I would presume the triangle between the
sternal and clavicular head of sternomastoid
Andy Webster
Registrar in Emergency Medicine
From:
Sent: 02 June 2005 16:34
To: [log in to unmask]
Subject: Re: Bone injection guns
Could I
ask an ignorant question???? When Rowley says Anterior
Triangle are we talking Anatomical anterior triangle (midline with right and
left sternomastoids and mandible as it's boundaries - in which case 'low in the
anterior triangle' is strictly midline - or the triangle between the sternal
and clavicular head of sternomastoid?
Genuine
question and not trying to be a smartass - these lines aren't my strongest and
any advice is welcome - as long as I don't get the wrong end of the stick!!
Nick
Jenkins
A&E Consultant, Abergavenny
http://www.emergencynhh.co.uk
-----Original
Message-----
From:
[mailto:[log in to unmask]]On
Behalf Of Dunn Matthew Dr. (RJC) A
& E - SwarkHosp-TR
Sent: 02 June 2005 09:20
To: [log in to unmask]
Subject: Re: Bone injection guns
>
Could not disagree more. It's training issue; I can obtain internal
> jugular access with a straight
single pipe like a Wallace in under 10
> seconds. There are three key
points.
>
> 1. Head down.
>
> 2. Go low in the anterior
triangle.
>
> 3. Aim for the opposing
femoral head.
>
> Guaranteed; venous puncture
every time.
I'd add:
Go for the right side (straighter
course, further from the lung and thoracic
duct)
Don't overrotate or overextend the
neck
Take your finger off the artery
(which seems to be the commonest reason for
failure)
Not guaranteed every time. Some
patients have anomalous veins; some have no
vein; some have a vein that
collapses with inspiration or the pressure of
the needle. There are certainly a
few where it is impossible for anyone to
put a jugular line in. Ultrasound
should identify these in a couple of
seconds. Not saying there's
anything wrong with an experienced person
putting in the jugular line.
However, if someone's not that slick with it
(as was suggested by the original
post), there are other routes (each with
their own problems) that could also
be considered.
My post was in reply to a post
saying that the BIG was a lot faster than an
IJ line. If you can get a line in
in 10 seconds, it isn't. If you can't, you
might want to think about a
different technique. These days,
will prevent most of the failures,
and speed you up in some cases.
>
Sorry Matt, don't agree. One of the many things I have
> learned about trauma
> (whilst working in
> can rely on to
> stay open is the subclavian.
Doesn't
always stay open. I've seen failures to put in subclavians, and have
scanned a few collapsed or absent
veins. Also, veins that stay open when the
pressure's negative tend to suck in
air. Not an absolute contraindication,
but a relative one. Down to
individual skill with the approach. Advantage of
cut down is that it is the only way
you can reliably cannulate a collapsed
vein. Reason for long saph at the
groin is that it's probably the quickest
(in an unconscious patient) and
easiest place to cut down. There are host of
reasons why you wouldn't put in a
either a femoral line or a long saph cut
down, but they're both useful
techniques to know. In cases where it's
impossible to use your favourite
technique, it's worth having a couple of
backups, though- so femoral line,
long saphenous cut down and IO needles all
have their place.
My other point was that if you're
not certain and you're in difficulty,
assess whether it's better to go in
and risk complications or get someone
more experienced with the balance
of a longer wait and higher complication
risk. If you make the call as soon
as you've assessed that the patient is
sick enough to maybe need a central
line; and start prepping while you're
waiting, the extra wait shouldn't
be long.
As before, these days we've got
ultrasound. Means you can tell which veins
will be easy before you put needle
(or knife) to flesh.
>
Another issue I want to clear up is I never said we were
> using BIG/Fast-1 in
> trauma. The majority of IO
attempts were made for arrests.
Now there
I'm with you. In non traumatic adult arrests I go for the
subclavian myself (although with
very few exceptions I remain to be
convinced of the benefits of giving
anything IV in the early stages of an
adult cardiac arrest). I'd thought
of the adult IOs for trauma as that was
what I'd heard about most (mainly
from
> I
agree that you may need an anaesthetic registrar there from
> an airway
> point of view (although we
never did in Jo'burg) but as
> emergency physicians
> shouldn't we be capable of
running a trauma?
Yes. My
post was in response to a post suggesting that the IOs were useful
if there wasn't an A and E
consultant present and (probably central) venous
cannulation was beyond the skills
of the A and E middle grade. It is
entirely possible to get a job as
an A and E middle grade with little
experience in central line
insertion. If you can't get an A and E consultant
in fast enough (and some are
neither resident nor living close to their
hospitals), you ought to have an
anaesthetic registrar to hand.
As an aside, the term "running
a trauma" is one we maybe ought to be moving
away from. Trauma is essentially a
surgical disease- treatment takes place
in an operating theatre. All we do
is to make an initial assessment of
severity of the trauma, make sure
the patient is ventilating OK and speed up
the process of controlling the
bleeding. The surgeon runs the trauma (in an
ideal situation), we serve as a
support speciality (like anaesthetics and
radiology). No evidence that pre-
op fluids benefit trauma cases; some
papers showing they worsen outcome.
From time to time you have to accept
that you aren't the one who saves
the patient.
Matt Dunn
Warwick
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