|
|
Click to set custom HTML
|
Emergency Strategy - General Facts ( Summary)
Triage
There are three different level of triage which are categorized based on the patient clinical appearance, history,physical examination, vital signs and mental status.
Triage is a brief clinical assessment of the patient in the emergency department.Patient in waiting area should be checked every 2 hours.
Priority 1
Also known as life threatening emergency. These includes cardiac arrest, major trauma, hypotension hematemesis,sudden loss of consciousness, major trauma, acute chest pain and seizures.Patient may look sick, poorly perfused and dehydrated. The patient may be unable to walk with altered mental status ( diabetic ketoacidosis/subdural hematoma) and fluctuating vital signs e.g high respiratory rates).
Priority II
Also known as potentially life threatening emergency. There might be a danger to the life or limb. These include large laceration, pain in the abdomen, high fever and dyspnea. 10 minutes may be required for the patient to arrive and perform full evaluation and assessment of the patient.
Priority III
Also known as non life threatening emergency.These include blood pressure check, mild cases of sore throat, mild adult upper respiratory tract infection, skins disorders ( chronic or self limiting disorders)
Patient's handling
For invasive procedure, remember to use gloves. Intramuscular injection is avoided in any patient with clotting abnormalities or suspected bleeding.
Patient who suffer from sepsis , renal failure or shock may require urinary bladder catheterization.
All patient especially the one who need resuscitation need to be monitored. The vital signs such as blood pressure, pulses, heart rates are important and need to be monitored.
The eyes of a comatose patient need to be closed with adhesive tape across the eyelid.
Blood sugar is considered if patient is suspected to suffer from multi organ failure, diabetes or sepsis.
Traumatic patient
Protective eye wear, mask, apron, gown and googles are worn in case of bodily fluid spill. Gloves need to be worn while handling and cleaning the laboratory samples.
All the equipments are cleaned and disinfect with 2 % of glutaraldehyde or 1 % sodium hypochlorite.
Hand washing facilities, disposable gloves and biohazard sharp container should be available in patient care areas.
The floor of resuscitation room need to be moped after every case of trauma with 8% of lysol.
Sharp container is useful for disposal of razors, cannula stylets, scalpel bladders and disposable needle.
Contagious and infectious disease
Gloves need to be worn while handling skin infections and wounds.
Wound need to be dressed before transfering the patient .
Impervious apron is used in case of soiling for cholera or acute gastroenteritis.
Wear a face mask if the patient tend to cough in case of pulmonary tuberculosis. The surgical room need to be fumigate in cases of patient presenting with tetanus, gas gangrene or spores of thorax.
Pulse oximetry
Pulse oximeter is useful in detecting the oxygenation of the blood hemoglobin.
The normal value for the oxygenation of the hemoglobin is around 96% - 99%.
The used of pulse oximeter is limited by the present of anemia, movement, inadequate nail polish, venous congestion, methamoglobinemia and carboxyhemoglobin as well as hypothermia or shock ( vasoconstriction of the blood vessel).
There are three different level of triage which are categorized based on the patient clinical appearance, history,physical examination, vital signs and mental status.
Triage is a brief clinical assessment of the patient in the emergency department.Patient in waiting area should be checked every 2 hours.
Priority 1
Also known as life threatening emergency. These includes cardiac arrest, major trauma, hypotension hematemesis,sudden loss of consciousness, major trauma, acute chest pain and seizures.Patient may look sick, poorly perfused and dehydrated. The patient may be unable to walk with altered mental status ( diabetic ketoacidosis/subdural hematoma) and fluctuating vital signs e.g high respiratory rates).
Priority II
Also known as potentially life threatening emergency. There might be a danger to the life or limb. These include large laceration, pain in the abdomen, high fever and dyspnea. 10 minutes may be required for the patient to arrive and perform full evaluation and assessment of the patient.
Priority III
Also known as non life threatening emergency.These include blood pressure check, mild cases of sore throat, mild adult upper respiratory tract infection, skins disorders ( chronic or self limiting disorders)
Patient's handling
For invasive procedure, remember to use gloves. Intramuscular injection is avoided in any patient with clotting abnormalities or suspected bleeding.
Patient who suffer from sepsis , renal failure or shock may require urinary bladder catheterization.
All patient especially the one who need resuscitation need to be monitored. The vital signs such as blood pressure, pulses, heart rates are important and need to be monitored.
The eyes of a comatose patient need to be closed with adhesive tape across the eyelid.
Blood sugar is considered if patient is suspected to suffer from multi organ failure, diabetes or sepsis.
Traumatic patient
Protective eye wear, mask, apron, gown and googles are worn in case of bodily fluid spill. Gloves need to be worn while handling and cleaning the laboratory samples.
All the equipments are cleaned and disinfect with 2 % of glutaraldehyde or 1 % sodium hypochlorite.
Hand washing facilities, disposable gloves and biohazard sharp container should be available in patient care areas.
The floor of resuscitation room need to be moped after every case of trauma with 8% of lysol.
Sharp container is useful for disposal of razors, cannula stylets, scalpel bladders and disposable needle.
Contagious and infectious disease
Gloves need to be worn while handling skin infections and wounds.
Wound need to be dressed before transfering the patient .
Impervious apron is used in case of soiling for cholera or acute gastroenteritis.
Wear a face mask if the patient tend to cough in case of pulmonary tuberculosis. The surgical room need to be fumigate in cases of patient presenting with tetanus, gas gangrene or spores of thorax.
Pulse oximetry
Pulse oximeter is useful in detecting the oxygenation of the blood hemoglobin.
The normal value for the oxygenation of the hemoglobin is around 96% - 99%.
The used of pulse oximeter is limited by the present of anemia, movement, inadequate nail polish, venous congestion, methamoglobinemia and carboxyhemoglobin as well as hypothermia or shock ( vasoconstriction of the blood vessel).
Assisted ventilatory support
Oxygen supplied is considered in cases where the patient is unable to breath normally as the amount of oxygen is inadequate or poor respiratory effect/inadequate ventilation.
There are two from of ventilatory support such as supplemental oxygen therapy or mechanical ventilator support.
Supplemental oxygen is given by mask ( 6-8 liters per min/60% of oxygen ), mask with bag of reservoir (80% of oxygen) or nasal pong ( 2 - 3 liters per min/30%) and venturi devices.
Venturi devices are color coded so that different FiO2 ( fraction of inspired oxygen) can be given based on the color of venturi devices.
Non invasive ventilation may be useful in cases of acute severe asthma, chronic obstructive pulmonary disease, palliative care, flail chest, fracture of the ribs, trauma to the chest, community acquired pneumonia, community acquired pneumonia and acute cases of cardiogenic pneumonia.
Non invasive ventilation is considered as it will reduce the risk of mortality and morbidity, does not require any relaxation or sedation, reduce the risk of developing nosocomial infection, preventing admission to ICU and provides as an excellent alternative to invasive intervention/intubation as well as immediate availability of support system
However, non invasive ventilation is contraindicated in cases of vomiting, respiratory arrest, glasgow coma scale less than 8, copious respiratory secretion and uncooperative patient. Patient may also feel uncomfortable with unprotected airway and patient need to be compliance.
Before beginning non invasive ventilation, make sure the patient is hemodynamically stable, awake with GSC more than 8 and explain the need for a tight fitting mask which is uncomfortable.
Positive end expiratory pressure of 5 cm H20 is the initial dose which later increase up to 15 cm with 2.5 cm increase every 30 minutes. Observe for any drop in blood pressure.Dyspnea may be relieved after 1 hour.
Haloperidol 2.5- 5 mg is considered only if the patient is restless and intubation is avoided.
Mechanical ventilation
Analysis by arterial blood gas is considered.
The tidal volume is set to 6ml/kg of body weight. The partial pressure of oxygen should be more than 75mmHg with less than 40mmHg of partial pressure of carbon dioxide.
The ventilators are able of automatic adjustment in case the tidal volume and respiratory volume are set. In asthmatic patient make sure that the more than 4 seconds are required for expiratory time.
The positive end expiratory volume is set at 5- 15 cm H20. The pressure is set to be less than 30mmHg.
The procedure may be repeated after 1 hour following resetting.
Ventilators are useful to humidify the gas to prevent dehydration.
Why do we require mechanical ventilation:
Mechanical ventilation is useful to avoid any damage to the lung parenchymal form high volume or pressure, It is also acts as an alternative if there is a failure in supplemental oxygen therapy. Mechanical ventilation may maintain the integrity and hygiene of the bronchial system and facilitating ventilation in case the patient develop reduction in lung compliance. Mechanical ventilation may guarantee optimum perfusion of the vital organ as well as useful in patient who develop respiratory fatigue.
The common mechanical ventilation is synchronized intermittent mandatory ventilation and pressure support which provide optimum fraction of inspired oxygen.
Intravenous access
Peripheral vein
In children peripheral veins include ankle veins and scalp veins.
In adult, peripheral veins include femoral vein, external jugular vein, ante - cubital vein and vein on the dorsum of the hand.
In children more than 2 months, fourth interdigital vein at the back of the hand and ante cubital fossa vein may also be tried.
21G to 23 G butterfly needle is used to cannulate the veins.
Tourniquet is used to occlude the sites/vein which is proximal to the sites of puncture.
The skin is cleaned with povidone iodine.
The needle/cannula is later introduce to the vein. The needle/cannula is later fixed with tape securely.
0.5 ml of heparin solution is considered to be injected if the cannula is used for intermittent delivery of IV drugs.
The cannula should be placed securely. Splint may required ( wrist slightly flexed and elbow extended) to limit the movement of the neighboring joints.
Scalp vein cannulation
Commonly useful in infant. It involves the auricular vein, temporal posterior and femoral superficial veins.
The affected area will be shave with povidone iodine and spirit. Tourniquet is used to occlude the vein proximal to the sites of fracture.
Flowing of the blood slowly through the tubing while performing venous cannulation means that the needle is in a correct position. The needle is then secured by using adhesive tape.
If there is a pulsatile spurting of the blood withdrawn the needle as the needle might hit the artery. Th bleeding need to be stopped by applying pressure.
It is important to differentiate between artery and vein as artery usual pulsatile in nature ( identified by palpation).
Femoral vein
1% of lignocaine is infiltrated. The patient hip joint is abducted and externally rotated while the knee is in a flexing position.
Patient need to lie supine with elevation of buttocks. Drape is required and skin is cleaned with povidone iodine.
The femoral vein lies medial to femoral artery. Femoral artery located below the inguinal ligament in the middle of the femoral triangle . The needle/cannula is introduced with 1- 2cm distal to the inguinal ligamet, 10 -20 degree to the skin and 0.5 cm to 1cm medial to femoral artery.
If the needle hit the femoral vein, blood will flow to the syringe.The cannula is anchored by non absorbable suture . Sterile occlusive dressing is applied. The leg should be immobile during the infusion.
The leg is splint to avoid flexion of the hip. The cannula will be dislodge by flexing of the hip.
External jugular vein
Patient is asked to turn into one side. The head need to be lowered down than the body. The patient need to be turn away from the site of puncture. 15 - 30 degree head down position is required.
Drape is required ( sterile procedure). Skin need to be cleaned with povidone iodine. The external jugular vein is identified as it passes over the sternomastoid muscles at the junction of the first middle and lower third towards the clavicle and supraclavicular fossa.
The needle is inserted and pointed in the direction of the clavicle.
If access and infusion through veins are failed, consider intra osseous infusion or venous cut down.
Intra osseous infusion
Intra osseous infusion is an alternative if cannulation through peripheral vein is impossible. It is contraindicated if there is a fracture of the bone or there is a signs of infection at the puncture sites.
It is a painful procedure. However, it is safe, reliable, simple and fast ( it takes less than 3 minutes to perform). Intra osseous infusion is important for almost all parenteral drugs and fluids.
Commonly intra osseous infusion may present a few complications.
The common complication include the calf which become tenses as the penetration of the posterior bony cortex occur. Index finger need to be applied against the skin to prevent deep penetration.
These include infection such as osteomyelitis or cellulitis which may occur if the infusion is left for more than 24 hours. In this case, the needle is removed and antibiotic is given.
The needle may not fully penetrating the bony cortex/ not properly fixed.. In this case the needle of the intra osseous need to be advanced further or the infiltration may just occur under the skin.
Certain drugs such as calcium chloride, adrenaline and sodium bicarbonate may lead to sloughing of the skin which later lead to necrosis of the skin when the drugs are administered by intra osseous infusion. The infusion need to be stop.
The intra osseous line need to e flushed by 5 ml of normal saline in case of blocking by marrow.
The procedure includes cleaning the skin with povidone iodine and drapes. The common site that is used include the middle of the antero- medial surface of the tibia which is 2cm below the tibial tuberosity ( proximal tibial). Consider insertion into 2cm above lateral condyle distal to the femur.
The heel need to be resting on the table and the knee need to achieve 30 degree angulation which can be achieved by placing padding under the knee.
One hand is used to hold the knee and thigh with fingers are used to wrapped around the knee. The aim of this action is to stabilize the proximal tibia.
The sites of cannulation is 2 cm medial and below the tibial tuberosity. tibial tuberosity is an important indication and need to be palpate to feel it.
The bevel of the intra osseous needle is inserted with 90 degree angle towards the foot. Besides intra osseous needle consider other alternative such as butterfly needle, large bore hypodermic needle and bone marrow aspiration needle.
Twisting /drilling motion is used to advance the needle gently but firm. The advancing of the needle need to be stop after a sudden decrease in resistance is felt.
The stylet is removed and 5ml syringe is used to aspirate the marrow contents just to confirm the placement of the needle in marrow cavity. Before starting the infusion, consider the administration of 3 ml of normal saline via syringe. Make sure no infiltration present.
Make sure that the infiltration/ swollen of the calf muscle is not present during infusion. Good clinical response and ease of fluid administered are an indication of the good infusion technique. If we managed to get peripheral veins and central veins stop intra osseous infusion ( not to continue after 8 hours).
Venous cut down
Venous cut down is considered as another alternative venous cannulation for infusion. Venous cut down is a second alternative after intra osseous infusion as intra osseous infusion is the first alternative due to its rapid and simple procedure.
The steps to perform venous cut down include infiltration of 1% lidocaine which follow later by draping and applying povidone iodine to cleanse the skin.
Make sure we manage to find the correct vein. The vein is a long saphenous vein which is 1- 2 cm anterior and superior to medial malleolus.
The step include incising the skin to a perpendicular direction to the vein. The hemostat forceps are useful to dissect the subcutaneous tissue.
The proximal and distal ligature are useful as to tie off the distal end of the vein (distal ligature) and to secure the cannula in place ( proximal ligature). Long saphenous vein is cut using a fine tipped scissors by making a v shaped cut.
The lumen of the vein is dilated using the vein dilator. The cannula will be inserted to the vein .
The cannula is flushed with the normal saline to make sure a normal flow of the fluid . The distal ligature is tied around the catheter. Interrupted sutures are useful to close the skin incision and finally cover with sterile dressing.
General fact about cannulation
Ante cubital vein cannulation with 16G needle should be avoided in case of chronic renal failure.
CVP or central venous pressure monitoring is useful in hypotensive patient with no evidence of hypovolemic shock.
Generally all patient will require cannulation at the dorsum of the hand in case of achieving intravenous access.
Oxygen supplied is considered in cases where the patient is unable to breath normally as the amount of oxygen is inadequate or poor respiratory effect/inadequate ventilation.
There are two from of ventilatory support such as supplemental oxygen therapy or mechanical ventilator support.
Supplemental oxygen is given by mask ( 6-8 liters per min/60% of oxygen ), mask with bag of reservoir (80% of oxygen) or nasal pong ( 2 - 3 liters per min/30%) and venturi devices.
Venturi devices are color coded so that different FiO2 ( fraction of inspired oxygen) can be given based on the color of venturi devices.
Non invasive ventilation may be useful in cases of acute severe asthma, chronic obstructive pulmonary disease, palliative care, flail chest, fracture of the ribs, trauma to the chest, community acquired pneumonia, community acquired pneumonia and acute cases of cardiogenic pneumonia.
Non invasive ventilation is considered as it will reduce the risk of mortality and morbidity, does not require any relaxation or sedation, reduce the risk of developing nosocomial infection, preventing admission to ICU and provides as an excellent alternative to invasive intervention/intubation as well as immediate availability of support system
However, non invasive ventilation is contraindicated in cases of vomiting, respiratory arrest, glasgow coma scale less than 8, copious respiratory secretion and uncooperative patient. Patient may also feel uncomfortable with unprotected airway and patient need to be compliance.
Before beginning non invasive ventilation, make sure the patient is hemodynamically stable, awake with GSC more than 8 and explain the need for a tight fitting mask which is uncomfortable.
Positive end expiratory pressure of 5 cm H20 is the initial dose which later increase up to 15 cm with 2.5 cm increase every 30 minutes. Observe for any drop in blood pressure.Dyspnea may be relieved after 1 hour.
Haloperidol 2.5- 5 mg is considered only if the patient is restless and intubation is avoided.
Mechanical ventilation
Analysis by arterial blood gas is considered.
The tidal volume is set to 6ml/kg of body weight. The partial pressure of oxygen should be more than 75mmHg with less than 40mmHg of partial pressure of carbon dioxide.
The ventilators are able of automatic adjustment in case the tidal volume and respiratory volume are set. In asthmatic patient make sure that the more than 4 seconds are required for expiratory time.
The positive end expiratory volume is set at 5- 15 cm H20. The pressure is set to be less than 30mmHg.
The procedure may be repeated after 1 hour following resetting.
Ventilators are useful to humidify the gas to prevent dehydration.
Why do we require mechanical ventilation:
Mechanical ventilation is useful to avoid any damage to the lung parenchymal form high volume or pressure, It is also acts as an alternative if there is a failure in supplemental oxygen therapy. Mechanical ventilation may maintain the integrity and hygiene of the bronchial system and facilitating ventilation in case the patient develop reduction in lung compliance. Mechanical ventilation may guarantee optimum perfusion of the vital organ as well as useful in patient who develop respiratory fatigue.
The common mechanical ventilation is synchronized intermittent mandatory ventilation and pressure support which provide optimum fraction of inspired oxygen.
Intravenous access
Peripheral vein
In children peripheral veins include ankle veins and scalp veins.
In adult, peripheral veins include femoral vein, external jugular vein, ante - cubital vein and vein on the dorsum of the hand.
In children more than 2 months, fourth interdigital vein at the back of the hand and ante cubital fossa vein may also be tried.
21G to 23 G butterfly needle is used to cannulate the veins.
Tourniquet is used to occlude the sites/vein which is proximal to the sites of puncture.
The skin is cleaned with povidone iodine.
The needle/cannula is later introduce to the vein. The needle/cannula is later fixed with tape securely.
0.5 ml of heparin solution is considered to be injected if the cannula is used for intermittent delivery of IV drugs.
The cannula should be placed securely. Splint may required ( wrist slightly flexed and elbow extended) to limit the movement of the neighboring joints.
Scalp vein cannulation
Commonly useful in infant. It involves the auricular vein, temporal posterior and femoral superficial veins.
The affected area will be shave with povidone iodine and spirit. Tourniquet is used to occlude the vein proximal to the sites of fracture.
Flowing of the blood slowly through the tubing while performing venous cannulation means that the needle is in a correct position. The needle is then secured by using adhesive tape.
If there is a pulsatile spurting of the blood withdrawn the needle as the needle might hit the artery. Th bleeding need to be stopped by applying pressure.
It is important to differentiate between artery and vein as artery usual pulsatile in nature ( identified by palpation).
Femoral vein
1% of lignocaine is infiltrated. The patient hip joint is abducted and externally rotated while the knee is in a flexing position.
Patient need to lie supine with elevation of buttocks. Drape is required and skin is cleaned with povidone iodine.
The femoral vein lies medial to femoral artery. Femoral artery located below the inguinal ligament in the middle of the femoral triangle . The needle/cannula is introduced with 1- 2cm distal to the inguinal ligamet, 10 -20 degree to the skin and 0.5 cm to 1cm medial to femoral artery.
If the needle hit the femoral vein, blood will flow to the syringe.The cannula is anchored by non absorbable suture . Sterile occlusive dressing is applied. The leg should be immobile during the infusion.
The leg is splint to avoid flexion of the hip. The cannula will be dislodge by flexing of the hip.
External jugular vein
Patient is asked to turn into one side. The head need to be lowered down than the body. The patient need to be turn away from the site of puncture. 15 - 30 degree head down position is required.
Drape is required ( sterile procedure). Skin need to be cleaned with povidone iodine. The external jugular vein is identified as it passes over the sternomastoid muscles at the junction of the first middle and lower third towards the clavicle and supraclavicular fossa.
The needle is inserted and pointed in the direction of the clavicle.
If access and infusion through veins are failed, consider intra osseous infusion or venous cut down.
Intra osseous infusion
Intra osseous infusion is an alternative if cannulation through peripheral vein is impossible. It is contraindicated if there is a fracture of the bone or there is a signs of infection at the puncture sites.
It is a painful procedure. However, it is safe, reliable, simple and fast ( it takes less than 3 minutes to perform). Intra osseous infusion is important for almost all parenteral drugs and fluids.
Commonly intra osseous infusion may present a few complications.
The common complication include the calf which become tenses as the penetration of the posterior bony cortex occur. Index finger need to be applied against the skin to prevent deep penetration.
These include infection such as osteomyelitis or cellulitis which may occur if the infusion is left for more than 24 hours. In this case, the needle is removed and antibiotic is given.
The needle may not fully penetrating the bony cortex/ not properly fixed.. In this case the needle of the intra osseous need to be advanced further or the infiltration may just occur under the skin.
Certain drugs such as calcium chloride, adrenaline and sodium bicarbonate may lead to sloughing of the skin which later lead to necrosis of the skin when the drugs are administered by intra osseous infusion. The infusion need to be stop.
The intra osseous line need to e flushed by 5 ml of normal saline in case of blocking by marrow.
The procedure includes cleaning the skin with povidone iodine and drapes. The common site that is used include the middle of the antero- medial surface of the tibia which is 2cm below the tibial tuberosity ( proximal tibial). Consider insertion into 2cm above lateral condyle distal to the femur.
The heel need to be resting on the table and the knee need to achieve 30 degree angulation which can be achieved by placing padding under the knee.
One hand is used to hold the knee and thigh with fingers are used to wrapped around the knee. The aim of this action is to stabilize the proximal tibia.
The sites of cannulation is 2 cm medial and below the tibial tuberosity. tibial tuberosity is an important indication and need to be palpate to feel it.
The bevel of the intra osseous needle is inserted with 90 degree angle towards the foot. Besides intra osseous needle consider other alternative such as butterfly needle, large bore hypodermic needle and bone marrow aspiration needle.
Twisting /drilling motion is used to advance the needle gently but firm. The advancing of the needle need to be stop after a sudden decrease in resistance is felt.
The stylet is removed and 5ml syringe is used to aspirate the marrow contents just to confirm the placement of the needle in marrow cavity. Before starting the infusion, consider the administration of 3 ml of normal saline via syringe. Make sure no infiltration present.
Make sure that the infiltration/ swollen of the calf muscle is not present during infusion. Good clinical response and ease of fluid administered are an indication of the good infusion technique. If we managed to get peripheral veins and central veins stop intra osseous infusion ( not to continue after 8 hours).
Venous cut down
Venous cut down is considered as another alternative venous cannulation for infusion. Venous cut down is a second alternative after intra osseous infusion as intra osseous infusion is the first alternative due to its rapid and simple procedure.
The steps to perform venous cut down include infiltration of 1% lidocaine which follow later by draping and applying povidone iodine to cleanse the skin.
Make sure we manage to find the correct vein. The vein is a long saphenous vein which is 1- 2 cm anterior and superior to medial malleolus.
The step include incising the skin to a perpendicular direction to the vein. The hemostat forceps are useful to dissect the subcutaneous tissue.
The proximal and distal ligature are useful as to tie off the distal end of the vein (distal ligature) and to secure the cannula in place ( proximal ligature). Long saphenous vein is cut using a fine tipped scissors by making a v shaped cut.
The lumen of the vein is dilated using the vein dilator. The cannula will be inserted to the vein .
The cannula is flushed with the normal saline to make sure a normal flow of the fluid . The distal ligature is tied around the catheter. Interrupted sutures are useful to close the skin incision and finally cover with sterile dressing.
General fact about cannulation
Ante cubital vein cannulation with 16G needle should be avoided in case of chronic renal failure.
CVP or central venous pressure monitoring is useful in hypotensive patient with no evidence of hypovolemic shock.
Generally all patient will require cannulation at the dorsum of the hand in case of achieving intravenous access.
