Arterial Pressure Index

TRAUMA TUESDAY POD- ARTERIAL PRESSURE INDEX

INDICATIONS

  • Severe extremity injury with...

  • Proximity of injury to vascular structures

  • Major single nerve deficit

  • Reduced pulses

  • Posterior knee or anterior elbow dislocation

  • Hypotension or moderate blood loss at scene

  • Concern for vascular injury

CONTRAINDICATIONS

  • Unable to place BP Cuff around ankle or arm due to injury

EQUIPMENT

  • Manual BP Cuff

  • Handheld Doppler Instrument

  • Ultrasound Gel

PROCEDURE

  1. Measure systolic pressure in injured extremity distal to the injury (may measure radial, ulnar, brachial, dorsalis pedis, posterior tibial)

  2. Measure systolic pressure in uninjured brachial artery

  3. Perform Calculation: Injured extremity SBP/ Uninjured brachial SBP

INTERPRETATION

  • API >0.9: Vascular injury very unlikely, CT angio unnecessary

  • API <0.9: Possible vascular injury, CT angio is indicated

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Needle Cricothyroidotomy and Transtracheal Catheter Ventilation

Needle Cricothyroidotomy and Transtracheal Catheter Ventilation

- Used in pediatric can’t-intubate can’t-ventilate situations

- Preferred over surgical cricothyroidotomy in children <10-12 years of age

- Our kit at Maimonides is located in the Peds ED Room 30 cabinet top shelf next to the surgical cricothyroidotomy trays

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Steps:

- Palpate landmarks

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- Clean

- Connect tubing

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- Enter at a 45 degree angle, advance while aspirating through a 5cc syrige filled with normal saline

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- Stop advancing when you see bubbles

- Advance the catheter while keeping the needle stationary

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- Confirm placement in the trachea by aspirating more air from the catheter directly

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- Connect tubing, O2 should be at 15 L/min

- Ventilate by covering the holes for 2-4 seconds at a time allowing for longer periods of expiration (chest recoil) to decrease risk of barotrauma (some sources recommend ratio of 1:5 covered:uncovered)

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Notes:

- Transtracheal catheter ventilation BUYS YOU TIME

- Transtracheal catheter “ventilation" does NOT ventilate, it only oxygenates; CO2 will build up

- ENT should perform a surgical tracheostomy or other airway secured within 30 minutes

- It is acceptable to use the spaces in between the tracheal rings if unable to identify the cricothyroid membrane or unable to achieve enough neck extension to make accessing it feasible, as is sometimes the case with infants and young children

- A similar set-up to the above kit can be improvised as follows: BVM—>ETT adapter—>3cc syringe (plunger removed)—>14 gauge angiocath —>patient’s neck

References:

- Okada Y, Ishii W, Sato N, Kotani H, Iiduka R. Management of pediatric “cannot intubate, cannot oxygenate.” Acute Medicine & Surgery. 2017;4(4):462-466. doi:10.1002/ams2.305.

- UpToDate: Needle cricothyroidotomy with percutaneous transtracheal ventilation

https://www.youtube.com/watch?v=kDL1Y3XlFaQ

 (Video demonstration using the Cook Enk Flow Modulator kit)

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SGARBOSSA'S CRITERIA POD

SGARBOSSA CRITERIA

  • Used to diagnose a myocardial infarction in an ECG with LBBB or ventricular paced rhythm

  • Score ≥3 90% specific for acute MI but only 36% sensitive.

    • Low score cannot rule out MI.

Original Criteria: less sensitive in detecting MI

  • Concordant ST elevation > 1mm in leads with a + QRS complex (+5 points)

  • Concordant ST depression > 1mm in V1-V3 (+3 points)

  • Excessively discordant ST elevations > 5mm in leads with a negative QRS complex (+ 2 points)

Modified Criteria: more sensitive in detecting myocardial infarction

Eliminates the point system.

  • ≥ 1 lead with ≥1 mm of concordant ST elevation

  • ≥ 1 lead of V1-V3 with ≥ 1 mm of concordant ST depression

  • ≥ 1 lead anywhere with ≥ 1 mm STE and proportionally excessive discordant STE, as defined by ≥ 25% of the depth of the preceding S-wave

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