BASICS
Failure to oxygenate or ventilate
Failure to protect airway
Anticipated clinical course
BASICS
Preoxygenate
Pretreat
• Lidocaine if reactive airway disease or increased intracranial pressure (ICP)
• Fentanyl in increased ICP or cardiovascular disease
Paralysis with induction agent
• Etomidate 0.3 mg per kg
Intubation paralytic agent
• Succinylcholine 1.5 mg per kg
Contraindications
– History of malignant hyperthermia
– Burns
– Crush injury
– Stroke or spinal cord injury <6 months
– Neuromuscular disease (multiple sclerosis, amyotrophic lateral sclerosis)
– Intra-abdominal sepsis
• Rocuronium 1 mg per kg
TREATMENT
Intubate
• Confirm with end tidal CO2
Sedation
BASICS
Creation of opening in trachea to oxygenate and ventilate
INDICATIONS
When a failed airway has occurred and the patient cannot oxygenate
Severe facial or nasal trauma and unable to intubate through mouth or nose
CONTRAINDICATIONS
Young age
Laryngeal or tracheal tumor, abscess, other pathology
TECHNIQUE
Identify the cricothyroid membrane
Above the thyroid cartilage and below the cricoid cartilage
Create a vertical incision
Apply traction
Intubate
Other techniques
• Seldinger technique
Used when provider is inexperienced or uncomfortable with surgical technique
• Needle cricothyrotomy
Used in children
CARDIAC PACING, DEFIBRILLATION, AND CARDIOVERSION
BASICS
Goal is to reestablish cardiac hemodynamics until cardiac problem is resolved or permanent pacing is applied
Regular pulses of electrical current are applied transcutaneously to stimulate heart muscle contractions
INDICATIONS
Hemodynamically unstable bradyarrhythmias
• Myocardial infarction
• Complete heart block
• Sinus node dysfunction
Tachyarrhythmias refractory to drug therapy or electrical cardioversion
Not recommended for asystole
CONTRAINDICATIONS
Severe hypothermia
Severely confused or agitated patients who may not be able to keep pads in place
METHOD
May be uncomfortable for the patient, consider sedation with analgesic or anxiolytic
Anterior-posterior or anterior-lateral pad placement
Fixed rate pacing: electrical stimulus is delivered at preset intervals
Synchronous pacing: pacer fires only when no impulse is sensed within a predetermined time
BASICS
Defibrillation is nonsynchronized delivery of energy applied usually transcutaneously to cardiac muscle during any phase of cardiac cycle
INDICATIONS
Pulseless ventricular tachycardia
Ventricular fibrillation
Cardiac arrest due to or resulting in ventricular fibrillation
CONTRAINDICATIONS
Multifocal atrial tachycardia
Digitalis toxicity or catecholamine-induced arrhythmias
METHOD
Anterior-posterior or anterior-lateral pad placement
Manual defibrillator for infants <1 year of age
Pediatric attenuator pads for children aged 1 to 8
Due to variability among manufacturers for biphasic waveform shock configurations, use the manufacturer’s recommended energy dose for its waveform
BASICS
Cardioversion is delivery of energy synchronized to the large R waves or QRS complex
INDICATIONS
Supraventricular tachycardia
Atrial fibrillation
Atrial flutter
Ventricular tachycardia
Any unstable patient with reentrant tachycardia with narrow or wide QRS complex
CONTRAINDICATIONS
Multifocal atrial tachycardia
Digitalis toxicity or catecholamine-induced arrhythmias
Ventricular fibrillation
METHOD
Almost always performed under induction or sedation
Atrial flutter: initial dose of 50 to 100 J of monophasic or biphasic energy
Atrial fibrillation: initial dose of 200 J of monophasic or 120 to 200 J biphasic energy
Monomorphic ventricular tachycardia: initial dose of 100 J of monophasic or biphasic energy, increased in a stepwise fashion
BASICS
Used to remove air or fluid from pleural space
INDICATIONS
Pneumothorax, hemothorax, pleural effusion, pleurodesis
CONTRAINDICATIONS
Anticoagulation or coagulopathy if nonemergent; sometimes pleural effusions from liver failure adhesions; need for thoracotomy
PROCEDURE
Elevate head of bed 30 degrees to minimize possibility of injuring intra-abdominal organs
Prep, sterilize, and anesthetize the skin with lidocaine
Incision at the 4th or 5th intercostal space at the anterior axillary or midaxillary line
Blunt dissection into the pleural space
Direct 8 to 14 Fr tube posteriorly and superiorly
• 36 to 40 Fr for tension pneumothorax
• Direct inferiorly for hemothorax
Set to suction or water device (usually—20 cm of water)
Confirm with chest x-ray
BASICS
Analgesia: can use lidocaine 2% over 1 minute in awake patients
Administer IV drugs or resuscitation fluid, followed by flushing
Prolonged intraosseous infusions after 24 hours are associated with increased risk of osteomyelitis
Can be used for diagnostic studies
Sites:
• Proximal tibia (recommended first attempt)
Children: 2 cm below tibial tuberosity and up to 1 cm medially on the tibial plateau
Adults: 2 cm medial and 1 cm above the tibial tuberosity
• Distal femur
Used as an alternative site in infants and small children
Midline, 1 to 2 cm above the superior border of the patella with leg extension
• Distal tibia or fibula
1 to 2 cm superior to the malleoli in the midline, medial malleoli preferred
• Proximal humerus
Greater tubercle, 2 cm below the acromion process, adduct and internally rotate the upper arm to palpate the tubercle
• Manubrium
Adults, superior one-third of the sternum
Complications
• Less than 1% rate of serious complications
• Tibia fracture
• Compartment syndrome
• Skin necrosis
• Osteomyelitis
• Subcutaneous abscess
• Theoretical long-term: bone marrow damage, disturbance of bone growth, fat embolism
INDICATIONS
Infants, children, or adults in full cardiopulmonary arrest or severe shock without IV access
It is recommended in all children after two failed attempts of IV access
Emergent or urgent situations where reliable venous access cannot be achieved quickly
CONTRAINDICATIONS
Bone fracture or previously penetrated bone (if unsuccessful at first attempt, go to another area or extremity for a second attempt)
Extremity with vascular interruption from trauma or venous cut down
If possible, avoid intraosseous in the following patients:
• At the site of a cellulitis, burn, or osteomyelitis
• Osteogenesis perfecta or osteopetrosis
• Right-to-left intracardiac shunts, may increase risk for bone marrow or fat emboli
BASICS
Sterile procedure to remove cerebrospinal fluid
Most common complication is a post–lumbar puncture (LP) headache (HA) (10% to 30%)
• Using a smaller needle is the only proven intervention that decreases the risk of post-LP HA
Head CT first if:
• Suspect a brain mass
• One or more of these risk factors
Seizure in the last week
Altered mental status
Papilledema
Focal neurologic signs
Immunosuppressed
Position
• Lateral recumbent (preferred)
• Upright (this position cannot accurately measure opening pressure)
Iliac crests align with L4
20 to 22 G needle insertion into the subarachnoid space of the interspace of L3 to L4 or L4 to L5
• Avoid higher vertebral levels to ensure that you stay away from the spinal cord
8 to 15 mL cerebrospinal fluid collected, more if sending for cytology or unusual cultures
• Tube 1 and 4: cell count/diff
• Tube 2: glucose, protein
• Tube 3: Gram stain, culture, hold the rest
See HA/meningitis for LP interpretation
INDICATIONS
Central nervous system infections
Subarachnoid hematoma
CONTRAINDICATIONS
Zero absolute
Coagulopathy
Raised ICP
Spinal epidural abscess
INDICATIONS
Evacuation and decompression of stomach contents
Diagnostic aspiration of contents
Monitoring blood loss in gastrointestinal bleed (GIB)
Decreasing pulmonary aspiration, treating gastric distention, and delivering meds in intubated patient
CONTRAINDICATIONS
Facial fracture
Severe coagulopathy
Ingestions likely to cause upper GI perforation such as alkaline substances
Esophageal strictures
Recent bariatric surgery
TECHNIQUE
Placement:
• Estimate tube length by measuring from xiphoid process to earlobe to tip of nose and add 15 cm
• Check nare patency
• Anesthetize
Lidocaine spray to oropharynx
Viscous lidocaine to nares, consider nasal vasoconstrictor to decrease traumatic bleeding
• Lubricate tube, insert into nare along floor close to 90-degree angle to the face, directed parallel to floor of nose
• Advance with gentle pressure and once in the posterior pharynx, ask patient to swallow sips of water to aid tube into esophagus
• Stop and secure at premeasured length
Verifying tube placement:
• Plain films most sensitive but not standard of care
• Three bedside measures to verify placement:
Insufflation of air, causing gurgling sounds over epigastrium
Aspiration of gastric fluid pH <4
Normal clear speech without coughing in a conscious patient
• Kidney, ureter, and bladder if any question on placement and always before formula or meds given
Complications:
• Epistaxis
• Tracheal or bronchial placement
• Pneumothorax
• Intracranial placement
• Esophageal perforation
• Gastric or duodenal rupture
• Esophageal obstruction or rupture
• Pulmonary aspiration
LOCATION TIPS
Face: can repair up to 24 hours without serious infection risk (except animal bites), select cases 48 to 72 hours
• 8 to 12 hours for the rest of the body
Lip: first suture the vermillion border
Muscle/mucous membranes: 4-0 or 5-0 absorbable sutures
Facial skin: 6-0 nonabsorbable
Primary closure
• Consider if deep and dirty
• If >6 hours and patient is at high risk for infection
SUTURE TYPE
Absorbable
• Vicryl or Chromic Gut: single or layered closure of tongue, oral mucosa, or nail bed
• Vicryl or Monocryl: deep facial laceration
Nonabsorbable
• Silk: rarely used
• Nylon (Dermalon, Ethilon)
• Polypropylene (Surgilene, Prolene): accommodates swelling
• Polybutester (Novafil): expands with wound edema
SUTURE REMOVAL
Eye lids: 3 days
Face: 4 to 6 days
Scalp: 7 days
Chest, hand, fingers: 8 to 10 days
Back, forearm: 10 to 14 days
Legs: 8 to 12 days
Foot: 10 to 12 days
ANIMAL/HUMAN BITES
Irrigation with warm normal saline is the most effective way to decrease bacterial load and remove foreign body material
Broad-spectrum antibiotics (i.e., Augmentin covers polymicrobial, consider methicillin-resistant Staphylococcus aureus coverage)
If debrided then can close, most cannot be closed primarily
ANESTHESIA
Two classes of local anesthetics include esters and amines
Esters:
• Benzocaine
• Procaine
• Tetracaine
• Cocaine
Amides:
• Lidocaine
• Bupivacaine: longest acting
• Prilocaine
When used with epinephrine do not use in fingers, toes, nose, genitals
Consider buffering with bicarb
