Emergency Procedure

DR. LAYLA RAAD

EMERGENCY MEDICINE

Name this procedure

Emergency
Pericardiocentesis

Emergency
Pericardiocentesis
Discuss

technique.

List
Indication
Contraindication
Complications

Anatomic Approaches
Subxiphoid

Needle is inserted between the

xiphoid process and the left
costal margin in a 30- to 45degree angle to the skin.

Parasternal

approach (more
common with bedside
ultrasonography)

Needle is inserted perpendicular

to the skin in the left fifth
intercostal space immediately
lateral to the sternum.

Ultrasound-guided approach
Place

a 3.5- to 5.0-MHz probe

in the subcostal position to
directly visualize both the
area of maximal effusion and
location of vital structures.
Insert

needle in left chest

wall using a parasternal
approach where the largest
pocket of fluid is seen.

Indications
Pericardial tamponade with
hemodynamic decompensation
Pulseless electrical activity with
clinical suspicion of tamponade
or with ultrasonographic
evidence of pericardial effusion

Contraindications
Coagulopathy is a relative
contraindication

Complications
1.

Dry tap (no fluid aspirated, more common without

ultrasonography)

2.

Pneumothorax

3.

Myocardial or coronary vessel injury

4.

Hemopericardium

5.

Air embolism

6.

Dysrhythmias

7.

Cardiac arrest and/or death (rare)

8.

Liver injury

Name this device

Intraosseous
Vascular Access

Intraosseous Vascular
Access
Discuss

technique.
Landmarks.
List
Indication
Contraindication
Complications

Landmarks

Standard placement of the IO line is 1 to 2 cm distal to

the tibial tuberosity on the antero-medial aspect of the
tibia

Alternate

sites for placement

Medial

aspect of the distal tibia approximately 1 to 2 cm

proximal to the medial malleolus

Anterior

aspect of the distal femur just proximal to the junction

of the femoral shaft and the lateral and medial condyles

Indications

Contraindications

Used as emergent vascular access for

fluid resuscitation and drug infusion
when unable to obtain peripheral
venous access.

Fracture at the insertion site

Primarily used in pediatric cardiac

arrestgenerally faster access than
central line in infants or children.

Previous attempt to place intraosseous

(IO) needle on the same bone

Used in adult resuscitation if other

forms of vascular access cannot be
established.

Osteogenesis imperfecta

Osteoporosis
Overlying infection, burn, or skin
damage at insertion site

Technique

Sterilize the insertion site with povidone-iodine solution or alcohol.

If the patient is awake, administer a local anesthetic to the skin and

periosteum.

Grasp the IO needle in the palm of the hand using the index finger and thumb
to guide and stabilize the needle.

Use non-dominant hand to stabilize the leg.

Insert the IO needle either perpendicular (90 degree) to the tibial surface.
Using firm, constant pressure and a twisting motion, puncture the bone.

The resistance suddenly decreases once the marrow

cavity is entered.

Remove the stylet.

Use a 5- to 10-mL syringe to aspirate blood for confirmation of placement.

If no aspirate is obtained, carefully infuse 3 mL of normal saline. Palpate the
area for any signs of extravasation.
Secure the needle and immobilize extremity.

Complications
1.

Undetected extravasation of fluid into the surrounding tissue leading to

compartment syndrome.

2.

Extravasation of medications into the surrounding skin leading to skin

necrosis

3.

Localized bleeding and hematoma.

4.

Fat embolization .

5.

Iatrogenic fractures.

6.

Cellulitis and osteomyelitis.

7.

Growth plate injuries.

8.

Local pain.

Name this procedure

Diagnostic
Peritoneal
Lavage

Diagnostic Peritoneal Lavage

Discuss

technique.
Landmarks.
List
Indication
Contraindication
Complications

Indications

In Blunt Trauma

Unexplained hypotension

Patient with an equivocal examination,

altered sensorium, or who is otherwise difficult to assess

(especially if computed tomography [CT] is unavailable)

Patient taken emergently to the operating room (OR) for

extra-abdominal procedure, who requires further abdominal
assessment or who will not be a candidate for serial
examinations because of anesthesia

In Penetrating Trauma

A hemodynamically stable, asymptomatic patient with an

anterior abdominal wall stab wound and evidence of fascial
penetration but no obvious indication for laparotomy

Contraindications

Absolute Contraindications

Meets indications for exploratory laparotomy

Relative Contraindications

Prior abdominal surgeryconsider open technique

Pregnancyconsider open technique with supraumbilical

approach

Morbid obesity

Ascites or advanced cirrhosis

Coagulopathy

Technique

Patient Preparation

Place a urinary catheter to empty the bladder (if not

contraindicated).

Place a nasogastric tube (if not contraindicated) and keep it

connected to suction to decompress the stomach.

Gather instruments, sterile supplies, and appropriate sterile gown.

Prepare the abdomen from costal margin to pubis and from flank to
flank with povidone/iodine solution (Betadine) or chlorhexidine and
create a sterile field with towels or drapes.

Inject local anesthesia (1% lidocaine with epinephrine is preferred) in

the skin area where the incision will be made.

Open Technique

Using a no. 10, 11, or 15 blade scalpel make a 2- to 4cm incision in the vertical direction at a site one-third
of the distance from the umbilicus to the pubis.

Divide the subcutaneous tissue down to the level of the

fascia.

Grasp the fascia with clamps and elevate it. Incise it

sharply.

Grasp the peritoneum with two clamps, release one and

re-grasp so that the bowel that may be caught can fall
away. Repeat with the second clamp. Incise peritoneum
sharply.

Insert a peritoneal dialysis catheter into the abdomen

directing it gently toward the pelvis.

Follow directions under Common Technique for

Aspiration and Lavage section.

At the conclusion of the procedure (after the catheter is

removed), the fascial incision should be closed with no. O
or no. 1 PDS or nylon suture. Skin can be closed with
staples.

Common Technique for Aspiration

and Lavage

Connect the dialysis catheter to a syringe and aspirate.

If 10 mL of gross blood is aspirated, the DPL is positive and the patient should
undergo immediate laparotomy.

If bile, enteric contents, or food particles are aspirated, the DPL is positive and
the patient should undergo immediate laparotomy.

If aspiration yields less than 10 mL of blood, instill 10 mL/kg (up to 1 L) of

warm normal saline into the abdomen. Shift the abdomen gently (i.e.,
place in Trendelenburg, then reverse Trendelenburg positions) and allow
the fluid to remain for 5 to 10 minutes.

Place the empty infusion bag or container on the floor below the patient to
allow the fluid to drain. The container should be vented to promote
drainage of the fluid. Drain at least half of the infused fluid.

Send a sample of 20 mL to the laboratory for red blood cell (RBC) and
white blood cell (WBC) counts.

COMPLICATIONS

Hemorrhage, secondary to injection of local anesthetic or

incision of the skin or subcutaneous tissues

Peritonitis due to intestinal perforation from the catheter

Laceration of urinary bladder (if bladder not evacuated prior to

procedure)

Injury to other abdominal and retroperitoneal structures

requiring operative Care

Wound infection at the lavage site (late complication)

A positive test
100,000
greater
a

RBCs/mm3 or more,

than 500 WBCs/mm3,

positive Gram stain for food fibers or

bacteria.

Name this device

standard
defibrillator with
monitor

Defibrillator Machine
Discuss

technique.
position.
List
Indication
Complications

Technique
Defibrillation is a non-synchronized

delivery of energy during any phase of

the cardiac cycle
Cardioversion is the delivery of

energy that is synchronized to the large

R waves or QRS complex.

Monophasic vs biphasic
waveforms
Monophasic

defibrillation delivers a charge in

only one direction, while biphasic defibrillation delivers

a charge in one direction for half of the shock and in
the electrically opposite direction for the second half.
Biphasic

waveforms defibrillate more effectively

and at lower energies than monophasic waveforms

Indications

Synchronized electrical cardioversion

Supraventricular tachycardia

Atrial fibrillation

Atrial flutter

Ventricular tachycardia

Defibrillation

Cardiac arrest with

Pulseless ventricular tachycardia (VT)

Ventricular fibrillation (VF)

Position

Anterolateral Position

a single paddle is placed on the

left fourth or fifth intercostal space
on the midaxillary line.

The second paddle is placed just to

the right of the sternal edge on the
second or third intercostal space.

Anteroposterior Position

a single paddle is placed to the

right of the sternum,

the other paddle is placed between

the tip of the left scapula and the
spine.

Complications
1.

Arrhythmias, such as atrial, ventricular, and

junctional premature beats and Serious
complications include ventricular fibrillation
(VF)

2.

Thromboembolization especially in patients

with atrial fibrillation who have not been
anticoagulated prior to cardioversion.

3.

Myocardial necrosis can result from highenergy shocks

4.

Pulmonary embolism

5.

Painful skin burns

Name this procedure

Thoracentesis

Indications

Diagnostic

Acquisition of pleural fluid for diagnostic

analysis

Therapeutic

Relief of respiratory distress caused by

the accumulation of fluid(pleural effusion)
or air( tension pneumothorax) in the
pleural space

Contraindications

Platelet

count <50,000

Prothrombin

time (PT)/partial thromboplastin time

(PTT) greater than twice normal

Cutaneous
Mechanical

infection (e.g., herpes zoster)

ventilation (can convert small

pneumothorax into tension pneumothorax)

Complications
1.

Pneumothorax

2.

Lung laceration

3.

Hemopneumothorax

4.

Intra-abdominal injuries

5.

Diaphragmatic tear

6.

Hypotension from removal of massive amounts of fluid

7.

Chest wall bleeding from lacerated intercostal artery

8.

Re-expansion pulmonary edema

9.

Subsequent development of empyema