Procedures

Tracheostomy

Anatomy/physiology: For all patients, the wall of the thorax is composed of the muscles of the anterior and posterior chest wall, the ribs, and three sets of intercostal muscles—the external intercostal muscles, the internal intercostal muscles, and the innermost intercostal muscles. The external intercostal muscle exists as a membrane anterior to the midclavicular line, and the internal intercostal muscle is a membrane posterior to the midaxillary line. The neurovascular bundles containing the veins, arteries, and nerves lie along the lower margins of the ribs. The ribs themselves are very pliable in infants and young children, but in older children and adolescents the ribs are more like those of adults. Deep to the ribs is the parietal pleura, which is adherent to the interior of the thoracic wall, and deep to the parietal pleura is the mediastinum, which contains the heart surrounded by the pericardium and the origins of the great vessels. Viewed from the standpoint of a thoracotomy, the right ventricle lies anterior, just beneath the sternum, with the left ventricle posterior and slightly lateral to the right ventricle. The left phrenic nerve lies on the pericardium on the lateral aspect of the left ventricle, placing it at risk during the procedure. Between the superficial tissues and the left ventricle is the left lung, which is invaginated by the ventricle. When the standard left lateral thoracotomy is used, the anterior and lateral walls of the left ventricle are visible once the left lung is retracted. Situated in a position cephalad to the heart itself lie the great vessels; lateral and slightly posterior to these are the structures of the pulmonary hili. One distinct, if obvious, difference between adults and children is the size of the structures involved. This procedure can be much more difficult in a small child simply because everything is smaller. The physiologic considerations involved in pediatric thoracotomy are likewise similar to those in the adult procedure. Direct trauma to the heart often allows blood to accumulate between the heart and the pericardial sac, particularly if the hole in the pericardium is small, because the pericardial defect will often partially or fully seal itself. Even a small amount of blood in the space between the heart and the pericardium can restrict cardiac function. In a small child, this can be a few milliliters. Fortunately, removal of even a portion of this fluid often results in dramatic improvement in cardiac output. Conversely, if the hole is large or fails to seal, then the blood exits the heart into the mediastinum or the thorax. The child can exsanguinate rapidly in this circumstance. It is for relief of pericardial tamponade and correction of a direct penetrating injury to the heart that thoracotomy is most likely to be successful, but it also may be used in cases of direct injury to the great vessels, to highly vascular abdominal structures, or to the pulmonary hilar structures. In the aforementioned situations, thoracotomy is done to halt exsanguinating hemorrhage into the thoracic or abdominal cavities. In cases of intra-abdominal hemorrhage, thoracotomy allows the interruption of blood flow to the abdomen (by clamping the aorta) and selective perfusion of the brain and the cardiopulmonary system. Experimentally, direct (open) cardiac compressions result in better cardiac output than do indirect (closed) cardiac compressions, maintaining homodynamic variables almost in a normal physiologic range . Indications: any victim of trauma who arrived in full cardiopulmonary arrest, who arrested in the resuscitation area, or who failed to respond to maximal resuscitation efforts was considered a candidate for this procedure. 1. Victims of either penetrating or blunt trauma who have no pulse, no detectable blood pressure, and no organized electrical activity on a cardiac monitor will benefit from thoracotomy only if the procedure is performed promptly. If thoracotomy cannot be undertaken within 5 minutes of the time of arrest, or if the victim of penetrating trauma is in asystole with injuries not isolated to the thorax, then thoracotomy is unlikely to be successful and should not be performed. 2. Victims of penetrating trauma, particularly those with penetrating trauma to the chest and upper abdomen, who have short arrest times or arrest en route to the ED and those who fail to respond to initial resuscitation should be considered candidates for this procedure . 3. Rarely, a victim of nontraumatic arrest may be considered a candidate for thoracotomy. Medical personnel should consider this technique in cases of severe chest wall abnormality and other situations that make traditional closed chest compressions impossible or ineffective 4. thoracotomy is most successful when used to relieve pericardial tamponade 5. purposes for this procedure include control of exsanguinating hemorrhage within the thoracic or abdominal cavity, redistribution of limited blood volume to the myocardium and brain, correction of an air embolism, and performance of open cardiac massage. Complications: Exigent thoracotomy has many potential complications, and careful attention should be given to correct technical performance. However, most of these complications are far less worrisome than the injury that led to the necessity for an open thoracotomy. The neurovascular bundles of the ribs lie along the lower rib margins. When opening the chest wall, the intercostal tissues should be cut near the upper border of the rib to avoid injury to these structures. Intercostal arteries, if damaged, are a potential source of significant bleeding. The Finochietto retractor should be inserted so that the bar and ratchet handle are at the base of the incision, with the bar extending into the patient's axilla. This allows the incision to be extended into the right chest if necessary. Placement of this device in the more traditional thoracotomy position, with the bar at the top (anterior portion) of the incision, prevents extension because the bar blocks any attempt to cut through the sternum Pitfalls: The most important pitfalls likely to be encountered in the performance of open thoracotomy are damage to breast tissue with the initial incision, injury to the intercostal vessels or nerves when opening the chest wall, failure to properly insert the Finochietto chest wall retractor, failure to recognize and relieve pericardial tamponade, and inadvertent ligation of the phrenic nerve or a coronary artery. As previously discussed, care should be taken to avoid injury to the breast tissue in female patients. In young children, the incision should be made so as to avoid cutting the breast bud, and in adolescents the breast should be retracted superiorly out of the line of the incision. Procedure: 1. Rapidly apply sterile povidone-iodine solution to chest wall. Make incision at fourth or fifth costal interspace from sternum along rib margin to posterior axillary line, cutting through skin and muscles of chest wall. Cut through intercostal muscles with heavy scissors along upper rib margin. 2. Insert Finichetto chest wall retractor with bar extending into axilla and use ratchet handle to open ribs. 3. Using suction, remove any blood obstructing a clear view of heart. Remember that blood can be saved for autotransfusion. 4. Open pericardium anterior to phrenic nerve. Remove any blood or clots and explore myocardium for injuries. Remember to keep heart as warm as possible through use of warm saline and/or heat lamps. 5. Apply direct pressure to any sites of hemorrhage from heart; pressure should be maintained until injury can be definitively repaired. 6. Repair any myocardial injuries, if possible. Be careful to avoid damage to coronary arteries or phrenic nerve. Atrial lacerations may be repaired with a simple running stitch, and ventricular lacerations with interrupted stitches reinforced with Teflon pledgets. 7. If no myocardial injury is found, retract left lung out of chest anteriorly and superiorly. Identify aorta, separate it from esophagus and prevertebral fascia, and occlude it using fingers, a vascular clamp, vascular tape, or an aortic tamponade device. 8. Extend incision into right chest by making a right-sided thoracotomy incision identical to left-sided one and then cutting sternum with a sternal saw or a Lebsche knife. Ligate internal mammary arteries, if possible. Explore thoracic cavity for other sources of bleeding and apply pressure to any bleeding site identified. Vessels that can be exposed may be cross-clamped. If heart is beating spontaneously, continue resuscitation with fluids and blood. If not, begin open cardiac massage and then defibrillate using internal paddles.

Needle cricothyrotomy Percutaneous Transtracheal Ventilation

Anatomy: The cricothyroid membrane is bound superiorly by the thyroid cartilage and inferiorly by the cricoid cartilage. The cricothyroid arteries typically course through the apical portion of the membrane, although aberrant vessels may rarely complicate procedures in this area. For young infants, performing PTV can be difficult due to the small size of the cricothyroid membrane. However, this is also true of other invasive airway techniques, and PTV can often be performed more rapidly and with fewer complications. Furthermore, if the cricothyroid membrane of a younger patient cannot be located, the procedure can be performed by introducing the needle through the tracheal cartilage without additional risk to the patient. The larynx, which consists of the thyroid cartilage, the cricothyroid membrane, and the cricoid cartilage, lies in the anterior neck, deep to the skin, subcutaneous tissues, and sternohyoid muscle. The thyroid cartilage is cephalad to the cricothyroid membrane, and the cricoid cartilage is caudad to it. The fibroelastic cricothyroid membrane can be palpated as an indentation between the two more prominent cartilage structures the cricothyroid membrane is approximately 20 to 30 mm in width and 9 to 10 mm in superior-to-inferior length Five specific landmarks should be identified: 1. the hyoid bone, 2. the laryngeal prominence of the thyroid cartilage, 3. the cricothyroid membrane, 4. the cricoid cartilage, 5. the remaining tracheal rings. The laryngeal prominence develops during adolescence and is easily palpable in most adults, whereas the most readily identifiable landmarks *With infants and younger children, the laryngeal prominence is not developed. The rings of the tracheal cartilage are followed superiorly to locate the prominence of the cricoid cartilage. The cricothyroid membrane is just superior to the cricoid cartilage Indications: The majority of children who require airway control or assisted ventilation can be managed with standard means such as bag-valve-mask (BVM) ventilation or tracheal intubation. Indications for the emergent use of PTV are similar to those for surgical cricothyrotomy; that is, any patient whose airway cannot be maintained with standard interventions or a "nonsurgical rescue" procedure (such as insertion of a laryngeal mask airway) should be considered a possible candidate Contraindication: PTV should not be performed when there is known damage to the cricoid cartilage or in the setting of tracheal rupture this is the only absolute contraindications for this procedure. Relative contraindications, such as mild to moderate local swelling of the anterior neck or the presence of a hematoma, should be balanced against the potentially devastating complications of failing to provide adequate airway intervention. Procedure: The operator can most easily locate the cricothyroid membrane in older adolescents and adults by running a finger in a caudal direction from the laryngeal prominence until a small bump is felt, which is the cricoid cartilage. The cricothyroid membrane is appreciated as a subtle depression with slightly more "give" or "bounce" just superior to the cricoid cartilage. However, because the laryngeal prominence does not develop fully until adolescence, this method may not be useful for infants and children. For these patients, the operator's most reliable method for locating the membrane is to run a finger in a cephalad direction along the tracheal rings until a more prominent bulge is felt, representing the cricoid cartilage. Even if the cricothyroid membrane is not palpable, its location can be assumed as just cephalad to the superior margin of the cricoid cartilage. 1. Attach a 3- to 5-mL syringe with a few milliliters of saline or lidocaine to the needle and catheter. 2, Locate the cricothyroid membrane, bound by the thyroid cartilage superiorly and the cricoid cartilage inferiorly. 3. Hold the trachea in place and provide skin tension with the thumb and middle finger of the nondominant hand. 4. Place the tip of needle at the inferior midline of membrane, directing the needle caudlly at a** 30- to 45-degree angle. 5. Advance the needle while pulling back on the plunger of the syringe. The appearance of air bubbles within the syringe confirms intratracheal placement. 6. Slide the catheter over the needle until the hub rests securely on the skin surface. 7. Remove the needle and the syringe as a unit. 8. Connect high-pressure tubing and an oxygen source to the catheter. 9. Confirm correct placement with a few short bursts of oxygen. 10. Ventilate at the appropriate rate by opening and closing the permanent valve or occluding the side port, stopcock, or Y-connector. 11. Assess patient response. 12. Suture the catheter securely in place. Complications: he most common complication associated with PTV is subcutaneous emphysema minor bleeding from arterial perforation, pneumatocele formation, prevertebral cellulitis and cervical osteomyelitis, and fire in conjunction with electrocautery use

Ulnar nerve block

At the level of the elbow, the ulnar nerve lies in the groove *between the medial epicondyle and the olecranon . As it approaches the middle of the forearm, the ulnar nerve lies between the flexor digitorum profundus and the flexor carpi ulnaris. In the distal forearm, it divides about 0.5 cm proximal to the wrist, giving off two cutaneous branches—the palmar cutaneous branch, which provides some sensation to the ulnar side of the wrist and hand, and the dorsal cutaneous branch, supplying the ulnar side of the hand and the ulnar half of the fourth finger and the dorsum of the fifth finger. *At the wrist, the ulnar nerve passes between the tendon of the flexor carpi ulnaris and ulnar artery, deep to the artery. Its superficial terminal branch supplies the skin of the anterior fifth finger and ulnar half of the fourth finger. If local anesthesia is needed throughout the entire ulnar distribution, it is preferable to block at the elbow (before the nerve subdivides) instead of at the wrist Procedure: 1. The tendon of the flexor carpi ulnaris is located by having the patient flex the wrist against mild resistance. 2. The skin of the lateral wrist is prepared with povidone-iodine or alcohol. 3. The palmar cutaneous branch of the ulnar nerve is anesthetized by raising a skin wheal at the level of the proximal wrist crease (ulnar styloid), between the tendon of the flexor carpi ulnaris and the ulnar artery. 4. A 25- to 27-gauge needle is advanced through the wheal to a depth of approximately 0.5 cm (just deep to the tendon). 5. Paresthesia indicates proximity of the needle tip to the nerve. 6. After slight withdrawal to avoid intraneuronal injection and aspiration to ensure that the needle is not intravascular, 1 to 3 mL of solution is injected. 7. If paresthesia is not felt, a larger volume (3 to 5 mL) of anesthetic solution should be administered. 8, Alternatively, repeated fanned insertions can be done until ulnar paresthesia is elicited. 9. If the dorsal cutaneous branch of the ulnar nerve is not adequately anesthetized, additional cutaneous infiltration should be instilled over the dorsal and ulnar aspect of the wrist, at the level of the ulnar styloid . Optimal anesthesia is usually achieved within 10 to 15 minutes. AT THE Elbow: 1. With the elbow flexed, the ulnar nerve is palpable in the groove between the medial epicondyle of the humerus and the olecranon. 2. A 25-gauge needle is inserted approximately 1 to 2 cm proximal and parallel to the course of the ulnar nerve in the groove . 3. Blocking the nerve within the groove is more likely to cause nerve injury, so the needle tip is advanced to the proximal end of the groove. Paresthesias indicate proximity to the nerve but are not necessary to elicit. 4. If paresthesias are noted, the needle is withdrawn approximately 2 mm to avoid injection into the nerve sheath. 5. An injection of 3 to 5 mL of 1% lidocaine on each side of the groove will block this rather large nerve. Anesthesia is usually achieved in 15 minutes.

Median nerve block

At the wrist, the median nerve enters the palm through the carpal tunnel and lies deep to the palmaris longus tendon, *between the tendons of the *flexor digitorum superficialis and *flexor carpi radialis. At the proximal end of the tunnel, the location of the nerve is easily identified between the *palmaris longus and *flexor carpi radialis tendons where the nerve is bridged by the retinaculum INJURY: ##Loss of pronation of forearm, weakness in flexion of the hand at the wrist, loss of flexion of radial half of digits and thumb, loss of abduction and opposition of thumb. Sensory deficit: Loss of sensation in lateral 3 1⁄2 digits including their nail beds, and the thenar area. Procedure: 1. Apposition of the thumb and fifth finger with flexion of the wrist against some resistance will easily identify the tendon of the palmaris longus, which protrudes along the volar aspect of the wrist. 2.The overlying skin is prepared with povidone-iodine or alcohol. 3. A 25- or 27-gauge, 0.5-inch needle is inserted perpendicularly, just radial to the palmaris longus tendon at the level of the proximal flexor wrist crease . 4. A "pop" may be felt as the retinaculum is pierced. Paresthesias occur when the needle mechanically stimulates nerve fibers. If a paresthesia is elicited, the needle tip is certain to be in close proximity to the nerve. 5. The needle is withdrawn slightly to avoid intraneuronal injection, and 2 to 3 mL of anesthetic is injected. 6. If a paresthesia is not elicited, a larger volume of anesthetic (about 3 to 5 mL) is injected to increase the likelihood that the nerve will blocked by diffusion of the medication. Optimal anesthetic effect is usually achieved after 10 to 20 minutes.

fish hook removal

Push Through: he push-through method of removal requires a digital block or local infiltration of the skin overlying the point of the hook with 1% lidocaine . The point of the hook is then advanced and pushed through the skin , the barb clipped off with a wire cutter , and the remainder of the shank and belly backed out of the entry wound . On occasion, particularly with a multiple-barbed hook, it might be easier to cut the eye of the hook and then advance the belly and shank forward through the exit wound The exit site is usually small and therefore suturing is not indicated String technique: The string technique begins by securing the body part containing the fishhook firmly against a table or flat surface to prevent movement during the procedure. A piece of string (e.g., silk suture) about 3 feet long should be looped around the belly of the fishhook . Using two loops around the belly of the fishhook increases the likelihood of the fishhook remaining attached to the string after the procedure. If the shank has been cut, the remaining portion of the shank can be grasped with a strong hemostat, which then will act as a substitute shank. The ends of the string should be wrapped securely around the clinician's right index finger (or left finger if the clinician is left-handed). The eye and shank of the fishhook should be firmly grasped between the clinician's left index finger and thumb and then depressed, disengaging the barb from surrounding tissue . The left middle finger applies slight pressure downward on the shank toward the patient's skin. The loop is then pulled slowly away from the hook, horizontally in the plane of the shank's long axis, until just taut. With use of the right index finger, the loop is allowed to relax slightly and then, reversing direction, is jerked suddenly away from the fishhook, flicking the hook from the skin . When done properly, this technique does not require local anesthesia . Because the hook often flies out of the wound, both patient and clinician should wear protective goggles, and bystanders should be cleared from the expected flight path Needle technique: A third technique uses a needle to cover the hook's barb, allowing the clinician to back the fishhook out of the skin. After local infiltration with 1% lidocaine using a 27-gauge needle, an 18- or 20-gauge needle is inserted through the wound along the shaft of the hook . With the bevel of the needle facing the inside of the hook's belly, the needle is advanced along the hook's belly until the needle opening slides over (engages) the barb of the hook . Once the barb has been covered, the needle and hook are held firmly together while backing the hook and needle out of the wound as a unit. Complications: Complications are rare when these procedures are performed properly. As with any wound, infection is a rare complication . The wound should be thoroughly irrigated and cleansed, and the patient instructed to return if any signs of infection arise. The push-through technique may cause additional tissue damage as the needle is advanced through intact skin: the deeper the needle, the higher the risk of causing significant damage. The string technique is effective and safe when done properly. If the body part containing the fishhook is not properly secured, however, movement when the hook is jerked can result in tissue damage and pain. Most failures of this technique are thought to be due to the lack of a quick and confident yank on the string. As mentioned, the patient and clinician should both wear protective goggles to prevent eye injury. It is also wise for the clinician and any bystanders to position themselves away from the expected flight path of the fishhook so that it does not become embedded in someone else after it is free of the patient. Finally, the needle technique is more difficult to perform without causing excessive local trauma when the fishhook is deeply embedded.

Central line seldinger technique

Indication: Indications for central venous access include administration of IV fluids or medications, measuring central venous pressures, or for access of a Swan-Ganz catheter or transvenous pacemaker placement Contraindications: There is no absolute contraindication for central venous access, although care should be taken to select the most appropriate site for the patient. Avoid the femoral route if there is a femoral hernia, abdominal trauma, or if the catheter is being placed for transvenous pacer placement. Avoid the subclavian route in patients receiving positive-pressure ventilation or those with known or suspected bleeding disorders because of the noncompressible nature of this site Seldinger technique: A. An introducer needle is used to puncture the vein and aspirate blood. B. With the syringe removed, the guidewire is passed through the needle and into the vein. C. Remove the needle over the guidewire. D. Use a scalpel to widen the skin puncture site adjacent to the guidewire. E. Advance the dilator over the wire, through the skin opening, and to the depth of its hub; remove the dilator. F. Insert the catheter over the wire and into the vein. G. Remove the guidewire while holding the catheter in place. Procedure: 1. Position the patient appropriately for the site into which the catheter will be inserted. *Subclavian and internal jugular vein catheter placement benefit from the patient in Trendelenburg position, whereas **femoral vein catheter placement benefits from the patient in reverse Trendelenburg. 2.Use appropriate analgesia or sedation, as appropriate, to minimize patient discomfort. 3. Sterilize the surrounding skin and site of insertion, and surround the area with sterile drape or towels. Observe sterile technique including personal sterile attire. 4 If available, use real-time ultrasound guidance 5. Anesthetize the site of insertion with local injection of anesthetic. 6. Insert the entry needle through the skin, applying negative pressure from an attached syringe. 7. Advance needle 1-2 mm after the initial flash of blood to ensure the needle tip is in the vein. 8. Remove the syringe from the needle, taking care not to move the needle during this process. Ensure that the blood return is dark and nonpulsatile. 9. Insert the guide wire through the needle into the vessel. Do not force the guide wire; reposition the needle if the wire does not advance freely. 10. Remove the needle over the guide wire while leaving the guide wire in place. Always have the guide wire secured with a grasp when it is in the vessel. 11. Use an 11-blade scalpel to create a nick in the skin at the site of entry, adjacent to the wire. 12. Advance a dilator over the guide wire and into the vessel. Once the dilator is inserted, remove the dilator, holding pressure over the skin where the dilator was located and maintaining the position and grasp of the wire. 13. Insert the catheter over the guide wire and into the vessel. Make note of the length of the catheter inserted. 14, Secure the catheter in place with suture. 15. Obtain and review a postprocedure chest x-ray for confirmation of placement (internal jugular and subclavian sites). Complications: There are a number of identified complications to central venous catheter placement. The catheterized vessel can become thrombosed, lacerated, or perforated. Cardiac dysrhythmias may occur when advancing the guide wire. Infection may occur as well. With internal jugular and subclavian catheter placement, pneumothorax and hemothorax are known complications. Femoral catheters have been associated with damage to the peritoneal contents as well as retroperitoneal hematomas.

Pericardiocentesis

Indications: The patient who has a pericardial effusion with hemodynamic instability, such as cardiac tamponade, benefits from timely pericardiocentesis. The patient with a more chronic pericardial effusion may have a diagnostic pericardiocentesis performed in order to evaluate the condition as an inpatient. Contraindications: There are no absolute contraindications to performing emergent pericardiocentesis in the setting of cardiac tamponade. Relative contraindications (relevant for non-life-threatening tamponade) are overlying skin infection and known or suspected bleeding disorders. Bedside ECG machines may be used to inform the practitioner if the tip of the needle comes into contact with the ventricular wall. This may reduce the complication of ventricular puncture. Procedure: 1. Apropriate analgesia or procedural sedation should be administered when possible. Pericardiocentesis is a sterile procedure. 2. The patient may require airway management prior to performance of pericardiocentesis. 3. After ensuring appropriate analgesia and observing sterile technique (when possible), position the patient in slight reverse Trendelenburg. 4. Select the appropriate size syringe and needle for the patient, or have the pericardial drain set at bedside. 5. Sterilize the proposed field for the procedure in a wide area over the subxiphoid space; drape the surround chest and abdominal walls. 6. Attach the needle to one of the V leads on the ECG machine with the limb leads attached. 7. Identify landmarks: *1 cm to the left of the inferior margin of the xiphoid process. Alternatively, consider a parasternal approach in the fifth intercostal space. 8. Advance the needle, with negative pressure through the syringe, through the skin. Xiphoid approach: *45-degree angle to the anterior plane of the skin, and 45 degrees to the midline aiming toward medial to the left shoulder. Parasternal approach: perpendicular to the skin through the fifth intercostal space. 9. Withdraw as much pericardial fluid as possible, or insert the pericardial drain. 10. When a drain is not utilized, remove the needle and cover the wound with a sterile dressing. 11. Obtain chest x-ray to evaluate for potential complications. Complications; Infection is a known complication. In addition, complications may include hemothorax or pneumothorax, damage to vasculature including the coronary vessels, as well as the potential for damage to peritoneal structures such as the liver

Surgical Cricothyrotomy

Indications: The primary indication for surgical cricothyrotomy is to achieve airway control when less invasive techniques are unsuccessful or contraindicated. In infants and children, this will occur most often when an upper airway obstruction results from an irremovable foreign body or massive edema (such as epiglottitis or Ludwig angina) or when significant maxillofacial, mandibular, oropharyngeal, or laryngeal trauma has occurred and caused significant edema or severe anatomic distortion. Contraindications: The major contraindication to this technique is the ability to provide adequate oxygenation and ventilation by more standard, less invasive means (see Chapters 13 to 18). Massive trauma to the larynx or the trachea, particularly transecting injury, is also a relative contraindication to surgical or needle cricothyrotomy; these techniques should be attempted under these circumstances only when other means of airway control are impossible and death is imminent. Additionally, because of the small size of the cricothyroid membrane in young children, some medical personnel suggest that this technique not be employed in children less than 5 years of age (1). Needle cricothyrotomy is preferred in younger children. Other relative contraindications include neck trauma or edema that hinders surgical dissection or landmark identification. Known bleeding diathesis also may increase the risk of failure to obtain airway control rapidly and increase the risk of other complications as well. Surgical cricothyrotomy most often will be performed by physicians; however, in many situations airway control must be accomplished in the field. It is therefore vital that prehospital providers be familiar with this technique or with one of the alternatives discussed Procedure: 1.Identify landmarks in anterior neck by palpating hyoid bone, thyroid cartilage, and cricoid cartilage. (The cricothyroid membrane should be identified below the tip or notch of the thyroid cartilage and above the cricoid cartilage, Once this structure is identified, its anterior surface should be palpated in a rostrocaudal fashion. The palpating finger should drop into the notch below the thyroid cartilage; this is the location of the cricothyroid membrane. When the thyroid cartilage cannot be identified by palpation, an alternative is to identify the hyoid bone and to then palpate caudally. Either the thyroid cartilage or the cricoid cartilage (or both) can be identified by this method) 2.When time permits, prepare skin with antiseptic solution and administer local infiltrative anesthesia. 3. Stabilize trachea with nonoperating hand. 4. Make vertical midline incision over cricoid membrane, attempting to avoid isthmus of thyroid gland. skin and subcutaneous tissue, bluntly dissect through sternohyoid muscle until cricothyroid membrane is visualized. The midline incision should protect most of the major neck vessels, which are located laterally, but some venous bleeding should be anticipated. 5, Using No. 11 scalpel blade, make small horizontal incision near inferior border of membrane. 6. Insert pair of curved Mayo scissors or small curved hemostat into incision and spread jaws of scissors or hemostat to enlarge incision. 7. Maintain patency of incision either by keeping scissors or hemostats in place or by inserting trachea hook into inferior margin and gently lifting edge of incision anteriorly. 8. Insert appropriate size endotracheal tube or tracheostomy tube into incision and secure. Assess adequacy of ventilation. Clinical Tips: Standard CricothyroidotomyPrint Section Alternative means of airway control, such as needle cricothyroidotomy or retrograde intubation, should always be considered first, particularly if the patient is a young child. The initial incision is made vertical and in the midline. This reduces the risk of damage to vascular structures. In some cases, the cricothyroid membrane may not be easily visualized. In these instances, the membrane should be palpated with a fingertip. "Blind" incision is a technique of last resort because of the risk of damage to vascular structures in the area. A tracheal hook or the blades of the scissors or hemostats should be used to keep the incision open and to maintain location of the incision. If the incision is "lost," bubbles of exhaled air will often identify its location. In the apneic patient, these may be produced by pressure on the anterior chest wall. Even a small airway is better than none. If a small endotracheal or tracheostomy tube is all that will pass through the incision, then it should be used until more effective airway control can be established. Complications: Complications include incorrect site of incision or tube placement, prolonged procedure time, hemorrhage, and failure of the procedure to access the airway. Less commonly, esophageal and mediastinal perforation, subcutaneous emphysema, pneumothorax, pneumomediastinum, and laryngeal injury may occur. Traditional teaching has emphasized the risk of subglottic stenosis after this procedure.

DPL

Indications: In the case of blunt trauma, DPL has traditionally been used to detect intra-abdominal bleeding in the hemodynamically unstable child unresponsive to appropriate resuscitation. It is most useful in the hypotensive child who is going to the operating room for urgent nonabdominal surgery when US is not available or produces equivocal results. Some have advocated using DPL in detecting bowel and mesenteric injuries, which are uncommon in blunt trauma but difficult to detect by CT scanning. DPL has been used traditionally to detect free hemorrhage or intestinal contents as evidence of potential bowel or mesenteric injury and is considered by some to be diagnostically superior to evaluation by CT. DPL is used in the evaluation of penetrating thoracoabdominal and abdominal trauma to detect peritoneal penetration and serves as an adjunct to local wound exploration. DPL has an accuracy rate of 90% for diagnosing injury when using the cell counts as described for blunt abdominal trauma . With the increased incidence of hollow viscus and diaphragm injury from stab wounds, some authors have recommended using lower RBC counts (5,000/mm3 for low chest and 20,000/mm3 for anterior abdomen) because there is less blood loss with these injuries. If DPL lavage fluid does not exit the wound and contains fewer cells than the previously described thresholds, the child can be observed. Laparotomy is no longer considered mandatory for all abdominal stab wounds Contraindications: The only absolute contraindication to DPL exists when its performance would delay surgical management of a patient for whom such intervention is clearly indicated. Relative contraindications are severe obesity, infection, previous abdominal surgery, coagulopathies, and second- or third-trimester pregnancy. Adhesions from prior abdominal surgery can compartmentalize the peritoneal cavity, leading to iatrogenic bowel perforation or inability to recover an adequate volume of fluid for interpretation. Procedure:In preparation for DPL, sedation may be administered as needed . The stomach is decompressed using a nasogastric or orogastric tube , and the bladder is emptied using a bladder catheter . These procedures decrease the risk of inadvertent puncture of these organs. The usual site for needle insertion is in the midline below the umbilicus approximately one third of the distance from the umbilicus to the symphysis pubis. In adults, this distance is usually approximately 3 cm but will be less in a small child (usually 1 to 2 cm). This infraumbilical approach is generally used unless the patient is pregnant or has a pelvic fracture, an abdominal wall hematoma, or local skin infection at the infraumbilical site. The supraumbilical approach is recommended for these patients, and the needle is inserted 1 to 3 cm above the umbilicus. Using the midline location allows the needle to pass through the relatively avascular linea alba. This helps to prevent bleeding and therefore a false-positive result. Once the patient is prepared and the site of insertion chosen, local anesthetic is administered into the skin and down to the fascia. Use of local anesthetic containing epinephrine is recommended to reduce the amount of local bleeding. The closed (Seldinger) technique is the preferred method because it is faster but has the same complication rates and accuracy as the open technique. Guidewire advanced through needle. B. Small puncture with scalpel. C. Lavage catheter advanced into the peritoneal cavity over the guidewire. D. An initial attempt is made to aspirate blood from the peritoneal cavity. E. 10-15 mL/kg normal saline or Ringer lactate is infused via the lavage catheter. F. The bag is dropped to a level below the abdomen, and the fluid is recovered by gravity. A cell count of **100,000 RBC/mm3 is the most common criteria used for the presence of intraperitoneal injury. This cell count represents about 20 to 30 mL of blood and is not considered an indication for laparotomy by all . WBC counts of **500 WBC/mm3 or greater have been used as an indication of small bowel injury, but this marker is considered controversial. Other controversial markers indicative of bowel injury are elevations in enzymes (amylase and alkaline phosphatase) in the lavage fluid Complications : Serious complications associated with diagnostic peritoneal lavage occur in 1% to 2% of patients . The morbidity associated with DPL can be categorized as infection, intraperitoneal injury, and technical failure. Wound infections and hematomas are rare complications; adherence to sterile technique and careful hemostasis should alleviate these problems. he most important complications involve direct injury to an intra-abdominal structure. Of all the intra-abdominal organs, the liver and spleen are the least likely to be injured; The two organs at greatest risk during DPL are the stomach and the bladder

Chest tube Thoracostomy

Indications: insertion of a tube thoracostomy may be indicated to relieve the accumulation of fluid or air from the pleural space. The patient may require a tube thoracostomy because of trauma, spontaneous pneumothorax, iatrogenic causes, or other systemic disease processes. Parapneumonic effusions may also require placement of a tube thoracostomy to assist in patient management Contraindications: coagulopathy or overlying skin infection Insertion site: The majority of chest tubes should be inserted in the, 3rd, 4th, or 5th intercostal space in the midaxillary line. Rarely, an anterior approach may be taken to place a small-bore chest tube in the second intercostal space, midclavicular line. The technique is primarily utilized for a pneumothorax; however, the location is utilized less in clinical practice because of potential complications and decreased patient satisfaction with an anterior chest tube. Procedure: Position the patient with the ipsilateral arm overhead or raised away from the field. 2. Prepare the sterile instruments and gown in sterile fashion. 3. Sterilize the skin at the appropriate predetermined site and several centimeters around the intended incision site. 4. Determine the interspace and palpate the rib above and below the intended site of insertion. Anesthetize the area over the interspace and the area inferior 5. Drape the surrounding chest wall with sterile towels, leaving an exposed window approximately 10 cm wide over the insertion site. 6. Make an incision with the scalpel through the skin one or two rib spaces below where the chest tube will insert into the pleural space. Ensure that the incision is large enough to allow both the tube and the operator's finger or other device (eg, Kelly clamp) to be inserted through the skin. Making the incision one or two rib spaces below where the chest tube will insert into the pleural space will allow tunneling to occur in the subcutaneous tissue and help to guide the chest tube to its appropriate final destination. The incision should be parallel to the adjacent rib. 7. Use blunt dissection with the Mayo clamp in a cephalad direction to identify the pleural space where the chest tube will insert. Blunt dissection should also be directed anterior or posterior, depending on the intention of the chest tube. In the supine patient, air preferentially will be located anterior, while fluid will be located posterior. Insertion of the chest tube **above the lower rib will help to minimize the possibility of damaging the neurovascular bundle running along the inferior edge of the upper rib. 8. Enter the pleural space just over the inferior rib of the interspace with the closed blunt tips of the Kelly clamp by maintaining steady pressure, and then spread the tips wide once past the parietal pleura and inside the pleural space. This will open the space wide enough to pass the tube. Many operators underestimate the amount of force needed to pass through the intercostal muscles and chest wall; use steady pressure and be prepared to release pressure when the clamp suddenly enters the pleural space. A sudden rush of air or fluid is to be expected. 9. If the intercostal space is of the appropriate size, the operator should insert one finger into the pleural space and sweep 360 degrees to confirm location. 10. Clamp the distal end of the chest tube prior to insertion; this will ensure that a rapid escape of blood or fluid does not cause unneeded exposure to bodily fluids. Guide the tube as it is inserted into the pleural space in a superior and anterior or posterior fashion, depending on the clinical situation. 11. Connect the distal chest tube to the suction device and evaluate for variance of the water columns with respiration. Improper placement will result in no water movement with inhalation and exhalation. 12. Secure the tube in place with silk suture. This is commonly performed by sewing a horizontal mattress suture around both sides of the tube, which aids in closing the incision on either side of the tube. Use the tails of the silk suture to wind around the tube from opposing directions (4-5 passes each) and tie the ends securely. 13. Wrap petrolatum gauze around the tube over the incision site to prevent leakage. Cut the 4-inch gauze squares and secure them around the tube, over the petrolatum gauze. Tape the gauze to the patient's chest wall, and secure the tube by taping it directly inferior to the insertion site to the chest wall. Secure the chest tube to suction device tubing connection with additional tape . 14.Evaluate tube placement by an upright chest radiograph, paying specific attention to lung re-expansion and improvement of fluid collection (if an initial radiograph was obtained). Complications:Damage to the neurovascular bundle including the thoracic nerve or intercostal arteries may occur while dissecting the tissue, prior to insertion of the chest tube. Inappropriately placed chest tubes may damage intra-abdominal or mediastinal structures. Damage to the lung tissue may also occur during tube thoracostomy placement. Hemodynamic instability may also be encountered due in part to rapid evacuation of an effusion or by direct compression of the heart. Infection may also occur when sterile technique is not followed during insertion of the chest tube or in maintenance of a placed chest tube.

Splinting

Radial Ulnar gutter splint: Once the splint is wrapped, it should be shaped as follows: the wrist should be in a neutral position, the metacarpophalangeal joints should be in 70 degrees flexion, and the proximal interphalangeal joints in 20 to 30 degrees flexion. Thumb Spica: After the outer wrap layer is applied, the operator should gently shape the splint as follows: the wrist should be placed in a neutral position, and the thumb should be abducted and in slight flexion at the metacarpophalangeal and interphalangeal joints ("wine glass" position of the thumb). Volar splint UE: The child is positioned lying on his or her side with the dorsal aspect of the affected forearm against the stretcher. After the outer wrap layer is applied, the splint should be shaped with the wrist in a neutral position, and the digits should be slightly flexed at all joints Long arm splint: with the forearm hanging down toward the floor (elbow flexed 90 degrees). After the outer wrap layer is applied, the splint should be shaped with the elbow flexed 90 degrees and the forearm in a neutral position Digit splinting: For optimal immobilization, the splint should be shaped to hold the metacarpal-phalangeal joint flexed 50 degrees and the interphalangeal joint flexed 15 to 20 degrees. The patient should be provided with extra tape so that the finger splint can be changed. For younger children, the finger splint should be protected with an outer wrap of elastic bandage or gauze roll. Post leg knee spint: The width of a long leg splint should be such that it covers at least half of the leg diameter, and the length should be such that it extends posteriorly from just below the buttock to the heel of the foot. For knee immobilization only, the splint length should extend posteriorly from the midthigh to about 3 inches above the malleoli. To apply the splint, the patient is placed in the prone position on a stretcher, exam table, or parent's lap. After the outer wrap layer is applied, the splint must be properly shaped. When the splint is being used to treat a fracture, the knee should be placed in slight flexion, and the ankle should be kept in neutral position; for knee injuries, the knee should remain in full extension but should not be hyperextended. To ensure integrity of the splint at the knee joint, excessive motion should be avoided until the splint has dried completely. Post Short leg: The splint is applied with the child prone on a stretcher, exam table, or parent's lap, with the lower leg flexed to 90 degrees at the knee. After the outer wrap layer is applied, the splint is shaped with the foot-ankle in neutral position at 90 degrees of flexion. This position can be held by an assistant, or the child can be repositioned in a chair with the foot flat on the floor until the splint has dried completely.

Cardia pacing

Sedate patient as indicated. Apply adhesive electrodes to anterior and posterior chest walls. Connect patient to monitoring system of pacing module. Set rate just above patient's rate. Set system on demand mode if patient has an intermittently acceptable intrinsic rate; otherwise set system on asynchronous mode. Set output to lowest value. Turn on pacer. Gradually increase output until capture is noted. Set output just above pacer threshold. Set rate to minimum desired rate. Make plans for transvenous pacing.

Femoral venous catheter insertion

The femoral artery lies halfway between the anterior superior iliac spine and pubic symphysis. 1 cm below the inguinal ligament Femoral vein: 0.5 cm to 1cm medial to femoral artery Femoral artery is 2cm below inguinal ligament Femoral lymphatics lie medial to the femoral vein The femoral vein lies medially to the femoral artery in the proximal thigh. This site is often considered a top choice for emergent central venous access. It is readily identified by anatomic landmarks, is able to have pressure applied in the event of bleeding, and does not interfere with other procedures such as airway management that may be ongoing. Procedure: 1, Position the patient's hip in abduction and external rotation. Palpate the femoral artery approximately 1-2 cm below the inguinal ligament. Approximately 1-2 cm medial to this site is where the femoral vein is located. 2. . Insert the needle at a 45-degree angle to the skin and advance toward the ischial tuberosity. 3. Once the needle has entered the vessel, consider flattening the angle toward the skin (20-30 degrees) if the guide wire does not freely advance. Do not allow the needle to pass beyond the inguinal ligament and into the peritoneal cavity

Internal jagular

The internal jugular vein runs within the carotid sheath with the carotid artery and vagus nerve. Preferentially, the right internal jugular vein should be catheterized because it is a more direct route to the superior vena cava. This site allows for central venous pressure monitoring, which is not possible from a femoral route Procedure: 1. The median approach is the most popular in pediatric patients. 2. Position the patient so that the head is rotated 30 degrees from midline, facing the contralateral side. 3. Identify the junction of the two heads of the sternocleidomastoid muscle, which will form an apex where the internal jugular vein is located. 4. Palpate the carotid artery and note that the internal jugular vein is**lateral to the artery. 5. Insert the needle at a 30-degree angle to the skin, and advance in the direction of the ipsilateral nipple

Radial nerve block

The radial nerve splits into peripheral branches about two thirds of the way down the forearm. At the wrist, one of the major branches of the nerve lies lateral to the flexor carpi radialis tendon in close proximity to the radial artery. Proximal to the wrist, sensory branches emerge and course subcutaneously around the distal radius to the dorsolateral portion of the wrist and hand. These branches innervate the dorsal aspect of the proximal thumb as well as the second and third fingers and the radial portion of the fourth finger. injury Loss of extension of forearm, weakness of supination, and loss of extension of hand and fingers. Presence of wrist drop, due to inability to extend the hand and fingers. Sensory deficit: Loss of sensation in lateral arm, posterior forearm, the radial half of dorsum of hand, and dorsal aspect of radial 3 1⁄2 digits, excluding their nail beds. Weakness of supination, and loss of extension of hand and fingers. Presence of wrist drop, due to inability to extend the hand and fingers. Procedure: 1. The flexor carpi radialis tendon is located by flexing the wrist slightly. 2. The skin over the distal radial portion of the wrist at the level of the skin creases is prepared with alcohol or povidone-iodine. 3. To anesthetize the major peripheral branch of the radial nerve, the flexor carpi radialis tendon and radial artery are palpated at the level of the proximal palmar crease. 4. A 25- to 27-gauge needle is inserted just lateral to the radial artery to the depth of the artery. Intravascular injection is avoided by aspirating for blood return. 5. Approximately 2 to 4 mL of local anesthetic is injected. 6. To anesthetize the dorsal cutaneous branches of the radial nerve, local anesthetic is infiltrated subcutaneously over the dorsoradial aspect of the wrist in a cuff-like distribution from the initial injection site to the midline of the dorsal aspect of the wrist . 7. After the initial injection, the needle can be repositioned to start the subcutaneous infiltration of the radial aspect of the wrist. 8. A second needle insertion may be necessary to complete the infiltration to the dorsal midline, but pain can be minimized by entering through previously anesthetized skin. 9. A volume of approximately 5 mL of lidocaine is usually sufficient (maximum dose 3 to 5 mg/kg). The onset of the anesthetic effect typically occurs within 10 minutes. 10 The effectiveness of a radial nerve block is assessed by applying a stimulus to the dorsal web space between the thumb and index finger, because this area is innervated solely by the radial nerve

Subclevian

The subclavian vein is the least common site to place a central venous catheter in the pediatric patient. Anatomic landmarks are not as well defined in children as they are in adults or adolescents. Similar to the internal jugular vein, the right subclavian vein should preferentially be chosen because of a lower cupola on the right as well as a more direct route to the superior vena cava. Procedure: 1. There are two approaches to cannulating the subclavian vein: supraclavicular and infraclavicular. 2 For the supraclavicular approach, locate the lateral border of the clavicular head of the sternocleidomastoid muscle and the superior aspect of the clavicle at this junction. 3. Insert the needle about one fingerbreadth laterally to this site at the superior margin of the clavicle, and advance the needle toward the suprasternal notch. 4. For the infraclavicular approach, identify the midclavicular line and the inferior border of the clavicle. 5. Insert and advance the needle under the clavicle aimed toward the suprasternal notch