Tag: Stacy Turner

ASV (Adaptive Support Ventilation) with the Hamilton Ventilator

Here is a video I produced for Adult Retrieval Victoria on Hamilton’s proprietary intelligent ventilation mode, ASV, using the Hamilton T1 Ventilator, but it’s applicable to our Hamilton C1.

Please do not distribute, as these videos are AV property.

 

ASV takes into account the patient’s respiratory mechanics, which are measured breath-by-breath by the proximal flow sensor. ASV ensures optimal ventilation for each patient during passive ventilation but also has automatic adjustment in spontaneously breathing and weaning patients.

In passive patients, ASV is a volume-targeted pressure controlled mode with automatic adjustment of inspiratory pressure, respiratory rate, and inspiratory/expiratory time ratio. Maximum tidal volume is controlled by setting a maximum inspiratory pressure. Expiratory time is determined according to the expiratory time constant in order to prevent dynamic hyperinflation.

 

Watch the following video, together with the Initial Setup (Page 2) & Troubleshooting Guides below:

Initial ventilator settings, Western, Draft, Feb 2020
 Ventilator problems algorithm, Hamilton, Version 5, May 2018

 

 

Hamilton Ventilator Education

Here are some videos I produced for Adult Retrieval Victoria, using the Hamilton T1 Ventilator, but all are applicable to our Hamilton C1.

Please do not distribute, as these videos are AV property.

 

To begin please watch the videos linked below produced by Hamilton to familiarize yourself with the Hamilton T1:

Device Overview

Setup and Preop Checks

User Interface

Basic ventilator settings

Alarm Management

 

Then watch the following videos, together with the Initial Setup & Troubleshooting Guides below:

Initial ventilator settings, Western, Draft, Feb 2020
 Ventilator problems algorithm, Hamilton, Version 5, May 2018

 

 

 

Initial Setup:

Troubleshooting:

Idiosyncracies of the Hamilton:

 

Coffee and cases – Consultant teaching 22 June 2018

Thanks for attending consultant teaching yesterday.
With my educator’s hat on, staged repetition is the best way to remember, so here are some links to some of the topics we discussed:

Propranolol OD (Justin Curran):

https://lifeinthefastlane.com/toxicology-conundrum-044/

http://www.emdocs.net/wp-content/uploads/2015/08/HighDoseInsulinCCB-Yuan-.pdf

Knee Dislocation (John Loy):

 

Knee Injury 2018

https://emergencymedicinecases.com/occult-knee-injuries/

Rice Bezoar (Gary Ayton):

Only 1 publication:

https://www.ncbi.nlm.nih.gov/pubmed/?term=rice+bezoar

– you definitely need to write this up!

A good summary:

https://med.virginia.edu/ginutrition/wp-content/uploads/sites/199/2015/11/Sanders-Jan-04.pdf

Bezoars are apparently highly prized and “ascribed mystical and medicinal powers and considered invaluable
possessions”

Cardiac Tamponade (Stacy Turner):

 

 

http://www.ultrasoundpodcast.com/2013/11/pericardial-tamponade-learn-know-foamed/
http://5minsono.com/tamp/
http://resus.me/tag/tamponade/

Thanks.
Stacy

Procedures for consultant education

Hi guys.

Here are some videos relating to the procedures we covered during the consultant education this month.

Enjoy!

Stacy

I-gel 2nd generation supraglottic airway

Surgical Airway – Scalpel

RIC line

MAC line

Humeral IO

CT6 femoral splint

SAM pelvic splint

 

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?

 

 

Central venous catheterisation (CVC)

Here are some resources that I’ve found useful.

  1. How to scrub. This is often done badly in ED – there’s no excuse for this. Please make sure that the insertion site, the patient and the bed are all covered by drapes.
  2. Blind insertion. This is not recommended. There is a ton of evidence supporting the use of ultrasound.
  3. Ultrasound-guided insertion:
  4. How to confirm line placement and avoid complications.
  5. Using an angiocath instead of the needle to avoid inadvertent displacement outside of the lumen of the vein.
  6. Where should the tip sit?
  7. Setting up the transducer.
  8. Which ports to use?:
    • distal port (usu ~ 16-gauge lumen): the largest lumen; used for CVP monitoring, emergency access, blood products
    • medial and distal port (smaller lumens, more chance of extravasation): used for everything else
    • don’t run anything else with inotropes/pressor
    • radiocontrast media (RCM) – CAN go through the CVC – any port ≥ 18-gauge – check CVC type and max flow rate; discuss with radiology

After all of this, you should be a line guru!

download

Thanks,

Stacy

Hyponatraemia

An in-depth look at the management of hyponatraemia, with special attention to a new concept called the “dDAVP clamp.”

Summary:

– only treat hyponatraemia if symptoms are severe – coma, seizures or severe delirium
– use 3% saline 100ml, up to three doses
– consider giving dDAVP to prevent a rapid climb in the serum sodium
– aim to correct the serum sodium by only 3-6mmol/L in the first 24 hours

For more information, have a look at Scott Weingart’s EMCrit Wee, and Josh Farkas’s blog post.

Thanks,
Stacy