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SAUSHEC EM Cadaver LabSep 2, 2021 0800-1400AMEDD/MEDCoE3630 Stanley Rd, lab 0505 BLDG 2841, San Antonio, Tx 78234***ABSOLUTELY NO PHOTOGRAPHY****Log all procedures in New Innovations*Contents SchedulePercutaneous Jet VentilationPericardiocentesisLower leg Fasciotomy Peritonsillar Abscess DrainageAuricular HematomaSuprapubic CatheterFemoral BlocksReferencesPGY1 0800-0940PGY2 0950-1130PGY3 1140-1320Cadaver?1: Drs Belcher (am only) and SlettenPercutaneous transtracheal ventilation Fiberoptic intubation?Digital intubation? ????Cadaver?2: Drs Matlock and CartwrightChest tube PerciardiocentesisLower leg fasciotomy Cadaver?3:??Dr. Maksimenko Peritonsillar Abscess DrainageAuricular hematoma?Lateral canthotomy?Cadaver?4:? Dr. MyersSuprapubic catheter?Femoral cutaneous nerve block?US guided LP?Questions/suggestions email: Joehiguerafisher@Percutaneous Transtracheal Ventilation Indication: Surgical airway?of choice for <12 years of age Equipment Lidocaine 1-2% O2 with flow at 10-15 L/minBag-valve-mask 14 gauge or 16 gauge IV cath and needle3 ml syringe, Luer lock tip, that fits tightly into a 7.5-mm inner diameter ET tube adapterInner adapter of 7.5 mm endotracheal tubeEquipment assemblyConnect IV catheter to a 3-mL syringe (with its plunger removed)Connect the 3mL syringe to a 7.5 mm inner diameter ET adapterAttach valve of the BVM and connect O2 tubing to an O2 source with flow at 10-15 L/minConnect the ET adapter to the BVMPercutaneous cricothyroidotomyIdentify cricothyroid membrane.Use 10 to 14 gauge needle for adult, 14 or 16 gauge for childAttach 10 ml syringe with 3-5 ml of saline the needle. Stand at head of the bed, aim needle slightly towards the head at an angle 30-40 degrees. Aspirate while slowly advancing, avoid puncturing the tracheal wall. As soon as you enter the tracheal lumen you will see bubbles in the saline as you aspirate Slide catheter off into the trachea, attach syringe to hub of the catheter and again aspirate air. There should be no resistanceJet ventilation -Start at 10 PSI in children, increase until you see adequate chest rise and fall, max ~30 PSI. Hospital wall outlet w/o a regulator set at 15 L/min provides O2 at 58 psi, for children use a flow rate of 10 to 12 L/min which is ~25 to 35 psi-Use I:E ratio of 1:4 to 1:5, with a RR of 10 to 14/min for most children.PericardiocentesisIndication: Cardiac tamponadeEquipment18 gauge spinal needle20mL (or larger) syringeCan also use abdominal paracentesis kit or central line kitProcedure: Subxiphoid ApproachUS GuidedUse ultrasound to identify location of effusionAiming toward effusion, insert needle through skin using real-time ultrasound guidance and aspirating throughout insertionRemove stylet from needle and attach 3-way stopcock and 20-mL syringeAspirate fluidDisconnect syringe and stopcockUse Seldinger technique to place pericardial drain if needed for ongoing drainageLandmark guided Insertion between xiphoid process and left costal marginAiming toward left shoulder, insert needle through skin at 30-45' angle while aspiratingRemove stylet from needle and attach 3-way stopcock and 20-mL syringeAspirate fluidDisconnect syringe and stopcockSeldinger technique to place pericardial drain if needed for ongoing drainageObtain post-procedure CXR to rule out iatrogenic pneumothoraxComplicationsCardiac puncturePneumothorax/pneumopericardiumDysrhythmias. PVC (most common). Vasovagal bradycardia (responsive to atropine)False negative (clotted pericardial blood)False positive (intracardiac puncture)Lower Extremity Fasciotomy Indication: Compartment syndromePain (early finding)Paresthesia (early finding)PallorParalysis. (late finding)Pulselessness. (late finding)Intracompartmental pressure > 30 mmHg or delta pressure <20 mmHg or intracompartmental pressure > 20 mmHg in the presence of hypotension Interruption in arterial perfusion > 4 hrs Fracture (can occur with open fracture), crush injury, immobilization, snake bites, burns, prolonged?tourniquet?application, fluid extravasation into a limb, soft tissue infection, extreme exertionMuscle and nerves can survive up to 4 hrs of ischemia without irreversible damage. Nerves may have damage at 4 hrs, greater ischemic?time will produce irreversible injury including axonotmesis at 8 hoursIndications for Fasciotomy in Austere Combat Environment4-6 hr delay after vessel injuryCombined vein and artery injuryArterial ligationConcomitant fracture/crush, severe soft-tissue injury, muscle edema or patchy?necrosisTense compartment/compartment pressures exceeding 40 mmHgEquipment 10 or 15 blade or electrocautery Dissecting scissors Lower Leg Compartments1.AnteriorNerve: deep fibular (peroneal): sensation of 1st webspaceMuscle: tibialis anterior: foot/ankle dorsiflexion2. LateralNerve: superficial fibular (peroneal) nerve: sensation of lateral aspect of lower leg, dorsum of footMuscle: peroneus longus and brevis: foot plantarflexion3. Deep posterior-most commonNerve: posterior tibial nerve: sensation of plantar aspect of footMuscle: tibialis posterior/flexor hallucis longus/flexor digitorum longus: Pain with passive extension of the toes4. Superficial posteriorNerve: sural cutaneous nerve: sensation of lateral aspect of footMuscle: gastrocnemius/soleus/plantaris: weakness of plantar flexionProcedureIncisions must extend entire length of calf (or at least 15 cm) to release all of?compressing fascia and skinlateral incision made centered between fibula and anterior tibial?crest lateral intermuscular septum and superficial peroneal nerve are?identified and anterior compartment is released in line with?tibialis anterior muscle, proximally toward tibial tubercle and?distally toward anterior ankle lateral compartment then released through this incision in line?with fibular shaft, proximally toward fibular head, distally?toward lateral malleloussecond incision made medially at least 2 cm medial to medial-posterior palpable edge of tibia (medial incision over or near?subcutaneous surface of tibia is avoided, preventing exposure of?tibia when tissues retract)saphenous vein and nerve are retracted anteriorlysuperficial compartment released through its length and then the deep posterior compartment over the flexor?digitorum longus is released identify tibialis posterior and release its fascia Peritonsillar Abscess DrainageIndication Peritonsillar abscessEquipmentLidocaine w/ epi 25 gauge needleScalpel #11 or #15 blade or 18 gauge needleProcedureNeedle AspirationUse?laryngoscope?or disassembled vaginal speculum with wand as tongue depressor and light sourceInject 1-2mL of lidocaine with epinephrine into mucosa of anterior tonsillar pillar using 25 gauge needleCut distal tip off of needle sheath and place over 18ga needle to expose 1 cm of needle Aspirate using 18 gauge needle just lateral to the tonsilI&D#11 or #15 blade Do not penetrate more than 1cm. Only advance posteriorlyMay be indicated if significant pus with needle aspirationMacintosh size 3 or 4 with handle in a "tomahawk" position provides visualization with lightingThe recurrence rate after aspiration is 10% and the cure rate is 93% to 95%. Recurrence rate for aspiration alone may be higher than I&D?ComplicationsIatrogenic laceration of carotid artery. Carotid artery is 2.5 cm posterior and lateral to tonsil. Should limit depth of needle insertion to <10mm during aspirationAuricular Hematoma Indications Traumatic swelling that deforms pinna within 7 days of traumaContraindications Recurrent or chronic hematoma > 7 days from traumaEquipmentLidocaine 1 or 2% w/o epiSuture kit (needle driver, scissors)Large bore needle Fast absorbing suture or 2-0 or 3-0 non absorbable depending on techniquePetroleum gauze and gauze ProcedurePerform an auricular blockEvacuate the clotOption 1) Make semi-circle incision inside the inner curvature of the helix or antihelixMake incisions along natural auricular crease for cosmesisRemove hematoma by milking of the hematoma toward the incision. Use needle driver to break up any hematoma that is not easily coming outOption 2) Use large-bore needle/syringe to aspirate hematomaNeedle aspiration generally is not sufficient treatment Prevent re-accumulation of hematoma-goal is to close dead space between perichondrium and cartilage. Option 1: Option 1) Compression dressingPack the helix with petroleum jelly-impregnated gauzePlace regular gauze both in front of and behind the earCircle the head with a compressive wrapAlternative to petroleum jelly gauze is to splint the ear with a molded piece of plaster?which fits better and does not need as tight of a compression dressing.Option 2) SutureUse fast-absorbing sutures. Place running or interrupted sutures through cartilage and both anterior and posterior skin of auricle in mattress fashion. This should reappose the perichondriumConsider leaving incision open (with wound edges approximated by mattress sutures) to allow for continued drainageOption 3) Bolster sutured in place- combination of the above two methodsUse non-absorbable 2-0 or 3-0 nylonPack the helix with petroleum jelly impregnated gauze. Place a thick layer of gauze behind the earPerform a running quilt stitch through the anterior gauze, through the pinna, and through the posterior gauzeSuprapubic catheter placementIndications Urethral disruption due to trauma or severe urethral stricture or complex prostate ContraindicationsEmpty or unidentifiable bladder. Empty bladder introduces risk of through-and-through penetration of the bladder. (No minimum reported bladder volume established)Bowel anterior to bladderEquipment Cook peel-away introducer sheath. If not available, can also CVC kit and use Seldinger technique to insert FoleyUltrasoundLidocaineSterile syringeSpinal needle (22 gauge for adult patients)ScalpelFoley catheterProcedureUse ultrasound to locate and mark the bladderPrep skinFill syringe with lidocaine and attach spinal needleRaise skin wheal at marked siteInfiltrate subcutaneous tissue and rectus muscle fasciaAdvance the spinal needle into the bladder while applying negative pressure to the syringeAfter locating the needle within the bladder, remove the syringeAdvance a guidewire through the needle and into the bladderRemove the syringe, leaving the guidewireMake a stab incision at the site of the guidewire, extending the opening for the sheath introducerPass the peel-away sheath and in-dwelling dilator over the guidewire and into the bladderRemove the guidewire and fascial dilator, leaving only the peel-away sheetInsert Foley catheter through sheath and into bladderAspirate urine through Foley catheter to confirm placementInflate Foley balloonDress the siteComplicationsBowel perforationThrough and through bladder penetration may lead to rectal, vaginal, or uterine injuryIntraperitoneal extravasationInfectionFemoral Nerve BlockIndications Pain control for femur fracture, hip fracture, patella fractureEquipment Syringe with 25-30ga needleSyringe with 22ga noncutting spinal needleLocal anesthetic (bupivicaine preferred due to long duration of action)Femoral Nerve BlockApply sterile ultrasound probe 1cm distal to inguinal ligamentFind the large nonpulsatile femoral vein as the initial landmark under ultrasoundIdentify femoral nerve (hyperechoic structure lateral to the femoral artery)Must also identify Fascia Lata and deeper Fascia Iliaca, as these two fascial planes overlie the femoral nerve. If anesthetic is not placed below these two fascial planes, the anesthetic will not reach femoral nerve and the block will fail.Inject a small amount of local anesthetic into skin and subcutaneous tissue at the needle entry siteUnder ultrasound guidance, advance noncutting spinal needle to the femoral nerve sheathAspirate to ensure not in blood vesselInject 20cc of 0.5%? HYPERLINK "" \o "Bupivicaine" bupivicaine?or another local anesthetic along nerve sheath.Fascia Iliaca BlockSimilar to the femoral nerve block, except the needle enters through the fascia iliaca at a more lateral site relative to the femoral nerve block to avoid hitting the femoral nerve, artery, or vein-this extends the block to include the lateral femoral cutaneous nerve, providing anesthesia to the lateral proximal thigh.-Infiltrate a larger volume of anesthetic (30-40cc), allowing anesthetic to travel along the fascial planes to the lateral femoral cutaneous nerve. The volume of anesthetic may be mixed with saline to create an adequate volume to ensure success of the block.3 in 1 BlockFemoral nerveLateral femoral cutaneous nerveObturator nerveAllows for greater anesthesia of the hip and knee.Technique is identical to Fascia iliaca block, but includes application of pressure 4cm distal to injection plicationsInadvertent intravascular injectionInfectionBleeding/hematomaReferencesDavis, & Alvarez. (2019, August 9). Trick: Peritonsillar abscess drainage 3.0 | All the steps with added variations. Www.. , M., Team, O., Team, O., Moore, D. W., Team, O., & Moore, D. W. (2021). Leg Compartment Syndrome - Trauma - Orthobullets. . . (2020, January 8). Needle cricothyroidotomy with percutaneous transtracheal ventilation. . Jet Ventilation. (2021, February 18). In . , S. (2020, June 23). Auricular Hematoma Management. REBEL EM - Emergency Medicine Blog. , W., MD. (2020, November 28). Fascia iliaca nerve block: A hip fracture best-practice. ALiEM. , A. (2015, September 9). Core EM: Ultrasound Guided Pericardiocentesis. - Emergency Medicine Education. ................
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