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Time Critical Procedures Part 1
This document discusses various time-critical procedures that may need to be performed in emergency situations. It provides guidance on being cognitively and materially prepared to perform these procedures. Specific procedures covered include intraosseous access, fasciotomy for compartment syndrome, lateral canthotomy for orbital compartment syndrome, and escharotomy for severe circumferential burns. Case examples are also provided to demonstrate how to apply these procedures.
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Time Critical Procedures Part 1
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- 2. Time Critical Procedures • Oftenperformed in frequently • Life saving • You must be prepared for these • Cognitive hurdle
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- 4. Being Ready • Thisis the sharpest end of what we do • Need to be ready: • Cognitively • Materially
- 5. Metacognition • Cognitively • Invisiblesimulation • Develop/prepare plans-scenarios in your mind • Knowing what you need to know • Leads = metacompetence
- 6. Human Factors • Manageyour catecholamines
- 7. Cognitive Hurdle • Hardestpart of doing most of these procedures is making the decision to do it!
- 8. Dominating the Resus Room •Know your environment • Know your equipment • Know your drugs • Know your algorithms
- 9. Getting the Mostout of the Team • Be Nice • Be authoritative • Stay patient focused • Ask for help • Use the group • Push the right buttons • Craft your language
- 10. Resus Room Law CliffReid. www.Resus.Me.com
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- 16. Case 1 • 44female • Rigid abdomen • Septic shock • IVDU
- 17. Difficult Vascular Access •Your options: • Ultrasound guided PIVC • CVC • IO
- 18. Intraosseous Access • Needleinserted into bone • Non-collapsible vein • Infuse into systemic circulation • 97% first pass success rate • Insertion in under 30secs
- 19. Intraosseous Access • Equalpredictable drug delivery • Equal pharmacological effect • Flow rates 125-250mls/min • Pain comparable to PIVC • Dwell time 24hours
- 21. Case 1 • Noluck PIVC • IO - humeral head • Given 2litres CSL • RSI- Ketamine-Roc • Given 2g ceftriaxone • 2/24 later CVC inserted
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- 25. Compartment Syndrome • Limb threateningcondition • Increased pressure with muscle compartment • Compression of - nerves, muscles & vessels within compartment
- 27. Causes • Fractures -75% • Crush injury • Snake bite • Excessive exertion/imobilisation • Constrictive -POP, tourniquet • Soft tissue infection/burns
- 28. Pearl • Patients witha coagulopathy are at particular risk of compartment syndrome.
- 29. History & Physical •Pain (especially on passive stretching) • Pallor • Perishingly cold • Pulselessness • Paralysis • Paraesthesia
- 30. Fasciotomy • Surgical procedurewhere the fascia is cut to relieve tension/pressure resulting in loss of circulation to tissue or muscle.
- 31. Indications • Delta pressure<20mmHG definite • <30mmHg relative • Clinical signs suggesting
- 32. Pearl • Palpable distalpulses & normal CRT does not exclude compartment syndrome!
- 33. Preparing • Best donein theater with orthopod! • May be done in ED • Scalpel & sterile area
- 35. Pearls & Pitfalls •Give analgesia • Keep these patient hydrated • Monitor urine output • Hopefully prevents rhabdomyolysis
- 37. Case 3 • 24male • Drunk • Baseball bat vs head http://lifeinthefastlane.com/ophthalmology-befuddler-033-2 /
- 38. Case 3 • Unableto detect light • Afferent pupil defect R eye • Reduced extraocular movement • Tonmetry reveals IOP 45mmHg
- 39. The Bulging Eye •Retrobulbar haemorrhage result in orbital compartment syndrome.
- 40. Acute Orbital Compartment Syndrome •Cause - trauma, operatively • Haemorrhage into orbital space • Transmits pressure onto optic nerve • Results- swelling, visual loss.
- 41. History • Symptoms: • pain •decreased vision • inability to ope eyelids • proptosis
- 42. Physical Exam • Decreasedvisual acuity • Swelling • Limited extraocular movements • Tonometry - raised IOP • Funduscopy - papilloedema
- 43. Treatment Options • Conservative •Topical timolol • Acetazolamide • Mannitol • Lateral Canthotomy
- 44. Lateral Canthotomy • Sightsaving procedure
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- 49. Case 4 • 29male • Meth lab explosion • Severe Burns • Struggling on the vent! http://lifeinthefastlane.com/trauma-tribulation-005/
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- 51. Indications • Circumferential burnsto chest - impair ventilation • Constrictive circumferential neck burns impair airway • Circumferential burns extremities
- 52. Preparing • Best donein theater • Need scalpel, diathermy, artery ties, topical haemostatics • Good anaesthesia - Ketamine
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- 55. Escharotomy Complications • Bleeding • Infection •Damage to underlying structures
- 56. Take Home Points •These procedures are uncommon • You need to be cognitively prepared • Know your equipment • Avoid failure to act
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