Emergency Procedures

Venipuncture

Should use lidocaine (Ann Emerg Med 2009;54:214)

May draw directly from IV cath if infusion is dced for 2 minutes. Do not even need to discard if at least 12cc are drawn. Not accurate for Bicarb, K, or Glucose (Ann Emerg Med 2001;38)

Apply tourniquet, draw and discard 5cc. Accurate for almost all values (Acad Emerg Med 2007;14:23)

article on venodilation techniques (JEM 2004;27:1)

Always start with gravity techniques

Fist clenching and isometric maneuvers cause dilation by muscarinic receptors

Vein tap and milking

Application of warmth via heat packs or warm moist towels

Esmarch Bandage flat tourniquet used by surgeons for limb exsanguination go proximal to distal in order to augment vein dilation

Rhys-Davies Exsanguinator double walled rubber sleave shaped like a sausage roll.

Venous Distention Device

Nitro Ointment

vein teardrop to know if uts-guided is in vein

Ski lift technique

The Ski Lift: A Technique to Maximize Needle Visualization with the Long-axis Approach for Ultrasound-guided Vascular Access. Academic Emergency Medicine, 17: e83e84

Saline infusion against Tourniquet

if you can not find a large enough vein, put a small iv in distal; leave on the tourniquet, and infuse 60 cc of saline (anesthes 2005;103(3):670)

(Emergency Medicine Journal 2007;24:371)

The study technique involved siting a small-calibre peripheral venous cannula (usual catheter-over-needle technique) distally in the upper limb, with the tourniquet remaining tightened, infusing 3050 ml 0.9% NaCl to distend the venous compartment distal to the tourniquet. A presenting distended vein was then cannulated with a large-bore catheter, again in a standard way. Achieving a cannnula bore of 18 G was the primary outcome measure. Twenty patients (aged 1978 years) with hypovolaemia of varying aetiology (7 with trauma, 6 with gastrointestinal tract haemorrhage, 5 with sepsis, 1 with abdominal aortic aneurysm rupture and 1 with fat emboli syndrome) were prospectively enrolled from a convenience sample of 52 presentations meeting the study criteria for hypovolaemia. Mean (SD) pulse rate was 119 (11.9) bpm and mean (SD) blood pressure was 86(10.9) mm Hg. Nineteen (95% CI 85 to 100) patients underwent successful incremental cannulation (median initial and subsequent cannula bore 20 (range 2420) G and 16 (range 1814) G, respectively). In six (30%) patients, the initial cannula was sited by a prehospital provider. One failure was observed in a 19-year-old patient with trauma treated with multiple prehospital venepuncture attempts (resultant extravasation) in the ipsilateral limb. All attempts were completed in <5 min. The described technique for upgauging peripheral venous cannulae is simple, relies on the existing skill set of prehospital and emergency practitioners, and is reliable in achieving large-bore peripheral venous cannulation. Although not universally successful, it should be considered as an adjunct to the emergency physicians armamentarium of vascular access techniques. Of note, due to saline haemodilution, blood aspirated from the second cannula is unsuitable for laboratory analysis.

Newest Study (Emerg Med J 2014;31:593)

Reactive Hyperemia

can also use reactive hyperemia: place on tight tourniquet; then inflate BP cuff to 200 mmHg for 6 seconds. When you release BP cuff, large amounts of flow to arm. (Can J Anesth 2006;53(8):759)

Converting 18G to 15cm line

In step 1 (the cannulation phase), the deep brachial or basilic vein was cannulated with a standard length catheter (32 mm, 18 gauge; ProtectIV; Ethicon Endo-Surgery, Inc., Cincinnati, OH) under ultrasonographic guidance using a 10-5-MHz linear ultrasonograph transducer (SonoSite, Inc., Bothell, WA) and nonsterile ultrasonographic gel. Choice of deep brachial or basilic vein and choice of single- or 2-person technique were left to the investigator. Alcohol or chlorhexidine was used to prepare the skin, and the catheter was inserted using nonsterile gloves. Once the catheter was successfully placed, a Luer lock was placed on the catheter hub. Multiple attempts at initial cannulation were permitted. Up to 15 minutes was allowed between steps 1 and 2.

In step 2 (the rewiring phase), the catheter and surrounding area were sterilized with povidone-iodine 10% or chlorhexidine 2%, and a wire was threaded through the catheter into the vein, using sterile gloves and drape. The initial catheter was then removed, and a 15-cm single-lumen catheter (16 gauge; Cook, Inc., Bloomington, IN) was inserted over the wire and secured with tape and transparent dressing. Nicking the skin with a scalpel and use of a dilator were not necessary.

Ann Emerg Med Volume 50, Issue 1, Pages 68-72 (July 2007)

A glove filled with warm water can make a pulse ox start working in a clamped down patients (anesthesia-analgesia 2012;114(4):917)

No need for empiric changing of IV catheters (The Lancet, Volume 380, Issue 9847, Pages 1066 – 1074)

Intraosseous

EZ-IO is quicker than manual needles (Resuscitation Volume 83, Issue 1, January 2012, Pages 20-26 )

IO is acceptable during a code, sternal had quicker serum levels than tibial (Resuscitation Volume 83, Issue 1, January 2012, Pages 107-112 )

Tibial IO was quickest when compared to humeral IO or peripheral during arrest (Ann Emerg Med 2011;58:509)

Why humeral may be better…

Gastric Tubes

Stimulate the hard palette to decrease gag reflex

put fingers on larynx to feel when the pt swallows

· Verification by EtCO2. This study used two phase verification. Place at 30 cm, check with detector, then advance fully and get an X-Ray. (Crit Care Med 2002, 30:10)

· 2.5 cc of 4% Lido for NGT placement, better than jelly. Use Afrin (Acad Emerg Med 2000, 7:4)

Use large bore endotracheal tube to facilitate OG tube placement; slit down middle prior to placement

Has since been validated in the literature (Anesth Analg 2009;109:832-5)

Give Reglan 10 mg 15 minutes prior to insertion for decreased discomfort, nausea, and vomiting (Int J Clin Pract 2005;59(12):1422)

Needle Thoracostomy

Heng K, Bystrzycki A, Fitzgerald M, Gocentas R, Bernard S, Niggemeyer L, Cooper DJ, Kossmann T. Complications of intercostal catheter insertion using EMST techniques for chest trauma. ANZ J Surg. 2004 Jun;74(6):420-3. Rawlins R, Brown KM, Carr CS, Cameron CR. Life threatening haemorrhage after anterior needle aspiration of pneumothoraces. A role for lateral needle aspiration in emergency decompression of spontaneous pneumothorax. Emerg Med J. 2003 Jul;20(4):383-4. Eckstein M, Suyehara D. Needle thoracostomy in the prehospital setting. Prehosp Emerg Care. 1998 Apr-Jun;2(2):132-5. ** Cullinane DC, Morris JA Jr, Bass JG, Rutherford EJ. Needle thoracostomy may not be indicated in the trauma patient. Injury. 2001 Dec;32(10):749-52.

Tube Thoracostomy (Chest Tubes)

Best Review Article (Injury 2008;39:9)

never needle decompress in the ED

Testing for Air Leak:

Clamp the vacuum

Ask the patient to cough (generates negative pressure)

Release the Vacuum

If there is an air leak, you will see bubbles

Risk Factors for Reexpansion Pulmonary Edema

Frequency varies between 1-14%

Onset is very soon after chest tube placement with 64% in the first hour.

Unresponsive to oxygen.

Sx take 24-72 hours to resolve.

Probably from combination of three factors: long duration of pneumo, greater size of pneumo, and rapid expansion.

ACCP recommend: Large primary pneumos (>30%) should be expanded with 14F catheter or 16-22 chest tube connected to Heimlich valve or water seal. Use suction only if lung fails to expand with above measures. (JEM 24:1, 2003)

A TREATMENT ALGORITHM FOR PNEUMOTHORACES COMPLICATING CENTRAL VENOUS CATHETER INSERTION (Laronga, C., et al, Am J Surg 180:523 December 2000)

Observation for <30%, pigtail if greater

Give proph antibiotics (J Accid Emerg Med 19:553, 2002) 24 hours of 1st gen cephalosporin. Meta-analysis.

more on ct drainage devices

One crappy study showed no difference in recurrence of pneumothorax post-pull regardless of when in the resp cycle you pull (J Trauma. 2001;50:674677.)

CT drainage less than 100 cc/day pre-pull

A normal chest radiograph obtained 3 hours after placing a chest tube on water seal effectively excludes development of a clinically significant pneumothorax. (J Trauma 59(1), July 2005, pp 92-95)

Arch Surg. 1997 Jun;132(6):647-50; discussion 650-1. Related Articles, LinksPosttraumatic empyema. Risk factor analysis. Aguilar MM, Battistella FD, Owings JT, Su T. Department of Surgery, University of California, Medical Center, Davis, USA. BACKGROUND: Empyema remains a distressing complication after thoracic injury. OBJECTIVE: To identify high-risk factors associated with the development of empyema. DESIGN: Retrospective cohort review. SETTING: University hospital, level I trauma center. PATIENTS: Trauma patients who required tube thoracostomy (TT) between January 1, 1991, and November 31, 1993 (n = 584). METHODS: Data (demographic characteristics, injuries, chest x-ray film reports, and setting of TT) were assessed using a stepwise logistic regression analysis to identify risk factors associated with the development of post-traumatic empyema. RESULTS: Empyema that required decortication developed in 25 patients (4%). Factors predictive of development of empyema were retained hemothorax (odds ratio, 12.5; 95% confidence interval, 0.96-163), pulmonary contusion (odds ratio, 6.3; 95% confidence interval, 1.53-25.8), and multiple chest tube placement (odds ratio, 2.5; 95% confidence interval, 1.91-3.28); factors not predictive of empyema were severity of injury, mechanism of injury, setting in which TT was performed, number of days chest tubes were in place, and antibiotic drugs at the time of TT. CONCLUSIONS: The extent of pulmonary injury (pulmonary contusion) is an important predictor of empyema development. Previously implicated factors such as setting in which a TT was performed and mechanism of injury did not correlate with the development of posttraumatic empyema. Based on the results of our study, we recommend early drainage of the pleural space with video-assisted thoracoscopic techniques in patients at risk of empyema, which may spare them the morbidity of a thoracotomy.

Residual hemothorax is associated with empyema (AAST abstracts 2008)

Test for CT kinking (Acad Emerg Med 2006;13(1):114)

MAC technique: grasp external portion of the tube and turn clockwise 180° and release.

If it spins back to previous position, then the tube is kinked.

If it doesn’t then it’s not.

The use of prophylactic antibiotics in patients with chest trauma and chest tubes is controversial. According to a meta-analysis by Sanabria et al. [21] of five randomized controlled trials, the frequency of posttraumatic empyema and pneumonia was reduced by prophylactic antibiotics. However, there was no difference in subgroup analysis regarding the duration of antibiotic therapy (24 h or longer). Sanabria A, Valdivieso E, Gomez G, Echeverry G. Prophylactic antibiotics in chest trauma: a meta-analysis of high-quality studies. World J Surg 2006; 30:18431847.

A chest tube thoracostomy needs to be placed 1 or 2 intercostal spaces higher than usual to avoid diaphragmatic injury (EM Clinics NA, Vol. 21:615).

Placement in the fissure doesn’t affect function (AJR 1994;163:1339-1342) (1) Meyers L, et al. Towards evidence based emergency medicine: Do patients with a thoracostomy tube placed in the lung fissure need an additional thoracostomy tube placed? Emerg Med J 200825(8):523-5.(2) Curtin JJ, et al. Thoracostomy tubes after acute chest injury: relationship between location in a pleural fissure and function Am J Roentgenol 1994;163(6):1339-42.(3) Lim KE, et al. Diagnosis of malpositioned chest tubes after emergency tube thoracostomy: is computed tomography more accurate than chest radiograph? Clin Imaging 2005;29(6):401-5.(4) Huber-Wagner S, et al. Emergency chest tube placement in trauma care – which approach is preferable? Resuscitation 2007;72(2):226-33.

Autotransfusion

Autotransfusion of Hemothorax

Blood in the chest cavity lacks clotting factors and has a slightly lower crit than venous. Autotransfusion of hemothorax blood in trauma patients: is it the same as fresh whole blood? Am J Surg 202(6):817-822, 2011.

Reexpansion Pulmonary Edema

The New EMedHome Clinical Pearl is: Re-Expansion Pulmonary Edema

Reexpansion Pulmonary EdemaReexpansion pulmonary edema (RPE) is a potentially lethal complication of tube thoracostomy treatment of pneumothorax. Hypoxemia, hypotension, and death have been reported in case studies. RPE typically occurs immediately or within one hour following reexpansion in the majority of cases. It usually occurs unexpectedly and dramatically. The development of edema has been attributed to increased pulmonary vascular permeability from hypoxemic lung injury and changes in intrapleural pressure.A large pneumothorax appears to be a prerequisite for the development of RPE; most authorities also cite as contributing factors the duration of collapse (greater than 2-3 days) and the rapidity in which the pneumothorax is drained with high negative intrapleural pressure. Young patients (under age 40) have been observed to be at greater risk for developing RPE. It should be noted, however, that RPE has been reported in patients without any of these risk factors.It has been recommended, therefore, that when a patient presents to the ED with a large, subacute pneumothorax, that drainage occur slowly with simple water seal, and wall suction not be applied. Alternative measures to prevent RPE include slow evacuation of the pneumothorax with intermittent clamping and simple repetitive aspiration of less than 1,000ml air and the avoidance of negative pressure suction.References: (1) Mingolla GP. Re-expansion pulmonary edema J Emerg Med 2009;36:80-2.(2) Volpicelli G, et al. A case of unilateral re-expansion pulmonary oedema successfully treated with non-invasive continuous positive airway pressure Eur J Emerg Med 2004;11: 291-4.(3) Beng ST, Mahadevan M. An uncommon life-threatening complication after chest tube drainage of pneumothorax in the ED Am J Emerg Med 2004;22: 615-9. (4) Sherman, SC. Reexpansion Pulmonary Edema: A Case Report and Review of the Current Literature J Em Med 2003; 24: 23-27.(5) Mahfood S, et. al. Reexpansion Pulmonary Edema Ann Thorac Surg 1998; 45: 340-345.

The intercostal arteries don’t sit nicely under the rib, they weave and wend all through the intercostal space (Intern Med. 2010;49(4):289-92. Evaluation of the risk of intercostal artery laceration during thoracentesis in elderly patients by using 3D-CT angiography.)

Makes Absolutely no difference which way the chest tube sits in the chest (Emerg Med J 2010;27(10):792

Pulling Chest Tubes (Removal of Thoracic Tubes)

4th ICS Mid-Clav absence of pneumo may obviate pre-pull cxr (Journal of Trauma and Acute Care SurgeryIssue: Volume 73(6), December 2012, p 1568–1573)

ED Thoracotomy

PICC

50 cm in men, 45 cm in women

This prospective study shows that PICCs used in high-risk hospitalized patients are associated with a rate of catheter-related BSI similar to conventional CVCs placed in the internal jugular or subclavian veins (2 to 5 per 1,000 catheter-days), much higher than with PICCs used exclusively in the outpatient setting (approximately 0.4 per 1,000 catheter-days), and higher than with cuffed and tunneled Hickman-like CVCs (approximately 1 per 1,000 catheter-days). A randomized trial of PICCs and conventional CVCs in hospitalized patients requiring central access is needed. Our data raise the question of whether the growing trend in many hospital hematology and oncology services to switch from use of cuffed and tunneled CVCs to PICCs is justified, particularly since PICCs are more vulnerable to thrombosis and dislodgment, and are less useful for drawing blood specimens. Moreover, PICCs are not advisable in patients with renal failure and impending need for dialysis, in whom preservation of upper-extremity veins is needed for fistula or graft implantation. (Critical Care 2006, 10: 315)

Cardiac Pacemakers

overdrive pacing can be used for monomorphic or polymorphic VT resistant to drugs/shock

faster paced rates lead to shortened QT terminating TdP

Black is distal and negative, red is positive

if properly placed in the right ventricle, a left bundle branch pattern should be seen with paced beats

initially set pacer to 5 mA

the threshold current should be less than 1.0 mA in a properly placed pacemaker

increase pacer to at least 2.5X the threshold current

blind placement

advance to 12 cm

inflate balloon

set rate to twice intrinsic vent rate

set amps at less than 0.2 mA

on entering the ventricle, the unit will sense with every other beat. the balloon can then be deflated and the amperage raised to 5 mA

the catheter can then be advanced to capture the ventricle

if this does not occur within 10 cm, the pacer should be pulled back to prior position and readvanced

electrocardiographic placement

connect patient to the limb leads

and connect distal electrode to one of the v leads

atrium=large ps

above atrium p and qrs neg

p becomes positive in low atrium and ventricle

To set pacer to demand, set rate to below patients intrinsic rate. Find sensitivity threshold and then make it a bit more sensitive. turn rate back up

pacer-simulator

review article (journal EM 2007;32(1):105)

DPL

Procedural Sedation

Paracentesis

(NEJM 2006;355(19):e21)

can perform in coagulopathy, but not in DIC: retro of 4500 pts showed minimal complication rate.

enter sub-umbilical or on either mid-clav line at level of umbilicus. Avoid inferior epigastric artery on either side of rectus sheath

use z-entry technique

purple top for: cell count with diff

culture bottles: for culture

red top: albumin, total protein, ldh, glucose, amylase, triglycerides

possibly: cytology or mycobacterium

get serum and ascites albumin

Serum-ascites>1.1 G=portal htn (cirrhosis, etoh hepatitis, cardiac ascites, port vein thrombosis, budd-chiari, liver mets) <1.1=carcinoma, tuberculosis, pancreatitis, biliary ascites, nephrotic syndrome, or serositis

can perform even in the face of coag. or thrombocytopenia

WBC>1000 or PMN>500 is definitely BP, should cover at PMN > 250

Blood-Ascitic pH gradient of 0.1 also points to SBP

JAMA 2008;299(10):1166

from Faried Banimahd and Irene M. Spinello

J Emerg Med. 2009;37(4):409-410.

(from life in the fast lane blog)

The Serum-Ascites Albumin Gradient (SAAG)

SAAG > 1.1 mg/dl SAAG < 1.1 mg/d

Microscopy and analysis

Red cell count

Interpretation

White cell count