This document discusses various emergency procedures including vascular access, central venous pressure monitoring and catheterization, intraosseous line placement, pericardiocentesis, and other essential procedures. It provides details on indications, contraindications, anatomy, equipment, techniques, complications, and aftercare for each procedure. The goal is to educate emergency physicians on how to properly perform these time-critical interventions.

1. VASCULAR ACCESS
AND OTHER ESSENTIAL
EMERGENCY PROCEDURE
2nd SP-ER day: Emergency Conference " Emergency Medicine Update “
8 August 2009
Borwon Wittayachamnankul MD.

2. VASCULAR ACCESSES

3. Indication
 Peripheral
 Blood example
 Drugs
 fluid
 Central
 Central venous pressure
 Inotropics
 TPN
 Cannot access peripheral line

4. Alternative
 Intraosseouss
 Endotracheal (Drugs only)

5. 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

6. 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

7. 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

8. Anatomy

9. 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

10. Venous access site
 Deep femoral vein
 Proximal great
saphenous vein in the
thigh
 Superficial saphenous
vein at the ankle

11. Venous access site
 External jugular vein
 Internal jugular vein
 Subclavian

12. APPROACH

13. Subclavian :
Infraclavicular approach

14. Subclavian :
Supraclavicular approach

15. Contraindications
 Infections
 Fractures of ipsilateral ribs and clavicles
 Coagulopathy
 Thrombosis

16. Internal jugular :
Central approach

17. Internal jugular :
Posterior approach

18. Internal jugular :
anterior approach

19. Contraindications
 Infections
 Thrombosis
 Coagulopathy “

20. Femoral vein catheterization

21. Equipment and general
technique for central venous
catheterization

22. TEACHNIQUE

23. Catheter-over-needle

24. Catheter-through-needle

25. Seldinger technique

26. Seldinger technique
Subclavian Infraclavicular approach

27. Identify the anatomic
landmarks

28. Anesthetize skin &
subcutaneous tissue with 1%
lidocaine.

29. Insert the introducer needle
while gently aspirating for
blood.

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withdrawn easily, remove the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

31. Pass the flexible guidewire
through the needle into the
vessel.

32. Remove the needle over the
wire.

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

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

35. Remove the dilator, keeping
the guidewire in place.

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

37. Remove the guidewire.

38. Withdraw blood from each
catheter port.

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

40. Attach the catheter to the IV
tubing.

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

42. Pitfalls
NEJM 357;9 august 30, 2007

43. Pitfalls
NEJM 357;24 december 13, 2007

44. Complications

45. Intraosseous line placement

46. 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

47. Contraindications
 fracture at proximal insertion site
 Skin infection at proposed insertion site

48. Equipment

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

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

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

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

53. Remove the troca.

54. Aspirate bone marrow to
confirm placement.

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

56. Attach IV tubing.

57. Saphenous vein cut down

58. Complications
 Local hematoma or cellulitis
 RARELY osteomyelitis

60. Alternative Insertion sites

61. Peripheral Insertion of Central Catheter (PICC)

63. Ultrasound guide cannulation

64. Issue of flow dynamics
 Rate of flow
 Internal catheter diameter
 Temperature
 Pressure
 Viscosity
 Catheter length

65.  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

66. OTHER ESSENTIAL PROCEDURE

67. CARDIAC TAMPONADE

68. 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

69. Pericardiocentesis
 If hemodynamic instability observed,
 Emergently performed underfluoroscopy or
echocardiographic guided
 With/without comfirmatory testing with
agitated saline injection
 Dramatical improvement is necessary

70. N Engl J Med 2003;349:684-90

71. Contra-indication
 Diagnosis is indoubt
 Rupture true or false aneurysm
 Rupture ventricular aneurysm
 Severe local infection

72. Post drainage monitoring
 Symptoms
 Physical findings of decompensation
 Blood pressure changes
 Evidence of hypoperfusion
 Pulsus paradoxus
 Imaging
 Chest X ray
 Echocardiography

73. 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

74. Indwelling catheter drainage
 Instillation of diluted heparin required
 Heparin 0.5 mL in PSS 9.5 mL
 Except with hemopericardium e.g. dissection

75. 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

76. Essential
 Indications
 Contraindications
 Methods
 Anatomy
 Materials
 Aftercare
 Complications