Procedures Flashcards
Describe the process for a cricothyroidotomy (surgical airway)
- Stab cricothryoid membrane (between thyroid and cricoid cartilage) with scalpel
- Keep scalpel in the membrane
- Use hook or dilators to dilate the incision
- Insert bougie (be mindful that it needs to only go a short way)
- Insert endotracheal tube
What are the indications for cricothyroidotomy?
PRIMARY INDICATIONS
- burns of airway (closes airway)
- difficulty getting to airway (pt trapped under rubble)
SECONDARY INDICATIONS
- failed intubation
What is the difference between cricothryoidotomy and tracheotomy?
Tracheotomy is lower, in the anterior wall of trachea.
Longer term solution for airway management
More complicated - large veins and part of thyroid gland overlies
What are the layers of the neck?
- Skin
- Connective tissue
- Small blood vessels
- Cricothyroid membrane
- Cricovocal membrane (membranes form cricothyroid ligament)
- Larynx
How is a subclavian vein line inserted?
- Head down position
- junction between medial 1/3 and middle 1/3 of clavicle
- 1cm below clavicle
- in direction of sternal notch
Why do you need a head down position for a subclavian vein line?
To avoid giving an air embolus -> death
What are the indications for a subclavian vein line?
- peripherally shut down
- IVDU
- need drugs centrally
- to give blood, fat
What are the steps for the seldinger technique?
- needle + syringe
- guide wire
- take off needle
- guidewire + scalpel
- catheter
- remove wire
WATCH A VID
Where can you insert an intraosseous needle?
- Proximal humerus: head of humerus
- Proximal tibia: tibial tuberosity -> medial and 2cm below
- Distal femur: medial to lateral femoral condyle
- Distal tibia: 3cm proximal to medial malleolus
- Pelvis: iliac crest (anterior superior iliac spine)
- Sternum
- Proximal tibia: tibial tuberosity -> medial and 2cm below
What are the indications for intraosseous insertion?
Fast access
If can’t get IV access
Often in children who have arrested
Burns patients
What is the surface landmark for a thoracostomy?
4th* or 5th intercostal space mid-axillary line
safe triangle
What are the boundaries of the safe triangle?
- Apex below axilla
- lateral edge of pectoris major
- lateral edge/anterior border of latissimus dorsi
- 5th intercostal space
How do you ventilate with thoracostomy?
Positive pressure ventilation - managed with RSI or surgical airway
What are the layers you would pass when doing a thoracostomy?
Skin Subcutaneous fat Superficial fascia External intercostal muscles Internal intercostal muscles Innermost intercostal muscles Parietal pleura
What are the indications for a thoracostomy?
Pneumothorax
Haemothorax
Traumatic arrest
Where does the neurovascular bundle lie in relation to the rib? Why is this important?
Inferior to the ribs therefore when make an incision, needs to be on the superior surface of a rib
Where would you place a chest drain and when would this be appropriate?
Same place as thoracostomy: 4/5th ICS MAL
Someone who is spontaneously breathing
Urine bag or bucket of water attached
What are the surface landmarks for a needle thoracocentesis? What is the indication?
2nd intercostal space, mid-clavicular line
Decompression of tension pneumothorax
What are the indications for a thoracotomy? How is it done?
- Penetrating trauma to the chest
- Cardiac tamponade (take clot out then massage heart if needed)
Join up thoracostomy incisions with ‘swallow’ incision
Which structures are often damaged in a thoracotomy?
Internal thoracic arteries -> supply anterior chest wall and breasts
Supplies anterior intercostal artery branches for ICS 1-6
What are the internal thoracic arteries a branch of?
Subclavian artery
Describe diagnostic peritoneal lavage
- make an incision 2cm inferior to umbilicus in midline
- Cut through linea albea -> enter peritoneum
- Insert catheter - insert saline into peritoneal cavity then move bag to side of patient -> force of gravity forces fluid out: check colour, ?blood, microscopic testing?
When would you do diagnostic peritoneal lavage?
To determine if there is free floating fluid (most often blood) in the abdominal cavity
What are the two different techniques used for DPL?
Open (mini - laparotomy)
Closed (seldigner technique)
