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Heroic Procedures in Emergency Medicine

Heroic Procedures in Emergency Medicine. Presented by Ammar Al-Kashmiri Emergency FRCP program, R IV. A “good” rule.

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Heroic Procedures in Emergency Medicine

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  1. Heroic Procedures in Emergency Medicine Presented by Ammar Al-Kashmiri Emergency FRCP program, R IV

  2. A “good” rule There are some procedures in EM that entail technical difficulty and moderate patient discomfort. Any hesitancy to perform the procedure must be put aside when it is clearly indicated. As it can be tricky knowing whether one of these procedures is truly needed, we come to rely on clinical instinct. Thus the rule, ‘think of it - do it’

  3. Case I • A 31-year-old woman brought to the ED by ambulance after being struck by a car. She was initially responsive at the scene but subsequently lost consciousness and had to be intubated. • Her exam reveals a GSC of 4. Her BP is 230/125 and HR is 60. Her pupils are unequal with a dilated and non-reactive left pupil.

  4. What’s the likely diagnosis?

  5. Epidural hematoma Diagnosis=

  6. What should you do next?

  7. Cranial trephination

  8. Pathophysiology of EDH • Approximately 70-80% of EDHs are located in the temporoparietal region where skull fractures cross the path of the middle meningeal artery or its dural branches. • Frontal and occipital EDHs each constitute about 10%, with the latter occasionally extending above and below the tentorium.

  9. Pathophysiology • Association of hematoma and skull fracture is less common in young children because of calvarial plasticity. • EDHs usually are arterial in origin but can result from venous bleeding in one third of patients.

  10. Pathophysiology • Expanding high-volume EDHs can produce a midline shift and subfalcine herniation. Compressed cerebral tissue can impinge on CN III, resulting in ipsilateral pupillary dilation and contralateral hemiparesis or extensor motor response.

  11. Pathophysiology • EDHs usually are stable, attaining maximum size within minutes of injury; progresses in 10% of patients during the first 24 hours. Rebleeding or continuous oozing presumably causes this progression.

  12. What is Kernohan’s notch syndrome?

  13. A false-localizing motor examination can be caused by compression of the contralateral cerebral peduncle against the tentorium cerebelli.

  14. Indications for trephination • Patient is herniating • All other treatments prove insufficient • Neurosurgery is unavailable • Air or ground medical transport is prolonged

  15. Equipment • Pentrator • Burr hole bit • Bone rongeur • Scalpel

  16. Procedure • A burr hole is placed on the side of the dilating pupil. • In the absence of a CT scan, the burr hole is placed 2 finger widths anterior to the tragus of the ear and 3 finger widths above the tragus of the ear.

  17. A vertical incision is made approximately 3 cm long, centred over the entry point all the way down to the temporalis muscle dividing the fibres of the muscle vertically. • The periosteum is then cut in the same manner.

  18. The outer table of the skull is drilled with the penetrator

  19. Follow with the burr hole bit and brace.

  20. The hematoma is evacuated using a soft suction tip (it can be surprisingly voluminous).

  21. If there continues to be excessive bleeding through the hole, packing the wound should be tried with Gelfoam or by cutting off a piece of temporalis muscle and stuffing it into the hole.

  22. If all else fails , a bone rongeur is used to eat away at the bone until the bleeding branch of the meningeal artery can be found and cauterized. (That is probably all the neurosurgeon would do anyway).

  23. Questions?

  24. Case II • A 37 yo man brought to the ED following an MVC. • He had suffered significant damage to the left side of his face. • On arrival, his GCS was 6. Shortly after intubation you notice the left eye is increasingly proptotic and noticeably firmer than the right. • You also find a left APD.

  25. What’s your diagnosis and what do you do next?

  26. Retrobulbar hematoma Diagnosis=

  27. L a t e r a l C a n t h o t o m o y

  28. Pathophysiology of RBH • The orbit is composed of 7 bones that enclose all but the anterior aspect. Here, the globe obstructs the opening to the bony orbit • Following trauma, the presence of hemorrhage, foreign body or edema can increase retrobulbar pressure.

  29. Pathophysiology (cont.) • The orbit compensates through proptosis, but the medial and lateral canthal tendons, which attach the eyelids to the orbital rim limit the forward movement of the globe. • As proptosis is restricted, the orbital pressure increases and impedes the optic nerve's vascular supply.

  30. Pathophysiology (cont.) • If IOP exceeds central retinal artery pressure, retinal ischemia results. In such situations, timely lateral canthotomy can save visual function

  31. Indications  • Decreased visual acuity  • Intraocular pressure > 40 mm Hg  • Proptosis • Afferent pupillary defect  • Cherry red macula  • Ophthalmoplegia  • Nerve head pallor  • Eye pain

  32. Contraindication  • Globe rupture

  33. Equipment • Hemostat or needle driver • Iris or suture scissors • Forceps

  34. The procedure • The surrounding skin is preped with NS to improve visualization and reduce the risk of infection. • If the patient is awake, an assistant should stabilize the head and maintain cervical immobilization. • The procedure is no more painful than laceration repair, however, it can be visually disturbing for the patient.

  35. Anesthetizing the lateral canthus • 1-2 cc of 1%-2% lidocaine with epinephrine is injected into the lateral canthus. • This provides both pain relief and hemostasis at the time of devascularization and incision.

  36. Devascularizing the lateral canthus • A hemostat or needle driver is applied from the lateral canthus towards the bony orbit to devascularize the area for 30-90 seconds.

  37. Incising the lateral canthus • The instrument is then removed and the demarcated area is cut laterally 1-2 cm in length

  38. Cutting the inferior lateral canthal tendon • Using the forceps, the lower lid is pulled down to visualize the inferior lateral canthal tendon which is then cut.

  39. After the inferior canthal tendon has been cut, intraocular pressure is reassessed with a tonometer. • If IOP remains >40 mm Hg, then decompression is inadequate. The upper lid should be lifted and the superior lateral canthal tendon should be severed.

  40. Questions?

  41. Case III • 48 yo male transferred from MCH to MGH where he presented with a stab wound to zone III of the neck. • On arrrival, GCS 15, stable BP with no active bleeding from wound. • After coming back from CTA neck, patient coughs and starts bleeding from wound. • RSI attempted but fails. Patient develops a large expanding hematoma and his SpO2 is dropping to 60s.

  42. What is the immediate management of this patient?

  43. Surgical Cricothyrotomy

  44. Indications • Failure of oral or nasal endotracheal intubation • Massive oral, nasal, or pharyngeal hemorrhage • Massive regurgitation or emesis • Masseter spasm or clenched teeth   • Structural deformities of oropharynx

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