Video intubation

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Bougie-aided cric

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needle cric

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finger thoracostomy

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Considerations:

• For most patients, needle thoracostomy should be sufficient

• Consider Finger thoracostomy for patients with:

  • refractory pathology

  • unfavorable body habitus

  • in cardiac arrest

• Provide Ancef if time permits, analgesia, and place chest seal dressing

pericardiocentesis

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t-pod

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CAT (combat application tourniquet)

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EZ-IO

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ktd (kendrick traction device)

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minnestoa tube

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Indications:

• Confirmed or suspected variceal upper GI bleed (gastric or esophageal)

  AND

• Life threatening hemorrhagic shock as evidenced by:

  • Shock index > 1.3

  • Significant pressor requirement despite blood product administration

  • Greater than 8 units of blood products given in 2 hours

  • Worsening hemodynamic instability and imminent cardiac arrest

Contraindications: Previous gastric bypass (risk of stomach rupture with gastric balloon inflation)

Minnesota Tube Adapter Preparation

• Minnesota tube should have inflation adaptors preassembled (Picture 2).

• Connect IV caps to three way stop cocks

• Connect stop cocks to the balloon inflation ports leaving the balloon inflation side ports occluded with white plastic funnel pieces (Picture 3).

Minnesota Tube Placement:

• Test balloons, inflate underwater to ensure no leaks, fully deflate

• Patient should be intubated prior to tube placement, preferably with rocuronium to assist with passage of tube

• Insert Minnesota tube like an OG tube to 50 cm

  • A laryngoscope and McGill forceps may assist with placement

  • Consider the Eschmann Stylet (aka “Bougie”) assisted method

• Inflate 50 mL of air into gastric balloon (Picture 4)

• Confirm gastric balloon is below diaphragm on XR

Gastric Hemorrhage Management:

• Inflate gastric balloon fully to a total of 500 mL, clamp balloon port (Picture 5)

• Retract tube gently until hold up is felt (usually ~40 cm)

• Secure tube with Hollister ETT holder under 1-2 lbs. of tension

  • Same Hollister is used for both ETT and Minnesota tube; an additional tube clamp is placed in series next to the ETT clamp (Picture 9).

Esophageal Hemorrhage Management:

• Aspirate from the esophageal aspiration port (Picture 6)

• If blood return, then inflate esophageal balloon to 30 m Hg using cufflator (pressure may vary slightly with ventilator cycles, Picture 7)

• Re-aspirate and if continued bleeding then inflate to 45 mmHg, clamp balloon port (Picture 8)

Assessing a Tube Placed by Another Provider:

• Identify tube type

  • Sengstaken-Blakemore tube

    1. 250 cc gastric balloon AND esophageal balloon

    2. Single gastric aspiration port

  • Minnesota tube

    1. 500 cc gastric balloon AND esophageal balloon

    2. Gastric aspiration port AND esophageal aspiration port

  • Linton-Nachlas tube

    1. 600 cc gastric balloon

    2. Single gastric aspiration port

• MANDATORY recent CXR should be obtained to confirm appropriate placement

• MANDATORY cuff pressure on esophageal balloon should be checked

• If tube is identified to be incorrectly placed then it should be corrected

• Tube should be secured with Hollister ETT holder for transport

• Aspirate all blood from the gastric aspiration port, clamp port

Bougie Assisted Minnesota Tube Placement:

1. A bougie may be used as an adjunct for assistance with placement of the Minnesota tube

2. Place the straight end of the bougie (not the coude tip) into the most proximal of the three gastric aspiration ports, insert approximately 0.5 cm

3. The fully assembled apparatus may be inserted as an OG by pushing the bougie intentionally down the esophagus

4. Once fully inserted to 50 cm inflate gastric balloon with 50 mL of air and verify placement below diaphragm with CXR

5. Continue inflating gastric balloon to 500

6. In one swift movement remove the bougie. The inflated Minnesota tube will remain in place. Previous placement of the bougie in the most proximal of the three gastric aspiration holes should prevent folding of the distal Minnesota tube between the inflated gastric balloon and gastric fundus.

lateral canthotomy

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Indications:

 “Look for proptosis, feel for pressure elevation, evaluate for visual dysfunction.”

• 2 out of 3 of the following must be present

  • Proptosis

  • Elevated IOP (by palpation)                  

  • Presence of an APD OR inability to count fingers 

Relative Contraindications :

• Suspected globe rupture (caution with palpation).

• Patient refusal or inability to tolerate procedure due to pain or anxiety.

• Other greater life threats (i.e. bigger fish to fry; GCS < 12, hypotension). Do not delay scene time for procedure. May consider doing in flight if time and flight permits

Exam Considerations:

• Assessing for proptosis

  • Caution to not mistake lid edema for proptosis. To assess for true proptosis the lids must be opened. This can be challenging when tight and edematous. This can be accomplished with assistance using 4x4s for traction, paperclips, and looking down on the patient’s face from the head of the bed

• Assessing elevated intra-ocular pressure

  • Gentle palpation of the globe can provide a rough assessment of the intra-ocular pressure. A hard “rock-like” globe is concerning. Avoid palpation if there is concern for globe rupture.

• Assessing visual acuity

  • And APD (afferent pupillary defect) is not equal to a blown pupil. The APD will still react consensually. Gross visual dysfunction will be evidenced by lack of ability to count fingers.

field amputation

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Indications

• Need for rapid removal of patient from environment due to EITHER life threatening patient medical factors (e.g., patient entrapped in MVC and peri-arrest) OR life threatening environment factors.

AND

• Entrapment of a limb amenable to amputation preventing removal of patient from environment.

Contraindications:

• Entrapment of limb at a proximal location precluding proper placement of tourniquet to control bleeding.

• Environmental factors that would make the procedure unsafe for the provider (e.g., car is on fire).

Considerations:

• Call medical control prior to performing

• If patient is awake MUST obtain consent

• If any awareness present provide analgesia/sedation with ketamine

Procedure:

• Place a tourniquet (CAT) as far distal as possible on the affected limb but proximal to the site of planned amputation (record tourniquet time)

• Prepare the skin using betadine, chlorhexidine, or alcoho

• Utilizing scalpel, make a circumferential skin incision at most distal point on the entrapped limb

• Incise through all of the soft tissue, down to bone

• Place Gigli saw around exposed bone and while holding a handle in each hand, perform slow back and forth motion while pulling tension on both ends of the saw in a “V” shape of roughly 90 degrees

• Cut completely through the bone

• Obtain hemostasis with direct pressure, application of a second tourniquet, and/or selective clamping of vessels

• Utilize bone wax if necessary to control bleeding from freshly cut bone

• Place sterile gauze over the end of limb and cover with an ace bandage

• If able to retrieve limb after amputation, place in hazardous materials bag and transport with patient

chest wall escharotomy

Indications:

• Chest wall full thickness burns hindering respiratory mechanics with imminent threat to life as evidenced by at-least one clinical indicator AND at-least one objective indicator.

  • Clinical Indicators:

    • Patient feels hard to ventilate with BVM

    • Lack of visible chest rise

  • Objective Indicators:

    • High pressures on BVM (>40 mmHg) despite removal of other potential obstructive hindrances (pneumothorax, obstructed ETT, right mainstem intubation).

    • High peak pressures on ventilator (>40 mmHg) with low tidal volumes without other more probable cause (Asthma/COPD, ARDS, vent dysynchrony).

    • Hypoxia (SpO2 < 90%) refractory to endotracheal intubation and not felt to be secondary to hypotension or another reversible etiology, e.g., a tension pneumothorax.

    • Persistently elevated EtCO2 (>60) despite adequate respiratory rate and tidal volumes.

    • Blood gas with evidence of significant respiratory acidosis despite adequate respiratory rate and tidal volumes (pH < 7.2, pCO2 > 60).

• Chest wall full thickness burns hindering BVM ventilation in a patient in full cardiac arrest undergoing CPR prior to termination of resuscitative efforts.

Relative Contraindications:

• Burns that are obviously non-compatible with life, i.e., burned beyond recognition

• Other greater threats to life needing assessment

• Procedure should not be done in flight

Procedure:

• Ensure patient has adequate analgesia and anxiolysis

• Outline the incision sites with marking pen (picture 1)

  • bilateral anterior axillary lines

  • elliptical incision inferior to the costal margin joining the vertical incisions

  • Avoid any incision below the clavicles

• Prep incision sites with chlorhexidine

• Incise with #10 blade through eschars until subcutaneous fat is visible

  • bleeding is normal and indicative of adequate release

  • Avoid cutting through fascia. 

• Run finger along incisions to break up fibrous bands

• Obtain hemostasis prior to transport

  • Pressure and gauze

  • Portable electrocautery device

• Place saline soaked kerlix in incision

Considerations:

• Strongly consider contacting medical control prior to performing

• Ensure hemostasis post-procedure

• Dress incision with saline soaked gauze/kerlix

resuscitative hysterotomy

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Indications:

• Pregnant female > 24 weeks gestation (fundus at umbilicus)

AND

• Cardiac Arrest < 15-20 minutes

  • Best outcomes if done within 5 minutes

  • Use crew judgment for 15-20 minutes

  • Strongly consider if any signs of life present

    • Spontaneous movements or breathing

    • Pupillary or gag reflexes present

    • PEA on monitor

Procedure:

• Large midline vertical incision from the umbilicus to the pubic symphysis (video 1). Cut through all layers of the abdominal wall. If apparent, use linea alba as a guide (video 2).

• Expose the anterior surface of the uterus. Move the bladder inferiorly. Try to avoid it, but do not waste excessive time retracting the bladder or catheterizing the patient.

• Make vertical incision through the lower uterine segment of the uterus until amniotic fluid is expressed (video 3). Insert index and long fingers into the defect lifting the uterus away from the fetus. Use scissors to extend the incision to the fundus

• Deliver infant (video 4). Apply pressure to the external part of the uterus to help deliver infant.

• Clamp and cut the cord. Then hand the infant off to an alternate provider for ongoing newborn resuscitation (video 5).

• Deliver the placenta (video 6).

• Pack the abdomen (video 7).

• Give oxytocin when available.

Considerations:

• Call medical control prior to performing

• As soon as loss of pulses noted, procedure should be started

• Crew resource management

  • If suspected sick mom then place 2nd helicopter on stand by

  • If no pulse then doc starts procedure, medic/nurse starts compressions

  • Nurse or Medic secures airway: iGel or ETT

  • Nurse prepares for newborn resuscitation, 2nd team en route