Emergency Procedures

May draw directly from IV cath if infusion is dced for 2 minutes. Do not even need to discard if at least 12cc are drawn. Not accurate for Bicarb, K, or Glucose (Ann Emerg Med 2001;38)

Apply tourniquet, draw and discard 5cc. Accurate for almost all values (Acad Emerg Med 2007;14:23)

Esmarch Bandage flat tourniquet used by surgeons for limb exsanguination go proximal to distal in order to augment vein dilation

Rhys-Davies Exsanguinator double walled rubber sleave shaped like a sausage roll.

Saline infusion against Tourniquet

if you can not find a large enough vein, put a small iv in distal; leave on the tourniquet, and infuse 60 cc of saline (anesthes 2005;103(3):670)

The study technique involved siting a small-calibre peripheral venous cannula (usual catheter-over-needle technique) distally in the upper limb, with the tourniquet remaining tightened, infusing 30–50 ml 0.9% NaCl to distend the venous compartment distal to the tourniquet. A presenting distended vein was then cannulated with a large-bore catheter, again in a standard way. Achieving a cannnula bore of 18 G was the primary outcome measure.
Twenty patients (aged 19–78 years) with hypovolaemia of varying aetiology (7 with trauma, 6 with gastrointestinal tract haemorrhage, 5 with sepsis, 1 with abdominal aortic aneurysm rupture and 1 with fat emboli syndrome) were prospectively enrolled from a convenience sample of 52 presentations meeting the study criteria for hypovolaemia. Mean (SD) pulse rate was 119 (11.9) bpm and mean (SD) blood pressure was 86(10.9) mm Hg. Nineteen (95% CI 85 to 100) patients underwent successful incremental cannulation (median initial and subsequent cannula bore 20 (range 24–20) G and 16 (range 18–14) G, respectively). In six (30%) patients, the initial cannula was sited by a prehospital provider. One failure was observed in a 19-year-old patient with trauma treated with multiple prehospital venepuncture attempts (resultant extravasation) in the ipsilateral limb. All attempts were completed in <5 min.
The described technique for upgauging peripheral venous cannulae is simple, relies on the existing skill set of prehospital and emergency practitioners, and is reliable in achieving large-bore peripheral venous cannulation. Although not universally successful, it should be considered as an adjunct to the emergency physicians’ armamentarium of vascular access techniques. Of note, due to saline haemodilution, blood aspirated from the second cannula is unsuitable for laboratory analysis.

Reactive Hyperemia

can also use reactive hyperemia: place on tight tourniquet; then inflate BP cuff to 200 mmHg for 6 seconds. When you release BP cuff, large amounts of flow to arm. (Can J Anesth 2006;53(8):759)

Converting 18G to 15cm line

In step 1 (the cannulation phase), the deep brachial or basilic vein was cannulated with a standard length catheter (32 mm, 18 gauge; ProtectIV; Ethicon Endo-Surgery, Inc., Cincinnati, OH) under ultrasonographic guidance using a 10-5-MHz linear ultrasonograph transducer (SonoSite, Inc., Bothell, WA) and nonsterile ultrasonographic gel. Choice of deep brachial or basilic vein and choice of single- or 2-person technique were left to the investigator. Alcohol or chlorhexidine was used to prepare the skin, and the catheter was inserted using nonsterile gloves. Once the catheter was successfully placed, a Luer lock was placed on the catheter hub. Multiple attempts at initial cannulation were permitted. Up to 15 minutes was allowed between steps 1 and 2.

In step 2 (the rewiring phase), the catheter and surrounding area were sterilized with povidone-iodine 10% or chlorhexidine 2%, and a wire was threaded through the catheter into the vein, using sterile gloves and drape. The initial catheter was then removed, and a 15-cm single-lumen catheter (16 gauge; Cook, Inc., Bloomington, IN) was inserted over the wire and secured with tape and transparent dressing. Nicking the skin with a scalpel and use of a dilator were not necessary.

Gastric Tubes

· Verification by EtCO2. This study used two phase verification. Place at 30 cm, check with detector, then advance fully and get an X-Ray. (Crit Care Med 2002, 30:10)

· 2.5 cc of 4% Lido for NGT placement, better than jelly. Use Afrin (Acad Emerg Med 2000, 7:4)

Use large bore endotracheal tube to facilitate OG tube placement; slit down middle prior to placement

Give Reglan 10 mg 15 minutes prior to insertion for decreased discomfort, nausea, and vomiting (Int J Clin Pract 2005;59(12):1422)

A measurement of opening pressure should be attempted, unless the patient is so uncooperative as to invalidate the reading. CSF pressure should be measured with the subject in the horizontal lateral decubitus position (as described previously) and relaxed as much as possible. Normal range is 80-180 mm H 20, with small, visible excursions related to respiration and pulse. In cases of extremely high pressure (eg, 730 mm H20) the smallest sample possible (for the required testing) should be removed, followed by consideration of CSF pressure-lowering treatment, with continuous monitoring of the pressure until it decreases significantly.

locate the mid point of the interspace between the dorsal spinous processes, then dropping laterally
1 cm, and caudally 1 cm. (for ease of wrist angle on insertion, it is easier if the lateral "drop" is downward toward the table with the patient lying flat on his side in the usual position) Then angle the needle 45 degrees cephalad and 45 degrees toward the midline. This allows you to "go around" the dorsal spinous processes and enter the dura at the base of the spinous processes. Recognize that this approach traverses a bit more territory so the needle hub is going to be closer to the skin when you enter the dura. You can do this also with the patient in the sitting position (useful in very obese patients when you are having difficulty palpating the dorsal spinous processes and need some extra help even finding the mid-line).

LP safe in kids with PLT as low as 10,000 with ALL, so probably applicable to adults (JAMA 284(17):2222, November 1, 2000)

Central Lines

Go straight through medial portion of lateral head of SCM muscle. (J. Cardio Vasc Anes 8:6)

Higher Infection Rate, Higher Thrombosis Rate than subclavian (French, Prospective Trial JAMA 286:6, 2001 JB )

Study of cath related infection shows Subclav<IJ<Femoral (Intensive Care Medicine Volume 30, Number 8 August 2004)

Central superior to peripheral Am J Emerg Med 1984:2, 385-390 Ann Emerg Med. 1981 Aug;10(8):417-9.

Finger in fossa technique to prevent guidewire malposition in subclavians (Ambesh SP, Dubey PK, Matreja P, et al. Manual Occlusion of the Internal Jugular Vein During Subclavian Vein Catheterization: A Maneuver to Prevent Misplacement of Catheter into Internal Jugular Vein. Anesthesiology. 2002; 97(2): 528-529.)

IJ Location confirmed by numerous CT scans (Khatri VP A Safer Technique of IJ Puncture. J Cardio and Vasc Anesthesis 1994;8(6))

Keep head in neutral not rotated for IJ (Journal of Emergency Medicine Volume 31, Issue 3 , October 2006, Pages 283-286)

Subclavians and IJs were safe during resuscitations (Scalea Acad Emerg Med. 1994 Nov-Dec;1(6):525-31.)

shoulder position for subclavian

(anes 2004;101:1306)
use lower shoulder position
puncture site just lateral to midclavicular line

Abdominal: neck line, no femorals (Scalea et al: Percutaneous central venous access for resuscitation in trauma Academy of Emerg Med 1994 6:525-31

Westfall et al: Intravenous access in the critically ill trauma patient: Ann Emerg Med 1994 23(3):541-5

Inflammation at CVC insertion site is not indicative of bloodstream infection (Crit Care Med 2002 30:12, 2632)

Get the veins real fat with IV fluid, try putting the patient head down,
try pulling down on the ipsilateral arm, try turning the j-wire through
90 degrees four times, try turning the patients neck one way and if that
doesn't work -- the other way, try using the other (non j-shaped) end of
the wire -- in the 21st century this is equally flexible as the j-end --
it was not always so.

Preventing cvc complications (NEJM 2003;348(12):1123)
Use subclavian site
Use maximal barrier precautions
avoid antibiotic ointments. promotes resistance and fungus
disinfect cath hubs
no routine changes

Zone A represents the lower SVC and upper RA. In this zone CVCs placed from the left side are likely to lie parallel to the vessel walls. However, a part of this zone lies within the RA and therefore within the pericardial reflection. This may represent a necessary compromise for left-sided CVCs to ensure they lie parallel to the vessel wall. Right-sided CVCs in this zone, however, should be pulled back to zone B. The azygous vein junction with the SVC lies within this zone and catheters may pass into this system.
Zone B represents the area around the junction of the left and right innominate veins and the upper SVC. This is a suitable area for CVCs placed from the right side, however left-sided CVCs will enter this area at a steep angle (see Fig. 4) and are at risk of abutting the lateral wall of the SVC and should ideally be advanced into zone A.

Zone C represents the left innominate vein proximal to the SVC. CVCs in zone C are probably suitable for short-term fluid therapy and CVP monitoring, but not for inotrope infusions or long-term use. The safety of this site has been questioned.14

Instructions accompanying the packaging of CVCs state that it is negligent to site the CVC with the tip in the RA. This is because of the potential risk of pericardial tamponade if the CVC tip erodes through the vessel wall below the pericardial reflection. The upper limit of the pericardial reflection cannot be seen on CXR, but anatomical studies have shown that it is very unlikely to extend above the level of the carina

There is literature out there to support you (especially supporting the notion when experienced clinicians use good technique, good clinical judgment, and discrimination- Puls LE.; Twed C; Hunter J; Langan E, Crane M. Confirmatory Chest Radiographs after Central Line Placement: Are They Warranted? Southern Medical Journal 2003; 96(11):1138-1141.). However a relatively recent reviews point out the relatively high rate of catheter tip malposition (Catheter tip malposition occurs in up to 14% of cases of IJ insertion and 11% of subclavian vein (Ruesch S, Walder B, Tramer M. Complications of Central Venous Catheters: Internal Jugular versus Subclavian access-A Systematic Review. Crit Care Med. 2002;30:454-60;Slo nim A, Landucci DL, et al. Cannulation of the Internal Jugular Vein: Is Postprocedural Chest Radiography Always Necessary? Crit Care Med. 1999; 27: 1819-1823). As far as pneumothorax, unless the patient is on positive pressure ventilation the presentation can be delayed (Tyburski, JG., Joseph, A.Thomas, G. Delayed pneumothorax after central venous access: a potential hazard. American Surgery 1993; 59(9), 587-589.).

Trendelenberg for Line Placement

(Emergency Medicine Journal 2005;22:867-868)
Conclusion: Increasing the degree of Trendelenburg tilt increases the lateral diameter of the IJV. Even a 10° tilt is effective. The cumulative effect of tilt (that is, the effect of the previous angle) is not significant. Ultrasound guided cannulation is ideal, but in its absence Trendelenburg tilt will increase IJV diameter and improve the chance of successful cannulation. While 25° achieved optimum distension, this may not be practical and may be detrimental (for example, risk of raised intracranial pressure).

Subclavian is 3 times less infection prone than IJ and much lower than femoral (CAn J Anesth 2006;53(5):524)

A persistent left superior vena cava (LSVC) that is not associated with other congenital heart defects is found in 0.3–0.5% of the population. During embryological development, venous return from the head and arms occurs via the left and right cardinal veins. At 8 weeks gestation, the caudal portion of the left cardinal vein degenerates, leaving the right cardinal vein to develop into the right superior vena cava. Failure of regression of the left cardinal vein results in a persistent LSVC (2). The LSVC courses in the anterior aspect of the aortic arch draining into the right atrium via the coronary sinus, which becomes dilatated (3). Unless associated with other anomalies, this condition does not cause any harmful hemodynamic effects (1).

The existence of a persistent left superior vena cava is suggested by an X-ray that implies aortic cannulation in the face of an uncomplicated venous puncture and no evidence to support arterial cannulation.

Alternative sites for HD access

placement of rapid infusion sheathes in separate veins, either side ported or not

Ultrasound Guidance

Ann Emerg Med Volume 48, Issue 5, Pages 540-547 (November 2006)
Ultrasonographically guided internal jugular vein catheterization in the ED setting was associated with a higher successful insertion rate and a lower complications rate.

Ambesh Maneuvers

After subclav line placement, if you push on IJ and CVP increases 3-5 mmHg then the lumen is in the IJ instead of the SVC

J Neurosurg Anesthesiol. 2006 Oct;18(4):268-9.
Flush test--a new technique to assess the malposition of subclavian central venous catheter position in the internal jugular vein.

Biopatch

J Antimicrob Chemother. 2006 Aug;58(2):281-7. Epub 2006 Jun 6. Links
meta-analysis.
Chlorhexidine-impregnated dressing is effective in reducing vascular and epidural catheter bacterial colonization and is also associated with a trend towards reduction in catheter-related bloodstream or CNS infections. A large randomized controlled trial is needed to confirm whether chlorhexidine-impregnated dressing is cost-effective in preventing bacterial infection related to vascular and epidural catheters.

The Wire

Safe use and handling of guidewires for central venous cannulation requires an understanding of the structure and physical characteristics of the wires. Monaca et al.6 have recently described the structure of a commonly used guidewire. According to their detailed description the guidewire consists of an inner single filament wire core and a surrounding coiled wire-cover. The latter is designed as a helix of stainless steel to form a tunnel for the inner wire and provides elastic properties. Apart from the two ends of the guidewire where the outer spiral is welded to the inner wire, there is no further point of attachment between the core and the outer wire. The typical J-shaped curvature is achieved by flattening the round core to a thickness of 0.1 mm wire at approximately 2.5 cm from the tip. This structure provides increased flexibility at the J-shaped tip. However it becomes an area of structural weakness at the junction of the rounded and flattened segments, which can lead to potential breakage.

Alternative approach to supraclavicular

Proposed (left) and traditional (right) supraclavicular approach techniques. Place a needle tip at the clavisternomastoid angle, then direct the needle 10° medially from the sagittal plane and 35° posteriorly from the coronal plane (that is to say, physician's hand moves 10° laterally and 35° anteriorly from the skin entry point). Keep the bevel of an introducer needle and the J-tip of a guidewire heading to the medial side (arrow) to prevent ipsilateral axillary vein placement of catheter. In the original description of the supraclavicular approach by Yoffa (6), the needle directs at an angle of 45° from the sagittal plane and 15° anteriorly from the coronal plane. SCM: the sternocleidomastoid muscle, IJV: the internal jugular vein, SCV: the subclavian vein, IV: the innominate vein.

in a pinch, use the packaging that the wire came in to transduce the central line catheter

Proper Position For Femoral Vein Access

If you are attempting to cannulate the femoral vein without the aid of an ultrasound machine, proper positioning of the leg can greatly enhance your chance of success. A recent study of health volunteers revealed that the femoral vein cannulation in adults is increased by placing the leg in abduction and external rotation.The mean percentage of the femoral vein accessible with the leg in external rotation/abduction was greater than with the leg straight. This simple position change not only increased the mean diameter of the vein, it prevented the vein from being directly posterior to the artery.

References:
(1) Werner SL, et al. Effect of hip abduction and external rotation on femoral vein exposure for possible cannulation J Emerg Med 2008;35: 73-5.
(2) Roberts JR, Hedges JR. Clinical Procedures in Emergency. Medicine, 4th edn. Saunders, Philidelphia,. 2003.

Pericardiocentesis

Thoracentesis

To find the level, use UTS or put stethoscope on the back and tap the sternum with your fingers.

a catheter length of 5 cm would only reliably penetrate the pleural space of 75% of patients. A longer catheter should be considered, especially in women (AEM Feb 2004)

Consider using ultrasound to guide your puncture site. In those cases where a puncture site was proposed clinically, 1/4 of them were deemed dangerous and inaccurate. Ultrasound was able to demonstrate a safe site in half of the cases when clinical exam did not yield a site. (Chest 2003, 123:436-441)

Ultrasound-guided thoracentesis: is it a safer method?

Jones PW, Moyers JP, Rogers JT, Rodriguez RM, Lee YC, Light RW.
Saint Thomas Hospital, and Vanderbilt University, Nashville, TN 37205, USA.

STUDY OBJECTIVES: The objectives of this study are as follows: (1) to determine the incidence of complications from thoracentesis performed under ultrasound guidance by interventional radiologists in a tertiary referral teaching hospital; (2) to evaluate the incidence of vasovagal events without the use of atropine prior to thoracentesis; and (3) to evaluate patient or radiographic factors that may contribute to, or be predictive of, the development of re-expansion pulmonary edema after ultrasound-guided thoracentesis.

DESIGN: Prospective descriptive study.

SETTING: Saint Thomas Hospital, a tertiary referral teaching hospital in Nashville, TN. PATIENTS: All patients referred to interventional radiology for diagnostic and/or therapeutic ultrasound-guided thoracentesis between August 1997 and September 2000.

RESULTS: A total of 941 thoracenteses in 605 patients were performed during the study period. The following complications were recorded: pain (n = 25; 2.7%), pneumothorax (n = 24; 2.5%), shortness of breath (n = 9; 1.0%), cough (n = 8; 0.8%), vasovagal reaction (n = 6; 0.6%), bleeding (n = 2; 0.2%), hematoma (n = 2; 0.2%), and re-expansion pulmonary edema (n = 2; 0.2%). Eight patients with pneumothorax received tube thoracostomies (0.8%). When > 1,100 mL of fluid were removed, the incidence of pneumothorax requiring tube thoracostomy and pain was increased (p < 0.05). Fifty-seven percent of patients with shortness of breath during the procedure were noted to have pneumothorax on postprocedure radiographs, while 16% of patients with pain were noted to have pneumothorax on postprocedure radiographs. Vasovagal reactions occurred in 0.6% despite no administration of prophylactic atropine.   Re-expansion pulmonary edema complicated 2 of 373 thoracenteses (0.5%) in which > 1,000 mL of pleural fluid were removed.

CONCLUSIONS: The complication rate with thoracentesis performed by interventional radiologists under ultrasound guidance is lower than that reported for non-image-guided thoracentesis. Premedication with atropine is unnecessary given the low incidence of vasovagal reactions. Re-expansion pulmonary edema is uncommon even when > 1,000 mL of pleural fluid are removed, as long as the procedure is stopped when symptoms develop.

Joe Lex, MD, FAAEM
Department of Emergency Medicine
1009 Jones Hall - Broad & Ontario
Temple University School of Medicine
Philadelphia, PA 19140
215 707.5036   Office
215 707.3494   Fax

Most uts-guided pneumothoraces are the result of non-expandable lungs, they are usually not preventable (Chest 2006;130;1173-1184)

Needle Thoracostomy

Heng K, Bystrzycki A, Fitzgerald M, Gocentas R,
Bernard S, Niggemeyer L, Cooper DJ, Kossmann T.
Complications of intercostal catheter insertion using
EMST techniques for chest trauma. ANZ J Surg. 2004
Jun;74(6):420-3.

Rawlins R, Brown KM, Carr CS, Cameron CR. Life
threatening haemorrhage after anterior needle
aspiration of pneumothoraces. A role for lateral
needle aspiration in emergency decompression of
spontaneous pneumothorax. Emerg Med J. 2003
Jul;20(4):383-4.

Eckstein M, Suyehara D. Needle thoracostomy in the
prehospital setting. Prehosp Emerg Care. 1998
Apr-Jun;2(2):132-5.

** Cullinane DC, Morris JA Jr, Bass JG, Rutherford EJ.
Needle thoracostomy may not be indicated in the trauma
patient. Injury. 2001 Dec;32(10):749-52.

Tube Thoracostomy (Chest Tubes)

Probably from combination of three factors: long duration of pneumo, greater size of pneumo, and rapid expansion.

ACCP recommend: Large primary pneumos (>30%) should be expanded with 14F catheter or 16-22 chest tube connected to Heimlich valve or water seal. Use suction only if lung fails to expand with above measures. (JEM 24:1, 2003)

A TREATMENT ALGORITHM FOR PNEUMOTHORACES COMPLICATING CENTRAL VENOUS CATHETER INSERTION (Laronga, C., et al, Am J Surg 180:523 December 2000)

Give proph antibiotics (J Accid Emerg Med 19:553, 2002) 24 hours of 1st gen cephalosporin. Meta-analysis.

One crappy study showed no difference in recurrence of pneumothorax post-pull regardless of when in the resp cycle you pull (J Trauma. 2001;50:674–677.)

A normal chest radiograph obtained 3 hours after placing a chest tube on water seal effectively excludes development of a clinically significant pneumothorax. (J Trauma 59(1), July 2005, pp 92-95)

MAC technique: grasp external portion of the tube and turn clockwise 180° and release.

The use of prophylactic antibiotics in patients with chest trauma and chest tubes is controversial. According to a meta-analysis by Sanabria et al. [21] of five randomized controlled trials, the frequency of posttraumatic empyema and pneumonia was reduced by prophylactic antibiotics. However, there was no difference in subgroup analysis regarding the duration of antibiotic therapy (24 h or longer). Sanabria A, Valdivieso E, Gomez G, Echeverry G. Prophylactic antibiotics in chest trauma: a meta-analysis of high-quality studies. World J Surg 2006; 30:1843–1847.

A chest tube thoracostomy needs to be placed 1 or 2 intercostal spaces higher than usual to avoid diaphragmatic injury (EM Clinics NA, Vol. 21:615).

Thoracotomy

In April 2001, the ACS-COT Subcommittee on Outcomes gave their final recommendations regarding EDT.^24,26 (See Table 2.) As expected there was insufficient evidence to support a Level I recommendation for this practice guideline. Their Level II recommendations are as follows:

EDTs should be performed rarely in patients sustaining cardiopulmonary arrest secondary to blunt trauma due to the unacceptably low survival rate and poor neurologic outcomes;²²
EDT should be limited to those that arrive with vital signs at the trauma center and experience a witnessed cardiopulmonary arrest;¹⁶
EDT is best applied to patients sustaining penetrating cardiac injuries who arrive at trauma centers after a short scene and transport time with witnessed signs of life;^12,13
EDT should be performed in patients sustaining penetrating non-cardiac thoracic injuries.^{12,13,15,16,22,23} They did acknowledge the difficulty in ascertaining whether the thoracic injury was cardiac or non-cardiac and promoted the use of EDT to establish the diagnosis; and
EDT should be performed in patients sustaining exsanguinating abdominal vascular injuries although these patients experience a low survival rate.

The above Level II recommendations also are applicable to the pediatric trauma population.

What is the true survival rate of this procedure? Of studies reporting EDT, 7035 procedures were performed with a survival rate of 7.83%. These procedures were stratified by the mechanism of injury. The survival rate for EDT based on penetrating trauma was 11.16%. The survival rate for EDT based on blunt trauma was 1.6%. The survival rate for EDT based on penetrating cardiac injury was 31.1%22,25,26,29

Four series included pediatric trauma patients. The overall survival rate for 142 patients who required an EDT was 6.3%. When stratified by the mechanism of injury, the survival rate for penetrating trauma was 12.2% vs. 2.3% for blunt trauma. There was no reliable data reporting penetrating cardiac injuries in the pediatric population.

How may survivors succumb to severe neurologic impairment? Of the series reporting neurologic outcomes, 4520 patients were subjected to EDT. There was a 5% overall survival rate. Of these survivors, 15% survived with severe neurologic impairment.

What are the valuable physiologic predictors of favorable outcomes? Physiologic predictors of outcomes for EDT have been identified. In 1983, Cogbill and associates determined four statistically significant indicators that portend a dismal outcome. They are: 1) no signs of life at the scene; 2) no signs of life in the ED; 3) no cardiac activity at the time of EDT; and 4) persistent hypotension (SBP < 70 mmHg) despite aortic occlusion. Five years later, Branney and his group determined that the absence of vital signs in the face of blunt trauma also led to a poor outcome.22,25,26,29

Accepted Indications

Penetrating thoracic injury
- Traumatic arrest with previously witnessed cardiac activity (pre-hospital or in-hospital)
- Unresponsive hypotension (BP < 70mmHg)

Blunt thoracic injury
- Unresponsive hypotension (BP < 70mmHg)
- Rapid exsanguination from chest tube (>1500ml)

Relative Indications

Penetrating thoracic injury
- Traumatic arrest without previously witnessed cardiac activity

Penetrating non-thoracic injury
- Traumatic arrest with previously witnessed cardiac activity (pre-hospital or in-hospital)

Blunt thoracic injuries
- Traumatic arrest with previously witnessed cardiac activity (pre-hospital or in-hospital)

Contraindications

Blunt injuries
- Blunt thoracic injuries with no witnessed cardiac activity
- Multiple blunt trauma
- Severe head injury

Ladd AP, Gomez GA, Jacobsen LE, et al., Emergency room thoracotomy: updated guidelines for a level I trauma center. Am Surgeon 2002;68:421–4.

This group from the Indiana University School of Medicine developed and published a protocol for Emergency Room Thoracotomy (ERT) in 1995, after reviewing their own experience with 160 patients undergoing ERT. The present study was undertaken to evaluate this protocol, reviewing the records of all patients undergoing ERT over the next 5 years. Of the 79 patients, 65 had suffered gunshot wounds and 14 stab wounds. The authors’ protocol divided patients into 4 physiologic classes. Class I patients had no signs of life: full arrest, absent reflexes, and no ECG activity. Class II were agonal: and electrical activity on ECG but no pulse. Class III were in profound shock, with BP < 60 torr, and Class IV were in mild shock, BP > 60 but < 90 torr. The authors found that there were no survivors among patients who were Class I or II at the scene, or Class I on ED arrival, and they therefore recommend that ERT not be performed henceforth for these groups.

I put into the right atrium whatever catheter is available and has a connector to be allowed to have a connection to venous fluids being administered

Then I place a right angled clamp, curved Glover vascular clamp, Satinsky clamp, or whatever I have across the atral appendage even occluding the catheter for a secord or two. I then ask for a large silk suture - 0 or 00 will do and I just tie it secure around the atrium, but not occluding the catheter. Works every time. Hemostatic. I use this same technique when I need to crash onto the pump in the OR with the atrial catheter connected to the pump. I can place a purse string later if necessary. If there are lots of people around, I will tie the knot on the silk suture, and then NOT cut the suture, but wrap it Roman sandle style around the catheter, so as to secure it so that none of the many people in the room or during transport can inadvertently pull it out. I then leave the silk ends long and un cut in case I need to use the loos ends for something else , but it someone cuts then at the second knot on the catheter, then I dont say anything, and just get moving with the resuscitation or move to the OR. (Mattox)

3-0 prolene with large curved MH needle to repair cardiac injuries. consider teflon pledgets

put 14 F foley in 3 cm and fill balloon with saline, pull back 1 cm if no output

Blunt trauma=5 minutes of CPR, bilat chest tubes. If no signs of life call code; if signs then open chest

D. Lockey, K. Crewdsen and G.E. Davies, Traumatic cardiac arrest: who are the survivors?, Ann Emerg Med 48 (3) (2006), pp. 240–244.

Recent article on thoracotomy for abd exsanguin, 16% of the group survived neuro intact (J Trauma 2008;64:1)

Rhee PM, Acosta J, Cridgeman A, et al. Survival after emergency department thoracotomy: review of published data from the past 25 years. J Am Coll Surg 2000;190:288-98.

PICC

This prospective study shows that PICCs used in high-risk hospitalized patients are associated with a rate of catheter-related BSI similar to conventional CVCs placed in the internal jugular or subclavian veins (2 to 5 per 1,000 catheter-days), much higher than with PICCs used exclusively in the outpatient setting (approximately 0.4 per 1,000 catheter-days), and higher than with cuffed and tunneled Hickman-like CVCs (approximately 1 per 1,000 catheter-days). A randomized trial of PICCs and conventional CVCs in hospitalized patients requiring central access is needed. Our data raise the question of whether the growing trend in many hospital hematology and oncology services to switch from use of cuffed and tunneled CVCs to PICCs is justified, particularly since PICCs are more vulnerable to thrombosis and dislodgment, and are less useful for drawing blood specimens. Moreover, PICCs are not advisable in patients with renal failure and impending need for dialysis, in whom preservation of upper-extremity veins is needed for fistula or graft implantation. (Critical Care 2006, 10: 315)

Cardiac Pacemakers

overdrive pacing can be used for monomorphic or polymorphic VT resistant to drugs/shock

if properly placed in the right ventricle, a left bundle branch pattern should be seen with paced beats

on entering the ventricle, the unit will sense with every other beat. the balloon can then be deflated and the amperage raised to 5 mA

if this does not occur within 10 cm, the pacer should be pulled back to prior position and readvanced

To set pacer to demand, set rate to below patients intrinsic rate. Find sensitivity threshold and then make it a bit more sensitive. turn rate back up

DPL

Procedural Sedation

Paracentesis

can perform in coagulopathy, but not in DIC: retro of 4500 pts showed minimal complication rate.

enter sub-umbilical or on either mid-clav line at level of umbilicus. Avoid inferior epigastric artery on either side of rectus sheath

Serum-ascites>1.1 G=portal htn (cirrhosis, etoh hepatitis, cardiac ascites, port vein thrombosis, budd-chiari, liver mets) <1.1=carcinoma, tuberculosis, pancreatitis, biliary ascites, nephrotic syndrome, or serositis

Blakemore Tube

numbers on tube should face the right lateral portion of the esophagus on the Bard tube