PEMSS PROTOCOLS INVASIVE PROCEDURES

Transcription

1 PEMSS PROTOCOLS INVASIVE PROCEDURES

2 Panhandle Emergency Medical Services System SURGICAL AND NEEDLE CRICOTHYROTOMY Inability to intubate is the primary indication for creating an artificial airway. Care must be taken, especially with children, to avoid damage to the cricoid cartilage, as this provides the only circumferential support to the upper trachea. Indications Oral, facial, or oropharyngeal injuries that preclude oral tracheal or nasotracheal intubation Laryngeal fracture with severe respiratory distress or compromise Failed Airway (Unable to ventilate and intubate) Relative contraindications Expanding anterior neck hematoma Inability to define anatomical landmarks Needle Cricothyrotomy Equipment: * 16 gauge or 14 gauge angiocath * Bag-mask device with oxygen source * Suction Procedure: 1. Locate cricothyroid membrane. 2. Insert needle/catheter through membrane and freely aspirate air 3. Remove needle 4. Support trachea 5. Once catheter is in place, attach ET tube adapter to hub of catheter 6. Verify placement and secure airway.

3 Surgical Cricothyrotomy Equipment: Scalpel blade and handle: #11 Endotracheal tube 6.0 mm Bag-mask device with oxygen source Securing device (tape or twill) Tracheal hook Procedure: 1. Hyperextend the neck; with suspected cervical spine injury maintain the head and neck in an in-line neutral position. 2. STAB: Palpate the cricothyroid membrane and stabilize the trachea. Make a transverse incision by stabbing through the cricothyroid membrane. This incision is accomplished with a controlled stabbing motion of the scalpel such that the blade only just enters the airspace below. 3. HOOK: Using a tracheal hook, hook the inferior opening (cricoid cartilage) to stabilize the trachea, and pull up with the tracheal hook to increase the tracheal opening 4. TUBE: Insert the tube into the cricothyrotomy directing it distally into the trachea; it should only be inserted 1-2 cm above the superior border of the cuff. 5. Remove the tracheal hook, inflate cuff and ventilate. 6. Evaluate ventilation and secure the tube. Complications from artificial airway placement Asphyxia Aspiration Cellulitis Esophageal hematoma Exsanguination hematoma Hematoma Posterior tracheal wall perforation Subcutaneous and/or mediastinal emphysema Thyroid perforation

4 Inadequate ventilation leading to hypoxia and death Pneumo peritoneum

5 When performing a cricothyroidotomy, the following points can be very helpful. If righthanded, stand on the patient s right side. Critical time can be saved in patients with distorted anatomy (e.g., the obese, those with neck trauma/swelling) by first finding the airway with a needle and syringe. Keep it in place and use it as a guide. Once you begin holding the larynx, do not let go until the procedure is completed. Identify the cricoid membrane with your index finger holding the larynx. By not releasing the larynx, your finger will remember the site of the cricoid membrane and aid in finding it throughout the procedure. Vertical, midline skin incisions will minimize bleeding. Even though this technique is always executed in a crash setting, watch for easily visible, large subcutaneous blood vessels, which, if violated, can produce enough blood to obscure the field. Another common mistake is to make the incision too small, which doesn t expose enough landmarks to permit quick, easy identification of the membrane. Once the cricoid membrane is incised, insert a tracheal hook to keep the larynx stable. Insert a size 6-0 ET tube through the trachea. Then remove the hook (in that order), and secure the tube.

6 Panhandle Emergency Medical Services Intraosseous Cannulation Vascular Access is vital for drug and fluid administration but may be difficult to achieve in certain patients and instances. Peripheral venous access is the preferred route for fluid and drug administration, but only if it can be achieved in a short period of time (2 minutes or less). In such cases the Intraosseous Access can be the alternate method to establishing a route for fluids, and medications in the adult and pediatric patient. This will be the preferred Bone needle in the PEMSS system. Indications: 1. Trauma Fluid replacement in shock Rapid vascular access 2. Non-trauma Cardiac arrest Acute respiratory Distress Any time rapid vascular access is required (all forms of shock) 3. Technique a. Adults the tibia is the only approved site. 2cm medially and 1cm proximally to the tibial tuberosity. 15 gauge b. Pediatric tibia is the primary site. Age 0-6: 1cm medially and 1cm distally to the tibial tuberosity. Age 6-12: 1-2 cm medially and 1-2 cm distally to the tibial tuberosity. 18 gauge

7 c. Position the Bone Injection Gun with one hand to the site and Pull out the safety latch with the other hand. d. Trigger the Bone Injection Gun at 90 degrees to the surface e. Remove the Bone Injection Gun, pull out the stylet trocar f. Fix the cannula with the safety latch, and attach IV tubing 4. Insertion Depths *(Adult Bone Injection Gun insertion depths are preset) 0-3 yrs 3-6 yrs 6-12 yrs Proximal Tibia *

8 Panhandle Emergency Medical Services Umbilical Vein Catheterization The umbilical vein is the preferred site for vascular access during neonatal resuscitation because it is easily located and cannulated. The following technique is recommended for paramedics operating under the PEMSS protocols. Technique 1. The cord is prepped with betadine solution and trimmed approximately 1cm above the skin attachment with a scalpel blade. Hold firmly with umbilical tape to prevent bleeding. The umbilical vein is identified as a thin walled single vessel, the arteries are paired, and have thicker walls, and usually constricted. The lumen of the vein is larger and when cut the vein continues to bleed. 2. A 3.5 or a 5.0 French umbilical catheter is used and flushed with NS. The umbilical vein catheter is inserted just until a good blood return is obtained. This should correspond to a depth of insertion of 1 to 4 cm and should avoid advancement of the catheter tip into the portal vein or hepatic circulation. 3. If free blood cannot be aspirated, withdraw the catheter until blood can be aspirated or another IV route may have to be obtained. If Sodium Bicarbonate is to be given via the UVC, it should be diluted prior to administration. Equipment Needed: 3.5 or 5.0 Fr UVC Catheter, umbilical tape, scalpel, NS for flush.

9 Panhandle Emergency Medical Services I. INTRODUCTION NEEDLE THORACOSTOMY Needle decompression is necessary when a patient exhibits signs and symptoms of a tension pneumothorax and extreme respiratory distress. It is a rare procedure but when used it may restore ventilation. A tension pneumothorax must be recognized and treated promptly. The indications and technique must be clearly documented whenever it is used. II. SIGNS AND SYMPTOMS (Typical - often not straight-forward and all signs & symptoms may not be present) A. Tension Pneumothorax 1. Progressive respiratory distress, tachypnea 2. Hypotension 3. Tachycardia 4. JVD - jugular venous distention 5. Absent breath sounds on affected side 6. Tracheal shift away from affected side 7. "Drum-like" percussion noted on affected side 8. Hyperexpanded chest on affected side 9. Signs and symptoms of shock 10. If patient intubated - increasing difficulty with ventilation 11. Cyanosis 12. Narrowing pulse pressure III. Recent trauma cardiac arrest, or imminent arrest: A. Cardiac arrest in a blunt trauma patient, with possible chest injuries. The onset of the arrest should be known or reasonably suspected to have occurred within 10 minutes. B. Cardiac arrest in a trauma patient from gunshot or stab wounds to the chest, neck, or abdomen. The onset of the arrest should be known or reasonably suspected to have occurred within 10 minutes. IV. PRECAUTIONS A. Tension pneumothorax may occur as a complication of CPR B. Misplacement of an endotracheal tube, i.e. right mainstem placement may lead to asymmetry or absent breath sounds and can be mistaken for a left pneumothorax. VI. INDICATIONS A. The prehospital diagnosis of tension pneumothorax should not be made unless the patient exhibits severe respiratory distress or cardiac arrest associated with trauma.

10 VII. Technique Palpate the 2 nd and 3 rd intercostal space at the mid-clavicular line. Prep the area with betadine. Insert a large angiocath (16 or 14 gauge) over the needle catheter, into the rib and continue over the top of the rib into the pleural cavity. Remove the needle and leave the catheter in place. If a tension pneumothorax is present, a large rush of air should be noted through the needle. A. 2 nd & 3 rd intercostal space (midclavicular) B. Mid-axillary (do not use this site)