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...
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...
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...
Intraosseous Access
• Equal predictable drug delivery
• Equal pharmacological effect
• Flow rates 125-250mls/min
• Pain co...
Case 1
• No luck PIVC
• IO - humeral head
• Given 2litres CSL
• RSI- Ketamine-Roc
• Given 2g ceftriaxone
• 2/24 later CVC ...
Case 2

http://lifeinthefastlane.com/ortho-library/2010/07/boneand-joint-bamboozler-002/
Compartment
Syndrome
• Limb threatening condition
• Increased pressure with muscle
compartment

• Compression of - nerves,...
Causes

• Fractures - 75%
• Crush injury
• Snake bite
• Excessive exertion/imobilisation
• Constrictive -POP, tourniquet
•...
Pearl

• Patients with a coagulopathy are at

particular risk of compartment syndrome.
History & Physical
• Pain (especially on passive stretching)
• Pallor
• Perishingly cold
• Pulselessness
• Paralysis
• Par...
Fasciotomy
• Surgical procedure where the fascia is cut

to relieve tension/pressure resulting in loss
of circulation to t...
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 rhabdomyolysi...
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 ont...
History
• Symptoms:
• pain
• decreased vision
• inability to ope eyelids
• proptosis
Physical Exam
• Decreased visual acuity
• Swelling
• Limited extraocular movements
• Tonometry - raised IOP
• Funduscopy -...
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-tribula...
Escharotomy
Indications
• Circumferential burns to chest - impair
ventilation

• Constrictive circumferential neck burns impair airway...
Preparing
• Best done in theater
• Need scalpel, diathermy, artery ties, topical
haemostatics

• Good anaesthesia - Ketami...
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 failu...
Questions
Time Critical Procedures Part 1
Time Critical Procedures Part 1
Time Critical Procedures Part 1
Time Critical Procedures Part 1
Time Critical Procedures Part 1
Time Critical Procedures Part 1
Time Critical Procedures Part 1
Time Critical Procedures Part 1
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Time Critical Procedures Part 1

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An introduction to time critical procedures in the emergency department for emergency nurses.

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Time Critical Procedures Part 1

  1. 1. Time Critical Procedures Kane Guthrie
  2. 2. Time Critical Procedures • Often performed in frequently • Life saving • You must be prepared for these • Cognitive hurdle
  3. 3. The Batterfield
  4. 4. Being Ready • This is the sharpest end of what we do • Need to be ready: • Cognitively • Materially
  5. 5. Metacognition • Cognitively • Invisible simulation • Develop/prepare plans-scenarios in your mind • Knowing what you need to know • Leads = metacompetence
  6. 6. Human Factors • Manage your catecholamines
  7. 7. Cognitive Hurdle • Hardest part of doing most of these procedures is making the decision to do it!
  8. 8. Dominating the Resus Room • Know your environment • Know your equipment • Know your drugs • Know your algorithms
  9. 9. 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
  10. 10. Resus Room Law Cliff Reid. www.Resus.Me.com
  11. 11. Cliff Reid. www.Resus.Me.com
  12. 12. Checklist Help
  13. 13. Always Ensure Safety
  14. 14. Time Critical Procedures
  15. 15. Warning
  16. 16. Case 1 • 44 female • Rigid abdomen • Septic shock • IVDU
  17. 17. Difficult Vascular Access • Your options: • Ultrasound guided PIVC • CVC • IO
  18. 18. Intraosseous Access • Needle inserted into bone • Non-collapsible vein • Infuse into systemic circulation • 97% first pass success rate • Insertion in under 30secs
  19. 19. Intraosseous Access • Equal predictable drug delivery • Equal pharmacological effect • Flow rates 125-250mls/min • Pain comparable to PIVC • Dwell time 24hours
  20. 20. Case 1 • No luck PIVC • IO - humeral head • Given 2litres CSL • RSI- Ketamine-Roc • Given 2g ceftriaxone • 2/24 later CVC inserted
  21. 21. Case 2 http://lifeinthefastlane.com/ortho-library/2010/07/boneand-joint-bamboozler-002/
  22. 22. Compartment Syndrome • Limb threatening condition • Increased pressure with muscle compartment • Compression of - nerves, muscles & vessels within compartment
  23. 23. Causes • Fractures - 75% • Crush injury • Snake bite • Excessive exertion/imobilisation • Constrictive -POP, tourniquet • Soft tissue infection/burns
  24. 24. Pearl • Patients with a coagulopathy are at particular risk of compartment syndrome.
  25. 25. History & Physical • Pain (especially on passive stretching) • Pallor • Perishingly cold • Pulselessness • Paralysis • Paraesthesia
  26. 26. Fasciotomy • Surgical procedure where the fascia is cut to relieve tension/pressure resulting in loss of circulation to tissue or muscle.
  27. 27. Indications • Delta pressure <20mmHG definite • <30mmHg relative • Clinical signs suggesting
  28. 28. Pearl • Palpable distal pulses & normal CRT does not exclude compartment syndrome!
  29. 29. Preparing • Best done in theater with orthopod! • May be done in ED • Scalpel & sterile area
  30. 30. Pearls & Pitfalls • Give analgesia • Keep these patient hydrated • Monitor urine output • Hopefully prevents rhabdomyolysis
  31. 31. Case 3 • 24 male • Drunk • Baseball bat vs head http://lifeinthefastlane.com/ophthalmology-befuddler-033-2 /
  32. 32. Case 3 • Unable to detect light • Afferent pupil defect R eye • Reduced extraocular movement • Tonmetry reveals IOP 45mmHg
  33. 33. The Bulging Eye • Retrobulbar haemorrhage result in orbital compartment syndrome.
  34. 34. Acute Orbital Compartment Syndrome • Cause - trauma, operatively • Haemorrhage into orbital space • Transmits pressure onto optic nerve • Results- swelling, visual loss.
  35. 35. History • Symptoms: • pain • decreased vision • inability to ope eyelids • proptosis
  36. 36. Physical Exam • Decreased visual acuity • Swelling • Limited extraocular movements • Tonometry - raised IOP • Funduscopy - papilloedema
  37. 37. Treatment Options • Conservative • Topical timolol • Acetazolamide • Mannitol • Lateral Canthotomy
  38. 38. Lateral Canthotomy • Sight saving procedure
  39. 39. Indications
  40. 40. Lateral Canthotomy
  41. 41. The Procedure
  42. 42. Case 4 • 29 male • Meth lab explosion • Severe Burns • Struggling on the vent! http://lifeinthefastlane.com/trauma-tribulation-005/
  43. 43. Escharotomy
  44. 44. Indications • Circumferential burns to chest - impair ventilation • Constrictive circumferential neck burns impair airway • Circumferential burns extremities
  45. 45. Preparing • Best done in theater • Need scalpel, diathermy, artery ties, topical haemostatics • Good anaesthesia - Ketamine
  46. 46. Completed Escharotomy
  47. 47. Escharotomy Complications • Bleeding • Infection • Damage to underlying structures
  48. 48. Take Home Points • These procedures are uncommon • You need to be cognitively prepared • Know your equipment • Avoid failure to act
  49. 49. Questions
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