Emergencyat2066.2.4
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Emergencyat2066.2.4

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

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

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