Resuscitation and emergency procedures

Published on 14/03/2015 by admin

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Chapter 3 Resuscitation and emergency procedures

Drew Richardson

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

Indications

• Administration of fluid—resuscitative and/or maintenance
• Administration of drugs
• Obtaining blood (rare)

Contraindications

• Overlying skin damage (e.g. burns) or infection
• Venous damage proximal to site insertion
• Arteriovenous (AV) fistula in the limb

Technique

1. Apply a venous tourniquet.
2. Identify a suitable vessel, ideally as peripheral as possible. Start looking on the back of the hands. Use cubital fossa veins only when large volume resuscitation is required or other sites have proven unsuitable.
3. Prepare the area with a disinfectant-soaked swab, swabbing in a distal direction.
4. Stretch the skin slightly over the vein.
5. Insert the needle, bevel upwards, until a flushback is obtained.
6. Advance the catheter over the needle.
7. Remove the needle, attach the intravenous line or bung and secure the catheter.
8. Check position and patency by infusion or injection to clear blood from the catheter.

Complications

• Haematoma
• Subcutaneous extravasation of fluid
• Damage to nearby structures
• Inter-arterial cannulation

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

Infraclavicular technique

1. Position the patient supine in 15° Trendelenburg with the arm adducted.
2. Enter at the junction of the middle and medial thirds of the clavicle.
3. Aim along the inferior surface of the clavicle towards the suprasternal notch, with a needle bevel facing inferomedially.
4. Advance 1–2 mm after first flush of blood to obtain reliable flow back into the syringe.

Complications

• Pneumothorax
• Arterial puncture
• Others as described above

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.

Internal jugular vein catheterisation

Technique

1. Position head down 10° and turned slightly away from side of entry.
2. Enter just above the point of the triangle formed by the two heads of sternocleidomastoid and 1 cm lateral to the internal carotid pulsation.
3. Aim parallel to the carotid artery (‘straight down the neck’).

Complications

• Arterial puncture
• More easily displaced by movement than subclavian lines
• Others as above (rare)

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
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