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
Soft tissue infection overlying site
Traumatic or congenital distortions
Superior vena cava syndrome
Deep venous thrombosis in vessel of choice
Combative or uncooperative patients
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
From Netter’s Atlas of Human Anatomy, 4th ed, 2006
Subclavian vein and IJ –> brachiocephalic vein + contralateral brachiocephalic vein –> SVC
Where it is
Posterior to medial 1/3 of clavicle ANDanterior to 1st rib
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)
PEARL #1: KNOW YOUR ANATOMY…
Why is this so important? First let’s explore some potential pitfalls….
PITFALL: You make your vertical incision OFF midline
You may not find the membrane
Complications: you may injure the following structures:
Video and idea proposed by the brilliant Dr. Michael Prucha
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)
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 seated upright, back of head against stretcher, mandible parallel to floor
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
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!
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.
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
Your 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.
Your patient is very sensitive to pain
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.
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).
Non-sterile marking pen.
Optional: Tech or RN for positioning assistance during procedure.
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 →