Critical Care Procedures Flashcards
Three concepts of ATLS
- Tx the greatest threat to life 1st
- The lack of a definitive dx should never impede the application of an indicated tx
- A detailed hx is not essential to begin the evaluation of a patient with acute injuries
ABCDE
A - airway w/C-spine protection B - breathing C - circulation, stop the bleeding D - disability or neuro status (AVPU) E - exposure (undress pt) & environment (temp control of the room)
8 MC life threatening breathing conditions
- airway obstruction
- tension ptx
- spontaneous ptx
- hemothorax
- flail chest
- aortic injuries
- cardiac tamponade
- pulmonary contusions
Primary Surveys
-Who, What, Where?
Non response to these questions suggests the patient has abnormalities to ABCD and warrants urgent intervention
Secondary Surveys
-Begin when the primary survey is complete, resuscitative measures are underway and vitals are stabilizing
**SHOULD NOT INTERFERE WITH A PRIMARY SURVEY, WHICH TAKES FIRST PRIORITY.
Secondary Survey pneumonic
AMPLE
- allergies
- meds
- past hx/preg
- last meal
- events/environment related to the injury
Parietal pleura
Lines the outer layer of the thoracic cavity
Pleural space
The small potential space between the parietal and visceral layers of the pleura
Visceral pleura
The thin serous membrane around the lungs and inner walls of the chest
What is a Simple PTX?
- Non-expanding collection of air around the lung
- The lung is collapsed, to a variable extent.
Signs/symptoms of simple PTX
- reduced air entry and resonance to percussion
- +/- subcutaneous emphysema and rib fractures
Tension PTX pathophysiology
- One way valve leak from lung or through chest wall
- ***Air forced into pleural space (clinical dx based on this)
- Eventual lung collapse
- Organ displacement
- Decreased venous return
- Reduction in cardiac output
- Obstructive shock
- Cardiac arrest
Tension PTX Signs/Symptoms
- CP
- Resp. distress (apprehension, agitation, cyanosis)
- tachycardia
- hypotension
- **tracheal deviation AWAY from affected side
- **u/l absent breath sounds
- neck vein distention
- shock (cool, clammy skin)
- **hyperresonance to percussion
Indication for needle decompression
Tension PTX
Complications of needle decompression
- Kinking of the catheter
- Anatomical issues (large body habitus)
- Can cause a subsequent PTX
- Clot in catheter/local hematoma
- Lung laceration
Systematic Approach to CXR
ABCDE&FGH
- airway
- bones
- cardiac
- diaphragm
- equal (lung) fields
- gastric bubble
- hilum (and mediastinum)
Needle decompression supplies
- Luer Lock syringe
- 14g needle
Needle Decompression Instructions
- High flow O2/ventilation
- 2nd ICS, midclavicular line
- Prep w/Betadine
- Local lidocaine
- Upright position if appropriate
- Keeping the Luer-Lock in the distal end of the catheter, insert an over the needle catheter 2 inches superior to the rib into the ICS
- Puncture the parietal pleura
- Remove Luer-Lock, listen for air
- **Prepare for chest tube insertion 5th ICS anterior to mid axillary line of affected side
- Connect the chest tube to an underwater-seal device or a flutter type valve apparatus and remove the catheter used to initially relieve the tension PTX
- Chest xray
What is the next step in this patient’s care after needle decompression?
Chest tube
Complications of chest injury
- ARDS
- Pulmonary contusion leading to ARDS & possible mechanical ventilation
- Aortic injury
- Bronchial tree injury
- Pericardial effusion
Chest tube Indications
- Post Needle decompression
- Hemothorax
- Fluid
- Pus (empyema)
- Air
Chest tube size for hemothorax
Large 30-40 French
Chest tube size for PTX
Small 12-22 French or smaller 9-12 French pigtail catheters
French chest tube equation
FR = D (mm) x 3
use external diameter
