Common pitfalls in ER Procedure

You should understand well about…You should understand well about…1.1. Indication Indication 2.2. Contraindication Contraindication 3.3. Step & techniques Step & techniques 4.4. After careAfter care5.5. Complication : to be aware ofComplication : to be aware of6.6. Options !! If the procedure FAIL !Options !! If the procedure FAIL !

PreparationProcedure

StepSkillPatient

After finish procedureFail to check & Secure

patient .

Other factorsRush/stress

step

““Patients do not die from a "failure to intubate." Patients do not die from a "failure to intubate." 'They die either from failure to stop trying to intubate 'They die either from failure to stop trying to intubate

or from undiagnosed esophageal intubation.”or from undiagnosed esophageal intubation.”

Scott, DB Endotracheal intubation: friend or foe Br Med J (Clin Res Ed). 1986 Jan 18;292(6514):157-8.

Indication : Indication :

1.1. Inability to maintain airway with Inability to maintain airway with less invasive techniquesless invasive techniques..

mostly : in case difficult airway , try ETT first mostly : in case difficult airway , try ETT first

with preparation for surgical airway by side.with preparation for surgical airway by side.

Contraindication : Contraindication :

1.1. Airway can be managed by less invasive method.Airway can be managed by less invasive method.

2.2. Others : Others : • Partial / complete transection of airway Partial / complete transection of airway preferred tracheostomy preferred tracheostomy• Not suitable in case with significant injury of Cricoid. Not suitable in case with significant injury of Cricoid.

Relative Contraindication : Relative Contraindication :

1.1. Known case of laryngeal pathology (tumor , fracture) Known case of laryngeal pathology (tumor , fracture)

prepare to extend to High tracheostomy.prepare to extend to High tracheostomy.

Special considerations :Special considerations :

1.1. Children : < 8-10 yrs. : Needle cricothyroidotomy only.Children : < 8-10 yrs. : Needle cricothyroidotomy only.

2.2. Bad positioning : not extend neck.Bad positioning : not extend neck.

Techniques :

1.Traditional surgical cricothyroidotomy

2.Alternative surgical cricothyroidotomy

3.Needle cricothyroidotomy

Identify landmarkIdentify landmark

Incision : transverse Incision : transverse • not more than 2-3 cm. not more than 2-3 cm. Anterior Jugular v. Anterior Jugular v.

Longitudinal only when :Longitudinal only when :• neck swelling , suspected High Tracheostomy neck swelling , suspected High Tracheostomy

need.need.

Not deeper than 1.5-2cm.

1.1. Internal jugular veinInternal jugular vein

2.2. Subclavian veinSubclavian vein

3.3. Peripherally Inserted Central Peripherally Inserted Central

Catheter : PICC Catheter : PICC

4.4. Femoral veinFemoral vein

5.5. Peripheral venous cut downPeripheral venous cut down

1.1. Seldinger Seldinger

2.2. Catheter over the needleCatheter over the needle

Rt. IJ 15

Rt. SC 18

Lt. IJ 18

Lt. SC 20

Scalenus anteriorScalenus anterior

Action tips

1.Prep skin For IJ , prep extend to SC

2. Prep cathetor Flush with Saline

3. Locate vein with finder needle IJ ~ 3 cm.

4. Remove finder needle Cap lock !!

5. Insert introducer needle Traction skin for fix landmark

6. Remove syringe : air embolism Don’t remove hand at all.

7.Insert guidewire Guide dislodge inside pt. or other damage with force.

8. Stop guidewire at 10 cm + skin mark Or when you see ectopy ! Heard arrhythmia.

9. Never let go of the guidewire.

10. Verify tip In SVC not in RA , above azygous v. an d carina. With tip parallel to vessel wall.

Distal tibia : malleolus

Humerus

Cook Jamshidi

Illinois

Bone injection gun

EZ IO

Needle decompression for Needle decompression for tension pneumothorax tension pneumothorax

And And Go-on ICDGo-on ICD

Landmark : Landmark : = 2= 2ndnd ICS mid clavicular line ICS mid clavicular line

• Pleural space must be identified.Pleural space must be identified.

• Obese patient : Semiupright , Obese patient : Semiupright ,

beware of diaphragm perforation.beware of diaphragm perforation.

• ICD with Trocar can cause ICD with Trocar can cause

significant injurysignificant injury

• not measurement the chest tubenot measurement the chest tube

last lumen is too closed to skin. last lumen is too closed to skin.

leakage & subcut.emphysema. leakage & subcut.emphysema.

You should understand well about…You should understand well about…1.1. Indication Indication 2.2. Contraindication Contraindication 3.3. Step & techniques Step & techniques 4.4. After careAfter care5.5. Complication : to be aware ofComplication : to be aware of6.6. Options !! Options !! If the procedure FAIL !If the procedure FAIL !

Question ? Question ?