1. ITE Procedures Angela Pugliese MD Department of Emergency Medicine Henry Ford Hospital

2. Studying Techniques Must know all procedures from EM model See outline Roberts and Hedges Chapter in First Aid for the EM Boards Questions from ROSH

3. Topics Outline ED Thoracotomy Pericardiocentesis Thoracostomy tube Cardiac Pacing Umbilical Vein Catheterization Paracentesis Local Anesthesia Perimorten C-section Arthrocentesis Compartment Pressure Measurement

4. ED Thoracotomy Indications: Penetrating trauma Loose vitals (while in route) or in ED Goal to cross-clamp aorta and control hemorrhage Technique: Intubate and place NG Enter Pericardium ANTERIOR to phrenic nerve Pearls: Learn indications

5. Pericardiocentesis Decipher tamponade from tension pneumo Technique: Use US – parasternal approach Blind approach – subxyphoid, attach EKG lead Major complication coronary vessel laceration Pearls: Treatable cause of PEA ABOVE THE RIB CXR post procedure

6. Thoracostomy Tube Indications: Pneumothorax/hemothorax Technique: Tension use needle decompression 4 th or 5 th intercostal space anterior to mid-axillary line ABOVE THE RIB Pearls: >1500 ml blood means OR (or >300 ml/hr after) Don’t clamp tube CXR post procedure NO CXR PRIOR TO NEEDLE DECOMPRESSION

7. Cardiac Pacing/Cardioversion Indications: UNSTABLE DYSRHYTHMIAS Technique: Cutaneous vs transvenous Right IJ then left subclavian Pearls: Pad placement: anterior and posterior Confirm pacing by palpating pulse with monitor Magnet deactivates or revert to asynchronous pacing Air embolism complication place patient in left lateral decubitus

8. Umbilical Vein Catheterization Access about 1 week after birth ONE VEIN (two arteries) located 12 o’clock Cut cord 2 cm from base (1cm NICU) Advance Catheter about 1-2 cm beyond good blood return CXR shows catheter going toward the head

9. Paracentesis Use an US Consider albumin if you take 5L or greater Diagnostic Tap >250 PMNs is SBP

10. Anesthesia Esters/Amides – Amides all have 2 I’s No cross reactivity (ie the allergic patient) NO EPI in end arteries (finger, nose, ear, penis) Learn Regional Blocks Max dose 4 mg/kg without epi, 7 mg/kg with

11. Perimortem C-section Indications: Pregnant woman greater than 24 wks with cardiac arrest Must complete within 5 minutes of maternal death Technique: Continue maternal CPR Midline vertical incision Pearls Fundus palpated above umbilicus assume viability Know APGAR

12. Arthrocentesis ABSOLUTE CONTRAINDICATION Infection over the joint WBC > 50,000 indicates infection (BOARDS) Pseudogout = Positively birefringent (pyrophosphate) Fat globules indicates intra-articular fracture

13. Compartment Measurement Approximate 6 hours of viability 30 mm Hg is cut off number Elevated pressure indicates need for fasciotomy Exception with snake bites (use hyperbarics, serial measurements and anti-venom), fasciotomy is last resort

14. Rapid Fire Pearls Subclavian/IJ pulled out and patient becomes hemodynamically unstable…. Air embolus, place left lateral decubitus, then aspirate RV (HBO) Anesthetic effect of Mental Nerve Block Lower lip Lower lip and inferior teeth Inferior Alveolar – too posterior causes facial nerve palsy Approach to elbow aspiration Lateral (avoid ulnar nerve which is medial)

15. Rapid Fire Pearls Pt getting blood develops hives, what next? Give benadryl and continue Correct direction for mandibular reduction Down and posterior IO placement in peds Tibia; 1 cm inferior of tuberosity, 1 cm medial Testicular Detorsion Open the book (remember 180 degrees)

16. Conclusion Complete ROSH questions Review Outline Email with questions