Do or Di-alysis there is no try... unless you use a trialysis catheter

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Ok, lets review the indications for emergent dialysis and the process of placing a dialysis catheter. Indications: -severe acidosis secondary to renal failure or unresponsive to medical therapy -toxic ingestion that is small not protein bound, such as alcohols salicylate, lithium, theophylline, valproate - symptomatic hyperkalemia - symptomatic hypernatremia -fluid overload with oliguria causing respiratory failure -uremia causing encephalopathy, pericarditis, or hemorrhage

placement:

**review your own kit to make sure you have everything you will need and to be mindful of possible extra steps for the following

  1. give anxiolysis if needed

  2. position patient and ultrasound for best place for your catheter

  3. sterilize skin

  4. prep your kit, gown, hat, mask, gloves, sterile cover for ultrasound

  5. flush lumens of your cathetern and apply lumen valves to each lumen but do not place one on the most distal luman through which your wire will pass

  6. have sterile heparin drawn up

  7. drape patient

  8. anesthetize skin

  9. find view use ultrasound guidance and advance needle into vein be sure to be drawing the syringe plunger back to aspirate for blood

  10. once in the lumen advance the needle slightly more in the middle of the lumen to prevent loosing your placement

  11. with non-dominant hand flatten need while making sure to not pull out of the vein

  12. remove syringe from the needle and advance your wire *if there is resistance ultrasound to recheck your placement

  13. advance wire while holding it securely (be sure to always have at least one hand holding the wire)

  14. remove needle

  15. load smaller dilator onto wire

  16. cut the dermis at wire insertion be sure to cutaway from wire

  17. advance dilator and push through skin with twisting motion and inline with trajectory of the wire

  18. remove dilator

  19. load second larger dilator and repeat steps 17 & 18

  20. remove dilator there will be lots of blood good job

  21. advance catheter holding close to the skin with a firm but gentle twisting motion

  22. remove wire

  23. check that all lumens draw back blood with ease

  24. flush each lumen with 1cc of heparin to prevent clotting of the catheter

  25. secure the catheter with sutures

  26. apply sterile dressing

  27. if in internal jugular of subclavian veins confirm placement with xray

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To Ponder Puncturing the Peritoneum?

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When and when not to perform paracentesis? Think of the indications for emergent paracentesis in a similar fashion to emergent thoracostomy.  Indications:

  • Relief of respiratory distress caused by massive ascites

  • Diagnostic for infection ie. suspected spontaneous bacterial peritonitis

Contraindications?

  • Overlying cellullitis

  • Vasculature or bowel obstructing desired site

  • Loculated fluid (concern this may be oncologic)

  • Significant coagulopathy INR < 8 platelets >20

2 minute EMRAP video outlining the procedure- https://youtu.be/9npNQM8ANds

Blog post explaining in-series suction canisters-  http://mmcedrco.w02.wh-2.com/EMBlog/suction-cannisters-in-series/

 

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Pulse Cooximeter: how to use it

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On my previous shift, we had 2 patients with a “gas” exposure at their apartment. 

So the clinical question arose: How can we rapidly screen patients with “gas” exposure? 

First, any abnormal vitals raise a red flag and automatically take us off the rapid discharge pathway. These patients need appropriate triage to (

likely

) north side. 

In any patient who has been exposed to a fire or there is concern for carbon monoxide exposure, we have the Masimo pulse-cooximeter. 

It is located in the south side charge nurse station. 

To utilize this device: hold down the power button while the pulse sensor is on the patients finger.

masimo_co-oximetry.jpg

After pressing the display button, it should look as below:

Please note that there is a continuous SpCO and SpMet in green on the left and right of the display, respectively. 

If results in an asymptomatic patient with a low risk exposure are normal, they can be safely discharged without further testing. However, in a symptomatic patient with a normal pulse-cooximetry, they should be further screened with blood gas cooximetry. Furthermore, a

ny abnormal value of %SpCO>5% should be repeated with a blood-cooximetry.

Smokers may have a baseline CO-Hgb of 5-6%, and may require confirmatory testing with blood-cooximetry through our blood gas lab. 

In short, if patient has a %SpCO <5% and is asymptomatic they may be safely discharged. This also requires a normal %SpO2 because %SpO2<85% decreases the accuracy of the Masimo pulse co-ox, as per the literature posted on their own product page. 

Final summary of this POD:

we have a pulse-cooximeter.

Utilize it for rapid screening and for reassurance of low risk patients. 

Please clean the finger sensor between patients with a purple wipe

As always: feedback both negative and positive IS STRONGLY ENCOURAGED. 

TR,

Wells 

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