In this video tutorial, we will be discussing the use of high flow nasal oxygenation as a therapy in hypoxemic respiratory failure. As we see an increase in the number of patients with COVID-19 pneumonia, this is a therapy that we need to have some familiarity with.
This video will discuss the following:
If you have any feedback or questions, please leave it in the comments 🙂
mdcalc
clinicians health channel – guidelines, eTG, MIMS
https://www2.health.vic.gov.au/clinicianshealthchannel
trauma victoria
https://trauma.reach.vic.gov.au/
uptodate – via western health library access
Austin Health Toxicology
http://www.austin.org.au/page?ID=1779
app also available
IC@N – Intensive Care at the Northern
– from appstore
APLS – app for algorithms
Visible Body – Anatomy Atlas (app)
References on Tap – quick literature search
Paediatric Emergencies – dose and tube size calculations
EM logbook – log procedures but remember to export to another source to save
Vic Emergency app – good for camping and travelling! Local warnings
we discovered at registrar training last week that many of our team had not placed a central line so here is a walk through the process….
Why does the patient need CVC – access, multiple lumens, centrally active medications, monitoring
Where should the CVC go – IJ, subclavian, femoral
Position – complications to lying flat, Trendelenburg, sedation/intubated
Potential complications – bleeding, pneumothorax, failure
Consent the patient – procedure, options, complications (pain, allergic reaction, bleeding, pneumothorax, infection, failure, neuropraxia)
Set it up yourself
US – cover, sterile gel, positioning
Procedure tray – large area
Dishes – antiseptic wash, saline, disposing sharps
CVC kit – introducer/seeker, guidewire (check glides, some unwrap but care doesn’t become unsterile), dilator, CVC – check each lumen/leave brown uncapped, caps, adjustable hubs)
Syringes – 5ml for local, 20ml for saline + needles
Gauze
Gown, gloves, mask, goggles, drapes
Suture material and instruments
Local anaesthetic
Antiseptic skin wash
Clear dressing to fix line
Team – performing clinician, assistant, supervising doctor, backup
Monitoring of patient – ECG (BP + Sats if sedated)
Timing
Nurse in charge aware
Check vein with US first – position, anatomy, thrombus
Position patient/US/procedure tray/staff to monitor
Scrub hands, glove + gown
Wash patient + drape – large sterile area
Draw up LA
Position equipment in order of use so easy to reach
Check CVC lumens with saline flush + leave brown lumen uncapped
US to identify vein
50mg lignocaine with adrenaline into skin
Seeker needle with saline in syringe, using US in longitudinal to guide and cannulate vein
Hold with other hand to fix position on skin
Remove syringe
Feed guidewire, remove needle
Confirm position of wire with US before dilating
Dilate vein
Feed CVC with one hand always holding guidewire (care that wire does not become unsterile), depth determined by line markings 10-15cm – confirm ECG trace
Remove wire – announce to staff to document
Aspirate and flush each lumen before capping
Fix to skin with hub (clamp and fastener)
Suture 4 points (hub and distal) position
Cover with clear dressing
Confirm position with CXR
Dispose of sharps/wire and biohazard material
Aseptic technique
Location
Local anaesthetic
Vein cannulated – number of attempts
Guide wire inserted, vein dilated, CVC inserted, GUIDE WIRE REMOVED, fixed at “x”cm
Complications
Confirmed with CXR – position in SVC at junction with RA (level of right main bronchus), no pneumothorax
For more information about MENTAL REHEARSAL and how this can help in critical situations and performing procedures, read this link:
/ EHPR Part 5: Using Mental Practice and Visualization Exercises by Mike Lauria
Congratulations to our Sim team – “The Doggies” – Dr Heather Deane, Dr Lucy Selleck, Dr Taz Dissanayake and Dr James McFarlane, who battled their way through scenarios including
neonatal arrest
paediatric snakebite
trauma
to make it to the final, only narrowly being defeated by the Austin team! Great work!
Thanks to Prof Anne-Maree Kelly – we reviewed these articles this week:
Caputo_et_al-2017-Academic_Emergency_MedicineTake home points:
shoulder dislocation
Take home points
Here’s the video from March 2018’s consultant education, on the theme of traumatic arrest.
It includes a case discussion of a gunshot wound to the chest in a young women with cardiac arrest, a talk on the management of traumatic arrest and the utility of CPR, and finally a discussion on ED thoracotomy.
The quality’s not great and we lost the AV halfway through, so I’ve patched in a PowerPoint presentation of the second part.
There’s also a video from the Alfred procedures course on thoracotomy- please don’t distribute this further, as it’s released to candidates on the course only.
Hope you enjoy, please post any comments or questions and we’ll attempt to answer them.
Thanks.
Further reading:
Cliff Read recently put out a great post on this issue.
The take home points:
A large effusion with a ‘little invisible man using the RV as a trampoline”
The danger is overshooting the BP, resulting in hypertension and extension of the dissection which can be fatal.
The kit:
The approach:
There are several approaches – subxiphoid, left parasternal, apical. Go where the most blood is.
Thanks,
Stacy
If they arrest To intubate or not to intubate?
CPR or no CPR?
How to transfer – physician escort or just send in an ambulance on lights and sirens?
lower motor neurone compression….
May not have ALL signs
Monitor for gradual progression of symptoms – repeat examinations
Ask “When was the last time you walked?”
If >48 hours since onset of symptoms, unlikely to see much improvement after surgical intervention
Causes:
Disc herniation – young more common
Abscess – elderly, immunocompromised, IVDU
tumour – mets, lymphoma
Examination tips:
Flex hips – remove tension on iliopsoas when lying flat
Flex knees ot 45 degrees
Clear commands
Can’t fake collapsing weakness
sensation in dermatome distribution
Ankle jerk – cross ankle over opposite ankle with foot in cocked position
PR – key to S1-S4 sensation, also anal tone – check after relax then repeat tone
Hamilton Ventilator Simulator: https://www.hamilton-medical.com/
take away points:
low pressure, low volume
optimise expiratory time if obstructive pathology
titrate FiO2 (88-95%), then adjust PEEP to FiO2
trouble shooting:
check compliance/resistance
MV depends on the patient – if awake patient has higher RR (eg: DKA, sepsis), need to raise RR to normalise pCO2 to awake patient compensation
set alarms to AUTO, check peak pressure set to “40”
“Deterioating patient” algorithm
Stress induced cardiomyopathy with normal coronary arteries – emotional stress, sepsis, respiratory failure
Usually completely recovers in weeks to months, may recur
Pathophysiology – catecholamine excess
Atypical features – no chest pain
ECG shows ST elevation, anterior leads
Echo – most common is left ventricular “ballooning” and apical hypokinesis
Consider concurrent LVOT: AVOID inotropes
b-blockers
fluid resuscitation
Medical duty of care – restraints required to complete medical responsibilities safely
RED form
Mental Health Act forms – must notify on-call psychiatrist
Document forms + in patient notes, maximal time for medical review is 4 hours – review of restraints must also be documented on forms and in notes
“Consent” – must inform patient or next-of-kin of use of restraints, document “consent” or why obtaining consent was inappropriate
Ordering of CT brain for trauma without radiology registrar approval – consider whether other imaging is required ie: Cervical spine or facial bones
Consideration of anti-platelet therapy as a risk factor for occurance or increased size of intracranial haemorrhage
Low risk of delayed bleed in anticoagulated patient and bleed may occur up to 2 weeks after initial trauma so admission for repeat scan is not usually indicated
Ensure clear documentation of decision to scan or not to scan and that appropriate discharge instructions are given to patient and carer
Dynamic presentation of HOCM:
Left Ventricular Outflow Tract obstruction
Mitral regurgitation
Diastolic dysfunction
Arrhythmias
LVH
“dagger-like” Q waves in lateral and inferior leads
atrial enlargement
atrial tachycardias – AF, SVT
Treatment of collapse in HOCM:
Increase PRELOAD and AFTERLOAD
IV fluids
elevate legs
IV b-blocker
NOTE: Metaraminol contraindicated in structural heart disease
Other key points: