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 Medicine Professor of Emergency Medicine Director, Center for International Emergency Director, Center for International Emergency Medicine Medicine M. S. Hershey Medical Center M. S. Hershey Medical Center Pennsylvania State University Pennsylvania State University Hershey, Pennsylvania, U.S.A. Hershey, Pennsylvania, U.S.A.
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Important Clinical Procedures in Procedures in Emergency Medicine Jim Holliman, M.D., F.A.C.E.P. Professor of Emergency Medicine Director, Center for International.
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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.
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
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 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