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NEEDLE CRICOTHYROTOMY
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This procedure involves the creation of a communication between airway and skin via the cricothyroid membrane. An over-the-needle catheter is then passed through the membrane. This procedure provides a temporary secure airway to oxygenate and ventilate a patient in severe respiratory distress when less invasive measures have failed or are unlikely to be successful.
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A high pressure gas source such as Jet Ventilation or percutaneous transtracheal ventilation (PTV) is then used to deliver oxygen to the lungs through the catheter. The gas source attaches to the inserted catheter through an improvised device. One can attach the catheter to a 3-mL syringe with the plunger removed and then attach the syringe to the proximal connection piece of a 7.5-mm internal diameter endotracheal tube (Figure 10-1). Alternatively, one can insert an endotracheal tube into the barrel of the 3-mL syringe and inflate the cuff.
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Needle cricothyrotomy is considered preferable in children less than 12 years of age because of the membrane's small size and close proximity of vascular structures
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Advantages over tracheostomy:
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Contraindications:
Injury to larynx with damage to cricoid cartilage
Laryngeal fracture
Tracheal rupture
Relative contraindications include anterior neck swelling that distorts anatomic landmarks, anatomic anomalies that distort the larynx or trachea, and bleeding disorders.
In most cases, the need for securing an airway will outweigh the risks involved in this procedure.
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Position patient supine with neck extended, if possible
Identify surface landmarks: thyroid cartilage, cricoid cartilage, and cricothyroid membrane (Figure 10-2)
Clean and sterile drape (universal precautions)
If time, inject 1% lidocaine into the skin, through the cricothyroid membrane and into airway, to anesthetize the airway and suppress the cough reflex
Palpate landmarks; fix thyroid cartilage with the first and third fingers of the nondominant hand, leaving the second finger to locate/palpate the cricothyroid membrane
With the dominant hand, pass a 12- or 14-gauge intravenous cannula attached to a syringe filled with sterile saline through the membrane, angling the needle caudally or inferiorly at 45-degree angle (Figure 10-3)
Apply negative pressure to the syringe; if in the trachea, escaping air should create air bubbles in the syringe
Advance the cannula and remove the needle
Secure catheter
Attach Jet ventilator and ventilate at 15 L/min
Monitor adequacy of ventilation by chest wall movement and breath sound auscultation. Can also interpose ETCO2 in the circuit to monitor exhalation
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Pericardiocentesis is the aspiration of fluid from the pericardial space that surrounds the heart. It is typically performed in patients experiencing cardiac tamponade and may be lifesaving.
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Echocardiography is now the most facile way to identify pericardial effusions, characterize their size and location, and assess dynamic findings associated with tamponade. Hemodynamic effects can be assessed by determining abnormal septal motion, right atrial or right ventricular inversion, and decreased respiratory variation of the inferior vena cava (IVC) diameter.
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Emergent pericardiocentesis:
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Nonemergent pericardiocentesis:
The aspiration of pericardial fluid in hemodynamically stable patients may be used for diagnostic, palliative, or prophylactic reasons. This procedure should be performed under ultrasonography, fluoroscopic visualization, or computerized tomography.
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Relative contraindications:
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EMERGENT NEEDLE PERICARDIOCENTESIS POSITIONING AND TECHNIQUE
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The patient can be positioned either supine or in a semirecumbent position at a 30- to 45-degree angle. This brings the heart closer to the anterior chest wall.
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The patient should have at least one intravenous line, should be receiving supplemental oxygen, and should be connected to a cardiac monitor and continuous pulse oximetry. If time permits, placement of a nasogastric tube is advised to decompress the stomach and decrease the chance of gastric perforation.
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Identify the anatomic landmarks, including the xiphoid process and the fifth and sixth ribs, and select a site for needle insertion. The subxiphoid approach is most commonly used, followed by the left sternocostal margin. See Figure 10-4.
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Sterilely clean and drape the subxiphoid area using universal precautions (if time allows).
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Create a skin wheal with local anesthetic solution, and use that wheal to infiltrate and anesthetize subcutaneous and deeper tissue and sternocostal margins.
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Connect a large syringe (20 or 60 mL) to the spinal needle, and aspirate 5 mL of normal saline into the syringe. Occasional injection of small amounts of saline can help keep your needle patent and free of clots or debris. If time allows, connect an alligator clip to the base of the spinal needle and connect it to the V1 lead of an electrocardiogram (ECG) machine (see Figure 10-4).
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Insert the spinal needle at the subxiphoid area at a 45-degree angle to the abdominal wall and direct toward the left shoulder at 45 degrees off the midline sagittal plane. If time permits, needle insertion should be done under ultrasonographic guidance.
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While applying negative pressure on the syringe, slowly advance the needle until there is return of fluid, cardiac pulsations are felt, or there is a change in ECG waveform. If the ECG waveform is consistent with myocardial injury (ST segment elevation), this may mean the needle is in direct contact with the myocardium; slowly withdraw the needle until the tracing returns to normal.
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Withdraw as much fluid as possible. One may want to configure a setup using a three-way stopcock in order to limit movement of the needle and syringe if there is a need to remove a large volume/effusion.
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Remove the needle once fluid can no longer be aspirated.
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CONFIRMATION TESTS TO DETERMINE IF FLUID IS PERICARDIAL VS. INTRACARDIAC
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Pericardial aspirate should not form a clot, whereas intracardiac blood will clot.
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Pericardial aspirate should have a lower hemoglobin concentration than peripheral blood.
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Fluorescein test: Intracardiac injection of fluorescein should cause a fluorescent flush when examining a patient's conjunctiva.
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Chest tubes are used to remove air (pneumothorax), fluid (pleural effusion, blood), or pus (empyema) in the thoracic space. To accomplish this task, either a needle thoracentesis or percutaneous thoracostomy can be performed.
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Pneumothorax (spontaneous, iatrogenic, tension)
Hemothorax
Parapneumonic effusion (if complex)
Empyema
Recurrent malignant effusion
Chylothorax
Penetrating chest trauma
Bronchopleural fistula
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Equipment
Needle size (dependent on patient size)
Infant: #23 to 25 gauge butterfly needle or #22 to 24 gauge IV catheter
Child: #18 gauge needle or #18 gauge angiocath
Young adult: #14 gauge needle (2″ catheter-over-needle)
Approved cleansing solution (chlorhexidine, povidone-iodine)
Sterile gown, gloves, mask, and cap/sterile drapes
Three-way stopcock, “T” connector/extension tubing
20 mL syringe
1% lidocaine
Sterile 2″ × 2″ gauze pads
Paper tape
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Patient preparation
Place the patient in the supine position (ensure thermoregulation is maintained in infants).
Augment oxygen concentration and delivery and/or ventilation as needed.
Monitor heart rate, color, and oxygen saturation.
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(Needle decompression in emergent situations)
Locate landmarks on the chest to find the second intercostal space (Figure 10-5).
Cleanse the insertion site with cleansing solution. Work from the identified site of insertion and clean in a concentric pattern outward. Allow ∼1 minute to dry. Drape with sterile field/towels.
Using 1% lidocaine, initially anesthetize the insertion site subcutaneously (above the rib to avoid the neurovascular bundle) and then advance to anesthetize the costal margins and deeper to the muscle and parietal pleura.
Insert the needle firmly into the second intercostal space, midclavicular line, just above the top of the third rib (again, inserting the needle at the superior edge of the rib avoids the neurovascular bundle) (Figure 10-6).
The operator can connect the needle/angiocath to extension tubing and a three-way stopcock set up with a 20-mL syringe attached to facilitate safe drainage.
As the needle is being advanced into the pleural cavity, a small amount of negative pressure should be exerted on the syringe plunger. Advance the needle until a “pop” is felt, signifying pleural entry. Air or fluid may rapidly flow into the syringe. Once the pleural space has been entered, the needle should be held steady and advanced no farther. If aspiration is not successful, then imaging (typically ultrasound) should be obtained.
For a tension pneumothorax, the inserted thoracentesis needle hub should be connected to extension tubing that is attached to a water seal/Pleur-evac. This will prevent air from being entrained and entering the pleural cavity and allows any trapped air to escape.
Needle thoracentesis is typically a temporary measure (unless being performed for diagnostics). A chest tube should be placed for more definitive treatment when the patient is stable.
Once the withdrawal of air or fluid is complete, withdraw the needle. Monitor the patient vigilantly for any signs of reaccumulation.
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PERCUTANEOUS THORACOSTOMY
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Equipment
Sterile gloves, gown, mask, and cap
Sterile surgical drapes
Chest tube tray that contains (at minimum):
3.0 silk suture
Chest tubes of age-appropriate size
Antiseptic skin preparation
1% lidocaine
3 mL sterile syringe
Occlusive dressing
Sterile gauze pads (4 × 4)
Chest drainage device (e.g., Heimlich one-way flutter valve, Pleur-evac)
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CHEST NEEDLE AND CHEST TUBE INSERTION
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Preparation
Administer sedation as required.
Place the patient in a supine position. The patient's arm can be raised/taped above the head on the insertion side to facilitate exposure.
Augment oxygen concentration and delivery and/or ventilation as needed. Monitor heart rate, color, and oxygen saturation.
For chest tubes placed along the anterior axillary line, the head of the bed can be elevated 30 to 60 degrees, lowering the diaphragm and decreasing the risk of injury to the diaphragm, liver, or spleen.
Technique
Apply mask, perform sterile scrub, and don sterile gown and gloves.
Estimate insertion distance. Using the chest tube, measure the distance from the insertion site to the lung apex and make a note of this.
Identify appropriate landmarks on the chest
The nipple is an anatomic landmark for the fourth intercostal space. Avoid the pectoralis muscle and the axillary artery.
Choose the appropriate insertion site at the fourth or fifth intercostal space at the midaxillary line.
Prepare the catheter for insertion. Close the hemostat or forceps around the insertion end of the chest tube. Clamp the end of the chest tube that will be connected to the Pleur-evac so that air cannot enter the pleural cavity once the chest tube is inserted.
Cleanse the identified insertion site with chlorhexidine 2%, cleaning from the insertion site outward in concentric circles. Allow to dry for 1 to 2 minutes.
Drape the desired anatomic region with a sterile drape or towels to create a surgical field. Make sure you can still view the patient's head and neck.
Using 1% lidocaine, anesthetize the insertion site. Some operators create a wheal. Infiltrate subcutaneous tissue first and then proceed to muscle, periosteum, and pleura. Infiltrating the pleura is vital to minimize discomfort in the awake patient.
Create a 2-cm superficial skin incision immediately above the rib, parallel to the rib and intercostal space. This will avoid injury to the neurovascular bundle if your incision extends more deeply than intended.
Insert a forceps or Kelly clamp into the incision to perform blunt dissection down to the intercostal space. This process may require several scissoring and separating maneuvers. Once the operator has dissected down to the pleura, gently advance the forceps in the closed position until the pleura is penetrated. Once pleural penetration is achieved, open the forceps to spread and dissect, creating a subcutaneous tunnel in the parietal pleura and intercostal muscles (Figure 10-7).
After penetrating the pleura with the instrument, a rush of air/fluid is often audible.
Grasp the curved hemostat that is holding the catheter and direct the catheter through the incision into the pleural cavity. Once this is achieved, stabilize the catheter with the opposite hand and release it from the hemostat. Slowly remove the hemostat from the chest and advance the catheter to the desired position. Condensation in the lumen of the tube indicates that it has entered the pleural space. Its entry site should be palpated to ensure that it is not in the subcutaneous tissue.
In most cases, the catheter will need to be directed anteriorly and superiorly. Advance the chest tube after releasing the hemostat. Ensure that the eyes/holes of the catheter are within the pleural space. Moisture that is present within the tube usually confirms its proper placement within the pleural space.
A purse string suture may be placed around the tube and the chest tube secured by wrapping and then tying the skin suture around the tube.
Cover the insertion site with an occlusive dressing. The use of Tegaderm over the insertion site permits visualization of the field.
After securing the chest tube, connect the chest tube to a Pleur-evac or similar device. If the chest tube is draining fluid, the operator may want to control the volume of drainage with intermittent clamping to avoid rapid fluid shifts and re-expansion pulmonary edema, especially in smaller children.
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Do not unclamp the chest tube until the drainage system is attached. This will prevent the inspiration of air into the pleural space.
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Abdominal paracentesis is a bedside procedure in which a needle is inserted into the peritoneal cavity and ascitic fluid is obtained. Diagnostic paracentesis involves the removal of a small amount of fluid for testing. Diagnostic peritoneal lavage is usually performed by a surgeon to rule out internal bleeding after a trauma and will not be explained here in detail. Therapeutic paracentesis typically involves the removal of a large volume of ascitic fluid to reduce intra-abdominal pressure and its associated symptoms (abdominal pain, dyspnea, feeding intolerance).
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Indications:
Evaluation of new-onset ascites
Diagnostic sampling of ascitic fluid (rule out bleeding, chyle leak, malignancy, or infection)
Therapeutic removal of ascitic fluid
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Relative
Potential sites on abdomen infected or compromised
Coagulopathy or bleeding diathesis
Recent intestinal tract surgery (<1 month)
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Equipment
Sterile gloves, gown, mask, and cap
Sterile surgical drapes
Antiseptic skin preparation
Local anesthetic (1% lidocaine)
21 or 23 gauge needles
Angiocatheters with syringes
Large-bore needle with plastic catheter
Sterile gauze pads (4 × 4)
Sterile containers for fluid collection
Culture tubes for samples
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Place the patient in a supine or side position.
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Cleanse the insertion site with cleansing solution. Work from the identified site of insertion and clean in a concentric pattern outward. Allow ∼1 minute to dry. Drape with sterile field/towels.
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Ultrasound guidance is recommended (if available) to locate the optimal pocket of fluid.
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Using 1% lidocaine, initially anesthetize the insertion site; injecting the skin first and then deeper into the subcutaneous layer.
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The anterosuperior iliac spine should be located and a site chosen that is ∼3 cm medial and ∼ 3 cm cephalad to this landmark (Figure 10-8). The inferior epigastric arteries run from a point just lateral to the pubic tubercle cephalad within the rectus sheath and should be avoided due to the risk of bleeding. Insert the tap needle into the anesthetized area. In most children, depending on size and body habitus, fluid can be obtained by inserting the needle 1 to 2 inches into the abdomen. To prevent ascites leak after the procedure, the Z-track technique can be utilized, which creates a nonlinear track to prevent direct connection between the ascitic fluid in the peritoneal cavity and the skin (Figure 10-9).
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If a large volume of paracentesis is required, connecting the insertion needle to a three-way stopcock may facilitate removal so that the operator does not need to disconnect the syringe from the needle and risk migration of the needle/catheter setup.
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Obtain as much fluid as desired for laboratory sampling or therapeutic relief.
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Remove the needle and place a pressure dressing at the insertion site.
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Colloid replacement is controversial and likely unnecessary unless removing more than 5 liters of fluid in larger children. Some studies suggest the use of colloid replacement when draining >200 mL/kg (dry weight) in children to prevent circulatory changes and potential renal compromise.
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albumin therapy in children with severe ascites due to liver disease.
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Van Heeckeren DW, Moss MM. Pericardiocentesis and pericardial tube insertion. In Blumer JL, ed. A Practical Guide to Pediatric Intensive Care. St. Louis, MO: Mosby-Year Book; 1990.
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