Time Critical Procedures

Kane Guthrie

Time Critical Procedures

•Often performed in frequently

•Life saving

•You must be prepared for these

•Cognitive hurdle

The Batterfield

Being Ready

•This is the sharpest end of what we do

•Need to be ready:

•Cognitively

•Materially

Metacognition

•Cognitively

•Invisible simulation

•Develop/prepare plans-scenarios in your mind

•Knowing what you need to know

•Leads = metacompetence

Human Factors

•Manage your catecholamines

Cognitive Hurdle

•Hardest part of doing most of these procedures is making the decision to do it!

Dominating the Resus Room

•Know your environment

•Know your equipment

•Know your drugs

•Know your algorithms

Getting the Most out of the Team

•Be Nice

•Be authoritative

•Stay patient focused

•Ask for help

•Use the group

•Push the right buttons

•Craft your language

Resus Room Law

Cliff Reid. www.Resus.Me.com

Cliff Reid. www.Resus.Me.com

Checklist Help

Always Ensure Safety

Time Critical Procedures

Warning

Case 1

•44 female

•Rigid abdomen

•Septic shock

•IVDU

Difficult Vascular Access

•Your options:

•Ultrasound guided PIVC

•CVC

•IO

Intraosseous Access

•Needle inserted into bone

•Non-collapsible vein

•Infuse into systemic circulation

•97% first pass success rate

•Insertion in under 30secs

Intraosseous Access

•Equal predictable drug delivery

•Equal pharmacological effect

•Flow rates 125-250mls/min

•Pain comparable to PIVC

•Dwell time 24hours

Case 1

•No luck PIVC

•IO - humeral head

•Given 2litres CSL

•RSI- Ketamine-Roc

•Given 2g ceftriaxone

•2/24 later CVC inserted

Case 2

http://lifeinthefastlane.com/ortho-library/2010/07/bone-and-joint-bamboozler-002/

Compartment Syndrome

•Limb threatening condition

•Increased pressure with muscle compartment

•Compression of - nerves, muscles & vessels within compartment

Causes

•Fractures - 75%

•Crush injury

•Snake bite

•Excessive exertion/imobilisation

•Constrictive -POP, tourniquet

•Soft tissue infection/burns

Pearl

•Patients with a coagulopathy are at particular risk of compartment syndrome.

History & Physical•Pain (especially on passive

stretching)

•Pallor

•Perishingly cold

•Pulselessness

•Paralysis

•Paraesthesia

Fasciotomy

•Surgical procedure where the fascia is cut to relieve tension/pressure resulting in loss of circulation to tissue or muscle.

Indications

•Delta pressure <20mmHG definite

•<30mmHg relative

•Clinical signs suggesting

Pearl

•Palpable distal pulses & normal CRT does not exclude compartment syndrome!

Preparing

•Best done in theater with orthopod!

•May be done in ED

•Scalpel & sterile area

Pearls & Pitfalls

•Give analgesia

•Keep these patient hydrated

•Monitor urine output

•Hopefully prevents rhabdomyolysis

Case 3

•24 male

•Drunk

•Baseball bat vs head

http://lifeinthefastlane.com/ophthalmology-

befuddler-033-2/

Case 3

•Unable to detect light

•Afferent pupil defect R eye

•Reduced extraocular movement

•Tonmetry reveals IOP 45mmHg

The Bulging Eye

•Retrobulbar haemorrhage result in orbital compartment syndrome.

Acute Orbital Compartment

Syndrome

•Cause - trauma, operatively

•Haemorrhage into orbital space

•Transmits pressure onto optic nerve

•Results- swelling, visual loss.

History

•Symptoms:

•pain

•decreased vision

•inability to ope eyelids

•proptosis

Physical Exam

•Decreased visual acuity

•Swelling

•Limited extraocular movements

•Tonometry - raised IOP

•Funduscopy - papilloedema

Treatment Options

•Conservative

•Topical timolol

•Acetazolamide

•Mannitol

•Lateral Canthotomy

Lateral Canthotomy

•Sight saving procedure

Indications

Lateral Canthotomy

The Procedure

Case 4

•29 male

•Meth lab explosion

•Severe Burns

•Struggling on the vent!

http://lifeinthefastlane.com/trauma-tribulation-005/

Escharotomy

Indications

•Circumferential burns to chest - impair ventilation

•Constrictive circumferential neck burns - impair airway

•Circumferential burns extremities

Preparing

•Best done in theater

•Need scalpel, diathermy, artery ties, topical haemostatics

•Good anaesthesia - Ketamine

Completed Escharotomy

Escharotomy Complications

•Bleeding

•Infection

•Damage to underlying structures

Take Home Points

•These procedures are uncommon

•You need to be cognitively prepared

•Know your equipment

•Avoid failure to act

Questions