Category Archives: tutorials

Trauma updates – T-PODs, Tourniquets and QuikClot

We are now stocking a few new items in the trauma room wall racks near bed 3 behind the nursing station.

 

T-POD/Pelvic binders

We have both the T-POD as well as pean clamps for sheet binding if preferred.  For those unfamiliar with T-POD application, here is a video tutorial for review.  In addition I have a trainer and will happy to inservice anyone interested.
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Tourniquets
 
Tourniquets are also now available.  Pretty self explanatory but Here and Here are a couple of videos regarding application of tourniquets.  I’ve also attached a scan of the product insert with instructions. 
QuiKClot Combat Gauze
 
QuikClot is a kaolin impregnated gauze pad that allows for topical hemostasis by activating factor VII.  It is clay based and unlike prior formulations of quikclot does not result in exothermic reaction and has not been found to be associated w/ allergic reaction.  It can be used in any situation in which you encounter difficult to control bleeding, eg. proximal injuries you are unable to tourniquet, avulsion injuries, oozing from vascular access sites including shunts, oozing from scalp wounds, etc.  If hemorrhage control is unsuccessful after application, leave the initial pad in place and apply another to minimize disrupting existing clot.  The gauze can be left in place for 24 hours but once dried should be soaked with saline prior to removal.

Transvenous Pacemaker Placement

The following tutorial is courtesy of Dr. Colleen Smith.

Supplies

Transvenous pacing trays and pacing generator are located in the green cabinets above the sink in the Cardiac Room.

  1. Transvenous Pacing Electrode Tray containing:
    • TVP catheter
    • Percutaneous sheath introducer w/ syringe/guidewire/dilator
    • Sterile sleeve
    • 2 adapter pins
    • Alligator clamp
    • 3ml syringe that stops at 1.5ml
  2. Pacing generator box with extension connecting cable (attached to the box)
  3. Central line bundle with sterile patient drape, and sterile gown
  4. Sterile gloves
  5.  Ultrasound machine with linear probe and sterile ultrasound probe cover,

Set up pacing generator box 

  1. Turn generator box on by pressing the on button. Insert a new battery if necessary.
  2. Set the mode or sensitivity to demand or asynchronous pacing
  3. Set rate control above the native rate or the transcutaneous pacing rate usually around 80bpm
  4. Turn V (ventricular) output control to the max mAmps (usually 20-25mAmps)

 

Placement (Under sterile field with large patient drape, sterile gown, gloves, etc.)

  1. Place sheath introducer as you would place a Cordis type of central line, confirm venous placement with ultrasound and suture in place.Preferred site: Right internal jugular. Secondary site: Left subclavian (Try to save this for permanent pacemaker if possible.)
  2. Connect the pacing extension cable(s) to the pacing generator box.
  3. Connect the proximal lead of the pacing catheter to the positive (+) port of the pacing extension cables (or generator box
  4. If using ECG to guide placement: Connect the distal or negative (-) lead of the pacing catheter to the V2 attachment of the monitor or ECG machine using the alligator clip in the TVP catheter kit. This lead will now display an ECG waveform based on input sensed by TVP catheter as you place it. *See image below
  5. Thread the STERILE SLEEVE over the TVP catheter PRIOR to inserting the catheter into the introducer. (Keep the sleeve collapsed and pull it far back.) The TVP catheter should go through the blue end of the sleeve first so that the green end of the sleeve can connect with the sheath introducer.
  6. Place the TVP catheter – oriented so that it curves toward the heart.
    • If using the balloon (optional):
      • Only use the syringe that comes in the kit.
      • Check the balloon for leaks by inflating it prior to inserting the catheter.
  7. Inflate the balloon when you have inserted to about 20cm (2 slender dashes on the catheter) and lock it in that position prior to advancing the catheter
  8. ALWAYS deflate the balloon and lock it down prior to retracting the TVP catheter.
  9. Correct placement should occur between 30 and 40cm, consider measuring with TVP catheter over the patient’s chest prior to placing.
  10. If you have gone too far, DEFLATE the balloon and retract the TVP catheter back to the 5-10cm mark, reinflate the balloon (if using) and reinsert the TVP catheter.
  11. Confirm capture with:
    • ECG waveform attached to negative lead of TVP wire (injury pattern, see attached images)
    • Capture on monitor (LBBB with ST elevation at set rate)
    • Cardiac ultrasound (wire visible in right ventricle)
  12. When you have capture. Deflate the balloon and lock it closed. Insert the TVP catheter another 5-10mm.
  13. Secure the green end of the sterile sleeve to the introducer. (This should hold the TVP catheter in place). Pull sleeve open fully and secure the blue end of the sterile sleeve to the TVP catheter. (This ensures continued sterility of the portion of the TVP wire within the sterile sleeve so that it can be adjusted.)
  14. Apply sterile dressing to the introducer insertion site

Procedure Completion (You can now break sterile field)

  1. Connect the distal lead of the TVP catheter to the negative (-) input of the generator box (if not already done.)
  2. Remove the syringe for the balloon and tape it to the wire.
  3. Adjust mAmps by decreasing the ventricular mAmps until you loose capture and then go up x2 (or 20% higher than your lowest capture number)
  4. Obtain a CXR to further confirm placement and location, check for pneumo- or hemothorax.
  5. Obtain a 12 lead ECG to confirm pacing spikes and widened QRS for every beat.

Potential complications

  • Same as any central line: pneumothorax, improper placement, arterial placement, etc.
  • Valve rupture or tear. Caused by retracting the TVP catheter with inflated balloon. Detect by new murmur, acute heart failure, echo.
  • Perforation of the LV causing tamponade. Detect by sudden hypotension with narrow pulse pressure, pericardial effusion on echo. DO NOT REMOVE TVP Catheter.
  • Pulmonary artery rupture or tear. Caused by inflating the balloon in the pulmonary artery. Results in tamponade physiology.
  • Septal wall perforation. Caused by pushing the TVP catheter through the septum. Results in left to right shunt physiology, acute right heart failure, hypoxia

 

How to Take Care of Video Laryngoscope Blades

I was hoping Joe would be the bad guy on this one, but I guess it falls to me.

There has been a relatively consistent lack of care for the video intubation equipment. I have walked into 5 shifts in the past 2 months with a dirty blade sitting on top of the intubation cart (if you think I am talking about you, I am, but not just you so don’t feel that bad).

Each of these blades cost a few thousand dollars. Joe & Stu worked to get us this new equipment. Convincing the hospital to replace broken items is going to be pretty tough.

IMG_0267
So the image above should never exist: Either the blade should be sitting in a drawer or it should be in your hand. NOWHERE ELSE. Getting ready for an intubation–keep it in the drawer. Things fall off flat tops, they do not fall out of drawers.

IMG_0268
Clean and ready blades go in the top drawer

SNAG-0000
Dirty blades go in the sterilization tray and get brought to the front desk to go to central sterile. Blades should not be sent down to central if they are not in the tray.

IMG_0271
If you have used a blade, but the sterilization tray is downstairs, put the blade in a specimen bag and put it in the lower drawer.

This should happen immediately after intubation as in IMMEDIATELY after intubation.

The residents should be taking care of this, but it is the responsibility of the ED attending to make sure it happens and happens properly. We will be blaming the attending not the resident if blades are not handled properly because we are consistent while residents come and go as outside rotators or while switching between institutions.

Please write Joe or me with any questions.

Dealing with Radiological Implants and How to use the Geiger Counter

A patient who comes in s/p I 131 (radioactive iodine) treatment within a month of their treatment

Isolate the patient in an Isolation room in the ED if condition allows.  Stay 6 feet away from the patient as much as possible at all times.
Keep pregnant staff and children away from the patient.
Take geiger readings as documented below.
Call Endocrinology Consult 24/7 to make them aware the patient is in the Emergency Department also page the Radiation Safety Officer (RSO).
If the patient needs admission, admit them to the “Radiation Room” on A3 OR a private room if this is not available.
If it was a patient recently discharged from EHC and needs admission – re-admit the patient back to the room from where they were discharged.
Individual Staff should have no greater than 30 minutes close contact (within 6 feet)
All trash except sharps, should be placed in a red biohazard bag near the patient’s bedside and not disposed of by housekeeping. The RSO will arrange for this trash to be picked up.

Prostatic Implants

Get readings with the Geiger Counter and call radiation safety officer.

How to use the Geiger Counter

Get the geiger counter from hospital police

Remove the red shield (do not discard)

Turn the on switch to x0.1

  1. Turn off audio
  2. Test the battery, when you press the button, the indicator should move to the battery test area of the display
  3. Press reset
  4. Make sure the f/s switch is turned to “f”
  5. Take a background reading at least 15 feet from the patient
  6. Now wand as close as possible to the affected area
  7. Look at the mR/hr area of the display (the one in the middle of the 3 arcs), look at the number and divide by 10 (you have set the machine to the “x0.1” setting so all readings need to be divided by 10)
  8. Where the arrow settles is the reading
  9. If the indicator moves all the way to the right, change the setting from x0.1 to x1, then to x10, x100
  10. Retake the reading
  11. Take readings at 1 inch, 1 foot, and 3 feet, 6 feet, and background readings (>12 feet from patient). The best way I have found is take a piece of paper and write down the reading and the dial setting next to it and do the multiplication later  (i.e. write down that at 3 feet the dial reads 0.4 mR/hour when set at 10x, then sit down out of the room and calculate the actual 3 foot reading is 4 mR/hr).

What to do with the readings

Call or Page the radiation safety officer

Until they advise–

  • < 2mr/ hr all children and pregnant staff need to stay 6 feet from patient.
  • >2mr/ hr all staff need to stay 6 feet from the patient.
  • If the patient is in extremis, treat the patient first as radiation emission is a secondary concern and brief exposure to implants will not cause a significant exposure to staff.  Pregnant staff should not treat the patient.