Procedural Facts to Know and Pearls
CardioThoracic Procedures
Pericardiocentesis
-indicated for tamponade
-muffled heart tones, JVD, hypotension, electrical alternans
-bilateral breath sounds
-use US when possible
-left 5th intercostal space, 3-4 cm lateral to sternum
-enter ABOVE the rib
-subxyphoid when going blind
-major complication coronary vessel lacaretion
-causing infarction or hemopericardium
Thoracentesis
-immediate needle decompression for tension pneumo
-2nd intercostal space mid-clavicular line
-DO NOT WAIT FOR CXR, STICK THE NEEDLE IN THE CHEST
-diagnostic taps know Exudative vs. Transudative
-exudative (if lower than this transudative)
-fluid/plasma protein >0.5
-LDH >200
-protein > 3
Thoracostomy Tube
-after needle decompression always for tension pneumo
-confirm tube placement with CXR
-4th to 5th intercostal space anterior to mid axillary line
-ABOVE THE RIB
-clamping tube will cause tension pneumo
- >1500 ml of blood out means OR (or >300 ml/hr after)
Thoracotomy
-penetrating trauma with loss of vitals in route or in ED
-cut pericardium anterior to phrenic nerve
Transcutaneous Pacing
-pads anterior and posterior placement
-initial stabilization
-over-drive pacing
-use if thrombolytics were given
Transvenous Pacing
-unstable bradydysrhythmias
-right IJ then left subclavian
1
-clinical status worsens while placing central line = air embolus
-place patient left lateral decubitus, aspirate RV if necessary, then HBO
-post procedure CXR and feel pulse to confirm capture
Venous Cutdown
-when other access not possible (now will usually use IO)
-go for greater saphenous, ankle 1 cm anterior to medial malleolus
-complication is loss of medial sensation
IO Access
-use in unstable peds without access (also in adults)
-do not place in fractured bone
-can infuse all drugs, fluids and blood for resuscitation
Umbilical Vein Catheterization
-can use up to 1 week after birth
-One vein (two arteries) at 12 o’clock
-advance catheter until get blood return, then place about 1 cm beyond
-Xray shows catheter going toward head, if in liver went too far, pull back
GI Procedures
Paracentesis
-therapeutic for tense ascites causing compartment or respiratory distress
-albumin for removing 5L +
-diagnostic : >250 PMNs is SBP
Balloon Tamponade of UGIB (Blakemore)
-must have endoscopy readily available
-intubate patient and provide adequate sedation
-Confirm with pressure read and xray that gastric balloon is in stomach prior
to full inflation
Neurologic Procedures
LP
-opening pressure only accurate in recumbent patient
-normal pressure <20cm in adults
-CT prior to procedure in altered mental status
Perimortem C-Section
-fundus above the umbilicus assume viability of infant
-must be done within 5 minutes of maternal death
-continue maternal CPR until procedure complete
-midline vertical incision on skin and uterus
2
Anesthesia
-Esters = one I in name (no I in ester)
-Amides = two I’s in name
-esters and amides don’t cross react (ie patient with allergies)
-pt allergic to lidocaine, answer ok to give ester (look for one i)
-board answer no epi in end artery areas (fingers, nose, ear, penis)
-max dose 4 mg/kg without epi, 7 mg/kg with
-know when to use regional block and which block
-face, (lip), rib, digits
-common to know: mental, infraorbital, inferior alveolar, sup alveolar
ophthalmic, median, ulnar
-RSI avoid (specifically paralytics) if pre-intubation concern for difficult
airway
Ophthalmologic Procedures
Lateral Canthotomy
-anything causing increased optic pressure about 40 with vision loss
-think retrobulbar hemorrhage in trauma
-avoid in globe rupture
-visualize lateral canthus tendon by pulling down on inferior lid and
with scissors pointing away from globe dissecting down to inferior
lateral canthus tendon and cut it
-irreversible vision loss if retinal ischemia time >90-120 mins
IOP measurement
-contraindicated with suspected globe rupture
-use topical anesthesia
-normal IOP 10-20, >20 is abnormal
Orthopedic Procedures
Extensor Tendon Repair
-we (EM) don’t repair flexor, need hand referral
-ideal 24 hours within injury
-use non-absorbable suture
Arthrocentesis
-absolute contraindication to tap with overlying infection
-must do if you suspect septic joint
->50,000 WBC is infection
-Pseudogout is positively birefringent (pyrophosphate crystals)
-gout is negative birefringent
-Elbow – go lateral distal to lateral epicondyle
-Shoulder –patient upright, go inferior and lateral to the coracoid and
3
aim towards glenoid rim
-Knee – many approaches, learn them, easiest joint tap
-Ankle – foot plantar flexed, go medial to anterior tibial tendon and
aim to the hollow at anterior edge of medial malleolus, must go
2 to 3 cm deep to penetrate joint
Splints and Casts
-always assess neurovascular before and after placement
-someone returns to ED with increased pain after splint or cast = remove
Compartment Pressure Measurement
-compartment should be at same level of heart for measurement
-pressure >30 mm Hg is abnormal
-treatment is fasciotomy, except for snake bites use HBO
Superpubic Catheterization
-indications
-men with strictures
-trauma with urethral injury or high riding prostate
-do not attempt to place foley in these patients
-pelvic fractures and suspected urethral injury (blood at meatus)
-do retrograde urethrogram (RUG) first
-needle 2-3 cm superior to pubic symphysis and directed toward pelvis
-aspirate urine then thread foley over guide-wire
-US helpful
Random Pearls
Airway
-always revert to basics (BVM, oral/nasal airways)
-blind nasotracheal intubation contra-indicated
-apnea and mid face fractures
-surgical
-precautions with cric: young age, laryngeal fracture, bleeding
diathesis, tracheal disruption
-jet insufflation in peds = oxygenate not ventilate
-obstruction: BLS first Heimlich then magills and finally cric
-Predicting difficult airway
-Mallampati
Blood Therapy
-O neg for emergent transfusion
-type specific for urgent (10-15 minutes)
-remember worry about hypothermia and coagulopathy
4
Know Indications, Technique and Complications of These Diagnostic
Procedures
-arthrocentesis
-cystourethrogram
-lumbar puncture
-para/thoracentesis
-tonometry
Testicular Detorsion
-open the book, remember attempt should be >180 degrees
Epistaxis
-anterior pack send out on antibiotics
-don’t cauterize both sides of septum (ie necrosis)
-posterior pack gets admitted
Tooth replacement
-DON’T touch or scrub (will injure the periodontal ligament)
-trasnport in Hanks solution or milk
-DON’T replace primary teeth
A-line placement
-do allen test prior
Central Lines
-always get CXR and review after, even if unsuccessful
-umbilical vein access up to 5-7 days of age
-IO’s for any age, any med
-don’t line the bone if broken, infected, previous failed attempt in
same bone
5