Heroic Procedures in Emergency Medicine

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Heroic Procedures in Emergency Medicine

• Presented by Ammar Al-Kashmiri
• Emergency FRCP program, R IV

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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

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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.

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• Whats the likely diagnosis?

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Diagnosis

• Epidural hematoma

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• What should you do next?

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• Cranial trephination

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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.

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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.

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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.

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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.

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• What is Kernohans notch syndrome?

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

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Indications for trephination

• Patient is herniating
• All other treatments prove insufficient
• Neurosurgery is unavailable
• Air or ground medical transport is prolonged

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Equipment

• Pentrator
• Burr hole bit
• Bone rongeur
• Scalpel

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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.

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• 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.

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• The outer table of the skull is drilled with the
  penetrator

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• Follow with the burr hole bit and brace.

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

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• 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.

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• 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).

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• Questions?

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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.

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• Whats your diagnosis and what do you do next?

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Diagnosis

• Retrobulbar hematoma

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• L a t e r a l

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

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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.

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Pathophysiology (cont.)

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

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Indications 

• Decreased visual acuity 
• Intraocular pressure gt 40 mm Hg 
• Proptosis
• Afferent pupillary defect 
• Cherry red macula 
• Ophthalmoplegia 
• Nerve head pallor 
• Eye pain

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Contraindication 

• Globe rupture

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Equipment

• Hemostat or needle driver
• Iris or suture scissors
• Forceps

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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.

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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.

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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.

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Incising the lateral canthus

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

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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.

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• After the inferior canthal tendon has been cut,
  intraocular pressure is reassessed with a
  tonometer.
• If IOP remains gt40 mm Hg, then decompression is
  inadequate. The upper lid should be lifted and
  the superior lateral canthal tendon should be
  severed.

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• Questions?

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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.

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What is the immediate management of this patient?
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• Surgical
• Cricothyrotomy

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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

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Indications

• AW obstruction
• Oropharyngeal edema
• Mass effect (cancer, tumor, polyp, web, or other
  mass)
•  Foreign body
•  Laryngospasm
•     

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Indications

• Traumatic injuries making oral or nasal
  endotracheal intubationdifficult or potentially
  hazardous     
• Cervical spine instability

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Contraindications (relative)

• Age less than 8
• Anterior neck hematoma
• Previous cricothyrotomy
• Tracheal tumor or mass
• Coagulopathy

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Equipment

• Scalpel with No. 11 blade
• Tracheal hook
• Tracheal dilator
• No. 4 or 5 Shiley cuffed tracheostomy tube with
  introducer and riser

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The Procedure

• Hyperextend the head to identify anatomy and
  control cricoid space.
• As a guide, a 20 ga needle can be inserted
  through the membrane with aspiration of air to
  confirm entry (optional).
• The larynx is stabilized by holding it between
  the non-dominant thumb and middle finger.

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The Procedure

• A vertical incision is made after puncture
  through the membrane

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• The opening is widened by insertion of the
  scalpel handle and rotating it 90 degrees.

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Alternate method
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Complications

• Thyroid gland damage
• Large vessel injury with hemorrhage
• Esophageal damage
• Infection
• Aspiration

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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

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• Questions?

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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.

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• What procedure should be considered at this stage?

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• Perimortem Cesarean Section

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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.

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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.

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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.

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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.

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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.

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Equipment

• Scalpel with a No. 10 blade
• Bandage scissors
• Bladder retractor
• Large retractors (2)
• Forceps
• Lap or gauze sponges
• Hemostats (curved and straight)
• Suction
• Obstetric pack

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• 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.

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• 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

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• 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

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• 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.

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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.

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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.

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Maternal resuscitation

• If OCM (or ECM) proves successful, then delivery
  should be delayed to improve chances of postnatal
  survival (esp. if lt 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.

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• Questions?

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Thank you