Emergency Procedures: Intraosseus Needle Insertion

emergency procedures-Intraosseus Insertion

Indications

  • Emergency intravenous access is required and Peripheral intravenous access is difficult or has failed.

This video has been provided by Emergency Procedures App developers (Dr John Mackenzie and Dr James Miers) in order to help medical students, interns in training. Please visit the video source or Emergency Procedures app for more procedure videos and information. 

Contributors

Dr John Mackenzie

Dr John Mackenzie

Dr John Mackenzie MBChB , Dip MSM, FACEM . Staff Specialist Emergency Medicine, Consultant Hyperbaric Medicine Specialist, at Prince of Wales Hospital. Known for cycling endlessly for no apparent reason. 20 years of developing virtual learning for clinicians at all levels.

Dr James Miers

Dr James Miers

Dr James Miers BSc BMBS (Hons) FACEM, Staff Specialist in Emergency Medicine, Prince of Wales Hospital, Sydney. Passion for gypsy jazz and chess. Lead author of Lead author of Emergency Procedures App.

Further Reading

Emergency Procedures: Patella Relocation

emergency procedures-patella relocation

Indications

  • Patella dislocation

This video has been provided by Emergency Procedures App developers (Dr John Mackenzie and Dr James Miers) in order to help medical students, interns in training. Please visit the video source or Emergency Procedures app for more procedure videos and information. 

Contributors

Dr John Mackenzie

Dr John Mackenzie

Dr John Mackenzie MBChB , Dip MSM, FACEM . Staff Specialist Emergency Medicine, Consultant Hyperbaric Medicine Specialist, at Prince of Wales Hospital. Known for cycling endlessly for no apparent reason. 20 years of developing virtual learning for clinicians at all levels.

Dr James Miers

Dr James Miers

Dr James Miers BSc BMBS (Hons) FACEM, Staff Specialist in Emergency Medicine, Prince of Wales Hospital, Sydney. Passion for gypsy jazz and chess. Lead author of Lead author of Emergency Procedures App.

Further Reading

Emergency Procedures: Shoulder Immobilisation

emergency procedures-shoulder immobilisation

Indications

  • Shoulder dislocation (post reduction)
  • Acromioclavicular injuries (grade 1-3)
  • Fracture of humeral head, greater tuberosity or clavicle

This video has been provided by Emergency Procedures App developers (Dr John Mackenzie and Dr James Miers) in order to help medical students, interns in training. Please visit the video source or Emergency Procedures app for more procedure videos and information. 

Contributors

Dr John Mackenzie

Dr John Mackenzie

Dr John Mackenzie MBChB , Dip MSM, FACEM . Staff Specialist Emergency Medicine, Consultant Hyperbaric Medicine Specialist, at Prince of Wales Hospital. Known for cycling endlessly for no apparent reason. 20 years of developing virtual learning for clinicians at all levels.

Dr James Miers

Dr James Miers

Dr James Miers BSc BMBS (Hons) FACEM, Staff Specialist in Emergency Medicine, Prince of Wales Hospital, Sydney. Passion for gypsy jazz and chess. Lead author of Lead author of Emergency Procedures App.

Further Reading

Emergency Procedures: Finger Splint

Indications

  • Fractures of distal and middle phalanx
  • Volar plate injury
  • Post reduction of dorsal PIP dislocation
  • Mallet injury (distal phalanx extensor tendon rupture with or without avulsion fracture)

This video has been provided by Emergency Procedures App developers (Dr John Mackenzie and Dr James Miers) in order to help medical students, interns in training. Please visit the video source or Emergency Procedures app for more procedure videos and information. 

Contributors

Dr John Mackenzie

Dr John Mackenzie

Dr John Mackenzie MBChB , Dip MSM, FACEM . Staff Specialist Emergency Medicine, Consultant Hyperbaric Medicine Specialist, at Prince of Wales Hospital. Known for cycling endlessly for no apparent reason. 20 years of developing virtual learning for clinicians at all levels.

Dr James Miers

Dr James Miers

Dr James Miers BSc BMBS (Hons) FACEM, Staff Specialist in Emergency Medicine, Prince of Wales Hospital, Sydney. Passion for gypsy jazz and chess. Lead author of Lead author of Emergency Procedures App.

Further Reading

Emergency Procedures: Short Leg Backslab

emergency procedures-short leg backslab

Indications

  • The distal tibia and/or fibula fractures
  • Ankle injuries
  • Tarsal injuries
  • Metatarsal injuries

This video has been provided by Emergency Procedures App developers (Dr John Mackenzie and Dr James Miers) in order to help medical students, interns in training. Please visit the video source or Emergency Procedures app for more procedure videos and information. 

Contributors

Dr John Mackenzie

Dr John Mackenzie

Dr John Mackenzie MBChB , Dip MSM, FACEM . Staff Specialist Emergency Medicine, Consultant Hyperbaric Medicine Specialist, at Prince of Wales Hospital. Known for cycling endlessly for no apparent reason. 20 years of developing virtual learning for clinicians at all levels.

Dr James Miers

Dr James Miers

Dr James Miers BSc BMBS (Hons) FACEM, Staff Specialist in Emergency Medicine, Prince of Wales Hospital, Sydney. Passion for gypsy jazz and chess. Lead author of Lead author of Emergency Procedures App.

Further Reading

Emergency Procedures: Long Leg Backslab

emergency procedures-long leg backslab

Indications

  • Tibia and/or fibula shaft fractures
  • Knee and patellar fractures
  • Distal femur fractures

This video has been provided by Emergency Procedures App developers (Dr John Mackenzie and Dr James Miers) in order to help medical students, interns in training. Please visit the video source or Emergency Procedures app for more procedure videos and information. 

Contributors

Dr John Mackenzie

Dr John Mackenzie

Dr John Mackenzie MBChB , Dip MSM, FACEM . Staff Specialist Emergency Medicine, Consultant Hyperbaric Medicine Specialist, at Prince of Wales Hospital. Known for cycling endlessly for no apparent reason. 20 years of developing virtual learning for clinicians at all levels.

Dr James Miers

Dr James Miers

Dr James Miers BSc BMBS (Hons) FACEM, Staff Specialist in Emergency Medicine, Prince of Wales Hospital, Sydney. Passion for gypsy jazz and chess. Lead author of Lead author of Emergency Procedures App.

Further Reading

Emergency Procedures: Volar Short Arm Slab

emergency procedures-volar short arm slab

Indications

  • Soft tissue injuries to hand and wrist
  • Carpal bone fractures (excluding scaphoid/trapezium)
  • Buckle fractures of the distal radius

This video has been provided by Emergency Procedures App developers (Dr John Mackenzie and Dr James Miers) in order to help medical students, interns in training. Please visit the video source or Emergency Procedures app for more procedure videos and information. 

Contributors

Dr John Mackenzie

Dr John Mackenzie

Dr John Mackenzie MBChB , Dip MSM, FACEM . Staff Specialist Emergency Medicine, Consultant Hyperbaric Medicine Specialist, at Prince of Wales Hospital. Known for cycling endlessly for no apparent reason. 20 years of developing virtual learning for clinicians at all levels.

Dr James Miers

Dr James Miers

Dr James Miers BSc BMBS (Hons) FACEM, Staff Specialist in Emergency Medicine, Prince of Wales Hospital, Sydney. Passion for gypsy jazz and chess. Lead author of Lead author of Emergency Procedures App.

Further Reading

Emergency Procedures: Long Arm Backslab

emergency procedures-long arm backslab

Indications

  • Acute management of elbow region injuries such as radial head fractures, distal humerus fractures, after reductions of elbow dislocations; 
  • Proximal and mid-forearm, and wrist injuries such as Colles or Smith fractures;
  • Acute management of distal radial (nonbuckle) and/or ulnar fractures in children.

This video has been provided by Emergency Procedures App developers (Dr John Mackenzie and Dr James Miers) in order to help medical students, interns in training. Please visit the video source or Emergency Procedures app for more procedure videos and information. 

Contributors

Dr John Mackenzie

Dr John Mackenzie

Dr John Mackenzie MBChB , Dip MSM, FACEM . Staff Specialist Emergency Medicine, Consultant Hyperbaric Medicine Specialist, at Prince of Wales Hospital. Known for cycling endlessly for no apparent reason. 20 years of developing virtual learning for clinicians at all levels.

Dr James Miers

Dr James Miers

Dr James Miers BSc BMBS (Hons) FACEM, Staff Specialist in Emergency Medicine, Prince of Wales Hospital, Sydney. Passion for gypsy jazz and chess. Lead author of Lead author of Emergency Procedures App.

Further Reading

Emergency Procedures: Thumb Spica Splint

emergency procedures-thumb spica splint

Indications

  • Injuries to scaphoid/trapezium
  • Nondisplaced, nonangulated, extra-articular first metacarpal fractures
  • Stable thumb fractures with or without closed reduction

This video has been provided by Emergency Procedures App developers (Dr John Mackenzie and Dr James Miers) in order to help medical students, interns in training. Please visit the video source or Emergency Procedures app for more procedure videos and information. 

Contributors

Dr John Mackenzie

Dr John Mackenzie

Dr John Mackenzie MBChB , Dip MSM, FACEM . Staff Specialist Emergency Medicine, Consultant Hyperbaric Medicine Specialist, at Prince of Wales Hospital. Known for cycling endlessly for no apparent reason. 20 years of developing virtual learning for clinicians at all levels.

Dr James Miers

Dr James Miers

Dr James Miers BSc BMBS (Hons) FACEM, Staff Specialist in Emergency Medicine, Prince of Wales Hospital, Sydney. Passion for gypsy jazz and chess. Lead author of Lead author of Emergency Procedures App.

Further Reading

Local Anaesthetic Toxicity (LAST)

Local Anesthetic Toxicity (LAST)

Think about the number of times a month you use a local anaesthetic; maybe not every day, but I know there are a lot of emergency department shifts when I use a local anaesthetic. The uses and applications for local anaesthesia abound: wound care and laceration closure, pain control with painful procedures like a paracentesis or lumbar puncture, and targeted regional anaesthesia blocks after a broken hip. It is important to know and understand a bit more about this commonly used class of drug given how often we use them in emergency medicine, including the recommended dosing, signs of toxicity, and treatment of toxicity.

Local anaesthetics fall into two divisions, based on their chemical structure:

  • the Esters (have one i): procaine, cocaine, tetracaine, chloroprocaine, etc
  • the Amides (have two i’s): lidocaine, bupivacaine, mepivacaine, prilocaine, ropivacaine, etc

Effect

These drugs have their effect as sodium-channel blocking medications with variable durations of action. Interestingly, 1% diphenhydramine has also been used as a local anaesthetic since the 1930s, given its sodium channel blocking mechanism. Local anaesthetics can be administered with other drugs, namely epinephrine, to help increase the duration of action and minimize the spread of the anaesthetic from the site of injection.

Maximum Dose

The safe maximal dose for the local anaesthetics is based on patient weight and correlates to the risk of systemic toxicity. The maximally safe dose of two common local anaesthetics is detailed below, and as you can see, the use of epinephrine allows for an increased dose of local anaesthetic injection.

Max dose without Epi Max dose with Epi Duration of Action
Lidocaine
4.5 mg/kg
7 mg/kg
0.5 - 1.5 hours
Bupivacaine
3 mg/kg
3 mg/kg
6-8 hours

Usage abd Absorbtion

Absorption into the bloodstream of a local anaesthetic can occur when the drug is injected directly into the bloodstream. Still, it can also occur in highly vascular areas or near neurovascular bundles in locations such as intracostal, epidural, and the brachial plexus. Local anaesthetic systemic toxicity (LAST) occurs when there are elevated circulating levels of local anaesthetic and occurs within minutes of injection. As you may know, lidocaine is used intravenously as an antiarrhythmic drug, and cocaine when used (or abused) systemically can cause numerous systemic effects and a sympathomimetic toxidrome. Bupivacaine is the most commonly discussed cause of LAST, and extra care should be taken when utilizing this for local anaesthesia.

Sign and Symptoms of LAST

Signs and symptoms of LAST predominate in the central nervous system and the cardiovascular system. CNS symptoms can include oral/perioral numbness, paresthesia, restlessness, tinnitus, fasciculations/tremors, seizures, decreased level of consciousness, and/or apnea. Cardiovascular symptoms can include: hypertension and tachycardia though more commonly vasodilation and hypotension, sinus bradycardia, AV blocs, conduction defects (notably: long PR and QRS), ventricular dysrhythmias, cardiovascular collapse, and/or cardiac arrest.

The differential diagnosis for LAST includes anaphylaxis (rare with amides), other sodium channel blockers (antihistamines, TCAs, cocaine, antimalarials), and anxiety. However, the timing nearly immediately following local anaesthetic administration should help one to hone in on the diagnosis.

Management

If a patient develops LAST, ACLS protocols should be followed. Furthermore, lipid emulsion (Intralipid) is the treatment that will help bind the anaesthetic in the bloodstream. While this medication is not on the WHO essential medication list, in a patient with LAST, Intralipid should be administered if available. Dosing is a 1.5 mL/kg bolus (standard dose of 100mL for 70kg patient), followed by a 0.25-0.5 mL/kg/min infusion until the patient is hemodynamically stable (and for at least 10 minutes).

How To Decrease Risk of LAST

A few strategies to minimizing the risk of causing harm to your patients when using local anaesthetics: 
 
  • know the maximum dose your patient can receive
  • know the dose you’re giving by dose (milligrams) and how that correlates to drug volume (mg/mL)
  • aspirate prior to injection(s) to ensure you are not in a blood vessel
  • consider using point of care ultrasound to ensure needle location

References and Further Reading

Cite this article as: J. Austin Lee, USA, "Local Anaesthetic Toxicity (LAST)," in International Emergency Medicine Education Project, November 23, 2020, https://iem-student.org/2020/11/23/local-anaesthetic-toxicity/, date accessed: May 25, 2022

More Posts By Dr. Lee

Question Of The Day #17

question of the day
qod17

Which of the following is the most likely cause for the patient’s elevated cardiac troponin level in the emergency department?

Elevated cardiac troponin levels, or troponinemia, are one sign that the myocardium may be infarcting or under some type of stressful condition. Cardiac troponin levels are assessed in conjunction with the clinical history, physical exam, EKG, and another laboratory testing in deciding if troponinemia is due to cardiac ischemia or another condition. Conditions associated with elevated cardiac troponin levels include cardiac ischemia (i.e. STEMI, NSTEMI), cardiac contusion, cardiac procedures, congestive heart failure, renal failure, aortic dissection, tachy- or bradyarrhythmias, rhabdomyolysis with cardiac injury, Takotsubo syndrome, pulmonary embolism, acute stroke, myocarditis, sepsis, severe burns, extreme exertion, and other conditions. It is unlikely that this patient had elevated troponin levels from Acute coronary syndrome (Choice D) as her cardiac catheterization results showed no significant occlusive lesions in the coronary arteries. D-Dimer levels do increase with patient age, but cardiac troponin levels do not increase with patient age (Choice B). Sepsis (Choice C) is a cause for elevated troponin levels, but this patient has no clinical signs or sepsis symptoms. Atrial fibrillation with a rapid rate (Choice A) is the most likely cause of this patient’s elevated troponin level. Correct Answer: A 

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #17," in International Emergency Medicine Education Project, October 16, 2020, https://iem-student.org/2020/10/16/question-of-the-day-17/, date accessed: May 25, 2022

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Question Of The Day #16

question of the day
qod16

Which of the following is the most appropriate next step in management for this patient’s condition?

This patient sustained a penetrating traumatic injury to the left chest and presented to the emergency department with hemodynamic instability (tachycardic and hypotensive). Some differential diagnoses to consider on arrival include tension pneumothorax, cardiac tamponade, aortic injury, or aero-digestive tract injury. Prior to taking a detailed history on any trauma patient, a primary survey should be performed. The goal of the primary survey in a trauma patient is to identify and treat any life-threatening injuries as soon as possible. The primary survey is also known as the “ABCs.” Sometimes it is referred to as the “ABCDEFs.” This acronym stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam (How to learn eFAST exam for free). Each letter is addressed and assessed in the order they exist in the alphabet. This creates a methodical, algorithmic approach to assist the practitioner in assessing the trauma patient for life-threatening injuries. The sonographic view shown in this question is the subxiphoid (cardiac) view and demonstrates the presence of free fluid. Free fluid on ultrasound appears black, or “anechoic” and is assumed to be blood in the setting of trauma. The free fluid is highlighted by red stars in the image below. The collapse of the right ventricle is shown by the yellow arrow in the below image.

cardiac tamponade - explained
SS Video 3 Pericardial Tamponade

In conjunction with hemodynamic instability and a history of penetrating chest trauma, this sonographic view strongly supports the diagnosis of cardiac tamponade. Consulting the general surgery team for exploratory laparotomy (Choice A) would be the correct course of action for a patient with hemodynamic instability and free fluid on the other abdominal views of the FAST exam. Needle decompression of the chest (Choice B) would be the correct initial treatment for a tension pneumothorax. The patient described in the case has clear bilateral lung sounds, no tracheal deviation mentioned, normal O2 saturation on room air, and sonographic demonstration of cardiac tamponade. A CT scan of the chest, abdomen, and pelvis (Choice D) would be indicated in this patient if he had normal vital signs and no free fluid on the FAST exam. A pericardiocentesis (Choice C) is the most appropriate next step in the management of this patient with cardiac tamponade to relieve signs of obstructive shock. It should be noted that this procedure has limitations and is not always effective. Pericardiocentesis is a temporizing treatment with pericardiotomy being the definitive therapy. Blood in an acute hemopericardium may clot and be unable to be aspirated with a large-bore needle. The procedure may injure surrounding organs, such as the liver, intestines, or heart itself. Ultrasound-guidance should be used whenever possible to avoid injury to surrounding organs. Emergent thoracotomy to relieve the cardiac tamponade should be performed on any patient with confirmed cardiac tamponade and cardiac arrest in the Emergency Department. Correct Answer: C

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #16," in International Emergency Medicine Education Project, October 9, 2020, https://iem-student.org/2020/10/09/question-of-the-day-16/, date accessed: May 25, 2022

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