Critical Care Tips & Tricks

1. Critical Care Tips & Tricks Dr. Matthew Inwood

2. Disclosures • None

3. 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.

4. 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.

5. 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?

6. 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

7. Case #1 • Nebulised Naloxone!

8. 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

9. 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

10. 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?

11. 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

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14. Case #2 • Guide Wire J-Tip Orientation: • Tripathi et al, Anesthesia & Analgesia 2005; 100: 21-4

15. Case #2 • Guide Wire J-Tip Orientation:

16. Case #2 • The “Ambesh” Maneuver: • Manual occlusion of the ipsilateral Internal Jugular vein at the supraclavicular fossa.

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19. Case #3 • 18 year old male, right sided thoracic stab wound. • Deviated trachea, shallow resps, absent right breath sounds.

20. Case #3 • Are you in the right place? Ferrie et al, EmergMed J 2005;22:788–789

21. Case #3

22. Case #3 • Is your patient too thick or your needle too short?

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24. 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

25. 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?

26. Case #3 2nd ICS MCL 5th ICS MAL

27. 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

28. 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

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34. Case #4 • High Flow Apneic Oxygenation • How Does it Work? • Complications?

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36. Questions?