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Common pitfalls in ER Procedure
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Common pitfalls in ER Procedure

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  • 1.  
  • 2.
    • You should understand well about…
    • Indication
    • Contraindication
    • Step & techniques
    • After care
    • Complication : to be aware of
    • Options !! If the procedure FAIL !
  • 3.
    • Preparation
    • Procedure
      • Step
      • Skill
      • Patient
    • After finish procedure
      • Fail to check & Secure patient .
    Other factors Rush/stress step
  • 4.  
  • 5.  
  • 6. “ Patients do not die from a "failure to intubate." 'They die either from failure to stop trying to intubate or from undiagnosed esophageal intubation.” Scott, DB Endotracheal intubation: friend or foe Br Med J (Clin Res Ed). 1986 Jan 18;292(6514):157-8.
  • 7.  
  • 8.  
  • 9.  
  • 10.  
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  • 12.  
  • 13.  
  • 14.  
  • 15.  
  • 16.  
  • 17.  
  • 18.  
  • 19.
    • Indication :
      • Inability to maintain airway with less invasive techniques .
      • mostly : in case difficult airway , try ETT first
      • with preparation for surgical airway by side.
    • Contraindication :
      • Airway can be managed by less invasive method.
      • Others :
        • Partial / complete transection of airway  preferred tracheostomy
        • Not suitable in case with significant injury of Cricoid.
        • Relative Contraindication :
            • Known case of laryngeal pathology (tumor , fracture)
            •  prepare to extend to High tracheostomy.
        • Special considerations :
            • Children : < 8-10 yrs. : Needle cricothyroidotomy only.
            • Bad positioning : not extend neck.
  • 20.
    • Techniques :
    • Traditional surgical cricothyroidotomy
    • Alternative surgical cricothyroidotomy
    • Needle cricothyroidotomy
  • 21.  
  • 22.
    • Identify landmark
    • Incision : transverse
    • not more than 2-3 cm.  Anterior Jugular v.
    • Longitudinal only when :
    • neck swelling , suspected High Tracheostomy need.
  • 23. Not deeper than 1.5-2cm.
  • 24.  
  • 25.  
  • 26.  
  • 27.  
  • 28.  
  • 29.  
  • 30.
    • Internal jugular vein
    • Subclavian vein
    • Peripherally Inserted Central Catheter : PICC
    • Femoral vein
    • Peripheral venous cut down
  • 31.
    • Seldinger
    • Catheter over the needle
  • 32.  
  • 33.  
  • 34. Rt. IJ 15 Rt. SC 18 Lt. IJ 18 Lt. SC 20
  • 35. Scalenus anterior
  • 36.  
  • 37. Action tips 1.Prep skin For IJ , prep extend to SC 2. Prep cathetor Flush with Saline 3. Locate vein with finder needle IJ ~ 3 cm. 4. Remove finder needle Cap lock !! 5. Insert introducer needle Traction skin for fix landmark 6. Remove syringe : air embolism Don’t remove hand at all. 7.Insert guidewire Guide dislodge inside pt. or other damage with force. 8. Stop guidewire at 10 cm + skin mark Or when you see ectopy ! Heard arrhythmia. 9. Never let go of the guidewire. 10. Verify tip In SVC not in RA , above azygous v. an d carina. With tip parallel to vessel wall.
  • 38.  
  • 39. Humerus Distal tibia : malleolus
  • 40.  
  • 41. Cook Jamshidi Illinois Bone injection gun EZ IO
  • 42. Needle decompression for tension pneumothorax And Go-on ICD Landmark : = 2 nd ICS mid clavicular line
  • 43.
    • Pleural space must be identified.
    • Obese patient : Semiupright , beware of diaphragm perforation.
    • ICD with Trocar can cause significant injury
    • not measurement the chest tube
    •  last lumen is too closed to skin.  leakage & subcut.emphysema.
  • 44.
    • You should understand well about…
    • Indication
    • Contraindication
    • Step & techniques
    • After care
    • Complication : to be aware of
    • Options !! If the procedure FAIL !
  • 45. Question ?
  • 46.  
  • 47.  
  • 48.