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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…

Thoracentesis

Thoracentesis is a percutaneous procedure during which a needle is inserted into the pleural space to remove fluid for diagnostic or therapeutic purposes. When performed using real-time ultrasound (US) guidance, thoracentesis has an extremely low rate of complications. Anatomy The thoracic cavity is lined by thin serous membranes: the visceral pleura, which wraps around the lungs, and the parietal pleura, which lines the inner surface of…

Mechanical Ventilation

Introduction Mechanical ventilation (MV) is an important tool for resuscitation of critically ill patients in the emergency department (ED). It is vital that ED practitioners have a thorough understanding of the basics of MV and to know when to apply these principles and how to support patients in respiratory or cardiac failure. Hospital overcrowding has led to a delay in transfer of mechanically ventilated patients out…

Tracheostomy Care

Introduction Placement of a tracheostomy tube is a common procedure in critically ill patients. Common indications for this procedure include upper airway obstruction, head or neck trauma, and prolonged respiratory failure. Approximately one fourth of patients in the intensive care unit (ICU) will require a tracheostomy tube for prolonged respiratory support or weaning from mechanical ventilation. Advances in health care allow many patients with tracheostomies to…

Cricothyrotomy and Percutaneous Translaryngeal Ventilation

Few clinical scenarios are as critical as when a patient's airway cannot be controlled with traditional endotracheal (ET) intubation. Although cricothyrotomy is rarely required, the incidence of surgical airways has decreased even further since the advent of adjunctive intubation techniques. The conditions accompanying an airway emergency are often stressful and chaotic and require the emergency department (ED) physician to be intimately familiar with this procedure. When…

Pharmacologic Adjuncts to Intubation

Endotracheal (ET) intubation in the emergency setting presents a challenge distinct from that associated with intubation of fasted, premedicated patients in the operating room (OR). Patients in the emergency department (ED) are frequently uncooperative and unstable and may have medical problems or anatomic abnormalities that are completely unknown to the treating clinician. It is challenging that within a matter of minutes and with scant data the…

Tracheal Intubation

Intubation is often the pivotal procedure in the emergency management of critically ill patients. There are several new devices that can improve the likelihood of successful intubation, and it is important to put the intubation procedure in perspective, understanding that intubation is just one part of airway management. The primary objective of airway management is to maintain adequate ventilation and oxygenation, and intubation only allows ventilation…

Basic Airway Management and Decision Making

Basic airway procedures are often overlooked in favor of more exciting intubation devices and techniques, but basic procedures are critically important and often lifesaving. Establishment of a patent airway, oxygenation, and bag-mask ventilation (BMV) remain the cornerstones of good emergency airway management ( Videos 3.1 – 3.11 ). These techniques can be used quickly and in any setting. They allow practitioners to keep apneic patients alive…