common emergency room procedures - no pics3/11/15 6 intubate!’ photo courtesy of garret...

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Common emergency room procedures

Jus$ne A. Lee, DVM, DACVECC, DABT CEO, VetGirl [email protected]

Garret Pach$nger, VMD, DACVECC COO, VETgirl [email protected]

Sponsorship

Introduc$on

Jus$ne A. Lee, DVM,

DACVECC, DABT

CEO, VetGirl

Conflict of Interest Disclosure

Introduc$on Garret Pach$nger, VMD,

DACVECC COO, VetGirl

Associate, VSEC

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Call in from Smart Phone! Some common emergency procedures you must feel comfortable performing!

•  Thoracocentesis •  Abdominocentesis •  DPL •  Pericardiocentesis •  Gastric lavage

•  Chest tube •  Coccygeal block •  Tracheostomy •  Jugular cutdown •  Nasogastric tubes •  Using syring pumps

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THORACOCENTESIS

Thoracocentesis

[With a 18 g needle and the good thrust of the hand, there is no body cavity you can’t penetrate…]

– House of God, Dr. Shem

Thoracocentesis

•  Supplies: –  20 cc syringe –  3 way stopcock –  16-‐22 ga. needle or bunerfly catheter –  Extension sepng

–  Empty bowl –  +/-‐ seda$on

• Butorphanol: 0.2-‐0.8 mg/kg IM or IV

• Diazepam: 0.1-‐0.25 mg/kg IV

ABDOMINOCOCENTESIS

ABDOMINOCENTESIS Procedure.

–  Blind vs AUS Guided • Four quadrants:

–  Cranial and led of the umbilicus

–  Cranial and right of the umbilicus

–  Caudal and led of the umbilicus

–  Caudal and right of the umbilicus.

Ultrasonography: FAST

JAVMA, Vol 225, No. 8, October 15, 2004

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Call it “AFAST3” for Abdominal FAST3

•  Diaphragmatico-Hepatic (DH) •  Spleno-Renal (SR) •  Cysto-Colic (CC) – •  Hepato-Renal or (HR)

•  Save NO Shave ☺ – Preferred position RIGHT lateral recumbency – All images in this talk are unshaved

Ultrasonography: FAST The History and Overview of FAST •  The Modification of FAST to AFAST

•  Target Organ Approach – Classic Views

The History and Overview of FAST

•  The Abdominal Fluid Scoring System – The patient’s abdominal fluid score (AFS)

•  Lateral recumbency have a depth gauge – Most common low-scoring sites (DH, CC)

Major Injury, Small Volume Bleeder

Major Injury, Big Volume Bleeder

Triage, Tracking, Trauma The History and Overview of FAST AFAST3 -applied Abdominal Fluid Scoring System Defined

Lisciandro et al. JVECC 2009

•  AFS score of 0 is FAST negative for any fluid

•  AFS score of positives range from 1-4 with a maximum score of 4

•  Simple, easy to remember scoring system, lateral recumbency “depth gauge”

The History and Overview of FAST AFAST3 -applied Abdominal Fluid Scoring System Defined


•  AFS- lower scoring (1,2) dogs on initial or serial examinations rarely become anemic called “small volume bleeders”

•  AFS-higher scoring (3,4) dogs always become anemic and ~25% become transfusion candidates (PCV< 25%) called “big volume bleeders”

The History and Overview of FAST Serial Exams are Key for a Number of Reasons


The History and Overview of FAST Serial Exams are Key for a Number of Reasons


•  Serial examinations 4-hour post admission allows you to re-score

•  Serial examinations evaluate the integrity of urinary bladder!

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•  Blind abdominocentesis: 5-‐25 ml/kg of effusion *

•  Palpable fluid wave: > 10-‐20 ml/kg

•  FAST-‐guided abdominocentesis: 2 ml/kg

* Crowe, 1984

PERICARDIOCENTESIS

Pericardiocentesis

•  Indica$ons: –  Pericardial effusion

•  Asep$c prepara$on/technique

•  16 ga., mul$-‐fenestrated catheter

•  3-‐way stopcock setup

GASTRIC LAVAGE

Performing gastric lavage for poisonings When to Decontaminate •  Emesis induc$on vs. gastric lavage

•  Gastric lavage: – More effec$ve at removing gastric contents –  Deadly meds:

•  Calcium-‐channel blockers/Beta-‐blockers •  Baclofen • Metaldehyde • Organophoshates/carbamates • Macrocylic lactones •  Anything approaching the LD50

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Intubate!

Photo courtesy of Garret Pachtinger, VMD, DACVECC


Inflate the ETT: Protect the Airway!


Pre-‐measuring the Tube

Courtesy of Garret Pachtinger, VMD, DACVECC

Gastric Lavage

Mouth gag and placing the orogastric tube!

Courtesy of Garret Pachtinger, VMD, DACVECC

Double lumen gavage tube

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CHEST TUBES/THORACOSTOMY TUBE

Chest Tubes

•  3-‐strikes-‐and-‐you’re-‐out rule

•  Sedate or anesthe$ze, if possible

•  Don’t clamp the tube, if anesthe$zed

•  Con$nuous vs. interminent suc$on

•  Blunt dissec$on vs Trocar (i.e. cat ca-‐bob) –  Surgical prepara$on –  Skin incision over 8th-‐10th intercostal space –  Pull skin cranially 2 intercostal spaces

Heimlich valve

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Over-‐the-‐wire chest tube

•  Sterile technique •  No need to tunnel the skin! •  Requires seda$on and local anesthesia •  No need for general anesthesia!

COCCYGEAL BLOCKS TRACHEOSTOMY

Knowing how to perform a tracheostomy

FEEDING TUBES

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Placing a nasogastric tube E-‐TUBE PLACEMENT -‐ PROCEDURE

E-‐TUBE PLACEMENT -‐ PROCEDURE

The Kitty Kollar (http://www.kittykollar.com)

has been used with success.

This is a washable, fabric collar designed to wear in

conjunction with an esophageal feeding tube.

E-‐TUBE PLACEMENT -‐ PROCEDURE

E-‐TUBE PLACEMENT -‐ CHECK

JUGULAR CUTDOWN

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COOL NEW BLING

@VetGirlOnTheRun

VetGirlOnTheRun

[email protected]

[email protected]

Questions?

This material is copyrighted by VetGirl, LLC. None of the materials provided may be used, reproduced or transmitted, in whole or in part, in any form or by any means, electronic or otherwise, including photocopying, recording or the use of any information storage and retrieval system, without the consent of VetGirl, LLC. Unless expressly stated otherwise, the findings, interpretations and conclusions expressed do not necessarily represent the views of VetGirl, LLC. Medical information here should be references by the practitioner prior to use. Under no circumstances shall VetGirl, LLC. be liable for any loss, damage, liability or expense incurred or suffered that is claimed to have resulted from the use of the information provided including, without limitation, any fault, error, omission, interruption or delay with respect thereto. If you have any questions regarding the information provided, please contact [email protected]

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Check out our 2015 upcoming VETgirl appearances!

Dr. JusAne Lee •  SAVMA, Minneapolis, March 2015 •  Interna$onal Veterinary Seminars

(IVS), Kiwah Island, April 2015 •  Merck, NYC, April 2015 •  IVS, Vancouver, June 2015 •  IVS, Amelia Island, July 2015

Dr. Garret PachAnger •  Hills Global Symposium, Miami, April

2015

common emergency room procedures - no pics3/11/15 6 intubate!’ photo courtesy of garret...

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