life support procedures

Life support procedures

Paleerat Jariyakanjana, MD

Faculty of Medicine

Naresuan University

Learning contents

1. Surgical cricothyroidotomy

2. Needle cricothyroidotomy

3. Interosseous puncture / infusion

4. Needle decompression

5. Chest tube insertion

6. FAST

SURGICAL

CRICOTHYROIDOTOMY

Indications

Failure of oral or nasal endotracheal intubation

Airway obstruction

Traumatic injuries making oral or nasal

endotracheal intubation difficult or potentially

hazardous

Contraindications

infants and young children <12 yr

Step

Supine position

Orientation: thyroid

notch, cricothyroid

interval, and sternal

notch

Step

Assemble the necessary equipment.

Sterile technique and local anesthesia

Stabilize the thyroid cartilage with the left

hand

Make a transverse skin incision over the

cricothyroid membrane and carefully

incise through the membrane transversely

Step

Insert hemostat or

tracheal spreader into

the incision and rotate

it 90 degrees

Step

Insert a proper-size,

cuffed endotracheal

tube or tracheostomy

tube (No. 5-6)

Step

Inflate the cuff and apply ventilation.

Observe lung inflation and auscultate the

chest for adequate ventilation.

Secure the endotracheal or tracheostomy

tube

Complications

Aspiration (blood)

Creation of a false passage into the tissues

Subglottic stenosis/edema

Laryngeal stenosis

Hemorrhage or hematoma formation

Laceration of the esophagus

Laceration of the trachea

Mediastinal emphysema

Vocal cord paralysis, hoarseness

NEEDLE

CRICOTHYROIDOTOMY

Indications

preferred method of securing the airway in

crash airway situations in infants and

young children

Contraindications

Transection of the distal trachea

Complete upper airway (oropharyngeal)

obstruction

Step

prepare oxygen

tubing

Step

Supine position

Assemble a 12- or 14-gauge, 8.5-cm,

over-the-needle catheter to a 6- to 12-mL

syringe.

Sterile technique

Palpate the cricothyroid membrane

Stabilize the trachea with the thumb and

forefinger of one hand

Step

Puncture the skin in

the midline directly

over the cricothyroid

membrane

45º angle caudally

with negative

pressure

Step

aspiration of air

entry into the tracheal

lumen

advancing the

catheter

Continue to observe

lung inflation and

auscultate the chest

for adequate

ventilation.

Complications

Inadequate ventilation

Aspiration (blood)

Esophageal laceration

Hematoma

Perforation of the posterior tracheal wall

Subcutaneous and/or mediastinal

emphysema

Thyroid perforation

Pneumothorax

INTRAOSSEOUS

PUNCTURE/INFUSION:

PROXIMAL TIBIAL ROUTE

Indications

patients in whom attempts at peripheral or

central venous access has been

unsuccessful

Contraindications

osteoporosis and osteogenesis imperfecta

fractured bone

recent prior use of the same bone for IO

infusion

cellulitis, infection, or burns

Step

supine position

Select an uninjured lower extremity

Padding, 30-degree flexion of the knee

Identify the puncture site

anteromedial surface of the proximal tibia,

approximately 1FB (1-3 cm) below the

tubercle


Step

Initially at a 90-degree angle, introduce a

short, large-caliber, bone-marrow

aspiration needle (or a short, 18-gauge

spinal needle with stylet) into the skin and

periosteum, with the needle bevel directed

toward the foot and away from the

epiphyseal plate.

After gaining purchase in the bone, direct

the needle 45-60 degrees away from the

epiphyseal plate.

Step

Confirmation of placement

Aspiration of bone marrow

saline flushes through the needle easily and

there is no evidence of swelling

needle remains upright without support

Secure the needle and tubing in place.

intraosseous infusion should be limited to

emergency resuscitation of the patient

and discontinued as soon as other venous

access has been obtained

http://emcrit.org/misc/how-to-secure-an-io-in-a-peds-patient/

Complications

Infection

Through-and-through penetration of the

bone

Subcutaneous or subperiosteal infiltration

Pressure necrosis of the skin

Physeal plate injury

Hematoma

NEEDLE THORACENTESIS

Indications

Tension pneumothorax

Contraindications

no absolute contraindications

Step

Identify the 2nd ICS, in the midclavicular

line on the side of the tension

pneumothorax.


Place the patient in an upright position if a

cervical spine injury has been excluded.

Step

Keeping the Luer-Lok

in the distal end of the

catheter, insert an

over-the-needle

catheter (minimum 16

gauge, 2 in. [5 cm]

long) into the skin and

direct the needle just

over the rib into the

intercostal space.

Step

Remove the Luer-Lok from the catheter and

listen for the sudden escape of air when the

needle enters the parietal pleura, indicating that

the tension pneumothorax has been relieved.

Remove the needle and replace the Luer-Lok in

the distal end of the catheter.

Leave the plastic catheter in place and apply a

bandage or small dressing over the insertion

site.

Prepare for a chest tube insertion.

Complications

Local hematoma

Pneumothorax

Lung laceration

CHEST TUBE INSERTION

Indications

Pneumothorax

Hemothorax

Empyema

Contraindications

Unstable injured patients: no absolute

contraindications

stable patient

anatomic problems: presence of multiple

pleural adhesions, emphysematous blebs, or

scarring

Coagulopathic patients

Step

Determine the insertion site, usually at the

nipple level (5th ICS), just anterior to the

midaxillary line on the affected side.


Step

Make a 2- to 3-cm transverse (horizontal)

incision at the predetermined site and

bluntly dissect through the subcutaneous

tissues, just over the top of the rib.

Puncture the parietal pleura with the tip of

a clamp

Digital assessment

Step

Clamp the proximal end of the

thoracostomy tube and advance it into the

pleural space to the desired length.

The tube should be directed posteriorly,

medially, and superiorly along the inside

of the chest wall.

Look for “fogging” of the chest tube with

expiration or listen for air movement.

Connect the end of the thoracostomy tube

to an underwater-seal apparatus.

Step

Suture the tube in place.

Apply an occlusive dressing and tape the

tube to the chest.

Obtain a chest x-ray film.

Complications

Laceration or puncture of intrathoracic

and/or abdominal organs

Introduction of pleural infection

Damage to the intercostal nerve, artery, or

vein

Incorrect tube position

Chest tube kinking, clogging, or dislodging

from the chest wall, or disconnection from

the underwater-seal apparatus

Complications

Persistent pneumothorax

Subcutaneous emphysema

Recurrence of pneumothorax

Lung fails to expand

FOCUSED ASSESSMENT

SONOGRAPHY IN TRAUMA

(FAST)

Indications

Blunt abdominal trauma

Stable penetrating trauma

Assessment of the degree of

intraperitoneal free fluid

Contraindications

no absolute contraindications

Step

Start with the

subxiphoid or the

parasternal view

Step

RUQ view

sagittal view in the

midaxillary line, at

approximately the 10th

or 11th rib space

hepatorenal fossa

(Morrison’s pouch)

Step

LUQ view

sagittal view in the

midaxillary line, at

approximately the 8th

or 9th rib space

splenorenal fossa

Step

suprapubic view

transverse view optimally obtained prior to

placement of a Foley catheter

Subxiphoid view

RUQ view

LUQ view

Suprapubic view

Reference

ATLS 9th Student Manual

Clinical procedures in emergency medicine

ANY QUESTIONS?

life support procedures

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