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
MORNING SESSION
7:00 - 8:00
8:00 - 8:15
8:15 - 8:30
8:30 - 8:50
8:50 - 9:00
9:00 - 10:00
10:00 - 10:10
10:10 - 10:20
10:20 - 10:30
10:30 - 11:30
Registration for Participants
Overview
Airway adjuncts
Intraosseous vascular access
Lateral canthotomy
Practice procedures
Chest tubes
Bronchoscopy
Pericardiocentesis
Practice procedures
Airway Adjuncts
Several varieties of airway adjuncts will be demonstrated during the lab session.
Examples of airway adjuncts available during the lab include:
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Direct laryngoscopy
Gum Elastic Bougie
Laryngeal mask airway/Laryngeal mask airway supreme
Glidescope
McGrath laryngoscope
King Vision
AirTraq
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.
Lateral Canthotomy
Chest Tubes
Bronchoscopy
o Indications
o Persistent or unexplained cough
o Blood in the sputum (coughed up mucus material from the lungs)
o abnormal chest x-ray such as a mass, nodule, or inflammation in the lung
o Evaluation of a possible lung infection
o To remove foreign bodies in the airway
o To place a stent (a tiny tube) to open a collapsed airway due to pressure by a
mass or tumor
o To remove a mass or growth that is blocking the airway
o Equipment
o Fiberoptic bronchoscopy device
o IV catheter for medication administration
o Heart rate monitor
o Oxygen saturation monitor
o Supplement oxygen equipment
o Equipment and expertise available for advanced airway interventions
o Topical lidocaine
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o Technique
o Prepare the patient: Controlled mode ventilation, increased FiO2, bite guard
and/or paralysis, connecting piece to the ETT.
The risk / benefit should be considered carefully in patients where Co2 control
(head injury) or PEEP control is critical, and in situation of severe bleeding
diathesis.
o Lubricating gel. Suction port connected. Sputum trap if required. Sterile
Saline for injection / wash.
o Complications
o Nose bleeding (epistaxis)
o Vocal cord injury
o Irregular heart beats
o Lack of oxygen to the body's tissues
o Heart injury due to medications or lack of oxygen
o Bleeding from the site of biopsy
o Punctured lung (pneumothorax)
o Damage to teeth (from rigid bronchoscopy)
o Complications from pre-medications or general anesthesia
Lung Anatomy
Pericardiocentesis