ITE Procedures
Angela Pugliese MD
Department of Emergency Medicine
Henry Ford Hospital
Studying Techniques
• Must know all procedures from EM model
• See outline
• Roberts and Hedges
• Chapter in First Aid for the EM Boards
• Questions from ROSH
Topics Outline
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ED Thoracotomy
Pericardiocentesis
Thoracostomy tube
Cardiac Pacing
Umbilical Vein Catheterization
Paracentesis
Local Anesthesia
Perimorten C-section
Arthrocentesis
Compartment Pressure Measurement
ED Thoracotomy
• Indications:
• Penetrating trauma
• Loose vitals (while in route) or in ED
• Goal to cross-clamp aorta and control hemorrhage
• Technique:
• Intubate and place NG
• Enter Pericardium ANTERIOR to phrenic nerve
• Pearls:
• Learn indications
Pericardiocentesis
• Decipher tamponade from tension pneumo
• Technique:
• Use US – parasternal approach
• Blind approach – subxyphoid, attach EKG lead
• Major complication coronary vessel laceration
• Pearls:
• Treatable cause of PEA
• ABOVE THE RIB
• CXR post procedure
Thoracostomy Tube
• Indications:
• Pneumothorax/hemothorax
• Technique:
• Tension use needle decompression
• 4th or 5th intercostal space anterior to mid-axillary line
• ABOVE THE RIB
• Pearls:
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>1500 ml blood means OR (or >300 ml/hr after)
Don’t clamp tube
CXR post procedure
NO CXR PRIOR TO NEEDLE DECOMPRESSION
Cardiac Pacing/Cardioversion
• Indications:
• UNSTABLE DYSRHYTHMIAS
• Technique:
• Cutaneous vs transvenous
• Right IJ then left subclavian
• Pearls:
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Pad placement: anterior and posterior
Confirm pacing by palpating pulse with monitor
Magnet deactivates or revert to asynchronous pacing
Air embolism complication place patient in left lateral decubitus
Umbilical Vein Catheterization
• Access about 1 week after birth
• ONE VEIN (two arteries) located 12 o’clock
• Cut cord 2 cm from base (1cm NICU)
• Advance Catheter about 1-2 cm beyond good
blood return
• CXR shows catheter going toward the head
Paracentesis
• Use an US
• Consider albumin if you take 5L or greater
• Diagnostic Tap
• >250 PMNs is SBP
Anesthesia
• Esters/Amides – Amides all have 2 I’s
• No cross reactivity (ie the allergic patient)
• NO EPI in end arteries (finger, nose, ear, penis)
• Learn Regional Blocks
• Max dose 4 mg/kg without epi, 7 mg/kg with
Perimortem C-section
• Indications:
• Pregnant woman greater than 24 wks with cardiac arrest
• Must complete within 5 minutes of maternal death
• Technique:
• Continue maternal CPR
• Midline vertical incision
• Pearls
• Fundus palpated above umbilicus assume viability
• Know APGAR
Arthrocentesis
• ABSOLUTE CONTRAINDICATION
• Infection over the joint
• WBC > 50,000 indicates infection (BOARDS)
• Pseudogout = Positively birefringent (pyrophosphate)
• Fat globules indicates intra-articular fracture
Compartment Measurement
• Approximate 6 hours of viability
• 30 mm Hg is cut off number
• Elevated pressure indicates need for fasciotomy
• Exception with snake bites (use hyperbarics, serial measurements
and anti-venom), fasciotomy is last resort
Rapid Fire Pearls
• Subclavian/IJ pulled out and patient becomes
hemodynamically unstable….
• Air embolus, place left lateral decubitus, then aspirate RV (HBO)
• Anesthetic effect of Mental Nerve Block
• Lower lip
• Lower lip and inferior teeth
• Inferior Alveolar – too posterior causes facial nerve palsy
• Approach to elbow aspiration
• Lateral (avoid ulnar nerve which is medial)
Rapid Fire Pearls
• Pt getting blood develops hives, what next?
• Give benadryl and continue
• Correct direction for mandibular reduction
• Down and posterior
• IO placement in peds
• Tibia; 1 cm inferior of tuberosity, 1 cm medial
• Testicular Detorsion
• Open the book (remember 180 degrees)
Conclusion
• Complete ROSH questions
• Review Outline
• Email with questions