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(BQ) Part 1 book Improvised medicine providing care in extreme environments presents the following contents: What is improvised medicine, what are resource poor situations, communications, preventive medicine public health, basic equipment, cleaning and reusing equipment,...
IMPROVISED MEDICINE Pro viding Care in Extre me Enviro nme nts Se co nd Editio n Kenneth V Iserson, MD, MBA, FACEP, FAAEM Fellow, International Federation for Emergency Medicine Professor Emeritus, Emergency Medicine The University of Arizona, Tucson, AZ Founder/ Director, REEME (www.reeme.arizona.edu) New York Chicago San Francisco Athens London Madrid Milan New Delhi Singapore Sydney Toronto Mexico City Copyright © 2016 by McGraw-Hill Education All rights reserved Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher ISBN: 978-0-07-184763-6 MHID: 0-07-184763-4 The material in this eBook also appears in the print version of this title: ISBN: 978-0-07-184762-9, MHID: 0-07-184762-6 eBook conversion by codeMantra Version 1.0 All trademarks are trademarks of their respective owners Rather than put a trademark symbol after every occurrence of a trademarked name, we use names in an editorial fashion only, and to the bene t of the trademark owner, with no intention of infringement of the trademark Where such designations appear in this book, they have been printed with initial caps McGraw-Hill Education books are available at special quantity discounts to use as premiums and sales promotions or for use in corporate training programs To contact a representative, please visit the Contact Us pages at www.mhprofessional.com Previous edition copyright © 2012 by The McGraw-Hill Companies, Inc NOTICE Medicine is an ever-changing science As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication However, in view of the possibility of human error or changes in medical sciences, neither the authors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in this work Readers are encouraged to rm the information contained herein with other sources For example and in particular, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this work is accurate and that changes have not been made in the recommended dose or in the contraindications for administration This recommendation is of particular importance in connection with new or infrequently used drugs TERMS OF USE This is a copyrighted work and McGraw-Hill Education and its licensors reserve all rights in and to the work Use of this work is subject to these terms Except as permitted under the Copyright Act of 1976 and the right to store and retrieve one copy of the work, you may not decompile, disassemble, reverse engineer, reproduce, modify, create derivative works based upon, transmit, distribute, disseminate, sell, publish or sublicense the work or any part of it without McGraw-Hill Education’s prior consent You may use the work for your own noncommercial and personal use; any other use of the work is strictly prohibited Your right to use the work may be terminated if you fail to comply with these terms THE WORK IS PROVIDED “AS IS.” McGRAW-HILL EDUCATION AND ITS LICENSORS MAKE NO GUARANTEES OR WARRANTIES AS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE McGraw-Hill Education and its licensors not warrant or guarantee that the functions contained in the work will meet your requirements or that its operation will be uninterrupted or error free Neither McGraw-Hill Education nor its licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages resulting therefrom McGraw-Hill Education has no responsibility for the content of any information accessed through the work Under no circumstances shall McGraw-Hill Education and/or its licensors be liable for any indirect, incidental, special, punitive, consequential or similar damages that result from the use of or inability to use the work, even if any of them has been advised of the possibility of such damages This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise Contents Preface to the Second Edition Acknowledgments Section I: The Situation What Is Improvised Medicine? Methods and Equipment Elegant Improvisation References What Are Resource-Poor Situations? Introduction Isolated Settings Remote Locations Least-developed Countries Disasters/Post-disaster Reducing Medical Improvisation Disaster Myths Ethics References Section II: Basic Needs Communications Post-disaster Communication Needs On-scene Command and Control Telephones Patient–Clinician Communication Local-area Communication Transferring Patient Information Teleconsultations Intra-institutional and Regional Communication Long-distance Communication References xi xiii 3 6 8 10 10 10 12 17 17 17 18 20 22 22 22 24 27 28 Preventive Medicine/Public Health Water Sanitation References 29 29 30 31 Basic Equipment Availability and Improvisation Facilities Essential Equipment Diagnostic Equipment Treatment Supplies/Equipment Patient Transport Equipment Safety/Maintenance Measurement Equivalents References 33 33 33 42 42 47 57 57 59 59 Cleaning and Reusing Equipment Policies on Reusing Medical Equipment Risk Stratification 61 61 61 iii iv CONTENTS Decontamination Cleaning Disinfection Sterilization Reusing Specific Equipment—Methods and Safety References Section III: Patient Assessment/Stabilization Vital Signs, Measurements, and Triage Pediatrics Adults Measuring Temperature Without a Thermometer Pulse and Respirations Blood Pressure Geriatric Vital Signs Pediatric Vital Signs Measuring Length, Area, and Volume Color Blood Loss Monitoring Patients Disaster Triage Diagnosing Death References 62 62 62 69 70 73 79 79 81 82 82 84 87 87 88 90 92 93 93 98 99 Airway Basic Airway Management Evaluate for Difficult Intubations Improvised Non-intubation Airways Indications to Intubate Improvised Intubation Equipment Non-laryngoscopic Intubation Laryngoscopic Intubation Tests for Endotracheal Tube in Trachea Post-intubation Management Surgical Airways References 102 102 103 107 110 110 115 123 124 127 129 134 Breathing/Pulmonary Lung Sounds Quantifying Pleural Fluid Using Ultrasound Pulmonary Treatment Makeshift Spirometers Oxygen Ventilation References 138 138 138 138 140 142 144 148 10 Circulation/Cardiovascular Diagnosis: Electrocardiogram Treatment Cardiopulmonary Resuscitation References 150 150 152 154 156 11 Dehydration/Rehydration Assessment Rehydration Plan Rapid Realimentation 158 158 159 161 CONTENTS Oral Rehydration Nasogastric Rehydration Intravenous Fluids References v 162 166 167 171 12 Vascular Access—Intravenous, Intraossseous, Clysis, and Peritoneal Intravenous Hydration Methods of Locating and Dilating Peripheral Veins Securing Intravenous Catheters Intraosseous Infusion Alternative Parenteral Hydration References 174 174 175 176 176 178 184 13 186 186 193 197 199 200 Medications/Pharmacy/Envenomations Six Problems Involving Medication The Pharmacy Toxicology Treatment Venomous Bites and Stings References 14 Analgesics Assessing Pain Treating Pain Uncommon Analgesics and Adjuvants Alternative Administration Methods References 203 203 204 206 210 214 15 217 217 219 223 232 236 236 239 239 241 Anesthesia—Local and Regional Topical Anesthetics Local Anesthetic Infiltration Regional Blocks Refrigeration Anesthesia: Amputations Testing an Anesthetic Block Spinal Anesthesia Epidural Blocks Hypnosis References 16 Sedation and General Anesthesia Introduction General Anesthesia Guidelines Anesthesia in Special Circumstances Procedural Sedation Intravenous General Anesthesia General Inhalation Anesthetics Rectal Anesthesia Anesthesia for Cesarean Sections Anesthesia Delivery Systems Postoperative Recovery References 244 244 245 250 251 254 255 256 257 258 260 260 17 262 262 262 269 277 278 Anesthesia: Ketamine, Ether, and Halothane Why This Chapter? Ketamine Ether Halothane References vi CONTENTS 18 Transfusion Dangers in Blood Supply Avoiding Blood Transfusion Deciding When to Transfuse Transfusing Blood How to Transfuse Autologous Blood Typing Blood Walking Blood Bank Blood Bank Blood Warming Alternatives to Standard Transfusion References 280 280 280 280 282 282 286 286 288 288 290 291 19 Radiology/Imaging Nonimage Diagnoses Essentials Viewing X-Rays Detecting Pneumothoraces on Supine Chest Radiographs Estimating the Size of a Pneumothorax Contrast Studies Stereoscopic Imaging Ultrasound References 294 294 294 294 296 296 297 298 300 304 20 Laboratory Laboratory Services Essentials Equipment and Materials Conversion Factors Sputum Blood Urine Stool Cerebrospinal Fluid Point-of-Care and Home Tests Restoring Equipment’s Operating Temperature References 305 305 305 305 313 314 315 317 318 319 320 320 320 21 Patient Transport/Evacuations Medical Transport in Austere Circumstances Transport the Patient? Prehospital Fluid Therapy Ivs During Transport Transporting Patients Without Litters Litters Vertical Transport Non-ambulance Transportation Aeromedical Transport Hospital/Health Care Facility Evacuation References 322 322 322 322 322 323 325 329 331 334 340 345 Section IV: Surgical Interventions 22 Surgical Equipment Wound Glues Staples Binding/Taping 349 349 350 351 CONTENTS Suture Materials Suture Needles Needle Holders Scalpels Skin Hooks Mayo Safety Pin Sponges/Lap Pads/Gauze Substitutes Cautery Sucker Petroleum Jelly Gauze Retractors Tweezers Improvised Curettes from Clamps Wound Bolsters–Urinary Catheter or Nasogastric Tube Marking Surgical Sites Sterile Drapes Surgical Table Cotton-tipped Applicators Disposal of Small Surgical Waste Protection from Injection Backspray Protection Against “Sharps” Needle Safety References vii 351 353 354 354 355 355 355 356 356 357 357 357 357 358 358 358 358 358 359 359 359 359 361 23 Surgery: Non-Trauma and Environmental Injuries Austere Surgical Situations Abdomen Environmental Injuries References 363 363 366 368 371 24 Surgery: Trauma Prioritizing Patients for the Operating Room Raking and Sweeping for Undetected Wounds Neck Abdomen Chest Injuries References 373 373 373 373 374 376 382 385 25 387 387 400 409 Wounds and Burns Wound Care Burns References 26 Dental: Diagnosis, Equipment, Blocks, and Treatment Basic Dental Anatomy Prevention/Cleaning Pain Without Trauma Dental Instruments and Equipment Cyanoacrylate for Dental Emergencies Anesthesia and Analgesia References 413 413 414 415 421 423 424 428 27 430 430 432 436 442 Dental: Fillings, Extractions, and Trauma Filling Cavities Extractions Oral Trauma References viii CONTENTS 28 Otolaryngology (Ear, Nose, and Throat) Headrest Regional Nerve Blocks Ear Nose Mouth/Pharynx Trauma References 444 444 444 444 446 452 454 456 29 Neurology/Neurosurgery Evaluation/Diagnosis/Treatment Trauma References 458 458 463 474 30 Ophthalmology Diagnostic Examination and Equipment Treatment and Equipment References 478 478 485 489 31 Obstetrics/Gynecology Gynecology Obstetrics References 491 491 495 508 32 Orthopedics Diagnosis of Fractures, Dislocations, and Soft-tissue Injuries Reduction and Treatment of Fractures and Dislocations Other Treatment Splints and Casts Traction Management of Complex Fractures Fracture Healing Times Analgesia Rehabilitation References 511 511 519 526 528 535 540 541 541 542 543 33 Urology Bladder Drainage/Tubes Diagnosis Penis and Prostate References 547 547 550 551 552 Section V: Nonsurgical Interventions 34 Gastroenterology Treatment Procedures References 35 Infectious Diseases Epidemics/Outbreaks Prevention Diagnosis Skin Lesions Treatment References 557 557 561 565 567 567 567 571 576 580 583 CONTENTS ix 36 Malnutrition Recognizing Malnutrition Malnutrition in Elderly Adults Classification of Pediatric Malnutrition Malnutrition Management in Children Preventable Nutritional Disorders References 585 585 586 586 587 591 592 37 Pediatrics and Neonatal General Approach to Children Hospitalized and Very Ill Children Neonates/Infants Equipment Procedures Children References 593 593 593 593 600 603 607 608 38 Psychiatry Basic Approach Diagnosis Treatment References 611 611 612 619 623 39 Rehabilitation Therapy Mobility and Activities of Daily Living References 625 625 626 631 40 Death and Survivors Risk of Disease from Corpses Body Recovery and Disposition Post-disaster Forensics Survivors References 632 632 633 637 641 642 Section VI: Appendices Appendix 1: Hospital Disaster Plan Appendix 2: Medical Kits 645 650 Index 655 Air w Ay 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 135 Grosshandler S, Vlazny F Universal adapter for endotracheal tubes Anesthesiology 1964;25:727 Albert SN A “homemade” endotracheal-tube adaptor Anesth Analg 1973;52(1):79-80 King MH, ed Primary Anesthesia Oxford, UK: Oxford University Press; 1986:102 Brock-Utne JG A leaking endotracheal tube in a prone patient Clinical Anesthesia: Near Misses and Lessons Learned New York, NY: Springer; 2008:127-128 Briskin A, Drenger B, Regev E, et al Original method for in situ repair of damage to endotracheal tube Anesthesiology 2000;93(3):891-892 Choi PT-L, Rhyddercb G An unusual cause of elevated airway pressures Can J Anaesth 1998;45:381 Bern MJ, Wilson IH Coathanger wire, as an aid to endotracheal intubation Trop Doct 1991;21(3): 122-123 Dexheimer Neto FL, de Andrade JMS, Raupp ACT, et al Use of a homemade introducer guide (bougie) for intubation in emergency situation in patients who present with difficult airway: a case series Brazilian J Anesth (English Ed.) March 2014, online Manos SJ, Brock-Utne JG, Jaffe RA An alternative to the gum elastic bougie and/or the jet stylet Anesth Analg 1994;79:1017 Tate N Transillumination of the larynx Lancet 1955;ii:980 Essien CK What you when the laryngoscope bulb fails during intubation? Pract Proced 1995;5(9):1 http://www.nda.ox.ac.uk/wfsa/html/u05/u0509_015.htm Accessed September 13, 2006 Ayim E, Bewes PC, Cory C, et al Primary Anaesthesia Oxford, UK: Oxford University Press; 1986:102 Gillett GB, Patkin M A laryngoscope for emergency use Anaesthesia 1964;19:595-597 Staff of CMC Hospital Vellore The Vellore laryngoscope J Christ Med Assoc India 1965;40:459 Yeats M Maintaining your laryngoscope Pract Proced 2004;4:(9)1 www.nda.ox.ac.uk/wfsa/html/ u04/u04_018.htm Accessed September 13, 2006 Roark GL Use of a fiberoptic cystoscope to facilitate intubation in a difficult airway Trop Doct 2006;36:104-105 Iserson KV Blind nasotracheal intubation Ann Emerg Med 1981;10(9):468-471 Tintinalli FE, Claffey J Complications of nasotracheal intubation Ann Emerg Med 1981;10(3): 142-144 Iserson KV Blind nasotracheal intubation—a model for instruction Ann Emerg Med 1984;13(8):6012 Reprinted in: Can J Prehosp Med 1986;1(3):30-31 Van Elstraete AC, Pennant JH, Gajraj NM, et al Tracheal tube cuff inflation as an aid to blind nasotracheal intubation Br J Anaesth 1993;70:691-693 Van Elstraete AC, Mamie JC, Mehdaoui H Nasotracheal intubation in patients with immobilized cervical spine: a comparison of tracheal tube cuff inflation and fiberoptic bronchoscopy Anesth Analg 1998;87:400-402 Casals-Caus P, Mayoral-Rojals V, Canales MA, et al El inflado del neumotaponamiento como ayuda para la intubación nasotraqueal a ciegas en pacientes predicción de laringoscopia difícil [Inflation of the cuff as an aid to blind nasotracheal intubation in patients with predicted difficult laryngoscopy.] Rev Esp Anestesiol Reanim 1997;44:302-304 Dryden GE Use of a suction catheter to assist blind nasal intubation (letter) Anesthesiology 1974; 45:260 Sloan EP, VanRooyen MJ Suction catheter-assisted nasotracheal intubation Acad Emerg Med 1994; 1:388 Findlay CW, Gissen AJ A guided nasotracheal method for insertion of an endotracheal tube Anesth Analg 1961;40(6):460-462 Kite C An Essay on the Recovery of the Apparently Dead London, UK: C Dilly in the Poultry; 1788 Hardwick WC, Bluhm D Digital intubation J Emerg Med 1984;1(4):317-320 Young SE, Miller MA, Crystal CS, et al Is digital intubation an option for emergency physicians in definitive airway management? Am J Emerg Med 2006;24(6):729-732 Stewart RD Tactile orotracheal intubation Ann Emerg Med 1984;13:175-178 Cook RT A modification to the standard digital intubation technique Am J Emerg Med 1992;10:396 Woody NC, Woody HB Direct digital intratracheal intubation for neonatal resuscitation J Pediatr 1968;73(6):903-905 Hancock P, Peterson G Finger intubation of the trachea in newborns Pediatrics 1992;89:325-327 Benumof JL Management of the difficult airway Anesthesiology 1991;75:1087-1110 136 PATiENT AS S ES S MENT/S TABiLiZATiON 61 Breen PH Simple technique to remove laryngeal mask airway “guide” after endotracheal intubation (letter) Anesth Analg 1996;82:1302 62 Breen PH An alternative way to remove the laryngeal mask airway “guide” after intubation (letter) Anesth Analg 1997;85:948-949 63 Kyama S An alternative way to remove the laryngeal mask airway “guide” after intubation (letter) Anesth Analg 1997;85:948-949 64 Barnard EBG, Moy RJ, Kehoe AD, Bebarta VS, Smith JE Rapid sequence induction of anaesthesia via the intraosseous route: a prospective observational study Emerg Med J June 24, 2014 (online) 65 Dobson MB Anaesthesia at the District Hospital 2nd ed Geneva, Switzerland: WHO; 2000:76-77 66 Morris IA Pharmacologic aids to intubation and the rapid sequence induction Emerg Med Clin North Am 1988;6(4):753-768 67 Kenny JF, Molloy K, Pollack M, et al Nebulized lidocaine as an adjunct to endotracheal intubation in the prehospital setting Prehosp Disaster Med 1996;11(4):312-313 68 King M Primary Surgery, Vol 2: Trauma Oxford, UK: Oxford University Press; 1987:11 69 Pearson JW, Safar P General anesthesia with minimal equipment Anesth Analg 1961;40(6):664-671 70 Walts LF, Kassity KJ Spread of local anesthesia after upper airway block Arch Otolaryngol 1965;81: 77-79 71 Boulton TB Anesthesia in difficult situations The use of local analgesia Anaesthesia 1967;22(1): 101-133 72 Duncan JAT Intubation of the trachea in the conscious patient Br J Anaesth 1977;49:619-623 73 Dobson MB Anaesthesia at the District Hospital 2nd ed Geneva, Switzerland: World Health Organization; 2000:89 74 Prior FN Anaesthetic household hints J Christian Med Assoc India 1964;39:282-287 75 Danzl DF, Thomas DM Nasotracheal intubation in the emergency department Crit Care Med 1980;8: 677-682 76 Gold MI, Buechel DR Translaryngeal anesthesia: a review Anesthesiology 1959;20:181-185 77 Botha MJ, Wells M Ujuzi (Practical Pearl/Perle Pratique) African J Emerg Med 2014 (in press) 78 Dobson MB Anaesthesia at the District Hospital 2nd ed Geneva, Switzerland: World Health Organization; 2000:14, Table 79 Andersen KH, Hald A Assessing the position of the tracheal tube: the reliability of different methods Anaesthesia 1989;44:984-985 80 Baigel G, Safranske J Clinical test to confirm tracheal intubation: a new method to confirm endotracheal intubation in the absence of capnography Eur J Anaesth 2003;20:475-477 81 Sellers SF, Holesworth SP Updating Wee’s oesophageal detector Anaesthesia 2003;8(6):615-616 82 Nicoll SJB, King CJ Airway auscultation: a new method of confirming tracheal intubation Anaesthesia 1998;53:41-45 83 Kaldirim U, Tuncer S, Eyi YE Does ultrasonographic lung sliding sign always verify the success in endotracheal tube intubation? Am J Emerg Med 2014;32:472 84 Raphael DT, Conard FU Ultrasound confirmation of endotracheal tube placement J Clin Ultrasound 1987;15:459-62 85 Sun JT, Sim SS, Chou HC, et al Ultrasonography for proper endotracheal tube placement confirmation in out-of-hospital cardiac arrest patients: two-center experience Crit Ultrasound J 2014;6(suppl 1); A29 86 Wee MYK The esophageal detector device: assessment of a new method to distinguish esophageal from tracheal intubation Anaesthesia 1988;43:27-29 87 O’Leary JJ, Pollard BJ, Ryan MJ A method of detecting esophageal intubation or confirming tracheal intubation Anaesth Intensive Care 1988;16:299-301 88 Nunn JF The esophageal detector device (letter) Anaesthesia 1988;43:804 89 Haridas RP Oesophageal detector devices Update Anaesth 1997;7(6) www.nda.ox.ac.uk/wfsa/html/ u07/u07_016.htm Accessed September 14, 2007 90 Zaleski L, Abello D, Gold MI The esophageal detector device Anesthesiology 1993;79:244-247 91 Wee MYK, Walker AKY The oesophageal detector device: an assessment with uncuffed tubes in children Anaesthesia 1991;46:869-871 92 Haynes SR, Morton NS Use of the oesophageal detector device in children under one year of age Anaesthesia December 1990;45(12):1067-1069 93 Jensen Neils F Securing an endotracheal tube in the presence of facial burns or instability (letter) Anesth Analg 1992;75:633-646 Air w Ay 137 94 Botts J, Srivastava KA, Matsuda T, et al Interdental wire fixation of endotracheal tube for surgery of severe facial burns Ann Burns Fire Disasters 1998;11(3):168-170 95 Kumar R, Mittal S, Kumar S, et al An easily available device as a makeshift tube changer J Anaesth Clin Pharmacol 2004;20(4):417-418 96 Murphy MF, Walls RM Identification of the difficult and failed airway In: Walls RM, Murphy MF, eds Manual of Emergency Airway Management 3rd ed Philadelphia, PA: Lippincott Williams & Wilkins; 2008:81-92 97 Husum H, Ang SC, Fosse E War Surgery: Field Manual Penang, Malaysia: Third World Network; 1995:139 98 Langvad S, Hyldmo PK, Anders Rostrup Nakstad AR, et al Emergency cricothyrotomy—a systematic review Scand J Trauma Resusc Emerg Med 2013;21:43 99 Katzenell U, Lipsky AM, Abramovich A, et al Prehospital intubation success rates among Israel Defense Forces providers: epidemiologic analysis and effect on doctrine J Trauma Acute Care Surg 2013;75(2):S178-S183 100 Murphy C, Wong DT Airway management and oxygenation in obese patients Can J Anesth 2013;60(9): 929-945 101 Bramwell KJ, Davis DP, Cardall TV, et al Use of the Trousseau dilator in cricothyrotomy J Emerg Med 1999;17(3):433-436 102 Jackson AS Emergency care of the trauma patient in remote regions of Papua New Guinea Papua New Guinea Med J 2002;45(3-4):222-232 103 Adams BD, Whitlock WL Bystander cricothyroidotomy performed with an improvised airway Mil Med January 2002;167:76-78 104 Fisher JA A “last ditch” airway Can Anaesth Soc J 1979;26:225-230 105 Blanas N, Fisher JA A “last ditch” airway revisited Can J Anaesth 1999;46(8):809-810 106 Platt-Mills TF, Lewin MR, Wells J, et al Improvised cricothyrotomy provides reliable airway access in an unembalmed human cadaver model Wild Environ Med 2006;17:81-86 107 McLaughlin JH, Iserson KV Emergency pediatric tracheotomies—a usable technique and model for instruction Ann Emerg Med 1986;15(4):463-465 108 Griggs WM, Gilliagan JE, Myburg JA A simple percutaneous tracheostomy technique Surg Gynecol Obstet 1990;170:543-545 109 Soni N Percutaneous tracheostomy: how to it Br J Hosp Med 1992;57(7):339-345 110 Bailitz JM Tracheostomy tubes in the emergency department: tricks & troubleshooting ACEP Scientific Assembly, Seattle, WA, October 11, 2007 111 Berrouschot J, Oeken J, Steiniger L, et al Perioperative complications of percutaneous dilational tracheostomy Laryngoscope Nov 1997;107(11 Pt1):1538-1544 112 Allan JS, Wright CD Tracheoinnominate fistula: diagnosis and management Chest Surg Clin North Am May 2003;13(2):331-341 Breathing/ Pulmonary LUNG SOUNDS Clinicians are exhorted to always place their stethoscopes directly on a patient’s skin Yet, when patients are examined in hallways and prehospital settings or in locations where cultural norms prevent patients from disrobing, this rule is often violated That is not a problem: By applying pressure on the stethoscope head, clinicians can hear all the sounds normally heard on bare skin, through up to two layers of indoor clothing—including double-layered flannel shirts Of course, inspection and percussion cannot be done through clothing, and clothing-induced acoustic artifacts may create problems.1 QUANTIFYING PLEURAL FLUID USING ULTRASOUND Estimate the amount of pleural fluid using an ultrasound examination on supine patients Elevate the chest to 15 degrees and move the probe perpendicular to the body axis along the posterior axillary line Measure the maximal pleural separation, which is usually visible at the lung base The simplified formula is: Volume of pleural fluid (mL) = 20 × Maximal distance between parietal and visceral pleura in end expiration (mm).2 PULMONARY TREATMENT Aerosols and Spacers The use of aerosol spacers more than doubles the amount of medication delivered to the lungs from metered-dose inhalers (MDIs); for steroid inhalers, an aerosol spacer diminishes the incidence of oral candidiasis by decreasing deposition in the oropharynx The tube from a roll of toilet paper works well as an aerosol spacer, as does a piece of ventilator tubing Dr Lara Zibners-Lohr wrote that in remote areas of the world, she uses large Styrofoam cups The cup lip (open end) goes over the nose and mouth The MDI goes through a hole in the bottom end of the cup She uses just the blue tubing from a nebulizer for older children: they close their mouth around one end and put the MDI in the other (Personal written communication, June 5, 2007.) Dr Karen Schneider uses a dry water bottle with a hole in the bottom for the MDI The hole is sealed with tape, leaving a small opening to allow air movement from the outside when the child inhales The inside of the bottle must be dry; otherwise, the aerosolized particles will stick to the water When the MDI is activated, the child places his or her mouth over the drinking end and inhales a few times until the mist is cleared (Fig 9-1) It is important that the child not exhale into the bottle because this will blow the mist out the small hole (Written communication, June 5, 2007.) Improvised spacers have been shown to be just as effective as the expensive commercial spacers.3 Treating Persistent Cough An unremitting cough may be due to airway hyperirritability caused by an upper respiratory infection, toxic inhalation, asthma (sometimes unrecognized), allergens, or the use of angiotensinconverting enzyme (ACE) inhibitors The cough is uncomfortable for the patient and may worsen bronchospasm For adults and children, add 0.5 mg/kg of lidocaine to 0.3 mL of albuterol solution in mL of normal saline; administer the combination by aerosol nebulization Lidocaine suppresses the cough reflex while the sympathomimetic agent relieves the bronchospasm.4 Positioning to Improve Lung Function and Maximize Oxygenation In patients with unilateral lung disease, positioning the healthy lung down—in the most dependent position possible—may improve the ventilation–perfusion mismatch and raise oxygen saturation levels This may buy valuable time, turning an emergent situation into an urgent one.5 138 Br e a t h in g /Pu l mo n a r y 139 FIG 9-1 Water bottle used as spacer by Dr Schneider in Peru (Drawn from a photo contributed by Dr Karen Schneider.) The FiO2 can be doubled by combining nasal oxygen (15 liters/minute) and non-rebreather face mask oxygen (15 L/min) (Fig 9-2) The technique delivers close to 100% FiO2 (rather than the typical 60%) by eliminating the accumulation and rebreathing of CO2 in the mask, hypopharynx, and nasopharynx This method is useful to buy time to set up formal noninvasive ventilation (NIV) equipment or to more quickly preoxygenate before intubation If using a bag-valve-mask (BVM), attach a positive end-expiratory pressure (PEEP) valve (set the dial at mm Hg) to produce a slightly positive end-expiratory pressure through the ventilation cycle.6 Under anesthesia, and probably in other critical care situations, morbidly obese patients have a wide alveolar–arterial oxygen gradient [P(A-a)O2] However, when they are placed in the reverse Trendelenburg position (RTP), with their head higher than their feet, their A-a gradient shows a significant improvement and a return toward baseline In addition, total respiratory system compliance is significantly higher in RTP, suggesting that RTP is an appropriate position Oxyge n fa ce ma s k Na s a l oxyge n tubing FIG 9-2 Nasal prongs combined with non-rebreather face mask 140 Pa t ie n t a S S e S S me n t /S t a Bil iZa t io n for obese subjects who can tolerate it, because it causes minimal arterial blood pressure changes and improves oxygenation.7 Sitting a ventilated patient up also helps avoid gastric aspiration Use this simple maneuver in any patient whose blood pressure can tolerate a semi-recumbent or upright position.8 Makeshift Noninvasive Ventilation (NIV) Clinicians now commonly use noninvasive ventilation to avoid or delay intubating patients Guidelines for Appropriate Use Outside Critical Care Areas ( from University Medical Center, Tucson, Ariz., 2014) Stable patients who require NIV for obesity hypoventilation syndrome, obstructive sleep apnea, or other chronic, stable conditions The patient can go to an unmonitored inpatient bed Palliative care use of NIV to alleviate suffering at the end of life The patient can go to an unmonitored inpatient bed Acute or acute-on-chronic respiratory distress, including patients listed under #1, above, with progressive or new problems The patient must go to a monitored inpatient bed Noninvasive Ventilation in Chest Trauma A meta-analysis suggests that early use of NIV in chest trauma patients may reduce mortality and the intubation rate without increasing complications However, the patient selection criteria and timing for NIV remain unclear.9 Bi-level Positive Airway Pressure Bi-level positive airway pressure (BiPAP) is becoming an increasingly useful modality to avoid intubations In settings with ventilators but no BiPAP equipment, BiPAP can be improvised For example, after Hurricane Katrina, Peter DeBlieux, MD, FACEP, reported that physicians at Charity Hospital improvised BiPAP machines from mechanical ventilators: “We used a pressurecycled ventilator with pressure support of 10 cm H2O and PEEP [positive end-expiratory pressure] of cm H2O and attached it to the circuit [However,] ventilators not tolerate the leak associated with noninvasive ventilation (NIV or NIPPV) and the alarms sound frequently with mouth opening and poor mask fit A full-face mask is necessary when using this system, rather than a smaller nasal mask Using BiPAP as invasive ventilators is not the standard, but could be used in a pinch for pressure supported ventilation.” (Written communication, February 2008.) Continuous Positive Airway Pressure Using a Nasopharyngeal Airway Use a nasopharyngeal airway (NPA) to generate positive-pressure oxygenation when other methods will not work This method can provide NIV in patients with a poor mask seal and apneic oxygenation during procedures, including intubation It also allows positive-pressure oxygenation without obstructing airway visualization To use this method, insert an NPA into the nostril and connect it, using standard wall suction tubing, to an oxygen regulator opened to >25 L/min, if the regulator goes that high (Fig 9-3) Excessive pressure exits through the open nare and mouth Aspiration and gastric insufflations are the primary risks, as with other NIV methods.10 Alternative Neonatal Continuous Positive Airway Pressure In neonates and infants, an infant feeding tube (IFT) can deliver continuous positive airway pressure (CPAP) simply, economically, and with fewer adverse effects than with traditional methods Insert an IFT into the nasopharynx, approximately the distance between the tip of the nose and the tragus Connect the tube to an oxygen flow meter (usually 2-6 L/min) with a humidifier This method is used in many developing countries with few complications (e.g., nasal mucosal injury, stomach distension, aspiration, hyperinflation, and pulmonary air leaks) that can be avoided with humidification and gastric decompression.11 MAKESHIFT SPIROMETERS To encourage patients to breathe deeply after surgery, trauma, or illness, use an incentive spirometer, such as a balloon or a surgical glove Have the patient blow one up several times an hour while awake It works, however, only if the patient has received adequate analgesia.12 Br e a t h in g /Pu l mo n a r y 141 Oxyge n re gula tor Na s opha rynge a l a irway S ta nda rd s uction tubing FIG 9-3 NIVsetup after inserting the tubing into an NPA Incentive spirometers can also be made from plastic bottles, such as those for milk or soda Fill the bottle about halfway with water Insert a tube with an internal diameter (ID) of at least 0.5 cm so that the resistance is not too great (Fig 9-4) Insert the tube into the bottle’s open mouth; this can be messy if the bottle tips over Instead, you can insert the tube through a hole drilled in the resealed cap, although, in that case, either the cap must be left loose or a small additional hole must be made so that air can escape Adjust the water height (resistance) for the patient; less water may be necessary for children and for the elderly and infirm Have the patient blow bubbles Coloring the water with food coloring makes it more fun for children Spirometers improvised to measure lung function produce unreliable measurements FIG 9-4 Incentive spirometer made from cola bottle 142 Pa t ie n t a S S e S S me n t /S t a Bil iZa t io n OXYGEN Oxygen is one of the most basic drugs we have In many acute illnesses, such as acute respiratory infections, asthma, fetal asphyxia, and shock, the availability of an oxygen supply can save a patient’s life It becomes especially important during resuscitations, in the operating room, or when treating cardiopulmonary illnesses and any illness (including acute mountain sickness) at altitude Industrial Oxygen In austere medical situations, industrial (or research or aviation) oxygen can be used instead of medical oxygen Oxygen gas is produced from the boiling-off of liquid oxygen, so it would appear that industrial oxygen is the same as medical oxygen However, there is an ongoing controversy about whether there is any difference between four kinds of oxygen that are sold: aviation, medical, welding, and research They are all at least 99.5% pure (usually 99.9% pure) and all are produced from an identical—often the same—system Any humidity present in medical oxygen is added at the bedside Purity is not an issue, because the purity required for welding is more critical than that for breathing The major differences between medical oxygen and industrial oxygen are how it is filtered and the amount of liability insurance paid by the manufacturer Microscopic filtration is used to remove air particles from both, but medical oxygen is run through filters that can also remove bacteria, and so is considered sterile.13-15 Oxygen Cylinders Oxygen often comes in bulky, expensive cylinders It may be difficult to identify which cylinders contain oxygen The international standard requires oxygen cylinders to be painted white In the United States, however, they are green, and in British Commonwealth countries, they are usually black with white shoulders Industrial oxygen cylinders may be painted almost any color, so don’t rely on the cylinder’s color to identify its contents.16 Note that you may see one of two terms used in descriptions of flow rates, either the term psi (pounds-force per square inch) or psig (pounds-force per square inch gauge; i.e., pressure related to the surrounding atmosphere) For medical purposes, they are generally equivalent In this book, I will use the term “psi.” Oxygen cylinders vary in size, from the small portable D or E cylinders, which supply to 10 hours of oxygen, to the larger stationary M, H, or K cylinders, which, at very low flow rates, supply oxygen for up to 56 hours The duration depends on the oxygen flow rate For example: D cylinder: 350 L @ 2200 psi (23 @ 15 L/min) E cylinder: 625 L @ 2200 psi (42 @ 15 L/min) M cylinder: 3000 L @ 2200 psi (200 @ 15 L/min) H and K cylinders: 6900 L @ 2200 psi (690 @ 10 L/min; ~33 hours @ L/min) Therefore, it is helpful to know how much oxygen each type of cylinder commonly contains and how long it will last Oxygen Concentrators Oxygen concentrators extract the nitrogen from room air to produce 95% oxygen They this by using zeolite granules to adsorb the nitrogen from compressed air.17 Zeolite crystals can be expected to last at least 20,000 hours—about 10 years’ use.15 Oxygen concentrators have been effectively used for surgery and related medical uses at extremely high altitudes (3650 m = 11,000 feet).18 Concentrators are available in sizes ranging from domestic models with flows of up to L/min to very large installations that supply an entire hospital They typically deliver to L/min of oxygen.19 Oxygen concentrators require 350 to 400 W of electric power and can run off a small gasoline generator, a solar- or wind-powered system with battery storage, or a domestic or commercial power source.20 However, the machine’s power requirements must match the available power supply The price to purchase an oxygen concentrator is about half that of purchasing a 1-year supply of oxygen in cylinders.15 The cost (electricity) to run it, regardless of the oxygen flow, is about 2.5 p/hr (UK) or ¢/hr (US) This is much cheaper than using cylinder oxygen, which costs from 10 p/hr (UK) or 20 ¢/hr (US) at a flow rate of 0.5 L/min, up to £1.00/hr (UK) to $2/hr (US) at L/min.15 Br e a t h in g /Pu l mo n a r y 143 Anesthesia Oxygen concentrators can be used to supplement oxygen to anesthetized patients, but the outlet pressure is insufficient to power an anesthesia machine.15 A flow splitter allows oxygen from a concentrator to be supplied to up to four separate sites simultaneously if required, depending on the concentrator’s capacity and the patients’ needs.17 The oxygen must be introduced upstream from the vaporizer in a drawover system or it will dilute the inspired vapor concentration.17 If added using a reservoir attachment above the vaporizer inlet, the 95% oxygen at a flow rate of L/min produces a FiO2 from 35% to 40%; a rate of L/min produces an FiO2 of up to 80%.21 To increase the FiO2 even more and provide an improved margin of safety, prefill a large plastic sack (e.g., trash bag) with concentrator oxygen and then attach this reservoir to the inlet side of the drawover system during preoxygenation Remove the empty sack as soon as preoxygenation and intubation are completed.22,23 Oxygen Delivery Improvised Oxygen Tent Oxygen tents are not the best way to administer oxygen But, when nothing else is available, the top of a plastic cake server with a hole cut out of the side for the neck works well as an oxygen tent for infants (Fig 9-5) Splitter High-pressure oxygen sources (25 or 50 psi) can be split for use by up to seven patients with commercially available devices These can also be “jury-rigged” by knowledgeable respiratory therapists Low-pressure oxygen sources (cylinders/concentrators) can also be split, depending on the patients’ needs Mouth-to-Mouth/Mouth-to-Tube Resuscitation For mouth-to-mouth resuscitation, make a shield by cutting out about half the length of the third (long) finger from a medical glove Extend the part of the finger still on the glove into the FIG 9-5 Improvised pediatric oxygen tent 144 Pa t ie n t a S S e S S me n t /S t a Bil iZa t io n patient’s mouth, and stretch the remainder of the glove over the mouth and nose as a protective shield.24 This works, but a handkerchief draped over the mouth and nose might work as well or better to protect the rescuer from at least the “big stuff.” With the new, “continuous” cardiopulmonary resuscitation (CPR), rescue breathing is taking a back seat to chest compressions, at least for cardiac events Often forgotten is that, if no other means is available, patients can be given mouth-to-tube ventilation through an endotracheal tube (ETT), a laryngeal mask airway (LMA), a tracheostomy tube, an esophageal obturator airway (EOA), a Combitube, a makeshift cricothyrotomy tube, or a similar device The problem is, other than covering the tube’s end with a thin cloth (e.g., a handkerchief) to avoid contact with large amounts of blood or other secretions, none of these devices provides infectious protection to the rescuer VENTILATION Cannot Ventilate: Semisolid Obstruction If the airway is open but the patient cannot be ventilated due to inhalation of a semisolid material, such as muddy water, rapidly irrigate the ETT with 100 mL 0.9% saline (adult) Immediately suction the fluid with an NG tube and ventilate.25 Masks Even the most experienced clinicians under optimal conditions have difficulty using a mask to ventilate in 2% to 5% of patients because of poorly fitting masks.26 Incorrect Mask Size: Adults When a mask is too small for the patient, place the mask over only the nose Seal the mouth by placing your long finger under the chin, or even with a piece of transparent dressing With very large patients (BMI >26), hold the mask with both hands over the mouth and nose, or just the nose, while someone else ventilates the patient.27 Incorrect Mask Size: Infants and Children When trying to use a small child’s oxygen mask on a neonate, simply turn it upside down and it fits well (Fig 9-6) If the ventilation mask is too large for a child’s face, bring the bottom of the mask below the chin (i.e., between the underside of the chin and the hyoid) This forms an adequate seal until the A B FIG 9-6 (A) Child size does not fit neonate (B) Turned 180 degrees, the mask fits well Br e a t h in g /Pu l mo n a r y 145 properly sized mask can be found Occasionally, turning the mask upside-down so that the nasal angle is caudad (toward the feet) and the more rounded edge of the seal is across the nasal bridge may help achieve a seal.27 Lack of Teeth It may be difficult to establish an effective seal in patients with no, or few, teeth If the patient has dentures, leave them in place (as long as they are firmly attached) until the patient is ready for laryngoscopy, at which time the upper teeth should be removed Not only is this safe, but it also decreases the incidence of difficulty with mask ventilation from 16% to 4% in this group.27,28 If the patient lacks teeth and dentures, place a large oral airway down the midline of the tongue Then use a large mask to cover the lateral aspects and angle of the mouth Put your third finger across the bottom of the jaw to keep the mouth closed and ventilate mainly through the nose.27 Beard In wartime, during disasters, and in many remote areas, many male patients have a beard If a beard is causing problems with getting a good mask seal, “simply shaving the beard may solve the problem.”27 Another option is to apply petroleum, KY jelly, or other soluble grease around the edge of the mask The beard has to be “filled” with the lubricant, which makes the mask slippery It does not work as well as shaving the beard, but the following method works almost as well Apply a large defibrillator pad or transparent sticky plastic dressing (i.e., Tegaderm or another clear plastic adhesive sheet) with a hole cut in it to expose the nose and mouth The sheet keeps the beard in check as the mask is applied.29,30 This also works well for CPAP/BiPAP masks A simpler solution may be to insert cotton between the mask and the skin After administering anesthesia for operations near the front lines during World War I, Flagg wrote: “The great majority of the patients one sees are unshaven In this connection it might be well to emphasize the great advantage of placing a layer of cotton between the skin and the face piece [mask].”31 Restoring the Seal of an Anatomical Face Mask With repeated use, the seal of the anatomical facemask commonly used for anesthesia becomes flattened due to the cushion losing air, resulting in a poor fit on the patient’s face The loss of air is due to damage to the filling tube or to the plug To at least temporarily re-inflate the mask, inject air through the filling tube by either using a 50-mL syringe or blowing into it If the plug is nonfunctional, insert a needle cap to plug the filling tube.32 Flavoring the Mask for Pediatric Patients Whether a mask is used for oxygenation, to deliver medications, or for anesthesia, children seem to tolerate both it and procedures better if it smells good Liberally coat the inside of the mask with a flavored lip balm, which is inexpensive and readily available The child can pick the flavor It is also useful to have the child breathe through a flavored mask before and after the instillation of intranasal medication, or when emerging from procedural sedation.33 Bag-Mask-Valves Caring for a Bag-Valve-Mask (Ambu) Valve Regularly inspect your reusable bag-mask-valves (BVMs) to be certain that the valves function properly If the BVM valve is stuck or needs cleaning, unscrew the two ends that not go to the patient Then remove the lugs on the leaflets Don’t pull on the flaps—they are fragile and you may tear them Wash the inside and outside of the valve with warm, soapy water and allow the parts to dry thoroughly Most of these BVMs can be disinfected with antiseptics or autoclaved, but this is only necessary if the bag has been used on an infected patient Carefully reassemble the valve, making sure that the flaps are not wrinkled Also, check the bag for cracks and for deterioration of the rubber This is almost impossible to repair, although you should be able to make a temporary patch with cyanoacrylate.34 146 Pa t ie n t a S S e S S me n t /S t a Bil iZa t io n The disposable BVMs have sealed valve chambers that cannot be opened without breaking the equipment These are designed for one-time use, but in settings with limited resources they may be used many times Use either a moist cloth or steam to try to clean disposable BVMs between uses; however, this may be less than adequate for infection control Improvising a Bag-Valve-Mask Nothing seems to work well as a substitute to a BVM other than mouth-to-mouth ventilation A number of alternatives, including using a plastic soda bottle, have been suggested; they not work Do not waste precious time trying them However, if a rebreathing bag fails in a neonatal anesthesia circuit, a size 7.5 latex surgical glove can be used temporarily to provide a tidal capacity of 500 to 600 mL Make a 2-cm diameter hole in the tip of the middle finger as a release valve.35 Improvised One-Way Valves One-way valves in ventilation devices allow the exhalation to the atmosphere of “used” air to prevent a buildup of CO2 While various types of one-way valves are commercially available, they also can be improvised, although the system requires both hands, and is somewhat cumbersome Pearson and Safar wrote about one such system: “A large hole, in the wall of the tracheal tube adapter, to permit exhalation through the hole and inflation while the hole is occluded with the finger … systems are relatively clumsy, as they occupy both hands of the anesthesiologist.”36 Although described for use with an endotracheal tube, this could also be used for a patient who is undergoing anesthesia with only a mask Mechanical Ventilation: Lung-Protective Strategies Use the following methods when starting mechanical ventilation for patients who not have acute respiratory distress syndrome: (a) Prevent volume trauma (keep tidal volume 4-8 mL/kg predicted body weight with plateau pressure