SMACC Chicago 2015
& the
American College of Emergency Physicians
Presents the
Procedural Skills Lab
Course Director
Christopher Ross MD
June 25, 2015
McCormick Convention Center
Chicago, Illinois
Course Schedule
Thursday, June 25, 2015
AFTERNOON SESSION
11:30 - 12:30
12:30 -12:40
12:40 - 12:55
12:55 - 1:15
1:15 - 1:30
1:30 - 2:15
2:15 - 2:30
2:30 - 2:45
2:45 - 3:00
3:00 - 4:00
Registration for Participants
Overview
Peripheral venous cutdowns
Intraosseous vascular access
Arthrocentesis
Practice procedures
Central lines
Cricothyrotomy
Percutaneous tracheostomy
Practice procedures
Peripheral Venous Cutdowns
Introduction
 Prior to the ascension of central venous catheters, emergent venous
cutdowns was the preferred means to deliver life-saving medications
and/or volume to the critically ill patient. When performed properly,
peripheral venous cutdowns remains a relatively rapid, technically simple,
and complication-free means to obtain and ensure vascular access.
Venous cutdown should still remain a tool of the practicing critical care
physician
Intraosseous Vascular Access
Procedure
o Position patient, sterile prep, and topical local anesthesia at the discretion
of the provider.
o Choose proper needle length. If using EZ-IO needle, it should have at least 1
hash mark (5mm) above skin line when needle is touching bony surface
o Insert needle perpendicular to bone after appropriate landmarking.
o If manually inserting, provide steady twisting pressure. If using EZ IO drill,
squeeze handle to drill with gentle pressure
o Sudden loss of resistance indicates that needle has entered marrow cavity.
o Pediatrics: Immediately release the trigger when you feel the “pop” or
“give” as the needle set enters the medullary space to avoid puncturing the
posterior aspect of the bone.
o Adults: Advance needle feeling a “pop” or change in resistance that
indicates the entry into the medullary space until the needle set hub is close
to the skin.
o Secure and dress the IO needle.
o Slowly infuse over 2 minutes 2 cc of 2% lidocaine without preservatives
(cardiac lidocaine) if patient is responsive (In pediatrics, utilize 2-5mg/kg of
lidocaine).
o Syringe bolus (flush) IO with 5-10ml of normal saline to open up the marrow
channels for infusion (In pediatrics utilize at 2-5ml flush).
o If required, slowly infuse another 20mg of lidocaine IO over 60 seconds,
repeat prn.
o Consider IO narcotics for pain if not responding to lidocaine.
o Secure the needle and attach tubing.
o Pressure bag is needed to infuse fluids.
Proximal Humerus
o Position the patient elbow bent and adducted with humerus internally
rotated so that the patient’s hand rests on the abdomen.
o Place your palm over the patient’s shoulder anteriorly.
o Feel for the “ball”, this is the area for the IO insertion.
o Place ulnar aspect of one hand over patient’s axilla and the other hand
along the midline of the upper arm laterally
o Place your thumbs together over the arm
o Palpate deeply as you move up the humerus to the surgical neck. It feels
like a golf ball on a tee. Surgical neck is where the “ball” meets the tee.
o IO insertion site is 1 to 2 cm above the surgical neck on the most prominent
aspect of the greater tubercle.
o Aim IO needle tip downward at a 45-degree angle to the horizontal plane.
Proximal Tibia:
o Pediatrics:
-Extend the leg.
-Insertion site is located approx. 1 cm below the patella, and 1cm medial
along the flat aspect of the tibia.
-Pinch the tibia between your fingers to identify the center of the medial
and lateral borders.
o Adults:
-Extend the leg.
-Insertion site is approx. 3 cm below the patella and approx. 2cm medial
along the flat surface of the tibia.
Distal Tibia
o Pediatrics:
-Insertion site is located approximately 1-2cm proximal to the most
prominent aspect of the medial
malleolus.
-Palpate the anterior and posterior
borders of the tibia to assure that your
insertion site is on the flat center aspect
of the bone.
o Adults:
-Insertion site is approx. 3cm proximal
to the most prominent aspect of the
medial malleolus.
-Palpate anterior and posterior borders
of the tibia to assure that your
insertion site is on the flat center
aspect of the bone.
Arthrocentesis
Central Venous Access
Cricothyrotomy
Melker Cricothyroidotomy
o Carefully palpate and stabilize the cricothyroid membrane (see above).
o Make a vertical incision in the midline using the #15 scalpel
o
With
18G
catheter
introducer needle or thin wall
introducer needle, advance through
the incision into the airway at a 45°
angle to the frontal plane in the
midline
in a caudal direction.
o When advancing the needle forward, verification of entrance into the
airway can be confirmed by aspiration on the syringe resulting in free air
return.
o If using catheter introducer needle,
remove the syringe and needle,
leaving the TFE catheter in place.
o If using 18G thin wall introducer
needle, remove only the syringe
leaving the needle in place.
o Advance wire guide through the TFE
catheter and several cms into the
airway.
o Remove the TFE catheter or the
n
e
e
d
l
e
,
l
e
a
ving wire guide in place.
o Advance the cuffed emergency airway access assembly over the wire
guide until the proximal stiff end of the wire guide is completely through
and
visible at the handle end of the dilator.
o Always visualize the guide wire to prevent its inadvertent loss into the
trachea.
o Advance the cuffed emergency airway access assembly over the wire
guide with a reciprocating motion until it is completely into the trachea.
o Remove the wire guide and dilator simultaneously.
o Inflate the cuff using a syringe; 8-10 cc volume in the cuff will yield a cuff
diameter of 22-29 mm.
o Warning: Inflation of the cuff with more than 20 cc is not
recommended.
o Secure the emergency airway catheter to keep in place
o Connect the emergency airway catheter, using its standard 15 mm
adapter to an appropriate ventilatory device.
Percutaneous
Guidance
Tracheostomy
under
Bronchoscopic
1. Patient Selection: Tracheostomy is an elective procedure and so the
optimal timing and choice of open surgical technique versus percutaneous
seldinger technique must be thoughtfully selected.
a. Considerations/ Contraindications
i. Obesity/ inability to identify anatomic landmarks
ii. Coagulopathy
iii. Severe acidosis, hypoxia requiring high FiO2 and mean airway
pressures , hemodynamic instability
2. Preparation/Positioning: There should be at least 2 clinicians, ideally 3; a
bronchoscopistf who can reintubate the patient if needed, the
proceduralist, and a nurse or tech to administer meds, tend to vent and
scope. This requires deep sedation & analgesia +/- neuromucular blockade.
Place in neck hyperextension to bring more of the trachea out of the
mediastinum using towel role beneath shoulder blades (if not requiring Cspine stabilization). Mechanical Ventilator should deliver an obligatory rate
at 100% FiO2. Sterile prep and drape as usual. Identify & palpate all
anatomic landmarks including thyroid cartilage, cricoid cartilage, tracheal
rings and sternal notch. Target landmark is between tracheal rings 2-3 or 12. Assure at least 1 cm between cricoid cartilage and sternal notch.
Tracheostomy balloon should be checked for patency and tracheostomy
loaded on the dilator (size 6 trach loaded onto 26 Fr dilator, size 8 trach
loaded onto 28 Fr dilator).
3. Bronchoscopic surveillance: advance bronchoscope to the level of carina
and assure satisfactory visualization clear from secretions
4. Local anesthesia; lidocaine with epi in the midline
5. Incise skin; vertical or horizointal incison 1.5 - 2.0 cm in the midline position
above tracheal rings 2-3
6. Blunt dissection: blunt dissection using curved mosquito clamp or hemostat
to the pre tracheal tissues, allowing for better identification of anatomical
landmarks
7. Withdrawing the endotracheal tube: The ETT must be withdrawn so that
the tip is just proximal to the 1st or 2nd tracheal ring/ anticipated puncture
site. This must be done carefully so to not withdraw the ETT cuff beyond the
vocal cords and extubate the patient. This can be done in a sequential
fashion (@ 1-2 cm intervals) to avoid extubation.
8. Identify puncture site: this can be done by visualizing the bronchoscope
light in the surgical site and by balloting the trachea and visualizing on the
monitor
9. Initial puncture with needle and plastic sheath: This should be in the midline
of the trachea at rings 2-3, visualized bronchoscopically. Assure free flow of
air into needle & syringe. Direct the needle caudally to avoid puncture of
posterior tracheal wall. Needle is withdrawn and sheath remains in trachea.
10.Seldinger technique: Advance wire, serial dilations over the wire, all
visualized bronchoscopically. The tracheostomy loaded on its dilator is
advanced over the wire with protective plastic sheath. The largest dilator
and tracheostomy sit on a flange/ plastic ridge on the protective wire
sheath.
11.Confirm trachesotomy tube placement: confirm chest rise with delivered
breaths and expiratory volumes on the ventilator. Place bronchoscope in
new tracheostomy to confirm placement proximal to carina.
12.Secure tracheostomy: using soft trach ties +/- skin sutures
13.Remove ETT & Obtain CxR: confirm placement, and exclude
pneumothoraces or lobar collapse