Hi everyone,
I hope everyone had a good time at Emergycare this Friday, thanks to all of you at Emergycare for being so accommodating and exposing us to so many new emergency care skills. I just wanted to provide you all with a review of what we went over.
1) Chest Decompression
As we learned chest decompression is indicated for tension pneumothorax and also should be considered in the setting of refractory pulseless electrical activity (PEA). First you begin by assessing breath sounds and an uneven chest rise in order to determine the side of the pneumothorax (absent breath sounds and no chest rise upon inspiration on the affected side.) Also remember that a late sign is the trachea to deviate away from the affected side. Next you want to find the space between the 2nd and 3rd intercostal space midclavicular line (you typically can’t feel the first rib due to it’s place partially underneath the clavicle). Finding this space is important because there are major vessels close by and obviously you don’t want to puncture through them.
(Click on images below to zoom in)
After you find this location clean the site and take a large bore needle and puncture the site at a 90 degree angle until you feel the needle enter the pleural space (the EMT suggested you have the barrel still connected to the needle, filled with sterile saline, and the plunger pulled out so when you hit the pleural space you see bubbling indicating air being released). From there you stabilize the catheter with some gauze and remove the needle and leave the catheter in until you arrive to the hospital and further interventions can be done. This intervention is typically performed out in the field because in the hospital we have a lot more technology at our disposal.
2) Endotracheal Intubation
Endotracheal intubation is the placement of a tube into the trachea (windpipe) in order to maintain an open airway in patients who are unconscious or unable to breathe on their own. Oxygen, anesthetics, or other gaseous medications can be delivered through the tube.
To begin the procedure open the patent’s mouth by separating the lips and pulling on the upper jaw with the index finger. Holding a laryngoscope in the left hand, insert it into the mouth of the patient with the blade directed to the right tonsil. Once the right tonsil is reached, the laryngoscope is swept to the mid line, keeping the tongue on the left to bring the epiglottis into view. The laryngoscope blade is then advanced until it reaches the angle between the base of the tongue and the epiglottis. Next, the laryngoscope is lifted upwards towards the chest and away from the nose to bring the vocal cords into view (be careful not to rock back onto the teach and smash them, not a good idea…). Then take the endotracheal tube, made of flexible plastic, in the right hand and start inserting it through the mouth opening. The tube is inserted through the cords to the point that the cuff rests just below the cords. Finally, the cuff is inflated to provide a minimal leak when the bag is squeezed. Using a stethoscope, listen for breath sounds to ensure correct placement of the tube. You should not hear any sounds over the stomach, if so you must restart from the beginning, filling the stomach with air can cause vomiting and may lead to aspiration. Remember the EMT said that from the last breath you deliver you have a full 6 minutes to get the tube into place to deliver further respirations before you have injury to brain tissue occur. This means that you need to take a moment to relax and collect your thoughts so you increase your chance of doing it right the first time, avoiding multiple attempts and risking further complications.
3) IV Insertion
Establishing a peripheral intravenous line
Begin by getting your supplies together (always grab two needles and two start kits just in case). Wash your hands and put on new pair of gloves. Next tighten your tourniquet tightly around the arm you want to start the IV, palpate and look for veins that pop up after you tighten the tourniquet (feeling is more important than seeing). It is important to look for veins lower down the arm because if the site fails you can always head up the arm for more sites. You cant move down the arm from a failed site, because the previously damaged site has the potential to leak when your infusing fluids. Once you have the vein selected, clean the area around it with chlorhexidine scrubbing in a back and forth motion, if you are using alcohol pads start from the center of your site and using a circular motion clean from the center out. Get your needle ready by rotating the catheter hub 360 degrees to prevent the hub from sticking when you need to slide it forward. Provide traction on the skin with your left hand to prevent the vein from moving and hold the needle with your thumb and middle finger and puncture the skin at approximately a 45 degree angle. You should see a blood flash as soon as you enter the vein, once you see this advance the needle slightly and then drop the your angle towards the angle of the arm and then continue carefully advancing the needle some more. Use your index finger to slide the hub and the catheter down the needle and further into the vein. Provide counter pressure on the vein, withdraw your needle and release the tourniquet (reduces the venous return pressure and decreases the likelihood of the vein blowing). Remove the cover from the end of the IV tubing and insert the IV tubing into the hub of the catheter. Secure the tubing to the catheter by screwing the Luer Lock tight. Check for blood return, (might not always get one if you are near the valve of a vein since the negative pressure will close the valve and occlude blood return), and flush the IV paying attention to any pain or discomfort and signs of infiltration. Then tape the hub per institutional policy (never pre-rip your tape and stick it to bed rails so you can grab the strips quicker and easier, the site underneath the dressing is supposed to be sterile and think of all the germs you are introducing to grow under the dressing if you do this). And finally don’t forget to dispose of you needle in a sharps container, date your IV, and document the number of attempts and location of the IV.
Well this is all for our meeting at emergycare sorry this was so long but I hope it was interesting and helpful to you. I know we went over heart rhythms as well but I am going to put that as it’s own separate review so keep a look out for that in the following week or so. As always any comments and suggestions are appreciated. We also need input for our next meeting later this month so send an e-mail to me (d791220o), Kelly (k693433m) or Mikah (msimmons) with your ideas. Thanks making this group so successful and a really good experience for everyone.
SN2RN
