Common pitfalls in ER Procedure


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Common pitfalls in ER Procedure

  1. 2. <ul><li>You should understand well about… </li></ul><ul><li>Indication </li></ul><ul><li>Contraindication </li></ul><ul><li>Step & techniques </li></ul><ul><li>After care </li></ul><ul><li>Complication : to be aware of </li></ul><ul><li>Options !! If the procedure FAIL ! </li></ul>
  2. 3. <ul><li>Preparation </li></ul><ul><li>Procedure </li></ul><ul><ul><li>Step </li></ul></ul><ul><ul><li>Skill </li></ul></ul><ul><ul><li>Patient </li></ul></ul><ul><li>After finish procedure </li></ul><ul><ul><li>Fail to check & Secure patient . </li></ul></ul>Other factors Rush/stress step
  3. 6. “ Patients do not die from a &quot;failure to intubate.&quot; '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.
  4. 19. <ul><li>Indication : </li></ul><ul><ul><li>Inability to maintain airway with less invasive techniques . </li></ul></ul><ul><ul><li>mostly : in case difficult airway , try ETT first </li></ul></ul><ul><ul><li> with preparation for surgical airway by side. </li></ul></ul><ul><li>Contraindication : </li></ul><ul><ul><li>Airway can be managed by less invasive method. </li></ul></ul><ul><ul><li>Others : </li></ul></ul><ul><ul><ul><li>Partial / complete transection of airway  preferred tracheostomy </li></ul></ul></ul><ul><ul><ul><li>Not suitable in case with significant injury of Cricoid. </li></ul></ul></ul><ul><ul><ul><li>Relative Contraindication : </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Known case of laryngeal pathology (tumor , fracture) </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li> prepare to extend to High tracheostomy. </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Special considerations : </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Children : < 8-10 yrs. : Needle cricothyroidotomy only. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Bad positioning : not extend neck. </li></ul></ul></ul></ul></ul>
  5. 20. <ul><li>Techniques : </li></ul><ul><li>Traditional surgical cricothyroidotomy </li></ul><ul><li>Alternative surgical cricothyroidotomy </li></ul><ul><li>Needle cricothyroidotomy </li></ul>
  6. 22. <ul><li>Identify landmark </li></ul><ul><li>Incision : transverse </li></ul><ul><li>not more than 2-3 cm.  Anterior Jugular v. </li></ul><ul><li>Longitudinal only when : </li></ul><ul><li>neck swelling , suspected High Tracheostomy need. </li></ul>
  7. 23. Not deeper than 1.5-2cm.
  8. 30. <ul><li>Internal jugular vein </li></ul><ul><li>Subclavian vein </li></ul><ul><li>Peripherally Inserted Central Catheter : PICC </li></ul><ul><li>Femoral vein </li></ul><ul><li>Peripheral venous cut down </li></ul>
  9. 31. <ul><li>Seldinger </li></ul><ul><li>Catheter over the needle </li></ul>
  10. 34. Rt. IJ 15 Rt. SC 18 Lt. IJ 18 Lt. SC 20
  11. 35. Scalenus anterior
  12. 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.
  13. 39. Humerus Distal tibia : malleolus
  14. 41. Cook Jamshidi Illinois Bone injection gun EZ IO
  15. 42. Needle decompression for tension pneumothorax And Go-on ICD Landmark : = 2 nd ICS mid clavicular line
  16. 43. <ul><li>Pleural space must be identified. </li></ul><ul><li>Obese patient : Semiupright , beware of diaphragm perforation. </li></ul><ul><li>ICD with Trocar can cause significant injury </li></ul><ul><li>not measurement the chest tube </li></ul><ul><li> last lumen is too closed to skin.  leakage & subcut.emphysema. </li></ul>
  17. 44. <ul><li>You should understand well about… </li></ul><ul><li>Indication </li></ul><ul><li>Contraindication </li></ul><ul><li>Step & techniques </li></ul><ul><li>After care </li></ul><ul><li>Complication : to be aware of </li></ul><ul><li>Options !! If the procedure FAIL ! </li></ul>
  18. 45. Question ?