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Emergency procedures

OXYGEN SUPPLEMENTATION

  • Reliable oxygen supply is essential for anaesthesia or any seriously ill patient
  • Oxygen concentrators are the most suitable, economical way to provide oxygen; few cylinders in case of power failure
  • Whichever source of oxygen, an effective system is needed for maintenance and repairs
  • Clinical staff need training in how to use oxygen safely, effectively, economically
Cylinder System Oxygen Concentrator
  • Inexpensive to buy
  • More expensive to buy
  • Expensive to operate
  • Inexpensive to operate
  • Needs year-round supply of cylinders
  • Requires only electricity
  • Training and maintenance needed
  • Training and maintenance needed
  • Can store oxygen
  • Cannot store oxygen; provides only when power supply is on
  • Start oxygen at 5 L/min
  • If no improvement, increase to:
      - 6-10 L/min via facemask or
      - 10-15 L/min via facemask with reservoir
  • When improving, titrate down 1-2 L/min, allowing at least 2-3 minutes to evaluate effect.
  • Strive to maintain saturation >90%

INTRAVENOUS ACCESS

  • Cannula should be placed in arm vein, not over joint, easy fixation. Comfortable and convenient for drug administration and care
  • Best veins in emergencies:
      - Antecubital fossa
      - Femoral
      - External jugular
  • Do not attempt subclavian vein due to high risk of pleural puncture
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Superficial veins

INTRAVENOUS ACCESS: Central veins

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Femoral vein

  • If right handed, stand on patient’s right, palpate femoral artery
  • Prep area carefully; site is contaminated
  • Use a 14, 16 or 18 G (20 G in child) cannula mounted on 5 ml syringe
  • Avoid injured extremities, if possible

VENOUS CUTDOWN

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  • Equipment
      - Small scalpel
      - Artery forceps
      - Scissors
      - Large catheter (or sterile infant feeding tube)
  • Transverse incision 2 finger breadths above, anterior to medial malleolus (A); (use patient's own finger breadths to define incision)
  • Place two sutures under vein (B)
  • Once catheter in place, tie sutures (C)
  • Use closing sutures to secure catheter

FLUIDS AND MEDICINES

  • Avoid fluids containing dextrose during resuscitation
  • Use Saline or Ringer's lactate
  • For shocked patient: give fluids as fast as drip runs until blood pressure responds
  • May need a pressure infusion bag to push fluids
  • Monitor response carefully; look at vital signs, urine output
  • Always give medicines intravenously during resuscitation

SURGICAL CRICOTHYROIDOTOMY

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  • Hyperextend neck, if possible
  • Identify groove between cricoid and thyroid cartilages just below "Adam's apple"
  • Clean area, infiltrate with local anaesthetic
  • Incise through skin vertically, use blunt dissection to clearly see membrane between thyroid and cricoid
  • Using small scalpel, stab through membrane into trachea
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  • Rotate blade, use curved forceps to widen opening
  • Pass thin introducer or nasogastric tube into trachea if small access
  • Run #4-6 size endotracheal tube over introducer, pass into trachea (D)
  • Remove introducer, if used

Do not attempt surgical cricothyroidotomy in children < 10 years

LARGE NEEDLE CRICOTHYROIDOTOMY

Module1_28 - Puncture the crico-thyroid membrane with a large bore catheter attached to syringe filled with water or saline.
- Aspirate as you insert. When entering the trachea, air bubbles will appear in the syringe.
- Advance the catheter and retract the needle
- Secure the catheter
- Connect the catheter to oxygen source, set to 15 L/min
- Use I:E ration 1:4 sec (Inspiration:Expiration ratio)
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