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This presentation was made by medical interns of 24th batch of Institute of Medicine, Maharajgunj Campus, Kathmandu, Nepal.

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  2. 2. PERIPHERAL IV CANNULATION <ul><li>That is damn easy! </li></ul><ul><li>That is commonplace!! </li></ul><ul><li>what a waste of time!!! </li></ul><ul><li>What a waste of energy!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! </li></ul>
  3. 3. A BIG NO <ul><li>The commonest procedure done in ER </li></ul><ul><li>simplest invasive procedures, </li></ul><ul><li>potentially life-saving intervention </li></ul><ul><li>requires refined skills and experience </li></ul>
  4. 4. indications <ul><li>intravenous drug administration, </li></ul><ul><li>intravenous hydration </li></ul><ul><li>transfusions of blood or blood components, </li></ul><ul><li>Emergency care, and in other situations in which direct access to the bloodstream may be needed </li></ul>
  5. 5. What to order? <ul><li>Iv cannula 20G usually (16, 18 for shock and 22, 24 for children) </li></ul><ul><li>Iv set </li></ul><ul><li>NS- II </li></ul><ul><li>Sometimes </li></ul><ul><li>KVO- keep vein open </li></ul><ul><li>Heplock- iv set and fluid not given </li></ul>
  6. 6. Equipments <ul><li>have it ready at the bedside before beginning the procedure. </li></ul><ul><li>gloves, non-sterile </li></ul><ul><li>tourniquet, </li></ul><ul><li>Cotton swab; ensure it is wet </li></ul><ul><li>Tape board with tape </li></ul><ul><li>Containers for blood- routine (test tube, EDTA vial); special (blood culture bottle, d/s syringe) </li></ul><ul><li>Ensure the drip is ready and free of gas bubbles </li></ul>
  7. 7. Contraindications <ul><li>Only relative </li></ul><ul><li>Local infection, </li></ul><ul><li>phlebitis, sclerosed veins, </li></ul><ul><li>Local burns or </li></ul><ul><li>Arteriovenous fistula in an extremity e.g. in CRF dialysis cases </li></ul>
  8. 8. Site Selection <ul><li>No local contraindications </li></ul><ul><li>upper-extremity veins preferred; more durable , fewer complications than that of lower-extremity veins. If upper-extremity veins inaccessible, dorsal veins of the foot or the saphenous veins of the lower extremity may be used; associated with a higher incidence of thrombosis and embolism. However, risk is lower in children and infants </li></ul><ul><li>the urgency of the situation; as distal as possible usually but if fluid administration required fast then proximal i.e. veins of the forearm preferred </li></ul>
  9. 9. Positioning <ul><li>supine position, arm supported. </li></ul><ul><li>The vein should be felt rather than seen; so how to make the vein prominent? </li></ul>
  10. 10. <ul><li>Tie the tourniquet with a half-knot 8 to 10 cm above the targeted insertion site. </li></ul><ul><li>Place the tourniquet flat against the skin. </li></ul><ul><li>Lower the arm below heart level, </li></ul><ul><li>Gently tap on the vein, </li></ul><ul><li>Instruct patient to open and close fist repeatedly, </li></ul>
  11. 11. <ul><li>apply a warm compress to the selected site to increase vasodilatation </li></ul><ul><li>Gently tilt the extremity or adjust the angle of the light to reveal better the contours of the vessel. </li></ul>
  12. 12. Procedure <ul><li>Swab the selected area. </li></ul><ul><li>Allow the area to dry completely and Do not repalpate the area. </li></ul><ul><li>Use your nondominant hand to apply traction to the skin distal to the venipuncture site. </li></ul><ul><li>Pull downward to flex the wrist and use your thumb to keep the skin taut. Always maintain a firm grip on the patient ’s hand throughout the procedure. </li></ul>
  13. 13. <ul><li>With your dominant hand, insert the catheter with the metal needle bevel up,at a 5- to 30-degree angle through the skin and into the vein </li></ul><ul><li>When the catheter enters the vein lumen, watch for the initial “flashback” of blood </li></ul><ul><li>lower the catheter so that it is almost parallel to the skin; or hematoma </li></ul>
  14. 14. <ul><li>Keep the needle safely into the cover ; be sure u don ’t prick urself </li></ul><ul><li>Get blood for investigations </li></ul><ul><li>Join the iv drip </li></ul><ul><li>secure the cannula with tape </li></ul><ul><li>After securing the cannula with tape, loop the intravenous tubing and secure it </li></ul>
  16. 16. Q. PUNCTUALITY IS IMPORTANT. WHO COMES FIRST IN ER? <ul><li>A. HOUSE OF? </li></ul><ul><li>B. NURSES? </li></ul><ul><li>C. INTERNS? </li></ul><ul><li>D. JUNIOR INTERNS? </li></ul><ul><li>E. ON DUTY DOCTORS? </li></ul><ul><li>The correct answer is………………… </li></ul>
  17. 17. <ul><li>SAFETY!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! </li></ul>
  18. 18. epidemiology <ul><li>first report of a health care worker infected with HIV by a needle stick in 1984 </li></ul><ul><li>CDC estimates that more than 380,000 needle-stick injuries occur in U.S. hospitals each year </li></ul><ul><li>Dec 2001, CDC received voluntary reports of 57 documented cases of HIV seroconversion temporally associated with occupational exposure to HIV among U.S. health care personnel </li></ul>
  19. 19. LET ALONE DEVELOPING WORLD <ul><li>protection of health care workers does not appear on any list of health care priorities </li></ul><ul><li>too easy to ignore a problem about which there are few data </li></ul><ul><li>Ghana study; 803 schoolchildren; 61.2 % one marker of HBV infection and anti-HCV antibodies of 5.4% </li></ul><ul><li>70% of world ’s HIV in sub-Saharan Africa, only 4% of worldwide cases of occupational HIV infection are reported from this region. </li></ul>
  20. 20. <ul><li>high demand for injections derives from the belief that they are more effective than other forms of treatment. In Ghana, 80-90% of the patients who visited a health center received one or more injections per visit. </li></ul><ul><li>A correlation has been documented between the frequency of injections and the prevalence of HBV, HCV and HIV in the population </li></ul>
  21. 21. AND OUR ER? <ul><li>Don ’t know exactly the data…sorry </li></ul><ul><li>But no complacency. </li></ul><ul><li>Incidences of accidental pricks </li></ul><ul><li>Iv cannulation……one incident </li></ul><ul><li>Drawing blood sample…….one incident </li></ul><ul><li>Suturing…………..one incident </li></ul><ul><li>Injecting local anesthesia……….one incident </li></ul><ul><li>Do u want to be a part of similar anecdote? </li></ul>
  22. 22. why are we worried? <ul><li>Each exposure is an urgent health issue for the exposed person </li></ul>
  23. 23. How does it occur commonly? <ul><li>Percutaneous injury, usually inflicted by a hollow-bore needle, most common mechanism </li></ul><ul><li>percutaneous exposure to HIV-infected blood: 0.3% (95% CI: 0.2-0.5) </li></ul><ul><li>mucous-membrane exposure: 0.09% (95% CI:0.006-0.5) </li></ul><ul><li>transmission risk increased if: </li></ul><ul><li>device causing the injury visibly contaminated with blood, </li></ul><ul><li>device used for insertion into a vein or artery </li></ul><ul><li>the device caused a deep injury </li></ul>
  24. 24. How to prevent? <ul><li>Vaccination against hepatitis B virus </li></ul><ul><li>In ER; take into mind; WHO COMES FIRST? </li></ul><ul><li>SAFETY </li></ul>
  25. 25. Universal precautions <ul><li>CDC: a set of precautions designed to prevent transmission of HIV, HBV, and other blood-borne pathogens when providing first aid or health care. </li></ul><ul><li>Applicable to: </li></ul><ul><li>blood, </li></ul><ul><li>other body fluids containing visible blood, </li></ul><ul><li>semen, and vaginal secretions. </li></ul><ul><li>tissues and </li></ul><ul><li>fluids: cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluids. </li></ul>
  26. 26. <ul><li>Not applicable to </li></ul><ul><li>feces, </li></ul><ul><li>urine, </li></ul><ul><li>sweat, tears, </li></ul><ul><li>nasal secretions, </li></ul><ul><li>Human breast milk, </li></ul><ul><li>sputum and vomitus unless they contain visible blood. </li></ul><ul><li>saliva except when visibly contaminated with blood or in the dental setting where blood contamination of saliva is predictable </li></ul>
  27. 27. What to do? <ul><li>don gloves on. </li></ul><ul><li>Gloves be changed after contact with each patient. </li></ul><ul><li>Hands and other skin surfaces should be washed immediately if contaminated with blood or body fluids requiring universal precautions. </li></ul>
  28. 28. <ul><li>Wear Face masks </li></ul><ul><li>Wear protective eyewear; so lucky people have glasses on </li></ul><ul><li>Wear apron </li></ul><ul><li>Careful during procedures………..practical tips at bedside, orientations and classes </li></ul>
  29. 29. Postexposure prophylaxis <ul><li>Has finally found its place in noticeboard after accident </li></ul><ul><li>Dont ’s: squeeze </li></ul><ul><li>Do ’s: wash with soap and running water </li></ul><ul><li>Contact duty officer and follow instructions as the notice in the board. </li></ul>
  30. 30. Hospital infection prevention policies <ul><li>Regular training on infection prevention every month at the end of month </li></ul><ul><li>Some handbook </li></ul>
  31. 31. When to check again?
  32. 32. RECOMMENDATIONS <ul><li>SAFETY training for ER health providers </li></ul>
  33. 33. Suggestions for improvements <ul><li>Instruments: quantity and quality </li></ul><ul><li>Stretchers- can be solved. </li></ul><ul><li>BP cuffs- 2; sometimes out of order; place on top of counter- a request </li></ul><ul><li>Thermometers- 2; sometimes only celsius scale </li></ul><ul><li>Tapeboards-2 </li></ul><ul><li>Face mask; nasal cannula </li></ul><ul><li>nebulizer </li></ul><ul><li>electrical circuits and plugs </li></ul><ul><li>Emergency drugs and iv cannula </li></ul><ul><li>Cervical collar </li></ul><ul><li>Blood glucometer </li></ul><ul><li>Protocols for common emergency cases e.g. OP poisoning </li></ul>
  34. 34. Interdepartmental issues <ul><li>priority emergency investigation at laboratory e.g. In MI, CPK-MB; in DKA, urine acetone, serum K, glucose </li></ul><ul><li>CT scan film be available </li></ul><ul><li>On duty be available at call and not be included in OPD or OT </li></ul><ul><li>On duty routine obsolete; messed up </li></ul><ul><li>Lunch for the evening shift duty house off and interns </li></ul>
  35. 35. Thanks Emergency Department for <ul><li>Golden opportunity for learning </li></ul><ul><li>Putting knowledge into practice </li></ul>
  36. 36. THANK U
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