The Central Line Part 2: Technique & Procedural Steps

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

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The Central Line Part 1: The Basics

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

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Auricular Hematoma Drainage

Auricular hematomas are common complications after direct trauma to the auricle of the ear. A shearing force causes capillary rupture and hematoma formation. If a patient  presents within 7 days of the injury, it falls within the EM Physicians skill set to evacuate the hematoma. The following is a video that walks one through the procedure…

The Cricothyrotomy Part 3: Pediatric Points

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

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

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The Cricothyrotomy Part 1: The Procedure

a blog series on emergency medicine procedures

A SURGICAL AIRWAY IS IMMINENT…

259_D3.2.9

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

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Procedural Blog EXTRA: Reduction of TMJ Dislocation

9fabe73c-e43e-47b4-9027-a14138593117_zpsf54998b4a blog series on emergency medicine procedures

Case:

  • 14 year old female presented with inability to close her mouth after yawning.
  • Exam: uncomfortable with jaw open. Limited ROM of jaw bilaterally. Tenderness at TMJ with mandibular displacement bilaterally.

TMJ Dislocation

  • Mandibular condyle moves anteriorly along the articular eminence and becomes locked in place
  • Spasm of the surrounding muscles lead to trismus
  • Condyle cannot return to its normal position

tmj1

From Roberts and Hedges’ Clinical Procedures in Emergency Medicine

Panorex of patient’s bilateral TMJ dislocation:

tmj2

Facial CT 3-D reconstruction showing bilateral TMJ dislocation: 

tmj3 tmj4

Facial CT showing TMJ dislocation: 

tmj5 tmj6

HUNTING & GATHERING

  • Universal precautions (gloves!)
  • Gauze
  • Tongue blade
  • Suction
  • Forceps

PREP

  • Conscious sedation especially in children
  • Massage the masseter muscles in order to relax and fatigue them, which may facilitate manual reduction
  • Consider local anesthesia
    • TMJ space (see below) OR directly into the lateral pterygoid muscle (not discussed)
    • TMJ local anesthesia:
      • Clean the skin anterior to the ear
      • Insert the needle into the TMJ space at the palpable depression caused by the dislocated condyle
      • Direct the needle anteriorly and superiorly onto the inferior surface of the glenoid fossa
      • Inject ~2 mL of local anesthetic (we used lido 1% with epi)

tmj7REDUCTION TECHNIQUES

Consider trying these methods first:

  • Gag technique: Elicit the gag reflex using a tongue blade or cotton swab. During the reflex, inhibition of the muscles of mouth closure permits the mandible to descend, which may free the condyle in some patients. Have suction handy in case of vomiting.
  • Syringe technique: Place a 5 or 10 mL syringe between the posterior upper and lower molars or gums on one of the affected sides. Have the patient gently bite down on the syringe while rolling it back and forth between the teeth until the dislocation on that side is reduced. The opposite side tends to reduce spontaneously. If this does not occur, place the syringe on the opposite side and try the same technique.
    • Note: this requires a high level of participation of the patient (i.e.: will not work in very young children)

If those fail…

  • “Classic Technique”/Intraoral reduction:

  • Have the patient sitting up, facing you, head against the back of the bed
  • Have your arms at the level of the mandible
  • Grasp the mandible with both hands
  • Rest your thumbs on the inside the mouth on the ridge of the mandible adjacent to the molars
  • Wrap thumbs in gauze (leave a trail of gauze outside of the mouth so that it can be easily removed)
  • Wrap your fingers around the outside of the jaw. You may place the thumbs on the occlusal surfaces of the teeth. If you do, keep your thumbs safe from being bitten by wrapping them in gauze
  • Have an assistant hold the head of the patient still.
  • Apply downward pressure to the mandible to free the condyles from the anterior aspect of the eminence, then guide the mandible posteriorly and superiorly back into the temporal fossae.

troubleshooting

You are still having trouble with the reduction:

  • Rock the mandible back and forth to facilitate muscle fatigue
  • Have the patient open the mouth wider while attempting reduction, which will relax the masseter and temporalis muscles

pearl12

Make a head-and-chin bandage after a successful reduction

  • Wrap gauze around the face so that the patient is unable to open their jaw widely while they are sedated/confused to avoid re-dislocation (see below)

tmj8

Image from :http://collections.infocollections.org/ukedu/en/d/Jh2113e/5.2.html

  • Other techniques: Wrist pivot, extraoral reduction, recumbent approach, posterior approach, and ipsilateral approach, which will not be discussed here.

After Discharge

  • Avoid extreme opening of the jaw for 3 weeks.
  • Support the lower jaw when yawning.
  • Soft diet, warm compress, NSAIDs, muscle relaxants.
  • Referral to ENT and/or oral surgery for possible future surgical fixation.

Thank you to Dr. Amir Yavari, Dr. Leslie Sowikowski, Dr. John Diune and the Samuels Sinclair Dental Center for their teaching and allowing us to use this footage. Thank you Dr. Gregory Lockhart, MD and Dr. Michael Prucha, MD for this interesting case. 

 

Authorship

Faculty Reviewer: Gita Pensa

Resident Reviewer: Jonathan Ameli

Author: Chana Rich  

 

Please offer your own tips on TMJ dislocation reductions in the comments section!

References

Riviello, Ralph. Dislocation of the Mandible, Chapter 63, 1298-1341.e1 In: Roberts J, et al. Roberts & Hedges’ Clinical Procedures in Emergency Medicine. 6th Saunders; 2013.

Reyes Mendez, Donna. Reduction of temporomandibular joint (TMJ) dislocation. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on November 17, 2015.)

 

Procedural Blog EXTRA: Inferior Alveolar Nerve Block

9fabe73c-e43e-47b4-9027-a14138593117_zpsf54998b4

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

Tricks of the Trade: A-Line Kits for Vascular Access

Ever struggle with vascular access?

Ever tried a 20G A-Line kit?

Even if you have,  once a flash is obtained it is common to not be able to thread the wire. If you pull the needle out of the catheter, it is rigid and difficult to replace in the catheter and rarely results in salvaging the attempt. In this video, I show you that by cutting the white cap off the back of the a-line kit, it will liberate the guide wire allowing the proceduralist to use it as a backup if the first attempt at placing the catheter fails. I have found,  many times when a flash is obtained but the wire doesn’t pass, the attempt can be salvaged with this technique. Enjoy…

 

Pigtail Catheter Placement for Pneumothorax

Traditionally, a pneumothorax has been treated with a large bore chest tube connected to suction, with inpatient observation until the chest tube can be pulled.   The patient, if stable, would then be discharged home.  Persistent discomfort, infection, and other complication rates are not insignificant.

More recently, there has been a push to treat stable small pneumothoraces with less invasive methods such as observation or small bore chest tubes. In cases of unstable patients or those with hemopneumothoraces, a large bore chest tube continues to be the most appropriate treatment.

Pigtail Catheter Indications

  • Drainage of air or thin simple fluid
  • Current teaching is for PTX usage only if <40%
  • How to know if fluid is simple? Lateral decub XR to see if fluid layers out onto the side

 

Hunting and Gathering

Find a workstation on wheels (WOW) with a functioning Topaz to obtain informed consent

Supplies

IMG_1946

  • Pigtail Catheter kits are currently not kept in clean utility rooms or in the critical care rooms. You will need to CALL SUPPLY and have them bring you a kit.
  • Extra 1% lidocaine
  • Sterile Gloves
  • Sterile Gown
  • Hat
  • Mask with eye shield
  • Sterile flush or 10cc of sterile saline

Setup

  • Patient Position: supine with arm above head, same as for a thoracostomy tube. Consider soft restraints to help the patient keep the arm in position.
  • Draw up your lidocaine into the provided syringe
  • Place the dilator all the way into the pigtail catheter
  • Prep the guidewire into the red applicator
  • Load the finder needle syringe with 3-4cc of sterile saline. Or take the sterile flush and discard 6-7cc of saline. Connect to the finder needle

The Procedure

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