After our last post, a few viewers have suggested that we continue the trend of elevated compartment pressures and address a super duper rare yet potentially life saving procedure today. So, escharotomy....here-a we go!
Let's say you have a patient brought in from a fire with full thickness burns to their torso. You intubate, start hydrating per the Parkland Formula, and you (assuming you are not one) get your burn center on the horn. Your respiratory tech suddenly notes that they are having an incredibly difficult time ventilating patient, and their peak pressures are shooting off the charts. Your trauma surgeon is not readily available, but you need to do something now.
It's time for escharotomy, as the full thickness burns are causing chest wall constriction. Eschars can also cause peripheral arterial occlusion (not unlike compartment syndrome!), and tracheal compression as well.
The pressure needs to be released in a fasciotomy-like release, and almost always this should be done in an operating room--if there's time. The procedure itself really does creep outside of the scope of our practice, and really should only be done in absolutely dire circumstances, mainly airway compromise and severe limb ischemia.
To prepare, you will mainly need some antiseptic prep and a scalpel. It will be handy to have electrocautery (cutting diathermy for the skin and coagulative diathermy for bleeding) available as you may encounter some significant bleeding.
The incisions to the chest should start at the clavicles at the anterior axillary line and extend inferiorally, down to the subcutaneous fat. You'll want to connect these lines with a transverse incision in the upper abdomen (the so-called "Roman Breast Plate"). If your pressures were significantly elevated you should see notable separation between the wound edges. If it's indicated, extremities can be incised in a similar manner along medial and lateral mid-axial longitudinal lines as depicted below. You'll want to avoid any extensor or flexor creases.
If the burns are full thickness, the skin should be insensate but local anesthesia may be indicated if there's a question if it's partial thickness or not. Overall optional as your patient is hopefully intubated and sedated at this point, and you may not have the time.
A very creative, MacGyver-esque simulation model can be seen here courtesy of Greater Sydney Area Helicopter Emergency Medical Service.
As always, these procedures are meant for medical professionals, and are for EDUCATIONAL PURPOSES ONLY. All efforts should be made for this one to be done in a controlled, operative setting with trained sub-specialists, and not in your shop.
Sources:
Roberts and Hedges Clinical Procedures in Emergency Medicine, 6th Edition. Chapter 38.
Life in the Fast Lane Blog - "Releasing the Roman Breastplate"
Let's say you have a middle aged otherwise healthy patient who, after throwing back a few cold brewskis, decides to "kick it" with a group of skateboarding youths. We'll cut to the chase and state that it doesn't go well, he's now in your ED, and his left calf doesn't look too hot. Maybe he's got a tibial fracture, maybe not. Either way his leg is tense as can be, and despite getting an adequate dose of narcotics he is in E-X-Q-U-I-S-I-T-E pain. You do an exam, and note a tense extremity with pain with passive stretch, some decreased sensation, but has a good distal pulse.
Just like Lloyd Bridges in Airplane, you should be shouting, "Stryker! Stryker! Stryker!" Stryker needle that is (it's the most commonly used product, so we'll only refer to that one), to rule out compartment syndrome.
The condition can occur in any extremity, but the most common presentation you'll see is the one stated above. It is an incredibly difficult diagnosis to make clinically, and it is a huge potential pitfall as correct identification can be delayed or even missed entirely. An interesting cohort study from the Canadian Journal of Medicine noted that patients at a hospital in Montreal who underwent fasciotomies noted a concerning "median event-to-operation" duration of 9 hours for traumatic cases and a shocking 34 hours for nontraumatic cases.
We are always taught the classic 5 P's (pain/swelling, pallor, paresthesias, paralysis, pulselessness), but if you're noting these findings the cat is already out of the bag, and your patient will likely have permanent deficits as a result. If it's early, you'll have to trust your gut and go check the pressure.
The set-up for this one is pretty simple, and everything you'll need should be in the pre-packaged kit. It includes a side ported needle, a diaphragm chamber, a prefilled 3 cc syringe, and the main monitoring unit. It is possible to jury rig a set-up to continuously transduce pressures like an arterial line, but it's beyond highly unlikely you would ever need to do this in the ED (more tailored for either the OR or a surgical ICU), so we will not cover that today.
Connect your needle to the diaphragm, and then screw in the syringe on the other side. Load this assembly by pushing it into the monitoring unit, with the black side of the diaphragm down. Snap the cover closed gently. To calibrate, hold the entire unit up at a 45 degree angle, and flush it to get the air out. Push the monitoring button to turn it on, then hold the monitor at the angle you're going to "Stryker at" and hold the zero button down. You should see "00" appear.
Then you'll need to identify the appropriate site to target. It all depends on where you think the affected compartment is. For sake of discussion, and since it's the most common one, we'll focus on the anterior compartment of the calf. Here, you'll identify the area where the proximal and mid thirds of the tibia meet, and then move 1 cm lateral to this.
You'll want to give them adequate local anesthesia at the site of injection, but you need to take care not too inject too deeply so that you get a falsely elevated reading. Once this is done and the area has been properly cleaned, insert your needle 1-3 cm into the compartment, and then, very, very slowly inject like an aliquot of saline (they state no more than 0.3 cc) and wait for the reading to appear.
If the pressure is greater than 30 mmHg, or within 30 mmHg of the diastolic blood pressure, your patient needs to be evaluated for a fasciotomy.
SoBroEm.com also features a nice step by step illustration here.
Here's another demonstration of the assembly and procedure from the Plastic Surgery Project:
If you haven't had a chance to check out the YouTube page of Dr. Nabil Ebraheim, go NOW. He's a veteran orthopedist with some incredibly high yield videos. Here's his clip on compartment syndrome (goes out of our scope but still a good watch):
As always, these writings are for medical professionals, and are for EDUCATIONAL PURPOSES ONLY. This is probably one of the least invasive procedures we've covered thus far, but that doesn't mean you should go running into a patient's room to needle their calf.
Sources:
Roberts and Hedges' Clinical Procedures in Emergency Medicine, 6th Edition. Chapter 54.
Messina et al. A human cadaver fascial compartmentpressuremeasurementmodel. J Emerg Med. 2013 Oct;45(4):e127-31. Vaillaincourt C. et al. Quantifying delays in the recognition and management of acute compartment syndrome. CJEM. 2001 Jan;3(1):26-30.
So let's say you have a patient--maybe they have a history of malignancy or renal failure or lupus or whatever--and the patient's having some trouble. Let's say they're dyspneic and hypotensive, and round out the classic Beck's Triad with some muffled heart sounds and distended neck veins (although only 33% of patients actually have all three of this point of medical masturbation). You astutely throw on your ultrasound on the chest, and you see something that looks like this:
Let's throw out the typical Procedures Club stem of "you're at a community hospital and there's no specialist around" blah blah blah and cut to the chase. You're doing a pericardiocentesis today!
But before you do any poking, let's review the basics for a spell. The pericardium is made of two layers, the visceral and parietal pericardia, with the potential pericardial space between them. Physiologically, there should be about 20ish cc's of fluid there for shock absorbancy and lubrication.
Generally speaking, once you've got about 200 cc of fluid acutely in there, you start to see some systolic dysfunction. Chronically, the space can accommodate quite well due to elasticity of the structures, so you could theoretically see a huge effusion with no symptoms as it has been there a while. Here's a demonstration of how you can fall off the curve, based on animal studies:
Some other things to note: first off, are they stable? If so, you might have enough time to treat what's causing the tamponade as opposed to the tap--i.e. if they're end stage renal, get them to HD. If they're not stable, consider fluid boluses and pressors to buy you some time. You do want to avoid positive pressure ventilation in these cases, however, as this may cause hemodynamic collapse.
In terms of preparation, you'll more or less need the following: an 18 G spinal needle, a 10 cc syringe, ECG wires with alligator clips, a guidewire, a pigtail catheter, a dilator, a stopcock, local anesthesia, sterile drape and wipes, and your trusty bedside ultrasound. If you're in a pinch, just grab the 18G and the syringe and go go go.
There are a few ways to approach the pericardium, The standard approach is subxiphoid, with you standing on the patient's right. After prepping and injecting some local anesthesia, you'll need to identify the left xiphocostal angle, and slide down about 1 cm. This will be your entry point, where you'll come in at about 30 degrees, aimed at the left shoulder. As with any other tap, you'll slowly aspirate as you go in. NEVER move the needle in a side to side fashion, as you may lacerate the underlying epicardium. Once you're in, try to get a good 60 cc out. If you've opted to attach your ECG wire, you can see if you hit epicardium by watching the waveform. If you start seeing ST elevations, back up and watch for them to resolve. After that, wire it and place your pigtail for continued drainage in an ICU setting.
If you have a legit tamponade, even a small amount of aspiration will cause a significant improvement in your patient. Remember, how they showed on Downton Abbey? Dr. Clarkson did that blind, in ONE POKE? That's how they did it back in the day.
If it's a hemorrhagic tamponade, the traditional teaching is that you can distinguish it from ventricular blood by looking for clot--pericardial blood shouldn't have any due to the fibrinolytic activity. However, this isn't totally reliable as you may just be tapping a brisk bleed. You'll definitely want to check a post procedure CXR to make sure you didn't put any air somewhere air isn't supposed to be.
If you're doing it blind, cadaveric studies have shown that subxiphoid is probably the safest way to go, although it is not without complications. Here's the (unauthorized?) ATLS version for your perusal:
If you have an ultrasound, however, you'll want to try a different route. Specifically, you'll take a parasternal long axis view to identify the tamponade. Your needle will be in plane with the probe. The best part about this one is that you can see the effusion decrease in size in real time.
Academic Life in Emergency Medicine has a featured a fantastic primer on these based on a paper published by Dr. Arun Nagdev from UCSF. If you want to look particularly slick with this one, you can identify the interior mammary artery with your probe and mark the skin so that you don't hit it with your approach.
I couldn't find a YouTube demonstration of this (which is a bummer as it appears to be awesome), but here is a subxiphoid approach from the Ultrasound Podcast page:
As always, these writings are for EDUCATIONAL PURPOSES ONLY. Would you want a family member to unnecessarily have a needle shoved in their pericardium by some overzealous scrub because "he always wanted to do one?" Be smart! Talk soon.
jps
Sources:
Roberts and Hedges' Clinical Procedures in Emergency Medicine, 6th Edition. Chapter 16.
Loukas, M., Walters, A., Boon, J. M., Welch, T. P., Meiring, J. H., & Abrahams, P. H. (2012). Pericardiocentesis: A clinical anatomy review. Clinical Anatomy, 25(7), 872–881. doi:10.1002/ca.22032
MPH, P. C. I. M., & MD, S. L. (2013). Techniques and Procedures. Journal of Emergency Medicine, 44(3), 661–662. doi:10.1016/j.jemermed.2012.06.019
MD, A. N., & MD, D. M. (2013). American Journal of Emergency Medicine. American Journal of Emergency Medicine, 31(9), 1424.e5–1424.e9. doi:10.1016/j.ajem.2013.05.021
Life in the Fast Lane Blog: http://lifeinthefastlane.com/ccc/pericardiocentesis/
Academic Life in Emergency Medicine Blog: http://www.aliem.com/ultrasound-guided-pericardiocentesis/
And we're back! In our last post, we discussed a number of approaches to the surgical airway, including the traditional "scalpel-hook-tube" method, the Seldinger technique, newer methods using bougies, and homemade/DIY/MacGyver approaches (a shout out to ALiEM's Dr. Andy Neill for sharing his study on emergently using Bic Pens!). But what about kids? That's truly a beast of its own, so today is dedicated to our precious we ones.
Clearly stating the obvious here: emergent pediatric airways are much less frequent than those in the adult world, and fortunately surgical airways in children are exceedingly rare. But you always have to remember that you cannot do a traditional cric on a child. Their cricothyroid membranes are just too small to accommodate an endotracheal tube, and you have an incredible high likelihood of damaging local structures. A paper we've referenced studied neonatal cadavers and found that in general their CTM's were about 2.8 mm tall, in comparison to the 2.0 ETT, which has an external diameter of 3.0 mm.
The exact cutoff age varies in the literature, anywhere from age five to age twelve. Generally speaking, if there's a kid, put your scalpel down. You could theoretically use this approach for adults as well, but they would require the jet ventilator--simply bagging them through the catheter won't generate adequate tidal volumes, and 15 L/min through the jet probably won't cut it either.
What you'll need is generally similar to the needle approach for kids: a 14 G angiocath with a 5 cc saline filled syringe (in a pinch, you can get this out of a central line kit), and some sort of adaptor for BVM (if that's your endpoint).
The big difference now is that you will need a jet ventilator--the system generally includes a hookup to high pressure wall O2 (generally at about 50 psi), tubing, an on-off valve/injector, a regulator, and a Luer lock to attach to your catheter (see below for images). Is this easily located in your shop? Best make sure that it is.
You'll start by identifying the laryngeal prominence, moving inferiorally to locate the CTM. In neonates and smaller children this may be difficult as their laryngeal prominence is not developed. In these instances, start low and move your finger up the tracheal rings until you've found the CTM. After cleaning, aim your needle caudad at about 30-40 degrees. Just like in our previous post, you'll want to aspirate to get air bubbles. And it should aspirate easily--any resistance suggests you're still in soft tissue. If your patient is awake (hopefully not), you can inject lidocaine via the syringe to suppress the cough reflex.
After that, just advance the catheter, and remove your needle. If you're going to be using a bag, toss on your adaptor (usually a 3 mL syringe MacGyvered into a 7.0 ETT adaptor--seen below), and start squeezing.
One big downside to using the standard angiocath is that it can kink relatively easy. An alternative, if you have it in your shop, is a nonkinking wire catheter, demonstrated here from the Walls text:
As for jet ventilating, you'll need to attach your apparatus and do some adjustments. To avoid barotrauma, you'll need to reduce the inspiratory pressures to less than 20-30 psi. This is where an expensive commercial device earns it weight in gold--you'll want a device that can reliably and easily do this quickly. You will want to set your flow rate at about 1 L/min per year of age, and then titrate up 1L/min based on how much chest wall movement you're seeing. Your control will either be a handle or a button, with several variations depicted below:
Due to their small lung volumes, the jet is generally contraindicated in kids younger than five. In these incidences, use the bag, ventilating carefully (but against a lot of resistance!) and with age appropriate equipment.
And now, here's your gratuitous Whit Fisher MacGyver video--this one features novel ways to jet ventilate when your equipment is not within grasp (along with some absolute ridiculousness):
As always, these writings on procedurology are for EDUCATIONAL PURPOSES ONLY. Do your own research, keep calm/carry on, and always do the right thing. You are the expert, and you are the one who will save a (young) life.
Thank you all for following! And thanks again to emcurious.com!
jps
References:
Navsa, N. et al (2005). Dimensions of the neonatal cricothyroid membrane--how feasible is a surgical cricothyroidotomy? Pediatric Anesthesia, 15:402-406. Walls RM, ed. Manual of Emergency Airway Management, Section 2. Roberts and Hedges' Clinical Procedures in Emergency Medicine, 6th Edition. Chapter 6. Whit Fisher's YouTube Page
Hey there, super friends! So far, we've managed to settle down into a groove with this whole blog thing with some solid posts about tough, challenging, weirdo, what-the-heck style procedures. Together, we've made our way through thoracotamies, Blakemores, and lateral canthotomies. We're bigger men and women in white as a result.
So, I think we're ready to tackle the elephant in the room. We're ready to battle Voldemort; we're willing to stop Johnny from "sweeping the leg"; we're going to confront the Emperor, and we will NOT turn to the dark side of the Force. Our archnemesis is calling, and we're not afraid.
That's right guys, we're doing the cric today.
Most providers I've talked to can count the number of cric's they've had in their career on one hand, but they remember every single, bloody detail of theirs, and will continue to do so until the day they die. And I'm not being glib there. The cases that lead to crics are always insanely unique; so unique that writing about any of my examples will surely open the medicolegal Pandora's box from hell. I'll abstain.
Remember your indications, mainly that you cannot oxygenate or ventilate. If you can't get the tube, but you can successfully place something temporary like an LMA, step back for a second. If there's an alternative, take it.
Anyway, just like many other things in medicine, there is more than one way to skin a cat. We will talk of a few, but not all, of the methods here, starting with the most rudimentary.
1.) Traditional Cric.
The motto of this one is: keep it simple, stupid! You need your knife, you need your hook, you need your dilator, and you need some sort of tube (either a nice trach or a sawed off 6.0 ETT). That's it!
1.) Find the cricothyroid membrane.
2.) Cut skin vertically 2-3cm--get ready for some bleeding to screw up your view!
3.) Cut membrane horizontally.
4.) Get your hook in the superior aspect before you remove your scalpel. Also get someone to hold traction on this!
5.) Get your dilator in laterally and rotate it down 90 degrees (the Trousseau's are kind of counter intuitive--squeezing opens them).
6.) Tube in, cuff up, start bagging.
In terms of incision the skin, there is a bit of discrepancy between our generally accepted way of doing these and what is done in the surgery world (i.e., vertically vs. horizontally). I personally remember taking ATLS and having an older trauma surgeon laugh hysterically in my face when I demonstrated doing the initial incision vertically on a model. Ignore the haters out there, this is how we do it and that's that.
Here's a very nice demonstration on a cadaver courtesy of the University of Maryland Department of Emergency Medicine:
2.) Seldinger Cric (aka "Melkering It").
I have never seen this one done but I love the sound of it. For one, my fear of a horribly bloody surgical field is alleviated. However, this option requires a good, confident ability to locate the membrane--this might be a problem if there's significant trauma.
The kits are as simple as you'd want them to be, including your scalpel, wire, 6 mL syringe, 18 G needle w/catheter, cuffed catheter, and dilator.
Identify your landmarks, and come at the cricothyroid membrane directed 45 degrees caudad. You'll want to have your syringe loaded with a bit of saline so you can confirm entry into the trachea with air bubbles. Thread your catheter, and the rest is just as you'd expect it--wire it, incise it, and then dilate it! Your dilator slides into the catheter, and you'll want to grip them like so as you push them in:
After you've hubbed it, pull out the dilator and guidewire. You should be good to go. Here's an incredibly dated looking video from Cook Critical Care:
3.) Bougie Cric.
It's all the rage! There's a lot of buzz about this one, and rightfully so--some initial data has shown that it is related to higher success rates and less risk of tracheal damage. And it's quicker!
You need even less for this one. Your kit will include a No. 20 scalpel, a bougie, a 6.0 ETT, and your finger (you could throw in a hook as well but it's not required).
The procedure: make a horizontal stab with the scalpel at the cricothyroid membrane (yes I realize what I said earlier). Do it all the way through the skin and the membrane. Bluntly dissect down with your finger, keeping it in there. Load the bougie in under your finger. Slide the tube in. Bougie out.
Done!
Here's some demonstration images majestically taken by AP:
Here's a demonstration from Darren Braude via Scott Weingart's YouTube page:
4.) Crazy MacGyver Cric.
We're entering the world of the unknown on this one, but essentially you resort to this when you're patient is crashing and you essentially have to grab whatever is nearby.
While I in no way shape or form recommend you try this, the ever brilliant Dr. Whit Fisher has an awesome technique for making a trach needle out of an IV spike (who would have known?):
Just threw it in for the sheer awesomeness of it all.
Pick your poison, but get it right. Practice makes perfect, and the more times you can simulate a cric, the more comfortable you will be when your number comes up. Academic Life in Emergency Medicine has a fantastic recipe to make a bleeding model for simulation here: http://www.aliem.com/simulation-trick-of-the-trade-bleeding-cricothyroidotomy-model/.
As always, these wannabe instruction manuals are made for EDUCATIONAL PURPOSES ONLY. You already know darn well enough that a cric is the last-ditchiest of last-ditch procedures, so don't go getting heroic on us after this one.
Stay tuned! Next up is the PEDIATRIC surgical airway.....
jps
Sources:
Robers and Hedges' Clinical Procedures in Emergency Medicine.
Makowski, A. L. (2013). A survey of graduating emergency medicine residents' experience with cricothyrotomy. The Western Journal of Emergency Medicine, 14(6), 654–661. doi:10.5811/westjem.2013.7.18183
Hill, C., Reardon, R., Joing, S., Falvey, D., & Miner, J. (2010). Cricothyrotomy Technique Using Gum Elastic Bougie Is Faster Than Standard Technique: A Study of Emergency Medicine Residents and Medical Students in an Animal Lab. Academic Emergency Medicine, 17(6), 666–669. doi:10.1111/j.1553-2712.2010.00753.x
Nakstad, A. R., Bredmose, P. P., & Sandberg, M. R. (2013). Comparison of a percutaneous device and the bougie-assisted surgical technique for emergency cricothyrotomy: an experimental study on a porcine model performed by air ambulance anaesthesiologists. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 21(1), 1–1. doi:10.1186/1757-7241-21-59
University of Maryland Department of EM's YouTube Page
Here's the scenario: you're a small community ED on a late Sunday morning. Let's say a middle aged gentleman walks in your door, complaining of left eye pain and loss of vision after blunt trauma to the area. Let's say the local Nelson Muntz threw a rock at his face. Haw haw!
On exam, he has proptosis of this eye, with significant chemosis. His visual acuity is 20/20 in his unaffected eye but is virtually nonexistent in the affected eye (he has light perception but that's about it). He has severe limitation of his extraocular muscles. You order a CT of his orbits, and it reveals a retrobulbar hemorrhage. You grab your TonoPen and check pressures, and it's off the charts. There is no ophthalmologist in house, and it will take up to an hour for him/her to get there. Better get out your scissors, doc, because you're about to do a lateral canthotomy.
In recent months I've asked multiple providers about which procedures make them squirm and this one often makes it to the top of their lists. In the end it's not a terribly complex procedure, but there's something about cutting around the eyeball that is inherently unsettling.
However, these patients have a compartment syndrome of the eye (involving the globe, the ophthalmic artery, and the optic nerve), and it is your job at this point to prevent the patient from having permanent vision loss. The setup is minimal and brief, as time = retina in this situation, and if the specialist isn't going to be in for a while you're responsible for this one. The literature suggests that after the initial loss of vision, you have about 120 minutes until the loss is permanent.
Quickly throw a few cc's of lido with epinephrine into the lateral canthus, and then squeeze it with a hemostat to reduce bleeding. Then snip through the canthus toward the orbital rim. Pull down and locate the inferior crus of the lateral canthal ligament (this is the cantholysis of the procedure, visualized with the cadaver image below). Recheck your IOP at this time--if it's still elevated you can snip the superior crus as well.
If done properly the lower lid should fall away from the lid margin. Often patients have dramatic improvement in vision but it's possible that this may take longer to return (assuming you've cut in time to save the structures). Just like other facial wounds they tend to heal well without any significant scarring. Regardless, now you'll really need the specialist for a definitive closure.
Here's a fantastic video courtesy of Dr. Larry Mellick (who is now also following the site!).
As always, these posts are for EDUCATIONAL PURPOSES ONLY. Don't go chopping up eyeballs ha-ha-ho-ho after one quick glimpse at this site (also a small prize to anyone who gets the reference I just dropped there).
Sources:
Dr. Larry Mellick's YouTube Page
Robers and Hedges' Clinical Procedures in Emergency Medicine. Chapter 62.
Ballard, S. R., Enzenauer, R. W., O'Donnell, T., Fleming, J. C., Risk, G., & Waite, A. N. (2009). Emergency lateral canthotomy and cantholysis: a simple procedure to preserve vision from sight threatening orbital hemorrhage. Journal of Special Operations Medicine : a Peer Reviewed Journal for SOF Medical Professionals, 9(3), 26–32.
Vassallo, S., Hartstein, M., Howard, D., & Stetz, J. (2002). Traumatic retrobulbar hemorrhage: emergent decompression by lateral canthotomy and cantholysis. Journal of Emergency Medicine, 22(3), 251–256.
We're moving on up! Procedures Club is now officially a part of EMCurious.com! Posts both old and new will be released at http://www.emcurious.com/procedures-club/. We'll attempt to get one out every week, although that may be a promise we regret at one point.
I think we'll at least keep this blog up for the time being, so keep following! Email us at proceduresclub@gmail.com with suggestions, tips, critiques, etc.
So what just rolled in the door, leaving a trail of blood behind? A 26 year old with a stellate laceration to the face after a night of drinking? No problem, he won't even need local anesthesia. A construction worker with a deep laceration down to his forearm muscle bellies? Might take up a big chunk of time, but no big deal, we can throw in a handful of horizontal mattresses.
What's that now? A 0.5 cm forehead laceration? What's the issue? Why are you so....oh good god...it's....it's....IT'S A TWO YEAR OLD!!?!??!?!
These seemingly trivial lacerations, often small and on the upper face, invoke true fear and loathing in the largely adult trained EP. We have to sew on a field that's moving and screaming? For god's sake man, I'm a doctor, not a...
Our friends in the PEM world fortunately have left us with a few hacks to make our lives significantly easier with these kiddos. So let's stand up to our demons and learn a thing or two!
Before we do anything, let's get this little fella comfortable. Slap on some of that LET we've heard so much about! Wait, does this stuff actually do anything?
An RCT from the Canadian Medical Association Journal in 2013 (n=221) showed that these kids did in fact have less pain with the procedure, and were more likely as compared to placebo (51.6% vs. 28.3%) to have a completely pain-free procedure. In short it often precludes the need for any local anesthesia (because it turns out that kids do not like needles). It also was shown to increase hemostasis. So slather that stuff on, but make sure you wait long enough for it to take effect (about 15-20 min).
Do you papoose? We sure like to! It is safer for the child in general, as well as it is for us. I've had a kid actually ask me to put him in there before--maybe it made him feel more secure?
From here on out, distraction is essential. Again, the data supports that things like music, video games, and cartoons can take the child's mind off what you're doing, and help them relax. It'll also take the stress away from what is likely an extremely anxious parent as well. There's a cool iPhone app called "Eye Handbook" that has tons of cartoon animations that kids can fixate on, so you always have something in your pocket.
Irrigation can also be alarming to the child, but you can employ a cool Macgyver maneuver thanks to the ingenious Dr. Michelle Lin. Essentially you can take a collection bin and cut out a rectangular or semi-circular hold from the edge, leaving enough of a lip so that water doesn't trickle out. You'll want it to look like a hair salon basin.
Anxiolysis isn't required but it can definitely be your friend. A very popular option is intranasal midazolam, with the dose being between 0.2-0.3 mg/kg. Your max dose will be 5 mg. This plus Thomas the Train on dad's iPad will put your little guy or girl in a zen-like state of serenity.
Some data has shown that intranasal ketamine (up to 9 mg/kg, go big or home!) can have a high success rate without the use of an IV. However, you're getting into the realm of sedation at this point, not just anxiolysis. My PEM sources are also not a big fan of this one either, so make sure you really do your research and have the appropriate setup (i.e. pulse ox, end tidal CO2, an extra nurse, etc.) if you're going to undergo this.
In terms of the actual repair, it really just helps to keep it simple. Simple interrupted! You may opt to use the absorbables for superficial closure if the wound is small, and you think removing sutures will be a major headache for the kiddo. Deeper lacs should always make you think of repairing deeper levels with absorbables as the frontalis muscle may be affected. Just remember that you do need to work faster than you're used to with adults, so make sure you get it right on the first try.
Adhesives like cyanoacrylates can also come in handy in a pinch but you need to ensure that nothing drips down into the eyes of your flailing kiddo if the laceration is on the forehead or eyebrow. You can get around this by placing a little ridge of petroleum jelly inferior to the wound as a barrier. You can also place them in Trendelenberg to limit the amount of drippage. If it does get in the eye, DON'T USE WATER TO IRRIGATE! This might cause the polymerization to accelerate, so you'll actually want to use topical antibiotics like erythromycin (remember, it causes it to break down) instead. And call an ophthalmologist.
As always, these posts are made for EDUCATIONAL PURPOSES ONLY. Treat each of these children as if they were one of your own!
jps
Sources:
Harman, S., Zemek, R., Duncan, M. J., Ying, Y., & Petrcich, W. (2013). Efficacy of pain control with topical lidocaine-epinephrine-tetracaine during laceration repair with tissue adhesive in children: a randomized controlled trial. CMAJ : Canadian Medical Association Journal = Journal De l'Association Medicale Canadienne, 185(13), E629–34. doi:10.1503/cmaj.130269
Academic Life in Emergency Medicine - "Trick of the Trade: Pediatric Distractors" http://www.aliem.com/trick-of-the-trade-pediatric-distractors/
Sinha, M. (2006). Evaluation of Nonpharmacologic Methods of Pain and Anxiety Management for Laceration Repair in the Pediatric Emergency Department. Pediatrics, 117(4), 1162–1168. doi:10.1542/peds.2005-1100
Tsze, D. S., Steele, D. W., Machan, J. T., Akhlaghi, F., & Linakis, J. G. (2012). Intranasal ketamine for procedural sedation in pediatric laceration repair: a preliminary report. Pediatric Emergency Care, 28(8), 767–770. doi:10.1097/PEC.0b013e3182624935
Before we cut to business (no pun intended), a little THANK YOU from our respective peoples, as a few generous tweets have caused our hits to explode in recent days! I promise we will get posts up more frequently to feed the demand. In the meantime, you all can now follow us on Twitter at @proceduresclub! Also, we've created a new email address at proceduresclub@gmail.com for any requests in the future.
Anyway, back to the matter at hand. Diagnostic. Peritoneal. Lavage. Yes, ok, everyone stop rolling their eyes. I get it. Many (moreso in our community rather than in the trauma world) now call DPL anachronistic with today's Emergency Department access to CT and FAST. And as they should! The test was a boon to trauma surgery when it was introduced in the 1960's but it is non-specific for intraperitoneal bleeding or diaphragmatic injury and insensitive for pneumoperitoneum.
However, in some cases your modern modalities may fail you. An example might be a patient with evidence of intraperitoneal fluid with no visible solid organ damage (i.e. you suspect CT is not detecting a hollow viscus injury, which is something that should be promptly taken to the OR). Again, we're being honest here, it may not be a procedure that you ever have to do, but that doesn't get you off the hook of knowing it.
The "dipple" as I've heard it called is actually an aspiration and a lavage if you want to be technically correct in your description. It can be done in a "semi-open" or "closed" technique, but for the purposes of this post we'll only cover the more EM-friendly, Seldinger-esque "closed" maneuver.
Think of it as a midline paracentesis, although you'll want to use a very small gauge needle. Get sterile as you normally would, and give a generous amount of local anesthesia just inferior to the umbilicus. The ideal entry site is in the midline here, as it is generally avascular, devoid of fat, and adherent to the peritoneum. Once you puncture through, wire it, puncture the skin with a scalpel, and advance a catheter, directing it caudad either to the right or left. Then, attach your tubing and aspirate for gross blood.
If no gross blood, allow 1 L of either normal saline or Lactated Ringers to run in. You can put a cuff on the bag to speed things up as this may take a while. After it's all in, drop the bag on the floor and let the fluid run back out to gravity. Some opt to roll the patient back and forth before this to make sure the lavage mixes in. You don't need to wait until the entire liter comes back out--700 mL has traditionally been noted as adequate. Send it off to the lab!
Here is an excellent primer from UCSD's Department of Trauma and Burn:
In terms of interpretation, let's just make it idiot proof:
1.) If you get over 10 mL of gross blood (or really any gross blood realistically), that's positive, you're done.
2.) In blunt trauma anywhere except the lower chest, you're positive if your RBC cell count is greater than 100,000.
3.) If there's blunt trauma to the low chest or a GSW, you need to drop that cutoff to 5,000.
If you did the DPL right, and there is no IPH, you really shouldn't see more than a few hundred RBC's in your sample.
Just as always, this post is meant to be for EDUCATIONAL PURPOSES ONLY. Be a smart doc, and don't go claiming we told you it was a good idea to "dipple" all of your blunt trauma patients from here on out.
jps
Sources:
Griffin, X. L., & Pullinger, R. (2007). Are Diagnostic Peritoneal Lavage or Focused Abdominal Sonography for Trauma Safe Screening Investigations for Hemodynamically Stable Patients After Blunt Abdominal Trauma? A Review of the Literature. The Journal of Trauma, 62(3), 779–784. doi:10.1097/01.ta.0000250493.58701.ad
MD, Y.-C. W., MD, C.-H. H., MD, C.-Y. F., MD, C.-C. Y., MD, S.-C. W., & MD, R.-J. C. (2012). Hollow organ perforation in blunt abdominal trauma: the role of diagnostic peritoneal lavage. American Journal of Emergency Medicine, 30(4), 570–573. doi:10.1016/j.ajem.2011.02.014
Roberts and Hedge's Clinical Procedures in Emergency Medicine. Chapter 43.
If you ever want to hear a story about the "good old days" in the ED you should sit down with our former department chair. He's a forty year veteran (i.e. he predates EM training) and has literally seen everything. The other day he was passing through and I asked him point blank, "What's the biggest thing you've pulled out of a patient's rectum?" He sat down, leaned back and without breaking stride he said, "It was a dill pickle. Really got the fella up there. And in my day we didn't use any sedation. All you had was your metal anoscope, and whup, how's yer father--you shoved that thing up there and hoped you could see something." So awesome. All chuckles aside, and despite the fact that this is a coveted procedure, we are often left a bit befuddled when these actually do roll in. Even if they're small, you need to always assume these FB's can perforate so they by definition need to come out. A good history will give you a good understanding of what you're dealing with, although patients may not always be forthcoming with you (for obvious reasons). Your DRE will be vital, as anything low lying will have a much higher chance of being retrieved in the ED. Finally a plain film of the abdomen is a quick and useful test you can order than can give you a lot of information, especially if the patient is being coy with you. These situations are great opportunities for us to use our ability to MacGyver devices to our advantage, but some ground rules should be established before we get too cavalier. If the patient is already peritonitic at presentation, stop what you're doing and call surgery as they may have perf'ed already. Do the same if there is glass involved and you're pretty sure that something has shattered. If you do decide to go after the FB, you'll need some sort of speculum. A vaginal speculum with a light can actually serve as a decent substitute for an anoscope. Once you have a good view you can try reaching with your bare fingers but a grabbing utensil like a ring forceps may come in handy.
Oh, and you'll need them comfortable as possible, which essentially means procedural sedation. Ketamine will likely make your life a lot easier in these situations. Typically patients are placed prone in a knee-chest position, or in a left lateral decubitus. Often there's a lot of negative pressure working against you, so you may choose to employ a Foley catheter to pass distally to break this up. An endotracheal tube can also achieve this goal, and it's less likely to bend. Here's an awesome example illustrated by Dr. Whit Fisher:
If the FB is a jar or bottle with the open side down, you can employ another neat trick by placing a Foley or ETT into the object, and then injecting Plaster of Paris via the tube. Once it solidifies around the tube, you have a nice handle to pull the object out with. As always, these posts are for EDUCATIONAL PURPOSES ONLY. The thought of a rectal FB may make you feel lighthearted and whimsical but you should never, ever treat them as such. Finally, give these patients their dignity--don't be stupid and go posting pictures of their KUB on Instagram once you get home from your shift. jps Sources: Cologne KG et al. Rectal Foreign Bodies: What Is The Current Standard? Clin Colon Rectal Surg. 2012 Dec; 25(4): 214-8. Roberts and Hedges' Clinical Procedures in Emergency Medicine. Chapter 45. Procedurettes YouTube Page
Imagine you're in a large metropolitan area with an uptick in summer gun violence. Let's say you're working an overnight shift on a busy Fourth of July weekend, and your department is already being strained to the limits due to insanely high volumes. Suddenly, at about 3AM, you get a frantic EMS call: a patient is coming to you, shot in the face, chest, and back. He still has vitals in the field and they are currently working on an airway. At our institution, we would instinctively get our trauma bay ready, alert our surgical team, and then all collectively clench our sphincters.
The patient eventually comes in fast with EMS a bloody mess with GSW's everywhere, yet the paramedics have miraculously been able to place an ETT in the field. He has already received bilateral needle decompressions of his chest. You quickly go to confirming the airway placement with a GlideScope (which, in our opinion, is FAR superior to DL in this scenario), but as the trauma surgeons are running through their primary survey the patient suddenly loses his pulses.
Suddenly, the knives are out. Before you know it the patient has been "clam-shelled", with bilateral anterolateral thoracotomies. The pericardium is opened, showing tamponade, and the heart is delivered. Shortly thereafter, ROSC is obtained, and the patient was whisked off to the OR.
Our surgery residents at our institution often do a fantastic job when this procedure is called for, and I am happy we have them around for things like this, but I've realized that we as emergentologists should not be totally exempt from knowing this one. We have tons of attendings in the academic world who have never done one in their careers but I know that in the community, the buck stops with you. So let's learn!
First of all, you need to remember the indications. Traditionally, we are taught that a patient with penetrating trauma with "signs of life" at the scene who loses them shortly prior to arrival or right at arrival needs to get his/her chest opened. Blunt trauma has more recently been included but has a much lower survival rate (around 2% vs. around 16%). The evidence is spotty at best for both.
One big disclaimer: this should not always be considered a mandatory procedure. If you're getting a pulseless patient status post GSW's, and the voice in the back of your head is telling you that cracking a chest is overkill (not to mention a giant waste of time to you and all of your staff if there's no surgical backup at your institution), you should probably listen. One should also be aware that the potential for needle/instrument sticks in these scenarios are heightened, so you are also putting yourself and others at risk for something that might be futile.
However, if you're committed to this route you'll need your kit, which usually includes most if not all of the above. In terms of airway, you'll want to shove the tube down there and deliberately right main-stem the patient so that the left lung can be deflated and moved out of the way.
Try to get as sterile as possible, but do it FAST. A big splash of betadine on the skin might be all you'll be able to do in terms of prep. In terms of landmarks, go to the same place you'd go for a chest tube (5th intercostal space), and open them up deep with a scalpel and blunt forceps.
Get the spreaders in there, preferably with the ratchet on the inferior side facing the axilla. Watch your fingers, because it might be sharp! Once inside the thorax, briefly hold ventilations and move the (hopefully) collapsed L lung out of the way and find the heart. Start your pericardiotomy by cutting into the pericardium anterior and parallel to the L phrenic nerve, which should be fairly visible at this point (and stating the obvious--DON'T CUT THE PHRENIC NERVE!). You should lift up with toothed forceps and cut with your Mayo scissors.
If you'll need to do open cardiac massage/compressions, you can "deliver" the heart from the pericardium to do so. This will also make it easier to visualize any cardiac injuries. In terms of hemorrhage control, you can temporarily use your finger, but you can also place a Foley through as well. For sutures, you can try throwing some buttressed Vicryl throws in there, but you should ultimately leave the definitive repair to the cardiothoracic surgeons (do you really want to try throwing pledgets into a moving field?).
For cardiac compressions, remember that you want to use your palms, not your fingers. Make sure that you compress perpendicular to the septum, and that you don't compress the coronaries. Also relax completely in between cycles. If there's ROSC but persistent hypotension, you can clamp the descending aorta with a DeBakey or a Kelley clamp but this can be quite challenging even with the chest open as the aorta is often collapsed in these scenarios.
Here's a very slow, methodical demonstration with a cadaver:
Here's how it will probably look in your ED (note the stress level is HIGH here):
Also note that Dr. Mellick is quick to point out that the spreaders are in upside down.
As always, (and especially for this, the most morbid procedure we can do) these procedure posts are for EDUCATIONAL PURPOSES ONLY! Do your own research and be smart. Cautious always wins over cavalier in the long run.
jps
Sources:
Wise, D., Davies, G., Coats, T., Lockey, D., Hyde, J., & Good, A. (2004). Emergency thoracotomy: “how to do it.” Emergency Medicine Journal, 22(1), 22–24. doi:10.1136/emj.2003.012963
Roberts and Hedges' Clinical Procedures in Emergency Medicine. Chapter 18
Life in the Fastlane - ED Thoracotomy: Is it Just the First Part of the Autopsy? http://lifeinthefastlane.com/ed-thoracotomy-is-it-just-the-first-part-of-the-autopsy/
We EP's pride ourselves on our ability to remain unfazed by a frighteningly unstable patient (a skill that most other specialties do not possess, I'll mind you), but admittedly there is that set of presentations that give even us the chills. I'm talking about the nightmare super-necky angioedema patient that needs a cric, the peri-arrest pregnant woman who's headed toward a crash section, and the spontaneously delivered 24-week preemie who requires an umbilical artery catheter. How's about we throw in a cirrhotic with a massively massive variceal bleed into the mix? That's a sphincter flexing sight if there's ever been one. Let's make the scenario a bit spookier by also having no endoscopist available (unlike our tertiary teaching institution). Enter the Sengstaken-Blakemore Tube, basically a last ditch effort for balloon tamponade. This procedure is not a common one given the prevalence and efficacy of endoscopy (I honestly don't even know where I'd find one in our ED), but when you're all out of options it's either this or a body bag. First, a little clarification. There are two kinds of tubes: the Sengstaken-Blakemore Tube, and The Minnesota Tube. For the longest time I had assumed they were one in the same but they are not. The Blakemore Tube has 3 ports: one for gastric aspiration, one for the gastric balloon, and one for the esophageal balloon. The Minnesota Tube is essentially the same except it has a fourth port for esophageal aspiration.
Before you even begin to insert one of these you almost certainly have to take the airway first--and with a massive bleed this alone will be far from easy. Also, you'll need to make sure both balloons are intact per usual, and then make sure they are completely decompressed before insertion.
When it's time to pass the tube, you can do it either orally or nasally, but orally is generally preferred. Pass the tube in as far as it can go, and then hook up your aspiration port (s) to suction. You'll need to confirm the placement with a CXR, and some have said that it makes it easier to visualize if you put 50 mL of air into the gastric balloon.
Then, hook up the gastric port to a manometer (doing it with syringes will take too long), and incrementally pump it up to the total volume, which is usually about 450 mL of air (it's a freaking huge balloon, and always use air, not liquid). After this, you'll need to clamp it, pull back until you feel resistance of the diaphragm, and secure with traction.
Start lavaging with the gastric port. If it doesn't clear, inflate the esophageal port as well (which requires much less air, usually only 45 mL). Clamp this one too and monitor the aspiration. If it continues you may need more traction on your gastric port.
Here's Scott Weingart running through the drill with the Blakemore Tube (note his patient is already tubed!).
And here's another helpful video from Yale-New Haven Hospital:
Again, this procedure is almost always a last resort, especially as it is fraught with potential complications, including esophageal rupture (why it's so important to confirm placement of that gigantic gastric balloon), mediastinitis, and aspiration pneumonia to name a few.
Just as always, these posts are meant for medical professionals and are meant for EDUCATIONAL USES ONLY. Do your own research, and be safe. Stay cool out there!
jps
Sources:
Greenwald, B. (2004). The Minnesota tube: its use and care in bleeding esophageal and gastric varices. Gastroenterology Nursing : the Official Journal of the Society of Gastroenterology Nurses and Associates, 27(5), 212–7
Roberts and Hedges' Clinical Procedures in Emergency Medicine, 6th Edition. Chapter 41. Scott Weingart's YouTube Page YNHH Clinical Videos YouTube Page
