CRITICAL CARE TIPS & TRICKSDr. Matthew Inwood

Disclosures None

Objectives

Identify & discuss procedural techniques and therapeutic modalities to improve quality of care & patient safety when caring for the critically ill.

Identify & discuss therapeutic modalities to improve efficiency & optimise resource utilisation in the Emergency Department.

Case #1

38 y.o male, found unresponsive at the bus station, with an empty oxycontin Rx container in his hand.

Pin-point pupils, SaO2 94%, GCS 11.

Case #1 Re-assessed 60 minutes later…

SaO2 90%, occasional desats & apneic periods

GCS 8 PCO2 95 & pH 7.10 on VBG

How do you treat this patient’s toxidrome?

Case #1 IV naloxone can precipitate a life-

threatening withdrawal reaction

IV access can be difficult

Needles convey a risk of exposure to blood bourne pathogens

Case #1 Nebulised Naloxone!

Case #1 Nebulised Naloxone, cont’d…

Weber et al, Pre-hospital Emergency Care 16: 2012

-105 patients

22%, complete response

59%, partial response

19%, no response

Case #1 Nebulised Naloxone, cont’d…

How many doses are required?

Weber et al, 10% of patients required IV rescue dose

Baumann et al, 40% of patients required > 1 dose

Case #1 Nebulised Naloxone, cont’d…

My Experience & Advice 2mg of naloxone & 3cc of normal saline

“Stimulate” patient to breathe

Allow patients to self titrate their medication

How much Naloxone do you have in your department?

Case #2 28 year old male.

MVC. Ejected from vehicle at 120 km/h

Arrives intubated, doesn’t move extremities

HR 65, BP 89/60

Case #2

Case #2

Case #2 Guide Wire J-Tip Orientation:

Tripathi et al, Anesthesia & Analgesia 2005; 100: 21-4

Case #2 Guide Wire J-Tip Orientation:

Case #2 The “Ambesh” Maneuver:

Manual occlusion of the ipsilateral Internal Jugular vein at the supraclavicular fossa.

Case #2

Case #2

Case #3 18 year old male, right sided thoracic

stab wound.

Deviated trachea, shallow resps, absent right breath sounds.

Case #3 Are you in the right place?

Ferrie et al, Emerg Med J 2005;22:788–789

Case #3

Case #3 Is your patient too thick or your needle

too short?

Case #3

Case #3 Is your patient too thick or your needle

too short? Zengerink et al 2008

Retrospective review of Chest CTs for blunt trauma

Measured distance from skin to pleura at 2nd ICS, MCL

Mean CWT = 3.51cm right, 3.5cm left

19% of men had CWT > 4.5cm

35.4% of women had CWT > 4.5cm

Case #3 Is there a preferred alternate site of

Needle Thoracostomy?

Inaba et al, 2011 Cadaver study. Needle thoracostomy at 2

different sites Does a lateral approach lead to more

successful placement?

Case #32nd ICS MCL

5th ICS MAL

Case #3 Is there a preferred alternate site of Needle

Thoracostomy? Inaba et al, 2012

Step-wise increase in CWT across all BMI quartiles @ each location

CWT was less at 5th ICS

42.5% of patients had CWT >4.5CM @ MCL, & 16.7% @ 5th ICS

Case #4 56 year old obese male, collapsed and

seized at a shopping mall food court.

Arrives in your ED GCS 3, sonorous resps and vomiting

Despite your best efforts, this patient desats before you can pass the ET tube

Case #4

Case #4

Case #4

Case #4

Case #4

Case #4

High Flow Apneic Oxygenation How Does it Work? Complications?

Case #4

Questions?