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Archive for the ‘Resus / Crit Care’ Category

Glidescope Cleaning Process

Written by phil

April 16th, 2012 at 3:34 pm

Chest tube insertion: the stab thoracostomy tray

If you are inserting a chest tube, you need a stab thoracostomy tray. Many useful items are in the stab thoracostomy tray, including kelly clamps, and 0-silk suture. The tray also contains some items that are not useful, such as trocars. DO NOT USE THE TROCARS.

Written by reuben

September 8th, 2011 at 12:34 am

Posted in Resus / Crit Care

NG Tubes / OG Tubes

1.  Intubated patients should have OG tubes placed in preference to NG tubes when possible, as there is no benefit to NG tubes (except maybe easier to insert), but they have the potential to cause sinusitis, and other complications like bleeding are more likely.  Awake patients obviously can’t tolerate OG tubes.
 
2.  All OG/NG tubes in the ED should be salem sump tubes (two lumens, one of them is blue). see picture.  Single lumen tubes are really only good for feeding, which is generally not a priority in the ED.  We are more interested in sucking things out, and single lumen tubes must be in low intermittent suction to prevent ulcers, which is less efficient.
 
3.  The blue lumen should be capped with a one-way valve to prevent regurgitation of gastric contents (blue end goes in blue tube).  If you tie it off, it defeats the purpose of using the 2-lumen tube (release valve to prevent sucking onto the gastric mucosa and causing ulcers).  

Kit



Written by reuben

January 31st, 2011 at 3:39 pm

Posted in Resus / Crit Care

Withholding Life Sustaining Treatments in the ED at EHC

Hi folks,

As some of you may know, the recently passed Family Health Care Decision Act allows the withholding and withdrawing of life sustaining treatments in patients who lack capacity, even in the absence of a health care proxy.

This is an enormous step forward for palliative care.

However, the procedure to do this is rigorous and exacting. I have gone through HHC’s 30 page policy and I have created a 3 page summary. It is absolutely critical that we follow all of the steps completely. If we half-ass this, I am sure there will be greater administration involvement. Once that happens, it becomes more difficult to give our patients the palliative care they deserve. Please, please comply with HHC’s policy.

Scott

Withholding Life Sustaining Treatments under FHCDA

Question 1- Does the patient have capacity to make the decision on the particular life sustaining therapy?

An attending physician must make the initial determination that the patient lacks decision-making capacity.
The note should include language similar to: I have determined, to a reasonable degree of medical certainty, that the patient lacks the ability to understand and appreciate the nature and consequences of proposed health care, including the benefits and risks of and alternatives to proposed health care, and lacks the capacity to reach an informed decision.

A concurring attending must make the same determination and document it in the chart as well.

If mental illness is the cause of the lack of capacity, one of the two attendings must be BC/BE in Psych or Neurology.
If mental retardation or developmental delay is the cause of the lack of capacity, call risk management to get involved.
If the patient has any ability to comprehend, you must tell them of the decision that he or she lacks capacity. If the patient objects to the determination of lack of capacity, call risk management and do not continue.

Question 2 – Did the Patient State His or Her Wishes Previously?

Statements that are acceptable for this purpose are:
A Living will
Written statement regarding their wishes
Prior medical orders pertaining to the particular life sustaining treatment (DNR or DNI signed at the same.) Document the nature of these prior statements, and if possible include a copy in the chart. If the patient stated their wishes in one of the above forms, the attending can honor them. If the patient did not state their wishes, then a surrogate will make the decisions regarding life sustaining treatment.

Notify the surrogate (if one is available) of the prior statement of wishes, if the surrogate objects, call risk management.

Question 3- Is there a surrogate who is reasonably available, competent, and willing to serve?

Search for one person from the following list who is reasonably available, willing and competent to serve as surrogate: (The list goes from highest to lowest priority class)
1. A guardian authorized to decide about health care pursuant to Mental Hygiene Law (Call risk management before making any decisions using a guardian)
2. Spouse, if not legally separated from the patient, or a domestic partner;
3. A son or daughter eighteen years of age or older;
4. A parent;
5. A brother or sister eighteen years of age or older;
6. A close friend. A close friend is any person, eighteen years of age or older, who is a close friend of the patient, or a relative of the patient (other than a spouse, adult child, parent, brother or sister), who has maintained such regular contact with the patient as to be familiar with the patient’s activities, health, and religious or moral beliefs. Such person must write and present a signed statement to that effect to the attending physician. This statement should be added to the chart.

Patient Objection to Choice of Surrogate
Notwithstanding a determination that an adult patient lacks decision-making capacity, if the patient objects to the choice of surrogate, the patient’s objection must prevail until Risk Management becomes involved.

Surrogate Designation of Another Surrogate
If the surrogate designates any other person on the surrogate list, such person designated will be the authorized surrogate, provided no one in a class higher in priority than person designated objects. If there is such an objection or disagreement, the attending physician must promptly refer the matter to Risk Management.

Document the surrogate in the chart.

Question 4 – Is there a situation which would allow a surrogate to make decisions to withhold or withdraw life-sustaining treatment?

In order for a surrogate to withhold or withdraw life sustaining treatments, one of the following must be satisfied:
1. If the patient has an illness or injury which can be expected to cause death within six months, whether or not treatment is provided, the attending physician determines with the independent concurrence of another attending physician that the treatment would be an extraordinary burden to the patient.
2. If the patient is permanently unconscious, the attending physician determines with the independent concurrence of another attending physician that the treatment would be an extraordinary burden to the patient.
3. If the patient has an irreversible or incurable condition, as determined by the attending physician with the independent concurrence of another attending physician, the provision of treatment would involve such pain, suffering or other burden that it would reasonably be deemed inhumane or extraordinarily burdensome under the circumstances.

If the decision revolves around the provision of artificial nutrition or hydration (unlikely in the ED), then you should consult risk management.

Duty to Give the Surrogate Information
Health care providers must provide the surrogate information necessary to make an informed decision, including information about the patient’s diagnosis, prognosis, the nature and consequences of proposed health care, and the benefits and risks and alternatives to proposed health care.

Expression of Decisions
The surrogate must express a decision to withhold or withdraw life-sustaining treatment either orally to the attending physician or in writing.

Documentation
Three conditions above was present as a progress note. The concurring attending must write the same sort of note as a progress note.

Patient Objection to Surrogate’s Treatment Decision
Notwithstanding a determination that an adult patient lacks decision-making capacity, if the patient objects to a health care decision made by a surrogate the patient’s objection prevails until a determination is made by risk management.

Standard Forms
If the decision revolves around DNR, the surrogate should sign a DNR form. If the decision concerns intubation, vasopressors, dialysis, etc.; then documentation should be done in a progress note by the attending and the concurring attending.

Health care decisions for adults without available, willing, and competent surrogates

***Consult Risk Management for these decisions***

Written by reuben

November 1st, 2010 at 9:55 pm

REASON study

Sinai is part of the national REASON network (Real Time Emergency Assessment with Sonography: Outcomes Research Network).

The first data for this network now being collected is on patients in cardiac arrest.  We need to save 2 clips of cardiac (in)activity in these patients one during a pulse check and one after the code.  Preferably these would come 15 minutes apart.

Full instructions on saving clips on the M-Turbo and for the REASON study are available help.

Multimedia post with more information to come soon at the sinai ultrasound site.

Written by phil

August 12th, 2010 at 6:51 pm

MSSM Central Venous Catheterization Safety Policy

Ultrasonic guidance is now required per Medical Board policy for placement of all non-emergency central venous catheters in the internal jugular vein.  Attendings must be present at all critical events during central venous catheterization.  Chest radiography is insufficient to determine if a central venous catheter is in the venous circulation.  We must also measure pressure through the catheter (by manometry or pressure transducer), perform a blood gas analysis, or certain other methods.  Please read the policy in detail.  It is in effect immediately, and failure to comply is a serious matter.  Thank you for your efforts to increase patient safety.

CENTRAL VENOUS CATHETERIZATION SAFETY POLICY
This policy pertains to all elective central venous catheterizations. The policy does not apply during emergency circumstances.  Ultrasonic guidance of central venous catheterization reduces the incidence of inadvertent arterial cannulation. Ultrasonic vessel finder usage is required in all non-emergency internal jugular central venous catheterizations performed without fluoroscopy.
All elective central line insertions on patient floors will be performed by dedicated central line placement teams, such as the Surgical and Medical Intensive Care Unit Line Placement Services.
Appropriately privileged physicians who practice anesthesia, emergency medicine, critical care, and interventional procedures (interventional cardiologists, interventional radiologists, and nephrologists) may insert elective central lines in their procedural areas.  The Chief Medical Officer may identify other physicians that may receive privileges to insert elective central lines in specific procedural areas.
The attending physician must be present and visually supervise critical portions of the procedure, especially the confirmation of catheter placement within the central venous circulation.
A surgeon who has privileges to insert surgical central lines (e.g., Broviac catheters) in the operating rooms shall not place elective central lines outside of the operating room setting unless he/she is a member of a dedicated central line placement team or otherwise qualified as defined by the Chief of Service and the Chief Medical Officer.
Non-contrast radiographic examination will NOT be used to confirm the venous position of central venous catheters.  Radiologic examination is useful for determining the depth of insertion and the presence or absence of complications related to the central line placement, such as pneumothorax or hemothorax.
For all central venous lines, the techniques to be used for confirmation of venous placement include:
Observation of the intravascular pressure waveform using an electronic transducer and pressure tubing;
Determination of the of the intravascular pressure using sterile tubing as a venous manometer;
Analysis of the PO2 of a blood specimen drawn from the needle/catheter;
Using real-time fluoroscopic or echocardiographic confirmation of venous catheterization (e.g., visualizing the guide wire or catheter within the superior vena cava); or
Using a contrast study to opacify the venous structures.
For Insertion of Large-Bore Catheters and Introducers
To prevent inadvertent arterial cannulation with large-bore catheters (>5 French diameter or equivalent pediatric sizes), venous localization of the introducing needle or (angio) catheter must be confirmed by one or more of several techniques noted above prior to vessel dilation.  If technically unfeasible to conduct a confirmatory test with a short catheter or introducer needle prior to dilation, the recommendation is that a temporary catheter (<5 French) be placed to conduct one of the confirmatory methods.
In the event that no confirmatory test is conclusive, then the catheter must be removed.
The medical and nursing personnel present at the central line insertion must complete all applicable checklists, follow strict asepsis, and use all precautions currently required by the Central Line Associated Bloodstream Infection (CLABs) protocols of The Mount Sinai Hospital.  Nursing personnel will retain the authority to supervise and intervene to ensure that CLABs protocols are followed by the physicians and teams that are placing the central lines.  The current checklist for central line insertion is attached to this policy.
Ideally, central lines shall be removed no more than 7-10 days following insertion unless there are extenuating circumstances, which should be documented in the medical record.  Peripherally-inserted central catheter (PICC) lines are exempt from this requirement.  The primary service responsible for patient care shall monitor central lines for duration of insertion and signs of CLABs.  If the patient has a positive blood culture (as defined by CDC guidelines), the primary service will complete and forward a Root Cause Analysis (RCA) form to the Director of Epidemiology.  The current RCA form is attached to this policy.
The Materials Management service shall only distribute central line insertion materials and catheters to dedicated central line placement teams, and the procedural areas and patient care units where the physicians have privileges to insert central lines (see #2 above).  Sterile tubing to facilitate venous manometry shall be distributed with central line insertion materials  Central line insertion supplies shall be restricted to resuscitation carts and other emergency supply locations on patient floors.
NOTES ON LIMITATIONS OF THE TECHNIQUES TO PREVENT INADVERTENT ARTERIAL CANNULATION:
No one technique is guaranteed to be completely accurate in confirming venous location of a needle or catheter.
The following issues must be considered in interpreting these tests:
The “arterial-like” blood spurt and “arterial-looking” blood color are unreliable markers of the exact arterial location of a catheter and should not be used as confirmation of position, except in dire emergencies, such as CPR.
Manometric observation of a liquid column in the tubing connected to the catheter will provide a rough estimate of the venous or arterial nature of the intravascular pressure. However, manometric observation can be misleading in circumstances where the arterial pressure is low and the venous pressure is high.
Blood gas analysis is most effective when the sample from the central line is compared with a known arterial sample, or is <50 mm Hg in the presence of a high arterial saturation (>90%) as assessed using pulse oximetry.
Radiologic interpretation of a single planar image is not conclusive evidence of central venous catheterization due to the proximity of arterial and venous structures in the thorax.

CENTRAL VENOUS CATHETERIZATION SAFETY POLICY

This policy pertains to all elective central venous catheterizations. The policy does not apply during emergency circumstances.  Ultrasonic guidance of central venous catheterization reduces the incidence of inadvertent arterial cannulation. Ultrasonic vessel finder usage is required in all non-emergency internal jugular central venous catheterizations performed without fluoroscopy.

All elective central line insertions on patient floors will be performed by dedicated central line placement teams, such as the Surgical and Medical Intensive Care Unit Line Placement Services.

Appropriately privileged physicians who practice anesthesia, emergency medicine, critical care, and interventional procedures (interventional cardiologists, interventional radiologists, and nephrologists) may insert elective central lines in their procedural areas.  The Chief Medical Officer may identify other physicians that may receive privileges to insert elective central lines in specific procedural areas.

The attending physician must be present and visually supervise critical portions of the procedure, especially the confirmation of catheter placement within the central venous circulation.

A surgeon who has privileges to insert surgical central lines (e.g., Broviac catheters) in the operating rooms shall not place elective central lines outside of the operating room setting unless he/she is a member of a dedicated central line placement team or otherwise qualified as defined by the Chief of Service and the Chief Medical Officer.

Non-contrast radiographic examination will NOT be used to confirm the venous position of central venous catheters.  Radiologic examination is useful for determining the depth of insertion and the presence or absence of complications related to the central line placement, such as pneumothorax or hemothorax.

For all central venous lines, the techniques to be used for confirmation of venous placement include:

Observation of the intravascular pressure waveform using an electronic transducer and pressure tubing;

Determination of the of the intravascular pressure using sterile tubing as a venous manometer;

Analysis of the PO2 of a blood specimen drawn from the needle/catheter;

Using real-time fluoroscopic or echocardiographic confirmation of venous catheterization (e.g., visualizing the guide wire or catheter within the superior vena cava); or

Using a contrast study to opacify the venous structures.

For Insertion of Large-Bore Catheters and Introducers

To prevent inadvertent arterial cannulation with large-bore catheters (>5 French diameter or equivalent pediatric sizes), venous localization of the introducing needle or (angio) catheter must be confirmed by one or more of several techniques noted above prior to vessel dilation.  If technically unfeasible to conduct a confirmatory test with a short catheter or introducer needle prior to dilation, the recommendation is that a temporary catheter (<5 French) be placed to conduct one of the confirmatory methods.

In the event that no confirmatory test is conclusive, then the catheter must be removed.

The medical and nursing personnel present at the central line insertion must complete all applicable checklists, follow strict asepsis, and use all precautions currently required by the Central Line Associated Bloodstream Infection (CLABs) protocols of The Mount Sinai Hospital.  Nursing personnel will retain the authority to supervise and intervene to ensure that CLABs protocols are followed by the physicians and teams that are placing the central lines.  The current checklist for central line insertion is attached to this policy.

Ideally, central lines shall be removed no more than 7-10 days following insertion unless there are extenuating circumstances, which should be documented in the medical record.  Peripherally-inserted central catheter (PICC) lines are exempt from this requirement.  The primary service responsible for patient care shall monitor central lines for duration of insertion and signs of CLABs.  If the patient has a positive blood culture (as defined by CDC guidelines), the primary service will complete and forward a Root Cause Analysis (RCA) form to the Director of Epidemiology.  The current RCA form is attached to this policy.

The Materials Management service shall only distribute central line insertion materials and catheters to dedicated central line placement teams, and the procedural areas and patient care units where the physicians have privileges to insert central lines (see #2 above).  Sterile tubing to facilitate venous manometry shall be distributed with central line insertion materials  Central line insertion supplies shall be restricted to resuscitation carts and other emergency supply locations on patient floors.

NOTES ON LIMITATIONS OF THE TECHNIQUES TO PREVENT INADVERTENT ARTERIAL CANNULATION:

No one technique is guaranteed to be completely accurate in confirming venous location of a needle or catheter.

The following issues must be considered in interpreting these tests:

The “arterial-like” blood spurt and “arterial-looking” blood color are unreliable markers of the exact arterial location of a catheter and should not be used as confirmation of position, except in dire emergencies, such as CPR.

Manometric observation of a liquid column in the tubing connected to the catheter will provide a rough estimate of the venous or arterial nature of the intravascular pressure. However, manometric observation can be misleading in circumstances where the arterial pressure is low and the venous pressure is high.

Blood gas analysis is most effective when the sample from the central line is compared with a known arterial sample, or is <50 mm Hg in the presence of a high arterial saturation (>90%) as assessed using pulse oximetry.

Radiologic interpretation of a single planar image is not conclusive evidence of central venous catheterization due to the proximity of arterial and venous structures in the thorax.

Written by reuben

March 12th, 2010 at 5:00 pm

Isolyte (Elmhurst)

Hi folks,

In the IV fluid cart in the trauma room, we are stocking a fluid called isolyte.
It is very similar to lactated ringers with three exceptions:
1. It does not contain lactate so it will not affect lactate levels in shock patients
2. It is a true isotonic solution, so it can be used in head injury patients
3. It has no calcium, so it is compatible with blood products

This begs the question: why don’t we just replace LR with isolyte.
Problem is that it costs twice as much, which when you talk about fluid bags still is not very much money, but it adds up.
At this point, the appropriate patient pop. to use this fluid is preexisting acidosis (bad DKA, sepsis, etc.) where NS will make things worse and you still want to send lactates.

Scott Weingart

Written by reuben

April 8th, 2009 at 5:12 pm

Prevention of Unrecognized Arterial Cannulation

Written by phil

August 17th, 2008 at 12:01 pm