H. Mitchell Shulman MDCM FRCPC CSPQ Assistant Professor, Dept. of Surgery, McGill Medical School Attending Physician, Royal Victoria Hospital,
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1 H. Mitchell Shulman MDCM FRCPC CSPQ Assistant Professor, Dept. of Surgery, McGill Medical School Attending Physician, Royal Victoria Hospital, Montreal General Hospital, McGill University Health Center
2 CME FACULTY DISCLOSURE Dr. Mitch Shulman has no affiliation with the manufacturer of any commercial product or provider of any commercial service discussed in this CME activity.
3 Miller 2005; Ch 42: p1622, 33 Airway Management Basic Principle
4 Indications: Cricothyroidotomy Inability to intubate the trachea is the primary indication for creating a surgical airway!!! i.e. Oral / nasal endotracheal intubation contraindicated / impossible
5 Cricothyroidotomy Definition Establishment of an opening to the airway at the level of the cricothyroid membrane
6 Age Pre-existing laryngeal pathology Inexperience Anatomic distortion Coagulopathy Cricothyroidotomy Contraindications
7 Cricothyroidotomy Anatomy
8 Cricothyroidotomy Anatomy Epiglottis Hyoid bone Thyroid cartilage Cricoid cartilage
9 Cricothyroidotomy Complications Total % Subglottic stenosis 1.4 Voice change 1.4 Local hemorrhage 2.7 Wound infection Misplaced tube Pneumo-thorax / mediastinum Esophageal injury Subcutaneous emphysema Mediastinal infection
10 Cricothyroidotomy Tools Shiley 4 Tracheostomy Tube Internal Diameter: 5 mm External Diameter: 8.5 mm Be Prepared! Saline filled syringe
11 Why??? Needle Cricothyroidotomy Be Prepared!
12 Needle Cricothyroidotomy Tools Be Prepared! Syringe: 3 cc Oxygen: 15 L / min Psi Connector: 7 ETT
13
14 Needle Cricothyroidotomy Tools Be Prepared!
15 Needle Cricothyroidotomy Tools One second on Four seconds off Alternative: Ctn O 2 6 L / min * Ctn O 2 15 L / min 18 ** * Cat study ** kg
16 Chest Tubes Indications: Pneumothorax Hemothorax Empyema Pleural effusion Chylothorax
17 Chest Tubes Contraindications: Need for immediate open thoracostomy Massive hemothorax 1000 ml Clotting disorder Multiple pleural adhesions / scarring Bleeding rapid 300 ml 1 st hr continued 200 ml / hr (3 hrs) increasing Persistent hemothorax Large air leak Bronchial / esophageal / diaphragmatic injury
18 Apical route rarely used Oxygen, IV, EKG, O 2 sat monitor Pt semi-erect Chest tube size: trauma Fr pneumo Fr Measure tube length Chest Tubes Procedure
19 Chest Tubes Procedure
20 Chest Tubes Complications Lacerated intercostal artery Non-functioning tube Slippage Crossing mediastinum In soft tissue of neck Lung laceration Pain Re-expansion pulmonary edema Infection
21 Indications Needle Thoracentesis Rapid deterioration Tension pneumothorax No air or no relief Pericardial tamponade Myocardial contusion / infarct Air embolus Complications: infection hemorrhage pneumo / hemo thorax
22 Venous Cutdowns Shock No other access Site: distal saphenous vein Contraindications previous use of vein phlebitis cellulitis trauma to the leg Medial & superior to the medial maleolus
23 Venous Cutdowns Procedure Skin incision perpendicular to the course of the vein Complications 15 % wound infection 4 phlebitis 4 embolization
24 Intraosseous Infusions Sites Children: Prox tibia anteromedial surface 1-3 cm below and medial to tibial tuberosity Dist femur 2 3 cm above epichondyles Adults: Distal tibia 1 cm above superior margin of medial maleolus
25 Intraosseous Infusions Sites Children: Prox tibia anteromedial surface below and medial to tibial tuberosity Dist femur 2 3 cm above epichondyles
26 Intraosseous Infusions Sites Adults: Distal tibia 1 cm above superior margin of medial maleolus
27 IntraOsseous (IO) Devices F.A.S.T.1 system (Sternal) Pyng Medical Corp Illinois sternal iliac IO needle Cook-type IO needle EZ IO Jamshidi IO needle Bone Injection Gun (B.I.G.) springloaded IO insertion device
28 Histoacryl Wound Repair Dermabond Pressure at ampule midpoint Crush inner glass Applicator tip up, away from pt
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