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Emergency Medicine - Common Procedures - Fast Facts | NEJM Resident 360

In this section, we review the following procedures. At the end you’ll find a list of links to videos of these and other common procedures performed in the emergency department:

• Intubation

• Premedication, Sedation, and Paralysis for Intubation

• Suturing

• Procedural Sedation

• Focused Assessment with Sonography for Trauma (FAST)

Ventilation is discussed in the Critical Care rotation guide.

Intubation

The decision to intubate a patient is based on clinical judgment; intubate in any situation where definitive control of the airway is indicated. Intubation is generally achieved through use of rapid sequence induction (RSI).

View a video of orotracheal intubation.

See Anesthesia Key for a thorough description of and images depicting tracheal intubation procedures.

Indications

• altered mental status and inability to protect the airway/aspiration risk, for example:

  • Glasgow Coma Scale (GCS) <8

  • pooled oral secretions

• severe hypoxia unlikely amenable to, or failed, noninvasive pressure-assisted ventilation, for example:

  • severe pulmonary edema/congestive heart failure (CHF) from any cause

  • pulmonary embolism

  • respiratory failure

• facilitate delivery of high-complexity critical care, for example:

  • status epilepticus

  • complex trauma patient

Contraindications

• other airway/respiratory interventions initially indicated, for example:

  • noninvasive ventilatory support, such as bilevel or continuous positive airway pressure (BiPAP or CPAP)

  • nasal trumpet may resolve tongue prolapse without other intervention in toxicologic situation

• severe anatomic distortion suggesting surgical airway should be attempted first (rare)

Equipment

• protective: gloves and protective face shield

• for preoxygenation: a bag-valve mask attached to an oxygen source

• preventative: a suction system actively suctioning, gum-elastic bougie, laryngeal mask airway, fiberoptic intubating bronchoscope, and a surgical technique near bedside

• at time of intubation: an endotracheal tube with stylet and video or standard laryngoscope; endotracheal tube and laryngoscopes should be sized appropriately for the patient

• after intubation: a 10-mL syringe, an endotracheal-tube holder or cloth tape, an end-tidal carbon dioxide detector, and a stethoscope

Preparation

• All equipment is readily accessible and functioning, and personnel are properly prepared.

• The patient has intravenous (IV) access and is on a monitor.

• Written informed consent has been obtained from the patient or the patient’s health care proxy if the clinical situation permits.

  • You can justify no consent if situation is emergent and there is no proxy or clear advanced directive.

• Position the patient.

  • Adjust the height of the bed so that the patient’s head is level with the lower portion of your sternum.

  • Move the patient into the “sniffing” position by placing a pillow or folded towel under the patient’s occiput.

  • Remove the patient’s dentures, if present.

  • If the patient’s mental status is diminished or if the patient is pharmacologically sedated, an assistant should apply firm pressure to the cricoid cartilage (the Sellick maneuver).

• Pre-ventilate the patient with a bag-valve mask to an adequate saturation. Assist ventilation ONLY if needed.

• Pediatric considerations:

  • Children’s anatomy requires additional positioning and thorax alignment with head by placing a rolled towel under the shoulders.

  • Tube size: General rule of thumb is 4 for patients age ≥16, or follow pediatric measuring tape (Broselow Pediatric Equipment).

• Apply strict in-line stabilization of the cervical spine if unstable injury is suspected. The anterior portion of the cervical collar is opened or removed to permit the patient’s mouth to be fully opened.

• If intubation by mouth is inappropriate, nasotracheal intubation may be attempted before a surgical airway.

Premedication, Sedation, and Paralysis for Intubation

These procedures are used if the patient is still having inefficient breath efforts, gag reflex, and withdrawal-from-pain movements that hinder or impede adequate intubation efforts. These agents will improve visualization of the vocal cords and prevent the patient from vomiting and aspirating gastric contents.

Pretreatment

Evidence is inconclusive on the benefit of using the following agents:

• lidocaine (1.5 mg/kg IV): may suppress the cough or gag reflex; blunts increases in mean arterial pressure, heart rate (HR), and intracranial pressure

• atropine (0.02 mg/kg IV): may decrease the incidence of bradycardia associated with direct laryngoscopy; use is considered generally only in young children

Induction

Induction provides a rapid loss of consciousness and should be administered before paralyzing a conscious patient.

• etomidate (Amidate; 0.3 mg/kg IV): rapid onset, short duration, cerebroprotective (reduces intracranial pressure and cerebral oxygen consumption while maintaining cerebral perfusion pressure), and less associated with significant drop in blood pressure (BP); may cause adrenal suppression

• • consider in head trauma; dose can be adjusted for hypotension

• ketamine (Ketalar; 1–2 mg/kg IV): results in a “dissociative” state, has analgesic properties and is a bronchodilator; may increase intracranial pressure

  • consider in asthma and hypotension

• propofol (Diprivan; 2 mg/kg IV): rapid onset, short duration, cerebroprotective; decreases systemic vascular resistance and blood pressure

  • consider for high blood pressure and seizures 

Paralysis

Paralysis for intubation provides neuromuscular blockade administered immediately after the induction agent. It does not provide sedation, analgesia, or amnesia.

• depolarizing neuromuscular blocker

• • succinylcholine (Anectine; 2 mg/kg IV): rapid onset and shortest duration of action (~10 mins); use with caution in patients with known or suspected hyperkalemia or neuromuscular disease

• nondepolarizing neuromuscular blocker

• • rocuronium (Zemuron; 1–1.2 mg/kg IV): slightly longer onset of action and longer duration of action (~30 mins); use with caution in patients at high risk of difficult intubation; does not result in muscle depolarization or fasciculation

Suturing

See the Color Atlas of Cutaneous Excisions and Repairs (Chapter 1) for instructions and illustrations of various suturing techniques.

General Suturing Guidelines

1. Wear protective equipment. Suturing is not a sterile procedure; however, you should strive for a clean environment.

2. Achieve homeostasis and then grossly inspect the wound.

• Never blind clamp.

• Assess and document neurovascular and mechanical compromise in the form of pulse, capillary refill, sensation, and intact range of movement.

  • Whenever suspicion exists that a wound has injured a tendon, nerve, joint, or other important anatomic structure, or has been caused by a foreign body, the wound should be explored before repair.

    • Contact the appropriate specialists.

• Wounds older than 6 hours (hands and feet) and 24 hours (on the face) or caused by animal/human bites usually should not be closed becasue of the high risk for infection. However, some clinicians choose to close animal bite wounds, particularly if the bite is on the face.

1. Numb the local area or perform a nerve block. Choose between lidocaine strength (higher concentration reduces injected volume) and addition of epinephrine for the wound area.

• Epinephrine is generally not recommended for distal areas where perfusion is of essence (fingers, ears, or nose).

1. Pressure irrigate copiously with clean water.

• Sterile water is best, but it is still acceptable to use normal saline or potable tap water if sterile water is not available.

• The volume of irrigation depends on the size and contamination of the wound. If grossly contaminated, irrigate until the wound is free from visible contamination (50–100 mL per cm wound length is a reasonable quantity).

• There are multiple commercial irrigation tools proven to provide the adequate pressure; optimal pressure also depends on the degree of contamination. High pressures reduce bacterial count at the expense of tissue injury. Irrigation from manually squeezed containers is now discouraged, given that the pressures achieved are too low.

• Use of a shield is recommended to limit clinician exposure to bodily fluids.

1. Select the type of wound closure and technique that best suits the area. (For an overview of wound closure materials see Cutaneous Wound Closure Materials: An Overview and Update.)

2. Provide the patient with good care instructions and return precautions.

• Advise good hygienic practice: Clean the wound at least two times per day.

• Counsel about cosmetic results: Exposure of the wound to the sun leads to increased scarring.

• Schedule suture removal: face, 3 to 4 days; scalp, 5 days; trunk, 7 days; arm or leg, 7 to 10 days; and foot, 10 to 14 days.

• No good evidence indicates that systemic antibiotics provide protection against development of wound infection for uncomplicated wounds and lacerations.

  • Consider prophylactic antibiotics for animal bites, especially to the hand, and for immunocompromised patients.

• The following are situations in which the immediate administration of intravenous antibiotics should be considered:

• • complex or mutilating wounds, especially of the hand or foot

  • grossly contaminated wounds with penetrating debris and foreign bodies

  • lacerations in areas of lymphatic obstruction and lymphedema

  • suspected penetration of bone (open fractures), joints, or tendons

  • animal bite wounds (only when there is exposed bone, an open fracture, or extensive injuries in a patient requiring hospital admission)

  • amputation injuries, especially where replantation is a consideration

  • significant lacerations in patients with preexisting valvular heart disease

  • presence of disease or drugs causing immunosuppression or altered host defenses

• The initial intravenous antibiotic of choice is usually a first-generation cephalosporin, such as cefazolin. For penicillin-allergic patients, ciprofloxacin and clindamycin are reasonable alternatives. For bites, consider ampicillin/sulbactam, ceftriaxone plus metronidazole, or trimethoprim-sulfamethoxazole (TMP-SMX) plus clindamycin.

• Consider rabies exposure and follow CDC guidelines.

• Ask about tetanus status: Tetanus should be administered if less than 48 hours from infliction of the wound (see CDC guidelines).

Procedural Sedation

As defined by the American College of Emergency Physicians (ACEP), “procedural sedation is a technique of administering sedatives or dissociative agents with or without analgesics to induce a state that allows the patient to tolerate unpleasant procedures.” The American Society of Anesthesiologists (ASA) developed Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists. Deep sedation is reserved for anesthesiologists. The guideline does not apply to patients receiving inhaled anesthetics, analgesia for pain control without sedation, sedation to manage behavioral emergencies, or patients who are intubated.

1. Educate and obtain patient consent before sedation.

2. Place the patient on the monitor and have intubation cart near and ready. Some institutions require immediate availability of respiratory therapy. 

3. Frequently reevaluate level of sedation and modify dosing accordingly.

4. Do not leave the room until patient is conscious and has purposeful movement.

Drugs for Procedural Sedation

Medication (Dose)	Action	Comments
Propofol
(0.5-1.0 mg/kg)	Onset 30 sec; Duration 10-15 min

• Lowers BP and HR

• Do not use with patients allergic to milk/egg/soy

• Good for short procedures

| | Midazolam
(0.02-0.05 mg/kg) | Onset 1-3 min; Peak 5-7 min; Duration 20-30 min |

• Causes respiratory depression

• Good for short procedures

| | Fentanyl
(1-2 mcg/kg) | Onset 1-2 min; Peak 10-15 min; Duration 30-60 min |

• Causes low BP and respiratory depression

• Do not redo quickly

| | Ketamine (1 mg/kg) | Onset 1-2 min; Duration 15-30 min |

• Good for pediatrics

• Increased incidence of emergence reaction (hallucinations and vivid dreams) in adults

• Could cause laryngospasm

• Increases HR and BP

• For longer procedures

| | Ketamine/Propofol combination
(0.5 mg/kg 1:1; start with ketamine and titrate propofol) | Onset 1-2 min; Duration 15-30 min |

• Good for pediatric patients

• Increased incidence of emergence reaction in adults

• Could cause laryngospasm

• Increases HR and BP

• Good for longer procedures

| | Etomidate
(0.1-0.15 mg/kg) | Peak 1 min; Duration 5-15 min |

• Causes myoclonus, emesis

• Does not change BP

|

Focused Assessment with Sonography for Trauma (FAST)

The objective of the FAST exam is to detect free fluid that might indicate internal bleeding in the trauma setting. A phased-array or curvilinear probe is most commonly used. Visual demonstrations of the FAST exam can be seen here (skip to the second video) and here. 

The FAST exam typically involves four views:

1. hepatorenal recess or Morison pouch (right upper quadrant)

• ultrasound reliably detects as little as 250 mL of free fluid in Morison pouch

1. splenorenal or perisplenic view (left upper quadrant)

2. pelvic view

3. pericardial or subxiphoid view

Videos of Related Procedures

Peripheral Intravenous Cannulation
Central Venous Catheterization
Orotracheal Intubation
Chest-Tube Insertion
Cricothyroidotomy
Needle Aspiration of Primary Spontaneous Pneumothorax
Noninvasive Positive-Pressure Ventilation
Lumbar Puncture
Procedural Sedation and Analgesia in Children
Conscious Sedation for Minor Procedures in Adults
Point-of-Care Ultrasonography
FAST Examination (video 2)
Technique for Temporary Pelvic Stabilization after Trauma
Pelvic Examination
Clinical Examination of the Shoulder
Clinical Evaluation of the Knee
Basic Splinting Techniques
Reduction of Paraphimosis in Boys
Basic Laceration Repair
Examination of the Hand and Wrist

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