Emergency Dept | Teaching Blog

ED THORACOTOMY

thanks Karen for a great talk on ED thoracotomy

Here are some of the take home messages and references

1) Penetrating stab wounds to the chest ( particularly in the area of the left parasternal /precordial area) are the sort of patients that may come to ED and having suddenly lost an output and need consideration for ED thoracotomy .These patients DO survive , commonly !

2) the ED thoracotomy is performed in the periarrest situation where the patient cannot be taken to theatre in sufficient time .  If the patient can be taken to theatre ( because he has a perfusing circulation ) then an Emergency Thoracotomy should be performed there instead .

 

3) penetrating stabs are the ones that may ( and often do ) survive. Blunt trauma is unlikely to survive ( < 1%) chance if they go into arrest in ED.  A patient with blunt trauma and cardiac tamponade who goes into arrest in ED could be considered for thoracotomy in ED . A patient with blunt trauma and massive Heamothorax who goes into arrest (and without a tamponade ) will not survive unless the person opening the chest can manage hemorrhaging mediastinal vessels ( and that just is not us in ED )

4) it would be considered worthwhile to attempt ED thoracotomy on a balllistics injury to the chest if there is evidence of tamponade in a patient who loses output on arrival . If there is no evidence of tamponade then ED thoracotomy should not be done unless there is a surgeon there who is willing to help ( stop catastrophic mediastinal vascular injury )

 

 

summary

1) make the decision that ED Thorocotomy (Be very clear of the indication and what you intend to do once you open the chest ) 

2) WHO DOES It? surgeon if he has experience and is there , if not the most senior ED doctor (hope its not me )

3) This is a periarrest scenario so no time for niceties – use poviodine if its there and protect yourself and your staff with appropriate surgical gowns and possibly eye gear

4) during the periarrest situation there should be someone managing the Airway and intubation ( RSI with or without sedation and paralysis ) and there should also someone managing access ( IO / rapid transfuser / activating MTP etc ) .ALTHOUGH CONTROVERSIAL TAMPONADE IS STILL TREATED WITH FLUID LOADING AS PRELOAD WILL HELP OVERCOME FORCE OF TAMPONADE

5) the third doctor who may be the team leader  : cut at or just below where the nipple line would be if the patient were a skinny male . Cut deep to fat and right down to intercostal ligament and either cut right down through pleura oruse a blunt dissector of this ( this is a life saving emergency so  speed is of the essence and cutting right down to lung would be considered acceptable ) . Be aware of two possible sources of iatrogenic bleeding , this would be the intercostal areteries running below the rib and the internal mammary arteries running parallell and close to the sternal margin. So if you are cutting so deep the Mantra ” above the rib below is of importance

6) The pericardium should be immediately exposed by this and the lung automatically collapsed and out or the way .The ribs are held back by the rib spreader . IF the pericardium is not exposed then continue the cut across the sternum and to the otherside (clam shell )

7) Divide the pericardium using forceps ( Beware of cutting the phrenic nerve – this should be visible on the pericardium ) . Look for a ventricular hole and suture it , put a finger on it , put a Foley catheter baloon through it and inflate it DO ANYTHING !

8) the patients heart may need to be restarted and hand cardiac massage may need to be performed (two hands ) during much of this period ( use paddles only 20-30 joules necessary )

9) if you have managed to gain a perfusing blood pressure then the patient needs to go to theatre and this needs to be in sligo , regardless of the expertise of the surgeon on call . He can be stabilised more before definitive transfer

 

a good start for learning more is this link (emcrit )

 

hi
To complement TRAUMA talk last week the following talks need to be covered next thursday
please pick a talk and post a summary on this website (via www.emsligo.blogspot.ie) the summary should be a paragragh and contain at least one reference

1) Thoracotomy – Karen ( or mick )
2) Chest drain placement / include indications for hand thoracostostomy ( Eimhear)
3) Massive transfusion protocol
4) sort of goes with 3 but good to divide up between two : DAMAGE CONTROL RESUSCITATION
5) the rectal exam in trauma – Mohamed
6) pelvic fracture classification ( young ) and significance – MEDICAL STUDENT PRESENTATION
7) RSI practice and  Gidascope demonstration ( rep )
8) review the FAST scan if time ( for people who werent there the last time )

remember to check this link for review of FAST SCAN -http://www.sonoguide.com/FAST.html

Greetings
We have a month or more of trauma ahead of us and a lot of interesting talks
The idea is to get through the most important and contemporary aspects of trauma management in ED and also to brush on some basic concepts of ATLS that we practice

There is a list of topics to present
this month we will summarise all our talks by leaving comments on this web page
any talks that are stored in open access cloud space (google drive / icloud etc ) will have links on this page

The value of this sort of teaching is that there is documentation of what we are learning and anopportunity for all of us to feedback perspective updates etc . This reflects what WEB 2.0 is all about !!

TOPICs ( to be covered over the month )

THE FAST and EFAST with practical demonstration – Mick (s) Karen et al

MASSIVE TRANSFUSION IN THE EXANGUINATING PATIENT –
PERMISSIVE HYPOTENSION IN TRUAMA – where do we stand – reg /middlegrade talk
CHRASH 2 – medical student
SAFE study (normal saline v chrystaloid ) – CONOR

 THE VALUE OF RECTAL EXAM IN TRUAMA  – Muhammed

Intercostal drain insertion – Eimhear
Thorocotomy- Karen
www.braintrauma.org guidelines – at least 5 guidelines with interesting topics – pick any even surgical managment  – 5 talks

EXANGUINATING PELVIC TRAUMA – MICK and Safa      link to MICKS PELVIC FRACTURE TALK HERE https://www.icloud.com/iw/#keynote/BAKG0mpd7MjKjYCmbMaBN-FZZ-89ia5nmvaF/PELVIC_FRACTURE_negative_fast

THORACOTOMY – sensible indications- KAREN
THORACTOMY – HOW TO – VIDEO

SHOCK AND SPINAL CORD INJURY ( neurogenic and spinal shock explained )
TRAUMA SCENARIOS – PICK ONE ( OR MAKE A BETTER ONE UP )
– PREGNANT PATIENT POLYTRUAMA
– MASS CASUALTY- > 2 CRITICAL PATIENTS – DISCUSSION  ON PLANNING ONCE THE AMBULANCE CALL COMES I
-PAEDIATRIC
POLYTRUAMA – REVIEW OF PALS VALUES /RSI
– GCS 3 BLOWN PUPIL !
-PELVIC FRACTURE

Summary of Ebola talk

Thanks Eimhear for a comprehensive review of recent updates on Ebola.
Today the WHO has predicted a worse case scenario of up to 20000 cases before the end of this epidemic is brought undercontrol (hopefully by the middle of next year) .The BBC reports that it is thought that the actual number of cases may be 4 x the advertised 3000 . The measures needed to control the outbreak will cost 500 million dollars and will involve 175 international case workes and more than 10 thousands national workers

current quick glance guidelines/ algorithm are available via the HSE website here

Precautions involve using personal protective gear ( Face mask , water proof gown, gloves over gown , closed shoes , eye shied ) . Although no droplet spread as such , infection occurs when there is close contact with bodily fluids ( semen , saliva , faecies , blood.) it appears that this fluid must come into contact with mucosa or broken skin. The virus can survive for many months in body secretions. Health workers within one metre contact are at risk unless full PPE is used

In our institution the current hospital protocol is that a patient that has any risk should be transported from triage to AAU ( with personel using PPE ) . The triage room should then be disinfected ( standard chlorhexidine etc)

Currently our ED is not equipped to handle suspected cases

Thanks also to Marcus Chou ( ENT consultant) for part one of ENT review – Epistaxis

To summarise
-epistaxis is common ( exact prevalence uncertain because it is mostly self limiting at home). Ninety percent idiopathic
– the management of epistaxis is the responsibility of ED until ENT takes over.
– ED may end up being responsible for the active treatment and resuscitation right up until the unstable patient is taken to theatre by ENT

Some of the essential equipment in ed must include
Head light source ( unless you have three hands)
Nasal speculum – do ed doctors really know how to hold a nasal speculum?

ENT suction

Co phenylcaine

Appropriate packing – rapid rhino  > merocel
Alternatives include ………
Silvernitrite sticks ( remember you just apply DRY for a second or two – to avoid septal perforation or unsightly staining of skin)

Approach
ED doctors know how to resuscitate ( I hope) – access/ airway / opiate analgesia prn/ monitoring
Remove clot with suction
apply cophenylcaine ( 120 euros per bottle )
use cotton wool or plegets as an added measure these can be soaked in cophenylcaine
visualize littles area
cauterise culprit vessel with care
pack with rapid rhino if this fails
pack ohter side with rapid rhino if this fails
take out and use standard packing if this fails – patient will not be liking this !

posterior bleeds are uncommon < 5 percent and are treated with tampnade ( ie a Foley catheter baloon to seal off the posteior part of nasal cavity in conjunction with packing and forceps at nose to hold taught – these patients will need to go to theatre and all patients will need ENT admission – current dogma recommends that packs stay in for three days and that antibiotics are given

talk one  – the futility of the exercise tolerance test . The goal is to squeeze all this information into two ten minute talks
see the following links for all the information you need (you may want to glance at some of the references )

http://emcrit.org/chestpain/

http://www.smartem.org/podcasts/stress-testing-moment-clarity

talk two – universal definition of MI / ECG criteria for STEMI including scarbossa dewinter posterior and right ventricular infarct and the significance of STE in AVR (ten minutes ).see the following links

talk three – MI Mimics ( on ECG) BER / ANEURISM / SAH / Dissection prox aorta / Pericarditis .

talk 4 – unstable angina – time for a requiem ?

talk 5 – regional wall abnormality on bedside echo -mick – if time

   TEACHING for Second half of the year (2014)
Purpose of teaching
-Cover some of the core medical and surgical and Paediatric topics of Emergency Medicine
-To maintain quality and uniformity or practice for all doctors in ED with a focus on day to day clinical practice as well as more rare but life-threatening emergencies
TOPICS ( not necessarily in this order )
1) Management of Acute cardiac emergencies including ACLS review
2) Management of acute respiratory emergencies including Airway management and  RSI )
3) Management of acute Neurological Emergencies including CVA (SAH/thrombolysis debate / stroke and TIA guidelines / syncope )
4) Vascular Catastrophes . AAA/ dissection  / cardiac Tamponade
5) Trauma management – Recent updates eg ICEM , Damage control resuscitation / crash 2 trial / TTM trial
6) Orthopaedic injuries ( pelvis / longbone / hand and foot / soft tissue injuries to shoulder , knee , wrist and ankle
7) The focussed clinical exam in 2014 – Different Joints / formal Cardiac exam / neurological examination .
8) ULTRASOUND TRAINING – (THREE LECTURES , LOGGING SCANS , SUPERVISION AND TESTING  )
9) Paediatric Emergencies ( Assessment of the unwell child / PALS / APLS / APLS review / NAI
10)Interpretation and management of Acute Electrolyte disturbances (hyperkaleamia / acid base / hyponatremia / Hypernatremia / DKA / Honk / Acute renal failure )
11) The critically ill patient – Sepsis bundles / BOIC / Post cardiac arrest management / post intubation check list / inotropes / antibiotics in serious sepsis
12) Toxicology – general approach / Specific and common life-threatening overdoses. Seratonin and anticoholinergic syndrome

SUB Structure

“Reversed class room” philosophy – Trainees present short talks for every teaching program ( no talk longer than 15 minutes , usually 5-10 minutes )
“Expert panel” discussion (consultant/SPR/guest )  will discuss afterwards
ideally real life cases will be discussed
A teaching session should have a summary / consensus at the end , so that the information obtained can be used for real life clinical work in ED ( or to pass exams!)
Talks will be posted on the blog each week ( with all patient sensitive information de-identified )

follow this link  (tap the images)  for trustworthy and free internet resources for up to date resources . A good start for any talk you might have to do .

http://lifeinthefastlane.com/foam/