Resuscitation and emergency procedures

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Chapter 3 Resuscitation and emergency procedures

This chapter gives a brief overview of major procedures which may be carried out in the emergency department. It is meant to be used as a reminder for a doctor who has already been trained in these techniques, and not as a training manual. The common procedures should be practised under supervision, and the uncommon procedures should be formally taught before they are attempted solo. Some procedures require both training and experience, and some institutions require formal accreditation for operators (e.g. for focused assessment with sonography for trauma (FAST) scanning). Many procedures and their integration into complex, team-based resuscitation are best learnt in a simulator laboratory rather than in an emergency department.

For all procedures, the following steps are essential:

1. Use the appropriate sterile technique and standard precautions. Minimally invasive procedures such as peripheral intravenous access require only gloves and a clean technique, but more invasive procedures mandate formal sterile technique with a sterile field, appropriate drapes, gown, gloves, mask and eye protection. Less formal technique may be acceptable only when the procedure is required within seconds (e.g. cricothyroidotomy or emergency department thoracotomy), and full protection for the staff must still be observed.

2. Obtain the patient’s informed consent whenever possible. The level of explanation obviously varies with the invasiveness of the procedure and the urgency of the patient’s condition, but all conscious patients should give their consent (even if only implied).

3. Ensure patient comfort and the safety of all parties by using appropriate analgesia and, if necessary, sedation. Do not attempt difficult procedures on patients who are unable or unwilling to lie still.

4. Utilise a ‘time-out routine’. Stop and reflect at least for a moment to ensure that the right procedure is being undertaken on the right patient at the right site—look again at any relevant imaging to confirm it is the right way around.

5. Ensure continuing care and resuscitation of the patient, particularly during long procedures, utilising other staff and patient monitoring throughout.

6. Document the time, operator and result of the procedure appropriately, in line with local practice. Even minor procedures such as insertion of an intravenous cannula normally require a standardised form of documentation such as a date written on the dressing.

Editor’s comment

Ask, can I do this procedure more safely with ultrasound guidance?

INTRAVENOUS ACCESS TECHNIQUES

There are four basic intravascular access techniques:

1. Indwelling metal needle is now used only rarely and in peripheral sites, e.g. ‘a butterfly’.

2. Catheter over needle technique includes common intravenous cannula.

3. Catheter through needle technique is used infrequently. A large-bore needle is inserted into the relevant vessel, and a smaller catheter advanced up the needle, usually into a central vein. The metal needle is then withdrawn and rendered safe in a plastic guard. This technique carries the disadvantage of a small-bore catheter and the risks of catheter tip embolisation with poor technique and ongoing ooze due to the diameter difference.

4. Seldinger technique is widely accepted for all large or long intravascular lines. The vessel is punctured with a long needle on a syringe, and a flexible guidewire passed down the needle (sometimes through the syringe). The syringe and needle are removed, and appropriate dilators passed over the wire, and then removed. The catheter is passed over the wire into the vessel, and the wire is then removed. With this technique it is important to:

a. check and understand the equipment before starting (various sets are available)

b. have cardiac monitoring in place if the wire is to be near the heart

c. secure the catheter properly (usually by stitching)

d. above all, never let go of the wire.

Editor’s comment

Ultrasound guidance is increasingly being used for all access and is considered very desirable for any central access procedures.

Intravenous lines—peripheral

Intravenous lines—paediatric

The selection of a site for intravenous infusion in the neonate or young child should include consideration of the femoral vein in the groin and the scalp veins.

Of these, the femoral vein is probably the best to use in the critically ill child. Although no tourniquet can be applied, the vein is reliably located medial to the femoral artery pulse just below the inguinal ligament.

The scalp veins can be rendered more visible by use of a rubber band tourniquet around the head and entered in the usual fashion. Always inject saline and check for blanching to exclude arterial puncture. Careful strapping and use of a protector (e.g. plastic cup) are essential to avoid displacement of the scalp vein catheter.

Intraosseous infusion—paediatric or adult

This is a rapid technique for reliably obtaining vascular access in sick, small children. It can be used in patients of all ages, but the thicker bones of older children and adults mandate the use of a specially designed drill rather than manual insertion. Blood can usefully be drawn for biochemistry (not haematology) and large volumes of fluid or drug infused. It is highly recommended that this technique be practised on animal bones before it is attempted on a patient.

Indications

• Critically ill patient (especially small child) in urgent need of drug or fluid administration

• No other vascular access readily available

Contraindications

• Infection at puncture site

• Fracture of the bone

• Osteogenesis imperfecta

• Recent nearby intraosseous puncture (relative contraindication that is likely to lead to extravasation)

Technique

1. Identify infusion site: preferably upper medial surface of the tibia, 1–2 cm distal to the tibial tuberosity, but the lower tibia (at the junction of the medial malleolus and the shaft) may be suitable.

2. Prepare the area with an iodine swab.

3. Insert intraosseous needle (16–18-gauge special needle with stylet) into the bone at 45°, aiming distally. If performed manually, this requires a rotary ‘grinding’ motion until a ‘crunch’ is felt as the cortex is penetrated. Using a drill, progress is faster, but the definite penetration is still felt.

4. Remove stylet and attempt to aspirate marrow contents. Success clearly indicates correct placement, but failure sometimes occurs despite placement.

5. Begin infusion or injection of fluids and drugs. Flow should be relatively free.

6. Secure and protect the infusion site.

Complications

• Extravasation of fluid

• Needle blockage

• Infection (rare, reduced by good technique and removal as soon as practicable)

Intravenous lines—central

Indications

• Central venous pressure monitoring

• Infusion of concentrated/irritant solutions (e.g. inotropes, parenteral nutrition)

• Insertion of specialised equipment (e.g. plasma exchange catheter, Swan-Ganz catheter, transvenous pacemaker)

• Emergency venous access when peripheral access is impossible

Contraindications

• Distorted local anatomy

• Known or suspected vessel damage (current trauma, previous radiation therapy, previous surgery)

• Coagulopathy or vasculitis

• Inability to provide cardiac monitoring

• Pneumothorax in central venous access on the opposite side (risk of bilateral pneumothoraces)

Technique—general

All of the techniques below carry different risks and benefits and benefit from ultrasound guidance. All require ongoing cardiac monitoring, but the choice of technique should depend on the experience of the operator and the technique favoured in the particular hospital.

Remember: The ICU may have to care for ‘your’ catheter for days or weeks so, if a choice is available, use the method preferred by the inpatient team.

1. Use local anaesthesia liberally, following down the intended track.

2. Have cardiac monitoring in place, and always withdraw the catheter/wire slightly when arrhythmias (usually ventricular ectopics) occur.

3. After catheter placement, always aspirate each part then inject adequate saline to clear the line.

4. Secure the catheter by stitching and apply dressing.

Complications

Arterial puncture. When detected, remove the needle or catheter and apply pressure over the site for a full 10 minutes, followed by arterial observation of the limb.

Pneumothorax. Always obtain chest X-ray (CXR).

Malposition of catheter tip. Always check X-ray.

• Wrong vein—passing into jugular vein to subclavian vein instead of superior vena cava (SVC). This is difficult to reposition without an image intensifier and may require repuncture.

• Excessive length—in right atrium or ventricle rather than SVC. The CXR should show that the tip is not below the carina. If it is too low, the catheter can be easily withdrawn.

Damage to mediastinal contents. Haemothorax, hydrothorax, arteriovenous fistula and perforation of any structure in the chest (even an endotracheal cuff has been reported) may occur.

Infection.

Embolism of air, wire or catheter parts.

Knotting/kinking of catheter.

Subclavian cannulation

Supraclavicular technique

1. Position the patient supine in 15° Trendelenburg.

2. Enter the neck just lateral to the lateral border of the clavicular head of sternocloidomastoid and just above the clavicle.

3. Aim approximately at the contralateral nipple with the bevel of the needle towards the patient’s toes.

4. Advance 1–2 mm after first flush of blood to obtain reliable flow back into the syringe.

Complications

Although the full range of complications as above is described, they occur significantly less frequently with the supraclavicular approach.

ARTERIAL ACCESS TECHNIQUES

The same basic types of cannula used for venous access are available for arterial access, often again in specialised kits. Note that arterial puncture is painful, and for a single sample puncture the smallest practical needle should be used—usually 25-gauge (radial) or 23-gauge (femoral). Indications for arterial blood gas measures are few in the emergency setting: the venous pH and PCO₂ are normally close enough to the arterial values for diagnostic purposes, and the peripheral oxygen saturation (SaO₂) is usually a good measure of gas exchange.

Editor’s comment

Even in the critically ill we should be doing fewer arterial punctures.

Indications

• Arterial blood gas measurement (see above)

• Need for recurrent (e.g. hourly) blood sampling—normally patients going to ICU

• Ongoing monitoring of arterial blood pressure—also ICU and theatre patients

Contraindications

• Overlying skin damage (e.g. burns) or infection

• Arteriovenous fistula in the limb

• Clotting diathesis (relative)

Radial artery cannulation

1. With the wrist in mild extension, palpate the radial arterial pulse over the distal radius.

2. Insert the catheter or needle into the centre of the pulsation, parallel to the long axis of the forearm with the bevel forward.

3. Pulsatile flushback into the syringe or cannula indicates successful puncture. If inserting a cannula, proceed another 1–2 mm to ensure the tip of the needle is entirely within the artery.

4. If puncture fails, apply pressure to the site to reduce haematoma formation.

CHEST DRAINAGE PROCEDURES

Needle thoracostomy

Needle thoracostomy is performed either with a soft flexible catheter ‘over a needle’, such as an IV cannula, or a specialised drainage set which may utilise a catheter through needle or the Seldinger technique. The location depends on the setting and urgency. For a tension pneumothorax, the procedure is performed rapidly and without anaesthetic over the anterior chest wall. For therapeutic drainage of an effusion, it is performed posteriorly, and for aspiration of a simple pneumothorax, laterally or posteriorly.

Indications

• Tension pneumothorax—drain direct to air

• Simple pneumothorax (spontaneous) up to 75% collapse

• Pleural effusion—drainage or sampling

Contraindications

• Traumatic pneumothorax (unless tension is present) since tube thoracostomy indicated

• Haemothorax

• Bleeding dyscrasias (relative)

Technique

1. Check equipment. For drainage of fluid or simple pneumothorax, a large syringe and three-way tap are required in addition to the soft catheter. A syringe is normally attached if an IV cannula is being used.

2. Position the patient:

a. lying flat for anterior puncture of tension pneumothorax—2nd interspace, midclavicular line;

b. head of bed elevated for lateral puncture of simple pneumothorax—4th–5th interspace, midaxillary line;

c. leaning forwards over a pillow for posterior puncture of pleural effusion—8th–10th interspace, midscapular line.

3. Inject local anaesthetic if needed.

4. Insert the needle just over the lower rib of the interspace (in order to avoid the neurovascular bundle that lies beneath the rib above).

5. Aspiration of air/fluid through a cannula or a ‘pop’ into the pleural space indicates correct placement—advance the catheter and remove the needle, or follow the technique appropriate to the individual kit.

6. For a tension pneumothorax, leave open and undertake subsequent tube thoracostomy.

7. For other drainage, connect a three-way tap and syringe to the catheter.

8. Aspirate air or fluid, emptying the syringe and sealing the catheter by means of the tap.

9. Remove catheter when aspiration is finished or when the tube thoracostomy is in place.

10. Always obtain repeat chest X-ray.

Complications

• Damage to local structures—neurovascular bundle, internal thoracic artery (anterior approach)

• Inadequate drainage due to small size of catheter, adhesions, or blockage

• Underlying lung damage—a pneumothorax will be created if one is not already present

• Infection at the site

Intercostal catheter—tube thoracostomy

Indications

• Tension pneumothorax—only after needle thoracostomy

• Traumatic pneumothorax

• Simple pneumothorax that has not responded to needle drainage or is causing significant respiratory compromise

• Haemothorax

• Haemopneumothorax

• ‘Prophylactic’ use in the chest trauma patient who is to receive positive pressure ventilation or aeromedical transport—depends on available skills and circumstance

Contraindications (all relative)

• Multiple adhesions

• Need for immediate thoracotomy

• Bleeding dyscrasias

Technique

1. Provide appropriate sedation/analgesia. The majority of conscious patients will tolerate narcotics well and should receive them.

2. Position the patient by:

a. elevating the head of the bed 45° if possible

b. raising the arm on the relevant side over the head and placing the fingers behind the head

c. tilting the patient slightly away.

3. Select and mark the site, the 4th or 5th interspace and the midaxillary line, i.e. at the level of the nipple just behind the muscle bulk of the anterior chest wall muscles.

4. Select appropriate tube size, in general the largest reasonable tube (32 Fr to 36 Fr) should be used in adults with haemothorax, but much smaller tubes are appropriate if only air is to be drained.

5. Prepare drainage system—normally disposable plastic sets with an in-built water trap, but bag drainage with some form of flutter valve is often used in the field.

6. Prepare the area and inject local anaesthetic down to the pleura over the line of the rib below.

7. Incise skin 3–4 cm along the line of the rib below.

8. Bluntly dissect through the subcutaneous tissue and muscle layers to the pleura, passing just above the rib to avoid the neuromuscular bundle. A hiss will normally be heard when the pleural space is entered.

9. Enlarge the tract with a finger and insert finger into chest cavity to ensure full penetration and check for adhesions.

10. Insert tube without stylet in one of three ways:

a. hold tube and advance through hole manually

b. grasp tip of tube in curved forceps and advance through hole

c. use specially designed forceps (Pollard forceps) to open a path through which the tube is passed.

Advance the tube upwards for a pneumothorax or downwards and backwards for a haemothorax to at least 3 cm beyond the last lateral hole.

11. Immediately connect the tube to the drainage system. If there is to be any delay, the tube should be clamped for a spontaneously breathing patient, but must not be clamped for a patient who is ventilated. ‘Fogging’ of the tube normally confirms its location inside the chest cavity.

12. Check that the underwater drain is bubbling or swinging; ask the patient to cough to confirm position. If it is not swinging, rotate the tube or remove and re-insert.

13. Close the skin wound with sutures and stitch the tube in place. Dress the wound and anchor the dressing to the tube.

14. X-ray to check position of tube and re-expansion of pneumothorax or drainage of haemothorax.

Complications

• Blockage or failure to drain due to blood clots, position against chest wall, multiple adhesions or kinks

• Puncture of solid organs—should not occur if stylet is not used and technique is followed, even in the presence of diaphragmatic hernia

• Reverse flow—keep drainage bottle below patient

• Re-expansion pulmonary oedema

• Local injury or infection

• Persistent bubbling or failure of re-expansion due to leakage in circuit, ICC hole outside pleural cavity, or (rare) oesophageal rupture/broncopleural fistula

Pericardiocentesis

Pericardiocentesis is an emergency procedure for the diagnosis of pericardial tamponade, a diagnosis made clinically, on the basis of high central venous pressure, hypotension, tachycardia and muffled heart sounds, or via ultrasonography (either FAST or formal echocardiography). It is relatively common after penetrating chest trauma, relatively uncommon after blunt chest trauma, and is seen in left ventricular free wall rupture after myocardial infarction. Survival is poor unless the patient is reasonably fit and there is access to cardiothoracic surgery facilities.

Indications

• Diagnostic—if the patient is stable, not indicated in the emergency department

• Pericardial tamponade or suspicion in deteriorating patient

• Electromechanical dissociation in cardiac arrest when other causes are excluded—low success rate as tamponade is a rare cause of cardiac arrest unless there is a sizeable hole in the ventricular wall

Contraindications

• Immediate need for thoracotomy, particularly in cases of trauma

• Stable patient—seek echocardiographic evidence before proceeding

• Prolonged cardiac arrest when good outcome is not possible

Technique

1. Position the patient with head up at 45°.

2. Pass a nasogastric tube if abdominal distension present.

3. Prepare equipment—syringe, three-way tap and large needle. Ideally an insulated 10-cm needle, purpose-designed for such taps, or a pericardial catheter (‘catheter over a needle’) should be used. However, when the diagnosis is clear or when the patient is in cardiac arrest, then a large needle or large-bore IV catheter may be used. The metal hub of the needle should be attached to a V lead of the ECG monitor, and monitoring must be ongoing throughout the procedure.

4. Approach—insert needle between xiphoid process and left costal margin at 30–45° advancing towards the left shoulder.

5. The pericardium is normally entered 6–8 cm below the skin, and any fluid will be aspirated. If the needle touches the epicardium, an injury current with high ST segment should be seen on the ECG. In this case, withdraw the needle a few millimetres.

6. Aspirate with a syringe, using the three-way tap to disperse the contents if necessary. If a catheter has been inserted, withdraw the needle and re-connect the catheter to the tap.

7. Withdraw whatever fluid can be obtained, but if blood continues to flow freely, suspect ventricular penetration. Pericardial fluid may have a lower haematocrit than blood and may not clot, but neither of these tests is absolutely reliable nor helpful within the first few minutes of aspiration.

8. If a response is obtained, leave the catheter in place and be prepared to re-aspirate prior to a thoracotomy.

9. Perform chest X-ray after the procedure to check for a pneumothorax.

Complications

• Myocardial damage—ventricular puncture or coronary artery laceration

• Arrhythmias—ventricular ectopics, ventricular fibrillation (VF), cardiac arrest

• Pneumothorax or lung laceration

• Air embolism if accidental injection of air occurs

• Local infection

URINARY CATHETERISATION

Indications

• Urinary retention

• Monitoring of urinary output

• Drainage of neurogenic bladder

• Diagnostic urinary specimen

• Pre-operative procedure for pelvic surgery

• Management of the unconscious patient

Contraindications

• Clinical suspicion of urethral injury—if there is a perineal haematoma and blood at the meatus, then an ascending urethrogram should be performed to identify urethral damage and/or a suprapubic catheter used as an alternative

• Urinary tract infection (UTI)—relative contraindication as introducing a foreign body to an infected area is undesirable

Technique—males

1. Position is supine.

2. Prepare penis using no-touch technique, retracting the foreskin in and swabbing the glans and surrounding areas. Drape with a fenestrated sheet and repeat swab.

3. Instil lignocaine gel into urethral opening while holding the penis in the ‘dirty’ hand. From this point on, the hand holding the penis should be considered ‘dirty’ and only the other hand should touch the tray and catheter equipment.

4. After a delay for the gel to take effect, hold the catheter in forceps and insert into the bladder to a distance of 20–25 cm.

5. Inflate the catheter balloon using 5–10 mL sterile saline.

6. Check for free flow of urine and collect a specimen if necessary.

7. Connect an appropriate drainage bag.

Technique—females

1. Position is supine with heels drawn up and thighs abducted.

2. Prepare external genitalia by swabbing and drape with a fenestrated sheet. Separate labia with gauze squares and identify urinary meatus and re-swab.

3. Apply sterile lubricant liberally to the catheter.

4. Insert catheter into bladder using forceps, to a distance of 10–12 cm.

5. If catheter is to be left indwelling, inflate balloon with 5–10 mL sterile saline.

6. Collect any specimens necessary and connect appropriate drainage bag.

Complications—both sexes

• Failure to catheterise—

• Inability to identify urethra (females). The urinary orifice is frequently displaced by gynaecological surgery or obscured by oedematous tissue. A more thorough examination, repositioning and better light are appropriate.

• Strictures of the urethra. Excessive force should not be used, but a smaller catheter may be tried.

• Prostatic obstruction. This is commonly the indication for catheterisation. Once again, a smaller catheter, and possibly an introducer, should be tried.

• Trauma—creation of false passage, partial or complete urethral tear, long-term risk of stricture

• Infection—urethritis, epididymitis, pyelonephritis

• Haemorrhagic cystitis—rare complication of rapid decompression of a chronically distended bladder

• Paraphimosis in males—always replace a retracted foreskin

Removal of trapped urinary catheter

Emergency medicine doctors may be called upon to remove a urinary catheter which either is blocked and unable to be removed or is simply ‘stuck’ at a time of routine removal. The usual cause is a ‘flap valve’ in the balloon tubing which prevents balloon deflation.

Various techniques are described. Cutting the catheter is rarely effective, since the blockage is usually proximal. If the patient’s bladder is not excessively distended and the catheter balloon definitely lies within the bladder, then the balloon may be overinflated with sterile water or saline until it bursts. If there is doubt about the position of the balloon, then ultrasound should be used to identify it, since it must not be overinflated in the urinary tract. The balloon within the bladder can also be punctured using a suprapubic needle.

SUPRAPUBIC CYSTOSTOMY

Indications

• As for urinary catheter but catheter cannot be passed due to a suspected or definite urethral trauma

• Failed catheterisation, usually strictures or prosthetic disease

• Other reasons, such as blockage of an existing catheter

Contraindications

• Previous lower abdominal surgery/scarring/radiation

• Inability to palpate the bladder (or visualise on ultrasound)

• Bleeding diathesis

• Urinary tract infection

Technique

1. Check equipment—a number of suprapubic catheter sets are available, mostly relying on a variant of the ‘catheter over the needle’ technique.

2. Position patient supine.

3. Inject local anaesthetic starting 2–3 cm above the symphysis pubis and heading down the expected track at approximately 20° towards the pelvis. When urine is drawn back into the anaesthetic syringe, the bladder has been reached.

4. Incise the skin with an appropriate scalpel blade.

5. Puncture the bladder down the same track used for the anaesthetic.

6. Follow appropriate technique to secure the catheter in the bladder. This varies between suprapubic catheter sets.

7. Collect any necessary specimens and connect the catheter to an appropriate drainage bag.

8. Apply adhesive and/or sutures as appropriate to maintain the catheter in place.

Complications

• Failure to catheterise the bladder—if in doubt, ultrasound-guided catheterisation is essential

• Bowel perforation

• Extravasation of urine—intraperitoneal or extraperitoneal

• Local bleeding—intraperitoneal, extraperitoneal or into bladder

• Infection

• Obstruction

PERITONEAL LAVAGE

Indication

Cardiovascular instability in a patient with potential abdominal injury in whom other investigative measures, such as computerised tomography (CT) scan, are inappropriate or unavailable.

Note: Peritoneal lavage is now rarely used in emergency medicine. Although it is an effective screening technique, and is very sensitive for the presence of intraperitoneal blood, it lacks specificity, and its use as the primary investigation for abdominal trauma will result in relatively more negative laparotomies. FAST is a more appropriate screening test, and abdominal CT scan is a better formal investigation.

Contraindications

• Any indication for urgent laparotomy

• Significant scarring from previous abdominal or pelvic operations

• Pregnancy

• Morbid obesity

• Severe fractured pelvis—a relative contraindication because sufficient blood to cause a positive test often leaks into the peritoneum without any other intra-abdominal injury

• Facilities for laparotomy unavailable—it is of no benefit to perform a peritoneal lavage and then have to transport the patient to another centre; the lavage fluid will simply further confuse the clinical picture

Technique

1. Position is supine, preferable on tilting table.

2. Ensure urinary catheter and nasogastric tube in situ and draining.

3. Prepare the abdomen (including shaving midline below umbilicus).

4. Anaesthetise with lignocaine and adrenaline in the midline below the umbilicus.

5. Incise the skin vertically for 3 cm. Continue the incision down to the linea alba and secure hemostasis.

6. Use an assistant or self-retaining retractor to hold the wound open.

7. Incise the fascia and peritoneum, grasping fascial edges with clamps to provide counter traction. The incision in the peritoneum needs to be only 5 mm long.

8. Insert the catheter into the peritoneum and advance downwards towards the pelvis.

9. Aspirate the catheter with a syringe.

10. If syringe aspiration negative, instil 10 mL/kg warmed saline.

11. Agitate the abdomen and briefly tilt the patient’s head down if possible.

12. Lower the IV bag to the floor to siphon fluid out.

13. Send fluid for testing. A positive test is indicated by aspiration of more than 10 mL gross blood or obvious enteric contents initially, or by analysis of the fluid showing greater than 100,000 red blood cells per cubic millimetre, greater than 500 white blood cells per cubic millimetre or presence of bacteria/vegetable fibres. As a practical guide, if newsprint cannot be read through the IV set, then the test is regarded as positive.

14. Remove the catheter and close the wound unless the patient is to have immediate laparotomy.

Complications

• Local bleeding and infection

• Perforation of intraperitoneal or retroperitoneal contents, including bowel, mesentery, vessels, bladder, uterus

• Peritonitis (usually due to bowel perforation)

CRICOTHYROIDOTOMY

Indications

• Supralaryngeal airway obstruction when tracheal intubation not possible (e.g. epiglottitis, burns, facial trauma)

• Ventilatory support required (e.g. apnoea) and tracheal intubation failed

Technique

1. Position the patient supine with the neck extended if possible.

2. Identify the cricothyroid membrane as a horizontal depression in the midline anteriorly between the notch of the thyroid cartilage and the cricoid cartilage. Prepare the area.

3. Make a 1.5-cm incision across the lower half of the cricothyroid membrane, then incise the membrane. This is best done with a guarded scalpel blade, usually supplied in cricothyroidotomy kits. However, it can be accomplished with any scalpel.

4. Open the cricothyroidotomy by dilating with artery forceps or gently twisting the scalpel blade.

5. Insert the tube (either a 6-mm cuffed endotracheal tube for an adult, or a 4.5-mm uncuffed cricothyroidotomy tube) in a downward direction.

6. Remove trochar, secure tube and ventilate the patient.

7. Check ventilation in the same way as for endotracheal intubation.

Complications

• Local bleeding—external or into the airway

• Creation of a false passage

• Damage to larynx, trachea, oesophagus

• Local infection

LUMBAR PUNCTURE

Indications

• Clinical suspicion of CNS infection, particularly meningitis

• Clinical suspicion of subarachnoid haemorrhage when CT scan unavailable or CT scan negative

• Sample of cerebrospinal fluid (CSF) required for non-emergent evaluation (e.g. Guillain-Barré syndrome)

• Therapeutic—drainage of CSF or installation of chemotherapy

Contraindications

• Clinical or CT evidence of raised intracranial pressure or localising signs

• Infected site of puncture

• Bleeding diathesis

Editor’s comment

Always explain, obtain consent (preferably written) as complaints, complications frequently follow.

Technique

1. Position the patient in the lateral recumbent position with knees drawn up. Mark the L4 spinous process which is palpable in a line connecting the posterior–superior iliac crests.

2. Prepare and drape the area.

3. Infiltrate local anaesthetic in L3/L4 or L4/L5. Gently insert a spinal needle in the midline. A non-cutting needle with side port is preferred, in which case the skin may need to be punctured first with a sheath. If a cutting needle is used, position the bevel horizontal. After penetrating the skin, aim approximately for the patient’s umbilicus.

4. Advance, feeling for the loss of resistance as the needle penetrates the ligamentum flavum.

5. Remove the stylet to check for CSF flow. If the subarachnoid space has not been reached, carefully re-insert the stylet and continue.

6. When CSF is obtained, connect a manometer to measure CSF pressure and then collect a sample, normally into three sterile bottles.

7. Remove the needle and dress the site.

Note: The CSF pressure is of little diagnostic significance in the emergency department setting. If lumbar puncture is unsuccessful in the lateral recumbent position, it is appropriate to sit the patient up, leaning forward over a pillow. This position makes the procedure easier and is routinely used to administer spinal anaesthetics, although it does not allow manometry.

Complications

• CSF infection—rare but potentially fatal

• Spinal cord or corda equina damage—should not occur if performed at the correct level

• Uncal herniation—described after lumbar puncture in cases with raised intracranial pressure

• Post-lumbar puncture headache

EMERGENCY DEPARTMENT THORACOTOMY

Emergency department thoracotomy should be considered only if the operator is experienced, there is some hope of meaningful survival based on the patient’s presentation, and facilities exist for rapid removal of the patient to a thoracic operating facility.

Indications

• Penetrating chest trauma with all of the following:

• signs of life present during pre-hospital phase

• any pneumothorax drained

• pericardiocentesis undertaken

• fluid load given

• continued poor response—in cardiac arrest or cardiac arrest clinically eminent

• Blunt trauma—only when signs of life have been present in the emergency department, no other lethal injuries (e.g. severe head injury) present, no response to standard resuscitation and electrical cardiac activity still present

Note: Even in these circumstances, the response rate to emergency department thoracotomy in blunt form is exceedingly low. The aim of emergency department thoracotomy is to drain pericardial tamponade, repair cardiac lacerations or cross-clamp the aorta. Internal cardiac massage or internal defibrillation may be performed, but does not constitute an indication for thoracotomy alone.

Contraindications

• Inadequately skilled personnel

• Thoracic operating theatre not available

• ‘Medical’ cardiac arrest

Technique

1. Patient is normally supine, intubated, undergoing CPR.

2. Prepare the left side of the chest.

3. Incise along the top of the left 5th rib down to the chest wall muscles. Begin 2 cm lateral to the sternum and extend beyond the posterior axillary line.

4. Dissect through the intercostal muscles into the pleura with Mayo scissors, stopping ventilation so that the lung collapses momentarily. Divide the intercostal muscles with a sweep of the Mayo scissors along the top of the 5th rib.

5. Insert rib spreaders with a handle and ratchet bar downwards and retract the ribs.

6. If pericardotomy is required (history consistent with pericardial tamponade, pericardium swollen and tense) perform it with scissors starting at the diaphragm and moving upwards, 1 cm anterior to the phrenic nerve. Use fingers to gently sweep clots of blood from the pericardium.

7. If direct cardiac compression is required use two hands, anterior and posterior to the heart, to gently compress.

8. If aortic cross-clamping is required, this is difficult to perform with a vascular clamp since the aorta must be separated from the oesophagus. It is easier to apply pressure through the pleura to compress the aorta against the thoracic spine.

9. Repair of lacerations in the myocardium is particularly difficult in the emergency setting, but may be attempted if necessary.

10. Proceed immediately to the operating theatre for further definitive treatment.

EDITOR’S COMMENT

Most problems arise when procedures are ill-prepared, ill-explained and performed with inadequate analgesia and in haste.

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