Need le and Tu be

Thoracostomy

Ann Buchanan, MD

Key Points

• Do not confuse a pulmonary bleb or bul lae for a

pneumothorax.

• The neurovascular bundle runs inferior to each rib. Always

enter the thoracic cavity over the rib, never under.

INDICATIONS

Needle thoracostomy is indicated for emergent decompression of suspected tension pneumothorax. Tube thoracotomy is indicated after needle thoracostomy, for simple

pneumothorax, traumatic hemothorax, or large pleural

effusions with evidence of respiratory compromise.

CONTRAINDICATIONS

A pneumothorax on chest x-ray may be confused with a pulmonary bleb or bullae. Bullae and blebs are large gas-filled

spaces with thin walls where pulmonary parenchyma has

been destroyed, therefore greatly increasing alveolar size and

mimicking pneumothorax. These are frequently located in

the lung apices and are often seen in patients with severe

chronic obstructive pulmonary disease. It is essential to confirm the presence of a pneumothorax before placement of a

thoracostomy tube. See Chapter 24 for further clinical scenarios in which tube thoracostomy can be substituted for less

invasive or conservative management of pneumothoraces.

EQUIPMENT

Needle thoracostomy requires a 12- to 16-gauge angiocatheter, 3 to 4.5 inches in length, and a 5-10 mL syringe. Tube

thoracostomy requires a 36- to 40-F tube for hemothorax in

adults or 20- to 24-F tube in children. For a simple pneumothorax, an 18- to 28-F tube in adults or 14- to 16-F tube in

children is sufficient Additional supplies required for tube

thoracostomy placement include povidone-iodine (Betadine)

24

• Never advance or replace a tube that has migrated out

of the chest. Always place a new one.

A

Figure 7-1. A-0. Steps in tube thoracostomy

placement. (Repri nted with permission from Cothren C,

Biffl WL, Moore EE. Chapter 7. Trauma. In: Brunicardi FC,

Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB,

Pollock RE, eds. Schwartz's Principles of Surgery. 9th ed.

New York: McGraw-Hill, 201 0.)

NEEDlE AND TUBE THORACOSTOMY

A B

Col lection bottle Water seal

(

Water column

_.To wal l

SUCtiOn

Commercial thoracostomy tube drainage system

Figure 7-2. Diagram of tube thoracostomy and 3-bottle suction apparatus. Bottle A is connected to the

thoracostomy tube and collects pleural drainage for inspection and volume measurement. Bottle B acts as a simple

valve to prevent collapse of the lung if tubing dista l to this point is open to atmospheric pressure. Pulmonary air

leak can be detected by esca pe of bubbles from the submerged tube. Bottle C is a system to reg ulate the negative

pressure del ivered to the pleural space. Wall suction should be regulated to maintain continuous vigorous bubbling

from the middle open tube in bottle C. The resulting negative pressure in em H20 is equal to the difference in the

height of the fluid levels in bottles B and C. The com mercial Pleur-Evac system works in a similar manner. One end

is attached to the chest tube and the other to wall suction. Each chamber of the Pleur-Evac is filled with sterile

water to the level noted in the manufacturer's instructions. (Stone CK and Humphries RL: Longe: Current Diagnosis

and Treatment Emergency Medicine, 7th edition . McGraw-Hill, New York, 201 1 .)

CHAPTER 7

solution, sterile drapes, sterile gloves, 20 mL of 1 o/o lidocaine

with epinephrine, scalpel with #10 blade, large curved and

straight clamps, a needle driver, 2-0 silk suture, and a commercial or 3-bottle suction apparatus.

PROCEDURE

Needle thoracostomy is accomplished by cleansing the skin

in the upper chest and inserting the catheter over needle

into the second intercostal space (just over the third rib) at

the midclavicular line. Tension pneumothorax is confirmed with a sudden rush of air followed by improvement

in the patient's vital signs. Tube thoracostomy placement

should follow this procedure.

Tube thoracostomy is performed by first positioning

the patient with the arm of the affected side above the

patient's head and securing it with a soft restraint. The

chest wall is prepared with povidone-iodine solution and a

sterile field in the area of the fourth intercostal space

(below the fourth rib) at the mid to anterior axillary line.

The skin is then anesthetized with lidocaine, followed by

anesthesia of the deeper structures tunneling above the

fifth rib. Next, inject the intercostal muscles of the fourth

to fifth intercostal space, extending into the parietal pleura.

Additionally, procedural sedation or intercostal nerve

blocks may be used. After adequate anesthesia, a 2- to 3-cm

 

incision is made at the fifth rib between the mid and anterior axillary lines (Figure 7-1A). Using a large curved

clamp, tunnel up through the soft tissues over the fifth rib

to the fourth to fifth intercostal space. Then, using the

same clamp, puncture through the intercostal muscles,

using care not to enter the pleural space too deeply (Figure

7-1B). Open the jaws of the clamp to widen the hole in the

intercostal muscles. Insert a gloved finger through the tract

into the pleural cavity, using the curved clamp as a guide,

and then remove the clamp. Using your finger, ensure there

are no lung adhesions (Figure 7- 1 C). Using your finger or

the curved clamp, insert the chest tube into the thorax,

directing the tube posterior and superior, ensuring that all

the evacuation holes of the tube are within the thorax

(Figure 7- lD). The tube is then attached to a suction

device (Figure 7-2). Secure the tube by placing a simple

interrupted suture inferior to the tube. After tying a knot,

the remaining suture should be wrapped around the t ube

several times and a second knot tied. The skin above the

tube should then be closed with simple interrupted sutures.

Cover the wound with Vaseline gauze and a bandage. A

postprocedure chest x-ray should be ordered to check tube

position and confirm lung reexpansion (Figure 7-3).

COMPLICATIONS

The most common complication of needle thoracostomy

is failure to decompress. The patient's body habitus should

dictate the size of the catheter over needle being used. If a

.A. Figure 7-3. Chest x-ray showing the proper position

of a chest tube in the right lung.

3-cm catheter over needle fails to reach the pleural space,

the procedure should be immediately repeated with a

4.5-cm catheter over needle.

Infection remains a serious complication of tube thoracostomy for patients with chest trauma, with incidences

ranging from 2o/o to 25%. Thus strict sterile technique

should always be followed. Tubes should never be

advanced back into the thoracic cavity if they have

migrated out. A new tube should be placed. Bleeding can

also complicate tube thoracostomy. It may occur from

superficial venules or arterioles at the incision site or

from iatrogenic injury to the lung or abdominal organs.

Incorrect tube placement may cause kinking, subcutaneous placement, or evacuation holes remaining outside the

thoracic cavity, which results in either a nondraining tube

or one with a persistent air leak. Reexpansion pulmonary

edema, a rare but life-threatening complication, is more

common when the lung has been completely collapsed

for several days. Avoid this complication by placing the

tube to water seal after insertion if the lung has been collapsed for a prolonged period. This allows for a more

gradual reexpansion.

SUGGESTED READING

Brunett PH, et al. Pulmonary trauma. 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, pp.

1 744-1 758.

Joseph KT. Tube thoracostomy. In: Reichman EF, Simon RR.

Emergency Medicine Procedures. 1st ed. New York, NY:

McGraw-Hill, 2004, pp. 226-236.

Introduction to Emergency

U ltrasonography

john Bail itz, MD

Basem F. Khishfe, MD

Key Points

• use of ultrasound by emergency physicians has grown

significantly in the last decade.

• Emergent appl ications include the setting of trauma,

abdominal aortic aneurysm, ectopic pregnancy, gall

bladder, and kidney and as an aid to procedures (eg,

intravenous access).

INDICATIONS

Emergency ultrasound (EUS) is preformed by emergency

physicians at the patient's bedside to rapidly answer an

increasing number of focused diagnostic questions, safely

guide invasive procedures, and monitor the response to

treatment. The 2008 American College of Emergency

Physicians ultrasound guidelines describe the history and

training process for the now 11 core EUS applications. EUS

is most commonly used to evaluate and manage patients

with the following clinical presentations:

Abdominal and chest trawna. The Focused Assessment

with Sonography for Trauma (FAST) exam evaluates

for blood in the pericardial, pleural, and peritoneal

compartments in a rapid, reproducible, portable,

and noninvasive approach. The extended FAST exam

evaluates for evidence of pneumothorax.

Ectopic pregnancy. Abdominal/pelvic pain or vaginal

bleeding are common presentations in the first trimester.

 

PROCEDURE

� Timing

Wound healing occurs by primary, secondary, or tertiary

intention. Primary intention is the most common method

of repair and involves the approximation of wound edges

soon after the injury with the use of sutures, staples, tape, or

tissue adhesive. In secondary intention, the wound is

cleaned but left open and allowed to heal spontaneously.

This method is used when the risk of infection after primary

closure is high. Tertiary intention (delayed primary closure)

decreases infection rate in highly contaminated wounds. It is

performed by cleaning and debriding contaminated wounds

acutely, then suturing the wound after 3-5 days.

� Wound Preparation

First, ensure adequate lighting and hemostasis to allow for

a complete evaluation. A thorough neurovascular examination is required for all wounds before administration of

local anesthesia. Tendon function must also be assessed,

when appropriate. Wound exploration may detect foreign

bodies and diagnose injuries to deeper structures. If the

depth of the wound is not easily appreciated and a foreign

body is suspected (ie, patient fell on broken glass), then a

plain radiograph is recommended. Glass fragments >2 mm

are almost universally visualized on plain radiographs.

Plastic and wood foreign bodies are not radiopaque and

may require further imaging (computed tomography scan,

ultrasound, or magnetic resonance imaging).

Lacerations through hair-covered surfaces require further preparation before proceeding with repair. Clipping

hair to 1-2 mm (but not shaving) or applying antibacterial

ointment to part hair away from wound edges will allow

better visualization during wound closure and decrease

risk of infection. Do not remove hair from eyebrows or the

hairline, as this can lead to impaired or abnormal regrowth.

The edges of the wound are prepped with povidoneiodine solution. Care should be taken not to get the solution

in the wound itself, as this inhibits healing. Draw up 1 o/o

lidocaine into a syringe and prepare to infiltrate using a 25-

or 27-gauge needle. Pain of injection can be reduced by

buffering the lidocaine with bicarbonate. To do this, mix

1 mL of sodium bicarbonate with 9 mL of 1 o/o lidocaine; this

solution must be used promptly. Lidocaine is infiltrated

within the wound edges and around the entire wound (field

block). In contaminated wounds, puncture the skin around

the laceration (theoretical lower risk of infection); in clean

wounds, puncture the wound edge within the wound itself

(decreases pain of injection). Remember, the maximum

dose of lidocaine without epinephrine is 4 mg!kg. This

equates to 280 mg in a 70-kg (154 lb) man or 28 mL of

1 o/o lidocaine ( 10 mgfmL). Lidocaine with epinephrine has a

maximum dose of 7 mg!kg. Other advantages of adding

epinephrine include decreased bleeding and increased dura ­

tion of anesthetic. Traditional teaching dictates that caution

should be used with epinephrine in end-arterial fields (eg,

fingers, toes) for patients with vascular injury or a history of

vascular disease; however, little evidence exists supporting

this practice.

 

and emergency department procedural sedation and analge ­

sia: a consensus-based clinical practice advisory. Ann Emerg

Med. 2007;49:454-46 1.

Miner JR. Procedural sedation and analgesia. 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 1:283-29 1.

Lumbar Puncture

Pilar G uerrero, MD

Key Points

• Knowledge of anatomical landma rks and proper steri le

techn ique are important when performing a lumbar

puncture (LP).

• Absolute contraindications to LP are skin infection over

puncture site and a brain mass causing increased intracranial pressure.

INDICATIONS

Lumbar puncture (LP) is performed in the emergency

department (ED) primarily to diagnose central nervous

system (CNS) infections (ie, meningitis) and subarachnoid

hemorrhage (SAH). It may also be performed to relieve

cerebrospinal fluid (CSF) pressure and to confirm the

diagnosis of idiopathic intracranial hypertension (pseudo ­

tumor cerebri). Other indications include the diagnosis of

demyelinating or inflammatory CNS processes and carcinomatous/metastatic disease.

CONTRAINDICATIONS

Absolute contraindications for performing a LP include

infected skin over the puncture site, increased intracranial

pressure (ICP) from any space-occupying lesion (mass,

abscess), and trauma or mass to lumbar vertebrae. A noncontrast head computed tomography ( CT) scan should be

performed to rule out an intracranial mass before performing an LP in the following clinical situations: altered

mental status, focal neurologic deficits, signs of increased

ICP (papilledema), immunocompromise, age >60 years,

or recent seizure. Relative contraindications include

patients who have bleeding diathesis or coagulopathy

(Table 5-1).

16

• Herniation is the most serious compl ication of a LP,

whereas post-LP headache is most common.

Table S-1. Contraind ications to lumbar pu ncture.

Skin infection near the site of lumbar puncture

Central nervous system lesion causing increased intracranial pressure

or spinal mass

Platelet count <20,000 mm3 is an absolute contraindication; platelet

counts >50,000 mm3 are safe for lumbar puncture*

International normal ized ratio 2:1 .5*

Administration of unfiltered heparin or low-molecular-weight heparin

in past 24 hours*

Hemophil ia, von Willebrand disease, other coagulopathies''

Trauma to lumbar vertebrae

···correct clotting factor and/or platelet levels before lumbar puncture.

Reprinted with permission from Ladde JG. Chapter 1 69. Central Nervous

System Procedures and Devices. In: Tintinalli JE, Stapczynski JS, Cline OM,

Ma OJ, Cydulka RK, Meckler GO, eds. Tintinalli's Emergency Medicine:

A Comprehensive Study Guide. 7th ed. New York: McGraw-Hill, 201 1.

EQUIPMENT

Most EDs have a commercially available LP kit, which contains a 20-gauge spinal needle, 22- and 25-gauge needles

for lidocaine administration, 4 collection tubes, stopcock

LUMBAR PUNCTURE

.A. Figure 5-1. Lumbar puncture kit.

and manometer with extension tubing, sterile drapes, skincleansing sponges, and lidocaine (Figure 5- 1). Smaller

spinal needles may be used ( 22, 25 gauge) and may

decrease the incidence of post-LP headache; however, a

22 or larger gauge needle must be used to determine an

accurate opening pressure. Other required supplies include

additional 1% lidocaine without epinephrine, povidoneiodine (Betadine), and sterile gloves.

PROCEDURE

Lumbar puncture is an invasive procedure. Always perform

a neurologic examination before LP. Explain the proce ­

dure, risks and benefits, and potential complications and

obtain written consent.

Level of i l iac crests

Assemble all equipment and have it within easy reach.

Position the patient in a lateral decubitus position with

hips and knees flexed and the upper back arched. This

will allow better opening of the interlaminar spaces.

Make sure the patient's shoulders, back, and hips are perpendicular to the stretcher. Alternatively, the patient may

be in a sitting position, leaning forward and resting their

arms on a tray stand. The latter may work well for

patients who are obese, have degenerative joint disease, or

have problems breathing. However, an accurate opening

pressures can only be obtained with the patient in the

lateral decubitus position.

Next, identify your landmarks by palpating the top of

the posterior superior iliac crests, moving your fingers

medially, as if drawing an imaginary line toward the spine.

This should be at the L4 interspace level. Palpate the spinous processes and identify the 13-14 and the 14-15

interspace. Either of these spaces can be used for the procedure (Figure 5-2).

Open the sterile tray and pour Betadine into the

empty receptacle in the kit. Put on the sterile gloves .

 

Draw up your lidocaine and place the collection tubes in

sequential order (numbers are written on the tubes,

#1-4). Connect the manometer to the stopcock. Clean the

area with Betadine-soaked handheld sponges in a circular

motion, from the site of planned puncture outward.

Include a spinal level above and below 14. Allow the area

to completely dry. Place the unfenestrated drape on the

patient's bed and the fenestrated drape (with the opening)

over the procedure site. Palpate landmarks again. Using

the 25-gauge needle, raise a skin wheal of lidocaine over

the interspace. Then, use a 20- or 22-gauge needle to

anesthetize the deeper subcutaneous tissue along the

approximate line that the spinal needle will pass. Aspirate

before injecting to make sure you are avoiding intravascular administration.

Identify your landmarks again by palpating the interspinous space with your nondominant hand. With the

.A. Figure 5-2. Decubitus position for lumbar puncture. (Reproduced with permission from Krupp MA, et al. Physician's

Handbook. 21st ed. Lange, 1 985.)

CHAPTER 5

Cauda equina

.A Figure 5-3. Anatomy of the lumbar spinal

interspaces for LP. (Reprinted with permission from

Ladde JG. Chapter 1 69. Central Nervous System

Procedures and Devices. In: Tintina lli JE, Stapczynski JS,

Cline OM, Ma OJ, Cyd ulka RK, Meckler G O, eds.

Tintinolli's Emergency Medicine: A Comprehensive

Study Guide. 7th ed. New York: McGraw-Hi ll, 201 1 .)

needle parallel to the stretcher, slowly insert in the mid ­

line aiming 10 degrees cephalad. T he needle will cross

3 ligaments (supraspinous, interspinous, and the strong

elastic ligamentum flavum) before entering the dura and

subarachnoid space (Figure 5-3). You may feel a "pop" as

you transverse the ligamentum flavum. T he bevel of the

needle should be pointed to the patient's side (left or

right) to prevent it from cutting the longitudinally oriented fibers of the dura. T heoretically, this will r educe the

risk of persistent CSF leak and subsequent post-LP headache. After inserting the needle 4-5 em or after feeling a

"pop;' remove the stylet and look for the efflux of CSF at

the base of your needle. If no fluid returns, replace the

stylet and advance or withdraw the needle and recheck.

You may have to withdraw the needle to the subcutaneous tissue and redirect it more cephalad. T he depth of

insertion before getting into the subarachnoid space

depends on the size of the patient. Never advance or

remove the needle without the stylet in place to avoid it

from becoming obstructed.

When the subarachnoid space is entered and CSF

begins to flow, assess the opening pressure. Attach the

manometer to the needle and direct the lever of the 3 -way

stopcock away from the needle to create a communication between the needle and glass column. At the point

when fluid stops flowing into the manometer, the pressure is recorded. Normal opening pressure is between

7-18 cmHp. Deposit the CSF from the manometer into

tube #1 and disconnect the manometer. In adults, proceed to collect 1 -2 mL of CSF per tube. More tubes may

be needed for additional tests or special situations

(VDRL, viral titer, Cryptococcus antigen, etc). When the

fluid has been collected in all 4 tubes, the needle is

removed with the stylet in place. T his too has been shown

to reduce the incidence of post-LP headache. T he theoretical explanation for this effect is that the stylet pushes

back any pia mater that may be sticking out from the hole

made in the dura. Any tissue in the dura puncture can act

to keep the hole from closing and result in a persistent

CSF leak.

Tubes #1 and 4 should be sent for cell counts with differential. Tube #2 is sent for protein and glucose. Tube #3

should be sent for culture and Gram stain. Patients with an

obese body habitus or with degenerative joints may present

a challenge when performing an LP. Fluoroscopy (per ­

formed by a radiologist) or the use of ultrasound may aid

in identifying the anatomical landmarks, making it possible to perform the procedure.

COMPLICATIONS

A "traumatic" LP (from injury to the dura or arachnoid

vessels) is a common occurrence, with more than 50o/o of

all LP procedures having from 1 to 50 red blood cells

(RBCs) in the CSF. T he incidence of traumatic LP may be

minimized by proper patient and needle positioning. T he

best method to differentiate a traumatic LP from an SAH

is noting that the number of RBCs significantly decrease

from tube #1 to tube #4 in a traumatic LP. Tube #4 should

have close to zero RBCs. T he presence of xanthochromia

indicates a SAH.

Spinal hematomas (epidural, subdural, and subarach ­

noid) are rare complications of LP, which are more likely to

occur in patients with coagulation disorders. Correcting

coagulation disorders (eg, Factor for a hemophiliac) is

required before LP is performed.

Herniation can occur when CSF is removed from a

patient with increased ICP from a mass, emphasizing the

importance of performing a head CT if a mass lesion is

suspected.

Post-LP headaches are the most common complication of LP and are thought to be from continued CSF

leakage through the dura at the puncture site. A post-LP

headache is observed in 20-?0o/o of patients and is more

common in young adults. Post-LP headaches are usually

fronto-occipital and may have associated nausea, vomiting, and tinnitus. In most cases, the headache begins

within 24-48 hours of the LP and is usually postural

(worse in the upright position or with valsalva maneuvers). Post-LP headaches usually last 1-2 days, but occasionally can persist up to 14 days. Treatment consists of

 

IV fluids, caffeine (IV or oral), antiemetics, analgesics,

barbiturates, diphenhydramine, and ergots. Headaches

lasting >24 hours may be alleviated by an epidural blood

patch performed by an anesthesiologist. If the headache

does not have a postural component, lasts more than 1

week, or recurs after initially resolving, consider the

LUMBAR PUNCTURE

possibility of a subdural hematoma. Subdural hemato ­

mas are due to tearing of bridging veins from decreased

CSF volume.

Patients may also complain of mild backache after an

LP. This is common from trauma of the spinal needle and

is usually self-limited, resolving in a few days. Other potential complications include iatrogenic infection caused by

improper sterile technique, a contaminated field, or contaminated needle. Infectious complications include cellulitis, skin abscess, epidural or spinal abscess, discitis, or

osteomyelitis.

SUGGESTED READING

Fong B, VanBendegom J. Lumbar puncture. In: Reichman EF,

Simon RR. Emergency Medicine Procedures. 1st ed. New York,

NY: McGraw-Hill, 2004.

Ladde JG. Central nervous system procedures and devices. 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, 2011:1178-1180.

Miles S. Ellenby, et al. Lumbar puncture. N Engl J Med. 2006;335:12.

Wright BL, Lai JT, Sinclair AJ. Cerebrospinal fluid and lumbar

puncture: a practical review. ] Neural. 2012;259:1 530-1545.

Laceration Repair

Jeffrey N. Siegelman, MD

Key Points

• The timing of wound closure is determined by balancing

the risk of infection with the likelihood of scarring.

• Identify and remove foreign bodies before wound closure.

INDICATIONS

Any wound deeper than a superficial abrasion should be

considered for closure to improve the cosmetic result, preserve viable tissue, and restore tensile strength. This can be

accomplished with sutures, tissue adhesive, or staples.

Tissue adhesive may be indicated for hemostatic wounds in

low tension areas that are at low risk for infection. Staples

are appropriate for relatively linear lacerations located on

the extremities, trunk, or scalp.

CONTRAINDICATIONS

The decision about whether and when to repair a laceration is based on many factors, which can be divided

broadly into host and wound factors. Host factors include

age (elderly patients have 3-4 times higher rate of infection

and slower wound healing), malnutrition, and immunocomprornise ( eg, diabetes mellitus). Wound factors include

timing, location, mechanism, and contamination. Bacterial

counts begin to increase 3-6 hours post-injury, and every

attempt is made to achieve primary wound closure as

expeditiously as possible. However, there is no evidencedbased definitive time by which wounds must be closed.

Wounds of the face and scalp rarely become infected

( 1-2%) because the face and scalp have an excellent blood

supply; such wounds may be closed safely 24 hours or

more after injury. Infection rates of upper ( 4o/o) and lower

(7%) extremity wounds are higher, and many practitioners

20

 

resuscitation cart, and reversal drugs should be readily

available. Personnel should be skilled in airway management and patient monitoring and recovery.

PROCEDURE

Appropriate preprocedure history includes allergies to or

adverse effects from anesthetic agents, medical conditions,

and time of last oral intake. Physical exam should include

a thorough airway assessment to predict difficulty with

bag-valve-mask ventilation or endotracheal intubation.

Consider the presence of dentures, neck mobility, obesity,

and Mallampati scale (Figure 4-1). Sedation in the emer ­

gency department should generally be limited to ASA class

I and II patients. A fasting period of 3 hours is recommended; however, studies have shown that a shorter period

does not increase the incidence of aspiration. The urgency

of the procedure often dictates acceptable preprocedure

fasting period. Obtain informed consent and document

the conversation in the record. Many institutions have a

standardized procedural sedation record for recording

consent as well as pertinent history and physical.

Appropriate personnel to perform the procedure,

administer medications, and monitor the patient should

assemble at the bedside. The medications are administered

and titrated to effect. Medication selection is guided by the

type of procedure being performed (Table 4-2). Using a

combination of a sedative/analgesic (eg, midazolam/

fentanyl) generally gives consistent clinical results. Other

commonly used regimens include ketamine alone or with

atropine (0.0 1 mg/kg IV or IM) for pediatric cases,

propofol plus an analgesic (fentanyl), or midazolam plus an

analgesic.

The physician should perform the procedure as a nurse

or other physician monitors the patient. After completion

of the procedure, the patient should be monitored until

mental status returns to baseline. Discharge criteria

include stable vital signs, return to baseline mental status,

Class I Class II

Class Ill Class IV

Figure 4-1. Mallampati classification. (Reprinted with

permission from Vissers RJ. Chapter 30. Tracheal

Intubation and Mechanical Ventilation. In: Tintinalli JE,

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