ITE Procedures

Angela Pugliese MDDepartment of Emergency MedicineHenry Ford Hospital

Studying Techniques• Must know all procedures from EM model • See outline

• Roberts and Hedges

• Chapter in First Aid for the EM Boards

• Questions from ROSH

Topics Outline• ED Thoracotomy• Pericardiocentesis• Thoracostomy tube• Cardiac Pacing• Umbilical Vein Catheterization• Paracentesis• Local Anesthesia• Perimorten C-section• Arthrocentesis• Compartment Pressure Measurement

ED Thoracotomy• Indications:• Penetrating trauma• Loose vitals (while in route) or in ED• Goal to cross-clamp aorta and control hemorrhage

• Technique:• Intubate and place NG• Enter Pericardium ANTERIOR to phrenic nerve

• Pearls:• Learn indications

Pericardiocentesis• Decipher tamponade from tension pneumo

• Technique:• Use US – parasternal approach• Blind approach – subxyphoid, attach EKG lead• Major complication coronary vessel laceration

• Pearls:• Treatable cause of PEA• ABOVE THE RIB • CXR post procedure

Thoracostomy Tube• Indications:• Pneumothorax/hemothorax

• Technique:• Tension use needle decompression• 4th or 5th intercostal space anterior to mid-axillary line• ABOVE THE RIB

• Pearls:• >1500 ml blood means OR (or >300 ml/hr after)• Don’t clamp tube• CXR post procedure• NO CXR PRIOR TO NEEDLE DECOMPRESSION

Cardiac Pacing/Cardioversion• Indications:• UNSTABLE DYSRHYTHMIAS

• Technique:• Cutaneous vs transvenous• Right IJ then left subclavian

• Pearls:• Pad placement: anterior and posterior• Confirm pacing by palpating pulse with monitor• Magnet deactivates or revert to asynchronous pacing• Air embolism complication place patient in left lateral decubitus

Umbilical Vein Catheterization

• Access about 1 week after birth

• ONE VEIN (two arteries) located 12 o’clock

• Cut cord 2 cm from base (1cm NICU)

• Advance Catheter about 1-2 cm beyond good blood return

• CXR shows catheter going toward the head

Paracentesis• Use an US

• Consider albumin if you take 5L or greater

• Diagnostic Tap• >250 PMNs is SBP

Anesthesia• Esters/Amides – Amides all have 2 I’s• No cross reactivity (ie the allergic patient)

• NO EPI in end arteries (finger, nose, ear, penis)

• Learn Regional Blocks

• Max dose 4 mg/kg without epi, 7 mg/kg with

Perimortem C-section• Indications:• Pregnant woman greater than 24 wks with cardiac arrest• Must complete within 5 minutes of maternal death

• Technique:• Continue maternal CPR• Midline vertical incision

• Pearls• Fundus palpated above umbilicus assume viability• Know APGAR

Arthrocentesis• ABSOLUTE CONTRAINDICATION• Infection over the joint

• WBC > 50,000 indicates infection (BOARDS)

• Pseudogout = Positively birefringent (pyrophosphate)

• Fat globules indicates intra-articular fracture

Compartment Measurement• Approximate 6 hours of viability

• 30 mm Hg is cut off number

• Elevated pressure indicates need for fasciotomy • Exception with snake bites (use hyperbarics, serial measurements

and anti-venom), fasciotomy is last resort

Rapid Fire Pearls• Subclavian/IJ pulled out and patient becomes

hemodynamically unstable….• Air embolus, place left lateral decubitus, then aspirate RV (HBO)

• Anesthetic effect of Mental Nerve Block• Lower lip

• Lower lip and inferior teeth• Inferior Alveolar – too posterior causes facial nerve palsy

• Approach to elbow aspiration• Lateral (avoid ulnar nerve which is medial)

Rapid Fire Pearls• Pt getting blood develops hives, what next?• Give benadryl and continue

• Correct direction for mandibular reduction• Down and posterior

• IO placement in peds• Tibia; 1 cm inferior of tuberosity, 1 cm medial

• Testicular Detorsion• Open the book (remember 180 degrees)

Conclusion• Complete ROSH questions

• Review Outline

• Email with questions