavity is clearly entered
  • 29.
    • The index and long fingers are then inserted into the incision and used to lift the uterine wall away from the fetus.
    • A bandage scissors is used to extend the incision vertically to the fundus until a wide exposure is obtained
  • 30.
    • The infant is then gently delivered, the nares and mouth suctioned, and the cord clamped and cut.
    • Neonatal resuscitation should be carried out as necessary.
  • 31. Maternal resuscitation
    • CPR should be initiated on the mother at the time of cardiac arrest and continued throughout the procedure
    • In rare instances relief of IVC compression improves maternal hemodynamics such that survival is possible, maternal pulses should be checked and CPR continued after delivery of the infant.
  • 32.
    • Case report on 2003 Perimortem cesarean delivery 30 minutes after a laboring patient jumped from a fourth-floor window: Baby survives and is normal at age 4 years
    • Gynecology, and Obstetrics, University of Sassari, Sassari, Italy
  • 33.
    • Perimortem Cesarean section in the helicopter EMS setting: a case report. - Kue R - Air Med J - 01-JAN-2008; 27(1): 46-7
  • 34. Cardiac arrest in pregnancy: increasing use of perimortem caesarean section due to emergency skills training? Dijkman A - BJOG - 01-FEB-2010; 117(3): 282-7
    • RESULTS: During the study period, 55 women had a cardiac arrest, 12 of whom underwent a PMCS. Before the introduction of the MOET course, four PMCSs were performed (0.36/year), compared with eight cases after its introduction (1.6/year, P = 0.01). No PMCS was performed within the recommended 5 minutes after starting resuscitation. Eight of the twelve women (67%) regained cardiac output after PMCS, with two maternal and five neonatal survivors. Maternal case fatality rate was 83%. Neonatal case fatality rate was 58%.CONCLUSIONS: Since the introduction of the MOET course, the use of PMCS has increased. Outcome, however, was still poor. An important factor to improve outcome is more timely application of this potentially life-saving procedure.
  • 35. Case III
    • A 37 yo man brought to the ED following an MVC.
    • He had suffered significant damage to the left side of his face.
    • On arrival, his GCS was 6. Shortly after intubation you notice the left eye is increasingly proptotic and noticeably firmer than the right.
  • 36.
    • What’s your diagnosis and what do you do next?
  • 37.
    • Retrobulbar hematoma
    Diagnosis= Orbital Compartment Syndrome
  • 38.
    • L a t e r a l
    C a n t h o t o m o y
  • 39. Other causes
    • Iatrogenic: otolaryngic and ophthalmologic procedures e.g. endoscopic sinus surgery
    • Spontaneous..
  • 40. Pathophysiology of RBH
    • The orbit is composed of 7 bones that enclose all but the anterior aspect. Here, the globe obstructs the opening to the bony orbit
    • Following trauma, the presence of hemorrhage, foreign body or edema can increase retrobulbar pressure.
  • 41. Pathophysiology (cont.)
    • The orbit compensates through proptosis, but the medial and lateral canthal tendons, which attach the eyelids to the orbital rim limit the forward movement of the globe.
    • As proptosis is restricted, the orbital pressure increases and impedes the optic nerve's vascular supply.
  • 42.  
  • 43. Pathophysiology (cont.)
    • If IOP exceeds central retinal artery pressure, retinal ischemia results. In such situations, timely lateral canthotomy can save visual function
  • 44. Indications 
    • Decreased visual acuity 
    • Intraocular pressure > 40 mm Hg 
    • Proptosis
    • Afferent pupillary defect 
    • Ophthalmoplegia  
    • Eye pain
  • 45. Contraindication 
    • Globe rupture
  • 46. Equipment
    • Hemostat or needle driver
    • Iris or suture scissors
    • Forceps
  • 47. The procedure
    • The surrounding skin is preped with NS to improve visualization and reduce the risk of infection.
    • If the patient is awake, an assistant should stabilize the head and maintain cervical immobilization.
    • The procedure is no more painful than laceration repair, however, it can be visually disturbing for the patient.
  • 48.
    • 1-2 cc of 1%-2% lidocaine with epinephrine is injected into the lateral canthus.
    • This provides both pain relief and hemostasis at the time of devascularization and incision.
    Anesthetizing the lateral canthus
  • 49. Incising the lateral canthus
    • The area is cut laterally 1-2 cm in length
  • 50. Cutting the inferior lateral canthal tendon
    • Using the forceps, the lower lid is pulled down to visualize the inferior lateral canthal tendon which is then cut.
  • 51.  
  • 52.
    • After the inferior canthal tendon has been cut, intraocular pressure is reassessed with a tonometer.
    • If IOP remains >40 mm Hg, then decompression is inadequate. The upper lid should be lifted and the superior lateral canthal tendon should be severed.
  • 53.  
  • 54.  
  • 55. Case IV
    • 48 yo male transferred from Sohar H. to SQUH where he presented with a stab wound to zone III of the neck.
    • On arrrival, GCS 15, stable BP with no active bleeding from wound.
    • After coming back from CTA neck, patient coughs and starts bleeding from wound.
    • RSI attempted but fails. Patient develops a large expanding hematoma and his SpO2 is dropping to 60s.
  • 56. What is the immediate management of this patient?
  • 57.
    • Surgical
    • Cricothyrotomy
  • 58. Indications
    • Failure of oral or nasal endotracheal intubation
      • Massive oral, nasal, or pharyngeal hemorrhage
      • Massive regurgitation or emesis
      • Masseter spasm or clenched teeth  
      • Structural deformities of oropharynx
  • 59. Indications
    • AW obstruction
      • Oropharyngeal edema
      • Mass effect (cancer, tumor, polyp, web, or other mass)
      •   Foreign body
      •   Laryngospasm
  • 60. Indications
    • Traumatic injuries making oral or nasal endotracheal intubation difficult or potentially hazardous    
  • 61. Contraindications
      • Tracheal transection
      • Laryngeal disruption/fracture
      • relative:
      • Age less than 8
      • Anterior neck hematoma
      • Previous cricothyrotomy
      • Tracheal tumor or mass
      • Coagulopathy
  • 62. Equipment
    • Scalpel with No. 11 blade
    • Tracheal hook
    • Tracheal dilator
    • No. 4 or 5 Shiley cuffed tracheostomy tube with introducer and riser
  • 63.
    • Hyperextend the head to identify anatomy and control cricoid space.
    • As a guide, a 20 ga needle can be inserted through the membrane with aspiration of air to confirm entry (optional).
    • The larynx is stabilized by holding it between the non-dominant thumb and middle finger.
    The Procedure
  • 64.
    • A vertical incision is made after puncture through the membrane
    The Procedure
  • 65.  
  • 66.  
  • 67.
    • The opening is widened by insertion of the scalpel handle and rotating it 90 degrees.
  • 68.  
  • 69. Complications
    • Thyroid gland damage
    • Large vessel injury with hemorrhage
    • Esophageal damage
    • Infection
    • Aspiration
  • 70. Vertical or horizontal incision?
    • Horizontal incision increases risk of tube misplacement
    • Does not allow extension of incision if more exposure needed
    • Increases risk of lacerating neck vessels with resulting hemorrhage
  • 71. Pericardiocentesis
    • Indications:
    • • Drainage of pericardial effusion causing
    • acute tamponade
    • Contra-indications:
    • • No evidence of effusion
  • 72. Complications:
    • • Bleeding
    • • Infection
    • • Solid and hollow viscus injury
    • • Hemothorax
    • • Pneumothorax
    • • Lung laceration
    • • Cardiac laceration
    • • Arrhythmia
    • • Air embolism
  • 73. Ultrasound Assisted Technique:
    • • Perform basic echocardiographic views
    • • Confirm the presence of life-threatening
    • effusion
    • • Identify the safest access point through
    • least tissue and largest target area
    • • Place needle using ultrasound marked
    • location
    • • Place catheter through standard seldinger
    • technique
    • • Drain effusion
  • 74.
    • Questions?