Procedures

Question 1

Indications for resuscitative thoracotomy

Answer 1

ED: no cardiac output or unconsciousness due to shock
Stab wound to heart with pericardial tamponade
Penetrating chest trauma with signs of life < 10 min
+/- blunt trauma with evidence of tamponade

Question 2

Steps in resuscitative thoracotomy

Answer 2

Intubation with right lung ventilation
4cm bilateral finger thoracostomy in 5th ICS (stop if ROSC)
W incision with centre over sternum
Cut intercostal tissues including pleura with heavy scisors to extend thoracostomies medially
Connect if in same ICS by cutting sternum
Expose heart, incise pericardium apex to base and form T
Inspect heart and address sites of bleeding
Internal CPR and compression of aorta

Question 3

Steps for transcutaneous pacing

Answer 3

AP pads
Select pacing and check sensing intrinsic rhythm.
Set rate of 60-80
Increase current output until each pacing spike followed by QRS (usually 40-60 mA)
Check for mechanical capture with palpable pulse

Question 4

Steps for transvenous pacing

Answer 4

Insertion of sheath introducer (RIJ, L subclavian)
Insert pacing catheter through sterile sleeve and into sheath
When past end of sheath, inflate baloon tip
Connect with alligator clip the pacing wire to V1 of the ECG machine and monitor
Slowly advance baloon tipped catheter
When evidence of RV injury pattern, stop, deflate baloon and secure position.
Extend sterile sleeve.

Set pacing box
attach lead cables to generator box
Commence rate at 80, output 1-2 and sensitivity high
Assess for electrical capture and pulse generation (mechanical capture)
Reduce output until capture is lost, set at 2x +1
Test sensitivity, 1-2 reasonable, reduce if triggered by P/T waves or increase if not sensing intrinsic rhythm.

Question 5

Pericardiocentesis (no US)

Answer 5

Elevate chest to 30-45 deg
antiseptic, local anaesthetic.
Introduce needle long 18g spinal needle 1cm inferior to left xiphocostal angle at 30 deg to skin, towards left shoulder
aspirate, and stop when fluid is returning, observe for injury current (attach to V1)
Advance J tipped wire and then remove needle
Advance 6-8 fr dilator and remove
Advance 6-8 Fr pigtail catheter over wire and remove wire.
Drain fluid

Question 6

Treatment of local anaesthetic toxicity

Answer 6

IV lipid emulsion 20% 1.5 mls/kg over 1-2 min, then repeated Q5 min to 3 times, and infusion of 0.25 - 0.5 mls/kg/min