Heroic Procedures in Emergency

Medicine

Presented by Ammar Al-Kashmiri

Emergency FRCP program, R IV

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’

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.

What’s the likely diagnosis?

Epidural hematoma

Diagnosis=

What should you do next?

Cranial trephinationCranial trephination

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.

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.

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.

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.

What is Kernohan’s notch syndrome?

A false-localizing motor examination can be caused by compression of the contralateral cerebral peduncle against the tentorium cerebelli.

Indications for trephination

Patient is herniating

All other treatments prove insufficient

Neurosurgery is unavailable

Air or ground medical transport is prolonged

Equipment

Pentrator

Burr hole bit

Bone rongeur

Scalpel

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.

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.

The outer table of the skull is drilled with the penetrator

• Follow with the burr hole bit and brace.

The hematoma is evacuated using a soft suction tip (it can be surprisingly voluminous).

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.

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).

Questions?

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.

What’s your diagnosis and what do you do

next?

Retrobulbar hematoma

Diagnosis=

L a t e r a lL a t e r a l

C a n t h o t o m C a n t h o t o m o yo y

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.

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.

Pathophysiology (cont.)

If IOP exceeds central retinal artery pressure, retinal ischemia results. In such situations, timely lateral canthotomy can save visual function

Indications 

Decreased visual acuity Intraocular pressure > 40 mm Hg Proptosis

Afferent pupillary defect 

Cherry red macula 

Ophthalmoplegia 

Nerve head pallor 

Eye pain

Contraindication 

Globe rupture

Equipment

Hemostat or needle driver

Iris or suture scissors

Forceps

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.

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.

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.

Incising the lateral canthus

The instrument is then removed and the demarcated area is cut laterally 1-2 cm in length

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.

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.

Questions?

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.

What is the immediate management of this patient?

Surgical Cricothyrotomy

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

Indications

AW obstruction

– Oropharyngeal edema

– Mass effect (cancer, tumor, polyp, web, or other mass)

–  Foreign body

–  Laryngospasm

    

Indications

Traumatic injuries making oral or nasal endotracheal intubationdifficult or potentially hazardous     

Cervical spine instability

Contraindications (relative)

Age less than 8

Anterior neck hematoma

Previous cricothyrotomy

Tracheal tumor or mass

Coagulopathy

Equipment

Scalpel with No. 11 blade

Tracheal hook

Tracheal dilator

No. 4 or 5 Shiley cuffed tracheostomy tube with introducer and riser

A vertical incision is made after puncture through the membrane

The Procedure

Alternate method

Complications

Thyroid gland damage

Large vessel injury with hemorrhage

Esophageal damage

Infection

Aspiration

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

Questions?

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.

What procedure should be considered at this stage?

Perimortem Cesarean SectionPerimortem Cesarean Section

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.

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.

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.

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%.

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.

Equipment

Scalpel with a No. 10 bladeBandage scissorsBladder retractorLarge retractors (2)ForcepsLap or gauze spongesHemostats (curved and straight)SuctionObstetric pack

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.

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

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

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.

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.

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.

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.

Questions?

Thank you