Author: 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:

 

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

 

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

 

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

https://youtu.be/qiJaxsMlwps

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

HMOs: Diabetic Emergencies

Updated: May 2017

 

(34min)

 

Some links and resources to look at with regard to diabetic emergencies:

EMBasic – a good overview of definitions, assessment, investigations and management

British Paeds Endocrine Guidelines – have a look at page 15 for the management flowchart

Paediatric Calculator – a useful doc for working out fluid and insulin doses in children.

 

For a more detailed discussion on the use of Hartmann’s vs saline, see my post on Acid-base & Fluids

 

HHS vs DKA

Management algorithm