CONTRAINDICATIONS

Central access should not be attempted when peripheral

access is obtainable and no other indication is present.

Central access should be avoided at sites with overlying

cellulitis or other anatomic abnormalities such as extensive

trauma that may cause distorted anatomic landmarks.

Known coagulopathy is an absolute contraindication to

subclavian vein cannulation (noncompressible site) and a

relative contraindication for internal jugular and femoral

cannulation. Finally, patients must be able to cooperate

during the procedure by remaining still. An uncooperative

8

chosen based on reason for access as well as body

habitus and pattern of injury for trauma patients.

• Although the overall complication rate for centra l line

placement is low for experienced providers, serious

complications may occur.

patient is a relative contraindication that may require sedation before the procedure.

EQUIPMENT

Most of the equipment needed to perform central venous

cannulation can be found in commercially available central

line kits (Figure 3-1). Kits include povidone-iodine swabs,

guidewire introducer needle, J-tip guidewire, multiple

5-mL syringes, 1% lidocaine, 22- and 25-gauge needles for

local anesthesia, #1 1 blade scalpel, dilator, central line, and

silk suture on a cutting needle.

There are multiple types of central lines. In general, 1 of

2 types is used in the ED (Figure 3-2). A triple-lumen catheter is used for patients who require multiple different

medication drips or when there is difficulty obtaining

peripheral venous access. A sheath introducer (Cordis) catheter is shorter and wider and is used for introducing transvenous pacers, Swan-Ganz catheters, and for rapid infusion

of fluid and blood products in the hypotensive patient.

These larger catheters can achieve flow rates up to 1 L/min.

PROCEDURE

The procedure including risks and benefits should be

completely explained to the patient or their representative. Informed consent should be obtained unless the

CENTRAL VENOUS ACCESS

Figure 3-1 . Tri ple lumen kit.

procedure is performed emergently. First locate the

appropriate anatomical landmarks for the chosen site

(see later). Next, apply povidone-iodine to the area of

needle insertion followed by the sterile drape. Then

.A. Figure 3-2. From left to right: A. sheath i ntroducer

kit (Cord is) with dilator. B. Triple lumen catheter.

C. triple lumen dilator.

anesthetize the area of needle insertion with lidocaine.

Once the preparation is complete, Seldinger technique

should be followed in a stepwise fashion to complete the

procedure .

..... Seldinger Technique

1. Use a large-bore needle with syringe to cannulate the

vein. There should be free flow of dark nonpulsatile

blood into the syringe with traction on plunger

(Figure 3-3A).

2. Thread the guidewire through the needle until 3-5 em

of the guidewire remains (Figure 3-3B). If resistance is

met, withdraw the wire and confirm that the needle is

in the vessel. Attempt to rethread the wire.

3. When the guidewire is in place, remove the needle

(Figure 3-3C). Never let go of the guidewire during any

part of the procedure because it can migrate fully into

the vessel.

4. Using a #1 1 blade scalpel, make a superficial stab incision in the skin at the site that the guidewire enters

(Figure 3-3D).

 

5. Pass the dilator over the wire and thread into the vessel

(Figure 3-3E). (For the Cordis catheter, the dilator and

catheter are inserted together.)

6. Remove the dilator and thread the triple lumen over the

wire, backing out the wire until it protrudes 2-3 em out

of the brown port.

7. Holding the free wire with one hand, thread the line

into the vein (Figure 3-3F).

8. Remove the wire and confirm placement with aspira ­

tion of blood (Figure 3-3G). Secure the catheter in

place with suture.

Internal jugular vein cannulation can be achieved by

multiple approaches. The central approach is described

here (Figure 3-4). Position the patient supine and in

slight Trendelenburg position, with the head rotated

75 degrees to the opposite side. Palpate the triangle

formed by the 2 heads of the sternocleidomastoid muscle.

Palpate the carotid artery pulse within this triangle. The

vein is lateral to the artery in this location and is widest

just below the level of the cricoid cartilage. Insert the

needle at the apex of the triangle, aiming toward the ipsilateral nipple with 30 degrees of angulation. The vein

should be entered within 2-3 em of needle advancement.

If unsuccessful, withdraw slowly, as the vessel, if punctured, may have been compressed during advancement

and will be pulled open on withdrawal. Do not palpate

the carotid pulse while attempting to cannulate the internal jugular vein. The slight compression that results can

compress the vein, making it more difficult to access.

Cannulation of the right internal jugular is preferred over

the left because of the straight line into the right atrium

CHAPTER 3

Figure 3-3. The Seldinger tech nique. (Reprod uced with permission from Reichman EF and Simon RR. Emergency

Medicine Procedures. New York: McGraw-Hill, 2004. Figure 38-1 0.)

CENTRAL VENOUS ACCESS

Figure 3-4. Internal jugular vein catheterization.

(Reproduced with permission from Dunphy JE, Way

LW. Current Surgical Diagnosis Er Treatment. 5th ed.

La nge, 1 981 .)

and the presence of the thoracic duct and a higher pleural

dome on the left side.

The subclavian vein can also be cannulated by multiple

approaches. The infraclavicular approach is described here

(Figure 3-5). Position the patient supine and in slight

Trendelenburg position. Place a rolled sheet or towel

between the patient's scapulas to allow the shoulders to fall

backward and flatten the clavicles. Insert the needle 1 em

inferior to the clavicle, at the junction of the middle and

medial thirds. Direct the needle under the clavicle and

toward the suprasternal notch, with the needle parallel to

the chest wall. The vein should be entered within 4 em of

needle advancement.

 

the radial and ulnar arteries using your fingers. Ask the

patient to clench the fist to increase venous drainage

from the hand for approximately 30 seconds. Ask the

patient to open the hand, which should be noticeably

pale. At this point, release only the ulnar artery. Rapid

return of color signifies adequate collateral flow.

Although the necessity of the test for arterial puncture is

questioned, common sense dictates that if collateral flow

in one wrist is noticeably decreased compared with the

other, the wrist with better collateral flow should be

accessed. In the absence of good collateral flow in both

wrists, the necessity of the procedure should be weighed

against the remote risk of serious vascular injury and

distal extremity ischemia.

The radial artery is easily palpated in a majority of

patients. It runs down the radial aspect of the forearm,

generally located between the styloid process of the

radius and the flexor carpi radialis tendon at the

.A. Figure 2-2. Position of the forea rm for puncture of

the radial artery. A kidney basin or rol led towel may

be helpful to hold the patient's wrist in this position.

proximal crease of the wrist. The patient's wrist should

be extended to bring the artery to a more superficial

position. A kidney basin or rolled towel as well as tape

may be helpful to hold the patient's wrist in this posi ­

tion ( Figure 2-2). The skin overlying the artery should

be cleaned. The skin and immediate subcutaneous

tissue should then be appropriately anesthetized. The

authors recommend massaging the area or letting it rest

for 1-2 minutes for the anesthetic to take complete

effect. This time may be used to prepare your other

equipment.

After locating the impulse of the artery with the nondominate hand, take the syringe and needle in your dominate hand and slowly advance the needle toward the

impulse at a 30- to 45-degree angle proximally toward the

patient. If the impulse is difficult to detect, an ultrasound

or Doppler may be helpful to locate the artery (Figure 2 - 3) .

Some practitioners use a direct 90-degree angle to the skin,

but this is largely a matter of preference. When the artery

is accessed, blood will passively fill the syringe. It should

not be necessary to draw back on the syringe. Pulsatile or

bright red blood signals the correct vessel has been

accessed; however, this may not be apparent in the criti ­

cally ill patient. If blood is not obtained, withdraw the

needle to just below the skin and reattempt the procedure

after slight adjustments have been made. Do not move the

needle in an arc deep in the skin, as this risks damage to

the vascular structures.

After blood is collected, the needle should be removed

and disposed of appropriately. Remove air from the syringe

and place the syringe cap, ensuring that blood contacts the

cap. Maintain pressure over the arterial site for approxi ­

mately 5 minutes to prevent development of a hematoma,

and dress the wound appropriately.

CHAPTER 2

Radial vein

Tendon

Radial vein

8

 

The femoral vein has a single approach. Palpate the

femoral artery 2 em below the inguinal crease. The vein

is usually 1 em medial to the artery at this location.

Insert the needle at a 45-degree angle to the skin, medial

to the femoral pulse, in a cephalad direction. In the

pulseless patient, palpate the anterior superior iliac spine

and the pubic tubercle. Draw an imaginary line connecting these 2 points. If this line is divided into thirds, the

vein will be located where the medial and middle thirds

intersect (Figure 3-6).

Figure 3-5. Subclavian vein catheterization.

(Reproduced with permission from Stone CK and

Humphries RL. Longe: Current Emergency Diagnosis

and Treatment. 57th ed. New York: McGraw-Hill,

2004-20 11. Figure 7-7.)

Empty space

Figure 3-6. Femoral vein anatomy. (Reprinted with

permission from Stone CK and Humphries RL. Longe:

Current Emergency Diagnosis and Treatment. 57th ed.

New York: McG raw-Hill, 2004-20 11. Figure 7-8.)

CHAPTER 3

COMPLICATIONS

Central venous access has multiple complications common

to each site, including bleeding, infection, arterial or

venous laceration, and air embolism. Site specific compli ­

cations include the following: for internal jugular, airway

compression from expanding hematoma, carotid artery

dissection, pneumothorax, and arrhythmia from cardiac

irritation; for subclavian, pneumothorax and arrhythmia;

for femoral, deep venous thrombosis, line sepsis, retroperitoneal bleeding, and bowel perforation.

SUGGESTED READING

Weber J, Schindlbeck M, Bailitz J. Vascular procedures. In: Simon

RR, Ross C, Bowman S, Wakim P. Cook County Manual of

Emergency Procedures. 1st ed. Philadelphia, PA: Lippincott

Williams & Wilkins, 20 12.

Wyatt CR. Venous and intraosseous access in adults. In:

Tintinalli JE, Stapczynski JS, Ma OJ, Cline DM, Cydulka

RK, Meckler GD. Tintinalli's Emergency Medicine: A

Comprehensive Study Guide. 7th ed. New York, NY:

McGraw-Hill, 20 1 1.

Procedu ral Sedation

Pa ula E. Oldeg, MD

Key Points

• Procedural sedation is the admin istration of analgesic

and sedative agents to induce a depressed level of

consciousness so that a medical procedure can be performed without patient movement or memory.

INDICATIONS

Procedural sedation is a clinical technique that creates a

decreased level of awareness, but allows maintenance of

protective airway reflexes and adequate spontaneous ventilation. The goals of procedural sedation are to provide

analgesia, amnesia, and anxiolysis during a potentially

painful or frightening procedure. Pharmacologic agents

used in procedural sedation are of 3 general classes: seda ­

tives, analgesics, and dissociative agents. The use of such

medications in the emergency setting is common and has

been shown to be safe. Before the procedure, the physician

should assess the patient for systemic disease and for a

 

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Incision and Drainage

David E. Manthey, MD

Key Points

• Incision and drainage is the procedure of choice for

subcutaneous abscesses.

• Antibiotics are not necessary unless there is associated

cellulitis.

INDICATIONS

Incision and drainage (I&D) is the definitive treatment

for any subcutaneous abscess. Abscesses should be drained

if larger than 5 mm and accessible to percutaneous incision. Antibiotics alone are not adequate treatment of an

abscess. In fact, skin abscesses without surrounding cel ­

lulitis, once drained, do not r equire any further treatment

with antibiotics.

Abscesses can be diagnosed by physical examination

based on swelling, pain, redness, and fluctuance (Figure 1-1).

Some abscesses will spontaneously drain, leaving little diagnostic doubt. Bedside ultrasound may aid in diagnosis by

identifying a hypoechoic area of fluid just under the skin.

Needle aspiration may also be employed to prove the presence of pus.

Abscesses are often denoted by various names depending on their location and/or structure involved. The t reatment remains the same. Paronychia and eponychia form

around the nail (Figure 1-2). Felons occur with infection of

the volar pad of the finger and require a specific approach

for drainage. Bartholin gland abscesses occur in the paired

glands that provide moisture to the vestibule of the vaginal

mucosa. When the opening becomes occluded, either an

abscess or a cyst can develop. After I&D, a Word catheter is

placed to insure continued drainage of the gland. Removal

or marsupialization of the gland may be required to prevent recurrence.

1

• Abscesses should be probed with curved hemostats to

break up loculations and identify deeper tracks.

• Local anesthesia may be difficult and require additional

field block, parenteral analgesics, or sedation.

Hidradenitis suppurativa is a chronic relapsing inflammatory process affecting the apocrine glands in the axilla,

inguinal area, or both. Multiple abscesses can form and

eventually lead to draining fistulous tracts that require

surgical management. I&D of these abscesses is frequently

necessary and performed in the emergency department.

Incision and drainage may also be used to treat infected

pilonidal or sebaceous cysts. Further treatment by a

.A. Figure 1-1. A subcutaneous abscess in an intravenous

drug user.

CHAPTER 1

Figure 1-2. Paronychia.

surgeon will often include removing the capsule to prevent

recurrence.

Perirectal abscesses include superficial abscesses (ie,

perianal), which can be drained by emergency physicians,

and deeper abscesses (ie, ischiorectal, intersphincteric,

supralevator), which require operative surgical drainage.

Perianal abscesses present as tender, fluctuant masses palpated around the anal verge. Deeper abscesses often present with rectal pain, pain with defecation, rectal and

buttock erythema and tenderness, and systemic symptoms

( ie, fever, lethargy).

CONTRAINDICATIONS

Cellulitis without evidence of underlying abscess should

not be incised. Pulsatile masses that may be infected pseudoaneuryms should not be incised.

Extremely large or deep abscesses should be considered

for drainage under anesthesia. As a result of transient bacteremia, those patients at risk for endocarditis owing to an

artificial or abnormal heart valve should be given appropriate perioperative antibiotics.

Abscesses of the palms, soles, nasolabial fold, breasts,

 

finger pads (felons), face, and deeper perirectal region can

be associated with complications. Consider consultation

with the appropriate surgical subspecialty.

EQUIPMENT

Povidone-iodine solution or chlorhexidine solution to

cleanse the skin

Anesthetic of 1 o/o lidocaine or 0.25% bupivacaine with

epinephrine

1 8-gauge needle (to aspirate anesthetic)

27-gauge needle and syringe (to inject local anesthesia)

Splash guard or 1 8-gauge angiocatheter (without needle)

30-mL syringe for irrigation

Sterile water or normal saline

1 1-blade scalpel

Swab for bacterial culture

Curved hemostat

;4-inch iodoform packing

Scissors

Gloves, gown, and facemask with shield (universal

precautions)

Gauze and tape

PROCEDURE

Discuss the risks and benefits of the procedure with the

patient before obtaining consent. Verify abscess location

with ultrasound if necessary. Wash your hands and wear

gloves, gown, and a face shield, as many abscesses are under

pressure. Position the patient and lighting to allow for the

best visualization and access to the abscess. Prepare the

area with povidone-iodine solution or chlorhexidine.

Utilizing a 27-gauge needle, inject the anesthetic j ust

under the dermis parallel to the surface of the skin.

Blanching of the tissue will occur as the anesthetic spreads

out through the skin. Cover the entire area to be incised.

Avoid injecting lidocaine into the abscess cavity. This may

increase the pressure in the cavity causing more pain. For

larger abscesses, local field blocks, parenteral analgesics,

and/or procedural sedation may be necessary.

If it is unclear whether an abscess exists, attempt aspiration of pus with a syringe and an 18- or 20-gauge needle.

If confirmed, use an 1 1-blade scalpel to make a single incision in the skin. The incision should be at the point of

maximal fluctuance oriented in the long axis of the abscess.

In general, the incision should extend two thirds of the

diameter of the abscess cavity ( except when draining

Bartholin gland abscesses, for which only an incision

0.5-1 em should be made). Attempt to incise parallel to

existing skin tension lines to promote cosmetic results.

Use gentle and steady pressure around the abscess to

express pus from the cavity. Insert a curved hemostat to

break loculations by working in a clockwise fashion

around the entire abscess cavity. This will also help identify

any deeper tracks. If desired, obtain a culture of the wound

at this time.

 

Consider gentle irrigation of the wound until the fluid

returning is clear. Pack the wound with enough iodoform

gauze to keep the sides of the abscess from touching. This

will allow for further drainage. Cover the wound with

gauze.

When treating a Bartholin gland abscess, a small catheter (Word catheter) is placed in the opening instead of

iodoform. The catheter should remain in place for several

weeks to allow for the development of a fistula for continued drainage.

I NCISION AND DRAINAGE

The patient is instructed to follow up in 48 hours to

have the packing removed. If pus is no longer present and

symptoms are resolving, the wound is allowed to heal by

secondary intention.

COMPLICATIONS

Scarring from the abscess and incision will occur. Numbness

from cutaneous nerve injury may occur. Seeding of the

blood with bacteria may transiently occur.

SUGGESTED READING

Fitch MT, Manthey DE, McGinnis HD, et al. Abscess incision

and drainage. N Eng! J Med 2007;357:e20.

Hankin A, Everett WW. Are antibiotics necessary after incision and

drainage of a cutaneous abscess? Ann Emerg Med. 2007;50:

49-5 1.

Kelly EW, Magilner D. Soft tissue infections. In: Tintinalli JE,

Stapczynski JS, Ma OJ, Cline DM, Cydulka RK, Meckler GD.

Tintinalli's Emergency Medicine: A Comprehensive Study Guide.

7th ed. New York, NY: McGraw-Hill, 20 11: Pages 1014-1024.

Arterial B lood Gas

Brian C. Kitamura, MD

John Sarka, MD

Key Points

• Arterial puncture for blood gas ana lysis is a common

procedure performed in the emergency department

(ED).

• Blood obtained from the radial artery can be used

to quickly provide qua ntitative information on the

INDICATIONS

The primary indication for obtaining an arterial blood

sample is for the assessment of the partial pressures of

oxygen and carbon dioxide and accurate assessment of

arterial pH. Secondarily, arterial blood can be analyzed

for carboxyhemoglobin, methemoglobin, and basic elec ­

trolytes depending on the capabilities of the laboratory.

Under certain circumstances it may be necessary to

obtain a sample of arterial blood for other routine laboratory tests, such as in patients who are obese or have a

history of intravenous drug abuse, in whom the radial

artery is palpable, but venous access is difficult or may be

delayed.

CONTRAINDICATIONS

There are few absolute contraindications for arterial puncture for blood gas analysis. Trauma, infection, or abnormalities of the overlying skin such as a burn are

contraindications because of concern for infection or further damage to the vascular structures. Patients with

known coagulopathies, taking anticoagulants, or who may

require thrombolytic agents should be approached with

caution because of the increased risk of bleeding, hema ­

 

decision-making thought processes, treatment plans, and dispositions that will actually allow you to function more comfortably in the clinical environment. The diagnostic algorithms are a unique feature that attempt to simplify the problem

and point the clinician in the right direction.

The book has 19 sections and 98 chapters that cover the entire contents of the EM clerkship curriculum

(Acad Emerg Med. 201 0; 1 7:638-643). The authors are all practicing emergency physicians and EM educators from throughout the country. For medical student clerkship directors, we believe that this text is the perfect book for the student to pick

up and digest during a 4-week rotation.

In summary, we hope this book will enhance the emergency medicine experience of all its users.

xvi

Scott C. Sherman, MD

Joseph M. Weber, MD

Michael Schindlbeck, MD

Rahul Patwari, MD

Acknowledgments

We have many people to thank in helping us bring this project to fruition. First and foremost, this text would have never made

it to print without the support and encouragement of our McGraw-Hill editor, Anne Sydor. Anne is a friend as much as an

editor. She took a chance on us and for that we will always be grateful. One of Anne's many gifts has been providing us with

such great editorial support in the form of Sarah M. Granlund. She has been the quarterback of this project from the onset,

and without her planning and attention to detail, we would not be here today. We would also like to acknowledge our project

manager, Charu Khanna, for her attention to detail during page proofs and willingness to go the extra mile.

 

Attending Physician

Department of Emergency Medicine

Cook County (Stroger) Hospital

Chicago, illinois

Jonathon D. Palmer, MD

Assistant Professor

Department of Emergency Medicine

University of Arkansas for Medical Sciences

Little Rock, Arkansas

Matthew S. Patton, MD

Department of Emergency Medicine

Northwestern University Feinberg School of Medicine

Chicago, illinois

Rahul G. Patwari, MD

Medical Student Clerkship Director

Assistant Professor

Attending Physician

Department of Emergency Medicine

Rush Medical College

Chicago, illinois

Monika Pitzele, MD, PhD

Attending Physician

Department of Emergency Medicine

Mount Sinai Hospital

Chicago, Illinois

Henry Z. Pitzele, MD, FACEP

Deputy Director

Emergency Medicine

Jesse Brown VA Medical Center

Clinical Assistant Professor

Department of Emergency Medicine

University of Illinois at Chicago

Chicago, Illinois

Natalie Radford, MD

Associate Professor

Department of Clinical Medicine

Florida State University

Attending Physician

Bixler Emergency Department

Tallahassee Memorial Hospital

Tallahassee, Florida

Christopher Reverte, MD

Chief Resident

Department of Emergency Medicine

LA County + USC Medical Center

Los Angeles, California

Attending Physician

Department of Emergency Medicine

St. Luke's-Roosevelt

New York, New York

Neil Rifenbark, MD

Department of Emergency Medicine

University of Southern California

Department of Emergency Medicine

LA County + USC Medical Center

Los Angeles, California

Rebecca R. Roberts, MD

Director, Research Division

Attending Physician

Department of Emergency Medicine

Cook County (Stroger) Hospital

Chicago, Illinois

Sarah E. Ronan-Bentle, MD, MS, FACEP

Assistant Professor

Department of Emergency Medicine

University of Cincinnati College of Medicine

Attending Physician

Center for Emergency Care

University Hospital

Cincinnati, Ohio

CONTRIBUTORS

David H. Rosenbaum, MD, FAAEM

Attending Physician

Department of Emergency Medicine

WakeMed Health and Hospitals

Raleigh, North Carolina

Adjunct Professor

Department of Emergency Medicine

xiii

University of North Carolina School of Medicine

Chapel Hill, North Carolina

Christopher Ross, MD, FRCPC, FACEP, FAAEM

Assistant Professor

Department of Emergency Medicine

Associate Chair

Planning, Education, and Research

Cook County (Stroger) Hospital

Chicago, Illinois

John Sarko, MD

Attending Physician

Department of Emergency Medicine

Maricopa Medical Center

Assistant Professor

Department of Emergency Medicine

University of Arizona Phoenix School of Medicine

Phoenix, Arizona

Shari Schabowski, MD

Assistant Professor

Department of Emergency Medicine

Rush Medical College

Attending Physician

Department of Emergency Medicine

Cook County (Stroger) Hospital

Chicago, Illinois

Conor D. Schaye, MD, MPH

Department of Emergency Medicine

Northwestern Memorial Hospital

Chicago, Illinois

Michael A. Schindlbeck, MD, FACEP

Assistant Professor

Department of Emergency Medicine

Rush Medical College

Assistant Residency Director

Cook County (Stroger) Hospital

Chicago, Illinois

Suzanne M. Schmidt, MD, FAAP

Clinical Instructor

Department of Pediatrics

Northwestern University Feinberg School of Medicine

Attending Physician

Department of Pediatrics

Ann & Robert H. Lurie Children's Hospital of Chicago

Chicago, Illinois

xiv