Download Clinical procedures

Important Clinical
Procedures in
Emergency Medicine
Jim Holliman, M.D., F.A.C.E.P.
Professor of Emergency Medicine
Director, Center for International Emergency Medicine
M. S. Hershey Medical Center
Pennsylvania State University
Hershey, Pennsylvania, U.S.A.
Clinical Procedures Reviewed
in this Lecture
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Peritoneal lavage
Intraosseous line insertion
Thoracostomy
Thoracotomy
Pericardiocentesis
Surgical airway
Venous cutdown
Abdominal Trauma
Percutaneous ("Closed") DPL Procedure
ƒ Prep abdominal skin with iodine
ƒ Local anesthesia at puncture site (midline, 1 to 4 cm.
below umbilicus)
ƒ Nick skin with # 11 knife blade
ƒ Insert 18 gauge needle at slight angle toward pelvis
ƒ Advance needle till second "pop" felt as needle
penetrates posterior rectus fascia & peritoneum
ƒ Insert guidewire thru needle & withdraw needle
ƒ Advance catheter over guidewire
ƒ Remove guide wire
ƒ Draw back on catheter with syringe
ƒ If no blood drawn, attach IV tubing & run in fluid
Return of the peritoneal lavage fluid
Abdominal Trauma
Open DPL Procedure
ƒ Iodine prep and local anesthesia
ƒ Incise skin, fat, & fascia with knife : usually need
3 to 5 cm. length incision
ƒ Retract wound edges (with hooks or wound
retractor)
ƒ Identify, lift, & incise peritoneum
ƒ Lift peritoneum and insert dialysis catheter
toward pelvis
ƒ Draw back on catheter with syringe
ƒ If no blood drawn, attach IV tubing and run in
fluid
Abdominal Trauma
Conclusion of DPL Procedure (either closed or open)
ƒ If gross blood drawn back in syringe, stop
procedure, withdraw catheter, & take patient to
operating room for laparotomy
ƒ If aspirate is negative :
–Infuse 1 liter of normal saline or lactated
Ringers (infuse 20 cc. per kg. for children)
–After infusate is in, drop IV tubing below level
of patient & allow fluid to run back out
–Check RBC & WBC counts (+/- amylase, gram
stain) on the lavage fluid
–Withdraw catheter & suture skin wound
Abdominal Trauma
Positive Peritoneal Lavage Criteria
ƒ Any of these indicate need for laparotomy :
–RBC count > 100,000 / mm3 (blunt)
–RBC count > 10,000 / mm3 (chest penetrating
wounds)
–WBC count > 500 / mm3
–Stool or food fibers or bile
–Lavage fluid exits via chest tube, NG tube, or foley
–Elevated amylase in lavage fluid
ƒ If unable to get fluid return, may need to consider
as positive
Estimating red cell content by checking reading newsprint
through the IV tubing containing the lavage effluent
Intraosseous Needle
Insertion and Infusion
ƒ Can be life-saving technique to give
parenteral meds or fluids to children
ƒ Recently proved possible to do in
adults
ƒ Best used when IV access is difficult
or anticipated to be difficult or timeconsuming, in the "unstable" child
(from neonate to 8 years old)
One type of intraosseous needle
Unstable Conditions For Which
Intraosseous Infusion May Be Indicated
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Cardiac arrest
Shock (of any cause)
Severe dehydration
Extensive burns
Multiple trauma
Status epilepticus
Sudden Infant Death Syndrome (SIDS)
Septic Shock
Drug overdose with circulatory collapse
Ventricular arrhythmias
Protocol for Medical Personnel Duties for
Potentially Unstable Pediatric Patient
ƒ Person # 1 : Airway management (+
intubation)
ƒ Person # 2 : Try to insert IV in arm
ƒ Person # 3 : Try to insert IV in leg or foot
ƒ Person # 4 : Insert intraosseous needle in
other leg
ƒ Note : All 4 of these actions should occur
immediately and simultaneously at the patient's
arrival
Contraindications to
Intraosseous Needle Insertion
ƒ Infection at the puncture site
ƒ Suspected fracture in long bone in same
limb
ƒ Previous punctures in bone in same limb
(fluid will leak out)
ƒ Osteogenesis imperfecta
What Can Be Administered
Through an Intraosseous Line?
ƒ Volume : IV fluids, blood, plasma, etc.
ƒ All "ACLS" medications
ƒ Hypertonic medications (NaHCO3, CaCl2, 50 %
dextrose)
–Note : these cannot be given by endotracheal tube
ƒ "Sclerotic" medications (tetracycline, erythromycin,
diazepam, diphenylhydantoin, etc.)
ƒ Antibiotics
ƒ Note : Meds given in an intraosseous line go thru the
marrow sinusoids to veins and reach the central
circulation faster than from peripheral IV's
Insertion Technique for Intraosseous
Needle and Infusion
ƒ Use special intraosseous needle or just a spinal needle (with
stylet ; usually 18 gauge ; small needles bend too easily)
ƒ Prep insertion site
–2 cm. below tibial tubercle
–Alternate site is lower 1/3 of femur anteriorly
ƒ Support back of leg with towel
ƒ Local anesthesia if child conscious & time allows
ƒ Insert needle vertically with firm twisting motion till "pop" or
"give" felt (as needle penetrates bone cortex)
ƒ Aspirate from needle with syringe
Insertion Technique for Intraosseous
Needle & Infusion (cont.)
ƒ If properly placed, needle will be tightly wedged
in bone and will not "wiggle" easily
ƒ If aspirate negative, infuse small amount of fluid
and observe for extravasation (leg swelling)
ƒ If no extravasation, run fluid in as needed
ƒ Stabilize needle with bandage & chevron tape
ƒ Should remove needle once stable intravenous
access is achieved
Insertion positioning
of the intraosseous
needle
Intraosseous line placement
Indications for Emergency Thoracotomy
in the Emergency Department
 Penetrating chest trauma with at least some
signs of life (agonal respirations, etc.) initially
and rapid transport to ED
 Penetrating chest trauma and cardiac arrest
after arrival in the ED
 CPR needed and flail chest, or major chest wall
abnormality, or advanced pregnancy present
(need to do open heart massage)
 Uncontrolled intraabdominal bleeding (need to
apply aortic clamp at level of diaphragm)
Procedure for Emergency
Thoracotomy
 Intubate and ventilate the patient
 Quick iodine prep of left chest wall
 Incision from 2 cm left of sternum to beneath nipple in
4th left intercostal space ; keep incision on upper
border of rib (avoid intercostal nerves & vessels on
lower edge of rib) ; extend to at least the anterior
axillary line
 Insert rib spreader and crank open
 Open pericardium horizontally (parallel to phrenic
nerve)
Procedure for Emergency
Thoracotomy (cont.)
 Cardiac massage / digital control of any cardiac lacerations
 Cross clamp aorta just above diaphragm (with vascular
clamp) ; dissect bluntly around aorta with finger
 Use vascular clamps on any major bleeding pulmonary
lacerations
 Pack off any major bleeding from the subclavian area
 Can place IV tubing into right atrium with purse-string
suture to allow large volume fluid resuscitation quickly
Tube Thoracostomy for Trauma
 Always indicated for :
Tension pneumothorax
Massive hemothorax
Suspected tracheo-bronchial laceration
Suspected esophageal rupture
Small pneumothorax and need for intubation &
general anesthesia
 Not alway indicated for :
Simple pneumothorax < 5 to 10 %
Small hemothorax (if from rib fractures)
Flail chest
Insertion Procedure for Tube
Thoracostomy
 Prep side of chest with iodine
 Preferred site usually 5th or 6th intercostal space in
midaxillary line
 Inject local anesthetic
 Make 2 cm skin incision
 Tunnel up over one rib with clamp
 Incise intercostal muscles above the rib
 Enter pleural space
 Do finger sweep to check for adhesions
 Place tube into pleural space using finger as guide
 Suture tube in place ; attach to waterseal
 Check tube position by CXR
Suction bottles or Pleurevac System to connect to chest tube
Malpositioned chest
tube (inserted
subcutaneously)
Diagram of the
McSwain Dart (a
simple
percutaneous chest
tube for treatment
of pneumothorax)
Procedure for Pericardiocentesis
 Prep left chest with iodine
 Consider local anesthesia
 Attach EKG lead to needle ; monitor EKG for ST segment
elevation
 Best to use a catheter over needle or Seldinger placement
technique
 Insert needle just to left of xyphoid and advance toward tip of
scapula (pulling back on syringe)
 Stop advancing if blood return in syringe or elevated ST on
EKG (signifies ventricular wall contact)
 Leave catheter (not needle) in place and attach to closed
stopcock once aspiration complete (allows recurrent aspiration
if needed)
 Obtain CXR to R/O pneumothorax
Peritoneal Lavage for Chest Trauma
 Indicated for :
Penetrating trauma below level of nipple
(4th interspace)
Suspected diaphragm rupture
 Red cell count criteria for laparotomy
should be only 10,000 / mm3 for these 2
situations
Indications for Surgical Airway
(Cricothyroidotomy)
ƒ Inability to orotracheally or nasotracheally
intubate and airway control required
–Failure or impossibility of "backup" intubation
methods
ƒ Upper airway obstruction (above level of
vocal cords)
Needle Cricothyroidostomy :
Technique
ƒ Prep neck with iodine or alcohol if time allows
ƒ Insert 14 gauge needle thru cricothyroid membrane (or
use IV catheter over needle & withdraw needle)
ƒ Attach stopcock and oxygen tubing
ƒ Run oxygen in for one second ; open stopcock for 3 to
4 seconds & keep repeating this cycle
ƒ Can instead attach 3 cc syringe barrel & then attach
ETT connector & ventilate with BVM directly
ƒ Prepare for surgical cricothyroidostomy if possible (to
establish larger diameter airway)
High pressure tubing
required for jet
ventilation for a needle
cricothyroidostomy
Technique of verifying
entry into the trachea
with a catheter over
needle
Setup for direct
ventilation of a
needle
cricothyroidostomy
Direct bag valve
ventilation to a
needle
cricothyroidostomy
Surgical Cricothyroidostomy :
Technique
ƒ Prep front of neck if time allows
ƒ Incise skin & cricothyroid membrane horizontally
ƒ Insert tracheostomy tube or 6.0 or 6.5 mm.
diameter endotracheal tube & inflate cuff balloon
ƒ Ventilate thru tube
ƒ Auscultate over chest and abdomen
ƒ Secure tube with tape or straps around neck
ƒ Chest X-ray to check tube position
Surgical
cricothyroidostomy
Minimum instruments needed for surgical cricothyroidostomy
Emergency
tracheostomy
One of several available types of percutaneous
cricothyroidostomy tubes
Venous Cutdown
ƒ Indicated if other attempts at vascular
access fail
ƒ Very seldom needed if proper attempts at
intraosseous or central IV lines are done
ƒ Difficult to perform quickly, even by
experienced physicians
ƒ Higher incidence of infection and
subsequent venous occlusion than from
percutaneous IV's