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Oxygen Delivery and High Flow Nasal Cannula

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:

  1. The benefits of high flow nasal oxygenation
  2. Commencement and titration
  3. When should we bail out?

If you have any feedback or questions, please leave it in the comments 🙂

 

 

Terence’s Guide to Appiness

 

mdcalc

https://www.mdcalc.com/

 

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

 

 

walking through the central line

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….

PREPARATION

 

Patient:

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)

 

Equipment:

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

 

Department:

Team – performing clinician, assistant, supervising doctor, backup

Monitoring of patient – ECG (BP + Sats if sedated)

Timing

Nurse in charge aware

 

PROCEDURE

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

DOCUMENTATION:

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:

EMCrit-RACC / EHPR Part 5: Using Mental Practice and Visualization Exercises by Mike Lauria

 

Thinking about research episode 1

Thanks to Prof Anne-Maree Kelly – we reviewed these articles this week:

Caputo_et_al-2017-Academic_Emergency_Medicine

Take home points:

  1. critically unwell patients in whom desaturation was particularly critical were not included
  2. not statistically powered to detected clinically significant desaturations
  3. apnoeic oxygenation has minimal harm – and its introduction likely has had intangible effects on our practice in terms of adherence to checklists

 

shoulder dislocation

Take home points

  1. a well designed study with patient centred outcomes
  2. some methodology issues in that pain rating was surveyed after the intervention
  3. your armamentarium for shoulder reduction should include at least one non sedation technique, and using a patient centred self-reduction technique allows the patient control over their medical experience

SMS Teaching: Traumatic Cardiac Arrest

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:

EMCrit

EMRAP – the quiet chest in trauma

ANZCOR guidelines

St Emlyn’s – CPR in TCA?

Pericardiocentesis in Cardiac Tamponade

Cliff Read recently put out a great post on this issue.

The take home points:

  1. Perform when refractory shock with evidence of tamponade physiology on ECHO:

A large effusion with a ‘little invisible man using the RV as a trampoline”

  1. Remove only small volumes of blood at a time (e.g. 30mls), aiming for a SBP of 90 mmHg.

The danger is overshooting the BP, resulting in hypertension and extension of the dissection which can be fatal.

  1. Avoid intubation if possible until a surgeon is ready to cut – positive pressures lead to worsening tamponade physiology (although mitigated by pericardiocentesis).
  2. Other options include intubation under local anaesthesia, allow the patient to breathe spontaneously through the tube, or preloading with fluid, using cautious doses of induction agent, and ventilating with low pressures & zero PEEP.
  3. CPR is futile in arrested patient.
  4. CPR leads to lower MAP and diastolic pressures, therefore worsening coronary perfusion. Only relief of tamponade will provide a chance of recovery.
  5. Patients requiring transport should be accompanied by a clinician able to perform pericardiocentesis in the event of deterioration en route.

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?

 

https://www.youtube.com/watch?v=nWJxZco6oCw

 

Winter’s Wrap 29.11.2017

CAUDA EQUINA SYNDROME

         

lower motor neurone compression….

  1. Urinary retention – flaccid bladder + detrusor
  2. Faecal incontinence – flaccid voluntary sphincter
  3. Flaccid paralysis of lower limbs
  4. Saddle anaesthesia (S1-S4)
  5. Bilateral loss of ankle jerk (S1)
  6. Compression of multiple nerve roots – bilateral sciatica is worse prognosis

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

Winter’s Wrap 22.11.2017

VENTING YOUR FRUSTRATIONS – Dr Stacy Turner

Ventilation Handout Nov 17

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

 

 

TAKOTSUBO TRICKS – Dr Ross McNaught

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

 

 

Restraint with Restraints

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

Mechanical Restraint Presentation

Winter’s Wrap 25.10.2017 – CTB, HOCM, Decision making

To scan or not to scan – Dr Mike Gibbons

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

 

 

HOCM and the bands – Dr Hans Hollerer

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:

  • Tamiflu – reduces symptoms by 3 days, indicated in first 48 hours in some populations
  • “Band forms” on blood film – white cell progenitors pushed out of bone marrow, indication of early stages of sepsis
  • “The blue book” – communicable diseases, incubation, notifiable illnesses

https://www2.health.vic.gov.au/getfile/?sc_itemid=%7b7A1F05A1-64B0-4B8C-A730-D4F8F107AA52%7d&title=The%20blue%20book

 

 

“It is in moments of decision that your

destiny is shaped”

Decision Making – Dr David Mai

heuristics and metacognition
croskerry - cognitive forcing strategies (1)
croskerry - cognitive debiasing 2
croskerry achieving quality in decision making
croskerry - cognitive forcing strategies