VASCULAR ACCESS AND OTHER ESSENTIAL

EMERGENCY PROCEDURE

2nd SP-ER day: Emergency Conference " Emergency Medicine Update “8 August 2009

Borwon Wittayachamnankul MD.

VASCULAR ACCESSES

Indication

Peripheral

Blood example

Drugs

fluid

Central

Central venous pressure

Inotropics

TPN

Cannot access peripheral line

Alternative

Intraosseouss

Endotracheal (Drugs only)

Central venous pressure catheterization and monitoring Performed when

Necessary for procedure such as pulmonary artery catheter or pacemaker placement

Peripheral vein cannot be cannulated

Desired for measurement of central venous pressure

Central venous pressure catheterization and monitoring Not performed in hypovolemic shock except

Massive volume repletion to elderly patients or heart disease

Fluid administration monitored in patients with visceral trauma & severe head injury

Central venous pressure catheterization and monitoring Sites

Most common: placed in the superior vena cava via internal jugular or subclavian vein

Less common: via external jugular vein or femoral vein

Peripheral veins: brachial-basilic system

Anatomy

Venous access site

Cephalic vein

Superficial radial vein at the wrist

Veins of the hand

Veins in the anticubital fossa

The large basilic vein in the upper arm

Venous access site

Deep femoral vein

Proximal great saphenous vein in the thigh

Superficial saphenous vein at the ankle

Venous access site

External jugular vein

Internal jugular vein

Subclavian

APPROACH

Subclavian :Infraclavicular approach

Subclavian : Supraclavicular approach

Contraindications

Infections

Fractures of ipsilateral ribs and clavicles

Coagulopathy

Thrombosis

Internal jugular :Central approach

Internal jugular : Posterior approach

Internal jugular :anterior approach

Contraindications

Infections

Thrombosis

Coagulopathy “

Femoral vein catheterization

Equipment and general technique for central venous catheterization

TEACHNIQUE

Catheter-over-needle

Catheter-through-needle

Seldinger technique

Seldinger technique

Subclavian Infraclavicular approach

Identify the anatomic landmarks

Anesthetize skin & subcutaneous tissue with 1% lidocaine.

Insert the introducer needle while gently aspirating for blood.

Once venous blood is being withdrawn easily, remove the syringe.

Pass the flexible guidewire through the needle into the vessel.

Remove the needle over the wire.

Make a small skin incision at the site of the guidewire.

Pass the dilator over the wire to make a tunnel through the subcutaneous tissue.

Remove the dilator, keeping the guidewire in place.

Pass the central venous catheter over the guidewire into the vessel.

Remove the guidewire.

Withdraw blood from each catheter port.

Flush each catheter port with sterile saline and cover each port with a Luer-Lok cap.

Attach the catheter to the IV tubing.

Suture the catheter into place, using the blue & white skin attachment collars.

Pitfalls

NEJM 357;9 august 30, 2007

Pitfalls

NEJM 357;24 december 13, 2007

Complications

Intraosseous line placement

Indications

•Immediate venous access for delivery of fluids, drugs or

blood products in patients cannot find out other site

• Recommended In PALS, ACLS • CPR more than 2 mins or more than 2 attempt

Contraindications

fracture at proximal insertion site

Skin infection at proposed insertion site

Equipment

Identify the anteromedial surface of the proximal tibia & palpate the tibial tuberosity.

The entry site is 1-2 cm distal to the tibial plateau & halfway between the anterior & posterior border of the tibia.

Support the patient’s leg from underneath with a small towel roll.

Using a twisting rather than rocking motion, advance the needle until a decrease in resistance is felt.

Remove the troca.

Aspirate bone marrow to confirm placement.

Inject 2-3 cc of sterile saline as a flush.

Attach IV tubing.

Saphenous vein cut down

Complications

Local hematoma or cellulitis

RARELY osteomyelitis

Alternative Insertion sites

Peripheral Insertion of Central Catheter (PICC)

Ultrasound guide cannulation

Issue of flow dynamics

Rate of flow

Internal catheter diameter

Temperature

Pressure

Viscosity

Catheter length

Stable adult trauma patients 2 large-bore 16-gauge or greater

Exsanquination 8.5-F catheter with Manually operated pressure bag or

Wall-mounted external pneumatic device

2nd catheter for drug infusion

Volume repletion & measurement of CVP Y arm catheter sheath

OTHER ESSENTIAL PROCEDURE

CARDIAC TAMPONADE

Treatment

Venous access

Rapid volume infusion

To less volume changes during respiration

And increase RV pressure to counter with pericardial pressure

These may prevent requirement for pericardiocentesis

Pericardiocentesis

If hemodynamic instability observed,

Emergently performed underfluoroscopy or echocardiographic guided

With/without comfirmatory testing with agitated saline injection

Dramatical improvement is necessary

N Engl J Med 2003;349:684-90

Contra-indication

Diagnosis is indoubt

Rupture true or false aneurysm

Rupture ventricular aneurysm

Severe local infection

Post drainage monitoring

Symptoms

Physical findings of decompensation Blood pressure changes

Evidence of hypoperfusion

Pulsus paradoxus

Imaging Chest X ray

Echocardiography

Indwelling catheter drainage

Catheter placement for 2-3 days

Could prevent recurrent even in idiopathic effusion from 23% to 6% in 3 years

Immediately drainage for subsequent decompensation

Indwelling catheter drainage

Instillation of diluted heparin required

Heparin 0.5 mL in PSS 9.5 mL

Except with hemopericardium e.g. dissection

Others Emergency procedure

Airway RSI Difficult airway management

Breathing Needle thoracocenthesis Tube thoracostomy

Circulation Venous access Pericardiocenthesis Emergency thoracotomy

Others Nasal pack DPL Ultrasound : diagnostic, Therapeutic

Essential

Indications

Contraindications

Methods

Anatomy

Materials

Aftercare

Complications