Author Archives: Jonathan Ameli

The Central Line Part 2: Technique & Procedural Steps

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a blog series on emergency medicine procedures

In the last post (the central line part 1) we focused on the indications/contraindications and anatomic considerations. Here we focus on technique and procedural steps. Enjoy. 

 

HUNTING & GATHERING

*note: images shown in this section are institution-specific (Rhode Island Hospital Emergency Department) 

Find a computer with a functioning Topaz to obtain informed consent:

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Go to this corner in any critical care room (here is a closer look) and obtain a central line kit:

OR

Finally, obtain these items:

  • mayo stand
  • sterile gloves
  • chlorhexidine scrub
  • 2-3 sterile saline flushes
  • non-sterile marking pen
  • ultrasound machine and ultrasound probe cover
  • in kit: hat, gown, facemask

 

PREP

PRE-STERILITY:

  • Open kit and empty sterile contents onto the field
  • ULTRASOUND:
    • Plug in ultrasound machine. It WILL run out of battery if you don’t and the screen will shut off in the middle of the procedure
    • Test your US probe orientation: tap gently on left side of probe…this should match left side of your screen
    • Examine the target vein: is it compressible? Is it plump and easily visualized?
  • PATIENT:
    • Position the patient
    • Scrub target area with chlorhexidine
    • Mark the site

TIMEOUT! 

…and document it:

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STERILIZE.

Watch this video. 

From EMCrit.org, Scott Weingart, RACC Sterile Line Preparation

Continue reading →

The Central Line Part 1: The Basics

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a blog series on emergency medicine procedures

In this first installment on central lines, we discuss central line indications/contraindications/alternatives, anatomic considerations, and the upsides and downsides of the 3 major sites (subclavian, internal jugular, and femoral)

Indications specific to the ER

  • Administration of harsh or concentrated fluids
  • High volume, high flow fluid administration
  • Emergency venous access
    • Alternatives: EJ, IO, ultrasound-guided peripheral IV
  • Conduit for transvenous pacer or dialysis catheter

Contraindications

  1. Soft tissue infection overlying site
  2. Traumatic or congenital distortions
  3. Superior vena cava syndrome
  4. Deep venous thrombosis in vessel of choice
  5. Coagulopathies
  6. Combative or uncooperative patients

troubleshooting

TROUBLESHOOTING: How to solve the above contraindications…

  • 1-4: move to another site
  • 5: consider reversal agents
  • 6: consider sedation and/or intubation, depending on the case
LOCATION

SUBCLAVIAN

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From Netter’s Atlas of Human Anatomy, 4th ed, 2006 

Pathway

Subclavian vein and IJ –> brachiocephalic vein + contralateral brachiocephalic vein –> SVC

Where it is

Posterior to medial 1/3 of clavicle AND anterior to 1st rib

Anatomic awareness Continue reading →

The Cricothyrotomy Part 3: Pediatric Points

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a blog series on emergency medicine procedures

PEDIATRIC POINTS

In our last 2 posts (the cricothyrotomy part 1 and the cricothyrotomy part 2), we focused on adults. That is because the open surgical airway is often contraindicated in children as we discuss below, and there is an alternative method depending on age.

pearl12

PEARL: the cricothyroid membrane in children is significantly different…

Ped cric anat

From Roberts and Hedges’ Clinical Procedures in Emergency Medicine, 6th ed, 2013

  • Smaller
  • More anterior
  • Funnel shape
  • Structures like the larynx are more difficult to stabilize

pearl12

PEARL: in the majority of cases, open surgical cric on children is contraindicated

  • Children younger than 10-12 years old should not have an open surgical cricothyrotomy according to most emergency medicine textbooks
  • Why: risk of injuring important structures due to the anatomical differences listed above
  • Instead, if a non-invasive airway is impossible, perform a percutaneous needle cricothyrotomy

pearl12

PEARL: what type of ventilation to use

  • Bag ventilate if the patient is < 5 years old (risk of barotrauma with jet)
  • Jet ventilate if the patient is greater than 5 years old

 

SUMMARY

Child < 10-12 years old, cannot intubate, cannot ventilate, and rescue airway devices not working? Perform percutaneous needle cricothyrotomy (see below).

< 5 years old? Bag ventilate.

> 5 years old? Jet ventilate.

 

TECHNIQUE

  • Percutaneous needle puncture of the cricothyroid membrane
  • Translaryngeal ventilation (PTLV) by jet insufflation OR bag insufflation (age dependent)

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From Roberts and Hedges’ Clinical Procedures in Emergency Medicine, 6th ed, 2013

From Beck et al, Academic Emergency Medicine, Percutaneous Transtracheal Jet Ventilation, 2011 

 

Please also view these resources from our own Brown faculty!

Dr. Valente Sim Video 

Procedurettes Junior Jet Job

 

PLEASE SHARE ANY PEDIATRIC POINTS ON THE CRICOTHYROTOMY IN THE COMMENTS SECTION! 

 

Textbook References

Hebert R, Bose S, Mace. Cricothyrotomy and Percutaneous Translaryngeal Ventilation. Chapter 6, 120-133.e2. In: Roberts J, et al. Roberts & Hedges’ Clinical Procedures in Emergency Medicine. 6th Saunders; 2013.

Smith M. Surgical Airway Management. In: Tintinalli JE, et al. Tintinalli’s Emergency Medicine. 7th ed. New York: McGraw-Hill; 2011.

Walls RM: Airway. In Marx JA, Hockberger RS, Walls RM: Rosen’s Emergency Medicine: Concepts and Clinical Practice, 6th ed, vol. 1. Philadelphia, Elsevier, 2006, pp 2-25.

Image References

Hebert R, et al. Cricothyrotomy. In: Procedures Consult. Elsevier; 2008.

Authorship

Faculty Reviewers: Gita Pensa MD and David Lindquist MD 

Author: Jonathan Ameli MD

 

The Cricothyrotomy Part 2: Pearls, Pitfalls, and Troubleshooting

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a blog series on emergency medicine procedures

In the last post (the cricothyrotomy part 1) we focused on the basics of preparation and technique for the cricothyrotomy procedure. Here we focus on the pearls, pitfalls, and troubleshooting with a strong emphasis on anatomy.

As an aside…

Always consider alternatives to the cricothyrotomy, and especially, the “crash” cricothyrotomy

  • Try other non-invasive rescue maneuvers including the intubating LMA as Dr. Nestor mentioned last week

  • Review the difficult airway algorithms that were briefly acknowledged last week, and strive for expertise in airway decision-making

  • Do not hesitate to overhead anesthesia for assistance in any difficult airway

  • Avoid paralyzing patients with tenuous airways in appropriate situations, and consider awake (fiberoptic or other) intubation, or even awake cricothyrotomy with ketamine (and local anesthetic)

pearl12

PEARL #1: KNOW YOUR ANATOMY…

Why is this so important? First let’s explore some potential pitfalls….

pitfall-sign

PITFALL: You make your vertical incision OFF midline

  • You may not find the membrane
  • Complications: you may injure the following structures:
    • Cricothyroid muscles
    • Recurrent laryngeal nerves (uncommon)
    • Carotid artery / Internal Jugular vein (very rare)

pitfall-sign

PITFALL: You make a horizontal cut too SUPERIOR

  • Superior to cricothyroid membrane:
    • This is above the cords, and likely the location of your issue (i.e.: obstruction or other)
    • Complications: increased risk of vascular and nerve damage: superior laryngeal vessels and the internal branch of the superior laryngeal nerve

Continue reading →

The Cricothyrotomy Part 1: The Procedure

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a blog series on emergency medicine procedures

A SURGICAL AIRWAY IS IMMINENT…

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YOU CANNOT INTUBATE – CANNOT VENTILATE!

2000px-Achtung.svg

INDICATIONS

  • Cannot intubate:
    • Multiple attempts with most experienced operator
    • Both conventional and rescue techniques attempted (1)
  • Cannot ventilate:
    • Cannot get chest rise with BVM, LMA, or other rescue devices between attempts
  • Cannot maintain O2 sat > 90%

OR

  • Extreme facial or oropharynx deformity

CONTRAINDICATIONS

  • Other airway options have not been considered
  • Pediatric patient (for open surgical method) (<10-12 years old, varies depending on expert opinion)
  • Tracheal transection, larynx or cricoid cartilage fracture, obstruction at or below the membrane

DIFFICULT AIRWAY ALGORITHMS

Watch this video to learn a simplified approach from Dr. Reuben Strayer.

From Dr. Reuben Strayer’s Advanced Airway Management for the Emergency Physician 

HUNTING & GATHERING

PROCEDURE

Continue reading →

Procedural Blog EXTRA: Inferior Alveolar Nerve Block

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A blog series on emergency medicine procedures

Video and idea proposed by the brilliant Dr. Michael Prucha

Goal:
  • Dental pain control
Location of Numbing:
  • Ipsilateral teeth along the mandible, as well as the lower lip and chin (mental nerve is distal to inferior alveolar nerve)
Prep:
  • 50/50 mixture: 1-2% lidocaine with epinephrine + 0.5% bupivacaine (lasts up to 6 hours)
  • Syringe with 25-27 g needle
  • Consider topical anesthesia on gauze or as viscous gel prior to injection
Patient:
  • Patient seated upright, back of head against stretcher, mandible parallel to floor
You:
  • Position yourself opposite side of target nerve
  • HAND #1: thumb in cheek (not in between the teeth…ouch!), palpate RETROMOLAR FOSSA and find CORONOID NOTCH (image A), visualize the PTERYGOMANDIBULAR TRIANGLE (image C)
  • HAND #2: syringe between first and second premolars on opposite side, enter space until mandibular bone is felt, pull back small amount (and check for aspiration of blood) (complication note: if no bone is felt, you increase your chances of injecting into the parotid gland, i.e.: facial nerve…a temporary facial nerve palsy may occur)
  • Inject (image B)
  • Patient may jump/jerk. BE PREPARED.
  • ~2ml or double amount if needed
  • Wait 3-5 minutes for anesthetic to work

1

2

Images from Roberts and Hedges’ Clinical Procedures in Emergency Medicine, 6th ed, 2013


Thank you to Dr. Fearon and the Samuels Sinclair Dental Center for allowing us to use this footage. Please offer your own tips on head and neck nerve blocks in the comments section!

Textbook References

Amsterdam JT, Kilgore KP. Regional Anesthesia of the Head and Neck. Chapter 30, 541-553.e1. In: Roberts J, et al. Roberts & Hedges’ Clinical Procedures in Emergency Medicine. 6th Saunders; 2013.

Jonathan Ameli MD

Lumbar Puncture Part 2: Pearls, Pitfalls, and Troubleshooting

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a monthly blog series on procedures

Take your LP skills to Eleven: this is spinal tap!

Last week we discussed the basics of the adult LP. This week we will guide you through some difficult scenarios and their solutions.

THE SPOOKED PATIENT

troubleshootingYour patient is nervous and squirmy

  • Consider having an assistant hold and position the patient.
  • Steady the shaft of the needle with your non-dominant hand.
  • Talk to the patient. Here are some examples of what you can say prior to the procedure:
    • “I will numb up your back, and that should be the only part that hurts.”
    • “Most of the procedure is just setting up my materials.”
  • During the procedure, the patient cannot see you, which can be anxiety provoking. Describe each step of the procedure in a calm manner. And try to avoid THIS.
  • If necessary, administer an anxiolytic such as a benzodiazepine.

troubleshootingYour patient is very sensitive to pain

  • First, lidocaine!
    • Did you inject enough volume into the deeper structures of the back? As Dr. Whit Fisher mentioned in the comments of the previous post, make sure you gather extra lidocaine (only 5ml in the LP tray). In a sterile fashion, draw up an extra 5-10 ml with the help of an assistant.
    • Note: if trying a new interspace, make sure this area is also anesthetized.
  • Patient still in pain? Consider administration of an analgesic such as an opioid.

Continue reading →

Lumbar Puncture Part 1: The Basics

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a monthly blog series on procedures

Hunting & Gathering

Find a Workstation on Wheels (WOW) with a functioning Topaz to obtain informed consent.

Place Epic orders for CSF. Print the stickers and sign each with your initials.

Locate an LP tray,  its contents, sterile gloves, eye protection, facemask.

Gather these optional supplies:

  • Extra spinal needles:
    • 20 gauge, 3.5 in Quincke = cutting needle (1 included in tray).
    • 22 gauge, 3.5 in Whitacre = atraumatic needle.
    • 20 gauge, 6 in “Harpoon” = longer needle.
  • Extra 1% Lidocaine (5ml in tray).
  • Extra Povidone-Iodine.
  • Non-sterile marking pen.

Optional: Tech or RN for positioning assistance during procedure.

Timeout!

Perform the LP (see below).

Collect CSF in 4 tubes and send to lab.

Choosing the right needle

The Whitacre needle (aka a type of pencil point needle, or “atraumatic” needle) contains side ports, and theoretically causes less damage to tissue fibers upon entry. They are more difficult to use for skin entry. However, studies have shown that atraumatic needles decrease the incidence of post-LP headache (1 and 2). As an aside, there is no evidence that lying supine for any fixed period time is helpful in the prevention of post-LP headache(3). Continue reading →