Procedures

Your patient has a pneumothorax and requires a pigtail chest X-ray. Outline your approach.

My approach is to confirm need, prepare appropriately, then perform the procedure, then ensure good post-procedure care. So I'll confirm the indication, explore any alternatives such as monitoring a small non-traumatic haem ophorex. I'll confirm no contraindications and explore any alternatives. For consent, I'm going to explain the alternatives, complications and reasons to the patient. For preparation, I'll do this in the resource room, full non-in vasive monitoring and supplemental oxygen on the patient. I'll have an experienced nurse assistant. I'll prepare my equipment, so I'm going to do this sterile procedure with sterile gloves, gowns, drapes, appropriate hand hygiene. I'll also get my local anesthetic, my chest strain kit with an appropriate size pigtail, so 14 if small. I find ball with very small, 14 if large and make sure I've got my underwater sealed chest strain and I'll make sure that the connections are compatible. Prior to procedure, I'll do a timeout, ensure correct placement and place. For the procedure itself, sit the patient up sitting 45 degrees, locate and mark the appropriate space, triangle safety, so mid axilla line between pec major and lat delta, so 15 to costal space. I'll confirm by checking this to the mid arm point. I'll have the patient put their arm behind their head and clean and drape . Once cleaned and draped, then local anesthetic. I'm going to be, I'm going to draw back, insert, draw back, infiltrate and continue until I'm in the pleural space. Then I'm going to remove this needle, wait a few, wait five minutes and now with the introducer needle, with saline, go into the same space, aspirating continuously. Once aspirating, air, stop, take note of the depth, verbal ize depth to assistant, feed the guide wire, noting depth, remove guide needle, small cut at the side of guide wire, insert dilator, remove dilator, insert pigtail, go to depth that final fenestration is within the pleural space, noting the depth from previous, remove the guide wire, connect under water seal drain, post procedure care, so ensure the drain is worked, we've ensured that there's bubbling and swinging, secure the drain with tape plus or minus suture, confirm the placement with a chest x-ray, ongoing monitoring, I'll be asking the, to monitor for bubbling, swinging and any volume drained, as well as regular obs, hourly and then we 'll document. In terms of complications, if there's no bubbling, I'm concerned for either a blocked or disconnected tube or it could mean re-expansion of the lung , so perform a chest x-ray to confirm and re-examine the patient and the tube. If there's no swinging, again this could mean a blocked or dislodged tube or it might mean the lung has expanded, so re-chest x-ray, re-examine patient and the tube. That's it.

Teach the intern a generic approach to performing procedures.

It's helpful to have a structured approach to procedures. This is my approach. You should read widely and find your own approach . I recommend a good start is Robert and Hedges clinical procedures in emergency medicine. So first you want to confirm that it's appropriate to perform the procedure. I'll go into this. Second it's prepare to perform the procedure. Third perform the procedure and four post procedural care. So for confirming it's appropriate to perform the procedure you need to confirm the indications. Confirm that there's no indications and consent the patient explaining alternatives and complications. For preparing to perform the procedure I do the four S's of preparedness. Space, staff, stuff and systems. So space make sure you're doing in the right place. Staff make sure you know who you need so this might include an assistant or a procedural sedation, someone to perform procedural sedation. For stuff this is your equipment. This includes your own PPE, sterile gear, gloves and the procedural equipment. You should lay out your equipment in the order that you will use it. Then for systems you should make sure that you've done a timeout prior especially if the patient's going to be sed ated or this is a high-risk procedure. Then performing the procedure itself . So position the patient appropriately and perform the procedure. Then post procedural care confirm that your procedure has been successful. Then monitor for complications and manage those complications.

Outline your approach to front of neck axis.

I'll stand to the patient's left, scalpel, budgie, tube, perform a laryngeal handshake to identify the cricothyroid membrane. If I can palpate the cricothyroid membrane, I'll do a trans verse horizontal stab incision through the cricothyroid membrane. I'll turn the blade 90 degrees, aiming the sharp edge towards the feet. I'll slide the tip of the budgie into the trachea, stopping at 15, early hold up, suggesting false passive, and I'll rail raid a lubricated cuff tube into the trachea, inflate cuff, ventilate, and confirm with capnography. If I cannot palpate the cricothyroid membrane, I'll make a large vertical midline incision, blunt the section with my fingers to separate the tissues, identify and stabilize the larynx, and proceed with a horizontal cut as above.

on the steps of pericardiosynthesis.

My practice is ultrasound guided and generally using a 5 inch 18 gauge spinal needle hooked to a 60 mil syringe. I would also consider using pigtail catheter and using cell dinger technique. So I'll confirm the need, consider sedating the patient if the procedure, giving procedural sedation to the patient if the procedure is non-emergent. Sit the patient up 45 degrees. Prep the skin with chlorhexidine and sterile drapes. Under ultrasound I will identify the site for the largest area of effusion with the best view. Or my most common place will be at the left of the 4/5 intercostal space. So 4/5 intercostal lateral to the left sternal border. So I aspir ate continuously whilst advancing the needle under vision and then aspirate 50 mils of fluid. If the fluid aspirated is not bloody then I have excluded vent ricular puncture. If the blood is aspirated I would confirm placement in the per icardial space with agitated saline test before doing any sort of, before placing guide wire and inserting pigtail drain. If my aspiration is successful I would expect rapid improvement in the patient's symptoms. Bye.

Outline your steps for perimortem c-section.

Continue ACLS. Do not delay to go to theatre. You're aiming to do this at the 4 minute mark. Aseptic technique, not sterile. Use a size 10 scalpel, make a midline vertical incision from the top of the fundus to the symphys pubis. Blunt the sect to the peritoneum. Using a size 10 scalpel, make a 5cm vertical incision at the uterus. Use your fingers to lift the uterine away from the fetus, then extend the uterine incision vertically with scissors. Reach in, grasp and deliver a head or foot of the fetus, and then have external uterine pressure to help you deliver the fetus. When the baby's out, clamp the cord in two places, cut between the clamps, hand baby to the neonatal team, then deliver the placenta, then clean and pack the ut erus.

Your patient has a pneumothorax and requires a pigtail chest strain. Outline your approach.

My approach, so first confirm the needs, so pneumophoric, pleural effusion and poiema. Exclude contraindications, overlying skin infection , coagulopathy. Consent the patient, including letting them know about complications, pain, hemorrhage, neurovascular injury, infection. So for patient positioning or position the patient head up 45 degrees with their arm that we're doing the procedure at behind their head, abducted, externally rotate. Locate where we're going to put the pigt ails, so locate a safe triangle, triangle safety, so lateral to pec major, medial lat dorsi, 4/4/5 intercostal space, anterior to the mid-axillary line. To double check that we 're in the right spot, I have the patient's arm by the side and mark the mid-arm point and that's generally your best spot. So procedure itself, once we've located the space, we'll go between the ribs, so above to avoid the neurovascular bundle, inject the lignocaine to skin and within muscle and periosteum. Then using a larger needle and syringe, insert in the same track aspir ating into a withdrawal of a pleural fluid or air. Then remove that syringe and thread the guide wire through the needle, then remove the needle, use a scalpel against the guide wire, then use the dilator over the wire into the pleural space. Then remove the dilator, pass the p igtail or the catheter over the guide wire into the pleural cavity, controlling the guide wire once in or all the way, so all drainage holds within the pleural cavity. Remove the guide wire and take samples of pleural fusion and place using a skin suture, so you simply interrupt it on either side and then attaching to the drain. Then use a dress with a water permeable transparent dressing, so the insertion site is visible and connect to underwater seal drain or hump valve. Post-procedural care, make sure the valve is working, confirm placements with chest x-ray. And yeah, that's it.

Explain finger thoracostomy.

Indication, tension pneumothorax, peri arrest or arrested patient where pneumothorax is suspected. PPE on, clean double glove, locate your triangle with safety 15 to costals, clean with claw hex or similar, then with a scalpel make an incision into the chest wall following the curve of the rib force four or five centimeters, then blunt dissect with forceps into your pleura, remove the forceps, finger in sweeping to lung, confirm either blood, air or lung up, remove finger, then can apply a seal over incision with continuous monitoring or convert to chest drain.

How do you perform a beers block?

I'm going to confirm the appropriateness to do the procedure and I'll do appropriate preparation and perform the procedure. So for the appropriateness I'll confirm the indication. I'll exclude any contraindications namely hypertension, non-compliant patient, burn or crush injury to the limb. I 'll consent the patient with key concerns being failure of procedure, local anesthetic toxicity, pain, skin injury. With our alternatives being procedural sed ation, hematoma block. For my preparation I'll have this patient in a monitored resource capable cubicle. I'll require a nurse assistant. My main equipment will be cardiac monitoring, adjunctive analgesia, IV access times two, double pneumonic blood pressure cuff, a local anesthetic ideally 0.5% prilocaine given at 0.5 mils per kilo and I'll have my equipment for complications so a sodium bicarb emulsion available. And in regards to situational awareness the department must be safe as this is a potentially resource intensive procedure. For the procedure itself first thing I'll do is gain IV access to both limbs. The affected limb distal to the injury. Then I 'm going to give some adjunctive analgesia so 50 microns of fentanyl to the non- affected limb. Then we'll elevate that limb for two minutes. Then we're going to inflate the cuff 100 milligrams 100 above the systolic, maximum 300. I'll confirm that there's no radial pulse and that the patient is tolerating the cuff up. Then I'll administer 0.5 mils per kilo of 0.5% priloc aine IV and we'll then be on the affected arm. We'll be assessing for the adequacy of the block and we'll perform the manipulation. If the patient's beginning to not tolerate the proximal cuff then we can inflate the distal cuff then deflate the proximal cuff so this that area will hopefully have local anesthetic. And then 20 to 40 minutes after we've given the local anesthetic I will do a trial deflation. So deflate for five seconds then re-inflate whilst assessing for evidence of local anesthetic toxicity. If none then deflate the cuff and ongoing care will be continuing monitoring of the patient namely for anesthetic toxicity.

What is the management of a patient presenting with a spontaneous pneumothorax?

Management is based on the patient factors and pneumothorax factors. With a patient with underlying lung disease or larger or sympt omatic pneumothorax being less likely to self-resolve and require more invasive treatment. So if there's patients unstable or there's evidence of tension, immediate decompression. If the patient is stable, the two patient groups is someone with no underlying lung disease, so primary spontaneous pneumothor ax, versus someone with underlying lung disease, e.g. COPD, which is secondary pneumothorax. Then my two, when we then we group these two patients into whether or not it's large, so greater than two centimeters at the apex, or if they're symptomatic, so if they're breathless, versus if it's both small and minimal symptoms. So in starting from less severe to more severe, if it's a patient with no underlying lung disease, so primary spontaneous, no shortness of breath, then these are someone that we can observe. For instance, they could be in the ED for four hours, repeat chest x-ray and if unchanged, small or same, then discharge with strict safety netting and a repeat x-ray in two weeks. If again, if no underlying lung disease, but it's greater than two centimeters at the apex of the lung, or symptomatic, then we can aspirate versus pigtail. If they have underlying lung disease and it's small and asymptomatic, these patients I would still not do not send home and these patients need to be admitted to hospital with oxygen therapy. If they have underlying lung disease and it's a large pneum ophorex, so greater than two centimeters at the apex, and/or they're short of breath, then I would generally pigtail catheter. All patients on discharge need follow-up, so they'll need return to the hospital for worsening shortness of breath, follow-up with respiratory or GP, no air travel until fully reserved, lifelong no driving unless they've get VATS or bilateral pleurodectomy and smoking cessation. The best resource for this is BTS guidelines.

Teach your surgical airway to an advanced stage trainee who is about to go on their real rotation. They're a competent intubator but have no experience with surgical airways.

I'm going to explain my approach to surgical airway. We don't have long today, so after we speak now, I want you to review the New South Wales Emergency Institute guidelines on surgical airway. It's got a great structure and useful video. Secondly, I want you to mentally rehearse this procedure until you feel confident. And then finally, I'm keen to organise for you to give a tu te on this topic to some of our junior registrars in a few weeks. So my approach is first, I establish the indication for the surgical airway. I do my preparation before the procedure. Then we do the procedure itself. My approach being scalpel, bougie, tube. Then we move to post-procedure monitoring. So the indication is a can't-oxygenate, can't-ventilate scenario. So make sure you declare this situation to the room so that everybody's got the same shared mental model that you're performing a surgical airway. The alternatives to surgical is a needle crike if they're under 10 years old and relative contraindications include severe tracheal injuries. So my preparation for staff, you need an airway assistant. You should ideally be doing this in the resource room where you're doing the intubation, but this is a critical procedure. Your stuff or equipment is you need PPE, including your own glove, gown, surgical mask, protective airway, eyewear. Your equipment, the crucial is scalpel, bougie, lubricate, size 6 tube. The extra things you might need, you'll need is also your syringe, sutures, BVM, ventilator. In terms of systems, you should be calling for help at this point as well. So the procedure itself. So first I declare to the room that I'm performing a surgical airway now. I position the patient with neck extended. I'm right-handed, so I stand on the patient's left and I use my left hand to perform the laryngeal handshake. So you stabilize the larynx with your thumb and middle finger and then you palpate the cricofibroid membrane with your index finger of that hand. Then with your right hand, you make a horizontal incision through the cricofibroid membrane into the trachea. I turn my blade down or rotate it down so the blade is facing the patient's feet and then I'll insert a bougie and advance it 15 centimetres . If you get early hold-up, that means you've created a face- path passage. Then I railroad the lubricated size 6 tube until the cuff is inside the trachea. Do not let go of the tube. Have your assistant remove the bougie, inflate the tube and connect to oxygen, or connect to your BVM. Now your post-procedure. So you're going to handbag this patient with 100% FiO2 and you're going to confirm placement with your end-tidal CO2, chest auscultation and later a chest X-ray and you're going to secure this tube with tape plus or minus sutures. You'll do your other post-resus or post-intubation care as standard. The other things I haven't mentioned is if you're unable to identify the cricofibroid membrane, then you'll need to do a vertical incision and blunt dissection prior to your horizontal cut. To do this, you're going to make a long midline vertical incision starting from 2cm above the sternal notch and then you're going to blunt dissect down until you can palpate the larynx or trachea and perform your horizontal incision as I described earlier . (shouting)

Explain post-procedure care following a chest strain for he mo or pneumothorax. you

My goal is to confirm procedure success, seek and treat complications and ensure ongoing appropriate care and monitoring. We're going to review the patient, the equipment, ensure we've got appropriate investigations and then our miscellaneous like housekeeping, making sure appropriate drugs, documentation, disposition and patient knows what's going on. So for the patient we're going to repeat top to toe but ensuring focusing on making sure that breathing circulation is improved or unchanged and making sure that disability that they're waking up from any sedation and they've got ongoing adequate analgesia. For equipment I've start from the patient and move away so I'm going to review the chest drain itself so make sure it's adequately secured, look for any pneumothorax, look for any misting. Then I'm going to ensure that it's connected to the three-way drain correctly. If this is haem othorax I'm going to be looking in the collection drain at how much blood is drained. If one litre, over one litre, refer to cardiothoracics immediately. Then I'm going to be assessing for any swinging so we should see oscillating of the fluid in the underwater seal drain with respiration and we're also going to and if there's a pneumothorax I'll be looking for any bubbling. Then on to investigations, all these patients need a repeat chest x- ray, confirm that we're in the correct space. If there's ongoing concerns there's a role for ultrasound and CT. Then they're miscellaneous things so all of my patients I'll give them kefazolin empirically, ensure that we've documented, that we've referred on to the appropriate team and then inform the patient that's the succeeder of this procedure's success and any issues. Ongoing care, again for patient monitoring, ongoing minimal hourly SATs blood pressure, heart rate, respiration, pain score, make sure that I've got ongoing analgesia. Then we need them to, then every hour we 're going to have nursing staff assess the drain site, assess that the drain is securely attached and not obstructed, look into the collection to look at blood and what blood and fluid has been collected. For blood we need to refer to cardiothoracics for a quodamion or VAT if there's more than , after the initial drain, if there's more than 300 each hour, more than 300 after the initial drain, meals in the first hour or over 200 meals per hour for three hours in a row or one and a half days in the first 24 hours. For the underwater seal drain, the two things we think about is bubbling and we think about swinging. For bubbling we anticipate bubbling if it's a pneumothorax as the air is resolved and it may stop. If there's bubbling that then stops this means that the either there's the tube has been blocked, disconnected, obstructed or that there's resolution so we need to review the patient and repeat chest x-ray and then looking for swinging. So if it's no more, no swinging this means that it's ever the pathology is resolved or that the tube is in no longer in the pleural space so we need to reassess the patient include repeat chest x-ray. Other things of note is we need to be when thinking about transport we need to always make sure that it's a low level chest, we need to make sure that suction is turned off during transport, we should not clamp during transport but be ready to clamp if there's accidental disconnection. That is the core. Thank you.

Explain how you do a pigtail catheter. You have under one minute.

I'll confirm the indication, exclude contraindications, consent the patient. I'll perform in the recess room with full non-invasive monitoring oxygen on patient. I'll have an experienced assistant. I'll prepare my equipment, sterile equipment, so PPE, gloves, gown. I'll have my local anaesthetic, chest strain kit, underwater sealed drain. With my equipment laid out in the order I'll use it. I'll do a team timeout and I'll locate my landmark, triangle safety, position the patient 45 degrees, hand of affected side behind head, clean and drape the skin, infiltrate my local anaesthetic to the pleura, wait, insert guide needle into the same tract, then insert guide wire through the needle, then remove the guide needle. Now whilst controlling the wire, small cut to skin at the base of the wire, then insert the introducer, not going into pleura, then remove the introducer, then insert the pigtail, all fenest rations within the pleura, attach the chest strain, ensure bubbling plus swinging, then secure the tube. My other post procedure care will be a chest x-ray to confirm placement, ongoing observations of bubbling, swinging and hourly vital signs. If there's a loss of bubbling or swinging, I'll be examining the tube to exclude blockage, disconnection, making sure the patient has not clinically deteriorated and I'll also confirm with the chest x-ray that there has been lung expansion.