**5. Central venous catheter placement**

Central venous catheterization is one of the fundamental requirements for resuscitating critically ill patient in ED and intensive care unit (ICU).

#### **5.1. Indications**

Rapid venous access in emergency situation, e.g., cardiac arrest.


#### **5.2. Contraindications**

Local infection in the area to be punctured.

Distorted anatomy-bleeding disorder.


#### **5.3. Equipment**


Gloves, gown, cap, and mask.


#### **5.4. Technique**

Seldinger (guidewire) technique is the most commonly used and it should be done under aseptic technique. The procedure should be explained to the patient if possible or his family and consent should be taken. All the equipment should be prepared. Patient should be placed in supine position and connected to a monitor. The selected area for puncture should be cleaned using the antiseptic solution and alcohol swabs. Locate the vein selected for puncture by anatomical landmark. It can also be done with ultrasound guidance as well.

Pneumothorax and hemothorax

Tracheal obstruction or perforation

• Provides a rapid and reliable method of getting access to the systemic circulation

IO line) and infuse fluids, blood, as well as contrast for imaging [21]

• Intraosseous needles: All are 15 G and vary in length, 15, 25, and 45 mm.

In any situation where peripheral access is not easily available.

• During life-threatening situations such as CPR or trauma

• Recommended by the American Heart Association if venous access cannot be quickly and

Resuscitation Procedures in Emergency Setting http://dx.doi.org/10.5772/intechopen.76165 75

• Can be used to give drugs (all the drugs given through an IV line can be given through an

• Manual needle and trochar devices or automated EZ IO drill. Several devices like Jamshidi needle, Sur-Fast intraosseous needle, Sussmane-Raszynski needle, FAST1 Intraosseous Infusion System, new intraosseous device(NIO), and bone injection gun(BIG) are available. • Lidocaine or lignocaine for local anesthesia and for use before starting any infusion (running infusions is more painful than insertion due to the expansion of the medullary plexus).

Bowel or bladder perforation

Local cellulitis and sepsis

Venous thrombosis[11].

**5.6. Intraosseous access**

reliably established[18]

• Still a widely underutilized modality[19, 20]

• 5–10-ml syringes for aspiration and flushing.

• EZ connect IV tubing if using EZ IO set.

Hemomediastinum

Neck hematoma

Neurologic injury

**5.7. Indications**

**5.8. Equipment**

• Dressing.

• Burns • Seizures • Edema

Local anesthetic lidocaine 1% can be used at the site of puncture and sedation for patient comfort. A large-caliber needle connected to 10-ml syringe with 1-ml saline is used for the venipuncture and should be advanced slowly under negative pressure till a free flow of blood is seen in the syringe; at this point the syringe should be removed, and at the same time occlude needle and stabilize it carefully to avoid air embolism and displacement. Then thread the guidewire through the needle and remove the needle. After that insert the catheter over the guidewire. A dilator can be used before passage of the catheter over the guidewire and tight control of the guidewire at the skin should be kept during placement. Once the catheter is inserted, then guidewire should be removed, and connect the catheter to intravenous tubing after checking blood backflow and flush with saline and secure it with suture. Confirm the position by ultrasound and obtain X-ray of the chest and abdomen.

#### **5.5. Complications**

Arterial puncture Air embolism and catheter embolus Local hematoma Pericardial tamponade Arteriovenous fistula

Pneumothorax and hemothorax Hemomediastinum Neck hematoma Tracheal obstruction or perforation Bowel or bladder perforation Local cellulitis and sepsis Neurologic injury Venous thrombosis[11].

#### **5.6. Intraosseous access**

Distorted anatomy-bleeding disorder.

74 Essentials of Accident and Emergency Medicine

**5.3. Equipment**

**5.4. Technique**

**5.5. Complications**

Arterial puncture

Local hematoma

Pericardial tamponade Arteriovenous fistula

Air embolism and catheter embolus

Gloves, gown, cap, and mask.

• Ultrasound and sterile probe.

• 10-ml syringe for catheter placement. • Catheter kits–drapes and gauze pads.

• Needle holder and suture material and scissors.

• -Pneumothorax on the contralateral side.

• -Anticoagulant therapy-IV drug abuse through the access.


Seldinger (guidewire) technique is the most commonly used and it should be done under aseptic technique. The procedure should be explained to the patient if possible or his family and consent should be taken. All the equipment should be prepared. Patient should be placed in supine position and connected to a monitor. The selected area for puncture should be cleaned using the antiseptic solution and alcohol swabs. Locate the vein selected for puncture

Local anesthetic lidocaine 1% can be used at the site of puncture and sedation for patient comfort. A large-caliber needle connected to 10-ml syringe with 1-ml saline is used for the venipuncture and should be advanced slowly under negative pressure till a free flow of blood is seen in the syringe; at this point the syringe should be removed, and at the same time occlude needle and stabilize it carefully to avoid air embolism and displacement. Then thread the guidewire through the needle and remove the needle. After that insert the catheter over the guidewire. A dilator can be used before passage of the catheter over the guidewire and tight control of the guidewire at the skin should be kept during placement. Once the catheter is inserted, then guidewire should be removed, and connect the catheter to intravenous tubing after checking blood backflow and flush with saline and secure it with suture. Confirm the

by anatomical landmark. It can also be done with ultrasound guidance as well.

position by ultrasound and obtain X-ray of the chest and abdomen.


#### **5.7. Indications**

In any situation where peripheral access is not easily available.


#### **5.8. Equipment**


#### **5.9. Sites and technique**

Take universal precautions and prepare the insertion site with an antiseptic. Use the needle size 15 mm for <40 kg, 25 mm for>40 kg, and 45 mm for proximal humerus or excessive body tissue.

**Proximal tibia:** Position the patient supine with the knee flexed, and identify the tibial tuberosity. Insert the needle two fingerbreadths distal and 1–2 cm medial to it. In a conscious patient, instill local anesthetic first. Tilt the needle caudally, away from the epiphysis. Manually insert in a screw-like motion or drill till you feel a give, remove trochar (very sharp, dispose in the sharp box), fix a syringe, and aspirate. The bone marrow is not always aspirated; flush and note for any extravasation. A needle that stands upright without support indicates correct placement. Secure with tape or dressing.

**Distal tibia:** Palpate the medial malleolus and identify the anterior and posterior borders as well as the most prominent part of the malleolus; insert the needle 2–3 cm proximal to the most prominent part in between the anterior and posterior borders of the tibia.

**Proximal humerus:** With the elbow adducted and the arm internally rotated, place the hand palm down on the abdomen, palpate the anterior shaft of the humerus till you palpate the greater tuberosity, and insert the needle about a cm above that, i.e., 1 cm above the surgical neck of the humerus.

**Other sites:** Femur, sternum, and anterior superior iliac spine (**Figure 6**).

Complications


### **6. ED thoracotomy**


• Unresponsive hypotension [systolic blood pressure (SBP) <70 mm Hg] despite vigorous

Resuscitation Procedures in Emergency Setting http://dx.doi.org/10.5772/intechopen.76165 77

The American College of Surgeons Committee on Trauma indications for EDT are as follows [24]:

• Previously witnessed cardiac activity (prehospital or in-hospital)

• Unresponsive hypotension (SBP <70 mm Hg) despite vigorous resuscitation

• Rapid exsanguination from the chest tube (>1500 mL)

resuscitation [23]

**Figure 6.** Intraosseous device and sites.

*6.1.2. Blunt chest trauma*

#### **6.1. Indications**

#### *6.1.1. Penetrating chest trauma*

• Previously witnessed cardiac activity (prehospital or in-hospital) or signs of life (pulse, BP, pupil reactivity, purposeful movement, and respiratory effort)

Resuscitation Procedures in Emergency Setting http://dx.doi.org/10.5772/intechopen.76165 77

**Figure 6.** Intraosseous device and sites.

• Unresponsive hypotension [systolic blood pressure (SBP) <70 mm Hg] despite vigorous resuscitation [23]

#### *6.1.2. Blunt chest trauma*

**5.9. Sites and technique**

76 Essentials of Accident and Emergency Medicine

neck of the humerus.

Complications

• Extravasation

• Osteomyelitis

**6. ED thoracotomy**

• Lifesaving procedure

*6.1.1. Penetrating chest trauma*

**6.1. Indications**

• Compartment syndrome

• Necrosis of the epiphyseal plate

great as 60% in a selected group of patients

• Failure

• Fracture

placement. Secure with tape or dressing.

Take universal precautions and prepare the insertion site with an antiseptic. Use the needle size 15 mm for <40 kg, 25 mm for>40 kg, and 45 mm for proximal humerus or excessive body tissue. **Proximal tibia:** Position the patient supine with the knee flexed, and identify the tibial tuberosity. Insert the needle two fingerbreadths distal and 1–2 cm medial to it. In a conscious patient, instill local anesthetic first. Tilt the needle caudally, away from the epiphysis. Manually insert in a screw-like motion or drill till you feel a give, remove trochar (very sharp, dispose in the sharp box), fix a syringe, and aspirate. The bone marrow is not always aspirated; flush and note for any extravasation. A needle that stands upright without support indicates correct

**Distal tibia:** Palpate the medial malleolus and identify the anterior and posterior borders as well as the most prominent part of the malleolus; insert the needle 2–3 cm proximal to the

**Proximal humerus:** With the elbow adducted and the arm internally rotated, place the hand palm down on the abdomen, palpate the anterior shaft of the humerus till you palpate the greater tuberosity, and insert the needle about a cm above that, i.e., 1 cm above the surgical

• Reported survival rates of 2% in blunt trauma and 16% in penetrating trauma[22] to as

• Previously witnessed cardiac activity (prehospital or in-hospital) or signs of life (pulse, BP,

pupil reactivity, purposeful movement, and respiratory effort)

most prominent part in between the anterior and posterior borders of the tibia.

**Other sites:** Femur, sternum, and anterior superior iliac spine (**Figure 6**).


The American College of Surgeons Committee on Trauma indications for EDT are as follows [24]:


• Cardiac massage and internal defibrillation can be done.

trauma without cardiac activity (prehospital).

• Improperly trained team or insufficient equipment

**6.4. Contraindications**

• Severe head injury

• Non-traumatic cardiac arrest

• Severe multisystem injury

**7. Pericardiocentesis**

*7.1.1. Emergent pericardiocentesis*

arrest secondary to cardiac tamponade.

*7.1.2. Nonemergent pericardiocentesis*

available.

**7.1. Indications**

malignant etiology).

*7.1.3. Contraindications*

*7.1.3.1. Relative contraindications*

• Dialysis available for uremic patients

• Uncorrected bleeding disorders in stable patients

• Immediate surgery or thoracotomy available for trauma patients

patient.

• Hilar clamping can be done in case of extensive lung laceration.

• Cross-clamping of the aorta can be done in case of persistent hypotension.

• Blunt injury without witnessed cardiac activity (prehospital) or penetrating abdominal

Resuscitation Procedures in Emergency Setting http://dx.doi.org/10.5772/intechopen.76165 79

Pericardiocentesis is the aspiration of fluid from the pericardial space that surrounds the heart. This procedure can be lifesaving in patients with cardiac tamponade, even when it complicates acute type A aortic dissection and when cardiothoracic surgery is not

Life-threatening hemodynamic compromise due to suspected cardiac tamponade. Cardiac

Diagnostic pericardiocentesis for pericardial effusions (due to infectious, hemorrhagic, or

There is no absolute contraindication to pericardiocentesis in hemodynamically unstable

**The Eastern Association for the Surgery of Trauma** strongly recommends resuscitative ED thoracotomy in patients presenting pulseless to the ED with signs of life after penetrating thoracic injury [25].

Can be considered for patients presenting with penetrating thoracic trauma without witnessed signs of life or cardiac activity and in penetrating abdominal trauma in traumatic arrest with prior witnessed cardiac activity and signs of life.

#### **6.2. Equipment**


#### **6.3. Technique**


#### **6.4. Contraindications**

• Precordial wound in a patient with prehospital cardiac arrest

• Profound hypotension (<70 mm Hg) in a patient with a truncal wound who is either uncon-

**The Eastern Association for the Surgery of Trauma** strongly recommends resuscitative ED thoracotomy in patients presenting pulseless to the ED with signs of life after penetrating

Can be considered for patients presenting with penetrating thoracic trauma without witnessed signs of life or cardiac activity and in penetrating abdominal trauma in traumatic

• Thoracotomy set including scalpel 10 blade, Mayo scissors, rib spreaders, Gigli saw, vascu-

• **Anterolateral approach:** Make an incision in the left fourth intercostal space extending from the sternum to the posterior axillary line cutting the skin, subcutaneous tissue, and

• **Clamshell approach:** Start as the left anterolateral approach, extend to the right in the space intercostal space, cut the sternum with the Gigli saw, and apply the rib spreader on

• **Pericardiotomy:** Move the lung out of the way and incise the pericardium anterior to the

• Inspect the myocardium for injury, which can then be occluded digitally, by skin stapler,

• Trauma patient with cardiac arrest after arrival to ED

arrest with prior witnessed cardiac activity and signs of life.

scious or an operating room is unavailable

78 Essentials of Accident and Emergency Medicine

• Sterile gloves, gown, and face shield

lar clamps, and needle holders

• Chest tubes and Foley catheter

the cut ends of the sternum.

• Intubate the patient and pass the nasogastric tube.

intercostal muscles in one go. Apply the rib spreaders.

phrenic nerve from the apex to the root of the aorta.

occluding it with a Foley catheter or sutures.

• Wear your personal protective equipment.

• Initiate the mass transfusion and commence with the blood products.

• Betadine and sterile drapes

thoracic injury [25].

**6.2. Equipment**

• Suture material • Aortic clamp

• Internal defibrillator

• Skin stapler

**6.3. Technique**

