Procedural Facts to Know and Pearls

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

-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

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

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

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

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