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Local and Topical Anesthesia

Local anesthetic agents are important tools used in the everyday practice of emergency medicine. This chapter describes the mechanism of action, the nuances of clinical use, and the adverse reactions to anesthetics that are commonly used in the emergency department (ED). Detailed technical guidance for the performance of topical and infiltrative local anesthesia is provided. Background The first local anesthetic was cocaine, an alkaloid in the…

Transfusion Therapy : Blood and Blood Products

Transfusion of blood components (red cells, white cells, platelets, whole plasma, or plasma fractions) is commonplace in the emergency department (ED). Annually in the United States, 15 million blood donations take place and 14 million units of red blood cells (RBCs) are transfused. Although acute hemorrhage is the most common emergency indication for blood transfusion, more nonemergency transfusions and blood component therapy now occur in the…

Autotransfusion

Introduction Autologous blood transfusion, or autotransfusion, is the collection and reinfusion of a patient's own blood for volume replacement. Preoperative blood banking and intraoperative cell salvage techniques have increased in a multitude of surgical specialties. Autotransfusion in the emergency department (ED) is usually limited to patients with severe, traumatic hemothorax and clinically significant blood loss. Autotransfusion is usually performed in trauma centers or in EDs with…

Alternative Methods of Drug Administration

The rapid administration of lifesaving, pain-relieving, and sedative medications lies at the core of the practice of emergency medicine. The intravenous (IV) route is usually the delivery method of choice. However, there are circumstances in which vascular access is either not available or contraindicated. Thus, emergency providers need to have a working knowledge of alternative routes of drug administration. This chapter describes the endotracheal (ET), intranasal…

Intraosseous Infusion

Establishing vascular access in critically ill and injured patients is central to the practice of emergency medicine. Moreover, placing an intravenous (IV) catheter in an acutely ill child can be one of the most challenging and frustrating procedures that a clinician can be called on to perform. Children have small peripheral vessels that collapse during shock, and their higher proportion of body fat makes visualization and…

Indwelling Vascular Access Devices: Emergency Access and Management

Indwelling vascular access devices (IVADs) provide routes for short- and long-term infusion of antibiotics, antifungal agents, hyperalimentation fluids, chemotherapeutic agents, blood products, analgesics, and anesthetic agents. In addition, they provide access for lifesaving procedures such as hemodialysis (HD) and plasmapheresis. As of 2013, nearly 422,000 patients were receiving HD therapy, with 3 to 5 million central venous catheters being placed yearly in patients in the United…

Venous Cutdown

Management of critically ill or injured patients requires immediate and adequate vascular access, especially during trauma resuscitation, when rapid infusion of crystalloid or blood products may be necessary. Venous cutdown, a time-honored surgical technique, has largely been replaced by alternative methods of obtaining venous access, including intraosseous lines, the Seldinger technique, and ultrasound-guided central and peripheral venous cannulation. Nonetheless, venous cutdown still has a role as…

Central Venous Catheterization and Central Venous Pressure Monitoring

Central venous access remains a cornerstone of resuscitation and critical care in both the emergency department (ED) and intensive care unit. Advanced hemodynamic monitoring, rapid infusion of fluid, placement of transvenous pacemakers, and administration of selected medications all require reliable central venous access. Central venous catheterization has also gained acceptance in the resuscitation and treatment of critically ill children (see Chapter 19 ). Traditionally, the subclavian…

Peripheral Intravenous Access

Introduction Intravenous (IV) access is a mainstay of modern medicine. IV cannulation is a procedure ( Videos 21.1 and 21.2 ) performed by a wide array of health care professionals, including physicians, nurses, physician assistants, phlebotomists, and emergency medical technicians. In the emergency department (ED), uncomplicated peripheral venous access is usually secured by a nurse or technician. In the United States, more than 25 million patients…

Arterial Puncture and Cannulation

Arterial puncture is the most accurate blood sampling technique for true arterial blood gas (ABG) and acid-base determination. The absence of arterial blood pressure defines cardiac arrest and serves as a definitive end point for resuscitative efforts. Intraarterial cannulation with continuous blood pressure measurement remains an accepted standard in critically ill patients. Intraarterial monitoring of blood pressure better reflects the force of systemic perfusion and is…

Pediatric Vascular Access and Blood Sampling Techniques

Obtaining vascular access and blood samples in an infant or child can challenge and frustrate even the most skilled emergency clinician and can be especially challenging in children who are dehydrated or in shock. Resuscitation of critically ill and injured children should not be delayed for lack of vascular access, and intraosseous (IO) access is the preferred technique if peripheral vascular access cannot be secured rapidly.…

Resuscitative Thoracotomy

In the United States trauma is the leading cause of death in people aged 1 through 44. Blunt trauma accounts for the majority of trauma mortality overall, but in urban settings penetrating trauma, including firearm-related injuries, accounts for an increased proportion of trauma deaths. In 2013, more than 33,000 firearm-related deaths occurred in the United States, with many victims arriving at the emergency department (ED) in…

Cardiopulmonary Resuscitation and Artificial Perfusion During Cardiac Arrest

Cardiopulmonary resuscitation (CPR) can be lifesaving for a patient in cardiac arrest, particularly in conjunction with other therapies such as defibrillation or delivery of medications. In several large clinical studies, data have shown that prompt delivery of CPR serves as an important predictor of successful outcome and increases the chance of survival by up to twofold. Each minute without treatment, however, is associated with a 10%…

Pericardiocentesis

Definition Pericardial effusion, the presence of fluid within the pericardial space, has a number of causes. As fluid accumulates, a critical point is reached at which pericardial pressure negatively affects cardiac filling and causes circulatory insufficiency. This is called pericardial tamponade. Once compensatory mechanisms begin to fail, obstructive shock ensues and a failure to restore hemodynamics eventually leads to cardiac arrest. Only removal of fluid can…

Emergency Cardiac Pacing

The purpose of cardiac pacing is to restore or ensure effective cardiac depolarization. Emergency cardiac pacing may be instituted either prophylactically or therapeutically. Prophylactic indications include patients with a high risk for atrioventricular (AV) block. Therapeutic indications include symptomatic bradyarrhythmias and overdrive pacing. Pacing for asystole has very minimal success but it has been used for this condition. Several approaches to pacing can be taken, including…

Basic Electrocardiographic Techniques

Introduction The electrocardiogram (ECG) is a graphic recording of the electrical activity of the heart. The standard ECG is obtained by applying electrodes over the chest and limbs to record the electrical activity of the cardiac cycle. Developed over 100 years ago, the ECG remains the most important initial diagnostic tool for the evaluation of patients presenting with chest pain, dyspnea, syncope, cardiac arrest, and toxicologic…

Assessment of Implantable Devices

Patients with implanted pacemakers or automatic implantable cardioverter defibrillators (AICDs) are commonly seen in the emergency department (ED). Fortunately, the increased reliability of these devices has precluded a marked increase in patients with true emergencies related to device malfunction, but such patients clearly have serious underlying medical problems that must be considered. Pacemaker complications are not uncommon, with rates ranging from 2.7% to 5%. Many pacemakers…

Defibrillation and Cardioversion

Introduction Defibrillation is an emergency procedure performed to terminate ventricular fibrillation (VF) ( Fig. 12.1 A ). VF is a potentially lethal, but survivable, rhythm commonly found in victims of sudden cardiac arrest (SCA). VF can be caused by myocardial infarction, myocardial ischemia, undiagnosed coronary artery disease, and electrical injuries. Medications such as tricyclic antidepressants, digitalis, quinidine, and other proarrhythmics can cause QT-segment prolongation and changes…

Techniques for Supraventricular Tachycardias

Introduction Patients in the emergency department frequently complain of palpitations, heart fluttering, or a rapid heartbeat, which is often coupled with weakness, chest pain, or dizziness. The physician must determine the exact rate, rhythm, origin, and cause of the tachycardia and then gain control of the heart rate (HR) by slowing or normalizing it, or by treating the underlying cause. Determining the cause, origin, and rhythm…

Tube Thoracostomy

Tube thoracostomy is a procedure used to evacuate an abnormal accumulation of fluid or air from the pleural space and can be performed on an elective, urgent, or emergent basis. Air or fluid can accumulate in the pleural space as a result of spontaneous or traumatic pneumothorax, pleural fluid accumulation of blood, malignancy, infection (empyema), or lymph (chylothorax). The first modern methods to evacuate the contents…