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

IndicationsFailure of oral or nasal endotracheal intubationAirway obstructionTraumatic injuries making oral or nasal

endotracheal intubation difficult or potentially hazardous

Contraindicationsinfants 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

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 tissuesSubglottic stenosis/edemaLaryngeal stenosisHemorrhage or hematoma formationLaceration of the esophagusLaceration of the tracheaMediastinal emphysemaVocal cord paralysis, hoarseness

NEEDLE CRICOTHYROIDOTOMY

Indicationspreferred method of securing the airway in crash

airway situations in infants and young children

ContraindicationsTransection of the distal tracheaComplete 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 Puncture the skin in the midline directly over

the cricothyroid membrane

Step

Step

45º angle caudally with negative pressure

aspiration of air entry into the tracheal lumen

advancing the catheter Continue to observe

lung inflation and auscultate the chest for adequate ventilation.

Step

Complications

Inadequate ventilationAspiration (blood)Esophageal lacerationHematomaPerforation of the posterior tracheal wallSubcutaneous and/or mediastinal emphysemaThyroid perforationPneumothorax

INTRAOSSEOUS PUNCTURE/INFUSION: PROXIMAL TIBIAL ROUTE

Indicationspatients in whom attempts at peripheral or

central venous access has been unsuccessful

Contraindicationsosteoporosis and osteogenesis imperfecta fractured bone recent prior use of the same bone for IO infusioncellulitis, 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 one fingerbreadth (1-3 cm) below the tubercle

Sterile technique and local anesthesia

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

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

Complications

InfectionThrough-and-through penetration of the boneSubcutaneous or subperiosteal infiltrationPressure necrosis of the skinPhyseal plate injuryHematoma

NEEDLE THORACENTESIS

IndicationsTension pneumothorax

Contraindicationsno absolute contraindications 

Step

Identify the second intercostal space, in the midclavicular line on the side of the tension pneumothorax.

Sterile technique and local anesthesia 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.

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.

Step

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 hematomaPneumothoraxLung laceration

CHEST TUBE INSERTION

Indications

PneumothoraxHemothoraxEmpyema

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 (fifth intercostal space), just anterior to the midaxillary line on the affected side.

Sterile technique and local anesthesia

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

Finger exploration

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 infectionDamage to the intercostal nerve, artery, or veinIncorrect tube position, extrathoracic or

intrathoracicChest tube kinking, clogging, or dislodging from

the chest wall, or disconnection from the underwater-seal apparatus

Complications

Persistent pneumothoraxSubcutaneous emphysemaRecurrence of pneumothoraxLung fails to expandAnaphylactic or allergic reaction to surgical

preparation or anesthetic

FOCUSED ASSESSMENT SONOGRAPHY IN TRAUMA (FAST)

IndicationsBlunt abdominal traumaStable penetrating traumaAssessment of the degree of intraperitoneal free

fluid

Contraindicationsno 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

RUQ view

LUQ view

LUQ view

Suprapubic view

Suprapubic view

Reference

ATLS 9th Student ManualClinical procedures in emergency medicine

ANY QUESTIONS?