life support procedures
DESCRIPTION
TRANSCRIPT
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Life support procedures
Paleerat Jariyakanjana, MD
Faculty of Medicine
Naresuan University
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Learning contents
1. Surgical cricothyroidotomy
2. Needle cricothyroidotomy
3. Interosseous puncture / infusion
4. Needle decompression
5. Chest tube insertion
6. FAST
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SURGICAL CRICOTHYROIDOTOMY
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IndicationsFailure of oral or nasal endotracheal intubationAirway obstructionTraumatic injuries making oral or nasal
endotracheal intubation difficult or potentially hazardous
Contraindicationsinfants and young children <12 yr
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Step
Supine position Orientation: thyroid notch, cricothyroid interval,
and sternal notch
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Step
Assemble the necessary equipment. Sterile technique and local anesthesia Stabilize the thyroid cartilage with the left hand Make a transverse skin incision over the
cricothyroid membrane and carefully incise through the membrane transversely
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Step
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Step
Insert hemostat or tracheal spreader into the incision and rotate it 90 degrees
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Step
Insert a proper-size, cuffed endotracheal tube or tracheostomy tube (No. 5-6)
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Step
Inflate the cuff and apply ventilation. Observe lung inflation and auscultate the chest
for adequate ventilation. Secure the endotracheal or tracheostomy tube
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Complications
Aspiration (blood)Creation of a false passage into the tissuesSubglottic stenosis/edemaLaryngeal stenosisHemorrhage or hematoma formationLaceration of the esophagusLaceration of the tracheaMediastinal emphysemaVocal cord paralysis, hoarseness
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NEEDLE CRICOTHYROIDOTOMY
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Indicationspreferred method of securing the airway in crash
airway situations in infants and young children
ContraindicationsTransection of the distal tracheaComplete upper airway (oropharyngeal)
obstruction
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Step
prepare oxygen tubing
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Step
Supine position Assemble a 12- or 14-gauge, 8.5-cm, over-the-
needle catheter to a 6- to 12-mL syringe. Sterile technique Palpate the cricothyroid membrane Stabilize the trachea with the thumb and
forefinger of one hand Puncture the skin in the midline directly over
the cricothyroid membrane
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Step
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Step
45º angle caudally with negative pressure
aspiration of air entry into the tracheal lumen
advancing the catheter Continue to observe
lung inflation and auscultate the chest for adequate ventilation.
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Step
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Complications
Inadequate ventilationAspiration (blood)Esophageal lacerationHematomaPerforation of the posterior tracheal wallSubcutaneous and/or mediastinal emphysemaThyroid perforationPneumothorax
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INTRAOSSEOUS PUNCTURE/INFUSION: PROXIMAL TIBIAL ROUTE
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Indicationspatients in whom attempts at peripheral or
central venous access has been unsuccessful
Contraindicationsosteoporosis and osteogenesis imperfecta fractured bone recent prior use of the same bone for IO infusioncellulitis, infection, or burns
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Step
supine position Select an uninjured lower extremity Padding, 30-degree flexion of the knee Identify the puncture site
anteromedial surface of the proximal tibia, approximately one fingerbreadth (1-3 cm) below the tubercle
Sterile technique and local anesthesia
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Step
Initially at a 90-degree angle, introduce a short, large-caliber, bone-marrow aspiration needle (or a short, 18-gauge spinal needle with stylet) into the skin and periosteum, with the needle bevel directed toward the foot and away from the epiphyseal plate.
After gaining purchase in the bone, direct the needle 45-60 degrees away from the epiphyseal plate.
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Step
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Step
Confirmation of placement Aspiration of bone marrow saline flushes through the needle easily and
there is no evidence of swelling needle remains upright without support
Secure the needle and tubing in place. intraosseous infusion should be limited to
emergency resuscitation of the patient and discontinued as soon as other venous access has been obtained
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Complications
InfectionThrough-and-through penetration of the boneSubcutaneous or subperiosteal infiltrationPressure necrosis of the skinPhyseal plate injuryHematoma
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NEEDLE THORACENTESIS
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IndicationsTension pneumothorax
Contraindicationsno absolute contraindications
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Step
Identify the second intercostal space, in the midclavicular line on the side of the tension pneumothorax.
Sterile technique and local anesthesia Place the patient in an upright position if a
cervical spine injury has been excluded.
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Step
Keeping the Luer-Lok in the distal end of the catheter, insert an over-the-needle catheter (minimum 16 gauge, 2 in. [5 cm] long) into the skin and direct the needle just over the rib into the intercostal space.
Remove the Luer-Lok from the catheter and listen for the sudden escape of air when the needle enters the parietal pleura, indicating that the tension pneumothorax has been relieved.
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Step
Remove the needle and replace the Luer-Lok in the distal end of the catheter.
Leave the plastic catheter in place and apply a bandage or small dressing over the insertion site.
Prepare for a chest tube insertion.
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Complications
Local hematomaPneumothoraxLung laceration
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CHEST TUBE INSERTION
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Indications
PneumothoraxHemothoraxEmpyema
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Contraindications
Unstable injured patients: no absolute contraindications
stable patient anatomic problems: presence of multiple pleural
adhesions, emphysematous blebs, or scarring Coagulopathic patients
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Step
Determine the insertion site, usually at the nipple level (fifth intercostal space), just anterior to the midaxillary line on the affected side.
Sterile technique and local anesthesia
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Step
Make a 2- to 3-cm transverse (horizontal) incision at the predetermined site and bluntly dissect through the subcutaneous tissues, just over the top of the rib.
Puncture the parietal pleura with the tip of a clamp
Finger exploration
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Step
Clamp the proximal end of the thoracostomy tube and advance it into the pleural space to the desired length.
The tube should be directed posteriorly, medially, and superiorly along the inside of the chest wall.
Look for “fogging” of the chest tube with expiration or listen for air movement.
Connect the end of the thoracostomy tube to an underwater-seal apparatus.
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Step
Suture the tube in place. Apply an occlusive dressing and tape the tube
to the chest. Obtain a chest x-ray film.
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Complications
Laceration or puncture of intrathoracic and/or abdominal organs
Introduction of pleural infectionDamage to the intercostal nerve, artery, or veinIncorrect tube position, extrathoracic or
intrathoracicChest tube kinking, clogging, or dislodging from
the chest wall, or disconnection from the underwater-seal apparatus
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Complications
Persistent pneumothoraxSubcutaneous emphysemaRecurrence of pneumothoraxLung fails to expandAnaphylactic or allergic reaction to surgical
preparation or anesthetic
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FOCUSED ASSESSMENT SONOGRAPHY IN TRAUMA (FAST)
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IndicationsBlunt abdominal traumaStable penetrating traumaAssessment of the degree of intraperitoneal free
fluid
Contraindicationsno absolute contraindications
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Step
Start with the subxiphoid or the parasternal view
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Step
RUQ view sagittal view in the
midaxillary line, at approximately the 10th or 11th rib space
hepatorenal fossa (Morrison’s pouch)
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Step
LUQ view sagittal view in the
midaxillary line, at approximately the 8th or 9th rib space
splenorenal fossa
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Step
suprapubic view transverse view
optimally obtained prior to placement of a Foley catheter
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Subxiphoid view
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RUQ view
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RUQ view
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LUQ view
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LUQ view
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Suprapubic view
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Suprapubic view
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Reference
ATLS 9th Student ManualClinical procedures in emergency medicine
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ANY QUESTIONS?