smacc.net.ausmacc.net.au/.../04/SMACC-Participant-Morning-Syllabus.docx · Web viewPlace your palm over the patient’s shoulder anteriorly. Feel for the “ball”, this is the area

SMACC Chicago 2015 & the

American College of Emergency Physicians

Presents the

Procedural Skills Lab

Course DirectorChristopher Ross MD

June 25, 2015McCormick Convention Center

Chicago, Illinois

Course Schedule

Thursday, June 25, 2015MORNING SESSION

7:00 - 8:00 Registration for Participants8:00 - 8:15 Overview8:15 - 8:30 Airway adjuncts8:30 - 8:50 Intraosseous vascular access8:50 - 9:00 Lateral canthotomy9:00 - 10:00 Practice procedures10:00 - 10:10 Chest tubes10:10 - 10:20 Bronchoscopy10:20 - 10:30 Pericardiocentesis10:30 - 11:30 Practice procedures

Airway Adjuncts

Several varieties of airway adjuncts will be demonstrated during the lab session. Examples of airway adjuncts available during the lab include:

Direct laryngoscopy Gum Elastic Bougie Laryngeal mask airway/Laryngeal mask airway supreme Glidescope McGrath laryngoscope King Vision AirTraq

Intraosseous Vascular Access

Procedureo Position patient, sterile prep, and topical local anesthesia at the discretion

of the provider.o Choose proper needle length. If using EZ-IO needle, it should have at least 1

hash mark (5mm) above skin line when needle is touching bony surfaceo Insert needle perpendicular to bone after appropriate landmarking.o If manually inserting, provide steady twisting pressure. If using EZ IO drill,

squeeze handle to drill with gentle pressureo Sudden loss of resistance indicates that needle has entered marrow cavity. o Pediatrics: Immediately release the trigger when you feel the “pop” or

“give” as the needle set enters the medullary space to avoid puncturing the posterior aspect of the bone.

o Adults: Advance needle feeling a “pop” or change in resistance that indicates the entry into the medullary space until the needle set hub is close to the skin.

o Secure and dress the IO needle. o Slowly infuse over 2 minutes 2 cc of 2% lidocaine without preservatives

(cardiac lidocaine) if patient is responsive (In pediatrics, utilize 2-5mg/kg of lidocaine).

o Syringe bolus (flush) IO with 5-10ml of normal saline to open up the marrow channels for infusion (In pediatrics utilize at 2-5ml flush).

o If required, slowly infuse another 20mg of lidocaine IO over 60 seconds, repeat prn.

o Consider IO narcotics for pain if not responding to lidocaine. o Secure the needle and attach tubing.o Pressure bag is needed to infuse fluids.

Proximal Humeruso Position the patient elbow bent and adducted with humerus internally

rotated so that the patient’s hand rests on the abdomen. o Place your palm over the patient’s shoulder anteriorly.o Feel for the “ball”, this is the area for the IO insertion.

o Place ulnar aspect of one hand over patient’s axilla and the other hand

along the midline of the upper arm laterallyo Place your thumbs together over the armo Palpate deeply as you move up the humerus to the surgical neck. It feels

like a golf ball on a tee. Surgical neck is where the “ball” meets the tee.o IO insertion site is 1 to 2 cm above the surgical neck on the most prominent

aspect of the greater tubercle. o Aim IO needle tip downward at a 45-degree angle to the horizontal plane.

Proximal Tibia: o Pediatrics:

-Extend the leg. -Insertion site is located approx. 1 cm below the patella, and 1cm medial along the flat aspect of the tibia. -Pinch the tibia between your fingers to identify the center of the medial and lateral borders.

o Adults: -Extend the leg. -Insertion site is approx. 3 cm below the patella and approx. 2cm medial along the flat surface of the tibia.

Distal Tibiao Pediatrics:

-Insertion site is located approximately 1-2cm proximal to the most prominent aspect of the medial malleolus. -Palpate the anterior and posterior borders of the tibia to assure that your insertion site is on the flat center aspect of the bone.

o Adults: -Insertion site is approx. 3cm proximal to the most prominent aspect of the medial malleolus. -Palpate anterior and posterior borders of the tibia to assure that your insertion site is on the flat center aspect of the bone.

Lateral Canthotomy

Chest Tubes

Bronchoscopy

o Indicationso Persistent or unexplained cougho Blood in the sputum (coughed up mucus material from the lungs)o abnormal chest x-ray such as a mass, nodule, or inflammation in the lungo Evaluation of a possible lung infectiono To remove foreign bodies in the airwayo To place a stent (a tiny tube) to open a collapsed airway due to pressure by a

mass or tumoro To remove a mass or growth that is blocking the airway

o Equipmento Fiberoptic bronchoscopy deviceo IV catheter for medication administrationo Heart rate monitoro Oxygen saturation monitoro Supplement oxygen equipmento Equipment and expertise available for advanced airway interventionso Topical lidocaineo

o Techniqueo Prepare the patient: Controlled mode ventilation, increased FiO2, bite guard

and/or paralysis, connecting piece to the ETT.The risk / benefit should be considered carefully in patients where Co2 control (head injury) or PEEP control is critical, and in situation of severe bleeding diathesis.

o Lubricating gel. Suction port connected. Sputum trap if required. Sterile Saline for injection / wash.

o Complicationso Nose bleeding (epistaxis)o Vocal cord injuryo Irregular heart beatso Lack of oxygen to the body's tissueso Heart injury due to medications or lack of oxygeno Bleeding from the site of biopsyo Punctured lung (pneumothorax)o Damage to teeth (from rigid bronchoscopy)o Complications from pre-medications or general anesthesia

Lung Anatomy

Pericardiocentesis