Important Clinical Important Clinical Procedures in Procedures in

Emergency Medicine Emergency Medicine

Jim Holliman, M.D., F.A.C.E.P.Jim Holliman, M.D., F.A.C.E.P.Professor of Emergency MedicineProfessor of Emergency MedicineDirector, Center for International Emergency Director, Center for International Emergency MedicineMedicineM. S. Hershey Medical CenterM. S. Hershey Medical CenterPennsylvania State UniversityPennsylvania State UniversityHershey, Pennsylvania, U.S.A.Hershey, Pennsylvania, U.S.A.

Clinical Procedures Reviewed in this Lecture

• Peritoneal lavage• Intraosseous line insertion• Thoracostomy• Thoracotomy• Pericardiocentesis• Surgical airway • Venous cutdown

Abdominal TraumaPercutaneous ("Closed") DPL Procedure

ƒ Prep abdominal skin with iodineƒ Local anesthesia at puncture site (midline, 1

to 4 cm. below umbilicus)ƒ Nick skin with # 11 knife bladeƒ Insert 18 gauge needle at slight angle

toward pelvisƒ Advance needle till second "pop" felt as

needle penetrates posterior rectus fascia & peritoneum

ƒ Insert guidewire thru needle & withdraw needle

ƒ Advance catheter over guidewireƒ Remove guide wireƒ Draw back on catheter with syringeƒ If no blood drawn, attach IV tubing & run in

fluid

Return of the peritoneal lavage fluid

Abdominal TraumaOpen DPL Procedure

ƒ Iodine prep and local anesthesiaƒ Incise skin, fat, & fascia with knife :

usually need 3 to 5 cm. length incisionƒ Retract wound edges (with hooks or

wound retractor)ƒ Identify, lift, & incise peritoneumƒ Lift peritoneum and insert dialysis

catheter toward pelvisƒ Draw back on catheter with syringeƒ If no blood drawn, attach IV tubing and

run in fluid

Abdominal TraumaConclusion 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 TraumaPositive 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 time-consuming, in the "unstable" child (from neonate to 8 years old)

One type of intraosseous needle

Unstable Conditions For Which Intraosseous Infusion May Be Indicated

ƒ Cardiac arrestƒ Shock (of any cause)ƒ Severe dehydrationƒ Extensive burnsƒ Multiple traumaƒ Status epilepticusƒ Sudden Infant Death Syndrome (SIDS)ƒ Septic Shockƒ Drug overdose with circulatory collapseƒ 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 armƒ Person # 3 : Try to insert IV in leg or

footƒ Person # 4 : Insert intraosseous

needle in other legƒ 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 siteƒ Suspected fracture in long bone in

same limbƒ 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" medicationsƒ Hypertonic medications (NaHCO3, CaCl2, 50 %

dextrose)–Note : these cannot be given by endotracheal tube

ƒ "Sclerotic" medications (tetracycline, erythromycin, diazepam, diphenylhydantoin, etc.)

ƒ Antibioticsƒ 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 towelƒ Local anesthesia if child conscious & time allowsƒ 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 pneumothoraxMassive hemothoraxSuspected tracheo-bronchial lacerationSuspected esophageal ruptureSmall 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 allowsƒ Insert 14 gauge needle thru cricothyroid

membrane (or use IV catheter over needle & withdraw needle)

ƒ Attach stopcock and oxygen tubingƒ Run oxygen in for one second ; open stopcock

for 3 to 4 seconds & keep repeating this cycleƒ 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 allowsƒ Incise skin & cricothyroid membrane

horizontallyƒ Insert tracheostomy tube or 6.0 or 6.5

mm. diameter endotracheal tube & inflate cuff balloon

ƒ Ventilate thru tubeƒ Auscultate over chest and abdomenƒ Secure tube with tape or straps around

neckƒ 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