Thoracocentesis

THORACOCENTESIS 

REQUIREMENTS:  

Written Informed Consent, Sterile gloves, povidone iodine solution, aspiration needle, 3 way stop cock, one 5 mL (for LA) and one 20 mL or 50 mL syringe, a reservoir (empty plastic bottle), one non-collapsible tube (iv set can be used for this), injection lignocaine and sterile dressing

PROCEDURE:

1. Check the vitals of the patient.

2. Position of the patient

(Sitting leaning forward with hands on the table)

• If no table is available, ask the patient to cross their arms in front of their chest.
• If the patient is unable to sit up, the lateral recumbent or supine position may be used. 

 

2. IV access should be established before procedure in most cases. 

3. Atropine should be on hand in case of profound vaso-vagal response and supplemental O2 should be administered throughout the procedure. It is given as IM routinely pre-procedure. 

4. Confirm the side by looking at the chest radiograph or sonography report) 

5. The skin at the puncture site will be cleansed with an antiseptic solution like povidone iodine. 

6. SITE: 7th or 8th intercostal space between the inferior angle of scapula (Aspiration site is determined by USG when done electively or by percussion when done during emergency.)  

7. Give local anesthesia. Infiltrate the skin and subcutaneous tissue and the parietal pleura over the chosen space at the upper border of the lower rib.   

8. The needle has to be inserted near the upper border of lower rib in the intercoastal space.

9. Insert the needle with the stop cock in closed position piercing the skin, subcutaneous tissue and the pleura. A 20 or 50 mL syringe is connected to the end of the stop cock and by turning the stop cock to on position, fluid is aspirated gently with the syringe (figure 1). The stop cock is turned on to the side channel and the fluid is pushed out from the syringe to the reservoir (usually a plastic bottle) via the side channel (figure 2). The process of aspiration is then repeated by turning the stop cock to on position. 

NEVER OPEN THE SIDE PORT ATTACHED TO TUBE DIRECTLY TO PLEURAL SPACE. (To avoid pneumothorax)

                                                

Figure 1- Showing the position of the 3-way during aspiration of pleural fluid

Figure 2- Showing the position of the 3-way while pushing out the fluid into reservoir

Not more than 1000 mL of fluid from pleural cavity is removed within first 30 minutes if done for therapeutic purpose (to prevent re-expansion pulmonary edema). 40-50 mL fluid is sufficient if done for diagnostic purposes. The fluid may be sent to a laboratory for testing (pleural fluid analysis). 

Place a small sterile dressing over the site of puncture.

  

10. Post-procedure X-ray to evaluate the fluid level.

VIDEO LINK:

https://youtu.be/2FviyY_XrEU

 

 

Written by our guest authors - Aishwarya Bagade and Ayushi Gupta 

Illustration by Anveshi Nayan 

#Ae(ONE)INTERN

 

 

CARDIOPULMONARY RESUSCITATION (CPR)

 CARDIOPULMONARY RESUSCITATION (CPR)

OUTSIDE HOSPITAL CPR

PRE- CPR PROCEDURE:

1. First, check the scene for factors that could put you in danger, such as traffic, fire, or falling masonry.

2. Next, check the person. Tap their shoulder and shout, "Are you OK?”. If they are not responding, call for help and call 108. If available, ask a near-by person to bring AED machine.

3. 
   

Remove any obstruction (food or vomitus) seen, only if it is loose. 

(If it is not loose, trying to grasp it may push it farther into the airway.)

• Check for breathing and feel for pulse (Brachial artery in infant, Carotid or femoral in a child and Carotid in adults) within 10 seconds:

  
  

  

  
  

1. No breathing, or occasional gasps + No pulse           Begin CPR

2. No breathing or occasional gasps + Pulse felt         Give 10-12 breaths/ minute

3. Unconscious but still breathing, do not perform CPR. Instead, place them in:

Keep monitoring the patient. Start CPR if the person stops breathing.

CPR

4. Perform chest compressions at the rate of 100-120/ min:

5. Open airway using triple maneuver: 

6. Give rescue breaths:

Pinch the nose while giving a breath mouth-to-mouth and look for chest rise.

If their chest does not rise with the first breath, tilt their head.

If their chest still does not rise with a second breath, the person might be choking. 

7. Try to synchronize the breaths with any voluntary breathing activity of the patient that might be present.

8. Repeat the cycle of 30 chest compressions and two rescue breaths until the person starts breathing or help arrives. If an AED arrives, carry on performing CPR until the machine is set up and ready to use. 

FOR CHILDREN (STEPS AS ABOVE WITH FOLLOWING MODIFICATIONS)

For children, give compressions using one hand only, between the nipples and press down around 2 inches.

For infants, give compressions using both the thumbs or index and middle fingers and press down approximately 1.5 inches.

If two rescuers present, try give 15 compressions followed by 2 rescue breaths and so on.

INSIDE HOSPITAL CPR

1. Recognize cardiac arrest and activate emergency team.

2. Start CPR as above (except that now, the person administering CPR should stand by the side of patient). 

3. Instead of using mouth-to-mouth for rescue breaths (may not feasible in case of infectious diseases), bag and mask ventilation is done and the patient is ventilated with a compression to ventilation ratio of 30:2

For Bag and mask ventilation, tilt the head of patient backwards.

Then, form a tight seal with the mask around the nose and mouth of patient forming letters E by fingers and thumb of one hand and C by the other.

Squeeze the AMBU bag and look for chest rise.

4. Airway may be secured by following methods while making sure that this process doesn’t compromise on the chest compressions.

• Combitube

• Laryngeal Mask Airway

• Endo-tracheal intubation (See document titled ‘ENDOTRACHEAL INTUBATION’)

Once advanced airway is secured give 1 breath every 6 seconds.

ADULT ALGORITH FOR MANAGEMENT OF CARDIAC ARREST

In brief:

• Shockable rhythm - ALWAYS Shock 

• Non- shockable rhythm – CPR with epinephrine (keeping approximately 4-minute interval between 2 epinephrine injections)

• Shock 🡪 CPR gain i.v. access + Inject Epinephrine 🡪Shock 🡪 CPR + Inject Amiodarone 🡪 Shock 🡪 CPR + Epinephrine 🡪 and so on...

• Time between 2 assessments/ 2 shocks/ time for which CPR is performed while injecting drugs = 2 mins

DEFIBRILLATION

For pediatric patients:

1st shock: 2-4 J/kg 

Subsequent 4J/kg (but not more than 10 J)

For adults:

Biphasic defibrillators: 100-120 J 

Monophasic defibrillators: 360 J

Placement of leads:

EPINEPHRINE:

1 mg 1:10000 i.v./ i.o. every 3-5 mins 

AMIODARONE:

1st Dose: 300 mg bolus dilute in 20-30 ml

2nd Dose: 150 mg bolus

VIDEO LINK:

ADVANCED CARDIAC LIFE SUPPORT (ACLS) ADULTS:

(2) ACLS Megacode - YouTube

Written by our guest authors - Hemant Kadam, Jignesh Bhadarka, Anveshi Nayan 

Illustrations by Anveshi Nayan and Devi Bavishi

#Ae(ONE)INTERN

 

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