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Slide 1 - Heroic Procedures in Emergency Medicine Presented by Ammar Al-Kashmiri Emergency FRCP program, R IV
Slide 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’
Slide 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.
Slide 4 - What’s the likely diagnosis?
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Slide 6 - Epidural hematoma Diagnosis=
Slide 7 - What should you do next?
Slide 8 - Cranial trephination
Slide 9 - 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.
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Slide 11 - 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.
Slide 12 - 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.
Slide 13 - 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.
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Slide 15 - What is Kernohan’s notch syndrome?
Slide 16 - A false-localizing motor examination can be caused by compression of the contralateral cerebral peduncle against the tentorium cerebelli.
Slide 17 - Indications for trephination Patient is herniating All other treatments prove insufficient Neurosurgery is unavailable Air or ground medical transport is prolonged
Slide 18 - Equipment Pentrator Burr hole bit Bone rongeur Scalpel
Slide 19 - 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.
Slide 20 - 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.
Slide 21 - The outer table of the skull is drilled with the penetrator
Slide 22 - Follow with the burr hole bit and brace.
Slide 23 - The hematoma is evacuated using a soft suction tip (it can be surprisingly voluminous).
Slide 24 - 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.
Slide 25 - 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).
Slide 26 - Questions?
Slide 27 - 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.
Slide 28 - What’s your diagnosis and what do you do next?
Slide 29 - Retrobulbar hematoma Diagnosis=
Slide 30 - L a t e r a l C a n t h o t o m o y
Slide 31 - 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.
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Slide 33 - 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.
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Slide 35 - Pathophysiology (cont.) If IOP exceeds central retinal artery pressure, retinal ischemia results. In such situations, timely lateral canthotomy can save visual function
Slide 36 - Indications  Decreased visual acuity  Intraocular pressure > 40 mm Hg  Proptosis Afferent pupillary defect  Cherry red macula  Ophthalmoplegia  Nerve head pallor  Eye pain
Slide 37 - Contraindication  Globe rupture
Slide 38 - Equipment Hemostat or needle driver Iris or suture scissors Forceps
Slide 39 - 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.
Slide 40 - 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.
Slide 41 - 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.
Slide 42 - Incising the lateral canthus The instrument is then removed and the demarcated area is cut laterally 1-2 cm in length
Slide 43 - 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.
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Slide 45 - 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.
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Slide 48 - Questions?
Slide 49 - 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.
Slide 50 - What is the immediate management of this patient?
Slide 51 - Surgical Cricothyrotomy
Slide 52 - 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
Slide 53 - Indications AW obstruction Oropharyngeal edema Mass effect (cancer, tumor, polyp, web, or other mass)  Foreign body  Laryngospasm
Slide 54 - Indications Traumatic injuries making oral or nasal endotracheal intubation difficult or potentially hazardous      Cervical spine instability
Slide 55 - Contraindications (relative) Age less than 8 Anterior neck hematoma Previous cricothyrotomy Tracheal tumor or mass Coagulopathy
Slide 56 - Equipment Scalpel with No. 11 blade Tracheal hook Tracheal dilator No. 4 or 5 Shiley cuffed tracheostomy tube with introducer and riser
Slide 57 - Hyperextend the head to identify anatomy and control cricoid space. As a guide, a 20 ga needle can be inserted through the membrane with aspiration of air to confirm entry (optional). The larynx is stabilized by holding it between the non-dominant thumb and middle finger. The Procedure
Slide 58 - A vertical incision is made after puncture through the membrane The Procedure
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Slide 62 - The opening is widened by insertion of the scalpel handle and rotating it 90 degrees.
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Slide 65 - Alternate method
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Slide 67 - Complications Thyroid gland damage Large vessel injury with hemorrhage Esophageal damage Infection Aspiration
Slide 68 - Vertical or horizontal incision? Horizontal incision increases risk of tube misplacement Does not allow extension of incision if more exposure needed Increases risk of lacerating neck vessels with resulting hemorrhage
Slide 69 - Questions?
Slide 70 - Case IV 29 yo female G1P0, 34 wks pregnant, presents with chest pain. As you are interviewing the patient she suddenly collapses and is found to be in PEA. CPR is commenced.
Slide 71 - What procedure should be considered at this stage?
Slide 72 - Perimortem Cesarean Section
Slide 73 - Legal and Ethical Considerations No emergency physician has ever been found liable for performing a postmortem cesarean section. The emergency physician has the legal right and responsibility to provide the unborn fetus with every possible chance of survival when there is no hope of maternal survival.
Slide 74 - Legal and Ethical Considerations Permission for the operation should be obtained from the family when possible but not at the expense of delaying the procedure. There is no standard of care relating to emergency physicians performing a postmortem cesarean delivery.
Slide 75 - Legal and Ethical Considerations In the absence of obstetric backup immediately at hand, it is reasonable for the emergency physician to proceed with delivery of the child if the mother cannot be resuscitated.
Slide 76 - Infant survival Most literature involves only small numbers of cases. Emphasis mainly on successful cases so survival statistics difficult to ascertain. Survival rates range from 11-40%.
Slide 77 - Indications PMCD must be considered in any woman who suffers irreversible cardiac arrest during 3rd trimester. Should be performed within 5 minutes of maternal demise.
Slide 78 - Equipment Scalpel with a No. 10 blade Bandage scissors Bladder retractor Large retractors (2) Forceps Lap or gauze sponges Hemostats (curved and straight) Suction Obstetric pack
Slide 79 - Using the scalpel, a midline vertical incision is made through the abdominal wall extending from the symphysis pubis to the umbilicus and carried through all abdominal layers to the peritoneal cavity.
Slide 80 - The bladder is reflected inferiorly; if full it may be aspirated to evacuate it and permit better access to the uterus approximately 5-cm, vertical incision is made through the lower uterine segment until amniotic fluid is obtained or until the uterine cavity is clearly entered
Slide 81 - The index and long fingers are then inserted into the incision and used to lift the uterine wall away from the fetus. A bandage scissors is used to extend the incision vertically to the fundus until a wide exposure is obtained
Slide 82 - The infant is then gently delivered, the nares and mouth suctioned, and the cord clamped and cut. Neonatal resuscitation should be carried out as necessary.
Slide 83 - Maternal resuscitation CPR should be initiated on the mother at the time of cardiac arrest and continued throughout the procedure In rare instances relief of IVC compression improves maternal hemodynamics such that survival is possible, maternal pulses should be checked and CPR continued after delivery of the infant.
Slide 84 - Maternal resuscitation At gestational age 26-32 wks, EDT “should be seriously considered” for OCM if no response to ACLS within 2-3 minutes. Emergency cesarean delivery (ECD) should then follow.
Slide 85 - Maternal resuscitation If OCM (or ECM) proves successful, then delivery should be delayed to improve chances of postnatal survival (esp. if < 28 wks). After 32 wks, ECD should be performed immediately to improve maternal cardiac filling and improve CPR success. If this fails to revive the mother then OCM may be considered.
Slide 86 - Questions?
Slide 87 - Thank you