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Time Critical
Procedures Part II
Kane Guthrie
Last Talk
This Talk
• Emergency Resuscitative Thoracotomy
• Pericardial Tamponade
• Tension Pneumothorax
• Peri-Mortem C section
Case 1
• 22 male
• Fight over girl
• Stabbed to L chest
• Goes into PEA
6 Killer Chest Trauma
• ATOM-FC
• Air obstruction - disruption
• Tension pneumothorax
• Open pneumothorax
• Massive haemot...
Emergency
Resuscitative
Thoracotomy
Indications
• Penetrating thoracic injury
• Traumatic arrest - previously SOL
• Unresponsive hypotension (BP <70)
• Blunt ...
Allows us to
• Evacuation pericardial tamponade
• Direct control intrathoracic
haemorrhage

• Control massive air embolism...
Relative Indications

• Traumatic arrest without witnessed
cardiac activity!
Contraindications
Survival Rates
• Penetrating > 9-12%
• Some institutions achieved >38%
• Blunt trauma > 1-2%
Risky Business
Factors associated
with survivors!
Equipment
Opening the Chest
• Left anterolateral incision
• Scissor through
muscle, periosteum, pleura

• Rib spreaders 6th ribs
• M...
Once Inside
• Relieve tamponade
• Look for bleeding source
• Suture
• Cross clamp
• IDC
Internal Cardiac
Compressions
• 2 handed technique
• Compress heart between:
• 2 flat hands
• Hinged clapping motion
Defib the Cracked
Chest

• Internal paddles
• Paddles each side of heart
• Low joules 15-30

• No internal paddles?
• Clos...
Case 2
• 60 male
• Hx lung ca on chemo
• Progressive SOB
• Now:
• Hypotensive/shocked
Pericardial
Tamponade
• is defined as the critical compression of
the heart by accumulation of blood in
the pericardial sp...
Beck’s Triad!
• Distended neck veins
• Hypotension
• Muffled heart sounds
• Only occurs 40% of time!
Use the Probe!
Pericardiocentesis
•
Handy Hints
• Pericardial blood doesn’t clot
• Intracardial blood does clot
Some Pearls
• Only 100ml of blood can cause it
• Early Dx is key -ECHO
• Best manage in OT
Complications
• Myocardial perforation
• Bleeding
• Pneumothorax
• Arrhythmia
Pericardiocentesis
Fails!
• Open thoracotomy
• Pericardio window
Case 3
• 24 male
• Fell from roof
• SOB, hypotensive, agitated
Signs of Tension PTX
• Anxiety, agitation, distress
• Tachycardia-hypotension
• Neck vein distention
• Decreased chest mov...
Should be found
clinically!
Managing Tension
PTX

• Give high flow O2
• Immediate:
• Needle thoracentesis
• Finger thoracostomy
• Proceed to:
• Interc...
Needle
Thoracentesis
• 14g inserted
• 2nd ICS
• Aim relive Tension PTX!
Needles Don’t Work
• Don’t reach target in 65% cases
• Prone to:
• Kinking
• Occluded
• Compress
A better spot
• 5th ICS in AAL
• Less failure rate (16%)
• Caution on the L side!
Finger Thoracostomy

• Chest tube insertion w/o chest tube
• Use prehospital- arrest situations
Indications
• PTX in PT undergoing ventilation
• Actual/near traumatic cardiac arrest
• Shocked state - no apparent cause
Advantages
• The lung can be felt/seen to re-expand
• Pt deteriorates lung can be “re-fingered”
• Avoids blockage/kinging ...
Trouble getting ICC
in?
Case 4
• 29 Female
• MVA -cardiac arrest
• Bun in the oven!
Determining
Gestation
• Hard to do!

• No magic number >20weeks
• If fundal height above umbilicus great
Peri-mortem Csection
• Ability for 200% mortality
Timing
Get as much help as
possible
• Obstetrician
• Paediatrician
• Midwife
• NICU
Remember

•PMCS is a
resuscitative
intervention for the
mother!
Equipment - Mum
• Scalpel
• Surgical scissors
• Towels
• Cord clamps
Equipment -Baby
• Baby warmer
• Neonatal BVM
• Intubation kit
• IO
• First line drugs
Procedure
Neonatal
Resuscitation
Questions
Take Home Points
• These are once in a career cases!
• Your own adrenaline is the enemy
• Be cognitive ready
• Know your e...
Thankyou
Time Critical Procedures Part 2
Time Critical Procedures Part 2
Time Critical Procedures Part 2
Time Critical Procedures Part 2
Time Critical Procedures Part 2
Time Critical Procedures Part 2
Time Critical Procedures Part 2
Time Critical Procedures Part 2
Time Critical Procedures Part 2
Time Critical Procedures Part 2
Time Critical Procedures Part 2
Time Critical Procedures Part 2
Time Critical Procedures Part 2
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Time Critical Procedures Part 2

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Part 2 of talk on Time Critical Procedures for the Emergency Nurse

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Time Critical Procedures Part 2

  1. 1. Time Critical Procedures Part II Kane Guthrie
  2. 2. Last Talk
  3. 3. This Talk • Emergency Resuscitative Thoracotomy • Pericardial Tamponade • Tension Pneumothorax • Peri-Mortem C section
  4. 4. Case 1 • 22 male • Fight over girl • Stabbed to L chest • Goes into PEA
  5. 5. 6 Killer Chest Trauma • ATOM-FC • Air obstruction - disruption • Tension pneumothorax • Open pneumothorax • Massive haemothorax • Flail chest • Cardiac tamponade
  6. 6. Emergency Resuscitative Thoracotomy
  7. 7. Indications • Penetrating thoracic injury • Traumatic arrest - previously SOL • Unresponsive hypotension (BP <70) • Blunt thoracic injury • Unresponsive hypotension (BP <70) • Chest tube output >1500ml
  8. 8. Allows us to • Evacuation pericardial tamponade • Direct control intrathoracic haemorrhage • Control massive air embolism • Open cardiac massage • Cross clamp aorta
  9. 9. Relative Indications • Traumatic arrest without witnessed cardiac activity!
  10. 10. Contraindications
  11. 11. Survival Rates • Penetrating > 9-12% • Some institutions achieved >38% • Blunt trauma > 1-2%
  12. 12. Risky Business
  13. 13. Factors associated with survivors!
  14. 14. Equipment
  15. 15. Opening the Chest • Left anterolateral incision • Scissor through muscle, periosteum, pleura • Rib spreaders 6th ribs • May need to move the lung
  16. 16. Once Inside • Relieve tamponade • Look for bleeding source • Suture • Cross clamp • IDC
  17. 17. Internal Cardiac Compressions • 2 handed technique • Compress heart between: • 2 flat hands • Hinged clapping motion
  18. 18. Defib the Cracked Chest • Internal paddles • Paddles each side of heart • Low joules 15-30 • No internal paddles? • Close chest- standard defib!
  19. 19. Case 2 • 60 male • Hx lung ca on chemo • Progressive SOB • Now: • Hypotensive/shocked
  20. 20. Pericardial Tamponade • is defined as the critical compression of the heart by accumulation of blood in the pericardial space.
  21. 21. Beck’s Triad! • Distended neck veins • Hypotension • Muffled heart sounds • Only occurs 40% of time!
  22. 22. Use the Probe!
  23. 23. Pericardiocentesis •
  24. 24. Handy Hints • Pericardial blood doesn’t clot • Intracardial blood does clot
  25. 25. Some Pearls • Only 100ml of blood can cause it • Early Dx is key -ECHO • Best manage in OT
  26. 26. Complications • Myocardial perforation • Bleeding • Pneumothorax • Arrhythmia
  27. 27. Pericardiocentesis Fails! • Open thoracotomy • Pericardio window
  28. 28. Case 3 • 24 male • Fell from roof • SOB, hypotensive, agitated
  29. 29. Signs of Tension PTX • Anxiety, agitation, distress • Tachycardia-hypotension • Neck vein distention • Decreased chest movement • Tracheal deviation • Decreased breath sounds
  30. 30. Should be found clinically!
  31. 31. Managing Tension PTX • Give high flow O2 • Immediate: • Needle thoracentesis • Finger thoracostomy • Proceed to: • Intercostal catheter
  32. 32. Needle Thoracentesis • 14g inserted • 2nd ICS • Aim relive Tension PTX!
  33. 33. Needles Don’t Work • Don’t reach target in 65% cases • Prone to: • Kinking • Occluded • Compress
  34. 34. A better spot • 5th ICS in AAL • Less failure rate (16%) • Caution on the L side!
  35. 35. Finger Thoracostomy • Chest tube insertion w/o chest tube • Use prehospital- arrest situations
  36. 36. Indications • PTX in PT undergoing ventilation • Actual/near traumatic cardiac arrest • Shocked state - no apparent cause
  37. 37. Advantages • The lung can be felt/seen to re-expand • Pt deteriorates lung can be “re-fingered” • Avoids blockage/kinging chest drain system
  38. 38. Trouble getting ICC in?
  39. 39. Case 4 • 29 Female • MVA -cardiac arrest • Bun in the oven!
  40. 40. Determining Gestation • Hard to do! • No magic number >20weeks • If fundal height above umbilicus great
  41. 41. Peri-mortem Csection • Ability for 200% mortality
  42. 42. Timing
  43. 43. Get as much help as possible • Obstetrician • Paediatrician • Midwife • NICU
  44. 44. Remember •PMCS is a resuscitative intervention for the mother!
  45. 45. Equipment - Mum • Scalpel • Surgical scissors • Towels • Cord clamps
  46. 46. Equipment -Baby • Baby warmer • Neonatal BVM • Intubation kit • IO • First line drugs
  47. 47. Procedure
  48. 48. Neonatal Resuscitation
  49. 49. Questions
  50. 50. Take Home Points • These are once in a career cases! • Your own adrenaline is the enemy • Be cognitive ready • Know your equipment • Hardest part is making the decision to do it
  51. 51. Thankyou

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