Emergency Medicine Procedures, Second Edition

Emergency Medicine
Procedures
NOTICE
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Emergency Medicine
Procedures
Second Edition
Eric F. Reichman, PhD, MD, FAAEM, FACEP

Associate Professor of Emergency Medicine
Attending Physician, Department of Emergency Medicine
Medical Director, Surgical and Clinical Skills Center
University of Texas Health Science Center at Houston-Medical School
Attending Physician, Emergency Department
Memorial Hermann Hospital-Texas Medical Center
Attending Physician, Emergency Department
Lyndon Baines Johnson General Hospital
Houston, Texas
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Copyright © 2013 by Eric F. Reichman, PhD, MD. All rights reserved. Except as permitted under the United States Copyright Act of 1976, no part of this publication
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To my wife, Kristi. Thanks for your patience with the
semi-permanent card table and computer in the living room,
and the mess with all the papers and files. Thanks for your support
and understanding. Thanks to Joey, Jake, Rocky, and Phoebe
for entertaining me each day.
This page intentionally left blank
Contents
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii 18 Supraglottic Airway Devices . . . . . . . . . . . . . . . . . . . 106

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxiii Fred A. Severyn
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxiv 19 Laryngeal Mask Airways . . . . . . . . . . . . . . . . . . . . . 110
Katrin Takenaka and Theltonia Howard
SECTION 1 Introductory Chapters . . . . . . . . . . . . . . . . 1 20 Double Lumen Airway Tube Intubation . . . . . . . . . . . . 122
1 Informed Consent for Procedures Joseph Weber
in the Emergency Department . . . . . . . . . . . . . . . . . . . 1 21 Fiberoptic Endoscopic Intubation . . . . . . . . . . . . . . . 127
Eric Isaacs Erika D. Schroeder, M. Scott Linscott, and Joseph Bledsoe
2 Aseptic Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 22 Nasotracheal Intubation . . . . . . . . . . . . . . . . . . . . . 134
John S. Rose Ned F. Nasr, Raed Rahman, and Isam F. Nasr
3 Basic Principles of Ultrasonography . . . . . . . . . . . . . . . 13 23 Retrograde Guidewire Intubation . . . . . . . . . . . . . . . 139
Gregory M. Press Roland Petri
4 Ultrasound-Assisted Procedures . . . . . . . . . . . . . . . . . 24 24 Percutaneous Transtracheal Jet Ventilation . . . . . . . . . . 143
Jehangir Meer, Sam Hsu, and Brian Euerle Eric F. Reichman and Aaron Brown
5 Trauma Ultrasound: The FAST Exam . . . . . . . . . . . . . . . 28 25 Cricothyroidotomy . . . . . . . . . . . . . . . . . . . . . . . . 148
Wes Zeger Eric F. Reichman
26 Tracheostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
SECTION 2 Respiratory Procedures . . . . . . . . . . . . . . 35 Teresa M. Romano and Christopher J. Haines
6 Essential Anatomy of the Airway . . . . . . . . . . . . . . . . 35 27 Tracheostomy Care . . . . . . . . . . . . . . . . . . . . . . . . 171
Ned F. Nasr, Serge G. Tyler, H. Gene Hern Jr.
Gennadiy Voronov, and Isam F. Nasr 28 Transtracheal Aspiration . . . . . . . . . . . . . . . . . . . . . 177
7 Basic Airway Management . . . . . . . . . . . . . . . . . . . . 40 Joseph A. Salomone III
Christopher J. Russo and Zach Kassutto
8 Pharmacologic Adjuncts to Intubation. . . . . . . . . . . . . . 47 SECTION 3 Cardiothoracic Procedures . . . . . . . . . . . 181
Ned F. Nasr, David W. Boldt, and Isam F. Nasr 29 Cardiac Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . 181
9 Endotracheal Medication Administration . . . . . . . . . . . . 56 Gregory M. Press and Amy Rasmussen
Shoma Desai 30 Cardioversion and Defibrillation . . . . . . . . . . . . . . . . 193
10 Rapid Sequence Induction . . . . . . . . . . . . . . . . . . . . . 60 Payman Sattar
Piotr C. Aljindi, Ned F. Nasr, and Isam F. Nasr 31 Transcutaneous Cardiac Pacing . . . . . . . . . . . . . . . . . 197
11 Orotracheal Intubation . . . . . . . . . . . . . . . . . . . . . . . 64 Todd M. Larabee
Eric F. Reichman and Joseph Cornett 32 Transthoracic Cardiac Pacing . . . . . . . . . . . . . . . . . . 202
12 Confirmation of Endotracheal Intubation . . . . . . . . . . . . 76 Simon M. Pulfrey
Tarlan Hedayati and Leonardo Rodriguez 33 Transvenous Cardiac Pacing. . . . . . . . . . . . . . . . . . . 205
13 Video-Assisted Orotracheal Intubation Devices . . . . . . . . 80 Eric F. Reichman, Myles C. McClelland, and Brian Euerle
Pholaphat Charles Inboriboon 34 Pacemaker Assessment . . . . . . . . . . . . . . . . . . . . . 212
14 Fiberoptic-Assisted Orotracheal Intubation Devices . . . . . 89 Nnaemeka G. Okafor
Michael Lutes and Olga Pawelek 35 Automatic Implantable
15 Endotracheal Tube Intubating Introducers and Bougies . . . 95 Cardioverter-Defibrillator Assessment. . . . . . . . . . . . . 218
Olga Pawelek and Eric F. Reichman Carlos J. Roldan
16 Digital (Tactile) Orotracheal Intubation . . . . . . . . . . . . 100 36 Pericardiocentesis . . . . . . . . . . . . . . . . . . . . . . . . . 225
O. John Ma and Amanda Munk Eric F. Reichman, Elisabeth Kang, and Jehangir Meer
17 Lighted Stylet Intubation . . . . . . . . . . . . . . . . . . . . . 102 37 Intracardiac Injection . . . . . . . . . . . . . . . . . . . . . . . 236
Philip Bossart and Michael Wallace Payman Sattar
vii
viii Contents
38 Needle Thoracostomy . . . . . . . . . . . . . . . . . . . . . . 238 61 Whole Bowel Irrigation. . . . . . . . . . . . . . . . . . . . . . 398

Eric F. Reichman and Elizabeth Sowell Steven E. Aks and David D. Gummin
39 Tube Thoracostomy . . . . . . . . . . . . . . . . . . . . . . . . 242 62 Esophageal Foreign Body Removal . . . . . . . . . . . . . . 401
Kimberly T. Joseph Bashar M. Attar
40 Thoracentesis . . . . . . . . . . . . . . . . . . . . . . . . . . . 250 63 Balloon Tamponade of Gastrointestinal Bleeding . . . . . . 407
Eric F. Reichman, Cristal R. Cristia, and Jehangir Meer Bashar M. Attar
41 Open Chest Wound Management . . . . . . . . . . . . . . . 263 64 Gastrostomy Tube Replacement . . . . . . . . . . . . . . . . 414
Eric F. Reichman Maggie Ferng and Ryan C. Headley
42 Emergency Department Thoracotomy . . . . . . . . . . . . 267 65 Paracentesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421
Kenny Banh Susan B. Promes, Elizabeth M. Datner, and Sam Hsu
43 Open Cardiac Massage. . . . . . . . . . . . . . . . . . . . . . 271 66 Diagnostic Peritoneal Lavage . . . . . . . . . . . . . . . . . . 431
Eric F. Reichman Sandeep Johar and Umashankar Lakshmanadoss
44 Cardiac Wound Repair . . . . . . . . . . . . . . . . . . . . . . 274 67 Anal Fissure Management . . . . . . . . . . . . . . . . . . . . 439
Eric F. Reichman Marilyn M. Hallock and Eric F. Reichman
45 Hilum and Great Vessel Wound Management . . . . . . . . 280 68 External Hemorrhoid Management . . . . . . . . . . . . . . 443
Eric F. Reichman Charles Orsay and Eric F. Reichman
46 Thoracic Aortic Occlusion . . . . . . . . . . . . . . . . . . . . 282 69 Prolapsed Rectum Reduction . . . . . . . . . . . . . . . . . . 446
Eric F. Reichman Jamil D. Bayram and Eric F. Reichman
70 Anoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 449
SECTION 4 Vascular Procedures . . . . . . . . . . . . . . . . 287 Charles Orsay and Eric F. Reichman
47 General Principles of Intravenous Access . . . . . . . . . . . 287 71 Rigid Rectosigmoidoscopy . . . . . . . . . . . . . . . . . . . . 453
Daniel Belmont Charles Orsay and Eric F. Reichman
48 Venipuncture and Peripheral Intravenous Access . . . . . . 296 72 Rectal Foreign Body Extraction . . . . . . . . . . . . . . . . . 458
Daniel Belmont Charles Orsay and Eric F. Reichman
49 Central Venous Access . . . . . . . . . . . . . . . . . . . . . . 308
Arun Nagdev and Craig Sisson SECTION 6 Orthopedic and
50 Ultrasound-Guided Vascular Access . . . . . . . . . . . . . . 327 Musculoskeletal Procedures . . . . . . . . . . 465
Srikar Adhikari 73 Bursitis and Tendonitis Therapy . . . . . . . . . . . . . . . . 465
51 Troubleshooting Indwelling Central Venous Lines. . . . . . 337 Dedra Tolson
James J. McCarthy 74 Compartment Pressure Measurement . . . . . . . . . . . . 473
52 Accessing Indwelling Central Venous Lines . . . . . . . . . . 340 Matt Kleinmaier and Sanjeev Malik
Lisa Freeman Grossheim 75 Fasciotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 480
53 Pulmonary Artery (Swan-Ganz) Catheterization . . . . . . 344 Justin Mazzillo, Sobia Ansari, and Eric F. Reichman
Pratik Doshi 76 Extensor Tendon Repair . . . . . . . . . . . . . . . . . . . . . 490
54 Peripheral Venous Cutdown. . . . . . . . . . . . . . . . . . . 350 Jaime Harper, Stanley Harper, and Ramasamy Kalimuthu
Flavia Nobay 77 Arthrocentesis . . . . . . . . . . . . . . . . . . . . . . . . . . . 495
55 Intraosseous Infusion . . . . . . . . . . . . . . . . . . . . . . . 361 Eric F. Reichman, John Larkin, and Brian Euerle
Amanda Munk and O. John Ma 78 Methylene Blue Joint Injection . . . . . . . . . . . . . . . . . 517
56 Umbilical Vessel Catheterization . . . . . . . . . . . . . . . . 369 Joseph E. Tonna, Heather H. Bohn, and Matthew R. Lewin
Eric F. Reichman, Amy Noland, and Antonio E. Muñiz 79 Basic Principles of Fracture and Joint Reductions . . . . . . 522
57 Arterial Puncture and Cannulation . . . . . . . . . . . . . . . 376 Scott C. Sherman
Zak Foy and Susan Stroud 80 Sternoclavicular Joint Dislocation Reduction . . . . . . . . . 526
Eric F. Reichman
SECTION 5 Gastrointestinal Procedures . . . . . . . . . . 387 81 Shoulder Joint Dislocation Reduction . . . . . . . . . . . . . 531
58 Nasogastric Intubation . . . . . . . . . . . . . . . . . . . . . . 387 Eric F. Reichman
Lisa Freeman Grossheim 82 Elbow Joint Dislocation Reduction . . . . . . . . . . . . . . . 549
59 Activated Charcoal Administration . . . . . . . . . . . . . . . 391 Angelique S. Kelly Campen
Jenny J. Lu 83 Radial Head Subluxation (“Nursemaid’s Elbow”)
60 Gastric Lavage . . . . . . . . . . . . . . . . . . . . . . . . . . . 393 Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 553
Jenny J. Lu Mark P. Kling and Eric F. Reichman
Contents ix
84 Metacarpophalangeal Joint Dislocation Reduction . . . . . 557 107 Paronychia or Eponychia Incision and Drainage . . . . . . 713
Michael Bublewicz and Antonio E. Muñiz Lisa R. Palivos
85 Interphalangeal Joint Dislocation Reduction . . . . . . . . . 561 108 Felon Incision and Drainage . . . . . . . . . . . . . . . . . . 716
Matt Kleinmaier and Sanjeev Malik Lisa R. Palivos
86 Hip Joint Dislocation Reduction . . . . . . . . . . . . . . . . 565 109 Pilonidal Abscess or Cyst Incision and Drainage. . . . . . . 718
George Chiampas and Steve Zahn Lauren M. Smith
87 Patellar Dislocation Reduction . . . . . . . . . . . . . . . . . 571 110 Perianal Abscess Incision and Drainage . . . . . . . . . . . . 722
Mark P. Kling Maggie Ferng and Ryan C. Headley
88 Knee Joint Dislocation Reduction . . . . . . . . . . . . . . . 574 111 Sebaceous Cyst Incision and Drainage . . . . . . . . . . . . 728
Sharad Pandit and Zach Kassutto Carlos J. Roldan
89 Ankle Joint Dislocation Reduction . . . . . . . . . . . . . . . 577 112 Hemorrhage Control . . . . . . . . . . . . . . . . . . . . . . . 731
Jim Comes Christopher Freeman and Eric F. Reichman
90 Common Fracture Reduction . . . . . . . . . . . . . . . . . . 582 113 Trigger Point Injections . . . . . . . . . . . . . . . . . . . . . . 738
Eric F. Reichman and Robert M. Zesut Danielle Campagne
91 Casts and Splints . . . . . . . . . . . . . . . . . . . . . . . . . 592 114 Escharotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 741
Eric F. Reichman and Harold A. Sloas Michael A. Schindlbeck
SECTION 7 Skin and Soft Tissue Procedures . . . . . . . 609 SECTION 8 Neurologic and
92 General Principles of Wound Management . . . . . . . . . 609 Neurosurgical Procedures . . . . . . . . . . . . 747
Lisa Freeman Grossheim 115 Lumbar Puncture . . . . . . . . . . . . . . . . . . . . . . . . . 747
93 Basic Wound Closure Techniques . . . . . . . . . . . . . . . 623 Eric F. Reichman, Kevin Polglaze, and Brian Euerle
Eric F. Reichman and Candace Powell 116 Burr Holes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 761
94 Tissue Adhesives for Wound Repair . . . . . . . . . . . . . . 647 Eric F. Reichman
Hagop M. Afarian 117 Lateral Cervical Puncture . . . . . . . . . . . . . . . . . . . . 767
95 Advanced Wound Closure Techniques . . . . . . . . . . . . 650 Eric F. Reichman
Eric F. Reichman 118 Ventriculostomy . . . . . . . . . . . . . . . . . . . . . . . . . . 770
96 Management of Specific Soft Tissue Injuries . . . . . . . . . 659 Eric F. Reichman
Christopher J. Russo and Ajay Desai 119 Ventricular Shunt Evaluation and Aspiration . . . . . . . . . 775
97 Subcutaneous Foreign Body Eric F. Reichman
Identification and Removal . . . . . . . . . . . . . . . . . . . 669 120 Subdural Hematoma Aspiration in the Infant . . . . . . . . 779
Samuel J. Gutman and Michael B. Secter Eric F. Reichman
98 Ultrasound-Guided Foreign Body 121 Skeletal Traction (Gardner-Wells Tongs) for
Identification and Removal . . . . . . . . . . . . . . . . . . . 676 Cervical Spine Dislocations and Fractures . . . . . . . . . . 783
Daniel S. Morrison Eric F. Reichman
99 Tick Removal . . . . . . . . . . . . . . . . . . . . . . . . . . . . 679 122 Edrophonium (Tensilon) Testing . . . . . . . . . . . . . . . . 786
Zach Kassutto Eric F. Reichman
100 Fishhook Removal . . . . . . . . . . . . . . . . . . . . . . . . 681
Eric F. Reichman and Renee C. Hamilton SECTION 9 Anesthesia and Analgesia . . . . . . . . . . . . 789
101 Ring Removal . . . . . . . . . . . . . . . . . . . . . . . . . . . 684 123 Local Anesthesia. . . . . . . . . . . . . . . . . . . . . . . . . . 789
Steven H. Bowman Michael A. Schindlbeck
102 Subungual Hematoma Evacuation . . . . . . . . . . . . . . . 690 124 Topical Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . 795
Steven H. Bowman Erika D. Schroeder and Peter Taillac
103 Subungual Foreign Body Removal . . . . . . . . . . . . . . . 694 125 Hematoma Blocks . . . . . . . . . . . . . . . . . . . . . . . . . 799
Steven H. Bowman Thomas P. Graham
104 Nail Bed Repair . . . . . . . . . . . . . . . . . . . . . . . . . . 697 126 Regional Nerve Blocks (Regional Anesthesia) . . . . . . . . 802
Raemma Paredes Luck and Eric F. Reichman Eric F. Reichman, Jehangir Meer, and Nikesh Seth
105 Ganglion Cyst Aspiration and Injection . . . . . . . . . . . . 704 127 Intravenous Regional Anesthesia . . . . . . . . . . . . . . . . 843
Thomas P. Graham Christopher Freeman
106 Subcutaneous Abscess Incision and Drainage . . . . . . . . 706 128 Nitrous Oxide Anesthesia . . . . . . . . . . . . . . . . . . . . 849
Samuel J. Gutman and Michael B. Secter Antonio E. Muñiz
x Contents
129 Procedural Sedation and 149 Phimosis Reduction . . . . . . . . . . . . . . . . . . . . . . . . 995

Analgesia (Conscious Sedation) . . . . . . . . . . . . . . . . 854 Eric F. Reichman and Natana Peres
Hagop M. Afarian 150 Dorsal Slit of the Foreskin . . . . . . . . . . . . . . . . . . . . 998
Carlos J. Roldan
SECTION 10 Obstetrical and 151 Manual Testicular Detorsion . . . . . . . . . . . . . . . . . . 1001
Gynecologic Procedures . . . . . . . . . . . . 869 Steven Go
130 Ultrasound in Pregnancy . . . . . . . . . . . . . . . . . . . . 869 152 Zipper Injury Management . . . . . . . . . . . . . . . . . . 1004
Srikar Adhikari and Wes Zeger Zach Kassutto
131 Normal Spontaneous Vaginal Delivery . . . . . . . . . . . . 883
Swati Singh and Susan B. Promes SECTION 12 Ophthalmologic Procedures . . . . . . . . 1007
132 Episiotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 896 153 Eye Examination . . . . . . . . . . . . . . . . . . . . . . . . . . 1007
Francisco Orejuela Shari Schabowski
133 Shoulder Dystocia Management . . . . . . . . . . . . . . . . 904 154 Contact Lens Removal . . . . . . . . . . . . . . . . . . . . . 1022
Eric F. Reichman and Camaran E. Roberts Dino P. Rumoro
134 Breech Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . 910 155 Ocular Burn Management and Eye Irrigation . . . . . . . 1026
Irene E. Aga Steven J. Socransky
135 Postpartum Hemorrhage Management . . . . . . . . . . . . 917 156 Intraocular Pressure Measurement (Tonometry) . . . . . 1032
Leah W. Antoniewicz Michelle M. Verplanck, Mark A. Rolain, and Aaron D. Cohn
136 Perimortem Cesarean Section . . . . . . . . . . . . . . . . . 922 157 Digital Globe Massage . . . . . . . . . . . . . . . . . . . . . 1038
Silvia Linares Carlos J. Roldan and Eric F. Reichman
137 Symphysiotomy . . . . . . . . . . . . . . . . . . . . . . . . . . 928 158 Anterior Chamber Paracentesis. . . . . . . . . . . . . . . . . 1041
Ikem Ajaelo Rene Pineda Carizey
138 Bartholin Gland Abscess or 159 Corneal Foreign Body Removal. . . . . . . . . . . . . . . . 1043
Cyst Incision and Drainage . . . . . . . . . . . . . . . . . . . 930 Eric F. Reichman
Charlie C. Kilpatrick 160 Corneal Rust Ring Removal . . . . . . . . . . . . . . . . . . . 1047
139 Sexual Assault Examination . . . . . . . . . . . . . . . . . . . 935 Eric F. Reichman
Ann I. Schutt-Ainé and Audra E. Timmins 161 Eye Patching and Eye Shields . . . . . . . . . . . . . . . . . 1050
140 Culdocentesis . . . . . . . . . . . . . . . . . . . . . . . . . . . 945 Rebecca R. Roberts
David L. Levine 162 Lateral Canthotomy and Cantholysis or Acute
141 Prolapsed Uterus Reduction . . . . . . . . . . . . . . . . . . . 948 Orbital Compartment Syndrome Management . . . . . . 1053
Eric R. Snoey Jamil D. Bayram and Sami H. Uwaydat
163 Globe Luxation Reduction . . . . . . . . . . . . . . . . . . . 1056
SECTION 11 Genitourinary Procedures . . . . . . . . . . . 953 Jeffrey S. Schlab
142 Urethral Catheterization . . . . . . . . . . . . . . . . . . . . . 953 164 Hordeolum (Stye) Incision and Drainage . . . . . . . . . . 1058
Richard Dean Robinson and Eric F. Reichman Sami H. Uwaydat and Jamil D. Bayram
143 Suprapubic Bladder Aspiration . . . . . . . . . . . . . . . . . 963
Richard Dean Robinson, Sam Hsu, and Eric F. Reichman SECTION 13 Otolaryngologic Procedures . . . . . . . . 1063
144 Suprapubic Bladder Catheterization 165 External Auditory Canal Foreign Body Removal . . . . . . 1063
(Percutaneous Cystostomy) . . . . . . . . . . . . . . . . . . . 968 Rebecca R. Roberts
Richard Dean Robinson, Sam Hsu, and Eric F. Reichman 166 Cerumen Impaction Removal . . . . . . . . . . . . . . . . . . 1070
145 Retrograde Urethrography and Cystography . . . . . . . . 976 Rebecca R. Roberts
Richard Dean Robinson and Eric F. Reichman 167 Tympanocentesis . . . . . . . . . . . . . . . . . . . . . . . . . 1075
146 Anesthesia of the Penis, Testicle, and Epididymis . . . . . . 981 Paul J. Jones
Eric F. Reichman 168 Auricular Hematoma Evacuation . . . . . . . . . . . . . . . . 1078
147 Priapism Management . . . . . . . . . . . . . . . . . . . . . . 984 Eric F. Reichman
Steven Go 169 Nasal Foreign Body Removal . . . . . . . . . . . . . . . . . 1084
148 Paraphimosis Reduction . . . . . . . . . . . . . . . . . . . . . 989 Raemma Paredes Luck
Ann P. Nguyen
Contents xi
170 Nasal Fracture Reduction . . . . . . . . . . . . . . . . . . . 1092 SECTION 15 Podiatric Procedures . . . . . . . . . . . . . 1169

Eric F. Reichman
184 Ingrown Toenail Management . . . . . . . . . . . . . . . . . 1169
171 Nasal Septal Hematoma Evacuation . . . . . . . . . . . . . 1099 Jeff Schaider
Michael Friedman, Meghan Wilson, and George Chiampas
185 Toe Fracture Management . . . . . . . . . . . . . . . . . . . . 1173
172 Epistaxis Management . . . . . . . . . . . . . . . . . . . . . . 1103 George Chiampas and Steve Zahn
Stephen M. Kelanic, David D. Caldarelli, and Eric F. Reichman
186 Neuroma Management . . . . . . . . . . . . . . . . . . . . . 1177
173 Laryngoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . 1113 Eric R. Snoey and Stephen Miller
Steven Charous
174 Airway Foreign Body Removal . . . . . . . . . . . . . . . . . 1120 SECTION 16 Miscellaneous Procedures . . . . . . . . . . 1181
David L. Walner 187 Relief of Choking and Acute Upper Airway
175 Peritonsillar Abscess Incision and Drainage . . . . . . . . . 1125 Foreign Body Removal . . . . . . . . . . . . . . . . . . . . . . 1181
Eric F. Reichman, Kellie D. Hughes, and Jehangir Meer Tamara Espinoza, Shekhar Menon, and John Bailitz
188 Induction of Therapeutic Hypothermia . . . . . . . . . . . . 1185
SECTION 14 Dental Procedures . . . . . . . . . . . . . . . 1131 Mark Hansen, Mike Nelson, and John Bailitz
176 Dental Anesthesia and Analgesia. . . . . . . . . . . . . . . . 1131 189 Hypothermic Patient Management. . . . . . . . . . . . . . . 1191
Eric F. Reichman Gary An and Nabil Issa
177 Dental Abscess Incision and Drainage. . . . . . . . . . . . . 1141 190 Hyperthermic Patient Management . . . . . . . . . . . . . . 1201
Daniel J. Ross Eileen F. Couture
178 Post-Extraction Pain and Dry Socket 191 Autotransfusion . . . . . . . . . . . . . . . . . . . . . . . . . 1205
(Alveolar Osteitis) Management . . . . . . . . . . . . . . . . 1146 Carlos J. Roldan and Amit Mehta
Eric F. Reichman
192 Helmet Removal . . . . . . . . . . . . . . . . . . . . . . . . . 1209
179 Post-Extraction Bleeding Management . . . . . . . . . . . . 1148 Eric F. Reichman
Eric F. Reichman
193 Hazmat Patient Management . . . . . . . . . . . . . . . . . . 1215
180 Defective Dental Restoration Management . . . . . . . . . . 1150 Atilla B. Üner
Daniel J. Ross
194 Physical Restraints . . . . . . . . . . . . . . . . . . . . . . . . 1218
181 Subluxed and Avulsed Tooth Management . . . . . . . . . . 1154 Cheryl Person, Dean Sagun, and Mark Fanning
Daniel J. Ross
195 Chemical Restraint . . . . . . . . . . . . . . . . . . . . . . . . 1224
182 Fractured Tooth Management . . . . . . . . . . . . . . . . . 1161 David K. Duong and Hemal Kanzaria
Daniel J. Ross
183 Temporomandibular Joint Dislocation Reduction . . . . . . 1165 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1231
Marilyn M. Hallock
Contributors
Srikar Adhikari, MD, MS, RDMS [50, 130] Leah W. Antoniewicz, MD [135]
Associate Professor Staff Physician
Department of Emergency Medicine Obstetrics and Gynecologic Associates
University of Arizona Medical Center Clear Lake Regional Medical Center
Tucson, Arizona Houston, Texas
Hagop M. Afarian, MD [94, 129] Bashar M. Attar, MD, PhD,

Assistant Clinical Professor of EM FACP, FACG, AGAF, FASGE [62, 63]
UCSF School of Medicine System-wide Chair for Gastroenterology and Hepatology
Department of Emergency Medicine Cook County Health and Hospitals System
UCSF Fresno Chairman, Division of Gastroenterology and Hepatology
Fresno, California Director, GI Fellowship Program
John H. Stroger Hospital of Cook County
Irene E. Aga, MD [134] Professor of Medicine
Assistant Professor Rush University Medical Center
Department of Obstetrics Chicago, Illinois
Gynecology, and Reproductive Sciences
The University of Texas Health Science Center John Bailitz, MD, FACEP, RDMS [187, 188]
Houston, Texas Emergency Medicine Ultrasound Director
Department of Emergency Medicine
Ikem Ajaelo, MD [137] Cook County Hospital
Staff Physician Assistant Professor of Emergency Medicine
Emergency Medicine Rush University Medical Center
Essentia Health-Sandstone Chicago, Illinois
Sandstone, Minnesota
Kenny Banh, MD [42]
Steven E. Aks, DO, FACMT, FACEP [61] Assistant Clinical Professor of Emergency Medicine, UCSF
Emergency Medicine
Director
University of California San Francisco Fresno
The Toxikon Consortium and Division of Toxicology
Fresno, California
Associate Professor of Emergency Medicine, Rush University
Cook County Hospital Jamil D. Bayram, MD, MPH, EMDM, MEd [69, 162, 164]
Chicago, Illinois Assistant Professor
Emergency Medicine
Piotr C. Aljindi, MD [10] Johns Hopkins University
Baltimore, Maryland
Attending Physician
Associate Program Director
Department of Anesthesiology Daniel Belmont, MD [47, 48]
Cook County Hospital Attending Physician
Assistant Professor of Anesthesiology Department of Emergency Medicine
Rush University Medical Center Elmhurst Memorial Hospital
Chicago, Illinois Elmhurst, Illinois
Gary An, MD [189] Joseph Bledsoe, MD [21]

Associate Professor of Surgery Surgery-Adjunct Assistant Professor
Department of Surgery Emergency Medicine
University of Chicago Medicine University of Utah School of Medicine
Chicago, Illinois Salt Lake City, Utah
Sobia Ansari, MD, MPH [75] Heather H. Bohn, DO [78]

Instructor Staff Physician
Emergency Department Arrowhead Regional Medical Center
Rush University Medical Center Loma Linda University Med Center
Chicago, Illinois Colton, California
xiii
xiv Contributors
David W. Boldt, MD, MS [8] Steven Charous, MD, FACS [173]

Assistant Clinical Professor Clinical Associate Professor
Anesthesiology and Critical Care Medicine Department of Otolaryngology-Head and Neck Surgery
Department of Anesthesiology Loyola University Medical Center
John H. Stroger Hospital of Cook County, Chicago, Illinois Maywood, Illinois
David Geffen School of Medicine
University of California Los Angeles George Chiampas, DO, FACEM [86, 171, 185]
Los Angeles, California
Assistant Professor
Philip Bossart, MD [17] Feinberg School of Medicine
Professor Northwestern University
Division of Emergency Medicine Team Physician Northwestern University
University of Utah Medical School Medical Director Bank of America Chicago Marathon
Salt Lake City, Utah Chicago, Illinois
Steven H. Bowman, MD, FACEP [101, 102, 103] Aaron D. Cohn, MD [156]
Program Director Glaucoma Specialists
Department of Emergency Medicine Riddle Eye Associates
Cook County Hospital Riddle Memorial Hospital
Assistant Professor of Emergency Medicine Media, Pennsylvania
Rush University Medical Center
Chicago, Illinois Jim Comes, MD [89]
Program Director
Aaron Brown, MD [24] Health Sciences Clinical Professor
Staff Physician Department of Emergency Medicine
Department of Emergency Medicine UCSF School of Medicine
Texas Health Presbyterian UCSF Fresno Emergency Medicine Program
Flower Mound, Texas Fresno, California
Michael Bublewicz, MD [84] Joseph Cornett, MD [11]

Clinical Assistant Professor of Emergency Medicine Staff Physician
Department of Emergency Medicine Emergency Department
University of Texas Health Science Center Baptist Health System
Houston, Texas San Antonio, Texas
David D. Caldarelli, MD [172] Eileen F. Couture, DO [190]

Professor and Chairman Emeritus Attending Physician
Department of Otolaryngology-Head and Neck Surgery Department of Emergency Medicine
Rush University Medical Center Cook County Hospital
Chicago, Illinois Assistant Professor of Emergency Medicine
Danielle Campagne, MD, FACEP [113] Chicago, Illinois
Assistant Clinical Professor of Emergency Medicine
Department of Emergency Medicine Cristal R. Cristia, MD [40]
UCSF-Fresno Staff Physician
Fresno, California Department of Emergency Medicine
Beth Israel Deaconess Hospital, Milton
Angelique S. Kelly Campen, MD [82] Milton, Massachusetts
Clinical Instructor of Emergency Medicine
Ronald Reagan UCLA Medical Center Elizabeth M. Datner, MD [65]
UCLA Emergency Medicine Center Vice Chair of Clinical Operations
Los Angeles, California Department of Emergency Medicine
Hospital of the University of Pennsylvania
Rene Pineda Carizey, DO [158] Philadelphia, Pennsylvania
Assistant Professor
Department of Emergency Medicine Ajay Desai, MD [96]
Rush University Medical Center Attending Physician
Chicago, Illinois Emergency Medicine
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Contributors xv
Shoma Desai, MD [9] Steven Go, MD [147, 151]

Assistant Professor Associate Professor of Emergency Medicine
Emergency Medicine Department of Emergency Medicine
LAC + USC Medical Center University of Missouri—Kansas City School of Medicine
Los Angeles, California Kansas City, Missouri
Pratik Doshi, MD [53] Thomas P. Graham, MD, FACEP [105, 125]

Assistant Professor of Emergency Medicine and Internal Medicine Professor of Medicine/Emergency Medicine
Emergency Medicine and Division of Critical Care Emergency Medicine Center
Department of Internal Medicine UCLA School of Medicine
University of Texas Health Science Center Los Angeles, California
Houston, Texas
Lisa Freeman Grossheim, MD, FACEP [52, 58, 92]
David K. Duong, MD, MS [195] Assistant Professor
Assistant Professor Department of Emergency Medicine
Department of Emergency Medicine University of Texas Health Science Center at
University of California, San Francisco Houston-Medical School
San Francisco, California Houston, Texas
Tamara Espinoza, MD [187] David D. Gummin, MD [61]

Assistant Professor of Emergency Medicine Medical Director
The Emory Clinic Poison Center
Atlanta, Georgia Children’s Hospital of Wisconsin
Professor of Emergency Medicine
Brian Euerle, MD, RDMS [4, 33, 77, 115] Section Chief of Medical Toxicology
Associate Professor Medical College of Wisconsin
Department of Emergency Medicine Milwaukee, Wisconsin
University of Maryland School of Medicine
Baltimore, Maryland Samuel J. Gutman, MD CCFP(EM) [97, 106]
Clinical Associate Professor
Mark Fanning, RN [194] Faculty of Medicine, Department of Emergency Medicine
Director of Nursing University of British Columbia
Department of Emergency Medicine Vancouver, British Columbia
Houston, Texas Christopher J. Haines, DO, FAAP, FACEP [26]
Drexel University College of Medicine
Maggie Ferng, MD [64, 110] Associate Professor of Pediatrics and Emergency Medicine
Instructor St. Christopher’s Hospital for Children
Department of Emergency Medicine Director, Department of Emergency Medicine
Rush University Medical Center Medical Director, Critical Care Transport Team
Chicago, Illinois Philadelphia, Pennsylvania
Zak Foy, MD [57] Marilyn M. Hallock, MD, MS, FACEP [67, 183]
Emergency Physician Assistant Professor
Emergency Department Emergency Department
Memorial Mission Hospital Rush University Medical Center
Asheville, North Carolina Chicago, Illinois
Christopher Freeman, MD, FACEP [112, 127] Renee C. Hamilton, MD [100]

Assistant Professor Staff Physician
Emergency Medicine Emergency Department
Assistant Medical Director University Emergency Department Baptist Health System
University of Alabama at Birmingham San Antonio, Texas
Birmingham, Alabama
Mark Hansen, MD [188]
Michael Friedman, MD [171] Staff Physician
Professor and Chairman, Section of Sleep Surgery Emergency Department
Rush University Medical Center Bon Secours-St. Francis Xavier Hospital
Professor and Chairman, Section of Otolaryngology Charleston, South Carolina
Advocate Illinois Masonic Medical Center
Medical Director
Chicago ENT an Advanced Center for Specialty Care
Chicago, Illinois
xvi Contributors
Jaime Harper, MD [76] Nabil Issa, MBChB, FRCS, FACS [189]

Emergency Medicine Attending Physician Assistant Professor
St Vincent Hospital Department of Surgery
Indianapolis, Indiana Northwestern University Feinberg School of Medicine
Chicago, Illinois
Stanley Harper, MD [76]
Board Certified Plastic Surgeon Sandeep Johar, DO, MS, FACEP [66]
St Vincent Hospital Assistant Professor
Indianapolis, Indiana Department of Emergency Medicine
Hartford Hospital
Ryan C. Headley, MD [64, 110] UCONN School of Medicine
General Surgeon Hartford, Connecticut
Suburban Surgical Associates
Berwyn, Illinois Paul J. Jones, MD [167]
Clinical Instructor of Surgery Acting Chairman and Assistant Professor
Feinberg School of Medicine Department of Otolaryngology-Head and Neck Surgery
Northwestern University Section Head, Pediatric Otolaryngology
Chicago, Illinois Rush University Medical Center
Chicago, Illinois
Tarlan Hedayati, MD, FACEP [12]
Assistant Professor Kimberly T. Joseph, MD, FACS, FCCM [39]
Assistant Program Director Division Chair
Department of Emergency Medicine Trauma ICU and Prevention
Cook County (Stroger) Hospital Department of Trauma
Chicago, Illinois John H Stroger Hospital of Cook County
Chicago, Illinois
H. Gene Hern Jr., MD, MS [27]
Associate Clinical Professor, UCSF Ramasamy Kalimuthu, MD [76]
Residency Director, Emergency Medicine Director of Microsurgery Services
Alameda County-Highland Clinical Professor of Plastic and Hand Surgery
Oakland, California Advocate Christ Medical Center
Chicago, Illinois
Theltonia Howard, MD [19]
Staff Physician Elisabeth Kang, MD [36]
South Fulton Medical Center Staff Physician
Wellstar Cobb Hospital Emergency Department
Atlanta, Georgia Baptist Health System
San Antonio, Texas
Sam Hsu, MD, RDMS [4, 65, 143, 144]
Assistant Professor Hemal Kanzaria, MD [195]
Emergency Department Attending Physician
University of Maryland School of Medicine Emergency Medicine
Baltimore, Maryland Ronald Reagan UCLA Medical Center
Kellie D. Hughes, MD [175]
Attending Physician Zach Kassutto, MD, FAAP [7, 88, 99, 152]
Department of Emergency Medicine Director
Anderson Hospital Pediatric Emergency Medicine
Maryville, Illinois Capital Health, New Jersey
Associate Professor Pediatrics and Emergency Medicine
Pholaphat Charles Inboriboon, MD, MPH, FACEP [13] Drexel University College of Medicine
Assistant Professor Philadelphia, Pennsylvania
Department of Emergency Medicine Attending Physician
University of Missouri Kansas City Department of Emergency Medicine
Truman Medical Center St. Christopher’s Hospital for Children
Kansas City, Missouri Philadelphia, Pennsylvania
Eric Isaacs, MD [1] Stephen M. Kelanic, MD, FACS [172]

Clinical Professor Assistant Professor
Department of Emergency Medicine Department of Otolaryngology and Bronchoesophagology
San Francisco General Hospital Rush University Medical Center
University of California, San Francisco Chicago, Illinois
San Francisco, California
Contributors xvii
Charlie C. Kilpatrick, MD [138] M. Scott Linscott, MD [21]

Vice Chairman Surgery-Adjunct Professor
Associate Professor Emergency Medicine
Department of Obstetrics and Gynecology University of Utah School of Medicine
Texas Tech University Health Science Center School of Medicine Salt Lake City, Utah
Lubbock, Texas
Jenny J. Lu, MD, MS [59, 60]
Matt Kleinmaier, MD [74, 85] Assistant Professor
Clinical Instructor Department of Emergency Medicine
Department of Emergency Medicine Division of Medical Toxicology
Northwestern Feinberg School of Medicine Cook County Hospital (Stroger)
Chicago, Illinois Chicago, Illinois
Mark P. Kling, MD, FAAEM, CSCS [83, 87] Raemma Paredes Luck, MD [104, 169]
Attending Physician Assistant Professor
Department of Emergency Medicine Department of Emergency Medicine
Cook County Hospital Temple University School of Medicine
Assistant Professor of Emergency Medicine Philadelphia, Pennsylvania
Chicago, Illinois Michael Lutes, MD [14]
Assistant Professor of Emergency Medicine
Umashankar Lakshmanadoss, MD, CCDS [66] Medical College of Wisconsin
Cardiovascular Fellow Madison Emergency Physicians
Division of Cardiology Madison, Wisconsin
Guthrie Clinic
Sayre, Pennsylvania O. John Ma, MD [16, 55]
Professor and Chair
Todd M. Larabee, MD [31] Department of Emergency Medicine
Assistant Professor Oregon Health and Science University
Department of Emergency Medicine Portland, Oregon
University of Colorado School of Medicine
Aurora, Colorado Sanjeev Malik, MD [74, 85]
Assistant Professor
John Larkin, MD [77] CAQ Sports Medicine
Attending Physician Assistant Medical Director
St. Luke’s Episcopal Hospital System Feinberg School of Medicine
Houston, Texas Northwestern University
Chicago, Illinois
David L. Levine, MD, FACEP [140]
Medical Director-Adult Emergency Services Justin Mazzillo, MD [75]
Cook County Hospital (Stroger) Chief Resident
Assistant Professor Emergency Medicine Department of Emergency Medicine
Rush University Medical Center University of Texas Health Science Center
Chicago, Illinois Houston, Texas
Matthew R. Lewin, MD, PhD, FACEP, FCAS [78] James J. McCarthy, MD [51]
Director Associate Professor of Emergency Medicine
Center for Exploration and Travel Health Vice-Chair of Operations
California Academy of Sciences Department of Emergency Medicine
San Francisco, California University of Texas Health Science Center at
Houston-Medical School
Silvia Linares, MD [136] Medical Director of Emergency Services
Memorial Hermann Hospital-Texas Medical center
Assistant Professor
Houston, Texas
Department of Obstetrics and Gynecology
University of Texas Health Science Center at
Houston-Medical School Myles C. McClelland, MD, MPH [33]
Attending Physician Attending Physician
Obstetrics and Gynecology Methodist Hospital-Texas Medical Center
Lyndon Baines General Hospital Attending Physician
Houston, Texas Methodist West Houston Hospital
Houston, Texas
xviii Contributors
Jehangir Meer, MD, RDMS, Ned F. Nasr, MD [6, 8, 10, 22]

FACEP, FRCPC [4, 36, 40, 126, 175] Vice Chairman for Academic Affairs and Program Director
Director of Emergency Ultrasound Chairman, Division of Neuroanesthesiology
Department of Emergency Medicine Department of Anesthesiology and Pain Management
Saint Agnes Hospital John H. Stroger, Jr. Hospital of Cook County
Baltimore, Maryland Chicago, Illinois
Amit Mehta, MD [191] Mike Nelson, MD, MS [188]

Resident Attending Physician Emergency Medicine
Department of Emergency Medicine Medical Toxicology Fellow
University of Texas at Health Science Center at Cook County Hospital (Stroger)
Houston-Medical School Chicago, Illinois
Houston, Texas
Ann P. Nguyen, MD [148]
Shekhar Menon, MD [187] Attending Physician
Staff Physician Emergency Trauma Department
NorthShore Medical Group Hackensack University Medical Center
Emergency Medicine Hackensack, New Jersey
Evanston, Illinois
Flavia Nobay, MD [54]
Stephen Miller, MD [186] Program Director
Attending Physician Department of Emergency Medicine
Emergency Medicine University of Rochester
Highland Hospital/Alameda County Medical Center Rochester, New York
Oakland, California
Amy Noland, MD [56]
Daniel S. Morrison, MD, RDMS, FACEP [98] Assistant Professor of Emergency Medicine
Department of Emergency Medicine University of Texas Health Science Center at
University of Medicine and Dentistry of New Jersey-Robert Wood Houston-Medical School
Johnson Medical School Houston, Texas
New Brunswick, New Jersey
Nnaemeka G. Okafor, MD, MS [34]
Amanda Munk, MD [16, 55] Assistant Professor
Staff Physician Medical Director of Informatics
Emergency Medicine Associates PC Department of Emergency Medicine
Southwest Washington Medical Center University of Texas Health Science Center at
Vancouver, Washington Houston-Medical School
Houston, Texas
Antonio E. Muñiz, MD [56, 84, 128]
Attending Physician Francisco Orejuela, MD [132]
Dallas Regional Medical Center Associate Professor
Dallas, Texas Department of Obstetrics and Gynecology
Arun Nagdev, MD [49] Houston-Medical School
Houston, Texas
Director of Emergency Ultrasound
Ultrasound Fellowship Director
Department of Emergency Medicine Charles Orsay, MD [68, 70, 71, 72]
Alameda County Medical Center Chair
Highland General Hospital Department of Colorectal Surgery
Oakland, California Cook County Hospital
Professor of Surgery
Isam F. Nasr, MD [6, 8, 10, 22] Rush University Medical Center
Chicago, Illinois
Attending Physician
Cook County Hospital Lisa R. Palivos, MD [107, 108]
Assistant Professor of Emergency Medicine Attending Physician
Rush University Medical Center Department of Emergency Medicine
Chicago, Illinois Cook County Hospital
Chicago, Illinois
Contributors xix
Sharad Pandit, MBBS, DABP, FACEP [88] Simon M. Pulfrey, MSc, MD, CCFP(EM) [32]
Attending Physician Clinical Assistant Professor
Emergency Department Department of Emergency Medicine
Royal Adelaide Hospital University of British Columbia
Adelaide, Australia Vancouver, British Columbia
Olga Pawelek, MD [14, 15] Raed Rahman, DO [22]

Assistant Professor Medical Director of Pain Management
Department of Anesthesiology Cancer Treatment Centers of America
University of Texas Health Science Center at Midwestern Regional Medical Center
Houston-Medical School Zion, Illinois
Houston, Texas
Amy Rasmussen, MD [29]
Natana Peres, MD [149] Staff Physician
Assistant Professor Emergency Department
Department of Emergency Medicine Doctors Medical Center of Modesto
University of Texas Health Science Center at Modesto, California
Houston-Medical School
Houston, Texas Eric F. Reichman, PhD, MD, FAAEM, FACEP [11, 15, 24,
25, 33, 36, 38, 40, 41, 43, 44, 45, 46, 56, 67, 68, 69, 70, 71, 72,
Cheryl Person, MD [194] 75, 77, 80, 81, 83, 90, 91, 93, 95, 100, 104, 112, 115, 116, 117,
Assistant Professor of Psychiatry 118, 119, 120, 121, 122, 126, 133, 142, 143, 144, 145, 146, 149,
Department of Psychiatry and Behavioral Sciences 157, 159, 160, 168, 170, 172, 175, 176, 178, 179, 192]
Houston-Medical School Associate Professor of Emergency Medicine
Houston, Texas Attending Physician, Department of Emergency Medicine
Medical Director, Surgical and Clinical Skills Center
Roland Petri, MD, MPH [23] Houston-Medical School
Attending Physician Houston-Medical School
Department of Emergency Medicine Attending Physician, Emergency Department
Mayo Clinic Arizona Memorial Hermann Hospital-Texas Medical Center
Scottsdale, Arizona Attending Physician, Emergency Department
Kevin Polglaze, DO [115] Houston, Texas
Emergency Department Physician
Infinity Healthcare Camaran E. Roberts, MD [133]
Milwaukee, Wisconsin Staff Physician
Methodist Willowbrook Hospital
Candace Powell, MD [93] Houston, Texas
Attending Physician
Emergency Department Rebecca R. Roberts, MD [161, 165, 166]
Methodist Willowbrook Hospital Director of Research
Houston, Texas Department of Emergency Medicine
Cook County Health and Hospitals System
Gregory M. Press, MD, RDMS [3, 29] Assistant Professor
Director of Emergency Ultrasound Rush University Medical Center
Department of Emergency Medicine Chicago, Illinois
Houston-Medical School Richard Dean Robinson, MD [142, 143, 144, 145]
Houston, Texas Chairman
Susan B. Promes, MD, FACEP [65, 131] John Peter Smith Health Network
Professor and Vice Chair for Education Fort Worth, Texas
University of California San Francisco Leonardo Rodriguez, MD [12]
San Francisco, California Assistant Professor of Emergency Medicine
Keck School of Medicine of USC
Emergency Department
LAC + USC Medical Center
xx Contributors
Mark A. Rolain, MD [156] Payman Sattar, MD, MS, FACC [30, 37]
Professor of Ophthalmology Attending Physician
Oakland University/William Beaumont Medical School Department of Cardiology
Director of Refractive Surgery and Clinical Instructor Cook County Hospital
Beaumont Eye Institute Associate Professor of Medicine
Royal Oak, Michigan Rush University Medical Center
Chicago, Illinois
Carlos J. Roldan, MD, FACEP, FAAEM [35, 111, 150, 157, 191]
Associate Professor of Emergency Medicine Shari Schabowski, MD [153]
Department of Emergency Medicine Attending Physician
The University of Texas Health Science Center at Department of Emergency Medicine
Houston-Medical School Cook County Hospital
Houston, Texas Assistant Professor of Emergency Medicine
Teresa M. Romano, MD [26] Chicago, Illinois
Pediatric Emergency Medicine Physician
Emergency Medicine Jeff Schaider, MD [184]
Lehigh Valley Hospital Chairman
Allentown, Pennsylvania Department of Emergency Medicine
Cook County Health and Hospital System
John S. Rose, MD, FACEP [2] Professor
Professor
Chicago, Illinois
University of California Health System
Sacramento, California
Michael A. Schindlbeck, MD, FACEP [114, 123]
Daniel J. Ross, MD, DDS, FACEP [177, 180, 181, 182] Assistant Program Director
Attending Physician
Cook County Hospital
Section of Emergency Medicine
Jesse Brown VA Medical Center
Chicago, Illinois
Chicago, Illinois
Clinical Assistant Professor
University of Illinois at Chicago Jeffrey S. Schlab, MD [163]
Chicago, Illinois Staff Physician
Dino P. Rumoro, DO, FACEP [154] Seton Medical Center
Austin, Texas
Assistant Professor and Clinical Chairman
Rush University Medical Center Erika D. Schroeder MD, MPH [21, 124]
Chicago, Illinois Attending Physician
Christopher J. Russo, MD [7, 96] Providence Regional Medical Center
Everett, Washington
Attending Physician
Division of Emergency Medicine
Nemours/A.I. duPont Hospital for Children Ann I. Schutt-Ainé, MD [139]
Wilmington, Delaware Assistant Professor of Obstetrics and Gynecology
Dean Sagun, BA, EMT-I [194] Baylor College of Medicine
Houston, Texas
Medical Student (MS4)
The University of Texas at Houston Medical School Michael B. Secter, MD [97, 106]
Houston, Texas Resident Physician
Joseph A. Salomone III, MD [28] University of Toronto
Toronto, Canada
EMS Medical Director
Section Chief and Associate Professor
EMS Section Nikesh Seth, MD [126]
Department of Emergency Medicine Valley Pain Consultants
UMKC School of Medicine/Truman Medical Center St. Joseph’s Hospital and Medical Center-Phoenix
Kansas City, Missouri Phoenix, Arizona
Contributors xxi
Fred A. Severyn, MD, FACEP [18] Susan Stroud, MD [57]

Associate Professor Associate Clinical Professor of Surgery
Emergency Medicine Division of Emergency Medicine
University of Colorado School of Medicine University of Utah School of Medicine
Aurora, Colorado Salt Lake City, Utah
Scott C. Sherman, MD, FAAEM [79] Peter Taillac, MD [124]

Associate Residency Director Clinical Associate Professor
Department of Emergency Medicine Department of Surgery
Cook County Hospital (Stroger) Division of Emergency Medicine
Associate Professor of Emergency Medicine University of Utah School of Medicine
Rush University Medical Center Salt Lake City, Utah
Chicago, Illinois
Katrin Takenaka, MD, Med [19]
Swati Singh, MD [131] Associate Program Director
Clinical Instructor Associate Professor
UCSF The University of Texas at Health Science Center at
San Francisco, California Houston-Medical School
Houston, Texas
Craig Sisson, MD [49]
Assistant Professor/Clinical Audra E. Timmins, MD, MBA [139]
Emergency Medicine Assistant Professor
The University of Texas Health Science Center at San Antonio Medical Director of Women’s Services
San Antonio, Texas Texas Children’s Hospital Pavilion for Women
Obstetrics and Gynecology
Harold A. Sloas, DO, RDMS [91] Baylor College of Medicine
Houston, Texas
Assistant Clinical Professor of
Adult and Pediatric Emergency Medicine
Department of Emergency Medicine Dedra Tolson, MD [73]
The University of Texas Health Science Center at Staff Physician
Houston-Medical School Department of Emergency Medicine
Houston, Texas Madigan Army Medical Center
Tacoma, Washington
Lauren M. Smith, MD [109]
Director, Observation Unit Joseph E. Tonna, MD [78]
Department of Emergency Medicine Emergency Medicine Resident
Cook County Hospital Stanford/Kaiser Emergency Medicine Residency
Assistant Professor of Emergency Medicine Stanford University
Rush University Medical Center Stanford, California
Chicago, Illinois
Serge G. Tyler, MD [6]
Eric R. Snoey, MD [141, 186] Chairman
Vice Chair Department of Anesthesiology and Pain Management
Department of Emergency Medicine Division of Adult Anesthesia
Alameda County Medical Center, Oakland, California John H. Stroger, Jr. Hospital of Cook County
Clinical Professor of Emergency Medicine, UCSF Medical Center Chicago, Illinois
San Francisco, California
Atilla B. Üner, MD, MPH, FAAEM [193]
Steven J. Socransky, MD, FRCPC, DABEM [155] Associate Clinical Professor of Medicine/Emergency Medicine
Assistant Professor David Geffen School of Medicine at UCLA
Northern Ontario School of Medicine Emergency Medicine Center
Emergency Physician and Trauma Director Ronald Reagan UCLA Medical Center
Health Sciences North Los Angeles, California
Sudbury, Ontario
Sami H. Uwaydat, MD [162, 164]
Elizabeth Sowell, MD [38] Assistant Professor
Assistant Medical Director Ophthalmology
Department of Emergency Medicine Jones Eye Institute/UAMS
St. Luke’s Hospital at The Vintage Little Rock, Arkansas
Houston, Texas
xxii Contributors
Michelle M. Verplanck, DO [156] Meghan Wilson, MD [171]

General Ophthalmologist Otolaryngology Resident (PGY4)
Kensington Ophthalmology Department of Otolaryngology
Brighton, Michigan Louisiana State University Health Sciences Center
New Orleans, Louisiana
Gennadiy Voronov, MD [6]
Chairman Steve Zahn, MD [86, 185]
Department of Anesthesiology and Pain Management Staff Physician
John H. Stroger, Jr. Hospital of Cook County Emergency Department
Chicago, Illinois Sherman Health
Elgin, Illinois
Michael Wallace, MD [17]
Emergency Medicine Wes Zeger, DO [5, 130]
University of Utah Associate Professor
Salt Lake City, Utah Department of Emergency Medicine
The Nebraska Medical Center
David L. Walner, MD [174] Omaha, Nebraska
Associate Professor
Department of Otolaryngology Robert M. Zesut, DO, MPH [90]
Rush University Medical Center Director of Physician Coding and Compliance
Chicago, Illinois Emergency Medicine
Pediatric Otolaryngology Medical Center Emergency Physicians / Endeavor Medical Systems
Advocate Children’s Hospital Houston, Texas
Park Ridge, Illinois
Joseph Weber, MD [20]

EMS Medical Director
Chicago EMS System
Cook County Hospital
Chicago, Illinois
Preface
The scope of Emergency Medicine is extremely broad and covers Each chapter, with a few exceptions, has a standard format. The
the neonate through the geriatric, surgical, and medical, and encom- relevant anatomy and pathophysiology are discussed followed by the
passes all organ systems. Emergency Medicine is rapidly evolving indications and contraindications for the procedure. A list is pro-
to reflect our increasing experience, knowledge, and research. vided of the necessary equipment. The patient preparation, includ-
Procedural skills must supplement our cognitive skills. Achieving ing consent, anesthesia, and analgesia, is addressed. The procedure
proficiency in procedural skills is essential for the daily practice is then described in a step-by-step format. Cautions are placed where
of Emergency Medicine. We have produced a clear, complete, and problems commonly occur. Alternative techniques and helpful hints
easy-to-understand textbook of Emergency Medicine procedures. for each procedure are presented. The aftercare and follow-up are
This text will provide all practitioners, from the medical student to discussed. Any potential complications are described, including the
the seasoned Emergentologist, with a single procedural reference on methods to reduce and care for the complications. Finally, a sum-
which to base clinical practices and technical skills. mary contains a review of any critical or important information.
The primary purpose of this text is to provide a detailed and This book covers a wide variety of procedures. We have made an
step-by-step approach to procedures performed in the Emergency effort to think of most procedures that may be performed in a rural
Department. It is expressly about procedures. While well referenced, or urban Emergency Department and have incorporated it into
it is not meant to be a comprehensive reference but an easy-to- this text. This includes procedures performed routinely or rarely. It
use and clinically useful procedure book that should be in every also includes procedures that are often performed in the acute care,
Emergency Department. The contents and information are complete. clinic, and office setting. Some of the procedures in this book may be
It is organized and written for ease of access and usability. The detail performed frequently in the daily practice of Emergency Medicine,
is sufficient to allow the reader to gain a thorough understanding of such as laceration repair or endotracheal intubation. Other proce-
each procedure. When available, alternative techniques or hints are dures, such as a cricothyroidotomy, are seldom to rarely performed
presented. Each chapter provides the reader with clear and specific but critical to the practice of Emergency Medicine. While many of
guidelines for performing the procedure. Although some may use the procedures are well known to the Emergentologist, some are
this text as a library reference, its real place is in the Emergency uncommon and may not be known to the reader. This provides
Department where the procedures are performed. Despite its size, an opportunity to acquire new information that may be converted,
we hope that this book will find its way to the bedside to be used by with proper practice and training, into a useful skill. A few of the
medical students, residents, and practicing clinicians. procedures are performed only by Surgeons. They are included to
This book will satisfy the needs of physicians with a variety of promote understanding by those who may later see the patients in
backgrounds and training. While this text is primarily written for the Emergency Department and have to provide emergent care for
Emergentologists, many other practitioners will find this a valuable a complication. This edition has added chapters to cover additional
reference. This book is written for those who care for people with procedures, especially the Respiratory section. A few chapters of
acute illness or injury. Medical students and residents will find this seldom used procedures have been eliminated.
an authoritative work on procedural skills. Medical students, resi- We have drawn on a wide variety of authors. The majority
dents, nurse practitioners, physician’s assistants, and practitioners of authors are residency-trained, board-certified, and practicing
with limited experiences will find all the information in each chap- Emergentologists. We have the honor of having many contributors
ter to learn the complete procedure. Family Physicians, Internists, from outside the field of Emergency Medicine, who are experts
and Pediatricians will find this text useful to review procedures in their own specialty. The authors do have biases because of dif-
infrequently performed in the clinic, office, or urgent care center. ferences in education, experience, and training. We have tried to
Intensivists and Surgeons involved in the care of acutely ill patients base all recommendations on sound clinical and scientific data.
will also find this book a wonderful resource. The experienced However, we have not excluded personal experience or preferences
clinician can get a quick refresher on the procedure while enhanc- when appropriate. In these cases, the authors also present alternative
ing their knowledge and skills. Physicians actively involved in the techniques.
education of medical students and residents will find this text an Hopefully, this book has grown and changed with this second
easy-to-understand and well-illustrated source of didactic material. edition. Suggestions from you, the reader, would be most appreci-
The text has 16 sections containing 195 chapters. The contents ated. Let us know what additional procedures should be included or
are organized into sections, each representing an organ system, an excluded in the future.
area of the body, or a surgical specialty. Each chapter is devoted to a
Eric F. Reichman, PhD, MD
single procedure. This should allow quick access to complete infor-
mation. The chapters have a similar format to allow information to
be retrieved as quickly and as efficiently as possible. There are often
several acceptable methods to perform a procedure. While alterna-
tive techniques are described in many chapters, we have not exhaus-
tively included all alternative techniques. Key information, cautions,
and important facts are highlighted throughout the text in bold type.
xxiii
Acknowledgments
This has been educational and time-consuming. I must thank my I would also like to acknowledge Marcy, Venettea, Shadi, Jim,
wife Kristi for all of her patience during this endeavor that took Hoan, and especially Yolanda of the SCSC. Their daily support was
thousands of hours and four years. Joey, Phoebe, Jake, and Rocky invaluable.
always kept me entertained, day and night. I want to thank all the authors. Many of you are good friends that
I would like to acknowledge the support of friends, colleagues, I cherish and whom gave of themselves and their time.
current residents, and former residents in the Departments of Susan Gilbert is a wonderful medical illustrator and friend. Her
Emergency Medicine at The University of Texas at Houston Medical input and assistance only added to the illustrations of both editions
School and Cook County Hospital. They provided friendship and of this book.
encouragement, and were always there when needed. A special Thanks to all those at McGraw-Hill, especially Anne Sydor and
thanks goes to Bob Simon and Jeff Schaider who got me started and Brian Kearns. You kept me on track, and provided assistance when
set me on this academic path. needed and a kick in the butt when needed.
A special thanks goes to Brent King, MD, Patricia Butler, MD, and
Eric F. Reichman, PhD, MD
Nancy McNiel, PhD, for all their support and encouragement.
xxiv
SECTION
Introductory Chapters 1
treating facility, which is often dictated by EMS protocols. Tension
Informed Consent may arise when a patient’s wishes conflict with greater societal or
1 for Procedures in the institutional needs for efficiency and protocol compliance inde-
pendent of the patient’s preferences and needs. Examples include
Emergency Department a trauma activation or a public health emergency. Increasing space
constraints and crowding found in most EDs create a lack of pri-
Eric Isaacs vacy that can impede the free exchange of sensitive information.
Procedural interventions in the ED are often concurrently diagnos-
This chapter is designed as a practical reference for the Emergency tic and therapeutic, further complicating informed decisions.
Physician (EP). It focuses on the unique challenges of informed con- The torrent of complex medical information physicians provide
sent in the Emergency Department (ED). It presents a practical guide patients is overwhelming in the most controlled settings, and is only
for the informed consent process, reviews the exceptions, and offers made worse in the high emotion and high stress environment of
suggestions on difficult scenarios of informed consent in the ED. the ED. Emergency Physicians often make rapid decisions with lim-
ited information on a daily basis. Many of our colleagues in other
INFORMED CONSENT specialties may not share this skill, and our expectations of patients
must be equally, if not more, tolerant. The absence of an ongoing
The right of a patient to make decisions about their body, includ- physician–patient relationship offers no basis on which to build
ing the refusal of recommended procedures and treatment, is an trust, elicit values, and draw preference knowledge. Lack of a prior
important concept in medical practice with foundations in law and relationship tests the EP’s ability to establish an immediate rapport
medical ethics. Informed consent is the process of communica- with the patient, and renders the patients’ ability to express their
tion that demonstrates a physician’s respect for a patient’s right values most important.
to make autonomous decisions about their healthcare. Informed When there is uncertainty about a patient’s preferences or a
consent is both an ethical practice and a legal requirement for all potential refusal, there may not be time to ponder the intricacies of
procedures and treatments. medical ethics in the ED or to satisfy all the requirements of search-
ing for the best surrogate decision maker. Many EPs will default to
UNIQUE CHALLENGES OF doing as much as possible in these difficult situations,2 but there is
INFORMED CONSENT IN THE ED often enough time to make a considered decision before acting in
the most aggressive fashion. While some say that it is easier to with-
Each practice environment presents its own challenges to the pro- draw care once the clinical picture becomes clearer, this aggressive
cess of obtaining informed consent. Physicians frequently fail to course of action must be balanced with the knowledge that EPs may
fulfill all the requirements of obtaining informed consent.1 The ED be performing a painful or unwanted procedure on a patient who
presents significant challenges, which, despite assumptions to the has previously made their wishes clear. Traditionally, informed con-
contrary, results in a greater need to spend time delivering infor- sent was often bypassed under the presumption that a patient would
mation and engaging patients in their care decisions to the fullest want aggressive treatment. The scope of ED care and societal norms
extent possible (Table 1-1). Time pressure and acuity are the most have shifted in recent years. Informed consent for procedures in the
critical factors that influence the care paradigm in the ED. Care pro- ED needs to reflect the current standards of practice.
vided in the ED spans the full continuum of care (nonacute care
is increasingly sought in the ED) and addresses the full spectrum
of society (patients from diverse health literacy, language origins, LEGAL FOUNDATION FOR INFORMED CONSENT
socioeconomic backgrounds, and other recognized vulnerable pop-
Consent originates in the legal doctrine of battery (touching of the
ulations—elderly, children, prisoners). Emergency Physicians need
body without permission). The notion of protecting a patient from
to be prepared to address the broad clinical needs of diverse patients
the bodily trespass of a procedural invasion was framed by Justice
under pressure without the historical physician–patient relation-
Cardozo in 1914, “[e]very human being of adult years and sound
ship. Systemic constraints exacerbate this challenged professional
mind has a right to determine what shall be done with his own body;
context as patients have no choice in the treating physician or the
and a surgeon who performs an operation without his patient’s
consent commits an assault, for which he is liable in damages … .”3
By 1957, the notion of consent shifted from mere permission to an
TABLE 1-1 Challenges for the Emergency Physician to Spend authorization following “the full disclosure of facts necessary to
Time Engaged in Conversation with a Patient an informed consent.”4 Emerging at the same time as the bioeth-
Time pressure ics movement’s shift away from paternalistic medicine toward a
Little privacy patient’s rights focus in medicine was Canterbury v Spence.5 This
Pace of care challenges lay person decisions case resulted in an appeals court establishing a physician’s duty
No prior relationship to disclose the risks and benefits of a procedure and its alterna-
Lack of facility choice tives and introduced the reasonable patient standard. The rea-
Public health- or system-imposed constraints sonable patient standard is what a reasonable patient would
1
2 SECTION 1: Introductory Chapters
need to know to make an informed choice shifting away from the TABLE 1-2 The Goals of Emergency Physicians in the
professional standard, what most physicians deemed necessary. Informed Consent Process
Today, the standard for disclosure varies by state.6 As a result of the Support patients to make their own decision
informed consent “duty,” the legal and risk management function of Give information (more than we think we need to give)
informed consent (consent process that meets institutional and/or Make information accessible
legal parameters for formal recognition referred to as ‘effective con- Offer guidance in weighing information
sent’) overshadows the ethically driven process of informed consent Allow autonomous authorization (patient may consent or refuse)
(consent as communication process that demonstrates respect for
a patient’s autonomy referred to as ‘autonomous authorization’).
Often conflated under the “informed consent,” these two aspects
not to overwhelm a patient with too much information or complex
serve distinct functions. Both are necessary for valid informed con-
clinical decisions. Including patients in appropriate care decisions,
sent and are addressed separately throughout this chapter.7
such as the informed consent process for a procedural intervention,
is an ethically important goal.
LEGAL FOUNDATION OF THE Emergency Physicians must pay particular attention to the
EMERGENCY EXCEPTION informed consent process to accomplish the goal of respect for
The exception presuming permission to treat in an emergency has autonomy (Table 1-2). Foremost, EPs need to provide more infor-
equally deep roots. Justice Cardozo’s opinion continues, “[t]his is true mation to the patient than they think is needed. Research indicates
except in cases of emergency where the patient is unconscious and that patients need more information than physicians think they
where it is necessary to operate before consent can be obtained.”3 In need in order to feel “informed” in the decision-making process.11
Canterbury v Spence, “the emergency exception” is included as a privi- The need for a procedure seems obvious to the EP and the balance
lege from the duty to disclose when “the patient is unconscious or of the considerations clearly tips in the favor of “do it.” Emergency
otherwise incapable of consenting, and harm from a failure to treat is Physicians must slow down to fully explain the rationale for their
imminent and outweighs any harm threatened by the proposed treat- recommendation with the patient and to offer the patient informa-
ments.” It also states that a “physician should, as current law dictates, tion that allows their meaningful consideration of the recommenda-
attempt to secure a relative’s consent if possible.” In the emergency con- tion allowing them to reach their own decisions. A good guideline is
text one may presume permission: (1) to do what is necessary when to offer more time and information for procedures carrying greater
(a) there is imminent harm from nontreatment and (b) harm from risk.12 Emergency Physicians must make an effort to work against
nontreatment outweighs the harm from the proposed intervention; the features of the ED (Table 1-1 and presumption of consent)
(2) where the patient is unconscious or unable to participate in care and allow patients who are capable of engaging in their care deci-
decisions; and (3) the patient’s preferences are not known and no sions to express autonomous authorization. This is achieved by
surrogate is immediately available to provide authorization.8 giving patients sufficient information, in an understandable way,
and by honoring their decisions.
ETHICAL FOUNDATION FOR INFORMED CONSENT
COMPONENTS OF THE INFORMED CONSENT
In an era of patients’ rights and shared decision making, robust AND INFORMED REFUSAL PROCESS
informed consent reflects a process of communication that secures
that a patient “gives an informed consent to an intervention if (and Informed consent is the communication process that both dem-
perhaps only if) one is competent to act, receives a thorough disclo- onstrates and protects a patient’s self-determination by providing
sure, comprehends the disclosure, acts voluntarily, and consents to a patient with decision-making capacity with sufficient, under-
the intervention.”9 standable information and allowing the patient to make a volun-
It is not uncommon to encounter the challenge of a patient refus- tary, knowledgeable decision. There are five requirements that must
ing a recommended procedure or intervention in a healthcare be satisfied.13 These include the patient having decision-making
environment where there is an expectation for more active patient capacity, the EP providing sufficient information, the patient under-
participation in healthcare decisions. Central to a strong patient– standing the information, the patient giving consent in a voluntary
physician relationship is the desire to promote patient well-being fashion without coercion, and the patient communicating their
and simultaneously respect patient autonomy. Conflict between EPs decision (Table 1-3).
and patients may arise when views of what is in a patient’s best inter-
est differ. Emergency Physicians with the greatest integrity come to DECISION-MAKING CAPACITY
work with the intention to act in the best interests of patients, and
While the terms “competence” and “decision-making capacity” are
do so with a focus on the prevention and eradication of disease in
frequently used interchangeably, their strict meanings are different.
order to preserve life and improve disability. After an EP has fully
informed a capable patient about an intervention in an understand-
able way, the patient may consent or refuse the recommendation.
An initial refusal of recommended treatment should begin a critical TABLE 1-3 Requirements of the Informed Consent Process13
conversation that confirms all the elements of an informed refusal. 1 Does the patient have the decision-making capacity to make this decision?
Ultimately, this informed refusal process will respect patient auton- 2 Has there been disclosure of relevant procedural information (including
omy by accepting a patient’s view of well-being and may require risks/benefits for intervention, alternatives, and nonintervention)?
honoring a refusal of the EP’s recommendation.10 3 Has the information been presented in a way that is understandable
to the patient?
4 Has the information been presented in a way that allows the patient to
EMERGENCY PHYSICIAN’S ROLE AND make his or her own decision voluntarily while still being informed of the
GOALS IN INFORMED CONSENT PROCESS physician’s recommendation?
The EP’s role in the informed consent process is to provide patients 5 Has the patient communicated a decision?
the information needed to make their own decisions. It is important 6 Does an exception apply?
CHAPTER 1: Informed Consent for Procedures in the Emergency Department 3
Competence is a legal term with broader applications related Efforts should be made whenever possible to enhance the patient’s
to financial matters and the determination of personal choices. decision-making capacity (reduce pain medication temporarily or
Decision-making capacity is a clinical term that speaks to the spe- visit patients at optimal times) in order to engage them to the fullest
cific capacity to make a particular clinical decision. Many people extent possible in their care.
who are legally “incompetent” retain healthcare decision-making Emancipated minor and adolescent laws vary from state to state.9
capacity. If the patient does not have decision-making capacity, It is important to note that emancipated minors are legally recog-
informed consent cannot be obtained and it must be obtained from nized as adults and responsible for their own finances and care.
a surrogate decision maker, or the patient may fall into an exception They are able to provide fully informed consent. It is important for
from informed consent. EPs to know their local laws where minors who are not emanci-
pated may give consent for sensitive conditions or procedures such
DETERMINING DECISION-MAKING CAPACITY as those of a reproductive nature or substance abuse.
Informed consent may not be possible with some populations,
The determination that a patient has decision-making capacity is at
such as young children and elderly with dementia. It is still possible
the core of informed consent. By default, EPs assume that a patient
to inform these patients of the procedure and to engage their assent.
has capacity and confirm this through routine dialogue with the
Unlike consent, assent is not determinative. It does offer the pos-
individual. There are six elements that should be confirmed when
sibility of the individual participating in their care.15
there is a question about a patient’s capacity to make an informed
decision about procedures or treatment.14 The patient must be able
to: understand and process the options, weigh the benefits and risks, PATIENTS LACKING DECISION-MAKING CAPACITY
apply a set of values and goals to the decision, arrive at a decision, It is not possible to obtain informed consent when a patient lacks
communicate a choice, and demonstrate capacity to make the deci- decision-making capacity. Necessary treatment may be provided to
sion (Table 1-4). patients who lack decision-making capacity without obtaining the
Determination of capacity is a clinical decision based on the patient’s informed consent. However, EPs should make every effort
judgment of the EP regarding the patient’s actual level of function- to learn the patient’s previously stated preferences for treatment
ing and appreciation of the ramifications of the clinical situation. (e.g., written advance directive or communication with a primary
The degree of capacity needed to understand risks and benefits of care provider). Efforts should be made to obtain consent from a
suturing a finger laceration differs from a cardiac catheterization. As surrogate decision maker if prior preferences are not available. A
such, a patient may be able to understand one choice, but not another. surrogate decision maker is a person entrusted with making health-
An Alzheimer patient (who is pleasant, oriented to place and year) care decisions because they know the patient best and can bring the
may be unable to appreciate the consequences of a decision. While patient’s values and goals into the clinical decision process. This role
this patient may have capacity for some tasks, they may lack the capac- can be challenging for even the most capable decision makers. It is
ity to consent for a specific procedure such as a lumbar puncture. not uncommon for surrogates to have a role conflict between apply-
The EP needs to assess the ability for the individual to weigh the ing their own values and/or wishes and those of the patient.
risks in light of their own values. An example would be the ramifica- Emergency Physicians must pay attention to the language used
tions of a fracture reduction on the dominant hand. A construction when asking a surrogate decision maker for consent. Frame the dis-
worker or musician may make a decision different than an indi- cussion with phrases asking what the patient would want in the situ-
vidual whose livelihood does not depend on perfect hand function. ation such as “How would your father view this situation?” or “What
A recognized element of decision-making capacity is whether would your father’s preference be based on his values?” Avoid gen-
the patient’s decision is consistent over time. This is not necessar- eral phrases such as “What should we do?”, “What do you want us to
ily applicable specifically to the ED. A possible heuristic is whether do?”, or “What do you think he would want?” If the decision seems
the decision is consistent with the person’s narrative and values to stem from a role conflict, an EP can ask the surrogate “Why do
as expressed consistently over time in life choices. The decision- you think he would choose that?” No prior conversation covers
specific nature of capacity acknowledges that the level of capacity every clinical scenario perfectly and the gravity of the decision can
needed depends on the complexity of the decision, with greater frequently be overwhelming for the surrogate.10
capacity needed for decisions with graver consequences. The degree The choice of a surrogate decision maker may be quite obvious
of capacity needed to consent does not necessary equal the degree of in some cases such as the parent or legal guardian of a child. The
capacity needed to refuse a recommended intervention.10 Informed choice can be more complex in other cases. Who may serve as a sur-
refusal will be discussed later in this chapter. rogate and their scope of authority varies by state. What if the appro-
Decision-making capacity is a dynamic process and changes priate surrogate is in question and there is no statutory guidance?
depending on the patient’s evolving condition and task in ques- A useful guide is that the surrogate’s authority arises from a close
tion. The ED patient may be able to participate to a greater or lesser relationship to the patient that affords accurate and informed com-
extent depending on fluctuations in their condition and altera- munication of the patient’s values. Challenges in resolving conflict
tions of their sensorium from the administration of medications. between potential surrogates (e.g., siblings with different opinions
regarding parental care) should be referred to an ethics committee
or other institutional mechanisms to offer guidance unless emer-
TABLE 1-4 Elements to Determine if a Patient has gent conditions make that impractical.
Decision-Making Capacity
1 The patient is able to understand and process the options presented INFORMATION TRANSMITTAL
2 The patient is able to weigh the relative benefits, burdens, and risks of
the options The EP must relate sufficient information about the procedure to
3 The patient is able to apply a set of values and goals to the decision the patient. This raises the questions of what information to pres-
4 The patient is able to arrive at a decision that is consistent over time ent and how much to present. Relevant information includes the
5 The patient is able to communicate a choice risks and benefits of the procedure, any alternatives to the pro-
6 The patient demonstrates capacity appropriate and sufficient to make posed course of action, and the consequences of nonaction. The
this decision question remains how much information needs to be disclosed to
patients, particularly in light of the potential that legal action may be EFFECTIVE INFORMED CONSENT AND REFUSAL
taken if an EP does not obtain informed consent properly.16
There are two standards that are commonly used, and these There is a difference between the autonomous authorization
standards vary by state. The traditional “professional standard” informed consent (information and dialogue) and the effective
requires the EP to provide information based on what the profes- informed consent (to meet legal and institutional requirements).
sion’s standard of practice would deem necessary to disclose for a The EP should document the discussion of the benefits, bur-
patient to be informed. The more common “reasonable person stan- dens, risks, and alternatives addressed in the discussion with the
dard” requires the EP to include all the information that a reason- patient in order for an autonomous authorization to be recog-
able patient would want to know in order to make a knowledgeable nized as effective and, thus, the entire informed consent valid.
decision. Information that should be communicated includes: the Local institutional policies should be referenced to confirm an effec-
patient’s current medical condition and how will it progress if no tive informed consent or refusal.7
treatment is given, the treatment alternatives, the risks and benefits Some hospitals have patients sign “blanket” consent forms agree-
of each potential treatment and their probabilities, and the financial ing to all emergency tests and treatments on their registration in the
costs of each if those estimates exist. Finally, the EP should provide ED. Such consent forms provide no information regarding specific
a personal recommendation as to the best alternative.17 individual procedures. These forms are not acceptable because they
fail to respect patient autonomy. Blanket consent forms cannot sub-
UNDERSTANDABLE PRESENTATION stitute for the usual informed consent process for procedures in the
ED, where a dialogue with the patient is required.24
OF INFORMATION
Information must be given in a way that is understandable. The EXCEPTIONS TO THE INFORMED
patient must be able to adequately weigh the benefits, burdens, and CONSENT PROCESS
risks of the treatment in the context of their own beliefs, life, val-
ues, and goals. The obvious differential in knowledge and under- THE EMERGENCY EXCEPTION
standing between patients and EPs may be exacerbated by language
barriers, literacy, numeracy, and low educational levels.18 Such bar- Society’s overriding assumption is that a person would want lifesav-
riers may be overcome by: speaking at a level easy for the patient to ing treatment in an emergency situation. Consent to treatment is
comprehend, being sensitive to patients who may be unable to read, generally presumed under specific emergency circumstances where
and being sensitive of patients who may not be highly educated. intervention is necessary to save life or limb, the harm of nontreat-
Understanding is bidirectional and necessitates that EPs confirm ment is greater than the harm of the intervention, a patient is unable
that the patient understands what they are told.19 Communicating to participate in care decisions, and patient preferences are not
numbers, such as risk and probabilities, is the most complex task known with no surrogate available. This emergency exception is not
asked of EPs.20 Frame numbers in multiple ways and present out- absolute. This is particularly true when there is clear evidence that
comes in both positive and negative contexts to enhance informed the patient’s wishes are contrary to the intervention being consid-
consent.20 For example, “3 out of 4 children have no side effect but ered, such as a prehospital advance directive or wallet card stating
one in four will have nightmares from this medication.” no blood transfusions.
Language barriers are frequent in the ED and pose signifi- Some EPs believe that any patient in the ED qualifies for an emer-
cant concern in obtaining and documenting informed consent.21 gency exception by virtue of the fact that they are in the ED. This is
Understanding languages is situational. Although some EPs may not true. Location by itself can be used neither to justify the emer-
have additional language (non-English) proficiency, it is imperative gency exception nor to infer an “implied consent” for broad ED
to know when to call an interpreter. Limited language skills allow care. Rather, the emergency exception may be invoked only when
the EP to extract critical clinical information. Patients may need the patient will be harmed by the delay necessary to obtain informed
more information than the EP’s skills allow. Calling an interpreter consent.25 EPs should ask themselves a few brief questions to deter-
may be essential for meeting a minimum standard of care.22 mine if a patient meets the criteria for an emergency exception to
informed consent (Table 1-5).
VOLUNTARY NATURE OF THE DECISION
THERAPEUTIC PRIVILEGE
Forced treatment where any real choice is removed from the patient
being involved in the decision-making process violates the doc- The therapeutic privilege is a disfavored concept but recognized
trine of informed consent. Any form of coercion based on threats exception. It excuses EPs from the duty to disclose in the limited
or intolerable consequences, such as the withholding of pain medi- circumstances where disclosure might create harm to the patient
cation, would fall into this category. Emergency Physicians cannot and interrupt the treatment process. This privilege is rarely invoked
manipulate patient decisions by withholding or distorting informa- as it could almost negate the entire informed consent process.
tion that the EP believes may sway the patient toward a preferred
course. Persuasion is permissible, and it is an obligation as trained
professionals to synthesize the information and recommend a TABLE 1-5 Questions to Justify an Emergency Exception
course of action. An appropriate recommendation includes laying 1 Will failure to treat quickly result in serious harm to the patient?
out the risks, benefits, and reasoning behind one’s recommenda- 2 If their condition worsens, will the patient die or suffer serious harm before
tion as well as explaining the reasoning for not selecting an alternate definitive care can be delivered?
approach. Emergency Physicians can also utilize the resources of the 3 Would most capable and reasonable people want treatment for
patient’s family or significant others to provide arguments in favor this type of injury?
of a particular course of treatment. The EP must be careful to avoid 4 Is the patient unable to participate in care decisions?
overwhelming the patient as the goal should be a shared solution by 5 Are the patient’s preferences known or knowable in a timely way from
consensus and not forcing the patient to surrender to the wants of a surrogate?
others.23 Strategies to approach a patient’s refusal are discussed in 6 Is there any evidence that the patient would refuse this specific treatment?
depth later in this chapter. 7 Would failure to treat result in greater harm than the proposed intervention?
CHAPTER 1: Informed Consent for Procedures in the Emergency Department 5
Therapeutic privilege may be applied when direct disclosure to a INFORMED REFUSAL

patient would create harm, generally recognized as occurring in
some psychiatric conditions and for some cultural groups.26 Emergency Physicians often begin with the presumption that
patients possess decision-making capacity to both consent and
refuse procedures. It is notable that in practice, EPs may ques-
WAIVER OF INFORMED CONSENT tion a patient’s capacity more readily when they disagree with
While EPs have a duty to disclose information, patients may dif- recommendations.
fer in how they approach their participation in care decisions.
Some patients may prefer that another person, such as a close UNDERSTAND THE REASONS FOR REFUSAL
family member, receive healthcare information and make treat-
ment decisions on their behalf (delegated autonomy). This may be A refusal for recommended intervention should be the beginning
due to personal preference or cultural variation. The delegation of of an important conversation with the patient. On first encounter,
the decision making must be confirmed with the patient and not a refusal of a recommendation may seem a rebuff or potential time
assumed based on cultural norms. The delegation reflects a patient’s challenge. Approach a refusal with openness and curiosity. Help the
right to waive informed consent. Their choice to delegate that right patient not feel cornered into following the recommendation while
to another person demonstrates an autonomous choice that should confirming their informed refusal. A refusal is an opportunity to
be honored.27 learn how to practice persuasive reasoning. During the barrage of
Some patients may interrupt the informed consent process after information disclosure, a patient might have misheard numbers or
only partial information is disclosed and elect to follow the EP’s the proposed procedure may resemble a prior negative experience.
recommendation. If the EP confirms the patient’s acceptance of Take time to listen to the patient’s concerns and reasons for refusal.
the consequences of consent with only partial information, the This can help navigate the informed refusal process.
EP may accept this as consent via waiver of the informed consent
process.25 The EP may accept a waiver of consent if, like other CONFIRM THE ADEQUACY OF INFORMATION
decisions, the patient has capacity, understands that they are giv- WITH AN EMPHASIS ON UNDERSTANDABILITY
ing up an important right, and has made the request voluntarily. With the patient’s reasons for refusal in mind, EPs should reflect
Emergency Physicians who are uncomfortable with this responsi- these reasons back to the patient so that they feel they have been
bility may ask the patient to designate another person to assume heard. It is important for EPs to acknowledge the patient’s perspec-
this role. tive, even if they disagree with the reasons. This allows the patient
to engage in listening as the EP provides additional information to
IMPLIED CONSENT support the recommendation. Normalizing an “irrational concern”
allows the patient to feel “OK” and still follow the EP’s recommen-
Implied consent is also a disfavored concept. It may be considered to
dation. For example, “I can understand that your sister’s compli-
“apply” in the very limited circumstances when an EP is undertak-
cation from procedural sedation several years ago would give you
ing a clinical activity with a well-known risk/benefit profile.28 The
some concerns about this recommendation. And I want to reassure
most favored implied consent example is when a patient extends his
you that today we take these additional steps.…” Tailor the revised
or her arm for a blood draw. The volitional act of extending the arm
recommendation to address the concerns of the patient and focus
is deemed as implied consent to the blood draw and its risks (pain
on making sure that the information provided is simple, direct, and
and possible bruising). The assumption of “implied consent” poses
understandable.
a dangerous trap for EPs, since what an EP considers routine and
well-known risks may differ greatly from what the patient knows.
This is particularly true in the ED where there is little trust and no
ADDRESS BARRIERS TO UNDERSTANDING
knowledge of the patient’s health literacy. Significant efforts should be undertaken to enhance the patient’s
Emergency Medicine research shows at least 50% of patients ability to understand the information when a refusal occurs. A
wanted time spent on “detailed” information, including a review professional interpreter must be utilized to compensate for any
of the risks of only 1% chance of occurrence. For example, while communication barriers to the patient’s understanding in an
lumbar punctures are clinically safe and pose little risk, patients per- informed refusal process. The EP should revisit all the informa-
ceive this as an invasive procedure that requires more information tion from the initial discussion of information that occurred with an
for informed consent.11 It is important to note that implied consent informal interpreter (e.g., family member or healthcare provider).
is not sufficient when informed consent is required or possible.10 Residual misinformation can prolong a patient’s refusal. Starting
from the beginning of the clinical communication, even if it takes
UNREPRESENTED PATIENTS/PATIENT ALONE more time, can often remedy the situation. Use language or pictures
tailored to a patient’s lower educational or functional level when
A patient who is unable to participate in care decisions and has necessary.19 Anxiety and pain may contribute as a barrier to under-
no surrogate decision makers is known as the “unrepresented standing and should be addressed as quickly as possible.
patient” or the “patient alone.” These highly vulnerable patients
have no social networks to assist the care team in navigating con- CONFIRM CAPACITY TO REFUSE
sent and care decisions, and attention to clinical decision mak- RECOMMENDATIONS
ing for this patient population is growing.29 Statutory guidance
on decision making for this patient population varies by region. Is decision-making capacity a potential issue? The EP must take
Institutional policies should be reviewed to determine whether a steps to mitigate any factors leading to impaired decision making
policy exists for decision making for the “unrepresented patient.” so that the patient may participate in their care to the fullest extent
In the absence of such a policy, consultation with the ethics service possible.
is recommended and efforts should be made to develop a consis- In the past, it was thought that patients with certain diagnoses
tent and transparent approach to care decisions for this vulnerable by default lacked decision-making capacity. Many clinicians now
population.27 recognize that patients with severe mental illness, early dementia,
TABLE 1-6 Red Flag Scenarios that Require Additional Assessments of TABLE 1-7 Mnemonic for Documentation of Decision-Making
the Patient’s Decision-Making Capacity Capacity Assessments
Refusal of recommended treatment “U and I GLAD”
Patients readily consenting to invasive or risky treatment U—understanding of the procedure/discussion
Abrupt change in mental status I—impairing conditions
Chronic psychiatric or neurologic conditions G—goals and values
Cultural and language barriers L—logic used to decide
Limited education A—actual functioning
Anxiety or untreated pain D—danger or risks of decision
Extremes of age
and some organic brain syndromes are at risk for impaired deci- the urgency and necessity. Document the patient’s current decision-
sion making but may possess decision-making capacity for selected making abilities with a description of the impediments to capac-
procedures and treatments.14 However, there are certain Red Flag ity and the actions taken by the provider to maximize capacity.
scenarios when an EP should scrutinize a patient’s decision-making Additional documentation should include the availability of family
capacity with greater depth (Table 1-6). Actions or decisions with or other surrogate decision makers and any relevant discussions.
greater consequences require a more intense evaluation of the Documentation will vary by institution and local laws. Being
patient’s capacity. A more careful evaluation of capacity is indicated familiar with the appropriate measures to make an informed consent
when the patient’s choice seems unreasonable or if the patient is or refusal is effective and is a critical part of the informed consent/
unwilling to discuss their thought process. Chronic psychiatric and refusal process in the ED.31
neurologic conditions remain a risk for, but should not be equated
with, impaired decision making. Cultural, educational, and language
barriers certainly impact a patients’ decision making. High levels of
anxiety, whether from untreated pain or the inevitable stress of the
ED, are known to impair decision making as well.30
Aseptic Technique
Many providers outside the ED setting will utilize psychiatric
consultations to assist with the evaluation of a patient’s decision-
making capacity. The utility of such a consultation in the ED is fre-
2 John S. Rose
quently limited by time and consultant availability. Consultations in

the ED may prove useful when evaluating a thought or delusional INTRODUCTION
disorder that may impede understanding.
The proper use and an understanding of aseptic technique are
critical for the care of patients in the Emergency Department (ED).
EFFECTIVE AUTHORIZATION: Aseptic technique dovetails with prescribed universal precautions
DOCUMENTATION OF INFORMED REFUSAL and is central to our practice. Knowledge of proper aseptic tech-
nique ensures that procedures performed in the ED provide maxi-
Honoring a refusal of emergency treatment that would be benefi- mal protection for both the patient and the physician while keeping
cial or may result in decompensation or death is never easy. Use of the risk of contamination as low as possible.1–15
the standard hospital “Against Medical Advice” form can create an Wound infection and sepsis are the two major complications
adversarial relationship that an EP may find damaging to future resulting from poor and improper aseptic technique. Other compli-
patient interactions and the subsequent treatment plan. However, cations that may contribute to the patient’s morbidity and mortality
anecdotal reports include cases where patients reconsidered their include increased length and cost of hospital stay, patient discom-
decision when presented with such a document. It is important to fort, scarring, and even death. With this is mind, it is clear that asep-
document refusal of care, not only for medicolegal protection but tic technique is warranted except in the most dire circumstances.
also to confirm that clear communication with the patient had Numerous terms are used to describe the establishment and
occurred. maintenance of a “sterile” environment. These include aseptic, ster-
Documentation recommendations when a patient refuses treat- ile technique, and disinfection, to name a few. Many people often,
ment should include the following elements: the patient has refused and incorrectly, interchange these terms. The proper definitions of
the recommended procedure, test, or treatment; the patient’s reasons the terms used to describe aseptic technique or associated with it
for refusal; the consequences of the refusal were explained to the can be found in Table 2-1.
patient including the alternatives, if any, being offered or performed
in lieu of the recommended procedure. Documentation should also
ANATOMY AND PATHOPHYSIOLOGY
include statements that show the patient understood and continued
to refuse the specific procedure or treatment and has the capac- The skin and hair are colonized with various organisms. The stratum
ity to do so. Document that the patient’s wishes are being honored corneum layer of the epidermis is colonized with a polymicrobial
against medical advice. It would be preferable if the EP could have flora. This includes Staphylococcus aureus, Staphylococcus epidermi-
the patient read this documentation followed by the patient signing dis, various Streptococcus species, viruses, yeasts, and molds. Many
the medical record below this documentation in acknowledgment. of these organisms are nonpathogenic, even when placed in envi-
Additional documentation is required when an EP recognizes a ronments considered appropriate for infection. S. aureus is the
“Red Flag” scenario for impaired decision making or has other rea- most common cause of wound infections. It can result in an infec-
sons for concern (Table 1-7). These are essential items that must be tion when introduced into deeper skin layers. Some species, such
documented in these cases. Document the patient’s medical con- as S. epidermidis, are pathologic only when inoculated into deeper
dition and the procedure or treatment that is suggested, including layers of the skin and soft tissue. For most infections, a significant
CHAPTER 2: Aseptic Technique 7
TABLE 2-1 Definitions of Terms Used to Describe • Sterile 4 × 4 gauze squares or applicator sticks
Aseptic Technique or Associated Processes • Sterile gloves
Term Definition • Face mask and eye protection
Aseptic Freedom from infection. Prevention of contact with • Sterile drapes or towels
microorganisms. Involves the use of sterile technique
and skin disinfection • Adequate lighting
Clean technique The practice of using nonsterile equipment to perform • Sterile gowns
procedures. This is considered as part of the universal • Bedside procedure table
body fluid precautions
Disinfection The cleaning of an area to make it free of pathogenic
organisms and microbes PATIENT PREPARATION
Sterile field The zone in which strict sterile technique is maintained. Inform the patient of what the procedure entails before perform-
Generally consists of an area 3 to 10 times larger than ing any procedure in the ED. This should include an explanation
the area of the primary procedure of sterile technique and a request that the patient not touch the
Sterile technique The practice of utilizing sterile equipment and
drapes or sterile equipment. Obtain any required informed consent
procedures to maintain an aseptic environment
(Chapter 1) before the patient is draped. The only exception to this
Super aseptic Ultrahigh state of an aseptic environment. Usually,
this is achievable only in the operating room
is if an emergent and lifesaving procedure must be immediately
performed.
Place the patient in the most comfortable position possible.
Patient discomfort frequently results in movement and the poten-
inoculation is required to create a critical level for microbial growth tial loss of the sterile field. Utilize sedation and/or analgesia (Chap-
to occur. Aseptic technique decreases bacterial exposure and ters 123-129) as necessary to facilitate proper patient positioning.
reduces the level of potentially pathologic organisms. The physician must also be comfortably positioned if possible and
have adequate lighting.
INDICATIONS
The role of aseptic technique in the ED is primarily for invasive pro- TECHNIQUES
cedures. Despite this, invasive procedures require varying degrees Aseptic technique can be divided into skin disinfection and sterile
of aseptic technique. Placement of a small peripheral intravenous technique. Skin disinfection removes any microorganisms found on
catheter may require no more than a brief wiping of the skin. In con- the skin and decreases potential contamination during the proce-
trast, a diagnostic peritoneal lavage requires operating room–level dure. Sterile technique is performed for the same reason. There are
disinfection and strict sterile technique. different levels of aseptic technique, ranging from full aseptic tech-
Routine and adequate provider disinfection involves careful hand nique (mask, gown, gloves, and drapes) to simple sterile gloves. The
washing, the use of clean and disinfected personal diagnostic equip- physician must use their judgment to determine which level is most
ment (e.g., stethoscopes), and wearing appropriately cleaned coats appropriate to the task at hand.8
and clothing. This is critical in preventing iatrogenic infections in
the ED. Aseptic technique in the ED can be referred to as clinical
aseptic technique, since it is virtually impossible to achieve an oper- SKIN DISINFECTION
ating room level of asepsis. Clinical aseptic technique involves the Disinfection involves the application and scrubbing of a disinfectant
combining of adequate disinfection with sterile techniques and pro- preparation onto the skin. Simple procedures, such as injections or
tocols at the bedside. venipunctures, may require little disinfection. Wipe the skin with
gauze that has been impregnated with 70% isopropyl alcohol for
CONTRAINDICATIONS simple procedures. The alcohol has an antibacterial effect. The mere
force of wiping the skin reduces bacterial counts. No disinfection is
There are very few contraindications to the maintenance of
used for simple venipunctures in some countries. More comprehen-
adequate clinical aseptic technique. One exception would be that
sive skin preparation involves the use of a disinfectant agent such as
extreme clinical circumstance in which time simply does not allow
povidone iodine or chlorhexidine solution.
proper aseptic technique, as in an emergent thoracotomy. Even in
Povidone iodine, 2% iodine tincture, and chlorhexidine are the
such situations, however, the physician can still use sterile gloves
most commonly used skin antiseptic solutions. Povidone iodine
and a quick application of an aseptic solution.
solution is highly germicidal for gram-positive and gram-negative
Always inquire about allergies and sensitivities to latex and anti-
bacteria, viruses, fungi, protozoa, and yeasts.7 It rapidly reduces
septic solutions. This information will affect the equipment that is
bacterial counts on the skin surface and these effects last up to
chosen to properly prepare the patient.8 Most, if not all, hospitals
3 hours.7,11 Allow the iodine solution to dry and then wipe it from
have a latex-free cart that contains equipment for use with latex-
the skin with 70% alcohol prior to beginning the procedure. The
allergic patients. Do not use povidone iodine solution in patients
iodine solutions work by oxidation and cross-linking of sulfhy-
allergic to iodine. Alternative agents include chlorhexidine and
dryl groups, killing bacteria as the solution dries. Isopropyl alcohol
hexachlorophene preparations.
can be applied to the skin and scrubbed vigorously for 2 minutes
to achieve disinfection, although this may cause skin irritation.
EQUIPMENT Chlorhexidine or hexachlorophene preparations may be routinely
• Povidone iodine solution used or as substitutes in iodine allergic or sensitive patients. These
agents provide good bactericidal activity against gram-positive bac-
• Chlorhexidine gluconate (chlorhexidine)– or hexachlorophene- teria but somewhat less activity against gram-negative organisms.8
based solutions Chlorhexidine-based solutions are being used more commonly
• Seventy percent isopropyl alcohol and are replacing the iodine-based solutions. Chlorhexidine
provides much longer antimicrobial activity (up to 48 hours) and is

more gentle on the skin than iodine.11–15 Chlorhexidine destroys cell
membranes of gram-positive and gram-negative bacteria while pre-
cipitating the intracellular contents. Some preparations contain 70%
isopropyl alcohol, further enhancing the antimicrobial activity.12–14
The use of chlorhexidine solutions is proving to be superior to
iodine solutions.14,15
Use a skin disinfectant for procedures other than simple veni-
puncture. Place the disinfectant solution onto either a sterile
sponge or sterile gauze if it is not supplied inside a single-use
applicator. Historically, the application of disinfectant to the skin
is in a circular motion, beginning with the central area of the pro-
cedure and working out toward the periphery of the sterile field
(Figure 2-1). There is no evidence to support this application
method. It has been suggested that scrubbing in a back-and-forth
motion creates friction to dislodge microbes and may be prefer-
able to the traditional circular application.9,10 The back-and-forth
motion drives the disinfectant solution into skin crevices and
deeper layers, thus killing more bacteria and hopefully preventing
infections.
Regardless of the disinfectant solution used, repeat the applica-
tion process three or four times using a new sponge, gauze square,
or applicator each time.8 This technique ensures that the central area
where the procedure is to be performed is the most sterile area of the
field. The area of disinfection must be much larger than the primary
area of the procedure, as the number of organisms increases toward
the periphery of the prepped area.
STERILE TECHNIQUE
General sterile technique is described, followed by specific details
for each step of the procedure. Strict sterile technique is virtually
impossible in the ED. However, make every effort to maintain a
sterile field in order to minimize infection. Assemble all equip-
ment necessary and place it on a small procedure stand. Do not use
the patient or their bed to set up supplies or equipment. Patient
movement and their irregular body surfaces can result in items fall-
ing, breaking, becoming contaminated, or iatrogenic needle sticks.
Avoid having different components scattered around the procedure
area. Open all sterile items, using proper sterile protocol, so as to
have them available once the physician has donned sterile gloves.
Use anesthetic solution containers with removable caps. This allows
the physician to draw up anesthetic without having an assistant and
minimizes the risk of occupational needle exposure. Perform a thor-
ough hand washing before the procedure.
Apply sterile gloves. Place sterile drapes or towels to form a field
wide enough to allow for a comfortable work space. Drape the area
near the patient closest to the bedside procedure table. This will
minimize inadvertent contamination in moving from the table to
the patient. Make a small flat sterile area near the procedure site
to allow for placement of important items that must be immedi-
ately available. Open all caps, position stopcocks, and prepare all
devices prior to starting the procedure. The likelihood of contami-
FIGURE 2-1. Preparation of the skin. Disinfectant solution is applied in a concen-
nation increases if devices are not adequately prepared, thus requir-
tric circular pattern starting from the procedure site and working outward. Apply
ing manipulation during the critical portion of a procedure. Adhere
the disinfectant solution with sterile gauze held in a clamp (A), with sterile gauze
to universal precautions guidelines. Use eye and face protection
held in a sterile gloved hand (B), or with a sponge on a stick (C).
during the procedure. This should be applied before donning gowns
and gloves.
indicator tape (Figure 2-2A). Place the sterile pack on a dry and level
OPENING A STERILE PACK surface with the outermost flap facing away from you (Figure 2-2B).
Always make sure that the outer wrapping is intact, the sterility Grasp the corners of the outermost flap (Figure 2-2B). Hold your
expiration date has not passed, and the sterility indicator tape is the arms to the sides of the pack to avoid reaching over the sterile area.
appropriate color before opening a sterile pack.2 Wash your hands Lift the flap up and away from you (Figure 2-2B). Open the side
and then remove the outer wrap if applicable. Remove the sterility flaps by grasping the folded corner with a thumb and index finger
A B
C D
FIGURE 2-2. Opening a sterile pack. A. Remove the sterility indicator tape.
E B. Grasp the edges of the outermost flap and open it away from you. C. Open the
side flaps. D. Open the remaining flap toward you. E. The open pack.
and pulling the flap to the side (Figure 2-2C). Open the bottom flap PLACING STERILE SUPPLIES ON A STERILE FIELD
(Figure 2-2D). Grasp and open the bottom flap while stepping back
to prevent contaminating the wrap on your clothing (Figure 2-2E). Sterile supplies are generally packaged in either a hard (hard pack)
Make sure that your arms and clothes do not contaminate the or a soft peel-back (soft pack) container. The general principle of
contents of the pack when opening the flaps. Repeat the procedure opening these is the same, although there are subtle differences.
if the pack has an inner wrap. Hold the hard peel-back container in the nondominant hand with
A B
FIGURE 2-3. Opening a hard peel-back container. A. Grasp the container with the flap facing the sterile field. Remove the flap. B. Drop the contents of the hard container
onto the sterile field.
the flap facing the sterile field (Figure 2-3A). Pull the flap toward Apply the mask before donning gloves and other sterile equip-
you with the dominant hand so that the open end of the pack will ment. Depending on the type and style of the mask, secure it by
be facing the field (Figure 2-3A). Hold the container 15 to 20 cm placing the elastic straps around the ears, placing the elastic straps
above the sterile field. This ensures that if the contents fall, it will around the head, or tying the mask securely to the face with ties
be onto the sterile field where they are wanted. Drop the contents of around the head and neck. Pinch the metal nose clip securely to the
the sterile pack onto the sterile field, taking care not to contaminate bridge of the nose for a tighter fit and to minimize the gap between
the field with the container itself (Figure 2-3B). the mask and the nose.
Gloves and syringes are wrapped in soft packs. Grasp both sides
of the unsealed edge of the soft pack and pull them apart slightly HAND WASHING
(Figure 2-4A). Hold the open end facing the sterile field (away
A physician must thoroughly wash their hands despite the fact that
from you). Continue to open the soft pack. Fold the sides of the
sterile gloves are worn for all sterile procedures. Good hand washing
sterile packing back and over your hands to keep the contents ster-
technique should not be overlooked. A full surgical scrub is neither
ile (Figure 2-4B). Gently drop the contents of the soft pack onto the
necessary nor feasible in the ED.
sterile field.
Rinse your hands in warm water prior to applying antiseptic soap.
Apply soap, lather your hands, and rub them together vigorously for
APPLICATION OF A MASK
approximately 10 seconds. Wash each wrist with the opposite hand.
Surgical masks serve a dual role in the performance of aseptic Interlace the fingers of both hands and slide them back and forth
technique. Masks have been shown to decrease contamination of to clean the web spaces. Clean around the nails with the fingertips
the sterile field that may result from aerosolized droplets from the and nails of the opposite hand. Completely rinse each hand from
mouth and nose. Masks protect the caregiver’s mucous membranes the fingers downward. Repeat the procedure a second time if your
from exposure and possible splashing during the procedure. Wear a hands were grossly contaminated. Dry your hands with a disposable
mask with an eye shield during high-risk procedures. towel. Turn off the faucet, using the towel with which you dried your
A B
FIGURE 2-4. Opening a soft peel-back container. A. Grasp both sides of the unsealed edge and pull them apart. B. Face the pack toward the sterile field. Continue to open
the edges until the contents fall onto the sterile field.
hands. Do not touch the faucet with clean hands. Otherwise they APPLICATION OF STERILE GLOVES
will become contaminated again.
Wash your hands thoroughly before putting on sterile gloves. Apply
APPLICATION OF A CLEAN GOWN a clean gown at this point if it will be worn during the procedure.
Open the outer wrap of the sterile gloves and remove the inner wrap
A clean (nonsterile) gown is often used as an additional barrier to (Figure 2-5A). Place the inner wrap on a clean surface with the
contamination of both the field and the provider’s clothing. Simply gloves’ wrists facing toward you. Unfold the inner wrap, touching
place your arms into the sleeves and pull on the gown with the open- only the outside edges (Figure 2-5B). Open the inner wrap accord-
ing toward the back. Secure the gown at the back of the neck and the ing to the procedure for opening a sterile pack (Figure 2-5C). Apply
lower back by tying the strings. a sterile gown at this point if it will be worn during the procedure.
Use the dominant hand to grab the opposite glove at the inner edge
APPLICATION OF A STERILE GOWN of its folded cuff (Figure 2-5D). Slip the nondominant hand into
A sterile gown is worn for procedures requiring a stricter sterile the glove, being careful not to touch the outer surface of the glove
technique (i.e., central venous access, diagnostic peritoneal lavage). (Figure 2-5E). Pull the glove further onto the nondominant hand
To open a sterile gown, use the procedure previously described to using the inner edge of the cuff (Figure 2-5F). Place the fingers of
open a sterile soft pack. Grasp and pick up the gown just below the the gloved nondominant hand into the folded cuff of the other glove
neckline, touching only the inner surface of the gown. Hold the (Figure 2-5G). Slip the dominant hand into the glove (Figure 2-5H).
gown up and let it unfold with the inside facing you. Do not allow Pull this glove over the dominant hand using the cuff (Figure 2-5I).
the gown to touch any nonsterile surfaces. Insert your arms into the Carefully unfold the cuff of each glove, taking care not to touch the
sleeves until the gown is in place. Have an assistant grasp the back of fingers and palms of the gloves to nonsterile skin. Adjust each glove
the gown, pull it completely on, and tie the strings securely. to ensure a snug fit over the fingers and hand.
A B C
D E F
G H I
FIGURE 2-5. Application of sterile gloves. A. Open the outer wrap and remove the inner wrap. B. Unfold the inner wrap. C. Completely open the inner wrap. D. Grasp
the cuff of a glove. E. Slip the glove onto the hand. F. Pull the glove onto the hand. G. Slip the gloved hand into the folded cuff of the second glove. H. Slip the glove onto
the hand. I. Pull the glove onto the hand.
A B C
D E
FIGURE 2-6. Removal of protective clothing. A. Untie the gown. B. Remove the gown by turning it inside out. C. Roll up the gown with the contaminated side facing inward.
D. Remove the glove from the nondominant hand. E. Remove the glove from the dominant hand. Remove the face mask and wash your hands.
REMOVAL OF PROTECTIVE CLOTHING COMPLICATIONS

Remove protective clothing in a systematic manner in order to protect Properly performed aseptic technique has very few complications.
yourself and others from the contaminants on your gown and gloves The primary risk is in patients with sensitivities or allergies to latex
(Figure 2-6). Place all removed garments into appropriate waste con- or the disinfectant preparations. Although povidone iodine prepa-
tainers. The first step is to untie the gown (Figure 2-6A). Have an rations are much less irritating than tincture of iodine, it is a good
assistant untie the neck strings of the gown or pull on both shoulders policy to clean all disinfectant off the patient at the end of the proce-
of the gown to break the neck strings. Untie the waist strings. Take off dure so as to minimize any skin irritation. This is especially true of
the gown by turning it inside out as it is removed (Figure 2-6B). Roll small children. Use alternate products for those patients with histo-
up the gown with the contaminated surface facing inward and away ries of allergies. The main complication of improper aseptic tech-
from you (Figure 2-6C). Dispose of the gown. Remove the gloves by nique is infection at the site of the procedure.8 This only serves to
turning them inside out, making sure that you do not touch the out- underscore the need to perform aseptic technique properly.
side (contaminated) surface with your ungloved hands. Use the dom-
inant hand to grasp the cuff of the glove on the nondominant hand
SUMMARY
(Figure 2-6D). Pull the glove inside out as you remove it and throw
it away. Place the ungloved fingers of the nondominant hand into the Aseptic technique is an important component of all invasive pro-
inside edge of the gloved dominant hand and remove it by pulling cedures performed in the ED. Adequate skin disinfection and the
the glove inside out (Figure 2-6E). Dispose of the glove. Remove the proper use of sterile technique will greatly decrease the risk of iatro-
mask by untying its ties or removing the elastic straps from behind genic infections. Aseptic technique allows a degree of protection for
your ears. Dispose of the mask. Finally, wash your hands. the caregiver as well as the patient.
CHAPTER 3: Basic Principles of Ultrasonography 13
Basic Principles of
3 Ultrasonography Patient Treating
physician
Gregory M. Press
Bedside
INTRODUCTION ultrasound
Emergency Physicians (EPs) have performed bedside ultrasound
(US) for more than three decades. Today, US is ubiquitous in our
specialty. Each year new physicians learn the skill, fresh evidence
is brought to light supporting the practice, and novel indications
Treating
are explored. Technological advances have delivered smaller
physician Sonographer
machines with improved image quality that are less expensive
than ever before. Several US manufacturers have developed
machines targeted to Emergency Medicine (EM), taking into
consideration our specific indications and less-than-forgiving
work environment. US training is an important component of
Emergency Medicine residency programs and a required core
competency procedure of the Accreditation Council for Graduate Radiologist
Medical Education Residency Review Committee.1 There are
numerous opportunities for supplementary training in emer- FIGURE 3-1. The paradigm of bedside US. The workflow of traditional US utilizing
gency US, ranging from local courses to established fellowship the radiology department (blue circle with red arrows) is a multistep process that
training programs. may take hours to days to complete. Bedside US (double yellow arrow) establishes
Safety considerations have also contributed to the acceptance an immediate and direct interaction between patient and physician. (Courtesy of
of bedside US. Sonography is noninvasive, safe in pregnancy, and Christopher Moore, MD, RDMS, RDCS.)
does not require contrast agents that risk kidney failure, subcu-
taneous extravasation, and allergic reactions.2 With increasing
concern in the medical community over the long-term effects of computers that fit on maneuverable carts. “Pocket-sized” machines,
ionizing radiation, US is recognized as an attractive alternative.3 not much larger than mobile phones, are being introduced and offer
Additionally, the U.S. Department of Health and Human Services’ even greater portability (Signostics, Palo Alto, CA; GE Corporation,
Agency for Healthcare Research and Quality has highlighted US Fairfield, CT). The notion of the “sono-stethoscope” promises
guidance for central line insertion as 1 of their top 10 recom- devices as small, easy to use, and available as the stethoscope, but
mended practices.4 with the superior insight of sonography. This device speaks to a true
The intent of this chapter is to provide an introduction to bedside paradigm shift in clinical medicine.
US for the EP. The physician-sonographer should have a general
understanding of the physics underlying the properties of an US INDICATIONS
wave. “Knobology” is a colloquial term used to describe the study The primary indications of emergency US have traditionally
of the buttons, dials, switches, and, of course, knobs, on the console included: cardiac US for the presence of pericardial fluid and for
of an US machine. It is important that all users have a good sense of cardiac activity; abdominal US for the identification of free perito-
their machine’s operational functions. Typical machines and trans- neal fluid; aortic US for abdominal aneurysms; biliary US for the
ducers used in the ED will be described. detection of gallstones and cholecystitis; renal US for hydronephro-
sis and nephrolithiasis; and pelvic US for the identification of an
THE PARADIGM OF BEDSIDE US intrauterine pregnancy and the exclusion of an ectopic pregnancy
(Table 3-1). Basic emergency US has operated on the binary prem-
Bedside US is a relatively new paradigm in clinical medicine. ise that emergencies are to be included or excluded by this diagnos-
Traditional radiology US involves a break in the patient–physician tic tool. As the field has developed, the boundaries between primary
encounter. The multistep process involves the EP evaluating the and secondary indications have blurred, and the yes/no equation for
patient and determining that an US is warranted, the radiologic the evaluation of emergencies has matured.
technologist performing the study in an US suite, the radiologist
reviewing the images and generating a report, and the EP ultimately
correlating that information back to the patient (Figure 3-1). TABLE 3-1 The Indications for Emergency Ultrasonography
Bedside US crafts a direct and immediate relationship between Primary indications Secondary indications Procedural indications
patient and EP (Figure 3-1). The technology is placed in the EP’s Abdominal Abscess Arthrocentesis
hand for both image acquisition and interpretation. The EP can Aorta Deep vein thrombosis Foreign body localization
immediately synthesize US findings with clinical and laboratory Biliary Gastrointestinal Lumbar puncture
data to paint a more complete diagnostic picture. A patient’s condi- Cardiac Genital Nerve blocks
tion can change on a moment’s notice in the ED, and, fittingly, US First trimester pregnancy Lung Paracentesis
is a dynamic tool that can be used swiftly and serially throughout a Renal Musculoskeletal Pericardiocentesis
patient’s course. Ocular Thoracentesis
In the early years of emergency US, EPs often used large tank-like Shock Transvenous pacer
machines that were not conducive to a fast-paced work environment. Other placement
The evolution of US has delivered small portable machines that pro- Vascular access
duce high-quality images. Many US devices are the size of laptop Other
The list of indications for present-day emergency US is long and

continually expanding (Table 3-1). Other common indications
include the evaluation for deep vein thrombosis. Lung US can be
used to diagnose pneumothorax, pleural fluid, and interstitial lung
diseases. US evaluation for abscesses, primarily subcutaneous but
also peritonsillar, deep-space, and abdominal is common. Ocular
US can be used to identify a retinal detachment, lens dislocation,
vitreous hemorrhage, foreign bodies, and optic nerve sheath assess-
ment for increased intracranial pressure. Patients in shock or hypo-
tensive may be evaluated by US of the inferior vena cava and internal
jugular veins to estimate central venous pressure. Gastrointestinal
US is used for the identification of appendicitis, pyloric stenosis,
and other conditions. Male and female genitourinary US is used Compression Rarefaction
to assess for testicular and ovarian torsion, intrauterine pregnancy, FIGURE 3-2. The longitudinal US wave. A force exerted in a parallel fashion along
and ectopic pregnancy. Musculoskeletal US is used to diagnose a coil will produce regions of compression and rarefaction. The particles of a sound
joint effusions, tendinopathy, and fractures. Procedural US is used wave vibrate in the direction the wave travels to create areas of high and low
for guided assistance of vascular access, paracentesis, thoracentesis, density and pressure. A sound wave is depicted as a classic waveform with peaks
pericardiocentesis, arthrocentesis, lumbar puncture, foreign body representing compression and valleys representing rarefaction.
removal, nerve blocks, and other procedures.
US PHYSICS
human hearing is approximately 20,000 Hertz (Hz), beyond which
HISTORY is considered “US.” Diagnostic US frequencies are generally in the
range of 1 to 10 million Hz or MHz. US transducers operate on
Bats and toothed whales have used sound for echolocation for
either the “low” or “high” end of this frequency spectrum, although
millions of years. Dolphins produce a series of clicks that pass
for each transducer frequency can be adjusted within a limited
through the lipid-rich melon on their heads, an acoustical lens of
range. Frequency is a principal determinant of the resolution and
sorts that focuses the sound waves into a beam. Returning echoes
penetration of an image.
are processed to determine the location of objects for navigational
Period is the time required for one cycle to occur. Thus, it is the
and hunting purposes.5 Sonar (acronym for sound navigation and
inverse of frequency (Figure 3-3). In ultrasonography, period is
ranging) is a maritime technique that uses sound waves for iden-
typically measured in microseconds (µs).
tifying oceanic objects. It was initially introduced in response to
the sinking of the Titanic in 1912.6 It was further developed and
employed in World War I for submarine detection.6 In the early WAVELENGTH AND PROPAGATION SPEED
1950s, a radiologist named Douglas Howry and a team of other While period measures the duration in time of a single cycle,
physicians introduced the first diagnostic US machine using a wavelength measures the distance in space of a single cycle
water-bath immersion tank. In the 1960s, direct contact (probe to (Figure 3-3). Wavelength is related to the propagation speed and
patient) scanners were developed, and the contemporary saga of the frequency of a wave. It is represented by the following equation:
US as a viable diagnostic modality commenced.7 wavelength = propagation speed/frequency.
Propagation speed is the velocity at which sound travels through
SOUND tissue. An average speed through soft tissues of 1540 m/s is generally
Sound is a variation in pressure traveling through a medium and assumed in basic US. Newer US machines incorporate the propaga-
it is described as a wave. We commonly understand the sound of tion speeds of different tissues to provide enhanced imaging.
our vocal communication to travel through air, but sound may also
travel through fluid and solid structures. Pressure variations pro-
duced by sound waves mechanically displace or oscillate the par-
ticles of the medium. This oscillation produces cycles of higher
and lower densities, or compression and rarefaction, respectively.
Sound waves differ from water waves in that they are longitudinal, Amplitude
meaning the cycles of compression and rarefaction travel in the
same direction as the wave. Imagine an analogous spring coil with
a force exerted into its length. A wave, or region of compression,
will pass down through the coil in a longitudinal or parallel fashion
(Figure 3-2). It is important to have an understanding of the terms
that describe sound waves as described in the following sections.
FREQUENCY AND PERIOD

Frequency is the number of cycles of pressure variation per 1 sec-
Period (µs) or
ond. A single cycle begins at a baseline of absent sound, increases
wavelength (mm)
to a maximum value (compression), decreases to a minimum value
(rarefaction), and returns to baseline (Figure 3-2). Frequency is FIGURE 3-3. The characteristics of an US wave. Period is the duration in time
measured in hertz with a unit of cycles per second and corresponds of a single cycle of a wave, while wavelength is the distance in space. Amplitude
to the pitch or tone of a sound. The upper acoustical frequency of measures the wave’s variation (height) from baseline.
AMPLITUDE, OUTPUT, AND BIOEFFECTS

Amplitude is a measure of the height or maximum variation of a
wave from baseline (Figure 3-3). While frequency corresponds to
the pitch or tone of a sound, amplitude is the “loudness” or volume
of a sound. In US, this correlates to the brightness of the image.
Adjustments of the machine’s output affect the amplitude, but
changing the gain produces a similar effect on received echoes. It
is preferable to alter brightness on the back end with gain, rather
than subject the patient to increased output. While diagnostic US
has proven to be exceedingly safe, concerns do exist over possible
thermal and mechanical adverse bioeffects.8 EPs should strive to
perform studies in the shortest time frame and at the lowest output
possible, in line with the safety acronym ALARA (as low as reason-
ably achievable).
FIGURE 3-5. The lateral resolution of structures. Blue curves represent the trans-
mitted US beam. Black curves represent the returning echoes. The structures
PULSED US must be able to produce separate echoes for the US machine to distinguish them.
The earliest US machines produced a continuous stream of US Focusing of the beam width improves lateral resolution.
waves. Today’s machines release pulses or packets of waves, that is,
a few cycles of US at a time. The repetitive pulses are separated by
gaps of no sound. Machines can generate pulses of varying dura- produce two separate echoes for each to be recognized as distinct.
tion, frequency, and fraction of time with respect to the soundless The smaller the wavelength of the transmitted US beam, the closer
gaps. Pulsed US has been essential in the development of advanced in position can be the two tiny distinguishable structures. The size
imaging. of the wavelength can be decreased by increasing the frequency of
the US beam. Increasing the frequency delivers greater axial reso-
AXIAL RESOLUTION lution. But a sacrifice is seen in penetration because of increased
attenuation at higher frequencies.
Axial resolution refers to the ability of the US machine to distin-
guish two separate structures that lie on top of one another and
in a parallel plane to the US beam (Figure 3-4). As viewed on the
LATERAL RESOLUTION AND FOCUS
screen, this is one structure on top of another. The structures must Lateral resolution refers to the machine’s ability to distinguish two
separate structures that lie side-by-side in a plane perpendicular to
the US beam (Figure 3-5). As seen on the screen, this is one struc-
ture to the side of another. Lateral resolution is a function of the
beam width. The narrower the beam, the greater is the ability to
produce separate echoes for two adjacent objects. Focusing narrows
an US beam at specific depths. The focal zone is the narrowest part
of the hourglass-shaped US beam. Focusing can be achieved auto-
matically by the machine or manually by the operator. One or mul-
tiple focal zones can be set at specific depths to narrow the beam for
optimal lateral resolution.
TEMPORAL RESOLUTION
Continuous US scanning is actually a collection of still frames dis-
played rapidly over time. US machines produce numerous frames
per second as the scan beam is transmitted over and over again
through the tissue. The number of frames per second is known as
the frame rate. The greater the frame rate, the better the temporal
resolution, and the smoother the moving image appears. High frame
rates are particularly important for scanning moving structures such
as the heart. Employing additional functions such as Doppler scan-
ning may limit the machine’s ability to produce high frame rates.
ECHOES
Diagnostic US is predicated on sound waves not only transmit-
ting through tissues but also reflecting back to the transducer
(Figure 3-6). At an interface of two different tissues, the propor-
tion of transmission and reflection is determined by the acoustic
impedance of the tissues. Acoustic impedance is a measure of a tis-
FIGURE 3-4. The axial resolution of structures. Blue curves represent the transmit- sue’s resistance to sound penetration (density × propagation speed).
ted US beam. Red and black curves represent the returning echoes of the superfi- Acoustic impedance is high in “hard” tissues such as bone, lower
cial and deep structures, respectively. Increasing the frequency, which shortens the in visceral organs, and negligible in fluid. Reflection of an echo is
wavelength, improves axial resolution. a function of the difference between the acoustic impedance of two
FIGURE 3-6. The echoes produced as the US beam penetrates tissue. The trans-
mitted beam (orange) attenuates as it penetrates. A reflected echo (green) is
produced at an interface. Refraction (purple) and scatter (brown) contribute to
attenuation. Scatter produces the imaging within homogenous tissue.
adjacent tissues. For instance, when a sound wave travels from soft
tissue to bone, a significant proportion of the wave will reflect back
to the probe, and a minimal amount will transmit through for imag-
ing of deeper structures.
When an US beam travels through parenchymal tissue with-
out interfaces (of homogenous acoustic impedance), such as the
liver, imaging is generated not by reflection but rather by scatter.
Scattering occurs when a sound wave encounters particles smaller FIGURE 3-7. The Press-ervation technique for transducer cords. Segments of a
than its wavelength or objects with rough and irregular surfaces. An coiled garden hose are sliced along their length and placed around the middle
analogous effect is seen when light is shone through fog. There is portion of a transducer cord. This prevents damage from wheels running over
some transmission and reflection of the light, but it is the scattering dangling cords.
of light that reveals the mass of fog.
In order for an US machine to generate an image, it must deter-
the vast majority of attenuation. Absorption has very limited clinical
mine not only the intensity of the returning echo but also the location
effect for diagnostic US but is the basis of therapeutic US. Reflection is
of the reflecting structure (aka reflector). With a given propaga-
the “echoing” of the wave back to the transducer. Refraction and scat-
tion speed (velocity of sound through tissue), the machine uses the
tering are the redirection of waves on encountering certain interfaces.
travel time of the sound wave to calculate the distance the reflector
sits from the transducer. The longer the travel time, the deeper is the
reflector or structure. US TRANSDUCERS (PROBES)
There are many types of transducers (also called probes) that vary
ATTENUATION in size, shape, construction, transmitted frequency, and function
(Table 3-2). Transducers can be expensive and are at risk for dam-
Sound weakens or attenuates as it propagates through a medium age in a busy ED. Probes are often dropped and cords frequently
(Figure 3-6). Attenuation is a result of absorption, reflection, refrac- run over by the wheels of the US machine. Creative solutions to pre-
tion, and scattering of the US wave. Absorption is the conversion vent damage to dangling cords have been developed (Figure 3-7),
of sound to heat as the wave passes through tissue and accounts for but the expense of replacing transducers should be factored into
TABLE 3-2 Common Types of US Probes Used in the ED

Transducer type Vascular Abdominal Endovaginal Cardiac
Transducer shape
Type of scanning Linear sequenced Curved sequenced Microcurved sequenced Phased array
Transducer frequency High Low High Low
Megahertz 7–10 2–5 7–100 2–5
Photographs courtesy of Zonare Medical Systems.
any warranty and maintenance considerations. Many US manufac- TRANSDUCER TYPES

turers offer multiport transducer connections that allow a number
of probes to be connected at once, each activated by the push of a The typical arsenal of transducers for emergency US includes a low-
button. Limiting the connecting and disconnecting of transducers frequency curvilinear or phased array probe, a high-frequency lin-
decreases the chance of damaging fragile connector pins. ear probe, and an endocavitary probe (Table 3-2). Numerous other
Transducers are the link between the US machine and the patient. types of transducers are manufactured. It is worthwhile evaluating
The essential component of the transducer for generating an image the options available before purchasing a transducer.
is the piezoelectric element. The piezoelectric principle states that
when an electrical voltage is exerted on certain materials, a mechan- CONVEX TRANSDUCERS
ical pressure or vibration will be produced. A transducer’s piezoelec-
tric elements, or crystals, when vibrated by an electrical voltage will Convex or curved transducers are low-frequency probes that pro-
generate a mechanical sound wave. The returning sound wave in duce a sector-shaped image by sequenced array scanning. These are
turn vibrates the elements creating an electrical voltage that carries commonly used in EM, as they are useful for most US examina-
image data back to the US machine. tions of the torso. The resolution of these probes is inferior to that
of linear transducers, but the greater penetration allows for imag-
AUTOMATIC SCANNING ing of relatively deep structures such as the aorta, gallbladder, liver,
kidneys, and heart. Microconvex probes have a similar but smaller
Transducers are constructed of numerous elements arranged along footprint with a tight curvature that allows for easier use between
the width of the probe. Unlike a flashlight that emits a single contin- adjacent ribs.
uous beam of light, the US beam is a composite of pulsed firings of
the elements. Automatic scanning is the electronic activation of the
elements or arrays of crystals to generate a beam for a cross-sectional
PHASED ARRAY TRANSDUCERS
image. Two types of automatic scanning currently employed by Phased array transducers are low-frequency probes made for echo-
transducers are sequenced array and phased array scanning. cardiography and general imaging of the torso. These probes have a
small flat footprint ideal for maneuvering between ribs and imaging
SEQUENCED ARRAY the heart.
Sequenced array scanning involves the sequential firing of groups
of elements across the transducer assembly (Figure 3-8). One scan LINEAR TRANSDUCERS
line after another is generated along the width of the probe. Linear Linear transducers are high-frequency probes that are ideal for
transducers are flat-topped and produce a rectangular beam made imaging superficial structures. They are generally wide and flat-
up of parallel scan lines. Curved transducers transmit scan lines topped, and produce a rectangular image by sequenced array scan-
similarly, but following the curve of the probe and create a sector ning. These transducers are useful in the ED for imaging of blood
or pie-shaped image. The elements are fired rapidly and multiple vessels and guided line placement, skin abscesses, musculoskeletal
frames of cross-sectional images are produced per second. pathology, pneumothoraces, ocular and testicular pathology, and a
host of other superficial parts.
PHASED ARRAY
Phased array transducers generally have a narrow flat-topped foot- ENDOCAVITARY TRANSDUCERS
print. The tightly packed elements are electrically activated as a sin-
gle unit, but with a slight time lag between each element resulting Endocavitary transducers are high-frequency probes that have ele-
in an angling of the pulse direction. The electronic activation and ments arranged in a tight curve at the end of a long handle. They are
angling of each subsequent pulse is slightly changed, and the resul- designed primarily for vaginal insertion and high-resolution imag-
tant composite beam is a sector or pie-shaped (Figure 3-8). ing of the female reproductive organs. These probes can be used for
US-guided vascular access if no other high-frequency probe is avail-
able. The small footprint and room afforded by the handle may even
Linear sequenced Curved sequenced Phased array prove superior to a linear probe in some instances. The probe can be
used in a patient’s mouth for the evaluation of oral and pharyngeal
pathology, such as a peritonsillar abscess.
FREQUENCY AND TISSUE HARMONIC IMAGING

Transducers may differ in inherent frequency. The frequency of
each probe can be adjusted within a narrow range of generally a
few megahertz. If greater depth is required to view pertinent struc-
tures, lowering the frequency may be beneficial. Conversely, if finer
resolution is desired more than deep penetration, increasing the fre-
quency may improve visualization.
Tissue harmonic imaging is another means of enhancing US scan-
ning. US echoes return from tissues in multiples of the transmitted
frequency. The machine can filter out the transmitted frequency and
FIGURE 3-8. The basic types of transducers. Linear sequenced and curved focus on receiving the second harmonic frequency (twice the trans-
sequenced array probes transmit beams in a sequential fashion following the mitted frequency). The returning harmonic beam is narrower than
shape of the transducer head to produce rectangular and pie-shaped images, the beam of the fundamental frequency, and, hence, lateral resolu-
respectively. The beams of phased array probes are steered by slight delays in the tion is improved. Artifacts and distortions are also reduced with
firing of the elements to produce a pie-shaped image. harmonic imaging.
LCD display
monitor
Speakers &
microphone
Adjustable height
control panel US probes
Scan engine
Docking deck
On/off button
Multi-transducer
port
CD/DVD drive
Printer bay
Swivel wheels
with locks
FIGURE 3-9. Components of a typical US machine.
COUPLING MEDIUM GAIN

Acoustic gel is the coupling medium used in diagnostic US. The Gain is the US analog to the volume control on a radio. It alters
gel obviates any air between the probe and the patient to improve not the transmitted beam, but the returning echo to amplify inten-
US beam transmission. Apply the gel across the footprint of the sity. Gain is measured in decibels and relates to the brightness of the
probe or onto the patient’s skin. A good rule of thumb is that too image. Machines generally have a knob that can be dialed to adjust
much gel is preferable to too little. the gain, increasing or decreasing the overall brightness of the image
(Figure 3-10).
ULTRASOUND MACHINE INSTRUMENTATION Time gain compensation (TGC) allows for adjustments of gain at
specific depths. Most TGC controls consist of a collection of sliding
An US machine is made up of numerous components (Figure 3-9). knobs arranged in a column (Figure 3-11). The knobs at the top
The imaging system hardware consists of a beam former, signal proof the column correspond to the near field and those at the bot-
cessor, and image processor. The console allows the user to interface tom correspond to the far field. As an US beam penetrates to greater
with and manage the imaging. The monitor screen provides for black depths, the intensity of the beam is attenuated or dampened. TGC
and white as well as color viewing of the imaging. Transducers, sin- allows compensation for attenuation. For general abdominal imag-
gle or multiple, have connecting ports onto the machine. Archiving ing, arrange the sliding TGC knobs with a slope of increasing gain
tools, such as a printer or digital storage media, are available stan- at greater depths. Use TGC to increase or decrease brightness at dis-
dard or as options. The following sections review the key functions creet depths of the image. To compensate for the artifactual bright-
that an EP should know when performing US examinations. ness seen deep to a fluid-filled structure, decreasing the gain at that
depth can improve visualization.
THE CONSOLE
The US console generally consists of a keyboard for data entry and
DEPTH
numerous knobs, buttons, dials, and toggle switches for manipu- The depth of the field of view can be adjusted by the turn of a dial
lating the images. Carefully read the user’s manual or undergo or toggle of a switch. Depth is conventionally measured in centi-
a detailed operations briefing by the manufacturer’s application meters. Hash marks along the side of the image denote units of
specialist after purchasing a new machine. While there are many distance. Depth adjustments alter the penetration of the imag-
functions that are universal to US machines, each machine has its ing beam and allow the user to appropriately “magnify” the organ
proprietary functions. or region of interest (Figure 3-12). If the depth is set too shallow
FIGURE 3-11. Time gain compensation (TGC) controls on an US machine consist

of a column of knobs that slide back and forth to adjust the gain at specific depths.
(“overmagnification”), the organ of interest will appear too large and

its deepest portion may be cut off the screen. If the depth is set too
deep (“undermagnification”), the organ of interest will appear too
B small in the near field with wasted space in the deeper regions.
PATIENT DATA ENTRY

All machines allow the entry of demographic information about the
patient and the US examination. The patient data entry screen pres-
ents numerous fields that can be filled by typing on the keyboard.
These fields commonly include patient name, medical record num-
ber, date of birth, and a comments section to name a few. Functions
also often available on this screen are exam and transducer selection.
FREEZE AND CINE

Most machines allow both still images and video loops to be saved.
Hitting the “freeze” button stops real-time continuous scanning.
The most recent image is displayed on the screen with a few seconds
worth of images (known as cine) available for review. Use the roll-
erball or trackpad to rewind through the cine memory of frames.
This allows the viewing and subsequent saving of the most desired
still image. A number of machines can allow the viewing of a loop
of images as a video.
C
MISCELLANEOUS FUNCTIONS
FIGURE 3-10. Gain adjustments brighten and darken the US image. These images There are numerous additional functions on the console. Magnify
of a kidney display a gain setting (A) too low, (B) appropriate, and (C) too high. images with the “zoom” function. The “measure” button activates
PRINCIPLES OF GENERAL US IMAGING
DIMENSIONALITY
Imaging with US is akin to shining a flashlight in the dark. While
a flashlight’s beam is conical, the US beam is flat, and, hence, the
image displayed on the screen is a two-dimensional slice. Sound
transmits through most tissues to allow for visualization of deep
structures in the cross-sectional slice. Scanning the beam back and
forth stacks multiple two-dimensional slices in a movie format and
provides a sense of spatial orientation. Rotating the probe 90° and
scanning through the perpendicular plane helps to gain a three-
dimensional comprehension of structures.
A ORIENTATION
Orientation is entirely dependent on how the transducer is
placed on the patient. Each transducer has a marker (usually a
bump, ridge, or indentation) that correlates with an indicator on
the screen to establish orientation. If the transducer is held with
the marker aimed cephalad, the screen indicator is located on the
left side of the screen (Figure 3-13). This results in the left side of
FIGURE 3-12. Depth adjustments increase and decrease the penetration of the
US beam. These images of a kidney display a depth setting: (A) too deep at 22 cm,
(B) appropriate at 10 cm, and (C) too shallow at 6 cm.
calipers that are moved with the trackpad or rollerball. This allows
for precise measurements to the millimeter. Adjust the dynamic
range to produce effects similar to modifying the contrast of a pho-
tograph. Other functions include gray-scale mapping, edge, and B
persistence for image alteration. A dual screen function displays two
side-by-side imaging fields. Function keys can be set for easy access FIGURE 3-13. The orientation marker (white arrow) on the transducer corre-
to commonly performed tasks. sponds with the indicator on the screen (red arrow).
FIGURE 3-15. Echogenic gallstones are present in the gallbladder. Shadowing is

seen deep to the gallstones.
D E
echoes deep to a structure that is hyperechoic as the lack of reflec-

tion, similar to that seen with fluid. This is seen as a black shadow
on the screen (Figure 3-15). While shadowing from ribs may
FIGURE 3-14. Echogenicity of structures is represented by their brightness on the obscure deep anatomy, the shadows of gallstones aid in their
screen. A. Anechoic fluid is black. B. Echogenic, or highly reflective, than adjacent identification.
tissues. C. Isoechoic, or same echo-texture, as adjacent tissue. D. Hypoechoic, or
less echoic (darker), than adjacent tissues. E. Hyperechoic, or more echoic, than REVERBERATION
adjacent tissues.
Highly reflective interfaces may result in multiple reflec-
tions. Bouncing of the sound beam between the reflector and
the image representing the cephalad aspect and the right side the the transducer can create false echoes known as reverberation
caudal aspect (Figure 3-13). For conventional radiology imaging, (Figure 3-16). It can be seen when the sound beam encounters
the screen indicator is located on the left side. Most emergency US two closely spaced interfaces, such as the two walls of a needle or
examinations require views with the transducer marker aimed to the visceral and parietal pleura. The echo reflects back and forth
the patient’s head and the patient’s right. The image is displayed between the interfaces, but with some transmission of the beam
with the near field (closest to the probe) at the top of the screen and back to the probe each time. These returning echoes generate arti-
the far field (farthest from the probe) at the bottom of the screen. factual reflections on the screen termed reverberation or comet
tails (Figure 3-17).
ECHOGENICITY
Fluid is anechoic, meaning US transmits through fluid without any
reflected echoes. The echogenic silence is processed to generate
black pixels on the screen. Highly reflective structures, such as the
diaphragm and pericardium, are termed echogenic or hyperechoic.
These structures will produce white imaging. Two structures of the
same echo-texture are isoechoic. Less reflective tissue is hypoechoic
and appears darker on the screen when comparing two tissues
(Figure 3-14).
ARTIFACTS
Imaging artifacts are frequently encountered in ultrasonography.
They are erroneous representations of the anatomy in the reflected
echo. It is important to understand and expect certain artifacts to
prevent misinterpretation of the images. Artifacts may also help to
appreciate certain structures that would otherwise be less obvious.
SHADOWING
A highly reflective object allows very little of an US beam to trans-
mit through it. Most of the beam is reflected back to the trans- FIGURE 3-16. The two walls (white arrows) of a cylindrical bullet are seen
ducer and the structure is represented as hyperechoic or white superficially. Reverberation artifact produces an additional false echo (red arrow).
on the screen. The US machine interprets the lack of returning Shadowing is seen deep to the bullet.
FIGURE 3-17. Each back and forth reflection between the visceral and parietal
pleura (white arrow) results in an echo transmitted back to the probe. Multiple
echoes returning one after another produce echogenic artifacts, each deeper than FIGURE 3-19. A mirror-image artifact (white arrow) of the spleen is seen cephalad
the next. The artifact resembles a comet tail (red arrow). to the diaphragm. This is distinct from fluid that appears black.
MIRROR IMAGE MISCELLANEOUS ARTIFACTS

Highly reflective tissues can cause mirror-image artifacts. Structures A number of additional artifacts can interfere with imaging. Side
seen on the near side of a bright reflector are displayed on the other lobes are weak beams emitted lateral to the central axis of the scan-
side of the reflector as well. This is common with the diaphragm. ning beam that may produce false echoes. Section thickness artifact
Triangulation of the beam path delays the return time of the echo is a result of interfering information from the outside of the flat slice
to mirror a second reflector (Figure 3-18). Mirror-image artifact of the scanning beam. Refraction of the beam tangentially off an
can help to exclude a hemothorax by visualizing the liver or spleen interface may produce a double image of a structure lateral to the
cephalad to the diaphragm (Figure 3-19). original. Shadowing in the narrow angle of refraction may be seen
deep to the interface.
ENHANCEMENT
US MODES
Attenuation does not occur when a sound beam passes through
a fluid-filled structure. The beam’s high intensity is maintained
BRIGHTNESS MODE
through the fluid. A strong echo is generated off the posterior wall
of the fluid-filled structure. The artifact seen on the screen is a Brightness mode is commonly referred to as B-Mode. This is
very hyperechoic region deep to the fluid-filled structure that may the basic scanning mode for US. It displays the standard two-
obscure the actual anatomy (Figure 3-20). dimensional gray-scale image.
FIGURE 3-18. Bright reflectors like the diaphragm (white) can generate mirror-
image artifacts. The initial beam (solid arrow) reflects off the diaphragm and then
an anatomical structure (A) before returning to the transducer. The machine pro-
cesses the delay as a signal from a deeper structure along the initial scan line FIGURE 3-20. High-intensity echo returns from the posterior wall of the bladder
(dashed arrow) and generates an artifact (B) on the screen. result in a hyperechoic region of enhancement artifact (white arrow).
FIGURE 3-21. The M-Mode. The B-Mode image is displayed at the top of the FIGURE 3-22. The color Doppler box, or region of interest (ROI), placed over the
screen. A green vertical line is seen over the B-Mode image. The area under the carotid artery reveals flow in the direction of the probe (red).
green line is displayed over time at the bottom of the screen. The fetal heartbeat is
seen at a depth of 3.6 cm and measured at 153 beats/min.
PULSED WAVE DOPPLER MODE

MOTION MODE Pulsed wave Doppler provides a quantitative assessment of flow
velocities. Activating pulsed wave Doppler splits the screen, typi-
Motion mode or M-Mode is used to assess moving struc- cally placing the image at the top of the screen and a dynamic graph
tures. Activating M-Mode produces a vertical line on the image of flow velocities at the bottom (Figure 3-23). A small “gate” can
(Figure 3-21). The line can be moved left or right with the rollerball be positioned over a specific vascular area to measure flow. The
or trackpad. The US beam penetrating the tissue along that single size of the gate can be adjusted, allowing very narrow regions to be
line is displayed in a continuous graphical manner on the bottom accurately assessed. The dynamic Doppler graph displays time on
of the screen (Figure 3-21). The x-axis of the display is depth and the x-axis and velocity on the y-axis. Movement toward the probe is
the y-axis is time. If the line is set on immobile tissue, there will be depicted as a positive velocity deflection. Movement away from the
no variation in the M-Mode display. Movement along the line, such probe is depicted as a negative deflection.
as a beating heart, allows measurements and rate determinations
(Figure 3-21). POWER DOPPLER MODE
DOPPLER MODE Power Doppler is another method of displaying blood flow or tissue
motion (Figure 3-24). It utilizes the same ROI box as color Doppler,
Doppler scanning allows the assessment of the presence, direction, but with only one shade of color. Power Doppler is very sensitive in
speed, and character of blood flow and tissue movement. Doppler identifying the presence of flow but does not reveal direction. It is
takes full advantage of the real-time dynamic nature of US. If an advantageous in identifying low flow states, subtle tissue motion,
object is moving toward or away from the transducer, the frequency and imaging small or deep vessels.
of the reflecting echo will be higher or lower, respectively, than the
transmitted frequency. The Doppler shift is the difference between
the transmitted and reflected frequencies. The US machine can cal-
culate velocity using the Doppler shift. Turbulence, or the variance
in velocity of multiple objects in flow, can be assessed. The com-
plexities of Doppler physics and operations are beyond the scope of
this chapter.
Emergency Physicians can utilize Doppler in the assessment of
deep venous thromboses, testicular or ovarian torsion, compromised
vascular flow in the extremities, inflamed or hypervascular tissues,
to differentiate vessels from nonvascular structures for diagnostic
and procedural purposes, and for advanced echocardiography.
COLOR DOPPLER MODE

A “C” button on the machine’s console usually signifies color Doppler
mode. Activating color Doppler produces a box, or region of inter-
est (ROI), overlying the image. The ROI can be maneuvered over the
desired area. The size of the box can be manipulated to be larger or
smaller depending on the study being performed. Within the ROI,
flow will be displayed in a color schematic (Figure 3-22). Flow toward FIGURE 3-23. The pulsed wave Doppler mode. A Doppler gate is placed over the
the probe is typically red. Flow directed away from the probe is typi- center of the carotid artery. Flow is displayed in active graphical format at the bottom
cally blue. Gradients of red and blue signify the speed of the flow. of the screen. Positive deflections indicate systolic flow in the direction of the probe.
SUMMARY
Ultrasound is fast becoming a commonly used modality in EDs.
All EPs should become familiar with US as it will soon become
the standard of care for patient evaluation, patient management,
and procedural guidance. Take the time to investigate the various
options available for machines, probes, and accessories. A thorough
understanding of the functioning and features of an US machine
is essential before making clinical decisions. Training is readily
available through US fellowships, CME courses, and ultrasound
manufacturers.
A
Ultrasound-Assisted
4 Procedures
Jehangir Meer, Sam Hsu, and Brian Euerle
INTRODUCTION
Emergency Physicians commonly perform invasive procedures.
These procedures have traditionally been taught using surface land-
marks, with the assumption that anatomy is reliably similar from
patient to patient. The increasing use of ultrasound (US) to assist
in procedural guidance has demonstrated that this is not the case.
Utilizing US to assist with procedures has numerous benefits.1–9
It is safer for patients as it has been shown to reduce complica-
tions. US improves patient comfort and satisfaction. This is due
primarily to decreased attempts at the procedure. The use of US
B usually decreases the duration of the procedure.
This chapter reviews the basic information regarding the use of
FIGURE 3-24. The power Doppler mode. A. Normal lung slide at the pleural line. US to assist or guide procedures in the Emergency Department
The tissue movement generates a power Doppler signal. B. No lung slide or tissue (ED). US can assist in many commonly performed ED procedures
motion is seen in the setting of pneumothorax. (Table 4-1). The specific US technique for a procedure is described
in the chapter for the particular procedure.
The sonographer must make several decisions prior to begin-
ning a procedure using US. Will the procedure be performed
under real-time US guidance or will US only be used to map the
US IMAGE ARCHIVING anatomy? Will one person (the sonographer) or two people (the
There are numerous ways to archive US images. Still images can
be sent to printers for hard copy archiving. Thermal printers are
relatively small and can be attached to the US cart. The gray-scale TABLE 4-1 Common ED Procedures that Use US Assistance or Guidance
printouts are fine reproductions of the image, but are at risk for deg-
Body region Procedures
radation over time.
Digital archiving allows users to save both still images and videos Abdomen and pelvis Paracentesis
with a far reduced need for physical storage space. Examinations Suprapubic bladder aspiration
can be saved to hard drives built into the US machine or to periph- Suprapubic bladder catheterization
Airway Endotracheal intubation
eral devices. Machines today offer many options for peripheral
Bones and joints Arthrocentesis
storage including compact discs, digital video discs, external Closed fracture reduction
drives with universal serial bus connections, and magneto-optical Fracture identification
disks. Chest Pericardiocentesis
Specific formats for digital archiving of medical imaging have Thoracentesis
been developed, in particular the digital information and commu- Cardiac pacing (transvenous and transthoracic)
nication in medicine (DICOM) format. Most US machines today ENT Peritonsillar abscess incision and drainage
have the ability to save images in the DICOM file format. Picture Nervous system Peripheral nerve blocks
archiving and communication system (PACS) has been developed Lumbar puncture
for viewing medical imaging in DICOM and other formats. These Soft tissue and Abscess identification
systems are employed by radiology departments for viewing US musculoskeletal Abscess incision and drainage
images, as well as computed tomography, magnetic resonance imag- Foreign body identification and removal
ing, plain radiographs, and other imaging modalities. Advantages Vascular Arterial line placement
to saving DICOM images on PACS include improved organization, Central venous access
reliability, and the ability to transmit remotely. Peripheral venous access
CHAPTER 4: Ultrasound-Assisted Procedures 25
sonographer and an assistant) be necessary? Which US probe is TABLE 4-2 Recommendations for the US Probe Type to Use for
the most appropriate for the procedure? Should the instrument Specific Procedures
or needle be imaged in the long-axis view or the short-axis view? Probe type Procedure
Are needle guides necessary? What is the ideal location of the US
Curvilinear Endotracheal intubation
machine in relation to the sonographer and patient? These general
Lumbar puncture
questions must be kept in mind when using US for invasive proce-
Paracentesis
dures and are discussed below. Pericardiocentesis
Suprapubic bladder aspiration
US GUIDANCE VERSUS MAPPING Suprapubic bladder catheterization
Transcutaneous cardiac pacing
US can be used in one of the two ways for procedural assistance: the
Transvenous cardiac pacing
dynamic technique or the static technique. The dynamic technique Endocavitary Peritonsillar abscess incision and drainage
is also known as US guidance. The sonographer uses US guidance in Linear array Abscess incision and drainage
real time during the procedure to survey the anatomy, to confirm a Endotracheal intubation
diagnosis, and to visualize the needle or instrument as it enters tissue Fracture identification
and reaches the target. The static technique is also known as US map- Fracture reduction
ping. The sonographer uses US mapping prior to starting the proce- Lumbar puncture
dure to map the local anatomy, to confirm a diagnosis, and to mark Peripheral nerve blocks
the site of needle entry. The US probe is then put away and the pro- Phased array Pericardiocentesis
cedure performed in the traditional fashion without real-time US. Thoracentesis
The decision between US guidance versus US mapping is influ- Transvenous pacing
enced primarily by the degree of inherent danger of the proce-
dure. Perform procedures that carry a higher risk or have greater
technical difficulty (e.g., central venous access, pericardiocentesis, probe and the phased-array probe (Table 4-2). High-frequency
or foreign body removal) under US guidance. Perform lower risk US probes include the linear probe and the endocavitary probe
procedures (e.g., thoracentesis, paracentesis, or abscess I&D) with (Table 4-2). More than one probe may be required for some pro-
US mapping. Another factor is sonographer experience. The experi- cedures. Another factor in selecting the US probe is its footprint or
enced sonographer is more technically adept and comfortable doing surface area. A larger footprint is recommended to get a larger scan
procedures under real-time US guidance. Novice sonographers who image unless specific anatomic barriers (e.g., ribs) dictate a smaller
do not have as much psychomotor training and experience may find footprint. The types of US probes recommended for specific pro-
it easier to use US mapping. cedures are listed in Table 4-2.
ONE-PERSON VERSUS ORIENTATION OF THE NEEDLE

TWO-PERSON TECHNIQUE AND THE US PROBE
The decision to perform a procedure with one or two people is based Two orientations or approaches are used for US guidance during
on the sonographers experience and the availability of an assistant. procedures. The longitudinal or long-axis approach refers to placing
Sonographers with more experience often prefer to guide the US the long axis of the needle in-line with the long axis of the US probe
probe and manipulate the instrument themselves. Their experience
and expertise allows them to work with a higher efficiency without
an assistant. Assistance during the procedure may not be an option
during a busy ED shift, in an ED with single physician coverage
or in an ED with limited personnel. For one-person US guidance,
the sonographer holds the US probe with the nondominant hand
and guides the needle or instrument with the dominant hand. This
requires a degree of hand-and-eye coordination to maintain con-
tinuous alignment of the needle with the US probe.
Novice sonographers may find it less daunting to use the two-
person technique and work with an assistant. The assistant holds
the US probe while the sonographer guides the needle or instru-
ment. The assistant’s responsibility is to maintain alignment of the
US probe with the needle during the procedure. The sonographer
must maintain good communication with the assistant throughout
the procedure in order to maintain sight of both the needle tip and
the target organ on the US screen.
TYPES OF US PROBES
The following general principle will be helpful in determining
which US probe is the most appropriate for a given procedure.
The higher the frequency of the US probe, the better the reso-
lution of the structures visualized, but the shallower the maxi-
mum depth of view. In other words, use a high-frequency US
probe for superficial structures and a low-frequency US probe for
deep structures. Low-frequency US probes include the curvilinear FIGURE 4-1. The longitudinal or long-axis approach of the US probe to the needle.
FIGURE 4-2. The transverse or short-axis approach of the US probe to the needle.
(Figure 4-1). The transverse or short-axis approach refers to plac-

ing the long axis of the needle 90° to the long axis of the US probe
(Figure 4-2). It is paramount for the sonographer to keep sight of
the needle regardless of which approach is used during the proce-
dure. It is helpful to have the US probe indicator facing the same side
as the marker on the top of the US screen to maintain left-to-right
alignment.
The long-axis approach allows the entire length of the needle
to be visualized as it approaches the target (Figure 4-3). Depth
perception is better with this approach. This is a more intuitive
approach for some ultrasonographers. The main disadvantage of FIGURE 4-3. Long-axis US view of the needle (arrows).
the long-axis approach is the poor lateral resolution. A needle
located to the side of a structure may appear in the same plane
as the structure when actually it is not. This approach requires procedure. A needle guide is not necessary for the vast majority
precise alignment of the US probe with the needle, otherwise the of Emergency Medicine procedures. It may actually be disad-
sonographer can lose sight of the needle. The one procedure best vantageous since it does not allow “on-the-fly” corrections of the
performed with the long-axis approach is a peripheral nerve block. needle path.
The short-axis approach requires the sonographer to center the
target of interest on the US screen. The long axis of the needle is
positioned 90° to the long axis of the US probe, at the center of
the long axis of the US probe (Figure 4-2). The short-axis view
of the needle is visible on the US monitor, resulting in better lat-
eral resolution (Figure 4-4). One disadvantage of this approach is
the challenge to maintain sight of the needle tip. The sonographer
must move the US probe forward along with the needle tip as it is
advanced. The depth of the needle tip can be misjudged if one is not
careful. This can sometimes result in the inadvertent puncture of the
anterior and/or posterior wall of the target structure or vessel, or of
another adjacent structure.
MECHANICAL NEEDLE GUIDES

Needle guides are attachments to the US probe that keep the nee-
dle in a predictable path during the procedure. They are often uti-
lized by radiologists for aspiration or biopsy of deep structures.
The benefit of using a needle guide is that less hand-to-eye coor-
dination is required to keep the needle aligned with the US probe
during the procedure. The disadvantage of a needle guide is that
the path angle is fixed and cannot be changed in the midst of the FIGURE 4-4. Short-axis US view of the needle (arrow).
CHAPTER 4: Ultrasound-Assisted Procedures 27
FIGURE 4-5. An example of a good setup with the US machine in relation to the
sonographer and the patient.
FIGURE 4-6. Ring-down artifact (arrow) showing the hyperechoic vertical line
originating from the needle tip.
GENERAL TIPS WHEN USING US GUIDANCE
Always ensure that there is a direct line of sight from the procedural
field to the US machine (Figure 4-5). The sonographer should not SUMMARY
need to turn their head to the side during the procedure to view
the US screen. This will greatly improve the sonographer’s comfort The use of US assistance for procedures is an important skill set
during the procedure and increase the likelihood of success. Having in the armamentarium of the Emergency Physician. It allows
to turn your head back-and-forth can result in the needle or the potentially dangerous procedures (e.g., incision and drainage of
US probe moving, an unsuccessful procedure, puncture of incorrect a peritonsillar abscess) to be performed in a safer manner due to
structures, and potential morbidity. Hold the US probe comfortably visualization of the surrounding anatomy. It allows for the rapid
in the nondominant hand using a pencil-like grip and maintain- confirmation of a diagnosis at the bedside, resulting in faster ther-
ing light contact with the patient. It is best to use short controlled apeutic interventions (e.g., pericardiocentesis). It usually results
movements to maintain visualization when manipulating a needle in greater patient satisfaction because of fewer attempts being
or other instrument under US guidance. required to successfully complete the procedure. ED ultrasonog-
Misalignment of the US probe and the needle is the most com- raphy can truly be a lifesaving modality when used by trained
mon reason for the needle tip not being visualized during the Emergency Physicians.
procedure. Stop advancing the needle if it is not visible on the US
screen. Reposition the US probe by dragging or fanning it back ACKNOWLEDGMENTS
and forth over the area of the needle until the needle can be seen.
Gently rocking or bouncing the needle within the soft tissue can The authors would like to thank Linda J. Kesselring, MS, ELS, for
sometimes assist in determining the location of the needle tip. copyediting the manuscript and incorporating our revisions into
Indirect clues can help determine the location of the needle tip the final document; and Angela Taylor for manuscript preparation.
if it cannot be seen directly. These include the ring-down arti-
fact (Figure 4-6) and the needle shadow artifact (Figure 4-7). The
ring-down artifact is a bright hyperechoic streak due to reverbera-
tion of the US beam from the highly reflective interface of the
needle. The shadow artifact is a hypoechoic line below the needle
due to the needle blocking the US beam. Follow either artifact
until the needle can be visualized on the US screen. Continue to
follow the needle until the tip is found.
Other factors can affect the ability to visualize the needle.
Consider these when preparing to perform a procedure. Use the
appropriate probe and depth of field for the procedure. Smaller
gauge needles produce smaller artifacts and are more difficult to
visualize, especially in cross section. It is easier to visualize needles
perpendicular, or in the short axis, to the US beam. Consider using
needles specific for ultrasonography that are extra reflective. The
costs of these needles are hard to justify, but may be acceptable for
teaching. Normal needles are appropriately reflective and it is dif-
ficult to justify these specific needles clinically. The beveled tip of
the needle is easier to visualize than the shaft. The irregular surface
of the bevel will reflect the US beam better than the shaft. Insert and
advance the needle with a slight “to-and-fro” motion to easily follow FIGURE 4-7. Needle shadow artifact (arrow) showing the hypoechoic vertical line
the needle path. originating from the needle tip.
BLUNT THORACOABDOMINAL TRAUMA

Trauma Ultrasound:
5 The FAST Exam
The most studied use of the FAST exam has been in adult patients
with blunt abdominal trauma. The early diagnosis of hemoperito-
neum and/or hemopericardium in the setting of blunt trauma is
Wes Zeger critical in the management of these patients. The sensitivity and
specificity for the presence of hemoperitoneum varies depending on
INTRODUCTION the comparison “gold standard,” and is generally reported between
Evaluation of blunt trauma patients with ultrasound (US) has 78% to 90% and 98% to 100%, respectively.7,10–14 It has been reported
been described for over 30 years.1,2 Its use in the United States to approach 100% sensitivity and 100% specificity in hypotensive
in the early assessment of blunt abdominal trauma patients rap- patients.6,10 One study by Miller et al. reported a sensitivity of 42%
idly increased in the 1990s.1 It is currently taught as an adjunct and a specificity of 98%.15 The difference between these studies was
to the secondary survey in the Advanced Trauma Life Support how CT was utilized as the gold standard. Pediatric blunt trauma
(ATLS) course.1,3 US evaluation of the trauma patients decreases patients have been less well studied, but the FAST exam has shown a
the time to operative care, resource utilization, and the costs of similar sensitivity and specificity.16–19 When used to predict the need
blunt trauma patients.4,5 The focused assessment with sonography for operative intervention in pediatric trauma patients, its sensitiv-
in trauma exam, also known as the FAST exam, can be completed ity approached 90%, but its specificity dropped.20 Current guidelines
within 5 minutes.1 It has essentially replaced the need for a diag- recommend evaluation of the pericardial space in patients with
nostic peritoneal lavage in the initial assessment of all but a few blunt thoracoabdominal trauma.21
trauma patients.6,7 This chapter reviews the technique and inter-
pretation of the FAST exam. PENETRATING THORACOABDOMINAL TRAUMA
Decreased mortality using US in the assessment of trauma was
ANATOMY AND PATHOPHYSIOLOGY first described in relation to penetrating chest trauma.22 Its appli-
cation in patients with penetrating abdominal trauma is less
The FAST exam evaluates four anatomical areas or potential clear. The sensitivity ranges from 48% to 100%, but its specificity
spaces for the presence or absence of intraperitoneal fluid. These remains high at 98% to 100%.13,14,23,24 Assessment of the pericar-
include the hepatorenal recess (Morrison’s pouch), the splenore- dial space can be helpful in guiding operative intervention in the
nal recess, the rectovesical or rectouterine space, and the pericar- unstable patient.
dial space. The assumption is that fluid represents blood in the
setting of trauma. The presence of ascites, urine, and bowel fluid
can appear similar. These spaces represent the most dependent
CONTRAINDICATIONS
areas in the supine patient (Figure 5-1). The volume of fluid US is a noninvasive diagnostic modality. In the setting of trauma,
accumulation required for visualization by US ranges from 250 to it is contraindicated only if it would delay and negatively impact a
620 mL.8,9 More experienced sonographers are able to visualize clinically obvious need for emergent operative intervention. The
volumes closer to 250 mL.8 FAST exam should not be performed unsupervised by providers
who have not been adequately trained.21
INDICATIONS
EQUIPMENT
The FAST exam is performed after the primary survey. It can be
performed in conjunction with ongoing resuscitative efforts. It is • US machine
indicated when evaluating for the presence of intraperitoneal or • US gel
pericardial blood in the setting of acute thoracoabdominal trauma.
It is useful in determining resource allocation in the setting of mul- • Abdominal US probe
tipatient trauma scenarios.1 • US probe cover or glove
A B
FIGURE 5-1. The posterior reflection of the peritoneum is where blood initially layers in the supine patient. The hepatorenal (A) and splenorenal (B) recesses represent
the posterior peritoneal reflections between the inferior pole of the kidney and the liver or spleen, respectively.
CHAPTER 5: Trauma Ultrasound: The FAST Exam 29
A complete discussion of US equipment is beyond the scope of

this chapter. Decisions regarding machines and probes depend on
the user, cost, and intended applications. The FAST exam can be
performed with a good-quality general abdominal probe. Probes
with smaller footprints allow for easier viewing between the ribs.
The US probe is generally used directly against the patient’s skin,
with gel between them. Place the probe in a probe cover or glove to
prevent contamination of the probe if the patient’s skin is covered
with blood, urine, feces, or other substances. Place US gel in the
probe cover or glove before inserting the probe. Squeeze out any
air in the space between the tip of the probe and the probe cover
or glove.
PATIENT PREPARATION
Little to no preparation is required to perform the FAST exam. Wipe
any debris and liquids from the patient’s skin in the areas to be scanned. A
Place the US probe in a probe cover or glove, as described above, if the
patient’s skin is contaminated with blood, vomit, other body fluids, or
other substances that may contaminate or damage the probe.
TECHNIQUE
Performance of any US exam assumes the probe marker orientation
is generally cephalad or toward the right relative to the patient. The
FAST exam traditionally demonstrates two-dimensional grayscale
images of four views reflective of their anatomic potential spaces.
These are the hepatorenal recess (Morrison’s pouch), the splenore-
nal recess, the rectovesical or rectouterine space, and the pericardial
space. View the rectovesicle space, the area between the rectum and
the bladder, in the male patient. View the rectouterine space, the
area between the rectum and the uterus, in the female patient.
The overall exam time should be less than 5 minutes, and fre-
quently can be completed in 1 or 2 minutes. If complete views of
either the liver or spleen are not visualized with a single image,
more than one image of the area is required. The order of image
acquisition depends on the mechanism of injury. In blunt trauma,
Morrison’s pouch is generally imaged first (the area where fluid will
most likely first accumulate), followed by the splenorenal view, the
rectovesical or rectouterine view, and then the pericardial space. In B
penetrating trauma, the pericardial space is often imaged first fol-
lowed by Morrison’s pouch, then the remaining two views.
FIGURE 5-2. Imaging of the hepatorenal recess. A. US probe placement with the
corresponding US screen image. B. A view of the US beam (green) as it passes
HEPATORENAL RECESS (MORRISON’S POUCH) through the liver and kidney with the corresponding US image.
The hepatorenal recess is located between the inferior margin of
the liver and inferior pole of the right kidney (Figure 5-1A). Place
the probe on the midaxillary line at the level of the 8th to 11th ribs blood and a positive FAST exam (Figure 5-5). Rib shadows obscur-
(Figure 5-2A). The liver and kidney should be visualized from the ing portions of the image may be prevented by a slight clockwise
diaphragm to the inferior tip of the liver (Figure 5-2B). It is impor- rotation of the probe so it lies between the ribs.
tant to visualize the space between, and including, the inferior
liver tip and the inferior pole of the right kidney as fluid tends RECTOVESICAL OR RECTOUTERINE SPACE
to accumulate near the tip of the liver first. A black, echolucent,
stripe between the liver and the kidney represents blood and a posi- The rectovesical or rectouterine space represents the most inferior–
tive FAST exam (Figure 5-3). Rib shadows obscuring portions of posterior reflection of the peritoneum. Place the probe just supe-
the image may be prevented by a slight counter-clockwise rotation rior to the pubic ramus (Figure 5-6). The probe can be oriented in
of the probe so it lies between the ribs. either the sagittal or transverse plane. View the rectovesicle space
(Figures 5-6A & B) or the rectouterine space (Figures 5-6C & D)
SPLENORENAL RECESS in both the sagittal and transverse planes. A black, echolucent,
stripe in either space represents blood and a positive FAST exam
The splenorenal recess is located between the inferior margin of the (Figures 5-7 & 5-8).
spleen and the inferior pole of the left kidney (Figure 5-1B). Place
the probe on the posterior axillary line at the level of the sixth to PERICARDIAL SPACE
ninth ribs (Figure 5-4). The spleen and kidney should be visual-
ized from the diaphragm to the inferior tip of the spleen. A black, In the supine trauma patient, fluid accumulates initially in the
echolucent, stripe between the spleen and the kidney represents inferior–posterior portion of the pericardial space. The probe and
A B
FIGURE 5-3. A positive FAST exam of the hepatorenal recess. A. An echolucent fluid stripe in Morrison’s pouch. B. A normal exam for comparison.
A B
FIGURE 5-4. Imaging of the splenorenal recess. A. US probe placement with the corresponding US screen image. B. View of the US beam (green) as it passes through
the spleen and kidney.
A B
FIGURE 5-5. A positive FAST exam of the splenorenal recess. A. An echolucent fluid stripe. B. A normal exam for comparison.
FIGURE 5-6. Imaging of the rectovesical and the rectouterine spaces. A. Transverse
US probe placement for the rectovesical view with the corresponding US image.
B. Sagittal view, and probe orientation, of the rectovesical space displaying the
US beam path (pink) and the corresponding US image. C. Transverse view of the D
rectouterine space. D. Sagittal view of the rectouterine space.
A B
FIGURE 5-7. A positive FAST exam of the rectovesical space. A. Transverse view of an echolucent fluid area. B. A normal exam for comparison.
A B
C D
FIGURE 5-8. A positive FAST exam of the rectouterine space. A. Sagittal view of an echolucent fluid area. B. A normal sagittal exam for comparison. C. A transverse view
of an echolucent fluid area. D. A normal transverse exam for comparison.
screen image orientation are different than traditional echocardio- increase the depth of the US beam to increase image quality. Fluid
graphic views. Place the probe with the marker oriented toward the will initially accumulate near the top of the US image, represent-
patient’s right and the tip of the probe aimed toward the patient’s ing the inferior portion of the pericardial space (Figure 5-9 inset).
left shoulder (Figure 5-9). Use the liver as an acoustic window and Visualize both the inferior and superior areas of the pericardial
space. A black, echolucent, stripe in either the inferior or superior
areas of the pericardial space represents blood and a positive FAST
exam (Figure 5-10).
ALTERNATIVE TECHNIQUES
The incorporation of thoracic imaging coupled with the tradi-
tional FAST exam has been referred to as an extended FAST or
EFAST exam. This additional imaging assesses for the presence of a
hemothorax or a pneumothorax. A hemothorax is best assessed by
visualizing the inferior–posterior aspect of the plural cavity in the
supine patient (Figure 5-11). This area is often visualized in rou-
tine views of Morrison’s pouch, but moving the US probe superior
one rib interspace may be required. The lung edges are not nor-
mally visualized on US. However, the lung can be seen “floating”
in fluid in the presence of a hemothorax (Figure 5-11B). Another
sign suggestive of a hemothorax is the “spine” sign (Figure 5-11B).
In the presence of a hemothorax, the portion of the thoracic spine
above the diaphragm can be visualized with US. The thoracic spine
is not normally well visualized on US superior to the diaphragm
(Figure 5-11C).
FIGURE 5-9. Imaging of the pericardial space. US probe placement for the subxy- A pneumothorax is best assessed in the supine patient with either
phoid view with the corresponding US image. (RV, right ventricle; RA, right atrium; a linear or a curvilinear probe. Place the probe on the anterior chest
LV, left ventricle; LA, left atrium). wall in the area bounded by the clavicle, sternum, nipple, and anterior
FIGURE 5-10. A positive FAST exam of the pericardial space. A. A large echolucent
area of fluid in the inferior–posterior aspect of the pericardial space and a small
amount of fluid in the more superior area of the pericardial space. B. A normal
exam for comparison.
axillary line. Start with the probe on the midclavicular line between
the nipple and the clavicle. It may be moved within the area to obtain
the best image possible. Position the probe perpendicular to two adja- B
cent ribs to visualize the intercostal space (Figure 5-12). The nor-
mal sliding of the visceral pleura against the parietal pleura during
respiration can be visualized (Figure 5-12A). This interface between
the two pleura is known as the “sliding-lung” sign and is absent in a
pneumothorax.
Use M-Mode to visualize the “sea-shore” sign (Figure 5-12B).
This is visualized as slightly wavy parallel lines from the thoracic
wall over an echogenic line (the pleural line), under which is a sandy
pattern produced by the lung parenchyma. The parallel lines at the
top of the screen represent the waves of the “sea.” The sandy pat-
tern at the bottom of the screen represents the “shore.” Together they
form the “sea-shore” sign. The echogenic line between the “sea” and
the “shore” represents the pleural lines. The “sea-shore” sign indi-
cates a normal chest wall–lung interface. Air interposed between the
chest wall and lung forms parallel, horizontal echogenic lines and
the loss of the “sea-shore” sign (Figure 5-12C).
C
ASSESSMENT
FIGURE 5-11. Imaging a hemothorax. A. The patient and US probe position.
The interpretation of each of the four views, and of the overall The US beam path (green) generates the pleural component (inset). B. Blood
FAST exam, is classified into one of the three categories: positive, in the pleural space provides an acoustic window to visualize the thoracic spine
negative, or indeterminate. Positive exams demonstrate echolucent (“spine sign”). C. A normal exam for comparison.
A B
FIGURE 5-12. Imaging a pneumothorax. A. Rib shadowing is seen on both sides

of the intercostal space. The echoic interface of the parietal and visceral pleura
demonstrates the “sliding-lung” sign. B. The “sea-shore” sign. It is visible when the
lung and chest wall are in contact with each other. Note the bright echogenic stripe
of the pleural interface between the chest wall (“sea”) and the lung (“shore”).
C. The “sea-shore” sign and the pleural interface are absent when a pneumothorax C
is present.
(seen as black on the image) fluid accumulations in any one of the hemodynamically stable or unstable penetrating trauma patient, a
four views. Negative exams and scans demonstrate no fluid with negative FAST exam is a reliable screen for the presence of intra-
complete visualization of all structures of each view. Indeterminate pericardial blood. It is not a reliable screening test for the pres-
exams are uncommon but may occur when fat or bowel cannot be ence of abdominal injury. In the unstable patient, its use is not
distinguished from peritoneal fluid, or if there is incomplete visual- well defined. In the hemodynamically stable blunt trauma patient,
ization of any of the four views. Women and children may normally a negative FAST exam should be followed by serial clinical exams
have a small amount of physiologic fluid in their pelvis. This find- and a repeat FAST exam.25 A negative FAST exam in the presence
ing may lead to an indeterminate exam in the setting of trauma. of hemodynamic instability has a high sensitivity, and an extraperi-
toneal source of bleeding or the instability should be considered.
AFTERCARE Indeterminate FAST exams require a follow-up alternative diagnos-
tic modality, usually a CAT exam.
Multiple algorithms exist for the management of trauma patients.1,3
In general, these are differentiated into blunt trauma versus pen-
etrating trauma and hemodynamically stable versus unstable. In the COMPLICATIONS
hemodynamically stable blunt trauma patient, a positive FAST exam Performance of the actual FAST exam has no associated complica-
is typically followed with an abdominal cat exam. In the hemody- tions. However, inaccurate interpretation or inappropriate appli-
namically unstable adult blunt trauma patient, a positive FAST exam cation of US findings in clinical decision making may complicate
indicates the need for emergent operative intervention without fur- its use.
ther imaging. In adult patients with penetrating trauma, a positive
FAST exam has good correlation with need for a therapeutic lapa-
SUMMARY
rotomy.23 Management of these patients may vary between institu-
tions. An unstable pediatric patient with a positive FAST exam may The FAST exam is a useful adjunct in the management of blunt
not necessarily proceed to laparotomy as the indications for opera- and penetrating trauma patients. It can be performed rapidly, it is
tive management differ between adults and children.3 very specific, and it can positively impact patient outcomes. Proper
A negative FAST exam needs to be evaluated within the training is required to ensure good-quality images and appropriate
patient’s clinical context (history, exam findings, vitals, etc.). In the interpretation.
SECTION
Respiratory Procedures 2
lined by 16 to 20 horseshoe-shaped cartilaginous rings. The primary
Essential Anatomy bronchi subsequently branch into three secondary bronchi on the
6 of the Airway right and two secondary bronchi on the left. The angle between the
primary bronchus and the trachea on the left is more acute than
on the right. This is due to the heart being located on the left side.
Ned F. Nasr, Serge G. Tyler,
This is clinically significant during aspiration and endobronchial
Gennadiy Voronov, and Isam F. Nasr
intubations. Because of the more direct path on the right side due
to the obtuse angle of the primary bronchi, objects (food, fluid,
INTRODUCTION and foreign bodies) are more likely to enter the right lung. The
A thorough understanding of anatomy is essential for the perfor- tracheal mucosa removes waste products by producing and moving
mance of any medical procedure.1–10 Untoward events due to a pro- mucus toward the pharynx via ciliary action. The trachea has a rich
cedure are usually the result of inexperience and/or an inadequate innervation from the vagus nerve, which permits a vigorous cough
understanding of the regional anatomy. The anatomy of the airway reflex (accompanied by hypertension and tachycardia) if a foreign
and airway procedures are no exception. From the evaluation of body is aspirated.
external anatomic landmarks to the performance of nerve blocks The inner diameter of the trachea varies between normal adult
for fiberoptic intubation, an understanding of the anatomy of the males and females. It ranges from about 15 to 20 mm.4 Since the
airway will result in fewer attempts at intubation and improved external diameter of a 7.5 mm internal diameter (ID) endotracheal
success with fewer iatrogenic misadventures. tube is 11.0 mm, the size must be taken into consideration in select-
ing an endotracheal tube. These considerations usually preclude
GENERAL ANATOMY using tubes much larger than 7.5 mm ID for normal adult females
or larger than 8.0 or 8.5 mm ID for normal adult males.
The upper airway comprises the nasal and oral cavities, the phar-
ynx, and the larynx. The lower airway consists of the subglottic ANATOMY OF THE LARYNX
larynx, the trachea, and the bronchi.8 Airway management typically
involves the upper airway, the focus of this chapter. The anatomy of The innervation of the larynx is relatively simple. The internal
the pharynx, larynx, and trachea are depicted in Figure 6-1. branch of the superior laryngeal nerve provides sensation above
The nares serves as the functional beginning of the airway, the vocal cords (vocal folds). The recurrent laryngeal nerve supplies
namely warming and humidification of air.4 The mucosa of the sensation below the vocal cords. The recurrent laryngeal nerve pro-
nasal passage is extremely vascular and fragile and therefore sus- vides the motor input to all of the intrinsic muscles of the larynx
ceptible to trauma. The nasal blood supply originates from branches except to the cricothyroid muscle, which is supplied by the exter-
of the internal and external carotid arteries. It is wise to consider nal branch of the superior laryngeal nerve. Bilateral injury to the
the use of a vasoconstricting agent, when appropriate, to help avoid recurrent laryngeal nerve will result in total airway closure due to
epistaxis which may obscure further attempts at securing the airway. unopposed stimulation of the vocal cord adductor, the cricothyroid
Although patients tolerate nasal intubation better than oral intuba- muscle.1
tion for a longer period of time, it is more important in an emer- There are three paired and three unpaired cartilages of the
gency to definitively secure the airway using a straightforward oral larynx.2 The paired cartilages are the smaller arytenoid, cornicu-
intubation if possible. late, and cuneiform cartilages (Figure 6-2). The unpaired cartilages
The sensory innervation of the upper airway is provided by are the larger thyroid, cricoid, and epiglottic cartilages. Although
branches of several cranial nerves. The mucous membrane of the not part of the larynx, the hyoid bone has many ligamentous and
nose is innervated anteriorly by the anterior ethmoid nerve (oph- muscular attachments to the larynx. The cricoid cartilage is signet
thalmic division of the trigeminal nerve) and posteriorly by the ring-shaped, as opposed to the C-shaped cartilages of the trachea
sphenopalatine nerve (maxillary division of the trigeminal nerve). (Figure 6-2). Because it forms a complete circle, depression of the
The tongue is innervated by the lingual nerve on its anterior two- cricoid cartilage will put pressure on structures located posteriorly
thirds (a branch of the facial nerve) and by the glossopharyngeal (i.e., the esophagus). The application of posteriorly directed pres-
nerve posteriorly. The glossopharyngeal nerve also innervates the sure on the cricoid cartilage during intubation is known as the
adjacent areas, including the palatine tonsils, the undersurface of Sellick maneuver (Figure 6-3). The Sellick maneuver will not
the soft palate, and the roof of the pharynx.1 The anatomy of the prevent regurgitation from active vomiting. It has been shown
oropharynx is discussed further under the “Airway Evaluation” to be effective in the prevention of passive regurgitation and
section and the anatomy of the larynx is covered in the next section. subsequent aspiration.3 However, the Sellick maneuver can impair
The trachea measures 10 to 16.5 cm in an average adult.4 The tra- insertion of the laryngoscope or an airway introducer, and can cause
chea is a tubular structure that begins at the level of the fifth or sixth airway obstruction.
cervical vertebrae and bifurcates at the level of the fifth thoracic The cricoid cartilage is also an important landmark for locat-
vertebra into two primary bronchi. The posterior aspect of the tra- ing the cricothyroid membrane, which lies inferior to the thyroid
chea is flat and membranous, while its anterior and lateral aspect is cartilage and superior to the cricoid cartilage (Figure 6-2). The
35
36 SECTION 2: Respiratory Procedures
Nasal concha
Vestibule of nose Nasopharynx
Hard palate
Soft palate
Oral cavity
Uvula of soft palate
Tongue Oropharynx
Palatine tonsil
Mandible
Hyoid bone
Epiglottis
Vocal fold
Larynx Thyroid cartilage
Cricoid cartilage Esophagus
Trachea
FIGURE 6-1. Anatomy of the airway as visualized in a midsagittal section through the head and neck.
cricothyroid membrane is usually located at the level of the sixth move the epiglottis anteriorly and out of the path of vision during
cervical vertebra. It is the anatomic location where emergency intubation. Another attachment of the hyoid bone to the larynx
cricothyroidotomies and recurrent laryngeal nerve blocks are is the thyrohyoid membrane (Figure 6-2). As its name implies, it
performed. runs from the inferior border of the hyoid bone to the superior
The three paired cartilages are located on the posterior aspect of aspect of the thyroid cartilage. Just inferior to the lateral border
the larynx (Figure 6-2). This position renders them vulnerable to of the hyoid bone, the internal branch of the superior laryngeal
injury during intubation.2 By maintaining an anterior insertion of nerve passes through the thyrohyoid membrane (Figure 6-2). At
the laryngoscope blade and by not inserting it too deeply during this point, the internal branch of the superior laryngeal nerve is
intubation attempts, it is less likely that these cartilages will become superficial and very easily anesthetized with an injection of local
dislocated or otherwise injured. This is particularly true if a straight anesthetic solution.
laryngoscope blade is used.
The hyoid bone is an important supporting structure of the
AIRWAY EVALUATION
upper airway. One of the attachments of the hyoid bone to the
larynx is the hyoepiglottic ligament located at the base of the val- The evaluation of the airway should always start with a thorough
lecula (Figure 6-4). This ligament is important because it is where history. An airway history should be conducted, when feasible,
the tip of the curved Macintosh laryngoscope blade is placed to prior to the initiation of airway management in all patients. It
CHAPTER 6: Essential Anatomy of the Airway 37
Epiglottis
Hyoid bone
Entry point of internal branch

of superior laryngeal nerve
Thyrohyoid
membrane
Cuneiform
cartilage
Arytenoid cartilage
Thyroid cartilage
Cricothyroid muscle
Cricothyroid cartilage
Trachea
Anterior view Posterior view
FIGURE 6-2. Right anterolateral and posterior views of the skeleton of the larynx. The thyroid cartilage shields the smaller cartilages of the larynx.
should include whether the patient has ever required intubation and External evaluation of the airway is a critical step to a success-
if there was any difficulty. Additional history should focus on the ful intubation. These brief evaluations are helpful in predicting a
patient’s dentition and any surgery on or near the airway. There are difficult intubation. External inspection should identify some obvi-
many congenital syndromes (Table 6-1) and acquired conditions ous problems that may interfere with airway management. These
(Table 6-2) that can complicate airway management. These should include as facial hair which prevents a good mask seal, cervical col-
be kept in mind when performing the airway history and physical lars which restrict neck movement, face and/or neck trauma, severe
examination. micrognathia, or obesity.
The next steps in evaluating the airway may help to identify
patients with potentially difficult airways. In adults, the distance
between the thyroid cartilage (“Adam’s apple”) and the inside of the
Vallecula (location of Epiglottis Tubercle of

hyoepiglottic ligament) epiglottis
Vocal fold
Aryepiglottic
fold
Trachea Corniculate Cuneiform

FIGURE 6-3. The Sellick maneuver. Posteriorly directed pressure is applied to the cartilage cartilage
cricoid cartilage to occlude the esophagus and prevent regurgitation and subse-
quent aspiration of gastric contents. FIGURE 6-4. Laryngoscopic view of the larynx.
TABLE 6-1 Selected Congenital Syndromes Associated TABLE 6-2 Acquired Conditions Affecting the Airway and
with Difficult Endotracheal Intubation Associated with Difficult Endotracheal Intubation
Syndrome Description Principal pathologic clinical
Down’s Cervical spine spondylolisthesis; large tongue, Condition features of the airway
small mouth make laryngoscopy difficult; Acromegaly Macroglossia; prognathism
small subglottic diameter possible; frequent Acute burns Edema of airway (worsens with time, secure
laryngospasm airway early!)
Goldenhar Mandibular hypoplasia and cervical spine Angioedema Obstructive swelling renders ventilation and
(oculoauriculovertebral abnormality make laryngoscopy difficult intubation difficult
anomalies) Arthritis
Klippel–Feil Neck rigidity because of cervical vertebral fusion Rheumatoid arthritis Temporomandibular joint ankylosis, cricoarytenoid
Pierre Robin Small mouth, large tongue, mandibular anomaly; arthritis, deviation of larynx, restricted mobility
awake intubation essential in neonate of cervical spine
Treacher Collins Laryngoscopy difficult Ankylosing spondylitis Ankylosis of cervical spine; less commonly
(mandibulofacial ankylosis of temporomandibular joints;
dysostosis) lack of mobility of cervical spine
Turner High likelihood of difficult intubation Benign tumors Stenosis or distortion of airway
Source: Data from Barash et al.1 Cystic, hygroma,
lipoma, adenoma
Diabetes mellitus May have reduced mobility of atlantooccipital joint
Foreign body Airway obstruction
anterior aspect of the mandible is known as the thyromental dis- Hypothyroidism Large tongue, abnormal soft tissue (myxedema)
tance. It should be at least 5 cm or about three large finger breadths.1 make ventilation and intubation difficult
A lesser distance suggests that the patient’s vocal cords are positioned Infectious
more anteriorly than normal. Distances less than 5 cm may indicate Supraglottitis Laryngeal edema
that visualization of the larynx during intubation may be difficult Croup Laryngeal edema
or impossible due to a lack of space in which to displace the tongue. Abscess (intraoral, Distortion and stenosis of airway and trismus
The next evaluation requires the patient to open his or her mouth retropharyngeal)
maximally. Ideally, the patient will be in a seated or semisitting posi- Ludwig’s angina Distortion and stenosis of airway and trismus
tion. The distance between the maxillary and mandibular incisors Malignant tumors Stenosis or distortion of airway; fixation of larynx
in an average adult is 3 to 5 cm or about two large finger breadths.5 Carcinoma of tongue, or adjacent tissues secondary to infiltration or
Limited mouth opening may impair visualization of the airway as larynx, or thyroid fibrosis from irradiation
well as expose the teeth to damage during intubation. Adults should Morbid obesity Short, thick neck, and large tongue are likely
be able to flex their cervical spine 35° and extend the cervical spine to be present
(atlantooccipital joint) 80° from a neutral position.6 This range of Pregnancy Edema of airway
neck movement allows for the alignment of the oral, pharyngeal, Sarcoidosis Airway obstruction (lymphoid tissue)
Scleroderma Tight skin and temporomandibular joint
and laryngeal axes during orotracheal intubation (Figure 6-5). This
involvement make mouth opening difficult
alignment of the axes provides the greatest chance for a successful Temporomandibular Severe impairment of mouth opening
intubation. Recent evidence suggests that slight head extension in joint syndrome
infants and young children by placing a rolled towel behind their
Thyromegaly Goiter may produce extrinsic airway compression
shoulders better aligns the vision of the glottic and laryngeal axes.10
or deviation
Observe the patient’s neck for length and thickness. A short, exces- Trauma Cerebrospinal rhinorrhea, edema of airway;
sively long, or thick neck may indicate difficulty in placing the Head, face, or cervical hemorrhage; unstable fracture(s) of maxillae
patient in the “sniffing position” and align the airway axes. spine injury and mandible; intralaryngeal damage; dislocation
The internal examination should evaluate the patient’s dentition, of cervical vertebrae
palate, and tongue. Note any protuberant incisors, loose teeth, bro-
Source: Modified from Miller.4
ken teeth, dental work, and dental devices. Prominent upper inci-
sors may complicate the insertion of the laryngoscope blade, make
laryngoscopy difficult, and predispose the patient to dental trauma.
Assess the relation of the maxillary and mandibular incisors dur- should not say “ahhh,” as this distorts the anatomy and may falsely
ing normal jaw closure. Lack of an overbite forces the laryngoscope improve the airway classification. The Mallampati classification,
blade to enter the mouth in a more cephalad direction than nor- named after its author, has four grades or classes.7 The anterior and
mal. This can result in difficulty visualizing the airway. Observe the posterior tonsillar pillars, the fauces, the soft palate, and the uvula
maxillary and mandibular incisors during voluntary protrusion of can be fully visualized in class I (Figure 6-6A). The fauces, the soft
the mandible to determine the degree of temporomandibular joint palate, and the uvula can be visualized in class II (Figure 6-6B). The
mobility. Determine if the palate is normal, high and arched, or anterior and posterior tonsillar pillars are covered by the base of the
cleft. Determine if the tongue is elevated, larger, or wider than nor- tongue and not visible. Only the soft palate and the base of the uvula
mal in comparison to the oral cavity. Any abnormality can make the are visible in class III (Figure 6-6C). None of the structures are
procedure of orotracheal intubation more difficult. visible in class IV (Figure 6-6D). The predictive value of this clas-
A common classification used by Anesthesiologists to grade the sification is that during direct laryngoscopy, the entire glottis can
difficulty of laryngoscopy and intubation involves the identification be exposed in 100% of class I airways, 65% of class II airways, 30%
of the size of the tongue in relation to the tonsillar pillars, the fauces, of class III airways, and 0.1% of class IV airways.7
the soft palate, and the uvula.7 It is important to perform this evalu- The airway evaluation is imperfect in predicting potential prob-
ation by first instructing patients to open their mouths and pro- lems and an airway strategy (combination of plans) should be drawn
trude their tongues maximally in the sitting position. The patient up for each patient. Additional evaluation may be indicated in some
CHAPTER 6: Essential Anatomy of the Airway 39
FIGURE 6-6. The Mallampati classification. A. Class I. B. Class II. C. Class III.
D. Class IV.
patients to characterize the likelihood or nature of the anticipated

airway difficulty. The findings of the airway history and physical
examination may be useful in guiding the selection of specific diag-
nostic tests and consultation.
ANATOMIC DIFFERENCES BETWEEN

THE ADULT AND THE YOUNG CHILD
There are numerous differences between the airway of an adult and
that of a child. The head-to-body ratio is larger in the child. This
causes the neck to be flexed when the child is supine. Placing a rolled
towel under the child’s shoulders will correct the flexion. A child has
a small mouth with a relatively large tongue as compared to an adult.
This can make orotracheal intubation difficult. The presence of
adenoidal tissue in the child makes nasotracheal intubation difficult
and orotracheal intubation the preferred method.
The anatomic differences between the larynx of an adult and that
of a young child are summarized in Table 6-3 and Figure 6-7.1 The
vocal cords are more obliquely inclined in the child. The cricothy-
roid membrane is very small and narrow. The most important dif-
ference is that the narrowest portion of the infant or young child’s
airway is below the level of the vocal cords at the level of the
FIGURE 6-5. Schematic diagram demonstrating head positioning for endotra-
cricoid cartilage. In an adult, the narrowest point of the airway
cheal intubation. A. The normal alignment of the oral, pharyngeal, and laryngeal
is at the level of the vocal cords. The cricoid cartilage is the only
axes. B. Elevation of the head about 10 cm with pads below the occiput, while
the shoulders remain on the table, aligns the laryngeal and pharyngeal axes. complete cartilaginous ring and the narrowest part of the trachea.
C. Subsequent head extension, at the atlantooccipital joint, serves to create the An endotracheal tube may therefore pass through the vocal cords
shortest distance and most nearly a straight line from the incisor teeth to glottic of a young child but might not advance past the cricoid cartilage
opening. due to normal anatomy. Forcing an endotracheal tube past the vocal
cords in a young child may result in trauma to the airway and sub-
sequent tracheal stenosis. Because the child’s larynx is located more
cephalad at the level of the third or fourth cervical vertebrae and
TABLE 6-3 Anatomic Differences Between the Child’s lead to more effective ventilation. The child’s diaphragm is shorter
and the Adult’s Larynx and flatter than the adult, and thus has a decreased excursion dur-
Child’s larynx Adult’s larynx ing respiration. The child’s relatively narrower airways result in an
increased resistance to inspiratory and expiratory airflow. They are
Size Smaller Larger
also more susceptible to airway edema and mucous plugs obstruct-
Shape Lumen is funnel shaped with the Narrowest part of
narrowest part below the vocal cords lumen is at the
ing their narrow airway. Children have smaller and fewer alveoli.
and within the cricoid ring vocal cords This results in less surface area for gas exchange compared to adults.
Location Higher, closer to the tongue base; Vertical extent is
vertical extent is opposite C3, C4, C5 lower, opposite C4, SUMMARY
vertebrae; more anterior C5, C6 vertebrae
Epiglottis Longer, narrower, and “U” shaped; the Shorter and wider It is essential for Emergency Physicians to know the anatomy of
angle between glottis and epiglottis is the airway, especially the differences found in the young child.
more acute; increased chance of airway The airway assessment is an essential element in the preparation to
obstruction (see Figure 6-7) intubate a patient. Unfortunately, there may be limited information
Vocal cords Angled in relation to the axis of trachea; Perpendicular to and time available to perform the full assessment in an emergent
shorter; more cartilaginous; more the axis of trachea setting. Performing the airway assessment in every patient before
distensible; more likely to be injured orotracheal intubation will allow one to perform it quickly in an
Rigidity The laryngeal cartilages are softer and More rigid emergency.
more pliable
Response Mucous membrane is more loosely Less vulnerable
to trauma attached and swells more readily when to trauma and
traumatized or infected infection
Basic Airway Management
angulated anterior to the glottis, blind nasal intubation in the case of
7 Christopher J. Russo and Zach Kassutto
airway emergencies is not possible. The child’s laryngeal inlet is nar-

row and more susceptible to obstruction. The U-shaped epiglottis INTRODUCTION
and a more acute angle between the epiglottis and glottis cause the
aryepiglottic folds to be more in the midline (Figure 6-7B). Airway management is one of the most basic and important aspects
Differences also exist in the trachea. Children have a relatively of Emergency Medicine. The concepts and techniques described
shorter trachea. This makes both right main bronchial intuba- in this chapter can be applied in a variety of environments.
tion and accidental extubation much easier. The narrower diam- Understanding the following concepts and having an opportunity
eter of the trachea with smaller spaces between the cartilaginous to practice them will allow one to provide the most fundamental of
rings makes a tracheostomy more difficult to perform. To avoid all medical care, support of a patient’s airway.
injury and subsequent subglottic stenosis, uncuffed endotra- Airway management remains crucial. Without oxygen, the brain
cheal tubes should be used in children less than 28 days of age.11 begins to die within minutes.1 The primary purpose of airway
A correctly sized endotracheal tube should have a leak at 15 to management is to facilitate the transport of oxygen to the lungs.
25 cm water. Using the uncuffed endotracheal tube with high The secondary purpose is to protect the airway from contamination
leak pressure more than 25 cm of H2O or the cuffed endotra- with blood, fluids, or food. Airway management can be as simple as
cheal tube can not only cause croup after extubation, but also lifting a snoring patient’s chin or as involved as awake, fiberoptic-
create an erosion of the mucosa and subglottic stenosis. A cuffed guided endotracheal intubation.
endotracheal tube is recommended for anyone above the age of The fundamental importance of airway management is reflected
28 days.10–13 by the fact that two-thirds of basic life support taught by the
The differences also continue into the chest. The infant thoracic American Heart Association is concerned with this vital function.2
cage is more compliant than the older child and adult. This can The mission of airway management is to ensure a patent airway,
provide supplemental oxygen, and institute positive-pressure
ventilation when spontaneous breathing is inadequate or absent.3
These three key aspects of airway management warrant repeat-
A ing. Ensure a patent airway. Provide supplemental oxygen.
Provide positive-pressure ventilation.
Epiglottis Time is always critical when a patient needs airway support.
B The body’s limited oxygen stores are rapidly exhausted once breath-
ing stops. A healthy individual having maximally breathed 100%
oxygen will begin to desaturate and have brain injury after 5 minutes
of apnea. However, a sick patient breathing room air will desaturate
almost immediately upon becoming apneic.1
Oxygenation and ventilation remain the essential goals of air-
way management. Inadequate ventilation may occur for a variety
Vocal fold
of reasons. Spontaneously breathing patients may develop an airway
obstruction due to food, blood, secretions, or tissue obstruction from
Aryepiglottic the loss of normal pharyngeal tone. The conscious patient with air-
fold way obstruction will be in obvious distress and is more likely to have
obstruction due to a foreign body, tissue swelling from an infection,
FIGURE 6-7. Differences between the adult’s larynx (A) and the child’s larynx (B). laryngeal edema, tumor, or laryngospasm. The unconscious patient,
CHAPTER 7: Basic Airway Management 41
despite spontaneous respiration, is at risk for aspiration of gastric TABLE 7-1 Indicators that Warrant Respiratory Assistance
contents. Unconscious patients should have their airway secured as
SaO2 < 90%
well as receive mechanical ventilation.
PaO2 < 60 mmHg on 40% O2
ANATOMY AND PATHOPHYSIOLOGY Respiratory rate > 35
PaCO2 > 55 mmHg
The “upper airway” includes the nasal, oral, pharyngeal, and laryn- Vital capacity < 15 mL/kg
geal anatomy and physiology. This highly complex system is respon-
A-a gradient > 350 mmHg on 100% O2
sible for conveying warmed and filtered air to the trachea and lungs
while simultaneously allowing for passage of liquids and solids to Source: Data from Shapiro et al.10
the esophagus. Phonation is a secondary physiologic function of the
larynx.4 This highly sophisticated system allows us to drink liquid, the landmarks for identifying the cricothyroid membrane, which is
eat food, breathe, and talk simultaneously. However, if a small drop essential in obtaining an emergent surgical airway.
of liquid or a particle of food enters the airway, a profound system of The sensory and motor innervation of the larynx is derived from
reflexes is activated to protect its integrity.5 the vagus nerve.6 The superior laryngeal nerve is a branch of the
The nasal cavity and the nasopharynx is the area from the tip of vagus nerve and gives rise to the internal branch, which provides
the nose to the palate. The nasal cavity is bounded laterally by the the sensory innervation of the upper larynx. The superior laryn-
bony framework of turbinates and medially by the nasal septum. geal nerve also gives rise to the external branch, which provides the
This area is highly innervated by the ophthalmic and maxillary motor innervation to the cricothyroid muscle (a vocal cord adduc-
branches of the trigeminal nerve. The mucosa of the nasal cavity tor). The recurrent laryngeal nerve provides the sensory innerva-
and the nasopharynx is highly vascular. It is this high degree of vas- tion to the larynx below the vocal cords and motor innervation to
cularity that allows cool air from the environment to be warmed all other laryngeal muscles.6
and humidified prior to entering the lungs. It also dictates that care The trachea is approximately 15 cm long in an adult. It is com-
be taken when nasal airways are placed. It takes very little trauma posed of 17 or 18 C-shaped cartilaginous rings.6 The rings are
to the nasal mucosa to cause significant epistaxis. Polyps or mucus essential to prevent the trachea from collapsing during the negative
can obstruct the nasopharynx, as can congestion due to an upper intrathoracic pressures generated on inspiration.
respiratory infection. The nasopharynx is oriented in an anteropos-
terior plane. In the supine patient, nasal airways or nasogastric tubes INDICATIONS
should always be passed perpendicular to the horizontal axis and
not in a cephalad direction. The decision to institute airway support must often be made very
The oropharynx extends from the palatoglossal fold down to the quickly and frequently without the aid of laboratory results, radio-
epiglottis. The primary structure contained within the oropharynx graphic studies, or pulmonary function tests. The decision to
is the base of the tongue. The anterior two-thirds of the tongue is institute emergent airway support is usually based on clinical
innervated by the lingual nerve, a branch of the facial nerve. The judgment and the signs and symptoms of inadequate oxygen-
posterior one-third of the tongue, the tonsils, and the palate are ation and ventilation. The signs of impending respiratory failure
innervated by the glossopharyngeal nerve.6 Salivary glands located are tachypnea, dyspnea, cyanosis, agitation, and the use of accessory
in the oropharynx can produce a significant volume of saliva, cre- muscles.9 In the case of a partial airway obstruction, the patient will
ating potential problems for mask ventilation or intubation. Loose demonstrate extreme anxiety, audible wheezing or stridor, as well
teeth can be inadvertently dislodged into the oropharynx, becoming as aggressive attempts to clear the obstruction. If the obstruction is
potentially hazardous foreign bodies in the airway. complete, there may be no audible breath sounds at all.
Edentulous patients present a unique set of problems for mask If time permits, a more formal evaluation of the indicators that
ventilation.7 The lack of a maxillary alveolar ridge allows the face warrant respiratory assistance should be performed (Table 7-1).
mask to collapse into the airway. Redundant tissue, due to lack of The ultimate signs indicating the necessity for airway assistance
teeth, tends to collapse into the airway as well, making mask ventila- are hypoxia and hypercarbia. The most common etiologies result-
tion without an oral or a nasal airway extremely difficult. An appro- ing in the need for airway support are cardiopulmonary arrest, drug
priately sized and placed oral airway is the best way to overcome overdoses, toxic reactions, and airway obstruction (food, vomit, or
the problem of upper airway obstruction in the unconscious and foreign body). Impending ventilatory failure due to congestive heart
edentulous adult patient. failure, severe asthma, or pneumonia are also common indications
The laryngopharynx extends from the epiglottis to the inferior for endotracheal intubation.
border of the cricoid cartilage. The piriform recesses lie in the phar-
ynx, on either side of the larynx, and the esophagus resides pos- CONTRAINDICATIONS
teriorly. The larynx is positioned at the entrance to the trachea,
acts as the sphincter of the pulmonary system, and is made up of There are no absolute contraindications for basic airway manage-
nine cartilages to support this function.6 There are three paired and ment. The contraindications for the various methods of endotra-
three unpaired cartilages. The unpaired cartilages are the epiglottis, cheal intubation are discussed in subsequent chapters.
the thyroid cartilage, and the cricoid cartilage. The paired cartilages
are the arytenoids, the corniculates, and the cuneiforms. The cricoid EQUIPMENT
cartilage is the only complete ring in the entire airway. This pres-
ents a unique opportunity for the practitioner to help prevent gastric • Bag-valve-mask device
aspiration. The cricoid cartilage can be firmly pressed posteriorly • Oxygen source
to pinch the esophagus against the cervical spine and prevent the • Clear face masks, various sizes and shapes
passive regurgitation of gastric contents. This is known as the • Oropharyngeal airways, various sizes
Sellick maneuver.8 The cricoid cartilage is the narrowest point of
the airway in the pediatric patient while the glottic narrowing is the • Nasopharyngeal airways, various sizes
most narrow point in adults. The cricoid and thyroid cartilages are • Head strap
• Yankauer suction catheter

• Suction source
• Pulse oximeter
• Tongue blades or tongue depressors
• Water-soluble lubricant or anesthetic jelly
TECHNIQUES
PATIENT POSITIONING
The first goal of airway management, regardless of a patient’s
ability to breathe spontaneously, is the establishment of a pat-
ent airway. This may be all that is required in a patient who has
an upper airway foreign body or a patient who has suffered a loss
of consciousness with loss of pharyngeal tone. The importance of
proper positioning cannot be overemphasized. The success of
airway management is predicated on this very basic but often
overlooked issue. Placing the patient in the “sniffing” position, or
lateral decubitus position, may correct many upper airway obstruc-
tions due to soft tissue impingement.11 The “sniffing” position
is achieved by flexing the cervical spine approximately 15° and
extending the atlantooccipital joint maximally (Figure 7-1). This
is the position one subconsciously adopts in order to sniff and smell.
Head extension in this manner must be omitted in the patient for
whom cervical spine precautions are in effect. This position can
also be achieved with the chin-lift and/or jaw-thrust maneuvers.
If the patient is obese or has large breasts, they often cannot be
effectively managed in a supine position. The normal sniffing posi-
tion in an obese person is often not sufficient to relieve an airway
FIGURE 7-2. Airway management in the obese patient. A. The normal “sniffing”
obstruction (Figure 7-2A). Place a ramp or shoulder roll under the
position is inadequate to open the airway. The dotted line represents the axis of
patient’s upper back to achieve the sniffing position (Figure 7-2B).
the airway. B. A ramp placed under the head and shoulders will achieve the “sniff-
ing” position.
JAW-THRUST MANEUVER
The jaw thrust is one of the most basic maneuvers and an initial
method of establishing a patent airway.12 The tongue is attached to fingers on the angles of the patient’s mandible bilaterally, then dis-
the mandible and falls into the pharynx in the supine patient. The places the mandible anteriorly (Figure 7-3). This maneuver elevates
goal of the jaw-thrust maneuver is to move the tongue away from the tongue from the pharynx and allows air to flow unobstructed
the palate and posterior pharyngeal wall. The jaw-thrust maneu- and posterior to the tongue.
ver is a two-handed technique that can also be used with the face
mask and a second person to provide positive-pressure ventilation. CHIN-LIFT MANEUVER
The operator is positioned at the head of the patient and places their The chin lift is also one of the most basic maneuvers and an initial
method of establishing a patent airway.12 The chin lift is performed
by the operator placing their fingers on the inferior surface of the
patient’s mandible (Figure 7-4). Do not place any of the fingers on
FIGURE 7-1. The “sniffing” position for successful airway management. FIGURE 7-3. The jaw-thrust maneuver.
FIGURE 7-6. Insertion of the nasopharyngeal airway.
FIGURE 7-4. The chin-lift maneuver.

nasal airway is more comfortable for the patient than an oral airway,
but nasal airways carry the significant risk that their placement may
result in epistaxis.3,10 A size 30 or 32 French nasal airway is appropri-
the soft tissues of the submandibular space, as this will elevate the
ate for most adults. It can be safely placed in the conscious, semicon-
tongue and cause further obstruction. Lift the chin in an anterior
scious, or unconscious patient, and can also be used when an oral
and cephalic direction. The head may also be tilted slightly posterior
airway cannot be placed (e.g., oral trauma, braces, seizures, trismus,
to aid in opening the airway.
etc.). It is imperative to also perform the jaw thrust and/or chin
lift to prevent the tongue from obstructing the patient’s airway
NASOPHARYNGEAL AIRWAYS when using a nasal airway.
The majority of airway obstructions occurs in the region of the Insertion of a nasal airway is a rapid procedure. Choose the proper
pharynx.13 In addition to proper positioning, one can use various size nasal airway by placing the flared end of the airway near the tip
aids to overcome this site of obstruction and facilitate effective ven- of the patient’s nose. The distal end of the nasal airway should be at
tilation. The most commonly used devices are oropharyngeal (oral) the external auditory canal. Liberally apply a water-soluble lubri-
and nasopharyngeal (nasal) airways. Regardless which device is cant or an anesthetic jelly to the nasal airway. If not contraindicated,
chosen, it is important to place a large enough airway to bridge the apply a vasoconstrictor to the patient’s nasal mucosa. Gently insert
area of soft tissue impingement on the pharynx. and advance the nasal airway with the beveled tip against the nasal
Nasal airways are soft rubber or plastic tubes that are inserted septum (Figure 7-6). This will prevent any epistaxis from the tip
through the nostril and into the oropharynx, just above the epiglot- of the nasal airway getting caught on the inferior or middle turbi-
tis. Nasal airways are available in numerous sizes (Figure 7-5). The nate. Also insert it along the floor of the nasal cavity adjacent to the
proximal end has an enlarged flange that rests against the patient’s septum. Continue to advance the nasal airway completely until the
nares and prevents the nasal airway from slipping backward into flared end is against the patient’s nostril. Rotate the nasal airway 90°
the nose and becoming a foreign body in the patient’s airway. The so it is concave upward. If resistance is encountered during inser-
larger the inner diameter, the longer the tube. Once positioned, the tion, slight rotation will often facilitate the passage of the nasal air-
way. If resistance is still encountered, insert the nasal airway into the
other nostril or use a smaller nasal airway. Supplementary oxygen
or positive-pressure ventilation with a bag-valve-mask device can be
started after insertion of the nasal airway.
Insertion of a nasal airway may be associated with complications.
If the device is too long, it may cause laryngospasm and vomiting. It
may also be placed with its tip in the esophagus, resulting in gastric
distention and subsequent aspiration. Nasal mucosal injury upon
insertion can result in epistaxis and aspiration of blood.
OROPHARYNGEAL AIRWAYS
The oropharyngeal (oral) airway is a semicircular plastic device
that holds the tongue up and away from the posterior pharyngeal
wall (Figure 7-7). Oral airways cause less trauma and are more
easily placed than nasal airways. Oral airways must be used only
in unconscious patients. They may result in laryngospasm and
vomiting if placed in a conscious or semiconscious patient.14 An
8.0, 9.0, or 10.0 cm oral airway is appropriate for most adults.
Oral airways have many uses. The primary indication is to
FIGURE 7-5. Nasopharyngeal airways. maintain a patent airway. It will prevent the patient from biting,
FIGURE 7-7. Oropharyngeal airways.
occluding, and lacerating an endotracheal tube. It facilitates oropha-

ryngeal suctioning by removing the tongue from the airway, and
will also protect the tongue from bites during seizure activity.
Insertion of the oral airway is a quick and simple procedure. Choose
the proper size oral airway. The correct size is estimated by placing
the proximal flange of the oral airway next to the patient’s mouth.
The distal tip should lie just above the angle of the mandible. Clear
the mouth and oropharynx of any blood, secretions, or vomit with a
Yankauer suction catheter. Open the patient’s jaw with the nondomi-
nant hand. Separate the patient’s jaws with a “scissors-like” action of
the thumb on the lower teeth and the index or middle finger on the B
upper teeth. Insert the oral airway curved side down (Figure 7-8A).
The tip will slide along the hard palate. Insert it until the plastic flange
FIGURE 7-8. Insertion of the oropharyngeal airway. A. It is inserted with the curve
on the proximal end is at the patient’s lips. Rotate it 180° so that the
toward the tongue. After insertion, it is rotated 180°. B. It is inserted with the curve
curve of the oral airway follows the curvature of the tongue. toward the palate. A tongue blade is used to depress the tongue and facilitate
An alternative method is to use a tongue blade to depress the insertion.
tongue and then insert the oral airway as described above. If the
tongue blade is used, the oral airway may also be inserted with
the curve side upward (Figure 7-8B). Supplementary oxygen or
positive-pressure ventilation with a bag-valve-mask device can be A distinction must be made between ease of mask ventilation and
started after the insertion of the oral airway. ease of oral endotracheal intubation. The two are often correlated
Insertion of an oral airway is not a benign procedure. If the oral but can, at times, be completely unrelated. For example, a patient
airway is not inserted properly, it can push the tongue posteriorly with a normal body habitus who is in a cervical halo may be very
and further obstruct the oropharynx. Significant lacerations can easy to ventilate by mask but impossible to intubate orally via direct
occur if the lips or tongue are caught between the teeth and the oral laryngoscopy. Conversely, the patient who is obese, suffers from
airway. If the oral airway is too long, it can force the epiglottis closed sleep apnea, but has a Mallampati class 1 airway may be very easy to
against the vocal cords and produce a complete airway obstruction. intubate but virtually impossible to ventilate by mask.
Too small of an oral airway will force the tongue against the pharynx After achieving the proper positioning, the presence of spontane-
and produce an obstruction. ous respirations must be evaluated. If the patient is not breathing
and there is no evidence of a foreign body, positive-pressure ventila-
tion must be initiated. In the awake patient with complete airway
MASK VENTILATION
obstruction due to a foreign body, the Heimlich maneuver is the
The likelihood of success in airway management is often predict- method of choice.2 If the patient has become unconscious and the
able, given enough time to fully assess a patient’s history and anat- foreign body is clearly visible, remove it. However, caution must
omy (please refer to Chapter 6).15 The ease of mask ventilation and be used to prevent forcing the object further into the airway.
intubation is directly related to anatomy. Anesthesiologists rely on Instrument removal of airway foreign bodies with a McGill forceps is
a series of evaluations and classification criteria to help predict the possible if the foreign body is visible and within reach of the forceps.
success of airway management. The most widely used classification Once the airway is patent, the options for positive-pressure ven-
is the Mallampati classification (Figure 6-6).16 This evaluation— tilation include mouth-to-mouth, mouth-to-mask, and bag-valve
coupled with an examination of the patient’s body habitus, thick- devices (mask ventilation). The remainder of this section will
ness of the patient’s neck, temporomandibular joint function, ability review the latter, as the other two options are not used in Emergency
to fully open the mouth, dental structures, cervical range of motion, Departments or hospitals. The key to effective mask ventilation
and thyromental distance—can help predict the ease or difficulty of is ensuring a continually patent airway. This is initially achieved
airway management.15–21 by placing the patient in the sniffing position, coupled with
FIGURE 7-10. The two-handed, two-person mask ventilation technique.

FIGURE 7-9. The one-handed, one-person mask ventilation technique.
THE NUMASK™
a combination of chin lift and jaw thrust. Neglect of this key A relatively new device can be used to assist in ventilation instead
maneuver leads to an excessive use of positive-pressure ventila-
tion in an attempt to compensate for an obstructed upper airway. ™
of a traditional face mask. The NuMask (NuMask Inc., Woodland
Hills, CA) solves the problem of having to create an airtight face
Improper patient positioning associated with positive-pressure ven- mask seal in patients. This device is an intraoral mask for teenag-
tilation will force gas into the stomach, increasing intraabdominal ers and adults that connects to a bag-valve device and eliminates
pressure and resulting in the need for ever-increasing positive pres- the need for a face mask (Figure 7-11A). It is especially useful in
sure on the airway. Rising intraabdominal pressure will eventually patients whom it is difficult to get a good face mask seal (e.g., obese,
make ventilation difficult or impossible, and significantly increase facial hair, and facial trauma) or for the one-person bagging tech-
the risk of gastric aspiration. When called upon to mask ventilate a nique. The company makes a retention shield that wraps around
patient, always keep in mind the importance of proper position- the patient’s head to secure the device and seal the patient’s nostrils.
ing and the use of an appropriately sized oral or nasal airway as This allows for easy one-person bagging.
an adjunct.
Face masks should be made of clear plastic and/or silicone, have ™
The NuMask is simple to insert into the patient’s mouth. Place
the device into the patient’s mouth. It should sit between the patient’s
a soft seal, and have an anatomic shape that conforms to the con- teeth/gums and the cheeks/lips (Figure 7-11B). Use the thumb and
tours of the patient’s face. Typical adult sizes are 3, 4, and 5. The index finger of the nondominant hand to pinch the patient’s nostrils
mask must be large enough to completely cover the nose, mouth, closed (Figures 7-11C & D). Use the hand and remaining fingers
and chin but not so large as to allow a leak. It should not cover to wrap around the external tube portion and to seal the patient’s
any part of the patient’s eyes. There are two ways to properly hold a lips over the intraoral portion of the device (Figures 7-11C & D).
face mask. The one-handed technique is performed with the non- The moisture in the patient’s oral cavity maintains the airtight seal.
dominant hand (Figure 7-9). The operator should be positioned Attach the bag-valve device and begin ventilations. If ventilation is
at the top of the bed looking down at the patient’s head. Place the
little, ring, and middle fingers under the patient’s mandible. Place ™
difficult, remove the NuMask , insert an oral airway, replace the
the index finger and thumb on the bottom and top portions of the ™
NuMask , and begin ventilations.
mask. This technique allows the operator to simultaneously lift
There are numerous advantages of using the NuMask over the ™
traditional face mask. It is ideal for operators with small hands who
the mandible and extend the atlantooccipital joint while applying have difficulty grasping and maintaining a seal with a face mask.
enough downward pressure on the face mask to create an airtight While initially cumbersome to use, it is easier to maintain a seal
seal. An elastic head strap is a very helpful device to aid in sealing than a face mask. Ventilation is easier when only one person is avail-
the mask tightly. The dominant hand is used to ventilate the patient able to bag and ventilate the patient. It can be used in patients in
through the bag-valve device. whom a good face mask seal is difficult. The device can be used in
A two-handed technique may be necessary in patients with facial both conscious and unconscious patients as it should not cause a
hair and those who are obese, elderly, or edentulous. Two people gag reflex. Finally, the one size available will fit most teenagers and
are required to perform this technique, in which both of the opera- adults. A pediatric version is not available.
tor’s hands are applied to the face mask to aid in the creation of a
tight seal and align the airway properly (Figure 7-10). Place the face
THE BAG-VALVE DEVICE
mask on the patient’s face. Place the index, middle, ring, and small
fingers of the left hand on the body of the left side of the patient’s A bag-valve device is used to provide positive-pressure ventilation.
mandible. Position the right hand similarly on the right side of the It consists of a self-inflating bag connected to oxygen on one end and
patient’s mandible. Apply both thumbs to the mask and apply pres- a one-way (nonrebreathing) valve on the other. They are available in
sure to create a seal. Anteriorly elevate the mandible to perform the several sizes depending on the age of the patient (Figure 7-12). The
jaw-thrust maneuver. This is the two-person technique and makes valve end is connected to the face mask, or other airway device, to
it necessary to have an assistant apply positive pressure through the allow one-way flow of oxygen. The other end has tubing to attach
bag-valve device attached to the face mask. It is preferable, when- the bag to an oxygen source. This device can also force air into the
ever possible, to use the two-person technique which allows for esophagus and stomach and place the patient at risk for aspiration
improved bag-valve-mask ventilation.25 if not used properly.
FIGURE 7-11. The NUMASK™ intraoral mask. A. The device. B. The device is inserted between the patient’s teeth/gums and their lips/cheeks. C. Proper hand positioning
to seal the patient’s nostrils and lips. D. An alternative hand positioning.
It may be difficult to provide adequate ventilatory volumes of the bag to generate an appropriate volume of air flow. Consider
through the bag-valve device attached to a face mask. This is often using the two-person technique to resolve these issues. If ventilation
due to an inadequate seal of the face mask on the patient while main- is difficult in a child, change the face mask from the standard tear-
taining an open airway. It can also result from inadequate squeezing drop shaped mask to a circular-shaped face mask.
Stand above the patient’s head. Place the patient in the sniffing
position. Apply a face mask. Attach the bag-valve device to the face
mask and begin positive-pressure ventilation. Begin ventilations at
a rate of 10 to 12 per minute, or squeeze the bag every 5 to 6 sec-
onds. If ventilation is difficult, apply the jaw-thrust and/or chin-lift
maneuvers. If ventilation is still difficult, insert an oral or nasal air-
way. If ventilation is still difficult, the patient requires an invasive
airway device immediately.
The American Society of Anesthesiologists has published an
algorithm to facilitate decision making in the face of airway man-
agement problems. A detailed discussion of the various intubation
options is presented in following chapters.
PEDIATRIC CONSIDERATIONS
Significant differences exist between the adult and pediatric air-
way as described in Chapter 6. The ratio of head-to-body size is
greater in infants and young children. Care must be taken to achieve
proper positioning for optimal airway angulation. A towel may be
placed under an infant’s shoulders, while younger children may be
optimally positioned while lying flat on the stretcher. Older chil-
FIGURE 7-12. The bag-valve-mask device. From left to right: adult size, child size, dren may require a towel under the head to achieve ideal position-
and infant size. ing.23 Despite proper head positioning, loss of tone in the muscles
CHAPTER 8: Pharmacologic Adjuncts to Intubation 47
supporting and protecting the upper airway may still result in an TABLE 8-1 Recommended Anesthetic Doses of Pharmacologic
airway obstruction. This may be corrected by the use of a jaw thrust, Agents Used for Rapid Sequence Induction
chin lift, nasal airway, or oral airway. Adult dose Pediatric Onset Duration
Infants and children have a higher minute ventilation and car- Medication (mg/kg) dose (mg/kg) (sec) (min)
diac output than adults, as well as higher basal oxygen consump-
tion. They also have a lower functional residual capacity which leads Thiopental 2–5 2–6 <30 5–10
Methohexital 1–3 1–2 <30 5–10
to oxygen desaturation more rapidly than in adults when apnea
Etomidate 0.2–0.3 0.2–0.3 15–45 3–12
occurs. When oxygenation and ventilation are provided in an effec- Ketamine 1–2 1–3 45–60 10–20
tive and efficient fashion, hypoxic bradycardia can be prevented or Propofol 1.5–2.5 2.5–3.5 15–45 5–10
reversed.23 Midazolam 0.2–0.4 0.5–1.0 30–90 10–30
Properly sized equipment remains crucial to the success of Fentanyl 0.005–0.015 0.005–0.015 15–45 30–60
airway management, and can be addressed by the use of the
Broselow tape. It should be noted that there is insufficient evidence
for or against the routine use of laryngeal mask airways during
pediatric cardiac arrest. While an acceptable adjunct in the hands the use of several pharmacologic adjuncts (Tables 8-1 & 8-2). This
of experienced providers, it is associated with a higher incidence of includes a potent anesthetic agent to induce unconsciousness and a
complications in young children.24 neuromuscular blocking agent to produce paralysis.
COMPLICATIONS INDUCTION AGENTS

The most serious complication of basic airway management is The ideal induction agent has an extremely rapid onset of action,
aspiration of gastric contents. The aspiration of acidic gastric con- produces predictable deep anesthesia, has a short duration of action,
tents can result in an acute chemical pneumonitis. This phenom- and has no adverse effects.2 Unfortunately, such an agent does not
enon is known as the Mendelson syndrome and has an associated yet exist. However, there are at least six drugs that can safely be used
50% mortality.22 It is a significant risk when airway management is for induction of anesthesia and intubation. These include thiopen-
needed emergently or routinely in the pregnant, trauma, diabetic, tal, methohexital, etomidate, ketamine, and propofol. Midazolam
or obese patient. and fentanyl may also be used alone or in conjunction with the
Less serious complications include soft tissue trauma to the lips, above agents.2 The decision as to which induction agent is the
tongue, oral cavity, and eyelids. Tooth fractures or avulsions are most suitable is largely dependent on the Emergency Physician’s
uncommon but possible. A dermatitis or allergic reaction to the experience and his or her understanding of each drug’s prop-
plastic material is rarely seen. Facial nerve dysfunction due to pres- erties. In this section, each of these drugs is briefly detailed as to
sure effects of the mask are transient. Corneal abrasions, conjuncti- its pharmacokinetics, mechanism of action, pharmacodynamics,
val chemosis, and increased intraocular pressure are common with administration, and adverse effects.
masks that are too large.
BARBITURATES
SUMMARY For more than 50 years, barbiturates have been a mainstay in the
Basic airway management is a fundamental skill that must be mas- induction of anesthesia. They rapidly produce sedation and hypnosis
tered by all caregivers. With an oxygen source, a means to deliver in a dose-dependent fashion. They are also less expensive than many
positive-pressure ventilation, attention to detail in positioning, and of the newer induction agents.3 Because of their high potency, rapid
the use of airway adjuncts, it is usually possible to prevent hypoxia onset, and short duration of action, the most commonly used bar-
and hypercarbia in the apneic patient. The ultimate measure of the ™
biturates are thiopental (Pentothal ) and methohexital (Brevital ). ™
efficacy of ventilation and oxygenation is a normal PaCO2 and PaO2.
The various methods of securing the airway are discussed elsewhere ■ PHARMACOKINETICS
in this text. When injected intravenously, these ultra-short-acting barbiturates
can produce effects in one arm-brain circulation time, or less than
30 seconds.4 The onset of central nervous system (CNS) depression
is primarily due to the rapid distribution of thiopental and metho-
hexital to the well-perfused, low-volume central compartment,
Pharmacologic
8 Adjuncts to Intubation TABLE 8-2 Recommended Neuromuscular Blocking Agents for
Intubation and Rapid Sequence Induction
Ned F. Nasr, David W. Boldt, and Isam F. Nasr
Adult dose Pediatric Onset Duration
INTRODUCTION Medication (mg/kg) dose (mg/kg) (min) (min)
Succinylcholine 0.6–1.0 1–2 1 2–3
Oral endotracheal intubation without pharmacologic assistance Succinylcholine 1.5 2 1 3–5
should be reserved for the unresponsive and apneic patient. for RSI
Unconscious patients capable of resisting laryngoscopy or those Pancuronium 0.1 0.07–0.10 2–5 40–60
with spontaneous respiratory effort should be intubated with the Atracurium 0.5 0.5 3 20–35
assistance of pharmacologic adjuncts. A rapid sequence induction Vecuronium 0.1 0.05–0.10 3 30–40
optimizes intubation conditions while minimizing the risk of aspi- Vecuronium for RSI 0.3–0.5 0.3–0.5 1 45–60
ration for the patient. It can be performed with a high rate of success Rocuronium 0.6 1.0 4–6 15–85
and minimal complications.1 Rapid sequence intubation requires Rocuronium for RSI 0.9–1.2 1.0–1.2 1.0–1.5 30–110
consisting mainly of the brain and liver. Approximately 15% of these cardiovascular depressant effects and a shorter duration of action,
lipid-soluble drugs remain unbound and free to diffuse across the likely making it more useful than thiopental in the Emergency
blood–brain barrier at high initial concentrations. Brain levels peak Department setting.
in about 1 minute. The duration of a single dose of thiopental is Barbiturates cause dose-dependent central respiratory depres-
approximately 5 to 10 minutes, while an equipotent dose of metho- sion characterized by diminished tidal volume and minute ven-
hexital lasts approximately 4 to 6 minutes.5 The short duration of tilation. The rate and depth of respiration may be suppressed to
action is due to the redistribution of the drugs from the small- the point of apnea. The physiologic response to hypercarbia and
volume central compartment to the large-volume peripheral com- hypoxemia may also be blunted, even after the hypnotic effects have
partment, which is predominantly made up of lean muscle. dissipated. All these effects may be greatly exaggerated with the
Both thiopental and methohexital are metabolized in the liver concomitant use of opioids and in patients with chronic obstruc-
and excreted by the kidneys. Methohexital has a substantially higher tive pulmonary disease.8
hepatic extraction ratio, which may account for its shorter duration
of action. Clearance of the drugs has little to do with the cessation ■ ADMINISTRATION
of CNS effects in single or multiple small doses. If barbiturates are Thiopental and methohexital are available as sodium salts and
given in multiple high doses or in an infusion, the concentration should be dissolved in 0.9% saline. The recommended dose of
in the peripheral tissue approaches the plasma concentration and thiopental is 3 to 5 mg/kg in adults, 5 to 6 mg/kg in children, and
the rate of redistribution is greatly diminished.6 This prolongs their 6 to 8 mg/kg in infants IV given over 1 minute. The recommended
anesthetic effects.6 dose of methohexital is 1 to 3 mg/kg IV over 30 seconds. The
induction dose should be reduced in patients premedicated with
■ MECHANISM OF ACTION fentanyl or midazolam. Doses may have to be adjusted in patients
Barbiturates, along with other common intravenous (IV) anesthetic with known hepatic or renal disease because decreased plasma
agents, are postulated to act on the γ-aminobutyric acid (GABA) albumin levels leave a greater fraction of barbiturate available to
receptor complex. Specifically, these drugs work on the GABAA cross the blood–brain barrier. A 30% to 40% reduction should be
receptor.7 GABA is the principal inhibitory neurotransmitter in the made in the geriatric population since their diminished muscle
CNS. The GABA receptor complex forms a transmembrane chloride mass slows the rate of redistribution and lengthens the duration
channel when activated. The influx of chloride ions causes hyper- of CNS effects.3
polarization and functional inhibition of the postsynaptic neurons.
Barbiturates can act on the GABA receptor in two ways. At lower ■ ADVERSE EFFECTS
doses, they may potentiate the action of endogenously produced The most significant complications of barbiturate therapy stem
GABA by decreasing the rate of its dissociation from the receptor from their cardiopulmonary depressant effects. As stated above,
complex. At higher doses, barbiturates may directly activate the these agents should be used with caution in patients who are hypo-
chloride ion channels and inhibit neuronal activity.3 It is impor- volemic, have significant cardiovascular disease, or have reactive
tant to note that barbiturates do not inhibit sensory impulses airway disease. Thiopental can raise plasma histamine levels, which
and therefore have no analgesic effect. In fact, they may produce may be associated with a transient skin rash and bronchospasm.
hyperalgesia (increased response to painful stimuli) when given in Its use should be avoided in patients with a history of hypersensi-
subhypnotic doses.3 tivity to barbiturates. Severe anaphylactic reactions are extremely
uncommon.3 Laryngeal reflexes appear to be more active with thio-
■ PHARMACODYNAMICS pental than with propofol. Thiopental should be avoided in people
Barbiturates produce dose-dependent depression of cerebral oxy- with asthma.3 Laryngospasm following induction with thiopental
gen metabolism (CMRO2), cerebral blood flow (CBF), and elec- is more likely the result of airway manipulation in a “lightly anes-
troencephalogram (EEG) activity. A flat EEG tracing correlates to thetized” patient.3 Methohexital has known epileptogenic effects
a maximal barbiturate suppression of CMRO2 to 55% of normal.3 and is frequently associated with myoclonic tremors and other
The diminished CMRO2 and CBF lead to a decrease in intracranial CNS excitatory side effects, such as hiccups.3 Barbiturates stimu-
pressure (ICP). Since barbiturates lower mean arterial pressure less late the production of porphyrins and thus are contraindicated in
than they lower ICP, cerebral perfusion pressure (CPP) is usually patients with acute intermittent porphyria, variegate porphyria,
enhanced. Barbiturates are commonly used in neuroanesthesia and and hereditary coproporphyria.3 Pain at the site of intravenous
in treatment of acute brain injury. injection is more common with the administration of methohexital
The cardiovascular effects of barbiturates include decreased than thiopental. Due to their high alkalinity (pH 10), extravascular
cardiac output, decreased systemic arterial pressure, and a direct or intraarterial injection of these drugs may cause severe pain, tis-
negative inotropic effect on the myocardium. Barbiturates decrease sue necrosis, and thrombosis, leading to potential nerve damage
cardiac output primarily by depressing the vasomotor center, caus- and gangrene.
ing peripheral vasodilatation, and decreasing venous return to the Intraarterial injection should be treated promptly by initially
heart. Both thiopental and methohexital have a positive chrono- diluting the barbiturate with saline injected through the catheter
tropic effect on the heart. Methohexital produces a greater increase in the artery. Next, intraarterial injections of heparin, papaverine,
in heart rate, which may explain why an equipotent dose of metho- lidocaine, or phenoxybenzamine may be administered to cause
hexital produces significantly less hypotension than does thiopen- vasodilation and prevent vessel thrombosis.3 Lastly, sympathectomy
tal.3 Although the increase in heart rate mitigates the drop in blood of the involved upper extremity by a stellate ganglion or brachial
pressure, myocardial oxygen demand is increased while coronary plexus block can be performed by an Anesthesiologist to relieve the
vascular resistance is decreased. If the aortic pressure remains vasoconstriction.
stable, coronary blood flow will increase to meet the increased An additional concern relating to the high alkalinity of these
demand. Therefore, barbiturates must be used cautiously in any solutions is that if they are injected rapidly through the same intra-
patient whose condition is sensitive to tachycardia or a decrease venous line along with highly acidic drugs, such as neuromuscu-
in preload (e.g., hypovolemia, congestive heart failure, ischemic lar blockers, precipitation will occur. This may lead to permanent
heart disease, or pericardial tamponade). Methohexital has less blockage of the line at a time when intravenous access is crucial. It
is recommended that the line be flushed thoroughly both before ■ ADVERSE EFFECTS
and following the administration of barbiturates, and before the The most common side effects of etomidate are nausea, vomiting,
administration of the next agent. and myoclonus during the induction phase, and injection site pain.
Myoclonic activity has been reported in about one-third of cases
ETOMIDATE and is attributed to interruption of inhibitory synapses in the thala-
mocortical tract rather than CNS excitation.2 Pretreatment with an
™
Etomidate (Amidate ) is an ultra-short-acting hypnotic unrelated
opioid analgesic or a benzodiazepine has been reported to diminish
to any other intravenous anesthetic agent. Like barbiturates, it is
highly potent and produces a rapid onset of anesthesia. It lacks the the frequency of myoclonic movements.11 Vein irritation and pain at
barbiturates’ cardiodepressant side effects. Given its favorable pro- the intravenous site can be attributed to the propylene glycol dilu-
file, etomidate has become a popular induction agent and, in many ent. Use of a large vein with simultaneous analgesic and saline infu-
Emergency Departments, is now the induction agent of choice for sion reduces the incidence of injection pain.17
rapid sequence intubation.9 Etomidate causes a dose-dependent suppression of adrenal cor-
ticosteroid synthesis by inhibiting the enzyme 11-β-hydroxylase.74
■ PHARMACOKINETICS A single induction dose of etomidate suppresses adrenocortical
hormone synthesis for more than 5 hours.75 In critically ill patients
Etomidate is a carboxylated imidazole agent that undergoes a molec-
on an etomidate infusion, increased mortality has been attributed
ular rearrangement at physiologic pH, which grants it greater lipid
to this reduction of endogenous steroids leading to acute adreno-
solubility. Approximately 75% of the drug is plasma protein bound.
cortical insufficiency.18 There is currently conflicting evidence,
The free fraction accumulates readily in the CNS. Unconsciousness
however, as to whether a single induction dose of etomidate has
is produced within one arm-brain circulation time. Peak brain con-
an effect on overall mortality in critically ill patients.76–81 Until
centration is achieved within 1 minute. Redistribution of the drug
significant randomized, controlled clinical trials can be performed,
is quite rapid. A single bolus dose produces hypnosis in 10 seconds
the use of etomidate for the induction of patients in early sepsis or
and lasts approximately 3 to 5 minutes. Since it has a high extrac-
septic shock should be cautioned.
tion ratio and undergoes rapid hydrolysis by the liver, clearance
of etomidate is dependent on hepatic blood flow, with inactive
metabolites excreted in the urine.10 KETAMINE
■ MECHANISM OF ACTION
™ ™
Ketamine (Ketalar , Ketaject ) is a phencyclidine derivative that
is unique among induction agents. It produces a dissociative anes-
By modulating GABA receptors to produce hyperpolarization and thetic state characterized by profound analgesia and amnesia.
functional inhibition of the postsynaptic neurons, etomidate (like Patients may appear awake with their eyes open, revealing a nystag-
barbiturates, propofol, and benzodiazepines) produces dose-depen- mic gaze. They may make spontaneous nonpurposeful movements.
dent CNS depression. GABA antagonists, such as flumazenil, may Protective reflexes are usually maintained, which is fortunate con-
attenuate its effects. Etomidate has no analgesic properties.11 sidering that increased salivation is a common side effect. Ketamine
is fast acting and has a brief duration of action. Although the likeli-
■ PHARMACODYNAMICS hood of emergence delirium limits the usefulness of this drug, it has
Etomidate produces dose-dependent depression of CMRO2, CBF, been widely used since 1970.19
and EEG activity analogous to that of the barbiturates. Since it
does not affect mean arterial pressure, etomidate decreases ICP ■ PHARMACOKINETICS
with minimal effect on CPP. It is useful in patients with ele- Ketamine has a pKa of 7.5. Approximately 12% is plasma protein
vated ICP, especially those who are hemodynamically unstable.12 bound. Therefore, roughly half of the unbound fraction is available
Etomidate causes minimal cardiovascular depression, even in to accumulate rapidly in the CNS. A single induction dose pro-
the presence of significant cardiac disease. Heart rate, blood duces anesthesia within 30 seconds and brain concentration peaks
pressure, and cardiac output are all adequately maintained. The at 1 minute. Like barbiturates and etomidate, ketamine follows the
respiratory depressant effects of etomidate appear to be substan- three-compartment model, with rapid redistribution to the periph-
tially less than those of thiopental or propofol, making it a safer eral tissues.19 Its CNS effects last approximately 10 to 15 minutes.
choice than barbiturates in patients with diminished pulmonary Recovery of full orientation and function may take an additional
function. Etomidate is therefore considered to be the induc- 60 minutes. Ketamine is readily metabolized by hepatic microsomal
tion agent of choice in patients with severe cardiopulmonary enzymes to norketamine. Norketamine is one-fourth as potent as its
disease and high-risk patients in whom maintenance of blood precursor. The active metabolite may explain the prolonged recov-
pressure is crucial.13 Because it does not blunt the sympathetic ery time. Norketamine is hydroxylated and excreted by the kidneys.
response to laryngoscopy and intubation, etomidate should be Ketamine has a high extraction ratio, and its clearance is dependent
combined with an opioid analgesic in patients who would be at on hepatic blood flow.2
risk from a transient elevation of blood pressure or heart rate.14
Etomidate is the only available intravenous anesthetic that ■ MECHANISM OF ACTION
does not induce the release of histamine and thus is safe for Ketamine acts by binding to the N-methyl-d-aspartate (NMDA)
patients with reactive airways.15 receptors on postsynaptic neurons. This receptor is a gated ion
channel that allows depolarization and initiation of an action poten-
■ ADMINISTRATION tial when activated by glutamate or NMDA. Ketamine blocks the
Etomidate is formulated in a 0.2% solution with 35% propylene flux of ions through this channel and inhibits the stimulatory effects
glycol. The standard induction dose is 0.3 mg/kg IV. There is of these neurotransmitters. Ketamine depresses neuronal activity in
virtually no accumulation of the drug. Emergence time is dose- the cerebral cortex and the thalamus. It also stimulates the limbic
dependent but remains short, even after repeated boluses.16 Dose system. Analgesia is produced by interrupting the association path-
adjustments for elderly patients or those with hepatic or renal dis- ways responsible for the interpretation of painful stimuli that run
ease may be required. from the thalamocortical and limbic systems.20
■ PHARMACODYNAMICS unbound drug rapidly accumulates in the brain and liver. A single
Although ketamine produces dose-dependent CNS depression, it bolus produces hypnosis in as little as 15 to 45 seconds. Its duration
increases CMRO2 and CBF, leading to an increase in ICP. Ketamine of action, like that of thiopental, is 5 to 10 minutes and reflects a
has a potent sympathomimetic effect. Its use often produces an rapid redistribution to lean muscle mass. Propofol is cleared from
increase in heart rate and arterial blood pressure. It has a direct neg- the central compartment by hepatic metabolism. Its metabolites are
ative inotropic effect on the myocardium, which is evident in the water soluble and excreted in the urine.2
critically ill patient with depleted catecholamines. Ketamine pro-
duces minimal to no respiratory depression and has a potent bron-
■ MECHANISM OF ACTION
chodilatory effect. It increases both bronchial and oral secretions. Propofol produces CNS depression by modulating the GABAA
In contrast to other anesthetic agents, ketamine is likely to preserve receptor by the same mechanism as barbiturates.2
protective airway reflexes. Skeletal muscle tone is also increased,
resulting in the occurrence of random movements.19 ■ PHARMACODYNAMICS
Propofol produces a dose-dependent CNS depression without
■ ADMINISTRATION analgesia. It does have a strong amnestic effect. It decreases CMRO2,
Ketamine is available in 1% and 5% aqueous solutions for intrave- CBF, and ICP. Since its cardiodepressant effects are greater than
nous administration and a 10% aqueous solution for intramuscular those of thiopental, CPP may be affected at high doses. Propofol is
(IM) injection. The induction dose of ketamine is 1 to 2 mg/kg IV a myocardial depressant and potent vasodilator that lowers blood
over 1 minute or 5 to 10 mg/kg IM.2 pressure and cardiac output. These effects attenuate the hemody-
In the Emergency Department, ketamine is indicated for the namic pressor response to laryngoscopy and intubation. Propofol
intubation of asthmatic patients due to its bronchodilatory proper- blunts the baroreflex, so that the heart rate does not increase in
ties. Ketamine may also be therapeutic for these patients, because proportion to a drop in blood pressure. Decreased respiratory rate
the increase in bronchial secretions may decrease the incidence of and tidal volume are seen with propofol, and ventilatory response to
mucous plugging.21 Due to its cardiostimulatory effects, ketamine hypercarbia is diminished. Propofol may produce bronchodilation
may be useful in the hemodynamically unstable patient. Ketamine in patients with chronic obstructive pulmonary disease (COPD).23
should not be used in those with suspected head trauma or Propofol appears to have a strong anticonvulsant effect and may be
intracranial pathology because it may increase ICP. It should used to terminate status epilepticus.24
not be used in patients with ischemic heart disease because it
can increase blood pressure, heart rate, and myocardial oxygen ■ ADMINISTRATION
demand. Propofol is prepared as a 1% oil-in-water emulsion that contains
egg lecithin, soybean oil, glycerol, and EDTA. The adult dose for
■ ADVERSE EFFECTS induction is 2.0 to 2.5 mg/kg IV. For sedation, an infusion rate of
The most significant side effect of ketamine is the occurrence of 25 to 75 µg/kg/min is titrated to effect. Dosages should be reduced
postanesthetic emergence reactions. Up to 30% of patients treated to 1.0 to 1.5 mg/kg IV in the elderly, in high-risk patients, and
with ketamine have reported unpleasant sensations, agitation, in anyone premedicated with an opioid or a benzodiazepine.23
hallucinations, restlessness, or nightmares.2 Those most affected Propofol supports bacterial growth, and any unused portion should
were elderly, females, and patients receiving more than 2 mg/kg. be discarded.
Children seem less adversely affected than adults. These reactions
can be attenuated or eliminated by the coadministration of a ben- ■ ADVERSE EFFECTS
zodiazepine (midazolam) or propofol. Other side effects include Propofol produces pain on injection in up to 75% of patients. This
hypersalivation, random movements, nystagmus, and increased may be reduced or prevented by pretreatment with an opioid or the
intraocular and intracranial pressure. The hypersalivation may addition of 0.01% lidocaine to the emulsion. Propofol may cause
be limited by the administration of atropine or glycopyrrolate. mild CNS excitation in the form of myoclonus, tremors, or hiccups.2
Ketamine may activate epileptogenic foci in patients with a sei-
zure disorder.19 BENZODIAZEPINES
PROPOFOL Benzodiazepines are a large class of drugs with anxiolytic, seda-
tive, hypnotic, and amnestic properties without any analgesic
™
Introduced in 1989, propofol (Diprivan ) is a sedative-hypnotic ™
properties. Of these, diazepam (Valium ), lorazepam (Ativan ), ™
agent used for procedural sedation, induction, and maintenance of
anesthesia. Although unrelated to any of the other induction agents,
™
and midazolam (Versed ) are most used to facilitate intubation.
They have a relatively short time of onset when given intravenously.
it has a profile similar to that of thiopental. Despite its cardiopulmo- Compared to midazolam, diazepam and lorazepam have longer
nary depressant effects, the use of propofol has greatly expanded. times of onset, less predictable dose–effect relationships, and lon-
It is well suited for ambulatory surgery performed on relatively ger elimination half-lives. They are also insoluble in water and are
healthy outpatients. Recovery after propofol anesthesia is rapid formulated in a propylene glycol diluent, which can produce a high
and is accompanied by less residual sedation, fatigue, and confu- rate of venous irritation as well as unpredictable absorption after
sion than any other induction agent. Propofol is associated with a intramuscular injection.25 Midazolam, on the other hand, is water
low incidence of postanesthetic emesis.22 While the role of propofol soluble at a low pH and therefore does not require propylene glycol.
as an adjunct to emergency airway management in the Emergency This decreases the incidence of erratic absorption after intramuscu-
Department is still unfolding, it is commonly used for procedural lar injection and pain on injection.
sedation (Chapter 129) or postintubation sedation. Midazolam is the newest of the three drugs. It has become the
standard choice for preinduction anxiolysis, sedation, and amnesia.
■ PHARMACOKINETICS Midazolam is well suited and widely used as an induction agent.26
Propofol is an alkyl-phenol compound that is insoluble in water. It may be administered alone or in combination with an opioid.
It is 98% plasma protein bound. Since it is highly lipophilic, any There is considerable hypnotic synergy when midazolam is used in
combination with an opioid. The opioids provide excellent analge- ■ ADVERSE EFFECTS
sia, which is a property lacking in midazolam.2 When midazolam Midazolam has relatively few adverse effects. It is a mild cardiorespi-
is used as the sole induction agent, recovery of consciousness takes ratory depressant. When it is combined with an opioid, a synergistic
longer than with thiopental, methohexital, etomidate, or propofol respiratory depressant effect may result in hypoxemia, apnea, and
as a single agent. Midazolam is often used as a coinduction agent death. Those patients receiving this combination should be moni-
with ketamine or propofol, as it facilitates the onset of anesthesia tored with pulse oximetry while being given supplemental oxy-
without prolonging emergence times.2 When combined with ket- gen.32 Unlike diazepam, midazolam produces little venous irritation
amine, midazolam attenuates ketamine’s cardiostimulatory side and pain upon injection. It may precipitate a psychotic episode in
effects as well as the incidence, severity, and recall of emergence patients taking valproate. It does cross the placenta and is associ-
reactions.27 ated with birth defects, especially involving the lip and palate, when
administered in the first trimester.28
■ PHARMACOKINETICS
Midazolam is formulated at a pH of 3.5, as it is water soluble in an OPIOIDS
acidic environment. At physiologic pH, it undergoes a molecular
rearrangement that makes it highly lipophilic. It is 94% protein Opioids produce dose-dependent analgesia, sedation, and
bound in the plasma. Unbound midazolam rapidly accumulates respiratory depression by mimicking the effects of endogenous
in the CNS, where it produces dose-dependent sedation or uncon- opiopeptins.34 Morphine is the standard to which all opioids are
sciousness in 30 to 90 seconds. The drug redistributes less rap- ™
compared. However, fentanyl (Sublimaze ) is the opioid of choice
idly than many of the other hypnotics. This is reflected in the for use in the Emergency Department due to its rapid onset and
10 to 30 minute duration of its CNS effects.28 Midazolam is oxidized short duration of action.35 It has been in use since 1968 and its
by the liver and excreted in the urine. Changes in hepatic blood flow effects are well documented. Unlike morphine, fentanyl is rarely
can influence the clearance of midazolam.29 Age has little effect on associated with a significant release of histamine.36 Fentanyl has
the elimination half-life.29 Fentanyl has been shown to competi- a remarkable hemodynamic stability profile.36 If given in a large
tively inhibit the hepatic metabolism of midazolam in vitro and to dose, fentanyl will produce anesthesia adequate for intubation.
decrease its clearance.30 It is more often used as a sedative-analgesic or as a pretreatment
adjuvant with one of the previously mentioned induction agents.
■ MECHANISM OF ACTION Fentanyl is a synthetic opioid that is 50 to 100 times more potent
Benzodiazepines bind to a specific site on the alpha subunit of than morphine. Structurally related to the phenylpiperidines, it is
the GABAA receptor and enhance inhibitory neurotransmission. highly lipophilic and produces excellent short-term analgesia and
Midazolam has the greatest affinity for the receptor when compared sedation.37
to other benzodiazepines.2 It has been proposed that the percent- ™
Alfentanil (Alfenta ) is a structural derivative of fentanyl. It has
age of benzodiazepine receptor occupancy accounts for its effects. A a more rapid onset of action than fentanyl and half the duration of
20% occupancy provides anxiolysis. A 30% to 50% occupancy causes effect. Alfentanil is between one-sixth and one-ninth as potent as
sedation. Greater than 60% occupancy produces unconsciousness. fentanyl. Its uses are analogous to those of fentanyl. It has been in
It is unknown how the benzodiazepines produce amnesia.2 use in the United States since 1982.38 Recent data show alfentanil
to be safe and effective for use in emergent rapid sequence intuba-
■ PHARMACODYNAMICS tion.39 In cardiac patients, it was associated with a greater degree
Like thiopental and propofol, midazolam decreases CMRO2 and of cardiovascular depression than fentanyl.40 Alfentanil is associated
CBF. Midazolam has a ceiling effect with respect to cerebral metab- with a greater incidence of nausea and vomiting than fentanyl.41
olism. The cerebrovascular response to carbon dioxide is unaffected There are no data to suggest that alfentanil is more efficacious than
by midazolam. It is also a potent anticonvulsant. Midazolam is a fentanyl for use in the Emergency Department.
mild cardiodepressant and can decrease systemic vascular resis-
tance.28 The cardiac output and coronary blood flow are usually ■ PHARMACOKINETICS
not affected by midazolam.31 The drop in blood pressure is often Upon intravenous injection, plasma fentanyl is 85% protein
masked by the sympathetic response to laryngoscopy. However, it bound. Its lipophilic nature allows it to enter highly perfused tis-
may be pronounced in hypovolemic patients or in those who were sues rapidly, including the brain, heart, and lungs. After a single
given large doses. bolus dose of fentanyl, effects may be seen in as little 10 seconds,
Midazolam’s respiratory effects also have a ceiling. It produces and they peak in 3 to 5 minutes. Morphine’s effects peak in 20 to
a mild and dose-dependent respiratory depression. In relatively 30 minutes. Fentanyl has a high affinity for adipose tissue and
healthy patients, the respiratory depression is insignificant. The redistribution accounts for the cessation of effects, which can take
respiratory depression is enhanced in patients with pulmonary up to 30 to 60 minutes. An equipotent dose of morphine has a
disease. Hypoxemia is more frequent in patients who receive mid- duration of 3 to 4 hours. Redistribution of fentanyl from periph-
azolam in combination with an opioid, such as fentanyl, than with eral tissues to the central compartment after large or repeat doses
either drug alone.32 may prolong its effects. Clearance of morphine and fentanyl is
by hepatic metabolism. These drugs have a high extraction ratio,
■ ADMINISTRATION and changes in hepatic blood flow can influence the clearance of
An induction dose of midazolam is 0.2 to 0.4 mg/kg IV. When fentanyl.38
used as a coinduction agent, the dose of midazolam is reduced to
0.1 to 0.2 mg/kg. For sedation, the dose is 0.04 to 0.1 mg/kg IV. It can ■ MECHANISM OF ACTION
also be administered intramuscularly at a dose of 0.07 to 0.1 mg/kg Fentanyl binds to the µ (mu) opioid receptor found throughout
when rapid onset is not required.2 Doses may have to be lowered the CNS. Activation of the opioid receptor causes hyperpolariza-
in older patients because sensitivity to the hypnotic effects of tion and inhibition of neurotransmitter release.34 It has been sug-
midazolam increases with age, independent of pharmacokinetic gested that fentanyl may also be a low-affinity NMDA receptor
factors.33 antagonist.42
■ PHARMACODYNAMICS Until a better agent is developed, succinylcholine (Anectine ) ™

Fentanyl decreases CBF and cerebral oxygen consumption. In remains the standard NMB agent for Emergency Department
patients with head trauma, a relatively small dose (3 µg/kg) pro- intubations.51
duced an elevation of ICP.43 Although fentanyl has little effect on
cardiac contractility, it may produce a mild reduction in the heart SUCCINYLCHOLINE
rate. Systemic vascular resistance and blood pressure may be slightly Succinylcholine is the only depolarizing NMB agent in clinical use.
reduced, but they are usually unaffected in patients without cardiac Introduced in 1952, it is a chemical combination of two acetylcho-
pathology.44 Respiratory depression induced by fentanyl is dose line molecules. It is the most widely used NMB in the Emergency
dependent. The respiratory rate first decreases, followed by the tidal Department because its onset of action is faster and its duration
volume and subsequent apnea. The patient’s response to hypercar- of action is shorter than that of any other NMB agent. This is
bia is blunted when sedated with fentanyl.45 particularly important in patients who cannot be intubated after
neuromuscular blockade and where the resumption of spontane-
■ ADMINISTRATION ous respirations is vital.
Fentanyl can be used in several ways to facilitate emergency intu-
bation. Given purely for analgesia, as little as 3 to 5 µg/kg IV over ■ PHARMACOKINETICS
2 minutes may allow for an awake intubation. For adults, incre- After a paralytic dose of succinylcholine, adequate intubating condi-
mental doses of fentanyl from 25 to 50 µg can be titrated to pro- tions are usually achieved in 60 seconds.53 The duration of apnea fol-
duce the desired effect.37 Fentanyl has a more stable hemodynamic lowing a single dose of succinylcholine is 3 to 5 minutes and reflects
profile during rapid sequence induction than either thiopental or the rapid degradation of the drug by pseudocholinesterase, also
midazolam.35 In hemodynamically unstable patients and those with known as plasma cholinesterase or butyrylcholinesterase.53 Repeated
poor cardiac reserve, 5 to 15 µg/kg of fentanyl may be used as the doses or infusion of succinylcholine may produce tachyphylaxis,
sole induction agent.35 prolonged paralysis, and repolarization of the neuromuscular mem-
The most prudent role for fentanyl is as an adjunct to an induc- brane, a condition referred to as phase II block.53 If this condition
tion agent. Three minutes prior to intubation, premedication with develops, it can be partially reversed by administration of an anticho-
2 to 4 µg/kg of fentanyl IV over 2 minutes provides excellent anal- linesterase agent, similar to the reversal of a nondepolarizing block.
gesia and attenuates the transient hypertension and tachycardia If paralysis of greater than 3 to 5 minutes is desired, a nondepo-
associated with laryngoscopy and intubation.46 Although lidocaine larizing agent can be administered after the patient is intubated.
and β-blockers have also been shown to blunt the pressor response,
opioids are more effective and reliable and do not produce rebound ■ MECHANISM OF ACTION
hypotension and bradycardia.47,48
The structure of succinylcholine allows it to bind noncompetitively
to acetylcholine receptors, causing depolarization of the postjunc-
■ ADVERSE EFFECTS
tional neuromuscular membrane. This initial depolarization is seen
Other than the respiratory depression that is common to all opioids, as a brief period of muscle fasciculation following the administra-
fentanyl has relatively few adverse side effects. Although it may pro- tion of the drug. Unlike acetylcholine, which is hydrolyzed within
duce nausea and vomiting, this side effect is relatively uncommon milliseconds, succinylcholine remains intact for several minutes. It
when compared to other opioids such as morphine.37 Fentanyl is not produces paralysis by occupying the acetylcholine receptors, and
associated with a significant release of histamine, which is reflected making the motor end plates refractory, so that muscle contraction
in its hemodynamic stability. Muscular rigidity involving the chest cannot occur. Muscle relaxation proceeds from the distal muscles
wall and diaphragm may occur, making ventilation difficult. This to the proximal muscles, and thus the diaphragm is one of the last
happens more often at higher doses, typically greater than 15 µg/kg, muscles to become paralyzed.52
and may be prevented or relieved by neuromuscular blockade or
by opioid antagonism with naloxone.49 Myoclonic movements may ■ PHARMACODYNAMICS
occur, but these do not reflect seizure activity on the EEG. As with
Succinylcholine is rapidly hydrolyzed by plasma pseudocho-
all opioids, biliary colic and urinary retention are associated with
linesterase to succinylmonocholine. Only a small fraction of
fentanyl administration.37
the IV administered dose reaches the neuromuscular junction.
Succinylmonocholine, which also has some neuromuscular block-
NEUROMUSCULAR BLOCKING AGENTS ing properties, is further hydrolyzed to succinic acid and choline.
Neuromuscular blockade is an integral part of the rapid sequence These end products are rapidly taken up by cells and reused in vari-
induction and intubation protocol. The combination of a para- ous biochemical molecules. The rapid degradation of succinylcho-
lytic agent and a sedative or an analgesic is superior to the use line provides a concentration gradient that causes the diffusion of
of any single agent. The use of a neuromuscular blocking (NMB) succinylcholine away from the acetylcholine receptors and allows
agent to facilitate intubation provides for control of the airway repolarization of the myocyte membrane.
and better visualization of the vocal cords than does sedation with- In patients with atypical pseudocholinesterase enzyme, a genetic
out paralysis.50 It is also well documented that, in the Emergency variant with autosomal semidominant transmission, the duration of
Department setting, rapid sequence induction with an NMB agent action of succinylcholine is markedly prolonged due to decreased
allows for faster intubations with fewer complications than sedation enzyme activity. In patients homozygous for the atypical allele, a
alone.1 The use of a sedative without a NMB should be reserved condition that occurs with an incidence of 1 in 3200, a single intu-
for the awake oral intubation of a patient with a difficult airway. bating dose of succinylcholine may last up to 8 hours.53
NMBs are classified as either depolarizing or nondepolarizing,
depending on their action at the nicotinic acetylcholine receptor of ■ ADMINISTRATION
the motor end plate. The optimal NMB agent has a rapid onset of The recommended dose of succinylcholine to produce optimal
action, a predictably short duration of action, and no side effects. As intubating conditions is 1.0 to 1.5 mg/kg IV bolus in adults and
with induction agents, the optimal NMB agent has yet to be found. 1.5 to 2.0 mg/kg in infants, with the twofold increased dose in this
population explained by their higher volume of distribution.53,83 with hepatic disease, anemia, renal failure, cancer, connective tis-
This dose should be increased by 50% in patients who have received sue disorders, pregnancy, cocaine intoxication, genetically deficient
a defasciculating dose of a nondepolarizing neuromuscular blocker enzyme activity, or taking cytotoxic drugs. In most cases, apnea
(see below under “Adverse Effects” section) prior to the administra- rarely exceeds 20 minutes.60
tion of succinylcholine.53 Intramuscular administration is also pos- Succinylcholine may produce an increase in serum potassium
sible, which may become important for use in an emergency when level, which is typically less than 0.5 meq/L. It should be used with
control of the airway is necessary and the patient has no IV access. caution in patients with significant hyperkalemia. Its use is not con-
The intramuscular dose is two to four times the IV dose.54 traindicated in patients with renal failure, but caution must be taken
if their serum potassium level is elevated. It has been associated
■ ADVERSE EFFECTS with cases of massive hyperkalemia (>5 meq/L) and cardiac arrest
in patients who have had digoxin toxicity, myasthenia gravis, mas-
Although relatively uncommon, a number of potential adverse
sive muscle trauma, crush injuries, severe burns, and major nerve
effects are associated with the administration of succinylcholine.
or spinal cord injury at least 1 week prior to receiving succinylcho-
These include muscular fasciculations and myalgia, autonomic
line.53 In such patients, succinylcholine should not be used starting
stimulation, histamine release, prolonged apnea, elevated intracra-
24 hours after the insult.
nial and intraocular pressure, hyperkalemia, and malignant hyper-
thermia.53 The use of succinylcholine is recommended for rapid
sequence induction and intubation as the risk of a compromised ■ MALIGNANT HYPERTHERMIA
airway far outweighs the potential harm from these side effects. Malignant hyperthermia (MH) is an extremely rare and life-
The fine, chaotic muscle contractions that are often observed at threatening autosomal dominant condition that can develop
the onset of paralysis are associated with several side effects, most following exposure to certain inhaled anesthetics and/or succi-
commonly myalgia, but also increased intraocular pressure (IOP), nylcholine in genetically susceptible individuals. It is character-
increased intracranial pressure (ICP), and increased intragastric ized by intense, sustained skeletal muscle contraction leading to
pressure. Muscle pain 24 to 48 hours after the administration of suc- severe acidosis, rhabdomyolysis, hyperthermia, hyperkalemia,
cinylcholine is most prominent in young, muscular men, while it arrhythmias and, if left untreated, death. The triggering expo-
is unlikely in children, the elderly, and those with undeveloped or sure is not dose-dependent, can occur following any single dose or
diminished muscle mass. Muscle fasciculations may be prevented combination of offending agents, and may occur even in individu-
by the administration of a defasciculating dose (10% of the paralytic als who have been exposed to the agents in the past without an
dose, a phenomenon known as “precurarization”) of a nondepolar- adverse effect. The incidence of MH during anesthesia is estimated
izing NMB agent given 3 to 5 minutes prior to the succinylcholine.55 to be 1 in 15,000 in children and 1 in 50,000 in adults.82 Although
Increased ICP may also occur with the use of succinylcholine. it is most notoriously characterized by a rapid elevation in tem-
While the magnitude and clinical significance of this increase perature, the earliest signs of the condition are usually profound
remains unclear, defasciculation with a nondepolarizing NMB agent tachycardia, tachypnea, and generalized skeletal muscle rigidity.
has been shown to prevent this rise in ICP.58 Laboratory blood analysis reveals severe respiratory and metabolic
To omit the use of a paralyzing agent entirely during the rapid acidosis, hyperkalemia, and elevation of serum creatine kinase.
sequence induction of patients with penetrating eye injuries or intra- Early and aggressive treatment is the key to patient survival.
cranial pathology for fear of the potential increase in IOP or ICP is a This involves active cooling measures, volume resuscitation, correc-
decision that must be made for each individual patient. Any attempt tion of acid–base and electrolyte disturbances, and rapid administra-
to intubate a nonparalyzed, lightly anesthetized patient could result tion of dantrolene (2 to 3 mg/kg IV bolus with additional increments
in gagging or “bucking,” which has been shown to increase both IOP up to 10 mg/kg).53,82 Dantrolene sodium is a muscle relaxant that is
and ICP far more than that which would be achieved from an intubat- supplied as a lyophilized powder in 20 mg vials. Prior to adminis-
ing dose of succinylcholine. In most patients, muscle fasciculations tration, each vial must be reconstituted with 60 mL of water.82 It is
are benign and precurarization is unnecessary. In patients with eye emphasized that rapid and early administration of dantrolene is
injuries or suspected intracranial pathology, however, it is prudent important to abort the reaction and greatly increases the chance
to either use a nondepolarizing NMB agent or utilize precurariza- of survival. Dantrolene administration should be continued until all
tion with succinylcholine to prevent worsening of an injury to these signs of MH have stabilized. Admit the patient to the intensive care
areas.56 Rocuronium is a nondepolarizing agent that has been shown unit for observation of any recurrence following the acute phase.
to significantly decrease IOP during rapid sequence induction.57 Its Isolated masseter muscle rigidity is a benign side effect in most
use may be indicated in patients with penetrating eye injuries.57 cases. It has been reported mainly in children receiving succinyl-
Increased intragastric pressure, which is also lessened by precu- choline. In several reported cases of fatal malignant hyperthermia,
rarization, may increase the risk of aspiration. On the other hand, however, masseter muscle rigidity was the first sign of an abnormal
succinylcholine favorably increases the tone of the lower esophageal reaction.61 Masseter rigidity occur following the administration
sphincter, which may mitigate the risk of aspiration.59 Regurgitation of succinylcholine requires the patient to be closely monitored
of stomach contents during intubation is more likely the result of for other signs of MH.
distention from overzealous mask ventilation. Patients of families with MH, those with suspected reactions, and
Succinylcholine binds to acetylcholine receptors throughout the other selected high-risk patients can undergo a muscle biopsy test
body, including those of the autonomic ganglia. Succinylcholine may known as the caffeine-halothane contracture test, which carries a
have direct muscarinic effects on the heart. It is difficult to charac- 100% sensitivity and 85% to 90% specificity for MH susceptibility.82
terize a specific cardiovascular effect typical of succinylcholine. It Patients who develop suspected MH reactions should be referred
may produce tachycardia, bradycardia, or dysrhythmias.53 Children immediately to their primary physicians for testing and follow-up,
are particularly susceptible to bradycardia following succinylcho- as documented positive susceptibility and patient education could
line administration. It is recommended that all children be given prevent a future potentially lethal exposure to offending agents.
0.01 mg/kg IV of atropine prior to administration of succinylcholine.54 Despite the lengthy list of potential adverse effects, the benefits
Prolonged apnea following succinylcholine is a sign of decreased of intubation with a rapidly acting and short-lasting paralytic
plasma pseudocholinesterase levels. This may occur in patients agent such as succinylcholine provide the safest conditions for
intubation in the Emergency Department. If prolonged paraly- water-soluble compounds that cannot easily cross lipid membranes
sis is required in an agitated patient, a nondepolarizing agent such as the blood–brain barrier and the placenta. As a result, they
should be administered for maintenance following intubation have no central nervous system effects and do not affect the fetus
with succinylcholine. when administered to pregnant women.53
NONDEPOLARIZING AGENTS ■ MECHANISM OF ACTION

Rocuronium binds nicotinic acetylcholine receptors at the neuro-
Nondepolarizing NMB agents act by competitive inhibition of the
muscular end plate and, once bound, it is unable to induce the con-
acetylcholine receptors at the motor end plate. They weakly bind
formational change necessary to open the ion channels and allow
to the receptor and block the binding site for acetylcholine without
subsequent depolarization. This results in a competitive and antago-
producing any effect on the postsynaptic neuromuscular membrane.
nistic block.
Following the kinetics of competitive inhibition, this blockade is
dependent on the relative concentrations of acetylcholine and NMB
■ PHARMACODYNAMICS
available in the synaptic cleft. As the ratio returns in favor of ace-
tylcholine, normal neuromuscular transmission is restored. Thus, Several drugs including volatile anesthetics, aminoglycosides, mag-
return of muscle function can be hastened by the use of a cholin- nesium, lithium, dantrolene, and certain antiarrhythmics will aug-
esterase inhibitor such as neostigmine or edrophonium, but only ment the neuromuscular blockade produced by nondepolarizers. In
after some muscular contraction can be observed. Nondepolarizing contrast, corticosteroids, certain anticonvulsants, and calcium will
agents have not only the potential for reversal, but also for fewer side diminish their effect. Patients with myasthenia gravis, Lambert–
effects than succinylcholine. Their longer time to onset and much Eaton myasthenic syndrome, and Duchenne’s muscular dystro-
longer duration of action make them less useful for rapid sequence phy exhibit varying sensitivity to nondepolarizing neuromuscular
induction, especially in the Emergency Department.53 blockers. Burn patients, on the other hand, are resistant to their
Nondepolarizing NMB agents can be grouped by chemical struc- effects. Careful titration of dosages, dosing intervals, and infusion
ture. The steroid-based agents include pancuronium, vecuronium, rates are necessary in these patient populations.
and rocuronium. The oldest nondepolarizing agent, d-tubocura-
rine, is a benzylisoquinoline, as are atracurium, cisatracurium, and ■ ADMINISTRATION
mivacurium.53 Pancuronium, vecuronium, and rocuronium have Rocuronium is administered at a usual intubating dose of 0.6 mg/kg,
been extensively studied for use in rapid sequence intubation.62 providing a clinical duration of roughly 45 minutes. Rapid sequence
™
Of these, rocuronium (Zemuron ) has become established as the induction with rocuronium is most rapidly achieved with a dose
of 1.2 mg/kg and is associated with an accompanying increase in
nondepolarizing NMB of choice for rapid sequence induction in
situations where succinylcholine is contraindicated. For this reason, duration. Following intubation, maintenance of paralysis can be
rocuronium is discussed separately from the other nondepolarizing achieved with intermittent 0.1 mg/kg boluses or by infusion rates of
NMB agents. 5 to 12 mcg/kg/min, titrated to effect.
ROCURONIUM ■ ADVERSE EFFECTS

Other than the potential for a severe anaphylactic reaction in aller-
When succinylcholine is contraindicated, rocuronium has been
gic patients, rocuronium is essentially devoid of any serious side
used at a dose of 1.2 mg/kg. This dose is twice the standard intubat-
effects. This should not be taken lightly, however, as neuromuscu-
ing dose to yield an onset of action in approximately 60 seconds and
lar blocking drugs are responsible for >50% of all life-threatening
intubating conditions that are comparable to succinylcholine.72 This
anaphylactic or anaphylactoid reactions occurring during anesthe-
has been demonstrated both in adult and pediatric populations.72,84
sia administration.53 While succinylcholine is the most common
It should be noted, however, that at this increased dosage, the dura-
offending agent, the nondepolarizers are the second.
tion of action is also prolonged to greater than 1 hour, which far
As a class, the steroidal nondepolarizers possess varying degrees of
exceeds the 3 to 5 minutes provided by succinylcholine.53,63 The
vagolytic activity and, fortunately, are not associated with histamine
nondepolarizing, competitive blockade produced by rocuronium
release. The vagolytic action of rocuronium is weak and rarely of clin-
cannot be immediately reversed by anticholinesterases such as
ical significance. This is in contrast to pancuronium, another steroi-
neostigmine until a partial competitive antagonism by acetylcho-
dal nondepolarizer, which can cause significant tachycardia following
line has taken place naturally at the motor end plate. This may take
administration. Patients may report pain on injection of rocuronium
an average of 20 minutes to occur, and must be measured by the
due to venous irritation. This may be reduced by prior adminis-
return of muscular twitch using a neuromuscular twitch monitor,
tration of IV lidocaine, but is usually not a problem as patients are
a device often used by anesthesia personnel in the operating room
unconscious or sedated at the time of rocuronium injection.
to monitor the level of intraoperative motor blockade.84 Therefore,
should unexpected difficulties with intubation or ventilation be
encountered, it is recommended that the practice of using high- OTHER NONDEPOLARIZING AGENTS
dose rocuronium during rapid sequence induction be limited in the Pancuronium, in use since 1972, is classified as a long-acting,
Emergency Department as much as possible. Should all attempts at bisquaternary steroidal nondepolarizing agent. At a dose of 0.08 to
intubation and ventilation fail, staff experienced in the attainment 0.12 mg/kg, it produces paralysis in 2 to 5 minutes and lasts approxi-
of a surgical airway must be immediately available. mately 60 to 90 minutes. Following intubation, supplemental doses
of 0.02 mg/kg can be given intermittently to maintain paralysis.53
■ PHARMACOKINETICS Its use is associated with an increased heart rate, blood pressure,
Rocuronium is eliminated primarily by the liver and <10% by the and cardiac output through a postganglionic vagolytic effect. It is
kidneys.53 Its duration of action, therefore, is significantly pro- not associated with the release of histamine. An estimated 80% to
longed in liver failure and only slightly in renal failure. There are 85% of a dose of pancuronium is eliminated unchanged in the urine.
no active metabolites, making it a good choice for prolonged infu- Therefore, in patients with renal failure its duration may be signifi-
sions. Nondepolarizing NMB agents as a class are highly ionized, cantly prolonged.53 Pancuronium’s low cost and familiarity have
made it popular, but its slow onset of action and extended duration GLYCOPYRROLATE
limit its usefulness in facilitating emergent endotracheal intubation.
Removing a quaternary methyl group from pancuronium yields Glycopyrrolate is a quaternary amine of the muscarinic anticho-
vecuronium, a monoquaternary steroidal nondepolarizer. This linergic class. Compared to atropine, it possesses significantly
small change does little to affect potency, but favorably alters the less of a vagolytic effect, but greater antisialagogue effects. This
side effect profile of the drug, most notably the vagolytic action. makes it the drug of choice for premedication to reduce pharyngeal
Similar to rocuronium, the vagolytic effects of vecuronium are neg- and tracheobronchial secretions. Glycopyrrolate does not easily
ligible and do not cause histamine release. This molecular change cross the blood–brain barrier due to its quaternary ammonium
also alters the metabolism and excretion of the drug when compared structure, making the occurrence of central anticholinergic side
with pancuronium. Vecuronium is metabolized to a small extent by effects much less likely. It should not be administered to neonates
the liver and depends primarily on biliary excretion and second- due to the benzyl alcohol component, which can cause significant
arily on renal excretion. Vecuronium is unstable in solution. It is adverse effects. The recommended antisialagogue dose of glyco-
prepared as a lyophilized powder that must be hydrated prior to use. pyrrolate is 0.004 mg/kg IM given 30 to 60 minutes prior to the
The normal intubating dose of vecuronium (0.1 mg/kg) takes procedure. It may be administered intravenously in boluses of
3 minutes to produce adequate paralysis for intubation, and the 0.1 mg every 2 to 3 minutes as needed until the desired effect. In
patient will remain apneic for 30 to 35 minutes. Although it can pro- the Emergency Department, one or two doses are typically required
duce good intubating conditions within 1 minute at 2.5 times the during procedural sedation as an adjunct to prevent ketamine’s
normal dose, this unfortunately results in paralysis for 1 to 2 hours. effect of increasing respiratory tract secretions.
Maintenance of paralysis can be achieved with boluses of 0.02 mg/kg. Glycopyrrolate is routinely administered with anticholinesterase
The most troublesome side effect of this drug is prolonged paralysis medications during reversal of nondepolarizing neuromuscular
(up to several days) following an infusion, a side effect attributed blockade to counteract the unwanted side effects of bradycardia,
possibly to accumulation of its active 3-hydroxy metabolite.53 bronchoconstriction, and intestinal hypermotility that accom-
Rapacuronium is a newer nondepolarizing NMB agent with onset pany the ensuing increase in cholinergic activity. Specifically, it is
times and duration of action similar to those of succinylcholine. It administered along with neostigmine and pyridostigmine at a dose
was developed as a replacement for succinylcholine in the rapid of 0.2 mg IV of glycopyrrolate for each 1 mg of neostigmine or 5 mg
sequence protocol. Due to reported incidences of fatal broncho- of pyridostigmine. When given IV, the onset is usually within 1 min-
spasm in patients, rapacuronium was voluntarily withdrawn from ute and the duration of the vagolytic and antisialagogue effects are
the US market by its manufacturer in March, 2001. At present, suc- 2 to 3 hours and up to 7 hours, respectively.
cinylcholine is firmly in place as the muscle relaxant of choice for
rapid sequence emergency intubations.64
DEXMEDETOMIDINE
Dexmedetomidine is a new centrally acting alpha2-adrenergic ago-
MISCELLANEOUS AGENTS nist similar to clonidine, but with more selectivity for the alpha2
receptor. It causes dose-dependent sedation and anxiolysis and
LIDOCAINE blocks the sympathetic response to stress and airway manipulation.
For this reason, it is increasingly being used with much success as an
Lidocaine is a local anesthetic agent that, in low doses, has an adjunct to awake fiberoptic intubations. Its main indication, however,
antiarrhythmic effect on the heart. At a dose of 1 to 2 mg/kg IV, it also is for sedation of intubated and mechanically ventilated patients in
attenuates the increase in ICP and the hypertensive and tachycardic the intensive care unit, especially around the time of planned extu-
response associated with laryngoscopy.65–68 It does not affect bation when other IV sedatives have been discontinued. Patients
myocardial contractility in therapeutic doses. Lidocaine is usually remain calm and sedated when left alone, but are readily arousable
administered to patients in which the increases in ICP, heart rate, and when stimulated and follow commands. Dexmedetomidine causes
blood pressure associated with direct laryngoscopy are undesirable. little to no respiratory depression.70,71 The main side effects of the
drug are hypotension and bradycardia. Dosing consists of an ini-
ATROPINE tial loading dose of 1 mcg/kg IV over 10 minutes followed by an
Atropine is a rapidly acting muscarinic acetylcholine receptor infusion of 0.2 to 0.7 mcg/kg/h, titrated to the desired level of seda-
antagonist with significant vagolytic effect. It is commonly used as tion.69 Its half-life is about 6 minutes following infusion due to rapid
part of the Advanced Cardiac Life Support (ACLS) protocol dur- redistribution. This short half-life has the potential for its use in the
ing resuscitation of patients in cardiac arrest and those with symp- Emergency Department for awake intubations.
tomatic bradycardia at doses of 1.0 mg and 0.50 mg IV, respectively. SUGAMMADEX
During rapid sequence induction of children using succinylcholine,
atropine is given to prevent significant bradycardia and possibly ™
Sugammadex (Bridion , Schering-Plough) is a novel agent that can
asystole, which may occur in this population much more frequently terminate the neuromuscular block associated with rocuronium,
than in adults.73 The dose is 0.01 mg/kg IV with a minimum dose vecuronium, and pancuronium.85–91 It is a cyclodextrin, or a cyclic
of 0.10 mg IV and a maximum dose of 0.40 mg IV. Atropine has a oligosaccharide carbohydrate, that is formed from the degradation
secondary antisialagogue effect of reducing secretions produced in of starch. It has a hydrophobic core surrounded by a hydrophilic
the respiratory tract and the salivary glands. outer rim. The hydrophobic core can trap other hydrophobic sub-
Atropine crosses the blood–brain barrier and overdoses may lead to stances and solubilize them. Cyclodextrins administered intrave-
central atropine intoxication, referred to as the central anticholinergic nously are not metabolized and are excreted by the kidney.
syndrome. This is characterized by agitation, restlessness, confusion, Sugammadex is the first agent of its class. It has an affinity for
and hallucinations that may progress to stupor, seizures, and coma. the aminosteroid nondepolarizing NMB agents. Its affinity is stron-
Provide supportive treatment, including seizure prophylaxis and pos- gest for rocuronium, followed by vecuronium then pancuronium. It
sibly mechanical ventilation. Reversal of this life-threatening condi- binds rocuronium in a 1:1 fashion to decrease rocuronium plasma
tion can be achieved with IV physostigmine, an anticholinesterase concentrations. Bound rocuronium cannot gain access to the motor
agent with the ability to cross the blood–brain barrier. endplate and cause paralysis. The reversal of the neuromuscular
block results from the binding of plasma rocuronium and the rapid Washitzky studied the ET application of strychnine, atropine,
movement of rocuronium from peripheral sites to the plasma to chloral hydrate, and potassium iodide.1
maintain an equilibrium. The sugammadex–rocuronium complex The first suggestion for using the ET route for the therapy of pul-
is excreted in the urine. monary disease was in 1915.2 This idea evolved, culminating in a
A variety of adverse events have been reported with the use of study in 1937, which recommended the use of inhaled epinephrine
sugammadex.86 These include anaphylactic reactions, back pain, in asthmatics.3 The rapidity of pulmonary absorption was even-
bronchospasm, cough, constipation, fever, headache, hypersensitiv- tually utilized for resuscitation purposes 1967. This study dem-
ity reactions, procedural hypotension and hypertension, prolonged onstrated the equality of the intratracheal, intravenous (IV), and
QT intervals, and vomiting. It binds to bone and teeth, but the effect intracardiac routes of epinephrine administration in resuscitating
of this is not fully known, especially in growing children. There is hypoxia-induced cardiorespiratory arrest in dogs. This study began
the possibility that sugammadex binds to and decreases plasma lev- the utilization of the ET route for medication administration in
els of other drugs with a steroid-based structure such as hormones, emergent clinical situations.
oral contraceptives, and some antibiotics among others.
Sugammadex has the potential for significant use in the Emer- ANATOMY AND PATHOPHYSIOLOGY
gency Department. The biggest concern with using rocuronium for
Most experiments involving ET medication administration are con-
intubation is the length of time a patient is paralyzed if they cannot
ducted on subjects with normal cardiovascular function. Thus, there
be intubated. The development of sugammadex can provide a “safety
are still many questions remaining about the utility of this route in
net” to reverse rocuronium’s effects if a patient cannot be intubated.
patients with cardiopulmonary arrest. While the alveolar-capillary
This agent may eventually allow rocuronium to become the NMB
membrane is a highly absorptive surface, numerous factors can
agent of choice for rapid sequence intubation in the Emergency
undermine this potential. These include reduced pulmonary blood
Department.88,89
flow (less than 30% of normal during CPR), ventilation–perfusion
Sugammadex is currently approved for use in numerous coun-
mismatch, and compromised alveolar absorption (e.g., pulmonary
tries. Unfortunately, it is not available in the United States.92 After an
edema and pneumonia) in cardiopulmonary arrest.5–7
expedited review, the FDA’s Anesthetic and Life Support Advisory
During a cardiopulmonary arrest, ET administered medications
Committee unanimously recommended approval of sugammadex
are absorbed in a protracted manner. This phenomenon, termed the
in March 2008.86 In August 2008, the FDA rejected approving this
“depot effect”, is observed in laboratory and clinical experiments.5
drug due to concerns regarding allergic reactions, hypersensitivity
Studying ET administered lidocaine (2 mg/kg) in nonarrest patients
reactions, and anaphylactic reactions. At the time of this writing,
revealed a biphasic pattern of absorption, an initial immediate peak,
sugammadex is still not approved by the FDA. Research is continu-
and a second higher peak approximately 24 minutes later.8 Plasma
ing on this drug with the hope of FDA approval in the near future.
lidocaine levels were still measurable 120 minutes postinstillation.8
SUMMARY In addition to the altered physiologic conditions of cardiopulmo-
nary arrest as described above, local vasoconstriction induced by
Numerous pharmacologic agents are available to sedate, relax, and epinephrine may contribute to this “depot effect.”9 The relatively low
paralyze a patient in preparation for intubation. These same agents initial plasma medication levels and then the subsequent extended
are used in lesser doses to maintain postintubation sedation and plateau of plasma medication levels are also exhibited by the ET
paralysis as well as for procedural sedation. There is no ideal seda- administration of atropine, epinephrine, and vasopressin.5,10
tive or paralytic agent. The combination of lesser doses of several
agents, depending on the patient’s condition, will maximize the MEDICATION DOSE
positive effects and minimize the adverse effects of each individual
The American Heart Association (AHA) suggests an ET medica-
drug. This requires Emergency Physicians to become familiar with
tion dose of 2 to 2.5 times the recommended IV dose (Table 9-1).11
several drugs in each class, so that they may choose the appropriate
The optimal dose of ET administered medications is unknown.
combination for each patient.
While there is a consensus that IV doses given endotracheally result
in subtherapeutic plasma levels, the equipotent dose ranges from
3 to 10 times the IV dose in the literature.12–42
Many studies have noted the inadequacy of the currently rec-
Endotracheal Medication
9 Administration
ommended dose of epinephrine and atropine in cardiopulmonary
arrest models.27,31,36 Niemann and Stratton retrospectively reviewed
136 adult medical arrests, both primary and secondary asystole,
Shoma Desai with less than 10 minutes to definitive care. The rates of response
(positive rhythm) and return of spontaneous circulation were sig-
INTRODUCTION nificantly greater in the IV medication group than both the ET
medication group and the no therapy group.27
Healthcare providers are charged with the primary goal of optimiz-
ing the oxygenation, ventilation, and the hemodynamic status of
the patient during a resuscitation. In most cases, the first definitive
intervention is to secure the airway through endotracheal (ET) intu- TABLE 9-1 Recommended Endotracheal Medication Doses2,11
bation. The establishment of access to the systemic circulation soon Medication Adults Pediatrics Neonates
follows. Vascular access in certain patients can be problematic. In Atropine 2–2.5 mg 0.03 mg/kg Unknown
such cases, the ability to administer medications endotracheally Epinephrine 2–3 mg 0.1 mg/kg (1:1000) 0.01–0.03 mg/kg
can be life saving. (1:10,000) (or 0.1 mL/kg) (1:10,000)
Bernard first reported the ET route of medication adminis- Lidocaine 2–3 mg/kg 2–3 mg/kg Unknown
tration in 1857, describing the alveolar absorption of curare in Naloxone 0.8–2 mg <5 y or ≤ 20 kg: 0.1 mg/kg 0.1 mg/kg
dogs. This discovery was followed by the observation that ET ≥5 y or >20 kg: 2 mg
instilled salicylates appeared in the urine (Peiper 1884). In 1897, Vasopressin 80 units Unknown Unknown
CHAPTER 9: Endotracheal Medication Administration 57
A recent discussion in the literature has drawn attention to that it seems to take 10 times the IV medication dose to achieve
the behavior of epinephrine when given at suboptimal doses. appropriate serum epinephrine levels and responses in the heart
Epinephrine is used in arrest situations for its α-adrenergic effects. rate and blood pressure.26,38,39 A retrospective study of neonates who
The β-adrenergic effects predominate when epinephrine is admin- received epinephrine in the delivery room underscores the diffi-
istered in small doses. This can transiently result in potentially culty of obtaining vascular access.40 Almost all the neonates (94%,
harmful hypotension, decreased coronary perfusion pressure, n = 52) received their first dose of epinephrine via the ET route.
and the diminished likelihood of return of spontaneous circula- Of these, 32% obtained return of spontaneous circulation while the
tion.11 Manisterski et al. documented an early drop in mean arterial rest required additional epinephrine through their IV line once it
blood pressure with prolonged tachycardia after ET epinephrine at was established. The authors concluded that the currently recom-
doses of 0.02, 0.035, 0.1, and 0.2 mg/kg in healthy dogs.28 Only the mended ET epinephrine dose of 0.01 to 0.03 mg/kg is ineffective.
0.3 mg/kg dose was effective in achieving an increase in blood pres-
sure without a transient drop.28 Findings such as this have prompted INDICATIONS
investigations on pretreatment with β-blockers (e.g., propranolol) The ET administration of medications is reserved for resuscitations
prior to ET epinephrine administration, which does blunt the early in which vascular access (i.e., IV or intraosseous (IO)) is delayed.11
β-effects.29,30 Although more research is needed in this area, these This may apply to the resuscitation of any patient with cardiovas-
studies do question the efficacy of the current recommended ET cular collapse. The ET route may be more frequently encountered
epinephrine dose, calling for higher ET doses. in certain patient populations traditionally associated with difficult
Despite these results, concerns regarding the “depot effect” vascular access such as neonates, the obese, cancer patients, sickle
have kept the current ET medication dose recommendation at cell patients, IV drug abusers, burn patients, and dialysis patients.12
2 to 2.5 times the IV dose. This is to avoid the prolonged side effects The goal is to increase the probability of successful resuscitation
in the critical postresuscitation period.5 This compromise leads to despite a delay in obtaining definitive systemic vascular access.
many uncertainties regarding the effectiveness and reliability of the The ET route is recommended for the administration of lidocaine,
ET route for medication administration.9,31,32 epinephrine, atropine, naloxone, and vasopressin.11 Other medi-
cations that can be administered but are not widely used include
DILUENT flumazenil, diazepam, midazolam, penicillins, sulfonamides, and
A primary goal in administering ET medications is to achieve aminoglycosides.13–17
rapid absorption. This goal can be reached with larger volumes of
CONTRAINDICATIONS
diluent, but is tempered by the potentially detrimental effects on
pulmonary function.4 The current recommended volumes for ET The absorption of medications given through an ET tube is unpre-
instillation of each medication are dilution to a total volume of dictable during a cardiopulmonary arrest. The only contraindica-
10 mL in adults, 5 mL for children, and 1 mL for neonates.11,26 tion to ET medication administration is the patient having IV or IO
Another controversy arises with respect to the type of diluent access. The ET route may be used initially until IV or IO access is
used. Distilled water and 0.9% saline have been utilized for ET established.
medication administration and are currently recommended by
the AHA.11 In theory, water creates a greater osmotic gradient to EQUIPMENT
potentially speed up medication absorption. This could also lead • ET tube, standard or specialty ET tube
to a greater disruption of pulmonary surfactant, thereby hindering
gas exchange.5 This has been confirmed in nonarrest experiments • Bag-valve device
using dogs.33 It was later disputed utilizing much smaller volumes • Medication to be administered
(2 and 10 mL) of instilled medication.34,35 These studies found that • Diluent, 0.9% normal saline or distilled water
distilled water provides more rapid and more effective absorption • 10 mL syringe
(higher peak serum medication levels) than 0.9% saline without a
physiologically significant drop in PaO2. • 18 gauge needle
• IV adapter lock
PEDIATRIC CONSIDERATIONS • Water-soluble lubricant
Much of the debate regarding ET medication administration still • Optional catheters (suction, feeding, or central venous)
exists in pediatrics. While approximately half of pediatric arrests are The patient may be intubated with a standard ET tube, an ET tube
resuscitated without the use of medications, resuscitation drugs may with a monitoring lumen, or a specialty ET tube with a medication
be required to achieve return of spontaneous circulation. Obtaining injection port.18 The EDGAR ET tube (endobronchial drug and gas
vascular access in children, especially in neonates, can be extremely application during resuscitation, Rusch, Germany) has a separate
difficult. This makes the ET medication administration route a pos- injection channel that terminates at the tip of the ET tube. This ET
sible option for early resuscitative efforts.37 There are no published tube is currently available in Europe, but not in the United States.
pediatric or neonatal studies examining the type or volume of dilu- The Stat-Med ET tube (Hudson RCI, Temecula, CA) has a separate
ent, only consensus recommendations.11,26 injection port and channel that terminates distal to the inflated cuff
A major difference between adults and children in arrest is the (Figure 9-1). These two ET tubes allow the ET administration of
absorptive capacity of the immature lung. In particular, the surface medications without interrupting CPR compressions or ventilation.
area is smaller, the diffusion coefficient is larger, and there exists The LITA ET tube (Hudson RCI, Temecula, CA) is a modification
the potential for right to left shunts in children.9,38 These conditions of the Stat-Med ET tube. Like the Stat-Med, it has a separate injec-
greatly affect an already unreliable absorptive process. tion port and channel. The channel has eight openings above the cuff
The indications, procedures, and complications are considered and two below the cuff. This ET tube was designed for use with local
to be much the same in pediatrics as in adults. There are very few anesthetic solutions to anesthetize the tracheal mucosa. It should not
published studies focused on ET medication administration in be used to administer resuscitation medications. They will mostly
pediatrics. Those that studied epinephrine in pediatric arrest agree pool above the cuff in the trachea and not get properly absorbed.
FIGURE 9-1. The Stat-Med tube (Hudson RCI, Temecula, CA).
Other, optional, equipment may be used depending on the tech-

nique used to administer the medications. A catheter may be used
to administer the medication. A suction, feeding, or central venous FIGURE 9-2. The MADett™ (Wolfe Tory Medical, Salt Lake City, UT).
catheter may be introduced into the ET tube to administer medica-
tions more distally. An IV adapter lock is required on the proximal
end of these catheters to allow the syringe to attach to the catheter.
proximal end of the ET tube. Replace the bag-valve-mask device
There are no formal guidelines regarding proper catheter size. There
and manually ventilate five times in quick succession. The forced
are recommendations to use a 16 French (Fr) suction catheter in
hyperventilation results in bilateral and distal distribution of the
adults,19 an 8 Fr feeding catheter in children,20 and a 5 Fr feeding
medication.12 Resume chest compressions.
catheter in neonates.21
Always remove the needle from the syringe when injecting
The administration of drugs through laryngeal mask airways
medication into the ET tube. Some medical personnel may choose
(LMAs, Chapter 19) and combitubes (Chapter 20) as compared with
to leave the needle attached to the syringe for convenience or to
ET tubes has been studied. Medication instilled through a catheter
decrease any delays in medication administration. The needle, if
inserted through an LMA and into the trachea achieved the equiva-
loose, can fall off the syringe and into the ET tube. It will then “ride
lent blood concentrations as through an ET tube.43 Unfortunately, it
the tube” and can become an airway foreign body in the distal tra-
is often difficult to successfully pass a catheter through an LMA and
chea or main bronchus. The needle also slows down medication
into the trachea.22 Administration of lidocaine through LMAs was
injection into the ET tube, delaying restarting CPR.
unreliable (4 out of 10 reached therapeutic plasma levels) as com-
pared with ET tubes (10 out of 10 reached therapeutic plasma lev-
els) in nonarrest patients.22 Subtherapeutic plasma medication levels PROXIMAL NEEDLE INJECTION OF
were noted when comparing lidocaine administration via combi- MEDICATION INTO THE ET TUBE
tubes (placed in the esophagus) versus ET tubes.23 An alternative approach is to piercing the proximal end of the ET
The intubating LMA (ILMA) is a modification of an LMA. It is tube with an 18 gauge needle attached to the medication-filled
designed to allow the blind passage of an ET tube through it and syringe.24 Care must be taken to assure that the needle does not
into the trachea. Insertion of a catheter through an ILMA was only damage the ET cuff inflation tube and the tip of the needle is com-
successful in 92% of the attempts.44 It also required a mean time of pletely within the lumen of the ET tube. Instill the medication dur-
20 seconds (range 11–44 seconds), which is too long by AHA guide- ing inspiration, when the bag is squeezed. Detach the syringe from
lines to discontinue CPR.11 the needle. Attach a new medication-filled syringe or refill the used
™
An interesting device is the MADett or mucosal atomizer syringe to instill other medications without removing the needle
device (Wolfe Tory Medical, Salt Lake City, UT, Figure 9-2). This from the ET tube. The remaining hole in the ET tube after the resus-
device allows ET medication administration without stopping com- citation and the needle is removed results in a negligible air leak that
pressions and ventilations of CPR, and no splash back into the face may be closed with a piece of tape.
of the person administering the medication. The MADett must ™
be used only with an ET tube size greater or equal to 7.0 mm inner DISTAL MEDICATION INSTILLATION
diameter and a length of at least 28 cm.
Medications may be administered deeper through a catheter
TECHNIQUES inserted into the ET tube. This technique minimizes medication
adherence to the walls of the ET tube. Prepare the medication and
catheter. Draw up the appropriate medication and diluent into a
PROXIMAL MEDICATION INSTILLATION syringe or use a prefilled syringe. Choose the appropriate type and
The simplest method for ET medication administration is direct size of catheter. Attach an IV adapter lock to the proximal end of the
instillation. Prepare the medication or use a prefilled syringe with a catheter. The proximal end of the catheter may have to be cut off if
needleless adapter. If drawing your own medications, use a syringe it is flared, tapered, or too big for the IV adapter lock to fit.25 After
with an 18 gauge needle to draw up the medication into the syringe. cutting the proximal end, attach the IV adapter lock.
Draw up sterile water or 0.9% normal saline to dilute the medica- Remove the bag-valve-mask device from the ET tube. Briefly
tion to the appropriate volume. Remove the bag-valve-mask device interrupt external chest compressions. Lightly lubricate the catheter
from the ET tube. Briefly interrupt external chest compressions. with a water-soluble lubricant, so that it will advance easily through
Remove the 18 gauge needle from the syringe. Inject the diluted the ET tube. Insert the catheter (feeding, venous, and suction) into
medication in the syringe or from the prefilled syringe into the the ET tube until its tip extends just beyond the distal end of the
CHAPTER 9: Endotracheal Medication Administration 59
ET tube by approximately 1 to 2 cm. Attach the medication-filled chapter. These ET tubes may be placed initially in a patient with
syringe to the IV catheter lock if using a feeding or suction tube, or a cardiopulmonary arrest. If a standard ET tube is initially placed,
the leur lock if using a central venous catheter. Inject the medication it can be exchanged for one of these specialized ET tubes. Prepare
into the catheter followed by 5 mL of air to clear the tube of any the medication. Attach the medication-filled syringe to the injection
residual medication. Replace the bag-valve-mask device and manu- port of the ET tube. Inject the medication into the ET tube injection
ally ventilate five times in quick succession. The forced hyperventi- port during inspiration with the bag-valve-mask device. The diluted
lation results in bilateral and distal distribution of the medication.12 drug solution may be followed by the injection of 5 mL of air to clear
Resume chest compressions. the tube of any residual medication.
An alternative to using these specialty ET tubes is to attach the
TECHNIQUES TO MINIMIZE INTERRUPTION ™ ™
MADett to a standard ET tube. The MADett is quick, simple,
and easy to use (Figure 9-3). The patient should already be intu-
OF VENTILATIONS AND COMPRESSIONS
bated. Stop ventilations, but not compressions, and remove the
The goal of CPR is to minimize interruptions of chest compres- ™
bag-valve device from the ET tube. Attach the MADett adapter
sion and ventilation. This can be accomplished using one of the onto the ET tube (Figure 9-3A). Resume ventilations by attaching
specialized ET tubes discussed in the “Equipment” section of this the bag-valve device to the side port of the adapter. Advance the
A B
FIGURE 9-3. Using the MADett™. A. The MADett™ is attached to the ET tube.
B. The black mark on the catheter lines up with the 26 cm mark on the ET tube.
C. Medication is injected while ventilating the patient. D. Medication is atomized D
into the airway.
™
MADett catheter into the ET tube until the black mark on the COMPLICATIONS
catheter lines up with the 26 cm mark on the ET tube (Figure 9-3B).
™
Tighten the lock nut on the MADett adapter to hold the catheter in The main complication of administering medications by the ET
place, so that it will not be advanced or withdrawn. Attach the med- route arises from the “depot effect.” Epinephrine, atropine, vaso-
ication-containing syringe to the luer lock attachment and inject the pressin, and lidocaine have been observed to be absorbed in a
medication while ventilating the patient (Figure 9-3C). Inject the prolonged fashion, much like a continuous intravenous infusion.
medication while bagging the patient to allow the atomized medi- This phenomenon has been attributed to local vasoconstriction
cation (Figure 9-3D) to penetrate deeply into the respiratory tract. (epinephrine), poor lung perfusion, vascular congestion due to
markedly diminished cardiac output, and comorbid conditions
WHICH IS THE BEST TECHNIQUE? (e.g., pulmonary edema, atelectasis, COPD, etc.) present at the
time of the arrest. However, this sustained drug effect has also been
Mielke et al. studied the time involved to perform each technique observed in nonarrest patients.8 The result, in the case of epineph-
by Paramedics and Emergency Physicians.25 These included direct rine, is prolonged hypertension, malignant arrhythmias, and tachy-
injection into the ET tube, via suction catheter, via central venous cardia in the postresuscitative period.36,41 Endotracheal atropine
catheter, and use of an EDGAR tube with an injection chan- can cause sustained tachycardia.5,42 Endotracheal vasopressin can
nel. Overall, both direct injection into the ET tube and use of the cause sustained bradycardia, prompting experiments with prophy-
EDGAR tube were significantly faster (median 7 and 8 seconds, lactic atropine.10 These prolonged effects may hinder both cerebral
respectively) than the catheter techniques (median 26 and 30 sec- and cardiac recovery once return of spontaneous circulation is
onds). In their discussion, a theoretical disadvantage of using a cath- established.42
eter was the instillation of medication unilaterally down one of the Another drawback to ET medication administration is the tran-
mainstem bronchi if the catheter was advanced too far down the ET sient impairment of gas exchange. Many studies describe an early
tube. This would thereby decrease the potential absorptive surface reduction in PaO2, which is directly correlated with the volume of
by half. This potential negative was offset, however, by the use of liquid instilled. There is a greater drop in PaO2 after instilling water
larger volumes of medication and the application of postinstillation than after saline. In nonarrest dogs using large volumes of diluent
hyperventilation.25 (2 mL/kg), there was a decrease in PaO2 to 61% of baseline with
Studying the same three techniques (direct ET instillation, via a distilled water as opposed to 75% of baseline with saline.33 In nonar-
suction catheter, and use of an EDGAR tube) in nonarrest patients, rest humans with instilled volumes of 10 mL through the ET tube,
no difference was found in the pharmacokinetic response to lido- there was a drop in PaO2 from 157 to 95 mmHg with saline and
caine administration.19 Specifically, there was no significant differ- from 157 to 103 mmHg with water.34 Hypoxia, to a much greater
ence in serum lidocaine concentration, heart rate, blood pressure, extent than hypercarbia, has been reported in nonarrest models.
end-tidal PCO2, and oxygen saturation among the three groups. Alterations in pulmonary gas exchange in arrest are less well under-
These findings disputed any previous assertion that using a catheter stood. However, adherence to recommended volumes and the use
provided an advantage by instilling medications more peripher- of hyperventilation postinstillation has the potential to offset this
ally (therefore closer to the absorptive surface). They also reported complication.
that catheter use led to a significantly longer interruption in venti-
lation (10.2 seconds) compared to the direct ET instillation group
(3.6 seconds).19
SUMMARY
These techniques were evaluated in a porcine model representing Despite concerns regarding the efficacy of ET medication adminis-
pediatric respiratory arrests.20 Epinephrine was instilled through an tration, this route remains second line for instances when vascular
ET tube, a feeding catheter, and an ET tube with a monitoring lumen. access (IV or IO) is not available for the instillation of resuscitation
There was no significant difference in hemodynamic response or medications. When IV or IO access is delayed, the ET route should
in the rate of successful resuscitation. Interestingly, by using radio- be considered to increase the chances of successful return of spon-
labeled epinephrine, they were also able to show that medication taneous circulation. Attempts at vascular access should be contin-
adherence to the ET tube was minimal and that there was no dif- ued during the administration of ET medications. The use of the
ference in bilateral pulmonary distribution among the three groups. ET route should be discontinued once vascular access is achieved.
Despite its inherent issues, knowledge of the ET medication admin-
ASSESSMENT istration procedure can be life saving.
There are no specific assessments related to the procedure of endo-
tracheal medication administration. Medications instilled through
the ET tube enter the respiratory tract. Large volumes of fluid in the
lung may interfere with oxygen exchange, cause a pneumonitis, or
cause pulmonary edema. The assessment is related to the resuscita- Rapid Sequence Induction
tion itself (chest compression, positive pressure ventilation, defibril-
lation, etc.). There is no method to determine plasma medication
10 Piotr C. Aljindi, Ned F. Nasr, and Isam F. Nasr
levels of endotracheally administered medications in a timely man-
ner to impact clinical care.
INTRODUCTION
AFTERCARE Rapid sequence induction (RSI) of anesthesia, sometimes referred
After a successful resuscitation, there is no indication to remove one to as “crash” induction, has become a safe and effective method of
of the specialty ET tubes if used. These can be left in place and used establishing emergent airway control in patients with suspected life-
similar to a standard ET tube. Place a piece of tape over the nee- threatening emergencies. It ensures optimal patient compliance in
dle hole in the ET tube if the needle injection technique was used. a well-controlled environment. RSI involves the near simultaneous
Otherwise, no aftercare specific to the procedure of endotracheal administration of a potent sedative–hypnotic agent and a neuro-
medication administration is required. muscular blocking agent.1–20 Various pretreatment drug regimens
CHAPTER 10: Rapid Sequence Induction 61
have been advocated to prevent potentially deleterious side effects, TABLE 10-2 Contraindications to the Use of Succinylcholine
such as aspiration of gastric contents, cardiovascular excitation or
Cardiac arrhythmia
depression, and intracranial pressure elevation. Children and adolescents unless no other option exists
The first endotracheal tubes were developed for the resuscitation Exaggerated hyperkalemia in susceptible patients
of the newborns and victims of drowning in the nineteenth century, More than 24 h after major burns and trauma
but were not used in anesthesia until 1878.13 Muscle relaxants were Crush injuries
not prepared until some 60 years later. Succinylcholine was prepared Denervation beyond 48–72 h after injury14
by the Nobel Laureate Daniel Bovet in 1949, after which it gained Prolonged immobilization
the widespread usage it still enjoys today. The RSI technique did not Paraplegia or hemiplegia
come into modern day practice until the end of World War II. Disuse atrophy
Patients can be hypoxic, confused, uncooperative, unstable, and Severe abdominal infection
unknowing of their medications or medical conditions and can Muscular atrophy
require airway control within minutes of arrival at the Emergency Metastatic rhabdomyosarcoma14
Department. RSI is the preferred method for securing the air- History of malignant hyperthermia in the patient or in their family history
Hypersensitivity to the drug
way in the Emergency Department, as these patients are at risk
for aspiration. These risks include vomiting from gastrointestinal Increased intracranial pressure (relative)
obstruction, opioids, or hypotension; regurgitation from diabetic Increased intragastric pressure (relative)
gastroparesis, gastroesophageal reflux, increased gastric pressure, or Increased intraocular pressure (relative)
decreased lower esophageal sphincter tone; impaired laryngeal pro- Masseter muscle spasm or rigidity
tective reflexes; and difficult airway management.7 Conditions such Plasma cholinesterase deficiency (relative)
as recent meal ingestion, pain, obesity, and pregnancy place patients Skeletal muscle myopathies in the patient or in their family history
at higher risk as well. Source: Adapted from Ref. 1, 2, 8, and 14.
INDICATIONS
should not have any muscle tone to overcome. A relative contrain-
The primary indication for RSI is to quickly protect and secure dication is a patient in whom bag-valve-mask ventilation is difficult
the patient’s airway. The rationale behind RSI is to create an envi- or anticipated to be difficult.
ronment in which the trachea can be intubated as quickly and with
as little difficulty as possible. The clinical conditions occurring at EQUIPMENT
the time of attempted intubation are therefore of great importance.
During RSI, the drugs used to produce hypnosis and muscle relax- • Supplemental oxygen with appropriate tubing and connectors
ation interact together to produce the intubating conditions. A com- • Laryngoscope handle with extra batteries
plete list of the indications for RSI appears in Table 10-1. • Laryngoscope blades, various sizes and types
• Endotracheal tubes, various sizes
CONTRAINDICATIONS
• Wire stylet, malleable type
There are few contraindications to RSI. It should not be performed • Nonrebreather oxygen masks, various sizes
by an inexperienced intubator. If the physician has doubts about his
or her ability to intubate the patient, an awake intubation should • Oropharyngeal airways, various sizes
be considered. The unavailability of equipment, contraindications • Nasopharyngeal airways, various sizes
to muscle relaxants, and critically ill patients in whom the airway • Alternative airway devices
can be secured by other methods (fiberoptic intubation, topical • Suction source with appropriate tubing
anesthesia, or minimal sedation with a benzodiazepine and/or nar-
cotic) are also contraindications to RSI. Any contraindication to the • Suction catheters for endotracheal tubes
use of succinylcholine is also a contraindication to RSI. Table 10-2 • Yankauer suction catheter
lists the many common contraindications to the use of succinylcho- • Bag-valve-mask devices, various sizes
line. Patients in cardiopulmonary arrest do not require RSI as they
• Face masks, various sizes
• Stethoscope
• Water-soluble lubricant or anesthetic jelly
TABLE 10-1 Indications for RSI in the Emergency Department
Airway protection and risk for pulmonary aspiration (e.g., full stomach, • Tape
pregnancy, and obesity) • Benzoin adhesive
Application of advanced cardiac life support and administration of drugs • Syringes, 10 and 20 mL
Definitive maintenance of airway patency
Depressed level of consciousness and questionable ability to maintain a • Medications drawn up and labeled
patent airway • Pulse oximeter
Emergency surgery and requirement for general anesthesia • Cardiac monitor
Head trauma with a decreased Glasgow Coma Scale score
Head trauma with the need for airway control • Automatic sphygmomanometer
Head trauma with the need for ventilation • End-tidal carbon dioxide (CO2) monitor/device
Potentially difficult intubation after airway evaluation
• Crash cart
Respiratory failure, actual or impending
Uncontrolled seizure activity requiring airway control • Resuscitation medications
Uncooperative or combative patient with compromised airway • Personnel (respiratory technician, medication nurse, recorder,
Source: Adapted from Ref. 2 and 7. in-line stabilization assistant)
TABLE 10-3 Pharmacologic Adjuncts to Intubation in the Premedication Phase

Agent Standard dose Trauma dose Blood pressure Cerebral perfusion pressure
Fentanyl* 2.0–8.0 µg/kg 1.0–3.0 µg/kg Stable Stable
Sufentanil† 0.25 µg/kg 0.1–0.2 µg/kg Stable Stable
Alfentanil‡ 5.0–25.0 µg/kg 5 µg/kg Stable Stable
Remifentanil¶ 0.25–1.0 µg/ 0.05–0.5 µg/ Stable Stable
kg/min kg/min
Lidocaine§ 1.0–1.5 mg/kg 1.0–1.5 mg/kg Stable Stable or increased
* Minimal hemodynamic or cerebrovascular effects. Useful agents for blunting the noxious stimuli of direct laryngoscopy or intubation. The halftime of equilibration between the effect and
plasma is relatively slow (5–6 minutes). May cause central vagal stimulation with resultant bradycardia and occasionally hypotension in patients with high sympathetic tone.
†
Similar to fentanyl, but more potent and faster offset.
‡
Similar to fentanyl, but faster onset and duration of action. The halftime of equilibration between the effect site and the plasma is 1.5 minutes, making this opioid a very appropriate drug to
provide a transient peak effect after a single bolus dose. May prevent the increase in intraocular pressure caused by succinylcholine.8
¶
Similar to alfentanil in terms of fast onset. Extremely rapid clearance (3–4 L/minute) due to esterase metabolism, resulting in a rapid and predictable recovery.
§
Useful adjuvant agent for blunting airway reflexes. Also blunts blood pressure, intracranial pressure, and intraocular pressure responses to intubation, involuntary muscle movements after
etomidate, and injection site pain from propofol and etomidate. Topical lidocaine is also effective in blunting reflexes.
Source: Adapted from Chapter 8.
The equipment required for RSI is the same as that for any intuba- TECHNIQUE
tion.10,13 Complete details regarding the selection of properly sized
equipment can be found in Chapters 7 and 11. In addition, backup The three main characteristics of RSI are preoxygenation, appli-
equipment should be readily available if the patient cannot be cation of cricoid pressure, and the avoidance of positive pressure
intubated. This can be a laryngeal mask airway, a cricothyroidot- ventilation (if possible) prior to securing the airway with a cuffed
omy tray, a retrograde guidewire kit, or a percutaneous jet ventila- endotracheal tube. In addition, RSI requires the presence of ancil-
tion system to name a few. lary equipment and experienced assistance. The details of timing,
drug choice, and dosage are not rigidly defined. A RSI protocol is
described below from start to finish.
PATIENT PREPARATION
Preoxygenate the patient with 100% O2 by a nonrebreather mask,
RSI can be performed with little or no preparation. If possible, a or ventilate with a bag-valve-mask device using cricoid pressure.
few steps can be performed while the patient is being evaluated. This will build an oxygen reserve and prevent hypoxemia during
Administer supplemental oxygen to the patient with a nonre- induction. Traditionally, preoxygenation for 5 minutes is the routine
breather mask. Apply a noninvasive blood pressure cuff, continuous practice. If this is not practical, attempt to preoxygenate the patient
pulse oximetry, and cardiac monitoring. Obtain intravenous access. for 3 minutes.6 However, four maximal inspirations are equally
If time permits, pharmacologic agents can be used to increase gas- effective in the cooperative patient.6 Oxygen administration via
tric pH and motility (antacids, H2 receptor blockers, and metoclo- noninvasive positive pressure ventilation can improve oxygenation
pramide). An antisialagogue (atropine or glycopyrrolate) may also more rapidly than by a face mask.21
be administered to decrease excessive oral and respiratory tract While an assistant is preoxygenating the patient, evaluate the air-
secretions. way to anticipate any difficulties during the intubation (Chapter 6).
Evaluate the airway (Chapter 6). If, after evaluation of the air- Assemble all required equipment. Connect the bag-valve device to
way, there is sufficient doubt as to the possibility of intubating a mask and an oxygen supply. Lubricate and place the malleable
the patient successfully, a neuromuscular relaxant should not be stylet into the endotracheal tube. Attach a syringe to the inflation
administered. Consideration should be given to securing the air- port of the endotracheal tube cuff. Inflate the cuff to look for any air
way in another fashion (e.g., awake intubation). leaks. Deflate the cuff and leave the syringe attached to the inflation
TABLE 10-4 Selected Pharmacologic Properties of the Neuromuscular Relaxants

Intubation Average intubating Clinical
Agent dose (mg/kg) time (min) duration (min) Comments
Succinylcholine 1 4–6 Agent used for rapid sequence intubation.1,2 Associated with side
Children: 2 mg/kg effects such as exaggerated hyperkalemia in susceptible patients
Adults: 1 mg/kg16 (>24 h after major burns and trauma, crush injury, denervation,
IM: 4 mg/kg prolonged immobilization, paraplegia, hemiplegia, muscular dystrophy)
and malignant hyperthermia. Elevates intraocular, intracranial, and
intragastric pressures. Use the total body weight (not the lean weight)
even in the morbidly obese or pregnant patient.
Rocuronium 0.6–1.2 0.7–1.1 31–67 An alternative to succinylcholine provided that there is no anticipated
Children 2–12 years old: 0.9–1.217 difficulty in intubation.4
Vecuronium 0.08–0.10 2.5–3.0 25–40 Cardiovascular effects unlikely. Alternative to succinylcholine.
Cisatracurium 0.15–0.20 1.5–2.0 55–65 Stereoisomer of atracurium. No cardiovascular effects.
Organ-independent elimination.
Atracurium 0.4–0.5 2.0–2.5 35–45 Elimination independent of liver and kidney. Releases histamine.
Pancuronium 0.06–0.10 2.0–3.0 56–100 Tachycardia and sympathetic nervous system activation.
Source: Adapted from Ref. 1, 2, 4, 5, and 9.
CHAPTER 10: Rapid Sequence Induction 63
TABLE 10-5 Pharmacology of the Anesthetic Induction Agents

Steady-state volume
Agent Dose (mg/kg) of distribution (L/kg) Clearance (mL/min/kg) Elimination half-life (h)
Thiopental Adults: 3.0–5.0 2.5 3.4 11.6
Children: 3.0–5.0
Infants: 7.0–8.018
Etomidate 0.2–0.3 2.5–4.5 10.0–20.0 2.0–5.0
Propofol Adults: 1.5–2.5 2.0–10.0 59.4 4.0–7.0
Children: 3.0–6.0
Midazolam 0.1–0.2 1.0–1.5 7.5 1.0–4.0
Ketamine 1.0–2.0 2.5–3.3 16.0–18.0 1.0–2.0
Methohexital 1.0–3.0 0.4 6.56 22 days
Fentanyl 0.002–0.02 4.0 4.8–10.5 3.5–4.0
Source: Adapted from References 3, 7, 8, and 18.
port. Attach the laryngoscope blade to the handle and make sure succinylcholine (1.0 to 1.5 mg/kg) or rocuronium (1.0 to 1.2 mg/kg).
that the light is functional. Simultaneously, the nurses should apply Succinylcholine is the preferred agent. Its effects are short lasting
a noninvasive blood pressure cuff, continuous pulse oximetry, and (4 to 6 minutes). This is especially useful if the patient cannot be
cardiac monitoring to the patient. They should also draw up and intubated, as they will need to be ventilated with a bag-valve-mask
label the required medications, establish intravenous access, set up device until the succinylcholine wears off. Rocuronium allows the
the suction, record all events, and continuously observe the nonin- same intubating conditions as succinylcholine except that it lasts
vasive blood pressure readings, cardiac monitor, and pulse oximeter. for 30 to 60 minutes. This is problematic if the patient cannot be
If there is no suspicion of a cervical spine injury, position the intubated.
patient in the optimum “sniffing” position. If there is suspicion An assistant should apply cricoid pressure as soon as the
of a cervical spine injury, an assistant should provide manual inpatient loses consciousness and maintain it until successful oral
line axial stabilization of the head and neck during the intubation endotracheal intubation has been confirmed. Avoid mask venti-
sequence and remove the anterior aspect of the cervical spine collar lation if possible. If hypoxemia or hypercarbia ensues, begin mask
to allow for maximal mouth opening and access to the neck. ventilation to a maximum pressure of 20 cmH2O while maintaining
Premedicate the patient (Table 10-3). The mnemonic “LOAD” cricoid pressure.
has been used to indicate the pretreatment drugs for RSI.15 The Intubate the trachea 60 to 90 seconds after the succinylcholine
mnemonic stands for lidocaine, opioid (specifically, fentanyl), (or rocuronium) has been administered and the patient’s muscles
atropine, and defasciculation. Lidocaine (1.0 to 1.5 mg/kg) can are relaxed, as noted by apnea and jaw relation. Confirm the cor-
be given to blunt the intracranial pressure response, transient rect position of the endotracheal tube by visualizing the tube
hypertension, bronchospasm, and tachycardia associated with passing through the vocal cords, observing sustained presence
intubation. Fentanyl (2 to 3 µg/kg) or one of its derivatives can of end-tidal CO2 on the capnograph, and auscultating breath
be given to also blunt the intracranial pressure response, transient sounds at the midaxillary lines.11,12 Auscultate over the epigas-
hypertension, and tachycardia associated with intubation. Atropine tric area to ensure that ventilation is not audible over the stomach.
(0.01 to 0.02 mg/kg, minimum 0.1 mg, maximum 1.0 mg) should Release cricoid pressure. If indicated, administer a long-acting par-
be given to children less than 1 year old to prevent bradycardia in alytic agent (Table 10-4). After successful intubation, administer
response to direct laryngoscopy. Administer a defasciculating dose additional sedative hypnotics and analgesics as dictated by clinical
of a nondepolarizing neuromuscular blocking agent. This is one- needs. Obtain a chest radiograph to confirm proper placement of
tenth of the intubating dose (Table 10-4). Phenylephrine (50 µg) the endotracheal tube.
can be given to attenuate the hypotensive response to intubation.
Administer an appropriate induction agent as indicated by the SPECIAL CONSIDERATIONS IN PEDIATRIC PATIENTS
clinical setting and patient’s hemodynamic status (Tables 10-5
and 10-6). Flush the intravenous line with 5 to 10 mL of 0.9% nor- Rapid sequence induction is often used in the Emergency
mal saline solution after each drug to ensure delivery. Department for securing the airway of pediatric patients. The indi-
Administer a neuromuscular blocking agent.1,2,5 Numerous agents cations and equipment, except for being smaller, are essentially not
are available (Table 10-4). The most commonly used medications are different than in the adult patient. Infants and young children have
TABLE 10-6 Cardiovascular and Central Nervous System Effects of Anesthetic Induction Agents
Cerebral Cerebral perfusion
Agent Blood pressure Cardiac contractility blood flow CMRO2 Intracranial pressure pressure
Thiopental Decrease Decrease or no change Decrease Decrease Decrease Decrease or no change
Etomidate Slight decrease or no change No change Decrease Decrease Decrease Increase
Propofol Decrease Decrease Decrease Decrease Decrease Decrease or no change
Midazolam Slight decrease No change Decrease Decrease Decrease No change
Ketamine Increase Increase Increase Increase Increase Increase or no change
Methohexital Decrease Decrease Decrease Decrease Decrease Increase
Fentanyl Slight decrease No change Decrease Decrease Increase or no change No change
Source: Adapted from Chapter 8.
developmental differences in head and neck anatomy (Chapter 6). TABLE 10-7 Complications of RSI
These differences make the Miller blade the preferred laryngoscope
Airway trauma
blade for intubation in this group. Infants and young children have Awareness
a higher volume of distribution, which is why they require different Bradycardia
doses of induction agents as reflected in Tables 10-4 & 10-5. Cerebral anoxia
Preoxygenation is particularly important for infants and chil- Complication specific to the medications administered
dren. Compared with adults, these young patients have a higher Corneal injury
oxygen consumption rate and a lower functional residual capacity. Death
Consequently, oxygen desaturation occurs much more rapidly. If the Dental damage
child is desaturating or apneic, careful bag-mask ventilation with Hypertension
small tidal volumes (while maintaining cricoid pressure) should be Hypotension
performed to achieve adequate preoxygenation. Hypoxia
The use of succinylcholine remains controversial in pediatrics. Increased intracranial pressure
Rapid sequence induction and laryngospasm are perhaps the last Increased intraocular pressure
Myocardial ischemia
remaining indications for the use of succinylcholine in pediatrics. In
Pulmonary aspiration
1994, the US Food and Drug Administration (FDA) recommended Tachycardia
that the use of succinylcholine in children be reserved for emer-
gency intubation and instances where the immediate securing of the
airway is necessary due to the risks of hyperkalemia. This includes
patients with laryngospasm, difficult airways, full stomachs, or for
intramuscular use. If a child has no vascular access, succinylcho-
COMPLICATIONS
line (4 mg/kg) can be administered intramuscularly. It will provide The complications associated with RSI are numerous (Table 10-7),
a maximum onset of blockade in 3 to 4 minutes and last approxi- ranging from minor airway trauma to cerebral anoxia and death.
mately 20 minutes. If there is a contraindication to using succinyl- These can result from the RSI or the intubation. The technique of
choline, rocuronium can be used for RSI. Children between 2 and RSI should be performed only by experienced physicians. The
12 years old require more rocuronium than adults. The recom- availability of alternate invasive airway devices and techniques
mended doses are 0.9 to 1.2 mg/kg in this age group. can often prevent complications if oral endotracheal intuba-
Atropine is commonly used in young children. Atropine tion is unsuccessful. A more complete discussion is contained in
(20 µg/kg) administered as a premedication is indicated in all chil- Chapter 11.
dren <1 year old and in all ages if a second dose of succinylcholine
is required to intubate the patient.19 There is a risk of bradycardia SUMMARY
with the use of succinylcholine in children. This can be attenuated
by premedicating the patient with atropine (20 µg/kg) or glycopyr- RSI is the preferred method to secure an airway on an emergent
rolate (10 µg/kg).20 basis and where there is a risk of aspiration of gastric contents. In
experienced hands, it is a relatively safe procedure with few compli-
cations. The choice of pharmacologic agents used will vary by physi-
ASSESSMENT cian experience, physician preference, the clinical condition of the
Confirm that endotracheal intubation is successful. This includes patient, and the pharmacology of the agents.
auscultation, fogging of the endotracheal tube with ventilations, as
well as presence of persistent end-tidal CO2. End-tidal CO2 can be
confirmed using a capnograph or a chemical (colorimetric) indicator
device that consists of a pH-sensitive indicator where the dye changes
its color in the presence of CO2. A minimum of six breaths should Orotracheal Intubation
be administered before a determination is made regarding successful
endotracheal intubation. This will eliminate false-positive readings
obtained by CO2 forced into the stomach during mask ventilation,
11 Eric F. Reichman and Joseph Cornett
antacids in the stomach, or carbonated drinks in the stomach. False-

negative results may be seen with very low tidal volumes and low INTRODUCTION
end-tidal CO2 concentrations during severe hypotension or cardiac
arrest. During cardiopulmonary resuscitation (CPR), a negative Airway control is the first and most critical action of the Emergency
result requires an alternative method of confirming the position of Physician. The “A” in the ABC’s demands that no other action may
the endotracheal tube because compromised circulation causes low take place until the airway is secure. Endotracheal (ET) intubation
end-tidal CO2.12 Other methods used to confirm endotracheal intu- inserts an artificial airway connecting the respiratory system to the
bation include fiberoptic endoscopy with direct visualization of the outside world and provides definitive control of the airway. Once
tracheal rings and carina, pulse oximetry (low saturation is a late sign the ET tube is in place, all methods of support can be applied. If
for esophageal intubation), blood gas analysis, chest radiography, and the airway is not secure, nothing can help the patient. ET intuba-
a variety of detection devices. Please refer to Chapter 12 for more tion can be accomplished by a variety of methods. The method of
information regarding the confirmation of endotracheal intubation. choice will be dictated by physician preference and experience, the
patient’s condition, and the available equipment. The most com-
mon method of ET intubation is orotracheal intubation. There
AFTERCARE are no good alternatives to intubation when oxygenation and
The aftercare is the same as for any intubated patient. Secure the ventilation are threatened. All actions should be focused on two
endotracheal tube with tape or a commercially available device. objectives: to get the ET tube placed quickly and in the right
Administer adequate sedation and neuromuscular relaxation as location. The proper preparation, practice, and personnel can
necessary. Place a nasogastric tube to decompress the stomach. assure that the “nightmare airway” is an extremely rare event.1
CHAPTER 11: Orotracheal Intubation 65

For the purposes of intubation, our discussion of the anatomy starts
at the lips and travels inward to end at the right mainstem bron-
Mandible
chus. As you approach the patient, visualize the normal structures
expected and match them with what is seen. Distortion occurs from
edema or trauma. Structures may be hidden by vomit or blood.
Airway structures are viewed upside down, from the position of Tongue
standing over the head of the supine patient, and the potential for
disorientation multiplies. Posterior pharyngeal wall
Begin at the face and move inward (Figures 11-1 & 11-2). The
philtrum of the upper lip will be located at the 6 o’clock (bottom) Palatopharyngeal arch
position. Symmetrical swelling, carbon deposits, blistering, or signs Palatoglossal arch
of trauma to the lips can indicate that the inner anatomy of the
airway may be altered and the intubation more difficult. Moving
inward, open the patient’s mouth and check the teeth for fractures, Uvula
size, and the presence of removable dental devices. Large upper
Philtrum
incisors and/or limited jaw opening will make orotracheal intu-
bation more difficult. The tongue hangs down from the floor of
the lower jaw (mandible) and ends with the tip against the upper
(maxillary) incisors (Figure 11-2). Visualize the tongue as a hang-
ing oval of tissue with two “tips.” The first is the anterior tip of the
tongue proper. The second is the epiglottis. The anatomic “floor”
of this view is formed by the hard and soft palates, which end at
the palatopharyngeal arch (Figure 11-2). The uvula is located
inferiorly and in the midline. The palatoglossal arch and palato-
pharyngeal arch form twin vertical pillars that lie posterior to the
FIGURE 11-2. The oral structures as viewed from above the supine patient’s head.
molars of the upper teeth (Figure 11-2). All of these structures are
potential sources of obstruction and must be evaluated for swelling,
deformity, or trauma. The “back wall” is the posterior wall of the
pharynx (Figure 11-2).
At the posterior wall of the pharynx, the airway bends 90° to position. From the viewpoint of the intubator, the hypopharynx
run almost parallel to the bed. Visualized from the perspective of appears like the numeral 8. The top half is the airway and the bot-
the top of the patient’s head, the root of the tongue and the lingual tom half the esophagus.
tonsils are located at the 12 o’clock position (Figures 11-3 & 11-4). Under the epiglottis is the larynx (Figure 11-5). The vocal cords
The tongue continues into a blind pocket known as the vallecula. are located in the midline and form an “A” shape, with its apex
Following the vallecula posteriorly, it is continuous with the epiglot- superior and toward the epiglottis. Identifying the vocal cords is
tis. The epiglottis hangs with its tip pointing downward. Directly important, since the visualization of the ET tube passing between
behind and protected by the epiglottis is the entry to the remain- the cords is proof of a successful ET intubation. The arytenoid
der of the airway (Figure 11-4). The esophagus lies at the 6 o’clock cartilages are paired structures. One lies at the posterior aspect of
each vocal cord. The aryepiglottic folds are paired structures that
span from the lateral edge of the epiglottis to the arytenoid carti-
lages. They contain the muscles that move the arytenoid cartilages,
Tip of tongue Tongue
and subsequently open and close the vocal cords. The trachea bifur-
cates at the carina into the right and left mainstem bronchi. In some
Lower lip Vallecula patients, the cartilaginous tracheal rings are visible through the
vocal cords.
Uvula
Trachea INDICATIONS
Esophagus Any threat to oxygenation and/or ventilation is a relative indica-
tion for orotracheal intubation. If the threat is simple and easily
removed, remove it. If there is uncertainty that the patient’s air-
way patency, respiratory drive, or oxygenation cannot be main-
tained without intervention, orotracheal intubation is required.
Epiglottis Time is of the essence. The decision to intubate early can make
the difference between a controlled, successful procedure and
a chaotic, “crashing” nightmare. Orotracheal intubation can be
performed to administer resuscitation medications, ensure a patent
airway, deliver oxygen, isolate the airway, reduce the risk of aspi-
ration of gastric or oral contents, suction the trachea, ventilate the
patient, and apply positive-pressure ventilation. Other indications
for orotracheal intubation include altered mental status, head injury
FIGURE 11-1. Schematic representation of the airway. The patient is in the requiring hyperventilation, hypoxemia, hypoventilation, apnea, lack
“sniffing” position. of a gag reflex, shock, and unconsciousness.
Ventral/Superior/Anterior
Body of
tongue
Palatoglossal arch
Root of
Lingual tonsil tongue
Palatine tonsil
Vallecula
Epiglottis
Dorsal/Inferior/Posterior
FIGURE 11-3. The tongue and adjacent structures as viewed from above the supine patient’s head.
immobile arthritis patients may be injured by the manipulation

CONTRAINDICATIONS required during orotracheal intubation.3 Severe orofacial injuries,
Orotracheal intubation is relatively contraindicated in patients bleeding, deep airway obstruction, or gross deformity of the head
who do not need it, who are likely to be injured by the procedure, and neck may make successful intubation impossible. A quickly
or whose injuries make success unlikely. Spontaneous breathing changing obstruction, such as edema or an expanding hema-
with adequate ventilation and normal mental status may allow toma, may require a surgical airway if orotracheal intubation is
less invasive techniques such as continuous positive airway pres- delayed. Choose a surgical airway if the manipulation or time
sure (CPAP) in patients whose medical conditions are likely to required for orotracheal intubation puts the patient at risk for
respond quickly to interventions, such as cardiogenic pulmo- spinal injury or hypoxia.4 Orotracheal intubation should not
nary edema or pneumonitis.2 Trauma patients, with likely cer- be performed by individuals unfamiliar with the equipment and
vical spine injury or anterior neck wounds, as well as severely technique.
Ventral/Superior/Anterior
Root of tongue
(lingual tonsil)
Lingual tonsils on
root of tongue Epiglottis
Vallecula
Vocal folds
Vallecula Vestibule
(true cords)
Aryepiglottic
Epiglottis fold
"Airway" trachea Trachea
protected behind
epiglottis
Arytenoid
Esophagus cartilages
Posterior pharynx
Posterior pharyngeal wall
Dorsal/Inferior/Posterior
FIGURE 11-4. Structures of the hypopharynx as viewed from above the supine FIGURE 11-5. The structures of the glottis as viewed from above the supine
patient’s head. patient’s head.
TABLE 11-1 Oral ET Tube Sizes and Positioning Based on Patient Age
Internal External Distance
Size* diameter diameter† inserted from
Patient’s age (French) (mm) (mm) lips (cm)
Premature 10 2.5 3.3 9–10
Full-term/newborn 12 3.0 4.0–4.2 11
1–6 months 14 3.5 4.7–4.8 11
6–12 months 16 4.0 5.3–5.6 12
1–2 years 18 4.5 6.0–6.3 13
3–4 years 20 5.0 6.7–7.0 14
5–6 years 22 5.5 7.3–7.6 15–16
7–8 years 24 6.0 8.0–8.2 16–17
9–10 years 26 6.5 8.7–9.3 17–18
11–13 years 28–30 7.0 9.3–10.0 18–20
Female ≥ 14 years 28–30 7.0 9.3–10.0 20–22
Male ≥ 14 years 32–34 8.0 10.7–11.3 22–24
* Calculated as follows: External diameter (mm) × π.
†
Varies by manufacturer.
Source: Modified from Stone and Gal.6
FIGURE 11-6. A variety of ET tubes.
EQUIPMENT
various sizes and types of laryngoscope blades, various sizes of
• ET tubes, various sizes (Table 11-1) oropharyngeal airways, various sizes of nasopharyngeal airways,
• 10 mL syringe tongue blades, malleable stylets, various sizes of ET tubes, syringes,
• Water-soluble lubricant or anesthetic jelly tape, and commercially available devices to secure the ET tube.
Some institutions may have a single kit, or separate kits for adult
• Wire stylet, malleable type
and pediatric patients.
• Laryngoscope handle
• Fresh batteries for the laryngoscope ET TUBES
• Laryngoscope blades, various sizes and shapes
The ET tube is a clear polyvinyl chloride disposable tube that is
• Supplemental oxygen with appropriate tubing and connectors open on both ends (Figure 11-6). The proximal end contains a
• Nonrebreather oxygen masks, various sizes standard size (15 mm) connector that will attach to the bag-valve
• Wall suction with appropriate tubing device, a ventilator, and other sources of positive-pressure ventila-
tion. The distal end is beveled. It has a perforation, located approxi-
• Yankauer suction catheter mately 0.5 to 0.75 cm from the tip and opposite the bevel, known as
• Bag-valve device, sizes: infant, child, adult small, adult medium, the Murphy eye. Printed on the tube are the size, a radiopaque line
adult large to aid in radiographic visualization, and 1 cm incremental marks
• Oral airways, sizes: infant, child, adult 3 to 5 beginning at the tip. An inflatable cuff is positioned proximal to
the Murphy eye. A pilot balloon with an inflation port, to inflate
• Nasal airways, various sizes
the cuff, hangs from the proximal third of the ET tube. A syringe,
• Benzoin adhesive filled with air, attaches to the inflation port to inflate and deflate
• Tape the cuff.
• Pulse oximeter The ET tube cuff is a high-volume, low-pressure balloon. It is
designed to accommodate a high volume of air before the intracuff
• Cardiac monitor
pressure rises. This is an extremely important feature. If the intra-
• Automatic sphygmomanometer cuff pressure rises, it is transmitted to the delicate tracheal mucosa
• End-tidal carbon dioxide (CO2) monitor/device where it can cause pressure necrosis and ischemia.
• Cricothyrotomy backup tray The choice of ET tube size will vary based on the patient’s age, ana-
tomic anomalies, body habitus, and airway anatomy (Table 11-1).
• Crash cart The ET tube is sized based on the internal diameter (ID) mea-
• Resuscitation medicines sured in millimeters. The size is printed onto the surface of the
• Personnel (respiratory technician, medication nurse, in-line sta- ET tube for reference. The sizes begin with 2.5 mm and increase in
bilization assistant, and recorder) 0.5 mm increments. Some generalities hold true in most patients.
Adult males usually require a size 7.5 to 9.0 cuffed ET tube. Adult
• Medications (premedications, induction, anesthetics, paralytics),
females usually require a size 7.0 to 8.0 cuffed ET tube.
see Tables 11-1 to 11-2
ET tube selection in children can be made by one of sev-
Many institutions make their own “intubating/airway kit.” It eral methods. A Broselow tape will identify the proper size tube.
contains all the commonly used equipment in a portable container Visually select a tube with an ID that matches the size of the width
or cart that can be moved wherever required in the Emergency of the nail of the patient’s little finger, the width or diameter of the
Department. While differences will exist between institutions, the fifth finger, the diameter of the distal phalanx of the third finger,
kit commonly includes adult and pediatric laryngoscope handles, or the external nares luminal diameter. All these visual methods
will approximate the same size ET tube. The following formula

may be used to confirm the uncuffed ET tube size: (16 + child’s
age in years)/4. Tables based on the child’s age, length (Broselow
tape), or weight may be used to estimate the proper ET tube size.
An uncuffed ET tube should be used in children under 28 days of
age to prevent the complications of subglottic and tracheal stenosis.
After determining the proper size ET tube, also select and prepare
a tube that is one size smaller in case the patient’s airway is smaller
than expected.
Traditional teaching holds that cuffed ET tubes increase the
risk of ischemic damage to the tracheal mucosa due to compres-
sion between the cuff and the cartilaginous rings, resulting in the
old mandate to use uncuffed ET tubes in children younger than 8
years of age. There have been numerous advances in modern ET
tubes that are changing this orthodoxy.41 Current American Heart
Association Guidelines now recommend, but do not require, a
cuffed ET tube for children older than 28 days of age. In the first
28 days of life, the cricoid narrowing functions as a cuff. For chil-
dren over 28 days of age, the cuffed ET tube is just as safe as an FIGURE 11-7. A variety of laryngoscope handles.
uncuffed ET tube.25,26 The high volume, low pressure cuffs found
on new ET tubes allow the cuff to produce a seal at much lower
pressures. The use of cuffed ET tubes is becoming more common
in pediatric ICUs and Emergency Departments. Several studies
have shown no increase in postintubation stridor or reintubation
when cuffed ET tubes are used in controlled settings with regular
cuff pressure monitoring.
In addition to providing some protection from aspiration, other
potential benefits resulting from the use of cuffed ET tubes in chil-
dren include allowing ventilation at higher pressures, maintenance
of more consistent ventilatory parameters, and fewer changes of
inappropriately sized ET tubes. Cuffed ET tube size can be calcu-
lated using the equation (age in years/4) + 3, or by use of an ET
tube one-half size smaller than the calculated uncuffed ET tube
size.7,21
All ET tubes should be examined for defects before use. Attach
a 10 mL syringe filled with air to the pilot balloon inflation port.
Inject the air to inflate the cuff. The cuff should inflate symmetri-
cally and have no air leak. Deflate the cuff completely. Leave the
syringe attached to the pilot balloon in order to inflate the cuff after
the ET tube has been inserted into a patient’s airway. If an ET tube is
defective, discard it and open a new ET tube.
FIGURE 11-8. The Macintosh laryngoscope blades.
LARYNGOSCOPES
The laryngoscope is a handheld device that is used to elevate
the tongue and epiglottis to expose the glottis. It is a device that
is held in the left hand regardless of which hand of the user
is dominant. It consists of a handle (Figure 11-7) and a blade
(Figures 11-8 & 11-9). The handle contains the battery for the
light source. The distal end of the handle has a fitting where
the handle connects to the blade. A transverse bar indicates where
the indentation on the proximal blade attaches to the handle.
There are many types of laryngoscope handles. They all have the
same basic design, but are available in a variety of diameters and
lengths (Figure 11-7). Smaller diameter (thinner) laryngoscope
handles may be better suited for use with the smaller sized pedi-
atric laryngoscope blades. Shorter, “stubby” laryngoscope handles
may offer an advantage when proceeding with intubation of obese
or barrel-chested patients, especially in cases where the neck can-
not be manipulated. The shorter handle will not catch on the
chest wall during attempts to place the laryngoscope blade in the
patient’s mouth.
The laryngoscope blade may have a removable bulb attached
to its distal third. A fiberoptic bundle within the blade transfers
power from the handle to the bulb. Other laryngoscope blades FIGURE 11-9. The Miller laryngoscope blades.
only contain fiberoptic bundles which transmit light, with the

light source located within the handle. The choice of the type and
size of laryngoscope blade will vary with physician experience and
preference. The best blade is one that the intubator feels com-
fortable and confident using. The curved Macintosh blade is
most commonly used (Figure 11-8). It is the easier blade to use
for those with little experience with orotracheal intubation. Many
feel that it requires less forearm strength to use as compared to
the straight blade. The large flange allows for easier control of the
tongue and the flat curved shape of the spatula fits the natural
curve of the tongue. The straight Miller blade is often reserved for
those experienced with the blade and with orotracheal intubation
(Figure 11-9).
The tip of the curved Macintosh blade fits into the vallec-
ula and indirectly lifts the epiglottis to expose the vocal cords
(Figure 11-10). A size 2 blade is used for 3 to 6 year olds. A size
3 blade is used for children starting at about age 6, for women, and
for small to average-size males. A size 4 blade is usually reserved for
large males.
The tip of the straight Miller blade goes directly under the
epiglottis to lift it and the tongue to expose the vocal cords
(Figure 11-11). Use the straight blade, if possible and the intuba-
tor is familiar with its use, to intubate patients under 2 years of age.
A straight blade makes controlling the epiglottis and tongue easier FIGURE 11-11. Use of the Miller blade. It is inserted below the epiglottis to elevate
than with a curved blade. It also makes visualization of the vocal the mandible, tongue, and epiglottis as a unit.
cords easier due to its smaller flange profile. A size 0 blade is used
for premature babies and neonates up to approximately 1 month of
age. A size 1 blade is used for children from approximately 1 month
of age to toddlers up to 2 years of age. A size 2 blade is used for chil- the handle insertion block, at the level of the patient’s upper incisor
dren 3 to 6 years of age. Children between 6 and 12 years of age may teeth. The tip of the blade should be located within 1 cm proximal
require either a size 2 or 3 blade depending on their body size. A or distal to the angle of the patient’s mandible. Correct blade size
size 3 blade is used for adolescents, women, and average-size males. allows for approximately 90% of first attempt intubations to be suc-
A size 4 blade is rarely used, and then primarily for large males. cessful versus 57% if the blade is too small.20
If one cannot remember the proper blade size, it can be determined There are a wide variety of laryngoscope blades commercially
based on patient anatomy.20 Place the base of the blade, excluding available. They tend to be variations of the curved Macintosh or
Straight Miller blades. The McCoy blade is a curved blade with a
hinged tip. The tip can be flexed by depressing a lever on the laryngo-
scope handle. This flexion augments indirect elevation of the epiglottis
by stretching the hypoepiglottic ligament. The Flexiblade (Arco-
Medic Ltd., Omer, Israel) laryngoscope also has a levering blade. The
extra lift provided by these blades may improve visualization of the
vocal cords.8,9 The Propper Flip-Tip laryngoscope blade (Propper
Manufacturing Co., Long Island, NY) has a lever that elevates its
tip up to 90° to lift the epiglottis. Other variations of the Macintosh
blade include the incorporation of a variety of prism or mirror sys-
tems. These modifications allow for indirect visualization of oth-
erwise obscured vocal cords. The Belscope (International Medical
Inc., Burnsville, MN), Truvue EVO2 (Truphatek International Ltd,
Netanya, Israel), Lee-Fiberview (Anesthesia Medical Specialties,
Beaumont, CA), and Viewmax (Rusch, Duluth, GA) blades are
examples of these types of modifications.8,10,11
There have also been many variations of the straight laryngoscope
blade. Today, the Miller is the most popular straight blade. Other
variants include the Phillips and Henderson blades. These modify
components such as the cross section, the blade channel width, tip
style, and light source placement. These modifications represent
efforts to avoid such problems as dental trauma, laceration of the
ET tube cuff, improve tongue displacement, minimize tip trauma,
and obscuration of the light source by secretions.
In addition to traditional metal laryngoscope blades, plastic sin-
gle-use blades are also available. These single-use plastic blades were
developed, in part, to concerns regarding possible transmission of
FIGURE 11-10. Use of the Macintosh blade. It is inserted into the vallecula to infectious agents by incompletely sterilized metallic blades. A study
elevate the mandible, tongue, and epiglottis as a unit. comparing plastic versus metallic Macintosh laryngoscope blades
in 1177 patients found that metallic blades had higher first attempt PREPARATION
intubation rates, fewer cases of difficult intubation, and used alter-
native airway interventions less often than when intubation was PHYSICIAN
attempted with a plastic blade.12 Plastic blades cause less dental
trauma when used on dental models.16 The rates of dental trauma in Once the decision to intubate has been made, the Emergency
patients when compared to metal blades are not known. The use of Physician must use their training and experience to begin leading
single-use disposable plastic blades cannot be recommended at this the team toward a successful intubation. Although the process
time unless circumstances do not allow proper cleaning of metallic must move quickly, the Emergency Physician must, by example,
laryngoscope blades. ensure a calm and orderly environment. Making the decision to
intubate earlier allows the team to follow a shorter and easier time
STYLETS line. The Emergency Physician must visualize this time line and
identify actions and potential problems before they occur. A backup
The stylet is a semirigid piece of metal that is bendable (Fig- plan should also be available in case orotracheal intubation is
ure 11-12). It is often plastic coated. It inserts into the lumen of the impossible. Any Emergency Department patient about to be intu-
ET tube. It should be lubricated with a water-soluble lubricant or an bated is a high priority, so do not be afraid to use resources liberally.
anesthetic jelly prior to insertion into the ET tube. The tip of the Obtain assistants to help as soon as the decision to intubate is made.
stylet should be 1 cm proximal to the tip of the ET tube to pre-
vent injury to the patient’s airway. The ET tube, with a stylet, can PERSONNEL
be bent to maintain a specific shape. The stylet is used to facilitate
passage of the ET tube through the vocal cords. It is commonly bent Shortly before the procedure begins, assemble the entire team near
into a “hockey stick” or “J” shape for most intubations. A greater the bed and go over “the game plan” calmly and quickly. All per-
curvature is often used for intubations when the larynx is “anterior,” sonnel involved with the procedure should be gloved, gowned, and
in difficult intubations, and in “blind” intubations. masked. Eye protection should be worn by all personnel to pro-
A modification of the traditional stylet is the Parker Flex-It ™ tect against splash injury from blood and secretions. Explicitly
Directional Stylet (Parker Medical, Highlands Ranch, CO). This is identify assistants and assign their roles early. Give instructions
a plastic articulating stylet that requires no prebending. The stylet clearly and calmly before the procedure begins. It is helpful to write
has a built-in gentle curve. It has a button on its proximal end that down medications and doses in the order that they will be given
extends from the ET tube. When pushed with the thumb, it allows and to review them quickly with the medication nurse. Emphasize
the curvature of the ET tube to be continuously adjusted during that it will be the nurse’s job to draw up, label, and administer the
intubation attempts. medications, followed by a saline flush. Reinforce that during the
procedure this will be a particular nurse’s only job. The respiratory
assistant has three important tasks: helping to ventilate the patient,
applying cricoid pressure, and handing the ET tube to the intuba-
tor so that visual contact with the vocal cords is not lost. If cervical
spine immobilization is needed, a third assistant should be explic-
itly instructed as to how and when the team leader would like the
patient’s neck secured.
EQUIPMENT
The mnemonic “SOAPME” can be used to help review the
equipment required for intubation: Suction, Oxygen, Airway,
Pharmacology, Monitoring, Equipment.13 Check that the room is
ready and all equipment is within arm’s reach. Turn on the suction
and the oxygen. Confirm that both systems work. Attach the suction
tip and check to see whether there is a small finger hole in the barrel
that must be covered for the suction to work. If so, close it with a
piece of tape so that the suction is “always on.” This is not a concern
if a Yankauer suction catheter is being used. Ensure that the suction
tubing is long enough to reach the center of the bed. Place the suc-
tion catheter under the mattress to the right of the patient’s head and
within easy reach. Place the spare suction tip nearby. Set the oxygen
flow regulator to 15 L/min. Apply a nonbreather mask to the oxygen
and the patient. Place the bag-valve device near the head of the bed
and within easy reach. Confirm that the noninvasive blood pressure
cuff, cardiac monitor, and pulse oximeter are working and attached
to the patient. Confirm that the end-tidal CO2 monitor is nearby
and working. If such a monitor is unavailable, a disposable in-line
monitoring device should be available. Ensure that the patient has at
least one working intravenous line.
Assemble the intubation equipment. Place the proper size laryn-
goscope blade on the handle. Open the blade and confirm that the
FIGURE 11-12. The intubating stylet. It may be bent into any required shape. light works. Close the blade into the ready position, flat against the
When inserted into an ET tube, it will form the ET tube into the desire shape. The handle, to keep the bulb cool and not drain the batteries. Take the ET
most common shapes are the “J” and the “hockey stick.” tube and the backup smaller one and prepare them. Insert the 10 mL
syringe into the inflation port of the pilot balloon for the ET tube needed, the assistant should stand at the intubator’s left hip, ready to
cuff. Inject enough air to inflate the balloon. If there is no leak, deflate remove the collar and hold the neck in position.
the balloon until it is completely flat against the ET tube. Leave the Grasp the laryngoscope with the left hand. It is a left-handed
syringe attached. Liberally lubricate the stylet with a water-solu- instrument regardless of the handedness of the intubator. Pull
ble lubricant. Insert the stylet into the ET tube until its tip is 1 cm it open and lock the blade onto the handle. Confirm that the
proximal to the distal tip of the ET tube. Place a bend in the stylet light is functioning. The tip of the laryngoscope blade should be
as it enters the proximal end of the ET tube to keep the stylet from pointed toward the patient’s chin. Pass the prepared ET tube and
advancing. Bend the stylet/ET tube assembly into a curve roughly suction catheter to the respiratory assistant, who will place them
approximating a “hockey stick” or “J” (Figure 11-12). Lubricate the into your right hand when asked. This allows the intubator to
tip of the ET tube and the collapsed cuff. This prevents the ET tube maintain constant visual contact with the patient’s airway during
from getting caught on the epiglottis and making its advancement the procedure.
through the vocal cords difficult. Place the assembly back into the Induction of anesthesia is the final preparation for orotracheal
ET tube package. Place the ET tubes, laryngoscope, backup laryn- intubation. The choice of drug sequence is based on the physi-
goscope handle and blades, oral airways, and tape on a tray within cian’s experience and the patient’s condition (Table 11-2). A typical
easy reach of the bed. Check the room lighting. Raise the bed to sequence begins with a defasciculating dose of a nondepolarizing
minimize excessive bending and better visualize the patient’s airway. neuromuscular blocking drug. After 2 to 3 minutes, induce anesthe-
sia with a sedative followed immediately by a paralytic agent (i.e.,
PATIENT PREPARATION succinylcholine). Apply cricoid pressure. Once the patient’s muscles
are relaxed, perform the intubation as described below. Please refer
If the patient is competent and awake, explain the procedure, clarify to Chapters 8 and 10 regarding the complete details of the pharma-
advance directives, and obtain consent. If time permits, a history cology of the induction agents and rapid sequence induction. Some
is especially helpful. The mnemonic AMPLE can help to provide patients, especially the old and sick, may stop breathing earlier
quick information: allergies, medications, past medical history, last than anticipated. Be prepared to intubate before the expected
meal, and events leading to the current problem. time of drug onset.
Confirm again that the appropriate monitoring sources are Observe the patient’s chest. Watch it rise. When it stops, note the
working and attached to the patient. Confirm adequate intrave- time. Place your right thumb on the patient’s jaw. Gently pull down
nous access. Place the patient, with a normal neck, in the “sniff- the lower lip and open the mouth. Reinspect the oral cavity. Remove
ing” position, with the head extended at the atlantooccipital joint any dentures or foreign bodies. Compare what you see with what
while the neck is relatively flexed. A folded towel under the occiput you expect to see. Fix any problems as you go further into the air-
helps to gently raise and tilt the head back into the proper position way. If blood or vomit is seen, ask for the suction catheter. Apply the
(Figures 7-1, 11-1, & 11-13). Correct positioning is probably the suction catheter without removing your gaze from the patient’s
most important preparation of the patient. Dentures should be left airway. When done suctioning, hold the suction catheter up for the
in place temporarily, as they help to stabilize the mouth and prevent assistant to take.
occlusion during preoxygenation and bag-valve-mask ventilation.
To intubate the obese patient, place them into the head-elevated INTUBATING WITH THE (CURVED)
position using a ramp or pile of sheets under their head and shoul- MACINTOSH BLADE
ders (Figure 7-2). This position facilitates spontaneous ventilation,
mask ventilation, and laryngoscopy.22–24 It also prolongs the patients Firmly grasp the laryngoscope in the left hand (Figure 11-13A).
oxygen saturation during and after rapid sequence induction. Insert the tip of the Macintosh laryngoscope blade into the right
If the patient is breathing spontaneously, begin preoxygenation for side of the patient’s mouth. Smoothly advance the blade inward
5 minutes before the procedure (if time permits). Use a well-fitting while keeping slight upward pressure against the tongue. Use the
nonrebreather mask with the oxygen flow regulator set at 15 L/min. blade to trap and push the tongue to the left as the blade is simul-
This displaces nitrogen from the lungs and gives the patient a taneously moved to the midline, “clearing a path” for your gaze.
physiologic reservoir of oxygen for approximately 5 minutes while Keep the left wrist firm. Use the forearm, wrist, and hand as a
apneic. Remember: 5 minutes of preoxygenation provides 5 min- single unit and avoid bending or flexing the wrist. It is essential
utes of protection.5 If bag-valve-mask ventilation is required, have to move the patient’s tongue up and to the left. The tongue will
an assistant apply posteriorly directed cricoid pressure to minimize protect the mandibular teeth from being injured by the laryngo-
gastric distention and decrease the chance of vomiting and aspira- scope blade. It allows the laryngoscope blade to be moved away
tion. Have assistants ready to turn the patient onto his or her left from the maxillary teeth. It also opens a path to visualize the
side to minimize the risk of aspiration if vomiting occurs. Monitor patient’s airway.
the pulse oximeter to assure good oxygenation and ventilation. It When the blade has been inserted all the way, lift the patient’s air-
should rise to the high 90s and remain there. If not, check the O2 way up and forward exactly along the long axis of the laryngoscope
circuit from the wall to the patient and confirm that spontaneous handle, which should be aimed toward a point directly above the
breathing is still occurring. patient’s chin (Figures 11-10, 11-11, & 11-13B). Do not “cock” or
“crank back” on the laryngoscope handle with your wrist, or the
back of the laryngoscope blade may break the patient’s incisors.
TECHNIQUE
The epiglottis should be seen at the base of the tongue.
The evaluation and preparation for orotracheal intubation are A variable amount of force is required to lift the mandible,
complex and essential. If done well, the intubation will hopefully tongue, and soft tissues to visualize the vocal cords. More force is
be quick and anticlimactic. Position the respiratory assistant to the required to visualize the vocal cords in patients who have a large
right side near the patient’s head. The intubator should stand at tongue, are obese, have redundant pharyngeal soft tissue, or have
the head of the bed. Adjust the bed to place the mattress level with trismus. Grasp the laryngoscope handle as close to its base as pos-
the intubator’s umbilicus. Pull the bed away from the wall at least sible in these patients. The lower grasp provides more control of the
2 feet and clear a “maneuvering space” of tubes, lines, and equip- laryngoscope and a mechanical advantage to apply more force with-
ment to prevent distractions. If in-line cervical immobilization is out dental trauma.
FIGURE 11-13. Orotracheal intubation with the Macintosh blade. The patient is in the “sniffing” position. A. Proper positioning of the laryngoscope blade above the
patient’s mouth. B. The blade is inserted into the vallecula. The handle is lifted anteriorly and inferiorly to elevate the mandible, tongue, and epiglottis (arrow). The glottis
will be visible. C. The ET tube is inserted into the trachea until the cuff is below the vocal cords. D. The laryngoscope has been removed and the cuff inflated. E. The ET
tube is secured.
TABLE 11-2 Rapid Sequence Induction Medications for Specific Patient Profiles
Patient type Premedication* Induction and paralysis†
“Normal adult” Vecuronium (0.01 mg/kg) Etomidate (0.3 mg/kg) or propofol (1–2.5 mg/kg) or
thiopental (3 mg/kg) and succinylcholine (2 mg/kg)
“Normal child” Vecuronium (0.01 mg/kg) and atropine (0.02 mg/kg, min dose 0.1 mg) Thiopental (5 mg/kg) and succinylcholine (2 mg/kg)
Asthma, adult Lidocaine (1.5 mg/kg) and atropine (0.5 mg) Ketamine (1–2 mg/kg) and succinylcholine (2 mg/kg)
Asthma, child Lidocaine (1.5 mg/kg) and atropine (0.02 mg, min 0.1 mg) Ketamine (1–2 mg/kg) and succinylcholine (2 mg/kg)
Head injury, adult Vecuronium (0.01 mg/kg) and lidocaine (1.5 mg/kg) and fentanyl (3–5 µg/kg) Etomidate (0.3 mg/kg) and succinylcholine (2 mg/kg)
Head injury, child Vecuronium (0.01 mg/kg) and atropine (0.02 mg/kg, min 0.1 mg) Thiopental (5 mg/kg) and succinylcholine (2 mg/kg)
and lidocaine (1.5 mg/kg) and fentanyl (3–5 µg/kg)
Head injury, adult, Vecuronium (0.01 mg/kg) and fentanyl (3 µg/kg) and Etomidate (0.2 mg/kg) and
hypotensive lidocaine (1.5 mg/kg) succinylcholine (1.5 mg/kg)
Head injury, child, Vecuronium (0.01 mg/kg) and atropine (0.02 mg/kg, min 0.1 mg) Midazolam (0.15 mg/kg) or etomidate (0.3 mg/kg)
hypotensive and lidocaine (1.5 mg/kg) and fentanyl (2–3 µg/kg) and succinylcholine (2 mg/kg)
Hyperkalemia or renal None Etomidate (0.3 mg/kg) or propofol (1.0–2.5 mg/kg) or
failure, adult thiopental (3 mg/kg) and rocuronium (0.6 mg/kg) or
vecuronium (0.01 mg/kg)
Hyperkalemia or renal None Thiopental (5 mg/kg) and rocuronium (0.6 mg/kg) or
failure, child vecuronium (0.01 mg/kg)
Status epilepticus, adult None Thiopental (3 mg/kg) and succinylcholine (2 mg/kg)
Status epilepticus, child None Thiopental (5 mg/kg) and succinylcholine (2 mg/kg)
Pregnancy Atropine (0.5 mg) Ketamine (1–2 mg/kg) and rocuronium (0.6 mg/kg) or
vecuronium (0.01 mg/kg)
* Given 3 minutes before intubating (T = 3).
†
Given simultaneously at the beginning of intubation (T = 0) and wait for 45 to 60 seconds for onset of paralysis.
Advance the tip of the laryngoscope blade into the vallecula— The fit of the ET tube through the vocal cords always seems to
the space between the base of the tongue and the body of the be tight, even in larger patients. A well-lubricated tip with the cuff
epiglottis (Figures 11-10 & 11-13B). Lift the laryngoscope handle completely collapsed is essential. Rolling the tube gently between
to raise the tongue, jaw, and epiglottis as a unit (Figure 11-10). the thumb and the index finger at the moment of insertion can
Observe carefully as the epiglottis pivots upward and uncovers the also help pilot the tip between the vocal cords. If the ET tube is too
glottis (Figure 11-5). The vocal cords should be visualized. Cricoid large or the vocal cord opening narrow, ask the assistant to pass the
pressure (Sellick’s maneuver) may make intubation more difficult. smaller ET tube, which has already been prepared.
If the cricoid pressure is adversely impacting the view, it should be The average depth of insertion (in cm) of the ET tube starting
relaxed or even removed.14 The application of cricoid pressure by an from the patient’s lips is listed in Table 11-1. It can also be calculated
assistant pressing the cricoid cartilage back, upward, rightward, and using one of the following formulas: ET tube ID (in mm) × 3, (age
posteriorly (in this sequence) can help bring the vocal cords into in years/2) + 12 for patients over 2 years of age to a maximum of
view when the intubator cannot apply more lifting force due to lack 18 years of age, or age + 10 for children less than 8 years of age.
of strength or reluctance to lift the airway, as in a suspected neck Once the ET tube has been inserted, the intubator’s right
injury. This is known as the BURP maneuver.27 hand must hold the tube in place continuously until it is prop-
Another anterior neck manipulation maneuver known as optimal erly secured. The assistant should inflate the ET tube cuff with the
external laryngeal manipulation (OELM) or bimanual laryngos- attached 10 mL syringe of air (Figure 11-13D) and then remove the
copy may be applied.28 They differ from the BURP maneuver in that syringe and stylet. The intubator must hold the ET tube firmly
the intubator uses their right hand to manipulate the larynx into the to make sure that it does not become dislodged when the stylet
optimal position while simultaneously viewing the patient’s airway is removed. The assistant should attach the end-tidal CO2 monitor
and controlling the laryngoscope with their left hand. An assistant and the bag-valve device to the ET tube. If symmetrical lung sounds
then assumes control of the larynx, maintaining the same position are heard on auscultation and if pulse oximetry and CO2 monitor-
as the intubator proceeds to insert the ET tube. Alternatively, to limit ing appear appropriate, secure the ET tube in position in the right
laryngeal movement during the hand-off, the intubator can use their corner of the patient’s mouth (Figure 11-13E).
right hand to manipulate an assistant’s hand on the patient’s larynx.
When properly positioned, instruct the assistant to keep their hand
INTUBATING WITH THE (STRAIGHT) MILLER BLADE
still while the intubator removes their hand off the assistant’s hand.
A third variation uses the assistant to manipulate the patient’s larynx Intubating with the straight blade is similar to the curved blade with
while the intubator verbally directs them. a few differences. Insert the laryngoscope blade completely. If the
When the vocal cords are visualized, instruct the assistant to pass epiglottis is seen, insert the tip directly under and slightly beyond
the ET tube into your right hand. This allows you to keep a “visual it. Lift the epiglottis and airway as above by raising your hand along
lock” on the vocal cords. Insert the ET tube into the right side of the long axis of the laryngoscope handle toward a point above the
the patient’s mouth. Advance the ET tube so that the tip reaches patient’s chin (Figure 11-11). If neither the epiglottis nor the vocal
the vocal cords without letting the body of the tube block the view. cords are seen, the tip of the laryngoscope blade is in the esopha-
Continue to advance the ET tube through the vocal cords until the gus. Locate the airway by lifting as above while slowly withdraw-
cuff passes through them and into the trachea (Figure 11-13C). ing the laryngoscope blade. As the tip slides back, it will “catch” the
Advance the tube an additional 2 to 3 cm. The tip and cuff of the epiglottis and the airway should “fall down” into view. The BURP or
ET tube must be visualized passing through the vocal cords to OELM maneuver may now be applied if necessary. Some physicians
assure placement in the trachea. use a variation of this to localize the epiglottis by inserting the blade
deeply and lifting, then withdrawing while feeling for the “give” as 30 seconds elapse or pulse oximetry falls to 92%, stop the intubation
the epiglottis tip falls off of the retreating blade, and then readvanc- attempt and ventilate the patient for 30 to 60 seconds, as above. In
ing a small distance to “scoop up” the epiglottis, exposing the airway. training programs, the third attempt should be made by the most
The remainder of the technique is the same as described above. skilled person available. Three failed attempts define a “failed air-
way” and call for rescue intubation by an alternative method. Any
ASSESSMENT patient in whom bag-valve-mask ventilation becomes impossible
must be given a surgical airway.
In the Emergency Department, simple common-sense methods will
quickly and accurately assess ET tube placement. The confirmation
of ET intubation is briefly described in this section. Please refer to AFTERCARE
Chapter 12 for a more detailed discussion. The assessment must The ET tube must be secured to prevent it from migrating distally
be made quickly! An ET tube in the wrong place, the esophagus, or proximally. The traditional method of wrapping tape around the
is as quickly dangerous as a properly placed one is lifesaving. Was ET tube then around the patient’s head is rarely used today. If used
the ET tube visualized passing through the “A frame” of the vocal properly, tape functions just as well or better than commercially
cords? This is the most important assessment. If it was directly available ET tube holders.19 A variety of disposable, relatively inex-
visualized being placed and continuously held in place, it is properly pensive, and single patient use ET tube holders are commercially
positioned. Is the pulse oximeter reading in the high 90s and steady available. They are easy to apply, adjust, and reposition if necessary.
or rising? Is the CO2 monitoring appropriate? Be familiar with the The basic unit is a nonlatex plastic ET tube holder that positions
monitor in your institution. Electronic monitors will show a respi- over the patient’s mouth, a cushioned neckband, and Velcro closures
ratory waveform and a numerical value. In-line colorimetric moni- for a snug fit. There are many variations of this basic unit.
tors connected between the ET tube and the respiratory circuit will A nasogastric tube or orogastric tube is often placed after orotra-
change color with inspiration and expiration to indicate the flow of cheal intubation to remove air, fluid, and gastric juices from the
CO2 passed the device. stomach. This tube must also be secured. It is either taped to the
Evaluate the patient. Symmetrical upper chest rise without patient’s face or to the ET tube to prevent it from migrating distally
increasing abdominal size suggests proper placement. Persistent or proximally. One specific ET tube holder is a novel device that
“fogging” or condensation inside the ET tube with each breath
for at least six ventilations will also confirm proper placement.
™
deserves mention. The Intubix (Intubix LLC, Houston, TX) is an
ET tube holder with a built-in bite guard and orogastric tube side
Auscultate lateral to the nipples for strong and symmetrical breath port (Figure 11-14). It allows the blind passage of the orogastric
sounds during positive-pressure breaths. Avoid auscultating in the tube through the side port as well as securing it in position.
midline, where “normal” breath sounds can be heard from a mis- Postintubation management should include pain control, seda-
placed ET tube in the esophagus. Auscultate at the lateral apices tion, and paralysis if indicated. The patient should be sedated, and
and bases of the lungs. Auscultate over the epigastrium. Correct possibly paralyzed depending on the situation, so they do not fight
placement will give strong, symmetrical breath sounds except in the ET tube and extubate themselves. The patient should never be
the epigastrium. If epigastric sounds are strongest or “gurgling” or paralyzed and not sedated so they are aware and but unable to
vocalization is heard, assume incorrect ET tube placement. Breath respond. This is considered cruel. Administer an opioid analgesic
sounds that are asymmetrical and stronger on the right indicate a as required for pain control. The patient may require repeated bolus
right mainstem intubation. Deflate the cuff and gently withdraw the dosing of these medications or a continuous infusion for analgesia,
ET tube in 1 cm increments while auscultating. Continue to with- sedation, and/or paralysis depending on their condition.
draw the ET tube until equal breath sounds are heard. Secure the
tube and reinflate the cuff.
Obtain a chest radiograph after clinically confirming the place-
COMPLICATIONS
ment of the ET tube. The tip of the radiopaque stripe of the ET tube
should be over the third or fourth thoracic vertebra and 3 to 4 cm HYPOXEMIA AND MISPLACED ET TUBES
above the carina of the trachea. Always inspect the radiograph for Hypoxia is the most destructive complication. It often results
any signs of a pneumomediastinum, pneumothorax, or hemothorax. from prolonged intubation attempts, with or without proper pre-
Clinical assessment of the ET tubes position should take less oxygenation, and unrecognized misplaced ET tubes. Without ade-
than 15 seconds. If you are unsure of the ET tube position, leave quate oxygenation, irreversible brain injury begins to occur within
the first tube in place while applying cricoid pressure. If the patient’s 2 to 3 minutes. Hypoxia can result in cardiac arrhythmias.
pulse oximetry reading is in the mid- to high 90s, reinsert the laryn- An unrecognized esophageal intubation will result in signifi-
goscope and look to see if the ET tube is passing between the vocal cant morbidity and mortality. After intubation, the proper ET tube
cords. Alternatively, the ET tube can be removed and intubation reat- placement should be confirmed by auscultation, chest rise, fogging
tempted. If the pulse oximetry is low, remove the ET tube and ven- in the ET tube, end-tidal CO2 monitoring, and chest radiography.
tilate the patient with a bag-valve-mask device for 30 to 60 seconds Any manipulation or movement of the ET tube or the patient’s
to allow the pulse oximetry to rise into the high 90s before making upper body (head, neck, and torso) should be followed by an
a second attempt at intubation. Do not ventilate the patient by a assessment of the ET tube position. It can easily become dis-
bag-valve-mask without the application of cricoid pressure. The lodged and migrate into the hypopharynx and esophagus. Other
stomach can inflate with air and increase the risk of aspiration. methods to confirm ET tube placement include inserting a fiberop-
Some physicians prefer to leave the misplaced ET tube in place. tic bronchoscope through the ET tube and visualizing the tracheal
Leaving the first tube might seem to complicate subsequent intu- rings and carina (Chapter 21) or inserting a lighted stylet and fol-
bation attempts but can serve to vent gastric vomit out of the oro- lowing the illumination into the trachea (Chapter 17).
pharynx as well as to locate the esophageal entrance during the next
attempt at direct visualization of the airway.
CARDIOVASCULAR COMPLICATIONS
As long as ventilation is possible with the bag-valve-mask device
and pulse oximetry can be maintained above 92% (PO2 = 60 mmHg), Bradycardia can be produced by pharyngeal manipulation. It may
two or three attempts can be made at orotracheal intubation. If be especially pronounced in children because of their higher vagal
A B
FIGURE 11-14. The Intubix ET tube holder. A. The unit. B. The unit with an ET tube and an orogastric tube attached.
tone. Pretreatment with atropine (0.02 mg/kg with a minimum dose using more rigid and less pliable stylets, pushing through a weak-
of 0.15 mg) in children under 6 years of age can avoid this. It will ness or defect, or from multiple intubation attempts. The complica-
also serve to decrease airway secretions. tions associated with cuff overinflation can be prevented by using
Increased intracranial pressure can occur as a result of the direct manometry, which is seldom used.
laryngoscopy. The exact cause of this transient rise is unknown.
Lidocaine has been postulated as being of benefit in blunting this but AIR LEAKS
is so far unproven. A dose of 1.5 to 2.0 mg/kg IV may be used as a pre-
medication if time allows and the patient’s condition warrants its use. A “leak” of air out from the patient’s mouth or nose during ventila-
tion signifies a mechanical problem with the ET tube. If the cuff is
MECHANICAL COMPLICATIONS damaged, the ET tube must be removed and replaced. Check the
position of the ET tube by direct laryngoscopy. If the cuff is located
Direct mechanical complications from the laryngoscope include lac- between or above the vocal cords, it will not secure the airway prop-
erations of the lips, trauma to the pharyngeal wall, broken teeth, or erly. Deflate the cuff, advance it through the vocal cords, and rein-
dentures that may be aspirated and require later removal. Vomiting flate the cuff. If the cuff slowly deflates, there may be a leak in the
can cause subsequent chemical and bacterial pneumonitis. A pneu- pilot balloon. Reinflate the cuff and apply a hemostat to the tubing
mothorax is a rarely seen complication of laryngoscopy. It is more attached to the pilot balloon or attach a closed stopcock to the infla-
often associated with positive-pressure ventilation. Laryngoscopy tion port.
may cause apnea, bronchospasm, and/or laryngospasm due to pro-
longed stimulation of the pharynx.
Laryngospasm may result from insertion of the laryngoscope
ASPIRATION
blade or attempts to advance the ET tube through the vocal cords. The risk of aspiration increases in patients with difficult airways or
This occurs more often in patients who are awake, semiconscious, full stomachs. This includes obese and pregnant patients. The use
not paralyzed, and not anesthetized. It may be prevented by the of an awake ET intubation or rapid sequence induction with cricoid
application of nebulized lidocaine, topical anesthetic spray, trans- pressure may minimize the risk of aspiration. A properly placed ET
tracheal injection of lidocaine, or laryngeal nerve blocks. If laryn- tube with the cuff inflated will decrease, but not totally eliminate,
gospasm occurs during intubation, remove the laryngoscope and the risk of aspiration.
begin positive-pressure ventilation. Positive-pressure ventilation
will often overcome the laryngospasm. If not, consider paralyz-
THE UTILITY OF THE SELLICK MANEUVER
ing the patient immediately with succinylcholine or performing
a surgical airway. The use of cricoid pressure was introduced in 1774 in its use to
The ET tube and stylet can be a source of mechanical complica- prevent gastric distention during artificial ventilation of drowning
tions.15,17,18 A sore throat is a common and self-resolving nuisance. victims.29 Sellick reintroduced the application of cricoid pressure
Uvular necrosis occurs when it is compressed between the ET tube in 1961.30 Cricoid pressure theoretically causes an occlusion of the
and palate. This rare complication is self-limited and often heals upper esophagus by trapping it between the cricoid cartilage and
within 2 weeks. Treatment includes antihistamines, steroids, and the vertebral bodies. It has since been used on a daily basis for rapid
possibly antibiotics. The stylet protruding from the distal end of the sequence induction by Anesthesiologists and Emergency Physicians.
ET tube can cause soft tissue contusions and lacerations, perfora- This maneuver was thought to prevent regurgitation and gastric
tion of the vocal cords, hemorrhage into the airway, and perfora- insufflation during positive-pressure ventilation. The application of
tion of the trachea. Proper stylet placement with its tip within the cricoid pressure was later termed the “Sellick maneuver.”
ET tube will prevent these complications. ET tube cuff overinflation Sellick’s original publications were small observational studies
can result in mucosal sluffing, pressure necrosis, and hemorrhage. self-reporting on his technique. These studies were not blinded,
Tracheal rupture is a rare but life-threatening complication.17,18 It controlled, or randomized. Several subsequent studies determined
may be due to cuff overinflation, a protruding stylet, intubation the amount of force required to occlude the esophagus on cadavers
and patients. It is not practical or possible to measure the cricoid Rapid patient assessment is important to prevent complications. If
force applied during clinical care in the Emergency Department. orotracheal intubation is unsuccessful, another form of intubation
Multiple studies have found adverse effects associated with the or a surgical airway should be performed.
Sellick maneuver.28,31–35 It can worsen the laryngoscopic view of
the airway. Other complications include bruising, airway obstruc-
tion, cricoid cartilage fracture, goiter hemorrhage, subconjunctival
hemorrhage, and esophageal rupture. Cricoid pressure decreases
Confirmation of
12
lower esophageal sphincter tone and may explain in part the cases
of pulmonary aspiration prior to intubation.
Although the Sellick maneuver is considered a “standard of
Endotracheal Intubation
care,” very little evidence supports its use to prevent aspiration.33–35 Tarlan Hedayati and Leonardo Rodriguez
This does not mean that the Sellick maneuver should not be per-
formed! It may be of benefit to prevent aspiration, especially in the INTRODUCTION
Emergency Department where patients often have “full stomachs.”
If intubation or ventilation is difficult using the Sellick maneuver, This chapter will review the various methods utilized to confirm
slowly release cricoid pressure in an attempt to improve ventilation appropriate endotracheal (ET) intubation. Direct visualization
or airway visualization. of the ET tube passing through the vocal cords is the preferred
method for the initial assessment of a properly placed airway.
ENDOTRACHEAL CUFF PRESSURE Unfortunately, this is not always feasible. Rates for incorrect ET tube
placement have been noted to be up to 25%.1,2 The verification of
Inflation of the ET tube cuff is required to adequately ventilate a correct ET tube placement is as or more important than the intu-
patient without an air leak, provide positive-pressure ventilation, bation procedure. Lack of proper confirmation of ET tube place-
and prevent aspiration. There can be a fine line between proper cuff ment has the potential for serious patient harm and catastrophic
inflation and overinflation. One of the goals of any procedure is to outcomes if unrecognized and uncorrected.
prevent complications from the procedure itself. Overinflation of For approximately 20 years, there has been ongoing research
the ET tube cuff can result in mucosal necrosis, mucosal slough- and development to improve upon the basic techniques of physical
ing, hemorrhage, tracheal rupture, or subsequent tracheal stenosis. examination confirmation of ET intubation. Physical examination
Physicians have traditionally palpated the pilot balloon to estimate with auscultation has been found to be inadequately sensitive (94%)
cuff pressure and prevent any complications from overinflation. and specific (83%) as an independent method for confirmation of
This method is not accurate.36,37 correct ET tube placement.3 This chapter discusses the use of physi-
Measurement of the cuff pressure is a simple, quick, and inexpen- cal exam findings, esophageal detection devices (syringe and bulb),
sive procedure. It should be considered whenever a patient is intu- carbon dioxide (CO2) detection devices (a qualitative detector and a
bated.38 Cuff pressure should be measured if a patient is transported continuous quantitative monitor), and imaging techniques (radiog-
by air as the cuff pressure changes at elevated altitudes.39,40 A pressure raphy and ultrasound). Each method is described for a patient with
of up to 20 cmH2O provides an adequate seal, without compromis- normal anatomy and the absence of any pathology (e.g., neck or
ing mucosal blood flow and lowers the risk of subsequent subglottic chest trauma). While all these methods can be used in all patients,
stenosis. Tracheal mucosal blood flow shows a decline at 30 cmH2O, certain patient conditions or pathology may affect the accuracy of
and is completely blocked at 45 cmH2O. An ET tube cuff pressure some methods. No single method is universally or completely
manometer is needed to measure these pressures accurately. reliable, obviating the need for a multiple method approach.
There are numerous methods to quickly assess cuff pressure. This multiple method approach to confirmation of ET intubation
Palpation is not accurate and should not be used. The simplest is now the accepted practice according to The American College of
method is to use a manometer. These devices (Cufflator, Posey Emergency Physicians (ACEP) Board of Directors policy statement
Corp., Pasadena, CA or Rusch Endotest, Teleflex Medical, Research as of April 2009.4
Triangle Park, NC) allow the simultaneous inflation of the cuff while
monitoring the cuff pressure on a dial. These devices function simi- PHYSICAL EXAMINATION
larly to those used to inflate a car tire. While simple to use, they can
be cumbersome due to their shape and weight. An in-line device Since the advent of ET intubation, the use of physical examination
that attaches to the cuff inflation port is available (PressureEasy methods has been the mainstay for the initial evaluation of proper
Cuff Pressure Controller, Smiths-Medical, Dublin, OH). The device ET tube placement. Direct visualization of the insertion of the ET
has an indicator window that signals when the cuff pressure is tube through the vocal cords and into the trachea is the first method
maintained between 20 and 30 cmH2O. A third novel device is the to confirm proper ET tube placement. Postintubation direct visual-
Pressure Alert Endotracheal Tube (www.jamesdysonaward.org/proj- ization of the ET tube using laryngoscopy or bronchoscopy, noting
ects/project.aspx?ID=598). This device is not yet commercially avail- tracheal rings past the end of the ET tube, is the next best method of
able. It incorporates a “pop-up” button into the pilot balloon that assessing correct ET tube placement.
alerts the user when the cuff pressure is too high. Secondary methods for confirmation of ET intubation are
an absolute requirement. Auscultate the chest and abdomen to
assess for delivery of air to the lungs via either a bag-valve device
SUMMARY
or a mechanical ventilator (Figure 12-1). First, auscultate over the
Orotracheal intubation is both common and lifesaving. It is the epigastrium to assess for the absence of sounds in the stomach.
primary and preferred method of airway management. Every The presence of an enlarging abdomen or audible air inflation into
Emergency Physician must master this skill. With proper prepara- the stomach with each positive-pressure ventilation may be the ini-
tion, definitive control of the airway can be obtained. This assures tial sign of an ET tube in the esophagus or an esophageal intubation.
that patients can be oxygenated and ventilated when they cannot do The next auscultation points are located at the chest wall lateral to
this on their own. Good team leadership skills are nearly as impor- the nipples. Auscultate bilaterally from top to bottom for the pres-
tant as physical dexterity and assure an orderly and quick procedure. ence and equality of breath sounds. Avoid auscultating over the
CHAPTER 12: Confirmation of Endotracheal Intubation 77
FIGURE 12-1. The order of auscultation after intubation to confirm ET tube place-
ment begins at the epigastrium1 listening for the absence of air sounds, then down FIGURE 12-2. Examples of the bulb and the syringe esophageal detector device
both sides of the chest wall, just lateral to the nipple line.2–4 (Photo courtesy of Wolf Tory Medical, Salt Lake City, UT).
central portion of the chest. This may lead to the misinterpre- constant open passage for the flow of air. The tubular esophagus
tation of the transmission of esophageal or gastric inflation.5 with its lack of a luminal support structure collapses and prevents
These sounds may mimic airway breath sounds and lead to fail- movement of air when suction is applied.9 The two types of ET tube
ure in detecting an esophageal intubation. confirmation devices that rely on this anatomical variance are the
The final note pertaining to auscultation involves equality of syringe and the manometer or bulb methods (Figures 12-2 & 12-3).
breath sounds. The anatomy of the left and right mainstem bronchi The syringe method relies on a gradual and constant retraction
allow for a preferential right mainstem bronchial intubation when of the plunger, while its tip is attached to the proximal end of the
the ET tube is placed too deep. As a general rule, insertion in centi- ET tube utilizing a manufactured connector (Figure 12-3).10 The
meters to a depth three times the diameter size of the ET tube (e.g., plunger will draw back easily and without resistance if the ET tube
21 cm for a 7.0 mm size ET tube) at the level of the incisor teeth is is correctly placed in the trachea (Figure 12-3A). The volume of
preferred. This will generally place the ET tube approximately 3 to aspirated air should be greater than 30 mL over a period less than
4 cm above the carina in an adult.6 If breath sounds are stronger over 4 seconds.11 Resistance when drawing back the plunger is seen when
the right lung fields, deflate the ET tube cuff and gradually withdraw the distal end of the ET tube is incorrectly placed in the esopha-
the ET tube in 1 cm increments until the bilateral breath sounds are gus (Figure 12-3B). An airtight seal must be created between the
equal. This will prevent complications from inadequate ventilation syringe and the ET tube to prevent any air leak that would lead to
and oxygenation as well as resultant pulmonary edema in the non- a false-positive test and result in the assumption that the ET tube is
ventilated lung.7 Please refer to Chapter 11 for a more complete dis- in the trachea.
cussion of ET tube size, insertion depth, and placement for adults Similarly, the manometer or bulb method relies on the collapse
and children. of the esophageal wall. Compress the bulb to remove any air con-
The next assessment involves taking a step back and visualizing tained within. Firmly and securely apply the bulb to the proximal
the chest wall and ET tube characteristics with each breath. Unequal end of the ET tube while still compressing the bulb. Release com-
or a lack of chest rise and fall with each instilled breath may indicate pression on the bulb. If the bulb inflates fully and easily, the ET tube
a misplaced ET tube either in a mainstem bronchus or in the esoph- is presumably in the trachea. If the bulb does not inflate fully and
agus, respectively. Condensation and/or fogging in the ET tube with easily, the ET tube is presumably in the esophagus.
each breath has been used frequently in the past to confirm proper There are numerous circumstances with which an esophageal
ET tube placement. This has been proven to be an unreliable source detector device has repeatedly failed to identify an improperly
of confirmation.8 It should only be used in conjunction with auscul- placed ET tube.9–14 Most notably is after bag-valve-mask ventila-
tation and visualization of bilateral chest wall movement. The pres- tions in the absence of cricoid pressure. The stomach and esophagus
ence of vomit in the ET tube, in the absence of an aspiration event, can inflate with air and allow for easy flow of air into the device
may be a sign of an esophageal intubation. simulating airflow from the airway. The device may fail to detect a
The final postintubation physical assessment is an evaluation misplaced ET tube when the distal end of the ET tube is just above
of oxygenation via skin signs and, more reliably, pulse oximetry. the vocal cords. In this instance, there is no resistance to airflow and
Cyanosis and a downtrending oxygen saturation seen on a pulse the bulb or syringe device easily fills with air.
oximeter are delayed findings. The patient may experience signifi- This method has been shown to falsely identify an esophageal
cant hypoxemia before cyanosis appears or before there is a signifi- intubation when the ET tube is placed into a mainstem bronchus or
cant drop in the pulse oximetry. Do not rely upon cyanosis and the tip of the ET tube is pressed against the tracheal wall. The subse-
pulse oximetry as a first-line assessment to confirm proper ET quent resistance to back flow of air into the syringe or bulb mimics
tube placement. that of the collapsed wall of the esophagus. If this should occur, with-
draw the ET tube 1 cm and attempt using the esophageal detector
device again. Repositioning should continue to result in resistance
ESOPHAGEAL DETECTOR DEVICES
to aspiration or bulb inflation if the ET tube is in the esophagus.
Esophageal manometer devices utilize the structural differences The presence of heavy or thick pulmonary secretions or fluid in the
between the trachea and esophagus in determining correct ET tube lungs can plug the airways and reduce the flow of air to prevent air
placement. The semicircular tracheal cartilaginous rings provide a aspiration by the syringe or bulb inflation.12 Care must be taken so
FIGURE 12-3. Using the syringe esophageal detector device. A. Correct placement of the ET tube in the trachea allows for aspiration of air. B. Placement of the ET tube in
the esophagus will result in resistance to aspiration due to collapse of the esophageal wall.
as not to rapidly aspirate and potentially draw the tracheal mucosa similar fashion. They are in-line devices that have two connectors,
into and obstructing the ET tube yielding a false-negative result.11 one of which attaches to the proximal end of the ET tube and the
In the obese patient, the posterior noncartilaginous segment of the other attaches to the oxygen delivery device (bag-valve device or
tracheal has been shown to collapse into the trachea and prevent the mechanical ventilator tubing).
flow of air.13–16 The colorimetric end-tidal CO2 detector utilizes a piece of pH-
When taking into account the limitations of esophageal detec- sensitive material that lies beneath a clear plastic window. The
tion devices and their use as an adjunct to other methods, they can presence of CO2 flowing through the device, typically using six
provide a rapid and inexpensive method for confirming ET tube manual breaths as the maximum number needed and the mini-
placement.17–19 This is especially evident in the patient with circula- mum amount to clear any gastric CO2, causes a color change from
tory collapse, hypotension, cardiac arrest, or a pulmonary embolism purple to yellow that then changes back to purple in the absence of
where other devices are limited.18 CO2 (Figure 12-4). The minimum concentration of end-tidal CO2
required for a color change is 0.5%. This is one reason that the recent
CARBON DIOXIDE DETECTORS literature has focused on whether newborns and children produce
AND CAPNOGRAPHY sufficient quantities of end-tidal CO2 for accurate detection.
Capnography, or continuous quantitative graphical demonstra-
Since 1985, the utility of end-tidal CO2 detection as a means for con- tion of end-tidal CO2 detection, involves placement of an infrared
firming proper ET intubation has been studied and recently con-
firmed to be the “most accurate” modality according to ACEP.20 The
premise of end-tidal CO2 detection devices requires the presence of
exhaled CO2 passing through and exiting the ET tube. Adequate cir-
culation is required for CO2 to be produced and transported from the
lung parenchyma. The accuracy of this modality relies on its use in
the noncirculatory collapsed/cardiac arrest patient. The April 2009
ACEP Board of Directors statement goes further to state that end-
tidal CO2 detection, using either qualitative or quantitative methods,
approaches 100% sensitivity and specificity in the patient with an
inflated cuffed ET tube and spontaneous circulation. Nearly every
case of a false-negative detection of a correct ET tube placement (i.e.,
correct ET tube placement in the absence of end-tidal CO2 detec-
tion) has been discovered in the cardiac arrest patient.15,16,21–25
End-tidal CO2 detection devices can be utilized either qualita- FIGURE 12-4. Colorimetric end-tidal CO2 detectors before (left) and after (right)
tively as a one-time spot check using a colorimetric detector or can exposure to exhaled CO2. Note the change in the color of the pH paper from
be monitored continuously via capnography. Both are utilized in a purple to yellow when exposed to CO2.
CHAPTER 12: Confirmation of Endotracheal Intubation 79
detector in-line between the end of the ET tube and the oxygen
delivery device (bag-valve device or ventilator tubing). The infrared
detector is then connected with a cable to the electronic monitor
that interprets the reading and generates a waveform representation
of the end-tidal CO2 levels. One of the advantages of this method
over the qualitative approach is the ongoing monitoring of CO2 pro-
duction. This allows a continuous assessment of the airway as well
as the overall quality of resuscitative efforts with some determina-
tion of outcome.3
The main disadvantage CO2 detectors for confirmation of ET
A
intubation are false-negative results in poor perfusion states, car-
diopulmonary arrests, and the presence of secretions on the device.
In the noncardiac arrest patient with adequate cardiac output and
pulmonary flow, sensitivities approach 100% (76% in cardiac arrest)
for ruling out esophageal intubation have been found in patients of
all ages.26–28
If the distal end of the ET tube is located just above the vocal
cords in the hypopharynx, a false-positive result may lead the physi-
cian to believe the airway is secure. The device may detect adequate
levels of CO2 without a properly secured and definitive airway in
the trachea. False-positive results from an improperly placed ET
tube erroneously believed to be in the trachea may occur when the
device is used a short time after the patient has consumed a carbon-
ated beverage. The device cannot recognize that the CO2 is actually
coming from the stomach.
The universal presence of capnography is not yet a reality. Its util-
ity in most circumstances with few exceptions is undeniable. The
colorimetric end-tidal CO2 detector is equally reliable to capnogra-
phy. It is a disposable, rapid, less expensive, and more widely avail-
able means to assess proper ET tube placement in the noncardiac B
arrest patient.20
FIGURE 12-5. Ultrasound images at the level of the sternal notch to confirm proper
RADIOGRAPHY ET tube placement. A. Endotracheal intubation. The signature double echo of the
Although there may be a lack of availability of capnography in plastic ET tube can be seen in the airway or trachea. (C, carotid artery; IJ, internal
most Emergency Departments, this is far less an issue with either jugular vein; T, thyroid gland). B. Esophageal intubation. The ET tube (arrow) is in
radiography or ultrasonography.29 These methods, unlike those the esophagus. It is positioned deep and lateral to the airway (Ultrasound images
mentioned previously, are unique in that they rely on anatomic courtesy of Sam Hsu, MD).
relationships for confirmation of ET tube placement. Radiography
and ultrasonography may be particularly useful in the cardiac
arrest patient. The first method uses a high frequency linear US transducer.
The main utility for radiography in the confirmation of ET intu- Place the US probe horizontally at the level of the suprasternal notch.
bation lies in its ability to detect whether the ET tube is placed A properly placed ET tube in the trachea will show the shadowing of
too deeply into the trachea. Locating the end of the ET tube the ET tube posteriorly without direct visualization of the esopha-
approximately 3 to 4 cm above the carina may prevent some of gus (Figure 12-5A). In the event of an esophageal intubation, the
the complications associated with a right mainstem intubation. trachea appears similarly to the previously described image but the
The postintubation chest radiograph can assist in identifying any esophagus will be visualized just to the left of the trachea with pos-
complications that may have resulted during the intubation. This terior shadowing due to the presence of the ET tube (Figure 12-5B).
includes aspiration, tracheal injury, a pneumomediastinum, or a A small, prospective, randomized, controlled study found 100%
pneumothorax. The postintubation chest radiograph does little to sensitivity and 100% specificity in the accuracy of US as a modality
distinguish between esophageal versus tracheal intubation. The to confirm ET tube placement.30
delay in obtaining a radiograph to confirm ET tube placement The second technique uses similar methodology over the cri-
puts the patient at significant risk. cothyroid membrane. Place the US transducer longitudinally over
the cricothyroid membrane to identify and the hyperechoic ante-
rior and posterior laryngeal walls are identified. The appearance of
ULTRASONOGRAPHY a “snowstorm” pattern between the two lines indicates correct ET
The use of ultrasound (US) in the Emergency Department has tube placement.31
gained significant popularity in the diagnosis of various diseases Foreign bodies are often hyperechoic and appear bright white on
and pathology. There are multiple methods for utilizing US guid- US. One study looked at using US to confirm ET tube placement
ance to assess for proper ET tube placement. Two common methods both with and without a stylet within the ET tube.34 The basic idea
of confirming proper ET tube placement are described below. The being the addition of the stylet would increase the sensitivity and
benefits of these two methods are that ventilation is not required for specificity of identifying correct ET tube placement. It would add
ET tube placement confirmation and, in the case of an accidental additional hyperechoic shadows to those of the ET tube. The use of
esophageal intubation, there is no risk of inflating the stomach, or a stylet did not improve the US localization of the ET tube within
its resultant emesis and aspiration of gastric contents. the trachea.
development of improved methods obviates the critical impor-

tance of rapid and accurate confirmation of ET intubation.
Video-Assisted Orotracheal
13 Intubation Devices
Pholaphat Charles Inboriboon
INTRODUCTION
Direct laryngoscopy was introduced in 1895 by Afred Kirstein. Since
that time, physicians have developed instruments to improve visu-
alization of the larynx while limiting tissue trauma. The Macintosh
and Miller laryngoscope blades were developed in the 1940s and
have been the primary tool for endotracheal (ET) intubation.1
FIGURE 12-6. Ultrasound through the chest wall demonstrating the bright inter- Although they have been effectively used for most ET intubations,
face (solid arrows) of the visceral and parietal pleura generating the “sliding lung there are limitations to their ability to allow direct visualization of
sign” during ventilation. The dashed arrows demonstrate echogenic bands moving the glottis and surrounding structures. Numerous adjuncts have
side-to-side with ventilations. The asterisks (*) identify the ribs (Ultrasound image since been developed to assist in ET intubation.1
courtesy of Sam Hsu, MD). The recent development of video laryngoscopy marks a new era
in airway management. Traditional direct laryngoscopy requires
alignment of the oral, pharyngeal, and laryngeal axes to visualize
Ultrasonography of the chest wall has been studied as a method the glottis (Figure 6-5). Despite mechanical manipulation, it is not
of confirming ET tube placement.32 This method does require ven- always possible to align these three axes. The major advantage of
tilation of the patient in that it utilizes the visceral–parietal pleu- video laryngoscopy is that it does not require the Emergency
ral interface of the lungs to confirm inflation of the lung. Apply Physician to align the three airway axes, reducing the need for
the US probe to the anterior-superior chest wall. Orient the US manipulation and potential traumatic forces on the airway.2
probe vertically over the second and third ribs in the midclavicular Through the use of a video camera, video laryngoscopes provide
line. The visceral and parietal pleural interface can be seen and a superior view of the glottis when compared to traditional direct
appreciated as the so-called “sliding lung sign” (Figure 12-6). The laryngoscopy. The eye of the video laryngoscope camera is within
hyperechoic interface will be seen moving back and forth with centimeters of the glottis and provides a wider angle of vision
each respiration.32 than the 15° of traditional direct laryngoscopy. The video moni-
tor magnifies the view of the airway making structures easier to
TRACHEAL TUBE INTRODUCERS visualize. This chapter reviews a representative number and types
of devices currently available and used in Emergency Departments.
The tracheal tube introducer (TTI) or gum elastic bougie has long
been used by Anesthesiologists to intubate in difficult conditions. PENTAX AIRWAY SCOPE
The TTI is a flexible rod-like device whose distal end is slightly
angled. It is inserted through the patient’s vocal cords with the The Pentax Airway Scope (Pentax Medical CO., Montvale, NJ), also
angled tip facing anteriorly during direct laryngoscopy. It is then known as the Pentax AWS or the AWS, is a rigid video laryngoscope
advanced into the trachea. Advancement of the TTI causes the tip to (Figure 13-1). It incorporates the blade, camera, and an ET tube
slide along the anterior tracheal cartilage rings. A “click” is palpable targeting mechanism into one device. It is designed for use in the
as the tip crosses each tracheal ring. Eventually, the TTI will stop prehospital setting, Emergency Department, and operating room.3,4
or “hang-up” as it passes into smaller bronchi. The ET tube is then
advanced over the TTI and into the lung. INDICATIONS AND CONTRAINDICATIONS
Intubate the patient using direct laryngoscopy. To verify proper The AWS can be used for elective and emergent intubations. Patients
positioning of the ET tube, insert the lubricated TTI into the ET with their head and neck immobilized can benefit from intuba-
tube with the angled tip facing anteriorly. Advance the TTI through tion with this device. It provides better visualization of the glottis,
the ET tube. The tip should catch on each tracheal ring and “click” decreased cervical movement, and a higher success rate in compari-
to verify proper ET tube position. The lack of any “clicks” or “hang- son to traditional direct laryngoscopy.5,6 Intubation with the AWS
up” suggests an esophageal intubation. Like all other methods of produces less airway stimulation than either the Glidescope or tra-
confirming ET intubation, this method is not 100% perfect.33 ditional laryngoscopes, thus minimizing the hemodynamic changes
associated with intubation.6,7 There are no contraindications to the
SUMMARY use of the AWS.
Insertion of an ET tube always requires verification that it is prop-
erly placed. No one tool or technique is sufficient for any or all
EQUIPMENT
situations or circumstances. The best method to confirm proper The AWS incorporates an imaging system and a targeting sys-
ET tube placement involves utilizing multiple methods, keeping tem into one portable tool. It is ergonomically designed to mini-
limitations in mind, and ongoing repeat assessments. Any change mize tissue trauma. Its use does not require the alignment of the
in a patient’s clinical condition requires reverification that the three airway axes. The imaging system provides an illuminated 90°
ET tube is still properly positioned. The ongoing research and field of view.3 The AWS produces better glottic visualization than
CHAPTER 13: Video-Assisted Orotracheal Intubation Devices 81
Attach the PBLADE to the AWS. Loosen the lock ring on the
scope by rotating it in a leftward direction. Align the triangular
marks on the PBLADE and on the AWS body to ensure proper
positioning prior to connection. Insert the flexible fiberoptic tube
through the scope insertion port on the PBLADE. Realign the tri-
angular marks. Keep the connector ring pressed in the direction of
the scope body and push in the connector of the PBLADE. Release
the connector ring. Confirm that the PBLADE is firmly attached
and that the tip of the AWS comes into close contact with the scope
window. Secure the connection by turning the lock ring in the right-
ward direction.
Load the ET tube. Liberally lubricate the ET tube with a water-
soluble lubricant. Insert the ET tube by sliding it along the ET
tube-guide groove. Fix the ET tube onto the hooks located on the
proximal end of the PBLADE. Adjust the ET tube so that the tip
is aligned with the inferior edge of the PBLADE tip (Figure 13-1).
Apply medical grade antifogging to the outside of the PBLADE’s
scope window.
TECHNIQUE
Gently insert the PBLADE into the patient’s mouth similar to a
traditional laryngoscope blade. Insert it along the right side of the
mouth. Gently and slowly advance the PBLADE. Always visually
observe the blade as it is inserted to prevent damage to the patient’s
lips, teeth, and other soft tissues during insertion. Do not put pres-
sure on the teeth and make sure that the tongue is not pushed
inward while inserting the PBLADE. Once inserted, reposition the
FIGURE 13-1. The Pentax AWS (Photo courtesy of Pentax Medical Co., Montvale, NJ). device to the midline.
Observe the monitor to visualize the airway and epiglottis.
Secretions can be suctioned by introducing a 12 French suction
traditional direct laryngoscopy.32 The external shell is composed of catheter through the suction catheter insertion port. Perform suc-
a water-resistant plastic making it suitable for use in the prehospital tioning while observing the location of the suction catheter tip on
setting and the Emergency Department. the monitor. Visualize the epiglottis. Slide the epiglottis lifting blade
The body is an integrated 12 cm long cable attached to a charge- underneath the epiglottis. Gently elevate the device to elevate the
coupled device camera and a 2.4 in full-color LCD monitor epiglottis. Gently manipulate the device until the glottis is aligned
(Figure 13-1). The monitor is hinged and allows a 0° to 120° angle with the target symbol on the monitor screen. Gently advance the
for optimal viewing. The monitor screen incorporates a target sym- ET tube through the glottis until the ET tube marker line reaches the
bol used to facilitate intubation. External monitoring and recording glottis. Inflate the ET tube cuff. Detach the ET tube from the hooks.
can be utilized with the external output. The device is battery oper- Gently remove the PBLADE from the patient’s mouth while securely
ated utilizing two AA alkaline batteries for 1 hour of continuous holding the ET tube in place. Confirm proper ET tube position.
operation.
The PBLADE is a plastic, single-use, disposable, and trans- ALTERNATIVE TECHNIQUES
parent laryngoscope blade that attaches to the body of the AWS
(Figure 13-1). It is designed to follow the natural curvature of the In rare circumstances, the Emergency Physician cannot be posi-
upper airway and minimize the need for manipulation of the three tioned above the patient’s head. An inferior or lateral approach
airway axes. The PBLADE is composed of Lexan plastic that resists can be utilized. Insert the PBLADE as described above. Adjust the
fogging, but not to the extent of the Glidescope antifogging mecha- position of the screen using the hinge to obtain an optimal view-
nism.8 The fiberoptic cable and camera rest inside the cavity of the ing angle. Once the epiglottis is visualized, the remainder of the
PBLADE. An ET tube is loaded into a track located on the right side technique is exactly as described previously. It may feel awkward to
of the PBLADE. It accommodates a size 6.0 to 8.5 ET tube. Through manipulate the device and the ET tube from a position inferior or
the use of this guided track, intubation is performed without the use adjacent to the patient’s head.
of a stylet. Suctioning can be performed under direct visualization Insertion of the fully assembled AWS may not be possible in
with a 4.0 mm (12 Fr) or smaller suction catheter inserted through obese patients and others with large chests.9 Separate the PBLADE
the PBLADE’s suction port. loaded with the ET tube from the AWS. Insert the PBLADE into the
oropharynx under direct visualization. Gently and carefully reattach
PREPARATION the AWS to the PBLADE. Be careful not to traumatize the patient’s
lips, teeth, or airway soft tissues. Once the device is reassembled,
Prepare and check the AWS before each use. Turn on the device. proceed with intubation as described above.
The video image and target symbol should appear on the moni- This technique can be used for patients in which deep seda-
tor. The power lamp below the monitor should illuminate. tion and induction are contraindicated. An off-label technique for
Immediately replace the batteries if the monitor displays a flicker- awake intubation has been described.10 Assemble the device. Attach
ing battery image. Check the light source. Place a hand below the a Bodai connector to the proximal end of the ET tube. Insert a
tip of scope to ensure that it is illuminating. Do not look directly 14 French suction catheter into the lumen of the ET tube via the
at the light source. Bodai connector. Attach the breathing circuit to the other branch of
FIGURE 13-2. The McGrath Laryngoscope. A. The

device. B. The blade has been inserted and the ET
tube is advanced through the vocal cords (Photos A B
courtesy of LMA North America, San Diego, CA).
the Y-connector to administer oxygen at a rate of 10 L/min. Insert laryngoscopy technique. It is the most portable video laryngoscope
a tracheal spray tube, smaller than 12 French, through the origi- and modeled after the traditional Macintosh laryngoscope blade
nal suction channel. Attach a syringe loaded with topical anesthetic (Figure 13-2A). It is a refinement of the “smart scope” laryngoscope
solution to the proximal end of the tracheal spray tube. Suctioning developed by Matt McGrath. As a British university student, he won
can be performed through the ET tube as the PBLADE is advanced. the 1999 Royal Society of Arts student design competition for out-
The topical anesthetic agent can be delivered via the spray tube. standing design achievement for his portable laryngoscope with a
Once the glottis is visualized, the local anesthetic solution can be small video monitor attached to the handle.8
delivered to and through the vocal cords prior to advancing the ET
tube through the glottic opening. INDICATIONS AND CONTRAINDICATIONS
COMPLICATIONS The McGrath laryngoscope is indicated for elective and emergent
intubations. It is useful in difficult intubations in which the three
Placement of the AWS may not be possible in patients with limited airway axes may be difficult to align.2,12–14 This includes patients
mouth opening.4 The diameter of the PBLADE is approximately with cervical spine immobilization, limited mouth openings, tongue
2.5 cm. An alternative airway device should be readily available if edema, and high Cormack and Lehane grade airways. It is indicated
paralysis does not improve mouth opening. Visualization of the for use in pediatric patients weighing 15 kg or more.15 The McGrath
vocal cords can be limited by secretions.11 A suction catheter should laryngoscope is not indicated for use in awake intubations.16
always be readily available. Insert the PBLADE slowly to prevent it
from being inserted into pooled secretions. Visualization may not EQUIPMENT
be possible despite aggressive suctioning in the case of particulate
matter or severe bleeding. If this occurs, be prepared to use an alter- The McGrath laryngoscope consists of three main components: the
native airway device. Incorrect or forceful insertion can result in handle module, the camera stick, and the blade (Figure 13-2A).
dental trauma and soft tissue injuries. The other complications asso- The handle module houses the power source and the video monitor.
ciated with this device are similar to those of direct laryngoscopy. The nonslip rubberized handle contains a single AA battery and the
Since the ET tube is loaded onto the PBLADE, its maneuverability power switch. At the crown of the handle module rests the 1.7 in
is limited. Employ a bougie in cases where visualization of the glottis color LCD monitor. The monitor can rotate around the handle
is possible but intubation is not successful. Align the PBLADE and 360° and can be tilted to adjust the viewing angle. The camera stick
ET tube as much as possible with the glottis. Pass a bougie through houses the camera and light source. Its length is adjustable to pro-
the ET tube. Advance and direct the bougie through the vocal cords. duce a blade length ranging from a Macintosh size 3 to 5 blade. The
Slowly and gently advance the ET tube over the bougie under video disposable single-use plastic blade fits over the distal camera stick to
guidance.11 protect the camera and to assist in lifting of the epiglottis.
Despite a quicker time to visualization and insertion of the ET
tube, the time from initiation of intubation to ventilation is not sig- PREPARATION
nificantly different from traditional direct laryngoscopy.8 It is specu-
lated that this is due to the increased time it takes to remove the Preparing the McGrath laryngoscope for use is quite simple.
ET tube from the AWS postintubation. The time to ventilation can Unscrew the cap on the top of the handle and insert the AA bat-
be reduced by beginning manual ventilation before removal of the tery. The top of the handle is opened by turning it counterclockwise
PBLADE from the oropharynx. This technique should be consid- and closed by turning it clockwise. Apply the camera stick onto the
ered in patients that are hypoxic postintubation.4 handle. Pull out the release safety catch at the base of the handle
and rotate it so that it is aligned parallel to the long axis of the cam-
era stick. Slide the camera stick into the base of the handle. Return
MCGRATH LARYNGOSCOPE
the safety catch to its original position. Firmly attach the disposable
The McGrath Laryngoscope (LMA North America, San Diego, CA) sterile laryngoscope blade to the camera stick. Slide it over the cam-
is a video laryngoscope that is designed to provide a clear video era stick until it firmly latches. Adjust the blade length by sliding
view of the glottis with minimal changes in the traditional direct the camera stick through the clamp handle. A click will be heard for
each adjustment in the blade size. Turn the power on by pressing the
power switch on the top of the handle. The LED light on the LCD
monitor will be continuously lit if there is adequate battery power. If
it blinks, the battery power is low and the battery should be changed
prior to using the device.
TECHNIQUE
The intubation technique using the McGrath laryngoscope is simi-
lar to that used in traditional direct laryngoscopy.16 Insert the tip of
the blade in the midline and superior to the tongue. Slowly advance
the blade and rotate its tip toward the larynx in the sagittal plane
until the epiglottis is visualized via direct visualization or via indi-
rect visualization using the camera monitor. Further advance the
blade until its tip rests in the vallecula. Gently lift the blade until
the glottis is visualized. Gently elevate the device to elevate the epi-
glottis. The monitor should show the vocal cords as well as the sur-
rounding structures (Figure 13-2B). If only a portion of the vocal
cords is visible, slightly withdraw the blade until the desired view
is obtained (Figure 13-2B). Gently manipulate the device until the
glottis is centered on the monitor screen. Insert and advance the
proper size ET tube through the vocal cords with the assistance of
either a malleable stylet or a bougie. The ET tube with a stylet should
ideally be hockey stick shaped 5 cm from the tip of the ET tube to
optimize maneuverability.12 Gently advance the ET tube through
the glottis until the ET tube marker line reaches the glottis. Inflate
the ET tube cuff. Withdraw the stylet or bougie. Gently remove the
blade from the patient’s mouth while securely holding the ET tube
in place. Confirm proper ET tube position.
ALTERNATIVE TECHNIQUE
FIGURE 13-3. The Berci–Kaplan DCI Video Laryngoscope (Photo courtesy of Karl
An alternative technique can be performed in those patients with Storz Endoscopy-America, El Segundo, CA).
limited mouth opening or chest anatomy that prevents placement of
the device into the oropharynx using the traditional laryngoscopic
technique.13 Disarticulate the camera stick from the handle to facili-
tate placement of the blade into the oropharynx. Insert the cam- BERCI–KAPLAN DCI VIDEO LARYNGOSCOPE
era stick and blade similar to introducing a tongue depressor into The Berci–Kaplan DCI video laryngoscope is a video Macintosh
the oral cavity. Attach the handle to the camera stick. Intubate the intubating laryngoscope developed by Drs. Kaplan, Ward, and Berci
patient as previously described. (Karl Storz Endoscopy-America, El Segundo, CA).17 It incorporates
micro video imaging technology into a traditional laryngoscope
COMPLICATIONS blade. This reduces the learning curve in operating this device for
If the epiglottis obstructs visualization of the glottic opening, apply those experienced with traditional direct laryngoscopy. It is ideal for
greater upward force to lift the epiglottis. If this is not success- use when training the novice in the traditional direct laryngoscopic
ful, the plastic blade may be used in the same manner as a miller technique.17,18 A fiberoptic bundle extends from the proximal end
blade. Redirect the blade to lift the epiglottis, visualize the glottis, of the laryngoscope blade allowing for a larger angle of viewing and
and intubate as previously described. Incorrect or forceful insertion a magnified view of the airway. This video laryngoscope has been
can result in dental trauma and soft tissue injuries. The other com- marketed for use as part of an “all-in-one” video intubation system
plications associated with this device are similar to those of direct (Figure 13-3).
laryngoscopy.
If the monitor image is unclear, check for fogging. Apply an anti- INDICATIONS AND CONTRAINDICATIONS
fog solution as needed.8 A blurred image can result from the blade The video laryngoscope is indicated for normal and difficult intuba-
not being latched onto the camera stick. The video lens should tions, in both pediatric and adult patients. The large video screen
be flush with the viewing window of the blade. If neither of these makes this device particularly useful for difficult intubations requir-
maneuvers is successful, remove the blade from the device and clean ing external manipulation of the airway by an assistant. There are no
the camera lens with a gentle soft wipe. contraindications to the use of the video laryngoscope.
A grade I view may be obtained of the glottis yet the ET tube can-
not be advanced into the trachea. This may be due to the acute bend EQUIPMENT
and long flange of the blade.30 The device provides a view of the
glottis without the alignment of the three airway axes. This requires The video laryngoscope device consists of various laryngoscope
the ET tube to have a more acute bend than normally used for direct blades, the DCI camera head, and the control unit. The video laryn-
laryngoscopy. Place an acute bend in the styletted ET tube approxi- goscope blade houses the camera optics. It is available in Macintosh
mately 7 to 10 cm from the tip. Another option is to advance the ET (sizes 3 and 4), Miller (sizes 0, 1, and 3), and the Doerges universal
tube into the glottis while simultaneously withdrawing the stylet, blade styles. The lens provides a viewing angle of 60° to 80°, depend-
thus not inserting the styletted ET tube into the glottis. ing on the type of laryngoscope blade. The laryngoscope blade is
integrated into the ergonomic handle (Figure 13-3). The handle

attaches to the camera head, the interface between the control unit
and the video laryngoscope. Other interchangeable airway devices
can be attached to the control unit including the Bonfil’s scope,
Brambrinck scope, and fiberoptic scope. The control unit incorpo-
rates the light source, an image processing module, imaging mem-
ory, power supply, a keyboard, and a color LCD monitor.
PREPARATION
Attach the selected laryngoscope blade to the camera head. Turn on
the control unit. The laryngoscope blades can be changed with the
control unit powered on. Apply medical grade antifogging solution
onto the camera lens.
TECHNIQUE
An advantage of this video laryngoscope is that the intubation
technique does not differ from that of traditional direct laryngos-
copy. The added benefit of indirect visualization is that less force
is needed to visualize the glottis. An assistant can view the monitor
to facilitate external manipulation of the larynx to bring the glottis A
into view. The ET tube can be passed through the glottic opening
under either direct or video-assisted visualization. Gently advance
the ET tube through the glottis until the ET tube marker line reaches
the glottis. Inflate the ET tube cuff. Withdraw the stylet or bougie.
Gently remove the blade from the patient’s mouth while securely
holding the ET tube in place. Confirm proper ET tube position.
A limitation of this video laryngoscope is its relatively large handle
with cables protruding from its proximal end. This can impede intu-
bation in patients with large chests, short necks, or cervical spine
immobilization.19 Insert and advance the laryngoscope blade into
the patient’s mouth from the side. Gently rotate and return the B
laryngoscope handle into the midline once the blade is deep enough
and the handle can clear the chest. Proceed with intubation as previ-
ously described.
COMPLICATIONS
A known issue with this video laryngoscope is lens fogging. This is
particularly problematic in patients that are not fully paralyzed. This
can be prevented by applying a medical grade antifogging solution,
a thin layer of water-soluble lubricant, or the patient’s saliva on the
lens.19 Blood and other secretions can obscure the view. This can be
reduced by not inserting the laryngoscope blade into pooled secre-
tions and by the use of suctioning.19 Incorrect or forceful insertion
can result in dental trauma and soft tissue injuries. The other com-
plications associated with this device are similar to those of direct
laryngoscopy.
Common barriers to purchasing this device are its cost and its
large size. The large size of the control unit limits its portability
unless it is placed on a rolling cart. Despite this, the control unit
can be used in conjunction with several other of the companies air-
way devices. This makes it a worthwhile investment in Emergency
Departments that utilize other compatible airway devices.19
C-MAC VIDEO LARYNGOSCOPE

The C-Mac (Karl Storz Endoscopy-America, El Segundo, CA) C
is a video laryngoscope system released in 2009 (Figure 13-4A).
It replaces the original video laryngoscope by Karl Storz. It has FIGURE 13-4. The C-Mac Video Laryngoscope. A. The C-Mac system. B. The
numerous advantages including being more compact and portable, C-Mac. C. The C-MAC PM (Photos courtesy of Karl Storz Endoscopy-America, El
the blade width is decreased, and the video technology has been Segundo, CA).
improved. The original video laryngoscope incorporated a fiberop- soft cloth or lens tissue if the video image is blurry. If this does not
tic camera and video system into a traditional laryngoscope blade. improve the image, clean the contacts of the electronic module.
The C-Mac abandons this technology for a CMOS micro video Recording can be performed by pressing the record button located
camera. This allows the video system to be incorporated within the on the laryngoscope blade handle.
laryngoscope blade. The CMOS micro video camera provides an
enhanced area of view and does not have the issue of fogging. TECHNIQUE
The intubation using the C-Mac is exactly the same as using tradi-
INDICATIONS AND CONTRAINDICATIONS tional direct laryngoscopy.20 Insert the laryngoscope blade into the
The C-Mac video laryngoscope is indicated for normal and difficult oral cavity under direct visualization. Advance it past the orophar-
intubations, in both pediatric and adult patients. There are no con- ynx and into the vallecula. Lift the laryngoscope handle upward
traindications to the use of the video laryngoscope. to improve visibility. Visualization can be performed by either
direct visualization or via the monitor. Gently advance the ET tube
EQUIPMENT through the glottis until the ET tube marker line reaches the glot-
tis. Inflate the ET tube cuff. Withdraw the stylet or bougie. Gently
The completely handheld portable C-Mac consists of three main remove the blade from the patient’s mouth while securely holding
components: the blade, the electronic module, and the monitor the ET tube in place. Confirm proper ET tube position.
(Figure 13-4B). The blade reproduces the curvature of the tradi-
tional Macintosh blade and is composed of stainless steel. The prox- COMPLICATIONS
imal end has been flattened to reduce the amount of mouth opening
required for intubation and to reduce the risk of oral trauma. The Incorrect or forceful insertion can result in dental trauma and soft
lens is located approximately one-third of the distance from the tissue injuries. The other complications associated with this device
tip of the blade and provides a 60° field of vision. The CMOS chip are similar to those of direct laryngoscopy.
housed in the blade provides lens antifogging and an optimal image
quality. The blade is available in several sizes. GLIDESCOPE
The electronic module is the interface between the laryngoscope
The Glidescope (Verathon Inc., Bothell, WA) combines a video
blade and the monitor unit. The module permits easy operator-con-
camera with a patented antifog system into a portable laryngoscope
trolled video documentation. Images can be recorded as still shots
blade and monitor system. The blade design modifies the traditional
or video sequences using the incorporated key pads.
Macintosh blade curvature to provide a more anterior view of the
The 7 in, high-resolution monitor is housed in an impact-
larynx. The Glidescope was developed by a Canadian surgeon.8
resistant and splash-protected plastic body. The top of the monitor
Modifications in the basic design have resulted in several models
has an integrated secure digital (SD) memory card and an USB port
(Figure 13-5). The Cobalt Glidescope utilizes a single-use dispos-
for video recording and transfer. The monitor automatically white
able blade for a rapid turnaround without sterilization between
balances when it is turned on. The monitor image can be further
uses.21 The Ranger Glidescope models provide a compact, high
modified using the touch key controls to the right of the monitor
impact device originally intended for military and prehospital use.22
screen. The monitor device also houses a lithium ion battery with a
2 hour operating time when fully charged.
Several new attachments make the C-Mac quite versatile (Fig- INDICATIONS AND CONTRAINDICATIONS
ure 13-4A). The C-Mac PM incorporates a 2.4 in LCD monitor that The Glidescope is indicated for routine and difficult intubations. It
inserts into the laryngoscope handle (Figure 13-4C). This elimi- is particularly useful for patients requiring cervical spine immobi-
nates the electronic module, cord, and base unit. The LCD moni- lization. It has been demonstrated to have a significant advantage
tor unit can be used with all the C-Mac laryngoscope blades. The over the Macintosh blade in the patient with tongue edema.23 It can
C-Cam is a camera head that attaches to the monitor unit. Through be used in pediatric patients that weigh as little as 1.8 kg. There are
this, numerous other airway devices can be attached including all no reported contraindications for using this device.
Storz airway devices, the Bonfil’s scope, and other fiberoptic scopes
(Figure 13-4A). EQUIPMENT
The primary components of the Glidescope are the blade and the
PREPARATION
video monitor. In the traditional Glidescope and the traditional
Preparing the C-Mac for use is quite simple.20 Insert the electronic Ranger Glidescope, all of the blade models incorporate an auto
module into the video laryngoscope blade receptacle. The blade can focusing CMOS camera, a LED light source, and a patented anti-
later be changed while the monitor is on. Insert the yellow connec- fogging mechanism housed inside of a medical grade plastic shell.
tion cord of the electronic module into the yellow socket on the back The Glidescope blade begins with the traditional Macintosh blade
of the monitor. If the battery symbol turns red, connect the power and adds a 60° curvature at the midpoint. This allows for a more
cord into the blue socket on the back of the monitor and plug in the anterior view of the airway with less lifting force required.8 The
power supply. The battery sign will indicate that the unit is charging. camera lens lies at the distal aspect of the blade’s curve to protect it
Insert an SD card into the monitor for recording and image capture. from secretions while providing a close-up view of the glottis. The
An alternative is to connect an external video recording source into Glidescope produces better glottic visualization than traditional
the USB port. direct laryngoscopy.31,33–35
Turn on the C-Mac using the power switch located at the left The traditional Glidescope blade is a reusable integrated blade
lower corner of the display monitor. Check the camera for proper and handle. It is available in four sizes. The traditional Ranger blade
functioning by focusing the lens under the laryngoscope blade on consists of a reusable integrated blade, a handle, and a video cable
your hand. The camera’s light source should be visible on the hand. that cradles into the body of the Glidescope monitor. It is currently
The light intensity, color saturation, and contrast can all be adjusted available in two sizes. The Ranger single-use blades are available in
using the key pads located on the monitor. Wipe the lens with a six sizes.
FIGURE 13-5. The Glidescope Video Laryngoscope. A. The Glidescope GVL sys-
tem. B. The Glidescope AVL system. C. The Glidescope Ranger system (Photos C
courtesy of Verathon Inc., Bothell, WA).
The Glidescope cobalt and Ranger single-use blade consists of a lithium ion battery. When fully charged, it can be used for 90 con-
video baton and a STAT blade. The video baton houses the CMOS tinuous minutes or approximately 20 intubations.22 Many of the
camera, LED light, and antifogging mechanism. The baton is inserted Glidescope models come with the GlideRite rigid stylet, though it
into a onetime use STAT blade constructed of medical grade plas- is not required for intubation. It is a rigid stylet designed to com-
tic. The STAT blade is shaped like the traditional Glidescope blade plement the angle of the Glidescope blades. Intubation with the
and provides the protective cover for the baton, reducing the risk GlideRite rigid stylet offers no advantages over the standard mal-
of transmitting an infection.23 This dramatically reduces Glidescope leable stylet.36
turnaround by eliminating the 30 minutes required to clean tradi-
tional blades prior to re-use.21,23 The baton is available in two sizes
PREPARATION
and four blade sizes.
The blades are connected to the video monitor through a video Preparing the Glidescope for use is quite simple. Attach the
cable. The traditional Glidescope and the Cobalt Glidescope have Glidescope blade to the monitor using the video cable. Turn on
a 7 in, nonglare, color LCD monitor. Housed within the monitor the device and it is ready for use. For the Cobalt and single-use
are the battery and the power source. The monitor includes the Ranger models, insert the baton into the STAT blade. A click will
power switch and control pads that allow adjustment of the video be heard to confirm that the blade has been securely attached. It is
image. The Ranger versions have a rugged shell for field use and a not required to use the GlideRite rigid stylet. It is recommended to
3.5 in color, nonglare LCD. The body of the monitor incorporates a curve the malleable stylet 90° to model the shape of the Glidescope
cradle for the blade. The Ranger Glidescope utilizes a rechargeable blade to facilitate manipulation of the ET tube.8,21,22,24–26
TECHNIQUE
The intubation technique using the Glidescope is similar to that of
traditional direct laryngoscopy.21,22 Insert the blade into the midline
of the oral cavity. Advance the blade under direct visualization until
its tip reaches the pharynx. Continue to advance the blade while
observing the monitor to identify the epiglottis. Advance the blade
into the vallecula. Lift the blade, if necessary, to elevate the epiglot-
tis. Under direct visualization, insert the ET tube until its tip nears
the tip of the laryngoscope blade. Guide the ET tube toward the
glottic opening. Pull the GlideRite stylet back approximately 2 cm
and advance the ET tube through the vocal cords. This will facilitate
passage of the ET tube through the vocal cords while reducing the
potential for injury. Gently advance the ET tube through the vocal
cords until the ET tube marker line reaches the glottis. Inflate the
ET tube cuff. Withdraw the stylet. Gently remove the blade from
the patient’s mouth while securely holding the ET tube in place.
Confirm proper ET tube position.
COMPLICATIONS
Use of a Glidescope for intubation can increase the time to advance
the ET tube through the vocal cords when compared to intubation
using direct laryngoscopy.6 This difference in time decreases with
increased use and familiarity with the device.27 It is strongly recom-
mended that novice operators use the Glidescopes on mannequin
models and for “routine” intubations prior to using it as a rescue
device for difficult intubations.
Intubation with the Glidescope can be difficult in patients with
small mouths or large tongues due to the limited area for both the
blade and ET tube. In these cases, it may be difficult to pass the ET
tube into the larynx. Do not blindly insert the ET tube as it may cause
injury to the oropharyngeal tissues.28 If space is a problem, insert the
Glidescope under direct visualization and then move it to the left.
The ET tube can then be inserted under direct visualization. The
view on the monitor of the larynx may appear deviated.28 Manipulate
the Glidescope to obtain an optimal view on the monitor. An addi-
tional technique is to shape the ET tube into a hockey stick or j-curve
to facilitate advancement and manipulation from the lateral aspect
of the mouth.6 Incorrect or forceful insertion can result in dental
trauma and soft tissue injuries. The other complications associated
with this device are similar to those of direct laryngoscopy.
CLARUS VIDEO SYSTEM

The Clarus video system (Clarus Medical LLC, Minneapolis, MN)
is a device that can be modified with various accessories for use as a
video laryngoscope, an ET tube exchange catheter, a flexible scope, FIGURE 13-6. The Clarus Video System (Photo courtesy of Clarus Medical LLC,
Minneapolis, MN).
and a malleable stylet.29 It incorporates the video, lighting, power,
and monitor system into one handheld product (Figure 13-6). The
malleable video stylet shaft and the disposable video laryngoscope
blade are designed for intubation.29 The optional flexible scope is viewing angle can be adjusted with an easy to reach thumb control.
detachable for use as an ET tube exchange catheter. The light intensity can be adjusted using controls on the handle. The
handle also contains the external video connector and the battery
INDICATIONS AND CONTRAINDICATIONS charger port. The distal lens, light LED, and camera are housed in
the distal tip of the video stylet shaft.
The Clarus Video System is intended for use in performing and con- A disposable tube stop fits on the malleable video stylet to hold
firming placement of an ET tube. It is indicated for use alone or as a the ET tube at the desired height on the stylet. An oxygen port
video stylet in conjunction with a standard laryngoscope. It can be can be connected to the tube stop to supply supplemental oxygen
used for routine and difficult intubations. There are no contraindi- through the ET tube. A detachable and flexible video scope is avail-
cations to using this device. able for use during ET tube exchange.
EQUIPMENT PREPARATION
The handle of the video system houses the rechargeable power unit. Preparing the Clarus video scope for use requires the device to
The color LCD display monitor attaches to the handle. The monitor be assembled. Place the disposable tube stop over the stylet shaft.
Attach the oxygen port to the matching circular receptacle on the Vision is significantly less expensive than most other video laryngo-
tube stop. Attach oxygen tubing to this port if desired. The oxygen scopes. The device uses newer organic light emitting diode (OLED)
flow rate and pressure must be monitored to prevent barotrauma.29 technology.
Apply an ET tube with a minimum diameter of 5.5 mm and a
maximum length of 34.3 cm over the distal tip of the stylet and INDICATIONS AND CONTRAINDICATIONS
fitted to the tube stop. Consider applying a water-soluble lubri-
cant onto the stylet to facilitate this process.29 Consider applying a The King Vision is indicated for routine and difficult intubations.
medical grade antifogging agent to the lens on the stylet tip. Adjust It can be used in both adolescent and adult populations. The laryn-
the tube stop so that the stylet tip rests just proximal to the distal goscope blade is equivalent to a Macintosh #3 size blade. There are
end of the ET tube in order to provide optimal visualization and no contraindications to using this device as long as a Macintosh #3
reduce the potential for tissue trauma. Tighten the clamp screw blade is appropriate for intubation.
on the tube stop to fix the position of the ET tube onto the stylet
shaft. The image on the monitor screen should automatically focus EQUIPMENT
when the device is turned on. The illumination can be adjusted The King Vision has a two-piece design consisting of the color
using the dial on the monitor. OLED monitor base unit that attaches to a disposable laryngoscope
blade (Figure 13-7). The two pieces snap together. The monitor
TECHNIQUE unit houses three AAA batteries as the power source, the on/off
Once the device has been properly assembled, it can be used for intu- switch, and a mini USB port for video output to a display monitor
bation with a traditional laryngoscope. Insert the laryngoscope and or recording device. The batteries provide at least 90 minutes of “on
attempt to visualize the vocal cords and other surrounding struc- time”. The OLED monitor offers increased contrast at a lower cost
tures. If visualized, insert the ET tube on the Clarus stylet similar to than LCDs and LEDs. In addition, the monitor is brighter, faster,
performing traditional direct laryngoscopy. Visualization of the air- lighter, thinner, and uses less power than LCDs.
way structures may not be possible in patients with difficult airways The blades are plastic, single use, and disposable. They are avail-
or those requiring cervical spine immobilization. Use the monitor able in two styles, with and without an ET tube channel. The chan-
on the Clarus Scope to direct, manipulate, and advance the styletted nelled blade accommodates a 6.0 through 8.0 ET tube. The blade is
ET tube through the glottis. Gently advance the ET tube through currently only available in a Macintosh #3 size. It differs from the
the glottis until the ET tube marker line reaches the glottis. Inflate standard Macintosh #3 blade in that it is slightly shorter and wider
the ET tube cuff. Withdraw the Clarus stylet. Gently remove the than the Macintosh #3 blade. The blade is smaller than most video
laryngoscope blade from the patient’s mouth while securely holding laryngoscopes. It requires a minimum mouth opening of 13 mm for
the ET tube in place. Confirm proper ET tube position. the standard blade and 18 mm for the channelled blade. A CMOS
camera and a LED light source are mounted on the disposable blade.
COMPLICATIONS The lens has an antifog coating.
Incorrect or forceful insertion can result in dental trauma and soft PREPARATION
tissue injuries. The other complications associated with this device
are similar to those of direct laryngoscopy. Preparation of the King Vision is quick and simple. Ensure that the
power is off. Applying a blade with the unit powered on will result
KING VISION VIDEO LARYNGOSCOPE in image distortion. Choose a laryngoscope blade either with or
without a channel. Slide the blade onto the monitor piece and snap
The King Vision Video Laryngoscope (King Systems Inc., Noblesville, it in place. The front and back of both the blades and the moni-
IN) is a battery operated, rigid, and portable digital video laryngo- tor unit are color coded to facilitate proper orientation. The blade
scope (Figure 13-7). It is simple to use and understand. The King with a channel can be used with or without an ET tube inserted
into the channel. If desired, load an appropriate size ET tube (size
6.0 through 8.0) without a stylet into the well-lubricated channelled
blade. Use only water-soluble lubricants. Avoid placing lubricant
over the lens. Align the distal tip of the ET tube with the end of
the channel. Turn on the device. Replace the batteries if the battery
indicator light is flashing red. Observe the monitor to ensure that
an image is present and clear. The image will be distorted if the unit
was powered on when the blade was attached. Simply turn the unit
off and then back on to obtain a clear image. The tip of the ET tube,
if using the channelled blade, should not be visible on the monitor.
If it is visible, pull the ET tube back until the tip is aligned with the
tip of the blade and no longer visible in the monitor.
TECHNIQUE
The technique for intubation is similar to traditional direct laryn-
goscopy if using the standard blade or the channelled blade without
loading an ET tube. Insert the blade in the midline and advance it
into the oropharynx. Continue to advance the blade toward the val-
lecula while observing the monitor. The blade can be placed into the
vallecula like a Macintosh blade or can be used to elevate the epiglot-
FIGURE 13-7. The King Vision Video Laryngoscope (Photo courtesy of King tis like a Miller blade. Use the monitor to direct, manipulate, and
Systems Inc., Noblesville, IN). advance the styletted ET tube through the glottis. Gently advance the
CHAPTER 14: Fiberoptic-Assisted Orotracheal Intubation Devices 89
ET tube through the glottis until the ET tube marker line reaches the laryngoscopy. The lens of these devices is within centimeters of the
glottis. Inflate the ET tube cuff. Withdraw the device. Gently remove glottis and provides a wider angle of vision than the 15° of tradi-
the laryngoscope blade from the patient’s mouth while securely tional direct laryngoscopy. The viewing port magnifies the view of
holding the ET tube in place. Confirm proper ET tube position. the airway making structures easier to visualize.
A slight technique modification is required if mounting an ET A generalized approach to using optical stylet-type devices
tube into the channelled blade. Insert the blade as described previ- will first be discussed, followed by the unique features of each
ously. Center the glottic opening on the screen. Slide and advance selected instrument. This chapter reviews a representative num-
the ET tube along the channel and through the vocal cords. Minor ber and types of devices currently available and used in Emergency
manipulation of the blade may be required to align and advance the Departments. The last two devices covered in the chapter, the
tip of the ET tube through the vocal cords. Airtraq and Bullard laryngoscope, function quite differently than
an optical stylet.
COMPLICATIONS
As with all video intubation devices, imaging can be compromised
INDICATIONS AND CONTRAINDICATIONS
by excessive secretions or blood in the oropharynx. Incorrect or Fiberoptic intubation devices can be used for adult and pediatric dif-
forceful insertion can result in dental trauma and soft tissue inju- ficult (actual or anticipated), elective, emergent, and routine intuba-
ries. The other complications associated with this device are similar tions. These devices can be used as “rescue devices” in cases of failed
to those of direct laryngoscopy. direct laryngoscopy. Patients with their head and neck immobilized,
limited mouth opening, morbid obesity, or those requiring awake
SUMMARY intubation or intubation while in a sitting position can benefit from
intubation with these devices. It provides better visualization of the
There is a growing array of video intubation devices available with glottis, decreased cervical movement, and higher success rates in
varied designs. This includes those that embed the camera into comparison to traditional direct laryngoscopy. These devices can be
the laryngoscope blade, those that embed the video camera into a used to aid in the localization and removal of airway foreign bodies.
scope or a stylet for use inside an ET tube, and those that utilize an There are no contraindications to the use of these devices.
ET delivery device. For the Emergency Physician, they represent a
simple method for routine intubation as well as promising rescue
devices for the difficult airway. These devices have varied learning USING FIBEROPTIC INTUBATION DEVICES
curves. Regardless of which device one uses, it is important to use There are some general guidelines to using fiberoptic intubation
these devices in both simulation and routine intubation prior to use devices that will improve the Emergency Physician’s success in their
as a rescue device. These devices are useful for training healthcare implementation. First, it is useful to understand the limitation of
personnel in the technique of orotracheal intubation in the pre- these devices. Fogging is a common problem. Fogging can be mini-
hospital and hospital setting. The use of a video laryngoscope to mized by applying a medical grade antifog solution to the lighted
intubate is much easier than using traditional direct laryngoscopy, end of the instrument or warming the distal tip by placing it in a
especially for novices. warm blanket or warmed saline solution. Any fluid (e.g., blood,
secretions, or vomitus) in the oropharynx will limit the usefulness
of these devices. First, suction any fluid and debris from the oro-
pharynx prior to device insertion. Second, care should be taken to
avoid touching any mucosal surface with the distal tip of the device.
Fiberoptic-Assisted Encountering the mucosa can cause “pink out” and promote fogging
14 Orotracheal Intubation of the device; both of which will impair visualization. Fiberoptic intu-
bation devices cannot be used to separate tissues, rather they should
Devices follow an open channel created either by a standard laryngoscope or
by manual distraction of the patient’s jaw.1 Lastly, small movements
Michael Lutes and Olga Pawelek are magnified by these devices. Proceed slowly and identify known
landmarks as the device is navigated from the mouth to the glottic
INTRODUCTION opening. Getting lost in a field of pink mucosa is best overcome by
slowly backing the device out until known landmarks are visualized
Recent years have seen a rapid expansion in optical devices used to and identified, and then slowly re-advancing the device along a path
aid in endotracheal intubation. All of these devices use fiberoptics of familiar anatomy.
that begin near the distal end and transmit an image to be viewed
at the proximal end. Many of these devices are variations on the
LEVITAN SCOPE
“optical stylet” concept. They consist of an eyepiece or other view-
ing mechanism attached to a stylet of varying degrees of flexibility. The Levitan Scope (Clarus Medical, Minneapolis, MN) was cre-
A standard endotracheal tube can be jacketed onto each device. The ated by Dr. Richard Levitan (Figure 14-1). He is an Emergency
stylet can then be used as an adjunct to standard endotracheal intu- Physician, a noted airway educator, and an innovator. The Levitan
bation or as a stand-alone device. Scope differs from other devices in this chapter in that it is shorter
Traditional direct laryngoscopy requires alignment of the oral, and requires the endotracheal tube to be cut to a length of approxi-
pharyngeal, and laryngeal axes to visualize the glottis. Despite mately 28 cm. While cutting the tube is an inconvenient step, doing
mechanical manipulation, it is not always possible to align these so makes the working length of the scope shorter and makes wield-
three axes. The major advantage of fiberoptic laryngoscopy devices ing the device easier. The scope is equipped with a side port that
is that they do not require the Emergency Physician to align the allows for oxygen insufflation. The distal end of the device is flex-
three airway axes, thus reducing the need for manipulation and ible, allowing it to be bent to the specific needs of the scenario. It
potential traumatic forces on the airway. Fiberoptic devices provide is powered by a detachable battery-operated light source or with a
a superior view of the glottis when compared to traditional direct standard green-line fiberoptic laryngoscope handle. It is relatively
Once the tip of the scope with the jacketed endotracheal tube has
been advanced through the vocal cords and into the trachea, remove
the laryngoscope. Advance the endotracheal tube by rotating it off
the stylet in a counterclockwise fashion. Rotating the endotracheal
tube while advancing it helps to prevent the beveled edge from
catching on the tracheal rings. Securely hold the endotracheal tube.
Remove the Levitan Scope and secure the endotracheal tube.
The Levitan Scope can also be used without a laryngoscope,
though it may require more practice to become adapt at this tech-
nique. Prepare the scope as described above, with the exception that
the distal 3 to 4 cm should be bent to approximately 70°. Grasp the
patient’s jaw and tongue in the left hand and lift to create an open
channel for the scope. Insert and advance the scope in the midline
while avoiding contact with the mucosal surfaces. Look through the
eyepiece and advance the device through the glottic opening.
FIGURE 14-1. The Levitan Scope (Photo courtesy of Clarus Medical, Minneapolis, VIDEO RIFL
MN).
The Video Rigid Intubating Fiberoptic Laryngoscope or Video RIFL
(AI Medical Devices Inc, Williamston, MI) is unique among the
optical stylets in that it has a flexible tip that can be manipulated
affordable compared to some other devices. Much of the intubation with a trigger at the handle-end of the device (Figure 14-2). There
strategy described for the Levitan Scope is generalizable to other were originally two models available, the Airway RIFL and the
optical stylets. The techniques and strategies are summarized from Video RIFL. The Video RIFL replaced the eyepiece of the Airway
a publication by the inventor.2 RIFL with a small LCD screen. The newer Nasal RIFL stylet attaches
to the device and allows nasal intubation. The high resolution LCD
PREPARATION
Prepare the scope for use. Liberally lubricate the scope with a water-
soluble lubricant. Do not get lubricant on the lens. Apply an endo-
tracheal tube (6.0 mm or larger) over the shaft. The tip of the scope
should be approximately 1 cm from the end of the endotracheal
tube. Connect the side port to oxygen tubing. Turn on the oxygen
source to provide a flow rate of 5 to 10 L/min. This flow rate allows
for oxygen insufflation and aids in keeping the lens clear. The man-
ufacturer recommends bending the distal tip to about 35° in the
straight-to-cuff fashion. Attach the light source, either a miniature
LED light source or a green-line fiberoptic laryngoscope handle.
TECHNIQUE
The Levitan Scope was designed with the intent of incorporating
the option of fiberoptic assistance into every intubation attempt. In
the majority of cases, where landmark visualization is feasible with
standard laryngoscopy, the scope will simply act as a stylet. Once
endotracheal intubation is achieved, additional confirmation can be
made by visualizing the tracheal rings via the eyepiece.
When endotracheal intubation is not possible by direct laryngos-
copy, the Levitan Scope jacketed with an endotracheal tube can be
used for fiberoptic intubation. Obtain the best visualization of the
airway anatomy possible using the traditional laryngoscope. Ideally,
at least the epiglottis should be visible. Introduce the scope into the
mouth under direct vision. Advance it until the tip of the scope is
positioned approximately 1 cm superior to the epiglottis. To main-
tain this position, it may be helpful to rest the device against the
patient’s dentition at the right corner of the mouth. Avoid touching
the distal tip of the scope against the mucosa to prevent “pink out”
and fogging.
Switch from direct visualization to fiberoptic viewing via the
device’s eyepiece. Identify the airway structures. Slowly advance and
direct the tip of the scope under the epiglottis. Continue to advance
the tip of the device into the glottic opening. If the device is resting
at the right corner of the patient’s mouth, pivoting the device toward
the Emergency Physician will direct the tip of the scope anteriorly
toward the glottic opening. Confirm proper placement by visual- FIGURE 14-2. The Airway RIFL (Photo courtesy of AI Medical Devices Inc.,
izing the trachea rings through the eyepiece. Williamston, MI).
screen rotates 180° to provide visualization from any angle. The

Video RIFL has a unique tip that articulates up to 135° to navigate
obstructions. The device can be used as a stand-alone device or as
an adjunct to standard laryngoscopy. It can be used to facilitate intu-
bation through many supraglottic airway devices such as the Air-Q
or I-gel. The primary disadvantages of this device are the cost, the
relative length of the device, and that it is top-heavy. The length may
prove cumbersome for users of shorter stature.
The two-sided RIFL blade can be used in conjunction with the
Video RIFL. It is a disposable, single use, plastic blade. Its use is
optional. The RIFL blade is inserted into the midline of the patient’s
mouth and lifted to elevate the tongue, open the airway, and provide
a path to the glottis.
PREPARATION FIGURE 14-3. The Air-Vu Plus Fiber Optic Scope (Photo courtesy of Mercury
Inspect the Video RIFL for any damage. Turn it on. Liberally lubri- Medical, Clearwater, FL).
cate the stylet portion of the device with a water-soluble lubricant.
Place a 6.5 mm or larger endotracheal tube onto the stylet. The cur-
rent model does not accommodate endotracheal tubes less than
6.5 mm. A smaller pediatric version is being developed. Set the tube SHIKANI OPTICAL STYLET
stop so that the tip of the stylet is just inside the distal end of the The Shikani Optical Stylet or SOS (Clarus Medical, Minneapolis,
endotracheal tube. MN) is unique among the optical stylets in that it comes in both
pediatric and adult sizes (Figure 14-4). The SOS can be used with
TECHNIQUE a variety of light sources. This includes its own specific handle, a
green-line laryngoscope handle, or a fiberoptic cable attached to a
The Video RIFL can be used as an adjunct to standard direct laryn- remote light source. The SOS is malleable, allowing it be shaped to
goscopy. If the glottic opening can be easily visualized using a a 70° to 80° angle at the tip for use as a stand-alone device or a
standard laryngoscope, the device can simply be used as a stylet to 30° angle when used as an adjunct to standard direct laryngoscopy.
introduce the endotracheal tube into the trachea. If the laryngeal The SOS can be attached to oxygen tubing to allow insufflation of
structures are not well visualized with direct laryngoscopy, insert oxygen at 5 to 10 L/min. Intubation is achieved in a manner simi-
and advance the device as described for the Levitan Scope. Attempt lar to other optical stylets. Advantages of the Shikani Optical Stylet
to visualize the epiglottis through the eyepiece or on the LCD include the availability of adult and pediatric sizes, its malleability,
screen of the Video RIFL. Advance the device under the epiglottis and the option of providing insufflation of oxygen. There are also
and through the vocal cords. The trigger-like handle of the Video
RIFL can be squeezed to direct the tip of the instrument. Release
the handle once the tip of the device passes through the vocal cords
in order to facilitate advancement of the endotracheal tube off the
device. Advance the endotracheal tube into the trachea. Withdraw
the device and secure the endotracheal tube. Confirm proper endo-
tracheal tube placement.
The Video RIFL can be used as a stand-alone device without the
aid of a laryngoscope. Grasp the patient’s mandible and tongue in
the left hand and manually distract it. Insert the Video RIFL into the
patient’s mouth with the long axis of the device parallel to the palate.
Look into the eyepiece or at the LCD screen and attempt to visualize
the airway structures. Flex the tip of the device to visualize the vocal
cords. Advance the Video RIFL through the vocal cords. Complete
the remainder of the procedure as described above.
AIR-VU PLUS FIBER OPTIC SCOPE

The Air-Vu Plus Fiber Optic Scope (Mercury Medical, Clearwater,
FL) is an optical stylet designed specifically for aiding in fiberoptic
endotracheal tube placement through the Air-Q supraglottic airway
(Mercury Medical, Clearwater, FL). It is a rigid device with a curved
tip designed to fit the shape of the Air-Q (Figure 14-3). The Air-Vu
Plus can be used with either a compact LED light source or a stan-
dard green-line fiberoptic laryngoscope handle. The device can be
used as an optical stylet or as a stand-alone device in the same fash-
ion as the Levitan Scope. The primary advantage of the Air-Vu plus
versus other devices is its compatibility with the Air-Q. The primary
disadvantage is the rigidity of the device and the fixed curve of the
shaft, both of which can make advancement of the device and the FIGURE 14-4. The Shikani Optical Stylet (Photo courtesy of Clarus Medical,
endotracheal difficult. Minneapolis, MN.
FIGURE 14-5. The Bonfils Retromolar Intubation Endoscope (Photo courtesy of

Karl Storz Endoscopy-America, El Segundo, CA).
several case reports of its successful use in children.3 The disadvan-

tages are primarily related to its length, which can make coordina-
tion of intubation difficult for some users.
B
BONFILS RETROMOLAR
INTUBATION ENDOSCOPE FIGURE 14-6. The Airtraq. A. The devices. B. An endotracheal tube loaded onto
The Bonfils Retromolar Intubation Endoscope (Karl Storz the device (Photos courtesy of Prodol Meditec S.A., Vizcaya, Spain).
Endoscopy-America, El Segundo, CA) is simple in appearance
(Figure 14-5). It can accommodate a 6.5 mm or larger endotracheal
tube and has an adjustable tube stop. It can be equipped with either video camera can be attached to the viewing window. It will trans-
an eyepiece or an adapter to couple with a monitor. It also allows for mit the viewing image to a wireless display monitor and recorder.
oxygen insufflation via a side port. The curvature at the tip of the The Airtraq has proven to be effective and easy for even novice
scope is fixed. practitioners to learn to use.7,8 The prehospital community favors
Intubation with the Bonfils Retromolar Intubation Endoscope the Airtraq for its compact size, portability, disposability, and being
can be achieved in the same fashion as described for other optical useful in less-than-standard patient positions.9 The use of an Airtraq
stylets in this chapter, either with or without the aid of a standard results in less cervical spine motion, less hemodynamic stimulation,
laryngoscope. In a study in the anesthesiology literature, 103 of and a decreased time required to intubate when compared to direct
107 patients with unanticipated difficult airways were successfully laryngoscopy.10–12
intubated with this device, with 80% intubated without the aid of
a laryngoscope.4 The other 20% were intubated with a Macintosh PREPARATION
blade and the Bonfils scope. A more recent study reports the device’s
success in the awake intubation of five patients with challenging air- Select the appropriate size Airtraq (Table 14-1). Confirm that the
ways.5 Despite having higher success rates than traditional direct patient’s mouth can be opened enough to accommodate the Airtraq.
laryngoscopy, it can be difficult to maneuver this device into proper Turn on the Airtraq with the switch on the left side of the handle.
position under the epiglottis.6 Turning the Airtraq on early (i.e., at least 30-45 seconds before it
is used) in the setup phase allows it to warm up, which also helps
AIRTRAQ OPTICAL LARYNGOSCOPE to prevent fogging. If the Airtraq is stored in a cold environment
(e.g., storage room or ambulance in winter), allow it to warm up
The Airtraq (Prodol Meditec S.A., Vizcaya, Spain) differs from other for at least 60 to 90 seconds before it is used. Select the appropriate
devices in this chapter in that it is not an optical stylet, but rather an
optical laryngoscope (Figure 14-6). It also differs from video laryn-
goscopes, such as the Glidescope, in that it is portable, completely
handheld, battery operated, and does not require an external moni- TABLE 14-1 Airtraq Sizes
tor for viewing. The Airtraq is disposable and designed for single Size Endotracheal tube size Minimal mouth opening (mm)
patient use. The guide channel on the side of the Airtraq is ana- #0: Infant 2.5–3.5 12.5
tomically shaped to deliver the endotracheal tube into the glottic #1: Pediatric 3.5–5.5 12.5
opening. The Airtraq is available in four sizes, each with a required #2: Small 6.0–7.5 16
minimal mouth opening (Table 14-1). An optional reusable wireless #3: Regular 7.0–8.5 18
size endotracheal tube. Test the endotracheal tube to ensure that the Adjustable
cuff inflates properly. Liberally lubricate the endotracheal tube and eyepiece
insert it into the channel of the Airtraq (Figure 14-6B). The patient Standard
can either be left in the neutral position or placed in the sniffing laryngoscope
position. Lubricate the Airtraq to prevent it from catching and handle
pushing the tongue posteriorly.
TECHNIQUE
Fiberoptic
Grasp the prepared device with the left hand. Insert the tip into the Working
bundle
midline of the patient’s mouth, with the long axis of the Airtraq port
parallel to the patient. Advance the Airtraq into the hypopharynx
by lifting and rotating the viewing end upward. The curved shape Site to
of the Airtraq will follow the patient’s normal anatomic curva- attach stylet
ture of the pallet and hypopharynx. When the device is just about Port to attach
upright and perpendicular to the patient, look into the eyepiece and light source
attempt to visualize the epiglottis. Once the epiglottis is visualized,
the Airtraq can either be advanced into the vallecula similar to a Intubating
Macintosh blade or used to directly lift the epiglottis similar to a blade
Miller blade. In either case, the Airtraq must be lifted up to elevate Contoured
the epiglottis and center the glottic opening on the viewing screen. handle
Visualize the vocal cords. Advance the endotracheal tube with
the right hand while securely holding the Airtraq with the left hand.
Visualize the endotracheal tube passing through the vocal cords. If
the vocal cords and airway structures are seen but the endotracheal Openings for the light
tube will not advance, the vocal cords are probably not in the center source, working port
of the viewing screen. Slowly withdraw the Airtraq, lift it slightly and optical port
until the vocal cords are positioned in the middle of the viewing Intubating
screen, and then advance the endotracheal tube.13 Once the proper blade
insertion depth is reached, securely hold the endotracheal tube.
Gently distract the Airtraq toward the patient’s left side while hold-
ing the endotracheal tube in its current location to release the endo-
tracheal tube from the side channel. Withdraw the Airtraq from FIGURE 14-7. Anatomy of the Bullard laryngoscope.
the mouth and inflate the cuff of the endotracheal tube. Confirm
proper endotracheal tube position and secure it with tape or a com-
mercial device.
The two most common mistakes are inserting the Airtraq too PREPARATION
deep and not lifting it to elevate the epiglottis. Either of these will Assemble the Bullard laryngoscope when the possible need for
result in a view of the arytenoid cartilages and the vocal cords, airway intervention is recognized. The working port can be fitted
with the viewing screen having the arytenoids centered in the view with a three-way stopcock to provide intermittent suction and oxy-
rather than the vocal cords. This will result in the advancing endo- gen insufflation. Attach a traditional laryngoscope handle as the
tracheal tube hitting the arytenoid cartilages, thus not advancing light source. If available, a fiberoptic light source, with the required
through the vocal cords. Simply withdraw the Airtraq slightly and adapter, may be used to provide illumination. Lubricate the lower
lift it upward to center the vocal cords in the viewing screen. half of the intubating stylet with a water-soluble lubricant. Attach
BULLARD LARYNGOSCOPE
The Bullard laryngoscope (Gyrus ACMI, Southborough, MA)
is a rigid laryngoscope that combines a curved blade with fiber-
optic visualization into a simple and easy-to-use handheld unit
(Figures 14-7 & 14-8). The proximal handle contains an 11 French
(3.7 mm) working port, a site to attach the light source such as
a traditional laryngoscope handle or a fiberoptic, and a visual-
ization port (Figure 14-7). The port allows oxygen insufflation,
suctioning, administration of pharmaceuticals, or the passage of a
guidewire to promote tracheal intubation.14,15 The curved blade is
similar in shape to a Macintosh blade. A fiberoptic bundle allows
visualization of the vocal cords and tracheal intubation without a
direct line of sight.
The Bullard laryngoscope is available in three sizes (Figure 14-8).
The device is handheld, readily portable, self-contained, and is oper-
ated as quickly as a traditional laryngoscope with a Macintosh blade.
The ability to visualize the vocal cords without aligning the oral,
pharyngeal, and laryngeal axes allows successful intubation with a FIGURE 14-8. Three versions of the Bullard laryngoscope. From left to right: the
minimum of cervical spine movement.14–19 pediatric model, the pediatric long model, and the standard model.
the stylet to the fiberoptic bundle, between the eyepiece and the TECHNIQUE
handle, on the right side of the laryngoscope. Select and load
the appropriate size endotracheal tube onto the intubating stylet. Stand at the head of the bed. Open the patient’s mouth to a mini-
The tip of the stylet should extend 0.5 cm past the distal end of the mum opening of 0.6 cm between the upper and lower incisors.
endotracheal tube. Place the tip of the stylet beneath the flange of Grasp the handle of the Bullard laryngoscope parallel to the patient
the blade. It is recommended, but not required, that a disposable and toward the patient’s feet (Figure 14-9A). Insert the blade into
plastic blade extender be placed on the tip of the metal blade for the midline of the mouth. Lift the laryngoscope handle upward
adult intubations. (Figure 14-9B). Slightly elevate the Bullard laryngoscope to lift up
FIGURE 14-9. Intubating with the Bullard laryngoscope. A. Inserting the laryngoscope. B. Rotation of the handle 90° properly positions the laryngoscope. C. Slight eleva-
tion of the laryngoscope moves the tongue and epiglottis out of the visual axis. D. Advancement of the endotracheal tube under direct visualization. E. Removal of the
Bullard laryngoscope. It is first rotated 90° toward the patient’s feet (curved arrow), then lifted out of the mouth (straight arrow).
CHAPTER 15: Endotracheal Tube Intubating Introducers and Bougies 95
the tongue (Figure 14-9C). The blade will follow the contour of the techniques for managing the airway. Every Emergency Department
tongue and pharynx with minimal effort. should have at least one of these devices available to aid in intuba-
The blade of the Bullard laryngoscope should elevate the epi- tion when direct laryngoscopy is difficult or fails.
glottis (Figures 14-9C and D). Visualize the airway through the
fiberoptic port (Figure 14-9D). The view can be focused by turn-
ing the eyepiece. If the blade is not beneath the epiglottis, it can
be repositioned by withdrawing the blade toward the posterior
pharynx in an attempt to catch the epiglottis. If blood, debris Endotracheal Tube
or secretions limit the view, suction through the working port.
When the vocal cords are visualized, advance the endotracheal 15 Intubating Introducers
tube under direct visualization (Figure 14-9D). Secure the endo-
tracheal tube at the patient’s teeth with your nondominant hand.
and Bougies
Remove the Bullard laryngoscope with your dominant hand by Olga Pawelek and Eric F. Reichman
reversing the technique of insertion (Figure 14-9E).
The Bullard laryngoscope allows for other strategies to aid in INTRODUCTION
endotracheal intubation. The stylet has a central opening (4.5 mm
in the adult, 3.6 mm in the pediatric long), which can be used to Airway management in the Emergency Department often occurs
pass an intubating guidewire through the vocal cords.15 An intubat- in an unpredictable and uncontrolled environment, sometimes
ing guidewire may also be passed through the working port and with the patient arriving unannounced.1 The American Society of
through the vocal cords. In either case, after inserting the guidewire, Anesthesiology defines a difficult intubation as an inability to prop-
remove the Bullard laryngoscope and pass the endotracheal tube erly insert an endotracheal tube with traditional direct laryngoscopy
over the guidewire and into the trachea. It is also possible to pass within three attempts or if it takes longer than 10 minutes.2 Difficult
an endotracheal tube with a standard malleable stylet. The styletted intubations usually reflect poor glottic visualization during direct
endotracheal tube can be bent into a shape approximating that of laryngoscopy. A four-grade classification system by Cormack and
the Bullard laryngoscope. Lehane describe the views of the laryngeal inlet during laryngos-
Problems specific to the Bullard laryngoscope include the inabil- copy.3 The exact incidence of difficult to intubate patients in the
ity to visualize the vocal cords. First, confirm that the laryngoscope Emergency Department is difficult to extrapolate but estimates
is midline. If the blade is above the epiglottis and the view obscured, range between 6% and 11%.4,5
reposition it by moving the blade into the posterior pharynx and Difficulties arise when the vocal cords cannot be fully visualized
attempt to capture the epiglottis. To avoid this difficulty, use a dis- due to airway distortion (e.g., edema, expanding hematomas, radia-
posable plastic blade extender. If the view is obscured by debris, tion, surgery, or trauma), airway masses, anatomical variations, cer-
suction through the working port. Once positioned, the stylet with vical collars, deformities of the head and neck, orofacial injuries, or
the loaded endotracheal tube should be visualized through the oropharyngeal blood and secretions. One study reported that the
scope. If not, it may have slipped underneath the blade. Reposition vocal cords could not be visualized in 22% of patients wearing a cer-
the stylet and endotracheal tube without removing the laryngo- vical collar.6 This failure to visualize the glottis can make intuba-
scope.15 The stylet, if extended too far beyond the endotracheal tion difficult or impossible. The intubating introducer, tracheal
tube, may cause abrasions, bleeding, and lacerations to the walls tube introducer, or bougie can be a good rescue device in these
of the oral cavity, oropharynx, and laryngopharynx. These can be situations. The main advantage of many of these devices is their
prevented with proper assembly of the Bullard laryngoscope. angled or coudé tip that can be aimed anteriorly, advanced under the
epiglottis, and into the trachea. Intubation with one of these devices
was first described by Macintosh in 1949.7 The device he used was a
COMPLICATIONS 60 cm long, 15 French, elastic catheter with a J or coudé tip that was
The majority of complications associated with fiberoptic devices bent 40° at the distal end.
mirror those of endotracheal intubation. These include failure to This chapter reviews the general principles for using tracheal
intubate, esophageal intubation, right mainstem bronchus intuba- tube introducers, intubating introducers, and bougies; as well as
tion, and all of the hemodynamic consequences of intubation. Refer reviewing some of the more commonly available devices. The
to Chapter 11 for a complete discussion of the complications asso- terms tracheal tube introducers, intubating introducers, and bou-
ciated with endotracheal intubation The most common difficulty gies are often used interchangeably. This chapter uses the term bou-
encountered in endotracheal tube passage is impaction of the endo- gie unless some other term is specific to a manufacturer’s device.
tracheal tube on the right arytenoid cartilage. This obstacle can be
overcome by directing the device slightly toward the patient’s left INDICATIONS
side. Alternatively, rotate the endotracheal tube until the bevel is The bougie is intended to facilitate endotracheal intubation in
facing the viewing channel. patients where visualization of the glottis is difficult or inadequate
despite external laryngeal manipulation and optimal patient posi-
tioning. The most frequent indication for the use of a bougie is
SUMMARY
the inability to intubate endotracheally using traditional direct
A variety of fiberoptic devices are available to help indirectly visual- laryngoscopy. It can also be used for “routine intubations.” The
ize the glottic opening and aid in intubating the trachea. The scopes narrower and more flexible bougie, compared to an endotracheal
have a variety of features including malleable stylets, articulating tube, can easily be inserted into the trachea when the glottis is
tips, and differing lengths. The devices can be shaped for differ- visualized during direct laryngoscopy and the endotracheal tube
ing applications such as being used with and without a laryngo- inserted then advanced over the bougie. A bougie can be inserted
scope or to be inserted through a supraglottic airway. The devices directly into the trachea or through a supraglottic airway device to
feature different visualization capabilities such as a fixed eyepiece facilitate endotracheal intubation. A bougie may be inserted when
or an optional video screen. Fiberoptic devices offer alternative the glottic opening is visible, but the endotracheal tube will not
pass through the vocal cords. The bougie serves as a placeholder in

these cases and avoids the need to remove the laryngoscope and re-
perform direct laryngoscopy when the bougie is available. The use FIGURE 15-1. The Portex Tracheal Tube Introducer (Photo courtesy of Smiths
of a bougie to intubate the trauma patient may result in less cervical Medical, Dublin, OH).
spine motion than traditional direct laryngoscopy.8 Long bougies,
at least 70 cm, can also be used as an endotracheal tube exchanger.
usually inserted independently of the endotracheal tube and is used
as a guide. The bougie is considerably softer, more malleable, and
CONTRAINDICATIONS blunter than a stylet. The insertion of a bougie is considered to be a
There are no absolute contraindications to the use of bougies. Use relatively atraumatic procedure.12
caution when inserting these in the patient with airway trauma as
they can result in additional injury and hemorrhage to the airway ESCHMANN TRACHEAL TUBE INTRODUCER
structures, perforation (e.g., piriform fossa, trachea, bronchus, or
The Eschmann tracheal tube introducer was formerly known as
esophagus), or barotrauma.9–11
the gum elastic bougie. Re-usable (or multiple-use) and single-
use disposable versions are available. The Eschmann multiple-use
EQUIPMENT introducer was introduced into clinical practice in 1973. The Portex
single-use introducer (Smiths-Medical, Dublin, OH) became avail-
• Endotracheal tubes, various sizes able in 1997 and replaced the Eschmann Introducer. It is a 60 cm
• 10 mL syringe long, 15 French, flexible device with a J-angle at its distal tip
• Water-soluble lubricant or anesthetic jelly (Figure 15-1). During use, the multiple-use introducer forms a
• Wire stylet, malleable type curve toward its distal end. The single-use introducer is more rigid
and is thus more likely to cause trauma.13 It does not maintain a
• Laryngoscope handle
curved shape when bent and it has a significantly lower tracheal
• Fresh batteries for the laryngoscope placement rate in simulated grade 3 laryngoscopic views.14 The
• Laryngoscope blades, various sizes and shapes multiple-use device retained the curved shape for longer compared
• Supplemental oxygen with appropriate tubing and connectors with the single-use device.
• Nonrebreather oxygen masks, various sizes
• Wall suction with appropriate tubing
FROVA INTUBATING INTRODUCER
• Yankauer suction catheter The Frova Intubating Introducer (Cook Medical Inc., Bloom-
• Bag-valve device, various sizes ington, IN) was introduced into clinical practice in 1998. The
Frova is a single-use device that is able to maintain the desired
• Oral airways, various sizes curvature—a feature shared with the Eschmann multiple-use
• Nasal airways, various sizes introducer.15 It is a flexible, hollow, radiopaque polyethylene
• Benzoin adhesive plastic catheter with centimeter markings, and a blunt curved
• Tape
• Pulse oximeter
• Cardiac monitor
• Automatic sphygmomanometer
• End-tidal carbon dioxide (CO2) monitor/device
• Cricothyroidotomy backup tray
• Crash cart
• Resuscitation medicines
• Personnel (respiratory technician, medication nurse, in-line sta-
bilization assistant, recorder)
• Medications (premedications, induction, anesthetics, and para-
lytics), see Table 11-2
• Endotracheal tube introducer or bougie
The bougie is used to facilitate difficult intubation. It is a thin,
long cylindrical rod composed of rubber or plastic. Despite some-
times being called “gum elastic bougies,” they are not composed
of gum or elastic. They are inexpensive, most costing less than US
$20.00 each. The bougie is available in numerous adult and pediatric
sizes, various degrees of flexibility, and equipped with a variety of
ports and/or devices. Bougies are flexible enough to allow an endo-
tracheal tube to freely pass over it or to be inserted through a supra-
glottic airway device, yet stiff enough to be easily maneuvered and
advanced into the airway.
The bougie should not be confused with the more rigid mal- FIGURE 15-2. The Frova Intubating Introducer with Rapi-Fit adapter. From left to
leable stylet that is inserted into an endotracheal tube and used right: the proximal end with the Rapi-Fit adapter, the body with centimeter mark-
to alter its shape prior to intubation. Unlike the stylet, a bougie is ings, and the distal end (Photo courtesy of Cook Medical Inc., Bloomington, IN).
tip (Figure 15-2). It is available in two sizes, the 14 French ver-

sion for 6.0 mm and larger endotracheal tubes and the 8 French
version for 3.0 mm and larger endotracheal tubes. It is packaged
with a removable metal cannula that stiffens the device except
for the distal tip. The advantages of the metal cannula are that
it can be bent to change the shape of the Frova and make it eas-
ier to advance. The disadvantages of the metal cannula are that
it makes the Frova more rigid, harder to maneuver, and poten-
tially increases airway soft tissue trauma. Products with the suffix
“-FII” also include a stiffening cannula and two Rapi-Fit® adapt- FIGURE 15-4. The Greenfield Flex-Guide Endotracheal Tube Introducer adult ver-
ers for connection to a ventilatory device. Products with the suffix sion (above) and pediatric version (below) (Photo courtesy of Greenfield Medical
“-FI” include two Rapi-Fit® adapters for connection to a ventila- Sourcing Inc., Austin, TX).
tory device, but no stiffening cannula. The adapter can be used
to ventilate the patient and confirm proper tracheal placement
before advancing the endotracheal tube. It takes only 15 seconds
to attach an aspirating esophageal detector device to the adapter AINTREE INTUBATION CATHETER
and confirm its position.16
The Aintree Intubation Catheter (Cook Medical Inc., Bloomington,
IN) was designed to be used with a fiberoptic bronchoscope
SUNMED BOUGIE (Figure 15-5). It is packaged with a Rapi-Fit Adapter, which allows
The SunMed Bougie (SunMed, Largo, FL) is made of a blend of low ventilation through the device and air exchange through the mul-
and high density polyethylene for optimal stiffness and has depth tiple distal side ports. The Aintree is only available in one size and
calibration markings. It is 70 cm long and available as a 10 French for use with endotracheal tubes greater than 7.0 mm in diameter. It
pediatric size or a 15 French adult size (Figure 15-3). Three ver- may also be used as a bougie without the fiberoptic bronchoscope.
sions of these devices are available: the original, the malleable, and a It is generally not used as a bougie due to it being hollow, flexible,
ported version. The original adult version is available with a straight straight, and lacking the flexed tip of a typical bougie.
or curved tip and fits 4.0 to 11.0 mm endotracheal tubes. The origi-
nal pediatric version is only available with a curved tip. The mal- ENDOTRACHEAL TUBE EXCHANGERS
leable version has a color-coded stopper and fits 6.0 to 11.0 mm
The use of an endotracheal tube exchanger to facilitate orotracheal
endotracheal tubes. A new ported version allows insufflation of
intubation similar to a bougie is not recommended. These devices
oxygen and gas sampling. It is available only in the 15 French size. It
are straight, very flexible, thin-walled, and hollow tubes. Their flex-
uses a blend of low and medium density polyethylene for optimum
ibility makes it difficult to advance into the trachea and more often
firmness, and it is depth calibrated in centimeters. A study compar-
enters the esophagus. When inserted and warmed by the patient’s
ing the SunMed, Portex, Greenfield, and Eschmann bougies dem-
body temperature, these thin-walled hollow tubes become even
onstrated that Emergency Physicians had better success rates using
more flexible.
the SunMed and Greenfield devices, but they had a low preference
for the Greenfield bougie.17
GREENFIELD FLEX-GUIDE ET TUBE INTRODUCER

The Flex-Guide ET Tube Introducer (Greenfield Medical Sourcing
Inc., Austin, TX) is a 60 cm long polyethylene tube that is avail-
able in a 15 French (5.0 mm) diameter for adults and a 10 French
(3.3 mm) diameter for children (Figure 15-4). The ends of the
Flex-Guide are smooth and rounded with a bend 2 cm from the
distal end, resulting in a 30° coudé tip. The tubing is flexible and
can be straightened or bent as required. The adult Flex-Guide has a
black band marking 37 cm from its proximal end (Figure 15-4) to
help determine correct placement depth. The pediatric Flex-Guide
has markings every 10 cm (Figure 15-4). The Flex-Guide is simi-
lar to the Eschmann or Portex bougie, only more economical. This
device has been used in the Emergency Department to intubate
difficult airways.18
FIGURE 15-3. The SunMed Bougie. From top to bottom: 10 French Coudé tip FIGURE 15-5. The Aintree Intubation Catheter. From left to right: the proximal end
pediatric version, 15 French straight tip adult version, and the 15 French Coudé tip with the Rapi-Fit adapter, the body with centimeter markings, and the distal end
adult version (Photo courtesy of SunMed, Largo, FL). (Photo courtesy of Cook Medical Inc., Bloomington, IN).
PATIENT PREPARATION Instruct an assistant to load the endotracheal tube over the bougie
and slide it to the level of the patient’s lips. The assistant should hold
The patient preparation is exactly the same as that for orotracheal and advance the endotracheal tube until its tip is at the patient’s
intubation (Chapter 11). Refer to Chapter 11 for a complete discus- lips while the Emergency Physician controls the bougie, controls
sion regarding the patient preparation. The patient should be appro- the laryngoscope, and provides instruction to the assistant. The
priately monitored with electrocardiography (ECG), end-tidal CO2 Emergency Physician must now grasp and control the endotra-
monitoring, noninvasive blood pressure cuff, and pulse oximetry. cheal tube with their right hand while the assistant holds the
As for any situation where airway manipulation is to occur and the bougie securely in place. Advance the endotracheal tube over the
patient’s protective airway reflexes are blunted or ablated, a fully bougie and into the trachea (Figure 15-6E). Under direct visualiza-
functioning suction apparatus with a variety of catheters must be tion, rotate the endotracheal tube 90° counterclockwise so that the
immediately available. Place the patient supine with their head in a bevel is facing posteriorly as the endotracheal tube passes through
neutral position. the vocal cords. This maneuver allows the endotracheal tube bevel
Place the patient, with a normal neck, in the “sniffing” position, to not get caught on the arytenoid cartilage and to gently spread the
with their head extended at the atlantooccipital joint while the neck arytenoids with a minimum of force, thus avoiding any injury to the
is relatively flexed. A folded towel under the occiput helps to gen- vocal cords.21 If resistance is felt, do not try to advance the endo-
tly raise and tilt the head back into the proper position. Correct tracheal tube. Instruct the assistant to slightly withdraw the endo-
positioning is probably the most important preparation of the tracheal tube, rotate it in a slightly more counterclockwise direction,
patient. Dentures should be left in place temporarily, as they help and re-advance it again.
to stabilize the mouth and prevent occlusion during preoxygenation Hold the endotracheal tube firmly in place. Remove the laryngo-
and bag-valve-mask ventilation. scope. Remove the bougie. Secure the endotracheal tube, confirm its
proper position, and begin ventilation of the patient.
TECHNIQUES ALTERNATIVE OROTRACHEAL
INTUBATION TECHNIQUE
OROTRACHEAL INTUBATION
An assistant is not always available to load the endotracheal
The bougie can be used in anticipation of a difficult airway or when tube and advance it over the bougie. An alternative is for the
a difficult airway is encountered and direct laryngoscopy is not suc- Emergency Physician to preload the endotracheal tube on the bou-
cessful. Instruct an assistant to ventilate the patient with a bag-valve- gie (Figure 15-7) and insert them as a unit without the use of an
mask device. Liberally lubricate the bougie with a water-soluble assistant. Load the endotracheal tube over the bougie so that the
lubricant. Insert the laryngoscope loaded with either a Macintosh or bougie projects approximately 10 cm from the distal end of the
Miller blade. Elevate the laryngoscope and attempt to visualize the endotracheal tube (Figure 15-7A). Form a loop with the endotra-
epiglottis and vocal cords. If the vocal cords are visualized, partially cheal tube and proximal bougie and grasp it with the right hand
or completely, insert the bougie through the vocal cords and into (Figure 15-7A). A second technique is to load the endotracheal tube
the trachea. on the bougie so that the bougie projects approximately 6 to 10 cm
If the vocal cords are not visualized, attempt to pass the bou- from the distal end of the endotracheal tube and grasp it with the
gie under the epiglottis with the curved distal tip facing anteriorly right hand (Figure 15-7B).
(Figures 15-6A & 16-6B). Slowly and carefully advance the bougie Insert the laryngoscope into the patient’s mouth and attempt to
distally toward the trachea. The bougie will slightly jump or bounce visualize the glottis. Grasp the bougie loaded with the endotracheal
as its tip is advanced over each tracheal ring (Figure 15-6C). This tube in the right hand. Insert the distal end of the bougie through
is sometimes referred to as the “palpation of a click” as the tip the vocal cords and into the trachea. Remove the laryngoscope.
passes over each tracheal ring. Advance the bougie approximately Advance the endotracheal tube over the bougie and into the trachea.
10 to 15 cm into the trachea (Figure 15-6D). Securely hold the Securely hold the endotracheal tube. Remove the bougie. Secure the
bougie in place. Do not remove the laryngoscope after the bou- endotracheal tube, confirm its proper position, and begin ventila-
gie is placed within the trachea. The laryngoscope will continue tion of the patient.
to elevate the tongue and allow easier passage of the endotra-
cheal tube.
There are several signs that signify proper bougie placement BOUGIE-GUIDED SUPRAGLOTTIC
within the trachea. If the bougie is unable to be advanced more AIRWAY INSERTION
than 40 cm from the patient’s lips in an adolescent or adult, or more Bougies can be used to guide supraglottic airway devices.22–24 A bou-
than 24 cm in the child, it is likely caught at the carina or bron- gie was utilized as a guide through the Pro-Seal LMA.22 The esoph-
chus as the airway narrows. This is sometimes referred to as the ageal channel of the LMA was used to load the bougie and place it
“hold-up” sign. The “hold-up” sign in addition to the palpation of in the esophagus. This resulted in a better success rate than using
“clicks” as it is inserted confirms proper tracheal positioning of the the LMA introducer tool. The bougie-guided insertion caused less
bougie.19 If the bougie freely advances more than 40 cm from the trauma than the LMA insertion tool after failed digital insertion of
adolescent or adult patient’s lips, or 24 cm in the child, it is most the ProSeal LMA. A similar technique has been used in the pediatric
likely in the esophagus or stomach. One study noted the bougie population.23 Other studies have used bougies as guides through a
getting caught and the palpation of “clicks” to be a less reliable indi- supralaryngeal device for rescue intubation.24
cator of tracheal placement than some other studies.20 An assistant
performing the Sellick maneuver should feel the tip of the bougie
passing under their fingertips as it is advanced down the trachea.
BOUGIE-ASSISTED RETROGRADE INTUBATION
The bougie will rotate as the tip passes the carina and enters the Retrograde intubation with a bougie may be considered as an
mainstem bronchus. It will rotate clockwise if it enters the right emergent airway management option.25 A patient was successfully
mainstem bronchus and counterclockwise if it enters the left main- intubated using a modified retrograde technique through a tra-
stem bronchus. cheal defect with a bougie. The bougie is often more conveniently
FIGURE 15-6. Intubation using a bougie. A. The laryngoscope has been inserted and the bougie advanced into the hypopharynx. B. The bougie is advanced under the
epiglottis. C. The bougie is inserted into the trachea and advanced over the tracheal rings. D. The bougie is advanced until its tip is at the carina or mainstem bronchus.
E. The endotracheal tube is advanced over the bougie and into the trachea.
available than a retrograde guidewire kit. A bougie can be inserted cricothyroidotomy.28 The military describes this as the preferred
through the skin and airway incision, laceration, or defect and technique of combat airway management.29 The three-step tech-
advanced superiorly to exit the patient’s mouth. The endotracheal nique using the bougie can be quickly taught to combat medics and
tube can then be loaded over the bougie and advanced into the performed in complete darkness using night vision goggles. A bou-
trachea. Refer to Chapter 23 for the complete details of retrograde gie placed through the incision maintains the open tract, provides
guidewire intubation. tactile confirmation of tracheal placement, and serves as a guide for
the endotracheal tube insertion.
BOUGIE-ASSISTED CRICOTHYROIDOTOMY
ALTERNATIVE USES
Various medical and surgical specialities have used the bougie
as an aid when performing a cricothyroidotomy.26,27 It was found Various other applications of the bougie have been described.30–33
using a bougie as an aid to be easier and faster to teach how to The bougie can be used as an adjunct in nasal intubation in the adult
perform a cricothyroidotomy in an animal lab than a traditional and pediatric populations.30,31 The bougie has been successfully used
of the bougie into the trachea or mainstem bronchus can induce

bronchospasm.34 The remainder of the complications is similar to
those of orotracheal intubation (Chapter 11).
SUMMARY
Bougies are widely used to aid in intubation with traditional direct
laryngoscopy when the glottic opening cannot be adequately visual-
ized. They have been successfully used both in the adult and pedi-
atric population, with devices available for use with endotracheal
tubes as small as 3.0 mm in size. They are also used to aid in place-
ment of supralaryngeal devices, blind nasotracheal intubations,
placement of double-lumen airway tubes, retrograde intubation,
and cricothyroidotomies. A bougie should be a required device in
any emergency or difficult airway cart.
Digital (Tactile)
16 Orotracheal Intubation
O. John Ma and Amanda Munk
INTRODUCTION
For patients who require orotracheal intubation, digital (tactile)
intubation is an alternative technique to traditional direct laryngos-
copy.1–12 This procedure involves using the index and middle fingers
as a guide to blindly place the endotracheal tube into the patient’s
larynx. Digital tracheal intubation has been demonstrated to be a
safe, simple, and rapid method.1 It should be considered as a sec-
ondary method of intubation when other methods prove difficult or
impossible.1 It is particularly suited for prehospital and aeromedi-
B cal use, where equipment and alternate intubation techniques are
limited or unavailable. One study demonstrated an 88% success rate
among paramedics who intubated with this technique.2
FIGURE 15-7. Two methods to preload an endotracheal tube onto a bougie.
A. The curved hold. B. The straight hold.
For this procedure, the only two significant anatomic structures that
to aid in correct placement of a double-lumen airway tube in a dif- the intubator will encounter are the patient’s tongue and the epiglot-
ficult airway.32 It has also been described and tested as a back-up tis. The epiglottis is the cartilaginous structure that is located at the
device during extubation to allow for a quick reintubation in case of root of the tongue and serves as a valve over the superior aperture of
the need to re-secure the airway.33 the larynx during the act of swallowing.3
COMPLICATIONS INDICATIONS
There are some complications specific to the use of a bougie. The Digital orotracheal intubation is an ideal alternative technique for
bougie can cause trauma to the airway soft tissues.9–11,34,35 The intubating the comatose or chemically paralyzed patient when other
Frova causes significantly more complications than other bou- more conventional methods for intubation have failed. In particu-
gies (5% incidence vs. rare).34 This difference is most likely due lar, this procedure is useful when oral secretions or blood inhibit
to using the metal cannula, making the Frova quite stiff. The the direct visualization of the upper airway.1 Since this technique
Frova with the metal cannula exerts more force on the airway tis- involves minimal movement of the head and neck, it may be a suit-
sues than other bougies.15,35 Using the Frova without the metal able method for intubating patients with known or suspected cervi-
cannula will reduce the incidence of tissue trauma. Single-use cal spine injuries. Digital intubation may be a useful procedure for
bougies may be more prone to cause soft tissue trauma when paramedics and aeromedical personnel in the out-of-hospital set-
compared to multiple-use bougies, especially if they are held close ting, when trapped patients require intubation but are not in a posi-
to the distal end.13,35 A false passage can be created by the tip of tion for more conventional methods.2 It is an alternative technique
the bougie penetrating the soft tissues.9 Insertion of an endotra- for out-of-hospital intubation where other techniques and equip-
cheal tube over the bougie and into a false passage can increase ment are unavailable or limited.
the amount of soft tissue damage and hemorrhage. Insufflation This procedure has also been performed successfully in intubat-
of air into the surrounding soft tissues can compress the trachea ing neonates.4,11,12 One study comparing neonatal digital intubation
and cause an external airway obstruction. A bougie can perforate with direct laryngoscopy demonstrated digital intubation to be
the airway and result in a tension pneumothorax.36 Advancement more rapid and more successful on the first attempt.5
CHAPTER 16: Digital (Tactile) Orotracheal Intubation 101
CONTRAINDICATIONS
There are no absolute contraindications to digital intubation. The
main danger of this procedure is to the healthcare worker perform-
ing the intubation, who is at risk for having his or her fingers bitten
by the patient. This technique should not be performed on any
patient who is awake or semiconscious. It should be performed
only on patients who are paralyzed or unconscious. Relative con-
traindications would be performing this procedure on a patient with
multiple fractured teeth that may abrade or cut the intubator’s fin-
gers, or a patient whose ingestion may present a biochemical hazard
to the intubator.
EQUIPMENT
• Wire stylet, malleable (optional)
• 10 mL syringe
FIGURE 16-1. The index and middle fingers are placed in the right side of the
• Water-soluble lubricant or anesthetic jelly patient’s mouth and advanced until the epiglottis is palpated. The endotracheal
• Bag-valve device tube is inserted into the patient’s mouth between the two fingers.
• Oxygen source and tubing
• Gauze, 4 × 4 squares between the two fingers and the tongue. Gently advance the tip of
the endotracheal tube into the patient’s trachea (Figure 16-2). Do
PATIENT PREPARATION not advance the endotracheal tube if any resistance is encountered.
Endotracheal intubation in the Emergency Department is com- Partially withdraw the endotracheal tube and reattempt to insert it
monly performed on an emergent or urgent basis. If there is time, into the patient’s trachea. Alternatively, withdraw the endotracheal
explain the risks, benefits, and complications of the procedure to the tube completely, bend it more sharply, and then attempt to insert
patient and/or the patient’s representative. it into the trachea. Have an assistant withdraw the stylet if one was
The use of gloves, a bite block, and gauze over the teeth as guards used. Advance the endotracheal tube approximately 3 to 4 cm.1,8
are recommended when performing this procedure. The patient While securely holding the endotracheal tube with the left hand,
should be lying supine. If the patient has sustained a concerning gently withdraw the right hand from the patient’s mouth. Inflate
mechanism of injury, the cervical spine should be immobilized. An the cuff of the endotracheal tube. Begin ventilating the patient
assistant can help hold the patient’s head to maintain in-line immo- while securely holding the endotracheal tube and confirming
bilization. Place the patient on continuous cardiac monitoring, proper placement.
pulse oximetry, and supplemental oxygen. The technique of digital orotracheal intubation is not as simple as
some may think. A patient’s mouth may appear too small to allow an
TECHNIQUE
Prepare the endotracheal tube. Attach a 10 mL syringe to the cuff ’s
inflation port. Inflate the cuff and inspect it for any air leaks. Deflate
the cuff and leave the syringe attached to the inflation port. The use of
a stylet is optional, but commonly used by most practitioners in this
procedure.6 It may be used if the patient’s larynx is anterior, the intu-
bator has short fingers, or it is the physician’s preference. Lubricate
and insert the stylet until it is 1 cm proximal to the distal end of the
endotracheal tube. Bend the malleable stylet just as it enters the endo-
tracheal tube. This will prevent it from migrating distally and injuring
the patient. Gently bend the distal end of the endotracheal tube into a
“J.”1 Liberally lubricate the distal end of the endotracheal tube. Induce
anesthesia (Chapters 8 and 10) if the patient is conscious.
The intubator should stand at the patient’s right side and be
facing the patient. Insert the index and middle fingers of the right
hand into the right angle of the patient’s mouth (Figure 16-1).1,5
Slide the fingers along the surface of the tongue until the epiglot-
tis is palpated. The metacarpophalangeal joints of the index and
middle fingers will usually be at the level of the patient’s incisors
in an adult. The tip of the epiglottis is approximately 8 to 10 cm
from the incisors. Elevate the epiglottis with the index finger
(Figure 16-2). The thumb of the left hand may be used to provide
cricoid pressure if needed.7
With the left hand, insert the endotracheal tube along the left side FIGURE 16-2. Advancing the endotracheal tube. The epiglottis is elevated with
of the patient’s mouth and between the two fingers (Figures 16-1 the index finger. The endotracheal tube is advanced between the fingers and into
& 16-2).1,5 Alternatively, the endotracheal tube can be advanced the larynx.
endotracheal tube and two fingers of the intubator. Use the fingers intubate a patient. It is an ideal method for intubating a comatose or
in the patient’s mouth to push their jaw and tongue forward. If the paralyzed patient if the upper airway cannot be visualized because
patient’s mouth still appears small, apply gauze squares over their of trauma, secretions, or blood. Digital intubation should also be
mandibular incisors and push their mouth open further with the considered when intubating the patient with a known or suspected
bases of the fingers in their mouth. cervical spine fracture, since this technique requires minimal head
It may be difficult to blindly identify the patient’s epiglottis. Insert and neck movement. It is also a viable method for out-of-hospital
your fingers in the midline of the patient’s mouth and slowly push intubation.
them posteriorly. The fingers will roll off the posterior portion of
the tongue and allow you to palpate the epiglottis. Be careful to not
push the epiglottis posteriorly. Once identified, move your fingers
to the right side of the patient’s mouth while the fingertips are in
constant contact with the epiglottis. Continue the procedure as
Lighted Stylet
described above.
Some may be concerned their fingers are not long enough to
palpate the epiglottis. Push the soft tissue in the right angle of the
17 Intubation
patient’s mouth posteriorly while inserting your fingers poste- Philip Bossart and Michael Wallace
riorly in their mouth. This will allow your fingers to reach more
posteriorly. INTRODUCTION
This technique can be used in patients of all ages, including neo-
nates.11,12 Use only the index finger of little finger when performing Direct laryngoscopy is the most common method of tracheal intu-
this procedure in young children. Use the appropriate size suction bation in the Emergency Department. However, in about 1% to 3%
catheter or endotracheal tube as would be used to orally intubate the of Emergency Department patients requiring intubation, direct
child. Do not insert the catheter or endotracheal tube if the child is laryngoscopy will be very difficult or impossible.1,2 This may be due
breathing using this technique or their vocal cords can be damaged. to many different causes including jaw immobility, limited cervi-
cal spine mobility, or excessive airway bleeding. In these situations,
blind intubation using a lighted stylet is a proven valuable tech-
ASSESSMENT nique.3–7 Lighted stylet intubation relies on the transillumination of
The placement of an endotracheal tube should be followed by an the soft tissues of the anterior neck to indicate intratracheal endo-
assessment to ensure its proper positioning (Chapter 12). This tracheal (ET) tube placement. A bright, well-defined glow is seen
includes visual inspection of chest rise and lack of abdominal in the anterior neck when the light is in the trachea. However, a
movement with ventilation, fogging in the endotracheal tube for at diffuse, less intense glow is seen with esophageal intubation. Lighted
least six breaths, auscultation, and end-tidal CO2 monitoring. This stylet intubation is a relatively easy technique to learn and rapid to
should be followed by a chest X-ray to confirm proper positioning perform.
of the endotracheal tube within the trachea. The first published report of using a light source to guide intu-
bation was in 1959.8 They described the device and technique in
order to perform blind nasal intubations in the operating room.
AFTERCARE However, this technique did not receive much attention until the
The steps of ensuring proper placement of the endotracheal tube late 1970s when the Flexi-lum light wand (Concept Corporation,
and securing the tube are the same as for any patient who has under- Clearwater, FL) was introduced.9 Over the years, more powerful
gone orotracheal intubation (Chapter 11). and less heat emitting light sources have been developed along
with more flexible stylets. Today there are at least four currently
COMPLICATIONS available devices, all of which are inserted into an ET tube instead
of a standard stylet. These include the Trachlight (Figure 17-1),
No significant complications to the patient have been identified the Light Wand (Figure 17-2), the Flexible Lighted Stylet
with digital intubation. One study involving a small number of (Figure 17-3), and the Tube-Stat (Figure 17-4). Although there
cadavers found that digital intubation predisposes to left mainstem are slight differences in design, they all rely on using a lighted sty-
intubation.9 The investigators concluded that decreased right-sided let to transilluminate the anterior neck and guide blind intubation
breath sounds after tactile intubation may represent an easily cor- of the trachea.
rected left mainstem intubation rather than other pathology. An
awake or semiconscious patient may gag, with subsequent vomiting ANATOMY AND PATHOPHYSIOLOGY
and aspiration and injury to the intubator’s fingers. For added safety,
insert a bite block between the patient’s molars if its placement still The trachea lies anterior to most structures of the neck and is cov-
allows enough space in the patient’s mouth for two fingers and the ered anteriorly only by skin, subcutaneous tissue, and pretracheal
endotracheal tube. The possibility of esophageal intubation is sig- fascia. A light source positioned within the trachea will transillu-
nificant, especially if the intubator has small fingers or the airway minate a bright and discrete glow that can easily be seen on the
is anterior. Hypoxemia can result from numerous attempts at intu- surface of the neck. In contrast, the esophagus lies posteriorly and
bation without any intervening ventilations. The endotracheal tube is surrounded by numerous soft tissue structures. A light source
should be inserted gently to prevent traumatic injury to the patient’s directed within the esophagus will be diffused by the surrounding
hypopharynx, vocal cords, or trachea.6 tissue and appears dull. At the bedside, the Emergency Physician
can easily discriminate between the dull, diffuse transillumination
of an esophageal light source and the more discrete, intense signal
SUMMARY transmitted from within the trachea. A submental, superior to the
Digital (tactile) intubation remains a viable alternative technique hyoid bone, glowing light indicates that the tip is positioned in the
for management of the airway. Every Emergency Physician should vallecula. A lateral glowing light indicates placement in the pyri-
become familiar with this technique. It is a rapid and safe method to form sinus.
CHAPTER 17: Lighted Stylet Intubation 103
TABLE 17-1 Indications for Intubating with a Lighted Stylet

Anatomic abnormalities Limited jaw mobility
Congenital head and neck anomalies Temporomandibular immobility
Pierre Robin syndrome Trismus
Treacher Collins syndrome
Midface hypoplasia Trauma
Dental trauma
Excessive secretions Maxillofacial trauma
Blood
Vomitus Miscellaneous
Unable to intubate by other methods
Limited cervical spine movement
Known or suspected cervical spine
FIGURE 17-1. The Trachlight (Laerdal Medical Inc., Wappinger Falls, NY). injury
Cervical arthritis
Burn strictures of the neck
INDICATIONS
There are numerous indications for lighted stylet intubation
(Table 17-1). Lighted stylet intubation is a valuable rescue technique
in patients who can be ventilated and oxygenated but are unable
to be intubated with direct laryngoscopy. It is particularly useful in
patients that have cervical spine immobilization or restricted neck
movement, limited jaw opening, extensive oral trauma, loose teeth,
or extensive blood or secretions in the hypopharynx that limit vis-
ibility. It can be used as a backup technique or primarily if direct
laryngoscopy is predicted to be difficult. There are limited data
FIGURE 17-2. The Light Wand (Vital Signs Inc., Totowa, NJ). comparing lighted stylet intubations to other rescue techniques.10–12
However, there is literature to suggest that lighted stylet intubations
are faster and have fewer complications than blind nasotracheal
and fiberoptic bronchoscopy-assisted intubations.6,11,12 In addition,
lighted stylets are easier to use, less expensive, and more portable
than fiberoptic bronchoscopes.12
Lighted stylet intubations can be performed as part of rapid
sequence intubation as well as on sedated, spontaneously breathing
patients with topical airway anesthesia. Lighted stylets can be used
for oral or nasal intubations.13 This technique can also be used for
pediatric patients and infants.14–16
CONTRAINDICATIONS
Intubation with lighted stylets is relatively safe and simple. There
are few contraindications to this technique. Patients with laryngeal
trauma should have direct laryngeal visualization for intubation
FIGURE 17-3. The Flexible Lighted Stylet (Aaron Medical, St. Petersburg, FL).
rather than a blind technique that may cause additional trauma.
As a blind technique, it should not be used if there is any active infec-
tion or known tumor of the posterior pharynx or upper airway. The
presence of epiglottitis, a retropharyngeal abscess, tracheal stenosis,
a laryngeal polyp or tumor, or an airway foreign body precludes the
use of this technology. It may be less successful in bright sunlight, in
those with very dark skin, and particularly in the obese patient.17,21,22
It is relatively contraindicated in patients who cannot be oxy-
genated and ventilated. However, it could be used in this situation
by very experienced physicians while simultaneous preparations
are underway for a cricothyroidotomy. Lighted stylets should be
used only by physicians who have sufficient experience and train-
ing with the equipment and the technique.
If the lighted stylet meets resistance, it should be withdrawn,
redirected, and advanced only if it passes with ease. Should unex-
pected difficulty occur during passage of the lighted stylet, the
FIGURE 17-4. The Tube-Stat Lighted Intubation Stylet (Medtronic Xomed Inc., technique should be abandoned and an alternative method used
Minneapolis, MN). to intubate the patient.
Check that the light source is working and apply a water-based

lubricant to the stylet. Attach a 10 mL syringe to the ET tube cuff
inflation port and ensure the integrity of the cuff. Insert the stylet
through the ET tube. The tip of the stylet should remain just inside
the ET tube so that the stylet does not damage soft tissues.
Bend the tip of the ET tube and stylet just proximal to the cuff or
about 3 to 6 cm from the distal end (Figure 17-5). The bend may
have to be a little more proximal or distal depending on the length
of the patient’s neck. Measure the mandibular–hyoid distance in the
FIGURE 17-5. The Trachlight brand lighted stylet patient. Place the index finger in the submental space below the chin
and determine the number of finger breadths between the mandible
and the hyoid bone.5 Typical measurements are one to three finger
breadths. Bend the tip of the ET tube and stylet sharply at a site
EQUIPMENT that approximates the mandibular–hyoid distance between the bend
• Lighted stylet and the junction of the lighted tip of the stylet. This is usually 3 to
• ET tubes, various sizes (ETT) 6 cm from the distal end of the ET tube and just above the cuff.
Avoid making the bend at the cuff, if possible, to prevent damaging
• 10 mL syringe the cuff. Be sure the bend is about 90° to allow the maximal light
• Water-soluble lubricant intensity to be directed anteriorly.
• Bag-valve device Stand above or to the side of the patient’s head. The lighted sty-
let, unlike the traditional laryngoscope, can be held in either hand.
• Equipment for orotracheal intubation (Chapter 11)
Lower the bed to facilitate insertion of the lighted stylet. Grasp the
The basic unit of a lighted stylet is quite simple. It consists of patient’s jaw with your nondominant hand. Place your thumb on
a handle, a malleable stylet, and a light on the end of the stylet the mandibular molars and your fingers under the body of the man-
(Figure 17-5). Numerous variations exist on the basic unit. The dible. Lift upward and inferiorly to open the jaw, elevate the tongue,
handle contains the battery, an on–off switch, and sometimes an and elevate the epiglottis. Grasp the lighted stylet with your domi-
on–off indicator light. They may be reusable or single-use dispos- nant hand and turn it on. It is best held with a “pencil-grip” over the
able devices. The stylet is malleable and available in numerous sizes. proximal ET tube.
Longer stylets allow for nasal and oral intubation in adults. Stylets Introduce the ET tube from the side of the patient’s mouth and
are also available in smaller lengths and widths to allow for use in bring it to the midline. As the hockey stick-shaped tip is placed
the small ET tubes for infants and children. The stylet is inserted over the tongue, the handle will project toward the patient’s feet
into the ET tube instead of a standard stylet. (Figure 17-6A). Advance the tip by moving the handle in a vertical
arc toward the patient’s head (Figure 17-6B). This will bring the
PATIENT PREPARATION ET tube tip toward the vocal cords. A bright light will be seen in
the midline of the neck just below the hyoid bone (Figure 17-7A).
Once the decision is made to intubate, the patient should be pre- If the light is in the submental space, the tip of the ET tube is in
pared as for any other intubation (Chapter 11). The patient should the vallecula (Figure 17-7B). If the light is lateral, the tip of the
have intravenous access secured and routine hemodynamic moni- ET tube is lodged in the pyriform sinus (Figure 17-7C). A dull,
toring, including an automatic blood pressure monitor, a cardiac faint light in the midline signifies that the tip of the ET tube is
monitor, and a continuous pulse oximetry monitor. Suction should in the esophagus (Figure 17-7D). If the glowing light is malposi-
be immediately available. Rapid sequence intubation with an induc- tioned, simply withdraw the ET tube, reposition it in the midline,
tion agent and paralytic agent is the most common technique used and advance it again.
in the Emergency Department. However, lighted stylet intubations Once a bright and discrete light is detected in the midline at the
can be performed with mild sedation and topical anesthesia in level of the thyroid cartilage (Adam’s apple), it is safe to advance the
cooperative patients. ET tube. If you are using the Trachlight, the manufacturer suggests
As with all intubations, the patient should be preoxygenated prior withdrawing the stylet 10 cm before advancing the ET tube. This
to airway manipulation. Unlike the case with other techniques, the makes the distal tip of the ET tube more flexible and helps it make
position of the neck can be neutral. The “sniffing” position is not the acute turn before advancing down the trachea.
required for this technique. If the patient is in a cervical collar, the Advance the ET tube while observing the transilluminat-
anterior half must be opened or removed to be able to visualize ing light march down the neck to the suprasternal notch
the glowing light. An assistant can maintain in-line stabilization of (Figure 17-7A). The light will disappear as the tube passes behind
the cervical spine when the collar is opened. the suprasternal notch. If the glowing light is in the midline and the
ET tube is resistant to advancement, the epiglottis is obstructing its
TECHNIQUE advancement. Slightly rock the unit in the sagittal plane (from the
patient’s head to the feet) to slip the tip of the ET tube under the
■ OROTRACHEAL INTUBATION epiglottis. If resistance is still encountered, remove the lighted stylet.
The exact technique will depend upon the type of lighted stylet or Ventilate the patient with a bag-valve-mask device. Load a smaller
lightwand used. Since this technology varies by the manufacturer, ET tube onto the lighted stylet and try again. At the point the light
anyone employing these airway adjuncts should be familiar with is lost, the tip of the ET tube is appropriately positioned midway
the equipment and manufacturer’s instructions prior to adopting between the vocal cords and carina.25 Remove the stylet, inflate the
them for use clinically. This text describes the general guidelines for ET tube cuff, confirm proper ET tube placement, secure the ET tube
the lighted stylets available at the time of this writing. The reader at the lips, and begin ventilating the patient.
is urged to take advantage of the teaching videos supplied by some Special caution should be used in very thin or very obese patients.
manufacturers. In the thin patient, a bright light may be visible even when the stylet
CHAPTER 17: Lighted Stylet Intubation 105
FIGURE 17-6. Insertion of the Trachlight lighted stylet. A. Insert the hockey stick-shaped ET tube and the stylet over the tongue. B. Move the tube in a vertical arc toward
the patient’s head. As the lighted stylet approaches the trachea, the bright light transilluminates the anterior neck. C. The ET tube is advanced into the trachea.
is in the esophagus. When the patient is thin, gently rock the light off intensifies after it exits the esophagus. Readvance the lighted stylet,
midline to compare the diffuse dull light to that seen when the light as previously described, while applying anterior traction on the unit
is truly midline. In the obese patient, the extra soft tissue may dull to help it enter the larynx.
the light. Dim the room lights to facilitate adequate visualization.
The glowing light must maintain a continual brightness to ■ NASOTRACHEAL INTUBATION
demonstrate tracheal intubation. If the glowing light is briefly The procedure for nasotracheal intubation is similar to orotracheal
lost or dulls and then returns, the ET tube has been misplaced intubation with the lighted stylet with a few differences. The nasal pas-
in the esophagus. The brief loss or dulling of the glowing light cor- sages should be treated with a topical anesthetic and a topical decon-
responds to its passage behind the larynx. The return of the bright gestant to vasoconstrict the mucosal tissue. The nasal passage may
glowing light corresponds to the ET tube advancing past the larynx need to be dilated to accommodate the ET tube. Please refer to Chapter
and into the esophagus. This is commonly seen in infants, small 22 for a complete discussion on the preparation of the nasal cavity for
children, and very thin adults. Gently withdraw the lighted stylet intubation. The lighted stylet should have a more gentle curve of about
while applying anteriorly directed traction to the tip of the stylet. 100° to 120°. The bend to tip length should correspond to the distance
Stop withdrawing the lighted stylet when the glowing light suddenly from the posterior nasopharynx to the cricothyroid membrane.
FIGURE 17-7. Appearance of the transilluminated light of the lighted stylet based on the location of the tip. A. Proper placement in the larynx with a bright distinct light in
the midline at the level of the thyroid cartilage. With advancement of the ET tube, the light moves down the anterior neck and disappears behind the sternal notch (dashed
arrow). B. Incorrect placement in the vallecula causes a submental glow, superior to the hyoid. C. Incorrect placement in the pyriform sinus causes a glow off the midline.
D. Incorrect esophageal placement causes a diffuse, dull, or absent light.
ASSESSMENT likely to be of greatest benefit in the occasional unexpected airway

emergency, maintaining sufficient skills to use it in the emergent
The patient should be assessed continuously at every step of the setting is a challenge. In order to be of use in the acute situation,
procedure to assure adequate oxygenation and ventilation. The Emergency Physicians will need to devote time and effort to devel-
position of the ET tube should be confirmed by end-tidal CO2 mon- oping and maintaining the skills they will need to cope with an air-
itoring, esophageal detector device, fogging in the ET tube for at way emergency when it presents.
least six ventilations, auscultation, and chest X-ray. Please refer to
Chapter 12 for a more complete discussion regarding the confirma-
tion of ET intubation.
AFTERCARE
Supraglottic
The ongoing care of the patient should proceed as with any other
intubation technique. Routine care of the ET tube is no different.
18 Airway Devices
The manufacturer’s guidelines should be followed for maintenance Fred A. Severyn
of the equipment.
COMPLICATIONS INTRODUCTION
Airway management remains one of the cornerstones of the clinical
Intubation with a lighted stylet is a very safe procedure with a very
practice of Emergency Medicine in both the Emergency Department
low complication rate.6,17 In over 30 years of use, there are only a
and the prehospital environment. The majority of advanced airway
small number of reported complications. These include two reports
placements in the prehospital environment occur in the cardiac
of accidental bulb dislodgment, two arytenoid dislocations, one case
arrest or trauma patient. Advances in the science of perform-
of stylet fracture, a lacerated frenulum, and varied reports of mild
ing better cardiopulmonary resuscitation (CPR) aim to limit the
soft tissue trauma.18–20 However, sore throat, hoarseness, and dys-
“no-flow-time” associated with resuscitation. Most supraglottic
phagia seem to occur less frequently with lighted stylets than with
airway devices aim for an insertion time under 30 seconds. Some
direct laryngoscopy.7 The cases of equipment failure noted above
Emergency Medical Service (EMS) systems have emphasized the
have been in older models of lighted stylets. There are data to suggest
use of an alternative airway device over endotracheal intubation.1,2
that lighted stylet intubations are less traumatic than direct laryngos-
In the overall performance of airway management, the provider
copy.7 No complications were noted in 253 patients intubated with
often begins with the basic life support (BLS) skill subset such as
light stylets.17 In addition, intubation with lighted stylets may cause
airway positioning, suctioning, and assisting spontaneous res-
less cervical spine motion compared with direct laryngoscopy.25
pirations with the use of a bag-valve-mask (BVM) device. They
Success rates with lighted stylet intubation are comparable to those
then jump to the advanced life support (ALS) skill subset such as
with other techniques. First attempt success rates are reported to be
placement of cuffed endotracheal tubes and surgical airway man-
from 70% to 92%.4,6,7 When multiple attempts were allowed, success
agement. Traditional ALS management has revolved around the
rates approached 100%. In the prehospital setting with suboptimal
concept of placing an endotracheal tube. Over time, this has rolled
intubating conditions, success rates of 88% have been reported.21
out to the prehospital environment of care and is now firmly estab-
Hung et al. reported successful intubation with lighted stylets in 95
lished into the current scope of practice for EMS professionals. The
out of 96 patients who had known difficult airways.22 This series
literature remains controversial and divided, with multiple recent
included patients with difficult or failed intubations by direct laryn-
studies suggesting limited benefit of prehospital endotracheal intu-
goscopy, patients with unstable cervical spines, severe jaw immobil-
bation in a variety of clinical settings. Even more disheartening are
ity, and morbid obesity. Holzman et al. reported successful intubation
numerous studies demonstrating a significant percentage of unrec-
of 30 out of 31 children with anatomic airway abnormalities.14
ognized esophageal airway placement or endotracheal tube migra-
Intubation times with lighted stylets are comparable to those with
tion out of the airway upon Emergency Department arrival. Such
other techniques and range from 16 to 45 seconds.3,4,22 There does
therapeutic misadventures guarantee bad outcomes.3 Most of these
not appear to be any significant difference in degree of sympathetic
studies describe relatively busy EMS systems with clearly defined
stimulation and hemodynamic alterations between intubations with
medical oversight. With inexperienced hands, the success rate is
direct laryngoscopy and those with lighted stylets.23,24 The skill level
lower and the complications rates are high, and aggressive airway
of the intubator is an important factor in the success rate, time to
management has been linked to a decreased odds ratio for patient
intubation, and possible complication rate.14 Experience leads to
survival. In between BLS and ALS lies a very large grey area, with
faster intubation times and skills most likely will improve with prac-
many airway adjuncts available to help with airway management.
tice in a cadaver lab or with a patient simulator.5,10
The creation of a wide variety of airway adjuncts termed “supra-
glottic airway devices” (SADs) has occurred in order to facilitate
SUMMARY airway management. Simplistically, SADs function as a bridge
Lighted stylet intubation is an easily learned technique that is a valu- between the mouth and the vocal cords, allowing for air movements
able adjunct for securing difficult airways. It is particularly useful while bypassing tongue-induced airway obstruction.4 Some recom-
in patients with limited jaw opening, limited neck movement, and mended the term “extraglottic” to replace supraglottic in order to
marked airway bleeding. The American Society of Anesthesiologists better define the relationship between function and not define ana-
includes use of lighted stylets in its recommendations for the manage- tomic position. For the purposes of this chapter, the two terms will
ment of difficult airways. The American Heart Association encour- be considered synonymous.
ages instruction in alternative airway approaches, including lighted The classic laryngeal mask airway (LMA) is a common example
stylets, for difficult airways. The use of lighted stylets has proven to be of a SAD. It is utilized daily in operating room cases with a cumu-
rapid, safe, and effective in emergent and difficult settings. lative record of over 200 million episodes of use in patient care.4,5
The success of lighted stylet techniques is determined by the Most Emergency Physicians in training will get some exposure to
experience of the Emergency Physician. Since this technique is the use of SADs as a result.5 Not surprisingly, the logical migration
CHAPTER 18: Supraglottic Airway Devices 107
of airway devices from the operating room to the prehospital and relative contraindications to using a SAD. These devices are contra-
Emergency Department environments has also begun. Each SAD indicated in the patient with known esophageal disease, a caustic
comes with manufacturing claims as to their device superiority over ingestion, or airway burns. Many SADs require the patient to be
the competition in a very competitive marketplace. It is difficult for over a certain height and/or weight to be used. Refer to the spe-
Emergency Physicians to keep up with the industry explosion of cific manufacturer recommendations when choosing a SAD and the
these airway adjuncts. The disadvantages of SADs are that they are appropriate size.
only temporary airway devices and must be removed or replaced
with another airway device within a few hours. EQUIPMENT
The Emergency Physician will be on the receiving end of patients
in which a wide variety of SADs have been used by EMS agencies. • SADs, various types and sizes
There is also a need for SADs in the event of airway rescue after • Endotracheal tubes
a failed intubation in the Emergency Department. The American • Water-soluble lubricant
Society of Anesthesiologists has incorporated SADs into their “Can’t
• Syringes, various sizes
ventilate, Can’t intubate” difficult airway algorithm. The American
Heart Association has also included their use in the algorithms • Oxygen source, tubing, and regulator
for airway management in association with CPR. It is a reason- • Face masks
able expectation for the Emergency Physician to develop exper- • Bag-valve device
tise and experience with SADs. This chapter discusses some of the
many commonly available SADs. The LMAs and supraglottic dual • Pulse oximeter
lumen airway tubes (i.e., Combitube and EasyTube) are discussed in • Cardiac monitor
Chapters 19 and 20, respectively. • Noninvasive blood pressure monitor
• ALS medications
• Advanced airway equipment
Endotracheal intubation relies upon the placement of a ventilation • Surgical airway equipment
tube between the vocal cords and into the trachea in order to pro-
vide a low resistance bridge between the trachea and the ventila- There are at least 17 variations of SADs on the market today. They
tion circuit. This bypasses the most common airway obstruction, are conceptually divided into three broad categories based on the
the posteriorly directed lax tongue. SADs do not pass between the primary separation between the respiratory and gastrointestinal
vocal cords. SADs offer low resistance to air flow, protect the tracts. These include cuffless anatomic preshaped sealers, cuffed
respiratory tract from gastric and oropharyngeal secretions to a perilaryngeal sealers, and cuffed pharyngeal sealers.6,7
variable degree, and are suitable for positive pressure ventilation The cuffless anatomic preshaped sealers are flexible devices
in the nonspontaneously breathing patient while limiting poten- whose shape is based on spiral computed tomography (CT) scan
tial adverse events.5 They rely on the close anatomic relationship investigations of normal subjects of varying heights and weights.8
between the laryngeal inlet and the upper esophagus. Many SADs These studies created a design template for a device that when
allow the insertion of an introducer or an endotracheal tube to be inserted will accommodate the “normal” airway in the majority of
passed through the airway tube and into the trachea. cases.8 Without an inflatable separation between the respiratory and
gastrointestinal tracts, there is less flexibility to their design and use.
These devices offer less protection from aspiration of gastric con-
INDICATIONS
tents than other SADs. SADs in this category include the single use
The use of SADs is reserved for the unconscious patient without liner of pharyngeal airway or SLIPA (Hudson RCI, Research Triangle
an intact gag reflex. They can be used in the unconscious patient Park, NC) and the I-gel (Intersurgical Ltd., Berkshire, England). The
who is difficult to ventilate with a face mask while preparations SLIPA (Figure 18-1) is more commonly used in the operating room
are being made for endotracheal intubation. The patient’s mouth
must be able to open at least 1.5 to 2.0 cm to allow for the insertion
of the SAD. They can be used as either a primary or secondary
airway. They are used more commonly as a primary airway, replac-
ing the endotracheal tube, in the prehospital environment. They
are used in the prehospital environment, and more often in the
Emergency Department, as a secondary airway or rescue airway
management device in cases of difficult or failed intubations. They
should be considered in the “can’t ventilate, can’t intubate” patient
when time is of the essence. Their use as a rescue airway device
can “buy time” until additional airway assistance, equipment, and/
or expertise can be brought to the patient. Consider using SADs
during the initial resuscitation of the cardiac arrest patient as they
are quick to insert and do not require stopping chest compressions
during CPR.
CONTRAINDICATIONS
The presence of an intact gag reflex is an absolute contraindication
to the use of SADs, regardless of which device is used. The inability
to open the patient’s mouth at least 1.5 to 2.0 cm will prevent the
insertion of most SADs. Oral, pharyngeal, and laryngeal trauma are FIGURE 18-1. The SLIPA.
FIGURE 18-2. The I-gel.
than the Emergency Department. The I-gel (Figure 18-2) can often
be found in the Emergency Department difficult airway cart. The FIGURE 18-3. The CobraPLA (Photo courtesy of Pulmodyne Inc., Indianapolis, IN).
I-gel performs as well as the LMA-Supreme in both ventilation and
protecting the airway from aspiration.9
Cuffed perilaryngeal sealers include the LMA (LMA North
America, San Diego, CA), its many variations, and other manu-
facturers’ laryngeal mask devices. These balloon sealers impact
above the laryngeal inlet. The narrowest part of the inflatable
lumen wedges into the upper esophagus, theoretically limiting gas-
tric inflation during positive pressure ventilation. Design advances
have allowed for inclusions of a potential gastric channel in the
tip of the laryngeal mask that allows for placement of a narrow
(typically 14 French or smaller) gastric tube for gastric suction
and decompression. Refer to Chapter 19 for the complete details
regarding LMAs.
Cuffed pharyngeal sealers utilize a design in which a balloon
seals the hypopharynx at the base of the tongue, preventing pas-
sive air escape through the mouth. Downstream from the hypopha-
ryngeal occluding balloon are a number and variety of ventilation
apertures that allow air to pass into both the trachea and esopha-
geal lumens. This category of SADs can be subdivided into those
devices with and without a second balloon for the esophagus.
Those devices without distal downstream esophageal balloons A
have a less specific anatomic placement. This may require more
device manipulation to allow for easy ventilation, with a theoreti-
cally lower aspiration protection. Devices in this category include
the cuffed oropharyngeal airway or COPA (Covidien, Mansfield,
MA), PAexpress or PAX (Vital Signs Inc., Totowa, NJ), and the
CobraPLA and CobraPlus (Pulmodyne Inc., Indianapolis, IN). Of
these, the CobraPLA (Figure 18-3) may be found in the Emergency
Department difficult airway cart.
Cuffed pharyngeal sealers with esophageal balloons not only
occlude the airway at the base of the tongue, but the esophageal bal-
loon theoretically isolates the esophageal lumen from the respira-
tory tract. Devices in this category include the Combitube (Kendall
Sheridan, Mansfield, MA), the EasyTube (Teleflex Medical,
Kernen, Germany), and the King Laryngeal Tubes (King Systems,
Noblesville, IN). All of these SADs may be found in the Emergency
Department difficult airway cart. Refer to Chapter 20 regarding the
complete details of the Combitube and EasyTube. These two SADs B
are more commonly used in the prehospital environment for a pri-
mary or secondary airway. The King Laryngeal Tubes (Figure 18-4) FIGURE 18-4. The King Laryngeal Tubes. A. King LTD models. B. King LTS-D
are available in several models. models (Photos courtesy of King Systems Inc., Noblesville, IN).
CHAPTER 18: Supraglottic Airway Devices 109
The specific equipment needed for the various SADs will vary relatively effortless air movement between the patient and the bag-
slightly according to the device used, but is relatively similar. The valve device. Successful placement of the SAD is most accurately
majority of the airway adjuncts are silicone based, and require the demonstrated by auscultation of bilateral breath sounds, chest wall
use of a water-soluble sterile lubricant to help ease airway placement movement, and end-tidal CO2 monitoring. One may also gain a
without mucosal trauma from abrasion. Size appropriate airway sense of accuracy of placement during insertion.
adjuncts must be chosen for the individual patient’s anatomy. There exists the possibility of failure to insert, migration of place-
ment after insertion, or the failure to maintain an adequate internal
PATIENT PREPARATION seal that prevents effective patient positive pressure ventilation.3 If
the patient cannot effectively be ventilated or oxygenated, remove
The patient should be appropriately monitored with electrocardiog- the SAD and fall back to BLS skills until either additional expertise
raphy (ECG), end-tidal CO2 monitoring, noninvasive blood pres- arrives or another airway option is available and successful.
sure cuff, and pulse oximetry. The patient preparation is exactly the
same as that for orotracheal intubation. As for any situation where AFTERCARE
airway manipulation is to occur and the patient’s protective airway
reflexes are blunted or ablated, a fully functioning suction apparatus Secure the SAD similar to that of an endotracheal tube. Place the
with a variety of catheters must be immediately available. Insertion patient on a ventilator. Periodically reevaluate the SAD to ensure
of the SAD requires an anesthetic depth similar to that which allows its position has not changed and it is still providing appropriate
placement and acceptance of an oropharyngeal airway. Successful ventilations. The SAD may need an occasional position adjust-
placement of the SAD is much more likely if the patient is premedi- ment during ventilation.
cated. The optimal induction agent should produce jaw relaxation The SAD does not protect against aspiration as well as an endo-
and attenuation of airway reflexes, permitting insertion of the SAD tracheal tube. It should be replaced with an endotracheal tube or a
within 30 to 60 seconds of loss of consciousness. A variety of induc- surgical airway. The method of securing the airway with a device
tion agents may be used. other than a SAD will be determined by the patient’s condition, if
Select the appropriately sized SAD. Inflate the cuff(s), if present, they have a “difficult airway,” available equipment, and experience
to ensure that there are no air leaks. Deflate the cuff(s) and leave the of the Emergency Physician. Some SADs allow the passage of an
air-filled syringe(s) attached to the SAD. Liberally lubricate the SAD endotracheal tube through the airway tube similar to the LMAs.
with a water-soluble lubricant to aid in its insertion.
COMPLICATIONS
TECHNIQUE There are numerous documented complications associated with
The basic insertion technique begins with choosing the appropri- the use of SADs. One of the most obvious of these and potentially
ate SAD and size. Gently access the airway. Use the nondominant the most devastating is the failure to place the device successfully
thumb and forefinger in a scissors-like manner to open the patient’s or to obtain a satisfactory seal. Fortunately, even in inexperienced
mouth, allowing for device insertion. Insert the liberally lubricated hands, the incidence of failure to achieve satisfactory ventilation
SAD. Insert the SAD until either resistance is noted, markers on the is quite low. Failure to place a SAD appropriately with inadequate
airway tube are at the incisor level, or the airway sealing balloon is ventilation has been estimated to occur in up to 5% of all insertions.
situated in the hypopharynx and cannot be advanced any further The SAD can be displaced if the patient moves their head or their
depending on the device.10 head and neck is moved during transportation and transfers.
Most SADs utilize a balloon cuff surrounding the air lumen that The insertion can result in mucosal damage and abrasions, espe-
limits leakage of instilled air back into the oropharyngeal cavity and cially if not properly lubricated or forcefully inserted. Unilateral
into the environment. The cuffless preshaped pharyngeal sealers do vocal cord paralysis can occur secondary to traumatic insertion.
not have a cuff that requires inflation. Each cuffed SAD has a range Bilateral vocal cord paralysis has not been reported. Dental trauma
of air required for cuff inflation. Inflate the cuff with the recom- may occur during the insertion or during maintenance of the airway.
mended volume of air. Injection of higher volumes of air above The cuffs are large and thin, thus they may be torn during use.11,12
the recommended volume risks SAD migration, airway or esoph- Overinflation of balloons and cuffs can result in tissue ischemia,
ageal trauma, balloon herniation over the airway passage ports, erosion, and rupture. Herniation of pharyngeal and airway struc-
or device rupture. tures into the SAD has been documented utilizing fiberoptic air-
The success rate for first pass insertion of SADs varies depending way evaluation.13 Trapping of the epiglottis in the distal aperture of
on the device, the indication for placement, the setting, and the per- the SAD may result in edema of the epiglottis. The oropharyngeal
son performing the procedure. Success rates between 72% and 95% balloons have been linked to the development of tongue swelling
are documented throughout the literature. secondary to venous congestion as a potential complication with
Begin ventilating the patient. Attach a bag-valve device to the prolonged use.11,14,15 Lingual nerve injury, tongue numbness, parotid
SAD airway tube and begin ventilations. Minor manipulations of gland swelling, and hypoglossal nerve palsy are sometimes noted.
the SAD may be required to maximize the ease of ventilation in SAD placement in the patient with an intact gag reflex can induce
each particular patient. Slightly rotate or withdraw the SAD with emesis and aspiration. Emesis and aspiration are associated with a
the nondominant hand while ventilating through the device until decreased survival.1,16,17 Always be vigilant to suspect, prevent, and
ventilations are smooth and without resistance. Repositioning of the identify aspiration. When the SAD permits, provide gastric decom-
airway device during its use over time may be required in up to 18% pression via a suction tube prior to device removal or additional
of patients.10 airway manipulation.18
ASSESSMENT SUMMARY
The SAD allows for air movement into the trachea, with varying Supraglottic airway devices can be effectively utilized for both pri-
degrees of potential air leakage into the digestive system during mary and secondary airway management in both the Emergency
positive pressure ventilation. Successful placement will allow for Department and the prehospital environment. A highly competitive
marketplace has allowed for a wide variety of constructions. These also referred to as the ILMA. It allows ventilation during intubation
devices are relatively simple and quick to insert. They provide an attempts. Its advantages include the following: no manipulation of
effective bridge between the tracheobronchial tree and the ventilat- the head and neck is required, it can accommodate up to a size 8
ing device. Many EMS agencies utilize SADs as either a primary or ET tube, it facilitates one-handed insertion, it can be inserted from
secondary airway. The Emergency Physician must be familiar with the patient’s side or from above the head, and it can be used in con-
their use and limitations. junction with fiberoptic intubation. The LMA ProSeal (LMA-PS)
features a cuff deflator, modified cuff design, dual tubes, and a
bite block. Similar to the LMA-PS, the LMA Supreme (LMA-S)
has a built-in drain tube and a bite block. However, the LMA-S is
intended for a single-use and has a more curved airway tube than
Laryngeal Mask the LMA-PS. The LMA CTrach (LMA-CT) includes an insertion
19 Airways
site for an ET tube and allows for direct visualization of the larynx
using built-in fiberoptics. The Ambu laryngeal mask (Ambu LM)
has an airway tube that is curved more acutely than the LMA-Cs.
Katrin Takenaka and Theltonia Howard This curve follows the anatomy of the upper airway and allows for
easier insertion without having to manipulate the head or neck.
INTRODUCTION The standard LMA, ILMA, LMA-PS, LMA-CT, or Ambu LM
may be available in the Emergency Department. The techniques for
The laryngeal mask airway (LMA) is a device that fills the gap in
inserting these devices are discussed in this chapter. The anatomic
airway management between that of endotracheal (ET) intuba-
differences between these devices produce subtle differences in
tion and the use of a face mask. It was introduced in the United
their insertion methods. The indications, contraindications, assess-
Kingdom in 1983 by British anesthesiologist A. I. J. Brain. His goal
ment, and complications associated with these devices are largely
was to develop an airway apparatus that could rapidly overcome an
identical.
obstructed airway, is simple to use, and is atraumatic to insert. In
1991, the LMA was approved for use in the United States by the
Food and Drug Administration.
The LMA was designed primarily as a means of providing venti- The anatomy of the airway is briefly reviewed (Figure 19-1). Refer
latory support while avoiding the fundamental disadvantage of the to Chapter 6 for the complete details of the airway anatomy. The oral
need to visualize and penetrate the vocal cords with an ET tube.1 cavity is bounded by the hard and soft palate above and the anterior
The LMA is introduced into the hypopharynx without direct visu- portion of the tongue and the reflection of its mucosa onto the floor
alization. It forms a low-pressure seal around the laryngeal inlet and of the mouth below. Posteriorly, the mouth opens into the orophar-
permits positive-pressure ventilation. With the introduction of the ynx through the oropharyngeal isthmus. The pharynx is a U-shaped
LMA ProSeal, pressures of up to 30 cmH2O may be administered tube extending from the base of the skull to the level of the cricoid
safely (A.I.J. Brain, M.D., personal communication). Once inserted, cartilage, at which point it becomes continuous with the esophagus.6
the LMA may be used as a conduit for fiberoptically guided ET
intubation or to place an ET tube blindly.2 The LMA has come to
be viewed as a viable method of airway management, with over
800 articles and case reports describing the advantages and disad-
vantages of the device.3 A more recent Medline search for articles
involving the use of LMAs yielded over 3500 results. Hard palate
Many disadvantages of the standard LMA became apparent with
widespread use of the device. More than 10 years after its introduc-
tion, Dr. Brain and colleagues began to work on a new airway system
with better intubation characteristics than the standard LMA. The Soft palate
intubating laryngeal mask airway (ILMA) was developed through
the aid of analysis of magnetic resonance images of the human phar- Oropharynx
ynx and laboratory testing of ET tubes.4 The new and more “ana-
Palatine tonsil
tomically correct” ILMA effects more precise placement. The design
of the ILMA also avoids head and neck manipulation and insertion Vallecula
of the intubator’s fingers into the patient’s mouth, both of which Tongue
Epiglottis
occur during the placement of the standard LMA.4,5
There are approximately nine different models of the LMA. The
term “laryngeal mask airway” is specific to one brand of laryngeal Mandible
mask devices produced by LMA North America, San Diego, CA.
Several other manufactures also make laryngeal mask devices. Some Esophagus
of these will also be described in this chapter. The LMA Classic Hyoid bone
(LMA-C) is the original and most commonly used version. The LMA Vestibular fold, ventrical Larynx
Classic Excel (LMA-CE) is more durable than the original LMA-C of larynx and vocal cords
and can be reused up to 60 times. The LMA Unique (LMA-U) is a
single-use disposable version of the LMA-C. The LMA Flexible is a Thyroid cartilage
wire-reinforced version of the LMA that is more flexible than the Cricothyroid membrane Trachea
original version and resists kinking. It is used by Anesthesiologists Anterior arch of cricoid cartilage
for patients undergoing head and neck procedures. It is not used in
the Emergency Department. The LMA Fastrach is a modified ver- FIGURE 19-1. Midsagittal section of the head and neck demonstrating the airway
sion of the LMA that allows ET intubation through the unit. It is anatomy.
CHAPTER 19: Laryngeal Mask Airways 111
LMA devices may be used in the event of a failed ET intuba-

tion. They have a role in securing the airway presumptively in
patients with an “anteriorly” situated larynx, a situation whereby
direct laryngoscopy and ET intubation are historically difficult. In
emergent situations, the LMA is a safe alternative to the esophageal
obturator airway, King tube, Combitube, and EasyTube. The LMA
has also proved to be useful in burn patients requiring repeated
dressing changes, especially of the face. Finally, the LMA may well
be the airway technique of choice for professional singers who
require short-term airway management since there is less like-
lihood of causing vocal cord or laryngeal nerve injury with this
approach.7
However, in all its uses, there is a conspicuous absence of air-
way protection from aspiration. The LMA-PS and LMA-S are
being marketed as superior to the LMA-C for use in nonfasting
patients. These versions feature an improved laryngeal seal for per-
mitting positive-pressure ventilation at pressures up to 30 cmH2O
and a drain tube in tandem with the airway tube. The drain tube
facilitates blind insertion of a gastric tube for decompressing the
stomach. An introducer aids insertion of the LMA-PS while obviat-
ing the need to introduce fingers into the patient’s mouth.
CONTRAINDICATIONS
There are no absolute contraindications to the use of LMAs.
However, there are several relative contraindications. These devices
should not be used in individuals who are at an increased risk of
regurgitation or aspiration unless the benefit of securing an airway
outweighs the risk of aspiration (e.g., when other techniques for
securing the airway have failed).8 This is supported by uncontrolled
studies using fiberoptic bronchoscopy, which have shown that the
esophagus is visible within the LMA mask in 6% to 9% of patients.7
Patients at high risk for aspiration include those with previous upper
FIGURE 19-2. Sagittal view of the airway demonstrating correct placement of gastrointestinal surgery, known or symptomatic hiatal hernia, gas-
the LMA. troesophageal reflux disease, women more than 10 weeks pregnant,
patients with intestinal ileus or peptic ulcer disease, obese patients,
or those individuals who are not fasted.5,9,10
The larynx extends from its oblique opening bordered by the aryepi- In emergent situations where cricoid pressure is needed to pre-
glottic folds, the tip of the epiglottis, and the posterior commissure to vent active or passive regurgitation of stomach contents prior to
the base of the cricoid cartilage.6 The esophagus lies posterior to the airway placement, the LMA is not an appropriate airway device.
airway. When inflated and properly positioned, the tip of the device It will not prevent subsequent aspiration of stomach contents as effi-
will lie in the esophagus at the level of the upper esophageal sphinc- ciently as will a cuffed ET tube. The act of placing an LMA after
ter and directly posterior to the cricoid cartilage (Figure 19-2). the application of cricoid pressure (i.e., the Sellick maneuver) has
been shown to have a significantly high failure rate.7 The LMA-PS
INDICATIONS and LMA-S feature dual tubes (i.e., airway and drain) as well as a
modified cuff designed to provide separation of the respiratory and
The indications for the use of an LMA device parallel the general alimentary tracts. As a result, they may prove invaluable in negating
indications for active airway management. These include the cor- this “Achilles’ heel” of the standard LMA.
rection of hypoxemia or hypercarbia, the provision of controlled These devices should not be used in individuals with severe respi-
hyperventilation, the provision of a secure airway in the presence ratory diseases.2,9,10 Specifically, individuals with airway obstruction
of obstruction, and the provision of airway access for pulmonary at or below the larynx and those with low pulmonary compliance or
hygiene and bronchoscopy. An LMA may aid in supporting airways high airway resistance (e.g., morbid obesity, bronchospasm, pulmo-
that are difficult to manage as well as being an invaluable aid to nary edema, pulmonary fibrosis, or thoracic trauma) are not appro-
blind and fiberoptic intubation. The success rate of correct place- priate candidates for LMAs. The only possible exception is that it
ment in inexperienced hands approaches 90%.7 This makes the can be inserted as a temporary airway rescue device in prepara-
LMA superbly suited for use by medical personnel who have had tion of another method of ET intubation or a surgical airway.
only a minimal amount of training in airway management. Patients must be able to assume the “sniffing” position, analo-
Airway control also facilitates emergent radiographic investiga- gous to that of individuals positioned for direct laryngoscopy prior
tions, for example, computed tomography (CT) or magnetic reso- to ET intubation. Patients who cannot passively or actively extend
nance imaging (MRI) scans without motion artifact.6 The standard their head and flex their neck are not candidates for the LMA-C,
LMA contains no ferromagnetic components and is a suitable alter- LMA-CE, LMA-U, or LMA-S. The ILMA, LMA-CT, LMA-PS with
native to an ET tube in many situations. It is ideal for use in patients an introducer, or the Ambu LM are more appropriate for these
emergently requiring diagnostic MRI scans. Use of the LMA does patients. Patients should not receive these devices if they cannot
not require a metal laryngoscope, which is contraindicated if a open their mouth at least 1.5 cm due to anatomic limitations (e.g.,
patient requires airway management in the MRI suite. ankylosing spondylitis, severe rheumatoid arthritis, cervical spine
instability, etc.).7 This is one situation where blind nasotracheal

intubation or fiberoptically guided nasotracheal tube placement has
an advantage over the LMAs.
Finally, the LMA is relatively contraindicated in cases of pharyn-
geal pathology. This includes but is not limited to abscesses, caus-
tic ingestions, hematomas, and tissue disruptions. These processes
make the use of the LMA difficult. The device may rupture abscesses
and hematomas, causing the patient to aspirate. The use of an LMA
after a caustic ingestion can result in perforation of the eroded
upper esophageal or hypopharyngeal walls from the pressure of the
inflated cuff.
EQUIPMENT
• LMAs, various types and sizes
• ET tubes
• Water-soluble lubricant
• Syringes, 10 and 20 mL
• Oxygen source, tubing, and regulator
• Face masks
• Bag-valve device
• Pulse oximeter
• Cardiac monitor
• Noninvasive blood pressure monitor
• Advanced Cardiac Life Support (ACLS) medications
• Advanced airway equipment
• Surgical airway equipment
LMA CLASSIC (LMA-C) AND UNIQUE (LMA-U)

The standard LMA preceded the ILMA by more than a decade. The
prototype of the LMA was constructed by forming a shallow mask
with an inflatable rubber cuff joined to a tube communicating with
the lumen of the mask at an angle.1,2 The modern LMA is made of
flexible silicone, is completely latex-free, and has a more tapered
FIGURE 19-3. The LMA-C (Photo courtesy of LMA North America, San Diego, CA).
appearance. It has a variably sized, internally ridged tube fused at a
30° angle to a spoon-shaped mask with a flexible rim.
The LMA-C is a disposable unit that can be used multiple times.
It must be sterilized between uses following specific manufacturer tube has a large bore and is clear, like an ET tube.2 The proximal
recommendations. The LMA-U is similar in construct to the LMA- end contains a standard 15 mm airway adapter that can connect to
C. However, the LMA-U is a single-use device. These LMAs are a bag-valve device or a ventilator. A black line along the posterior
designed to conform to the contours of the hypopharynx, with the border is used as a marker for proper positioning. The distal end of
lumen facing the glottic opening (Figure 19-2). the airway tube connects to the mask.
They consist of an airway tube, an inflation line, and a mask The mask is elliptical in shape (Figure 19-4). The outer rim of
(Figure 19-3). Overall, they resemble a giant spoon. The airway the mask contains an inflatable cuff. When inflated and properly
A B
FIGURE 19-4. The distal end or mask of the LMA-C. A. The deflated cuff. B. The inflated cuff.
TABLE 19-1 LMA-C and LMA-U Size Selection TABLE 19-2 LMA-CE Size Selection
Maximum Fiberoptic Patient’s Maximum cuff inflation Largest ET
Patient’s LMA cuff inflation Largest ET bronchoscope weight (kg) LMA size volume (mL) tube size*
weight (kg) size volume (mL) tube size* size (mm) 30–50 3.0 20 7.0 (cuffed)
<5 1.0 4 3.5 2.7 50–70 4.0 30 7.5 (cuffed)
5–10 1.5 7 4.0 3.0 70–100 5.0 40 7.5 (cuffed)
10–20 2.0 10 4.5 3.5 * The inner diameter in millimeters.
20–30 2.5 14 5.0 4.0
30–50 3.0 20 6.0 (cuffed) 5.0
50–70 4.0 30 6.0 (cuffed) 5.0
70–100 5.0 40 7.0 (cuffed) 5.0 uses following specific manufacturer recommendations. The
>100 6.0 50 7.0 (cuffed) 5.0 inflatable cuff is made of soft silicone to minimize throat stim-
* The inner diameter in millimeters. ulation and irritation. The LMA-CE is available in three sizes
(Table 19-2).
Several modifications have been made in order to facilitate ET
intubation with the aid of a fiberoptic bronchoscope. Proximally, the
positioned, the tip of the LMA will lie in the esophagus at the level airway tube has a 15 mm connector that can be easily removed to
of the upper esophageal sphincter and directly posterior to the cri- allow for access. The airway tube has been designed to accommo-
coid cartilage (Figure 19-2). The lateral edges of the mask rest in the date up to a 7.0 cuffed ET tube. It is short enough that the cuff of the
pyriform fossae. The upper edge rests against the base of the tongue. ET tube can pass through the LMA-CE and beyond the vocal cords.
The LMA provides a seal against the upper esophageal sphincter, The mask aperture includes a vertically oriented epiglottic elevating
aryepiglottic folds, and distal epiglottis so as to direct air into the bar, also known as the EEB (Figure 19-5). The EEB is free at the
trachea and avoid insufflation of the stomach (Figure 19-2).2,3 caudal end and fixed at the cephalad end, effectively creating a hinge
The distal end of the airway tube opens into the mask. This open- mechanism. An ET tube passed through the mask aperture swings
ing is covered by two vertical aperture-bars that prevent the epi- the EEB backward and elevates the epiglottis away from the path of
glottis from obstructing the lumen of the airway tube (Figure 19-4). the advancing ET tube.
The aperture bars should be cut off prior to inserting the LMA if an
ET tube is to be inserted through the LMA. LMA FASTRACH (ILMA)
The inflation line is used to inflate and deflate the cuff
(Figure 19-4). The distal end of the inflation line attaches to the The LMA Fastrach is also known as the intubating LMA or ILMA
upper border of the cuff. The proximal end contains an infla- (Figures 19-6 & 19-7). The form of the ILMA was derived from
tion port and balloon, similar to an ET tube. An air-filled syringe head and neck sagittal MRI studies in 50 normal subjects whose
attaches to the inflation port to inflate the cuff.
The correct size of the LMA is based on the patient’s weight
and is crucial to ensure a proper seal and reduce complications
(Table 19-1).8 The distal end assumes a different shape when the
cuff is inflated and deflated. The distal end is pentagon-shaped
when deflated (Figure 19-4A). It is oval-shaped when inflated
(Figure 19-4B).
LMA CLASSIC EXCEL (LMA-CE)

Although similar in construct to the standard LMA, the LMA-CE
has been designed as an “enhanced” version of the LMA-C
(Figure 19-5). The airway tube has been reinforced, allowing the
LMA-CE to be used up to 60 times. It must be sterilized between A
FIGURE 19-6. The ILMA. A. The reusable device (left) and the single-use device
FIGURE 19-5. The LMA-CE. (Photo courtesy of LMA North America, San Diego, CA). (right) (Photo courtesy of LMA North America, San Diego, CA). B. The mask.
FIGURE 19-7. An ET tube is inserted through the ILMA. The tip of the ET tube is
guided by the V-shaped EEB.
FIGURE 19-8. The silicone ET tube and pusher used with the ILMA (Photo cour-
tesy of LMA North America, San Diego, CA).
heads were held in a neutral position. The convex radius of the
curve of the silicone-covered steel tube represents a value close to
the best-fit curve derived from the MRI studies.4 The new prototype
consists of an anatomically curved steel tube connected to standard LMA CTRACH (LMA-CT)
LMA cuff sizes 3, 4, and 5.5,9 The LMA-CT is basically an ILMA with built-in fiberoptics that
The ILMA has several significant modifications that make it dif- allow direct visualization of airway anatomy (Figure 19-9). Two
ferent from the LMA-C (Figures 19-6 & 19-7). It is available in a fiberoptic channels lie along the lateral edges of the airway tube.
reusable stainless steel version and a plastic single-use disposable These channels merge and exit under the EEB. The properly posi-
version (Figure 19-6A). Both versions are available in three sizes tioned LMA-CT fiberoptics project an image of the laryngeal inlet
(Table 19-3). The airway tube is stainless steel covered with sili- directly in front of the mask aperture. A portable color display,
cone rubber. The proximal end has a handle fused to the airway the LMA CTrach Viewer, attaches magnetically to the top of the
tube to facilitate insertion, manipulation, and removal of the ILMA. LMA-CT airway tube. This allows the intubator to monitor the pas-
It is curved to follow the curve of the hypopharynx and position sage of the ET tube through the vocal cords. The LMA-CT Viewer
the mask aperture over the glottic aperture. It has a larger diameter lies just above the patient’s chin and in line with the actual airway
(13 mm vs. 9 mm) than the LMA.9 This allows the ILMA to accom- anatomy, making intubation easier from a hand-eye coordination
modate a cuffed ET tube with an inner diameter up to 9.0 mm.5,11 standpoint. Images may be recorded and downloaded onto a com-
It is significantly shorter (14.5 vs. 20 cm) than the LMA-C.9 puter for later documentation and teaching purposes.
The mask of the ILMA is similar to that of the LMA with two
major modifications. The ILMA contains a ramp inside the distal
airway tube as it meets the mask and continues into the mask aper-
ture. It is designed to direct the ET tube into the center of the aper-
ture and into the patient’s airway. It also has a large, single, and stiff
EEB designed to lift the epiglottis out of the way of the advancing ET
tube (Figures 19-6B & 19-7).
The ILMA was designed to be used with a wire-reinforced cuffed
silicone ET tube with an 8.0 mm inner diameter (Figure 19-8).5 The
ILMA ET tube is available in 6.0, 6.5, 7.0, 7.5, and 8.0 mm sizes. The
molded tip allows atraumatic insertion through the vocal cords. It
has a transverse block line along its posterior surface. This line serves
as a marker to let the intubator know when the tip of the ET tube
is positioned at the EEB. This occurs when the ET tube is inserted
through the ILMA, and the transverse bar is located at the proximal
end of the airway tube. While it is ideal to use the wire-reinforced
silicone ILMA ET tube, a standard ET tube may also be used.
TABLE 19-3 LMA Fastrach or ILMA Size Selection

Patient’s LMA Maximum cuff inflation Largest ET
weight (kg) size volume (mL) tube size*
30–50 3.0 20 7.0 (cuffed)
50–70 4.0 30 7.5 (cuffed)
70–100 5.0 40 8.0 (cuffed)
* The inner diameter in millimeters. FIGURE 19-9. The LMA-CT (Photo courtesy of LMA North America, San Diego, CA).
TABLE 19-4 LMA-PS Size Selection

Maximum
Patient’s LMA cuff inflation Largest ET Largest size OG
weight (kg) size volume (mL) tube size* tube/Salem Sump
5–10 1.5 7 4.0 10 French/8 French
10–20 2.0 10 4.5 10 French/8 French
20–30 2.5 14 5.0 14 French/12 French
30–50 3.0 20 5.0 16 French/14 French
50–70 4.0 30 5.0 16 French/14 French
70–100 5.0 40 6.0 (cuffed) 18 French/16 French
* The inner diameter in millimeters.
anatomically shaped (Figure 19-11). It has a more rigid airway tube

than the LMA-PS, thus it requires no digital or metal introducer for
placement. It can be used for the blind passage of an orogastric tube.
The drain tube can help monitor correct positioning of the LMS-S.
Gases will audibly leak from the drain tube if the LMA-S does not
have a tight airway seal. The LMA-S incorporates a bite block. It is
available in numerous sizes (Table 19-5).
AMBU LARYNGEAL MASK (AMBU LM)

The Ambu LM (Ambu Inc., Glen Burnie, MD) consists of an air-
way tube, spoon-shaped mask, and inflatable cuff similar to the
LMA-C (Figure 19-12). However, the airway tube of the Ambu
LM is bent into a smooth curve of approximately 90° to conform
to the anatomy of the upper airway and to facilitate easier insertion.
Because of this anatomically correct curve, the device can be placed
without manipulating the patient’s head or neck. The airway tube is
D-shaped and easier to grip than other tubes. The distal tip of the
Ambu LM is reinforced so that the cuff does not fold over during
insertion.
FIGURE 19-10. The LMA-PS (Photo courtesy of LMA North America, San Diego, CA).
KING LARYNGEAL AIRWAY DEVICE (KING LAD)
The King LAD (King Systems, Noblesville, IN) is a disposable, sin-
LMA PROSEAL (LMA-PS) gle-use, silicone device similar to the LMA-C. It is available in two
The LMA-PS has been designed to be inserted manually or with
the aid of a metal introducer (Figure 19-10). The use of the intro-
ducer obviates the need for the intubator to place their fingers in
the patient’s mouth. The LMA-PS has been modified to allow for
ventilation at higher airway pressures. A combination of a softer
silicone cuff, an additional rear cuff in larger sizes, and a deeper
bowl mask permit higher seal pressures up to 30 cmH2O. This is
approximately 50% higher than with the LMA-C. The LMA-PS pro-
vides a tighter seal without increasing mucosal pressure or the risk
of complications. It is a reusable device that is available in numerous
sizes (Table 19-4).
The LMA-PS features a dual tube (i.e., drain tube and airway
tube) system that decreases the risk of rotational dislodgement of
the device. The drain tube communicates with the upper esophageal
sphincter, allowing for blind insertion of an orogastric tube and for
venting of gastric gases and liquids. The drain tube is positioned
in the cuff to prevent the epiglottis from blocking the airway tube.
The LMA-PS has been designed to decrease the risk of aspiration.
Despite this, the manufacturer cautions that the LMA-PS does not
provide complete protection against aspiration.
LMA SUPREME (LMA-S)

The LMA-S, like the LMA-PS, is a dual tube system that provides
some separation of the respiratory and digestive tracts. The LMA-S
is a single-use device and has an airway tube that is more curved and FIGURE 19-11. The LMA-S (Photo courtesy of LMA North America, San Diego, CA).
TABLE 19-5 LMA-S Size Selection

Patient’s LMA Maximum cuff Largest ET Largest size
weight (kg) size inflation volume (mL) tube size* OG tube
<5 1 5 4.0 6 French
10–20 2 12 4.5 10 French
30–50 3 30 5.0 14 French
50–70 4 45 5.0 14 French
70–100 5 45 6.0 (cuffed) 14 French
* The inner diameter in millimeters.
styles (Figure 19-13), and a wide range of sizes in each style. The
standard model has a curved airway tube while the flexible model
has a straight and easily bendable airway tube.
AIR-Q MASKED LARYNGEAL AIRWAY (AIR-Q)

The Air-Q Masked Laryngeal Airway or Air-Q (Mercury Medical,
Clearwater, FL) is another commonly used device (Figure 19-14A).
It is available in a full range of sizes (Table 19-6). The airway tube
shape and mask inlet have a different shape than the LMAs. An ET
tube can be inserted through the Air-Q similar to the ILMA.
The Air-Q Blocker Masked Laryngeal Airway or Air-Q Blocker
(Mercury Medical, Clearwater, FL) has been modified from the
Air-Q to include a soft guide tube along side of the airway tube
(Figure 19-14B). A lubricated suction catheter or nasogastric tube
(up to size 18 French) can be inserted and directed into the pos- FIGURE 19-13. The King LAD standard model (left) and flexible model (right).
terior pharynx and esophagus to suction secretions. A proprietary
suction catheter with an inflatable balloon near the distal end can
be inserted through the guide tube (Figure 19-14B). The inflated PATIENT PREPARATION
balloon blocks the upper esophagus to prevent aspiration. The tip
of this catheter has multiple holes to allow esophageal venting while The patient should be appropriately monitored with electrocardiog-
the balloon prevents aspiration. The Air-Q Blocker is available in raphy (ECG), end-tidal CO2 monitoring, noninvasive blood pres-
three sizes (Table 19-6). sure cuff, and pulse oximetry. The patient preparation is exactly the
The Air-Q Self-Pressurizing Masked Laryngeal Airway or Air-Q same as that for orotracheal intubation. As for any situation where
SP (Mercury Medical, Clearwater, FL) is similar to the Air-Q except airway manipulation is to occur and the patient’s protective airway
for one major structural change. The Air-Q SP has a self-pressur- reflexes are blunted or ablated, a fully functioning suction apparatus
izing cuff that does not require a pilot balloon, a inflation line, or a with a variety of catheters must be immediately available. Insertion
syringe to inflate the cuff (Figure 19-14C). Positive-pressure ven- of the LMA requires an anesthetic depth similar to that which allows
tilation provided by a bag-valve device or ventilator inflates and placement and acceptance of an oropharyngeal airway.7 Successful
self-pressurizes the cuff. The Air-Q SP is available in a full range of placement of the standard LMA is much more likely if the patient
sizes (Table 19-6). is premedicated. In the case of the ILMA, the successful placement
of the ET tube is highly dependent on adequate sedation and/or
muscle relaxation. The optimal induction agent should produce jaw
relaxation and attenuation of airway reflexes, permitting insertion
of the LMA device within 30 to 60 seconds of loss of consciousness.
A variety of induction agents may be used.
There is some controversy as to what physical examination find-
ings represent the endpoint for judging when to insert the LMA.
The consensus is that the first attempt at insertion should occur fol-
lowing the loss of the eyelash reflex (seventh cranial nerve) as when
the jaw is relaxed.10,12 This typically occurs 30 to 60 seconds after
administration of the ultra-short-acting induction agents. Some
practitioners also rely on the onset of apnea and/or loss of response
to verbal stimuli as signs of adequate depth of anesthesia.12
TECHNIQUES
LMA CLASSIC, UNIQUE, AND CLASSIC EXCEL

Prior to insertion, carefully inspect the cuff for leaks with the cuff
slightly overinflated. Completely deflate the cuff so that it forms
a smooth wedge shape. The technique for inserting the LMA-C,
FIGURE 19-12. The Ambu LM. LMA-U, and LMA-CE is rather simple (Figure 19-15). Lubricate the
A B C
FIGURE 19-14. The Air-Q Masked Laryngeal Airway. A. The Air-Q. B. The Air-Q Blocker with the proprietary suction catheter inserted. C. The Air-Q SP. (Photos courtesy
of Mercury Medical Inc., Clearwater, FL).
posterior surface of the LMA with a water-soluble lubricant. Care Insert the LMA into the oral cavity with the aperture facing but
must be taken to avoid lubricating the anterior surface of the device, not touching the tongue (Figure 19-15A). It is essential that the
as the gel might obstruct the distal aperture or trickle into the larynx leading edge of the cuff be smooth, wrinkle-free, and shaped
and provoke laryngospasm.7 Avoid using silicone-based lubricants like a wedge. This facilitates passage of the cuff around the pos-
that may degrade the cuff.8 Avoid lubricants containing lidocaine as terior pharyngeal curvature and into the hypopharynx while
they may provoke an allergic reaction or decrease laryngeal protec- avoiding the epiglottis. Place the index and middle fingers of the
tive reflexes.8 dominant hand against the junction between the LMA and the cuff
Position the patient’s head as for ET intubation in the sniffing (Figure 19-15B). Advance the LMA in one smooth movement fol-
position. Place the nondominant hand behind the patient’s head lowing the curvature of the pharynx until it enters the hypophar-
to stabilize the occiput and slightly flex the neck (Figure 19-15A). ynx (Figure 19-15B). The fingers should lie almost horizontally
Allow the patient’s jaw to fall open. An assistant may be required to when the LMA is properly positioned.13,14 Grasp and stabilize the
help open it. airway tube with the nondominant hand, then remove the index
and middle fingers of the intubating hand (Figure 19-15C).
Slightly advance the LMA further downward until resistance is
felt. At this point, it is important to not push further. If difficulty
TABLE 19-6 Air-Q, Air-Q Blocker, and Air-Q SP Size Selection is encountered, a rotational movement of the tube, slight inflation
Maximum Air-Q of the cuff, a jaw-thrust maneuver, or, in rare cases, the use of a
Patient’s cuff inflation Largest ET Air-Q Blocker Air-Q laryngoscope may be helpful.7
weight (kg) Size volume (mL) tube size* sizes sizes SP sizes Inflate the cuff with the recommended volume of air (Fig-
<7 1.0 3 4.5 X X ure 19-15D). Do not overinflate the cuff. Inflation usually causes
7–17 1.5 5 5.0 X X a characteristic outward movement of the airway tube of up to
17–30 2.0 8 5.5 X X 1.5 cm as the cuff centers itself around the laryngeal inlet. A slight
30–50 2.5 12 6.5 X X X forward movement of both the thyroid and cricoid cartilages will be
50–70 3.5 18 7.5 X X X noted. The longitudinal black line on the shaft of the tube should
70–100 4.5 25 8.5 X X X lie in the midline against the upper lip. Any deviation may indi-
* The inner diameter in millimeters. cate the wrong size device was used or misplacement of the cuff
FIGURE 19-15. Insertion of the LMA. A. The patient’s head is properly positioned and the LMA is inserted into the patient’s mouth. B. The LMA is advanced with two
fingers. C. The LMA is stabilized while the insertion hand is removed. D. The cuff is inflated.
and a partial airway obstruction.7 When correctly positioned, the posterior surface of the LMA with a water-soluble lubricant. Insert
tip of the LMA cuff lies at the base of the hypopharynx against the the LMA-PS like that described above for the LMA-C. The only dif-
upper esophageal sphincter, the sides lie in the pyriform fossae, and ference is that the fingertip should be pushed into the introducer
the upper border of the mask lies at the base of the tongue, pushing strap at the rear of the cuff.
it forward.7 Even when grossly malpositioned, the mask may still An alternative method of insertion involves a metal introducer.
create a useful airway.8 Secure the LMA like an ET tube. When using the introducer, head and/or neck manipulation may
not be required. Place a properly sized introducer into the strap.
Fold the tubes around the convex surface of the introducer and fit
LMA PROSEAL
the proximal end of the airway tube into the matching slot. Insert
Prior to insertion, carefully inspect the cuff for leaks with the the LMA-PS into the oral cavity with the aperture facing, but not
cuff slightly overinflated. Completely deflate the cuff so that it touching, the tongue. The back of the mask must remain in con-
forms a smooth wedge shape. The LMA-PS features a cuff defla- stant contact with the hard palate. Rotate the LMA-PS inward in one
tor, which is a compact, portable instrument for assuring complete smooth movement following the curvature of the introducer until it
removal of air without causing the silicone to wrinkle. Lubricate the enters the hypopharynx and resistance is felt. Grasp and stabilize the
airway tube with the nondominant hand. Remove the introducer. is at the proximal end of the airway tube (Figure 19-16D). At this
Inflate the cuff and secure the LMA-PS. The LMA-PS includes a point, the tip of the silicone tube will be just inside the distal end of
built-in bite block. the airway tube. If necessary, an assistant can connect a bag-valve
device to the silicone ET tube and ventilate the patient. Make sure
LMA SUPREME that the longitudinal black line on the posterior surface of the sili-
Prior to insertion, carefully inspect the cuff for leaks with the cuff cone ET tube is facing upward.
slightly overinflated. Completely deflate the cuff so that it forms a Slowly and gently advance the silicone ET tube 1.5 cm beyond
smooth wedge shape. Lubricate the posterior surface of the LMA-S the transverse black line. If no resistance is felt, the tip of the sil-
with a water-soluble lubricant. Position the patient’s head in a semi- icone tube is just past the vocal cords. Continue to advance the
sniffing position. The neutral position or a full “sniffing” position silicone ET tube an additional 4 cm (Figure 19-16E). The patient
may preclude proper placement of the LMA-S. can be ventilated by an assistant during this procedure if necessary.
Insert the LMA-S. Grasp the LMA-S by the connector end. Insert Inflate the cuff of the silicone ET tube and ventilate the patient
the LMA-S into the oral cavity with the aperture facing, but not through the silicone ET tube (Figure 19-16F). Confirm proper
touching, the tongue. Briefly rub the mask tip across the palate in tube placement by the auscultation of breath sounds, observation
order to lubricate the area. Rotate the LMA-S inward in one smooth of chest rise, and end-tidal CO2 monitoring.
movement following the curvature of the pharynx until it enters the The ILMA should now be withdrawn. Deflate the cuff of
hypopharynx and resistance is felt. Directing the distal tip toward the ILMA. Have an assistant remove the bag-valve device and
the right or left side of the throat may facilitate placement. Grasp the 15 mm adapter on the proximal end of the silicone ET tube.
and stabilize the airway tube with the nondominant hand. Inflate Withdraw the ILMA by gently reversing the ILMA over the silicone
the cuff and secure the LMA. ET tube (Figure 19-16G). Simultaneously apply slight pressure
to the proximal end of the silicone ET tube so that it does not
LMA FASTRACH (ILMA) become dislodged (Figure 19-16G). When the mask begins to exit
the patient’s mouth, stop withdrawing the ILMA. Grasp the sili-
The technique for inserting the ILMA is not very different from cone ET tube firmly at the patient’s mouth and hold it securely.
that for the standard LMA. It involves a one-handed rotational Withdraw the ILMA in a smooth curved motion (Figure 19-16H).
movement in the sagittal plane with the patients head supported to Reattach the standard respiratory connector, ventilate the patient,
achieve a neutral position.5 The ILMA may be inserted from above and reconfirm proper placement of the silicone ET tube.
the patient’s head (like the LMA) or standing to the side of the Some physicians prefer to use a “pusher” to prevent accidental
patient’s head. It may be inserted with the right or left hand. extubation while the ILMA is being withdrawn. Cut a 25 cm length
Prior to insertion, slightly overinflate the cuff and check it for from a second silicone ET tube. Insert this into the ILMA as it is
leaks. Completely deflate the cuff. Lubricate the posterior surface being removed. Apply slight pressure so it pushes against the first
of the airway tube and the mask liberally. Grasp the ILMA by its ET tube and prevents it from moving proximally. When the ILMA
handle. Place the patient in the sniffing position if no contraindica- exits the patient’s mouth, remove the ILMA and pusher as a unit.
tions exist. Open the patient’s mouth with the nondominant hand. Secure and assess the proper positioning of the ET tube, as men-
Position the ILMA over the patient with the tip of the mask in the tioned previously.
patient’s mouth (Figure 19-16A). Slowly insert the mask while
the posterior aspect of the mask remains in constant contact with
LMA CTRACH (LMA-CT)
the hard palate. When the entire mask is inside the patient’s mouth
and against the hard palate, rotate the ILMA inward along the natu- The technique for inserting the LMA-CT is similar to that for the
ral curve of the hard palate and pharynx (Figure 19-16B). The air- ILMA. The LMA-CT may be inserted from above the patient’s
way tube should maintain constant contact with the upper central head like the LMA-C or standing to the side of their head. Place
incisors as the unit is advanced. Stop advancing the unit when resis- the patient in the neutral position to avoid head extension. The
tance is felt. This signifies that the tip of the mask is in the upper manufacturer recommends only using the LMA-CT with straight,
esophagus (Figure 19-16B). wire-reinforced cuffed silicone ET tubes with a 6.0 to 8.0 mm inner
Inflate the cuff with the recommended volume of air (Figure diameter. Standard curved plastic ET tubes may lead to an increased
19-16C). Inflation usually causes a characteristic outward move- incidence of laryngeal trauma.
ment of the airway tube, up to 1.5 cm, as the cuff centers itself Insert the LMA-CT using the technique described for the ILMA.
around the laryngeal inlet. A slight forward movement of the thy- Inflate the cuff with the recommended volume of air and confirm
roid and cricoid cartilages will be noted. The airway tube should lie proper placement of the ILMA. Have an assistant attach a bag-
in the midline against the upper central incisors. Any deviation may valve device to the proximal end of the airway tube and ventilate
indicate the misplacement of the cuff and a partial airway obstruc- the patient. Observe the upper chest rise, auscultate bilateral breath
tion. When correctly positioned, the tip of the ILMA cuff lies at the sounds, and observe end-tidal CO2 monitoring to confirm proper
base of the hypopharynx against the upper esophageal sphincter, the placement.
sides lie in the pyriform fossae, and the upper border of the mask Attach the Viewer by placing the Viewer’s socket onto the mag-
lies at the base of the tongue, pushing it forward. netic latch connector on the LMA-CT. Turn on the Viewer to visual-
Confirm proper placement of the ILMA. Have an assistant attach ize the glottis. Lubricate the wire-reinforced silicone ET tube. Grasp
a bag-valve device to the proximal end of the airway tube and ven- the LMA-CT by its handle and pass the ET tube back-and-forth
tilate the patient. Observe the upper chest rise, auscultate bilateral through the airway tube several times in order to lubricate the entire
breath sounds, and observe end-tidal CO2 monitoring to confirm airway tube. Do not pass the lubricated silicone ET tube beyond
proper placement. An anterior movement, or bulging, of the cricoid the transverse black line on its posterior surface in order to avoid
and thyroid cartilages during or after cuff inflation also indicates obscuring the fiberoptics with lubricant. Make sure that the lon-
correct positioning of the ILMA.1 gitudinal black line on the posterior surface of the silicone ET tube
Insert an ET tube. Lubricate the wire-reinforced silicone ET tube is facing upward.
(or a standard ET tube) liberally. Insert the silicone ET tube into Slowly and gently advance the silicone ET tube 1.5 cm beyond
the ILMA until the transverse black line on its posterior surface the transverse black line. Gripping the handle and lifting a few
FIGURE 19-16. Insertion of the LMA Fastrach or ILMA. A. The ILMA is inserted. B. The ILMA is advanced until resistance is encountered. C. The cuff is inflated. D. The
ILMA is stabilized and the ET tube is inserted. E. The ET tube is advanced into the trachea. F. The ET tube cuff is inflated. G. The ILMA is carefully removed. H. When the
ILMA has exited the patient’s mouth, grasp and stabilize the ET tube. Completely remove the ILMA.
millimeters optimize the alignment of the silicone ET tube and the will be determined by the patient’s condition, if they have a “diffi-
trachea. As the silicone ET tube passes the mask aperture, the EEB cult airway,” available equipment, and experience of the Emergency
will be seen to rise on the Viewer display. Continue to advance the Physician.
silicone ET tube through the vocal cords. The patient can be ven-
tilated by an assistant during this procedure if necessary. Detach COMPLICATIONS
the Viewer. Then, inflate the cuff of the silicone ET tube and venti-
There are numerous documented complications associated with
late the patient through the silicone ET tube. Confirm proper tube
the use of LMAs. One of the most obvious of these, and potentially
placement by the auscultation of breath sounds, observation of chest
the most devastating, is the failure to place the device successfully
rise, and end-tidal CO2 monitoring. Withdraw the LMA-CT similar
or to obtain a satisfactory laryngeal seal. Fortunately, even in inex-
to the technique described for the ILMA.
perienced hands, the incidence of failure to achieve satisfactory
OTHER LARYNGEAL MASK DEVICES ventilation is quite low. One large study, a retrospective review of
11,910 surgical cases where the standard LMA was used, noted an
The Ambu Laryngeal Mask (Ambu LM), King Laryngeal Airway overall success rate of 99.81%.18 Success rates have been classified as
Device (King LAD), and the Air-Q Masked Laryngeal Airway success on one single attempt and overall success. The overall suc-
(Air-Q) can be inserted and secured similar to the LMA. An ET tube cess rate allows up to three attempts to be considered for successful
can be inserted through all the Air-Q models similar to the ILMA. placement. One investigator claimed a 99.5% single-attempt success
rate in a retrospective analysis of 1500 cases.10 Most studies imply
ALTERNATIVE TECHNIQUES correct LMA placement in 88% to 90% of first attempts.7 Several
It is generally held that difficulty in insertion of the standard LMA studies have found success rates of 90% to 99% for ILMAs. Success
occurs most frequently at the point where the tip of the mask passes rates appear to be higher if a wire-reinforced silicone ET tube is used
just behind the tongue as it changes direction toward the hypophar- rather than a standard ET tube.19,20 Besides failure, there are other
ynx.15 Most of the suggested alternative methods for inserting the complications, which may be divided into minor complications and
LMA involve the negotiation of direction change from the pharynx major complications.
to the hypopharynx. Some authors suggest that a partially inflated
mask is easier to place in the correct position.15 Others employ a MINOR COMPLICATIONS
jaw-thrust maneuver. After adequate jaw relaxation has been estab- Minor complications are those that may result in significant
lished, the mask is positioned firmly and flatly against the hard pal- patient morbidity but usually are not associated with mortality
ate, as recommended. Perform the jaw-thrust maneuver with the or extremely deleterious outcomes. Stomach inflation can occur
nondominant hand while firmly thrusting the mask into place with during positive-pressure ventilation at pressures greater than
the dominant hand, in one motion.16 The jaw-thrust creates a space 20 cmH2O for the standard LMA. Cuff herniation secondary to
in the hypopharynx for the mask. In rare cases, the use of a laryngo- overinflation may result in failure of the cuff to seal effectively.
scope may help facilitate LMA placement, though this reduces the Partial airway obstruction may occur in up to 10% of adults and
inherent simplicity of the technique of LMA insertion. 25% to 50% of pediatric patients when standard LMA cuffs are
One study of the LMA-PS showed that a 90° rotation would examined by fiberoptic bronchoscopy.7 Trapping of the epiglot-
improve rates of successful placement.17 This technique was also tis in the distal aperture of the LMA may result in edema of the
associated with a lower incidence of mucosal bleeding and sore epiglottis. Air leaks around the cuff can occur during positive-
throat. After preparing the LMA-PS and the patient as usual, insert pressure ventilation at pressures greater than 20 cmH2O for the
the device until the entire cuff is inside the mouth. Rotate the standard LMA and 30 cmH2O for the LMA-PS. Forceful attempts
LMA-PS 90° counterclockwise and advance until resistance is felt. to pass the LMA around the posterior pharyngeal curvature can
Once the LMA-PS is in the hypopharynx, straighten it out. result in uvular bruising.7 Lingual nerve injury, tongue numbness,
Given that there is less experience with the ILMA, few alternative parotid gland swelling, and hypoglossal nerve palsy are some-
methods of insertion exist. However, one must remember that the times noted. Unilateral vocal cord paralysis can occur secondary
metal handle on the tip of the ILMA tube may be used to mod- to traumatic insertion. Bilateral vocal cord paralysis has not been
ify the position of the cuff within the hypopharynx.9 Pulling back reported. Dental trauma may occur during the insertion or during
on the metal handle toward the intubator rotates the tube caudally maintenance of the airway.
in the sagittal plane. Pushing on the metal handle away from the
intubator rotates the tube cephalad in the sagittal plane. MAJOR COMPLICATIONS
ASSESSMENT Major complications are those from which significant patient mor-
bidity may be expected, including patient mortality. Fortunately, as
Successful placement of an LMA device is most accurately demon- regards the LMA, major complications are exceedingly rare. In a
strated by auscultation of bilateral breath sounds, chest wall move- report of 11,910 surgical cases where the standard LMA was used,
ment, and end-tidal CO2 monitoring.5,9 One may also gain a sense of there were a total of 18 critical events related to the LMA, for an
accuracy of placement during insertion. During observation of the overall incidence of 0.15%.18 These events included regurgitation of
front of the neck while inserting an LMA, one may see a bulging of stomach contents (0.03%), vomiting of stomach contents (0.017%),
the tissues overlying the larynx. Visualization of this bulge, in addi- pulmonary aspiration (0.009%), laryngospasm (0.07%), broncho-
tion to increased resistance to forward motion of the mask, indicates spasm (0.025%), cardiac dysrhythmias (0.09%), and cardiac arrest
that the device is in the correct position.1 A chest radiograph should (0.06%). While there appears to be a higher incidence of critical
be obtained if an ET tube has been placed through an LMA. events when the device is used for controlled ventilation and posi-
tive-pressure ventilation, the incidence has not proved to be statisti-
AFTERCARE
cally significant.
The LMA does not protect against aspiration as well as an ET tube. In general, the complication rate (defined as events not attribut-
It should be replaced with an ET tube or a surgical airway. The able to the patient’s underlying condition or to surgical or other
method of securing the airway with a device other than an LMA interventions) should be equivalent to that seen during placement
of either a Guedel or Berman type oropharyngeal airway. Referring only two double lumen devices used in the prehospital setting and
to standard anesthesiology textbooks, one realizes that the compli- the Emergency Department. The Emergency Physician should be
cation rate in each of the aforementioned categories when using familiar with these devices so that it can be removed and exchanged
the LMA is significantly lower than that occurring during direct with an endotracheal tube if placed in the prehospital environment
laryngoscopy and ET intubation, potentially due to the intense or if required in the Emergency Department to manage a difficult
autonomic nervous system stimulation occurring with the latter airway.
procedures.
SUMMARY The ETC is a double-tube, double lumen, and double-cuffed device
A major advancement in airway management was made with the (Figure 20-1). The ETC starts as two distinct tubes that fuse into
introduction of the LMA. It is superior to a face mask in that it pre- one, but remain functionally separated by a partition. The shorter
vents supraglottic obstruction and reduces the likelihood of gastric clear tube is continuous with the distal open port, also known as
insufflations.2 However, it does not provide protection from aspira- the tracheoesophageal lumen. At its distal end is the distal tracheo-
tion. The LMA-PS and LMA-S, with their dual tube system, may esophageal cuff, similar to that of an endotracheal tube. It is a high-
help decrease the risk of aspiration. volume, low-pressure balloon that is inflated through the white
The standard LMA has clearly earned a valuable place in the inflation port. The longer blue tube is continuous with the eight
armamentarium of clinicians who provide airway management. The perforations known as the proximal ports. A large pharyngeal cuff
technique is easy to learn, easy to teach, and requires no specialized is just proximal to the perforations. This cuff is positioned between
equipment. The LMA causes minimal autonomic nervous system the base of the tongue and the palate, separating the oral and nasal
activation and less of a response from the cardiovascular system cavities from the remainder of the airway. It is inflated through the
than with direct laryngoscopy. The LMA is not associated with a blue inflation port.
risk of esophageal or endobronchial intubation. Both, however, are The EzT is also a double-tube, double lumen, and double-cuffed
possible complications following use of the ILMA. The LMA has device with a structure similar to the ETC (Figure 20-2). However,
minimal effects on the intraocular pressure response to airway it has several differences in comparison to the ETC. First, the shorter
manipulation. The LMA may be of use in cases of suspected cervi- clear tube ends as a conventional single lumen 7.5 mm endotracheal
cal spine injury. tube. Second, the longer blue tube ends in an open aperture, rather
The use of an LMA in place of a face mask avoids many risks, than multiple perforations. Third, the EzT is latex free.6
such as injury to the eyes, supraorbital and facial nerves, nose, Both the ETC and EzT may be inserted blindly into a patient’s
and lips. There is less risk of hand fatigue than with the bag-valve- airway. If the distal tip enters the trachea, the patient is ventilated
mask device. The LMA provides a safer and more secure airway in through the shorter clear tube and the distal cuff prevents aspira-
children and adults than does a face mask, with fewer episodes of tion of gastric contents into the trachea. If the distal tip enters the
hypoxemia as detected by pulse oximetry.7 esophagus, the patient is ventilated through the longer blue tube,
The introduction of the ILMA more than a decade after the stan- whose proximal ports lie in the hypopharynx, while the distal cuff
dard LMA further defined and expanded the role of this appara- will occlude the esophagus.
tus in airway management. It allows for precise ET tube placement, The EzT may also be used as a primary airway device under direct
therefore ensuring airway protection. It is anatomically designed to laryngoscopy. When placed successfully into the trachea, it func-
ensure more accurate placement of the cuff. Given the ease of place- tions as a 7.5 mm endotracheal tube. If unable to pass it into the
ment of the ILMA without the need for the rescuer to be positioned trachea, it can be advanced into the esophagus and the patient ven-
behind the head, there may be a significant place for the ILMA in tilated through the blue tube.6,7
future airway management algorithms.4 The advent of the LMA-CT Both devices are available in two sizes. The 37 French SA model of
allows for direct fiberoptic visualization of the vocal cords prior to the ETC is meant for small adults. The manufacturer recommends
intubation. its use in patients with a height of 122 to 168 cm (4.0 to 5.5 ft). The
41 French model of the ETC is meant for larger adults with a height
of 152 cm (5 ft) and greater. Patients in the intermediate range of
152 to 168 cm (5.0 to 5.5 ft) can use either model. A recent study
demonstrated that the 37 French SA model can be used in patients
up to 183 cm (6 ft, 1 in) in height. The EzT is available in a 28 French
Double Lumen Airway
20
model for patients with a height from 90 to 130 cm (3.0 to 4.3 ft) and
Tube Intubation a 41 French model for patients over 130 cm (4.3 ft).
Several attributes specific to these devices contribute to their
Joseph Weber usefulness in the acute setting. Both are effective as either a
primary or backup airway management device. A patient can
INTRODUCTION be ventilated with the tip positioned in either the esophagus or
the trachea. Minimal training is necessary. There is no need for
The Esophageal-Tracheal Combitube (ETC; Kendall Sheridan, a laryngoscope. They are easily inserted with patient’s head and
Mansfield, MA) and the EasyTube (EzT; Teflex Medical [Ruesch], neck in a neutral position. The dual lumens and balloons also
Kernen, Germany) are double lumen airway devices that can be offer certain advantages. When placed in the esophagus, the distal
blindly inserted into the unconscious and unresponsive patient. lumen of both allow for gastric suctioning. The proximal lumen of
The ETC and EzT function to adequately ventilate and oxygenate the EzT is an open lumen rather than perforations as in the ECT.
a patient while simultaneously protecting the airway from aspira- This allows for the passage of a suction catheter, fiberoptic scope,
tion.1,2 They are most often used in the prehospital setting by emer- or endotracheal tube changer (maximum diameter 3.99 mm) into
gency medical technicians not trained in standard orotracheal the trachea.6 The balloons firmly secure the device, making dis-
intubation and by paramedic-level rescuers as an alternative airway lodgment unlikely. The proximal balloon can functionally tam-
device when standard orotracheal intubation fails.3–5 These are the ponade oropharyngeal bleeding and serve to minimize the risk of
CHAPTER 20: Double Lumen Airway Tube Intubation 123
Ventilates through
distal port
Ventilates through
proximal ports
Distal cuff
inflation port
Proximal
pharyngeal cuff Proximal cuff
inflation port
Proximal ports
Distal
tracheoesophageal cuff
A B Distal port
FIGURE 20-1. The Combitube. A. Photograph. B. Illustration.
aspirating oral debris.8 These attributes make these devices suit- to premedicate the patient and induce anesthesia before inserting
able for rescuers of all skill levels. them. Size limits apply to both the ETC and the EzT. The standard
ETC cannot be used in patients under 5 feet tall. The smaller ETC
INDICATIONS SA model cannot be used in patients under 4 feet tall. The EzT can-
not be used in patients under 3 feet tall. The ETC cannot be used in
The primary indication for an ETC or an EzT is as a backup device patients with a latex allergy. The EzT is latex free and can be used
for airway management in and out of the hospital. It can be used in all patients.
for difficult or failed orotracheal intubations. It should be placed on Their use is contraindicated if the patient has known esophageal
crash carts for use by individuals not skilled with orotracheal intu- disease or an airway obstruction. Patients with known esophageal
bation. In situations with limited access to the patient’s head (e.g., disease (e.g., strictures, cancer, or victims of caustic ingestions)
extrication situations), they can be used where standard orotra- are at an increased risk of complications such as perforation and
cheal intubation cannot be performed. They should be considered failed performance of the device. Patients with known upper airway
in situations of potential cervical spine injury as the device can be obstruction (e.g., secondary to congenital disorders, cancer, or other
inserted with the patient’s head and neck in a neutral position. The anatomic abnormalities) are also at increased risk for complications
ETC is an appropriate device for management of the airway when and performance failure.
visualization is limited due to bleeding or secretions. All Emergency
Physicians should become familiar with these devices if they are
used by emergency medical technicians in their region as well as EQUIPMENT
considering it as an alternative airway device for difficult airways in • Gloves, gown, and mask
the Emergency Department.8,9
• Eye protection, goggles or a face mask with an eye shield
CONTRAINDICATIONS • Pulse oximeter
• Noninvasive blood pressure cuff
Certain contraindications exist and should be addressed. These
devices should not be used on patients with an intact gag • Cardiac monitor
reflex. If intubation is anticipated, there should be enough time • IV access equipment
FIGURE 20-2. The EasyTube. A. Photograph. B. Illustration. B
• ETC or EzT kit contents directed at the healthcare professional. The suction cath-
• Oxygen source and tubing eter included is designed to be inserted through the smaller tube
and to exit the tracheoesophageal port.
• Suction source and tubing
PATIENT PREPARATION
• Bag-valve-mask device
• Advanced Cardiac Life Support equipment and medications Preoxygenate the patient with a bag-valve-mask device using 100%
oxygen. Establish IV access. Apply the pulse oximeter, noninvasive
• Surgical airway equipment
blood pressure cuff, and the cardiac monitor. Place the patient in the
The ETC and the EzT are prepackaged in a kit form with the supine position, or in any position that may be required. The neutral
dual lumen airway tube, two syringes for balloon inflation, a 90° position is not required. Prepare the equipment while an assistant is
elbow, and a flexible suction catheter (Figures 20-3A & B). The ventilating the patient. Remove the ETC or EzT and equipment from
ETC kit also contains a vomit deflector that is not routinely used, the package. Attach the syringes to their respective ports and inflate
as it may be associated with significant complications and gastric the cuffs (Figure 20-4). If a leak of air is present or if the cuff does
CHAPTER 20: Double Lumen Airway Tube Intubation 125
simultaneously. Remove any dental devices and foreign bodies.

Grasp the device with the dominant hand. The curve of the device
should be in the same direction as the natural curve of the pharynx.
Insert the device into the midline of the patient’s mouth. Advance
it in a downward curved motion until the patient’s teeth or alveolar
ridge lies between the two printed bands of the ETC (Figure 20-5B)
or the black stripe of the EzT (Figure 20-6). Do not insert the device
forcefully as significant injury can occur. If it does not advance
easily, redirect it and then reinsert the device. Inflate the pharyngeal
cuff with the volume of air marked on the blue port (100 mL for the
ECT, 85 mL for the ECT SA, or 80 mL for the EzT). The device will
withdraw slightly from the patient’s mouth as the pharyngeal cuff is
A inflated. Inflate the distal cuff with the volume of air marked on the
white port (15 mL for the ECT, 12 mL for the ECT SA, or 10 mL for
the EzT).
Because most blind intubations are esophageal, begin ven-
tilation through the longer blue tube (Figures 20-5C & 20-6).
Auscultation of breath sounds, symmetric rise of the chest, fog-
ging in the tube for more than six breaths, and lack of gastric insuf-
flation confirm placement within the esophagus and ventilation
through the proximal ports/aperture (Figures 20-5C & 20-6). If
no breath sounds are auscultated and gastric insufflation occurs,
the trachea is intubated (Figure 20-5D). Begin ventilation through
the shorter clear tube and verify by auscultation the presence of
breath sounds.
If breath sounds cannot be auscultated when ventilating through
either tube, the device may be too far into the pharynx. Deflate the
pharyngeal cuff and withdraw the device 2 to 3 cm. Reinflate the
B pharyngeal cuff. Ventilate through the longer tube and confirm tube
placement as noted above.
FIGURE 20-3. The contents of the double lumen kits. A. The Combitube kit.
B. The EasyTube kit. AFTERCARE
Secure the device. This is accomplished using the standard method
of taping or a commercially available endotracheal tube holder.
not inflate properly, discard the device and open another kit. Deflate Although there are reports of short-term (e.g., 4 to 6 hours) ven-
the cuffs and leave the syringes attached to the ports. Liberally lubri- tilator use with these devices, it should be replaced with a standard
cate the tip of the device with a water-soluble lubricant. endotracheal tube for long-term ventilation.10
Several methods for replacing the device are available. The first
TECHNIQUE is to remove the device entirely and intubate the patient orotrache-
Insert the thumb of the nondominant hand into the patient’s ally. Deflate the pharyngeal cuff. Suction the patient’s mouth and
mouth and over their tongue (Figure 20-5A). Place the nondomi- oropharynx. Tilt the device to the left side of the patient’s mouth.
nant fingers under the chin. Depress the tongue and open the jaw Deflate the distal cuff. Remove the device. Intubate the patient
orotracheally.11
Alternative methods of intubation are also possible. Deflate the
pharyngeal cuff. Suction the mouth and oropharynx. Tilt the device
to the left side of the patient’s mouth. Insert the laryngoscope and
visualize the tip of the device. If it is in the esophagus, orotracheally
intubate the patient, deflate the distal cuff of the device, and remove
the device. This method will prevent aspiration, especially if endo-
tracheal intubation is unsuccessful. If it is in the trachea, instruct an
assistant to deflate the distal cuff of the device and remove it slowly.
After the device clears the patient’s vocal cords, immediately insert
the endotracheal tube.
The EzT has a significant advantage over the ECT when attempt-
ing to replace it with a conventional endotracheal tube. If the dis-
tal end is in the trachea and the patient is being ventilated through
the short clear tube, it can be left in place as it is functioning as a
7.5 mm endotracheal tube. If the distal end is in the esophagus and
the patient is being ventilated through the long blue tube, a fiberop-
tic scope or an endotracheal tube changer can be passed through the
blue tube and into the trachea. The EzT can then be removed and an
endotracheal tube passed over the endotracheal tube changer. This
FIGURE 20-4. The Combitube (above) and the EasyTube (below) with their cuffs cannot be done with the ECT because it has perforations rather than
inflated. an open aperture.6,7
FIGURE 20-5. Insertion of the ETC. A. Positioning of the patient and the physician. B. The tube is inserted until the patient’s teeth are between the black lines and the cuffs
are inflated. C. The tube is inserted into the esophagus. The patient is ventilated through the longer tube (1) and air is directed from the proximal ports (arrows). D. The
tube is inserted into the trachea. The patient is ventilated through the shorter tube (2) and air is directed through the distal port (arrows).
CHAPTER 21: Fiberoptic Endoscopic Intubation 127
It offers an additional technique for emergency care providers to

secure the airway in both the prehospital and hospital environment.
It should be included in every armamentarium dedicated to the dif-
ficult airway.
Fiberoptic Endoscopic
21 Intubation
Erika D. Schroeder, M. Scott Linscott,
and Joseph Bledsoe
INTRODUCTION
The flexible fiberoptic bronchoscope is a useful instrument for plac-
ing endotracheal (ET) tubes in awake and nonparalyzed patients
who may have contraindications to paralysis, as well as in patients
undergoing rapid sequence intubation when other means of orotra-
cheal intubation have failed. The device is unique in that its flex-
ible cord allows it to conform to the patient’s anatomy, making
intubation possible in a variety of clinical situations when intuba-
tion by direct laryngoscopy is likely to be difficult or impossible.
It is most useful in performing awake intubations as it is accepted
by more patients and is associated with fewer complications than
awake laryngoscopy.1 Proficiency in the skills required for fiberop-
FIGURE 20-6. Insertion of the EzT with the distal end in the esophagus. tic intubation requires both instruction and practice.2 Technical
problems and failure to successfully intubate patients using this
technique are usually due to a lack of familiarity and expertise
with the fiberoptic bronchoscope, using it in the wrong clinical
COMPLICATIONS setting, and inadequate patient preparation.
Despite the potential utility of the ETC or EzT in the acute setting,
several disadvantages must be kept in mind. These include the high
cost, bulky packaging, and the fact that the ETC detachable “vomit A more detailed description of the airway anatomy is provided in
deflector” can expose providers to gastric contents if improperly Chapters 6 (Essential Anatomy of the Airway), 7 (Basic Airway
managed. It is best not to use the vomit deflector, as it can be asso- Management), and 11 (Orotracheal Intubation). A brief description
ciated with aspiration. Several risks are also inherent to the inser- of the flexible fiberoptic bronchoscope is presented in this section.
tion and mechanics of the devices. It should be recognized that the There are other sources for a more in depth description of the fiber-
presence of a rigid cervical collar can cause great difficulties in the optic bronchoscope’s anatomy.3
proper placement of this device.12 The device is most frequently The basic anatomy of the flexible fiberoptic bronchoscope is
inserted into the esophagus. Therefore, there is a risk of esophageal shown in Figure 21-1. The major components are the handle, the
injury.13 There is no way to suction the trachea with the open dis- insertion cord, and a light source. The handle contains the eyepiece
tal port in the esophagus. It is important to note that resuscita- for image viewing and a dial to bring the image into focus. A lever
tion drugs that can be routinely given through an endotracheal controls an angulation wire, which allows for movement of the
tube cannot be given through the device positioned with the tip bronchoscope’s insertion cord tip in one plane.
in the esophagus. Drugs will accumulate in the blind end of the The bronchoscope’s insertion cord is composed of thousands of
tube or the hypopharynx. Significant soft tissue injury can occur glass fibers, each approximately 10 μm in diameter. The fibers in the
due to the tip of the device or if the balloons contain too much cord transmit an image to the proximal viewing lens. There is a side
air.12,14 If forced, the tip can perforate the esophagus, piriform sinus, port that can be used for the insufflation of oxygen, instillation of
or vallecula. The increased cuff pressure of the ETC versus the EzT local anesthetic or saline solution, limited suction (due to the small
can result in mucosal injury.15 An overinflated distal balloon located size of the port), passage of a guidewire, and end-tidal CO2 monitor-
in the esophagus can compress the trachea and cause an airway ing. Any fiberoptic bronchoscope used for intubation should have a
obstruction.16 Always inflate the balloons with the recommended length of at least 55 to 60 cm.4 Fiberoptic laryngoscopes or nasopha-
volume of air and not more. Prolonged use of up to 4 hours can ryngoscopes are usually unsuitable for intubation because of their
result in the proximal cuff obstructing the lingual veins and resul- short length.
tant tongue engorgement.17 This can result in a difficult intubation
when exchanging the device for an endotracheal tube. INDICATIONS
SUMMARY Fiberoptic intubation of the airway is indicated in situations where
an awake intubation technique is preferable to one that renders the
The Esophageal-Tracheal Combitube and the EasyTube can ade- patient unconscious. The awake technique is indicated when it is
quately ventilate a patient whether it is placed in the esophagus or anticipated that direct laryngoscopy might be difficult to perform or
trachea. It is relatively simple to use and requires minimal training. if paralysis is contraindicated.2 This would include morbidly obese
intubation. Occasionally, an emergent tracheostomy or cricothy-

roidotomy cannot be successfully performed in these patients before
complete airway obstruction occurs. Therefore, one should always
be prepared to provide oxygen emergently by another route (e.g.,
transtracheal jet ventilation) to prevent hypoxic brain damage.
EQUIPMENT
Nasal Anesthesia
• Cotton-tipped applicators
• 4% lidocaine
• 0.05% oxymetazoline (Afrin®)
• 4% cocaine
Oropharyngeal Anesthesia
• 1%, 2%, or 4% lidocaine or benzocaine spray
• Nebulizer device with tubing or a Mucosal Atomizer Device
(MAD®, Wolfe Tory Medical, Salt Lake City, UT)
• Cotton 4 × 4 swabs soaked in 4% lidocaine
• Emesis basin
• Yankauer suction
• Tongue blade
Laryngeal Anesthesia
FIGURE 21-1. Anatomy of the flexible fiberoptic bronchoscope.
• Alcohol swabs
• 10 mL syringes
• 21 gauge needle, 1½ inches
patients, those having limited mandibular opening, an unstable or
• 2% lidocaine for atomization
immobile cervical spine, macroglossia, CHF, micrognathia, patients
who appear to have pathologic airway anatomy (e.g., tracheal devia- • 1% and 4% lidocaine solution
tion, tracheal stenosis, tumors, and trauma), and those who appear to • Nebulizer device with tubing
be at increased risk for dental damage.5 Fiberoptic bronchoscopy has
Fiberoptic Bronchoscopy and Intubation
been used successfully in the case of a rapidly enlarging neck mass.6
It should be considered in patients in whom neck extension should • An assistant
be avoided or who are at increased risk of aspiration of their gastric • Fiberoptic bronchoscope with working channel
contents (e.g., those not fasted, pregnancy, alcohol intoxication, and • Bite block
bowel obstruction).4
• Oral/nasopharyngeal airways
CONTRAINDICATIONS • Light source
• ET tubes, various sizes
Fiberoptic intubation is not recommended for patients who are
actively vomiting or have significant oropharyngeal bleeding. • Suction source and catheters
Opaque fluids cover the fiberoptic port and prevent adequate visu- • Cuffed tracheal tubes of various sizes, especially 5 and 7 mm
alization through the bronchoscope. Patients who are hypoxic or • Oxygen source
require assisted ventilation by mask are poor candidates for fiber- • Oxygen tubing
optic intubation as the technique may require several minutes to
perform. An exception may be made if the patient can be ventilated • Bag-valve device
by a laryngeal mask airway (LMA) through which fiberoptic ET • Face masks
intubation may be performed.7,8 Contraindications specific to nasal • Water-soluble lubricant or anesthetic jelly
fiberoptic intubation would include coagulopathy, significant mid- • Gauze 4 × 4 squares
face trauma, severe intranasal pathology, fracture of the cribriform
plate, and leakage of cerebrospinal fluid.9 • Antisialagogue (glycopyrrolate 0.3-0.4 mg IV or IM, atropine
Relative contraindications to fiberoptic intubation of the airway 0.5 mg IV)
are situations when instrumentation of the airway may further Miscellaneous Supplies
compromise airway patency, such as stridor resulting from airway
• Povidone iodine solution or chlorhexidine
edema, infection, or epiglottitis. Some authors advocate fiberoptic
intubation as an option to consider in these circumstances, but • Alternative intubation kit/devices (difficult airway cart)
only by individuals extremely proficient at fiberoptic endoscopic • Cricothyroidotomy tray or kit
intubation and only with a qualified physician standing by to • Rapid sequence induction medications
perform an emergent tracheostomy or cricothyroidotomy if the
• Crash cart
need arises.10 In these circumstances, it would probably be prudent
to establish a surgical airway in the operating room, under a more • Cardiac monitor
controlled setting, rather than attempt a fiberoptic bronchoscopic • Pulse oximetry
PATIENT PREPARATION level of consciousness, while at the same time avoiding respira-
tory depression. Ketamine given in small doses (0.5 to 1.0 mg/kg)
Fiberoptic intubation is best performed on awake and spontaneously has the advantage of producing minimal respiratory depression
breathing patients. Rendering the patient unconscious might relax and may be preferable to opioids in some cases. Other agents that
and distort the airway anatomy, placing the patient at risk for more have been successfully used for sedation during fiberoptic intuba-
serious complications including apnea, airway obstruction, and aspi- tions include midazolam, propofol, fentanyl, dexmedetomidine,
ration of gastric contents.11 Proper patient preparation is essential to and remifentanil.4,16 Please refer to Chapter 8 for a more complete
the successful completion of a fiberoptic intubation. Proper patient discussion of the pharmacologic adjuncts to intubation. Avoid
preparation includes counseling the patient, clearing the airway of sedation if the patient has a tenuous airway, labored respira-
secretions and blood, judicious sedation, and airway anesthesia (naso- tions, a distended abdomen, or is vomiting.
pharynx, larynx, and trachea).9 Counseling is an important and often
underestimated part of patient preparation. Thoroughly explain the
necessity for the procedure and the technique. The bronchoscopist
AIRWAY ANESTHESIA
can gain the patient’s confidence and cooperation, which are invalu- Adequate anesthesia of the airway is extremely important when
able aids for the performance of a successful fiberoptic intubation. intubating an awake patient. In order to establish a quiet larynx
Before proceeding with fiberoptic bronchoscopy, monitors for devoid of reflexes, it is extremely helpful, prior to attempting fiber-
electrocardiogram, blood pressure, and pulse oximetry should be optic bronchoscopy, to provide anesthesia of the airway. It is espe-
placed along with an intravenous line for the administration of cially effective in improving the success rate of individuals who are
drugs. Supplemental oxygen should be administered and can be less experienced at performing fiberoptic intubation. The regional
delivered either by nasal cannula, “blow-by,” or through the side anesthesia technique employed to anesthetize the larynx is the bilat-
port of the fiberoptic bronchoscope. Delivering oxygen through the eral superior laryngeal nerve block.
side port offers the additional advantage of blowing airway secre- Bilateral blockade of the superior laryngeal nerves will provide
tions away from the fiberoptic bronchoscope’s tip and can be used effective anesthesia of the supraglottic structures. Prepare a 5 mL
to help visualize the vocal cords when redundant tissue is obscuring syringe attaching a 21 gauge needle and filling it with 1% or 2% lido-
the view. Unfortunately, it has the potential disadvantage of causing caine solution. Identify the hyoid bone by palpation. Slide your finger
gastric distention and rupture.12,13 laterally to identify the superior cornua. Clean and prepare the skin
The patient may be in a sitting, semirecumbent, supine, or left over the superior cornua bilaterally. Insert the needle and advance
semilateral position during fiberoptic bronchoscopy.14 In mor- it until it contacts the superior cornua of the hyoid bone. Contact
bidly obese patients, the sitting position will, by virtue of gravity, with the bone can be made easier by extending the patient’s head
displace redundant pharyngeal tissue anteriorly and open the pha- and gently palpating the hyoid bone with the thumb and forefinger
ryngeal space.15 However, use of the sitting position also requires of one hand. By applying gentle pressure to one side, the opposite
the bronchoscopist to stand at the patient’s side, thus inverting the cornua comes into closer contact with the skin and is subsequently
image seen through the fiberoptic bronchoscope. Alternatively, the easier to contact with the needle. Walk the needle tip inferiorly and
bronchoscopist can stand on a platform in order to be of sufficient off the bone. Advance the needle 3 to 4 mm and through the thyro-
height to correctly perform the procedure. When performing the hyoid membrane (Figures 21-2 & 21-3). Aspirate before injecting
procedure with the patient in the supine position, the patient’s head the local anesthetic solution to confirm that the needle has not
should lie flat against the table surface with the neck extended (if it entered the external carotid artery. Inject 2 to 3 mL of lidocaine.
is safe to do so). This head position brings the tracheal axis more in Repeat the procedure on the contralateral side. The hyoid bone
line with the nasal and oral passageways and elevates the epiglottis may not be palpated due to obesity, infections, or masses. In those
from the posterior pharyngeal wall. The “sniffing position,” while instances, a superior laryngeal nerve block should not be attempted.17
optimal for direct laryngoscopy, increases obstruction of the glot- It remains an unresolved controversy whether to abolish the
tis by the epiglottis during fiberoptic bronchoscopy and makes the laryngeal reflexes of a patient considered to have a “full stomach.”
passage of the fiberoptic bronchoscope more difficult.15 Maneuvers In considering this option, one must weigh the risk of abolishing
performed by an assistant, such as the jaw thrust or pulling the the laryngeal reflexes and rendering the patient potentially vulner-
tongue forward with a cotton swab, can help to move the pharyn- able to gastric aspiration versus leaving the laryngeal reflexes intact
geal soft issues anteriorly and allow increased maneuverability of and thus causing significant discomfort for the patient. When
the fiberoptic bronchoscope’s tip.9 deliberating whether or not to proceed with a regional block of the
Instrumentation of the airway may cause the patient to produce larynx in a patient considered to be at risk for gastric aspiration,
copious secretions, making an otherwise straightforward fiber- bear in mind that aspiration of gastric contents occasionally does
optic bronchoscopy extremely difficult. Bronchoscopy via a “dry” occur in patients with intact laryngeal reflexes. Instrumentation of
airway devoid of secretions can be accomplished in most instances the airway in patients with an intact gag reflex can induce vomiting.
by administering 0.3 to 0.4 mg of glycopyrrolate. This is a potent The larynx and trachea can be effectively anesthetized by perform-
antisialagogue and should be administered intravenously at least ing a transtracheal injection of 4 mL of lidocaine. Clean and prepare
10 minutes before or intramuscularly 30 minutes before fiberop- the surface of the skin over the cricothyroid membrane. Prepare a 20
tic bronchoscopy. Atropine is often more readily available in the gauge intravenous catheter-over-the-needle on a 5 mL syringe con-
Emergency Department than glycopyrrolate. It can be administered taining 2 to 3 mL of sterile saline. Prepare a second syringe contain-
in a dose of 0.5 mg intravenously at least 10 minutes before fiberop- ing lidocaine solution. Insert the catheter-over-the-needle on the
tic bronchoscopy. The only disadvantage of atropine is that it crosses syringe containing sterile saline perpendicular through the skin in
the blood–brain barrier and can cause central nervous system the midline over the cricothyroid membrane (Figures 21-2 & 21-4).
effects whereas glycopyrrolate does not. Please refer to Chapter 8 Advance the syringe until the tip of the catheter-over-the-needle is
for a more complete discussion of these two antisialagogues. in the trachea. The lumen of the trachea is identified by the loss of
Sedation can be extremely beneficial in gaining the patients resistance. Aspirate air into the syringe, as evidenced by the pres-
cooperation during the performance of a fiberoptic bronchoscopy. ence of bubbles in the saline, to confirm that the catheter-over-the-
Sedative drugs, if used at all, should be judiciously titrated to needle is within the trachea. Care should be taken to not advance
the desired effect with continual assessment of the patient’s the catheter-over-the-needle too far and perforate the posterior
Internal branch of superior

laryngeal nerve
Hyoid bone
Superior laryngeal
nerve block
Thyroid cartilage
External branch of
Transtracheal block
superior laryngeal nerve
Cricoid cartilage
Recurrent
laryngeal nerve
FIGURE 21-2. The anatomy of the larynx. The syringes demonstrate the superior
laryngeal nerve block and the transtracheal block.
trachea, as this could result in a pneumomediastinum.18 Securely

hold the syringe in place and advance the catheter into the trachea.
Securely hold the catheter hub at the skin. Withdraw the needle
and syringe. Attach the syringe containing lidocaine to the cath-
eter. Briskly inject 3 to 4 mL of lidocaine through the catheter and
into the tracheal lumen. This will cause the patient to cough and FIGURE 21-4. Transtracheal anesthesia of the trachea and larynx. The catheter
disperse the local anesthetic solution throughout the trachea and enters the trachea through the midline of the cricothyroid membrane.
larynx. Remove the syringe and catheter. The physician perform-
ing this block should be wearing a gown, a face mask, and eye pro-
tection to prevent exposure to the respiratory secretions when the
(maximum dose 200 mg) has the advantage of providing profound
patient coughs.
vasoconstriction and anesthesia to the nasal passageways. Similar
The nasal passages, pharynx, and larynx can be anesthetized by
effects can be provided by applying 0.25% to 1.0% phenylephrine
several other techniques. If the nasal passageways are the antici-
topically to the nasal mucosa, followed by lidocaine 4% via cotton-
pated route for intubation, they should be prepared by shrinking
tipped applicators. These applicators should be gently placed, one at
and anesthetizing the nasal mucosa. Cocaine (4%) applied topically
a time, through the middle meatus and back to the inferior turbi-
nate. A nasal passage that accommodates four to five single cotton-
tipped applicators will usually allow passage of a 7.0 mm ET tube.9
Also effective in providing profound vasoconstriction of the nasal
mucosa is the use of three to four sprays of atomized oxymetazoline
(Afrin®) into one or both nares.
Once the antisialagogues have taken effect, the tongue and phar-
ynx can be anesthetized. Place a tongue blade on the patient’s tongue
and apply topical anesthetic spray (Figure 21-5). Benzocaine or
lidocaine spray will usually provide effective anesthesia for the pos-
terior pharynx within 30 seconds. They can be administered from a
commercially available spray container or using an atomizer device.
There are reports of methemoglobinemia from the overzealous use
of benzocaine.19 Its use should be limited to several short sprays.
Alternatively, the patient can swish 2% viscous lidocaine in their
mouth for several minutes to provide effective anesthesia. One of
the most effective methods of blocking the glossopharyngeal nerve
is the “lollypop method.” Create a lollypop by soaking sterile gauze
in lidocaine ointment and taping it to a tongue depressor. Place the
lidocaine lollypop into the patient’s posterior mouth while setting
up for the bronchoscopy. Advance the lollypop 1 cm every 2 min-
FIGURE 21-3. The recurrent laryngeal nerve block. The needle is inserted and utes until the patient’s posterior pharynx is completely anesthetized.
advanced just below the superior cornua of the hyoid bone.
straighten the inner fiberoptic strands. Identify the plane in which

the angulation lever moves the tip. When fiberoptic bronchoscopes
are stored coiled in a case, over time the insertion cord may develop
a curve. Slightly rotate the fiberscope to the right or left until the
angulation of the tip is in the midline plane. Look through the eye-
piece and note the position of the directional arrow (▼) on the ante-
rior edge of the image that correlates with the midline.
To prevent fogging, apply an antifog solution to the insertion
cord tip or place the tip in warm water before inserting the fiber-
optic bronchoscope into the patient’s nose. Warming the ET tube
with warm water just prior to placing it on the insertion cord will
soften the tube and may make the later advancement of the ET tube
through the mouth or nares easier.
Apply a thin film of silicone spray or a water-soluble lubricant
over the insertion cord to facilitate passage of the ET tube over the
flexible cord. Insert the flexible insertion cord completely through
the ET tube, taking care not to get any of the lubricant on the lens
tip. The insertion tip should exit the distal tip of the ET tube. Do not
place the tip of the insertion cord through the Murphy eye of the ET
tube. Lubricate the ET tube liberally.
Estimate the distance from the patient’s mouth to their glottis.
Place the tip of the insertion cord by the patient’s ear. Mark the point
the insertion cord touches the patient’s mouth. The distance from
the mouth to the ear is approximately the distance from the mouth
to the glottic opening. Add 3 cm to this length if performing the
procedure through the nose instead of the mouth.
Hold the fiberoptic bronchoscope in your dominant hand with
the angulation lever operated by the thumb and the suction port (if
used) covered by the index finger. The other end of the scope should
be held between the index finger and the thumb of the nondominant
hand. Place the nondominant hand at the patient’s nose or mouth.
There should be no slack in the fiberoptic bronchoscope between
FIGURE 21-5. Anesthetizing the posterior oropharynx with atomized lidocaine the two hands. The removal of slack from the insertion cord makes
solution.
more precise rotary movements of the tip possible.
NASAL INTUBATION
As an alternative, nebulized 4% lidocaine administered at least
20 minutes prior to fiberoptic bronchoscopy will usually provide Nasal fiberoptic intubation has several advantages over the oral
adequate anesthesia of the supraglottic structures. A second alterna- route. For those less experienced at fiberoptic bronchoscopy, nasal
tive is the “spray as you go” technique.20 Once the epiglottis is visual- fiberoptic bronchoscopy is usually easier to perform because less
ized through the fiberoptic bronchoscope, instill 3 to 4 mL of 2% angulation of the tip is required. Once inserted, nasal ET tubes are
lidocaine through the working channel of the scope and onto the better tolerated by patients and are associated with a lower incidence
epiglottis and the surface of the vocal cords. This will induce cough- of accidental extubation. Disadvantages include a higher incidence
ing and temporarily obliterate the view of the laryngeal structures. of bacteremia, middle ear infection, epistaxis, and alar necrosis.9
Allow 2 to 3 minutes for the anesthetic solution to exert its effect Nasal intubation, unlike oral intubation, may produce bactere-
before proceeding with fiberoptic bronchoscopy. mia; therefore appropriate endocarditis prophylaxis should be
After anesthesia is accomplished, place a suction catheter into the provided for those at risk.
oropharynx. This will clear the airway of secretions and blood that Examine the patient to determine which is the most patent nos-
can impair the visual image. It will also determine the adequacy of tril. Insert and navigate the insertion cord’s tip along the posterior
the topical anesthesia for preventing coughing and gagging. floor of the nares (Figure 21-6). Continue to advance the insertion
cord and ET tube as a unit until the ET tube enters the orophar-
TECHNIQUES ynx (Figure 21-7). This will serve to minimize patient discomfort
and the risk of epistaxis early in the procedure. Occasionally, loss
Prepare the fiberoptic bronchoscope. Attach the light source. Check of view and maneuverability of the insertion cord tip occur in the
the focus of the image by holding the tip of the insertion cord 1 to oropharyngeal area as the tip encounters the pharyngeal mucosa.
2 cm over a printed page. Adjust the eyepiece until the letters on the Pulling the patient’s tongue forward with gauze, using the jaw-
image are clear. Note how the image appears as you move toward thrust maneuver, or simply advancing the insertion cord a few cen-
and away from the page. Briefly use the angulation lever to move timeters further will usually bring pharyngeal structures back into
the tip of the insertion cord and learn its movements. The most view. Continue to advance the tip of the insertion cord until the
difficult aspect of mastering fiberoptic bronchoscopy is learning epiglottis is visualized (Figure 21-7). Maneuver the insertion cord
to simultaneously angle the tip, rotate the scope, and advance the tip with the lever until the glottis comes into view (Figure 21-8).
insertion cord.21 It requires repetition and practice to develop these Continue to advance the insertion cord tip through the vocal cords
skills before attempting to intubate a patient. and to a point approximately 3 cm above the carina. Advance the
Before placing of the fiberoptic bronchoscope insertion cord ET tube over the insertion cord and into the trachea to the appro-
into the ET tube, let the insertion cord hang toward the floor to priate depth.
FIGURE 21-8. Visualization of the glottis through the flexible fiberoptic broncho-
scope just prior to its insertion cord passing through the vocal cords.
redirect the tip upward with a slight downward movement of the

angulation lever.21 This will usually bring the glottic opening into
view (Figure 21-8). Occasionally, the epiglottis will obscure the
glottic opening. Position the tip of the insertion cord just above the
tip of the epiglottis, then advance it a few millimeters posterior to
the epiglottis while angulating the tip of the insertion cord slightly
anterior by pressing down on the angulation lever. This will bring
the glottic opening into view. Simultaneously rotate, angulate, and
advance the insertion cord tip toward and past the vocal cords.
FIGURE 21-6. The technique of placing the fiberoptic bronchoscope insertion
An alternative technique would be to advance the ET tube through
cord into the nares. Note the position of the ET tube over the proximal portion of
the nares until the tip is just past the soft palate. This is usually at
the insertion cord.
a depth of 10 to 12 cm. The insertion cord is then passed through
the ET tube and through the vocal cords (Figure 21-9). The ET
tube is then advanced over the insertion cord into the trachea. This
The distance from the nares to the epiglottis is usually about 15 to approach has the advantage of bringing the tip of the insertion cord
17 cm. At this position, the epiglottis should be visible. If the 15 cm directly midline and toward the epiglottis. However, this can cause
mark has been passed, it is very likely that the insertion cord has some patient discomfort early on in the procedure and may decrease
entered the esophagus. If that is the case, withdraw it to 12 cm and patient cooperation before the insertion cord has entered the trachea.
FIGURE 21-7. Visualization of the epiglottis (at the top of the photo) through the FIGURE 21-9. The ET tube has been inserted into the nares and advanced into the
flexible fiberoptic bronchoscope. oropharynx. The insertion cord is advanced through the ET tube.
There is the potential for epistaxis, making visualization of laryngeal in the patient’s mouth like any other oral airway. They allow for the
structures difficult if not impossible. Despite the application of topi- midline passage of the insertion cord and protect the delicate glass
cal anesthesia to the nasal passages, they are difficult to anesthetize fibers within it from the patient’s teeth.
completely. For the awake patient, passage of the ET tube is often the Technical problems exist in attempting oral fiberoptic intubation.
most uncomfortable part of the fiberoptic intubation procedure. As stated earlier, oral fiberoptic intubation requires that the inser-
Occasionally, some operators have difficulty passing the insertion tion cord tip traverse a more acute angle to reach the vocal cords
cord through the vocal cords. There are several causes for this. The than it would by the nasal route. If one can safely do so, maximally
tip of the insertion cord may remain angulated and abut against the extending the patient’s head at the atlantooccipital joint will bring
wall of the trachea. The vocal cords may not be properly anesthetized the oropharyngeal and laryngeal axes more closely in line. This
and may have closed reflexively. Finally, the insertion cord tip may maneuver will reduce the angle that the insertion cord tip must
be abutting the arytenoid cartilages or the pyriform sinus. If inade- traverse.
quate anesthesia is the cause, inject 2 mL of either 2% or 4% lidocaine In performing an oral fiberoptic intubation, the ET tube becomes
through the working channel of the insertion cord and wait several hung up on the vocal cords more frequently than with the nasal
minutes for it to take effect. Additionally, having the patient inspire route. A technique believed to significantly improve the first-time
deeply will bring the vocal cords into greater opposition. Once the pass rate with oral fiberoptic bronchoscopic intubation is to pass a
insertion cord tip has passed the vocal cords, bring the tip into neu- lubricated 5.0 mm ID ET tube through a 7.0 mm ID ET tube that has
tral position with a light downward motion of the angulation lever. been cut to 24 cm. This should leave 2 cm of the 5.0 mm ID ET tube
Once past the vocal cords, advance the insertion cord tip further to protruding from the distal end. It is believed that the close approxi-
bring the bifurcation of the trachea at the carina into view. The tra- mation of the diameters of the 5.0 mm ID ET tube and the fiberoptic
chea can easily be identified anteriorly by the cartilaginous rings and bronchoscope allows easier passage of the scope. After the 5.0 mm
posteriorly by the smooth mucosa of the posterior wall. Advance the ID/7.0 mm ID ET tube complex is in place, withdraw the 5.0 mm ID
ET tube over the insertion cord and into the trachea. The arytenoids ET tube, leaving the 7.0 mm ID ET tube in the trachea.24
or the interarytenoid soft tissues can impede advancement of the ET
tube past the vocal cords and into the trachea. If the ET tube advance- ALTERNATIVE TECHNIQUES
ment is inhibited, withdraw it slightly, rotate it 90° counterclockwise,
Alternative techniques that have been shown to be as effective as
and reattempt intubation.22 If this maneuver fails, rotate the ET tube
fiberoptic intubation for intubating patients with unstable cervical
so that its bevel faces either posteriorly or to the left and laterally. The
spines include the Bullard laryngoscope25 and the lighted stylet.26
inability to advance the ET tube occurs with greater frequency when
Blind nasotracheal intubation is as successful as nasal fiberoptic
the diameter of the insertion cord is significantly smaller than that
intubation in anesthetized patients with unstable cervical spines.27
of the ET tube or with oral fiberoptic intubation, due to the greater
The Glidescope, a video laryngoscope, causes less cervical spine
curve that the ET tube must assume for it to enter the trachea.21 If
movement than direct laryngoscopy.28
these maneuvers are unsuccessful, consider substituting a smaller ET
A combined technique using oral fiberoptic intubation through
tube, a spiral-bound ET tube, or an ET tube with a flexible tip.23
a LMA or alternative supraglottic airway can be extremely helpful
Occasionally, when the trachea is not anesthetized, the patient’s
in instances where there is severe oropharyngeal bleeding or when
subsequent coughing and the associated muscular contractions of
direct laryngoscopy is not possible.7,29 After confirming successful
the trachealis muscle will collapse the trachea almost completely.
placement of the LMA, place a self-sealing bronchoscopy elbow
This makes it difficult to discern if the insertion cord tip is actually
over the proximal end of a 6.0 mm ID ET tube. Advance the ET
in the trachea or whether to advance the insertion cord or ET tube
tube tip through the LMA until the LMA grille is encountered
into the trachea. Wait until the trachealis muscle relaxes and then
(resistance will be felt). Inflate just enough air into the ET tube cuff
continue with the procedure.
to provide a seal for positive-pressure ventilation via the ET tube.
To prevent endobronchial intubation in adults, which can occur
Advance the insertion cord through the ET tube and into the tra-
with flexion of the head, confirm that the tip of the ET tube is 3 cm
chea under direct visualization. Deflate the ET tube cuff. Advance
above the carina. This is accomplished by advancing the tip of the
the ET tube over the insertion cord and into the trachea until the ET
insertion cord to the carina with the thumb and forefinger of the
tube adapter meets the adapter of the LMA. Inflate the ET tube cuff
nondominant hand. Mark the point on the insertion cord where it
and confirm ventilation through the ET tube.
exits the ET tube. Withdraw the insertion cord until the distance on
Because standard ET tubes are not long enough to allow removal
the insertion cord between the marked point and the tracheal tube
of the LMA, longer ET tubes have been developed. If you do not
connector is 4 cm. While looking through the eyepiece, advance the
have access to a specially made ET tube, use a nasal Rae tube, which
ET tube until its tip is visible. This places the tip of the ET tube at
is 6 cm longer than a standard ET tube. If a longer ET tube is not
approximately 3 cm above the carina.
available, another ET tube can be temporarily lengthened by remov-
Occasionally, difficulty is encountered while attempting to pass
ing the adapter of the 6.0 mm ID ET tube and placing the tip of a
the ET tube through the nares and nasal cavity. This might be
5.0 mm ID ET tube into the lumen of the 6.0 mm ID ET tube. This
caused by a deviated nasal septum, enlarged turbinates, a nasal spur
maneuver lengthens the ET tube enough that the LMA cuff can be
(which can also tear the ET tube cuff), or nasal polyps. Selection
deflated and withdrawn, leaving the 6.0 mm ID ET tube correctly
of an ET tube that is too large, inadequate lubrication, or failure to
placed in the trachea. Additionally, ventilation can be maintained
presoften the ET tube can be the cause. Reattempt insertion with a
the entire time simply by using a bag-valve device connected to the
well-lubricated, presoftened ET tube that is 0.5 to 1.0 mm smaller.
5.0 mm ID ET tube adapter. After removing the LMA, remove the
Alternatively, try placing a 5.0 mm inner diameter (ID) ET tube in a
5.0 mm ID ET tube from the 6.0 mm ID ET tube, replace the adapter,
7.0 mm ID ET tube as discussed below.
and resume ventilation.30 After removing the LMA and establishing
ventilation, always confirm by fiberoptic bronchoscopy that the ET
ORAL INTUBATION
tube is correctly positioned.
Begin by noting any loose or broken teeth. After ensuring an ade- An alternative to the traditional LMA is the intubating LMA or
quate sensory block by the absence of a gag reflex, insert an oral ILMA. The ILMA is a valuable resource in patients with an antici-
intubating airway into the patient’s mouth. These devices are placed pated difficult airway.31
ASSESSMENT
Nasotracheal Intubation
The placement of an ET tube should be followed by an assessment
to ensure its proper positioning. Please refer to Chapter 12 for a
more complete discussion. This includes visual inspection of chest
22 Ned F. Nasr, Raed Rahman, and Isam F. Nasr
rise and lack of abdominal movement with ventilation, fogging in

the ET tube for at least six breaths, auscultation, and end-tidal CO2 INTRODUCTION
monitoring. This should be followed by a chest X-ray to confirm
proper positing of the ET tube within the trachea. Nasotracheal intubation is a relatively simple procedure that is per-
formed rapidly without the aid or risks of neuromuscular blockade.1
This method of intubation is sometimes favored in difficult airway
AFTERCARE cases, especially when oral access is limited or impossible. Such con-
The steps of ensuring proper placement of the ET tube and securing ditions include trismus, oral injuries, and obstructive oral processes
the tube are the same as for any patient who has undergone orotra- such as angioedema. Nasotracheal intubation is also the method of
cheal intubation (Chapter 11). intubation preferred by some authors for acute epiglottitis.2
Nasotracheal intubation is well tolerated by most patients and
produces less reflex salivation than orotracheal intubation, thus
COMPLICATIONS leading to fewer attempts at self-extubation. The nasotracheal tube
is more easily stabilized and is generally easier to care for than an
Many of the complications associated with fiberoptic intubation are
orotracheal tube. This method prevents biting of the tube by the
the same as those seen with direct laryngoscopy (Chapter 11). The
patient and manipulation by the patient’s tongue.2,3
most severe complication is hypoxemia from a prolonged procedure
or delays due to an inexperienced bronchoscopist. Use the suction INDICATIONS
channel on the bronchoscope to provide oxygenation to the patient
during the procedure. Epistaxis can be minimal or significant Nasotracheal intubation is indicated in any patient with sponta-
enough to complicate the procedure. Bleeding can be minimized by neous respirations, especially those whose period of intubation is
using the correct ET tube size and pretreatment with a nasal vaso- anticipated to be brief.1–3 It is indicated in patients who are unable
constrictor and anesthetic. Failure to intubate can be due to narrow to lie supine due to respiratory distress from severe asthma, chronic
nasal or airway passages, blood or vomitus limiting the fiberoptic obstructive pulmonary disease (COPD), or congestive heart failure.
field of view, or an inexperienced bronchoscopist. It is also indicated in patients who are unable to open their mouths
While the insertion cord is passed through the glottis and into due to facial trauma, mandibular trauma, or trismus. Nasotracheal
the trachea under direct vision, the ET tube is passed blindly over intubation can be performed in patients with limited airway patency
the insertion cord tip. It is thus possible to cause injury to the aryte- due to obstruction from neoplasm or tongue swelling. Nasotracheal
noids, resulting in permanent hoarseness, particularly if the ET tube intubation is an appropriate method of intubation in patients who
bevel faces anteriorly. However, in a recent randomized control trial, require neck immobilization for suspected cervical spine injuries as
there was no difference in the incidence of vocal cord injury for well as patients who are unable to move their necks due to cervical
nasotracheal fiberoptic intubation versus orotracheal intubation.32 kyphosis, severe arthritis, or postradiation fibrosis. Because they are
The ET tube may also become blocked in the nasal cavity or larynx, often intubated for a short time, patients with severe alcohol intoxi-
resulting in epistaxis, nasal turbinate fracture, and tearing of the ET cation or drug overdose whose level of consciousness is decreased
tube cuff1,9 Sinusitis and otitis media are known complications from are good candidates for nasotracheal intubation.1–3 Nasotracheal
nasal intubation.9 intubation may be performed in patients who have contraindica-
tions to the use of succinylcholine (Table 11-2).
SUMMARY CONTRAINDICATIONS
Awake intubation under direct visualization in spontaneously Nasotracheal intubation is contraindicated in patients with apnea,
breathing patients by either the oral or nasal route is possible with severe facial or maxillofacial fractures, basilar skull fractures, head
the fiberoptic bronchoscope. Intubation by means of the fiberoptic injury with an elevated intracranial pressure, recent nasal surgery,
bronchoscope is an option to consider when direct laryngoscopy is nasal or nasopharyngeal obstruction (nasal polyps), patients receiv-
difficult, or impossible. In some instances, awake fiberoptic intuba- ing thrombolytics or parenteral anticoagulants, and in the presence
tion may be preferable to other emergency intubation techniques of a coagulopathy.1–3
that render the patient unconscious and apneic. Fiberoptic intuba- Nasotracheal intubation should not be performed in neonates,
tion is associated with a high success rate when performed by appro- infants, or very young children. The more anterior and cephalic
priately trained individuals. Training and practice are required to position of the airway in these age groups makes blind passage of an
develop and master the necessary skills.33 Appropriate patient selec- endotracheal (ET) tube almost impossible. A patient must provide
tion, preparation, and physician patience are essential for a safe and a degree of cooperation during the procedure. A crying, kicking,
successful fiberoptic intubation. and struggling child who must be restrained is not a candidate for
The benefits of performing regional anesthesia of the orophar- nasotracheal intubation.
ynx, larynx, and trachea prior to fiberoptic intubation are a quiet
visual field and improved patient acceptance. Oral fiberoptic intu- EQUIPMENT
bation may be performed in conjunction with an LMA. It should be
• Nasal mucosa vasoconstrictor (4% cocaine, 0.05% oxymetazoline,
emphasized that while in most instances fiberoptic intubation is an
or 0.25% phenylephrine)
extremely safe and effective means of securing the airway, one must
be prepared to implement an alternate plan for securing the airway • Nasal mucosa anesthetic (viscous lidocaine, cocaine, benzocaine
and for providing oxygen to the lungs in the case of failure or sud- spray, or xylocaine spray)
den deterioration of the patient’s condition. • Nasopharyngeal airways, multiple sizes
CHAPTER 22: Nasotracheal Intubation 135
• Laryngoscope handle Prepare the mucous membranes. Apply a topical vasoconstrictor

• Laryngoscope blades, various sizes and types to shrink the nasal mucosa followed by a topical anesthetic to the
nasal mucosa. Cocaine is preferred if not contraindicated, because it
• ET tubes, various sizes (avg female 7.0–7.5 and avg male 7.5–8.0)
is a single agent that acts as both a vasoconstrictor and an anesthetic.
• Endotrol tubes, various sizes (Mallinckrodt Medical, St. Louis, MO) Dilate the nasal passage by serial dilation. Liberally lubricate a series
• Magill forceps of increasingly larger-size nasopharyngeal airways. Insert and then
• Suction apparatus remove the smallest nasopharyngeal airway. Continue to insert
and remove each successively larger nasopharyngeal airway until
• Topical anesthetic (4% cocaine or 2% lidocaine with epinephrine)
the nasal passage is dilated. This procedure can take 2 to 3 min-
• Gauze strips utes. If time is an issue, insert a gloved and lubricated pinky finger
• Water-soluble lubricant or anesthetic jelly into the nostril to dilate it. For routine nasotracheal intubations of
• Bag-valve device healthy adults, serial dilation of the nasal passages can be bypassed
in patients with large nostrils.6 Next, apply a topical anesthetic spray
• Face mask
to the palate and oropharynx.
• Oxygen source and tubing Choose an ET tube. The proper size tube should be at least 0.5 to
1.0 mm smaller than the size chosen for orotracheal intubation of
PATIENT PREPARATION the same patient. If possible, soften the ET tube by placing it in
Explain the risks, benefits, and potential complications of the pro- warm saline or warm water before use to reduce epistaxis and nasal
cedure to the patient and/or their representative if time permits. All damage.7 Apply a 10 mL syringe to the inflation port and inflate the
procedural steps should be clearly outlined, with the understand- cuff. Check the integrity of the cuff. Deflate the cuff and leave the
ing that an orotracheal intubation may be necessary should the syringe attached. Lubricate the ET tube.
Emergency Physician fail to secure the airway nasotracheally. Since
this is a lifesaving procedure, a signed consent may not be necessary, TECHNIQUES
but a procedure note should be included in the medical record.
Prepare the patient with preoxygenation, hemodynamic monitor- ■ BLIND PLACEMENT OF AN ET TUBE
ing, pulse oximetry, and intravenous access. Place the patient supine The technique of blind nasotracheal intubation was first described
and in the “sniffing” position if there is no suspicion of a cervical by Magill in 1930. The technique essentially remains the same with
spine injury. If the patient needs to remain sitting due to respiratory some modifications to increase the success rate and limit complica-
distress, also place them in the sniffing position. tions. This technique is technically more difficult than the place-
Examine the patient’s nostrils. Choose the larger and more patent ment under direct vision described below. Its major advantages are
nostril for the intubation. The choice of the nostril to use is not an that the patient’s mouth does not have to be opened and minimal
exact science.11 Look into each nostril and determine which one is to no cervical spine movement is required. This procedure may be
more patent. Estimate the airflow through each nostril. Occlude one performed while the patient is sitting or supine. Prepare the patient
nostril and instruct the patient to exhale with their mouth closed. as mentioned previously.
Repeat the process with the other nostril. Ask the patient which nos- Stand to the right side of the patient’s bed and facing them.
tril they feel is more patent. This test can be repeated after the appli- Insert the ET tube into the nostril with the bevel facing the sep-
cation of a vasoconstrictor agent. There is no evidence suggesting tum (Figures 22-1 and 22-2A). If the patient’s right nostril is being
one nostril is better than the other (i.e., left vs. right) for intubation used, insert the ET tube concave side down (Figure 22-1A). If the
in a patient with normal anatomy. patient’s left nostril is being used, insert the ET tube concave side up
FIGURE 22-1. Insertion of the nasotracheal tube. The bevel of the ET tube should face the septum. A. Placement in the right nostril with the concave side of the tube
downward. B. Placement in the left nostril with the concave side upward. When the tip of the tube enters the nasopharynx, rotate it 180°.
FIGURE 22-2. Blind nasotracheal placement. A. The nasotracheal tube is placed within the nasal cavity. B. The tube is advanced along the floor of the nasal cavity and
into the nasopharynx. C. The tube is advanced into the laryngopharynx. D. At the start of inspiration, the tube is advanced through the vocal cords and into the trachea.
(Figure 22-1B). Advance the ET tube with gentle pressure along the of resistance signifies that the ET tube has made the curve. Stop
nasal floor to pass it through the nasal cavity (Figure 22-2B). If any advancing the ET tube and rotate it so that the tube’s natural curve
resistance is felt, slightly withdraw the ET tube. Readvance the tube is concave upward and in the same curvature of the airway. If the
with a slight twisting motion to bypass the obstruction. If resistance ET tube will not curve from the nasopharynx into the oropharynx,
is still met, withdraw the ET tube, prepare the other nostril, and several options are available. These include trying the other nos-
insert the tube into the other nostril. tril, using an ET tube 0.5 mm smaller and reattempting intubation
When the ET tube is inserted approximately 5 to 7 cm, the tip through the original nostril, or using an Endotrol tube (described in
will be past the choana and in the nasopharynx (Figure 22-2B). the next section).
Continue advancing the ET tube as resistance is met while the Advance the ET tube through the oropharynx and into the laryn-
tube makes a 90° change of direction into the oropharynx. A slight gopharynx (Figure 22-2C). Listen for breath sounds through the
twisting motion may be required to advance the ET tube. A loss proximal end of the ET tube while advancing it. The breath sounds
CHAPTER 22: Nasotracheal Intubation 137
and air movement will be maximal when the tip of the ET tube is
just above the glottis. As soon as an exhalation is heard, the patient
will take a breath and advance the ET tube. The vocal cords are
opened their widest during inspiration, and this will facilitate
passage of the ET tube.
The patient will often cough or gag as the ET tube traverses the
vocal cords. At this point, breath sounds should be audible from the
proximal end of the ET tube and it should fog with each breath. If
the patient is able to groan or speak, the esophagus has been intu-
bated. Withdraw the ET tube and reinsert it during inspiration. The
application of posteriorly applied pressure on the trachea (Sellick’s
maneuver) will occlude the esophagus and may allow easier ET
intubation.
If resistance to the advancement of the ET tube is felt, it may be
caught in the hypopharynx. Common sites for the tip of the ET tube
to get caught are the arytenoid cartilage, piriform sinus, vallecula,
and the vocal cords. Withdraw the ET tube 3 to 4 cm, slightly rotate
the ET tube, and readvance it.
Inflate the ET tube cuff. Confirmation of ET tube placement
should be assessed by auscultating both lungs while ventilating
the patient with a bag-valve device through the nasotracheal tube.
Adjust the position of the tube until both lungs are being ventilated
equally and secure the tube (Figure 22-2D). Continue to ventilate FIGURE 22-4. Blind nasotracheal placement of an Endotrol tube. Tension exerted
the patient. on the ring of the tube causes the curvature of the tube to increase (arrow).
■ BLIND PLACEMENT OF THE ENDOTROL TUBE

The indications, contraindications, and patient preparation are the direct visualization must be performed with the patient supine.
same as described above. The Endotrol tube is an ET tube whose tip The indications and precautions are similar to those for orotracheal
can be controlled. It looks like a cuffed ET tube but has a plastic liga- intubation (Chapter 11). This method should be considered in the
ture along the inner side that is connected to a ring on the proximal event of an oral injury that renders an orotracheal tube a nuisance
end of the ET tube (Figure 22-3). Pulling of the ring exerts tension or if blind nasal intubation is unsuccessful.
on the plastic ligature, leading to an increase in the curvature of the This procedure is initially performed as previously described.
tip of the ET tube. This will project the tip anteriorly and inferi- Once the tube is inserted into the hypopharynx, direct laryngos-
orly (Figure 22-4). The procedure for inserting the Endotrol tube is copy is performed. Using the left hand, grasp the laryngoscope and
the same as that for inserting an ET tube. Changing the curvature insert the blade. Visualize the patient’s epiglottis and vocal cords
of the tip will aid in passage of the tube from the nasopharynx to as well as the ET tube. Using a Magill forceps with the right hand,
the oropharynx and from the hypopharynx into the trachea. If the grasp the ET tube just above the cuff (Figure 22-5). Never grasp the
ring is sitting firmly against the nares after intubation, the tip of the cuff, as it is delicate and can easily be damaged by the Magill for-
tube may be exerting continuous pressure on the anterior tracheal ceps. Have an assistant grasp the proximal end of the ET tube and
mucosa. Cut the ligature and remove the ring. gently advance it while the physician simultaneously guides the tip
through the vocal cords (Figure 22-5). Remove the Magill forceps
■ PLACEMENT UNDER DIRECT VISION and the laryngoscope. Inflate the cuff, secure the tube, and ventilate
The technique begins with nasotracheal intubation, followed by the patient.
direct laryngoscopy. The placement of a nasotracheal tube using
■ BLIND DIGITAL NASOTRACHEAL INTUBATION
A technique was developed that combines blind nasotracheal intu-
bation and digital orotracheal intubation.12 This technique starts
with the procedure of blind nasotracheal intubation. If not suc-
cessful, insert the index and middle fingers of the nondominant
hand into the patient’s mouth. Slide these fingers posteriorly over
the tongue to palpate the epiglottis. Grasp the tip of the ET tube
between the two fingers (Figure 22-6A). Pull the ET tube anteri-
orly and behind the epiglottis (Figure 22-6A). Use the nondomi-
nant hand to advance the ET tube further into the patient’s nose,
thus advancing the tip into the trachea (Figure 22-6B).
ASSESSMENT
The position of the ET tube should be confirmed by end-tidal CO2
monitoring, fogging in the ET tube for at least six ventilations,
loss of voice, auscultation over the chest and the epigastrium, and
FIGURE 22-3. The Endotrol endotracheal tube. The curvature can be changed by a chest X-ray. Please refer to Chapter 12 for a more detailed dis-
pulling on the ring to facilitate intubation. cussion regarding confirmation of endotracheal intubation.
AFTERCARE
The ongoing care of the patient should proceed as with any other
intubation technique.
COMPLICATIONS
The immediate complications of nasotracheal intubation include
epistaxis, laryngeal and tracheal trauma, mucosal avulsion, retro-
pharyngeal laceration, turbinate avulsion, intracranial placement,
bacteremia, esophageal intubation, and prolonged attempts to place
the tube.4,5 Many of these can be prevented by choosing the appro-
priate size ET tube, ensuring adequate nasal mucosal vasoconstric-
tion, and applying a liberal amount of lubricant to the ET tube. Risk
factors for epistaxis should be assessed on every patient prior to
nasotracheal intubation.8 Long-term complications include maxil-
lary sinusitis, retropharyngeal abscess, mediastinitis, nasal mucosal
necrosis, and cellulitis.4,5
Very little literature is available regarding nasotracheal intubation
on children. In the past, this approach was an option for patients
with epiglottitis and acute laryngotracheobronchitis.9 The most
recent data reserve nasotracheal intubation for children with con-
genital facial anomalies.10 This technique cannot be recommended
for children in the Emergency Department. Their small nostrils
limit ET tube size. Large adenoids may make passage of the ET tube
difficult and increases the risk of bleeding.
SUMMARY
Nasotracheal intubation is an alternative to orotracheal intubation
to secure an airway in the spontaneously breathing patient. It allows
FIGURE 22-5. Nasotracheal intubation under direct visualization. awake intubations while the patient maintains protective airway
FIGURE 22-6. Blind digital nasotracheal intubation. A. The ET tube is grasped with the fingertips and pulled anteriorly (arrow) behind the epiglottis. B. The ET tube is
advanced into the trachea.
CHAPTER 23: Retrograde Guidewire Intubation 139
reflexes, and it avoids the risks of paralytic agents. It is a fairly simple cervical arthritis, mouth tumors, and muscular dystrophy repre-
procedure that should be considered in patients in whom an oral sent less common but equally challenging airway situations.4,7
airway is considered difficult and in those with an anticipated short Another clinically important situation arises when a patient pres-
intubation period. ents with impending ventilatory failure. While retrograde intubation
is generally a longer procedure than orotracheal intubation, oxy-
genation and ventilation can be maintained with a bag-valve-mask
device during the procedure. It is useful when bleeding obstructs
visualization of the glottis.
A less common indication includes retrograde intubation of a
Retrograde Guidewire
23 Intubation
difficult airway in a patient being ventilated with a laryngeal mask
airway. This indication exists because withdrawal of the laryngeal
mask airway over a blindly placed catheter can result in dislodge-
Roland Petri ment of the catheter, necessitating replacement of the laryngeal
mask airway.8
INTRODUCTION
Failure to establish a definitive airway is a significant cause of death CONTRAINDICATIONS
and disability among emergency patients. Oral endotracheal intu- The major contraindication to retrograde intubation is the
bation via direct laryngoscopy, increasingly often video-assisted, ability to control the airway with less invasive techniques.
remains the “gold standard” of airway management. Difficult sit- Other contraindications include an anterior neck mass, infec-
uations arise in which oral endotracheal intubation is impossible, tions, or cancerous process overlying the cricothyroid membrane.
is contraindicated, or fails. Retrograde guidewire intubation is an Trismus, or the inability to open the mouth, is a contraindica-
alternative airway management technique that should be familiar tion to this technique. Apneic patients who cannot be ventilated
to those involved with emergency airway management.1 with a bag-valve-mask device should receive a cricothyroidotomy
Retrograde intubation was first described in 1960 by Butler and and not a retrograde guidewire intubation. Those unfamiliar with
Cirillo.2 In 1963, Waters described insertion of an epidural catheter the equipment and/or technique should not attempt this proce-
through a cricothyroid puncture as an alternative means of estab- dure. While one case report presents the successful use of a man-
lishing an airway.3 Powell and Ozdil reported a series of 15 patients nequin to teach retrograde intubation to emergency caregivers,
in whom retrograde intubation was employed without complica- familiarity with the procedure is required for optimum patient
tions using a plastic catheter rather than an epidural catheter as a management.1
guide into the trachea.4 The current technique of retrograde intuba-
tion varies little from these original descriptions.
EQUIPMENT
Retrograde intubation represents one of several alterna-
tive maneuvers for securing the difficult airway. While mouth • 68 to 80 cm spring guidewire with a J tip
tumors, cervical arthritis, and jaw ankylosis represent rare cases of • 16 to 18 gauge catheter-over-the-needle (angiocatheter)
difficult-to-control airways, maxillofacial trauma continues to rep-
resent the most common indication for alternative airway manage-
ment. Retrograde intubation has proven to be an effective method • Sterile saline
used by Emergency Physicians and prehospital personnel to estab- • 10 mL syringes
lish an airway. • 18 gauge needles
Completion times for retrograde intubation vary based on physi-
cian experience. Among healthcare professionals who had no prior • Hemostats, 2
experience with the technique but who had just completed a man- • Magill forceps
nequin-aided training course, the mean length of time to intubation • Sterile drape
was 71 ± 4 seconds.1 In a second study involving resident physicians
• 20 mL syringe
after a brief instruction course, 36 of 40 residents (90%) completed
retrograde intubation within 150 seconds, with a mean intubation • Povidone iodine or chlorhexidine solution
time of 56 ± 6 seconds.10 • Face mask
• Bag-valve device
INDICATIONS • Oxygen source and tubing
The American Society of Anesthesiologists defines a difficult • Suction source and tubing
airway as the clinical situation in which a conventionally trained • Yankauer suction catheter
Anesthesiologist experiences difficulty with mask ventilation, dif-
• 1% lidocaine
ficulty with tracheal intubation, or both.5 Retrograde intubation,
among other invasive back-up techniques such as cricothyroid- • 4% viscous lidocaine (optional)
otomy, should be considered in any patient in whom endotra- • Spray anesthetic (lidocaine or benzocaine)
cheal intubation may be difficult, is contraindicated, or has • Tape (or a commercially available endotracheal tube holder)
failed. It is potentially indicated when airway control is required
and less invasive methods have failed. Maxillofacial trauma and Retrograde guidewire intubation can be performed using a
cervical spine fractures represent the most common etiologies of a standard commercial retrograde intubation kit (Cook Retrograde
difficult airway.6 In one report of 19 patients with either maxillo- Intubation Set, Cook Incorporated, Bloomington, IN). It consists
facial trauma or fractures of the cervical spine, six had prior, failed of an 18 gauge needle set, 68 to 80 cm spring guidewire, and an
orotracheal intubation attempts. In all of these patients, retrograde 11 French introducer catheter (Figure 23-1). The remainder of the
intubation was successful on the first attempt.6 Jaw ankylosis, material must be supplied as listed above.
confirm correct needle placement (Figure 23-2A). Advance the

catheter until the hub is against the skin. Remove the needle and
syringe, leaving the catheter pointed upward and through the cri-
cothyroid membrane. If this has not already been done and the
patient is awake, inject 2 mL of 1% lidocaine through the catheter
to anesthetize the airway.
Advance the guidewire through the catheter and into the oro-
pharynx (Figures 23-2B & 23-3). The guidewire may exit the
mouth or nose. The preferred site of exit is the mouth, but the nose
is acceptable. If it is not visualized, insert a laryngoscope and look
for the guidewire. It is often in the oropharynx or hypopharynx.
Retrieve it with a Magill forceps. Continue to advance the guide-
wire through the mouth (or nose) until only 4 to 5 cm of the wire is
protruding from the patient’s neck. Carefully remove the catheter
while firmly holding the guidewire in place. Place a hemostat on
the guidewire where it enters the skin of the neck (Figure 23-2C).
This will ensure that the tip does not pull through the skin and into
the trachea.
FIGURE 23-1. The retrograde guidewire intubation kit. If the kit is being used, select the introducer catheter contained
in it. Pass the introducer catheter over the guidewire that is exit-
ing the mouth (or nose). Advance the catheter until resistance is
met. This signifies that the tip of the introducer catheter is at the
PATIENT PREPARATION inside of the cricothyroid membrane (Figure 23-2C). Advance the
well-lubricated endotracheal tube over the introducer and guide-
If time permits, and the patient is aware of pain, anesthetize the wire (Figure 23-2D). Continue to advance the endotracheal tube
airway. Nebulized viscous lidocaine will anesthetize the airway in until resistance is met. The tip of the endotracheal tube should be
15 to 20 minutes. Alternatively, inject 2 mL of 1% lidocaine percuta- at the inside of the cricothyroid membrane (Figure 23-2D). While
neously through the cricothyroid membrane and into the trachea.6 securely holding the endotracheal tube at the patient’s mouth,
This may cause the patient to cough and gag, with the subsequent remove the hemostat from the guidewire. Pull on the proximal end
possibility of aspiration. Lidocaine or benzocaine may be sprayed of the guidewire until the distal tip is through the skin and just into
into the pharynx. An alternative anesthetic method includes a supe- the endotracheal tube. Simultaneously withdraw the guidewire
rior laryngeal nerve block.9 Refer to Chapter 21 for details regarding and introducer catheter while advancing the endotracheal tube
this nerve block. into the trachea (Figure 23-2E). Inflate the endotracheal tube cuff
Clean the patient’s neck of any dirt and debris. Identify, by pal- and confirm proper placement (i.e., auscultation, detection of end-
pation, the hyoid bone, thyroid cartilage, cricoid cartilage, and cri- tidal CO2, fogging in the endotracheal tube, etc.).
cothyroid membrane. Apply povidone iodine to the patient’s neck, A second method can also be used to insert the endotracheal
followed by sterile drapes. tube. This follows the same technique described above to the point
of the guidewire exiting the mouth (or nose), being secured with
TECHNIQUE a hemostat at the neck, and passing the introducer catheter over
The procedure is relatively simple in theory but difficult to perform the guidewire. Remove the hemostat from the guidewire. While
“in the heat of battle.”1,10–13 Prepare the equipment. Place the 16 to securely holding the introducer catheter at the patient’s mouth
18 gauge catheter-over-the-needle onto a 10 mL syringe containing (or nose), remove the guidewire through the mouth (or nose).
3 to 5 mL of sterile saline. Select an appropriate size endotracheal Advance the introducer catheter an additional 2 to 3 cm into the
tube for the patient. Check the integrity of the cuff. Lubricate the trachea. Lubricate the endotracheal tube liberally. Place the endo-
inside and outside of the distal tip of the endotracheal tube liberally. tracheal tube over the introducer catheter. While holding the
Open the retrograde guidewire kit and/or assemble all equipment. introducer catheter securely, advance the endotracheal tube into
The equipment should be preassembled, prepackaged, sterilized, the patient’s trachea. Remove the introducer catheter. Inflate the
and stored in an easily accessible site. endotracheal tube cuff and confirm proper placement (i.e., aus-
Stabilize the patient’s larynx with the thumb and middle finger cultation, detection of end-tidal CO2, fogging in the endotracheal
of the nondominant hand (Figure 25-2). Identify the cricothy- tube, etc.).
roid membrane with the index finger of the nondominant hand.
Leave the index finger on the cricothyroid membrane. Infiltrate
lidocaine subcutaneously over the cricothyroid membrane if the This technique may be performed without a formal retrograde
patient is awake to minimize discomfort from the percutane- intubation kit as the introducer catheter is not required.7,12,13 This
ous catheter insertion. Insert the 16 to 18 gauge catheter-over- follows the same technique described above to the point of the
the-needle guided along the index finger, at a 20° to 30° angle guidewire exiting the mouth (or nose) and being secured with a
upward and through the cricothyroid membrane (Figure 23-2A). hemostat at the neck (Figure 23-2C). Lubricate the endotracheal
Although not recommended, some physicians prefer to use the tube liberally. Insert the guidewire through the Murphy eye and into
needle without the catheter. The sharp needle within the trachea the endotracheal tube. This allows the distal tip of the endotracheal
can cause significant injury when compared to the soft catheter. tube to project approximately 1 cm distal to the site at which the
Care should be taken to puncture the cricothyroid membrane guidewire enters the larynx. As an alternative, some physicians pre-
just above the cricoid cartilage to avoid injury to the cricothy- fer to load the guidewire through the tip of the endotracheal tube
roid arteries. The loss of resistance signifies that the needle is (Figure 23-4). Always hold the proximal end of the guidewire to
in the larynx. Aspirate air through the saline-filled syringe to maintain control during the procedure. Advance the endotracheal
CHAPTER 23: Retrograde Guidewire Intubation 141
FIGURE 23-2. Retrograde guidewire intubation. A. A syringe containing saline is attached to the catheter-over-the-needle. The catheter-over-the-needle is inserted through
the cricothyroid membrane. The air bubbles in the syringe indicate air aspirated from the trachea. For clarity, the physician’s hand and fingers stabilizing the airway and
identifying the cricothyroid membrane are not seen in this illustration. B. The needle and syringe have been removed and the catheter remains. The guidewire is fed
through the catheter and out the patient’s mouth. C. The distal guidewire is clamped with a hemostat as it exits the skin of the neck. The introducer catheter is fed over the
guidewire and advanced to the cricothyroid membrane. D. An endotracheal tube is advanced over the guidewire and introducer catheter until its tip is at the cricothyroid
membrane. E. The hemostat has been removed. The endotracheal tube is advanced as the guidewire and introducer catheter is removed.
tube over the guidewire until resistance is felt. The tip of the endo- patient’s lips. Withdraw the guidewire through the patient’s mouth.
tracheal tube should be at the inside of the cricothyroid membrane. Inflate the endotracheal tube cuff and confirm proper placement
Hold the proximal end of the guidewire firmly. Release the hemo- (i.e., auscultation, detection of end-tidal CO2, fogging in the endo-
stat over the neck. Pull the guidewire through the skin and just into tracheal tube, etc.).
the endotracheal tube. Advance the endotracheal tube until it is at When the endotracheal tube is advanced over the guidewire until
20 to 21 cm at the teeth for an adult female or 22 to 23 cm at the resistance is met, the tip should be situated against the inside of the
teeth for an adult male. Hold the endotracheal tube securely at the cricothyroid membrane. It is imperative to determine if the tip of
FIGURE 23-3. The guidewire is inserted through the needle

(or catheter depending on physician preference) until it exits
the mouth.
the tube is in the trachea or caught on the epiglottis, arytenoid carti- mouth of the severely injured patient with significant intraoral
lage, pyriform recess, vallecula, or vocal cords. If concern exists as to blood or secretions. This technique requires a relatively long central
the position of the tip, withdraw the endotracheal tube 2 cm, rotate venous catheter. It does allow retrograde intubation without the use
it 90°, and readvance it into the trachea. As an alternative, a laryngo- of a formal retrograde intubation kit.
scope or fiberoptic broncho/nasopharyngoscope can be inserted to Finally, another version uses a lighted stylet attached to the endo-
help visualize the placement of the endotracheal tube. tracheal tube.14 The lighted stylet acts as a guide to indicate the tube’s
Another variation involves the use of the guidewire sheath as an location. When the tip of the endotracheal tube enters the glottic
introducer catheter.12,13 Shorten the sheath by 3 to 5 cm using sterile opening, a bright, circumscribed glow is readily seen in the anterior
scissors. The remainder of the technique is the same as described neck, below the thyroid prominence. This glow acts as an indicator
above. The only drawback to this technique is that the curvature of of correct endotracheal tube placement.
the sheath must be straightened before use to allow easy threading When continuous oxygenation is required throughout the pro-
over the guidewire. cedure, two possibilities exist.12 A T-adapter (1260, Deseret, Sandy,
In another description, a central venous catheter is used rather UT) can be connected to the needle hub with its side arm for oxy-
than a guidewire.6 It allows the physician to inject air through the gen insufflation. Alternatively, a swivel adapter with a fiberoptic
catheter in retrograde fashion to help locate the catheter in the bronchoscopic cap (1/25/09, Portex, Wilmington, MA) can be
FIGURE 23-4. The endotracheal tube is advanced over the

guidewire until the tip is against the cricothyroid membrane.
CHAPTER 24: Percutaneous Transtracheal Jet Ventilation 143
interposed between the endotracheal tube and the bag-valve-mask While complications may occur in association with retrograde
device or anesthesia breathing circuit. intubation, the rate of complications is relatively low. In one study,
20 resident physicians performed retrograde intubation twice each
ASSESSMENT on 40 cadavers.10 In two cases (5%), the wire was fed caudad into
the trachea due to improper angling of the needle. The remaining
Auscultation of both lungs will confirm proper placement of the intubations were performed without complications.
endotracheal tube and minimize the risk of intubation into the right
mainstem bronchus. End-tidal CO2 has also become part of the SUMMARY
postintubation routine. After the procedure is completed, a chest
radiograph will confirm the placement of the endotracheal tube tip Retrograde guidewire intubation requires little operator experi-
in relation to the clavicles and carina. Please refer to Chapter 12 for ence or equipment. Multiple reports suggest that this technique
a more complete discussion of the methods to confirm endotracheal is safe, relatively easy to learn, and routinely successful. All physi-
intubation. cians involved in the airway management of critically ill and injured
patients should be aware of this technique as a potential method
to overcome the challenge of a difficult airway. Within the arma-
AFTERCARE
mentarium of management techniques for the difficult airway, ret-
The patient should receive standard wound care and dressing of the rograde guidewire intubation should be given due consideration
skin at the neck entrance site. Wound checks and infection moni- in any situation in which orotracheal intubation is impossible or
toring should continue as with any other surgical procedure. The contraindicated.
risk of skin, tracheal, or pharyngeal infection is minimal if sterile Numerous difficult airway management devices and adjuncts
technique was followed. If infection develops, wound evaluation have been invented and marketed. Arguably, the various video-
and treatment with appropriate antibiotics is warranted. assisted laryngoscopy devices have come to dominate the realm of
alternative airway management techniques. The role of retrograde
COMPLICATIONS guidewire intubation as a difficult airway management approach
has further diminished as a consequence. However, retrograde
Complications of retrograde guidewire intubation include those of guidewire intubation remains an easy-to-learn and potentially life-
standard endotracheal intubation. Complications can occur when saving tool in the Emergency Physician’s growing airway manage-
the needle traverses the cricothyroid membrane.10 Hypoxia due to ment armamentarium.
prolonged intubation time or incorrect endotracheal tube placement
remains an important complication. Drug reactions or side effects
secondary to administered medications must always be considered.
Retrograde intubation is associated with additional complications
due to use of the guidewire. One case report discusses a patient with Percutaneous Transtracheal
a history of retrograde intubation for coronary bypass surgery who
experienced a foreign-body sensation and bloody sputum 2 years
after the procedure.15 Upon radiographic examination, the patient
24 Jet Ventilation
was found to have a 10 cm segment of guidewire fixed in the soft Eric F. Reichman and Aaron Brown
tissue of the puncture site and extending cephalad 2 cm past the
true vocal cords. INTRODUCTION
In one cadaveric study, numerous complications were noted dur- Percutaneous transtracheal jet ventilation (PTTJV) provides emer-
ing 40 cricothyroid punctures. Two punctures (5%) occurred below gency ventilatory support in patients who cannot be adequately ven-
the cricothyroid membrane. One was between the cricoid cartilage tilated with a bag-valve-mask device (with oral or nasal airways), a
and the first tracheal ring. The other was between the first and sec- laryngeal mask airway (LMA), or endotracheally intubated.1,2,10 This
ond tracheal rings. Four cases (10%) showed minor injuries to the includes patients with upper airway foreign bodies or neoplasms,
thyroid or cricoid cartilage. Three cases (7.5%) showed injuries to maxillofacial trauma, laryngeal edema, or infection.2,3 It is also used
the posterior wall of the larynx, epiglottis, or soft palate. No pos- electively with general anesthesia for surgery involving the larynx
terior tracheal perforations were found in this study. The clinical and subglottic areas.4 PTTJV involves placement of a percutaneous
importance of these injuries is unclear given the nature of this post- catheter into the trachea and ventilation via a cyclic delivery of tidal
mortem study. volume to the lungs.5
Three technical complications from retrograde guidewire intu-
bation have been identified.10,12 Difficulties inserting the guidewire
can be prevented by first aspirating air into a saline-filled syringe to
confirm the proper intratracheal needle tip position. Endotracheal Early studies of transtracheal ventilation used transtracheal cath-
intubation over a flexible guidewire necessitates keeping the guide- eters connected to 4 to 5 L/min of oxygen.6 Oxygenation with this
wire taut to minimize the risk of kinking. Unfortunately, this moves apparatus was adequate, but patients quickly developed hypercarbia
the guidewire anteriorly toward the narrowest portion of the glottis due to lack of ventilation.5 This “apneic oxygenation” also occurs
and may prevent passage of the endotracheal tube, as the tip can in ventilation through a catheter attached to a bag-valve device.7
become caught on the epiglottis or the vocal cords. This problem The low pressure and flow of oxygen generated by the bag-valve
is obviated by the use of the introducer catheter in the retrograde device result in increases in PaCO2 of 4 mmHg/min and the rapid
guidewire intubation kit. It lies in the posterior pharynx and glot- development of respiratory acidosis.1,8 Numerous studies have since
tis and allows for easier passage of the endotracheal tube into the demonstrated that intermittent jets of pressurized 100% oxygen at
trachea. The tip of the endotracheal tube may flip out of the lar- 50 pounds per square inch (psi) allows for both oxygenation and
ynx when the introducer is being removed, because the distance adequate ventilation.8,9
between the vocal cords and the point where the introducer enters The anterior neck provides direct access to the airway via the tra-
and anchors the larynx averages only 1.0 to 1.3 cm in adults. chea as it extends from the larynx into the lungs (Figure 24-1). At
procedure of choice in the pediatric age group for establishing an

emergent airway when endotracheal intubation fails.7 PTTJV can
serve as a quick alternative to a difficult intubation. It is especially
valuable in cases of maxillofacial trauma, suspected cervical spine
injury, or when nasal intubation is contraindicated or unsuccess-
ful.5,6,13 PTTJV is also used routinely by Anesthesiologists in the
operating room. Electively, transtracheal catheters are placed in
patients undergoing surgery of the upper airway, including the lar-
ynx and subglottic structures.7
This procedure is also indicated in cases of partial upper airway
obstruction due to foreign bodies, laryngeal edema, neoplasm, or
Hyoid bone infection.2,3 In cases of upper airway foreign bodies, PTTJV not only
serves as an emergent airway but can also assist in dislodging the
Laryngeal prominence foreign body.6,7 Animal studies have demonstrated that the expul-
of thyroid cartilage
sion of foreign bodies from the hypopharynx and upper trachea
is possible with high-frequency jet ventilation, in effect similar to
Cricothyroid membrane
the Heimlich maneuver.13 Approximately 30% of the air flow from
Cricoid cartilage transtracheal jet ventilation is directed cephalad and can therefore
Tracheal rings assist in the expulsion of airway foreign bodies.14
PTTJV has a large number of advantages when compared to an
emergent cricothyroidotomy.1–21 It is easier and faster to perform.
The technique is simpler to learn. The need for a large number of
FIGURE 24-1. Airway structures of the neck. instruments, surgical preparation and technique, and an assistant is
eliminated. The complications of bleeding, glottic stenosis, subglottic
stenosis, and tracheal erosion are significantly lessened. If the patient
survives, PTTJV causes less cosmetic disfigurement. Finally, PTTJV
the top of the laryngeal skeleton is the thyroid cartilage, which lies can direct secretions and foreign bodies out of the proximal trachea.
at the level of the fourth and fifth cervical vertebrae. The laryngeal
prominence of the thyroid cartilage (more prominent in men) is eas-
ily palpated with the thumb and index finger. The cricoid cartilage CONTRAINDICATIONS
lies just inferior to the thyroid cartilage at the level of the sixth cer- PTTJV is contraindicated in patients who can be orally or nasally
vical vertebra. It serves as the junction of the larynx and trachea. intubated. Anterior neck trauma may be a contraindication to
Multiple cartilaginous rings support the trachea. Between the cricoid PTTJV. Damage to the larynx or cricoid cartilage is a contraindica-
and thyroid cartilages lies the cricothyroid membrane. The cricothy- tion to PTTJV. If laryngeal trauma is suspected, catheter placement
roid membrane is a palpable membranous depression just infe- may result in laryngeal disruption.5,12 It should not be performed
rior to the laryngeal prominence and is the access site for PTTJV.11 in patients with partial or complete transection of the trachea.
The cricothyroid artery is a branch of the superior thyroid artery. It Lower tracheal or proximal bronchial tree disruption can result in
travels transversely across the cricothyroid membrane just below the an increased risk of pneumothorax and pneumomediastinum with
thyroid cartilage. Placement of the catheter through the lower half of high-pressure ventilation.5,7,12
the cricothyroid membrane will prevent injury to this small artery.22 Complete airway obstruction is also an absolute contraindica-
Once the catheter is placed and appropriately connected to an tion to PTTJV.5,8,12 Exhalation requires passive recoil of the lungs
oxygen source, oxygen is delivered via bulk flow through the can- and chest wall, and a patent airway for outflow of gas. A patient
nula into the trachea and lungs. Entrainment of room air transla- with a complete upper airway obstruction is at an increased risk
ryngeally via the Venturi principle is negligible, even with minimal for barotrauma (i.e., pneumothorax and pneumomediastinum).
upper airway obstruction.1 Therefore, near 100% O2 is delivered Numerous studies have been performed to evaluate PTTJV with
with each insufflation. varying degrees of upper airway obstruction. Ward et al. found that
Inhalation occurs through the catheter via a pressurized flow of progressively increasing airway obstruction up to 80% did not cause
oxygen. Exhalation occurs passively through the elastic recoil of barotrauma.20 With upper airway obstruction, less air is allowed
the lungs and chest wall.10 The minute ventilation delivered during to escape and more volume is forced into the lungs. Therefore,
PTTJV is proportional to the volume of air injected, the driving tidal volume increases with increasing airway obstruction. Once a
air pressure, and the degree of upper airway obstruction.2,12 Animal patient develops complete upper airway obstruction, auto-PEEP
studies demonstrate that PTTJV delivers more tidal volume than (end-expiratory alveolar pressure above the set level of positive
positive-pressure mask ventilation with the same tracheal and end-expiratory pressure) will develop as air is trapped within the
transpulmonary pressures despite delivery of oxygen from a pres- thoracic cavity with no outlet and insufflation of air under pressure
surized source.2 continues. This will ultimately result in barotrauma and decreased
mean arterial pressure.19
INDICATIONS
PTTJV is indicated as a backup emergent airway in any patient EQUIPMENT
who cannot be endotracheally intubated or ventilated with a bag- • Pressurized oxygen source, wall source or tank at 50 psi
valve-mask device despite the use of a jaw-thrust maneuver, oro-
• Povidone iodine solution or Chlorhexidine prep
pharyngeal airway, or nasopharyngeal airway or LMA.1,2,5 It serves
as a simple, relatively safe, and effective alternative to cricothyroid- • Commercially available PTTJV kit or a self-assembled kit from
otomy.1,6 This is especially true in pediatric patients below 5 years of available components
age, in whom a cricothyroidotomy is contraindicated. PTTJV is the • 12 to 16 gauge, 2 to 3 in catheter-over-the-needle (angiocatheter)
FIGURE 24-2. The manual jet ventilation system (Instrumentation Industries, FIGURE 24-4. The Norgren jet ventilation system (Norgren Inc., Littleton, CO).
Bethel Park, PA).
• Noncompressible high-pressure oxygen tubing can provide 100% O2 at 50 psi through noncompressible and high-
• Valve device (manual push valve, Y connector, T piece) pressure tubing. Along the tubing there must be a valve (Y connec-
tor or manual push valve) to allow intermittent flow of oxygen.5 The
• 10 mL syringe
flow into the trachea is regulated by manual control of this valve.
• Sterile saline Ventilations should be delivered at a rate of 12 to 20 breaths per
• Sterile drapes minute. Oxygen flow rates will vary with catheter size. Flow rates for
• Local anesthetic solution (1% lidocaine) 20, 16, and 14 gauge catheters at 50 psi are 400, 500, and 1600 mL/s,
respectively.9 The inspiratory time is brief compared to the expira-
• 3-0 nylon suture tory time by a ratio of 1:2 to 1:9 seconds.2,10,15
• Needle driver If a high-pressure system is unavailable, the patient may still be
• Bag-valve device temporarily oxygenated through a transtracheally placed catheter.23
Attach a 3 mL syringe without the plunger to the catheter. Insert a
• 3 mL syringe
standard endotracheal tube connector, from a size 5 to 9 mm i.d.
• Adult endotracheal tube connector endotracheal tube, into the barrel of the syringe. Connect the bag-
A PTTJV system can be purchased from a commercial company. valve device to the connector and begin ventilation while preparing
It may also be assembled with individual parts.1 Examples of PTTJV for more definitive airway control.6,7,24,25
systems are shown in Figures 24-2, 24-3, & 24-4. The components of The commercially available PTTJV kits are designed to provide
a PTTJV system are quite simple (Figure 24-5). The oxygen source 100% oxygen at 50 psi which has been shown to provide both ade-
may be a wall supply or tank. It should have a pressure regulator that quate oxygenation and ventilation.8,9 Several recent studies have
compared the effectiveness of a self-made apparatus with the com-
mercial kits. They have shown that flow rates of >15 L/min (regula-
tor wide open) are needed to produce equivalent flow rates.26 Using
flow rates less than 15 L/min will result in failure of ventilation
within 60 seconds. Therefore, if a high pressure system is unavail-
able and a more definitive airway cannot be obtained, a surgical cri-
cothyroidotomy should be performed.27
PATIENT PREPARATION
The establishment of PTTJV requires not only proper insertion of
the transtracheal catheter, but also a proper setup of the ventila-
tory equipment. The required equipment should be prepackaged
and placed where it is readily accessible. Ensure that the fittings are
secure and the tubing is not damaged. Place the patient supine and
in the “sniffing” position if no contraindications exist. The patient
is most likely already in the proper position, as this technique is
most often performed on apneic patients in whom other intuba-
tion techniques have failed. Place a rolled towel behind the middle
of the neck to hyperextend the neck and allow for better access.
Identify by palpation the hyoid bone, thyroid cartilage, cricoid car-
FIGURE 24-3. The Manujet jet ventilation system (VBM Medizintechnik, tilage, and cricothyroid membrane. Clean the anterior neck of any
W. Germany). dirt and debris. Apply povidone iodine solution or chlorhexidine
Regulator
Pressure
A meter
In-line
valve
Tubing
Tubing
Catheter
Oxygen supply
Oxygen
Oxygen regulator
outlet
Catheter
Tubing
Tubing
Manual
trigger
FIGURE 24-5. The components of high-pressure jet ventilation systems. A. Modified from Greenfield.21 B. Modified from Patel.10
prep to the anterior neck. Prepare the needed equipment. Attach a pressure until air bubbles are visible in the syringe and a loss of
12 to 16 gauge catheter-over-the-needle (angiocatheter) to a 10 mL resistance is felt.5,10 These both signify that the angiocatheter is
syringe containing 5 mL of sterile saline. within the trachea.
Once placement within the trachea is confirmed, securely hold
TECHNIQUE the needle and advance the catheter until the hub is against the skin
(Figure 24-6C). Remove the needle and syringe (Figure 24-6C).
Stand at the side of the bed and adjacent to the patient’s head and Reattach the syringe without the needle to the catheter. Aspirate
neck. Reidentify the anatomic landmarks. This is crucial to per- once again to reconfirm placement of the catheter within the tra-
form this procedure. Using the nondominant hand, place the chea. The 2 to 3 cm catheter should be long enough to pass into the
thumb on one side of the thyroid cartilage and the middle finger on tracheal lumen without sitting against the posterior wall. If the cath-
the other side. Use these fingers to stabilize the larynx. Use the index eter tip directly touches or faces the posterior tracheal wall, there
finger to identify the anatomic landmarks.5,10 Start at the laryngeal is the risk of forcing air submucosally.12 Firmly grasp and hold the
prominence (Adam’s apple) and work inferiorly. The soft membra- catheter hub at the skin of the neck. Remove the syringe. Attach the
nous defect inferior to the laryngeal prominence is the cricothyroid oxygen tubing to the catheter (Figure 24-6D). Begin ventilation and
membrane. Below this is the firm cartilaginous ring of the cricoid continue until a more permanent and secure airway is established.5
cartilage. Watch for adequate chest rise with ventilation and allow for com-
Insert the catheter-over-the-needle (angiocatheter) through the plete elastic recoil of the chest wall before giving the next breath
skin, subcutaneous tissue, and inferior aspect of the cricothyroid to avoid air trapping and barotrauma.
membrane. The inferior aspect of the cricothyroid membrane
is the preferred site as it avoids injury to the cricothyroid arter-
ASSESSMENT
ies.7 Direct the catheter-over-the-needle inferiorly and at a 30° to
45° angle (Figure 24-6A). Maintain constant negative pressure PTTJV requires continuous cardiac and pulse oximetry monitoring
within the syringe as it is advanced (Figure 24-6B). Continue to to evaluate oxygenation. Continuous capnography can be used to
advance the catheter-over-the-needle while maintaining negative assure adequate ventilation. Arterial blood gas samples should be
FIGURE 24-6. Insertion of the transtracheal catheter. A. The catheter-over-the-needle is inserted 30° to 45° to the perpendicular (dotted line) and aimed inferiorly.
B. Application of negative pressure to a saline-containing syringe during catheter insertion (arrow). Air bubbles in the saline confirm intratracheal placement of the catheter.
C. The catheter is advanced until the hub is against the skin. The needle and syringe are then removed. D. High-pressure oxygen tubing is attached to the catheter and
ventilation is begun.
obtained periodically to look for hypoxia and hypercarbia. Careful The catheter, oxygen tubing, and patient must be continually
attention must be paid to maintaining a patent upper airway to assessed during PTTJV. Check the catheter tubing at regular inter-
allow for passive expiration and avoid barotrauma. Oropharyngeal vals for signs of dislodgement or kinking. Examine the patient for
and/or nasopharyngeal airways, or a jaw-thrust maneuver, are often crepitus in the neck and torso. If crepitus is present, the catheter tip
adequate. is most likely directly against or directed toward the mucosa of the
posterior tracheal wall. Oxygen is being forced into the submucosal The catheter may be inappropriately placed. Misplacement of the
tissues and tracking subcutaneously. Remove the catheter and rein- catheter into the submucosa of the larynx can lead to a laryngeal
sert a new one. Obtain a chest radiograph to assess the patient for a pneumatocele. If this is suspected or identified, remove the catheter
pneumomediastinum, pneumopericardium, or pneumothorax that and reinsert a new one. The pneumatocele can be aspirated with a
may require decompression. Pulse oximetry and cardiac monitoring needle and syringe after placement of a new transtracheal catheter.5
and capnography should also be continuously monitored. Misplacement of the catheter posteriorly through the back of the
trachea and perforation of the esophagus is a theoretical concern
AFTERCARE that has never been reported.1,5,6
Pulmonary aspiration is another potential complication of PTTJV.
The catheter and tubing must be secured to prevent accidental The epiglottis provides no airway protection, and the small transtra-
dislodgement.10 One person must continuously hold the hub of the cheal catheter does not prevent aspiration of secretions or gastric
catheter against the patient’s skin during PTTJV while a second per- contents into the lungs. Animal studies have demonstrated that pul-
son secures it. There are three ways to secure the equipment. The monary aspiration in fact did not occur despite variable frequencies
first and preferred method is to suture it in place. Place a skin wheal of ventilation, variable oxygen flow pressure, and cardiac compres-
of local anesthetic solution (1% lidocaine) next to the catheter hub. sions during cardiopulmonary resuscitation (CPR).17,18 Studies have
Using 3-0 nylon suture, place a stitch through the skin wheal and tie shown that the pressurized flow of air through the catheter provides
it securely. Do not cut the suture. Wrap the long end of the suture an adequate forceful gas outflow from the lungs which may prevent
around the catheter hub two or three times and tie it securely to pulmonary aspiration. 17,18 Secretions and foreign bodies have been
the tail of the suture. Wrap the long end of the suture around the shown to stay above the jetting catheter while PTTJV is in progress.
oxygen tubing, just above the attachment to the catheter hub, two or If PTTJV is to be discontinued, great care must be taken to assure
three times and tie it securely to the tail of the suture. Alternatively, complete suctioning and cleansing of the upper airway above the
wrap a piece of umbilical or plain tape around the patient’s neck, catheter.18
the catheter hub, and the oxygen tubing. A second alternative is to Less serious complications include local hematoma formation
attach a commercially available endotracheal tube holder around at the catheter insertion site, hemoptysis, and cough.1,5,6 The use of
the patient’s neck and connect it to the oxygen tubing. The catheter nonhumidified oxygen in the catheter has been reported to cause
will still have to be secured with suture or by being taped to the irritation and erosion to the tracheal mucosa.1
oxygen tubing and skin.
The patient should be reevaluated for possible endotracheal intu-
SUMMARY
bation. Studies have shown that subsequent attempts have been
successful. It is possible that the positive pressure used in PTTJV PTTJV is an effective and easy method for establishing an emer-
increases the success rate.10 gent airway in patients who cannot be ventilated with a bag-valve-
mask device or intubated. The indications for PTTJV are the same
COMPLICATIONS as those for a cricothyroidotomy. Placement of a catheter through
the cricothyroid membrane and attached to a high-pressure oxygen
PTTJV is a relatively safe and effective means of establishing an source will provide adequate oxygenation and ventilation until a
emergent airway in a patient who cannot be intubated or ventilated more definitive airway can be established. This is an airway manage-
by another mechanism. Complications are fewer than with a crico- ment technique that is rapidly performed and should be considered
thyroidotomy, but they do occur and must be anticipated. as a reliable backup rescue technique for the “can’t intubate, can’t
Subcutaneous emphysema occurs most commonly when the ventilate” patient.
transtracheal catheter is misplaced, becomes dislodged into the
soft tissues of the neck during ventilation, or is placed against
the mucosa of the posterior tracheal wall.1,5,6 It may also occur if
catheter placement is unsuccessful on the first attempt, creating a
port for leakage of pressurized air into the subcutaneous tissues of
Cricothyroidotomy
the neck.5 Frequent examination of the catheter site for evidence of
subcutaneous emphysema may provide the earliest clue to catheter
malfunction.
25 Eric F. Reichman
Barotrauma may present as a pneumothorax, pneumomedias-

tinum, or pneumopericardium. It may be a result of upper airway
INTRODUCTION
obstruction. The exhalation of air is passive and depends on a pat-
ent upper airway. It is therefore important to monitor chest rise Establishment of an airway is of prime importance to survival. The
and fall as evidence of continued air exchange.1 An oropharyngeal most predictive factor of survival from cardiac arrest is establish-
airway, nasopharyngeal airway, or jaw-thrust maneuver will often ment of an airway.1 Unfortunately, the Emergency Physician is occa-
provide adequate upper airway patency.5 Assume, until proven sionally confronted with an airway that is extremely difficult or even
otherwise, that any sudden change in the patient’s heart rate or impossible to obtain by endotracheal intubation. Between 1% and
blood pressure during PTTJV is secondary to a tension pneumo- 4% of all emergent airways require a cricothyroidotomy.2–5 Up to
thorax. There has been a case report of laryngospasm with PTTJV 7% of trauma patients who present in cardiopulmonary arrest will
use during an elective surgical procedure.16 It resulted in sudden require a cricothyroidotomy.3
desaturation and hypotension that were easily resolved with the The technique of cricothyroidotomy has been documented in
administration of a paralytic agent. use since the early 1900s. In 1921, Chevalier Jackson condemned
Catheter obstruction is another potential complication. Most its use because of fears of subglottic stenosis.6,7 Jackson’s tech-
commonly, the catheter will kink as it traverses the soft tissues of the nique involved incising the cricoid cartilage, which led to the
neck.1,5 This may occur if the catheter is dislodged or as a result of subglottic stenosis. The technique was popularized again in 1966
high-pressure ventilation. The use of a commercially available kink- by Brantigan and Grow, but it was considered primarily an elec-
resistant catheter greatly reduces this risk. tive procedure.6,7 Cricothyroidotomy has since evolved into the
CHAPTER 25: Cricothyroidotomy 149
surgical airway of choice for emergent situations in which other

intubation methods have failed or are contraindicated.2,8 The
Emergency Physician using rapid sequence induction to intubate
patients should be knowledgeable and skilled in performing a cri-
cothyroidotomy.3 The success rate of a cricothyroidotomy ranges
from 96% to 100%.4,9
A cricothyroidotomy has numerous advantages over a tra-
cheostomy.6,10,11 A cricothyroidotomy is easier, faster, and safer
to perform. It can be performed in less than 2 minutes. It can be
performed by those with little or no surgical training. It does not
require the support of an operating room and a large amount of
equipment. The anatomic landmarks are superficial, easily seen,
and easily palpated. The procedure does not require a deep dissec-
tion, as the structures are located subcutaneously. The cricothyroid
membrane is not covered by any structures that would interfere
with the procedure. Because the cricothyroid membrane is in the
upper part of the neck, there is less chance of injuring the esopha-
gus. A cricothyroidotomy can be performed with the patient’s neck
in a neutral position. This is especially important in those with
potential cervical spine injuries. The procedure has fewer associ-
ated complications than a tracheostomy. Although not a concern FIGURE 25-2. Proper hand positioning to identify the airway structures of the
when securing an airway, the skin incision will heal with a smaller neck.
and less noticeable scar.
ANATOMY AND PATHOPHYSIOLOGY The cricothyroid membrane itself is a thin membrane measur-
The cricothyroid membrane is located between the thyroid carti- ing 2 to 3 cm in width and only 9 to 10 mm in height.8,11 It is
lage superiorly and the cricoid cartilage inferiorly (Figure 25-1). located approximately 1 cm below the true vocal cords.11 There
The cricothyroid membrane must be identified by palpation of is relatively little subcutaneous tissue overlying the cricothyroid
the surrounding cartilaginous structures. Using the nondominant membrane. There are few to no vascular structures overlying the
hand, place the thumb on one side of the thyroid cartilage and the cricothyroid membrane. The anterior cricothyroid arteries travel
middle finger on the other side (Figure 25-2). Palpate the laryngeal from lateral to medial over the superior border of the cricothy-
prominence (Adam’s apple) with the index finger. It is important roid membrane. The anterior jugular veins may lie immediately
to locate the hyoid bone superiorly to ensure that the incision is superior and lateral to the cricothyroid membrane. Farther lateral
not superior to the vocal cords. Moving inferiorly, the index finger and posterior are the great vessels of the neck. Posterior to the
will fall into a hollow, which is the location of the cricothyroid mem- larynx and trachea is the esophagus. It is therefore important not
brane. The next structure palpated is the firm cartilaginous ring of to make the incision too deep, thus risking an esophageal intuba-
the cricoid cartilage, followed by the tracheal rings. tion or injury.
B
A Hyoid bone
Thyroid cartilage Thyrohyoid

muscle
Laryngeal
prominence
Sternothyroid
Cricothyroid muscle
Hyoid bone
membrane
Laryngeal prominence Cricothyroid
Cricoid muscle
Inferior edge of thyroid
cartilage cartilage
Thyroid gland
Cricoid cartilage
Trachea Isthmus of
Thyroid gland
thyroid gland
Sternocleidomastoid
muscle
Sternoclavicular notch
Esophagus
FIGURE 25-1. Anatomy of the airway in the neck region. A. Topographic anatomy. B. The framework of the airway.
INDICATIONS • Syringes, 5 and 10 mL

• Needles, 18 to 27 gauge
The most frequent indication for an emergent or urgent surgical
airway is the inability to intubate endotracheally with less inva- • Bag-valve-mask device
sive techniques. These less invasive techniques may have failed or • Oxygen source and tubing
been contraindicated.10 Attempts at orotracheal or nasotracheal • Suction source, tubing, and catheter
intubation should be made prior to attempts at creating a sur-
gical airway.4,8 A common reason for the failure of orotracheal • Pulse oximeter
intubation is not using rapid sequence induction and the patient’s • Noninvasive blood pressure cuff
clenched teeth precluding intubation.9 Other common reasons for • Cardiac monitor
failure to establish endotracheal intubation include severe neck or • End-tidal CO2 monitor
facial injury resulting in distortion of the normal anatomy, edema,
masseter spasm, laryngospasm, cervical spine injury, deformities Surgical Cricothyroidotomy
of the mouth and/or pharynx, upper airway hemorrhage, large
• Povidone iodine or chlorhexidine solution
amounts of vomitus in the oropharynx, and upper airway obstruc-
tion.8,9,11 Although endotracheal intubation should be attempted • #11 scalpel blade on a handle
first, it is prudent to have the surgical airway supplies nearby if it • Trousseau tracheal dilator or curved 6 in hemostat
is suspected that the patient may have a difficult airway. The old • Tracheal hook
saying among Anesthesiologists “A surgical airway is better than a
deceased patient with a good-looking neck” holds quite true. • Hemostats, 4 small
Needle cricothyroidotomy is the emergent “surgical” airway of • Needle driver
choice in a patient younger than 8 to 10 years of age.11,12 In young • Suture scissors
children, the cricothyroid membrane as well as the surrounding • Tracheostomy tubes, sizes #4 and #6
structures are much smaller and more difficult to access. It is easier
to injure one of the cervical vessels or the esophagus when a stan- • Endotracheal tubes, various sizes
dard cricothyroidotomy is performed in a child. Subglottic stenosis • Tracheostomy tape (twill tape)
is a common late complication following cricothyroidotomy in chil- • 3-0 sutures for hemostasis (e.g., Dexon, Vicryl, or chromic)
dren.12 A needle cricothyroidotomy is a safer alternative and allows
• 3-0 nylon sutures for skin closure
for adequate oxygenation and ventilation until a formal tracheos-
tomy or other method of endotracheal intubation can be performed. • 1 in tape (or a commercially available endotracheal tube holder)
Unfortunately, the small caliber of the catheter may not provide • Gauze 4 × 4 squares
adequate oxygenation and ventilation in an adult. • Iodoform gauze ribbon
• Percutaneous cricothyroidotomy kit, adult and pediatric sizes
CONTRAINDICATIONS
There are a few absolute contraindications to performing a crico- Needle Cricothyroidotomy
thyroidotomy. The most important is if the patient can be endo- • Povidone iodine or chlorhexidine solution
tracheally intubated by less invasive methods. Partial or complete • 14 gauge catheter-over-the-needle (angiocatheter), 2 in long
transection of the airway is a contraindication to a cricothyroid-
• 5 mL syringe
otomy. In these cases, a tracheostomy is the preferred method to
secure the airway. Finally, this procedure should not be performed • Tape
in cases of significant injury or fracture of the cricoid cartilage, lar- • Percutaneous transtracheal jet ventilator (Chapter 24)
ynx, and/or thyroid cartilage.
The equipment should be prepackaged in a sterile tray that is
There are some situations where the performance of a crico-
readily accessible. Some institutions maintain separate cricothyroid-
thyroidotomy may be less desirable. The presence of laryngeal
otomy and tracheostomy trays. Others have one tray that contains
pathology (e.g., tumor, fracture) may preclude the performance
the equipment necessary to perform both procedures. If a cricothy-
of a cricothyroidotomy and necessitate a high tracheostomy.11,13 If
roidotomy tray is not immediately available, a thoracotomy tray usu-
a patient has been previously intubated endotracheally for a pro-
ally contains all the required equipment to perform this procedure.
longed period, there is a higher incidence of long-term complica-
Should the Emergency Department stock surgical cricothyroid-
tions following a cricothyroidotomy.13 While this does not prevent
otomy kits, percutaneous cricothyroidotomy kits, or both? The
the performance of a cricothyroidotomy, one should consider an
answer to this will depend on Emergency Physician preference, hos-
early revision to a tracheostomy to minimize these complications.
pital stores, and available budget. The Melker Universal Emergency
Other relative contraindications to performing a cricothyroidotomy
Cricothyroidotomy Catheter Set (Cook Inc., Bloomington, IN) may
are the presence of a coagulopathy, massive neck swelling, or a
resolve this issue for some Emergency Departments. This single-
hematoma in the neck; all of which increase the risk of bleeding and
use, disposable kit contains all the equipment required to perform
distortion of the anatomy. Finally, unfamiliarity with the technique
both types of cricothyroidotomies. The convenience of having all
may lead to increased complications.11
the required equipment readily available in one kit can clearly justify
the cost. Unfortunately, this kit is only available in one adult size.
EQUIPMENT
General Supplies PATIENT PREPARATION
• Sterile gloves, gowns, and drapes
A cricothyroidotomy is most commonly an emergent procedure.
• Face mask and eye protection There is little if any time to explain this to the patient and obtain
• 1% lidocaine local anesthetic solution their consent. If there is sufficient probability that an awake and
drapes placed to isolate a surgical field. The Emergency Physician

performing the procedure should be clad in a mask, a sterile gown,
and gloves. The circumstances in which the procedure is usually
performed often require that the airway be obtained rapidly. In
these cases, a quick spray of povidone iodine or chlorhexidine and
sterile gloves will suffice.
TECHNIQUES
During the performance of this procedure, one or two assistants
should be maintaining the airway by providing ventilation and
oxygenation with a bag-valve-mask device or a supraglottic airway
device. The right-handed Emergency Physician should be stand-
ing at the patient’s right side. The position is reversed for the left-
handed Emergency Physician.
Stabilize the large thyroid cartilage in place with the thumb
FIGURE 25-3. Patient positioning with a rolled towel under their neck and upper
and middle finger of the nondominant hand (Figure 25-2).8,14
shoulders.
The immobilization of the larynx cannot be overemphasized.
If the larynx is not secure and thus the landmarks are lost, the
procedure will fail. Identify the anatomic landmarks necessary
stable patient will require a surgical airway, informed consent may
to perform this procedure. This is critical to the performance
be obtained.
of a cricothyroidotomy. Place the index finger over the laryngeal
The patient should be appropriately monitored with electrocardi-
prominence (Adam’s apple). Move the index finger inferiorly to
ography (ECG), end-tidal CO2 monitoring, noninvasive blood pres-
identify the cricothyroid membrane, cricoid cartilage, and tracheal
sure cuff, and pulse oximetry. The patient preparation is exactly the
rings (in this order). Move the index finger superiorly until it falls
same as that for orotracheal intubation. As for any situation where
back into the cricothyroid membrane. Leave the index finger over
airway manipulation is to occur and the patient’s protective airway
the cricothyroid membrane. Using the index finger of the dominant
reflexes are blunted or ablated, a fully functioning suction apparatus
hand, confirm that the nondominant index finger is situated over
with a variety of catheters must be immediately available.
the cricothyroid membrane. If the patient is awake and stable, infil-
Place the patient supine with their head in a neutral position.
trate the area of the incision with local anesthetic solution after the
Place a rolled towel under the patient’s upper shoulders and neck if
landmarks are identified.
no contraindications exist (Figure 25-3). This position offers excel-
lent exposure, stabilizes and prevents the airway structures from
TRADITIONAL TECHNIQUE
moving, and lengthens the cricothyroid membrane. While it is not
impossible to perform a cricothyroidotomy with a cervical collar on Make a 2 to 3 cm transverse incision, centered in the midline,
the patient, it is very difficult. If the patient is at risk for a cervical through the skin and subcutaneous tissue (Figures 25-4 & 25-5A).
spine injury, it is preferable to remove the collar while an assistant Continue the incision through the cricothyroid membrane. As one
maintains in-line stabilization of the head and neck in a neutral gains skill with this procedure, all layers may be incised simultane-
position. An additional assistant should maintain the airway and ously with one incision. The beginner should proceed with some
provide ventilatory support with a bag-valve-mask device. caution because there is a small risk of incising through the posterior
In the ideal situation, the skin of the anterior neck should be wall of the airway.8,11 The incision should be no longer than 3 cm or
prepped with povidone iodine or chlorhexidine solution and sterile 1.5 cm on either side of the midline, as this represents the width
Hyoid bone
Thyroid
cartilage
Cricothyroid
membrane
Cricoid
cartilage
Trachea
FIGURE 25-4. The cricothyroidotomy site. The dotted line represents

the incision over the cricothyroid membrane.
FIGURE 25-5. A surgical cricothyroidotomy. A. The nondominant hand stabilizes the cricothyroid membrane. A transverse incision is made through the skin, subcutane-
ous tissue, and cricothyroid membrane. B. A tracheal hook has been inserted over the scalpel blade to grasp the inferior border of the thyroid cartilage. The hook is lifted
anteriorly and superiorly to control the airway (arrow). C. A Trousseau dilator is inserted into the incision and opened to dilate the incision site. D. A tracheostomy tube
is inserted through the cricothyroid membrane.
of the cricothyroid membrane.7,14 Longer incisions risk injury to incision. Open the jaws of the dilator to dilate the incision in the
the anterior jugular veins that lie just lateral to the thyroid cartilage.11 transverse plane. Remove the dilator while continuing to maintain
Longitudinal incisions in the midline are not recommended. control of the airway with the tracheal hook.
They take longer to perform and require repositioning after the skin Select a tracheostomy tube that is of an appropriate size for the
incision. The primary indication for a longitudinal skin incision is patient. Instruct an assistant to lubricate the obturator and outer
in the patient with a suspected laryngeal injury and distortion of cannula, then insert the obturator into the outer cannula. While
the anatomic landmarks.11 In these cases, the longitudinal incision maintaining control of the airway with the tracheal hook, insert the
permits the extension of the incision inferiorly in order to perform tracheostomy tube perpendicularly (90°) to the skin (Figure 25-5D).
a high tracheostomy. Continue to advance the tracheostomy tube with a semicircular
Once the cricothyroid membrane has been incised and the airway motion and inferiorly until the flange is against the skin. The trache-
entered, a hiss of air with ventilations and bubbling should be noted ostomy tube should pass with minimal difficulty. Remove the tra-
through the wound. This is true if the patient is ventilating sponta- cheal hook. Securely hold the outer cannula. Remove the obturator,
neously or with the assistance of a bag-valve-mask device. Do not insert the inner cannula, inflate the cuff of the tracheostomy tube,
remove the scalpel. Insert the tracheal hook along the scalpel and connect the bag-valve device, and ventilate the patient.4 Confirm
grasp the inferior border of the thyroid cartilage (Figure 25-5B). the intratracheal position of the tube by auscultating bilateral breath
Elevate the tracheal hook to retract the thyroid cartilage anteriorly sounds, noting the absence of breath sounds over the stomach, and
and superiorly.4,5 The scalpel may now be removed. The incision site a colorimetric or quantitative end-tidal CO2 assessment.
must be expanded to accommodate the passage of an endotracheal
tube or a tracheostomy tube. While controlling the airway with
ALTERNATIVE SURGICAL TECHNIQUE
the tracheal hook, insert the jaws of a Trousseau dilator (or 6 in
hemostat) through the cricothyroid membrane in the midsagittal An alternative surgical approach to a cricothyroidotomy was first
plane (Figure 25-5C). Open the jaws of the instrument to dilate the developed by Oppenheimer.17 It is simpler, more rapid, and eas-
opening in the sagittal plane.4,5,7,8 Rotate the dilator 90° within the ier to perform than the traditional technique described above
FIGURE 25-6. An alternative method to perform a surgical cricothyroidotomy. A. The thyroid cartilage is secured while a stab incision is made in the cricothyroid mem-
brane. B. The scalpel blade penetrates the midline and enters the airway. C. The incision is extended laterally from the midline. D. The scalpel is rotated 180° and extends
the incision to the other side. E. A tracheal hook is inserted in the midline and grasps the inferior border of the thyroid cartilage. F. The thyroid cartilage is lifted anteriorly
and superiorly to control the airway (arrow). After the airway is controlled, the scalpel is removed. G. A Trousseau dilator is inserted into the incision, and the jaws are
opened to dilate the incision. H. A tracheostomy tube is inserted into the trachea using a semicircular motion.
(Figures 25-6 & 25-7). The technique has been modified from the Move it laterally 0.75 cm to extend the incision (Figures 25-6C
original description.18 & 25-7C). Rotate the scalpel blade 180° and extend the incision
Clean, prepare, and drape the neck as mentioned previously. 0.75 cm in the opposite direction (Figures 25-6D & 25-7D). Do
Position the nondominant hand with the thumb on one side of the not remove the scalpel blade. Removing the scalpel from the
thyroid cartilage and the middle finger on the other side (Figures incision will result in losing the landmarks and the location of
25-6A & 25-7A). Identify the anatomic landmarks as described pre- the incision through the cricothyroid membrane.
viously. Leave the nondominant index finger over the cricothyroid With the scalpel blade in place, insert a tracheal hook into the
membrane. If the patient is awake, infiltrate local anesthetic solution midline of the incision (Figures 25-6E & 25-7E). Grasp the inferior
subcutaneously over the cricothyroid membrane. border of the thyroid cartilage with the tracheal hook. Lift the tra-
Guide a #11 surgical blade along the nondominant index fin- cheal hook upward and superiorly to elevate and control the airway
ger and into the cricothyroid membrane using a stab incision (Figures 25-6F & 25-7F). Remove the scalpel from the incision
(Figures 25-6A, B, & 25-7B). Do not insert the scalpel blade only after the airway is controlled with the tracheal hook.
more than 1.5 to 2.0 cm to prevent it from injuring the esopha- The incision site must be expanded to accommodate the passage
gus. It is recommended to hold the scalpel just above the blade with of an endotracheal tube or a tracheostomy tube. While controlling
the thumb and index finger to prevent it from plunging too deep.18 the airway with the tracheal hook, insert the jaws of a Trousseau
Air or bubbles from the incision signify that the tip of the scal- dilator (or 6 in hemostat) through the cricothyroid membrane in the
pel blade is inside the trachea. Do not remove the scalpel blade. midsagittal plane (Figures 25-6G & 25-7G). Open the jaws of the
A B
C D
E F
FIGURE 25-7. The alternative method performed on a cadaver. A. The larynx is stabilized and the Emergency Physician’s index finger overlies the cricothyroid membrane.
B. A stab incision is made into the cricothyroid membrane using the finger as a guide. C. The incision is extended toward the Emergency Physician. D. The scalpel is rotated
180° and the incision is extended away from the Emergency Physician. E. A tracheal hook is inserted over the scalpel blade to grasp the inferior border of the thyroid
cartilage. F. The tracheal hook is lifted upward and superiorly to control the airway. The scalpel has then been removed.
instrument to dilate the opening in the sagittal plane (Figure 25-7H). PATIENTS WITH MASSIVE NECK SWELLING
Rotate the dilator 90° within the incision (Figure 25-7I). Open
the jaws of the dilator to dilate the incision in the transverse plane Patients may present with massive neck swelling secondary to hem-
(Figure 25-7J). Insert an endotracheal tube or a tracheostomy tube orrhage, hematoma, edema, or subcutaneous emphysema after
through the incision and into the trachea (Figures 25-6H & 25-7K). trauma.19 These patients often have no palpable anatomic land-
Hold the tube securely against the skin and remove the tracheal marks in the neck, making it difficult to create a surgical airway. The
hook. The remainder of the procedure is as described previously. traditional surgical methods used to perform a cricothyroidotomy
G H
I J
FIGURE 25-7. (Continued ) G. The Trousseau dilator is inserted into the cricothy-
roid membrane. H. The jaws of the dilator are opened in the sagittal plane to widen
the incision. I. The dilator is rotated 90°. J. The jaws of the dilator are opened to
K open the incision transversely. K. An endotracheal tube is inserted through the
incision and into the trachea.
are not usable due to hemorrhage and difficulty in identifying the (Figure 25-8A, line 2). An imaginary line should be drawn from the
anatomic landmarks. However, a technique has been developed to free end of the folded suture to the angle of the patient’s mandible
perform a cricothyroidotomy in these patients.20–22 (Figure 25-8A, line 3). This third line is the line used to identify the
To use this technique, the location of the hyoid bone must be hyoid bone.
determined (Figure 25-8A). A piece of suture, string, or tracheal tie Insert a #11 scalpel blade through the midline of the neck in
is required. Place one end of the suture at the angle of the patient’s an upward and posterior direction along line 3 (Figure 25-8B).
mandible. Stretch the suture along the mandible and note where it Advance the scalpel blade until it meets resistance as it contacts
contacts the tip of the chin (Figure 25-8A, line 1). Cut the suture the hyoid bone. Alternatively, a spinal needle can be inserted
at the point where it contacts the tip of the chin. Fold the suture in along line 3 until it contacts the hyoid bone (Figure 25-8C). Then,
half. Place one end of the folded suture on the tip of the chin. Pull insert the #11 scalpel along the track of the spinal needle until the
the other end of the folded suture tight to make a 90° angle to line 1 hyoid bone is also contacted. Do not remove the scalpel. Insert a
FIGURE 25-8. Cricothyroidotomy in a patient with neck swelling. A. Locate the hyoid bone. Line 1 is from the angle of the mandible to the tip of the chin. Line 2 is half the
length of line 1 and perpendicular to it. Line 3 is from the end of line 2 to the angle of the patient’s mandible. B. A #11 scalpel blade is inserted in the midline and aimed
along line 3 until it contacts the hyoid bone. C. An alternative method. A spinal needle is used to locate the hyoid bone. A #11 scalpel blade is inserted along the tract of the
spinal needle until the hyoid bone is contacted. D. A tracheal hook is inserted along the scalpel blade and used to grasp the hyoid bone. The tracheal hook is lifted (arrow)
anteriorly and superiorly to elevate and control the airway.
tracheal hook along the scalpel blade until the hyoid bone is con- SELDINGER TECHNIQUE
tacted. Move the tip of the tracheal hook under the hyoid bone
(Figure 25-8D). Lift the tracheal hook anteriorly and superiorly to A percutaneous cricothyroidotomy kit is available from several
elevate and control the airway (Figure 25-8D). Do not release the manufacturers. One of the more commonly used kits is the Melker
hold of the tracheal hook on the hyoid bone. Remove the scalpel Percutaneous Cricothyrotomy Set (Cook Inc., Bloomington, IN). It
from the incision. is a self-contained kit that may be used in the prehospital setting,
Make an incision inferiorly and in the midline starting at the Emergency Department, or Operating Room. It contains percuta-
site the tracheal hook exits the skin. The incision should extend neous needles, a catheter-over-the-needle, a syringe, a #15 scalpel
directly inferiorly without regard to the anatomy of the neck. Do blade, adult and pediatric airway catheters, dilators that fit inside
not release the tension on the tracheal hook. Identify the cricothy- the airway catheters, a 30 cm flexible guidewire, and a tracheal tie
roid membrane. Make a transverse incision through the cricothy- (Figure 25-9). The dilator was developed to fit inside the airway
roid membrane. Dilate the opening and insert a tracheostomy tube catheter (Figure 25-10). The dilator and airway catheter are inserted
or an endotracheal tube into the trachea as described previously. as a unit during the procedure.
Clean, prep, drape, and anesthetize the patient’s neck as men-

tioned previously. Lubricate the dilator liberally and insert it
through the airway catheter (Figure 25-10). Lubricate the airway
catheter and dilator after it has been assembled into a unit. Stabilize
the trachea with the nondominant hand and identify the landmarks
as previously described. Leave the nondominant index finger over
the center of the cricothyroid membrane.
Make a stab incision just through the skin over the center of the
cricothyroid membrane with the #11 scalpel blade (Figure 25-11A).
Insert the catheter-over-the-needle attached to a 5 mL syringe
containing saline through the skin incision and aimed inferiorly
(Figure 25-11B). Insert and advance the catheter-over-the-needle
at a 30° to 45° angle to the skin (Figure 25-11B). Advance the cathe-
ter-over-the-needle while applying negative pressure to the syringe.
Stop advancing the catheter-over-the-needle when the airway has
been entered. This will be signified by a loss of resistance and air
FIGURE 25-9. The percutaneous cricothyroidotomy kit (Cook Critical Care, bubbles in the syringe (Figure 25-11B).
Bloomington, IN). Hold the syringe securely and advance the catheter over the nee-
dle until the hub is at the skin of the neck. Hold the catheter hub
securely against the skin of the neck and remove the needle and
The percutaneous cricothyroidotomy kit can be used to establish syringe. Insert and advance the guidewire through the catheter
an airway using a modification of the Seldinger technique.23–25 This and into the trachea (Figure 25-11C). Grasp the guidewire securely
technique can be used to establish an airway in about the time it and remove the catheter over the guidewire (Figure 25-11D). Do
takes to create a surgical cricothyroidotomy.23,24 For those with little not release your grasp on the guidewire in order to prevent it
surgical experience, a percutaneous cricothyroidotomy is a simpler from completely entering the patient’s airway.
and quicker technique with which to establish an airway than tradi- Insert the dilator/airway catheter unit over the guidewire and into
tional surgical methods. The technique is quite similar to inserting the trachea in a semicircular motion (Figure 25-11E). The tip of the
a central venous line.28 dilator is rigid. Insert it gently to prevent injury to or perforation
of the posterior tracheal wall. Continue to advance the unit until
the flange is against the skin of the neck. Hold the airway catheter
securely. Remove the guidewire and dilator as a unit, leaving the
airway catheter in place (Figure 25-11F). Begin ventilation of the
patient and secure the airway catheter as previously described.
NEEDLE CRICOTHYROIDOTOMY
A needle cricothyroidotomy, rather than a surgical cricothyroid-
otomy, should be performed in children less than 8 years of age.
The latter is technically more difficult. The child has a laryngeal
prominence that is difficult to palpate as it is not well developed.
The cricothyroid membrane is small and often will not allow the
passage of an airway tube. The larynx is anatomically positioned
relatively higher than in an adult and is more difficult to access.
A commercially available kit (ENK Oxygen Flow Modulator
Set, Cook Inc., Bloomington, IN) or commonly available equip-
ment in the Emergency Department may be used to perform this
procedure.
Stand at the side of the bed and adjacent to the patient’s head and
neck.11 Reidentify the anatomic landmarks. This is crucial to per-
forming this procedure. Using the nondominant hand, place the
thumb on one side of the thyroid cartilage and the middle finger
on the other side. Use these fingers to stabilize the larynx.8,14 Use
the index finger to identify the anatomic landmarks.4,5,11 Start at
the laryngeal prominence (Adam’s apple) and work inferiorly. The
soft membranous defect inferior to the laryngeal prominence is the
cricothyroid membrane. Below this is the cartilaginous ring of the
cricoid cartilage.
Attach a 12 to 16 gauge catheter-over-the-needle (angiocatheter)
onto a 10 mL syringe containing 5 mL of sterile saline. Insert the
catheter-over-the-needle through the skin, subcutaneous tissue, and
inferior aspect of the cricothyroid membrane. The inferior aspect of
the cricothyroid membrane is the preferred site, as use of it avoids
FIGURE 25-10. The dilator is placed inside the airway catheter to form a unit. injury to the cricothyroid arteries. Direct the catheter-over-the-nee-
The pediatric unit (left) and the adult unit (right) are both contained within each dle inferiorly and at a 30° to 45° angle (Figure 25-12A). Maintain
percutaneous cricothyroidotomy kit. constant negative pressure within the syringe as it is advanced
FIGURE 25-11. The percutaneous cricothyroidotomy. A. A stab incision is made in the midline over the cricothyroid membrane. B. A catheter-over-the-needle is inserted
at a 30° to 45° angle to the skin and advanced in a caudal direction. Negative pressure is applied to a saline-containing syringe during catheter insertion. Air bubbles in the
saline confirm intratracheal placement of the catheter. C. The catheter has been advanced until the hub is against the skin. The needle and syringe have been removed.
A guidewire is inserted through the catheter. D. The catheter has been removed, leaving the guidewire in place. E. The dilator/airway catheter unit are advanced over the
guidewire. F. The guidewire and dilator have been removed, leaving the airway catheter in place.
(Figure 25-12B). Continue to advance the catheter-over-the-needle Once breath sounds are confirmed, the catheter can be secured to
while maintaining negative pressure until air bubbles are visible in the skin. This may be done with nylon sutures or strips of adhesive
the syringe and a loss of resistance is felt. These both signify that the tape. The patient should undergo orotracheal intubation or a for-
catheter-over-the-needle is within the trachea. mal tracheostomy as soon as possible because of the risk of dislodg-
Once placement within the trachea is confirmed, securely hold ing the catheter and the suboptimal ventilation associated with this
the needle and advance the catheter until the hub is against the skin technique.
(Figure 25-12C). Remove the needle and syringe (Figure 25-12C).
Reattach the syringe without the needle to the catheter. Aspirate
once again to reconfirm placement of the catheter within the tra-
chea. The 2 to 3 cm catheter should be long enough to pass into the If a tracheostomy tube is not available, an endotracheal tube can be
trachea without sitting against the posterior wall. If the catheter tip used. The endotracheal tube is much longer than is needed. Remove
directly touches or faces the posterior tracheal wall, there is the risk the 15 mm connector from the proximal end of the endotracheal
of forcing air submucosally. Grasp and hold the catheter hub firmly tube. Cut the endotracheal tube with scissors just above where the
at the skin of the neck. Remove the syringe. Attach the oxygen tub- tubing to inflate the cuff enters the tube. Place the 15 mm connec-
ing to the catheter (Figure 25-12D). Begin ventilation and continue tor on the shortened endotracheal tube. The procedure to insert an
until a more permanent and secure airway is established. endotracheal tube is the same as that for a tracheostomy tube.
At this point, the patient may be oxygenated and ventilated by A cricothyroidotomy is a seldom performed procedure. A tra-
two methods. The first involves inserting the adapter piece from a cheal hook may not be immediately available or found when
#3.0 endotracheal tube to the catheter hub and then connecting it one is required. A simple alternative is to make one using a 16 or
directly to the bag-valve device or a ventilator. This method allows 18 gauge needle, a 10 mL syringe, and a hemostat or needle driver
for the confirmation of breath sounds and provides better ventila- (Figure 25-13). Securely apply the needle onto the syringe. Use the
tion of the patient. hemostat or needle driver to place two 90° bends in the distal needle
The second method of oxygenation involves direct connection of (Figure 25-13). The syringe acts as a handle and the bent needle as
the high-flow oxygen tubing to the hub of the catheter. This method a tracheal hook.
requires cyclic ventilation for 1 to 2 seconds followed by exhalation Numerous other percutaneous cricothyroidotomy kits are
for 4 to 5 seconds.12 This method provides adequate oxygenation available. The QuickTrach (Rusch Inc. of Teleflex Medical,
but less adequate ventilation and is more labor-intensive. The com- Research Triangle Park, NC) is a preassembled, one-piece device
plete details of percutaneous transtracheal jet ventilation can be (Figure 25-14). The Bivona Nu-Trake (Smiths Medical, Inc., Gary,
found in Chapter 24. IN) is also preassembled, but requires the use of an obturator
FIGURE 25-12. Needle cricothyroidotomy. A. The catheter-over-the-needle is inserted 30° to 45° to the perpendicular (dotted line) and aimed inferiorly. B. Application of
negative pressure (arrow) to a saline-containing syringe during catheter-over-the-needle insertion. Air bubbles in the saline confirm intratracheal placement of the catheter.
C. The catheter is advanced until the hub is against the skin. The needle and syringe are then removed. D. High-pressure oxygen tubing is attached to the catheter and
ventilation is begun.
(Figure 25-15). These devices are quick, simple to use, and do not The use of a bougie or endotracheal tube introducer may aid the
require the use of a guidewire or the Seldinger technique. These performance of a surgical cricothyroidotomy.26 Begin the procedure
are more likely to be used in the prehospital setting than in the as described previously. Once the airway is controlled with the tra-
Emergency Department. cheal hook, insert a bougie or endotracheal tube introducer through
FIGURE 25-13. A “homemade” tracheal hook.
the incision, directed inferiorly, and into the trachea. The bougie FIGURE 25-15. The Bivona Nu-Trake.
or endotracheal tube introducer will provide tactile feedback as it
crosses the tracheal rings. Advance the tracheostomy tube or endo-
tracheal tube over the bougie or endotracheal tube introducer and
into the trachea. The major advantages of these devices are their AFTERCARE
lengths. It will not pull out and it will ensure that the tract is not lost.
Several quick assembly and low cost needle cricothyroidotomy The tracheostomy tube should be held in place firmly while the
setups can be put together quickly with commonly available equip- patient is ventilated with a bag-valve device or a ventilator.11 Do
ment in the Emergency Department.27 Insert a catheter-over-the- not release the hold on the tracheostomy tube until it is secured.
needle as previously described. Remove the needle, leaving the Obtain hemostasis of the wound edges by grasping any bleeding
angiocatheter through the skin and into the airway. Attach and vessels with a hemostat and place an absorbable 3-0 suture over the
connect the following components in the listed order to the hub of vessel. If the skin incision is significantly larger than the tracheos-
the angiocatheter. The first consists of a 3.5 mm endotracheal tube tomy tube, pack the wound with iodoform gauze. Secure the trache-
respiratory adapter and a bag-valve device. The second consists of ostomy tube by placing twill tape (tracheostomy tape) through one
a 10 mL syringe without the plunger, a 7.0 mm endotracheal tube end of the flange, around the patient’s neck, and through the other
inserted into the syringe, and a bag-valve device. The third consists end of the flange.11,12 An alternative is to suture the four corners of
of a 3 mL syringe without the plunger, a 7.0 mm endotracheal tube the tracheostomy flange to the patient’s skin using 3-0 nylon suture.
respiratory adapter, and a bag-valve device. The fourth consists of If an endotracheal tube was inserted, it should also be secured.
the cut distal 10 cm of an intravenous infusion tubing, a 2.5 mm Wrap tape around the endotracheal tube as it exits the incision site.
endotracheal tube respiratory adapter, and a bag-valve device. Wrap the tape around the patient’s neck and back onto the endo-
tracheal tube. Alternatively, a commercially available endotracheal
tube holder can be used to secure the tube.
ASSESSMENT The tracheostomy or endotracheal tube can be removed easily
Immediately after securing the tracheostomy tube, confirm its when the indication for airway control no longer exists. This usually
proper positioning by auscultation of bilateral breath sounds, chest occurs after the patient is orotracheally intubated, nasotracheally
rise, and end-tidal CO2 monitoring. Obtain a chest radiograph intubated, or has a formal tracheostomy performed. After removal
to confirm the position of the tube and rule out the presence of a of the tube, place an occlusive dressing, such as petroleum gauze,
pneumothorax.12 over the incision until it heals. If the patient is predicted to require
ventilatory management for more than 7 days, it is advised that the
cricothyroidotomy be converted to a formal tracheostomy to mini-
mize the risk of long-term complications.
COMPLICATIONS
Complications following a cricothyroidotomy can be classified as
early or late based on when they occur. Early complications will be
recognized either immediately after insertion of the tracheostomy
tube or within a few hours. Late complications may not be apparent
for weeks to months following the procedure.
The most serious early complication is malposition of the trache-
ostomy tube within the soft tissues of the neck. If the tube is not
within the trachea, the patient cannot be ventilated or oxygenated.
This, fortunately, is easily recognized on auscultating the chest. It
can be remedied by removing the tracheostomy tube and replac-
ing it in its proper location. The tube may also be misplaced above
or below the cricothyroid membrane. Placement above the crico-
thyroid membrane often results from inadequate palpation of land-
FIGURE 25-14. The Rusch QuickTrach. marks and is associated with an incision into the larynx. The airway
CHAPTER 26: Tracheostomy 161
should be converted to a tracheostomy once this malposition is rec-

ognized.6 Placement below the cricoid cartilage has been estimated Tracheostomy
to occur in 10% of cricothyroidotomies.2 There is no specific treat-
ment required for this other than the recognition that the patient
actually has a high tracheostomy.
26 Teresa M. Romano and Christopher J. Haines
Laryngeal injury may occur if the tracheostomy tube that is

inserted is larger than the cricothyroid membrane. The cricothy- INTRODUCTION
roid membrane is only 9 to 10 mm in height in the average adult.8,11
Placement of a tracheostomy tube with a larger outer diameter Control of the airway is the first priority in the resuscitation of a criti-
may cause a fracture of the thyroid cartilage. It is important that cally ill patient and must be accomplished before any other interven-
the tracheostomy tube placed is no larger than a #6.0 or a #7.0.8,11 tion can proceed. Emergency Physicians are equipped with multiple
Placement of a larger tube is also associated with an increased inci- nonsurgical techniques and devices to secure an airway includ-
dence of subglottic granulation and stenosis.2,4 ing orotracheal intubation, nasotracheal intubation, and laryngeal
Incisional bleeding occurs in 4% to 8% of patients following a cri- mask airways. Unfortunately, there are cases in which these meth-
cothyroidotomy.2,4,6,8,15 This may result from transection of the ante- ods become impossible or are contraindicated. In these instances, a
rior jugular veins if the incision extends too far laterally. Bleeding surgical airway must be obtained and can be accomplished by per-
is usually easily treated by point ligation of the bleeding vessels and forming a cricothyroidotomy or tracheostomy. Cricothyroidotomy
packing around the tracheostomy tube with iodoform gauze. A is described in Chapter 25. This chapter will focus on the indica-
small amount of bleeding or oozing from the cricothyroid arteries tions, technique, and complications for a tracheostomy.
can be tamponaded by packing iodoform gauze around the trache- A tracheotomy is the surgical creation of an opening into the tra-
ostomy tube. chea, while tracheostomy refers to the more permanent procedure
An emergent cricothyroidotomy is usually performed in less than of bringing the tracheal mucosa into contact with the skin of the
sterile circumstances. There is thus a risk of developing a wound neck.1,2 The most traditional role for a tracheostomy is as an elective
infection.15 This is usually the result of skin flora. It can often be procedure done in patients with the need for a prolonged artificial
treated with wet-to-dry saline dressing changes. Occasionally, the airway. The role of a tracheostomy for emergent airway access has
infection will not resolve until the cricothyroidotomy tube has been diminished as newer, safer, and equally effective techniques have
removed, either by decannulation or conversion to a formal trache- evolved.
ostomy. Antibiotics are usually not required. Familiarity with the methods to perform a tracheostomy is still
Late complications take two general forms: progressive airway valuable. Knowledge of proper techniques, possible indications, lim-
obstruction and chronic voice changes. Patients with progressive itations, and likely complications will guide one’s judgment in criti-
airway obstruction present with slowly increasing stridor and dys- cal moments, when it most counts. Understanding the procedure
pnea weeks to months after the procedure. This usually results for a tracheostomy will allow Emergency Physicians to properly care
from subglottic stenosis and granulation tissue formation at the for a problem or complication when a patient with a tracheostomy
site of the stoma.2,6,13 It is unclear whether this complication results tube presents to the Emergency Department.
from the cricothyroidotomy or the tracheostomy tube. The major-
ity of these patients have had prolonged endotracheal intubations
before the cricothyroidotomy or prolonged tracheostomy place- A surgical approach to the airway relies upon a sound knowledge of
ment after the cricothyroidotomy.2,13,14,16 In one series, patients with the anatomy of the neck and a safe approach to the trachea. A care-
a cricothyroidotomy for a prolonged period (average 72 days) had ful review of this anatomy illustrates how critical it is to remain
a 52% incidence of chronic obstruction compared to no obstruc- in the midline in order to avoid morbidity and mortality. External
tion in patients with cricothyroidotomy for a shorter period (aver- landmarks are useful in identifying the significant structures of the
age 27 days).16 Another study recommended that the tracheostomy airway (Figure 26-1).3,4 The laryngeal prominence is a useful guide
tube be removed by the fourth day to minimize these long-term to the thyroid cartilage. The cricoid cartilage can be identified as a
complications.9 ring just inferior to the thyroid cartilage. In the absence of edema or
A final late complication is that of voice changes. This has been
described in up to 25% of patients that received a cricothyroidot-
omy.6,13–15 Again, many of these patients had other methods of air-
way management either before or after the cricothyroidotomy. Voice
changes tend to be somewhat nonspecific. Patients will complain
of hoarseness, decreased volume, and fatigue. These changes may
be due to small amounts of granulation tissue at the stoma site and
generally resolve over time.4 Hyoid bone
Laryngeal prominence
SUMMARY
Inferior edge of thyroid
A cricothyroidotomy is a potentially lifesaving airway manage-
cartilage
ment technique. It is an important procedure for the Emergency
Physician to be skilled in, as it may represent the only access to the Cricoid cartilage
patient’s airway. It can be used to provide oxygenation and ventila- Thyroid gland
tion to a patient when other less invasive airway control methods
Sternocleidomastoid
have failed or are contraindicated. It is a relatively safe, simple, and
muscle
reliable procedure that can be performed within a few minutes. A Sternoclavicular notch
self-contained percutaneous cricothyroidotomy kit is commercially
available and simple to use. Knowledge of the anatomy of the ante-
rior neck is essential in order to minimize complications. FIGURE 26-1. Lateral view of the topographic anatomy of the neck.
Body of hyoid bone
Angle of mandible Thyrohyoid membrane
Superior belly of the Thyroid cartilage

omohyoid muscle
Sternohyoid muscle
Cricoid cartilage
Sternocleidomastoid
muscle Thyroid gland
Isthmus of thyroid gland Trachea
Sternothyroid muscle Suprasternal notch
FIGURE 26-2. The superficial muscles and air-

way structures in the neck.
a hematoma, a finger marched down the midline from the cricoid of pathology, the hyoid bone is remarkably constant in position and
cartilage can palpate and identify the cartilaginous rings of the tra- can be considered a stable landmark.6–8
chea. In an emergent situation, these external landmarks may be all The larynx is easy to identify externally. The prominent thyroid
a physician has to guide the establishment of a surgical airway. cartilage forms the laryngeal prominence (Adam’s apple) at its infe-
The neck is a complex three-dimensional structure with numer- rior pole (Figure 26-3). It is a freely mobile structure that is anchored
ous vital structures coursing through a small space (Figures 26-2 by muscles and moves with deglutition. Airway manipulation done
through 26-6). The cervical portion of the airway is anterior, super- on an awake patient will need to fix the larynx to avoid involuntary
ficial, and midline. It is covered by skin, subcutaneous tissue, and movement of the larynx from reflex swallowing. The thyroid carti-
numerous muscles (Figure 26-2). The basic cartilaginous frame- lage is attached to the cricoid cartilage via the cricothyroid membrane
work of the airway begins superiorly at the hyoid bone and con- (Figure 26-3). This is the site for a cricothyroidotomy and can be
tinues inferiorly with the larynx and trachea (Figure 26-3). The identified by palpating a slight indentation inferior to the laryngeal
external skeleton of the larynx comprises the hyoid bone, thyroid prominence. The cricoid is signet ring-shaped and is the only com-
cartilage, and cricoid cartilage.5 The hyoid bone is a U-shaped struc- plete cartilaginous ring in the airway. Procedures should avoid dam-
ture attached to the mandible, tongue, and base of the skull by mus- age to the cricoid cartilage, fearing a loss of stability in the airway. The
cles. It is the most stable portion of the airway. Even in the presence cricotracheal ligament attaches the cricoid cartilage to the trachea.
Hyoid bone
Thyrohyoid muscle
Thyroid cartilage
Laryngeal prominence
Sternothyroid muscle
Cricothyroid muscle
Cricoid cartilage
Thyroid gland
Isthmus of thyroid gland
Trachea
Esophagus
FIGURE 26-3. The framework of the airway in the neck.
20 incomplete U-shaped cartilaginous rings anteriorly and laterally.

The posterior portion is comprised of a fibromuscular membrane.
Thyroid This membrane attaches the cartilaginous rings to one another and
cartilage imparts great elasticity in the trachea.2 Full extension of the neck
adds significant length to the supraclavicular trachea. This feature
Cricothyroid Cricoid cartilage should be taken advantage of when performing a tracheostomy.10
membrane The trachea is bordered anteriorly by skin, subcutaneous tissue, pla-
tysma muscle, pretracheal fascia, and the thyroid gland (Figure 26-5).
The pretracheal fascia is the anterior portion of the deep cervical
Trachea
fascia. It descends from the thyroid and cricoid cartilages and splits
to enclose the thyroid gland, trachea, and esophagus. The pretra-
cheal fascia continues downward into the thorax and mediastinum.
Anterior to the trachea, it is very thin and inconsequential. Laterally,
it is extremely thick and blends with the carotid sheath.
The thyroid gland lies anterior to the second through fourth tra-
cheal rings and is inevitably encountered during a tracheostomy. It
is a richly vascular structure (Figure 26-6) that receives its blood
supply from the superior thyroid artery (a branch of the external
carotid artery) and the inferior thyroid artery (a branch of the thy-
Carina rocervical trunk). These vessels anastomose into a rich plexus on
Left main the anterior surface of the thyroid gland. These major arteries do
Right main bronchus not usually cross the midline.
bronchus Unfortunately, the midline is not always free of blood vessels. An
unpaired thyroid ima artery will occasionally be found in the mid-
line to supply the isthmus of the thyroid gland. The anterior thyroid
veins often form a vascular arch across the midline and just inferior
to the thyroid gland. A hastily performed tracheostomy or one car-
ried out under difficult conditions may encounter significant hem-
orrhage from transected vessels.
A number of vital structures surround the trachea and are at risk
for injury during a tracheostomy. Their positions relative to one
another are best appreciated in a cross-sectional view of the neck
(Figure 26-5). The deep strap muscles, the sternohyoid and ster-
nothyroid, run adjacent to the trachea and may have to be reflected
FIGURE 26-4. The cartilaginous framework of the airway. away for adequate visualization (Figure 26-2). The right and left
lobes of the thyroid gland encase the upper trachea (Figures 26-5 &
26-6) with the thyroid isthmus crossing anteriorly from the second
The trachea is a cartilaginous and membranous tube that is to the third tracheal rings.2 Close to the thyroid lobes, the recurrent
approximately 10 to 11 cm long and 2 to 2.5 cm wide in the average laryngeal nerves run vertically on both sides of the trachea. These
adult. In the pediatric patient, the length and width of the trachea will nerves are particularly vulnerable when dissection is extended later-
vary depending on the size and age of the child.9 It extends from the ally.11 The common carotid artery, internal jugular vein, and vagus
neck into the thorax, where it ends at the carina by dividing into the nerve are contained by the carotid sheath and lie adjacent to the
right and left mainstem bronchi (Figure 26-4). It is made up of 16 to thyroid gland. The carotid sheath lies extremely close to the trachea
Pretracheal Esophagus
fascia
Carotid
sheath Common Trachea Thyroid gland
carotid artery Recurrent
Internal
jugular vein laryngeal nerve
Platysma
Vagus
nerve
FIGURE 26-5. Cross-sectional anatomy of the neck at the level of the

isthmus of the thyroid gland.
Superior laryngeal
artery & vein
Internal jugular vein
External carotid Superior thyroid

artery artery & vein
Middle thyroid
Right lobe of vein
thyroid gland
Isthmus
Thyrocervical Inferior thyroid

trunk artery
Brachiocephalic trunk Inferior thyroid vein

FIGURE 26-6. Vascular structures supplying and surrounding the
thyroid gland.
in infants and have been mistaken for the trachea in emergent situ- is generally considered an elective procedure done under nonemer-
ations.11 The innominate or brachiocephalic artery crosses left to gent conditions after the airway has been secured by other tech-
right immediately anterior to the trachea, while the esophagus lies niques.19–23 Its use as an emergency procedure is controversial. Used
immediately posterior to the trachea. Erosion of the anterior tra- by battlefield surgeons during wartime, its reputation as a procedure
cheal wall can occur with prolonged tracheostomy tube placement of last resort is not without reason. When performed under emer-
leading to a tracheoinnominate artery fistula. The parietal pleura gency circumstances, it is fraught with danger.
can be found on either side of the trachea at the sternal notch and is A tracheostomy is frequently considered in the treatment of
also at risk of injury during a tracheostomy. upper airway obstructions including epiglottitis, deep space neck
infections, angioedema, airway foreign bodies, multiple lacerations
INDICATIONS to the floor of the mouth, and complex facial fractures. Although
these conditions can create serious and immediate airway compro-
The tracheostomy is an ancient and time-honored technique
mise, the airway can be managed in most cases with orotracheal
for securing and maintaining an artificial airway. The American
Academy of Otolaryngology—Head and Neck Surgery has pro-
posed specific clinical indicators for the use of a tracheostomy
(Table 26-1).12 A number of indications for tracheostomy are widely
accepted (Table 26-2).11–18 As mentioned previously, a tracheostomy TABLE 26-2 Commonly Cited Indications for Performing a Tracheostomy
Airway obstruction13–15,17
Tumor, trauma, hemorrhage
Edema, foreign body, infection
TABLE 26-1 Clinical Indications for Performing a Tracheostomy, as Congenital airway anomalies
Proposed by the American Academy of Otolaryngology— Trauma to face and neck with airway compromise13,14,16
Head and Neck Surgery Inability to open mouth
Upper airway obstruction, including Maxillomandibular fixation, trismus18
Obstructive sleep apnea Angioedema15,17
Bilateral vocal cord paralysis Need for prolonged ventilatory support14
Need for prolonged mechanical ventilation Impaired clearance of secretions
Inability of patient to manage his or her secretions Need for aggressive pulmonary toilet15
Facilitation of ventilation support Laryngeal injury7,10,15
Adjunct to manage head and neck surgery Unstable cervical spine16
Adjunct to manage head and neck trauma Laryngospasm17
Difficulty with intubation and need for airway Surgical airway in an infant7
Source: Adapted from Weissler.12 Inability to intubate by other measures16
intubation. An emergency tracheostomy is not the treatment of child, the larynx is positioned more cephalad than in the adult,
choice but rather the choice of last resort. allowing relative protection by the mandibular arch.9 It is more
There are a few clinical settings in which an emergency trache- anteriorly located and significantly smaller than in adults, as well
ostomy should be considered: laryngotracheal injury with airway as more floppy and mobile. The infant’s cricothyroid membrane,
disruption;11,28,29 severe maxillofacial trauma; complete subglottic unlike that of the adult, is extremely narrow and cannot easily be
obstruction; and the need for an airway when all other methods used for access to the airway. For this reason, a surgical cricothy-
have failed. With the exception of these limited applications, an roidotomy should be avoided until a child is greater than 12 years
emergency tracheostomy is discouraged.11,14,32,33 old.9,11 Attempts at creating emergency surgical airways in children
are typically acts of desperation. A calm, reasoned approach to the
■ LARYNGOTRACHEAL TRAUMA pediatric airway and common respiratory problems is essential.
Most head and neck trauma patients can be managed with non- Efforts should first be made to suction the airway clear of secre-
surgical airway techniques. There are a number of options available, tions, followed by ventilation with a bag-valve-mask device. Direct
including orotracheal intubation, nasotracheal intubation, intuba- visualization by laryngoscopy and orotracheal intubation should
tion guided by a lighted stylet or “lightwand,” retrograde guidewire be attempted before resorting to a surgical airway. If an unstable
intubation, and fiberoptic-assisted intubation. Nasotracheal intu- patient cannot be ventilated, a needle cricothyroidotomy can serve
bation should be avoided in patients with a potential head injury. as a temporizing measure until a surgical team can be assembled
If a surgical airway is necessary, a cricothyroidotomy is usually the and better control achieved.9,11
procedure of choice. In the pediatric population, laryngotracheal injury is rare.11
Laryngotracheal injuries are rare but potentially life threaten- Typically, children sustain blunt anterior neck injury as the result
ing. When suspected, immediate efforts should focus on getting the of high-speed accidents involving bicycles, falls, and motor vehicles.
patient to the operating room. These injuries can result from either Additionally, this injury type may be the result of sports-related
blunt or penetrating injury to the neck. They are often accompanied activity. Clinical signs and symptoms of laryngeal or tracheal trauma
by edema, hemorrhage, subcutaneous emphysema, and fracture mirror that of adults. Airway management in these patients can be
of either the thyroid or cricoid cartilages. In their presence, rapid achieved with a tracheostomy. However, this may be quite difficult
access to the cricothyroid membrane may be limited, making it dif- and is only advocated by some authors.9 Attempts to obtain surgical
ficult to perform a cricothyroidotomy, and tracheostomy should be assistance should be sought immediately.
considered.11,34–36 Blunt injury has been described when the anterior
neck forcefully strikes a fixed object such as a rope or a cable. A clas- CONTRAINDICATIONS
sic example of this type of injury is forcefully striking the anterior
neck against the steering wheel during high-speed motor vehicle Simply stated, an emergency tracheostomy is contraindicated
accidents.11,35,36 Penetrating injuries to the airway are usually appar- when other methods can be used to secure the airway. There are
ent; however, blunt injuries to the trachea require a high index of a few instances when an immediate surgical airway is necessary.
suspicion.36,37 In a review of 51 patients with blunt injury to the tra- Cricothyroidotomy is the procedure of choice when a surgical
chea, the most common presenting signs and symptoms included approach to the airway is required. Compared to a tracheostomy,
subcutaneous emphysema, respiratory distress, hoarseness or dys- a cricothyroidotomy is faster and more direct; it relies predomi-
phonia, and hemoptysis.36 In this same review, a high rate of endo- nantly on external landmarks, requires only a single operator, can
tracheal intubation failure was reported with the conclusion that be done with ambient lighting, and requires a limited amount of
emergent tracheostomy was the best means of airway control.36 In equipment.12,24 In contrast, a tracheostomy is a procedure requir-
cases of penetrating trauma to the larynx, physicians may consider ing multiple steps. It involves direct visualization to dissect through
obtaining emergent airway control directly through the wound as a vascular structures and requires better light than is commonly pres-
temporary measure prior to operative management.9 ent at the bedside. It is easier and therefore faster to execute if one
Laryngotracheal disruption, occurring when the larynx and tra- has an assistant, proper suctioning equipment, and electrocautery.
chea become separated, is an unusual injury. This is the one injury in Without these advantages, the technique is difficult and likely to be
which a tracheostomy is the undisputed method for establishing and complicated. A “timely trach” can be performed within 5 to 10 min-
securing the airway. Patients with laryngotracheal disruption may utes.12 However, reported times to definitive airway during elective
exhibit varying degrees of respiratory distress, visible bruising over open tracheostomies have ranged from 13.5 to 105 minutes.24–27
the anterior neck, hoarseness or aphonia, subcutaneous emphysema Although this time frame may be adequate for urgent situations, it
or blood-streaked sputum. A defect may be palpable in the neck. is too slow for the true emergency in a patient who lacks an airway.
Soft tissue radiographs of the neck may reveal an interrupted air
column. If the airway is disrupted, a “low tracheostomy” between EQUIPMENT
the fourth and fifth tracheal rings should be performed. The severed A tracheostomy requires an extensive amount of equipment.
airway will tend to retract into the thorax, and a low tracheostomy Appropriate supplies should be sterilized and assembled in a pre-
will offer the best chance of securing the dismembered segment. packaged tray. A list of required equipment is given in Table 26-3.
Misguided attempts to visualize the airway, intubate orally, or per- If such a tray is not available, supplies that are immediately on hand
form a cricothyroidotomy may further damage the already precari- have to suffice. A thoracotomy or a major procedure tray will con-
ous airway. This is fortunately a rare injury with only a few case tain most of the required equipment.
reports in the literature.28,29 A tracheostomy performed in this set-
ting is more treacherous than usual. Although a tracheostomy may
be the only way to secure the airway, this airway intervention has PATIENT PREPARATION
a better chance of success when performed in the operating room. Patient preparation will depend largely on the circumstances dictat-
ing the procedure. If the patient is uncooperative, hypoxic, or thrash-
■ SURGICAL AIRWAYS IN THE PEDIATRIC PATIENT ing about, rapid control will have to be established with a sedative.
Surgical approaches to the airway are more difficult and compli- The ideal agent is one that sedates with minimal hemodynamic con-
cated in pediatric patients, especially newborns and infants. In the sequences, preserves spontaneous respirations, and leaves an intact
TABLE 26-3 The Supplies Required to Perform a Tracheostomy

Patient preparation Setup
Cardiac monitor Povidone iodine or chlorhexidine
Pulse oximeter solution
Intravenous line with saline Surgical drapes to enclose the field
Oxygen Sterile gown, gloves, and mask
Ambu bag for ventilating patient
Procedure
Local anesthesia Two pairs of scissors, one straight and
10 mL syringe one curved
1% lidocaine Two tissue forceps without teeth
18 gauge needle Two Allis forceps, to grasp the trachea
25 gauge needle Two small rakes, for exposure
#10 scalpel blade and handle Mastoid retractor
#11 scalpel blade and handle Trousseau dilator
Two skin forceps Two tracheal hooks
Eight small curved hemostats 10 mL syringe
Sterile 4 × 4 gauze squares, two dozen Umbilical tape
Two Kocher forceps (if needed, to Needle holder
clamp the thyroid)
Frazier suction catheter with suction FIGURE 26-8. Hand positioning to palpate the anatomic landmarks.
tubing
Suture ligatures (3–0 chromic,
3–0 silk, and 3–0 nylon)
Tracheostomy tube, appropriate size the pediatric patient, a certain degree of extension is helpful, but
for patient full extension may occlude the airway.
Water-soluble lubricant or Prior to beginning the incision, the physician should check the
anesthetic jelly equipment. A tracheostomy tube that is appropriate for the patient’s
Suction source and tubing size should be selected. An average male will accommodate a size
7 or 8 Shiley tracheal tube. An average-size female will accommo-
date a size 6 or 7 Shiley tracheal tube. The cuff of the tracheal tube
should be tested prior to use. As an alternative, an endotracheal tube
gag reflex. If the patient is awake and cooperative, calm reassurance can be used.
may allow the procedure to be performed under local anesthesia. If Identify the anatomic landmarks required to perform this
the patient is unconscious, a local anesthetic is sufficient. procedure. Using the nondominant hand, place the thumb on one
Place a rolled towel under the patient’s shoulders and neck if side and the middle finger on the other side of the patient’s trachea
no contraindications exist (Figure 26-7). This detail cannot be (Figure 26-8). Identify the laryngeal prominence (Adam’s apple)
emphasized enough. Full neck extension brings the airway ante- with the index finger. Slide the index finger caudally to identify the
rior and increases the length of the supraclavicular trachea by as cricothyroid membrane, cricoid cartilage, and tracheal rings.
much as 2.6 cm.9 It enlarges the surgical field for improved access. Clean the neck of any dirt and debris. Even during the resuscita-
Neck extension tends to fix the airway in position and pull it taut. tion of an unstable patient, there should be adequate time for the
When the neck is in a neutral or flexed position, the trachea lies use of aseptic solution as well as sterile technique. Prepare yourself
more posteriorly and is more “floppy.” In this situation, it is easier by applying a mask, eye protection, sterile gown, and sterile gloves.
for the operator to stray off midline. When the neck is flexed, the Apply a sterile drape to isolate a surgical field. Infiltrate local anes-
surgical field may be reduced to a dark hole with poor visibility. In thetic solution along the planned incision line. It was once thought
that injection of local anesthetic into the trachea blunts the cough
reflex and provides a sense of depth of the airway. A recent review
of 97 patients who underwent an awake tracheostomy noted that
this could result in cough, agitation, and less beneficial outcomes.38
Once the patient is positioned, prepped, and anesthetized, estab-
lishment of the airway should be just 2 to 3 minutes away. The last
step in preparation should be the mental decision that no other
technique will suffice and the commitment to proceed with
confidence.
TECHNIQUE
In the most critical situation, the simplest technique is likely to be
the most successful.39 The right-handed operator should stand to the
patient’s right and fix the airway with their left hand (Figure 26-8).
Left-handed operators should adjust their technique based on
their preference for handedness. Apply the thumb and third digit
of the nondominant hand on the thyroid cartilage while the index
FIGURE 26-7. Optimal patient positioning for a tracheostomy with the neck finger palpates the cricoid and tracheal rings (Figure 26-8). An
extended. awake or lightly anesthetized patient may swallow or gulp during
Hyoid bone
Thyroid cartilage
Cricoid cartilage
Trachea
FIGURE 26-9. The skin incision is made in the midline, beginning below the cricoid cartilage and extending down toward the supraclavicular notch. An incision made with
these landmarks will lie over the second through fourth tracheal rings.
the procedure, thereby moving the landmarks. Fixing the left hand the assistant hold the tracheal hook in position. This will elevate
firmly on the upper airway will minimize this distraction. and immobilize the trachea. The assistant should direct their hands
A vertical incision is preferred in the emergent setting because it superior to the wound to keep the field unobstructed. If the neck is
allows greater exposure of the cricothyroid membrane and the tra- properly extended, this may be unnecessary. If at any time identi-
chea, and avoids traversing lateral structures.11 Make a 3 or 4 cm fication of the trachea becomes difficult, needle aspiration may be
vertical midline incision through the skin and subcutaneous tissues used to confirm the presence of an air-filled tube.
beginning just below the cricoid cartilage and extending inferiorly Make an incision in the trachea. The preferred tracheotomy is a
to the supraclavicular notch (Figure 26-9). A larger skin incision midline vertical incision extending from the second through the
causes no harm as long as it remains superficial, to avoid damaging
the cricoid cartilage. Extreme care should be taken to ensure that
the incision and further dissection remain in the midline.11
Once the skin and subcutaneous tissue have been incised, atten-
tion should be directed toward clearing the pretracheal space and
defining the tracheal rings. Divide the superficial and deep strap
muscles in the midline and retract them away from the trachea
(Figure 26-10). Bluntly dissect free and reflect away any blood ves-
sels in front of the trachea. If they impede progress, they can be
clamped with hemostats and divided. The thyroid gland lies above
the trachea. Bluntly dissect between it and the trachea with a hemo-
stat to mobilize the thyroid gland (Figure 26-11). An alternative
option to consider in the emergent setting is to use the nondomi-
nant index finger to dissect the pretracheal space bluntly and reflect
the thyroid isthmus either superiorly or inferiorly. This minimalist
blunt approach lacks finesse but is effective and timely.14
Retract the thyroid gland upward (Figure 26-12). If this becomes
difficult, it may be faster to divide the isthmus between two hemo-
stats (Figure 26-13). The divided edges can be oversewn after the
tracheostomy tube is in place. Once the thyroid has been divided,
the operating field will be cluttered with hemostats and may be par-
tially obstructed. Do not apply traction to the instruments, as this
can avulse tissue, leading to bleeding and further obstruction of the
surgical field.
When ready to make the tracheal incision, it may be helpful to
have an assistant place a tracheal hook under the first tracheal ring FIGURE 26-10. The skin and subcutaneous tissues have been retracted. The strap
and apply traction superiorly and anteriorly (Figure 26-14). Have muscles are divided in the midline to expose the pretracheal space.
FIGURE 26-13. An alternative method of clearing the thyroid gland from the surgi-
cal field. The isthmus is clamped and transected.
FIGURE 26-11. The thyroid gland is bluntly dissected from the trachea. Arrows
represent movement of the hemostat.
Lubricate the appropriate size tracheostomy tube liberally. Insert
the tracheostomy tube, with its obturator, through the trache-
fourth tracheal rings (Figure 26-15A). There are other options, otomy while the incision is held open (Figure 26-16A). Advance
but they are discouraged in the emergent setting because they stray the tracheostomy tube and inflate the cuff (Figure 26-16B). Hold
from the midline (Figures 26-15B to 26-15D). Insert a Trousseau the tracheostomy tube in place securely. Remove the obturator and
dilator or hemostat into the incision. Use the dilator to open and insert the inner cannula. Attach a bag-valve device and begin ven-
widen the incision. Alternatively, the sides of the tracheal incision tilating the patient.
can be grasped and held open with Allis forceps (Figure 26-16A).
FIGURE 26-14. A tracheal hook is placed below the first tracheal ring to elevate
FIGURE 26-12. The thyroid gland is retracted upward and out of the surgical field. and immobilize the trachea.
FIGURE 26-15. Types of tracheal incisions. A. A midline vertical incision through the second, third, and fourth tracheal rings. This is the preferred technique in an emergent
procedure. B. A U-shaped inferiorly based window. C. A window has been created by excising the second and third tracheal rings. D. A T flap.
ALTERNATIVE TECHNIQUES a recent case series of four patients undergoing percutaneous

dilatational tracheostomy in the intensive care setting illustrated
Since 1969, a number of authors have described a third invasive the possible benefits of performing the procedure in combination
option for airway control, the percutaneous dilatational tracheos- with ultrasound guidance.54 The authors concluded that the use of
tomy. Although techniques vary somewhat, they all rely on an initial ultrasound could identify patients unsuitable for the procedure,
puncture of the airway followed by progressive dilatation of a tract. prevent puncture of aberrant vessels, estimate the distance from
Once a sufficiently large tract is formed, an airway tube is placed. the surface of the skin to the trachea, and ensure accurate place-
There is now enough evidence to argue that percutaneous tracheos- ment of the needle into the trachea.54 While these studies are prom-
tomies are competitive with, and perhaps preferable to, formal open ising, larger studies are needed to determine the ultimate role of
tracheostomies done under elective conditions.25,26,40–52 Several large percutaneous dilatational tracheostomy in the emergency setting.53
series of percutaneous tracheostomies are now complete, but sig- Cricothyroidotomy remains the procedure of choice for emergency
nificant results are available only for elective tracheostomies done surgical access to the airway.
in patients who have already been intubated.41,43,44,49 There are small
case studies that have been published regarding the successful use ASSESSMENT
of percutaneous dilatational tracheostomy in an emergency setting.
These authors conclude that percutaneous dilatational tracheos- Once the airway is established, tracheostomy tube positioning
tomy is an effective airway, providing an alternative to endotracheal should be confirmed by auscultation, ease of ventilation, and pulse
intubation. The resultant airway is stable and does not require con- oximetry. Obtain a chest and neck radiograph to confirm tracheos-
version in the immediate postresuscitation period.53 Furthermore, tomy tube position and exclude a pneumothorax.
FIGURE 26-16. Insertion of the tracheal tube. A. The incision is held

open with a Trousseau dilator, hemostat, or Allis forceps (shown
here) as the tracheostomy tube is inserted. B. The tracheostomy tube
is advanced and the cuff inflated.
TABLE 26-4 Complications of Tracheostomies

Immediate Delayed Postoperative
Hemorrhage Hemorrhage Disrupted tract
False passage Tracheal stenosis Displaced tube
Damage to surrounding Subglottic stenosis Obstructed tube, mucus
structures Tracheoinnominate plugging
Recurrent laryngeal artery fistula Delayed hemorrhage
nerve Tracheoesophageal Subcutaneous
Esophagus fistula emphysema
Posterior tracheal Fused vocal cords Mediastinal emphysema
perforation Delayed wound Infection: wound,
Common carotid problems tracheitis, mediastinitis,
artery Excess granulation tissue and pneumonia
Internal jugular vein Persistent stoma Aspiration
FIGURE 26-17. The tracheostomy tube is secured in place with umbilical tape Anterior jugular vein
(“tracheal tie”), then sutured. Pleura, pneumothorax
Cricoid
Air embolism
Apnea
AFTERCARE Cardiac dysrhythmias
Cardiac arrest
Once the airway has been established, inspect the wound to ensure Source: Adapted from references 12, 14, 17, 19–21, 27, 32, 33, and 56.
hemostasis. Any clamped vessels or thyroid tissue should be tied.
The skin edges do not need to be closed unless the skin incision was
overly zealous. If the skin is reapproximated, close it loosely to avoid
the development of subcutaneous emphysema. Secure the trache- vessels. The next most likely problem is inadvertent injury to adja-
ostomy tube with umbilical tape wrapped around the neck. Suture cent structures. This can be avoided by remaining strictly in the
the flange of the tracheostomy tube to the skin using 3-0 silk as an midline, positioning the patient properly, and using a tracheal
additional safeguard (Figure 26-17). If the wound is oozing, place a hook. Additional problems that can be encountered include the
loose gauze pad between the skin and the tracheostomy. creation of a false passage. This should not occur if the operator
Special care should be taken to protect the artificial airway. has visualized the trachea and remained in the midline. In pediat-
Suction the lumen frequently and as necessary to prevent obstruc- ric patients, pneumomediastinum is one of the most frequent early
tion from blood or secretions. Administer humidified oxygen complications of tracheostomy.55
through the tube to prevent dried and inspissated secretions from The Emergency Physician should be cautious not to adopt meth-
occluding it. ods for tracheostomies learned from elective procedures performed
in the operating room under controlled circumstances. The emer-
COMPLICATIONS gent tracheostomy must be carried out with the simplest, fast-
est, and most straightforward technique possible. Tracheostomies
An elective tracheostomy is a relatively basic and common surgi- done under elective conditions may use rescue stay sutures and
cal procedure. Despite this, it has an unusually high complica- more elaborate tracheal incisions. The added benefits of these fea-
tion rate. Authors report widely different morbidity rates, perhaps tures do not offset the additional time required to perform them.
determined in part by the clinical settings if not their own biases. Any physician who cares for patients under emergency circum-
Reported morbidity ranges from 6% to 58%, with procedures done stances should think through the clinical scenarios in which an
emergently having the highest rates.20,21,23,24 However discomforting emergent tracheostomy may be necessary. Expertise in surgical
these numbers may be, the risk is certainly acceptable in the face of airway techniques should first be obtained in a laboratory setting.
an unstable airway in a dying patient. Unless one is poised to respond with a plan of action for the emer-
Complications from a tracheostomy can be divided into imme- gent airway and prepared with the necessary surgical skills, such
diate operative complications, postoperative complications, and situations create chaos and all too often end in disaster.
delayed complications. A summary of reported complications are
listed in Table 26-4. It cannot be stressed enough that the best
way to avoid complications is to avert the need for a tracheos-
SUMMARY
tomy. Under emergent circumstances, a variety of things can and A well-trained Emergency Physician must be prepared for any
do go wrong. It is best if one has thought about these possibili- kind of airway emergency and should be skilled in a variety of
ties, considered alternative strategies for airway management, and approaches. Optimal airway management begins with optimal
sought assistance from surgical colleagues. A more detailed dis- medical management of the patient, including the early identifi-
cussion regarding chronic complications is found in Chapter 27 cation of possible airway compromise and aggressive preventive
(Tracheostomy Care). treatment. Many airway problems can be averted with anticipatory
The most common problem with a hastily performed trache- action. In the armamentarium of airway procedures, a tracheos-
ostomy is hemorrhage. Most bleeding can be controlled with the tomy will be (and should be) a rare solution. The physician who
application of direct pressure. An assistant may be invaluable in is knowledgeable about and comfortable with alternative airway
providing sufficient control until the airway is established. The techniques, including surgical access, will be prepared to act deci-
search for a bleeding source during the procedure will waste valu- sively yet appropriately upon encountering a challenging airway cri-
able time and can usually wait until the airway is established. The sis. While a cricothyroidotomy is the surgical airway procedure of
best way to avoid this difficulty is strict hemostasis during the choice, a tracheostomy should be considered for laryngeal injuries
procedure and being careful to avoid the transection of any blood with airway disruption, or when all other methods have failed.
CHAPTER 27: Tracheostomy Care 171
Tracheostomy Care
27 H. Gene Hern Jr.
INTRODUCTION
Tracheostomy care and management of tracheostomy complica-
tions are tremendously important to the Emergency Physician.
Rapid assessment and understanding of tracheostomies and their
potential complications can be lifesaving in the critically ill and tra-
cheostomy dependent patient.
Tracheostomies have been performed since ancient times but
have been perfected in the last few centuries. A Greek physician
named Asclepiades of Bismuth was the first credited with perform-
ing a successful tracheostomy in 100 bc.1 Two of the four physicians
summoned to President George Washington’s deathbed were said to FIGURE 27-1. The tracheostomy tube consists of an outer cannula (left) and an
have argued for tracheostomy as his only means of survival. In the inner cannula (middle). The inner cannula inserts and locks into the outer cannula
1800s, Trousseau reported successful tracheostomies in more than (right).
2000 cases of upper airway obstruction secondary to diphtheria.2
Chevalier Jackson, in the 20th century, perfected the tracheostomy
technique and reduced the operative mortality from 25% to below cannulas contain a locking mechanism by which the inner cannula
1%.3 This is roughly what it remains today. is secured into the outer cannula. The proximal end of the inner
The important aspects of tracheostomy care include the assess- cannula contains a standard 15 mm connector that allows direct
ment of respiratory distress in the tracheostomy patient, proper connections to a ventilator or a bag-valve device.
suctioning techniques, and assessment and evaluation of possible Pediatric tracheostomy tubes, it must be noted, have a much
complications arising from the tracheostomy itself or its placement. smaller inner diameter and do not accommodate inner cannulas
For the purposes of this chapter, tracheostomy care will be divided (Figure 27-2). Since pediatric tracheostomy tubes are not made
into routine care and emergent care. with an inner cannula, they require more frequent suctioning and
changing.
ANATOMY AND PATHOPHYSIOLOGY Tracheostomy tubes are manufactured with and without cuffs
(Figure 27-3). Older high-pressure, low-volume cuffs produced
The trachea is a fibromuscular tube with approximately 18 to 20 car- tracheal mucosal injury within hours. They have been replaced by
tilaginous arches extending from the cricoid cartilage to the division high-volume, low-pressure cuffs that can be used for extended peri-
into right and left mainstem bronchi (Figure 26-4). The surface of the ods with minimal mucosal injury.
tracheal mucosa is covered in respiratory epithelium. This epithelium Obturators are solid devices that aid in the smooth insertion of
is responsible for tracheal secretion, mucociliary “elevator” move- the tracheostomy tube (Figure 27-4). When placed inside the outer
ment of secretions and debris, and humidification. The remaining cannula, an obturator will totally occlude the cannula and extend a
part of the upper respiratory tract, which is bypassed by the trache- few millimeters beyond the distal end. The smooth tip of the obtura-
ostomy, plays a major role in warming and humidifying inspired air. tor allows the outer cannula to be inserted with minimal effort and
The term tracheostomy and tracheotomy are widely interchanged prevents the edges of the cannula from getting caught and damaging
in current parlance. Tracheotomy refers to the actual incision tissue. Once the outer cannula has been inserted, the obturator is
through the skin to the trachea, which is then kept open by a tra- removed and replaced with a low-profile inner cannula.
cheotomy tube. A tracheostomy refers to the procedure in which
the tracheal opening is sutured to the skin incision. This creates a
more permanent orifice. The term tracheostomy will be used for the
remaining sections of this chapter.
A tracheostomy is created by an incision at the level of the sec-
ond or third tracheal rings. After the subcutaneous tissue is dis-
sected and anatomic structures identified, an incision is made into
the trachea. A hook is inserted into the incision and used to stabi-
lize the trachea while a tube is placed into the trachea. The trachea
is secured to the overlying skin and the tube is secured in place.
Further details can be found in Chapter 26.
TRACHEOSTOMY TUBES
Tracheostomy tubes vary in their composition, angles, and types
and the presence or absence of a cuff. The basic tube consists of
an outer cannula and an inner cannula (Figure 27-1). The size of
the tracheostomy tube is usually defined by its inner diameter. The
outer cannula is the more permanent fixture in the tracheostomy.
The inner cannula is a low-profile tube that inserts into the outer
cannula. It can easily be removed and replaced. The inner and outer FIGURE 27-2. The pediatric tracheostomy tube.
FIGURE 27-4. The obturator is a solid device (left) that inserts into the proxi-
FIGURE 27-3. Tracheostomy tubes may be uncuffed (left) or cuffed (middle). The mal end of the outer cannula and projects from the distal end of the outer
inflated cuff is a high-volume, low-pressure system (right). cannula (right).
ROUTINE CARE anxiety levels are quite high, as their ability to breathe may be
compromised by secretions, they may be hypoxic, and they have a
The routine care of the patient with a tracheostomy includes humidi- decreased ability to communicate freely at baseline.4
fication of air as well as cleaning and suctioning of the tracheostomy.
Inspired air that bypasses the upper respiratory tract in patients ■ EQUIPMENT
with tracheostomies is not as warm or humidified as air inspired • Protective clothing (disposable gowns, gloves, face shields, gog-
through the nose or mouth. When cold, dry air is inspired into the gles, and shoe covers)
trachea, the mucociliary “elevator” becomes impaired, resulting in
thicker secretions. It is important, especially in the postoperative • Bag-valve device
period, to warm and humidify the inspired air for the patient with • Flexible multi-eyed suction catheter, less than half the diameter
a tracheostomy.4 of the inner cannula
Care of the tracheostomy must include ensuring adequate cleanli- • Saline bullets
ness of the tube. Cleanse the skin site with diluted hydrogen perox- • Continuous wall suction
ide, at a 50% concentration, applied to cotton-tipped swabs or other
similar absorbent devices.5 The skin surrounding the tracheostomy • Pressure regulator to maintain suction pressure
should be kept dry between cleanings with tracheal bandages or
gauze sponges. It is important to note the underlying skin condition. ■ PATIENT PREPARATION
Erythematous or macerated skin can become eroded or infected. Place the patient in an upright or semirecumbent position. If pos-
Proper skin-care techniques should be used to ensure skin viability. sible, hyperextend the patient’s neck. Preoxygenate the patient with
Tracheal bandages or tape used to secure the tracheostomy in place 100% oxygen prior to suctioning. Hypoxia is a common complica-
should not be so tight as to compromise skin perfusion. A good rule tion of suctioning and can be virtually eliminated with proper
of thumb is to have two finger breadths of laxity between the skin preoxygenation. In addition, proper preoxygenation often pre-
and the securing ties.5 vents cardiac arrhythmias from occurring during suctioning.8
Pretreatment with atropine in neonates and children has been sug-
gested to minimize bradycardic episodes.9
SUCTIONING It has been debated which technique of preoxygenation is best.
Suctioning of the tracheostomy should be conducted when there Options include hand ventilation with a bag-valve device for five to
are thick and tenacious secretions at the tracheostomy lumen or eight breaths, hyperventilation with 100% O2 via a nonrebreathing
when the patient is having difficulty clearing secretions. Suctioning mask, or hyperventilation with 100% O2 via a ventilator. The advan-
through the tracheostomy will eliminate debris and infectious tage of hand ventilation is that there is faster delivery of oxygen to
agents, improve oxygenation, and prevent atelectasis. Other indi- the lungs rather than waiting for the higher percentage of oxygen to
cations for suctioning include diminished or coarse breath sounds, bleed down the ventilator tubing into the lungs. However, maintain-
unexplained decreases in oxygen saturation levels, or increased air- ing tidal volumes and positive end-expiratory pressure may be more
way pressures.6 Suctioning should not be done as part of “routine important in particular settings. The bag-valve device may result in
care” when there are few secretions or if the patient is adequately decreased cardiac output and hypotension secondary to increased
able to generate enough force to clear the secretions.7 While the intrathoracic pressures.6 The method of preoxygenation is left up
suctioning of tracheostomies is often essential to proper pulmonary to the physician.
toilet, it can also be hazardous. Known complications to tracheal
suctioning include hypoxia, hypotension, atelectasis, infections, tra- ■ TECHNIQUE
cheal mucosal damage, vagus stimulation, arrhythmias, and even Assemble and prepare the equipment. Set the pressure regulator to
cardiac arrest.6,8 60 to 80 mmHg for infants, 80 to 100 mmHg for children, and 100 to
Suctioning can also be very frightening to the patient and must 120 mmHg for adolescents and adults. Higher pressures may cause
be done with some expediency and professionalism. These patients’ injury to the tracheal mucosa. The suction catheter chosen should
be approximately one-half the diameter of the tracheostomy tube. EMERGENT CARE

The catheter has an open valve that must be covered to apply suction
through the tip of the catheter. If available, apply cardiac monitoring When a patient with a tracheostomy presents to the Emergency
and pulse oximetry to the patient prior to suctioning. Department complaining of shortness of breath or respira-
The procedure should be performed with aseptic technique. The tory distress, immediate attention must be given to them.
physician should wash his or her hands and apply sterile gloves. Obstruction and hypoxia are frequent causes of morbidity in this
The use of a face mask, eye protection, and a gown is highly rec- patient population. What follows is a discussion of the algorithm
ommended. The insertion of the suction catheter often induces the for airway obstruction and respiratory distress in the patient with a
patient’s cough reflex. Proper protective clothing will prevent the tracheostomy.9
physician from being exposed to respiratory secretions.
Gently insert the suction catheter into the trachea (Figure 27-5). ■ EQUIPMENT
Advance it approximately 8 to 10 cm until the tip is at the level of the • Protective clothing (disposable gowns, gloves, face shields, gog-
carina. Suction pressure should never be applied during insertion gles, and shoe covers)
of the suction catheter. Withdraw the catheter approximately 2 to
• Bag-valve-mask device
3 cm and apply suction by placing a finger over the catheter’s open
valve.10 Continue to apply suction as the catheter is simultane- • Flexible multi-eyed suction catheter less than half the diameter of
ously rotated and withdrawn. This technique will limit the amount the inner cannula
of mucosal damage from the suction catheter. If the catheter is not • Saline bullets
being withdrawn when suction is applied, the mucosal surface will • Continuous wall suction
invaginate into the holes in the suction catheter tip. The result-
• Suction pressure regulator
ing trauma may cause bleeding or erosion of the tracheal mucosal
surface.7 • Continuous ECG monitor
Suction the airway for no more than 10 to 15 seconds.7,11 This • Pulse oximetry
will ensure that the patient experiences a minimal amount of • Tracheal tubes of various sizes, at least the current size of the tube
hypoxia. If the suctioning must be repeated, preoxygenation with and one smaller
100% oxygen must precede each suctioning episode.
The standard use of saline to loosen secretions is somewhat • Water-soluble lubricant
controversial. Some authors have suggested that saline is used to • Tracheal Airway kit (hook, dilator, and forceps)
break up thick and tenacious sputum and mucus.9 There is little • Endotracheal tubes
support for this assertion. It has been shown that saline instillation
• Laryngoscope handle and blades
increases the cough reflex and stimulates a cough response, which
may increase mucus clearance. Others have noted that little saline is • Access to advanced airway equipment, including a fiberoptic
actually recovered with suctioning and that saline itself may cause scope
a gradual decrease in oxygen saturation.6 The instillation of saline
into the tracheostomy cannot be recommended at this time. ■ PATIENT PREPARATION
The evaluation of any patient with a tracheostomy who is in respi-
ratory distress begins with placing the patient in a room capable
of advanced airway management. Place the patient on 100% oxy-
gen and obtain intravenous access, cardiac monitoring, and con-
tinuous pulse oximetry. Equipment should be readily available and
accessible. This includes endotracheal and tracheostomy tubes of
various sizes as well as a laryngoscope and laryngoscope blades.
The practitioner must evaluate the type of tracheostomy tube
present.12 Recognition of the type of tube will aid in the evaluation
of possible complications and the management of the respiratory
distress. For instance, if the tube has no inner cannula (pediatric
tubes), the entire tracheostomy tube may have to be removed for
further cleaning after suctioning is performed. If the tracheostomy
tube has no cuff, the patient’s respiratory distress may be due to aspi-
ration of secretions or gastric contents.
■ TECHNIQUE
Inspect the tracheostomy tube for obvious signs of obstruction.
The degree of obstruction will increase exponentially as the cross-
sectional diameter of the tracheostomy tube decreases. As dried
secretions, blood, or aspirated material gathers in the inner cannula,
the amount of force required to create airflow through the tube
increases dramatically. In addition, secretions may act as a ball-valve
mechanism, allowing air to move inward but not outward.
An obvious obstruction or foreign body, if visible at the tracheos-
tomy tube opening, must be removed. The practitioner must then
suction the patient through the inner cannula using the technique
FIGURE 27-5. Insertion of a suction catheter. The vent is uncovered during inser- described above. Keep in mind the importance of preoxygen-
tion to prevent tracheal mucosal injury. ation. If this does not adequately relieve the patient’s respiratory
FIGURE 27-6. Removal of the outer cannula over a catheter. A. The catheter is inserted through the outer cannula to a depth of 8 to 9 cm. B. The outer cannula has been
removed over the catheter. C. The new outer cannula is inserted over the catheter and into the trachea.
distress, remove the inner cannula. Inspect it for dried secretions If no assist device is used, the tracheostomy tube can be replaced
and clean it later if necessary. The patient may again be suctioned, manually (Figure 27-7). Lubricate the obturator and insert it into
this time through the outer cannula. If no diminution of symptoms the outer cannula. Inflate the cuff and check its integrity. Deflate
is noted, the outer cannula may need to be removed. the cuff. Lubricate the outer cannula liberally. Place the tip of the
Before removing the outer cannula, it is important to have obturator perpendicular to the patient’s neck and insert it with a
all the necessary equipment to replace it at the bedside. If the semicircular motion (Figure 27-7A). Continue advancing the outer
outer cannula has a cuff, deflate it. Remove the outer cannula with cannula with a semicircular motion as it curves into the trachea
a smooth circular motion. Inspect it for a foreign body and dried (Figure 27-7B). Remove the obturator and insert the inner cannula
secretions. The outer cannula may be cleaned then replaced or may into the outer cannula. Begin ventilation of the patient if necessary.
be replaced with an entirely new tracheostomy tube. The practitio- If the new tracheostomy tube will not advance into the trachea,
ner may elect to use a fiberoptic scope or red rubber catheter to aid repeat the procedure with a tracheostomy tube one size smaller. Do
in tube placement. Each of these devices allows the tracheostomy not force the tube, as this can create a false passage in the subcu-
tube to be placed over it and guided into the tracheal lumen. taneous tissues of the neck. If it still will not advance, attempt to
If the tracheostomy is relatively new, less than 4 weeks old, it insert an uncuffed tube. Alternatively, insert the tracheostomy tube
should be removed over a red rubber catheter (Figure 27-6). This over a catheter (Figure 27-8). Lubricate a red rubber catheter (or
will ensure that the tracheostomy tube is inserted into the tra- oxygen catheter) and insert it 8 or 9 cm through the tracheostomy
chea and not a false passage. Lubricate the red rubber catheter. (Figure 27-8A). Insert a lubricated outer cannula over the cathe-
Insert the catheter through the outer cannula and into the trachea ter and into the trachea (Figure 27-8B). Remove the catheter and
(Figure 27-6A). Advance the catheter 8 or 9 cm. While holding insert the inner cannula. As a last resort, a tracheostomy hook and
the catheter securely, remove the outer cannula over the catheter Trousseau dilator can be used to lift and open the tracheostomy site
(Figure 27-6B). Lubricate a new outer cannula. Insert the outer to allow the insertion of a tracheostomy tube.
cannula over the catheter and gently advance it into the trachea
(Figure 27-6C). Remove the catheter and insert the inner cannula
ASSESSMENT
into the outer cannula.
A suction catheter can be used as an alternative to a red rubber The adequacy of airway maneuvers in the patient with a tracheostomy
catheter. Attach the suction catheter to an oxygen source. Lubricate resides in the patient’s response to the interventions. If the patient’s
the end of the suction tubing. Advance an outer cannula over the pulse oximetry and heart rate return to baseline and the patient
distal end of the suction tubing. Insert the suction catheter into appears more comfortable, secure the tracheostomy tube. Take care
the tracheostomy to a depth of 8 or 9 cm. Place a finger over the to ensure adequate skin care beneath the tracheostomy tube site.
open valve of the suction catheter to provide oxygen to the patient If a patient remains in respiratory distress despite all appropriate
through the catheter. This will prevent the patient from becoming actions, then further causes of respiratory distress must be evalu-
hypoxemic during the procedure. Advance the outer cannula over ated. Obtain a chest radiograph. Consult a Pulmonologist for fiber-
the catheter and into the trachea. Remove the suction catheter and optic bronchoscopy to evaluate the patient for mucus plugging or
insert the inner cannula into the outer cannula. foreign-body aspiration. Do not forget to consider other causes
FIGURE 27-7. Manual insertion of a tracheostomy tube. A. It is positioned 90° to the tracheostomy site and advanced with a semicircular motion (arrow). B. The system
continues to be advanced, following the curve of the tube, until the flange is against the skin.
of respiratory distress in the patient with a tracheostomy. This Once the patient’s respiratory distress has been addressed, the
includes, but is not limited to, a pneumothorax, pneumonia, pulmo- patient should be evaluated for further conditions that may pre-
nary embolus, congestive heart failure, and myocardial infarction. clude him or her from being discharged. Were there just some
dried secretions in the inner cannula? Does the patient have a
new source of secretions (bacterial pneumonia) that could not
AFTERCARE be managed at home? Are the caregivers at home knowledgeable
The patient should be observed for a few hours to ensure the stabil- about the tracheostomy and trained to deal with complications?
ity of the airway. During this time, further suctioning can be per- If there is any question about the patient’s ability to deal with
formed as required. Educate the patient and family about preventive further episodes of respiratory compromise, the patient should
measures regarding tracheostomy care. be admitted for further evaluation by an Otolaryngologist. The
FIGURE 27-8. Insertion of the tracheostomy tube over a catheter. A. Insert the catheter through the tracheostomy to a depth of 8 to 9 cm. B. Advance the outer cannula
over the catheter.
patient may require skilled home care or a skilled nursing facility in origin. Common bacterial etiologies include Staphylococcus
in order to fully care for the tracheostomy. aureus, group A streptococcus, and Haemophilus influenzae. The
determination of a bacterial infection versus colonization should
COMPLICATIONS OF THE TRACHEOSTOMY be based on clinical findings and culture results. Management of
tracheitis includes broad-spectrum antibiotics for common patho-
In addition to respiratory compromise from plugging of the tra- gens, maintenance of a patent airway through suctioning, and pos-
cheostomy with secretions, other complications may cause the sible bronchoscopy.
patient to present to the Emergency Department. One retrospective
review over a 7-year period showed that 33% of patients presented ■ LARYNGOTRACHEAL STENOSIS
with dislodged tracheal tubes, 30% presented with infection (one-
Laryngotracheal stenosis is a complication of long-term endotracheal
quarter of these had cellulitis around the tracheostomy, the rest had
intubation or direct tissue trauma from the tracheostomy. The tracheal
bronchitis or pneumonia), 18% had plugged tracheal tubes, 11%
tissues become irritated from the tracheostomy tube. This results in
had bleeding, 5% had tracheal or stomal stenosis, and 3% had a
tissue edema that leads to erosions into the mucosa, ulcerations, and
pneumothorax.2
eventually scar tissue. Treatment involves surgery to remove the scar
tissue and create an artificial airway to bypass the stenosis.
■ BLEEDING
Bleeding is a significant concern in the patient with a tracheostomy. ■ DEPRESSED SCAR FORMATION
While bleeding at the site of a recent tracheostomy may be a fre-
The tracheostomy wound is left open to granulate and heal by sec-
quent complication, it may also be extremely serious. Bleeding can
ondary intention. This can result in skin and soft tissue atrophy and
arise from granulation tissue, venous sources, or arterial sources
tissue adhesions to the anterior tracheal wall. As the tissue heals,
including the great vessels. Tracheoinnominate fistulas are quite
scar contracture and a depress scar can result. This may result in
rare, occurring in less than 2% of cases, but they carry a mortality
patient discomfort with head movement or swallowing. Treatment
rate of 25% to 50%.9 They may present as the classic “exsanguinat-
requires surgical scar excision and revision.
ing bleed” but often present with a less impressive sentinel bleed.
Any bleeding of more than a few milliliters of blood should raise ■ SUPRASTOMAL COLLAPSE
concern for a possible fistula of the innominate artery. Prompt
critical resuscitation measures and emergent consultation with Pressure placed on the tracheal cartilages by the tracheostomy tube
a Vascular Surgeon and Otolaryngologic Surgeon is required. results in cartilage inflammation, chondritis, and necrosis of the
Definitive management is surgical. Techniques for temporarily con- cartilaginous rings. Mild suprastomal collapse usually requires no
trolling bleeding from the innominate artery include local digital treatment. Moderate and severe collapse may require a tracheal
pressure, hyperinflation of the tracheostomy tube cuff, and trac- stent, suturing the anterior trachea to the skin and subcutaneous
tion on the tracheostomy tube. An alternative method is to deflate tissues, or pulling the anterior trachea anteriorly and securing it
the tracheostomy tube cuff, reposition the cuff at the bleeding site, in place.
and then reinflate or hyperinflate the cuff. When bleeding occurs,
■ TRACHEOESOPHAGEAL FISTULA
the tracheostomy tube should not be removed until the airway is
secured by another means from above (orally or nasally). A tracheoesophageal fistula is a rare complication of a tracheostomy.
The tracheostomy tube can cause pressure necrosis on the posterior
■ FREE AIR tracheal wall that continues to erode into the esophagus. The result
Pneumothoraces, pneumomediastinum, and subcutaneous air occur is an open tract between the trachea and the esophagus. Patients
in a small number of patients.9 Pediatric patients are at a higher risk, often have difficulty eating, aspiration pneumonitis, or respiratory
as the dome of the pleura in a child is closer to the site of the opera- difficulty associated with eating and drinking. Treatment requires
tion. As patients “fight” a ventilator or attempt to inspire against an surgical management.
obstructed airway, they can generate tremendous negative inspira-
■ TRACHEOMALACIA
tory pressures. This can result in the dissection of air between the
tissue planes and into the thoracic cavity, causing a pneumothorax. Tracheomalacia is the lack of support for the trachea by its carti-
Small pneumothoraces and pneumomediastinum can be observed laginous rings. It can result from degradation of the cartilaginous
as they will most likely resorb with no further complications. A tracheal rings from the tracheostomy tube or from a tracheoesopha-
large pneumothorax will require drainage. The possibility of a ten- geal fistula. Bronchoscopy is required to assess the severity of the
sion pneumothorax must always be considered in patients with tracheal collapse prior to possible intratracheal stenting.
tracheostomies and respiratory distress or hypotension.
SUMMARY
■ GRANULOMAS Emergency Physicians should be familiar with tracheostomy equip-
Tracheal wall granulomas can develop at the tracheostomy site or ment including the outer and inner cannulae, obturators, and cuff
near the tip of the tracheostomy tube. They are formed in response management. Patients presenting to an Emergency Department
to mechanical trauma to the mucosa. Granulomas are sometimes a may require immediate and critical intervention to resuscitate
source of bleeding. Direct pressure or cautery may be required for them. Familiarity with various techniques to evaluate the patient
hemostasis. Small granulomas are often observed, while large or with a tracheostomy should include tracheal suctioning, removal of
symptomatic ones require excision. the inner and outer cannulae, replacement of a tracheostomy tube,
and evaluation for other emergent conditions relating to tracheos-
■ INFECTIONS tomies. This would include bleeding, infection, and pneumotho-
Tracheostomy-related infections can present at any time. Stoma rax at the very minimum. In addition, the Emergency Physician
infections are considered to be local skin infections. Antibiotic should be mindful of other conditions of the esophagus, trachea,
treatment should be based on potential pathogens and local anti- or soft tissues that might complicate the care of the patient with a
biotic resistance patterns. Tracheitis may be bacterial or viral tracheostomy.
CHAPTER 28: Transtracheal Aspiration 177
where this technique may yield superior culture results when com-
Transtracheal Aspiration pared to sputum samples.6
28 Joseph A. Salomone III CONTRAINDICATIONS
Patients who are unable to cooperate with or tolerate the required
INTRODUCTION positioning should not be selected for this technique.7 Agitated
patients requiring sedation that may affect respiratory effort should
Transtracheal aspiration is a technique for the collection of bron- be avoided. Traumatically injured patients should have the cervi-
chial secretions for laboratory evaluation and culture. This tech- cal spine cleared for possible injury prior to performing the pro-
nique is useful when standard sputum collection has not provided cedure. Patients with known or suspected blood dyscrasias (e.g.,
adequate material or determination of the infective agent(s). abnormal platelet counts, elevated prothrombin, or partial throm-
Specimens collected by this technique are free of contamination boplastin times) should not be subjected to this technique due to
from nasal, oral, and pharyngeal secretions. This technique was the increased risk of tracheal hemorrhage. The physician must be
first described in 1959.1 Several modifications to the original tech- able to easily identify the patient’s anatomic landmarks, including
nique have been made.2–5 This technique may be more properly the thyroid and cricoid cartilages and the intervening cricothyroid
named transcricothyroid membrane aspiration. membrane. Patients with abnormal or distorted anatomy should be
excluded. Patients who are endotracheally intubated or have a tra-
cheostomy do not require this procedure.
The most superficial portion of the cervical airway begins at the EQUIPMENT
inferior thyroid cartilage and extends inferiorly to the thyroid isth-
• Sterile gown, gloves, and mask
mus (Figure 28-1). The inferior border of the thyroid cartilage
is attached to the cricoid cartilage by the cricothyroid ligament. • Pillow or padding for shoulders
This is formed by a thicker central conus elasticus and laterally • Povidone iodine solution or chlorhexidine solution
by thinner ligaments that are covered by the cricothyroid muscles • Sterile gauze squares
(Figure 28-1B). The internal surface is covered by the mucous
membrane of the larynx. Collectively, this is often referred to as • Normal saline solution, sterile and preservative-free
the cricothyroid membrane or cricovocal membrane. The paired • Local anesthetic solution, 3 mL (1% lidocaine HCl)
cricothyroid arteries cross from lateral to medial to form an arch • 3 mL syringes
that anteriorly crosses the upper one-third of the cricothyroid mem-
• 30 mL syringe
brane. The pyramidal lobe of the thyroid occasionally extends supe-
riorly to this level. • 25 to 27 gauge needles, ½ in
• 18 to 22 gauge catheter-through-the-needle
INDICATIONS • 18 to 22 gauge catheter-over-the-needle, 3 in long
• 18 to 19 gauge needles, 1½ in
Transtracheal aspiration is indicated for the collection of tracheo-
bronchial secretions for laboratory evaluation. Often, previous • Pulse oximeter
attempts to collect standard coughed and expectorated sputum sam- • Cardiac monitor
ples have failed to yield adequate samples or reveal the etiology of a • Sterile specimen container
pulmonary infection. Patients who do not appear to be responding
• Bandage, 1 in wide
to the appropriate antibiotic regimen that was indicated by evalua-
tion and culture of sputum samples may benefit from this technique • Sterile drapes or towels
to better determine the pathogen(s). This is particularly true in cases • Resuscitation equipment including emergent airway manage-
of atypical or mixed flora, as in suspected aspiration pneumonias, ment supplies
FIGURE 28-1. Anatomy of the airway structures of the neck. A. Topographic anatomy. B. The cartilaginous structures.
PATIENT PREPARATION prominence, cricoid cartilage, and cricothyroid membrane. Leave

the nondominant index finger over the cricothyroid membrane for
Explain the procedure, its risks, and its benefits to the patient and/or reference.
their representative. Obtain an informed consent. Place the patient Apply a small subcutaneous wheal of local anesthetic solution
on cardiac monitoring and continuous pulse oximetry. Administer below the skin at the anterior midpoint of the cricothyroid mem-
supplemental oxygen and establish intravenous access. brane (Figure 28-2). Inject 0.5 to 1.0 mL of local anesthetic solution
Sedation is not generally required. A small dose of midazolam into the subcutaneous tissues down to the level of the cricothyroid
(1 to 5 mg IV) may be used, if appropriate, for light sedation. Deep membrane, taking care not to distort the anatomy. Reidentify the cri-
sedation should be avoided, as it may compromise respiratory cothyroid membrane by palpation. Insert the needle on the syringe,
efforts and increase the risk of aspiration of gastric contents. directed caudally and at a 30° to 45° angle to the skin (Figure 28-3).
Place the patient supine in bed. Place a pillow or appropriate Continue to advance the needle while applying negative pressure
padding under the patient’s shoulders and upper back to allow for to the syringe (Figure 28-3A). Stop advancing the needle when air
comfortable hyperextension of the neck. Identify by palpation the is aspirated into the syringe. This signifies that the needle is inside
thyroid cartilage, laryngeal prominence (Adam’s apple), cricoid car- the trachea. If using a saline filled syringe, air bubbles will be clearly
tilage, and cricothyroid membrane. These are the anatomic land- visible within the saline. Hold the needle securely and remove the
marks that will be used to identify the proper site for performing syringe. Insert the catheter through the needle (Figure 28-3B). While
the procedure. holding the catheter securely, withdraw the needle until the tip has
exited the skin of the neck (Figure 28-3C). Place the needle guard
TECHNIQUE over the needle. This will prevent shearing off of the catheter. Apply
the 30 mL syringe containing saline to the catheter (Figure 28-3C).
■ CATHETER-THROUGH-THE-NEEDLE TECHNIQUE Ask the patient to cough if they are not already doing so. Aspirate
The operator should follow universal precautions with the use of a with the 30 mL syringe as the patient coughs. If no specimen is
mask, eye protection, a sterile gown, and sterile gloves. Using sterile obtained, instill the sterile saline. Once again, ask the patient to
technique, prepare the equipment. Draw 3 to 5 mL of sterile and cough if not stimulated by the saline. Aspirate until a specimen is
preservative-free normal saline solution into a 30 mL syringe with a acquired. An alternative to using a large syringe for aspiration is the
sterile needle. Attach an appropriately sized needle from a catheter- use of low wall suction and a Lukens tube or a similar trap device to
through-the-needle set (18 to 20 gauge for an adult, 20 to 22 gauge collect the specimen.
for a child) to a 3 mL syringe. An alternative technique is to draw Remove the catheter, needle, and syringe as one unit. Hold direct
up 1 to 2 mL of sterile saline into the syringe before attaching the pressure on the puncture site for 3 to 5 minutes. Apply a bandage or
catheter-through-the-needle. Draw up 1 to 3 mL of local anesthetic sterile dressing to the puncture site. Place the specimen in a sterile
solution into a 3 mL syringe armed with a 25 to 27 gauge needle. container and have it transported to the laboratory.
Position the patient as noted above. Using sterile technique, pre- Many physicians are reluctant to use the catheter-through-the-nee-
pare the neck. Clean the anterior neck of any dirt and debris. Apply dle system as there is the possibility of shearing off the catheter within
povidone iodine or chlorhexidine solution and allow it to dry. Place the trachea. This can be prevented by applying the needle guard
sterile towels or a sterile drape to isolate the anterior neck. Palpate over the needle immediately after it is withdrawn from the skin.
the anterior neck and reidentify the thyroid cartilage, laryngeal
■ CATHETER-OVER-THE-NEEDLE TECHNIQUE
The more commonly used technique is to use a catheter-over-the-
needle (angiocatheter) system (Figure 28-4). The operator should
follow universal precautions. Cleanse, prepare, and anesthetize the
patient as above.
Using sterile technique, prepare the equipment. Draw 3 to 5 mL
of sterile and preservative-free normal saline solution into a 30 mL
syringe with a sterile needle. Attach an appropriately sized catheter-
over-the-needle (18 to 20 gauge for an adult, 20 to 22 gauge for a
child) to a 3 mL syringe. An alternative technique is to draw up 1 to
2 mL of sterile saline into the syringe before attaching the catheter-
over-the-needle. Draw up 1 to 3 mL of local anesthetic solution into
a 3 mL syringe armed with a 25 to 27 gauge needle.
Reidentify the cricothyroid membrane by palpation. Insert the
catheter-over-the needle on the syringe, directed caudally and at a
30° to 45° angle to the skin (Figure 28-4A). Continue to advance
the catheter-over-the-needle while applying negative pressure to
the syringe. Stop advancing the catheter-over-the-needle as soon
as air is aspirated into the syringe. This signifies that the needle is
inside the trachea. If using a saline filled syringe, air bubbles will be
clearly visible within the saline (Figure 28-4B). Hold the syringe
securely and advance the catheter until its hub is against the skin
(Figure 28-4C). Remove the needle and syringe. Apply the 30 mL
syringe containing saline to the catheter (Figure 28-4D).
Ask the patient to cough if they are not already doing so. Aspirate
with the 30 mL syringe as the patient coughs. If no specimen is
FIGURE 28-2. A subcutaneous wheal of local anesthetic solution is placed over obtained, instill the sterile saline. Once again, ask the patient to
the middle of the cricothyroid membrane. cough if not stimulated by the saline. Aspirate until a specimen is
CHAPTER 28: Transtracheal Aspiration 179
FIGURE 28-3. The transtracheal aspiration technique with a catheter-through-the-needle system. A. The needle is inserted through the cricothyroid membrane while
negative pressure is applied to the syringe. B. The syringe has been removed and the catheter advanced through the needle. C. The needle has been withdrawn until its
tip exits the skin. A syringe containing saline is attached to the hub of the catheter.
acquired. An alternative to using a large syringe for aspiration is the AFTERCARE

use of low wall suction and a Lukens tube or a similar trap device to
collect the specimen. The patient should remain on continuous pulse oximetry to moni-
Remove the catheter. Hold direct pressure on the puncture site for tor possible deterioration in respiratory status. Obtain a chest
3 to 5 minutes. Apply a bandage or sterile dressing to the puncture radiograph in 24 hours to look for subcutaneous air and/or a pneu-
site. Place the specimen in a sterile container and have it transported mothorax. Any procedure that might stimulate coughing should be
to the laboratory. avoided for at least 24 hours.
ASSESSMENT COMPLICATIONS
The patient should be observed for bleeding at the puncture site, The complications range from minimal hemoptysis and localized
the development of subcutaneous emphysema, any changes in spu- subcutaneous emphysema to massive pulmonary hemorrhage and
tum production, or hemoptysis. Obtain a chest radiograph imme- death.8–13 Minimal hemoptysis was seen in 15% of pediatric patients
diately after the procedure to look for subcutaneous air and/or a in one study and commonly in several adult studies. Localized sub-
pneumothorax. cutaneous emphysema in the anterior neck occurred in 5% to 18%
FIGURE 28-4. The transtracheal aspiration technique with a catheter-over-the-needle system. A. The catheter-over-the-needle is inserted through the cricothyroid mem-
brane. B. Negative pressure is applied to the syringe. C. The catheter is advanced until its hub is against the skin. D. The needle and syringe have been withdrawn. A syringe
containing saline is attached to the hub of the catheter.
of patients. There are rare reports of fatal endotracheal hemorrhage, SUMMARY

profound coughing with development of massive subcutaneous and
mediastinal emphysema, vomiting and aspiration of gastric contents, Transtracheal aspiration is a useful technique for obtaining uncon-
cardiac dysrhythmias, and sudden cardiac death. There is at least one taminated specimens for analysis and culture. The procedure is best
case of fatal gastrointestinal hemorrhage from ruptured esophageal used in those patients who have complicated courses or are failing to
varices and Mallory–Weiss tears following “unrestrainable” coughing. respond to appropriate treatment or when there is a high index of sus-
picion for aspiration pneumonia and more atypical infectious agents.
SECTION
Cardiothoracic Procedures 3
Cardiac ultrasonography can be one of the most challenging
Cardiac Ultrasound areas of emergency US. The EP must have a keen grasp of the spa-
29 Gregory M. Press and Amy Rasmussen
tial anatomy of the heart to properly perform and interpret the US
examination. An EP can become competent in basic cardiac ultra-
sonography with practice. This tool can be utilized to gain great
insight into the body’s most vital organ. This chapter will cover basic
INTRODUCTION cardiac anatomy, the indications for emergency echocardiography,
techniques, and image interpretation.
Pericardial tamponade is arguably the most dramatic ultrasound
(US) finding for the Emergency Physician (EP). The diagnosis is
difficult to make without cardiac US, and acute intervention can ANATOMY AND PATHOPHYSIOLOGY
be lifesaving. Cardiac US has proven to be an invaluable tool for
identifying critical pathology and directing decision making in GENERAL ANATOMY AND PHYSIOLOGY
the Emergency Department (ED).1 A quick bedside US can assess
a patient’s cardiac activity, global cardiac function, presence or It is essential to know the anatomy of the heart before performing
absence of effusion, and volume status. Cardiac US is an essential any US examination (Figure 29-1). The heart lies obliquely in the
part of the evaluation of the trauma patient,2 the cardiac arrest middle of the chest. It consists of four chambers: the left atrium,
patient,3,4 and the patient with undifferentiated hypotension.5,6 the right atrium, the left ventricle, and the right ventricle. The atria
Aorta
Pulmonary artery
Superior vena cava
Aortic valve
Right pulmonary arteries Left pulmonary arteries
Right pulmonary veins

Left pulmonary veins
Right atrium Left atrium
Pulmonary valve Mitral valve
Tricuspid valve
Right ventricle Left ventricle
Inferior vena cava

Septum
FIGURE 29-1. The cardiac anatomy. The long axis of the heart (long arrow) extends from the base to the apex. The short axis (short arrow) is a transverse slice perpen-
dicular to the long axis.
181
182 SECTION 3: Cardiothoracic Procedures
are thin-walled muscular structures. The ventricles are more volu-

minous and muscular, with the left ventricle having the thickest wall.
The base of the heart is the superior portion. It is formed by the left
atrium, and to a lesser extent the right atrium. The apex of the heart Pericardial
consists of the inferolateral portion of the left ventricle. The anterior fluid
surface of the heart abuts the chest wall and is mainly formed by
the right ventricle. The left ventricle forms the majority of the infe-
rior surface, with the inferior portion of the right ventricle making
a minor contribution. The heart has two axes; both are used exten-
sively in ultrasonography. The long axis extends from the base to
the apex, roughly along a line from the right shoulder to the left hip.
The short axis slices the heart transversely and perpendicular to the
long axis, roughly along a line from the left shoulder to the right hip.
The right heart delivers blood to the lungs to be oxygenated, and
the left heart distributes it to the rest of the body. The right atrium
receives deoxygenated blood from the body via the superior and
inferior vena cava. Blood flows from the right atrium through the
tricuspid valve and into the right ventricle during diastole. Blood
is pumped from the right ventricle through the pulmonary valve
and into the pulmonary artery during systole. The blood is oxygen- FIGURE 29-2. Free pericardial fluid is visualized as an anechoic stripe surround-
ated by the lungs then flows into the left atrium via the pulmonary ing the heart. (Modified with permission from: Ma OJ, Mateer JM, Blaivas M:
veins. Blood flows across the mitral valve into the left ventricle dur- Emergency Ultrasound, 2nd ed. New York: McGraw-Hill, 2008.)
ing diastole. It is then pumped by the left ventricle for distribution
to the body via the aorta during systole.
The heart is contained within the two-layered pericardial sac. The seen in systolic heart failure.12 With a loss of healthy contractility
visceral pericardium is a single layer of cells in direct approximation and enlargement of the left ventricle, dilation of the other cardiac
with the epicardium. The tougher outer fibrous parietal pericardium chambers generally ensues. Diastolic failure is due to prolonged
surrounds the visceral pericardium. The two layers form a potential exposure to high cardiac afterload as seen with aortic stenosis and
space that contains a small volume of fluid of approximately 20 to uncontrolled hypertension.13 This results in hypertrophy of the left
50 mL.7 This pericardial fluid allows the heart to freely move within ventricular myocardium. The thickened myocardium cannot relax
the fibrous pericardium. Larger volumes of fluid can collect in this appropriately to allow ventricular filling during diastole. Diastolic
potential space in pathologic states. and systolic heart failure both result in a heart that appears globally
enlarged. The point of maximal impulse (PMI) is lateralized due to
PERICARDIAL EFFUSION enlargement of the left ventricle from either dilatation or hypertro-
phy. Both disease states can be visualized on US.
A pericardial effusion is a collection of fluid in the space between
the visceral and parietal pericardium. Effusions can be due to
trauma, uremia, infection, neoplasm, connective tissue disorders,
US FOR SUSPECTED PERICARDIAL FLUID
iatrogenic complications, idiopathic conditions, chyle, and numer- Pericardial fluid appears as an anechoic collection between peri-
ous other rare causes.8 Cardiac tamponade occurs when the fluid cardium and myocardium (Figure 29-2). Small effusions may layer
collects rapidly, such as in the setting of trauma, where it can cause posteriorly or appear as thin black stripes under the pericardium.
collapse of the ventricles and decreased cardiac output.8,9 Fluid that Larger effusions extend anteriorly to surround the heart entirely.
collects more slowly will allow the parietal pericardium to expand Epicardial fat may be confused for pericardial fluid but can usually
accordingly and usually does not lead to cardiovascular collapse.9 be differentiated because it appears as an isolated thin hypoechoic
layer along the anterior aspect of the heart (Figure 29-3).18 Fluid
CARDIAC ARREST generally appears anechoic and not hypoechoic like the epicardial
fat. Loculated effusions are usually spherical or lenticular collec-
Cardiac arrest is the end result of numerous different pathologic tions with echogenic borders and septae.
states. Asystole is the complete absence of cardiac activity, or akinesis
of the heart.10 While atrial twitching may be visualized on US, the lack US FOR TRAUMATIC HEMOPERICARDIUM
of ventricular activity is uniformly seen in asystole. Pulseless electrical
activity (PEA) describes the state in which no pulses are palpable, but Cardiac US has been used to diagnose hemopericardium in the set-
cardiac electrical activity is visible on ECG monitoring. Cardiac activ- ting of trauma, particularly penetrating injuries.2,19 US is a rapid
ity may or may not be present upon US of a heart in PEA. Cardiac and noninvasive means of determining the need for operative inter-
arrest can occur from nonperfusing tachyarrhythmias and bradycar- vention. The physical exam is generally unreliable in diagnosing a
dias. Cardiac motion is present in the case of ventricular fibrillation hemopericardium.20 A subxiphoid pericardial window is invasive
but is unorganized, preventing adequate cardiac filling and ejection of and unwarranted in low-risk patients.2 Rozycki et al. evaluated the
blood. Severe bradycardia causes the heart to beat at a rate too slow to use of US performed by Surgeons, Cardiologists, and technologists
provide adequate perfusion of the heart and other tissues. for diagnosing a hemopericardium due to penetrating torso trauma.
This study revealed a sensitivity of 100%, specificity of 96.9%, and
an accuracy of 97.3%.2 Plummer et al. demonstrated that a rapid
CONGESTIVE HEART FAILURE
sonographic evaluation of the heart performed by EPs expedites
Congestive heart failure (CHF) is an increasingly common condi- lifesaving management for victims of penetrating trauma.19 Both
tion that distorts normal cardiac anatomy.11 Dilation of the left ven- length of time to operative intervention and mortality were signifi-
tricle, decreased ejection fraction, and decreased cardiac output are cantly improved by ED cardiac US.
CHAPTER 29: Cardiac Ultrasound 183
Epicardial
fat
Right
ventricle
Left
ventricle
FIGURE 29-4. Pressure–volume relationship of the pericardial space. An acute

effusion is represented by the solid line. A chronic effusion is represented by the
dotted line. (Used with permission from: Ma OJ, Mateer JM, Blaivas M: Emergency
FIGURE 29-3. Subcostal long axis view of the heart demonstrating the epicardial
Ultrasound, 2nd ed. New York: McGraw-Hill, 2008.)
fat pad anterior to the right ventricle. The epicardial fat pad is hypoechoic and not
anechoic as usually seen with fluid. (Modified with permission from: Ma OJ, Mateer
JM, Blaivas M: Emergency Ultrasound, 2nd ed. New York: McGraw-Hill, 2008.)
PEA refers to a state in which the heart generates electrical activ-
ity on the ECG monitor but is unable to perfuse a palpable pulse.
The spectrum of etiologies for this condition can be visualized with
The Focused Assessment with Sonography for Trauma (FAST)
US, from “subpalpable hypotension” with contracting ventricles to
exam is the cornerstone of trauma ultrasonography.17 This study
terminal erratic cardiac twitches. In an observational study per-
consists of four views: three abdominal views and a single cardiac
formed by Tayal and Kline, PEA patients without sonographic car-
view. The incidence of hemopericardium is significantly lower for
diac activity all died.3 Several patients with sonographic motion of
blunt trauma than for penetrating injuries. Substantial blunt force to
the myocardium had reversible causes such as a pericardial effusion
the chest or deceleration injuries may result in myocardial or aortic
survived. US has value in diagnosing several other etiologies of PEA
tears and a hemopericardium.21 Refer to Chapter 5 for the complete
including: cardiac tamponade,1 myocardial infarction,22 cardiogenic
details of the FAST exam.
shock,5,6 pulmonary embolism (PE),23 aortic rupture,24 hypovole-
mia, and hemorrhagic shock states.14
US FOR NONTRAUMATIC EFFUSIONS Circumstance may arise when ventricular fibrillation is not
The clinical suspicion for a pericardial effusion should prompt the appreciated on the ECG monitor but is diagnosed by US. Fine
EP to perform bedside ultrasonography. The diagnosis of pericar- ventricular fibrillation can look like asystole on the ECG monitor.
dial effusion should be considered in any patient presenting with Ultrasonography of fine ventricular fibrillation appears as rapid
shortness of breath, chest pain, and decreased exercise tolerance. trembling of the ventricular myocardium versus the lack of any
Hypotension, distended neck veins, pulsus paradoxus, a pericardial motion for asystole.
rub on physical examination, and low voltage or electrical alternans
on ECG are all consistent with a pericardial effusion. Unfortunately, US FOR LEFT VENTRICULAR FAILURE
most of these findings are neither sensitive nor specific for a pericar-
The high prevalence of CHF makes the assessment of left ven-
dial effusion or cardiac tamponade.20 Hence, cardiac US is critical
tricular (LV) function particularly valuable in the ED. New-onset
in making the diagnosis. It is important to note that chronic peri-
CHF is generally a clinical diagnosis for the EP. However, cardiac
cardial effusions are generally better tolerated than acute effusions.
US allows for direct evaluation of LV function. Cardiac US may aid
Pericardial compliance over time allows for a greater volume that
in distinguishing CHF from other causes of dyspnea such as chronic
exerts less pressure upon the cardiac chambers (Figure 29-4).9
obstructive pulmonary disease, pneumonia, pericardial effusion,
Mandavia et al. investigated the ability of EPs to diagnose a peri-
and PE.25,26 US can help differentiate cardiogenic shock from other
cardial effusion with US.1 Of the 515 patients enrolled, 103 had
types of shock in a patient with unexplained hypotension.6
pericardial effusion identified by the EPs for a sensitivity of 96% and
Moore and Agur investigated the use of bedside US for estima-
a specificity of 98% according to the comparative standard.
tions of LV function in hypotensive patients.27 They concluded that
EPs can make accurate determinations. Randazzo et al. conducted
US IN CARDIAC ARREST a study in which EPs performed bedside cardiac US examinations
US is useful for guiding the management of patients in cardiac on 115 patients.28 Overall agreement between EP categorization
arrest. Confirmation of asystole helps the EP in deciding to termi- of LV ejection fraction and formal Cardiologist echocardiogram
nate resuscitation efforts. The sonographic findings of an arrested was 86.1%.
heart include still ventricular walls, sporadic nonperfusing twitches Complex statistical calculation packages exist in echocardiog-
of the valves or myocardium, and at times a “smoky” appearance raphy for determining the function of the left ventricle. However,
to the intracardiac blood without forward motion. Blaivas and Fox the echocardiographer’s estimation of LV ejection fraction has been
evaluated the predictive value of cardiac US in cardiac arrest.4 Of shown to be quite accurate.29 Rapid general assessment of LV func-
136 patients with cardiac standstill on US, 71 had an identifiable tion is suited for the EP. LV function can be categorized as hyper-
rhythm on the monitor. No patient with PEA and cardiac standstill dynamic, normal, moderately impaired, and severely impaired for
survived to leave the ED. practical purposes in the ED. The more cardiac US’s one performs,
Right
ventricle
Left ventricle
Right
Left
ventricle
ventricle
FIGURE 29-5. Parasternal long axis view of the heart in a patient with CHF. The
enlarged left ventricle has limited contractility and a poor ejection fraction.
FIGURE 29-7. Right ventricular dilatation and bulging of the septum into the left
ventricle are seen in the presence of a large PE.
the more comfortable one becomes categorizing a patient’s LV func-

tion. A hyperdynamic heart is seen in the setting of hypovolemia or
et al. showed that in hemodynamically stable patients with a PE and
distributive shock. The tachycardic contractions cause the ventricu-
cardiac US findings of right heart dysfunction, administration of
lar walls to nearly approximate or “kiss” each other. Hypokinetic
thrombolytic therapy reduced the need for escalation of treatment
contractions appear stiff. Patients with impaired LV function gen-
but did not affect mortality.33
erally have dilated cardiac chambers, limited contractility, and
limited inward movement of the ventricular walls during systole
US TO ASSESS SHOCK STATES
(Figure 29-5).
Bedside US is a valuable tool in the management of patients with
US FOR PULMONARY EMBOLISM undifferentiated shock. US provides a direct view into the cardio-
vascular system and allows the EP to make determinations about
Patients with a large PE and hemodynamic compromise are often
the hemodynamic status of a patient. Shock due to heart failure,
too unstable for conventional diagnostic imaging such as computed
cardiac tamponade, and PE was described previously. Hypovolemic
tomography and ventilation–perfusion scans. US can provide clues
and distributive shock generally presents with a tachycardic hyper-
at the bedside for the diagnosis of a PE. The deep veins of the extrem-
dynamic heart. Rose et al. presented a protocol for the sonographic
ities can be assessed for clot.30 A large obstructive PE will produce
evaluation of the heart, peritoneal space, and aorta for undifferenti-
signs of right heart strain on cardiac US.31,32 Dilation of the right
ated hypotension.5 Jones et al. concluded that implementing a simi-
ventricle should raise concern for a PE (Figure 29-6). Paradoxical
lar protocol resulted in a more focused differential diagnosis and a
bulging of the septum toward the left ventricle during diastolic fill-
more accurate ultimate diagnosis for patients in shock.6
ing is a sign of right heart strain (Figure 29-7).32 Numerous other
Central venous pressures (CVP) and right atrial pressures can
conditions such as emphysema, pulmonary hypertension, and right
be estimated by US evaluation of the inferior vena cava (IVC) and
ventricular infarction cause right heart strain.25,26 Konstantinides
the internal jugular veins, respectively.16,34 An IVC diameter of
1.5 to 2 cm is considered normal (Figure 29-8).16 A larger diameter
Right ventricle
RV Left
ventricle
LV
IVC
FIGURE 29-6. Concern for a PE is raised by the dilatation of the right ventricle.
The diameter of the right ventricle is essentially equal to the diameter of the left FIGURE 29-8. The normal caliber of the IVC as it passes beneath the liver in the
ventricle. caudal-cephalad direction.
IVC
A B
FIGURE 29-9. Longitudinal view of the IVC. A. The diameter of the IVC is narrow in this septic patient. B. Upon inspiration, the IVC collapses nearly completely
(white arrow).
indicates elevated CVP while a smaller diameter is indicative of CONTRAINDICATIONS

depressed CVP. The diameter of the IVC varies with respiration.
Negative intrathoracic pressure produced by inspiration causes the US is a noninvasive diagnostic modality. It is contraindicated only
IVC to collapse (Figure 29-9). A collapse of 50% is considered nor- if it would delay and negatively impact a clinically obvious need for
mal, with greater collapse indicative of low CVP and negligible col- emergent operative intervention. The cardiac US exam should not
lapse indicative of high CVP.14–16 Simply stated, “fat” great veins are be performed unsupervised by providers who have not been ade-
consistent with an elevated CVP and “flat” great veins are consistent quately trained.
with a low CVP.
EQUIPMENT
INDICATIONS • US machine
The list of indications for cardiac US in the ED is continually • US gel
expanding (Table 29-1). The two indications first described for ED • Phased array low frequency US probe
US were for the identification of pericardial fluid (traumatic and • US probe cover or glove
nontraumatic) and the evaluation of cardiac activity.17 These are still
the primary examinations the EP must gain comfort in performing. A complete discussion of US equipment is beyond the scope of
Additional echocardiographic studies can be undertaken once these this chapter. Decisions regarding machines and probes depend on
two have been mastered. This includes, but is not limited to, evalua- the user, cost, and intended applications. The cardiac US exam can
tion for left ventricular failure, chamber dilatation, myocardial wall be performed with a good quality low frequency probe. Probes with
motion defects, PE, evaluation of shock states, cardiac valve throm- smaller footprints allow for easier viewing between the ribs.
bus or vegetations, valvular dysfunction, procedural guidance (i.e., The vast majority of cardiac US examinations performed by EPs
pericardiocentesis and transvenous pacer placement), and estima- are performed via the transthoracic approach. The preferred probe
tion of CVP by great vein measurements. for transthoracic imaging is a small footprint, low frequency, phased
Numerous other indications exist for emergency US. EPs have
begun to use cardiac US to evaluate wall motion defects in the
setting of myocardial infarction.22 Valvular abnormalities such as
stenosis, regurgitation, thrombus, and vegetations (Figure 29-10)
can also be assessed by emergency cardiac US.35 The evaluation for
cardiac myxomas, cardiac tumors, septal defects, dynamic function,
and pediatric echocardiography are other cardiac US considerations
in the future for the EP.
TABLE 29-1 Indications for Emergency Cardiac Ultrasonography

Primary indications Advanced indications
Pericardial effusion Cardiac chamber dilation
Cardiac arrest Central venous pressure estimates
Traumatic hemopericardium Intracardiac thrombus identification
Left ventricular function
Myocardial wall motion defects
Procedural guidance
Valvular dysfunction FIGURE 29-10. An infectious thrombus (white arrow) is located on the anterior
Valvular vegetations leaflet of the mitral valve in this parasternal long axis view.
array, or microconvex probe (Table 3-2). Curved sequential probes

can be used and may produce superior images. The large footprint
of these probes can be cumbersome when trying to image between
ribs or in a small subxiphoid space.
The US probe is generally used directly against the patient’s skin,
with gel between them. Place the probe in a probe cover or glove to
prevent contamination of the probe if the patient’s skin is covered
with blood, urine, feces, or other substances. Place US gel in the
probe cover or glove before inserting the probe. Squeeze out any
air in the space between the tip of the probe and the probe cover
or glove.
PATIENT PREPARATION
Little to no preparation is required to perform the cardiac US exam.
Wipe any debris and liquids from the patient’s skin in the areas to be
scanned. Place the US probe in a probe cover or glove, as described
above, if the patient’s skin is contaminated with blood, vomit, other A
body fluids, or other substances that may contaminate or damage
the probe.
TECHNIQUES Liver
Echocardiography is a complex field. US is a dynamic tool that is Right
well suited to imaging an organ in motion such as the heart. Much ventricle
Right atrium
information about cardiac function and flow can be gained from
complicated statistical calculation packages, advanced Doppler, and
M-Mode measurements. This section focuses on the primary views
most relevant to the EP with the hope of providing a foundation Tricuspid
for more in-depth study of advanced cardiac US techniques in the valve
future. Mitral
valve
ORIENTATION INDICATOR
The probe orientation indicator in echocardiography is convention- Left atrium Left ventricle
ally set to the right side of the screen. In Radiology, the probe indi- B
cator is set to the left side of the screen. Some controversy exists
in EM as to which side of the screen to have the probe indicator
for cardiac US. The approach preferred by the present authors is T
to set the orientation indicator on the left side of the screen, con-
sistent with its location for other emergency US indications. It is
impractical to switch the location of the indicator in the middle of
a FAST exam or when performing multiple studies in a hypotensive
patient. To obtain the conventional echocardiographic views, the
probe must be rotated 180° from the conventional emergency US RV
position. The left–right reversal of the indicator and the rotation of
the probe result in the same image displayed on the screen. Most
RA
modern machines have a cardiac preset that automatically adjusts a LV
number of factors to maximize cardiac imaging. It is important for
the sonographer to be aware that this preset places the orientation
indicator on the right side of the image. Left–right inversion is easily LA
achieved on most machines.
SUBXIPHOID VIEW
C
The subxiphoid view is probably the most commonly used view by
EPs. It provides visualization of the four heart chambers and allows
FIGURE 29-11. The subxiphoid view. A. Patient and probe positioning. B. Diagram
for a superior evaluation for pericardial fluid. It can be performed
of the US image. C. The US image. (Used with permission from: Ma OJ, Mateer JM,
without interruption of cardiopulmonary resuscitation or the inser-
Blaivas M: Emergency Ultrasound, 2nd ed. New York: McGraw-Hill, 2008.)
tion of chest tubes and subclavian central venous lines. The subxi-
phoid view is often the easiest view to incorporate into the FAST
exam. This view can be limited in patients with a protuberant abdo-
men, abdominal pain, abdominal injuries, free air below the dia- right (Figure 29-11A). Hold the probe with your fingers out from
phragm, and/or nausea. the underside or topside to allow for a shallow angle (approximately
Place the probe in the subxiphoid space. Angle the probe cepha- 20°) between the probe and the patient. The shallow angling of the
lad into the patient’s chest with the marker aimed to the patient’s transducer risks breaking contact between the footprint and skin.
Apply an adequate amount of gel and firm pressure into the subxi-
phoid space to maintain contact.
To obtain a complete view of the heart, the US beam depth must
be increased beyond that typically used for most other cardiac and
abdominal imaging. To grasp the spatial orientation of this view,
bear in mind that the probe is aimed from the inferior aspect of
the heart. The US beam first traverses the left lobe of the liver, and
hence, liver tissue is seen at the top of the image (Figures 29-11B
& C). The plane of the beam then slices through the right-
sided chambers, the septum, and then the left-sided chambers
(Figures 29-11B & C). The echogenic pericardium is seen sur-
rounding the myocardium.
Adjustments in a number of planes may improve the quality of
the image. First, try to increase or decrease the steepness of the angle
of the probe. While the heart lies more to the patient’s left, so does
the stomach, which contains air that scatters the US beam. The liver,
on the other hand, serves as a good “acoustic window” or a transmit- A
ter of the beam allowing for better image acquisition. Taking advan-
tage of imaging through the liver often involves veering from just
right of midline, a slight counter clockwise rotation of the probe, Right
and angling toward the patient’s left shoulder. Ask the patient to take ventricle RV free
a deep breath to bring their heart inferiorly and into the scanning Interventricular wall
plane to improve the image. septum
PARASTERNAL LONG AXIS VIEW

Ascending
The parasternal long axis view may not be familiar to most EPs. It RCC aorta
often is easier to obtain, provides clearer images, and is better toler- AML NCC
ated by the patient. Place the probe to the left of the sternum, along Aortic
the long axis of the heart (Figure 29-12A). Hold the probe perpen- Left PML valve
dicular to the chest wall with the marker aimed toward the apex of ventricle
the heart or the PMI. This is roughly toward the patient’s left hip. LV posterior
Unfortunately, shadowing from bone and scattering from air in the Left
wall atrium
lung surrounds the heart. Place the probe between two ribs and just
lateral to the sternum, but not over lung tissue. The third or fourth Mitral
intercostal space affords the best view. valve
The right ventricle sits underneath the probe and is visualized in B
the near field of the screen (Figures 29-12B & C). This view also
provides an excellent glimpse into the left side of the heart. The left
ventricle lies beneath the right ventricle. The interventricular sep-
tum is well visualized and extends to the apex of the heart on the
left side of the screen. The base of the heart can be visualized on the
right side of the screen (Figure 29-12C). The left ventricle empties
into the aortic outflow tract, with the aortic valve and root usually RV
visible. The left atrium lies deep, and the mitral valve can be seen
opening into the left ventricle (Figures 29-12B & C). To visualize
the apex of the heart in the center of the screen, slide the probe in Ao
the direction of the marker (toward the PMI) and in the opposite
direction to the center of the base of the heart. The descending aorta LV
may be visualized in a transverse slice along the underside of the
heart and is an important landmark in distinguishing pericardial LA
from pleural fluid. Pericardial fluid collects posteriorly and will
appear as a black stripe separating the myocardium from the peri-
cardium and descending aorta (Figure 29-13). Pleural fluid, on the
other hand, will reside outside of the bright pericardium and tapers
to a stop at the descending aorta. C
Adjustments on the tilt of the probe may optimize the view. Place
the patient in the left lateral decubitus position to bring the heart FIGURE 29-12. The parasternal long axis view. A. Patient and probe position-
closer to the chest wall and improve the image. Slide the probe later- ing. B. Diagram of the US image. C. The US image. (Used with permission
ally, to a more cephalad intercostal space, or open its rotation with a from: Ma OJ, Mateer JM, Blaivas M: Emergency Ultrasound, 2nd ed. New York:
counter-clockwise turn to better optimize the view for patients with McGraw-Hill, 2008.)
CHF. Move the probe to a more caudal intercostal space, close the
angle of the probe with a clockwise rotation, or use the subxiphoid
view to better optimize the view for patients with emphysema and
an inferiorly displaced heart.
Pericardial
fluid
FIGURE 29-13. The parasternal long axis view of a pericardial effusion. Pericardial A
fluid separates the myocardium from the pericardium and the poorly visualized
descending aorta (white arrow).
PARASTERNAL SHORT AXIS VIEW

The parasternal short axis view slices through the heart transversely.
Place the probe similar to the parasternal long axis view, but with the
probe rotated 90° to rest along the heart’s short axis (Figure 29-14).
Aim the marker toward the patient’s right hip. The left ventricle
appears as a prominent circle in the center of the screen, with the
right ventricle resting atop it as a flatter or a crescent-shaped cham-
ber (Figures 29-14B & 29-15). Tilting or sliding the probe along
the heart’s long axis toward the patient’s left hip allows visualiza-
tion of the apex of the heart. Tilting or sliding the probe toward
the patient’s right shoulder allows visualization of the base of the
heart. The ventricles should cone down to a tip at the apex. When
tilting back up from the apex through the heart, the papillary mus-
cles (Figure 29-15) and mitral valve with its “fish-mouth” appear-
ance (Figure 29-16) will come into view. Continue tilting the probe
upward toward the base of the heart. The three leaflets of the aortic
valve will be seen centrally (Figure 29-17). At this point, the scan is
beyond the left ventricle, allowing the atria to be visualized as well as
the right ventricle emptying into the pulmonary artery.
B
APICAL FOUR-CHAMBER VIEW
The apical four-chamber view is obtained by placing the probe at the FIGURE 29-14. The parasternal short axis view. A. Patient and probe positioning.
PMI, just inferior to the left nipple and angling up through the heart B. Diagram of the three US views depending on probe angulation. (Used with
(Figure 29-18). Aim the marker toward the patient’s right. This study permission from: Ma OJ, Mateer JM, Blaivas M: Emergency Ultrasound, 2nd ed.
is relatively simple to perform by transitioning from the parasternal New York: McGraw-Hill, 2008.)
short axis view. Slide the probe down to the apex of the heart and
then tilt it upward toward the base of the heart (Figure 29-18A). The
image reveals a side-by-side view of the ventricles in the near field
and the atria in the far field (Figures 29-18B & C). The lung adja-
space, perpendicular to the patient’s abdominal wall and with the
cent to the heart impedes imaging. Place the patient in the left lateral
marker aimed toward the patient’s head (Figure 29-19A). The
decubitus position to alleviate scattering. The left ventricle appears
longitudinal IVC will appear posteriorly, beneath the liver and
larger and has thicker walls than the right ventricle. The mitral valve
the bowel, as a long black cylinder. It is important to distinguish
sits slightly lower than the tricuspid valve. Ventricular function, flow
the IVC from the aorta. The aorta lies on the patient’s left side,
across the valves, and septal defects can be assessed with this view.
is more “pipe-like” in appearance, is noncompressible when pres-
This view allows for comparing chamber size and evaluating for right
sure is applied by the US probe, and has a recognizable pulsatil-
ventricular dilatation if there is concern for an obstructive PE.
ity. The IVC is compressible when pressure is applied by the US
probe and varies in diameter with respiration (Figures 29-19C &
SUBCOSTAL INFERIOR VENA CAVA VIEW D). It may be beneficial to start in the transverse plane in which
Sonographic evaluation of the IVC can provide valuable hemo- both the IVC and the aorta are visualized (Figure 29-20). Starting
dynamic information to the EP.14,15 This view is also referred to as with the transverse view, rotate the US probe 90°, maintaining the
the subxiphoid long axis view. Place the probe in the subxiphoid IVC in the center of the screen to obtain the longitudinal view
Septum
Right ventricle Papillary muscles

T
RV
LV
Left ventricle
B
A
FIGURE 29-15. The parasternal short axis view at the level of the papillary muscles. A. Diagram of the US image. B. The US image. (Used with permission from: Ma OJ,
Mateer JM, Blaivas M: Emergency Ultrasound, 2nd ed. New York: McGraw-Hill, 2008.)
(Figure 29-19). Tilt the probe cephalad to visualize the IVC enter- cycle (Figure 29-19). M-Mode tracing of the respiratory cycle
ing the right atrium (Figures 29-19C & D). allows for precise measures of the inspiratory and expiratory IVC
Measurements of the IVC proximal to its entrance into the right diameters (Figure 29-21).
atrium allows for a noninvasive estimate of CVP. The negative pres-
sure generated in the chest by inspiration draws blood cephalad and US GUIDANCE FOR PERICARDIOCENTESIS
decreases the diameter of the IVC (Figures 29-19C & D). Normal
dimensions for the IVC include a diameter of 1.5 to 2.0 cm and US-guided pericardiocentesis has proven to be safe and is the
an inspiratory collapse of 50%.14,15 A smaller diameter and greater method of choice for most institutions.36 A brief description of the
inspiratory collapse are indicative of a low CVP.14–16 A larger diam- procedure is provided in this section. Please refer to Chapter 36 for
eter and lesser inspiratory collapse reflect a high CVP.14–16 Obtain the complete details regarding pericardiocentesis.
estimates by having the patient sniff deeply and freeze the image Emergent pericardiocentesis can be guided by US using either a
postinspiration. Use the cine-rewind feature on the US machine static or a dynamic approach. For the static approach, visualize the
to identify images or frames that allow for the measurement of effusion by US and determine the best approach for needle place-
the maximal and minimal IVC diameters through the respiratory ment. Remove the probe from the patient and proceed with the
Right
ventricle
Anterior leaflet
mitral valve
Posterior leaflet
mitral valve
B
A
FIGURE 29-16. The parasternal short axis view at the level of the mitral valve. A. Diagram of the US image. B. The US image. (Used with permission from: Ma OJ, Mateer
JM, Blaivas M: Emergency Ultrasound, 2nd ed. New York: McGraw-Hill, 2008.)
Tricuspid Right
valve ventricle
RV
RCC Pulmonary
NCC LCC valve
RA Ao V
Aortic valve PA
Right
NCC = noncoronary cusp
atrium
RCC = right-coronary cusp LA
LCC = left-coronary cusp
Left
atrium
B
A
FIGURE 29-17. The parasternal short axis view at the level of the base of the heart. A. Diagram of the US image. B. The US image. (Used with permission from: Ma OJ,
Mateer JM, Blaivas M: Emergency Ultrasound, 2nd ed. New York: McGraw-Hill, 2008.)
Apical four-Chamber view

Moderator Interventricular septum
band (septal wall)
LV lateral
wall
Right Left
ventricle ventricle
Tricuspid Mitral
valve valve
Pulmonary
vein (L lower)
A
Left
atrium
Right
atrium Pulmonary
vein (L upper)
Pulmonary
vein (R upper)
B
LV
RV
TV MV
RA
LA
FIGURE 29-18. The apical four-chamber view of the heart. A. Patient and probe
positioning. B. Diagram of the US image. C. The US image. (Used with permission
C from: Ma OJ, Mateer JM, Blaivas M: Emergency Ultrasound, 2nd ed. New York:
McGraw-Hill, 2008.)
Diaphragm
Hepatic
Right Liver vein
atrium
Inferior
vena cava
A
B
T T
RA
RA IVC
IVC
C D
FIGURE 29-19. The subcostal IVC view. A. Patient and probe positioning. B. Diagram of the US image. C. US of the IVC during expiration. D. Diagram of the IVC during
inspiration. (Used with permission from: Ma OJ, Mateer JM, Blaivas M: Emergency Ultrasound, 2nd ed. New York: McGraw-Hill, 2008.)
IVC Aorta
FIGURE 29-21. M-Mode tracing of the IVC. Respiratory variation is seen. The dark
FIGURE 29-20. The transverse IVC view. The IVC is located to the right of the stripe represents the diameter of the IVC over time. Measurements are taken at the
patient’s aorta. point of inspiratory collapse (white lines).
pericardiocentesis procedure. For the dynamic approach, the heart

is visualized throughout the procedure to guide needle placement.
Sterile technique is required for the US probe and cord. The availabil-
ity of a second ultrasonographer or an assistant for dynamic guidance
is helpful, particularly if an agitated-saline injection is attempted.
The pericardiocentesis site depends on the patient’s body habitus,
the location of the maximal visualized effusion, and the US views
obtainable. The two most common sites for needle insertion are the
subxiphoid space and left anterior parasternal chest wall.
For the static approach, visualize the path of needle penetration
with the corresponding US image. Measure the distance from the
top of the image to the pericardial space to determine the depth of
needle insertion. It is important to note that the liver is often visu-
alized in the anticipated needle trajectory with the subxiphoid US
view. Use the parasternal long axis view because the pericardium
is more superficial in this view. This author prefers the parasternal
long axis approach for these reasons. Proceed with the pericardio- A
centesis procedure.
For the dynamic approach, insert the needle directly adjacent to
the transducer. Angle the probe to interface with the plane of needle
insertion (Figure 29-22). Aim the US probe marker cephalad and
between the ribs to provide good visualization of the intercostal
space. Insert the needle over the superior edge of the rib and along
the plane of the US beam. It is optional to use color Doppler in the
near field to ensure the intercostal and internal mammary arteries
are not punctured. Advance the needle while aspirating with the
syringe as the needle is advanced. The pericardium may “tent” as the
echogenic needle presses upon it (Figure 29-23A) and then enters
the pericardial space (Figure 29-23B).
Injection of agitated saline may be attempted to confirm nee-
dle placement in the pericardial space. Agitate the saline by rap-
idly injecting saline back and forth from one syringe into another
through two ports of a three-way stopcock: with the third port
connected by sterile tubing to the pericardiocentesis needle. Once
microbubbles have formed, inject the agitated saline into the peri-
cardial space. The fluid will appear on US as a bright white scatter- B
ing within the pericardial sac.
FIGURE 29-23. Pericardiocentesis. A. The needle is visualized tenting (white
US GUIDANCE FOR CARDIAC PACING arrow) the anterior pericardium. A hazy pericardial effusion is present. B. The nee-
US can be used to confirm capture of transcutaneous (Chapter 31) dle is visualized within the pericardial fluid as a bright white point (white arrow).
or transvenous (Chapter 33) cardiac pacing.37,38 It is difficult to (Image courtesy of Jason Gookhul, MD.)
appreciate mechanical capture by simply looking for electrical
changes on the ECG monitor. Transcutaneous cardiac pacing dis-
charges often cause simultaneous jerking of the patient that masks a
palpable pulse. Cardiac US evaluation during cardiac pacing allows
visualization of mechanical contractions of the heart. During place-
ment of the transvenous cardiac pacing wire, it can be visualized
passing through the right atrium and tricuspid valve into the right
ventricle. A subcostal view of the IVC can confirm errant passage of
the wire down the IVC.
SUMMARY
Limited ED cardiac ultrasonography provides real-time informa-
tion to answer specific questions. It is not intended to replace formal
cardiac echocardiography. There is a body of evidence that shows
non-Cardiologists can accurately and safely perform limited cardiac
US exams. The use of cardiac US in the ED has risen from a few
basic examinations into a sophisticated series of exams in a very
short time. This chapter provides an introduction to ED cardiac
ultrasonography. The EP can become very comfortable with cardiac
US as a supplement to the evaluation and management of patients.
ED cardiac ultrasonography is a very valuable tool that can easily be
FIGURE 29-22. US probe and pericardiocentesis needle positioning. incorporated into the daily clinical practice of Emergency Medicine.
CHAPTER 30: Cardioversion and Defibrillation 193
different lead and/or increase the gain to determine if the cardiac

Cardioversion and rhythm is fine ventricular fibrillation or asystole. Ventricular fibril-
30 Defibrillation lation or ventricular tachycardia secondary to myocardial ischemia
or infarct, electrolyte abnormalities, long-QT syndromes, hypother-
mia, or drug toxicity (e.g., digoxin, tricyclic antidepressants, antiar-
Payman Sattar
rhythmics, antihistamine, and macrolide antibiotic combinations)
may convert to a more stable rhythm with defibrillation.
INTRODUCTION
The application of electricity to the heart induces depolarization of CONTRAINDICATIONS
the myocardial cells in a uniform fashion. This may interrupt reen-
try circuits that are inducing an arrhythmia. Once depolarization
of the myocardium has been achieved, the sinus node may then CARDIOVERSION
resume its normal pacing function. This is accomplished with the Cardioversion is contraindicated for several cardiac rhythms or
transthoracic application of a direct-current electrical shock. conditions. Do not cardiovert a patient with a rhythm of ectopic
The techniques of cardioversion and defibrillation are relatively atrial tachycardia, junctional tachycardia, multifocal atrial tachy-
straightforward and practically identical. The main differences cardia, sick sinus syndrome, or sinus tachycardia. Cardioversion is
are the indications and use of synchronization with cardioversion. not effective for these rhythms and may result in a worse (i.e., ven-
The purpose of cardioversion is to deliver a precisely timed tricular fibrillation or ventricular tachycardia) postshock rhythm.
electrical current to the heart to convert an organized rhythm Cardioversion of atrial fibrillation should not be attempted
to a more hemodynamically stable rhythm. The purpose of unless it is known with certainty that the rhythm initiated within
defibrillation is to deliver a randomly timed high-energy elec- the last 48 hours. Cardioversion of chronic atrial fibrillation, or
trical current to the heart to restore a normal sinus rhythm. atrial fibrillation having lasted longer than 48 hours, may dislodge
These techniques are currently performed by emergency medical atrial thrombi, resulting in thrombus embolization and end organ
technicians, nurses, paramedics, physicians, and a variety of other injury (e.g., stroke). There is some controversy in the literature
healthcare workers on a daily basis. This chapter discusses the regarding the cardioversion of atrial flutter greater than 48 hours
techniques of manual cardioversion and defibrillation. A discus- old without anticoagulation.3,4 In general, elective cardioversion of
sion of Advanced Cardiac Life Support (ACLS), cardiac rhythms, atrial flutter should not be performed if the rhythm has lasted for
chemical cardioversion, and Pediatric Advanced Life Support is longer than 48 hours. Often times, atrial fibrillation and flutter can
beyond the scope of this work. The technique of automatic exter- coexist. Do not cardiovert a patient with a known thrombus in
nal defibrillation is not discussed. the atria, atrial appendage, or ventricle without first consulting
a Cardiologist. Cardioversion in patients with digoxin toxicity
INDICATIONS should be avoided. Cardioversion in digoxin toxicity is usually
ineffective and has been associated with postshock ventricular
CARDIOVERSION tachycardia and ventricular fibrillation.5 Cardioversion is also con-
traindicated when the patient is without a pulse or has an underly-
In general, electrical cardioversion is performed either electively ing cardiac rhythm of asystole.
or emergently. In the Emergency Department, the role of electri- Alterations in the chemical or metabolic milieu of the myocar-
cal cardioversion is usually limited to urgent or emergent situations dium may cause subsidiary pacemakers to become more dominant
or when medical therapy has failed.1,2 This includes symptomatic and overtake the sinus mode. This is referred to as enhanced automa-
reentry tachycardias (e.g., supraventricular tachycardia, atrial fibril- ticity and can be due to drugs (e.g., digoxin), hypoxia, or electrolyte
lation, atrial flutter, and Wolff–Parkinson–White syndrome) and abnormalities (e.g., hypokalemia or hypomagnesemia). Uniform
hemodynamically stable ventricular tachycardia associated with depolarization with electricity does not terminate this abnormal-
acute myocardial infarctions, altered levels of consciousness, chest ity, as uniform depolarization already exists. The rhythms that may
pain, congestive heart failure, dizziness, dyspnea, hypotension, pre- occur are sinus tachycardia, ectopic atrial tachycardia, multifocal
syncope, pulmonary edema, shock, or syncope. atrial tachycardia, and the digoxin toxic rhythms. Treatment of the
In the Emergency Department, electrical cardioversion is often underlying etiology is the treatment of choice.
preferred to chemical cardioversion for many reasons. Electrical
cardioversion is simple and quick to perform. It is effective—in
most cases almost immediately. It may be more successful than
DEFIBRILLATION
chemical cardioversion. The complications are usually minimal. There are few contraindications to defibrillation. The main con-
Potential allergic reactions and toxic effects are nonexistent with traindication is in a patient who has made it clear that they does
electrical cardioversion. not wish to be resuscitated. Defibrillation should not be used for
arrhythmias other than ventricular tachycardia or ventricular
DEFIBRILLATION fibrillation.
Defibrillation is indicated when ventricular fibrillation or ven-
tricular tachycardia has not spontaneously converted to an orga- EQUIPMENT
nized rhythm. Ventricular fibrillation and ventricular tachycardia
are rarely spontaneously reversible and are not compatible with • Cardioverter-defibrillator unit
life. Defibrillation must be performed immediately if the patient • Conductive jelly or pads
is found pulseless, unconscious and apneic, or during the ACLS • Suction source, tubing, and catheter
protocol. “Fine” ventricular fibrillation can be present and may be
• Airway management supplies
confused with asystole. It may be secondary to low gain amplitude
or improper lead positioning. If “quick-look” paddles are being • Advanced Cardiac Life Support (ACLS) medications
used, they may be rotated 90°. If a monitor is being used, select a • Intravenous sedative agents
TABLE 30-2 Recommended Initial and Subsequent Monophasic

Energy Levels for Cardioversion or Defibrillation
Initial energy Subsequent energy
Cardiac rhythm setting settings*
Adults
Atrial fibrillation 100 J 200, 300, 360 J
Atrial flutter 50 J 100, 200, 300, 360 J
Supraventricular tachycardia 50 J 100, 200, 300, 360 J
Ventricular tachycardia 200 J 300, 360 J
Ventricular fibrillation 200 J 300, 360 J
Children
Supraventricular tachycardia 0.5 J/kg 1.0 J/kg
Ventricular tachycardia 2.0 J/kg 4.0 J/kg
Ventricular fibrillation 2.0 J/kg 4.0 J/kg
* To be performed sequentially in this order.
FIGURE 30-1. Two examples of cardioverter-defibrillator units. “quick-look” paddles). The depolarizer within the machine pro-
vides direct electric current for cardioversion and defibrillation.
The synchronizer permits the discharge of electric current based
on the patient’s ECG waveform. It searches for the R and S waves of
• Cardiac monitor the ECG tracing to determine the proper time to discharge the cur-
• Noninvasive blood pressure monitor rent. It avoids delivering the current during the repolarization phase
• Pulse oximeter of the myocardial action potential, when the heart may convert to
• Oxygen source and tubing ventricular fibrillation or ventricular tachycardia. When the opera-
tor pushes the button to discharge the unit, a brief delay is noted
• Nasal cannula or face mask to deliver oxygen while the synchronizer searches for an appropriate time to discharge
the current.
THE CARDIOVERTER-DEFIBRILLATOR UNIT
The typical cardioverter-defibrillator unit performs both cardiover- MONOPHASIC VERSUS BIPHASIC UNITS
sion and defibrillation (Figure 30-1). A list of available features on
In the past, all cardioverter-defibrillator units generated mono-
a typical unit is listed in Table 30-1. Newer models feature lower
phasic waveform current to deliver the shock. Biphasic wave-
power outputs to accommodate their use in children, pediatric and
form current generating units were developed in the late 1990s.
adult paddles, biphasic waveforms, and cardiac pacing capabilities.
The biphasic units deliver more current at a lower energy level
Each Emergency Physician should be familiar with the specific unit
to cardiovert or defibrillate (Tables 30-2 & 30-3). They have also
at their facility. The general features of the unit are discussed below.
been shown to be more effective in cardioverting and defibrillat-
The unit is self-contained. It plugs into a standard electrical out-
ing a patient. Unfortunately, biphasic units are significantly more
let. The unit also contains rechargeable batteries, which allow it to
expensive than monophasic units. Determine which type of unit is
be portable. An oscilloscope provides real-time monitoring of the
available at your facility to determine the proper energy levels to
patient’s cardiac rhythm. A continuous electrocardiographic (ECG)
administer.
rhythm strip providing documentation on paper is standard with
each unit, producing a hard copy to attach to the patient’s medi-
cal record. Numerous dials or electronic touchpads with digital TYPES OF ELECTRODES
displays allow the operator to set the working mode, energy level, The electrodes are referred to as either paddles or patches depend-
pacemaker settings, and oscilloscope input (e.g., ECG leads or ing on their configuration. The paddles or patches must be firmly
applied to the patient’s torso. They allow a “quick look” and transmit
TABLE 30-1 Characteristics of a Typical Cardioverter-Defibrillator Unit

Adult and pediatric paddles TABLE 30-3 Recommended Initial and Subsequent Zoll® Biphasic Energy
Cardioversion capability Levels for Cardioversion or Defibrillation
Continuous ECG rhythm-strip documentation on paper
Initial energy Subsequent energy
Defibrillator capability
Depolarizer Situation setting settings*
On/off switch Adults
Oscilloscope to monitor cardiac rhythms Defibrillation 120 J 150, 200, 200 J
Pacing capabilities Synchronized cardioversion 70 J † 120, 150, 150 J
Portability 75 J ‡
“Quick-look” paddles Children
Safety mechanism to prevent accidental electrical discharge Defibrillation 2.0 J/kg 2.0, 2.0, 2.0 J/kg
Synchronizer * To be performed sequentially in this order.
Standard ECG leads (three) to attach to the shoulders and lower extremity †
E Series.
Wide range of energy selection ‡
M Series, CCT, R Series.
CHAPTER 30: Cardioversion and Defibrillation 195
the patient’s cardiac rhythm to the oscilloscope, letting the operator

make medical decisions before the ECG leads are attached to the
patient. Each paddle has a button on which a thumb is to be placed.
This serves as a safety mechanism. Both buttons must be depressed
simultaneously to discharge the current. This prevents accidental
and premature discharge of current, which may injure the patient,
the operator, or bystanders. Most newer units use self-adhesive, sin-
gle patient use, disposable patches as an alternative to paddles. The
patches apply to the torso similar to ECG leads. They connect by
cables to the cardioverter-defibrillator unit.
Paddles or patches come in various shapes and sizes. Adult pad- FIGURE 30-3. Anteroposterior pad and paddle positioning.
dles or patches are round, oval, or rectangular in shape. They mea-
sure 8 to 10 cm in greatest diameter. They can be used on children
weighing more than 10 kg or over 1 year of age, adolescents, and over the second and third intercostal spaces. The lateral paddle or
adults. Pediatric paddles or patches also come in a variety of shapes patch is placed in the left midaxillary line centered over the fourth
and measure 4 to 6 cm in greatest diameter. The pediatric paddles and fifth intercostal spaces. Anteroposterior placement is often
are to be used in children weighing less than 10 kg or less than 1 year used with disposable patches rather than paddles (Figure 30-3).
of age. Some units contain both adult and pediatric paddles or the The anterior patch is centered over the sternum, and the posterior
ability to use both adult and pediatric patches. In these units, the patch is placed between the scapulae. A randomized and prospec-
adult electrode slides off the paddle handle to reveal the pediatric- tive trial evaluated the anteroposterior versus anterolateral patch
size electrode. position in converting atrial fibrillation.13 The anteroposterior patch
In choosing the proper paddle or patch for a small child, the cut- position was more effective in converting the rhythm. If pediatric
off of 10 kg and 1 year of age is relative. Choose the largest paddle paddles are required but not available, adult paddles can be sub-
or patch that will achieve complete and full contact with the child’s stituted.6 Roll the child onto their right side and place the paddles
chest wall. Larger paddles and patches will allow a greater amount in the anteroposterior position. Other paddle positions include the
of myocardium to be depolarized while decreasing the current den- laterolateral (axilla-to-axilla) position and the parasternal-infracla-
sity applied, so as to minimize myocardial injury. The paddles or vicular (oblique, left anterior chest to right posterior infrascapular)
patches must be at least 2 to 3 cm apart to prevent electrical bridg- position.7
ing and burn injury to the child. Using paddles or patches that are
too large will deliver the electric current over too great an area CONDUCTIVE CONTACT MEDIUM
and decrease its effectiveness. The opposite is true in adults (using
paddles or patches that are too small will deliver the electric cur- Electrically conductive contact medium should always be applied
rent over a small area, which makes it too intense and increases the between the electrode and the patient’s chest wall. Conductive
potential damage to the myocardium). gel pads are commercially available and primarily used. The con-
tact material helps to maximize current flow, minimize resistance,
ELECTRODE POSITIONING reduce transthoracic impedance, and prevent thermal or electrical
burns to the chest wall. The self-adhesive disposable patches are
The paddles or patches may be positioned in several different pat- prelubricated with contact medium and need no additional contact
terns.6,7,13 The most commonly used positions are anterolateral for medium.
paddles (Figure 30-2) and either anterolateral or anteroposterior Contact medium is required with the older units that use pad-
(Figure 30-3) for patches. Anterolateral paddles or patches are posi- dles. Self-adhesive, disposable conductive gel pads can be used. An
tioned with the anterior paddle at the right upper sternal border alternative is the gel or paste form of contact medium. The contact
medium should be applied to the paddles generously. It should not
connect the paddles, because then it would divert the electric cur-
rent along the chest wall, away from the heart, and cause burns to the
chest wall. If contact medium is not available, saline-soaked gauze
squares can be used in an emergency. The saline must be squeezed
out of the gauze squares to prevent the accumulation of liquid on the
chest wall, which could bridge the two paddles.
PATIENT PREPARATION
Place the patient supine on a bed. Attach the cardiac monitor, non-
invasive blood pressure monitor, pulse oximetry, and oxygen to the
patient. Obtain intravenous access. Suction and resuscitation equip-
ment should be readily available in case it is needed. Cardioversion
is scary and extremely uncomfortable for patients. Briefly explain
the procedure to the patient, including the risks, benefits, and com-
plications. Premedicate the patient prior to cardioversion if no con-
traindications exist, the patient is hemodynamically stable, and they
can tolerate a delay to cardioversion. The choice of the appropri-
ate sedative agent is physician-dependent. Commonly used agents
include etomidate, ketamine, midazolam, methohexital, propofol,
and thiopental. Diazepam and lorazepam are not often used because
FIGURE 30-2. Anterolateral pad and paddle positioning. of the long delay to onset of action.
TECHNIQUES burn. Continuously monitor the patient after they are cardioverted
or defibrillated. Almost all patients receiving cardioversion or defi-
Stand at the patient’s left side. Turn on the cardioverter-defibrillator brillation will be admitted to the hospital. Occasionally, a success-
unit. Set the display to the “quick-look” paddles. Instruct the nurses fully cardioverted patient may be discharged home. The decision
to apply the ECG leads to the patient. Grasp the left paddle (ster- to discharge the patient should be made in consultation with the
num) with the left hand and the right paddle (apex) with the right patients’ Primary Care Physician and a Cardiologist.
hand. This is the anterolateral paddle position. Apply the paddles
and observe the patient’s cardiac rhythm. Set the mode as asynchro- COMPLICATIONS
nous (defibrillation) or synchronous (cardioversion) based on the
patient’s cardiac rhythm. Set the energy level (Tables 30-2 & 30-3). Complications of cardioversion and defibrillation can range from
Older defibrillator units deliver monophasic waveform energy. none to death. Thermal and electrical burns are potential injuries.
Newer units deliver biphasic energy, which has been shown to be Skin burns may result, the severity of which increases depending on
more effective, and deliver more current at lower energy settings. the energy level utilized and the number of shocks delivered. Care
Apply conductive pads to the patient’s torso in the anterolateral must be taken to avoid contact between the ECG monitor leads and
position. Alternatively, apply conductive jelly to the paddles liber- the paddles, or of the paddles with each other, as sparks or fire may
ally and rub them together to coat the electrode surface completely. result. Burns can be minimized by utilizing electrically conduc-
Apply the paddles firmly to the torso in the anterolateral position. tive contact media and firmly applying the paddles to the patient.
The paddles should be separated from each other by at least 2 to Remove any fluid materials on the chest wall (i.e., conductive jelly,
3 cm to prevent arcing of the current and injury to the patient. saline, sweat, urine, and water), as they can form a bridge between
Prepare to deliver the electric current to the patient. Charge the the paddles or pads and result in arcing and thermal burns to the
paddles. This must be done on the unit or the paddles before the thorax. Also, remove any nitroglycerin patches or ointments from
initial and each subsequent discharge. It takes approximately 2 to the patient’s torso. Ensure that there are no open oxygen sources
5 seconds to charge the paddles following activation of the charge that could ignite when the unit is discharged. If performed properly,
button. Ensure that nurses and other assistants are not touch- repeated shocks will produce only a mild erythema to the chest wall.
ing the patient or the stretcher by saying “clear.” The assistant Systemic emboli may occur from clots in the left atrium becoming
ventilating through a bag-valve device attached to an endotra- dislodged if the underlying rhythm prior to the cardioversion or
cheal tube does not need to drop the bag, as plastic is noncon- defibrillation is atrial fibrillation.
ductive. Turn off any open oxygen sources during shock delivery. Occasionally hypertension, other arrhythmias, or heart block
The person who will deliver the charge to the patient should may develop. If a synchronized or nonsynchronized shock is deliv-
ensure that their body is not in direct contact with the patient ered on the T wave, ventricular fibrillation may result.9–11 This
or the stretcher. usually occurs immediately and can be corrected with an nonsyn-
Reevaluate the patient’s cardiac rhythm. If still required, deliver chronized countershock. Ensure that the unit is in synchronous
the charge by simultaneously pressing the discharge buttons on each mode, not asynchronous mode, when cardioverting an organized
paddle. Observe the monitor and reevaluate the patient’s cardiac cardiac rhythm. Always observe the monitor before delivering a
rhythm. The unit can be recharged to deliver another electric charge countershock to ensure that it is required. If the T wave is large,
to the patient if indicated. change the monitor lead so that the T wave is smaller than the
The technique using self-adhesive disposable patches on newer R wave and the unit will not cardiovert during a vulnerable period.
units is similar with a few exceptions. Apply the patches in the Ventricular fibrillation that occurs within 30 to 60 seconds after the
anteroposterior position. No supplemental contact medium is delivery of a synchronous shock is often due to digoxin toxicity and
required. The desired energy level is selected (Tables 30-2 & 30-3). is difficult or impossible to correct. Transient ST-segment elevation
Charge the cardioverter-defibrillator unit by pressing the charge may occur.12
button on the unit. Press the discharge button on the cardioverter- Creatine kinase enzyme elevations may occur, most being skeletal
defibrillator unit to deliver the charge to the patient. Again reevalu- muscle in origin.10 Cardiac enzymes can also become elevated. The
ate the need for further therapies as above. higher the energy level used and the more countershocks given, the
Occasionally, the cardioverter-defibrillator unit may not deliver greater the muscle damage that may result. Usually, no significant
a shock. Check that the unit is plugged in, no touching or bridging permanent myocardial damage occurs.
of the pads or gel has occurred on the patient’s chest, and that the Do not apply the paddles or patches directly over an implanted
paddles are charged. The cardioverter-defibrillator unit may not be defibrillator or pacemaker. The electric discharge can permanently
able to properly sense the R-wave in synchronization mode with a damage these devices. Adjust the paddle or patch position so they
rapid supraventricular rhythm. Reattempt to deliver the shock by are not directly over these devices.
holding down the discharge button for 15 seconds. This will give Avoid injury to yourself or others by ensuring that no one is
the cardioverter-defibrillator unit more time to determine and find in contact with the bed or the patient when the shock is adminis-
a proper time to deliver the shock. Switching to asynchronous mode tered. Such injuries can range from mild shocks and burns to car-
will allow the delivery of the shock, but risks shocking at the inap- diac dysrhythmias. An improperly functioning unit can cause injury
propriate time and converting the rhythm to ventricular tachycardia despite being used properly. Periodic maintenance and calibration
or ventricular fibrillation. Consider intravenous medication to slow of the unit is necessary.
the heart rate or chemically convert the rhythm rather than applying
an asynchronous shock. SUMMARY
AFTERCARE Cardioversion and defibrillation are the processes of applying elec-
tric current to a patient’s chest to terminate a dysrhythmia.
No specific aftercare is required related to the procedure of cardio- Cardioversion is a safe and effective method of converting reentry
version or defibrillation. If using a cardioverter-defibrillator unit arrhythmias. If the patient is stable, a trial of medical therapy is
with paddles and conductive gel or paste, it is possible to cause a warranted. If the patient is “unstable,” cardioversion should be
thermal burn to the skin. This should be treated as any other skin initiated as soon as possible. Consider administering parenteral
CHAPTER 31: Transcutaneous Cardiac Pacing 197
sedation, as cardioversion is anxiety-provoking and painful for the ANATOMY AND PATHOPHYSIOLOGY
patient. Cardioversion should be performed in the synchronized
mode. Always be prepared for ventricular fibrillation or ventricu- In the normal heart, electrical impulses originating in the sinoatrial
lar tachycardia as a result of cardioversion of an organized rhythm. (SA) node create an action potential that is conducted along the
ACLS medications and airway support must be readily available. intrinsic cardiac nerve pathways to the atrioventricular (AV) node
Defibrillation is essentially cardioversion of unstable ventricular and disseminated through the His-Purkinje system. This action
tachycardia or ventricular fibrillation. It is performed like cardio- potential stimulates electrolyte flux, myocardial muscle depolariza-
version except that synchronization and sedation are not required. tion, and subsequent cardiac muscle contraction. Electrical propa-
gation and myocardial contraction occur separately in the atria and
ventricles, with the atria contracting slightly ahead of the ventricles
during ventricular diastole. This timing delay assists in filling the
ventricles prior to their next ventricular systolic phase. The intrinsic
heart rate is controlled by a balance of input from the sympathetic
Transcutaneous
31 Cardiac Pacing
nervous system acting directly on the cardiac muscle and the para-
sympathetic nervous system acting most prominently at the SA and
AV nodes.
Todd M. Larabee The intrinsic heart rate can be disrupted due to a wide variety of
disease processes. The usual blood supply for the SA node is from
INTRODUCTION an early branch of the right coronary artery. Coronary artery disease
can disrupt blood flow and oxygen supply to the myocardium, creat-
First documented as a technique in 1872, transcutaneous cardiac ing areas of cardiac ischemia that affects the conduction system, the
pacing (TCP) was successfully demonstrated in two patients with impulse production, or conduction at the SA and AV nodes. Cardiac
underlying cardiac disease and symptomatic bradycardia by Paul ischemia can result in action potential conduction delays and heart
Zoll in 1952.1 Studies involving open-chest and transvenous pac- blocks, with resultant symptoms in the patient of bradycardia and
ing, as well as open-chest cardiac massage, were occurring simul- hypotension. Electrolyte disturbances (e.g., hyperkalemia), struc-
taneously by other groups. Zoll recognized the clinical difficulty of tural heart disease, drug toxicity (e.g., calcium channel blockers and
these approaches for the treatment of “ventricular standstill” in an β-blockers), systemic toxins (e.g., cyanide), or systemic hypother-
emergent setting.1,2 Zoll and colleagues performed animal experi- mia are other causes of intrinsic conduction delays and heart blocks
ments using electrodes placed in various positions prior to the use that can be considered in the differential diagnosis.
of subcutaneous needle electrodes at points “in a line transversing TCP delivers an extrinsic electrical impulse that overrides the
the ventricles” as described in the initial case report.1 In 1956, they intrinsic cardiac action potential. Initial pulse durations used were
described the use of their procedure during eight surgical cases in short at 1 to 2 milliseconds (ms). They have now been extended
which cardiac arrest occurred, with five patients successfully surviv- to 20 to 40 ms to decrease the threshold current or the current
ing to discharge.2 At this time, cardiac monitoring during surgery needed for cardiac muscle stimulation. The longer pulse duration
was not routinely performed, thus the underlying rhythm being also decreases patient comfort, as it is the degree of skeletal muscle
paced was not specifically determined in all reported cases. contraction generated by the TCP pulse that determines patient dis-
Further work related to TCP seems to have lapsed until the 1980s, comfort.8 Most TCP devices can generate up to 200 milliamps (mA)
when several groups studied the technique for treatment of symp- of current, while mean pacing currents needed to obtain capture
tomatic bradycardias, asystolic cardiac arrest, and bradyasystolic have been shown to range from 40 to 100 mA.8–11
cardiac arrest both in-hospital and in the Emergency Department.
The results of these investigations were summarized by Hedges INDICATIONS
et al.3 They concluded that TCP is as successful as transvenous car-
diac pacing in obtaining electrical and mechanical capture in brady- Transcutaneous cardiac pacing is technically the fastest and easi-
asystolic arrests. TCP was easier to initiate than transvenous cardiac est method of emergency cardiac pacing. It is a temporary inter-
pacing. However, TCP did not improve the overall survival rates for vention prior to implementation of transvenous cardiac pacing
these patients.3 or placement of a permanent cardiac pacemaker for primary car-
TCP was recommended for cardiac emergencies by the diac dysfunction or until the underlying etiology of the bradycar-
International Liaison Committee on Resuscitation (ILCOR) guide- dia can be reversed. It is indicated for patients with symptomatic
lines beginning in 1980, and is currently recommended for treat- bradycardia from any etiology in whom pharmacologic interven-
ment of symptomatic bradycardias, especially when the conduction tions such as atropine have been unsuccessful. It can be effectively
block is at or below the His-Purkinje level.4,5 TCP is no longer indi- applied in the prehospital setting by EMS personnel, in a clinic, in
cated for the treatment of asystolic cardiac arrest as there are no the Emergency Department, or in the hospital. In patients with
improvements in the rate of hospital admission or survival to hospi- bradyarrhythmias that are expected to be transient (e.g., digoxin
tal discharge in this setting.5–7 toxicity or AV block in the setting of an inferior wall myocardial
With current technology and equipment, TCP offers several infarction), TCP is quick, simple, and not associated with the mor-
advantages when compared to the placement of a transvenous bidity or mortality of transvenous cardiac pacing.
cardiac pacemaker in the Emergency Department. The procedure It is indicated in patients with AV conduction blocks and sinus
requires minimal training and can be performed quickly. TCP is a node dysfunction. It should be performed in symptomatic patients
noninvasive procedure and is not associated with the major compli- (e.g., syncope, presyncope, dizziness, fatigue, etc.) with complete
cations of placing a transvenous cardiac pacemaker. This includes or third-degree AV block, asystolic pauses exceeding 3 seconds, or
inadvertent arterial puncture, hemorrhage, pneumothorax, or car- an escape pacemaker rate less than 40 beats per minute. Patients
diac tamponade from cardiac rupture. TCP is an ideal early and with type I or type II second-degree AV block who are symptom-
temporary intervention for patients requiring stabilizing cardiac atic should be transcutaneously paced. Symptomatic bifascicular
pacing support until more invasive procedures can be arranged block is also an indication for temporary TCP. Patients with sinus
in the proper clinical setting. node dysfunction are candidates for pacing. Sinus node dysfunction
includes sinus pause with symptoms of cerebral hypoperfusion

(e.g., syncope, presyncope, and dizziness), chronic sinus node dys-
function with or without symptoms but with escape rates of less
than 40 beats per minute, or symptomatic sinus bradycardia.
TCP electrodes should be placed on patients in anticipation
of potential clinical deterioration and bradyarrhythmias in the
appropriate setting.10 For example, a patient with a β-blocker over-
dose may present with a slow or normal heart rate but are otherwise
asymptomatic. In this clinical scenario, hemodynamic deteriora-
tion is possible. Preparation for TCP (i.e., electrodes applied and
connected to a generator unit, unit in standby mode, etc.) can be
easily accomplished while further efforts related to the diagnosis
and treatment are undertaken. If the patient develops bradyarrhyth-
mias, the transcutaneous pacer can be immediately activated with-
out the delays associated with obtaining the equipment and setting
up the system.
TCP can also be used for overdrive cardiac pacing in event of a FIGURE 31-1. The cardiac monitor/defibrillator with TCP capabilities and attached
supraventricular or ventricular tachydysrhythmia such as ventricu- surface patches.
lar tachycardia, torsade de pointes, or paroxysmal supraventricular
tachycardia in the patient who is clinically stable.12–15 A major limi-
tation to overdrive cardiac pacing would be the maximum rate that
the pulse generating unit can achieve. The technique requires pac- and cardiac pacer with an associated ECG monitor. (Figure 31-1)
ing the patient at a rate of 20 to 60 beats per minute faster than the The unit is usually available on all code carts in the Emergency
tachydysrhythmia.14 Patients do not usually tolerate transcutaneous Department and throughout the hospital. The Emergency Physician
overdrive pacing due to the accompanying chest wall contractions should become familiar with their specific institutional equipment
and discomfort. The transvenous or transthoracic routes are pre- prior to an emergent situation requiring its use.
ferred for overdrive pacing of the myocardium. The pacing patches are either round or rectangular, and come
packaged as pairs with illustrations to demonstrate proper place-
CONTRAINDICATIONS ment of the electrode (Figure 31-2). The negative electrode will
be labeled “front” or “apex.” The positive electrode may be labeled
There are no absolute contraindications to TCP. Hypothermia has “back” or “posterior.” Most modern TCP electrodes are disposable,
been considered a relative contraindication to TCP. The associated single patient use, and multipurpose. The one electrode can be used
bradycardia seen during hypothermia is thought to be a result of to perform cardioversion, defibrillation, ECG monitoring, and TCP.
direct myocardial depression and decreased metabolic rate.16,17 Some older units may not have this flexibility and require separate
Concerns related to ventricular irritability, dysrhythmias, and resis- ECG leads.
tance to defibrillation have led to the idea that electrical manipu-
lation of the hypothermic myocardium should be avoided.18 There
are, however, case reports of successful TCP use during rewarm-
PATIENT PREPARATION
ing for severe hypothermia.19 TCP is also relatively contraindicated If time allows, discuss the procedure with the patient and/or their
for prolonged bradyasystolic cardiac arrest due to the overall poor representative. This should include the reason for performing the
resuscitation rates and outcomes of these patients.6,7,10 TCP is no procedure, the risks of the procedure including pain-related issues
longer indicated for the treatment of asystolic cardiac arrest as there and how pain will be addressed, and the benefits of the proce-
are no improvements in the rates of hospital admission or survival dure including expected symptom improvement. There is a small
to hospital discharge in this setting.10 risk of developing a ventricular tachydysrhythmia during TCP.20
EQUIPMENT
• Pulse generator and monitor unit
• Pacing cable attached to the monitor
• Pacemaker patches or electrodes:
▶ 6 × 7 cm2 for infants and young children
▶ 13 × 15 cm2 for older children and adult
• ECG patches or electrodes (if pacemaker patches and unit do not

monitor patient)
• ECG cable attached to cardiac monitor (if pacemaker patches and
unit do not monitor the patient)
• Intravenous access supplies
• Sedative and analgesic medications
• Skin razor
Most commercially available cardiac defibrillators used in the FIGURE 31-2. TCP electrodes with diagrams demonstrating placement on the
Emergency Department are a combination cardioverter, defibrillator, electrode.
A B C
FIGURE 31-3. Placement of TCP electrodes. A. Anterior (negative) electrode placed over the cardiac apex. B. Anterior (negative) electrode position centered over the
V3 lead position. C. Posterior (positive) electrode position.
A written and signed consent documenting this conversation is current output by 5 to 10 mA at a time until capture is achieved
always preferred. However, it is not required in an emergent situ- (Figure 31-6). Note the mA output value that is required to initiate
ation. Documentation of the conversation in the medical record TCP. This is known as the threshold current. Increase the output
should be adequate in an emergent situation. Preparation for trans- current approximately 10%, or 5 to 10 mA, above the threshold cur-
venous cardiac pacing (Chapter 33) can be simultaneously under- rent. Maintain the output current at this level.
taken in the event that TCP is unsuccessful. In the near-arrest or unconscious patient, start with the output
The patient’s skin should be relatively clean and free of debris. current set at maximum. Turn the unit on. Dial the output current
Warm, soapy water can be used as a cleansing agent. Avoid poten- down until capture is lost. This is the threshold current. Raise the
tially flammable cleansing solvents such as alcohol-based solutions. output to restore capture. Increase the output current approximately
The skin should be dry. Trim the patients back and chest hair if 10%, or 5 to 10 mA, above the threshold current. Maintain the out-
the patient is hirsute and the pacing patches are poorly adherent. put current at this level.
Trimming is preferred to shaving to avoid skin disruption or abra- Some pacer/monitor units can operate in a “standby mode.” This
sions that may cause increased pain, skin irritation, and bacteremia mode can be used for patients who are at risk of developing symp-
during the procedure. If shaving is required, and pacing is not emer- tomatic bradycardia, but who are currently clinically stable. Set the
gently required, first apply povidone iodine or chlorhexidine to the unit to “pacing mode.” Attach the pacer electrodes to the patient
area and allow it to dry. This will decontaminate the skin prior to and the unit. Initiate a brief period of TCP at a rate slightly faster
shaving. than the patient’s intrinsic rate to determine the threshold current
Administer sedative and analgesic medications to manage the and if capture is possible. Turn the unit off. Set a reduced rate on
discomfort related to the chest wall skeletal muscle contractions the pacer dial. This rate should be below the patient’s current heart
associated with TCP.20 Pain levels associated with TCP were found rate but also be the minimal heart rate acceptable to the Emergency
to be moderate to moderately severe (mean of 3.2 on a five-point Physician for the patient. Switch the unit to “standby mode” and
scale) in 30 healthy volunteers.11 One volunteer quit the study due to turn it on. If the patient’s heart rate falls below the value set on the
the severity of the pain. unit, the pacer function will automatically engage.
TECHNIQUES OVERDRIVE PACING

When performing overdrive TCP, full cardiac resuscitation
PAD PLACEMENT
equipment should be available and ready at the bedside, as
Two pacing electrodes must be applied to the thorax (Figure 31-2). rhythm acceleration and subsequent hemodynamic instability
Place the front, anterior, or negative labelled electrode on the anterior are possible. The pacer electrodes and pacing unit setup remain
chest wall, and centered over the apex of the heart (Figure 31-3A) the same to perform overdrive TCP for a tachydysrhythmia.
or over the V3 lead position (Figure 31-3B). In females, the anterior
electrode should be positioned by lifting the breast and placing it
under the fold of the breast and against the chest wall. Place the back,
posterior, or positive labelled electrode directly behind the anterior
electrode and to the left of the thoracic spine, between the spine and
the scapula (Figure 31-3C). Avoid trapping air or debris under the
pad during placement. As an alternative, the positive electrode may
be placed on the right upper chest and the negative electrode over
the apex of the heart (Figure 31-4).
PACING
Once the pacing electrodes are positioned, connect the cable from
the electrodes to the pacer/monitor unit. Turn the output current
(mA) dial as low as possible (Figure 31-5). Set the pacing rate FIGURE 31-4. Alternative transcutaneous pacing electrode positions. The negative
between 80 and 90 beats per minute. Select the pacer function of electrode is positioned over the cardiac apex. The positive electrode is positioned
the pacer/monitor unit. Turn the unit on. Gradually increase the on the right anterior chest wall.
Administer sedative and analgesic medications as required. Set

the current output at 120 mA, as this current generally will exceed
the threshold value for most patients. Turn on the unit and ini-
tiate asynchronous cardiac pacing at a rate of 20 to 60 beats per
minute higher than the intrinsic rate of the tachydysrhythmia.14
Once capture is achieved, decrease the current output to just above
the threshold current. Slowly lower the pacing rate to decrease the
patient’s heart rate to the desired level. TCP for overdrive pacing
may not be possible due to the upper heart rate limit of the avail-
able pacing unit.
PACING PEDIATRIC PATIENTS

There is limited data available on the use of TCP in the pediatric
population. The indications for the procedure, however, are the
same as those in adults. The technique used to accomplish TCP
is the same as in an adult. TCP is often more effective in children
because their smaller chest wall results in a lower transthoracic
resistance to the pacing current.
There are, however, special considerations when performing TCP
in the pediatric population. TCP was undertaken in newborns with
complete AV node block.21 This small case series of two patients,
as well as others, documented significant thermal injury to the
underlying skin.21,22 This was most likely related to the newborn’s
thin and fragile skin. Increased monitoring of the skin surround-
ing the electrodes is mandatory in children, especially in cases of
prolonged TCP. Pediatric-sized transcutaneous pacing electrodes
are available and should be used to limit surface contact. One
study comparing the use of adult versus two specially sized pediat-
ric electrodes for TCP demonstrated a lower mean current output
with the smaller pads (63 mA vs. 51 to 53 mA).23 Appropriately
FIGURE 31-5. Monitor dials demonstrating separate defibrillation and pacing func- sized electrodes are available for children under 15 kg (33 lbs) and
tions; also demonstrating electrical current (mA) and heart rate dials to set for TCP. should be used.
FIGURE 31-6. Assessing electrocardiographic capture with transcutaneous pacing. A. Intrinsic patient bradycardic rhythm. B. No electrical capture as TCP is below the
threshold level. C. TCP with electrical capture.
Only one study has documented the outcomes of TCP in pedi- healthy individuals or in patients with minimal hemodynamic com-
atric out-of-hospital cardiac arrest.24 In six drowning victims and promise. In these settings, the threshold is usually in the range of
three sudden infant death syndrome patients who received TCP by 40 to 80 mA.10,28 Most patients are paced using a current in the range
EMS providers, only two patients achieved electrical and mechani- of 20 to 140 mA.10 No clear correlation has been established between
cal capture, both with an initial rhythm of asystole. In total, seven the pacing threshold and patient age, weight, body size, chest diam-
patients presented with asystole and two patients presented with eter, or etiology of heart disease.10,29,30 However, thresholds are usu-
ventricular fibrillation. Only one patient, with an initial rhythm of ally elevated following thoracic surgery or in patients with COPD,
asystole, survived to hospital discharge but was severely neurologi- a pneumothorax, a pericardial effusion, heavy thoracic chest wall
cally impaired and died 6 months later. Further study in this area is musculature, and after positive-pressure ventilation.10
warranted. Success rates in achieving ventricular capture vary widely depend-
ing on the setting where TCP is being used. Success rates appear
ASSESSMENT OF SUCCESSFUL PACING to be highest when TCP is used prophylactically or early (within
5 minutes of bradycardic arrest). In these settings, success rates may
The Emergency Physician must assess the patient for both electri- exceed 90%.10 Zoll et al. reported a 78% success rate in diverse clini-
cal capture and associated mechanical capture when considering cal situations.10 The time to the initiation of TCP largely determines
whether or not the procedure was successful. Successful capture is the success rate. With prolonged pacing, there can be changes in
usually characterized by a wide QRS complex, since it is ventricular pacing threshold leading to capture failure. Failure to capture may
in origin, and a broad T wave. It is easy to mistake the wide, slurred be encountered due to a variety of reasons.
afterpotential following an external pacing spike for electrical cap- Ultrasound has been used as a method to confirm electrical and
ture. Electrical capture is best judged by the presence of a con- mechanical capture.25,31,32 Use ultrasound to determine the ventricu-
sistent ST segment and T wave after each generated pacer spike lar contraction rate. The patient will have a heart rate that is exactly
(Figure 31-6C). Paced beats below the patient’s intrinsic cardiac rate equal to that of the set paced rate if mechanical capture is achieved.
may not produce an associated QRS complex (Figure 31-6B), and This eliminates the artifact seen on the ECG monitor from chest
electrical capture is not achieved. In this situation, the pacing rate wall muscle contractions. Refer to Chapter 29 for the complete
must be increased to achieve capture. Table 31-1 discusses common details of cardiac ultrasonography.
causes of failure to capture and suggested solutions.
Once electrical capture is achieved, mechanical capture must be
AFTERCARE
ensured by either a palpable pulse rate or arterial catheter blood
pressure monitoring. The patient will have a pulse rate that is The most important assessment in the aftercare period is to ensure
exactly equal to that of the paced rhythm on the cardiac monitor continuous electrical and mechanical capture. This should be
if mechanical capture is achieved. Assess the pulse using palpation accomplished by frequent checks of the cardiac monitor, palpation
of the carotid or femoral artery to avoid confusion with skeletal of a pulse, and measurement of a blood pressure. This is more eas-
muscle contractions generated by the pacing current. If the palpated ily established using an arterial line. Threshold current values can
pulse rate is less than that of the paced rate, mechanical capture has change with prolonged TCP. The system can be somewhat tenuous
not been achieved. Increase the threshold current. Mechanical cap- in practical use, so frequent checks are advisable. Insert a transve-
ture is also achieved when the invasive arterial blood pressure line nous cardiac pacer in the Emergency Department or make arrange-
demonstrates a pulse rate that is exactly equal to that of the paced ments with a Cardiologist to place one in the catheterization lab if
rhythm on the cardiac monitor. the patient requires prolonged TCP.
Threshold current values will vary depending on the clinical Patient comfort must be continuously re-assessed. Pain can be
situation. Transcutaneous pacing thresholds tend to be lowest in due to chest wall muscle contractions or other causes (Table 31-2).
Do not assume that pain is from chest wall muscle contractions
until other etiologies are ruled out. Repeated doses of sedative and/
or analgesics may be required to ease the discomfort of chest wall
TABLE 31-1 Common Causes of Failure to Capture and muscle contractions. Periodically assess the skin under the elec-
Suggested Solutions trodes for burns or damage. Reposition the electrodes if skin ery-
Etiology Solution thema or any sign of a burn is present. This is especially important
Suboptimal electrode Reposition electrodes, avoiding the spine,
placement scapula, and sternum
Negative electrode placed Place negative electrode anteriorly over the
TABLE 31-2 Causes of Painful Transcutaneous Pacing and
posteriorly cardiac apex or the V3 lead position Suggested Solutions
Poor skin-electrode contact Clean skin of sweat and debris; dry skin
thoroughly; trim hair Etiology Solution
Faulty electrical contact Check electrical connections Conductive foreign body beneath Remove foreign body
Generator battery depletion Change battery; plug generator into an electrode
electric outlet Electrode over skin abrasions Reposition electrodes; avoid shaving
Increased intrathoracic air Reduce positive-pressure ventilation; relieve (shaved) beneath electrodes
pneumothorax Apprehensive patient or low pain Administer parenteral narcotics and/or
Pericardial effusion Pericardiocentesis; pericardial window tolerance benzodiazepines
Myocardial ischemia/ CPR; ventilation; correct acidosis; correct Sweat or salt deposits, saline, Cleanse and dry skin
metabolic derangement hypoxia; correct electrolyte abnormalities conductive jelly, blood, or
High threshold Use stimuli of longer pulse width; shave hair vomitus on skin
for improved pad attachment; apply pressure High threshold to pacing Use longer pulse-width stimuli
to pads; apply pads with fresh gel Thoracic wall muscle contractions IV sedation and/or analgesics
Modified from: Ellenbogen KA, Wood MA: Cardiac Pacing and ICDs, 5th ed. Modified from: Ellenbogen KA, Wood MA: Cardiac Pacing and ICDs, 5th ed.
Oxford: Blackwell, 2008. Oxford: Blackwell, 2008.
in patients who are young children, unconscious, or have altered directly to heart muscle.5 Zoll accomplished the first successful clin-
mental status as they cannot complain of pain. ical application of external cardiac pacing in 1952 by resuscitating
two patients in asystole following bradycardia from a high-degree
COMPLICATIONS AV block.6 He concluded that external cardiac pacing was a safe and
effective means of resuscitating ventricular standstill. Unfortunately,
There are few major complications related to this procedure. One Zoll’s devices caused significant chest pain, skeletal muscle spasm,
of the most important complications to consider is the failure superficial skin burns, and disrupted electrocardiographic patient
to recognize underlying rhythm changes in the patient or loss of monitoring.6 The quest for alternative pacing modalities continued
electrical or mechanical capture once the procedure is completed. with the refinement of the transesophageal technique, initially sug-
A rhythm change to ventricular fibrillation is easy to miss and can gested by Zoll in 1952, and clinically demonstrated by Shafiroff and
be ascribed to pacing artifacts and chest wall muscle contraction. Linder in 1957.7 In 1958, Thevenet et al. reported the emergency use
These complications are mitigated by close patient and monitor sur- of a lumbar puncture needle introduced 5 mm into the myocardium,
veillance during TCP. Tachydysrhythmias related to TCP have been through which a conducting wire was introduced, to produce trans-
documented, but the overall risk for this complication is considered thoracic cardiac pacing.8 In 1959, Furman and Robinson passed a
small.14 Myocardial damage from TCP has been examined in ani- transvenous wire catheter and successfully applied an electrical cur-
mals and humans without significant findings.2,26,27 Thermal injury rent to the endocardial surface of the right atrium.9 Transvenous
to the skin from the electrodes is a known complication, especially pacing subsequently became the most widely accepted method of
in situations of prolonged TCP, but can be minimized with careful emergency cardiac pacing until the reemergence of Zoll with a mod-
observation and electrode adjustments. Pain is the most commonly ified external pacing system in 1981.10
reported complication (Table 31-2) and needs to be continually
addressed. The most common etiology of the pain is from chest wall ANATOMY AND PATHOPHYSIOLOGY
muscle contractions.
The heart is the only muscle of the body that generates its own elec-
trical impulses. The initial cardiac impulse starts in the right atrium
SUMMARY of the heart at the sinoatrial (SA) node. The sympathetic and para-
TCP is a temporary method of cardiac pacing in patients with severe sympathetic nervous system controls the rate of impulse generation
symptomatic bradyarrhythmias due to high-grade AV blocks, sinus at the SA node. Once the electrical stimulus is generated, it is con-
node dysfunction, bradyasystolic cardiac arrest, or rarely for over- ducted along the internal conduction pathways of the heart to the
drive pacing to suppress ventricular and supraventricular tachyar- muscular atrial and ventricular walls. A delicate balance between
rhythmias. It is comparatively easy to perform and requires minimal electrolyte flux to create action potentials, myocardial integrity
training. Once capture is achieved, the current output should be to allow impulses to become contractions, and an intact conduc-
set at a level slightly higher (5-10 mA) than the pacing thresh- tion system must be maintained. The blood supply to the conduc-
old. Successful TCP can be established in 80% to 90% of patients. tion system of the heart originates from the right coronary artery.
Discomfort and pain due to muscle contraction are the most com- Arrhythmias and conduction delays are often the result of inade-
mon side effects. Most patients will require sedation and/or analge- quate blood flow to the heart due to ventricular infarction and coro-
sics to tolerate TCP for a significant length of time. nary artery occlusion.
INDICATIONS
Considering the proven efficiency and efficacy of transcutaneous
pacing modalities, the indications for transthoracic pacing appear
Transthoracic extremely limited. Preston estimated a 40% success rate in achieving
32 Cardiac Pacing pacing by the transthoracic route.11 Transcutaneous pacing success
rates of greater than 80% have been routinely demonstrated.12
Simon M. Pulfrey Transthoracic cardiac pacing is a simple procedure and can be
accomplished rapidly. Transthoracic pacing should be reserved for
clinical situations where there is no transcutaneous pacing avail-
INTRODUCTION
able, or when transcutaneous pacing in the perimorbid patient
Transthoracic cardiac pacing is a historic technique of pacing the has been unsuccessful and the placement of a transvenous pacer
heart with an electrode introduced percutaneously into the ventric- is thought to be too time consuming.13,14
ular cavity using a needle trocar introducer. There is sparse literature Unstable bradydysrhythmia is the obvious indication for emer-
on transthoracic cardiac pacing, and the benefits and complications gency cardiac pacing. Several case reports document successful
are not well defined. Before the advent of effective and efficient transthoracic pacing intervention in two patients with asystolic
transcutaneous pacing, transthoracic pacing was a faster alterna- arrest.1 Other studies document successful pacing out of asystole
tive to transvenous pacing in the patient with an acutely unstable in patients with in situ pacemakers.15 A more recent and prospec-
dysrhythmia. Presently, the indications for transthoracic pacing are tively designed study of approximately 300 patients with witnessed
extremely rare. The technique of transthoracic pacing is included in or early asystole demonstrated no improved outcome with early
this text as it is occasionally performed in situations where transcu- transcutaneous pacing intervention by first response emergency
taneous pacing is unavailable or ineffective.1–3 medical personnel.16 It can be concluded that although emergency
The history of electrical stimulation of the heart dates back to transthoracic cardiac pacing has a very low success rate in asystole,
1862 when Walsh discussed the possibility of causing the heart to the procedure may be lifesaving in the rare case.
contract through stimulation of the sympathetic nervous trunk by Transthoracic cardiac pacing would be most effective following
an induced current.4 By 1910, it was largely understood that the cardiac arrest from primary cardiac disease.13 Transthoracic cardiac
neuromuscular mechanism of the heart was electrically dependant. pacing may not be effective in cardiac arrest secondary to hypovo-
In 1932, Hyman used a needle electrode to carry stimulating current lemia (e.g., trauma), severe electrolyte or acid–base abnormalities,
CHAPTER 32: Transthoracic Cardiac Pacing 203
sepsis, or drug intoxication. Transthoracic cardiac pacing may be connector that accepts the pacing wire and can be attached to a
lifesaving when bradycardia or asystole secondary to prolonged battery-powered external pacemaker generator. The cannula and
ischemia during hypovolemic shock persists despite correction of trocar function as a catheter-over-the-needle.
the underlying pathology.
The use of transthoracic cardiac pacing in unstable patients is PATIENT PREPARATION
more controversial. Transthoracic cardiac pacing may be considered
Explain to the patient the risks and benefits of the procedure if they
in patients with unstable sinus bradycardia, junctional bradycardia,
are awake and alert. A signed consent is not required and time is
atrial fibrillation with high-degree atrioventricular (AV) block, and
often lacking to obtain a signature. Document in the medical record
AV dissociation with inadequate ventricular response, producing
that the patient was informed of the risks and benefits of the proce-
pulmonary edema, seizures, ventricular fibrillation, or ventricular
dure. Place the patient supine. Clean the chest and subxiphoid area
tachycardia.13
of any dirt and debris. Apply povidone iodine or chlorhexidine solu-
CONTRAINDICATIONS tion to the chest and subxiphoid area. Allow it to dry if time permits.
Apply sterile drapes to delineate a sterile field.
Transthoracic cardiac pacing should not be performed in stable, Cardiopulmonary resuscitation (CPR) can be continued during
awake patients. It is also contraindicated if the patient has a dys- most of the procedure but should be stopped while the intracar-
rhythmia that could be quickly and easily corrected by medication, diac needle is being inserted to avoid possible damage to the lung
cardioversion, or electrical defibrillation. or myocardium. Full ventilation of the lungs is recommended dur-
Transthoracic cardiac pacing may be ineffective in pulseless elec- ing subxiphoid cannula placement to depress the diaphragm and
trical activity and ventricular fibrillation. In ventricular fibrillation, thus minimize the risk of injury to the liver and stomach. Insert a
the heart becomes insensitive to pacemaker activity, and in pulse- nasogastric tube to decompress the stomach prior to performing the
less electrical activity, any mode of pacing is ineffective.20–23 Bellet procedure.
et al. demonstrated that a pacemaker was ineffective in patients with The Emergency Physician should prepare themselves and the
prolonged cardiac arrest.15 Patients with cardiac arrest for more than equipment. Put on a cap, mask, sterile gloves, and sterile gown. Open
5 to 10 minutes could not be resuscitated with the use of cardiac the transthoracic cardiac pacing kit onto a sterile field. Lubricate the
pacing; but patients who had pacemakers placed within 2 to 4 min- trocar liberally and insert it securely into the steel cannula.
utes after cardiac standstill were successfully resuscitated. Hence, as
shown in many studies, transthoracic cardiac pacing may be ineffec- TECHNIQUE
tive if used as a last alternative, as any technique of pacing would be.
Quickly identify the anatomic landmarks necessary to perform this
procedure and determine the approach to be used. The cannula-
EQUIPMENT
over-the-trocar can be inserted through the left fifth intercostal
• Povidone iodine or chlorhexidine solution space either parasternally, 4 cm lateral to the midsternal line, or
• Transthoracic cardiac pacing wires/kit 6 cm lateral to the midsternal line (Figure 32-2A). The tip of the
cannula-over-the-trocar should be aimed toward the second costal
• Pacemaker generator
cartilage. Alternatively, the cannula-over-the-trocar can be inserted
• 10 mL syringe through the left xiphocostal junction and aimed toward the right
• Water-soluble lubricant shoulder, left shoulder, or sternal notch (Figure 32-2B).
• Sterile gauze 4 × 4 squares If bedside ultrasound is available, the parasternal approach
through the fifth intercostal space may be the technique of choice.
• Sterile drapes Without ultrasound, the simplest and quickest approach is to insert
• Sterile gloves and gown the trocar at the left xiphocostal junction and aimed toward the ster-
• Face mask nal notch. This technique is described below.
Briefly stop CPR. Insert the cannula-over-the-trocar from the left
• Cap
xiphocostal region at a 30° to 40° angle to the skin and directed
The widely used instrumentation for transthoracic cardiac pac- toward the sternal notch. Advance the cannula-over-the-trocar
ing is a sterile, one-time-use, prepackaged kit. One example is the approximately three-fourths of its length. Hold and stabilize the
Elecath 11-KTM 1 kit (Figure 32-1). The apparatus consists of a cannula and withdraw the trocar. Attach a 10 mL syringe to the can-
37 cm bipolar J-shaped pacing wire, a 6 inch 18 gauge blunt-end nula. Apply negative pressure to the syringe. If the cannula is within
steel cannula with a pointed inner trocar, and a plastic electrical the ventricle, the aspiration of blood into the syringe confirms
FIGURE 32-1. Equipment required for transthoracic cardiac pacing. A. Electrical connector. B. Bipolar pacing wire with a sleeve. C. Blunt steel cannula with pointed trocar.
A B
SX-SN
SX-RS SX-LS
5ICS-4
5ICS-6
5ICS-PS
FIGURE 32-2. Placement of a percutaneous transthoracic cardiac pacemaker. A. Parasternal approaches. 5ICS-PS, fifth intercostal space immediately to the left of the
sternum; 5ICS-4, fifth intercostal space, 4 cm from the midsternal line; 5ICS-6, fifth intercostal space, 6 cm from the midsternal line. B. Subxiphoid approaches. SX-RS,
subxiphoid—right shoulder; SX-SN, subxiphoid—sternal notch; SX-LS, subxiphoid—left shoulder.
proper positioning. If blood is not aspirated, withdraw the cannula ASSESSMENT

and restart the procedure. Ideally, confirm placement with bedside
ultrasound. The positioning of the pacing wire should be verified by a chest X-ray.
Insert the transcutaneous pacing wire. Advance the plastic sheath Obtain a 12-lead ECG to document capture and to verify the position-
over the pacing wire until it straightens out and covers the J-shaped ing of the pacing wire based on the QRS configuration in the ECG. A
end of the pacing wire. Insert the plastic sheath into the cannula left bundle-branch-block configuration will be demonstrated on the
hub. Advance the pacing wire through the cannula and into the ECG if the pacing wire is in the right ventricle. If the pacing wire is in
ventricle. Stop advancing the pacing wire when 4 to 5 cm remains the right atrium or left ventricle, it will still pace the myocardium but
outside the cannula. No resistance should be felt while the pacing the ECG will have a different QRS configuration. If the patient is in
wire is being advanced. If resistance is felt, the cannula is not within AV block, an atrially positioned pacing wire will be ineffective.
the ventricle. Remove the cannula and pacing wire as a unit and
restart the procedure. When it is inside the ventricle, the pacing wire AFTERCARE
will reform its J shape. Hold the pacing wire securely. Withdraw the
If the patient survives, secure the pacing wire to the skin with
cannula over the pacing wire. Do not release the hold on the proxi-
3-0 nylon suture. A transvenous or permanent pacemaker should
mal end of the pacing wire outside the patient’s thorax, so as to
be inserted as soon as possible. Consult a Cardiologist immediately
prevent it from slipping inside the thorax.
and admit the patient to an intensive care unit.
Insert the proximal end of the pacing wire into the plastic con-
nector. Secure it with the screws in the body of the connector.
Connect the positive and negative terminals of the plastic connec- COMPLICATIONS
tor to the pacemaker generator. Turn on the pacemaker generator. Analysis of the complications of transthoracic cardiac pacing is
Set the pacing rate at 70 to 90 beats per minute in an asynchronous greatly limited by the paucity of short-term survivors and the
mode. Set the current output to the maximum milliampere rate on absence of radiographic or pathologic evaluation of nonsurvivors.
the pacemaker generator. After myocardial capture of the electrical Complications include laceration of the right atrium, ventricles,
stimulus is demonstrated (i.e., each pacer spike followed by a QRS coronary arteries, great vessels, vena cava, stomach, liver, and lung.
complex on the cardiac monitor), lower the current output until Hemopericardium is a ubiquitous finding in some autopsy stud-
1:1 pacing is lost. Gradually increase the current output to attain ies, and cardiac tamponade has been reported.17,18 Pneumothorax
stimulation threshold when 1:1 capture is regained. The optimal has been reported and is a particular concern in persons receiving
current output is two to three times the stimulation threshold. positive-pressure ventilation.19
Change the mode of the pacemaker to a demand pacemaker with
a backup rate of 60 to 70 beats per minute. A complete descrip-
tion of the functioning of the pacemaker generator is reviewed in
SUMMARY
Chapter 34. The technique of transthoracic cardiac pacing has been clinically
Pacer spikes should be seen on the electrocardiogram (ECG) trac- feasible for more than 50 years, but there is extremely limited lit-
ing on the cardiac monitor. If not, check the contact between the pacer erature supporting its regular use. The technique of transthoracic
wire and electrical connector. Check the batteries in the pacemaker cardiac pacing is simple, can be performed in less than a minute, but
energy source. Pacer spikes not followed by myocardial capture usu- carries a high risk for multiple significant complications. There is
ally indicate inadequate positioning of the pacing electrode. Gently no clear understanding of the effect of transthoracic cardiac pacing
manipulate the transthoracic pacemaker wire to change its position. on the outcome of cardiac arrest and the complications associated
CHAPTER 33: Transvenous Cardiac Pacing 205
with the procedure. Most of the available information comes from ANATOMY AND PATHOPHYSIOLOGY
animal studies, retrospective analysis, and anecdotal data.
Transthoracic cardiac pacing may be useful in the setting of car- The heart is the only muscle of the body that generates its own
diac arrest with asystole or a pulseless idioventricular rhythm. It may electric impulses. Its automaticity and subsequent rhythmic con-
be performed if a transcutaneous cardiac pacing system is not avail- tractions propel blood to the tissues of the body. The initial cardiac
able or not effective. In unstable patients with drug-resistant brady- impulse starts in the right atrium of the heart at the sinoatrial (SA)
cardia producing cardiovascular collapse or lethal escape rhythms node. The sympathetic and parasympathetic nervous systems con-
whose clinical condition does not warrant a delay to insert a trans- trol the rate of impulse generation at the SA node. Once the electric
venous pacing catheter, transthoracic cardiac pacing can be initiated stimulus is generated, it is conducted along the internal conduc-
promptly. Bedside ultrasound may be useful in guiding and con- tion pathways of the heart to the muscular atrial and ventricular
firming appropriate placement of the transthoracic pacing device. walls. A delicate balance between electrolyte flux to create action
potentials, myocardial integrity to allow impulses to become con-
tractions, and an intact conduction system must be maintained.
Conduction system problems are often the result of inadequate
blood flow to the heart due to ventricular infarction and coronary
Transvenous
33
artery occlusion. The blood supply to the conduction system of the
Cardiac Pacing heart usually originates from the right coronary artery. Occlusion
of the right coronary artery can result in arrhythmias and conduc-
Eric F. Reichman, Myles C. McClelland, tion delays.
and Brian Euerle A transvenous pacing catheter may be introduced through the
femoral, internal jugular, or subclavian veins. In the Emergency
Department, the right internal jugular vein and left subclavian
INTRODUCTION
vein are the recommended sites (Figure 33-1). These routes allow
Emergency cardiac pacing can be accomplished by several meth- a more direct and easy access for the pacing catheter to enter the
ods. These include epicardial, esophageal, transcutaneous, trans- right ventricle. The right internal jugular vein is preferred, as it
thoracic, and transvenous pacing. Emergency cardiac pacing can be allows a relatively straight line of access through the superior vena
a temporizing and lifesaving technique that should be familiar to all cava and right atrium into the right ventricle.2 The left subclavian
Emergency Physicians. It will allow the patient to maintain a cardiac vein is a good second choice if access to the right internal jugular
rhythm while providing oxygen and nutrients to the vital organs. vein is not accessible. Unfortunately, the left subclavian vein is the
The earliest use of electricity to stimulate the heart can be found site of choice for a permanent pacemaker if required. Thus, many
in an essay written in the late 1700s.1 It discusses the use of elec- physicians will not use this site. The other routes are technically
tric current and artificial ventilation to revive victims of drowning. more difficult to use and often require fluoroscopy for proper place-
Transvenous pacing was first attempted on dogs in 1905 by Floresco. ment of the pacing catheter.
The transvenous approach in humans was developed in 1959 using The femoral vein is often used in infants and younger children
a stiff pacing wire. Semiflexible pacing wires were developed in to insert a transvenous cardiac pacing catheter (Figure 33-2).
1964 and were placed using fluoroscopic guidance. The demand Insertion of the pacing catheter via the femoral vein often requires
pacemaker was developed in 1966. Catheter technology improved fluoroscopy. The disadvantages of using the femoral vein for vas-
with the semifloating catheter in 1969 and the balloon tip catheter cular access include the potential for deep venous thromboses,
in 1973. The technology and technique have since been developed to infection, restricted mobility, and thrombophlebitis. The infant and
allow successful transvenous cardiac pacing in humans. It involves young child’s relatively large head and short neck make access to the
the placement of a pacing wire through the central venous circulation internal jugular vein difficult. The subclavian vein in an infant and a
and into direct contact with the myocardium of the right ventricle. child is situated more posterior to the clavicle than in an adult. This
FIGURE 33-1. Common sites for introducing a transvenous pacing catheter. A. The right internal jugular vein. B. The left subclavian vein.
or ventricular arrhythmias that require overdrive pacing can benefit

from transvenous pacing.1,2,5,6 Specific bradycardic conditions that
may benefit from transvenous cardiac pacing include sinus node
dysfunction, sinus arrest, sick sinus syndrome, sinus bradycardia,
atrial fibrillation with a slow ventricle response rate, second-degree
heart block, and third-degree heart block. Patients with myocar-
dial infarctions and symptomatic bradycardia or new heart blocks
require cardiac pacing. Tachyarrhythmic conditions that may benefit
from overdrive cardiac pacing include atrial flutter, atrial fibrillation,
Wolff–Parkinson–White tachyarrhythmias, supraventricular tachy-
cardias not responsive to drugs or cardioversion, ventricular tachyar-
rhythmias due to drug toxicity (quinidine or digoxin), and torsades
de pointes. Transvenous pacing may be used in patients who do not
tolerate or whose heart does not capture with transcutaneous pacing.
If a permanent pacemaker is not functioning, a transvenous pacing
catheter may be temporarily inserted to pace the myocardium. A
more complete discussion on the indications for cardiac pacing is
presented in Chapter 31 (transcutaneous cardiac pacing).
CONTRAINDICATIONS
Patients who are hypothermic should not have a transvenous pac-
ing catheter inserted into the heart. These patients have increased
irritability of the myocardium and are prone to life-threatening ven-
tricular fibrillation if the pacing wire contacts the heart muscle.1,2
Digoxin toxicity and other drug ingestions that may increase the
irritability of the myocardium are relative contraindications to the
placement of a transvenous pacing catheter. Patients who are asys-
tolic for extended periods of time have a low likelihood of success-
ful resuscitation.2 These patients are not candidates for transvenous
pacer placement. Do not insert a pacing catheter through infected
skin or areas with any skin lesions (e.g., burns, cellulitis, or derma-
tides) to prevent possible infections such as endocarditis, myocar-
ditis, or sepsis. Avoid areas that contain subcutaneous devices (e.g.,
permanent pacer, AICD, port-a-cath, etc.) and choose an alternative
site. Do not prophylactically place a transvenous pacing catheter in
a patient with a myocardial infarction unless they have a new heart
block or symptomatic bradycardia. Patients with bleeding diatheses,
anticoagulant therapy, or concurrent thrombolytic therapy should
not have a transvenous pacing catheter placed except in truly emer-
gent situations due to the risk of hemorrhage and bleeding com-
plications. Other relative contraindications include the presence of
a prosthetic tricuspid valve, coagulopathy, distortion of local and
FIGURE 33-2. The femoral vein is used in children to access the central venous anatomic landmarks, and known abnormal cardiac anatomy.
circulation and introduce a transvenous pacing catheter.
makes it more difficult to access the subclavian vein while increas-

ing the chance of causing a pneumothorax.
Pacing the left ventricle through a femoral artery approach has
been suggested in emergent situations.3 These instances usually
involve the inability to obtain venous access due to scarring, previ-
ous procedures, or venous thrombosis. This nonstandard approach
has been used successfully in situations when transvenous cardiac
pacing was not feasible.3,4 This technique cannot currently be rec-
ommended for routine use, but is a potential alternative technique
in the Emergency Physicians armamentarium for use in the most
dire of circumstances.
INDICATIONS
The indications for transvenous pacing are the same as for other
methods of cardiac pacing. Patients with symptomatic bradycardia
unresponsive to drug therapy, conduction delays that may degener-
ate into complete heart block, atrioventricular dissociation, and atrial FIGURE 33-3. The flexible transvenous pacing catheter.
EQUIPMENT • Sterile drapes

• Sterile gloves and gown
• Flexible transvenous cardiac pacing catheter (Figure 33-3):
▶ 3 or 4 French for infants and children
• Face mask with face shield or goggles
▶ 5 or 6 French for adolescents and adults
• Cordis or Swan introducer catheter kit, one size larger than the
• Pacemaker generator (Figure 33-4)
pacing catheter
• Spare battery for pacemaker
• Cardiac monitor
B Connector terminals
MEDTRONIC® 5375
DEMAND PULSE GENERATOR
Pace
Sense indicator
indicator SENSE BATTERY PACE light
light TEST
Battery
test
OUTPUT MA RATE/PPM button
3 5 60 70 80 90
2 7 50
Output 100
1 10 120 Rate
control dial 40 control
.5
.1 15 150
20 30 180 dial
SENSITIVITY/MV
3 2 SLIDE PUSH & HOLD
2 1
Sensitivity 5 OFF
1.5
control dial
10
1
DEMAND SN EHOOOO701R On-off
switch
A Battery
chamber
C
FIGURE 33-4. Examples of pacemaker generators.
• Local anesthetic solution catheter is advanced through the heart.2,5,7 This technique is known
• 3-0 nylon suture as ECG positioning and requires the patient to have intrinsic car-
diac activity.
• Gauze squares
• Skin tape PATIENT PREPARATION
• Alligator clips and connecting wire
Explain the risks, benefits, and possible complications to the patient
• Towels for shoulder rolls and/or their representatives. If the patient is unable to consent, an
• Defibrillator appropriate representative may accept for the patient. The patient
• Airway management equipment may also give verbal consent if they are unable to sign but fully
• Resuscitative drugs understands the risks and benefits of the procedure. The Emergency
Physician should wear full personal protective equipment to protect
• Ultrasound machine with a 3.5 MHz curvilinear or cardiac array themselves from contact with the patient’s blood and body fluids.
probe While time is of the essence and this is an emergent procedure,
• Sterile ultrasound gel aseptic technique should always be followed.
• Sterile ultrasound probe covers Place the patient supine and, if possible, in the Trendelenburg
position. Place the patient on continuous pulse oximetry, cardiac
Transvenous cardiac pacing kits are commercially available. They monitoring, and supplemental oxygen. Establish peripheral intra-
contain the central venous introducer catheter, transvenous pacing venous access. Clean and prep the skin in a sterile fashion with
wire, and all the required supplies except the pacemaker genera- povidone iodine or chlorhexidine at the site chosen to access the
tor. These single patient use and disposable kits are convenient and central venous system. If the internal jugular vein or the subclavian
worth the expense so that time is not expended gathering multiple vein is being used as the site of vascular access, place rolled towels
kits and supplies in an emergent situation when time may be of the under the patient’s shoulders. Turn the patient’s head to the opposite
essence. side of venous access. Apply sterile drapes to fully cover the patient
The pacemaker generator is a simple device (Figure 33-4). except the site used for vascular access.
An example is the Medtronic 5375 demand pulse generator
(Figures 33-4A & B). Newer models of pacemaker generators
(Figure 33-4C) have digital displays and other more sophisticated
TECHNIQUE
pacing options, but function essentially the same as older models. Access the central venous circulation by placing a Swan or Cordis
The Emergency Physician must be familiar with the pacemaker introducer catheter sheath. Some authors recommend using the
generator and its use prior to needing it in an emergent situation. supraclavicular approach for central venous access.8 This approach
The on/off switch is used to turn the unit on. In the “on” position, may decrease complications due to well-defined surface landmarks,
a spring-loaded safety prevents the unit from accidentally being high success rates of vascular access, minimal interference with
turned off. The rate-control dial allows the physician to adjust the other procedures, location away from the pleural dome, avoidance
number of pacing stimuli per minute. The upper rate limit is often of scarring and thrombosis from previous central venous access
inadequate if overdrive pacing is required. A pacemaker generator attempts, minimization of catheter movement, and having a straight
with higher rates for overdrive pacing is available. These are rarely path into the right ventricle. Refer to Chapter 49 for the complete
kept in the Emergency Department, but are usually available from details on inserting central venous catheters.
the hospital catheterization lab. The pace indicator light is illumi- Prepare the pacing catheter (Figure 33-5). Attach the precor-
nated whenever a pacing stimulus is generated. The sense indica- dial lead V1 to the pacemaker catheter negative terminal. This is
tor light is illuminated whenever a cardiac impulse is sensed. The accomplished using an insulated wire with an alligator clip at each
battery test button is used to determine if the battery has sufficient
voltage to operate the pacemaker generator. Depress the battery test
button to check the battery voltage. If both the pacing and sensing
indicator lights illuminate simultaneously, the battery has sufficient
voltage. The output control dial is used to adjust the amplitude of
the stimulus current. The sensitivity control dial is used to suppress
the pulse generator. The bottom of the pacemaker has an access
panel under which the battery is located. The top of the pacemaker
has positive and negative terminals where the electrodes of the
pacemaker catheter insert. Numerous pacemaker generators are
available, each with its own idiosyncrasies. The above instructions/
functions are similar to most models.
The pacemaker wires are enclosed in a catheter and come in a
variety of lengths and sizes (Figure 33-3). They are typically 100 cm
in length with markings at intervals of every 10 cm. They come in
both flexible and rigid styles. The rigid catheters are not often used
due to the possibility of venous and myocardial perforation. The
flexible catheters have a balloon at the tip, which allows the catheter
to flow with the blood into the chambers of the heart.
The pacemaker catheter should ideally be inserted under electro-
cardiographic (ECG) guidance. An insulated wire with an alligator
clip at each end is required. One end is attached to the pacemaker
wire and the other to the ECG lead. This allows the Emergency FIGURE 33-5. The negative pacemaker terminal is connected to an insulated wire.
Physician to observe the ECG waveforms as they change while the The insulated wire will be connected to the ECG lead V1.
FIGURE 33-6. Typical ECG tracings seen with the transvenous pacing catheter within the different anatomic sites. A. The subclavian or internal jugular vein. B. The superior
vena cava. C. The high right atrium. D. The low right atrium. E. Free-floating in the right ventricle. F. Abutting the right ventricular wall. G. The inferior vena cava. H. The
pulmonary artery.
end. Attach one alligator clip to the negative pacemaker wire. Attach 1.5 mL of sterile saline. Slowly advance the catheter while always
the other alligator clip to the V1 lead of the ECG monitor. Inflate the observing the ECG monitor (Figure 33-6). In the subclavian or
pacing catheter balloon with 1.5 mL of air in a container of sterile internal jugular vein, the P wave and the QRS complex are both small
saline to assess the integrity of the balloon. The presence of bubbles in amplitude and inverted (Figure 33-6A). In the superior vena
in the saline indicates a balloon leak. Turn on the ECG monitor and cava, the P wave increases in amplitude but is still inverted while
set it to lead V1. Touch the tip of the pacing catheter and observe the the QRS complex is unchanged (Figure 33-6B). When the pacing
monitor to confirm that the monitor is recording. A large pressure catheter reaches the right atrium, a large P wave with a negative
wave should be seen that soon returns to the baseline. polarity and a small QRS complex will be observed (Figure 33-6C).
Insert the pacemaker catheter through the rubber diaphragm of Continue to advance the catheter. As the lower atrium is entered,
the central venous introducer sheath. Advance the catheter 10 cm. the P waves become upright and the QRS complex increases in
This ensures that the pacing catheter balloon is past the introducer amplitude (Figure 33-6D). Continue to advance the catheter into
catheter and within the vascular system. Inflate the balloon with the right ventricle. The QRS complex should appear normal on
be confirmed. Aguilera and colleagues reported success in eight of

nine patients in whom ultrasound-guided transvenous pacing was
attempted in the Emergency Department.9 In three of these patients,
initial misplacement of the electrode was visualized, allowing cor-
rect repositioning. They concluded that ultrasound has promising
potential use as an adjunct in emergency cardiac pacing. Ultrasound
can delineate the right ventricle as well as provide quick and non-
invasive confirmation of lead placement. It is useful as an aid to
detecting and repositioning misplaced pacer leads. Given the time-
sensitive nature of transvenous pacing, consider using ultrasound in
conjunction with ECG guidance.
The subxiphoid view is preferred as it allows visualization of the
right atrium and right ventricle. It is also a view easily obtained with
the patient in the supine position. The subxiphoid view is likely
to be the cardiac window with which Emergency Physicians are
most familiar and comfortable. The transvenous pacing electrode
is a strong reflector of ultrasound waves and will appear as a linear
hyperechoic structure.9 In the subxiphoid view, the electrode can be
seen passing through the right ventricle to the apex (Figure 33-8).
The apical cardiac view is an option. However, obtaining an api-
cal view is more technically difficult and is preferentially performed
FIGURE 33-7. The transvenous pacing catheter connected to the pacemaker with the patient in the left lateral decubitus position, which may not
generator. be practical. Care must be taken not to mistake the ventricular
septum or wall for the electrode.
There are limitations in the use of ultrasound. Visualization
may be difficult in the obese or those with COPD and resultant
the V1 lead. When the catheter is floating freely in the right ven- expanded lung volumes. Mechanical heart valves may cause signifi-
tricle, the P waves are upright with a large-amplitude QRS complex cant artifacts that obscure the images. The pacing catheter often lies
(Figure 33-6E). Stop advancing the catheter once the right ventricle in multiple echo planes, making visualization more difficult. The
is entered and deflate the balloon. Slowly advance the catheter until lack of catheter visualization may require multiple repositionings of
ST-segment elevation is observed (Figure 33-6F). This indicates the catheter. Visualization of the catheter may require tilting of the
that the catheter is abutting the right ventricular wall. probe, looking at several different angles with the probe, and look-
Occasionally, the transvenous pacing catheter may not enter ing at additional views of the heart. All these maneuvers can result
the right ventricle or it may advance past the right ventricle. If in delays before being able to pace the heart.
the catheter exits the right atrium and enters the inferior vena Visualize the patient’s heart using a subxiphoid view with a
cava, the amplitude of the P wave and QRS complex will decrease 3.5 MHz curvilinear array probe. Instruct an assistant to hold the
(Figure 33-6G). Withdraw the catheter several centimeters until the probe in position while the Emergency Physician performs the pro-
atrial waveforms are again seen (Figures 33-6C & D), then read- cedure. Insert the pacing catheter as described above using the
vance the catheter. If the catheter exits the right ventricle and enters
the pulmonary artery, the P wave will become negative and the QRS
amplitude will decrease (Figure 33-6H). Withdraw the catheter sev-
eral centimeters until the right ventricle waveforms are again seen
(Figure 33-6E), then readvance the catheter.
Connect the pacemaker generator to the catheter (Figure 33-7).
Disconnect the negative terminal of the pacemaker catheter from
the ECG lead. Connect the pacemaker catheter terminals on the
proximal end of the catheter to the negative and positive terminals
of the pacemaker generator. The positive (+) lead connects to the
proximal port on the pacemaker generator. The negative (−) lead
connects to the distal port on the pacemaker generator. Set the
pacemaker generator on demand mode with a rate of 70 to 80 beats
per minute. Start with 5 mA of energy on the output dial. Turn on
the pacemaker. Increase the energy until capture is seen on the
monitor. This is signaled by pacing spikes and a wide QRS complex
in lead V1 in a left bundle branch pattern. Once capture is attained,
decrease the pacemaker generator output to just below where
pacing stops. This is known as the threshold point. Resume pac-
ing at 2 mA above the threshold point.2
ULTRASOUND-GUIDED TECHNIQUE
It is often difficult to successfully place the tip of the pacing catheter FIGURE 33-8. Subxiphoid cardiac ultrasound image. The transvenous pacing
into the apex of the right ventricle. Lead placement can be guided electrode (large arrow) is seen as a linear hyperechoic structure passing through
and confirmed with the assistance of ultrasonography.9 The pacing the right ventricle to its apex. The interventricular septum is denoted by the
electrode is easily visible on ultrasound, and its correct position can small arrows.
ECG-guided technique. Visualize the pacing catheter using ultra- Once electrical capture is achieved, mechanical capture must be
sonography after it enters the right atrium and then as it enters ensured by either a palpable pulse rate or arterial catheter blood
the right ventricle as also noted by the changing ECG waveforms. pressure monitoring. The patient will have a pulse rate that is
Continue to advance the pacing catheter under ultrasound guidance exactly equal to that of the paced rhythm on the cardiac monitor
until its tip is lodged in the apex of the right ventricle (Figure 33-8). if mechanical capture is achieved. Assess the pulse using palpation
This may require manipulation of the pacing catheter and/or ultra- of the carotid or femoral artery to avoid confusion with skeletal
sound probe to maintain visualization. Continue the remainder of muscle contractions generated by the pacing current. If the palpated
the procedure as noted in the previous section. Ventricular capture pulse rate is less than that of the paced rate, mechanical capture has
is noted as cardiac contractions on the ultrasound monitor that are not been achieved. Increase the threshold current. Mechanical cap-
at the same rate as the pacemaker generator setting. ture is also achieved when the invasive arterial blood pressure line
demonstrates a pulse rate that is exactly equal to that of the paced
ALTERNATIVE TECHNIQUE rhythm on the cardiac monitor.
Ultrasound can confirm electrical and mechanical capture. Use
Blind transvenous catheter placement is an alternative to the above ultrasound to determine the ventricular contraction rate. The
method. The pacing catheter is inserted “blindly” and without ECG patient will have a heart rate that is exactly equal to that of the set
guidance. This technique is often used when alligator clips are not paced rate if mechanical capture is achieved. Refer to Chapter 29 for
available to connect the pacing catheter terminals to the ECG moni- the complete details of cardiac ultrasonography.
tor. A flexible catheter should always be used. Never place a rigid
catheter blindly due to the risk of myocardial perforation.
AFTERCARE
Prepare the catheter. Test the balloon as described previously.
Make sure the pacemaker generator is off. Connect the pacemaker Secure the pacing catheter by suturing it to the chest wall. Infiltrate
catheter terminals to the pacemaker generator. Insert the pacemaker subcutaneously with 2 mL of local anesthetic solution 1 cm from
catheter through the rubber diaphragm of the central venous intro- where the catheter exits the central venous sheath. Using 3-0 nylon,
ducer sheath. Advance the catheter 10 cm. Inflate the balloon with secure the catheter to the skin. Apply antibacterial ointment to
1.5 mL of sterile saline. the site where the pacing catheter exits the central venous sheath.
Turn on the pacemaker. Set the pacemaker on demand mode Apply an adhesive dressing, such as Tegaderm, over the sheath and
with a rate twice the patient’s native heart rate. This usually ranges catheter. Obtain an ECG. It will show the characteristic left bundle
from 80 to 120 beats per minute. Set the output dial to 1.5 to 2.0 mA. branch block pattern. Obtain a postprocedural chest radiograph to
Advance the catheter while observing the sensing indicator light. assess the catheter position and to rule out an iatrogenic pneumo-
When the catheter enters the right ventricle, the sensing indica- thorax and/or hemothorax. Admit the patient to an intensive care
tor will illuminate with every other native heartbeat. Stop advanc- unit. Consult a Cardiologist for possible permanent pacemaker
ing the catheter. Deflate the balloon. Increase the output dial to placement.
10 mA. Slowly advance the catheter until ventricular capture occurs The most important assessment in the aftercare period is
on the cardiac monitor. Electrical capture is indicated when the to ensure continuous electrical and mechanical capture. This
ECG monitor attached to the patient’s skin by electrodes shows should be accomplished by frequent checks of the cardiac moni-
pacer spikes and the development of wide QRS complexes. Do tor, palpation of a pulse, and measurement of a blood pressure.
not advance the catheter more than 10 cm past the point where This is more easily established using an arterial line.
the sensing indicator began to illuminate. If ventricular capture
is not successful within 10 cm, withdraw the catheter and rotate it COMPLICATIONS
90°. Readvance the catheter up to 10 cm. The pacemaker generator
output may be set at 20 mA and the pacing catheter readvanced. Perforation of the ventricular septum, the atria, or the free wall of
Continue to repeat the process until ventricular capture is success- the ventricle may occur during catheter placement.10 This is more
ful. Once this occurs, slowly decrease the ventricular rate to 70 beats commonly seen with the rigid catheters, and in elderly patients with
per minute. Decrease the pacemaker generator output to 2 mA kyphoscoliosis where right heart catheterization can be more dif-
above the threshold point.2 ficult.11 Septal perforation should be suspected if the pattern on the
This blind procedure can be modified to be used with ultrasound. ECG changes from a left to a right bundle branch block.2,12 Septal
Visualize the pacing catheter after it enters the right ventricle. Use perforation should also be suspected if there is an increase in the
ultrasound to help guide the tip of the pacing catheter into the apex pacing threshold. Ventricular perforation can present as a failure to
of the right ventricle or to confirm proper positioning of the pacing capture or as cardiac tamponade. A friction rub may be audible on
catheter (Figure 33-8). cardiac auscultation if a perforation is present. Perforation of the
inferior wall could stimulate and pace the diaphragm.2,12 The treat-
ment for these complications is to withdraw and reposition the pac-
ASSESSMENT OF SUCCESSFUL PACING
ing catheter. The patient must then be evaluated and observed for
The Emergency Physician must assess the patient for both electri- the possibility of cardiac tamponade.
cal capture and associated mechanical capture when considering Multiple attempts to place the tip of the pacing catheter in the
whether or not the procedure was successful. Successful capture is apex of the right ventricle can result in complications. Movement
usually characterized by a wide QRS complex, since it is ventricular of the catheter forward and backward can form a loop within the
in origin, and a broad T wave. It is easy to mistake the wide, slurred cardiac chambers. The catheter tip can advance through the loop
afterpotential following an external pacing spike for electrical cap- and result in a knot being formed in the pacing catheter. This
ture. Electrical capture is best judged by the presence of a con- requires an Interventional Cardiologist to unknot and remove the
sistent ST segment and T wave after each generated pacer spike catheter in the cardiac catheterization laboratory under fluoro-
(Figure 31-6C). Paced beats below the patient’s intrinsic cardiac scopic guidance.
rate may not produce an associated QRS complex (Figure 31-6B), Advancement of the pacing catheter through a patent foramen
and electrical capture is not achieved. In this situation, the pacing ovale will result in left ventricular pacing.13 This is recognized as a
rate must be increased to achieve capture. right bundle branch pattern on the ECG. Ultrasonography can be
used to visualize the pacing catheter in the left ventricle or the lack
of it in the right ventricle. Radiographic or angiography studies will Pacemaker Assessment
be needed to determine if the tip of the catheter passed through the
foramen or perforated the interatrial or interventricular septum.
Cardiac arrhythmias may occur during insertion of the pacing
34 Nnaemeka G. Okafor
catheter. Ventricular arrhythmias can occur during the procedure

and even after the procedure is completed. Immediately withdraw INTRODUCTION
the catheter a few centimeters and observe the rhythm. If that
resolves, readvance the catheter. A defibrillator and cardiac resus- Pacemakers are common among Emergency Department patients.
citation drugs must be available to facilitate immediate treatment of Patients may present due to symptoms referable to pacemaker mal-
any rhythm disturbance.2,12 function or symptoms unrelated to the pacemaker, and its presence
In transvenous pacing, as with any procedure, infection can be a may modify the investigation and therapeutic approach. It is impor-
delayed complication. Always use strict aseptic techniques when tant for the Emergency Physician to understand the workings of a
inserting the central venous introducer sheath and the transve- pacemaker, the problems that may be encountered, the etiologies
nous pacing catheter. There is currently no clinical evidence to sug- of the problems, and the assessment of a patient with a pacemaker.
gest that the use of prophylactic antibiotics decreases infections or There are numerous indications for the implantation of a cardiac
infectious complications. The use of prophylactic antibiotics cannot pacemaker.1–8 However, a detailed discussion regarding the indica-
be currently recommended. The most common organisms are skin tions for permanent pacemaker insertion is beyond the scope of
flora. The types of infection can range from cellulitis at the puncture this chapter.1,6,7 The most common indication for permanent pace-
site to myocarditis and florid sepsis.2,5,12 Antibiotic therapy should maker placement is symptomatic bradycardia. Mortality rates can
be started and the catheter removed and cultured. If the pacing cath- be decreased in these patients with pacing. A permanent pacemaker
eter is absolutely required, a new puncture site should be selected is inserted prophylactically when intrinsic cardiac rhythms can
and a new pacing catheter inserted. degenerate to higher-degree blocks or in patients who may develop
The pacing catheter balloon can be a source of complications.14,15 symptoms in the near future even though the initial presentation
Air embolism has been reported. This can be prevented by assessing was asymptomatic. An example would be the Mobitz type 2 second-
the balloon for leaks prior to inserting the catheter. Do not overin- degree atrioventricular (AV) block. In addressing the treatment
flate the balloon. An air embolism or a piece of ruptured balloon modalities for cardiac rhythm disturbances, the decision to implant
may obstruct part of the pulmonary circulation. Do not inflate the a pacemaker can be difficult and must be reached by a careful review
balloon after it is inserted more than 10 to 15 cm into the ventricle. of each patient on an individual basis.
If the balloon is inflated when the catheter tip is in a branch of the The pacemaker unit is implanted by a Cardiologist in the cardiac
pulmonary artery, the vessel may rupture. Forward and backward catheterization laboratory. The pacemaker unit consists of the pace-
movement of the pacing catheter with the balloon inflated may maker generator, the pacemaker wires (also known as electrodes or
result in rupture of the chordae tendineae with subsequent tricuspid leads), and the terminal electrodes. The square or rectangular pace-
regurgitation. maker generator is implanted subcutaneously in the left or right
The pacing circuit (i.e., catheter, wires, and pacemaker) can also upper chest. It is responsible for the functioning of the unit and con-
be a source of complications. The catheter may become dislodged or tains the battery that powers it. A reed switch in the pacemaker gen-
fractured. The pacemaker may fail due to battery drainage, genera- erator can be used to inactivate its sensing mechanism and cause
tor failure, or electrical interference. it to perform in an asynchronous mode. The pacemaker wires are
Anatomic variations may be present and not known to the patient embedded in plastic catheters and attached to the pacemaker genera-
or the Emergency Physician. These include persistent left-sided tor. The wires are inserted through the subclavian vein or, less com-
superior vena cava, congenital lack of a vein, or congenital dupli- monly, through the cephalic vein and into the right side of the heart.
cation of a vein.16 Anatomic variations can increase the technical The terminal electrodes are at the distal end of the pacing wires and
difficulty of the procedure. It might be necessary to use a femoral are designated as unipolar or bipolar. The terminal electrodes are
approach if the internal jugular or subclavian vein approaches are placed under fluoroscopic guidance in the right ventricle for single
unsuccessful, regardless of the reason.16 chamber pacing or the right atrium and right ventricle for dual
Complications related to obtaining central venous access are dis- chamber pacing. After insertion, the unit is programmed and tested.
cussed in Chapter 49. They include air embolism, infection, sepsis, The North American Society for Pacing and Electrophysiology
cellulitis, pneumothorax, improper placement, arterial puncture, and the British Pacing and Electrophysiology Group have accepted a
venous thrombosis, venous thrombophlebitis, and guidewire com- five-letter pacemaker code, which is also followed by the pacemaker
plications. Complications may be decreased by using the supra- industry (Table 34-1). The code is generic in nature. The character
clavicular approach rather than the subclavian or internal jugular position is labeled in Roman numerals I through V. The first letter
approaches.8 designates the chamber(s) in which pacing occurs. It can be des-
ignated as none (0), atrial (A), ventricular (V), or both atrial and
ventricular (D or dual). The second letter designates which cardiac
SUMMARY chamber(s) the pacemaker uses to sense intrinsic electrical cardiac
Placement of a transvenous cardiac pacing catheter can be a life- activity. It can be designated as none (0), atrial (A), ventricular (V),
saving procedure. It is a safe method to electrically stimulate the or both atrial and ventricular (D or dual). The third letter desig-
heart. It is indicated when an unstable rhythm of the heart is refrac- nates how the pacemaker responds to sensed intrinsic electrical
tory to medications and transcutaneous pacing. Proper placement activity. A sensed event may inhibit (I), trigger (T), both inhibit and
of the pacing catheter is cardinal to its functioning. Recognition of trigger (D), or cause no response (O) from the pacemaker genera-
the ECG changes that occur in the different anatomic areas helps to tor. To have a designation other than O, the pacemaker must be a
guide its placement. One must also be aware of the potential compli- dual-chamber system. The fourth letter reflects the programmabil-
cations and their management. This procedure should be mastered ity and rate modulation of the unit. The fifth letter designates the
by all Emergency Physicians caring for critically ill and/or injured antitachyarrhythmia function(s) of the pacemaker. The fourth and
patients. fifth letters are rarely used, as these functions are not often required.
CHAPTER 34: Pacemaker Assessment 213
TABLE 34-1 The Generic and Standard Pacemaker Codes

Position I II III IV V
Chamber(s) Chamber(s) Response to Programmability Antitachyarrhythmia
Interpretation paced sensed sensing rate modulation function(s)
Variable 0 0 0 0 0
A A T P1 P2
V V I M S
D (A + V) D (A + V) D (T + I) C D (P + S)
R
Key : A, atria; C, communicating; D, dual; I, inhibited; M, multiprogrammable; 0, none; P1, simple programmable; P2, pacing; R, rate modulation; S, shock; T, triggered; V, ventricle.
The code does not describe the characteristics, specific functions, ELECTROCARDIOGRAM
or unique functions that are specific to each pacemaker unit or the
manufacturer of the unit. The most common mode for a pacemaker Obtain a 12-lead ECG. This recording will disclose whether the
is VVI. The reader is referred to other references for a more com- patient is presently being paced and in what manner (e.g., ventricu-
plete discussion of pacemaker modes.1,6,7 lar or atrioventricular pacing). If not, the underlying rhythm and
PR interval of an intrinsic cardiac beat can be readily established
(Figure 34-1A). Bipolar spikes tend to be smaller, and examina-
EVALUATION OF PACEMAKER FUNCTION tion of various leads of the ECG tracing may clarify the presence or
Pacemaker patients who present to the Emergency Department with absence of capture. A paced beat occurs when ventricular depolar-
a complaint that may be associated with their pacemaker require ization is secondary to pacer stimulation (Figure 34-1B). The pacer
a thorough evaluation. Place the patient on the pulse oximeter spike is seen immediately preceding the QRS complex. A fusion or
and cardiac monitor and apply a noninvasive blood pressure cuff. pseudofusion beat can occur due to pacemaker firing on an intrin-
Provide supplemental oxygen via a nasal cannula or face mask. A sically occurring P wave or QRS complex. A fusion beat is a QRS
history and physical examination should be performed while simul- complex that has been formed by depolarization of the myocardium
taneously obtaining a 12-lead electrocardiogram (ECG). Obtain that was initiated by both the pacemaker spike and the patient’s
posteroanterior and lateral chest radiographs if the patient is sta- intrinsic electrical activity (Figure 34-1C). The QRS configuration
ble. If not, a portable anteroposterior chest radiograph will suffice. of the fusion beat is different from the paced QRS morphology and
Perform a magnet examination of the pacemaker. A Cardiologist the intrinsic cardiac QRS morphology. It is a hybrid of the paced
should always be consulted regarding a patient with an actual or and intrinsic QRS complex morphology. A pseudofusion beat is
a potential pacemaker problem. a QRS complex that is formed by the depolarization of the myo-
cardium initiated by the patient’s intrinsic electrical activity, and a
HISTORY AND PHYSICAL EXAMINATION pacemaker spike is present distorting the terminal QRS complex.
The morphology is similar to that of the intrinsic QRS complex
The initial evaluation begins with a complete history. Palpitations, (Figure 34-1D). It is often due to the pacemaker firing during the
dizziness, near syncope, syncope, or any symptom that may resem- refractory period of an intrinsic P wave or during the beginning of
ble those prior to pacemaker implantation may reflect a potential the QRS complex before intracardiac voltage increases to activate
pacemaker malfunction. In patients who have had their pacemaker the sensing circuit and inhibit the pacemaker. Pseudofusion beats
placed recently, the complaints related to potential pacemaker infec- can be normal occurrences in pacemaker patients.
tion should also be explored. Determine if the patient is taking med- A properly functioning pacemaker will sense intrinsic car-
ications that can raise the myocardial threshold to pacing. Traumatic diac electrical activity. If the intrinsic cardiac activity is below
injury to the torso can cause the leads to displace or fracture. Direct the programmed rate, a pacemaker spike will be seen followed
trauma over the pacemaker generator can render it inoperable. by a QRS complex in a single-chamber or ventricular pacemaker
Ask the patient if they have a pacemaker card. This is a busi- (Figure 34-2). If the patient has a dual-chamber pacemaker, a
ness card-size piece of paper that is given to the patient after pace-
maker implantation to identify the pacemaker type, manufacturer
of the unit, programmed rate, the five-letter code programmed in
the pacemaker, and the manufacturer’s phone number. The patient
should be questioned regarding any known changes in the pace-
maker settings since receiving the pacemaker card.
Perform a thorough examination of the patient. Observe the vital
signs for bradycardia, fever, hypertension, hypotension, or tachycar-
dia. Evaluate the veins of the head and neck for venous engorge-
ment suggesting a central venous thrombosis or a superior vena
cava syndrome. Edema of the ipsilateral upper extremity indicates
thrombosis and possible occlusion of the subclavian vein. Identify
the location of the pacemaker pocket and implantation scar on the
skin. Note if the pacemaker generator has moved from its original
position. This can cause a partial or complete disconnection of the
pacemaker wires from the generator. Inspect the pacemaker pocket
for signs of infection, including a discharge, edema, skin erosion,
erythema, redness, tenderness, and/or warmth. FIGURE 34-1. Schematic of typical electrocardiographic beats.
FIGURE 34-2. A 12-lead electrocardiogram of a single-chamber or ventricular pacemaker.
pacemaker spike will be followed by a P wave; then a second pace- MAGNET EXAMINATION
maker spike will be seen followed by a QRS complex (Figures 34-3
& 34-4). If the intrinsic cardiac electric activity is above the pro- A magnet may be used to assess battery depletion, failure of a com-
grammed rate, no pacemaker spike should be seen on the ECG. ponent of the system, or the possibility of oversensing. It can also be
Since the pacemaker wire is usually implanted in the right ven- used in an attempt to terminate pacemaker-mediated tachycardia
tricle, a typical paced QRS complex will have a left bundle branch (PMT, discussed further on in this chapter). A doughnut-shaped
pattern (Figures 34-1 to 34-4). Occasionally, the pacing wire will magnet is required for this procedure. A standard or generic magnet
be implanted in the left ventricle and the QRS complex will have a may be used. Occasionally, but rarely, a brand-specific magnet may
right bundle branch pattern. be required to evaluate a pacemaker. A transcutaneous pacemaker
Examine the current ECG and determine the electrical axis of generator, defibrillator, the required cables and skin electrodes,
the pacemaker spike, the electrical axis of the QRS complex, and and ACLS resuscitation medications must be available in case of
the morphology of the QRS complex. These must be compared to an emergency during the magnet examination.
the same features on previously obtained ECGs. A change in the To obtain the magnet rate, place a standard magnet over the
axis of the pacemaker spike may be seen in cases of lead migra- pacemaker generator while simultaneously obtaining a 12-lead
tion. A change in the ECG morphology from a left bundle branch ECG and rhythm strip. The magnetic field causes the reed switch
pattern to a right bundle branch pattern suggests that the lead to close, bypass the sensing amplifier, and temporarily convert
has perforated the interventricular septum and is now within the the pacemaker into the asynchronous (VOO or DOO) mode
left ventricle. (Figure 34-5). This essentially turns off the sensing mode and
the pacemaker fires at the programmed rate. The magnet rate
may be slower or faster than the program rate and depends on
the model of the pacemaker. Pacemaker spikes occurring during
the refractory period of an intrinsic QRS complex will not be cap-
tured (Figure 34-5B). Theoretically, a pacing spike occurring on
the T wave could induce ventricular arrhythmias, but this is rarely
a practical problem.
The application of the magnet over the pacemaker generator can
have a variety of results. If it is working properly, the pacemaker
will fire at the programmed rate. This indicates that the failure to
pace the myocardium in a patient with bradycardia is due to over-
sensing. The unit may be sensing a large T wave as a QRS complex.
FIGURE 34-3. Schematic of an electrocardiographic monitor strip of a dual-cham- Alternatively, it may be sensing a normal T wave as a QRS complex if
ber pacemaker. Atrial (first arrow) and ventricular (second arrow) pacing spikes the QRS complexes are small in amplitude. If a patient’s bradycardia
are clearly visible. is corrected, tape the magnet in place over the pacemaker generator.
FIGURE 34-4. A 12-lead electrocardiogram of a dual-chamber or atrioventricular sequential pacemaker.
If the generator is pacing intermittently, the magnet may not be The pacemaker lead may have become dislodged from its implan-
directly over the pacemaker generator. Reposition the magnet and tation site. This is extremely uncommon with current systems, as
observe the results. If no pacemaker spikes are seen on the ECG, a they have safety mechanisms to prevent lead dislodgement. Ensure
component of the system (i.e., generator, battery, or leads) has failed. that the distal end of the pacing wire is within the cardiac silhou-
If the pacemaker spikes occur at less than the programmed rate, the ette and against the myocardium. It may be free-floating within
battery may be depleted or the set rate has been changed. the ventricle or may have perforated the ventricular wall. Previous
chest radiographs should be obtained and compared to the current
radiographs to help determine if the leads have been displaced.
CHEST RADIOGRAPHY
Lead fractures can occur anywhere along the length of the pacing
Obtain overpenetrated posteroanterior and lateral chest radio- wire. They most often occur at stress points adjacent to the pacemaker
graphs. This is helpful in locating the pacemaker generator and or just under the clavicle as the pacing wire enters the subclavian vein.
lead positions. Look for a loose connection where the lead connects The lead also has a J-shaped retention wire to help maintain its shape.
to the pacemaker generator. Manipulation of the pulse generator The tip of the retention wire may occasionally protrude from the
within the pocket may relieve or reproduce the patient’s problem. plastic-coated lead. This protruding wire has the potential to punc-
A pneumothorax and/or hemothorax may be detected in patients ture the right atrium or superior vena cava and cause a hemorrhagic
whose pacemakers have been recently implanted. pericardial effusion that may result in cardiac tamponade.
FIGURE 34-5. Schematic of a pacemaker’s electrocardio-

graphic monitor strip. A. Pacemaker activity without a mag-
net applied. B. Pacemaker activity with a magnet applied.
FIGURE 34-6. Schematic of an electrocardiographic monitor strip of an AV sequential pacemaker demonstrating lack of capture or intermittent capture.
PACEMAKER INTERROGATION is corrected, tape the magnet in place over the pacemaker genera-
tor. If the generator is pacing intermittently, the magnet may not be
Recent pacemakers contain crucial information such as the range directly over the pacemaker generator. Reposition the magnet and
of heart rate, percentage of pacing, intracardiac ECG recordings observe the results. If no pacemaker spikes are seen on the ECG, a
as well as arrhythmia logs.9 The pacemaker can be interrogated to component of the system (i.e., generator, battery, or leads) has failed.
obtain generator life, lead integrity, false discharges, undersensing, If the pacemaker spikes occur at less than the programmed rate, the
and oversensing. The device interrogation by the industry represen- battery may be depleted or the set rate has been changed.
tative or a cardiology technician is a vital part of the Emergency
Department evaluation of a patient presenting with symptoms that
FAILURE TO CAPTURE (LACK OF
might be attributed to the pacemaker. The interrogator, in consul-
tation with the patient’s Cardiologist, may have the capability of
CAPTURE OR INTERMITTENT CAPTURE)
changing the threshold setting on the device to resolve certain prob- Failure to capture is detected by the lack of a QRS complex after
lems and negating the need for admission.10 an appropriately timed and placed pacemaker spike on the ECG
(Figure 34-6). It occurs when the generated pacing impulse is inca-
ELECTROCARDIOGRAPHIC ABNORMALITIES pable of effectively depolarizing the myocardium. Lack of capture or
intermittent capture could be as a result of the inadequate energy gen-
FAILURE TO PACE eration by the pacemaker (i.e., battery failure), increased resistance
at the electrode–myocardium interface (i.e., lead fracture or dis-
Failure to pace is a result of either pacemaker output failure (i.e., placement), poor electrode positioning, prolongation of the refrac-
lack of a pacer spike) or failure to capture (i.e., lack of a myocar- tory state of the myocardium (e.g., myocardial infarction, electrolyte
dium stimulation after a pacer spike). Failure to pace is noted by a abnormalities, supratherapeutic levels of antidysrhythmic drugs), or
lack of the pacemaker spike on the ECG and the failure to deliver perforation of the myocardium by the electrode.10 For patients with
a stimulus to the myocardium when there is a pause in the intrin- failure to capture as a result of high antidysrhythmic drug levels, iso-
sic cardiac electrical activity. The pacer-dependent patient may proterenol has been shown to be an effective therapy.10,11
complain of chest pain, dizziness, lightheadedness, weakness, near- Failure to capture during the postimplantation period could
syncope, syncope, or other signs of hypoperfusion. result from an elevated voltage threshold for pacing due to tissue
The failure of pacemaker output is detected by the lack of pac- changes at the electrode–myocardium interface.10,11 The occurrence
ing activity (i.e., pacer spikes) on the ECG in a patient with a of postimplantation failure to capture typically occurs in the first
heart rate lower than the programmed rate. It can be the result of few weeks after implantation. However, its incidence has decreased
oversensing or an inherent problem with the device. Total or nearly because of recent advances in steroid-eluting leads.10,11
total battery failure, complete inhibition of a demand pacemaker A poor threshold may be present from the time of implantation.
by skeletal muscle contraction or electrical magnetic interference, A chronic rise in threshold can be related to fibrosis around the tip
oversensing, insulation failure, lead fracture, or an improper con- of the lead, causing lack of capture or intermittent capture. Severe
nection between the electrode and the pulse generator can all cause metabolic abnormalities and drugs can increase the pacing thresh-
total lack of pacemaker stimulus. The incorrect diagnosis of a failure old. A myocardial infarction involving the myocardium at the tip of
to pace and a lack of pacemaker output can be made if the patient’s the pacer leads will cause a rise in the pacing threshold. Lead fracture
pacemaker spike is very small. The evaluation of multiple leads of and poor connections between the electrode and generator can pres-
the ECG tracing usually prevents this misdiagnosis. ent as lack of capture or intermittent capture. The pacemaker genera-
Oversensing is the inappropriate inhibition of the pacemaker tor battery may fail and present with too low a voltage to capture the
due to its sensing of signals that it should otherwise ignore. For heart but enough voltage to generate a pacemaker spike. Insulation
instance, P or T waves or skeletal muscle activity may be misinter- breaks in the pacemaker lead allow parallel electrical circuits to
preted as QRS complexes resulting in the inhibition of pacemaker occur in the system and may cause various pacemaker abnormalities.
function. Oversensing has decreased in prevalence due to the use
of bipolar pacing devices.9 Oversensing can be detected by placing a
RATE CHANGE
magnet over the pacemaker. If it is working properly, the pacemaker
will fire at the programmed rate. This indicates that the failure to Rate change is defined as a stable change in the pacemaker’s rate
pace the myocardium in a patient with bradycardia is due to over- of firing compared to the pacemaker’s rate at the time of implan-
sensing. The unit may be sensing a large T wave as a QRS complex. tation. Minor chronic changes in the pacemaker rate of one or
Alternatively, it may be sensing a normal T wave as a QRS complex if two beats per minute can occur in some patients. The most com-
the QRS complexes are small in amplitude. If a patient’s bradycardia mon cause for a marked drop in the paced rate is battery depletion.
FIGURE 34-7. Schematic of an electrocardiographic monitor strip demonstrating

intermittent or erratic prolongation of the pacing spike interval. FIGURE 34-8. Schematic of an electrocardiographic monitor strip demonstrating
lack of appropriate sensing or failure to sense.
This is a sign that the elective battery replacement time is nearing. PMT. Management includes the application of a magnet, Valsalva
Inappropriate sensing of the preceding T wave as a QRS complex maneuvers, transcutaneous pacing, and various isometric pectoral
can also result in a paced rate several beats per minute slower than exercises. Other methods to terminate this rhythm include a precor-
the programmed rate. dial thump, reprogramming the pacemaker, and cutting the leads as
they exit the pacemaker generator. Consult a Cardiologist prior to
INTERMITTENT OR ERRATIC PROLONGATION performing any of these maneuvers.
OF THE PACING SPIKE INTERVAL
COMPLICATIONS OF
A prolongation of the pacing spike interval can be due to inappro-
CARDIAC PACING UNRELATED TO
priate sensing of the T wave, pacemaker afterpotential, or skeletal
muscle activity (Figure 34-7). Intermittent fracture of leads, poor
ELECTROCARDIOGRAPHIC ABNORMALITIES
electrode–generator connection, breaks in the insulation of the
leads, external electromagnetic interference, or radiofrequency IMPLANTATION-RELATED COMPLICATIONS
interference can also cause this malfunction. Complications may occur from the implantation procedure.
Discomfort and ecchymosis at the incision site or the pacemaker
FAILURE TO SENSE OR UNDERSENSING pocket are common in the first few days. Dehiscence of the incision
Failure to sense is a result of the inability of the pacemaker to can occur, especially if a large hematoma in the pocket puts excessive
sense the native cardiac activity. It is recognized by noting pace- stress or pressure on the incision. Nonsteroidal anti-inflammatory
maker spikes on the ECG despite the patient’s intrinsic car- drugs, excluding aspirin, are adequate and appropriate to alleviate
diac rate being higher than the pacemaker’s programmed rate the discomfort. Assure the patient that the discomfort and ecchy-
(Figure 34-8). Patients with an undersensing pacemaker might mosis will resolve spontaneously. The patient should not be taking
present with weakness, lightheadedness and syncope due to altera- aspirin in the immediate postimplantation period unless authorized
tions in rhythm due to competition with the native cardiac rhythm. and/or prescribed by the Cardiologist. The pacemaker can migrate,
The pacemaker does not sense the preceding QRS complex appro- cause pressure on the overlying skin, and result in skin erosions that
priately and fires. Causes of undersensing include conditions that require pacemaker relocation and wound debridement.
alter the nature of cardiac signals such as new bundle branch blocks, The most common insertion site for the pacemaker wires is
myocardial ischemia, premature ventricular contractions (PVCs), through the subclavian vein using a blind insertion technique.
or premature atrial contractions.10 Other etiologies of failure to Complications include air embolism, arteriovenous fistula forma-
sense include poor electrode position, lead dislodgement, reed tion, brachial plexus injury, hemothorax, pneumothorax, subcla-
switch malfunction, breaks in the lead insulation, battery failure, vian artery puncture, subcutaneous emphysema, and thoracic duct
and inappropriate programming of the sensitivity of the pulse gen- injury. Refer to Chapter 49 for complete details on complications
erator. However, many of these etiologies can also result in failure to related to the placement of a central venous line.
capture. Low-amplitude QRS complexes or broad QRS complexes A hematoma may form at the site of the subcutaneous pacemaker
with a low slow rate, as in a bundle branch block, may be responsible generator. This can be due to anticoagulation therapy, aspirin ther-
for pacemaker sensing problems. apy, or an injury to a subcutaneous artery or vein. A hematoma can
be managed with the application of dry, warm compresses to the area
and oral analgesics. The Cardiologist may evacuate the hematoma if
PACEMAKER-MEDIATED TACHYCARDIA
it continues to expand and threatens to compromise the incision site.
Pacemaker-mediated tachycardia (PMT) is a paced rhythm in Otherwise, a hematoma is self-limited and resolves spontaneously.
which the pacemaker is firing at a very high rate (Figure 34-9). Do not attempt to aspirate a hematoma. This is usually unsuccess-
PMT can occur only when the pacemaker is programmed to an ful, can introduce an infection, may damage the pacemaker or leads,
atrial synchronized pacing mode (e.g., DDD). PMT is a reentry and does not address the etiology of the bleeding.
dysrhythmia commonly precipitated by a PVC in a patient with a The ventricular wall may be perforated during the implantation
dual-chamber pacemaker. If the PVC is conveyed in a retrograde of the pacemaker lead or postimplantation. The patient may be
fashion through the AV node, it may be sensed as a retrograde P asymptomatic, complain of chest pain and/or dyspnea, or have signs
wave. The sensed retrograde P wave is considered by the pace- and symptoms of cardiac tamponade. Other signs suggestive of ven-
maker as atrial activity and the pacemaker initiates ventricular pac- tricular perforation include diaphragmatic contraction or hiccups
ing.10,12 This continues via an endless loop involving the pacemaker. at a rate equal to the pacemaker rate, a friction rub, intercostal mus-
Modern pacemakers have algorithms to prevent and terminate cle contractions at a rate equal to the pacemaker rate, pericardial
FIGURE 34-9. Schematic of an electrocardiographic moni-

tor strip demonstrating pacemaker-mediated tachycardia.
effusions, pericarditis, or a right bundle branch pattern on the ECG. few complications. Diaphragmatic stimulation can also occur with-
The evaluation may include chest radiography, echocardiography, out perforation of the right ventricular wall. Decreasing the pulse
and/or pacemaker interrogation and evaluation. width and/or voltage output can minimize the stimulation until the
defective component can be replaced.
PACEMAKER SYNDROME Pectoral muscle stimulation is less common with the currently
available bipolar pacemakers. An insulation break or a defect in
The pacemaker syndrome is defined as adverse hemodynamic
the pacing wire before it enters the subclavian vein will allow the
effects that cause the patient to become symptomatic or limit their
current to flow in the area of the pacemaker generator and cause
ability to be fully functional even though the pacemaker system is
skeletal muscle stimulation. This can also be seen with current leak-
functioning normally. Patients may complain of anxiety, apprehen-
age from the connector of the pacing wires or sealing plugs. In rare
sion, dizziness, fatigue, pulsations in the neck, or shortness of breath.
instances, erosion of the protective coating of the pacemaker gen-
Ventricular pacing can cause a lack of atrioventricular synchrony,
erator can cause this phenomenon. Decreasing the pulse width and/
leading to decreased left ventricular filling and subsequent decreased
or voltage output can minimize the stimulation until the defective
cardiac output. Syncope and near-syncope are thought to be associ-
component can be replaced.
ated with a vagal reflex initiated by elevated right and/or left atrial pres-
sures caused by dissociation of the atrial and ventricular contractions.
THROMBOSIS
The high wedge pressure can result in shortness of breath. Patients
with the pacemaker syndrome most commonly have documented Thrombosis of the vein (e.g., subclavian or cephalic) containing
one-to-one ventricular-to-atrial conduction during ventricular pac- the pacemaker lead occurs commonly, but rarely causes clinical
ing. Patients with retrograde AV conduction are more symptomatic. symptoms. Patients with symptomatic thrombosis and occlusion
However, a pacemaker syndrome can occur in the absence of retro- of the subclavian vein may present with ipsilateral edema and pain
grade atrioventricular conduction. Provide supportive care until the in the upper extremity. Occlusion of the superior vena cava can
pacer can be upgraded to one that restores AV synchrony, such as result in a superior vena cava syndrome. Thrombus formation in
changing a single-chamber pacer to a dual-chamber pacer. the right atrium and/or right ventricle can result in pulmonary
emboli and hemodynamic compromise. Fortunately, these events
RUNAWAY PACEMAKER are extremely rare.
The runaway pacemaker is a rare medical emergency in which ALLERGIC REACTIONS
rapid pacer discharges occur above its preset upper limit.
Ventricular tachycardia or fibrillation may be induced. The cause is Allergic reactions to the metal components of the pacemaker have
a malfunction in the pacemaker pulse generator, unlike PMT, which been noted in the past. Current pacemaker generators and leads are
is caused by an external re-entrant loop.10,11,13 Runaway pacemaker coated with a substance to prevent the body from being exposed to
can be differentiated from PMT by the response to the application of the metal. Allergic reactions to the pacemaker covering are very rare
a magnet. PMT will usually stop temporarily by inducing asynchro- but have been reported.
nous pacing with a magnet. However, magnet application generally
has little or no affect on a runaway pacemaker.12 Treatment requires SUMMARY
emergent pacemaker interrogation and reprogramming. If this fails,
Routine follow-up of patients with pacemakers in the pacemaker
emergent surgical intervention to disconnect or cut the leads in the
clinic helps to identify pacemaker malfunction earlier and often
pacemaker pocket is necessary. Fortunately, all modern pacemakers
before problems occur. Patients presenting to the Emergency
are programmed to prevent discharges at rates above a set limit, usu-
Department with symptoms referable to pacemaker malfunction
ally 180 beats per minute.13
should have a history and physical examination, chest radiograph,
routine ECG, and ECG recording with a magnet over the pace-
INFECTION maker. This helps to identify patients with pacemaker malfunc-
Infection often occurs shortly after implantation and is usually local- tion who require detailed pacemaker interrogation. A Cardiologist
ized to the pacemaker pocket area. However, endocarditis has also should be consulted on every patient who presents with an actual or
been reported in association with pacemakers. Infection may pres- a potential pacemaker problem.
ent as localized erythema and tenderness, localized inflammation,
purulent discharge from the skin incision, skin erosion, sepsis, and/
or bacteremia. Staphylococcus aureus is responsible for many acute
infections while Staphylococcus epidermidis is a frequent culprit of
late or chronic infection.14 The pacemaker generator and leads usu- Automatic Implantable
ally have to be removed to eradicate an infection. In some instances,
the infection has been treated successfully with vancomycin or other
35 Cardioverter-Defibrillator
parenteral antibiotics and the pacemaker did not require removal.
The pacemaker electrode becomes endothelialized in a few weeks
Assessment
postimplantation. Patients generally do not require prophylactic Carlos J. Roldan
antibiotics when they undergo a procedure that is likely to produce
transient bacteremia. Prophylactic antibiotics are required only in INTRODUCTION
the first few weeks after permanent pacemaker implantation.
The introduction of implantable cardioverter-defibrillator (ICD)
STIMULATION OF THE DIAPHRAGM technology has revolutionized the fields of cardiology and electro-
physiology. More than 100,000 such devices are implanted annually
AND PECTORAL MUSCLE
in the United States alone. ICDs allow life-threatening ventricu-
Stimulation of the diaphragm may be caused by perforation of the lar tachycardia and ventricular fibrillation to be safely controlled
right ventricular wall by the pacing wire and can occur with very and benefit patients at risk for sudden cardiac death. Multiple
CHAPTER 35: Automatic Implantable Cardioverter-Defibrillator Assessment 219
studies (e.g., CABG patch, MADIT, MADIT II, MUSTT, DINAMIT,

AMIOVIRT, COMPANION, SCD-HEFT) have examined the pro-
phylactic indication for ICD therapy in high-risk groups.1–7 The
ICD is becoming a more common therapeutic option for the young
population with a diagnosis of Brugada syndrome, prolonged QT
syndrome, and hereditary cardiomyopathies to name a few.
The Emergency Department is often the initial contact point for
these patients. Now more than ever Emergency Physicians must
be familiar with the problems that can be encountered by a patient
with an ICD. This chapter describes technical aspects, basic inter-
rogation of the device, and a general approach to a patient who
presents to the Emergency Department with an ICD.
TECHNICAL CONSIDERATIONS
The ICD has four main functions. It recognizes and records local
atrial and ventricular electrogram signals. It then classifies the
sensed signals according to programmable heart rate zones. The
ICD provides therapy (i.e., a shock) to terminate ventricular tachy-
cardia or ventricular fibrillation. It has a pacing capability for bra-
dycardia and/or cardiac resynchronization therapy. When detection
criteria are satisfied, therapy to terminate the arrhythmia is initiated
with high-energy shock of up to 40 Joules (J).
ICD technology has progressed exponentially since its intro-
FIGURE 35-2. The current nonthoracotomy system. The development of smaller
duction by Mirowski and colleagues in the early 1980s.8 The ICD
generators and biphasic waveforms for defibrillation allowed for transvenous posi-
system is comprised of a pulse generator, a battery, and a lead tioning of the ICD leads and a pectorally located generator.
system. The lead system is required for sensing, pacing, and the
delivery of therapy. Earlier systems required that the pulse genera-
tors be placed abdominally due to their large size (Figure 35-1).
Defibrillation was delivered via two epicardial patches positioned electrodes. Initial lead placement required either a sternotomy, lat-
anteriorly and posteriorly. Occasionally, a transvenous spring elec- eral thoracotomy, or a subxiphoid approach, making early implants
trode in the superior vena cava was utilized with an epicardial quite cumbersome.9
patch. Sensing was achieved through separate epicardial screw-in The smaller size of the newer devices allows for superficial implan-
tation of the pulse generator in the anterior chest wall, similar to a
pacemaker (Figure 35-2). The current ICD systems are comprised
of three main parts. The pulse generator is programmable and capa-
ble of analyzing and recording the patient’s heart and rhythm. The
ICD generator houses the batteries, high-voltage capacitors, and
microprocessors necessary to process sensed intrinsic cardiac elec-
trical activity. In essence, the generator is a minicomputer within a
hermetically sealed titanium can (aka case) capable of generating
shocks. Typical ICDs contain lithium silver vanadium oxide cells
that store between 2 and 7 Volts (V).12 The high voltages necessary
for defibrillation are generated with the aid of high-voltage capaci-
tors that are able to generate 700 to 800 V of defibrillation energy
in under 20 seconds. The lead system or wires are inserted into the
right ventricle for single chamber devices or both the right atrium
and right ventricle for dual chamber devices. The leads are required
for sensing, pacing, and the delivery of therapy. The final compo-
nent is the battery to power ICD system.
ICD implantation has evolved quite rapidly due to advancements
in lead technology, generator technology, and the development
of biphasic defibrillation waveforms, which lowered the energy
requirements necessary for successful defibrillation.10 The creation
of a (bipolar) lead combining pacing and sensing capabilities with
a high-voltage electrode coil allowed for nonthoracotomy system
implants, which reduced surgical morbidity and mortality.11 The
leads were now positioned transvenously via the subclavian vein and
fixed to the inside of the right ventricle. However, the leads still had
to be tunneled subcutaneously to the abdomen, as the generators
remained fairly large. Technology has advanced the development
FIGURE 35-1. Abdominal placement of the ICD generator. Initial implants of more compact generators. The smallest commercially available
required a thoracotomy to position the epicardial patches needed for defibrillation devices today are under 40 cm3 and weigh well under 100 grams.
as well as the screw-in sensing leads. The leads were tunneled abdominally to the Smaller generators allow for subcutaneous pectoral implantation
ICD generator. and simplification of the implantation process (Figure 35-2).12
Current ICDs allow extensive programmability for tiered anti- interval values, classification markers for each interval, episode
tachycardia pacing (ATP), tiered high voltage therapies, single or plots, textual episode descriptions, energy, charge time and imped-
dual chamber bradycardia pacing, supraventricular tachycardia ance values for shocks, and device classifications of therapy success.
(SVT) discrimination algorithms, and detailed diagnostics of tachy- This diagnostic information can be extremely valuable to determine
cardic and bradycardic episodes. Implantable loop recorders and whether programming changes should be made.18
home monitoring (HM) functions extend the technical capabilities
for automatic detection of arrhythmias that may not be symptom- BATTERY AND CAPACITORS
atic. It also allows for a fully automatic and wireless data transmis-
sion, including episode counters.9,10 This allows alterations in device Battery longevity is significantly different among manufactur-
programming or medication dose modifications in the outpatient ers. Battery voltages and capacitor charge times must be noted.
setting, thus avoiding hospitalization.13,14 Capacitors with smaller or larger capacities and changes in the ini-
ATP may be enabled to manage ventricular tachycardia. ATP tial shock polarity have not significantly improved defibrillation
commonly consists of a burst of pacing (i.e., 6 to 10 beats) at a rate efficacy.19 A variation in the number and position of electrodes
faster than the ventricular tachycardia rate. ATP may be felt by the can significantly influence the defibrillation threshold.19 Generator
patient. It is painless and often terminates the ventricular tachycar- replacement is usually recommended when voltages fall below the
dia before the patient becomes symptomatic. ATP is the initial pre- elective replacement indicator (ERI), which is approximately 2.6 V.
ferred treatment, even for fast ventricular tachycardias, with shocks When battery voltage falls below 2.2 V, the battery has reached its
programmed as a backup if ATP fails.15 In addition, current ICDs end of life (EOL). This signifies a more urgent need for battery
have an antibradycardia function that works like a pacemaker. If the replacement. The need to replace a generator is also dependent
heart rate falls below the programmed rate, the ICD will provide a on capacitor charge times. Two consecutive charge times greater
pacing function with significantly less forceful shocks. than 16 seconds is considered prolonged and may warrant urgent
Exercise testing should be performed with the realization that replacement regardless of the battery voltage. Automatic capaci-
increasing the heart rate above the programmed ventricular tachy- tor reformation is usually set to every 6 months to replenish their
cardia and ventricular fibrillation detection rate is likely to elicit charge. This function can be programmed at preset time intervals.
therapy (i.e., a shock) from the ICD. Consult the patient’s Elec- More frequent reformation is required and performed as the device
trophysiologist before any exercise or stress testing. Determine reaches the battery EOL.
the programmed the ICD arrhythmia detection rate. During the
exercise or stress test, if the programmed rate is approached, stop LEAD INTEGRITY
the test to avoid the delivery of inappropriate therapy (i.e., a shock).
With the growing number of prophylactic ICD implantations and
generator replacements, concern about the long-term reliability
ROUTINE ICD FOLLOW-UP of chronically implanted leads increases. ICD lead failure can be
A systematic follow-up procedure to assess the integrity of the ICD caused by an insulation defect or conductor disruption. Lead failure
system is recommended every 1 to 6 months depending upon the can affect the high voltage lead or the pace–sense circuit of the lead.
device, battery status, and arrhythmia frequency (Table 35-1). The Newer ICDs provide lead-impedance monitoring for early detection
device should be interrogated with the appropriate system analyzer of lead failure. An abnormal impedance indicates conductor frac-
to assure battery voltage, lead and electrode integrity, and capacitor ™
ture or insulation defect. An audible signal (Patient Alert ) notifies
charge times. System integrity test results can reveal malfunctions the patient who should then immediately contact their Cardiologist
that may compromise the device’s ability to treat an arrhythmia or present to the Emergency Department. Retrospective data from
effectively.16,17 Once the system’s integrity has been verified, each single centers suggest a potential clinical benefit of Patient Alert™
recorded arrhythmic episode should be analyzed to determine the for ICD lead failure detection.20
appropriateness and effectiveness of therapies. This is achieved by Various parameters are checked to ensure lead integrity, includ-
examining the stored diagnostic information contained within the ing pacing thresholds, lead impedance, and the size of intracardiac R
ICD, which may include intracardiac electrograms, arrhythmic waves. At the time of implantation, a pacing threshold of ≤1.0 V at a
pulse width of 0.5 milliseconds is desired. An acute rise in threshold
may be seen initially; it generally falls with time. Chronic thresh-
olds range between 0.5 and 2.0 V. Epicardial leads generally exhibit
TABLE 35-1 The ICD Follow-Up Checklist
higher thresholds. Any change in thresholds must be compared
• Detailed history of shocks, palpitations, light-headedness, syncope, chest with prior trends to assess its significance. Pacing thresholds may
pain, and dyspnea, or symptoms of congestive heart failure also change with the administration of antiarrhythmic drug ther-
• Note any changes in medications (i.e., antiarrhythmic therapy) apy. Potential complications of ICD lead failure include oversensing
• Physical examination (examine incision site for any indication of infection)
of electrical noise, undersensing of ventricular tachyarrhythmias,
• Interrogate device with appropriate system analyzer
• Check lead parameter including pacing thresholds and lead impedances inappropriate therapy, and lethal antiarrhythmic therapy.21
(sensing is established by examining intracardiac R waves) Current devices measure lead impedance only once a day. It is
• Determine capacitor reformation times unlikely that such discrete measurements will reveal abnormal
• Check battery voltage (longevity is typically 5–10 years dependent on use) impedance if lead failure causes sporadic dysfunction. Thus, multi-
• Measure impedance of the high-voltage coil (In older ICDs, this may require ple impedance measurements per day may be necessary to enhance
the administration of a subthreshold shock) ™
the sensitivity of the Patient Alert .22 Lead impedances will vary
• Analyze arrhythmia counters. Examine corresponding intracardiac based on the type of lead. The high voltage impedance measure-
electrograms to determine appropriateness of therapy ment differs between devices.23 Normal impedances range from
• Make the necessary program changes. These include adjusting the 300 to 1200 Ohms (Ω). A sudden change in impedance may signal
tachycardia zones, changing the detection cutoff rates, turning on special a problem with lead integrity. A high impedance reading suggests
features to aid tachycardia discrimination (stability, sudden-onset criteria, the possibility of lead or patch fracture. A low impedance indicates
and electrogram width), and adjusting the sensitivities a problem with the insulation. The impedance of the high-voltage
• Confirm changes and reinterrogate device coil must also be evaluated. Epicardial and active can systems
FIGURE 35-3. The intracardiac electrogram as recorded by the ICD. Printouts were obtained from a Medtronic Gem II DR dual-chamber ICD. The first line shows an ECG
rhythm strip (lead II). The marker channel directly under the rhythm strip indicates behavior (sensing/pacing) in each chamber. The third line represents the intracardiac
electrogram from the atrium (left) and ventricle (right). Measured in millivolts per millimeter, larger signals imply better sensing.
demonstrate lower impedance values compared to endocardial premarket and postmarket safety and effectiveness of medical
systems due to their larger surface area. Normal values generally devices marketed in the United States. They require manufacturers
range between 20 and 80 Ω. High impedance values, as with the to submit annual reports detailing the number of device implants
pace/sense leads, usually indicate a fracture in the defibrillation and malfunctions that have occurred.24
system. Any stark changes in impedance levels may suggest a patch Individuals with recently implanted devices may be quite anxious
problem. This includes crinkling, seroma formation, or migration. and may seek medical attention even after a single ICD discharge.
Any impedance change in an endocardial system may indicate lead Patients may also present after multiple ICD discharges or in full
dislodgement. cardiac arrest, requiring cardiopulmonary resuscitation (CPR). The
R-wave amplitude is a direct measure of intracardiac electrogram warmth, local redness, and pain associated with a potential infec-
activity and determines the device’s ability to sense. At implantation, tion of the ICD pocket may prompt the individual to seek medical
an R wave of ≤5 mV is desired to ensure adequate detection of ven- attention. Questions regarding interactions between ICDs and elec-
tricular fibrillation. The most common explanations for a decrease tromagnetic interference (EMI) will arise more frequently. These
in R-wave amplitude after an implant are lead dislodgment or local clinical situations are discussed in more detail below.
factors such as edema or fibrosis. This change may be associated Patients with ICDs must be placed on continuous telemetry.
with an increase in lead impedance and pacing thresholds. Perform a detailed and complete history and physical examina-
tion. The patient should be questioned regarding the number of
ANALYZING APPROPRIATENESS OF THERAPY shocks received, symptomatic palpitations, presyncope, symp-
toms of congestive heart failure, or symptoms consistent with
Current ICDs have simultaneous marker channels with real-time angina. The pocket site must be examined for evidence of local
intracardiac electrograms (Figure 35-3). It is important to docu- infection, including warmth, tenderness, and discharge. Upper
ment intracardiac activity during sinus rhythm. These electrograms extremity or neck swelling ipsilateral to the inserted endocardial
can be used as a basis of comparison with tachycardia events. The lead suggests the possibility of a subclavian vein or superior vena
signals should be examined for evidence of noise, which may be an cava thrombosis.25 Bilateral head edema and neck vein swelling
indicator of sensing problems, a connector issue, or a faulty adaptor. suggest the possibility of a superior vena cava thrombosis or a
In the event of noise detection, electrograms must be examined dur- superior vena cava syndrome. It is important to document any
ing various maneuvers including deep breathing, arm maneuvers, changes in medications or whether antiarrhythmic therapy has
and bending. Intracardiac electrograms should be examined for recently commenced. Routine blood work should be obtained,
T-wave oversensing or detection of pacemaker spikes as ventricu- including a complete blood count, serum electrolytes, magnesium
lar signals. In dual-chamber devices, oversensing by the atrial lead level, renal function indices, and quantitative levels of measurable
should be ruled out. Wide variations in electrogram size may sug- medications.
gest that the lead is not stable or well fixed. The ICD model should be identified. Patients are generally given
identification cards that list the manufacturer, lead system, genera-
tor model, and a 24 hour emergency contact number. Often this
THE ICD IN THE EMERGENCY DEPARTMENT
information is not available. However, in an emergency situation, an
A patient with an implantable defibrillator may present to the overpenetrated chest radiograph showing the generator will demon-
Emergency Department for various reasons. Manufacturers strate the radiopaque identifier of the manufacturer.
offer 24 hour technical support. They also maintain a registry of The chest radiograph may be of diagnostic importance. It is not
devices implanted and evaluations performed. A staff of field only important for device identification but can also give useful
engineers are often available for help with the assessment, inter- information about lead integrity. In a recent implant, a chest radio-
rogation, and management of ICD function. The US Food and graph is routinely performed to assure lead positioning, slack in
Drug Administration (FDA) is responsible for assessing both the the lead, and to rule out other thoracic pathology. In patients with
epicardial patches, the chest radiograph is an excellent tool for dem- generate before it stops producing shocks. This number is usually
onstrating patch crinkling, fracture, or migration. With endocardial five to seven shocks. However, if the patient’s cardiac rhythm reverts
systems, the lead can again be assessed for fractures or discontinui- to normal sinus rhythm, the ICD can reset and start shocking the
ties. Fractures can occur anywhere along the lead. They are most patient again to the set maximum number of shocks. Multiple ICD
commonly seen near the junction of the first rib and the clavicle, a discharges or shocks in a short period of time can cause severe bat-
condition referred to as “subclavian crush.” tery depletion. Ongoing arrhythmias not adequately treated by the
If the patient presents with a ventricular arrhythmia and is hemo- device, myocardial infarction, electrolytes imbalances, and ICD mal-
dynamically stable, attempts should be made to obtain a 12-lead function are all possible etiologies that warrant medical attention.
electrocardiogram (ECG) before any interventions are made to ter- Emergency Department patients presenting with multiple ICD
minate the arrhythmia. Often this may be difficult due to concomi- discharges require immediate attention. From a psychological
tant discharges from the device, an anxious staff, and an anxious perspective, multiple discharges are usually not well tolerated and
patient. Antiarrhythmic medications such as amiodarone, procain- can be emotionally devastating to the patient.25 Myocardial injury
amide, and β-blockers may have to be considered in the event of and transient reduction in left ventricular function can occur as a
recurrent ventricular tachycardia. Despite the absence of clinical result of multiple shocks.28 This has been associated with a poorer
trials examining the efficacy of lidocaine, it is generally considered long-term prognosis. Multiple discharges can lead to premature
the treatment of choice in the setting of an acute myocardial infarc- depletion of battery life.
tion or acute ischemia if the patient is experiencing a ventricular
arrhythmia. ESTABLISHING THE ETIOLOGY
It is important to establish the etiology of the shocks in order to
EMERGENCY DEACTIVATION administer proper and prompt management (Table 35-2). It is
(MAGNET BEHAVIOR) of the utmost importance to determine whether the shocks are
The ability of an ICD to identify and treat tachyarrhythmias appropriate for ventricular tachycardia or fibrillation, inappropri-
can be temporarily disabled with the use of a magnet. This sit- ate therapy, or phantom shocks.49 More than one-third of patients
uation may arise in the setting of multiple ICD discharges where with a history of ventricular tachycardia or ventricular fibrillation
the shocks are not tolerated or prior to a surgical procedure where receive a shock within 2 years of the ICD implantation.29 Recurrent
electrocautery is necessary. Emergency deactivation with a magnet ventricular tachyarrhythmia is a common cause of repeated ICD
can result in serious complications such as causing a battery indica- firing. Ineffective termination of a tachyarrhythmia in this situ-
tor to switch to “end of life” and the loss of some antitachycardia ation can be the result of an increase in defibrillation thresholds
therapies.26 The application of a donut-shaped magnet overlying secondary to concomitant antiarrhythmic drug therapy and lead
the ICD pulse generator forms a magnetic field that trips a reed migration or lead dislodgement. Inefficient termination can occur
switch in the ICD generator circuit. This results in a suspension if inappropriately low amounts of energy are programmed for the
of tachycardia detection and therapy delivery. Generally, a single initially administered shock. Shocks may also be the result of inap-
magnet will suffice. In obese patients or in the presence of pock- propriate detection of SVTs, the most frequent of which include
ets with significant edema, two or more magnets may be required sinus tachycardia and atrial fibrillation.30 The administration of
to achieve deactivation.27 The patient must be fully monitored, a low-energy shock may convert a benign SVT into an unstable
a cardioverter-defibrillator unit must be readily available, and ventricular arrhythmia resulting in an ICD proarrhythmia. The
Advanced Cardiac Life Support (ACLS) medications must be introduction of an atrial lead in dual-chamber devices has aided
readily available if an ICD is to be deactivated. in the discrimination process between SVTs and ventricular
The magnet response of an ICD varies subtly from manufacturer tachyarrhythmias. Rapid SVTs are particularly a problem in chil-
to manufacturer. In Medtronic devices, the application of a mag- dren and athletic individuals in whom exercise or reductions in
net temporarily disables tachycardia detection and therapy with no
effect on bradycardia pacing. Removal of the magnet will resume
arrhythmia detection. When activated, newer Medtronic ICDs (Gem TABLE 35-2 Causes of Frequent ICD Discharges
II DR, patient alert function) will elicit a continuous beep lasting for
Appropriate
15 seconds if a magnet is placed directly over the ICD. A magnet
Sustained ventricular tachyarrhythmias
applied over Guidant (CPI) ICDs also inhibits tachycardia therapy Recurring episodes, each one terminated by a shock
with no effect on bradycardic pacing. These devices will generate One shock needed to terminate each episode of sustained ventricular
beeping tones, which change to a continuous tone. The constant tachyarrhythmia
tone indicates that the device is off and will not deliver tachycardia Nonsustained ventricular tachyarrhythmias
therapy. The device can be turned back on by reapplying the magnet Inappropriate
over the ICD for 30 seconds. Tones will now change from continu- Supraventricular tachyarrhythmia that satisfies detection criteria
ous to beeping synchronous with R waves, signifying that the device Atrial fibrillation
is on again. Newer-generation Guidant ICDs (Prism II) have a built- Sinus tachycardia
in electrocautery feature that can be activated by use of the Guidant Paroxysmal SVT
programmer. This will suspend tachyarrhythmia therapies and pace Oversensing of signals
in the DOO mode. Regular functioning of the ICD is restored by Sensing lead failure (migration or dislodgement)
turning this feature off. Environmental electrical noise
Double and triple counting of pacing artifacts
ICD DISCHARGES P-wave oversensing
T-wave oversensing
Patients who experience a shock but feel unwell after the event or Electromagnetic interference
who receive more than one symptomatic ICD therapy within a Increase in defibrillation thresholds (antiarrhythmic drug therapy)
short period of time (i.e., minutes to hours) require emergent evalu- Phantom (absence of both arrhythmia and ICD discharge)
ation.27,28 Most ICDs have a limit to the number of shocks it can Random component failure
FIGURE 35-4. Inappropriate ICD discharge. Intracardiac electrogram of a patient with a Ventak Mini III presenting with repetitive ICD discharges. Examination of the intra-
cardiac electrograms (line 2) demonstrates noise sensed as ventricular fibrillation (FS) resulting in an inappropriate shock (CD). Noise was traced to an insulation break in
the ICD lead. Lead replacement corrected the problem.
medications that slow the heart rate, such as β-blockers, are com- control the patient’s ventricular response with atrioventricular (AV)
monly encountered causes of inadequate shocks from sinus or nodal blocking agents such as diltiazem, verapamil, β-blockers, and
SVT. Inappropriate ICD firing can occur because of the erroneous digoxin. Chemical cardioversion or electrical cardioversion may be
detection of noise or interference that can be the result of insula- attempted in the event of hemodynamic instability. Shocks second-
tion breakdown or a loose set screw (Figure 35-4). Oversensing ary to prolonged episodes of nonsustained ventricular tachycardia
of T waves, pacing artifacts, R waves, and electromagnetic inter- can be prevented by adjusting initial detection parameters coupled
ference may also lead to inappropriate detection and discharge. with the addition of antiarrhythmic drug therapy.
Patients who have received painful shocks occasionally suffer Patients with an ICD can develop “electrical storm.” Patients
from phantom shocks, which are the perception of a shock in the in electrical storm require immediate attention. This condition
absence of any arrhythmia or therapy from the ICD.49 Finally, ran- involves recurrent, hemodynamically unstable ventricular tachy-
dom component failure should be considered if all other causes cardia or fibrillation occurring two or more times in a 24-hour
have been ruled out. period.32 Potential triggers can be found in approximately 66% of
patients and include new or worsened heart failure, changes in anti-
APPROACH TO THE PATIENT arrhythmic medication, psychological stress, and hypokalemia. In
WITH MULTIPLE ICD DISCHARGES most patients, electrical storm consists of monomorphic ventricu-
lar tachycardia indicating the presence of a reentry mechanism.
These patients must be under constant ECG monitoring. Apply Ventricular fibrillation is rare and may be indicative of acute isch-
defibrillator pads in anticipation of the development of an unstable emia. The key intervention in electrical storm is reduction of the
cardiac arrhythmia. In devices with limited stored diagnostic capa- elevated sympathetic tone by intravenous β-blockers, benzodiaz-
bilities, this may be the only means of establishing a shock-rhythm epines, and amiodarone.33
correlation. Sedation is reasonable in extremely anxious patients. An Electrophysiologist should be promptly consulted and
Once the patient is stabilized, obtain an electrophysiology consulta- the patient stabilized prior to transfer to the intensive care unit
tion for assistance in interrogating the ICD. The device should be (ICU). Defibrillator pads should be applied in anticipation of the
interrogated and stored electrograms obtained for analysis.31 For development of unstable cardiac arrhythmias. Potential reversible
instance, it is often useful to inquire about the pattern of ICD dis- causes, such as electrolyte abnormalities, need to be identified and
charge. Consecutive shocks occurring within a few seconds suggest promptly corrected. If torsades de pointes is established, the treat-
an inappropriate discharge for SVT, oversensing, or device failure. ment of choice is magnesium and/or temporary cardiac pacing.
On the other hand, isolated shocks occurring every few minutes Thrombolysis or urgent catheterization/intervention may be needed
may be indicative of recurrent ventricular tachycardia. Progressive in the setting of an acute myocardial infarction. If analysis of stored
dyspnea on exertion, shortness of breath, orthopnea, or paroxysmal electrograms demonstrates ineffective discharges, the ICD should
nocturnal dyspnea suggests new onset or worsening heart failure, be deactivated. Attempts to terminate the arrhythmia in the hemo-
which can precipitate ventricular arrhythmias. Potential reversible dynamically stable patient via ATP is a useful option. Intravenous
causes, such as electrolyte abnormalities, need to be identified and antiarrhythmic drugs are a necessary adjunct in these situations.
promptly corrected. The administration of amiodarone in combination with β-blocker
Careful examination of the 12-lead ECG is crucial. Specific therapy has been shown to be successful in the management of elec-
ST-segment changes may imply an acute coronary syndrome and trical storm.34 Often a combination of antiarrhythmic drugs will be
determine the need for primary intervention or thrombolytic required. Bretylium should be reserved until other antiarrhythmic
therapy. An ECG obtained during an actual shock may establish agents have failed.
whether the culprit arrhythmia is a supraventricular or ventricular
tachycardia.
ICDS AND CARDIAC RESUSCITATION
If the discharges are inappropriate, the ICD should be emergently
deactivated, as previously described. Supraventricular tachyarrhyth- Patients who have an ongoing arrhythmia when evaluated emer-
mias should be managed with intravenous drug therapy, such as gently should be managed according to ACLS guidelines regard-
adenosine, diltiazem, or verapamil. In the situation where discharges less of the presence of an ICD. Although in the vast majority of
are secondary to rapid atrial fibrillation, attempts must be made to instances ICD function will be found to be appropriate, this cannot
be assumed.18 ACLS guidelines should be followed and the device APPROACH TO AN INFECTED ICD
considered inactive.35,36 If the clinical situation permits and an ICD
programmer is readily available, the device should be deactivated. The goals of therapy include identifying the culprit organisms,
This will prevent the reinduction of ventricular fibrillation or tachy- establishing the extent of the infection, and containment of the
cardia due to concomitant ICD discharges that may occur during infection. In the Emergency Department, routine laboratory tests
CPR. There is often some hesitation to initiate resuscitative mea- should be obtained that include a complete blood count and differ-
sures in patients with an ICD for fear of getting shocked. This ential. Blood for cultures should also be drawn, but it must be kept in
fear is understandable but unwarranted. Although a mild electric mind that they are often negative. Wound cultures and gram stains
shock might be perceived, these discharges do not pose a risk to may be helpful in differentiating an infection from a pocket hema-
persons administering CPR, nor do they damage external monitor- toma, sterile subcutaneous fluid accumulation, or an inflammatory
ing devices. reaction to pacemaker components. Attempts to aspirate the pocket
External defibrillation is permissible, although the paddles or should be performed in consultation with an Electrophysiologist
pads should be positioned away from the ICD. Individuals with and/or a Surgeon. A sterile pocket or hematoma can often become
epicardial patches may require higher energies for defibrillation. infected after an aspiration.
Current can be shunted from the myocardium through the patches. There is no single diagnostic modality that can determine the
Moreover, the insulated portion of the patch serves as a shield from extent of the infection. ICD infections should never be assumed
the administered shock. In patients with epicardial patches, an to be localized, as organisms can migrate from the leads into
anteroposterior paddle configuration has been suggested for chang- the heart. In patients with epicardial patches, a chest radiograph
ing the defibrillation vector.37 may reveal patch deformities or wrinkling, suggesting distal
The ICD may be reset after external defibrillation is delivered, migration of the infection. A computed tomography (CT) scan
especially if the paddles or pads are located in close proximity to can also detect localized fluid accumulation and patch wrinkling.
the generator. It is important that ICDs be reinterrogated after Echocardiography has been utilized to confirm the presence of veg-
the successful completion of a resuscitation to ensure that pro- etations on the leads or coil. Gallium and indium scans may be help-
grammed parameters have not been altered, including the pacing ful in localizing an infection.
thresholds. Although a few reports suggest that infection of a defibrillator
system may be controlled, the treatment of choice continues to be
removing the entire system followed by the administration of par-
INFECTION OF AN ICD enteral antibiotic agents. Some localized infections restricted to the
ICD generator have been managed with the removal of the genera-
Technological advances have made a gradual reduction in the size tor, debridement, and systemic antibiotic therapy. Vancomycin is
of the pulse generator possible. This small size permits superficial frequently used as an empiric agent when cultures are still pending
implantation of the pulse generator in the anterior chest wall.38 The given its good coverage against coagulase-negative staphylococci
ICD implantation technique is similar to pacemaker implantation. and methicillin-resistant S. aureus (MRSA). Empiric gram negative
ICD infections can involve the generator pocket, the leads, or both. and fungal coverage may be necessary in the immunocompromised
Infection is more likely after a recent generator replacement.39 An patient.
infected ICD system represents a serious medical situation that
should be dealt with urgently. The incidence of infection ranges ELECTROMAGNETIC
from 2% to 11% in systems that were implanted via thoracotomy INTERFERENCE AND ICDS
or sternotomy.40 The infection rates for nonthoracotomy implants
approach those of pacemakers and range from 0.8% to 1.5%.39–43 The ability of ICDs (and pacemakers) to function is dependent on
Infections generally present clinically within 6 months of the their ability to sense intrinsic cardiac electrical activity. Hermetic
implant, but more typically within the first 3 months. Infection shielding, filtering, interference rejection circuits, and bipolar sens-
should be suspected when local and systemic signs and symptoms ing have safeguarded ICDs (and pacemakers) against the effects
of inflammation are apparent. Prompt referral to a specialist is of common electromagnetic sources. However, exposure to elec-
warranted. In almost all cases, removal of the ICD and all leads is tromagnetic interference (EMI) may still result in oversensing,
required. Endocarditis prophylaxis with antibiotics is not generally asynchronous pacing, ventricular inhibition, and spurious ICD
warranted. discharges. EMI may also lead to loss of output, increased pacing
Systemic symptoms are seen in up to 50% of patients, especially in thresholds, and decreased R-wave amplitude. Common sources of
those with infections caused by Staphylococcus aureus.44 The pocket EMI include cellular phones, electronic article surveillance (anti-
and/or incision site is often visibly erythematous, warm, and tender. theft) devices, and metal detectors. Occupational sources of EMI
A fever may be present. Blood work often reveals a leukocytosis. include high-voltage power lines, electrical transformers, arc weld-
Frank suppuration or device erosion may be seen. Pericarditis may ing, and electric motors. Interference can also be encountered
be evident if epicardial patches are infected. Blood cultures may aid through medical equipment and procedures such as magnetic
in documenting the culprit organism. Infections occurring late are resonance imaging, electric cautery, spinal cord stimulators, trans-
generally indolent and rarely present with fever or leukocytosis; cutaneous electric nerve stimulator units, radiofrequency catheter
moreover, blood cultures are generally negative. ablation, therapeutic diathermy, and lithotripsy.46
The most common microorganisms in 50% of infections Patients with ICDs and pacemakers should be instructed to avoid
include S. aureus and coagulase-negative staphylococci. Other environments with large magnetic fields. The use of cellular phones
common organisms include Escherichia coli, Pseudomonas, is permissible. However, the US Food and Drug Administration
Serratia, Corynebacterium, Propionibacterium acnes, Candida spp., (FDA) recommends that direct contact of the phone with the device
Streptococci, and atypical mycobacteria.45 Infection is generally the should be avoided. Use of the contralateral ear while using the phone
result of skin contamination during implantation of the ICD. It can is suggested. Although inappropriate shocks have been documented
also occur due to hematogenous seeding from distant intravenous through electronic article surveillance systems, recent studies have
sites, indwelling catheters, or from concomitant respiratory or uri- deemed it safe for patients to walk through these systems as long
nary tract infections. as they avoid lingering around these devices. New concerns have
CHAPTER 36: Pericardiocentesis 225
been raised regarding household appliances. Patients can be reas- an intervention for pericarditis.4 In 1829, Baron Larrey, Napoleon’s
sured that EMI is unlikely to affect their devices if induction ovens Surgeon, is reported to have performed the first successful pericar-
are used in their kitchens.47 diocentesis.5 By 1939, Bigger had suggested that some patients with
The strong magnetic fields of MRI can interfere with ICD func- cardiac tamponade could be managed with pericardial tubes alone,
tioning and induce electrical current flow in the ICD lead that can with prompt operation for recurrence.7
initiate an arrhythmia or be sensed as an arrhythmia and precipitate
spurious therapies. In general, patients with an ICD should not be ANATOMY AND PATHOPHYSIOLOGY
placed in an MRI field. Ongoing work is aimed at developing MRI-
compatible ICDs. There is no such problem with fluoroscopy, CT ANATOMY OF THE HEART AND PERICARDIUM
scanning, or nuclear-based imaging.
The pericardium is an inverted cone-shaped sack surrounding the
FUTURE DIRECTIONS IN ICD TECHNOLOGY heart and lying on top of the diaphragm (Figure 36-1). The inner
portion, or visceral pericardium, is a single layer of mesothelial cells
There are constant improvements being made in ICD technology. covering the epicardium. The outer layer is composed of a dense
A minimally invasive, entirely subcutaneous ICD (S-ICD®) has outer fibrous tissue with an inner layer of mesothelial cells known as
been developed (Cameron Health Inc., San Clemente, CA). The the parietal pericardium. The fibrous pericardium is attached to the
advantages include a simplified implantation procedure, it does not central tendinous portion of the diaphragm inferiorly. Superiorly,
require vascular access or intracardiac leads, no imaging or fluoros- the outer fibrous layer blends with the sheath covering the great ves-
copy equipment is required, and the device may be as effective as sels. Anteriorly, it attaches to the posterior surface of the sternum.
current ICD systems.48 Potential complications such as deep venous Posteriorly, it is attached to the thoracic vertebral column, esopha-
thrombosis, intracardiac thromboses, tricuspid valve disease, as well gus, bronchi, and aorta.
as those related to central venous access can be eliminated. The elec- The heart is contained within the pericardial sac (Figure 36-1B).
trode is implanted parasternally, and the ICD generator is implanted Numerous portions of the heart are exposed behind the anterior
on the anterolateral chest wall. Small trials have demonstrated that chest wall (Figure 36-2). This includes the right ventricle, left ven-
this system can effectively treat ventricular fibrillation.48 Further tricle, right atrium, left atrium, aorta, pulmonary artery, and inferior
clinical trials are required before this technology can be routinely vena cava (IVC). These structures are vulnerable to injury behind
implanted. the anterior chest wall9,10 (Table 36-1). The surface area that each of
these structures contributes to the anterior cardiac silhouette is also
SUMMARY listed in this table. These numbers reflect, roughly, the anatomic
incidence of injury with cardiac trauma.11 Traumatic injury to any
Expanding clinical indications, advanced new technology, and of these structures can result in a pericardial effusion and cardiac
the increasing number of annual implants require Emergency tamponade.
Physicians to become familiar with problems typically encoun- The pericardial cavity is a potential space between the visceral
tered by the patient with an ICD. Complications associated and parietal layers of the pericardium. Up to 50 mL of fluid is
with ICDs are not uncommon. Troubleshooting and program- normally contained within this space. The fluid acts as a lubri-
ming should ideally be performed in conjunction with a trained cant to the motion of the heart. Accumulation of fluid in the
Electrophysiologist. Patients presenting with cardiopulmonary pericardial space requiring drainage can have a variety of etiolo-
arrest may require the device to be deactivated and external defi- gies. From a review of several retrospective series, the estimated
brillation performed. Do not apply external defibrillation paddles causes and relative frequencies of pericardial effusions are listed
directly over the ICD. in Table 36-2.12–18
Cardiac tamponade is a life-threatening condition that must
be diagnosed and treated emergently. The diagnosis of cardiac
tamponade is primarily clinical. It may easily be overlooked
unless a high index of suspicion is maintained in both medical
Pericardiocentesis and trauma patients. Sauer and Murdock describe a “danger zone”
36 Eric F. Reichman, Elisabeth Kang,
and Jehangir Meer
for penetrating torso trauma19 (Figure 36-3). The superior border
is bounded by a line through the sternal notch. The lateral borders
are bound by a line through the midclavicle. The inferior border
is identified by a line through the epigastric area. Any penetrating
INTRODUCTION injury in the danger zone or through it has the potential to cause a
cardiac injury and pericardial tamponade.
Pericardiocentesis is the removal of fluid from the pericardial space
surrounding the heart. The fluid is usually aspirated with a needle
PATHOPHYSIOLOGY OF CARDIAC TAMPONADE
and syringe. Occasionally, a catheter is placed within the pericar-
dium or a surgical approach is used. This may be performed for The clinical effects of cardiac tamponade occur due to accumu-
diagnosis, to obtain pericardial fluid; to relieve a pericardial effu- lation of fluid under pressure in the pericardial space. This space
sion and improve cardiac output; or as a lifesaving measure to can become quite large over time. In some chronic disease states,
relieve a cardiac tamponade. The technique is relatively simple to pericardial effusions of 1 to 2 L can occur without signs of cardiac
perform yet has a significant rate of complications. tamponade.14,20 The ability of the pericardial sac to acutely stretch
Since humanity’s earliest times, penetrating cardiac injuries have is limited. Estimates of the volume of fluid required to acutely
held a dramatic place in both romantic and medical literature.1–8 In accumulate and produce a cardiac tamponade range from 60 to
1649, Riolanus first described pericardial tamponade.3 He noted 200 mL.
that an abundance of moisture is collected therein [the pericar- Cardiac tamponade should always be considered as a cause of
dium], which causes suffocation, and overwhelms the heart. In shock in the medical patient. This includes patients who are taking
1827, Thomas Jowett described the first use of pericardiocentesis as oral or parenteral anticoagulants, have known cancer, have known
A Pleural
Right lung reflection Left lung
B
Aortic arch
Internal thoracic
artery Pulmonary
Parietal layer trunk
Pericardium of serous
pericardium Transverse
Cardiac notch sinus
Pericardial
Oblique
cavity
sinus
Visceral layer Ascending

of serous aorta
pericardium
Fibrous Central tendon

pericardium of diaphragm
Lower border Pleural Liver Xiphoid
of lung reflection process
FIGURE 36-1. The pericardium. A. Relationship of the pericardium to the major thoracic structures. B. Midsagittal section through the heart and pericardium.
pericardial disease, are suspected of having an aortic dissection, or The pressure–volume relationship between the size of the peri-
have had a recent myocardial infarction. Cardiac tamponade can cardial effusion and the pressure imposed on the cardiac chambers
also be due to iatrogenic causes, including central venous line place- is exponential. The initial accumulation of fluid produces little or
ment, transthoracic cardiac pacing, transvenous cardiac pacing, and no clinical effect. The initial physiologic strategies of compensation
cardiopulmonary resuscitation. include an increase in the systemic venous pressure, catecholamine
release, and tachycardia. At some point, the ability of the pericar-
dial space to distend and accommodate more fluid is overwhelmed.
From this point on, even small amounts of fluid generate signifi-
cant and increasing pressure on the heart chambers. As the peri-
cardial pressure rises, venous filling of the right heart is drastically
impaired. The interventricular septum bulges into the left ventricle.
Left ventricular filling becomes compromised from the lack of flow
from the right ventricle and the bulging inward of the interventricu-
lar septum. Eventually, cardiac perfusion decreases, the heart suffers
injury, and the patient goes into a state of shock.
A progressive decline in cardiac output occurs as pericardial fluid
accumulates and intrapericardial pressure increases.21 Initially, the
right atrial pressure is greater than the intrapericardial pressure as
the body compensates by increasing venous return. This is followed
by the equilibration of the right atrial and intrapericardial pressures.
Eventually, as the heart chambers cannot achieve a pressure lower
than the surrounding pericardial fluid pressure, equilibration of
TABLE 36-1 Structures Vulnerable to Injury Behind the

Anterior Chest Wall
Anatomic structure %*
Right ventricle 55
Left ventricle 20
Right atrium 10
Left atrium 1
FIGURE 36-2. View of the heart and great vessels, which can become injured Aorta and pulmonary artery 10
behind the anterior chest wall (AO, aorta; IVC, inferior vena cava; LA, left atrium; Inferior vena cava 4
LV, left ventricle; PA, pulmonary artery; RA, right atrium; RV, right ventricle; SVC, * The percentages represent the surface area of each structure and the estimates of
superior vena cava). incidence of injury with cardiac trauma.9–11
TABLE 36-2 The Etiologies and Relative Frequencies of by the accumulating pericardial fluid. The only time the right heart
Pericardial Effusions can fill is during systole, when the internal volume of the heart is
Etiology Relative frequency (%) reduced. The changes in the jugulovenous waveforms cannot be
evaluated in the supine and/or immobilized trauma patient.
Cancer 15–40
Kussmaul’s two signs, paradoxical increase of the jugulove-
Connective tissue diseases 2–11
Idiopathic 13–14 nous pressure during inspiration and pulsus paradoxus, may be
Infectious (including HIV) 2–14 seen in patients with cardiac tamponade. Pulsus paradoxus is a
Postpericardiotomy 2–16 drop in systolic blood pressure of ≥10 mmHg during inspiration. To
Radiation therapy 4–7 measure this, inflate the blood pressure cuff until the cuff pressure
Trauma 7–9 is greater than the patent’s systolic pressure. Slowly release the cuff
Uremia 5–10 pressure until beats are heard only during expiration. Keep deflating
Source: Adapted from references 12 to 18. the cuff pressure until beats are heard continuously in both inspira-
tion and expiration. The difference between these two physiologic
points is the amount of pulsus paradoxus. This normal physiologic
finding is exaggerated by the accumulation of pericardial fluid, forc-
diastolic pressure in each heart chamber occurs and produces the ing the right heart and interventricular septum into the left ventricle.
greatest drop in cardiac output. As the intrapericardial pressure Electrocardiographic and radiographic signs of cardiac tampon-
continues to increase, the cardiac chambers collapse, resulting in ade are often not present. Changes on the electrocardiogram (ECG)
intractable hypotension and death. The disproportionate effects of may be present in patients with cardiac tamponade. A pericardial
the later accumulation of small amounts of fluid explain why with- effusion surrounding the heart, if large enough, can result in a “low
drawal of even a small amount of fluid from the pericardial cavity voltage” ECG tracing. Electrical alternans is a change in the mor-
can produce dramatic temporary improvements in the clinical sta- phology or amplitude of the QRS complexes on the ECG as the heart
tus of the patient. It also explains why “monitoring” patients for the swings to and fro within the pericardial fluid (Figure 36-4). It may
evolution of cardiac tamponade with central venous pressure lines is be associated with pericardial tamponade but is not pathognomonic.
dangerous, as the patient will proceed from stable and compensated Pulseless electrical activity (PEA) in the absence of hypovolemia or
to profoundly unstable quite suddenly. a tension pneumothorax is highly suggestive of cardiac tamponade.
Opinions differ as to the clinical significance of these findings. The
PATIENT EVALUATION finding of an enlarged cardiac silhouette on a chest radiograph may
Several clinical findings are associated with cardiac tamponade. be useful in chronic pericardial effusions but is usually absent or
Beck’s triad of muffled heart sounds, hypotension, and jugular nonspecific in the acute setting.
venous distention is associated with cardiac tamponade. Almost Traumatic cardiac tamponade can be caused by a variety of agents
all patients with cardiac tamponade will have at least one of these and etiologies. This includes bullets, knives, ice picks, displaced
signs. Unfortunately, very few patients with cardiac tampon- fractured ribs, central venous line placement, pacemaker insertion,
ade will have all three signs. Beck’s triad has been found in only pericardiocentesis, intracardiac injection, surgery, migrating pins or
up to 40% of patients with cardiac tamponade.22 These findings needles, nails ejected from machinery, and venous bullet emboli-
may be absent if the patient is hypovolemic due to hemorrhage. zation. Cardiac tamponade is the most common presentation of
Restlessness, fatigue, tachycardia, and tachypnea are often present. penetrating cardiac injuries overall. It occurs in 80% to 90% of
These can progress to shock, coma, and eventually death. stab wounds and 20% of gunshot wounds.11
Changes in the jugulovenous waveforms may be seen in cardiac Cardiac ultrasound has become the diagnostic procedure of
tamponade. Instead of the normal systolic X descent and diastolic choice to identify cardiac tamponade (Table 36-3). A prospective
Y descent, only the systolic X descent occurs in cardiac tampon- study showed that bedside ultrasound performed by Emergency
ade. This is a result of the increased diastolic pressure being exerted Physicians and Trauma Surgeons was 96% accurate and 90% sensi-
tive.23 Cardiac ultrasonography performed on trauma patients can
be 98% to 100% accurate and sensitive in diagnosing pericardial
fluid and cardiac tamponade.22,24–27 The series of 261 patients had no
false negatives. Other studies have demonstrated false-negative rates
in the range of 5% to 40%.19,28,29
Bedside ultrasound can rapidly confirm a suspected pericardial
effusion or cardiac tamponade and guide drainage. Blind pericar-
diocentesis has a complication rate as high as 50%, and an associated
mortality.15,16,30 Ultrasound-guided pericardiocentesis can decrease
the rate of complications by allowing visualization and avoidance
of adjacent anatomic structures. This increased safety factor is sup-
ported by multiple studies from the cardiology literature.31–33
Other ultrasonographic findings in pericardial tamponade include
a swinging heart, collapse of the right and left ventricular chambers,
and marked inspiratory changes in ventricular dimensions.10 Some
authors advocate using transesophageal echocardiography, even in
unstable patients, because of its superior imaging when compared
to transthoracic echocardiography.34 Other methods of imaging the
pericardium include computed tomography (CT), helical CT, and
magnetic resonance imaging. These modalities should be used only
for stable patients in whom the diagnosis of a pericardial effusion
FIGURE 36-3. The “danger zone” for penetrating chest trauma.19 and not cardiac tamponade is being considered.
FIGURE 36-4. Electrocardiogram of electrical alternans. A. Initial ECG in the Emergency Department. Bedside echocardiography revealed a large pericardial effusion with
right ventricular diastolic collapse. B. Resolution of electrical alternans after pericardiocentesis.
INDICATIONS • Three-way stopcock

• Plastic tubing
Significant controversy exists over the role of pericardiocentesis.9
The only indication for emergent pericardiocentesis would be in • Ultrasound machine
a patient in whom the life-threatening physiologic changes of car- • 3.5 to 5.0 MHz phased-array or curvilinear ultrasound probe
diac tamponade were present and the diagnosis was consistent with • Sterile ultrasound probe cover (can be a sterile glove)
known prior disease, a traumatic mechanism of injury, or a bed-
side Emergency Department ultrasound demonstrating a pericar- • Sterile ultrasound gel
dial effusion and/or cardiac tamponade. Pericardiocentesis is also • Variable-angle needle guide attachment if available
performed in the cardiac catheterization laboratory or the intensive • Nasogastric tube
care unit to obtain pericardial fluid for diagnostic testing. It may
also be performed in a cardiac arrest patient with PEA when other Subxiphoid Pericardial Window
etiologies for PEA have been ruled out or a pericardial effusion is • Electrocautery set
seen on ultrasonography. • Forceps
• Small retractor
CONTRAINDICATIONS
• Small rib spreaders
There are no absolute contraindications to performing a pericar- • Sutures, 2-0 Vicryl and 3-0 nylon
diocentesis in the unstable patient with signs of cardiac tamponade.
Uncorrected bleeding disorders in a stable medical patient would be • Sterile suction device
an absolute contraindication to performing the procedure. Small, • Yankauer suction catheter
loculated, or posteriorly located effusions in a stable patient are also • Suction tubing
considered contraindications. It is also contraindicated in cardiac
tamponade associated with an aortic dissection.35 Most Emergency Departments do not have single guidewires
While the dramatic beneficial effects of withdrawing even a small and 6 to 10 French flexible catheters readily available to use for a
amount of pericardial fluid are well documented, many authors feel pericardiocentesis. A commercially produced pericardiocentesis
that there is little or no role for pericardiocentesis in the trauma kit is available from numerous manufacturers and contains all the
patient. These authors argue that once the diagnosis of a pericardial required equipment (e.g., Merit Medical, South Jordan, UT; Boston
effusion is made, the patient should receive a prompt sternotomy.11 Scientific, Natick, MA). In an emergency situation, a 6 to 10 French
If the patient is too unstable for transport to the operating room, single-lumen central venous line access kit may be substituted.
an emergent thoracotomy should be performed. Aggressive fluid
replacement with crystalloid and blood products, as well as per- PATIENT PREPARATION
forming a needle thoracostomy (Chapter 38) to rule out a tension Explain the procedure, its risks, and benefits to the patient and/or
pneumothorax before a pericardiocentesis is contemplated in the their representative if time and the patient’s clinical condition per-
trauma patient.36 mit. A signed consent is not necessary as this is an emergent pro-
cedure. If possible, place the patient semirecumbent at a 30° to 45°
EQUIPMENT angle (Figure 36-5). This position brings the heart closer to the
anterior chest wall. The supine position is an acceptable alternative.
Pericardiocentesis Assess the patient for any mediastinal shift by physical examination
• Povidone iodine or chlorhexidine solution and chest radiography (if time permits). Apply the cardiac monitor,
• Sterile gloves and gown pulse oximeter, and supplemental oxygen to the patient. While the
• Face mask with eye shield or goggles placement of an arterial line is ideal, such a line may not be avail-
able. Place the noninvasive blood pressure cuff on the patient’s arm.
• Local anesthetic solution (1% lidocaine) Insert a nasogastric tube to decompress the stomach and decrease
• 25 gauge needle, 5/8 in. long the possibility of gastric perforation during the procedure.
• 18 gauge needle, 1½ in. long
• Syringes (10, 20, and 60 mL)
• Sterile drapes
• Towel clips
• 16 to 18 gauge spinal needle or catheter-over-the-needle, 7.5 to
12.5 cm long
• 18 to 20 gauge spinal needle or catheter-over-the-needle, 3.75 cm
long
• #11 scalpel blade
• 4 × 4 gauze squares
• Alligator clips connected by a wire
• Collection basin
• ECG monitor
• J-tipped guidewire, 0.035 mm in diameter
• Size 6 to 10 French flexible multihole catheter, 5 to 6 in long, with
or without a pigtail FIGURE 36-5. Ideal patient positioning for performing a pericardiocentesis.
local anesthetic solution at the site chosen to insert the needle. Inject
local anesthetic solution through the skin wheal and into the subcu-
taneous and muscular tissues of the wall of the torso.
Prepare the equipment. Set up a sterile field on a bedside table.
Open all required equipment and place it on the sterile field. The
Emergency Physician should wear full personal protective equip-
ment to protect themselves from contact with the patient’s blood
and body fluids. While time is of the essence and this is an emer-
gent procedure, aseptic technique should be followed. Attach the
spinal needle onto a 20 mL syringe containing 5 mL of sterile saline.
TECHNIQUES
BLIND INSERTION TECHNIQUE

Puncture the skin with a # 11 scalpel blade between the xiphoid pro-
cess and the left costal margin. Grasp the syringe with the dominant
hand. Insert the spinal needle through the skin incision and at a 45°
FIGURE 36-6. Potential sites to perform a pericardiocentesis.
angle to the midsagittal plane (Figure 36-7A) and at a 45° angle to
the abdominal wall (Figure 36-7B). Aim the tip of the spinal needle
toward the patient’s left shoulder (Figure 36-7A). Alternatively, the
Identify the anatomic landmarks necessary to perform this pro- spinal needle can be aimed toward the patient’s left midclavicle,
cedure. The needle can be inserted at numerous sites (Figure 36-6). right midclavicle, or sternal notch to theoretically lessen the chance
These include the following: below the xiphoid process, at the right of iatrogenic damage to the coronary arteries.
sternocostal margin, at the left sternocostal margin (subxiphoid Advance the spinal needle 4 to 5 cm while applying negative pres-
approach), in the left or right fifth intercostal space parasternally sure to the syringe and observing the cardiac monitor. Inject 0.25
(parasternal approach), or in the left fifth intercostal space at the to 0.50 mL of saline occasionally to ensure that the needle remains
midclavicular line (apical approach). The most commonly used site patent while advancing the needle. Continue advancing the spinal
is at the left sternocostal margin or the subxiphoid approach. This needle while applying negative pressure until there is a return of
is the approach described throughout the “Techniques” section of blood, cardiac pulsations are felt, or an abrupt change in the ECG
this chapter. waveform occurs. If the ECG waveform shows an injury pattern,
Surgically prepare the xiphoid and subxiphoid areas. Clean any dirt, withdraw the needle in 1 to 2 mm increments until the ECG pat-
debris, and fluid from the area. Apply povidone iodine or chlorhexi- tern normalizes. This indicates that the needle is touching or has
dine solution to the xiphoid and subxiphoid areas and allow it to dry. penetrated the myocardium. Stop advancing the needle.
Apply sterile drapes to delineate a sterile surgical field. Reidentify the Aspirate with the syringe. If a large volume of blood is quickly
anatomic landmarks. If the patient is awake, anesthetize the needle and easily withdrawn, it often means that the tip of the spinal needle
tract with local anesthetic solution. Place a subcutaneous wheal of is within the ventricle. Techniques to confirm the intraventricular
FIGURE 36-7. The subxiphoid approach. The needle is inserted at a 45° angle to the midsagittal plane (A) and at a 45° angle to the abdominal wall (B). The alligator clip
attached to the spinal needle is for the ECG-monitored technique and not the blind technique.
placement of the needle tip have been described and include the fol- needle in 1 to 2 mm increments until the injury pattern disappears.
lowing: observing that the aspirate does not form a clot, comparing Aspirate the pericardial fluid as described in the preceding section.
the patient’s hemoglobin to that of the aspirate, injecting fluorescein
and looking for a fluorescent flush under the skin of the eyelids, or SELDINGER TECHNIQUE
injecting 3 mL of dehydrocholic acid (decholin) and asking whether
An indwelling catheter may be placed in the pericardial cavity to
the patient experiences a bitter taste. These are time-consuming and
drain the pericardial fluid (Figure 36-9). This may be done in cases
less reliable than ultrasound, if available.
of medical or traumatic pericardial effusions, since the pericardial
When the pericardial space is entered and fluid is aspirated,
fluid often reaccumulates. An indwelling catheter allows intermit-
there should be a marked improvement in the patient’s clinical
tent drainage of pericardial fluid without the potential complications
status. The procedure can be terminated at this point. Alternatively,
associated with repeated needle sticks from a pericardiocentesis. This
the Emergency Physician may want to withdraw as much fluid as
procedure can “buy time” if an operating room and/or a Surgeon is
possible. When the syringe is filled with fluid, stop withdrawing
not immediately available to perform a pericardial window.
the plunger. Stabilize the spinal needle against the patient’s torso
The technique is similar to that of placing an indwelling central
and remove the syringe. Replace the syringe with a new one and
venous line. Clean and prepare the patient. Insert the spinal needle,
continue the procedure. Alternatively, attach a three-way stopcock
blindly or with ECG monitoring, as described in the previous sec-
between the spinal needle and the syringe. Attach intravenous
tions (Figure 36-7). Aspirate to confirm that the tip of the spinal
extension tubing to the stopcock. An assistant can open and close
needle is within the pericardial cavity (Figure 36-9A). It is impera-
the stopcock while the physician aspirates fluid and ejects it through
tive that the tip of the spinal needle be within the pericardial cav-
the intravenous extension tubing and into a basin. As the pericar-
ity and not within the cardiac chamber. If intracardiac placement
dial space is drained, the epicardium will approach the needle tip.
of the needle is suspected, the position of the needle must be
If an injury pattern appears on the cardiac monitor, withdraw the
verified by one of the methods described in the section on “Blind
needle slightly and continue to aspirate fluid. Remove the needle
insertion technique,” by fluoroscopy, or using ultrasonography.
when fluid can no longer be aspirated.
Grasp and stabilize the spinal needle with the nondominant
hand. Gently remove the syringe from the spinal needle with the
ECG-MONITORED TECHNIQUE
dominant hand. Insert the guidewire through the needle and into
The purpose of ECG monitoring is to prevent accidental ventricu- the pericardial cavity (Figure 36-9B). Advance the guidewire until
lar puncture with the spinal needle. Attach one alligator clip to the approximately one-third of its length is within the patient. Stabilize
base of the spinal needle and the other to the V1 lead of the ECG the guidewire with the nondominant hand. Remove the needle over
machine or cardiac monitor (Figure 36-8). The V1 lead will serve the guidewire while leaving the guidewire within the pericardial
as an active electrode based at the tip of the spinal needle. As the cavity (Figure 36-9C).
spinal needle is advanced, an injury pattern noted by ST-segment Stabilize the guidewire with the nondominant hand. Advance
elevation will be seen if the myocardium is contacted or penetrated the dilator over the guidewire and into the pericardial cavity (Fig-
by the spinal needle. The presence of a premature ventricular con- ure 36-9D). If the guidewire is within the heart, dilating a tract
traction or a ventricular arrhythmia can also signify contact with through the myocardium can result in cardiac tamponade and/or
the myocardium. exsanguination. It is therefore imperative to know that the guide-
Prepare the patient as previously described. Prepare the equip- wire is within the pericardial cavity and not within the heart.
ment (Figure 36-8). Turn on the ECG machine or cardiac moni- Remove the dilator while leaving the guidewire within the peri-
tor. Insert and advance the spinal needle, as described previously, cardial cavity. Advance the soft multihole catheter over the guide-
while observing the ECG monitor or cardiac monitor. If an injury wire and into the pericardial cavity (Figure 36-9E). Remove the
pattern or premature ventricular complexes are seen, withdraw the guidewire while leaving the catheter within the pericardial cavity
FIGURE 36-8. Equipment preparation for the ECG-monitored

technique.
FIGURE 36-9. The Seldinger technique. A. The spinal needle is inserted into the pericardial space. B. The guidewire is inserted through the needle. C. The needle has
been removed and the guidewire remains within the pericardial cavity. D. The dilator is advanced over the guidewire to dilate the needle tract. E. The catheter is advanced
over the guidewire. F. The guidewire has been removed and the catheter remains within the pericardial cavity.
(Figure 36-9F). Secure the catheter at the skin with the nondomi- TABLE 36-3 Ultrasonographic Findings of Cardiac Tamponade
nant hand. Attach a syringe to the catheter and aspirate pericardial
Ultrasonographic mode Findings
fluid. This should cause a rapid improvement in the patient’s clinical
status. Detach the syringe and attach a three-way stopcock to the Doppler Mitral flow decreases during inspiration
Mitral flow increases during expiration
catheter.20 Secure the catheter to the skin with nylon sutures.
Tricuspid flow increases during inspiration
ULTRASOUND-GUIDED TECHNIQUE Tricuspid flow decreases during expiration
Peripheral flow decreases in expiration
Many authors feel that ultrasound-guided pericardiocentesis is now M-mode color Doppler Mitral flow decreases during inspiration
the standard of care.14,20,37,38,44 The heart is best scanned with the Mitral flow increases during expiration
patient in the semierect or left lateral position if no contraindica- Tricuspid flow increases during inspiration
tions exist. Use the 3.5 to 5.0 MHz phased-array or curvilinear ultra- Tricuspid flow decreases during expiration
sound probe. Examine the heart and pericardial space in 2D and M-mode/2D Diastolic collapse of the right ventricular free wall
Doppler mode to determine the extent of the pericardial effusion Inferior vena cava dilation
and the area with the largest pericardial effusion.39,40 This is usually Inferior vena cava does not collapse on inspiration
around the apex of the heart. There are established ultrasonographic Increase left ventricular wall thickness in diastole
findings that help to distinguish a pericardial effusion from a car- Left atrial collapse
diac tamponade (Table 36-3).35 Left ventricular collapse
View the heart and pericardial space using the three standard car- Right atrial collapse
diac ultrasound views. These are the subxiphoid or subcostal view, the Swinging heart to and fro
parasternal long axis view, and the apical four-chamber view. Refer Source: Adapted from reference 35.
FIGURE 36-12. A curvilinear probe placed in the subxiphoid region. The probe
is aimed toward the patient’s left shoulder. The probe marker is pointing to the
patient’s right. Note the shallow angle required to visualize the heart.
FIGURE 36-10. A phased-array probe placed in the left parasternal window adja-
cent to the sternum, between the second and fourth interspace. The probe marker
is pointing to the patient’s left hip.
Ultrasonographic features that suggest cardiac tamponade are
noted in Table 36-3. This includes right ventricular diastolic col-
lapse (Figure 36-14), right atrial systolic collapse, large pericardial
to Chapter 29 for a more complete discussion on cardiac ultrasonog- effusion, and dilatation of the IVC. Evaluate the IVC. Place the
raphy. Pericardial fluid is anechoic, appears black on ultrasound, and ultrasound probe in the subxiphoid region, with the probe marker
will collect in a dependent location. Thus, small pericardial effusions pointing toward the patient’s head. The IVC runs parallel with and
will be first seen in the posterior pericardium. Large pericardial effu- to the right of the aorta. Use M-mode to measure the diameter of
sions appear circumferential, extending around the heart. the IVC. The normal IVC ranges from 1.5 to 2.5 cm in diameter
The decision to use a parasternal (Figure 36-10) or an apical and displays respiratory variation. In cardiac tamponade, the IVC is
(Figure 36-11) window depends on which ultrasound views of the dilated, measuring >2.5 cm in diameter, and does not display respi-
pericardial effusion and heart are able to be obtained. The ideal ratory variation.
site is where the pericardial effusion is most superficial, has a large Position the patient. Determine the location to perform the
stripe or thickness, and where no other structures (e.g., lung or pericardiocentesis. Clean, prep, and drape the patient as described
liver) are in the path from the skin to the heart.33,41 The subxiphoid
window (Figures 36-12 & 36-13) is not recommended for ultra-
sound-guided pericardiocentesis. This view commonly includes the
left lobe of the liver in the anterior portion of the ultrasound image.
Under these conditions, the needle might puncture the liver on the
way into the pericardial cavity.
FIGURE 36-13. Subxiphoid ultrasound window demonstrating the four-chamber

view (RV, right ventricle; LV, left ventricle; RA, right atrium; LA, left atrium) of a heart
FIGURE 36-11. A phased-array probe placed in the apical window at the point of with a pericardial effusion (asterisks). The liver is noted anterior to the heart. The
maximal impulse (PMI). The probe marker is pointing to the patient’s right. arrows point to the posterior pericardium.
FIGURE 36-14. Pericardial tamponade with right ventricular collapse (arrowhead). FIGURE 36-16. Needle seen entering the pericardial effusion from the right of the
A large pericardial effusion (asterisks) is visible. Arrows point to the posterior peri- image (Ultrasound image courtesy of Beatrice Hoffman, MD.)
cardium (RV, right ventricle; LV, left ventricle; LA, left atrium; AO, aortic root).
ultrasound image confirms the location of the needle. An alternative

previously. Apply a sterile probe cover over the ultrasound probe. to this technique is to use color Doppler to localize the needle tip.45
Apply sterile ultrasound gel over the prove cover. Reidentify and con-
firm the proper ultrasound probe position.41 This is usually the point SUBXIPHOID PERICARDIAL WINDOW
where the pericardial effusion is closest to the chest wall.39,40 Insert
the spinal needle under ultrasound guidance into the chest wall A pericardial window will minimize false-negative results seen with
(Figure 36-15). Insert the needle over the superior border of the rib a pericardiocentesis, iatrogenic bleeding, and cardiac tamponade
to avoid the neurovascular intercostal bundle under the inferior edge from myocardial injury by the pericardiocentesis needle. Prepare
of the rib. Aspirate as the needle tip is carefully advanced under direct the patient as previously described. Inject local anesthetic solution
ultrasound visualization into the pericardial space (Figure 36-16). subcutaneously from the xiphoid process across the confluence of
If there is any question as to whether the needle tip is in the peri- the lower ribs and 6 cm down the midline (Figure 36-17A). Inject
cardial space, or if bloody fluid is aspirated, use agitated saline to local anesthetic solution into the muscular layers in the midline over
confirm proper needle placement.39–42,46 This requires two 5 mL the xiphoid process and continue approximately 8 cm inferiorly.
syringes, one filled with sterile saline and the other filled with air. Make a midline longitudinal incision from the xiphisternal
Attach the syringes to a three-way stopcock. Rapidly move the ster- junction to about 8 cm below the tip of the xiphoid process (Fig-
ile saline back and forth through the two syringes, creating an aer- ure 36-17A). Incise down to the linea alba. Bluntly dissect the space
ated saline solution. Rapidly inject the aerated solution through the behind the xiphoid and lower sternum to separate the anterior dia-
spinal needle. The identification of hyperechoic “bubbles” on the phragm from the sternum. Lift the lower sternum with a retractor
(Figure 36-17B). Use an electrocautery unit, if available, for hemo-
stasis. Bluntly divide the fatty tissue and retrosternal attachments of
the diaphragm to reveal the pericardium beneath the angle of the
xiphoid and the left costal margin.47 It will often appear blue in color
due to underlying blood.
Grasp the pericardium with a forceps. Incise the pericardium
with a scissors or with shallow strokes of a scalpel (Figure 36-17B).
Fluid should rush out rapidly. Remove a piece of the pericardium to
make sure that it remains open. Gently explore the pericardial space
digitally and with the suction catheter to remove any clot and fluid.
Allow the skin to stay open to permit free drainage of the pericardial
space. Alternatively, place a 28 French chest tube in the pericardial
space and secure it with a purse-string suture through the pericar-
dium (Figure 36-17C). The chest tube may exit the skin incision
or a separate incision in the skin. Attach the chest tube to a suc-
tion source. Close the linea alba with interrupted 2-0 Vicryl sutures.
Close the subcutaneous tissue and skin with 3-0 nylon sutures.
CATHETER-OVER-THE-NEEDLE TECHNIQUE
FIGURE 36-15. Ultrasound probe and the pericardiocentesis needle in the apical A long catheter-over-the-needle mounted on a syringe may be used,
window. if available, instead of a spinal needle mounted on a syringe. Use a
FIGURE 36-17. The pericardial window. A. The site of the skin incision. B. The xiphoid and sternum are lifted upward to expose the pericardium. An incision is made and
a piece of the pericardium is removed. C. A chest tube is inserted into the pericardial space to allow continuous drainage of fluid.
16 to 18 gauge, 7.5 cm or longer catheter-over-the-needle for older The blind technique can also be performed using the paraster-
children, adolescents, and adults. Use an 18 to 20 gauge, 3.75 cm nal, intercostal, or periapical approaches. It was previously recom-
catheter-over-the-needle for infants and small children. The pro- mended to insert the needle perpendicular to the skin and 3 to 4 cm
cedure is the same as using a spinal needle up to the point of the lateral to the sternum for the parasternal approach to avoid the
needle entering the pericardial space. Stop advancing the catheter- internal mammary artery. Needle insertion just lateral to the sternal
over-the-needle once the pericardial space is entered. Securely hold border will also avoid the internal mammary artery.48 The intercos-
the syringe so it does not move inward or pull outward. Advance the tal approach should not be blindly used as it increases the risk of
catheter over the needle and into the pericardial cavity. Continue to lung penetration by the needle and a subsequent pneumothorax. A
advance the catheter until its hub is against the skin. Securely hold blind apical approach is also not recommended. The lingula of the
the catheter hub against the skin. Remove the syringe and needle as left lung and the pleural space are close to this site. A needle can
a unit. Attach a 20 mL syringe to the catheter hub and aspirate. The puncture the lung or aspirate a pleural effusion.
remainder of the procedure is as described previously.
ALTERNATIVE APPROACHES ASSESSMENT

The subxiphoid approach is the classic or traditional approach, and It must be emphasized that the lack of blood return does not rule
has been described previously. The use of bedside ultrasonography out the diagnosis of cardiac tamponade. False-negative aspirations
is changing the technique to a more apical approach.31,42 This area from a pericardiocentesis are well documented and are described at
tends to be closer to the anterior chest wall and where the pericar- rates as high as 80%.36 The occurrence of false-negative aspirations
dial effusion is the largest; both of which make the procedure easier is often due to clotted blood in the pericardial space that cannot be
to perform under ultrasound guidance. aspirated or from failure to enter the pericardial space.
A dramatic improvement in the patient’s clinical status should be false diagnoses and complications. The exact role of pericardiocen-
observed after the successful drainage of the pericardial space. This tesis in trauma remains controversial, but it may be lifesaving in the
is true even if only a small volume of 15 to 20 mL is drained. The unstable patient before they are able to receive definitive surgical
patient’s blood pressure and cardiac output should increase while therapy.
intracardiac pressure and intrapericardial pressure decrease. Obtain
a chest radiograph after the procedure to rule out a hemothorax
and/or pneumothorax. Obtain an ECG to look for changes consis-
tent with coronary artery injury from the needle.
A pericardiocentesis is often performed in the nontraumatic
medical patient. In these cases, send the pericardial fluid for chemi- Intracardiac Injection
cal, cytologic, and microbial analyses to determine the etiology of
the pericardial effusion. Routine laboratory analysis should include 37 Payman Sattar
the appearance of the fluid, a cell count and differential, glucose
level, lactate dehydrogenase (LDH) level, pH, and total protein
level. Cytology may reveal a malignant etiology of the effusion. INTRODUCTION
The microbiology lab should perform a gram stain, acid-fast stain,
The practice of intracardiac injection originated in the 1800s. It was
aerobic and anaerobic bacteria cultures, fungal cultures, and viral
quite commonly performed throughout the 1960s, as it was thought
cultures.
to be the most expeditious route of drug delivery during a cardiac
arrest.1,2 By the mid-1970s, the practice of intracardiac injection
AFTERCARE declined. Safer and simpler routes of medication administration
Secure the catheter with sutures to the skin and check for stabil- (i.e., intravenous, endotracheal, and intraosseous) became avail-
ity. If not already done, consult a Surgeon for definitive care of able. Experimental data suggested that there was no advantage to
trauma patients. Prepare these patients for rapid transport to the intracardiac injection over intravenous administration of medica-
Operating Room. Monitor patients for reaccumulation of pericar- tions. Cardiopulmonary resuscitation (CPR) must be interrupted to
dial fluid and for hemodynamic instability. If fluid reaccumulates, perform an intracardiac injection. In difficult patients or in inexpe-
the procedure should be repeated or the stopcock opened (if placed) rienced hands, the time required for this procedure may be too pro-
and the pericardial space reaspirated. Flush with sterile saline after longed. Finally, many serious complications may occur as a result of
each aspiration to maintain the patency of the catheter. Consult a an intracardiac injection.2
Thoracic Surgeon if purulent fluid is aspirated in medical patients.
All patients must be admitted to an intensive care unit for further ANATOMY AND PATHOPHYSIOLOGY
monitoring, evaluation, and treatment.
The technique of intracardiac injection is similar to that of a peri-
cardiocentesis (Chapter 36). Both techniques use the same anatomic
COMPLICATIONS landmarks, the same anatomic approach, and the transthoracic
Complication rates vary from 4% to 40%.14,43 The complication insertion of a needle through the pericardium. In performing a
rates of ultrasound-guided aspirations have been reported to be pericardiocentesis, the tip of the needle is inserted into the pericar-
less than 5%.14 Death may result from recurrence or occurrence dial space. Intracardiac injection requires the tip of the needle to
of tamponade, bleeding, or dysrhythmias. Few if any deaths have be inserted through the myocardium and into a cardiac chamber.
been reported with ultrasound-guided aspirations. Reaccumulation Echocardiography or bedside ultrasound may be useful in pericar-
of pericardial fluid may occur in up to 70% of blind aspirations.14 diocentesis to avoid the lung or myocardium.
Continuous drainage with a pericardial catheter can reduce this to Time is of the essence when performing an intracardiac injec-
25%.14 Bleeding, hemothorax, and/or cardiac tamponade can occur tion. Since the objective is to quickly enter the myocardial cavity,
due to injury of the myocardium, coronary arteries, pericardial vas- ultrasonographic guidance is generally not necessary. Keeping this
culature, or internal mammary vessels by the spinal needle. To mini- in mind, certain situations such as COPD, a prior lung resection, or
mize injury, do not rock the spinal needle or change its direction dextrocardia may benefit from ultrasonographic guidance to avoid
once it is inserted into the patient. A pneumothorax or pneumo- puncturing the lung.
pericardium can form from penetration of the lung by the spinal The technique of intracardiac injection is easy to teach, is rapid
needle. Dysrhythmias, ventricular fibrillation, ventricular tachycar- and simple to perform, and requires no special equipment. It begins
dia, or asystole can occur if the needle penetrates the myocardium. with identification of the anatomic landmarks required to perform
Hepatic damage leading to leakage of bile or blood can be seen if the the procedure (Figure 37-1). For the subxiphoid approach, iden-
needle penetrates the liver. If the patient is awake and alert, a vaso- tify and palpate the xiphoid process of the sternum and the left
vagal reaction can occur. False-negative aspirations (i.e., a dry tap) costosternal angle. For the left parasternal approach, identify and
occur if the blood in the pericardial cavity is clotted or if the needle palpate the left fourth or fifth intercostal spaces immediately adja-
is not within the pericardial cavity. False-positive aspirations may be cent to the sternum.
seen if the needle is within the heart chamber or a vascular structure.
INDICATIONS
SUMMARY
The primary indication for an intracardiac injection is when vascu-
Pericardiocentesis is an infrequently performed procedure. It can be lar access is not readily available or unobtainable in a patient with
lifesaving when a patient has a pericardial tamponade. The proce- asystole, pulseless electrical activity, pulseless ventricular tachycar-
dure is relatively simple yet has a significant rate of complications, dia, or ventricular fibrillation. The intracardiac injection of resusci-
morbidity, and mortality. The use of bedside Emergency Department tative medications may be warranted and can be attempted as a last
ultrasonography to assist in making the diagnosis and in guiding effort to resuscitate the patient if other routes of medication admin-
the placement of the pericardiocentesis needle dramatically reduces istration have failed.
CHAPTER 37: Intracardiac Injection 237
by palpation, the anatomic landmarks required to perform the pro-

cedure. Draw up the required dose of epinephrine into a syringe or
use prefilled syringes. Attach a spinal needle to the syringe contain-
ing the epinephrine.
TECHNIQUES
The two routes for intracardiac injection are the subxiphoid and
left parasternal approaches (Figure 37-1). Both are utilized in a
similar fashion. The left parasternal approach offers a more direct
and shorter route. However, it is associated with a higher rate of
complications. Both approaches require cessation of CPR in order
to perform the procedure. The procedure of intracardiac injec-
tion should be performed as rapidly as possible to avoid pro-
longed cessation of CPR, but not at the expense of safety to the
Emergency Physician, Nurses, and ancillary staff. It should take
less than 10 seconds to perform an intracardiac injection.
SUBXIPHOID APPROACH
Stop performing CPR. Stop ventilating the patient and allow the
FIGURE 37-1. Intracardiac injection. The needle is inserted 1 cm to the left of lungs to passively deflate. Identify the spot 1 cm to the left of the
the xiphoid process and aimed toward the left shoulder. The needle may also be patient’s xiphoid process in the costosternal angle (Figure 37-1).
inserted parasternally in the left fourth or fifth intercostal space (as denoted by the
Insert the needle with the bevel up, at a 30° to 45° angle to the skin
symbol “⊗”).
of the abdominal wall, and aimed toward the patients left shoulder.
Advance the needle while applying negative pressure to the syringe.
Stop advancing the needle when blood flows freely into the syringe.
CONTRAINDICATIONS This signifies that the tip of the needle is within the cardiac chamber.
Quickly inject the epinephrine, then withdraw the needle. Resume
As candidates for this route of medicinal delivery have undergone a CPR and ventilation of the patient.
cardiac arrest, there are no absolute or relative contraindications to If the attempt at intracardiac injection is unsuccessful, the nee-
performing this procedure. A few clinical conditions may make the dle should be withdrawn and flushed and intracardiac injection
procedure more difficult to perform. Chronic obstructive pulmo- reattempted. The needle can become plugged with subcutaneous
nary disease can shift the heart from its normal position and increase fat. CPR and ventilation must be resumed after each attempt at
the risk of a pneumothorax (with or without tension). Therapeutic intracardiac injection, whether successful or not. Variations on
or overanticoagulation may result in a hemopericardium and car- the direction of the needle can be made for subsequent attempts.
diac tamponade. Dextrocardia requires identification of different The needle may be directed toward the suprasternal notch, left mid-
anatomic landmarks and alterations in needle positioning. clavicle, or right midclavicle.
As an alternative, the spinal needle can be inserted through the skin
EQUIPMENT and into the subcutaneous tissue with its obturator in place. Remove
the obturator when the tip of the spinal needle is in the subcutane-
ous tissue. Attach the syringe containing epinephrine to the spinal
• 18 gauge spinal needle or 18 gauge 3½ in. needle (for adults) needle. Gently depress the plunger of the syringe to expel the air
• 22 gauge spinal needle (for children) within the needle into the subcutaneous tissues. Advance the needle
• Syringes, 5 and 10 mL while applying negative pressure. Stop advancing the needle when
blood flows freely into the syringe. Quickly inject the epinephrine,
• Nasogastric tube
and withdraw the needle. Resume CPR and ventilation of the patient.
• Epinephrine, 1:1000 and 1:10,000
Epinephrine is the only resuscitative medication that should LEFT PARASTERNAL APPROACH
be administered by intracardiac injection. Administer 1 mg of This approach utilizes the fourth or fifth intercostal space, approxi-
epinephrine as the initial and subsequent doses in an adult patient. mately 1 cm (or 1 finger breadth) lateral to the left sternal border
Administer 0.01 mg/kg (or 0.1 mL/kg) of the 1:10,000 concentra- (Figure 37-1). Stop performing CPR. Stop ventilating the patient
tion of epinephrine as the initial dose in children. Administer 0.1 to and allow the lungs to passively deflate. Insert the needle perpen-
0.2 mg/kg (or 0.1 to 0.2 mL/kg) of the 1:1000 concentration of epi- dicular to the chest wall. Stabilize the needle with one hand and the
nephrine for subsequent doses in children. syringe with the other. Advance the needle with both hands and
without excessive force.3 It is very easy to plunge into the heart if
PATIENT PREPARATION too much force is applied to the needle. Apply negative pressure to
the syringe as it is advanced. Stop advancing the needle when blood
This procedure is often performed on a patient who is clinically
flows freely into the syringe. Quickly inject the epinephrine, then
“dead” and as a last effort at resuscitation. An informed consent is
withdraw the needle. Resume CPR and ventilation of the patient.
not required to perform this procedure. The patient will be supine
with CPR in progress. If time permits, insert a nasogastric tube to
INFANTS AND CHILDREN
decompress the stomach. Apply povidone iodine or chlorhexidine
solution to the area around the lower sternum, xiphoid process of The technique of intracardiac injection for infants and children is
the sternum, upper epigastric, and left costosternal angles. Identify, essentially the same as that described above for the adult patient.4
While the subxiphoid approach has been “adopted as the standard,” hypotension, tachycardia, diaphoresis, unilateral absence of or
the left parasternal approach can also be effectively utilized. Use a decrease in breath sounds, hyperresonance to percussion, increased
22 gauge spinal needle for infants and children. Use caution when central venous pressure, hypoxemia, cyanosis, deviation of the car-
inserting and advancing the spinal needle since the pediatric skin diac point of maximal impulse, and tracheal deviation.
and subcutaneous tissue are thin and easily penetrated. The dose
of epinephrine administered is weight-based and varies from the ANATOMY AND PATHOPHYSIOLOGY
initial dose to subsequent doses (see the “Equipment,” section, for
The most common cause of a tension pneumothorax is mechanical
discussion).
ventilation with positive pressure in a patient with a visceral pleu-
ral injury.1 A tension pneumothorax is present in 50% of ventilator-
COMPLICATIONS associated pneumothoraces.2 When this occurs in intensive care unit
Overall, according to pooled data, complications are rare.2,5–7 A (ICU) patients, they often have minimal functional reserve. To fur-
pneumothorax is the most common complication, especially with ther cloud the issue, they are frequently on other supports (i.e., ino-
the parasternal approach. Other reported complications include tropic agents, complex ventilator settings, etc.), making their physical
coronary artery laceration, myocardial laceration, hemopericar- examination difficult and confusing. They may also have a number
dium, cardiac tamponade, pulmonary artery laceration, and perfo- of other coexisting factors that are making them unstable. This group
ration of the stomach or liver. Intramyocardial injection has been of patients has a particularly disastrous course if a tension pneumo-
reported and is associated with intractable ventricular fibrillation. thorax develops. Rapid diagnosis and treatment are imperative.3
Identification of the appropriate anatomic landmarks for needle The placement of a central venous catheter has been associated
insertion and direction can minimize complications. Careful with the development of a pneumothorax. The incidence of this
adherence to proper technique can also minimize complications. is approximately 3% to 6% with use of the subclavian approach. A
The use of a small-gauge spinal needle and the subxiphoid approach tension pneumothorax may be delayed in approximately 0.4% of
may result in fewer complications versus a large-gauge needle and attempts to gain central venous access. In one case report, a patient
the left parasternal approach.8 developed a tension pneumothorax while under general anesthesia
10 days after the placement of a subclavian central venous line.4
SUMMARY A tension pneumothorax may also occur in the setting of blunt
or penetrating trauma of the lung. It may occur uncommonly fol-
Although intracardiac injection is an effective route of medication lowing a tracheobronchial or esophageal injury. It may complicate
delivery to a patient in cardiac arrest, its popularity has declined a simple pneumothorax if the parenchymal lung leak does not seal
due to safer, simpler, and more effective methods of vascular access. spontaneously. In this case, the site of the lung injury acts as a one-
When intravenous access is not readily accessible or when the endo- way valve, allowing air entry into the pleural space and not allowing
tracheal administration has not provided the desired effect, intra- it to escape. Occasionally, chest wall defects may result in a tension
cardiac injection should be considered as an alternative technique. pneumothorax if the wound is completely covered by an occlusive
It is important not to permit prolonged cessation of CPR during the dressing or if the wound itself acts as a ball-valve mechanism. More
procedure. rarely, it may occur following markedly displaced fractures of the
thoracic spine. In the past, based on studies using the canine model,
the pathophysiology of this disease was considered to be associated
primarily with a mechanical pressure-related phenomenon.5 Air
accumulated in the involved pleural space and caused an increasing
Needle Thoracostomy intrapleural pressure. This pressure caused compression of the ipsi-
38 Eric F. Reichman and Elizabeth Sowell

lateral lung, displacement of the diaphragm caudally, movement of
the mediastinum and heart toward the uninjured side, kinking of the
great vessels, and compression of the contralateral lung. This ana-
tomic shift of structures would result in impaired filling of the heart
INTRODUCTION and a disastrous fall in cardiac output.6 Unfortunately, the canine
model is not as similar to the human as was once thought. The
A tension pneumothorax is a unilateral progressive collection of mediastinum in the dog is more mobile. It is fenestrated, so that air
air in the pleural space. If not treated, it results in increasing intra- communicates from one hemithorax to the other. Therefore, eleva-
pleural pressures, shifting of intrathoracic structures, hypoxemia, tions of intrapleural pressure in dogs would affect central structures
and death. It occurs from a one-way air leak into the pleural cavity and cause cardiovascular compromise more readily than in humans.
from the airway conduits, the lung, or the thoracic wall. The air leak Recently, this pressure-related mechanism has come into question
causes air to enter the pleural cavity and become trapped, without a as the primary event. Experiments have been performed in goats,
method of egress. Rapid decompression of the tension pneumotho- monkeys, sheep, and swine; all of which have a mediastinum that
rax with a catheter-over-the-needle is known as a needle thoracos- is more similar to that of the human than the dog.7–10 These studies
tomy and can be lifesaving. support the hypothesis that central hypoxemia is the primary fac-
A tension pneumothorax is an immediate life-threatening con- tor in the lethality of a tension pneumothorax and occurs prior to
dition that requires prompt recognition and treatment to prevent the development of significant hypotension. In this hypothesis, the
the patient’s imminent demise. The diagnosis must be suspected mechanical pressure-related phenomenon is a late event.
based upon the patient’s prior medical history, the mechanism of These mechanisms become more confusing and mixed in the
injury, physical examination findings, and a patient in extremis. ventilator-dependent patient. There is a lack of studies document-
Importantly, treatment must not be delayed to obtain further ing hemodynamic changes in the human subject with a tension
diagnostic testing (e.g., chest radiograph). These patients most pneumothorax.11–14 In one case report, three ventilated ICU patients
often present with acute and dramatic cardiopulmonary compro- demonstrated decreased cardiac output as the first sign of a tension
mise, which may be manifest by a combination of the following pneumothorax.12 The authors proposed that the absence of spon-
signs and symptoms: respiratory distress, chest pain, air hunger, taneous breathing did not allow increased variations in negative
CHAPTER 38: Needle Thoracostomy 239
intrathoracic pressure to act as a compensatory mechanism to pre- • Sterile gloves and gown
vent hemodynamic compromise. In another similar case, decreased • Face mask with an eye shield or goggles
cardiac output and mixed venous oxygen saturation were the domi-
• Ultrasound machine (optional)
nant signs of a tension pneumothorax.13 Hemoglobin desaturation
via pulse oximetry was shown to be the earliest sign in a ventilator- • Low frequency (2-5 MHz) ultrasound probe
dependent patient with a tension pneumothorax.14 • Sterile ultrasound probe cover
Electrocardiographic (ECG) changes may be seen in association • Sterile ultrasound gel
with a tension pneumothorax. In a left-sided tension pneumotho-
rax, the more commonly described ECG changes are a rightward
shift of the mean frontal QRS axis, precordial T-wave inversions,
PATIENT PREPARATION
reduced R-wave voltage, and decreased and/or alternating QRS Briefly describe the procedure to the patient if they are competent,
amplitude.15–17 Other unique changes include PR-segment elevation able to understand, and cooperative. Place the patient supine. Some
in the inferior leads and reciprocal PR-segment depression in lead Emergency Physicians place the patient supine with the head of the
aVR.18 A case report cited transient bradycardia, hypotension, and bed elevated to 30°. This will allow the air to rise to the anterior
precordial ST-segment elevation; all of which reversed after treat- upper chest. Unfortunately, this is not the most functional position.
ment of a right-sided tension pneumothorax.19 It is from the supine position that the patient can most easily be
Numerous mechanisms have been proposed as the causes of these accessed and controlled by the greatest number of practitioners. The
ECG changes. They include simple displacement of the heart, rota- supine position is optimal to allow for other lifesaving maneuvers
tion of the heart around its anteroposterior or longitudinal axis, (e.g., airway management, cardiopulmonary resuscitation, etc.).
transient hypoxia, changes in coronary artery blood flow, changes Clean the skin of any dirt and debris in the area of the procedure.
in pleural pressure, pulmonary resistance, pericardial tension, acute Apply povidone iodine or chlorhexidine to the skin.
ventricular dilatation, alterations in ventricular repolarization, Simultaneous with the performance of this procedure, other
pressure-induced atrial injury, and insulation of the chest wall from interventions should be requested: 100% face-mask oxygen (if the
the associated air.15–20 The vast majority of ECG changes have been patient is not already intubated), pulse oximetry, cardiac monitor-
noted with left-sided rather than right-sided tension pneumothora- ing, chest tube setup, intravenous access, and STAT chest radiogra-
ces. The degree of pneumothorax and the severity of symptoms phy. The Emergency Physician should wear full personal protective
do not seem to correlate with the magnitude of the ECG abnor- equipment to protect themselves from contact with the patient’s
malities. In summary, ECG changes are not uncommon in tension blood and body fluids. While time is of the essence and this is an
pneumothorax and should not distract from the true diagnosis. emergent procedure, aseptic technique should be followed.
INDICATIONS TECHNIQUE
A tension pneumothorax must be considered in the differential The safest, easiest, and most reliable site for a needle thoracos-
diagnosis of any patient in extremis. If it is a possible etiology tomy to decompress a tension pneumothorax is the second inter-
for the patient’s cardiopulmonary collapse, needle decompres- costal space in the midclavicular line1,2,6,21 (Figure 38-1). Apply
sion should be performed without delay. In every circumstance, a 12, 14, or 16 gauge catheter-over-the-needle onto a 5 or 10 mL
and especially in the emergent setting, one may not be able to be syringe without the plunger. Identify the second intercostal space
100% certain of the diagnosis. However, needle decompression in the midclavicular line. Place the nondominant index finger over
is a relatively low-risk procedure with great lifesaving potential. the needle insertion site. Grasp the syringe with the dominant hand.
One setting that may be particularly confusing is in the dying Insert the catheter-over-the-needle perpendicular to the skin and
patient with left precordial penetrating trauma. The immediate dif- just above the superior border of the third rib (Figure 38-2A). This
ferential would be tension pneumothorax versus pericardial tam- will avoid injury to the neurovascular bundle underlying the inferior
ponade versus massive hemothorax. Physical examination findings
are usually helpful but may also be confusing, mixed, or difficult to
elicit in a chaotic and noisy resuscitation. Needle decompression
should be the first maneuver in this situation. It may be lifesaving
and will aid in the diagnosis. It is less invasive, quicker, and easier
to perform than a pericardiocentesis or a thoracotomy. A tension
pneumothorax is more common than pericardial tamponade in this
setting. As for a massive hemothorax, a chest tube setup requires
some time but should be requested at the time needle decompres-
sion is proceeding.
CONTRAINDICATIONS
There are no absolute contraindications to performing a needle tho-
racostomy to decompress a tension pneumothorax. It is imperative
to identify the anatomic landmarks properly and perform this proce-
dure carefully if the patient has a known or suspected coagulopathy.
EQUIPMENT
• 12 to 16 gauge catheter-over-the-needle, 4.5 cm in length FIGURE 38-1. A right-sided tension pneumothorax. The preferred site for a needle
• 5 or 10 mL syringe thoracostomy is the second intercostal space in the midclavicular line.
FIGURE 38-2. Decompression of a tension pneumothorax with a catheter-over-the-needle. A. The catheter-over-the-needle is inserted through the second intercostal
space and into the pleural cavity. B. The catheter is advanced and the needle is removed.
border of the second rib. Some Emergency Physicians prefer to con- HANGING DROP TEST
tact the upper portion of the third rib with the tip of the needle, walk
it up the rib until it goes over the edge, and then advance it into the A novel idea has been proposed to use the “hanging drop” test to
pleural space. identify the pleural space and determine if a tension pneumothorax
Advance the catheter-over-the-needle until a loss of resistance is is present.26 It is quick, easy to perform, and uses supplies readily
felt as the tip of the needle penetrates the pleural space. A rush of available in the Emergency Department. Be aware that gathering the
air, with or without blood, will be heard escaping from the syringe. supplies and performing this test can take a few minutes, thus delay-
Stop advancing the catheter-over-the-needle. Advance the catheter ing the needle decompression.
until the hub is against the skin while simultaneously withdrawing Using strict aseptic technique, insert a 4.5 cm long spinal nee-
the needle (Figure 38-2B). dle into the second intercostal space in the midclavicular line and
advance it until the tip is touching the upper border of the third
ALTERNATIVE TECHNIQUES rib. Remove the trocar. Place one to two drops of sterile saline or
sterile water into the hub of the spinal needle. The fluid bubble will
Other sites have been described for performing a needle thora- be elevated above the needle hub. Gently walk the needle up and
costomy. These include the fourth or fifth intercostal space in the over the edge of the third rib. Slowly advance the needle through
midaxillary line or the second intercostal space in the anterior axil- the intercostal tissues while observing the fluid bubble. The negative
lary line.22–25 There are several problems with these alternative sites. intrathoracic pressure will suck the fluid bubble into the chest of
In the fourth or fifth intercostal space, the ribs are close together, there is no tension pneumothorax. The fluid bubble will be pushed
with narrower interspaces making needle placement more difficult. out of the hub if a tension pneumothorax is present.
There is more rib motion with breathing and arm movement can The author suggests using a spinal-type needle.26 This cannot be
make catheter dislodgment more likely. In the supine patient, air recommended for two reasons. First, if a tension pneumothorax
will rise ventrally rather than laterally. Practically speaking, during is present, the sharp needle should not be advanced or left in the
the resuscitation of the unstable patient, the most important posi- pleural cavity to relieve a tension pneumothorax. It can puncture
tion for the Emergency Physician is at the patient’s head. Insertion an organ or blood vessel. Second, the spinal needle would have to
of a catheter in the second intercostal space in the midclavicular line be removed and the procedure repeated with a catheter-over-the-
is easier from this position than inserting a laterally placed cath- needle. Consider using a catheter-over-the-needle to perform this
eter. The fourth or fifth intercostal space in the midaxillary line is procedure to avoid these issues.
the ideal space for a chest tube. Placement of the catheter in these
alternative sites would mean having to penetrate more tissue, espe-
cially in the obese patient, making reaching the pleural space more
difficult, and dislodgment of the catheter more likely. The major The basic technique is the same in pediatric patients. Use a smaller
drawback to using the fourth or fifth intercostal space is the risk length and gauge catheter-over-the-needle in pediatric patients.
of inserting the catheter-over-the-needle below the diaphragm and A 20 or 22 gauge, 1 inch (in) or 2.5 cm catheter-over-the-needle
into the liver (on the right) or the spleen (on the left). should be used in preterm children and neonates. This same size
If the first attempt at needle thoracostomy fails to decompress the can also be used in children up to approximately 1 to 2 years of age.
pleural space, ultrasound can be used to measure chest wall thick- Between the approximate ages of 2 and 6 years, consider using an
ness in order to determine the appropriate needle length and to con- 18 or 20 gauge, 1.5 in or 3.75 cm long catheter-over-the-needle.
firm the presence or absence of a pneumothorax. Subcutaneous fat Over the age of 6 and into early adolescence, consider using a 16 or
and tissue can be differentiated from air in the pleural space by the 18 gauge, 4.5 cm long catheter-over-the-needle. Use the adult size
presence of the pleura seen deep to the pneumothorax and repre- catheter-over-the-needle for older adolescents or obese children.
sented by a bright white line along with the absence of “lung slide.” These are just general recommendations. The individual child’s size
If the patient is in extremis, a definitive chest tube should not be and body habitus need to be taken into consideration when choos-
the primary therapy for a tension pneumothorax. The setup and ing a catheter-over-the-needle size and length.
performance of a tube thoracostomy take much longer than rapid Some Physicians prefer to use a butterfly needle with attached
decompression with a catheter-over-the-needle. tubing instead of a catheter-over-the-needle in preterm children,
CHAPTER 38: Needle Thoracostomy 241
neonates, and up to the first year of life. Select a butterfly needle size cannula would fail to penetrate into the pleural cavity in 57% of the
as described above. Place sterile water or sterile saline in a sterile patients in this study. A 4.5 cm cannula would fail to penetrate into
specimen cup. Insert the distal hub end of the butterfly tubing into the pleural cavity in 4% of the patients. In this case, the procedure
the bottom of the specimen container and submerged in the liquid. should be repeated with a longer catheter-over-the-needle. If one
Tape the tubing onto the rim of the specimen container to secure it is not immediately available, a tube thoracostomy should be per-
and ensure it does not pull out of the liquid in the specimen con- formed immediately.
tainer. Insert the butterfly needle into the pleural space as described Several studies have evaluated chest wall thickness using ultra-
above. Air bubbles will move through the tubing and into the sterile sound and computed tomography (CT) scans in order to deter-
liquid as the tension pneumothorax is decompressed. The specimen mine the needle length required to appropriately decompress the
container also forms a water seal, preventing ingress of air into the pleural space in the general adult population. Initial studies using
pleural space, until a tube thoracostomy can be performed. ultrasound seemed to indicate that using needle lengths of 4.5 cm
would be sufficient to reach the pleural space in most patients.30
ASSESSMENT More recent studies using CT have shown that chest wall thickness
varies significantly by gender and age. A study by Zengerink et al.
Once the catheter has been placed into the pleural space, a gush of air found that chest wall thickness was greater than 4.5 cm 10% of the
should rush out of the syringe. The procedure will have converted time in men younger than 40 and 19% of the time in men older than
a tension pneumothorax into a simple pneumothorax requiring 40 years of age.31 The same study found almost one-third of women
a tube thoracostomy. The patient should improve hemodynami- less than 40 years had a chest wall thickness greater than 4.5 cm, fall-
cally and symptomatically. Saturations on pulse oximetry should ing to one-fourth for those over 40. Harcke et al. found a mean chest
rise after the decompression. If this does not occur, too short of a wall thickness of 5.36 cm in autopsy CT scan studies.34 They recom-
catheter-over-the-needle may have been used and the procedure mended a 3.25 in or 8 cm long catheter-over-the-needle be used. It
should be repeated with a longer one. If a longer catheter-over-the- is important to note these variations. However, most authors still
needle is not available, rapidly perform a tube thoracostomy. The advocate a needle length of 4.5 cm as longer needle lengths increase
other possibility is that the pleural space was entered appropriately the risk of vascular, pulmonary, or cardiac injury.
but the diagnosis was incorrect. In this event, another cause of the The second intercostal space in the midclavicular line is the rec-
patient’s shock state should be sought and consideration should be ommended location for a needle thoracostomy. A prospective study
given to “prophylactic” chest tube placement. This may prevent later of needle thoracostomy sites found that a more medial placement
sequelae from the iatrogenic catheter stab wound to the chest and was often used.35 A needle thoracostomy insertion point not in
simplify the further workup and monitoring of this unstable patient. the midclavicular line is more likely to be associated with vascular
injury and hemorrhage. This includes injury to the internal mam-
AFTERCARE mary artery medially, subclavian vessels superiorly, and the pulmo-
After insertion of the catheter and improvement in the patient’s nary trunk and heart inferiorly.
clinical status, the immediate life threat has been treated. Secure After the initial effective decompression of a tension pneumotho-
the catheter against the skin with a suture or an assistant holding rax, the catheter may become dislodged, clotted, kinked, or its tip
it in place. Continue to observe and monitor the patient closely may retract from the pleural space into the surrounding soft tissues.
for recurrence of the tension pneumothorax and procedural If the tension pneumothorax recurs, immediately repeat the pro-
complications. Establish intravenous access, cardiac monitoring, cedure. Once needle decompression is reaccomplished, immediately
and pulse oximetry if not already done. Obtain baseline laboratory perform a tube thoracostomy. If possible, a tube thoracostomy can
studies, an arterial blood gas, and a chest radiograph. Obtain a thor- be initiated by the Emergency Physician while other members of the
ough history and physical examination to search for the etiology resuscitation team continue with other interventions. This would
of the tension pneumothorax. A definitive chest tube should be hopefully prevent recurrence of the tension pneumothorax second-
placed using sterile technique to prevent recurrence of the ten- ary to a delay in chest tube placement because other interventions
sion pneumothorax and to treat the simple pneumothorax. Refer (e.g., CPR, intubation, venous access, etc.) must also be performed.
to Chapter 39 for the complete details regarding the placement of a There may be complications secondary to the catheter place-
chest tube. After a chest tube is inserted, remove the needle thora- ment.37–40 A local hematoma or underlying lung laceration may
costomy catheter and place a simple bandage over the puncture site. occur. Infectious agents may be introduced into the pleural cavity. If
the catheter-over-the-needle is introduced too close to the sternum,
the underlying mediastinal vessels or internal mammary artery
COMPLICATIONS
may be penetrated or lacerated. If the catheter-over-the-needle is
An incorrect diagnosis of a tension pneumothorax in an unstable introduced under the inferior border of the second rib instead of
patient is always a possibility, even in the best of hands. If this is the over the superior border of the third rib, the intercostal vessels or
case, the cause of the patient’s shock state must still be aggressively nerve may be lacerated. A proper technique in placing the cathe-
sought and treated. A prophylactic chest tube should be considered ter-over-the-needle should be observed to minimize preventable
for a presumed parenchymal lung injury and potential pneumotho- complications.
rax from the needle thoracostomy.27–29 This is especially true if the The standard approach to relieving a tension pneumothorax is
patient is going to be transported out of the resuscitation area, will the placement of a large-bore needle in the ipsilateral second inter-
be given a general anesthetic, or is to be placed on positive-pressure costal space. This works well in the standard patient where there are
ventilation. no adhesions or scarring in the pleural space. However, this may not
Failure to reach and decompress the pleural space is the major be the proper needle location in the patient with prior pulmonary
argument against the use of needle thoracostomy. Depending on the disease, pleural disease, or pleural adhesions. The classic hospital
patient’s body habitus and the catheter length, the pleural space may patient in this category is the patient with adult respiratory distress
not have been reached to be decompressed. In an initial study from syndrome on positive end-expiratory pressure (PEEP) with high
the UK, the chest wall thickness was estimated to range from 1.3 to airway pressures who develops a loculated tension pneumothorax.
5.2 cm by ultrasound in the second intercostal space.30 A 3.0 cm The needle placed in the standard manner often fails to reach the
affected pleural area. Stat chest radiographs are often required to not under pressure within the pleural space. It may cause the ipsi-
help guide placement of the needles and/or chest tubes in these lateral lung to collapse. As air continues to accumulate and if there
more complex patients.6 Bedside ultrasonography is also useful to are no adhesions, the increased pressure in the thoracic cavity may
help guide the procedure. push the mediastinum toward the noninjured side. This can cause
The needle thoracotomy procedure is not without its complica- angulation of the atriocaval junction, impairment of atrial filling,
tions. This leads some to question the performance of a needle tho- and a subsequent decrease in cardiac output manifest by hypoten-
racostomy instead of just performing a tube thoracostomy. There sion. The presence of a pneumothorax under pressure accompa-
are no clinical trials comparing needle versus tube thoracostomy to nied by respiratory and/or circulatory compromise is termed a
relieve a tension pneumothorax in human subjects. This study was tension pneumothorax and is an immediate life threat.
recently undertaken in a swine model.36 The authors demonstrated There are two important points to remember about a ten-
that a properly performed needle thoracostomy is as effective over sion pneumothorax. First, it is a clinical diagnosis based on the
a 4-hour period as a tube thoracostomy. While the authors did not patient’s presenting signs and symptoms. Do not wait for a chest
record the time it took to perform the procedures, performing a film to establish the diagnosis. Second, the initial treatment of
needle thoracostomy is quicker, easier, and simpler and now just as this entity is needle decompression followed by tube thoracos-
effective when compared to a tube thoracostomy. tomy. A large-bore needle is inserted in the second intercostal space
(ICS) in the midclavicular line at the superior border of the rib. If
SUMMARY the patient has a tension pneumothorax, a gush of air will ensue
and the patient’s symptoms will improve. Thus, the tension pneu-
Tension pneumothorax is a clinical diagnosis that is often made in mothorax is converted to a simple pneumothorax and a chest tube
an agonal patient with respiratory distress, absent (or decreased) is inserted for more definitive management. Refer to Chapter 38 for
breath sounds over a hemithorax, and severe cardiopulmonary complete details regarding the needle thoracostomy procedure.
compromise. Needle thoracostomy to decompress the tension pneu- An open pneumothorax is caused by a traumatic chest wall
mothorax should be performed immediately in the second intercos- injury that results in a defect that is greater than or equal to two-
tal space in the midclavicular line. This is a lifesaving procedure that thirds the diameter of the patient’s trachea. Air passes via the path
is quick, simple to perform, easy to learn, and requires no special of least resistance (i.e., the defect) and leads to equilibration of the
equipment. Needle thoracostomy should be followed as soon as fea- intra- and extrathoracic pressures, thus compromising both oxy-
sible by a definitive tube thoracostomy. genation and ventilation. Like a tension pneumothorax, this is an
immediate life threat. Initial treatment may consist of a nearly occlu-
sive “three-sided” dressing creating a one-way valve for egress of air
from the pleural cavity. Alternatively, the patient may be placed on
positive-pressure ventilation. The chest tube can then be inserted at
Tube Thoracostomy
39
a site remote from the actual defect. Refer to Chapter 41 for com-
plete details regarding the management of open chest wounds.
Kimberly T. Joseph
Injury to the chest may also result in laceration of vascular struc-
tures, including the lung parenchymal vessels, intercostal vessels,
internal mammary arteries, great vessels, or the heart. Although
INTRODUCTION the body can absorb small amounts of free blood from the pleural
A tube thoracostomy is the placement of a tube through the tho- space, the presence of free blood over a prolonged period of time
racic wall and into the pleural cavity. It is commonly referred to as a leads to increased risk of infection and fibrosis.3,4 The body cannot
chest tube. It is placed in order to evacuate air, blood, or other fluid effectively clear large quantities of blood or clot from the pleural
that collects within the pleural space. The etiology of the air or fluid cavity. Blood in the pleural space, otherwise known as a hemotho-
collections can be due to iatrogenic complications, infection, lung rax, can in most cases be treated with the insertion of a chest tube.
disease, malignancy, or trauma. However, when a major systemic or pulmonary vessel has been
Thoracic trauma continues to account for nearly one-quarter injured, resulting in massive hemothorax (i.e., greater than 1500 mL
of all trauma-related mortality.1,2 Although some injuries require of blood in the pleural space), tube thoracostomy is usually followed
surgical intervention, the majority may be treated nonoperatively. by urgent surgical intervention.
Injuries to the chest wall, lung, trachea, bronchi, or esophagus may Penetrating wounds or blunt rupture of the thoracic esophagus
lead to the presence of abnormal air and/or fluid in the pleural may result in a pneumomediastinum, pneumothorax, hydrothorax,
space. The use of a tube thoracostomy (chest tube) in these situa- or some combination thereof. Esophageal injury should be sus-
tions may be both diagnostic and therapeutic. Historically, closed- pected in any patient with a knife or ice pick wound in a suspicious
tube drainage of the pleura has been used for various indications for location, a transmediastinal bullet trajectory, or a severe and sud-
more than a century.3 This chapter deals primarily with the use of den compression of the chest or abdomen.2 If a pneumothorax or
tube thoracostomy following trauma. However, much of the infor- hydrothorax is a presenting finding, tube thoracostomy is used as
mation remains the same regardless if the patient is a trauma victim part of the treatment. However, these patients require urgent surgi-
or a medical patient. cal attention. Tube thoracostomy may also be used in the treatment
of traumatic chylothorax resulting from injury to the thoracic duct.
One special circumstance deserves mention. Certain patients
ANATOMY AND PATHOPHYSIOLOGY who have sustained significant blunt trauma to the torso may have
On inspiration, the diaphragm and accessory muscles of respiration a diaphragmatic rupture. Chest radiographs may reveal an air den-
contract and generate negative pressure within the pleural space. sity in the hemithorax that could be mistaken for a pneumothorax.
Penetration of the visceral or parietal pleura due to injury disrupts However, this may actually represent the presence of the stomach or
this pressure gradient and allows air to enter the “potential space” colon in the thoracic cavity. When a chest tube is inserted in such a
between the parietal and visceral pleurae, resulting in a pneumotho- case, extra care must be taken when entering the pleural cavity so as
rax.1,2 A simple pneumothorax is the accumulation of air that is not to injure a hollow viscus inadvertently.
CHAPTER 39: Tube Thoracostomy 243
INDICATIONS There has been some suggestion in the literature that there may
be a role for the prehospital placement of chest tubes.10,11 Although
The indications for a tube thoracostomy following blunt or pen- this has not gained widespread acceptance, aeromedical crews fre-
etrating trauma to the chest include the presence of a simple quently perform tube thoracostomies in the field.
pneumothorax, hemothorax, hemopneumothorax, hydrothorax,
or chylothorax. A chest tube is placed prophylactically in patients EQUIPMENT
with penetrating injuries to the chest who do not have evidence of
a pneumothorax on initial chest radiographs but are expected to • Povidone iodine or chlorhexidine solution
undergo endotracheal intubation and general anesthesia. The medi- • 10 to 20 mL syringe
cal indications for a tube thoracostomy include a pneumothorax,
• Local anesthetic solution with epinephrine (1% lidocaine or
empyema, recurrent pleural effusion, pleurodesis, or a malignant
0.25% bupivacaine)
pleural effusion. A tube thoracostomy should also be performed
after the needle decompression of a tension pneumothorax into a • 25 or 27 gauge needle
simple pneumothorax. • #10 scalpel blade on a handle
• Kelly clamps, large and medium
OCCULT PNEUMOTHORAX • Chest tubes, sizes 12 to 42 French
With the advent of computed tomography (CT), traumatic pneu- • Sterile water
mothoraces and hemothoraces that are not evident on plain chest • Chest tube drainage apparatus with a water seal
radiographs are being diagnosed more frequently. The question
then arises as to whether or not these pneumothoraces should be • Christmas tree connector
treated. The management of these “occult pneumothoraces/hemo- • Suction source and tubing
thoraces” is somewhat controversial. One study looked at 40 patients • Needle driver
who sustained chest trauma and were discovered by CT scan to
• Mayo scissors, large curved
have pneumothoraces.5 The study concluded that patients undergo-
ing positive-pressure ventilation should have placement of a chest • Size 0 or 1-0 suture, silk or nylon
tube. However, the study could not confirm that patients with small • Petrolatum-impregnated gauze
pneumothoraces who were not going to be ventilated could safely • 4 × 4 gauze squares
be observed. Plurad et al. reviewed 2326 CT scans, 80.5% after nega-
tive chest radiographs, in which 102 occult pneumothoraces and/or • Adhesive tape, 3 to 4 in. wide
hemothoraces were noted.6 Only 12 of these patients required tube • Sterile drapes
thoracostomy. Similar results for small, isolated occult hemothora- • Sterile gloves and gown
ces were seen by Stafford et al.7 A smaller study by Enderson et al. • Face mask with a face shield or goggles
noted a higher percentage of patients requiring tube thoracostomy,
but these patients were undergoing positive-pressure ventilation.8 • Tincture of benzoin spray or swabs
As a general guideline, nonprogressive occult pneumothoraces can • 0.25% bupivacaine
usually be managed without a tube thoracostomy.9 However, close
Most hospitals and Emergency Departments have prepared their
clinical observation and/or follow-up plain radiographs are recom-
own “chest tube trays” that contain all the equipment required to
mended. An initially occult pneumothorax that is increasing in size
place a chest tube except the chest tubes, local anesthetic solution,
or in a patient who develops respiratory distress requires a tube
and a collection system. These last three items will vary based on
thoracostomy.9 A patient with an occult pneumothorax and who
the etiology of the air and/or fluid in the pleural cavity, the age and
also requires positive-pressure ventilation, endotracheal intubation,
size of the patient, and physician preference. Commercially pro-
and/or general anesthesia is an indication for a tube thoracostomy.
duced chest tube kits are also available (e.g., Atrium Medical Corp.,
Hudson, NH and Centurion Medical Products, Howell, MI).
CONTRAINDICATIONS Chest tubes used in the Emergency Department are hollow, clear,
The only absolute contraindication to performing a tube thoracos- straight plastic tubes (Figure 39-1). The distal end of the chest tube
tomy is in the patient who requires an open thoracotomy. Although
there are no firm contraindications to performing a tube thoracos-
tomy in a trauma patient, there are some areas of controversy. It has
been suggested that a patient with a small (<20%) pneumothorax
without an associated hemothorax following trauma may be man-
aged with close observation rather than a chest tube, especially in
the case of blunt injuries. If observation is selected for such a patient,
chest radiographs should be repeated within 3 to 6 hours to rule
out an enlarging pneumothorax or the delayed manifestation of a
hemothorax.2,5
There are several relative contraindications to performing a tube
thoracostomy in the medical patient. These include the presence of
a skin infection over the chest tube insertion site, a coagulopathy,
large pulmonary blebs or bullae, pulmonary adhesions, loculated
pleural effusions, tuberculosis, or previous tube thoracostomies.
These patients may require CT or ultrasound guidance to place the
chest tube. A coagulopathy should be corrected before the chest FIGURE 39-1. The chest tube. The proximal end is beveled while the distal end
tube is inserted if such placement is not required emergently. is fenestrated.
has numerous fenestrations or holes that allow the passage of air

and/or fluid into and through the tube. A radiopaque stripe allows
for radiographic localization of the chest tube after it is inserted into
the patient. The proximal end of the chest tube is beveled to allow it
to fit better on a plastic connector.
Chest tubes are available in numerous sizes and from multiple
manufacturers. The lower the number, the smaller the size of the
chest tube. A spontaneous pneumothorax may be drained with an
18 to 26 French tube in adults, a 14 to 16 French tube in children,
a 12 to 16 French tube in infants and small children, and an 8 to
12 French tube in neonates. Traumatic pneumothoraces are usually
drained with a 32 to 36 French tube in adults and a 16 to 20 French
tube in children. Traumatic hemothoraces, traumatic hemopneu-
mothoraces, and empyemas require larger-size tubes. A 36 to
42 French tube in adults and a 20 to 24 French tube in children will
provide adequate drainage without becoming occluded by blood
clots or purulent material.
The procedure requires the use of a large Kelly clamp to bluntly
dissect a subcutaneous tract as well as to puncture and dilate a
tract through the intercostal muscles. The Kelly clamp requires the
Emergency Physician to pull the ringed handles apart and in opposite
directions to open the jaws of the clamp. Opening the jaws of the Kelly
clamp when it is within the subcutaneous tissues or intercostal mus-
cles can be quite difficult. A new clamp, the Centurion Blunt Dissector
(Figure 39-2), was specifically designed to aid in the insertion of a
chest tube (Centurion Medical Products, Howell, MI). The mechani-
cal action of this new clamp is opposite that of the Kelly clamp. In the
resting position, the jaws are closed and the ringed handles are held
open with a spring mechanism. To open the jaws of the clamp, the
ringed handles are squeezed together. This is a more natural, intuitive,
and easier motion to perform. This chest tube clamp is disposable and
available individually or incorporated into a chest tube insertion tray.
FIGURE 39-3. A commercially available chest tube drainage system.
DRAINAGE SYSTEMS
It is important to know how to use the drainage system available at
your institution to prevent any complications arising from the use of these devices. The classic glass bottle system with rubber corks
is rarely, if ever, used in the United States today in the Emergency
Department. Commercially available drainage systems are currently
available in most hospitals (Figure 39-3). They are made of light-
weight plastic, sterile, and intended for single-patient use. They are
preassembled, disposable, and also may be used for autotransfu-
sions. They have clear plastic covers to allow easy visualization of
the fluid within the unit.
The system is a single unit that consists of three or four chambers,
depending on the manufacturer. The first chamber connects to the
chest tube with flexible rubber tubing. It collects blood clots and/or
other fluid expressed through the chest tube. The second chamber
is the water seal. It allows one-way flow of air away from the patient
and maintains a negative intrathoracic pressure gradient compared
to the atmosphere. The third chamber is the suction regulator, which
attaches to the wall suction. It draws in atmospheric air when needed
to limit the negative pressure of the vacuum. Some manufacturers
have included a fourth chamber to assess the patient’s intrapleural
pressure (e.g., Sentinel Seal, Sherwood Medical, Ireland).
PATIENT PREPARATION
Explain the risks, benefits, complications, and aftercare to the
patient and/or their representative if time and the patient’s clinical
condition permit. Obtain an informed consent for a tube thora-
costomy or document in the medical record the verbal discussion
whenever possible. It should be understood that following trauma,
FIGURE 39-2. The Centurion Blunt Dissector (Photo courtesy of Centurion a tube thoracostomy is often performed under urgent or emergent
Medical Products, Howell, MI). conditions. Lifesaving care should always proceed on the patient’s
FIGURE 39-4. Patient positioning for a tube thoracostomy.

Note the application of supplemental oxygen, pulse oximetry,
cardiac monitoring leads, and a soft restraint.
behalf with the appropriate documentation in the medical record If the patient is awake and aware of their surroundings, infil-
after the patient is resuscitated. trate local anesthetic solution into the chest wall and pleural cav-
In recent years, there has been considerable discussion in the lit- ity. This should be performed regardless of whether the patient
erature regarding the use of antibiotics in patients requiring a tube receives parenteral analgesics, sedatives, and/or procedural seda-
thoracostomy for trauma in the hope of preventing an empyema.12–14 tion. Approximately 10 to 20 mL of local anesthetic solution with
The Eastern Association for the Surgery of Trauma (EAST) practice epinephrine (e.g., lidocaine or bupivacaine) is required to provide
management guidelines work group reviewed the literature regarding adequate analgesia. Consider using bupivacaine as it provides lon-
the use of antibiotics in conjunction with chest tube insertion. They ger analgesia than lidocaine. Be aware of the maximum weight
found several trials, including four double-blinded, randomized tri- based volume of local anesthetic solution to administer to prevent
als that evaluated infectious complications after a tube thoracotomy toxicity (Chapter 123). Raise a subcutaneous wheal of local anes-
using Centers for Disease Control (CDC) criteria. The studies each thetic solution one interspace below the one to be used to insert
had their weaknesses. Despite these weaknesses, the working group the chest tube (i.e., the sixth ICS). Infiltrate local anesthetic solution
recommended that there was sufficient class 1 and class 2 evidence subcutaneously and upward to a point above the fifth ICS. Redirect
to support a recommendation of administering a first-generation the needle to anesthetize the intercostal muscles and parietal pleura
cephalosporin intravenously just before making the skin incision of the fifth ICS. Advance the needle into the pleural cavity and inject
and continuing the intravenous antibiotic for 24 hours.15 2 to 3 mL of local anesthetic solution to adequately anesthetize the
If not contraindicated, the administration of parenteral analge- pleura (Figure 39-5).
sics, sedatives, and/or procedural sedation (Chapter 129) will be
greatly appreciated by the patient, as the procedure is quite painful. TECHNIQUE
Appropriate protocols for patient monitoring should be employed.
The technique described here is an “open” technique, as opposed to
At minimum, the patient should have supplemental oxygen applied,
that employing the use of a trocar. Trocar-aided insertion of chest
continuous pulse oximetry, and frequent checks of vital signs.
tubes is associated with a higher incidence of major complications
Continuous cardiac monitoring should also be employed and
monitored.
Place the patient supine or semierect with the arm on the involved
side raised away from the chest (Figure 39-4). Identify the fifth ICS
in the mid-to-anterior axillary line (Figure 39-4). Consider mark-
ing this point on the patient’s skin with a pen or marking pen. A
soft restraint may be placed around the wrist to prevent the arm
from moving during the procedure. Apply povidone iodine or
chlorhexidine solution to the chest wall and allow it to dry. Apply
sterile drapes to demarcate a sterile field. Sterile technique should
be observed and followed by all involved personnel, who should
be fully capped, gowned, masked, and gloved.
Reidentify the fifth ICS in the mid-to-anterior axillary line
(Figure 39-4). This is the preferred site for chest tube insertion.
The reasons for this are twofold. The diaphragm rises during respi-
ration to the level of the nipple. Chest tube insertion below the fifth
ICS unnecessarily risks puncture of the diaphragm or abdominal
organs. The area of the midaxillary line is the least muscular area of
the chest wall and is thus an easier area from which to gain access to FIGURE 39-5. Infiltration of local anesthetic solution into the chest wall and
the pleural cavity.1–3 pleural cavity.
tips of the clamp through the intercostal muscles and parietal pleura
and into the pleural cavity (Figure 39-7C). This maneuver requires
a significant amount of force to enter the pleural cavity. A twist-
ing motion as the clamp is advanced may facilitate penetration into
the pleural cavity. If the clamp is advanced slowly, the intercostal
muscles will stretch and entering the pleural cavity will be difficult.
A loss of resistance associated with a rush of air or fluid should
occur as the pleural cavity is entered with the closed tips of the
clamp (Figure 39-7C). If under pressure, the fluid contained within
the pleural cavity may exit the tract forcibly. It is important not to
plunge too deeply with the clamp as the pleural cavity is entered.
The tips of the clamp can injure the diaphragm, great vessels, heart,
or lung. The forward motion of the clamp can be partially opposed
by bracing the nondominant hand on the underside of the clamp
and applying counterpressure away from the patient as the clamp
FIGURE 39-6. The initial skin incision is made over the rib one interspace below enters the pleural cavity.
the desired chest tube insertion site. Spread the jaws of the clamp to enlarge the tract through the sub-
cutaneous tissue, intercostal muscles, and parietal pleura. Insert a
finger through the tract and into the pleural cavity (Figure 39-7D).
and does not result in any significant saving of time.1–3 For these The lung should be felt as it expands with inspiration and con-
reasons, a trocar should never be used. tracts with expiration. Rotate the finger to ascertain the presence or
Make a 3 to 5 cm incision with the #10 scalpel blade over the rib absence of adhesions. Gently break any loose adhesions between the
one ICS below (i.e., the sixth ICS) the desired ICS (Figures 39-6 & lung and thoracic cage with the finger. Dense adhesions require the
39-7A). Bluntly dissect a tract or tunnel with the 6 in Kelly clamp chest tube to be inserted at another site.
in the subcutaneous tissue in a cephalic direction to the rib above. Prepare to insert the chest tube. Estimate the distance from the
Orient the clamp with the tips curved toward the skin. Advance the skin incision to the apex of the lung by laying the chest tube over
closed tips of the clamp in 1 cm increments and open the jaws to the patient. Apply a clamp onto the chest tube at the estimated site
dissect the tract (Figure 39-7B). The tract should terminate at the at which it should exit the skin incision. This location should be 4 to
upper border of the fifth rib. This will avoid injury to the neurovas- 5 cm proximal to the fenestrations in the chest tube. Cut off the bev-
cular bundle lying under the inferior border of the rib. Rotate the eled proximal end of the chest tube just above the bevel.
clamp 180° such that the tip is aimed just above the superior border Grasp and clamp the tips of the large Kelly clamp onto the dis-
of the fifth rib and toward the pleural cavity. Briskly push the closed tal end of the chest tube. Insert the tips of the clamp and chest tube
FIGURE 39-7. The tube thoracostomy. A. The skin incision is made. B. A tract is bluntly dissected in the subcutaneous tissues. C. The Kelly clamp is forced into the pleural
cavity. D. A finger is inserted through the tract to feel for adhesions. E. The chest tube is held in the Kelly clamp and inserted through the tract. F. The chest tube is guided
into the pleural cavity.
suture firmly around the chest tube three or four times. Tie a knot in
the suture to secure the chest tube to the skin (Figures 39-8A & 9A).
Place the second stitch as a purse-string suture encompassing the
chest tube (Figure 39-8B). Leave both ends of the suture long. Wrap
both ends of the suture around the chest tube and tie a bow, not a
knot. This stitch will be used later to close the skin incision after the
chest tube is removed. Place simple interrupted or horizontal mat-
tress sutures to close the remainder of the skin incision.
Apply an occlusive dressing over the incision site (Figure 39-9B).
Apply petrolatum gauze over the incision site and around the chest
tube as it exits the incision. Place gauge squares over the incision
site. Apply tincture of benzoin to the chest wall surrounding the
gauze squares. Tape the gauze and chest tube to the torso. The ends
of the tape should be adherent to the tincture of benzoin. Do not
place tape over the patient’s nipple. If the tape must cover the
nipple, protect it with a piece of gauze.
FIGURE 39-8. Securing the chest tube to the thoracic wall. A. The stay suture. An alternative to the above dressing is a new product, the
B. The purse-string suture. Centurion Chest Tube Anchor (Centurion Medical Products,
Howell, MI). This is a sterile, adherent patch that surrounds the
chest tube as it exits the skin (Figure 39-10). It forms an occlu-
through the tract and into the pleural cavity (Figures 39-7E & F). Use sive dressing. It has an attached cable tie to wrap around the chest
the clamp to direct the tip of the chest tube posteriorly and superiorly. tube and secure it in place. This cable tie replaces suturing the chest
Alternatively, the dominant index finger can be placed through the tube in place. The device can be trimmed to a smaller size for pedi-
tract to direct the chest tube. The use of the finger in the tract is the atric patients. The cable tie will secure all sizes of chest tubes.
preferred method to guide the chest tube. The finger will be able to Connect the chest tube to a drainage system (Figure 39-11),
confirm the proper intrapleural placement of the chest tube. Release which is a self-contained multichamber device.3 The first chamber
the Kelly clamp and advance the chest tube until all the fenestrations is a collecting chamber that connects directly to the chest tube. The
are within the pleural cavity and the preplaced clamp on the chest tube second chamber contains a small amount of saline or water and
is at the skin incision. Hold the chest tube securely in place. Remove acts as a one-way valve. This assures flow only in the direction away
the Kelly clamp from the incision. Release the clamp on the chest tube. from the patient. The third chamber controls suction, with a capa-
Secure the chest tube with 0 or 1-0 silk or monofilament nylon bility of at least 20 cm of water suction, and attaches to the wall
suture (Figure 39-8). The many techniques that have been described suction system. Commercially available systems encompass all three
for securing chest tubes are idiosyncratic and probably equivalent. chambers in one unit.
Suffice it to say that the tube should be sewn in such a way that the
incision is closed fairly tightly around the tube to assure a better seal
ASSESSMENT
and that routine movements of the patient should not dislodge it.
Place the first stitch as a simple interrupted stitch at one end of Obtain an anteroposterior portable chest radiograph. Observe the
the skin incision (Figure 39-8A). Leave both ends of the suture long position of the chest tube. Remove the chest tube and insert a new
after tying the knot in the first stitch. Wrap the needle end of the one if it is bent, kinked, or in the fissure of the lung. If its tip is against
FIGURE 39-9. Securing the chest tube. A. The chest tube has been secured with suture to the chest wall. B. An occlusive dressing has been placed over the incision and
taped to the chest wall.
the trachea, mainstem bronchus, a large bronchiole, or the esopha-

gus can cause a persistent air leak. Insert a second chest tube to keep
up with the leak and prepare the patient for bronchoscopy and/or
esophagoscopy to diagnose the etiology of the persistent air leak.
AFTERCARE
Patients with chest tubes require close monitoring. If administered,
continue prophylactic antibiotics for 24 hours. Obtain daily serial
chest radiographs to monitor for resolution of the inciting process.
The presence of air leaks from the chest tube indicates that the
injury has not completely healed and the seal between the parietal
and visceral pleurae has not yet been restored. Suction should be
maintained until there is no evidence of an air leak. The acceptable
minimal daily output from a chest tube as a criterion for removal
varies according to the institution, the physician, and the reason
for insertion. It is also unclear whether a trial period of water seal
following suction is strictly necessary. There is literature to suggest
that both suction and water seal protocols for removing chest tubes
are effective and have similar incidences of recurrent pneumotho-
races.16 However, there is also literature supporting an abbreviated
trial of water seal following suction, as it may allow time for occult
pneumothoraces to manifest themselves and thus alleviate the need
for reinsertion of a chest tube.17 The chest tube insertion site should
FIGURE 39-10. The Centurion Chest Tube Anchor (Photo courtesy of Centurion
be monitored for signs of infection.
Medical Products, Howell, MI).
The chest tube and collection tubing should be checked periodi-
cally for blockage. If blocked, the tubing may be milked or stripped
to alleviate the blockage and avoid the need to replace the chest
the mediastinum, unsecure the tube, withdraw it a few centimeters, tube. Milking refers to forcing air, fluid, or clots back into the chest.
resecure the tube, and obtain a repeat radiograph. If the chest tube Stripping refers to creating negative pressure within the tubing to
is located in the subcutaneous tissue, remove it and insert a new move fluid or clots distally and into the collecting chamber. To milk
one. Observe the fenestrations on the distal end of the chest tube in the tube, clamp or pinch the tubing shut distally while using the
the radiograph. They all must be within the thoracic cavity. If not, other hand to compress the tubing and move proximally to force the
remove the chest tube and insert a new one. Never advance a chest contents back into the thoracic cavity. To strip the tube, clamp or
tube further into the thoracic cavity after obtaining a chest radio- pinch the tubing shut proximally while using the other hand to com-
graph, as this may track infectious material into the pleural cavity. press the tubing and move distally followed by the sudden release of
Persistent bubbling in the system or failure of the lung to reex- the proximal tubing.
pand indicates a leak in the system. Check the system to ensure CHEST TUBE REMOVAL
that all connections are secure. Place tape over the connections to
eliminate leaks and prevent the components from becoming dis- In planning to remove a chest tube, one must be prepared to replace
lodged. Check the tubing for any holes or fissures. Examine the it. All the necessary equipment and supplies should be readily avail-
chest tube and the radiograph to confirm that all fenestrations are able in case the patient urgently requires a new chest tube. The phy-
within the thoracic cavity. If not, replace the chest tube. An injury to sician should wear gloves, a gown, a face mask with an eye shield
FIGURE 39-11. The chest tube is connected to a drainage system.

or goggles, and a cap to prevent becoming contaminated when the the inferior surface of the rib may tamponade the bleeding. If the
chest tube is removed. bleeding continues, attempt to tamponade it with a Foley catheter.
Place the patient supine or semirecumbent. The use of paren- Insert the catheter into the pleural cavity, inflate the cuff, and with-
teral sedation and soft restraints is rarely necessary when remov- draw the catheter to lodge the cuff against the posterior surface
ing a chest tube. Carefully remove the tape securing the chest tube of the rib. Another option is to extend the incision to expose and
to the chest wall. Be cautious when removing the tape if it covers ligate the bleeding vessel. Lung injury and bleeding from penetra-
the patient’s nipple, so as to prevent any injury. Remove the gauze tion into the pleural cavity are often self-limited and minor. Rarely
squares and petrolatum gauze covering the incision site. Untie will an injury be serious enough to warrant surgical intervention.
the bow securing the free ends of the purse-string suture that was A trocar should never be used, as risk of injury to intrathoracic
previously placed. Cut the suture that is holding the chest tube to structures is significantly increased. An anteriorly placed chest
the chest wall. Remove this suture. Place the first half of a surgeon’s tube should be at least 3 cm from the lateral border of the sternum
knot in the free ends of the purse-string suture. Pass the ends of the to prevent injury to the internal mammary artery.
suture to an assistant. Instruct the patient to inhale or exhale fully The chest tube can become occluded and stop functioning. A
and hold their breath.18 This results in a Valsalva-type maneuver, large tube should always be inserted if its purpose it to drain blood,
and will prevent ambient air from being drawn through the chest clots, or purulent material. Attempt to milk and/or strip the tubing,
wall and into the pleural cavity. Quickly and smoothly remove the as described previously. Obtain a chest radiograph to determine if
chest tube while the assistant cinches down the knot of the suture to the chest tube is kinked. Twist the chest tube 180° and release it. If
seal the skin incision. Tie additional knots to secure the purse-string it spins back into its original position, it is kinked.24 If the occlusion
suture. Place petrolatum jelly or topical antibiotic ointment over the cannot be dislodged or the tube is kinked, the chest tube should be
incision. Cover the site with gauze squares and tape it securely. removed and a new one inserted.
Observe the patient for 4 to 6 hours for any signs of cardiovas- Subcutaneous emphysema results from air from an inadequately
cular or respiratory compromise. If the patient remains asymptom- decompressed pneumothorax that tracks into the subcutaneous tis-
atic, obtain expiratory posteroanterior and lateral chest radiographs. sues. Ensure that the chest tube, drainage system, and suction source
Evaluate the radiograph for the recurrence of the pneumothorax, are functioning properly. Replace any component that is not func-
hemothorax, pyothorax, and/or hydrothorax. The dressing may be tioning. Verify that the chest tube is within the pleural cavity and
removed in 24 to 48 hours. Remove the chest wall sutures in 8 to not within the subcutaneous tissues using either plain chest radiog-
10 days. raphy or ultrasound.25 Evaluate the chest radiograph to ensure that
all of the drainage holes are within the pleural cavity and not in the
COMPLICATIONS subcutaneous tissues.
Reexpansion pulmonary edema occurs from the rapid expan-
Tube thoracostomy is often described as a simple procedure. But
sion of a lung that has been collapsed for over 48 to 72 hours or
if it is not performed with care and attention, it can result in seri-
from the removal of a large pleural effusion.26,27 Patients will begin
ous complications, including injuries to thoracic and abdominal
to experience increasing shortness of breath and hypoxemia within
organs.1,2,19 An unusual occurrence of sudden death following chest
a few hours of the procedure. Repeat chest radiographs will show
tube insertion has been reported.20 It was attributed to hemorrhage
an expanded lung with pulmonary edema. The exact etiology of
near the vagus nerve, causing irritation and stimulation of the vagus
this complication is unknown. This complication may be prevented
nerve and refractory bradycardia. Injury to the thoracic duct from
by the slow expansion of a lung and the removal of pleural fluid
the chest tube being inserted too deeply can result in a chylothorax.21
in increments. Treatment includes supportive care, supplemental
Injury to the heart and great vessels can occur if the chest tube is
oxygenation, and positive-pressure ventilation (i.e., BiPAP, CPAP,
placed anteriorly or a trocar was used to insert the chest tube. Lung
and/or intubation). Diuretics have no role in relieving the edema.
injury can occur if the clamp plunges inward on entering the pleu-
Reexpansion pulmonary edema has an associated mortality rate of
ral cavity. It is imperative that the Kelly clamp be controlled as it
up to 20%.27
enters the pleural cavity. If the lung is adherent to the chest wall,
The sources of pain for a patient with a tube thoracostomy are
it may be penetrated by the Kelly clamp or the chest tube. A trocar
numerous. These include the skin incision, subcutaneous dissec-
should never be used to insert a chest tube, as it can cause signifi-
tion, intercostal muscle transection, the chest tube, and the underly-
cant injury to the heart, lung, or other intrathoracic structures.
ing injury. Pain can often be managed with parenteral analgesics and
Other complications associated with chest tube placement and
sedation. Intrapleural bupivacaine has been found to be effective in
removal include recurrent, residual, and loculated pneumothora-
reducing pain.28,29 Administer 20 to 40 mL of 0.25% bupivacaine
ces. These may require the placement of additional chest tubes. A
through the chest tube and into the pleural cavity. Clamp the chest
retained hemothorax may require decortication and may develop
tube or the tubing for up to 10 minutes to allow the bupivacaine to
into an empyema.4,22,23
thoroughly coat the pleural cavity. Carefully monitor and observe
Posttraumatic empyema remains a serious complication of tho-
the patient to ensure that they do not develop a tension pneumo-
racic trauma with incidences ranging from 2% to 25%.1,2,4,23 The eti-
thorax while the chest tube is clamped. Unclamp the chest tube
ology of the infection is not always clear. A break in sterile technique
and allow the excess anesthetic to drain into the collection system.
on chest tube insertion, nosocomial pneumonia, superinfected
This can provide several hours of pain relief to a patient who may
pulmonary contusion, and undrained hemothoraces have all been
have limits on or contraindications to parenteral analgesics.
implicated. Empyemas that can be attributed to the chest tube inser-
tion process are completely preventable complications that can be
SUMMARY
avoided by strict adherence to aseptic technique.
Bleeding can occur from several sites. Incision site bleeding is Tube thoracostomy is useful in the treatment of thoracic injuries
often due to superficial venules and arterioles. The application of resulting in pneumothoraces, hemothoraces, hydrothoraces, and
pressure and the suturing of the incision closed will alleviate this chylothoraces. Attention must be paid to observe sterile technique,
bleeding in most cases. If the dissection or penetration into the choose the proper insertion site, carefully enter the pleura, and
pleural cavity occurs along the inferior surface of a rib, an intercos- verify entry via digital exam. Appropriate drainage systems should
tal artery or vein can be lacerated. Securing the chest tube against be employed to assure maintenance of a closed, water-tight system.
Monitor the patient regularly while the chest tube is in place. thoracentesis procedural guidance. The portable AP (anteroposte-
Emergency Physicians performing this procedure should be cogni- rior) radiograph cannot always reliably distinguish between a pleu-
zant of the serious complications that may be associated with tube ral effusion, a pneumonia, or atelectasis.8 In these indeterminate
thoracostomies, some of which are directly related to the insertion cases, ultrasound can be clinically useful. Pleural fluid can be iden-
technique. Adherence to the principles described above will assist in tified as a black hypoechoic area, which appears darker than the sur-
avoiding many of these complications and provide optimal care for rounding lung, diaphragm, and liver. Ultrasound can aid in the
victims of thoracic trauma. identification of small effusions. Thoracentesis performed blindly
has an associated complication rate of up to 30%.9 Ultrasound
allows the Emergency Physician to map the pleural effusion and
choose the best site for thoracentesis, thereby reducing the rate of
pneumothoraces to less than 3%.10–14 Ultrasound guidance has been
Thoracentesis shown to be very safe in assisting with thoracentesis in intubated
40 Eric F. Reichman, Cristal R. Cristia,
and Jehangir Meer
and mechanically ventilated patients, both high-risk populations for
complications.12,15
A pneumothorax may be simple or under pressure (also known as
tension). A simple pneumothorax may present clinically with chest
INTRODUCTION pain, dyspnea, hypoxia, and tachycardia. Physical examination may
reveal, on auscultation, decreased breath sounds on the affected side.
Thoracentesis is a term derived from the Greek meaning “to pierce
Performance of a thoracentesis to relieve a tension pneumothorax
the chest.” It is used today to refer to the removal of air or fluid from
is based on the mechanism of lung injury, the patient’s symptoms,
the thoracic cavity. Accumulation of pleural fluid is not a specific
and physical examination findings. Mechanisms of injury to the
diagnosis but rather a reflection of an underlying process. In almost
lung include mechanical ventilation, chest trauma, instrumentation
all newly discovered pleural effusions, thoracentesis should be per-
of the chest, and spontaneous lung rupture. Classically, the patient
formed to aid in the diagnosis and management of the underlying
has a clinical presentation of hypotension, tachycardia, and absent
etiology.
breath sounds on the affected side. Other symptoms may include
Hippocrates first described thoracentesis in the management of
a deviated trachea, acute change in mental status, air hunger, chest
an empyema.1 Thoracentesis was used widely in World War II and
pain, cyanosis, diaphoresis, hypoxia, and cardiorespiratory arrest.1,4
the Korean conflict in lieu of a thoracotomy for chest drainage. By
Sometimes a patient with a tension pneumothorax may have a nor-
the time of the Vietnam War, this practice was replaced by tube tho-
mal physical examination due to subtle auscultation findings often
racostomy. Today, thoracentesis is used in the diagnosis and therapy
missed in a noisy Emergency Department. Tactile fremitus may be
of pleural effusions, emergent and temporizing treatment of a ten-
absent and percussion is typically hyperresonant over the hemitho-
sion pneumothorax, and the management of small, nontraumatic
rax with the tension pneumothorax.
pneumothoraces.1–4
There are two major indications for performing a thoracente-
A pleural effusion can be identified clinically and radiologically.
sis.1–3,6 The first is for the evacuation of air. This includes a simple
Clinically, the patient may develop pain related to irritation of the
pneumothorax and the emergent diagnosis and temporizing treat-
parietal pleura, compromised pulmonary mechanics, or interfer-
ment of a tension pneumothorax. The second is for the evacuation
ence with gas exchange.3 The pain may be located in the chest,
of fluid. This may be done to help diagnose the etiology of pleural
abdomen, or ipsilateral shoulder. Another common symptom is a
effusion or for the treatment of a symptomatic pleural effusion.
cough; its mechanism is unclear. Dyspnea occurs secondary to the
space-occupying effect of the fluid and alterations in gas exchange.
In extreme cases, pleural effusions can reduce cardiac output. On PLEURAL EFFUSIONS
physical examination, tactile fremitus is absent or attenuated and
there is dullness to percussion. Auscultation reveals decreased
breath sounds on the involved hemithorax.
Radiographically, on a posteroanterior (PA) chest radiograph, The pleura is a serous membrane that covers the lungs, mediasti-
an effusion can be diagnosed when there is homogeneous opaci- num, diaphragm, and thoracic cavity. The pleural space is a potential
fication in the hemithorax, absent air bronchograms, and clouded space between the lung and the thoracic cavity. A thin layer of fluid
vesicular vascular markings. In a cadaveric study, the minimum normally exists between the visceral pleura covering the organs and
fluid volume needed to blunt the costophrenic angle was 175 mL.5 the parietal pleura covering the chest wall. This fluid acts as a lubri-
More than 500 mL had to be injected into some cadavers to blunt cant.3 Pleural fluid originates from three sources: parietal capillaries,
the costophrenic angle.5 In a study on mechanically ventilated visceral capillaries, and the interstitium. Hydrostatic and oncotic
patients, ultrasound consistently identified nonloculated pleural forces govern the flow of fluid in the pleural space. These forces are
effusions when the effusion was at least 500 mL.6 A lateral decu- summarized in Figure 40-1. In a healthy person, protein-free fluid
bitus film is often necessary and will determine whether the fluid enters the pleural space from the parietal pleura and is absorbed
is loculated or free-flowing. It will also be helpful if one of the fol- by the visceral pleura. Small amounts of protein then leak into the
lowing signs is present on the PA chest radiograph: a clear costo- pleural space. Approximately 10% of the pleural fluid and large pro-
phrenic angle, an elevated hemidiaphragm, a blurred contour of the teins are removed by the lymphatics at a rate of up to 20 mL/h for
diaphragmatic dome, or the gastric bubble seen more than 2 cm each hemithorax.2 Ventilation and muscular activity facilitate the
from the lung border in patients with left-sided pleural effusions.2 action of the lymphatics.3
If the fluid collection is 10 mm thick on the lateral decubitus film, Alterations in pleural fluid homeostasis will lead to a pleural effu-
thoracentesis can most likely be performed using clinical skills to sion: a pathologic collection of excess fluid, located between the vis-
locate the fluid.7 If it is less than 10 mm thick, ultrasound may be ceral and parietal pleura. Hydrostatic changes result in protein-free
needed for localization.3 effusions (transudates). Changes in oncotic pressure (abnormality
The use of ultrasound is no longer limited to Radiologists. With in the lung or pleura) lead to effusions. The differential diagnosis of
proper training, Emergency Physicians can utilize ultrasound for transudates and exudates is listed in Table 40-1.
CHAPTER 40: Thoracentesis 251
FIGURE 40-1. Schematic of pleural fluid homeostasis in a

normal lung.
INDICATIONS perform and increase the risk of complications.16 Patients undergo-

ing positive-pressure ventilation (i.e., mechanical ventilator, BiPAP,
A thoracentesis may be performed to remove pleural fluid for analy- or CPAP) are at an increased risk of developing a pneumothorax
sis to diagnose the etiology of the fluid (e.g., malignancy, infection). and a tension pneumothorax.1 Although, one study has shown
It may also be performed to relieve the patient’s symptom of dys- that a thoracentesis can be done as safely in a ventilator-dependent
pnea when a large pleural effusion interferes with normal respira- patient as in patients not being mechanically ventilated.17 Pleural
tion or results in respiratory compromise. adhesions may limit the amount of fluid obtained or require mul-
tiple thoracenteses to drain the fluid.1 Loculated pleural adhesions
CONTRAINDICATIONS should be drained under ultrasound guidance. Areas of cellulitis
or other infection on the chest wall should be avoided unless no
The only absolute contraindications are an uncooperative patient or
alternate site can be identified for the procedure.1,3 Unsupervised
a patient who refuses to give informed consent for the procedure.16
physicians with little or no experience should not perform this
Uncooperative patients or patients with altered levels of conscious-
procedure, as the risk of complications is increased.7 Patients with
ness may require sedation for the procedure.
chronic obstructive pulmonary disease are at increased risk for
There are numerous relative contraindications to performing a
complications.
thoracentesis. Patients receiving anticoagulants, with a bleeding
diathesis (whether known or suspected), or thrombocytopenia have
a significant risk of bleeding.2,16 Consider reversing the anticoagu- EQUIPMENT
lant or the bleeding disorder prior to performing the thoracentesis.
A small volume of pleural fluid may make the procedure difficult to Diagnostic Thoracentesis for Pleural Effusions
• Face mask with a face shield or goggles
TABLE 40-1 Differential Diagnosis of Fluid Exudates and Fluid Transudates • Local anesthetic solution, 1% to 2% lidocaine
in the Pleural Space • Heparin, 1000 U/mL
Exudates Transudates • Atropine, 1 mg
Asbestos exposure Atelectasis • Alcohol pads
Collagen vascular disease Cirrhosis of the liver with ascites
Drug-induced Congestive heart failure • Povidone iodine or chlorhexidine solution
Empyema Nephrotic syndrome • Gauze 4 × 4 squares
Esophageal rupture Peritoneal dialysis • Sterile drapes
Idiopathic Pulmonary embolism
Malignancy • Sterile towels
Pancreatitis • Sterile gloves
Parapneumonic
• Band-aids
Pulmonary embolism
Rheumatoid arthritis • 25 or 27 gauge needle
Systemic lupus erythematosus • 21 and 22 gauge needles, 1.5 in. long
Thoracic duct exposure
Trauma • 10 mL syringes
Tuberculosis • 50 mL syringe
Viral • 18 or 20 gauge needle
Ultrasound Guidance
• Ultrasound machine
• 3.5 to 5.0 MHz phased-array ultrasound probe
• Sterile ultrasound gel
• Sterile ultrasound probe cover
Therapeutic Thoracentesis for Pleural Effusions

• The supplies listed above
• 16 to 18 gauge catheter-over-the-needle
• 14 to 18 gauge catheter-through-the-needle
• Three-way stopcock
• Connector tubing (connects to three-way stopcock and sterile
container)
• Sterile container for pleural fluid
• 50 mL syringe
• Intravenous extension tubing
Commercial kits have been developed and are available to pro-
vide the equipment needed to perform a thoracentesis. The kits are
disposable, intended for single-patient use, and contain the required
equipment. They save time in that the equipment does not have to
be found and set up. Disadvantages include potential increased
cost and limited equipment in the kit.18 Common kits include the
Pharmaseal, distributed by Baxter (Jacksonville, TX); the Arrow
Clark Thoracentesis Kit, distributed by Arrow (Reading, PA); the
Argyle Turkel Safety Thoracentesis Kit, distributed by Boston
Scientific (Miami, FL), and the Turkel Thoracentesis Kit, distributed
by Tyco Healthcare (Mansfield, MA).3 FIGURE 40-2. Recommended positioning of an ambulatory patient for a diag-
nostic or therapeutic thoracentesis for the evacuation of fluid.2
PATIENT PREPARATION
Explain the procedure, its risks, and benefits to the patient and/or
their representative and obtain a signed consent form.1 The posi- If the fluid thickness is less than 10 mm on radiographs, ultra-
tion of the patient can vary depending on their clinical condition. sound may be used to locate the fluid.5,16 Alternatively, ultrasound
Patients who are ambulatory and cooperative should sit up at the can be routinely used to locate pleural fluid. Ultrasound has been
edge of a bed with their feet on the floor or a stool (Figure 40-2). shown to be comparable to CT for diagnosing and managing a pleu-
Place the patient’s head and arms on an elevated bedside tray. The ral effusion.19
patient’s back should be as vertical as possible so that the lowest part Although not required, some Emergency Physicians place the
of the hemithorax is posterior. This will ensure that the free-flowing patient on the cardiac monitor, noninvasive blood pressure cuff,
fluid remains posteriorly.1–3,16 pulse oximetry, and supplemental oxygen to monitor them dur-
In debilitated patients, one of three other positions is recom- ing and after the procedure. Apply povidone iodine or chlorhexi-
mended. Place the patient in the lateral decubitus position, lying on dine solution to the skin surface and allow it to dry. Apply sterile
the side of the pleural effusion. The patient’s back should be along drapes around the site of the procedure. If using an ultrasound-
the edge of the bed. The procedure would then be performed in the guided technique, be sure to fit the transducer with a sterile glove or
midscapular line or the posterior axillary line. Place a ventilator- probe cover before exposing the probe to the sterile skin. Use sterile
dependent patient into the lateral decubitus position, lying on the ultrasound gel. Atropine should be at the bedside. It can be admin-
side with the pleural effusion.17 Second, place the patient supine istered (1.0 mg subcutaneously or intramuscularly or 0.5 mg intra-
and elevate the head of the bed as much as maximally possible. The venously) to patients who develop symptomatic bradycardia during
patient would then be sitting with the assistance of the bed, and the the procedure. The Emergency Physician should wear full personal
procedure would be performed in midaxillary or posterior axillary protective equipment to protect themselves from contact with the
line.3 Finally, the patient can be placed supine. The procedure would patient’s blood and body fluids as well as protect the patient from
then be performed at the posterior or midaxillary line. With the infection.
patient supine, ultrasonography may be required to locate the pleu- Place a skin wheal of local anesthetic solution over the thoracen-
ral fluid. Sedation or paralysis may be needed for optimal position- tesis site using a 25 or 27 gauge needle on a 10 mL syringe contain-
ing depending on the patients clinical condition. ing the local anesthetic solution. Remove the 25 or 27 gauge needle
After positioning the patient, clean any dirt or debris from the from the syringe. Apply a 21 or 22 gauge, 1.5 to 3.0 in needle to
skin. Identify the anatomic landmarks required to perform the the syringe containing the local anesthetic solution. Anesthetize the
procedure. After viewing the chest radiograph and estimating subcutaneous tissues and the periosteum of the rib (Figure 40-3).
the amount of pleural fluid, percuss from superior to inferior start- Walk the needle up the rib while simultaneously injecting local
ing at the midscapular or posterior axillary line. The site chosen anesthetic solution. Gently aspirate prior to injecting each time the
for aspiration should be a single interspace below the top of the needle is advanced to ensure that the needle is not within a blood
dullness to percussion. vessel. When the superior border of the rib is located, slowly and
FIGURE 40-3. Administration of local anesthesia. A skin wheal is made. The nee-
dle is inserted through the skin wheal while local anesthetic solution is injected to
anesthetize the subcutaneous tissues and the periosteum of the rib. The needle FIGURE 40-4. Needle positioning for a diagnostic thoracentesis. A. The pleural
is “walked” above the upper border of the rib (red jagged line) to avoid the neu- space is entered above the effusion (too high). B. The pleural space is entered
rovascular bundle inferior to the rib. The intercostal muscles, parietal pleura, and properly, over the rib and into the fluid. C. The needle is too low and enters the
pleural space are then infiltrated with local anesthetic solution. abdominal cavity below the diaphragm.
carefully advance the needle over the rib while applying negative
pressure on the syringe. Be sure not to insert the needle below the rib THERAPEUTIC THORACENTESIS TECHNIQUES
to avoid injury to the neurovascular bundle inferior to the rib. When FOR PLEURAL EFFUSIONS
the pleural space has been entered, fluid will flow into the syringe.
The same sterile preparation, location of fluid, positioning, and
Inject and aspirate small volumes (1 to 2 mL) while the needle is
anesthesia considerations apply for therapeutic thoracentesis as
within the pleural cavity. This will distribute the local anesthetic
with the diagnostic procedures. However, there is one difference
solution into the pleural fluid and ensure anesthesia of the pleura.
between a diagnostic and a therapeutic thoracentesis—that is, the
Withdraw the needle from the pleural cavity and out the skin.
quantity of fluid removed. Up to 1.5 L is removed in a therapeutic
DIAGNOSTIC THORACENTESIS TECHNIQUE thoracentesis. A diagnostic thoracentesis requires approximately
10 to 20 mL of pleural fluid.
FOR PLEURAL EFFUSIONS
Attach an 18 gauge needle to a 50 mL syringe containing 1 mL of ■ CATHETER-OVER-THE-NEEDLE TECHNIQUE
heparin. The heparin will ensure accurate pH and cell counts as Two types of catheters can be used to perform this procedure. They
it prevents the fluid from clotting. Introduce the needle through are the catheter-over-the-needle and the catheter-through-the-nee-
the anesthetized track and into the pleural cavity (Figure 40-4B). dle (Figures 40-5 & 40-6). The catheter-over-the-needle technique
Aspirate up to 50 mL of fluid. Withdraw the needle and place the
fluid into the appropriate sterile containers. Use proper techniques
when transferring the fluid into containers or specimen tubes to
prevent a needlestick injury.
If pleural fluid cannot be aspirated, also known as a dry tap, four
possibilities must be considered. The needle may be too short, posi-
tioned too high to reach the fluid (Figure 40-4A), positioned too
low to reach the fluid (Figure 40-4C), or there may not actually be
an effusion. Repeat the physical examination and review the chest
radiograph to reconfirm the presence of a pleural effusion. Use
ultrasound, if available, to assess the presence of a pleural effusion.
Penetration of the lung with the needle is rarely catastrophic but can
result in a pneumothorax.3
For debilitated patients, the principles are the same with the
exception of the site for the procedure. If the patient is supine,
use the midaxillary line or the posterior axillary line. Be cautious
of the diaphragm, as it can be as high as the fifth interspace on
expiration at the anterior axillary line. If the patient is in the lateral FIGURE 40-5. The catheter-over-the-needle technique. A. The needle and cath-
decubitus position, use the midscapular line or the posterior axil- eter are inserted over the rib and aimed slightly caudally into the pleural cavity.
lary line for the procedure. B. The catheter is advanced into the pleural cavity and the needle is removed.
pressure to the syringe as the needle is advanced along the anesthe-

tized tract and into the pleural cavity (Figure 40-6A). Stop advanc-
ing the needle when fluid is aspirated. Securely hold the needle so it
does not move. Remove the syringe and cover the needle hub with
a gloved finger. This will prevent ambient air from entering the
pleural cavity. Angle the needle slightly caudally and advance
the catheter through the needle (Figure 40-6B). Withdraw the nee-
dle, leaving the catheter within the pleural cavity (Figure 40-6C).
Once the needle is removed, do not readvance the needle, as the
catheter may shear off and fall into the pleural cavity. Place a
three-way stopcock or a large syringe onto the hub of the catheter.
Place the needle guard on the needle. Secure the catheter by taping
it to the skin. Withdraw fluid as previously described. Fluid can be
removed in 50 mL aliquots up to 1.5 L. As a general rule, this is
the limit, due to the risk of postevacuation pulmonary edema and
excessive protein loss.1
■ SELDINGER TECHNIQUE
An alternative approach is to use the Seldinger technique to insert a
small bore catheter into the pleural cavity. The major disadvantages
to this technique include the time it takes to insert the catheter, the
cost of the catheter kit versus a catheter-over-the-needle, and cath-
eter blockage (from cells, debris, and protein) requiring insertion of
a second catheter. Another option is to use a central venous catheter
FIGURE 40-6. The catheter-through-the-needle technique. A. The needle is kit.20,21 The larger catheter opening may not become obstructed as
inserted over the rib and aimed slightly caudally into the pleural space. B. The easily.
catheter is inserted through the needle and into the pleural cavity. C. The needle is
removed and the catheter remains within the pleural cavity. ■ ULTRASOUND-GUIDED TECHNIQUE
FOR PLEURAL EFFUSIONS
Ultrasound can be used to map the location and the extent of
is most commonly used (Figure 40-5). Make a small “nick” in the pleural effusion, and to help identify the appropriate site of needle
skin with a #11 surgical blade at the needle insertion site. Attach a entry. Real-time guidance is usually not required. A 3.5 to 5.0 MHz
14 to 18 gauge catheter-over-the-needle to a 10 mL syringe as a han- phased-array probe is recommended for ultrasound-guided exami-
dle. Insert the catheter-over-the-needle into the nick and advance it, nation of the pleural space.22 In general, orientation of the probe
reproducing the original anesthetized tract (Figure 40-5A). Apply follows the convention that the probe marker should correlate to the
negative pressure to the syringe as the catheter-over-the-needle is reference point in the left upper corner of the screen.
advanced. Stop advancing the catheter-over-the-needle when fluid With the patient in an upright sitting position, percuss and aus-
is aspirated. Angle the catheter-over-the-needle caudally. Securely cultate the posterior thorax to estimate the location of pleural fluid.
hold the syringe and needle so they do not move. Advance the Apply sterile ultrasound gel onto the ultrasound probe cover. Place
catheter until the hub is against the skin. Withdraw the needle and the probe at the intercostal space of the estimated level of pleural
syringe as a unit while the catheter remains in the pleural cavity fluid in the posterior axillary line, usually at the level of ribs 9 to 11.
(Figure 40-5B). When the needle is removed, quickly cover the Sweep the probe superiorly and inferiorly, as well as transversely, to
catheter with a gloved finger. This will prevent ambient air from assess the location and size of the fluid collection. Identify the liver
entering the pleural cavity. Attach intravenous catheter exten- on the right, the spleen on the left, and the diaphragm.
sion tubing to the hub of the catheter. Place a three-way stopcock In a debilitated patient in the lateral decubitus position, place the
attached to a 50 mL syringe onto the extension tubing. Hold the ultrasound probe in the midscapular line or, if possible, the pos-
catheter hub against the skin securely. Aspirate fluid into the syringe terior axillary to locate the fluid. A ventilator-dependent patient
and then advance the fluid into the sterile container by adjusting should be placed in the lateral decubitus position. If the patient is
the three-way stopcock. supine, place the probe in the posterior or midaxillary line. The real-
An alternative option is to set up a siphon through the three-way time movement of the diaphragm can be used as a key reference
stopcock. Prime the tubing with pleural fluid. Place the end of the point when examining the pleural space.23 The liver may also be
tubing into a sterile container that is located below the site of the used as a echogenic reference point for the identification of adjacent
catheter. This allows the fluid to flow freely into the sterile container. hyperechoic or hypoechoic structures. Keep in mind that the best
Fluid can be removed in 50 mL aliquots up to 1.5 L. As a general window to view the intrathoracic contents is through the intercostal
rule, this is the limit, due to the risk of postevacuation pulmonary space, as ultrasound penetration through the soft tissue is superior
edema and excessive protein loss.1 to that of bone.
The ultrasound waves will initially penetrate the skin, subcutane-
■ CATHETER-THROUGH-THE-NEEDLE TECHNIQUE ous tissue, and muscle to produce multiple layers of varying echo-
The second option is to utilize the catheter-through-the-needle sys- genicity. The echogenic ribs cast an acoustic shadow (Figure 40-7).
tem (Figure 40-6), known as the Bardig Intracath system. It is not The parietal and visceral pleura are encountered posterior to the
as popular as the catheter-over-the-needle systems. Place the needle rib as two hyperechoic lines, each <2 mm thick.23,24 The diaphragm
on a tuberculin syringe. Insert the needle and advance it through can be identified as a hyperechoic transverse structure at the base of
the anesthetized tissues (Figure 40-6A). A small “nick” in the skin the chest wall. The lung is visualized as a bright, hyperechoic struc-
with a #11 surgical blade will facilitate needle entry. Apply negative ture just cephalad to the diaphragm. The lung should become more
FIGURE 40-7. Ultrasound image of a normal lung. Visualized from top to bottom FIGURE 40-8. Ultrasound image of a pleural effusion. The pleural effusion
are the subcutaneous tissues, muscle (M), rib shadow (arrowhead), and pleural appears black or anechoic (asterisk). The pleura is not brightly echogenic (arrows)
line (arrows). due to the separation of the two layers. Note the rib shadow (arrowhead) in the
upper part of the image.
intensely hyperechoic, or brighter in the inspiration phase. A pleu- scan the posterior hemithorax from the inferior border of the scap-
ral effusion can be identified as an anechoic to a hypoechoic image ula to the upper lumbar region and from the paravertebral area to
above the diaphragm that decreases in size with inspiration. the posterior axillary line. Note the minimum depth of the effu-
Two additional ultrasound findings should be identified on exam: sion and the location of other vital structures (i.e., diaphragm, liver,
“lung slide” and “comet tail” artifact. The movement of the lung in spleen, and lung). Scan with the probe parallel to and perpendicular
reference to the surrounding parietal pleura with inspiration and to the ribs, and observe the structures during the full respiratory
expiration produces an artifact referred to as “lung slide.” Normal phase. The diaphragm can go as low as the 12th rib posteriorly and
inspiration should produce a “slide” with each breath, representing as high as the 8th rib laterally. Determine the location of the skin
movement between the visceral and parietal pleural interface. The entry site. Mark the site with a pen, surgical marker, or by indent-
thin, hyperechoic sliding line is located approximately 0.5 cm below ing the skin with the cap of a needle. The ideal site should have a
the surface of the rib, and should move back and forth with each large area of pleural effusion and be free of any internal structures
inspiration.25 A “comet tail artifact” is another normal finding that (i.e., liver, spleen, or diaphragm) along the needle path.
can be readily identified in a healthy patient. The comet tail artifact The lateral approach is used for mechanically ventilated patients
is identified as a hyperechoic vertical artifact that slides transversely and for those who are unable to sit up for the procedure. Abduct
and is oriented perpendicular to the transverse “lung slide” previ- the ipsilateral arm and place the hand behind the patient’s head,
ously mentioned.25 as one would in preparation for the placement of a chest tube
A pleural effusion is easily visualized using ultrasound (Figure 40-11). Survey the anterior and lateral thorax from the
(Figure 40-8). It appears black or anechoic. A distinct hyperechoic midclavicular line to the posterior axillary line. Note the depth of
pleural line is not seen as the parietal and visceral pleura are sepa- the effusion and the location of any vital structures to be avoided.
rated by the effusion. Lung tissue appears hyperechogenic compared Determine and mark the skin entry site.
with the anechoic effusion (Figure 40-9). The pleural effusion can The lateral decubitus approach is an alternative for patients
be seen moving during the respiratory cycle. unable to sit upright. Place the patient on their side with the pleu-
The posterior approach is the preferred choice in the stable, ral effusion side down. Use ultrasound to map the effusion. Note
cooperative patient who is able to sit up and lean over a table the distance from the skin to the effusion, the depth of the effu-
(Figure 40-10). To survey the lung anatomy and map the effusion, sion, as well as the presence of any important structures to be
FIGURE 40-11. Lateral approach in the supine patient. A curvilinear probe is

positioned in the midaxillary line. Note the coronal plane of the probe.
avoided. Determine and mark the skin entry site, usually at the
posterior axillary line.
Regardless of the patient position or approach, do not allow
the patient to move once they have been scanned and the skin
entry site marked. Prep and drape the patient similar to that for the
blind thoracentesis approach. Use local anesthetic to anesthetize the
skin, rib, and pleura. The catheter-over-the-needle can be inserted
blindly, as described previously, at the skin insertion site or using
real-time ultrasound guidance.
The use of ultrasound guidance can be helpful. Place a sterile
FIGURE 40-9. Ultrasound image of a pleural effusion (asterisk) with the underly- cover over the ultrasound probe. Apply sterile ultrasound gel over
ing hyperechoic lung tissue (L). Note the rib shadow (arrowhead) in the upper
the cover. Rescan the patient in the area previously identified the
left of the image.
skin entry site (Figure 40-12). Verify that no structures are along
FIGURE 40-10. Posterior approach in the sitting patient. A linear ultrasound probe
is seen here, although a phased-array probe is often preferred to visualize deeper FIGURE 40-12. The pleural effusion (asterisk) is visible above the diaphragm
structures. (arrows). The liver (L) is seen below the diaphragm.
TABLE 40-2 Laboratory Analysis of Pleural Effusions

Acid-fast stain
Amylase
Cell count and differential
Color
Cultures
Acid-fast
Aerobic
Anaerobic
Fungal
Glucose
Gram stain
Hemoglobin and hematocrit
pH
Triglycerides
chylothorax. The fluid’s white blood cell count is of limited benefit.

If it is >10,000, the fluid likely represents a parapneumonic effu-
sion. A pleural fluid hemoglobin and hematocrit can be compared
to that of the blood. Bloody pleural effusions are usually associated
with malignancy, pneumonia, pulmonary embolism with a lung
infarction, or trauma.29 If the fluid is grossly bloody, consider a
hemothorax. If the pleural fluid’s hematocrit is >50% of the serum
hematocrit, a hemothorax is likely and chest tube placement should
be considered. Other helpful tests include a fluid pH. If the pH is
below 7.25 to 7.30, consider it the result of a parapneumonic pro-
cess, rheumatologic process, esophageal rupture, or malignancy.
An elevated amylase level suggests esophageal rupture, malig-
nancy, or pancreatic disease.30 Elevated triglyceride levels suggest
a chylothorax. Cytology is important to search for an underlying
malignancy. Up to 50% of patients with a pulmonic malignancy
will have neoplastic cells in the pleural fluid.3 Bacteriologic infor-
mation such as Gram’s stain, acid-fast, and fungal preparations
are also important, although the yield can be below 30%.16 Fluid
should always be sent for aerobic and anaerobic cultures to rule
FIGURE 40-13. Long-axis view of a thoracentesis needle (arrows) being placed out an infectious etiology for the pleural effusion. The appearance
into a pleural effusion (asterisk) under ultrasound guidance. The rib shadow is of pleural fluid on ultrasound may help identify whether the pleu-
denoted by an arrowhead. ral fluid is a transudate or an exudate. Transudates are consistently
seen as anechoic, whereas exudates may range from an anechoic to
a hyperechoic.31,32
the needle path between the skin and the pleural effusion. Insert an
18 gauge catheter-over-the-needle into the pleural space using the AFTERCARE
technique already described while using ultrasound for real-time When done aspiring fluid, remove the catheter and apply a bandage
visualization of the needle entering the pleural cavity. The needle will to the puncture site. Several authors have suggested that a postpro-
appear as a thin, bright, hyperechoic structure moving through the cedure chest radiograph may not be necessary.33,34 These were small
skin, subcutaneous tissue, parietal pleura, visceral pleura, and finally studies with methodologic errors. Omitting the postprocedure chest
reaching the hypoechoic pleural effusion (Figure 40-13). Aspirate radiograph cannot be recommended at this time. Obtain a plain
to confirm that the catheter-over-the-needle is within the pleural chest radiograph upon completion of the procedure to assess for a
effusion. Place the ultrasound probe aside. Continue the remainder pneumothorax. An expiratory film is the best film to look for a pneu-
of the procedure as described previously. mothorax, especially if it is small. Repeat a chest radiograph in 4 to
6 hours to look for a delayed pneumothorax. If no pneumothorax is
ASSESSMENT present and if appropriate for the clinical condition, the patient may
be discharged with good instructions and close follow-up.
Numerous analyses of the pleural effusion fluid are required to
determine its etiology (Table 40-2). Large pleural effusions are
more commonly associated with infections and malignancy.26
Fluid analysis criteria have been established to separate transu-
dates and exudates.10,27 If the fluid fits one of the criteria in Table TABLE 40-3 Laboratory Features of a Pleural Fluid Exudate
40-3, it is an exudate. These parameters have been confirmed to Fluid/serum lactate dehydrogenase (LDH) > 0.6
have 98% sensitivity and 83% specificity in detecting exudates.28 Fluid/serum protein > 0.5
Color and odor can be helpful. If the fluid has a putrid odor, con- Pleural fluid LDH > 200 IU/mL
sider an infection. White or yellow fluid suggests an empyema or Pleural fluid LDH > 2/3 upper limit of normal for serum
TABLE 40-4 Potential Complications Associated with a Thoracentesis common etiologies being pleural biopsy, subclavian vein catheter-
ization, and thoracentesis.
Cough
Hemothorax The pressure in the pleural space is negative in reference to the
Hypovolemia atmosphere. This is due to the tendency of the lung to collapse
Hypoxemia and the chest wall to expand. The alveolar pressure is greater than
Inadequate yield the pleural space pressure due to the elastic recoil of the lung. As a
Intrapleural infection result, if a communication occurs between the alveolar and pleural
Laceration of an intercostal nerve or vessel space, the air will preferentially move into the pleural space until
Laceration of the liver or spleen the pressure equalizes. The physiologic consequence is a decrease
Pain at the procedure site in vital capacity and PaO2. This may be well tolerated in otherwise
Pneumothorax healthy people but not in patients with underlying cardiac and/or
Reexpansion pulmonary edema pulmonary disease. If a one-way valve develops such that air can
Shortness of breath only enter the pleural space from the alveolus but not return, the
Tension pneumothorax intrapleural pressure will eventually exceed atmospheric pressure,
Vasovagal reactions
with a progressive increase in air occupying the pleural space.
Clinical deterioration may occur due to a decreasing PaO2 and car-
diac output.50–52 Other data point to hypoxia and hypercarbia as the
The procedure site should be evaluated two to three times a day cause of clinical deterioration.18
for signs of infection. These patients should be educated about the Ultrasound guidance may aid in locating a pneumothorax, with
signs, symptoms, and significance of an infection. They should the best viewing window being the intercostal space. Zhang et al.
return to their primary physician or the Emergency Department showed a sensitivity and specificity of ultrasound in diagnosing a
immediately if they develop fever, chills, shortness of breath, red- pneumothorax of 86% and 97%, respectively; whereas conventional
ness or pus at the puncture site, or if any concerns arise. radiography was 28% and 100%, respectively.53 In addition, ultra-
sound diagnosed a pneumothorax within only 2 to 5 minutes, com-
pared to 20 to 30 minutes for chest radiography.53 In a similar study,
COMPLICATIONS ultrasound showed a sensitivity and specificity of 100% and 94% for
The potential complications of a thoracentesis are listed in detection of pneumothoraces, compared to 36% and 100% for chest
Table 40-4.1,3,16,28,35 Complication rates range from 20% to 50%. The radiography.54
major complications are a 5% to 19% incidence of pneumotho- Controversy exists to the exact management of a spontaneous
rax and a 1% to 7% incidence of pneumothorax requiring a chest pneumothorax.55–60 Options include simple aspiration, tube thora-
tube.11,36 One author recommends ultrasound-guided thoracentesis costomy, and simple aspiration followed by a tube thoracostomy if
for all patients as the safest approach, although this is disputed by aspiration fails. Simple aspiration is more likely to fail with larger
others.9,36 The majority of studies report lower rates of postproce- pneumothoraces.58,59 Several recent reviews, including a Cochrane
dural pneumothoraces with ultrasound-guided thoracentesis per- Collaboration, came to similar conclusions regarding simple aspira-
formed by an experienced operator.9–11,15,37–41 However, others have tion.55–57 These conclusions, while not definitive, were that simple
not shown a significant difference in the incidence of postproce- aspiration is associated with a reduction in the percentage of patients
dural pneumothoraces with the use of ultrasound.42,43 requiring hospitalization compared to tube thoracostomy. There
The use of the proper technique and the Emergency Physician’s were no differences between the two procedures in early failures,
experience are important in reducing the rate of complications.44–46 immediate success rate, duration of hospitalization, one-year success
Despite this, it is difficult to predict which patients may be at risk of rates, and the number of patients requiring a subsequent pleurode-
developing a postprocedural pneumothorax.47 Drainage of large vol- sis. Advantages of simple aspiration compared to tube thoracostomy
umes of fluid, greater than 1.5 to 2 L, may increase the risk of devel- include less equipment costs, easier to perform, simpler to perform,
oping a pneumothorax.48 Improper technique or tortuosity of the quicker to perform, and the potential to avoid hospitalization.
intercostal artery can result in intercostal artery injury.49 Qureshi
compiled methods to reduce the incidence of pneumothorax.16 They INDICATIONS
are direct supervision of inexperienced operators, removal of small
amounts of fluid, use of small-gauge needles, use of ultrasound for All tension pneumothoraces require needle drainage followed
small effusions, and use of a needle-catheter system for a therapeu- by tube thoracostomy. Patients usually present with respiratory
tic procedure. distress, tachycardia, unilateral absence of breath sounds, hypoten-
sion, and neck vein engorgement. Although difficult to assess, these
patients have tracheal deviation that is often limited to the thoracic
PNEUMOTHORAX cavity.
Not all simple pneumothoraces require drainage, as they may
ANATOMY AND PATHOPHYSIOLOGY resolve spontaneously. Conservative management has shown a
spontaneous resorption rate of 1.25% per day.46 A pneumothorax
A thoracentesis can be performed to relieve a simple pneumotho- should be drained if the patient complains of dyspnea, dyspnea on
rax or a tension pneumothorax. A pneumothorax can be defined exertion, pain, or if the pneumothorax is estimated to be 15% or
by the presence of air between the visceral and parietal pleura.25 greater.
Primary spontaneous pneumothoraces occur in otherwise healthy
people without antecedent trauma. Secondary spontaneous pneu-
mothoraces occur as a complication of underlying lung disease,
CONTRAINDICATIONS
most commonly chronic obstructive pulmonary disease.1,3 A trau- There are no absolute or relative contraindications to relieving a
matic pneumothorax occurs as a result of penetrating or blunt tension pneumothorax, as it is a life-threatening emergency.
trauma to the thoracic cavity. An iatrogenic pneumothorax is a Contraindications to thoracentesis to relieve a simple pneumo-
subcategory of the traumatic pneumothorax, with the three most thorax are few. These include infection at the site of the procedure,
in which case an alternate site should be selected.3 A traumatic

pneumothorax or a pneumothorax associated with a hemothorax
or pyothorax requires tube thoracostomy. Any pneumothorax that
is expanding or expanding despite thoracentesis also requires a tube
thoracostomy. Any patient on anticoagulation or with a suspected
bleeding diathesis, whether known or suspected, may require rever-
sal of the condition before the procedure.1 A patient with minimal
symptoms and a small pneumothorax may be observed before
deciding to evacuate the pneumothorax.
EQUIPMENT
Pneumothorax—Tension
• Alcohol swab, povidone iodine solution, or chlorhexidine solution
• 12 to 16 gauge catheter-over-the-needle, 2 in. long
Pneumothorax—Stable
• Face mask with a face shield or goggles FIGURE 40-14. Relief of a tension pneumothorax. The patient should be in the
• Povidone iodine or chlorhexidine solution supine position, with the head of the bed elevated 30° if not contraindicated. The
second intercostal space in the midclavicular line is the recommended site. For
• Sterile gauze sponge pleural effusions or a debilitated patient, the midaxillary line or posterior axillary
• Sterile towels line may be used at the level of the fourth or fifth intercostal space.
• Sterile basin
• Syringes for anesthesia infiltration, 5 and 10 mL
• 25 gauge needle for anesthesia infiltration of the skin PATIENT PREPARATION
• 21 or 23 gauge needle for infiltration of subcutaneous tissue,
periosteum, and pleura Explain the procedure, its risks, and benefits to the patient and/
or their representative and have a consent form signed.1 Place the
• 16 or 18 gauge catheter-over-the-needle patient supine on the bed. Alternatively, the patient may be supine
• 14 to 18 gauge catheter-through-the-needle with the head of the bed elevated to 30° (Figure 40-14). Clean
• Pigtail or straight catheter kit any dirt or debris from the skin. Identify the anatomic landmarks
required to perform the procedure. Although not required, it is
• Three-way stopcock
recommended to place the patient on the cardiac monitor, non-
• 50 mL syringe invasive blood pressure cuff, pulse oximetry, and supplemental
• Intravenous extension tubing oxygen. Apply povidone iodine or chlorhexidine solution to the
• Heimlich valve skin surface and allow it to dry. Apply sterile drapes around the
site of the procedure. Atropine should be at the bedside. It may
Ultrasound Guidance be administered (1.0 mg subcutaneously or intramuscularly or
• Ultrasound machine 0.5 mg intravenously) to patients who develop symptomatic bra-
dycardia during the procedure. The most common approach is the
• 3.5 to 5.0 MHz phased-array ultrasound probe
second intercostal space in the midclavicular line (Figure 40-14).
• Sterile ultrasound gel An alternate site is the fourth or fifth intercostal space in the
• Sterile ultrasound probe cover midaxillary line. The Emergency Physician should wear full per-
sonal protective equipment to protect themselves from contact
Commercial kits have been developed and are available to pro- with the patient’s blood and body fluids as well as protect the
vide the equipment needed to perform a thoracentesis. These kits patient from infection.
are disposable, single-patient use, and contain all the required
equipment. They save time in that the equipment does not have to TENSION PNEUMOTHORAX TECHNIQUE
be found and set up. Disadvantages include potentially increased
cost and limited equipment in the kit.18 Common kits include the If the patient has a tension pneumothorax, thoracentesis is both a
Pharmaseal, distributed by Baxter (Jacksonville, TX); the Arrow diagnostic and therapeutic procedure. A tension pneumothorax is
Clark Thoracentesis Kit, distributed by Arrow (Reading, PA); and a true life threat. Identify the needle insertion site by palpating the
the Argyle Turkel Safety Thoracentesis Kit, distributed by Boston second intercostal space in the midclavicular line. If a tension pneu-
Scientific (Miami, FL).3 mothorax is clinically evident, ultrasound guidance is not neces-
The TRU-CLOSE Thoracic Vent (UreSil, Skokie, IL) is an alterna- sary prior to needle decompression and should not delay treatment.
tive device to the pigtail catheter and Heimlich valve combination. Insert the catheter-over-the-needle over the superior border of
It is a one-piece unit that combines an intrapleural catheter and an the third rib to avoid the neurovascular bundle, which is located
external one-way antireflux valve that attaches to the chest wall by on the inferior border of the second rib. Advance the catheter-
an adhesive pad. Its insertion is quicker, easier, and simpler than over-the-needle into the pleural space. If time permits, a 5 to 10 mL
a traditional catheter. The low profile makes ambulation and out- syringe without the plunger can be attached to the catheter-over-
patient management easier for the patient. These devices are rarely the-needle. The syringe barrel can be used as a handle to advance
available in the Emergency Department. the catheter-over-the-needle.
When the pleural cavity is entered, a release of pressure and a advance it through the anesthetized tissues (Figure 40-6A). A small
small “pop” may be felt. Stop advancing the needle. Securely hold “nick” in the skin with a #11 surgical blade will facilitate the nee-
the needle so it does not move. Advance the catheter until the hub dle entry. Apply negative pressure to the syringe as the needle is
is against the skin. Remove the needle. If the patient has a tension advanced along the anesthetized tract and into the pleural cavity
pneumothorax, a continuous rush of air will be heard or felt. Needle (Figure 40-6A). Stop advancing the needle when air is aspirated.
thoracentesis for a tension pneumothorax is a temporizing Securely hold the needle so it does not move. Remove the syringe
measure; therefore, a tube thoracostomy should be performed and cover the needle hub with a gloved finger. This will prevent
immediately after this life-saving procedure. Refer to Chapter 39 ambient air from entering the pleural cavity. Angle the needle
for complete details regarding this procedure. slightly superiorly and advance the catheter through the needle
(Figure 40-6B). Withdraw the needle, leaving the catheter within
SIMPLE PNEUMOTHORAX TECHNIQUES the pleural cavity (Figure 40-6C). Once the needle is removed, do
not readvance the needle, as the catheter may shear off and fall
A primary spontaneous pneumothorax occupying over 15% of the into the pleural cavity. Place a three-way stopcock attached to a
hemithorax is the indication for simple aspiration via a thoracen- 50 mL syringe onto the hub of the catheter. Place the needle guard
tesis.3 The same sterile preparation, location of fluid, positioning, on the needle. Secure the catheter by taping it to the skin. Withdraw
anesthesia considerations, and ultrasound-guided technique apply air as previously described.
to the evacuation of a simple pneumothorax as to a diagnostic
thoracentesis. ■ SELDINGER TECHNIQUE
Spontaneous pneumothoraces used to be drained by tube thora- Drainage can also be accomplished using a pigtail or straight cath-
costomy. Simple aspiration may be just as effective as a tube thora- eter and the Seldinger technique (Figure 40-15). An alternative is to
costomy.55–60 If a tube thoracostomy is required, a small bore straight use a central venous catheter if a pigtail catheter is not available.18,19
or pigtail catheter can be just as effective to manage a spontaneous Attach a 16 gauge, 2 in catheter-over-the-needle to a 5 or 10 mL
pneumothorax.61–65 While an initial study recommends using small syringe. Insert the catheter, as described above, aimed superiorly.
bore tubes in patients with chest trauma, further clinical information Securely hold the needle and syringe so it does not move. Advance
is required before this becomes standard of care.66 The advantages the catheter to the hub. Remove the needle and syringe. Quickly
of a small bore catheter include: less pain on insertion, decreased cover the catheter hub with a gloved finger. Insert the guide-
need for analgesics and sedation, and the potential to discharge the wire through the catheter (Figure 40-15A). Hold the guidewire
patient with outpatient management. securely to prevent it from falling completely into the pleural
cavity. Remove the catheter over the guidewire, leaving the guide-
■ CATHETER-OVER-THE-NEEDLE TECHNIQUE wire in place (Figure 40-15B). Extend the skin incision with a #11
Two types of catheters can be used to perform this procedure. They scalpel blade by 3 to 5 mm to allow the catheter to enter into the
are the catheter-over-the-needle and the catheter-through-the- pleural space without “crumpling” (Figure 40-15C). Advance the
needle (Figures 40-5 & 40-6). The catheter-over-the-needle tech- dilator over the guidewire and into the pleural cavity to dilate the
nique is most commonly used (Figure 40-5). Make a small “nick” in tract (Figures 40-15C & D). A gentle twisting motion of the dila-
the skin with a #11 surgical blade at the needle insertion site. Attach a tor as it is advanced will aid in its insertion into the pleural cavity
14 to 18 gauge catheter-over-the-needle to a 10 mL syringe as a han- (Figure 40-15D). Hold the guidewire securely. Remove the dilator
dle. Insert the catheter-over-the-needle into the nick and advance it, while leaving the guidewire in place. Insert the catheter over the
reproducing the original anesthetized tract (Figure 40-5A). Apply guidewire and into the pleural cavity (Figure 40-15E). Remove the
negative pressure to the syringe as the catheter-over-the-needle is guidewire and attach a three-way stopcock to the catheter. Aspirate
advanced. Stop advancing the catheter-over-the-needle when air is the air as described previously.
aspirated. Angle the catheter-over-the-needle superiorly. Securely
hold the syringe and needle so they do not move. Advance the ■ DRAINAGE SYSTEMS
catheter until the hub is against the skin. Withdraw the needle and Drainage systems for a pneumothorax vary in style but function with
syringe as a unit while the catheter remains within the pleural cavity the same “one-way valve” principle. The simplest method is a flutter
(Figure 40-5B). When the needle is removed, quickly cover the valve. It is best illustrated by the following noncommercial method.
catheter with a gloved finger. This will prevent ambient air from Cut a premoistened finger from a sterile glove. Tie the proximal end
entering the pleural cavity. Attach intravenous catheter extension to the thoracentesis catheter with a silk suture and cut the distal end
tubing to the hub of the catheter. Place a three-way stopcock attached so that it is open to the air1 (Figure 40-16). This creates a flutter
to a 50 mL syringe onto the extension tubing. Hold the catheter valve and allows air to escape with coughing or expiration and pre-
hub against the skin securely. Aspirate air into the syringe and then vents air from reentering the pleural space on inspiration.
advance the air into the room by adjusting the three-way stopcock. A commercial kit often contains a Heimlich flutter valve1
Air is then withdrawn manually. This process should be continued (Figure 40-17). The arrow on the clear protective tube covering the
until resistance is felt. If no resistance is felt after 4 L of aspiration, Heimlich valve must point away from the patient. Suction is usu-
it is presumed that expansion has not occurred and a continual ally not needed. Stable patients can be sent home with this setup. This
leak of air exists from the lung into the pleural cavity; therefore a includes patients with a primary spontaneous pneumothorax and a
tube thoracostomy should be performed. After no more air is aspi- small apical pneumothorax with initial reexpansion and good appo-
rated, close the stopcock and secure it to the chest wall. The success sition of the lung with the lateral chest wall. Up to 30% of patients
rate for the aspiration of a pneumothorax is 64%.67,68 with a secondary pneumothorax can be treated on an ambulatory
basis. Additional requirements include good residual lung function,
■ CATHETER-THROUGH-THE-NEEDLE TECHNIQUE normal oxygen saturation, and an air leak adequately treated by tho-
The second option utilizes the catheter-through-the-needle sys- racentesis.35 A contraindication to using the flutter valve is a hemo-
tem (Figure 40-6), which is known as the Bardig Intracath sys- thorax. A closed underwater seal system is recommended in these
tem. It is not as popular as the catheter-over-the-needle systems. cases. Refer to Chapter 39 for details regarding the use of a closed
Place the needle on a tuberculin syringe. Insert the needle and underwater seal system and the other indications for its use.
FIGURE 40-15. The Seldinger technique for inserting a catheter to aspirate a pneumothorax. A catheter-over-the-needle has been placed into the pleural cavity and aimed
superiorly. The needle has been removed while the catheter remains in the pleural cavity. A. A guidewire is inserted through the catheter. B. The catheter is removed while
the guidewire remains in the pleural cavity. C. The skin incision is enlarged with a #11 scalpel blade. A dilator is placed over the guidewire. D. The dilator is advanced
over the guidewire and into the pleural cavity. A gentle twisting motion will help guide the dilator through the tract. E. The dilator has been removed while the guidewire
remains inside the pleural cavity. The catheter is advanced over the guidewire and into the pleural cavity. The guidewire is then removed while the catheter remains inside
the pleural cavity.
■ ULTRASOUND-GUIDED TECHNIQUE pleural space.22 In general, the orientation of the probe follows the
FOR A PNEUMOTHORAX convention that the probe marker should correlate to the reference
point in the left upper corner of the screen.
The same sterile preparation applies to ultrasound evaluation of a
The key ultrasound features of a pneumothorax include: absence
pneumothorax as for evaluation of a pleural effusion. However, a
of inspiration–expiration related “lung slide,” loss of “comet tail”
pneumothorax may be more readily identified with the patient posi-
artifact, and broadening of the pleural line to a thick band.24 In the
tioned supine rather than upright. A 3.5 to 5.0 MHz phased-array
case of a unilateral pneumothorax, the hemithorax suspected of
probe is recommended for ultrasound-guided examination of the
FIGURE 40-16. Use of a finger from a sterile glove as a one-way valve. Place the proximal end of the finger on the drainage system and cut the distal tip. It will act as a
one-way valve.
The procedure site should be evaluated two to three times a day

for signs of infection. These patients should be educated about the
signs, symptoms, and significance of an infection. They should
return to their primary physician or Emergency Department imme-
diately if they develop fever, chills, shortness of breath, redness or
pus at the puncture site, or if any concerns arise.
A patient may be a candidate for outpatient management with
a Heimlich valve under the following conditions: a stable primary
spontaneous pneumothorax, close apposition of the lung to the lat-
eral chest wall with initial thoracentesis or aspiration and drainage
procedures, Emergency Physician satisfaction with the position of
the catheter, and an air leak that is manageable with one thoracen-
A tesis. A small study has confirmed this outpatient management,
whereas many Emergency Physicians have been managing patients
like this for years.70 Contraindications for outpatient management
include traumatic pneumothoraces, secondary pneumothoraces, a
patient with poor residual function, a large air leak requiring tube
thoracostomy, a hemothorax, unacceptable residual collapse defined
as poor apposition of the lateral lung to the lateral chest wall, or if
the patient is not reliable.6
B Instructions to the patient should include the following: clean
the thoracentesis site with mild soap daily; apply a split dressing
FIGURE 40-17. The Heimlich valve. around the catheter and tape it to the skin; make sure that the tubing
is taped firmly to the valve to prevent accidental dislodgment; the
arrow on the valve should point away from the patient; the sound of
air exiting the valve is expected; and showers are permitted but not a
bath or swimming. If these patients experience shortness of breath,
having a pneumothorax should be compared to the unaffected side, chest pain, or difficulty breathing, they should call 911 and imme-
with the unaffected side showing normal “lung slide,” “comet tail” diately return to the Emergency Department. Instruct the patient
artifact, and pleural line <2 mm thick. on the removal of the Heimlich valve from the catheter if significant
shortness of breath develops as they may have developed a tension
ASSESSMENT pneumothorax. They should also be instructed on the signs of an
infection at the chest wall insertion site.
Relief of a tension pneumothorax will equalize the pressure between
The patient should follow-up daily for radiographic evaluation.
the atmosphere and the pleural space. The patient will now have a
Upon complete inflation of the lung, the thoracentesis catheter
simple pneumothorax. The vital signs should begin to normalize,
can be removed. The patient should be observed for 4 to 6 hours
the pulse oximetry improves, and the respiratory distress improves.
after catheter removal and a repeat chest radiograph obtained.
If the patient had a tension pneumothorax, they will need a tube
The patient can be discharged if the lung is completely expanded.
thoracostomy followed by a chest radiograph. The patient may
If not, a thoracostomy tube should be reinserted and the patient
begin to cough when the lung reexpands. Breath sounds should be
admitted.
present bilaterally upon reexpansion.
If the patient does not improve clinically after needle decompres-
sion for a tension pneumothorax, there are two possibilities. First, COMPLICATIONS
the pleural space may not have been entered with the needle. This
Complications associated with this procedure can be numerous.
occurs when the patient is obese or very muscular. The procedure
Clinically, a pneumothorax can become worse. Causes include
may then be repeated with a longer needle. Second, the patient
lacerating the lung with the needle, inadequate coverage of the
may not have had a tension pneumothorax. Reevaluate the patient
hub of the needle or catheter with a gloved finger after enter-
by physical examination, bedside ultrasonography, and review the
ing the pleural space, and an air leak in the drainage system. It
chest radiograph to determine if a tension pneumothorax is present.
may also occur from a lung parenchymal-pleural fistula that can
Obtain a chest radiograph after the relief of a simple pneumotho-
develop from poor lung expansion during large-volume pneu-
rax. It will allow the Emergency Physician to determine the success,
mothorax drainage.71 A tension pneumothorax can occur from
or lack thereof, of the procedure. Perform a tube thoracotomy if at
a lung laceration along with inadvertent plugging of the drainage
any point the pneumothorax is not improving with a thoracentesis
system (e.g., fluid in tube, kinking). A hemothorax is possible if
or if the patient’s symptoms worsen.
the lung, intercostal artery, or mammary artery is lacerated with
the needle. Less common complications include cardiac or great
AFTERCARE
vessel perforation due to poor positioning of the needle upon
Obtain a follow-up chest radiograph upon completion of the pro- insertion. Infection occurs about 2% of the time if sterile tech-
cedure to assess for a pneumothorax. An expiratory film should be nique is observed. Catheter shearing is possible with the catheter-
obtained, especially if the pneumothorax was small. A chest radio- through-the-needle system if the needle guard is not placed on
graph should be repeated 4 to 6 hours after the procedure to look the needle or the catheter is withdrawn through the needle. Many
for a delayed pneumothorax. If no pneumothorax is present and of these complications can be prevented by the use of proper and
if appropriate for their clinical condition, the patient may be dis- careful technique.
charged with good instructions and close follow-up. An alternative Reexpansion hypotension has been reported following rapid
is placement in an observation unit and discharge within 24 hours.69 evacuation of persistent unilateral pneumothoraces of at least
CHAPTER 41: Open Chest Wound Management 263
1 week duration. The mechanism is unclear. It is associated with the chest at the battle of Mantinea. Once he discovered that the
reexpansion pulmonary edema that precipitates intravascular vol- Thebans had been victorious, he pulled the spear out, knowing that
ume depletion, myocardial depletion, or large volume aspiration.1 he would die.
Reexpansion pulmonary edema may be precipitated by pneumotho- Galen cared for chest wounds in gladiators. Treatment consisted
races over a few days duration before reexpansion or large volume of a poultice and leaving the wound open. This treatment did not
aspiration.72–74 change until the time of Theodoric, who advised the closing of chest
wounds. In 1267, he was quoted as saying, “The stitches should be
placed in accordance with the size of the wound so that the natural
SUMMARY heat cannot escape in any way nor the air outside be able to enter.”
A thoracentesis can help differentiate between transudates and exu- His advice was not accepted by all. The Master Military Surgeon
dates. Together with the clinical presentation, the information can Paré left these wounds open for 2 to 3 days to allow drainage of
be useful in diagnosing the patient’s condition. It can be lifesaving blood, after which he would close them.
if the patient has a tension pneumothorax. It offers an alternative During the Battle of Crecy in 1346, firearms and firearm inju-
to tube thoracostomy for patients with stable spontaneous primary ries were first introduced. In 1382, small guns were used against the
pneumothoraces. Outpatient management can be considered in Venetians. Injuries from these weapons were documented in the
some cases with the addition of a Heimlich valve. Regardless of what chronicles of these battles.
method is used, physicians in training should be supervised until Techniques for managing chest wounds have improved with each
competency with this procedure is demonstrated. subsequent war. The most important treatable aspect of these chest
wounds was the associated open pneumothorax. The question of
whether to manage such injuries open or closed remained con-
troversial. In Rome in 1514, John de Vigo was the first surgeon to
present his views on gunshot wounds of the chest. He thought them
to be universally fatal and, for the most part, untreatable. William
Open Chest Wound Hewson, in 1767, observed that a patient with a large open chest
41 Management wound was not able to breathe but could do so easily once the injury
was closed.
Eric F. Reichman It took another 40 years for Baron Larrey, Napoleon’s Surgeon, to
confirm Hewson’s observation in a wounded soldier. He gave one
of the best descriptions of an open pneumothorax, shock, and air
INTRODUCTION
hunger in his memoirs of the Napoleonic wars:
Open chest wounds come in a variety of shapes and sizes. Their one “A soldier was brought to the hospital at the Fortress of Ibrahym
commonality is an open communication between the pleural space Bey, immediately after a wound penetrated the thorax between the
and the external environment. The wounds have often been sealed fifth and sixth true ribs. It was 8 cm in extent. A large quantity of
by the soft tissues of the chest wall in the vast majority of patients frothy and vermillion blood escaped from it with a hissing noise at
with penetrating injuries to the chest. The primary concern with each inspiration. His extremities were cold, pulse scarcely percep-
these patients is the diagnosis and treatment of underlying thoracic, tible, countenance discolored, and respiration short and laborious.
cervical, and/or abdominal injuries. Rarely, small perforations In short he was every moment threatened with a fatal suffocation.
may produce a valve-like entry into the pleural space, enabling After having examined the wound, the divided edges of the part, I
air to be “sucked in” during inspiration but blocking air egress immediately approximated the two lips of the wound and retained
during expiration. Thus air will continue to accumulate, leading them by means of adhesive plaster, and a suitable bandage around
to a tension pneumothorax requiring needle decompression fol- the body. In adopting this plan I intended only to hide from the
lowed by a tube thoracostomy. Larger, more destructive wounds sight of the patient and his comrades, the distressing spectacle of
of the chest may also occur. These are most common in combat the hemorrhage, which would soon prove fatal; and I therefore
injuries. In civilian practice, they are often secondary to shotgun thought that the effusional blood into the cavity of the thorax could
injuries. The larger wounds are also caused by high-velocity weap- not increase the danger. But the wound was scarcely closed, when
ons, explosions, on-the-job injuries, propeller injuries, or fencepost he breathed more freely, and felt easier. The heat of the body soon
impalements, to name a few. Clothing, wadding, shell fragments, returned, and the pulse rose. In a few hours he became quite calm,
and pieces of the chest wall may all be driven into the thoracic and to my great surprise, grew better. He was cured in a very few
cavity. Such injuries are associated with physical loss of a portion days, and without difficulty.”
of the chest wall itself, making adequate ventilation impossible.1 Another famous accounting of an open chest wound was by William
These wounds are known by numerous names including open chest Beaumont in 1825. He attended Alexis St. Martin in 1822, who was
wounds, open pneumothoraces, sucking chest wounds, and com- shot in the lower chest. Beaumont arrived within one-half hour of the
municating pneumothoraces. These specific open chest wounds are injury and noted that the wound had been caused by a short-range
the focus of this chapter. blast, within a yard of St. Martin’s chest: “fracturing and carrying away
Wounds of the chest are described in the earliest of medical docu- the anterior half of the sixth rib, fracturing the fifth, lacerating the
ments, the Edwin Smith papyrus. This document dates from the lower portion of the left lobe of the lungs, the diaphragm and per-
time of Imhotep (3000 b.c.). It contains descriptions of 58 cases, forating the stomach. The whole mass of materials forced from the
three of which involved chest injuries per se. One was actually an musket, together with fragments of clothing and pieces of fractured
open chest wound, case number 40. The patient sustained a pen- ribs, were driven into the muscles and cavity of the chest.”
etrating injury to the anterior thorax through the manubrium. Upon Beaumont’s arrival, he found lung and stomach herniating
Treatment consisted of binding the wound with fresh meat on the from the wound. “After cleaning the wound from the discharges and
first day and, later, with grease, honey, and lint. other extraneous matter, and replacing the stomach, and the lung as
During Greco-Roman times, open chest wounds were univer- far as practicable, I applied the carbonated fermenting poultice and
sally fatal. In 362 b.c., Epaminondas was wounded by a spear to kept the surrounding parts constantly wet with a lotion of muriate of
ammonia and vinegar.” After an hour, Beaumont returned expecting may expand slightly or remain completely collapsed upon expira-
to find his patient dead. To his pleasure and surprise, the patient was, tion, depending on the size of the chest wall defect (Figure 41-1B).
in fact, improved. He had saved his life by closing his chest wound. There may also be mediastinal motion toward the noninjured lung
By the final years of World War I, the controversy of “to close during inspiration and toward the injured lung during expiration.
or not to close” was resolved in favor of immediate wound closure. This to-and-fro motion compromises the function of the healthy
However, when closing these wounds it was important to under- lung as well as the injured lung because it prevents its full expan-
stand the physiology of negative intrathoracic pressure. The German sion during inspiration. During expiration, some of the air from
internist Buelau introduced closed underwater seal drainage of an the noninjured lung may shift to the injured lung, and the reverse
empyema in 1875. In 1889, T. Holmes, a consulting Surgeon at St. may happen during inspiration (an element of the “pendelluft” phe-
George’s Hospital in London, introduced intercostal drainage for nomenon). This entire mechanism results in a large functional dead
large chest wounds. However, he did not advocate an underwater space in the noninjured lung and loss of ventilation of the injured
seal. It was not until World War II that closed tube drainage was lung, causing severe ventilatory derangement, asphyxia, hypoxemia,
added to the treatment of an open pneumothorax as a routine and hypercarbia.2–4
measure. Positive-pressure ventilation was introduced in the early The patient with an open pneumothorax may manifest a spec-
1900s. The most recent advancement in the treatment of these inju- trum of presentations, ranging from asymptomatic and stable to
ries came from the Scandinavians, who invented respirators in the severely dyspneic and agonal. The presentation depends on the
early 1950s. Mortality from chest wounds steadily decreased in each size of the chest wall defect, the extensiveness of the injuries to
war. It was 79% in the Crimean War, 62.5% in the Civil War, 55.7% the lung and other structures, the preinjury pulmonary status, and
in the Franco-Prussian War, 24.6% in World War I, 12% in World whether the pleural space is free or has adhesions. The patient
War II, and in recent civilian experience is now 4% to 7%.2 may present with progressive respiratory insufficiency leading to
a rapid demise if not treated. The critical diameter of the chest
wall wound has been described as two-thirds (or greater) the
diameter of the trachea.5 It is thought that at this size, air moves
The pathophysiology of an open pneumothorax has not much been preferentially through the chest wall rather than through the
improved upon since the days of Hewson and Larrey. The patho- trachea.
physiologic changes of a sucking chest wound depend on the size of Two additional “open chest wounds” deserve mention. First is the
the wound and the intactness of the pleural space and lung. A defect wound that fully penetrates the chest wall but seals itself and closes.
in the chest wall is usually of no major clinical significance if the It can seal from apposition if adjacent chest wall soft tissues, a hema-
pleural space is obliterated.3 However, most commonly, the pleural toma, underlying pleural adhesions that do not allow air into the
space is free and the air and/or blood moves in and out through the pleural space, or from a combination of these. This type of injury
chest wall defect, making a “sucking” sound. prevents air from entering the pleural space and does not signifi-
A sucking chest wound or open pneumothorax results in a mostly cantly alter respiratory physiology except for the pain of breathing.
unidirectional flow of air through the wound and into the pleural This type of wound does not indicate that there is no underlying
space. During inspiration, the intrathoracic pressure is negative cardiac, intrathoracic, lung, or mediastinal injury. These types of
compared to the extrathoracic pressure. This allows air to flow wounds require management of hemorrhage, the application of a
through the wound and into the pleural space. During expira- simple dressing, and a Surgeon for management of the wound, con-
tion, the tissues surrounding the wound come into apposition and tinued hemorrhage, and any internal injuries.
decrease the wound diameter. This results in air becoming trapped The final type of open chest wound is one that allows bidirec-
within the pleural space. As breathing continues, this process pro- tional airflow. Breathing results in bidirectional airflow through
gresses and air increasingly accumulates in the pleural space, com- both the trachea and the chest wound, thus decreasing airflow
presses the lung, and prevents lung expansion during inspiration. through the trachea. This results in hypoventilation and hypoxemia.
The open pneumothorax can become large enough to exert tension These patients require positive-pressure ventilation with either a
on the hemithorax contents and the mediastinal structures. bag-valve-mask device, CPAP or BiPAP machine through a face
In larger injuries, this air movement causes the ipsilateral lung to mask, or endotracheal intubation. The wound must be covered with
move inward and collapse on inspiration (Figure 41-1A). The lung a three-sided dressing, or an occlusive dressing after the placement
FIGURE 41-1. The effects of an open chest wound. A. Air moves into the pleural cavity and the lung collapses with inspiration. B. Air exits the pleural cavity and the lung
expands slightly with expiration. The arrows represent the direction of airflow.
CHAPTER 41: Open Chest Wound Management 265
Sucking chest wound
Severe respiratory distress Mild, moderate, or no symptoms
Immediate tube
Seal wound Chest X-ray
thoracostomy
Seal, debride, and

Tube thoracostomy No pneumothorax Pneumothorax
repair chest wall
Seal, debride, and Seal, debride, and

Tube thoracostomy
repair chest wall repair chest wall
FIGURE 41-2. Algorithm for the diagnosis and

Seal, debride, and
treatment of an open pneumothorax. (Modified
repair chest wall
from Symbas.3)
of a chest tube, and a Surgeon for management of the wound, con- EQUIPMENT
tinued hemorrhage, and any internal injuries.
INDICATIONS • Petrolatum gauze
Diagnosis of these injuries can be made easily based upon the obvi- • Gauze 4 × 4 squares
ous presence of the chest wall defect and the noise produced as the • Reinforcing sterile dressings
air moves in and out through the wound. In the symptomatic patient, • Tincture of benzoin
all open chest wounds should be treated immediately.3,6 Treatment
techniques should be selected based on the patient’s clinical condi- • Adhesive tape
tion and stability (Figure 41-2). The three-sided dressing is only a • Sterile gloves and gown
temporary measure and it must be followed with the placement • Face mask with an eye shield or goggles
of a chest tube.
Most experts agree that only the symptomatic patients should The supplies for an occlusive dressing (i.e., petrolatum gauze)
be treated in the field. An occlusive dressing should be placed may not be readily available within or outside of the Emergency
over the wound and taped on only three sides. The three-sided Department. Numerous substitutes for the petrolatum gauze are
dressing allows air within the pleural cavity to be expelled into available. This includes a defibrillator pad. These gel-like pads are
the atmosphere while preventing atmospheric air from enter- large, can be cut to size, and adhere to both dry and wet skin. Other
ing the pleural cavity. If the wound is taped on all four sides, an alternatives include coating a water-soluble lubricant onto one side
open pneumothorax may quickly be converted into a tension of a piece of aluminum foil, plastic food wrap, plastic from the pack-
pneumothorax.4,5,7–10 aging of sterile procedure packs, a piece cut from a plastic trash bag,
In the Emergency Department, the very symptomatic patient or a zippered sandwich bag.
should be treated as in the field. However, a completely occlusive
dressing may be placed over the wound if a chest tube is subse- PATIENT PREPARATION
quently to be placed. Continuously and closely monitor the patient The amount and timing of patient preparation will be dictated by
for the development of a tension pneumothorax if the wound is the location of the patient and his or her physiologic status. An
completely sealed prior to the tube thoracostomy. If a tension pneu- informed consent is not required, as this is a noninvasive and life-
mothorax occurs, remove the occlusive dressing on at least one saving procedure. Such procedures should occur emergently with
side or perform a needle thoracostomy (Chapter 39) to relieve it. minimal patient preparation. If time permits, place the patient on
Obtain a rapid, portable anteroposterior chest radiograph if the the cardiac monitor and pulse oximeter and provide supplemental
patient is asymptomatic, mildly symptomatic, or moderately symp- oxygen by face mask. The Emergency Physician should wear full
tomatic. If a pneumothorax is present, perform a tube thoracostomy personal protective equipment to protect themselves from contact
and seal the wound. If the patient becomes severely symptomatic, with the patient’s blood and body fluids.
the Emergency Physician should default to the other limb of the If the patient has severe respiratory insufficiency, consider per-
algorithm (Figure 41-2). forming orotracheal intubation before or simultaneously with the
application of the three-sided occlusive dressing. Positive-pressure
CONTRAINDICATIONS ventilation through the endotracheal tube will expand the col-
There are no contraindications to the placement of a three-sided lapsed lung and force the intrapleural air out the wound and into
occlusive dressing, as this is a treatment for a life-threatening emer- the atmosphere.
gency. It must be properly placed to prevent the accidental conver- Prepare the chest wall if the patient is asymptomatic, mildly symp-
sion to a totally occlusive dressing and the progression of an open tomatic, or moderately symptomatic. Clean the wound and sur-
pneumothorax to a tension pneumothorax. rounding chest wall of any dirt and debris. Apply povidone iodine
pneumothorax. Periodically evaluate the three-sided dressing to

ensure it is not covered with another dressing or blankets, not posi-
tioned between the patient and the bed or another object, and that it
has not become occluded on all four sides. If a tension pneumotho-
rax occurs, remove the occlusive dressing on at least one side or
perform a needle thoracostomy (Chapter 38) to relieve it. Patients
with an open chest wound have typically sustained an injury com-
prising great kinetic energy, whether from a blunt or penetrating
event. Associated injuries will be very common. A head-to-toe sec-
ondary survey is imperative.
AFTERCARE
The aftercare of these patients consists of a tube thoracostomy (i.e.,
chest tube) followed by aggressive wound care, pain management,
pulmonary toilet, continued monitoring, and investigation for other
underlying injuries. Once the wound is closed, the underlying
pneumothorax or hemopneumothorax should be treated with
the placement of a chest tube placed through an incision away
from the injury site and not through the open chest wound.
Pain will be a major problem for these patients. Trauma to the
parietal pleura, bony structures, and intercostal nerves is very pain-
ful. It is imperative that these patients be able to make adequate ven-
FIGURE 41-3. The three-sided occlusive dressing. tilatory efforts, cough, deep breathe, perform incentive spirometry,
and have aggressive pulmonary toilet. These are all necessary to pre-
vent atelectasis, retained secretions, and pneumonia.11 Various pain-
relieving techniques may be utilized. Infiltration of long-acting local
or chlorhexidine solution to the skin surrounding the wound and
anesthetic solution may give initial relief, especially during wound
allow it to dry. Do not place the povidone iodine or chlorhexidine
debridement. Parenteral analgesics are the initial treatment modal-
into the wound, as this has been shown to inhibit wound healing.
ity. Advanced techniques to consider include regional nerve blocks,
Apply the three-sided occlusive bandage as described below. If the
intercostal nerve blocks, and indwelling intrapleural or epidural
patient is moderately to severely symptomatic, no preparation
catheters.
is required, as this wastes valuable time. Immediately apply the
More definitive wound care should be considered once the
three-sided occlusive bandage.
patient is stabilized. Small, clean wounds may be managed sim-
ply with routine wound care and changes of the occlusive dress-
TECHNIQUE ing. Local irrigation and debridement may be added if there is a
The safest initial therapy for symptomatic sucking chest wounds is limited amount of contamination. Large, grossly contaminated,
the careful application of a petrolatum gauze-based dressing taped and/or complex wounds are best managed in the operating room.
on three sides (Figure 41-3). Apply three or four layers of petrola- Optimally, these wounds should be debrided and closed primarily.
tum gauze over the wound. The dressing should extend 6 to 8 cm However, some wounds may be contaminated or complex, such that
beyond the margins of the wound so that it will not be sucked into closure is not possible initially. In such cases, the wound should be
the pleural cavity in the spontaneously breathing patient. Cover the debrided and left open. Large, occlusive dressings are placed along
petrolatum gauze with dry 4 × 4 gauze squares. Apply tincture of with chest tubes for removal of air, fluid, and blood. Multiple opera-
benzoin around three sides of the dressing. Apply tape to secure the tive debridements may be required. When the wound is clean and
three sides of the dressing to the chest wall. the patient is optimized, secondary closure may be performed.11
Closure of large wounds may require a combination of complex
ALTERNATIVE TECHNIQUE techniques. These may include various skin, subcutaneous tissue,
and muscle flaps.12 Free rib grafts, pectoral muscle flaps, latissimus
An alternative to the three-sided dressing is one that is totally dorsi muscle flaps, abdominal muscle flaps, omentum flaps, skin
occlusive or a four-sided dressing. There is little to no clinical evi- grafts, or a myocutaneous flap can be utilized.12–19 If using these are
dence that a three-sided dressing is superior to a four-sided dress- not possible, closure may be accomplished with a prosthetic mate-
ing. The four-sided dressing should be placed only in the setting rial such as Prolene or Marlex, either temporarily or definitively.20–22
where rapid placement of a chest tube will be undertaken. This In wounds of the lower chest, detachment of the diaphragm with
occurs most commonly in the Emergency Department. It may be reattachment at a higher level may be utilized. This converts an
considered in the field when a tube thoracostomy is included in the open chest wound to an intraabdominal wound and alleviates the
prehospital standing medical orders.23 ventilatory problems.
Once the three-sided dressing has been placed, continue to closely Complications may occur acutely or may be delayed. Occlusion
monitor the patient for associated complications and evaluate them of the chest wall defect and decompensation of the patient from
for underlying injuries. Paramount among the complications a simple pneumothorax being converted to a tension pneumo-
is conversion of a simple pneumothorax to a tension pneumothorax is the primary early complication. The patient must be
thorax. Do not be led into a false sense of security after placing closely monitored until a chest tube can be inserted. A tension
the three-sided dressing. A patient can still develop a tension pneumothorax can result if the wound is completely occluded by
CHAPTER 42: Emergency Department Thoracotomy 267
a blood clot, a dressing that has been sucked into the wound, soft of the anterior chest wall just lateral to the sternum. The intercos-
tissue, or a bandage that is adherent on all four sides. Immediately tal vessels run along the inferior aspect of the ribs. The subclavian
remove the bandage to relieve a tension pneumothorax. Some vessels are at the very superior aspect of the thorax. They course
physicians and authors remove only one side of the occlusive ban- directly under the clavicles and can be very difficult to visualize via
dage to relieve the pneumothorax. The choice to remove part or all an anterolateral thoracotomy. The azygos vein can be found cours-
of the bandage is physician-dependent. If the patient is still symp- ing along the posterior right hemithorax and emptying into the
tomatic, ensure that the wound is not occluded by a blood clot or superior vena cava.
soft tissue. The heart is covered by the tough pericardial sac. The phrenic
Other complications would ensue from the failure to seek, diag- nerves run superiorly to inferiorly on each side of the pericardiac
nose, and treat other underlying, potentially life-threatening inju- sac. They can be visualized as white or yellow strands on either side
ries. The patient may develop respiratory insufficiency secondary of the pericardium. Once the pericardial sac is opened, the left ante-
to multiple causes, some of which may be preventable with optimal rior descending coronary artery can be visualized on the anterior
care. These causes include inadequate pulmonary toilet, inadequate surface of the heart. It overlies the interventricular septum. Injuries
pain management, pulmonary contusion, pneumonia, and/or adult to the left of this artery usually denote left ventricular damage while
respiratory distress syndrome. Wound complications may include injuries to the right usually denote right ventricular damage. The
infection, fasciitis, osteomyelitis, empyema, hemothorax, and locu- majority of the anterior surface of the heart is occupied by the right
lated hemothoraces or pneumothoraces. These wounds require fre- ventricle.
quent evaluation and aggressive care to prevent these sequelae. The posterior mediastinum contains the aorta. It is located pos-
terior to the esophagus and runs lateral to the vertebral bodies.
SUMMARY The thoracic aorta gives off the intercostal vessels. If torn during
the mobilization of the aorta, the intercostal vessels can cause trou-
Open chest wounds are easily diagnosed by the evident chest wall blesome bleeding.
defect and the auscultation of air moving into and out of the pleural Beall et al. originally introduced the ED thoracotomy for pen-
cavity. This is a true life-threatening emergency. Treatment is dic- etrating chest wounds.4 This procedure was subsequently used for
tated by the patient’s clinical presentation. Lifesaving therapy should patients with penetrating abdominal wounds and victims of blunt
be undertaken with the simple application of a three-sided petrola- trauma. In recent years, several studies have shown an abysmal
tum gauze dressing. The three-sided dressing allows air within the survival rate associated with an ED thoracotomy in victims of
pleural cavity to be expelled into the atmosphere while preventing blunt trauma. When vital signs are present in the field, the survival
atmospheric air from entering the pleural cavity. This converts the rates for such individuals range from 0.6% to 6.0%.5–7 Patients who
open pneumothorax to a closed pneumothorax and eliminates the undergo an ED thoracotomy for penetrating abdominal injuries
major physiologic derangement. Once the patient is stabilized, more have survival rates of approximately 5%.8 In these cases, the ED tho-
definitive care should be carried out with chest tube placement and racotomy is performed for resuscitation purposes.
appropriate wound care. Patients presenting to the ED with penetrating chest trauma
who present without signs of life in the field have a poor prognosis.
Survival for these patients ranges from 0% to 9%.9,10 If the patient
sustains penetrating chest trauma and has signs of life in the field,
survival averages 14%, with a range of 0% to 36%.1 The reason for
the wide range probably lies in the small numbers of patients in the
42 Thoracotomy
studies and the varying definitions of “signs of life.”
The best survival for penetrating chest injury and an ED thoracot-
omy is in patients with stab wounds resulting in cardiac tamponade.
Kenny Banh The use of bedside ED ultrasonography allows better identification
of these patients. The survival for this entity ranges from 21% to
INTRODUCTION 71%, averaging 31%.6,11–14 It should be noted that 90% of patients
who survive an ED thoracotomy for penetrating chest injuries have
An increase in urban violence combined with better triage and trans- good neurologic outcomes.11 This must be contrasted with a 50%
port systems has resulted in the arrival of sicker trauma patients at incidence of good neurologic outcome in survivors of blunt trauma
the Emergency Department (ED). Previously, these patients might who receive a thoracotomy.15
not have survived long enough to make it to the ED.1 The major-
ity of individuals with penetrating chest injuries arrive in the ED INDICATIONS
in stable condition and are managed without major operative pro-
cedures.2 A subset of individuals, however, arrive in extremis and Signs of life, if present at the scene or at any time during the
may require a thoracotomy. The purpose of the ED thoracotomy transport or resuscitation and a short transport time, should
may be to control hemorrhage within the chest, to relieve a pericar- prompt an ED thoracotomy in patients with penetrating chest
dial tamponade surgically or one that cannot be decompressed by a trauma.13,16 These signs include a palpable pulse, a blood pressure,
needle thoracotomy, to redistribute cardiac output to the brain and pupil reactivity, any purposeful movement, an organized cardiac
the heart, or to provide more effective cardiac massage.3 rhythm, or any respiratory effort. Thus, the patient must have
signs of life on presentation or have lost them en route to the
ED if a thoracotomy is to be considered. A thoracotomy should
be performed to control hemorrhage within the thoracic cavity,
The structures within the chest include the heart, esophagus, lungs, to decompress a pericardial tamponade, to cross-clamp the aorta
bronchi, pulmonary hilar vessels, and numerous other vascular and redistribute the cardiac output to the brain and heart, and to
structures. The heart is located in the anterior mediastinum. The provide open cardiac massage. Patients who are in shock or rap-
aorta and esophagus are located in the posterior mediastinum. idly deteriorating clinically after penetrating chest trauma and are
The internal mammary arteries course along the posterior aspect not responding to aggressive fluid resuscitation are also candidates
for an ED thoracotomy. It is also indicated to cross-clamp the aorta • Satinsky vascular clamp
when the patient is exsanguinating from injuries below the level of • Finochietto rib retractor, 12 in spread
the diaphragm.17
• Suction source
• Suction tubing
CONTRAINDICATIONS
There are a few well-supported contraindications to performing
• 2-0 silk suture on a large curved needle
an ED thoracotomy. A thoracotomy should not be performed in
patients with penetrating chest trauma who have no vital signs • Hemostats, needle driver, 10 in
in the field.18,19 In the absence of field vitals, the survival rates are • Gauze 4 × 4 squares
at the lower end of the range. The few that survive have severe neu- • Sternal saw, hand-operated
rologic impairment. Outside of patients that collapse in the ED,
victims of blunt trauma with or without field vitals should not • Lebsche knife (sternal osteotome) and mallet
routinely undergo an ED thoracotomy.20 It is also contraindi- All hospitals and EDs have preprepared, prepackaged, and sterile
cated when prehospital CPR exceeds 10 minutes without a return thoracotomy trays. Review the equipment available on the trays at
of spontaneous circulation after blunt trauma, when prehospital your institution to become familiar with their contents before the
CPR exceeds 15 minutes without a return of spontaneous circula- tray is required emergently.
tion after penetrating trauma, and when the patient presents to the
ED in asystole without a pericardial tamponade.18,19 An ED thora- PATIENT PREPARATION
cotomy should not be performed regardless of the indications
if a Trauma Surgeon, or other qualified Surgeon, is not imme- The patient should already be supine, intubated, and ventilated.
diately available to take the patient to the Operating Room for Abduct the left upper extremity 180° (Figure 42-1). The extremity
definitive management. Do not perform an ED thoracotomy with should be held in position by an assistant or with the use of a soft
the anticipation of transferring the patient to another facility if they restraint. Place sandbags or towels under the patient’s left scapula.
can be resuscitated. This will elevate the torso off the bed to allow for more complete
access. Apply povidone iodine or chlorhexidine solution to the
patient’s left chest. Apply sterile drapes over the chest to demarcate a
EQUIPMENT surgical field.
• Povidone iodine or chlorhexidine solution An ED thoracotomy is primarily performed on patients who are
unresponsive. As such, there is no immediate need for analgesics,
• Sterile towels sedatives, or local anesthetic solution. If the patient is resuscitated,
• Sterile gloves and gown they will experience significant postprocedural pain. Parenteral
• Face mask with an eye shield or goggles analgesics and sedatives should be available and administered if
the patient survives and there are no contraindications.
• Sandbags or towels
Set up the required equipment. Open the prepackaged, sterile
• #3 scalpel handle thoracotomy tray on a bedside table. The tray should contain all
• #10 scalpel blade the equipment required for the procedure. Sterile technique should
• US Army retractors, 1 set be observed and followed by all involved personnel, who should
be fully capped, gowned, masked, and gloved. This will protect
• Curved Mayo scissors, 8¾ and 6¾ in.
the healthcare personnel from exposure to the patient’s blood and
• Curved Metzenbaum scissors, 5½ in. body fluids as well as minimizing the risk of infection if the patient
• Toothed forceps survives.
FIGURE 42-1. Patient positioning. Place a sandbag or towel under the left shoulder and abduct the left arm 180°. Identify the fifth intercostal space in the male (A) or the
inframammary line in the female (B).
CHAPTER 42: Emergency Department Thoracotomy 269
FIGURE 42-2. ED thoracotomy. A. The initial incision is made through the skin, subcutaneous tissue, and superficial muscles. B. The intercostal muscles are incised with
Mayo scissors. C. The Finochietto rib spreader is inserted and opened. D. The pericardium is grasped and opened.
TECHNIQUES thoracic cavity while still ventilating the right lung. Alternatively,
temporarily discontinue mechanical ventilation. Puncture through
LEFT-SIDED THORACOTOMY the intercostal muscles in the anterior axillary line with the curved
Mayo scissors. Carefully extend the puncture 2 to 3 cm using the
Apply the scalpel blade to the handle. Identify the site to be used curved Mayo scissors. Insert the nondominant index and middle
to make the initial skin incision. This is the left fourth or fifth fingers through the incision and separate the lung from the chest
intercostal space, corresponding to the intercostal space below the wall. Advance the fingers and Mayo scissors simultaneously, supe-
nipple in a male and below the inframammary fold in a female riorly then inferiorly to cut the intercostal muscles along the entire
(Figure 42-1). Using one stroke of the scalpel, make an incision inner space (Figure 42-2B). Resume mechanical ventilation.
extending from the sternum to the posterior axillary line or Insert the Finochietto retractor with the arm and crank posi-
the gurney (Figure 42-2A). Carry the incision through the skin, tioned near the gurney (Figure 42-2C). Turn the crank to open the
subcutaneous tissues, and superficial chest musculature down to arms of the rib spreader. Clear any blood from the left hemithorax
and through most of the intercostal muscles (Figure 42-2A). An and inspect for any brisk bleeding. If extensive bleeding is observed,
Army retractor may be used to open and separate the edges of it must be controlled. Use digital pressure or hemostats to initially
the incision. This step is based on physician preference and is not control intercostal artery or other bleeding vessels. Subsequently
required. place 2-0 silk stitches to tie off the bleeding vessels. For subclavian
Discontinue mechanical ventilation. Consider advancing the vessels, digital control must be followed by rapid transport to the
endotracheal tube into the right mainstem bronchus. This will allow operating room, since these vessels are difficult to control through
the left lung to deflate and minimize injury upon entering the left an anterolateral thoracotomy.
OPENING THE PERICARDIUM a hand-held sternal saw or a Lebsche knife (Figure 42-4). Pass one
end of the sternal saw from the left fifth intercostal space, behind the
Move the left lung superiorly and laterally to expose the pericardial sternum, and out of the right fifth intercostal space (Figure 42-4A).
sac. A pericardiotomy should be routinely performed if blood is Place an index finger through the loop on each end of the sternal
seen within the pericardial sac, if the heart cannot be visualized saw. Move the hands toward and away from the patient in a to-and-
through the pericardium, or if there is no other obvious injury fro motion until the sternum is transected. Alternatively, a Lebsche
within the chest and a potential cardiac injury may exist. Many knife can be used to transect the sternum. Place the hooked portion
Emergency Physicians and Trauma Surgeons will routinely open of the knife under the sternum with the sharp blade against the lat-
the pericardium when they are performing a thoracotomy, as a eral border of the sternum (Figure 42-4B). Lift up the handle of the
pericardial tamponade is difficult to detect visually and a poten- Lebsche knife to lock it against the posterior surface of the sternum.
tial cardiac injury may exist. This will prevent the tip of the Lebsche knife from cutting the heart.
Open the pericardial sac anterior to the phrenic nerve. Grasp Hit the flat knob on the back of the Lebsche knife with a mallet to
and elevate the pericardium with a toothed forceps anterior to drive the knife through the sternum (Figure 42-4B).
the phrenic nerve, which appears as a white or yellow strand
along the lateral aspect of the pericardium (Figure 42-2D). Make
an incision in the pericardium near the apex of the heart using a
ASSESSMENT
curved Mayo scissors. Note the color of the fluid that is expressed Any bleeding should be controlled with the application of pressure,
from the pericardial sac. It should normally be straw-colored with- hemostats, and/or sutures. Any injuries to the heart (Chapter 44) or
out any hint of red. Carefully insert one of the jaws of the Mayo scis- the hilum and great vessels (Chapter 45) should be managed. Cross-
sors into the pericardial sac. Extend the incision with the Mayo clamping of the proximal aorta will prevent further exsanguination
scissors parallel to the phrenic nerve, from the apex of the heart from more distal injuries (Chapter 46). Open cardiac massage can
to the root of the aorta. Deliver the heart from the pericardium and be performed while the resuscitative efforts continue (Chapter 43).
inspect it for any injury. Internal cardiac massage may be performed
for asystole, bradycardia, and/or hypotension. The technique is AFTERCARE
described in Chapter 43. Any cardiac wounds identified should be
temporarily plugged or closed as described in Chapter 44. If the patient is resuscitated in the ED, they should be immediately
transported to the Operating Room for definitive care as soon as the
RIGHT-SIDED THORACOTOMY Anesthesiologist and Surgeon are available. Continue the admin-
istration of fluids, packed red blood cells, platelets, plasma, and
If there is a high index of suspicion of injury in the right hemi- inotropic agents as necessary until the patient is hemodynamically
thorax with minimal or no injury found in the left hemithorax, stable. Administer broad spectrum antibiotics intravenously if the
the thoracotomy must be extended to the right side. If possible, patient is resuscitated and survives. Administer parenteral analge-
extend the incision through the sternum using a curved Mayo scis- sics and/or sedation if not contraindicated.
sors and continue it to the right posterior axillary line (Figure 42-3).
Remove the Finochietto rib spreaders from the left side and apply
them to the patient’s right fifth intercostal space. Examine the right COMPLICATIONS
hemithorax for injury. When the sternum is cut, the internal mam- The ED thoracotomy has many potential and serious complications.
mary arteries on both sides will be lacerated. Apply hemostats to the Fortunately, this procedure is often being performed as a last effort
transected vessels to obtain hemostasis. They may later be tied off if at resuscitation of a “dead patient.” The complications are, therefore,
the patient is resuscitated. not significant when the alternative to this procedure is death.
Occasionally, the large curved Mayo scissors cannot transect the The ED thoracotomy is rarely ever performed under truly sterile
calcified sternum. Perform a right-sided thoracotomy similar to conditions. Time is often of the essence in performing this proce-
that on the left. If further access is required, cut the sternum with dure. Povidone iodine or chlorhexidine solution and sterile drapes
are rarely applied before an emergent ED thoracotomy. If applied,
the povidone iodine or chlorhexidine solution does not have time to
dry before the skin incision is made. Parenteral antibiotics should be
administered if the patient is resuscitated.
The complications of the thoracotomy include vascular and
organ injury. Lacerations of the internal mammary or intercostal
arteries can be ligated with silk suture. There is also the possibil-
ity of inadvertent laceration of the lung or the myocardium during
the initial incision. By temporarily halting mechanical ventilation
while performing the thoracotomy, injury to the underlying lung
can often be prevented. These injuries will need repair at the appro-
priate time.
A pericardiotomy can result in significant complications. The
left phrenic nerve may be transected. The myocardium or a coro-
nary artery can be lacerated. The heart may be fixed by adhesions
to the pericardium from prior pericardial disease or pericarditis.
Attempting to remove the heart from the pericardium can result
in avulsion of the atrial or ventricular myocardium. Performance
of the pericardiotomy adds another delay in initiating cardiac
compressions.
FIGURE 42-3. The left-sided incision is continued across the sternum and the right Care should be taken to prevent injury to any of the health-
fifth intercostal space to perform a right-sided thoracotomy. care providers. Universal precautions should be followed by all
CHAPTER 43: Open Cardiac Massage 271
FIGURE 42-4. Cutting the sternum. A. The sternal saw

is moved to-and-fro while maintaining upward pressure.
B. The Lebsche knife is hooked under the sternum and
lifted upward to secure it in place. The mallet strikes the
Lebsche knife and drives it through the sternum.
personnel. The use of gloves, goggles, masks, and gowns will protect performed in hospitals by Surgeons. Most of the patients were sur-
against exposure to the patient’s blood. All needles, scalpels, and scis- gical and open cardiac massage had a high success rate. After the
sors should be returned to the bedside tray immediately after use and development of closed chest CPR in the early 1960s, there was a
not left on the patient or the bed. Use extreme caution when placing dramatic decline in open cardiac massage in the mid-to-late 1960s
your hands inside the patient’s hemithorax. Fractured ribs from the and 1970s. The exceptions were cardiac arrests due to trauma or in
trauma or the Finochietto rib spreader can easily penetrate gloves the Operating Room.
and skin. The costs associated with an occupational exposure associ-
ated with an ED thoracotomy are quire significant.21 This is espe-
cially true if the healthcare provider develops hepatitis C or HIV.21 ANATOMY AND PATHOPHYSIOLOGY
The efficacy of cardiac massage can be established by measuring
SUMMARY the cardiac output, coronary perfusion pressure, and cerebral per-
An ED thoracotomy is a lifesaving procedure when used on patients fusion pressure. Del Guercio et al. showed that a higher cardiac
in extremis secondary to penetrating chest or abdominal trauma. To index can be achieved with open than with closed cardiac mas-
be considered for this procedure, the patient must have signs of life sage.1 A minimal coronary perfusion pressure of 15 mmHg must
when brought to the ED, must have lost them en route, or have lost be maintained for return of spontaneous circulation. While not all
them on the scene. This procedure should rarely be used in patients patients with this pressure will have a return of spontaneous circu-
with blunt trauma. The Emergency Physician must have the appro- lation, a pressure of less than 15 mmHg predicts a uniformly fatal
priate surgical backup before performing a thoracotomy, since this outcome.2 While closed chest CPR generated only 1 to 9 mmHg
procedure does not provide definitive therapy. of pressure, Boczar et al. found that their patients all had a coro-
nary perfusion pressure of almost 20 mmHg throughout open chest
massage.3 Open chest CPR produces improved cerebral perfusion
and better neurologic recovery.4,10 Open cardiac massage can gen-
erate near normal cerebral blood flow and improve cardiac perfu-
Open Cardiac Massage sion pressure.
43 Eric F. Reichman
INDICATIONS
Open cardiac massage is indicated if absent or inadequate cardiac
INTRODUCTION activity is noted after a thoracotomy for penetrating trauma, a tho-
The purpose of cardiopulmonary resuscitation (CPR) during car- racotomy to decompress pericardial tamponade (spontaneous, post-
diac arrest or hypovolemic shock is to provide adequate cardiac surgical, or from an aortic dissection), or a cardiac arrest after recent
output. This can be done using either closed or open chest cardiac chest surgery.7,9,11 Other possible indications include abnormal chest
massage. Open cardiac massage may on rare occasions be performed wall anatomy that prevents closed chest CPR, hypothermic cardiac
in the Emergency Department. It is performed on patients who have arrest, refractory ventricular fibrillation, massive air embolism, and
had an emergent thoracotomy after penetrating chest trauma and if standard CPR is not effective.
have inadequate cardiac activity. It may also be performed, in rare
instances, after a thoracotomy to decompress a pericardial tam-
CONTRAINDICATIONS
ponade in a medical patient. Open cardiac massage is considered a
heroic procedure in the Emergency Department that can be lifesav- The only absolute contraindication to performing open cardiac
ing if performed on the appropriate patient.1–11 massage is the presence of a palpable pulse. Open cardiac massage
Open cardiac massage was routinely performed before the is ineffective if the patient has a pericardial tamponade. Perform a
introduction of closed chest CPR. This technique was primarily pericardiotomy and remove any clots from the pericardial sac. The
FIGURE 43-1. The anterolateral thoracotomy.
heart may then begin to beat spontaneously. If not, repair any lacera- rupturing the atria or ventricles should the heart be grasped incor-
tions to the myocardium prior to performing cardiac compressions. rectly. The pressure from open cardiac massage is distributed over
a larger area if the pericardium remains intact. The heart will move
EQUIPMENT within the pericardial sac, prevent the fingers from compressing one
spot for a prolonged time, and may decrease the chance of myocar-
No equipment is required to perform open cardiac massage other dial rupture.
than that needed to perform the thoracotomy and pericardiotomy
(Chapter 42). TECHNIQUES
Several important principles must be kept in mind prior to per-
PATIENT PREPARATION
forming open cardiac massage. The heart must be angled not
The preparation and positioning of the patient is exactly the same more than 20° to 30° into the left hemithorax (Figure 43-2A).
as that for a thoracotomy. A thoracotomy must first be performed Angulation of more than 30° may crimp the pulmonary veins
(Figure 43-1). Refer to Chapter 42 for the complete details of a tho- and vena cava closed and thus minimize cardiac output. The
racotomy. A pericardiotomy should be performed only if absolutely compressive forces should be applied perpendicular to the
necessary—that is, if blood is seen within the pericardial sac or car- interventricular septum. Your hands should be placed directly
diac tamponade is suspected. Remove any blood and clots from the behind and in front of the heart. The left anterior descending
pericardial sac, deliver the heart from the pericardial sac, and repair artery can be used as a landmark, as it runs above the inter-
any myocardial lacerations. ventricular septum. Do not place the fingers over the coronary
An intact pericardium is preferable if open cardiac massage arteries so that their flow is occluded. The fingertips should
is to be performed. It prevents the fingertips from inadvertently never be used to compress the heart, as they may rupture the
CHAPTER 43: Open Cardiac Massage 273
FIGURE 43-2. One-handed open cardiac massage. A. The dominant hand angles the heart 20° to 30° into the left hemithorax. B. One-handed cardiac massage with
sternal compression. C. The one-handed compression technique.
myocardium. Use only the palm, volar surfaces of the fingers, be consistently superior to the other two techniques in generating
and pads of the fingers to perform cardiac compressions. The cardiac output.5
fingers should always be held tightly together to form a flat
surface. This allows the force of compression to be spread out ONE-HANDED MASSAGE WITH
and not concentrated over one finger. Each compression of the
STERNAL COMPRESSIONS
heart must be followed by complete relaxation of the heart. It
is during this relaxation phase (i.e., diastole) that the cardiac Tightly adduct the fingers of the dominant hand to make a flat sur-
chambers fill with blood and the coronary arteries perfuse the face. Insert the hand into the thoracotomy incision and against the
myocardium. posterior surface of the heart (Figures 43-2A & B). Angle the heart
Three techniques have been described to perform open cardiac 20° to 30° into the left hemithorax. Compress the heart against the
massage (Figures 43-2 & 43-3). These include one-handed mas- sternum, beginning with the heel of the hand, then the palm, then
sage with sternal compression, one-handed compression, and two- fingers in sequence. This method is difficult to perform in children
handed compression. Two-handed compression has been shown to because of the plasticity of the sternum.6
FIGURE 43-3. Two-handed open cardiac massage. A. The hands are positioned on the anterior and posterior surfaces of the heart. B. Compressions begin at the cardiac
apex with the palms and progress toward the base of the heart with the fingers.
ONE-HANDED COMPRESSIONS SUMMARY

Tightly adduct the fingers of the dominant hand to make a flat sur- Open cardiac massage is a more efficient way of maintaining circula-
face. Insert the hand into the thoracotomy incision and against the tion than closed chest massage. Cardiac compressions can be per-
anterior surface of the heart (Figure 43-2C). Place the thumb against formed with one or two hands, depending on physician preference.
the posterior surface of the heart. The apex of the heart will lie in the The two-handed technique is preferred, as it generates greater cardiac
palm of the hand (Figure 43-2C). Angle the heart 20° to 30° into output than the one-handed techniques. Once a cardiac rhythm and
the left hemithorax. Appose the thumb and fingers to compress the blood pressure are restored, definitive treatment for injuries must be
heart. This is not the preferred method, as the thumb can place sig- provided expeditiously by a Surgeon in the Operating Room.
nificant pressure on the left ventricle and possibly cause it to rupture.
TWO-HANDED COMPRESSIONS
Cardiac Wound Repair
44
This is the technique of choice in children. The child’s sternum, the
costochondral tissues, and the ribs are mostly cartilage. Thus, the
Eric F. Reichman
sternum is very pliable. This makes the one-handed massage with
sternal compression technique not very effective. The one-handed
compression technique can rupture the thin myocardial walls.
Tightly adduct the fingers and cup the left hand. Insert the left INTRODUCTION
hand into the thoracotomy incision and against the anterior sur- Wounds of the heart are highly lethal. Traumatic cardiac penetration
face of the heart (Figure 43-3A). Tightly adduct the fingers of carries a 70% to 80% fatality rate.1 Major factors determining sur-
the right hand to make a flat surface. Insert the right hand into vivability include whether or not cardiac standstill has occurred as
the thoracotomy incision and against the posterior surface of the well as the amount of tissue destruction sustained from the injury.2
heart (Figure 43-3A). Angle the heart 20° to 30° into the left hemi- Penetrating wounds can be caused by knives, bullets, ice picks, and
thorax. Appose the hands to compress the heart (Figure 43-3B). (infrequently) rib or sternal fragments. Regardless of the offending
Compressions should ideally begin with the heel of the hands and agent, repair must be done as expeditiously as possible. The right
progress toward the fingers. ventricle is the most frequently injured chamber. However, injury
to the heart may occur at more than one site. This is especially true
ASSESSMENT with gunshot wounds.
The treatment goal in the Emergency Department is temporary
Compressions should begin at a rate appropriate for the patient’s hemostasis. Many different techniques of cardiorrhaphy have been
age as specified by the American Heart Association (Pediatric described. We will limit our discussion to five possible approaches
Advanced Life Support and Advanced Cardiac Life Support). to dealing with these injuries (i.e., digital or Foley catheter occlu-
Ideally, compress the heart at a rate of at least 100 times a minute if sion, vascular clamps, staples, and sutures).
possible. This compression rate is based on consensus and not clin-
ical research. Assess the effectiveness of the cardiac compressions ANATOMY AND PATHOPHYSIOLOGY
by noting a palpable carotid pulse. A radial or femoral arterial line
can be placed to monitor the effectiveness of the compressions. The heart is contained within the pericardial sac. Numerous por-
The arterial line allows for repeated blood and blood gas sampling. tions of the heart are exposed behind the anterior chest wall
The arterial line will also allow the Emergency Physician to ensure (Figure 36-2). This includes the right ventricle, left ventricle, right
that the heart is completely relaxed between compressions. atrium, left atrium, aorta, pulmonary artery, and inferior vena cava.
These structures are vulnerable to injury behind the anterior chest
wall.3,4 The surface areas that each of these structures contributes
AFTERCARE to the anterior cardiac silhouette are as follows: 55% right ventri-
If a spontaneous cardiac rhythm and a peripheral pulse return, cover cle, 20% left ventricle, 10% right atrium, 10% aorta and pulmonary
the thoracotomy incision with sterile saline-moistened gauze and artery, 4% inferior vena cava, and 1% left atrium.5 These numbers
a simple dressing. Administer intravenous antibiotics whose spec- also reflect, roughly, the anatomic incidence of injury with cardiac
trum covers skin flora. The patient must be taken emergently to the trauma.5 Traumatic injury to any of these structures can result in a
Operating Room by a Trauma Surgeon or Cardiothoracic Surgeon pericardial effusion and cardiac tamponade.
for definitive treatment and closure of the chest wall.
INDICATIONS
COMPLICATIONS Any penetrating injury to the heart requires immediate and tem-
porary repair to prevent the patient from exsanguinating. A bluish
The major complication of open cardiac massage is myocardial rup-
hue behind the pericardium or a tense pericardial sac after penetrat-
ture or perforation. This can occur from compression of the heart
ing trauma suggests an underlying cardiac injury. A pericardiotomy
against a jagged and fractured rib or sternum. Incorrect technique
should be performed, any blood and clot removed from the pericar-
with too vigorous a massage can result in perforation of the isch-
dial sac, and the heart explored for the site of injury. The indications
emic myocardium by the fingertips. Other complications include
to perform a thoracotomy are described in Chapter 42.
decreased cardiac output with compressions if the heart is angled
more than 30° into the left hemithorax and kinks shut the vena cava
CONTRAINDICATIONS
or pulmonary veins. Infection is possible if the patient survives.
Parenteral antibiotics should be administered to prevent infection The only absolute contraindication to performing a cardiorrhaphy
and sepsis. The complications associated with the thoracotomy and is if the patient has obvious signs of death. It should not be per-
the pericardiotomy are discussed in Chapter 42. The quality of life formed if the patient has not had any vital signs for over 15 minutes,
of survivors can be poor to normal.8 as anoxic brain injury is irreversible. It is also contraindicated in
CHAPTER 44: Cardiac Wound Repair 275
FIGURE 44-1. Examples of several atraumatic vascular clamps.
patients with penetrating chest trauma who do not meet the criteria
for performing an anterolateral thoracotomy (Chapter 42).
EQUIPMENT
• Face mask with an eye shield or goggles FIGURE 44-2. The apical traction suture known as Beck’s suture may be placed
• Silk suture, 4-0 and 5-0 (or Prolene) to control the heart.
• 2-0 silk, on a semicircular atraumatic needle
• 10 in. needle driver the Anesthesiologist, Surgeon, and/or Operating Room may not be
• Foley catheter, sizes 14 to 20 French immediately available. If the Emergency Physician performs a tho-
racotomy, they should be versed in methods of temporary cardiac
• Satinsky, or other, atraumatic vascular clamp (Figure 44-1)
wound repair. Several techniques are available to control hemor-
• Allis clamps rhage from a cardiac wound.
• Defibrillator with internal cardiac paddles
• Mayo scissors CONTROL OF THE HEART
• Metzenbaum scissors, curved It is extremely difficult to maintain a finger over a cardiac wound or
• Teflon pledgets to stitch a cardiac wound if the heart is beating. An apical traction
• Sterile saline suture known as Beck’s suture can be placed to control the heart
(Figure 44-2). The apex of the heart is the ideal site because it is
• 20 mL syringe often away from most lacerations, is a thick portion of the heart,
• Standard skin stapler, 6 mm wide staples and is away from any major coronary arteries. Place a 2-0 silk suture
• Laparotomy pads through the apex of the heart and remove the needle from the suture.
• Gauze 4 × 4 squares The ends of the suture can be grasped by hand or with a hemostat to
elevate and control the heart while it is beating.
• Hemostats
PATIENT PREPARATION SAUERBRUCH MANEUVER

Large cardiac wounds and wounds with significant bleeding are dif-
No preparation is required other than that of performing a thora-
ficult to repair, as the blood obscures the surgical field. Experienced
cotomy and a pericardiotomy (Chapter 42). The patient should be
Surgeons may temporarily clamp the inferior and superior vena cava
intubated, ventilated with 100% oxygen, and fully monitored (i.e.,
to maintain a bloodless field. Clamping the vena cava should not be
telemetry, a noninvasive blood pressure cuff, and pulse oximetry).
performed by an Emergency Physician, as it is time-consuming
Instruct a nurse to administer intravenous broad spectrum antibiot-
and can injure other structures. A quicker and safer alternative
ics that cover skin flora, gram-positive organisms, and gram-nega-
is the Sauerbruch maneuver, or grip, to partially occlude venous
tive organisms. The Emergency Physician should wear full personal
inflow through the inferior and superior vena cava (Figure 44-3).
protective equipment to protect themselves from contact with the
This technique will stabilize the heart for wound repair and allow
patient’s blood and body fluids. While time is of the essence and
the bleeding site to be identified and repaired.
this is an emergent procedure, aseptic technique should be followed.
Insert the nondominant hand into the pericardial cavity and
toward the vena cava. Place the middle finger behind the vena
TECHNIQUES
cava and the index finger in front of the vena cava (Figure 44-3).
Bleeding from a cardiac wound should ideally be stopped by plac- The thumb should be resting on the anterior surface of the heart.
ing a finger over the wound and immediately transporting the The ring and little fingers should be resting on the posterior surface
patient to the Operating Room for definitive repair. Unfortunately, of the heart. Use the thumb and the ring and little fingers to cradle
the heart while apposing the middle and index fingers to partially
occlude the vena cava. This technique can be used to control hem-
orrhage from the heart, great vessels, or hilum. While effective at
controlling hemorrhage, this technique will significantly reduce
cardiac output and result in cardiac arrest. The grip should
be released every 30 to 60 seconds to ensure coronary artery
perfusion.
DIGITAL OCCLUSION
Digital occlusion of small cardiac wounds can provide excellent
hemostasis while awaiting definitive repair. Once a finger is placed
on or over the defect, it must remain there until the appropriate
materials to perform cardiorrhaphy are available. Do not place a
finger into the defect as this may increase the size of the wound.
Unfortunately, the fingertip often slips off the wound if the heart is
beating. The fingertip interferes with visualization and repair of the
wound. It also places the healthcare worker at risk for a needle-stick
injury while attempting to repair the wound.
FOLEY CATHETER TECHNIQUE

A Foley catheter may be used to provide temporary hemostasis. As
with digital occlusion, this is only a temporizing measure. Inflate
the cuff of the Foley catheter with sterile saline to check its integrity
and look for leaks. Deflate the cuff. Place a hemostat on the Foley
catheter 3 to 4 cm proximal to the cuff. This will prevent air from
being drawn through the catheter and causing an air embolism.
FIGURE 44-3. The Sauerbruch maneuver to partially occlude venous inflow from
Identify the location of the cardiac wound (Figure 44-4A). Insert
the superior and inferior vena cava.
the Foley catheter through the cardiac wound until the balloon is
FIGURE 44-4. The Foley catheter technique to occlude and repair a cardiac wound. A. The cardiac wound is identified. B. The Foley catheter is inserted through the wound.
C. The cuff is inflated. D. Gentle traction is applied to occlude the wound with the cuff. E. A purse-string suture is placed around the wound. F. The cuff is deflated and the
Foley catheter is removed. G. The purse-string suture is tightened and tied to occlude the wound.
within the cardiac chamber (Figure 44-4B). Release the hemostat,

inflate the cuff with 10 to 20 mL of sterile saline, and reclamp the
Foley catheter (Figure 44-4C). This step should be done quickly to
prevent air from being drawn through the Foley catheter.
Apply gentle traction to the catheter (Figure 44-4D). Apply
just enough traction to mostly occlude the wound and slow the
bleeding. A small amount of bleeding is adequate and accept-
able to visualize the wound and perform a temporary repair.
Do not try to provide complete hemostasis. This will result in
excessive traction on the Foley catheter causing the cuff to pull
through the wound, enlarge the wound, and further lacerate the
myocardium.
Repair the cardiac wound. Place a purse-string suture around
the wound (Figure 44-4E). Use caution when placing the suture
so that the needle does not pierce and rupture the cuff of the
Foley catheter. The Foley catheter may be advanced into the car-
diac chamber temporarily while the suture is being placed. This will
prevent the needle from piercing the cuff. Do not advance the cuff
too far into the heart and for too long a time period. The cuff
may occlude blood flow through the valves and result in cardiac
arrest. After the purse-string suture is placed, deflate the cuff and
quickly remove the Foley catheter (Figure 44-4F). Tie the ends of
the suture to close the cardiac wound (Figure 44-4G). Place addi-
tional knots to secure the suture.
FIGURE 44-5. A Satinsky vascular clamp provides hemostasis for atrial wounds.
The Foley catheter technique is simple and effective. It avoids
the problems associated with digital occlusion. The catheter may be
placed in posterior cardiac wounds that are difficult to visualize and
where it is hard to maintain digital occlusion. The Foley catheter
SUTURE TECHNIQUES
does not interfere with visualization of the wound, wound repair, Suturing of cardiac wounds is more time consuming than the other
or the simultaneous performance of cardiac massage. Intravenous methods previously described. It requires technical proficiency
catheter tubing may be inserted into the lumen of the Foley cath- and understanding of the heart’s surface anatomy. Place horizon-
eter to infuse crystalloid solutions or red blood cells directly into tal mattress sutures using 2-0 or 3-0 silk or Prolene suture material
the heart and central circulation. This technique is especially valu- (Figure 44-7). Do not tie the sutures tightly. It is easy to inad-
able in repairing wounds at the junction of the right atrium and vertently tear through the myocardium. Use teflon pledgets to
vena cava. reinforce the repair and prevent cutting through the heart tissue
(Figures 44-7A & B). This is especially important when the wound
CLAMP TECHNIQUE edges are irregular or tattered. Use care to avoid injury to the coro-
nary vessels, which may lie in close proximity to a cardiac wound.
Atrial wounds can bleed profusely and are difficult to control. The Ensure that the sutures are placed adjacent to and underneath the
thin walls do not allow digital occlusion to be effective. The atrial coronary vessels (Figure 44-7C).
wound can be grasped and compressed between the thumb and
index finger. An atraumatic Satinsky vascular clamp can be placed
around the wound to provide hemostasis (Figure 44-5). The wound
may then be repaired with 4-0 or 5-0 interrupted silk sutures.
Allis clamps may be substituted if an atraumatic vascular clamp is
not available. Place an Allis clamp on each of the opposing edges of
the atrial wound. Apply upward traction, then cross the Allis clamps
to approximate the wound edges. The wound may now be sutured
closed. The Allis clamps do not provide as bloodless a field as does
the atraumatic vascular clamp.
STAPLE TECHNIQUE
Skin staplers provide a quick and easy method to repair cardiac
wounds. Careful approximation and stapling of the wound will
rapidly close the defect and aid in controlling massive blood loss.
Staples may be used to close small, large, or multiple lacerations.
Its use avoids the potential complication of a needle stick to the
Emergency Physician.
Cardiac wounds are closed similarly to skin lacerations (Fig-
ure 44-6). Obtain a standard skin stapler with 6 mm wide staples.
These are readily available in Emergency Departments for wound
closure. Use the nondominant hand to appose the wound edges.
Grasp the stapler with the dominant hand. Place staples at 5 mm
intervals until the wound is closed. FIGURE 44-6. The cardiac stapling technique provides temporary hemostasis.
FIGURE 44-7. Horizontal mattress sutures used to close cardiac wounds. A. Teflon pledgets are placed on either side of the wound to prevent the suture from pulling
through the myocardium. B. Wounds are closed with multiple horizontal mattress sutures. C. When suturing near a coronary artery, ensure that the sutures pass completely
below the artery.
FIGURE 44-8. Incomplete horizontal mattress stitches may be placed on each side of a large wound. Tension applied to the sutures will appose the wound edges (arrows).
repair are unsuccessful. Choose the proper size internal cardiac

paddles. The paddle size for an infant is 2 cm, for a child is 4 cm,
and for an adolescent or adult is 6 cm. Insert the sterile paddles into
the sterile handles (Figure 44-9). Pass the cables exiting the base of
the handles to an assistant to insert into the defibrillator machine
ports. Instruct the assistant to turn on the defibrillator.
Place the internal cardiac paddles on the anterior and posterior
surfaces of the heart (Figure 44-10). While the paddles can be
placed directly on the heart, it is recommended by some to place
sterile saline-moistened gauze squares between the paddles and
the heart to aid in conduction. Apply 20 Joules (J) of energy through
the paddles to fibrillate the adolescent or adult heart. Begin with
5 J of energy to fibrillate the infant or child heart. Proceed upward
incrementally as required to a maximum of 20 J to fibrillate the
infant or child heart. Quickly repair the cardiac wound.
Perform intermittent cardiac massage while repairing the fib-
rillating myocardium to maintain cardiac output. Do not allow
the heart to fibrillate for more than 3 minutes. Defibrillate the
FIGURE 44-9. The internal cardiac paddles inserted into the handles.
heart with the internal paddles using 20 J of energy for the adult
and adolescent heart. Repeat the defibrillation with 20 J of energy
until the heart begins beating. In general, do not use more than
Large cardiac wounds are difficult to repair. They bleed profusely. 20 J to defibrillate the adult or adolescent heart with the internal
The digital occlusion and Foley catheter techniques are ineffec- cardiac paddles as myocardial necrosis can occur. It may be occa-
tive on large wounds. The wound edges are difficult to grasp and sionally necessary increase the energy in the adolescent or adult to
appose so that they can be repaired with a skin stapler. Place an 40 J then 60 J if multiple attempts at 20 J are ineffective. Begin with
incomplete horizontal mattress stitch on each side of the wound 5 J of energy to defibrillate the infant or child heart. Proceed upward
(Figure 44-8). Grasp the free ends of the sutures and cross them incrementally as required to a maximum of 20 J to defibrillate the
across the wound to appose the wound edges. Instruct an assistant infant or child heart.
to hold the suture ends while the cardiac wound is repaired with
2-0 or 3-0 silk, Prolene, or staples. The incomplete mattress sutures AFTERCARE
may then be removed or tied to each other.
If the patient is resuscitated, cover the thoracotomy wound with
saline-moistened gauze and a simple dressing. Administer broad
FIBRILLATION spectrum antibiotics if not done previously. Immediately transport
The myocardium can be deliberately placed in fibrillation to halt the patient to the Operating Room for definitive repair of the car-
myocardial contractions and repair large ventricular wounds. This diac wound and any other injuries by a Trauma or Cardiovascular
should be performed only if other techniques of cardiac wound Surgeon.
FIGURE 44-10. Application of the internal cardiac paddles.

Sterile saline-moistened gauze can be placed between the
paddles and the heart to increase conductivity.
COMPLICATIONS deviation, or tracheal deviation, all of which suggest injury to a great

vessel. Other findings suggestive of such an injury include depres-
The complications associated with digital pressure include further sion of the left mainstem bronchus, left apical capping, narrowing of
destruction of tissue. If pulled too tightly, Foley catheters can become the carinal angle, sternal fractures, opacification of the aortopulmo-
dislodged and restart troublesome bleeding. They can also enlarge a nary window, and widening of the paraspinous stripe.
cardiac wound if the cuff pulls through the wound. A drop in cardiac Numerous physical examination findings are suggestive of a
output can result if the cuff obstructs the cardiac valves, impinges thoracic great vessel injury. Asymmetric pulses or unequal blood
on the chordae tendineae, or occupies too much space within the pressures between the extremities are quick and simple to evalu-
cardiac chamber. Decrease the cuff size by withdrawing some of the ate. Hypotension may be due to internal or external hemorrhage.
saline from the cuff. Suturing is probably associated with the great- Steering wheel contusions, sternal fractures, thoracic spine frac-
est rate of complications. Tearing of the myocardium is a frequently tures, and a left-sided flail chest signify potential intrathoracic
encountered problem. The suture should be tied just tight enough to injury. A thoracic outlet hematoma or a hoarse voice can occur from
stop the bleeding. Care should be exercised to avoid ligation of the injury to the aorta or one of its major branches. Paraplegia may be
major coronary vessels and their branches. Dysrhythmias can result due to hypotension or an aortic disruption.
from occlusion of venous inflow (Sauerbruch maneuver) or injury
to the coronary vasculature. If the patient is resuscitated, adminis- INDICATIONS
ter broad-spectrum antibiotics to prevent any potential infectious
complication. Attempts should be made to control any laceration or rupture of the
thoracic great vessels.
SUMMARY
CONTRAINDICATIONS
Injuries to the heart can be devastating. The role of the Emergency
Physician is to rapidly and temporarily control bleeding and ensure There are no absolute contraindications to temporarily controlling
the transport of the patient to the Operating Room for definitive any hemorrhage from a thoracic great vessel after performing a tho-
repair. If there is a delay in transporting the patient to the operating racotomy (Chapter 42). The thoracotomy should not be performed
room, the Emergency Physician must be versed in the techniques if the patient has obvious signs of death, no vital signs in the field,
used to repair cardiac wounds and resuscitate the patient. or no vital signs for over 15 minutes. A pericardial tamponade or
cardiac injury may require management prior to managing a great
vessel injury.
EQUIPMENT
Hilum and Great Vessel
45 Wound Management
•
•
•
3-0 Prolene suture
Foley catheters, sizes 14 to 20 French
10 in. needle driver
Eric F. Reichman
INTRODUCTION • Sterile saline
Injuries to the thoracic great vessels can be a significant cause of • 20 mL syringe
morbidity and mortality. Large vessels in the hilum of the lung • Laparotomy pads
include the pulmonary artery and vein. The great vessels also • Gauze 4 × 4 squares
include the vena cava, aorta, innominate artery, subclavian artery, • Umbilical clamp
and subclavian vein. The mortality from injuries to the subclavian
artery is approximately 5% if patients who are moribund on admis- • Hemostats
sion to the Emergency Department are excluded.1 However, the
mortality from injury to the vena cava and the pulmonary vessels
is over 60%.2 While over 85% of patients with penetrating injuries
to the thorax are stable, the remainder present in varying levels of
hypovolemic shock. They may have bled externally or into the chest.
Each hemithorax can hold up to one-half of an individual’s blood
volume. In these cases, an Emergency Department thoracotomy
may be performed for hypovolemic shock.

Injury to the thoracic great vessels may be due to blunt trauma,
diagnostic procedures, iatrogenic causes, or penetrating trauma.
Crush injuries, deceleration injuries, motor vehicle versus pedes-
trian collisions, and penetrating thoracic injuries may all signify an
injury to a thoracic great vessel. The vessels that are most commonly
injured include the aorta, innominate artery, pulmonary vein, and
venae cavae.
The portable anteroposterior chest radiograph is the initial radio-
graphic screening. It may reveal loss of the aortic knob contour,
left-sided pleural effusions, mediastinal widening, nasogastric tube FIGURE 45-1. Examples of several atraumatic vascular clamps.
CHAPTER 45: Hilum and Great Vessel Wound Management 281
FIGURE 45-2. The Foley catheter technique to occlude an injury to a great vessel. A. The catheter is inserted through the wound and into the vessel. B. The cuff is inflated
and gentle traction (arrow) is applied to occlude the wound with the cuff. C. An umbilical clamp is placed to prevent the catheter from migrating inward.
PATIENT PREPARATION enough traction to mostly occlude the wound and slow the bleed-
ing. Do not try to provide complete hemostasis. This will result in
There is no preparation required other than performing an antero- excessive traction on the catheter, causing the cuff to pull through
lateral thoracotomy (Chapter 42). The patient should be intubated, the wound, enlarge the wound, and further injure the vessel. Place
ventilated with 100% oxygen, and fully monitored (i.e., telemetry, an umbilical clamp or a hemostat on the catheter just outside the
a noninvasive blood pressure cuff, and pulse oximetry). Instruct a vessel to prevent it from migrating into the vessel (Figure 45-2C).
nurse to administer intravenous broad-spectrum antibiotics that The Foley catheter technique is simple and effective. It avoids the
cover skin flora, gram-positive organisms, and gram-negative problems associated with digital occlusion. It does not interfere with
organisms. The Emergency Physician should wear full personal visualization of the wound or the simultaneous performance of car-
protective equipment to protect themselves from contact with the diac massage. Intravenous catheter tubing may be inserted into the
patient’s blood and body fluids. While time is of the essence and lumen of the Foley catheter to infuse crystalloid solutions or red
this is an emergent procedure, aseptic technique should be followed. blood cells directly into the heart and central circulation.
TECHNIQUES CROSS-CLAMPING TECHNIQUE
DIGITAL OCCLUSION Injuries to the thoracic great vessels can bleed profusely and are dif-
ficult to control. Digital occlusion is often ineffective. An atraumatic
Digital pressure may be used to control small lacerations of the tho- Satinsky vascular clamp can be placed to partially occlude the great
racic vena cava. It will provide adequate hemostasis while repairing vessel and isolate the injury (Figure 45-3). This will provide tempo-
the wound. Place a fingertip over the defect. Do not place a finger rary hemostasis until definitive repair in the Operating Room.
in the defect. Place horizontal mattress sutures using 3-0 Prolene
to close the defect. Unfortunately, the fingertip interferes with visu-
alization of the wound and places the Emergency Physician at risk
for a needlestick injury. The fingertip will have to be intermittently
removed to place the sutures.
Digital pressure and rapid transport to the operating room is the
most practical method of dealing with injuries to the subclavian
vessels. These vessels are extremely difficult to control through a
traditional anterolateral thoracotomy incision. If digital pressure
is ineffective, pack the apex of the thoracic cavity with laparotomy
pads or gauze squares and apply compression from below.

By inserting a Foley catheter into the vessel, inflating the cuff, and
placing it under gentle traction, one may occlude a wound to a great
vessel (Figure 45-2). As with digital occlusion, this is only a tem-
porizing measure. Inflate the cuff of the Foley catheter with sterile
saline to check its integrity and look for leaks. Deflate the cuff. Place
a hemostat on the Foley catheter proximal to the cuff. This will
prevent air from being drawn through the catheter and causing
an air embolism.
Identify the location of the vascular injury. Insert the catheter
through the wound until the cuff is within the vessel (Figure 45-2A).
Open the hemostat, inflate the cuff with 5 to 10 mL of sterile saline,
and reclamp the Foley catheter. This step should be completed
quickly to prevent air from being drawn through the catheter. Do
not overinflate the cuff so that it occludes flow through the vessel. FIGURE 45-3. A Satinsky vascular clamp may be used to partially occlude the
Apply gentle traction to the catheter (Figure 45-2B). Apply just great vessel and isolate the injury.
FIGURE 45-4. Cross-clamping of vascular injuries. A. Cross-clamp the great vessels to provide temporary hemostasis. B. Distal vessels must also be cross-clamped to
prevent backbleeding.
Large wounds and complete transections are difficult to manage.

Injuries to the pulmonary vasculature in the region of the hilum Thoracic Aortic Occlusion
are most expeditiously controlled by placing an atraumatic vascu-
lar clamp across the respective hilum.3 Grasp the hilum between
the thumb and the forefinger. Place the clamp carefully around the
46 Eric F. Reichman
entire hilum. Take care not to injure the pulmonary parenchyma

or the vessels any further. Vascular injuries may be controlled by INTRODUCTION
placing a cross-clamp proximal to the injury and occluding the
backbleeding with additional clamps (Figure 45-4). These patients Temporary thoracic aortic occlusion should be performed during an
should be immediately transported to the Operating Room to be Emergency Department thoracotomy for hypovolemic shock. It pre-
placed on bypass and repair the injuries. It is not recommended serves cerebral and coronary artery perfusion pressure.1 The blood
for the Emergency Physician to suture great vessel injuries in an flow to the viscera below the cross clamp, however, falls to less than
attempt to repair them. 10% of baseline flow.2 This can be advantageous since it stops distal
hemorrhage, but it can later result in the undesired metabolic conse-
AFTERCARE quences of acidosis, hyperkalemia, and multiple organ system failure.3,4
If the patient is resuscitated, cover the thoracotomy wound with ANATOMY AND PATHOPHYSIOLOGY
saline-moistened gauze and a simple dressing. Administer broad-
spectrum antibiotics if not done previously. Immediately transport The aorta begins at the left ventricle and gives rise to the arteries of
the patient to the Operating Room for definitive repair of the great the body, directly or indirectly (Figure 46-1). It leaves the ventricle
vessel injury and any other injuries by a Trauma or Cardiovascular and is directed upward as the ascending aorta. It arches to the left and
Surgeon. backward at the level of the sternal angle to become the aortic arch.
The arch gives rise to the brachiocephalic trunk, left common carotid
artery, and left subclavian artery. The aortic arch is directed inferi-
COMPLICATIONS orly after giving rise to the left subclavian artery and is known as the
The complications associated with digital pressure include extend- descending aorta. The descending aorta is subdivided into the tho-
ing the injury if the procedure is not performed carefully. Inaccurate racic portion above the diaphragm and the abdominal portion below
digital control can lead to unnecessary loss of blood during trans- the diaphragm. It descends through the posterior mediastinum,
port of the patient to the operating room. Foley catheters, if pulled lying first against the left side of the fifth thoracic vertebral body. As
too tightly, can become dislodged and restart troublesome bleeding. it descends, it gradually approaches the midline of the 12th thoracic
They can also enlarge a wound if the cuff pulls through the wound. vertebral body, at which point it passes through the diaphragm.
The cuff may obstruct flow through the vessel and compromise The esophagus is a thin, muscular tube measuring approximately
cardiac output. Decrease the cuff size by withdrawing some of the 2.0 to 2.5 cm in diameter. It descends along the vertebral bodies. It
saline from the cuff. An overly rough mobilization and clamping can travels forward, away from the vertebral bodies, and to the right at
increase the size of the injury and cause massive bleeding. Cross- the level of the ninth thoracic vertebral body. It traverses the dia-
clamping of the aorta and/or pulmonary artery will obstruct periph- phragm at the level of the 10th thoracic vertebral body. It lies poste-
eral blood flow. The vessel must be repaired or the patient placed rior and medial to the descending thoracic aorta throughout most
on bypass to prevent anoxia and permanent neurologic dysfunction. of its course. It migrates as it travels distally, so that its lower part lies
in front of the aorta just above the diaphragm (Figure 46-1).
SUMMARY
Injuries to the thoracic great vessels carry a high mortality as bleed-
INDICATIONS
ing occurs unimpeded into the pleural space. The survival of the The primary reason to occlude the descending thoracic aorta is to
patient depends on their presenting condition as well as the speed temporarily direct blood flow from below the diaphragm to pre-
and accuracy with which the intrathoracic hemorrhage is controlled. serve flow to the brain and heart. The descending thoracic aorta
CHAPTER 46: Thoracic Aortic Occlusion 283
Esophagus
Left vagus nerve
Thoracic duct
Left brachiocephalic vein
Aortic arch
Ascending aorta
Parietal pleura (cut) Accessory

hemiazygos vein
Pulmonary trunk
Hemiazygos vein
Left phrenic nerve
Left
pericardiacophrenic
artery
Esophagus and
esophageal plexus
Pulmonary ligament
Descending
thoracic aorta
FIGURE 46-1. Anatomy of the aorta and surrounding structures of the mediastinum and left hemithorax. The mediastinal pleura has been removed to visualize the
underlying structures.
may be occluded in patients with penetrating thoracic or abdominal Insert a nasogastric tube. Instruct a nurse to administer intrave-
trauma in which hypovolemic shock and clinical deterioration are nous broad-spectrum antibiotics that cover skin flora, gram-pos-
not responsive to aggressive fluid resuscitation and blood transfu- itive organisms, and gram-negative organisms. The Emergency
sion. These patients should have the appropriate indications to per- Physician should wear full personal protective equipment to protect
form an anterolateral thoracotomy (Chapter 42). The thoracic aorta themselves from contact with the patient’s blood and body fluids.
may also be occluded immediately prior to laparotomy if the patient While time is of the essence and this is an emergent procedure,
has a tense abdomen filled with blood. The abdominal incision will aseptic technique should be followed.
decompress the abdomen and result in hypotension, decreased cor-
onary and cerebral perfusion pressure, exsanguination, and death. TECHNIQUE
Uncontrollable hemorrhage below the diaphragm can be controlled
by temporarily occluding the descending thoracic aorta. Identify the aorta by palpation. It is often easier to identify and iso-
late the aorta just above the diaphragm. In this location, the aorta
is slightly separated from the adjacent esophagus. Elevate the left
CONTRAINDICATIONS
lung with the nondominant hand superiorly and medially. Instruct
There are no absolute contraindications to temporarily occluding an assistant to maintain the lung out of the way. Place the dominant
the descending thoracic aorta after performing an anterolateral tho-
racotomy. The thoracotomy should not be performed if the patient
has obvious signs of death, no vital signs in the field, or no vital signs
for over 15 minutes.
EQUIPMENT
• Metzenbaum scissors
• DeBakey or large Kelly clamp
• Aortic compressor, Conn or homemade
• Gauze 4 × 4 squares
PATIENT PREPARATION
No preparation is required other than that of performing a thora-
cotomy and a pericardiotomy (Chapter 42). The patient should be
intubated, ventilated with 100% oxygen, and fully monitored (i.e.,
telemetry, a noninvasive blood pressure cuff, and pulse oximetry). FIGURE 46-2. Examples of several atraumatic vascular clamps.
hand through the thoracotomy incision and into the posteroinferior CROSS-CLAMPING
recess of the thoracic cavity. Advance the hand along the diaphragm
and toward the midline. The fingers will first encounter the verte- The descending thoracic aorta is most commonly occluded with an
bral bodies. The next palpable structure is the aorta. It lies anterior atraumatic or Satinsky vascular clamp. Aortic compression devices
to the vertebral bodies. The aorta may be difficult to palpate if it are rarely available in Emergency Departments or on thoracotomy
is collapsed in the patient with hypovolemic shock. In the elderly, trays. The aorta must first be separated and isolated from the esoph-
the aorta may be significantly calcified, which helps to identify it agus, as described above. Place an index finger behind the descend-
despite hypovolemia. The aorta is covered by the mediastinal pleura. ing thoracic aorta to elevate it away from the underlying esophagus
Place the thumb and index finger of the nondominant hand over the (Figure 46-4A). Place the Satinsky or other atraumatic vascular
aorta just above the diaphragm. clamp over the aorta. One jaw should be posterior to the aorta and
Isolate the aorta. Bluntly dissect open the mediastinal pleura adjacent to the index finger while the other jaw is anterior to the
overlying the aorta with a DeBakey clamp or a large curved Kelly aorta. Clamp the aorta and remove the index finger (Figure 46-4B).
clamp. Never use a scalpel to open the mediastinal pleura, as It is imperative not to clamp the esophagus. Do not clamp the
it may lacerate the aorta. Some physicians may prefer to use a aorta before it is dissected from the esophagus. Esophageal injury
Metzenbaum scissors to dissect and open the mediastinal pleura. can lead to perforation, ischemia, and sepsis if the patient is resusci-
Identify the aorta by palpation. Bluntly separate the aorta from the tated. Ideally, the clamp should be placed under direct visualization
esophagus with the dominant hand. It may be extremely difficult of the aorta. Unfortunately, this is not always practical. The index
to separate the aorta from the esophagus in the patient with hypo- finger under the aorta can confirm the proper isolation of the aorta
tension, hypovolemia, and/or shock. Place a nasogastric tube if this and the proper position of the jaws of the clamp before the aorta is
has not been done previously. The nasogastric tube will be palpable occluded.
within the esophagus and can be used to identify the esophagus.
Hook the dominant index finger around the aorta. Use the finger AFTERCARE
to separate the aorta from the vertebral bodies. The dissection
should not be extensive. It should free approximately 3 to 4 cm of If—after the thoracotomy, open cardiac massage, and aortic cross-
the descending thoracic aorta. clamping—there is return of a cardiac rhythm and a carotid pulse,
the patient must be taken immediately to the Operating Room for
DIRECT COMPRESSION definitive treatment. Cover the thoracotomy wound with saline-
moistened gauze and a simple dressing. The patient’s blood pressure
Direct compression of the aorta is fast and simple, it does not inter- in the upper extremity should be monitored every 30 to 60 seconds
fere with the operative field, and it causes less damage than the appli- after the aorta is occluded. An elevated blood pressure can result in
cation of a clamp. Digital compression is often ineffective. Aortic a hemorrhagic stroke or left ventricular failure. Elevated blood pres-
compression devices have a unique shape to occlude the aorta atrau- sure will require intermittent release of the aortic occlusion and/or
matically by compressing it against the vertebral bodies. It may be pharmacologic management. Parenteral broad-spectrum antibiotics
applied before or after the aorta is isolated. Homemade compression should be administered to prevent infection if not done previously.
devices may use rubber tubing to occlude the aorta5 (Figure 46-3A).
The Conn compressor is commercially available and uses a metal COMPLICATIONS
plate to occlude the aorta (Figure 46-3B). Place the distal end of
the compression device against the distal descending thoracic aorta Intercostal arteries arising from the thoracic aorta can be damaged
(Figure 46-3C). Apply downward pressure to occlude the aorta. The during mobilization of the aorta. This will result in troublesome
degree of occlusion can be controlled by increasing or decreasing bleeding that requires operative control. The aorta, vena cava, or the
the pressure applied to the aorta. esophagus can be damaged by the clamp. Aortic cross-clamping can
FIGURE 46-3. Aortic compression. A. The homemade aortic compression device.5 B. The commercially available Conn compressor. C. The aorta is compressed between
the distal end of the compression device and the thoracic vertebral body.
CHAPTER 46: Thoracic Aortic Occlusion 285
FIGURE 46-4. Aortic cross-clamping. A. The mediastinal pleura has been bluntly opened and the aorta isolated from the esophagus. B. The Satinsky, or other atraumatic,
vascular clamp is placed across the aorta to occlude distal blood flow.
precipitate hypertension, stroke, and left-sided heart failure. If the metabolism in these organs generates lactic acid. When the aor-
patient is successfully resuscitated, this should be dealt with by peri- tic clamp is released, acid and potassium are released into the
odically releasing the clamp. Lack of blood flow through the artery central circulation and can cause a cardiac arrest. Thus, bicar-
of Adamkiewicz will cause ischemia of the distal spinal cord. There bonate must be given at this time and the cardiac rhythm moni-
is a 5% incidence of paraplegia when the blood supply to the distal tored carefully.
aorta and spinal cord is disrupted. This incidence increases dramati-
cally when the spinal cord is ischemic for more than 30 minutes.6
SUMMARY
Aortic cross-clamping causes visceral ischemia. The gut loses its
barrier function and becomes a cytokine-generating organ, which Aortic cross-clamping is a useful adjunct to open cardiac massage in
leads to a systemic inflammatory response and multiple organ fail- hypovolemic shock. It can help salvage patients by increasing coro-
ure. Renal and liver failure can result from a lack of blood flow. nary and cerebral perfusion. It may be performed as a lifesaving and
The organs distal to the aortic clamp become severely ischemic temporizing measure until the patient can be taken to the Operating
and receive only 10% of the basal cardiac output. The anaerobic Room for definitive management.
SECTION
Vascular Procedures 4
and are easier to access. The use of venous tourniquets, dependent
General Principles of positioning, “pumping” via muscle contraction, and the local appli-
47 Intravenous Access cation of heat or nitroglycerin ointment all contribute to venous
engorgement.2 These maneuvers can be used to aid in the identifica-
tion of a peripheral vein.3
Daniel Belmont
The connective tissue surrounding veins can be a help or a hin-
drance during attempts at peripheral venous access. Deficient con-
INTRODUCTION nective tissue permits the vein to “roll” from side to side and evade
The practice of Emergency Medicine frequently requires access to a the needle. Tough connective tissue can impede the entry of a flex-
patient’s venous circulation. Venous access allows sampling of blood ible catheter through the soft tissues and into the vein. This tissue
as well as administration of medications, nutritional support, and also serves to stabilize the vein and prevent its collapse.
blood products. Devices such as cardiac pacing wires and pulmo- Venous valves are an important aspect of peripheral venous anat-
nary artery catheters can be introduced into the patient’s central omy (Figure 47-2).1 They encourage unidirectional flow of blood
venous circulatory system. back toward the heart. Venous valves prevent blood from pooling
Percutaneous, as opposed to surgical, venous access is usually in the dependent portions of the extremities due to gravitational
rapid, safe, and well tolerated. An understanding of the various tech- forces. Valves can impede the passage of a catheter through and into
niques available, the venous anatomy, and the indications for the a vein. Forcing a catheter past venous valves may damage them and
procedure allows the Emergency Physician to choose the appropri- contribute to later venous insufficiency. Valves are more numerous
ate site and method of venous access. at the points where tributaries join larger veins and in the lower
extremities. Valves are almost totally absent within the large central
veins, the veins of the head, and the veins of the neck.
ANATOMY AND PATHOPHYSIOLOGY Veins can be subdivided into central veins and peripheral veins.
Veins, like arteries, have a three-layered wall composed of an inter- The important central veins with regard to venous access are the
nal endothelium surrounded by a layer of muscle then a layer of internal jugular, subclavian, and femoral veins. Central veins are
connective tissue (Figure 47-1).1 The muscular layer of a vein is usually larger than peripheral veins and have fewer tributaries.
much smaller than that of an artery. While veins can dilate and con- Superficial peripheral veins are generally visible beneath the sur-
strict somewhat on their own, they do so mostly in response to the face of the skin of the extremities and neck. They are often tortu-
pressure within them. Veins with high pressures become engorged ous and continually merge and divide. Peripheral veins are easiest
A Nerve of B Vasa
blood vessel Adventitia Nerve vasorum
Vasa Tunica media
vasorum
Tunica intima
External Nonstriated
elastic lamina myocytes
in media
Lumen Muscular artery
Nonstriated
myocytes
Internal
in media
elastic lamina Vein
Endothelium of
tunica intima
FIGURE 47-1. Comparative anatomy of an artery and a vein. A. The generic blood vessel. B. A muscular artery. C. A vein. Note the vein’s thinner wall with fewer myocytes
and elastic fibers. This is indicative of the lower pressure within veins compared to arteries.
287
288 SECTION 4: Vascular Procedures
FIGURE 47-2. Venous valves. Cross-section of converging veins demonstrating the

valve leaflets that only permit forward flow, proximally, toward the right heart. The
arrows represent the directional flow of blood.
to access at the apex of the “Y” formed when two tributaries merge
into a larger vein or where the vein is straight and free of branches
(and hence valves) for approximately 2 cm proximal to the site of
puncture (Figure 47-3). These sites tend to be anchored and “roll”
less than other sites. The superficial veins of the upper extremity
are preferred to those of the lower extremity for peripheral venous
Cephalic vein
Basilic
vein
Accessory
cephalic vein
Median cephalic FIGURE 47-4. The angle between the needle and the skin must be varied based
vein upon the depth and diameter of the target vein. A. A shallow angle must be used
for small and superficial veins. B. A steeper angle must be used for deeper veins.
Cephalic C. A butterfly-type needle permits the shallowest angle of entry for very small and
vein superficial veins.
Median
antebrachial vein access. Indwelling catheters in the upper extremity interfere less
with patient mobility and the risk of phlebitis is lower.1
The depth of the vein beneath the epidermis will affect the ease
with which it may be accessed. Very superficial veins are often
small, fragile, and easily passed “through and through” with a
needle, resulting in a hematoma. The deeper veins are often not
visible and must be located by surface landmarks and palpation.
The angle of insertion of the needle must be varied depend-
FIGURE 47-3. Preferred venous access sites. Preferred sites (open circles) are ing on the depth of the vein being punctured (Figure 47-4). A
at the apex of converging veins or in the middle of a long straight vein. Sites just shallow angle of approximately 30° to 45° should be used for
distal to branching or convergence of veins (red ⊗) are best avoided due to the most small and superficial veins (Figure 47-4A). A more obtuse
presence of valves and the difficulty in threading a cannula. angle of approximately 60° should be used to access deeper veins
CHAPTER 47: General Principles of Intravenous Access 289
(Figure 47-4B). This steeper angle allows the vein to be penetrated The pressure gradient and resistance to flow are inversely pro-
within a reasonable horizontal distance from the skin puncture portional to the length of the tubing. Changes in catheter diameter
site. Very small and superficial veins should be entered at a very will have the most effect on flow rates. The flow rate increases to
acute angle of approximately 15° to 30° (Figure 47-4C). the fourth power as the catheter’s internal radius increases. Flow
rates can be maximized by using the largest internal diameter (i.e.,
INDICATIONS smallest gauge) catheter that will fit inside the chosen vein. Large-
bore venous catheters are preferred for the highest-volume rapid
Venous puncture (venipuncture) with a needle is indicated only fluid resuscitations, particularly of viscous blood products. Flow
for the sampling of venous blood. Medications may be adminis- rates decrease as the catheter length increases. Use of the shortest
tered as a one-time dose via this technique. The risk of medication possible catheter to access the chosen vein will permit the highest
extravasation with this technique is high, and it has therefore fallen fluid infusion rates. External pressure applied to the bag of infu-
out of favor. sion solution will linearly increase the flow rate.
Venous cannulation is indicated for repeated sampling of venous
blood. It is also performed for the administration of intravenous
medications, fluid solutions, blood products, and nutritional sup- LOCATING A PERIPHERAL VEIN
port. The specific indications for peripheral venous access, central
Identifying a peripheral vein can sometimes be quite difficult.
venous access, and the various techniques of venous cannulation are
Dilating a vein (venodilation) can make a vein larger, easier to iden-
discussed below and in Chapters 48 and 49.
tify, and easier to access. These techniques are easy to perform.
Several venodilation techniques do not require any special
CONTRAINDICATIONS equipment. Place the extremity in a dependent position.15 This
Veins should not be accessed through infected skin. A vein proximal position allows gravity to decrease venous return and dilate the
to a running venous infusion should not be used for venous blood veins.16 Gently tap the skin in the area to dilate the underlying
sampling. The blood sample will be tainted or diluted by the infused veins.15,16 The exact mechanism of how this works is not known.
solution. The hole in the vein may allow blood, infused solutions, It may be due to the release of chemical mediators, stimulation of
and medications to extravasate into the surrounding tissues. nerve fibers, or a combination of both. Instruct the patient to open
Venipuncture and venous cannulation of veins in an extremity and close their hand. The muscular contractions of the forearm
with an arteriovenous fistula should be avoided. Veins in the upper muscles increase arterial inflow distally while venous outflow is
extremity that may be needed for arteriovenous fistula construction inhibited by the tourniquet.15,17–19 Try to “milk” the veins in a distal
for hemodialysis in the near future should not be punctured unless direction. Apply your fingers over the skin, press downward, and
absolutely necessary. Scarring of the vein may complicate later sur- then move the fingers distally to “milk” or back-flow the blood and
gical procedures. dilate the distal veins.15 Apply a warm compress, heat pack, warm
towel, or submerge the extremity in warm water to dilate the veins.
Be careful to not use too hot of a temperature to prevent burning
CATHETER MATERIALS the patient.
Indwelling catheters are made of flexible polymers that are less likely Several commercially available devices can be used to produce
to break or erode through the blood vessel wall than more rigid venodilation. The Esmarch Bandage is a tourniquet system used to
materials such as steel or glass. Polymer resins, Teflon, and poly- exsanguinate a limb prior to surgery. Apply it to the upper extrem-
urethane are commonly used materials. Latex-containing products ity starting proximally and wrap it distally, the reverse of applying
should be avoided due to the risk of allergic reactions. Polyurethane it to exsanguinate the extremity. It will result in blood pooling in
catheters may be weakened by alcohol-based solutions.1 Thus, such the distal veins and subsequent venodilation. The Rhys-Davies
solutions should not be infused through polyurethane catheters. Exsanguinator can also be placed proximal to distal to pool blood
All catheters are potentially thrombogenic. They should be left in distally and cause venodilation.20 This device is usually not available
place only as long as needed. Catheters impregnated with antisep- in the Emergency Department. A vacuum device was developed to
tics, such as chlorhexidine and silver sulfadiazine, are commercially aid in obtaining venous access.21,22 It was cumbersome and is also
available and may decrease the incidence of catheter-related sepsis.4 not available in the Emergency Department.
Chlorhexidine has been associated with immediate hypersensi- Topically applied pharmaceuticals can be used to dilate the dor-
tivity reactions, most commonly in persons of Japanese descent.5 sal hand veins.23–25 Topical nitroglycerine ointment has been used
Silver sulfadiazine has not been proven safe to use in sulfa-sensitive for many years. Apply 1 in. of the ointment and rub it into the skin
patients. Catheters are also available that, when immersed briefly on the dorsal hand. Use gloves while applying the ointment to pre-
in an antibiotic solution prior to insertion, allow an antibiotic to vent the side effects of a headache or hypotension to the healthcare
bind to the catheter surfaces. These catheters may reduce the risk of provider. Allow the ointment to sit for 2 minutes then completely
infection with organisms susceptible to the chosen antibiotic. wipe it off the skin. Clean any residual nitroglycerine ointment
from the skin with an alcohol swab. Identify a vein by palpation.
Topical nifedipine is an alternative, but not currently available in
FLUID-FLOW CONSIDERATIONS the United States.
Both the diameter and the length of the infusion device will affect In recent years, numerous commercial devices have become
the flow rate through the catheter. Viscous fluids (e.g., blood available to visualize veins. The VeinViewer (Christie Medical
products and albumin) will infuse more slowly than less viscous Holdings Inc., Memphis, TN) uses polarized near-infrared light
fluids (e.g., saline). These relationships can be seen in the solution from light-emitting diodes to penetrate the skin and subcutane-
of Poiseuille’s equation for ideal fluid flow through a cylindrical ous tissues.26–28 The device projects the underlying blood-filled
tube: veins onto the skin using a visible green light. The AccuVein
AV300 (AccuVein LLC, Cold Spring Harbor, NY) and the Veinlite
(π × catheter radius4 × pressure gradient along the tube) (TransLite, Sugar Land, TX) are similar devices, but handheld. The
Flow rate ∝
(8 × tube length × dynamic fluid viscosity) Venoscope (Venoscope LLC, Lafayette, LA) is a handheld device
that is also available in a neonatal version. The major drawback of

these devices is their cost.
ANESTHESIA
The use of anesthesia prior to venipuncture or venous cannulation
is much appreciated by the patient, especially if the patient is a child.
The injection of local anesthetic solution will decrease the pain of
venous access. Unfortunately, the pain of injection can be just as
uncomfortable as the venous access procedure. The application
of a topical anesthetic, such as ELA-Max (Ferndale Laboratories,
Ferndale, MI) or EMLA (Astra Zenica, Wilmington, DE), that is
designed to enhance transdermal absorption requires approxi-
mately 30 to 60 minutes to adequately anesthetize the skin and sub-
cutaneous tissues. This time delay limits their use in the Emergency
Department. Refer to Chapters 123 and 124 for a more complete
discussion of topical anesthetics.
Numerous alternative anesthesia methods can be considered.
These are rarely available or used in the Emergency Department.
Local anesthetic absorption through the skin can be enhanced to
decrease the time it takes to provide anesthesia. These methods
include using sound energy (sonophoresis), electrical energy (ion-
tophoresis), and epidermal tape stripping.29–31 A portable, hand- A
held laser used prior to the application of topical anesthesia for
5 minutes effectively reduces the pain of venous access.32,37 Topical
vapocoolant spray will briefly anesthetize the skin long enough to
allow for venous access.33–35 Local anesthetic patches that are heat
activated to increase transdermal absorption of the local anesthetic
agent in approximately 20 minutes have been found to be effective.36
Needleless jet injections of local anesthetics effectively anesthetize
the skin and subcutaneous tissues.38–40 One study questioned if the
anesthesia was due to the local anesthetic agent or the jet injec-
tion procedure itself as the placebo group was just as effective in
terms of anesthesia.39 The main advantages of these techniques,
compared to injectable anesthetics, are the lack of pain during the
application and the lack of tissue distortion making identification
of the vein difficult.
VENIPUNCTURE
Five types of devices are used for vascular access (Figure 47-5).
There are numerous variations of these devices. The butterfly nee-
dle and hollow needle are used for venipuncture. Blood may be
FIGURE 47-6. The butterfly-type needle. A. Butterfly needle with attached exten-
sion tubing. B. The wings of the catheter are folded together and used to direct the
needle into the superficial vein. The needle may be secured within the vein and
used as an infusion cannula or removed after blood samples are collected.
withdrawn using a butterfly-type needle (Figure 47-6) or a standard

hypodermic needle. The butterfly needle, attached to a short length
of plastic tubing, allows for greater control while accessing small and
superficial veins. It is often too short to reach deeper veins. Versions
with an integral sheath to minimize accidental needlestick injuries
are available (Figure 47-7A).
Venous blood sampling can be accomplished by one of several
methods. Blood may be allowed to drip from the open end of the
butterfly extension tubing into small-volume collection tubes for
FIGURE 47-5. Venous access devices. From top to bottom: butterfly needle with pediatric patients. Some form of suction is used to withdraw the
extension tubing, hollow needle, catheter-over-the-needle, catheter-through-the- blood more rapidly in older children and adults. A syringe or a vac-
needle, and the wire-guided catheter. uum tube may be used (Figure 47-8). Vacuum tubes reduce the risk
FIGURE 47-8. The Vacutainer. Once the needle is inserted into the vein, a
B Vacutainer adapter is connected to the female Luer hub. Specimens can be col-
lected into different types of vacuum tubes without the risk of an accidental needle
stick. However, the suction applied by the vacuum tube, unlike a syringe, cannot be
FIGURE 47-7. Needle stick prevention devices. A. Butterfly needle with an
controlled and may cause hemolysis and/or a small vein to collapse.
integral needle sheath. The left figure demonstrates the sheath retracted and
the needle exposed. The right figure demonstrates the needle safely sheathed.
B. The spring-loaded catheter-over-the-needle system. The top figure demon-
strates the catheter-over-the-needle. The bottom figure demonstrates the needle
inside the safety handle. used for central venous access. The major advantages and disadvan-
tages of each technique are summarized in Table 47-1.
Identify the vein to be cannulated and the site of the skin punc-
of needlestick injuries. The amount of suction provided is fixed and ture. Clean the area of any dirt and debris. Cleanse the skin with
may result in hemolysis of the specimen and cause small veins to isopropyl alcohol, chlorhexidine solution, or povidone iodine
collapse. Syringe aspiration allows greater control over the amount solution and allow it to dry. Apply a tourniquet to the extrem-
of suction applied. Large syringes can be difficult to manipulate ity, proximal to the venous cannulation site, to engorge the vein.
while maintaining the tip of the needle within the vein. Use a 5 to Additional engorgement of the vein or the use of a device to locate
10 mL syringe, as larger syringes result in hemolysis of the specimen a vein, both described previously, can aid in the identification of
and collapse of the vein. Use caution, as the needle used to transfer a peripheral vein. Do not attempt cannulation if the vein can-
the specimen from the syringe to the laboratory tubes can cause a not be seen, palpated, or otherwise visualized (e.g., ultrasound)
needlestick injury. in the engorged state. Place a small subcutaneous wheal of local
anesthetic solution, or some other previously mentioned alter-
VENOUS CANNULATION TECHNIQUES native, at the skin puncture site to provide some comfort to the
patient. The next step is to cannulate the vein by one of the meth-
There are four main techniques of vein cannulation.6–8 The first is ods described below.
the needle-only technique using a butterfly-type needle. This is sel-
dom used today. The catheter-over-the-needle technique is the one NEEDLE-ONLY TECHNIQUE
most commonly used for peripheral venous cannulation. The cath-
eter-through-the-needle technique is occasionally used but not very This technique is used occasionally for short-term venous access in
popular. The Seldinger wire-guided technique is most commonly young children and elderly patients with fragile veins. This system is
TABLE 47-1 Features of Venous Catheterization Techniques

Butterfly needle Catheter-over-the-needle Catheter-through-the-needle Seldinger
Diameter of vein punctured Same Slightly smaller Larger Smaller
compared to catheter diameter
Catheter length compared to needle Same Slightly shorter Longer, up to 61 cm (24 in) Unlimited
Speed of insertion Rapid Rapid Slower Slowest
Risk of extravasation Highest Low, higher with shorter catheters Low Very low
Security of catheter with Lowest Fair to good Good Excellent when
patient movement sutured
Best choice for Peripheral venous Peripheral venous infusion Central venous access Central venous access
sampling
Can change catheter without No Can use small wire and No Yes
new venous puncture? Seldinger technique
prone to malposition and infiltration. The tip of the needle can eas- CATHETER-OVER-THE-NEEDLE TECHNIQUE
ily lacerate the vein if the needle is not secure and allowed to move.
Grasp and fold the wings of the butterfly needle with the domi- The catheter-over-the-needle systems are the ones most commonly
nant index finger and thumb (Figure 47-6B). Briskly insert the used for venous access. The infusion catheter fits closely over a
needle, with the bevel facing upward, through the skin and into hypodermic needle. The needle and the catheter are advanced as
the vein.14 A flash of blood will be seen in the tubing when the tip a unit into the vein. These devices are inexpensive (about $1-4
of the needle enters the vein. Carefully advance the needle an addi- each), come in a variety of diameters (12- to 24-gauge) and lengths,
tional 3 to 5 mm into the vein. Attach a 5 mL syringe to the exten- and are widely available. Versions designed to minimize acciden-
sion tubing and aspirate blood. The flow of blood into the syringe tal needlestick injuries are available and their use is encouraged
confirms proper intravascular placement of the needle. Remove (Figure 47-7B).9
the tourniquet from the extremity. Securely tape the wings of the Insert the catheter-over-the-needle, with the bevel facing upward,
butterfly needle to the patient’s skin. Remove the 5 mL syringe, through the skin and into the vein (Figure 47-9A).14 A flash of blood
attach intravenous tubing to the catheter, and begin the intrave- in the hub of the needle confirms that the tip of the needle is within
nous infusion. the vein. Advance the unit an additional 2 to 3 mm to ensure that
FIGURE 47-9. The catheter-over-the-needle technique. A. The vein is punctured and blood returns in the needle hub. B. The catheter is advanced over the needle and
into the vein. C. The needle is removed. D. Intravenous extension tubing is attached to the catheter.
FIGURE 47-10. Pitfalls of the catheter-over-the-needle technique. A. Through-and-through puncture of the vein. B. The catheter can push the vein off the needle and pre-
vent cannulation. C. Push a finger into the skin distal to the puncture site and pull back (arrow) to keep the vein straight and prevent it from moving. D. The nondominant
thumb is used to pull the skin and stabilize the vein.
the catheter is within the vein. Hold the hub of the needle securely. CATHETER-THROUGH-THE-NEEDLE TECHNIQUE
Advance the catheter over the needle until its hub is against the skin
(Figure 47-9B). Apply pressure, with the nondominant index fin- As opposed to the over-the-needle approach, this technique
ger, over the skin above the catheter to prevent blood from exiting eliminates the need for a needle that is as long as the catheter and
the catheter. Remove the tourniquet from the extremity. Securely eliminates the possibility of pushing the vein off the end of the nee-
hold the hub of the catheter against the skin. Withdraw the needle dle when the catheter is advanced.10 This system is used most com-
(Figure 47-9C). Attach intravenous tubing to the hub of the catheter monly for central, rather than peripheral, venous access. Catheters
and begin the infusion (Figure 47-9D). Secure the catheter to the up to 61 cm (24 in) long are available and allow central venous
skin with tape. access from the antecubital vein or the femoral vein. Select a cath-
Placement of these catheters is usually quick and simple. Several eter size that is appropriate for the patient and the site of entry.
considerations should always be kept in mind when using the Packaged with each catheter are a needle and a needle guard. The
catheter-over-the-needle technique. Intravascular placement of the needle will have an inner diameter that is slightly larger than the
system is indicated by a flash of blood in the hub of the needle. If outer diameter of the catheter. The needle guard has a beveled
the patient’s venous pressure is very low or if the needle is long channel in which the needle can reside. The needle guard hinges
and narrow, both sides of the vessel may be traversed (i.e., through- closed over the needle to hold it securely and prevent the needle
and-through) before the practitioner realizes that the needle was from shearing the catheter. Holes in the corners of the needle guard
within the vein (Figure 47-10A). If the tip of the needle has with- allow it to be sewn to the patient’s skin.
drawn from the vein, the catheter will not advance. If the catheter Place the needle on a tuberculin syringe. Insert the needle, with
is advanced when the tip of the needle but not the catheter is within the bevel facing upward, through the skin and into the vein while
the vein, the catheter will not advance. The catheter will push the applying negative pressure to the syringe (Figure 47-11A).14 A flash
vein off the needle (Figure 47-10B). Place a finger just distal to of blood in the syringe confirms that the tip of the needle is within
the puncture site. Depress the skin and pull it distally to prevent the the vein. Advance the needle an additional 2 mm to ensure that the
vein from “rolling” as the catheter-over-the-needle is inserted into tip of the needle is completely within the vein. Grasp and hold the
the vein (Figures 47-10C & D). needle securely with the nondominant hand. Remove the syringe
the venous circulation. This can be prevented by not withdrawing

the catheter through the needle and applying the needle guard
immediately after the needle is withdrawn from the skin. The
contaminated needle must be handled to some extent, creating a
potential risk for a needlestick injury. The needle used for the veni-
puncture must be larger in diameter than the catheter. This limits
the practical diameter of the catheter. The needle punctures a hole
in the vessel larger than the catheter and increases the risk of hema-
toma formation.
SELDINGER TECHNIQUE
First described by Seldinger in 1953, this technique allows for
the placement of a catheter over a wire rather than directly over a
needle.11,12 The wire used must be longer than the catheter. The needle
used to insert the wire can be short and of a smaller gauge than the
catheter. If desired, the catheter type may be changed later without
the need for a new venous puncture. Materials needed for catheter
insertion are commercially available in a prefabricated kit (Teleflex
Medical, Cleveland, OH; Cook Medical Inc., Bloomington, IN).
The Seldinger technique is most commonly used for central
venous catheter insertion. It can be used for peripheral venous
access if a short, thin guidewire is available. Ultrasound may be
a useful adjunct with this technique.13 Please refer to Chapter 50
regarding ultrasound-guided vascular access for a complete discus-
sion. All-in-one arterial line kits are commercially available. They
are intended for peripheral arterial line placement but can also be
used to place catheters in peripheral veins, the brachial veins, and
the external jugular veins.
The Seldinger technique for venous catheter insertion is described
briefly here. Refer to Chapter 49 (central venous access techniques)
for a more complete discussion. Choose the puncture site. Prepare
the patient for the procedure. Clean and prepare the puncture site
as previously described. The vein may first be located with a small
“finder” needle if there is doubt about its exact location. Insert a 25
or 27 gauge needle attached to a 5 mL syringe, with the bevel facing
upward, through the skin. Advance the needle while applying nega-
tive pressure to the syringe. A flash of blood signifies that the tip of
the needle is within the vein. Note the depth and location of the vein
FIGURE 47-11. The catheter-through-the-needle technique.9,11 A. The vein is based on the depth and direction of the “finder” needle.
punctured with the needle. B. The syringe has been removed. The catheter is Insert the thin-walled introducer needle while applying negative
inserted through the needle and into the vein. C. The needle is withdrawn over the pressure to the syringe. The introducer needle has a tapered hub on
catheter and completely outside the skin. D. The needle guard is attached to secure the proximal end to guide the wire into the needle lumen. Avoid
the needle and prevent it from shearing the catheter. using a standard hypodermic needle, as it does not allow for the
passage of the guidewire. A flash of blood in the needle hub signi-
fies that the tip of the needle is within the vein (Figure 47-12A).
with the dominant hand. Immediately place the nondominant Advance the needle an additional 1 to 2 mm into the vein. Hold the
thumb over the needle hub to prevent air from entering the vein. needle securely in place and remove the syringe.
Remove the tourniquet from the extremity. Occlude the needle hub with a sterile gloved finger. This will
Insert the catheter through the hub of the needle (Figure 47-11B). prevent air from entering the venous system. Insert the guide-
Advance the catheter through the needle until the desired length of wire through the hub of the needle (Figure 47-12B). Advance it
catheter is within the vein. If the catheter will not advance, remove to the desired depth, ensuring that it is at least several centime-
the catheter and needle as a unit. Never withdraw the catheter ters beyond the beveled end of the needle. To prevent loss of the
through the needle. The sharp bevel of the needle may cut the wire into the venous circulation, never let go of the guidewire
catheter as it is being withdrawn and result in a catheter embo- with both hands at the same time. Hold the guidewire securely
lism in the central venous circulation. in place. Remove the needle over the guidewire (Figure 47-12C).
Withdraw the needle over the catheter (Figure 47-11C). Do not Make a small nick in the skin adjacent to the guidewire with a
allow the catheter to be withdrawn through the needle. Continue #11 scalpel blade (Figure 47-12D). Direct the sharp edge of the
to withdraw the needle until the tip is completely outside the skin. scalpel blade away from the guidewire to prevent nicking the
Apply the needle guard over the needle (Figure 47-11D). Attach guidewire.
intravenous tubing to the hub of the catheter and begin infusing Place the dilator over the guidewire. Advance the dilator over
fluids through the catheter. Secure the catheter and needle guard to the guidewire to enlarge the subcutaneous passage for the catheter.
the skin with tape and/or sutures. Continue to advance the dilator until its hub is against the skin.
The main disadvantage of this technique is the possibility of the Withdraw the dilator over the guidewire while leaving the guide-
needle tip shearing off the catheter, causing a catheter embolism in wire in place. Advance the catheter over the guidewire until its hub
FIGURE 47-12. The Seldinger technique. A. The vein is punctured by the needle and blood is aspirated. B. The syringe has been removed. The guidewire is inserted
through the needle and into the vein. C. The needle is withdrawn over the guidewire. D. The skin puncture site is enlarged to permit catheter passage. E. The catheter is
advanced over the guidewire and into the vein. F. The guidewire is withdrawn through the catheter.
is against the skin (Figure 47-12E). A twisting motion of the cath- COMPLICATIONS
eter may aid in its advancement through the subcutaneous tissues
and into the vein. Securely hold the hub of the catheter. Remove the Complications specific to each technique and site are discussed
guidewire through the catheter (Figure 47-12F). more fully in the following chapters. Venous catheters should be
Aspirate blood from the catheter with a syringe to confirm assessed immediately after their placement and also be reassessed
intravenous placement. Flush the catheter with sterile saline or frequently. The assessment must include the skin puncture site,
begin an infusion. Secure the catheter to the skin with sutures and catheter function, the extremity distal to the catheter, and the
tape. While this technique seems complicated at first glance, it is patient’s overall condition. Some of the common problems are
easy to learn and can be performed in a few minutes by an experi- noted in Table 47-2. Other specific complications of peripheral
enced Emergency Physician. and central venous access are discussed in the following chapters.
TABLE 47-2 Complications of Venous Catheterization

Observation Complications Errors in technique Response
Skin puncture site Immediate swelling Hematoma Laceration or through-and-through Remove catheter, apply pressure
puncture
Skin puncture site Delayed swelling Extravasation or hematoma Catheter dislodged or damaged, Remove catheter, apply pressure
vein lacerated
Skin puncture site Erythema or discharge Infection Catheter in place too long, catheter Remove catheter, give parenteral
or skin contaminated antibiotics
Catheter Cannot infuse Thrombosis or kinking Catheter not flushed enough, Flush catheter, check position,
catheter not secured properly remove catheter
Catheter Blood runs up Arterial placement Arterial puncture not recognized Remove catheter, apply pressure
IV tubing
Catheter Cannot aspirate from Extravascular placement Not enough catheter inserted; Change catheter over a wire
proximal lumens of or migration of proximal patient movement; catheter if distal port is intravascular
multilumen line lumens not properly secured
Systemic Fever Line sepsis Catheter left in place too long Remove catheter once infection
or contaminated is verified
Systemic Hemodynamic Pneumothorax, pericardial Pleura punctured during insertion; Chest radiograph, auscultate chest;
or respiratory tamponade catheter tip malpositioned pericardial or pleural drainage
compromise
SUMMARY venous engorgement.2 These maneuvers can be used to aid in the

identification of a peripheral vein.
Venous access is an essential skill for all providers of care to The connective tissue surrounding veins can be a help or a
the acutely ill and injured. As with most procedures, success hindrance during attempts at gaining peripheral venous access.
rates increase and complication rates decrease with experience. Deficient connective tissue permits the vein to “roll” from side to
Successful venipuncture or cannulation is not the end of the pro- side and evade the needle. Tough connective tissue can impede the
vider’s obligation to the patient. Frequent reassessment of the entry of a flexible catheter through the soft tissues and into the vein.
venous access site, the equipment, and the patient is essential to This tissue also serves to stabilize the vein and prevent its collapse.
prevent complications. Venous valves are an important aspect of peripheral venous anat-
omy (Figure 48-2).1 Venous valves encourage unidirectional flow
of blood back to the heart. Because of gravitational forces, they pre-
vent blood from pooling in the dependent portions of the extremi-
Venipuncture ties. Valves can impede the passage of a catheter through and into a
48 and Peripheral
vein. Forcing a catheter past venous valves may damage them and
contribute to later venous insufficiency. Valves are more numerous
at the points where tributaries join larger veins and in the lower
Intravenous Access extremities. Valves are almost totally absent within the large central
veins and the veins of the head and neck.
Daniel Belmont Veins can be subdivided into central veins and peripheral veins.
The important central veins with regard to venous access are the
INTRODUCTION internal jugular, subclavian, and femoral veins. Central veins are
Puncture of a peripheral vein is the most common invasive pro- usually larger than peripheral veins and have fewer tributaries.
cedure performed in the Emergency Department. While some Superficial peripheral veins are generally visible beneath the sur-
newer point-of-care testing techniques require only capillary face of the skin of the extremities and neck. They are often tortu-
blood, the vast majority of laboratory studies require venous blood. ous and continually merge and divide. Peripheral veins are easiest
Cannulation of a peripheral vein is performed on a daily basis and to access at the apex of the “Y” formed when two tributaries merge
is the cornerstone of circulatory resuscitation. It is an essential skill into a larger vein or where the vein is straight and free of branches
for all emergency personnel, from phlebotomists to nurses to the (and hence valves) for 2 cm or more proximal to the site of punc-
Emergency Physician. A variety of approaches for obtaining periph- ture (Figure 48-3). These sites tend to be anchored and hence “roll”
eral venous access are described in this chapter. less than other sites. The superficial veins of the upper extremity
are preferred to those of the lower extremity for peripheral venous
access. Indwelling catheters in the upper extremity interfere less
ANATOMY AND PATHOPHYSIOLOGY with patient mobility, and they pose a lower risk of phlebitis.2 The
Veins and arteries are composed of a three-layered wall of internal superficial veins of the extremities are shown in Figures 48-4 &
endothelium surrounded by a layer of muscle then a layer of con- 48-5. The veins most commonly used for venipuncture and venous
nective tissue (Figure 48-1).1 The muscular layer of a vein is much access are the basilic and cephalic veins as well as their branches and
thinner and weaker than that of an artery. While veins can dilate and tributaries (Figure 48-4). The veins of the dorsal foot and the distal
constrict somewhat on their own, they do so mostly in response to saphenous veins are the most commonly used veins in the lower
the pressure within them. Veins with high internal pressures become extremity (Figure 48-5).
engorged and are easier to access. The use of venous tourniquets, The depth of the vein beneath the epidermis will affect the ease
dependent positioning, “pumping” via muscle contraction, and the with which it may be accessed. Very superficial veins are often
local application of heat or nitroglycerin ointment all contribute to small, fragile, and easily passed “through-and-through” with a
CHAPTER 48: Venipuncture and Peripheral Intravenous Access 297
A Nerve of B Vasa
blood vessel Adventitia Nerve vasorum
Vasa Tunica media
vasorum
Tunica intima
External Nonstriated
elastic lamina myocytes
in media
Lumen Muscular artery
Nonstriated
myocytes
Internal
in media
elastic lamina Vein
Endothelium of
tunica intima
FIGURE 48-1. Comparative anatomy of an artery and a vein. A. The generic blood vessel. B. A muscular artery. C. A vein. Note the vein’s thinner wall with fewer myocytes
and elastic fibers. This is indicative of the lower pressure within veins compared to arteries.
needle, resulting in a hematoma. The deeper veins are often not vis- The upper extremity is preferred to the lower for venous can-
ible and must be located by surface landmarks and palpation. The nulation, and distal placement should be attempted before moving
angle of insertion of the needle must be varied depending on the proximally.3 Avoid veins overlying a joint if possible. Adherence to
depth of the vein being punctured (Figure 48-6). A shallow angle these simple principles will allow the patient maximum mobility
of approximately 30° to 45° should be used for small and superficial
veins (Figure 48-6A). A more obtuse angle of approximately 60°
should be used to access deeper veins (Figure 48-6B). This angle
allows the vein to be penetrated within a reasonable horizontal dis-
tance from the skin puncture site. Very small and very superficial
veins should be entered at a very acute angle of approximately 15°
to 30° (Figure 48-6C). Cephalic vein
Basilic
vein
Accessory
cephalic vein
Median cephalic
vein
Cephalic
vein
Median
antebrachial vein
FIGURE 48-3. Preferred vein entry points. Preferred sites (open circles) are at the
FIGURE 48-2. Venous valves. Cross section of converging veins demonstrating the apex of converging veins or in the middle of a long straight vein. Sites just distal to
valve leaflets that permit only forward flow, proximally, toward the right heart. The branching or convergence of veins (red ⊗) are best avoided due to the presence
arrows represent the directional flow of blood. of valves and the difficulty in threading a cannula.
A
A
Cephalic vein
Median cubital Great

vein Popliteal
Basilic vein saphenous
vein
vein
Accessory Small
cephalic vein Patella saphenous
vein
Cephalic vein Median vein

of forearm
Basilic Cephalic
vein vein Lateral Medial
malleolus malleolus
Dorsal
venous arch
Metacarpal FIGURE 48-5. Superficial veins of the lower extremity. A. Anterior surface.
veins B. Posterior surface.
Dorsal digital
veins
forearm, hand, and median nerve. The deep brachial veins may
be used when superficial veins have been destroyed by scarring
B due to intravenous drug abuse, chemotherapy, or prior infusions.
The location and cannulation of the brachial veins can be aided
through the use of ultrasound.6
FIGURE 48-4. Superficial veins of the upper extremity. A. Volar surface of the The neck is an important potential site for peripheral venous
upper extremity. B. Dorsal surface of the hand and wrist.
access through the external jugular vein (Figure 48-8). This vein
begins at the level of the mandible and runs obliquely across the
sternocleidomastoid muscle. It dives beneath the fascia in the sub-
and increase the chance of successfully cannulating a vein in the clavian triangle in the neck to join with the subclavian vein.5 Some
chosen extremity. Any solutions or medications infused distally can patients have two external jugular veins on one or both sides as an
extravasate and injure the surrounding tissues once a proximal vein anatomic variant. The external jugular vein has two sets of valves
has been punctured unsuccessfully. (Figure 48-8). One is located where the external jugular vein joins
It is easiest to insert a venous cannula where two tributaries merge the subclavian vein and the other is located approximately 4 cm
and form a “Y.” Choose a straight portion of vein without branches above the clavicle. These valves are not fully competent but may
to minimize the chance of hitting valves within the vein. This also prevent the passage of a guidewire or catheter.5,7
makes it easier to thread the catheter (Figure 48-3).
The deep brachial veins are variably located alongside the INDICATIONS
brachial artery, running lateral and/or medial to the artery
(Figure 48-7).4,5 The brachial veins are relatively small, deep and Peripheral venous access is indicated for venous blood sampling.
not visible, have a close relationship to the brachial artery, and are It is also performed for the administration of intravenous medica-
thus not normally accessed. It is important to prevent injury to tions, fluid solutions, and blood products. Peripheral venous lines
the brachial artery when cannulating or puncturing the bra- may be used for short-term partial nutritional support; full nutri-
chial veins. The brachial artery is the sole arterial supply of the tional support requires central venous access.
EQUIPMENT
• Alcohol swabs
• Local anesthetic solution
• 25 gauge needle
• 1 mL syringe
• Gloves
• Immobilization supplies if necessary
• 1 in. tape, waterproof or plastic
• Transparent dressing
• Tourniquet
• Desired venous access device
• Heparin/saline lock or infusion set
• Intravenous fluids
• Vacuum blood collection tubes
• Heparin
• Medicine cup
• Scissors
• Gauze roll or stockinette
PATIENT PREPARATION
Explain the procedure to the patient and/or their representative.
Obtain verbal consent for the venipuncture unless it is an emer-
gency. Select a site for the venipuncture. A site in the upper extrem-
ity is preferred. While a satisfactory vein is usually evident upon
inspection, the placement of a venous tourniquet will aid the process
greatly. It is easiest to place the tourniquet a few inches proximal to
the elbow when first trying to locate a vein in the upper extremity.
This restricts venous return from the entire extremity distal to the
tourniquet and allows rapid inspection of the entire limb. Release
the tourniquet once the site is chosen.
If difficulty is encountered in finding a vein, the use of dependent
positioning, “pumping” via muscle contraction, and the local appli-
cation of heat or nitroglycerin ointment will all contribute to venous
engorgement.2 These maneuvers can be used to aid in the perfor-
mance of a venipuncture or peripheral venous access. A device
specifically designed to identify veins may also be used. Refer to
FIGURE 48-6. The angle between the needle and the skin must be varied based Chapter 47 for a more complete discussion regarding how to locate
upon the depth and diameter of the target vein. A. A shallow angle must be used a vein.
for small and superficial veins. B. A steeper angle must be used for deeper veins. Clean the puncture site of any dirt and debris. Apply an alcohol
C. A butterfly-type needle permits the shallowest angle of entry for very small and swab, povidone iodine solution, or chlorhexidine solution to the
superficial veins. area above the identified vein and allow it to dry.8 If using povidone
iodine, wipe it off with an alcohol swab after it dries to lessen the
chance of a local skin reaction. Infiltrate a small amount of local
anesthetic solution subcutaneously, with a 25 gauge needle, over the
puncture site. Take care not to puncture the target vein accidentally.
CONTRAINDICATIONS Other methods of anesthesia are reviewed in Chapter 47. Reapply
the tourniquet.
Sclerosing solutions, vasopressors, concentrated solutions of elec-
trolytes or glucose, and chemotherapeutic agents are more safely TECHNIQUES
infused into a central vein. Peripheral venous access in an injured
extremity should be avoided, if possible, so as not to interfere with
care of the injury and venous drainage of the limb. Avoid using the
PERIPHERAL VENIPUNCTURE
veins of an upper extremity for peripheral venous access if they may Stabilize the vein with the nondominant hand (Figure 48-9). Insert
be used for the construction of an arteriovenous fistula for future the needle attached to a syringe or vacuum tube adapter, with the
dialysis. If possible, venipuncture should not be performed through bevel upward, into the vein at a 30° to 45° angle (Figure 48-6A).
infected or burned skin. Lower angles, at times nearly parallel to the skin, may be needed
A Biceps brachii
muscle
B
Cephalic Basilic
vein vein Deep
Median
brachial
nerve
veins
Cephalic Basilic
vein vein
Deep brachial
veins
Bicipital
Brachial aponeurosis Brachial
artery artery
FIGURE 48-7. The deep brachial veins. A. The deep brachial veins are located deep to biceps tendon and muscle and adjacent to the brachial artery. B. Cross section of
the arm 2 cm above the elbow. Note the two deep brachial veins, one on each side of the brachial artery.
Retromandibular
vein
Superficial Facial vein
temporal vein
Platysma muscle
Anterior jugular vein
Sternocleidomastoid
muscle
Posterior
auricular vein
Subclavian vein
External Posterior external Clavicle

jugular vein jugular vein
FIGURE 48-8. The external jugular veins. The anterior external jugular vein is usually larger than the posterior and runs deep to the platysma muscle. Note its relationship
to the internal jugular vein. Valves (noted by the ⊗) are normally present in the external jugular vein where it enters the subclavian vein and approximately 4 cm superior
to the clavicle.
FIGURE 48-9. Stabilization of the vein during venipuncture. A. Without stabilization, the vein may kink or roll away from the tip of the hypodermic needle. B. Gentle
stabilizing pressure with the operator’s fingertip allows entry into the vein, as shown in (C).
to enter very narrow or superficial veins. This is easiest to achieve vein will often have been punctured through-and-through
with a butterfly-type needle (Figure 48-6C). Apply negative pres- (Figure 48-10B), and the specimen will be obtained as the nee-
sure to the syringe. A flashback of blood in the hub of the needle dle is withdrawn (Figure 48-10C). If no blood is obtained by
indicates that the tip of the needle is within the vein. Pulsatile blood the time the needle is withdrawn to just beneath the skin, redi-
that pushes back the syringe plunger indicates an arterial puncture. rect the needle and make another attempt at puncturing the vein.
Unless venous blood is specifically needed for a test, collect the Before redirecting the needle, it must be withdrawn to just beneath
necessary samples before removing the needle. No additional harm the skin. Never sweep the point of the needle around without
will be done by withdrawing a blood sample from an artery that has withdrawing it, as the sharp bevel of the needle can lacerate
already been punctured. nearby structures. If swelling develops, indicating a hematoma
If no blood is obtained, slowly advance the needle until it is formation, remove the tourniquet and apply direct pressure for
deeper than the judged depth of the vein. Apply negative pres- several minutes. Search for another venous access site. Accidental
sure to the syringe and slowly withdraw the needle. Occasionally, peripheral arterial punctures should have direct pressure applied
the advancing needle can collapse a vein (Figure 48-10A). The for at least 5 minutes.
FIGURE 48-10. Through-and-through puncture of the vein.

A. The tip of the hypodermic needle can collapse the vein,
preventing a flashback of blood in the syringe. B. The vein may
then be punctured through-and-through without the operator’s
knowledge. C. Slow withdrawal of the needle permits the vein
to open, and blood returns into the syringe.
FIGURE 48-11. The catheter-over-the-needle technique. A. The vein is punctured

and blood returns in the needle hub. B. The catheter is advanced over the needle
and into the vein. C. The needle is removed. FIGURE 48-12. Advancing the catheter-over-the-needle. A. Drop the catheter hub
toward the skin, then advance the catheter-over-the-needle 2 to 3 mm into the
vein. B. If it is advanced at the original angle to the skin, the far wall of the vein
may be punctured. C. If the catheter is advanced over the needle as soon as the
vein is entered, the catheter may push the vein off the end of the needle, resulting
PERIPHERAL INTRAVENOUS CANNULATION in unsuccessful venous cannulation.
Cannulation of a vein begins with a successful venipuncture with
the desired device, as described above. This section focuses on the
use of the catheter-over-the-needle technique of peripheral venous needle until its hub is against the skin (Figure 48-11B). Securely
access, as it is the most commonly used method. hold the hub of the catheter against the skin. Withdraw the needle
Insert the catheter-over-the-needle through the skin and into (Figure 48-11C). Apply pressure, with the nondominant index fin-
the vein (Figure 48-11A). A flash of blood in the hub of the needle ger, over the skin above the catheter to prevent blood from exiting
confirms that the tip of the needle is within the vein. Advance the the catheter (Figure 48-13A).
catheter-over-the-needle an additional 2 to 3 mm to ensure that While applying digital pressure over the catheter, apply a device
the catheter is within the vein. An alternative is to drop the hub of or intravenous tubing to the hub of the catheter. A syringe or vac-
the needle nearly parallel to the skin before advancing the catheter- uum device may be attached to the catheter to draw blood samples
over-the-needle (Figure 48-12A). This will prevent the needle from (Figure 48-13B). Intravenous tubing can be attached to the cath-
puncturing the far wall of the vein (Figure 48-12B) and the catheter to begin a fluid infusion (Figure 48-13C). A saline or heparin
eter from pushing the vein away from the needle (Figure 48-12C). lock may be attached to the catheter to be used later for intravenous
Hold the hub of the needle securely. Advance the catheter over the access (Figure 48-13D).
FIGURE 48-13. Peripheral intravenous cannulation. A. Apply gentle pressure over the catheter with a gloved finger to prevent hemorrhage from the catheter hub. B. Blood
samples may be withdrawn from the cannula via a syringe or vacuum tubes. C. Intravenous infusion tubing is attached to the catheter. D. A saline (heparin) lock is attached
to the catheter.
Secure the intravenous catheter to the skin (Figure 48-14). There a feed tube, and a lever to advance the guidewire (Figure 48-15).
are numerous methods to tape the catheter to the skin; only a few The black mark on the feed tube is a reference mark. The tip of the
are described here. Place a 2 in. piece of adhesive tape sticky side up guidewire is positioned at the tip of the needle when the advance-
under the catheter hub (Figure 48-14A). Fold the ends of the adhe- ment lever is at the reference mark. The unit is also available
sive tape over the catheter and onto the skin to form a “chevron” without the catheter-over-the-needle as the Positive placement
(Figure 48-14B). Alternatively, fold the adhesive tape to form a “U” Spring-Wire Guide (Arrow International, Bloomington, IN). It
(Figure 48-14C). Apply a 2 in. piece of adhesive tape over the cathe- can be attached to a standard stock catheter-over-the-needle. A
ter hub (Figure 48-14D). Place a transparent dressing over the cath- similar device is The WAND (Access Scientific, San Diego, CA).
eter hub and distal intravenous tubing (Figure 48-14E). Some prefer The integral guidewire and soft, 2 in. long, 20 gauge catheter
to use the transparent dressing without the adhesive tape. The cath- found in the QuickFlash set can ease the process of catheterization
eter may be sutured to the skin when vascular access is essential and considerably. The depth of the deep brachial vein combined with
when the catheter may be pulled out by a young child or combative the overlying skin (which is often scarred from previous venipunc-
patient. It is very rare that a peripheral intravenous catheter must be tures) makes catheterization with the usual 1¼ in catheter difficult.
sewn into place. The external jugular vein is quite mobile, and the overlying tissues
are fairly tough. This can make it quite difficult to thread an over-
ALTERNATIVE TECHNIQUES the-needle catheter into the vein without pushing the vein off the
end of the needle.
Select a vein to cannulate. Clean and prep the skin overlying the
ARTERIAL LINE KIT
puncture site. Place a tourniquet on the extremity. Open the package
The modified Seldinger technique, used with a QuickFlash radial and remove the unit. Advance the guidewire through the needle and
artery catheterization set (Arrow International, Bloomington, IN), then retract it. Do not use the catheterization unit if the guidewire
is very useful for the catheterization of deep brachial and exter- does not advance and retract smoothly. Ensure that the guidewire
nal jugular veins. The unit is commonly available in Emergency advancement lever is retracted as far as possible so that the guide-
Departments and Intensive Care Units. It consists of a one-piece wire is not within the needle. The flashback of blood will not be
unit that incorporates a catheter-over-the-needle, a guide-wire in seen if the guidewire is not fully retracted and out of the needle.
FIGURE 48-14. Securing the intravenous catheter. A. Place a narrow strip of adhesive tape sticky side up under the catheter hub. B. Fold the tape over the catheter to
form a “chevron.” C. Alternatively, the tape with the sticky side up can be folded to form a “U.” D. A second piece of tape is applied to better secure the catheter to the skin.
E. A transparent dressing is applied over the catheter.
Stabilize the vein with the nondominant hand. Insert the as far as possible into the vein. The advancement lever must be
catheter-over-the-needle through the skin and into the vein distal to the reference mark to ensure that the guidewire is past
(Figure 48-16A). A flash of blood in the hub of the needle indi- the tip of the needle. Stop advancing the guidewire if resistance
cates that the tip of the needle is within the vein. Hold the needle is encountered. Do not force the guidewire against resistance.
hub securely. Advance the guidewire, using the advancement lever, Do not retract the guidewire if resistance to advancement is
into the vein (Figure 48-16B). Continue to advance the guidewire encountered. Doing so may damage the vein or shear off a piece
of the guidewire. Withdraw the entire unit and repeat the pro-
cedure with a new unit.
Advance the guidewire as far as possible into the vein. Advance
the catheter-over-the-needle an additional 1 to 2 mm into the vein.
This will ensure that the tip of the catheter is within the vein. Hold
the hub of the needle securely. Advance the catheter over the needle
and guidewire until its hub is against the skin (Figure 48-16C). A
twisting motion may help to advance the catheter against resistance.
FIGURE 48-15. The Arrow QuickFlash radial artery catheterization set. Note the Release the tourniquet. Hold the catheter hub firmly against the
different positions of the guidewire. The guidewire is within the feed tube (top). skin. Remove the needle and guidewire, through the catheter, as a
The tip of the guidewire is at the tip of the needle when the advancement lever is unit. Attach a syringe, vacuum blood collection system, intravenous
at the reference mark (middle). The guidewire is advanced through the catheter- line, or saline (heparin) lock onto the catheter hub. Secure the cath-
over-the-needle (bottom). eter with adhesive tape.
FIGURE 48-16. The Arrow QuickFlash radial artery catheterization set. A. The vein is punctured and blood returns into the hub of the needle. B. The guidewire is advanced
into the vein. C. The catheter is advanced over the needle and guidewire with a back-and-forth rotating motion. The needle and guidewire are then removed as a unit.
EXTERNAL JUGULAR VEIN CANNULATION DEEP BRACHIAL VEIN CANNULATION

Place the patient in the Trendelenburg position to distend the Extend the patient’s arm. By palpation, identify the brachial artery
external jugular vein. Turn the patient’s head to the opposite side. pulse in the antecubital fossa. Clean and prep the skin of the ante-
This will gently stretch the vein and prevent it from rolling. Clean cubital fossa. Place a tourniquet on the upper arm. Reidentify the
and prep the skin of the neck. Place the nondominant thumb brachial artery pulse. Place a 2 to 3 in. long catheter-over-the-
or index finger above the midportion of the clavicle to obstruct needle onto a 5 mL syringe and insert it just medial or lateral to
outflow and distend the external jugular vein. Align the catheter- the brachial artery pulse and at a 30° to 45° angle to the skin with
over-the-needle parallel to the vein with the bevel of the needle the tip of the needle pointing cephalad. Advance the catheter-
upward and the tip of the needle pointing toward the clavicle. over-the-needle while applying negative pressure to the syringe.
Enter the vein midway between the angle of the mandible and A flash of blood in the syringe indicates that the vein has been
the midclavicle. Insert the catheter-over-the-needle during inspi- entered. If a flash is not seen, slowly withdraw the catheter-over-
ration, when the valves of the external jugular vein are open. Be the-needle. It may have gone “through-and-through”. A flash will
sure to cover the open hub of the needle and/or catheter with a be seen as the catheter-over-the-needle is withdrawn and the tip
finger at all times to prevent an air embolism. If the vein rolls, of the needle reenters the vein. The remainder of the technique
attempt to insert the catheter-over-the-needle obliquely into the is similar to that described previously. The use of ultrasonogra-
vein. Another option is to cannulate the vein in the area where a phy can significantly improve the success rate of deep brachial
tributary joins it. These areas are often anchored in the subcu- vein cannulation. Complications include brachial artery punc-
taneous tissue. The remainder of the technique is similar to that ture, hematoma formation, loss of vascular access, and transient
described previously. paresthesias.20,21
FIGURE 48-17. Scalp vein cannulation in the neonate. A rubber band makes a convenient tourniquet.
ULTRASOUND-GUIDED process. Aside from the techniques discussed above, there are a
PERIPHERAL VEIN CANNULATION few techniques that can facilitate pediatric vascular access.12,13 The
scalp veins can be used for venous access in newborns, infants,
A deep peripheral vein, often the brachial or basilic vein, may be and children up to 1 year of age. They are most easily cannulated
cannulated under direct visualization using ultrasonography.9 with a small (i.e., 23 or 25 gauge) butterfly needle or catheter. A
Ultrasound may also be used to identify a superficial vein when rubber band can be placed about the baby’s head as a tourniquet
one is not palpable or visible. Place a tourniquet on the upper arm. (Figure 48-17). Other veins commonly used include those of the
Identify the vein by placing the ultrasound probe perpendicular to antecubital fossa, dorsal hand, dorsal foot, external jugular vein,
the vein. Identify the vein as a thin-walled, nonpulsatile, vascular and the saphenous vein at the knee or groin. For small and super-
structure. Move the probe along the vein to identify its most superfi- ficial veins, it can be helpful to place a small bend at the hub of the
cial and easiest accessed point. A catheter-over-the-needle can then catheter-over-the-needle assembly (Figure 48-18). This allows
be inserted in the vein under direct visualization.10,11 for the use of a less acute angle and easier entry into the vein
The easiest way to determine the depth of the vein is to note its without puncturing the far wall.
depth on the ultrasound screen. Move the ultrasound probe distally The best guide to the gauge or diameter of catheter to use is to
this same distance while still maintaining visualization of the vein. compare the catheter to the vein. The catheter should be at least
Insert the catheter-over-the-needle at a 45° angle and advance it slightly smaller than the vein. In practice, the smallest readily avail-
until the tip of the needle is seen on the ultrasound screen. Puncture able catheters are 24 gauge. A 22 gauge catheter will allow a much
the vein wall using a quick and short jabbing motion. Take care to higher flow rate if it can be inserted successfully.
not puncture through the posterior wall of the vein. Once the tip of Keeping a peripheral intravenous line from being pulled out
the needle is seen within the vein, advance the catheter over the nee- by an active child is quite a challenge. Each institution has its
dle and into the vein. Refer to Chapter 50 for the complete details of own “recipe” for securing pediatric IVs. The catheter is taped to
ultrasound-guided vascular access. the skin in the usual manner. Several strips of tape can be placed
to secure the tubing to the skin and act as “strain reliefs” to pre-
PEDIATRIC CONSIDERATIONS vent traction applied to the tubing from being transmitted to the
Venipuncture and peripheral venous access can be quite a chal- catheter. Half of a medicine cup can be used as a shield for the
lenge in the infant, neonate, and small child. Proper restraint catheter itself (Figure 48-19A). Apply tape over the cut edges
of the extremity with a board or an assistant will greatly aid the of the cup to prevent the sharp edges from cutting the child’s
FIGURE 48-18. Cannulation of a small superficial vein with a catheter-over-the-

needle. A. The “shoulder” of the catheter hub prevents the needle from being
placed nearly parallel to the skin. B. A slight bend at the base of the needle permits
the needle to run nearly parallel to the skin surface, enabling the subcutaneous
vein to be cannulated. Always make sure that the catheter can be advanced over
the needle before puncturing the patient’s skin.
delicate skin. The clear medicine cup acts as a window, so that

the catheterization site can easily be inspected without removing
all the dressings. The whole assembly, or just the taped intrave-
nous line, can then be covered with a gauze roll or stockinette
(Figure 48-19B). A cup with one-quarter or one-third cut away
may be used to protect a scalp vein access site (Figure 48-19C). A
splint applied to the extremity will increase the duration of intra-
venous line patency.14
ASSESSMENT
Refer to Table 47-2, in the preceding chapter, for some general
principles of intravenous line assessment. The line should flush
easily. Any infusions should flow by gravity alone. Progressive
swelling at the catheterization site indicates the formation of a
hematoma or extravasation of infused fluids. Peripheral infusions
of vasopressors and caustic solutions require the skin puncture site
to be assessed frequently and carefully, since extravasation may
lead to extensive local soft tissue necrosis. Pain at the intravenous
access site must be taken seriously and should prompt a search
for the cause. Pinched skin, extravasation, or thrombosis must be
looked for and ruled out.
AFTERCARE
Most authorities recommend changing peripheral infusion FIGURE 48-19. Securing pediatric intravenous lines. A. Use a clear plastic medi-
sites at least every 3 days, although this is probably overly cau- cine cup, cut in half lengthwise, to protect the skin puncture site. B. A stockinette or
tious.15,16 It may be impractical if the patient has poor superfi- gauze roll can be used to further protect the site from manipulation. C. Protecting
cial veins. Any cannula with signs of venous thrombosis, skin a scalp vein cannula with tape and a clear plastic medicine cup.
erythema, or puncture site discharge must be removed at once.
Heparin or saline locks that have not been accessed should be
flushed regularly, usually every 8 hours. Saline works as well as
heparin solutions for most applications.17 Approximately 1 to some studies suggesting that transparent occlusive dressings are
2 mL of sterile saline to flush is adequate for peripheral venous associated with higher rates of infection than plain gauze dress-
catheters. Heparin flushed cannulations have an increase in dura- ings.18 Transparent dressings have the advantages of allowing easy
tion of patency.12 inspection of the catheter site and holding the catheter securely
Dressings should be inspected and changed if they have become in place. Individual institutions often have their own nursing
moist or contaminated. Routine dressing changes are probably guidelines and infection control statistics to support their choice
unnecessary.17 The transparent dressings are widely used despite of dressing.
REMOVAL OF INTRAVENOUS CATHETERS SUMMARY

Turn off any intravenous infusions and clamp the tubing. Place the Venipuncture and peripheral venous access is an essential skill for
infusion site in a dependent position below the right atrium to pre- nearly all medical practitioners, from paramedics to physicians. The
vent a venous air embolism. Remove any tape and dressings from only way to become proficient at these techniques is to master them
the infusion site. Apply direct pressure to the skin puncture site with during training and to practice them regularly. Equally important is
a gauze pad. Briskly remove the catheter or needle. Hold firm direct the frequent reassessment of venous cannulas so that complications
pressure for several minutes. Apply a bandage. Instruct the patient can be detected and treated early, before they become major prob-
to check for signs of thrombophlebitis, cellulitis, and an infection for lems for the patient and the Emergency Physician.
the next several days.
COMPLICATIONS
PERIPHERAL VENIPUNCTURE Central Venous Access

The main complications of venipuncture are pain and hematoma
formation. Pain during venipuncture can be minimized by using
49 Arun Nagdev and Craig Sisson
small gauge needles, clearly identifying a vein before attempts at

venipuncture, and minimizing the number of attempts at venipunc- INTRODUCTION
ture. Hematomas and bleeding can be prevented by removing the
tourniquet before removing the needle and applying direct pressure Percutaneous cannulation of the central veins is an essential tech-
after the needle is removed. Hematomas are self-limited and easily nique for both long-term and emergent medical care. Access to the
treated with nonsteroidal anti-inflammatory drugs, cool compresses major veins of the torso allows rapid high-volume fluid resuscita-
for analgesia, and warm compresses to hasten hematoma resorption, administration of concentrated ionic and nutritional solutions,
tion. Other complications include nerve injury, usually reversible and hemodynamic measurements.
paresthesias. Arterial puncture is common with deep brachial lines Obtaining venous access is an essential skill for the Emergency
and may rarely be catastrophic if it causes thrombosis of the brachial Physician. Indications for peripheral venous access are broad, rang-
artery, the sole arterial supply of the forearm and hand.18 Infection ing from simple fluid and medication administration to delivery of
from simple venipuncture is uncommon. intravenous (IV) contrast for imaging studies. Central venous access
is less often compulsory, but still remains an indispensable proce-
dure in the practice of Emergency Medicine. Central venous access
PERIPHERAL INTRAVENOUS CANNULATION allows for multiple critical actions to be performed from the admin-
In addition to the complications described for venipuncture, istration of blood products and vasoactive medications to transve-
indwelling venous catheters pose additional risks. Some of these nous cardiac pacing. Central venous access is often undertaken in
are summarized in Table 47-2 of the preceding chapter. The steel cases where peripheral IV access cannot be obtained.
needle cannula of the butterfly needle can move easily, causing lac- Even the most experienced provider can have difficulty securing
erations of the vein and neighboring structures. The risk of infec- rapid and functional access to the venous system in specific situa-
tion is greater the longer a catheter is left in place. Intravenous tions such as severe dehydration, cardiac arrest, large body habitus,
catheters increase the risk of superficial venous thrombosis and and injection drug users with sclerosed veins. The classical “blind”
thrombophlebitis. This may be prevented by limiting catheter technique, based on anatomical and vascular landmarks, has been
manipulation during tubing changes and by using extension tub- the most commonly taught method. The growing integration of
ing at the catheter hub. Complications are more common when bedside ultrasound (US) into the practice of Emergency Medicine
the intravenous catheter is placed in the hand or forearm when has slowly changed the way Emergency Physicians are choosing to
compared to other sites.19 This may be the result of the higher fre- perform central venous access. US visualization of the patients’ vas-
quency of catheters placed in these two sites in this small study. cular anatomy allows the specific advantage of determining the ideal
It is possible to injure a number of structures in the neck during location to access the central venous circulation. A thrombosed
external jugular vein cannulation. This includes the carotid artery, femoral vein can be identified, allowing the Emergency Physician
internal jugular vein, and trachea. It is also possible to cause a to preemptively choose another site. The visualization of the overlap
pneumothorax. None of these complications should occur as long of the right internal jugular vein and the carotid artery may pre-
as deep penetration with the needle is avoided. vent inadvertent arterial puncture and the resultant sequelae in the
Extravasation of vasopressors or caustic solutions can cause local anticoagulated patient. US guidance for central venous access has
skin necrosis. Extravasation of large volumes into a muscle com- altered the clinical algorithm of obtaining vascular access, mak-
partment can lead to a compartment syndrome, although this is rare ing the procedure easier for the Emergency Physician and safer for
with superficial peripheral venous lines. Extravasation and tissue the patient.
injury may be prevented by using a small gauge catheter in a large Evidence supporting US guidance for central vascular access
vein, diluting medications before administration, and observing is fairly robust.1–5 Convincing data from the Critical Care and
intravenous access sites frequently. Emergency Medicine literature indicate an increased success rate
Infections can often be prevented by using aseptic technique and a decrease in the complication rates. Recently, the Agency for
and sterile dressings, and changing peripheral catheters every 48 to Healthcare Research and National Institute for Clinical Excellence
72 hours. The complications of peripheral nerve palsies, pressure both recommended US guidance for central venous access. The
necrosis, and compromised peripheral circulation are rare but do availability of small, low cost, and portable US machines has
occasionally occur. They can be prevented with frequent neurovas- made US guidance for central venous access a requisite skill for all
cular checks to any restrained extremity, by padding all pressure Emergency Physicians. A brief description of US-guided central
points, and by avoiding the placement of circumferential tape on venous access is discussed in the following sections as appropriate.
an extremity. Refer to Chapter 50 for the complete details.
CHAPTER 49: Central Venous Access 309
Brachiocephalic
Internal and external veins Left subclavian
jugular veins vein
Superior
vena cava
Right
atrium
Inferior
vena cava
Aorta
Anterior superior Common

iliac spine iliac vein
Inguinal
ligament Femoral
vein
Pubic
symphysis
FIGURE 49-1. The anatomy of the central venous system.
ANATOMY AND PATHOPHYSIOLOGY is essential for successful cannulation. The internal jugular vein
is a direct continuation of the sigmoid sinus and exits the skull
The tip of the central venous catheter must lie in the superior through the jugular foramen, just anteromedial to the mastoid
or inferior vena cava and never in the right atrium. The thin process.6 It joins the subclavian vein deep and just lateral to the
wall of the right atrium may easily be perforated by the catheter head of the clavicle (Figure 49-2).6 The internal jugular vein
tip, resulting in hemorrhage and cardiac tamponade. The central drains blood back to the heart from the brain, face, and neck.
venous anatomy is shown in Figure 49-1. The superior vena cava There is a proximal and distal dilatation of the vein known as
is accessed through the internal jugular veins, the subclavian veins, the superior and inferior bulbs of the internal jugular vein. The
and less commonly via the external jugular veins. The inferior vena inferior bulb contains a bicuspid valve to prevent retrograde flow.
cava is accessed through the femoral veins. These access routes are The surface projection of the internal jugular vein runs from the
discussed in greater detail in the corresponding sections below. earlobe to the medial clavicle, between the sternal and clavicu-
The advantages and disadvantages of each route for central venous lar heads of the sternocleidomastoid muscle. The internal jugular
access are summarized in Table 49-1. vein increases in diameter as it descends. It is joined by tributary
veins in the upper neck, making it easier to cannulate below the
level of the cricoid cartilage.
INTERNAL JUGULAR VEIN
The internal jugular vein is collapsible (Figure 49-3). Its overall
The internal jugular vein is not directly visible from the surface diameter is dependent on the patients’ intravascular volume status
of the skin. A thorough knowledge of its anatomic relationships as well as their position. It has a very small diameter in low-flow
TABLE 49-1 Characteristics of the Different Routes for Central Venous Cannulation
Internal jugular vein External jugular vein Subclavian vein Femoral vein
Risk of infection Low Low Low High
Patient mobility Fair Poor Good Bedridden
Trendelenburg required? Yes Yes Yes No, best for CHF or dyspnea
Need to stop CPR? Probably Probably Yes No, may continue CPR
Suitable for long-term use? Yes, but not if ambulatory No Yes—best choice No, remove within 2–3 days
Risk of venous thrombosis Low Low Low High
Facial Left common Left subclavian

vein carotid artery vein and artery
Aortic arch
Superior
vena cava
Right
brachiocephalic
artery and vein
Internal
jugular vein
FIGURE 49-2. Anatomy and surface relationships of the internal Mastoid Apex
jugular vein. process of lung
A B
FIGURE 49-3. Transverse US images of the left internal jugular vein (IJV) and
carotid artery (CA). A. The patient is supine. B. With gentle external pressure
applied, the low-pressure internal jugular vein collapses easily while the carotid
is still patent. C. The Valsalva maneuver or placement of the patient in the C
Trendelenburg position dilates the internal jugular vein.
states, as during cardiopulmonary resuscitation (CPR) and when

the patient is upright. The vein is easily compressible and will col-
lapse with gentle external pressure from a palpating finger or a large-
diameter needle indenting the skin (Figure 49-3B). Local masses
such as tumors, a goiter, and a hematoma can also easily collapse
the internal jugular vein. Fortunately, the vein is also very distensi-
ble. Placing the patient in the Trendelenburg position or having the
patient perform the Valsalva maneuver will distend the vein, mak-
ing it easier to locate and cannulate (Figure 49-3C).
Along its course, the internal jugular vein lies in close proximity
to the carotid artery, vagus nerve, phrenic nerve, brachial plexus,
cervical sympathetic plexus, thyroid gland, and the pleural cupula
of the lung. Inferiorly, the left internal jugular vein also lies in close
proximity to the thoracic duct. The location of these structures
places them at risk for injury during central venous cannulation of
the internal jugular vein.
The position of the internal jugular vein in relation to the com-
mon carotid artery within the carotid sheath can vary considerably
between individuals. The simple assumption that the internal jugu-
lar vein is always lateral to the carotid artery has not born out in
ultrasonographic studies. Overlap with the carotid artery can vary
from 0% to 100% depending on individual anatomic variation, FIGURE 49-4. Central approach to the right internal jugular vein.
patient positioning, and where along its course the internal jugu-
lar vein is imaged.7–12 It can even lie medial to the carotid artery in
some patients, making blind needle puncture nearly impossible and
extremely dangerous.7,8,12
the internal jugular vein and form the brachiocephalic trunk, which
This variability in location is mirrored by the size variability of
empties into the superior vena cava. Because the subclavian vein lies
the internal jugular vein. Between individuals, the actual and appar-
directly underneath the clavicle, US visualization of the vein is not
ent size of the internal jugular vein can vary widely for anatomic and
usually possible.
physiologic reasons. Mey et al. showed that an internal jugular vein
The subclavian veins are 1 to 2 cm in diameter in an adult. Fibrous
size of less than 0.7 cm may be an independent risk factor for unsuc-
connective tissue joins the subclavian vein to the clavicle and first
cessful venous cannulation.13 The internal jugular vein can vary in
rib, preventing collapse of the vessel even in the event of a low-flow
size and location when comparing the right to the left and the proxi-
state. Anatomically associated structures include the thoracic duct,
mal vein to the distal vein.7,10 Each of these individual factors form
which joins the left subclavian vein at its junction with the left inter-
a strong argument for ultrasonographic assistance during internal
nal jugular vein. The right subclavian vein is preferred to the left
jugular vein central line placement.
for central venous access for this reason. The domes of the pleura
The common carotid artery travels alongside the internal jugular
lie posterior and inferior to the subclavian veins and medial to the
vein and is an important anatomic landmark for locating the inter-
nal jugular vein. The carotid artery runs deep and slightly anterior
to the internal jugular vein. The left internal jugular vein usually
overlaps the carotid artery in the lower neck (Figure 49-3A). The
right internal jugular vein and the right carotid artery are usually
separated slightly.
The right internal jugular vein is generally preferred to the left
internal jugular vein as the site of central venous cannulation.
The right internal jugular vein provides a nearly direct route to
the superior vena cava. The dome of the right lung is somewhat
lower than that of the left lung and thus decreases the chance
of an iatrogenic pneumothorax. The thoracic duct is relatively
large and lies high in the left chest. These favor the right inter-
nal jugular approach to central venous cannulation to minimize
complications.
There are three main “blind” or landmark approaches to the
internal jugular vein as defined by their relationship to the ster-
nocleidomastoid muscle. These are the anterior, central, and pos-
terior approaches (Figures 49-4 to 49-6). The central approach is
most commonly used. These three approaches are summarized in
Table 49-2 and described below.
SUBCLAVIAN VEIN
The subclavian vein begins as the continuation of the axillary vein
at the lateral edge of the first rib (Figure 49-7). The subclavian vein
courses anterior to the anterior scalene muscle, which separates it
from the subclavian artery. The subclavian vein descends to join FIGURE 49-5. Anterior approach to the right internal jugular vein.
FEMORAL VEIN
Anatomically, the femoral vein is a continuation of the iliac vein
after it crosses the inguinal ligament (Figure 49-8). The femoral
vein lies within the femoral sheath and just medial to the femoral
artery in the groin. This relationship can be remembered by the
mnemonic “toward the NAVEL.” This describes, from lateral to
medial, the contents of the femoral sheath (femoral Nerve, femo-
ral Artery, femoral Vein, Empty space, and Lymphatics). The femo-
ral artery lies at the midpoint of the line connecting the symphysis
pubis and the anterior superior iliac spine.17,18 The femoral vein lies
approximately 1 cm medial to the femoral artery pulse in an adult
and approximately 0.5 cm medial in infants and young children.19,20
Recent anatomical US surveys on adult and pediatric populations
have demonstrated variation in the classical anatomical teaching.
Hughes et al. demonstrated an increased overlap between the femo-
ral vein and artery as they moved distally to the inguinal ligament.21
Warkentine et al. evaluated the amount of venous and arterial over-
lap in euvolemic children 1 cm distal to the inguinal ligament.22 They
noted that in 12% of cases, the femoral vein had either partial or
complete overlap with the femoral artery. Both these studies noted
the great variability of the vascular anatomy and recommended US
visualization before femoral venous cannulation attempts.
Classically, the puncture site for femoral vein cannulation lies
medial to the femoral artery and inferior to the inguinal ligament
FIGURE 49-6. Posterior approach to the right internal jugular vein. (Figure 49-8).17,18,23 Femoral venous cannulation should be per-
formed 1 to 2 cm inferior to the inguinal ligament (a commonly
difficult landmark in the obese patient), in order to prevent inad-
vertent intraabdominal external iliac vein puncture. The femoral
vein becomes the external iliac vein superior to the inguinal liga-
anterior scalene muscles. The subclavian arteries lie immediately ment (Figure 49-8). Blood can flow freely into the retroperito-
posterior to the veins (Figure 49-7). neal space, forming a potentially large and externally invisible
Subcutaneous fatty tissue, chest morphology, the close proxim- hematoma if the posterior wall of the femoral vein is punctured
ity of the pleura, and the close proximity of the subclavian artery by a through-and-through needle track above the inguinal liga-
make the subclavian vein the least favored site for central venous ment. It is imperative to puncture the femoral vein inferior to the
access in children. This is especially true in infants. An experienced inguinal ligament!
Emergency Physician must perform the procedure if this route must Despite the believed higher rates of line infection and thrombo-
be used in a neonate, an infant, or a small child. sis associated with femoral venous cannulation, this access remains
a popular route due to its relative ease of placement.24 A recent
AXILLARY VEIN large, randomized, multicenter study put into question the classi-
cally held notion that the femoral venous cannulations have higher
The axillary vein is defined as the continuation of the brachial vein rates of infection.25 The study did not demonstrate a higher rate of
from the medial border of the teres major to the lateral border of infection between catheter tips (a well-accepted surrogate marker)
the first rib. The axillary vein continues under the clavicle as the removed from the femoral vein and the internal jugular vein. The
subclavian vein, which then joins the internal jugular vein to form rate of catheter-related bloodstream infection between femoral
the brachiocephalic vein (Figure 49-2). Cadaver-based and radio- vein cannulation and internal jugular vein cannulation were simi-
logic studies have demonstrated a great variation in the anatomic lar (2.3% vs. 1.5%, respectively).
relationship between the axillary vein and artery.14,15 This makes
the blind or landmark technique difficult for even the most experi-
enced Emergency Physician.14,15 An US study of the axillary vein in
CENTRAL VENOUS ACCESS IN THE OBESE PATIENT
volunteers demonstrated a decreased overlap between the axillary Central venous access is more complicated in the obese patient.26
vein and artery, and a farther distance from the pleura, as it was Surface landmarks may be obscured by adipose tissue and skin
followed laterally.16 folds. The clavicle, carotid artery pulses, the thyroid cartilage, and
TABLE 49-2 Approaches to the Internal Jugular Vein

Central Anterior Posterior
Insertion landmark Superior apex of the triangle formed by the Medial edge of the sternocleidomastoid Lateral edge of sternocleidomastoid muscle,
two heads of the sternocleidomastoid muscle at the level of thyroid cartilage 1/3 of the way from the clavicle to the
muscle and the clavicle mastoid process
Angle with skin 30° (child), 45°–60° (adult) 30° (child), 45° (adult) 30°–45°, dive under the border of the
sternocleidomastoid muscle
Aim toward Ipsilateral nipple Ipsilateral nipple Sternal notch
Internal jugular vein Within 3 cm Within 3 cm Within 5 cm
depth in an adult
A
External B
jugular vein
Internal Stellate ganglion External Vertebral

jugular vein jugular vein artery
Scalenus anterior Esophagus
Brachial muscle
plexus
Internal
jugular
Subclavian Inferior trunk vein
artery of brachial plexus
Trachea
Clavicle
Subclavian Brachiocephalic
artery artery
C D Sternum
First rib
Subclavian
vein
Axillary Subclavian Pleura
vein vein
C Sternocleidomastoid D
muscle
Scalenus Sternocleidomastoid
anterior muscle muscle
Dome of Dome of
Clavicle Clavicle
pleura pleura
Subclavian Subclavian Subclavian
vein Subclavian
artery artery vein
First rib Pectoral First rib
muscles Pectoral
muscles
FIGURE 49-7. The anatomy of the subclavian vein. A. The right subclavian vein. B. Magnified view of the right subclavian vein demonstrating adjacent structures that may
be injured during attempted cannulation. C. Sagittal section through the midclavicle. Note that the first rib protects the subclavian artery during an infraclavicular approach
to the subclavian vein. D. Sagittal section through the medial third of the clavicle. Note the proximity of the subclavian artery and pleural dome to the subclavian vein.
FIGURE 49-8. Anatomy of the femoral vein.

the trachea can be difficult to palpate. This makes internal jugular CONTRAINDICATIONS
and subclavian venous access problematic. The anterior superior
iliac spine, femoral artery pulse, and the pubic symphysis can be The usual contraindications to any invasive procedure apply to
difficult to palpate. This makes femoral venous access problem- central venous access. Cellulitis or overlying infection at the punc-
atic. Femoral venous access is often performed lower than normal ture site is a contraindication to central venous access. A mass or
due to an overhanging pannus. Placing the obese patient in the hematoma causing external compression and/or obliteration of
Trendelenburg position may not be possible. They may acutely the vessel lumen, an intraluminal thrombosis, or a small size vein
decompensate in this position due to their poor pulmonary when visualized by US are also contraindications. An alternative
reserves, decreased lung and tidal volumes, increased intraab- should be sought if the patient is combative, agitated, or uncoop-
dominal pressure against the diaphragm, and difficult airway erative. These patients require sedation and/or paralysis prior to
anatomy. All these factors may increase the rate of complications insertion of the central venous line. Distorted anatomic landmarks
in the obese patient. due to fractures, deformities, obesity, previous catheterization at
the site, surgery, or trauma are relative contraindications. There is
a small but real risk of serious morbidity and even death due to the
INDICATIONS procedure. Do not place a central venous line unless a periph-
The internal jugular route is acceptable for central venous access eral IV line or an intraosseous line is inadequate or unobtain-
in most cases. It allows ready access to the superior vena cava for able and unless personnel capable of managing the procedural
long-term central venous access, caustic infusions, and monitor- complications are immediately available.
ing of central venous pressure. Pulmonary artery catheters and
transvenous pacing wires can be introduced through the right INTERNAL JUGULAR VEIN CANNULATION
internal jugular vein. The internal jugular vein is accessible with-
out terminating CPR efforts, although chest compressions and the Anatomic distortion of the neck, such as from subcutaneous emphy-
lack of carotid pulsations make accessing it difficult. The risk of sema or a hematoma, may make placement of an internal jugular
an iatrogenic pneumothorax is probably less with internal jugu- line difficult and hazardous. Known severe carotid artery stenosis
lar vein cannulation as opposed to the subclavian vein, although or atherosclerosis on the desired side of cannulation is a relative
patient mobility is less and discomfort is greater. In the coagulo- contraindication to internal jugular vein cannulation. Accidental
pathic patient, the internal jugular vein puncture site is compress- carotid artery puncture during line placement may result in plaque
ible, but a hematoma formation may lead to airway compromise. rupture and a subsequent stroke. The vein may be collapsed and
Oguzkurt et al. showed that patients historically labeled as having difficult to access in the hypovolemic patient. Other contraindica-
“difficult access” had very low complication rates using US-guided tions to cannulating the internal jugular vein include cervical spine
central venous access of the internal jugular vein.27 In this study, fractures (actual or suspected) or penetrating neck injuries. Do
27.7% (61/220) of the total procedures performed were on patients not cannulate the ipsilateral internal jugular vein if the patient has
with disorders of hemostasis. an implanted pacemaker or a defibrillator. Central venous access
The subclavian vein is the preferred route for long-term cen- can result in needle injury to the leads, lead displacement, and
tral venous access. This site allows for ambulation (unlike a thromboembolism.
femoral line) and neck movement without discomfort (unlike an The subclavian or femoral route may be preferable in some
internal jugular line). The catheter is concealable under clothing, circumstances. The subclavian route is probably a better choice
making outpatient use more acceptable. for long-term lines in ambulatory patients, as for hemodialysis.
The axillary vein is not a commonly used venous access site. It is The limited neck mobility due to an internal jugular line is very
more commonly used in children for long-term access. The use of uncomfortable. Ongoing or impending thrombolytic administra-
US guidance has allowed the axillary vein to be used as an alternate tion is a relative contraindication to internal jugular puncture. A
access site. Due to the depth of the vessel and its close proximity to femoral central venous line is preferable in this case. Successful
the brachial plexus, the axillary vein should only be cannulated in internal jugular cannulation requires the patient to be placed
thin patients and as an alternative site when other sites are not avail- supine and preferably in 15° to 30° of Trendelenburg tilt. This
able, have failed, or are contraindicated. may be impossible in a patient with severe pulmonary compro-
The femoral vein is often the preferred route for emergent mise. The femoral route is preferred in this case. Internal jugu-
central venous cannulation. The indications are the same as for lar vein cannulation is difficult in children under 1 year of age
any other site with a few exceptions. The femoral vein is not a due to poor landmarks and a very short neck. Internal jugular
suitable route for ambulatory patients beyond the initial resus- cannulation is contraindicated in any child who cannot be ade-
citation and stabilization period, as patients with femoral central quately immobilized or paralyzed after insertion of the central
venous lines must be confined to bed. Femoral venous access venous line. Internal jugular cannulation will be more difficult
is easily obtained in patients with respiratory distress and pul- if the patient’s neck cannot be turned. However, the more rota-
monary edema, since they do not need to be placed in the tion applied to the neck the greater the vascular overlap between
Trendelenburg position. Femoral venous access is relatively easy the internal jugular vein and carotid artery. This will increase the
during CPR and does not require the cessation of chest compres- risk of arterial puncture. Head rotation should be minimized if
sions. The femoral vein is easily compressible. This makes it pref- a blind technique is used. US guidance can minimize head rota-
erable to the subclavian vein in coagulopathic patients or those tion and free the Emergency Physician from the historical ana-
undergoing thrombolysis, although peripheral access would be tomic approaches. This allows for any needle approach to be used
preferred in these cases.6 There is no risk of injury to the airway, depending on the location of the internal jugular vein in relation
pleura, or carotid arteries in very young or combative patients. to the carotid artery.
Femoral central venous lines are generally preferred for initial A left bundle branch block is a relative contraindication to
central venous access in the very young or combative patient if central venous cannulation. The guidewire can induce complete
deep sedation or neuromuscular paralysis is contraindicated or heart block when it enters the right ventricle.28 Extreme cau-
otherwise unnecessary. tion should be taken if an internal jugular or subclavian central
line is necessary. Avoid inserting the guidewire into the heart. • Thin-walled introducer needle or catheter-over-the-needle
Continuous cardiac monitoring should be used and transcutane- • Guidewire
ous and transvenous cardiac pacing equipment should be readily
available.
• Central venous line
SUBCLAVIAN VEIN CANNULATION • Dilator
The subclavian vein is incompressible and should be accessed with • #11 scalpel blade
care in any patient who is coagulopathic. Current or imminent • Nylon or silk suture, 3-0 or 4-0
systemic thrombolysis is an absolute contraindication to placing a • Sterile saline
subclavian vein catheter.6 Subclavian vein cannulation should be
• Needle driver
performed on the contralateral side if the patient is relying on a sin-
gle lung. Chest wall deformities, distorted anatomy, and suspected • Tape and catheter site dressing material
vascular injury to the chest or ipsilateral upper extremity are also • Catheter clamp, if supplied with the kit
contraindications. This route should also be avoided if the patient
A variety of standard kits are commercially available
has had prior surgery or trauma to the clavicle, the first two ribs,
(Figure 49-9). They contain all required equipment except local
or the subclavian vessels. Do not cannulate the ipsilateral subcla-
anesthetic solution and sterile gloves. The appropriate catheter
vian vein if the patient has an implanted pacemaker or defibrillator.
should be chosen based on the patient’s needs. The optimal catheter
Central venous access can result in needle injury to the leads, lead
lengths for patients of different ages are summarized in Table 49-3.
displacement, and thromboembolism.
Catheters with between one and four lumens are available.
Multiple-lumen catheters are available in a variety of sizes and
AXILLARY VEIN CANNULATION allow simultaneous venous pressure measurement, adminis-
US-guided axillary vein cannulation can be difficult for the tration of numerous medications, and venous sampling with-
Emergency Physician inexperienced in accessing this vein. Use the out disconnecting the infusion apparatus. Disadvantages of
axillary vein as an access point only when other central veins are multiple-lumen catheters over single-lumen catheters include
not accessible or contraindicated, and the Emergency Physician is smaller lumen sizes for a given catheter’s outside diameter, greater
comfortable with the procedure of US-guided vascular access. The cost, and the need to maintain unused lumens to prevent them
depth of the axillary vein, commonly >3 cm, makes access difficult becoming thrombosed. There is probably no increased risk of
in patients who are not thin. The close proximity of the brachial infection in using triple-lumen versus single-lumen catheters.29–31
plexus can result in significant injury if the needle penetrates it. The Some comparisons between these devices are summarized in
length of the catheter may be too short to reach the superior vena Table 49-4.
cava if placed in the left axillary vein. Percutaneous sheaths are intended primarily for the introduc-
tion of intravascular devices, such as pulmonary artery catheters
FEMORAL VEIN CANNULATION and transvenous pacing wires. They are most often used in the
Emergency Department as a large-bore line for the rapid resuscita-
Contraindications to femoral line placement include infection, tion of hypotensive and hypovolemic patients. Sheaths are available
venous thrombosis, or significant trauma to the ipsilateral lower in many sizes and configurations. Many models have an adjustable
extremity or groin area. Abdominal trauma may result in an inter- hemostasis valve that may be removed and a side port that allows
ruption of the inferior vena cava, allowing any infused fluid or infusion while the main lumen is being used for monitoring.
blood to flow into the abdomen rather than into the central circu- The equipment required for subclavian vein cannulation is the
lation. During CPR, blood return below the diaphragm is reduced same as that for internal jugular vein cannulation. Subclavian vein
and a femoral catheter must end near the level of the diaphragm for catheters must be slightly longer or inserted farther than internal
medications to be most effective. jugular vein catheters. Left-sided catheters must be a few centime-
Catheterization via the internal jugular vein or subclavian vein is ters longer or inserted farther than right-sided catheters. The longer
usually easier if the purpose of central venous access is pulmonary needle should be used for subclavian vein cannulation if the kit used
artery catheterization or transvenous cardiac pacing. These proce- has two different lengths of introducer needles.
dures often require fluoroscopy when they are performed through
the femoral vein. Central venous pressures measured through PATIENT PREPARATION
a femoral vein catheter may be inaccurate unless the patient is
perfectly supine. Explain the procedure, its risks, and its benefits to the patient and/
or their representative. Obtain an informed consent for the proce-
EQUIPMENT dure unless it is being performed emergently. Place the patient in
the Trendelenburg position if catheterization of the internal jugu-
• Sterile gloves and gown lar vein is being attempted. Position the patient in at least 15° of
• Face mask and cap Trendelenburg to prevent an air embolism. Slightly rotate the
• Povidone iodine or chlorhexidine solution patient’s head toward the side opposite that to be cannulated. A
large degree of head rotation has been show to increase the overlap
• Sterile drapes or towels between the internal jugular vein and carotid artery, theoretically
• Local anesthetic solution increasing the risk of carotid artery puncture.32
• 25 gauge needle The subclavian vein is fixed to the surrounding tissues and will
neither collapse nor distend. Therefore, the Valsalva maneuver or
• 5 mL syringes
the extreme Trendelenburg position is not necessary. Head rotation
• “Finder” needle, usually 22 gauge for an adult is neither necessary nor helpful. Slightly abduct the patient’s arm
• 5 mL syringe with a nonlocking hub on the side to be cannulated. Avoid placing rolled towels between
FIGURE 49-9. Equipment needed for central venous catheterization. A. A com-

mercially available central venous line kit. B. Examples of different catheter types
available. From left to right: single-lumen, double-lumen, triple-lumen, and intro- B
ducer sheath (Cordis).
TABLE 49-3 Catheter Sizes, Types, and Characteristics

Catheter size (French) Number of lumens Patient size Venous access site Minimum catheter length (cm)*
2 1 Infant Femoral, internal jugular, external jugular, 5
or subclavian
3 1 <5 kg Femoral, internal jugular, external jugular, 5
or subclavian
4 1, 2 5–10 kg Femoral 5
10–15 kg Femoral, internal jugular, external jugular, 8–12
or subclavian
5 1, 2, 3 >15 kg Femoral, internal jugular, external jugular, 12–25
or subclavian
7 1 (sheath), 2, 3 >40 kg Femoral, internal jugular, external jugular, 15–25
or subclavian
8 and larger 1 (sheath), 2, 3, 4 Adult Femoral, internal jugular, or subclavian 15–25
* The longer end of the catheter length range is for use in the subclavian veins, with the longest catheters needed for the left subclavian vein.
TABLE 49-4 Comparisons Between Central Venous Catheter Types

Single-lumen Multiple-lumen Sheath (Cordis)
Minimum outer diameter Smallest Intermediate Largest
Infusion rate Moderate Lowest (resuscitation catheters Fastest (for central lumen;
with larger lumen available) side port is slower)
Simultaneous infusions, or No Yes Yes, if central lumen and
infusion while monitoring side port both used
Length Varies, fairly long Long Short
Allows device insertion No No Yes
(pulmonary artery lines and
transvenous pacemakers)
the shoulder blades as this can decrease the distance between the at hand on the sterile field. This includes a sterile drape, syringe,
clavicle and first rib, compress the subclavian vein, and make the large-bore hollow needle, guidewire, and gauze squares. Any other
procedure more difficult.33 equipment, including the catheter itself, may be temporarily left in
Place the patient supine or in slight reverse Trendelenburg the kit. Never use the patient as a table. If they move, everything
if femoral vein catheterization is being attempted. The reverse can fall onto the floor. A needlestick injury can occur from the fall-
Trendelenburg position will increase the cross-sectional area of ing needles or if the instinct to grab the falling equipment occurs.
the femoral vein.34 The Trendelenburg position is contraindi-
cated due to the risk of venous air embolism. Slight external rota- INTERNAL JUGULAR VEIN
tion and abduction of the extremity may increase the amount of CATHETERIZATION TECHNIQUES
femoral vein accessible for cannulation.35 It is easier for a right-
handed Emergency Physician to perform the procedure standing CENTRAL APPROACH TO
on the patient’s right side, regardless of which femoral vein is being
THE INTERNAL JUGULAR VEIN
accessed. The opposite is true for those that are left-handed.
Identify the anatomic landmarks for the procedure after posi- While an internal jugular vein cannula can be inserted using the
tioning the patient. Clean any dirt and debris from the area of the over-the-needle and through-the-needle techniques, the Seldinger
puncture site. Apply povidone iodine or chlorhexidine solution and technique is often preferred.37,38 See Chapter 47 and Table 49-5 for
allow it to dry.36 It is recommended to prepare the entire neck and a more complete discussion. The Seldinger technique uses a flexible
clavicular area if the internal jugular or subclavian routes are guidewire, inserted through a special thin-walled hollow needle, to
attempted so that, if access to one site is unsuccessful, another guide a catheter of any desired length through the skin and into the
site may be accessed without re-prepping and draping. Due to the central circulation. This technique is described below and summa-
risk of inducing a pneumothorax, attempts at contralateral inter- rized in Table 49-6.
nal jugular or subclavian vein cannulation after an unsuccessful Clean, prep, and drape the area as described previously. Place
attempt must be delayed until a chest radiograph is checked to the patient in the Trendelenburg position with their head down
prevent bilateral pneumothoraces. 15° to 30°. Slightly rotate the patient’s head away from the side that
Infiltrate the subcutaneous tissues at the needle puncture site will be cannulated. Excessive rotation will distort the anatomic
with a generous volume of local anesthetic solution, including any landmarks and may bring the internal jugular vein closer to the
areas that will be used for suturing the catheter in place. This allows carotid artery.
the local anesthetic to diffuse throughout the area and take effect Several cardinal rules for the insertion of the catheter should
before the main procedure begins. Any distortion of anatomic land- be observed. Always occlude the open hub of a needle or cath-
marks caused by anesthetic infiltration decreases as the anesthetic is eter in a central vein to prevent an air embolism. Never let go of
absorbed into the subcutaneous tissues. the guidewire, so as to prevent its embolization into the central
Apply electrocardiographic monitoring, pulse oximetry, and venous circulation. Never apply excessive force to the guidewire
noninvasive blood pressure monitoring to the patient and admin- on insertion or removal. Doing so may injure the vessel, break the
ister supplemental oxygen. Electrocardiographic monitoring dur- guidewire, and/or embolize the guidewire.
ing insertion of a central line is recommended due to the risk of Attach the thin-walled introducer needle to a 5 mL syringe con-
ventricular dysrhythmias should the guidewire or catheter enter the taining 1 mL of sterile saline or local anesthetic solution. The spe-
right ventricle. It is preferable to have a designated person—physi- cially designed introducer needle included with the catheter should
cian or nurse—whose only job is to watch the monitoring equip- be used, as it has a relatively thin wall and a larger internal diameter
ment. The patient’s face and chest will be draped for the internal relative to its external diameter. It has a shorter bevel than a con-
jugular or subclavian vein cannulation procedure. The Emergency ventional hypodermic needle. It also has a tapered hub to guide the
Physician will be focused on the procedure and unaware of any sud- guidewire into the needle proper.
den patient deterioration, ventilator disconnect, or other irregulari- If there is doubt about the exact location of the vein, it may first be
ties. Resuscitation equipment should be immediately available. A located with a small “finder” needle. Insert a 25 or 27 gauge needle
postinsertion chest radiograph to verify line placement and the lack attached to a 5 mL syringe through the skin puncture site previously
of a pneumothorax must be immediately available. chosen. Advance the needle at a 30° to 60° angle to the skin while
Prepare for the procedure. Apply sterile gloves, a sterile gown, and applying negative pressure to the syringe. A flash of blood signifies
a face mask. Some Emergency Physicians prefer to double-glove. If that the tip of the needle is within the vein. Note the depth and loca-
one glove becomes contaminated, it can be discarded and the pro- tion of the vein. Remove the finder needle. Alternatively, the finder
cedure continued without interruption. Open the desired venous needle may be left in place for reference.
access kit using aseptic technique on a bedside table. Perform a Insert the introducer needle at a 30° to 60° angle at the apex of
quick inventory and identify all necessary equipment before begin- the triangle formed by the sternal and clavicular heads of the ster-
ning the procedure. Set up a sterile field next to the patient and nocleidomastoid muscle and the clavicle (Figure 49-4). This point
within easy reach. Place the equipment that must be immediately is just lateral to the carotid artery pulse. Direct the introducer needle
TABLE 49-5 Comparison of Central Venous Catheterization Methods

Seldinger Catheter-over-the-needle Catheter-through-the-needle
Insertion needle Small Large Largest
Speed Slowest Fastest Fast
Number of steps 4+ 1 2
Risk of catheter shear None Low Highest
Catheters and lumens available Single- or multiple-lumen, sheath/introducer Single-lumen only Single-lumen only
Rate of infusion Highest (with sheath) Moderate Low to moderate
TABLE 49-6 Summary of the Seldinger Method of Central Venous Cannulation*

Step Action Tips and caveats
1 Prep and drape the skin puncture site. For internal jugular vein, prepping down to the clavicle and up to the
jaw will enable an attempt at the ipsilateral subclavian vein
(or vice versa).
2 Anesthetize the puncture site if not already done. Anesthetize the suture sites also.
3 Uncap the distal lumen. Additional lumens may be flushed at this point or after insertion, as desired.
4 Locate the vein using the finder needle and aspirating syringe. Internal jugular vein should be reached within 3 cm. Stop advancing after
4–5 cm if the vein is not located.
5 Remove the finder needle, noting the direction and depth of A few drops or a line of blood may be left on the skin as the finder is
the internal jugular vein. Or withdraw the needle slightly so withdrawn to show the proper direction.
it is outside the internal jugular vein and leave it in place
as a guide
6 Insert introducer needle on a syringe along the “finder’s” path Syringe must have a nonlocking hub. A little saline in the syringe allows
until venous blood is aspirated. Alternatively, an introducer any occluding skin plug to be ejected. The vein is often located on
catheter and needle assembly can be used to cannulate withdrawal of the needle, since the friction of the large needle in the
the internal jugular vein; the needle is then withdrawn. tissues can compress the internal jugular vein.
7 Disconnect the syringe from the needle, immediately Do not move the needle at all! Keep the hand holding the needle in
occluding the open needle hub to prevent air embolism. contact with the patient’s skin to prevent movement.
8 Insert the guidewire through the introducer needle and Do not move the needle! Do not force the guidewire—it should
into the vein. pass easily!
9 Advance the guidewire into the vein to the desired depth The guidewire must be securely in the vein, not just in the
or until ventricular ectopy is seen on the ECG monitor. subcutaneous tissue.
10 Withdraw the introducer needle a few millimeters and use the Keeping the needle in place eliminates any possibility of
scalpel to enlarge the puncture site slightly. cutting the guidewire.
11 Remove the introducer needle. Never let go of the guidewire!
12 Thread the dilator over the guidewire until it can be grasped Always keep a firm grip on the guidewire!
outside the hub, then insert and withdraw the dilator.
13 Thread the catheter tip over the guidewire and withdraw Never let go of the guidewire.
the guidewire from the skin until it can be grasped at the
infusion hub.
14 Insert the catheter to the desired depth; most catheters are The tip of the catheter should be in the superior vena cava, at
marked in centimeters, with larger markings every 5 and 10 cm. the level of the manubriosternal angle.
Introducer sheaths should be inserted completely.
15 Holding the catheter in place, remove the guidewire. Occlude Do not apply excessive force to the guidewire. If it is trapped,
the open hub with a gloved finger to prevent air embolism. withdraw the catheter a few centimeters and try again. Do not
break the wire!
16 Attach a syringe to the catheter hub and aspirate blood, taking Other lumens may be aspirated, flushed, and clamped.
samples as desired; then flush the lumen with saline and
begin the desired venous infusion.
17 Verify intravenous placement before suturing the catheter in place If the patient’s blood travels up the intravenous tubing, the catheter is
in the carotid artery!
18 Remove the patient from the Trendelenburg position.
19 Suture the catheter to the skin with sutures and tape. Take care not to puncture the catheter or to occlude it with a
tight suture
20 Apply a dressing to the catheter site.
21 Verify catheter tip position by chest X-ray. Catheter tip must be in the superior vena cava, not in the right atrium.
Tip should be above the azygos vein and the carina, with the tip
parallel to the vessel wall.
* The central approach to the internal jugular vein is used as an example, although the same technique is used for other approaches and central veins.
toward the ipsilateral nipple. Shallower angles make it necessary to needle slowly while continuing to aspirate. Often, the vessel will
traverse a greater amount of subcutaneous tissues and structures have been completely traversed and no blood will return due to col-
before entering the vessel. Steeper angles make insertion of the lapse of the vein by the pressure of the skin being forced inward
catheter over the guidewire difficult, as the guidewire tends to kink. as the introducer needle passes through it. Under normal physi-
Shallower angles are generally necessary in children whose ves- ologic conditions, veins have very low pressures within them and
sels are smaller. Inject a small amount of the fluid in the syringe to are easily collapsed by external pressure. If no blood is aspirated
remove any skin plug that may block blood return once the vein has while withdrawing the needle, withdraw the introducer needle to
been penetrated. the subcutaneous plane and redirect it slightly medially. Avoid put-
Apply negative pressure to the syringe by withdrawing the plunger. ting continuous pressure on the carotid artery pulse, as even gentle
Advance the introducer needle into the vein (Figure 49-10A). If pressure may collapse the internal jugular vein (Figure 49-3B).
the vein is not located within 3 to 5 cm of the skin—this distance Stabilize and hold the introducer needle perfectly still with the
will vary depending on the patient’s size and the target vessel’s nondominant hand once blood returns in the syringe. The carotid
location—stop advancing the introducer needle. Withdraw the artery has been entered if the blood is bright red and/or forces
FIGURE 49-10. The Seldinger technique. A. The vein is punctured by the introducer needle and blood is aspirated. B. The syringe has been removed. The guidewire is
inserted through the introducer needle and into the vein. C. The introducer needle and guidewire sleeve are withdrawn over the guidewire. D. The skin puncture site is
enlarged. E. The dilator is advanced over the guidewire until the hub is against the skin; then it is removed. F. The catheter is advanced over the guidewire and into the
vein. G. The guidewire is withdrawn through the catheter.
the plunger of the syringe back. Remove the syringe. Blood should Even a millimeter of movement may result in failure of the needle
flow slowly and freely from the hub of the needle. The introducer tip to stay within the lumen of the vein.
needle is in the carotid or subclavian artery if blood squirts out Prepare the guidewire (Figure 49-11). Grasp the guidewire and
the introducer needle hub. If blood dribbles out or does not flow its sleeve with the dominant hand. The tip of the guidewire has a “J”
from the hub and the patient has spontaneous circulation, reattach shape when the sleeve is retracted (Figure 49-11A). Slide the sleeve
the syringe and reposition the introducer needle until free flow forward to straighten out the “J” of the guidewire (Figure 49-11B).
is obtained. Occlude the open hub of the introducer needle with Insert the wire sleeve into the hub of the introducer needle
the thumb of the nondominant hand while keeping the small fin- (Figures 49-10B & 49-11C). Advance the guidewire through the
ger of the hand in contact with the patient’s skin. The Emergency sleeve and into the introducer needle. Never let go of the guide-
Physicians proprioceptive reflexes will prevent movement of the wire! One end of the wire must always be held to prevent loss of
introducer needle by maintaining contact with the patient’s skin. the wire and embolization into the central circulation.
A A
B B
FIGURE 49-12. Straightening the “J” tip. A. Grasp the guidewire between the
ring and small fingers and the palm. B. Apply traction using the thumb and index
fingers, stretching the outer coil of the wire over the solid core to straighten the
C “J” tip.
FIGURE 49-11. Guidewire preparation. A. The plastic sleeve is retracted, showing

the “J” tip. B. The plastic sleeve is advanced to cover the guidewire tip, allowing the
wire to be threaded into the introducer needle. C. The sleeve is inserted into the nondominant hand as soon as the guidewire is visible between the
hub of the introducer needle. tip of the introducer needle and the skin. Finish removing the nee-
dle over the guidewire.
Make a small incision in the skin adjacent to the guidewire using
a #11 scalpel blade (Figure 49-10D). Place the dilator over the
Do not simply reverse the guidewire if the sleeve used to straight end of the guidewire (Figure 49-10E). Advance the dila-
straighten the curved end of the guidewire is lost. The straight tor over the guidewire, through the skin, and into the vein. A slight
end of the guidewire can puncture the wall of the vein. Grasp the twisting motion of the dilator as it is advanced may aid in its inser-
guidewire between the fourth and fifth fingers and the palm of tion. Continue to advance the dilator until its hub is against the skin.
the dominant hand (Figure 49-12A). Apply gentle traction on the Do not release hold of the guidewire at any time. Remove the dila-
curved guidewire tip with the thumb and the second and third tor over the guidewire.
fingers in order to straighten the guidewire (Figure 49-12B). The Place the catheter tip over the guidewire. Advance the cath-
guidewire can then be inserted into the introducer needle hub with- eter over the guidewire and into the vein to the desired depth
out the use of the sleeve. (Figure 49-10F). Do not release hold of the guidewire. Gently
Advance the guidewire through the introducer needle and into rolling or twisting the catheter between the thumb and the fore-
the vein (Figure 49-10B). The guidewire should advance easily into finger may aid in its advancement. Hold the catheter securely in
the vein. Never force the guidewire. Guidewire resistance may indi- place and remove the guidewire (Figure 49-10G). Occlude the
cate that the introducer needle is not within the vein, is against the open catheter lumen with a sterile-gloved finger to prevent an air
wall of a vessel, or is caught as the vessel bends. Slightly withdraw embolization and excessive blood loss.
the guidewire, rotate it slightly, and readvance it. The use of force Attach a syringe to the catheter hub and aspirate blood to confirm
will kink the guidewire and may cause it to damage the vein and that the catheter is within the vein. Withdraw any necessary blood
adjoining tissues. Advance the guidewire 5 to 10 cm into the vessel samples from the catheter. Attach infusion tubing or a heparin
or until ectopic beats are seen on the cardiac monitor. Withdraw lock to the port and flush the catheter to prevent a blood clot from
the introducer needle and guidewire sheath while securely hold- obstructing the lumen. If a multilumen catheter is inserted, flush
ing the guidewire (Figure 49-10C). Grasp the guidewire with the any other lumens after first withdrawing any air (Figure 49-13).
TABLE 49-7 Comparison of Subclavian Vein Cannulation Routes

Infraclavicular approach Supraclavicular approach
Entry site Just inferior to the clavicle 1 cm lateral to the
at the midclavicular line clavicular head of the
sternocleidomastoid
muscle, 1 cm posterior
to the clavicle
Needle orientation Keep as close to the Tip aimed 10° anterior
coronal plane as to the coronal plane
possible
Needle bevel and Medially and caudally Medially
“J” wire directed
Aim toward Just posterior to the Contralateral nipple,
sternal notch needle bisects
angle formed by
the clavicle and the
clavicular head of the
sternocleidomastoid
muscle
Distance from skin 3–4 cm 2–3 cm
to subclavian vein
SUBCLAVIAN VEIN
FIGURE 49-13. Aspiration and flushing of catheters. A. Any air in the lumen of CATHETERIZATION TECHNIQUES
the tubing is aspirated into the syringe of flush solution. The syringe must be held
upright, as shown. B. Stop aspirating once all the air is removed from the catheter The technique is identical to that described above for internal jugu-
and blood begins to enter the syringe. C. Flush solution is injected until the lumen lar vein cannulation except for the puncture site. Two techniques,
is filled and contains no blood. This usually requires 2 to 4 mL of flush solution. infraclavicular and supraclavicular, are described below and sum-
marized in Table 49-7.
INFRACLAVICULAR APPROACH
Securely attach the catheter to the skin with nylon or silk sutures.
Cover the skin puncture site with a sterile dressing.
TO THE SUBCLAVIAN VEIN
The infraclavicular approach to the subclavian vein is most often
ANTERIOR APPROACH used. It is commonly thought to be easier to perform and less likely
TO THE INTERNAL JUGULAR VEIN to result in a pneumothorax than the supraclavicular approach,
although data for this belief are lacking.39 Some Emergency
The skin puncture site is at the anterior border of the sternal head of Physicians prefer not to use a finder needle for infraclavicular sub-
the sternocleidomastoid muscle, just lateral to the carotid artery and clavian vein cannulation as there is no danger of penetrating the
at the level of the cricoid cartilage (Figure 49-5). Enter the skin at a carotid artery. This also makes as few needle passes near the pleura
45° to 60° angle. Direct the introducer needle toward the ipsilateral as possible in order to decrease the risk of an iatrogenic pneumotho-
nipple. The internal jugular vein in an adult should be encountered rax. Estimate the distance from the skin puncture site to the supe-
within 3 to 5 cm. If the vein is not encountered by 5 cm, withdraw rior vena cava (i.e., the manubriosternal junction).
the tip of the introducer needle to the subcutaneous space and Several different skin entry sites are described in the literature.
redirect it slightly medially. The remainder of the procedure is as Some feel that the preferred entry site is 1 cm caudal to the junction
described for the central approach above and in Table 49-6. of the medial and middle thirds of the clavicle. The subclavian vein
lies just posterior to the clavicle at this site (Figure 49-14). The first
POSTERIOR APPROACH rib lies between the pleural dome and the subclavian vein. Direct
TO THE INTERNAL JUGULAR VEIN the introducer needle just superior and posterior to the supra-
sternal notch while staying as close to the frontal (coronal) plane
Enter the skin at the posterior edge of the sternocleidomastoid mus- as possible. The needle and syringe should be parallel to the bed
cle, one-third of the way from the clavicle to the mastoid process (Figure 49-14A). Placing the nondominant index finger in the ster-
(Figure 49-6). Alternatively, the point where the external jugular nal notch will help to guide placement (Figure 49-14A).
vein crosses the lateral border of the sternocleidomastoid muscle Some Emergency Physicians prefer to enter the skin inferior to
can be used. Direct the introducer needle under the sternocleido- the clavicle at the deltopectoral groove, or the point just lateral to
mastoid muscle at a 30° to 45° angle to the skin and toward the ster- the midclavicular line along the inferior surface of the clavicle. This
nal notch. Place the index finger of the nondominant hand in the is the point where the skin may be maximally depressed. Direct the
sternal notch to provide a landmark with the patient draped. In an introducer needle parallel to the bed and toward the sternal notch.
adult, the internal jugular vein should be encountered within 5 cm. This entry site may make it easier to keep the introducer needle in
This approach is not recommended in children. The remainder of the coronal plane. The distance before entering the subclavian vein
the procedure is as described for the central approach above and in is longer than in the preceding approach and the protection offered
Table 49-6. by the first rib is lost.
FIGURE 49-14. Infraclavicular approach to subclavian vein cannulation. A. Frontal (oblique) view of the procedure. B. Sagittal section through the medial third of the
clavicle. Note the proximity of the pleura and subclavian artery.
One additional landmark can be used to identify the skin punc-

ture site. Palpate the bony tubercle, or protrusion, on the inferior
surface of the clavicle and approximately one-third to one-half the
length of the clavicle from the sternoclavicular joint. The advantage
of this site is that it is a definitive landmark and avoids approxi-
mating distances, as described for the other sites above. Insert the
introducer needle parallel to the bed and aimed just posterior to the
sternal notch.
The bevel of the introducer needle should be oriented caudally,
as should the “J” in the guidewire (Figure 49-15). This position will
allow the guidewire to enter the innominate vein and superior vena
cava rather than being directed upward into the internal jugular
vein or across to the contralateral subclavian vein (Figure 49-15).
Once venous blood is aspirated, the Seldinger technique for catheter
insertion is otherwise the same as previously described for internal
jugular vein cannulation. Aspiration of bright red blood under pres-
sure indicates subclavian artery puncture, which will be incompress-
ible. Remove the introducer needle and observe the patient for signs
of significant hemorrhage over the next several hours. Aspiration of
air indicates penetration of the pleura. Observation with serial chest
radiographs for at least the next 6 to 24 hours is essential to evaluate
the size of the potential resulting pneumothorax.
SUPRACLAVICULAR APPROACH
TO THE SUBCLAVIAN VEIN
While most Emergency Physicians are more comfortable with the
infraclavicular approach to the subclavian vein, the supraclavicu-
lar approach offers some distinct advantages. The supraclavicular
subclavian vein is closer to the skin. The route from a right-sided FIGURE 49-15. Introducer needle bevel orientation for subclavian vein cannula-
skin puncture site to the superior vena cava is more direct. It allows tion. Varying the orientation of the introducer needle bevel for infraclavicular and
easier access to the superior vena cava while avoiding the hazards of supraclavicular techniques helps guide the “J” shaped guidewire into the superior
a left-sided puncture (i.e., the thoracic duct). The skin entry site is vena cava.
FIGURE 49-16. Supraclavicular approach to subclavian vein cannulation. A. From the insertion point 1 cm superior to the clavicle and 1 cm lateral to the border of the ster-
nocleidomastoid muscle, direct the introducer needle tip at a 45° angle to the transverse and sagittal planes and slightly anterior toward the contralateral nipple. B. Sagittal
section through the medial third of the clavicle. Note that the introducer needle track must be directed anteriorly to avoid the subclavian artery and the dome of the pleura.
more accessible during CPR and requires less interruption of exter- size or decreasing arteriovenous overlap.16 Locate the axillary
nal chest compressions.40 With experience, the complication rate vein using a high frequency, 5 to 10 MHz, US probe. Place the US
for the supraclavicular approach is probably lower than that for the probe, with the marker pointing cephalad, just below the clavicle at
infraclavicular approach.39,41 approximately its middle third. Identify the axillary artery, axillary
Estimate the distance from the skin puncture site to the supe- vein, and the pleura to obtain proper orientation. Manual compres-
rior vena cava to guide the catheter insertion depth. The skin is sion and color flow Doppler can be used to differentiate between
entered at a point 1 cm lateral to the lateral border of the clavicular the vein and the artery. Follow the axillary vein laterally on the
head of the sternocleidomastoid muscle and 1 cm superior to the chest until overlap with the artery is minimized and the pleura is
clavicle (Figure 49-16).42 The introducer needle should bisect the out of the view of the probe. Rotate the US probe into a parallel
angle formed by the clavicle and the lateral border of the sternoclei- orientation in respect to the axillary vein with the probe marker
domastoid muscle (Figure 49-16A). Direct the introducer needle toward you to obtain a long axis view of the axillary vein. Gently
toward the contralateral nipple or a point just superior and posterior pivot the US probe in a cephalad and caudal direction to clearly
to the sternal notch. Orient the introducer needle bevel medially differentiate the axillary vein from the axillary artery. Slight move-
(Figure 49-15). The subclavian vein should be entered within 2 to ments of the probe will alter the US image between the vein and
3 cm in an adult. The length of catheter inserted will be 2 to 4 cm artery. It is recommend to stabilize the US probe by resting your
less than that for the infraclavicular approach. distal forearm and wrist against the anterior chest. Note the depth
Alternative skin entry sites and approaches have been described. of the vein to ensure that the central venous catheter needle will be
Enter the skin 1 cm medially and 1 cm superiorly to the midpoint of able to puncture the vessel. The remaining details of the technique
the clavicle with the introducer needle directed toward the ipsilat- are as described in Chapter 50 (US-Guided Vascular Access).
eral sternoclavicular joint.43 The skin can be entered just posterior
to the clavicle, at the junction of the medial and middle third of the FEMORAL VEIN
clavicle, with the introducer needle directed toward the ipsilateral CATHETERIZATION TECHNIQUE
sternoclavicular joint and parallel to the coronal plane.44 This last
approach is probably the simplest, although the study cited was per- This technique is often performed blind using landmarks. It can also
formed on cadavers rather than live patients. be performed under US guidance. The use of an ECG monitor is
still recommended even though the short guidewire may not reach
AXILLARY VEIN the heart. Particular care must be taken if the patient has a preexist-
ing left bundle branch block, as complete heart block may result if
CATHETERIZATION TECHNIQUE
the guidewire or catheter enters the right ventricle.28 Premeasuring
The axillary vein must be accessed using US guidance and not from the insertion site to the xiphoid process will give the maximum
blindly using landmarks. Place the patient supine with their depth of catheter insertion.
arm abducted in a comfortable position. A recent US study dem- The introducer needle should enter the skin 2 to 4 cm inferior
onstrated no benefit of arm abduction in increasing axillary vein to the midpoint of the inguinal ligament and 1 cm medial to the
FIGURE 49-17. Femoral vein cannulation. The skin puncture

site is 1 cm medial to the femoral artery pulse and 2 to 4 cm
inferior to the inguinal ligament. Direct the introducer needle
posteriorly at a 45° to 60° angle while aspirating.
femoral artery pulse (Figure 49-17). In an infant or young child, MULTIPLE-LUMEN CATHETERS
the introducer needle should enter the skin 1 to 2 cm inferior to the
inguinal ligament and 0.5 cm medial to the femoral artery pulse. Prior to skin puncture, remove the cap from the distal port’s injec-
The cannulation technique is as described previously for the inter- tion hub. It is usually marked “distal.” The other lumens may be
nal jugular vein. flushed with saline or heparin solution and recapped or left capped
Two site-specific considerations deserve mention. The use of a and flushed later (Figure 49-13). Heparin concentrations no higher
finder needle is unnecessary, since there are no vital structures in than 100 U/mL should be used to avoid temporarily anticoagulating
the area other than the femoral artery that is compressible if it is the patient.45
punctured. The introducer needle is directed at a 45° to 60° angle The introducer needle and guidewire are inserted as described
to the skin and parallel to the long axis of the thigh. Shallower previously. Place the multiple-lumen catheter tip over the guide-
angles may be necessary in very small and thin patients. Use cau- wire. Advance the catheter until the guidewire emerges from the
tion to avoid puncturing the posterior wall of the vein above distal port hub (Figure 49-18). Insert the catheter to the desired
the inguinal ligament, since this can result in a retroperitoneal depth. Remove the guidewire. Flush the distal lumen and connect it
hemorrhage. to the desired infusion. If not done previously, aspirate and flush the
other lumens with the desired solution (Figure 49-13).
PERCUTANEOUS INTRODUCER SHEATH (CORDIS)
USE OF THE SELDINGER-HUB INTRODUCER CATHETER
The insertion technique differs slightly from those described above
Some central venous access kits include a catheter-over-the-needle (Figure 49-19). Locate the vein, insert the needle followed by the
with a tapered hub that can be used in place of the thin-walled guidewire, and remove the needle leaving the guidewire in place
introducer needle. This technique has the advantage of allowing the as described previously. Insert the plastic dilator into the lumen of
introducer catheter to remain in place while venous placement is the sheath. The entire assembly must be advanced over the guide-
verified. It provides less likelihood of the vein being lost as the aspi- wire as a unit rather than utilizing separate dilation and insertion
ration syringe is removed and the guidewire advanced. A guidewire steps (Figure 49-19C). A correspondingly larger skin nick must be
advanced through the introducer catheter cannot become sheared made with the scalpel, since the sheath is usually of larger diameter
off, as when it is inserted through the needle. than a catheter. Advance the dilator–sheath unit over the guide-
The vein is entered with the catheter-over-the-needle assem- wire (Figure 49-19C) and into the vein (Figure 49-19D). A twist-
bly attached to an aspirating syringe, as described previously. ing motion may aid in its advancement. Continue to advance the
Once the flashback of blood is obtained, advance the catheter- unit until the hub of the sheath is against the skin (Figure 49-19E).
over-the-needle 2 mm further into the vein. This will ensure that Remove the guidewire and dilator as a unit (Figure 49-19E). The
the tip of the introducer catheter is within the vein. Hold the hub remainder of the procedure is as described previously.
of the needle securely. Advance the catheter into the vein until
its hub is against the skin. Withdraw the needle. If necessary, the
introducer catheter may be attached to a pressure transducer and
US-GUIDED CENTRAL VENOUS ACCESS
the venous waveform verified to confirm venous rather than arte- The use of bedside US to guide central venous access is becoming
rial placement. Blood gas measurements may also be performed. more common. The availability of US, its low cost, portable units,
Advance the guidewire through the introducer catheter and and training during residency are making its use standard proce-
into the vein. The remainder of the procedure is as previously dure for central venous line placement. Please refer to Chapter 50
described. for the complete details of US-guided vascular access.
FIGURE 49-18. Inserting a multiple-lumen catheter. The

guidewire exits through the uncapped distal port. The proximal
port(s) must be clamped or capped to prevent air embolism.
The anterior or central approach to the internal jugular vein is
preferred for children. Appropriate catheter sizes and lengths are
shown in Table 49-3. The child must be sedated and immobilized
prior to attempts at cannulation of the internal jugular or subcla-
vian vein. The femoral vein is the vein of choice if central venous
access is needed in a combative child who cannot be completely
restrained. The patient need not be in the Trendelenburg position,
the consequences of a misdirected needle are less severe, and the
procedure is less threatening as the face is not draped. A shallower
angle of skin entry than in an adult is necessary to access the femoral
vein. Enter the skin 1 to 2 cm inferior to the inguinal ligament and
0.5 mm medial to the femoral artery. Subclavian vein access in the
small child can be difficult due to the anatomic relationships of the
vessels as previously described. Despite this, the subclavian vein, in
addition to the femoral vein, can be safely and effectively accessed in
children less than 1 year of age.46
ASSESSMENT
Examine the patient. Examine the lung fields carefully to exclude
a significant iatrogenic pneumothorax. Recheck the patient’s vital
signs frequently after the procedure. Obtain a portable anteropos-
terior chest radiograph to verify line tip placement in the superior
vena cava and rule out an iatrogenic pneumothorax. Check the cath-
eter site for hematoma formation or hemorrhage along the dilated
catheter track. Control any hemorrhage with direct pressure.
US, if immediately available, can be used postinsertion to deter-
mine the presence or absence of an iatrogenic pneumothorax.
Detection of an anterior pneumothorax in a supine patient has
been shown to more sensitive using US than standard plain radio-
graphs.47,48 The use of US does not negate the need to determine
catheter location by plain radiographs. US may be a useful tool
when postline chest radiographs are delayed or the patient suddenly
decompensates during or immediately after central line placement.
Check the function of the catheter by aspiration and infusion
FIGURE 49-19. Inserting an introducer sheath. A. The sheath. B. The dilator. through all ports, as discussed above. A proximal lumen may be
C. The dilator is inserted into the sheath and the unit is threaded over the guide- extravascular if it fails to aspirate blood easily. A catheter may be
wire. D. Advance the unit over the guidewire and into the vein using a twisting exchanged over a guidewire as long as the distal tip of the catheter is
motion (arrow). E. The dilator and guidewire are removed as a unit, leaving the definitely intravascular. Do not attempt to advance the catheter once
sheath in place. the guidewire has been removed.
Check the position of the catheter tip on the chest radiograph. While the short-term infection rate of femoral lines compares
The catheter must not be in the heart due to the risk that ero- favorably with that in other central lines, some precautions are
sion through the thin right atrial wall will result in a pericardial necessary to prevent soilage of the site.20,55 Consider the judicious
hemorrhage and tamponade.49,50 Landmarks for an internal jugu- use of bladder catheterization in patients who are incontinent of
lar or subclavian vein catheter tip include the following: above urine and of rectal tubes in patients with loose stools. Patients with
the level of the carina, above the azygos vein, and at/above the percutaneous femoral vein catheters must be confined to bed to
manubriosternal junction. The tip of the catheter should be paral- prevent catheter dislodgment and hemorrhage around the catheter.
lel to the vein to prevent erosion through the wall of the vein. If Frequent assessment for venous thrombosis in the lower extremity
the catheter crosses over to the opposite subclavian vein and the is essential. It is recommended that femoral lines be discontinued
patient cannot tolerate an attempt at repositioning, it may be used when an alternative venous access site is available or within 3 days,
for intravenous infusion. Lines placed from the subclavian vein whichever is sooner.56
into the jugular system must be replaced. Catheters in or below
the right atrium must be pulled back immediately to prevent any REMOVAL OF THE CENTRAL VENOUS CATHETER
arrhythmias and perforation of the myocardium.
It is important to ensure that the catheter is within a vein and not It has been, and sometimes still is, routine policy in some institu-
an artery. This can be accomplished by US as described in Chapter tions to change all central venous lines placed in the Emergency
50. An arterial line monitoring setup can be attached to the cath- Department when the patient arrives in the Intensive Care Unit. It
eter to measure intravascular pressures. This is time consuming, was believed that these lines placed in the Emergency Department
expensive, and takes some time to prepare. A device was recently were “dirty” and at a higher risk of infection. This practice results
approved by the FDA to assist in this evaluation. The Compass in an additional procedure, the additional time and cost of the pro-
Vascular Access pressure measurement device (Mirador Biomedical, cedure, the associated discomfort or pain of the procedure, and
Seattle, WA) is a disposable, single patient use, digital manometer the potential for complications. A recent study demonstrated that
that attaches between the syringe and introducer needle. It provides the infection rate of central venous lines placed in the Emergency
a digital pressure measurement through the needle when it is within Department using aseptic technique was no different than those
the blood vessel. It also provides pressure measurements while the placed in the Intensive Care Unit.57
guidewire is being inserted through the needle. When removing a central venous catheter from the internal
Most femoral vein catheters can be fully inserted. Premeasurement jugular or subclavian vein, place the patient in the Trendelenburg
is recommended to make sure that the catheter tip will not reach position. To remove a femoral vein catheter, place the patient
the right atrium. If there is any doubt about the catheter position, supine. Remove the dressing overlying the skin puncture site.
postinsertion abdominal and chest radiographs should be obtained. Cut the suture securing the catheter to the skin. Ask the patient
The tip of the catheter must be at or below the xiphoid process of to exhale and hold their breath. Briskly remove the catheter and
the sternum. Reassess the distal neurovascular status of the lower cover the puncture site with a gauze dressing. The track from the
extremity after line placement. skin surface to the vein can be a source of a fatal venous air embo-
lism.58 If the catheter had a large diameter or remained in place for
AFTERCARE more than 2 to 3 days, apply an occlusive dressing to the site for
the first 1 to 2 days after the catheter has been removed. The skin
The catheter must be sutured in place to prevent malpositioning puncture site should be observed for signs of infection twice a day
of the line. Tie a surgeon’s knot at the skin, then secure the suture for 48 hours.
to the hole(s) provided in the catheter wings. The straight needle
contained within most central venous access kits can be difficult
to use and it poses a needlestick risk. One option is to use nylon COMPLICATIONS
suture on a curved needle and a laceration repair kit. This requires Mechanical complications can occur. The needle and/or guidewire
additional equipment and at an additional cost. Another option is may puncture the lateral or posterior wall of the vein.59–62 This can
to use a needle cap or syringe contained within the kit to protect result in a hematoma formation, arterial puncture, arterial cannu-
against the advancing straight needle puncturing your finger.51,52 lation, and an arteriovenous fistula. The use of US guidance does
Use the cap to apply counter pressure against the skin as the straight not prevent these complications.59–61 The guidewire or catheter can
needle tip exits the skin. A catheter clamp is often provided in the break, fragment, or become knotted intravascularly. The guidewire
kit for longer catheters. It too should be sutured in place. The clamp can become a venous embolus if it completely enters the vein.
holds the catheter in place by friction. It is not a guarantee that the
catheter will not move. The catheter depth should be checked daily
INTERNAL JUGULAR VEIN CATHETERIZATION
by inspection and by frequent chest radiographs. Movement of the
patient’s head and neck may move the tip of the internal jugular vein Internal jugular venous access has a myriad of potential complica-
catheter by as much as 4 cm.53 tions.49,63–66 Infection can be either at the local site or in a systemic
Introducer sheaths have large lumens and present a significant line due to bacteremia and sepsis. A pneumothorax can occur dur-
risk of causing an air embolism. Cap the main lumen if it is not ing line placement. A hemothorax may be life-threatening, espe-
being used for an infusion. Any built-in diaphragm is not a reli- cially if a venopleural fistula is created. A chylothorax occurs if the
able means of preventing an air embolism.54 Do not use the dilator thoracic duct is lacerated. Occasionally, carotid artery puncture can
as an occluder or infusion port, as the stiff plastic can easily erode result. It may be complicated by a stroke if the blood supply to the
through the wall of the vein. An occlusive dressing can be used if no brain is interrupted or if a plaque embolizes. Airway compromise
occluder is available. can occur due to the formation of a hematoma and compression of
The skin puncture site should be checked regularly for signs the airway. An air embolism can occur if the catheter lumens are
of infection. Cellulitis or purulent drainage requires a new cen- left open to the air during insertion or if connections loosen and
tral venous line at another site. Remember to restrain any patient separate at a later time. Right ventricular irritation from the catheter
who is uncooperative so as to prevent inadvertent removal of the tip can cause cardiac dysrhythmias. Puncture of the right atrial wall
central line. can lead to pericardial tamponade and death. The guidewire can
CHAPTER 50: Ultrasound-Guided Vascular Access 327
become entrapped, necessitating surgical or interventional radiol- arteriovenous overlap. In either situation, correction with reverse
ogy removal. Embolization of the guidewire or catheter parts occurs Trendelenburg or proper leg positioning under US guidance may
with improper use of the equipment. Anaphylactic reactions to allow the Emergency Physician a better target for cannulation and
antibiotic-impregnated catheters have been reported. The cardiac reduce complications. During periods of severe hypotension or car-
monitors should be observed during the procedure to prevent the diac arrest, palpation of the femoral artery may not be feasible. This
death of a critically ill patient from being unnoticed while the cath- can lead to failed access or arterial cannulation. Hilty et al. demon-
eter is being inserted. Thrombosis of the catheter or vein may lead strated a higher rate of success and a decreased rate of arterial can-
to pulmonary embolism. nulation with US guidance during CPR.75 US guidance for femoral
Many of these complications can be prevented or minimized with vein cannulation may not yet be a standard practice, but it may be a
the use of US guidance. Karakitsos et al. showed a statistically sig- useful technique that can reduce the rates of complication of central
nificant difference between the blind and US-guided techniques venous cannulation.
with regard to arterial puncture, hematoma formation, hemothorax,
pneumothorax, and infection rate.67 All of these were in favor of the SUMMARY
US-guided study arm. Multiple smaller studies have shown similar
results in favor of the US-guided technique.2,68–72 There is no spe- Central venous access is often necessary in critically ill patients and
cific report of complication rates involving the thoracic duct, nerve in those with poor peripheral veins. Mastery of these techniques is
injury, or thyroid injury. This is likely due to the extremely rare inci- essential for anyone who will be caring for acutely ill and unstable
dence of damage to these structures. Overall, US guidance has been patients. While all approaches to the central circulation have accept-
shown to significantly reduce complications and improve patient ably low complication rates (1% to 5%) when performed by experi-
safety for internal jugular vein access. Complications during cath- enced providers, they all carry real risks to the patient.39,49 Be certain
eterization occur in proportion to the operator’s inexperience.64 If that there is no safer peripheral access alternative before placing a
the patient is unlikely to survive a mistake, the most experienced central venous line.
person available should perform the procedure! The internal jugular vein is a good choice for central venous
access in nonambulatory patients. The right internal jugular vein
provides easy access to the superior vena cava for monitoring and
SUBCLAVIAN VEIN CATHETERIZATION
for infusion of solutions too concentrated or irritating for peripheral
Complications of subclavian vein cannulation are similar to those veins. This route poses a slightly lower risk of complications than
of internal jugular vein cannulation, as described above. While the subclavian route.64,66
there is no risk of carotid artery injury if the procedure is per- The subclavian vein provides easy access to the central circula-
formed correctly, the subclavian artery can be lacerated if the nee- tion. Subclavian vein catheters are more easily tolerated by awake
dle is advanced too deeply. Malposition of the catheter tip, usually and ambulatory patients than are internal jugular or femoral cath-
due to overinsertion of the catheter, is common. Lacerations of the eters. Subclavian vein cannulation does present very real risks to the
thoracic duct can be avoided by performing the procedure on the patient that must be balanced against the need for the procedure
right side, avoiding overpenetration with the introducer needle, and other alternatives. Subclavian vein access is the least preferred
and avoiding directing the needle too superiorly toward the junc- route in young children due to their small size, the proximity of the
tion of the subclavian vein and internal jugular vein. Other com- pleura, and the proximity of the subclavian artery.
plications, such as injury to the brachial plexus and phrenic nerve, Femoral vein cannulation is an essential emergency skill. It allows
are uncommon but possible.73 They can be prevented by avoiding the easiest central venous access in most patients with the lowest
over-insertion of the needle during the procedure and avoiding risk of catastrophic immediate complications compared to jugular
needle paths superior and posterior to the subclavian vein. and subclavian access procedures.
A pneumothorax is a very real risk with subclavian vein cath- US guidance for central venous access, specifically the internal
eterization. The procedure should not be performed unless jugular vein has rapidly become integrated into the practice of
personnel are immediately available who can deal with this com- Emergency Medicine. Familiarity with US guidance is become a
plication.74 The risk of a pneumothorax is probably higher in obese mandatory skill for the Emergency Physician when placing central
patients, who may have distorted anatomic landmarks and in whom venous lines. Refer to Chapter 50 regarding the complete details of
a more acute angle is required to enter the subclavian vein. Patients US-guided central venous access.
with emphysema and COPD may have higher pleural domes and
less pulmonary reserve in the event of a pneumothorax.
FEMORAL VEIN CATHETERIZATION

Deep venous thrombosis of the femoral and more distal veins is a Ultrasound-Guided
recognized complication of femoral venous lines.56 Inadvertent can-
nulation of the femoral artery may occur. This is particularly true
50 Vascular Access
during an episode of severe hypotension or cardiac arrest. If such an Srikar Adhikari
episode goes unrecognized, infusion of vasopressors into the artery
may result in ischemic injury to the distal limb.
INTRODUCTION
Even though US guidance for femoral vein cannulation does not
currently have large studies with robust data in the literature, ana- Central venous catheterization is essential in the management of
tomical visualization can be useful in multiple situations. Recent critically ill patients seen in the Emergency Department (ED). It
research depicting the anatomical variation and overlap between allows for fluid resuscitation, central venous pressure monitoring,
the femoral artery and the femoral vein in normal patients brings pacemaker placement, and administration of vasoactive medica-
to question the safety of blind or landmark based venous cannu- tions. Complications such as arterial puncture, hematoma, pneu-
lation. In a stable patient with a palpable pulse, US guidance may mothorax, hemothorax, and air embolus have been reported to
aid in identifying a very small femoral vein and/or significant occur in 5% to 20% of patients.1–3 Unsuccessful cannulation has
been reported in up to 20% of cases.4,5 Central venous catheter-

ization has traditionally been performed using surface anatomic
landmarks as a guide to locate the veins. Catheterization is not
always successful using the landmark method due to anatomical
variations or obscured landmarks. Other factors such as obesity,
shock, dehydration, intravenous drug abuse, congenital defor-
mities, thromboses, and scarring can complicate the procedure.
Ultrasound (US)-guided vascular access is widely supported
in current medical practice. The use of US guidance for central
venous cannulation has been endorsed by several medical societ-
ies and supported by numerous trials in the literature. US guid-
ance has been shown to improve cannulation success rates,
reduces mean insertion attempts, and reduce placement failure
rates.6–11 US guidance allows the Emergency Physician to more
precisely locate target vessels and also provide real time visualiza-
tion of needle placement.
Peripheral venous access is more commonly performed in the ED FIGURE 50-2. The US probe is used to apply external pressure to the soft tis-
sues of the neck. The internal jugular vein collapses with gentle compression (CA,
than central venous cannulation. Patients with a history of chronic
carotid artery; IJV, internal jugular vein; SCM, sternocleidomastoid muscle).
kidney disease, intravenous drug abuse, vascular disease, organ
transplantation, and obesity lack easily located peripheral venous
sites. Obtaining peripheral intravenous (IV) access in these patients
can be a challenge, even for the most experienced medical person-
nel. Multiple studies have shown US-guided peripheral IV access is CENTRAL VEINS
safe and successful in these patients.12–17 US-guided peripheral IV The internal jugular and femoral veins are commonly used for
access prevents the need for central venous catheterization and the US-guided central venous catheterization. US-guided subcla-
pain of multiple needle sticks in many “hard-to-stick” patients. vian vein cannulation is technically more challenging because the
vein runs for a significant distance under the clavicle. The clavicle
ANATOMY AND PATHOPHYSIOLOGY obstructs the US beam and produces a large acoustic shadow, which
makes US visualization of this area difficult.
It is important to recognize the differences in sonographic appear- The internal jugular vein traverses the neck and is unopposed
ance between arteries and veins when performing US-guided vas- by bone, making it an ideal vein to visualize with US. The inter-
cular access. Arteries and veins can be distinguished by their size, nal jugular vein lies underneath the bifurcation of the sternal and
shape, location, ability to be compressed, Doppler mode signal, clavicular heads of the sternocleidomastoid muscle. It continues
and spectral Doppler waveforms. Arteries have relatively thick and to run vertically downward in the neck, lying at first lateral to the
hyperechoic (white) walls and anechoic (black) lumens. Veins have internal carotid artery, and then lateral to the common carotid
relatively thin and hypoechoic (gray) walls and anechoic (black) artery. It eventually enters the subclavian vein (Figure 49-2).
lumens. The thin-walled veins are usually oval, easily compressible, The common femoral vein lies medial to the common femo-
and have no pulsations on Doppler mode (Figures 50-1 & 50-2). ral artery and inferior to the inguinal ligament. In the upper
Arteries are typically round in appearance and pulsatile on Doppler thigh, the superficial femoral and deep femoral veins unite to
mode (Figure 50-1). Arteries and veins are often found adjacent to form the common femoral vein. The greater saphenous vein
each other. Veins are usually larger in diameter than arteries in a joins the anteromedial aspect of the common femoral vein below
well-hydrated patient (Figure 50-1). The anatomy relevant to the the inguinal ligament (Figure 50-3). The common femoral vein
sonographic evaluation of central and peripheral veins is described becomes the external iliac vein after it passes under the inguinal
in the following sections. ligament.
PERIPHERAL VEINS
The three veins of the upper extremity that are most commonly
used for US-guided vascular access are the basilic, cephalic,
and brachial veins. The venous drainage of the upper extrem-
ity consists of a deep system and a superficial system. The deep
system includes radial and ulnar veins in the forearm that unite
to form the brachial vein, which is the deep vein in the upper
arm. The brachial vein lies next to the pulsatile and noncom-
pressible brachial artery (Figure 50-4). It is not uncommon to
find paired superficial and deep brachial veins. The two major
superficial veins of the upper arm are basilic and cephalic veins.
The cephalic vein arises from the radial aspect of the dorsal hand
venous network, ascends proximally along the anterior border of
the brachioradialis muscle, runs lateral to biceps muscle and joins
axillary vein. The basilic vein begins in the ulnar side of the dor-
sal hand venous network, ascends along medial aspect of forearm
FIGURE 50-1. US image of the neck vessels. The internal jugular vein (IJV) is thin- and upper arm, and unites with the brachial veins to form the
walled and oval. The carotid artery (CA) is thick-walled and round. axillary vein.
FIGURE 50-3. US image of the femoral vessels. The common femoral vein (CFV) FIGURE 50-4. Transverse US view of the upper arm veins (BA, brachial artery;
lies medial to the common femoral artery (CFA). The superficially located greater BAV, basilic vein; BV, paired brachial veins).
saphenous vein (GSV) enters the common femoral vein 2 to 3 cm below the
inguinal ligament.
axis approach allows better depth and needle slope information.
The entire needle can be tracked with this approach. The long
STATIC APPROACH TO VASCULAR ACCESS axis approach provides much better visualization of the tip of the
needle and its trajectory, thus avoiding inadvertent puncture of
The static approach to vascular access involves confirming the the posterior wall of the vein. The long axis approach requires
location of the vein prior to performing the cannulation. Place more hand–eye coordination and is technically more difficult
the US transducer perpendicular to the course of the vein to visu- to learn.
alize the vein and verify compressibility. Adjust the probe so that
the target vein is in the center of the US monitor screen. This INDICATIONS
places the vein directly under the center of the US probe. Place
a mark on the skin at the midpoint of the US probe to mark the US can be used to mark the site of needle entry or provide real
vein location. To assess the path of the vein, repeat this process at time guidance. Ideally, US guidance should be used for all inter-
a point 2 cm away and along the vein. These two points marked nal jugular and femoral vein cannulations if the equipment is
on the skin will serve as a guide to direct the needle. Determine available. It should also be used for peripheral IV access in all
how deep the vein is located. Look at the depth markers on the “hard-to-stick” patients or when a peripheral vein is not visible or
side of the US monitor screen. Remove the probe and prepare the palpable. The use of US-guided peripheral IV access in the patient
patient as usual. with difficult peripheral IV access can prevent the need for cen-
Proceed with the catheterization. Insert the needle approxi- tral venous access. It is highly recommended in the patient with
mately 0.5 cm above or below the mark. Advance and direct the poor anatomic landmarks, coagulopathies, anticoagulant use, a
needle to the appropriate depth underneath the skin markings. If history of difficult IV access, DIC, thrombocytopenia, prior sur-
the patient changes position after marking the skin but before nee- gical interventions or radiation in the area, scarring on the skin
dle puncture, the patient must be re-imaged and the skin markings above veins, intravenous drug abuse, obesity, hypotension, and
repeated prior to inserting the needle. The advantages of the static severe dehydration.
approach are its simplicity and that the US probe does not need
to be prepared for the sterile portion of the procedure. The disad- CONTRAINDICATIONS
vantage of this technique is that the needle is not visualized in real
There are no absolute contraindications to the use of US for cen-
time while performing the procedure.
tral or peripheral venous access except lack of US training and
experience.
DYNAMIC APPROACH FOR VASCULAR ACCESS
The dynamic approach to vascular access involves inserting the EQUIPMENT
needle into the vein under real time US guidance. Two techniques
are used for the dynamic approach and they refer to the orientation
of the US probe and target vein during the venipuncture. The short • Ultrasound gel
axis approach visualizes the vein in a cross section. The long axis • High frequency, 5 to 10 MHz linear array US probe
approach visualizes the vein longitudinally. • Sterile US probe cover (clear plastic cover, US gel, and rubber
Each approach has its own advantages and disadvantages. The bands)
short axis approach provides better medial to lateral orienta-
tion of the needle in relation to the target vein and also allows • Povidone iodine or chlorhexidine solution
for visualization of adjacent structures in the same image. Novice • Equipment for peripheral IV access (Chapters 47 and 48)
sonographers can learn the short axis approach more quickly and • Equipment for central venous access (Chapter 49)
it can be performed in anatomic locations where space is limited
• Water-soluble lubricant, sterile
such as the neck or the groin in an obese patient. One potential
danger with the short axis approach is unseen penetration of the • Translucent dressing (e.g., Tegaderm)
posterior wall of the target vein and adjacent structures. The long • 2 to 3 inch (in) long catheter-over-the-needle, various sizes
PATIENT PREPARATION patient in the Trendelenburg position with their head turned
to the contralateral side or kept in a neutral head position
CENTRAL VENOUS ACCESS (Figure 50-5A). The relationship of the internal jugular vein to
the carotid artery changes with head position. In the neutral posi-
Position the patient the same as if performing central venous tion, the internal jugular vein assumes a more lateral position to
catheterization using the landmark method (Figure 50-5). Place the carotid artery. This minimizes the risk of arterial puncture
the US machine across from where you will be standing to min- while accessing the target vein. For femoral vein access, stand
imize the body movement required to view the US image. For at the bedside adjacent to the patient’s hip with the US machine
internal jugular vein access, stand at the head of the patient with above the patient’s shoulder (Figure 50-5B). Place the patient in
the US machine at the patients hips (Figure 50-5A). Place the the reverse Trendelenburg position with their hip abducted and
externally rotated (Figure 50-5B). This position enhances the
success rate of catheterization by increasing the surface area of
the femoral vein available for cannulation.18
Perform a preliminary scan prior to preparing the patient for
the sterile procedure. Survey the underlying vasculature to con-
firm the patency of the target vein, determine the optimal site
for venipuncture, and adjust the US machine settings to optimize
the image. The ability of the vein to be compressed distinguishes
artery from vein, confirms the patency of the vein, and reduces
the risk of cannulating a thrombosed vein. Do not assess com-
pressibility in the long axis. The US probe may slide off the vein
and be seen as the vein lumen disappearing and misinterpreting
it as being compressible. Clean and prep the skin at the access
site as if performing a traditional central line placement. Follow
strict aseptic technique and all barrier precautions during the
procedure.
The procedure can be performed by either one person (the
Emergency Physician) or two people (the Emergency Physician and
A an assistant). Using the two-person technique, one person stabilizes
the US probe over the vein and the other performs the procedure.
Prepare the US probe as discussed below.
US PROBE PREPARATION
A high frequency, 5 to 10 MHz, linear array US probe is typically
used for US-guided vascular access. These US probes produce lin-
ear images and are ideal for visualization of superficial structures
such as veins. Always use a sterile US probe cover and sterile
US gel when performing central venous catheterization. Set up
a sterile field on a bedside table. Open the US probe cover set onto
the sterile field.
Instruct an assistant to hold the US probe upright and
place standard or sterile US gel on the footprint of the US probe
(Figure 50-6A). Apply the sterile probe cover over the US probe
(Figure 50-6B). Smooth all the air bubbles away from the foot-
print of the US probe to prevent imaging artifacts. Secure
the cover with rubber bands to prevent it from sliding off the
US probe (Figure 50-6C). Place the US probe on the sterile field
(Figure 50-6D). Apply sterile US gel onto the cover over the
probe footprint just before scanning.
US PROBE ORIENTATION
Orient the US probe. In the short axis approach, the marker on
the US probe and the marker on the US machine screen should be
aimed in the same direction (Figure 50-7). If the needle moves to
the right side of the US probe, the needle also moves to the right
on the US machine screen. This helps to accurately move the nee-
dle right to left while directing the needle towards the vein. This
makes performing the procedure less complicated. In the long axis
B approach, it is important to know which way the probe marker is
directed (cephalad or caudad) so that the Emergency Physician
FIGURE 50-5. Patient and US machine positioning for central venous access. knows which side of the screen the needle will come from (i.e., the
A. Internal jugular vein access. B. Femoral vein access. right or left of the image).
FIGURE 50-6. Preparing the US probe. A. An assistant holds the US probe

upright and US gel has been applied. B. The sterile probe cover is applied.
C C. The sterile probe cover is secured with sterile rubber bands. D. The prepared
US probe on a sterile field.
IDENTIFICATION OF VEINS
Identify and verify the vein depth, direction, and patency prior
to the procedure. To locate the internal jugular vein, place the
US probe in the triangle formed by the two heads of sternoclei-
domastoid muscle and clavicle (Figure 50-8A). Scan from the
apex of the triangle to the clavicle. Visualize the internal jugular
vein, carotid artery, and thyroid gland (Figure 50-8B). The inter-
nal jugular vein is an irregular and oval-shaped structure lateral
to the carotid artery (Figures 50-8B & C). Visualize the internal
jugular vein and identify its widest diameter, the depth from the
skin surface, and its relationship to the carotid artery. Instruct
the patient to perform a Valsalva maneuver to increase venous
flow and distend the internal jugular vein while observing the
US machine screen to note the changes in the US appearance of
the vein.
To locate the common femoral vein, scan below the mid- FIGURE 50-7. The US probe marker and the marker on the US machine screen
point of inguinal ligament (Figure 50-9A). The common femoral are aimed in the same direction.
A A
B
B
FIGURE 50-9. Identification of the common femoral vein. A. Patient and US probe
positioning. B. US image of the transverse or short axis view in B-mode (CFA, com-
mon femoral artery; CFV, common femoral vein).
Do not apply excessive pressure with the US probe when assess-

ing the vein. Excessive pressure can collapse the vein and makes it
difficult to identify. Verify that the identified vessel is compressible
and truly a vein (Figure 50-2). The ability of the vein to be com-
pressed distinguishes artery from vein, confirms the patency of
the vein, and reduces the risk of cannulating a thrombosed vein.
C Do not assess compressibility in the long axis. The US probe may
slide off the vein and be seen as the vein lumen disappearing and
misinterpreting it as being compressible.
FIGURE 50-8. Identification of the internal jugular vein. A. Patient and US probe Doppler US can be used to identify vascular structures. Color
positioning. B. US image of the transverse or short axis view in B-mode. C. Short Doppler ensures the patency of blood vessels (Figure 50-8C).
axis view in color Doppler mode. The large blue internal jugular vein is clearly vis- Spectral Doppler distinguishes blood flow patterns. Spectral
ible adjacent to the red carotid artery (CA, carotid artery; IJV, internal jugular vein; Doppler demonstrates continuous venous flow in the internal
SCM, sternocleidomastoid muscle).
jugular and femoral veins (Figure 50-10A). Triphasic pulsatile
flow is seen on spectral Doppler in the carotid and femoral arteries
(Figure 50-10B).
artery should be clearly visible next to the common femoral vein TECHNIQUES
(Figure 50-9B). The greater saphenous vein merges with the com-
mon femoral vein on the medial aspect. Visualize the common
femoral vein and identify its widest diameter, the most superficial
SHORT AXIS APPROACH TO CENTRAL VENOUS ACCESS
location, the depth from the skin surface, and a location that does The short axis approach allows visualization of the vein in
not overlap with the common femoral artery. cross section. This view is obtained by placing the US probe
A B
FIGURE 50-10. Long axis US images of spectral Doppler waveforms. A. The internal jugular vein. B. The carotid artery.
perpendicular to the long axis of the vein. The vein appears oval- needle is inserted 1.4 cm. It is very useful to assess the distances
shaped in this view (Figures 50-1, 50-8B, & 50-9B). Place ster- using this method before venipuncture to avoid complica-
ile US gel on the skin above the vein and on the footprint of the tions. If the vein is not punctured within the expected inserted
sterile US probe. Grasp the US probe with the nondominant hand needle length, the needle trajectory is not accurate and should be
and the needle with the dominant hand. As described previously, reassessed.
reidentify the vein and the optimal site of needle insertion. Adjust It is important to understand that the US beam is very narrow and
the US probe to center the target vein on the US machine screen. only 1 to 2 mm wide despite the US probe being approximately 1 cm
The midpoint of the US probe now becomes the reference point wide. The needle will be visualized only when it is within this nar-
for needle insertion. row beam width. The cross section of the needle in the short axis
Select the skin entry site to maximize the chances that the tip approach will be seen only when it crosses the US scan plane that
of the needle punctures the vein as well as intersect the US probe is oriented perpendicular to the needle. The needle tip or shaft
scan plane. The geometry of the Pythagorean Theorem (a2 + b2 = will appear as a hyperechoic dot within the vein (Figure 50-12A). It
c2) can be used to assess the distance to insert the needle into the will be seen in association with either an acoustic shadow (black) or
skin and away from the US probe (Figure 50-11). Measure the a reverberation or ring down artifact (white echoes) posterior to the
distance from the skin surface to the center of the vein. This dis- needle (Figure 50-12B).
tance is equal to the distance from the probe to where the needle Clean, prep, and anesthetize the skin after estimating the dis-
punctures the skin at a 45° angle. For example, if the distance from tance to the vein. Insert and advance the needle at a 45° angle
the skin surface to the center of the vein is 1 cm, make the skin (Figure 50-13). During the initial portion of the needle path,
puncture 1 cm from the midpoint of the US probe along the tra- its location can only be identified by signs of it pushing through
jectory of the vein (Figures 50-11A & B). Insert and advance the the tissue as soft tissue movement. This is because the needle has
needle at a 45° angle. The vein will then be punctured after the not yet crossed the US probe scan plane. Small, rapid, and in-line
FIGURE 50-11. The short axis approach needle insertion based on the Pythagorean theorem. A. The depth (a) equals the distance from the US probe (b) to insert the
needle at a 45° angle. B. A sample calculation where a2 + b2 = c2.
FIGURE 50-14. Short axis US image demonstrating tenting of the anterior wall of
the vein as it is penetrated by the needle.
collapse downward as it is being punctured and then return to nor-

mal after the wall is punctured. Visualize the hyperechoic needle tip
within the lumen of the vein to confirm the needle entered the vein
(Figure 50-12). A concurrent flash of blood will be seen in the
syringe. Place the US probe back onto the sterile field. The remain-
der of the procedure is as described for the landmark technique of
central venous access (Chapter 49).
LONG AXIS APPROACH

B TO CENTRAL VENOUS ACCESS
The long axis approach targets the vein along its length in the lon-
FIGURE 50-12. Short axis US image of a needle within a vein. A. The needle tip
gitudinal plane. Grasp the US probe in the nondominant hand and
is visible as a hyperechoic dot inside the lumen. B. The reverberation or ring down
artifact from the needle.
the needle with the dominant hand. Locate the target vein using the
short axis approach. Verify it is compressible. Slowly rotate the US
probe to visualize the vein in the long axis. The US probe should be
positioned directly over the vein so that its long axis is parallel to the
movements of the needle are helpful to locate the needle tip on the long axis of the vein (Figure 50-15). Adjust the US probe to visual-
US image. Do not mistake the needle shaft for the needle tip. ize the vein at its greatest anteroposterior diameter.
Always try to locate the needle tip by angling or fanning the US Insert the needle through the skin at approximately a 30° angle
probe. As the needle contacts the anterior vein wall, it will tent or adjacent to one end of the US probe (Figures 50-15 & 50-16).
buckle the vein wall (Figure 50-14). The wall of the vein will first
FIGURE 50-13. The short axis approach for venous access. FIGURE 50-15. The long axis orientation and needle insertion.
FIGURE 50-18. Patient and US machine positioning for upper extremity periph-
eral venous access.
FIGURE 50-16. The long axis approach for venous access. Place a tourniquet on the upper arm, just below the axilla, to
distend the veins. Sit or stand at the patient’s bedside facing the
patient. Position the US machine so that the screen is easily visible
(Figure 50-18). To locate the veins and find the ideal venipuncture
site, scan the entire upper arm from just below the tourniquet to
The needle should be in the plane that is in-line with the long the elbow. Identify the basilic vein along the medial aspect of the
axis of the US probe and in the exact same plane as the US beam. upper arm (Figure 50-19). Move the US probe slightly laterally to
With this approach, it is crucial to keep the US probe steady and visualize the brachial vein adjacent to the brachial artery. Scanning
over the vein. Advance the needle. The needle tip and shaft will further laterally will identify the cephalic vein. Peripheral veins
be visualized in real time as it travels through the subcutaneous collapse very easily. Minimize the pressure placed upon the skin
tissues and into the lumen of the target vein (Figure 50-17). If it surface with the US probe. Too much pressure can collapse these
is not visualized in the US image, the needle plane and US probe veins and make them difficult to identify. Identify the segment of
scan plane are not aligned. Do not advance the needle any further. vein that is widest in diameter, closest to the skin surface, and not
Withdraw the needle toward the skin and redirect it to align it adjacent to an artery. Verify that the vein is compressible and pat-
with the US beam and the long axis of the vein. ent as described previously.
Prepare the skin insertion site similar to peripheral IV place-
ment. There is no need to follow any special precautions such
PERIPHERAL VENOUS ACCESS as a sterile US probe cover. Apply a large transparent dressing
Place the patient supine with their upper extremity abducted to (e.g., Tegaderm) onto the footprint of the linear array US probe.
expose the anteromedial aspect of the upper arm (Figure 50-18). Make sure that no air bubbles are trapped between the transparent
FIGURE 50-17. Long axis US image of the needle shaft in the subcutaneous FIGURE 50-19. Short axis US image of the basilic and brachial veins (BA, brachial
tissues and the tip inside the lumen of the vein. artery; BAV, basilic vein; BV, brachial vein).
FIGURE 50-21. Long axis US image of a cannulated peripheral vein. The catheter
is visible inside the lumen of the vein.
ASSESSMENT
Scan along the length of the cannulated vein in both the long axis
view and the short axis view. Confirm the placement of the catheter
within the lumen of the vein (Figure 50-21).
AFTERCARE
No specific aftercare is required following the US guidance. The
aftercare procedures are related to the central venous line (Chapter
49) and peripheral IV (Chapters 47 & 48) placement.
COMPLICATIONS
Complications related to using US for vascular access are gen-
FIGURE 50-20. US probe and needle insertion for upper extremity venous access. erally due to a poor technique or misinterpretation of images.
A. Long axis approach. B. Short axis approach. An artery can be misinterpreted as a vein. There is no exposure
to ionizing radiation. No increased risk of infections has been
reported with the use of US when aseptic technique was followed.
US guidance can be more time consuming when used for routine
dressing and the US probe. The transparent dressing keeps the peripheral IV access. Its use may actually save time in the patient
field sterile and prevents contamination of the US probe with with difficult venous access. Using too short of a peripheral IV
blood. Use a water-soluble lubricant (e.g., Surgilube) instead of US catheter can result in it being pulled out of the vein and the infu-
gel for scanning. Use a 2.5 to 3.0 in long catheter-over-the-needle sion solution extravasating. This can be prevented by using a
for US-guided peripheral IV access. Standard length peripheral longer (2 to 3 in) catheter-over-the-needle and/or inserting the
IV catheters are too short to reach or stay within the lumen of catheter at a steeper angle to minimize the distance it travels in
the vein. Identify the vein in either the long axis (Figure 50-20A) the subcutaneous tissues.
or the short axis (Figure 50-20B) using the methods described
previously. Insert the catheter-over-the-needle under US guid-
SUMMARY
ance. Once the tip of the needle is within the lumen of the vein,
advance the catheter into the vein (Figure 50-21). Put down the US-guided vascular access is widely supported in current clinical
US probe. Withdraw the needle, attach IV tubing onto the hub of practice. It can be used for both central and peripheral IV access.
the catheter, and secure the catheter. US guidance has been shown to reduce failure rates and many of
the complications associated with the traditional landmark tech-
nique. The benefits of US guidance include precise localization of
ARTERIAL ACCESS the target vein, visualization of adjacent structures, identification of
US guidance can be used to assist in obtaining an arterial blood gas anatomic variations, avoidance of veins with thromboses, and real
and the placement of an arterial catheter. Identify the artery by its time visualization of venipuncture. Knowledge of the sonographic
round shape, relatively thicket walls, noncompressibility, and pulsa- anatomy and basic US technology combined with hand–eye coor-
tile contractions. The procedure of cannulating an artery is the same dination are essential to perform this procedure. Understanding the
as described above for a vein. Refer to Chapter 57 for the complete principles discussed in this chapter will enhance the success rate of
details regarding arterial puncture and cannulation. vascular access.
CHAPTER 51: Troubleshooting Indwelling Central Venous Lines 337
is discouraged. Manipulation of a dialysis line should only be

Troubleshooting Indwelling undertaken in a true emergency or if the line is malfunctioning
51 Central Venous Lines and is needed for hemodialysis.
James J. McCarthy EQUIPMENT

INTRODUCTION
• Sterile alcohol prep pads
Indwelling central venous lines are an essential part of the care of • Thrombolytic agent
both the acutely and chronically ill patients. These patients may
require implanted venous access devices due to their poor periph- • Syringes, 5 mL and 10 mL
eral venous access or for long-term intravenous therapies. When an • 18 gauge needles
indwelling central venous line is malfunctioning, the Emergency • Noncoring (Huber) needle
Physician must act quickly and thoughtfully to diagnose and
• 70% ethanol solution
correct the malfunction without further damaging the device.
Understanding the different etiologies and a thorough assessment • 0.1 N hydrochloric acid (HCl) solution
are critical to the successful management of a central venous cath- • Sterile saline
eter malfunction. • Heparinized saline flush solution (100 U/mL)
• Sterile gauze squares
• Sterile gloves
Indwelling central venous catheters allow access to the central
venous circulation from a peripheral site. This access to the cen- Repair kits are available to repair some externally damaged par-
tral circulation is via the end of a partially implanted catheter that tially implanted catheters. The kits avoid the need to remove the
protrudes from the body or through the skin into a subcutaneous device and implant a new catheter. If the external tubing of the
reservoir of a fully implanted catheter.1,2 The proximal tip of the device is damaged, apply a smooth catheter clamp proximal to
central venous line will typically reside in either the superior vena the damaged area and arrange to have the device repaired. The use
cava, the inferior vena cava (less commonly), or the right atrium. of these kits is beyond the scope of this chapter.
Indwelling central venous access devices can malfunction for a
variety of reasons. The two most common types of vascular catheter THROMBOLYTIC AGENTS
complications are thrombotic occlusions and infections.3 The etiol-
ogy of the malfunction can be divided into two main categories: The use of a specific thrombolytic agent is institution-specific
external to the catheter and internal to the catheter. External mal- and physician-specific. Streptokinase, recombinant tissue plas-
functions are for the most part mechanical malfunctions. Examples minogen activator (t-PA), Reteplase, and urokinase have all been
include catheter migration, the catheter tip abutting a vessel wall, successfully used to dissolve a clot within a central venous cath-
a mural thrombus, and kinked catheters. Internal malfunctions eter.4,7–12 Volumes and doses of the drugs differ significantly and
can be further divided into thrombotic (e.g., intraluminal throm- careful attention should be paid to the medication administra-
bus, fibrin sheath, and fibrin tail) and nonthrombotic (e.g., drug/ tion. Urokinase and recombinant tissue plasminogen activator
drug precipitate, insoluble salts, lipid precipitate, and drug/solution are most commonly used. Streptokinase is more likely to lead to a
precipitate).3–5 Phenytoin and diazepam cannot be given through hypersensitivity reaction, especially if the patient has prior expo-
silicone indwelling lines as they can crystallize and permanently sure to it, and is therefore not recommended. Urokinase is the
obstruct the catheter lumen.4 Calcium and phosphate can form an thrombolytic agent used by most institutions because it is much
insoluble precipitate within the catheter lumen. Infused lipids can less expensive than t-PA. Urokinase may be purchased in concen-
form waxy casts within the catheter lumen. trations of 5000 U/mL and 250,000 U/5 mL (50,000 U/mL). The
concentration of 5000 U/mL is used for dissolving a clot within a
catheter. Some institutions prefer to use t-PA for this process. The
INDICATIONS Pharmacist dilutes a 50 mg vial of t-PA with 50 mL of sterile water
Any catheter that cannot be easily flushed or aspirated requires fur- to produce 25 syringes containing 2 mg of t-PA in 2 mL (1 mg/mL).
ther investigation. If peripheral venous access is readily available, The syringes of t-PA are then frozen until needed. It is also avail-
and the patient is not acutely ill due to catheter sepsis or central able from the manufacturer in 2 mg single use vials. Standard dos-
venous thrombosis, catheter troubleshooting may be deferred to ing for catheter obstructions is 1 mL of urokinase (5000 U/mL),
the Primary Care Provider. It is important to consider that delay- 2 mL of t-PA (1 mg/ml), or 0.4 units of Reteplase.15
ing troubleshooting may make management more difficult and
therefore necessitate line replacement. However, the Emergency PATIENT PREPARATION
Physician will have to address the problem if emergent or urgent
access to the patient’s central vascular system is required. Discuss the procedure with the patient and/or their representa-
tive. Most patients with indwelling central venous access devices
are very familiar with their use and idiosyncrasies. The patient
CONTRAINDICATIONS
will often be able to tell the Emergency Physician if the line has
Any device that is obviously displaced from the central circula- had problems in the past and the method used to correct the
tion is not salvageable and should not be used. Dislodging a clot problem. Some patients will be able to suggest postural changes
or septic thrombus from a catheter tip can lead to a fatal pul- (e.g., raising an arm or lying in the Trendelenburg position) that
monary embolism. Catheter manipulation should be avoided if will help the catheter function better. Obtain a posteroanterior
signs of sepsis or central venous thrombosis are present.6 The and lateral chest radiograph to confirm that the tip of the catheter
use of indwelling dialysis lines for purposes other than dialysis is in a proper location.
Catheter occluded
• CXR to verify catheter tip position
• May infuse with caution if able to
inject but not aspirate
Change patient position

• Raise arms
• Deep breath
• Trendelenburg or recumbent
• Cough
No precipitate Still occluded Precipitate seen or suspected
Attempt to aspirate clot of large-bore Waxy Particulate or crystalline

partially implanted catheter with a • TPN • Medications
syringe connected directly to the • Intralipids • Minerals (calcium & phosphate)
catheter Luer hub
Urokinase, t-PA or reteplase EtOH ⫻ 1 HCI ⫻ 3

injection ⫻3
Contrast dye study

HCI ⫻ 3 EtOH ⫻ 1
No clot or cannot infuse

Clot present
contrast material
Urokinase, t-PA or
reteplase injection ⫻3
HCI ⫻ 3
Urokinase or t-PA
infusion, may repeat Contact consultant, catheter will
dye study & infusion probably need to be replaced
EtOH ⫻ 1 once
FIGURE 51-1. An algorithmic approach to the occluded central venous catheter. Continue to work down the protocol until the occlusion is resolved (CXR, chest radiograph;
EtOH, 70% ethanol in water; HCl, 0.1 normal hydrochloric acid solution; TPN, total parenteral nutrition).
The chest radiograph is a good screening tool that allows the and debris from the distal port of a partially implanted device or
Emergency Physician to often diagnose catheter complications. A the skin overlying the reservoir of a fully implanted device. Apply
malpositioned catheter or one with the tip abutting the vessel wall povidone iodine or chlorhexidine and allow it to dry. Wipe off the
must be removed and replaced. A catheter whose flow changes iodine (if used) with a sterile alcohol prep pad. This process must
with patient arm position may be subject to the “pinch-off ” phe- be performed every time a needle is inserted into a central venous
nomenon. This may be visible as a kinking of the catheter as it access device.
passes between the clavicle and first rib. A series of chest radio-
graphs with the arm at the patient’s side and elevated may reveal
TECHNIQUES
the kinking or pinching-off of the catheter. These catheters require
removal. A catheter may migrate intravascularly so that it is within An algorithmic approach to the occluded indwelling central venous
the contralateral subclavian vein. An Interventional Radiologist catheter is summarized in Figure 51-1.9,14 The key principle is that
may be able to insert a wire or snare into the femoral vein to forced irrigation of the catheter, especially with a 1 mL syringe, is
grasp and reposition the catheter. Arrhythmias associated with a never performed as the catheter may rupture.
catheter tip positioned within the heart require the catheter to be A catheter that flushes easily but cannot be aspirated may have
removed and a new one inserted. The distal catheter can curve a fibrin sheath around the catheter tip forming a one-way valve.
upward so that it lies within the jugular vein. An Interventional The tip may also be lodged against the wall of the superior vena
Radiologist may be able to reposition it. Otherwise, it must be cava or the right atrium. Repositioning the patient may alleviate
removed and replaced. the problem. The catheter may be cautiously used for an infusion
Any manipulation, injection, or aspiration of a central venous if there are no signs of infection (e.g., new heart murmur, fever,
line must be done using strict aseptic techniques. Clean any dirt erythema, or discharge at the catheter or subcutaneous reservoir
CHAPTER 51: Troubleshooting Indwelling Central Venous Lines 339
site) and the catheter tip is in good position. Refer the patient to an intravenous line equipped with a 0.22 micron or 0.45 micron
their Primary Care Provider or a consultant for follow-up of the filter. A urokinase infusion may be begun over a 24-hour period.
malfunction. Administer the urokinase at a dose of 200 U/kg-hr mixed to run at
The problem is more serious if the catheter does not easily flush. a rate of at least 20 mL/h.8,9 A continuous t-PA infusion may also
Attempt to obtain peripheral intravenous access while attempting to be started. Use 2 mg/20 mL as a low dose for ports, 4 mg/20 mL
correct the problem with the central venous catheter. If there are no as a high dose for ports, or 5 mg/50 mL as a high dose for tun-
signs of infection, and the catheter is not ruptured or malpositioned, neled catheters. Set the t-PA infusion rate at 10 mL/h for low and
the Emergency Physician must decide if a prolonged effort at resolv- high doses for ports or 20 mL/h for high dose tunneled catheters.
ing the occlusion is necessary. If so, proceed as described below and Thrombolytic infusions should be undertaken in consultation with
in Figure 51-1. the patient’s Primary Care Provider as the patient will require hos-
pital admission.
PARTIALLY IMPLANTED CATHETERS Consider consulting an Interventional Radiologist if these meth-
ods do not successfully clear the catheter or if a thrombolytic infu-
A clot or small amount of precipitate within the partially implanted
sion is contraindicated. They can perform percutaneous fibrin
catheter may be able to be aspirated if the catheter bore is large
sheath stripping, exchange over a wire, or removal and replace-
enough to permit passage. Remove the Luer-lock cap from the
ment of the malfunctioning catheter. Alternatively, the Emergency
catheter. Connect a 10 mL syringe with 2 to 3 mL of sterile saline
Physician may place a new central venous catheter at another site if
directly to the occluded port’s Luer adapter. Any clot large enough to
the patient requires immediate vascular access.
occlude the catheter will not pass through a needle. Apply negative
pressure to the syringe. The catheter is probably occluded by a clot
or a precipitate if the obstruction cannot be aspirated. Remove the FULLY IMPLANTED CATHETERS
syringe and attach a new Luer-lock cap. The procedure is the same for a fully implanted central venous
If a precipitate is seen in the catheter aspirate, determine if it is access device with one exception. The subcutaneous reservoir will
waxy or solid. Waxy precipitates are due to the lipid component of not be able to be initially cleared by aspiration. Any clot or pre-
parenteral nutrition fluids. Waxy precipitates may be dissolved with cipitates large enough to occlude a catheter will not pass through
a solution of 70% ethanol in water. Inject 1 to 2 mL of this alcohol– a noncoring (Huber) needle. Always use a noncoring (Huber)
water solution and allow it to dwell in the catheter for 1 hour. needle when aspirating or injecting through a fully implanted
Aspirate the catheter to determine patency. If still occluded, inject catheter.
1 to 2 mL of 0.1 N hydrochloric acid solution. Allow the solution to
dwell in the catheter for 20 minutes. Aspirate the catheter to deter-
mine patency. Attempt to infuse 0.1 N hydrochloric acid solution AFTERCARE
two more times. The next step is to infuse a thrombolytic agent, as Indwelling central venous lines must be flushed with saline,
described below, or to replace the catheter. followed by the appropriate heparin solution if necessary, after
Solid precipitates are due to precipitation of medications or min- clearing the obstruction. Refer to Chapter 49 for the complete
erals. Dilute 0.1 hydrochloric acid solution may be used to dissolve details. Patients given thrombolytics must be assessed for bleed-
precipitated calcium and phosphate crystals. Infuse 1 to 2 mL of ing at the catheter site and elsewhere prior to discharge, if they do
0.1 N HCl and allow it to dwell in the catheter 20 minutes. Aspirate not require hospital admission. The success rate for thrombolyt-
the catheter to determine patency. The process may be repeated up ics restoring catheter patency are greater than 80%.16,17 Patients
to three times. If still occluded, inject 1 to 2 mL of 70% ethanol in receiving prolonged thrombolytic infusions should be admitted
water and allow it to dwell in the catheter for 1 hour. Aspirate the for the infusion and for monitoring of potential bleeding com-
catheter to determine patency. The next step is to inject a thrombo- plications. Patients and their care providers must be made aware
lytic agent, as described below, or to replace the catheter. of any catheter malfunctions and the attempts made at restoring
If no precipitate is present, or if efforts to clear the precipitate catheter patency.
fail, a clot may be present within the catheter lumen. Clots prob-
ably form to some extent in the majority of implanted central
venous catheters. The clots may obstruct the catheter lumen.13
COMPLICATIONS
Thrombosis of the central veins, superior vena cava, or right The complications associated with attempts to de-occlude a cath-
atrium may also occur. Suspect a major vein thrombosis if there eter include catheter rupture, disconnection of the catheter from
is swelling, pain, or edema of anatomic structures that are drained any implanted reservoir, hemorrhage, and contamination of the
by the cannulated vein(s). catheter with subsequent infection. No major bleeding episodes or
Small clots may be dissolved by a bolus or infusion of a throm- deaths have been associated with intracatheter thrombolysis.15–17
bolytic agent. Inject 1 mL of urokinase (5000 U/mL), 2 mL of t-PA Assessment for these complications is discussed in Chapter 49.
(1 mg/mL), or 0.4 units of Reteplase into the catheter. Allow the solu-
tion to dwell in the catheter for 30 minutes. Aspirate the catheter to
SUMMARY
determine patency. This process may be repeated up to three times.
For catheters with multiple occluded ports, the medication dosing In the course of their treatment, a number of patients with indwell-
should remain the same but divided into equal doses between the ing central venous access devices will present to the Emergency
ports. If still occluded, inject 2 mL of intravenous contrast dye under Department with malfunctioning catheters. Familiarity with the
fluoroscopy or inject the dye and obtain a radiograph. If no clot is strategies for diagnosing and correcting the catheter dysfunc-
present or if the contrast material will not infuse, attempt to clear tion will enable the Emergency Physician to restore the function
the catheter with hydrochloric acid solution (up to three times) and of some, but not all, indwelling lines. Early consultation with the
70% ethanol in water. patient’s Primary Care Provider, Vascular Surgeon, or Interventional
If a clot is present within the catheter, a continuous thrombolytic Radiologist is essential if the procedures outlined do not promptly
infusion may be considered. The infusion should occur through restore the catheter’s function.
venous access. These catheters are unlikely to erode through or

Accessing Indwelling perforate the thin right atrial wall.
52 Central Venous Lines The internal jugular, subclavian, and femoral veins can all be
utilized as a route for a central venous line to access the superior
vena cava or right atrium. The subclavian veins are most commonly
Lisa Freeman Grossheim
used to maximize patient comfort and mobility. When the line is
initially inserted, the vein is punctured transcutaneously, the cath-
INTRODUCTION eter is inserted into the vein, and its distal end is tunneled under
Venous access for medication administration, nutritional sup- the skin. If the line is partially implanted, the distal end of the
port, hemodialysis, and blood sampling is essential for the man- catheter is brought external to the skin through a small puncture
agement of many chronic diseases. A variety of indwelling central (Figure 52-1A). If the line is fully implanted, its distal end is con-
venous access devices have been developed to avoid repeated nected to a subcutaneous reservoir that is placed in a pocket dis-
venipunctures and permit direct access to the central circulation. sected under the skin of the chest wall (Figure 52-1B).
These devices may be partially or completely implanted under the
patient’s skin. The Emergency Physician must be able to access PARTIALLY IMPLANTED CATHETERS
these devices to administer medications and withdraw blood
samples without damaging the device or causing it to clot off. The Partially implanted central venous catheters (Figures 52-1A & 52-2)
necessary procedures for successfully accessing indwelling cen- are those whose distal end emerges from the skin via a subcutaneous
tral venous lines are described in this chapter. tunnel.3 This tunnel helps prevent the spread of skin flora along the
outside of the catheter and toward the central circulation. Most par-
tially implanted catheters use a subcutaneous Dacron cuff to further
ANATOMY AND PATHOPHYSIOLOGY insulate the proximal catheter from skin flora and help anchor the
catheter in place.4
Indwelling central venous lines allow access to the central venous A variety of models are in use, including the Broviac,5 Hickman,6
circulation from a peripheral site.1,2 This is accomplished through and Groshong7 catheters. All are available in single-lumen or
either the end of a partially implanted catheter or through the multiple-lumen versions. Broviac and Hickman catheters must be
skin into a subcutaneous reservoir of a fully implanted catheter flushed with heparin solution twice weekly. The Groshong cath-
(Figure 52-1). The proximal tip of the central venous line may lie eter is unique in that it has a slit valve at its proximal end that pre-
in the superior vena cava or in the right atrium. Catheters designed vents blood from reentering the catheter once it has been flushed
for right atrial placement are made of softer and more pliable mate- (Figure 52-3). Groshong catheters need only a weekly saline flush
rial than are catheters used for short-term transcutaneous central to prevent clot formation.
Superior vena cava Subcutaneous

Right subclavian reservoir
vein
Vein entry site
Cephalic
vein
B
A
Dacron cuff
(under skin)
Skin exit site
Right atrium
FIGURE 52-1. Indwelling central venous lines. A. The partially implanted central venous line. The distal end of the line emerges from the chest wall. Contamination of the
implanted portion is prevented by a subcutaneous tunnel and a Dacron cuff around the catheter. B. The fully implanted central venous line. The catheter is connected to
a reservoir that is contained in a subcutaneous pocket.
CHAPTER 52: Accessing Indwelling Central Venous Lines 341
Female luer
adapter
Catheter lumen diameter & volume

printed on luer adapter sleeve
Clamp
Protective
clamping sleeve
Dacron cuff
Strengthening sheath
(Broviac catheters only)
FIGURE 52-4. The fully implanted central venous catheter. The reservoir lies in the
subcutaneous tissue and is anchored with sutures to keep the diaphragm facing
the skin surface.
catheter’s distal end is attached to a subcutaneously implanted

reservoir.4 Various catheters, including Hickman and Groshong
FIGURE 52-2. The partially implanted central venous catheter. A single-lumen
catheters, can be attached to a subcutaneous reservoir. Most fully
(Hickman or Broviac) line is shown schematically. The Dacron cuff lies in the sub-
implanted central venous access systems are known by the brand
cutaneous tissue just proximal to the skin entry site. The catheter tip lies in either
the proximal superior vena cava or the right atrium. names Port-A-Cath and Infusaport. Most manufacturers recom-
mend that these catheters must be flushed with a heparin solution
monthly when not in use.7 However, there are some data that sug-
gest that flushing of the port system can be done every 3 months
The Hemocath or Permacath is the largest bore of the right atrial without any increase in complications.7 The reservoir’s infusion
catheters. It is manufactured by Quinton and is used for hemodi- port is covered with a self-sealing silicone rubber membrane
alysis, plasmapheresis, long-term nutritional support, and analgesia. (Figures 52-4 & 52-5). Specially designed noncoring or Huber
These catheters are typically flushed during dialysis, but otherwise
should be flushed three times per week with heparinized saline.
FULLY IMPLANTED CATHETERS Right angle

Huber needle
Fully implanted central venous catheters are those that are entirely
embedded and do not exit the skin (Figures 52-4 & 52-5). The
Clamp
Catheter
Stabilizing Self-sealing
suture membrane
FIGURE 52-3. The Groshong central venous catheter tip. Detail of the Groshong Fluid flow
three-position slit valve that prevents venous blood from passively entering the
catheter when it is not in use. A. The closed or resting position of the slit valve. FIGURE 52-5. Accessing the fully implanted central venous catheter system.
B. The valve opens outward from positive pressure when the catheter is flushed The reservoir is stabilized between the fingers of the Emergency Physician’s non-
or infused. C. The valve opens inward from negative pressure when the catheter dominant hand as a noncoring (Huber) needle is used to penetrate the skin and
is aspirated. reservoir.
needles must be used when accessing the subcutaneous reservoir infection. An inability to dialyze the patient will lead to significant
to avoid permanently damaging the self-sealing membrane. morbidity and mortality. There are a finite number of veins avail-
able for dialysis access.
PERIPHERALLY INSERTED CENTRAL CATHETERS
EQUIPMENT
Peripherally inserted central catheters are also known as PICC lines.
They are inserted into the brachial, cephalic, or antecubital vein of • Povidone iodine or chlorhexidine solution
the upper extremity and advanced into the subclavian vein. The • Sterile gauze, 4 × 4 squares
greatest drawback for the use of PICC lines is the 50% risk of cath-
• 10 mL syringes
eter-related thrombosis. PICC lines are made of either silicone or
polyurethane. They are 50 to 60 cm long and have an outside diam- • 20 gauge needles
eter of 2 to 7 French, with the 5 French being most commonly used. • Sterile saline, 0.9%
They are available in both single-lumen and double-lumen versions. • Heparinized saline flush (100 and 1000 U/mL)
Some PICC catheters are equipped with a Dacron cuff similar to the
• Adhesive tape
Broviac and Hickman catheters.
• Luer-lock caps
PERCUTANEOUS CENTRAL VENOUS CATHETER • Blood collection tubes
A device similar to the PICC is known as the percutaneous cen- • Infusion set
tral venous catheter (PCVC). This catheter is often used in neo- • Any intravenous fluids or medications to be injected
nates in the neonatal intensive care unit and not in the Emergency • Huber needle, noncoring right angle or straight angle
Department. It is available in three sizes (1.1, 1.9, and 2.8 French).
• Topical anesthetic (EMLA cream, ethynyl chloride spray, or ice)
The 2.8 French size is used more often because the smaller sizes tend
to become occluded with a thrombus. This device is only mentioned • Injectable anesthetic without epinephrine, 1% lidocaine
for completeness. • Sterile alcohol prep pads
• Sterile gloves
INDICATIONS • Sterile drapes
PATIENTS REQUIRING PATIENT PREPARATION

INDWELLING CENTRAL VENOUS LINES Discuss the necessary procedure with the patient and/or their rep-
Patients of all ages and with a variety of diagnoses may present with resentative. Obtain an informed consent for accessing the device.
an indwelling central venous line. Some examples of such presenta- Patients with indwelling central venous lines are usually very famil-
tions are chronic painful conditions requiring parenteral analgesia iar with their care and use. They can often advise the Emergency
(e.g., sickle cell disease), chronic infections requiring long-term Physician on the correct procedure, the appropriate flush solution,
parenteral antibiotics (e.g., endocarditis, osteomyelitis), the need and any anatomic manipulations necessary to optimize flow through
for prolonged hyperalimentation, patients with difficult peripheral the line (e.g., raising the arms, turning the head, etc.). Aseptic tech-
intravenous access, and cancer patients required chemotherapy nique is required at all times when accessing indwelling central
and blood sampling. Any patient who will require several weeks of venous catheters.
repeated intravenous blood sampling and/or drug administration is
a candidate for an indwelling central venous line. TECHNIQUES
ACCESS OF INDWELLING CENTRAL VENOUS LINES PARTIALLY IMPLANTED CATHETERS
Fully or partially implanted central venous access devices may be Accessing a partially implanted central venous catheter is simple
accessed routinely when phlebotomy is required, medications must and similar to accessing a heparin-locked peripheral intravenous
be administered, or intravenous fluids must be administered. catheter.7,10 Remove any adhesive tape and gauze wrapped around
the distal end of the lumen to be accessed. Fasten the catheter clamp
CONTRAINDICATIONS on the desired lumen (Figure 52-2). Clean the catheter cap and Luer
adapter with povidone iodine or chlorhexidine solution and allow it
Do not access an indwelling central venous device if periph- to dry. The technique for accessing the catheter will vary depending
eral intravenous access can be obtained. The use of bedside on whether blood sampling with or without a subsequent infusion
ultrasound may facilitate peripheral intravenous access and avoid is required. Both techniques are described below.
accessing the indwelling device. Fully implanted devices should
not be accessed through infected skin. Partially implanted cath-
BLOOD SAMPLING FROM
eters known or suspected to be infected should be used cautiously,
as they may be a source of septic emboli, although it is sometimes
PARTIALLY IMPLANTED CATHETERS
possible to treat catheter sepsis without removing the device.8,9 Blood samples may be withdrawn through the catheter cap using a
Phenytoin and diazepam cannot be given via silicone indwell- 20 gauge hypodermic needle attached to a 10 mL syringe if blood
ing central venous lines as they can crystallize and permanently is to be sampled without beginning an infusion. Insert the needle
obstruct the catheter lumen.10 through the Luer cap. Open the catheter clamp. Withdraw 5 mL
Devices used for hemodialysis should be accessed only in a of blood from the catheter. Discard the blood sample, needle, and
true emergency and if no other method of venous access can syringe. This blood sample is diluted by the catheter contents (i.e.,
be readily obtained. This guideline is intended to prevent loss of saline or heparinized saline) and does not truly represent the circu-
the patient’s dialysis access due to device damage, clotting, or an lating blood. This step is essential when accessing dialysis catheters
CHAPTER 52: Accessing Indwelling Central Venous Lines 343
as they contain a dose of concentrated heparin (1000 U/mL). If clamp. Remove and discard the syringe with the original blood
unable to aspirate blood, gently flush the catheter with 2 to 3 mL of sample. Apply a new syringe, open the catheter clamp, and with-
sterile saline. Avoid using a syringe smaller than 5 mL to inject as draw the blood sample. Close the catheter clamp. Remove the
pressure high enough to damage the catheter can be generated. syringe. Continue this sequence of events until all required blood
Refer to Chapter 51 for troubleshooting instructions if the catheter samples are obtained. It is imperative to make sure that the
does not flush easily. catheter is clamped when the cap or syringe is removed to pre-
Withdraw the required blood samples using a new needle and vent an air embolism. Securely attach primed intravenous tubing
syringe. Transfer the blood samples into collection tubes for the to the hub of the catheter, open the catheter clamp, and begin the
laboratory. The catheter must now be flushed to prevent it from infusion.
clotting off. Flush the catheter with the appropriate solution in a Clamp the catheter lumen when terminating the infusion or if
10 mL syringe armed with a 20 gauge needle. Inject 3 to 5 mL of no infusion is to be started. Remove the intravenous tubing or the
heparinized saline (100 U/mL) into Broviac and Hickman cath- syringe from the catheter. Attach a syringe containing the appropri-
eters. Inject 5 mL of normal saline into a Groshong catheter. Inject ate flush solution, open the catheter clamp, and flush the catheter.
dialysis catheters with the volume printed on the catheter, usually Close the catheter clamp. Remove the syringe. Apply a new sterile
≤2 mL, of heparinized saline (1000 U/mL). Wipe off the cap with cap onto the hub of the catheter. Never use “needle-less” caps, as
an alcohol pad. they are a potential source of air emboli. Open the catheter clamp
Secure the free end of the catheter. Tape the catheter to the to prevent catheter damage from long-term clamping. Secure the
patient’s chest wall to prevent accidental traction on the catheter. catheter to the patient’s chest wall.
Evaluate the skin puncture site. Reapply a dressing over the skin
puncture site if necessary. FULLY IMPLANTED CATHETERS
A noncoring Huber-type needle must be used to access subcuta-
BLOOD SAMPLING AND INFUSION
neous injection ports (Figures 52-5 & 52-6). A small-gauge stan-
THROUGH PARTIALLY IMPLANTED CATHETERS dard hypodermic needle can be used only in a dire emergency if
The Luer catheter cap can be removed entirely and the catheter a noncoring needle is not available. The diaphragm covering the
lumen accessed directly with a Leur-hub syringe if an infusion injection reservoir can be damaged by a standard hypodermic
is to be subsequently started. Ensure that the catheter clamp needle, leading to subcutaneous hemorrhage and necessitating
is securely closed. Remove the cap from the catheter. Attach a surgical replacement of the implanted device.
10 mL syringe to the hub of the catheter. Open the catheter clamp. Clean and prep the skin overlying the injection port with
Withdraw 5 mL of blood into the syringe. Close the catheter povidone iodine or chlorhexidine solution and allow it to dry.
FIGURE 52-6. The Huber needle. A. Photo of a complete right-angle Huber

needle set, including the extension tubing and clamp. B. Photo showing the
right-angle Huber needle compared with a standard hypodermic needle.
C. Drawing showing the key difference between a standard hypodermic needle
and the Huber needle. The hypodermic needle tip can cut a cylindrical core of
subcutaneous tissue and the diaphragm sealing the subcutaneous reservoir. The
Huber needle pushes the subcutaneous tissue and the diaphragm material aside
without removing any of it.
TABLE 52-1 Volumes and Concentrations of Heparin Flushes for Pediatric discharge, or serous discharge). Instruct the patient to immediately
Indwelling Devices contact their Primary Care Provider or return to the Emergency
Children < 6 months old Children > 6 months old Department if they develop a fever or other signs of an infection.
Partially implanted 3 mL heparin (10 U/mL) 5 mL heparin (100 U/mL)
device COMPLICATIONS
PICC line 3 mL heparin (10 U/mL) 5 mL heparin (100 U/mL) The most important elements after accessing indwelling lines are
Fully implanted 3 mL heparin (10 U/mL) 5 mL heparin (100 U/mL) to not allow the central venous line to clot off and not to contami-
device
nate the line. Strict adherence to the procedures described above will
minimize the chances of these problems occurring. Complications
associated with the catheter include right atrial thromboses, right
atrial erosion with pericardial tamponade (rare with implanted
The application of a topical or injectable anesthetic over the reser-
lines), catheter-related infections, and pulmonary embolism.7,9,11,12
voir is optional but greatly appreciated by the patient. Remove the
Fully implanted catheters may become disconnected from the sub-
iodine solution (if used) with an alcohol swab. Flush the Huber
cutaneous reservoir or may leak into the subcutaneous tissue due
needle and extension tubing with normal saline using a 10 mL
to diaphragm failure. Any hematoma formation near the reservoir
syringe. Leave the syringe attached. Locate the center of the self-
must be assessed promptly to prevent major hemorrhage. Infection
sealing membrane (diaphragm). Stabilize the reservoir with the
and line sepsis can be prevented using strict sterile technique.
nondominant hand (Figure 52-5). Slowly and steadily insert the
An air embolism should be suspected if the patient becomes con-
needle through the skin and into the reservoir (Figure 52-5). Stop
fused, hypotensive, and/or tachycardic while accessing the central
advancing the needle when it touches the far wall of the device.
venous access device. This complication is 100% preventable by
Gently flush 2 to 3 mL of saline through the needle. Refer to
ensuring that the catheter tubing is clamped closed whenever the end
Chapter 51 for troubleshooting instructions if the catheter does
of the tubing is without a cap. Immediately place the patient in the
not flush easily.
Trendelenburg position and on their left side (i.e., left lateral decu-
If the catheter can be flushed easily, secure the Huber needle
bitus position). This will hopefully cause any air emboli to collect in
in place by stabilizing it with gauze squares and tape. Withdraw
the apex of the right ventricle and not enter the pulmonary artery.
5 to 10 mL of blood. Close the clamp on the extension tubing
Repair kits are available for damaged partially implanted cath-
(Figure 52-5). Remove and discard the syringe. Attach a new
eters. These can serve to avoid the need to remove the device
syringe, open the clamp, and withdraw the required blood samples.
and implant a new catheter. If the external tubing of the partially
Clamp the extension tubing and remove the syringe. If an infusion
implanted catheter is damaged, apply a smooth catheter clamp
is to be started, attach the primed intravenous tubing and begin
proximal to the damaged area and arrange to have the device
the infusion. If no infusion is desired or when discontinuing an
repaired. Instructions for the use of these kits are beyond the scope
infusion, clamp the extension tubing and disconnect the intrave-
of this chapter.
nous tubing. Attach a 5 or 10 mL syringe containing heparinized
saline (100 to 200 U/mL) to the Huber needle extension tubing.
Open the clamp and flush the device with 3 to 5 mL of heparinized SUMMARY
saline. Use only saline if a Groshong catheter is attached to the res- The Emergency Physician will encounter many patients with
ervoir. Remove the Huber needle from the skin. Control any skin indwelling central venous lines. Careful adherence to sterile tech-
bleeding with direct pressure. Apply a sterile dressing. nique as well as proper blood sampling and infusion techniques
will allow access for phlebotomy, medication administration,
PEDIATRIC CONSIDERATIONS and fluid administration while preserving the indwelling line for
future use.
The management of pediatric indwelling devices is similar to those
in adults with a few noted exceptions. The catheters, reservoirs, and
tubing are often smaller than those used in adults or adolescents.
The volumes and concentrations of heparin flushes differ in these
smaller catheters (Table 52-1). The external portion of partially
Pulmonary Artery
implanted devices and PICC lines must be secured with a dressing
so that the child does not pull it out. 53 (Swan-Ganz)
ASSESSMENT Catheterization
Assessment of line function after accessing a central venous access Pratik Doshi
device will not occur until the next access attempt. This procedure is
described above. Troubleshooting nonfunctioning indwelling cen- INTRODUCTION
tral venous lines is discussed in Chapter 51.
The routine clinical catheterization of the pulmonary artery was
made possible by the pioneering work of H.J.C. Swan and William
AFTERCARE
Ganz. Together they developed the soft, balloon-tipped, flow-
Secure the partially implanted catheter to the skin with tape so directed pulmonary artery catheter (PAC) that bears their names.1
that the tubing will not get caught on the patient’s clothing. The Prior to the work of Swan and Ganz, pulmonary artery catheter-
patient should be given a written record of how the access device ization was performed using a stiff catheter that required fluoro-
was used and flushed in the Emergency Department to convey to scopic guidance and was associated with a high complication rate.
their Primary Care Physician should problems with the line become The Swan-Ganz PAC allows reliable and continuous measurement
evident at a later time. Patients must regularly assess their indwell- of hemodynamic parameters to be performed safely, even in criti-
ing access sites for signs of infection (i.e., erythema, pain, purulent cally ill patients.2–4 While complications are uncommon, they can
CHAPTER 53: Pulmonary Artery (Swan-Ganz) Catheterization 345
occur. The optimal application of the PAC, both its insertion and
interpretation of the data, requires appropriate training and skill.5–7 Right internal
This chapter concentrates on the technique of PAC insertion. jugular vein
Obtaining central venous access is a necessary prerequisite for this
technique and is discussed in Chapter 49. A detailed discussion of
the interpretation of the abundant variety of data that the PAC may
provide is beyond the scope of this chapter.8 The interpretation of Right subclavian
data is discussed primarily as it concerns PAC insertion and associ- vein
ated complications.
ANATOMY AND PATHOPHYSIOLOGY Pulmonary

artery
The PAC is advanced into the right atrium from a venous access site Superior
in the neck, chest, upper extremity, or lower extremity. The balloon vena cava
near the tip of the catheter is inflated during its insertion. The bal-
loon follows the flow of blood through the right heart—from the
right atrium through the tricuspid valve into the right ventricle,
then up the right ventricular outflow tract through the pulmonic
valve into the pulmonary artery, and from there into a branch of the
pulmonary artery (Figure 53-1).
When the PAC is correctly positioned, inflating the balloon near Pulmonary artery
its tip will occlude the forward blood flow to that arterial segment catheter
(Figure 53-2). The lumen opening at the tip of the PAC will there-
fore measure the downstream pressure in that vessel, rather than FIGURE 53-1. Cardiac anatomy as it pertains to pulmonary artery catheter inser-
pulmonary artery pressure. Because the pulmonary circulation tion. The PAC enters the right atrium from the superior vena cava, crosses the
has no valves, the pressure that the PAC tip measures beyond the tricuspid valve into the right ventricle, and then crosses the pulmonic valve into the
inflated balloon is equal to the pressure in the pulmonary capillar- pulmonary artery. The catheter tip lies in a branch of the right pulmonary artery.
ies. This pressure is, in turn, equal to the pressures in the pulmonary
veins and the left atrium. During diastole, when the mitral valve
is open, this pressure is equal to the left ventricular diastolic pres- The PAC may also be used to measure cardiac output using the
sure. The left ventricular end-diastolic pressure is a very important thermodilution method. The tip of the PAC has a temperature-
parameter because it is the best clinical indicator of preload. Thus, sensitive probe. When a given volume of cold saline is injected into
measurement of the pulmonary capillary wedge pressure (or pul- the right atrial port of the PAC, it cools the temperature of the blood
monary artery occlusion pressure, as it is sometimes called) pro- flowing past the catheter tip. If the cardiac output is high, the cold
vides an excellent assessment of left ventricular filling without the saline is mixed with and carried along by a larger flow of blood so
need to catheterize the left side of the heart. that the temperature change detected at the PAC tip is smaller and
Right Left
pulmonary artery pulmonary artery
Branch of right
pulmonary
artery
Pulmonary
capillaries Main pulmonary
artery
Pulmonary artery catheter

from right ventricle
Pulmonary
veins
FIGURE 53-2. Diagram of the principle underlying pulmo-

Left atrium nary capillary wedge pressure. Balloon inflation blocks trans-
mission of the forward pulmonary artery pressure to the
tip of the catheter. The catheter tip therefore measures the
downstream pressure of the pulmonary circulation. Because
Mitral valve the pulmonary circulation has no valves, the pressure mea-
sured at the catheter tip is equal to the pressure in the left
Left ventricle
ventricle when the mitral valve is open (diastole).
dissipates faster. If cardiac output is low, the cold saline mixes with a decision to place a PAC. There is an actual cost and potential com-
smaller volume of blood and the temperature change is more appar- plications associated with placement of these catheters.21–28
ent and slower to dissipate.
CONTRAINDICATIONS
INDICATIONS There are no circumstances in which PAC insertion is absolutely
The major advantage of the PAC is that it provides accurate mea- contraindicated. Insertion of a PAC may be relatively contraindi-
surements of hemodynamic parameters such as pulmonary capil- cated in cases where the risks of obtaining vascular access (e.g.,
lary wedge pressure and cardiac output. This is particularly useful severe bleeding diathesis) or of passing the catheter (e.g., a mobile
in critically ill patients, as the clinical estimation of these param- thrombus in the right heart or right-sided endocarditis) outweigh
eters is frequently incorrect.9–13 The PAC may be used for diagnos- the potential benefits of obtaining the data the PAC provides.
tic or therapeutic purposes. Diagnostically, the PAC is usually used A PAC is not indicated in situations where it will provide no
in situations where clinical judgment alone cannot reliably deter- diagnostic information that cannot be acquired by less invasive
mine the physiologic basis for hemodynamic instability, pulmonary means. For example, while a PAC may be helpful in diagnosing
edema, or reduced urine output. Therapeutically, the PAC may help or treating patients with mitral regurgitation or ventricular septal
to direct therapy in patients in whom noninvasive clinical parame- defects following myocardial infarction, echocardiography may be
ters are insufficient guides of treatment efficacy. The most common sufficiently diagnostic and may obviate the need for a PAC. The
clinical indications for the PAC in medical and surgical patients are same can be true in cases of cardiac tamponade. The PAC may
listed in Table 53-1. also be superfluous in situations where it will provide little or no
It should be noted that despite the prevalence of PAC use, few therapeutic guidance. The insertion of a PAC is not necessary if a
prospective studies have documented improved clinical out- therapeutic trial of fluid administration restores urine output and
comes with the PAC except in perioperative surgical patients. blood pressure in a hypovolemic patient who has normal cardiac
Retrospective studies have suggested that the use of the PAC may function. Other contraindications include patients with: cardiac
be associated with worse outcomes.14–17 Over the last 10 years, this dysrhythmias, implanted pacemakers or defibrillators, pulmonary
question has been further studied in randomized controlled tri- hypertension, right-sided endocarditis, right-sided intracardiac
als as a result of the retrospective data suggesting worse outcomes valvular abnormalities, right-sided prosthetic heart valves, right-
with the use of PAC. In all of these trials, PACs do not appear to sided intracardiac thrombi, or severe hypotension. A PAC should
improve survival or decrease length of stay. However, these trials not be inserted if the appropriate equipment is unavailable or if
also do not confirm the suggestion of worse outcomes with the personnel experienced with the insertion and interpretation of the
use of PAC. As with any intervention, the Emergency Physician PAC data are not present.19,20
must carefully assess the potential benefits and risks in making the
EQUIPMENT
TABLE 53-1 Common Clinical Indications for Pulmonary Artery Catheter • Povidone iodine or chlorhexidine solution
Placement in Medical and Surgical Patients • Sterile gloves and gown
Cardiac • Face mask and cap
A. Complicated myocardial infarction
• Saline or dextrose solution with or without heparin (1 to 2 U/mL)
i. Management of refractory hypotension or left ventricular failure
ii. In the presence of hemodynamic deterioration due to a mechanical • Pressure bag with manometer
complication, to differentiate mitral regurgitation from acute ventricular • Pressure tubing
septal defect
• Pressure transducer for distal port (CVP port optional)
B. Other cardiac conditions
i. Diagnose/manage cardiac tamponade • Stopcocks and occlusive caps for each port of PAC
ii. Distinguish cardiogenic from noncardiogenic pulmonary edema • Fluid infusion tubing for sheath sideport and for PAC ports
iii. Management of severe cardiomyopathy
• PAC
iv. Diagnose/manage severe pulmonary hypertension
Medical/Surgical • Balloon inflation syringe
In the setting of sepsis, trauma, burns, multiple organ failure, pulmonary • Catheter sleeve
embolus, or drug overdose. • Sterile dressing for site
If any of the following is found to be unresponsive to conventional • Electrocardiogram (ECG) and pressure monitor
medical management:
A. Hypotension The materials required to place a percutaneous introducer sheath
B. Low urine output are available in commercially prepared prepackaged kits. Refer to
C. Hypoperfusion (evidenced by cool skin, mental obtundation, and lactic Chapter 49 for the details regarding the placement of the intro-
acidosis) ducer sheath. Note that many PACs require an 8.5 French intro-
D. Severe hypoxemia requiring high levels of PEEP (>10 cm) ducer sheath. In addition, it is desirable to use an introducer sheath
Preoperative that allows the sterile protective sleeve over the PAC to be affixed
A. High-risk cardiac surgery (e.g., CABG in elderly patients, multiple valve securely to the sheath.
replacement, and ventricular aneurysm resection) The PAC consists of a balloon lumen that ends in a balloon just
B. Complicated vascular surgery (dissecting aneurysm, resection of thoracic proximal to the catheter tip, a distal lumen that opens at the end
or abdominal aneurysm) of the PAC, a lumen that opens approximately 30 cm proximal to
C. Other surgical patients with multiple risk factors the tip, and a thermister (Figure 53-3). Many PACs have one or
i. Myocardial infarction within 6 months more additional lumens opening proximal to the tip. Some of these
ii. Poor left ventricular function lumens are designed to accommodate a cardiac pacing wire. A 3 mL
iii. Elevated Goldman or ASA score syringe with a safety stop at 1.5 mL is supplied with each PAC.
Thermister lumen port float into the desired position more easily from these two sites. The
left internal jugular vein and the right subclavian vein are accept-
Distal lumen port able alternatives. The femoral vein may also be used. The femoral
approach may be quite difficult without fluoroscopic guidance of
the catheter. The external jugular veins, basilic veins, and axillary
veins are additional alternatives that carry the same difficulty.
It is essential that strict sterile technique be maintained
Proximal throughout the insertion procedure. The Emergency Physician
lumen port and their assistant should be wearing sterile gloves, a sterile gown,
a face mask, and a cap. A large sterile field is necessary, as is close
attention to the long PAC, which can easily become contaminated. It
is also very important to take all necessary precautions with syringe
Balloon channel
needles, scalpel blades, and suture needles to prevent a needlestick
(inflation) port injury.
Insert a percutaneous introducer sheath into the central venous
system. Refer to Chapter 49 for the complete details regarding the
Pressure insertion of the sheath. If the patient already has a single-lumen or
release valve multi-lumen central venous catheter inserted, it may be exchanged
for an introducer sheath. Remove any bandages and dressings on
the catheter and skin access site. Thoroughly prep the catheter,
Extension skin access site, and surrounding skin with povidone iodine or
divided junction chlorhexidine solution and allow it to dry. Drape a sterile field.
Discontinue any infusions through the catheter. Open an intro-
ducer sheath kit. Cut any sutures securing the catheter to the skin.
Insert a guidewire through the hub of the distal port and into the
central venous circulation. Withdraw the catheter over the guide-
wire. Insert and secure the percutaneous sheath over the guidewire
Rounded
as described in Chapter 49.
20 cm tip
10 cm Balloon TECHNIQUE
Port Set up a bedside sterile table and open the PAC kit. Remove the
protective sleeve. It allows later repositioning of the PAC while
FIGURE 53-3. The pulmonary artery catheter.
maintaining sterility. Place the sleeve over the catheter and slide it
far back (>60 cm) from the catheter tip. Attach the balloon infla-
tion syringe to the PAC. Inflate the balloon once to confirm the
This syringe is used to inject air into the balloon. Distances from integrity of the balloon. It is a good idea to inflate the balloon in
the tip of the PAC are indicated by linear markings on the shaft. By a full bowl of sterile saline and observe for air bubbles to ensure
the standard designation, each thin line represents 5 cm increments that there are no leaks or gross eccentricities. Allow the balloon
and each thick line 10 cm increments. to deflate passively. Deflation by aspirating air from the balloon
should be avoided as it places undue stress on the balloon. Flush
the PAC ports with sterile saline and attach a stopcock to each
PATIENT PREPARATION port. Attach the pressure tubing to the distal port. Flush the entire
Routine laboratory studies are advisable prior to PAC insertion apparatus, including the PAC and the pressure monitoring system,
in nonemergent circumstances. Hematologic abnormalities (e.g., with sterile saline to ensure that no air remains in any part of the
severe anemia, thrombocytopenia, and coagulation system defi- system. Have an assistant set up, calibrate, and level the transducer.
ciencies) can increase the risk or adverse consequences of bleeding. Hand the proximal end of the PAC to an assistant to attach to the
Electrolyte derangements (e.g., hyperkalemia, hypokalemia, and ECG monitor. Finally, shake the tip of the PAC while observing the
hypomagnesemia) that may predispose to arrhythmias should be pressure waveform on the monitor to confirm that the monitoring
identified and corrected when possible. system is operative.
Explain to the patient and/or their representative the risks, ben- Insert the PAC through the diaphragm on the introducer sheath,
efits, and complications of the procedure. Obtain informed con- taking care to orient the natural curve of the catheter toward the
sent for the procedure if possible. The use of mild sedation may be right ventricular outflow tract. Continue to advance the PAC until
advantageous in some patients. Place the patient supine if possible. it is inserted 10 to 15 cm and exits the sheath. This ensures that
Continuous ECG monitoring is essential. Pulse oximetry should be the balloon is not inflated within the sheath. Stop advancing the
routinely monitored. Arterial pressure monitoring is often desirable PAC. Inflate air into the balloon and lock the pressure release valve.
in patients receiving a PAC. Apply supplemental oxygen. Equipment The PAC should never be advanced through the central venous
and personnel necessary for assisting with the PAC insertion pro- system with the balloon deflated, as this may provoke ectopy or
cedure and for managing potential complications should be imme- injure the heart or other vascular structures. Conversely, the PAC
diately available. This should include equipment for emergency should always be withdrawn with the balloon deflated.
airway management and emergency cardiac pacing. Pay close attention to the distance markings on the PAC and
The choice of which central venous access site to use for PAC to the pressure waveform on the monitor when advancing the
insertion must be individualized. The preferred sites are the right PAC. Typical pressure waveforms are illustrated in Figure 53-4.
internal jugular vein or the left subclavian vein. The PAC tends to The average distances from the different catheter insertion sites
20
B. Right ventricle
A. Right atrium
Pressure
(mmHg)
20
C. Pulmonary artery D. Pulmonary capillary wedge pressure

Pressure
(mmHg)
0
FIGURE 53-4. Typical pressure waveforms recorded by the pulmonary artery catheter during insertion.
into each chamber of the heart are listed in Table 53-2. Advance critically ill patients should be familiar with the standard informa-
the PAC into the right atrium (Figure 53-4A). Continue to advance tion provided by the PAC. The data generated by the PAC can be
the PAC into the right ventricle, which will be apparent by an divided into two categories. The first set of information comprises
abrupt change in the pressure waveform (Figure 53-4B). Continue data that are directly measured and include the right-sided heart
to advance the PAC into the pulmonary artery outflow tract, again pressures, thermodilution cardiac output, and blood gas obtained
confirmed by a change in the pressure waveform (Figure 53-4C). from a mixed venous sample from the distal pulmonary artery port.
Passing the PAC through the right ventricle may produce some These data, including normal values, are listed in Table 53-3. The
ventricular ectopy, which is generally uncomplicated. Advance second set of data comprises the variables that are mathematically
the PAC a few centimeters further to produce a wedge tracing derived from the measured data (Tables 53-4 & 53-5). These pro-
(Figure 53-4D). Deflate the balloon. This will result in the reap- vide information crucial to understanding cardiac and pulmonary
pearance of the pulmonary artery waveform. If the wedge tracing physiology and pathology. Today, this information is routinely avail-
persists, withdraw the PAC with the balloon deflated until the pul- able on an instantaneous basis as part of computer software pack-
monary artery waveform reappears. Whenever it is unclear where ages that accompany the monitoring equipment. PAC users should
the tip of the PAC is located, deflate the balloon and withdraw become familiar with both sets of information and their applica-
the PAC to a spot where the waveform is recognizable. Take tion in different clinical situations. The reader is advised to consult
notice of the distance marking. Inflate the balloon and advance a current textbook of cardiology or critical care medicine for a more
the PAC until the desired tracing is obtained. detailed description of the hemodynamic data provided by the PAC.
Difficulties in passing the PAC into the pulmonary artery may
occur in patients with pulmonary hypertension, significant tricus- COMPLICATIONS
pid regurgitation, or markedly dilated right heart chambers. Instruct
the patient to inspire slowly and deeply to increase venous return to In addition to the complications associated with obtaining cen-
the right heart. This may allow the PAC to be advanced successfully. tral venous access and with prolonged use of indwelling catheters
Tilting the patient’s head upward and repositioning the patient on (Chapter 49), complications may occur during or after the insertion
their left side may also be helpful. Fluoroscopic guidance may be of the PAC. The complications directly related to the PAC may be
necessary if repeated attempts are unsuccessful. divided into those that are associated with catheter insertion and
Pull up the protective sleeve over the catheter and secure it to the those associated with long-term maintenance (Table 53-6). Both
introducer sheath. It is important not to advance the PAC itself dur- sets of complications can be further divided into those problems
ing this manipulation. Begin any infusions through the PAC. Secure where there has been systematic study and the incidence of com-
the PAC, dress the access site, and document correct positioning by plications has been published and those that have been observed
obtaining an anteroposterior chest radiograph. The assessment and and published as case reports but the actual incidence of which is
aftercare of the skin puncture site is described in Chapter 49. unknown.
Problems with tracing quality may occur due to problems involv-
ing the catheter itself or other parts of the system. Catheter problems
DATA INTERPRETATION
include positioning too distal or not distal enough, balloon rup-
As mentioned in the introduction to this chapter, a detailed dis- ture, or clot formation at the tip. Problems elsewhere in the system
cussion of PAC data interpretation cannot be undertaken here. include air in the lines, loose connections, failure of the transducer,
However, anyone who places or uses PACs in the management of failure of the wires, or failure of the monitor. The system should be
TABLE 53-2 Average Distances from the Catheter Insertion Site to the Catheter Tip Position*
Catheter insertion site Right atrium distance (cm) Right ventricle distance (cm) Pulmonary artery distance (cm) Wedge distance (cm)
Subclavian vein 10 20 30–40 40–45
Right internal jugular vein 15 25 35–45 45–50
Left internal jugular vein 20 30 40–50 50–55
Right antecubital vein 45 60 70–80 80–85
Left antecubital vein 50 65 75–85 85–90
* These distances are considered the common estimates for uncomplicated PAC placement in patients with normal-sized hearts. The distances will vary in patients and may
be greater, especially in the patient with a dilated right ventricle. Any time there is a gross discrepancy between these distances and the actual observed placement distance, the
physician should consider catheter misplacement, catheter looping, or catheter knotting. An immediate portable anteroposterior chest radiograph should be obtained to evaluate
the situation.
TABLE 53-3 Variables Obtained from the Pulmonary Artery Catheter Through Direct Measurement
Variable Normal values Main utility Comments
Cardiac output (CO) 4–6 L/min Diagnosis of shock (high output vs. Measurement is prone to error;
low output); titration of vasoactive should be indexed to patient’s size
medications
Pulmonary capillary wedge 5–15 mmHg Volume status, diuresis, Often overinterpreted; must be used
pressure (PCWP) fluid challenges with other values
Right atrial pressure (RAP) 0–10 mmHg Status of right ventricle Less useful than PCWP
Pulmonary artery pressure (PAP) 15–25 mmHg systolic; Status of right ventricle and Pulmonary artery diastolic can be
8–15 mmHg diastolic pulmonary circuit substituted for PCWP in most patients
Mixed venous oxygen 70%–80% Evaluation of oxygen delivery; Best obtained by blood gas from
saturation (SvO2) pulmonary shunt fraction distal pulmonary artery
TABLE 53-4 Derived Variables Obtained from the Pulmonary Artery Catheter
Variable Normal values Main utility Comments
−5
Systemic vascular 800–1600 dynes/s/cm Shock states, vasodilator versus Unclear whether value should
resistance (SVR) vasopressor therapy (afterload) be indexed to patient’s size
Pulmonary vascular 20–200 dynes/s/cm−5 Pulmonary hypertension; acute Unclear whether value should
resistance (PVR) and chronic lung disease be indexed to patient’s size
Left ventricular stroke work 56 ± 6 g m/m2 Left ventricular performance Clinical utility uncertain
index (LVSWI)
Right ventricular stroke 8.8 ± 0.9 g m/m2 Right ventricular performance Clinical utility uncertain
work index (RVSWI)
•
Oxygen DO delivery DO2 900–1100 mL/min Shock states, anemia, low Often amenable to therapy,
cardiac output but controversial
•
Oxygen consumption VO2 200–250 mL/min Sepsis, burns, trauma, ventilator patients Affected by many variables;
use is controversial
Pulmonary shunt fraction (Qs /Qt) 3%–5% Acute and chronic lung disease Underused in the evaluation
of pulmonary disease
TABLE 53-5 Formulas for the Derivation of Variables

SVR = (mean arterial pressure – mean arterial pressure) × 80 cardiac output
PVR = (mean pulmonary artery pressure − pulmonary capillary wedge pressure) × 80 cardiac output
LVSWI = SV × (mean arterial pressure – pulmonary capillary wedge pressure) 0.0136 body surface area
RVSWI = SV × (mean arterial pressure − right atrial pressure) × 0.0136 body surface area
(DO2) = [(cardiac output × hemoglobin) × (13.4) × (% O2 saturation)] + (PO2 × 0.0031)
(VO2) = (cardiac output × hemoglobin) × (13.4) × (SaO2 − SvO2)
Qs /Qt = (pulmonary capillary O2 content − CaO2)/(pulmonary capillary O2 content − CvO2)
Key : CaO2, arterial oxygen content; CvO2, mixed venous oxygen content; PO2, partial pressure of oxygen; SaO2, arterial oxygen saturation;
SV, stroke volume. Other terms are defined in Tables 53-3 and 53-4.
TABLE 53-6 Recognized Complications of Pulmonary Artery The most serious complications related to long-term mainte-
Catheterization nance of the PAC are pulmonary artery rupture, pulmonary artery
Related to catheter insertion (published incidence) infarction, and catheter infection. Pulmonary artery rupture is usu-
Complete heart block (0%–2.6%) ally the result of the catheter becoming overwedged and/or the bal-
Ventricular arrhythmias requiring treatment (0%–3%) loon over-inflated. Pulmonary infarction has been seen primarily in
Hematoma (0%–3%) patients with mitral regurgitation or pulmonary hypertension and
Air embolism (0.1%) may be avoided if the duration of balloon inflation is kept to a mini-
Pneumothorax (0.1%–1.5%) mum. Catheter infection occurs in 1% to 5% of PAC placements and
Inability to place catheter with multiple attempts (1.7%) can be minimized by strict sterile maintenance of the PAC as well
Injury to great vessels (0.1%–13%) as continually reevaluating the need for the PAC and keeping the
Ventricular arrhythmias (20%–50%) placement time as short as possible. The majority of PACs should be
Related to catheter insertion (reported, but incidence unpublished) used for 72 hours or less.
Hemothorax
Hemomediastinum SUMMARY
Lymphatic duct perforation
Since its introduction four decades ago, the PAC was initially
Injury to trachea
Injury to phrenic or vagus nerve embraced by Emergency Physicians and Critical Care Physicians for
Guidewire embolism its ability to provide real time information regarding variables such
Catheter knotting (requiring surgical removal) as cardiac output and pulmonary capillary wedge pressure at the
Cardiac perforation bedside. PAC use had become common practice. However, over the
last 15 years this has come into significant question. At this point,
Related to long-term maintenance (published incidence) the utility of the PAC is unclear. The PAC has not led to improved
Pulmonary artery rupture (0%–0.5%)
outcomes, decreased mortality, or decreased ICU length of stay.
Pulmonary infarction (0%–0.5%)
Thus, its use as common practice cannot be supported. However,
Catheter infection (1%–5%)
there are still many clinical situations for which the use of the PAC
Related to long-term maintenance (reported, but incidence unpublished) may benefit the Emergency Physician to make crucial decisions.
Catheter shearing with embolization The PAC is a tool in the armamentarium of any clinician taking care
Misreading or misunderstanding of data provided by catheter of critically ill patients. Therefore, it is important to be well versed
in the information that it provides and its application in the clinical
context of the disease state that they are managing.
zeroed and calibrated again to confirm the accuracy of the pressure
values if abnormally high or low values are obtained. Sometimes it
is just not possible to obtain a good wedge tracing despite repeated
attempts. In such cases, the pulmonary diastolic pressure may be
used as a surrogate for the wedge.
A right bundle branch block may occur due to impact of the PAC Peripheral Venous
with the right side of the septum during insertion. This is usually
transient. Even if it persists for hours, it is well tolerated in most
54 Cutdown
patients. However, superimposition of a right bundle branch block Flavia Nobay
in the presence of a preexisting left bundle branch block leaves the
patient with complete heart block. This complication can result in
severe bradycardia and hemodynamic embarrassment. It is impor-
INTRODUCTION
tant to be prepared to institute temporary transcutaneous or Venous access in the critically ill patient is of the utmost impor-
transvenous pacing when placing a PAC in patients with a left tance. The literature regarding peripheral venous cutdowns extends
bundle branch block. back to 1940 when Keeley introduced this technique as an alterna-
Arrhythmias during insertion, most commonly premature ven- tive to venipuncture in patients with shock.1 Interestingly, there has
tricular beats, are usually due to irritation of the right ventricle. been a noticeable lack of recent investigations regarding venous cut-
This is especially true of the outflow tract. Premature ventricular downs, most likely due to the focus on central venous access via
contractions are usually well tolerated unless sustained ventricular the Seldinger technique with ultrasound guidance and intraosse-
tachycardia or ventricular fibrillation occurs. Slight withdrawal and ous access. Recent editions of the ATLS text refer to the saphenous
redirection of the PAC is usually adequate. Arrhythmias after inser- venous cutdown as an optional skill to be taught at the discretion
tion may be due to catheter loops in the right heart, which will be of the instructor.2 However, despite the apparent lack of popular-
apparent on the chest radiograph and can be corrected by careful ity of the peripheral venous cutdown, the importance of obtaining
withdrawal of the PAC until the loop is removed. Arrhythmias may venous access in critically ill patients supports the need to know a
also occur if the PAC tip slips back into the right ventricle. In this wide variety of techniques in order to be successful in every situa-
case, the pressure tracing will show a typical right ventricular wave- tion. The steps outlined in 1940 by Keeley to expose and cannulate
form. Readvancement of the PAC into the pulmonary artery should the saphenous vein remain mostly unchanged.1
eliminate the arrhythmias. Peripheral venous access can be extremely difficult due to vas-
Other potentially serious but rare complications during place- cular collapse from shock, vascular injury, obesity, or scars. Direct
ment include injuries to the great vessels, trachea, lymphatic duct, visualization of the vein to be cannulated can be more fruitful than
vagus nerve, or phrenic nerve as well as a pneumothorax, hemotho- indirect visualization with central venous lines without ultrasound
rax, hemomediastinum, and cardiac perforation. On occasion, the guidance in the patient with shock. However, in a study in 1994 com-
PAC can become knotted intravascularly or within the heart during paring venous cutdowns versus percutaneous femoral venous access,
placement. This requires an Interventional Radiologist to unknot it all times to completion of the procedure and infusion times were
or surgical removal if this fails. faster in the percutaneous femoral access group versus the cutdown
CHAPTER 54: Peripheral Venous Cutdown 351
group.3 Despite these statistics, it is not uncommon to be manag- GREATER SAPHENOUS VEIN
ing a critically ill patient who cannot be cannulated peripherally or
centrally and the venous cutdown becomes a procedure of necessity The greater saphenous vein is the longest vein in the body. It is the
for resuscitation. An additional advantage of the venous cutdown is ideal vein for a peripheral venous cutdown due to its anatomical
that it does not interfere with concurrent resuscitative efforts at the regularity and superficiality (Figure 54-2). The superficial and
head, neck, thorax, and abdomen. consistent position of the saphenous vein, in both adults and
Familiarity with this procedure allows for large-bore access and children, makes this the ideal vessel for a peripheral venous cut-
the rapid infusions required in the critically ill trauma or medical down. The saphenous vein begins at the medial dorsal venous arch
patient with difficult access. All Emergency Physicians should be of the foot. It passes upward and 1.5 to 2.5 cm directly anterior to
familiar with the peripheral venous cutdown in order to effectively the medial malleolus (Figure 54-2A). At the level of the medial
manage resuscitations in the trauma or medical setting. This tech- malleolus, the saphenous vein lies just above the periosteum of the
nique can only be successfully performed if one understands the tibia.4 It continues to ascend in the leg, along with the saphenous
anatomy and details of venous cannulation. Practicing the cutdown nerve, in the superficial fascia over the medial aspect of the leg.
technique before its critical need will help one to perform optimally The vein passes posteromedially to the knee. Above the knee, it
in the emergent setting. curves forward onto the anteromedial thigh. It passes over the fal-
ciform margin of the deep investing fascia to join the femoral vein
ANATOMY AND PATHOPHYSIOLOGY approximately 4 cm below and 3 cm lateral to the pubic tubercle
(Figure 54-2B).
There are three critical areas for venous cutdowns (Figure 54-1). All The greater saphenous vein is easily identified at the ankle. It will
Emergency Physicians should be knowledgeable of the anatomy of be found, approximately, 2.5 cm anterior and 2.5 cm superior to
the saphenous vein at the ankle, the saphenous vein at the groin, and the medial malleolus. It may be palpable if the patient is not hypo-
the basilic vein at the elbow. The potential injury to the patient can volemic or obese. The saphenous nerve, a branch of the femoral
be significant if one approaches this procedure without regard to nerve, travels with the greater saphenous vein. It supplies sensory
the clinical anatomy. innervation to the skin of the medial leg and foot as far as the first
metatarsal. This nerve is often transected when isolating the greater
saphenous vein at the ankle. Fortunately, this nerve is of minimal
clinical significance.
The saphenous vein in the thigh travels on the anterome-
dial surface and enters the fossa ovalis to join the femoral vein
(Figure 54-2B). The femoral vein is at its largest diameter 3 to 4 cm
distal to the inguinal ligament. This is approximately 2 cm distal to
the approach for the placement of a femoral central venous line, at
the same level where the scrotal or labial fold meets the thigh. The
greater saphenous vein is also at its largest diameter in this loca-
tion. At the level of the scrotal or labial fold meeting the thigh, the
greater saphenous vein is easily isolated from the surrounding sub-
cutaneous tissue. If the deep investing fascia of the thigh muscles
is visible, the dissection has progressed deeper than the position of
the greater saphenous vein.
BASILIC VEIN
The basilic vein is the site of choice for a peripheral venous cut-
down in the upper extremity (Figure 54-3). It can be traced start-
ing from the dorsal venous arch of the hand. It ascends on the
posteromedial forearm to become anteromedial on the mid-to-
upper forearm. It continues to ascend to the midportion of the arm
where it pierces the deep fascia. The basilic vein runs in the groove
between the biceps and triceps muscles in the distal one-third of
the arm. The vein can always be found in the groove between the
biceps and triceps muscles. A peripheral venous cutdown should
be performed in this location. The basilic vein is more consistently
found 2 cm cephalad and 1 to 2 cm lateral to the medial epicondyle
of the humerus on the volar (anterior) surface of the arm. The bra-
chial artery and median nerve lie deep to the basilic vein in this
location and are unlikely to be injured if the dissection remains
superficial.
Simon et al. recommend the approach to the basilic vein
through the groove between the biceps and triceps muscles in the
distal one-third of the arm.5,6 These authors feel that locating the
vein above and lateral to the medial epicondyle of the humerus
will result in difficult cannulation secondary to the surrounding
dense venous plexus. There is a significant risk of injury to the
FIGURE 54-1. Common sites for peripheral venous cutdowns include the inner medial antebrachial cutaneous nerve and the deep brachial artery
arm above the elbow (1), the inner thigh (2), and the inner ankle (3). if one tries to find and isolate the basilic vein in the middle third
FIGURE 54-2. Anatomy of the greater saphenous vein. A. The subcutaneous course of the vein in the lower extremity. B. Detail of the greater saphenous vein at the groin.
or proximal third of the arm. Injury to the median antebrachial INDICATIONS

cutaneous nerve will result in sensory loss to the ulnar aspect of
the forearm. The primary indication for a peripheral venous cutdown is the
need for venous access in a patient with no peripheral access
BRACHIAL VEIN and in whom central access is not obtainable or contraindicated.
This is the ideal procedure for the intravenous drug user with no
Brachial vein cutdowns should not be performed in the Emergency peripheral veins and scarred central access sites, the burn patient
Department. The brachial vein is small in diameter. It is located with peripheral venous collapse and scarring, the patient in cardio-
relatively deep and would require significant and time-consuming respiratory arrest, or the hypovolemic trauma patient that requires
steps to locate it. The anatomical structures surrounding the bra- definitive and lifesaving volume resuscitation.7 Hypovolemic shock
chial vein include major arteries and nerves that can easily become is well treated with peripheral venous cutdowns because a unit of
injured while isolating the vein. Patients in hypovolemic shock will blood can be infused in less than 3 minutes with intravenous exten-
often not have a brachial artery pulse. This can lead to confusion as sion tubing inserted directly into the vein.4
to which vessel is the artery and which is the vein.4 Inadvertent can- This is also an excellent technique for emergent pediatric vascular
nulation of the brachial artery can result in a brachial artery throm- access. Direct visualization of the vein will aid in cannulation of a
bosis and upper extremity ischemia. vessel that may be collapsed secondary to hemorrhage, hypovole-
mia, and/or shock. This technique should only be used after other
AXILLARY VEIN access attempts (i.e., interosseous access, ultrasound-guided central
venous access, peripheral venous access—including scalp veins)
The axillary vein is rarely used as a site for a venous cutdown. The have failed.8
axillary vein, in the axilla, is contained within the axillary sheath.
Also contained within the axillary sheath are the axillary artery and
brachial plexus. A venous cutdown for the axillary vein can injure
CONTRAINDICATIONS
these structures and is associated with a high rate of complications. The absolute contraindications to a peripheral venous cutdown are
It is not recommended to perform a cutdown for the axillary vein vascular injury, saphenous vein removal, or long bone fractures
unless the Emergency Physician has specific experience with this proximal to the cutdown site. Relative contraindications include
particular technique. infection overlying the cutdown site, bleeding disorders, or severely
• Sterile polyethylene intravenous tubing

• Sterile intravenous extension tubing
• Central line kit (for Seldinger method)
• Catheter-over-the-needle, 16 or 18 gauge
• Sterile 4 × 4 sponges
• 5 mL syringe
• 18 gauge needles
• Self-retaining skin retractors
Cephalic vein • Small rake, two
• Needle driver
• Silk suture, 3-0 and 4-0
Basilic vein
• Injectable sterile saline
Median • Intravenous tubing and solution
Median cephalic basilic vein • Wound dressing supplies
vein
• Antibiotic ointment
Cephalic vein Basilic vein PATIENT PREPARATION

The patient is usually in extremis and positioned supine if a periph-
eral venous cutdown is to be performed. They may also be in the
Median vein Trendelenburg position, although this is not ideal for the procedure.
of forearm The limb selected for the peripheral venous cutdown should be
secured to the bed with a restraint, tape, or by an assistant. Although
this is an emergent procedure, time should be taken to perform it
in as sterile a manner as possible.
Identify the landmarks for the procedure. Clean the skin of any
dirt and debris. If the patient is awake and aware of the surround-
ings, the area of the cutdown should be anesthetized. Infiltrate local
anesthetic solution into the subcutaneous tissue where the incision
will be made. Prepare the skin with povidone iodine or chlorhexi-
dine solution and allow it to dry. Apply sterile drapes to isolate a
FIGURE 54-3. The superficial veins of the upper extremity. surgical field. Collect and set up all the required equipment on a
bedside table covered with a sterile drape.
distorted anatomy from congenital malformations, blunt trauma, TECHNIQUES TO ISOLATE THE VEINS
or penetrating trauma in the area of the cutdown or the limb. A
cutdown should not be performed unless peripheral intravenous The technique of cannulation is the same regardless of the vein
access has failed and intraosseous access equipment is not available chosen. The methods to isolate the saphenous vein and the basilic
or has failed. vein will be discussed in this section. A discussion of three different
techniques to cannulate the isolated vein will be presented in the
following section.
EQUIPMENT
• Povidone iodine or chlorhexidine solution GREATER SAPHENOUS
• Local anesthetic solution VEIN ISOLATION AT THE ANKLE
• 10 mL syringe The saphenous vein is easily found and isolated at the ankle
• 22 gauge needle (Figure 54-4). Extend and externally rotate the lower extremity.
• #10 scalpel blade Identify the medial malleolus of the tibia. Find the location 2.5 cm
anterior and 2.5 cm superior to the medial malleolus. The greater
saphenous vein will be found at this site. Alternatively, place your
• #3 scalpel handle index and middle fingers at the level of the malleolus (Figure 54-4A).
• Curved Kelley hemostat The vein will be found two finger breadths cephalad and two finger
• Small mosquito hemostat breadths in anterior of the medial malleolus. The vein may be pal-
pable if the patient is not hypovolemic or obese. Alternatively, the
• Vein pick vein may be visualized in patients with thin skin, superficial veins,
• Fine tooth forceps minimal subcutaneous tissue, or dark vessels.
• Iris scissors Stretch the skin taught over the distal tibia with the nondomi-
nant hand (Figure 54-4B). Note the position of the hands in the
• Sharp tissue-cutting scissors
illustration. The nondominant hand is placed with the finger-
• Sterile drapes tips pointing toward the Emergency Physician. This will prevent
• Towel clips inadvertent injury while making the skin incision. Transversely
FIGURE 54-4. Isolation of the greater saphenous vein at the ankle. A. Identifying the vein. B. A transverse skin incision is made from the anterior to the posterior border of
the medial tibia. C. The tip of a curved hemostat is scraped along the tibia then rotated 180° (curved arrow). D. The hemostat is spread to separate the tissues. E. A straight
hemostat is inserted between the jaws of the curved hemostat to elevate the vein. F. The curved hemostat has been removed.
incise the skin overlying the great saphenous vein using a #10 scal- Femoral Femoral Great
pel blade, from the anterior tibial border to the posterior tibial artery vein saphenous
border after appropriate anesthesia (Figure 54-4B). This incision vein
should be superficial so that the subcutaneous tissue is barely
exposed. A deep incision may transect the vein causing significant
bleeding, difficulty visualizing the surgical field, and difficulty
finding the ends of the vein that retract proximally and distally.
Apply tension to the skin on either side of the incision to expose
the underlying structures. This can be accomplished with the non-
dominant hand, a self-retaining retractor, or skin rakes held by an
assistant.
Isolate the greater saphenous vein.5 This may be difficult in some 6 cm
patients in shock or patients in the Trendelenburg position as the Incision
vein may be poorly perfused. Grasp and hold a curved hemostat line
(Kelly clamp) with the tip facing downward. Insert the hemostat
along the posterior border of the tibia and scrape the tip anteriorly
along the tibia (Figure 54-4C). If done properly, all of the tissue
between the skin and the tibia will be above the hemostat. Rotate
the hemostat 180° (Figure 54-4C). The tip of the hemostat will be
facing upward (Figure 54-4D). Widely open the arms of the hemo-
stat (Figure 54-4D). This will open the jaws of the hemostat and
separate the saphenous vein from the saphenous nerve and fibrous FIGURE 54-5. Isolation of the greater saphenous vein at the groin. The skin inci-
strands of connective tissue. The saphenous vein should be visible sion should begin where the scrotal or labial fold meets the thigh. Extend the inci-
between the jaws of the hemostat. If there is difficulty identifying sion laterally until it meets a vertical line from the lateral edge of the mons pubis.
the vein, squeeze the foot to backfill the vein with blood. Insert a
straight hemostat (Kelly clamp) between the jaws of the curved
hemostat and below the greater saphenous vein (Figure 54-4E).
Remove the curved hemostat to leave the straight hemostat elevat- thigh after appropriate anesthesia. Extend the incision laterally until
ing the greater saphenous vein (Figure 54-4F). This straight hemo- it meets the vertical line from the lateral edge of the mons pubis.
stat will be useful as a “cutting board” to later transect the vein by Dissect the subcutaneous tissue to locate the greater saphenous
allowing more manual control of the vein. vein. Place the jaws of a curved hemostat parallel to the greater
An alternative technique to isolate the vein is used by some saphenous vein. Open the arms of the hemostat to allow the jaws
Physicians. This technique is not recommended by the editor to dissect through the subcutaneous tissue. Continue placing the
but is briefly described for the sake of completeness. Make the hemostat and opening the jaws until the vein is isolated. The dissec-
transverse skin incision. Place the jaws of a curved hemostat paral- tion is too deep if the deep investing fascia or the muscle bellies of
lel to the greater saphenous vein. Open the arms of the hemostat to the thigh muscles are encountered. Stop, reidentify the landmarks,
allow the jaws to dissect through the subcutaneous tissue. Continue and adjust the skin incision and dissection as necessary.
placing the hemostat and opening the jaws until the vein is isolated. Alternatively, the subcutaneous tissues can be bluntly dissected
This technique is harder to perform because the vein is less likely using 4 × 4 gauze squares. Grasp two or three gauze squares in
to be identified given the white background of the periosteum.1,8,9 each hand. Put the fingertips of both hands, covered with gauze, in
Additionally, this technique takes significantly longer to find and the center of the incision. Move the hands in opposite directions,
isolate the vein. cephalad and caudad, while scraping the subcutaneous tissue with
the gauze. Reapply the hands in the incision and repeat the motion
until the greater saphenous vein is exposed. This technique applies
GREATER SAPHENOUS pressure parallel to the greater saphenous vein and will not injure
VEIN ISOLATION AT THE GROIN the vein.
The groin vasculature offers the potential for massive infusion of
blood or fluids in a matter of minutes. These vessels are closer to
BASILIC VEIN ISOLATION AT THE ELBOW
the central circulation and large enough to easily accommodate The basilic vein may be used for a peripheral venous cutdown.
intravenous tubing, cut off at a 45° angle, as a catheter. The greater This is often performed when the greater saphenous vein cannot
saphenous vein is superficial at the groin and lies in a meshwork of be accessed due to lower extremity amputation, deformity, injury,
subcutaneous tissue. It is superficial to the femoral artery and vein. or trauma. This site is not ideal as it may interfere with resuscitative
The saphenous vein travels on the anteromedial surface of the thigh efforts while the basilic vein is being exposed. The basilic vein is
and enters the fossa ovalis to join the femoral vein (Figure 54-2B). consistently found 2 cm cephalad and 1 to 2 cm lateral to the medial
The greater saphenous vein is at its largest diameter 3 to 4 cm distal epicondyle of the humerus on the volar surface of the arm. It may
to the inguinal ligament. This is approximately 2 cm below the site also be found in the groove between the biceps and triceps muscles.
for placement of a femoral central venous line and level with where There is controversy in the literature as to where the incision for
the scrotal or labial fold meets the thigh. the basilic vein cutdown should be performed. The simple answer is
Identify the location where the scrotal or labial fold meets the that if one fails in isolating the vein in one location, make an incision
thigh (Figure 54-5). Identify the lateral edge of the mons pubis. in the second location to isolate the vein.
Identify the point where a vertical line from the lateral edge of the Position the patient to allow exposure of the basilic vein. Abduct
mons pubis meets a horizontal line from the scrotal/labial fold. Make the patient’s arm 90° with the elbow flexed 90° and the palm fac-
a transverse, medial to lateral, incision with a #10 scalpel blade on ing upward (Figure 54-6). This positioning is required to access the
the patient’s thigh starting where the scrotal or labial fold meets the basilic vein at either location.
(Figure 54-7A). Slightly elevate the hemostat. Pass a silk suture

under the vein at its proximal end and a second silk suture at its
distal end (Figure 54-7B). Grasp the silk sutures with a hemo-
stat to maintain the position of the tie and to allow for manipula-
tion of the vein. Tie the distal suture to occlude inflow of blood
from distal veins (Figure 54-7C). Do not cut either of these two
sutures. The proximal suture will be left untied at this time to
allow for control and manipulation of the vein.
Have an assistant prepare the catheter. Attach sterile intravenous
polyethylene tubing to a bag of sterile saline. Cut the angiocathe-
Basilic vein ter attachment hub off the end of the tubing at a 45° angle. Some
authors suggest using a feeding tube instead of intravenous tubing.8
Incision line This is not recommended. Intravenous tubing is ubiquitously avail-
able. With a feeding tube, the rounded tip may be more difficult to
Brachial artery advance into the vein. The only advantage to using a feeding tube
is that the rounded tip has less chance of puncturing the posterior
wall of the vein.
Incise the vein. With the nondominant hand, grasp the hemostat
holding the proximal suture. Raise the hemostat to flatten the vein
and prevent back bleeding. Make an incision through half of the
vein with the tip of a #11 scalpel blade (Figure 54-7D). Do not cut
the entire vein as this will cause significant bleeding and loss of
the proximal end. If the incision is too large, greater than one-
half the vein’s diameter, the vessel may be torn completely and
retract from the surgical field.8 The straight hemostat below the
3 cm
vein will act as a “cutting board” and prevent injury to underlying
Medial epicondyle structures from the scalpel blade. As an alternative, the jaws of the
of humerus straight hemostat can be opened and the vein cut with an iris scis-
sors (Figure 54-7E).
FIGURE 54-6. Isolation of the basilic vein. Insert the intravenous tubing into the vein. Gently relax the ten-
sion on the proximal suture to allow the vein to open. Advance the
intravenous tubing 2 to 3 cm into the vein (Figure 54-7F). Often
times, there is considerable difficulty advancing the catheter. Do
Identify the point 2 cm cephalad and 2 cm lateral from the medial
not force the catheter through the vein as it is very delicate.
epicondyle of the humerus. This is the location of the basilic vein.
Troubleshoot by removing the catheter and make sure that the
Make a 4 to 6 cm transverse incision with a #10 scalpel blade cen-
lumen of the vein has been cannulated. This is sometimes difficult
tered on the reference point after appropriate anesthesia. The inci-
to accomplish. If so, have an assistant control the proximal suture.
sion should only cut through the epidermis. Bluntly dissect the
Using a mosquito hemostat, grasp the cut edge of the vein and lift
subcutaneous tissue with a curved hemostat or 4 × 4 gauze squares,
upward to expose the vein’s lumen and insert the intravenous tub-
as described previously, to locate the basilic vein. The dissection is
ing (Figure 54-7G). For small veins, a mosquito hemostat may be
too deep if the brachial artery, median nerve, or muscle fibers
too large to grasp the cut edge of the vein. Insert a vein pick or an
are encountered. Stop, reidentify the landmarks, and adjust the skin
18 gauge needle with the tip bent into a 90° angle into the lumen of
incision as necessary.
the vein (Figure 54-7H). Lift upward to expose the vein’s lumen and
Alternatively, the basilic vein can be isolated in the middle of the
insert the intravenous tubing.
distal third of the arm. Palpate the groove between the biceps and
After inserting the intravenous tubing, palpate the posterior
triceps muscles. This is the location of the basilic vein. Make a 4 to
aspect of the vein for penetration of the catheter. The catheter
6 cm horizontal incision centered about the groove after appropriate
must be removed if it penetrates through the posterior wall of
anesthesia. Bluntly dissect with a curved hemostat until the vein is
the vein. Release the proximal suture and allow the intravenous
located. The basilic vein is superficial to the muscle fascia and the
fluid to flow into the vein if the tubing has not penetrated the pos-
brachial artery.
terior wall of the vein. Tie the proximal suture to secure the intra-
venous tubing within the vein if the fluid flow is unobstructed
TECHNIQUES FOR and the fluid is not extravasating into the surrounding tissues
CANNULATION OF THE VEIN (Figure 54-7I). Do not tie the suture too tight to occlude the
There are a number of techniques to cannulate a vein after it has tubing. Tying the suture too tightly may also result in a throm-
been isolated. Either of the following techniques can be used to can- bosis.10 If the tubing is within the lumen of the vein and the fluid
nulate the greater saphenous vein or the basilic vein. It is important is not flowing, the tubing may be against a venous valve. Gently
to realize that this may be a lifesaving procedure in an emergent advance the catheter 2 to 3 mm or withdraw it 2 to 3 mm and
setting, and the rapid and definitive cannulation of the vessel is the observe the fluid for flow. It is not necessary to close the skin inci-
primary goal and not the technique chosen. sion at this time. Place saline moistened gauze over the incision
site. Wrap a sterile dressing (e.g., Kerlix) around the extremity
and the skin incision site.
SURGICAL TECHNIQUE USING INTRAVENOUS TUBING
If the patient survives the episode for which a venous cutdown
Isolate the chosen vein as described previously. Place a straight was performed, the skin incision must be closed. If the intrave-
hemostat (Kelly clamp) under the midportion of the vein nous tubing was inserted as above, the skin incision will be sutured
FIGURE 54-7. Venous cannulation using intravenous tubing. A. The vein has been isolated. B. A silk suture has been placed proximally and distally around the vein.
C. The distal suture is tied. D. An incision is made through half of the vein with a #11 scalpel blade. E. Alternatively, the hemostat is opened and an iris scissors is used
to cut half of the vein. F. The catheter is inserted into the vein and advanced. G. A mosquito hemostat can be used to grasp the vein and hold it open while the tubing
is inserted. H. For small veins, a vein pick or 18 gauge needle with the tip bent can be used to hold open the vein. I. The proximal suture is tied to secure the tubing.
closed and the tubing will exit the incision. This is not optimal, previously made skin incision (Figure 54-8A). Use caution not
according to some physicians, as it may allow access of bacteria to cut the underlying vein. Insert the intravenous tubing through
through the wound and into the underlying vein. An alternative the stab incision and pull it through the skin incision. Incise the
method is available (Figure 54-8). After exposing the vein, grasp vein and insert the tubing as described previously. This allows the
and elevate the distal skin edge with a hemostat. Make a stab inci- tubing to be tunneled through the subcutaneous tissue before can-
sion with a #11 scalpel blade approximately 1 cm distal to the nulating the vein (Figure 54-8B).
FIGURE 54-8. Alternative technique of venous cannulation with intravenous tub-

ing. A. The distal skin edge is elevated. A #11 scalpel blade is used to make a stab
incision in the skin and subcutaneous tissues. B. The tubing is fed through the stab
incision and into the vein.
SELDINGER TECHNIQUE
Another technique of venous cannulation uses the Seldinger
method.9,11 This technique will insert the catheter as if cannulating
a central vein. Refer to Chapter 49 for complete details. All of the
required equipment can be found in a prepackaged central venous
line access kit. This includes the guidewire, introducer sheath, dila-
tor, and the venous catheter. This technique can accommodate a
large caliber line, such as an 8 or 9 French introducer sheath. This
technique may save 1 to 2 minutes on cannulation time by eliminat-
ing the ligature and tie off steps.
Isolate the chosen vein as described previously. Place a straight
hemostat (Kelly clamp) under the midportion of the vein and
open the jaws (Figure 54-9A). Insert the catheter-over-the-needle
into the vein (Figure 54-9A). Stop advancing the catheter-over-
the-needle when a flash of blood is seen in the needle hub. Be
cautious not to puncture the posterior wall. Remove the straight
clamp. Advance the catheter into the vein while securely holding
the needle. Remove the needle. Insert the guidewire through the
catheter. Remove the catheter by backing it out over the guide-
wire which will remain in the vein. Place the dilator through
the introducer sheath. Feed the dilator–introducer sheath unit FIGURE 54-9. The Seldinger technique of venous cannulation. A. The vein
over the guidewire (Figure 54-9B). Advance the unit into the has been isolated. The catheter-over-the-needle is inserted into the vein. B. A
vein with a twisting motion while securely holding the guide- guidewire has been placed into the vein. The dilator and sheath are fed over the
wire (Figure 54-9C). Continue to advance the unit until the hub guidewire. C. The dilator and sheath are advanced into the vein with a twisting
of the introducer sheath is just above the vein (Figure 54-9D). motion. D. The guidewire and dilator are removed as a unit.
Remove the guidewire and dilator as a unit (Figure 54-9D).
Attach intravenous tubing to the hub of the introducer sheath and
begin instilling fluids. It is not necessary to close the skin incision
at this time. Place saline-moistened gauze over the incision site.
Wrap a sterile dressing (e.g., Kerlix) around the extremity and the jaws (Figure 54-10A). Assemble the unit by placing the dilator
skin incision site. through the sheath and insert the guidewire through the dila-
tor (Figure 54-10B). The guidewire should protrude 3 to 4 mm
beyond the tip of the dilator. Make an incision in the lateral half of
MODIFIED SELDINGER TECHNIQUE the vein (Figure 54-10C). While holding the proximal guidewire
An alternative and quicker method can be used to insert the and sheath, insert the distal guidewire into the vein. Continue
introducer sheath into the vein (Figure 54-10). Isolate the cho- to insert the entire unit with a twisting motion into the vein
sen vein as described previously. Place a straight hemostat (Figure 54-10D). Continue to advance the unit until the hub of
(Kelly clamp) under the midportion of the vein and open the the introducer sheath is just above the vein. Remove the guidewire
FIGURE 54-11. Intravenous catheter technique of venous cannulation. A. A

catheter-over-the-needle is inserted into the vein. B. A catheter-over-the-needle is
inserted through the skin and into the vein.
FIGURE 54-10. The modified Seldinger technique of venous cannulation. A. The

vein has been isolated. B. The dilator, guidewire, and sheath are assembled as
a unit. C. An incision has been made in the vein. D. The unit is inserted into the Isolate the chosen vein as described previously. Place a straight
vein, guidewire first. A twisting motion will aid in its insertion. E. The guidewire and hemostat (Kelly clamp) under the midportion of the vein and
dilator are removed as a unit. open the jaws (Figure 54-11A). Insert the catheter-over-the-nee-
dle into the vein under direct visualization (Figure 54-11A). Stop
advancing the unit when a flash of blood is seen in the needle hub.
and dilator as a unit (Figure 54-10E). Attach intravenous tubing Advance the catheter into the vein while removing the straight
to the hub of the introducer sheath and begin instilling fluids. clamp. Advance the catheter until the hub is just above the vein.
Remove the needle. Attach intravenous tubing to the catheter hub
INTRAVENOUS CATHETER TECHNIQUE and begin instilling fluids. Gently tie the proximal suture to secure
the catheter within the vein. It is not necessary to close the skin
This final technique involves the insertion of a standard, 16 to incision at this time. Place saline-moistened gauze over the inci-
18 gauge, intravenous catheter-over-the-needle into the vein sion site. Wrap a sterile dressing (e.g., Kerlix) around the extremity
(Figure 54-11). This technique is sometimes referred to as the and the skin incision site.
mini-cutdown. The vein is cannulated under direct visualization Alternatively, insert the catheter-over-the-needle through the
through a skin incision. This technique will insert the catheter skin, 1 cm distal to the distal skin edge, until the tip is visualized in
as if cannulating a peripheral vein. Refer to Chapters 47 and 48 the incision (Figure 54-11B). Insert the catheter-over-the-needle
for complete details. This method is very quick, provides a more into the vein under direct visualization. Stop advancing the unit
secure cannulation, and potentially decreases the chance of when a flash of blood is seen in the needle hub. Advance the cath-
infection. eter into the vein while removing the straight clamp. Advance
FIGURE 54-12. The skin incision is closed with interrupted 4-0 nylon sutures. The
catheter exits a separate skin incision (A) or the original skin incision (B) and is
secured with a suture.
the catheter until the hub is against the skin. Remove the needle.
Attach intravenous tubing to the catheter hub and begin instill-
ing fluids. The advantage of this method is that the catheter goes
through the skin, which will stabilize the catheter and prevent it
from becoming dislodged.
AFTERCARE
Suture the wound closed with simple interrupted 4-0 nylon sutures
(Figure 54-12). Place a suture through the skin, wrap it around
the catheter and tie it to secure the catheter to the skin. Apply
antibacterial ointment to the incision, the sutures, and the site
where the catheter exits the skin. Secure the intravenous tubing
(Figure 54-13). The catheter can be looped around the toe, for a
cutdown at the ankle, and secured with gauze wrap or an elastic
wrap (Figure 54-13A). The catheter can be secured by taping it to
the skin (Figure 54-13B). The limb can be immobilized on a board, FIGURE 54-13. Securing the intravenous catheter. A. The catheter is looped
after the catheter is secured at the ankle or elbow, for added security around the great toe, for an ankle cutdown, and secured with gauze or elastic
from inadvertent dislodgement of the catheter (Figure 54-13C). wrap. B. The catheter is secured with tape. C. The ankle or elbow can be secured
to a board for additional security.
COMPLICATIONS
The complications of a peripheral venous cutdown include arterial due to the primary problem (e.g., hypovolemia, sepsis, shock,
injury, nerve injury, phlebitis, thromboembolism, wound dehis- trauma, etc.). The knowledge of the local anatomy and the techni-
cence, and wound infection. The incidence of complications ranges cal aspects of the various cutdown techniques may avoid arterial,
from 2% to 15%.12,16 The difficulty in reporting complications is that venous, and nerve injury. The other complications may be reduced
there is a high mortality rate in patients undergoing this procedure by removal of the catheter within 12 hours after placement.16
CHAPTER 55: Intraosseous Infusion 361
PHLEBITIS
Intraosseous Infusion
It is generally agreed that phlebitis occurs more commonly in
the lower extremity than the upper extremity. However, there are
little data to support this. Phlebitis usually results from prolonged
55 Amanda Munk and O. John Ma
catheterization. It may be seen within hours of catheter placement

and as long as 18 days after the removal of the catheter.16 In 1960, INTRODUCTION
Bogen looked at 234 ankle cutdowns and found a 4% phlebitis
rate.14 He felt this was secondary to infection. The strength of Obtaining peripheral vascular access in the critically ill patient
the correlation was attributed to a previous nonrelated study that may be difficult and time-consuming. The vascular collapse that
found Staphylococcus aureus on almost all catheter tips in patients may accompany severe dehydration or a cardiac arrest can be pro-
with phlebitis as opposed to catheter tips in patients without found and delay administration of essential therapies. Pediatric
phlebitis. Interestingly, these cases of phlebitis all resolved with- patients, in particular, may present a challenge due to the small size
out the use of antibiotics. Moran et al. cultured 89 cutdown sites of their peripheral veins and the increased subcutaneous tissue.
and observed that the pathogenic species causing infection were Administration of endotracheal medications may not provide rapid
S. aureus, Enterococcus, and Proteus. These organisms were cul- and reliable drug absorption during a cardiorespiratory arrest.1,2
tured more frequently in patients that had cutdowns that were Intraosseous (IO) access was first described in 1922 by Dr.
left in place for longer periods of time. Moran et al. did not find Drinker. He referred to the medullary cavity as a “non-collapsible
a correlation between infection and phlebitis and postulated that vein” that can be used for obtaining rapid vascular access. IO access
phlebitis was due to irritation of the vein wall by the catheter.13 for pediatric use was introduced in 1941. The first IO blood trans-
Regardless of the rates and species, it is clear from all of these fusion was documented in1942. The IO route of venous access did
studies that early removal of the intravenous catheter within not become popular for many reasons. The equipment at the time
12 hours of placement will significantly decrease the incidence was crude and did not improve until the 1970s. The technique of a
of phlebitis. saphenous venous cutdown was soon developed as an alternative
method for obtaining vascular access. The development of plastic,
disposable, and single use intravenous (IV) catheters revolutionized
INFECTION the technique of IV access.
Moran et al. did not find that prophylactic antibiotics reduced IO access is an alternative route for blood, drug, and fluid admin-
infection rates.13 They found that daily topical antibiotic ointment, istration. This previously abandoned technique was reintroduced in
the mid-1980s in response to the need for more immediate vascu-
™
in particular Neosporin , reduced positive local wound cultures
lar access during cardiopulmonary resuscitation.3,4 This procedure
from a rate of 78% to 18%. In 1968, Collins et al. studied polyethyl-
ene catheters and found a 2% bacteremia rate and a 1% death rate has focused on pediatric patients due to the increased difficulty and
from Pseudomonas species in debilitated patients.15 Rhee et al. in necessity of access in critically ill children. Studies have demon-
1988 found only one case of cellulitis in their study of 78 patients.11 strated that peripheral venous access during pediatric cardiac arrest
Regardless of the rates and species, it is clear from all of these constituted the most expeditious manner of obtaining vascular
studies that early removal of the intravenous catheter within access (mean time of 3.0 minutes). However, it was only successful
12 hours of placement will significantly decrease the incidence in 17% of patients. This was in stark contrast to the 83% success
of infection and subsequent complications. Obviously, sterile rate for IO lines, 81% for peripheral venous cutdowns, and 77% for
technique is also encouraged with this procedure in order to mini- central venous lines.5,6 The time required to place an IO line was
mize complications related to infection. 4.7 minutes compared to 8.4 minutes for a central venous line and
12.7 minutes for a peripheral venous cutdown. The insertion of an
IO line was recently studied in the prehospital arena, where it was
ASSOCIATED INJURIES shown to be safe and effective.7,8 IO infusion is also quick, safe, and
Injury to adjacent arteries, nerves, and veins can be avoided by effective in compromised neonates.9
a detailed understanding of the local anatomy and careful pro- IO access has been increasingly used in the resuscitation of adult
cedural technique. Aggressive and forceful dissection without an patients when vascular access is unobtainable.10,11 For prehospital
understanding of the anatomy or the procedure will increase the providers, IO access has proved to be an invaluable procedure. One
incidence of complications. Injury to adjacent cutaneous nerves national prehospital study noted success rates for IO placement at
is unavoidable and inconsequential. Venous spasm, which causes 91%, with the majority of patients being adults.12 In adults over the
nonuniform acceptance of the intravenous extension tubing, may age of 80 years, success rates neared 97%. The newer powered devices
also occur.16 make penetrating the adult cortical bone much less difficult.12

SUMMARY
Long bones are composed of a dense outer cortex and inner soft,
The peripheral venous cutdown is an excellent technique for spongy (cancellous) bone (Figure 55-1). The nutrient artery sup-
rapid fluid or blood product infusion in the emergent setting. plies the bone with a rich vascular network. It pierces the cortex and
This is usually performed when other methods of venous access divides into ascending and descending branches that further divide
are unavailable or have failed. It is a relatively simple procedure. into arterioles and then capillaries. Venous drainage from the capil-
If learned properly, it can be lifesaving in the critically ill or laries into the medullary venous sinusoids, located at the proximal
injured patient. It is imperative to understand the relevant local and distal portions of the long bone, flows into the central venous
anatomy and identify the clinical landmarks before this proce- channel located in the shaft of the long bone.13
dure is performed. Strict adherence to sterile technique and the The IO needle is inserted through the cortex and into the bone
early removal of the catheter will decrease the rate of infection marrow (medullary) cavity of a long bone. Numerous anatomic sites
and complications. can be used to access the medullary cavity. The most traditional
Epiphysis Distal tibia
Growth Greater
X Medial
plate saphenous vein malleolus
Medullary venous Intraosseous

sinusoids needle
Emissary
veins
Central venous
canal
Nutrient
vein FIGURE 55-3. The distal tibia is one of the preferred sites for IO access in adult
patients. The ⊗ represents the site of IO needle insertion.
FIGURE 55-1. Venous anatomy of a long bone.
INDICATIONS
site, which is favored in pediatric patients, is the flat anteromedial The placement of an IO line is indicated when vascular access is rap-
surface of the proximal tibia (Figure 55-2). The distal tibia just idly required for the resuscitation of a patient and standard vascu-
above the medial malleolus is the preferred site in adult patients lar access is unobtainable or delayed. It may be operationally useful
(Figure 55-3). In the adult, it is easier to penetrate the cortex of to define a specific time frame or a specified number of peripheral
the medial malleolus than the thicker cortex of the proximal tibia. IV attempts before proceeding to IO access. Situations that may
Other sites for IO access include the flat anterior surface of the distal require the placement of an IO line are cardiac arrest, shock, sepsis,
femur (Figure 55-4) and the anterolateral surface of the proximal trauma, severe dehydration, extensive burns, status epilepticus, or
humerus (Figure 55-5).14 any condition that requires urgent administration of fluids, medi-
Crystalloid infusion studies through an IO line in animals have cations, or blood products.18 Current American Heart Association
demonstrated an infusion rate of approximately 10 to 20 mL/min Advanced Cardiac Life Support guidelines recommend IO access if
with gravity and up to 40 mL/min under pressure.15,16 Fluids and IV access is unobtainable within 90 seconds or two attempts and
medications administered through an IO line are immediately for the administration of medications over endotracheal medication
absorbed into the systemic circulation. Sodium bicarbonate infu- administration.
sion, even during a cardiac arrest, was shown to have superior buff- In addition to resuscitation, IO access can provide blood samples
ering capacity when administered via an IO line than by a peripheral for typing, crossmatching, and laboratory analysis. Electrolytes, cre-
IV line.17 Medications and fluids that may be administered by the IO atinine, blood urea nitrogen (BUN), glucose, calcium, and arterial
route are listed in Table 55-1.18,19 The medication concentrations, blood gas values from blood samples obtained through an IO needle
dosages, and infusion rates through an IO line are the same as
those through a peripheral IV line. Succinylcholine has been effec-
tively infused by the IO route for muscle paralysis prior to endotra-
cheal intubation.20
Medial condyle
Tibial tuberosity
2 cm
X
X 2 cm
Flat anteromedial surface
of proximal tibia
Lateral Medial
condyle condyle
Patella
FIGURE 55-2. The proximal tibia is the traditional site used in pediatrics for IO FIGURE 55-4. The distal femur is an alternative site for IO access. The ⊗ repre-
access. The ⊗ represents the site of IO needle insertion. sents the site of IO needle insertion.
TABLE 55-1 Medications and Fluids that may be Administered Through

an IO Line16–19,43,44
Medications
Adenosine Diazoxide Lorazepam
Amiodarone Digoxin Mannitol
Antibiotics Dobutamine Morphine
Antitoxins Dopamine Naloxone
Anesthetics Ephedrine Norepinephrine
Atracurium besylate Epinephrine Pancuronium
Atropine Heparin Phenobarbital
Calcium gluconate Insulin Phenytoin
Calcium chloride Isoproterenol Propranolol
Contrast media Ketamine Sodium bicarbonate
Dexamethasone Levarterenol Succinylcholine
Diazepam Lidocaine Tenecteplase
Thiopental
Vecuronium
Fluids
Blood products
Dextrose solutions
Iodinated contrast agents
Lactated Ringer’s solution
Packed red blood cells
FIGURE 55-5. The proximal humerus is an alternative site for IO access in the
Plasma
adult. The ⊗ represents the site of IO needle insertion.
Sodium chloride solutions
are similar to those from samples taken via traditional routes.21,22 • Plastic protective cup
Laboratory values may be less accurate after five or more minutes of • Leg board for immobilization
active resuscitation, or if drugs or fluid have been infused through
• IO access device
the IO site.22
IO needles are available in a number of sizes and styles
(Figure 55-6). Only specifically designed IO needles should be
CONTRAINDICATIONS used for this procedure. Spinal needles often bend and do not pen-
Placement of an IO line is contraindicated in diseased or osteopo- etrate the cortex of the bone. Their long length causes increased
rotic bone. The placement of an IO line through areas of cellulitis, resistance to fluid flow. Standard hypodermic needles also often
abscesses, or burns should be avoided.23 Fractures in the ipsilateral bend and do not penetrate the cortex of the bone. Both these types
bone increase the risk of an extravasation-induced compartment of needles may break while being inserted and injure the healthcare
syndrome and nonunion of the fractures.24 Failed placement of provider.
an IO line in the same bone is a relative contraindication. Do not Available models of manually inserted IO devices include the
use a bone that has had a previous orthopedic procedure, contains hand-driven threaded-needle SurFast and Cook Intraosseous
hardware, or may contain hardware (i.e., pins, plates, screws, and needle (Cook Critical Care, Bloomington, IN), the Jamshidi
artificial joints). An IO line should not be inserted if the patient is bone marrow needle (Baxter Healthcare, Valencia, CA), and the
morbidly obese as the needle is too short to enter the medullary MedSurg Industries Illinois sternal/iliac aspiration needle (MedSurg
cavity or if the patient is so obese that the bony landmarks cannot Industries, Rockville, MD). The typical unit consists of a detachable
be palpated.
There are contraindications specific to sternal IO access. Do not
attempt sternal IO access in patients who weigh less than 50 kg,
are small in stature, have a small sternum, have congenital sternal
malformations, or have chest wall malformations. The blunt trauma
patient with a suspected sternal fracture or soft tissue injury over the
sternum should not be considered for sternal IO access. A history of
a sternotomy or osteoporosis is also a contraindication.
EQUIPMENT
• Sandbag or towels
• Local anesthetic solution, 1% or 2% lidocaine
• Syringe, 5 to 60 mL
FIGURE 55-6. IO infusion needles. From left to right: the Cook Intraosseous
• Primed intravenous tubing with normal saline infusion needle, two models of the Illinois sternal/iliac aspiration needle, and the
• Tape Jamshidi bone marrow needle.
A
FIGURE 55-8. The BIG in adult and pediatric sizes (Photo courtesy of Wais
Medical, Houston, TX).
the manual devices. They are easier to use, quicker to establish IO

access, require less or no force to insert the IO needle, and do not
bend during insertion.
™
Sternal access devices include the MONOJECT I-Type Sternal-
Iliac Aspiration Needle (Covidien, Mansfield, MA), the First Access
™
for Shock and Trauma (FAST1 and FASTX , Pyng Medical,™
Richmond BC), and Life/form® Adult Sternal Intraosseous Infusion
™
System (Nasco, Modesta, CA). The F.A.S.T.1 is a multiple-com-
ponent kit to be used for sternal IO access in the adult patient.
A special introducer limits the depth to which the needle can be
inserted. This prevents injury to the underlying great vessels, heart,
lung, and mediastinum. This system was evaluated in Special Forces
military settings, and found to be equally useful and safe in terms
of IO access.27 Sternal IO access devices are used less often than the
previously described powered devices due to the possible interfer-
ence with resuscitation attempts and their incomplete removal on
occasion requiring surgical removal.
PATIENT PREPARATION
B
their representative if time permits. This procedure is often per-
FIGURE 55-7. The EZ-IO. A. The driver and three lengths of IO needles. B. The formed in emergencies; therefore, informed consent can often be
EZ-Stabilizer (Photos courtesy of Vidacare, San Antonio, TX). waived. Currently, the primary site of choice for IO line placement
is the proximal tibia. Alternate sites include the distal tibia, dis-
tal femur, proximal humerus, and the sternum. Even with sternal
handle, an IO needle, an obturator, and a sleeve to prevent the nee- access, it is possible to perform a cricothyroidotomy and cardiopul-
dle from penetrating too deeply. The IO needle ranges in size from monary resuscitation (CPR).25 The proximal humerus allows more
12 to 20 gauge. The IO needles available today are variations of the central access, while the proximal tibia is often accessible without
basic unit and include adjustable-length shafts to decrease the risk disrupting airway management and CPR.14
of penetrating too deeply, a variety of tips on the obturator (e.g., lan- Place the patient supine with the lower extremity supported
cet, pencil point, and trocar), threaded versus nonthreaded shafts, behind the knee with a towel or sandbag. Identify by palpation the
needle side ports to increase flow rates, numerous lengths, and landmarks required to perform the procedure. Palpate the bony
numerous handle types. landmarks with the nondominant hand. The bony landmarks for
New powered and spring loaded injection devices have evolved. the proximal tibia approach are the tibial tuberosity and the flat
Two currently available devices are the EZ-IO Intraosseous Driver anteromedial surface of the proximal tibia. The site of IO needle
(Vidacare, San Antonio, TX) and the Bone Injection Gun (BIG, placement is approximately 2 cm below the tuberosity on the flat
Wais Medical, Kress USA Corporation). The EZ-IO uses a battery- anteromedial surface of the proximal tibia (Figure 55-2). The bony
powered driver to insert the needle to a preset depth (Figure 55-7).14 landmark for the distal tibia approach is the junction of the medial
The BIG incorporates a loaded spring to inject the IO needle, and malleolus and the flat anteromedial surface of the distal tibia just
the desired depth of injection may be adjusted (Figure 55-8).25 posterior to the greater saphenous vein18 (Figure 55-3). This is the
Both devices are available in adult and pediatric needle sizes. The preferred site in the adult patient. The bony landmarks for the distal
EZ-IO and the BIG have numerous advantages when compared to femur approach are the medial and lateral condyles of the femur
FIGURE 55-9. Placement of an IO line. A. The nondominant hand is used to support the extremity. The IO needle is inserted with a twisting motion to cut through the
cortex of the bone. B. The handle and obturator are removed. C. A syringe is attached to the hub of the IO needle and bone marrow is aspirated.
and the patella. The IO needle should be positioned approximately Advance the IO needle through the skin and subcutaneous tis-
2 cm above these structures (Figure 55-4). This site is utilized less sue until the bone is contacted. Advance the IO needle through the
often due to the abundance of muscle and soft tissue structures. The bone. A twisting or rotary motion with the simultaneous application
bony landmarks for the humeral approach are slightly anterior to of downward pressure should be used to cut through the cortex of
the lateral midline of the arm, with care to avoid the bicipital groove the bone (Figure 55-9A). A significant reduction in the resistance to
(Figure 55-5). The arm should be adducted and internally rotated forward motion will be encountered when the cortex is penetrated
for optimal positioning.14 and the needle enters the medullary canal. This distance is rarely
Prepare the patient. Clean any dirt and debris from the skin. greater than 1 cm in most patients. An index finger may be placed
Apply povidone iodine or chlorhexidine solution to the skin and 1 cm from the bevel of the IO needle prior to advancement. This
allow it to dry if time permits. This procedure is extremely painful. will help prevent overpenetration into and through the cortex on
If time permits, the use of a local anesthetic solution in the con- the opposite side of the bone.28 Alternatively, adjust the sleeve so
scious or semiconscious patient will be greatly appreciated. Infiltrate that only 1 cm of the IO needle is exposed. Stop advancing the IO
local anesthetic solution into the skin, subcutaneous tissues, and needle when it enters the medullary canal.
periosteum overlying the bone puncture site. Additionally, in the Remove the stylet when the medullary canal is entered
alert patient, consider infusing 3 to 5 mL of 2% lidocaine intrave- (Figure 55-9B). Attach a 5 or 10 mL syringe onto the hub of the
nously both initially and at regular intervals to minimize patient IO needle (Figure 55-9C). Aspirate blood from the medullary
discomfort.11 canal to confirm proper placement of the IO needle. Any samples
obtained may be sent to the laboratory for subsequent analysis.
TECHNIQUE The aspiration of more than 2 to 3 mL of blood may not be pos-
sible in cardiac arrest situations. Attach IV tubing to the hub of
MANUALLY INSERTED IO DEVICES the IO needle and begin the infusion of fluids. Medications can be
administered through the injection port of the IV tubing. Place a
Examine the IO needle to ensure that it appears to have been sterile dressing around the skin puncture site and apply pressure
manufactured properly. Reidentify the landmarks with the non- for 5 minutes.29
dominant hand. Stabilize the extremity with the nondominant
hand (Figure 55-9A). Grasp the IO needle firmly with the domi-
IO ACCESS USING THE EZ-IO
nant hand. The handle of the IO needle should be firmly planted in
the palm of the dominant hand. Insert the needle perpendicularly The EZ-IO is a reusable, nonsterile, battery powered driver that
or slightly angulated (at a 10° to 15° angle) to the long axis of the uses sterile, disposable, single patient use IO needles. The IO nee-
bone (Figure 55-9). The IO needle should always be directed away dles are available in three lengths (15, 25, and 45 mm). Choose
from the growth plate to avoid injuring it. Direct the needle cau- the proper IO needle for the patient, their body habitus, and the
dad in the proximal tibial approach and cephalad in the distal tibial insertion site. Assess the tissue depth by palpation. Choose an IO
and distal femoral approaches. needle so that at least one black line on the IO needle shaft will be
FIGURE 55-10. Using the EZ-IO. A. An IO needle has been applied onto the
driver. B. Insert the IO needle at a 90° angle to the skin. C. The driver has been
E removed. D. The stylet is removed. E. The EZ-Stabilizer and tubing have been
applied.
above the patient’s skin when the tip is against the bone. The IO syringe containing 10 mL of sterile normal saline. Leave the syringe
needle tip is designed to cut the bone and create a hole the same attached to the tubing after it is flushed.
size as the needle. Reidentify the landmark for the insertion site. Inject local
Identify the IO insertion site and prepare for the procedure. anesthetic solution subcutaneously and down to the periosteum.
Clean and prep the skin at the site and surrounding area. The pro- Remove the cap from the IO needle. Insert the IO needle perpen-
cedure requires aseptic technique. Select the appropriate size IO dicular or at a 90° angle to the skin (Figure 55-10B). Advance the
needle. Open the cover of the case that holds the sterile IO needle. IO needle through the skin and subcutaneous tissues until the tip
Insert the bit on the EZ-IO driver into the base of the IO needle is against bone. At least one black line on the needle shaft should
(Figure 55-10A). Leave the cap on the IO needle until it is ready be visible above the patient’s skin. If a black line is not visible on
to be inserted. Open the EZ-Connect tubing and flush it with a the needle shaft, withdraw the needle and replace it with a longer
IO needle. Press the trigger to start the driver shaft and IO nee- insertion site is different for adults and children. Always start at
dle rotating. Apply gentle and minimal downward pressure to the tibial tuberosity as the initial landmark. For adults, move 2 cm
advance the IO needle into the medullary canal. Stop advancing medially toward the inner leg and then 1 cm proximally toward the
the driver when a loss of resistance is felt. patient’s head. For children, move 1 to 2 cm medially toward the
Grasp and firmly hold the hub of the IO needle. Remove the inner leg and then 1 to 2 cm distally toward the patient’s foot. Mark
driver (Figure 55-10C). Do not allow the IO needle to move while this final location as the insertion site. It may also be inserted in the
removing the driver. Twist the stylet counterclockwise and remove proximal humerus in the adult patient.
it while securely holding the IO needle hub (Figure 55-10D). Prepare for the procedure. This procedure requires aseptic tech-
Attach the EZ-IO stabilizer (Figures 55-7B & 55-10E), if using it, nique. Clean and prep the skin at the insertion site and surrounding
followed by the primed EZ-Connect tubing. Aspirate bone mar- area. Open the package and remove the sterile BIG. Rotate the base
row to confirm proper needle placement. Do not attach a syringe of the unit to adjust the IO needle penetration depth according to
directly to the IO needle hub. A syringe attached to the hub can the pediatric patient’s age: 0 to 3 years at 0.5 to 1.0 cm, 3 to 6 years
result in a fracture of the hub. Always attach the EZ-Connect tub- at 1.0 to 1.5 cm, and 6 to 12 years at 1.5 cm (Figure 55-11A). Use
ing then aspirate and inject through it and not directly through the adult BIG for patients over the age of 12 years. Reidentify the
the IO needle hub. Begin using the IO access. landmark for the insertion site. Inject local anesthetic solution sub-
cutaneously and down to the periosteum.
IO ACCESS USING THE BIG Position the BIG at the insertion site with the base perpen-
dicular or at 90° to the skin (Figure 55-11B). Firmly grasp the
The BIG is an automatic, spring loaded device that does not require BIG with the nondominant hand. Squeeze and pull out the red
a power source. It is available in two sizes, adult and pediatric. The safety latch while firmly holding the BIG against the insertion
A B
C D
FIGURE 55-11. Using the BIG. A. Adjust the penetration depth. B. Apply the BIG at a 90° angle to the skin. C. Remove the safety latch. D. Grasping the BIG in preparation
of triggering the unit.
E F
G H
FIGURE 55-11. (continued ) E. Remove the BIG. F. Attach and secure the safety latch. G. Pull the stylet-trocar from the IO cannula. H. Attach IV tubing onto the hub
and aspirate bone marrow (Photos courtesy of Wais Medical, Houston, TX).
site (Figure 55-11C). Do not discard the safety latch as it will gently twist to remove the IO needle. Repeat the procedure at
be used later to secure the IO needle. Grasp the upper part of another site. Attach the IV tubing onto the hub of the cannula
the BIG with the dominant hand (Figure 55-11D). Place two (Figure 55-11H). Aspirate bone marrow to confirm proper place-
fingers under the wings and the palm on the top of the BIG ment (Figure 55-11H). Flush the IV tubing and cannula with 5 to
(Figure 55-11D). Continue to firmly hold the base against the 10 mL of sterile saline. Begin using the IO access.
patient’s skin with the nondominant hand.
Insert the IO needle. Trigger the BIG by gently pressing down
ASSESSMENT
with the palm. The device will eject the spring loaded IO needle
into the bone. The IO needle should be standing upright, firmly Assess whether the IO needle is correctly positioned within the
in the bone, and stable. If not, it has been placed into muscle or medullary cavity. First aspirate blood from the marrow cavity. This
soft tissue. Gently lift and remove the BIG device without catch- may not be possible because of poor circulation in patients with
ing on the IO needle hub (Figure 55-11E). Attach the safety latch a cardiac arrest. A second sign of correct placement is to assess
onto the cannula between the patient’s skin and the IO cannula whether the IO needle will stand erect without support. Finally,
hub (Figure 55-11F). Secure the safety latch to the skin with flush the IO line. The ability of the fluid to flow without inducing
tape (Figure 55-11F). Gently remove the stylet-trocar, leaving soft tissue swelling can also be used to confirm proper placement.
the cannula in place (Figure 55-11G). If the stylet-trocar is Ultrasonic visualization of flow within the medullary cavity using
“stuck” and not easily removable, do not pull or try to force- color flow Doppler can also confirm proper placement.45 A reas-
fully remove it. The IO needle did not penetrate all the way into sessment must be performed again at regular intervals to ensure
the medullary cavity and is embedded in the cortex. Insert the that extravasation does not occur.30 Circumferential pressures
square end of the safety latch into the hub of the IO needle and of the involved extremity may be used for serial examination.30
CHAPTER 56: Umbilical Vessel Catheterization 369
A C-arm fluoroscopic imaging device may be used at the bedside The complications specific to the EZ-IO include hub fracture after
to confirm accurate placement of the IO needle.31 insertion and separation of the needle from the hub upon removal.
Too much downward pressure upon IO needle insertion can result
AFTERCARE in it penetrating the back of the bone. The other general complica-
tions are described above.
Secure the IO needle. Secure the manually inserted IO needle by The complications associated with the BIG are primarily from
taping it in place. It may be easier to apply 4 × 4 gauze squares on incorrect use. Never remove the safety latch until the BIG is
two sides of the IO needle to support it and then tape the needle against the patient’s skin over the insertion site. Removal of the
and gauze in place. Secure the EZ-IO needle in the same manner. safety latch activates the device. The IO needle can be forcefully
Tape the safety latch of the BIG to the skin to secure it. Tape the IV ejected and injure someone if the BIG is squeezed after the safety
tubing securely at several points. This will prevent traction on the latch is removed. Never place a finger over the distal end of the BIG.
tubing from pulling the IO needle out of the bone. Tape a plastic cup Always grasp the BIG properly. Grasping it upside down can
over the IO needle to avoid inadvertent disruption during patient result in the IO needle penetrating the Emergency Physician’s
resuscitation or positioning. Immobilize the extremity, if necessary, hand. Incorrectly adjusting the penetration depth can result in the
to help secure the IO line. IO needle penetrating the back of the bone. The other general com-
Remove the IO line once the resuscitation is complete and another plications are described above.
form of secure vascular access has been obtained. Manually inserted
IO devices can be removed by gently twisting it and pull it straight
SUMMARY
out. Do not rock the device. To remove the EZ-IO, attach a 5 or
10 mL Luer lock syringe onto the IO needle hub. Rotate the syringe The placement of an IO line is a viable option in the resuscita-
clockwise and pull it straight out. It may take several rotations of the tion of a patient when traditional vascular access techniques have
syringe before the IO needle can be removed. Do not rock the IO failed. The procedure is technically straightforward and has been
needle or syringe. To remove the BIG cannula, insert the square demonstrated to be successful in the hands of trained healthcare
end of the safety latch into the hub of the cannula and gently twist workers, including prehospital personnel. Complications have
and pull to remove it. Bleeding at the insertion site can be controlled been related mostly to technical mistakes and can be avoided if
with a sterile pressure dressing followed by cleansing the skin and a care is taken to correctly identify landmarks, avoid the growth
simple bandage. plate, regulate the depth of IO needle placement, and ensure the
early removal of the IO line.
COMPLICATIONS
The most common complication of IO infusions are subcutaneous
and subperiosteal extravasation of fluid due to technical difficulty.4
Under ideal circumstances, the type of IO needle used should not
affect extravasation rates.30,32 Extravasation is usually due to under- Umbilical Vessel
or overpenetration of the cortex. There have been cases of tibial
fracture due to overpenetration of the cortex.33,34 A compartment
56 Catheterization
syndrome may occur when there is extravasation or when IO lines Eric F. Reichman, Amy Noland, and Antonio E. Muñiz
are placed in fractured bones.26 Necrosis and sloughing of the skin
at the insertion site of the IO needle are due to extravasation of fluid
INTRODUCTION
or medication.35
Localized infections may occur after IO needle placement. Cellu- Umbilical vessel catheterization was first described by Diamond
litis or the formation of subcutaneous abscesses occur in 0.7% of in 1947 for an exchange transfusion in a neonate.1 Umbilical ves-
patients.24 Osteomyelitis has been reported in less than 1% of patients sel catheterization serves many important functions in the ill
with IO needles.25 Risk of osteomyelitis increases with prolonged neonate. Umbilical vessel catheterization can be used as a reli-
IO use, administration of hypertonic fluids, and bacteremia.25,36 able method of obtaining rapid vascular access in the neonate.
Injury to the growth plate is a commonly mentioned complica- Umbilical vessel catheters may be used for fluid resuscitation,
tion; however, the literature does not support this.37,38 Additionally, blood transfusion, medication administration, frequent blood
in recent animal studies, the rate of the IO infusion and the osmo- sampling, and cardiovascular monitoring.2–5 However, the use of
larity of the infused fluid did not adversely affect the bone marrow these catheters also carries significant risk of permanent mor-
or bone development.42 Fat embolism has also been mentioned as bidity and even death. Either the umbilical artery or vein may
a possible complication.41 Consider a fat embolism if the patient be used for vascular access. The artery can usually be accessed
becomes hypoxic or experiences respiratory difficulty shortly after within the first 24 hours of life. It is occasionally possible to use
beginning an IO fluid infusion or bolus. The use of an IO line for the umbilical artery up to 7 days after birth.2 The umbilical vein
the infusion of emergency drugs and fluids does not increase the can be accessed for up to 2 weeks of age.2,6
magnitude of fat embolization during CPR.39,40 Animal studies have Umbilical artery catheterization is more desirable than umbili-
shown no significant increase in fat emboli in lung tissue when IO cal vein catheterization because it allows frequent arterial
infusion is used.39 blood gas sampling and continuous blood pressure monitor-
The flow rate of fluid through an IO line is slower than that ing, in addition to fluid, blood, and medication administration.
through a peripheral intravenous line. This may be due to a small Unfortunately, umbilical artery catheterization is more difficult
marrow cavity, a fibrous marrow cavity, and/or the replacement of and time consuming to perform, especially in unskilled hands.
red marrow with yellow marrow. Fluid flow rates can be signifi- Therefore, umbilical vein catheterization is the preferred proce-
cantly increased by applying a pressure bag onto the intravenous dure for the infant in shock and in need of rapid resuscitation.
fluid bag or using a level-one infuser. The placement of a second Arterial access can be obtained later in a more controlled envi-
IO line may be required to further increase the amount of fluid that ronment, such as in the neonatal intensive care unit. Umbilical
can be infused. vessel catheterization can lead to serious complications and
Ductus
arteriosus
Foramen
ovale
Inferior vena
cava
Descending
aorta
Ductus venosus
Umbilical cord
Urachus
External iliac
artery
Internal iliac
artery
Umbilical arteries
Umbilical vein
Placenta
FIGURE 56-1. The fetal circulation.
should be reserved for the patient in whom peripheral venous the right ventricle and is pumped to the pulmonary artery. It then
access attempts have been unsuccessful.5,7 passes through the ductus arteriosus to meet the oxygenated blood
in the aorta.
Pulmonary vascular resistance decreases dramatically as the
infant takes its first breaths. The systemic vascular resistance
The fetal circulatory system is quite different from that of the neo- increases when the umbilical cord is clamped. The foramen ovale
nate or infant (Figure 56-1). Oxygenated blood from the placenta closes with the combination of decreased pulmonary artery pres-
travels via the umbilical vein, through the ductus venosus in the sure and increased systemic resistance. The ductus arteriosus closes
liver, to the inferior vena cava (IVC), and into the right atrium. within 24 to 48 hours due to the release of prostaglandins and
Oxygenated blood from the IVC preferentially enters the left atrium increased blood oxygen tension. The ductus venosus closes when
through the foramen ovale. It then enters the left ventricle, then the the umbilical cord is clamped.
aorta. This oxygen-rich blood supplies the brain prior to mixing The umbilical vein and arteries can easily be differentiated by
with the oxygen-poor blood coming through the ductus arterio- examination of a cross section of the umbilical cord (Figure 56-2).
sus. Deoxygenated blood from the superior vena cava (SVC) enters The umbilical vein is a single vessel with thin walls and a large
• Sterile gauze
• Sterile drapes
• Sterile gown and gloves
• Cap and face mask
• Adhesive tape
• Radiant warmer with a light
• Cardiac monitor
• Pulse oximeter
• 3-0 or 4-0 silk suture with a needle
• Needle driver
FIGURE 56-2. Anatomy of the umbilical cord. • Smooth-curved iris forceps
• Iris scissors
• Two small, smooth-curved hemostats
lumen. It is usually flattened in one direction. There are two thick- • Straight Crile forceps
walled umbilical arteries that are significantly smaller in diameter • #10 or #11 scalpel blade on a handle
than the umbilical vein. Occasionally, only a single umbilical artery
is present. • Three-way stopcock
• 10 mL syringe filled with normal saline
INDICATIONS • Heparinized sterile saline solution, 1 unit of heparin/1 mL of
saline
Umbilical artery catheterization is indicated when frequent arterial
blood gas determinations and continuous monitoring of blood pres- Umbilical artery and vein catheters are available in a variety of
sure are required in the first few days of life in critically ill neonates.4 sizes. Umbilical vein catheters are available as a single-lumen or
Umbilical artery catheters can be used for delivering blood, fluids, double-lumen catheter. They should not have side holes unless it is
total parenteral nutrition, medications, and for exchange transfu- to be used specifically for an exchange transfusion. Use a 5.0 French
sions.2,3 It reduces the need for multiple venipunctures and heel umbilical venous catheter in neonates weighing >1200 g and a
prick capillary blood sampling in the critically ill neonate.8 Neonates 3.5 French catheter in neonates weighing <1200 g. Use a 5.0 French
under 24 hours of age can usually be catheterized without much dif- umbilical artery catheter in neonates weighing >3500 g and a
ficulty. Skilled Emergency Physicians can sometimes perform this 3.5 French catheter in neonates weighing <3500 g.
in neonates up to 7 days of age.2 Umbilical vessel catheterization kits are commercially avail-
Umbilical vein catheterization is easier to perform than umbilical able from several manufacturers. One example is the Argyle Neo-
artery catheterization. It is the preferred procedure for the neonate ™
Sert Umbilical Vessel Catheter Insertion Tray (Tyco Healthcare,
in shock needing rapid administration of intravenous fluids, blood, Mansfield, MA). The kits are sterile, disposable, and intended for
or medications.1 In critically ill neonates, the umbilical vein can be single patient use. They contain all the equipment required includ-
used to monitor central venous pressure. This procedure is possible ing the instruments and catheters.
in neonates up to 2 weeks of age.2 Recently, the umbilical vein has
been used to perform invasive cardiac procedures.9 PATIENT PREPARATION
Attempts at peripheral venous access should have failed in a sick
CONTRAINDICATIONS neonate prior to attempting umbilical vessel catheterization. All
Umbilical vessel catheterization in the Emergency Department equipment should be readily available on a pre-prepared sterile
should be performed only on severely ill neonates in whom tray. Place the tray with the instruments on a Mayo stand next to
peripheral vascular access attempts have failed. The contraindica- the neonate’s bed. Place the neonate under a radiant warmer with
tions are similar for the umbilical vein and umbilical artery cathe- a light source. Place the neonate on a cardiac monitor, continuous
terization. These include gastroschisis, an omphalocele, omphalitis, pulse oximeter, and supplemental oxygenation if needed. Place the
and peritonitis.2,10 Never insert an umbilical catheter if there are any neonate supine with the lower extremities in the frog-leg position
signs of infection on or around the remnant of the umbilical cord. (Figure 56-3). Their arms and legs may need to be restrained to
Umbilical vessel catheterization is contraindicated if a neonate is prevent contamination of the sterile field.
older than the previously stated ages. An alternate route of vascu- This procedure requires strict sterile technique. The Emergency
lar access is required if the possibility of an abdominal abnormal- Physician performing the procedure should wear a cap, mask, ster-
ity exists, as manifested by a distended abdomen or visible defects.2 ile gloves, and sterile gown. Scrub the umbilical cord, umbilical
Relative contraindications for placement of an umbilical artery cord clamp, and the neonate’s abdomen with povidone iodine or
catheter include decrease perfusion to the lower extremities or but- chlorhexidine solution and allow it to dry. Place sterile drapes to
tock and suspicion of necrotizing enterocolitis. form a sterile field around the umbilical area, ensuring the neonate’s
head is exposed for observation.
EQUIPMENT
TECHNIQUES
• Umbilical vein catheters, 5.0 French and 3.5 French
Sterile technique must be maintained throughout the entire pro-
• Umbilical artery catheters, 5.0 French and 3.5 French
cedure. Loosely tie a piece of umbilical tape around the base of the
• Umbilical tape umbilical cord (Figure 56-4). Place a 3-0 or 4-0 silk purse-string
• Povidone iodine or chlorhexidine solution suture through the base of the umbilical cord and just above the
umbilical tape (Figure 56-4). Avoid piercing the umbilical vessels

and the skin of the abdominal wall. Leave the suture untied and
the ends uncut. This will be used later to secure the umbilical vessel
catheter. Gently grasp the umbilical cord clamp. Use an #10 or #11
scalpel blade to cut the umbilical cord just beneath the clamp to
expose a smooth, clean surface of the umbilical cord (Figure 56-4).
Do not cut the cord too close to the base in case it needs to be re-
cut for a repeat attempt. Tighten the umbilical tape if blood is ooz-
ing from the cut umbilical cord. Blot the blood with gauze squares.
Do not rub the gauze against the umbilical cord to prevent dam-
aging the fragile umbilical cord. Grasp the umbilical cord with
forceps or fingers and identify the three vessels, two arteries, and
one vein. The arteries are smaller, round, and have thick muscular
Shoulder to
walls. The vein is larger, has thinner walls, and is less round than the
umbilicus length
arteries. The umbilical artery or vein may now be catheterized as
described in the following sections.
Umbilical
stump
UMBILICAL ARTERY CATHETERIZATION
Determine the desired position of the catheter tip (Figure 56-5).
There are two possible positions for the umbilical artery catheter
tip, the high or low position. In the low position, the catheter tip is
placed between the third and fifth lumbar vertebrae, a level corre-
sponding to just above the aortic bifurcation.2,11 In the high position,
Adhesive
tape
FIGURE 56-3. Positioning of the neonate. The dotted line represents the shoulder-
umbilical length.
Purse-string
suture Umbilical
tape
FIGURE 56-5. Positioning of the tip of the umbilical artery catheter. The low posi-
FIGURE 56-4. Preparing the umbilical cord stump. Umbilical tape has been placed tion, between L3 and L5, is just above the aortic bifurcation. The high position,
at the base and tied loosely. A purse-string suture has been placed through the between T6 and T9, is above the diaphragm, between the ductus arteriosus and
stump and just above the umbilical tape. The distal end of the umbilical cord is the mesenteric arteries. The shaded boxes represent the vertebral bodies in
removed along the dotted line. the midline.
the catheter tip is placed between the sixth and ninth or tenth tho-
racic vertebrae, a level corresponding to just above the diaphragm,
between the ductus arteriosus and the origins of the mesenteric
arteries.2,11–13 Controversy exists over which position is the preferred
site for the catheter tip.14 A recent Cochrane Database review of six
controlled trials demonstrated that the high position was associated
with a lower occurrence of clinical vascular complications, removal,
and adverse sequelae.4,5,21
A variety of methods have been used to determine the insertional
length of umbilical arterial catheters. Some of these include electro-
cardiographic changes during placement, echocardiography-guided
insertion, and ultrasound-guided insertion.15–19 However, these are
hard to perform in clinical practice. Other methods for determining
the appropriate depth of catheter insertion are based on the shoul-
der-to-umbilicus length and the neonate’s birth weight. There are
also standardized graphs for determining the appropriate catheter
insertion depth.
Most centers use a calculation derived by Dunn on post-mortem
infants where the length of insertion to the high position is mea-
sured from the external shoulder to the umbilicus (Figure 56-3).20
Measure the shoulder to umbilicus length by measuring the distance FIGURE 56-7. Preparation for catheter insertion. The upper edges of the umbilical
between the top of the shoulder to the level perpendicular to the cord stump are stabilized with two smooth-jaw curved hemostats. A smooth-jaw
umbilicus (Figure 56-3). Using the shoulder-umbilical length and curved iris forceps is placed into one umbilical artery and allowed to open and
the desired position of the catheter tip, determine the umbilical dilate the artery.
catheter length to be inserted into the artery (Figure 56-6). Add the
length of the umbilical stump to the umbilical artery catheter length
found on the y-axis of the graph to determine the corrected length
Flush the catheter with the heparinized saline solution, if there
of catheter to be inserted.
are no contraindications to heparin. Attach the three-way stop-
Another popular way to measure the length of insertion is the
cock, in the closed position, to the hub of the catheter. Identify the
formula derived by Shulka and Ferrara.21 The insertion length (cm)
arteries and choose one for catheterization. Grasp the distal por-
at the high position = (3 × body weight [kg]) + 9 + the length (cm)
tion of the umbilical cord with the two smooth-curved hemostats
of the umbilical cord stump. To place it in the low position, use this
to stabilize the end of the umbilical cord (Figure 56-7). Instruct
value divided by 2. For neonates <1000 g body weight, another for-
an assistant to hold the hemostats. Do not apply traction to the
mula seems to be more accurate.22 The insertion length (cm) at the
hemostats to prevent injury to the umbilical cord. Insert the tips
high position = (4 × body weight [kg]) + 7 + the length (cm) of the
of the smooth-curved iris forceps approximately 0.5 cm into the
umbilical cord stump.
lumen of the artery and gently allow the jaws of the forceps to
open (Figure 56-7). This will dilate the arterial lumen. Repeatedly
insert and open the tips of the curved iris forceps within the arte-
rial lumen to a depth of 0.5 to 1.0 cm.2
30 Grasp the umbilical catheter approximately 1.0 cm from the tip.
Gently insert the tip of the catheter into the artery (Figure 56-8).
Apply gentle pressure for about 30 seconds. The muscles of the
Umbilical artery catheter
25
artery may spasm and prevent the catheter from advancing. If
20 the spasm persists, remove the catheter. Place 0.1 mL of a 2%
length (cm)
lidocaine solution into the catheter tip.2 Reinsert the catheter and
flush the lidocaine into the artery at the level of the spasm. If the
15
catheter still will not advance, a gentle twisting motion may allow
it to advance. Catheterize the other umbilical artery if this fails.
10
Advance the catheter to the predetermined length. Increased resis-
tance will be felt as the catheter goes through the base of the umbil-
5
ical cord and navigates the curve of the umbilical artery entering
into the femoral artery. Tighten the umbilical tape to temporarily
0
9 12 15 18 secure the catheter.
Obtain fluoroscopic, plain radiographic, or ultrasonic confir-
Shoulder-umbilical length (cm)
mation of placement prior to using the catheter. The single lumen
Aortic bifurcation Diaphragm catheter may not be properly positioned. The catheter may pass into
Aortic valve the aorta but curve distally into the iliac or femoral artery. This can
result in cyanosis, blanching, or necrosis of the extremity and/or
FIGURE 56-6. Graph to determine the correct length of catheter to insert into the buttock.23,24 This occurs more frequently when a 3.5 French catheter
umbilical artery. Using the shoulder-umbilical length and the desired position of is inserted in a large neonate. Using a larger catheter (i.e., 5 French)
the catheter tip, determine the length of catheter on the y-axis to be inserted into will usually allow the catheter to go cephalad in the aorta. If the
the artery. Add the length of the umbilical stump to the umbilical artery catheter catheter goes distally, it can be partially withdrawn, twisted 90°, and
length found on the y-axis of the graph to determine the corrected length of cath- re-inserted only if done during the procedure with real-time fluoros-
eter to be inserted. (Modified from Shilkofski.11) copy or ultrasound during the procedure. Never advance a catheter
FIGURE 56-8. The catheter is inserted into the umbilical artery and advanced to
the desired depth.
FIGURE 56-9. Positioning of the tip of the umbilical vein catheter. The tip
should be above the diaphragm, at the junction of the inferior vena cava and the
that has been previously placed as it can introduce an infection. right atrium.
The catheter may also enter the aorta, turn 180° to reverse itself,
and enter the iliac or femoral artery. This also occurs more often
when a smaller (i.e., 3.5 French) catheter is used in a large neonate.
The catheter must be removed if it is placed correctly but there is catheter should only be inserted 3 to 5 cm until there is free
persistent lower extremity cyanosis, blanching, or decreased distal flow of blood. It is imperative that the catheter not be inserted
perfusion. too deeply in order to prevent entry into the hepatic vessels via
the ductus venosus, since medications could potentially cause
UMBILICAL VEIN CATHETERIZATION hepatocellular damage.2,5–7,26 The catheter can be replaced with
a more permanent line once the patient has been stabilized.25 The
Catheterizing the umbilical vein is much easier than the umbili- nonemergent umbilical venous catheter should be placed with
cal artery. The lumen is larger and easier to negotiate. This qual- the tip above the diaphragm, at the junction of the IVC and right
ity makes the umbilical vein more desirable for vascular access in atrium as determined previously. Tighten the umbilical tape to
emergency situations.7,25 temporarily secure the catheter. Obtain fluoroscopic, plain radio-
First determine the desired position of the catheter tip. Ideally, graphic, or ultrasonic confirmation of placement prior to using
it should be located at the junction of the IVC and the right the catheter.18
atrium (Figures 56-9 & 56-10). Measure the shoulder-umbilical
length (Figure 56-3). Using the shoulder-umbilical length and the
UMBLICAL MULTIPLE-LUMEN CATHETERS
desired position of the catheter tip, determine the umbilical cath-
eter length to be inserted into the vein (Figure 56-10). Add the Reliable vascular access can be problematic in the sick neonate.27
length of the umbilical stump to the umbilical vein catheter length Insertion of a double-lumen or triple-lumen catheter into the
found on the y-axis of the graph to determine the corrected length umbilical vein can provide additional venous access for the admin-
of catheter to be inserted. Another method to calculate the depth istration of incompatible drugs such as vasopressor agents, calcium,
of insertion is length (cm) = (3 × body weight [kg]) + 9, divided by or sodium bicarbonate solutions.28 It is also useful for drugs requir-
2, then add 1 cm. ing continuous infusions, leaving other ports for blood sampling,
Umbilical vein catheterization is similar to that of the artery central venous pressure measurements, maintenance fluids, or med-
with three exceptions. Any visible clots must be removed from ication administration. Infuse all these solutions into the proximal
the lumen of the vein prior to inserting the catheter. The vein lumen(s), allowing measurements of central venous pressures from
requires no dilating. In an emergency, when awaiting radio- the distal port. Multi-lumen catheters can be placed directly by the
graphic confirmation is not feasible, the umbilical vein same methods as a single-lumen catheter or using the Seldinger
16 guidewire must always remain within the vein. Advance the multi-
lumen catheter over the guidewire and into the vein while securely
14 holding the guidewire. Remove the guidewire while maintaining
Umbilical vein catheter
12 the catheter in the umbilical vessel. Advance the multi-lumen

catheter to the predetermined length. Tighten the umbilical tape
length (cm)
10 to temporarily secure the catheter. Obtain fluoroscopic, plain

8 radiographic, or ultrasonic confirmation of placement prior to
using the catheter.
6
4 ASSESSMENT
2 Confirm the proper placement of the catheter tip. The umbilical
tape has been tightened to temporarily secure the catheter within
0
9 12 15 18 the umbilical cord. Do not infuse anything through the line until
proper placement is confirmed. This can be accomplished with
Shoulder-umbilical length (cm)
fluoroscopy, plain radiographs, or ultrasonography. If the catheter
Left atrium Diaphragm is in too far, withdraw it and reevaluate the new catheter tip posi-
tion. If the catheter is not in far enough, do not advance the cath-
eter. Withdraw the catheter and restart the procedure with a new
FIGURE 56-10. Graph to determine the correct length of catheter to insert into
catheter.
the umbilical vein. Using the shoulder-umbilical length and the desired position
of the catheter tip, determine the length of catheter on the y-axis to be inserted
into the vein. Add the length of the umbilical stump to the umbilical vein catheter AFTERCARE
length found on the y-axis of the graph to determine the corrected length of
catheter to be inserted. (Modified from Shilkofski.11) Secure the catheter more permanently after confirming that the
catheter tip is in the desired location (Figure 56-11). Tighten and tie
a knot in the previously placed purse-string suture. Wrap the loose
ends of the suture around the catheter as it enters the umbilical ves-
sel, then secure it with several square knots (Figure 56-11). Loosen
technique similar to inserting a central venous line (Chapter 49). and remove the umbilical tape to avoid umbilical cord necro-
The increased pliability of the multi-lumen catheter makes passage sis.4 Secure the catheter to the abdominal wall with adhesive tape.
into the hepatic veins more likely. Antibiotic ointment may be applied at the junction of the umbilical
A wire exchange technique may be used to place a multiple-lumen cord and the catheter.
catheter in neonates with an indwelling single-lumen catheter. This
method decreases the probability of loss of vascular access during
COMPLICATIONS
the exchange. It has the risk of the guidewire entering the heart
and causing a cardiac dysrhythmia and/or myocardial perforation. Significant morbidity can be associated with umbilical artery
This technique should only be performed by those familiar with the and vein catheterization.29 Prevention of complications requires
Seldinger technique. strict adherence to sterile technique, flushing of the catheter
The catheter exchange over a guidewire requires strict sterile prior to insertion, gentle catheter manipulation during inser-
technique. Insert a guidewire through the catheter. Firmly hold tion, and accurate positioning of the catheter. It is essential that
the guidewire. Withdraw the catheter over the guidewire. The no air be allowed to enter the catheter. An air bubble can enter the
FIGURE 56-11. Securing the umbilical vessel catheter. A. The purse-string suture is tied about the umbilical cord and the umbilical tape is removed. The ends of the
suture are wrapped around the catheter, as it enters the umbilical vessel, and secured with square knots. B. Tape is applied to secure the catheter to the abdominal wall.
central circulation, pass through the foramen ovale, and lodge in an

end artery. This air embolism can cause a stroke if it ends up in a Arterial Puncture
central nervous system artery, a myocardial infarction if it ends up
in a coronary artery, and it may lead to death.30,31
Even if all precautions are observed, complications are still
57 and Cannulation
Zak Foy and Susan Stroud
unavoidable.5 Complication rates as high as 20% for venous cath-
eters and 10% for arterial catheters have been reported.32 A venous
catheter placed in the portal system may lead to hepatic necrosis, INTRODUCTION
hemorrhage, and thrombus formation, which may lead to a pul- Arterial blood gas (ABG) sampling is an essential component of
monary embolus or portal hypertension.3–6 Neonates are at higher the care of many Emergency Department patients. It provides key
risk for thromboembolic events because of their underdeveloped information regarding a patient’s oxygenation and acid-base status.
clotting mechanisms, small vessel diameters, and critical under- Arterial cannulation allows for continuous and accurate blood pres-
lying diseases when compared with older children and adults.29 sure monitoring and frequent blood gas sampling in the care of the
Phlebitis or nosocomial sepsis can ensue if strict aseptic technique critically ill patient.
is not followed.32 Rarely, the catheter can be transected or form a
knot intravascularly.33,34 Vessel and bowel perforation from force- ANATOMY AND PATHOPHYSIOLOGY
ful manipulation of the catheter, an air embolus from an unflushed
catheter prior to insertion, false track formation, cardiac arrhyth- Knowledge of the arterial anatomy is a key factor in the success
mias, damage to cardiac valves, and myocardial perforation have of arterial puncture and cannulation. It is important to recognize
all been reported.3,6,7,32,58 Necrotizing enterocolitis, biliary venous that nerves and veins are located in close proximity to the desired
fistula, pericardial effusion, hypoglycemia from high positioning arteries in order to avoid complications. The anatomy and position-
of an umbilical artery catheter, bladder rupture, congestive heart ing for radial, brachial, femoral, and dorsalis pedis artery access is
failure, hypertension, transection of an omphalocele, transection described below.
of the catheter, intravascular knots in the catheter, and Wharton’s
jelly embolus have also been reported.58–65 Occasionally, a persis- RADIAL ARTERY
tent urachus in the umbilical cord stump may be mistaken for an The radial artery is the preferred site for arterial puncture and can-
umbilical vein. Catheterization of the urachus will result in the flow nulation. One reason is the comparative ease of identifying the
of urine, and not blood, from the catheter. This is easily identified anatomical location of this artery. A second reason is the collat-
and corrected. eral nature of the arterial blood supply to the hand provided by the
Malpositioning of the umbilical vein catheter has resulted in radial and ulnar arteries. The ulnar artery is not often used due to
rare complications such as pneumopericardium, cardiac tampon- its smaller size. Terminal branches of these two arteries meet in the
ade, pleural effusion, pulmonary hemorrhage, pulmonary edema, palm of the hand to form the deep and superficial palmar arterial
pulmonary infarction, pulmonary abscess, cardiac thrombosis, arches (Figure 57-1).
endocarditis, myocardial perforation, atrial flutter, hyponatremia,
perforation of the peritoneum, perforation of a Meckel’s diver-
ticulum, perforated urachal remnant, ascites from intraperitoneal
extravasation of total parenteral nutrition (TPN), esophageal vari-
ces, hepatic laceration, hepatic necrosis, hepatic abscess, hepatic
calcifications or bladder calcifications with infusion of calcium
gluconate, biliary fistula, perforation of the IVC, gastric outlet
obstruction, or bladder rupture.8,34–54
Malpositioning of the umbilical artery catheter has rarely resulted
in sciatic nerve damage, refractory hypoglycemia from infusion into
the celiac axis, or spinal cord injury with paraplegia from infusion
into the artery of Adamkiewicz.2,23,32,56,57 Umbilical artery catheter-
ization may be complicated by vasospasm, thrombosis or embo-
lism, causing ischemia of the lower extremities or intraabdominal
organs.2,5,6,32,55 Vasospasm can occur within moments of catheter
insertion or up to several hours following placement. The signs
include progressive ischemia resulting in discoloration or mottling
of the lower extremities and/or buttocks. Embolization of clots can
cause loss of digits, hematuria, kidney failure, hypertension, necro-
tizing enterocolitis, bowel infarction, cyanosis or blanching of the
skin (of the back, buttocks or legs), or skin ulceration.
SUMMARY
Umbilical vessel catheterization is a readily available method of
obtaining vascular access in the sick newborn. These vessels can be
used for fluid resuscitation, blood transfusion, medication admin-
istration, frequent blood sampling, and cardiovascular monitoring.
Because serious complications may result from using this route, it
should be reserved for infants in whom peripheral vascular access FIGURE 57-1. Anatomical location of the radial and ulnar arteries. Collateral circu-
is unsuccessful. lation is provided by the superficial and deep palmar arches.
CHAPTER 57: Arterial Puncture and Cannulation 377
monitor. Either an ulnar dominant system or a radial dominant

system with adequate collateral circulation is likely if the waveform
remains unchanged during radial artery occlusion.3
The performance of an Allen test to confirm adequate collateral
circulation to the hand is generally advocated before radial artery
puncture or cannulation. There is concern that radial artery occlu-
sion from an intraluminal clot or an external hematoma can result in
hand ischemia if the ulnar artery cannot provide adequate collateral
blood flow. Some authors have questioned the utility of perform-
ing an Allen test.1,2,4,38 The Allen test is subjective, often improperly
performed, and has poor sensitivity and specificity to predict com-
plications.39 The relative safety of radial artery cannulation without
the Allen test has been demonstrated in a large case series of patients
without major peripheral vascular disease.4 Although an abnormal
Allen test may not preclude radial artery puncture or cannulation,
it may indicate a greater need for caution and alert the Emergency
Physician to potential problems after the procedure is performed.2
This can include arterial thrombosis, hand ischemia, and hand
necrosis. Thus it is recommended, but not required, to cannulate
another site if the Allen test is abnormal.
BRACHIAL ARTERY
The brachial artery courses along the medial side of the antecubital
fossa just lateral to the median nerve (Figure 57-3). The brachial
artery divides at approximately the level of the neck of the radius
to become the ulnar and radial arteries. In the antecubital fossa,
the brachial artery is located lateral to the medial epicondyle of
the humerus and medial to the biceps brachii muscle. The brachial
artery is more easily identified when the elbow is fully extended. In
order to locate the artery, start by palpating the medial epicondyle
FIGURE 57-2. The modified Allen test. A. The distal radial and ulnar arteries are
of the humerus. Move laterally until the medial edge of the biceps
occluded. B. The ulnar artery remains occluded while determining if the radial
artery can supply adequate blood flow to the hand.
The radial artery can be found just medial and proximal to the
radial styloid process on the ventrolateral wrist (Figure 57-1).
Dorsiflexing the wrist approximately 60° can aid in palpating
the arterial pulse. Another notable landmark is the flexor carpi
radialis tendon that runs immediately medial to the radial artery.
The recommended point of needle or catheter insertion is at the
proximal flexor crease of the wrist and directly above the radial
artery pulse.
An Allen test should be performed to assess the adequacy
of the collateral circulation to the hand prior to radial artery
puncture or cannulation (Figure 57-2).1,2 Ask the patient to
repeatedly close their hand tightly into a fist and open it, to force
blood out of the fingers, while manually occluding the radial
and ulnar arteries (Figure 57-2A). Continue this process for
1 minute. Ask the patient to open their hand. The fingers should
be blanched and pale due to the occlusion of the arterial inflow.
Release the finger occluding the ulnar artery. Measure the time
it takes for blushing of the palm to occur. It is considered nor-
mal if it is <7 seconds, equivocal at 8 to 14 seconds, and abnor-
mal if >14 seconds.1 Repeat the test, but this time release the
radial artery compression to confirm arterial flow into the hand
(Figure 57-2B). The purpose is to confirm arterial inflow from
both the radial and ulnar arteries.
An alternative method of evaluating the collateral circulation
involves the use of a pulse oximeter with a visual pulse wave-
form display.3 This is useful in the young, unconscious, or unco-
operative patient. Place the pulse oximeter sensor on the patient’s FIGURE 57-3. Anatomical location of the brachial artery. Note the median nerve
thumb. Observe the visual display to confirm a waveform is pres- running just medial to the artery and the biceps brachii muscle just lateral to
ent. Occlude the radial artery and examine the waveform on the the artery.
or have significant variability in its anatomic location. It may be dif-

ficult to identify the pulse in the hypotensive patient.
ALTERNATIVE ARTERIAL SITES

There are several alternative sites that are occasionally used for arte-
rial puncture and cannulation. These include the superficial tempo-
ral artery, the axillary artery, and the ulnar artery. The superficial
temporal artery is often used in neonates and young infants in the
intensive care unit. Cannulation of this artery is rarely performed in
the Emergency Department because of its location and the ability to
maintain access.
The axillary artery is a continuation of the subclavian artery after
the first rib. The axillary artery crosses the teres major tendon to
enter the arm as the brachial artery. The axillary artery can be deep
to the skin surface. The advantages of this artery include the ease of
locating a the palpable pulse, even in the hypotensive patient. An
accurate blood pressure, devoid of the effects of vasoconstriction,
can be obtained. Unfortunately, the disadvantages of cannulating
the axillary artery are significant. The axilla is poorly accessible. The
patient’s arm must be abducted, externally rotated, and immobilized
during and after the procedure. The course of the artery changes
FIGURE 57-4. Anatomical location of the femoral artery. Note the proximity to the with arm position. The artery is contained within the axillary sheath
femoral nerve and vein. along with the axillary vein and brachial plexus. There is a signifi-
cant risk of nerve injury if the needle penetrates the brachial plexus.
The risk of an arterial embolus is higher in central arteries when
compared to peripheral arteries.
muscle is palpated. The brachial artery pulse should be palpable just The ulnar artery, along with the radial artery, is one of the termi-
medial to the biceps muscle. The arterial pulsation is most easily nal branches of the brachial artery. It is superficial at the wrist and
identified at the level of the proximal flexor crease of the antecubi- the pulse is easily palpable. The ulnar artery is significantly smaller
tal fossa. The preferred location for puncture or cannulation of the in most people when compared to the radial artery, making the pro-
brachial artery is in, or just proximal to, the antecubital fossa and cedure more technically difficult. An ulnar artery may be absent or
directly above the brachial artery pulse. If the artery is to be can- extremely small in some patients. The ulnar artery lies adjacent to
nulated, the arm should remain in extension while the cannula is the ulnar nerve. This increases the possibility of nerve injury if the
in place. needle penetrates the ulnar nerve. It can be difficult to identify the
artery in the patient with anasarca, obesity, peripheral edema, or
peripheral vascular disease.
FEMORAL ARTERY
The bony anatomic landmarks used to identify the femoral artery INDICATIONS
are the anterior superior iliac spine and the tubercle of the pubic
symphysis. The artery lies approximately midway between these two The principal indications for arterial blood sampling include the
points after it courses under the inguinal ligament to enter the thigh determination of the blood carbon dioxide (CO2) content, oxygen
(Figure 57-4). The femoral nerve and vein are found running in (O2) content, and acid–base status.5,6 The need for ABG sampling
parallel and adjacent to the artery. The vein lies just medial to the for determination of oxygenation has decreased substantially with
artery and the nerve just lateral. The femoral artery is larger than the advent of pulse oximetry. Pulse oximetry may poorly reflect
other arteries commonly cannulated and lies significantly deeper true oxygenation in the setting of severe hypoxia or severe hypoten-
than the radial or brachial arteries. This makes it necessary to use sion. Therefore, ABG analysis persists as the true measure of arte-
a longer cannula and, depending on the patient’s body habitus, may rial oxygenation.7 End-tidal CO2 (ETCO2) monitoring has decreased
require a longer needle for a simple arterial puncture to be success- the utilization of ABG samples for CO2 measurement. In patients
ful. Extension and slight abduction of the hip maximizes access to who have large dead space ventilation or low cardiac output, ETCO2
the femoral triangle, improves the ability to palpate the artery, and measurements may grossly underestimate the true CO2 contents of
provides a maximal work area for the procedure. the blood.8
Arterial blood gas samples are useful for accurate pH moni-
toring of patients with shock, obstructive lung disease, and other
DORSALIS PEDIS ARTERY
pulmonary disorders. Possibly the most important indication for
The dorsalis pedis artery is a continuation of the anterior tibial ABG sampling in the critically ill patient is the determination of the
artery on the dorsal surface of the foot. Puncture and cannulation of patient’s acid–base status. Venous sampling may occasionally suffice
the dorsalis pedis artery is a good second choice if the radial artery for monitoring the pH in a few illnesses such as diabetic ketoacido-
is unsuccessfully cannulated or unavailable. The pulse is often easily sis.9 The measurement of venous blood pH is much less reliable as
palpable between the first and second metatarsal due to its superfi- a surrogate for arterial pH in patients with shock and other critical
cial location. Its distal location does not interfere with other resus- illnesses.10 Arterial blood samples are still used for the measurement
citative efforts and is convenient for the patient. The risk of foot of carboxyhemoglobin and methemoglobin level. One study found
ischemia is minimal due to the abundant collateral circulation to the that venous and arterial co-oximetry carboxyhemoglobin values are
foot and ankle. There are no significant structures to injure adjacent closely correlated and may be used to screen a patient thought to
to the dorsalis pedis artery. This artery can be absent in some people have been exposed to carbon monoxide.11
The three principal indications for arterial catheter placement are • 4 × 4 gauze squares
the need for continuous monitoring of arterial blood pressure, the • #11 scalpel blade
need for frequent ABG sampling, and the need for frequent blood
sampling for laboratory analysis in the critically ill patient. Cycled • Nylon suture, 3-0 or 4-0 and needle drivers
oscillometric blood pressure measurement may be insufficient to • Femoral artery needle, approximately 18 gauge, 2 7/8 in.
gauge rapid hemodynamic changes in critically ill hypertensive or • 4 French single lumen catheter, at least 15 cm in length
hypotensive patients. Continuous blood pressure monitoring facili- • 30 cm guidewire compatible with above needle and catheter
tates titration of rapid-acting vasodilators and vasopressors. The
accuracy of auscultated or oscillometric blood pressure readings Ultrasound Guidance
under conditions of severe shock or malperfusion are suspected.1,2
Centrally measured aortic pressure is the true gold standard.1,2
However, given the impracticality of measurement of aortic pres- • 5 to 10 MHz linear array ultrasound probe
sure, peripheral arterial pressure measured with an intraarterial • Sterile ultrasound gel
catheter connected to a pressure transducer is the next best gauge. • Sterile ultrasound probe cover
CONTRAINDICATIONS If a syringe that has not been designed specifically for ABG sam-
pling is used, and it has not been pretreated with heparin or does
Contraindications to arterial puncture and catheter placement not contain a lyophilized heparin pellet, it is necessary to prepare
relate primarily to abnormalities at the insertion sites. Avoid skin the syringe using heparin solution. Draw up 1 to 2 mL of heparin
and arteries that are already compromised by trauma, burns, infec- solution into the syringe and then expel the heparin, leaving only
tion, severe dermatitis, severe peripheral vascular disease, or pre- the heparin remaining in the dead space of the syringe and the nee-
vious surgery in the area.1,5 Puncture or cannulation of synthetic dle. This amount of heparin is sufficient to prevent clotting of the
vascular grafts is also relatively contraindicated. Do not puncture sample.5 It is important to remove all but the necessary amount of
where the artery “should be” if the arterial pulsation cannot heparin as excess heparin has been found to falsely lower the PCO2
be palpated. Attempts at cannulation of nonpalpable arteries are measurement and may elevate the PO2 measurement.37
generally fruitless and sometimes hazardous. Arterial puncture or Commercially produced, prepackaged kits are available for arte-
catheterization is relatively contraindicated in patients with bleed- rial puncture and arterial cannulation. These kits are complete and
ing diatheses and those who have received, or may receive, throm- contain all the required equipment. Also available are individually
bolytic therapy. packaged heparinized ABG syringes and arterial line catheters in
various sizes.
EQUIPMENT The catheter size used for the procedure will vary by patient age
and the artery chosen to cannulate. In neonates and infants, use a
Arterial Puncture for Single ABG Sample 22 or 24 gauge catheter for the radial or dorsalis pedis arteries and an
• Povidone iodine or chlorhexidine solution 18 or 20 gauge for the femoral artery. In children up to 8 to 10 years
of age, use a 22 gauge catheter for the radial or dorsalis pedis arteries
• Dorsal wrist extensor splint or small rolled up towel
and a 16 to 20 gauge for the femoral artery. In a larger child, adoles-
• 1% lidocaine, 1 mL in a tuberculin syringe cent, or adult, use a 20 or 22 gauge catheter for the radial or dorsalis
• 5 mL syringe for blood collection with cap retained pedis arteries and a 14 to 20 gauge for the femoral artery.
• Prepackaged blood gas syringe with lyophilized heparin pellet
• 20 to 22 gauge needle for arterial puncture PATIENT PREPARATION
• 1 to 2 mL of heparin (1000 U/mL) Explain the procedure, its risks, and benefits to the patient and/or
• Gauze pads their representative. Obtain an informed consent unless the proce-
dure is being performed emergently or the patient is unable to give
• Adhesive tape consent. Identify by palpation the arterial pulse at the intended
• Specimen collection bag or cup with 2 to 3 inches (in) of ice skin puncture site. Clean the skin of any dirt and debris. Cleanse
the skin with chlorhexidine or povidone iodine solution and allow
Arterial (Brachial, Radial, Dorsalis Pedis) Cannulation it to dry.
• Povidone iodine or chlorhexidine solution Studies that examined the use of topical anesthetic agents have
not shown a benefit that outweighs the delay required to perform
• Dorsal wrist extensor splint or small rolled up towel the procedure.12 The use of an injectable local anesthetic agent,
• 1% lidocaine, 1 mL in a tuberculin syringe however, may greatly aid in the process of arterial puncture or can-
• 4 × 4 gauze squares nulation and significantly reduces patient discomfort.13 Infiltrate
• Adhesive tape 1 mL of local anesthetic solution subcutaneously over the bra-
chial, dorsalis pedis, or radial arteries. Infiltrate 2 to 5 mL of local
• Nylon suture, 3-0 or 4-0 and needle drivers anesthetic solution subcutaneously and into the subcutaneous
• 20 or 22 gauge, 1¾ in polyurethane angiocatheter or catheter- tissues over the femoral artery. Aspirate before infiltrating the
over-the-needle local anesthetic solution to prevent inadvertent intravascular
• 0.45 mm diameter, 5¼ in spring wire guide compatible with injection.
above catheter Descriptions of the anatomy for arterial puncture or cannulation
sites are described in detail earlier in this chapter. The preferred
Femoral Artery Cannulation site for the initial attempt at arterial puncture or cannulation is the
radial artery.1 Begin distally where the pulse is most palpable near
• Povidone iodine or chlorhexidine solution the proximal wrist flexor crease. If the first attempt at needle or
• 1% lidocaine, 3 mL in a syringe armed with a 25 gauge needle catheter introduction is unsuccessful, and the pulse is still palpable,
reattempt the procedure more proximally along this same artery. needle and watch for blood flow into the syringe. If it is neces-
The radial artery on the contralateral wrist is also a satisfactory sary to redirect the needle, it is imperative to first withdraw
second site for attempted access. Other acceptable second-attempt the needle until the tip is just below the skin surface before
sites of access include the femoral, dorsalis pedis, and brachial arter- changing the angle in order to avoid lacerating the artery or
ies. An attempt at ipsilateral ulnar artery catheterization is not adjacent structures. To minimize the possibility of error due to
advisable as both limbs of the hand’s circulation may be compro- the presence of heparin, it is necessary to collect at least 1 mL of
mised. The discussion below focuses on puncture or cannulation of blood in a prepackaged syringe or 3 mL of blood if preparing your
the radial and femoral arteries as over 90% of arterial punctures or own syringe with heparin.5
cannulations occur at these sites.1 The use of other sites generally Withdraw the needle after the arterial sample has been collected.
follows the techniques described below for the radial artery with the Apply pressure to the puncture site for 3 to 5 minutes followed by
exception of the regional anatomic differences. Other useable sites a bandage or gauze dressing. Carefully remove the needle from the
include the dorsalis pedis, brachial, posterior tibial, and superficial syringe if not using a safety needle. Evacuate any air from the syringe
temporal arteries. and apply a cap on the syringe. Place the syringe on ice for immedi-
ate transportation to the laboratory. Recheck the skin puncture site
TECHNIQUES in 5 to 10 minutes to assess for the formation of a hematoma and/or
vascular compromise to the distal extremity.
ARTERIAL PUNCTURE FOR A SINGLE SAMPLE
Position the patient to maximize exposure of the skin surface over-
lying the chosen artery. For the radial artery, this is best accom-
plished by dorsiflexing the wrist and supporting this position with a
small towel rolled up under the dorsal wrist surface (Figure 57-5).
For brachial and femoral artery puncture, ensure that the elbow
or hip is extended fully. These positions provide maximum expo-
sure and working area for the procedure. Locate the chosen artery,
prep the overlying skin, and infiltrate local anesthetic solution
subcutaneously.
Reidentify the pulse by palpation with the nondominant hand
(Figure 57-6A). Grasp the heparinized syringe with the dominant
hand. Withdraw the plunger of the syringe so that 1 to 3 mL of air
space is available in the syringe. This will allow for easier assess-
ment of arterial blood return. Insert the needle at a 30° to 45°
angle to the skin and just above the arterial pulse (Figure 57-5).
Advance the needle through the skin until blood enters the syringe
(Figure 57-6B). The blood flow will generally fill the syringe
without necessitating the withdrawal of the plunger in a patient
with a brisk pulse. If no blood return occurs, slowly withdraw the
Radial
artery
Towel
30° - 45°
FIGURE 57-5. Correct positioning for radial artery puncture and cannulation.
Dorsiflexing the wrist and supporting it with a small towel facilitates palpation of FIGURE 57-6. Radial artery puncture for an ABG sample. A. The pulse is palpated
the artery and provides maximum working space. The needle or catheter-over-the- with the nondominant hand. The heparinized syringe is inserted at a 30° to 45°
needle is aimed toward the oncoming blood flow at a 30° to 45° angle to the skin. angle to the skin surface. B. Arterial blood fills the syringe.
RADIAL ARTERY CANNULATION: RADIAL ARTERY CANNULATION: SELDINGER-TYPE,

CATHETER-OVER-THE-NEEDLE-TECHNIQUE SINGLE ARTERIAL WALL PUNCTURE
The most basic method is direct introduction of the catheter- The second technique for arterial cannulation is a Seldinger-type
over-the-needle in a manner similar to that of inserting an technique (catheter-over-the-wire) utilizing one of a number of pre-
intravenous catheter (Figures 57-5 & 57-7). This method is as packaged commercially available kits. A commercially available one-
effective as the more specialized wire-guided-catheter technique, piece catheter-over-the-needle kit is very popular (Figure 57-8). As
except in situations where the pulse is weak, the pulse is absent, noted previously, these wire-guided catheters have not been shown
or in the hands of more experienced operators.14,15 Clean, prep, to increase successful cannulation or reduce the number of attempts
and identify the radial artery as described previously. Insert the except in situations where a weak or absent pulse is present, or with
catheter-over-the-needle at a 30° to 45° angle to the skin and more experienced Physicians.14,15 One study noted that the guide-
directly over the arterial pulse (Figures 57-5 & 57-7A). Advance wire can be useful in salvaging an arterial line when a catheter-over-
the catheter-over-the-needle into the artery (Figure 57-7A). the-needle cannot be effectively advanced.
Bright red blood in the hub of the needle indicates that the tip Open the package, remove the unit, and remove the protective
of the needle is within the artery. Advance the catheter-over- cover over the needle. Advance and retract the guidewire to confirm
the-needle another 1 to 2 mm to ensure that the catheter tip is it moves smoothly and does not get caught on the needle. Retract
completely within the arterial lumen. Securely hold the hub of the guidewire as far back as possible. Identify the arterial pulse with
the needle. Advance the catheter over the needle until its hub is the nondominant hand. Insert the catheter-over-the-needle through
against the skin (Figure 57-7B). Remove the needle and confirm the skin and into the artery using a slow and continuous forward
pulsatile arterial flow from the hub of the catheter. Free-flowing, motion (Figure 57-8A). A flash of blood in the hub of the needle
pulsatile blood confirms proper catheter placement within the confirms successful entry through the arterial wall and into the ves-
artery. Apply a stopcock or intravenous extension tubing to the sel lumen. Stabilize the catheter-over-the-needle.
hub of the catheter. Secure the catheter to the skin. Apply a dress- Advance the guidewire through the needle by pushing the actu-
ing to the skin puncture site. ating lever as far as possible toward the needle (Figure 57-8B).
Immediately stop if resistance is encountered while advanc-
ing the guidewire. The guidewire may be within the artery wall
or through the artery wall and into the perivascular tissue. Do
not try to force the guidewire into the vessel. Do not retract the
guidewire. Withdraw the entire unit and apply pressure to the
puncture site to prevent a hematoma. Obtain a new kit and repeat
the procedure.
Once advanced, the guidewire is successfully within the arterial
lumen. Firmly grasp the clear hub of the needle and advance the
catheter over the guidewire and into the artery (Figure 57-8C). A
rotating motion of the catheter is often helpful to advance it if
difficulty is encountered. Securely hold the catheter at the level of
the skin. While firmly holding the catheter hub, remove the guide-
wire, needle, and feed tube assembly as a unit. Free-flowing, pul-
satile blood confirms proper catheter placement within the artery.
Apply a stopcock or intravenous extension tubing to the hub of the
catheter. Secure the catheter by suturing it to the skin or by using
commercially available devices that do not require suturing. Apply a
dressing to the skin puncture site.
A commercially available Seldinger-type catheter-over-the-nee-
dle kit is an alternative to the one-piece unit (Figure 57-9). Open
the package and review the equipment it contains. Place the finder
needle on the syringe. Withdraw the plunger 1 cm to break the bead
of the syringe. Identify the arterial pulse by palpation with the non-
dominant hand. Insert the needle through the skin and into the
artery using a slow and continuous forward motion (Figure 57-9A).
A flash of blood in the syringe confirms the successful entry through
the arterial wall and into the vessel lumen. Firmly hold and stabilize
the needle. Remove the syringe. Advance the guidewire through the
needle (Figure 57-9B). The guidewire should advance without
resistance. Immediately stop if resistance is encountered while
advancing the guidewire. The guidewire may be within the artery
wall or through the artery wall and into the perivascular tissue.
Do not try to force the guidewire into the vessel. Do not retract
the guidewire. Withdraw the entire unit and apply pressure to the
puncture site to prevent a hematoma. Obtain a new kit and repeat
the procedure.
FIGURE 57-7. The catheter-over-the-needle technique for arterial cannulation. After the guidewire is inserted, withdraw the needle while leaving
A. The unit is held at a 30° to 45° angle to the skin and advanced into the artery. the guidewire in place (Figure 57-9C). Do not re-advance the nee-
B. The catheter is advanced over the needle and into the artery. dle as it can shear off the guidewire. Make a 3 mm puncture wound
FIGURE 57-8. Catheter-over-the-needle technique using a commercially available one-piece unit. A. The catheter-over-the-needle is inserted into the artery. B. The guide-
wire is advanced through the needle and into the artery. C. The catheter is advanced over the guidewire into the artery with a twisting motion.
next to the skin puncture site of the guidewire using a #11 scalpel rise up through the needle. However, when trying to advance the
blade to facilitate inserting the catheter (Figure 57-9D). Thread the catheter, it may get hung up outside the lumen with the catheter-
catheter over the guidewire. Advance the catheter over the guide- over-the-needle technique.17 The guidewire may not easily pass or
wire until the hub of the catheter is against the skin (Figure 57-9E). may dissect into the vessel wall creating a false lumen when using
A rotating motion of the catheter is often helpful to advance it if the Seldinger-type single arterial wall puncture technique. Since
difficulty is encountered. Securely hold the catheter at the level of pulsatile flow is more easily confirmed prior to the passage of the
the skin. Remove the guidewire while firmly holding the catheter guidewire, this third technique in which both walls of the radial
hub against the skin. Free-flowing, pulsatile blood confirms proper artery are punctured may offer an advantage in passing the guide-
catheter placement within the artery. Apply a stopcock or intrave- wire and catheter into the arterial lumen.
nous extension tubing to the hub of the catheter. Secure the catheter It is imperative that the Emergency Physician assumes a posi-
by suturing it to the skin. Apply a dressing to the site. tion out of the trajectory line of the catheter to avoid being
sprayed with blood when using this technique. This method is
RADIAL ARTERY CANNULATION: SELDINGER-TYPE, also a Seldinger-type technique that utilizes a guidewire separate
from the catheter-over-the-needle. Locate the arterial pulse and
DOUBLE ARTERIAL WALL PUNCTURE
insert the catheter-over-the-needle into the artery. Immediately
While localization and needle puncture of the artery are identical advance the catheter-over-the-needle through the posterior wall
in all three techniques, commonly encountered difficulties include as confirmed by no blood exiting the needle hub. Withdraw the
threading of the catheter with the first technique and threading of needle while leaving the catheter in place through the artery.
the guidewire into the vessel lumen with the second technique.16 If Flatten the angle of the catheter to the skin to less than 30°. Hold
the needle orifice is merely at the vessel edge, blood may enter and the tip of the guidewire poised at the hub of the catheter. Slowly
FIGURE 57-9. The Seldinger technique for arterial catheterization. A. The needle is inserted into the artery. B. The syringe has been removed from the needle. The guide-
wire is advanced through the needle and into the artery. C. The needle is removed while leaving the guidewire in place. D. The skin is punctured with a #11 scalpel blade
to allow easy insertion of the catheter. E. The catheter is advanced over the guidewire and into the artery. F. The guidewire has been removed.
withdraw the catheter with the nondominant hand. Promptly

insert the guidewire through the catheter and into the artery
when pulsatile blood flow is noted from the hub of the catheter.
Advance the catheter over the guidewire and into the lumen of the
artery. Withdraw the guidewire and apply a stopcock or intrave-
nous extension tubing. Secure the catheter and apply a bandage
or dressing.
This double-puncture technique for cannulation theoretically
may be associated with greater vascular damage. The technique
should be reserved for instances in which the prior two arterial can-
nulation techniques have been unsuccessful. However, in an analysis
of the complications associated with various techniques of periph-
eral artery cannulation, investigators found no difference in compli-
cations when using this technique.18
FEMORAL ARTERY CANNULATION

The femoral artery may be cannulated if the radial artery is inacces- A
sible or attempts at cannulation are unsuccessful. A longer catheter,
catheter-over-the-needle, and needle is required as the femoral
artery is not superficial. Slightly abduct the patient’s leg and iden-
tify the femoral artery pulse. Prep, drape, and anesthetize the skin
and subcutaneous tissues. Maintain the fingers of the nondominant
hand on the arterial pulse. Insert the needle or the catheter-over-
the-needle at a 45° angle to the skin with the needle bevel point-
ing superiorly. The remainder of the technique is as described
previously.
DORSALIS PEDIS ARTERY CANNULATION

The procedure for cannulation of the dorsalis pedis artery is the
same as that described for the radial artery. Clean, prep, and plantar
flex the foot. Do not plantar flex the foot more than 45° as this can
stretch and occlude the artery. The needle angle of entry should be
less than that used for the radial artery due to the superficial loca-
tion of the artery. Insert it at 20° to 30° to the skin rather than 30°
to 45°.
ULTRASOUND-GUIDED ARTERIAL CANNULATION

Ultrasound can be used to guide arterial puncture or cannulation.
It can be a rescue method if the palpation technique fails. It can
also be used initially to decrease the number of puncture attempts,
to decrease the amount of time spent gaining access, and to poten-
tially decrease complications such as hematomas and arterial lac-
eration.19,20 Most studies have focused on radial artery cannulation, B
but the technique for alternative sites is the same.
Clean and prep the skin over the artery. Apply a sterile probe
FIGURE 57-10. Ultrasound-guided arterial puncture. A. The artery is seen at the
cover or a sterile glove over the linear array ultrasound probe. top of the image (asterisk). B. The longitudinal view demonstrating the needle
Orient the probe marker on the side of the probe so it matches entering the artery.
that on the screen. Identify the artery. It will appear as a round,
thick-walled, and pulsatile vessel that is not easily compressible
(Figure 57-10A). Move the probe proximally and distally over the When the needle reaches the artery, it will dimple the wall of the
artery to approximate its course, which is sometimes not perfectly artery. Advance the needle slowly while watching for the flash of
parallel to the long axis of the extremity. Once the vessel has been blood in the needle hub. Once the flash is seen, ultrasound can be
identified, center it on the screen. The center of the probe is now used to confirm placement of the needle and/or catheter within
directly over the vessel and can act as a guide to skin puncture. the artery (Figure 57-10B). Proceed from this point with either the
Hold the probe with the nondominant hand or have an assistant catheter-over-the-needle or the Seldinger-type technique to com-
hold the probe. Insert the catheter 1 to 2 cm distal to the probe. plete the procedure.
When the needle is into the subcutaneous tissue, rock it in and out
very slightly to create movement that is apparent on the screen.
This will help to identify the location of the needle in relation to
the artery. Slowly advance the needle. The needle itself may or may A cutdown technique may be performed to cannulate an artery. It
not be apparent, but motion through the tissue can be used to infer is primarily used for the brachial or radial arteries but may be used
the site of the needle tip. to access other peripheral arteries. This technique is rarely required
with the availability of ultrasound to locate an artery The technique are infection, bleeding, arterial injury, and thrombosis.2,21–30 While
is briefly described here. Please refer to Chapter 54 for more com- secondary bacteremia and septic emboli may occur, infection is
plete details. usually limited to the site of catheterization. The risk of catheter
Clean, prep, anesthetize, and drape the skin overlying the chosen site infection is linearly related to the length of time the cathe-
artery. Make a 1.5 to 2.0 cm transverse skin incision centered over ter is in place.2 The infection rate is similar for both femoral and
the artery. Do not cut into the subcutaneous tissue so that blood radial artery sites.2,23,31–33 Nerve injury from direct puncture of the
vessels, nerves, and tendons are not transected. Spread the sub- nerve has been reported in connection with arterial puncture or
cutaneous tissues parallel to the artery with a mosquito hemostat. cannulation.34 Multiple cases of neuropathy have occurred as a
Expose 1.0 cm of the length of the artery. Pass a silk suture under result of a hematoma formation and subsequent nerve compres-
the proximal end of the exposed artery. Insert a catheter-over-the- sion.35 In order to minimize hematoma formation after arterial
needle through the skin just distal to the incision and advance it into puncture or arterial catheter removal, apply at least 3 minutes of
the incision. Elevate the suture to control the artery and occlude direct pressure to radial, brachial, and dorsalis pedis puncture sites
distal blood flow. Advance the catheter-over-the-needle into the and 5 to 10 minutes of pressure to the femoral site.34,36 Although
artery. Release the suture and advance the catheter into the artery. small hematomas are common after arterial puncture, major
The remainder of the procedure is as described previously. Apply bleeding is unusual and generally occurs only in the concealed
pressure over the incision site for 5 to 10 minutes to prevent the retroperitoneum after femoral artery puncture or cannulation.
formation of a hematoma or seroma. Angiographically demonstrable thrombosis is common (25% to
40%) after prolonged arterial catheterization.2 This rarely results
AFTERCARE in clinically significant morbidity. Secondary limb ischemia and
necrosis requiring amputation occur in less than 1:2000 arterial
Apply direct pressure for 3 to 5 minutes to the skin puncture site catheterizations.2 Other rare complications include the formation
after an arterial puncture or removal of an arterial catheter. Apply of a pseudoaneurysm or arteriovenous fistula.
direct pressure for 10 minutes or more if the patient has a bleed- The complications associated with an arterial catheter can be
ing diathesis or has received thrombolytic therapy. Apply a ban- limited. Only insert an arterial catheter if it is truly needed. Always
dage or gauze dressing to the skin puncture site. Reassess the skin insert it using strict aseptic technique. Remove the catheter as
puncture site in 15 minutes for continued bleeding or hematoma soon as it is determined it is no longer required to assist in the
formation. management of the patient. Frequently check the skin puncture
An arterial catheter must be secured to the skin to prevent site for signs of bleeding, a hematoma, and infection. Frequently
inadvertent dislodgement, hematoma formation, and exsanguina- assess the distal extremity for signs of perfusion. Remove the cath-
tion. Sew the hub of the catheter to the skin using 3-0 or 4-0 nylon eter at the first sign of a complication. Place the catheter in the
sutures. Apply a protective dressing over the site. A splinting device patients’ nondominant hand, if known, to limit the impact of any
should be used to secure the limb in the desired position for optimal complications.
monitoring if the catheter is in the wrist, arm, or foot. Monitor the
site regularly to assess for signs of bleeding, infection, hematoma,
arterial thrombosis, or catheter dislodgement. It is also important to SUMMARY
assess the extremity distal to the catheter for evidence of ischemia.
Arterial puncture and cannulation are quick, safe, and simple to
Replace the dressing regularly in accordance with your institutional
perform. Arterial blood sampling may aid in determining the
guidelines.
ventilator and acid–base status of critically ill patients. An arterial
Flush the arterial catheter with sterile saline solution. In the past,
catheter is appropriate in patients who need continuous monitor-
heparinized saline was the standard arterial line flush solution. The
ing of arterial blood pressure or frequent ABGs. Arterial puncture
use of heparinized saline has not been shown to improve function-
and cannulation should be avoided in skin areas with evidence
ality, prevent thrombotic complications, or increase the duration
of burn, trauma, infection, severe dermatitis, or severe periph-
of catheter patency when compared to saline.40 The use of heparin
eral vascular disease. Palpation of the arterial pulse and correct
risks an adverse reaction or heparin-induced thrombocytopenia.
anatomical positioning are necessary before these procedures are
attempted. It is necessary to monitor the cannulated site for signs
COMPLICATIONS of bleeding, hematoma, thrombosis, or infection. After an arterial
Arterial puncture and catheterization are generally safe proce- puncture or removal of an arterial catheter, it is necessary to apply
dures with an incidence of clinically significant complications direct pressure to the skin puncture site to prevent the formation
under 5%.1 The primary complications of arterial catheterization of a hematoma.
SECTION
Gastrointestinal Procedures 5
The placement of a NG tube in children is often difficult. Their
Nasogastric Intubation large tonsils and adenoids may hinder the passage. These tissues are
58 Lisa Freeman Grossheim
soft, easily injured, and may bleed as the NG tube is passed. The
tongue, large by comparison with adults, may push into the oro-
pharynx and impede passage of the NG tube. Their nostrils and
nasal passage are quite small and limit the size of NG tube that may
INTRODUCTION be passed.
Nasogastric (NG) intubation is one of the commonly performed
procedures in the Emergency Department.1 Its use as a conduit INDICATIONS
into the stomach was first popularized in the early twentieth cen- Nasogastric intubation may be performed for diagnostic or thera-
tury mainly through the efforts of Dr. Levin. Clinicians have since peutic indications.15 The primary indication for NG intubation is to
studied its use, have proposed methods to improve the ease with aspirate stomach contents. It is used to evaluate the presence, rapid-
which the NG tube is inserted, and determined ways to diminish ity, and volume of an upper gastrointestinal hemorrhage. However,
the incidence of potentially lethal complications. A NG tube is often unless the aspirate is grossly bloody, detection of blood may be unre-
placed in patients who have a bowel obstruction, intractable nausea liable. The fecal Hemoccult card should not be used to test for occult
and vomiting, intoxication, significant trauma, upper gastrointesti- blood in gastric aspirates, as it may be accurate. The Gastroccult
nal bleeding, or who are endotracheally intubated. The procedure is card uses a developer that neutralizes gastric acid, rendering it able
rapid, simple, and straightforward. to detect hemoglobin.11 A NG tube may be inserted to instill air into
the stomach to assess for an intraperitoneal perforation. Gastric
ANATOMY AND PATHOPHYSIOLOGY fluid and contents may be aspirated for laboratory analysis. It may
The nasal cavity is lined by the very vascular nasal mucosa. The also be placed to visualize the stomach on chest radiography to
medial wall of the nasal cavity is composed of the septum. The lateral assess for a diaphragmatic hernia. A NG tube is placed in patients
wall of the nasal cavity is covered by the turbinates. The posterior for medication administration, relief of a bowel obstruction, treat-
nasal cavities are continuous with the nasopharynx that develops ment of recurrent vomiting, administration of oral contrast for
into the posterior oropharynx as you move caudally (Figure 58-1). diagnostic imaging, and to perform gastric lavage. They are placed
The oropharynx continues inferiorly as the esophagus that enters to decompress the stomach preoperatively, postintubation, prior to a
the stomach below the diaphragm.2 diagnostic peritoneal lavage, or prior to a pericardiocentesis.
CONTRAINDICATIONS
Absolute contraindications do not exist for NG tube placement. The
relative contraindications are geared toward predicting which patients
Nasopharynx
are more likely to experience complications and which patients
Tongue
Oropharynx are likely to have misplaced tubes. Insertion of a NG tube should
be avoided, unless necessary, in the patient with midface trauma.
Intubation through the nasal cavity can result in the NG tube being
Epiglottis
misdirected blindly into the respiratory tract or through the rare per-
foration of the thin cribriform plate of the ethmoid bone and into the
brain. Patients with facial trauma are best served with orogastric intu-
bation.3 Patients with esophageal varices pose potential problems.
Placement of a semi-rigid tube into the esophagus or stomach has the
Esophagus potential to cause rupture of the varices and uncontrollable hemor-
rhage. However, NG placement is generally considered safe in these
patients if done carefully.12,13 Other relative contraindications include
patients with coagulopathies, esophageal strictures, ingestions of
alkaline substances, nasal obstruction, or recent nasal surgery.
EQUIPMENT
Stomach
• Topical anesthetic (benzocaine spray, cocaine, or viscous
lidocaine)
• Topical vasoconstrictor (phenylephrine, oxymetazoline, or
cocaine)
FIGURE 58-1. Basic anatomy of the path of the NG tube. • 4% lidocaine
387
388 SECTION 5: Gastrointestinal Procedures
• Glass of water with straw

• Emesis basin
• Water-based lubricant
• NG tube, various sizes
• 60 mL syringe
• Wall suction, set to low intermittent suction
• Suction tubing
• Benzoin spray
• 1 in. adhesive tape
• Tongue depressor
NG tubes are usually made of clear polypropylene. They are some-
what rigid and single patient use devices. Typically used are the Levin
tube and the Salem Sump tube. They both have multiple distal side-
ports. The Levin tube is a single-lumen tube that is easy to insert. It
is simple to use for the aspiration of gastric contents, the instillation
of fluids and/or medications, and the application of low intermittent
suction. The tube is nonradiopaque. Unfortunately, the amount of
suction is difficult to control with the Levin tube. The distal sideports
often become occluded with the gastric mucosa, and damage this tis-
sue, when the tube is attached to suction. The Salem Sump tube is a
double-lumen, radiopaque tube. It has a smaller suction lumen than
the Levin tube. The second lumen allows a constant inward airflow to
prevent the sideports from becoming occluded by the gastric mucosa.
PATIENT PREPARATION
The most beneficial factor in the successful placement of a NG tube
is a patient who is informed of the procedure and can cooperate
with the instructions. Explain the risks, benefits, and complications
associated with the procedure to the patient and/or their represen-
tative. Take the patient through each step prior to the start of the
procedure to ensure maximal cooperation. Drape the patient to pro-
tect them and the bedding from soilage if there is emesis. A glass of
water and a straw should be within reach, if not contraindicated, as FIGURE 58-2. Determining the proper length of the NG tube to insert. A. The
should an emesis basin. length is determined by the distance from the xiphoid process to the tip of
Place the patient seated upright in the Fowler’s or semi-Fowler’s the nose to the earlobe. B. The length is determined by the distance from the tip
position. Examine the patient for nasal septal deviation or other of the nose or lip to around the left ear and to just below the left costal margin.
anatomic abnormalities that may hinder the passage of the NG tube. A piece of tape should be used to mark the distance on the NG tube.
Ask the patient to breathe through one nostril while the other nos-
tril is occluded to determine which nostril is the most patent.4
While often underused, consider using some form of anesthesia Choose a size of NG tube that is appropriate for the patient. A size
to make the procedure more tolerable.20 A recent study suggests that 16 to 18 French is typically used for an adolescent or adult patient.
the application of topical lidocaine and phenylephrine to the nose A formula ([age in years + 16] ÷ 2) may be used to choose the proper
and benzocaine spray to the throat resulted in significantly less pain size NG tube for children. Other less commonly used methods are
and discomfort than the use of lubricant alone.5 The patient should also available to determine the proper size NG tube in children.21
be screened for allergies and contraindications, such as hyperten- Typical sizes include 8 French for infants, 10 to 12 French for small
sion, if these adjuncts are to be used. A sample protocol would children, and 12 to 14 French for older children.
include the instillation of 0.5% phenylephrine nasal spray followed Estimate the length of the NG tube to be inserted (Figure 58-2).
by viscous lidocaine. Cetacaine spray can be used to anesthetize the Place the tip of the NG tube on the patient’s xiphoid process and
nose and the throat.4 Nebulized 4% lidocaine (2.5 mL containing extend it to the tip of the nose and over the earlobe (Figure 58-2A).
100 mg of lidocaine) via a face mask can be used in adolescents Mark this distance with a piece of tape.4 Alternatively, place the tip
and adults. It has been shown to be superior to lidocaine spray as of the NG tube on the tip of the nose or lip and extend it over the left
an anesthetic to reduce gagging and vomiting and can increase the ear and to just below the left costal margin (Figure 58-2B). Mark
success of NG tube placement.14,16 The dose used in children has this distance with a piece of tape.4
been 4 mg/kg of lidocaine.17 Either 2% or 4% lidocaine solutions can
be used. Be cautious when calculating the proper weight-based TECHNIQUE
doses and volume of solution for children. Lidocaine can also
be administered in the nasal cavity, nasopharynx, and oropharynx Lubricate the first 4 in. (10 cm) of the NG tube with a water-
using a mucosal atomizer device (MAD, Wolfe Tory Medical Inc., soluble lubricant. Position the patient. Place their neck in slight
Salt Lake City, UT). Allow 3 to 5 minutes for these medications to flexion. Gently introduce the NG tube along the floor of the nos-
take full effect before inserting the NG tube. tril (Figure 58-3A). Advance the NG tube parallel to the nasal
CHAPTER 58: Nasogastric Intubation 389
Floor of
nasal cavity Nasopharynx
o
90
Philtrum
FIGURE 58-3. Insertion of the NG tube. A. The NG tube is inserted parallel to the floor of the nasal cavity and at a 90° angle to the philtrum. B. The NG tube is advanced
along the floor of the nasal cavity, through the nasopharynx and oropharynx, and into the esophagus. It is further advanced until the tape mark is at the philtrum.
floor until it reaches the nasopharynx as indicated by mild resis-

tance (Figure 58-3A). Do not insert and advance the NG tube in
an upward or lateral direction to prevent impingement and dam-
age to the turbinates. Instruct the patient to swallow. This may be
assisted by having the patient sip water through a straw if not con-
traindicated. Continue to advance the NG tube (Figure 58-3B).
Advancement may be aided by rotating the NG tube medially.
Withdraw the NG tube if at any time significant resistance to
advancement, respiratory distress, the inability to speak, or
significant nasal hemorrhage occurs.5
Advance the NG tube until the distance previously measured with
the tape is at the nostril (Figure 58-4). Verify proper placement by
aspirating stomach contents, by auscultating a rush of air over the
stomach while 60 mL of air is insufflated through the NG tube, or by
radiographically demonstrating the tip of the NG tube in the stom-
ach and below the diaphragm. The latter is the most reliable and
should be strongly considered when the NG tube is to be used for
medication administration or alimentation.6 Infusion of substances
through a misplaced NG tube could be disastrous. Apply benzoin
to the patient’s nose. Apply tape to the nose and around the NG tube
to secure it in place (Figure 58-5). Attach the NG tube to wall suction.
AND HELPFUL HINTS
One study attempted to improve the success rate of NG tube place-
ment by providing external and medially directed pressure on the
ipsilateral neck at the level of the thyrohyoid membrane.7 This
maneuver will collapse the piriform sinus and eliminate it as a FIGURE 58-4. Proper placement of the NG tube. The tip of the tube resides within
potential site for impaction. This maneuver was successful for dif- the stomach. To confirm proper placement, inject air through the NG tube while
ficult NG intubation in 85% of patients. simultaneously auscultating over the stomach.
this unless the patient is unconscious or paralyzed to prevent

them from biting and injuring the fingers.
The NG tube may easily pass the hypopharynx but not be able to
be passed completely through the esophagus and into the stomach.
The tip of the tube may be caught at the level of the cricopharyngeus
muscle, behind the left mainstem bronchus, or at the lower esopha-
geal sphincter. Attempt to pass a NG tube that has been cooled for
3 to 5 minutes in cold tap water or ice water. Grasp the thyroid carti-
lage and lift it anterior and upward to open the esophagus and allow
passage of the NG tube through the upper esophagus.
An orotracheally intubated patient requires a NG tube to decom-
press the stomach. Unfortunately, one cannot always be passed into
the stomach. Remove the respiratory adapter from the proximal end
of a second endotracheal tube. Liberally lubricate the endotracheal
tube and insert it through the patient’s mouth and into the esopha-
gus. Insert a well-lubricated NG tube through the endotracheal
tube and into the stomach. Confirm the proper position of the NG
tube. Carefully withdraw the endotracheal tube over the NG tube.
Reconfirm that the distal end of the NG tube still remains within
the stomach.
The risk for tube misplacement is greater in the intubated patient
who is unable to assist with NG intubation. Observe that the NG
FIGURE 58-5. Securing the NG tube. Apply tincture of benzoin to the bridge of the
nose. A piece of tape is attached to the nose with the distal end split into two and tube does not come out of the patient’s mouth and that there are no
intertwined around the NG tube. changes in the patient’s oxygen saturation when inserting the NG
tube. It is very easy for the NG tube to pass by the cuff of an endotra-
cheal tube without much resistance.7 It is paramount that correct
placement of the NG tube is verified both clinically and radio-
The NG tube may coil in the oropharynx, mouth, or hypophar- graphically before it is used to instill any fluid or medication.
ynx. A larger-bore NG tube may be used and may not coil. Cool the A final technique to help pass a NG tube involves direct visu-
NG tube in cold tap water or ice water for 5 minutes to make the alization using a laryngoscope and Magill forceps. Insert the NG
tube stiffer and then reinsert it. An alternative is to place the distal tube through the nose and advance it into the oropharynx or hypo-
end of a NG tube into an oropharyngeal airway then chill it in ice pharynx. Insert the laryngoscope blade and visualize the distal tip
water (Figure 58-6). The oropharyngeal airway will place a curve in of the NG tube and the esophageal opening. Grasp the tip of the
the chilled NG tube, which may allow it to pass easier. The chilled NG tube with the Magill forceps and advance it into the esophagus.
NG tube will retain this curve for 30 to 60 seconds until it rewarms Continue to advance the NG tube until the tip is within the stom-
(Figure 58-6). ach. The technique can be used on the unconscious and intubated
A final option is to place several fingers through the patient’s patient in which a NG tube will not pass into the esophagus.
mouth and into the oropharynx. The fingers can be used to guide
the NG tube against the posterior oropharyngeal wall and into the
hypopharynx without it coiling. A tongue depressor may be used
ASSESSMENT
to move the tongue to the floor of the mouth and make manipula- The patient should be able to speak without respiratory distress
tion of the NG tube easier by creating more space in the mouth to immediately after placement of the NG tube. Observe the patient for
maneuver. This finger technique should be reserved for intubated complaints of neck pain, substernal chest pain, dysphagia, drooling,
patients in whom the gag reflex is not a concern. Do not attempt trismus, fever, or subcutaneous and mediastinal air. These would be
signs of esophageal perforation or errant placement of the NG tube.6
Although auscultation of air in the stomach has been classically used
to determine correct placement, air insufflated into the pleural space
or the esophagus after misplacement of the NG tube can be just as
easily heard over the upper abdomen.6 Gastric contents should be
able to be aspirated through the NG tube. Testing the pH of the gas-
tric contents can help predict the placement of the NG tube. The pH
of the aspirated fluid will be ≥7 in 99% of patients if the NG tube is in
the respiratory tree.8 The pH of the aspirated fluid will be ≤5 in 70%
of the patients if the NG tube was correctly placed in the stomach.
The use of H2 blockers makes the assessment of gastric pH difficult.
Radiographic demonstration of the tube in the antral or fundal por-
tion of the stomach is the preferred method of confirmation.9
NASOGASTIC TUBE REMOVAL

Explain to the patient the procedure and what they will experience
as the NG tube is removed. It is recommended for the Emergency
Physician to wear gloves, a mask with an eye shield, and a gown to
FIGURE 58-6. A NG tube is inserted into an oropharyngeal airway before being prevent being contaminated during the removal. Place the patient in
chilled in ice water. The chilled NG tube will retain its curve for 30 to 60 seconds. the Fowler’s or semi-Fowler’s position. Place towels or pads over the
CHAPTER 59: Activated Charcoal Administration 391
patient’s neck and chest. Have an emesis basin, tissues, and Yankauer radiographic confirmation of gastric placement is considered the
suction immediately available. Disconnect the NG tube from suc- gold standard. Postintubation patients should be carefully observed
tion. Fold over the proximal end of the NG tube and hold it tightly. for signs of esophageal perforation.
Ask the patient to slightly flex their neck, breath in, and hold it. Place
a drape or towel around the NG tube as it is exiting the patient’s nose.
Firmly squeeze the drape around the NG tube. Briskly withdraw the
NG tube through the drape. The drape will contain all the secretions
Activated Charcoal
59
and bodily fluids and prevent them from splashing on the patient or
the Emergency Physician. Discard the NG tube and the drape.
Administration
COMPLICATIONS Jenny J. Lu
The most common complication of NG intubation is discomfort in
the nasopharynx and oropharynx. Placement in the nares can result INTRODUCTION
in epistaxis if the nasal mucosa is irritated, abraded, or ulcerated. The adsorptive capacity of charcoal has been documented since
These complications can be reduced or avoided with generous lubri- the time of Hippocrates and has been known for centuries. Two
cation of the NG tube and the instillation of topical anesthetics and independent researchers were responsible for its wide acceptance
vasoconstrictors prior to inserting the NG tube. Sinusitis may occur in the early nineteenth century when each of them performed
from the NG tube obstructing the sinus ostia. These complications a demonstration of its effectiveness by ingesting lethal doses of
are usually of no clinical significance. strychnine and arsenic, respectively, followed by charcoal. Both of
A more serious consequence of NG intubation is misplacement them survived. The twentieth century has seen charcoal come into
into the respiratory tree. This is estimated to occur in up to 15% of wide medical use as further investigation showed its effectiveness
cases.10 The incidence increases in frequency with the patient who at adsorbing a wide variety of compounds.1 Activated charcoal is
has a diminished gag reflex or a decreased level of consciousness. currently the most commonly used mode of decontamination in the
The presence of a cuffed endotracheal tube does not preclude Emergency Department for poisoned patients.2
passage into the respiratory tree. The NG tube will pass the cuff
of the endotracheal tube without significant resistance. Advancing ANATOMY AND PATHOPHYSIOLOGY
the NG tube into the airway can result in perforation of a bronchus
or the lung and result in a pneumothorax, hydropneumothorax, Charcoal is produced by the distillation of the pyrolysis products of
pulmonary hemorrhage, empyema, or bronchopulmonary fistula.10 vegetable matter or wood. It works by directly adsorbing toxicants
These complications are increased if medication or alimentation is via a variety of chemical binding properties, and thus preventing
infused into the respiratory tree. substances in the gastrointestinal tract from being absorbed into the
The most serious complication of NG tube placement is esoph- circulation. Enhancement of the adsorptive capability of charcoal is
ageal perforation. This most often occurs in the posterior wall of achieved by heating it to a temperature of 900°C and then subjecting
the cervical portion of the esophagus and through the cricopha- it to a stream of oxidizing gas such as carbon dioxide gas or steam.
ryngeus muscle. Risk factors for esophageal perforation include a This process is termed “activation” and creates an internal pore
preexisting esophageal abnormality, altered mental status, cervical structure, which increases the surface area from 2 to 4 square meters
osteophytes, cardiomegaly, tracheal intubation, a stiff NG tube, and per gram to greater than 2000 square meters per gram.2 A typical
multiple attempts.6 Other risk factors for esophageal perforation dose of 50 g of activated charcoal has the surface area of 10 football
include esophageal cancer or the ingestion of alkaline substances. fields. Charcoal is not absorbed from the intestinal lumen nor is it
Perforation often results in mediastinitis with a subsequent mor- modified by the numerous enzymes that aid in the digestion of food.
tality rate of up to 30%.6 Prompt recognition, surgical repair, and It passes through the intestinal tract unchanged and is expelled as a
parenteral antibiotics can reduce the mortality rate to less than 10%. sticky black substance.
The use of softer and smaller NG tubes with generous lubrication Some charcoal preparations contain sorbitol. Sorbitol is typically
can reduce the risk of esophageal perforation. used as a flavoring agent to make food, drinks, and medications more
Use caution when inserting a NG tube in patients who have suf- palatable. It is also used as a hyperosmotic laxative agent. It is poorly
fered trauma to the face, neck, and/or skull, or if they have medical absorbed from the gastrointestinal tract and converted into fructose
conditions affecting these areas.18,19 Fractures of the base of the skull, by the liver. Its limited absorption results in an increased volume of
cribriform plate, maxilla, nasal walls, orbital floors, and palate may water being secreted into the intestine causing an increased intralu-
allow a nasally inserted tube to exit the nasal cavity and cause fur- minal pressure that stimulates a catharsis.
ther injury. The NG tube may exit traumatic or medical wounds and Charcoal can help enhance the elimination of certain compounds
penetrate neighboring vascular structures.19 by disrupting the enteroenteric or enterohepatic circulation. A
diffusion gradient is created in the intestine due to the enormous
adsorptive ability of charcoal to bind free toxicants. The intestinal
SUMMARY
mucosa essentially functions as a semipermeable membrane allow-
NG intubation is a widely used procedure in the Emergency ing absorbed drug or toxin to diffuse from the capillaries back into
Department. It is primarily used to evacuate air and stomach the lumen of the intestine. Charcoal can adsorb and “trap” it within
contents in the poisoned, intubated, or bowel obstructed patient. the intestinal lumen to be subsequently eliminated.3,4 This mecha-
Placement is generally considered easy, although it can be uncom- nism essentially dialyzes the blood in the capillaries of the intesti-
fortable. Recent studies suggest that topical anesthetics and vaso- nal circulation, hence the term “gastrointestinal dialysis.” Similarly,
constrictors, along with generous lubrication, can diminish the drugs and drug metabolites secreted into the bile may be absorbed
discomfort and reduce the chance of misplacement. and trapped by charcoal within the intestinal lumen. By adsorb-
Placement of the NG tube into the airway or coiled in the esoph- ing these substances, activated charcoal may shorten the half-life,
agus can result in serious complications. Although auscultation although evidence for clinical benefit of doing so remains limited.
of air has been classically used to determine correct placement, Substances that may benefit from multiple dosing of charcoal for
enhanced elimination include phenobarbital, theophylline, dap- and pesticide ingestions. Besides being minimally effective in pre-
sone, diazepam, amitriptyline, carbamazepine, phenytoin, quinine, venting the absorption of caustics, administration of charcoal can
salicylates, piroxicam, digoxin, doxepin, quinine, tricyclic antide- render endoscopic visualization technically difficult. However, for
pressants, and meprobamate.3,4 most other ingestions, including mixed ingestions, a dose of acti-
vated charcoal can be given, if no contraindications exist. Charcoal
INDICATIONS combined with cathartics is contraindicated in young children
due to the risk of severe electrolyte imbalances and it should be
Activated charcoal binds to most commonly ingested substances used with caution in renally impaired patients.12
and is currently considered the modality of choice for gastrointes-
tinal decontamination.5 It is generally indicated for an ingestion of EQUIPMENT
toxic materials that are adsorbable to charcoal. Charcoal may be
used to enhance the elimination of toxicants that are metabolized by Several charcoal preparations are available.13 These include capsules,
the liver and secreted into the bile. tablets, powder, oral suspensions, and suspensions containing sorbi-
Charcoal has an excellent safety profile. It can be used in preg- tol. Powder, premixed oral suspensions, and suspensions with sorbi-
nancy, in lactation, and in the pediatric population. Its use is widely tol are the only preparations indicated for use in an acute poisoning.
accepted even though no good randomized controlled clinical Powder is available in doses from 15 to 500 g that must be mixed
studies have been performed.4 Animal and volunteer studies have with water to make a slurry. The premixed suspension is available
repeatedly shown activated charcoal’s efficacy. Activated charcoal in strengths of 12.5 g/60 mL to 50 g/240 mL. Charcoal suspensions
has been found in clinical studies to be as efficacious and safer with sorbitol are available containing 25 to 50 g of activated charcoal
when compared with emetics or gastric lavage as a single modality and 25 to 96 g of sorbitol in a volume of 120 to 150 mL.
for decontamination purposes. A large randomized controlled trial
examined gastric emptying procedures, comparing ipecac-induced PATIENT PREPARATION
emesis, gastric lavage and activated charcoal, and activated charcoal A cuffed endotracheal tube should be placed prior to the adminis-
alone in patients with drug overdoses.6 No significant differences tration of activated charcoal in patients who are comatose, drowsy,
in clinical severity, length of hospital stay, morbidity, or mortality obtunded, unconscious, or have an absent or impaired gag reflex.
among the treatment groups were found. These findings are similar Endotracheal intubation should be strongly considered in any
to those found in other studies.7,8 patient who has ingested a central nervous system depressant, tri-
Ipecac-induced emesis, activated charcoal, and gastric lavage cyclic antidepressants, a sympathomimetic or other agent that may
were compared in volunteers 1 hour after the ingestion of ampi- result in seizures, or any substances that can cause an altered men-
cillin.9 Activated charcoal was found to be superior in decreasing tal status. A patient may become nauseous and vomit due to the
the absorption of blood ampicillin levels by 57%. Gastric lavage ingested substances, the nasogastric tube, or the activated charcoal
decreased absorption by 32% and emesis decreased it by 38%. The slurry. This can be controlled with the intravenous administration
authors concluded that activated charcoal without a gastric emp- of an antiemetic medication.
tying procedure may be the preferred method of gastrointestinal Thoroughly mix the charcoal slurry prior to opening the con-
decontamination. Limitations of the study included using subtoxic tainer. Some preparations settle with the charcoal in the bottom of
doses of ampicillin on volunteers and the small sample size. the container. Activated charcoal suspensions are gritty and unpleas-
The optimal timing for administration of charcoal remains con- ant to swallow but have no taste. Some newer charcoal preparations
troversial. None of the studies demonstrating efficacy of activated dissolve completely when added to water to form a solution that
charcoal administered it more than 1 hour after the ingestion.10 The is not gritty (Paddock Laboratories, Minneapolis, MN). The addi-
American Academy of Clinical Toxicology has noted that there is tion of sorbitol causes the suspension to be less gritty and have a
insufficient evidence to support or exclude the use of activated char- sweet taste. This may enhance the palatability of the charcoal. Some
coal more than 1 hour after a toxic ingestion.11 Additionally, there manufacturers supply cherry or other flavorings to make the char-
is no evidence that the use of activated charcoal decreases mortality coal more palatable.
or improves clinical outcome.11 This does not mean that activated
charcoal should not be given if the patient presents later than 1 hour TECHNIQUE
after ingestion. It simply means that this has not been studied and
not enough evidence exists to make a firm decision. Charcoal should be administered as early as possible after the
ingestion and optimally within the first hour after an ingestion
as its efficacy is reduced with the passage of time. An aqueous
CONTRAINDICATIONS
slurry should be used rather than tablets or powder. A single dose
One absolute contraindication to the use of activated charcoal is is typically administered. Multiple doses may be considered if the
in the patient with an unprotected airway. The patient must be able xenobiotic is expected to be absorbed slowly (e.g., massive inges-
to maintain an intact gag reflex or should be endotracheally intu- tions or sustained release preparations) or if enhanced elimination
bated to protect against aspiration, although it is not recommended of amenable substances is the objective. The recommended dose for
that patients be intubated solely for the purpose of decontamina- the single or initial dose is five to 10 times the amount (in grams) of
tion. Patients with depressed levels of consciousness and those at toxicant ingested, although standard practice is to give 1 g/kg (50 to
risk for seizures from their toxic ingestions should not be given acti- 100 g to an adult or 10 to 25 g child <5 years).13 An alert patient
vated charcoal. Patients with absent bowel sounds, evidence of gas- typically tolerates drinking the slurry well. Repeated doses may
trointestinal obstruction, or recent gastrointestinal surgery should range from 15 to 30 g every 2 to 4 hours, although optimal dosing
not be given charcoal secondary to the risk of bezoar formation or is not known.13 A cathartic may be used in special circumstances
perforation and leakage of charcoal into the abdominal cavity. with alternating doses as long as hydration and electrolyte levels are
Activated charcoal is not effective against xenobiotics such as vigorously monitored.13
acids and alkalis, alcohols, fluoride, heavy metals, inorganic salts, Sorbitol may be premixed with the charcoal. The sorbitol will
iron, lithium, or potassium. Its use is limited in liquid ingestions decrease gastrointestinal transit time and may prevent bezoar for-
where absorption is rapid. It is unlikely to be helpful in hydrocarbon mation. However, it may also increase nausea and vomiting and the
CHAPTER 60: Gastric Lavage 393
risk of aspiration. Sorbitol-containing charcoal should be given SUMMARY

only to adults and only with the first dose. Attention should be
paid to verify whether or not the charcoal preparation contains sor- Activated charcoal is currently the most commonly used modality
bitol, especially where multiple doses are given. of gastrointestinal decontamination in the acutely poisoned patient.
A nasogastric tube can be placed in the cooperative or unco- This is despite limited evidence demonstrating improved clinical
operative patient to facilitate administration of the charcoal. outcomes or decreased mortality rates. Administration of charcoal
Correct placement of the nasogastric tube in the gastrointesti- is relatively straightforward and is generally well tolerated orally.
nal tract is absolutely essential prior to charcoal administration. The usual dose of activated charcoal is 50 to 100 g in an adult and
Confirmation of gastric placement can be done by auscultation 1 g/kg in a child. Preparations containing a cathartic such as sorbitol
of insufflated air into the stomach over the epigastrium, by the can be used with the first dose in the adult unless contraindicated.
aspiration of stomach contents through the nasogastric tube, or Cathartics and charcoal preparations containing sorbitol should
radiographically by demonstrating the tube below the level of the not be used in children or those with renal impairment due to the
diaphragm. Please refer to Chapter 58 for the details regarding risk of electrolyte disturbances. The most significant complications
the placement of a nasogastric tube. Attempts should be made to occur as a result of aspiration and can be minimized by paying close
minimize gastric pressures by the overly aggressive administration, attention to the patients at risk (i.e., those with a decreased level of
which can increase the risk of aspiration.14 consciousness or a weakened gag reflex) and by checking placement
of the nasogastric tube prior to administration of charcoal. The risks
COMPLICATIONS and benefits of multiple dosing must be carefully weighed when
considering to prevent the absorption or to enhance the elimination
The most feared complication of activated charcoal use is pulmo- of the toxicants. Activated charcoal may be judiciously administered
nary aspiration. Activated charcoal can cause severe pneumonitis in appropriately selected acutely poisoned patients as long as there
that can lead to respiratory failure, prolonged ventilatory support, are no contraindications.
and death. In addition to pneumonitis, an empyema and bronchiol- Should the use of activated charcoal continue because there may
itis obliterans can occur. Avoiding aspiration is paramount when be some benefit despite the potential complications?17–19 Should
giving charcoal. The patient must be awake and have an intact gag activated charcoal not be used until it is proven to be beneficial
reflex in order to protect against aspiration. Errant placement of compared to the potential complications? This continuing contro-
a nasogastric tube into the trachea or bronchi, and even past the versy in toxicology will persist until more evidence becomes avail-
inflated cuff of a properly placed endotracheal tube, can result in able. The decision to use activated charcoal should be determined
aspiration.12 The proper placement of nasogastric tubes must be on a case-by-case basis by the treating Emergency Physician, with
confirmed prior to instilling activated charcoal. Reports of life- possible consultation from a poison control center.
threatening pulmonary complications as a result of aspiration have
also been reported with the removal of the nasogastric tube subse-
quent to charcoal administration.15 Aspiration of activated charcoal
can occur in the intubated patient with an inflated endotracheal cuff
and a properly placed nasogastric tube.16
Gastric Lavage
Charcoal containing or administered with sorbitol or magnesium
decreases the risk of intestinal obstruction and constipation. Yet,
this can induce its own set of problems. Electrolyte disturbances
60 Jenny J. Lu
can result despite the benefits of decreasing transit time through the
gut and the concomitant decrease in toxicant absorption. Cathartic-
induced hypernatremia, typically a complication seen in the very INTRODUCTION
young, can lead to serious central nervous system damage, brain Gastric lavage is a method of gastrointestinal decontamination, per-
swelling, long-term morbidity, and death. Sorbitol dosing in children formed in the setting of an acute poisoning by ingestion, to decrease
is not clearly established, and the typical premixed preparations are the absorption of substances in the stomach. This technique was
not appropriate in the pediatric population. Hypermagnesemia is first described in 1812 and has been used for nearly 200 years.1 It
seen in the adult population when a magnesium-containing cathar- was repopularized in the 1950s and 1960s and thrived during the
tic is given in a patient with gastrointestinal abnormalities or renal heyday of the “tricyclic era” of the 1970s and 1980s. The use of gas-
compromise. Dehydration is a problem encountered in the elderly tric lavage in the Emergency Department has decreased greatly in
and young. Osmotic volume loss from the gastrointestinal tract can modern toxicology for several reasons. Most notable is the trend
cause these fragile populations to decompensate.12 toward evidence-based medicine and the growing body of experi-
Intestinal obstruction is a rare complication but carries significant mental and clinical data pointing to the limited efficacy of gastric
morbidity. Case reports of obstruction and perforation requiring lavage. Gastric lavage was performed in approximately 10.3% of all
laparotomy have been documented. Charcoal bezoars are the usual ED-treated poisoning cases between 1998 and 2003, a decrease from
culprits. Bezoars can form when intestinal motility is compromised 18.7% during the period of 1993 through 1997.2 The increasing use
allowing continued absorption of water from the intestinal con- of other modalities for gut decontamination, especially activated
tents. Once sufficient water has been absorbed, bonds form between charcoal, has further limited the role of gastric lavage.1,3
charcoal particles and the mass continues to harden. Ingestions of
anticholinergic substances, antiperistaltic coingestions, or medica- ANATOMY AND PATHOPHYSIOLOGY
tions administered during the hospital course have also been impli-
cated. Caution should therefore be used when giving these patients With the widespread administration of activated charcoal as the
narcotic or anticholinergic medications. Typically, patients receiv- current decontamination measure of choice, there remain very few
ing multiple-dose activated charcoal therapy or activated charcoal indications for performing gastric lavage for decontamination, if any.
without cathartics are at the greater risk. Constipation is a milder These rare indications would include a highly toxic or potentially
form of this complication and is uncommon and rarely of clinical lethal ingestion presenting acutely where no antidote exists or where
significance.12 other usual therapies are ineffective, unavailable, or nonexistent.
The optimal timing of gastric lavage is also controversial.

Any benefit of gastric lavage would likely be gained if performed
promptly and within 1 hour of an oral ingestion.3 Authors agree
that the sooner it is instituted, the better. The range of recovered
ingestant is highly variable at each time point following an ingestion
in volunteer and overdose studies. The trend for mean removal of
ingestants is 90% recovery at 5 minutes postingestion, 45% recovery
at 10 minutes, 30% recovery at 19 minutes, and as little as 8% recov-
ery at 60 minutes.3
Undoubtedly, the efficacy of gastric lavage diminishes rapidly
over time. Some toxicants or coingestants may cause delayed gas-
tric emptying, while others may form masses or concretions in the
stomach. Removal of only a small percentage of the ingested dose
may theoretically lessen the severity of the poisoning in some cases,
but these benefits remain unproven. Gastric lavage has never been
demonstrated to decrease mortality. A reasonable approach when
considering gastric lavage is in the acutely poisoned patient who
presents within 1 hour of a life-threatening ingestion. The deci-
sion should be made with consideration to the specifics of the inges-
tion. Delayed gastric lavage should be considered only in a severely
toxic poisoning or where delayed gastric emptying is suspected (e.g.,
anticholinergic or opioid coingestant). It would be prudent to con-
sult a poison control center or a Medical Toxicologist when consid-
ering gastric lavage in any poisoned patient.
Nasogastric placement of a gastric lavage tube is not advised.
The orogastric route should be used to avoid traumatic injury to
the nasal mucosa, nasal turbinates, and nasal septum. The use of a
small-bore nasogastric tube is discouraged if the objective is gastric
emptying. If an appropriately sized nasogastric tube is placed for
other reasons and if the ingestant is in liquid form, aspiration of gas-
tric contents can be attempted through a nasogastric tube. Lavage
fluid can be instilled through a nasogastric tube with the expecta-
tion that the return of gastric contents may be inadequate. Lavage
fluid that does not return through the nasogastric tube will pass
through the pyloric sphincter and could potentially allow increased
absorption of the toxicant.4 Sustained-release tablets or capsules are
particularly large in size and unlikely to be removed through a naso-
gastric tube or through the fenestrae of a 40 French orogastric lavage
tube (Figure 60-1).
Placement of gastric lavage tubes in the pediatric population
is precarious and may result in complications (Figure 60-2).5 A
formula for the depth of insertion has been prospectively evalu- FIGURE 60-2. Malposition of an orogastric tube placed for gastric lavage in a
ated to ensure adequate placement in this population and is pediatric patient (Courtesy of Ann E. Klasner, MD, MPH).
depicted graphically in Figure 60-3.5,6 Moreover, the size of the
oropharyngeal aperture and esophagus are proportional to the
size of the individual. Appropriate tube diameter is essential to
minimizing complications.
INDICATIONS
Gastric lavage is indicated for immediate stomach emptying
within 1 hour after an orally ingested overdose or poisoning
and when not contraindicated. Consideration should first be
given to other less invasive modalities of gastrointestinal decon-
tamination such as activated charcoal or whole bowel irrigation.
Consideration should be given to the specific characteristics of the
toxicant, the ingested dose, and the risks versus benefits of per-
forming the procedure. Gastric lavage should be considered only
where there is risk of significant toxicity or imminent fatality and
where antidotal or other supportive modalities are inadequate
FIGURE 60-1. Orogastric lavage tubes demonstrating sideport size. A 36 French (Table 60-1). It may be considered beyond 1 hour in patients with
tube with a Stresstab™ 600 multivitamin in the sideport (top). A 40 French tube known or suspected delayed gastric motility (e.g., in the setting of
with a 450 mg sustained-release theophylline tablet in the side port (middle). anticholinergic or opioid ingestion) or where the evidence of a dura-
A generic 250 mg ampicillin tablet (bottom) (Courtesy of F.P. Paloucek, PharmD). ble mass (concretion) of pill fragments is a concern.
70
65
Tube insertion depth (cm)

60
55
50 OG
45 NG
40
35
30
25
20
60 70 80 90 100 110 120 130 140 150 160 170 180 190 200
Height (cm)
FIGURE 60-3. Estimated lavage tube insertion depth in children based on their height. The lengths for both nasogastric (NG) and orogastric (OG) tubes are represented
on the graph (Reprinted from Scalzo et al.,5 with permission from Elsevier Science).
CONTRAINDICATIONS Vomiting is common after many overdoses and may serve as a

“natural” decontamination measure. Multiple episodes of emesis
The contraindications to performing a gastric lavage are sum- may clear the majority of a toxicant from the stomach and obviate the
marized in Table 60-2. An absolute contraindication to gastric need for gastric lavage. Vomiting in the setting of caustic ingestions,
lavage is in a patient with a depressed level of consciousness who however, can cause further harm by re-exposing the gastrointestinal
is at risk of losing protective airway reflexes. Gastric lavage should mucosa to the caustic substance. Attempts at gastric intubation in
also not be performed in combative patients, patients at high risk the setting of an actively vomiting patient are likely to be met with
of seizures, and in those who may be expected to deteriorate rap- minimal success and may cause injury.7 Gastric lavage is thus con-
idly. Gastric lavage can be performed, as indicated, if the airway traindicated in the vomiting patient due to the risk of aspiration and
is protected, but intubating a patient solely for the purpose of gas- perforation in a setting where it is unlikely to be beneficial.
tric lavage is not recommended. Gastric lavage is contraindicated Gastric lavage is unlikely to change the outcome of a nontoxic
in caustic ingestions. Local mucosal damage amplifies the risk for or minimally toxic ingestion. It must be ascertained that sig-
traumatic perforation. Gastric lavage should not be performed to nificant toxicity or death may result if the patient is not lavaged.
retrieve large pills, large foreign bodies, or sharp foreign bodies. It Otherwise, the risk–benefit ratio is unacceptably high. The deter-
is relatively contraindicated in hydrocarbon ingestions, especially mination of whether or not to perform a gastric lavage must be
where there is high pulmonary aspiration potential. Significantly individualized and rests upon the evaluating Emergency Physician.
abnormal upper airway or upper gastrointestinal anatomy (i.e., Consult a Medical Toxicologist or a poison control center in ques-
anomalies, strictures, or a fresh interposition graft) may restrict the tionable cases.
use of gastric lavage in rare circumstances.
EQUIPMENT
TABLE 60-1 Indications for Performing a Gastric Lavage • Pulse oximeter
Acute presentation (within 1 h) and: • Cardiac monitor
1. Evident or high risk of morbidity or mortality
• Noninvasive blood pressure monitor
Beta-blockers Heterocyclic antidepressants
Calcium channel blockers Iron • Protective clothing
Chloroquine Paraquat • Bite block
Colchicine Salicylates
Cyanide Selenious acid • Oral airway
Heavy metals
2. Poor absorption by activated charcoal
Heavy metals TABLE 60-2 Contraindications to Performing a Gastric Lavage
Iron Abnormal or absent pharyngeal or upper gastrointestinal anatomy
Lithium Active or substantial antecedent vomiting
Toxic alcohols Caustic ingestion
3. Evidence of formed concretion Coagulopathy
Enteric-coated preparations Combative or uncooperative patient
Iron Decreased level of consciousness
Phenothiazines Diminished or absent airway reflexes
Salicylates Large pills
4. Ineffective or no antidotal therapy available Large or sharp foreign body
Cellular poisons (e.g., colchicine) Nontoxic or minimally toxic ingestion
Paraquat Significant aspiration risk (e.g., hydrocarbon ingestion)
Selenious acid Seizures or high risk of seizures
• Emesis basin from the orogastric tube to be filled with fresh lavage fluid, and
• Suction source used lavage fluid must be discarded after each lavage cycle. Closed
systems are commercially available, single-patient use devices, self-
contained, easy to use, and do not cause a mess (Figure 60-4). The
• Suction tubing Emergency Physician should be familiar with the type of system
• Funnel or large (50 to 100 mL) syringe available at their institution.
• Tap water or normal saline Gastric lavage solution typically consists of tap water or normal
saline. Do not use tap water in small children, as this can result
• Bulb suction device or large syringe
in electrolyte abnormalities. Specialized lavage solutions may
• Water-soluble lubricant be indicated if the ingested substance is fluoride, formaldehyde,
• Orogastric lavage tube iodine, iron, or oxalic acid. Fluoride ingestions may be lavaged
• Resuscitative equipment readily available with 15 to 30 g/L of calcium gluconate to produce an insoluble
calcium fluoride. Formaldehyde ingestions may be lavaged with
All required instrumentation should be gathered at the bedside 10 mg/L of ammonium acetate to produce the nontoxic substance
prior to initiating the procedure. A variety of orogastric lavage tubes methenamine. Iodine ingestions may be lavaged with 75 g of
are available. Most have a distal port and at least one sideport. A cornstarch in 1 L of water. Iron ingestions may be lavaged with
semirigid tube is preferable to soft rubber or polyvinyl chloride col- 2% sodium bicarbonate (50 mEq in 150 mL of normal saline) to
lapsible tubes. Several additional ports should be cut in the sides of produce the insoluble ferrous carbonate. Oxalic acid ingestions
the tube near the tip to maximize the return of pill fragments if the may be lavaged with 15 to 30 g/L of calcium gluconate to form
tube has only a single sideport. Examples of rigid tubing are shown the insoluble calcium oxalate. These specialized lavage solutions
in Figures 60-1 & 60-4. A larger tube diameter provides less flex- should be used only in consultation with a Medical Toxicologist
ibility, so that the tube is less likely to kink, collapse, or curl back or a poison control center.
on itself. Larger-diameter tubes are more likely to facilitate retrieval
of larger pill fragments. A 30 to 50 French lavage tube is preferred
in an adult. A 30 to 34 French tube is adequate for an adolescent.
PATIENT PREPARATION
Small children can generally accommodate 24 French tubes. Gastric Explain the indications, details of the procedure, risks and benefits,
lavage is generally contraindicated in neonates and infants. and alternative modalities with the patient and/or their representa-
There are numerous types of gastric lavage systems. Open sys- tive when possible. Informed consent should be obtained or may be
tems are less expensive, messy, and time-consuming to use. A pas- presumed in the setting of a suicidal overdose.
sive open system uses gravity to instill and drain the lavage fluid. An Place the patient in the left lateral decubitus position and in 15° to
active open system uses a large syringe to inject and aspirate lavage 20° of Trendelenburg. This position is intended to maximize gastric
fluid through the orogastric tube. The syringe must be removed emptying.7,8 However, the removal of ingestants by gastric lavage in
the overdose setting is modest, and other circumstances may inter-
vene, such as an uncooperative patient or technical factors.3 The
supine and lateral decubitus positions are associated with a higher
risk of pulmonary aspiration in comatose and mechanically ven-
tilated patients.9–12 It is assumed that this positioning risk is simi-
larly increased in patients who are not mechanically ventilated and
undergoing gastric lavage. Most gastric lavages can be performed
safely and effectively with the conscious patient placed in the semi-
upright position. The use of a topical anesthetic spray into the
oropharynx may decrease the patient’s gag reflex and allow easier
passage of the orogastric tube. Unfortunately, this can also increase
the risk of aspiration.
It is recommended that a cardiac monitor, noninvasive blood
pressure cuff, and pulse oximeter be placed on the patient prior to
performing gastric lavage. This equipment may also be required
based upon the patient’s physiologic status, the nature of the inges-
tant or toxicant, and/or other underlying problems.
TECHNIQUE
Measure the length of the orogastric lavage tube to be inserted
(Figure 60-5). The length should be marked with a permanent
marker or a piece of surgical tape. Liberally lubricate the tip of
the lavage tube. Place a bite block into the patient’s mouth if they
are conscious. A bite block or oral airway may preclude biting of
the tube by an uncooperative or stuporous patient.13
Gently insert the lavage tube into the patient’s mouth and direct
it into the hypopharynx. Flexion of the patient’s neck may facilitate
passage of the tube into the esophagus and avoid endotracheal inser-
tion. Conscious and cooperative patients may be asked to swallow
water through a straw or their saliva to facilitate passage of the tube.
FIGURE 60-4. Example of a closed lavage pump system (Courtesy of Kimberly- Stridor, cough, or cyanosis indicates that the lavage tube is in the air-
Clark Corporation). way and should prompt removal of the tube. If significant resistance
gravity instillation or they may be infused with a Toomey syringe.

Remove the lavage fluid after a brief (i.e., 1 to 2 minutes) equili-
bration period by either gravity drainage into an emesis basin or
aspiration with a syringe or suction bulb. Repeat the lavage process
until 2 to 3 L of irrigant has been used in the adult or the lavage fluid
is free of particulate matter and pill fragments. Some authors have
suggested that agitation of the stomach by manual massage of the
epigastrium during the equilibration period will ensure mixing of
the gastric contents.13 No substantive data support this approach.
Alternatively, closed systems are available for both instilling and
suctioning lavage fluids through a common tube (Figure 60-4).
Activated charcoal may be administered, if indicated, through the
lavage tube before it is removed. A dose of 1 g/kg of body weight is
typically recommended, either in a premixed slurry or diluted in
normal saline or tap water (30 g charcoal per 240 mL of diluent).
Refer to Chapter 59 regarding the details of administering activated
charcoal.
Remove the lavage tube. It is recommended for the Emergency
Physician to wear gloves, a mask with an eye shield, and a gown
to prevent being contaminated during the removal. Place towels or
pads over the patient’s neck and chest. Have an emesis basin, tis-
sues, and Yankauer suction immediately available. Disconnect the
lavage tube from its proximal attachment. Fold over the proximal
end of the lavage tube and hold it tightly. Ask the patient to slightly
flex their neck, breath in, and hold it. Place a drape or towel around
the lavage tube as it is exiting the patient’s mouth. Firmly squeeze
the drape around the lavage tube. Briskly withdraw the lavage tube
through the drape. The drape will contain all the secretions and
bodily fluids and prevent them from splashing on the patient or the
Emergency Physician. Discard the lavage tube and the drape.
Further gastric access, when needed, should be provided by the
subsequent placement of a smaller-bore nasogastric tube.
Because of concern over toxicants passing or being pushed through
the pyloric valve during the gastric lavage procedure, an alternative
FIGURE 60-5. Determining the proper length of an orogastric tube to insert.
sequence could be considered. Administer activated charcoal after
A. The length is determined by the distance from the xiphoid process to the tip of
the initial aspiration of gastric contents through the lavage tube.
the nose to the earlobe. B. The length is determined by the distance from the tip of
the nose or lip, around the left ear, and to just below the left costal margin. A piece Perform the gastric lavage anticipating that a significant amount of
of tape is used to mark the distance on the orogastric tube. activated charcoal will be removed along with the ingestant. Infuse
a second dose of activated charcoal through the lavage tube before it
is removed. The rationale here is an attempt to make charcoal avail-
able to adsorb toxicant from any gastric contents pushed into the
is met in the hypopharynx, applying gentle pressure to the tube while small bowel during the lavage procedure.1 While no human data
instructing the patient to swallow should allow passage through the support this technique, it is reasonable to consider.
upper esophageal sphincter. The tube should not be forced, as
misplacement may damage the larynx or perforate the pyriform
sinus. Slowly advance the tube to the premeasured depth. ASSESSMENT
Confirmation of intragastric tube placement must precede The patient should be continuously monitored and reassessed
instillation of any fluid through the tube. Proper placement should throughout the procedure so as to avoid complications. Strict
be confirmed by aspiration of gastric contents, auscultation of insuf- adherence to the procedures noted will help minimize the risk of
flated air over the epigastrium (from a 50 mL Toomey syringe), and/ complications. Prompt removal of the lavage tube at the end of the
or by radiography. Gastric irrigation should be preceded by aspira- procedure will help decrease the risk of delayed complications.
tion of available gastric contents. The initial aspirate may be sent for
toxicologic assay.
AFTERCARE
Perform the gastric lavage. Instill normal saline or tap water
through the lavage tube. The lavage fluid should ideally be warmed Most patients who require gastric lavage for an overdose or poi-
to body temperature. This is often not practical, and room tempera- soning will require inpatient monitoring for complications of the
ture lavage fluid is satisfactory. Instill aliquots of 10 to 15 mL/kg ingestion. A situation wherein a patient requires gastric lavage and
to a maximum of 300 mL of the irrigant solution. Instillation of is then sent home immediately is conceivable though unlikely. An
larger volumes may result in vomiting, with pulmonary aspiration observation period of 6 to 8 hours for the immediate complications
and the passage of gastric contents past the pyloric sphincter where of gastric lavage and the effects of the ingested substance is probably
subsequent absorption may occur.2 Lavage aliquots may be instilled appropriate. Delayed complications related to the perforation of the
by placing a funnel in the free end of the lavage tube and allowing upper gastrointestinal tract may occur.14
TABLE 60-3 Complications Associated with Gastric Lavage

Whole Bowel Irrigation
Cardiac dysrhythmias
Electrolyte abnormalities
Empyema
61 Steven E. Aks and David D. Gummin
Esophageal tear or perforation
Gastric perforation
Hypothermia INTRODUCTION
Laryngospasm
Nasal, oral, or pharyngeal injury Whole bowel irrigation is the infusion of polyethylene glycol elec-
Pneumothorax trolyte lavage solution into the stomach at flow rates higher than are
Pulmonary aspiration otherwise commonly used. This technique can be used to decon-
Pyriform sinus perforation taminate the gastrointestinal tract after an acute toxic ingestion or
Tracheal placement overdose. Most of the literature supporting its use is in the form of
Tube impaction case reports or case series.1 While available reports are compelling,
the indications for whole bowel irrigation are mostly theoretical and
will be refined as more extensive data become available. The role of
whole bowel irrigation currently remains limited.
COMPLICATIONS
The complications associated with gastric lavage can be minimized ANATOMY AND PATHOPHYSIOLOGY
by careful patient selection and technique7 (Table 60-3). Placement
of the lavage tube can result in mucosal injury, bleeding, esophageal Current methods of gastrointestinal decontamination (i.e., emesis,
perforation, gastric perforation, or endotracheal placement. The gastric lavage, and activated charcoal administration) focus pri-
patient should be monitored, as the procedure may result in cardiac marily on decontaminating the stomach. Absorption of most toxi-
arrhythmias, hypoxemia, and tachycardia.1,7 No more than 15 mL/kg cants occurs principally in the proximal small bowel. Sustained- or
or 300 mL aliquots of lavage fluid should be used to prevent vomit- delayed-release preparations continue to liberate drug during intes-
ing, aspiration, or pushing of gastric contents into the small bowel. tinal transit that is then available for absorption throughout the
The impaction of a lavage tube may prevent its removal.1,7,14 Do not bowel. Infusion of polyethylene glycol electrolyte lavage solution
use force to remove the lavage tube, as this may injure or rupture decreases the enteric transit time, attenuating the contact time of
the stomach or esophagus. Evaluate the tube using fluoroscopy a toxicant with the gastrointestinal mucosa.2 This reduces absorp-
or plain radiographs. A lavage tube that is kinked or knotted will tion of the drug or toxin throughout the gastrointestinal tract. The
require endoscopically aided or surgical removal. 3500 Da molecular weight polyethylene glycol solution is specifi-
Gastric lavage with large volumes of cold fluid can result in hypo- cally designed to prevent electrolyte and fluid shifts.
thermia. Warmed lavage fluid should be used if available, although
this is somewhat controversial. Warm lavage fluid may dissolve INDICATIONS
more of the intoxicant and allow rapid access of gastric contents past Whole bowel irrigation may be indicated for acute inges-
the pylorus, to be absorbed into the systemic circulation. Electrolyte tions where severe or potentially fatal toxicity is anticipated
abnormalities may result, especially in children, if the lavage fluid (Table 61-1). Other decontamination methods, such as activated
is hypotonic (i.e., tap water). The use of normal saline for lavage is charcoal, should be employed if they are known to be effec-
recommended. tive rather than whole bowel irrigation. Whole bowel irrigation
There are definite risks and complications associated with gastric may be indicated in situations where activated charcoal is known
lavage. It is usually unknown if pills and/or pill fragments remain to be ineffective. Whole bowel irrigation has been safely utilized to
within the patients stomach when they present to the Emergency decrease bioavailability of ingested iron, lithium, and heavy met-
Department. Two recent case reports used CT scans to determine als.3–7 Whole bowel irrigation has been proposed to be effective in
that pills and/or pill fragments remained in the stomach and sub- flushing the gastrointestinal tract free of toxicant before absorption
sequently performed gastric lavage.15,16 The use of CT scans to can be affected by sustained-release preparations.8 Whole bowel
identify pills and/or pill fragments in the stomach cannot be rec- irrigation may speed gastrointestinal transit of ingested packets or
ommended. There is no evidence that the expense and radiation vials of illicit drugs ingested by a “body packer.”9 Recently, the role of
exposure prevent any morbidity or mortality nor provides any whole bowel irrigation in the “body stuffing syndrome” has recently
benefit to the patient. been questioned.10 While the indications are limited, additional
settings may be envisioned where whole bowel irrigation might
SUMMARY be useful. Unfortunately, there is not yet data to support broader
Gastric lavage is an invasive procedure to decontaminate the stom- indications.
ach of patients following an ingested overdose or poisoning. While
its use has significantly decreased as a mode of decontamination,
there are a few specific indications in an acute poisoning or over- TABLE 61-1 Conditions in Which Whole Bowel Irrigation
dose in which it should be considered. Complications can be mini- Can Be Considered
mized if the procedure is performed cautiously. Maximal efficacy 1. Acute, life-threatening, or serious ingestion and hemodynamically stable
can be expected if it is performed within 1 hour of an acute inges- 2. Any of the following:
tion. Gastric lavage is not indicated in the setting of a nontoxic or Delayed or enteric-coated preparation
minimally toxic ingestion or where specific and less invasive anti- Heavy metals
dotes exist and are readily available. Consultation with a Medical Ingested packets of illicit drug
Toxicologist or a poison control center is prudent and can provide Iron
valuable information regarding the indications, contraindications, Lithium
complications, and techniques associated with gastric lavage. Toxin or toxicant poorly adsorbed by activated charcoal
CHAPTER 61: Whole Bowel Irrigation 399
TABLE 61-2 Contraindications to Performing Whole Bowel Irrigation • Polyethylene glycol electrolyte lavage solution (packets or recon-
stituted)
Bowel obstruction or perforation
Hypotension or hemodynamic instability • Emesis basin
Ileus • Stethoscope
Intractable vomiting
Nontoxic ingestion • Toomey syringe
Potentially compromised or unprotected airway • Intravenous extension tubing
Significant gastrointestinal bleeding
The equipment required for whole bowel irrigation is readily
available in most Emergency Departments. A small-bore, 10 to
12 French, nasogastric tube is sufficient for an adult or adolescent.
CONTRAINDICATIONS An enteral feeding tube can be substituted if a sufficient flow rate
There are few contraindications to performing whole bowel irriga- can be ensured. A smaller tube is required in infants or very small
tion (Table 61-2). It should not be used in the setting of a patient children. Infants will tolerate an 8 French tube and a 10 to 12 French
with a potentially compromised or unprotected airway. Whole tube is adequate beyond the first year.13,14
bowel irrigation could result in pulmonary aspiration.11,12 Significant Standard enteral feeding reservoirs and tubing are typically avail-
vomiting will hinder the ability to perform whole bowel irrigation. able as packaged kits. An enteral feeding or an enema bag with
It should not be performed in the hypotensive or hemodynamically enteral feed tubing may be substituted. Enteral feeding pumps,
unstable patient.11 Other contraindications include abnormal upper however, are not useful, as the flow rate through the pump is typi-
airway or upper gastrointestinal anatomy (e.g., anomalies, strictures, cally inadequate to perform whole bowel irrigation effectively.
or fresh interposition graft). Ingestion of toxic substances that mark- Alternatively, an empty 1 L intravenous fluid bag with intravenous
edly slow gastrointestinal motility (e.g., anticholinergics or opioids) extension tubing can be used for the procedure.
may cause an ileus, diminishing the ability to perform whole bowel
irrigation effectively. The administration of polyethylene glycol in a
patient with a bowel obstruction will result in vomiting with the poten- PATIENT PREPARATION
tial for aspiration. This solution should not be used in patients with an Explain the procedure, its risks, its benefits, and alternatives to the
actual or suspected perforated bowel. The risk of whole bowel irriga- patient and/or their representative. Informed consent should be
tion is quite small but the procedure is not without effort, expense, obtained. Informed consent can be assumed in the case of suicidal
and risk of complications. In this light, the risk–benefit ratio would be ingestions. Inspect the nasal passages and oropharynx to rule out
high if whole bowel irrigation were used to treat a nontoxic ingestion. any anatomic abnormalities or obstruction that would preclude the
passage of a nasogastric tube.
EQUIPMENT Place the patient in the upright or semi-upright position
(Figure 61-1).14 The supine and lateral decubitus positions are asso-
• Nasogastric or enteral feeding tube, size 10 to 12 French
ciated with a higher risk of pulmonary aspiration in comatose and
• Water-soluble lubricant mechanically ventilated patients.15–18 It can be assumed that this
• Nasal decongestant and anesthetic positioning risk is similarly increased in patients undergoing whole
• Enteral feeding reservoir and tubing bowel irrigation.
NG tube
Irrigant solution
in reservoir bag
IV extension
tubing
Junction of IV
and NG tubes
FIGURE 61-1. Setup required to perform whole bowel irrigation.

It is recommended that a cardiac monitor, noninvasive blood bowel irrigation is ineffectively performed if a nasogastric tube is
pressure cuff, and pulse oximeter be placed on the patient prior to not placed. Even the most cooperative patient is unlikely to drink
performing gastric lavage. This equipment may also be required the solution at the required administration rate.
based upon the patient’s physiologic status, the nature of the inges-
tant or toxicant, and/or other underlying problems. ASSESSMENT
Choose the smallest diameter nasogastric or feeding tube that will
allow adequate flow of polyethylene glycol electrolyte lavage solu- Patient assessment must be continuous throughout the process
tion into the stomach. All necessary equipment should be placed at of whole bowel irrigation. Mild abdominal distention, gassiness,
the bedside and assembled prior to beginning the procedure. and mild abdominal discomfort are common side effects and do not
A cuffed endotracheal tube should be placed prior to perform- require the discontinuation of the infusion. Providers must be vigi-
ing whole bowel irrigation in patients who are comatose, drowsy, lant in monitoring the patient’s bowel sounds. If bowel sounds cease
obtunded, unconscious, or have an absent or impaired gag reflex. or significant abdominal distension is noted, the irrigation should be
Endotracheal intubation should be strongly considered in any patient held for 30 to 90 minutes and the patient reassessed. Resume the irri-
who has ingested a central nervous system depressant, tricyclic anti- gation at a reduced rate if bowel sounds return, if the clinical status
depressants, a sympathomimetic or other agent that may result in improves, and if the patient then tolerates the infusion. Significant
seizures, or any substances that can cause an altered mental status. electrolyte or osmotic shifts do not occur solely from whole bowel
irrigation. Electrolytes may be monitored if otherwise indicated for
TECHNIQUE the type of ingestion or for overall patient status. Of greater concern
is vomiting with the risk of aspiration. The patient’s posture should
Insert a nasogastric tube. Refer to Chapter 58 for the complete be maintained in the upright sitting or the semi-upright position
details regarding nasogastric tube placement. Measure the length to facilitate passage of irrigant solution into the small bowel and to
of the nasogastric tube to be inserted. Place the tip of the nasogas- protect against aspiration. Discontinue whole bowel irrigation if the
tric tube over the xiphoid process. Extend the tube over the anterior patent develops an altered mental status or hemodynamic instability.
chest, lateral neck, behind the angle of the mandible, and to the tip
of the nose. Mark this length with a permanent marker or a piece of
AFTERCARE
surgical tape. Liberally lubricate the tip of the nasogastric tube. The
application of a nasal anesthetic and decongestant is optional but Patients who undergo whole bowel irrigation must all be admitted
can facilitate the passage of the nasogastric tube. to the hospital for ongoing assessment of the intervention and the
Gently insert the nasogastric tube into the naris. Advance it pos- underlying ingestion or overdose. In most cases, intensive care or
teriorly along the nasal floor into the nasopharynx and through step-down monitoring will be required to ensure adequacy of the
to the hypopharynx. Flexion of the neck may facilitate passage of intervention and to monitor for complications of the ingestion or
the tube into the esophagus and avoid endotracheal insertion. The overdose. Delayed complications from whole bowel irrigation are
conscious and cooperative patient may be asked to swallow water unlikely once the procedure is completed.
through a straw or to swallow their saliva to facilitate passage of
the tube. Stridor, cough, or cyanosis may indicate endotracheal pas- COMPLICATIONS
sage and should prompt removal of the tube. Gentle pressure and
patient swallowing should allow passage through the upper esopha- Documented complications from whole bowel irrigation include
geal sphincter if significant resistance is met in the hypopharynx. pulmonary aspiration of the irrigant solution and/or ingestant.11,12
Do not force the nasogastric tube as misplacement may damage This would be especially concerning in the patient with an unpro-
the larynx or perforate the pyriform sinus. Advance the naso- tected and potentially compromised airway. An ileus and intestinal
gastric tube to the marked level. Confirm proper placement by the distension has been documented in a hypotensive patient receiving
aspiration of gastric contents, by auscultation of insufflated air over whole bowel irrigation.12
the epigastrium (from a 50 mL syringe), and/or by radiography. Osmotic and electrolyte abnormalities will not occur with the
Confirmation of intragastric placement must precede adminis- standard preparations of high molecular weight (c. 3500 Da) poly-
tration of any fluids through the nasogastric tube. A radiograph ethylene glycol electrolyte lavage solutions (e.g., Colyte, GoLYTELY,
must be obtained prior to using the nasogastric tube if any ques- NuLYTELY). Complications of nasogastric tube placement are well
tion exists regarding its position. described and can occur. Refer to Chapter 58 for the complications
Instill the polyethylene glycol electrolyte lavage solution through associated with nasogastric intubation. These are unlikely if proper
a setup such as that shown in Figure 61-1. Flow rates are dependent technique is employed and can be minimized by use of the smallest
upon the size of the patient. Begin instillation at an initial rate of effective diameter nasogastric tube.
25 to 30 mL of polyethylene glycol electrolyte lavage solution per
kilogram per hour. Adults may tolerate more than 3 L of solution SUMMARY
per hour. The rate may be adjusted somewhat to accommodate
patient tolerance (e.g., vomiting, abdominal distension). Irrigation Whole bowel irrigation is a technique performed to speed gastro-
should be continued until the patient passes the ingestant in the intestinal transit and decontaminate the gut after an acute toxic
stool or until clear liquid rectal effluent is passed. Liquid stools will ingestion. Available reports suggest that whole bowel irrigation can
continue to be passed after discontinuing whole bowel irrigation. decrease bioavailability of toxicants by two-thirds in volunteers.4,14 It
Stop the irrigation if the patient vomits, develops an ileus, or if may be useful where activated charcoal is not expected to adequately
gastrointestinal perforation is suspected. bind ingestants (e.g., iron, lithium). Efficacy is still undefined in the
setting of sustained- or delayed-release preparations. Whole bowel
irrigation is not the method of choice, however, when more effec-
ALTERNATIVE TECHNIQUES tive methods of gastrointestinal decontamination are possible (e.g.,
Some Emergency Physicians may attempt whole bowel irrigation repetitive-dose activated charcoal for sustained-release theophyl-
by offering the patient polyethylene glycol electrolyte lavage solu- line). Until further data emerge, whole bowel irrigation’s role in
tion to drink. This is rarely successful. Experience shows that whole managing the toxic ingestion remains limited.
CHAPTER 62: Esophageal Foreign Body Removal 401
endoscope is successful in 84% to 98% of cases and with no associ-

Esophageal Foreign ated complications.8,9 Success is more likely and complications are
62 Body Removal minimized with proper patient preparation.
Bashar M. Attar INDICATIONS

Esophageal foreign body extraction is required in a minority of
INTRODUCTION patients, as most foreign bodies will pass spontaneously into the
stomach. The indications for removal depend upon the type of for-
Most foreign bodies (90%) that are ingested enter the gastrointesti- eign body and whether it impacts in the esophagus. Sharp objects
nal tract while 10% enter the tracheobronchial tree.1 Approximately impacted above the cricopharyngeus should be removed under
1500 people die annually in the United States from ingested for- direct vision using a laryngoscope to elevate the soft tissues and a
eign bodies in the upper gastrointestinal tract.2 Most objects (80% Magill forcep to grasp it.
to 90%) usually pass spontaneously but about 10% to 20% must Meat boluses are commonly impacted in the esophagus. Patients
be removed endoscopically. Approximately 1% require surgical will swallow large pieces that may or may not be well chewed.
removal.3 Most (80%) esophageal foreign bodies occur in children Impaction of a meat bolus, or another foreign body, at or just
followed by edentulous adults, prisoners, and psychiatric patients.4 below the cricopharyngeus muscle with tracheal compres-
Recurrent episodes of foreign body ingestion occur in 5% to 10% of sion and resultant respiratory obstruction is a true emergency.
patients, especially prisoners and psychiatric patients.1 The Heimlich maneuver may be lifesaving in this situation.10 The
The presentations are best divided according to accidental and patient should be immediately orotracheally intubated or a crico-
deliberate ingestors.1–5 The accidental ingestion patient is usually thyroidotomy performed if the Heimlich maneuver is unsuccess-
cooperative and has a single foreign body. Conversely, the deliberate ful. Early removal of a meat bolus impaction is recommended,
ingestion patient is often uncooperative and the foreign bodies are even when the bolus is located in the distal third of the esophagus.
multiple and often unusual. It is important to identify such indi- Delays in extraction allow the food to soften, making extraction
viduals at their initial presentation since foreign body removal is more difficult. The administration of glucagon intravenously may
usually performed under procedural sedation or general anesthesia. lead to esophageal relaxation and facilitate spontaneous passage of
The patient’s history is the most important part of the diagnostic the food bolus to the stomach. If this fails, it must be endoscopically
evaluation.3 The identity of the object ingested is usually known to removed.
the patient. Persistent odynophagia, dysphagia, or foreign body Blunt and round objects may become impacted in the esophagus.
sensation may indicate the presence of an esophageal foreign Earlier removal is necessary if a blunt object is impacted higher in
body despite negative radiographic results. A high index of suspi- the esophagus with associated sialorrhea and the potential for pul-
cion must be maintained in younger children and mentally retarded monary aspiration. Esophageal obstruction at lower levels requires
adults. Patients with a history of eosinophilic esophagitis have a prompt, but not emergent, treatment. Most rounded objects in
higher incidence of food impaction and higher risk of perforation the lower third of the esophagus will pass spontaneously into the
associated with interventions.6 stomach. Therefore, a 12-hour period of observation is permissible
The physical examination is most likely negative unless complica- in this situation.11 It is common for sharp, pointed, and elongated
tions are present. Stridor, wheezing, signs of consolidation, and the objects to become impacted in the esophagus. Toothpicks, open
absence of breath sounds should be sought. Subcutaneous emphy- safety pins, nails, and chicken bones are associated with up to a 35%
sema in the neck or chest indicates perforation of the esophagus incidence of esophageal perforation and should be removed.12,13
or the stomach. The most common sites for a foreign body to get Toothpicks should be removed promptly from the esophagus or
trapped are where the esophagus is narrow: at the cricopharyngeus stomach even if they are not impacted because they are particularly
muscle, where the aortic arch crosses the esophagus, and at the gas- prone to penetration of the gastrointestinal wall. Toothpicks may
troesophageal junction. migrate into surrounding structures, leading to vascular and other
Radiographic evaluation is often helpful in the evaluation of an serious complications.12
esophageal foreign body.3–5,7 Obtain plain radiographs of the neck Numerous other objects can also become impacted in the esopha-
and chest in the posteroanterior and lateral positions. Evaluate gus. Elongated, narrow foreign bodies such as stiff wires are prone
the radiographs for the presence of a foreign body in all planes. to penetration and perforation of the esophageal wall. They should
Air in the subcutaneous tissues, mediastinum, and/or beneath be removed even if they passed through the esophagus and into the
the diaphragm is indicative of a perforation. Barium studies are stomach. These objects may become trapped by the retroperitone-
undesirable in patients with a food bolus impaction and obscure ally fixed angles of the duodenum and eventually result in perfora-
endoscopic visualization. Esophagrams performed using a minimal tion. Plastic bag clips, although not sharp and pointed, should be
amount of thin barium may be necessary in situations where the removed before they pass from the esophagus into the stomach and
foreign body is made of wood, thin metals, aluminum can tops, and through the pylorus. They have claws that can attach to the small
plastics. Meglumine diatrizoate (Gastrografin) is contraindicated bowel mucosa leading to ulceration, stricture formation, and bleed-
in food bolus impactions because it is highly hypertonic and can ing.14 Toxic foreign bodies such as button batteries that become
lead to severe chemical pneumonitis if aspirated into the lungs.5 impacted in the esophagus should be removed promptly to prevent
Toothpicks, wood, and fishbones may not be seen on radiographs. perforation and systemic toxicity.
Food or meat bolus impaction may not be evident radiographically
unless it contains bony tissue. Failure to locate an object on radio-
CONTRAINDICATIONS
logic examination should not rule out its presence. Computerized
tomography may be useful, especially in cases where the foreign There are no absolute contraindications to the removal of an esoph-
body could not be detected as it may have become embedded in or ageal foreign body. Serious, life- and limb-threatening injuries
penetrated the esophageal wall.7 should be treated prior to esophageal foreign body removal. The
Endoscopy is important for both the diagnosis and possible patient’s airway, breathing, and circulation should be evaluated and
removal of an esophageal foreign body. Extraction with the flexible supported as necessary prior to removing the foreign body.
EQUIPMENT through an overtube to prevent secondary injury. Elongated foreign

bodies such as wires or pens should be grasped with a snare close to
• Flexible upper gastrointestinal endoscope the cephalad end of the object so it can align itself with the long axis
• Rigid gastroscope of the esophagus during withdrawal. Foreign bodies that penetrate
the mucosa can be safely extracted with the endoscope if frank per-
• Through-the-scope-balloon
foration or vascular penetration has not occurred.
• Stiegmann-Goff friction-fit adaptor of the esophageal variceal
rubber banding ligating kit
FOOD IMPACTIONS
• Glucagon
• 44 French Maloney rubber dilator ■ ENDOSCOPY
• Lubricant gel Food impactions are more likely to occur in the distal esophagus.
• Endoscopic overtube, for use with sharp or pointed foreign If the patient is symptomatic, there is no need for barium studies
bodies because it will obscure visualization during endoscopy. Endoscopic
intervention should be carried out immediately to prevent
• Soft latex protector hood for the flexible scope
aspiration if the patient is salivating and unable to handle oral
• Rat-tooth or alligator forceps secretions. The impacted food bolus should not remain in the
• Retrieval nets or Dormia baskets esophagus for more than 12 hours. Thereafter, the risk of compli-
• Polypectomy snares cations increases significantly.
• Laryngoscope Underlying esophageal disease is found in 65% to 97% of adults
presenting with an esophageal food impaction.8,15 Endoscopic
• Laryngoscope blades, Miller and Macintosh of various sizes removal is the procedure of choice if a meat bolus does not pass
• Curved clamp spontaneously or after an unsuccessful trial of gas-forming
• Medications for providing procedural sedation (Chapter 129) agents, glucagon, nifedipine, or nitroglycerine. The entire bolus
• Cardiac monitoring could be removed slowly with a polypectomy snare or Dormia bas-
ket under direct visualization. When the endoscope is just below
• Pulse oximetry
the cricopharyngeus muscle, snugly pull the snare with the food
• Supplemental oxygen bolus against the tip of the endoscope. Extend the patient’s head and
• Foley catheters, 14 to 16 French quickly remove the endoscope.16
• Topical anesthetic spray If the food bolus is soft, a piecemeal approach can be accom-
plished with several passages of the endoscope through an over-
• Water-soluble contrast material
tube.17 The overtube will facilitate reinsertion of the endoscope.
• 5 mL syringe Insert a Maloney rubber dilator (44 French) into the esophagus and
• Fluoroscopy machine, optional proximal to the foreign body. Pass the overtube, lubricated inter-
nally and externally, over the Maloney dilator. Remove the Maloney
PATIENT PREPARATION dilator. Introduce the flexible endoscope through the overtube.
Another method, the push technique, has been useful in dealing
If possible, obtain a duplicate sample of the ingested foreign body. with an impacted food bolus.9 A small-caliber flexible endoscope
Manipulate the duplicate object with available foreign body forceps may be used to bypass the food bolus and evaluate the area distal
and snares. Determine which instrument is best suited to grasping to the obstruction. If the endoscope is able to pass into the stomach
the foreign body. Instruments that are most useful include alligator successfully, pull it back until it is just proximal to the food bolus. Use
and rat-toothed forceps, polypectomy snares, and Dormia baskets. the endoscope to gently push the food bolus into the stomach. It is
Explain the risks, benefits, and aftercare of the procedure to the preferable to push from the right side of the food bolus rather than
patient and/or their representative. Obtain an informed consent for straight, especially in patients with a hiatal hernia, since the gastro-
the procedure. Place the patient supine. Obtain intravenous access. esophageal junction usually takes a left turn as it enters the hernia.
Apply the cardiac monitor, pulse oximeter, and supplemental oxy- The presence of a bone spicule should always be considered, whether
gen to the patient. Administer intravenous sedation or procedural the meat bolus is being extracted or pushed into the stomach.
sedation (Chapter 129) as necessary. A newer technique is accomplished by attaching the Stiegmann-
Goff friction-fit adaptor of the esophageal variceal rubber banding
TECHNIQUES ligating kit to the tip of the endoscope.18 The tip of the endoscope is
replaced with a screw-on drum from the variceal ligation kit. After
placing an esophageal overtube proximal to the food bolus, the
GENERAL PRINCIPLES endoscope is passed through the overtube.19–22 To avoid the risk of
The flexible upper gastrointestinal endoscope should be inserted dropping the food in the trachea, a Roth retrieval net may be passed
under direct visualization to avoid inadvertently striking an through the endoscope to retrieve food from the esophagus.23,24
object and further impacting it or causing it to penetrate the A last resort approach is the use of Nd:YAG laser to burn an
esophageal wall. Blunt foreign bodies such as coins can be securely opening in the center of an impacted meat bolus. This method is
grasped with a forceps or a snare. A firm grasp on the foreign body expensive and carries a high risk of complications.25 Finally, if a food
is required before withdrawal is attempted. Otherwise, the foreign impaction of the esophagus cannot successfully be removed using
body may become dislodged as it is withdrawn through points of the flexible endoscope, rigid endoscopy under general anesthesia
anatomic narrowing. This can result in aspiration of the foreign body. should be considered.26
An overtube should be used if multiple insertions and withdrawals
of the endoscope are needed. Pointed foreign bodies should be with- ■ GAS-FORMING AGENTS
drawn with the point trailing to avoid perforating any structures. Gas-forming agents can be used to relieve a distal esophageal food
Objects with sharp edges, such as razor blades, should be extracted impaction. They are occasionally used in an attempt to relieve a
food impaction in the proximal and middle thirds of the esopha- or ingested a sharp or irregular shaped foreign body. With a single
gus. These agents produce carbon dioxide gas that distends the dose, nifedipine has few side effects. These are usually minimal (i.e.,
esophagus, relaxes the lower esophageal sphincter, and “pushes” the dizziness, flushing, headache, hypotension, lightheadedness, muscle
food bolus through the gastroesophageal junction with the aid of cramps, nausea, nervousness, and palpitations) and do not preclude
esophageal peristalsis. Gas-forming agents may be used in conjunc- its use. The most significant effect of nifedipine is hypotension that
tion with glucagon, nifedipine, or nitroglycerine to help relieve the may last 6 to 8 hours. Some patients will have a significant hypo-
impacted food bolus. Complications associated with gas-forming tensive response to nifedipine and there is no way to predict which
agents include aspiration, vomiting, forceful vomiting, and esoph- patients will be affected. For these reasons, many physicians will not
ageal perforation due to distention and/or vomiting. Many physi- use nifedipine in the elderly or in patients with a history of cardiac
cians do not use these agents due to the risk of perforation. disease, coronary artery disease, stroke, or who are concurrently tak-
Three classes of gas-forming agents have been used. Commonly ing antihypertensive medications. The typical dose is 10 mg of oral
used are commercially available agents that are used by Radiologists nifedipine. The medication may be chewed then held in the mouth
for upper gastrointestinal contrast studies. A mixture of tartaric acid and subsequently swallowed. Alternatively, open the capsule, place the
(1.5 to 3.0 g in 15 mL H2O) immediately followed by sodium bicar- medicine sublingually, and have the patient hold it in their mouth and
bonate (1.5 to 3.0 g in 15 mL H2O) has been successfully used. A then swallow the dissolved nifedipine. Attempt another technique if
final agent is carbonated soda pop. the food bolus does not pass with one dose of nifedipine.
■ GLUCAGON ■ NITROGLYCERINE
A trial of intravenous glucagon before endoscopic therapy is a Sublingual nitroglycerine (0.3, 0.4, or 0.5 mg) relaxes vascular
reasonable approach. It may disimpact a food bolus in the distal smooth muscle and the smooth muscle contained within the middle
esophagus and allow it to pass into the stomach. Glucagon relaxes and distal thirds of the esophagus. The use of sublingual nitroglyc-
the smooth muscle of the lower esophagus and decreases lower- erine may allow the esophagus to dilate enough so that a food bolus
esophageal sphincter tone. It relaxes the esophageal smooth muscle can pass into the stomach. Nitroglycerine should not be adminis-
within 1 minute of intravenous injection, and its effects last approxi- tered if the patient is hypotensive or has ingested a sharp or irreg-
mately 20 to 25 minutes. Glucagon has no effect on the proximal ular shaped foreign body. It should also not be administered if the
third of the esophagus that is composed of skeletal muscle. It has patient is taking prescription medications for erectile dysfunc-
a minimal effect on the middle third of the esophagus that is com- tion (e.g., Levitra, Cialis, and Viagra). The combination of these
posed of both skeletal and smooth muscle. Glucagon has an overall medications with nitroglycerine can result in life-threatening
success rate of ≤50%. Glucagon has been also combined with gas- hypotension. The onset of action is within 1 to 3 minutes with a
forming agents to enhance esophageal clearance. maximum effect by 4 to 5 minutes. The major side effect of nitro-
The dose of glucagon is 0.03 to 0.1 mg/kg intravenously with a glycerine is hypotension, but that is short-lived. Administer one pill
maximum dose of 1 mg in children and 2 mg in adults. It should be sublingually and allow 4 to 5 minutes for an effect. The dose may be
administered over 1 to 2 minutes. It is recommended to give a test repeated a second time. Attempt another technique if the food bolus
dose (1/10 of the full dose) and observe the patient for 5 minutes does not pass after two doses of nitroglycerine.
for signs of hypersensitivity or hypotension before giving the
full dose. Have the patient take one to two sips of water after the ■ PAPAIN
administration of glucagon to stimulate lower esophageal peristal- Papain is a proteolytic enzyme that has been used to dissolve an
sis. Administer a second dose of glucagon if the food bolus impac- impacted food bolus. It is available in markets as meat tenderizer
tion is not relieved within 10 to 20 minutes. and in health food stores as a digestive supplement. It will dis-
Glucagon is a relatively safe medication. It should not be admin- solve the esophageal mucosa and continue to work its way through
istered to patients with known hypersensitivity to glucagon, the esophageal wall and into the mediastinum if it does not first dis-
esophageal fibrosis, esophageal rings, esophageal strictures, insuli- solve the food bolus. The use of papain to dissolve an impacted food
nomas, pheochromocytomas, sharp or irregular foreign bodies, or bolus may be associated with a fatal esophageal perforation and, if
Zollinger–Ellison syndrome. Exogenous glucagon stimulates the aspirated, hemorrhagic pulmonary edema. Papain should never be
release of catecholamines. It can stimulate a pheochromocytoma to used to dissolve an impacted food bolus.
release catecholamines resulting in marked hypertension and tachy-
cardia. The hypertension can be controlled using 5 to 10 mg of intra- ■ SUMATRIPTAN
venous phentolamine. Glucagon’s hyperglycemic effect can cause an Sumatriptan is a 5-HT1 agonist that reduces fasting fundic tone,
insulinoma to release insulin and cause subsequent hypoglycemia. prolongs fundic relaxation, and delays gastric emptying.27 It also
Common complications associated with glucagon include nausea, increases the number of esophageal motor waves. This may be use-
vomiting, transient hyperglycemia, allergic reactions, tachycardia, ful in cases of distal esophageal food boluses and coins, although no
and hypertension. Glucagon is a polypeptide hormone synthe- formal studies have been conducted.
sized in nonpathogenic Escherichia coli that have been genetically
altered. This is the basis of the allergic/hypersensitivity reactions.
A transient rise in blood pressure and heart rate is often seen after SHARP AND POINTED FOREIGN BODIES
administration of glucagon. Patients taking β-blockers may be more Removal of sharp and pointed objects requires extreme caution due
susceptible to transient hypertension and tachycardia. These side to potential life-threatening complications, higher morbidity, and
effects are short-lived as the half-life of glucagon is 8 to 18 minutes. higher mortality. An experienced Endoscopist should manage these
cases. It may be safer, in some cases, to consider surgical interven-
■ NIFEDIPINE tion. Toothpicks and bones are the most common foreign bodies
Nifedipine is a calcium channel blocker that decreases lower esopha- requiring surgical removal.28–30 Nails, needles, razor blades, safety
geal sphincter tone. It has been administered to allow an impacted food pins, and dental prostheses may be removed endoscopically.28–30 It
bolus to pass into the stomach. It should not be administered if the is important to remember that “advancing points puncture while
patient has an allergy to calcium channel blockers, has hypotension, trailing points do not.”31 Objects longer than 5 cm and wider than
2 cm require removal as they will rarely pass through the pylorus.32 battery falling into the airway. The patient should be admitted to
Intravenous glucagon (0.4 to 0.6 mg in adults) may be used to facili- the intensive care unit and monitored for signs of perforation and
tate extraction from the stomach and duodenum. sepsis if they suffered severe esophageal injury when evaluated by
An alligator forceps or snares are needed to grasp the object over endoscopy after removal of the button battery. If the injury is local-
the feeding tube. A plastic overtube should be considered for the ized to the anterior wall of the esophagus, bronchoscopy may be
removal of any sharp object.19,33 The overtube should be at least performed to evaluate the extent of injury.
60 cm long to remove a sharp object from the stomach. This will Generally, a button battery in the stomach need not be removed
limit objects for endoscopic removal to those smaller than 11 to unless the patient is symptomatic with abdominal pain, tender-
15 mm in diameter that fit within the overtube.34 A soft latex protec- ness, or gastrointestinal bleeding. Asymptomatic patients with but-
tor hood may be used for the removal of large objects. ton batteries less than 15 mm in diameter in their stomachs need
Razor blade ingestions may be managed with the flexible esopha- follow-up abdominal radiographs every 24 hours to document for-
goscope in adults. An alligator forceps, a snare, and an overtube will ward progress until it is expelled. In a child less than 6 years old,
be needed. A razor blade that has passed the pylorus will often tra- the battery should be endoscopically removed if it is larger in size
verse through the intestinal tract without difficulty. and has not passed within 48 hours.38,41 Patients may be placed on
Safety pins and toothpicks pose additional risks due to their sharp H2 blockers and/or proton pump inhibitors to decrease the acid in
ends that may perforate the esophagus. An open safety pin in the the stomach and therefore decrease the battery reaction. If mercury
esophagus, with the open end proximal, should be pushed into poisoning is expected, serum and urine mercury levels should be
the stomach with the flexible endoscope. Once in the stomach, the obtained and monitored.
object is turned and the hinged end is grasped and pulled out first.
A closed safety pin in the stomach will often pass without difficulty. MAGNETS
Grasp a toothpick with an alligator forceps or snare very close to
the tip so that the longitudinal axis of the toothpick is parallel to the Magnets are commonly found in homes and are easily accessible
scope as it is withdrawn into the overtube.16 to children. They are contained in appliances, jewelry, and toys.
Numerous other sharp objects are often encountered in the The ingestion of a single magnet is usually not problematic. The
esophagus. Pens, pencils, thermometers, and wires are extracted in ingestion of multiple magnets should be considered an emergency
a fashion similar to a toothpick with a snare grasping the end of the requiring removal. The magnets can move separately through the
object.15 Glass may be withdrawn similarly or by using an end-hood gastrointestinal tract. They then have the potential to attract each
attachment.33,35 other and trap bowel between them. This can result in pressure
Attempts should be made to remove all sharp and pointed for- necrosis, fistula formation, and perforation.
eign bodies before they pass from the stomach. Approximately Perform plain radiographs to determine the number and the loca-
15% to 35% of sharp or pointed foreign bodies will cause intestinal tion of the magnets. A single magnet should be treated as any other
perforation, especially in the area of the ileocecal valve.36,37 small, nonsharp, foreign body ingestion. Multiple magnets require
removal. Remove them endoscopically if they are located within the
BUTTON BATTERIES esophagus and/or stomach. If they have passed the pylorus, consult
a Surgeon for urgent removal versus careful inpatient monitoring by
Most button batteries ingested (96%) are small and 7.9 to 11.6 mm the Surgeon and frequent radiographs to localize the magnets.
in diameter.39 Batteries less than 15 mm in diameter almost never
lodge in the esophagus. Only 3% of button batteries are larger than
20 mm but are responsible for the severe esophageal injuries.39,50–53
Guidelines for the evaluation and treatment of button battery inges- A Foley catheter has been successfully used to remove recently
tions are available from the National Capital Poison Center.54 ingested, radiographically opaque, smooth and blunt foreign bod-
Button batteries cause injury by multiple methods. Their electri- ies from the esophagus. This technique is inexpensive, has a high
cal discharge causes hydrolysis and the creation of hydroxide ions success rate, does not require hospitalization, and avoids the com-
in tissue, which causes alkali burns. Leakage of the high pH con- plications associated with endotracheal intubation and general
tents can result in alkali burns. Their physical presence cause direct anesthesia. Coins are the foreign bodies primarily removed with a
pressure necrosis. Some button batteries contain mercuric oxide. Foley catheter. The technique has also been used to remove button
Mercury toxicity can result if the mercuric oxide leaks from the batteries, food boluses, and other smooth foreign bodies.
batteries. This technique cannot be used on all patients with an esopha-
The majority of these batteries contain manganese dioxide, silver geal foreign body. This technique should not be attempted in
oxide, mercuric oxide, zinc air, or lithium. Obtain anteroposterior patients who are confused or uncooperative. Patients with an
and lateral abdominal and chest radiographs to distinguish between altered mental status, airway compromise, or potential airway
coins and button batteries. A double density shadow is suggestive of compromise should be endotracheally intubated prior to Foley
batteries. The coin has a much sharper edge. catheter removal of the foreign body. Sharp or irregular shaped
A button battery lodged in the esophagus is a true emergency objects can lacerate or perforate the esophagus upon removal.
and immediate removal is indicated to avoid the rapid corrosive Known or suspected esophageal perforation is a contraindication
action of the alkaline substance on the mucosa and subsequent to this technique. Patients with complete esophageal obstruction,
complications.38,40 Endotracheal intubation is usually necessary as demonstrated by an esophageal air-fluid level on radiographs,
to protect the airway prior to endoscopic removal. The battery is are not candidates. Esophageal fibrosis, esophageal tumors, ana-
removed from the esophagus under direct viewing using a through- tomic anomalies, or a history of prior esophageal surgery is also a
the-scope balloon. A biopsy forceps may be needed to free the contraindication.
edge of the battery prior to removal. Alternatively, the battery may The equipment required for the technique is minimal. This
be pushed to the stomach and then removed using a polypectomy includes topical anesthetic spray, a bite block, and a size 12 to
snare or a Dormia basket. Do not use a Foley catheter or a magnet 16 Foley catheter with a 5 to 10 mL balloon. The technique may be
to remove a button battery without the aid of endotracheal intu- performed ideally in a fluoroscopy suite or blindly in the Emergency
bation and general anesthesia due to the possibility of the button Department. A water-soluble contrast agent is required if using
fluoroscopy. The most dangerous and immediate complication Insert the Foley catheter. Some physicians insert a bite block and
of this technique is airway obstruction. Airway and emergency place the Foley catheter through the mouth (Figure 62-1). Others
equipment must be available if this technique is to be performed. use the nasal route. The oral route avoids the potential problem of
Explain the procedure to the patient, including the sensations lodging the foreign body in the nasopharynx with subsequent aspi-
they will experience. The use of a topical anesthetic spray for the ration. Advance the Foley catheter under fluoroscopy until the bal-
oropharynx is beneficial but optional. Its use may increase the risk of loon is just distal to the foreign body (Figure 62-1A). Slowly inflate
aspiration. The use of physical restraints, procedural sedation, and/ the balloon with 5 mL of contrast material (Figure 62-1B). Stop
or intubation may be required as needed on a case-by-case basis. inflating the balloon if the patient complains of pain; deflate the bal-
Preinflate the Foley catheter balloon with 5 to 10 mL of water-soluble loon, then reposition the catheter before reinflating. Withdraw the
contrast material. Inspect the integrity of the balloon. Withdraw catheter with moderate and steady traction until it exits the mouth
the contrast material back into the syringe to deflate the balloon. (Figures 62-1C & D). Stop withdrawing the catheter if resistance
The small amount of contrast material left in the balloon will facili- is met to prevent an esophageal tear or perforation. The bal-
tate identification under fluoroscopy. Place the patient prone in 10° loon may occasionally slide past the foreign body as the catheter
to 20° of Trendelenburg or in the left lateral decubitus position in is being withdrawn. Reinsert the catheter and inflate the balloon
10° to 20° of Trendelenburg. The fluoroscopy technique and then with 7 to 8 mL of contrast material and then withdraw the catheter.
the blind technique are described in the following paragraphs. Do not overinflate the balloon as it can rupture the esophagus.
FIGURE 62-1. The Foley catheter technique to remove an esophageal foreign body. This illustration demonstrates the oral route for catheter insertion. The nasal route
may also be utilized. A. The catheter is inserted and advanced until the balloon is just distal to the foreign body. B. The balloon is inflated. C. The catheter is withdrawn and
pulls the foreign body into the hypopharynx. D. Completely withdrawing the catheter will pull the foreign body into and out the mouth. Steps (C) and (D) are performed
in one smooth motion.
Do not attempt this technique more than twice. The balloon will ALTERNATIVE TECHNIQUES
pull the foreign body ahead of it into the hypopharynx and then the
mouth. Tell the patient to spit out the foreign body; or you can grasp Numerous other methods for the removal of esophageal foreign bod-
it with fingers, forceps, or a hemostat. ies have been tried and reported in the literature. Surgical removal
This technique may also be used “blindly” if fluoroscopy is not is rarely indicated except when complications such as perforation
available. Estimate the distance, on the radiographs, from the mouth or vascular penetration have occurred. Do not blindly push food
or nose to the foreign body. Place the Foley catheter over the radio- boluses into the stomach. This is hazardous because many patients
graph with the balloon just distal to the foreign body. Mark the dis- have underlying esophageal disease. Blind maneuvers can result in
tance with tape on the catheter as it exits the mouth or nose. The esophageal perforation.
catheter will then be inserted into the patient until the tape is posi-
tioned at their mouth or nose. Use saline rather than contrast mate- PEDIATRIC CONSIDERATIONS
rial to inflate the balloon. Obtain repeat radiographs if the foreign
body is not expelled with the catheter as it may have been pushed Children less than 4 years of age are predisposed to occasionally have
into the stomach. The remainder of the technique is the same as an esophageal foreign body. They explore objects with their mouth,
described for removal under fluoroscopy. have a high curiosity level, lack molars to chew food, and have poor
Complications with this technique are uncommon but do occur. motor and sensory coordination. Common esophageal foreign bod-
This technique may not be able to remove the foreign body. Insertion ies include balls, button batteries, buttons, candies, coins, gumballs,
of the catheter can cause laryngospasm or vomiting. The Foley cath- jacks, marbles, partially chewed food, and pen caps. A high index
eter may enter the airway, resulting in coughing and laryngospasm. of suspicion must be maintained as a history of an ingestion may
The esophagus may be lacerated or perforated if the foreign body not be obtained.
is large, completely impacted, sharp, irregular, or has been in place Children may present asymptomatically or with cough, drooling,
for over 12 to 24 hours. Overinflation of the balloon can rupture dysphagia, respiratory distress, unwillingness to eat, or vomiting.
the esophagus. Removal through the nose may result in epistaxis or An asymptomatic child with an esophageal coin or round object,
impaction of the foreign body in the nasopharynx or nasal cavity. except button batteries, can be admitted to the hospital and watched
The most feared complication is complete or partial airway obstruc- for 24 hours to see if the object will spontaneously pass into the
tion if the foreign body falls into the larynx. stomach. The object should be removed with a Bougie dilator, a
Foley catheter, or an endoscope if the child is or becomes symptom-
atic, or if the object does not pass within 24 hours. Foreign bodies
BOUGIENAGE in a mainstem bronchus require removal by an Otolaryngologist in
The use of a Bougie dilator to push an esophageal foreign body into the operating room with a rigid bronchoscope. Turning the child
the stomach has been used in children.42–44 The technique has been upside down or performing the Heimlich maneuver may move the
successfully used in asymptomatic children who have radiographs foreign body into the trachea or larynx and cause a complete air-
documenting a coin in the esophagus, no history of esophageal way obstruction.
disease, and less than 24 hours has passed from the time of inges- Waltzman et al. reported that 25% to 30% of esophageal coins in
tion. The advantages of this technique are that it is quick, simple to children pass spontaneously without complications.45 Treatment
perform, does not require sedation, does not require intravenous of these patients may reasonably include a period of observation
access, decreases length of stay, and saves money when compared (e.g., 8 to 16 hours), especially in older children with coins in the
to endoscopy.55 distal esophagus. A “combination” technique using fluoroscopy
Apply a topical anesthetic spray to the child’s oropharynx. Select an and endoscopic forceps, called the “penny-pincher,” has been
appropriate size Bougie dilator. Physically restrain the patient while described to remove coins in children.46 In this technique, grasping
they are sitting upright or standing on the bed. Place the tip of the endoscopic forceps are covered by a soft rubber catheter and fluo-
Bougie dilator at the mouth and run the rest of the dilator to the ear- roscopically guided into place. The forceps firmly hold the coin
lobe and to just below the left costal margin. Place a piece of tape on while the catheter protects the oropharynx and aligns the device
the Bougie dilator 3 to 4 cm below the costal margin. Insert the Bougie with the coin. When the tip of the catheter is close to the upper
dilator through the mouth and advance it in one smooth motion until edge of the coin, the retracted radiopaque prongs of the forceps
the tape is at the mouth. Remove the Bougie dilator. Obtain a repeat are deployed. At this point, the coin edge is grasped, and the coin
radiograph to confirm that the coin is now in the stomach. is extracted.
Complications can occur and are avoided with proper patient It is important not to attempt these techniques or bougienage
selection. Esophageal perforation may occur if the patient has with patients with known anomalies of the gastrointestinal tract.
known esophageal disease, prior esophageal surgery or manipu- These anomalies may be anatomic, functional, or postsurgical.
lation, a sharp foreign body, or an irregular shaped foreign body. They can lead to the coin again becoming lodged, this time in a
A foreign body present for more than 24 hours can cause pressure position that would require a more invasive intervention than
necrosis to the esophagus and increase the risk of perforation. endoscopy.47
OROGASTRIC TUBE MAGNET ASSESSMENT

The orogastric tube magnet (OGTM) is an orogastric tube that has The patient should be observed until the effects of the sedation have
a magnet sealed within the distal end. It may be used to retrieve resolved. This includes monitoring the vital signs as per protocol
smooth, metallic foreign bodies from the esophagus and stomach of the hospital. The patients should be given a trial of liquids to
under fluoroscopy. Place the patient in the lateral decubitus posi- swallow prior to discharge. The patient may be safely discharged
tion. Apply a topical anesthetic spray to the oropharynx. Insert the after they tolerate oral fluids, are awake and oriented, and are able
OGTM through the mouth. Advance the OGTM under fluoroscopy to ambulate without difficulty. The patient should be driven home
into the esophagus and directed toward the foreign body until it by another person if sedation was used to extract the foreign body.
makes contact. Withdraw the OGTM and the foreign body out the Admission is required in a few instances. The inability to tolerate
mouth. This is a rarely used technique. oral fluids is a contraindication to discharge. Foreign bodies that are
CHAPTER 63: Balloon Tamponade of Gastrointestinal Bleeding 407
not retrievable must be removed. These patients should be admit- Numerous techniques may be used to remove an esophageal
ted for observation, further endoscopy, or operative removal. Any foreign body. The technique of choice depends upon the level of
patient with evidence of esophageal perforation should be admitted, patient cooperation, the type of foreign body, the time since inges-
observed, and evaluated by a Surgeon. tion, physician experience and comfort, Gastroenterology consulta-
The esophagus should be endoscopically examined after removal tion, and presenting symptoms. Complications can be minimized
of most foreign bodies. A Gastroenterologist should be consulted by the proper selection of the removal technique and the appropri-
on anyone with an esophageal foreign body. All patients dis- ate patient for the technique.
charged from the Emergency Department should follow up with a
Gastroenterologist in 24 to 48 hours. The presence of any lacera-
tions, perforations, or erosions should be noted and may require
repair. Any strictures will require dilation in the future. Some rec-
ommend a second endoscopic follow-up in 3 to 6 weeks for reevalu-
Balloon Tamponade of
ation of the esophagus. This is Endoscopist-specific.
AFTERCARE
63 Gastrointestinal Bleeding
Bashar M. Attar
Instruct the patient to only ingest liquids for the first 12 to
18 hours. A soft diet should begin after this trial period of liq- INTRODUCTION
uid and advanced to a general diet over 24 hours. Instruct the
patient to take small bites of food and completely chew it before Gastroesophageal varices are among the most dangerous complica-
swallowing. They should immediately return to the Emergency tions associated with cirrhosis. They are present in 50% to 60% of
Department if they experience abdominal pain, chest pain, dys- cirrhotic patients, and about 30% of them will experience an episode
phagia, hematemesis, hemoptysis, melena, odynophagia, or if they of variceal hemorrhage within 2 years of the diagnosis of varices.1
have any concerns. The major factors that determine the risk of bleeding are variceal
size and the degree of liver dysfunction.1–3 While variceal bleeding
COMPLICATIONS stops spontaneously in 20% to 30% of cases, it recurs in 70% within
1 year of the initial episode.1–4 Mortality is as high as 50% in the first
Esophageal perforation can occur due to the foreign body or the year.5 Variceal bleeding accounts for almost one-third of deaths in
extraction procedure. The patient may present with fever, tachycar- cirrhotic patients. Variceal hemorrhage has a poor prognosis if it
dia, shortness of breath, chest pain, abdominal pain, and crepitation is associated with coexisting or subsequent complications includ-
in the neck. An immediate chest radiograph and/or a radiographic ing rebleeding, infection, hepatic dysfunction, and portal pressure
contrast study should be performed if the extraction of the foreign ≥12 mmHg.6,7 Somatostatin and its analogs cause splanchnic vaso-
body has been difficult.1–3 An aortoesophageal fistula can form constriction leading to reduced portal pressure and portal blood
due to sharp foreign bodies in the esophagus that erode through flow while venodilators reduce portal pressure by reducing resis-
the esophageal wall. This should be considered when the patient tance to portal flow.7,8
presents with dysphagia and significant hematemesis.9,33 A latency Doctors Sengstaken and Blakemore developed the concept of bal-
period between the ingestion of the foreign body and hemateme- loon tamponade to control bleeding esophageal and gastric varices
sis is usually 1 to 3 weeks, though it can occur years later.15 in 1950. They developed a triple-lumen and double-balloon sys-
Tracheoesophageal fistulas can occur more than a year after inges- tem that bears their names. The Sengstaken–Blakemore (SB) tube
tion of the foreign body.3 is used as a temporizing measure to stop variceal bleeding until
Other life-threatening cardiopulmonary emergencies include more definitive means are available. A variant of the SB tube is the
mediastinitis, lung abscess, pericarditis, cardiac tamponade, pneu- Minnesota tube. It is a quadruple-lumen, double-balloon system.
mothorax, and pneumomediastinum. These complications mostly These tubes are rarely used today due to the significant complica-
result from a delay in recognizing an esophageal perforation.8,9,15 tions and the widespread availability of endoscopy and its therapeu-
The remaining complications are discussed with each of the indi- tic interventions. Removal of the balloon after its initial control of
vidual techniques of foreign body removal. the bleeding results in a 50% rebleeding rate. It is also associated
with serious complications such as esophageal ulceration and per-
SUMMARY foration.9 Emergency Physicians should become familiar with the
SB and Minnesota tubes, as they can be potentially lifesaving in
Foreign body ingestion and food bolus impaction in the upper an emergent setting, especially when endoscopy is not available or
gastrointestinal tract are relatively common problems seen in the contraindicated.
Emergency Department. Several studies have shown that 80% to
90% of foreign bodies in the gastrointestinal tract will pass spon-
taneously. Approximately 10% to 20% will require nonoperative
intervention while 1% will require surgical removal.3,48 The most Cirrhosis results in portal venous hypertension and a decrease in
common presenting symptoms are chest or pharyngeal pain, ody- blood flow through the portal system. Collateral circulation devel-
nophagia, dysphagia, foreign body sensation, and sialorrhea.48 ops, so that the blood in the portal vein can find an alternative
Despite performing emergent upper endoscopy, no foreign body route to the inferior vena cava. Large collateral systems include the
could be found in almost half of patients.49 The urgency for the esophageal, gastric, paraumbilical, and rectal veins. The left gastric
endoscopic examination depends upon the potential risk of aspi- and esophageal veins form one of the larger collateral circulation
ration or perforation, the type and size of the foreign body, the channels due to the pressure generated from the portal venous
degree of obstruction, and the inability to manage secretions.9 system and the large volume of blood flow through them. The col-
The presence of dysphagia and the immediate onset of symptoms lateral veins distend from the pressure and large volume of blood
would increase the probability of a positive foreign body finding flow, resulting in weakening of the walls of the vein. Ulceration and
on endoscopy. rupture of these veins can result in large amounts of blood entering
the esophagus and stomach. Patients may present with bright red • Lidocaine or water-soluble jelly
blood per rectum, hematemesis, hemorrhagic shock, hypotension, • 60 mL syringe
or complications associated with hypotension and hemorrhage (e.g.,
• Catheter tips for the syringe
cerebrovascular accidents and myocardial infarction).
The inflated balloons will control most bleeding. The esophageal • Two wall-suction setups with plastic connectors and suction
balloon exerts lateral pressure to tamponade esophageal varices. tubing
The gastric balloon exerts pressure on the gastric cardia to tam- • Adhesive tape
ponade varices. When both are inflated, they meet to compress the • Rubber shod clamps, hemostats, or plugs
gastric cardia against the diaphragm and block the upward flow of
collateral blood from feeding the esophageal varices. • Scissors
• Y-adapter or three-way stopcock
INDICATIONS • Intravenous extension tubing
Balloon tamponade should be considered in patients with acute • Pressure bulb
bleeding from esophageal and/or gastric varices if medical therapy • Mercury manometer or handheld manometer
(e.g., somatostatin, octreotide, and vasopressin) or emergent endo- • Bite block
scopic therapy (i.e., banding or sclerotherapy) is not available, con-
traindicated, or unsuccessful.
• Football helmet, catcher’s mask, or endotracheal tube holder
CONTRAINDICATIONS The SB tube is a triple-lumen and double-balloon system
Absolute contraindications to balloon tamponade of variceal bleed- (Figures 63-1 & 63-2). It is available in a variety of sizes, including
ing include a history of esophageal stricture, a history of recent sur- pediatric sizes. The proximal end contains three ports. A syringe
gery involving the gastroesophageal junction, or if the hemorrhage attaches to the esophageal balloon inflation port to inflate the
has terminated based upon nasogastric lavage and aspiration. esophageal balloon. A syringe attaches to the gastric balloon infla-
There are numerous relative contraindications to balloon tion port to inflate the gastric balloon. The gastric aspiration port
tamponade of variceal bleeding. The procedure should not be may be used to aspirate gastric contents, instill fluid into the stom-
performed if the equipment required is defective or missing com- ach, or lavage the stomach. The ports may be opened and closed
ponents. Untrained support staff make the procedure, as well as the by the application of rubber shod clamps, hemostats, or plugs. The
aftercare, more difficult. Significant active medical problems (e.g., tube is made of a soft rubber and is extremely flexible. The proximal
respiratory failure, congestive heart failure, and cardiac arrhyth- or esophageal balloon is elongated. The distal or gastric balloon is
mias) preclude the use of balloon devices. Incomplete gastric lavage round. The maximum volume to inflate each balloon is manufac-
leaving particulates in the stomach can cause retching and elevated turer- and size-specific. Numerous perforations in the distal end of
intraabdominal pressure. The balloons will not properly position the tube allow for gastric aspiration and lavage.
and may perforate the esophagus if the patient has a hiatal hernia. The Minnesota tube is a quadruple-lumen and double-balloon
Esophageal ulcerations preclude the use of the esophageal balloon (a system (Figure 63-3). It is similar to the SB tube with the exception
gastric balloon may be used). The device is not helpful if a variceal of an additional port and lumen. The esophageal aspiration port
source of bleeding cannot be demonstrated by examination, history, allows saliva and esophageal secretions to be aspirated from a per-
and/or nasogastric aspiration. Patients with altered mental status, foration just above the esophageal balloon. The only advantage of
confusion, diminished gag reflexes, hypoxemia, or who are unco- this tube over the SB tube is that the SB tube requires a nasogastric
operative should have their airway secured by endotracheal intu- tube to be passed nasally or orally into the esophagus to aspirate
bation prior to this procedure. Recurrent bleeding after the initial secretions.
successful tamponade should be followed by endoscopic or opera-
tive intervention. PATIENT PREPARATION
EQUIPMENT Explain the risks and benefits of the procedure to the patient and/
or their representative. An informed consent should be obtained for
• SB tube (or Minnesota tube)
the procedure. Thoroughly assess the patient’s airway and breathing.
• Topical anesthetic spray Have a low threshold to protect the airway by endotracheal intu-
• Tongue blades bation. Endotracheal intubation is required before performing the
Gastric Esophageal
aspiration port balloon
Gastric
balloon
Gastric balloon
inflation port
Perforations for
Esophageal gastric aspiration
FIGURE 63-1. Schematic illustration of the Sengstaken– balloon
Blakemore tube. inflation port
A B
C D
FIGURE 63-2. The Sengstaken–Blakemore tube. A. Overall view of the SB tube. B. The proximal ports. C. The esophageal and gastric balloons in the inflated and deflated
states. D. The distal end.
procedure if the patient has altered mental status, airway compro- procedure can be performed with the patient in the left lateral
mise, or the potential for airway compromise. Patients are often ill decubitus position if they cannot sit upright. The procedure can
and require intubation anyway. The procedure and the tube are not be performed with the patient supine if they are is endotracheally
well tolerated, and intubation makes it easier. Endotracheal intuba- intubated.
tion reduces the risk of aspiration. Apply topical anesthetic spray to the nostrils and pharynx. Insert
The patient should have intravenous access established with at a nasogastric tube or an Ewald tube. Aspirate the stomach contents.
least two large-bore catheters. Cardiac monitoring, continuous Evacuate the stomach with tap-water lavage through the nasogastric
pulse oximetry, and supplemental oxygen should be applied. The tube (or Ewald tube), then remove the nasogastric tube.
patient may require the judicious use of intravenous sedatives and Prepare the equipment. Flush the aspiration ports with air to
soft restraints during the insertion and inflation of the tube. The ensure their patency. Inflate the balloons with the maximum rec-
patient should be resuscitated, including blood transfusion, to stabi- ommended volume of air and check for leaks. It is advisable to
lize them hemodynamically. inflate the balloons under water to look for small leaks. Connect the
Place the patient sitting upright to semi-upright by elevating mercury manometer to the balloon ports and inflate the balloons
the head of the bed at least 45°. This is the ideal position. The to the recommended pressures and check for leaks. Completely
Esophageal Esophageal
aspiration port balloon
Gastric
balloon
Gastric
aspiration port
Perforation for
esophageal aspiration
Gastric balloon Perforations for

Esophageal inflation port
gastric aspiration
balloon
inflation port FIGURE 63-3. Schematic illustration of the Minnesota tube.
Tape
Gastric
Esophageal
aspiration port
balloon
Gastric
balloon
FIGURE 63-4. Preparing the nasogastric tube. Place the

Gastric balloon
nasogastric tube alongside of the SB tube with the tip just
inflation port
above the esophageal balloon. Place tape on both tubes to Esophageal
mark a common point proximal to the 50 cm mark on the balloon
SB tube. inflation port
deflate the balloons. Record the manometric pressure of each bal- inflation port when the gastric balloon is inflated initially with
loon when it is deflated. Insert the plastic plugs in the balloon infla- 200 to 250 mL of air. Gently pull the SB tube back until resistance is
tion ports or loosely clamp each port with a hemostat or rubber felt as the gastric balloon lodges against the gastroesophageal junc-
shod clamp.10–12 Lubricate the SB tube with a water-soluble lubri- tion (Figure 63-8).
cant. Place the SB tube on a table. Position a nasogastric tube next Apply slight tension to the SB tube to occlude the veins at the
to the SB tube so that the tip of the nasogastric tube is just above gastroesophageal junction. This tension must be maintained by one
the esophageal balloon (Figure 63-4). Place a piece of tape on both of several methods. Fix the upper end of the SB tube as it exits from
tubes to mark a common point, proximal to the 50 cm mark of the the mouth or nose to the crossbar of a football helmet or a catcher’s
SB tube, that will be outside of the patient. The nasogastric tube will mask (Figure 63-9). Apply over-the-bed traction with a one pound
be inserted after the SB tube is placed. Alternatively, position the weight. Alternatively, fix the upper end of the SB tube, if it emerges
tubes as above and tape both tubes together at two or three sites. from the nostril, by a cuff of sponge rubber held in place by an adhe-
This allows the nasogastric tube to be inserted simultaneously with sive tape band. Insert the nasogastric tube until the tape is at the
the SB tube. level of the tape on the SB tube (Figure 63-10).
The SB tube may be inserted through the nose or through the
mouth. The nasal route is more difficult to use and may be associ-
ated with a higher rate of complications. Despite this, many physi-
cians recommend this route in the awake patient. The oral route is
the preferred route of insertion by some physicians, especially if the
patient is intubated. Apply topical anesthetic spray into the nasal
cavity and oropharynx if the SB tube will be placed nasogastrically.
Apply topical anesthetic spray into the oropharynx if the SB tube
will be placed orally. Place a bite block in the patient’s mouth if
the SB tube will be placed orally to prevent the patient from biting
the SB tube.
TECHNIQUE
Insert the lubricated SB tube until the 50 cm mark is located just
outside the nares, or outside the teeth if inserted through the mouth.
Flush the gastric aspiration port with air while auscultating over the
epigastrium (Figure 63-5). A rush of air should be heard to ensure
that the distal end of the SB tube is properly positioned within
the stomach. If possible, confirm the position of the SB tube with
portable plain radiographs or fluoroscopy. It is imperative to know
that the gastric balloon is within the stomach before it is inflated.
Apply suction to the gastric aspiration port.
Remove the rubber shod clamp and plastic plug from the gastric
balloon inflation port. Connect the Y-adapter with a handheld or
mercury manometer and a pressure bulb or a 50 mL syringe with
a catheter tip to the gastric balloon inflation port (Figure 63-6).
Measure the intragastric balloon pressure. If the intragastric bal-
loon pressure after intubation is 15 mmHg greater than that prior
to the intubation, deflate the balloon, as it may be located within
the esophagus. Inflate the gastric balloon in increments with 50 to
100 mL boluses of air (Figure 63-7). Deflate the balloon imme- FIGURE 63-5. The SB tube has been inserted until the 50 cm mark is just outside
diately if the patient experiences chest pain. This signifies that the teeth. Inject 50 mL of air while auscultating over the epigastric area. A rush of
the gastric balloon is in the esophagus. Clamp the gastric balloon air should be heard if the distal end of the SB tube is within the stomach.
Blood pressure
manometer Esophageal balloon
Esophageal balloon
inflation port inflation port
Gastric
Gastric aspiration
aspiration port
port
Gastric balloon
Gastric balloon inflation port
inflation port
Pressure
bulb
Handheld
manometer
A B
FIGURE 63-6. Connecting the handheld manometer (A) or mercury manometer (B) to the gastric aspiration port. A 50 mL syringe may be used if a handheld pressure
bulb is not available.
FIGURE 63-7. The gastric balloon is inflated with 50 to 100 mL increments of air FIGURE 63-8. Tension is applied to the SB tube to lodge the gastric balloon
to a volume of 250 to 300 mL. against the gastroesophageal junction.
FIGURE 63-9. The SB tube is commonly secured to the faceguard of a football helmet (A) or to a catcher’s mask (B).
Connect the gastric aspiration port and the nasogastric tube to until 45 mmHg is achieved or the bleeding stops. Double clamp
the suction source (Figure 63-11). Place the gastric aspiration port the SB tube to prevent accidental deflation of the balloons. If
and the nasogastric tube on low intermittent suction. Unclamp the bleeding continues despite maintaining the esophageal balloon
esophageal balloon port clamp. Attach the Y tubing, manometer, pressure at 45 mmHg, this is suggestive of a gastric wall varix. In
and pressure bulb (or 50 mL syringe) to the esophageal balloon this case, check that the tube is snugged up on the nose firmly and
port (Figure 63-11). Inflate the esophageal balloon to a pressure taped securely. Finally, fill the gastric balloon with more air gradu-
of 25 mmHg if bleeding continues through the gastric aspira- ally up to a total volume of 300 mL of air.
tion port or the nasogastric tube. If bleeding continues to persist,
increase the esophageal balloon pressure in 5 mmHg increments
FIGURE 63-10. The nasogastric tube is inserted until the tape mark lines up with FIGURE 63-11. The esophageal balloon is inflated after the gastric aspiration port
the tape mark on the SB tube. The football helmet/catcher’s mask is omitted from and the nasogastric tube have been attached to a suction source. The football
this illustration for the sake of clarity. helmet/catcher’s mask is omitted from this illustration for the sake of clarity.
ALTERNATIVE TECHNIQUE aspiration port. Deflate the esophageal balloon for 5 minutes every
6 hours to avoid esophageal pressure necrosis. Give the patient
The above technique is also applicable to the four-lumen esopha- nothing by mouth. Oral medications, if required, may be adminis-
gogastric tamponade (Minnesota) tube. This tube is a modification tered through the gastric aspiration port. Check the tension on the
of the triple-lumen SB tube that incorporates a separate esophageal SB tube every 3 hours and adjust it as necessary. Verify patency of
suction port to the existing gastric suction port.13,14 The design of the SB and nasogastric tubes by checking the gastric and esophageal
the Minnesota tube may help prevent aspiration of esophageal con- return regularly and periodically flushing both lumens.
tents.15 Always check the manufacturer characteristics regarding the Monitor the patient continuously for signs of chest pain, respira-
maximum inflation volume of both the gastric and esophageal bal- tory distress, and aspiration. Migration of the esophageal balloon
loons, as these are dependent upon the tube manufacturers. into the hypopharynx of an awake patient will result in respiratory
Recently proposed is an effective methodology for placement distress. This situation is a true emergency and the tube should be
of the SB tube endoscopically.16 This method will avoid the need removed immediately. Cut the SB tube between the ports and the
to obtain radiologic confirmation of the gastric balloon within the patient with a scissors (Figure 63-12). The balloons will immedi-
stomach.16 Delay in treatment while waiting for a radiologic confir- ately deflate and allow the removal of the SB tube.
mation may put patients at risk, as they are almost always in critical The esophageal balloon should not remain inflated for more than
condition and require immediate attention.4–6 If endoscopic inter- 24 hours to avoid mucosal necrosis. The SB tube is usually left in
vention is not successful, pass an SB tube and confirm the position place with the gastric or gastric and esophageal balloons inflated
of the gastric balloon under direct visualization through the endo- for 24 hours if variceal bleeding is controlled. If there is no bleeding
scope. The balloons are inflated and secured in the usual fashion.16 after 24 hours, deflate the esophageal balloon and leave the gastric
balloon inflated for an additional 24 hours. The SB tube may be left
ASSESSMENT in place for an additional 24 hours after both balloons are deflated.
Check the pressure in the balloons periodically with the mercury If variceal hemorrhage recurs, the appropriate balloons should be
manometer or keep the manometer attached for constant monitor- reinflated while alternative therapy to control bleeding is sought.
ing. Obtain a portable radiograph to confirm proper placement of Patients who rebleed have a higher mortality rate. Therefore, other
the SB tube and the inflated balloons. The patient may be reclined, therapeutic interventions—such as rubber banding, sclerotherapy,
but always maintain at least 6 to 10 in. of head elevation on the bed transjugular intrahepatic portocaval shunt, or surgery—should be
to prevent aspiration in the awake patient. Tape a scissors to the considered. Remove the SB tube if hemostasis persists for 24 hours
head of the bed for quick access in case the balloon requires emer- after deflation of both balloons. Control of esophageal variceal
gent deflation (Figure 63-12). bleeding can be achieved by balloon tamponade in 50% to 94% of
patients.18–22 However, rebleeding occurs in 38%.
AFTERCARE COMPLICATIONS
If the bleeding is controlled, reduce the esophageal balloon pres- Major complications occur in up to 15% of patients and lethal com-
sure by 5 mmHg every 3 hours until 25 mmHg is reached without plications have been described in up to 6.5% of patients.18–22 Com-
bleeding from the nasogastric tube in the esophagus or the gastric plications associated with the SB tube are often life-threatening.
The airway may become occluded due to proximal migration of the
esophageal balloon into the hypopharynx of the awake patient from
traction on the SB tube.17 The patient will begin choking and gag-
ging if not intubated. Cut the SB tube distal to the ports to imme-
diately deflate the balloons and allow the SB tube to be removed.
Pulmonary aspiration, and subsequent pneumonia, may occur dur-
ing SB tube insertion. Airway protection by endotracheal intuba-
tion should be considered in all patients prior to insertion of the
SB tube.18
Despite endotracheal intubation, the SB tube may still become
malpositioned and end up in the airway.27 Inflation of the balloons
in the airway can result in respiratory distress, respiratory tract
obstruction, tracheal or bronchial rupture, or tracheoesophageal fis-
tulas from pressure necrosis. This is why it is essential to confirm
proper placement prior to inflating the balloons.
Excessive balloon pressure or prolonged balloon inflation may
lead to pressure necrosis and ulcerations of the esophagus, gas-
troesophageal junction, and/or stomach. Periodic deflation of the
esophageal balloon every 6 hours will help prevent this. Rupture
or lacerations of the esophagus, stomach, or small intestine may
occur.19 Esophageal rupture can result in mediastinitis, abscess for-
mation, and sepsis. These can be prevented by adhering to proper
balloon inflation techniques with pressure monitoring. Cardiac
arrhythmias and pulmonary edema can occur and require continu-
ous monitoring in the setting of an intensive care unit. Pulmonary
edema is often due to pressure from the esophageal balloon on
mediastinal structures.
FIGURE 63-12. Emergent removal of the SB tube. Cut the SB tube between the Numerous other complications are associated with the use of the
ports and the patient to deflate both balloons rapidly. SB or Minnesota tube. Unintentional deflation of the balloons can
be prevented by the application of rubber shod clamps or hemostats PLACEMENT OF GASTROSTOMY TUBES
to the balloon inflation ports after the balloons are inflated. Cut the
SB tube distal to the ports if the balloons will not deflate. The patient Feeding tubes have been surgically placed in patients for more than
may become agitated from the discomfort of the tube, migration of a century. Three main procedures that remain in use today are the
the tube into the hypopharynx resulting in hypoxemia and asphyxi- Stamm (described in 1894), the Witzel (described in 1891), and the
ation, or as chest and back pain is experienced from a misplaced or Dupage and Janeway (described in 1913)1–6 (Figure 64-1). They all
overdistended balloon. Hiccoughs are due to pressure on the dia- require a laparotomy under general anesthesia and provide long-
phragm by the balloons. Excessive traction on the tube can result term access to the stomach for feedings or decompression while
in epistaxis or pressure necrosis of the lips, nose, or tongue. Use air attempting to minimize the potential for gastric leakage.
and not a liquid to inflate the balloons. Liquid in the balloons causes Each of the techniques attempts to create a leakproof interface
them to be heavy, increases the risk of pressure necrosis, and makes between the stomach, the feeding tube, and the anterior abdominal
them hard to deflate. wall. The Stamm gastrostomy secures the stomach to a gastrostomy
tube using a double purse-string suture to invaginate the stomach
about the feeding tube (Figure 64-1A). The Witzel technique places
SUMMARY the gastrostomy tube through a seromuscular tunnel in the stomach
Balloon tamponade of variceal bleeding is an uncommonly per- wall (Figure 64-1B). The Janeway technique creates a formal tun-
formed procedure in the Emergency Department. The SB tube nel from a gastric flap to envelop the gastrostomy tube and form
plays an important role in the temporary control of hemorrhage a gastrocutaneous stoma (Figure 64-1C). Importantly, all three
from esophageal or gastric varices.20–22 It is used in cases of variceal techniques involve suturing the stomach wall to the undersurface of
bleeding, usually documented by endoscopy, that continues despite the abdominal wall. This is significant because if a surgically placed
aggressive medical management including lavage, correction of gastrostomy tube is accidentally dislodged in the early postoperative
blood clotting abnormalities, intravenous somatostatin or vasopres- period, the stomach wall remains attached to the abdominal wall
sin infusion, rubber banding, and emergent sclerotherapy.16,23–25 The and the chance of intraperitoneal contamination is decreased. These
SB tube can also be placed if these methods are contraindicated or surgical gastrostomies are considered long-term, semipermanent
unavailable. Despite the initial success of balloon tamponade in stomas.
the control of variceal hemorrhage, sustained control of bleeding Modern endoscopic techniques have provided a less invasive
occurs in only 40% to 50% of patients.26 Balloon tamponade has option for the placement of percutaneous feeding tubes (also
been shown to be as effective as intravenous vasopressin in control- known as gastrostomy tubes, percutaneous endoscopic gastrosto-
ling esophageal variceal bleeding. Only 25% of patients with ascites, mies, or PEGs).7 Distinct advantages of endoscopically placed gas-
jaundice, and encephalopathy achieve lasting hemostasis with bal- trostomy tubes over surgically placed tubes include relative ease of
loon tamponade. Long-term efficacy in terms of rebleeding depends placement, avoidance of general anesthesia, smaller incision, and
in part on the patient’s underlying liver disease.16 Maintain a low a lower morbidity rate.2,7,8 The disadvantages of endoscopic tech-
threshold to intubate the patient endotracheally in order to prevent niques include the inability to place tubes in patients with thick
aspiration, protect the airway, and prevent airway occlusion from abdominal walls, a history of multiple previous operations, and
migration of the esophageal balloon. the presence of abdominal wall hernias, as well as an increased risk
of injuring overlying viscera during the “blind” placement of the
PEG tube. Another disadvantage is the unique danger of acciden-
tal dislodgement of a newly placed PEG tube. If a new PEG tube
is dislodged, the stomach wall gastrotomy can pull away from the
abdominal wall allowing the escape of gastric secretions and feed-
Gastrostomy Tube
64
ings with resultant peritonitis.
Replacement Popular endoscopic techniques in use today require two
persons—an endoscopist and an operator at skin level. An endo-
Maggie Ferng and Ryan C. Headley scope is first advanced into the stomach (Figure 64-2A). The stom-
ach is then insufflated with air to displace adjacent or overlying
INTRODUCTION loops of bowel and appose the stomach wall to the anterior abdomi-
nal wall (Figure 64-2B). The endoscopist then visualizes the light
Gastrostomy tubes are commonly used devices that provide proof the endoscope as it transilluminates the abdominal wall. They
longed enteral support in patients who are unable to obtain suffi- then pierce the anterior abdominal wall with a hollow-bore needle
cient nutrition orally. Simplified techniques for their placement and (Figure 64-2C). The endoscopist confirms placement of the device
improved materials have made gastrostomies common in the out- into the gastric lumen (Figure 64-2C).
patient setting. Emergency Physicians fill a valuable role in solving The gastrostomy tube is then placed. A guidewire is fed into the
gastrostomy tube problems as many patients present to Emergency stomach through the needle, grasped with an endoscopic snare, and
Departments with various gastrostomy tube complaints. This chap- pulled out of the patient’s mouth (Figure 64-2C). The “Ponsky pull”
ter reviews the methods and materials used in gastrostomies and the technique uses this guidewire as a means for pulling the gastrostomy
approaches to replacing displaced or malfunctioning gastrostomy tube into position through the patient’s mouth (Figure 64-3A). The
tubes. guidewire is secured around a gastrostomy tube and pulled retro-
grade from the mouth to the exit site on the anterior abdominal
ANATOMY AND PATHOPHYSIOLOGY wall. The “Ponsky push” technique involves pushing the tube down
and over the guidewire toward the gastrostomy site9 (Figure 64-3B).
Familiarity with the basic techniques used to create gastrostomies A third technique, the “Russell poke” eliminates the need to direct
and the characteristics of common gastrostomy tubes is helpful the gastrostomy tube through the mouth.10 Under direct visualiza-
in solving problems with their function and replacing tubes when tion, a dilator is used to enlarge the skin puncture site. An intro-
appropriate. ducer and a peel-away sheath are then used to place the gastrostomy
CHAPTER 64: Gastrostomy Tube Replacement 415
FIGURE 64-1. Surgical gastrostomies. A. The Stamm technique. B. The Witzel technique. C. The Janeway technique.
tube directly through the anterior abdominal wall (Figure 64-3C). TYPES OF GASTROSTOMY TUBES
Regardless of which technique is used to establish the gastros-
tomy, the stomach is not sutured to the abdominal wall. Instead, a Although there are many types available, a basic understanding of
fibrous tract eventually forms between the anterior abdominal wall gastrostomy tubes is all that is needed to diagnose and treat most
and the stomach. The maturation of this tract is an important problems. Familiarity with the characteristics of gastrostomy tubes
consideration in assessing gastrostomy tubes. is helpful in assessing tube function and determining appropriate
replacements.
FIGURE 64-2. Endoscopic gastrostomy tube placement. A. The endoscope is inserted. B. The stomach is inflated with air and transilluminated. C. The anterior abdominal
wall is pierced with a cannula or needle under endoscopic guidance. A suture or guidewire is then introduced into the gastric lumen and grasped with a snare.
FIGURE 64-3. Endoscopic gastrostomy tube placement. A. The “Ponsky pull.” A suture is attached to a modified gastrostomy tube and pulled in a retrograde direction
through the anterior abdominal wall. B. The “Ponsky push.” A guidewire serves as a trolley for the gastrostomy tube to be pushed over. C. The “Russell poke.” The gastros-
tomy tube is inserted through a peel-away sheath.
The gastrostomy tube is simply a conduit for enteral feedings. nature of the internal bolster will determine if a gastrostomy tube
The essential features of the gastrostomy tube include four compo- can be removed at the bedside or requires endoscopic removal.
nents: the tube itself, an internal bolster, an external fixation (bolster External bolsters are devices at the skin exit site that secure the
or retention) device, and the ports (Figure 64-4). The main body gastrostomy tube to the abdominal wall and prevent its inward
of the gastrostomy tube is made of silicone or polyurethane. It is migration (Figure 64-4). Surgical gastrostomies frequently rely on
designed to minimize tissue reactions and optimize patient comfort. only a silk suture. PEGs typically use a T-bar or retention disk. The
Gastrostomy tubes come in a variety of sizes ranging from 12 to external bolster has little impact on the function of the gastrostomy
24 French. Some are reinforced with an inner steel wire. Many come tube or the technique used to place it. The external bolster may
with external identification marks to denote caliber, commercial cause the gastrostomy tube to kink, fracture, or clog if it is too tight.
brand name, centimeter markings to aid in positioning, and radi- Additionally, an external bolster that pulls the internal bolster too
opaque lines to aid in radiographic identification (Figure 64-4). tightly toward itself may cause stomach wall and/or abdominal wall
The internal bolster fixes the gastrostomy tube within the necrosis. Conversely, the gastrostomy tube may migrate inward with
lumen of the stomach and creates a seal to discourage leaking peristalsis and cause a bowel obstruction if the external bolster is too
(Figure 64-4). Commercially available PEG catheters come with loose. Inappropriate care of the external bolster may lead to prob-
a variety of choices for internal bolsters including balloons, cross- lems that contribute to the need for replacement, although it does
bars, T-bars, flanges, round disks, three-leaf retainers, soft domes, not affect the ability to remove the gastrostomy tube. Identification
and others (Figure 64-5). The most basic tubes use a balloon as an and correction of problems with the external bolster can prevent
internal bolster. Surgical gastrostomies commonly use Foley balloon unnecessary damage to the gastrostomy tube.
catheters, mushroom-tip de Pezzer catheters, or Malecot catheters. The external end of the gastrostomy tube contains the port(s)
Some internal bolsters are deformable and allow removal with gen- to access the lumen(s). Many tubes have a Y port, with one port
tle traction on the external tube. Others are not intended to give way for enteral feedings and a pop-off valve port to access a balloon
with traction and require more invasive techniques for removal. The (Figure 64-4). Some tubes have multiple ports to access each
FIGURE 64-4. The basic gastrostomy or percutaneous endoscopic gastros- B

tomy (PEG) tube. A. Photograph of a typical tube. B. Schematic illustration.
separate lumen that is designated for a specific purpose, such as replacement because they wear out, kink, or fracture. They should be
medication administration. Others have a suction port for gastric replaced if the lumen becomes clogged with precipitate and cannot
suctioning and a port for distal feeding. be unclogged. Most of these problems can be avoided with diligent
In an effort to improve patient comfort and acceptance, some care of the gastrostomy tube. Feedings should never be forced—a
manufacturers now supply skin-level devices. These are also common error that can weaken the tube. The feeding tube should
referred to as low-profile systems or buttons. These tubes combine be flushed with water after each use. Medications should never be
the external access port and the external bolster to provide a more mixed with enteral feeding solutions. Proper care of the gastrostomy
cosmetically appealing look without a dangling tube. tube should prevent premature loss. Family members and healthcare
providers should receive detailed instructions regarding gastros-
INDICATIONS tomy tube management so as to avoid common problems.
There is no need for routine removal or replacement of gastrostomy
CONTRAINDICATIONS
tubes. The most common indication for gastrostomy tube replace-
ment is accidental removal. Occasionally, gastrostomy tubes require A damaged, malfunctioning, or displaced gastrostomy tube should
be replaced as soon as possible, with a few exceptions. The existing
tube should be left in place if the tract is immature. Premature
removal of a tube in an immature tract, particularly if it is endo-
scopically placed, can lead to gastric spillage and peritonitis. The
exact time for a tract to mature depends upon the procedure used
and the patient’s nutritional status. A conservative approach is to
consider any tract less than 4 weeks old to be immature. The special-
ist who performed the original procedure should be consulted prior
to any manipulation of the immature tract. The gastrostomy tube
and tract should be left alone and a Surgeon consulted if a patient
has peritonitis at the time of presentation. If the patient has acute
abdominal pain after manipulation of a gastrostomy site, feedings
should be withheld until an investigation determines the source of
the problem. Do not manipulate or change the gastrostomy tube
if the patient has pain at the skin entry site or with movement of the
tube. This may alert the clinician to an underlying abscess, infec-
tion, or intraabdominal pathology.
EQUIPMENT
FIGURE 64-5. Examples of internal bolsters used in PEGs. A. Mushroom tip with • Commercial replacement gastrostomy tube kits
de Pezzer flange. B. Crossbar. C. Round disk. D. Balloon tip. E. Malecot. F. Soft dome. • Foley catheter of a similar caliber as the original tube
• 20 mL syringe with saline to fill the Foley balloon duodenum, then terminates in the proximal jejunum. If a patient
• Water-soluble lubricant is known to have a jejunostomy (sometimes referred to as a percu-
taneous endoscopic jejunostomy, or PEJ), the tract may be stented
• Toomey syringe or bulb syringe to aspirate gastric contents
with a replacement gastrostomy tube. More information should be
• Some form of external bolster (see the text below) obtained prior to resuming feedings.
• Adapter to cap off Foley catheter or attach it to feeding assembly Some catheters are not intended to be replaceable. Small needle
• Gloves jejunostomies may use 5 to 7 French catheters. Should such a cath-
eter become disrupted or occluded, there is little one can do to cor-
rect it. Consult with the patient’s primary care provider to discuss
PATIENT PREPARATION the variable options for management and follow-up.
Explain the procedure to the patient and/or their representative.
Gastrostomy tube replacement can usually be accomplished with PLACING AN EXTERNAL BOLSTER
little preparation or anesthesia. Place the patient supine. Clean
the skin surrounding the entry site of any dirt and debris. Apply After the successful insertion of a replacement tube, it needs to be
povidone iodine or chlorhexidine solution and allow it to dry. secured in place. The tube should be kept 90° relative to the skin
Anesthesia should not be necessary, as the gastrostomy site should and fixed in some way to prevent migration into the distal bowel.
not be tender. Significant pain at the site should alert the clinician A short-term solution is to dress the site with 4 × 4 gauze squares,
to an infection, abscess, or intraabdominal pathology. If anything building them up along the exit site to create a pyramid-shaped
more than minor discomfort occurs, the gastrostomy should not dressing several inches high. A strip of urethane foam can be used
be manipulated. Small children or anxious patients may benefit to bolster the tube14 (Figure 64-6A). A 3 cm section of latex tubing
from mild sedation. can be wrapped about the base of the gastrostomy tube and secured
with a plastic cable tie15 (Figure 64-6B). A modification to a Foley
catheter uses a retention disk and a plastic ring from a nasogastric
TECHNIQUES tube to secure the Foley catheter (Figure 64-6C).13
The technique for replacing a gastrostomy tube will depend upon Another option is to secure and bolster the tube with a suture
the original procedure used to place the tube, the maturity of the (Figure 64-7). Some prefer to inject local anesthetic solution
tract, and the nature of the internal bolster. Obtain as much infor- subcutaneously to minimize the discomfort of placing the single
mation as possible about the age and nature of the existing tube. suture. Others believe placing the one suture is equal to the pain of
The following discussion reviews the procedure for replacing gas- injection of the local anesthetic agent and do not use it. This deci-
trostomy tubes in mature tracts, factors to consider prior to remov- sion should be decided on a case-by-case basis after a discussion
ing an existing but dysfunctional tube, and techniques to employ in with the patient and/or their representative. Place a suture using a
fashioning replacement systems. large bite of tissue near the skin exit site. This serves as a retention
suture. Leave an open loop of 1 to 2 cm between the skin and the
REPLACING A DISLODGED GASTROSTOMY TUBE knot to avoid unnecessary traction on the skin. Wrap the ends of
the suture up the gastrostomy tube in a laddered fashion and tie
Every effort should be made to replace a dislodged gastrostomy them securely. This method allows some room for the gastrostomy
tube as soon as possible. Gastrostomy sites begin to close as soon
as the tube is removed. The tract will close within hours to days
depending on its age, maturation, and size of the tube. If the origi-
nal tube is in good condition, it can simply be reinserted to stent
the tract until a permanent replacement is found. A commercially
available replacement that is compatible with the original tube may
be used. Foley catheters are simple to use, are widely available, and
function well as temporary replacements.8,11–13
Select a tube of similar caliber to the patient’s gastrostomy tube.
Most commonly, a Foley catheter is used. A decision regarding the
choice of external fixation should be made, and the tube adapted
appropriately prior to its insertion (see discussion below). Lubricate
the replacement tube liberally. Gently insert the replacement tube
through the tract. Do not advance the tube against any signifi-
cant resistance. Advancement against more than mild resistance
can result in complications. Aspirate gastric contents to confirm
proper placement. Inflate the Foley catheter balloon with saline. Pull
the Foley catheter snug to lodge the balloon immediately behind
the anterior abdominal wall. The entire process should be painless
and should not require dissection or force. Inject the feeding port
with water-soluble contrast and obtain a KUB to confirm proper
placement
A few types of feeding tubes merit special attention. While many
gastrostomies have a short, direct route to the stomach, the Witzel
uses a more circuitous tunnel and a smaller tube. The tract may be
difficult to maneuver. When problems replacing a surgical gastros-
tomy tube arise, obtain surgical consultation. FIGURE 64-6. Types of external bolsters. A. Urethane foam dressing. B. Latex
Not all feeding tubes terminate in the stomach. In some cases, the tubing wrapped about the base of the tube and secured with a plastic cable tie.
feeding tube enters the stomach, travels through the pylorus and C. A Foley catheter modified with a retention disk and plastic ring.
external bolsters have been described that can be fashioned from

materials available in most healthcare facilities. A T-bar external
bolster can be made by cutting a 3 cm piece of tubing from a latex
or silicone Foley catheter or feeding tube11 (Figure 64-8). Fold the
piece of tubing in half. Make two diamond-shaped cuts placed on
the sides of the fold and opposite each other (Figure 64-8A). Insert
a hemostat through the holes and grasp the replacement Foley
catheter (Figure 64-8B). Slide the latex T-bar along the catheter
(Figures 64-8C & D). In order to function satisfactorily, the latex
T-bar must be snug enough to prevent migration but not so snug as
to compress the Foley catheter lumen. After placement of the Foley
catheter, position the latex T-bar so that it is about 0.5 to 1.0 cm
from the skin surface.
There are several commercially available products designed spe-
cifically for replacement gastrostomies. They are convenient. Unfor-
tunately, they are expensive, may not be compatible with the original
tube, and may not be on hand at the moment they are needed.
Once the replacement tube’s position is confirmed and secured,
the end of the tube should be clamped or fitted with an appropriate
feeding adapter.
NONFUNCTIONING GASTROSTOMY TUBES

A patient may present with a clogged, leaking, cracked, or fractured
gastrostomy tube. A number of factors should be considered prior
FIGURE 64-7. Simple external fixation using a silk suture laddered up the gas-
to removing any existing tube. Is the tract mature? Is replacement
trostomy tube.
actually necessary or can other measures remedy the problem?
What is the type of internal bolster and can it be removed by exter-
nal traction? The most important factor is the age and maturity
tube to move while preventing inward migration as the patient of the tract. Premature removal of the gastrostomy tube from
changes position. a fresh tract may lead to peritoneal contamination with gastric
These techniques are adequate for short-term use, but a more contents and peritonitis. A new gastrostomy site should not be
permanent form of external fixation is desirable. A number of manipulated without consultation with the specialist who placed
FIGURE 64-8. Fashioning an external bolster from a latex tube and a Foley cath-
eter. A. The 3 cm piece of latex tube is folded and cut. B. A hemostat is inserted
through the latex T-bar and grasps the distal end of the Foley catheter. C. The latex
D tube T-bar is advanced onto the catheter and pulled into position. D. The modified
Foley catheter with a latex T-bar.
the original tube. A malfunctioning tube may have to remain in ■ THE BALLOON DOES NOT DEFLATE
place to stent a fresh tract while alternative methods of nutri- The balloon may not deflate if the balloon inflation port is clogged
tional support are provided to the patient. or damaged. There are four options to remedy this situation. Simply
The underlying problem with a nonfunctioning gastrostomy cutting the gastrostomy tube may allow the balloon to deflate on its
tube should be investigated prior to its removal and replace- own. Cut the gastrostomy tube close to the ports. Maintain a firm
ment. A fractured tube or a tube with a ruptured balloon will need hold, manually or with a hemostat, so that the cut tube does not
replacement. A kinked tube may only need revision of the exter- migrate inside the patient and require endoscopic removal. The gas-
nal bolster. A clogged tube should first be irrigated with warm tap trostomy tube can be pulled taut to the skin and a needle advanced
water, saline, or a carbonated beverage in an attempt to open the into the tract to puncture the balloon.18–20 Alternatively, a guidewire
lumen. Do not force the irrigation fluid into the gastrostomy may be advanced through the balloon port to puncture and deflate
tube, as it may then rupture and injure the patient. A variety of the balloon.21 If these fail, the balloon may have to be ruptured inter-
other options may be tried to open a clogged gastrostomy tube. nally with an endoscopic snare.
These include the instillation of enzymes to break up or dislodge
the clog with an endoscopic snare, biopsy forceps, or Fogarty cath- ■ THE TUBE DOES NOT WITHDRAW WITH EASE
eter.16,17 The latter methods are usually performed by a consultant
and not the Emergency Physician. Although not universally recommended, one may simply cut the
A simple, quick, inexpensive, and easy to use device has been feeding tube at the skin level and push the remaining tube through
developed to declog a gastrostomy tube (Feeding Tube DeClogger®, the tract and into the stomach. This will allow the internal compo-
Bionix Medical Technologies, Toledo, OH). These are flexible plastic nents to pass through the patient’s gastrointestinal tract. Retained
wands with a basic screw thread. They come in lengths for gastros- gastrostomy tube components have been known to cause bowel
tomy and jejunostomy tubes, and various sizes (12 to 24 French). obstructions and perforations; however, the majority pass without
Insert the DeClogger® into the feeding port (Figure 64-9). Slowly incident.22 This procedure works for many types of gastrostomy
advance it while rotating it clockwise. Once fully inserted, slowly tubes, but it is not clear that this is a safe option for balloon bolsters
remove the device from the feeding port. Aspirate and insufflate air that have not been deflated. This option should be used only if a
to confirm the gastrostomy tube patency. This device may prevent Primary Care Provider agrees with that choice and is available
the time and expense of replacing a clogged feeding tube. The to follow the patient until the contents have passed. Radiopaque
patient and/or their caretaker can be taught how to use this device components can be followed by plain radiographs at 24 to 48 hour
at home, which may prevent a trip to the physician or Emergency intervals. The gastrostomy “hardware” may have to be retrieved
Department. endoscopically or surgically if it fails to pass within 2 to 3 weeks or the
Once the decision has been made to replace a gastrostomy tube, patient experiences obstructive symptoms. This option is not recom-
information should be obtained regarding the type of tube in place. mended for small children under the age of 6 years or weighing less
Many are removable by gentle external traction. Never apply more than 20 kg.23 These patients have a greater risk for complications.23
than gentle traction when removing a gastrostomy tube. If the
internal bolster is a balloon, simply deflating the balloon will allow
■ INADVERTENT REMOVAL OF THE TUBE
the tube to be removed. Other bolsters such as soft domes and FROM A FRESH OR IMMATURE TRACT
T-bars may deform easily with gentle constant traction. If gentle Whenever a fresh tract is disrupted, there is the possibility of gastric
traction is not sufficient to remove the gastrostomy tube, either the spillage and peritonitis. In such an event, all enteral feedings should
internal bolster is not intended to be removed externally or it may be discontinued and the patient observed for the development of
have become embedded within the gastric wall. When difficulty peritonitis. A number of replacement options have been described.
occurs trying to remove a gastrostomy tube, consult the physician The tract may be allowed to close spontaneously and a replacement
who placed the tube. The most likely problems and alternate solu- PEG placed in 7 to 10 days if the patient remains well.24 Alternatively,
tions are discussed below. endoscopy can attempt to reintroduce a replacement tube under
direct visualization through the original tract.25 A General Surgeon
should be consulted and laparotomy considered if peritonitis devel-
ops. Under these circumstances, the Surgeon may choose to place a
surgical gastrostomy.
■ THE TRACT IS CLOSED

A gastrostomy tract that is not stented will begin to close within
hours. A lost tract may require a repeat procedure. This problem
requires consultation with an Endoscopist. Dilation of a closing
gastrostomy site has been described using filiform catheters and
followers or urethral sounds, a procedure adapted from Urology.26
This procedure should be performed with caution as it can result
in numerous complications. Interventional Radiologists can often
replace dislodged tubes using special techniques.
■ EARLY BALLOON RUPTURE IN

AN INTACT TUBE IN AN IMMATURE TRACT
In this instance, the tract is stented but there is the risk of gastric
leakage about a deflated balloon. Esker and Hall report successful
FIGURE 64-9. Using the Bionix Feeding Tube DeClogger. A. The clogged gas- replacement using a guidewire to exchange the gastrostomy tube.27
trostomy tube. B. The DeClogger is slowly advanced through the clog while being This technique is performed using endoscopic guidance to snare the
rotated clockwise. C. The clog has been removed and free flow reestablished. guidewire and withdraw the original gastrostomy tube.
CHAPTER 65: Paracentesis 421
ASSESSMENT bleeding, gastric perforation, intraperitoneal penetration, pain, and

the formation of a false passage. Pass a smaller-size tube if necessary
The replacement gastrostomy tube should be placed to gravity drain- to reestablish the tract and maintain its patency.
age or the stomach contents should be aspirated. Use of the gastros- An indwelling or replacement gastrostomy tube may result in
tomy tube can be resumed if there is free flow of gastric contents. If a gastric outlet obstruction. The patient usually presents with
there was any difficulty with placement of the gastrostomy tube or distention of the stomach and vomiting. Immediately and gen-
if the return is equivocal, its position should be confirmed radio- tly, pull back on the gastrostomy tube until it is snug against the
graphically. A small amount of water-soluble radiopaque contrast abdominal wall. Secure the gastrostomy tube with an external bol-
should be administered through the gastrostomy tube and a KUB ster. Observe the patient for resolution of their symptoms and any
should be obtained. Normal gastrostomy tube placement will show complications.
intraluminal contrast. Any extravasation of contrast is abnormal The skin exit site may become edematous, erythematous, and
and requires enteral feedings to be withheld and a General Surgeon tender. A simple cellulitis should be managed with oral antibiotics
to be consulted. In most instances, the patient will require hospital- and local wound care. Failure to resolve with antibiotics alone may
ization for parenteral antibiotics, observation, and bowel rest until suggest the presence of an abscess and further imaging or drainage
the tract heals. Some physicians elect to evaluate all replaced gas- may be required. A dermatitis can result from leakage of gastric con-
trostomy tubes radiographically prior to their use. While doing so tents around the gastrostomy tube. Ensure that the internal bolster
is harmless to the patient and causes no complications, this process is secured against the anterior abdominal wall. If the leakage per-
cannot be routinely recommended, as it is time-consuming and sists, replace the gastrostomy tube with a larger one that occludes
expensive.29,30 the tract. Local wound care is all that is necessary once the problem
with the gastrostomy tube is corrected. Occasionally, hypersensitiv-
AFTERCARE ity to the adhesive, cleansing solutions, or the gastrostomy tube itself
may develop. The use of different materials and topical corticoste-
Routine maintenance can resume after successful replacement of roids will correct this problem. A yeast infection (Candida albicans)
the gastrostomy tube. Any factors that contributed to the malfunc- appears erythematous and moist, with satellite lesions. Topical anti-
tion should be addressed to prevent a recurrence. The patient and/ fungal creams and local wound care will alleviate the yeast infection.
or their caregivers should be taught the proper care and mainte- Granulation tissue around the stoma can be eliminated by coagu-
nance of a gastrostomy tube. The patient should follow up with their lation with silver nitrate sticks. The patient should follow up with
primary physician in 24 to 48 hours for evaluation, removal of the their primary physician in 24 to 48 hours for a reevaluation of all
temporary tube, and placement of a gastrostomy tube. Instruct the these clinical entities.
patient to immediately return to the Emergency Department if they
develop a fever, abdominal pain, nausea, or vomiting.
SUMMARY
COMPLICATIONS Both surgical and endoscopically placed gastrostomy tubes result in
a simple fibrous tract connecting a feeding tube to the stomach. A
A variety of complications may accompany the initial insertion of a mature tract can be safely and easily manipulated. Problems with
gastrostomy tube.2,6,31 However, replacement at a mature site should an immature tract should prompt consultation. Techniques for the
be relatively free of problems. Excessive force during replacement basic maintenance and repair of gastrostomy tubes are straightfor-
can disrupt the tract. A misdirected tube may end in a blind pouch ward. Familiarity with the procedures and equipment used to estab-
or the peritoneal cavity if the stomach separates from the anterior lish gastrostomies will help the Emergency Physician solve common
abdominal wall. Installation of enteral feedings intraperitoneally gastrostomy tube problems and intervene in an appropriate and
will cause a chemical peritonitis. This should be suspected if there is timely manner.
poor return from the replaced gastrostomy tube, difficulty installing
feedings, or the patient develops pain or fever after the procedure.
Peritonitis is preventable if proper positioning is confirmed prior to
using the replacement tube.28
A replacement gastrostomy tube must be sufficiently secured
Paracentesis
externally so that the effect of peristalsis does not carry it distally.
This is particularly true of balloon-tipped tubes. Once the tube
migrates past the pylorus, it can cause bowel obstructions and perfo-
65 Susan B. Promes, Elizabeth M. Datner, and Sam Hsu
rations.2,6 This can be avoided by carefully securing the replacement
gastrostomy tube with an external device or suturing it securely to
the skin.
INTRODUCTION
Always advance the Foley catheter into the stomach before The word ascites is derived from the Greek askos meaning “bag” or
carefully and slowly inflating the balloon. Inflation of the balloon “sac.” Ascites, an abnormal accumulation of fluid in the abdomi-
within the gastrocutaneous tract can result in hemorrhage, pain, nal cavity, has important implications diagnostically, therapeuti-
and rupture of the tract. Overinsertion of the catheter can cause cally, and prognostically. Cirrhosis of the liver, which is usually
the balloon to enter the esophagus, duodenum, or gastroesophageal related to alcoholism, accounts for 75% of cases of ascites; malig-
junction. These structures can rupture when the balloon is inflated. nancy accounts for an additional 10% to 12%, and cardiac failure
These complications can be avoided by inserting the Foley catheter for another 5%. The remaining cases have a variety of etiologies.1
8 to 10 cm, slowly inflating the balloon, and not inflating the bal- Unfortunately, the physical examination is not very reliable when
loon to its maximal volume. it comes to detecting ascites, making paracentesis and ultrasound
A mature gastrostomy tract begins to close as soon as the tube (US) important clinical tools.2 US-guided paracentesis has two key
is removed. The tract narrows without the presence of the gastros- benefits. It not only facilitates performance of the procedure, but it
tomy tube to keep it patent. Replace the gastrostomy tube as soon also identifies patients in whom the procedure is not warranted or
as possible. Never force a tube through the tract. This can result in could potentially be harmful.3
A Midline
Lateral
Skin
Subcutaneous fat
Linea alba
External oblique muscle
Extraperitoneal fat Internal oblique muscle

Peritoneum
Rectus muscle Transversus abdominus muscle
Transversalis fascia
Abdominal cavity
B Midline
Lateral
Skin
Subcutaneous fat
Linea alba
Extraperitoneal fat
Peritoneum Internal oblique muscle

Abdominal cavity
FIGURE 65-1. The layers of the anterior abdominal wall vary above (A) and below (B) the level of the anterior superior iliac spine.
Peritoneal aspiration of ascitic fluid or paracentesis was first protected from the environment by the abdominal wall muscu-
described by Saloman in the early twentieth century.4 With the lature, fat, and skin. The right and left rectus muscles, which are
introduction of diuretics as well as a fear of procedure-related com- nourished by the epigastric vessels, meet in the midline at the avas-
plications, paracentesis fell out of favor in the 1950s, being replaced cular linea alba. The umbilicus is located along the lower portion of
by medical management. At that time, large-bore needles were the linea alba. The layers of the anterior abdominal wall structures
being used and complication rates were significant. Clinical studies vary above and below the level of the anterior superior iliac spine
published in the late 1980s demonstrated that performing a para- (Figure 65-1).
centesis was, in fact, a safe procedure.5,6 Nowadays, the procedure is The liver sits in the upper right quadrant; when enlarged, it can
commonplace in Emergency Departments. be palpated in the lower right quadrant. The spleen is normally
Paracentesis is an important diagnostic tool for patients with contained in the upper left quadrant, but when it is enlarged, it can
new-onset ascites to determine its etiology and in those patients extend into the left lower quadrant (LLQ) of the abdomen. The
with long-standing ascites to detect the presence of infection. intestines occupy most of the abdominal cavity and are not rigidly
Spontaneous bacterial peritonitis can be a very subtle disease. adherent, allowing them to move about in the abdominal cavity. The
Infection occurs in as many as 27% of cirrhosis patients admitted bladder sits in the pelvis but can enter the abdominal cavity when it
for evaluation of symptoms associated with their ascites.7 It is well is distended with urine.
known that some patients with spontaneous bacterial peritoni- The abdominal cavity is divided into compartments according to
tis are asymptomatic, making peritoneal fluid aspiration, analysis, mesenteric attachments. Ascitic fluid can be found anywhere in the
and cultures imperative.8 In addition to the diagnostic usefulness peritoneal cavity. The location of the ascitic fluid depends primarily
of paracentesis, large volumes of ascitic fluid can be removed thera- upon the amount of fluid present and the patient’s position. Fluid
peutically by this procedure in order to improve a patient’s respira- follows the law of gravity. Small amounts of fluid generally accumu-
tory status and comfort level from the pressure of tense ascites. This late in the cul-de-sac and pericolic gutters. Large amounts of fluid
often occurs in patients with end-stage liver disease as well as in can be found bathing the intestines (Figure 65-2). There can also
some cases of malignancy. Malignant ascites may occur with car- be distinct pockets of fluid in areas of bowel adhesions or scarring.
cinoma of the ovary, pancreas, stomach, colon, breast, testes, and a These localized areas of fluid are typically found in those patients
variety of sarcomas and lymphomas. who have had previous surgery, trauma, or infection.
Although paracentesis is easily performed blindly, US can provide
several benefits. US is diagnostically useful to ensure there is enough
fluid to perform a paracentesis. It will identify and help avoid solid
The gross anatomy of the abdomen is well known to the Emergency organs, masses, and vascular structures. If there are bowel adhe-
Physician and is important to review in preparing for a para- sions, US will also identify areas where the bowel is adherent and
centesis. The abdominal cavity is lined by the peritoneum and is puncture should not occur. In obese patients, US can measure the
support these contentions.11 Many, however, would suggest using

an infraumbilical midline, also known as a linea alba, approach in
coagulopathic patients. This area is free of any vasculature, thus
reducing the possibility of bleeding complications. A recent study
in which the majority of ascites patients had a paracentesis per-
formed in the LLQ did not demonstrate any bleeding complica-
tions.12 With this in mind, and given that the abdominal wall is
thinner and ascitic fluid pools more in the LLQ, this location may
be chosen over the infraumbilical approach when US is not being
used to guide the procedure.13
EQUIPMENT
• Protective eyewear
• Cap and mask
FIGURE 65-2. US of the abdomen demonstrating loops of bowel floating in ascitic • Sterile 4 × 4 gauze
fluid (black). • Sterile drape
• Local anesthetic solution with epinephrine
• 25 or 27 gauge needle to anesthetize the skin
soft tissue thickness to the peritoneum, locate the thinnest entry • 10 mL syringe for anesthetic
point, and determine the needle length required. US can be used to • Choice of needle options: 18 to 22 gauge needle, 3½ in. needle or
position the patient so that the maximum amount of fluid collects spinal needle
at the sampling site.
• Seldinger-type guidewire kit
INDICATIONS • Catheter-through-the-needle
• Catheter-over-the-needle—consider Caldwell needle
A paracentesis can be performed for diagnostic or therapeu-
tic purposes. A paracentesis or “abdominal tap” is warranted in a • Large syringe(s) for fluid collection (20 to 60 mL)
patient with new-onset ascites to establish the etiology of the fluid. • Intravenous tubing or blood collection tubing if vacuum bottles
A patient with a history of ascites may need the procedure if they are being used
have associated signs and symptoms suggestive of infection such as • Collection bottles (vacuum) or collection bag
fever, dyspnea, abdominal pain, encephalopathy, renal impairment,
• Adhesive dressing
or peripheral leukocytosis.9 A paracentesis can be performed thera-
peutically for patients in whom medical management with diuretics • Three-way stopcock
has not been successful. It is most commonly performed when an • Blood collection tubes for white blood cell (WBC) count, electro-
intraperitoneal infection is suspected. Clinical guidelines recom- lytes, albumin, pH, etc.
mend that patients with ascites admitted to the hospital whether or • Blood culture bottles (aerobic and anaerobic)
not they have symptoms of spontaneous bacterial peritonitis should
undergo a paracentesis.9,10 Paracentesis has been used to aid in the • Sterile specimen container for cytology (optional)
diagnosis of ruptured ectopic pregnancy, bowel perforation, and • US machine and probe
hemoperitoneum due to trauma. More accurate diagnostic proce- • Sterile US gel
dures should be used rather than a paracentesis for these conditions • Sterile US probe cover
if they are available.
Commercially available paracentesis kits are available. These con-
CONTRAINDICATIONS tain all the required equipment except the collection bottles. They
include the sterile drapes and local anesthetic solution. These are
There are no absolute contraindications to performing a paracen- convenient and relatively inexpensive.
tesis. The relative contraindications include pregnant patients or A general-purpose curvilinear or phased-array US probe provides
patients who have a history of abdominal surgery, a current bowel the best combination of penetration and field of view into the abdo-
obstruction, a coagulopathy, or thrombocytopenia. Pregnancy is men. A linear probe can be used for thin, small adults, and children.
listed because the gravid uterus may fill the space where the proce-
dure is normally performed. If a paracentesis is indicated, it should
be performed superior to the uterine fundus. It is important to
PATIENT PREPARATION
avoid sites of previous surgical incisions, because adhesions may fix Explain the procedure, its risks, and its benefits to the patient and/or
the bowel wall to the abdominal wall, thus increasing the possibility their representative. Obtain an informed consent for the procedure.
of perforation. Many patients who are subjected to a paracentesis The patient’s bladder should be empty. Use an US machine to check
have underlying liver disease and resultant coagulopathies. Some for a full bladder or place a Foley catheter to decompress the bladder
advocate that patients with thrombocytopenia or an abnormal if the patient is unable to urinate voluntarily. Placement of a naso-
international normalized ratio (INR) should have platelet trans- gastric tube is recommended, although not routine. It prevents an
fusions or factor replacement prior to performing a paracentesis. iatrogenic perforation if the stomach is dilated or if a concomitant
This practice is controversial and there are no controlled data to bowel obstruction is present.
and along the needle insertion tract. Allow 3 to 5 minutes for the
local anesthetic to take effect.
TECHNIQUES
Z-TRACT TECHNIQUE
A “Z-tract” is used to decrease the possibility of an ascitic fluid leak,
especially in patients with tense ascites (Figure 65-4). This is the
preferred method for inserting the needle. This technique should
also be followed when using the other techniques described below.
Apply traction on the skin cephalad or caudad to the needle inser-
tion site so that the skin is pulled taut when the needle enters the
peritoneum (Figures 65-4A & B). The idea is that when the skin
tension is released, the skin returns to its normal position and seals
off the pathway of the paracentesis needle.
Apply an 18 to 22 gauge, 3½-in needle or spinal needle to a 60 mL
syringe. Slowly insert and advance the needle perpendicular to
the skin (Figure 65-4A) or at 45° to the skin and aimed caudally
(Figure 65-4B). Apply negative pressure to the syringe as it is being
advanced. A loss of resistance should be felt as the needle enters
the peritoneal cavity. Stop advancing the needle when ascitic fluid
enters the syringe. Continue to aspirate until the syringe is one-half
to three-fourths filled with fluid. Depending on the size of syringe
consider using a three-way stop cock so syringes can be removed as
they are filled.
The omentum, a loop of bowel, peritoneal fat, or other tissue may
be occluding the needle tip if ascitic fluid suddenly stops flowing
into the syringe. Release the plunger of the syringe. Reattempt to
aspirate. If fluid still will not flow, inject 1 to 2 mL of ascitic fluid back
into the peritoneal cavity and then reattempt to aspirate. Reposition
the needle if ascitic fluid still does not flow into the syringe. Never
reposition the needle while the sharp tip is within the perito-
neal cavity. The needle can lacerate the bowel, the omentum, or
FIGURE 65-3. Needle insertion sites to perform a paracentesis (indicated by
a red ⊗). The preferred site is in the midline and 2 cm below the umbilicus.
a blood vessel. Withdraw the needle to the dermis, reposition it,
Alternative sites are just medial and 4 to 5 cm above the anterior superior iliac and then readvance it into the peritoneal cavity. The Caldwell needle
spines. appears to be superior to a conventional angiocatheter needle when
it comes to problems with fluid return. The Caldwell needle’s unique
design with fenestrations on the side is believed to allow for contin-
ued flow despite occlusion of the needle tip.14,23
There are two recommended areas of entry for the paracentesis Note the color and clarity of the ascitic fluid. Aspirate 30 to
needle (Figure 65-3). The first site is in the midline and 2 cm below 50 mL if the procedure is being performed for diagnostic purposes.
the umbilicus. Alternatively, the region 4 to 5 cm superior and just Withdraw the needle after obtaining the fluid. Immediately place
medial to the anterior superior iliac spine in one of the lower quad- the fluid into the appropriate collection tubes and culture bottles.15
rants may be used. Some physicians choose the right lower quad- If the reason for the paracentesis is therapeutic and there is a large
rant to avoid the sigmoid colon and spleen. Others choose the LLQ collection of fluid that must be drained, hold the needle or catheter
to avoid the cecum and liver. Remember to exercise caution in the securely and remove the syringe. An assistant can place the sample
region of a scar, prominent veins, caput medusa, or over an area of into laboratory containers. Connect the needle or catheter to intra-
inflamed or infected skin to minimize complications. US-assisted venous tubing. Connect the other end of the intravenous tubing to
paracentesis is recommended if an US machine is readily available. a suction bottle or bag in order to drain off the desired amount of
Not only can US assist in identifying the ideal fluid pocket but also ascitic fluid. Remove the needle or catheter once the procedure has
hopefully avoid a “dry tap”.3 been completed. Removal results in the formation of the Z-tract, so
Place the patient sitting upright for a midline or linea alba that ascitic fluid will not leak from the skin (Figure 65-4C). Apply a
approach, lying in the right lateral decubitus position for a right bandage to the skin puncture site. Consider a compression dressing
lower quadrant approach, or lying in the left lateral decubitus posi- with an occlusive bandage if fluid is oozing from the puncture site.
tion for a LLQ approach. Another position one might consider is
having the patient assume a hand-knee or “crawling” position.
This position, however, is awkward for the Emergency Physician
SELDINGER TECHNIQUE
performing the procedure. Remember that the fluid will pool in First described by Seldinger in 1953, this technique allows for the
dependent areas and the bowel will float on top of it—barring any placement of a catheter over a wire (Figure 65-5). The wire used
adhesions or masses. must be longer than the catheter. The needle used to insert the wire
Prepare the patient. Clean the skin around the chosen puncture can be short and of a smaller gauge than the catheter. Materials
site of any dirt and debris. Apply povidone iodine or chlorhexidine needed for catheter insertion are commercially available in a pre-
solution and allow it to dry. Apply sterile drapes to delineate a sterile fabricated kit. The Seldinger technique is most commonly used for
field. Inject 2 to 5 mL of local anesthetic solution subcutaneously central venous catheter insertion.
Linea alba Peritoneum
Umbilicus Skin
Peritoneal cavity
B
Peritoneum
Umbilicus
C Linea alba Skin
Peritoneal cavity
FIGURE 65-4. The Z-tract. A. The needle is inserted perpendicular to the skin while the skin is pulled taut. B. Alternatively, the needle can be inserted at 45° to the skin
and aimed caudally. C. The resultant Z-tract (arrows).
Choose the puncture site and prepare the patient for the proce- least several centimeters beyond the beveled end of the needle.
dure. Insert the thin-walled introducer needle in a Z-tract manner Always have at least one hand holding the guidewire at all times
while applying negative pressure to the syringe (Figure 65-5A). The to prevent it from slipping completely into the peritoneal cav-
introducer needle has a tapered hub on the proximal end to guide ity. Hold the guidewire securely in place. Remove the needle over
the wire into the needle lumen. Avoid using a standard hypodermic the guidewire (Figure 65-5C). Make a small nick in the skin adja-
needle, as it will not allow for the passage of the guidewire. A flash cent to the guidewire with the #11 scalpel blade included in the kit
of fluid in the needle hub signifies that the tip of the needle is within (Figure 65-5D). Direct the sharp edge of the scalpel blade away
the peritoneal cavity (Figure 65-5A). Advance the needle an addi- from the guidewire to avoid nicking the guidewire.
tional 2 to 3 mm. Hold the needle in place securely and remove the Place the dilator through the sheath (or catheter) to form a
syringe. unit. Advance the dilator and sheath unit over the guidewire
Occlude the needle hub with a sterile gloved finger. This will (Figure 65-5E). Continue to advance the dilator and sheath unit
prevent air from entering and ascitic fluid from exiting. Insert over the guidewire and into the peritoneal cavity (Figure 65-5F). A
the guidewire through the hub of the needle (Figure 65-5B). twisting motion may aid in its advancement through the skin and
Advance the guidewire to the desired depth, ensuring that it is at into the peritoneal cavity (Figure 65-5F). Advance the unit until the
FIGURE 65-5. The Seldinger technique. A. The needle is advanced into the peritoneal cavity. B. The syringe is removed and a guidewire is inserted through the needle
and into the peritoneal cavity. C. The needle is removed, leaving the guidewire in place. D. An incision is made where the guidewire enters the skin. E. The dilator and
sheath are advanced as a unit over the guidewire. F. The dilator and sheath are advanced into the peritoneal cavity with a twisting motion. G. The guidewire and dilator are
removed as a unit, leaving the sheath in place. H. A syringe is attached to the sheath. The aspiration of ascitic fluid confirms proper intraperitoneal placement of the sheath.
FIGURE 65-6. The catheter-through-the-needle technique. A. The

needle is advanced into the peritoneal cavity while maintain-
ing negative pressure on the syringe. B. The syringe has been
removed. The catheter is inserted through the needle. C. The
needle is withdrawn and the catheter is left within the peritoneal
cavity. D. A syringe is attached to the catheter and the needle guard
applied. The aspiration of ascitic fluid confirms proper intraperito-
neal placement of the catheter.
hub of the sheath is against the skin. Hold the hub of the sheath channel in which the needle can reside. The needle guard hinges
securely. Remove the guidewire and dilator as a unit (Figure 65-5G). closed over the needle to hold it securely and prevent the needle
Attach a syringe to the hub of the sheath (Figure 65-5H). from shearing the catheter.
Aspirate fluid from the sheath to confirm intraperitoneal place- Choose the puncture site and prepare the patient for the proce-
ment. Hold the hub of the sheath securely and remove the syringe. dure. Place the needle on a tuberculin syringe. Insert the needle
Pass the syringe to an assistant to place the sample into laboratory through the skin in a Z-tract manner and into the peritoneal cav-
containers. Connect the hub of the sheath to intravenous tubing. ity while applying negative pressure to the syringe (Figure 65-6A).
Connect the other end of the intravenous tubing to a suction bottle A flash of fluid in the syringe confirms that the tip of the needle
or bag in order to drain off the desired amount of fluid. An alterna- is within the peritoneal cavity. Advance the needle an additional
tive is to attach a three-way stopcock to the distal end of the intra- 2 to 3 mm to ensure that the tip of the needle is completely within
venous tubing. A syringe may then be attached to the stopcock to the peritoneal cavity. Securely grasp and hold the needle with the
withdraw laboratory samples or “pump out” the ascitic fluid into nondominant hand. Remove the syringe with the dominant hand.
a nonsterile container. Remove the sheath once the procedure is Immediately place the nondominant thumb over the needle hub to
completed. Apply a bandage to the skin puncture site. While this prevent air from entering and fluid from exiting.
technique seems complicated at first glance, it is easy to learn and Insert the catheter through the hub of the needle (Figure 65-6B).
can be performed in a few minutes by an experienced Emergency Advance the catheter through the needle until the desired length
Physician. of catheter is within the peritoneal cavity. If the catheter will not
advance, remove the catheter and needle as a unit. Never with-
draw the catheter through the needle. The sharp bevel of the nee-
CATHETER-THROUGH-THE-NEEDLE TECHNIQUE
dle may cut the catheter as it is being withdrawn and result in a
This system is used most commonly for central venous access. catheter embolism in the peritoneal cavity.
Select a catheter size that is appropriate for the patient and the site of Withdraw the needle over the catheter (Figure 65-6C). Do
entry. Packaged with each catheter are a needle and a needle guard. not allow the catheter to be withdrawn through the needle.
The needle will have an inner diameter that is slightly larger than Continue to withdraw the needle until the tip is completely outside
the outer diameter of the catheter. The needle guard has a beveled the skin. Apply the needle guard over the needle (Figure 65-6D).
Attach a syringe onto the hub of the catheter. Aspirate fluid from flash of fluid in the hub of the needle confirms that the tip of the
the catheter to confirm intraperitoneal placement. Hold the hub needle is within the peritoneal cavity. Advance the catheter-over-
of the catheter securely and remove the syringe. Pass the syringe the-needle an additional few millimeters to ensure that the catheter
to an assistant to place the sample into laboratory containers. is within the peritoneal cavity. Hold the hub of the needle securely.
Connect the catheter to intravenous tubing. Connect the other Advance the catheter over the needle until its hub is against the skin
end of the tubing to a suction bottle or bag in order to drain off (Figure 65-7B). Withdraw the needle and syringe as a unit. Attach
the desired amount of fluid. An alternative is to attach a three- a syringe onto the hub of the catheter (Figure 65-7C). Aspirate
way stopcock to the distal end of the tubing. A syringe may then fluid from the catheter to confirm intraperitoneal placement. Hold
be attached to the stopcock to withdraw laboratory samples or the hub of the catheter securely and remove the syringe. Pass the
“pump out” the ascitic fluid into a nonsterile container. Remove syringe to an assistant to place the sample into laboratory contain-
the catheter once the procedure is completed. Apply a bandage to ers. Connect the catheter to intravenous tubing. Connect the other
the skin puncture site. end of the tubing to a suction bottle or bag in order to drain off
The main disadvantage of this technique is the possibility of the desired amount of fluid. An alternative is to attach a three-way
the needle tip shearing off the catheter and resulting in a catheter stopcock to the distal end of the tubing. A syringe may then be
embolism. This can be prevented by not withdrawing the catheter attached to the stopcock to withdraw laboratory samples or “pump
through the needle and applying the needle guard immediately out” the ascitic fluid into a nonsterile container. Remove the cath-
after the needle is withdrawn from the skin. Another disadvantage eter once the procedure is completed. Apply a bandage to the skin
is that the contaminated needle must be handled to some extent, puncture site.
creating a potential risk for needle-stick injuries.
US ASSISTED AND GUIDED PARACENTESIS
CATHETER-OVER-THE-NEEDLE TECHNIQUE The use of US increases the success rates for performing a para-
The catheter-over-the-needle systems are most commonly used for centesis and decreases complications.22 US may be used to assist
peripheral venous access. The infusion catheter fits closely over a or guide the paracentesis. A static technique is used to identify the
hypodermic needle. The needle and the catheter are advanced as skin puncture site and ascitic fluid location. The remainder of the
a unit into the peritoneal cavity. They are inexpensive, come in a procedure is “blind” using one of the above-described techniques.
variety of diameters and lengths, and are widely available. Versions If ascites is not aspirated, the US probe can be placed back on
designed to minimize accidental needle-stick injuries are available, the abdomen to locate the needle and determine if it is off target
and their use is encouraged (Figure 47-7B). Placement of these or not long enough to reach the peritoneal cavity. Occasionally,
catheters is usually quick and simple. Consider using a Caldwell a dynamic technique is used and the needle inserted using
needle with fenestrations on the side to help minimize problems real-time US.
with the flow of fluid. Position the patient. Clean and prep the skin. Scan longitudinally
Choose the puncture site and prepare the patient for the pro- and transversely with the US probe to survey each potential nee-
cedure. Insert the catheter-over-the-needle through the skin in a dle entry site (Figure 65-8). Ascites appears anechoic (black) and
Z-tract manner and into the peritoneal cavity (Figure 65-7A). A outlines the loops of bowel (Figure 65-9). The bowel may be seen
FIGURE 65-7. The catheter-over-the-needle technique.

A. The catheter-over-the-needle is inserted into the peri-
toneal cavity while maintaining negative pressure on the
syringe. B. The needle and syringe are removed. C. A syringe
is attached to the catheter. The aspiration of ascitic fluid con-
firms proper intraperitoneal placement of the catheter.
FIGURE 65-8. The patient is positioned and being surveyed for the location of
ascitic fluid.
undulating in the ascites as a result of peristalsis. Without ascites,

individual loops of bowel cannot be visualized.
Note the amount of fluid and the presence of any structure that
might make a particular site undesirable. If no site seems suitable,
try repositioning the patient. Note the depth from the skin surface
to the fluid. Choose a site with the most fluid at the least depth.
Position the US probe so that the target is in the middle of the US
view screen. The entry site will now be under the center of the probe.
Mark the skin, wipe off the US gel, re-prep the area, and proceed
with the procedure. If difficulties are encountered, use the probe to
determine the needle’s location (Figure 65-10).
Do not mistake a cystic fluid collection or the bladder for asci-
tes. Ascites will outline individual bowel loops and appears in many
places around the abdomen. Fluid in a cyst or the bladder has FIGURE 65-10. The needle (arrows) is inserted through the abdominal wall and
into the free fluid.
rounded borders and is localized. Loculated ascites will occasionally

mimic a cyst but will still outline the bowel.
AFTERCARE
Once the procedure is completed, the puncture site should be ban-
daged. The site will occasionally ooze fluid in patients with tense
ascites. These patients should be directed to change their dressings
regularly. Occlusive tape can be helpful in preventing the fluid from
leaking onto the patient’s clothing and bedding. At times, a simple
mattress or figure-of-eight suture is necessary to control the drain-
age. More recently, Emergency Physicians have used a tissue adhe-
sive such as Dermabond, Indermil, or Histoacryl to help control a
fluid leak. The patient may be discharged home if the purpose of the
paracentesis was to relieve tense ascites and no signs or symptoms of
spontaneous bacterial peritonitis exist and the fluid analysis is unre-
markable. The patient should immediately return to the Emergency
Department if they develop abdominal pain, nausea, vomiting,
abdominal distention, or a fever.
The patient will require hospitalization and intravenous anti-
biotics if spontaneous bacterial peritonitis is suspected or diag-
FIGURE 65-9. The presence of anechoic free fluid (FF) allows the individual bowel nosed. Empiric antibiotics that cover gram-negative enterics (of
loops to be discerned. which Escherichia coli is the most likely) and streptococcal species
(including Enterococcus) should be administered in the Emergency TABLE 65-1 Laboratory Tests for Ascitic Fluid
Department. A third-generation cephalosporin, such as cefotaxime,
Recommended Optional Unusual
covers the most common causative agents in this disorder and
should be administered.9 Ampicillin may be added if Enterococcus is Cell count Total protein Acid-fast smear and culture
Albumin Glucose Cytology
suspected. Check previous culture results for antibiotic sensitivities
Cultures LDH Triglycerides
if the patient has a history of spontaneous bacterial peritonitis. pH Amylase
Gram’s stain
COMPLICATIONS
Complications from abdominal paracentesis are infrequent and
rarely serious. However, known complications include shearing of The serum-ascites albumin gradient is approximately 97% accurate
the peritoneal catheter, abdominal wall hematoma, hemoperito- in indicating portal hypertension.5,21 The gradient is calculated by
neum, bowel perforation, infection, persistent ascitic fluid leak, and subtracting the ascitic fluid albumin concentration from the simul-
systemic hemodynamic compromise. taneously measured serum albumin concentration. A gradient of
Although bleeding is a potential complication of paracentesis, ≥1.1 g/dL suggests portal hypertension as the etiology of the ascites
administration of prophylactic blood products such as fresh fro- (Table 65-2). A gradient of <1.1 g/dL suggests that the patient does
zen plasma does not appear to be warranted.16 Spontaneous hemo- not have portal hypertension and that the ascites has some other
peritoneum secondary to mesenteric variceal bleeding has been etiology (Table 65-2).
reported to occur in patients receiving large-volume (i.e., >4000 mL) Peritoneal carcinomatosis should be suspected and cytology
paracentesis.17 Patients who developed this complication have had ordered in those patients with a history of breast cancer, colon
advanced cirrhosis with refractory ascites, previous large-volume cancer, gastric cancer, pancreatic cancer, or the suspicion of undi-
paracentesis, and hemorrhagic shock without evidence of gastro- agnosed malignancy and ascites. Cultures for mycobacteria are
intestinal bleeding. Mortality for this complication is exceedingly approximately 50% sensitive. They should be ordered when the sus-
high. An additional vascular complication, an inferior epigastric picion for tuberculous peritonitis is high, as in patients who have
artery pseudoaneurysm, has been described as a result of a thera- immigrated from endemic areas or have an immunocompromised
peutic paracentesis.18 status.
Perforation of the bowel during paracentesis is rare. Additionally, Patients with uncomplicated ascites secondary to cirrhosis should
most of these injuries are self-sealing and develop no further prob- have an ascitic fluid WBC count < 500 cells/mm3. The cells should
lems. Generalized peritonitis and abdominal wall abscesses have be predominantly lymphocytes and there should be no clinical evi-
also been reported and are exceedingly rare. Do not move the needle dence of peritonitis. If an infection is suspected, a WBC count of
when it is within the peritoneal cavity in order to avoid lacerating >250 cells/mm3 with greater than 50% polymorphonuclear leuko-
the bowel wall. cytes confirms spontaneous bacterial peritonitis. In order to adjust
Ascitic fluid may continue to leak from the site of paracentesis. for significant blood in a specimen (RBC > 10,000 cells/mm3),
A simple suture at the site may correct the problem. Patients with subtract one neutrophil per 250 RBC.9 A Gram’s stain is usually
persistent leaks should also be evaluated for peritonitis. not helpful other than in the case of spontaneous bowel rupture.
Rapid removal of significant amounts of ascitic fluid has been Otherwise, the concentration of bacteria is too low to justify utili-
found to cause hemodynamic compromise. Initially, removal of zation of a Gram’s stain. All potentially infected ascitic fluid should
large amounts of ascites causes improvement in circulatory func- be cultured by directly inoculating blood culture bottles at the
tion, likely related to both mechanical (i.e., improved cardiac venous bedside.15,23
return) and neurohumoral factors. However, total paracentesis in
cirrhotic patients may cause delayed (i.e., >12 to 24 hours postpro-
cedure) effective hypovolemia by accentuation of baseline arteriolar
SUMMARY
vasodilation through neurohumoral mechanisms.19 The literature Paracentesis is a safe procedure that is common in the practice of
suggests that some of the postparacentesis circulatory dysfunction Emergency Medicine. There are few relative contraindications to
may be avoided by pretreating patients with an intravenous colloid its performance. It is most commonly performed diagnostically to
such as albumin.20 This is not a universally accepted practice. detect spontaneous bacterial peritonitis. It can also be performed
therapeutically for symptomatic relief in patients with tense ascites.
ASCITIC FLUID ANALYSIS Complications, although they do occur, are rare.
Normal ascitic fluid should appear clear with a yellow color.
Increased turbidity may suggest infection, elevated triglycer-
ide levels, or other particulate matter. Sanguinous fluid is present TABLE 65-2 Classification of Ascites by the Serum to Ascites
in patients with malignancy, intraperitoneal bleeding from the Albumin Concentration Gradient
intraabdominal organs (spontaneous or iatrogenically introduced), High gradient (≥1.1 g/dL) Low gradient (<1.1 g/dL)
or tuberculous peritonitis. Cirrhosis Peritoneal carcinomatosis
The specific analytical tests ordered on ascitic fluid should reflect Alcoholic hepatitis Tuberculous peritonitis
the Emergency Physician’s clinical suspicion (Table 65-1). Simple Cardiac ascites Pancreatic ascites
analysis of fluid with a cell count and differential, routine cultures, Massive liver metastases Nephrotic syndrome
and albumin concentration are all that is necessary in patients with Fulminant hepatic failure Serositis in connective tissue diseases
uncomplicated cirrhosis. These initial tests can be supplemented Budd–Chiari syndrome
depending upon clinical suspicion. An ascitic fluid pH <7.35 and Portal vein thrombosis
a blood–ascitic fluid pH gradient ≥ 0.10 can aid in the diagnosis Venoocclusive disease
of spontaneous bacterial peritonitis.7 Total protein, glucose, LDH, Fatty liver of pregnancy
amylase, triglyceride, and bilirubin levels are not helpful except Myxedema
in select circumstances and are not warranted on a routine basis. Mixed ascites
CHAPTER 66: Diagnostic Peritoneal Lavage 431
the sensitivity and specificity of a DPL for the diagnosis of signifi-

Diagnostic cant penetrating intraabdominal injury. While the DPL was first
66 Peritoneal Lavage described for blunt abdominal trauma, it has found an indication in
the patient with penetrating abdominal trauma.2 Initial attempts to
quantify the effluent based on its appearance have been replaced by
Sandeep Johar and Umashankar Lakshmanadoss
the red blood cell (RBC) count, the white blood cell (WBC) count,
and the measurement of various enzymes.9–11 The debate still rages
INTRODUCTION in the literature as to which criterion best determines the need for
The diagnostic peritoneal lavage (DPL) was first described in a laparotomy.
1965 by Root who described a method for sampling the peritoneal
cavity to determine more rapidly the presence of a hemoperitoneum ANATOMY AND PATHOPHYSIOLOGY
after trauma.1 The initial physical examination can be misleading in
up to 45% of blunt trauma patients.2 A DPL can be useful in diag- The gross anatomy of the abdomen is well known to Emergency
nosing abdominal injury in a timely fashion.2 It is performed less Physicians and is important to review when preparing for a DPL.
frequently today due to the use of focused abdominal sonography The abdominal cavity is lined by the peritoneum and is protected
for trauma (FAST) bedside ultrasound scanning and helical com- from the environment by the abdominal wall musculature, fat,
puted tomography (CT). The DPL is the only invasive test of the and skin. The right and left rectus muscles, which are nourished
three and remains the most sensitive test for mesenteric and hollow by the epigastric vessels, meet in the midline at the avascular
viscus injuries.3,4 linea alba. The umbilicus is located along the lower portion of the
Dr. Root’s description of the DPL represented an improvement linea alba. The layers of the anterior abdominal wall structures
upon the use of paracentesis to identify a hemoperitoneum as vary above and below the level of the anterior superior iliac spine
described by Salomon in 1906.5 His initial description of a DPL uti- (Figure 66-1).
lized a trocar placed into the peritoneal cavity to instill fluid. The DPL, unlike a paracentesis, is always performed in the anterior
fluid was visually inspected upon removal and the patient then midline of the abdomen (Figure 66-2). The linea alba is an avas-
underwent a laparotomy if it appeared bloody. cular location through which the peritoneal cavity may be entered
DPL has undergone several modifications since its initial descrip- using either an open technique or a closed Seldinger type technique.
tion. The trochar technique was abandoned first in favor of the open This midline location minimizes the number of false-positive
technique, and later the Seldinger or closed technique.7,8 A novel lavages that occur due to bleeding from the abdominal wall muscles
method which combines the use of diagnostic laparoscopy and DPL or blood vessels. This also allows the Surgeon to perform a midline
has been termed laparoscopic diagnostic peritoneal lavage (L-DPL).6 laparotomy, if necessary, through the lavage site and avoid the for-
This procedure combines the visual advantages of laparoscopy with mation of an avascular skin bridge.
A Midline
Lateral
Skin
Subcutaneous fat
Linea alba
Extraperitoneal fat Internal oblique muscle

Peritoneum
Abdominal cavity
B Midline
Lateral
Skin
Subcutaneous fat
Linea alba
Extraperitoneal fat
Peritoneum Internal oblique muscle

Abdominal cavity
FIGURE 66-1. The layers of the anterior abdominal wall vary above (A) and below (B) the level of the anterior superior iliac spine.
surgery, the DPL should be performed using an open technique to

avoid any adhesions and minimize complications.13
INDICATIONS
A DPL is indicated in any patient with suspected abdominal
trauma, blunt or penetrating, that does not have an obvious indi-
cation for a laparotomy and in whom serial physical examina-
tions are not practical. It can be performed quickly, will reliably
exclude significant intraabdominal trauma, and allow the diagno-
sis and treatment of associated injuries. It does not require transfer
of the patient out of the monitored environment of the Emergency
Department, as does a CT scan. It likewise does not require sophis-
ticated equipment and extensive training comparable to those
required to perform abdominal ultrasonography.
A DPL is especially useful in patients with an unreliable or equiv-
ocal abdominal examination and those who will be unavailable for
serial physical examinations. The patient with an altered mental
status (e.g., alcohol, drugs, head injury, etc.) or abnormal sensation
due to a spinal cord injury is considered to have an unreliable physi-
cal examination.7,11,14 Patients may have an equivocal examination
due to tenderness from surrounding fractures of the ribs, spine, or
pelvis.11,13 They may also have tenderness over the wound or an area
of injury that is difficult to distinguish from peritonitis. The third
group of patients who may benefit are those that undergo surgery
for another injury, such as a neurosurgical or an orthopedic proce-
dure.14 These patients are unavailable for serial examinations while
in the operating room. Their examination may be altered postop-
eratively as well due to the analgesics that they receive.
FIGURE 66-2. The preferred sites to perform a DPL. A. The midline and approxi- DPL may be useful in the occasional circumstance when the
mately 1 to 2 cm below the umbilicus is the location for a closed DPL. B. A midline patient presents in shock with other potential sources of hemor-
incision beginning 1 to 2 cm below the umbilicus and extending inferiorly for 5 rhage, such as intrathoracic or retroperitoneal bleeding. It may con-
to 6 cm is the location for semi-open and select open DPLs. C. A midline incision firm or rule out the abdomen as the source of the patient’s bleeding
beginning 2 cm above the umbilicus and extending superiorly for 5 to 6 cm is the and shock.7 It is important to remember that an injury confined
location for most open DPLs. to the retroperitoneum will not result in a positive DPL.15
CONTRAINDICATIONS
Most DPLs may be safely performed 1 to 2 cm below the umbi- The only absolute contraindication to performing a DPL is if the
licus (Figures 66-2A & B). This location allows the DPL catheter patient has an obvious indication for a laparotomy. Patients who
to be directed into the pelvis, minimizes the occurrence of inad- present following abdominal trauma who are in shock, have perito-
vertent vascular injury, and increases the likelihood that fluid will nitis, pneumoperitoneum on chest radiography, evisceration, blood
be sampled from a dependent portion of the abdomen. It is more per orifice, or a retained stabbing implement have obvious indica-
difficult to retrieve fluid if the DPL is performed above the umbi- tions for a laparotomy.
licus due to interference from the omentum. All closed and semi- Several relative contraindications to DPL do exist. These actually
open DPLs, as well as many open DPLs, are performed below the represent contraindications to performing the closed technique.
umbilicus. Patients with a pelvic fracture may have a large retroperitoneal
The resultant retroperitoneal hematoma in patients with a pelvic hematoma that extends anteriorly to the linea semilunares. The DPL
fracture may extend anteriorly to the level of the linea semilunaris. may be performed using the open technique above the umbilicus to
Therefore, it is important to perform the DPL in patients with avoid decompression of the hematoma.12 Pregnant patients should
a pelvic fracture using an open technique above the umbilicus not have a closed DPL performed because of the risk of injury to the
(Figure 66-2C). This will avoid a false-positive DPL and the inad- uterus. It is safe, however, to perform an open DPL above the uter-
vertent decompression of the hematoma.12 ine fundus.7 Patients with evidence of previous abdominal surgery
Another special situation occurs in the pregnant patient. The may have adhesions of the viscera to the abdominal wall that make
DPL should be performed using an open technique superior to intraabdominal injury more likely to result when a closed DPL is
the uterine fundus.7 It may be performed below the umbilicus if performed.1,9 An open technique may be performed in a location
the patient is in an early stage of pregnancy. The DPL should be away from the scar.13 One must recognize, however, that compart-
performed more cephalad as the pregnancy progresses to minimize mentalization of the abdomen may have occurred due to intra-
the chance of injuring the gravid uterus. peritoneal adhesions, thus making it more likely to have a falsely
The third situation that may necessitate a change in the location negative DPL result.
to perform the DPL is in the patient with previous abdominal sur- The DPL should be performed using the open technique in
gery. These patients must be individualized based upon the loca- patients who are unable to have a Foley catheter placed due to ure-
tion of their scar. The DPL should be performed supraumbilically thral injury or stricture. This minimizes the chance of inadvertent
if the patient has a lower abdominal scar and infraumbilically if injury to the bladder. Morbid obesity is a relative contraindication
the patient has an upper abdominal scar.1,9 In all cases of previous to closed DPL. This represents a difficulty in technically performing
the DPL when the abdominal wall is thicker than the 2.5 in. long
locator needle. It is useful to perform the DPL in these patients
using a semi-open technique.16 Preexisting coagulopathy is also a
relative contraindication.
EQUIPMENT
Closed Technique
• Face mask
• Sterile gloves
• Sterile gown
• Purple top blood collection tube
• 5 mL syringes FIGURE 66-3. Midsagittal section through the abdomen and pelvis demonstrating
decompression of the stomach with a nasogastric tube and decompression of the
• 18 gauge needles bladder with a Foley catheter.
• Foley catheter These organs require decompression prior to performing a DPL
• 1 L of IV fluid to infuse, 0.9% NaCl or lactated Ringer solution (Figure 66-3). Decompress the stomach using a nasogastric or oro-
• Commercial Peritoneal Lavage Kit (e.g., Arrow AK-0900) gastric tube.14,17 Refer to Chapter 58 regarding the details of nasogas-
tric tube insertion. Decompress the bladder using a Foley catheter
Semi-Open or Open Technique once a urethral injury has been ruled out.7,8,14,17 Refer to Chapters
• All items listed above 142 and 145 regarding the details of urethral catheterization and
• Razor evaluation of a urethral injury.
Prepare the abdomen.14 Shave the area surrounding the inci-
• #10 scalpel blade on a handle sion site if an open or semi-open DPL is to be performed. Clean
• Abdominal skin retractors, Weitlaner or skin rakes the skin of any dirt, debris, and blood. Apply povidone iodine or
• Two tissue forceps chlorhexidine solution and allow it to dry. Apply sterile drapes to
• Two Allis clamps delineate a sterile field. Each healthcare provider who is involved
in the procedure should don a face mask, a sterile gown, and sterile
• Four hemostats gloves.14
• Needle driver
• Suture for vessel ligation (4-0 Vicryl, 4-0 Dexon, or 4-0 chromic) TECHNIQUES
• Suture for fascial closure (0 Vicryl, 0 Dexon, 0 Maxon, or A DPL is performed one of three different ways.18,19 The open tech-
0 Prolene) nique utilizes a vertical infraumbilical incision and direct visualiza-
• 4-0 nylon suture or skin stapler for skin closure tion of the peritoneal cavity before inserting the catheter. The closed
• Suture scissors technique relies on percutaneous needle access to the peritoneal
cavity, followed by the insertion of a catheter using the Seldinger
A commercially available, disposable, and single-patient use peri- technique. The semi-open technique follows the same principles of
toneal lavage kit is available from numerous manufacturers. The kit the open technique except that the midline fascia is penetrated with
includes all the material required to perform a closed DPL except a needle and the catheter is advanced using the Seldinger technique.
lavage fluid. An example is the Arrow kit (Arrow International, There is no difference in overall outcomes or rates of injury to vis-
Reading, PA). It contains 10% povidone iodine swabs, gauze squares, ceral contents between the three techniques.20–24
a fenestrated drape, IV fluid administration tubing, 1% lidocaine,
5 mL syringes, 22 and 25 gauge needles, an 18 gauge × 2.5 in. intro- PERCUTANEOUS (CLOSED) TECHNIQUE
ducer needle, an 0.89 mm × 45 cm J-tipped guidewire, an 8 French
lavage catheter, and a #11 scalpel blade on a handle. The closed technique is the preferred method unless contraindica-
tions exist (Figure 66-4). The closed DPL can be performed in a
PATIENT PREPARATION significantly shorter time than the open technique.23,24 There is no
difference in the amount of fluid retrieved from the abdomen, the
Explain the procedure, its risks, and benefits to the patient and/or diagnostic accuracy, or the complication rate between the closed
their representative. This should include the possible complications. and open techniques.23
Informed consent should be obtained from the patient or from the The closed DPL is performed in the midline and approximately
family if the patient is unable to consent due to age or mental status. 1 to 2 cm below the umbilicus (Figure 66-2A).17 Prepare the patient
The consent process should not unduly delay the performance of as described previously. Infiltrate the skin, subcutaneous tissue, and
the DPL in an unstable patient. fascia with local anesthetic solution. Place the 2.5 in. introducer
Place the patient in the supine position. A distended stomach needle onto a 5 mL syringe. Insert the needle in the midline and 1 to
or bladder may be inadvertently perforated during the procedure. 2 cm below the umbilicus. Advance the needle at a 45° angle and
FIGURE 66-4. The percutaneous or closed DPL technique. A. The introducer needle is advanced caudally and at a 45° angle to the skin of the abdominal wall while
negative pressure is applied to the syringe. B. The syringe has been removed and the guidewire is inserted through the introducer needle. C. The introducer needle is
withdrawn over the guidewire, leaving the guidewire in place. D. A small nick is made in the skin and subcutaneous tissue adjacent to the guidewire using a #11 scalpel
blade. E. The lavage catheter is placed over the guidewire. F. The lavage catheter is advanced over the guidewire and into the peritoneal cavity. A twisting motion may aid
in the advancement of the catheter. G. The guidewire is removed, leaving the lavage catheter in place.
direct it into the pelvis (Figure 66-4A). Apply negative pressure to if the patient has a massive hemoperitoneum. This is considered a
the syringe as it is advanced. Three “pops” are felt as the needle pen- positive tap and concludes the procedure.
etrates the skin, fascia, and peritoneum. After the third pop, slowly Continue the procedure if no blood is aspirated into the
advance the needle another 2 to 3 mm while maintaining negative syringe. Stabilize the introducer needle with one hand at the level
pressure on the syringe. A flash of blood will be seen in the syringe of the abdominal wall and remove the syringe. Do not allow the
introducer needle to move as it may lacerate the intraabdominal

organs. Insert the guidewire through the introducer needle until
only 7 to 10 cm of the guidewire remains outside of the hub of the
needle (Figure 66-4B). The guidewire should advance through the
needle easily with only minimal resistance. Difficulty in advancing
the guidewire or the patient complaining of pain requires removal
of the guidewire and introducer needle as a unit. Never withdraw
the guidewire through the introducer needle. The tip of the intro-
ducer needle can shear off the guidewire resulting in a piece of the
guidewire in the peritoneal cavity and necessitating an operative pro-
cedure. Reinsert the introducer needle and restart the procedure.
Stabilize the guidewire and withdraw the introducer needle over
the guidewire (Figure 66-4C). Make a small incision in the skin and
subcutaneous tissue alongside the guidewire with a #11 scalpel blade
to facilitate passage of the lavage catheter (Figure 66-4D). This inci-
sion should be no more than 5 mm in length. It is important not to
incise the skin until the operator is sure that the guidewire is within
the peritoneal cavity. Making the skin incision prior to inserting the
guidewire may result in unnecessary skin incisions if the introducer
needle is placed at another location.
Place the lavage catheter over the guidewire (Figure 66-4E).
Advance the lavage catheter into the peritoneal cavity (Figure 66-4F).
It may be helpful to twist the catheter as it passes through the fascia
to aid in inserting it into the peritoneal cavity. Advance the cath-
eter until its hub is against the abdominal wall in the adult patient.
Securely hold the hub of the lavage catheter. Remove the guidewire
(Figure 66-4G). Attach a 5 to 10 mL syringe to the hub of the lavage
catheter. Apply negative pressure to the syringe. Note if any blood is
aspirated. The aspiration of blood is not considered to be a positive
tap and the procedure should continue.
The presence of gross blood upon entering the peritoneal cavity
should be considered an indication for laparotomy. Likewise, blood
obtained through the introducer needle is considered a positive
peritoneal tap and represents blood throughout the peritoneum.
Confusion exists, however, when blood is withdrawn through the
lavage catheter (peritoneal aspirate). Because the catheter has been
directed into the most dependent portion of the peritoneal cavity,
the pelvis, a small amount of blood withdrawn through the cath-
eter may represent the only blood present within the abdomen.
This does not indicate that the patient is intrinsically unstable. The
patient does not require a laparotomy if the subsequent lavage is
negative.14 Therefore, while the aspiration of blood through the
introducer needle (positive tap) does require a trip to the Operating
Room, aspiration of blood through the catheter (positive aspirate)
means nothing and is not a reason to terminate the procedure.
Continue the procedure. Pass the proximal end of the IV tubing to
a nonsterile assistant to insert into a bag of IV fluid (i.e., 0.9% NaCl
or Ringer lactate) and prime the tubing. Warmed IV fluid is prefer-
able to room temperature fluid, if available. Attach the distal end of
the IV tubing to the lavage catheter (Figure 66-5A). Open the clamp
on the IV tubing and allow the lavage fluid to flow freely into the
peritoneal cavity (Figure 66-5A). The lavage catheter may not be FIGURE 66-5. The instillation and removal of lavage fluid. A. The bag of IV fluid is
within the peritoneal cavity if the lavage fluid does not flow quickly attached to the lavage catheter using IV tubing. The bag of fluid is then suspended
but seems to drip in slowly. Reassess the catheter position. If nec- and allowed to infuse into the peritoneal cavity. B. The IV bag is placed on the floor
essary, remove and reinsert the lavage catheter. Infuse 1 L in the to allow the lavage fluid to exit the peritoneal cavity and flow back into the bag.
adult patient and 10 to 20 mL/kg (maximum 1 L) in the pediatric
patient.8,13 Stabilize the catheter with one hand during the infusion
of the lavage fluid.
After the lavage fluid has been instilled, place the IV bag on
the floor to allow the fluid to flow out from the peritoneal cavity may need to be withdrawn slightly and reinserted. These maneuvers
(Figure 66-5B). There should be a steady rate of flow. Diminution may help to dislodge the omentum. If manipulation of the catheter
of flow usually results from the omentum blocking the side holes does not improve flow, a second liter of fluid may be infused (addi-
of the lavage catheter. Firm palpation of the patient’s abdomen may tional 10 mL/kg in children). If this becomes necessary, the thresh-
increase the flow rate if it seems to drop off. The lavage catheter old for a positive DPL must be halved (i.e., down from 100,000 to
50,000 RBC/mm3 in blunt trauma); as twice the fluid is infused and abdominal wall is thicker (>2.5 in.) than the length of the intro-
results in a halving of the RBC count. ducer needle. The procedure often begins as a closed technique and
At least 200 to 250 mL of lavage fluid should be returned from is converted to a semi-open technique once it is realized that the
the peritoneal cavity to result in a reliable cell count.24–26 This fluid introducer needle is not long enough to enter the peritoneal cavity.
is referred to as the effluent. Place a new lavage catheter if less It is a modification of both the closed and open techniques.16
than 200 to 250 mL of effluent is obtained after the manipulations Prepare the patient and begin the procedure as if performing the
described above.8 Remove the existing lavage catheter while main- open technique. Make the midline incision and retract the tissues
taining the sterility of the distal end of the IV tubing. Place a second (Figures 66-6A & B). Identify the interdigitations of the fascia in the
lavage catheter 1 cm inferior to the site of the first lavage catheter. midline. Place the introducer needle on a 5 mL syringe. Insert the
Reconnect the IV tubing and place the IV bag to gravity drainage to introducer needle through the midline and at a 45° angle directed
obtain the effluent. toward the pelvis (Figure 66-4A). Apply negative pressure to the
Remove the lavage catheter after obtaining as much effluent as syringe while advancing the needle. A pop will be felt as the intro-
possible from the peritoneal cavity. Place a small gauze dressing ducer needle penetrates the peritoneum. The remainder of the
over the skin puncture site and remove the drapes. Transfer a small procedure is as described above under the percutaneous or closed
aliquot of the lavage effluent to a purple top blood collection tube. technique.
Transport the tube to the laboratory for a cell count. The remainder Remove the lavage catheter after obtaining as much lavage fluid as
of the lavage effluent may be discarded or reserved for subsequent possible from the peritoneal cavity. Inspect the edges of the incision
testing. for any bleeding blood vessels. Obtain hemostasis of the subcuta-
neous tissue by ligating small vessels with absorbable suture. Close
OPEN TECHNIQUE the skin using interrupted 4-0 nylon sutures or skin staples. Place a
gauze dressing over the skin incision site. Remove the drapes.
Prepare the patient as described previously. Infiltrate the skin, sub-
cutaneous tissue, and fascia with a local anesthetic solution in the
area where the incision is to be made. Begin the incision 2 cm below
LAPAROSCOPIC DPL
the umbilicus and extend it 5 to 6 cm inferiorly in patients who have The technique of laparoscopic DPL (L-DPL) should be considered
an upper abdominal scar (Figure 66-2B). Begin the incision 2 cm in hemodynamically stable patients with penetrating lower thoracic
above the umbilicus and extend it 5 to 6 cm superiorly in patients or abdominal stab wounds.6 It is especially applicable for Trauma
with a pelvic fracture or lower abdominal scar (Figure 66-2C). Make Surgeons with only basic experience in laparoscopic techniques.
the incision in the midline above the uterine fundus in patients who The procedure is used to obtain conclusive evidence of significant
are pregnant. intraabdominal injury, confirm peritoneal penetration, control
Incise the skin and subcutaneous tissue longitudinally for a dis- intraabdominal bleeding, and repair lacerations to the diaphragm
tance of 5 to 6 cm in the midline (Figure 66-6A). The incision may and abdominal wall. The combination of laparoscopy and DPL adds
need to be longer in an obese patient. Clamp and ligate any small to the sensitivity and specificity of DPL and avoids under or over
vessels that are bleeding with absorbable suture prior to incising sensitivity, which has limited the use of DPL in the hemodynami-
the fascia. This will minimize the incidence of false-positive lavage cally stable trauma patients with suspicious or proven peritoneal
results. Retract the skin and subcutaneous tissues with a Weitlaner penetration.
retractor or skin rakes to aid in viewing the fascia (Figure 66-6B).
The fascial midline may be identified by the interdigitation of its ANALYSIS OF PERITONEAL LAVAGE FLUID
fibers (Figure 66-6B). Carefully incise the fascia longitudinally
along the length of the previous skin incision (Figure 66-6C). There are several laboratory evaluations that can be performed on
Identify the peritoneum. Any preperitoneal fat that is present can the lavage effluent to determine whether the patient requires a lapa-
be gently moved aside by an assistant using either a forceps or rotomy.39 Gross evidence of injury exists when there is a positive
gauze. Grasp and elevate the peritoneum using two Allis clamps peritoneal tap (i.e., gross blood obtained either through the intro-
(Figure 66-6D). Use extreme care to ensure that no bowel is ducer needle or noted upon opening the peritoneum during the
included in the clamps. open DPL), bile stained peritoneal fluid is noted, or enteric contents
Make a small (<5 mm) incision in the peritoneum. Insert the are seen in the effluent.9,27 The most commonly used laboratory
lavage catheter through the incision and directed caudally into determination is that of the erythrocyte or RBC count. Other deter-
the pelvis (Figure 66-6E).7 The remainder of the procedure is as minations include the leukocyte count and the presence of amylase
described above in the percutaneous (closed) technique. It may be in the lavage effluent.
necessary to gently retract the peritoneum upward with the Allis Peritoneal lavage was first described as utilizing visual inspection
clamps to prevent leakage of the lavage fluid around the catheter. of fluid for the presence of blood.1,3,9 This has been subsequently
Remove the lavage catheter and Allis clamps after obtaining as shown to be very inaccurate, even when performed by experienced
much effluent as possible from the peritoneal cavity. It is not nec- physicians.28 A much better method of quantification of the pres-
essary to suture the peritoneum. Close the fascia with # 0 Maxon, ence of blood utilizes the counting of erythrocytes, done either
Prolene, Vicryl, or Dexon suture in a running fashion. Inspect the manually or with an automated cell counter.
edges of the incision for any bleeding blood vessels. Obtain hemo- A positive DPL in an adult classically requires one of the follow-
stasis of the subcutaneous tissue by ligating small vessels with ing results: 10 mL of gross blood on initial aspiration, greater than
absorbable suture. Close the skin with interrupted 4-0 nylon sutures 500/mm3 RBCs, greater than 100,000/mm3 WBCs, or the pres-
or skin staples. Place a gauze dressing over the incision site. Remove ence of enteric contents or food matter. The RBC count thresh-
the drapes. old can be adjusted from 100,000 RBC/mm3 in patients who have
sustained blunt trauma or an anterior abdominal stab wound, to
SEMI-OPEN TECHNIQUE a lower 10,000 RBC/mm3 in patients who may have suffered pen-
etration of the abdominal cavity. Both counts appear to be very
This technique is used primarily for patients in whom there is no sensitive, specific, and accurate at diagnosing either injury or
contraindication to the performance of a closed lavage and their penetration.29
FIGURE 66-6. The open DPL. A. An incision is made in the skin and subcutaneous tissues. B. The skin and subcutaneous tissues are retracted. Note the interdigitation of
the fibers of the fascia in the midline. C. An incision is made in the fascia. D. The peritoneum is grasped and elevated with Allis clamps. E. The lavage catheter is inserted
through a small incision (<5 mm) in the peritoneum.
In blunt abdominal trauma, 100,000 RBCs/mm3 is the most diaphragm, organs that may not bleed enough to result in a positive
commonly used threshold for a laparotomy.7,11,27 This corresponds lavage.
roughly to the presence of 20 mL of blood in the peritoneal cavity. Penetrating trauma, on the other hand, has no universally agreed
Using the count of 100,000 RBCs/mm3 to determine the presence upon threshold for a laparotomy. Documentation of penetration of
of a hemoperitoneum provides a sensitivity of 97%, a specificity of the peritoneal cavity is felt to be an indication for laparotomy in all
99.6%, and an accuracy of 99%.11 The false positives that occur are gunshot wounds and most stab wounds to the abdomen. Penetration
usually the result of bleeding from the lavage site. False-negative of the peritoneum by a gunshot wound results in a significant intra-
DPLs usually result in RBC counts in the mid-10,000s, which some peritoneal injury in 98% of cases.30 Therefore, DPL to prove abdom-
authors refer to as indeterminate.7 The injuries that are missed by a inal penetration is useful in cases of potentially tangential gunshot
count of 100,000 RBCs/mm3 are injuries to hollow viscera and the wounds.15,32 Likewise, penetration into the peritoneal cavity from a
thoracoabdominal wound results, by definition, in a diaphragmatic in 7 to 10 days for removal of the skin sutures or staples. No evi-
injury that should be repaired.17,33 Penetration through the retro- dence exists supporting the use of prophylactic antibiotics.
peritoneum, from the back or flank, will cause a significant injury in
73% of cases.15,25 Therefore, DPL is useful in these wounds as well. COMPLICATIONS
Penetration of the peritoneal cavity may not bleed enough to result
in a 100,000 RBCs/mm3 count. Most authors believe that a lower The complication rate for a DPL is relatively low. It varies between
RBC count should be used. Unfortunately, there is little consensus 0.6% and 2.3%.13,38 There is no difference in complication rates
as to what that count should be. between the three techniques.20–24 The complications may be classi-
The RBC count varies from 1000 to 50,000 RBCs/mm3 as a fied as wound-related or puncture-related.
threshold for laparotomy in penetrating trauma.11,15,24,33–35 The Wound-related complications occur primarily with open or semi-
higher the count that is used, the more likely there will be a missed open lavage techniques. Inadequate hemostasis during performance
injury with an increased false-negative rate.11,14,17 The lower the of the DPL may result in bleeding and a hematoma formation at
count that is used, the more likely that a negative laparotomy will the wound site.7,13,38 As with any surgical procedure, there is a risk
result with an increased false-positive rate.11,14,17 A threshold of of wound infection at the lavage site.7 This infection is usually due
10,000 RBCs/mm3 provides the most acceptable balance between to skin flora and may be treated simply by opening the wound and
false-negative and false-positive results.17,31,32 This threshold results performing twice daily wet-to-dry dressing changes.
in a sensitivity of 88% to 99%, a specificity of 97% to 98%, and an Puncture-related complications may occur after any DPL tech-
accuracy of 95% to 98%.14,17,32 nique. Virtually any organ within the abdominal cavity may be
A special case of penetrating abdominal trauma exists when punctured by the introducer needle, the guidewire, or the lavage
there is a stab wound to the anterior abdomen. We know that catheter. Puncture of the bladder and stomach may be avoided by
only two-thirds of these wounds will penetrate the peritoneum, placing a Foley catheter and nasogastric tube, respectively, prior to
and of those that penetrate, less than 50% will cause an injury that performing the DPL.14,17 A punctured bladder is usually noted by
requires repair.15 Therefore, using a lower threshold for DPL to obtaining urine during syringe aspiration or by lavage fluid exit-
determine penetration will result in a greater than 50% negative ing through the Foley catheter. Removing the lavage catheter and
laparotomy rate. For this reason, wounds to the anterior abdomen continuing Foley catheter drainage for 24 to 48 hours will treat this
are lavaged with the standard RBC count of 100,000 RBCs/mm3 complication.9 Puncture of the small bowel, colon, and their mes-
to determine injury, and not penetration, as the threshold for an enteries may also occur.7,13,14,31,38 Likewise, puncture of blood vessels
operation.36 ranging from mesenteric vessels to iliac vessels has been described.1
Many laboratories will routinely report the WBC count on the These latter complications will usually result in a positive DPL
lavage effluent. The presence of over 500 WBCs/mm3 is often quoted based on bleeding or return of enteric contents and are repaired at
as a standard indication for laparotomy.27 Unfortunately, the pres- laparotomy.
ence of an elevated lavage WBC count by itself has poor predictive Some advocate using the abdominal wound to insert the lavage
value in the trauma patient.25 Most commonly, there is an associated catheter and not making a fresh entry site.40 This cannot be rou-
elevation in the RBC count that will trigger a laparotomy. A recently tinely recommended. This can result in false-positive results from
described “cell count ratio” may help to diagnose the presence of a blood in the wound tract, the potential for infection, the wound
hollow viscus injury by comparing the WBC/RBC ratio in the lavage may be too far away that the catheter cannot reach into the pel-
effluent to the WBC/RBC ratio in the blood.37 If the lavage ratio is vic recesses, and the lavage catheter could track through injured
greater than that of blood, there is a high likelihood of hollow viscus organs.
injury. This ratio is not universally accepted. Occasionally, the lavage fluid may be instilled into the abdomi-
While the quantification of RBCs, and occasionally WBCs in the nal wall or the retroperitoneum.1,14 This may result in a false-
DPL effluent is the most common test, other laboratory tests may positive lavage, a false-negative lavage, or more commonly an
be utilized in indeterminate cases. The most commonly used is the inadequate lavage fluid return. This complication requires no spe-
determination of amylase.2,7,9 Amylase may be elevated in the pres- cific treatment other than recognition. The body will reabsorb the
ence of an injury to the gastrointestinal tract. Unfortunately, the fluid over time.
amylase level is neither sensitive nor specific.10
SUMMARY
AFTERCARE The DPL is a well-described procedure for determining the need for
The patient should be observed in the hospital for up to 24 hours a laparotomy after trauma. It has undergone several modifications
after a negative DPL. The Foley catheter and nasogastric tube may since its initial description over 45 years ago. The procedure may be
be removed if they are no longer needed for other indications. performed using a closed, semi-open, or open technique depend-
Reexamine the patient periodically during this observation period ing upon the patient’s history and associated injuries. All three tech-
for the development of peritonitis that may result from a false-neg- niques are safe, accurate, and easily performed. Several criteria may
ative lavage or a complication of the lavage procedure itself. The indicate a positive result, and knowledge of these criteria is impor-
performance of the lavage should not alter the patient’s examina- tant in the evaluation of the DPL effluent.
tion; although there may be localized wound tenderness if the Because this is an invasive procedure, it is important that it should
lavage was performed using the open or semi-open technique.1 The be performed after informed consent (if feasible) and using strict
patient should receive analgesics as needed after an open or semi- aseptic technique. There is a small risk of complications as well as
open DPL. Keep the patient NPO during the initial portion of their missed injuries necessitating the close observation of the patient
observation. They can be fed near the end of the 24 hours to insure with a negative DPL.
that they tolerate oral intake prior to discharge. The DPL remains one of the most useful tests in the patient with
Discharge instructions to the patients should instruct them to abdominal trauma.41 Despite advances in imaging technology,
return for the development of a fever, increasing abdominal pain, the DPL remains the test of choice in the patient with penetrat-
nausea, vomiting, worsening wound pain, or wound drainage. After ing abdominal trauma and in select patients with blunt abdominal
undergoing an open or semi-open DPL, the patient should be seen trauma.
CHAPTER 67: Anal Fissure Management 439
epithelium. The transitional zone lies between the two different

Anal Fissure Management types of mucosa. The anoderm is a thin layer of stratified squamous
67 Marilyn M. Hallock and Eric F. Reichman
epithelium around the anus, distal to the dentate or pectinate line,
that lacks sweat glands and hair follicles. This area is richly endowed
with cutaneous sensory nerve endings.
It is hypothesized that anal fissures usually occur in the posterior
INTRODUCTION midline secondary to a decreased vascular supply causing ischemia
or a decreased number of external sphincter muscle fibers predis-
An anal fissure, or fissure-in-ano, is one of the most common anal posing the posterior area to a weakness.9 Constipation or a hard
disorders seen by physicians. It is a linear tear or crack that extends bowel movement causes a tear in the anoderm that causes pain.
into the anoderm from the mucocutaneous junction to the dentate The tear often results in a vicious cycle of injury by exposing the
line (Figure 67-1). An anal fissure usually results from the passage of underlying internal sphincter muscle. This results in spasms of the
hard stool that traumatizes and tears the anoderm. Frequent bowel muscle, which causes severe pain, and results in further separation
movements with diarrhea can cause similar “cracks” that eventually of the fissure edges and possible further tearing during subsequent
result in fissures. Anal fissures are often seen in infants, but primar- stool passage. A delay in wound healing may result, and can ulti-
ily are a condition of young and middle-aged adults.1–3 It is the most mately lead to a chronic anal fissure.
common cause of acute onset painful rectal bleeding in adults and Ischemia may contribute to the cycle of injury. The posterior mid-
in the first year of life. line, being the primary location for anal fissures, has less than half
A fissure may be acute or chronic, occur at any age, and affect the blood flow compared to other quadrants in the anal canal.10,11
both genders equally. It is the most common cause of rectal bleeding Individuals with chronic anal fissures have higher anal pressures
in infants. Fissures are typically a few millimeters long and occur than controls or patients with other colorectal disorders due to
primarily (90%) in the posterior midline. The remaining 10% are increased internal anal sphincter tone, which results in blood flow
found in the anterior area.4–6 There is a slight gender difference reduction as well.12,13 These factors lead to the rationale for the use
with 1% to 7% of anal fissures found anteriorly in men and up to of topical nitroglycerin in treating anal fissures.
12% anteriorly in women.7 Atypical locations (e.g., lateral) suggest A tight anal sphincter is another hypothesis for the etiology of a
the presence of an underlying disease such as Crohn’s disease, anal fissure. Anal manometry in patients with fissures reveals an eleva-
cancer, previous anal surgery, leukemia, syphilis, tuberculosis, and tion of the resting anal canal pressures and infrequent spontaneous
other infections. relaxation of the internal anal sphincter muscle.13 These high pres-
sures can impede blood flow. The anodermal blood supply passes
ANATOMY AND PATHOPHYSIOLOGY through the internal anal sphincter muscle and increased resting
The anal canal begins at the level of the anorectal ring and extends pressure may result in an ischemic ulcer or fissure.
distally for 4 cm to the anal verge. The internal anal sphincter and An acute anal fissure has the appearance of a clean longitudinal
external anal sphincter muscles surround the anal canal. The inter- tear in the anoderm with minimal inflammation (Figure 67-1). A
nal anal sphincter muscle is a continuation of the involuntary layer chronic anal fissure is deeper, and exposed internal anal sphincter
of circular smooth muscle of the rectum that begins at the ano- muscle fibers may be seen at its base. A skin tag or sentinel pile is
rectal ring. It is contracted at rest so that the lower margin can be usually seen externally and a hypertrophied anal papilla may be
palpated 1 to 2 cm below the dentate line in the intersphincteric found at its upper aspect. Patients with a chronic anal fissure may
groove. The internal anal sphincter muscle supplies up to 60% of also complain of anal discharge, pruritus, or “a lump.” Many people
the resting tone of the anus.8 The external anal sphincter muscle complaining to their physicians of bright red blood per rectum and
is an elliptical cylinder of voluntary striated muscle tethered to the anal pain think they are suffering from “hemorrhoids.” A good his-
coccyx and surrounding the anal canal. Columnar epithelium lines tory and physical examination can confirm the diagnosis of an anal
the upper anal canal while the lower anal canal is lined by squamous fissure. These patients will typically describe a sharp, burning, or
shearing pain with defecation that lasts for a few moments up to an
hour afterward. Some people will complain of a chronic ache that is
exacerbated with a bowel movement. The prolonged pain is usually
attributed to internal anal sphincter muscle spasm. Bright red blood
is usually seen on the stool or toilet paper. Occasionally, a few drops
of blood will fall into the toilet bowl.
Patients can usually describe the initial event that triggered the
fissure as either an episode of constipation with a hard bowel move-
ment or diarrhea. Most patients with a painful anal fissure will not
tolerate a digital rectal examination or anoscopy. A close inspection
of the anus can be performed after reassuring the patient and gently
pulling the buttocks apart. An anal fissure with a sentinel pile, an
abscess, or a thrombosed external hemorrhoid may also be seen.
The application of anesthetic jelly may be required to examine the
patient with an acute, painful anal fissure. Palpating the anal fissure
with a gloved finger or cotton swab will reproduce the patient’s pain.
INDICATIONS
Anal fissures are extremely painful and uncomfortable for the
patient. They can cause poor job attendance or performance. All
anal fissures should be treated when they are identified. Initial ther-
FIGURE 67-1. The anal fissure. apy is conservative, followed by topical medications and injection
therapy. Surgical treatment is warranted for patients for whom non-

operative therapy fails or who experience severe anal pain.
CONTRAINDICATIONS
A patient with perianal Crohn’s disease or ulcerative colitis is a
relative contraindication to performing a lateral internal sphincter-
otomy. Medical management is advocated to initially treat these fis-
sures associated with inflammatory bowel disease followed by the
judicious use of an internal sphincterotomy.14 A patient who has had
multiple fistulotomies in the past or a sphincteroplasty should have
their anal sphincter evaluated by anal ultrasound or manometry.
The patient may have marginal sphincter function and an internal
sphincterotomy can render them completely incontinent. A sphinc-
terotomy should be performed only by a Colorectal Surgeon in
these difficult patients.
EQUIPMENT FIGURE 67-2. The prone jackknife position. Note that the lower abdomen is not
touching the edge of the table.
Anal Anesthesia
• 10 mL syringe solution. Inject the anesthetic solution into the subcutaneous tissue
circumferentially around the anus, under the fissure, and laterally
• 27 gauge needle, 2 in. long
to anesthetize the pudendal nerves. The use of procedural sedation
• Local anesthetic solution with epinephrine (Chapter 129) is recommended, but not required.
• Sodium bicarbonate solution TECHNIQUES
Lateral Internal Sphincterotomy Begin the examination with a slow, gentle separation of the buttocks.
This usually provides adequate visualization of the clean slit-like,
• Anal speculum acute anal fissure. The chronic fissure will appear similar to a deep
• #15 scalpel blade on a handle ulcer with skin tags and enlarged anal papillae. Chronic fissures can
• Metzenbaum scissors be confused for external hemorrhoids when accompanied by a sen-
tinel pile, which is a swollen external tag of skin at the base of the
• Forceps
fissure. Test for adequate anesthesia. Inspect the lateral areas for an
• 4-0 chromic gut sutures avascular area, usually on the right side between the right posterior
Miscellaneous (depending on technique) and right anterior hemorrhoid complexes. Palpate the intersphinc-
teric groove in the avascular area. It is a palpable depression between
• Topical nitroglycerine (0.2% to 2%) the caudal ends of the internal and external anal sphincter muscles.
• Topical nifedipine Anoscopy can be performed for enhanced visualization when
• Botulinum toxin necessary. Most patients have too much pain and involuntary
Dressing
• Gelfoam
• 2 in adhesive tape
PATIENT PREPARATION
Explain to the patient and/or their representative the risks, benefits,
complications, and the options for treatment. The following discus-
sion applies to the injection or surgical treatment of an anal fissure.
Explain the postoperative care if a surgical technique is to be per-
formed. Obtain an informed consent for the procedure. Undress the
patient from the waist down. Place the patient prone or in the prone
jackknife position (Figure 67-2). Tape the buttocks apart and to the
procedure table to gain better exposure of the anus (Figure 67-3).
Clean any dirt and debris from around the anus. Apply povidone
iodine or chlorhexidine solution and allow it to dry. Place drapes to
delineate a sterile field.
Perform an anal block. Mix 10 mL of local anesthetic solution FIGURE 67-3. Taping the buttocks open in the prone patient allows for unob-
with epinephrine in a syringe with 1 mL of sodium bicarbonate. This structed access. The lateral traction strips are taped to the examination table or
will decrease the burning sensation upon injection of the anesthetic gurney.
CHAPTER 67: Anal Fissure Management 441
sphincter spasm, which precludes a digital or anoscopic exam. Some nifedipine, topical nifedipine 0.2% gel, oral diltiazem, topical diltia-
require an exam under anesthesia. A proctoscopic exam may assist zem, and bethanechol have also been studied for the treatment of
for ruling out secondary causes. anal fissures.23–29,36,37 They were all found to be comparable to topical
Atypical appearances of anal fissures, which might be eccentrically nitroglycerin and with fewer side effects.23–29,36,37
located, should prompt alternative diagnoses, such as inflammatory Side effects such as a headache, primarily, may occur 10 min-
bowel disease, ulcerative colitis, and Crohn’s disease. Sexually trans- utes after application of topical nitroglycerin and typically lasts less
mitted infections, such as chlamydia, gonorrhea, herpes, syphilis, than 30 minutes. Orthostatic hypotension has also been described
and HIV, as well as tuberculosis, anal neoplasms, and sickle cell dis- in patients. Patients taking medications for erectile dysfunction
ease can present with anal fissures. If rectal bleeding is a prominent (i.e., Cialis, Levitra, or Viagra) should not receive nitroglycerin-
finding, endoscopy plus sigmoidoscopy or colonoscopy should be containing medications within 24 hours of their use due to the
performed. potential for life-threatening hypotension. After 24 hours, a lower
Management of an anal fissure begins conservatively. If unsuc- concentration of nitroglycerin (e.g., 0.2% glyceryl trinitrate) is rec-
cessful, the next steps include topical preparations and injection ommended compared to standard 2% ointments.
therapy. A surgical sphincterotomy is the procedure of choice in Topical nifedipine gel in a concentration of 0.2% used every
refractory cases and has a 95% success rate. 12 hours for 3 weeks has been successfully used to decrease anal
sphincter pressures and help heal fissures.30 No systemic side effects
FOUR-FINGER ANAL STRETCH or significant anorectal bleeding was observed in 141 patients
treated with topical nifedipine.30
In the past, a four-finger anal stretch technique was performed. This
involved putting the index and long fingers of both hands into the
BOTULINUM TOXIN
patient’s anal canal and pulling the anal canal forcibly open. This
would often cause an uncontrolled tear in the internal anal sphinc- Botulinum toxin is another pharmacological approach to the treat-
ter muscle. Although patients had relief of their symptoms, 40% ment of a chronic anal fissure. Botulinum toxin inhibits the release
developed a recurrence of the fissure and a significant proportion of acetylcholine from nerve endings and has been shown to be a
had some level of incontinence. This technique is no longer rec- beneficial treatment for chronic anal fissures.31 Injection close to
ommended and should never be performed. It is included only for each side of the fissure improves healing rates.31 Inject 20 units of
the sake of completeness. botulinum toxin A (Botox, Allergan, Irvine, CA) or 0.4 mL (50 U/
mL) into the internal anal sphincter muscle on either side of the fis-
CONSERVATIVE MANAGEMENT sure using a 27 gauge needle. This can alleviate anal pain, decrease
anal sphincter pressure, and promote healing.32 Unfortunately, this
Most remedies for an anal fissure aim to alleviate internal sphinc- can result in some form of temporary incontinence.31,32
ter hypertonia and anal pain. A trial of conservative treatment is
employed for acute fissures and chronic fissures with mild to mod-
LATERAL INTERNAL SPHINCTEROTOMY
erate symptoms. This consists of bulk fiber supplements, a high-
fiber diet, increased oral intake of water, sitz baths, and topical The mainstay of operative therapy is a lateral internal sphincterot-
anesthetics. The large, soft, bulky stools that result gently dilate the omy. This technique is curative in 95% of patients. Unfortunately,
anal sphincter. The topical anesthetics and sitz baths in warm water approximately 15% of patients will be left with some form of minor
after bowel movements will cleanse the area, alleviate the anal pain, incontinence. The technique divides the internal anal sphincter
and relieve internal anal sphincter muscle spasm.15 Topical anesthet- muscle between the dentate line and the anal verge. A meta-analysis
ics such as lidocaine gel may be soothing, but are not more effective of 2727 patients undergoing operative techniques for anal fissures
than fiber and sitz baths alone.16 Oral pain medications and muscle revealed no significant difference between open versus closed lateral
relaxants such as diazepam may benefit. Suppositories are not rec- internal sphincterotomy for persistence of fissure or incontinence.33
ommended because they ascend to the rectal ampulla and do not However, significant differences were found when anal stretch was
effectively treat the problem within the anal canal. If an initial trial compared to all forms of sphincterotomy.
of conservative therapy for 4 weeks fails, the patient can undergo
pharmacological therapy, injection therapy, or operative treatment. CLOSED LATERAL INTERNAL SPHINCTEROTOMY
The closed lateral internal sphincterotomy technique is preferred
TOPICAL TREATMENT
by some physicians (Figure 67-4). Its advantage is that a smaller
Nitric oxide has been identified as a chemical messenger mediat- wound is created. Unfortunately, this is a blind procedure and can
ing relaxation of the internal anal sphincter muscle. Patients treated result in injury to the patient and the physician.
with 0.2% glyceryl trinitrate ointment to their lower anal canal (near Prepare the patient as described previously. Place a well-lubricated
the fissure) twice daily exhibited relief of their anal pain, reduced anal speculum into the anal canal. Open the speculum to provide a
maximal anal resting pressure, and increased anodermal blood flow slight stretch to the anal sphincter muscles. Expose and view the left
as measured by laser Doppler flowmetry.17 Topical nitroglycerin or right posterolateral quadrant of the anal canal. Place a gloved fin-
increases blood flow to the site, which is thought to result in less ger into the anal canal and palpate the internal aspect of the internal
internal anal sphincter pressure, less pain, and a resultant improve- anal sphincter muscle. Perform the remainder of this procedure
ment in healing rates in acute and chronic anal fissures.18,19 After while carefully palpating the course of the scalpel blade with the
8 weeks, 68% of patients treated with glyceryl trinitrate had healed gloved finger in the anus.
their fissures. Some studies have shown no significant difference in Insert a #11 scalpel blade horizontally through the skin and into
healing rates when compared to placebo.20 However, up to 75% of the intersphincteric groove (Figure 67-4A). Advance the scalpel
patients will have an adverse reaction, mainly a headache unrespon- blade into the plane between the internal and external anal sphincter
sive to mild pain relievers or develop a tolerance to the nitrate.21 Up muscles and up to the level of the dentate line (Figure 67-4A). Direct
to 33% of patients will have a recurrence of an anal fissure after the the scalpel blade medially by turning it 90° (Figure 67-4B). Slowly
initial anal fissure has healed with nitroglycerin treatment.22 Oral divide the full thickness of the internal anal sphincter muscle while
FIGURE 67-4. The closed lateral internal sphincterotomy.

A. The #11 scalpel blade is inserted horizontally between the
internal and external anal sphincter muscles. B. The scalpel
blade is turned 90° (1) then withdrawn (2) to transect the inter-
nal anal sphincter muscle.
withdrawing the scalpel blade. Do not cut the anoderm. Withdraw or right posterolateral quadrant of the anal canal (Figure 67-5B).
the scalpel from the anal canal. Remove the anal speculum. Close Place a gloved finger into the anal canal and palpate the internal
the incision site with 1 or 2 size 4-0 chromic gut interrupted sutures. aspect of the internal anal sphincter muscle.
Pack the anal canal with 4 × 4 gauze squares for 10 to 15 minutes to Make a 1 cm longitudinal incision through the skin and sub-
aid hemostasis and prevent the formation of a hematoma. cutaneous tissue, between the dentate line and the anal verge
(Figure 67-5B). This will center the edge of the internal anal
OPEN LATERAL INTERNAL SPHINCTEROTOMY sphincter muscle in the middle of the incision. Slide a scissors sub-
mucosally along the white internal anal sphincter muscle until the
The open technique provides a clear exposure to the anatomy of tips are at the level of the fissure, but not beyond the dentate line.
the region. This is especially important for those less experienced Spread the arms of the scissors once to open the jaws of the scissors.
with the procedure. It avoids the potential for injury to the physician Repeat this process on the other (deep) side of the internal sphincter
when compared to the closed technique. muscle. Grasp and elevate the internal anal sphincter muscle with a
Prepare the patient as described previously. Place a well-lubri- forceps. Use a scissors to make a cut in the internal sphincter muscle
cated anal speculum into the anal canal. Open the speculum to the same length as the length of the anal fissure (Figure 67-5C).34
provide a slight stretch to the anal sphincters and view the fissure Do not completely transect the internal anal sphincter muscle.
(Figure 67-5A). Rotate the speculum 90° to expose and view the left Preserve at least one-third of the proximal internal sphincter
A B
Internal anal Fissure
Fissure sphincter muscle
Subcutaneous
external anal 90°
sphincter muscle
C D
FIGURE 67-5. The open lateral internal sphincter-
otomy. A. The anoscope is inserted so that the anal
fissure is visible. B. The anoscope has been rotated
90°. An incision has been made through the ano-
derm and subcutaneous tissue to expose the under-
lying anal sphincter muscles. C. The internal anal
sphincter muscle is partially transected with a scis-
sors. D. Closure of the incision.
CHAPTER 68: External Hemorrhoid Management 443
muscle intact.34 Pack the anal canal with 4 × 4 gauze squares to the clot over time. Therefore, treatment should give the maximum
apply pressure to the area for 10 to 15 minutes to aid in hemostasis amount of pain relief with the least chance of complications. To
and to prevent the formation of a hematoma. Suture the incision make this decision it will be important to obtain a good history
closed with size 4-0 interrupted chromic gut (Figure 67-5D). Place of the length of the pain, how severe it is, and whether there has
a small piece of Gelfoam over the wound. Remove the anal specu- been improvement. It is important to perform a physical examina-
lum. Dress the incision site with 4 × 4 gauze squares. tion to rule out prolapsed grade IV internal hemorrhoids, perianal
abscesses, and other perianal masses.
AFTERCARE
Instruct the patient to remove the dressing in 12 to 24 hours or
before a bowel movement. Warm sitz baths four times a day will External hemorrhoids fall into three main groups: left lateral, right
keep the area clean and alleviate any pain. Prescribe a high-fiber anterior, and right posterior (Figure 68-1). They are covered with
diet with oral stool softener supplements to keep the stools soft and anoderm and visible on the outside of the anal canal. They are
bulky. Oral analgesics such as acetaminophen or nonsteroidal anti- composed of a venous plexus mixed with connective tissue. They
inflammatory medications with supplementary narcotic analgesics drain into the middle and inferior rectal veins that terminate into
will often ease the immediate and postoperative pain. The patient the internal iliac and femoral veins, respectively. External hemor-
should follow up in 1 to 2 weeks for reevaluation. The patient should rhoids do not prolapse like internal hemorrhoids. They engorge and
immediately return to the Emergency Department if a fever, severe thrombose. It will not benefit the patient to try to reduce an external
pain, or bleeding from the incision site develops. hemorrhoid since their normal location is mostly outside the anal
canal and reduction will not remove the clot. External hemorrhoids
COMPLICATIONS are never covered with mucosa. The overlying skin may appear to
look shiny, swollen, gangrenous, or like an orange peel mimicking
Many complications have been associated with a lateral sphincter- the look of mucosa.
otomy. Itching, burning, bleeding, delayed wound healing, and con- It is important to differentiate internal versus external hemor-
stipation are minor problems. The patient may complain of mucus rhoids. Internal hemorrhoids originate above the dentate line, lack
drainage or fecal soiling during the healing phase. Bulking agents or sensation, and are covered with mucosa. Prolapsed internal hemor-
a high-fiber diet may help decrease the drainage. Recurrent fissures rhoids are painless unless they become gangrenous, infected, stran-
occur in about 8% of patients, 66% of which heal with conservative gulated, or thrombosed. External hemorrhoids originate below the
treatment. Up to 45% of patients may experience some degree of dentate line, have sensory innervation, and are covered with squa-
incontinence, but only 3% of patients may have their life affected.35 mous epithelium that matches the surrounding skin.
A fecal impaction, abscess, or hemorrhage can become significant. The patient usually complains of a history of the sudden onset of
Enemas are useful for the constipated patient. An abscess should pain and swelling. The exact cause of thrombosed external hemor-
be incised and drained, preferably in the Operating Room for ade- rhoids is unknown. It is probably related more to straining with lift-
quate anesthesia to completely explore the wound and debride any ing, jogging, or bicycling than chronic constipation. This explains
necrotic tissue. A subcutaneous fistula can develop if the anoderm why this problem occurs more often than internal hemorrhoidal
is violated during the sphincterotomy and not recognized. This is disease in a younger age group.
easily taken care of by doing a fistulotomy of this superficial skin External hemorrhoids can be diagnosed when a patient com-
bridge. The physician may be injured while performing the closed plains of a sudden onset of pain and swelling, usually with no
technique. This technique should be reserved for those with experi-
ence and a patient that is sedated to decrease the chances of injury.
SUMMARY
Anal pain with bleeding due to an anal fissure is initially treated
conservatively with a high-fiber diet, stool softeners, and warm sitz
baths. Most patients will respond to these measures. A few will fail
conservative therapy and need pharmacological or operative ther-
apy. The goal of all the different regimens is to decrease anal pain,
reduce anal sphincter spasm, and heal the fissure.
External Hemorrhoid
68 Management
Charles Orsay and Eric F. Reichman
INTRODUCTION
The primary disease process affecting external hemorrhoids is
thrombosis. The mainstay of treatment is excision. It is important
to remember that the excision is to alleviate or palliate the pain.
The natural history of an untreated thrombosed external hemor-
rhoid is to rupture and spontaneously evacuate the clot or to resorb FIGURE 68-1. The position of the three main groups of external hemorrhoids.
bleeding. The physical examination will reveal a tensely swollen • 2-0 absorbable sutures (Vicryl, Dexon, chromic gut, or plain gut)
area covered with anoderm. The swelling will be visible by gently • 3-0 absorbable sutures (Vicryl, Dexon, chromic gut, or plain gut)
spreading the buttocks and inspecting the area near the anal canal.
• Small dissecting scissors
They have a bluish coloration, especially in patients with little skin
pigmentation, and almost no redness. The swelling is abrupt, like • Small grasping forceps
placing a marble under a sheet and tucking in the edges. This differ- • 2 in. adhesive tape
entiates the appearance of a thrombosed external hemorrhoid from • Tincture of benzoin
the appearance of an abscess that would have erythema and gently
sloping sides from edema. • Silver nitrate applicator sticks
• Moisture-resistant drapes
INDICATIONS • Posthemorrhoidectomy pack or 18 gauge Foley catheter
The primary indication for the excision of a thrombosed external
hemorrhoid is pain. The excision should occur as soon as possible PATIENT PREPARATION
from the onset of pain and usually not after the fourth day.1 The Explain the risks, benefits, and potential complications of the proce-
pain should become tolerable in the normal course of events after dures to the patient and/or their representative. It is also important
the fourth day. The clot is already being absorbed at this time and to explain to the patient what to expect after the procedure. Obtain
the chance of having problems with bleeding increases and median informed consent for the procedure.
cal management is indicated. Improving pain suggests that medical It is crucial to position the patient so that the anus is clearly
management is the more appropriate method of care as thrombosed visible and the Emergency Physician can work with both
external hemorrhoids will spontaneously resolve in a few weeks with hands. Place the patient in the prone or prone jackknife posi-
no complications. Medical management includes fiber supplements, tion with their hips flexed (Figure 68-2). Tape the buttocks to the
sitz baths, stool softeners, topical corticosteroids (i.e., Proctofoam procedure table (Figure 68-3). Apply tincture of benzoin to the
HC or Anusol HC), and over the counter hemorrhoidal agents (e.g., buttocks and allow it to dry. Place strips of 2 inch adhesive tape
Preparation H). There is, however, a small subgroup of patients who on the left and right cheeks of the buttocks and perpendicular to
do not seem to improve with medical management and will require the anus. Apply lateral and slightly cranial traction with adhe-
excision, even late in the course of the disease. Surgical excision has sive tape to get the proper exposure. Attach the distal ends of the
a lower frequency of recurrence and a longer time interval to recur- tape to the procedure table or stretcher to maintain exposure dur-
rence than conservative treatment.2 The thrombosis to be excised ing the procedure. This positioning works best in the Operating
should involve one or at most two hemorrhoids. Room when the patient is under anesthesia and unlikely to move.
Explain to the patient that they must relax and refrain from
CONTRAINDICATIONS squeezing their buttocks shut. If the patient is poorly positioned
There are several contraindications to the Emergency Department and there is difficulty with hemorrhage in the middle of the pro-
incision and drainage of a thrombosed external hemorrhoid. cedure, it is very difficult to stop and reposition the patient to
Grade IV internal hemorrhoids with thrombosed external hem- place a suture for control. Apply drapes to protect the patient and
orrhoids, circumferential hemorrhoids, or very large thrombosed clothing from spills. Clean the anus and surrounding area of any
external hemorrhoids should be managed by a Surgeon in the dirt and debris. Apply povidone iodine or chlorhexidine solution
Operating Room using electrocautery or suture ligation to con- and allow it to dry.
trol hemorrhage. Patients taking anticoagulants require meticu- The patient usually is in significant pain. The injection of local
lous care and possible reversal of the coagulopathy. An allergy to anesthetic solution can be excruciating. Consider the use of ice
local anesthetic agents will require a trip to the Operating Room packs to the area for 5 to 10 minutes before injection, intravenous
to excise the hemorrhoid. Painless masses are never thrombosed analgesics, sedatives, or procedural sedation. This will be greatly
external hemorrhoids and require evaluation by a Surgeon. appreciated by the patient.
Draining external hemorrhoids should be followed up in 24 hours
by a Surgeon. Patients who are unable to cooperate with the pro-
cedure may require procedural sedation or general anesthesia. A
Surgeon should manage patients who have thrombosed external
hemorrhoids and also have inflammatory bowel disease, anorectal
fissures, perianal infections, portal hypertension, rectal prolapse,
anorectal tumors or who are immunocompromised. Patients with
external hemorrhoids that are not thrombosed usually require no
treatment for their external hemorrhoids. They may need appro-
priate referral for their anal pain.
EQUIPMENT
• Local anesthetic solution with epinephrine
• 5 mL syringe
• 25 gauge needle
• 18 gauge needle
• #11 scalpel blade on a handle FIGURE 68-2. The prone jackknife position. Note that the lower abdomen is not
• 4 × 4 gauze squares touching the edge of the table.
CHAPTER 68: External Hemorrhoid Management 445
hemorrhoid (Figure 68-4B).1 The injection should include both

lines of the planned incision and, if possible, the area medial to the
thrombosis. The local anesthetic agent should also cross the midline
anteriorly and posteriorly to include nerve fibers crossing over from
the opposite side of the anus. Allow 5 minutes for the local anes-
thetic to take effect. The degree of local anesthesia can be checked by
pinprick or by pinching the thrombosed hemorrhoid with forceps.
Make the incisions with a #11 scalpel blade when satisfac-
tory local anesthesia has been achieved. Dissect the ellipse of skin
and the underlying clot from lateral to medial with a scissors
(Figure 68-4C). Do not cut the anal sphincter at the base of the
wound (Figure 68-4D). It is important to remove the entire clot
since the purpose of the excision is only to palliate the patient’s
pain. Small clots in or between the sphincter muscles may still cause
considerable pain. These can be grasped with a fine forceps and
removed.
Examine the wound carefully for hemostasis. Localized areas of
bleeding can often be controlled with the application of silver nitrate
FIGURE 68-3. Taping the buttocks open in the prone patient allows for unob- to cauterize the wound. It is the author’s personal belief that there is
structed access. The lateral traction strips are taped to the examination table or less discomfort if silver nitrate is used for hemostasis than if one is
gurney. forced to use suture ligature. However, if there is continued bleeding,
a 3-0 absorbable suture can be used in a figure-of-eight formation
over the area of bleeding. Plain catgut is preferred because the suture
will dissolve very quickly. A suture that remains in place for sev-
TECHNIQUE eral weeks in this area can sometimes be very uncomfortable for the
patient. Dress the wound with 3 or 4 gauze squares folded in half and
Determine the area of the incision. The best pain relief will be one piece of tape across the buttocks to hold the dressing in place.
achieved if the thrombosis is excised rather than incised. If the
hemorrhoid is very large, one-third or greater of the anal circumfer-
AFTERCARE
ence, it is best to excise the middle third of the hemorrhoid leaving
as much anoderm as possible to prevent the wound healing with a The patient should leave the dressing in place until the next day or
stricture. Excision can be achieved with two radial incisions starting the next bowel movement. It is best to remove the dressing in a sitz
near the center of the anus and enclosing an ellipse of skin that will bath and replace it with dry 4 × 4 gauze placed between the buttocks
be removed with the thrombosis (Figure 68-4A). to collect any moisture. Frequently, tape is not necessary. Encourage
Inject local anesthetic solution containing epinephrine start- the patient to take three or four sitz baths per day and after every
ing laterally and injecting medially to and beyond the thrombosed bowel movement. The water should be warm, not hot, and the bath
FIGURE 68-4. Excision of the thrombosed external hemorrhoid.

A. The dotted line represents the incision lines to remove the
skin and underlying thrombosis. B. Injection of local anesthetic
solution. C. The skin incision has already been performed. The
skin and underlying thrombosis are dissected free with a scissors.
D. The ellipse of skin and the underlying thrombosis have been
removed. The fibers of the underlying external anal sphincter
muscle are visible.
should be for 20 minutes each time. The sitz bath serves two func- thrombosed external hemorrhoid will provide considerable relief if
tions. It keeps the wound clean and helps relax the internal anal the patient presents acutely. It is important to achieve good hemo-
sphincter muscle spasm, which helps relieve the pain. An alterna- stasis and not damage the underlying external anal sphincter muscle
tive to wiping after bowel movements and sitz baths is to shower. or remove too much anoderm to avoid problems with continence or
The shower will gently wash away any material and not hurt like stricture formation. Fiber supplements and sitz baths should be pre-
wiping. The sitz baths and dressing changes should continue until scribed rather than surgical excision if the patient presents later in
the wound is healed. the course of the disease.
Fiber supplements and stool softeners should be continued for at
least 6 weeks. Prescribe one tablespoon of psyllium products (e.g.,
Metamucil) with water twice a day to soften and bulk the stool. The
goal is to achieve an atraumatic stool that gently dilates the anus
as it passes. If the patient is unable to tolerate psyllium, 100 mg of
Prolapsed Rectum
docusate orally once or twice a day can be used to soften the stool
but will not provide the bulk.
The patient should feel much less pain after the thrombosed
69 Reduction
hemorrhoid is excised. The remaining pain can frequently be con- Jamil D. Bayram and Eric F. Reichman
trolled with the sitz baths. Some form of oral analgesia is required.
Acetaminophen or ibuprofen is usually adequate. The use of codeine INTRODUCTION
or opiates has a pronounced constipating effect that could result in
painful bowel movements. Do not prescribe narcotic analgesics for Rectal prolapse is an uncommon condition. It was first described in
more than 24 hours. The patient should return to the Emergency the Bible (2 Chronicles 21). “You yourself will be very ill with a lin-
Department if the pain is not improved, if bleeding continues, or gering disease of the bowels, until the disease causes your bowels to
if they develop a fever. The wound must be watched for infection, come out. . . . After all this, the Lord afflicted Jehoram with an incur-
which fortunately is very rare. able disease of the bowels. In the course of time, at the end of the
second year, his bowels came out because of the disease, and he died
COMPLICATIONS in great pain.” The pathophysiology of a rectal prolapse has been
evolving since 1543 when Vesalius described the detailed anatomy
The rate of complications for excision of thrombosed external hem- of the anorectum. Today, three types of rectal prolapse are recog-
orrhoids is not well reported.1–6 Reported complication rates for nized and they represent three stages of a continuum.1
more major anal surgery show that bleeding occurs in 1.5% to 4.0% Rectal prolapse usually affects people at the extremes of age. It
of patients and infection occurs in 2% of patients.1–3 Considering the is most common in the very young and the elderly. The condition
persistent fecal contamination at the anus, this is a very low rate of usually manifests itself in children within the first 4 years of life,
infection. We can estimate that the complication rate for the exci- with the highest incidence occurring in the first year.2 The gender
sion of a thrombosed external hemorrhoid would be even less. incidence in children is equal but slightly weighted toward males.1
Any posthemorrhoidectomy bleeding that is minimal can be The peak incidence in the elderly is approximately between 60 and
managed by the application of local pressure. Moderate to severe 70 years of age. It affects primarily elderly women, with a 6:1 ratio
bleeding will require the insertion of a commercially available post- of females to males.3
hemorrhoidectomy pack.7 This is an accordion-like pack that is
inserted through the anoscope and into the anal canal. Pulling the
two strings of the pack accordions the pack down into the anal canal ANATOMY AND PATHOPHYSIOLOGY
to tamponade the bleeding. A Foley catheter may be substituted if A rectal prolapse is classified into one of three stages (Figure 69-1).
the packs are not available. These patients require intravenous anal- An internal prolapse is the prolapse of the upper rectum and sig-
gesics, intravenous sedation, and hospitalization. moid colon into the rectal ampulla (Figure 69-1A). It is also known
The treatment for a patient with an infection in the perianal area as a hidden or occult prolapse. This type of prolapse does not emerge
who has not had surgery is to open the abscess and place the patient through the anus. Mucosal prolapse is more common in children. It
on sitz baths. Infection is very unlikely since the wound is already results from the loose attachment of the mucosa to the submucosal
open from the excision procedure and the patient is taking sitz layers and an associated weakness of the anal sphincter. A mucosal
baths. Broad-spectrum antibiotics for aerobic and anaerobic bacte- prolapse is diagnosed by the presence of radial folds and the absence
ria should be given to any patient with a postprocedural infection of muscular wall.3
and the wound examined under general anesthesia to rule out any If the condition progresses, it leads to the protrusion of part or all
underlying pathology. layers of the rectum through the anal orifice. If only the mucosa is
Long-term theoretical complications include stricture and incon- prolapsed, it is classified as an incomplete prolapse (Figures 69-1B
tinence. These are exceedingly rare and can be prevented by not & C). Synonyms include mucosal prolapse and partial prolapse. A
removing too much anoderm and not injuring the underlying exter- complete rectal prolapse occurs when all bowel layers, including the
nal anal sphincter muscle. muscular wall, are involved (Figures 69-1D & E). This condition is
The use of a linear incision should be avoided. The stretched also known as a procidentia. The complete rectal prolapse is more
skin will close and create a pocket in which a hematoma or abscess common in the elderly. It results from generalized weakening of the
can form. Removal of clots through a linear incision (rather than an pelvic floor and anal sphincter muscles. A complete rectal prolapse
elliptical incision) is often difficult, inadequate, and may lead to a is characterized by the presence of concentric folds. A double thick-
higher incidence of recurrence. ness muscular wall will be felt upon palpation.4
Numerous risk factors are associated with a rectal prolapse.4–11
SUMMARY
These include malnutrition, chronic constipation, excessive strain-
External hemorrhoids may thrombose and cause the patient consid- ing, and diarrheal disorders such as amoebiasis, giardiasis, and other
erable pain. The natural history of this disease is for the clot to drain parasitic infections. Rectal prolapse in children is often idiopathic.
or resorb without significant long-term morbidity. Excision of the However, there is an association with paraplegia, meningomyelocele,
CHAPTER 69: Prolapsed Rectum Reduction 447
FIGURE 69-1. Types of rectal prolapse. A. Midsagittal view of the internal, hidden, or occult prolapse. B. Midsagittal view of the incomplete, mucosal, or partial prolapse.
C. Posterior view of the incomplete, mucosal, or partial prolapse. D. Midsagittal view of the complete prolapse or procidentia. E. Posterior view of the complete prolapse
or procidentia.
and pinworms. Anatomic variations such as a vertical course of the The differential diagnosis of a rectal prolapse includes anal warts,
rectum, flat sacrum and coccyx, and lack of levator ani support can hemorrhoids, intussusception, prolapsed rectal polyp, or a prolapsed
also result in a rectal prolapse. Children placed on adult toilet seats rectal tumor. Mistaking an intussusception for a rectal prolapse
for prolonged periods of time may develop a rectal prolapse. One of may result in significant morbidity and mortality. Differentiating
the most serious risk factors for a rectal prolapse in children is cystic features of an intussusception include the ability to pass the finger
fibrosis.6 Patients with cystic fibrosis have an 18% incidence of rec- between the prolapsed bowel and the anal sphincter (Figure 69-2).
tal prolapse. Children with no apparent cause for a rectal prolapse This is in contrast to patients with a rectal prolapse in which the
should be considered for a sweat chloride test. In the elderly, rectal protruding mucosa is continuous with the perianal skin and the
prolapse is associated with collagen vascular diseases, malignancy, examiner’s finger will not pass that junction (Figure 69-1D).1,2,7
pelvic floor weakness, mental retardation, organic brain syndrome, Patients with an intussusception usually appear ill whereas those
stroke, chronic psychiatric conditions, and chronic neurologic con-
ditions (e.g., tabes dorsalis, cauda equina, and multiple sclerosis).5,11
It is important to note that patients with rectal prolapse often pres-
ent with no apparent causes. The physician should maintain a high
index of suspicion for the risk factors mentioned above.
The diagnosis can be difficult in the early stages when the pro-
lapse remains in the upper canal (i.e., internal or hidden prolapse).
The patient may complain of anorectal pain, back pain, discomfort
during defecation, difficulty initiating a bowel movement, feeling
of incomplete evacuation, tenesmus, pelvic fullness or pain, bloody
discharge, or mucoid discharge. At this stage, asking the patient to
strain may provoke the prolapse.
The diagnosis becomes easier in a partial or complete prolapse
because it protrudes through the anus (Figures 69-1C & E). These
patients may complain of an anal mass when they sit, stand, or
walk.1,5 It is usually the parent who notes the anal mass during def-
ecation in the pediatric patient. The Emergency Physician should
consider the mass described by the parents to be a rectal prolapse
if the physical examination is negative.2 Spontaneous reduction will
often occur in this age group. It might be noted as an incidental FIGURE 69-2. An intussusception. Note the junction where the finger can be
finding on physical examination. passed (arrows).
with a rectal prolapse appear well.2 Prolapsing hemorrhoids are more

often seen in adolescents and adults, are usually purple in color, have
deep grooves between the areas of prolapsing tissue, and lack radial
or concentric folds. A prolapsed polyp or tumor is plum-colored,
does not involve the entire anal circumference, is movable, and is
usually palpable as a small growth on a stalk.2,8
INDICATIONS
Reduction should be attempted on all patients with a visible rec-
tal prolapse as soon as possible to avoid vascular compromise of
the bowel. It is easier to reduce before edema occurs from prolonged
prolapse. Early reduction may avoid complications and stretch dam- FIGURE 69-3. The prone knee-chest position for children.
age to the pelvic floor ligaments, the pelvic floor muscles, and the
anal sphincter muscles.
thumb pressure to gently roll the prolapsed rectum back through the
CONTRAINDICATIONS anus. Alternatively, the index and the middle fingers can be used
There are few absolute contraindications to the reduction of a rec- to reduce the prolapsed rectum (Figure 69-5B). Regardless of the
tal prolapse. Gangrene, necrosis, or ulceration of the mucosa are method used, constant and steady pressure must be applied to
signs of vascular compromise or ischemia and require an emergent the prolapse. The reduction often requires patience as it may take
consultation by a General Surgeon or Colorectal Surgeon. Do not up to 15 minutes to reduce a prolapsed rectum.
reduce ischemic tissue as it may precipitate peritonitis or cause The rectum will become edematous, and swelling will be noted,
a perforation of the rectum. If the Surgeon’s arrival is delayed, if the rectal mucosa has been prolapsed for a prolonged period of
prompt gentle reduction should be attempted only after dis- time. Wrap a gauze square around the prolapsed rectum and apply
cussions with the Surgeon. Do not reduce an intussusception. gentle manual compression for 3 to 5 minutes before attempting the
Consult a Surgeon for further evaluation and management of an reduction. If the first effort is unsuccessful without sedation, a sec-
intussusception. ond attempt at reduction after administering sedation is appropriate.
If the prolapse rectum will not reduce (i.e., incarcerated), consult a
EQUIPMENT General Surgeon or Colorectal Surgeon for reduction under general
anesthesia and possible surgical repair.
• Gloves
• Water-soluble lubricant ALTERNATIVE TECHNIQUES
• 4 × 4 gauze squares A novel method to help reduce a prolapsed rectum uses simple
• 2 in. wide adhesive tape table sugar.12 The longer the rectum is prolapsed, it becomes more
• Benzoin spray or swabs edematous and the more difficult to reduce. Apply a liberal amount
of sugar onto the prolapsed rectum and cover it with several lay-
• Sedatives as necessary
ers of gauze. Allow the patient to relax for 15 to 30 minutes. The
hyperosmotic sugar draws fluid out from the edematous prolapsed
PATIENT PREPARATION rectum. Gently wipe off the sugar with saline or water moistened
Explain the reduction procedure to the patient and/or their repre- gauze. Attempt manual reduction as described above.
sentative. Reduction is most likely successful in a relaxed and non-
straining patient. Sedation may sometimes be required in adults.
Sedation is more often needed in pediatric patients. Children tend
to be more anxious, crying, fighting, or straining; all of which will
increase the intraabdominal pressure and make reduction more dif-
ficult. The sedation may be administered intramuscularly, intrave-
nously, orally, or subcutaneously.
Position the patient.8,9 Place the child in the prone knee-chest posi-
tion on the parent’s lap or on the examination table (Figure 69-3).
Place the adult patient in the prone position on an examination
table. Large buttocks or tense buttocks may interfere with the reduc-
tion of a prolapsed rectum. In these cases, apply benzoin to the but-
tocks and allow it to dry. Tape the buttocks open for better access
(Figure 69-4). Alternatively, in both age groups, the patient can be
placed in the lateral decubitus position.
TECHNIQUE
Position the patient. Liberally apply water-soluble lubricant onto the
prolapsed rectum. Apply gauze squares onto the prolapsed tissue at
the 3 o’clock and 9 o’clock positions (Figure 69-5). The bowel wall is
quite slippery after lubrication and the gauze will improve the grip FIGURE 69-4. Taping the buttocks open in the prone patient allows for unob-
on the mucosa. Place both thumbs near the bowel lumen with the structed access. The lateral traction strips are taped to the gurney or examination
hands stabilized on the buttocks (Figure 69-5A). Apply steady, gentle table.
CHAPTER 70: Anoscopy 449
FIGURE 69-5. Rectal prolapse reduction techniques. A. Thumb method. B. Finger method.
ASSESSMENT rectal prolapse can lead to vascular compromise. Signs of vascular

compromise include mucosal gangrene, necrosis, and ulceration.
Perform a digital rectal examination to ensure that the reduction These patients require admission to the hospital with an emergent
is complete.8 If not, apply pressure with the examination finger to surgical consultation, even if the reduction is felt to be success-
completely reduce the prolapse. ful, due to the risk of reducing ischemic bowel that could perfo-
rate. Very rarely, the rupture of an incarcerated rectal prolapse with
AFTERCARE small bowel herniation through the tear has been reported during
attempted reduction.10 Fecal and urinary incontinence may also
The application of a bulky pressure dressing will prevent an acute
occur as a result of a long-standing prolapse. This is due to the
recurrence of the prolapse. Apply petrolatum gauze over the anus.
entrapment and stretching of the pudendal or perineal nerve result-
Apply several gauze squares over the petrolatum gauze and into the
ing in neurovascular dysfunction and not a complication of the
gluteal cleft. Tape the buttocks together. The patient and the fam-
reduction procedure.
ily must be informed that reduction might be temporary and
the prolapse could recur. Training cooperative parents to reduce
the prolapse is warranted in cases of recurrent rectal prolapse in the SUMMARY
pediatric age group. Be sure to send them home with gauze squares,
Rectal prolapse is an uncommon condition affecting the very
gloves, and lubricant.
young and the elderly. Reduction can usually be performed in
The underlying cause of the rectal prolapse should be treated.
the Emergency Department. It is important to differentiate a
A prophylactic regimen of laxatives and stool softeners should be
prolapsed rectum from an intussusception and from external
started if the patient is constipated. Instruct the patient on proper
hemorrhoids. The reduction procedure is quick and simple. The
eating habits including fruits, vegetables, and roughage. In cases
application of constant, firm, and gentle pressure to the rectum
of diarrhea, treatment should target the underlying causes. Seating
in a relaxed and nonstraining patient will reduce most rectal pro-
children on a child’s potty-chair or on an adult toilet seat with a small
lapses. All patients with a prolapsed rectum should be referred for
hole may prevent future episodes of rectal prolapse. Discourage
further evaluation to rule out underlying pathologic causes for the
excessive squatting and straining.3
prolapse.
All patients who have undergone successful reduction should be
referred to a Colorectal Surgeon for further evaluation. Children
should be followed up to rule out serious etiologies such as cystic
fibrosis. As the child grows, the supporting tissue around the rec-
tum develops. Therefore, rectal prolapse in this age group is usually
self-limited and surgery is rarely required. Adults should be referred Anoscopy
for proctosigmoidoscopy to rule out a tumor. Conservative manage-
ment in the elderly is rarely successful and most patients eventually
require surgical repair. Early referral can avoid complications and
70 Charles Orsay and Eric F. Reichman
stretch damage to the pelvic floor ligaments, pelvic floor muscles,

and the anal sphincter muscles. INTRODUCTION
Examination of the anal canal is important to evaluate several com-
COMPLICATIONS mon patient complaints relating to the anus including itching, pain,
The complications of the procedure are often minimal. The reduc- and bleeding. While it is possible to examine parts of this area with
tion itself may lead to minimal mucosal bleeding that is self-limited. flexible instruments or a rigid rectosigmoidoscope, the only method
The patients may experience a slight discomfort in the anus for up that will give a consistent clear view of the anal canal is anoscopy.1
to 24 hours after the reduction. This can be managed with oral acet- To properly perform this examination, it is necessary to thoroughly
aminophen or nonsteroidal anti-inflammatory drugs. understand the anatomy, be aware of the possible causes of the
The inability to reduce a rectal prolapse is an indication for sur- symptoms you are evaluating, use the appropriate equipment, and
gical consultation in the Emergency Department. An incarcerated position the patient correctly.
Column
of Morgagni
Dentate line Transitional Anal

zone canal
Anal gland
Anal crypt
Anoderm
FIGURE 70-1. The topical anatomy of the anal canal.
ANATOMY AND PATHOPHYSIOLOGY right-posterior, and right-anterior positions. They are normally
located in the distal rectum and are covered with transitional epi-
It is necessary to understand the anatomy of the anal canal in order thelium and rectal mucosa. They can best be examined with an
to evaluate the patient’s signs and symptoms properly. The anatomy anoscope if they are not prolapsed. It is possible to see them with
can be divided into topical anatomy and major supporting struc- a retroflexed sigmoidoscope or colonoscope, but the increased air
tures.2 The topical anatomy is depicted in Figure 70-1. pressure tends to flatten them out giving a false impression as to
Perineal skin covers the perineum, is fully innervated, and their size.
includes both hair follicles and apocrine glands. It can be grossly The anoscope is used to examine the closed portion of the anal
distinguished from the anoderm surrounding the anal canal by the canal. It dilates the anal sphincter and allows one to examine the
visible hair. The anoderm is specialized squamous epithelium that underlying canal through an opening cut out from the side of
lines the majority of the anal canal. It is fully innervated but does the anoscope called a fenestration. It is important to understand
not have apocrine glands or hair follicles. This epithelium is very the anatomy and functions of the anal sphincter musculature to
thin, elastic, and if destroyed by surgery or infection may relate to properly perform this examination (Figure 70-2). Immediately
stricture formation during healing. below the anoderm is the internal anal sphincter muscle. It is cir-
Looking into the anal canal, the anoderm can be seen to end in cumferential and consists of a thickening and rounding of the con-
an irregular line called the dentate line. This is a demarcation of tinuation of circular smooth muscle from the rectum. This muscle
anoderm to transition zone mucosa. Proximal to the dentate line is not under conscious control. The first response of the internal
there is no longer cutaneous sensation. This allows minor therapeu- anal sphincter muscle to a rectal examination or anoscopy is con-
tic procedures like banding or suture ligation to be done without traction. It is necessary to pause and use slow gentle dilatation to
an anesthetic agent. It is also the reason that internal hemorrhoids prevent patient discomfort and complete the examination. The axis
do not routinely cause pain. The transition zone continues prox- of the anal canal will normally follow an imaginary line drawn from
imally for a variable length of 6 to 12 mm before it becomes the the anus to the umbilicus. Surrounding the internal anal sphincter
rectal mucosa. The junction of the transitional zone with the rectal muscle is the external anal sphincter muscle. This is comprised of
mucosa is not visible to the naked eye. The rectal mucosa decreases three external sphincters of striated muscle that are more loop-like
in diameter in the area of the transitional zone. The mucosa appears than circumferential. Deep to these muscles and at the top of the
to be bunched together in columns called the Columns of Morgagni anal canal is the puborectalis muscle. This forms a sling, pulling
at the level of the dentate line. Crypts are formed between the col- the anus anterior. It is connected to both the anal sphincters and the
umns as the transitional zone becomes the dentate line. Under the levator ani group of muscles. The puborectalis muscle can be felt as
anoderm in the crypts are multiple anal glands. Blockage of the anal funnel-shaped during the digital rectal examination.
glands by foreign material leads to infection. Blockage or primary
infection of the glands causes the majority of abscesses that arise
INDICATIONS
around the anus. The crypts also are areas to look for foreign bodies
such as fish or chicken bones. Anoscopy is indicated for the evaluation of most anal symptoms.1–6
External hemorrhoids are located in the left-lateral, right- There are numerous common complaints and conditions where
posterior, and right-anterior portions of the distal anal canal and an anoscope, in conjunction with visualization and a digital rectal
are covered with anoderm. Their normal position is outside the examination, would be used for evaluation or therapy.3–5 Anoscopy
anal canal and they can be examined by gently spreading the but- can be used diagnostically to evaluate rectal bleeding, anal pain,
tocks. The internal hemorrhoids also are located at the left-lateral, pain with defecation, perirectal infections, fistulas, foreign bodies,
CHAPTER 70: Anoscopy 451
Longitudinal
muscle
Levator ani muscle

Valve of Houston
Circular muscle
Puborectal muscle
Conjoined
longitudinal muscle
Internal anal sphincter muscle
Column of Morgagni Deep

External anal
Anal gland
sphincter muscles
Superficial
Subcutaneous
Corrugator cutis External

ani muscle hemorrhoidal plexus
FIGURE 70-2. The major supporting structures of the anal canal.
internal hemorrhoids, anal masses, and abnormal digital rectal • Drapes

examinations. Anoscopy can be used therapeutically to open the • Examination table, preferably a proctoscopy table
anus and allow the application of medications, procedures to be
• Nonsterile examination gloves
performed, or for observation in the management of anal fissures,
intraanal condylomata, and hemorrhoids. • 4 × 4 gauze squares
• Large cotton-tipped applicators
CONTRAINDICATIONS • 4-0 chromic gut suture
Most contraindications to anoscopy are relative. The amount of • Suction, optional
discomfort a patient will undergo relates to their tolerance. Minor • Bright directional light source
discomfort associated with topical skin excoriations can be treated
• Tincture of benzoin
with 2% lidocaine jelly used as a lubricant and the examination can
then continue. Moderate pain can be managed with the application • 2 in. adhesive tape
of procedural sedation. Severe pain associated with anal fissures or There are many different types of anoscopes available. The type of
anal abscesses is best managed in the Operating Room under gen- instrument chosen is largely the preference of the examining physi-
eral anesthesia. cian. The Vernon-David type anoscope is often preferred as it has
Strictures can occur from postsurgical changes, inflamma- a wide fenestration and a diameter that is not too large for most
tory bowel disease, chronic diarrhea, and other disease processes. patients while allowing the best view. The Ives anoscope may be
Anoscopy should not be performed if the patient has anal strictures, used if a larger diameter instrument is required. Some of the metal
a partially imperforate anus, or a completely imperforate anus. The reusable and plastic disposable anoscopes allow for the attachment
physician should determine if the anoscope will pass through the of a fiberoptic light source. Unfortunately, many of these anoscopes
anus during the visual examination and the digital rectal examina- do not allow the same view as a Vernon-David anoscope. Some phy-
tion. Never insert the anoscope if resistance is encountered. The sicians use a glass test tube as a substitute for an anoscope. This
anoscope should not be used to dilate the anus. is to be discouraged as the test tube can break and cause serious
Anoscopy is contraindicated if any recent surgical procedure has complications.
been performed on the anus. The possible exception is for that of the The anoscope is a two-piece device (Figure 70-3). It ranges from
physician who performed the surgical procedure. 7 to 25 cm in length. It can be manufactured from clear plastic,
opaque plastic, or metal. The anoscope may have a handle that allows
EQUIPMENT the operator to control its movements. The proximal end is funnel-
like and tapers into the cylindrical shaft that is approximately 2.5 cm
in diameter. The distal end of the anoscope is tapered on one side
• Lidocaine jelly, can be used as lubricant for patients with pain and known as the fenestration. The fenestration allows the mucosa
• Anoscope or Vernon-David rectal speculum to be viewed within the anoscope. It is also where procedures are
Examination of the anus in this position is easiest on a proctoscopy

table, but can also be performed on an examination table. The lat-
eral decubitus position with the knees drawn up and the buttocks
protruding partly off the table is acceptable for limited diagnostic
examinations. Large buttocks may prevent the examination. Apply
tincture of benzoin to the buttocks and allow it to dry. Apply 2 in.
adhesive tape to the buttocks and tape them to the examination
table to spread the buttocks apart (Figure 68-3). Place a Mayo stand
or bedside examination table next to the patient’s buttocks.
Carefully inspect the entire perineum and anal verge. Many types
of pathology such as fissures, fistulas, hemorrhoids, condylomata,
and dermatologic conditions can be seen at this time. A digital
rectal examination with a well-lubricated gloved finger prior to
anoscopy is mandatory. The digital rectal examination has many
advantages. It allows one to find pathology that is better palpated
than viewed. It gives the examiner the size and angle of the anal
FIGURE 70-3. An example of an anoscope. canal. It will allow the examiner to identify if the patient has tender-
ness that would preclude anoscopy. Any strictures will be identi-
fied, allowing the examiner to prevent the anoscope from advancing
through these strictures and lacerating the tissues. It may identify
performed through the anoscope. Some anoscopes have a site proxi- pathology, so that the examiner can focus the anoscopy in a spe-
mally to attach a light source. The obturator is smooth tipped, fits cific area. It prelubricates the anal canal, making insertion of the
within the anoscope, and occludes the anoscope. Its rounded, distal anoscope easier. Lidocaine jelly can be used as a lubricant and as
end protrudes from the anoscope. The obturator is used each time an anesthetic if the patient has pain from excoriation. The use of
the anoscope is inserted to prevent trauma to the anal mucosa. It is intravenous analgesics, intravenous sedatives, procedural sedation,
removed after the anoscope is inserted to allow viewing through the or general anesthesia may be occasionally required if the patient has
anoscope. significant pain.
PATIENT PREPARATION TECHNIQUE

The area being examined is within the anal canal and requires no The technique of anoscopy is rather simple.6 Look closely at the
special preparation to view correctly. The patient should be given anoscope and be sure it is intact and correctly assembled. Liberally
an opportunity to voluntarily evacuate their bowels prior to the lubricate the obturator and anoscope. Ensure that the obturator is
examination. It is necessary to have the patient remove their clothes easily removed and replaced from within the anoscope. Grasp the
from the waist down and provide protective barriers to protect the anoscope with the dominant hand, with the obturator secured in
patient, the patient’s clothing, and the surrounding area from spills. place by the thumb of that hand (Figure 70-5A).
It is usually wise to avoid enema preparations, as liquid stool is Use the nondominant hand to spread the anus (Figure 70-5A).
much more difficult to contain than solid stool. Place the obturator at the center of the anus. Slowly insert the
Explain the risks, benefits, and potential complications of the anoscope, giving time for the internal anal sphincter muscle to
procedure to the patient and/or their representative. Explain to the relax. Direct the tip of the obturator toward the patient’s umbi-
patient what to expect. Discuss the order of examination, the impor- licus (Figure 70-5A). Insert the anoscope to its fullest depth
tance of relaxing, the reason for multiple insertions and withdrawals to start the examination with the area of fenestration pointed
of the anoscope, and what you are looking for or expect to find. toward the area you wish to view first (Figures 70-5B & C). Slowly
Anoscopy can be performed with the patient in one of many posi- remove the obturator and place it on a Mayo stand or a bedside
tions. The position that allows the best observation in most patients table where it can easily be retrieved. Adjust the directional light
is the knee-chest or prone position (Figure 70-4). This allows the for the best illumination.
buttocks to be to either side and places the anus at the proper angle. The usual starting place for the examination is the posterior mid-
line (Figures 70-5B & C). Slowly withdraw the anoscope under
direct observation to evaluate the entire depth of the anal canal
exposed by the fenestration. Remove any fecal material with a cot-
ton-tipped applicator. Note the appearance of the dentate line, the
mucosa, and the anoderm. Note the presence and location of any
blood, hemorrhoids, masses, mucus, purulence, or other abnormal-
ities. If the anoscope does not fully dilate the columns of mucosa, a
cotton-tipped applicator can be used to gently move the mucosa to
view between the columns. Continue to withdraw the anoscope as
the mucosa is viewed.
Replace the obturator when the anoscope is fully removed from
the patient. Rotate the anoscope 30° to 40° and reinsert it into the
anal canal. It often takes four or five repeated insertions to evaluate
the entire circumference of the anal canal. Some physicians prefer to
replace the obturator and rotate the anoscope while it is still within
the anal canal. This method is discouraged as it may pinch the tissue
of the anus between the obturator and the viewing tube and does not
FIGURE 70-4. The knee-chest position. allow the examiner to see the entire depth of the anal canal.
CHAPTER 71: Rigid Rectosigmoidoscopy 453
FIGURE 70-5. Placement of the anoscope. A. The nondominant hand is used to spread the anus. The anoscope is inserted at an angle and aimed toward the umbilicus.
Note that the dominant thumb is used to secure the obturator within the anoscope. The anoscope is completely inserted with the fenestration pointed toward the posterior
midline (B) or the area of interest (C).
It is helpful to ask the patient to bear down when examining the SUMMARY
left-lateral, right-posterior, and right-anterior sections of the anal
canal when evaluating the internal hemorrhoids. It is often possible Anoscopy is a commonly performed procedure in the Emergency
to reproduce the prolapsing of internal hemorrhoids to evaluate Department. The anal canal is a cylindrical structure surrounded
the grade of the hemorrhoids. Bearing down is particularly impor- by sensitive anoderm and contracting anal sphincter muscles. The
tant if bleeding is the symptom. It is possible to identify the area of best way to examine this area is with a side-viewing fenestrated
bleeding. anoscope. Anoscopy allows direct viewing of the anal canal to
best evaluate anal and perianal complaints. Anoscopy will give
ANOSCOPY IN CHILDREN the most information with minimal discomfort when properly
performed. Always perform a digital rectal examination prior to
Anoscopy may be performed in children for the same indications as anoscopy.
an adult. An anoscope of 8 to 10 cm in length and 1 cm in diameter
is appropriate for a neonate and young infant. An anoscope of over
12 cm in length and 1.5 cm in diameter is appropriate for an older
infant and child. An adult anoscope is appropriate for an older child
and adolescent. Position the young child supine with their buttocks
at the edge of the examination table. Have an assistant grasp, abduct, Rigid Rectosigmoidoscopy
and flex the child’s thighs so they touch the abdomen without com-
pressing the abdominal wall. The remainder of the procedure is as 71 Charles Orsay and Eric F. Reichman
described above.
COMPLICATIONS INTRODUCTION
Examination of the anal canal with an anoscope should have Rigid rectosigmoidoscopy has largely been replaced by the flex-
minimal or no complications. It is possible to cause abrasions or ible sigmoidoscope for routine elective screening and diagnostic
lacerate the very thin anoderm. This is normally avoidable with workups. The rigid rectosigmoidoscope is superior to the flexible
adequate lubrication, the use of the obturator when inserting the sigmoidoscope in measuring distances accurately, examining an
anoscope, and gentle technique. Minimal bleeding from mucosal unprepared patient, and when trying to work within the bowel
irritation is common and self-limited. Dislodgement of a clot may lumen, for example when removing foreign bodies. The larger
result in hemorrhoidal bleeding that can be controlled with direct lumen of the rigid rectosigmoidoscope allows for a larger biopsy
pressure, packing the anal canal with gauze squares, or a 4-0 chro- of lesions where pathology is in question. The cost associated with
mic gut figure-of-eight suture. The most common complication this examination is less than that for flexible sigmoidoscopy. The
is pain. This is avoidable by allowing enough time for the anus to rigid rectosigmoidoscope can be purchased in a disposable model
relax while gently inserting the anoscope. The presence of an anal that performs well. It is important for a physician who evaluates and
fissure may preclude the examination. The use of a topical anes- treats problems related to the colon, rectum, and anus to be familiar
thetic will usually allow the examination to proceed. with rigid rectosigmoidoscopy.
Transverse colon
Ascending
colon
Descending colon
Caecum
Sigmoid colon
A Rectum B
Valves of Houston
FIGURE 71-1. Anatomy of the colon. A. The gross anatomy. B. Cross-section through the colon demonstrating the valves of Houston.
ANATOMY AND PATHOPHYSIOLOGY helpful to determine if stool is mixed with blood when evaluating
hematochezia and determining if colonoscopy is indicated. Foreign
The significant anatomy of the anal canal that is necessary to bodies in the rectum or sigmoid colon can be removed. The rigid
understand and to perform rigid rectosigmoidoscopy is covered in rectosigmoidoscope will allow a much larger biopsy and grasping
Chapter 70 describing the anatomy for anoscopy (Figures 70-1 & forceps to assist in removing foreign bodies. Traumatic injuries can
70-2). The gross anatomy of the colon is reviewed in Figure 71-1A. be assessed. Since the rectum is seldom prepared in the evaluation
It is important to be aware of the large folds that impinge on the of a traumatic injury and flexible instruments are unable to clear
lumen of the colon called the valves of Houston (Figure 71-1B). solid or thick stool, the rigid rectosigmoidoscope is superior in this
These folds must be gently flattened to advance the rigid rectosig- instance. A sigmoid volvulus can be decompressed using the rigid
moidoscope and clearly see the proximal side of the valve when rectosigmoidoscope to pass a tube to splint the volvulus. It is much
looking for pathology. It is also necessary to understand the three- easier to suction out a large volume of obstructed material in the
dimensional path followed by the distal colon, rectum, and anus. colon and leave a large tube with the rigid rectosigmoidoscope. It
The direction to follow will be toward the patient’s umbilicus for 3 to can be used for surveillance of colon or rectal cancer after a subtotal
5 cm initially. The anus then turns posteriorly as it becomes the rec- colectomy. It can be used to accurately measure the distance to rec-
tum and follows the curve of the sacrum. The rectosigmoid junction tal lesions from the anus prior to surgery.
is reached at 10 to 15 cm, at which point the lumen sharply angulates
anteriorly and to the left. Because the scope is rigid and straight, it CONTRAINDICATIONS
is necessary to angle the tip of the rigid rectosigmoidoscope toward
the lumen of the bowel and then gently flatten the haustra or move There are no absolute contraindications to rigid rectosigmoidos-
the patient’s colon so that the lumen is in a straight line. copy.1 Relative contraindications include severe anal pain that may
require general anesthesia, recent surgical anastomosis in the distal
INDICATIONS 25 cm of the colon and rectum, severe stenosis of the anus or rec-
tum, and peritonitis. This procedure should not be performed by
Many of the indications for rigid rectosigmoidoscopy are the same anyone unfamiliar with the equipment and technique as significant
as those for performing flexible sigmoidoscopy. The rigid scope is complications can occur.
more useful when the bowel is not properly prepared, if a bigger
biopsy is needed, or if a larger instrument needs to be passed to the EQUIPMENT
last 25 cm. The following is a list of such indications.
The rigid rectosigmoidoscope may be used to evaluate the rectum • Phosphate soda enemas
and sigmoid colon in the office or the Emergency Department. Rectal • Rigid rectosigmoidoscope with obturator, air insufflator, eye-
bleeding can be evaluated in the unprepared patient. It is particularly piece, and light source
FIGURE 71-2. The instruments required to perform rigid rec-

tosigmoidoscopy. A. Obturator. B. Rigid rectosigmoidoscope.
C. Suction catheter. D. Polypectomy snare. E. Biopsy forceps.
F. Cotton-tipped applicator with silver nitrate matchstick taped
to the opposite side.
• Suction catheter The remainder of the equipment must be gathered from around
• Suction machine or wall suction the Emergency Department.
The rigid rectosigmoidoscope is a simple instrument
• Biopsy forceps
(Figures 71-2A & B). The shaft is approximately 30 to 40 cm in
• Long cotton-tipped applicator with a silver nitrate applicator on length and has 1 cm increments marked on the outside. Attached
the opposite end to the proximal end are an eyepiece, a handle, and an inflation port.
• Proctoscopy table or examination table The eyepiece swings to open and close over the proximal shaft of
• Protective drape with exam fenestration the scope. The handle is used to direct and move the scope. Inside
the handle is a fiberoptic light source that transmits into the shaft.
• 4 × 4 gauze squares The insufflator bulb and tubing attach to the inflation port. These
• Water-soluble lubricant are used to insufflate air through the scope and into the colon.
• Exam gloves The obturator fits within the shaft of the scope. The distal end of the
obturator is smooth, occludes the shaft of the scope, and projects
• Impermeable gown
1 to 2 cm distal to the scope.
• Instrument stand
• Anoscope, should be available to examine the anal canal if PATIENT PREPARATION
indicated
Explain the risks, benefits, and potential complications of the proce-
The rigid rectosigmoidoscope and other required instruments dure to the patient and/or their representative. It is also important to
are available in preassembled sterile trays. The tray usually con- explain to the patient what to expect. Discuss the order of examina-
tains the rigid scope, an obturator, a suction catheter, polypectomy tion, the importance of relaxing, the reason for multiple insertions
snare, and biopsy forceps (Figure 71-2). These trays are available and withdrawals of the rigid rectosigmoidoscope, and what you
from the Operating Room, hospital central supply, or the surgi- expect to find. It is important to explain the reason for insufflating
cal clinics. The trays may contain disposable single-use instru- air and how this may produce discomfort. Explain that the proce-
ments or multiuse instruments depending upon the institution. dure should not require procedural sedation and that the patient
FIGURE 71-3. Patient positioning. A. The prone jackknife position on a proctoscopy table. B. The left lateral decubitus position on an examination table with the buttocks
extended over the edge of the table. Note that the drape is placed so that the buttocks are completely exposed.
should inform the physician of any discomfort. Assure the patient

that the complaint of pain will at least temporarily stop the exami-
nation. Perforations are unlikely with a relaxed, cooperative patient.
Obtain a signed informed consent for this procedure.
While it is possible to perform a rigid rectosigmoidoscopy with
this instrument on an unprepared rectum, more information about
the mucosa will be obtained if the bowel has been prepared. Two
4 ounce phosphate soda enemas given at 2 and 1 hours before the
examination will give an adequate preparation in most patients.
The use of high-volume PEG preparations, saline, or mannitol
should be reserved for colonoscopy. There is no need to clean the
entire colon. The preparations used for colonoscopy are expensive,
involve too much preparation, and cause patient discomfort for the
extent of this examination. The judicious use of intravenous seda-
tion may be required in some patients who are anxious.
It is important to check the equipment prior to its inser-
tion into the patient. Open the tray and place the instruments
and supplies on the Mayo stand. The eyepiece on the proximal
end of the scope should open easily, close easily, and seal against
the rigid rectosigmoidoscope. Open the eyepiece and insert the
obturator completely within the rigid sigmoidoscope. The han-
dle, including the light source, must be firmly attached. Turn on
the light source. The light must be seen coming from the end
of the scope. The bulb of the insufflator must pump air into the
rigid rectosigmoidoscope and should reinflate after the bulb is
released. Liberally lubricate the distal 5 cm of the rigid rectosig-
moidoscope and the obturator. Reinsert the obturator into the
rigid rectosigmoidoscope.
Disrobe the patient from the waist down. Place the patient in the
prone jackknife position on a proctoscopy table if one is available
(Figure 71-3A). If the patient is unable to get in this position, or
only a routine examination table or stretcher is available, place the
patient in the left lateral decubitus or Sims position (Figure 71-3B).
The Emergency Physician should be prepared with an impermeable
gown and one glove on the left hand and two on the right hand (if
right handed). If possible, it is helpful to have someone assist with
the remainder of this procedure. Place the fenestrated drape over the FIGURE 71-4. Insertion of the rigid rectosigmoidoscope. A. The left (nondomi-
patient so that the buttocks are completely exposed (Figure 71-3). nant) hand is placed on the buttocks and used to spread the buttocks. B. The right
Place a Mayo stand or bedside procedure table within reach of the (dominant) hand is used to insert and advance the scope while the thumb keeps
patient’s buttocks. the obturator properly seated.
FIGURE 71-5. Advancement of the rigid rectosigmoidoscope. A. The nondominant hand stabilizes the scope while the dominant hand advances it under direct visualiza-
tion. B. The rectum begins as the anal canal turns posteriorly toward the sacrum.
As in anoscopy, it is important to carefully inspect the entire insufflating air to distend the walls of the colon (Figure 71-5A). The
perineum and anal verge prior to the examination. Many types of anal canal is approximately 4 to 5 cm in length (Figure 71-6). The
pathology such as fissures, fistulas, hemorrhoids, condylomata, and rectum will be seen to turn somewhat posteriorly and follow the hol-
dermatologic conditions may be seen at this time. low of the sacrum (Figure 71-5B). Moving the right hand and the
Digital rectal examination prior to the procedure with a well- rigid rectosigmoidoscope anteriorly will direct the tip posteriorly
lubricated, gloved finger is mandatory. It gives the following (Figure 71-6B). Use the left hand as a fulcrum to help maneuver
advantages. It allows the examiner to find pathology that is better
palpated than viewed. It gives the examiner the size and angle of
the anal canal. It will allow the examiner to identify if the patient
has tenderness that would preclude the examination. It may identify 16 cm
pathology so that the examiner can focus in a specific area. It prelu- A
bricates the anal canal, making insertion of the rigid rectosigmoido-
scope easier. If the patient has pain from excoriation, 2% lidocaine
jelly can be used as a lubricant and will provide some local anes- Rectum
thesia. This examination is usually performed with the right hand.
C
Remove the extra glove from the dominant hand before picking
up the rigid sigmoidoscope. This prevents the contaminated glove
from holding the scope near the Physician’s face.
B
TECHNIQUE
Stand to the left side of or directly behind the patient. Place the left, 4 to 5 cm Sigmoid
or nondominant, hand on the patient’s buttocks (Figure 71-4A). colon
Grasp the handle of the rigid rectosigmoidoscope with the right,
or dominant, hand. Place the right thumb on the obturator to keep
it properly seated (Figure 71-4B). Spread the buttocks with the left Pubic
hand (Figure 71-4). Gently and slowly insert the rigid rectosig- symphysis
moidoscope into the anus and aimed toward the patient’s umbilicus.
Advance it to the 5 cm mark.
Support the rigid rectosigmoidoscope at the anus with the left
hand (Figure 71-5A). This is necessary so that if the patient moves,
the instrument will move with the patient. Remove the obturator
Umbilicus
and place it on the Mayo stand. Close the eyepiece and insufflate air
into the rectum. FIGURE 71-6. Insertion and advancement of the rigid rectosigmoidoscope. A. The
One must control the insertion and direction of the rigid rec- scope is inserted and aimed toward the umbilicus. B. Moving the handle anteriorly
tosigmoidoscope with the right hand while stabilizing it with will direct the tip of the scope posteriorly. C. The rectosigmoid junction is located
the left hand (Figure 71-5A). Continue to slowly advance the rigid approximately 16 cm from the anus, where the rectal lumen turns anteriorly and
rectosigmoidoscope under direct viewing while simultaneously to the right.
lesions, masses, mucosal irregularities, and/or polyps. Document

any findings in the medical record.
AFTERCARE
The patient may be discharged home after the procedure if there
are no complications and there is no other reason to admit them
to the hospital. They may experience mild discomfort, flatus, and
spotting of blood in the stool for several hours. Instruct the patient
to immediately return to the Emergency Department if they develop
a fever, abdominal pain, nausea, vomiting, bright red blood per rec-
tum, or if they have any concerns. Follow-up should be arranged
with a Family Practitioner, Internist, Gastroenterologist, or Surgeon
depending upon the findings of the examination.
COMPLICATIONS
The primary complication of rigid rectosigmoidoscopy is perfora-
tion of the rectum or sigmoid colon. Air insufflation may cause an
existing perforation, such as may be associated with diverticulitis, to
burst, and is the reason one should not perform this examination if
the patient has existing peritonitis. Perforation can occur with force-
FIGURE 71-7. The rigid rectosigmoidoscope is rotated in a circular motion while ful insertion of the instrument without viewing the colonic lumen
simultaneously withdrawing the scope and visualizing the mucosa. or if the patient moves suddenly and the scope is not supported with
the left hand. Perforation may also occur with instrumentation in
related procedures, such as a biopsy. Perforation should be almost
nonexistent if one supports the scope well, views the colonic lumen
the distal tip of the rigid rectosigmoidoscope to follow the lumen of while advancing the scope, and listens to the patient about com-
the rectum (Figure 71-6). The sigmoid colon can also be identified plaints of pain.
by the presence of transverse folds that are lacking in the rectum. Minor complications may occur. Trauma to the mucosa from the
The rectosigmoid junction is approximately 16 cm from the anus rigid rectosigmoidoscope or instrumentation in related procedures,
and can be seen when the lumen turns anteriorly and to the right such as a biopsy, can result in minor bleeding that is usually self-lim-
(Figure 71-6C). It is necessary to use the rigid rectosigmoidoscope ited. Brisk bleeding can be controlled by the judicious use of a silver
to gently straighten the colon while completely inserting the instru- nitrate matchstick. Bacteremia may occur in up to 10% of patients.
ment to a depth of 25 cm. It is important to view the bowel lumen Antibiotic prophylaxis for endocarditis should be administered, if
at all times. Never advance the instrument blindly as this may indicated, prior to the procedure. Mild abdominal discomfort and
cause a perforation. flatus can last a few hours.
Maintain communication with the patient, inform them of what
is happening, and elicit the status of their comfort. Open the eye- SUMMARY
piece if it becomes clouded with moisture and wipe it with dry gauze
Rigid rectosigmoidoscopy is inexpensive, easy to perform, and
so the view is kept clear. Do not keep your face near the eyepiece
useful in bowels with poor preparation or where a wider access is
when opening the eyepiece. The insufflated air may forcefully expel
needed. These characteristics make the instrument useful in many
stool and secretions. The bowel must be reinflated when the eye-
indications. With proper training and understanding of the anat-
piece is reclosed.
omy, this examination is well tolerated by the patient and will be
After the rigid rectosigmoidoscope is advanced to 25 cm, or as
useful to diagnose and treat many colonic and rectal problems.
far as the patient will allow, slowly remove it with a circular motion
(Figure 71-7). View the mucosa while removing the rigid rectosig-
moidoscope in a circular motion. This flattens out the haustra and
valves of Houston so that the entire mucosal surface can be viewed.
Attempt to keep at least 50% of the colonic lumen in view at all
Rectal Foreign
times. Open the eyepiece just prior to completely removing the rigid
rectosigmoidoscope to release as much of the insufflated air as pos-
sible. This will make the patient more comfortable.
72 Body Extraction
The viewing window, which seals in the air, must be opened if it is Charles Orsay and Eric F. Reichman
necessary to biopsy or to grasp something. This will result in the col-
lapse of the rectum and loss of view. It is important to place the tip INTRODUCTION
of the rigid rectosigmoidoscope over the area in question so it will
stay in the examiner’s view. The obturator should be reinserted if it Foreign bodies within the rectum are the result of an ingestion from
is necessary to reinsert or readvance the rigid rectosigmoidoscope. above or are placed into the anus from below.1 Fortunately, the major-
ity of items ingested from above that pass the pylorus and ileocecal
valve also pass the anal sphincter. The most frequent types of items
ASSESSMENT
found in the anus from above are undigested fish or chicken bones.
Completely and carefully inspect the colonic mucosa. Note the Foreign bodies that are placed into the rectum from the anus are
presence, location (i.e., anterior, posterior, left, and right), and placed iatrogenically (e.g., enema tips and thermometers), inserted
the depth of any bleeding, diverticulum, fistulas, hemorrhoids, by the patient in an attempt to remove impacted stool, inserted by
CHAPTER 72: Rectal Foreign Body Extraction 459
the patient or their partner as a form of anorectal auto-eroticism, are removed at home. It is estimated that very few objects inserted
forcibly placed in the anus during a rape, or placed in the rectum to through the anus will pass spontaneously. Waiting is detrimental for
smuggle objects across a border illegally. the vast majority of items. Sharp foreign bodies may already have
The items placed into the rectum from the anus seem to be limit- begun to perforate the rectum. Large foreign bodies will continue
less and represent all the shapes and sizes imaginable.2 This makes to cause irritation and edema, making removal more difficult with
their removal more difficult. It is important to attempt to identify the passage of time.
the characteristics of the foreign body in order to devise the safest
way of removal. As an example, consider the typical electric light- CONTRAINDICATIONS
bulb. The glue that attaches the metal base to the glass loosens with
moisture and time. Pulling off the metal base exposes a thin, sharp There are a few absolute contraindications to removing a rectal for-
glass edge. The glass globe is very thin and breaks very easily. If the eign body in the Emergency Department. However, the removal of
glass breaks, it may take a long time to remove the fragments and a rectal foreign body that has not perforated is not an emergency.
cause considerable damage to the surrounding rectal mucosa or the Time taken to plan the removal and obtain adequate anesthesia
examining finger. The idea is to remove the foreign body with- and relaxation of the anal sphincter muscles is well spent, espe-
out causing further damage to the rectum or the anal sphincter cially if the object is difficult to retrieve. The patient’s general con-
muscle. The more knowledge the Emergency Physician has about dition must be taken into account. Patients with peritonitis require
the foreign body and how it was inserted, the more likely it is that it operative removal and exploration. The time taken to remove the
will be removed safely. object is wasted and identification of the perforation is easier in
the Operating Room with the item in place. Patients with lower
ANATOMY AND PATHOPHYSIOLOGY abdominal pain and fever may have a perforation below the perito-
neum that can be confirmed with a water-soluble contrast enema.
The significant anatomy of the anal canal is discussed in Chapter 70, Foreign bodies that are large, irregularly shaped, or have sharp edges
describing the anatomy for anoscopy. Important anatomic consid- should be extracted in the Operating Room. In patients who have
erations in removing rectal foreign bodies include the axis of the been assaulted, a complete assessment of all the patient’s injuries is
lumen of the anus. The anus is pointed toward the patient’s umbili- mandatory. It usually is better to leave the object in place to help
cus, while the curve of the sacrum forms a posterior arc. If the length identify all the possible associated injuries that may have occurred.
of the foreign body is longer than the curve of the sacrum, such as The foreign body should be removed in the Operating Room if it
a long vibrator or dildo, the sacral promontory causes the distal end is not palpable, not visible upon dilating the anus, or removal of
of the foreign body to be directed toward the tip of the sacrum or the object may cause injury to the patient. Packets containing illicit
coccyx. When the object is being removed by bringing the distal drugs should be extracted with a rigid rectosigmoidoscope or in the
end anteriorly, the middle portion may push anteriorly (i.e., into the Operating Room. Rupture of the packets can result in significant
prostate, uterus, or bladder) and cause considerable discomfort. morbidity and mortality.
The important physiologic considerations include the anal
sphincter muscles, edema, and the creation of a vacuum. The anal
sphincter is a complex group of muscles. The external anal sphinc- EQUIPMENT
ter muscle is made up of voluntary muscle fibers. The internal • Local anesthetic solution with epinephrine (1% lidocaine or 0.5%
anal sphincter muscle is made of smooth muscle fibers. The reflex bupivacaine)
response to dilatation of the rectum is contraction of the external
• 25 gauge needle, 2 in. long
anal sphincter muscle. The normal tone of the anal sphincter comes
from the internal anal sphincter, which can go into spasm with • 10 mL syringe
manipulation. • Povidone iodine or chlorhexidine solution
Therefore, it is very important to try to remove foreign bod- • Anoscope
ies with slow and steady traction. Maintain constant pressure and
• Ring forceps
wait for the sphincter muscle to fatigue. The technique is not too
dissimilar to the methods used to relocate a shoulder. The slow and • Tenaculum
constant traction will also help with the edema that forms around • Park retractor
rectal foreign bodies that have remained in the rectum for a pro- • Hill-Ferguson retractor
longed period of time.
Finally, it is important to consider the formation of a vacuum, • Large spoons
which may result from pulling a large, smooth foreign body such as • Foley catheters
a bottle or lightbulb. It is sometimes necessary to place one or more • Endotracheal tubes
soft catheters above the foreign body so that air may get around the
• Endoscopic snare
object as it is removed. This will prevent the formation of a vacuum
and allow the foreign body to be removed. Large Foley catheters • Rigid rectosigmoidoscope
with the balloon inflated can be used for air insertion to prevent • Vacuum extractor (optional)
the vacuum and traction to bring the object further down into the
rectum. PATIENT PREPARATION
The patient must undergo a complete history and physical exami-
INDICATIONS
nation. It is important to ascertain the overall health of the patient
The indication to remove a foreign body from the rectum is the in case it is necessary to go to the Operating Room to extract
identification of a foreign body in the rectum. The majority of the foreign body. Attempt to identify patients with rectal per-
patients with this problem have already tried to pass the item with forations as they need to go to the Operating Room quickly.
a bowel movement. They may also have already tried oral laxatives. Biplane plain radiographs with an upright are useful to determine
It is impossible to estimate the number of rectal foreign bodies that the number, shape, and location of the foreign bodies as well as the
FIGURE 72-1. Anesthesia of the anal region. A. Local anesthetic solution is infiltrated subcutaneously and circumferentially around the anus. B. Injection of local anesthetic
solution into the anal sphincter muscles.
presence of free air under the diaphragm. It is necessary to look at a sharp foreign body. If the examiner is not able to palpate the for-
both the anteroposterior view as well as the lateral view to com- eign body, a rigid rectosigmoidoscope should be used to identify
pletely appreciate the object in three dimensions.1 It is important and remove the object. The technique of rigid rectosigmoidoscopy
to inform the patient in advance that while 90% of the objects can is described in Chapter 71.
be removed from below, some may require general anesthesia or
even an operation and a temporary colostomy. Explain the local ANESTHESIA
anesthesia and the extraction procedures to the patient and/or
their representative. Obtain an informed consent for the extraction The second general consideration is to have a relaxed anal sphincter.
of the foreign body. The use of intravenous or procedural sedation will relax the patient
Ascertain the type and number of objects in the rectum. It is and relieve any discomfort associated with the procedure. It may
possible to remove one foreign body and miss others that the be necessary to inject the anus with local anesthetic solution if the
Emergency Physician was not aware were present. Unfortunately, it patient experiences pain or if slow steady traction will not overcome
is common to find that the patient is unsure of this part of the his- the tone of the anal sphincter.3,4 Anesthesia of the sphincter muscles
tory; this is why plain radiographs can be so helpful. It is also impor- will provide for patient comfort and allow dilation of the sphincter
tant to identify the technique of insertion. Patients with objects that muscles. Place the patient in the lithotomy position (Figure 72-1A).
were inserted forcefully should undergo a trauma-oriented workup, Wipe away any dirt, debris, and fecal material from the perianal
and sexual abuse must be considered. Determine the length of time skin and surrounding area. Apply povidone iodine or chlorhexidine
since insertion. Edema formation will be significant if the object has solution and allow it to dry. Inject local anesthetic solution subcu-
been present more than 24 hours. This will make it more likely that taneously and circumferentially around the anus (Figure 72-1A).
an anesthetic will be needed or that it will be necessary to use cath- Inject 1 to 1.5 mL of local anesthetic solution into the anal sphincter
eters to break the vacuum that forms during extraction. muscles at the 12, 3, 6, and 9 o’clock positions (Figure 72-1B).
The parts of the physical examination that are most helpful An alternative is a pudendal nerve block. Determine if the ischial
are the abdominal and rectal examinations. The abdominal exami- spines are palpable through the rectum. Insert the needle through
nation should focus on the presence or absence of tenderness, peri- the skin and toward the ischial spine. Use the finger inside the rec-
tonitis, and the palpation of a mass. Many objects are long enough tum to palpate and guide the needle to the ischial spine. Inject 3 to
to be palpated in the left lower quadrant. It may be useful to apply 5 mL of local anesthetic solution just medial to the ischial spine.
pressure on the lower portion of the abdomen to help remove the Repeat this procedure on the other side. The main disadvantage of
object. The rectal examination should include a careful external the pudendal nerve block is that it is a blind procedure and has the
examination looking for evidence of trauma. The digital portion potential for a needle stick. If these are not successful, it will be nec-
of the examination should roughly quantify the sphincter tone and essary to take the patient to the Operating Room for regional or
squeeze pressure. general anesthesia.
The remainder of the examination should consist of careful pal- The patient may remain in the lithotomy position for the extrac-
pation of the foreign body to determine its location, texture, and tion of the foreign body (Figure 72-2A). Other positions include the
mobility and to identify possible areas to grasp. Examples would modified Lloyd Davies position (Figure 72-2B) and the Sims posi-
include the open end of a bottle or the narrow end of a lightbulb. tion (Figure 72-2C). The choice of positions is physician dependent
Determining if the object is hard, soft rubber, or plastic will help and limited by patient comfort.
determine which tool would be best suited to grasp the object. One
exception to performing the digital rectal examination would be
TECHNIQUES
determining, on radiographs or by history, whether the object is
sharp (such as a knife blade) or consists of broken glass. It is rec- It is important to understand that since the types of foreign bod-
ommended to postpone the digital rectal examination, especially ies found in the rectum are so variable, it is impossible to give
in prisoners and psychiatric patients, until a radiograph rules out exact instructions on how to remove them. There are some general
foreign body is visualized. Blind insertion of instruments may

push the foreign body more proximally or perforate the rectum.
Never grasp a foreign body blindly. This can cause injury to the
rectum upon removal of the instrument if the rectal mucosa is
entrapped between the instrument and the foreign body.
DIGITAL EXTRACTION TECHNIQUE

Foreign bodies within reach may be grasped with the fingers and
extracted. This often proves very difficult as the foreign body will
be coated with lubricant, mucus, and/or stool. Instruct the patient
to bear down as if having a bowel movement. The intraabdominal
pressure generated in this way may expel the foreign body. The for-
eign body may become entrapped against the sacrum. Insert a fin-
ger into the rectum to dislodge the foreign body from against the
sacrum as the patient continues to bear down. Attempt one of the
techniques described below if digital extraction is ineffective.

A Foley catheter has been successfully used to aid in the extraction
of rectal foreign bodies.5–7 This is especially helpful if the foreign
body is made of glass, an inverted bottle or can, large, or present
for more than 12 to 24 hours. Pulling these types of foreign bodies
can result in the formation of a vacuum proximally and inhibit their
extraction.
Liberally lubricate a Foley catheter. Insert the Foley catheter
between the foreign body and the rectal mucosa. Advance the cathe-
ter until the balloon is proximal to the foreign body (Figure 72-4A).
Fluoroscopy, if available, can be used to confirm the location of the
balloon and guide the removal of the foreign body.13 Inflate the bal-
loon with 30 mL of saline or water. Inject air with a syringe through
the Foley catheter to break the vacuum proximal to the foreign
body. Remove the syringe so that air can move freely through the
Foley catheter and prevent a vacuum from becoming reestablished.
Apply constant, gentle, and steady traction to the Foley catheter.
This will prevent the foreign body from migrating proximally. It
may also move the foreign body distally so that it can be grasped
and extracted with fingers or an instrument. The use of two to four
circumferentially placed Foley catheters may apply evenly distrib-
uted traction to extract the foreign body more easily.
FIGURE 72-2. Patient positioning for removal of rectal foreign bodies. A. Lithotomy
position. B. Modified Lloyd Davies position. C. Sims or lateral decubitus position. ENDOTRACHEAL TUBE TECHNIQUE
An endotracheal tube has been used in place of a Foley catheter by
some physicians (Figure 72-4B). The advantage of using an endo-
tracheal tube is that it is relatively stiff and can apply more traction
considerations to remember. The first is to visualize the foreign
than a Foley catheter to help remove the foreign body. Unfortunately,
body. Gentle suprapubic pressure will often push the foreign body
there are also disadvantages. The endotracheal tube is larger and less
into the distal rectum. The distal end of the foreign body may get
flexible than a Foley catheter. This may result in difficulty advanc-
caught along the curve of the sacrum. Place a finger in the rectum ing it past the foreign body. The larger and stiffer endotracheal tube
to redirect the orientation of the foreign body. The second con- can more easily lacerate the rectal mucosa and perforate the rec-
sideration is to grasp the object. Sometimes an object is low-lying tum. For these reasons, the use of an endotracheal tube cannot be
and may be grasped with gloved fingers. The object can then be recommended.
removed by gentle continuous traction. Low-lying objects may be
soft enough to be grasped with an instrument. It is necessary to do
this under direct vision so that the rectum will not be damaged
SPOON TECHNIQUE
in the attempt to grasp the foreign body. Hard, low-lying objects The removal of smooth, round, fragile, or glass foreign bodies can
made of metal or plastic may be grasped with a tenaculum. be problematic. This can include lightbulbs, balls, fruits, and veg-
Insert two well-lubricated fingers into the anesthetized anus and etables. These foreign bodies can be extracted with a pair of large
gently dilate the anal sphincter muscles. The anus can be main- spoons. Liberally lubricate the posterior surface of a pair of spoons.
tained in the open position by the insertion of a Park retractor Insert a Foley catheter to eliminate the vacuum proximal to the for-
(Figure 72-3A) or a Hill-Ferguson retractor (Figure 72-3B). An eign body. Insert the spoons until they are cupping the foreign body
anoscope or vaginal speculum may be used if these retractors are (Figure 72-4C). Grasp and gently squeeze the handles of the spoons
not readily available in the Emergency Department. View the dis- so that they hold the foreign body. Withdraw the spoons and the
tal end of the foreign body. Never insert instruments unless the foreign body.
FIGURE 72-3. Retractors placed in the anus allow for better exposure and easier extraction of the foreign body. A. The Park retractor. B. The Hill-Ferguson retractor.
A more readily available alternative to large spoons are obstet- It may be beneficial to have an Obstetrician, Gynecologist, Family
ric forceps. These have also been successfully used to extract a Practitioner with obstetric experience, or a Nurse Midwife to assist
rectal foreign body. The use of obstetric forceps cannot be recom- with this technique.
mended due to their large size, unfamiliarity to most Emergency Insert a Foley catheter to eliminate the vacuum proximal to the
Physicians, and the potential to perforate the rectum. foreign body. Place the vacuum cup of the device onto the foreign
body. Ensure that none of the rectal mucosa is entrapped between
RING FORCEPS OR TENACULUM TECHNIQUE the rim of the suction cup and the foreign body. Apply the suction
to seal the cup against the foreign body. Recheck to ensure that
Rectal foreign bodies that are not fragile may be grasped with a ring none of the rectal mucosa has become entrapped. Apply steady
forceps or tenaculum and then extracted. Insert a Foley catheter to traction to extract the foreign body.
eliminate the vacuum proximal to the foreign body. Firmly grasp
the foreign body with a ring forceps or a tenaculum (Figure 72-4D). MISCELLANEOUS TECHNIQUES
A tenaculum has teeth on its distal tips. These may be advantageous
as the teeth can grip and firmly hold the foreign body, making the Numerous other techniques have been devised to remove a rectal
extraction easier. This must be performed under direct visualiza- foreign body.9–12 These include the use of proctoscopes and snares,
tion to ensure that the rectal mucosa is not entrapped between de Pezzer catheters, cyanoacrylate glue, clamps covered with rub-
the instrument and the foreign body. Apply gentle, firm traction ber tubing, a tonsil snare, Sengstaken–Blakemore tubes, and plaster
to extract the foreign body. of Paris. Cyanoacrylate glue can be used to attach a handle to the
foreign body. The foreign body can be extracted by withdrawing the
handle after the glue has dried. A Sengstaken–Blakemore tube can be
VACUUM EXTRACTION TECHNIQUE
inserted into a foreign body with a small opening (e.g., glass bottle,
A vacuum dart or obstetrical vacuum extractor may be used to soda can, etc.). Inflate the balloons and apply traction to extract the
extract a rectal foreign body.6,8 Emergency Physicians are usu- foreign body. Plaster of Paris can be used to fill a hollow object and
ally not trained in the proper use of a vacuum extraction device. allowed to harden around a tongue blade (Figure 72-4E). This is
FIGURE 72-4. A sampling of methods to remove rectal foreign bodies. A. Foley catheter technique. B. Endotracheal tube technique. C. Spoons to remove a fragile object.
D. Ring forceps technique. E. Plaster and a tongue depressor are placed in a jar. After the plaster cures, the tongue depressor can be used as a handle to remove the jar.
analogous to making a popsicle on a stick. The major disadvantage ASSESSMENT

of using plaster of Paris is that it generates heat as it hardens. This
heat may damage the rectal mucosa or shatter a glass bottle. The Examine the rectum with a rigid rectosigmoidoscope to assess the
technique used and the choice of devices are limited only by one’s mucosa for tears or perforations after the foreign body is extracted.
imagination. Some physicians believe that this examination is not necessary if the
patient is asymptomatic, the foreign body is smooth, it was extracted examination. Rectal bleeding is common after a difficult extrac-
atraumatically, and no complications arose from the extraction pro- tion. It is important to rule out a perforation. This can be performed
cedure. These patients may be discharged with follow-up as an out- with the rigid rectosigmoidoscope after the extraction. Most per-
patient for rectosigmoidoscopy. If obvious damage to the mucosa forations occur at the rectosigmoid junction, approximately 15 to
exists, the patients should remain in the hospital for observation. 16 cm from the anus. Perforation above the peritoneal reflection
The patient should remain NPO and be prepared for possible sur- will result in peritonitis and free air noted under the diaphragm on
gery. Other indications for admissions include abdominal pain, upright plain radiographs. Perforation below the peritoneal reflec-
significant bleeding, or the suspicion of a rectal perforation. Broad- tion may take several days to manifest pelvic pain, signs of a pelvic
spectrum intravenous antibiotics should be administered if a rectal abscess, or sepsis. If there is no evidence of perforation or signifi-
perforation is suspected. cant mucosal damage, the patient may still be discharged. However,
Perform a digital rectal examination to document the presence large amounts of bleeding or significant mucosal damage require
and quality of anal sphincter tone after the procedure. This should observation at the least. A Gastrografin enema without the use of
be delayed until the effects of any general, local, or regional anesthe- the balloon may be used to identify a perforation if there is signifi-
sia have dissipated. Rectal tone that is decreased or diminished from cant concern that it exists. Patients with perforation of an unpre-
the initial (i.e., preprocedural) digital rectal examination requires pared rectum require surgical intervention and broad-spectrum
the consultation of a General or Colorectal Surgeon. intravenous antibiotics. Any evidence of acute sphincter damage
requires a surgical evaluation for possible debridement. The major-
AFTERCARE ity of these lesions are observed, allowed to heal secondarily, and
then repaired surgically.
Patients may be discharged home after the extraction procedure if
they are asymptomatic, have normal rectal tone, and have no com- SUMMARY
plications demonstrated on rigid rectosigmoidoscopy. They should
be instructed to return to the Emergency Department immediately The majority of rectal foreign bodies can undergo transanal
if they develop abdominal pain, pelvic pain, bright red blood per extraction. Removal of rectal foreign bodies should include an
rectum, or a fever. appropriate history and physical; biplane abdominal radiographs;
relaxation of the anal sphincter; firm attachment to the foreign body
and slow, firm traction extraction; and postextraction rectosigmoid-
COMPLICATIONS
oscopy. Inpatient observation is indicated if the rectal mucosa is
The major complications include rectal bleeding, rectal perforation, traumatized. The patient should be taken to the Operating Room if
and damage to the anal sphincter. Since the patient may very well the foreign body cannot be removed in the Emergency Department,
have presented with these complications, it is important to doc- for pain control, if a perforation is suspected, or if removal may
ument them or their absence on the initial (i.e., preprocedural) result in secondary injury.
SECTION
Orthopedic and Musculoskeletal Procedures 6

provide pain control, and promote healing. The goal of injection
Bursitis and into tendon sheaths and bursae is to attain concentrated steroid
73 Tendonitis Therapy levels to maximize the local anti-inflammatory effect while mini-
mizing systemic effects.
Dedra Tolson
INDICATIONS
INTRODUCTION Injections of corticosteroids should be performed for an inflamma-
Bursitis and tendonitis are frequent complaints evaluated in the tory bursitis or synovitis when systemic therapy is contraindicated
Emergency Department. Bursitis represents an acute or chronic and as an adjunct to physical therapy or systemic therapy. Many
inflammation of the bursa. Similarly, tendonitis involves inflam- inflammatory conditions, including articular and nonarticular pro-
mation surrounding the bony insertion sites of the tendons. cesses, are improved with local corticosteroid injection therapy.1,7,8
Typically, these complaints are treated conservatively with reduc- The articular processes that are helped by injection therapy include
tion of inflammation as the goal. Treatment often includes rest, gout, pseudogout, spondyloarthropathies, rheumatoid arthritis,
elevation, application of cold and heat, and the introduction of neuritis, osteoarthritis, and crystalloid arthropathies. The nonar-
anti-inflammatory agents. However, joint and soft tissue injections ticular processes that are helped by injection therapy include bur-
are helpful for both the diagnosis and therapy of a variety of mus- sitis, periarthritis, adhesive capsulitis, tenosynovitis, epicondylitis,
culoskeletal complaints. Diagnostic goals include a means for fluid trigger points, ganglion cysts, entrapment syndromes, tendonitis,
aspiration and to provide symptom relief of the affected body part. plantar fasciitis, and neuritis.
Therapeutic goals include delivery of local anesthetics for acute
pain relief, delivery of corticosteroid for suppression of inflam- CONTRAINDICATIONS
mation, and increased mobility.1 Injection therapy along with the
Both absolute and relative contraindications should be assessed
above generalized treatment guidelines are a critical component of
when corticosteroid injection therapy is contemplated. The abso-
a multifaceted treatment regimen that should be considered by the
lute contraindications include overlying cellulitis, septic arthritis,
adjacent acute fracture, bacteremia, unstable joints, joints contain-
Definitive care can often be easily initiated by the administration
ing a prosthesis, and a history of an allergy or anaphylaxis to local
of a steroid injection during the patient’s earliest presentation. It has
anesthetics. Relative contraindications include inaccessibility of
been shown that the clinical response to injectable corticosteroids
the joint, joints requiring radiographic guidance to ensure proper
is quite positive.2–5 The techniques of aspiration and injection are
needle placement, meniscal or labral tears as a cause of symptoms,
easily mastered. These techniques are generally safe and effective
joints with loose bodies as a cause of symptoms, coagulopathy, anti-
when appropriate guidelines are followed.1 While injection therapy
coagulant therapy, or greater than three injections annually into a
can be effective, it must be remembered that this treatment should
weight-bearing joint. Systemic conditions such as renal failure, car-
not replace cessation or modification of the offending activity if
diac failure, hypertension, diabetes, and other conditions that may
identified.
be affected by the injection of corticosteroids should also be consid-
ered prior to proceeding with any injection therapy.
Bursae are round, fluid filled, pad-like sacs or cavities. There are EQUIPMENT
roughly over 160 bursae in the body. They are usually located at
sites of friction such as joints, or in areas where tendons pass over • Povidine iodine or chlorhexidine solutions
bony prominences. Bursae are lined with a synovial membrane and • Sterile gloves
contain synovial fluid. Their primary purpose is to reduce friction • Sterile drapes and towels
when movement occurs and to provide a mechanical advantage for
• 18 gauge needles, 1.5 to 2 in. long
tendon function. Bursitis often results from trauma, chronic over-
use, inflammatory arthritis such as rheumatoid arthritis, crystal • 22 gauge needles, 1.5 to 2 in. long
deposition, and infection. • 23 gauge needles, 1.5 to 2 in. long
Tendons are fibrous connective tissue bands attaching muscles • 25 gauge needles, 1.5 to 2 in. long
to bones. A synovial sheath containing synovial fluid surrounds
most tendons. Tendons mainly transmit forces from muscle to the • Syringes (1, 5, and 10 mL)
skeleton. Pathologic findings are typified by inflammation, mucoid • Injectable steroidal preparation (Table 73-1)
degeneration, and fibrinoid degeneration.6 • Licocaine (1% and 2%) without epinephrine
Bursitis and tendonitis are often grouped together because the
• Bupivacaine (0.25% and 0.50%) without epinephrine
history, symptomatology, physical examination findings, and
the treatment for these two inflammatory processes often coin- • Mepivacaine (1%) without epinephrine
cide. Corticosteroid injections serve to decrease inflammation, • Adhesive bandages (to be placed postinjection)
465
466 SECTION 6: Orthopedic and Musculoskeletal Procedures
TABLE 73-1 Corticosteroid Preparations Available for Injection

Generic name Trade name Strength (mg/mL) Relative potency Dose range (mg) Biological half-life (h)
Hydrocortisone acetate Cortef Solu-Cortef 25 1 12.5–100 8–12
Triamcinolone acetonide Kenalog-10 10 2.5 4.0–40 18–36
Kenalog-40 40 10.0
Triamcinolone hexacetonide Aristospan 20 8 4.0–25 18–36
Dexamethasone acetate Decadron, Hexadrol, Dexone 4, 8 20–30 0.8–4.0 36–54
Betamethasone sodium phosphate Celestone 6 20–30 1.5–6.0 36–54
Methylprednisolone acetate Medrol, Depo-Medrol, 20, 40, 80 5, 10, 20 4.0–30 18–36
Solu-Medrol
PATIENT PREPARATION target structure is difficult to reach, ultrasound can be helpful.6,10,11

The deep injections requiring ultrasonographic guidance may
Explain the procedure, its risks, and its benefits to the patient and/or require a specialist. The procedure can be time consuming and dif-
their representative. Obtain a written informed consent to perform ficult to perform for the Emergency Physician who does not possess
the procedure. Position the patient so that they are comfortable and the skills and experience with ultrasound-guided procedures.6,10,11
the injection site is easily accessible. Identify the injection site using
the appropriate anatomic landmarks. It may be necessary to out- SUBACROMIAL BURSITIS
line structures with a skin pencil when landmarks are difficult to
palpate. Clean any dirt and debris from the skin. Apply povidone The subacromial bursa lies between the rotator cuff muscles inferi-
iodine or chlorhexidine solutions over the injection site and sur- orly (i.e., supraspinatus, infraspinatus, teres minor, and subscapu-
rounding skin. Allow it to dry. Generally, sterile drapes and gloves laris muscles) and the overlying acromion, teres major muscle, and
are recommended for the novice but are not absolutely necessary deltoid muscle. It cushions the coracoacromial ligament from the
depending upon operator experience.9,12 A no-touch technique is supraspinatus muscle. The subacromial space contains the long
indicated if a sterile field is not created. head of the biceps, the rotator cuff tendons, and the subacromial
bursa. The syndromes of calcific tendonitis, supraspinatus tendon-
itis, and subacromial bursitis are so similar that the signs of each are
TECHNIQUES difficult to distinguish. Anatomic proximity may cause associated
Medication dosing in bursae and soft tissue injections is influenced irritative inflammation of adjacent structures, so that these condi-
by the bursa size, the presence or absence of synovial fluid, the pres- tions often overlap and coexist. Pain from these syndromes is elic-
ence or absence of edema, the severity of synovitis, and the steroid ited by shoulder abduction.
preparation selected. Table 73-1 summarizes the characteristics of Patients often present holding the affected arm in a protective
commonly available corticosteroid preparations. The duration of fashion against the chest wall. The classic sign of subacromial bur-
action is chiefly dependent on the solubility of the preparation. For sitis is tenderness over the greater trochanter that disappears with
example, a dose of 20 to 30 mg of methylprednisolone acetate or arm adduction. The “subacromial painful arc” is painful active
equivalent is appropriate for large spaces such as the subacromial, abduction of the shoulder with maximal pain occurring between
olecranon, and the trochanteric bursae. This can be increased to a 70° and 100° of abduction. This differs from acromioclavicular joint
30 to 40 mg dose if a large amount of synovial fluid is present. A inflammation, which results in a painful arc from 120° to 180° of
dose of 10 to 20 mg is appropriate for intermediate size bursae pres- shoulder abduction.
ent in the wrists, knees, and heels. A dose of 5 to 15 mg is appropri- Three techniques are described to inject the subacromial bursa:
ate for tendon sheaths. Triamcinolone hexacetonide and acetonide the lateral approach, the anterior approach, and the posterior
are the least soluble preparations available. The local effects of these approach. The lateral approach is the most commonly used tech-
steroid preparations may take several days for effects to be noticed nique. Some prefer the anterior (or subcoracoid) approach provided
initially, but these effects will ultimately last weeks or months. More that the practitioner has good familiarity with the anatomic land-
soluble preparations such as hydrocortisone acetate have effects that marks. However, the anterior approach is more difficult for the less
last a few days. Many physicians prefer triamcinolone due to its pro- experienced to perform.
longed duration of action. Corticosteroids are often mixed with a Place the patient seated upright or supine on a gurney. Palpate
local anesthetic solution prior to injection. The local anesthetic the indentation under the acromion process of the scapula for the
solution provides immediate pain relief for the patient. It also lateral approach. This indentation is located between the acromion
confirms for the physician that the injection was placed at the process and the greater tuberosity of the humerus. Fill a syringe with
appropriate anatomic site. If less volume is needed for the injec- 1 mL of local anesthetic solution and 1 mL of a selected corticoste-
tion, consider using higher concentrations of local anesthetics such roid such as dexamethasone. Apply a 22 to 25 gauge needle to the
as 2% lidocaine instead of 1%. syringe. Insert the needle into the indentation and direct it supero-
Injection techniques for pediatric patients are not different than medially. Advance the needle until the tip touches the inferior sur-
those for adults. However, smaller injected volumes maybe required face of the acromion (Figure 73-1). Inject the steroid–anesthetic
depending on the age and size of the child. Soft tissue corticoste- mixture. Withdraw the needle and apply a bandage.
roid injections should be performed by a Rheumatologist or an Alternative approaches include the anterior and posterior
Orthopedic Surgeon as these injections can affect bone growth, car- approaches. Position the patient as above for the anterior approach.
tilage growth, and damage growth plates. Identify the coracoid process of the scapula. Insert the needle 1.5 cm
The sites for joint injections are typically based on anatomic land- lateral to the coracoid process. Direct the needle horizontally and
marks. When superficial bursitis, tendonitis, and large effusions posteriorly. Advance the needle approximately 2.5 cm to gain direct
are involved, ultrasound may be helpful if available and depending access to the subacromial space. Inject the steroid–anesthetic mix-
upon physician experience. When deep bursae are involved or the ture. Withdraw the needle and apply a bandage.
CHAPTER 73: Bursitis and Tendonitis Therapy 467
FIGURE 73-3. Injection for painful arch (impingement) syndrome.
common. The clinical hallmark is a painful arch of abduction from

60° to 120°. Pain typically begins at 60° to 70° of abduction and is
FIGURE 73-1. Lateral approach for subacromial bursitis. maximal from 100° to 120°. Tenderness at the tendon insertion site
over the greater tuberosity of the humerus may be present.
The impingement injection test may separate the pain of impinge-
ment from other causes of shoulder pain. First, the examiner pre-
The posterior approach may also be used. The distance from the vents scapular rotation by holding the patients scapula against their
coracoacromial ligamentous arch in this approach is great and may rib cage. Extend the patient’s affected arm in forced forward eleva-
limit efficacy. Place the patient sitting upright with the effected fore- tion. Pain with this movement may signify a number of inflam-
arm resting in their lap. Palpate the most lateral point of the acro- matory shoulder conditions. Repeat this maneuver after injecting
mion process posteriorly. Insert the needle at this landmark. Aim 10 mL of local anesthetic solution beneath the anterior acromion
the needle toward the center of the humeral head and at an upward process. The absence of pain after local anesthetic injection defines
angle of 10° (Figure 73-2). Advance the needle 3 to 5 cm until the an impingement syndrome.
bursa is entered. Inject the steroid–anesthetic mixture. Withdraw Place the patient sitting upright or supine on a gurney. Identify
the needle and apply a bandage. the coracoacromial ligament, which is found by palpating the cora-
coid process and the tip of acromion process. The coracoacromial
ligament connects these two bony points (Figure 73-3). This liga-
SHOULDER IMPINGEMENT SYNDROME ment is a thick, dense, fibrous band. Fill a syringe with 80 mg of
A shoulder impingement syndrome results from rotator cuff, partic- triamcinolone and 2 mL of bupivacaine or mepivacaine. Apply
ularly the supraspinatus muscle, compression between the humerus a 22 to 25 gauge needle to the syringe.12 Insert the needle under
and the coracoacromial arch. This is part of a pathophysiologic con- the coracoacromial arch and inject the steroid–anesthetic mixture
tinuum with an endpoint of complete rotator cuff rupture in some (Figure 73-3). The plunger should depress easily and without
cases. A history of overhead activities such as painting a ceiling is resistance. Forceful injection indicates that the tip of the needle
is within the rotator cuff tendons. Advance the needle another
0.5 cm and reattempt the injection, seeking minimal resistance.
Withdraw the needle and apply a bandage.
BICIPITAL TENDONITIS
The long head of the biceps tendon passes through the bicipital
groove of the humerus (Figure 73-4). In this condition, the inflamed
tendon is tender to palpation along the anterior humerus. Yergason’s
test is a clinical indicator of bicipital tendonitis. Flex the patient’s
elbow 90°. Grasp the patient’s affected arm as if shaking hands. A
positive test is the elicitation of pain in the biceps muscle while the
examiner provides resisted supination to the patient’s hand. Lipman’s
test is another clinical indicator of bicipital tendonitis. Tenderness
of the bicipital tendon as it is rolled or plucked within the bicipital
groove is considered a positive test. In general, pain causes restricted
motion. Shoulder elevation will aggravate the patient’s symptoms.
Place the patient seated with the affected arm externally rotated
20°. The bicipital groove and tendon are now pointing directly
FIGURE 73-2. Posterior approach for subacromial bursitis. anterior. Fill a syringe with 10 to 15 mg of triamcinolone and 2 mL
area and redirecting the tip 2.5 cm inferiorly to the first injection site
and touching the border of the bicipital groove (Figure 73-4(3)).
LATERAL EPICONDYLITIS (TENNIS ELBOW)

Lateral epicondylitis, or tennis elbow, is pain at the origin of the
wrist and finger extensor muscles. Pain is elicited on palpation
of the lateral epicondyle of the humerus. It is also elicited during
resisted wrist extension. A history of playing racquet sports or doing
manual labor is common.
Locate the injection site by palpating the base of the lateral
epicondyle with the elbow flexed 90°. Fill a syringe with 1 mL of
local anesthetic solution, 1 mL of methylprednisolone, and 0.5 mL
of dexamethasone. Apply a 22 to 25 gauge needle to the syringe.
Alternatively, mix the local anesthetic solution with 40 mg of triam-
cinolone. A total volume of 2 mL is required. Insert the needle in
the indentation between the lateral epicondyle and the radial head,
beginning at the radial head (Figure 73-5A). Slowly advance the
needle toward the lateral epicondyle. The radial nerve runs in this
area, and care must be taken not to penetrate and inject the nerve.
FIGURE 73-4. Injection for bicipital tendonitis. Paresthesias and pain will be felt if the needle enters the nerve.
Inject 0.5 mL of the steroid–anesthetic mixture into the teno-
periosteum at the base of the lateral epicondyle. Withdraw the
needle until the tip is at the level of the radial head while simulta-
of local anesthetic solution. Apply a 22 to 25 gauge needle to the neously infiltrating with 0.25 mL of the steroid–anesthetic mixture.
syringe. Palpate the bicipital tendon and identify the point of maxi- Infiltrate 0.5 mL of the steroid–anesthetic mixture when the tip of
mal tenderness. Insert and direct the needle into the tendon sheath the needle reaches the level of the radial head. Redirect the needle
and aim toward the border of the bicipital groove at the site of maxi- over the proximal extensor muscle bellies (Figure 73-5B). Inject
mal tenderness (Figure 73-4). Inject one-third of the dose into the the remaining steroid–anesthetic mixture in a fan-like pattern over
peritendinous space (Figure 73-4(1)). Confirmation of the needle the extensor muscle bellies (Figure 73-5B). Withdraw the needle
placement within the tendon sheath is made by free flow of the and apply a bandage.
steroid–anesthetic mixture with minimal resistance. Difficulty
depressing the plunger indicates that the tip of the needle is
MEDIAL EPICONDYLITIS (GOLFER’S ELBOW)
within the tendon. If resistance to injection occurs, withdraw the
needle slightly and aim more parallel to the tendon to allow pen- Patients affected with medial epicondylitis, or golfer’s elbow, are
etration of the sheath and not the tendon substance. Withdraw most commonly Little League pitchers, golfers, and bowlers. Pain
the needle to just under the skin and redirect it 2.5 cm superiorly, is felt in the medial aspect of the elbow upon flexion and supina-
touching the border of the bicipital groove, and inject another one- tion of the wrist. Tenderness is elicited on palpation just distal to the
third of the dose (Figure 73-4(2)). The final one-third of the dose medial epicondyle. It is important to exclude an avulsion fracture of
is deposited by again withdrawing the needle to the subcutaneous the medial epicondyle or a compression fracture of the subchondral
FIGURE 73-5. Injection for lateral epicondylitis. A. The needle is inserted at the level of the radial head and advanced to the base of the lateral epicondyle. B. The needle
is redirected in a fan-like pattern over the muscle bellies.
Seat the patient upright with their elbow flexed 90°. Fill a syringe
with 30 to 40 mg of triamcinolone and 1 mL of local anesthetic solu-
tion. Insert an 18 gauge needle on an empty syringe into the most
dependent aspect of the bursal sac. Aspirate the bursal fluid to drain
it completely. The bursa may be “milked” by palpation and com-
Ulnar nerve pression of the tissues toward the draining needle. Hold the needle
securely. Remove the syringe while the tip of the needle remains
within the bursa. Attach the syringe containing the steroid–anes-
Median artery thetic mixture. Inject the steroid–anesthetic mixture. Withdraw the
and nerve needle and apply a bandage. Wrap the elbow region with an elastic
compression bandage (Jones compression dressing) for 7 to 10 days.
Instruct the patient to limit elbow movement for 7 to 10 days to
prevent reaccumulation of the fluid.14
Medial
epicondyle DEQUERVAIN’S TENOSYNOVITIS
DeQuervain’s tenosynovitis is an inflammation of the tendon
sheaths of the abductor pollicis longus and extensor pollicis brevis
muscles as they cross the wrist (Figure 73-7A). The precise cause is
unknown. Excessive friction from overusing the thumb and wrist
Common
such as repetitive and excessive gripping and grasping may be a pos-
flexor tendon
sible etiology. Cases have been seen in bricklayers, golfers, those
who sew, and piano players. Pain is elicited by the classic Finkelstein
test, in which the patient deviates the wrist ulnarly while holding
the thumb between the palms and fingers (Figure 73-7B). Palpation
along the course of the tendon will also cause pain.
Fill a syringe with 40 mg of triamcinolone and 1 to 2 mL of mepi-
vacaine or bupivacaine. Apply a 25 gauge needle to the syringe.
Bending the needle approximately 30° at its base makes it easier
to negotiate the area and insert the needle alongside the tendon.14
Introduce the needle through the skin overlying the point of maxi-
mal tenderness. This is usually just distal to the radial styloid pro-
cess (Figure 73-8). Inject the steroid–anesthetic mixture into the
FIGURE 73-6. Injection for medial epicondylitis. tendon sheath. Resistance to injection signifies that the tip of the
bone of the lateral condyle or radial head in children with nonfused

Abductor pollicis Extensor pollicis
epiphyses. Radiographs are suggested to exclude these causes. A longus brevis
Place the patient supine on a gurney. Place the arm in 90° of
external rotation and abducted 90°. Flex the elbow 90°. Prepare a
steroid–anesthetic mixture similar to that used for lateral epicon-
dylitis. Identify by palpation the volar surface of the medial epi-
condyle. Insert the needle 2 cm proximal to the medial epicondyle
and advance it distally to the tenoperiosteal region (Figure 73-6).
The ulnar nerve is better protected than the radial nerve, as it
runs posterior to the epicondyle. Proximal needle insertion pre-
vents striking the ulnar nerve. Paresthesias and pain are indica-
tors of nerve penetration. Inject 1.5 mL of the steroid–anesthetic
mixture over the medial epicondyle while withdrawing the needle.
OLECRANON BURSITIS B
Olecranon bursitis is usually sterile even though the olecranon
bursa is the most frequent site of a septic bursitis. The bursa is
located subcutaneously overlying the olecranon process of the ulna.
Olecranon bursitis is not very painful except for the discomfort due
to bursal expansion. An enlarged olecranon bursa may limit elbow
extension. Studies have demonstrated that corticosteroid injection
is superior to oral regimens for resolution of bursal inflammation.13
Simple aspiration without corticosteroid injection is often followed
by reoccurrence. Since the olecranon bursa is the most common
site of a septic bursitis, aspiration with fluid analysis is recom-
mended before corticosteroid injection unless infection can be
ruled out clinically. FIGURE 73-7. DeQuervain’s tenosynovitis. A. Anatomy. B. Finkelstein’s test.
from sleeping on the affected side. Pain is also severe with walk-
ing, especially up stairs. The deep trochanteric bursa lies between
the tendon of the gluteus maximus and the greater trochanter of
the femur. Another lies between the gluteus medius and the greater
trochanter (Figure 73-9). Pain is elicited on palpation of the greater
trochanter of the femur. Pain can be reproduced by hip adduction in
superficial bursitis or on a resisted active abduction in deep bursitis.
The principal bursa lies between the gluteus maximus and the
posterolateral prominence of the greater trochanter. Pain may radi-
ate from the greater trochanter down the lateral or posterior thigh,
mimicking sciatica or hip joint disease. In contrast to these syn-
dromes, passive range of motion of the hip is nearly painless in the
trochanteric bursitis. However, active abduction of the affected hip
while the patient is lying on the unaffected side increases symptoms.
Pain is also elicited by abduction and external rotation of the hip.
Place the patient prone on a gurney. Fill a syringe with 80 mg of
triamcinolone and 3 to 10 mL of local anesthetic solution. Apply a
22 to 23 gauge needle on the syringe. Insert the needle at the point
FIGURE 73-8. Injection for DeQuervain’s tenosynovitis. of maximal tenderness and aimed toward the greater trochan-
ter. Advance the needle until the tip strikes the greater trochanter.
Withdraw the needle 1 to 2 mm and inject the steroid–anesthetic
needle is within the tendon. Withdraw the needle slightly and rein- mixture. Withdraw the needle and apply a bandage.
ject, feeling for the loss of resistance. Withdraw the needle and apply
a bandage. Apply a light thumb splint for approximately 10 days. ISCHIAL BURSITIS
The splint is especially useful at night or when there is significant
activity. The ischial bursa lies between the ischial tuberosity and the over-
lying gluteus maximus (Figure 73-9). It becomes inflamed from
TROCHANTERIC BURSITIS trauma or prolonged sitting on a hard surface. Pain may radiate
down the back of the thigh and mimic sciatica. Pain can be elicited
Trochanteric bursitis typically affects women in the fourth to sixth by applying pressure over the ischial tuberosity.
decades of life. It also occurs in runners, ballet dancers, and as a form Place the patient prone on a gurney. Fill a syringe with 30 to
of overuse or trauma to the hip. Hip pain often prevents the patient 40 mg of triamcinolone and 5 to 10 mL of local anesthetic solution.
FIGURE 73-9. Selected bursa of the hip region.

Apply a 22 to 23 gauge needle to the syringe. Insert the needle over is within the tendon. Withdraw the needle slightly and reinject,
the most prominent section of the ischium. Hip flexion may facili- feeling for the loss of resistance. Withdraw the needle and apply a
tate palpation of the ischium in obese patients. Care must be taken bandage.
not to injure the sciatic nerve. Striking the nerve will cause pares-
thesias across the buttocks and down the leg. Advance the needle ANSERINE BURSITIS
until it contacts the ischial tuberosity. Withdraw the needle 2 to
3 mm and inject the steroid–anesthetic mixture. Withdraw the nee- Anserine or pes anserine bursitis is an inflammation of the bursa
dle and apply a bandage. located 5 cm below the medial joint line of the knee at the tibial
insertion of the gracilis, sartorious, and semitendinosus muscles
ILIOTIBIAL BAND SYNDROME (Figure 73-11). The anserine bursa is superficial to the tibial inser-
tion of the medial collateral ligament. The syndrome occurs pre-
Patients with iliotibial band syndrome present with lateral knee dominately in overweight women with osteoarthritis of the knees. It
pain. This condition is commonly seen in cyclists, dancers, long- may also be found in equestrians. The anserine bursa will be tender
distance runners or walkers, and football players. These patients to palpation.
have a painful limp that is exacerbated with walking or running. Place the patient supine with the affected leg externally rotated.
Climbing stairs or walking up an incline will increase their pain. Identify the anteromedial joint line of the knee. The bursa is located
Tenderness is elicited with the patient lying supine and knee flexed inferior to the joint line at the insertion of the sartorius, gracilis,
90°. Instruct the patient to extend their knee as you press over the and semitendinosus tendons (Figure 73-11). Palpate the area of
lateral femoral condyle. Pain will be localized to the lateral femoral maximal tenderness at this site. Fill a syringe with 40 mg of triam-
condyle. The patient will have pain at 30° of flexion as the iliotibial cinolone and 2 to 4 mL of local anesthetic solution. Apply a 23 to
band slides over the condyle. A positive Rinne test occurs when the 25 gauge needle to the syringe. Insert the needle and direct its tip
patient stands with their weight on the affected leg and flexes their into the bursa at the point of maximal tenderness. Inject the ste-
knee. Pain at 30° of flexion is considered in a positive test. roid–anesthetic mixture into the bursa. Withdraw the needle and
Place the patient supine on a gurney. Fill a syringe with 80 mg apply a bandage.
of triamcinolone and 2 mL of local anesthetic solution. Apply a
22 to 25 gauge needle to the syringe. Typically, at 30° of flexion, PREPATELLAR BURSITIS
the iliotibial band is at the midpoint of the lateral femoral condyle
(Figure 73-10). Support the patient’s leg in this position to bring the Prepatellar bursitis is caused by direct pressure, such as when a
tendon to its most superficial point. Identify the point of maximal person is kneeling on a firm surface. It is also known as nun’s, rug
tenderness as the patient flexes their knee. Insert the needle per- cutter’s, or housemaid’s knee. Tenderness and/or crepitance is elic-
pendicular to the skin and 1 cm inferior to the point of maximal ited by direct palpation overlying the patella. Extreme knee flexion
tenderness. Aim the needle superiorly. Inject the steroid–anesthetic causes pain. There is often a fluctuant, well-circumscribed, and
mixture in an arc from anterior to posterior. The goal is to deposit warm bursal pouch overlying the patella. The prepatellar space is
corticosteroid in the tendon sheath and the surrounding inflamed a common site for septic bursitis. Aspiration with fluid analysis is
tissues. Resistance to injection indicates that the tip of the needle recommended to rule out an infection before any corticosteroid
injection is considered.
Place the patient supine on a gurney with the affected knee
slightly flexed. Note that the bursa is very superficial and may be
entered by passing the needle just through the skin and subcuticular
tissues (Figure 73-11). Fill a syringe with 30 to 40 mg triamcinolone
and 1 to 2 mL of local anesthetic solution. Apply a 23 to 25 gauge
needle to the syringe.14 Insert the needle into the bursa at the point
of maximal fluctuance. Inject the steroid–anesthetic mixture into
the bursa. Withdraw the needle and apply a bandage.
INFRAPATELLAR BURSITIS
The infrapatellar bursa has two components (Figure 73-11). The
superficial infrapatellar bursa lies between the patellar ligament and
the skin. The deep infrapatellar bursa lies between the patellar liga-
ment and the anterior tibia. Inflammation of the superficial bursa
occurs due to friction from the overlying skin. Clinically, there is no
pain with passive flexion. Active knee flexion and extension causes
pain in the deep infrapatellar bursa. Edema and tenderness may be
found on both sides of the patellar tendon.
Place the patient supine on a gurney with the affected leg and
knee extended. Palpate the patellar tendon. Identify the superfi-
cial inflamed bursa. Fill a syringe with 20 mg of triamcinolone and
1 mL of local anesthetic solution. Apply a 23 to 25 gauge needle to
the syringe. Insert the needle into the superficial bursa and inject
the steroid–anesthetic mixture. Withdraw the needle and apply a
bandage.
FIGURE 73-10. Injection for iliotibial band syndrome. The knee is flexed 30° to Patients with deep infrapatellar bursitis have maximal tender-
bring the tendon to its most superficial position overlying the midportion of the ness and swelling both medially and laterally to the patellar tendon.
lateral femoral condyle. Fill a syringe with 30 mg of triamcinolone and 1 to 2 mL of local
FIGURE 73-11. Bursae of the knee.
anesthetic solution. Apply a 23 to 25 gauge needle on the syringe. complain of medial heel pain, particularly after standing for a
Insert the needle into the infrapatellar bursa, either medially or long period of time. These patients have minimal to no swelling
laterally to the patellar tendon. Attempt to aspirate, although fluid but feel acute tenderness to palpation over the calcaneal inser-
accumulation is minimal and usually no return will be found. Inject tion of the plantar fascia. Maximum tenderness is palpated just
the steroid–anesthetic mixture. Withdraw the needle and apply a beneath the spring ligament at the insertion of the plantar fascia
bandage. on the calcaneous. Radiographs may demonstrate a calcaneal spur.
However, the presence of a spur does not correlate with plantar fas-
ciitis. Patients may have plantar fasciitis with or without a calcaneal
ACHILLES TENDONITIS
spur. The optimal therapy for these patients is to elevate the heel
Achilles tendonitis causes tightness and pain in the heel region with a felt heel pad inserted in the shoe. In addition, they may begin
upon first awaking. This discomfort improves with ambulation. stretching exercises that are designed to stretch the plantar fascia.
The Achilles tendon will be tender to palpation and may be visu- This often relieves the condition without an injection. In significant
ally swollen. Corticosteroid injection around the Achilles tendon cases where conservative therapy is unsuccessful, injection of the
has been associated with tendon rupture.15 Therefore, this injection calcaneal insertion of the plantar fascia with a steroid–anesthetic
is reserved for the Podiatrist, Rheumatologist, or the Orthopedic mixture is advocated.
surgeon.15 Place the patient supine on a gurney with the affected leg exter-
nally rotated. Fill a syringe with 20 mg of triamcinolone and 1 mL
of local anesthetic solution. Apply a 25 gauge needle on the syringe.
PLANTAR FASCIITIS
Insert the needle into the medial aspect of the foot and aimed just
Plantar fasciitis is a common problem presenting to the Emergency anterior to the base of the calcaneous (Figure 73-12). Advance the
Department and the primary care physician. Patients typically needle 1.5 cm and inject the steroid–anesthetic mixture. Withdraw
CHAPTER 74: Compartment Pressure Measurement 473
Subcutaneous fat atrophy and atrophy of the overlying skin may

develop if the steroid is injected less than 5 mm beneath the skin
surface. A depigmentation in darker-skinned individuals may also
occur due to superficial steroid injections. The depigmentation typ-
ically resolves spontaneously over a period of 6 months to 1 year.
SUMMARY
Local corticosteroid injections are useful diagnostic and therapeu-
tic adjuncts for the Emergency Physician. Many patients with an
inflammatory bursitis or tendonitis will benefit greatly from these
simple and effective injections. Mastery of the techniques is quite
easy. They require a familiarity with the indications, the local anat-
omy, and the injectable corticosteroid preparations. Complications
associated with the injection of a steroid–anesthetic mixture are
minimal if it is not injected into an infected space.
FIGURE 73-12. Injection for plantar fasciitis.
the needle and apply a bandage. The patient should avoid weight Compartment
bearing for 3 to 4 days and immediately begin oral nonsteroidal
anti-inflammatory drugs. 74 Pressure Measurement
Matt Kleinmaier and Sanjeev Malik
ASSESSMENT
The patient must be observed for several minutes after the injection. INTRODUCTION
Reexamine the patient to compare pre- and postinjection tender-
The ability to diagnose a compartment syndrome is a critical skill
ness and mobility. The patient’s symptoms should abate within a few
for the Emergency Physician (EP). Early identification of a com-
minutes from the local anesthetic. Lack of relief indicates deposition
partment syndrome can enable the appropriate treatment and may
of the steroid–anesthetic mixture away from the target structure. In
facilitate limb salvage. A compartment syndrome begins when an
these cases, a second attempt may be performed if the injection site
imbalance of volume and pressure within a myofascial compartment
can be properly identified. Otherwise, refer the patient to their pri-
results in diminished blood flow.1 A compartment syndrome has
mary care physician, a Rheumatologist, or an Orthopedic Surgeon
been classically described in the early literature as a Volkmann isch-
for reevaluation and reassessment.
emic contracture following vascular insufficiency in the forearm.3
A compartment syndrome can occur in almost any muscle group
AFTERCARE that is contained within a confined fascial space. Common locations
Instruct the patient to limit movement and/or weight bearing of include the leg, forearm, and gluteal area. There are many causes of
the affected area after a corticosteroid injection. The duration of a compartment syndrome. These include protracted muscle isch-
rest is dependent on the injection site. Larger and weight-bearing emia secondary to necrosis from a contusion, swelling secondary to
joints may require up to 2 to 3 weeks of rest, with range-of-motion volume overload states or a fracture, or a thrombus in a vessel that
exercises encouraged. Immobilization with splints or bandages may traverses the compartment. In the Emergency Department (ED),
be necessary to prevent weight-bearing. A rehabilitation program a compartment syndrome is most commonly associated with long
including range-of-motion exercises, stretching, and strengthening bone fractures or blunt trauma.2 Most compartment syndromes are
may be recommended depending upon the chronicity and severity caused by trauma; 58% of all cases are due to fractures of the tibia
of the presenting condition. or forearm.27 Other etiologies for a compartment syndrome include
complications from a coagulopathy, dialysis, surgery, or states of
obtundation (Table 74-1).4–6
COMPLICATIONS Identifying a compartment syndrome in a timely fashion can be
Local infection is rare after corticosteroid joint injection and occurs challenging. The sensitivity and specificity of manual palpation to
from 1 in 17,000 to 50,000 injections.1,8,16,17 A local reaction con- identify a compartment syndrome is 24% and 55%, respectively.34
sisting of swelling, tenderness, and warmth may occur a few hours Manual palpation has a positive predictive value of 19% and a nega-
postinjection and last up to 2 days. This is known as the “postinjec- tive predictive value of 63%.34 Thus, manual palpation cannot be
tion flare” or “steroid flare.”9 It is self-limited, and responds to ice used to rule in or rule out a compartment syndrome. The hall-
packs and nonsteroidal anti-inflammatory drugs. The etiology of mark symptom is persistent and progressive pain that is dispro-
the steroid flare is attributed to preservatives in the steroid suspen- portionate to the underlying cause. The pain typically increases
sion inducing a local synovitis. Steroid flares occur in approximately with passive motion. A catastrophic mistake is to attribute the
2% of patients injected with corticosteroids.1 etiology of the patient’s pain solely to the underlying problem,
Tendon rupture is a theoretical complication thought to be due such as the fracture or trauma.7,8 Other signs and symptoms asso-
to corticosteroids weakening the collagen matrix. Tendon ruptures ciated with a compartment syndrome occur late in the course and
after corticosteroid injections have been reported, but direct cau- include paresthesias of the involved nerve, paralysis of the involved
sality has not been established.15,18–21 Rupture is more likely if the muscle group, pallor of the skin, and diminished pulses.9 Waiting
injection is made into the tendon matrix rather than the synovial for the development of all the clinical signs and symptoms is an
sheath, if the patient does not rest the tendon appropriately after the invitation for permanent and dangerous sequelae, including mus-
injection, or with multiple repeat injections. cle necrosis and possible loss of a limb. Measurement of elevated
TABLE 74-1 Common Causes of a Compartment Syndrome is a potential site for the development of a compartment syndrome.
The muscles, nerves, and vasculature within the affected muscle
Anticoagulation therapy or coagulopathy
Bleeding into compartment group are all potentially compromised by a prolonged ischemic state
Burns which involve muscle followed by swelling. A basic knowledge of the anatomy of com-
Exercise-induced (chronic exertional compartment syndrome) monly affected compartments is necessary to successfully and safely
External compression perform compartment pressure measurement.
Iatrogenic closure of fascial injuries The initial imbalance of a compartment syndrome occurs
Immobility between the volume and pressure within the myofascial compart-
Improper casting or tight dressings ment. The arterial inflow and venous outflow diminish as either
Infusion of fluids into muscle compartment (blown forearm IV) intracompartmental volume or pressure increases. The blood begins
Nephrotic syndrome (lower extremity swelling) to be shunted via capillaries into the muscle tissue. This compensa-
Reperfusion injury after prolonged OR positioning or tourniquet use tory shunting of blood further disturbs the volume–pressure bal-
Seizures (increased capillary permeability) ance, resulting in impaired tissue oxygenation.2,9,10
Trauma The extent of the tissue damage is determined by the duration of
Long bone fractures
ischemia. Numerous experimental studies have documented a lack
Blunt trauma (Crush injury)
Vascular injury
of muscle viability after 6 to 8 hours of total ischemia and a lack of
Venous thrombus nerve viability after 8 hours of total ischemia.11,12 Thus, reversing the
ischemia well before this time period is crucial to restoring tissue
function. The definitive factor in the development of a compart-
ment syndrome is the alteration of the pressure gradient between
tissue pressure within the muscle compartment is currently the arterial and venous flow. Measurement of the intracompartmental
most common objective means of diagnosing this syndrome. pressures is used to determine the extent of ischemia.
Compartment pressure measurement provides objective sup- The pressure of a healthy muscle compartment ranges between
port for the diagnosis of a clinically suspected compartment syn- 0 and 8 mmHg.13 Although there is no absolute value that deter-
drome, leading to the appropriate treatments designed to salvage mines the presence of a compartment syndrome, values above 30 to
the afflicted limb. 35 mmHg are considered abnormal and should be the cutoff point
Numerous methods have been evaluated to diagnose a com- for performing a fasciotomy.9,14,15 Although this value is referred to
partment syndrome.35 The inflammatory biomarkers and proteins commonly, several studies confirm that a compartment syndrome
released from damaged muscle are either late markers or nonspe- does not develop definitively at or above this pressure threshold.16,17
cific to distinguish between muscle injury from trauma versus a A prospective study of patients with isolated lower leg fractures
compartment syndrome. MRI is not reliable or specific to iden- without clinical signs of compartment syndrome showed signifi-
tify the early changes of a compartment syndrome. Pulsed phase- cant elevations in compartment pressure compared to the contra-
locked loop (PPLL) ultrasound identifies subtle movements of the lateral normal leg (35.5 ± 13.6 mmHg in the injured leg vs. 16.6 ±
fascia and may be helpful in the diagnosis. Further investigations 7.5 mmHg in the control leg; P = 0.0001).33 Other studies use a com-
using this technology are required before it can be used clinically. partmental pressure that is within 10 to 30 mmHg of the patient’s
Radionuclide imaging is not feasible in the acute setting of the ED diastolic pressure as one of the indications for a fasciotomy.2,11
due to its lack of specificity, the complexity of the procedure, the Finally, a measurement that is within 10 to 30 mmHg of the patient’s
time required for testing, and the inability to perform repeated mean arterial pressure is also suggested as an indication for a fasci-
measurements. Near-infrared spectroscopy measures changes otomy.18 Nonetheless, if the compartmental pressure is 30 mmHg
in oxygenated hemoglobin and tissue perfusion. Further investi- or greater, one must consider the development of a compartment
gations using this technology are required before it can be used syndrome and the need to perform a fasciotomy.
clinically in the diagnosis of a compartment syndrome. Pulse oxim- Studies have investigated the correlation between perfusion
etry cannot be used to measure intracompartmental oxygenation. pressure (diastolic blood pressure minus compartment pressure,
It can measure if distal blood flow is present but is limited due to also known as delta pressure) and compartment syndrome, with
collateral circulation and the loss of pulses being a late finding for compartment syndrome suggested if delta pressure is less than
a compartment syndrome. Laser Doppler flowmetry measures 30 mmHg.2,11,27 In equivocal cases, newer adjunctive and nonin-
microvascular perfusion and has potential in the future when more vasive testing such as T2-weighted MRI28 and near-infrared spec-
clinical information regarding its use becomes available. Tissue troscopy28,29 may be helpful if available. Despite advances in testing,
ultrafiltration requires the extraction of tissue fluid and the time there is as yet no gold standard for diagnosis, and compartment syn-
consuming measurement of biomarkers. Differences in vibratory drome remains a clinical and operative diagnosis.
sensation using a 256 cycle tuning fork show some promise in the A compartment syndrome can occur in any muscle group. This
diagnosis of a compartment syndrome. It cannot be used in young includes the hand, foot, thigh, arm, and intercostal spaces, to name
children, patients that cannot appropriately communicate, and a few. This chapter reviews the anatomy of the two most common
those with an altered sensorium. Tissue hardness measurement sites of a compartment syndrome, the leg and the forearm.
techniques evaluate skin surface pressure and are in the early stages
of testing. Direct nerve stimulation is not for the early evaluation of LOWER EXTREMITY: LEG
a compartment syndrome because nerve damage is a later finding.
Finally are the invasive techniques to measure compartment pres- The lower leg consists of four distinct muscle compartments: ante-
sure, which are the focus of this chapter. rior, lateral, deep posterior, and superficial posterior (Figure 74-1).
A general understanding of the components of each compartment
is important.19,20
The anterior compartment contains the four extensor muscles of
The anatomy of a compartment syndrome is variable, as it can occur the leg. These muscles function together to dorsiflex the foot. The
in any enclosed muscle group. Any muscle tissue that is confined in deep peroneal nerve travels through this compartment to innervate
space by fascia, skin, or any external forces (e.g., casting material) the extensors and provide sensory innervation to the web space
A Medial Lateral B
Tibialis anterior Anterior
Extensor
compartment
Tibialis posterior hallucis longus
Extensor
digitorum longus
Tibia Lateral
Peroneus compartment
brevis
Flexor
digitorum Peroneus
longus longus
Soleus Fibula
Flexor
hallucis longus
Medial head Lateral head

gastrocnemius gastrocnemius Deep posterior
Superficial posterior compartment
compartment
FIGURE 74-1. Cross section through the middle of the right leg demonstrating the four compartments. The size and proportion of the compartments change as one travels
proximally or distally from this middle section. A. The anatomy. B. The compartments.
between the first and second toes. The anterior tibial artery travels significant because release of the pressure in one compartment will
through this compartment and provides bloodflow to its contents. reduce some of the pressure into the adjacent compartments. The
The lateral compartment contains the peroneus longus and brevis volar compartment is most at risk for development of a compart-
muscles. Their chief function is to evert the foot, with some conse- ment syndrome in traumatic injuries of the forearm.
quent abduction and plantarflexion of the foot. The major nerve in The forearm includes the volar, dorsal, and mobile wad compart-
the lateral compartment is the superficial peroneal nerve to supply ments (Figure 74-2). The volar compartment contains all of the
motor innervation to the compartment muscles and sensory inner- hand and forearm flexor muscles, the median and ulnar nerves, and
vation to the lower leg and dorsum of the foot. the radial, ulnar, and common interosseous arteries. The mobile
A fascial layer divides the posterior muscle group into superficial wad contains the brachioradialis, the extensor carpi radialis brevis,
and deep compartments. The superficial posterior compartment and the extensor carpi radialis longus muscles. No major arteries
contains the muscles of plantarflexion (gastrocnemius, soleus, and or nerves are contained within this compartment. The radial artery
plantaris tendons). No major nerves or blood vessels travel in the and a branch of the radial nerve may sometimes lie between the
superficial compartment. The deep posterior compartment con- mobile wad and the volar compartment. The dorsal compartment
tains the four deep flexor muscles (flexor digitorum longus, flexor contains the hand and forearm extensor muscles, the posterior
hallucis longus, tibialis posterior, and popliteus). This group of interosseous artery, and the posterior interosseous nerve.
muscles contributes to inverting and adducting the foot in addi-
tion to flexing the toes and foot. The primary sensory innervation INDICATIONS
is from the tibial nerve, which courses through the deep posterior
compartment. The tibial nerve supplies most of the muscles of the The earliest and most reliable indication for measuring compart-
posterior compartment before dividing into several branches that ment pressures is the development of increasing pain in a tense
provide sensory innervation to the sole of the foot. The posterior and swollen muscle group.2 This pain tends to be disproportion-
tibial artery and the peroneal artery are also contained within this ate to the underlying cause (e.g., fracture, soft tissue contusion,
compartment. thrombus, etc.). Pain that increases with passive motion of the
Although any of these compartments can suffer from ischemia, affected muscles is also an indication for compartmental pressure
the deep posterior compartment and the anterior compartment measurement. Sensory deficits and paresis of the affected mus-
have the highest incidence of developing a compartment syn- cles are two late findings for the development of compartment
drome.17 It is difficult to simply observe the patient in the face of a syndrome.9 It is important to remember that the presence of
normal compartmental pressure when they clinically present with palpable pulses and capillary refill do not rule out an evolv-
increasing pain and the features suggestive of a compartment syn- ing acute compartment syndrome. The absence of pulses may
drome. Thus, multiple compartmental syndrome readings must suggest arterial injury or hypovolemia. One must measure and
be taken when the suspicion is high and the compartmental pres- monitor all compartments at risk if the patient is obtunded or
sures are normal. unreliable. This usually refers to the forearm and lower leg com-
partments in the multiple trauma patient.
Have a very low threshold for measuring pressures within a
UPPER EXTREMITY: FOREARM
muscle compartment. Compartmental pressures must be mea-
The forearm consists of three compartments that are intercon- sured if a compartment syndrome is considered as a diagnosis.
nected at various levels (Figure 74-2).20,21 This interconnection is Do not rely solely on the compartmental pressure measurements
A Medial Lateral B
Flexor carpi
radialis
Flexor digitorum Flexor
superficialis pollicis longus Anterior compartment
Pronator teres
Mobile wad
Flexor carpi Brachioradialis
ulnaris
Extensor carpi
radialis longus
Flexor and brevis
digitorum
profundus
Radius
Ulna Supinator
Extensor carpi
Abductor
ulnaris
pollicis longus Posterior compartment
Extensor
pollicis longus Extensor Extensor
digiti minimi digitorum
FIGURE 74-2. Cross section through the middle of the right forearm demonstrating the dorsal and volar compartments separated by the line of the radius, the ulna, and
the interosseous membrane. A. The anatomy. B. The compartments. The mobile wad forms a distinct muscle compartment coursing along the radius.
to make a decision regarding the need for fasciotomy. A com- Stryker Monitor System
partment syndrome is primarily a clinical diagnosis. Pressure • Stryker pressure monitor unit
measurements should be taken in each compartment at risk, in at
• Sterile quick pressure monitor set (single use, contains: needle,
least two sites within the compartment. If concern persists, serial
syringe, diaphragm chamber)
measurements or continuous pressure measurement should be
performed even if initial pressures are normal or only mildly Arterial Manometer Technique
elevated. Compartment pressures should be interpreted in the • 18 gauge needle or Angiocath
clinical context of the patient; normal compartment pressures do
not rule out the diagnosis. • Sterile saline
• Arterial line tubing and manometer (identical to that used for
CONTRAINDICATIONS arterial line)
There are no absolute contraindications to the measurement of PATIENT PREPARATION

compartment pressures. Given the importance of prompt diag-
nosis, compartment pressure measurements should be performed Explain the risks and benefits of the procedure to the patient and/
while evaluating for coexistent traumatic injuries. The EP can still or their representative. Discuss the low risk of infection or bleeding,
assess the compartmental pressures even though the patient may be and the possibility of obtaining erroneous values. Written informed
undergoing other invasive and/or surgical procedures. Time is of consent should be obtained from the patient and/or their represen-
the essence. Postponing compartmental pressure measurements tative if possible. If the patient is unable to consent and no repre-
or a fasciotomy may lead to irreversible damage to the affected sentative is available, proceed after documentation of the medical
extremity. necessity.
Wash away any blood, dirt, or debris on the patient’s skin. Apply
EQUIPMENT povidone iodine or chlorhexidine solution to the skin around the
puncture sites. The measurement of compartment pressures is con-
General Supplies sidered a sterile procedure and the EP should don a hat, mask, sterile
• Povidone iodine or chlorhexidine solution gloves, and a sterile gown. Create a sterile field with either surgical
towels or drapes. Identify the landmarks for needle insertion and
mark the skin puncture sites.
• Sterile drapes or towels The exact location at which to measure the intracompartmental
Needle (Whiteside) Manometer Technique pressures is not clearly defined. There were no clearly established
guidelines for determining the appropriate location for compart-
• 18 gauge needles, 1.5 in. long mental pressure measurements in patients with fractures prior to
• 20 mL syringe the recent study of Heckman et al.24 The results of their study suggest
• Three-port, four-way stopcock that measurements must be performed at the level of the fracture as
well as locations proximal and distal to the zone of the fracture. A
• Intravenous extension tubing
5 cm distance was used from the fracture site to the proximal and
• Sterile saline distal needle insertion sites. In the absence of a fracture, insert the
• Mercury manometer needle at the point of maximal tightness of the compartment, as
TABLE 74-2 Needle Insertion Sites for the Compartments of the Leg TABLE 74-3 Needle Insertion Sites for the Compartments of the Forearm
Compartment Needle insertion site Insertion depth (cm) Compartment Needle insertion site Insertion depth (cm)
Anterior 1 cm lateral to the anterior 1.0–3.0 Anterior 1.5 cm medial to a vertical line 1.0–2.0
tibial ridge and directed drawn through the middle of
perpendicular to the long the forearm
axis of the leg Mobile wad Perpendicular to the long axis of 1.0–1.5
Lateral Just anterior to the posterior 1.0–1.5 the radius and into the muscles
border of the fibula and lateral to the radius
directed toward the fibula Posterior 1 to 2 cm lateral to the posterior 1.0–2.0
Superficial posterior 3 cm medial or lateral to a 2.0–4.0 aspect of the ulna
vertical line drawn through
the midcalf
Deep posterior Just posterior to the medial 2.0–4.0
border of the tibia, directed and sterile saline flush.23 More recently, a technique involving a
posterolaterally and toward 16 gauge angiocatheter or needle connected by arterial line tubing
the posterior border of the to a standard manometer has been described.30 While all three of
fibula these methods will be discussed in this chapter, recent data suggest
that the Stryker method and the arterial manometer method are sig-
nificantly more accurate, are more convenient, and require only a
small number of components readily available in most EDs than the
well as in at least two other sites within the compartment. General needle manometer method.31,32
anatomic landmarks for needle insertion into the various compart- While each of these techniques may be performed with a stan-
ments of the lower leg and forearm are described in Tables 74-2 & dard straight needle, all are more accurate if used with a special
74-3, and graphically depicted in Figure 74-3. The authors recom- side-ported needle or slit catheter, if available.32 Similar measure-
mend using the highest measured intracompartmental pressure ment systems that introduce a wick or slit catheter into the tissue
in making the decision for further intervention. have been shown to be equally effective. For simplicity’s sake, expla-
nations of these techniques have been omitted, as they are rarely
TECHNIQUES performed.
Several techniques for measuring compartmental pressures have
been developed. Some use isolated intracompartmental pres-
NEEDLE MANOMETER TECHNIQUE
sure measurements while others monitor pressure continuously. Begin by setting up the system (Figure 74-4A). Attach the hub of a
Obtaining isolated intracompartmental pressure measurements is 20 mL syringe to the middle port of a three-way stopcock. Attach
most important in the ED. Whitesides et al. described the needle one end of the intravenous extension tubing to one of the ports
manometer method utilizing a manual manometer and a saline–air of the stopcock. Attach an 18 gauge needle to the free end of the
meniscus in standard IV tubing connected to a 16 gauge needle.22 intravenous extension tubing. Insert a second 18 gauge needle into
Stryker (Stryker Instruments, Kalamazoo, MI) introduced an elec- a container of sterile normal saline to release the vacuum. Insert the
tronic system consisting of a reusable digital pressure monitor and 18 gauge needle attached to the intravenous extension tubing into
a single-use measurement set with a needle, diaphragm chamber, the normal saline so that the needle port is well immersed. Open
FIGURE 74-3. Needle insertion sites to measure intracompartmental pressures. A. The leg compartments: anterior (1), lateral (2), superficial posterior (3), and deep
posterior (4). B. The forearm compartments: anterior (1), mobile wad (2), and posterior (3).
FIGURE 74-5. The air–saline interface. A. The air–saline meniscus will form a
convex shape away from the patient when the tissue pressure is greater than the
pressure of the system. B. The meniscus will flatten out when the pressure within
the system equals that of the tissue.
depressed. The point where the meniscus is flat and the saline
column begins to move equals the pressure within the compart-
ment (Figure 74-5B). Note and document the pressure on the
manometer.
It is important to equilibrate the system between measure-
ments. With the needle still positioned in the tissue, pull back on
the syringe plunger until the manometer reads 0 mmHg. Withdraw
the needle from the tissue. This will prevent any saline from being
deposited in the tissue. The same needle can then be reinserted in
another location to obtain additional pressure measurements if ster-
ile technique was used throughout the procedure.
The needle puncture sites will bleed. It is important to complete
the procedure by properly dressing these puncture wounds. Apply
FIGURE 74-4. The needle manometer technique. A. The initial system setup. gauze over the puncture sites and tape it in place.
B. The final system should form a closed system of space from the manometer
through the tissue space. STRYKER METHOD
The Stryker intracompartmental pressure monitor system is a self-
contained device that is convenient, accurate, and relatively easy
the stopcock ports only to the syringe and the extension tubing. to use (Figure 74-6). The unit should be kept in a secure, yet eas-
Aspirate the saline to fill one-half of the length of the intravenous ily accessible location. The pressure monitor is a battery operated,
extension tubing. Make sure that no bubbles enter the system. reusable unit with a digital display (Figure 74-6A). The quick pres-
Turn the stopcock valve so that the port to the saline is closed. sure monitor pack is a disposable, single-patient-use kit that con-
Attach a second piece of intravenous extension tubing to the tains a needle, the diaphragm chamber, and a saline-filled syringe
remaining open port of the stopcock (Figure 74-4B). Attach the (Figure 74-6B).
opposite end of this tubing to a manometer or arterial pressure Turn the pressure monitor unit on. The digital display should
monitor. Remove the 20 mL syringe from the system and aspirate read 0 to 9 mmHg. The steps for setting up the system must be per-
15 mL of air into the syringe. Reattach the syringe to the stopcock. formed using sterile technique. Take the diaphragm chamber from
Remove the extension tubing with the 18 gauge needle from the the quick pressure monitor pack. This chamber ensures sterility
saline container. between the system and the patient. Place the 18 gauge, 2.5 in side-
Insert the 18 gauge needle into the affected muscle compartment ported needle firmly on the smaller tapered stem of the diaphragm
(Figure 74-4B). Turn the stopcock valve so that all three ports are chamber (Figure 74-7A). This needle must remain sterile. Uncap
open. Position the intravenous extension tubing with the normal the 3 mL syringe filled with sterile normal saline and screw it onto
saline so that the meniscus of the saline–air interface is exactly the larger stem of the diaphragm chamber (Figure 74-7A). Open
level with the tip of the needle inserted into the patient’s tissue. The the clear plastic lid of the monitor unit. Place the needle–diaphragm
position of the saline–air interface in relation to the tip of the chamber–syringe unit on the monitor such that the diaphragm
needle is important for an accurate intracompartmental pressure chamber sits in the well (Figure 74-7B). Push down gently so that
measurement. the diaphragm chamber is firmly and evenly positioned on the
The saline–air interface will form a meniscus when the needle is monitor. Close the cover so that a snap is heard at the latch site.
in the patient. The meniscus will be convex-shaped away from the Hold the monitor unit so that the needle is at a 45° angle from
patient when the tissue pressure is greater than the pressure within the horizontal. Depress the plunger of the syringe to pass saline
the system (Figure 74-5A). Depress the plunger of the syringe through the diaphragm chamber and needle until saline drips from
gradually and delicately to increase the pressure within the sys- the tip of the needle. This will remove any air within the system.
tem. The shape of the meniscus begins to flatten as the plunger is Position the needle next to the skin at the angle needed for insertion.
FIGURE 74-6. The Stryker intracompartmental pressure monitor system. A. The

Stryker pressure monitor unit. Note the power switch, zero button, and digital
readout. Under the clear plastic cover, the round well will secure the disposable
drum, while the syringe will clip into the plastic bracket at right. B. The quick pres-
sure monitor pack contains (from left to right): an 18 gauge, 2.5 in side-ported B
needle, the diaphragm chamber, and a 3 mL syringe filled with sterile saline.
Press the “zero” button on the pressure monitor. The display should An optional indwelling slit catheter set is also available for use
read “00” after a few seconds. Insert the needle into the desired on the Stryker pressure monitor. This set substitutes a slit cath-
compartment at the same angle used during the zeroing process eter, breakaway needle, and extension tubing for the side-ported
(Figure 74-8). Slowly inject 0.3 mL of saline into the compartment. needle. The slit catheter is intended to be left within the patient
This volume of fluid is used to equilibrate with the interstitial fluids. so that multiple sequential intracompartmental pressure measure-
Wait a few seconds as the system is measuring the compartmental ments may be obtained. This is not intended for use in the ED.
pressure. The final compartmental pressure measurement will be
displayed on the digital screen. Remove the needle from the patient.
ARTERIAL MANOMETER TECHNIQUE
Reset the system to zero before taking additional measurements.
This is accomplished by positioning the needle at a new site and The third method of checking compartment pressures in the ED
desired angle of insertion and pressing the zero button. This must requires only an 18 gauge needle or angiocatheter, arterial line tub-
be repeated between each measurement. Apply bandages over the ing, and an arterial manometer set up as if for an arterial line. For a
skin puncture sites. one-time reading, use a straight or side-port needle. If continuous
FIGURE 74-7. Assembly of the Stryker system. A. The contents of the quick pressure monitor pack are assembled. B. The assembled needle–diaphragm–syringe is placed
onto the monitor unit.
readings must be taken when suspicion is high and the com-

partment pressures are read as normal.
SUMMARY
A compartment syndrome is a well-documented phenomenon.
The clinical presentation is variable and changes over time. It is a
difficult clinical diagnosis that is critical for the EP to make in a
timely fashion. While the most common sites are the lower leg and
forearm, compartment syndrome can occur in any muscle compart-
ment of the body. Determining the pressure within a compartment
is a fundamental and essential tool to aid in this diagnosis. Many
methods exist for the measurement of compartment pressures. Use
of the traditional needle manometer system, the Stryker pressure
FIGURE 74-8. The needle is inserted into the desired compartment and the monitor kit, and the arterial manometer are three established tech-
pressure measurement read on the digital display. niques that can easily be performed in the ED. These techniques
represent the standard of practice in most EDs. Other methods
using noninfusing catheter tips and emission tomography are under
investigation as potentially noninvasive procedures.25,26 Any con-
compartment pressure monitoring is preferable, use an 18-gauge cern for a compartment syndrome should be followed up with an
angiocatheter. Attach the desired needle or angiocatheter to the emergent Orthopedic Surgeon or General Surgeon consultation in
end of the arterial line tubing, which leads to the prepared arterial the ED, as continuous observation and repeated measurements are
manometer. Flush the entire line with sterile saline. Place the tip of often indicated. Pressures over 30 mmHg or within 30 mmHg of the
the needle adjacent to the skin insertion site and zero the system. diastolic blood pressure warrant an emergent evaluation for a pos-
Insert the needle into the compartment and slowly infuse 0.3 mL of sible fasciotomy and limb salvage.
sterile saline to equilibrate the system with the interstitial pressure.
The manometer will provide continuous real-time measurement of
the compartment pressure for as long as the needle or angiocatheter
remains in place.
Fasciotomy
AFTERCARE
Control any bleeding from the skin puncture sites with direct pres-
75 Justin Mazzillo, Sobia Ansari,
and Eric F. Reichman
sure. Apply gauze and tape dressings to all puncture sites. Perform
and document a repeat neurovascular exam of the extremity distal
to the procedure site.
INTRODUCTION
A compartment syndrome is a serious and sometimes catastrophic
COMPLICATIONS entity that can lead to irreversible local and systemic damage.1 It
typically results from increased interstitial pressure in a closed and
There should be no complications for the patient if sterile technique confined space that leads to inadequate perfusion and impaired
is maintained throughout this procedure. Inserting a needle into a function of the tissues contained within that space. Locally, a com-
tissue compartment introduces the theoretical risk of infection or partment syndrome may lead to loss of function, contractures,
damage to the nerves or vessels. No study has shown this to be a rhabdomyolysis, infection, and amputation. This can be followed
significant complication. by systemic complications such as renal failure, sepsis, and possibly
A realistic complication of the procedure is obtaining erroneous death.2 Common causes of a compartment syndrome include cir-
values. The greatest risk to the patient is if an artificially low pressure cumferential burns, constrictive dressings, crush injuries, electrical
is obtained and the needed fasciotomy is not performed. Although injuries, exercise, external compression of a limb, external trauma to
false high-pressure readings may also be obtained, the consequences the extremity, open or closed fractures, reperfusion after a vascular
of receiving an unnecessary fasciotomy are less disastrous. insult, snakebites, and tight fitting casts or splints (Table 74-1).1–20
It is important to understand how the mechanics of the needle- The difficulty in diagnosing a compartment syndrome is that the
manometer system can alter the pressure readings. Injection of physical examination is a poor indicator of the degree of microcir-
normal saline into the tissue will raise the pressure reading. The culatory compromise.3 The diagnosis requires a high level of sus-
manometer reading will not accurately reflect the pressure of the picion on the part of the Emergency Physician. Refer to Chapter
compartment if the needle is inserted into a tendon rather than the 74 regarding the complete details of a compartment syndrome.
muscle. A piece of tissue from the compartment can obstruct the Maintaining a low threshold for performing a fasciotomy can be
needle and lead to erroneous pressure measurements. Failing to the safest course for the patient. The prognosis is more favorable
match up the saline–air meniscus with the level of the needle in the if a fasciotomy is performed soon after the onset of symptoms. If
tissue can produce false pressure measurements as well. delayed, there may be little or no benefit to performing a fasciotomy.
One must take multiple pressure measurements around the
injury site. To decide whether or not to perform a fasciotomy
on an isolated pressure reading is to proceed without all the
necessary data. It becomes difficult to simply observe the The anatomy of a compartment syndrome is variable, as it can occur
patient when they clinically present with increasing pain and in any enclosed muscle group. Any muscle tissue that is confined in
features suggestive of a compartment syndrome when the com- space by fascia, skin, or any external forces (e.g., casting material)
partmental pressure measurement is normal. Thus, multiple is a potential site for the development of a compartment syndrome.
CHAPTER 75: Fasciotomy 481
The muscles, nerves, and vasculature within the affected muscle contribute to tissue perfusion and should be taken into account
group are all potentially compromised by a prolonged ischemic state when deciding to perform a fasciotomy. Hypertension may be
followed by swelling. A basic knowledge of the anatomy of com- protective of perfusion whereas hypotension may further compro-
monly affected compartments is necessary to successfully and safely mise perfusion.1 More recently, a “delta P” or ∆P of less than 30
perform a fasciotomy. mmHg has been suggested as a better indication for performing
The initial imbalance of a compartment syndrome occurs a fasciotomy.3 The ∆P is calculated as the difference between the
between the volume and pressure within the myofascial compart- diastolic blood pressure and the absolute or measured compart-
ment. The arterial inflow and venous outflow diminish as either ment pressure.
intracompartmental volume or pressure increases. The blood begins Maintaining a low threshold for performing a fasciotomy can be
to be shunted via capillaries into the muscle tissue. This compensa- the safest course in patients who are at risk of extremity ischemia.7
tory shunting of blood further disturbs the volume–pressure bal- Any patient with the appropriate history and any of the clinical
ance, resulting in impaired tissue oxygenation. signs of a compartment syndrome should be considered a candidate
Skeletal muscles, major nerves, and major blood vessels of the for a fasciotomy. Strongly consider performing a fasciotomy if the
extremities are contained within a noncompliant connective tissue patient has a fascial compartment with a ∆P < 30 mmHg. An abso-
membrane known as the investing or deep fascia. Connective tissue lute compartment pressure ≥30 mmHg, or ≥20 mmHg if the patient
septa from the investing fascia to the bones of the extremities form is hypotensive, combined with any clinical signs of a compartment
compartments within the extremity. Each fascial compartment has syndrome is an indication for a fasciotomy. The prognosis is favor-
a relatively constant range of pressure within it in which perfusion is able if the fasciotomy is performed within 30 hours of symptom
maintained.3 Under normal circumstances, the compartment pres- onset.8 If delayed longer, there is usually little or no benefit. This is
sure is ≤10 to 12 mmHg. Any of the previously mentioned insults particularly true if the fasciotomy is performed greater than 2 days
may set off a cascade of events. This includes edema, hemorrhage, after the onset of symptoms.
and/or external compression. The pressure within the compartment
begins to rise. A critical pressure is reached within the compart- CONTRAINDICATIONS
ment and perfusion is impaired. This results in altered metabolic
processes, muscle cell death, cell wall dysfunction, and vascular A fasciotomy in the setting of a true compartment syndrome has
compromise. This eventually leads to extravasation of intracellular few absolute contraindications. Any life-threatening conditions
contents and edema within the enclosed space, further raising com- must first be addressed. If performed beyond the third or fourth day
partment pressures.4 after symptom onset, there is a high incidence of severe infections.8
Increased intracompartmental pressure, from edema or hem- A fasciotomy should not be performed if the Emergency Physician
orrhage within the compartment or from external compression, is not familiar with the local anatomy or the technique.
affects perfusion. Compartmental perfusion is a dynamic pro-
cess, which is maintained by arterial blood pressure and limited EQUIPMENT
by the absolute compartment pressure. Elevated compartmental
pressure leads to venous outflow obstruction and eventually tissue
ischemia. • Face mask and cap
Skeletal muscle and peripheral nerves can survive under isch- • Sterile gloves and gown
emic conditions for up to 4 hours before irreversible damage • Sterile drapes or towels
begins to occur. At 6 hours of ischemia, muscle and nerve injury
• Equipment for compartment pressure measurement (refer to
may still be reversible. Ischemia for greater than 8 hours, how-
Chapter 74)
ever, will lead to irreversible damage to muscles and nerves.5 The
resulting ischemic contractures of the extremities were described • 4 × 4 gauze squares
over 100 years ago by Richard Von Volkmann and are now referred • # 10 scalpel blade on a handle
to as “Volkmann’s ischemic contracture.” Treatment of a compart- • Tissue forceps
ment syndrome with a fasciotomy was first suggested in 1906 by
Bardenheuer.6 • Metzenbaum scissors
The pertinent anatomy for each fasciotomy described is included • Curved forceps
in the respective techniques section. Refer to Chapter 74 for the • Surgical retractors
details of the anatomy, pathophysiology, evaluation, and diagnosis
• Kerlix dressings
of a compartment syndrome.
Clinical signs of a compartment syndrome consist of the 5 “Ps” • Splint material
for any region at risk. These include pain out of proportion to exam,
paresthesias, pallor, pulselessness, and paralysis. Some may choose PATIENT PREPARATION
to include poikilothermia as the sixth “P.”4 These clinical findings
Perform and document a thorough neurological and vascular
are generally late findings and may be completely absent early in the
examination of the affected extremity.1 Remove any constric-
course of the disease process. Measure the compartment pressures
tive dressings, casts, and/or splints that may be contributing to the
when any signs or a clinical suspicion exists for a compartment syn-
increased compartment pressures. Place the patient supine on the
drome. Refer to chapter 74 for the complete details of compartment
gurney so that the limb at risk is at heart level. If time is permissi-
pressure measurement.
ble and a Surgeon is available, it may be more appropriate to perform
the fasciotomy in the Operating Room by an experienced Surgeon.
This is often not possible and the fasciotomy must be performed
INDICATIONS
in the Emergency Department.
Classically, it has been taught that a fascial compartment with an Inform the patient and/or their representative of the risks, ben-
absolute pressure of greater than 30 mmHg will require a fasci- efits, complications, and aftercare associated with a fasciotomy.
otomy. Other factors besides the absolute compartmental pressure The procedure must be performed using strict aseptic technique.
The Emergency Physician and any assistants must be wearing sterile

gloves, a sterile gown, a face mask, and a cap. Clean the extremity of
any blood, dirt, and debris. Apply povidone iodine or chlorhexidine
solution to the extremity and allow it to dry. Apply sterile drapes or
towels to isolate the extremity and form a sterile field. Collect and
place all required supplies on a bedside table covered with a sterile
drape. Using a sterile marking pen, draw the incision lines onto the
skin prior to making any incisions.
A fasciotomy is a painful procedure. If the patient is conscious,
some form of analgesia is required. The infiltration of local anes-
thetic solution provides appropriate analgesia. Ensure that the toxic
dose of the selected local anesthetic solution is not exceeded (Chap-
ter 123). Alternatives include a regional nerve block (Chapter 126)
or procedural sedation (Chapter 129).
TECHNIQUES
THE ARM
The arm consists of three compartments (Table 75-1 & Figure
75-1).9 The anterior compartment contains the biceps, brachialis,
and coracobrachialis muscles. The posterior compartment contains
the triceps muscle. The proximal anterolateral arm contains the del-
toid compartment.
A fasciotomy of the arm requires two longitudinal incisions. FIGURE 75-1. The compartments of the arm. Fasciotomy incisions have been
Decompress the anterior compartment with a longitudinal inci- made (arrows) by cutting through the skin, subcutaneous tissues, and deep or
sion over the entire anterior surface of the arm overlying the biceps investing fascia.
muscle (Figures 75-1 & 75-2A). Decompress the posterior com-
partment with a longitudinal incision on the posterior surface of the
arm overlying the triceps muscle (Figures 75-1 & 75-2B). Use a #10
scalpel blade to cut through the skin and subcutaneous tissues down tissues down to the level of the investing fascia. The cutaneous
to the level of the investing fascia. Carefully cut the fascia parallel to branch of the axillary nerve becomes superficial inferior and pos-
the skin incision with a scissors. The fascial incision should be the terior to the acromion and continues anteriorly over the lateral
same length of the skin incision. Use caution so as not to cut the deltoid muscle. It should not be cut when performing a fasciot-
muscle itself. omy. It may be necessary to decompress each fascial compartment.
A fasciotomy of the deltoid compartment muscle may occasion- Carefully cut open the fascia of the anterior deltoid muscle with a
ally be indicated. The deltoid muscle has three heads that are sepa- scissors. Use caution so as not to cut the muscle itself. Measure
rated by septae. Therefore, it is often necessary to decompress each the compartment pressure in the remaining two compartments.
muscle belly.10 Begin the skin incision over the anterior origin of the Sometimes, decompressing one compartment allows the remain-
deltoid muscle (Figure 75-3). Extend the incision superiorly and lating compartment(s) to spontaneously decompress. If elevated,
erally, going just lateral to the acromion process. Continue the inci- incise the fascia of the second compartment. Measure the pressure
sion posteriorly along the origins of the posterior deltoid muscle. of the remaining compartment. If elevated, incise the fascia of that
Use a #10 scalpel blade to cut through the skin and subcutaneous compartment.
TABLE 75-1 The Compartments of the Arm and Their Contents

Compartment Contents
Anterior Biceps muscle
Brachialis muscle
Coracobrachialis muscle
Brachial artery
Median Nerve
Ulnar Nerve
Musculocutaneous nerve
Lateral cutaneous nerve
Antebrachial nerve
Radial nerve
Posterior Triceps muscle
Radial nerve
Ulnar nerve
Deltoid Anterior deltoid muscle
Lateral deltoid muscle
Posterior deltoid muscle FIGURE 75-2. Fasciotomy incisions of the arm. A. Anterior compartment.
Axillary nerve B. Posterior compartment.
TABLE 75-2 The Compartments of the Forearm and Their Contents

Lateral (mobile wad) Brachioradialis muscle
Extensor carpi radialis longus muscle
Extensor carpi radialis brevis muscle
Dorsal Extensor carpi ulnaris muscle
Extensor pollicis longus muscle
Abductor pollicis longus muscle
Extensor pollicis brevis muscle
Extensor digitorum communis muscle
Posterior interosseous artery
Interosseous perforators from the anterior
interosseous artery
Posterior interosseous nerve
Volar Flexor pollicis longus muscle
Flexor carpi ulnaris muscle
Flexor carpi radialis longus muscle
FIGURE 75-3. Fasciotomy incision for the deltoid compartment. Flexor carpi radialis brevis muscle
Palmaris longus muscle
Flexor digitorum superficialis muscle
Flexor digitorum profundus muscle
THE FOREARM Pronator teres muscle
Pronator quadratus muscle
The forearm is one of the most common regions afflicted by a com- Radial artery
partment syndrome.1,11,12 The forearm consists of three compart- Ulnar artery
ments that are interconnected at various levels. This interconnection Anterior interosseous arteries
is significant because release of the pressure in one compartment Median nerve
will reduce some of the pressure in the adjacent compartments. The Ulnar nerve
volar compartment is most at risk for development of a compart- Carpal tunnel Extrinsic flexor tendons
ment syndrome in traumatic injuries of the forearm.11 This is Median nerve
followed by the dorsal compartment then the lateral compartment.
The lateral compartment is the easiest compartment to decompress
because it is located superficially.5
The forearm includes the volar, dorsal, and mobile wad compart- and the extensor carpi radialis longus muscles. No major arteries
ments (Figure 75-4). The contents of each forearm compartment or nerves are contained within this compartment. The radial artery
are listed in Table 75-2. The volar compartment contains all of the and a branch of the radial nerve may sometimes lie between the
hand and forearm flexor muscles, the median and ulnar nerves, and mobile wad and the volar compartment. The dorsal compartment
the radial, ulnar, and common interosseous arteries. The mobile contains the hand and forearm extensor muscles, the posterior
wad contains the brachioradialis, the extensor carpi radialis brevis, interosseous artery, and the posterior interosseous nerve.
A Medial Lateral B
Flexor carpi
radialis
Flexor digitorum Flexor
superficialis pollicis longus Anterior compartment
Pronator teres
Mobile wad
Flexor carpi Brachioradialis
ulnaris
Extensor carpi
radialis longus
Flexor and brevis
digitorum
profundus
Radius
Ulna Supinator
Extensor carpi
Abductor
ulnaris
pollicis longus Posterior compartment
Extensor
pollicis longus Extensor Extensor
digiti minimi digitorum
FIGURE 75-4. The compartments of the forearm.

as described below. It may also be reached through a different volar

approach such as the volar-curvilinear incision (Figure 75-5C).
If a fasciotomy is indicated for the dorsal compartment, place the
patient prone if not contraindicated and their arm extended on a
bedside table. If the patient is supine, completely flex the supinated
arm so that the dorsal surface is exposed. Make the incision along
a line between the lateral epicondyle of the humerus and the distal
radioulnar joint (Figure 75-5A). Be sure to incise the fascia along
the entire length of the incision. It is important to avoid incising
too deep at the wrist and cutting the extensor retinaculum. If the
skin is adequately undermined, the mobile wad will be accessible
via this approach.
Although the carpal tunnel does not contain muscle bellies and
FIGURE 75-5. Fasciotomy incisions for the forearm. A. The dorsal incision. B. The is thus not a true compartment, it can achieve acute compart-
anterior volar-ulnar incision. C. The volar curvilinear incision. ment syndrome physiology.10 Some authors recommend routinely
decompressing the carpal tunnel during a forearm fasciotomy while
others maintain that doing so is of limited benefit.7,14 This decision
is left to the Physician performing the fasciotomy. Many impor-
The volar and dorsal compartments can be further subdivided
tant structures run through the carpal tunnel including the median
into superficial and deep muscles. Evaluation of the deep muscles
nerve. Structures within the carpal tunnel become compromised at
becomes important when these muscles are preferentially injured.
pressures greater than 40 mmHg. The signs and symptoms will be
This includes electrical injury as the bone transmits thermal injury
similar to a chronic carpal tunnel syndrome, but more severe.
to adjacent muscles, crush injuries, sepsis, and prolonged external
A carpal tunnel release can be performed as part of the fore-
pressure on the forearm.
arm fasciotomy as described above or as an isolated procedure.
Decompression of the volar compartment can lead to the simulta-
To perform an isolated carpal tunnel release, begin the skin inci-
neous decompression of the other compartments. Thus, a volar fas-
sion on the proximal portion of the hand between the thenar and
ciotomy is generally performed first.11 There are multiple approaches
hypothenar creases.10,14 Extend the incision proximally toward the
to making the incision for a forearm fasciotomy (Figure 75-5). This
flexor crease of the wrist. Make a slight ulnar deviation of the
section chapter will describe the volar-ulnar incision for the anterior
incision so that the flexor crease is not crossed at a 90° angle. This
fasciotomy (Figure 75-5B). Some authors feel that this incision is
will prevent injury to the palmar branch of the medial nerve as it
associated with the least amount of iatrogenic injury.1,12,13
courses between the palmaris longus and the flexor carpi radialis
Place the patient supine with their arm supinated on a bedside
tendons. Reflect the skin edges to identify the superficial palmar
table to decompress the volar compartment. Begin the incision
fascia and the transverse carpal ligament. Make a longitudinal
proximally and laterally to the antecubital fossa. Extend the incision
midline incision though the superficial palmar fascia and the
transversely and distally across the antecubital fossa until it reaches
transverse carpal ligament.
the anteromedial aspect of the antecubital fossa. Continue the inci-
sion distally on the anteromedial surface of the forearm toward the
wrist. Just proximal to the wrist, extend the incision in an S-shape THE HAND
toward the radial aspect of the forearm while remaining just proxi- There are 11 compartments in the hand. This includes the midpalm,
mal to the wrist. Do not extend the incision as lateral as the radial hypothenar, thenar, adductor pollicis, four dorsal interosseous, and
artery pulse. Continue the incision back medially to the midline of three palmar or volar interosseous compartments (Figure 75-6 &
the wrist. Continue down the midline of the wrist and make a turn Table 75-3).10 Each hand compartment is completely isolated from
along the thenar crease. Be sure to incise deep enough to include
the superficial fascia along the length of the entire forearm with-
out cutting into the muscles or tendons.
Identify the median nerve proximally. Release the bicipital apo-
neurosis at the level of the antecubital fossa and overlying the
median nerve. Retract the flexor carpi ulnaris muscle medially and
the flexor digitorum superficialis muscle laterally. Follow the median
nerve all the way to the carpal tunnel. Decompress the median nerve
at the carpal tunnel. Be careful not to injure the ulnar artery, ulnar
nerve, and the palmar cutaneous branch of the median nerve.
Incise the superficial palmar fascia in the midline followed by incis-
ing the transverse carpal ligament in the midline.
At this point, the superficial forearm contents are completely
open and the deep contents of the volar compartment are
exposed. Inspect the flexor digitorum profundus, flexor pollicis
longus, and pronator quadratus muscles. Using aseptic technique,
measure the pressures within the deep muscles to determine
whether the fascia covering these muscles needs to be incised. If
the muscle pressures are greater than 15 to 20 mmHg, incise the
deep fascial coverings.
The major disadvantage to the volar-ulnar incision is that the mobile
wad is not easily accessible via this incision. If the mobile wad is at
risk, it may be reached through the dorsal incision (Figure 75-5A) FIGURE 75-6. The 11 compartments of the hand.
TABLE 75-3 The Compartments of the Hand and Their Contents

Midpalm Extrinsic flexor tendons
Lumbrical muscles
Superficial palmar vascular arches
Deep palmar arches
Common digital arteries
Common digital nerves
Proper digital nerves
Thenar Abductor pollicis brevis muscle
Flexor pollicis brevis muscle
Opponens pollicis muscle
Hypothenar Abductor digiti minimi muscle
Flexor digiti minimi muscle
Opponens digiti minimi muscle
Dorsal interossei Dorsal interossei muscles FIGURE 75-7. Fasciotomy incisions for the hand. A. Dorsal and palmar interosse-
Volar interossei Volar interossei muscles ous compartments. B. The adductor pollicis compartment. C. The midpalm com-
Adductor pollicis Adductor pollicis muscle partment. D. The thenar compartment. E. The hypothenar compartment.
the others. Decompression or release of one compartment will not tissues until the thenar muscle fascia is visible. Carefully incise the
help to decompress any of the others. The pressures required to fascia with a scissors. Be careful to not cut the underlying muscle.
cause an acute compartment syndrome in a hand compartment may To access the hypothenar compartment, make a 3 to 4 cm long
be as low as 15 to 20 mmHg. longitudinal incision along the ulnar aspect of the fifth metacarpal
Decompress the dorsal interosseous, palmar interosseous, and over the hypothenar muscles (Figures 75-7E & 75-8). Continue
adductor compartments through dorsal incisions (Figure 75-7). the incision through the subcutaneous tissues until the hypothenar
Decompress the first and second dorsal interosseous compart- muscle fascia is visible. Carefully incise the fascia with a scissors. Be
ments with a 3 to 4 cm long incision over the second metacarpal careful to not cut the underlying muscle.
(Figure 75-7A(1)). Extend the incision into the fascia on both sides The midpalm compartment of the hand is located between the
of the metacarpal to access the compartments. Continue deeper, thenar and hypothenar compartments (Figure 75-6). Make a 3 to
using gentle blunt dissection, to access the adductor compartment 4 cm long longitudinal incision in the middle of the hand, between
on the radial aspect and the first palmar interosseous compart- the thenar and hypothenar muscles (Figure 75-7C). If a fasciotomy
ment on the ulnar aspect (Figure 75-7B). Decompress the third of the forearm or carpal tunnel has already been performed, that
and fourth dorsal interosseous compartments with a 3 to 4 cm long incision can be extended distally to gain access to the fascia of the
incision over the fourth metacarpal (Figure 75-7A(2)). Incise the midpalm compartment. Continue the incision through the subcu-
fascia on both sides of the metacarpal to access the compartments. taneous tissues until the fascia is visible. Carefully incise the fascia
Use gentle blunt dissection to access the second palmar interosse- with a scissors. Be careful to not cut the underlying muscle.
ous compartment on the radial aspect and the third palmar inter-
osseous compartment on the ulnar aspect.
THE DIGITS
To perform a fasciotomy of the thenar compartment, make a 3 to
4 cm long longitudinal skin incision over the thenar muscles on the The digits do not contain muscle bellies or true fascial compart-
lateral aspect of the hand, just volar to the first metacarpal (Fig- ments (Table 75-4 & Figure 75-8). The ligaments and restrictive
ures 75-7D & 75-8). Continue the incision through the subcutaneous skin create a contained compartment that can exhibit large pressure
FIGURE 75-8. Fasciotomy incisions for the hand and fingers.

TABLE 75-4 The Compartments of the Digits and Their Contents

Digits Common palmar digital arteries
Proper palmar digital arteries
Proper palmar digital nerves
Tendons
Ligaments
increases, thus resulting in a compartment syndrome.10 Cleland’s

and Grayson’s ligaments are constrictive ligaments that encircle
the finger and overlie the neurovascular bundles (Figure 75-9).
Measurement of pressures in these “pseudocompartments” is very
difficult. The indications for decompression are based more on clin- FIGURE 75-9. Cross section through a digit.
ical findings and suspicion. The fingers and toes have very similar
anatomy and are managed in the same manner.
A fasciotomy of the digit is performed using a single midaxial The thigh contains three compartments. These are the anterior,
longitudinal incision along the length of the digit. Make the incision medial, and posterior compartments (Figure 75-10). They are sepa-
along the ulnar aspect of the index, long, and ring fingers and along rated from each other by intermuscular septa. The lateral intermus-
the radial aspect of the thumb and small fingers (Figure 75-8). Be cular septum is the thickest of the three and separates the anterior
careful to avoid injuring the underlying neurovascular bundle. and posterior compartments. The contents of the compartments are
Identify the neurovascular bundle and release any constrictive fas- listed in Table 75-5.
cial bands from Cleland’s or Grayson’s ligaments (Figure 75-9). Place the patient supine with their foot pointing upward. Expose
Continue dissecting along the palmar aspect of the flexor tendon the thigh from the iliac crest to the lateral epicondyle.8 Begin the
sheath and release any vertical bands of connective tissue. If severe incision just distal to the intertrochanteric line and extend it to
swelling is present with dysfunction of both the ulnar and radial the lateral epicondyle (Figure 75-11A). Expose the iliotibial band,
neurovascular bundles, a second longitudinal incision can be placed a thickening of the investing fascia, by subcutaneous dissection.
on the opposite side of the digit to decompress the underlying neu- Release the anterior compartment of the thigh by making an inci-
rovascular bundle. sion in the iliotibial band that parallels the skin incision. Retract the
vastus lateralis muscle medially to expose the lateral intermuscular
THE THIGH septum (Figure 75-11B). Make a 1.5 cm incision in the lateral inter-
muscular septum using Metzenbaum scissors. Extend the incision
A compartment syndrome of the thigh is not common, despite how proximally and distally to decompress the posterior compartment.
commonly femur fractures occur.15 The pressure at which a com- Once the anterior and posterior compartments have been decom-
partment syndrome of the thigh develops is not known. A case pressed, determine the pressure in the medial/adductor compart-
report of three patients who developed a thigh compartment syn- ment. If the pressure is elevated, make a separate medial incision to
drome in association with a femur fracture noted that two of the release this compartment.
patients had significant arterial bleeding into the thigh and the third
had prolonged extrinsic compression of the leg. The Emergency THE LEG
Physician will need to rely on clinical signs and symptoms, mea-
sured pressures, as well as the mechanism of injury to make the The leg is the most common location for a compartment syn-
diagnosis of a thigh compartment syndrome. drome.1,6 A tibial fracture is the most common injury leading to a
FIGURE 75-10. The compartments of the thigh.

TABLE 75-5 The Compartments of the Thigh and Their Contents

Anterior Sartorius muscle
Iliacus muscle
Pectineus muscle
Psoas muscle
Quadriceps femoris muscle
Femoral artery and vein
Femoral nerve
Lateral femoral cutaneous nerves
Medial Adductor longus muscle
Adductor magnus muscle
Adductor brevis muscle
Obturator externus muscle
Gracilis muscle
Obturator artery and veins
Profundus femoris artery and veins
Obturator nerve
Posterior Semitendinosus muscle
Semimembranosus muscle
Biceps femoris muscle
Adductor magnus muscle
Profundus femoris artery
Sciatic nerve
Posterior femoral cutaneous nerves
leg compartment syndrome.17 The lower leg consists of four distinct

muscle compartments: anterior, lateral, deep posterior, and super-
ficial posterior (Figure 75-12).8,16 A detailed list of the contents of
each compartment is noted in Table 75-6.
The anterior compartment contains the four extensor muscles of
the leg. These muscles function together to dorsiflex the foot. The FIGURE 75-11. Fasciotomy of the thigh. A. The fasciotomy incision. B. The vastus
deep peroneal nerve travels through this compartment to innervate lateralis muscle is retracted to expose the lateral intermuscular septum.
the extensors and provide sensory innervation to the web space
between the first and second toes. The anterior tibial artery travels
through this compartment and provides bloodflow to its contents.
A Medial Lateral B
Tibialis anterior Anterior
Extensor
compartment
Tibialis posterior hallucis longus
Extensor
digitorum longus
Tibia Lateral
Peroneus compartment
brevis
Flexor
digitorum Peroneus
longus longus
Soleus Fibula
Flexor
hallucis longus
Medial head Lateral head

gastrocnemius gastrocnemius Deep posterior
Superficial posterior compartment
compartment
FIGURE 75-12. The compartments of the leg.

TABLE 75-6 The Compartments of the Leg and Their Contents compartment. The tibial nerve supplies most of the muscles of the
posterior compartment before dividing into several branches that
provide sensory innervation to the sole of the foot. The posterior
Anterior Tibialis anterior muscle tibial artery and the peroneal artery are also contained within this
Extensor hallucis longus muscle
compartment.
Extensor digitorum communis muscle
Although any of these compartments can suffer from ischemia,
Anterior tibial artery and vein
Deep peroneal nerve
the deep posterior compartment and the anterior compartment
Lateral Peroneus longus muscle have the highest incidence of developing a compartment syn-
Peroneus brevis muscle drome.21 It is difficult to simply observe the patient in the face of a
Superficial peroneal nerve normal compartmental pressure when they clinically present with
Superficial posterior Gastrocnemius muscle increasing pain and the features suggestive of a compartment syn-
Soleus muscle drome. Thus, multiple compartmental syndrome readings must
Plantaris muscle be taken when the suspicion is high and the compartmental pres-
Sural nerve sures are normal.
Deep posterior Tibialis posterior muscle If the physical examination of the leg reveals clinical concern
Flexor hallucis longus muscle for a compartment syndrome of only one compartment, then a
Flexor digitorum longus muscle single-incision fasciotomy can be performed. However, in cases of
Posterior tibial artery and vein prolonged limb compression or severe trauma, a double-incision fas-
Peroneal artery and vein ciotomy for decompression of all compartments will be required.16,18
Tibial nerve Perform an anterolateral incision to decompress the anterior and
lateral compartments. Make a 20 to 25 cm long longitudinal inci-
sion between the fibular shaft and tibial crest (Figure 75-13A).1
The incision will thus be located over the anterior intermuscular
The lateral compartment contains the peroneus longus and brevis septum, allowing access to both the anterior and lateral compart-
muscles. Their chief function is to evert the foot, with some conse- ments (Figure 75-13C). Undermine the skin edges to expose more
quent abduction and plantarflexion of the foot. The major nerve in of the fascial covering. Make a small transverse incision through
the lateral compartment is the superficial peroneal nerve to supply the fascia at the midpoint of the incision to expose the intermuscu-
motor innervation to the compartment muscles and sensory inner- lar septum. Be cautious not to cut the superficial peroneal nerve
vation to the lower leg and dorsum of the foot. that lies just lateral to the septum. Instruct an assistant to retract
A fascial layer divides the posterior muscle group into superficial the skin edges. Open the anterior compartment using Metzenbaum
and deep compartments. The superficial posterior compartment scissors. Extend the facial incision longitudinally, both distally and
contains the muscles of plantarflexion (gastrocnemius, soleus, and proximally, the length of the skin incision. Next decompress the
plantaris tendons). No major nerves or blood vessels travel in the lateral compartment by incising the fascia longitudinally in a simi-
superficial compartment. The deep posterior compartment con- lar manner.
tains the four deep flexor muscles (flexor digitorum longus, flexor Perform a posteromedial incision to decompress the posterior
hallucis longus, tibialis posterior, and popliteus). This group of compartments. The two posterior compartments can be decom-
muscles contributes to inverting and adducting the foot in addi- pressed with one skin incision (Figure 75-13C). Make a 20 to 25 cm
tion to flexing the toes and foot. The primary sensory innervation long longitudinal incision 2 to 3 cm posterior to the posterior tibial
is from the tibial nerve, which courses through the deep posterior margin (Figure 75-13B). Undermine the skin and subcutaneous
FIGURE 75-13. Fasciotomy incisions for the leg. A. The anterolateral incision. B. The posteromedial incision. C. Cross section through the leg demonstrating the
fasciotomy incisions.
Interosseous compartment
Medial Dorsal Plantar

Lateral aspect of Metatarsals and Interosseous
first metatarsal shaft interosseous fascia fascia
Medial compartment
Dorsal Lateral compartment
Inferior surface first
metatarsal shaft Dorsal
Fifth metatarsal shaft
Medial
Extension of plantar Lateral
aponeurosis Plantar aponeurosis
Lateral Medial
Intermuscular septum Intermuscular septum
Interosseous fascia
Dorsal
Plantar aponeurosis Intermuscular septum
Inferior Lateral
Central compartment
FIGURE 75-14. The compartments of the foot.
tissues on both sides of the incision. Instruct an assistant to retract The dorsal approach can also be used to access all of the compart-
the skin and subcutaneous tissue on both sides of the incision. ments but is best to access the interosseous compartments and the
Incise the fascia transversely to expose the septum dividing the deep lateral compartment (Figure 75-15B). This approach is superior to
and superficial posterior compartments. Decompress the superficial the medial approach in the setting of metatarsal or Lisfranc frac-
posterior compartment. Make a longitudinal incision posterior to tures. Make the first incision along the medial aspect of the second
the intramuscular septum, extending the length of the skin incision. metatarsal. Make the second incision along the lateral aspect of the
Decompress the deep posterior compartment. Make a longitudinal fourth metatarsal. Incise the superficial fascia of each compartment
incision starting from the anterior edge of the initial transverse inci- and elevate the muscles off the bone for more effective decompres-
sion. Extend this incision both proximally and distally. sion. Use a clamp to bluntly dissect, access, and decompress the
remaining compartment (Figure 75-14B). The lateral compartment
THE FOOT can be accessed and decompressed via the space between the fourth
and fifth metatarsals. The central compartment can be accessed
The number of compartments within the foot is a matter of con- and decompressed via the spaces between the second and third and
troversy (Figure 75-14).19 It was initially believed that there were the third and fourth metatarsals. The medial compartment can be
four compartments. Further research has shown that up to nine accessed and decompressed via the space between the first and sec-
compartments exist. Subsequent studies have shown that the barri- ond metatarsals.
ers between many of these compartments break down at pressures
greater than 10 mmHg, far less than that required to cause a com-
partment syndrome. For the sake of this chapter, we will divide the
ASSESSMENT
nine compartments into four groups: the intrinsic compartment Aseptically measure all compartment pressures after each fas-
that contains the four muscles between the first and fifth metatar- ciotomy. As previously mentioned, many compartments com-
sals, the medial compartment, the central compartment, and the municate and a fasciotomy of one compartment may relieve the
lateral compartment.20 A list of the contents of each compartment is
noted in Table 75-7 & Figure 75-14.
There are two main incisions used to access the compartments
of the foot and both approaches can potentially reach all of the TABLE 75-7 The Compartments of the Foot and Their Contents
compartments. The most popular approach is the medial approach Compartment Contents
(Figure 75-15A). Make the skin incision starting just below the Intrinsic Interosseous muscles
medial malleolus. Continue the incision distally along the inferior Digital nerves
border of the first metatarsal, but superior to the abductor mus- Medial Abductor hallucis muscle and tendon
cle. Retract the skin edges. Identify the neurovascular bundle and Flexor hallucis brevis muscle
retract it out of the way. Incise the fascia of the medial compart- Central Flexor digitorum brevis muscle
ment. Continue incising laterally through the medial intermuscular Quadratus plantae muscle
septum of the medial compartment. The remaining compartments Adductor hallucis muscle
can be accessed by blunt dissection with a clamp or by performing Lateral Flexor digiti minimi muscle
additional incisions via the dorsal approach. Abductor digiti minimi muscle
FIGURE 75-15. Fasciotomy incisions for the foot. A. The medial approach. B. The dorsal approach.
pressure in others and obviate the need for additional fascioto- Infection after a fasciotomy is a definite possibility. While the
mies. After the fasciotomy is complete, compartment pressures use of aseptic technique is mandatory, it does not prevent subse-
should be measured again to ensure successful decompression. quent infections. The presence of crush injuries, myonecrosis, poor
Check multiple readings throughout the same compartment.1 If perfusion, preexisting peripheral vascular disease, and the patient
compartment pressures are still elevated, ensure that the fascia immune status can predispose the site to an infection. The decision
is completely incised and consider increasing the length of the to use of broad-spectrum prophylactic antibiotics should be made
fasciotomy. in consultation with a Surgeon.
Hemorrhage is often minimal when performing a fasciotomy.
AFTERCARE Most hemorrhage can be controlled with direct pressure. Small
subcutaneous blood vessels transected during the procedure can be
Once decompressed, the wound is left open. Apply sterile saline- controlled with electrocautery or figure-of-eight sutures.
soaked gauze into the incisions followed by a nonrestrictive and
bulky dressing wrapped around the limb. The dressing should
SUMMARY
be loose and allow the wound to easily drain.12 Splint the limb to
prevent contractures. In cases where the decompressed limb has a Emergency Physicians must have an understanding of the signs and
fracture, the limb must be splinted so that the fractured bones are symptoms of a compartment syndrome. Always maintain a high
in appropriate alignment.13 Consult the appropriate Surgeon (e.g., level of suspicion in patients presenting with limb injuries. The
Hand, Orthopedic, Plastic, or Trauma) to manage the patient. The technique itself is quite simple as long as the incision is made in the
decision to administer prophylactic antibiotics should be made in proper location. Performing a fasciotomy in a timely fashion can
consultation with the Surgeon. Admit the patient for further surgi- prevent serious and irreversible consequences.
cal care.
COMPLICATIONS
The goal of surgical decompression is to open the tight fascial lay-
Extensor Tendon Repair
ers.13 Minimizing the length of the skin incisions or limiting the
number of compartments decompressed will lead to substandard
results. Continued edema and postischemic hyperemia in the first
76 Jaime Harper, Stanley Harper,
and Ramasamy Kalimuthu
hours after a decompression can lead to increased compartment
pressures in adjacent compartments that were not decompressed.
INTRODUCTION
There is a significant risk of an iatrogenic injury to arteries, nerves,
tendons, and veins during the fasciotomy.1 A thorough understand- The Emergency Physician (EP) commonly encounters lacerations
ing of the local anatomy and the procedure will help to minimize or trauma to the dorsum of the hand and forearm. In evaluating
these injuries. Adequate visualization using proper overhead light- these patients, the possibility of extensor tendon lacerations must
ing and proper retraction will further minimize injury. be considered. The extensor mechanism of the hand and forearm is
The diagnosis of a compartment syndrome may be delayed typically disrupted in association with penetrating trauma. It must
because of a missed diagnosis or because the patient does not pres- be remembered, however, that blunt trauma, such as sudden forced
ent immediately to the Emergency Department. The Emergency flexion, can also result in injury to the extensor tendons. Performing
Physician may be faced with a situation in which the muscles of the an extensor tendon repair is an important skill in the EP’s surgical
limb are in varying stages of ischemia, irreversible injury, and con- armamentarium.
tracture. In these cases, performing a fasciotomy may predispose Although the diagnosis of an extensor tendon injury must be
the limb to secondary infection with subsequent gram-negative sep- identified at the initial examination, the timing of the tendon
sis.12 The Emergency Physician must weigh the risks and benefits repair is not a critical aspect of its management. Successful repair
before proceeding. Consider consulting a Surgeon to assist in the of extensor tendons may be accomplished acutely, or within a 7 day
decision to perform a fasciotomy. window following the injury.1 One should also be aware that at some
CHAPTER 76: Extensor Tendon Repair 491
Juncturae
tendinum
Extensor
digiti minimi
Extensor
pollicis longus
Extensor
digitorum Extensor
communis pollicis brevis
Extensor carpi Extensor carpi

ulnaris radialis longus
Extensor carpi
radialis brevis
Extensor Abductor pollicis longus
retinaculum
Lister's tubercle
FIGURE 76-1. The extensor tendons of the hand begin just proxi-
Synovial sheaths
mal to the extensor retinaculum. After exiting from under this encas-
ing sheath, the tendons form an interconnected network as they
cross the dorsum of the hand.
anatomic sites, splint immobilization of the damaged tendon can ANATOMY AND PATHOPHYSIOLOGY
produce a similar outcome to surgical reapproximation. This is most
evident in the conservative management of a mallet finger injury. The extensor tendon mechanism is an intricate system of pulleys
Repair of an extensor tendon by an EP requires them to have a and levers coursing along the dorsum of the forearm, wrist, and
familiarity with the anatomy of the region and be skilled in the hand.6,7 The function of these tendons is to extend the fingers and
surgical technique. Although complications of tendon repair are wrist from a flexed position. This finger motion is complemented
more frequently associated with flexor tendons, follow-up studies by the actions of the intrinsic hand muscle groups (i.e., lumbricals
of extensor tendon repairs reveal similar pitfalls and problems.2 and interossei).
Adhesions, loss of length, and diminished flexion can all complicate The elegant anatomy of the hand extensor mechanism is best
the repair of an extensor tendon.3 appreciated in diagrammatic representation (Figure 76-1). The
The anatomy of the extensor mechanism prevents tendon retrac- forearm tendons pass through the extensor retinaculum of the wrist
tion far from the site of a laceration or partial disruption.4 This is to travel across the dorsum of the hand to each of the fingers. The
mostly due to the tethering of tendons by multiple interconnections extensor tendons are reinforced in the fingers by the lateral bands
as the tendons cross the dorsum of the hand. Additionally, the ten- of the intrinsic hand muscles to form a complex tendon that inserts
dons over the dorsum of the hand are ensheathed in a paratenon into the distal phalanx (Figure 76-2).
layer of tissue. This covering is extrasynovial, thus containing the Knowledge of the anatomy of the extensor mechanism reveals
cut ends of the tendons in a tissue layer that prevents their wide certain salient points. The extensor retinaculum of the wrist is a
separation. These properties frequently allow both ends of a lacer- complicated structure of fibrous canals through which the ten-
ated extensor tendon to be located with local wound exploration, at dons pass and whose repair necessitates a Hand Surgeon’s inter-
which point they may be safely repaired. vention. The paucity of soft tissue covering the dorsum of the
The techniques for extensor tendon repair originate in studies of hand makes the tendons quite vulnerable to penetrating trauma.
flexor tendons. The goal of extensor tendon repair is to restore ten- The extensor tendons of the fingers are interconnected across the
don continuity and function while minimizing interference from dorsum of the hand by the juncturae tendinum. This intercon-
the repair itself. The suture techniques of Kessler and Bunnell are nection of tendons distributes the work of extension among the
two of the methods traditionally used in this repair. Modifications involved fingers. Redundancy is built into the extension of the
of these original methods have resulted in the greatest outcome first and small fingers with the presence of two separate extensor
measurements of tendon strength.5 Facility with these two suture systems. An isolated tear of the extensor tendon of the index or
techniques, as well as the anatomy, is essential to the repair of any small finger, therefore, may not result in lack of function because
extensor tendon in the Emergency Department (ED). of the contributing band from the extensor digitorum communis
A Central Terminal
slip insertion
Sagittal
band
Dorsal and volar
interossei
Vincula
Flexor digitorum
profundus
Flexor digitorum
superficialis
Lumbrical
B
Terminal
insertion
Lumbrical
Central slip
Dorsal and volar

interossei
FIGURE 76-2. The central extensor tendons of the digits are reinforced and aided
by the lateral bands of the interosseous and lumbrical muscles. The extensor ten-
don is tethered to the joint surface by a sagittal band, which forms a protective
hood. A. Lateral view. B. Superior view.
FIGURE 76-3. Division of an extensor tendon in the dorsum of the hand may still
allow for full finger extension because of the communicating juncturae tendinum.
(Figure 76-3). It is important to realize that there is great ana-

tomic variability in the detailed distribution of these tendons.
lacerated tendon that is associated with significant overlying skin
The location of an extensor tendon injury is important in deter-
loss, joint space penetration, or a bony fracture will require repair
mining whether tendon repair in the acute ED setting is feasible.
by an Orthopedic or Hand Surgeon.
A range of eight zones defines the location of an extensor tendon
Defining the location of the tendon injury according to the
injury (Figure 76-4). The zone chart first described by Kleinert
Kleinert zone system guides one in deciding what tendon lacera-
and Verdan helps to classify and organize the modes of repair.8 The
tions can be safely repaired in the ED. Although there are no pub-
odd-numbered zones refer to areas over the joints, while the even-
lished guidelines on where these procedures should be performed,
numbered zones refer to the bony areas. Although any zone can
a thorough understanding of the extensor tendon’s anatomy and a
undergo injury and repair, the outcome is variable, depending upon
good dose of common sense are imperative.
the suture technique and the mode of rehabilitation.
The following zones and types of injury represent sites where
extensor tendon repair in the ED is feasible with minimal compli-
INDICATIONS cations. The thickness of the extensor pollicis longus allows for a
The decision to surgically repair a lacerated extensor tendon is core-type suture in zone 2 of the thumb. The broad configuration
multifactorial. One must consider the extent of the tendon lacera- of the extensor tendon allows for a core-type suture in zone 4 of
tion, the involvement of other tissues (e.g., bone or joint space), all digits. Isolated involvement of the extensor tendon allows for
and the location of the tendon injury. Studies that define a mini- a core-type suture unless the joint is involved (rare) in zone 5 of
mum laceration width that requires tendon repair have not been the fingers. Isolated involvement of the extensor tendon allows
performed. It is generally accepted that a laceration greater for a core-type suture and good prognosis in zone 6 of the hand.
than 50% of the tendon width requires surgical repair.1 A ten-
don that has a laceration less than 50% of its width will usually
heal with conservative management. One must put the finger
CONTRAINDICATIONS
through its entire range of motion to confirm normal function There are definite contraindications to repairing an extensor ten-
and movement of the affected tendon prior to making the deci- don in the ED. First and foremost, the lack of skill on the part of
sion as to whether conservative management is appropriate. A the EP performing this repair may result in loss of function or may
CHAPTER 76: Extensor Tendon Repair 493
EQUIPMENT
Digital or Hand Anesthesia
• 10 mL syringe
• 25 to 27 gauge needle, 2 in. long
• Local anesthetic solution without epinephrine
Extensor Wound Irrigation and Preparation
• 250 to 500 mL of sterile saline or Ringer’s lactate solution
• Irrigation set
• 60 mL syringe
• 16 gauge angiocatheter
• Intravenous tubing
• Personal protective equipment
• Blood pressure cuff, preferably automatic
• Overhead lamp or source of intense lighting
Extensor Tendon and Skin Repair
• Sterile surgical towels
• Forceps
• #11 blade disposable scalpel
• Needle driver
• Nonabsorbable, synthetic, and braided suture (4-0, 5-0, and 6-0
Ethibond or Mersilene)
• Nylon suture (4-0 and 5-0) for skin closure
FIGURE 76-4. The extensor tendons of the hand are easily classified by the Wound Dressing and Splint
Kleinert zone system. The odd numbers represent joint spaces. The even numbers
• Topical antibiotic ointment
represent long bones. Note that the thumb zones are distinct from the other digits.
• Gauze squares
• Elastic gauze bandage
further compromise the patient’s result. Consult an Orthopedic or • Splinting materials
Hand Surgeon if any doubt exists. The skin wound can be closed
loosely, the hand splinted, and the patient referred for delayed PATIENT PREPARATION
repair. Surgical repair of the tendon is not recommended if less
than 50% of the tendon is lacerated and the finger functions as Explain the risks, benefits, and potential complications of the
well as the corresponding finger on the unaffected opposite hand. planned procedure to the patient and/or their representative. The
The presence of a bony fracture, an open joint space, or the lack broad risks to the procedure include, but are not limited to, bleed-
of adequate soft tissue or skin covering are contraindications to ing, infection, nerve damage, additional tendon damage, temporary
repairing an extensor tendon in the ED. A tendon laceration as a or permanent stiffness, and a need for additional operations in the
result of a human bite wound is an absolute contraindication to future. Additionally, alternative forms of therapy should be dis-
closure and repair of the injury. The management and rehabilita- cussed. Upon receiving verbal or written consent, the physician may
tion of these wounds necessitate consultation with the appropriate proceed with prepping and positioning the patient.
surgical specialist. Place the patient in a supine and comfortable position to minimize
The Kleinert zone chart can be used to help determine the suit- movement during the course of the procedure. Place the involved
ability of repairing an extensor tendon in the ED. The following hand on a bedside procedure table ideally at the heart level so that
zones on the forearm, wrist, and hand represent areas where wound the patient’s arm is resting comfortably. Temporarily diminish arte-
care, skin closure, and splinting are highly recommended until an rial blood flow with either a digital tourniquet or a blood pressure
Orthopedic or Hand Surgeon can perform definitive surgical repair. cuff applied to the arm if vascular bleeding is active and obscures
Extensor tendon remnants may be too short in zone 1 of all dig- the site of repair. Padding should be applied under the tourniquet.
its. Except in the thumb, extensor tendons of the fingers that are The maximum tourniquet time should be less than 2 hours.8 Any
very thin in zone 2 should not be repaired. Actual or potential joint surgical procedure that takes this long should not be performed in
or lateral band involvement in zone 3 of all digits should not be the ED.
repaired. Actual or potential joint or sagittal band involvement in Anesthesia to the affected area can be accomplished with either a
zone 5 of all digits should not be repaired. Actual or potential exten- digital or wrist block. The choice of procedures depends upon the
sor retinaculum involvement in zone 7 should not be repaired. The location and extent of the injury. Descriptions of these procedures
actual or potential need for a tendon transfer in zone 8 requires an can be found in Chapter 126, Regional Anesthesia. Once the patient
Orthopedic or Hand Surgeon. has adequate anesthesia, the wound can be debrided and copiously
FIGURE 76-5. Suture techniques for extensor tendon repair. A. Mattress stitch. B. Figure-of-eight stitch. C. The modified Kessler stitch. The numbers represent the
sequence of steps. D. The modified Bunnell stitch. The numbers represent the sequence of steps.
irrigated with 250 to 500 mL of sterile saline (if no open joint is A retracted tendon can be held in place with a needle piercing
involved). Following irrigation, the wound is considered sterile. All it perpendicularly. Judiciously debride the tendon ends if they
techniques must be aseptic from this point forward. Apply sterile are jagged or dirty. This can be performed with a fresh 11-blade
drapes or towels to delineate a sterile field. Place a sterile drape over scalpel, cutting down against a wooden tongue depressor. Do not
the bedside procedure table. Lay out the required instruments and remove too much length from the tendon. Place the affected
suture material on the bedside procedure table. digit and wrist in maximum extension to facilitate approximation
of the tendon ends.
Hold one end of the tendon gently with your fingers or a
TECHNIQUES stitch. Introduce the needle into the cut end of the tendon
Many techniques are used to repair lacerated tendons. All of the (Figure 76-5C(1)). The entrance point should be about one-
original techniques were described with reference to flexor ten- third of the diameter of the tendon, beginning on either its ulnar
dons. These techniques have been extended to include the repair of or radial side. For simplicity, we begin on the radial side. Pass
the extensor tendons. Four common suture techniques used for a the suture approximately 1 cm through the length of the tendon
“core” repair of the extensor tendon include the mattress stitch, the and exit dorsally (Figure 76-5C(2)). Wrap the suture around the
figure-of-eight stitch, the modified Bunnell stitch, and the modified tendon (Figure 76-5C(3)). Reenter the radial side of the ten-
Kessler stitch (Figure 76-5). No single stitch is optimal for any one don perpendicularly and 1 to 2 mm closer to the tendon end
zone of injury. The type of stitch must be individualized based on (Figure 76-5C(3)). Pull the suture straight through the tendon to
the properties of the tendon at the site of injury. While evidence exit on its ulnar side (Figure 76-5C(4)). Wrap the suture around
exists that the modified Kessler and Bunnell stitches produce the the tendon (Figure 76-5C(5)). Enter the dorsal aspect of the
greatest strength for a core-type tendon repair,5 they may not be best ulnar half of the tendon (Figure 76-5C(5)). This entrance stitch
suited for extremely thin tendons (such as in zones 4 or 6). Instead, a must line up with the first dorsal stitch (Figure 76-5C(2)). Pass
figure-of-eight or mattress stitch may be necessary. The Bunnell and the needle through the length of the tendon to exit the end of
Kessler techniques are more useful in round, thicker tendons such the tendon (Figure 76-5C(6)). The needle must exit on the ulnar
as the flexor tendons or more proximal extensor tendons.5,10 one-third of the tendon.
Repeat the same stitch on the opposing piece of the tendon. Pass
the needle into the ulnar one-third of the tendon (Figure 76-5C(7)).
MODIFIED KESSLER STITCH
Pass the suture approximately 1 cm through the length of the ten-
This “core” stitch is designed to place the direction of force perpen- don and exit dorsally (Figure 76-5C(8)). Wrap the suture around
dicular to the longitudinal axis of the tendon (Figure 76-5C). If the the tendon (Figure 76-5C(9)). Reenter the ulnar side of the ten-
force of the suture is placed in the tendon’s longitudinal axis, there don perpendicularly and 1 to 2 mm closer to the tendon end
is a tendency for the suture to pull through and shred the tendon. (Figure 76-5C(9)). Pull the suture straight through the tendon to
Identify the two ends of the lacerated extensor tendon. Handle exit its radial side (Figure 76-5C(10)). Reenter the dorsal aspect of
the cut ends with maximal care. Blindly or bluntly grabbing the radial half of the tendon (Figure 76-5C(11)). The stitch must
the ends traumatizes the tendons and compromises the repair. line up with the previous dorsal stitch (Figure 76-5C(8)). Pass the
CHAPTER 77: Arthrocentesis 495
needle through the length of the tendon to exit the end of the tendon injuries in zones 1 to 4 can be temporarily immobilized in exten-
(Figure 76-5C(12)). The needle must exit on the radial one-third of sion until follow-up by an Orthopedic or Hand Surgeon determines
the tendon. the definitive splinting management. Tendon injuries in zones 5 to
The two free ends of the suture should be on the radial side of the 8 can be placed in a temporary static splint with the wrist in 30° of
tendon. Apply tension to the two free ends of the suture to gently extension, the MCP joints in 15° of flexion, and the interphalangeal
approximate the ends of the lacerated tendon. Do not apply so much joints in full extension.
force that the ends bunch up. Secure the stitch with a knot that will The aftercare of extensor tendon lacerations necessitates close
remain buried between the tendon ends (Figure 76-5C(13)). follow-up by an Orthopedic or Hand Surgeon for the evaluation of
tendon function, wound evaluation, and rehabilitation strategies.
MODIFIED BUNNELL STITCH Proper aftercare and hand rehabilitation is crucial to ensure suc-
cessful results of a tendon repair.
This stitch follows the same principle as the Kessler stitch. It incor-
porates a crossing of the suture in its pathway (Figure 76-5D).
Remember to minimize the handling of the tendon in perform-
COMPLICATIONS
ing this stitch. Instrumentation of the tissue is detrimental to its Surgical repair of any open wound or tendon laceration can result
nutritional supply and can lead to adhesions. Ideally, one should in unforeseen infections. Careful instructions for wound care and
immobilize the tendon ends with one’s fingers or a single suture. follow-up evaluations are important for early detection and treat-
Enter the tendon end on the radial half and at approximately ment of tissue infection.
one-third of the diameter of the tendon (Figure 76-5D(1)). Failure of the tendon repair can be due to several etiologies.
Pass the needle diagonally through the tendon and exit on the Disruption of the surgical repair, the formation of adhesions, and
ulnar side (Figure 76-5D(2)). Wrap the suture around the ten- joint stiffness can produce an inadequate outcome.9 It is rare to
don (Figure 76-5D(3)). Reenter the tendon on its dorsal half encounter these complications in the ED. Nonetheless, they are real
(Figure 76-5D(3)). Pass the needle directly through the ten- complications that both the EP and patient must discuss before pro-
don to exit the dorsal surface of the radial aspect of the ten- ceeding with the repair procedure.
don (Figure 76-5D(4)). Enter the radial side of the tendon
(Figure 76-5D(5)). Cross the suture diagonally through the ten- SUMMARY
don to exit its ulnar end (Figure 76-5D(6)). The needle must exit
through the ulnar one-third of the tendon end. The repair of an extensor tendon laceration can and does occur in
Repeat the same stitch on the opposing piece of the ten- the ED. While the literature and authors have found that the use of
don. Pass the needle into the ulnar one-third of the tendon the Bunnell and Kessler stitches for the repair of extensor tendon
(Figure 76-5D(7)). Pass the needle diagonally through the ten- injuries produces good results, the mattress technique and figure-
don and exit on the radial side (Figure 76-5D(8)). Wrap the of-eight stitch may be more useful in the thinner extensor tendons.
suture around the tendon (Figure 76-5D(9)). Reenter the ten- Effective communication with an Orthopedic or Hand Surgeon is
don on its dorsal half (Figure 76-5D(9)). Pass the needle directly imperative in optimizing the patient’s outcome. Even if the ten-
through the tendon to exit the dorsal surface of the ulnar aspect don repair does not occur in the ED, the wound must be irrigated,
of the tendon (Figure 76-5D(10)). Wrap the suture around the explored, and closed for delayed surgical repair by an Orthopedic
tendon (Figure 76-5D(11)). Enter the ulnar side of the tendon or Hand Surgeon. Postoperative rehabilitation is crucial to ensure
(Figure 76-5D(11)). Cross the suture diagonally through the ten- an optimal outcome. Splinting in the ED should only be a temporiz-
don to exit the radial end of the tendon (Figure 76-5D(12)). The ing immobilization procedure until rehabilitation therapy occurs.
needle must exit through the ulnar one-third of the tendon end.
The two free ends of the suture should be on the radial side of
the tendon. Pull gently on the suture ends to approximate the ends
of the lacerated tendon. Do not apply so much force that the ends
bunch up. Secure the stitch with a knot, which will remain buried Arthrocentesis
within the tendon ends (Figure 76-5D(13)).
77 Eric F. Reichman, John Larkin,
and Brian Euerle
AFTERCARE
Close the overlying skin with nylon suture, ideally everting the skin
INTRODUCTION
edges with a horizontal mattress suture. Apply topical antibiotic
ointment. Apply 4 × 4 gauze squares to cover the wound. Apply an Arthrocentesis is the insertion of a needle into a joint cavity for
elastic bandage for protection. Splint the extremity to immobilize the removal of synovial fluid and/or the injection of pharmaceuti-
the repaired tendon and its associated muscle belly. cal agents into the joint cavity. Fluid can be aspirated from almost
The patient may be discharged home with follow-up arranged any joint. Arthrocentesis is used to diagnose and make treatment
within 24 to 48 hours with an Orthopedic or Hand Surgeon. decisions regarding a joint. Obtaining synovial fluid is safe, simple,
Instruct the patient to elevate the extremity. They should return to relatively pain free, inexpensive, and extremely beneficial to the
the ED immediately if there is increased pain, numbness or tingling patient.
in the digits, if the digits become cold or blue, or if a fever develops. Arthrocentesis may be diagnostic or therapeutic. Diagnostically,
Pain can be controlled by the use of nonsteroidal anti-inflammatory it is performed to identify the cause of an acute arthritis, to identify
drugs supplemented with an occasional narcotic analgesic. an intraarticular fracture, to identify the causes of an effusion, or to
Static immobilization may not be the optimal postoperative man- give a therapeutic trial of pharmaceuticals. It can also be therapeutic
agement for extensor tendon repairs. The affected tendon may bene- by relieving pain from elevated intraarticular pressure, to drain sep-
fit from early mobilization exercises or dynamic splinting depending tic or crystal-laden fluid, or to inject pharmaceuticals. Ultrasound
upon the zone of injury. Dynamic extension splinting may produce (US)-guided joint aspiration is a supplemental technique that
fewer complications and less postoperative adhesions.11–13 Tendon improves several aspects of the arthrocentesis procedure.
TABLE 77-1 General Principles for Arthrocentesis become more commonly used in the ED, more EPs are appreciat-
ing and reporting on the benefits of its use in guiding arthrocen-
Know the anatomical relationships
Avoid piercing any tendons tesis.46–51 Arthrocentesis is commonly performed on the shoulder,
Do not damage articular cartilage elbow, hip, knee, and ankle joints. It may also be performed on
Do not penetrate bone other joints. US guidance can be a useful adjunct in all of these
Use sterile technique procedures.
Provide adequate analgesia There are several possible approaches for the use of US-guided
Place the joint in slight flexion arthrocentesis in the ED. Knee arthrocentesis is commonly per-
Apply distal traction to small joints formed with a high success rate using only the landmark-pal-
Apply compression to large joints pation technique. Many EPs feel comfortable performing this
Enter the extensor surface procedure without the routine use of US guidance. Wiler and
Use US guidance if available colleagues compared US-guided versus standard landmark tech-
niques for knee arthrocentesis and found that US guidance did
not improve overall success.50 Others may use US guidance in
cases anticipated to be difficult, such as small effusions or prior
Synovial fluid analysis will provide unique and valuable infor-
joint surgery. Some EPs feel that US guidance improves the safety
mation about the affected joint.32 It is the only method to defini-
of arthrocentesis and thus choose to use it whenever an arthro-
tively diagnose or rule out a septic arthritis. The fluid should be
centesis is performed. This approach is especially appealing in
analyzed for the presence of crystals. A white blood cell count and
light of the fact that US is noninvasive and does not add any risk
differential may help identify the causes of an effusion. A Gram’s
to the procedure.
stain can be quickly performed to identify bacteria in the synovial
fluid. Bedside gross analysis of the fluid’s physical properties such
as clarity, viscosity, and color has been shown to be a reliable clini- INDICATIONS
cal predictor of a potentially septic joint.30 A culture of the synovial Arthrocentesis is indicated to evaluate the cause of an arthritis or a
fluid should be performed to definitively identify any microbiologic joint effusion (Table 77-2).4–7 All patients presenting with an acute
pathogen in the joint. monoarthritis or an acute nontraumatic effusion should undergo
There are several general principles that should be followed arthrocentesis when the diagnosis is not clear based upon the his-
when performing an arthrocentesis (Table 77-1). The Emergency tory and physical examination. Analysis of the synovial fluid is
Physician (EP) must know the anatomical relationships around essential to help differentiate inflammatory from noninflammatory
the joint. The needle should go around and not through any ten- causes of joint disease. Arthrocentesis is the only reliable method
dons. Avoid piercing the articular cartilage, which is avascular to confirm the presence of an infectious agent as the cause of an
and may not heal. Do not bounce the needle off the bone, as this arthritis. The presence of crystals within the synovial fluid can
is extremely painful for the patient. Insert the needle through the diagnose gout or pseudogout from other crystal-induced arthriti-
extensor surface of the joint. The synovial cavity is closest to the des. Always keep in mind that two or more types of arthritis can
skin over the extensor surface of the joint. The extensor surface coexist in a patient or in a single joint.4
has fewer tendons and ligaments than the flexor surface. Most of Arthrocentesis may be therapeutic.8 A large effusion, regardless
the blood vessels and nerves are located on the flexor surface of of the cause, stretches the joint capsule, causing pain and limit-
the joint. Using the extensor surface of the joint for the procedure ing range of motion. Removal of the fluid will decrease pain and
will avoid potential injury to these structures. Place the joint in increase the joint’s range of motion. An effusion caused by inflam-
slight flexion to maximize the size of the joint cavity. Apply distal mation or sepsis contains numerous mediators of inflammation.
in-line traction to the small joints of the wrists, hands, and feet to Removal of this synovial fluid will help to relieve the patient’s dis-
enlarge the joint cavity. This allows the needle to more easily enter comfort. The removal of purulent fluid will decrease the number of
the small joint spaces. Compression of large joints will mobilize organisms in the joint cavity and, theoretically, may limit further
peripheral fluid. This is helpful when the volume of synovial fluid joint destruction.
is small. Compression may be applied manually or with an elastic Injection of therapeutic agents into nonseptic joints is com-
bandage. monly performed in the Emergency Department (ED). Local
It is critical to use sterile technique to prevent the infection of anesthetic solutions may be injected to relieve pain. A joint exami-
a nonseptic joint as well as to ensure the joint fluid is uncontami- nation after trauma may be limited secondary to pain. Injection
nated for microbiological cultures. Sterile drapes, sterile gloves, of local anesthetic solutions can relieve pain and allow an exami-
and face masks are not needed to perform the procedure.1–3 It is nation for ligamentous and joint instability. Corticosteroids are
necessary to wear gloves to prevent transmission of blood-borne injected into joints to control inflammation and arthritis pain.
diseases to the EP.1,4 The skin should be cleansed and prepped in the
usual manner. The needle may then be grasped, with clean gloves, at
the hub and inserted. As long as the skin and needle are not handled,
sterile gloves are not required. This is sometimes difficult to mas- TABLE 77-2 The Indications for Performing an Arthrocentesis
ter if the EP has little practice with the technique of arthrocentesis. To evaluate a monoarticular arthritis
It may be better to err on the side of conservatism and use sterile To diagnose and treat a traumatic arthritis
gloves and drapes; particularly with inexperienced EPs and in train- To diagnose an intraarticular fracture
ing situations. To diagnose an intraarticular ligamentous disruption
US has been used by Interventional Musculoskeletal Radiologists To relieve pain
and Rheumatologists to guide needles for joint injections and aspi- To diagnose inflammatory versus noninflammatory disorders
rations.44,45 US guidance allows these procedures to be performed To identify the cause of an effusion
in a safer manner because the needle is less likely to injure nerves, To rule out an infection
tendons, and blood vessels. US also allows a comparison with the To identify a crystal-induced arthritis
asymptomatic opposite-side joint. As bedside ultrasonography has To inject therapeutic agents
Sometimes, corticosteroids and local anesthetic solutions are patient. Uncooperative patients require sedation and/or restraint
combined into one syringe and injected intraarticularly. The local prior to performing the procedure.
anesthetic provides immediate pain relief and assures the EP of A prosthetic joint increases the risk of a septic arthritis.
proper needle placement. Arthrocentesis is technically more difficult secondary to scar for-
Arthrocentesis can be used to diagnose and treat traumatic arthri- mation and alteration of the normal anatomic relationships. Joints
tides. The traumatic event is usually acute, obvious, and followed that contain a prosthesis should be aspirated only to rule out a
by joint pain and swelling. Occasionally, the trauma is minimal or septic arthritis. Arthrocentesis for other reasons, including joint
remote and not recalled by the patient. A traumatic effusion can injection, should be referred to a consultant.
be grossly bloody and, if acute, may contain a large amount of red Corticosteroids are instilled into joints for a variety of conditions.
blood cells. The bloody synovial fluid represents an intraarticular If the patient has no response to the injection within a few weeks,
fracture or a disruption of an intraarticular structure. An intraar- it may be repeated. If multiple injections cause no improvement, an
ticular fracture may be suspected based on mechanism of injury and alternative form of therapy should be explored.9 Multiple injections
yet radiographic findings may be negative. The synovial fluid may into a joint increase the risk of complications.
then be evaluated for fat globules, which are released from the mar-
row cavity of the fractured bone, which confirm the presence of an EQUIPMENT
intraarticular fracture.
The temporomandibular joint is a highly specialized joint that has • Clean gloves
a unique set of problems associated with it. Arthrocentesis can be • Gauze squares
an easy, minimally invasive, and efficient procedure used to solve • Povidone iodine or chlorhexidine solution
some of these issues. Degenerative joint disease and joint lock are
• Sterile skin marking pen
two examples of conditions that are amenable to therapeutic arthro-
centesis, although much debate still exists concerning efficacy and • Local anesthetic (injectable, vapor coolant, or ice)
therapeutic value of this procedure. • 25 to 27 gauge needle
• 3 mL syringe
CONTRAINDICATIONS
• Needles to aspirate fluid (18/20/22 gauge)
There are no absolute contraindications to arthrocentesis. All • Syringes to aspirate fluid (1/3/5/10/20/30/60 mL)
contraindications are relative. The risks and benefits of the proce-
dure should be evaluated and a decision made with the informed • Hemostat
consent of the patient. If a septic joint is suspected, it should be • Specimen tubes
aspirated despite the presence of any relative contraindication. • Culturettes or culture tubes
The benefit of the procedure outweighs any relative contrain-
dication when compared to the morbidity of an undiagnosed Optional Equipment
septic arthritis. • US machine
The presence of a suspected or known skin cellulitis, or other • US gel
infection overlying the joint, is a relative contraindication. A der-
• US transducers (5 to 10 MHz)
matitis or skin lesion overlying the joint should also be avoided. The
skin or subcutaneous tissue can harbor organisms that may contam- • Sterile US probe covers
inate the joint when the needle passes through the dermatitis or skin Arthrocentesis should be performed with a needle of sufficient
lesion. Often, an alternative site can be found to perform the arthro- bore to allow the aspiration of thick fluid, fluid with debris, or
centesis and avoid the above obstacles. If the needle is inserted into purulent fluid. An 18 to 20 gauge needle is recommended for large
the joint through any potential or obvious source of infection, anti- joints (i.e., shoulder, elbow, ankle, knee, and hip). A 22 to 23 gauge
biotic treatment is required due to the theoretical risk of introducing needle is recommended for all other joints. Using too small a needle
an infection into the joint cavity.5 In these cases, patients should be makes the procedure technically more difficult and more painful
admitted for 23 hours of intravenous antibiotics whose spectrum for the patient.
covers skin flora. A high-frequency (5 to 10 MHz) linear array transducer is pre-
Infections after arthrocentesis, in previously sterile joints, have ferred for arthrocentesis and should be used whenever possible.44
been reported in bacteremic patients.5 It is not clear whether the If this type of transducer is not available, or if more depth of field
source of the septic arthritis was from the arthrocentesis or bacte- is required, a curvilinear array may be used. Cavalier and col-
remia coincidentally seeding the joint. It is recommended to avoid leagues reported using color Doppler and a sterile needle guide
arthrocentesis in any patients with bacteremia or sepsis except to attached to the transducer when performing US-guided arthro-
rule out a septic arthritis. centesis in children.52 Doppler was used to localize the blood ves-
Patients may be coagulopathic due to heparin or Coumadin sels so that they could be avoided by the needle. While Doppler
therapy, factor deficiencies, liver dysfunction, or many other causes. may occasionally provide additional anatomic information, it
When possible, the coagulopathy should be reversed prior to arthro- is not routinely used when performing an arthrocentesis. The
centesis. Unfortunately, this is not always possible or practical. An use of a needle guide depends on the personal preference of the
experienced EP can safely perform the procedure without reversing sonographer.
the coagulopathy. Use the smallest needle gauge possible (i.e., 22 or
23 gauge) to aspirate the joint fluid. Avoid injury to the articular car-
PATIENT PREPARATION
tilage by identifying the anatomic landmarks prior to the procedure.
Do not bounce the needle off any bony surfaces. A complete history and physical examination should be per-
The procedure may be difficult in some patients. In the mor- formed prior to the arthrocentesis. The affected joint should
bidly obese, it may be difficult to identify anatomic landmarks. The be thoroughly assessed. Inspect the skin overlying the joint for
standard needle may be too short to enter the joint cavity. A spinal breaks, infection, old scars, prior incisions, superficial lesions, or
needle may be required to perform an arthrocentesis in an obese any wounds. Palpate the joint to identify any warmth, tenderness,
or effusion. Evaluate the joint for any crepitation, deformity, liga- For diagnostic aspirations, it is not necessary to aspirate all of the
mentous instability, or limitations in motion. fluid from the joint. Synovial fluid analysis can be performed on
As with any nonemergent procedure, consent should be obtained 1 to 5 mL of fluid.
from the patient or their representative. Ideally, the consent should If additional fluid is to be removed after the original syringe is
be documented in the medical record and signed by the patient. filled, or if pharmaceuticals are to be injected into the joint, do not
Some prefer to note on the patient’s chart “indications, risks, and remove the needle from the joint cavity. Grasp the hub of the needle
benefits were discussed with the patient” rather than having the with a hemostat. Remove the syringe and attach the second syringe.
patient sign a consent form.4,10 The following is a sample consent for Continue to aspirate fluid or inject the desired pharmaceutical.
performing an arthrocentesis (which may be written on the medical Remove the needle when the procedure has been completed. Apply
record and signed by the patient): a bandage to the skin. Transfer the synovial fluid into appropriately
Arthrocentesis involves inserting a small needle into labeled tubes or containers. Document the procedure in the medical
your_______ joint. The skin is anesthetized prior to the proce- record. A sample procedure note is described below:
dure. Ordinarily, the procedure has no significant complications. After informed consent, the skin overlying the________joint
Occasionally, a patient may experience bleeding into the joint, was cleaned and prepped with povidone iodine/chlorhexidine
infection of the joint or skin, pain, bruising, nerve injury, or an solution. The skin was anesthetized with (_____mL of_____%
allergic reaction to the medications administered. These compli- lidocaine, ethyl chloride vapor coolant, ice for_____minutes).
cations are minimized by the use of sterile technique and proper Using sterile technique, an_____gauge needle was inserted
techniques. on the (supero-/infero-,medial/lateral/inferior/superior) surface
Position the patient based on the specific joint to be aspirated of the joint. It was directed (supero-/infero-,medially/laterally/
and the approach to be used. Expose the joint and surrounding inferiorly/superiorly). _____mL of fluid was obtained. It was
areas. Identify the anatomic landmarks required for proper needle (thin, thick, yellow, clear, straw-colored, bloody, purulent, with
placement. The landmarks may be difficult to identify on a swollen debris, without debris). No complications were noted.
and tender joint. Compare the “affected” joint to the “normal” joint The joint was injected with_____mL of_____% (name of local
on the opposite side of the body. Identify the joint and a landmark anesthetic) and/or_____mL of_____%________(name of corti-
on the normal joint and transfer this to the affected joint. Clean costeroid). No complications were noted.
any dirt and debris from the skin. Scrub the needle insertion site
with povidone iodine or chlorhexidine solution and allow it to dry. THE BASIC US TECHNIQUE
Apply anesthesia to the skin and subcutaneous tissue using 1%
lidocaine, topical vapor spray, or ice.11 The administration of some The acoustic windows used for US-guided arthrocentesis are
form of local anesthesia is recommended but not required.4,12 The the soft tissues overlying the joint. The transducer is most com-
most common local anesthetic used is a short-acting injectable monly oriented across a joint so that the bones on each side of
anesthetic solution of 1% lidocaine. Do not inject the local anes- the joint are visualized and the joint space between them. Bone
thetic solution deeper than the subcutaneous tissues. Deep injec- is highly reflective of US waves and the cortex is seen as a bright
tions may instill anesthetic solution into the joint cavity, which may white echogenic line on the US image. Synovial fluid will be seen
interfere with the synovial fluid analysis. There is disagreement if as an anechoic line or hypoechoic collection within the joint space.
the additional needle stick to administer the anesthesia causes as When visualized longitudinally, the needle will appear as a narrow,
much discomfort as aspiration without any anesthesia. This deci- linear hyperechoic structure with a posterior reverberation artifact
sion is specific to each patient and EP. (Figure 77-1). When visualized transversely, the needle appears as
Alternative methods of anesthesia include ice and topical vapor a small hyperechoic round object.45
coolants. A sterile drape may be placed over the prepped skin and a The general procedure and technique depend on whether the
bag of ice water placed over the drape. Remove the ice water bag and static or dynamic method is used. Using the static technique,
drape after 5 minutes and perform the procedure. Ethinyl chloride manipulate the US transducer over the joint until the optimal
topical vapor coolant may be used as an anesthetic. Spray the solu- spot for needle entry is found based on fluid accessibility and a
tion onto the area of skin in which the needle will be inserted. Apply needle path that avoids major blood vessels, nerves, and tendons.
the spray from 6 in. above the skin. Spray until the skin turns white Mark the skin on the midpoint of each side of the US transducer.
and frosty. This usually takes 5 to 10 seconds. Immediately perform Rotate the transducer 90° and repeat the process. Connect the two
the procedure, as the anesthesia lasts only 30 to 60 seconds. sets of lines to form an “X” that marks the spot for needle entry
(Figure 77-2). Set aside the US transducer, prepare the skin in a
TECHNIQUES sterile manner, and proceed with the arthrocentesis using the stan-
dard landmark-based technique.
The dynamic or real-time method is slightly more demanding
THE BASIC TECHNIQUE
technically but offers the advantage of allowing visualization of the
The general procedure preferred by one of the authors and the edi- needle and needle tip.44 Prepare the patient’s skin in a sterile man-
tor (EFR) will be described. Some may prefer to insert the needle ner. Place a sterile probe cover over the US transducer and apply
into the joint space and then attach the syringe. Specifics will be sterile US gel to the skin. Place the transducer over the joint in the
addressed with each individual joint. appropriate orientation and manipulate it until the synovial fluid
Apply the needle to the syringe and break the resistance. This is visualized. Inject a local anesthetic agent into the skin and sub-
avoids any sudden and painful movements of the needle within cutaneous tissue along the projected course of the arthrocentesis
the joint cavity. Stretch the skin over the site where the needle will needle. In many cases, it is possible to observe the infusion of the
be inserted. Penetrate the skin briskly with the needle and enter anesthetic agent on the US image.44 Advance the needle through
the joint cavity. Gently aspirate synovial fluid. If bone is encoun- the skin and soft tissue and direct it toward the synovial fluid. The
tered, slightly withdraw the needle and re-advance it in a different needle can be advanced either longitudinally or transversely to the
direction. If no fluid is obtained, reevaluate the joint to determine axis of the US transducer. The longitudinal axis allows visualiza-
if an effusion is present, if another site is more appropriate for the tion of the entire needle along its path and is the technique utilized
procedure, or if another physician may offer a different perspective. by most EPs. Visualization in the transverse axis allows only one
FIGURE 77-2. The “X” marks the spot for needle entry.
solution can be achieved with the first needle as input and the sec-
ond needle as output. Continuous fluid can be infused and removed
FIGURE 77-1. Longitudinal view of a needle approaching a joint effusion. using a 10 mL syringe or attaching IV tubing to each needle.42
STERNOCLAVICULAR JOINT ARTHROCENTESIS

cross-sectional area of the needle to be seen so it can be difficult to
identify the needle and its tip. Regardless of orientation, continue to Landmarks The sternal end of the clavicle and the suprasternal
advance the needle until its tip is visible within the synovial fluid. notch are the landmarks for this joint (Figure 77-3). The joint can
Aspirate the synovial fluid. It is often possible to watch the synovial be palpated just medial to the sternal end of the clavicle and just
fluid diminish in size as it is aspirated. lateral to the suprasternal notch.
Patient Positioning Place the patient supine on a stretcher with their
TEMPOROMANDIBULAR JOINT ARTHROCENTESIS arm hanging over the edge of the table (Figure 77-3A). Abduct the
arm 90°. Externally rotate the arm so that the palm faces upward.
Landmarks The landmarks for temporomandibular joint (TMJ)
This position maximally opens the sternoclavicular joint to allow
arthrocentesis are found by first drawing a line on the patients face
easy access.
from the corner of the eye to the ipsilateral tragus (canthal-tragus
line). Mark the point 10 mm from the tragus along the line and Needle Insertion and Direction Insert a 23 gauge needle through the
0.5 mm below the line. This marks the superior compartment. anterior joint surface and perpendicular to the skin (Figure 77-3B).
Mark a second point 20 mm from the tragus along the line and Advance the needle to a depth of 2 to 5 mm.
1 mm below the line. This marks the superior compartment. Remarks This joint is often involved with degenerative arthritis.
Patient Positioning Place the patient sitting upright with their jaw Septic arthritis is commonly seen in intravenous drug abusers who
held slightly open. inject drugs into the great vessels; also known as “pocket shooting.”
This joint may only contain 0.25 to 0.50 mL of fluid.
Needle Insertion and Direction Use two 21-gauge needles to access
the joint space compartments. Insert the first needle at the first Joint Injection A maximum volume of 1 mL may be instilled into this
mark and advance it into the joint space. Inject 2 to 3 mL of sterile joint. A maximum dose of 10 mg of corticosteroids may be instilled
saline to insufflate the joint space. Insert and advance the second into this joint.
needle at the second point and into the joint space. Correct place-
ment is confirmed when the saline flows out the needle.41
ACROMIOCLAVICULAR JOINT ARTHROCENTESIS
Remarks Arthrocentesis of this joint is a unique solution to a spe-
cialized TMJ disorder called closed lock, in which the patient’s jaw Landmarks The acromioclavicular (AC) joint is very superficial
is felt to be locked and will not open greater than 20 to 25 mm. It is (Figure 77-4). Palpate the clavicle and move laterally until a promi-
theorized to be the result of small adhesions and nongliding of the nence is felt. This is the AC joint. Have the patient move their arm
intraarticular disk in the TMJ space. Arthrocentesis and subsequent to confirm the joint location.
lavage can relieve the symptoms of closed lock. Patient Positioning Place the patient sitting upright on a stretcher
Joint Injection Once the two needles are in place in the superior with the affected arm hanging by their side. A weight may be placed
compartment, massive lavage with normal saline or lactated ringers in the patient’s hand to distract and open the joint space.
Acromioclavicular Clavicle
joint
Acromion
process
Humerus
Anterior
sternoclavicular
B ligament Scapula
Costoclavicular
Clavicle Interclavicular ligament FIGURE 77-4. Acromioclavicular joint arthrocentesis.
ligament
First rib X In the proper position, the forearm is resting against the patient’s
Second rib abdomen.
Needle Insertion and Direction Insert an 18 gauge needle perpen-
dicular to the skin and into the groove just lateral to the cora-
coid process (Figure 77-5B). Aim the needle directly posterior.
Advance the needle until a loss of resistance is felt as the joint cav-
ity is entered.
Ultrasound Probe Placement With the patient positioned as above,
Sternum place the US probe inferior and lateral to the coracoid process.
FIGURE 77-3. Sternoclavicular joint arthrocentesis. A. Patient positioning.

B. Anatomy and needle insertion. The site of needle insertion is represented by
an “⊗”.
Clavicle
Coracoid
process
Acromion
Needle Insertion and Direction Insert a 22 gauge needle through process
the superior surface of the AC joint and perpendicular to the skin
(Figure 77-4). Advance the needle to a depth of 3 to 5 mm.
A
Remarks The AC joint is very superficial. It has a dense, thick cap-
sule anteriorly that is lacking on its superior surface. The joint may
contain only 0.25 to 0.50 mL of fluid.
Joint Injection A maximum volume of 1.5 mL may be instilled into
this joint. A maximum dose of 10 mg of corticosteroids may be
Greater tubercle X
instilled into this joint.
of the humerus
GLENOHUMERAL JOINT (SHOULDER)

ARTHROCENTESIS, ANTERIOR APPROACH B
Landmarks Palpate the coracoid process of the scapula (Figure 77-5).

It will be found below the lateral third of the clavicle. Internally
rotate and adduct the humerus. Palpate the groove between the cor-
acoid process and the humeral head. This groove is the landmark for
introduction of the needle.
Patient Positioning Place the patient sitting upright or supine on a FIGURE 77-5. Shoulder joint arthrocentesis. A. Lateral approach. B. Anterior
stretcher. Flex the elbow 90°. Internally rotate and adduct the arm. approach. The site of needle insertion is represented by an “⊗”.
Rotate the probe so that the marker is cephalad and angled medi- Spine of scapula Acromion process
ally toward the patient’s head. The curve of the humeral head will
appear different than the flat portion of the glenoid, and between
these hyperechoic surfaces lies the V-shaped hypoechoic joint space.
Remarks This approach is the simplest yet most painful of the three
approaches. The needle must penetrate the tendons of the coraco-
brachialis, subscapularis, biceps, and pectoralis major muscles in
addition to the very tough anterior joint capsule. The major disad-
vantage of this approach is the possible (but rare) penetration of the
brachial plexus or the axillary vessels with the needle. The patient
can view the large needle as it approaches the skin and this may
increase their anxiety level. The posterior approach is preferred
when using US guidance.44 Humerus
Joint Injection A maximum volume of 15 mL may be instilled into
GLENOHUMERAL JOINT (SHOULDER) Scapula

ARTHROCENTESIS, LATERAL APPROACH
FIGURE 77-6. Posterior approach for shoulder joint arthrocentesis.
Landmarks Identify the acromion process of the scapula (Fig-
ure 77-5). A groove can be found just inferior to the lateral surface
of the acromion and above the greater tubercle of the humerus. medially or laterally. The echogenic cortex of the humeral head is
Patient Positioning Place the patient sitting upright on a stretcher visible along with the adjacent glenoid rim (Figure 77-8). The joint
with the affected arm hanging by their side. A weight may be placed fluid is visible as an anechoic area between these two bony struc-
in the patient’s hand to distract and open the joint cavity. tures (Figure 77-8). Insert and advance the needle from the lateral
Needle Insertion and Direction Insert an 18 gauge needle into the edge of the US transducer, oriented along the long axis of the trans-
midpoint of the groove (Figure 77-5A). Direct the needle medi- ducer, and into the joint fluid.
ally and slightly posterior. Advance the needle to a depth of Remarks This is felt by some physicians to be the preferred approach
2.5 to 3 cm. to shoulder arthrocentesis. The needle will pierce the deltoid and
Remarks Immediately below the deltoid muscle is the subacromial infraspinatus muscles and avoid the tendons of the rotator cuff. This
bursa. This bursa does not communicate with the shoulder joint. approach avoids the anxiety associated with the patient observing
The needle must be inserted 2.5 to 3 cm to ensure the needle is in the large needle and syringe used for the procedure during the ante-
the shoulder joint and not in the subacromial bursa. The anterior or rior or lateral approach. The posterior joint capsule is much thinner
posterior approach to shoulder arthrocentesis avoids this potential and more easily penetrated than the anterior joint capsule. There
problem. are no significant neurovascular structures that may be injured from
this approach.
GLENOHUMERAL JOINT (SHOULDER)

ARTHROCENTESIS, POSTERIOR APPROACH
Landmarks Identify the spine of the scapula (Figure 77-6). Follow
the spine laterally until it turns anterior to become the acromion
process. This posterior border of the acromion process is the land-
mark for this technique. Locate the coracoid process of the scapula,
just inferior to the lateral third of the clavicle.
Patient Positioning Place the patient sitting upright on a stretcher.
Place the palm of the hand of the affected shoulder on the anterior
surface of the opposite shoulder. The arm and forearm should be
held against the chest. This position maximally opens the posterior
joint space.
Needle Insertion and Direction Place the nondominant thumb on the
posterior border of the acromion process. Place the nondominant
index finger on the coracoid process. Insert an 18 gauge needle 1 to
2 cm below the thumb and parallel to the floor (Figure 77-6). Aim
the needle toward the tip of the index finger, approximately 30°
medially. Advance the needle to a depth of 2 to 3 cm.
US Probe Placement Position the patient as described above. Place
the US transducer across the posterior aspect of the shoulder in a FIGURE 77-7. In the posterior approach to the shoulder, the US transducer is
transverse orientation (Figure 77-7). The marker may be directed placed in a transverse orientation.
HUMERORADIOULNAR JOINT (ELBOW)

ARTHROCENTESIS, POSTERIOR APPROACH
Landmarks Identify the top of the olecranon process of the ulna
and the triceps muscle insertion into the olecranon process
(Figure 77-9B). Find the point just proximal to the top of the olec-
ranon and just lateral to the triceps insertion. This point is the land-
mark for insertion of the needle.
Patient Positioning Place the patient sitting upright on a stretcher.
Flex the elbow 90° with the hand supinated. The forearm and hand
should be resting on a tabletop or on the patient’s leg.
Needle Insertion and Direction Approach the joint from the pos-
terolateral surface with the needle parallel to the radial shaft.
Insert a 22 gauge needle perpendicular to the skin at the landmark
(Figure 77-9B). Advance the needle to a depth of 1 cm.
the US transducer along the posterior elbow in a longitudinal ori-
entation, with the marker toward the shoulder (Figure 77-10). This
produces an image with the humerus located to the left, the olec-
ranon located to the right, the olecranon fossa at the bottom, and
the triceps tendon passing from side to side across the top of the
screen (Figure 77-11). Keep the US transducer in the same ori-
entation and slide it laterally to move off the triceps tendon. The
joint effusion will be visualized in or adjacent to the olecranon fossa
(Figure 77-11). Be sure to avoid the ulnar nerve which passes over
the medial epicondyle, by choosing a location as far lateral as pos-
sible.33,34 Advance the needle over the superior edge of the US trans-
ducer and into the synovial fluid.
Remarks Potential complications include needle penetration of the
FIGURE 77-8. US image of the posterior shoulder. The hypoechoic joint fluid triceps tendon or the radial nerve. This approach is reserved for
(asterisk) is located between the echogenic cortices of the humeral head (arrow) patients in whom the lateral approach is contraindicated.
and the glenoid rim (arrowhead). Joint Injection A maximum volume of 5 mL may be instilled into
instilled into this joint. HUMERORADIOULNAR JOINT
(ELBOW) ARTHROCENTESIS,
HUMERORADIOULNAR JOINT (ELBOW) POSTEROLATERAL APPROACH
ARTHROCENTESIS, LATERAL APPROACH Landmarks Identify the lateral surface of the olecranon process of
Landmarks The lateral epicondyle of the humerus, the radial head, the ulna and the lateral epicondyle of the humerus (Figure 77-9C).
and the tip of the olecranon process of the ulna are the landmarks Find the indentation just lateral to the olecranon and just distal to
for this joint (Figure 77-9A). Flex the elbow 45° and pronate the the lateral epicondyle. This point is the landmark for the insertion
hand. Pronation of the hand stretches the radial collateral ligament, of the needle.
moves the radial nerve out of the needle’s path, and widens the Patient Positioning Place the patient sitting upright on a stretcher.
synovial cavity. Identify the depression between the landmarks. The Flex the elbow 90° with the hand supinated. The forearm and hand
depression is located proximal to the radial head in the area where should be resting on a tabletop or on the patient’s leg.
no bony structures are palpated. Needle Insertion and Direction Approach the joint from the pos-
Patient Positioning Place the patient sitting upright or supine on a terolateral surface with the needle parallel to the radial shaft.
stretcher. Flex the elbow 45° and pronate the hand. This position Insert a 22 gauge needle perpendicular to the skin at the landmark
widens the joint cavity and avoids any neurovascular structures. (Figure 77-9C). Advance the needle to a depth of 1 cm.
Needle Insertion and Direction Insert a 22 gauge needle perpendic- Remarks This approach is an alternative when the lateral approach
ular to the skin and into the depression just proximal to the radial is contraindicated.
head (Figure 77-9A). Advance the needle to a depth of 0.75 to Joint Injection A maximum volume of 5 mL may be instilled into this
2.0 cm. joint. A maximum dose of 20 mg of corticosteroids may be instilled
Remarks This is the preferred approach for elbow arthrocentesis. It into this joint.
avoids tendons and neurovascular structures, thereby reducing the
risk of complications.13
RADIOCARPAL JOINT (WRIST) ARTHROCENTESIS
Joint Injection A maximum volume of 5 mL may be instilled into this
joint. A maximum dose of 20 mg of corticosteroids may be instilled Landmarks Identify the lunate bone (Figure 77-12). Palpate
into this joint. the middle (third) metacarpal and follow it proximally until a
A
Joint cavity
Head of radius
Lateral X
epicondyle
of humerus
Olecranon
process of ulna
B C
Medial Lateral
Humerus
Triceps
tendon
X
Medial Lateral
Olecranon epicondyle epicondyle
X FIGURE 77-9. Elbow joint arthrocentesis. The site of needle
insertion is represented by an “⊗”. A. Lateral approach.
Olecranon
Elbow B. Posterior approach. C. Posterolateral approach.
rounded bean-like elevation is felt (Figure 77-12A). This is the

lunate. Palpate the indentations proximal and distal to the lunate.
The indentation proximal to the lunate is the landmark for needle
insertion.
Alternatively, identify Lister’s tubercle and the extensor pollicis
longus (EPL) tendon (Figure 77-12B). Lister’s tubercle is a bony
prominence in the center of the dorsal aspect of the distal radius.
The EPL tendon can be found lateral (radial) to Lister’s tubercle.
If the EPL tendon is difficult to find, extend the hand and thumb
against resistance and it will become prominent. The lunate is the
bony prominence distal to Lister’s tubercle. The indentation proxi-
mal to the lunate is the landmark for needle insertion.
Patient Positioning Place the patient sitting upright or supine on a
stretcher. Pronate the hand with the wrist in slight (e.g., 20°-50°)
flexion and ulnar deviation (Figure 77-12A). The palm of the phy-
sician’s nondominant hand should be holding the patient’s palm.
Reidentify the lunate with the nondominant thumb.
FIGURE 77-10. The US transducer is placed along the posterior elbow in a longi- Needle Insertion and Direction Insert a 22 gauge needle perpen-
tudinal orientation. dicular to the skin in the indentation proximal to the lunate
(Figure 77-12A). Advance the needle to a depth of 0.75 to 1.25 cm.
A Extensor pollicis
longus
Ulna
Extensor pollicis
Distal radius
brevis
Lunate bone
Navicular bone
B Lunate bone
FIGURE 77-11. US image of the longitudinal view of an elbow joint. The
hypoechoic joint fluid (asterisk) is located between the echogenic cortices of the Lister's
humerus (arrow) and the olecranon (arrowhead). tubercle
Alternatively, insert the needle in the indentation just distal to

Lister’s tubercle and ulnar to the EPL tendon (Figure 77-12B).
Remarks The preferred, and easiest, method is to identify the lunate
and then insert the needle in the indentation just proximal to the
lunate.
Extensor pollicis
joint. A maximum dose of 20 mg of corticosteroids may be instilled
longus
into this joint.
FIGURE 77-12. Radiocarpal joint arthrocentesis.

INTERCARPAL JOINT ARTHROCENTESIS
Landmarks Identify the lunate bone (Figure 77-12). Palpate the
middle (third) metacarpal and follow it proximally until a rounded CARPOMETACARPAL JOINT
bean-like elevation is felt (Figure 77-12A). This is the lunate. OF THE THUMB ARTHROCENTESIS
Palpate an indentation distal to the lunate and proximal to the base
of the third metacarpal. This indentation is the landmark for inser- Landmarks The base of the first metacarpal and the abduc-
tion of the needle. tor pollicis longus (APL) tendon are the landmarks for this joint
Patient Positioning Place the patient sitting upright or supine on a (Figure 77-14). Identify the radial aspect of the base of the first
stretcher. Pronate the hand with the wrist in slight (e.g., 20°-50°) metacarpal. Have the patient rotate the affected thumb to help iden-
flexion and ulnar deviation (Figure 77-12A). The palm of the phy- tify the joint. Identify the APL tendon by extending the patient’s
sician’s nondominant hand should be holding the patient’s palm. thumb against resistance.
Reidentify the landmarks with the nondominant thumb. Patient Positioning Place the patient sitting upright or supine on a
Needle Insertion and Direction Insert a 22 gauge needle perpendicu- stretcher. Flex the thumb into the palm with the tip of the thumb
lar to the skin in the indentation distal to the lunate. Advance the touching the fifth metacarpal head. Clench the remaining fingers
needle to a depth of 0.5 to 1.0 cm. into a fist (Figure 77-14A).
Remarks The joints between the carpal bones are all connected to Needle Insertion and Direction Insert a 22 gauge needle into the joint
each other (Figure 77-13). Fluid aspirated from one of these joints is space at the radial aspect of the base of the first metacarpal and just
representative of all the joints. Likewise, injection of one joint allows lateral (radial) to the APL tendon (Figure 77-14A). Direct the tip of
the pharmaceutical to be distributed to all the joints. the needle toward the base of the fourth metacarpal. Advance the
Joint Injection A maximum volume of 1.5 mL may be instilled into needle to a depth of 0.5 to 1.0 cm.
this joint. A maximum dose of 15 mg of corticosteroids may be Remarks If difficulty is encountered when inserting the needle,
instilled into this joint. try an alternative thumb position (Figure 77-14B). Flex the first
carpometacarpal joint 45° and apply traction to the distal thumb.

This in-line traction will enlarge the joint cavity and allow easier
access.
Joint Injection A maximum volume of 1.5 mL may be instilled into
METACARPOPHALANGEAL JOINT ARTHROCENTESIS

Landmarks Identify the metacarpophalangeal (MCP) joint and the
Capitate extensor digitorum tendon (Figure 77-15A). The MCP joint can be
Scaphoid
located just proximal to the prominence at the base of the proximal
phalanx of the finger. Identify the extensor tendon by having the
Lunate
Radial patient extend the finger against resistance.
Ulnar collateral Patient Positioning Place the patient sitting upright or supine on a
collateral ligament stretcher. Pronate the hand and abduct the fingers. Grasp the finger
ligament
and apply distal traction.
Distal Needle Insertion and Direction Insert a 22 gauge needle into the
Articular radioulnar
disk joint
dorsal joint space just medial or lateral to the extensor tendon
(Figure 77-15B). Direct the tip of the needle toward the center of
the joint. Advance the needle to a depth of 0.3 to 0.5 cm.
Remarks The application of distal traction often causes a depression
to appear on both sides of the extensor tendon (Figure 77-15B).
Ulna Radius
These depressions can be used as landmarks for the site of needle
insertion into the joint cavity.
FIGURE 77-13. Intercarpal joint arthrocentesis. Coronal section through the wrist
and hand demonstrating that the joints between the carpal bones are all intercon- Joint Injection A maximum volume of 1 mL may be instilled into this
nected. The site of needle insertion is represented by an “⊗”. joint. A maximum dose of 5 mg of corticosteroids may be instilled
into this joint.
FIGURE 77-14. Carpometacarpal joint of the thumb arthro-

centesis. A. Recommended approach. The dotted line rep-
resents the proper direction for needle insertion, toward the
base of the fourth metacarpal. B. An alternative technique.
The arrow represents the application of distal traction.
Interphalangeal Metacarpophalangeal
A joint joint
Extensor
tendon
Metacarpophalangeal
joint
Dorsal extensor
expansion
Interphalangeal
B joint
FIGURE 77-15. Arthrocentesis of the metacarpophalangeal and

interphalangeal joints. A. Proper needle placement. B. Distal
traction will cause dimpling of the skin in the areas noted by the Tendon of
“⊗”. These areas of skin dimpling are the landmarks for needle extensor digitorum
insertion. The arrow represents the application of distal traction.
INTERPHALANGEAL JOINT needle is 2 to 3 cm below the ASIS and 2 to 3 cm lateral to the femo-
OF THE FINGER ARTHROCENTESIS ral artery pulse.
Patient Positioning Place the patient supine on a stretcher with the
Landmarks Identify the interphalangeal (IP) joint and the extensor affected leg internally rotated and the knee slightly flexed.
tendon (Figure 77-15A). The IP joint can be located just proximal
to the prominence at the base of the middle or distal phalanx of the Needle Insertion and Direction Insert a 3.5 in., 18 gauge needle at the
finger. Identify the extensor tendon by having the patient extend the landmark (Figure 77-16). Direct the tip of the needle posteromedi-
finger against resistance. ally. Insert the needle at a 60° angle to the skin of the thigh. Advance
the needle until bone is encountered. Slightly withdraw the needle
and begin aspirating the synovial fluid.
stretcher. Pronate the hand and abduct the fingers. Grasp the finger
and apply distal traction. US Probe Placement Position the patient as described above.49 Place
Needle Insertion and Direction Insert a 22 gauge needle into the the US transducer over the anterior hip and aligned with the long
dorsal joint space just medial or lateral to the extensor tendon axis of the femoral neck, with the marker in a superior-medial
(Figure 77-15B). Direct the tip of the needle toward the center of direction and aimed toward the umbilicus (Figure 77-17).44 The
the joint. Advance the needle to a depth of 0.3 to 0.5 cm. echogenic cortex of the femoral head is visible to the left of the
image and the femoral neck to the right. The concave transi-
Remarks The application of distal traction often causes a depression tion between these two areas is the anterior synovial recess.44,49
to appear on both sides of the extensor tendon (Figure 77-15B). Synovial fluid will be seen in this recess and tends to displace the
These depressions can be used as landmarks for the site of needle joint capsule anteriorly (Figure 77-18).43 Insert the needle from
insertion into the joint cavity. The joints are small and normally the inferolateral edge of the US transducer and advance it into the
contain almost no synovial fluid. When inflamed or infected, the synovial fluid.
joint cavity may contain up to 2 mL of synovial fluid.
Remarks This approach is technically easier and recommended
joint. A maximum dose of 5 mg of corticosteroids may be instilled by many authors. A long spinal needle is usually required for this
into this joint. procedure. Use caution as the needle may injure the articular car-
tilage. This procedure should be performed by an Orthopedist, a
Rheumatologist, or a Radiologist under fluoroscopic guidance if US
HIP JOINT ARTHROCENTESIS, is not available in the ED.
ANTERIOR APPROACH
Landmarks Identify the anterior superior iliac spine (ASIS) and the this joint. A maximum dose of 40 mg of corticosteroids may be
femoral pulse (Figure 77-16). The landmark for insertion of the instilled into this joint.
FIGURE 77-16. Anterior approach for hip joint arthrocen-

tesis. The curved arrow represents internal rotation of the
femur.
HIP JOINT ARTHROCENTESIS, LATERAL APPROACH Patient Positioning Place the patient supine on a stretcher with the
affected leg internally rotated (Figure 77-19A). Identify the greater
Landmarks The greater trochanter is the landmark for this tech- trochanter and hold it between the thumb and index finger. A
nique (Figure 77-19). Place the patient supine with the affected leg second patient position may be used for the alternative approach
internally rotated. Palpate the greater trochanter. (Figure 77-19B). Place the patient lying on the unaffected side. Flex
FIGURE 77-18. US image of a hip effusion. The hypoechoic effusion (asterisk)

FIGURE 77-17. The US transducer is placed anteriorly over the hip joint and is located in the anterior synovial recess between the echogenic cortices of the
aligned with the long axis of the femoral neck. femoral neck (arrowhead) and the femoral head (arrow).
FIGURE 77-19. Lateral approach for hip joint arthrocentesis. A. The patient is supine with the leg internally rotated (curved arrow). A needle is inserted above the greater
trochanter and advanced until the femoral neck is encountered (1). The needle has been withdrawn slightly, redirected cephalad, then readvanced into the joint cavity (2).
B. An alternative approach.
the unaffected, lower leg 90°. Fully extend the upper, affected, leg flexion. Place the US transducer in a longitudinal orientation
with a pillow supporting the ankle. superior to the patella, with the probe marker directed toward the
Needle Insertion and Direction Insert a 3.5 in., 18 gauge needle patient’s head. The cortex of the distal femur is visible as a bright
just superior to the superior margin of the greater trochanter echogenic line to the right of the image and the synovial fluid is
(Figure 77-19A). Advance the needle horizontally, parallel to the visible deep to the quadriceps tendon (Figure 77-21). Keep the US
stretcher, until it contacts the femoral neck. Withdraw the nee- transducer in oriented longitudinally and slowly slide it medially or
dle 2 to 4 mm and redirect it slightly cephalad. Advance the needle laterally to move off the quadriceps tendon. Insert the needle from
while applying negative pressure to the syringe until synovial fluid the superior edge of the US transducer in a longitudinal orientation
enters the syringe. Stop advancing the needle and continue to aspi- and direct it toward the synovial fluid. Advance the needle into the
rate the synovial fluid. The alternative technique requires the inser- synovial fluid.
tion of the needle perpendicular to the skin and 1 cm proximal to
the greater trochanter (Figure 77-19B). Advance the needle until
the femoral neck is contacted. Withdraw the needle 2 mm and begin
aspirating synovial fluid.
Remarks In the morbidly obese, the greater trochanter may not be
palpable. This approach is technically more difficult than the anterior
approach. The advantage of this approach is that the articular carti- A A
lage will not be in the needle’s path and so avoids injury. This proce-
dure should be performed by an Orthopedist, a Rheumatologist, or
a Radiologist under fluoroscopic guidance. B B
instilled into this joint. C C
PATELLOFEMOROTIBIAL JOINT (KNEE)

ARTHROCENTESIS, SUPRAPATELLAR APPROACH
Patellar
Landmarks Identify the midpoint of the superolateral or supero- tendon
medial border of the patella (Figure 77-20A). Either of these land-
marks may be used as the site for needle insertion.
affected knee fully extended.
Needle Insertion and Direction Insert an 18 gauge needle through the
Lateral Medial
midpoint of the superolateral or superomedial border of the patella
(Figure 77-20A). Direct the tip of the needle toward the intercon-
dylar notch of the femur. Advance the needle to a depth of 1.5 to Fibula Tibia
3.0 cm. FIGURE 77-20. Knee joint arthrocentesis. The site of needle insertion is repre-
US Probe Placement Position the patient as described above. A sented by an “⊗”. A. Medial and lateral suprapatellar approach. B. Medial and
small roll or towel can be used behind the knee to provide slight lateral parapatellar approach. C. Medial and lateral infrapatellar approach.
Insert and advance the needle along the superior edge of the US
transducer and into the joint fluid.
Remarks The easiest site for arthrocentesis is the medial parapatellar
region. There are no disadvantages to using the medial parapatellar
site.
PATELLOFEMOROTIBIAL JOINT (KNEE)

ARTHROCENTESIS, INFRAPATELLAR APPROACH
Landmarks Identify the inferior border of the patella and the patel-
lar tendon (Figure 77-20C). The tendon is a thick band that passes
from the inferior border of the patella to the tibial tuberosity.
Patient Positioning Place the patient sitting upright on a stretcher
with the affected knee bent 90° over the edge of the bed and the leg
hanging freely and unsupported.
Needle Insertion and Direction Insert an 18 gauge needle 0.5 cm
below the inferior border of the patella at the level of the joint line
and just medial or lateral to the patellar tendon (Figure 77-20C).
Direct the needle perpendicular to the long axis of the leg and aimed
toward the intercondylar notch of the femur. Advance the needle to
a depth of 1.5 to 2.0 cm.
Remarks The weight of the leg helps to open the joint cavity. The
risk of injury to the articular cartilage is minimal. This approach
FIGURE 77-21. US image of a knee effusion. The hypoechoic joint fluid (asterisk) was popular in the past but is not often used today. Do not pierce the
is located above the echogenic cortex of the distal femur (arrow). patellar tendon with the needle.
Remarks The needle enters the suprapatellar bursa and avoids any
potential damage to the articular cartilage. The bursa is a direct TIBIOTALAR JOINT (ANKLE)
continuation of the synovial cavity.44 There are no neurovascular ARTHROCENTESIS, ANTEROLATERAL APPROACH
structures of significance to injure with this approach. If the knee
effusion is minimal, synovial fluid may not be able to be aspirated Landmarks Identify the joint cavity, the lateral malleolus, and the
from this approach. Approximately 10% of the population has a extensor digitorum longus (EDL) tendons (Figure 77-22). The joint
plica completely separating the suprapatellar bursa from the knee cavity is located below the distal edge of the fibula and between the
joint. If this variation exists in the patient, the bursa fluid will not bases of the malleoli. Extend the toes against resistance to identify
represent synovial fluid. the EDL tendons. Palpate the base of the lateral malleolus.
Joint Injection A maximum volume of 10 mL may be instilled into Patient Positioning Place the patient sitting upright or supine on
this joint. A maximum dose of 40 mg of corticosteroids may be a stretcher. The patient can also be placed sitting upright on a
instilled into this joint. stretcher with affected knee bent 90° over the edge of the bed and
the foot hanging freely and unsupported. Plantar flex the ankle.
PATELLOFEMOROTIBIAL JOINT (KNEE) Needle Insertion and Direction Insert a 22 gauge needle perpendicu-
ARTHROCENTESIS, PARAPATELLAR APPROACH lar to the fibular shaft at the level of the base of the lateral malleolus;
midway between the malleolus and the lateral border of the EDL
Landmarks Identify the midpoint of the lateral or medial border of
tendon (Figure 77-22A). Advance the needle to a depth of 0.5 to
the patella (Figure 77-20B). Either of these landmarks may be used
1.0 cm.
as the site for needle insertion.
the US transducer over the anterior tibiotalar joint in a longitudi-
affected knee fully extended.
nal orientation, with the marker of the US transducer toward the
Needle Insertion and Direction Insert an 18 gauge needle just patient’s head (Figure 77-23).44,46 Manipulate the US transducer
below the midpoint of the lateral or medial border of the patella with a slight rotation until the echogenic cortex of the tibia and talus
(Figure 77-20B). Direct the needle perpendicular to the long axis bones are both visible (Figure 77-24). The tibia is visible to the left
of the leg and aimed toward the intercondylar notch of the femur. of the image and the talus to the right. During the rotation of the
Advance the needle to a depth of 1 to 2 cm. US transducer, note the location of the dorsalis pedis artery and
Ultrasound Probe Placement Place the US transducer oriented the extensor tendons so that they may be avoided when inserting
longitudinally, and either lateral or medial to the patella, with the needle.44 The joint fluid is visible as a hypoechoic area in the
the marker directed toward the patients head. Identify the joint V-shaped recess between the tibia and talus (Figure 77-24). Insert
fluid. Slowly rotate the US transducer to a horizontal orientation the needle at the inferior end of the transducer and advance it into
to identify the area with the largest anechoic fluid collection.44 the joint fluid.
Tibialis Anterior
Extensor
digitorum longus
Joint line C
A
X Medial
X malleolus
Inferior extensor
X
retinaculum
Deep peroneal
nerve
Extensor hallucis
brevis and extensor Dorsalis pedis
digitorum brevis artery
Tendon of
extensor
hallucis longus
FIGURE 77-22. Arthrocentesis of the ankle joint. The site of needle insertion is represented by an “⊗”. A. Anterolateral approach. B. Anteromedial approach. C. An alter-
native technique for the anteromedial approach.
Remarks This approach avoids potential injury to the dorsalis pedis TIBIOTALAR JOINT (ANKLE) ARTHROCENTESIS,
vessels and the deep peroneal nerve. ANTEROMEDIAL APPROACH
joint. A maximum dose of 20 mg of corticosteroids may be instilled Landmarks Identify the joint cavity, the medial malleolus, and the
into this joint. tendons of the tibialis anterior (TA) and the extensor hallucis longus
plantar flex the ankle and invert the subtalar joint to use the TA
tendon as the landmark for the procedure.
Needle Insertion and Direction Insert a 22 gauge needle perpendicu-
lar to the tibial shaft at the level of the base of the malleolus and
medial to the EHL tendon (Figure 77-22B). Alternatively, insert the
needle medial to the TA tendon (Figure 77-22C).
Ultrasound Probe Placement The procedure is exactly as described
above for the anterolateral approach.
Remarks If using the EHL tendon as the landmark, use caution to
avoid the dorsalis pedis vessels and the deep peroneal nerve that
usually lie immediately lateral to the EHL tendon.
joint. A maximum dose of 20 mg of corticosteroids may be instilled
into this joint.
SUBTALAR JOINT ARTHROCENTESIS

Landmarks Identify the tip of the medial malleolus. Palpate the sus-
FIGURE 77-23. The US transducer is placed over the anterior tibiotalar joint in a
tentaculum tali of the calcaneus (Figure 77-25). It is approximately
longitudinal orientation.
1.5 to 2.0 cm below the tip of the medial malleolus.
foot held at a right angle to the leg. Externally rotate the hip until the
(EHL) muscles (Figure 77-22). The joint cavity is located below the medial malleolus is pointing upward.
distal edge of the tibia and between the bases of the malleoli. Extend
Needle Insertion and Direction Insert a 22 gauge needle immedi-
the great toe against resistance to identify the EHL tendon. Plantar
ately above and slightly posterior to the sustentaculum tali (Fig-
flex the ankle against resistance to identify the TA tendon. Palpate
ure 77-25). Advance the needle to a depth of 1.5 to 2.0 cm.
the base of the medial malleolus.
Remarks This is a difficult procedure because the joint space is very
small. Fluoroscopy may be required to gain entry into the joint cav-
stretcher. The patient can also be placed sitting upright on a stretcher
ity. This procedure is seldom performed in the ED. US is not very
with the affected knee bent 90° over the edge of the bed and the
helpful due to the small joint space and irregular body surfaces.
foot hanging freely and unsupported. Plantar flex the ankle to use
the EHL tendon as the landmark for the procedure. Alternatively, Joint Injection A maximum volume of 1.5 mL may be instilled into
INTERTARSAL JOINT ARTHROCENTESIS

There are no specific landmarks for the many intertarsal joints.
Radiographs are required to identify the location of a specific
joint. Plain radiographs are often not helpful and fluoroscopic
guidance is required. For these reasons, arthrocentesis of these
joints is not routinely performed in the ED. Some authors
Talus
Navicular
Medial cuneiform
Middle cuneiform
Calcaneus
FIGURE 77-24. US image of the longitudinal view of the anterior tibiotalar joint. Sustentaculum tali
The hypoechoic joint fluid (asterisk) is located in the recess between the echo-
genic cortices of the tibia (arrow) and talus (arrowhead). FIGURE 77-25. Subtalar joint arthrocentesis.
FIGURE 77-26. Arthrocentesis of the metatarsophalangeal and interphalangeal joints of the foot. A. The ankle is plantar flexed. The affected toe is flexed 15° to 20° at
the metatarsophalangeal joint and distal traction is applied (arrow). B. The needle is inserted just inferomedial or inferolateral to the extensor tendon at the level of the
metatarsophalangeal joint (1) or the interphalangeal joint (2).
recommend probing the general area of the joint with a needle Needle Insertion and Direction Insert a 23 gauge needle into the
until it enters the joint cavity. This is extremely painful for the dorsal joint space and just medial or lateral to the extensor tendon
patient and risks injury to the articular cartilage. Therefore, this (Figure 77-26B). The needle should be aimed toward the center of
technique cannot be recommended. the joint. Advance the needle to a depth of 0.3 to 0.5 cm.
METATARSOPHALANGEAL JOINT ARTHROCENTESIS to appear on both sides of the extensor tendon. These depressions
can be used as landmarks for the site of needle insertion into the
Landmarks Identify the metatarsophalangeal (MTP) joint and the joint cavity. These joints are small and normally contain almost no
extensor tendon. The MTP joint can be located just proximal to the synovial fluid. When inflamed or infected, the joint cavity may con-
prominence at the base of the proximal phalanx of the toe. Identify tain up to 1.5 mL of synovial fluid.
the extensor tendon by having the patient extend the toe against Joint Injection A maximum volume of 1 mL may be instilled into this
resistance. joint. A maximum dose of 5 mg of corticosteroids may be instilled
Patient Positioning Place the patient sitting upright or supine on a into this joint.
stretcher. Plantar flex the foot. Grasp and plantar flex the toe 15° to
20° and apply distal traction (Figure 77-26A). JOINT INJECTION TECHNIQUE
Needle Insertion and Direction Insert a 22 gauge needle into the A joint may be injected with corticosteroids and/or local anesthetic
dorsal joint space and just medial or lateral to the extensor tendon solution to relieve pain and inflammation. Identify the anatomic
(Figure 77-26B). Direct the tip of the needle toward the center of landmarks, prepare the patient, and insert the needle as if perform-
the MTP joint. Advance the needle to a depth of 0.3 to 0.5 cm. ing an arthrocentesis. Inject the pharmaceutical(s), remove the nee-
Remarks The application of distal traction often causes a depression dle, and apply a bandage.
to appear on both sides of the extensor tendon. These depressions Occasionally, synovial fluid may be required for analysis prior
can be used as landmarks for the site of needle insertion into the to the injection of pharmaceuticals. A prospective randomized
joint cavity. study in rheumatoid arthritis patients found that aspirating all
Joint Injection A maximum volume of 1.5 mL may be instilled into the synovial fluid prior to therapeutic steroid injection reduced
this joint. A maximum dose of 10 mg of corticosteroids may be the risk of relapse, led to better outcomes, and increased symptom
instilled into this joint. relief.40 Identify the anatomic landmarks, prepare the patient, and
insert the needle as if performing an arthrocentesis. Aspirate the
synovial fluid into the syringe. With the needle still in the joint,
INTERPHALANGEAL JOINT grasp the hub of the needle with a hemostat. Remove the original
OF THE TOE ARTHROCENTESIS syringe containing the aspirated synovial fluid. Attach a second
syringe containing the pharmaceutical(s) to be injected into the
Landmarks Identify the IP joint and the extensor tendon. The IP synovial cavity. Reaspirate to confirm that the needle tip remained
joint can be located just proximal to the prominence at the base of within the synovial cavity. Inject the pharmaceutical(s). While
the middle or distal phalanx of the toe. Identify the extensor tendon injecting, no resistance should be felt. If resistance is encountered,
by having the patient extend their toes against resistance. the needle may have dislodged from the joint cavity. Remove the
Patient Positioning Place the patient sitting upright or supine on a needle, reinsert it into the synovial cavity, aspirate to confirm
stretcher. Plantar flex the foot. Grasp and plantar flex the toe 15° to proper positioning, and then inject the pharmaceutical(s). After
20° and apply distal traction (Figure 77-26A). injection, remove the needle and apply a bandage.
ULTRASOUND AND TABLE 77-3 Complications Associated with the Aspiration and/or
PEDIATRIC HIP EFFUSIONS Injection of Joints
Allergic reactions
The evaluation of a suspected pediatric hip joint effusion requires Bleeding
the consideration of septic arthritis versus a toxic synovitis. Toxic Cartilage injury
synovitis is the most common cause of hip pain in children and Dry tap
occurs most frequently in ages 3 to 6 years old. It is a nonpyogenic, Infection
inflammatory condition of the joint synovium with an unknown Joint instability
etiology. It occurs most commonly in the hip joint and occasionally Needle-associated complications
in the knee joint. Corticosteroid-induced complications
In contrast, septic arthritis is an acute pyogenic inflammation that Vasovagal reactions
occurs most commonly in children below the age of 4 years, with
a peak incidence between 6 and 24 months of age. Useful studies
include serum WBC, ESR, blood cultures, plain films, CT, MRI, and
US. The aspiration and analysis of joint fluid being most critical. alternative. Some authors believe local anesthesia is not required,
US has been shown to be as accurate as MRI in detecting effu- as the pain of anesthetic injection is equal to performing the pro-
sions. It is most easily performed using an anterior approach with cedure without injectable anesthesia.4,12 If one is concerned about
the US transducer oriented in the sagittal plane and parallel to the a potential allergic reaction associated with local anesthetic solu-
femoral neck. An effusion is visible as a convex rather than concave tions, topical ice, or vapor coolant is an acceptable alternative to
joint capsule that is greater than 5 mm in thickness. Transudates are nothing. A solution of 1% to 2% diphenhydramine can also be
more often hypoechoic whereas exudates and hemorrhage are usu- used as an injectable local anesthetic agent for the skin and soft
ally more hyperechoic.35 tissues. Do not inject diphenhydramine into the joint cavity as
Many imaging techniques such as plain film, scintigraphy, MRI this can result in a significant inflammatory reaction and possible
or CT are useful to help differentiate these two clinical entities. MRI crystal deposition.
and CT provide the highest quality information. However, these
studies usually require sedation or even general anesthesia in young CARTILAGE INJURY
children due to the long exam times and requirement for no motion.
US-guided hip joint arthrocentesis is a useful bedside imaging tech- The articular cartilage can be damaged from improper needle
nique to help solve this problem. US can only detect the presence insertion or needle movement within the joint cavity. The actual
of a joint effusion. It cannot reliably differentiate between the incidence of cartilage injury is unknown. The cartilage is avascu-
two entities without further joint fluid aspiration and analysis. lar and injuries do not heal. Damaged cartilage can lead to focal
US should not be used as a primary means to rule out a suspected degenerative changes and be a nidus for future infection. Injury
septic arthritis.35 to the articular cartilage can be prevented with a few simple steps.
Select a site for the procedure and a needle path that avoids the
articular cartilage. Aspirate as you slowly enter the joint cavity and
AFTERCARE stop inserting the needle when synovial fluid enters the syringe.
There is no advantage to plunging the needle into the middle of
There is no special care or precautions required after performing the joint cavity. Avoid needle movement once the joint cavity has
an arthrocentesis. Pain can be relieved with the use of ice, eleva- been entered. Finally, do not try to completely aspirate all the fluid
tion, and nonsteroidal anti-inflammatory drugs. Joint injection, within the joint cavity.
on the other hand, often requires some precautions. Some rec-
ommend limiting joint activity for 4 to 8 hours if an anesthetic
solution is injected into a joint. An anesthetized joint, especially DRY TAP
weight-bearing joints, may be susceptible to further injury when A needle inserted into a joint does not always guarantee fluid will
the joint has decreased sensation. Injection of corticosteroids into be aspirated.14 A dry tap can occur due to improper needle place-
a joint cavity often requires a period of immobilization. This dis- ment, small or absent effusion, mechanical obstruction, or chronic
cussion is beyond the scope of this chapter. The readers should inflammation.
refer to a rheumatology or orthopedic textbook, or the medical A dry tap can result from improper needle placement. If the nee-
literature, for this information. dle is not within the joint cavity, no fluid will be aspirated. Slightly
withdraw the needle and reinsert it at a different angle. Alternatively,
COMPLICATIONS remove the needle, re-identify the anatomic landmarks, and then
reinsert the needle.
Complications can occur with joint aspiration and/or injection One of the most common reasons for a dry tap is the lack of an
(Table 77-3). Most of the complications are minor. Significant com- effusion or a small one. It may be difficult on physical examination
plications are rare; but they do occur. to determine if an effusion is present. This is especially true if the
patient is obese or if a large amount of subcutaneous edema is pres-
ALLERGIC REACTIONS ent. Try using the non-syringe-bearing hand to “milk” fluid toward
the needle while aspirating. Alternatively, if a small effusion is sus-
Allergic reactions can occur from hypersensitivity to the local pected, inject a small amount of sterile saline into the joint cavity.
anesthetic solution. Symptoms can range from mild itching and Allow the saline to remain for 30 to 60 seconds, then aspirate the
urticaria to circulatory collapse and death. Severe allergic reac- fluid.
tions are extremely rare but may occur. Taking a thorough his- Synovial fluid may be loculated or inaccessible by the chosen site
tory can prevent many allergic reactions. The preservative in the of needle entry if the joint has been previously injured. Choose an
local anesthetic solution is often the cause of the allergic reac- alternate approach or site to enter the joint cavity. This may facilitate
tion. Local anesthetic solutions containing no preservatives are an synovial fluid aspiration.
Mechanical obstruction can result in a dry tap. Gently move CORTICOSTEROID-INDUCED COMPLICATIONS
the needle tip to determine if it can move freely. If it does not, it
may be caught or embedded in cartilage, periosteum, or synovium. Corticosteroid-induced complications can be acute or chronic.3,4,16–18
Withdraw the needle 1 to 2 mm and reaspirate. The needle may also The most severe acute complication is injection of corticoste-
be within the intraarticular fat pad. Slightly withdraw the needle roids into an infected joint. A septic arthritis must be ruled out
and reaspirate. A plica may be obstructing the lumen of the needle. prior to instillation of corticosteroids into a joint cavity. Other
Rotate the needle and reaspirate. If no fluid is aspirated, slightly local complications include steroid arthropathy, Charcot arthropa-
advance the needle and reaspirate. If still no fluid is obtained, thy, osteonecrosis, aseptic necrosis, tissue atrophy, tendon rupture,
attempt an alternate approach or reconsider if an effusion is present fat necrosis, formation of calcifications, joint instability, intraneural
and if the procedure is actually required.31 injection, and postinjection flare. Systemic complications include
The synovial fluid itself may be the cause of a dry tap. The pres- flushing, pancreatitis, posterior subcapsular cataracts, and hyper-
ence of purulent fluid or fluid with debris may clog the needle. glycemia. Due to the potential for complications, many clinicians
Remove the needle and repeat the procedure with a larger gauge defer corticosteroid injections to the Orthopedist, Rheumatologist,
needle. If the needle clogs during the aspiration, try reinjecting a or Sports Medicine consultant.
small amount of the synovial fluid to dislodge the obstruction and
then reaspirate. A larger gauge needle may be required to complete VASOVAGAL REACTIONS
the procedure.
Aspiration of synovial fluid from a chronically inflamed joint The patient may experience an increase in vagal tone from appre-
may be problematic. The synovium may undergo fatty replacement hension, needle phobias, and/or pain. Vasovagal reactions are rela-
known as lipoma arborescens. Long-standing inflammatory fluid tively common and may be associated with light-headedness and/or
may be resorbed, leaving a thick gelatinous material that is difficult fainting. To prevent secondary injury to the patient, arthrocentesis
to aspirate. In these cases, arthrocentesis should be referred to the should be performed with the patient on a stretcher or in a chair that
experienced clinician or a consultant. reclines. These vasovagal reactions are self-limited and only require
reassurance.
HEMORRHAGE SYNOVIAL FLUID ANALYSIS

Significant bleeding is extremely rare. External hemorrhage can be Hailed as the most valuable test in rheumatology, synovial fluid
controlled with direct pressure over the puncture site. Hemarthroses analysis provides essential diagnostic information for the appropri-
are usually small, self-limited, and only require observation. If a sig- ate management and treatment of urgent and emergent arthritic
nificant hemarthrosis or external hemorrhage occurs, treatment conditions.4,30 It has been established as a fundamental component
may be required to reverse the anticoagulant or replace clotting fac- to the complete and appropriate work-up of arthritic diseases. With
tors. The readers should refer to another source for management of the possibility of potential joint destruction and chronic disability,
these complications, as a detailed discussion is beyond the scope of the role of synovial fluid analysis in the expedient diagnosis and
this chapter. treatment of acute joint disease cannot be overemphasized.
Arthrocentesis can be safely performed in patients who are Controversy exists concerning what constitutes the appropriate
anticoagulated or have a bleeding disorder. The most experienced guidelines for a “routine” synovial fluid analysis.4,19–21,23,24 This con-
EP should perform the procedure to limit any potential complica- troversy arises from multiple issues that include the clinical scenario,
tions and bleeding. Also reconsider if the procedure must be done physician competency with appropriate arthrocentesis techniques,
immediately in the ED. The only true indication to perform an the sensitivity and specificity of individual tests, the availability and
arthrocentesis in a coagulopathic patient in the ED is to rule-out proficiency of laboratories, and cost. Classification schemes have
a septic joint. been established based upon gross, microscopic, biochemical, and
microbiological analyses. The most traditional and cited classifica-
tion for synovial fluid is normal, noninflammatory, inflammatory,
INFECTION septic, or hemorrhagic (Table 77-4).4,19,20,24 Despite the controversy
Infection of a sterile joint can occur when the needle penetrates that exists with guidelines and classification schemes, it is critical
unclean skin, cellulitic skin, infected subcutaneous tissues, or skin to differentiate between an inflammatory and noninflammatory
lesions. If proper aseptic technique is used, the risk of infecting process, with the intent of expediting the diagnosis and treat-
a sterile joint occurs in less than 1:10,000 arthrocenteses.4 The ment of a possible infectious etiology.4
risk of infection is negligible when the skin is properly cleansed, A detailed discussion of synovial fluid analysis is beyond the
aseptic technique is used, and the skin is not punctured through scope of this book. A brief discussion of the most essential compo-
an obvious infection or through a skin lesion that may harbor nents that can be performed in the ED will be presented.
microorganisms.
PATHOPHYSIOLOGY OF SYNOVIAL FLUID
HYPODERMIC NEEDLE-ASSOCIATED Synovium refers to the 1 to 3 cell thick structure that lines the joint
COMPLICATIONS space and terminates at the articular cartilage margin.19 This struc-
ture overlies a highly vascularized subsynovium, both of which
The hypodermic needle can be the source of complications in rare are supported by the dense fibrous joint capsule.19 The synovium
circumstances. The needle may separate from the hub during the produces synovia, an ultrafiltrate of plasma that includes hyaluro-
procedure and require a minor surgical procedure to recover it.15 nate. The synovia serves to lubricate, nourish, and clear the meta-
The needle tip may be advanced too deep and become embedded bolic waste of the avascular articular cartilage.20 Synovial fluid has
in the bony skeleton surrounding the joint. Upon withdrawing the been demonstrated to possess potent bactericidal activity against
syringe, the needle tip may break off and remain embedded in the the most common gram-positive organisms responsible for septic
bone or the needle may separate from the hub. arthritis.28
TABLE 77-4 Synovial Fluid Analysis

Normal Noninflammatory Inflammatory Septic Hemorrhagic
Gross analysis
Color Clear/yellow/straw Straw/xanthochromic Xanthochromic/cloudy/white White/variable Red
Clarity Transparent Transparent Translucent/opaque Opaque Opaque
Viscosity Very high High Low Very low/variable
Mucin clot Good/firm Fair-to-good/firm Fair-to-poor/friable Poor/friable
Microscopic analysis
Total leukocyte count <150 <3000 3000–50,000 >50,000
(WBC/mm3)
Polymorphonuclear <25 <25 >70 >90
leukocytes (%)
Biochemical analysis
Glucose (mg/dL)* Normal Normal 70–90 >90
Protein (mg/dL)† 1.3–1.8 3–3.5 >4.0 >4.0
Microbiological analysis
Gram’s stain Negative Negative Negative Positive‡ Negative
Culture Negative Negative Negative Positive‡ Negative
Differential diagnosis
Osteoarthritis Rheumatoid arthritis Bacterial infections Trauma coagulopathy
Traumatic arthritis Acute crystal Anticoagulant therapy
Early rheumatoid Synovitis Tumor
arthritis Viral arthritis Charcot’s arthropathy
Avascular necrosis Psoriatic arthritis Hemangioma
Crystal synovitis§ Reiter’s syndrome A-V malformation
Osteochondritis Arthritis of IBD** Sickle cell disease
dissecans SLE Postsurgical
SLE Polyarteritis Joint prosthesis
Polyarteritis Scleroderma
Scleroderma Amyloidosis
Amyloidosis
WBC, white blood cells; * and † variable interpretation (refer to the text); ‡ variable results depending on organism (refer to the text); § chronic or subsiding; SLE, systemic lupus erythematosus;
**IBD, inflammatory bowel disease.
The synovium has been described as a double barrier in which and newspaper print can be easily read through a glass tube contain-
molecules must pass through the endothelial microvasculature ing this fluid.19 Inflammatory and purulent synovial fluid is trans-
as well as the synovium and its matrix.20 This double barrier is lucent to opaque secondary to the presence of leukocytes. Opaque
responsible for the retention of plasma protein. In the presence of fluid can also represent crystals and other particulate matter.
an inflammatory process, the barrier is disrupted and protein can Infected synovial fluid cannot be differentiated from noninfected
leak through the synovium. Difficulty arises in the diagnostic inter- synovial fluid based on gross appearance alone.4
pretation of protein and smaller molecules (i.e., sodium, chloride, Synovial fluid viscosity is determined by the intactness and
urea, urate, and lactate) found in synovial fluid secondary to the concentration of hyaluronate. Viscosity can grossly be assessed by
effects of damaged endothelial permeability and variable lymphatic observing a drop of fluid fall from the tip of the needle. The “string”
drainage.20,23,24 formed will normally be 5 to 10 cm in length.22 In inflammatory
and septic synovial fluid, the hyaluronidase is depolymerized and
degraded.20 The string formed in these conditions is shorter, or not
GROSS ANALYSIS OF SYNOVIAL FLUID
formed at all, and the fluid falls as a drop. Processes resulting in a
The color of synovial fluid varies depending on the amount of significant effusion without inflammation may also dilute hyaluro-
protein, blood, and breakdown products of hemoglobin. Normal nate without degrading it and result in decreased viscosity. Clotted
synovial fluid usually appears clear to a straw or yellow color. white blood cells may enhance viscosity in the presence of inflam-
Inflammatory and purulent synovial fluid may appear xanthochro- mation.20 EPs must be cautious with their interpretations of viscosity
mic to white. Hemorrhagic synovial fluid is red and must be dis- because even quantitative measures often fail to distinguish between
tinguished from a traumatic arthrocentesis. A traumatic aspiration inflammatory and noninflammatory states.4
usually clots and is more than often nonhomogenous.19,20 A hemato- The mucin clot test evaluates the degree of polymerization of hyal-
crit may be sent on a bloody aspirate to distinguish between a trau- uronate.4,19 The mucin clot test is performed by one of two methods.
matic tap and hemorrhagic fluid. A vein was pierced by the needle The first method involves mixing the supernatant of a centrifuged
(i.e., traumatic tap) if the synovial fluid hematocrit is equal to the specimen with a few drops of glacial acetic acid. The second method
serum hematocrit.20 involves mixing 1 mL of synovial fluid to 4 mL of 2% acetic acid.
The following synovial fluid properties observed during bedside A “good” clot consists of a dense white precipitant that indicates a
gross analysis were found to better predict a potentially septic joint high degree of polymerization and a high viscosity.19 A “poor” clot
when compared to synovial fluid cell count alone.30 consists of little to no precipitate and suggests an inflammatory
The clarity of synovial fluid refers to the amount and type of par- process that has depolymerized the hyaluronate. Controversy exists
ticles within the fluid. Normal synovial fluid is usually transparent concerning the subjectiveness of the clot’s endpoint.4
MICROSCOPIC ANALYSIS OF SYNOVIAL FLUID weeks after injection and have variable shapes but no regular geo-
metric form. Maltese crosses are strong birefringent particles that
The total leukocyte count, more than any other test, aids in dis- are secondary to multiple compounds such as talc powder, lipids,
tinguishing between an inflammatory, noninflammatory, and sep- calcium oxalate, and dust.22
tic process.20 Although a significant overlap may exist, the total
leukocyte count can be used to identify synovial fluid as normal,
noninflammatory, inflammatory, or septic (Table 77-4). Using
BIOCHEMICAL ANALYSIS OF SYNOVIAL FLUID
this classification scheme, a total leukocyte count of less than 3000 As discussed previously under the pathophysiology section, diffi-
cells/L is considered noninflammatory. A count between 3000 and culty arises with the interpretation of total protein secondary to the
20,000 cells/L is considered inflammatory. The range of 20,000 effects of damaged endothelial permeability and variable lymphatic
to 50,000 cells/L may be inflammatory or septic. A count greater drainage.20 In theory, the damage caused by an inflammatory process
than 50,000 cells/L is considered septic until proven otherwise. The should increase the permeability of proteins into the synovial fluid.
overlap between categories is considerable and clinicians must be Multiple studies have shown that protein samples were only able to
cautious of basing a diagnosis solely on the total leukocyte count. classify synovial fluid into an inflammatory or noninflammatory
Depending on the acuteness of the inflammation, several arthritic process in approximately 50% of the cases.23 Furthermore, the total
conditions such as gout, pseudogout, and rheumatoid arthritis may protein count was unable to differentiate among various groups of
yield a significantly elevated total leukocyte count approaching arthritides, including rheumatoid arthritis and osteoarthritis.4
100,000 cells/L.21 Immunocompromised hosts and some infectious Theoretically, inflammatory and infectious processes consume
diseases, such as tuberculosis and Neisseria gonorrhoeae, may have glucose and thus lower the level present in synovial fluid. One
lower absolute counts than expected.4 study has shown that glucose levels were able to classify synovial
The differential leukocyte count may further aid in distinguish- fluid into an inflammatory or noninflammatory process in less
ing between inflammatory, noninflammatory, and septic synovial than 50% of cases.23 In 50% of the septic joints analyzed, the glu-
fluid. The cell count and differential (WBC) of the joint fluid is the cose level was not significantly decreased. Another study reports
best diagnostic test for septic arthritis, while the serum ESR and glucose analysis having a sensitivity of 20% and specificity of 84%
WBC perform poorer in the identification of infection.37 However, in detecting inflammatory joint disease.24 Synovial fluid glucose
using the traditional cut-off value of 50,000 WBC/mm3 lacks sen- levels can vary from serum glucose levels when taken less than
sitivity enough to safely rule-out a septic arthritis.39 Inflammatory 6 hours after oral intake.24 These studies are just a few of many
processes generally have greater than 70% neutrophils while septic that confirm synovial fluid glucose levels are not reliable to
synovial fluid has greater than 90% neutrophils.19 Again, the overlap diagnose or rule out a septic joint.
can be significant depending on the arthritic process and its acute- Other biochemical markers have been studied to elicit a marker
ness. Crystal-induced processes may present with high neutrophil to differentiate a septic from a nonseptic joint. These include lac-
counts, while immunocompromised hosts, fungal infections, and tate, lactic dehydrogenase, and numerous immunologic and inflam-
tuberculosis may present with lower neutrophil counts.4,21 In gen- matory mediators. These biochemical markers, at present, are not
eral, a synovial fluid containing greater than 90% neutrophils in sensitive or specific to rule out a septic joint. They are not recom-
the presence of an elevated total leukocyte count should be highly mended for routine synovial fluid analysis. Bacterial polymerase
suspicious of a septic process. High eosinophil counts may suggest chain reaction (PCR) techniques with aspirated joint fluid are cur-
parasitic infection, allergic reactions, tumor, or Lyme disease.20,23 rently being studied and are theoretically superior tests, able to
High monocyte counts may suggest viral infection (e.g., rubella and identify difficult to culture organisms. However, many drawbacks
hepatitis B) or serum sickness.22 including high false positives due to contamination limit usage until
Crystal identification is an essential component of synovial fluid further studies are done.38
analysis. Crystal identification requires the use of a polarized light
microscope with higher-powered lenses and oil immersion capabili-
ties. Crystals can be identified based on their shape, size, and bire-
MICROBIOLOGICAL ANALYSIS OF SYNOVIAL FLUID
fringence. Birefringence is defined as the crystals’ ability to bend The Gram’s stain is an easily performed test that yields rapid results
the light passing through it into two distinct directions, negative or and can lead to the expedient diagnosis and treatment of a septic
positive. The light’s ability to bend negatively or positively is trans- joint. The Gram’s stain has a sensitivity of 50% to 70% for non-
formed into a specific color (yellow or blue) under the polarized gonococcal infections and less than 10% for gonococcal joint infec-
microscope.19,20 Caution must be taken as artifact and tissue debris tions.24 Although the sensitivity of this test is low, the specificity of
can often imitate birefringent material. the Gram’s stain approaches 100%. This makes it an essential com-
Crystal analysis requires an experienced technician and is rarely ponent of routine synovial analysis. N. gonorrhoeae is identified as
if ever performed in the ED. Monosodium urate crystals are com- a gram-negative intracellular diplococci. Staphylococcus aureus and
monly seen in gout. These crystals are needle-shaped, 2 to 25 µm Streptococcus are responsible for approximately 70% of nongono-
in length, and have strong negative birefringence. They may clump coccal septic arthritis and can be identified as gram-positive cocci
together in sheets.22,25 Local anesthetic solutions have the ability in clusters and gram-positive cocci in chains, respectively.27 Recent
to dissolve monosodium urate crystals. Therefore, the joint cavity studies have identified an increased prevalence of MRSA-associated
should not be penetrated with the needle when anesthetizing the osteoarticular pathology such as septic arthritis and subperiosteal
skin and subcutaneous tissue.21 Calcium pyrophosphate dihydrate abscesses.36 These diagnoses should be considered in patients with
crystals are seen in pseudogout. These crystals are rhomboidal or and without risk factors for community-acquired MRSA infection.36
rectangular, 2 to 10 µm in length, and have weak positive bire- Bacterial identification is essential when confronted with the
fringence.22,25 These crystals may be more difficult to detect than possibility of a septic joint. Synovial fluid cultures have a sensitiv-
monosodium urate crystals because of the weaker birefringence. ity of 75% to 95% for nongonococcal bacteria and 10% to 50% for
Cholesterol crystals may present in multiple forms and sizes. They gonococcal bacteria in the absence of previous antibiotic treat-
are typically flat rhomboidal plates, 5 to 50 µm in length, and have ment. Difficulty arises from the low sensitivity of cultures for some
both negative and positive birefringence.22 Artifact “crystals” can be organisms, culture methods, specimen preparation, and the length
produced by a variety of substances. Corticosteroids can be detected of time for some bacteria to grow.24 Recent advances with the use
CHAPTER 78: Methylene Blue Joint Injection 517
of polymerase chain reaction techniques have shown increased sen-

sitivity and specificity for detecting N. gonorrhoeae.19,26
SPECIMEN COLLECTION
Minimal quantities of synovial fluid can yield valuable information.
Analysis can be performed with as little as two drops of synovial
fluid.21 The total leukocyte count, differential leukocyte count, crys-
tal analysis, and Gram’s stain can be obtained from the first drop
while the second drop can be sent for cultures.21 Unfortunately, few
institutions or laboratories can perform synovial fluid analysis with
only two drops of fluid.
The specimen may be transported for analysis by one of two
methods. First, the syringe with the synovial fluid may be capped
and sent to the laboratory. The laboratory technicians will then
divide the specimen for analysis. Alternatively, the synovial fluid
may be placed into tubes. A new sterile needle, different from the
arthrocentesis needle, should be used to place fluid in the test tubes. FIGURE 78-1. The anatomy of the knee joint.
A needle used for steroid injection should never be used second-
ary to the formation of a crystal-like substance.4 Synovial fluid for
microscopic analysis should be collected in test tubes with and with-
out preservatives. Fluid should be placed in a Culturette or culture of the joint capsule, especially through dirty skin, can introduce
bottle for microbiological analysis. Synovial fluid for crystal analy- environmental contaminants and risk septic inoculation of the joint.
sis should be sent in a test tube with liquid heparin (green-topped The injection of joints with methylene blue dye is a simple, rapid,
tube) because EDTA and powdered anticoagulants interfere with and definitive way to assess joint capsule integrity in cases of periar-
crystal identification.21 A red-topped tube containing no preserva- ticular trauma where the clinical examination is inconclusive.
tives should be used to test for chemistries, serology, and viscosity. A
tube with an anticoagulant (purple-topped tube) is used for the cell ANATOMY AND PATHOPHYSIOLOGY
count, cell differential, and cytology. Prompt examination of fluid Synovial joints, such as those of the fingers, wrist, shoulder, and
specimens is urgent to avoid the following problems: misdiagnosing knee, consist of a fibrous capsule that overlies a thin, delicate syno-
borderline inflammatory fluids because of decreased WBC counts, vial membrane (Figure 78-1). The synovial membrane is a highly
not identifying crystals that dissolve with time, or over interpreting vascular structure and the site of synovial fluid production. The
findings because of new, artifactual crystals.29 synovial fluid provides nutritional support to the relatively avas-
cular articular cartilage. Joint capsules contain varying volumes of
SUMMARY fluid, and can be greatly expanded under conditions of inflamma-
Arthrocentesis is used to diagnose and make treatment deci- tion or injection.
sions regarding a joint. It is a safe, easy, and simple procedure. Methylene blue is a relatively safe and stable deep blue dye used
Arthrocentesis is relatively painless and extremely beneficial to in both chemistry and medicine. It has most frequently been used
the patient. It may be performed for diagnostic information and/ to treat methemoglobinemia and for marking skin and lymphatic
or therapeutic treatment. Analysis of the synovial fluid provides tracts for oncologic surgery. It is readily oxidized, which has been
unique and valuable information about a joint. It is the only method the proposed basis for its vasoconstrictive effects.1 Methylene blue
to accurately and definitively diagnose or rule out a septic arthritis. can cause local necrosis without an immune sensitization when
Arthrocentesis is indicated to evaluate the cause of an arthritis or a injected at full strength directly into tissues.2
joint effusion. All patients presenting with an acute monoarthritis The literature regarding the safety of methylene blue, even during
or an acute, nontraumatic effusion should undergo arthrocentesis direct intradermal injection, is supportive of its use. When used for
when the diagnosis is not clear based upon the history and physical lymph node mapping (i.e., direct intradermal and intraparenchy-
examination. mal injection), there is consistent evidence of local inflammatory
reactions ranging from local wheal and flare (0.5% of patients) to
focal erythema with induration (5% of patients).3,4 Superficial tissue
toxicity occurred in only 1.25% of patients.4 These reactions were
proportional to the concentration of methylene blue dye (ranging
from a dilution of 1:1 to 1:7) and the superficiality of the injec-
Methylene Blue
78 Joint Injection
tion.4 Emergency Physicians (EPs) need to be aware of the poten-
tial complications arising from its use just as with any drug or dye
introduced parenterally or intradermally. The tissue toxic effects are
Joseph E. Tonna, Heather H. Bohn, believed to be much less for intra-articular injections than direct
and Matthew R. Lewin intradermal injection.
INTRODUCTION INDICATIONS
Trauma can breach the integrity of the joint capsule and result in The primary indication for injecting a joint with methylene blue dye
infection, long-term arthritis, and other serious and potentially is to assess the integrity of the articular joint capsule (Figure 78-2).
permanent morbidity. Synovial joint fluid provides nutrition to the This includes any of the following injuries in close proximity to a
articular cartilage. Loss of synovial fluid without prompt joint cap- joint: skin laceration, a visible joint capsule through a wound, an
sule closure can lead to cartilage wasting. Additionally, any breach open fracture, extravasation of serous or serosanguineous fluid
• Eye protection
• Sterile gauze
• Sterile dressing or tape
• Sterile saline
• Sterile basin
• Local anesthetic solution (lidocaine 1% or 2%, etc.)
• 25 g or 27 g needles for infiltrating local anesthetic
• 18 g or 21 g needles for joint injection
• 5 mL syringes for local anesthetic injection
• 10 mL syringes for fingers or toe injection
• 30 mL syringes for wrist or elbow injection
• 60 mL syringes for hip, knee, or shoulder injection
• 1% methylene blue dye
PATIENT PREPARATION
FIGURE 78-2. Methylene blue dye injection into a knee joint. The loss of capsule A complete history and physical examination should be performed
integrity allows the dye to flow out of the joint cavity. prior to the injection of methylene blue dye. The affected joint
should be thoroughly assessed. Inspect the skin overlying the joint
for breaks, infection, old scars, prior incisions, superficial lesions, or
from a wound, or a traumatic loading of the joint with evidence of any wounds. Palpate the joint to identify any warmth, tenderness, or
a deformity or an acute effusion. The finger, wrist, elbow, shoul- effusion. Evaluate the joint for any crepitation, deformity, ligamen-
der, toe, ankle, knee, and hip (with varying success) joints can all be tous instability, or limitations in motion.
injected with methylene blue. As with any nonemergent procedure, consent should be obtained
from the patient or their representative. Ideally, the consent should
CONTRAINDICATIONS be documented in the medical record and signed by the patient. The
patient should be consented for both the arthrocentesis procedure
There are few contraindications to injecting methylene blue dye
(joint injection) as well as for the use of methylene blue.
into a joint. It should be avoided in patients with a known allergy
Position the patient based on the specific joint to be injected
to methylene blue. Patients with glucose-6-phosphate dehydroge-
and the approach to be used. Expose the joint and surrounding
nase (G6PD) deficiency can develop acute reactions as they do not
areas. Identify the anatomic landmarks required for proper needle
generate sufficient NADPH to efficiently reduce methylene blue
placement. The landmarks may be difficult to identify on a swol-
to leukomethylene blue. These individuals are prone to methylene
len and tender joint. Compare the “affected” joint to the “normal”
blue-induced hemolysis, oxidative hemolysis, and hemolytic ane-
joint on the opposite side of the body. Identify the joint and a
mia. Methylene blue can itself initiate methemoglobin formation. It
landmark on the normal joint and transfer this to the affected
should not be injected intraspinally or intrathecally.
joint. Clean any dirt and debris from the skin. Scrub the needle
There are a few relative contraindications to the injection of
insertion site with povidone iodine or chlorhexidine solution and
methylene blue. It should be used cautiously in a patient with a
allow it to dry. Apply sterile drapes or a clear sterile dressing to
known coagulopathy, especially a factor deficiency, to prevent intra-
maintain sterility of the injection site (Figure 78-3). The rate of
articular hemorrhage. Consider reversing the coagulopathy before
infection resulting from intra-articular injections is very low if
the injection. Methylene blue should not be used if there is a lack of
sterile technique is used.5
procedural knowledge or skill by the EP. Not all synovial joints can
A comfortable, relaxed patient will facilitate arthrocentesis, as
be injected due to structural instability.
tense muscles distort the anatomy of the joint and make anatomic
Joint injection is not contraindicated, but often unnecessary,
palpation more difficult. Oral analgesics for the precipitating injury
when definitive operative treatment of the joint is indicated. This
along with adequate local anesthesia for the procedure are often suf-
includes a visibly open joint capsule, a fracture with obvious joint
ficient. The articular cartilage has no intrinsic pain fibers, but the
involvement, intra-articular air on radiographs, and an intra-artic-
synovial membrane, joint capsule, and skin are richly innervated.
ular foreign body. In many injuries, the articular capsule will be
Adequate time should be taken for the infiltration of local anesthetic
breached but not externally open to the environment if there is no
solution. The subcutaneous injection of local anesthetic solution is
wound tracking to the skin surface. These injuries may present with
often most practical for larger joints such as the knee, shoulder, and
an acute joint effusion or radiographic evidence of a periarticular
hip. A regional block is often easier for small and more distal joints
fracture with or without intra-articular air. Despite capsular rup-
such as the finger and ankle.
ture, methylene blue is not helpful in such cases.
Apply anesthesia to the skin and subcutaneous tissue using 1%
lidocaine, topical vapor spray, or ice. The administration of some
EQUIPMENT form of local anesthesia is recommended but not required. The most
• Sterile drapes common local anesthetic used is a short-acting injectable anesthetic
solution of 1% lidocaine. There is disagreement if the additional
• Sterile gloves
needle stick to administer the anesthesia causes as much discomfort
• Sterile gown as performing the procedure without any anesthesia. This decision
• Face mask is specific to each EP and patient.
FIGURE 78-3. An injury at the level of the knee joint. The patient is prepared by
draping the lateral joint where the needle will be inserted (A) or by dressing the B
area with a sterile clear dressing (B).
Alternative methods of anesthesia include ice and topical vapor needle position within the joint cavity. If bone is encountered,
coolants. A sterile drape may be placed over the prepped skin and slightly withdraw the needle and re-advance it in a different direc-
a bag of ice water placed over the drape. Remove the ice water bag tion. Grasp the hub of the needle with your finger or a hemostat.
and drape after 5 minutes and perform the procedure. Ethinyl chlo- Remove the syringe while leaving the needle in place. Attach the
ride topical vapor coolant may be used as an anesthetic. Spray the syringe filled with the diluted methylene blue onto the needle.
solution onto the area of skin in which the needle will be inserted. Inject the methylene blue slowly into the joint cavity. There should
Apply the spray from 6 in. above the skin. Spray until the skin turns be no resistance to flow if the needle is within the joint capsule. The
white and frosty. This usually takes 5 to 10 seconds. Immediately injection should not be painful if the needle is within the synovial
perform the procedure, as the anesthesia lasts only 30 to 60 seconds. capsule. Observe the skin wound for extravasation of blue dye while
Because of the aforementioned effects of methylene blue dye, it is it is being injected into the joint cavity. Remove the needle when the
common, though not universal, to dilute the dye in normal saline procedure has been completed. Apply a bandage to the skin.
before the injection. Draw up one to two drops of 1% methylene Different joints will accommodate various amounts of injected
blue dye into an appropriately sized syringe. Fill the remainder of volume. The knee may allow for 30 mL or more, whereas the fin-
the syringe with sterile saline to dilute the dye. Apply an appropri- ger may accommodate only 1 mL. It is only necessary to inject a
ately sized needle for the joint to be injected onto the syringe. minimal amount of dye before extravasation is seen. If the joint cap-
sule is ruptured, a greater amount of fluid can be injected, as it will
escape through the breach. In intact joints, the capsule will expand,
TECHNIQUES increasing pressure and resistance to continued injection. There is
often visibly swelling of the skin around the injected joint if there is
THE BASIC TECHNIQUE no breach.
Complete a procedure note in the medical record. A sample pro-
The use of musculoskeletal ultrasound is useful to assist in arthro-
cedure note is described below:
centesis and has been shown to have many benefits including
After informed consent, the skin overlying the_________ joint
greater fluid aspiration and greater novice physician confidence.
was cleaned and prepped with povidone iodine solution. The
It does not result in more pain for the patient and takes minimal
skin was anesthetized with (_____mL of_____% lidocaine, ethyl
additional time to perform at the bedside. The reader is referred to
chloride vapor coolant, ice for_____minutes). Using sterile
an ultrasound technique text for full instruction, but a few impor-
technique, an_____gauge needle was inserted on the (supero-/
tant points are included here. Bone will appear hyperechoic and
infero-,medial/lateral/inferior/superior) surface of the joint. It
easily differentiated from muscle and subcutaneous tissue. Tendons
was directed (supero-/infero-,medially/laterally/inferiorly/supe-
will appear fibrillar in nature, like a bundle of drinking straws.
riorly). _____mL of fluid was obtained. It was (thin, thick, yel-
Joint fluid will appear hypoechoic and dark. The “seagull sign” is
low, clear, straw-colored, bloody, purulent, with debris, without
a shape that can be seen on most joint images and represents the
debris). No complications were noted.
joint space between the articular surfaces of two opposing bones.
The joint was injected with_____mL of sterile saline contain-
It is a V-shaped hypoechoic area surrounded by hyperechoic bone.
ing less than 0.2 mL of 1% methylene blue dye. No complications
Once the landmarks are identified, the needle can be inserted with
were noted.
or without ultrasound guidance.
Apply the needle to the syringe and break the resistance. This
SPECIFIC SITES
avoids any sudden and painful movements of the needle within
the joint cavity. Stretch the skin over the site where the needle will Methylene blue joint injection can be reasonably accomplished at
be inserted. Penetrate the skin briskly with the needle and enter any joint. The concern for joint capsule rupture without concomi-
the joint cavity. Gently aspirate synovial fluid to confirm proper tant obvious need for operative exploration and fixation is rare
FIGURE 78-4. Methylene blue dye injection of the knee. A. Anatomy of the
C region. B. Palpating the boundaries of the patella. C. Injection of methylene blue
using the medial parapatellar approach.
in joints other than the knee and fingers. The knee is relatively Needle Insertion and Direction Insert an 18 gauge needle just
easy to inject while the fingers are more difficult. Arthrocentesis below the midpoint of the lateral or medial border of the patella
with methylene blue injection in the knee and finger is discussed (Figure 78-4C). Direct the needle perpendicular to the long axis
below. The principles and techniques described below can be of the leg and aimed toward the intercondylar notch of the femur.
used on any synovial joint for which there is concern of a capsule Advance the needle to a depth of 1 to 2 cm. Inject the methylene
breach and for which the EP feels competent to perform arthro- blue dye.
centesis. Please refer to Chapter 77 for the complete details of Ultrasound Probe Placement Start with probe placement longitudi-
joint arthrocentesis. nally lateral or medial to the patella for a first view of the possible
fluid collection. Then change the probe to a horizontal orienta-
PATELLOFEMOROTIBIAL JOINT (KNEE) tion, and rotate the probe like the hand of a clock around the
ARTHROCENTESIS, PARAPATELLAR APPROACH patella 360° to discover the area with the largest anechoic fluid
collection.
Landmarks The knee joint can be injected in a variety of locations Remarks The easiest site for arthrocentesis is the medial parapatellar
and with the knee extended or flexed. Palpate the borders of the region. There are no disadvantages to using the medial parapatellar
patella (superior, lateral, and inferior) and the patellar tendon site. The lateral and medial parapatellar approaches are used with
(Figures 78-4A & B). Identify the midpoint of the lateral or medial high relative success, most likely due to the large joint space and
border of the patella (Figure 78-4B). Either of these landmarks may minimal accessory structures. Studies have demonstrated decreased
be used as the site for needle insertion. success of the medial midpatellar approach (56%), relative to the
Patient Positioning Place the patient supine on a stretcher with the lateral midpatellar (76%-93%) or the infrapatellar (71%-85% lateral
affected knee fully extended. and 73%-75% medial) approaches.6,7
FIGURE 78-5. Methylene blue dye injection of the metacarpophalangeal (MCP)

C joint. A. Anatomy of the region. B. Palpation of the MCP joint. C. Injection of
methylene blue.
METACARPOPHALANGEAL proximal interphalangeal joint compared to the distal interpha-

JOINT ARTHROCENTESIS langeal joint or carpometacarpal joint of the thumb.
Landmarks Identify the metacarpophalangeal (MCP) joint and the
The relatively thin dermal and subcuticular layers over the pha- extensor digitorum tendon (Figures 78-5A & B). The MCP joint
langes often make one wonder about deep soft tissue avulsions can be located just proximal to the prominence at the base of the
or lacerations and the potential involvement of the joint capsule. proximal phalanx of the finger. Identify the extensor tendon by hav-
Injection with methylene blue dye is an ideal method to assess ing the patient extend the finger against resistance.
joint capsule integrity. The success rate of arthrocentesis is much
lower in the phalangeal joints than larger joints. The overlying Patient Positioning Place the patient sitting upright or supine on a
ligaments and tendons are more prominent and the synovial stretcher. Pronate the hand and abduct the fingers. Grasp the finger
capsule is smaller. A failure rate of 15% for finger arthrocentesis and apply distal traction.
was found among skilled surgeons, and as high as 32% among Needle Insertion and Direction Insert a 22 gauge needle into the
first year residents.8 Successful arthrocentesis was highest in the dorsal joint space just medial or lateral to the extensor tendon
(Figure 78-5C). Direct the tip of the needle toward the center of or admitting a patient to the hospital for joint exploration and clo-
the joint. Advance the needle to a depth of 0.3 to 0.5 cm. Inject the sure. Joint injection with methylene blue is technically simple with a
methylene blue dye. low rate of complications.
to appear on both sides of the extensor tendon. These depressions
can be used as landmarks for the site of needle insertion into the
joint cavity.
Basic Principles of Fracture
79
this joint.
and Joint Reductions
ASSESSMENT Scott C. Sherman
The lack of methylene blue extravasation reassures the EP of an INTRODUCTION

intact joint capsule. Extravasation of dye through the injury site is
indicative of a ruptured joint capsule. These require exploration, Orthopedic injuries are some of the most common presenting
high volume irrigation, and adjunctive medical treatment such as complaints facing the Emergency Physician (EP). Forces that cause
antibiotics. Although some wounds can be closed primarily in the injury can be large enough to result in fractures, displaced frac-
Emergency Department after consultation with an Orthopedic or tures, and joint dislocations. While each injury is different, some
Hand Surgeon, open joints require management in the operating general principles can be applied to all displaced fractures and joint
room. dislocations. For specific instructions on the techniques to reduce
A minimal amount of methylene blue dye needs to be injected common fractures and dislocations, please refer to Chapters 80
before visible extravasation will occur. Upon injection, if no extrav- through 91.
asation occurs, attempt to aspirate fluid. This may be difficult in
small joints. Aspiration of blue fluid provides additional confirma- ANATOMY AND PATHOPHYSIOLOGY
tion of intracapsular needle placement.
Given the not insignificant rate of ectopic needle placements The most common reason for a fracture to be displaced or a joint to
(i.e., extrasynovial, intraligamentous, or intratendinous), a high be dislocated in a particular direction is the mechanism of injury. In
index of clinical suspicion should be maintained for a joint cap- the upper extremity, for example, a fall forward on an outstretched
sule rupture, even in the face of a negative study. Clinical intu- arm is the most common mechanism. Therefore, elbow dislocations
ition and judgment should guide all decisions. occur most frequently in a posterior direction, distal radius frac-
tures are most often Colles fractures, and supracondylar fractures
are extension type fractures in 95% of cases.1
AFTERCARE The deforming forces of muscles and ligaments also play an
Arthrocentesis with methylene blue dye is a relatively benign pro- important role in the appearance of a fracture. Injury results in the
cedure. The postprocedural care consists of monitoring for external muscles surrounding a fracture to contract or spasm. This leads
bleeding and swelling. Musculoskeletal and neurovascular checks to further deformity such as shortening, angulation, and rotation
should be performed at the area and distal to the joint. Apply a ban- of the bone fragments distal and proximal to the fracture. For
dage to the injection site. Pain should be minimal and analgesia can example, depending on the location of a humeral shaft fracture, the
be achieved with oral nonnarcotic analgesics alone. In the setting of bone fragments will displace in different directions (Figure 79-1).
a significant traumatic injury, the patient may already be receiving Fractures that occur between the insertions of the pectoralis
opioid analgesics. major and deltoid muscles will result in a proximal humerus that
is adducted from contraction of the pectoralis major muscle and
a distal humerus that is abducted from contraction of the deltoid
COMPLICATIONS muscle (Figure 79-1A). Conversely, if the fracture occurs distal
Complications are rare and include hemarthrosis, nerve injury, to the deltoid insertion, the proximal humerus will be abducted
tendon injury, cartilage damage, and infection. External bleeding from contraction of the deltoid muscle and the distal humerus will
and nerve damage should be immediately apparent. A hemarthro- be adducted from contraction of the biceps and triceps muscles
sis may be insidious and appear with progressive swelling, pain (Figure 79-1B).
with joint motion, and often without joint warmth. Tendon and
cartilage damage may not be apparent for some time and present INDICATIONS
with joint stiffness or arthritis. Septic arthritis is the most con-
cerning complication, evidenced by swelling, erythema, warmth, The reduction of fractures and joint dislocations in the Emergency
pain with range of motion, and systemic symptoms. Cellulitis may Department (ED) is more frequently indicated than it is not.
also complicate the procedure, appearing some time later with Reduction is more readily achieved if it occurs soon after an
local warmth, erythema, and induration over the site. Please refer injury. No fracture benefits from a prolonged period of angula-
to Chapter 77 for a more complete discussion regarding the com- tion or displacement because the reduction becomes more dif-
plications of arthrocentesis. ficult the longer the fracture has been present. No joint benefits
from a prolonged dislocation as damage to articular cartilage
increases with time.
SUMMARY
Reduction should occur on an emergent basis when perfusion
Synovial joint injection with methylene blue dye provides the EP to the extremity is absent. A nonperfused extremity has a finite
with a simple, rapid, and definitive method of assessing joint cap- period of time before nerve and muscle death occur. For this reason,
sule integrity in cases of periarticular trauma. This procedure can reduction should occur as soon as possible. The earlier perfusion is
determine between repairing a wound and sending a patient home restored, the better the chance of avoiding tissue necrosis.
CHAPTER 79: Basic Principles of Fracture and Joint Reductions 523
FIGURE 79-1. The direction of fracture displacement is influ-

enced by muscle contraction following the injury. A. Humeral
shaft fracture between the insertions of the deltoid and pecto-
ralis major muscles. Arrows represent the direction of pull on
the fracture fragments. B. Humeral shaft fracture distal to the
deltoid muscle insertion.
Vascular injury can occur after any displaced fracture or disloca- dislocations are difficult to reduce in a closed manner and overly
tion. The EP should note the presence of an expanding hematoma, forceful attempts increase the chances of causing a fracture. An
absent distal pulses, or delayed capillary refill. Some examples of example is a surgical neck of the humerus fracture in a patient when
orthopedic injuries more commonly associated with vascular injury attempting to reduce a chronic shoulder dislocation. Reduction
include knee dislocations, posterior sternoclavicular joint disloca- in the ED is contraindicated when the patient requires immedi-
tions, and supracondylar fractures. The importance of early reduc- ate operative treatment. An open fracture in a perfused extremity
tion and repair of vascular injuries is emphasized in the case of a should be reduced in the operating room where an appropriate sur-
knee dislocation. If surgery is delayed more than 8 hours, up to 86% gical washout can occur.
of patients will require an amputation.2 Reduction is unnecessary when the potential for remodeling is
Not all displaced fractures and dislocations suspected of caus- such that the fracture angulation will correct without the need of a
ing vascular injury should be reduced by the EP. When vascular painful reduction or the risk of procedural sedation. For example,
injury is suspected in a patient with a posterior sternoclavicular distal radius fractures in children have been shown to heal well even
joint dislocation, for example, reduction is best performed in the when they are 15° to 20° angulated.7–10 Other fractures where some
operating room with a cardiothoracic surgeon available because degree of displacement or angulation may be acceptable and fre-
the distal clavicle may be tamponading a lacerated subclavian quently do not require reduction include the clavicle, humeral shaft,
vessel.3 In a similar manner, supracondylar fractures require and neck of the fifth metacarpal.1,11–17
immediate reduction only when the extremity is pulseless and Reduction may be contraindicated in the ED for numerous
perfusion is absent.4 other reasons. Adequate analgesia may not be possible due to the
Urgent reduction of displaced fractures and joint dislocations patient’s medical condition or the inability to appropriately moni-
is also indicated to reduce the incidence of other potential com- tor the patient. These cases may require general anesthesia in the
plications. The incidence of compartment syndrome of the forearm operating room. It is prudent to consult and wait for an Orthopedic
is reduced by early reduction of displaced supracondylar fractures.5 Surgeon when the potential complications of a reduction attempt
Likewise, a posterior hip dislocation should be reduced in a timely are high or the EP is uncomfortable performing the technique. A
manner. The likelihood of avascular necrosis rises exponentially busy EP in a chaotic ED with single coverage may not have the time
from a rate of 5% with less than 6 hours of being dislocated to 50% or resources to adequately sedate a patient and reduce the fracture
with greater than 6 hours of being dislocated.6 or dislocation. This situation may require calling in an additional
Neurologic injury results from the original injury, traction on a EP or an Orthopedic Surgeon to assist.
nerve, or compression of a nerve. Patients may experience altered
sensation, decreased sensation, and/or paresthesias. These inju-
ries require urgent reduction to decrease potential long-term EQUIPMENT
complications. • Procedural sedation equipment and supplies (Chapter 129), if
applicable
CONTRAINDICATIONS • Hematoma block supplies (Chapter 125), if applicable
• Regional nerve block supplies (Chapter 126), if applicable
Despite the potential advantages of early reduction of fractures and
dislocations in the ED, the EP should be aware of potential relative • Stretcher
and absolute contraindications. Chronic or previously unrecognized • Weights for distraction
• Bed sheets for traction–countertraction techniques

• Splinting/casting material or commercially made splints (e.g.,
knee immobilizer)
• Finger traps for upper extremity reductions
• Fluoroscopy, if available, to assist with the reduction and postre-
duction radiographs
• Assistants depending on the reduction technique
PATIENT PREPARATION
Reduction techniques require a well-informed patient and a signed
consent if possible. Explain the risks, benefits, and alternatives to
the patient and/or their representative. Tell the patient what to
expect. This knowledge may actually assist in the successful per-
formance of the procedure. Anterior shoulder dislocation reduc-
tion, for example, can be performed with minimal or no sedation if
the patient is able and willing to relax their musculature while the
EP slowly manipulates the humeral head back into position.18 The
patient should also be consented for the anesthesia technique as this
is a second procedure with potential complications much different
from the reduction.
The physical preparation of a patient for the reduction of a frac-
ture or dislocation is dependent on the type of injury and the clinical
setting. In general, the patient should be resting as comfortably as
possible on a gurney. The patient should be supine whenever pos-
sible. Fully expose the involved extremity. Remove any constricting FIGURE 79-2. Distraction for reduction of a forearm fracture.
pieces of clothing or jewelry both proximal and distal to the injury.
If fluoroscopy is judged to be useful and it is available it should be
moved into position. Frequently splint material is measured and set
up prior to the start of the procedure so that it may be immedi-
ately applied to the extremity in the setting of an unstable fracture
or dislocation.
TECHNIQUE
The basic principles to reduce a displaced fracture or a joint dislo-
cation are similar. The procedure can be divided into four steps.19
These are distraction, disengagement, reapposition, and release.
The four steps can be used to reduce most, but not all, displaced
fractures or joint dislocations.
The first step is distraction. It involves creating a longitudinal
force to pull the fracture fragments or bones involved with a dis-
located joint apart. This step should be performed gradually and
sometimes requires time to be most effective in overcoming muscle
spasm. Distraction is important when the fractured ends of the bone
are overriding. It can be applied manually with the help of an assis-
tant or by using weights.
To reduce a distal radius fracture, for example, one common
technique to distract the injury uses finger traps to hold the hand
in place while weights are wrapped around the arm (Figure 79-2).
Saline bags placed in stockinette are equally effective and comfort-
able for the patient when weights are not available (Figure 79-3).
Each liter bag of saline is equivalent to 1 kg or 2.2 pounds.
Disengagement is the second step to reduction. It allows for fur-
ther disimpaction of the fracture fragments than distraction alone.
Disengagement can be achieved by rotation of the distal fragment
or more classically by “recreating the fracture deformity.” It relieves
tension on the surrounding soft tissues to allow the interlocking
fracture fragments to reposition (Figure 79-4).
Disengagement is also important for dislocation reduction. It is
most frequently achieved by rotation of the bone distal to the joint.
An example is the external rotation technique to reduce an anterior FIGURE 79-3. Four 1 L bags of saline in stockinette is the equivalent of 8.8
shoulder dislocation. pounds. This setup is useful when weights are not available to distract a fracture.
CHAPTER 79: Basic Principles of Fracture and Joint Reductions 525
FIGURE 79-4. Disengagement. Recreating the fracture deformity allows the

release of interlocking fragments by lengthening and relaxing the soft tissue hinge.
The third step is reapposition. This is achieved by reversing the FIGURE 79-5. Reapposition of a forearm fracture.
forces that caused the injury to bring the bony fragments back into
alignment (Figure 79-5). While this step seems simple conceptu-
ally, it may not be as easy in clinical practice. One important pit-
fall to avoid is ignoring a rotational deformity that might create
functional problems if the bone healed with a rotational deformity.
This is especially important when treating fractures of the hand
where a 5° rotational deformity of a proximal metacarpal fracture
can translate into a distal fingertip that is 1.5 cm out of position20
(Figure 79-6).
Release refers to the removal of the initial distracting force with
the intent that alignment will be maintained. It is at this point that
forces such as muscle contraction and gravity return and the frac-
ture fragments are at risk for becoming malaligned again. A properly
applied splint or cast can protect from loss of fracture alignment. It
is advisable to have the splint measured and ready to apply before
manual reduction is initiated.
There are frequently alternative techniques or variations of the four
steps outlined above that are available to the EP depending upon the
circumstance or the success of previous attempts. If the initial tech-
nique is unsuccessful, then the next maneuver is attempted and so
on. The author uses the following sequence of maneuvers to reduce
an anterior shoulder dislocation: scapular manipulation with down-
ward arm traction (disengagement and distraction), then external
rotation (disengagement), followed by the Milch technique (disen-
gagement), and finally traction–countertraction (distraction).18,21–24
The astute EP should also be aware of the limitations of the closed
reduction technique. If soft tissue is interposed in an interphalan-
geal finger dislocation, for example, no amount of distraction or an
alternative technique will reduce the dislocation without taking the
patient to the operating room. FIGURE 79-6. Rotational deformity of the fifth digit.
ASSESSMENT Sternoclavicular dislocations are the result of direct trauma to the

sternoclavicular joint or to the glenohumeral joint with the force
The neurovascular status of the extremity must be assessed to directed toward the sternoclavicular joint. This injury is usually
ensure that pulses are present, the extremity is perfusing, and associated with a tremendous force. The most commonly reported
that nerve function has not been compromised before and after mechanisms of injury are motor vehicle collisions and contact
any reduction attempt. It should also be assessed after any cast- sports.2,5 Anterior dislocations are often due to indirect forces trans-
ing or splinting to the extremity. Postreduction radiographs are mitted through the anteromedial shoulder. As the shoulder is exter-
taken to assess the success of the reduction, look for any fractures nally compressed and rolled backward, the lateral clavicle is pulled
that may have been missed on the prereduction radiographs, and back and down beyond its limit of motion. The first rib acts as a
assess any complications from the reduction. fulcrum to spring the sternal end of the clavicle anteriorly from its
articulation.2,6
AFTERCARE Posterior dislocations may be due to direct or indirect forces.3,4,7–13
Immobilize the extremity as required for the specific fracture or dis- With indirect trauma, the shoulder is externally compressed and
location. A record of the procedure should be placed in the chart rolled forward from a posterolaterally applied force to the shoul-
including any complications and the method of reduction. The der. The costoclavicular ligament acts as a fulcrum that produces
patient should undergo repeat plain radiography in most cases to displacement of the sternal end of the clavicle posteriorly from its
document the success of the reduction. Patients with reduced frac- articulation.4,9,11,13 Less commonly, a posterior dislocation may be
tures and dislocations should be referred to an Orthopedic Surgeon. due to a direct blow to the anteromedial clavicle.
Occasionally, a fracture that is properly reduced and immobilized There are reports of spontaneous and nontraumatic sternocla-
will be unstable and become displaced again, frequently necessitat- vicular subluxations and dislocations.14 These are usually seen in
ing operative fixation. females less than 20 years of age with sternoclavicular joint laxity.
The clavicle dislocates anteriorly during abduction or flexion of the
COMPLICATIONS arm to the overhead position. The clavicle reduces spontaneously
when the arm is returned to the side. This condition is usually asso-
When performed properly, complications of fracture and dis- ciated with laxity in numerous other joints.
location reduction are uncommon. However, even with proper
techniques, complications can occur. These include converting a
closed fracture to an open fracture, soft tissue trauma that pro- ANATOMY AND PATHOPHYSIOLOGY
duces a compartment syndrome, a reduction attempt that causes
injury to the soft tissues making the fracture more unstable, pro- The sternoclavicular joint is a diarthrodial joint with both surfaces
ducing a fracture during the dislocation reduction attempt by covered by fibrocartilage (Figure 80-1). The intraarticular disk
using excessive force, or neurovascular injury/compromise due to ligament divides the joint into two separate compartments, each
bony laceration, or compression of a nerve or blood vessel. of which is lined with synovium.15 This joint is freely movable and
functions almost like a ball-and-socket joint in that it has motion,
SUMMARY including rotation, in almost all planes.3,6,16 This includes 30° to
35° of upward elevation, 35° of combined forward/backward
Displaced fractures and joint dislocations requiring reduction are movement, and 40° to 45° of rotation about its long axis.3,6,16 Less
commonly seen in the ED. As the EP approaches these injuries, the than half of the medial clavicle articulates with the upper angle of
initial step in assessment should be determining the neurovascu- the sternum. This gives the sternoclavicular joint the distinction
lar status of the extremity. When vascular compromise is present, of having the least amount of bony stability of any of the major
emergent reduction is the rule with few exceptions. While all dis- joints.3 Given this amount of joint incongruity, it is surprising that
locations require reduction, not all displaced fractures necessitate sternoclavicular joint dislocations are uncommon. However, its
reduction. The EP should be familiar with which displaced fractures stability comes from strong surrounding ligaments (Figure 80-1).
benefit from reduction. When fracture reduction is indicated, the These ligaments include the intraarticular disk ligament, the
basic elements of the procedure are distraction, disengagement, extraarticular costoclavicular ligament (rhomboid ligament), the
reapposition, and release. anterior and posterior sternoclavicular ligaments, and the inter-
clavicular ligament.15
The region that lies directly posterior to the sternoclavicular
joint contains numerous vital structures (Figure 80-2). Within
the confines of the thoracic inlet are the trachea, esophagus, lungs,
Sternoclavicular Joint and great vessels. This proximity, and the small size of the thoracic
80 Dislocation Reduction inlet, accounts for the injuries that may occur to these structures
with posterior sternoclavicular joint dislocations.
Eric F. Reichman The medial clavicular epiphysis is the last epiphysis of the long
bones to appear. It usually ossifies by the age of 18 to 20 and occa-
sionally not until the age of 25.3,17 It is also the last to fuse.3,17 This
INTRODUCTION epiphysis is difficult to see on plain radiographs. Many injuries
Sternoclavicular dislocations are uncommon injuries and account in patients under 25 years of age that are initially felt to be ster-
for less than 3% of shoulder girdle dislocations.1 The medial clav- noclavicular joint dislocations are actually Salter I or II epiphyseal
icle may be displaced anteriorly or posteriorly. Anterior disloca- injuries.3,10,18–23
tions are more common by a ratio of 3:1 to 20:1.2,3 Case reports The diagnosis of a traumatic sternoclavicular joint dislocation may
of the less common posterior dislocations are more common in be difficult and delayed. This is particularly true in the patient with
the literature due to the higher incidence of associated complica- multiple injuries.7,24,25 Symptoms include severe pain that increases
tions. Posterior sternoclavicular joint dislocations are often seen with movement of the ipsilateral arm. Physical signs include edema
in younger individuals.2,4 and ecchymosis over the region of the sternoclavicular joint. The
CHAPTER 80: Sternoclavicular Joint Dislocation Reduction 527
Intraarticular Interclavicular Anterior Clavicle

disk ligament sternoclavicular
ligament
First rib
Costoclavicular
ligament
Second rib
FIGURE 80-1. Anatomy of the ster-

Costal Sternum Costalsternal noclavicular joint and surrounding
cartilages ligaments structures.
Trachea Esophagus
Right vagus nerve Left vagus nerve
Right internal carotid artery Left common

carotid artery
Right internal jugular vein
Left internal
Right external jugular vein jugular vein
Right subclavian Left external
artery and vein jugular vein
Left subclavian
Innominate artery vein and artery
Aortic arch
Right brachiocephalic vein
Pulmonary artery
Superior vena cava
Sternoclavicular joint Sternum Left common carotid artery
Right
Clavicle
innominate
artery Left subclavian vein
Right
subclavian vein
Left subclavian artery
Lymph node
Esophagus
Trachea
Left lung
Right lung
FIGURE 80-2. Anatomic relationships of structures to the sternoclavicular joint. A. Anteroposterior view. B. Cross section through the level of the sternoclavicular joint.
patient usually holds the injured arm adducted across the trunk. intervene should any thoracic emergency develop.25 The disloca-
Their head may be tilted toward the affected side to relieve the pain tion should be reduced emergently if neurologic or vascular com-
caused by traction of the sternocleidomastoid muscle on the medial promise exists in the affected extremity.
clavicle. With anterior dislocations, the medial end of the clavicle Many of these injuries are in fact Salter–Harris I or II epiphyseal
may be palpated anterior to the sternum. It may also be fixed or injuries in patients less than 25 years of age.3,10,18–23 Closed reduc-
mobile. A visible depression may be noted or a hollow palpated tion should still be attempted after consultation with an Orthopedic
at the location of the sternoclavicular joint with posterior sterno- Surgeon.
clavicular joint dislocations. However, accompanying edema may
obscure these physical findings. The shoulder may be held forward.
When the patient is supine, the affected shoulder does not lie flat CONTRAINDICATIONS
against the bed. Reduction may be postponed to attend to more serious injuries
Additional signs and symptoms associated with a posterior ster- unless a posterior sternoclavicular joint dislocation is present and
noclavicular joint dislocation may also be due to injury or com- is compromising adjacent structures. Open reduction of posterior
pression of mediastinal structures.3,4,7,9,11–13,18,25–32 It is extremely sternoclavicular joint dislocations may be preferred if surgery is
important to perform a careful and complete physical examina- planned for associated injuries.
tion, as associated injuries are common. Compression of the tra- Attempted reduction of chronic traumatic anterior dislocations or
chea or esophagus may result in cyanosis, dyspnea, or dysphagia. spontaneous anterior dislocations is not indicated.41 These patients
Circulation to the ipsilateral arm may be reduced if the subclavian usually have minimal discomfort, normal range of motion, and
artery is compressed. Venous congestion of the upper extremity or can return to normal activity.3,14 Patients do well without treatment
neck can result from compression of the subclavian or jugular veins. other than nonsteroidal anti-inflammatory drugs, the application of
The patient may present in shock due to compression or injury to heat, and rest.2,14,35 The results of operative treatment of such injuries
the retrosternal great vessels. Paresthesias of the upper extremity are have not been impressive.3,14
due to a brachial plexus injury. Voice changes are due to compres- There is controversy regarding the necessity of reducing chronic
sion of the recurrent laryngeal nerve. Tracheal or lung injuries can posterior sternoclavicular joint dislocations. Some feel that all
result in pneumothoraces. should be reduced due to the potential compression of adjacent
The clinician cannot always rely on the clinical findings of obser- structures or erosion into them.3,28,36,37 However, there have been
vation and palpation to distinguish between anterior and posterior reports of patients who have chronic dislocations without sequelae.6
sternoclavicular joint dislocations.3 Documentation with appropri- Treatment decisions for such injuries should be made in consulta-
ate radiologic studies is recommended prior to the decision to treat. tion with an Orthopedic Surgeon. Reduction would require general
Routine radiographs of the sternoclavicular joint are often difficult anesthesia and operative intervention.35
to interpret due to overlapping structures. Several different radio-
graphic projections have been reported to improve the ability to
demonstrate asymmetry of the joints.3,8,9,33 Computed tomography EQUIPMENT
(CT) is the preferred imaging modality to study the sternoclavicu-
• Sandbags or folded towels
lar joint. It should always be performed if the diagnosis is uncer-
tain.9,10 The use of ultrasound to aid in the diagnosis has also been • Povidone iodine or chlorhexidine solution
reported.12,34 • Sterile towel clamps
With posterior sternoclavicular joint dislocations, the • Sterile gloves
Emergency Physician should also consider appropriate studies
to rule out associated injuries to neighboring structures. This
could include a chest radiograph, which may reveal mediastinal • 18 gauge needles
widening, a pneumomediastinum, or a pneumothorax. CT will • 25 gauge needles
reveal the relationship of the clavicle to the great vessels, esopha- • 10 mL syringe
gus, and trachea. It may also demonstrate compression of these
structures, a mediastinal hematoma, or mediastinal emphysema.
Angiography, venography, and Doppler studies may be consid- PATIENT PREPARATION
ered to investigate potential vascular injury. Esophagoscopy and/
Explain the risks, benefits, potential complications, and aftercare of
or an esophagram may be employed to evaluate the esophagus.
the procedure to the patient and/or their representative. Obtain a
Bronchoscopy is indicated if a tracheal or bronchial injury is
signed consent to perform the reduction.
suspected.
Place the patient supine with the affected side near the edge of
the gurney. Place sandbags or towels between the patient’s scapu-
INDICATIONS lae. They should be thick enough to raise the patient 5 cm off the
gurney.4
It is generally held that closed reduction should be attempted on all A form of anesthesia and analgesia is required to reduce a
acute traumatic anterior and posterior sternoclavicular joint dislo- sternoclavicular joint dislocation. Closed reduction of anterior
cations.3,10,27 Anterior sternoclavicular joint dislocations have been sternoclavicular joint dislocations may be performed with local
reduced via closed techniques up to 10 days postinjury.9 Successful anesthetic solution infiltrated about the medial clavicle and ster-
closed reduction of posterior sternoclavicular joint dislocations has noclavicular joint. Consider the administration of supplementary
been reported up to 5 days postinjury.12,27 Posterior sternoclavicular intravenous sedation or procedural sedation. Posterior sterno-
joint dislocations are uncommon injuries. Early consultation with clavicular joint dislocations have also been reduced using local
an Orthopedic Surgeon is recommended. Careful evaluation of the anesthesia. However, procedural sedation or general anesthesia
patient’s airway, breathing, and circulation should be performed is recommended. Infiltrate local anesthetic solution about the
prior to the reduction. It is recommended that the reduction be medial clavicle and sternoclavicular joint if procedural sedation
performed where staff and facilities are immediately available to will be performed.
CHAPTER 80: Sternoclavicular Joint Dislocation Reduction 529
A B C
FIGURE 80-3. Reduction of an anterior sternoclavicular joint dislocation. A. Patient positioning. B. An assistant applies anterior pressure to both shoulders. C. The medial
clavicle is pushed posteriorly.
TECHNIQUES an assistant to apply downward pressure to the anterior surface of both

shoulders (Figure 80-3B). Pushing the shoulders posteriorly pulls the
ANTERIOR STERNOCLAVICULAR clavicles laterally and distracts the dislocated medial clavicle. Push
the medial clavicle posteriorly and into anatomic position (Figure
JOINT DISLOCATION REDUCTION 80-3C). Relocation of the clavicle usually occurs promptly. Carefully
Position the patient as mentioned above. The patient’s arms should be sit the patient upright while the assistant maintains the shoulders in
at their sides (Figure 80-3A). Apply analgesia and sedation. Instruct a posterior position. Apply a figure-of-eight splint (Figure 90-3C).
A B
Towel
clamp
Clavicle
C D
FIGURE 80-4. Reduction of a posterior sternoclavicular joint dislocation. A. Patient positioning. B. An assistant applies distal in-line traction. C. The medial clavicle is
grasped and elevated while maintaining distal traction on the extremity. D. An alternative technique. A towel clamp is placed around the medial clavicle. The clamp is used
to elevate the medial clavicle while maintaining distal traction on the extremity.
POSTERIOR STERNOCLAVICULAR while the assistant is maintaining traction on the abducted and
JOINT DISLOCATION REDUCTION extended extremity (Figure 80-4D).
Position the patient as mentioned previously. Apply analgesia and ALTERNATIVE TECHNIQUES
sedation. Abduct the affected extremity 90° and extend it 20° in
line with the clavicle (Figure 80-4A). Spontaneous reduction An alternative technique may be applied to reduce a posterior
may occur at this point. If not, instruct an assistant to apply dis- sternoclavicular joint dislocation.4 It uses the first rib as a lever
tal inline traction to the extremity (Figure 80-4B). This may be and has been reported to be successful when the previous tech-
aided by wrapping a sheet about the patient’s upper torso to provide nique has failed. Position the patient with their arms adducted
countertraction. The clavicle may reduce under traction. Keep the (Figure 80-5A). Apply analgesia and sedation. Instruct an assistant
patient’s arm abducted, extended, and under traction if the sterno- to apply distal in-line traction to the adducted arm (Figure 80-5B).
clavicular joint does not reduce. Manually manipulate the clavicle This will lever the medial clavicle over the first rib and above the
into position. Grasp the medial clavicle and pull it upward into ana- superior sternum (Figure 80-5B, inset). Apply downward pressure
tomic position (Figure 80-4C). to the anterior shoulder, forcing it into retraction (Figure 80-5C).
It may be difficult at times to achieve a secure grasp on the This will lever the medial clavicle anteriorly and laterally into ana-
medial clavicle. In such cases, clean the skin surrounding the tomic position (Figure 80-5C, inset). Reduction may occur at this
medial clavicle of any dirt and debris. Apply povidone iodine or point. If not, elevate the medial clavicle either by manual grasp or
chlorhexidine solution and allow it to dry. Grasp through the skin using a towel clamp, as described previously. It is postulated that
and around (not through) the shaft of the medial clavicle with a this technique requires less force than the prior technique. A varia-
towel clamp (Figure 80-4D). The thick cortical bone often pre- tion of this technique involves applying lateral traction to the upper
vents purchase of the towel clamp into the clavicle. Ensure that humerus using a sheet looped around the upper arm.38
the towel clamp follows the contours of the clavicle when applying Other methods of closed reduction for a posterior sternocla-
it. Grasping too deep can result in injury to the subclavian artery vicular joint dislocation have been described but are not often
and/or vein. Elevate the medial clavicle into anatomic position performed. Successful reduction has been described using 4.5 kg
First rib
Clavicle
Sternum
FIGURE 80-5. An alternative technique for reducing a poste-

rior sternoclavicular joint dislocation. (Modified from the study
of Buckerfield and Castle.4) A. Patient positioning. B. An assis-
tant applies distal in-line traction (large arrow). The medial
clavicle will be elevated above the sternum (small arrows).
C. A posteriorly directed force is applied to the shoulder to
draw the medial clavicle anteriorly and laterally into its normal
anatomic position. C
CHAPTER 81: Shoulder Joint Dislocation Reduction 531
(10 pounds) of lateral skin traction on the abducted arm for 30 dislocation can result in an anterior subluxation or dislocation.42
minutes.39 Reduction has also been achieved by simple forced This conversion of a posterior to anterior dislocation during reduc-
retraction of the lateral clavicle.8 Reduction has been reported tion should not be reduced as it may resolve spontaneously or require
in a sedated patient who was placed for 8 hours on rolled towels open management.
between the scapulae.13
SUMMARY
ASSESSMENT Sternoclavicular joint dislocations are uncommon injuries. They are
Assess all patients, both initially and following any reduction usually due to high-impact forces from motor vehicle collisions or
attempts, for neurologic and vascular integrity of the upper contact sports. Anterior sternoclavicular joint dislocations are eas-
extremity. Obtain postreduction radiographs to confirm proper ily reduced but often do not maintain reduction. However, patients
bony positioning. The procedure may be repeated if the radiographs tend to do well with persistent dislocations. Posterior sternocla-
show incomplete reduction. Positioning is not critical if the reduc- vicular joint dislocations are even less common. The Emergency
tion was performed for neurologic or vascular compromise. The Physician should be aware of the high incidence of associated inju-
primary consideration is the relief of the compromised nerve ries. These dislocations tend to be stable after reduction.
and/or artery. The Orthopedic Surgeon can later reduce the defect
that remains.
AFTERCARE
Shoulder Joint
The general principles of orthopedic care should be applied. These
include rest, ice, nonsteroidal anti-inflammatory drugs, and supple-
mental narcotic analgesics.
81 Dislocation Reduction
Eric F. Reichman
ANTERIOR STERNOCLAVICULAR JOINT DISLOCATIONS
The sternoclavicular joint is often unstable following reduction.
INTRODUCTION
These injuries require splinting to maintain the normal anatomic The shoulder joint is the most commonly dislocated of all joints.1–4
relationships and allow ligamentous healing. This is best accom- Shoulder dislocations were depicted in Egyptian murals as early as
plished with a figure-of-eight splint (Figure 90-3C). Unfortunately, 3000 BC.1 Despite 5000 years of medical advancements, shoulder
patients do not often tolerate this splint. Alternatives include a sling, dislocations continue to be a major cause of Emergency Department
sling and swath, or a sling and Velpeau dressing (Figures 90-3A (ED) visits. They account for more than 50% of all joint complica-
& B). Apply one of the above splints if the medial clavicle will not tions treated by Emergency Physicians (EPs).2
remain reduced. Orthopedic follow-up should be scheduled within The human shoulder is remarkable for its degree of motion. The
5 to 7 days of the reduction. anatomic features that contribute to this mobility also contribute to
its instability.3 The shallow glenohumeral joint allows the shoulder
POSTERIOR STERNOCLAVICULAR to be dislocated anteriorly, posteriorly, or inferiorly. The anterior
JOINT DISLOCATIONS shoulder dislocation is the most common and accounts for 95% of
all shoulder dislocations.1–4 The overall incidence of shoulder dis-
The sternoclavicular joint is usually stable following reduction. The locations is 17 per 100,000. There is a bimodal age distribution.1,4 It
splinting and follow-up are the same as with an anterior sternocla- occurs in males from 20 to 30 years of age most commonly related
vicular joint dislocation. to athletics and trauma. The other large group is women from 60 to
80 years of age, primarily due to falls.
COMPLICATIONS
ANTERIOR STERNOCLAVICULAR JOINT DISLOCATIONS The shoulder (glenohumeral) joint is a multiaxial ball-and-
Complications of the reduction are relatively minor. The sterno- socket type of synovial joint that permits a wide range of motion.
clavicular joint is usually unstable postreduction and often dislo- Unfortunately, the range of motion is at the expense of stability.5 The
cates spontaneously. This should be explained to the patient prior shoulder has greater than 180° of motion in both the sagittal and
to attempted reduction. A “cosmetic bump” can remain if reduction coronal planes as well as 180° of rotary movement.6 The spheroidal
is not maintained. Occasionally, these patients will continue to have head of the humerus articulates with the shallow glenoid fossa of the
persistent pain.3 scapula. The glenoid fossa accommodates roughly one-third of the
humeral head. The bony landmarks surrounding the shoulder joint
POSTERIOR STERNOCLAVICULAR are the coracoid and acromion processes of the scapula. A loose,
thin fibrous capsule encloses the glenohumeral joint. The muscu-
JOINT DISLOCATIONS
lar component of the shoulder is a fusion of four separate muscles
Most complications result from the original injury and are due to (supraspinatus, infraspinatus, teres minor, and subscapularis) that
compression or injury of neighboring structures. The incidence of together form the rotator cuff. These muscles have a tendency to be
associated injuries is reported to be 25%.25 Death secondary to these torn and injured in shoulder dislocations, especially posterior and
complications has been reported.31,40 inferior dislocations.7 The shoulder receives its blood supply from
Complications of the reduction include pain, incomplete reduc- branches of the axillary artery (the anterior and posterior circum-
tion, subclavian vessel injury, and brachial plexus injury. A higher flex humeral arteries).
incidence of injury to the subclavian vessels may be seen if a Innervation of the shoulder is from branches of the suprascapu-
towel clamp is used in the reduction. The reduction of a posterior lar, axillary, and lateral pectoral nerves. The axillary nerve lies at
the level of the humeral neck. When it is dislocated anteriorly, the Radiographs are required to classify the type of dislocation
humeral head is displaced into the quadrangular space where it may and diagnose fractures. Associated fractures are detected in up to
compress and damage the axillary nerve. This can result in a neura- 24% of anterior shoulder dislocations.3 They include fractures of
praxia, paralysis of the deltoid muscle, and/or a sensory loss to the the greater tuberosity, humeral head, coracoid process, acromion
skin over the shoulder. process, clavicle, and glenoid. Recent evidence suggests that clini-
Shoulder dislocations can occur anteriorly, posteriorly, or inferi- cally obvious dislocations without a high-energy mechanism can
orly depending on the mechanism of injury. Anterior shoulder dis- be reduced without prior radiographs.61–66 There is no consensus at
locations are by far the most common and account for 95% of all present to eliminate prereduction radiographs versus the current
dislocations. An anterior dislocation usually results from direct or recommendation that all patients have at least two-view prereduc-
indirect forces causing abduction, extension, and external rotation tion plain radiographs of the affected joint.12 Postreduction films
of the limb. Anterior dislocations are classified based on the loca- should be obtained both to document the reduction of the joint
tion of the humeral head into subcoracoid, subglenoid, subclavicu- and any injury induced by the reduction technique as well as to
lar, and intrathoracic. Subcoracoid dislocations account for 75% of document bony abnormalities (Hill–Sachs lesions, Bankart lesion)
all anterior shoulder dislocations. The dislocated humeral head can or previously hidden fractures that were not visible on the initial
shift between the first three positions but generally remains in one radiographs. There is some evidence that postreduction radio-
anatomic location.2 In younger patients, the injury is usually linked graphs may be unnecessary, but further study is required before
to athletics, such as spiking a volleyball or blocking a basketball this can be made the standard of care.13,14,64–68
shot. Older patients may sustain anterior shoulder dislocations from The anteroposterior (AP) view will clearly demonstrate anterior
falling on an outstretched arm or from a direct blow on the posterior dislocations, inferior dislocations, and almost all humeral fractures.
shoulder.4 The patient will present in obvious distress, holding the In evaluating radiographs of anterior shoulder dislocations, look
affected arm in slight abduction and internal rotation. Typically, the for an impaction fracture defect in the posterolateral portion of the
elbow is flexed and supported by the unaffected arm. The shoulder humeral head, called a Hill–Sachs deformity. These are found in
will have the typical “squared off ” appearance, with loss of the nor- up to 50% of all anterior shoulder dislocations.2 A Bankart lesion is
mal deltoid contour. The humeral head may be palpable anteriorly.1 an avulsed fragment of the glenoid labrum with contiguous bone.6
Posterior shoulder dislocations account for 4% of all shoulder dis- Both lesions tend to get worse the longer the humeral head remains
locations.1–4 They have a tendency to be missed, even by experienced dislocated.
EPs. Delayed diagnoses have been made up to a year after the initial In patients with posterior shoulder dislocations, however, the AP
injury.8 The mechanism of injury is usually indirect, with a combina- view often shows a “normal” picture, which accounts for the high
tion of internal rotation, adduction, and flexion. The most common incidence of missed dislocations. One study showed that up to 50%
precipitating mechanism is a seizure. Other etiologies include high of posterior shoulder dislocations were missed using only the AP
voltage electrical injury, direct trauma, and falls.3 Direct trauma, view, whereas lateral views increased the diagnostic accuracy to
such as a head-on motor vehicle collision in which the patient braces 100%.15 There are four features that suggest a posterior dislocation
their hands against the dashboard, can result in bilateral posterior on AP films. First is the loss of the normal elliptical pattern pro-
shoulder dislocations in rare instances. Posterior shoulder disloca- duced by overlap of the humeral head and the posterior glenoid rim.
tions are classified based on the location of the humeral head into Second, the distance between the anterior glenoid rim and the artic-
subacromial, subglenoid, or subspinous. Subacromial dislocations ular surface of the humeral head will be increased. This is known as
account for 98% of posterior shoulder dislocations.2,8 The patient the “rim sign.” The third is internal rotation of the greater tuberos-
usually presents with the arm held in adduction and internal rota- ity to make the humerus take on a “light bulb” or “ice cream cone”
tion.9 The shoulder will appear flat anteriorly. The coracoid process appearance.2,4 Finally, an isolated fracture of the lesser tuberosity on
of the scapula will be visually prominent and palpable.1 the AP view is suggestive of a posterior shoulder dislocation until
Inferior shoulder dislocations are the least common type.1–4 They proven otherwise.2 If there is any question, a lateral view (either the
represent less than 0.5% of all shoulder dislocations. The inferior Y view or an axillary view) will help delineate the posterior position
shoulder dislocation is also known as luxatio erecta, because the of the humeral head behind the glenoid fossa.1
dislocated extremity is extended upward. Inferior shoulder dis-
locations are usually sustained from indirect forces with the arm INDICATIONS
hyperabducted, causing the rotator cuff to tear and the arm to rotate
Shoulder dislocations, whether first-time or recurrent, are typi-
180° externally.7 Alternatively, a direct axial force applied to the
cally very painful and distressing for the patient. All attempts
arm above the head, as in a fall or Olympic-style weight lifting, will
should be made to reduce the joint as quickly as possible once
drive the humeral head inferiorly.10 The patient will present with the
the diagnosis is made. In general, uncomplicated joint disloca-
affected arm shortened and fixed above their head, with the hand
tions should be reduced within 20 to 30 minutes to alleviate fur-
rotated as if asking a question.7 The humeral head may be palpable
ther injury to surrounding neurologic and vascular structures. A
along the lateral chest wall. Inferior shoulder dislocations are often
patient with a neurologic deficit or a compromised distal pulse
associated with fractures.1 The fractures can involve the acromion
in the setting of a shoulder dislocation should undergo imme-
process, coracoid process, clavicle, greater tuberosity, humeral head,
diate reduction.
and/or glenoid rim.1,2,6,11 Complete disruption of the rotator cuff
often occurs with inferior shoulder dislocations.1,2,6,11 Dislocations
can cause capsular and rotator cuff tears, compression or tears of the
CONTRAINDICATIONS
axillary artery and its branches, and injury to the subclavian vein. There are no absolute contraindications to reducing a dislocated
Because of their anatomic proximity, damage to the brachial plexus, shoulder. The patient’s airway, breathing, and circulation should be
suprascapular nerve, and the axillary nerve occur at a rate of 21% assessed and managed prior to reducing the dislocated shoulder.
to 36% due to traction and compression of these nerves.8 Prompt Any life- or limb-threatening injuries should be managed before the
reduction of the dislocation may alleviate compression injuries and shoulder reduction is attempted.
enable a more thorough examination and evaluation of all compo- An Orthopedic Surgeon should be consulted prior to the reduc-
nents of the shoulder. tion of a shoulder dislocation in patients with posterior and inferior
dislocations. They are relatively rare, there is a high incidence of informed consent should be obtained for procedural sedation and/
complications requiring operative management, dislocations asso- or an intraarticular injection if they are performed in addition to the
ciated with fractures may make the reduction difficult, and other reduction procedure.
indications for surgical management may exist.69 The indications Place the patient in a position of maximal comfort, usually sitting
for surgical intervention in anterior shoulder dislocations include upright or at a 45° angle, with the affected extremity supported and
complete rotator cuff tears, fracture of the greater tuberosity with its motion limited. Placing the patient supine or prone is difficult,
displacement of more than 1 cm, or fractures of the glenoid rim that painful, and often requires analgesia before being attempted. The
are displaced more than 5 mm.2 Posterior shoulder dislocations with patient presenting in spinal immobilization should remain supine.
major displacement of a fractured lesser tuberosity or an impression If the spine cannot be cleared, shoulder reduction can be performed
defect greater than 20% of the articular surface necessitate surgical without changing the patient’s position. Intravenous access should
intervention or open reduction.2,3 Open dislocations require opera- be obtained if indicated. Pain should be addressed quickly and
tive management but may be reduced in the ED if there is a delay aggressively.
in getting the patient to the Operating Room. Surgical reduction is
indicated in patients with evidence of hemorrhagic shock from a sus- ANALGESIA
pected axillary artery injury sustained during a shoulder dislocation.
An Orthopedic Surgeon should be consulted before reduc- There are several methods to control pain for patient comfort
ing a dislocated shoulder that presents greater than 7 to 10 days before and during the joint reduction procedure. Intravenous or
after the acute injury. There is a higher risk of vascular injury intramuscular narcotics should not be withheld pending prolonged
when an “old” dislocation is mistaken for an acute injury and sub- radiographic studies. Commonly administered medications include
sequently reduced. The axillary artery, which is bound down by morphine, meperidine, hydromorphone, and fentanyl.
the pectoralis major muscle and anterior pericapsular scarring, An alternative to intramuscular or intravenous narcotics is the
becomes brittle and may not withstand the traction required to intraarticular instillation of local anesthetic solution.16,70–73 This
reduce an “old” dislocation. This is especially true in the elderly. was formally introduced in 1991 as an effective method of analge-
A 1941 study reported a 50% hemorrhage-related mortality in sia for anterior shoulder dislocations. It is often used in addition
patients who had shoulder reductions performed several weeks to procedural sedation. It can also be used as the only method of
after initial injury.11 analgesia when procedural sedation is contraindicated. Clean
Shoulder dislocations in children present unique problems. the anterolateral shoulder of any dirt and debris. Apply povidone
Pediatric patients whose ossification centers have not yet fused iodine or chlorhexidine solution to the shoulder area and allow it
tend to have Salter-Harris type fractures of the epiphyseal plate. An to dry. Identify the hollow 2 cm inferior to the lateral border of the
Orthopedic Surgeon should be consulted prior to the reduction acromion process (Figure 81-1). Using sterile technique, insert a
of a pediatric shoulder dislocation unless neurologic or vascu- 25 gauge needle perpendicular to the skin and into the hollow to
lar compromise is present in the affected extremity. Otherwise, a depth of 2 cm (Figure 81-1). Inject 10 to 20 mL of a 50:50 mix-
the same techniques for reduction can be applied to both adult and ture of sterile saline and local anesthetic solution. This technique is
pediatric patients.
EQUIPMENT
General Supplies
• Equipment and supplies for procedural sedation (Chapter 129)
• Assistants
• Sheets
• 10 to 15 pounds of weights
• Sling and swath or shoulder immobilizer
• Splinting material (plaster, fiberglass, and prepackaged casting
material)
Intraarticular Analgesia
• 20 mL syringe
• 25 gauge, 2.5 in. needle
• Local anesthetic solution (Carbocaine, lidocaine, and bupiva-
caine)
Miscellaneous
• Equipment and supplies for nitrous oxide anesthesia (Chapter 128)
• Equipment and supplies for regional anesthesia (Chapter 126)
PATIENT PREPARATION
The risks, benefits, potential complications, and aftercare of the pro-
cedure should be explained to the patient and/or their representa- FIGURE 81-1. Local anesthesia for a shoulder dislocation. The needle is intro-
tive. Obtain an informed consent for the reduction procedure. An duced in the hollow under the lateral surface of the acromion process.
effective in controlling muscle spasm and pain. The book editor and Posterior and inferior shoulder dislocations definitely require pro-
chapter author believes this should be performed on every dislo- cedural sedation prior to reduction.
cated shoulder before attempts at reduction.
Alternative methods for providing analgesia include the use
of nitrous oxide, procedural sedation, and regional nerve blocks.
ANTERIOR SHOULDER
Nitrous oxide has numerous advantages including a short onset, it DISLOCATION REDUCTION TECHNIQUES
wears off quickly, self-administration by the patient as needed, and The methods for treating a closed shoulder dislocation depend
a decreased ED length of stay.74 Unfortunately, the use of nitrous on overcoming muscular spasm to relocate the humeral head into
oxide produces a quite variable analgesic response. Please refer to the glenoid fossa. Reduction techniques are classified into traction
Chapter 128 for a discussion regarding the use of nitrous oxide techniques, leverage techniques, scapular manipulation, and com-
anesthesia. Procedural sedation is commonly used us aid in the binations of the three previous techniques. A study evaluating the
reduction of a dislocated shoulder. Please refer to Chapter 129 for various reduction techniques found similar success rates of 70% to
a discussion regarding the use of procedural sedation. Ultrasound- 90% regardless of the technique.20 However, postreduction com-
guided brachial plexus blocks provide excellent analgesia but plication rates are variable.20 The major considerations in deciding
require equipment and training on the part of the EP.75–79 Please which technique to use are physician experience, familiarity with
refer to Chapter 126 regarding the details of this technique. the technique, availability of time, and the presence or absence of
Several sources suggest that patients with an anterior shoulder an assistant.20
dislocation without a significant trauma history may actually accept
some degree of discomfort as a tradeoff for the prompt resolution
HENNEPIN TECHNIQUE
of pain by reduction without anesthesia.17–19 Patient comfort should
not be sacrificed for expediency. Anterior shoulder dislocations The Hennepin technique, popularized at Hennepin County
may require procedural sedation prior to reduction, depending on Medical Center, is often the preferred method to reduce ante-
the patient’s level of discomfort and the reduction method chosen. rior shoulder dislocations (Figure 81-2). This technique can
FIGURE 81-2. The Hennepin technique to reduce an anterior shoulder

dislocation. A. Patient positioning and external rotation of the humerus.
B. Abduction of the arm with the elbow flexed 90°.
be accomplished with no anesthesia or with the intraarticular

instillation of local anesthetic solution. Procedural sedation is
not required but may be used if the patient has severe pain and
muscle spasms.
Place the patient seated, supine, or reclined 45° on a gurney
(Figure 81-2A). Place the affected arm in adduction. Flex the
elbow 90°. Support the patient’s flexed elbow against their torso
with the nondominant hand. Grasp the patient’s forearm with the
dominant hand. Slowly rotate the arm externally. If pain becomes
severe, typically as a result of rotator cuff spasm, stop the motion
and wait until the spasm subsides. Do not release the arm or
return it to its original position. Continue to rotate the arm exter-
nally until the humeral head reduces or the arm reaches the coronal
plane (90° of external rotation). This can take up to 10 minutes to
accomplish. If the humeral head is still dislocated, slowly abduct the
arm until the humeral head reduces or full abduction is obtained2
(Figure 81-2B). Full abduction occurs when the patient’s hand
crosses over their head and is able to touch the contralateral ear.
Adduct the arm until it is against the patient’s torso. Another tech-
nique should be attempted if the humeral head is still dislocated.
The advantages of this technique include little to no patient
manipulation or positioning, the relative ease of reduction, mini-
mal equipment, the requirement of only a single operator, and the
ability to perform the reduction without analgesia. The success rate
when performed by EPs is approximately 80%, with 36% of patients FIGURE 81-3. The Stimson technique to reduce an anterior shoulder dislocation.
not requiring analgesia.3 The major disadvantage is that patients are Weights are progressively added to the wrist to distract the humerus.
often too apprehensive and experiencing too much discomfort to
relax their arms sufficiently to allow for reduction to occur. This
problem can be eliminated by the intraarticular instillation of local
and then internally while the patient is prone and the arm is main-
anesthetic solution. Occasionally, patients will require procedural
tained under traction. This maneuver will often reduce the disloca-
sedation.
tion if the weights alone are unsuccessful.
An alternative method is to have the patient grip a bucket approx-
EXTERNAL ROTATION TECHNIQUE imately half full of water. This will provide the necessary traction
This is a modified version of the Hennepin technique.21–24,98 The weight to reduce the joint. The disadvantage of the bucket technique
technique is identical to the Hennepin technique except that the is that the patient will have to grip the bucket for a considerable
procedure is terminated when the arm reaches 90° of external rota- length of time without releasing it.
tion. The step of abduction is not performed. The advantages and The advantage of the Stimson technique is that it is safe and does
disadvantages are as listed for the Hennepin technique. not require the presence of an assistant. A 96% success rate has been
reported with this technique.3 The disadvantage of the procedure is
that the patient must be placed in a prone position that may be pain-
STIMSON TECHNIQUE ful, uncomfortable, or impossible because of other injuries. There is
The Stimson technique is a safe first-line technique that uses gravity a small risk of the patient slipping off the elevated gurney. A strap
and weights to overcome muscle spasm and reduce the dislocated or sheet tied around the patient and the gurney is recommended in
shoulder25–28 (Figure 81-3). Instill intraarticular local anesthetic order to prevent this. Procedural sedation is not recommended due
solution into the shoulder joint prior to attempting the reduction. to the prolonged prone positioning required, which may interfere
Procedural sedation is usually not necessary. The patient must be with the patient’s respiration. Additionally, procedural sedation for
under constant observation to monitor their pulse oximetry and 15 to 30 minutes is relatively contraindicated and difficult to main-
respiratory status if procedural sedation is used because of the tain without potential complications.
patient’s prone positioning.
Place the patient prone with the dislocated arm hanging over the
SCAPULAR MANIPULATION TECHNIQUE
side of the gurney (Figure 81-3). Flex the shoulder 90°. A pillow
or folded sheets may be placed beneath the affected shoulder for Scapular manipulation accomplishes reduction by repositioning
patient comfort. Tie a sheet around the patient’s hips and the gur- the glenoid fossa rather than manipulating the humeral head4,29–33
ney to prevent them from falling off the bed (Figure 81-3). Apply (Figure 81-4). This is a popular technique due to its low compli-
3 to 5 pounds of weight to the wrist or forearm. The weights can cation rate and high patient satisfaction. This technique can be
be attached by a commercially available device, hung off a padded accomplished with no anesthesia or with the intraarticular instil-
wrist restraint, or hung off gauze wrapped circumferentially around lation of local anesthetic solution. Procedural sedation is usually
the wrist. Raise the gurney so that the weights are suspended off the not required.
ground (Figure 81-3). Every few minutes, add an additional 3 to Place the patient prone with the dislocated extremity hanging
5 pounds of weights until a total of 10 to 15 pounds is achieved. The over the side of the gurney (Figures 81-4A & B). Flex the shoulder
weights will provide traction in a position of forward flexion and are 90°. A pillow or folded sheets may be placed below the affected
usually sufficient for reduction to take place within 15 to 30 min- shoulder for patient comfort. Place 5 to 15 pounds of weights sus-
utes.4 If the reduction is unsuccessful after 30 minutes, grasp the pended from the patient’s wrist or in their hand. If weights are
patient’s forearm and twist it to gently rotate the humerus externally not available, an assistant may apply downward traction on the
FIGURE 81-4. The scapular manipulation technique to reduce an anterior shoulder dislocation. A. Proper hand positioning. The upper hand stabilizes the base of the
scapula while the lower hand applies medial and upward pressure on the tip of the scapula (curved arrow). B. Reduction with the patient prone. Traction is applied by an
assistant (straight arrow). Occasionally, external rotation is also required (curved arrow). C. Reduction with the patient supine. Traction is applied on the humerus to elevate
the shoulder off the bed (arrow). D. Reduction with the patient sitting. Traction is applied on the humerus (arrow).
extremity (Figure 81-4B). The weights or the assistant will pro- other injuries or conditions preclude using the prone position. Flex
vide in-line traction to the arm. the affected shoulder 90°. Instruct an assistant to grasp the forearm
Identify the scapula and its borders. The scapular tip will “wing” and apply upward traction to elevate the shoulder off the bed. Apply
laterally. Stabilize the superior portion of the scapula with one hand your hands to stabilize and manipulate the scapula as described in
(Figure 81-4A). Place the thumb of the stabilization hand along the the previous paragraph.
superolateral border of the scapula. Apply constant and firm medial This technique may also be performed with the patient sitting
and upward pressure to the inferior tip of the scapula using the (Figure 81-4D). This is particularly helpful when other injuries or
other hand or thumb (Figure 81-4B). The thumb of the stabiliz- conditions preclude using the prone or the supine position. Flex
ing hand can also be used to apply medially directed pressure to the affected shoulder 90°. Instruct an assistant to grasp the forearm
the tip of the scapula. Push the tip of the scapula as far medially and apply horizontal traction. Apply your hands to stabilize and
as possible. The shoulder should reduce within 1 to 3 minutes. A manipulate the scapula as described in the previous paragraphs.
small degree of dorsal displacement of the scapular tip has also been This method is technically a more difficult version of the scapular
recommended.3,33 If the reduction is unsuccessful, slight external manipulation technique because the patient’s torso is not stabilized
rotation of the humerus (by an assistant) while the scapula is being and moves during the traction and scapular manipulation.3,31,33
manipulated and the arm is under traction may facilitate reduction The reduction of an anterior shoulder dislocation by the scapular
(Figure 81-4B). This maneuver releases the superior glenohumeral manipulation technique is usually quite subtle and may be missed
ligament and presents a favorable profile of the humeral head to the by both the patient and the physician. In a few rare cases, the act of
glenoid fossa.31,33 lying prone will be sufficient to relocate the shoulder. Success rates
The scapular manipulation technique may be performed with of over 90% have been reported with this technique.3,30–33 The proce-
the patient supine (Figure 81-4C). This is particularly helpful when dure is well tolerated.3,29–33 In addition, there is a very low incidence
of complications with this procedure and it can be performed with-

out analgesia and monitoring.97 Disadvantages include the prone
position and the need for an assistant to apply traction on the arm.
TRACTION-COUNTERTRACTION TECHNIQUE
The traction-countertraction technique is commonly performed
in the ED, mostly out of tradition (Figure 81-5). It may be used as
a first-line technique or a backup for patients who have failed the
Stimson technique.2 This technique requires anesthesia and anal-
gesia. Instill local anesthetic solution intra-articularly. This may be
sufficient, but most patients will require procedural sedation. This
technique can cause significant patient discomfort.
Place the patient supine. Pass a sheet around the chest and axilla
of the affected arm (Figure 81-5A). Abduct the affected arm 45°.
Instruct an assistant to grasp the loose ends of the sheet firmly.
Grasp the patient’s wrist and apply slow and steady traction. Instruct
the assistant to apply countertraction. The assistant and EP should
be exerting equal and opposite forces. If pain becomes severe, typi-
cally as a result of rotator cuff spasm, stop the motion and wait
until the spasm subsides. Do not release the arm or return it to
its original position. After the spasm subsides, continue applying
traction and countertraction until the shoulder reduces.
Direct traction on the extended arm may result in rapid EP
fatigue. This is especially true if the EP is creating most of the force
of traction through contraction of their biceps (Figure 81-5A). A
less strenuous alternative is available and preferred (Figure 81-5B).
Position the patient as above. Flex the elbow of the affected arm
90°. Place a looped sheet over the proximal forearm and the EP’s
hips. Do not loop the sheet around your back, as this can cause
low back strain. This method allows the EP to lean back slowly
and use their body weight to supply the traction force. The EP’s
arms should be extended with the hands grasping the patient’s dis-
tal forearm. When leaning back to apply traction, the EP’s hands
should maintain the patient’s forearm upright with the elbow flexed
90° (Figure 81-5B).
Traction may have to be applied for several minutes. The applica-
tion of gentle and limited external rotation to the affected arm while
under traction may speed up the reduction. Alternatively, a second
assistant can apply lateral pressure (lateral traction) on the humeral
head with their hands. A variation of this technique involves a sec-
ond assistant with a looped sheet placed high in the patient’s axilla
(Figure 81-5C). This second assistant is used to create lateral traction
at the proximal humerus that is perpendicular (90°) to the traction-
countertraction axis.2 As lateral traction is applied, the EP continues
in-line traction and can simultaneously adduct the patient’s arm to
maneuver the humeral head back into position (Figure 81-5C). The
second assistant may also be used with the technique demonstrated
in Figure 81-5A or B.
Successful reduction is noted by a lengthening of the arm, a
noticeable “clunk,” and/or a brief fasciculation of the deltoid
FIGURE 81-5. The traction-countertraction technique to reduce an anterior or
muscle. Disadvantages of the traction-countertraction technique posterior shoulder dislocation. A. In-line traction is applied to the affected extrem-
include the need for more than one person, the significant degree ity after it is abducted 45°. An assistant provides equal and opposite countertrac-
of force required, the prolonged time and endurance required of the tion with a sheet. B. An alternative method. A sheet is looped around the flexed
EP and assistant, and the need for procedural sedation. This tech- forearm and the EP’s hips. The EP leans back (arrow) to allow their body to do the
nique should not be used to reduce shoulder dislocations asso- work of reduction while their hand maintains the patient’s elbow in 90° of flexion.
ciated with significant fractures. The force required for this C. An additional assistant is applying traction 90° to the traction-countertraction
technique can displace fracture fragments, necessitating an open axis with a sheet in the axilla. Simultaneous adduction (curved arrow) and in-line
reduction or operative management of the displaced fragments. traction by the EP may aid in the reduction.
SNOWBIRD TECHNIQUE also conserving time and resources. This is an effective alternative
The Snowbird technique was named after a ski area in Utah where reduction technique as compared with the more traditional meth-
this technique originated.34 It was developed in order to reduce the ods. While this technique can be accomplished with no anesthesia,
large number of ski-related glenohumeral dislocations quickly while the intraarticular instillation of local anesthetic solution is highly
on the muscles of the shoulder girdle.35–37 Accordingly, the tech-

nique that Milch developed relies on gentle manipulation through
abduction, external rotation, and traction on the arm.19,35–40 The
patient’s affected arm moves in a gradual arc, assisted by the EP, to
reduce the dislocation without extensive or forceful manipulation
(Figure 81-7). While this technique can be accomplished with no
anesthesia,95 the intraarticular instillation of local anesthetic solu-
tion is highly recommended. Procedural sedation is not usually
required for this reduction technique.
Place the patient supine. Position one hand with the thumb under
the dislocated humeral head (Figure 81-7A). Slowly abduct the
affected arm 180° to an overhead position (Figure 81-7B). This
can be accomplished by having the patient lift the affected arm.
Many patients are unable to do this due to pain, muscle spasm, or
apprehension. Gently grip the elbow or wrist and slowly abduct the
arm to 180° (Figure 81-7B). Once the arm is fully abducted, grasp
the patient’s distal arm or proximal forearm with one hand. Apply
gentle longitudinal traction with slight external rotation to the arm
(Figure 81-7C). The humeral head may reduce. If not, while main-
taining traction with external rotation, apply upward pressure under
the humeral head with the other hand to guide it into the glenoid
fossa (Figure 81-7C).
Successful reduction is attained in 70% to 90% of the cases with no
requirement for assistance, other equipment, or medications.19,35–40
Advantages of the Milch technique include its gentleness, high
success rate, limited complications, and good patient tolerance.
Disadvantages include positioning the arm in full abduction with or
without analgesia, as many patients cannot attain the optimal posi-
FIGURE 81-6. The Snowbird technique to reduce an anterior shoulder dislocation. tion due to severe pain, muscle spasm, and/or apprehension. This
Downward traction is applied to the humerus (arrow) while the humeral head is technique can be modified slightly so that the patient can perform a
manipulated back into the glenoid fossa. self-reduction under the instruction of the EP.96
ALTERNATIVE ANTERIOR SHOULDER

recommended. Procedural sedation is usually not required for this DISLOCATION REDUCTION TECHNIQUES
reduction technique.
Place the patient in a sitting position on a chair with a back Numerous alternative and less commonly used techniques are avail-
(Figure 81-6). Completely adduct the affected arm. Flex the elbow able to reduce an anterior shoulder dislocation. Some of these are
to greater than 90°. Support the affected arm with the other arm or modifications of existing methods. Others are original techniques
a pillow. Make a 3 foot long loop of 4 in wide cast stockinette. Place that had too many associated complications and were modified with
the stockinette around the proximal forearm. Instruct the patient time and experience. Some are well known and effective techniques
to sit as straight as possible. Instruct an assistant to maintain the that have been used for many years. There is very little research
patient in an upright position by standing adjacent to the unaffected regarding many of these techniques. Some of these techniques may
shoulder and clasping their hands around the chest, in the axilla, prove to be useful in the reduction of an anterior shoulder reduc-
of the affected shoulder. The EP then places one foot in the stocki- tion. None of these techniques are advocated as first-line treat-
nette loop and applies firm downward traction with the foot while ments for the reduction of shoulder dislocations. Their inclusion
the patient tries to keep the shoulder relaxed and the affected elbow here is for the sake of completeness; it does not necessarily con-
flexed. Instruct the assistant to provide countertraction to keep the stitute an endorsement for their use. Only a select few of these
patient from moving. The shoulder may reduce. If not, with con- techniques are discussed.
tinued downward traction on the stockinette, the EP will have both
hands free to apply gentle rotation and pressure on the humeral HIPPOCRATIC TECHNIQUE
head until the shoulder is reduced.34
The Snowbird physicians had a 97% success rate and were able The Hippocratic technique is the original traction-countertraction
to reduce 93% of anterior shoulder dislocations without any form technique41 (Figure 81-8). It is one of the oldest documented tech-
of analgesia.34 The advantages of this technique include the rela- niques to reduce a shoulder dislocation.2,11,26,41 This technique has
tive ease of setup, the rapid nature of the technique, limited use the advantage that it can be performed by one person in any setting.
of analgesia, and limited patient positioning. Potential disadvan- While effective, the Hippocratic technique is not recommended
tages include the use of an assistant and the fact that this technique due to the great force required to achieve reduction. Common
was used and developed on a limited patient population of young complications of the technique include fractures, brachial plexus
healthy skiers. injury, vascular injury, and poor patient tolerability.2,6,11
Place the patient supine (Figure 81-8). Grasp the wrist of the
affected arm and abduct the arm 20° to 30°. Place one foot into the
MILCH TECHNIQUE
axilla of the affected arm. Firmly grasp the patient’s wrist and apply
Milch, in describing this technique, wrote that a fully abducted arm traction to the arm while extending the foot in the axilla to provide
is in a natural and neutral position in which there is little tension countertraction.
FIGURE 81-8. The Hippocratic technique to reduce an anterior shoulder disloca-

tion. Traction is applied to the arm while countertraction is applied using a foot in
the axilla.
KOCHER TECHNIQUE
The Kocher technique was first recorded on an Egyptian mural
dated 1200 BC.42 It is another traditional method that has come into
disfavor. This maneuver relies upon leverage and humeral manipu-
lation to reduce the shoulder (Figure 81-9). The humeral head is
levered on the anterior glenoid while the humeral shaft is levered
against the anterior thoracic wall until reduction is achieved.11,42,43
A substantial amount of force must be applied while adducting and
externally rotating the arm in order to reduce the joint.
Place the patient sitting at a 45° incline or supine. Abduct the
affected arm 45° and flex the elbow 90° (Figure 81-9A). Grasp the
patient’s distal humerus with the dominant hand and the patient’s
wrist with the nondominant hand (Figure 81-9A). Apply in-line
traction to the distal humerus. Rotate the arm externally to its maxi-
mum extent while maintaining in-line traction (Figure 81-9B). Move
the patient’s elbow across their chest and to the midline while main-
taining in-line traction and external rotation (Figure 81-9C) while
the elbow is held tightly against the patient’s chest. Finally, inter-
nally rotate the arm while in-line traction is maintained and until
the patient’s hand touches their opposite shoulder (Figure 81-9D).
The main advantage of this method is that it is a one person tech-
nique that has withstood the test of time. However, studies have
shown that the forces generated are sufficient to cause fractures of
the humeral neck, spiral humeral fractures, vascular trauma, and
brachial plexus injury.11
ESKIMO TECHNIQUE
The Eskimo technique uses the patient’s body weight and gravity
as a traction mechanism to reduce an anterior shoulder disloca-
tion.44 It can be performed in the field, where access to a healthcare
facility may be limited. Disadvantages of this technique include the
strength and stamina required to lift the patient, EP injury due to
heavy lifting, poor patient tolerability, and increased stress on the
brachial plexus and axillary vessels.
FIGURE 81-7. The Milch technique to reduce an anterior shoulder dislocation. Place the patient on the floor and lying on the unaffected side
A. The distal humerus is grasped with one hand while the thumb of the other (Figure 81-10). Instruct the patient to place the affected arm tightly
hand is placed under the dislocated humeral head. B. The arm is abducted to adducted with the elbow flexed 45° (Figure 81-10A). Grasp the
180°. C. In-line traction is applied to the humerus while the thumb pushes the injured arm and slowly lift the patient 6 to 12 in. off the ground
humeral head into the glenoid fossa. (Figure 81-10A) so that the patient’s body weight produces enough
traction to reduce the joint. Poulsen initially described this tech-
nique and reported a 74% success rate.44
Alternatively, the patient can be positioned on the unaffected side
with the affected arm abducted 90° (Figure 81-10B). One or two
FIGURE 81-9. The Kocher technique to reduce an anterior shoulder dislocation. A. The arm is abducted 45° with the elbow flexed 90°. In-line traction is applied to the
humerus (arrow). B. The arm is rotated externally (curved arrow) while traction is maintained (straight arrow). C. The elbow is brought across the chest to the midline
while the arm is still rotated externally and traction on the arm is maintained (straight arrow). D. Traction is maintained while the arm is rotated internally until the patient’s
hand touches their opposite shoulder.
people can then grasp the patient’s wrist and forearm and lift the overhanded with the opposite hand and move the hand from the
patient 6 to 12 in. off the ground (Figure 81-10B). condyles through the acute angle of the arm, grasping the wrist of
the hand holding the forearm. The wrestling hold is now estab-
CHAIR TECHNIQUE lished (Figure 81-12). With the hold in place, the patient’s forearm
will be used as a fulcrum. Abduct the patient’s shoulder 45° while
The chair technique is a simple method to reduce an anterior maintaining constant traction. Externally rotate the arm in a slow,
shoulder dislocation.45–47,80 It is a variation of the traction-coun- smooth motion. While maintaining traction and external rotation,
tertraction technique. Place the patient sitting sideways or back- move the patient’s arm over their chest wall and rotate it internally.1
wards in a chair with the affected arm draped over the back rest The shoulder should then reduce.
(Figure 81-11). Supinate the patient’s wrist and apply downward This technique has the advantages of requiring no equipment,
traction while the patient attempts to stand and provide counter- no analgesia, and no assistants. It may be used in the field where
traction (Figure 81-11). a healthcare facility is not readily available. The main disadvan-
This technique has a 72% success rate.3 The advantages include tage is the amount of force applied to the shoulder and surround-
the simplicity of the technique and the fact that analgesia is not ing structures. The twisting of the forearm as a lever can displace
required. Unfortunately, a large amount of force is required to fracture fragments or cause fractures. This technique also requires
reduce the shoulder. These forces can cause injury to the brachial the EP to have a significant amount of upper body strength and
plexus and axillary vessels as the axilla is impinged on the back of arms long enough to accomplish the wrestling hold, especially if
the chair. the patient has large arms. The series of movements is difficult to
accomplish while always maintaining distal traction.
WRESTLING TECHNIQUE
PNEUMATIC STRETCHER TECHNIQUE
Zahiri et al. recently described a new technique based on opti-
mal anatomic positioning with limited complications.48 Place This technique was developed to reduce a shoulder dislocation
the patient supine with the elbow of the affected shoulder flexed when assistants were not available or if the physician did not
120°. Grasp the dislocated arm just above the humeral condyles have the physical strength required to use other techniques.49
and apply distal traction to the arm. Grasp the distal forearm It is a modification of the traction-countertraction technique.
FIGURE 81-10. The Eskimo technique to reduce an anterior shoulder dislocation. The patient is lying on the floor on the unaffected side. A. The patient is lifted off the
ground by grasping the adducted arm. B. The patient is lifted off the ground by grasping the distal forearm of the affected arm.
This technique should never be used to reduce a shoulder Place the patient prone with the affected arm hanging off the
dislocation. It will cause stretching and possible rupture of the gurney (Figure 81-13). Wrap a sheet around the patient’s waist
brachial plexus, ligaments of the shoulder region, muscles and and hips and the gurney to hold the patient in position. Tie the
tendons crossing the shoulder, nerves of the upper extremity, ends of the sheet into a knot or have them held by an assistant.
vascular structures of the upper extremity, and injury to other Wrap the patient’s wrist with gauze and tie it to the base or wheel
joints. Tremendous forces are applied to the extremity with this of the gurney. Begin elevating the bed until the dislocation is
technique. reduced.
FIGURE 81-11. The chair technique to reduce an anterior shoulder dislo-

cation. Traction is applied to the arm as the patient attempts to stand and
provide countertraction.
FIGURE 81-12. The wrestling technique to reduce an anterior shoulder dislocation.

After the hold is established, traction and external rotation are applied to the arm.
SPASO TECHNIQUE
The Spaso technique is a one person technique that is simple to
perform.81–85 It uses minimal force and can be performed with-
out procedural sedation. This technique is similar to the Stimson
technique with the main difference being the patient’s posi-
tion.82 Successful rates of reduction can be seen in up to 87% of
patients.83–85
Place the patient supine. Grasp the wrist of the affected arm
FIGURE 81-14. The Spaso technique to reduce an anterior shoulder dislocation.
with the dominant hand and the patient’s proximal forearm with Upward traction is applied (arrow) as the arm is externally rotated (curved arrow).
the nondominant hand (Figure 81-14). Slowly flex the patient’s
shoulder until the arm is upright and the shoulder flexed 90° (Fig-
ure 81-14). Apply upward traction to the arm while gently exter-
nally rotating the arm. Slowly increase the upward traction until the
shoulder reduces. If reduction does not occur, use the nondominant
OZA MANAUVER
hand to apply externally directed pressure to the humeral head to Direct manipulation of the humeral head with simultaneous arm
push it into the glenoid fossa while maintaining the arm in traction traction may allow for a simple reduction of the humeral head.86
and external rotation with the dominant hand. An assistant may be This technique is a modification of the traction-countertraction
required to push on the humeral head while the EP uses both hands technique. Very little information exists in the literature regarding
to apply upward traction. the effectiveness of this maneuver.
FIGURE 81-13. The pneumatic stretcher technique to

reduce an anterior shoulder dislocation. The gurney is raised
to provide countertraction to the traction applied to the wrist
that is tied to the base of the gurney.
and does not use procedural sedation. It requires the patient to sit
upright with their legs dangling off the gurney. Thus, this maneu-
ver is not appropriate to use with procedural sedation, intubated
patients, multiply injured patients, those who cannot sit upright,
or anyone with altered mentation. The BOB maneuver can be per-
formed with no analgesia or the instillation of local anesthetic solu-
tion intra-articularly.
Lower the gurney as much as possible. Elevate the head of the
gurney 90°. Place the patient sitting upright on the side of the gur-
ney with their unaffected arm against the upright head of the gur-
ney. The patient’s feet may touch the floor or dangle. Instruct the
patient to “scoot over” until their unaffected shoulder and hip are
tight against the head of the gurney. Kneel on the gurney facing the
patient (Figure 81-16). Flex the elbow of the affected arm 90°. Place
one hand on the patient’s proximal forearm adjacent to the antecubi-
tal fossa. Grasp the patient’s wrist with your other hand. Lean down
with your body weight, pulling the patient’s humerus downward
FIGURE 81-15. The Oza maneuver to reduce an anterior shoulder dislocation. (Figure 81-16). Instruct an assistant to simultaneously stand behind
Traction is applied to the arm as the humeral head is pushed outward. the patient and perform the scapular manipulation technique. The
combination of traction of the humerus and scapular manipulation
will allow the humeral head to relocate in the glenoid fossa.
Place the patient supine with the affected arm and their body
against the edge of the gurney (Figure 81-15). Instruct an assistant LEGG REDUCTION MANEUVER
to grasp the patient’s wrist and slowly abduct the arm until it is at 45°
to 90°. Stand between the patients abducted wrist and their body, This maneuver is a simple technique to reduce an anteriorly dislo-
with your back against the patient’s body. Place both thumbs against cated shoulder.88 It was developed and used to treat athletes in the
the dislocated humeral head. Wrap the fingers of both hands around field. Many patients may not tolerate the pain associated with this
the proximal humerus and interlace your fingers. Instruct the assis- maneuver. It is not appropriate to use with procedural sedation,
tant to apply traction to the arm while simultaneously using your intubated patients, multiply injured patients, those who cannot sit
thumbs to lift and push the humeral head up and over the anterior upright in a chair, or anyone with altered mentation. The maneuver
glenoid lip and back into the glenoid fossa. Alternatively, the EP can can be performed with no analgesia or the instillation of local anes-
stand outside the patient’s abducted arm, wrap their fingers around thetic solution intra-articularly.
the proximal humerus, and pull the humeral head back into the gle- Place the patient sitting upright in a chair. Instruct an assistant
noid fossa. to provide slight downward pressure on the unaffected shoulder
(Figure 81-17A). Instruct the assistant to maintain downward pres-
BEST OF BOTH (BOB) MANEUVER sure on the shoulder throughout the maneuver. Place one hand on
the affected shoulder and apply downward pressure while abducting
The BOB maneuver is a combination of distally applied traction the patient’s arm with your other hand (Figure 81-17A). Externally
and scapular manipulation.87 This maneuver is quick to perform rotate the arm and flex the elbow 90° until the patient’s palm faces
FIGURE 81-16. The best of both (BOB) maneuver to reduce an anterior shoulder dislocation. Traction is applied to the humerus as the tip of the scapula is pushed medi-
ally. A. Superior view. B. Lateral view.
FIGURE 81-17. The Legg reduction maneuver to reduce an anterior shoulder dislocation. A. Initial positioning. B. The arm is externally rotated and the elbow flexed 90°.
C. The arm is moved posteriorly. D. The arm is adducted while fully flexing the elbow. E. Internal rotation of the arm.
outward (Figure 81-17B). Pull the elbow and forearm posteriorly Place the patient supine on a gurney. Elevate the head of the
until it crosses a plane across the occiput (Figure 81-17C). Adduct gurney to 90°. Bind the patient’s wrists together with an elastic
the arm while simultaneously flexing the elbow from 90° to full flex- or gauze bandage. Instruct the patient to flex their knee on the
ion (Figure 81-17D). Once fully adducted, internally rotate the arm affected side. Instruct the patient to place their bound wrists in
until the hand touches the unaffected shoulder and the humerus front of the flexed knee (Figure 81-19). Lower the head of the
relocates (Figure 81-17E). gurney completely. Instruct the patient to slowly lean back while
simultaneously hyperextending their neck and shrugging their
CUNNINGHAM TECHNIQUE shoulders anteriorly to antevert the glenoid fossa. The humeral
Dr. Cunningham developed a technique to simply, quickly, and
painlessly reduce an anterior shoulder dislocation without the use of
drugs.89,90 This small case series is based on the principle of relaxing
the biceps brachii muscle with massage while the rhomboids retro-
vert the scapula to allow the humeral head to relocate.
Place the patient sitting upright in a chair or on a gurney
(Figure 81-18). Stand next to the affected arm and face the patient.
Fully adduct the humerus and flex the elbow 90°. Insert one hand
between the patient’s forearm and their body. Grasp the patient’s
proximal forearm so that their hand and wrist is resting on your
upper forearm (Figure 81-18). Instruct the patient to shrug their
shoulders superiorly and posteriorly to square-off the angle of their
shoulder. Apply steady and downward pressure to the patient’s fore-
arm. With your other hand simultaneously massage the patient’s
trapezius, deltoid, and biceps muscles sequentially. While maintain-
ing the downward traction, repeat the massage process while con-
centrating on the biceps until the shoulder reduces.
BOSS-HOLZACH-MATTER TECHNIQUE
This technique allows the patient to self-reduce an anterior shoul-
der dislocation.91–93 The patient can control the application of force
so that their pain can be minimized during the reduction. It is a
hybrid of the traction-countertraction and scapular manipulation
techniques. The EP instructs the patient through the technique.
This technique is only successful in 60% of anterior shoulder dislo- FIGURE 81-18. The Cunningham technique to reduce an anterior shoulder dislo-
cations, significantly lower than many other commonly used reduc- cation. Traction is applied to the humerus while the trapezius, deltoid, and biceps
tion techniques. muscles are massaged sequentially.
FIGURE 81-19. The Boss-Holzach-Matter technique to reduce an anterior shoul-

der dislocation. The patient leans back to provide countertraction while the wrists
are secured over the knee to provide distal traction.
head will reduce as the glenoid fossa moves toward the humeral
head while traction is applied to the humerus.
FARES METHOD
This technique can reduce an anteriorly dislocated shoulder in an
average of 2 to 3 minutes with the use of procedural sedation.94 The
FARES method has a 78% success rate and only requires one person
to perform the reduction.
Place the patient supine with the affected arm at their side. Fully
extend the elbow and place the forearm in the neutral position with
the patient’s thumb pointing upward. Grasp the distal forearm and
hand. Apply longitudinal traction on the arm (Figure 81-20A).
Oscillate the forearm continuously with brief (two to three cycles
per second) and short range (5 cm above and below the hori-
zontal plane) vertical movements of the arm (Figure 81-20A).
Slowly abduct the arm while maintaining longitudinal traction
and vertical oscillatory movements (Figure 81-20B). Externally
rotate the arm until the palm is facing upward when the arm is
approximately 90° abducted. Continue to slowly abduct the arm
while maintaining longitudinal traction and vertical oscillatory
movements until the shoulder reduces (Figure 81-20C). The
shoulder usually reduces at approximately 120° of abduction.
Once reduced, gently internally rotate the arm and adduct it until
the humerus is against the chest and the forearm is resting across
the chest.
POSTERIOR SHOULDER
DISLOCATION REDUCTION TECHNIQUE
An Orthopedic Surgeon should be consulted before attempt- FIGURE 81-20. The FARES method to reduce an anterior shoulder dislocation.
ing to reduce the shoulder due to the rarity of posterior shoul- A. Longitudinal traction is applied to the abducted arm as vertical oscillatory move-
der dislocations, the difficulty of reduction, the high incidence of ments are made with the forearm. B. The arm is further abducted and externally
associated injuries, and the need to operate to repair the associ- rotated as longitudinal traction and vertical oscillatory movements are continued.
ated injuries.2,4,8,11,99,101 The only exception is when the affected C. The arm is further abducted as longitudinal traction and vertical oscillatory
movements are continued until the shoulder reduces.
extremity has signs of neurologic or vascular compromise and
the Orthopedic Surgeon is not immediately available to reduce
the shoulder. The patient will require intraarticular instillation of
local anesthetic solution and procedural sedation for the perfor-
mance of this technique. around the patient’s torso. The traction and countertraction should
be equal in force and in opposite directions. While maintaining
traction, gently internally rotate and adduct the arm. The shoulder
TRACTION-COUNTERTRACTION may reduce. If not, instruct a second assistant to apply simultane-
Place the patient supine. Perform procedural sedation. Pass a sheet ous lateral pressure on the humeral head.3 While continuing to exert
around the axilla and torso of the affected arm in the same manner pressure on the humeral head, in trying to work it over the glenoid
as in the traction-countertraction technique (Figure 81-5A). Grasp rim, the arm may need to be gently rotated externally. If this fails to
the distal forearm. Apply axial traction in-line with the humerus. reduce the shoulder, apply lateral traction, with a second assistant
Instruct an assistant to apply countertraction on the sheet looped using a sheet looped around the proximal humerus, and repeat the
process (Figure 81-5C). If the shoulder will still not reduce, this is
an indication for general anesthesia and an open or closed reduction
in the Operating Room.4,9 The shoulder joint is usually unstable and
may not remain articulated once it is reduced.
An alternative to grasping the forearm is to apply a padded wrist
restraint. Tie the loose ends of the restraint straps to create a loop
around the EPs hips. A second alternative is to loop a sheet around
the patient’s flexed forearm and the EPs hips as in the traction-
countertraction technique (Figure 81-5B). These two alternatives
are preferred, as they allow the EPs body to reduce the shoulder
rather than depending on biceps strength.
INFERIOR SHOULDER DISLOCATION

REDUCTION TECHNIQUE
Like posterior shoulder dislocations, inferior shoulder dislocations
require an Orthopedic Surgeon to be consulted before attempt-
ing closed reduction unless neurologic or vascular compromise is
present in the affected extremity. Consultation is required because FIGURE 81-22. The two-step maneuver to reduce an inferior shoulder dislocation.
of the rarity of inferior shoulder dislocations, the difficulty of reduc- Step one involves pushing the lateral aspect of the distal humerus while pulling on
tion, the high incidence of associated injuries, and the need to oper- the medial condyle to convert the inferior dislocation into an anterior dislocation.
ate to repair the associated injuries.2–4,10,50–52,100,101 The patient will Step two is the external rotation technique (Figure 81-2A).
require intraarticular instillation of local anesthetic solution and
procedural sedation for the performance of these techniques.4 An
inferior shoulder dislocation is usually reduced using the traction-
countertraction technique.10,100–102 TWO-STEP MANEUVER
This maneuver consists of two steps.103 The first step converts an
TRACTION-COUNTERTRACTION inferior shoulder dislocation into an anterior shoulder disloca-
Place the patient supine. Loop a sheet over the clavicle of the tion. Step two is the reduction of the anterior shoulder dislocation
affected shoulder with the loose ends of the sheet at the opposite using the external rotation technique described previously in this
hip (Figure 81-21). Stand above the patient’s head and grasp the chapter. The two-step maneuver has several advantages over using
distal forearm. Apply axial traction to the arm. Instruct an assis- the traction-countertraction technique. This includes requiring
tant to apply equal countertraction on the sheet. While maintain- a single person, using one reduction attempt, possibly using less
ing axial traction on the humerus, gently adduct the arm in a full sedation, and not requiring a trip to the Operating Room for the
arc from the patient’s head to their side (Figure 81-21). The shoul- reduction.
der should reduce. The shoulder joint is usually unstable and may Place the patient supine. Stand adjacent to the affected shoulder
not remain articulated once reduced. In rare instances, buttonhol- and facing the patient’s feet. Place one hand on the distal aspect
ing of the joint capsule will prevent closed reduction and require of the lateral humerus and the other hand on the medial epicon-
an open reduction.2 dyle (Figure 81-22). Use the hand on the lateral aspect of the distal
humerus to push inward while simultaneously pulling the elbow
outward (Figure 81-22). This will convert the inferior dislocation
into an anterior dislocation. Apply the external rotation technique
to reduce the anterior dislocation.
ASSESSMENT
The postprocedural care of the dislocated shoulder is as important as
the initial reduction. Successful shoulder reduction is usually sensed
by the operator as a shift or “clunk” in the shoulder joint. Sometimes
this can be a very subtle sign. Generally, the normal contour of the
shoulder is restored and patients often report marked improvement
in their pain. A simple test to evaluate the success of the reduced
joint, especially in anterior and posterior dislocations, is to have the
patient touch their nose or contralateral shoulder with the hand of
the affected limb.3 The ability to do so usually signifies a relocated
shoulder joint. The patient should have a thorough examination
to evaluate the extremity for vascular and/or neurologic compro-
mise. Any compromise requires immediate consultation with an
Orthopedic Surgeon.
It is important to immobilize the shoulder to prevent fur-
ther external rotation or abduction of the reduced shoulder by
FIGURE 81-21. Reduction of an inferior shoulder dislocation. Axial traction the patient. Place the affected extremity in a shoulder immobi-
(straight arrows) is applied and maintained on the dislocated extremity while it is lizer (Figure 81-23A) or a conventional sling with a swath (Fig-
simultaneously hyperadducted (curved arrows). ure 81-23B).1,2,11,20,53,54 The shoulder should be immobilized in
FIGURE 81-23. Methods of shoulder immobilization after reduction of a dislocation. A. Shoulder immobilizer. B. Velpeau dressing. C. Spica cast. D. Immobilization in
external rotation.
external rotation in a spica cast if a successful reduction is unsta- for recurrence. Patients under 20 years of age should be immo-
ble3 (Figure 81-23C). Recent studies have shown that splinting bilized for 3 weeks and then begin active range-of-motion exer-
the shoulder with the arm adducted and in 10° to 20° of exter- cises. Patients aged 20 to 40 years should be immobilized for 1 to
nal rotation may prevent recurrent dislocations.106–109 Patients 2 weeks and begin active range-of-motion exercises 5 days postre-
should remain in this position for 3 weeks.106 A splint to hold duction. Patients older than 60 years of age should have minimal
the shoulder in external rotation can be made with splinting immobilization—less than 1 week—and begin active range-of-
material or a commercially available product may be purchased motion exercises within 72 hours postreduction to limit subse-
(Figure 81-23D).106–109 quent shoulder stiffness.2,11 Patients should be instructed to avoid
Postreduction films are indicated after immobilization to confirm external rotation and abduction activities, such as combing their
the reduction of the joint, to rule out missed fractures on the origi- hair, to avoid a recurrent dislocation.1
nal radiographs, to rule out a fracture from the reduction proce- Range-of-motion exercises should include dangling-arm rota-
dure, and to evaluate for displacement of fracture fragments. There tion.2,11 While supporting the torso with the other arm, the patient
is some evidence that postreduction radiographs may be unnec- makes a small circular motion with the injured arm against the force
essary, but further study is warranted before this can be routinely of gravity. For anterior dislocations, strengthening the subscapularis
recommended.13,14 muscle by doing internal rotation against a resistance band with the
Bedside ultrasound (US) can be used to verify the shoulder is elbow flexed 90° is advocated.2
reduced.104,105 A high frequency (7-13 MHz) US probe is preferred,
but a lower frequency probe can also be used if available. Place the
US probe transversely on the patient’s back just inferior to the lateral
COMPLICATIONS
aspect of the scapular spine to obtain a posterior US.104 It may be Complications of shoulder dislocations can occur as a result of the
more practical to obtain anterior or lateral US image in the supine initial injury, the reduction technique, or a combination of both.
patient.105 The advantages of bedside US over plain radiographs Complications are discussed with respect to both the initial injury
include time saving, lack of radiation, not waiting for procedural and the reduction. They include fractures, displacement of fracture
sedation to wear off before transporting the patient to the radiology fragments, rotator cuff tears, vascular injury, neurologic injury,
suite, US can be performed with the patient in any position, and it recurrence of dislocation, hemarthroses, and the inability to reduce
does not require patient cooperation. the shoulder.
AFTERCARE FRACTURES
Following procedural sedation, the patient will need to be observed Most fractures are caused during the dislocation and rarely
before being discharged home in the care of friends or family. during the reduction procedure if the proper techniques are
It is necessary to have the patient awake, alert, oriented, and to used.2,4,8,11,50 Prereduction radiographs will identify most frac-
have the pain adequately controlled before discharge. The patient tures. Postreduction radiographs are required to identify frac-
should be discharged with adequate pain control and follow-up tures initially missed or new ones associated with the reduction.
care by an Orthopedic Surgeon. Generally, oral nonsteroidal anti- Fractures of the humerus and coracoid process are rare and
inflammatory drugs are sufficient to control pain. Oral narcotics almost always associated with traumatic anterior shoulder dislo-
may be given as needed for 2 to 3 days to aid with pain during the cations.1,2,8 These fractures make closed reduction very difficult
acute inflammatory response period. Orthopedic follow-up should and should generally be treated under general anesthesia by an
be arranged within 24 hours for anterior shoulder dislocations Orthopedic Surgeon or by open reduction.
complicated by fractures or soft tissue injuries beyond ligamen- More common bony injuries include the Hill–Sachs deformity
tous strain. Orthopedic follow-up within 5 to 7 days is generally and the Bankart lesion, both caused during and from the disloca-
sufficient for uncomplicated anterior shoulder reductions. tion. The Hill–Sachs lesion occurs in up to 50% of shoulder dislo-
The duration of immobilization depends on the patient’s cations.1,2 More significant fractures can occur during reduction in
age.2,11,20 The only large-scale prospective study of first-time ante- rare situations in which the humeral head is dislocated anteriorly
rior shoulder dislocations followed patients over a 10 year period. with impaction on the glenoid rim.1,2,8,11 The Bankart lesion is more
It found that the duration of immobilization had no effect on commonly seen in recurrent dislocations and is associated with rup-
the incidence of recurrence. Age was the only prognostic factor ture of the joint capsule, but it spares the rotator cuff.1,2,8,11
DISPLACEMENT OF FRACTURE FRAGMENTS DISLOCATION RECURRENCE

Prereduction radiographs should be obtained on all traumatic The incidence of recurrence is variable, age-dependent, and gender-
shoulder dislocations. They will identify most fractures and any dependent.54,60,119,120 Among patients under the age of 20 years, 90%
associated displacement. Many of the reduction techniques use sig- will dislocate again, while only 14% of those over the age of 40 will
nificant force and may displace a fracture fragment. Postreduction redislocate.1 Recurrences are much more common in men, with
radiographs are required to evaluate for displacement of fracture a ratio of 4:1 to 6:1 as compared to women.11 Recurrent shoulder
fragments. The displacement of fracture fragments may make dislocations have other associated morbidities. A triad of lesions—
reduction difficult or impossible, in some cases necessitating opera- including a detached labrum and anterior capsule, a Hill–Sachs
tive reduction under general anesthesia. deformity, and erosion of the anterior glenoid—develops in 85% of
recurrent shoulder dislocations.4 The methods for reduction are not
ROTATOR CUFF TEARS different from those of a first-time shoulder dislocation. Patients
who have had multiple shoulder dislocations are generally easier to
Rotator cuff injury is most commonly seen in inferior dislocations reduce using nonanalgesic manipulation techniques. The orthope-
and in patients greater than 60 years of age.11,51,52 Overall, 38% dic literature suggests that three shoulder dislocations in a single
of shoulder dislocations will have associated rotator cuff tears at extremity indicate the need for surgical repair.11
the time of injury. This injury is not typically seen as a complica-
tion of the reduction technique.3,11 Rotator cuff tears generally do HEMARTHROSIS
not impede reduction, as they are often missed during the initial
evaluation. One study showed that 86% of shoulder dislocations Blood collections in the shoulder joint are rare complications and
had rotator cuff tears diagnosed by arthroscopy an average of are seen almost exclusively in traumatic shoulder dislocations asso-
7 months after the dislocation.1,4 Rotator cuff injuries complicate ciated with fractures. Typically, older patients (greater than 60 years
restoration of normal shoulder function and may require surgical of age) will return to the Emergency Department within 24 to
correction. 48 hours with a tense, swollen, painful shoulder. The shoulder joint
should be aspirated. Refer to Chapter 77 for the complete details
regarding shoulder arthrocentesis. Aspiration is usually sufficient to
VASCULAR INJURY
relieve pain and restore function.
Vascular injuries are seen in the arteries and veins of the shoulder
region in association with shoulder dislocations.1,8,11,50,55,56 An evalu- INABILITY TO REDUCE
ation for the signs of an axillary artery injury should be sought
before and after any reduction attempt. The most common vessel There are a few reasons for the inability to reduce a dislocated shoul-
injured, during both dislocation and forceful reduction, is the axil- der completely.121,122 The most common is inadequate medication
lary artery.110–112 Such an injury is usually seen in older patients who and sedation to overcome muscle spasm and pain. Occasionally, the
have brittle vessels that have lost some elasticity. Inferior disloca- humeral head may be “buttonholed” through the joint capsule.11
tions have the highest association with vascular injuries.11 The sec- A fracture fragment may be impinged or interposed between the
ond and third parts of the axillary artery are deep to the pectoralis humeral head and the glenoid cavity. Significant or complete dis-
major muscle and sustain the most damage.8 These injuries include ruption of ligamentous structures, as in an inferior or posterior dis-
a decreased radial pulse, an axillary mass, an axillary bruit, or lateral location, or soft tissue interposition will not allow the humeral head
chest wall bruising.1 An angiogram is indicated if a vascular injury to remain in the glenoid cavity.121 The inability to reduce a shoulder
is suspected. dislocation is an indication for reduction, open or closed, under
The subclavian vein is rarely injured. Direct injuries to venous general anesthesia in the Operating Room.
vessels are atypical. The most common injury is a venous throm-
bosis.113,114 Physical signs include extremity edema and occasionally SUMMARY
paresthesias. However, these signs are typically seen days after the
reduction. The diagnostic test of choice for venous evaluation is an Shoulder dislocations are common due to the inherent instability
ultrasound with Doppler study.8 of the glenohumeral joint. There are three different types of dis-
location, each of which has different mechanisms of injury and
incidences of associated injuries. The vast majority are anterior
NEUROLOGIC INJURY
shoulder dislocations. The diagnosis of a shoulder dislocation is
Neurologic injury is seen in 5% to 12% of all shoulder disloca- generally uncomplicated given the history and patient presentation.
tions.8,11,50,56–59 An evaluation for the signs of any neurologic The EP must be expeditious in reducing the dislocated joint once
injury should be sought before and after any reduction attempt. the patient is stabilized, other injuries have been ruled out, pain
Anterior shoulder dislocations with humeral fractures have a 45% control has been addressed, and radiographs have been obtained
incidence of nerve injury, with the axillary nerve being injured in to confirm the type of dislocation along with associated injuries.
up to 36% of cases.8 Older patients tend to be more prone to nerve Orthopedic Surgeons may need to be involved with the acute
injury from the dislocation and the reduction techniques.8 Of the care of a dislocated shoulder. They should be involved in the initial
techniques described, those that cause significant downward trac- reduction care of all posterior and inferior dislocations because of
tion typically cause more reduction-induced neurologic injuries. the rarity of these shoulder dislocations, the difficulty of reduction,
Fortunately, most neurologic injuries are neuropraxias and will the high incidence of associated injuries, and the need to operate to
completely resolve within 2 to 5 months.11,115–118 A small percent- repair the associated injuries.
age of axillary nerve injuries that do not resolve may require nerve Multiple closed reduction techniques are available. They have
grafting. Brachial plexus injuries are much more common in poste- similar success rates. The method chosen, as well as the decision to
rior and inferior shoulder dislocations. Because the brachial plexus use analgesia, is individualized to the EP and the patient. Certain
surrounds the axillary artery, injuries to the artery should raise the traditional techniques (e.g., Hippocratic and Kocher) have been
suspicion for a brachial plexus injury. demonstrated to have a higher incidence of complications and
CHAPTER 82: Elbow Joint Dislocation Reduction 549
should be avoided. Patients should be thoroughly evaluated before pulls a child up into a standing position by one arm. The annular
and after any closed reduction attempt for neurologic, vascular, soft ligament slips between the capitellum and the head of the radius,
tissue, or bony injury. The shoulder should be immobilized after it impeding supination of the arm. The patient will present with the
is reduced. arm held in slight flexion and pronation, usually in not much dis-
Patients should be instructed on proper aftercare and should be tress, and not using the affected arm. The simple reduction of this
provided with adequate oral analgesia. This can be accomplished dislocation is also addressed.
with nonsteroidal anti-inflammatory drugs supplemented with nar-
cotics. All patients discharged from the Emergency Department ANATOMY AND PATHOPHYSIOLOGY
should follow-up with an Orthopedic Surgeon within 24 hours to
5 days based on associated injuries and age. The elbow is a hinge joint comprising articulations between
the humerus, the ulna, and the radius (Figure 82-1). The distal
humerus consists of the extraarticular medial and lateral epicon-
dyles, which are diverging columns separated by the intraarticular
trochlea and capitellum. The trochlea articulates with the proximal
ulna. The articular surfaces of the trochlea extend from the coro-
Elbow Joint noid fossa anteriorly to the olecranon fossa posteriorly. The anterior
82 Dislocation Reduction and posterior fossae provide space for the coronoid and olecranon,
respectively, at the extremes of motion. The capitellum is a spherical
Angelique S. Kelly Campen structure that articulates with the concave radial head.
Numerous neurovascular structures cross the elbow (Fig-
ure 82-2). The prominent medial epicondyle protects the ulnar
INTRODUCTION
nerve, which travels in its posterior sulcus. The radial nerve travels
The elbow is inherently subjected to dislocations because of its just anterior to the lateral epicondyle. The median nerve travels with
mechanical structure.1 Elbow dislocations are one of the more com- the brachial artery through the antecubital fossa.
mon joint dislocations in the body, second only to dislocations of There are four ligamentous structures of importance in consider-
the shoulders and fingers.2 Injuries to the elbow have a high poten- ing injuries to the elbow: the radial collateral ligament, the ulnar
tial for complications and residual disability.3 Timely reduction is collateral ligament, the annular ligament, and the anterior capsule
imperative to relieve pain and reduce the possibility of neurovas- (Figure 82-3). The annular ligament and radial collateral ligament
cular sequelae.3 Closed reduction of the elbow is unlikely to be suc- hold the radial head in position. The annular ligament allows the
cessful if not performed promptly.4 radial head to rotate under it during pronation and supination.
The most common mechanism for a dislocation is a fall onto an The relationship of the radius and ulna to the humerus is used to
extended and abducted arm. The patient usually presents with a classify elbow dislocations into posterior, anterior, medial, lateral,
swollen and painful arm that is held in flexion. Elbow dislocations and divergent (Figure 82-4). The majority of elbow dislocations are
require a significant amount of force. Up to 20% of elbow disloca- posterior in direction.6 The other types of elbow dislocations are
tions are associated with fractures.2 Simple elbow dislocations have uncommon.6 The radius and ulna are held tightly together by the
a better prognosis and are less likely to require surgical intervention annular ligament and the interosseous membrane (Figure 82-3).
than complex ones (fracture-dislocations). This chapter deals with Posterior elbow dislocations result in the radius and ulna project-
the closed reduction of simple elbow dislocations. ing posterior to the humerus (Figures 82-4A & 82-5). The radius
One particular type of dislocation pertains primarily to the and ulna may be slightly lateral or medial in posterior elbow dis-
pediatric population. Subluxation of the radial head, often locations in addition to being posteriorly displaced. This does
referred to as a “nursemaid’s elbow,” occurs commonly in pre- not affect the management or prognosis. The presence of a frac-
school children. It is rarely seen after age 7 and represents 20% ture of the radial head or coronoid process may frequently ren-
of upper extremity injuries in children.5 It occurs after sudden der any attempt at reduction unstable and will usually require an
traction on the radius with an extended elbow, as when an adult open reduction.7 Anterior elbow dislocations occur from traction
A B C D
Humerus Olecranon Humerus
fossa
Coronoid fossa
Capitulum
Radius
Trochlea Olecranon
Radius Ulna
Radius
Ulna
FIGURE 82-1. Bony anatomy of the elbow region. The right arm is demonstrated in these illustrations. A. Anterior view. B. Posterior view. C. Posterior view of the elbow
in 90° of flexion. D. Lateral view of the elbow in 90° of flexion.
FIGURE 82-2. Major neurovascular structures that cross the elbow.
of the forearm with the elbow extended or a blow to the posterior

aspect of the flexed elbow. Anterior elbow dislocations result in the FIGURE 82-3. Major ligamentous structures of the elbow. A. Lateral view.
B. Medial view.
radius and ulna projecting anterior to the humerus (Figure 82-4B).
Medial (Figure 82-4C) and lateral (Figure 82-4D) dislocations are
rare injuries with poorer prognoses. Divergent dislocations (Fig-
ure 82-4E) are rare injuries that are distinct from the other types relationship of the humeral epicondyles to the tip of the olecranon.
of elbow dislocations because there is dissociation of the radius and The bony landmarks may be identified if the patient is seen imme-
ulna. The annular ligament and interosseous membrane must be diately after the injury. However, the swelling and hemarthrosis
torn for a divergent dislocation to occur. that develop over time make it difficult to palpate these landmarks.
The patient usually presents with pain and swelling of the elbow. Posterior dislocations are further apparent by a shortening of the
All elbow dislocations are characterized by loss of the normal forearm and the elbow being fixed in flexion.
FIGURE 82-4. Classification of elbow dislocations. A. Posterior.

B. Anterior. C. Lateral. D. Medial. E. Divergent.
CHAPTER 82: Elbow Joint Dislocation Reduction 551
between the distal humerus, radius, and ulna. The only case for
which a preprocedure radiograph is not indicated is when neu-
rologic or vascular compromise exists in the distal extremity and
an expeditious reduction is required.
Closed reduction of elbow dislocations requires adequate anal-
gesia and muscle relaxation. In most cases, procedural sedation is
useful. Regional anesthesia (axillary nerve or Bier blocks) is useful
if procedural sedation is contraindicated. Refer to Chapters 126 and
127 for details regarding regional anesthesia of the upper extremity.
General anesthesia with fluoroscopy is rarely necessary unless the
dislocation is associated with an undisplaced fracture of the radial
head or neck.
TECHNIQUES
FIGURE 82-5. Radiograph of a posterior elbow dislocation. POSTERIOR ELBOW DISLOCATION

REDUCTION TECHNIQUES
The goal of closed reduction is to distract the radius and ulna, allow-
ing them to relocate. The preferred technique that provides the
INDICATIONS least complications is a modification of the Stimson technique
used for shoulder dislocations.8 Place the patient prone with the
All elbow dislocations require reduction. Early reduction of a dis-
affected arm hanging off the gurney (Figure 82-6). Place padding
location, by open or closed means, is of paramount importance
anteriorly in front of the arm and shoulder so that the arm does
if good functional results are to be obtained. Closed reduction is
not drag along the side of the gurney. Care must be taken that the
unlikely to be successful if attempted later than 14 days after the
patient does not fall from the gurney. Tie a sheet circumferentially
injury.4 The more promptly the reduction is attempted, the more
around the patient’s hips and the gurney. Ensure that the patient
likely it is to be successful.
does not have any respiratory difficulty while in the prone posi-
The vascular status of the extremity also dictates the need for
tion. Suspend a weight from the patient’s wrist to apply traction
emergent relocation. Emergent and immediate relocation is nec-
to the arm (Figure 82-6). The weight should be approximately
essary when there is neurologic or vascular compromise of the
5 pounds and may go up to 15 pounds, depending on the patient’s
distal extremity. Relocation can await titration of sedation and
musculature and weight. Allow the arm to dangle over the edge of
analgesia when the extremity is neurovascularly intact.
CONTRAINDICATIONS
There are no absolute contraindications to the closed reduction of
an elbow dislocation. A relative contraindication to the procedure
is when there is uncertainty, before radiographic evaluation, if the
injury is a dislocation or a fracture. Closed reduction is not indi-
cated if there is an interposed osteochondral fragment preventing
concentric reduction or when there is a concomitant displaced frac-
ture of the radial head or neck. Elbows that have been dislocated for
a prolonged period of time may have closed reduction attempted
but will most likely require an open procedure.
EQUIPMENT
• Towel or sheet to aid in applying traction
• Splinting materials
• Weight (sandbag, bucket with water, or any other weight)
• Procedural sedation supplies (see Chapter 129)
PATIENT PREPARATION
Explain the risks, benefits, and potential complications to the patient
and/or their representative. The postprocedural care should also be
discussed. Obtain an informed consent for the reduction procedure.
Carefully assess and document the preprocedural neuro-
logic (median, radial, and ulnar nerves) and vascular (brachial,
radial, and ulnar arteries) status of the extremity. Splint and/or
sling the affected extremity until radiographs are obtained and a
closed reduction can be performed. Obtain anteroposterior and lat-
eral radiographs to confirm the diagnosis of an elbow dislocation. FIGURE 82-6. The modified Stimson technique for reducing posterior elbow dis-
Oblique views may be helpful to further define the relationship locations.
A B
FIGURE 82-7. The traction-countertraction technique to reduce a posterior elbow dislocation. A. The one-person technique. The physician stabilizes the humerus with one
hand and distracts the forearm with the other hand. B. The two-person technique. The assistant stabilizes the humerus and provides countertraction while the physician
applies traction to the forearm.
the gurney for 10 minutes. If the elbow dislocation will not reduce, Anterior elbow dislocations should be reduced by an Orthopedic
attempt the traction-countertraction technique. Surgeon for the same reasons as a medial or lateral elbow dislo-
The traction-countertraction technique can be performed but cation. The only exception to this is if there is neurologic and/or
is not the optimal approach. Place the patient’s arm in slight flex- vascular compromise of the distal extremity and no Orthopedic
ion. Grasp the patient’s midhumerus with the nondominant hand Surgeon is immediately available.
and the patient’s wrist with the dominant hand (Figure 82-7A).
Alternatively, an assistant can grasp the humerus while the physi-
cian uses both hands to grasp the patient’s wrist (Figure 82-7B). DIVERGENT ELBOW DISLOCATION
Stabilize the patient’s humerus. Apply steady and constant traction REDUCTION TECHNIQUE
to the patient’s wrist to distract the coronoid process and allow it to Fortunately, divergent dislocations are exceedingly rare. They are
slip past the humerus and back into anatomic position. The appli- commonly associated with severe articular damage, interosseous
cation of downward pressure on the proximal forearm can help to ligamentous tears, neurologic injuries, and vascular injuries. The
disengage the coronoid process from the olecranon fossa and ease reduction technique is complex; the elbow is reduced as a two-part
the reduction. dislocation and often requires surgical fixation to be stabilized.
Simple traction can be applied to relieve stress on the neurovascular
MEDIAL AND LATERAL ELBOW structures but will not reduce the dislocation due to the instability
DISLOCATION REDUCTION TECHNIQUE of the joint.
Divergent elbow dislocations should be reduced by an Orthopedic
Medial and lateral dislocations of the elbow are extraordinarily
Surgeon in the Operating Room. The only exception to this is if there
uncommon. They are usually associated with a posterior elbow
is neurologic and/or vascular compromise of the distal extremity
dislocation. These dislocations can be reduced in a similar manner
and no Orthopedic Surgeon is immediately available.
using the traction-countertraction technique for that of the poste-
rior elbow dislocation. For lateral dislocations, apply traction to the
patients wrist with one hand while using your other hand to guide RADIAL HEAD
the proximal ulna downward, then medially, and finally backward. SUBLUXATION REDUCTION
For medial dislocations, apply traction to the patients wrist with one
hand while using your other hand to guide the proximal ulna down- This condition is also referred to as a “nursemaid’s elbow.” Reduction
ward, then laterally. of a radial head subluxation is a maneuver involving supination and
Emergency Physicians should not reduce a medial or lateral elbow flexion of the affected forearm. The forearm is quickly supinated
dislocation. They are uncommon, may be associated with neuro- and the elbow flexed completely in one smooth motion. A pop or
vascular complications, have severe ligamentous tears, and should click is sometimes heard or felt by the Emergency Physician as the
be reduced by an Orthopedic Surgeon. The only exception to this subluxation is reduced. Most patients are asymptomatic within 5 to
is if there is neurologic and/or vascular compromise of the distal 10 minutes and 90% within 30 minutes.9 The Emergency Physician
extremity and no Orthopedic Surgeon is immediately available. should leave the room for 5 to 10 minutes after the procedure. Ask
the parents to distract the child to see if they begins to move the
ANTERIOR ELBOW DISLOCATION arm. A fearful child will often not use a successfully reduced arm
in fear of pain. Place an object (e.g., car keys, popsicle, toy, or other
REDUCTION TECHNIQUE
object the child may want) within grasp of the reduced extremity
Anterior elbow dislocations are uncommon. They are often associ- to encourage the child to use the extremity. Refer to Chapter 83
ated with intimal injuries to the brachial artery, from being stretched for the complete details regarding the reduction of a radial head
during the injury. subluxation.
CHAPTER 83: Radial Head Subluxation (“Nursemaid’s Elbow”) Reduction 553
ASSESSMENT
After a reduction, gently move the joint through the entire range
of motion to ensure smooth movement and proper joint reduction.
This also tests for joint stability and whether or not the joint will
easily re-dislocate. The joint may need to be repaired operatively
if it dislocates during this examination. The neurovascular sta-
tus of the extremity must again be evaluated and documented.
The integrity of the median, ulnar, and radial nerves as well as the
brachial artery and its distal branches must be evaluated and docu-
mented. All reductions except radial head subluxations should have
postprocedural radiographs to ensure proper bony alignment and
the lack of a fracture. If full and smooth passive range of motion is
not possible, which is especially common in children, postreduc-
tion radiographs should be examined for entrapment of the medial
epicondyle.
FIGURE 82-8. Postreduction radiograph demonstrating a fracture of the coronoid
AFTERCARE process.
Place the reduced extremity in a posterior long arm splint, from

the midhumerus to the base of the fingers, with the elbow in 90° of are commonly associated injuries and will usually come into near-
flexion. Do not apply a circumferential cast due to the subsequent normal opposition once reduction occurs (Figure 82-8). Large frag-
swelling and edema. Suspend the arm with a sling to aid in elevat- ments that are displaced may require operative fixation.
ing the extremity. The patient should be carefully observed for 12 to Late complications of elbow dislocations include posttraumatic
36 hours for vascular impairment. Instruct the patient to return to stiffness, posterolateral joint instability, ectopic ossification, and
the Emergency Department if they develop weakness, numbness, occult distal radioulnar joint disruption.15
paresthesias, cold fingers, or cyanotic fingers. The patient should
be admitted for observation if there is any question of neurovascu-
lar compromise. Gentle range-of-motion exercises can be started as SUMMARY
early as 3 to 5 days postreduction if the elbow is stable.10 Schedule Elbow dislocations are the second most common large joint disloca-
follow-up with an Orthopedic Surgeon 3 to 4 days postreduction tions that occur in adults. The majority of dislocations are posterior
to test for joint stability. Prescribe nonsteroidal anti-inflammatory elbow dislocations, although the radius and ulna can dislocate into
drugs supplemented with narcotic analgesics to control pain. just about any other position. Relocation involves distracting the
No immobilization is necessary for a radial head subluxation forearm while stabilizing the humerus and putting pressure counter
that is reduced. Immobilization in a sling with follow-up by an to the direction of the dislocation. It is not uncommon to have asso-
Orthopedic Surgeon is recommended only for recurrent radial head ciated fractures, so radiographic studies are imperative. The neu-
subluxations. rovascular status of the extremity must be carefully monitored and
documented both before and after any attempts at reduction. Splint
COMPLICATIONS the elbow in flexion postreduction. Follow-up with an Orthopedic
Surgeon and early range-of-motion exercises are recommended to
Several serious complications exist with elbow dislocations. The ensure proper joint function.
most serious and first to happen are ischemic complications.
Damage to and obstruction of the brachial artery can occur with
any of the elbow dislocations. Brachial artery injury occurs in 5% to
13% of patients with an elbow dislocation.11 It is a serious complica-
tion that can occur even without an associated fracture.11 The pres-
Radial Head Subluxation
ence of a distal pulse is not proof that there is no vascular injury.
Collateral circulation around the elbow can result in a distal pulse
despite a complete brachial artery laceration or occlusion.12 Signs of
83 (“Nursemaid’s Elbow”)
an arterial injury include: cyanosis, an expanding hematoma, pallor, Reduction
pulselessness, and severe pain. Any suspicion of a brachial artery
injury necessitates prompt angiography.12,13 Mark P. Kling and Eric F. Reichman
The second serious complication resulting from an elbow dislo-
cation is nerve injury from traction or entrapment. Loss of median INTRODUCTION
nerve function postreduction should prompt an immediate consul- Subluxation of the radial head is one of the most common pediatric
tation with an Orthopedic Surgeon. The ulnar nerve is most com- orthopedic injuries. This can occur in children whose age ranges
monly injured.14 It is seen in 8% to 20% of patients with posterior from less than 6 months to the preteens. The majority of radial head
elbow dislocations.14 subluxations occur between 1 and 3 years of age.1 It is a rare injury
Fractures commonly occur with elbow dislocations. Radiographs before 1 year of age and after 8 years of age.
should always be obtained before and after any attempt at reduc-
tion. The only exception to obtaining prereduction radiographs
is if the extremity has signs of distal neurovascular compromise
and obtaining radiographs will delay the reduction. A fractured Historically, the classic mechanism involves axial or longitudinal
coronoid process can sometimes become entrapped in the joint, traction on an extended elbow with the forearm pronated. This
requiring an open reduction. Fractures of the coronoid process often occurs while someone is holding onto the child by the hand
FIGURE 83-1. Anatomy of the elbow region. A. Normal anatomy. B. A radial head
subluxation. Note the entrapped annular ligament.
or wrist. While being held, the child is then pulled or the child falls
and is suspended by the arm. The subluxation is seen more often in
the left arm than the right. This is due to more people being right-
handed and holding the child’s left hand or wrist while walking. It is
not uncommon, however, for the child to present with a history of a
fall or rolling over in bed.1
This orthopedic injury involves the region of the elbow
(Figure 83-1). The annular ligament is a thick band that wraps
around the upper radial neck and radial head (Figure 83-1A). It
guides the radial head as the forearm moves through pronation and B
supination. The injury causes the radial head to become partially
dislocated from its articulation with the ulna and the capitellum of
the humerus while the forearm is in a pronated state. The annular
ligament then slips proximally and its lateral end becomes entrapped
between the radial head and the capitellum (Figure 83-1B). The
forearm becomes locked in pronation due to the entrapped annular
ligament. This condition is painless as long as the forearm is held
in pronation. Supination of the forearm causes pain, so the child
holds the extremity in pronation. The act of supination would also
spontaneously return the annular ligament to its anatomic position
and reduce the subluxation.
Children will present in no apparent distress.2 They are usually
resting comfortably and have some reservation in using the affected
extremity. The arm will be held with slight flexion of the elbow and
pronation of the forearm (Figure 83-2A). The child may point to
an area of pain, but this is not often the case. A child may be much
more comfortable with the parent examining and questioning areas C
of tenderness as opposed to the unknown and sometimes intimidat-
ing Emergency Physician.
FIGURE 83-2. A child with a radial head subluxation. A. The subluxed left forearm
Radiographs are not required unless other trauma or diagnoses
is held flexed, pronated, and adducted. B. Reduction technique. C. Postreduction.
are suspected. If radiographs are obtained, the child often returns
The forearm is freely mobile with normal extension and abduction.
from the radiology suite using the affected extremity. Radial head
subluxations often reduce spontaneously during positioning for
radiographs (Figure 83-2B).
appear normal and a repeat history and physical examination are
INDICATIONS consistent with the original diagnosis, a decision to repeat the
reduction should be considered.
Any child presenting with the inability to utilize the partially flexed
elbow, the forearm pronated and adducted, and a mechanism for CONTRAINDICATIONS
a radial head subluxation should be reduced. Many Emergency
Physicians may be hesitant to repeat the procedure multiple times if The presence of edema, ecchymoses, tenderness other than over
a child was not utilizing the arm normally within 15 to 30 minutes the radial head, suspicion of a fracture, or a mechanism of injury
after a clinically successful reduction. However, if the radiographs not consistent with a radial head subluxation should first be
CHAPTER 83: Radial Head Subluxation (“Nursemaid’s Elbow”) Reduction 555
evaluated radiographically.2,8 The presence of any distal neurologic If you feel the traditional click or feel satisfied with the attempted
or vascular compromise excludes the diagnosis of a radial head reduction, allow 5 to 15 minutes to pass and return for a repeat
subluxation. examination. Children may cry at the end of the procedure but will
generally only do so for a moment. As the child feels more comfort-
able, they will proceed to use the arm (Figure 83-2C). This freedom
EQUIPMENT of use can be accelerated by the caregiver or physician stimulating
No equipment is required for the reduction of a radial head the patient to use the arm with an incentive (e.g., by offering candy,
subluxation. a pen, or a popsicle for the child to grab).
■ HYPERPRONATION
PATIENT PREPARATION Position the patient as described above. There are two variations
on this technique. The first holds the child’s elbow at 90° of flex-
Explain the risks, benefits, potential complications, and aftercare of
ion and hyperpronates the forearm without any additional flexion
the procedure to the child and their representative. Obtain a signed
at the elbow (Figure 83-4).5 The second holds the child’s elbow at
consent to perform the reduction. Place the patient sitting in the
90° of flexion and hyperpronates the forearm while simultaneously
parent’s lap or supine on an examination table or gurney. No pre-
fully flexing the elbow (Figure 83-5).9 Both of these techniques can
medication is required.
successfully reduce a radial head subluxation. Some feel that hyper-
pronation causes less pain to the child than the supination tech-
TECHNIQUES nique.5,9–11 This is because the arm is already being held in pronation
and the additional pronation (hyperpronation) requires less force
■ SUPINATION AND FLEXION and motion than the supination technique.
Place one hand on the child’s elbow with the thumb over the radial
head (Figure 83-3A). This will aid in palpation of the traditional ASSESSMENT
“click” of reduction. Gently grasp the child’s wrist with the other The child should have uninhibited use of the forearm within 30 min-
hand (Figure 83-3A). Perform the following maneuvers in one utes. If not, reconsider the diagnosis. Alternative diagnoses include
smooth motion to reduce the subluxation. Apply distal traction clavicular fractures, distal humeral fractures, osteomyelitis, radial
while supinating the forearm (Figure 83-3B), followed by flexion head fractures, septic arthritis, and stress fractures. Reevaluate the
of the elbow (Figure 83-3C). A click may be felt as the radial head elbow joint for signs of trauma. Obtain plain radiographs if not done
is reduced.1,4 If not, flex the forearm until the hand is upright. Other previously. Full recovery may take 24 to 48 hours if the reduction is
methods of reduction are often compared to this method.3,5 delayed for more than 8 hours from the time of injury.
FIGURE 83-3. Reduction of a radial head subluxation using supination and flexion. A. Positioning of the physician’s hands. B. Distal traction is applied (straight arrow)
while supinating the forearm (curved arrow). C. The forearm is maximally flexed.
FIGURE 83-4. Reduction of a radial head subluxation using

hyperpronation. A. Positioning of the physician’s hands.
B. Hyperpronation of the forearm.
AFTERCARE Phone consultation with an Orthopedic Surgeon is recommended

if the reduction is unsuccessful. It is not unusual to have a sponta-
Radiographs, immobilization, splinting, analgesics, and orthopedic neous reduction on repeat examination and follow-up. Immobilize
follow-up are not necessary if the subluxation is reduced and the the arm until the child is evaluated by an Orthopedic Surgeon.
child is using their arm. Educate the caregiver regarding the mecha- Immobilization will aid in pain relief. Consider the use of nonste-
nism of injury and prevention of future subluxations.6,7 roidal anti-inflammatory drugs.
FIGURE 83-5. Reduction of a radial head subluxation using hyperpronation and flexion. A. Positioning of the physician’s hands. B. Hyperpronation of the forearm.
C. Flexion of the hyperpronated forearm.
CHAPTER 84: Metacarpophalangeal Joint Dislocation Reduction 557
COMPLICATIONS the proximal phalanx is displaced in a dorsal direction relative to

the metacarpal bone (Figure 84-1A). A volar MCP joint dislocation
There are no complications associated with the reduction of a radial describes a dislocation in which the proximal phalanx is displaced
head subluxation. in a volar direction relative to the metacarpal bone (Figure 84-1B).
SUMMARY
A radial head subluxation is one of the more common orthopedic
injuries of childhood. Children present with the inability to utilize ■ FUNCTIONAL ANATOMY
the affected upper extremity. They hold the forearm flexed, pro- The metacarpals are tubular bones structurally divided into a
nated, and adducted. The reduction technique is quick and simple. head, neck, shaft, and base. When viewed in the sagittal plane, the
It is important to educate the caregivers regarding the mechanism of metacarpal head has an increasing diameter beginning dorsally
injury and prevention of future subluxations. and extending along the articular surface to the volar side. When
viewed in the coronal plane, the metacarpal head is pear-shaped or
dumbbell-shaped, with the volar surface extending out of each side.
The metacarpal head is broader in volar orientation, which results
in increasing bony stability as the joint is flexed. The volar plate,
Metacarpophalangeal Joint collateral ligaments, dorsal capsule, deep transverse intermetacarpal
84 Dislocation Reduction ligament, extensor tendon, and intrinsic tendons provide additional
support and stability to the MCP joint.
Michael Bublewicz and Antonio E. Muñiz The MCP joints are resistant to ligamentous injury and dislocation
because of their inherent ligamentous structure, their surrounding
supporting structures, and their protected position at the base of
INTRODUCTION the fingers. The volar plate is a fibrocartilaginous structure that is
Hand injuries are among the most common injuries encountered attached firmly to the base of the proximal phalanx. It originates just
in the Emergency Department (ED). They are responsible for 5% proximal to the metacarpal head where it is thin and transparent.
to 10% of ED visits, with approximately 6% of these patients having This allows for hyperextension of the MCP joint yet makes it vulner-
significant injuries.1,2 Many hand injuries occur from sports-related able to injury during dorsal dislocations.
events or in the workplace. Data suggest that hand injuries account Side-to-side stability of the MCP joint is provided mainly by the
for 19% of lost-time injuries and 9% of workers’ compensation collateral and accessory collateral ligaments, and to some extent by
cases.3 Approximately 3 to 4 million working days are lost each year the lumbrical and the interossei muscles and tendons.8 The collateral
as a result of hand injuries.4 It is estimated that 10% of patients with ligaments originate from the mediolateral recesses in the metacar-
hand injuries require referral to a hand specialist.5 Proper motion pal head and travel to insert onto the base of the proximal phalanx.
and function of the hand are intimately related to normal anatomic The eccentric configuration of the metacarpal head and the rela-
alignment. The Emergency Physician (EP) must be skilled in the tively fixed length of the collateral ligaments cause it to tighten when
diagnosis and management of injuries about the hand. An improp- the joint is in flexion (Figure 84-2). This accounts for the limited
erly managed hand injury can result in significant disability that abduction and adduction of the MCP joint in flexion as compared to
the patient is reminded of on a daily basis and may include chronic the laxity in extension. The collateral ligaments of the MCP joint are
pain, decrease range of motion, stiffness, joint swelling, deformity, most vulnerable to injury from forces directed ulnarly and dorsally.
or early degenerative arthritis. The accessory collateral ligament spans from the true collateral liga-
Dislocations of the metacarpophalangeal (MCP) joint are rela- ment to the volar plate, providing additional joint stability in exten-
tively uncommon due to the protected location of this joint in the sion. The central extensor tendon and sagittal band augment the
hand.6 Injuries to the MCP joint of the thumb are more common thin dorsal capsule. The tendons of the palmar and dorsal interossei
than the other digits. Most of these injuries are to the collateral liga- add a small degree of dynamic stability.
ments rather than a true dorsal or volar dislocation.7 The spectrum The interphalangeal (IP) joints are hinges and motion only
of injury to the ligaments extends from a minor stretch or sprain to occurs as flexion and extension while the MCP joints are con-
a complete disruption. dyloid joints. The range of motion about the MCP joint includes
The deformity caused by a joint dislocation is classified by the 120° of flexion and 30° of hyperextension. It has up to 30° of addi-
position of the distal skeletal unit in relation to its proximal counter- tional mediolateral laxity and a small degree of rotational laxity
part. A dorsal MCP joint dislocation describes a dislocation in which to facilitate an efficient grasp.9 The clinical importance of these
FIGURE 84-1. Dislocations are classified by the position of

the distal skeletal unit in relation to its proximal counterpart.
A. Dorsal MCP joint dislocation. B. Volar MCP joint dislocation.
is seen on radiographs when the volar plate is interposed in the

joint. Complex MCP dislocations occur more frequently in the
index finger. They can be difficult to manage because reduction is
often blocked by the interposed soft tissue.13
The MCP joint of the thumb is very mobile. Dislocations of the
thumb MCP joint are more common than the MCP joints of the
fingers. The MCP joint can be dorsally dislocated by a hyperexten-
sion injury or shearing forces that ruptures the volar plate, joint
capsule, and at least part of the collateral ligament. The proximal
phalanx will come to rest in a position dorsal to the first meta-
carpal. Displacement of the proximal phalanx varies from a sub-
FIGURE 84-2. The shape of the metacarpal head is eccentric, making the collateral luxation to the complete dislocation. For the latter to occur, the
ligaments tighter in flexion (A) than in extension (B). volar plate and the collateral ligaments must completely tear. Volar
dislocations are rare and result from extensive tearing of the dorsal
capsule and the extensor pollicis brevis tendon, leaving the joint
differences is that to minimize the development of contrac- very unstable.14
tures after joint injuries. The preferred position of immobili- A simple MCP joint dislocation can be converted into a com-
zation of the IP joints is in extension, whereas the MCP joints plex one during prolonged or repeated reduction attempts, espe-
are immobilized in flexion. cially those in which axial traction is the primary component.2
The opposable thumb is an essential structure for countless This should not deter the EP from attempting a closed reduction for
activities. Despite its strong ligamentous and capsular support, the any MCP dislocation.
exposed positioning of the thumb makes it a frequent site of dislo-
cations and subluxations. The MCP joint of the thumb is similar to ■ RADIOGRAPHIC EVALUATION
those of the fingers but has a stronger volar plate and collateral liga- Radiographic evaluation of all hand injuries is relatively straight-
ments with less side-to-side mobility.2 The MCP joint of the thumb forward. It should include at least three views (i.e., anteroposte-
is also a condyloid joint with a quadrilateral rather than a spherical rior, oblique, and lateral) of the injured area. The most important
metacarpal head that allows mainly flexion and extension. However, radiographic error in evaluating joint injuries of the hand is fail-
it also permits some degree of abduction, adduction, and rotation. ing to get a true lateral view of the injured joint. This may result
There is a large variability among individuals in its range of flexion in missing a fracture or a loose body in the joint.2 Radiographic
and extension. examination will show an obvious dislocation in the lateral view.
The metacarpal head is bicondylar, with the radial condyle being Anteroposterior views may reveal widening of the joint space in
slightly larger. This structural difference provides the thumb proxi- complex dislocations. In addition, the sesamoid bones may be
mal phalanx with a modest degree of pronation during flexion. Its seen in the joint space, a pathognomonic sign for a complex MCP
range of motion consists of 15° to 20° of extension and 80° of flex- joint dislocation.
ion. However, the range of motion of the MCP joint of the thumb
is restricted, especially in lateral motion with only 10° of adduction INDICATIONS
and abduction.
All MCP joint dislocations should have an initial attempt at reduc-
■ PATTERNS OF INJURY tion in the ED unless they are unstable, chronic, open, or associated
with a fracture. This is true even if it is suspected to be a complex
MCP joint dislocations are considerably less common than dislo-
MCP joint dislocation.15 Reduction of the dislocation will provide
cations of the IP joints. Most MCP joint dislocations are dorsal.
significant pain relief. If a Hand Surgeon is not immediately avail-
These were first described by Kaplan in 1957.10 A volar MCP joint
able, an open MCP joint dislocation should be reduced after copious
dislocation is a rare finding.11 Dislocation of any of the MCP joints
irrigation with sterile saline to remove any dirt and debris.
is possible from hyperextension injuries. The dorsal dislocation
of the thumb MCP joint is the most common type of MCP joint
dislocation.
CONTRAINDICATIONS
Hyperextension of the MCP joint results in the rupture of Certain MCP joint dislocations require an immediate evaluation
the volar plate. Injuries are classified as simple (reducible with by a Hand Surgeon for open reduction and repair of any ligamen-
closed technique) or complex (irreducible with closed technique). tous or associated injuries. Closed reduction of an MCP joint dis-
Unless there is associated twisting of the finger, the collateral liga- location should not be performed in the ED for unstable, chronic,
ments remain intact. Clinical and radiographic features can be and open injuries or if it is associated with a fracture. Instability
used to differentiate simple from complex dislocations. In cases in a joint through active range of motion indicates complete and
of simple dislocations, the joint usually hyperextends to approxi- multiple ligament disruption requiring an open surgical repair.2,17
mately 90° and the volar plate is not interposed between the dis- Chronic injuries greater than 3 weeks old generally require surgi-
located bones.12 The deformity is obvious with the finger in a claw cal repair.16
position of extreme dorsiflexion at the MCP joint. In complex dis- If the closed reduction attempt is unsuccessful, repeated attempts
locations, the metacarpal and proximal phalanx usually lie more at reduction are contraindicated as a simple dislocation can be con-
parallel to each other, with the metacarpal head causing a dimple verted to a complex dislocation requiring an open surgical reduc-
on the volar skin and palpable underneath the skin. Clinical fea- tion. The ligaments, tendons, or sesamoid bones may become
tures that suggest a complex MCP dislocation include a proximal entrapped by bony and soft tissue structures in and around the
phalanx that is less acutely angulated than with a simple dislo- MCP joint and prevent the reduction. Complex dislocations usually
cation.2 The volar plate, sesamoids, flexor tendon, adductor ten- require open surgical reduction.15,18 Open MCP joint dislocations,
dons, extensor expansion, collateral ligaments, or capsule may whether reduced in the ED or not, will require operative manage-
become entrapped and prevent reduction.2 A widened joint space ment after initiation of antibiotics in the ED.
CHAPTER 84: Metacarpophalangeal Joint Dislocation Reduction 559
There are few contraindications to the use of local anesthesia

solutions.19 Relative contraindications include injection through
infected skin, history of coagulopathy from heparin or warfarin
therapy, factor deficiencies, liver dysfunction or bleeding disor-
der, or an allergy to the anesthetic medication. Another relative
contraindication includes preexisting neurovascular damage prior
to the procedure. Uncooperative patients can make the injection
procedure technically more difficult and dangerous to perform.
Procedural sedation should be considered for these patients and
children.
EQUIPMENT
• 18 gauge needle to draw up the local anesthetic solution
• 27 or 30 gauge needle, 2 in. long FIGURE 84-3. Reduction of a dorsal MCP joint dislocation. A. Dorsal dislocation
• 10 mL syringe of the MCP joint. B. The deformity is exaggerated by hyperextension of the MCP
• Alcohol swab joint as the proximal end of the proximal phalanx is pushed volarly and over the
metacarpal head while simultaneously flexing the IP joint to relax the flexor ten-
• Sterile gloves dons. C. The reduced MCP joint.
• Sterile drapes
• Equipment and supplies for procedural sedation (Chapter 129) to remember that applying simple traction alone as an initial
• Adhesive tape, ½ in. maneuver risks trapping the volar plate and transforming a sim-
• Webril padding ple dislocation into a complex dislocation.
Hyperextend the MCP joint while simultaneously pushing
• Casting material the proximal end of the proximal phalanx volarly and over the
• Ace bandage metacarpal head (Figure 83-3B). This maneuver diminishes the
• Scissors buttonhole effect on the metacarpal neck that is accentuated by
traction. Flex the MCP joint as the proximal phalanx returns to
position (Figure 84-3C). Simultaneously flexing the IP joint and
PATIENT PREPARATION wrist can help to relax the flexor tendons and make the reduction
Explain the risks, benefits, potential complications, and aftercare of easier. This maneuver can sometimes trap the displaced fibrocar-
the reduction to the patient and/or their representative. The patient tilaginous plate and carry it to its normal position anterior to the
must be aware that irreducible dislocations will require an open sur- metacarpal head.
gical reduction and possible repair of damaged structures within If the reduction is unsuccessful, repeated attempts to reduce
and surrounding the joint. Inform the patient that the injury can the dislocation are contraindicated. Consider open reduction to
result in joint swelling for weeks to months and possibly perma- disengage the metacarpal head from a probable buttonhole slit in
nent joint enlargement. Loss of motion with stiffness and residual the anterior capsule and from the surrounding muscles and ten-
soreness may last for months. Obtain an informed consent for the dons. Consult a Hand Surgeon for these MCP joint dislocations that
reduction procedure. An informed consent should also be obtained cannot be reduced after one attempt in the ED.
for procedural sedation (Chapter 129) and/or the intraarticular
injection (Chapter 77) if they are performed in addition to the ■ VOLAR MCP JOINT DISLOCATIONS
reduction procedure. Volar MCP joint dislocations (Figure 84-4A) are generally associ-
Clean the involved joint of any dirt or debris. Apply povidone ated with collateral ligament ruptures. They are commonly irreduc-
iodine or chlorhexidine solution and allow it to dry. Perform a wrist ible due to interposition of the extensor tendons and the dorsal joint
block (Chapter 126), the instillation of the local anesthetic solution capsule. Consultation with a Hand Surgeon is often required for
into the joint (Chapter 77), and/or procedural sedation and analge- operative reduction.
sia (Chapter 129). Volar MCP joint dislocations require minimal, if any, dis-
tally applied traction for reduction. It is important to remem-
TECHNIQUES ber that applying simple traction alone as an initial maneuver
risks trapping the volar plate and transforming a simple dis-
Early closed reduction may be easy provided that the thumb is location into a complex dislocation. Flex the MCP joint while
maintained in adduction, the fingers are flexed, and the wrist is simultaneously pushing the proximal end of the proximal pha-
flexed to relax the intrinsic hand muscles. The major obstruction lanx dorsally and over the metacarpal head (Figure 84-4B).
preventing reduction of the dislocated MCP joint is the displaced Extend the MCP joint as the proximal phalanx returns to posi-
volar fibrocartilaginous plate lying dorsal to the metacarpal head. tion (Figure 84-4C).
Approximately 50% of MCP joint dislocations can be reduced in the If the reduction is unsuccessful, repeated attempts to reduce
ED using the closed method. the dislocation are contraindicated. Consider open reduction to
disengage the metacarpal head from a probable buttonhole slit in
■ DORSAL MCP JOINT DISLOCATIONS the anterior capsule and from the surrounding muscles and ten-
Dorsal MCP joint dislocations (Figure 84-3A) require minimal, dons. Consult a Hand Surgeon for these MCP joint dislocations
if any, distally applied traction for reduction. It is important that cannot be reduced after one attempt in the ED.
flexion.2 Volar finger MCP joint dislocations require splinting in

extension for 1 to 3 weeks. The thumb should be immobilized in a
thumb spica splint in 20° of flexion for dorsal dislocations and in
extension for volar dislocations for 3 weeks. A proper program of
gradual active range-of-motion exercises should follow splinting.18
With adequate protection and splinting of uncomplicated disloca-
tions, athletes may return to activities within 1 to 2 weeks, sooner
for low-risk sports with minor injuries, and longer for more seri-
ous injuries requiring surgery.20
COMPLICATIONS
Allergic reactions can occur from hypersensitivity to the local anes-
thetic solution. Symptoms can range from mild pruritus and urti-
carial rash to circulatory collapse and even death. Severe allergic
reactions are extremely rare. Taking a thorough history might pre-
FIGURE 84-4. Reduction of a volar MCP joint dislocation. A. Volar dislocation of vent such a reaction. The preservative in the anesthetic is often the
the MCP joint. B. The deformity is flexed at the MCP joint as the proximal end of culprit. The possibility of injury to structures in the joint may occur
the proximal phalanx is pushed dorsally and over the metacarpal head. C. The from improper insertion of the needle or needle movement within
reduced MCP joint. the joint cavity. Infection of the joint can occur when the needle
penetrates unclean skin, infected skin, or infected subcutaneous tis-
sue. If proper aseptic technique is followed, the risk of infection is
negligible. Please refer to Chapters 77 and 123 regarding the com-
ASSESSMENT plete details of local anesthetic complications and joint injection
complications.
■ CLINICAL ASSESSMENT Complications of the reduction procedure are primarily related
Assess the collateral ligaments for stability. Because the goal of to failure of reduction, especially complex dislocations. Entrapment
treatment is to restore functional stability, it is essential to of ligaments, tendons, or sesamoid bones leads to an unsuccessful
perform a systematic evaluation of joint stability. An accurate reduction. A simple MCP joint dislocation can be converted into
assessment generally requires adequate pain control, even in the a complex one during prolonged or repeated reduction attempts,
most cooperative patients. Active stability is tested by allow- especially those in which axial traction is the primary component.2
ing the patient to move the joint through the normal range of Irreducible MCP joint dislocations require an immediate evaluation
motion. Completion of a full range without displacement indi- by a Hand Surgeon.
cates adequate joint stability. Passive stability is assessed by apply- Collateral ligament injuries occur infrequently and are often
ing gentle radial and ulnar stress to each collateral ligament and missed in the acute setting. The presence of an avulsion frac-
posteroanterior stress to assess volar plate integrity. Stress testing ture from the metacarpal head or corner fracture of the base
should be performed in extension and flexion to avoid the stabi- of the proximal phalanx suggests a collateral ligament injury.
lizing effect of the volar plate. Comparisons with the same joint of Consultation with a Hand Surgeon is recommended for patients
the uninvolved hand may assist in the diagnosis.2 Stability of the with a collateral ligament injury. Some surgeons prefer immediate
joint provides strong evidence that optimal functional recovery operative repair of these injuries. ED care involves immobilization
would result from short-term immobilization rather than surgical in a gutter splint, with the MCP joint in 45° to 50° of flexion, and
intervention. appropriate referral.
Joint stability of the thumb MCP joint is tested in full extension as Ulnar collateral ligament of the thumb rupture, also known as
well as in 30° of flexion. Complete ligament disruption is suspected gamekeeper’s or skier’s thumb, results from a laterally directed force
if the joint can be stressed in a radial direction 25° to 35° beyond a at the thumb MCP joint. The ligament is important to the grasping
similar stress to the patient’s opposite thumb MCP joint. This insta- function of the thumb. Early recognition of this injury is key. The
bility should be demonstrated in both full extension and 30° of flex- diagnosis is generally made through stress testing of the reduced
ion. Flexion at 30° lessens the stabilizing effects of the volar plate.2 MCP joint. Radiographs occasionally demonstrate an avulsion-type
The presence of ecchymosis suggests a complete ligament tear as fracture. Treatment of partial ligament tears requires splinting in a
well as a volar subluxation of the proximal phalanx.19 thumb spica for 6 weeks, while complete rupture requires operative
repair.
■ RADIOGRAPHIC ASSESSMENT Radial collateral ligament injuries of the MCP joint of the
Postreduction radiographs are essential to demonstrate adequate thumb are less common but equally debilitating. The usual mech-
reduction. Occasionally, a fracture is only visible on these views and anism is forced adduction with or without hyperextension. The
not on the prereduction films.1,20 Joint subluxation after reduction diagnosis is generally made through stress testing of the reduced
is associated with interposed soft-tissue or severe capsular injury. MCP joint. Radiographs occasionally demonstrate an avulsion-
type fracture. Treatment of partial ligament tears requires splint-
ing in a thumb spica for 6 weeks, while complete rupture requires
AFTERCARE operative repair.
Splinting of any MCP joint dislocation should provide adequate Degenerative arthritis may occur after multiple closed reductions
immobilization and protection. Splinting is maintained for at or an unrecognized chronic dislocation.21 Inadequate immobiliza-
least 1 week to no more than 3 weeks to prevent joint stiffness. tion or early return to high-stress activities may result in ligamen-
Simple dorsal finger MCP joint dislocation injuries generally tous laxity or recurrent instability. Excessive joint contractures
require splinting for 1 to 3 weeks with the joints in 45° to 50° of unresponsive to physical therapy may require surgical release.
CHAPTER 85: Interphalangeal Joint Dislocation Reduction 561
SUMMARY
Injuries to the MCP joints of the hand are occasionally encountered
in the ED. They may be associated with significant morbidity if not
properly managed. The most common dorsal MCP joint dislocation
seen is that of the thumb. Volar dislocations of the MCP joints are
rarely seen. A thorough understanding of the anatomy and func-
tion of the MCP joint is essential to diagnose and manage these Phalanx
injuries. A detailed physical assessment of the soft tissues, bones,
and neurovascular structures is essential to prevent occult injuries.
Radiographic evaluation is required for all potential injuries. This
should include anteroposterior, lateral, and obliques views in order
to not miss associated avulsion fractures or evidence of complex Collateral ligament
Volar plate
dislocations. All MCP joint dislocations should have an attempt at
reduction, except those that are unstable, chronic, open, or associ-
ated with a fracture. A Hand Surgeon should evaluate any unstable, FIGURE 85-1. A schematic drawing of the box complex surrounding the PIP joint.
chronic, open, or irreducible dislocation. MCP joint dislocations
reduced in the ED must be appropriately splinted and follow-up
arranged with a Hand Surgeon.
Interphalangeal Joint
85 Dislocation Reduction Central slip
Matt Kleinmaier and Sanjeev Malik
INTRODUCTION
Lateral band
Dislocation of the interphalangeal (IP) joints is one of the most (or slip)
common orthopedic injuries seen in the Emergency Department
(ED).1–3 Most of these injuries occur during athletic activities.
The proximal interphalangeal (PIP) joint is especially suscep-
tible to injury during ball-handling sports.2–4 An epidemiologic
study of injuries in the National Football League over a 10-year
period from 1996 to 2005 showed that PIP dislocations accounted
for 17% of all hand injuries, making it the second most common
hand injury in professional football.14 Among dislocations, IP joint
injuries are second only to shoulder dislocations in incidence.4 FIGURE 85-2. Dorsal view of the extensor mechanism.
While IP joint dislocations are generally easy to reduce, improp-
erly treated injuries can result in chronic pain, swelling, restricted
range of motion, deformity, and early degenerative arthritis.1,5,6
The Emergency Physician (EP) must be proficient in diagnosing
and treating IP joint dislocations.
ANATOMY AND PATHOPHYSIOLOGY Central slip

The bicondylar conformation of the PIP joint creates an inher-
ently stable hinge joint with movement restricted to flexion and
extension from 0° to 120°.1,7,8 Additional stability comes from the
complex of ligaments and tendons, which form a box around the Dorsal
joint (Figure 85-1). The elements of this complex include the volar
plate, lateral and collateral accessory ligaments, and the exten-
sor tendon dorsally. The volar plate’s dense, fibrous distal aspect
attaches firmly to the middle phalanx, while its more membranous Volar Lateral band
proximal portion is continuous with the synovial reflection. This Collateral plate (or slip)
conformation resists dorsal dislocation at the joint.4 The three Volar ligament
bands of the extensor tendon mechanism (the central slip with
a lateral band on each side) provide dorsal support which resists FIGURE 85-3. Lateral view demonstrating the anatomy of supporting structures.
joint dislocation (Figures 85-2 & 85-3). Lateral collateral liga- The volar plate and collateral ligaments form a box around three sides of the joint,
ments bridge the PIP on the radial and ulnar sides, stabilizing it while the extensor mechanism (consisting of central and lateral slips) lies along the
against lateral dislocation.3 dorsal aspect of the joint.
A B C D
FIGURE 85-4. Dislocations of the PIP joint. They are classified based on the rela-
tionship of the distal bone to the proximal bone. A. Dorsal or posterior disloca-
tion. B. Dorsal dislocation with an associated fracture. C. Volar, ventral, or anterior
dislocation. D. Lateral dislocation.
The less-commonly dislocated IP joints (finger DIP and thumb IP

joint) are similar in anatomy to one another. They are more broad-
based than the PIP and range from 0° in extension to 90° in flexion,
with no significant lateral or rotary movement.3 The distal phalanx
in both joints is firmly attached to the skin, accounting for the high
percentage of open dislocations involving these joints.
Dislocations of the PIP joint are the most common and may be
classified as dorsal, volar, and lateral (Figure 85-4).1,4 Each type of
dislocation results from a different mechanism of injury and has
specific associated complications.
Dorsal (or posterior) dislocations are the most common type of
PIP joint dislocation (Figures 85-4A). They usually result from
hyperextension injuries.4,7,8 A dorsal dislocation occurs when the
middle phalanx is displaced dorsally from the proximal phalanx.
These dislocations involve injury to the volar plate and may be
associated with an avulsion fracture of the base of the middle pha- FIGURE 85-6. Volar dislocation with an associated fracture of the middle phalanx.
lanx (Figures 85-4B & 85-5). Avulsion fractures involving greater
than 30% of the articular surface are considered unstable and
require immediate referral to an Orthopedic or Hand Surgeon.4
Volar (or anterior) PIP joint dislocations are far less common and
are more severe than dorsal PIP joint dislocations (Figures 85-4C & than other types of dislocation, often presenting as subtle sublux-
85-6). They occur from a simultaneous axial load and a rotational ation at the PIP joint with rotational deformity of the middle and
force on the IP joint. Volar PIP joint dislocations are associated with distal phalanx seen on plain films.9
rupture of the collateral ligament and disruption of the central slip If left untreated, volar PIP joint dislocations may result in a
of the extensor tendon mechanism. These injuries may preclude boutonniere deformity (Figure 85-7).1 This injury should be sus-
closed reduction.4 These injuries can be more difficult to diagnose pected in patients with pain over the PIP joint and the inability
to fully extend the digit against active resistance. Plain films are
usually unremarkable. Splinting in full extension with early fol-
low-up with an Orthopedic or Hand Surgeon is mandatory in all
suspected cases.
Lateral PIP joint dislocations are uncommon (Figure 85-4D).3
They result from a pure radial or ulnar force on the joint with
either partial or complete rupture of the collateral ligament. Ulnar
dislocation with radial collateral ligament injury is six times more
common than radial dislocation with ulnar collateral ligament
disruption.3 Lateral PIP joint dislocations are often reducible by
closed methods.
Distal IP joint dislocations and IP joint dislocations of the thumb
(Figure 85-8) are rare. They are often due to a direct blow to the
distal portion of the digit.7 They are most often dorsally dislocated
and frequently open due to the firm attachment of the distal phalanx
FIGURE 85-5. Lateral view of dorsal dislocation with a minor avulsion fracture to the subcutaneous tissue and skin. All open dislocations require
involving less than 30% of the articular surface. This is a stable fracture-dislocation. immediate orthopedic consultation.
CHAPTER 85: Interphalangeal Joint Dislocation Reduction 563
Central slip
disruption
Volar migration
of lateral bands
FIGURE 85-7. The boutonniere deformity.
IP joint dislocations of the toes are primarily dorsal. They occur

secondary to an axial compression load to the digit, such as kicking
a toe against a wall. IP joint dislocations of the toe are reduced simi-
larly to dorsal IP dislocations of the finger.
INDICATIONS
Most IP joint dislocations that present to the ED are amenable to
closed reduction by the EP. Factors to be considered include time
from injury, closed versus open dislocation, associated fracture pat-
terns, and direction of dislocation. The majority of IP joint disloca-
tions present within hours of the injury, and closed reduction may
be safely performed up to 3 weeks from the time of injury.6 If there
is no disruption of the skin overlying an IP joint dislocation, it is
considered a closed injury and suitable for closed reduction. Small
fractures involving less than 30% of the joint surface are considered
stable for closed reduction.3
The direction of the dislocation should also be considered prior
to any attempted reduction. Most dorsal dislocations are reduc-
ible by closed methods. Open reduction is occasionally necessary
due to interposition of the ruptured volar plate or trapping of the
proximal phalanx between the volar plate and flexor tendon.10
Lateral dislocations are almost always successfully managed by FIGURE 85-8. Dorsal dislocation of the thumb IP joint.
closed reduction.10
The management of volar dislocations is more controversial.
These injuries are often irreducible with closed methods due to trap-
ping of soft tissue in the joint space (usually the ruptured extensor disruption of multiple ligaments or tendons surrounding the joint
mechanism) or are unstable after reduction due to extensive damage and often require open reduction and repair due to interposition
to the supporting ligaments.10 A single attempt at closed reduction of disrupted soft tissues between the articular surfaces of the IP
may be performed. If successful, splint the finger in extension and joint.1,7,11,12
consult an Orthopedic or Hand Surgeon as open repair of the exten-
sor mechanism is usually required to prevent boutonniere defor- EQUIPMENT
mity.9,10 All irreducible injuries require emergent consultation with
an Orthopedic or Hand Surgeon. Digital Block
CONTRAINDICATIONS • 27 gauge needle, 2 in. long
Contraindications to closed reduction of IP joint dislocations • 5 mL syringe
include chronic dislocations, open dislocations, unstable disloca- • Alcohol swab
tions, or complex dislocations. A chronic dislocation is defined • Local anesthetic solution without epinephrine (1% lidocaine,
as an IP joint dislocation of longer than 3 weeks duration. These 0.25% or 0.5% bupivacaine)
injuries generally require open reduction and should not be
reduced in the ED.7 Careful inspection of the digit should be made Postreduction Splint
looking for any breaks in skin integrity. Any skin wound, espe- • Aluminum finger splint with foam padding
cially in the direction of the dislocation, mandates treatment as
• Gauze padding
an open dislocation by an Orthopedic or Hand Surgeon. Unstable
injuries are generally fracture-dislocations involving greater than • Adhesive tape, ½ in.
30% of the articular surface.3 Complex injuries involve complete • Scissors
PATIENT PREPARATION finger to an adjacent unaffected finger (“buddy taping”). Gauze

padding must be placed between the fingers before buddy taping
Explain the risks and benefits of the procedure to the patient and/ to prevent skin breakdown. During immobilization, it is important
or their representative. Obtain a written consent for the reduction to avoid hyperextension if the finger is buddy taped, as this may
procedure. Inform the patient that up to 30% of PIP and DIP joint lead to further injury of the volar plate. The presence of an avulsion
injuries may remain swollen for many months and will likely result fracture involving less than 30% of the articular surface does not
in permanent joint enlargement. Loss of motion and residual sore- alter this management plan.
ness may last several months.1,6 Rarely, a dorsal dislocation can be irreducible due to interposed
The use of local anesthesia is based on EP and patient prefer- soft tissue or impingement of the proximal phalangeal head between
ence. Many EPs and patients believe that the pain of reduction is the central slip and the lateral bands.9 This type of dislocation is
less than that of a digital block and more tolerable. For this reason, referred to as “complex.” Failure of two or three attempts at closed
many EPs will reduce an IP joint dislocation without the use of local reduction should raise the suspicion of an irreducible joint and an
anesthesia. Orthopedic or Hand Surgeon should be consulted.
Clean the finger of any dirt and debris. Apply povidone iodine
or chlorhexidine solution and allow it to dry. Insert a 27 gauge
needle into the lateral aspect of the base of the proximal phalanx. VOLAR DISLOCATION OF THE PIP JOINT
Inject 0.5 mL of local anesthetic solution. Redirect the needle dor- Volar dislocations of the PIP joint are almost always accompanied
sally while depositing 1 mL of local anesthetic solution. Withdraw by an injury to the central slip of the extensor tendon, causing
the needle and redirect it volarly while depositing 1 mL of local an inability to extend the PIP joint (Figure 85-7). These disloca-
anesthetic solution. Repeat the procedure on the medial aspect of tions are generally irreducible and need early consultation with
the base of the proximal phalanx. Refer to Chapter 126 for a more an Orthopedic or Hand Surgeon for operative repair due to the
detailed description of the methods to anesthetize a finger. extensive soft tissue damage. Although controversial, some authors
recommend a single attempt at closed reduction by applying a longi-
TECHNIQUES tudinal (distal) force, hyperextending the joint, and applying dorsal
pressure to the base of the middle phalanx. During this procedure,
the metacarpophalangeal and DIP joints should be flexed and the
DORSAL DISLOCATION OF THE PIP JOINT wrist extended to relax the anteriorly displaced lateral bands and
A dorsal dislocation of the PIP joint involves a partial or complete extensor mechanism. Splint the joint in extension and arrange for
disruption of the volar plate. Most dorsal dislocations of the PIP early follow-up with an Orthopedic or Hand Surgeon if closed
joint are easily reduced (Figure 85-9). Firmly grasp the middle pha- reduction is achieved. It is important to note that splinting in even
lanx of the affected finger with the dominant hand. Grasp the base mild flexion or “buddy taping” may lead to a boutonniere defor-
of the proximal phalanx with the nondominant hand. Hyperextend mity (Figure 85-7).
the PIP joint and apply longitudinal traction to separate the articu-
lar surfaces (Figure 85-9B). The nondominant hand is used to sta- LATERAL DISLOCATION OF THE PIP JOINT
bilize the proximal phalanx and apply countertraction. Flex the PIP
joint while maintaining traction and apply dorsal pressure on the Lateral dislocations of the PIP joint involve a partial or complete rup-
base of the middle phalanx (Figure 85-9C). This should restore the ture of the radial and ulnar collateral ligaments. There is a 6:1 ratio
proper alignment of the proximal and middle phalanx. of radial to ulnar collateral ligament tears with the digit being dis-
Immobilize the reduced PIP joint in 30° of flexion for approxi- placed in the opposite direction of the ligament rupture.3 Generally,
mately 3 weeks (Figure 85-9D). Alternatively, tape the injured reduction is easy and the joint is stable after the procedure. Recreate
FIGURE 85-9. Reduction technique for an IP joint dislocation.

A. Dorsal PIP joint dislocation. B. Exaggerate the deformity by C
hyperextending the middle phalanx and applying longitudinal
traction distal to the injury. C. Flex the PIP joint while applying
pressure to the dorsum of the middle phalanx with continued D 30°
traction. D. The PIP joint is placed in 30° of flexion for splinting.
CHAPTER 86: Hip Joint Dislocation Reduction 565
the injury and apply longitudinal (distal) traction to the finger. COMPLICATIONS
Bring (move) the distal phalanx in line with the proximal phalanx.
After reduction, determine by physical examination if the col- Most complications of IP joint dislocations are secondary to the
lateral ligaments are partially or completely torn. Buddy tape the injury itself rather than the reduction procedure. Even seemingly
finger to the adjacent finger for 3 weeks for incomplete collateral minor injuries can have complications such as prolonged swelling,
ligament tears. Early active motion of the finger is encouraged after pain, and stiffness. A thorough evaluation of the digit, prompt diag-
this time. Complete collateral ligament tears are repaired operatively nosis, and proper treatment will help minimize these complications.
and require early consultation by an Orthopedic or Hand Surgeon. Complications of the reduction procedure are primarily related
to failure of reduction.13 Entrapment of soft tissues should be sus-
INTERPHALANGEAL JOINT pected in cases with multiple failed attempts at reduction. Numerous
attempts at reduction may lead to trauma at the articular surface,
OF THE THUMB DISLOCATION predisposing to the development of premature degenerative arthri-
Dislocations of the IP joint of the thumb are rare. The injury is usu- tis. Irreducible or complex IP joint dislocations require an immedi-
ally dorsal and open. If the dislocation is closed, the joint can be ate evaluation by an Orthopedic or Hand Surgeon.
reduced in the same manner as PIP dislocations of the fingers.11 Prolonged or improper splinting of a joint can lead to chronic
Splint the reduced joint in slight flexion and arrange for early fol- complications. Extended splinting and immobilization can lead to
low-up by an Orthopedic or Hand Surgeon. permanent joint stiffness. In general, IP joints should not be immo-
bilized for greater than 3 weeks. Inappropriate splinting of a volar
DISTAL INTERPHALANGEAL JOINT DISLOCATION dislocation in even mild flexion may lead to long-term complica-
tions such as the boutonniere deformity.
DIP joint dislocations are rare, usually dorsal, and open. They are
easily reduced in a similar manner to other IP joint dislocations and SUMMARY
are generally stable after reduction.12 Reduction is accomplished by
application of longitudinal (distal) traction, hyperextension of the Injuries to the IP joints of the hand are commonly encountered in
distal phalanx, and the application of dorsal pressure on the base of the ED and may be associated with significant morbidity. The most
the distal phalanx. Immobilize only the DIP joint with a dorsal splint common injury encountered is a dorsal IP joint dislocation. Other
in 5° to 10° of flexion. Arrange for follow-up with an Orthopedic or dislocations include volar and lateral IP joint dislocations. A thor-
Hand Surgeon. ough understanding of the anatomy and function of the IP joint is
The DIP joint may be irreducible if there is an avulsion and essential to diagnose and treat these common injuries appropri-
entrapment of the volar plate in the joint, entrapment of the long ately. A detailed physical examination of the soft tissues, bones, and
flexor tendon in the joint, or entrapment of a bony fragment. neurovascular structures is necessary. Radiographic evaluation is
Immediate consultation with an Orthopedic or Hand Surgeon required for all potential injuries, including an anteroposterior and
should be sought if the DIP joint is irreducible. a lateral view of the affected digit. Acute stable dislocations can be
reduced immediately in the ED. An Orthopedic or Hand Surgeon
ASSESSMENT should evaluate any unstable, chronic, open, or complex dislocation.
Joints reduced in the ED must be splinted and appropriate follow-up
Fully evaluate the finger after the reduction or any reduction arranged.
attempt. Perform and document a complete neurologic and vas-
cular exam of the finger. An Orthopedic or Hand Surgeon should
be consulted immediately if any neurologic or vascular deficits
are identified. Obtain postreduction radiographs of the digit to
identify an avulsion injury or an incomplete reduction. Test the
joint for functional stability by having the patient actively move the Hip Joint Dislocation
injured finger through a full range of motion. Stability of the joint is
maintained if the collateral ligaments and volar plate are intact and
86 Reduction
no subluxation or dislocation occurs. Test the collateral ligaments George Chiampas and Steve Zahn
by applying radially and ulnarly directed stresses with the joint in
20° of flexion. Test the integrity of the volar plate by having the
INTRODUCTION
patient hyperextend the joint and comparing the range of motion
to that of the other fingers. The joint is considered stable if there is Hip dislocations are true orthopedic emergencies. The Emergency
no displacement during active range of motion and passive stress- Physician (EP) must be capable of reducing a dislocated hip.
ing of the joint. If stable, place the joint in an appropriate splint and Neurovascular damage to the hip and leg is a consequence of a hip
refer the patient to an Orthopedic or Hand Surgeon for follow-up. dislocation. Avascular necrosis (AVN) may occur in up to 20% of
Immediately consult an Orthopedic or Hand Surgeon if the joint is patients with a hip dislocation. Other studies show that AVN follow-
not easily reduced or if it is not stable after the reduction. All open ing a hip dislocation is a time-dependent phenomenon. The longer
dislocations require immediate evaluation by an Orthopedic or a hip is dislocated, the higher the incidence of avascular necrosis.
Hand Surgeon for irrigation, reduction, and closure. Dislocation of a hip for more than 6 hours almost universally results
in this devastating complication.
AFTERCARE The main etiologies of a hip dislocation are traumatic disloca-
tions of a normal hip, mechanical dislocations of a prosthetic hip,
Splinting of any finger injury should provide adequate immobili- spontaneous dislocations, and pathologic dislocations. Less impres-
zation and protection while allowing maximal range of motion of sive mechanisms may result in hip dislocations in the young and the
the unaffected joints. The method of splinting for each specific dis- elderly. A simple fall from standing may dislocate a geriatric hip.
location is described in the “Techniques” section for each type of Dislocations may occur with minor force in children, as during ath-
dislocation. letic activities.
Many techniques have been described to reduce dislocated CONTRAINDICATIONS

hips.1–7 The EP must be familiar with some of these methods and
how to apply them appropriately to optimize patient management Any life-threatening conditions must be treated before the hip is
and outcome. Dislocations of both normal and prosthetic hips are reduced. Closed reduction is contraindicated if a surgical indica-
seen in the Emergency Department. Dislocations of prosthetic tion for repair exists. Surgical exploration is required for hip dis-
hips are now more common than those of normal hips.8 While locations associated with femoral head fractures, femoral shaft
these are not associated with avascular necrosis, the pressure from fractures, or the finding of sciatic nerve dysfunction. Surgery is
the dislocated prosthetic head may result in other neurovascular also indicated for an irreducible dislocation, persistent instability
complications. of the joint after closed reduction, and for any postreduction neu-
rovascular deficits.

EQUIPMENT
Ball-and-socket joints are inherently stable. The strong muscles,
ligaments, and fibrous joint capsule of the hip reinforce this innate • Procedural sedation equipment and supplies (Chapter 129)
stability. Consequently, in the average adult, a great deal of force • Assistants
must be transmitted to dislocate the hip. This is significant, as the • Sheets
patient with a hip dislocation may have other life-threatening inju-
ries that take precedence over the management of the hip disloca-
tion. The mortality associated with a hip dislocation results from PATIENT PREPARATION
associated injuries of the head, thorax, or pelvis. The patient must be appropriately stabilized with prioritization
Hip dislocations are classified into anterior, posterior, and cen- of the ABCs (airway, breathing, and circulation). Life-threatening
tral based upon the relationship of the dislocated femoral head to associated injuries and comorbid conditions must be adequately
the acetabulum. Anterior hip dislocations occur with the leg in a addressed. Obtain plain radiographs to define the anatomic disloca-
neutral or abducted position. The femoral head is pushed anterior tion pattern, to rule out any associated fractures, and to guide relo-
to the coronal plane of the acetabulum. These patients present in cation attempts.
extreme pain with the hip and knee flexed 90°. The leg will be held Explain the risks, benefits, complications, and aftercare of the
in external rotation. A slight shortening of the leg may be noted, but reduction procedure and obtain an informed consent from the
this is difficult to detect with the knee in flexion. There are three patient and/or their representative. The patient must be sedated
subtypes of an anterior hip dislocation: anterior obturator, anterior to achieve optimal muscle relaxation and pain control. Perform
iliac, and anterior pubic. The femoral head displaces medially and procedural sedation after obtaining a separate informed consent for
lies in the obturator canal in anterior obturator dislocations. The this procedure.
femoral head moves superiorly and lies over the iliac wing in ante-
rior iliac dislocations. The femoral head moves inferiorly over the
pubic ramus in anterior pubic dislocations. TECHNIQUES
Posterior hip dislocations are the most common type. They Hip reduction techniques have been described with the patient in
account for nearly 90% of all hip dislocations. This is because the every imaginable position.1–9 The relative success rates for each
posterolateral half of the femoral neck lies outside the joint cap- technique have not been reliably reported.8 Therefore EPs typi-
sule and the weaker posterior support of the hip. Posterior disloca- cally use the technique(s) that was demonstrated to them dur-
tions result from force transmitted along the femoral shaft with the ing their residency training. The editor recommends using the
leg adducted. The most common mechanism of injury is a motor Allis maneuver as the treatment of choice for the reduction of
vehicle collision where the knees strike the dashboard and the posterior hip dislocations. The other techniques are described
femoral head is pushed posterior to the coronal plane of the ace- in the text primarily for historical information, to give the reader
tabulum. The presentation of a posterior dislocation is of a patient full information regarding procedures that have been used and
in extreme pain. The leg will be internally rotated with marked described for the reduction of this common problem, and as alter-
knee flexion and adduction of the thigh. The femoral head is rarely native techniques if the Allis maneuver is not successful in reduc-
visible but may be palpable in the buttock region. Posterior hip ing the hip.
dislocations are further categorized into posterior ischial and pos-
terior iliac sub-types. The femoral head is displaced inferiorly and
lies over the ischium in posterior ischial dislocations. The femoral ALLIS MANEUVER
head is displaced superiorly and lies over the iliac wing in poste- This is the most common hip reduction method (Figure 86-1A). It
rior iliac dislocations. was described by Allis in 1893.1 The technique has been improved
Central hip dislocations are the rarest form. The femoral head by the addition of procedural sedation. Place the patient supine and
remains on the same coronal plane as the acetabulum in central perform procedural sedation. Instruct an assistant to stabilize the
dislocations. However, it is displaced superiorly. Most central hip patients pelvis to the gurney by pressing down on the anterior supe-
dislocations are associated with acetabular fractures. rior iliac spines. It may be necessary for the assistant to use both
hands on the side of the pelvis associated with the hip dislocation
to stabilize the pelvis. Flex the affected knee and hip 90°. Grasp the
INDICATIONS
affected knee with both hands. Apply axial traction to the thigh with
All hip dislocations must be reduced. Emergent hip reduc- incrementally increasing force. Simultaneously rotate the femur lat-
tion by the EP is indicated when distal neurologic or vascu- erally and medially until the hip relocates.
lar deficits are present or if the Orthopedic Surgeon is not If relocation is not easily accomplished, instruct a second assistant
immediately available. The incidence of avascular necrosis is to apply lateral traction to the inner thigh of the affected proximal
time-dependent and necessitates reduction as soon as possible to femur (Figure 86-1B). Repeat the entire procedure with the addi-
limit this complication. tion of lateral traction to reduce the dislocation.
(1)
(1)
(2)
(2)
A B
FIGURE 86-1. The Allis maneuver. A. An assistant stabilizes the pelvis. The EP simultaneously distracts the femur (1) and rocks it medial to lateral (2, curved arrow).
B. The same maneuver with the addition of a second assistant to apply lateral traction to the thigh.
MODIFIED ALLIS MANEUVER breathing when placed prone. Associated injuries may preclude
prone positioning of the patient.
This technique incorporates all of the maneuvers described above. Place the affected leg hanging over the side of the gurney with
Additionally, place the hip in maximum adduction. Apply longitu- the knee and hip each flexed 90°. Alternatively, hang both legs off
dinal traction to the femur while an assistant presses down on the the distal edge of the gurney with the knees and hips flexed 90°
pelvis with one hand and pushes the head of the affected femur (Figure 86-2A). Instruct an assistant to hold the patient down on
toward the acetabulum with the other hand. the gurney by applying downward pressure on the posterior pelvis
at the posterior superior iliac spines.
Grasp the ankle in one hand to support the limb and to be
GRAVITY METHOD OF STIMSON
able to apply internal and external rotation to the extremity
Place the patient prone on the gurney. Perform procedural seda- (Figure 86-2A). Place the other hand on the proximal posterior
tion. Monitoring may be more difficult due to the prone position- calf. Exert gradual longitudinal traction on the femur by placing
ing. Extra attention must be paid to the patient’s airway and pressure on the affected calf until the hip is felt to pop into place.
(1)
(2) (1)
(2)
A B
FIGURE 86-2. The gravity method of Stimson. A. An assistant stabilizes the pelvis. The EP applies downward pressure on the calf (1, straight arrow) while applying subtle
and external rotation to the femur (2, curved arrow). B. An alternative method.
(1)
(3)
(2)
FIGURE 86-3. The Whistler (or Rochester, or Tulsa) technique.
Elevation of the EPs shoulder (1) while simultaneously flexing
the patient’s knee (2) moves the femoral head anteriorly and
around the acetabular rim. Externally rotating the patient’s leg
(3, curved arrow) by swinging the ankle laterally allows the
femoral head to reduce.
A subtle internal and external rotary motion may help to move the FULCRUM TECHNIQUE
femoral head over the acetabular rim. Care must be taken not to
compress the structures in the popliteal fossa with excessive pres- Lefkowitz described this technique in 1993 and Bergman described
sure behind the knee. it in 1994.6 The advantage of this technique is that leverage allows
A much greater degree of force can be applied to the hip if the greater reduction forces to be applied to the hip with less strength
EP, instead of generating traction with their arm, places a knee in and effort on the part of the EP (Figure 86-4). A steady and con-
the affected popliteal fossa (Figure 86-2B). Pull the affected ankle stant force can easily be applied that reduces the risk of fractures
upward while simultaneously exerting downward force on the calf and nerve injuries. This constant traction is superior to the sudden
to reduce the dislocation. jerks that are inevitable in some of the other reduction techniques.6
Place the patient supine and perform procedural sedation. Secure
the patient to the gurney with a sheet or use an assistant to stabilize
WHISTLER/ROCHESTER/TULSA TECHNIQUE
This technique was described at three separate sites (Figure 86-3).
Whistler Healthcare Center in Vancouver, Canada, described it
in 1997.10 The Orthopedic Associates of Rochester described it in
1999. Vosburgh described it in 1995 as the “Tulsa method.”11 It is
reported as being easier to implement than the other techniques
and appropriate for use in the Emergency Department.10,11 Another
advantage is that it can be performed without the aid of an assistant.
Pelvic stabilization is provided by a counterforce on the uninjured
knee. The force and counterforce occur through the same fulcrum
and are therefore exactly equivalent.9
Place the patient supine. Perform procedural sedation. Stand to
the side of the affected hip. Flex the unaffected knee 130°. Place
your elbow under the affected knee, allowing the leg to dangle
over your forearm. Reach to grasp the flexed unaffected knee with
the palm. Grasp the affected ankle with your other hand in order
to flex the knee and rotate the hip. The hold is now established
(Figure 86-3).
Elevate the affected knee by raising your shoulder and using your
arm as a lever (Figure 86-3(1)). Simultaneously apply a longitudi-
nal force by progressively flexing the patient’s knee over your arm
(Figure 86-3(2)). This applies traction to the femoral head, mov-
ing it anteriorly and around the acetabular rim. Once the acetabular
rim is cleared, externally rotate the leg to allow the femoral head to
reduce (Figure 86-3(3)). External rotation is achieved by swinging
the ankle laterally. A pop should be felt as the femoral head falls into
the acetabulum. Reduction can be verified by internal and external FIGURE 86-4. The fulcrum technique. The EP applies downward pressure on the
rotation of the hip. An assistant may occasionally be required to sta- patient’s ankle while simultaneously plantarflexing their foot to move the femoral
bilize the pelvis. head around the acetabular rim and reduce the hip.
the patient’s pelvis. Lower the bed, preferably to within 2 to 3 feet of BIGELOW MANEUVER
the floor. Stand on the side of the affected hip. Place one foot on the
edge of the bed at the level of the patient’s hip. A platform or foot- Bigelow described this technique in the literature in 1870 (Fig-
stool may be used to gain a mechanical advantage if the level of the ure 86-6). It was the first documented hip reduction technique.
bed is too high or you are too short. Perform procedural sedation. Place the patient supine with the
Flex the affected knee 90° over your knee (Figure 86-4). Grasp affected hip and knee flexed 90°. Hold the affected knee in the
and hold the affected ankle. Apply steady, gentle downward traction crook of your flexed elbow with the patient’s foot in the opposite
on the ankle to flex the knee while simultaneously plantarflexing hand (Figure 86-6A). Instruct an assistant to stabilize the pel-
your foot on the gurney. This will cause the knee to exert an upward vis by applying downward pressure to the anterior superior iliac
force on the patient’s knee, raising the femoral head around the edge spines. Lift your shoulder and arm supporting the patient’s knee
of the acetabulum and reducing the hip. It may be necessary to gen- to apply distal traction to the femur (Figure 86-6A). Externally
tly rotate the affected foot internally and externally if the hip does rotate and extend the hip while distracting the femur to reduce the
not reduce easily. hip (Figure 86-6B).
This is considered the “classic” reduction technique. Its disad-
SIMPLE LONGITUDINAL TRACTION vantages are that it requires great strength on the part of the EP to
reduce the hip. The force applied is often jerking and inconsistent.
This technique is similar to the reduction of a shoulder dislocation The aid of a strong assistant is required to stabilize the pelvis.
(Figure 86-5). Place the patient supine and perform procedural
sedation. Extend the affected lower extremity at the hip and knee. LATERAL REDUCTION TECHNIQUE
Wrap a sheet around the affected proximal thigh. Grasp the patient’s
ankle with both hands. Do not grasp the foot, as this can result This technique was described in 1986 by Skoff.8,12 It gives a
in secondary injury. Instruct an assistant to apply lateral traction mechanical advantage to the EP, as most of the force exerted is by
to the sheet and proximal thigh to move the femoral head over the the EPs own body weight (Figure 86-7). It also capitalizes on the
acetabular rim while simultaneously exerting longitudinal trac- principle of recreating the position of injury in order to exactly
tion to the leg by pulling on the patient’s ankle to reduce the hip reverse the forces of the injury to produce the reduction.
(Figure 86-5). Place the patient in the lateral decubitus position lying on the
The editor prefers to use a padded leather restraint around the unaffected extremity. Perform procedural sedation. Flex the
affected ankle. Wrap the two ties of the restraint around your hips affected hip 100° and allow it to gravitate to adduction. This posi-
and secure them with a knot. You can then slowly lean backward to tion recreates the typical position of the hip during the disloca-
allow your body weight to reduce the hip. This method is especially tion. Internally rotate the patients hip 45° while maintaining 45°
useful if you are small in stature or do not have significant upper of adduction to exaggerate the hip dislocation. Place a looped sheet
body strength. Do not wrap the ties around your waist, as this can around the patient’s hips and an assistant’s hips. Place a second
cause low back strain. looped sheet around the patient’s knee and your own hips. The
FIGURE 86-5. The simple longitudinal traction technique.

An assistant applies lateral traction to the thigh while the
EP simultaneously applies in-line traction to the leg.
FIGURE 86-6. The Bigelow maneuver. A. The EP applies

upward traction on the femur while an assistant stabilizes the
pelvis. B. The hip is externally rotated and extended while
the femur is distracted. B
use of sheets allows optimal leverage by using body weight as the require immediate evaluation by an Orthopedic Surgeon. Obtain
reduction force. Grasp the affected ankle to maintain the patient’s a postreduction radiograph to confirm the reduction and rule out
knee flexed 90°. Apply distal traction to the femur by slowly lean- any fractures missed on the initial radiographs or as a result of the
ing backward while the assistant simultaneously applies posteriorly reduction procedure. Monitor the patient until they recover from
directed countertraction to the femoral head. The assistant can use the procedural sedation. A computed tomography scan may help
their hands to apply a distally directed force to the femoral head to identify any acetabular or osteochondral fractures.
assist in the reduction.
AFTERCARE
ASSESSMENT All patients with a hip dislocation require an evaluation by an
The appropriate evaluation of any dislocation requires a thor- Orthopedic Surgeon. All native hip dislocations and most pros-
ough pre- and postreduction neurologic and vascular examina- thetic hip dislocations require hospitalization and traction after
tion of the distal extremity. Any neurologic or vascular deficits reduction.13
CHAPTER 87: Patellar Dislocation Reduction 571
FIGURE 86-7. The lateral reduction technique. The hip is flexed 100°, adducted 45°, and rotated internally 45°. The EP applies traction to the femur. The assistant applies
countertraction while simultaneously applying distally directed pressure on the femoral head with their hands.
COMPLICATIONS outcomes. The sooner a dislocated hip is reduced, the fewer the
potential complications.
The complications of a hip dislocation itself are fractures, avascular
necrosis of the femoral head, injury to the sciatic and femoral nerve,
and injury to the femoral artery. Posttraumatic arthritis, recurrent
dislocation, and myositis ossificans can also occur.13 Complications
may occur despite the most expedient treatment, and prosthetic hip
replacement may become necessary. Patellar Dislocation
The complication of avascular necrosis is time-dependent.
Reductions delayed over 6 hours are at an extreme risk for avas- 87 Reduction
cular necrosis. The risk of avascular necrosis increases as the time Mark P. Kling
of the dislocation increases. Reductions that apply steady, non-jerk-
ing force to the limb have a lower incidence of associated fractures
as well as fewer neurovascular complications. Multiple attempts
INTRODUCTION
at reduction are also associated with an increase risk of avascular Dislocation of the patella generally results from a traumatic event.1–9
necrosis. More than three attempts at closed reduction are associ- It is most commonly due to a direct blow to the flexed knee. It may
ated with an increase risk of avascular necrosis and should prompt also occur from a forceful quadriceps contraction while the femur
the EP to seek orthopedic consultation.14 is internally rotated on the tibia. Many patients may not notice the
Neurologic injury is one of the most common complications of dislocation as it may spontaneously reduce immediately after the
hip dislocations, even when successful closed reduction is achieved. injury. There are numerous theories as to the predisposition, if any,
Sciatic neurapraxia, from peroneal branch damage, occurs in up to to a patella dislocation.1,2 These include adolescents, females, flat
15% of adult traumatic dislocations though symptoms resolve in intercondylar groove, joint laxity, “knock-knees” or genu valgus,
60% to 70% of cases.15 Sciatic dysfunction may lead to an equinus large Q-angles, obesity, and vastus medialis muscle atrophy. This
deformity and will need immediate consultation with an Orthopedic condition is most commonly seen in adolescents and females.
Surgeon.15
SUMMARY
The knee consists of the patellofemoral and the tibiofemoral joints.
Multiple techniques exist to reduce hip dislocations. The EP The patellofemoral joint is a gliding joint. The patella is an oval-
should master one or two methods in order to provide essen- shaped sesamoid bone that develops in the tendon of the quadri-
tial care to these patients, limit complications, and enhance ceps muscle. It is suspended between the quadriceps superiorly and
Lateral Medial Superior the tibial tuberosity inferiorly. The patella articulates between the
femoral condyles. It is held in place by the vastus medialis muscle,
the medial retinaculum, the medial and lateral patellofemoral liga-
ments, and the patellotibial ligament.
The patella may dislocate in numerous directions (Figure 87-1).
Lateral dislocations are the most common type (Figure 87-2). The
patella usually dislocates laterally due to its asymmetrical shape and
the normal upward and lateral pull of the quadriceps muscle. The
patella may also dislocate superiorly, medially, and intraarticularly
in rare instances.3,4
The clinical determination of a lateral patellar dislocation is usu-
ally simple and quite obvious (Figure 87-3). The knee is held in
partial flexion. The patella can be seen and palpated on the lateral
surface of the knee. This may be accompanied by edema and/or
ecchymoses over the anterolateral knee.
Horizontal Intercondylar
Pain over the parapatellar ligaments may be the only clinical sign
in patients whose patellar dislocation has spontaneously reduced.
The physical examination usually reveals mild edema in the parapa-
tellar recesses. There is often laxity in the tendons and ligaments
surrounding the patella. A patellar apprehension test is generally
positive. The knee joint is usually stable.
The pathophysiology of this dislocation may include abnor-
malities secondary to malalignment, laxity, and hyper-elasticity
of the joint. Osteochondral fractures are common but seen only
on arthroscopy.1,2,5 Magnetic resonance imaging, bone scans, and
arthroscopy are considerations for further evaluation and diagnosis
of the patellofemoral joint by the Orthopedic Surgeon.
Prereduction radiographs should be obtained to document patel-
lar fractures or other bony abnormalities prior to the reduction.
These may be difficult to obtain if the patient has significant dis-
FIGURE 87-1. Types of patellar dislocations. comfort and may be delayed until after the reduction. Radiographs
may also be used to identify a foreign body if abrasions or lacera-
tions are present over the knee. The patella often reduces sponta-
neously in the radiology suite as the leg is extended to obtain the
radiographs.
Quadriceps Quadriceps
muscle muscle
Quadriceps Quadriceps
tendon tendon
Normal location Normal location

of patella of patella
Laterally
Patellar surface dislocated
of femur patella
Patellar Patellar
ligament ligament
Tibial
tuberosity Tibial
tuberosity
Tibia
Tibia
Fibula Fibula
A B
FIGURE 87-2. Anatomy of a lateral patellar dislocation. A. Anteroposterior view. B. Lateral view.
CHAPTER 87: Patellar Dislocation Reduction 573
FIGURE 87-3. The lateral patellar dislocation. The presentation is often clinically
dramatic. (Photograph courtesy of Dr. Robert R. Simon.)
B
INDICATIONS FIGURE 87-4. Reduction of a lateral patellar dislocation. A. Manipulation of the

knee begins with gradual extension. B. Medially directed pressure applied to the
Any medial or lateral patellar dislocation that does not reduce spon- patella when the knee is fully extended reduces the dislocation.
taneously should be reduced manually.
CONTRAINDICATIONS
anatomic position in the intercondylar fossa of the femur. The tech-
As with any traumatic injury, the evaluation and management of nique to reduce a medially dislocated patella is similar with the
the patient’s airway, breathing, circulation, and other significant exception of the application of a laterally directed force on the patella.
injuries take priority over the reduction of a patellar dislocation. Intraarticular and horizontal patellar dislocations are some-
There are a few relative contraindications to the reduction of a times reduced by closed manipulation, although most require open
patellar dislocation. An Orthopedic Surgeon should be consulted reduction. Superior patellar dislocations require operative reduc-
for the evaluation and reduction if the dislocation is superior, tion. These dislocations should not be reduced in the Emergency
horizontal, intercondylar, or associated with fractures of the distal Department. Patients with these types of patellar dislocations
femur or proximal tibia. The only exception to this is if there is require urgent consultation with an Orthopedic Surgeon and hos-
neurologic and/or vascular compromise of the distal extremity. pital admission for reduction.
This requires immediate reduction by the Emergency Physician if,
after phone consultation, the Orthopedic Surgeon is not immedi- AFTERCARE
ately available to perform the reduction.
Obtain a postreduction radiograph to rule out any osteochondral
EQUIPMENT fractures that were not diagnosed initially and to ensure position-
ing of the patella. Maintain the knee in extension by immobiliza-
No special equipment is required for the reduction of the dislocation with a long leg splint or knee immobilizer until follow-up for
tion. A knee immobilizer or splinting material (plaster, fiberglass, reevaluation. The Orthopedic Surgeon may elect to take a conser-
and prepackaged splints) should be available to temporarily splint vative approach with the leg in a long leg cast and the knee in full
the patella and knee after the reduction. extension for 6 weeks.6 Some Orthopedic Surgeons believe that all
first-time dislocations should be repaired surgically. Thus, phone
PATIENT PREPARATION consultation with an Orthopedic Surgeon is recommended before
Patient preparation is minimal in the case of a lateral or medial the patient is discharged home.
patellar dislocation. Explain the risks, benefits, complications, The general principles of orthopedic care can be applied. These
and aftercare to the patient and/of their representative. Obtain an include rest, ice, elevation, and nonsteroidal anti-inflammatory
informed consent prior to performing the procedure. Verbal con- drugs. Narcotic analgesics are not necessary or required in most
sent is usually sufficient, since the reduction of a patellar dislocation cases. The patient should follow up with an Orthopedic Surgeon
is relatively simple, with infrequent complications. Place the patient in 5 to 7 days. The patient will most likely need physical therapy.
supine on a gurney. No premedication or sedation is required for The instability and resultant tracking abnormalities will require
this procedure. strength, proprioceptive, and isometric rehabilitation.7 Patients who
are placed in splints or casts should use crutches and not bear weight
TECHNIQUES on the affected extremity. Crutches may be of use to those placed in
a knee immobilizer.
The technique for the reduction of a lateral patellar dislocation is
rather simple (Figure 87-4). Slightly flex the patient’s hip to release
COMPLICATIONS
the tension on the quadriceps muscles. Slowly and gently extend
the knee (Figure 87-4A). The patella may relocate spontaneously Patellar dislocations are subject to degenerative arthritis, osteochon-
by simply extending the knee. If it is still dislocated, apply gentle dral fractures (which may be difficult to diagnosis initially), and
and medially directed pressure to the lateral surface of the patella recurrent dislocations or subluxations. No complications are associ-
(Figure 87-4B). This will allow the patella to move into its normal ated with the reduction procedure.
SUMMARY Emergency Physician (EP) may be reasonable if the Orthopedic

Surgeon is not immediately available and/or if the injured extrem-
Patellar dislocations are common. The reduction of a lateral or ity shows signs of distal neurologic or vascular compromise.
medial patellar dislocation is a safe, simple, and gratifying proce- A careful examination of the distal extremity must be performed
dure. Education of the patient and follow-up with an Orthopedic and documented. It must include an assessment of the capillary
Surgeon is a requirement for successful rehabilitation. refill, the dorsalis pedis pulse, the posterior tibial pulse, peroneal
nerve function, and tibial nerve function.

Knee Joint Dislocation A knee dislocation is the displacement of the tibiofemoral articu-
88 Reduction lation (Figure 88-1). It involves the rupture of the anterior cru-
ciate ligament, the posterior cruciate ligament, the joint capsule,
Sharad Pandit and Zach Kassutto and/or the collateral ligaments of the knee. Anterior knee disloca-
tions are the most common type of knee dislocation. This injury is
defined as anterior displacement of the tibia relative to the femur
INTRODUCTION (Figure 88-1A). It results from an acute hyperextension injury to
Dislocations of the knee are rare. They are true orthopedic emergen- the knee joint that ruptures the anterior cruciate ligament com-
cies and have a significant association with soft tissue injuries and pletely, the posterior cruciate ligament partially, and the posterior
neurovascular compromise. A dislocated knee occurs most com- joint capsule. The distal femur is driven posterior to the proximal
monly after a major force is applied to the knee joint from motor tibia. The collateral ligaments usually remain intact. Tibial spine
vehicle trauma, pedestrian–vehicle collisions, bicycle collisions, or fractures, osteochondral fractures of the tibia or femur, and menis-
motorcycle collisions. The forces necessary to cause a dislocation of cal injuries are avulsion-type fractures resulting from the rupture
the knee joint often fracture the bones of the leg. of the anterior cruciate ligament. Distal femoral epiphyseal sep-
Complete dislocation of the knee joint results in a gross defor- aration, rather than complete dislocation, as a result of a hyper-
mity that is confirmed by plain radiographs. Reduction by the extension injury is more common in children.
FIGURE 88-1. The classification of knee dislocations. A. Anterior. B. Posterior. C. Lateral. D. Medial. E. Rotary.
CHAPTER 88: Knee Joint Dislocation Reduction 575
An anterior knee dislocation is associated with a popliteal artery INDICATIONS

injury in 30% to 40% of patients.1 The popliteal artery is at particu-
lar risk for injury because it is anchored proximally at the adduc- Any dislocation of the knee joint requires prompt reduction in order
tor hiatus and distally at the soleus arch. The collateral circulation to reestablish the normal anatomy of the knee joint. The reduction
around the knee joint is relatively poor. Therefore disruption of the should ideally be accomplished within 6 to 8 hours after the injury.
popliteal artery may result in distal ischemia and limb loss if the The incidence of limb loss is greater than 85% if the knee is dislo-
reduction is delayed. It is important to note that the presence of cated longer than 6 to 8 hours.5 Knee dislocations associated with
distal peripheral pulses and capillary refill does not preclude an distal neurologic or vascular insufficiency require immediate
arterial injury. and emergent reduction.
The peroneal nerve is tethered as it winds around the fibular
neck. With knee dislocations, the peroneal nerve is at risk. Peroneal CONTRAINDICATIONS
nerve injury may occur in up to 23% of patients with knee disloca-
tions. Nearly one-half of the patients with peroneal nerve injuries There are no absolute contraindications to the reduction of a dis-
have a permanent deficit.10 located knee joint. Reduction of the knee joint may be performed
A posterior knee dislocation is defined as the posterior displace- intraoperatively if the patient requires surgery for other reasons. An
ment of the tibia relative to the femur (Figure 88-1B). It occurs Orthopedic Surgeon should reduce the knee if it is dislocated medi-
less commonly than an anterior knee dislocation. It results from a ally, laterally, or rotatorily; if it is associated with fractures of the
direct force applied to the anterior tibia with the knee slightly flexed, extremity; or if the joint is open. Emergent reduction by the EP is
which ruptures the posterior joint capsule and both cruciate liga- indicated if the Orthopedic Surgeon is not immediately avail-
ments. The collateral ligaments usually remain intact. It is associ- able and/or if there is evidence of distal neurologic or vascular
ated with popliteal artery damage and disruption of the extensor compromise.
mechanism of the knee joint.
A posterolateral knee dislocation is a rare type of knee disloca- EQUIPMENT
tion that is associated with peroneal nerve injury in up to 35% of
patients.2–4 These patients must be examined for peroneal nerve • Procedural sedation equipment and supplies (Chapter 129)
dysfunction (i.e., anesthesia or paresthesia on the lateral aspect of • Assistants
the leg and impaired dorsiflexion of the foot). • Compressive cotton wrap (Webril)
Medial, lateral, and rotary dislocations of the knee joint are
• Splinting material
less common than anterior or posterior knee dislocations (Fig-
ures 88-1C, D, & E). Medial knee dislocations result from an adduc- • Elastic bandage
tion force on the tibia that ruptures the lateral collateral ligament,
the posterior joint capsule, and both cruciates. Damage to the pero- PATIENT PREPARATION
neal nerve is common, while injury to the popliteal artery is not.
Lateral knee dislocations result from an abduction force on the tibia Explain the risks, benefits, and potential complications of the pro-
that ruptures the medial collateral ligament, the posteromedial joint cedure to the patient and/or their representative. The necessary
capsule, and both cruciates. Neurovascular injuries are uncommon postprocedural care should also be discussed. Obtain an informed
with a lateral knee dislocation. consent for the reduction procedure as well as for the procedural
Rotary dislocations are subdivided into posterolateral and pos- sedation. Place the patient supine on a gurney. Apply procedural
teromedial types. Posterolateral rotary dislocations result from sedation. The key to performing this procedure is to have the
an anteromedial force on the tibia that ruptures the posterior and patient adequately sedated and their muscles relaxed.
medial joint capsule, partially avulses the gastrocnemius, damages
the menisci, and has an associated chondral fracture. Posteromedial TECHNIQUES
rotary dislocations result from an anterolateral force on the tibia that
ruptures both cruciates, the medial collateral ligament, the postero-
medial joint capsule, partially avulses the gastrocnemius, damages
ANTERIOR KNEE DISLOCATION REDUCTION
the menisci, and has an associated chondral fracture. Both of these Reduction of an anterior knee dislocation is usually performed
rotary dislocations are associated with peroneal nerve and popliteal without difficulty using a modified traction-countertraction
artery injuries. technique (Figure 88-2). Instruct an assistant to grasp the tibia
Medial, lateral, and rotary dislocations of the knee are and apply in-line traction while a second assistant grasps the
uncommon injuries that should be managed by an Orthopedic thigh and applies countertraction. It is extremely important to
Surgeon. The reduction technique for these dislocations is quite avoid putting pressure over the popliteal fossa as this could
similar to that for the reduction of anterior or posterior knee injure the structures traversing that space. The EP then pushes
dislocations. the proximal tibia posteriorly (Figure 88-2(1)) while the distal
Although the presentation of a knee dislocation is usually clini- femur is simultaneously lifted anteriorly into anatomic position
cally obvious, it can also occur with a spontaneous reduction. This (Figure 88-2(2)). Do not allow the knee to become hyperex-
type of injury is classified as an occult dislocation and can be eas- tended during the reduction as this may further injure neuro-
ily missed if the patient is not thoroughly examined. vascular structures.
Anteroposterior and lateral radiographs of the knee will con- Some EPs feel that the reduction procedure may be easier to
firm the diagnosis of a knee dislocation. Postreduction films in two perform if the patient is in the prone position. Performing the pro-
planes will detect any occult fractures of the tibial spine, the distal cedure in the prone position is quite cumbersome, it is a difficult
femoral physis, or the proximal tibial physis. Obtain postreduc- position to attain if other injuries are present, and it makes moni-
tion stress views if damage to the collateral ligaments is suspected. toring patients undergoing procedural sedation difficult. Therefore
Radiographs of the pelvis and hip should also be considered to rule placing the patient in the prone position is not recommended.
out any associated injuries.
FIGURE 88-2. Reduction of an anterior knee dislocation.

An assistant applies inline traction to the tibia while a sec-
ond assistant applies countertraction to the femur. The
proximal tibia is pushed posteriorly (1) while the distal
femur is pulled anteriorly (2) to reduce the dislocation.
POSTERIOR KNEE DISLOCATION REDUCTION require immediate angiography and operative intervention.
Obtain postreduction radiographs to confirm proper anatomic
Reduction of a posterior knee dislocation is similar to that of an reduction, to rule out any fractures not evident on the prereduc-
anterior knee dislocation. The two assistants provide in-line traction radiographs, and to rule out the displacement of any fracture
tion and countertraction while the EP grasps the proximal tibia and fragments. Stress radiographs are recommended if injury to the col-
pulls it anteriorly into anatomic position (Figure 88-3). lateral ligaments is suspected.
MEDIAL KNEE DISLOCATION REDUCTION AFTERCARE

Reduction of a medial knee dislocation is similar to that of the ante- The postprocedural care of the knee joint is as important as the ini-
rior knee dislocation. The two assistants provide in-line traction tial reduction. Immobilize the extremity in a posterior long leg splint
and countertraction while the EP grasps the proximal tibia and pulls with the knee in 15° of flexion. Administer intravenous and/or oral
it laterally into anatomic position. analgesics as necessary to control the patient’s pain. All patients
require admission to the hospital for observation and monitoring
LATERAL KNEE DISLOCATION REDUCTION of the distal neurovascular status of the extremity. Arteriography
Reduction of a lateral knee dislocation is similar to that of the ante- should be obtained to exclude injury to the popliteal artery, espe-
rior knee dislocation. The two assistants provide in-line traction cially if there is any irregularity in the dorsalis pedis or posterior
and countertraction while the EP grasps the proximal tibia and pulls tibial pulse before or after the reduction. Arteriography may not be
it medially into anatomic position. necessary if the distal pulses are normal before and after the reduc-
tion; however, the vascular status should be closely monitored for
48 to 72 hours after the reduction.6
ROTARY KNEE DISLOCATION REDUCTION The mandatory use of arteriography to evaluate vascular injuries
Reduction of a posteromedial knee dislocation is similar to that of in patients with a normal postreduction physical examination may
the anterior knee dislocation. The two assistants provide in-line not be necessary.13,14 These select patients who have a normal physi-
traction and countertraction while the EP grasps the proximal tibia cal examination and a normal ankle brachial index may not require
and simultaneously externally rotates and lifts it upward into ana- angiography and its associated complications. This is a decision that
tomic position. must be made in consultation with the Orthopedic Surgeon who
Reduction of a posterolateral knee dislocation should be per- will be managing the patient.
formed in the Operating Room. These dislocations are irreducible An inpatient magnetic resonance imaging (MRI) scan of the knee
using closed reduction techniques. The medial femoral condyle joint should be obtained to evaluate ligamentous injury. The patient
evaginates through the medial joint capsule in a process known may require reconstructive surgery on the knee joint. This is espe-
as “buttonholing.” This dislocation requires open reduction under cially true if they are young, physically active, and well motivated to
general anesthesia. cooperate with rehabilitation therapy.7
Immediately evaluate and document the neurologic and vascular Knee dislocations are true orthopedic emergencies because of
status of the distal extremity after any attempts at reduction. Any the potential for associated vascular and neurological injuries.
diminished or absent sensation, motor deficits, and/or pulses Complications are primarily related to injuries of the neurovascular
FIGURE 88-3. Reduction of a posterior knee disloca-

tion. An assistant applies inline traction to the tibia while
a second assistant applies countertraction to the femur.
The proximal tibia is pulled anteriorly to reduce the dis-
location.
CHAPTER 89: Ankle Joint Dislocation Reduction 577
structures crossing the popliteal fossa. These include popliteal arte- traction-countertraction.1 Postreduction management invariably
rial injury and peroneal nerve injury, as well as knee instability, knee involves leg immobilization and consultation with an Orthopedic
arthrosis, knee stiffness, and chronic pain.11,12 Surgeon. Some closed ankle dislocations may be managed nonop-
Anterior knee dislocations have a high incidence (up to 40%) of eratively with good long-term results from a closed reduction and
associated vascular injuries usually involving the popliteal artery, casting for 6 to 9 weeks.2–5
and of these, up to one-half can result in amputation of the leg.8
Nerve damage has been reported in the literature to occur in 20% to
40% of knee dislocations.9 These injuries and any associated frac- ANATOMY AND PATHOPHYSIOLOGY
tures should not be missed. Pressure to the popliteal fossa dur- The ankle joint is composed of the talus, tibia, and fibula. The infe-
ing the reduction and hyperextension of the knee postreduction rior articular surface of the tibia is concave in both the coronal
must be avoided to prevent iatrogenic neurovascular damage. and sagittal planes. The articular surface of the talus is broader
Injuries to neurologic and vascular structures can occur during the anteriorly and longer on its medial and lateral aspects.6 The ankle
reduction. These include lacerations, traction injuries, and nerve mortise limits rotation of the talus, making the ankle joint inher-
or vascular entrapment between the tibial plateau and the femoral ently stable.
condyles. There are three groups of ligaments that provide added stabil-
Irreducible dislocations may be secondary to interposed soft tis- ity to the ankle joint. It is stabilized laterally by the anterior talo-
sue, ligamentous instability, buttonhole tears in the medial joint fibular, the calcaneofibular, and the posterior talofibular ligaments
capsule, or entrapment of the medial femoral condyle. These (Figure 89-1). It is stabilized medially by the deltoid ligament, which
patients require operative reduction under general anesthesia by an comprises a group of four adjoining ligaments: the anterior and pos-
Orthopedic Surgeon. terior tibiotalar, the tibionavicular, and the tibiocalcaneal ligaments
(Figure 89-2). The third group of ligaments stabilizes the tibia to
SUMMARY the fibula and forms the tibiofibular syndesmosis. This includes the
anterior and posterior tibiofibular ligaments.
Knee dislocations occur after significant trauma to the knee joint. Almost all ankle dislocations are associated with ligamentous
Fortunately, knee dislocations are rare events. They are associated ruptures, either partial or complete (Figure 89-3). They are often
with significant morbidity and require prompt reduction to restore associated with malleolar and distal fibula fractures. While poste-
the normal alignment of the bony structures. Arteriography to rule rior or posteromedial ankle dislocations are the most commonly
out damage to the popliteal artery and an MRI scan to rule out soft described dislocations of the ankle joint4,7 (Figures 89-3A & 89-4).
tissue injuries should be performed after the knee joint has been The most common ankle dislocations seen by the editor are lateral
reduced and adequately splinted. All patients require admission for ankle fracture-dislocations (Figure 89-3B). Posterior ankle dis-
observation and eventual reconstructive surgery. Frequent neuro- locations are associated with posterior marginal fractures of the
vascular evaluation is extremely important during the hospitaliza- tibia. An anterior ankle dislocation is rare and usually associated
tion. Evidence of distal leg ischemia requires immediate surgical with a fracture of the anterior margin of the tibia (Figure 89-3C).
exploration. The talus may also dislocate laterally or medially if the tibiofibu-
lar ligaments are disrupted or a fracture of one or both malleoli
occurs. The medial and lateral ligamentous complexes are usu-
ally stronger than the malleoli. This results in one or both mal-
leoli fracturing, rather than the ligaments tearing, with a lateral
fracture-dislocation.8
Ankle Joint Dislocation Due to the low incidence of reported ankle dislocations with-
89 Reduction out fractures, data on the mechanism of injury are incomplete.9
A posteromedial ankle dislocation occurs when a force is applied
Jim Comes against the posterior distal tibia with the foot plantarflexed.
Anterior ankle dislocations occur from a forcible dorsiflexion of
the foot (e.g., fall on the heel with the foot dorsiflexed) or from
INTRODUCTION
a force applied to the distal anterior tibia while the foot is fixed.
The foot and the ankle are the most frequently injured parts of Injury to the tibiofibular joint is variable, and the fibula may be
the body. Fractures of the ankle associated with dislocations of dislocated posteriorly or anteriorly. Diastasis of the tibiofibular
the ankle joint (fracture-dislocations) are serious injuries that syndesmosis is uncommon. Lateral ankle dislocations are always
can lead to long-term morbidity. They occur most commonly in associated with fractures of the malleoli. They occur from a force
young people who participate in sports, in those suffering from on the distal fibula with the foot fixed to the ground. Superior
falls, or in those involved in motor vehicle collisions. The ankle ankle dislocations are uncommon (Figure 89-3D). They occur
mortise and surrounding ligaments make the ankle joint strong when a force from above is driven through the leg and to the
and stable. As a result, isolated ankle dislocations are uncom- ankle (e.g., a fall from a height).
mon. Ankle dislocations are usually associated with malleolar Physical examination often reveals the type of ankle dislocation.
fractures or a fracture of the tip of the tibia. They are open 25% Prominence of the talus and a change in the length of the foot are
of the time. While there are limited data on the mechanism of common. Neurovascular injury is uncommon, although there is a
injury, most ankle dislocations lead to posterior or posterome- higher incidence of this with open dislocations. Ankle dislocations
dial displacement and occur from a force against a plantarflexed are associated with a risk of vascular injury and the development of
foot. Fracture-dislocations are often treated definitively in the a compartment syndrome from severe swelling.7 Most vascular inju-
Operating Room. Despite this, patients benefit from early analge- ries are to the dorsalis pedis or posterior tibial vessels and may be
sia and prompt reduction. accompanied by damage to the adjacent superficial peroneal nerve
Ankle dislocations can be successfully reduced in the Emergency or sural nerve, respectively.1,6 Tibiotalar dislocations rarely result in
Department with the use of procedural sedation and longitudinal avascular necrosis.
Tibia
Fibula
Anterior
tibiofibular ligament
Posterior
tibiofibular Anterior
ligament talofibular ligament
Talus
Posterior
talofibular
ligament
Calcaneus
Calcaneofibular
ligament
Lateral Interosseous
FIGURE 89-1. The bony and ligamentous structures of the lateral
ankle. Talocalcaneal ligaments
INDICATIONS dislocation, open or closed, that has evidence of distal neurologic

or vascular compromise must be reduced emergently. Extreme
All closed ankle fracture-dislocations and isolated dislocations lateral deviation may compromise the dorsalis pedis artery and
should be reduced urgently not only to protect the soft tissues requires prompt reduction.10 All open dislocations require intrave-
and decrease swelling, but also to minimize articular injury. nous antibiotics, irrigation, surgical debridement, and reduction by
Some authors recommend reduction prior to radiography.10 Any an Orthopedic Surgeon in the Operating Room. However, reduction
Anterior
tibiotalar
Tibia ligament
Posterior
tibiotalar Deltoid
Talus ligament
ligament
Tibiocalcaneal
Navicular
ligament
Tibionavicular
ligament
Medial
talocalcaneal
ligament
Calcaneus
FIGURE 89-2. The bony and ligamentous structures of the Plantar calcaneonavicular
medial ankle. ("spring") ligament
A B C D
FIGURE 89-3. Types of ankle dislocations. A. Posterior. B. Lateral. C. Anterior. D. Superior.
should occur in the Emergency Department if the Orthopedic EQUIPMENT

Surgeon or the Operating Room is not immediately available.3
CONTRAINDICATIONS • 18 gauge needle
There are no absolute contraindications to reducing a dislocated • 22 gauge needle, 2 in. long
ankle. Some authors would not recommend Emergency Department • Equipment and supplies for procedural sedation (Chapter 129)
reduction of an open fracture-dislocation without evidence of neu- • Equipment and supplies for IV regional anesthesia (Chapter 127)
rovascular compromise or in a setting where immediate orthopedic • Stockinette
and operative intervention was available.
• Compressive wrap (Webril)
• Plaster, fiberglass, or commercially prepared splinting material
• Elastic bandage
PATIENT PREPARATION
Explain the risks, benefits, and potential complications of the reduc-
tion procedure and the procedural sedation to the patient and/or
their representative. Obtain an informed consent for both proce-
dures. Place the patient supine with the affected foot at the edge of
the gurney. Patients should be premedicated with an opioid analgesic
prior to the procedure and ideally prior to radiography. Procedural
sedation (Chapter 129) provides excellent analgesia, muscle relax-
ation, and sedation, allowing the reduction procedure to be more
tolerable for both the patient and the physician. Intra-articular
lidocaine has been reported as an effective alternative to conscious
sedation for closed reduction of ankle fracture dislocations.11 Please
refer to Chapter 77 regarding the details of ankle arthrocentesis. An
additional alternative is IV regional anesthesia (Bier block) of the
lower leg (Chapter 127).
TECHNIQUES
The techniques described below to reduce ankle dislocations have
three things in common. The hip and knee are flexed to relieve
the tension on the gastrocnemius and soleus muscles. The foot is
flexed (plantarflexed or dorsiflexed) to unlock or disengage the
talus. Finally, the talus is maneuvered into its proper anatomic
position.
LATERAL ANKLE DISLOCATIONS

Flex the patient’s hip and knee by placing a pillow behind their knee.
Grasp the calcaneus with one hand and the forefoot with the other
hand (Figure 89-5A). Instruct an assistant to grasp the patient’s calf.
Apply distal traction to the heel while the assistant provides coun-
FIGURE 89-4. Radiograph of a posterior ankle dislocation. tertraction to the leg (Figure 89-5A). The next step is to rotate the
FIGURE 89-5. Closed reduction of a lateral ankle dislocation.

A. The heel is distracted while an assistant provides counter-
traction. B. Simultaneously, medially rotate and dorsiflex the
foot while distracting the heel.
foot medially so that the great toe is in alignment with the anterior provides countertraction to the leg (Figure 89-7A). The next step
tibia while simultaneously dorsiflexing the foot and distracting the is to push the foot posteriorly while distracting the heel and a sec-
heel (Figure 89-5B). The talus will reduce easily with a palpable and ond assistant provides anteriorly directed pressure on the distal leg
audible “clunk.” (Figure 89-7B). The talus will reduce with a palpable and audible
“clunk.”
POSTERIOR ANKLE DISLOCATIONS
SUPERIOR ANKLE DISLOCATIONS
Flex the patient’s hip and knee by placing a pillow behind their
knee. Grasp the calcaneus with one hand and the forefoot with Superior ankle dislocations are associated with significant soft tis-
the other hand (Figure 89-6A). Instruct an assistant to grasp the sue and articular damage. Neurovascular injury is uncommon with
patient’s calf. Simultaneously apply distal traction to the heel and these dislocations. Superior ankle dislocations should be reduced,
plantarflex the foot while the assistant provides countertraction to splinted, and managed by an Orthopedic Surgeon. The only excep-
the leg (Figure 89-6A). The next step is to dorsiflex the foot while tion to this is if there is neurologic and/or vascular compromise
distracting the heel and a second assistant provides posteriorly of the distal extremity and no Orthopedic Surgeon is immediately
directed pressure on the distal leg (Figure 89-6B). The talus will available.
reduce with a palpable and audible “clunk.”
OPEN ANKLE DISLOCATIONS
ANTERIOR ANKLE DISLOCATIONS
The Emergency Physician occasionally reduces open ankle dis-
Flex the patient’s hip and knee by placing a pillow behind their locations if neurologic and/or vascular compromise of the foot is
knee. Grasp the calcaneus with one hand and the forefoot with present and an Orthopedic Surgeon is not immediately available.
the other hand (Figure 89-7A). Instruct an assistant to grasp the Copiously irrigate the wound with sterile saline before attempting
patient’s calf. Simultaneously apply distal traction to the heel and the reduction. The technique to reduce an open ankle dislocation is
dorsiflex the foot until the toes point upright while the assistant the same as that for a closed ankle dislocation.
FIGURE 89-6. Closed reduction of a posterior ankle disloca-

tion. A. The heel is distracted and the foot is plantarflexed
while an assistant provides countertraction. B. The foot is
dorsiflexed while the heel is distracted and a second assistant
applies posterior traction on the distal leg.
FIGURE 89-7. Closed reduction of an anterior ankle dislo-

cation. A. The heel is distracted and the foot is dorsiflexed
until the toes are upright, while an assistant provides coun-
tertraction. B. The foot is pushed posteriorly while the heel
is distracted and a second assistant applies anterior traction
on the distal leg.
ASSESSMENT require reduction by the Emergency Physician (EP). These include

clavicular fractures, Colles fractures, displaced surgical neck frac-
Verify and document the neurologic and vascular status of the tures of the humerus, and supracondylar fractures of the humerus.
foot before and after any attempts at reduction. Any diminu- The reduction of fractures in the ED should involve consultation
tion or the absence of normal neurologic or vascular signs requires with an Orthopedic Surgeon prior to performing the procedure.
emergent consultation with an Orthopedic Surgeon. The only exception to this is if neurologic or vascular compro-
mise exists in the extremity.
AFTERCARE
Splint the extremity. Apply a three-sided short leg splint from the CLAVICULAR FRACTURES
base of the toes to just below the knee for posterior, lateral, and
superior ankle dislocations that have been reduced. Immobilize INTRODUCTION
the ankle in 90° of flexion and in a neutral position with respect
to inversion and eversion.7 Immobilize the reduced anterior ankle Clavicular fractures are common and represent approximately 5%
dislocation with the ankle in slight plantarflexion. The limb should of all fractures.1–3 Most of these occur at the junction of the middle
be elevated, not bear weight, have frequent neurologic and vascular and distal third of the clavicle, just medial to the coracoclavicu-
checks, and have frequent assessments for the development of the lar ligament. The clavicular fracture is the most common fracture
signs associated with a compartment syndrome.7 encountered in childhood and occurs most often as a result of a fall.
These fractures are usually detectable clinically, with plain radio-
COMPLICATIONS graphs helping to confirm the diagnosis. Although these fractures
are relatively common, there is a small but definite risk of associated
Most complications occur as a result of the fracture-dislocation complications.
and not the reduction procedure. This includes neurologic dam-
age, vascular damage, and compartment syndromes. A posttrau-
matic peroneal tendon dislocation can occur and may be initially ANATOMY AND PATHOPHYSIOLOGY
unrecognized. The patient usually becomes symptomatic after the The clavicle is the only bony attachment of the upper extrem-
acute stage, when the tendon subluxes and dislocates. There is a low ity to the axial skeleton. It serves as a strut to support the shoul-
rate of subsequently developing avascular necrosis and degenerative der girdle. It provides support and stabilization of the upper
joint disease with isolated ankle dislocations. limb while allowing a broad range of movements. The clavicle is
Complications associated with the reduction procedure, if they securely attached at both the acromioclavicular and sternocla-
occur at all, are usually neurologic and vascular injuries. These struc- vicular joints by ligaments (Figure 90-1). The great vessels of the
tures may become impinged, or trapped, in the relocated joint or on upper extremity and nerves of the brachial plexus pass posteriorly
a fracture fragment. Emergently consult an Orthopedic Surgeon if to the clavicle at its midportion where it overlies the first rib. The
there is any diminished or absent function of any nerve or artery. proximity of these neurovascular structures, as well as the under-
lying lung, accounts for most of the potential complications of
SUMMARY clavicular fractures.
The most commonly used classification for clavicular fractures
Ankle dislocations without fractures are uncommon yet serious
was proposed by Allman.4 This simple classification is useful clini-
injuries. Closed ankle dislocations can be reduced emergently and
cally and mechanistically to the EP. Group I fractures are midcla-
successfully with the use of procedural sedation. Open ankle dis-
vicular and account for approximately 80% of clavicular fractures.
locations should be irrigated in the Emergency Department and
These most often result from a shearing force applied to the lateral
reduced rapidly after consultation with an Orthopedic Surgeon.
aspect of the shoulder. Group II fractures involve the distal third of
Reduction, irrigation, and debridement are all likely to occur in the
the clavicle and account for approximately 15% of all clavicular frac-
Operating Room if an Orthopedic Surgeon is immediately avail-
tures. These most often result from a direct blow to the top of the
able. Any ankle dislocation with evidence of distal neurovascular
shoulder. Several additional subclassifications have been proposed
compromise should be reduced immediately. All patients with ankle
for these fractures based on the location of the fracture and asso-
dislocations should have an Orthopedic Surgery consultation. The
ciated ligamentous injury. Operative repair is suggested for some
majority of closed ankle dislocations are managed nonoperatively
of these subtypes. All distal clavicular fractures should therefore be
with good long-term results.
referred for follow-up within 24 hours to an Orthopedic Surgeon.1,2
Group III fractures represent about 5% of clavicular fractures and
involve the proximal third of the clavicle. They often result from a
direct blow to the chest.
Patients with clavicular fractures are easily identified clinically.
Common Fracture The clavicle is almost entirely subcutaneous, allowing most frac-
90 Reduction tures to be palpated. Presenting signs and symptoms include local-
ized pain, ecchymoses, and edema. Physical examination findings
Eric F. Reichman and Robert M. Zesut include superior and posterior displacement of the proximal por-
tion of the clavicle due to traction from the sternocleidomastoid
INTRODUCTION muscle (Figure 90-2). The shoulder is often displaced inferiorly by
the weight of the upper extremity and the force of gravity. Medial
Extremity fractures are a common reason for Emergency displacement of the shoulder may be seen due to traction from the
Department (ED) visits. If there is no neurologic or vascular com- pectoral and the latissimus dorsi muscles.
promise, most closed fractures can be managed conservatively in the Most fractures are readily identifiable on standard anteroposte-
ED with splinting and Orthopedic Surgeon follow-up. This chapter rior radiographs. Some group II and III fractures may not be read-
addresses four common fractures of the upper extremity that may ily identifiable.1 Additional views at a 45° angle cephalad (apical
CHAPTER 90: Common Fracture Reduction 583
Trapezoid Conoid
ligament ligament
Acromioclavicular
Costoclavicular
ligament Sternoclavicular
ligament
ligament
Coracoacromial
ligament
Glenohumeral
ligaments
FIGURE 90-1. The clavicle serves as a strut between the torso and upper extremity; it is held firmly by the acromioclavicular and sternoclavicular ligaments. The brachial
plexus and great vessels pass behind the middle third of the clavicle.
lordotic view) or 15° posteroanterior radiograph may be useful to visualization of medial-end fractures, particularly those extend-
assess displacement.1,3,11 Evaluation of fracture union with spiral ing into the sternoclavicular joint.12 Special views (e.g., cone views,
computed tomography may allow the best assessment of displace- tomograms, and upper rib films) may be required and are best
ment. Computed tomography is usually required for adequate determined in consultation with an Orthopedic Surgeon.
Sternocleidomastoid muscle:
Clavicular head
Sternal head
Clavicle
(1)
Acromion
(2)
Humerus
(3)
Pectoralis muscle
FIGURE 90-2. Displacement of the clavicle and shoulder after a clavicular fracture. The clavicular head of the sternocleidomastoid muscle displaces the proximal clavicular
fragment superiorly and posteriorly (1). The pectoralis major and latissimus dorsi muscles pull the shoulder medially (2). The force of gravity displaces the distal clavicle
and shoulder inferiorly (3).
Clavicular injury and pain in children present two concerns. First, or a Velpeau wrap (Figure 90-3B). However, many physicians still
nondisplaced greenstick fractures to the clavicle may not be radio- prefer the use of a figure-of-eight strap (Figures 90-3C & D). The
graphically visible for 7 to 10 days.2,3 Clinical suspicion of a clavicu- figure-of-eight splint still represents the treatment of choice in
lar fracture with a negative radiograph should prompt conservative patients over the age of 10 years in the presence of greatly displaced
management. Follow-up should be arranged for 7 to 10 days after fragments.2,3 Despite this, there is no evidence that the figure-of-
the injury to obtain repeat radiographs. Second, it may be unclear if eight splint offers any advantage over a simple sling for midcla-
the epiphyses are involved in some group II and III fractures.2,3 Any vicular fractures. It is of note that the rates of compression of the
fracture through the epiphysis, or possibly through the epiphy- neurovascular bundle, axillary pressure sores, and nonunion are
ses, requires an urgent referral to an Orthopedic Surgeon. higher in patients treated with the figure-of-eight splint.11,12
Contraindications to the reduction of a clavicular fracture include
INDICATIONS other injuries that represent a threat to life or limb. The patient’s
airway, breathing, and circulation must first be addressed and stabi-
Reduction of clavicular fractures is necessary in a few circum- lized. Patients with open clavicular fractures require emergent con-
stances. It is required if neurologic and/or vascular compromise sultation with an Orthopedic Surgeon, intravenous antibiotics, and
is present in the affected extremity. This includes medial fracture hospital admission for possible open reduction and internal fixa-
displacement producing superior mediastinal compromise. In these tion. Reduction is also contraindicated if an expanding hematoma,
circumstances, an emergent attempt at closed reduction should be indicative of a vascular injury, is observed. Finally, unfamiliarity
made.11,13 Consider patients who are actively involved in athletics with technique is a relative contraindication.
or have jobs that require overhead use of their arms (e.g., painters)
for operative reduction by an Orthopedic Surgeon. Distal clavicular
fractures that are displaced should be reduced. Otherwise, reduc- EQUIPMENT
tion is optional and at the discretion of the treating physician.
• Figure-of-eight splint strap (commercially available)
CONTRAINDICATIONS • Sling
• Swath
Reduction of most clavicular fractures is not usually necessary in
either the pediatric or adult patient.1,2 A sling for simple arm sup- • Kerlix rolls
port provides results comparable to the figure-of-eight reduction • Elastic bandage
without the risk of brachial plexus injury or patient discomfort.1–3
The sling may be additionally supported by a swath (Figure 90-3A)
PATIENT PREPARATION
Explain the risks, and benefits of the reduction technique and
aftercare to the patient and/or their representative. As with any
procedure, informed consent should be obtained. Consider the
administration of oral, intramuscular, or intravenous analgesics for
patient comfort during the procedure. Procedural sedation is not
needed or required for this fracture reduction.
TECHNIQUE
Sit the patient upright on the side of the stretcher with their feet on
the floor. Alternatively, the patient may be standing upright. Stand
behind the patient. Grasp and pull both of the patient’s shoulders
backward as if the patient were standing at attention. Instruct an
assistant to apply the figure-of-eight splint while the patient is in
this position. Apply the splint like a backpack and tighten the straps
(Figures 90-3C & D). Reassess the neurologic and vascular integ-
A B rity of the affected extremity after applying the splint.
ASSESSMENT
The neurologic and vascular integrity of the upper extremity
should be assessed for all patients both initially, following any
reduction attempts, and after the application of a figure-of-eight
splint. Any neurologic and/or vascular compromise requires an
emergent consultation with an Orthopedic Surgeon.
AFTERCARE
Patients with uncomplicated fractures should be referred to
C D an Orthopedic Surgeon in 7 to 10 days. Patients with group II
distal fractures and any fracture in a child potentially involv-
FIGURE 90-3. Treatment of clavicular fractures. A. Sling-over-swath immobiliza- ing the epiphysis should have an urgent consultation with an
tion. B. Velpeau sling immobilization. C. Anterior view of the figure-of-eight splint Orthopedic Surgeon within 24 to 48 hours. Any patient with
D. Posterior view of the figure-of-eight splint. neurologic or vascular compromise, a pneumothorax, or signs of
vascular injury should be admitted to the hospital after an emer-

gent consultation with an Orthopedic Surgeon.
Once the acute pain has subsided, the use of the sling can nor-
mally be discontinued and patients are encouraged to participate
normal activities as pain allows. Most patients respond well to self-
administered range-of-motion exercises. Recovery of the range of
motion of the shoulder is usually swift, and supervised physiother-
apy is very rarely required.13
General principles of orthopedic care are recommended. These
include the application of ice, rest, nonsteroidal anti-inflammatory
drugs, and narcotic analgesics as needed. Most patients find the
figure-of-eight splint difficult to apply, extremely uncomfortable,
and remove it shortly after its application. If the patient tolerates the
splint, it should be tightened daily. The figure-of-eight splint should
be worn until there is evidence of clinical union and the arm can be
abducted without pain. This generally requires 3 to 5 weeks in chil-
dren and 6 or more weeks in adults.1,2 It may be more advantageous
to apply a sling and swath or a sling and Velpeau wrap for patient
comfort and compliance (Figures 90-3A & B). The outcomes of
applying a figure-of-eight splint versus a sling are equivalent.18,19 A B C
Alternatively, apply a shoulder immobilizer.
The sling is used to immobilize and elevate the elbow, forearm, FIGURE 90-4. The Colles fracture. A. The dinner fork deformity, which is often
and hand. It is also used to support the upper extremity. Slings seen. B. Anteroposterior view. C. Lateral view.
are often used to support casts or splints of the upper extrem-
ity. These devices are simple, inexpensive, and effective. It is
imperative that the sling not be too short to allow the wrist and
hand to hang over the sling. This can result in an ulnar nerve a Colles fracture is a fall on an outstretched hand.5,6 The majority of
neuropraxia. fractures occur in patients 50 years of age and older.5,6 This fracture
The addition of a swath to a sling is used to immobilize dislocated is more commonly seen in women than in men.
shoulders that have been reduced and proximal humeral fractures The Colles fracture is the most common fracture of the wrist.5,6
(Figure 90-3A). The swath immobilizes the humerus against the Familiarity with its presentation, indications for reduction, and
torso to limit motion at the shoulder. A shoulder immobilizer may method of reduction are essential for the EP. Consult an Orthopedic
be substituted for a sling and swath. Surgeon for the reduction of most fractures, due to the high inci-
The Velpeau wrap is a sling-and-swath technique that positions dence of long-term complications that may result, even when these
the forearm diagonally rather than horizontally (Figure 90-3B). fractures are appropriately managed and reduced.5,6
The Velpeau wrap has no practical advantages over a sling and
swath. ANATOMY AND PATHOPHYSIOLOGY
The distal radius is involved in two important articulations. First is
COMPLICATIONS the distal radioulnar joint, which is responsible for pronation and
Complications of the reduction procedure include injuries to supination of the forearm. The second is the wrist articulation. The
the brachial plexus, subclavian artery, and/or vein.1,2 Commonly, distal radius normally displays approximately 15° to 30° of angu-
these are the result of the initial injury and not the reduction pro- lation relative to the ulna. It also has a volar tilt of up to 23°. It is
cedure. It is imperative to perform a neurologic and vascular important to maintain this anatomic position of the distal radius
examination prior to and after any attempt at reducing a cla- with the reduction of a Colles fracture so that the patient retains
vicular fracture. Any neurologic or vascular deficit requires an good function of the wrist and distal radioulnar joints.6
immediate consultation with an Orthopedic Surgeon. The Colles fracture can be associated with several other significant
injuries. Up to 60% of patients have a fracture of the ulnar styloid
process.5,6 Other injuries include carpal fractures, distal radioulnar
SUMMARY joint subluxations, flexor tendon injuries, median nerve injuries,
Clavicular fractures are common, easily diagnosed, and often ulnar neck fractures, and ulnar nerve injuries. A thorough physical
treated in the ED. Fractures of the distal or medial third may be examination and evaluation of the radiographs will uncover these
more challenging. Although the incidence of complications is low, injuries.
a thorough search for resultant or concomitant injury is required. Standard radiographs include the anteroposterior and lateral
Any evidence of neurologic or vascular compromise requires an views of the wrist. The Colles fracture is classically described as a
emergent consultation with an Orthopedic Surgeon. “dinner fork” deformity when seen on lateral view (Figure 90-4A).
Intraarticular involvement with the fracture is rare and should
COLLES FRACTURE prompt an emergent consultation with an Orthopedic or Hand
Surgeon in the ED for reduction.6
A variation of the Colles fracture is the Smith fracture (reversed
INTRODUCTION Colles). The Smith fracture is similar to the Colles fracture except
A Colles fracture is a transverse fracture of the distal radial that the distal fracture fragment is displaced in a volar direction. This
metaphysis with dorsal displacement and angulation of the distal fracture most often results from a direct blow to the wrist while the
fragment. The fracture usually occurs 2 cm from the distal end of hand is flexed. It is more commonly seen in young males. The man-
the radius (Figure 90-4). The most common mechanism producing agement of these fractures is similar to that of the Colles fracture.
INDICATIONS skin and into the hematoma. Aspirate blood from the hema-
toma site to confirm proper needle placement. Inject 5 to 10 mL
Nondisplaced Colles fractures can be placed in a splint or cast of the local anesthetic solution into the hematoma surrounding
and the patient follow-up with an Orthopedic or Hand Surgeon the fracture. Although a hematoma block will provide adequate
on an outpatient basis. Displaced fractures should be reduced in anesthesia in most patients, it may be incomplete. Adjunctive or
the ED.5,6 Simple Colles fractures may be reduced after consul- alternative anesthesia includes intramuscular analgesics, intra-
tation with an Orthopedic or Hand Surgeon. Many Orthopedic venous analgesics, regional nerve blocks (Chapter 126), intrave-
and Hand Surgeons prefer to reduce these fractures themselves, nous regional anesthesia (Chapter 127), and procedural sedation
often prior to open reduction and internal fixation. The fracture (Chapter 129).
must be emergently reduced if the patient has any neurologic
and/or vascular compromise. The EP should reduce the fracture
if the Orthopedic or Hand Surgeon is not immediately available. TECHNIQUE
The goal is to relieve the neurologic and/or vascular compromise.
Place the patient supine on a stretcher. Perform a hematoma block
Ideal positioning is not required as the Surgeon can later reduce
as described above. Provide supplemental analgesia to the patient if
the bony defect.
required. Position the patient as in Figure 90-5A. Abduct the arm
90° and allow it to hang over the edge of the bed. Flex the elbow
CONTRAINDICATIONS 90° with the hand pointing upright. Insert the thumb, index fin-
ger, and long finger into the finger trap (Figure 90-5B). Suspend
Contraindications to the reduction of a Colles fracture include 8 to 10 pounds of weights from the distal humerus (Figure 90-5C).
other injuries that represent a threat to life or limb. Airway, Allow the patient to remain in this position for 5 to 10 minutes to
breathing, and circulation must first be addressed and stabilized. distract and disimpact the fracture fragments.
An Orthopedic or Hand Surgeon should reduce any fractures that The fracture reduction involves traction followed by manip-
involve the radioulnar or wrist joint. Complex, comminuted, or ulation of the distal radial fragment to reverse the action that
open fractures also require reduction by an Orthopedic or Hand resulted in the fracture (Figure 90-6). Place both hands around
Surgeon. Unfamiliarity with the reduction technique is a relative the patient’s wrist with the thumbs at the base of the fracture site
contraindication. (Figure 90-6A). Displace the fracture fragment distally with your
Any patient presenting with a Colles fracture should be evalu- thumbs while maintaining traction with the finger trap and the
ated for the presence of a compartment syndrome. Any suspicion weights (Figure 90-6A). This maneuver allows the distal fragment
of a compartment syndrome necessitates having intracompart- to become free from any contacts with the proximal radius, which
mental pressures measured. Elevated compartmental pressures may prevent its movement. Continue to manipulate the fragment
require an emergent consultation with an Orthopedic, Hand, distally while simultaneously manipulating it in a volar direction
or General Surgeon. Reduction and fasciotomies should be per- until the fragment assumes the proper anatomic position. In the
formed in the Operating Room. Refer to Chapters 74 and 75 for case of a volar angulation or Smith fracture, these manipulations
the details regarding a compartment syndrome and a fasciotomy, would simply be reversed to reduce the displacement. Slight ulnar
respectively. deviation of the fragment is often necessary (Figure 90-6B).
Remove the weights. Palpation of a smooth surface at the radial
EQUIPMENT and dorsal aspects of the radius indicates an appropriate reduc-
tion. Remove the finger trap and apply a splint.
• Povidone iodine or chlorhexidine solution Immobilize the forearm with a sugar tong splint. Place the
• Local anesthetic solution, 1% to 2% lidocaine forearm in a neutral position, halfway between pronation and
• 10 mL syringe supination. Place the wrist in 15° to 20° of flexion and 20° of
ulnar deviation. Unstable fractures are best splinted immediately
• 18 gauge needle after the reduction while the hand is still maintained in the finger
• Finger trap trap for traction (Figure 90-6C). If a long arm cast is applied, be
• Compressive cotton bandage (Webril) sure to bivalve it to prevent complications. A short arm splint
or cast may be used if the fracture is stable and impacted or is
• Elastic wrap
stable in an elderly person who needs to maintain mobility of
• 8 to 10 pounds of weights the elbow.
• Casting material (plaster, fiberglass, and prepackaged splints)
• Anesthesia and analgesia supplies ASSESSMENT
PATIENT PREPARATION All patients should be assessed both initially and following any
reduction attempts for neurologic and vascular integrity of the
Obtain an informed consent for reduction of the fracture after extremity. Postreduction radiographs should be obtained to con-
explaining to the patient and/or their representative the indications, firm proper bony positioning. The procedure may be repeated if
anticipated outcome, risks, benefits, and potential complications. the radiographs show an incomplete reduction. Bedside ultra-
The patient should be given adequate anesthesia for the pro- sound is a reliable and convenient method of assessing the reduc-
cedure. This can often be accomplished with a hematoma block. tion.20 It is noninvasive, does not use ionizing radiation, involves
The procedure is briefly described here. Refer to Chapter 125 for a minimal contact, and does not require the patient to remain
more complete discussion of this procedure. Clean the skin over- motionless.14
lying the fracture of any dirt and debris. Apply povidone iodine or The goal is the restoration of the normal relationships and angles
chlorhexidine solution to the skin and allow it to dry. Place a sub- of the radius with congruity of the radiocarpal and radioulnar
cutaneous wheal of local anesthetic solution over the area of the joints. The lateral radiograph should reveal a 23° angle of the radio-
hematoma. Insert an 18 gauge needle through the anesthetized carpal joint in a palmar direction with no dorsal angulation. The
B C
FIGURE 90-5. Patient positioning for the reduction of a Colles fracture. A. The arm is abducted 90° and the elbow is flexed 90°. B. The thumb, index finger, and long
finger are placed in the finger trap. C. Weights are suspended from the distal humerus.
anteroposterior radiograph should reveal a radioulnar joint angle of AFTERCARE

15° to 30° with the ulna in relation to the radiocarpal joint.
Positioning is not critical if the reduction was performed for Patients with uncomplicated or nondisplaced fractures should
neurologic and/or vascular compromise. The primary consider- be referred to an Orthopedic or Hand Surgeon in 24 to 48 hours.
ation is the relief of the compromised nerve and/or artery. The Patients with unstable fractures should be evaluated within
Orthopedic or Hand Surgeon can later reduce the bony defect 24 hours. All patients should be given written instructions
that remains. regarding the signs and symptoms of the splint or cast being
A B C FIGURE 90-6. Reduction of a Colles fracture. A. Proper

positioning of the EP hands. The arrows represent the
application of a distally directed force. B. Application of an
ulnar-directed force to reduce the radial deviation. C. The
application of a splint to an unstable fracture. The finger trap
and weights remain during the splinting.
too tight or a potential compartment syndrome. Any patient proximal humeral fractures are one-part or minimally displaced
with an open fracture, evidence of neurologic and/or vascular fractures.3,7 These fractures can be managed conservatively.
compromise, or suspicion of a compartment syndrome should be Multiple-part fractures often require surgical intervention by an
admitted to the hospital after an emergent consultation with an Orthopedic Surgeon. A surgical neck fracture of the humerus
Orthopedic or Hand Surgeon. is the only proximal humeral fracture that should be reduced
General principles of orthopedic care are recommended. These by the EP.
include rest, elevation of the arm, nonsteroidal anti-inflammatory
drugs, and narcotic analgesics as needed. The patient should be
INDICATIONS
instructed to exercise the fingers and shoulder to prevent weakness,
muscular atrophy, and the ligaments surrounding these joints from Surgical neck fractures of the humerus may be reduced in the ED
becoming taut. after consultation with an Orthopedic Surgeon. If the patient has
neurologic and/or vascular compromise, the reduction should be
COMPLICATIONS undertaken emergently after consultation with the Orthopedic
Surgeon.
Complications of the reduction procedure include postreduction
edema and bleeding into the forearm. These may contribute to the
development of a compartment syndrome. Although infrequent, a CONTRAINDICATIONS
neuropraxia of the median nerve is possible. Most complications Contraindications to the reduction of humeral fractures include
result from the injury that produced the fracture and underlie other injuries that represent a threat to life or limb. Airway, breath-
the need for a good neurologic and vascular examination prior to ing, and circulation must first be addressed and stabilized. An
any attempts at reduction. Any diminished or absent neurologic Orthopedic Surgeon should manage any open fracture, complex
or vascular function requires an emergent consultation with an comminuted fracture, or multiple-part fracture as the patient often
Orthopedic or Hand Surgeon. Incomplete reduction can result requires operative repair and reduction.2,3,7 Unfamiliarity with the
in future morbidity (i.e., pain, decreased range of motion, and reduction technique is a relative contraindication. Children pre-
deformity). senting with separation of the proximal humeral epiphyses require
meticulous realignment. These fractures should be reduced by an
SUMMARY Orthopedic Surgeon.2
The Colles fracture is the most common fracture of the wrist.
Familiarity with its presentation and method of reduction are EQUIPMENT
essential for the EP. Many Orthopedic and Hand Surgeons prefer
to reduce these fractures. Consultation is advised prior to reduction • Supplies and equipment for procedural sedation (Chapter 129)
unless the extremity has evidence of neurologic or vascular compro- • Compressive cotton bandage (Webril)
mise. These fractures have a high incidence of long-term complica- • Casting material (plaster, fiberglass, and prepackaged splints)
tions, even when appropriately managed and reduced.5,6
• Sling
• Elastic wrap
DISPLACED SURGICAL NECK
FRACTURE OF THE HUMERUS
PATIENT PREPARATION
INTRODUCTION Obtain an informed consent for reduction of the fracture after
Proximal humeral fractures are relatively common. Most patients explaining to the patient and/or their representative the indica-
presenting to the ED with a proximal humeral fracture are elderly tions, anticipated outcome, risks, benefits, and potential complica-
and usually have osteoporosis. The most common mechanism tions of the procedure. Adequate anesthesia for this procedure is
of injury involves a fall on an outstretched hand with the elbow best accomplished with procedural sedation. Obtain an informed
extended.3,7 The EP can manage most of these fractures conserva- consent for the procedural sedation procedure. Refer to Chapter
tively. However, the EP must have a basic knowledge of the types 129 for complete details regarding procedural sedation.
of proximal humeral fractures, those that should be managed
by the Orthopedic Surgeon, and the indications for emergent TECHNIQUE
reduction.
Place the patient supine. Apply procedural sedation. Completely
flex the patient’s elbow. Apply a distractive force along the long
axis of the humerus by applying traction on the patient’s elbow
The proximal humerus is composed of the articular segment, the (Figure 90-7A). Simultaneously slightly adduct the arm across the
greater and lesser tuberosities, and the proximal humeral shaft. chest (to allow relaxation of the pectoralis muscle), slightly flex the
This anatomic division is based on the epiphyseal lines and the arm, and apply lateral pressure to the fracture site while distract-
development of the humerus.2,3,7 The commonly used Neer clas- ing the humerus (Figure 90-7B). Slowly release the traction on the
sification utilizes the observation that proximal humeral fractures elbow as the fragments come into good reduction.
separate primarily along these epiphyseal lines.2,3,7 Using this clas- Apply a sugar tong splint from over the deltoid muscle, under the
sification, it is the displacement of fragments, not the total num- elbow, and up into the axilla (Figure 90-8A). Secure the splint in the
ber of fracture lines, that is important. Significant displacement is usual manner with an elastic wrap. Apply a sling (Figure 90-8B).
considered to be a separation of greater than 1 cm, angulation of Place the arm slightly across the chest and apply a sling and swath in
more than 45°, or displacement of the greater tuberosity greater the event of an unstable proximal humeral fracture (Figure 90-3A).
than 0.5 cm.3,7 The classification separates fractures into one- to This can help to limit the pull of the pectoralis muscle on the frac-
four-part fractures. The vast majority, approximately 80%, of ture site.
FIGURE 90-7. Reduction of a displaced surgical neck frac-

ture of the humerus. A. The application of distal traction to
the elbow. B. Lateral pressure is applied to reduce the fracture
while maintaining distal traction, adducting the elbow, and
A B slightly flexing the arm.
ASSESSMENT result from the injury that produced the fracture. This underlies the
need for a good neurovascular examination prior to any reduction
All patients should be assessed both initially and following any attempt.
reduction attempts for neurologic and vascular integrity of the
extremity. Postreduction radiographs should be obtained to con- SUMMARY
firm proper bony positioning. The procedure may be repeated if the
radiographs show incomplete reduction. Proximal humeral fractures are common. While the EP can manage
Positioning is not critical if the reduction was performed for most of these conservatively, a displaced surgical neck fracture is the
neurologic or vascular compromise. The primary consideration is only proximal humeral fracture that should be reduced in the ED.
the relief of the compromised nerve and/or artery. The Orthopedic Reduction is often reserved for patients who have evidence of neu-
Surgeon can later reduce the bony defect that remains. rologic and/or vascular compromise. Most of these injuries require
open reduction and internal fixation in the Operating Room by an
Orthopedic Surgeon. Close follow-up should be arranged for any
AFTERCARE patient discharged from the ED.
Patients with uncomplicated or nondisplaced fractures should be
referred to an Orthopedic Surgeon in 24 to 48 hours. All patients SUPRACONDYLAR FRACTURE
should receive written instructions on the signs and symptoms OF THE HUMERUS
of the splint being too tight or a potential compartment syn-
drome. Patients with unstable fractures should be evaluated within INTRODUCTION
24 hours. Any patient with an open fracture, evidence of neurologic
and/or vascular compromise, or suspicion of a compartment syn- Distal fractures of the humerus located within 2 cm or just proxi-
drome should be admitted to the hospital after an emergent consul- mal to the epicondyles are known as supracondylar fractures
tation with an Orthopedic Surgeon. (Figure 90-9). Supracondylar fractures are classified as extension
and flexion fractures.8–10 These fractures are common in chil-
dren under the age of 15 and are rare in people over the age of
COMPLICATIONS 20.8–10 Supracondylar fractures are the most common elbow frac-
Complications of the reduction procedure include primarily neu- tures seen in children.15 The most common mechanism of injury
rologic and/or vascular compromise. However, most complications involves a fall onto an outstretched hand with the elbow locked
FIGURE 90-8. Immobilization of the reduced surgical neck

fracture of the humerus. A. Application of a sugar tong splint.
B. A sling is applied after padding is placed between the
A B upper arm and the thorax.
Median
nerve
Brachial artery
Ulnar
nerve
Radial nerve
A B
Medial
FIGURE 90-9. Supracondylar fracture of the humerus. A. Anteroposterior view. epicondyle Lateral
B. Lateral view. epicondyle
in extension.8–10 The same mechanism of injury in an adult often

results in a posterior elbow dislocation. The bones of an adult are
much stronger than those of a child, so that the ligaments rupture Radius
Ulna
rather than the bone fracturing.8,9 These injuries have a signifi-
cant incidence of associated neurologic and/or vascular injury.
There is a significant incidence of a subsequent compartment
syndrome. All supracondylar fractures should be referred to an
Orthopedic Surgeon for follow-up care.

FIGURE 90-10. Major neurologic and vascular structures crossing the elbow.
On presentation, the child will be holding the affected extremity
with the elbow flexed 90° and the arm adducted.8,10 Localized ten-
derness and swelling will be found upon examination. Extension
fractures have posterior displacement of the distal fragment of
the humerus that is aggravated by the pull of the triceps mus- sign and anterior humeral line should be closely examined. Initial
cle.8,10 The olecranon will be displaced posteriorly due to traction radiographs may show no evidence of a fracture except for a pos-
from the triceps muscle. The posterior displacement of the olec- terior fat-pad sign.15 Even without any radiologic signs, a child
ranon may mimic a posterior elbow dislocation. Anterior angu- with localized tenderness in the supracondylar area should be
lation of the sharp proximal fragment (Figure 90-9B) may treated conservatively with splinting and referral to an Orthopedic
injure the brachial artery or median nerve (Figure 90-10). A Surgeon.8,10 The anteroposterior view allows an assessment of any
thorough neurovascular examination is essential. There will be displacement. Displaced fractures should be emergently referred
loss of the normal olecranon prominence with flexion injuries. to and reduced by an Orthopedic Surgeon.
These fractures are frequently open and vascular injury is less
frequent.8,10 INDICATIONS
The modified Gartland classification of supracondylar humeral
fractures is the most commonly accepted and used system.17 A The only indication for reducing a supracondylar fracture of the
Gartland type-I supracondylar fracture is nondisplaced or mini- humerus emergently is neurologic and/or vascular compromise
mally displaced by <2 mm and is associated with an intact ante- of the extremity distal to the fracture and an Orthopedic Surgeon
rior humeral line. A type-II supracondylar fracture is displaced is not immediately available.
by >2 mm, and the posterior cortex is intact, but may be hinged.
On a true lateral radiograph of the elbow, the anterior humeral
line does not go through the middle third of the capitellum. Type-
CONTRAINDICATIONS
III fractures are displaced with no meaningful cortical contact. Contraindications to the reduction of a supracondylar fracture
Gartland type-IV fractures are characterized by an incompetent include other injuries that represent a threat to life or limb.
periosteal hinge circumferentially and are defined by instability in The patient’s airway, breathing, and circulation must first be
both flexion and extension.17 The EP’s primary role in a supracon- addressed and stabilized. An Orthopedic Surgeon should manage
dylar humeral fracture is to ascertain if there is any neurological any open or displaced fractures. Unfamiliarity with the reduc-
and/or vascular compromise of the extremity distal to the fracture. tion technique is a relative contraindication. If the EP is uncom-
Radiological evaluation of supracondylar fractures is best fortable with the reduction procedure, simple traction on the
appreciated on the lateral view. One-quarter of these fractures extended elbow may be sufficient to restore neurologic and/or
in children are of the greenstick variety.8,10 The posterior fat pad vascular integrity.
EQUIPMENT
• Supplies and equipment for procedural sedation (Chapter 129)
• Compressive cotton bandage (Webril)
• Elastic wraps
• Casting material (plaster, fiberglass, and prepackaged splints)
A
• Prepackaged splinting sheets
• Sling
PATIENT PREPARATION
Obtain an informed consent for the reduction of the fracture after
explaining to the patient and/or their representative the indications,
anticipated outcome, risks, benefits, and potential complications.
Adequate anesthesia for this procedure is best accomplished with
procedural sedation. Obtain an informed consent for this procedure B
in addition to the reduction procedure. Refer to Chapter 129 for the
complete details regarding procedural sedation.
TECHNIQUE
Place the patient supine. Apply procedural sedation. Slightly
abduct the affected extremity. Place the patient’s hand in the
midposition between pronation and supination with the thumb
pointing upward (Figure 90-11A). Grasp the patient’s elbow
region with the dominant hand and grasp the wrist with the non-
dominant hand (Figure 90-11A). Instruct an assistant to stabi-
lize the distal humerus (Figure 90-11A). Apply distal traction in
line with the long axis of the arm by pulling on the wrist while C
simultaneously correcting any medial or lateral displacement at
the elbow (Figure 90-11A). Supinate the patient’s arm and correct FIGURE 90-11. Reduction of a supracondylar fracture. A. Positioning of the
any remaining medial or lateral displacement at the elbow while hands of the EP and the assistant. Distal traction is applied (arrow) while reduc-
simultaneously distracting the wrist (Figure 90-11B). Place the ing the medial or lateral displacement (arrowheads). B. The patient’s hand is
thumb of the dominant hand across the joint line of the elbow supinated while maintaining distal traction (arrow). Any remaining medial or
with the fingers behind the olecranon process and slowly flex lateral displacement is also corrected (arrowheads). C. The patient’s elbow is
the elbow to just beyond 90° while distracting the elbow (Fig- flexed (curved arrow) just beyond 90° while maintaining distal traction (straight
ure 90-11C). Splint the arm in this position. Avoid tight bandag- arrow).
ing or splinting as significant swelling may occur up to 24 hours
after the reduction. Excessive flexion or extension may compro-
mise the limb’s vascularity and increase compartment pressures.16
COMPLICATIONS
ASSESSMENT Most complications result from the injury that produced the
All patients should be assessed both initially and following any fracture and not the reduction. Complications of the reduction
reduction attempts for neurologic and vascular integrity of the procedure include primarily neurologic and vascular compro-
extremity. Postprocedural swelling is common. Postreduction mise. This is most often a neuropraxia and may involve any of the
radiographs should be obtained to confirm proper bony position- three nerves crossing the fracture. The neurovascular structures
ing. The procedure may be repeated if the radiographs show incom- crossing the fracture may become lacerated or entrapped during
plete reduction. the reduction. The necessity of an accurate and complete neu-
Positioning is not critical if the reduction was performed for rovascular examination prior to and after reduction cannot be
neurologic or vascular compromise. The primary consideration is overemphasized.
the relief of the compromised nerve and/or artery. The Orthopedic
Surgeon can later reduce the bony defect that remains.
SUMMARY
Supracondylar fractures of the humerus are common in children
AFTERCARE under the age of 15 and rare over the age of 20. The most com-
Patients with supracondylar fractures should be admitted to the mon mechanism of injury involves a fall onto an outstretched hand
hospital to be monitored for a delayed compartment syndrome, with the elbow locked in extension. These injuries have a signifi-
neurologic compromise, or vascular compromise. Any patient with cant incidence of associated neurologic injury, vascular injury, and
an open fracture, evidence of neurologic or vascular compromise, the subsequent development of a compartment syndrome. The
or suspicion of a compartment syndrome should be admitted to only indication for the reduction of a supracondylar fracture of the
the hospital after an emergent consultation with an Orthopedic humerus by the EP is neurologic and/or vascular compromise distal
Surgeon. to the fracture.
Casts and Splints

91 Eric F. Reichman and Harold A. Sloas
INTRODUCTION
External immobilization of the extremities is the oldest form of
fracture treatment. References to plaster use and various immo- FIGURE 91-1. Three points of force are acting on the injured extremity in a well-
bilization techniques are scattered throughout historical records. applied cast or splint. One force is applied to the convex side of the fracture site
The use of plaster of paris (plaster) in fracture management dates (1). Two opposing forces are applied at sites proximal and distal to the fracture and
back to the eighteenth century Turkish Empire. Plaster bandages on the concave side of the fracture (2).
became commercially available in 1931. Despite the development
of plastic (i.e., fiberglass) casting products, the plaster bandage
persists as the most economical and versatile material for immo- Casts and splints also rely on hydraulic force to maintain limb
bilization techniques.1 length and alignment. One may think of the soft tissues surround-
Immobilization of an injured extremity begins at the scene of ing the broken bones as constituting a flexible cylinder that contains
the accident. According to Advanced Trauma Life Support guide- the underlying fracture, hematoma, and edema. Axial loading of
lines, the injured extremity must be aligned and immobilized after the bones will cause the soft tissue to expand and allow the limb to
the appropriate management of any life-threatening problems.2 shorten. A well-applied cast or splint will resist the outward expan-
Prehospital immobilization of fractures is invaluable for pain sion from axial loading and provide additional support for the limb.4
control, prevention of soft tissue injury, prevention of any new or Plaster is made of finely ground calcium sulfate that has been
further injury to neurovascular structures, and management of dehydrated by heat. The calcium sulfate is impregnated into mus-
edema. External immobilization with splinting or casting is often lin sheets containing dextrose or starch. The addition of various
the definitive management of injured extremities in the Emergency chemicals (e.g., alum, aluminum, copper, iron, magnesium, salicylic
Department. Knowledge of and expertise in this therapeutic proce- acid, or zinc) to the calcium sulfate alters the rate of hardening after
dure is essential for any EP. the addition of water. Plaster grades include fast-setting and extra-
Splints are commonly used for the immobilization of upper and fast-setting plaster, which are useful for different applications. Long
lower extremity injuries. A splint is a hard bandage that is not cir- cylindrical crystals form and interlock as the plaster sets to give
cumferential and prevents movement of the fracture site. Splinting strength to the cast. For this reason, plaster should not be moved
may be the definitive management of certain injuries. Splints have once it begins to set, as these crystals may fracture, causing the
the distinct advantage of being quick, easy to apply, and they are plaster to lose strength. Careful lamination of the plaster while it
designed to accommodate postinjury swelling. The major disadvan- is still wet will add strength by enabling the formation of longer
tages of splints are that they provide slightly less rigid immobiliza- crystals.
tion than casting and require a Physician visit within a few days to Crystal formation during the setting of plaster is an exothermic
be replaced with a cast. process that is initiated by the addition of water to the plaster. Using
Casts, which are generally circumferential, are better suited for warm water will accelerate the chemical reaction, harden or set the
the definitive treatment of fractures and ligamentous injuries. plaster sooner, and decrease the setting time. Unfortunately, the
Casts provide superb immobilization and allow for the main- use of very warm or hot water will also increase heat production
tenance of a reduced fracture. The rigidity of a cast limits the while the plaster sets. The use of very thick splints or fast-setting
amount of swelling and soft tissue edema in the first 24 to 48 hours plaster will also increase the heat produced during setting. Use cold
after the injury and is therefore associated with an increased risk water to activate the plaster, increase the setting time, and decrease
of developing a compartment syndrome. Casts should be used the heat produced during setting. Great care should be taken if
with caution in the management of acute fractures. They are warm water is used in applying a cast or splint to an anesthetized
often split (i.e., bivalved) to allow swelling and prevent the patient, unconscious or altered patient, or an insensate limb. The
development of a compartment syndrome before the patient is setting plaster may burn the skin in these cases as the patient will
discharged from the Emergency Department. not notice the heat and pain associated with the exothermic reac-
tion. Rubbing and working with the plaster will also accelerate the
ANATOMY AND PATHOPHYSIOLOGY setting process.5
The same principles described above regarding plaster apply to
Casts and splints rely on the principle of a three-point mold to the use of fiberglass. The fiberglass splinting material consists of
maintain fracture reduction (Figure 91-1). When applying a cloth impregnated with a plastic and spun glass resin and a water-
cast or splint, the application of directed force to the under- activated catalyst.
lying bones should be uppermost in one’s mind. To obtain
a three-point mold, place one point of contact over the convex INDICATIONS
side of the fracture site. The other two points of force are aimed
in an opposite direction, proximal and distal to the fracture, and SPLINTS
from the concave side. This is the classic teaching of Sir John
Charnley, who noted that “a curved plaster is necessary in order An injured extremity should be splinted as soon as possible after
to make a straight limb.”3 A skin-tight cast that closely follows the the injury. Splinting results in the reduction of pain, reduction of
contours of the extremity will not maintain the fracture in align- edema, relieves pressure on neurovascular structures, and the
ment, as it does not apply appropriate pressure to the underlying prevention of further soft tissue injury.6 Any available material
bones. can be used to immobilize or realign the affected extremity in the
CHAPTER 91: Casts and Splints 593
prehospital setting and in the Emergency Department. A thorough EQUIPMENT

neurologic and vascular examination of the extremity should be
performed and documented before temporarily splinting the • Bucket or basin to hold water
extremity. A thorough neurologic and vascular examination of • Source of cool or tepid water
the extremity should be performed and documented after tempo-
rarily splinting the extremity. The initial neurovascular examina- • Cotton cast padding (e.g., Webril), various widths
tion, temporary splinting, and the postsplinting neurovascular • Plaster strips or rolls, various widths
examination should be performed before the patient undergoes • Fiberglass strips or rolls, various widths
radiographic studies. Immobilize an extremity in the appropriate • Prefabricated splinting material, various widths
and definitive splint after diagnosing and stabilizing the fracture. A
thorough neurologic and vascular examination of the extremity • Bias stockinette, various widths
should be performed and documented after the placement of the • Cloth tape, 1 in. wide
definitive splint. • Bias stockinette, optional
An extremity fracture is the most common reason for place-
• Elastic bandages (e.g., Ace wraps), various widths
ment of a splint. A splint is also indicated following the reduc-
tion of a dislocated joint. The patient with ligamentous sprains or • Slings, various sizes
muscle strains will also receive significant pain relief with splint The width of the cotton cast padding, plaster, and bias stocki-
immobilization. Splints are placed following orthopedic or soft nette required will vary by the site of application. In general, 1 to
tissue surgery of the extremities. 3 in. material can be used for the hands and digits, 3 to 4 in. wide
material can be used for the upper extremity, and 4 to 5 in. wide
CASTS material can be used for the lower extremity. Alternative materials
There are few reasons to immobilize an acutely injured extrem- include fiberglass strips and rolls instead of plaster strips. Elastic
ity with a cast in the Emergency Department. Most injuries can bandages (e.g., Ace wraps) can be substituted for bias stockinette.
be initially stabilized with a splint. Following reduction of certain Prefabricated splinting material is also available, with the padding
fractures, placement of a cast will secure the bones in their proper and fiberglass (or plaster) already assembled and covered with cot-
alignment and allow for a primary union (e.g., distal radius, tibial ton material (e.g., Parker Splints or Orthoglass). It is important
shaft).6,7 Placement of a cast instead of a splint should be per- to remember that all of the casts and splints described in this
formed only if the patient has access to close follow-up or can chapter can be constructed using plaster or fiberglass splinting
return to the Emergency Department for a cast check within material.
24 hours. Fiberglass rolls must be cut to the appropriate length with scissors
Patients with casts may present to the Emergency Department while plaster can easily be torn by hand. The fibers are too strong
with various cast-associated problems. The cast may have become to be torn by hand. Gloves should always be worn when handling
wet and lost its strength and integrity. The cast may no longer fit fiberglass because the resin will stick to skin and is exceedingly dif-
properly if the affected extremity has decreased in size from reduc- ficult to remove.4–6 Otherwise, the same principles described for
tion of swelling. The cast must be removed and the affected area plaster apply to fiberglass.
examined if the patient complains of persistent pain.6,7 All these
patients may safely be placed back in a cast. They may also be placed PATIENT PREPARATION
in an appropriate splint and follow-up arranged with an Orthopedic
Surgeon for casting. Whether reducing a fracture or simply manipulating the
extremity to place a cast or splint, make sure that the patient
has received appropriate analgesia. Conduct a thorough exami-
CONTRAINDICATIONS nation of the skin overlying the site of injury. It is inexcusable to
miss the diagnosis of an open fracture. All skin wounds must be
SPLINTS inspected and explored. Exploration of the wound is undertaken
There are no absolute contraindications for the placement of a splint. cautiously with a sterile probe or gloved finger according to wound
Relative contraindications include soft tissue injuries or wounds that size. Fractures may puncture the skin from the “inside-out,” result-
need regular care and evaluation. In this setting, the wounds should ing in an innocuous appearing pinhole in the skin. These are grade
be appropriately dressed and padded and the splint constructed so I open fractures and carry with them a 5% risk of infection.8 Cover
that it can easily be removed and replaced. A “window” may also any open fractures with sterile saline-soaked gauze until formal
be cut in the splint as it is being applied to facilitate access to the irrigation and debridement can be undertaken in the Operating
wound. The splint should not place pressure over the wound. Room. Do not examine open wounds repeatedly due to the risk
of increased contamination. Administer tetanus prophylaxis as
CASTS indicated. Administer the appropriate intravenous broad spectrum
antibiotics for an open fracture if present.
Do not cast an extremity that has the potential for significant Document a thorough neurologic and vascular examination of
edema or that may develop a compartment syndrome. An injured the injured extremity before and after any splinting or casting.
extremity with significant edema or soft tissue injuries should not A change in the neurologic or vascular status of an extremity may
be constrained by a cast. Similarly, infections of joint spaces or soft be the result of the fracture reduction, the splint or cast application,
tissues must remain exposed for frequent evaluations. Any frac- or a compartment syndrome. The fracture may have to be reduced
ture that is not adequately reduced by closed manipulation should and held in position while a splint or a cast is applied. If no reduc-
not be placed in a cast.3,7 A cast should not be applied by someone tion is needed, splint the affected extremity in a position of stability.
unfamiliar with the technique and unable to manage the associated Techniques for achieving and maintaining fracture reduction are
complications. beyond the scope of this chapter.
GENERAL SPLINTING CONSIDERATIONS placing it over the individual prominences. Alternatively, cotton
cast padding may be applied directly by wrapping the pressure
The general considerations and techniques common to the applica- point or bony prominence circumferentially as is done in cast
tion of all splints are discussed in this section.14,15 It describes the application.
techniques for splints utilizing cotton cast padding, plaster, and bias Begin applying the splint once the padding and splinting
stockinette. Many alternative materials are available and may be material have been cut to the appropriate lengths. Be sure that
substituted, such as fiberglass for plaster or elastic wraps for stocki- all required materials have been collected before dipping the
nette. Prefabricated splint materials that incorporate padding may splinting material in water to activate it. Only a limited amount of
also be used. The techniques described in these chapters are appli- time, less than 10 minutes, is available for splint application and
cable for all splinting materials. Where alterations in technique are molding once the splinting material is wet. Completely immerse
required, they are so noted. all of the splinting material in a bucket of tepid, clean tap water.
Splints are constructed of cotton padding overlaid by splinting Keep the splinting material submersed until no more bubbles
material (i.e., strips of plaster or fiberglass) and subsequently held arise from under the water (Figures 91-2B & C). At this point, the
in position by an overwrap of bias stockinette or an elastic bandage. splinting material can absorb no more water. Suspend the splint-
Splint padding should be thick enough to provide protection for the ing material over the bucket and lightly squeeze out the excess
skin from the plaster. The splint or cast will be unable to provide water by running your fingers down its length (Figure 91-2D).
sufficient immobilization of the fracture to maintain a reduction It should only take two or three passes of the fingers to remove
if the padding is too thick. One to two layers of cotton cast padding the excess water. Do not wring the plaster strips like a dish
are sufficient over the fracture site. Three to four layers of cotton rag, as that will cause loss of plaster into the bucket! Lay the
cast padding are required at the proximal and distal extents of the splinting material on a clean flat surface. Run your hands over the
splint to distribute the stresses. Thinner padding can be used when splinting material to laminate the individual strips into one slab.
maintenance of fracture reduction is a priority (e.g., with a fracture Laminating the strips together adds significant strength. Lay the
of the distal radius). splinting material onto the cotton cast padding (Figure 91-2E).
Plaster strips are available in precut slabs measuring either 4 by Fold the edges of the cotton cast padding over the splinting mate-
15 or 5 by 30 in. The precut strips have the advantage of speed and rial to cover all the edges completely. Apply the splint to the
ease of application. Alternatively, plaster and fiberglass are avail- extremity.
able in rolls of various widths ranging from 2 to 8 in. The rolls of An alternative and more commonly used method that is preferred
splinting material may be rolled out to the precise length desired by many is to apply the cotton cast padding circumferentially over
and cut appropriately. The rolls of splinting material are useful for the extremity, overlapping each layer by 50%, and then applying the
splints requiring long strips, such as coaptation splints. The ideal wet splinting material. In this fashion, the splinting material will
thickness for most upper extremity splints is 10 sheets or layers “stick” to the cotton cast padding. Smooth the splinting material
of plaster or five to six layers of fiberglass. The use of 15 sheets with the broad aspect of your hand and not your fingers to help
or layers of plaster or 8 to 10 sheets of fiberglass is preferable for minimize irregular indentations.
lower extremity splints. The strength of the splint depends on the The cotton cast padding should be facing the patient and no
number of layers as well as the lamination of the layers during their splinting material should directly contact the skin regardless of
application. the method used. Secure the splint with a wrap of bias stockinette
A piece of cotton cast padding may be used as a template for or an elastic bandage. The wrap must be applied under minimal ten-
the length of the required splinting material. Roll a piece of cotton sion when you are using an elastic wrap to affix the splint. The elas-
cast padding over the desired location of the splint to determine tic may cause increasing pressure over time. Gently apply strips of
the length of the splinting material required (Figure 91-2A). Roll tape to the end of the wrap to secure the bias stockinette or the elas-
out the splinting material to the appropriate lengths and cut them tic bandage. Tape should never be applied circumferentially, as
slightly shorter than the template. this can impede expansion of the splint due to underlying swell-
An alternative is to cut the splinting material approximately 1 to ing and create a tourniquet effect. Application of the tape under
2 in. longer than necessary so that the ends may be folded back on tension before the splint is completely hard will cause indenta-
themselves. This will prevent any contact of the sharp splint ends tions in the splinting material and result in pressure points on
with the patient’s skin. Prefabricated splinting material covered with the underlying skin.
padding has jagged ends and once it has been cut it begins to harden The splinting material may be molded at this point to achieve
immediately; even prior to the addition of water. These sharp ends greater conformity to the extremity or better reduction of the frac-
will rub against the patients exposed skin, even through cotton cast ture. It is paramount to use only the palms and not the finger-
padding or bias, and for that reason should be folded back. To avoid tips when molding the finished splint. Finger pressure induces
premature hardening of the prefabricated splinting material, keep it deformity in the splint that will result in skin breakdown under
inside of the protective foil and seal it with tape or the manufacturer those defects. All molding must stop once the splinting mate-
provided clips. rial begins to harden. The plaster is quite fragile, and cracks that
Bias stockinette may be applied to the extremity for extra pad- weaken the splint may be propagated. Apply 1 in. wide tape in a
ding and comfort. This may also be omitted depending on EP spiral fashion to secure the bias or elastic wrap after the plaster has
preference. Prepare strips of cotton cast padding. The strips of hardened.
cotton cast padding should always be longer and wider than If using prefabricated splinting materials, cut it to length,
the plaster. This prevents the plaster from touching the skin and remove it from the sealed foil, and wet it to activate the splint-
causing a pressure sore, abrasion, or burn. Padding is especially ing materials. Briefly pass the prefabricated splinting material
important at the proximal and distal edges, as this is where sig- under cool water. Place the wet prefabricated splinting material
nificant pressure originates. Apply additional pieces of padding on a towel and roll it up. This will remove any excess water. The
over pressure points and bony prominences (e.g., the olecranon). splinting material should not be soaked or placed in a bucket
Additional padding may also be created by folding a loose of water. It requires only one pass under the running water. The
piece of cotton cast padding back on itself several times and prefabricated splinting material should not be squeezed dry as
FIGURE 91-2. Preparing the splint. A. Cotton cast padding to measure the length
of material needed. B. Plaster is submersed in tepid water and air bubbles arising
from it. C. Fiberglass is submerged in tepid water and air bubbles arising from it.
E D. Suspend the lengths of wet splinting material over the bucket and gently squeeze
out the excess water. E. The splinting material is placed on the cotton cast padding.
this tends to deform the splinting material and result in a poorly GENERAL CASTING CONSIDERATIONS
molded final product.
Apply the splint and mold it to the extremity. It is paramount The general considerations and techniques common to the applica-
to use only the palms and not the fingertips when molding the tion of all casts are discussed in this section.3,5,6,10 Casting requires
finished splint. Finger pressure induces deformity in the splint careful circumferential turns of material instead of longitudinal
that will result in skin breakdown under those defects. Any layers of material, as for splints. Casts are constructed of cotton
excess length of splinting material should be folded back on itself cast padding overlaid with either fiberglass or plaster bandages (i.e.,
so that the cut ends do not come in contact with the patient’s skin. casting materials). The four areas that require particular attention
The distal part of any extremity should always be left visible so that and are discussed in this section are the application of padding, pad-
the EP may recheck a neurovascular exam. The patient will also ding pressure points, application of casting material, and molding
be able to visualize any changes in color that may occur latter. It is the cast.
held in place by circumferentially wrapping the splinting material Begin by organizing the required supplies. Cast application
with an elastic bandage. The elastic bandage should be applied requires the same material as that used in splinting (i.e., water,
relatively loosely so it will not induce increased compartment cotton cast padding, stockinette, and casting material). The width
pressures. of the padding and casting material depends on the size of the
A B
FIGURE 91-3. Preparing to place a cast. A. Apply an initial layer of tubular stocki-
nette. B. The stockinette has been unrolled over the extremity. C. Begin and end
the layering of the cotton cast padding at a site distal and proximal to where the
casting material will end. Unroll the cotton cast padding in a circumferential man-
ner, covering each preceding layer by one-third to one-half of its width. D. The
C cotton cast padding tears easily to provide additional layers of padding over bony
prominences.
extremity. Generally, the 4 to 6 in. wide rolls of casting material are

used for lower extremity casts while 3 or 4 in. wide rolls are used for
the upper extremity. Use the widest casting material available and
possible in order to limit the number of turns of the fiberglass or
plaster roll over joints and other curved surfaces. Place all materi-
als on a tray near the bedside, including a bucket of tepid water. An
assistant designated to dip and drain the casting material and help
with patient positioning is immensely helpful.
Prepare the patient. Position the extremity and the patient appro-
priately for cast placement. The patient is frequently able to assist in
the process. Cover the patient with gowns or towels to keep casting
material off their clothes.
Apply tubular stockinette to the extremity (Figures 91-3A & B).
The stockinette is not a necessary component of casting, but many
EP use it as a first layer.5 It provides a smooth covering over the skin
that wraps neatly over both ends of the cast. Roll up the stockinette.
Place it over the distal extremity as if you were putting on a sock FIGURE 91-4. Hold the casting material roll in both hands and gently twist each
(Figure 91-3A). Unroll the stockinette up the leg (Figure 91-3B). end to squeeze out the excess water. Keeping the free end of the casting material
Care must be taken to apply the stockinette gently. Do not create folded over will facilitate access after it has been removed from the water.
tension in the stockinette by pulling it tightly. Eliminate any
creases or redundancy of material by trimming any overlapping
folds with a scissors. For upper extremity injuries, cut a small hole
one-third of the way from the end of one side of the stockinette to Apply the casting material (Figure 91-5). Place the roll of casting
allow the thumb to pass through. material on the extremity (Figure 91-5A). Unroll the casting mate-
The primary layer of padding is provided by the cotton cast pad- rial in a circumferential fashion around the extremity. Never lift the
ding. Casts and cast padding should be applied from distal to roll of casting material off the extremity! Continue each consecu-
proximal. Begin wrapping the cotton cast padding at a point that tive wrap around the extremity by overlapping the casting material
will be distal to the start of the plaster (Figure 91-3C). This ini- by approximately 50%. The free border of the casting material will
tial band of padding is essential for protection against the cast edge. have excess material in it as the extremity changes in size. Grasp
Keep the roll of padding in contact with the skin so that the mate- this excess casting material with the thumb and index finger of the
rial conforms easily to the contours of the extremity as it unrolls. nondominant hand (Figure 91-5B). Pull it outward to create a tuck
Unroll the padding in a circumferential manner around the extrem- or a fold. Wrap this fold around the extremity (Figure 91-5C) and
ity. The cotton cast padding must be laid down neatly and cleanly smooth the fold down against the extremity. This fold will barely be
with no kinks or creases. Each turn should overlap one-third to noticeable in the final product. As one roll of casting material ends,
one-half of the previous turn. Tear off the extra cotton cast pad- another should begin with a small amount of end-to-end overlap.
ding to eliminate excess material as you turn angles (e.g., ankle, Do not make consecutive folds at the same site as this will create
heel, elbow, or thumb). Lay the torn edges down by rubbing the bumps and add bulk to the cast.
padding smoothly. Continue applying the padding, ensuring that it Continuously mold and smooth the casting material with wet
extends beyond the proximal end of where the cast edge will be to hands as each layer is applied. This action ensures continuity of
ensure skin protection at the cast edge. Excess length can easily be casting material throughout the cast and forms a smooth cast
torn away after the cast is applied and hardened. Typically, two lay- that conforms to the contours of the extremity. Use only the pal-
ers of cotton cast padding are adequate for protection between the mar surface of the hands and proximal digits to mold and smooth
skin and the casting material. the casting material (Figure 91-5D). Excessive use of the finger-
Pressure points occur over bony prominences or where excess tips will produce irregular indentations and pressure points.
padding has created an unnatural prominence. Palpate the obvious Molding around irregular bony areas is best accomplished with two
bony prominences to get a sense of whether or not there is adequate hands simultaneously rubbing the casting material. Do not allow
padding after the application of the two layers of padding. If the area excessive time to pass between applying each layer of the casting
feels vulnerable, place torn off pieces of cotton cast padding onto material, as lamination between layers may not occur. This will
the exposed areas (Figure 91-3D). Do not over-pad bony promi- weaken the cast considerably.
nences, as excess layering can also lead to excess pressure. Two to A cast thickness of 1/4 in. is felt to be adequate. This usually
three layers of padding are adequate for most pressure points and requires four to five layers of plaster or three to four layers of
bony prominences. Rub the torn edges of the padding so that they fiberglass. Allow the cast to set and dry with no further manipu-
fuse smoothly to the underlying padding. lations by the EP or the patient. The time for drying is variable
Place the rolls of casting material in a bucket of tepid water so depending upon the casting material used, the water temperature,
that they are standing on end. Let the casting material remain sub- and the thickness of the cast. Typically, let the casting material set
mersed as long as air bubbles rise out from the center of the roll over a period of 10 to 15 minutes. Fold the free ends of the cotton
(Figures 91-2B & C). Remove the rolls of casting material when all cast padding and the stockinette over the edges of the cast as it
bubbles stop rising. Hold the casting material in both hands and sets (Figure 91-6). This prevents the rough edges of the casting
squeeze some of the water out (Figure 91-4). Do not wring the roll. material from irritating and abrading the skin. Secure the edges
Do not eliminate all the water from the roll. Squeeze it gently. The of the cotton cast padding neatly with tape or thin strips of cast-
remaining water in the roll is necessary for smoothing and molding ing material.
the casting material into one solid unit. In general, casts should be It is a common practice to bivalve the cast with a cast saw if
applied with “wetter” material and splints with “drier” material as the potential for increased swelling of the extremity is a concern
less time is required to apply a splint. (Figure 91-7). Cut completely through the length of the cast in two
A B
FIGURE 91-5. Apply the casting material to form the cast. A. Lay the roll of casting material on the extremity and unroll it. B. As the limb changes in girth, there will be
excess plaster. Use the nondominant hand to pull on the excess material. C. Fold the excess material back onto the extremity in a neat tuck. Each tuck should be laid down
smoothly with a molding of the hand. D. The casting material is laminated smooth with a continuous motion of the palmar surface of the hand and the proximal fingers.
FIGURE 91-7. Splitting of the cast can be achieved with a cast saw that cuts
FIGURE 91-6. Fold the free ends of the cotton cast padding and the stockinette through the thickness of the fiberglass or plaster. Cut the underlying protective
over the edges of the casting material to finish the cast. material with a scissors.
spots 180° apart (i.e., medial and lateral or anterior and posterior).
This simple maneuver provides some room for edema without
compromising the integrity of the reduction or the strength of the
cast. The underlying cast padding must also be split. Splitting the
plaster alone will not reduce the pressure sufficiently.
UPPER EXTREMITY CASTS AND SPLINTS
COAPTATION SPLINT
A coaptation (“to bring together”) splint is used primarily in the
acute setting for humeral shaft fractures that are nondisplaced or
minimally displaced. This splinting technique allows for motion
of the hand and wrist while limiting shoulder and elbow mobility.
The cotton cast padding should extend from the nape of the neck
to the axilla to avoid skin breakdown. The patient should then be
placed in a sitting position to minimize splint displacement during
FIGURE 91-9. The sugar tong splint. Leave the metacarpal joints free for flexion
the actual application process. The length of the splint extends from and extension. The overwrap has been omitted for easier visualization of the splint.
the axilla, around the 90° flexed elbow, along the outer arm, over
the deltoid muscle, and over the acromion process (Figure 91-8).
It is critical that the splinting material extend over the deltoid
muscle and the acromion process. The shoulder portion can be too short and having it fall off! A splint that is too long will not pro-
held down by applying 3 in. wide tape over the portion of the splint vide proper immobilization. Always leave plenty of length over the
that covers the acromion. Secure the splint with an elastic bandage shoulder. Padding is required to minimize axillary irritation. The
that covers the entire splint. The major pitfall is making the splint disadvantages of this splint include the possibility of fracture dis-
placement and extremity shortening. The splint should be replaced
with a functional brace or cast after a short period of immobiliza-
tion for pain control.4
SUGAR TONG SPLINT

Sugar tong splints may be used for mid-forearm fractures, distal
forearm fractures, and some wrist fractures. They are most com-
monly recommended for minimally displaced and distal ulnar and
radial fractures (i.e., Colles and Smiths fractures). This splint immo-
bilizes the elbow and wrist joints to prevent supination and prona-
tion of the forearm (Figure 91-9). The splint begins at the palm,
just proximal to the metacarpophalangeal (MCP) joints. It has the
distinct advantage of allowing the MCPs to remain free preventing
stiffness in those joints. Measure the required length of splinting
material along the volar surface of the hand (starting just proximal
to the MCP joints) and forearm, around the elbow, and back on
the dorsal surface of the forearm ending just proximal to the MCP
joints. The MCP joints should be left completely free to prevent
stiffness. Early mobilization of the fingers will help to reduce swell-
ing. Apply cotton cast padding from the MCP joints to just proximal
to the elbow. The ulnar styloid process and the olecranon process
are two bony prominences that need extra padding for comfort and
prevention of pressure sores. The free ends of the splint also need
added protection to minimize hand discomfort. Apply the splint.
Mold the splinting material with great caution to prevent closure
of the sides of the splint, thus forming a closed cast. Fold and/or
cut the volar and dorsal splinting material to ensure that the finger
MCP joints are freely mobile (Figure 91-9).
POSTERIOR LONG ARM SPLINT

Distal humeral fractures and proximal forearm fractures can be
immobilized in a posterior long arm splint (Figure 91-10). It is also
useful for fractures of the radial head and neck, olecranon frac-
tures, and severe ligamentous injuries to the elbow. The posterior
long arm splint extends from the axillary crease area, behind the
elbow, distally to incorporate the wrist joint, and ending at the MCP
FIGURE 91-8. The coaptation splint. The overwrap has been omitted for easier shafts (Figure 91-10). This splint immobilizes the elbow in a range
visualization of the splint. of 45° to 90° with the forearm in supination, pronation, or neutral
FIGURE 91-11. The radial gutter splint with the hand in the “safe” position.9
FIGURE 91-10. The posterior long arm splint. The forearm and wrist are in a neu-
tral position. The padding and overwrap have been omitted for easier visualization
of the splint.
holding a can of soda. The fingertips should be visible to allow for
repeat neurovascular examinations.
positioning depending upon the type of injury. The wrist can also be
in a flexed, extended, or neutral position. The metacarpals should ULNAR GUTTER SPLINT
not be immobilized in this splint unless the distal forearm or This splint is used for the treatment of stable metacarpal and phalan-
wrist fracture is comminuted. Despite the many possibilities, the geal fractures of the ring and small fingers (Figure 91-12). The long
posterior long arm splint is usually applied with the elbow flexed axis of the plaster extends from the pulp of the distal fingers to the
90°, the forearm neutral, and the wrist neutral (Figure 91-10). proximal forearm. Place cotton cast padding between the ring and
little fingers to prevent any maceration (Figure 91-12A). The width
RADIAL GUTTER SPLINT of the plaster must wrap around the ulnar aspect of the hand and
forearm. Mold the splint around the forearm, hand, fourth finger,
The radial gutter splint is used for the treatment of stable phalangeal
and fifth finger. The radial side of the hand is left entirely free. The
and metacarpal fractures of the index or middle fingers. The splint-
hand is immobilized in the “safe” position with the wrist dorsiflexed
ing material extends from the pulp of the distal fingers to the proxi-
20°, the MCP joints flexed 60° to 70°, and the IP joints extended
mal forearm (Figure 91-11). It is helpful to measure and cut a hole
or slightly flexed at 10°9 (Figure 91-12B). The fingertips should
in the middle of the splinting material to allow for the insertion of
remain visible to allow for repeat neurovascular examinations.
the thumb prior to wetting the splinting material. Place cotton cast
padding between the index and middle fingers prior to applying the
splint to prevent skin maceration. Mold the width of the splinting VOLAR SPLINT
material around the radial aspect of the index finger, middle finger, The volar splint can be used for the treatment of wrist fractures,
hand, and forearm to create a stabilizing force. The ulnar aspect of radial styloid fractures, ulnar styloid fractures, metacarpal frac-
the hand and forearm is left entirely free. The hand is immobilized tures, middle phalangeal fractures, and proximal phalangeal frac-
in what is considered a “safe” position with the wrist dorsiflexed 20°, tures. This splint remains only on the volar surface of the hand and
the MCP joints flexed 60° to 90°, and the interphalangeal (IP) joints forearm, as the name suggests. The splint begins at the proximal
extended or slightly flexed at 10°9 (Figure 91-11). This is also known forearm and ends just proximal to the MCP joints (Figure 91-13).
as the “position of comfort.” It can be described as if the patient were The splint can be modified and extended to include the fingers
A B
FIGURE 91-12. The ulnar gutter splint. A. Padding is necessary between any fingers that are immobilized together. B. The final product with the hand in the “safe” position.9
for phalangeal fractures with the wrist dorsiflexed 20°, the MCP
joints flexed 60° to 90°, and the IP joints extended or slightly
flexed at 10°.
DORSAL (“CLAM DIGGER”) SPLINT

The dorsal splint can be used in place of a volar splint for injuries
of the distal forearm, wrist, or hand. The splint runs along the dor-
sal surface of the forearm and hand, from the proximal forearm to
the ends of the digits. As with the volar splint, the wrist is extended
15° to 20°, the MCP joints are flexed 60° to 90°, and the IP joints are
extended or slightly flexed to a maximum of 10°.
The dorsal splint maintains better control of the MCP and IP
joints, assuring that the hand remains in the “safe position,” when
compared to the volar splint. Pad the splint adequately to prevent
pressure sores, since the dorsal surface of the hand lacks the intrin-
sic fat pads of the palm.
THUMB SPICA SPLINT

Scaphoid fractures, navicular fractures, carpometacarpal sublux-
ations and dislocations of the thumb, and collateral ligament inju-
ries of the thumb can all be immobilized in a thumb spica splint
(Figure 91-14). This splint extends to the proximal forearm. It
can be extended proximally to include the elbow joint if required.
It is positioned on the forearm, like a radial gutter splint, but only
the thumb is immobilized. There are several methods to form-
ing a thumb spica splint. One can simply lay the plaster over the
radial aspect of the forearm and thumb. It is useful to cut one
side of the splint into a shape that conforms to the thumb to
facilitate the placement of the splint material around the thumb
FIGURE 91-13. The volar splint. The overwrap has been omitted for easier visu- (Figure 91-14A). Cutting a wedge out of one side of the plaster
alization of the splint. will allow for easier splinting of the thumb without excess material
A B
FIGURE 91-14. The thumb spica splint. A. One technique of thumb spica applica-
tion with the splinting material cut to conform to the thumb. B. Cutting the splint-
ing material facilitates this different technique of thumb spica application. C. The
C final product with the wrist dorsiflexed 20° and the thumb positioned as if a glass
were being held in the hand.
collecting in the first web space (Figure 91-14B). Position the if it involves the strain of a joint or ligament. The finger can be
thumb as if a glass were being held in the hand with the wrist in splinted in isolation, or it can be immobilized with the adjacent fin-
20° of dorsiflexion (Figure 91-14C). ger for additional stability. Applying a single-digit or two-digit splint
allows neighboring joints to remain mobile. Splinting material is
rarely used for finger splints in the modern Emergency Department
FINGER SPLINTS
setting. The creation of foam-padded metal or plastic splints has
Immobilization of the finger lends itself to great creativity in the facilitated immobilization of the affected digit. Nonetheless, small
field of splinting. Finger splints may be adequate for immobilization strips of cut splinting material can still be used to stabilize any finger
of stable finger fractures, reduced dislocated joints, or ligamentous injuries. The juxtaposition of the affected finger with its neigh-
strains. Splint the finger in full extension if it involves an extraartic- boring finger requires padding between the digits to prevent skin
ular fracture of the distal phalanx. Splint the finger in slight flexion maceration and breakdown.
A B C
D E F
FIGURE 91-15. The short arm cast. A. Flex the elbow 90°. The patient can help position the wrist and fingers in a position of function. B. Tubular stockinette is applied to
the entire arm in anticipation of a long arm cast. C. Cotton cast padding is applied to the forearm. Adequate padding is also needed at the thumb, as it will remain exposed
and mobile. D. Cut one side of the casting material as it is wrapped around the thumb. Less bunching of excess material occurs with quick cuts of the casting material. E. An
additional length of casting material (four to five layers) can be applied along the ulnar length of the cast. This serves as reinforcement if additional strength is necessary.
F. Mold the cast with the palmar aspect of the hands.
FIGURE 91-15. (continued) G. The wet cast-

ing material and underlying padding are cut
G H and folded back to fully expose the thumb.
H. The “okay” sign of a properly exposed thumb.
SHORT ARM CAST LOWER EXTREMITY SPLINTS AND CASTS

The short arm cast is used for stable fractures of the metacarpals,
the carpal bones, the distal radius, and the radial or ulnar styloid ANKLE (SHORT LEG) SPLINT
processes (Figure 91-15). The short arm cast begins at the proxi- The ankle splint helps to immobilize isolated ankle injuries with
mal forearm and extends to include the palm and the dorsum of the the joint at a 90° angle (Figure 91-17). This splint is commonly
hand. The metacarpophalangeal and elbow joints are left exposed used for ankle fractures and sprains. It can also be helpful for cer-
to allow for full motion at these joints. Flex the patient’s elbow 90° tain stable fractures of the foot. This splint can be applied as a pos-
(Figure 91-15A). Place the wrist in the desired position. The extent terior splint or a lateral to medial stirrup splint.13 Combining the
of flexion and ulnar-radial deviation of the wrist is determined by two techniques can provide additional support for the ankle and is
the underlying injury. The forearm can be in a neutral, pronated, or known as a trilaminar splint. The first part (posterior splint) pro-
supinated position. Apply bias stockinette (Figure 91-15B). Apply vides posterior support to the foot and ankle. The second part cre-
cotton cast padding (Figure 91-15C). Ensure that extra padding is ates a medial-to-lateral stirrup-like splint around the sides of the
applied to the bony prominences of the base of the thumb and the ankle for additional stability.
ulnar styloid. Place the patient prone with their knee flexed 90° and the foot
Apply the casting material. Roll the casting material over the pointing upward (Figure 91-17A). Place the posterior support of
padding from the hand to the forearm. A quick trim of the cast- splint material from the proximal posterior calf, passing under the
ing material will allow for a better fit as it passes around the thumb heel, and along the plantar surface of the foot (Figure 91-17B). It
(Figure 91-15D). Provide adequate space for the thumb so that
its motion is not limited. The application of additional layers to the
anteromedial surface will strengthen the cast (Figure 91-15E). Mold
the cast with an anterior–posterior force applied to the forearm and
not up and down strokes (Figure 91-15F). Use smooth, rapid, and
repetitive motions to mold and laminate the casting material. Trim
the casting material while it is still wet to even out the thumb open-
ing and the cast ends (Figure 91-15G). Ensure that all protective
padding is pulled out from under the casting material to protect the
skin from the sharp edges (Figure 91-15G). The patient should be
able to touch the tips of the thumb and index fingers when the cast
is properly applied (Figure 91-15H).
LONG ARM CAST

A short arm cast can easily be extended into a long arm cast if
needed. Simply extend the cast proximally with the elbow in 90° of
flexion. Extend the padding and the casting material to the proxi-
mal humerus, ending two or three finger breadths distal to the axilla
(Figure 91-16). Be careful to provide adequate padding around the FIGURE 91-16. The short arm cast is extended into a long arm cast. The axilla
axilla or the patient will complain about the sharp cast edge. needs adequate padding for protection of its sensitive skin.
A B C
FIGURE 91-17. The ankle splint. A. Stockinette is

applied and the leg is positioned. B. The splinting
material is applied posteriorly. C. A stirrup splint is
applied around the medial to lateral ankle. D. Fold
the corners and smooth out the splint. E. An elastic
wrap is applied over the splint after folding back the
stockinette. The foot is maintained in this position D E
until the plaster sets.
can be extended distal to the toes to provide protection. Place the lengths of splinting material are used to stabilize the leg while the
foot 90° to the tibia and in neutral rotation. anterior aspect of the leg is left exposed. Measure the extremity
For a “stirrup” support of the ankle, begin by applying splinting from the gluteal crease distally to the tips of the toes. It is impor-
material onto the length of the medial aspect of the proximal calf, tant to add an additional 1 to 2 in. to the measured length so that
over the medial malleolus, under the heel, and up the lateral aspect the splinting material can be folded back on itself to protect the
of the ankle and calf (Figure 91-17C). The stirrup portion should patient from the sharp ends. The application of medial and lateral
be long enough to go from mid-tibia to mid-fibula when wrapped splinting material begins at the upper thigh just below the level of
under the affected foot. Fold and smooth the edges of the stirrup the gluteal crease and travels down the knee, calf, and under the
around the heel (Figure 91-17D). Keep the ankle flexed 90° with the ankle. The posterior portion of splinting material begins at this
foot neutral while the splint material sets (Figure 91-17E). same level and travels down the posterior aspect of the leg, behind
the knee, curving around the heel, and ending just beyond the
ends of the toes. Flex the foot 90° to the tibia, flex the knee 10° to
LONG LEG SPLINT
30°, and mold the splint. Failure to keep the ankle at 90° will allow
This splint is commonly used for knee and tibial injuries prior the Achilles tendon to shorten and stiffen. A pillow may be placed
to and after surgical fixation. It is basically a longer extension of under the knee to maintain 20° to 30° of flexion while the splint
the short leg splint described above. Posterior, medial, and lateral hardens.
FIGURE 91-19. The short leg cast leaves the knee and tibial tuberosity exposed.
The finger is pointing to the tibial tuberosity.
The short leg cast begins at the proximal calf, below the knee,
and extends down to the toes (Figure 91-19). The knee and tibial
tuberosity are left entirely free to allow for full flexion and exten-
sion. The toes can be left entirely exposed or the cast can provide
a hard sole of support and protection beneath the toes. Apply
cotton cast padding with extra attention to the areas of bony
prominence such as the fibular head, the lateral malleolus, and
the medial malleolus. Apply the casting material from the calf to
the toes as if applying a short arm cast. Mold the casting mate-
rial around the Achilles tendon, away from the malleoli and to
conform to the plantar arch. Cut the wet casting material under
the metatarsal heads to expose the toes or leave it long to support
the entire toes.
Converting a short leg non-weight bearing cast to a walking
cast requires small adjustments to the existing cast. Supplement
FIGURE 91-18. Positioning and splinting of the patient with an Achilles tendon
the arched foot of the short leg cast with additional casting mate-
injury.
rial to form a flat surface. Apply a preformed heel after the cast
has completely dried to prevent any indentation. Place the
walking heel in the midsagittal plane of the foot with the center
SPLINT FOR ACHILLES TENDON RUPTURE aspect lining up with the anterior calf. Secure the heel in place
Rupture of the Achilles tendon can be managed surgically or con- with copious casting material wrapped around the foot and ankle
servatively with immobilization. Surgery is often delayed and the (Figure 91-20).
patient will require immobilization. Position the patient as if placing
an ankle splint or have the patient sit up with the affected extremity
hanging over the gurney’s edge. Position the foot in 20° to 30° of
plantarflexion (Figure 91-18). This is a position that the foot will
naturally relax into. Place a posterior splint on the lower extremity
extending from the proximal calf to the distal aspect of the toes. Cut
out wedges of plaster in order to minimize buckling at the malleoli
as the splint material wraps around the heel.
SHORT LEG CAST

The short leg cast is used for stable ankle fractures and stable frac-
tures of the hindfoot, midfoot, and forefoot (Figure 91-19). Place
the patient either supine or sitting on the edge of the gurney. Place a
padded block under the distal thigh if the patient is supine. Instruct
an assistant to hold the patient’s toes to help keep the lower extrem-
ity in a good position. Holding the leg by the toes may allow the
force of gravity to disrupt fracture alignment. Care must be taken
to prevent this outcome. The patient can sit upright on the edge of
the gurney with the affected leg hanging down freely if no assistant FIGURE 91-20. Converting the short leg cast into a walking cast. A walking heel is
is available. secured with an additional casting material over-wrappings.
fingers and toes should be encouraged to help reduce edema in the

extremity. The cast or splint must be kept completely dry. Should
bathing be desired, instruct the patient to place two plastic bags
over the extremity and tape the proximal edge to the skin of the
extremity. Sufficient pain medication should be supplied to last
the patient until their follow-up visit with an Orthopedic Surgeon.
This should include nonsteroidal anti-inflammatory drugs supple-
mented with narcotic analgesics. A sling may facilitate mobiliza-
tion for some upper extremity injuries.
COMPLICATIONS
The most common complications associated with the application of
a cast or splint include plaster sores, compartment syndrome, joint
stiffness, thermal injury, infection, and allergic reactions. The fol-
lowing section focuses on the prevention of these complications.4,6,10
FIGURE 91-21. The long leg cast.
PLASTER SORES
Plaster sores result from ischemic necrosis of the skin under-
neath a cast or splint. The skin begins to exhibit necrosis after
LONG LEG CAST only 2 hours of continuous pressure. Great care should be taken
The long leg cast can be used for immobilization of distal femoral or in applying a cast or splint and only molding it with the broad
proximal tibial fractures (Figure 91-21). The cast extends from the surfaces of the hands. Molding with the fingers can result in
metatarsal heads to several finger breadths below the groin. The leg indentations and localized areas of pressure. The cast or splint
is immobilized with the knee in slight flexion and the foot 90° to the should never be allowed to rest on a hard or pointed surface
tibia with no internal or external rotation (Figure 91-21). Extending until it is completely dry. Points of contact on the hard surfaces
the short leg cast up to the groin is a safe and stepwise technique may cause impressions that result in increased pressure. Extra
of forming a long leg cast. Be sure to provide sufficient overlap of padding over bony prominences may decrease the incidence of
casting material at the junction between the two casts. Inadequate plaster sores.
overlap will weaken the integrity of the cast. Support the knee in Complaints of pain should be taken very seriously. The cast or
slight flexion while the casting material sets. Make sure that there splint should be split or removed immediately and the skin exam-
is adequate padding around the proximal free edge of the cast to ined. If the pressure point is not addressed rapidly, the pain will often
protect the groin. subside as the skin becomes necrotic. This oversight often results
in a foul smelling pressure sore under the cast or splint when the
patient returns for follow-up. Cast and splint treatment may be rife
KNEE IMMOBILIZERS with complications for patients with limited sensation from under-
Knee immobilizers can be made using splinting material and are lying medical conditions (i.e., diabetes, paraplegia, and myelome-
indicated for ligamentous injuries. Measure the extremity start- ningocele). Great care should be taken and extra padding used
ing 10 in. above the patella to 10 in. below the patella. Double that when casting or splinting these individuals.
length and cut the splinting material. Fold the splinting material Common areas of pressure necrosis also include the proximal and
end-to-end. Make a cut in the folded side extending from one edge distal ends of the cast or splint. These are areas of stress concentra-
to the middle of the folded side to create a hinge. Apply cotton cast tion. Great care should be taken in padding the ends of the cast or
padding starting 10 in. above the patella to 10 in. below the patella. splint during the application. No plaster or fiberglass should ever
Place the hinged portion of the splinting material 10 in. below the touch the skin directly. If the edges of the splint are sharp or too
anterior patella with the cut ends extending proximally up both the long, they should be folded out and away from the patient.
medial and lateral leg. Secure the splinting material with a loose fit-
ting elastic bandage. COMPARTMENT SYNDROME
A compartment syndrome is a significant complication from
AFTERCARE the application of a cast or, less commonly, a splint. The rigid
The most feared complication of a splint or cast application is the immobilization prevents soft tissue expansion from edema and
development of a compartment syndrome. The aftercare is geared decreases the amount of fluid needed to raise compartment
toward edema reduction and patient education. Instruct the pressures.11 In cases of acute fractures, casts should be used with
patient regarding the early signs of a compartment syndrome. This caution and always split in the direction perpendicular to the force
includes increased pain, pain with passive motion, paresthesias, needed to maintain the reduction. For example, after casting a dis-
pallor, decreased or altered sensation, as well as delayed capillary tal radius fracture where a dorsal mold is needed to maintain the
refill. The patient should return to the Emergency Department reduction, split the cast longitudinally on the volar and dorsal
immediately if they develop any of these symptoms, if the digits surfaces (i.e., bivalved) to allow for mediolateral spread of the
become cold or blue, or if the patient has other concerns. The plaster. Splinting greatly reduces the chance of iatrogenic-induced
extremity should be maintained above the level of the heart for compartment syndromes because unlike casting, splints do not
the first 48 to 72 hours after the injury. Ice should be applied to harden circumferentially.
the surface of the cast or splint for at least 15 minutes three times a It is not sufficient to split only the plaster. The plaster and
day. The cold therapy will be transmitted through the cast or splint underlying cotton cast padding must be split to visualize the skin
and result in significant reduction of edema. Active motion of the underneath. Making a single longitudinal cut (i.e., univalving) in
the cast can also decrease the compartment pressure. Univalving the used in the application of a cast or splint to anesthetized patients,
cast can decrease intracompartmental pressures by 30%.12 Spreading insensate limbs, or confused patients.
the cast 1 cm after cutting it can lower the pressure 60%.12 Splitting
the cotton cast padding will decrease the pressure by 70%.12 INFECTION
Infection secondary to a cast or splint is uncommon and is usu-
JOINT STIFFNESS
ally related to open wounds or exposed surgical pins underneath
Joint stiffness is a significant complication of joint immobilization the plaster. Fresh water should be used to wet the plaster. Do not
with casts and splints. Sometimes the immobilization is unavoid- use standing or previously used water, as it is an excellent culture
able, as the incorporation of the ankle and the knee in a long leg cast. medium. All wounds should be dressed with sterile gauze and cot-
Every effort should be made to decrease adjacent joint immobili- ton cast padding prior to applying the cast or splint. Windows can
zation as soon as it is safe and practical. For example, by convert- be created over wound sites to allow for regular care and evaluation.
ing a long leg cast into a short leg cast. Patients should be instructed to keep casts and splints clean and dry
Immobilize the extremity in a position of function as long as so as to prevent skin maceration.
this does not interfere with the maintenance of fracture reduc-
tion. For example, take great care not to immobilize the ankle in ALLERGIC REACTIONS
plantarflexion when applying a lower extremity splint or cast. This
mistake is commonly seen when a long leg cast is placed. This pitfall Allergic reactions to cotton, fiberglass, and plaster have been
may be avoided by the stepwise application of the cast. First apply reported but are exceedingly rare. Orthopedists and orthopedic
the cast to the foot and ankle with the ankle held 90° to the tibia. technicians may develop a contact dermatitis from continued expo-
Second, extend the cast proximally to become a short leg cast and sure to plaster over many years. Gloves should be worn for plaster
mold the reduction. Finally, extend the cast up the thigh as needed. and fiberglass application.
An additional benefit is the reduction of anterior compartment
pressures of the leg when the foot is held in 0° to 37° of dorsiflexion. SUMMARY
Great care should also be taken in splinting the upper extremity.
Every effort should be made to leave the fingers mobile at the The initial management of orthopedic trauma is a fundamental
metacarpophalangeal joints. Immobilization of the metacarpo- aspect of Emergency Medicine. Fractures and dislocations of the
phalangeal joints in extension results in shortening of the collateral extremities are routinely handled in the Emergency Department
ligaments and thus limits flexion. Immobilize the metacarpopha- with prompt Orthopedic follow-up or consultation. The applica-
langeal joints in 90° of flexion if they must be immobilized. This tion of external immobilization can be the definitive or temporiz-
position keeps the collateral ligaments in a lengthened position and ing management of the injured extremity. The application of splints
allows a rapid return to function. accounts for the majority of immobilization of injured extremities.
Cast application plays a role in maintaining bony alignment follow-
ing closed reductions of fractures.
THERMAL INJURY
Clear benefits of external immobilization include pain relief and
Thermal injury may result from the exothermic reaction of the reduction of further soft tissue injury from bony fragments.
plaster or fiberglass as it sets (i.e., dries). The heat generated Immobilization of the fracture decreases motion and traction
during the setting increases as the number of layers (i.e., thick- on the nerve-rich periosteum.4,7 The immobilization of fracture
ness) increases as well as the temperature of the water increases. ends protects adjacent neurovascular structures from injury and
Also important is the ability to dissipate the heat generated by helps prevent bony fragments from penetrating the skin. External
the drying plaster or fiberglass. Placing a cast or splint on a plas- immobilization also reduces the area available for hemorrhage and
tic pillow as it dries will result in reflection of the heat and an decreases bone bleeding.4 Early immobilization leading to fracture
increased temperature within the cast or splint. The use of cloth stabilization is also important in reducing the morbidity associated
pillows or towels under the cast or splint allows for some dissipa- with long bone fractures.12 Finally, the closed treatment of fractures
tion of the heat. Optimal heat dissipation occurs by exposing the facilitates the body’s natural processes of repair. External periosteal
cast or splint to circulating air. and internal intramedullary callus formation is optimized in the set-
Sufficient cotton cast padding must be used to protect the skin. ting of bony alignment that has been secured by casting or splinting.
Plaster and fiberglass must never touch the skin directly. The The application of splints is an essential skill for any Emergency
incidence of thermal injury can be decreased by using cool water Physician. The application of a cast in the Emergency Department is
and as thin a layer of plaster or fiberglass as possible to accom- appropriate in some select situations. The casting or splinting of an
plish stable immobilization of the extremity. Great care should be extremity is simple, easy to perform, and relatively quick.
SECTION
Skin and Soft Tissue Procedures 7

1 year after wounding. The skin will eventually regain only 70% to
General Principles of 90% of its original tensile strength.
92 Wound Management FACTORS AFFECTING NORMAL REPAIR
Lisa Freeman Grossheim
The most common causes of improper wound healing are tension on
the wound edges, necrosis and/or ischemia of the tissues from local
INTRODUCTION conditions (e.g., crush injuries and contusions decrease blood flow
An acute wound can be defined as an unplanned disruption in the and lymphatic drainage, which alters local defense mechanisms),
integrity of the skin, including the epidermis and dermis. The goals or shock. Hypovolemia is the major deterrent to wound healing in
of wound management are to restore tissue continuity and func- patients with hemorrhage and shock, hemorrhage from inadequate
tion, minimize infection, repair with minimal cosmetic defor- hemostasis, infection, or retention of foreign bodies. Systemic con-
mity, and be able to distinguish wounds that require special ditions such as malnutrition, immunosuppression, shock, diabe-
care. The principles of wound management should be emphasized tes secondary to microangiopathy, decreased oxygen and nutrient
over the repair technique. Appropriate wound management prior delivery to the wound, renal insufficiency, cytotoxic drugs, vitamin
to approximating the wound will allow it to heal with minimal deficiency, trace metal deficiency, and collagen vascular disease can
complications. This includes wound cleansing, debridement of the result in poor wound healing. Polymorphonuclear leukocyte func-
wound edges, wound approximation, and prevention of secondary tion is known to be impaired from hyperglycemia, jaundice, uremia,
injury. cancer, or chronic infections.
Drugs and medications can contribute to good wound healing or
HEALING OF WOUNDED TISSUE affect it adversely. Malnutrition, lack of protein, and lack of vita-
mins (e.g., vitamins A and C) may inhibit or prolong healing. Zinc
deficiency, which is reversible, may play a role in retarding the heal-
PHASES OF WOUND HEALING ing process.3 Anti-inflammatory drugs (e.g., colchicine, aspirin, and
The response of tissue to an injury is described in three phases. The glucocorticoids) disrupt macrophage function, collagen synthesis,
first phase is coagulation and inflammation. The second phase is and polymorphonuclear neutrophil concentrations. Pretreatment
the proliferative phase. The final phase is the reepithelialization or or early introduction of glucocorticoids results in retarded wound
remodeling phase. repair by slowing cell proliferation.4
Phase I consists of coagulation and inflammation. It occurs in
the first 5 days. This phase is also known as the vascular phase. A
fibrin clot forms a transitional matrix that allows for the migration
SCAR FORMATION
of cells into the wound site over a period of 72 hours. Inflammatory Some 6 to 12 months are required to form a mature scar. This
cells (i.e., neutrophils, monocytes, and macrophages) kill microbes, explains why scars should not be revised until 12 months have
prevent microbial colonization, break down soluble wound debris, passed. A wider scar, inadequate wound closure, or a wound dehis-
and secrete cytokines. The cytokines signal synthetic cells, such cence may occur in areas with increased skin tension or if the
as fibroblasts, to initiate phase II. Most sutured wounds develop wound is in an area of excessive motion (e.g., over joints). Adequate
an epithelial covering that is impermeable to water within 24 to immobilization of the approximated wound (but not necessarily
28 hours. the entire anatomic part) is mandatory after wound closure for
Phase II is the proliferative phase. It occurs during days 5 to efficient healing and minimal scar formation. Contractures can
14 after the injury. Fibroblasts proliferate and synthesize a new con- develop when a scar crosses perpendicular to a joint crease. These
nective tissue matrix that replaces the transitional fibrin matrix. patients may require physical therapy to prevent the loss of range of
Granulation tissue consisting of fibroblasts, immature connective motion secondary to contractures.
tissue, epidermal cells that have migrated, and abundant capillaries Hypertrophic scars result from full-thickness injuries. Hyper-
forms within the wound. Fibroblasts release collagen, a protein sub- trophic scars are characterized by a thick and raised scar that
stance that is the chief constituent of connective tissue. At 5 days, remains within the boundaries of the original injury. They must
the tensile strength of the wound itself is 5% that of normal skin. often be corrected by surgical intervention.1
Collagen formation peaks at day 7. Keloids are hypertrophic scars (i.e., thick and raised) that
Phase III is known as the remodeling, reepithelialization, or mat- exceed the boundaries of the initial injury. They can develop
uration phase. It occurs from day 14 and lasts until there is complete from superficial injuries and appear to have a genetic basis. Surgical
healing of the wound. The new granulation tissue is being converted intervention rarely resolves keloids. They may be prevented or
into a scar. The scar consists of a rich matrix with decreasing cell minimized by the local application of pressure dressings, Silastic
density, decreasing vascular density, and increasing thickness of dressings, glucocorticoids, and calcium channel blockers.1
collagen fiber bundles packed in parallel arrays.1 The wound will The repair procedure may result in more scar tissue. Absorbable
have 15% to 20% of its full strength at 3 weeks and 60% of its full suture materials contribute to the formation of suture marks because
strength at 4 months. Tensile strength continues to increase up to of their increased reactivity, whereas nonabsorbable materials do
609
610 SECTION 7: Skin and Soft Tissue Procedures
not. Wounds that are approximated too tightly can result in tissue clean the wound. Scrub the wound base and edges with saline-
ischemia and more scar tissue formation. moistened gauze and irrigate the wound to remove any dirt,
debris, and granulation tissue. Suture the wound to approximate
WOUND CLOSURE TECHNIQUES and evert the wound edges. The postprocedural wound care is
the same as if the wound was closed primarily.
PRIMARY INTENTION
Primary intention involves surgically approximating the wound
WOUND INFECTION
edges shortly after the time of injury. The skin’s greatest strength Wound infections occur as a result of the patient’s resident flora and
is in the dermal layer. The best repair results when the entire depth the environment. It is related to wound age, the amount of devi-
of the dermis is accurately approximated to the entire depth of the talized tissue, and the tissue concentration of pyogenic bacteria. A
opposite dermis. Accurate approximation of the epidermis gives a wound infection exists when there are bacterial densities of more
cosmetically appealing effect to the repair but does not contrib- than 10,000 organisms per gram of tissue.5 Bacteria slow wound
ute to its strength. Wound eversion and the use of buried sutures healing by secreting proteases that directly injure the tissue in the
can greatly improve healing by primary intention. wound.2 They also secrete other factors that lead to excess inflam-
matory cells in the wound, which also injures the tissue.2
SECONDARY INTENTION
Secondary intention involves allowing the wound to heal without PATIENT EVALUATION AND ASSESSMENT
any surgical intervention. The wound is left open and allowed to heal
from the inner layer to the outer surface. It is a more complicated HOST HISTORY
and prolonged healing process than primary intention. Infection,
excessive trauma, tissue loss, or imprecise approximation of tissue A thorough and accurate history and physical examination are
can result due to healing by secondary intention. Wound contrac- essential for optimum wound management. Documentation of the
tion by granulation tissue containing myofibroblasts is the major patient’s age, prior tetanus immunization history, systemic illnesses,
influence on this type of healing. Wound contraction becomes more medications, allergies (such as to latex or local anesthetics), and
significant when the dermis is lost. the circumstances of the injury are essential to good wound man-
Concave skin wounds heal with the best results. These areas often agement. These principles are emphasized because the presence of
heal better by secondary intention than by primary intention. Such disease processes (such as diabetes mellitus, chronic malnutrition,
concave areas include the inner ear, the nasal alar crease, the naso- alcoholism, hepatic or renal insufficiency, asplenism, malignancies,
labial fold, the temple, and the concave areas of the pinna. Flat sur- and extremes of age) may impair host defenses or complicate wound
faces can also heal well by secondary intention, although surgical healing.6,7 Second, the wound itself is often less important than an
intervention may be best. Some examples include the forehead, the associated injury to an adjacent structure or cavity. Associated
side of the nose, and periorbital areas. Wounds on convex surfaces injuries can easily be missed without a specific directed search
are not optimal for healing by secondary intention. Convex surfaces for their presence.
include the malar cheek, the tip of the nose, and the vermilion bor-
der of the lip.2 TETANUS PROPHYLAXIS
A thorough history must be obtained concerning the patient’s teta-
TERTIARY INTENTION
nus immunization status. Important factors to consider in assessing
Tertiary intention, or delayed primary closure, can often decrease the risk of developing tetanus include prior immunization history,
infection rates. Wound closure by tertiary intention is accom- the type of wound, the degree of wound contamination, the time
plished 3 to 5 days following the initial injury. It is a combination from injury to treatment, and the presence of underlying medical
of allowing the wound to heal secondarily for 3 to 5 days and then disease.
primarily closing the wound. It is the safest method of repair for Wounds may or may not be prone to tetanus (Table 92-1).
wounds that are contaminated, dirty, infected, traumatic, associ- The administration of tetanus prophylaxis is based upon the
ated with extensive tissue loss, at high risk for infection, and for patient’s immunization history and the risk of developing tetanus
wounds that are “too old” to close. The ultimate cosmetic result is (Table 92-2). Current guidelines state that tetanus toxoid (Td) may
the same as that of primary wound closure. This method may not be deferred in patients with “clean, minor” wounds who have com-
be suitable for young children, having to return a second time for pleted a primary series or received a booster dose (Td 0.5 mL IM)
an uncomfortable procedure. within 10 years. Consider tetanus immune globulin (TIG 250 to
During the interim period, instruct the patient to apply wet- 500 U IM) in addition to Td for patients at risk of developing teta-
to-dry dressing changes twice a day. Upon the patients return, nus. Elderly patients without documentation of a primary series,
assess the wound for any signs of infection. Anesthetize and patients from nonindustrialized nations, and those from rural or
TABLE 92-1 Characteristics of Tetanus-Prone and Non-Tetanus-Prone Wounds

Clinical feature Tetanus-prone wounds Non-tetanus-prone wounds
Contaminants (feces, foreign body saliva, and soil) Present Absent
Devitalized tissue Present Absent
Infection Present Absent
Ischemic or denervated tissue Present Absent
Mechanism of injury Burn, crush, bullet Sharp and smooth (knife or glass)
Wound age >6 h <6 h
Wound depth >1 cm <1 cm
Wound type Abrasion, avulsion, crush, irregular, stellate Linear or straight
CHAPTER 92: General Principles of Wound Management 611
TABLE 92-2 Tetanus Prophylaxis

Immunization history Tetanus-prone wounds Non-tetanus-prone wounds
History of adsorbed Td Td and TIG Td and TIG
Unknown or less than three doses Td, TIG, and complete the series Td and complete the series
Fully immunized, >5 years and <10 years since last dose Td None needed
Fully immunized; ≤5 years since last dose None needed None needed
Fully immunized, ≥10 years since last dose Td and TIG Td
Td, tetanus and diphtheria toxoids; TIG, tetanus immune globulin.
inner-city areas may never have received tetanus immunization and The wound may also be clinically classified based upon an esti-
should be considered for TIG. mate of microbial contamination and the subsequent risk of infec-
tion. Clean wounds are those that occur under aseptic technique.
MECHANISM OF INJURY These are usually surgical incisions that are elective in nature and
preceded by a thorough skin cleansing and decontamination pro-
Severity of injury as well as associated injuries can be anticipated by cess. Clean-contaminated wounds are those associated with the
determining the precise mechanism of injury. This will often indi- usual and normal flora of the region. There is no contamination
cate additional soft tissue injury, the presence of a foreign body, or from foreign bodies or pus. Contaminated wounds are those that
the amount of contamination present. are traumatic (e.g., lacerations, open fractures), less than 12 hours
Soft tissue injuries are rarely surgical emergencies. The patient’s old, or associated with a break in aseptic technique. Most wounds
general condition should be attended to, with priority given seen in the Emergency Department are of the contaminated type.
to observing the ABCs (airway, breathing, and circulation) of They may be associated with the introduction of “dirt” or foreign
Emergency Medicine. The skin margins of a laceration can be bodies into the wound. Dirty wounds are those that are heavily
tacked together with well-placed atraumatic sutures and the wound contaminated (e.g., soil or feces), occur through infected tissue,
covered with a moist pressure dressing until the time is more oppor- are over 12 hours old, are associated with retained foreign bodies,
tune for definitive repair. or associated with devitalized tissue.
Important questions and answers that must be documented
are exactly how the injury occurred, when and where the injury
occurred, and what contaminants were present or involved. If the TIME OF INJURY
injury involves the hand, what position was the hand in at the time This is probably the most pertinent factor of the history. After
of the injury, what kind of work does the patient do, and which is 3 to 6 hours, the bacterial count in a wound increases dramati-
the patient’s dominant hand? Complicated wounds, such as those cally. Few studies have been conducted to determine the maximal
caused by animal or human bites, chemical exposure, or high- time in which lacerations can be closed without resulting in infec-
pressure injection may require a more extensive evaluation and tious complications. One study performed in an underdeveloped
consultation with the appropriate specialist. country indicated that wounds might be closed up to 18 hours
postinjury.9 Lacerations of the face and scalp that are reasonably
CLASSIFICATION OF WOUNDS clean may be closed primarily up to 12 to 24 (or even 48) hours
Wounds are described and classified based upon their cause and postinjury with little risk of infection because of the excellent cir-
the type of injury. Abrasions are the result of grinding or abrading culation in these areas. Other lacerations may generally be closed
forces on the skin. The epidermis and/or dermis is disrupted but primarily if they are less than 6 to 12 hours old provided that they
not removed in its entirety. Crush injuries are due to compressive are not heavily contaminated or located in high-risk areas (i.e.,
forces. The patient sustains a large amount of kinetic energy that hand or foot). The infection rate rises rapidly after 12 hours.
results in microvascular disruption, edema, and devitalized tissue.
Crush wounds are 100-fold more likely to become infected than
WOUND ASSESSMENT
lacerations because of the much lower bacterial loads required for
infection.8 A complete examination and documentation of the laceration is
Lacerations are wounds that are caused by shear forces that result necessary. This includes noting the location and depth of the lacera-
in a tearing of the tissue. They are subclassified as avulsion, shear, tion, the presence of any gross contamination, the presence of an
or tension lacerations. Avulsion lacerations are injuries where there obvious foreign body, and any associated injuries.
is sharp trauma at an angle that removes the epidermal and possibly Assessment of soft tissue wounds involves an examination of
also the dermal layer of skin. The injury creates a skin flap. Shear the surrounding tendons as well as the vascular and neurologic
lacerations are produced by a sharp force, usually perpendicular to structures; bony injuries and foreign bodies should also be sought.
the skin surface, that results in a tidy or clean wound. These wounds Emergency Physicians must possess a working knowledge of func-
are usually caused by knives, glass, or sharp metal objects. There is tional anatomy, particularly of the face and distal upper extremity.
little tissue damage, and this type of wound is not prone to infection. Hemostasis can be achieved by direct pressure with a gauze
Tension or tensile lacerations are injuries with jagged or contused sponge or gloved finger for simple lacerations. Suturing the wound
edges that are created by a compressive force. These wounds pose a best controls bleeding of the scalp. Extremity wounds, particu-
greater risk for infection than shear lacerations.8 larly of the wrist and hand, should have a pneumatic tourniquet
Punctures result in a wound that is deeper than it is wide. The applied after the extremity is elevated for 1 minute to promote
skin opening is small and the depth of the wound is often unknown. venous drainage. Inflate the cuff above the patient’s systolic blood
Such wounds are made by discrete and thin objects, and they carry a pressure for 20 to 30 minutes at a time. A blood pressure cuff may
high risk for infection. Irrigation is mandatory for puncture wounds; be substituted if a pneumatic tourniquet is not available. For more
however, the pressure must not be so high as to drive contaminants severe bleeding, there are several commercial tourniquets available,
deeper into the wound. as well as new hemostatic agents such as Quick Clot.37–39 Vascular
structures (with the exception of small arterioles, small venules, neurovascular injury. Puncture wounds have not been proven to
and vessels within muscles) should not be clamped and may benefit by coring or probing to determine the depth of the wound.
require special techniques for hemostasis. Imaging may be required to detect retained foreign bodies. Retained
Wounds may cross tissue planes, opening them and creating wood, thorns, and plastic are often detectable only by wound explo-
potential pockets or dead spaces. Elimination of the dead space ration and may not be visible on plain radiographs. Radiographs
has been advocated in the past to decrease the probability of this will identify retained metallic fragments and more than 90% of glass
area becoming a nidus for infection. This once traditional practice foreign bodies if the glass does not have a low lead content and the
of obliteration of dead space to avoid infection of a nonvascular- fragments are at least 2 mm long.15,16 Wound markers can be used
ized space or to prevent hematoma formation is now considered during radiography. Radiographs obtained in two planes can help
controversial. Studies in animal models have found the incidence localize the object for recovery. Glass may penetrate at an angle and
of infected wounds to be consistently proportional to the num- be buried deeper than it appears. The use of ultrasound is contro-
ber of suture layers.10,11 Leaving dead space open resulted in lower versial because of its lack of specificity, lack of sensitivity, and opera-
rates of infection than obliterating it with sutures.10,11 Studies in tor dependency.
1994 and 1996 concluded that buried absorbable sutures increase Foreign bodies that do not cause an inflammatory reaction are
the infection rate and the degree of inflammation in contaminated often not removed from lacerations. This is especially true if there
wounds and do not significantly increase the degree of inflamma- are multiple fragments or if excessive tissue disruption will result
tion in noncontaminated wounds.12 Sutures placed in fat contribute with attempted removal. The patient should be made aware of any
no strength to the repair and fail to prevent hematoma formation retained foreign bodies at the time of discharge, their benign
and infection. Deep absorbable sutures may be placed to repair presence, why removal was not attempted, the possibility of later
the periosteum, muscles, or fascia or to minimize tension on skin infection, and the fact that they may eventually self-extrude. This
sutures. Use only enough subcutaneous sutures to restore ana- must also be documented in the medical record. If the wound is
tomic and functional integrity. In most wounds, however, leaving in a complex area, such as the palm, it may be necessary to gain
potential space may be preferable to attempting to obliterate it. consultation for immediate or delayed removal. The wound can be
It is important to explore the deep structures through a full range approximated loosely and immobilized for comfort and to avoid
of motion in order to detect partial tendon lacerations or joint cap- further tissue disruption, antibiotics prescribed, and arrangements
sule disruption. Tendons can be evaluated by inspection, but indi- made for appropriate out-patient follow-up in 24 to 48 hours.
vidual muscles must also be tested for full range of motion and Soils have varied levels of contamination potential. Sandy soils
full strength. present a low risk of wound contamination. Clay-containing soils
A distal neurologic and vascular examination should be per- are pyogenic because they impair host defense mechanisms and
formed on extremity injuries. Capillary refill should be checked dis- promote inflammation. Organic soils contain Clostridium tetani
tally and take less than 2 seconds. Neurologic assessment involves and a more concentrated bacterial inocula. Soil contaminants, when
checking distal muscle strength and sensation. Check two-point present, can be removed by copious irrigation. These contaminated
discrimination prior to the administration of anesthesia for wounds should be left open and allowed to heal by secondary or
hand and finger lacerations. Two-point discrimination at 5 mm on tertiary intention.
the radial and ulnar aspects of the finger pads is the most efficient
method of assessing median and ulnar nerve function. Two-point HIGH-RISK WOUNDS
discrimination should be less than 1 cm at the fingertips. A crush
injury may be associated with decreased two-point discrimination Many wounds require special consideration in deciding upon the
and may take several months for recovery. Numbness may also be method of closure, the type of suture to use, and the use of antibiotic
the first sign of a developing compartment syndrome. Nerve lac- prophylaxis. These include wounds contaminated by saliva, feces,
erations can be repaired immediately or the wound can be loosely vaginal secretions, soil, and organic material. Wounds in immu-
approximated and repair of the lacerated nerve delayed. nocompromised patients or patients taking immunosuppressive
Obvious as well as questionable fractures should receive a radio- drugs may require antibiotics and longer times for the sutures to
graph of the area. Bone injuries require checking the overlying skin remain before removal. Hand wounds, including bite wounds, and
to exclude an open fracture. An open fracture is an indication for foot wounds require special care. Wounds greater than 6 to 12 hours
surgical debridement and repair except in the case of a distal pha- old, other than wounds on the face, may require delayed closure.
lanx fracture, which can be treated with copious irrigation, oral anti- Puncture wounds may require radiographs, incision and explora-
biotics, and detailed discharge instructions. tion, and antibiotic prophylaxis. Wounds accompanied by excessive
tissue damage and devitalization or crush injuries are prone to infec-
WOUND FOREIGN BODIES tion. Wounds with retained foreign bodies may require radiographs,
exploration, and removal. Major tissue defects may be closed with
Failure to identify foreign bodies in wounds may lead to complications advanced wound closure techniques. Wounds overlying sites of
such as an increased risk of infection, delayed wound healing, and active infection require antibiotics and delayed closure. These topics
loss of function.36 Foreign bodies and foreign matter greatly enhance are covered further on in this chapter and in other chapters of this
the infectivity of a given bacterial inoculum.13 Retained foreign bod- book (see Chapters 95 through 98 for details).
ies are a common complication of simple wound repair. Perform a
thorough inspection to attempt to diagnose the presence of a for- SKIN AND WOUND PREPARATION
eign body. Missed foreign bodies are the second leading cause (14%)
of lawsuits brought against Emergency Physicians.14 Some foreign
ANESTHESIA
bodies cause an inflammatory reaction (e.g., wood, thorns, splinters,
cloth, teeth, and rubber from shoes or foam insoles), while others do Wounds must be anesthetized with either local or regional tech-
not (e.g., metal, glass, most plastics, and pencil graphite). niques prior to cleansing and repair. Local anesthesia distorts
Wound exploration, irrigation, and radiography may be wound edges; therefore regional nerve blocks should be used where
needed when the clinical setting suggests a possible foreign body. appropriate (e.g., the hand, face, ear, nasal cartilage, palm, sole).
Spread the tissue during exploration. Do not cut tissue and risk Refer to Chapters 123 through 129 for a complete discussion of local
anesthetic agents, regional anesthesia, topical anesthesia, nitrous light, anesthesia, and equipment are a must in order to avoid
oxide anesthesia, and procedural sedation. inadequate debridement, a retained foreign body, or a wound
Lidocaine (Xylocaine) in a dose not to exceed 4.5 mg/kg is an hematoma that can result in a necrotizing soft tissue infection.
effective and standard local anesthetic agent. Lidocaine anesthesia Disinfecting the intact skin surrounding the wound and ridding it
lasts approximately 60 to 90 minutes. If a longer period of anesthe- of foreign bodies, debris, and particulate matter is the initial step in
sia is required, bupivacaine may be used. It provides approximately wound preparation. This technique can be accomplished by scrub-
120 to 180 minutes of anesthesia. The addition of a 1:100,000 dilu- bing the skin with povidone iodine, chlorhexidine, or poloxamer
tion of epinephrine to lidocaine or bupivacaine will prolong the 188 (Shur Clens) skin-prep solutions. Do not expose the wound
duration of anesthesia, promote hemostasis, allow a larger dose to itself to these solutions. Povidone iodine and chlorhexidine solu-
be used, and reduce systemic absorption of locally infiltrated local tion are bactericidal and work as it dries. Its toxicity to wound tissue
anesthetic solution. Epinephrine is a potent vasoconstrictor and is controversial. Shur Clens has no tissue toxicity but also has no
should not be used near end organs such as the fingers or toes. It antibacterial activity. A wide area surrounding the wound should be
may decrease blood flow and induce ischemia. Epinephrine should prepped with an antimicrobial agent, preferably povidone iodine or
also be avoided near the tip of the nose, the ear, and the penis. chlorhexidine solution.
Animal model studies have consistently shown that epinephrine
increases the incidence of infection in contaminated wounds. This HAIR REMOVAL
may be due to vasospasm-induced local ischemia. Epinephrine
should not be used to enhance local anesthesia in contaminated Hair removal is often unnecessary prior to closing wounds, can be
wounds. Consider the use of regional anesthesia or procedural seda- embarrassing for the patient after discharge from the Emergency
tion in these patients. Department, and may increase the risk of wound infection. Shaving
The pain of local anesthetic injection can be reduced. The use can cause minimal soft tissue trauma and wound infections.17
of a 27 or 30 gauge needle, slower and deeper infiltration (into the Eyebrows should never be shaved, as they can grow back unpre-
dermis), warming the local anesthetic solution, and the addition of dictably or not at all. Simple scalp lacerations can be exposed by
bicarbonate to lidocaine (9 mL lidocaine to 1 mL of bicarbonate) using antibiotic ointment (or lubricating gel) to move the hair away
may decrease the pain of anesthetic injection.21–26 Other strategies from the wound margins prior to placing sutures.
involve anesthetizing as much tissue as possible through a single
site, starting proximally on the extremity and moving distally. WOUND IRRIGATION
Infiltration of the local anesthetic solution through the wound edges Wound cleansing and preparation have been proven to be the
is less painful than through intact skin. foundations of proper wound management and the prevention
Most “allergic” reactions are actually vasovagal or other adverse of wound infections. Irrigation removes contaminants, reduces
responses. Allergies to “caines” are attributed to what is often a vaso- infection, and improves visualization. There are two concerns
vagal or other side effect. True allergies to local anesthetics are rare regarding wound irrigation: the pressure required for adequate
and are generally seen only with the ester class of local anesthetics. cleansing of the wound and the means to irrigate the wound safely
If an allergy to lidocaine (an amide class of local anesthetic) is sus- while protecting the healthcare worker from the threat of human
pected, the use of an ester class of local anesthetic is suggested. An immunodeficiency virus and hepatitis B (by contamination of their
alternative is the use of cardiac lidocaine, the prefilled syringes used own skin surfaces, mucosal surfaces [eyes, nose, or mouth], or
in codes and cardiac arrests, which contains no preservative. It is felt minor open skin wounds).
that the preservative in lidocaine is responsible for the allergic effect. Irrigation pressures of 5 to 8 pounds per square inch (psi) are
Another alternative is to use a 1% to 2% solution of diphenhydr- felt to be adequate to cleanse a wound that is not heavily contami-
amine (Benadryl). This provides adequate but not ideal anesthesia. nated. This surface pressure can be generated by the combination
The most common complication of local anesthesia infiltration is of a 35 mL syringe and a 19 gauge angiocatheter held 2 cm from
hypotension and bradycardia as a result of a vasovagal reaction. the wound surface.18,40–42 Unfortunately, this process can be quite
Topical anesthesia is an attractive alternative to injection, particu- messy (Figure 92-1). High-pressure irrigation, which generates
larly in the management of pediatric patients with simple wounds.
Lidocaine, epinephrine, and tetracaine (LET) gel or tetracaine,
adrenaline, and cocaine (TAC) are two agents that can be used as
effective local anesthesia.27 Both of these agents contain epinephrine
and should not be used on areas involving an end artery or contam-
inated wounds. TAC involves expense and incorporates problems
with the use and maintenance of a controlled substance. TAC also
has the potential for toxicity, especially when applied to mucosal
surfaces. EMLA (eutectic mixture of local anesthetics) cream, also
used for local anesthesia, has been found to provide effective anes-
thesia for extremity lacerations. EMLA is a combination of 2.5%
lidocaine and 2.5% prilocaine suspended in an oil-in-water emul-
sion. Studies have found that it takes longer to obtain optimal anes-
thesia with EMLA than with TAC.28
SKIN CLEANSING
Meticulous preparation of the skin surrounding the wound and
the actual wound, irrigation, and wound debridement are tanta-
mount to good wound healing. The goal is to remove bacteria, FIGURE 92-1. Wound irrigation with an angiocatheter on a syringe. This process
foreign matter, and tissue debris. Wounds should be adequately is quite messy and can result in an occupational exposure. (Photo courtesy of
anesthetized prior to cleansing and/or local exploration. Adequate Zerowet Incorporated.)
peak pressures of 25 to 40 psi, has been a controversial issue in the the bag of saline and direct the stream of fluid through the device
Emergency Medicine literature. The theory is that high pressures and into the wound. Wound Wash Saline (Church & Dwight, East
may cause tissue disruption and increase infection rates. High- Princeton, NJ) is sterile normal saline within a pressurized can
pressure irrigation should be reserved for highly contaminated (Figure 92-2B). Direct the tip of the can toward the wound, press
wounds. High-pressure irrigation may drive contaminants deeper the button, and direct the saline stream into the wound. This is also
into puncture wounds and should be avoided. available at retail stores for patients to use at home for wound care.
Though there are a variety of irrigation fluids, the optimal type The company offers a convenient chart that uses wound depth and
is unknown. Normal saline is the most commonly used irrigant. base characteristics to determine how much saline to use to irrigate
The volume of irrigation fluid to be used has not been well estab- the wound. The can controls the pressure (6 to 13 psi), so that tis-
lished. The use of 100 to 300 mL has been suggested in the literature. sue is not devitalized during the irrigation. Unfortunately, using this
Heavily contaminated wounds require larger amounts of irrigant. method is quite messy as the saline and wound materials (e.g., tissue
Anecdotal recommendations suggest using 50 mL/cm for clean fluid, blood, and debris) splash all over.
wounds and 100 mL/cm for dirty wounds. Heavily contaminated The Emergency Physician should use barrier protection to shield
wounds may have to be scrubbed (after adequate anesthesia) with their face, eyes, skin, and submucosal surfaces during the irriga-
fine-mesh gauze or a micropore sponge using a 1% solution of povi- tion process. There are several barrier devices on the market that
done iodine or poloxamer 188. Tap water can be used for irrigation decrease the splatter of irrigation fluid19 (Figure 92-2). Some of these
with no increased incidence of infection, especially when a large devices are preattached to a wound irrigation device. Others can be
volume of irrigant is required.43–47 Soaking of wounds is discour- attached to a wound irrigation device. The Zerowet Supershield
aged as a poor substitute for the preparation of contaminated or (Zerowet Inc., Palos Verdes Peninsula, CA) is a dome-shaped
clean wounds. Do not soak wounds in any fluid. Soaking does not device that attaches to a syringe (Figure 92-2C). The Combiguard
reduce bacterial contamination or decrease infection rates. It may Irrigation Splash Guard (Moog Medical Devices, Salt Lake City, UT)
actually increase infection rates. Do not use undiluted povidone- is similar in function to the Zerowet Splashield and has a slightly
iodine, hydrogen peroxide, or detergents in the wound as they different shape. The Combiguard can attach to a syringe or the
cause tissue toxicity.48 Combiport Wound Irrigation Device (Figure 92-2D). The Igloo
Numerous commercially available devices are available to irrigate Wound Irrigation System (Bionix Medical Technologies, Toledo,
a wound (Figure 92-2). The Combiport (Moog Medical Devices, OH) is a similar device that provides a multiport shower effect to
Salt Lake City, UT) is a wound irrigation device that inserts directly deliver the irrigation solution (Figure 92-2E). The Irrijet (Cooper
into the port of an intravenous fluid bag (Figure 92-2A). Squeeze Surgical, Trumbull, CT) is a spring-loaded, self-refilling system that
FIGURE 92-2. Commercially available wound irrigation devices. A. The Combiport

Wound Irrigation Device (Moog Medical Devices, Salt Lake City, UT). B. Wound B
Wash Saline (Church & Dwight, East Princeton, NJ).
FIGURE 92-2. (continued ) C. The Zerowet Supershield (Zerowet Inc., Palos

Verdes Peninsula, CA). D. The Combiguard (Moog Medical Devices, Salt Lake
City, UT) attaches to the Combiport or a syringe. E. The Igloo Wound Irrigation
System (Photo courtesy of Bionix Medical Technologies, Toledo, OH). F. The Irrijet
(Cooper Surgical, Trumbull, CT). G. The Canyons Wound Irrigation System (Wolf G
Tory Medical Inc., Salt Lake City, UT).
FIGURE 92-2. (continued ) H. The Squirt Wound Irrigation Kit (Merit Medical
Systems Inc., South Jordan, UT). I. The Klenzalac (Zerowet Inc., Palos Verdes
Peninsula, CA). J. The Splashcap (Splash Medical Devices, Atlanta, GA). K. The K
Irrisept (Photo courtesy of Irrisept, Gainesville, FL).
is operated with one hand (Figure 92-2F). A Splashield or Splash

Guard can be attached to the Irrijet. The Canyons Wound Irrigation
System (Wolfe Tory Medical Inc., Salt Lake City, UT) is a similar
device with the exception of using the built-in Zerowet Splashield
(Figure 92-2G). The Squirt Wound Irrigation Kit (Merit Medical
Systems Inc., South Jordan, UT) is a manually operated system that
may be used alone or attached to the Splashield, Combiguard, or an
angiocatheter (Figure 92-2H). The Klenzalac (Zerowet Inc., Palos
Verdes Peninsula, CA) is a similar device with the exception of
using the built-in Zerowet Splashield (Figure 92-2I). The Splashcap
(Splash Medical Devices, Atlanta, GA) attaches to a bottle of ster-
ile saline (Figure 92-2J). The Irrisept (Irrisept, Gainesville, FL)
attaches to a proprietary bottle containing a saline and chlorhexi-
dine mixture (Figure 92-2K).
FIGURE 92-4. Wound excision. Removal of an ellipse of tissue that contains the
WOUND DEBRIDEMENT wound results in smooth, clean edges that can be approximated.
Debridement creates straight and clean wound edges that are easier
to repair by removing tissue that is devitalized, contaminated by
bacteria, or contaminated by foreign matter and may impair the contaminated tissue. Wound edges should be handled delicately
ability of the tissue to resist infection. Successful wound closure may or gingerly in order to avoid further soft tissue damage and devi-
require the transformation of a ragged laceration, the removal of talization of injured tissue.
devitalized tissue, or the removal of contaminated tissue in order
to convert a traumatic wound into a surgical wound. Devitalized WOUND EXCISION
and necrotic tissue must be removed in order to remove a nidus for
bacterial growth and wound infection.20 The entire wound may be excised in areas of excess tissue or tissue
Close approximation of the wound requires that debridement laxity if no blood vessels, nerves, tendons, or joints lie within or at
of jagged edges not be too vigorous in order to avoid widening the base of the wound (Figure 92-4). The excision of a wound cre-
the scar and making it difficult to close. Wounds of the face or ates smooth, clean edges that may be approximated with sutures.
areas that are devoid of redundant tissue require conservative This is especially useful in wounds that are heavily contaminated.
debridement. Debridement to simplify wound closure is not Most wounds are excised with an elliptical incision (Figure 92-4).
always the answer for a superior cosmetic result in the repair of Other types of wound excision are discussed in Chapters 95 and 96.
irregular wound edges. The meticulous repair of complex wound Carefully plan the excision before removing any tissue. Mark
edges can often provide a superior cosmetic result. the edges of the proposed incision with a marking pen. The long
Debridement can be accomplished mechanically, hydrody- axis of the ellipse should be two-and-a-half to four times as long
namically, or with a combination of both methods. Tissue must be as the greatest width of the ellipse. Removal of too much tissue will
removed mechanically with a #11 or #15 scalpel blade or a scissors produce a large defect that may not be possible to close primarily.
(Figure 92-3). Superficial debris and contaminants can be removed Remove the tissue using aseptic technique, preventing any contami-
with a pulsatile stream of normal saline solution during the irriga- nation of the new wound edges.
tion process. Debridement must be performed using aseptic tech-
nique. Scrubbing is not a substitute for debridement of heavily WOUND UNDERMINING
The undermining of tissue creates a “flap” that involves the sep-
aration of the skin and superficial subcutaneous tissue from the
deeper subcutaneous tissue and fascia (Figure 92-5). The process
of undermining tissue minimizes skin tension, allows for eversion
of the approximated skin edges, and relieves the extrinsic ten-
sion from sutures. Undermining is performed when the wound
cannot be closed due to a tissue defect or if a wound is under
tension. This procedure requires the Emergency Physician to be
familiar with the local anatomy so that no blood vessels, nerves,
or tendons are injured in the process. Do not undermine con-
taminated wounds. Undermining large areas can separate the
skin from its underlying blood supply and result in a diminished
blood flow that predisposes the area to infection and necrosis.
Undermining may be useful on the forehead, scalp, arm, forearm,
thigh, calf, and torso. Never undermine wounds on the palms,
soles, and face.
Undermine tissue at the dermal-epidermal junction or within the
subcutaneous adipose tissue. The amount of undermining neces-
sary to close a laceration is approximately double the width of the
gap of the laceration at its widest point. A 1 cm wide laceration
should be undermined for 1 cm on both sides of the wound, includ-
FIGURE 92-3. Wound debridement. Removal of the wound edges with a scissors ing the ends (Figure 92-5). The use of a Mayo scissors versus a #15
(or a scalpel). scalpel blade to undermine tissue is based on physician experience
FIGURE 92-5. Wound undermining. A. Sharp undermining with

a #15 scalpel blade. B. Blunt undermining with a Mayo scissors.
and preference. A Mayo scissors is recommended as it may cause tissue damage caused by the suture, and the resulting scar will be
less secondary injury, especially in experienced hands. minimized. The tensile strength of the suture should never exceed
the tensile strength of the tissue, or it can pull through and damage
EMERGENCY DEPARTMENT VERSUS the tissue. The sutures should be at least as strong as the normal tis-
OPERATING ROOM MANAGEMENT sue through which they are being placed.
OF WOUNDS The size of the suture material is related to the diameter of the
suture. As the number of 0s in the suture size increases, the diameter
Laceration repair may sometimes have to be performed in the oper- of the strand decreases. For example, size 5-0, or 00000, is smaller in
ating room. Indications for operating room repair of lacerations diameter than size 4-0, or 0000. The smaller the size, the less tensile
include those associated with open fractures, major or complex strength the suture will have.
wounds involving devitalized tissue, heavily contaminated wounds, Suture description entails numerous characteristics. Sutures
wounds with associated injuries (e.g., visceral, neurovascular, frac- can be classified into two major groups based upon the number
ture, and tendon), perineal wounds, large or complicated soft tissue of strands of which they are composed. Monofilament sutures
injuries, compartment syndromes, wounds with extensive amounts are made of a single strand of material. They encounter less resis-
of necrotic or ischemic tissue, the total local anesthetic solution tance passing through tissue and resist harboring organisms that
required would exceed toxic tissue levels, and high-pressure injec- may cause suture-line infections. Multifilament sutures consist of
tion injuries. several filaments, or strands, that are twisted or braided together.
This affords greater tensile strength, pliability, and flexibility.
ANTIBIOTIC PROPHYLAXIS Unfortunately, bacteria can migrate between the filaments and into
the wound.
Despite the best wound care and management, the rate of infection Another classification is based on the ability of the body to break
has been determined to be approximately 1% to 12%. Not all wounds down and absorb the suture material. Absorbable sutures are digested
result in infection. Most uncomplicated wounds heal without the by body enzymes or hydrolyzed in body tissue. Nonabsorbable
need for antibiotics. Wounds associated with an increased risk for sutures are not digested by body enzymes or hydrolyzed.
infection are those of the extremities (especially the lower), complex Absorbable suture can be made of natural or synthetic mate-
wounds, or wounds over 3 to 5 cm in length. The use of antibiotics rial. Natural absorbable suture is classified as surgical gut (plain or
for traumatic wounds is controversial. Prophylactic antibiotics are chromic). Plain surgical gut is composed of collagen from bovine
not indicated for uncomplicated minor wounds with a low chance or sheep intestine. It is rapidly absorbed, maintaining its tensile
of becoming infected. It has not been proven that oral antibiotic
administration following injury actually reduces the probability of
infection. However, the use of topical antibiotics can decrease the
TABLE 92-3 Antibiotic Prophylaxis for High-Risk Wounds35
rate of wound infection.34 Useful preparations include bacitracin,
triple antibiotic ointment, or silver sulfadiazine. Situation Antibiotic of choice Days of treatment
It is necessary to identify those patients who may benefit from Open fractures First Generation Cephalosporin 1–3
early antibiotics. Antibiotic therapy should be considered in the Add an aminoglycoside for more
following situations: where wounds are heavily contaminated or extensive injuries
associated with major soft tissue injury; open fractures, intraoral Intraoral injuries Penicillin VK or Clindamycin 5
lacerations, wounds associated with active infection; when there is Human bites First dose: parenteral ampicillin 3–5
sulbactam or Ertapenem, then
a delay in care that results in a prolonged time from debridement or
Augmentin
treatment (>3 hours); when the patient is immunocompromised or
Or
has cardiac valvular disease; when there are bites to the hand or face, Clindamycin plus fluoroquinolone
deep puncture wounds, or lacerations to lymphedematous tissue; or (Bactrim in children)
when the patient has prosthetic joints (Table 92-3). Or
Augmentin
SUTURES Dog/cat bites First dose: parenteral ampicillin 3–5
sulbactam or carbapenem or
clindamycin, then clindamycin
SUTURE TYPES plus fluoroquinolone
Proper size suture material can be summarized as the smallest Or
suture needed to approximate the edges of a wound. This will reduce Augmentin
strength for only 7 to 10 days, and is completely absorbed within edges, conventional cutting needles have a third cutting edge on
70 days. Chromic gut is treated with a chromium salt solution to the inside concave curvature of the needle. This needle type may
resist body enzymes. It retains its tensile strength for 10 to 14 days be prone to “cutout” of tissue because the inside cutting edge cuts
and is absorbed over 90 days. toward the edges of the incision or wound.
Synthetic absorbable sutures include polyglactin 910 (Vicryl, Reverse cutting needles are as sharp as the conventional cutting
Ethicon) and polyglycolic acid (Dexon). They were developed needle except that the third cutting edge is located on the outer
because of the tissue reaction, suture antigenicity, and unpredictable convex curvature of the needle (Figure 92-6B). Reverse cutting
rates of absorption of natural absorbable sutures. These sutures are needles have more strength than similar-sized conventional cut-
braided synthetic materials that retain 50% of their initial strength ting needles. The danger of tissue “cutout” is greatly reduced. The
at 4 weeks. The synthetic absorbable sutures retain their tensile hole left by the needle leaves a wide wall of tissue against which the
strength long enough to ensure the security of the subcutaneous suture is to be tied.
layers after the removal of percutaneous sutures. Taper point needles have a pointed end (Figure 92-6C). The rest
Nonabsorbable sutures are made of silk, nylon, polypropylene, of the needle is a smooth, rounded tube with no cutting edges. This
cotton, linen, or metal. They can be monofilament or multifila- type of needle is commonly used in surgery to close tissues with
ment in construction. Nylon is the most commonly used suture in minimal trauma. It is used for all tissues except skin.
the Emergency Department. It is used to approximate lacerations Two other types of needles are often available but not used in the
at the skin surface. Silk may occasionally be used in the mouth. It Emergency Department. The blunt point needle has a smooth tip
causes significant tissue reactions that result in inflammation and and tapered body (Figure 92-6D). It is used for suturing friable tis-
granuloma formation as the body “fights off ” this natural fiber. The sue and blunt dissection. The taper cut needle has a cutting tip and
other types of nonabsorbable sutures are generally not utilized in a tapered body (Figure 92-6E). It is a combination of the tapered
the Emergency Department. point and cutting needle. It is used to place sutures through tough
Several factors must be considered in choosing suture material. tissues. Numerous other needles are available, as are modifications
Choose sutures that match the healing properties of the tissues. of the five basic needle types. These needles are used by Surgeons
Approximate slow-healing tissues (e.g., fascia and tendons) with for specialized tissues.
nonabsorbable sutures or a long-lasting absorbable suture. Foreign Always keep some general principles in mind when suturing.
bodies in potentially contaminated tissues may result in an infec- Needles should be pulled through tissue using a needle driver
tion. Multifilament sutures can act as a foreign body and may con- and never a hemostat. A hemostat or other clamp can damage the
vert a contaminated wound into an infected one. Multifilament needle. Avoid injury to yourself and others. Keep all open nee-
sutures should generally be avoided. Use monofilament sutures or dles in a place so that they will not injure you or your assistant.
absorbable sutures that resist harboring infection. Use the smallest Account for and discard all suture needles in a “sharps” container.
inert monofilament suture materials (such as nylon or polypropyl- Following these two steps will dramatically decrease the chance for
ene), avoid using skin sutures alone (use subcuticular closure when- a needle-stick injury.
ever possible), and use sterile skin closure strips for apposition when
possible. Use the smallest possible size of the chosen suture type NEEDLE DRIVERS AND HANDLING SUTURES
that is capable of closing the wound to help minimize scarring.
Always use a needle driver when suturing. The use of a hemostat or
other type of “clamp” can damage the needle and cause it to bend or
NEEDLES
break in the tissue. Needle drivers are generally made of steel with a
Needles are generally of two types, tapered and cutting jaw designed to hold the needle securely without damaging it. They
(Figure 92-6). Cutting needles have sharp ends and sharp edges come in numerous sizes and shapes. Choose a needle driver that is
that act as a cutting instrument (Figure 92-6A). The cutting needle an appropriate size for the needle that is to be grasped. A 4.5 to 6 in.
is commonly used for tougher tissues such as subcutaneous, intra- long needle driver is appropriate for Emergency Department use.
dermal, and cutaneous (skin) closure. In addition to the two cutting Grasp and remove a clean needle from its package with your hands,
A B
FIGURE 92-6. Common types of suture needles. A. The cut-

ting needle. B. The reverse cutting needle. C. The taper point
C D E needle. D. The blunt point needle. E. The taper cut needle.
FIGURE 92-8. Examples of snag-free needle drivers. From left to right: The
Centurion SnagFree (Centurion Healthcare Products, Howell, MI), the SutureCut
needle driver (SutureCut LLC, Lexington, KY), and the Olsen-Hegar needle driver
(Henry Schein Inc., Port Washington, NY).
Some needle drivers are designed to be snag-free (Figure 92-8). Two

of these, the Centurion SnagFree (Centurion Healthcare Products,
Howell, MI) and the SutureCut (SutureCut LLC, Lexington, KY)
needle drivers, are available both as individual disposable instru-
ments and in disposable laceration repair trays.
Suturing lacerations can take a significant amount of time. Much
FIGURE 92-7. Using a needle driver. A. Grasp the proximal one-third to one-half
of this time is spent tying knots or switching between instruments
of the needle. B. Always use the tips of the jaws to grasp the needle. C. Drive the
needle through the tissue following the natural curve of the needle. D. Grasp (i.e., the needle driver and scissors). Two needle drivers are designed
the distal needle proximal to the cutting edges. E. Correct method to pass a needle to also cut suture. This decreases the total time required to repair
driver armed with a needle. a laceration as well as avoiding the constant switching between
instruments. The SutureCut (SutureCut LLC, Lexington, KY) and
the Olsen-Hagar (Henry Schein Inc., Port Washington, NY) needle
drivers cut the suture in their specially designed joint located at the
forceps, or a needle driver. Securely grasp the proximal one-third to base of the jaws.
one-half of the needle with the needle driver (Figure 92-7A). Do We are all not fortunate to have suture-cutting needle driv-
not grasp the distal one-third of the needle. This can damage its ers in our laceration repair trays. A needle driver and scissors can
cutting surfaces. Always use the tips of the needle driver to grasp be simultaneously held in the same hand to improve efficiency
the needle (Figure 92-7B). Grasping a needle with the base of the (Figure 92-9). While awkward at first, this technique is easy to
jaws may damage the needle. learn. Grasp a scissors with the tip pointing ulnarly (Figure 92-9A).
Use the needle driver when pushing the needle through the tissue Insert your middle finger through the adjacent ring on the handle.
to place a suture (Figure 92-7C). Apply the force in a direction fol- Grasp a needle driver in the same hand with the tip pointing radi-
lowing the curve of the needle. Do not twist or force the needle ally (Figure 92-9A). Insert your thumb and ring finger through the
to push the point through the tissue and out the other side. Use a rings on the handle of the needle driver. Grasp a suture needle with
larger needle if the first one is too short or too small. Do not use a the needle driver. Place a stitch and tie it. Remove your thumb from
needle that has become dull and difficult to pass through the tis- the ring of the needle driver and place it in the open ring of the scis-
sue. Obtain a new needle and continue the procedure. Grasp the sors. Use the thumb to open and close the scissors. Cut off the excess
distal tip of the needle with a needle driver when it emerges from suture (Figure 92-9B). Place your thumb back into the ring of the
the tissues (Figure 92-7D). Always grasp the needle proximal to needle driver and place the next stitch. Repeat this process until the
its distal third to prevent damage to the cutting edges. laceration is closed.
Always use caution when handing a needle driver armed with
a needle to another person. Grasp the needle driver between the
WOUND CLOSURE
thumb, index, and middle fingers (Figure 92-7E). Hand the base of
the needle driver to another person. Do not blindly pass the needle The goal of wound closure is approximation of the skin under
driver. Do not pass the needle driver over a third party without minimal tension while achieving eversion of the wound edges
their knowledge of the transfer. Never grasp the distal end of an (Chapter 93). Wound eversion slightly raises the wound edges
armed needle driver. to keep the epidermal cells from migrating into the dermal lay-
Typical needle drivers contained within most disposable, com- ers, therefore leaving a flat scar (Figure 92-10). Sutures should
mercially available laceration repair trays are not ideal. The suture be placed closely enough to approximate wound edges, but not so
often snags on the jaws or hinge when performing an instrument tie. tight as to cause tissue necrosis. The time from the injury to the
A B
FIGURE 92-9. A one-handed method to simultaneously hold a needle driver and scissors. A. Placing a stitch. B. Cutting the suture.
presentation and the mechanism of injury will indicate whether wound infection. Muscle fibers do not support sutures. Muscle is
the laceration mandates delayed closure instead of primary closure best treated by repair of the overlying fascia and immobilization to
and whether tetanus prophylaxis is required. With the exception of prevent motion and to allow coaptation of the muscle fibers.
patients who are immunocompromised or taking immunosuppres-
sive therapy, those with high-risk wounds should be considered for STERILE GLOVES
delayed closure.
It is a common practice to wear sterile gloves when repairing a lacer-
ation. The advantages of sterile gloves include a better fit, improved
SINGLE-LAYER VERSUS MULTILAYER CLOSURE
tactile sensitivity, and improved dexterity. The use of sterile gloves
The greatest strength of the skin (and of the wound) is contained for laceration repair costs significantly more than using nonster-
within the dermis. The better the coaptation of the dermal edges, ile, clean gloves from a box. Clean, nonsterile, powder-free, boxed
the narrower the scar will be. The best results occur when the entire examination gloves can be used for uncomplicated wound repair
depth of the dermis is accurately approximated to the entire depth in the Emergency Department. No clinically important differences
of the opposite dermis. Dermal closure is best performed with syn- in infection rates has been found when comparing sterile gloves to
thetic monofilament absorbable suture that requires enzymatic clean gloves.49,50
degradation (e.g., Vicryl). Chromic or plain catgut suture dissolves The use of clean gloves from a box is not always ideal. Clean
much more rapidly by means of hydrolysis. gloves come in a limited number of sizes (i.e., extra small, small,
Close the wound in multiple layers if the goal is cosmesis. Close medium, large, and extra large). The fit and feel of clean gloves may
the wound with a minimal number of sutures in a single layer if the not be as comfortable for the Emergency Physician. Clean gloves
goal is a functional result. Do not suture through fat and muscle. may have more manufacturing defects when compared to sterile
Fat has no tensile strength. Sutures placed tightly in fat can cause gloves.51 These defects can result in the loss of personnel protection
ischemia and necrosis in the wound and increase the risk of a and the potential to contaminate the wound. Others have shown
clean gloves to have comparable quality to sterile gloves.52–54 A box
of clean gloves that has become wet can harbor mold.55 While the
use of clean gloves in uncomplicated wound repair is acceptable, the
decision is physician dependent.
WOUND CLOSURE PROCEDURE

Clean any dirt and debris from the skin. Scrub the skin surrounding
the wound with an antiseptic skin cleanser (e.g., povidone iodine or
chlorhexidine). Anesthetize the wound with a 27 to 30 gauge hypo-
dermic needle and local anesthetic solution. Irrigate the wound with
normal saline. Use a mask with a face shield to prevent exposure
to the patient’s blood and tissue fluid. Debride and undermine the
wound as necessary. Irrigate the wound again to remove exposed
debris and devitalized tissue. Repair the wound with sutures or pack
it with saline-soaked fine-mesh gauze for delayed closure. Clean the
repaired wound with normal saline and apply a dressing for com-
fort and protection. Consider the application of a splint for wounds
across joints or muscle lacerations.
Write a procedure note describing the sterile preparation of the
FIGURE 92-10. Eversion of the wound edge signifies proper suture placement wound, the type and volume of anesthesia administered, the type
and knot tension. of suture(s) used in the repair, the layers repaired, the type of repair
(interrupted vs. continuous), and how the procedure was tolerated TABLE 92-4 Suture Removal Recommendations
by the patient. Any complications should also be noted.
Location Days
Face 3–4 (child), 3–5 (adult)
AFTERCARE Neck 2–3 (child), 3–4 (adult)
Wound care has become a specialty involving sophisticated research Upper extremity 7–10
in many areas, including dressings and the environment in which Hand 10–14
wounds heal best. Clean the area surrounding the repaired wound Chest 7–10
Back 10–14
with normal saline to remove any antimicrobial agents and blood. It
Buttocks 10–14
has been demonstrated that optimal growth of fibroblasts in tissue Legs 8–10
culture occurs at low partial pressures of oxygen (5 to 10 mmHg). Foot 10–14
Epidermal cell growth is inhibited at oxygen levels higher than that Delayed closure 8–12
in surrounding air. It has been shown clinically that hydrocolloid Retention sutures 14–30
dressings are capable of maintaining low oxygen tension inde- Overlying joints 10–14
pendent of the underlying disease process.29 The application of an
occlusive dressing has been shown to increase the rate of wound
healing by approximately 40%, as well as preventing environmental scars, and possibly infections. Suture removal kits are commercially
trauma and keeping bacteria out of the wound. available. They typically contain a metal or plastic forceps, a scis-
Dressings, regardless of the type used, should produce a moist sors, and a few gauze squares. These kits are inexpensive, disposable,
but not macerated wound that is free of infection, toxic chemicals, and intended for single-patient use.
and foreign material while maintaining an optimum temperature Sutures should be removed using aseptic and sterile techniques.
and pH. Layered dressings of nonadherent gauze, such as Xeroform, Clean the wound with saline. Apply hydrogen peroxide to remove
covered with dry gauze can be used for large sutured lacerations any dried blood and serum encrusted around the sutures. Grasp
and abrasions. This dressing draws exudate into a layer that can be the suture at the knot with forceps (Figure 92-11). Lift the knot
replaced without disturbing the underlying wound. Shear wounds off the skin. Cut the suture as close to the skin as possible with a
or hematomas may require gauze that is fluffed and formed into a scissors and where the suture enters the skin (Figure 92-11). This
pressure dressing. Dressings of antibiotic ointment with a standard will avoid drawing contaminated suture through the depth of the
adhesive bandage (e.g., Band-Aid) provide adequate healing and wound. Sutures that are close together, small, or tight may require
protection for smaller repaired lacerations. The topical application a #11 scalpel blade to cut them rather than a scissors. Gently pull
of topical antibiotics to the suture line after wound closure may help the suture strand out of the tissue with the forceps and across the
to protect against exogenous bacterial contamination. No stud- wound. Pulling a suture out away from the wound may result in the
ies have shown that topical antibiotic ointments have an effect on wound edges opening (dehiscing). Remove one to three sutures and
the final outcome of a wound. Despite this, their use is still recom- ensure that the wound edges do not dehisce. Remove the remain-
mended because they keep the wound surface moist and their use ing sutures. Apply skin adhesive strips (e.g., Steri-strips) across the
has not been shown to have any negative effects. The use of paper wound to provide support.
gauze and Telfa pads is not advisable.
MANAGEMENT OF PUNCTURE WOUNDS
DISCHARGE INSTRUCTIONS Puncture wounds are considered to be at higher risk for infec-
High-risk wounds such as animal and/or human bites, hand wounds, tion than simple lacerations. They should be allowed to heal by
heavily contaminated wounds, and wounds that require prophylac- delayed intention, particularly if they penetrate into the subcuta-
tic antibiotic coverage should be reevaluated within 24 hours. neous tissues. Local cleansing is the initial step in management.
Patients should be made aware, orally and in writing, that up to High-pressure irrigation, coring, and probing are generally not
one in 10 persons develops a wound infection that can be treated recommended.
with an oral antibiotic. Puncture wounds are considered high-risk Infection is most frequently due to Staphylococcus aureus,
injuries that can result in bone infections. Patients should immedi- Staphylococcus epidermidis, or streptococcal species. Treatment
ately return to the Emergency Department or their primary physi- should be reserved for compromised hosts, dirty wounds, or actual
cian if a wound becomes red or has a discharge, if redness or red infected wounds.30 Puncture wounds of the foot are of special con-
streaks are emanating from the wound, or if they develop a fever. cern due to the risk of Pseudomonas aeruginosa infection, particu-
Explain briefly the progression of healing. The new scar’s appear- larly with wounds through athletic shoes. A tender wound that
ance is usually worst at 3 to 5 weeks. Most scars remodel within 6 to is not infected usually indicates that there may be a retained for-
12 months. Any revision of the wound should be postponed for at eign body. Persistent infection from a plantar wound suggests an
least 6 to 12 months from the time of injury.
SUTURE REMOVAL
The length of time that the sutures remain in place depends upon
the location of the wound, the amount of tension on the wound,
and the healing time of the involved tissue. Some general guide-
lines are listed in Table 92-4. Appropriate and timely removal of
sutures minimizes scarring. Full-thickness sutures can be left in
place for 2 or more weeks without risk of suture-track formation in
areas where sebaceous glands and other adnexal structures are not
present, such as the plantar and palmar surfaces. Leaving sutures in
place too long results in epithelialization of the suture tracts, larger FIGURE 92-11. Suture removal.
CHAPTER 93: Basic Wound Closure Techniques 623
underlying osteomyelitis that requires radiographs and treatment Aggressive attention to the presence of foreign bodies, underlying
with a fluoroquinolone.31 injury to anatomic structures of significance, and the possibility of
subsequent wound infection should be kept in mind at all times.
PEDIATRIC ISSUES OF WOUND HEALING An effort should be made to educate the patient about the possible
outcomes of wounds and lacerations and to encourage expedited
Pediatric patients less than 15 years of age experience infection rates follow-up.
of less than 1% for clean surgical wounds.7 This is less than that seen
in adults. Young children, despite the ultimate in the way of gentle
reassurance, will sometimes require sedation in order to make pain-
ful or difficult procedures possible. Safe and effective procedural
sedation for patient comfort or cooperation to facilitate or expedite
medical care is described in Chapter 129. Undermining is not useful Basic Wound Closure
in most pediatric wounds as they do not usually require advance-
ment of skin over a significant tissue defect. Scalp lacerations
93 Techniques
account for 30% of pediatric lacerations. Scalp lacerations are well Eric F. Reichman and Candace Powell
suited for single-layer repair with staples. Cosmetic results are com-
parable with those of sutured repairs, with no differences in compli-
cation and infection rates. Staples are six times faster, less expensive
INTRODUCTION
in cost of supplies and physician time than standard sutures, and Wound management is crucial to the practice of Emergency
can be implanted rapidly and accurately, even in a moving child. Medicine. Emergency Physicians routinely care for wounds ranging
from simple lacerations to complex injuries in the trauma patient.1–6
ALTERNATIVE CLOSURES Wound repair is always secondary to the evaluation and stabilization
of any life-threatening and limb-threatening emergencies. However,
Alternative methods of wound closure include skin closure tapes,
patients are often legitimately concerned about the outcome of
tissue adhesives, and staples. These are mentioned briefly below. A
wounds and lacerations. There are several basic suture principles
more complete discussion can be found in Chapters 93 and 94.
that will help to provide optimal wound healing and ensure a more
than acceptable cosmetic result. The previous chapter outlines the
SKIN CLOSURE TAPES essential principles of wound management. This chapter describes
Skin closure tapes are adhesive strips that are used when skin tension the basic methods used to close wounds.
and wound contamination are not concerning factors. Adhesive-
backed long and narrow strips are used for approximating the edges SUTURES
of lacerations (with or without staples or sutures) and for closing the
skin following many operative procedures. The most common type The choice of suture materials is important in wound closure.
is the Steri-strip. Skin closure tapes are felt to develop and increase Sutures are made of a wide variety of materials, both natural and
wound tensile strength faster than sutured wounds because uni- synthetic. Natural substances include gut (sheep and beef), cotton,
formly orienting collagen fibers apply equal stress across the wound. and silk. Natural substance sutures cause more tissue reactions
Skin closure tapes are porous, which allows for good air inflow and and scarring, which limits their use. Cotton sutures are not dis-
the escape of water vapor from the wound during the healing pro- cussed, as they are no longer used in clinical practice. Synthetic
cess. Strips are placed perpendicular to the wound in conjunction sutures can be made of nylon, polyethylene (Dacron), polygla-
with an adhesive such as tincture of benzoin, taking care not to get ctin (Vicryl), polypropylene (Surgilene, Prolene), polyglycolic
benzoin in the wound. acid (Dexon), poliglecaprone (Monocryl), polydiaxanone (PDS),
polyglyconate (Maxon), and metal.6 Metal sutures are used in the
TISSUE ADHESIVES Operating Room and not in the Emergency Department as they
are difficult to handle, prone to breakage, and indicated in only
Tissue adhesives such as the older and weaker butyl cyanoacrylates a few situations. Synthetic sutures tend to have a problem with
focused on small linear lacerations. Newer and stronger medical- “memory.” That is, they tend to retain the shape of their packag-
grade octyl cyanoacrylate formulations have been approved by the ing. This can make it difficult to manipulate the suture during
US Food and Drug Administration. It has been clinically proven wound closure.
that there is no difference 1 year after treatment in the cosmetic out- Sutures are constructed as monofilaments or polyfilaments.
come of wounds repaired with suture versus those closed with octyl Polyfilament fibers consist of multiple filaments braided together
cyanoacrylate tissue adhesive.32 to form one suture. They are easier to handle than monofilament
sutures, as they tend to be more pliable. Polyfilament sutures have
STAPLES better knot security and therefore reduce the incidence of knot
slippage. However, they can be associated with a higher incidence
Staple closure is time-efficient compared to the suture repair of lac-
of infection than monofilament sutures. They allow bacteria to
erations.33 It is primarily used for large wounds that are not on the
migrate (or wick) between the strands of the suture located at the
face, neck, hands, or feet. Stapling is especially useful for closure of
skin surface and into the wound.
incisions in hair-bearing skin (i.e., scalp) areas as well as the trunk
Select the smallest diameter suture that can adequately hold
and extremities. The wound edges require manual eversion with
the tissue edges together in order to reduce tissue damage and
forceps prior to placing the staples.
scarring. The largest suture material available is size #5. The suture
sizes decrease to zero (#4, #3, #2, #1, #0) and then are followed by
SUMMARY #00 (2-0), #000 (3-0), and #0000 (4-0), in decreasing size. The small-
Expert wound management consists of attention to the details sur- est suture commonly used in the Emergency Department is 6-0 for
rounding the wound, gleaning important information concern- facial lacerations, nail bed lacerations, as well as lacerations in cos-
ing the host’s history, as well as meticulous wound preparation. metically sensitive areas. The tensile strength of sutures is related
TABLE 93-1 Absorbable Suture Materials

Suture type Source Tensile strength Tissue reaction Knot security Absorption
Plain surgical gut Beef or sheep collagen Poor Moderate Poor 1–2 weeks
Chromic surgical gut Beef or sheep collagen Poor Moderate Fair 2–3 weeks
Monocryl Poliglecaprone 25 20% remains by 3 weeks Minimal Good 3 months
Coated Vicryl Polyglycolic 910, polyglactin 370, 65% remains at 2 weeks; Minimal Fair 3–6 months
and calcium stearate 40% at 3 weeks
Dexon Polyglycolic acid 50% remains at 4 weeks Minimal Good 3–4 months
Vicryl Rapide Polyglactin 910 50% remains in 5–6 days Minimal Good 42 days
PDS polydioxanone Polyester polymer 70% remains at 2 weeks; Slight Poor 6 months
50% at 4 weeks
Maxon Polyglyconate 50% remains at 7 weeks Slight Fair 6 months
to their size. The tensile strength of suture increases as the size Synthetic absorbable sutures, such as Dexon and Vicryl, are
increases. For example, 4-0 is stronger than 5-0. typically used more often than natural absorbable sutures in the
The other main category of suture classification is absorbable Emergency Department. They are degraded by the body more slowly
versus nonabsorbable. In the past, absorbable sutures were pri- than natural fibers and can therefore help maintain the strength of
marily used to close the subcutaneous layers of a wound. More the wound longer. Vicryl and Dexon maintain their tensile strength
recently, absorbable sutures have also been used for skin closure. at 80 days and 120 days, respectively. They cause less reaction in the
Nonabsorbable sutures are primarily used for skin closure. tissues as they break down when compared to natural absorbable
sutures.
ABSORBABLE SUTURE MATERIALS Recently, absorbable sutures have gained some popularity for use
in skin closure.7–10 Absorbable sutures have been shown to yield
Absorbable sutures are degraded by the body and do not require equal results in their rate of dehiscence, rate of infection, and cosme-
removal. They usually do not maintain their tensile strength for lon- sis when compared to nonabsorbable sutures.7 Absorbable sutures
ger than 60 days. Body enzymes dissolve the absorbable sutures with have the added benefit for the patient of not having to return to have
the aid of an inflammatory reaction. The rate of absorption of the their sutures removed. Vicryl Rapide is a newer form of Vicryl that
sutures varies based upon the tissue where it is placed, the compo- is especially suited for this purpose. This type of suture is rapidly
sition of the suture, and the size of the suture. Absorbable sutures absorbed. They begin to fall off in 7 to 10 days as the wound heals.
placed in mucous membranes absorb faster than those placed in This can be especially useful for children in whom suture removal
muscle tissue or fascia. Smaller sizes of suture dissolve faster than can be difficult, under casts, or if a patient will not be able to follow
larger sizes. up due to travel.
There are several types of absorbable sutures, both natural and
synthetic (Table 93-1). The most commonly used absorbable
NONABSORBABLE SUTURE MATERIALS
sutures in the Emergency Department are plain gut, chromic gut,
polyglycolic acid (Dexon), polyglactin (Vicryl), and Vicryl Rapide. Nonabsorbable sutures are not degraded by the body and must
Plain gut and chromic gut are both natural forms of absorbable be removed. They maintain their tensile strength for longer than
sutures. They are made from the intestines of sheep and cattle. Gut 60 days. They are composed of monofilament or polyfilament strands
is a tissue irritant and can cause a substantial tissue reaction while of organic, synthetic, or metal fibers (Table 93-2). Nonabsorbable
it is being absorbed and degraded by the body. Chromic gut is plain sutures generally have greater tensile strength and lower tissue reac-
gut that has been soaked in chromic acid salts. This process helps to tivity than absorbable sutures. They are used in a variety of appli-
extend the half-life of the suture and allows it to maintain its tensile cations including skin closure. Nonabsorbable sutures can be used
strength longer than plain gut. Chromic gut may retain its tensile within a body cavity and subcutaneously, where they will eventually
strength for 2 to 3 weeks, while plain gut retains its tensile strength become encapsulated in connective tissue.
for 1 to 2 weeks. Both types of gut are packaged wet in order to keep Nonabsorbable sutures can be classified as organic, synthetic, and
them from drying out and becoming too stiff. wire. Organic sutures include those made of cotton or silk. Cotton
TABLE 93-2 Nonabsorbable Suture Materials

Suture type Source Tensile strength Tissue reaction Knot security Absorption
Silk (braided) Organic protein Gradual loss by progressive High Good Gradual encapsulation
degradation by connective tissue
Ethilon Polyamide (nylon) Progressive hydrolysis may result Minimal Fair Gradual encapsulation
in gradual loss of tensile strength by connective tissue
Nurolon Polyamide (nylon) Progressive hydrolysis may result Minimal Fair Gradual encapsulation
in gradual loss of tensile strength by connective tissue
Prolene Polyamide (nylon) Not subject to degradation Minimal Poor Nonabsorbable
Mersilene Polyester No significant change occurs Minimal Good Gradual encapsulation
by connective tissue
Ethibond Coated polyester No significant change occurs Minimal Good Gradual encapsulation
by connective tissue
Stainless steel Stainless steel Indefinite Minimal Good Nonabsorbable
is the oldest of the nonabsorbable sutures. It is not discussed here

as cotton sutures are no longer used in general medical practice.
Silk is a polyfilament suture that has limited use in the practice of
Emergency Medicine. There are several advantages to silk suture
material. Its pliability makes it very easy to handle. It holds knots
better than other types of suture. However, as with all natural and/
or polyfilament sutures, it has a greater tendency to cause wound
infections. The polyfilament braids can provide a place for bacteria
to lodge. Silk suture may actually protect the bacteria from attack
by the body’s defenses if the wound becomes infected. The primary
use of silk sutures is for the repair of lip, oral cavity, and tongue
lacerations.
Synthetic nonabsorbable sutures are available in monofilament
and polyfilament forms. Commonly used synthetic sutures include
nylon, polypropylene, polybutester, and Dacron. Nylon, polypropyl-
ene, and polybutester are monofilament synthetic sutures. Dacron
is a polyfilament synthetic suture. The synthetic nonabsorbable
A
sutures have several advantages over the natural nonabsorbable
sutures. They are less reactive in tissues, generally stronger than the
natural sutures, and retain their tensile strength over many years.
Nylon (Ethilon, Dermalon) is the most common nonabsorbable
suture used in the Emergency Department. It is a monofilament
suture, it is inert, and it does not tend to harbor bacteria. It is pri-
marily used for skin closure. Nylon has good tensile strength and
minimal tissue reactivity. However, nylon is difficult to handle and
difficult to tie. It requires more knots to achieve good knot security
than other types of suture. This is primarily due to the tendency of the
suture to return to its packaged shape. This tendency is also known
as “memory.” Because the knot can unravel or slip, it is important to
place at least four or five knots when using nylon suture.
Polypropylene and polybutester are less commonly used syn-
thetic nonabsorbable sutures. Polypropylene (Prolene) is stronger
but more difficult to work with than nylon because it has greater
memory. Polybutester (Novafil) is a newer suture in this category.
It is stronger than the other monofilaments and does not have sig- B
nificant memory. Therefore, it is easier to work with than the other
monofilament synthetic sutures.
FIGURE 93-1. The equipment required for basic wound closure techniques.
A. The contents of a disposable and commercially available wound closure kit.
EQUIPMENT B. A hospital packaged kit with reusable instruments.
• Needle drivers, 4.5 and 6.0 in.
• Skin hooks
• Scalpel blades (#10, #11, and #15) manufacturers (Figure 93-1A). These kits tend to be expensive and
• Scalpel handles occasionally have a limited amount of equipment. Many hospitals
• Iris scissors, straight 4 in. and curved 4 in. package and sterilize their own wound repair kits (Figure 93-1B).
• Suture scissors, 6 in. This decreases the cost, as the equipment can be repeatedly steril-
ized and reused. It also allows the kits to contain a wide variety of
• Forceps, toothed Adson instruments for multiple situations (e.g., minor laceration, large lac-
• Metzenbaum scissors, curved 6 in. eration, and plastics closure).
• Hemostats, straight 6 in., and curved mosquitoes Needle drivers come in a variety of sizes. A 4.5 in. needle driver
• Suture material can be used comfortably with most types of needles. A 6 in. needle
driver may be required if large needles are used to close a wound.
• Skin closure tapes Hold the needle driver with the fingertips to provide greater flex-
• Benzoin solution, swabs, or spray ibility. The fingers can also be placed through the finger holes, but
• Gum mastic (e.g., Mastisol) this is not as efficient when closing a wound. Grasp the needle
one-third of the way from the swag (distal) end with the tip of the
• Tissue adhesive
needle driver.
• Tissue adhesive forceps The skin must be grasped and manipulated during wound repair
• Skin stapler to allow for proper suture placement. Forceps are most commonly
• Staple remover used to grasp and manipulate the skin. Smooth (nontoothed) for-
ceps should never be used to grasp skin. They require the applica-
• Gauze, 4 × 4 squares
tion of a large amount of force to grasp the tissue. This can crush
Much of the above equipment can be purchased in single- tissue very easily. An Adson forceps is the forceps of choice. It has
use, sterile, and disposable suture kits from several commercial fine teeth that grasp tissue securely with minimal force.
TABLE 93-3 Typical Suture Choices for Each Body Site

Anatomic site Deep-layer suture size Deep-layer suture material Skin-layer suture size Skin-layer closure material
Scalp 2–0, 3–0, or 4–0 Absorbable 4–0 or 5–0 Nylon, polypropylene, or staples
Eyelid 5–0, 6–0, or 7–0 Absorbable 6–0 or 7–0 Nylon or polypropylene
Face 4–0 or 5–0 Absorbable 5–0 or 6–0 Nylon or polypropylene
Neck 4–0 or 5–0 Absorbable 4–0 or 5–0 Nylon or polypropylene
Trunk 3–0 or 4–0 Absorbable 3–0 or 4–0 Nylon, polypropylene, or staples
Extremities 3–0 or 4–0 Absorbable 3–0, 4–0, or 5–0 Nylon, polypropylene, or staples
Hands and feet Not advisable Not applicable 4–0 or 5–0 Nylon or polypropylene
Sole of foot 3–0 or 4–0 Absorbable 3–0 or 4–0 Nylon or polypropylene
A skin hook is a sharp, pointed instrument that is inserted into heal with a better cosmetic result if the wound edge is everted and
the wound edge and grasps the tissue from the undersurface. It pro- slightly elevated. The wound edges will contract into a “pit” below
duces a small puncture wound in the subcutaneous tissues and does the plane of the skin, will be more noticeable, and the final result will
not penetrate the skin surface. Skin hooks are preferable to forceps, be less appealing cosmetically if the wound edges are not everted.
as they do not crush tissues. A skin hook is awkward to use at first. Handle the tissues gently and do not squeeze or twist them too
With proper instruction and experience, the Emergency Physician tightly with the instruments. This helps to avoid strangulation,
will most certainly prefer a skin hook to forceps. which can result in tissue necrosis. The sutures should be placed
Several types of scissors are required for proper wound closure. carefully and with the proper amount of tension to help promote
Iris scissors have sharp, delicate tips for making precise cuts in tis- healing. Sutures should be snug. Attempts should be made to avoid
sue. They should not be used to cut suture material, as this rapidly excessive tension on the wound edges in order to prevent wound
dulls and nicks the blades. Suture scissors have one blunt tip and one dehiscence. The use of the smallest suture size necessary to approxi-
pointed tip. Both blades of the suture scissors are sharp. Suture scis- mate the wound edges will reduce tissue damage and minimize scar-
sors are used to cut adhesive tape, gauze, rubber drains, and suture ring. Table 93-3 lists the appropriate suture types and sizes for each
material. Metzenbaum scissors should be used to debride heavy tis- body region.
sue, bluntly dissect tissue, and undermine tissue. If there will be a temporary delay in the closure of a laceration
Hemostats are used to clamp small vessels that are bleeding, because of other injuries that may be life-threatening or of greater
to explore a wound, and to grasp fascia. Hemostats are available importance, cover the wound with a saline-soaked gauze in order to
in a variety of sizes and styles. A straight 6 in. hemostat is used keep the tissues from drying.
for most purposes during wound repair. A curved 5 in. mosquito
hemostat can be used for small wounds or delicate tissues. Do not PRINCIPLE OF HALVING
use a hemostat to grasp or drive the suture needle. The suture
needle can bend, rotate, and break as it enters tissue if driven by a Large wounds gape open and are difficult to approximate. Closure
hemostat. of the deeper layers will often bring the skin edges into apposition. If
Three different scalpel blades should be available when a wound not, the principle of halving may be used to approximate the wound
is being repaired. A #11 blade is used to make stab incisions. It is (Figure 93-2). Identify the midpoint of the laceration. Place the first
often used for the incision and drainage of abscesses, cricothyroid- suture at the midpoint (Figure 93-2A). This stitch is known as the
otomies, and the removal of small or tight sutures. A #10 blade is central suture. The next sutures are placed in halves on each side
used to make straight cuts in the skin and debride wound edges. It of the central suture (Figures 93-2B & C). Continue the process by
is rarely used in laceration repair. A #15 blade is small and curved placing sutures halfway between previous sutures until the wound is
to allow precise incisions. It is used for excising foreign bodies and approximated. This results in even closure of the wound edge. This
wound debridement. principle can be used for closure of both the deep layers and the skin.
SUTURE TECHNIQUES TWO-HANDED SQUARE KNOT

Proper wound closure requires an understanding of certain basic This is the easiest and most reliable method of tying most suture
principles. The needle should enter and exit the skin at a 90° materials. It involves the classic “right-over-left and left-over-right”
angle and perpendicular to the wound edges. By doing so, when
the suture loop is closed, the wound edges will be everted. Sutures
should be placed as close to the wound edge as possible (2 to
3 mm) in order to avoid excessive tension on the wound. More
force will be required to close the wound if the sutures are placed too
far from the wound edge. Edema develops in a wound in the first
48 hours after closure. Sutures placed too far from the wound edge
can result in large scars when the edema subsides.
The layers of the wound should be matched evenly and each
layer should be closed separately. If a wound involves the deeper
layers of skin, fascia should be matched to fascia, dermis should be
matched to dermis, and epidermis should be matched to epidermis.
The proper matching of layers avoids an uneven closure, helps to FIGURE 93-2. The principle of halving. A. The first suture is placed in the middle
prevent an unnecessarily large scar, and eliminates dead space. of the laceration. B. The second suture is placed halfway between the first suture
The epidermal edges of the wound must be everted to allow and the upper end of the laceration. C. The third suture is placed halfway between
for proper healing. Scars contract with time. They will flatten and the first suture and the lower end of the laceration.
tie (Figure 93-3). The incorrect “right-over-left and right-over-left” Place a suture through the skin on both sides of the laceration
is a granny knot, which will slip if it is tied in this manner. This (Figure 93-3A). Pull the suture through the wound until half is
square knot is quick and simple to perform. However, it does take on each side of the laceration. Grasp the right half of the suture
significant practice to master this technique. with the right thumb and index finger (Figure 93-3A). Grasp
FIGURE 93-3. The two-handed square knot.

FIGURE 93-3. (continued )
the left half of the suture with the left third through fifth fingers hand (Figure 93-3J). Regrasp the suture with the right hand after
and the suture draped over the thumb (Figure 93-3A). Cross it passes through the loop (Figure 93-3K). Pull the suture com-
the right hand toward the left hand (Figure 93-3B). Continue to pletely through the loop with the right hand. Simultaneously move
move the right hand until the suture is between the left thumb the left hand toward the left and move the right hand toward the
and index finger (Figure 93-3C). Close the left thumb and right (Figure 93-3L). Cross the hands so that the left hand goes
index finger to entrap the right half of the suture in the pads toward the right side and the right hand goes toward the left side
of the fingers (Figure 93-3D). Pull the right hand down and to (Figure 93-3M). Continue to pull both sides of the suture until
the left so that the two halves of the suture form an X over the the knot lies flat and the skin edges are apposed (Figure 93-3M).
left thumb (Figure 93-3E). Flex the left wrist to slide the X off The first half of the knot is now complete.
the left thumb and onto the left index finger (Figure 93-3F). Make the second half of the knot to complete the square knot.
Lift the left thumb backward and upward so that the X overlies Raise both hands upward and uncross them until an X is formed
the tip of the left index finger (Figure 93-3G). Reapply the left over the left index finger (Figure 93-3N). Close the left thumb
thumb over the left index finger to entrap the X (Figure 93-3H). and index finger to entrap the suture being held with the right
Extend the left wrist to push the left thumb and the X through hand (Figure 93-3O). Extend the left wrist to push the left thumb
the loop (Figure 93-3I). Release the suture held with the right through the loop (Figure 93-3P). Lift the left index finger upward
FIGURE 93-4. The square knot (A) versus the surgeon’s knot
(B). The first throw of the square knot has one loop (A), while that
of the surgeon’s knot has two loops (B). The second throw of both
knots is a simple loop.
(Figure 93-3Q). Move the right hand away from you until the suture Place a suture through the skin on both sides of the laceration
it holds drapes over the left thumb (Figure 93-3R). Reapply the left (Figure 93-5A). Carefully grasp the needle in its midportion and
index finger onto the thumb to entrap the suture held with the right pull it through the laceration (Figure 93-5B). Continue to pull
hand (Figure 93-3S). Release the suture held with the right hand the needle until approximately 1 to 2 cm of suture on the tail end
(Figure 93-3T). Flex the left wrist to push the left index finger and remains outside the laceration (Figure 93-5C). A large amount of
suture through the loop (Figure 93-3U). Regrasp the free suture suture will be wasted if the tail is left too long, as it will be later cut
with the right hand after it passes through the loop (Figure 93-3V). off and discarded. On first learning the instrument tie, it may be best
Move the right hand upward and to the right to complete the sec- to leave a tail of 3 to 4 cm until one is proficient with this technique.
ond half of the knot overlying the left index finger (Figure 93-3W). Place the needle driver over the laceration but not touching it
Simultaneously move the left hand toward the left and move the (Figure 93-5C). Loosely loop the needle end of the suture over
right hand toward the right (Figure 93-3X). Continue to pull both (Figure 93-5D) and around (Figure 93-5E) the needle driver.
halves of the suture until both halves of the knot come into contact Loosely loop the needle end of the suture over and around the nee-
(Figure 93-3Y). Pull both halves of the suture to secure the knot. dle driver a second time (Figures 93-5F & G). This will eventually
The square knot is now complete. Continue the process to add addi- result in the first half of a surgeon’s knot. Looping the suture once
tional knots onto the suture. Cut off excess suture on both sides of around the needle driver will result in a simple square knot. Move
the knots. the tip of the needle driver toward the tail of the suture without let-
ting the loops fall off the needle driver (Figure 93-5H). Grasp the
tail of the suture with the needle driver (Figure 93-5I). Pull the tail
SURGEON’S KNOT
of the suture through the loop (Figure 93-5J). Pull the tail com-
The physician may choose to use a surgeon’s knot instead of a pletely through the loops (Figure 93-5K). Simultaneously move the
square knot (Figure 93-4). The square knot has one loop in the first left hand toward the right and the right hand/needle driver toward
throw and one loop in the second throw (Figure 93-4A). The sur- the left (Figure 93-5L). Continue to pull both sides of the suture
geon’s knot has two loops in the first throw and one loop in the until the hands are opposite each other, the knot lies flat, and the
second throw (Figure 93-4B). The only difference between these skin edges are apposed (Figure 93-5M). The first half of the knot is
two knots is the two loops in the first throw. The second throw and now complete.
subsequent knots are exactly the same for both knots. The advan- Make the second half of the knot. Continue to hold the nee-
tage of the surgeon’s knot is that the two loops are more secure and dle and release the tail of the suture from the needle driver
stay in place while the second throw is being tied. The choice to use (Figure 93-5N). Place the needle driver over the laceration but
either knot is dependent on the experience and the training of the not touching it (Figure 93-5N). Loosely loop the needle end of
physician. the suture over (Figure 93-5O) and around (Figure 93-5P) the
needle driver. Move the tip of the needle driver toward the tail
of the suture without letting the loop fall off the needle driver
INSTRUMENT TIE
(Figure 93-5Q). Grasp the tail of the suture with the needle driver
The instrument tie is the most efficient method to complete a sim- (Figure 93-5R). Pull the tail of the suture completely through
ple interrupted suture (Figure 93-5). It is the tie that is most com- the loop (Figure 93-5S). Simultaneously move the left hand
monly used in the Emergency Department. An instrument tie is toward the left and the right hand/needle driver toward the right
often quicker, requires less dexterity, and is easier to perform than (Figure 93-5T). Continue to pull both sides of the suture until
the two-handed method. It may be used with the square knot or the both halves of the knot come into contact. Pull both sides of the
surgeon’s knot. suture to secure the knot. The knot is now complete. Continue
FIGURE 93-5. The instrument tie.

FIGURE 93-5. (continued )
this process three or four more times, each in alternative direc- Insert the needle at a 90° angle to the skin (Figure 93-6A).
tions, to place additional knots. Cut off the excess suture on both Drive the needle through the tissue until the tip exits the skin
sides of the knots. (Figure 93-6B). Grasp the needle behind the tip and pull it
through the wound (Figure 93-6C). The suture should enter
and exit the skin equidistant from the wound edges (Figure
SIMPLE INTERRUPTED STITCH 93-6D). If it does not, pull the suture out and repeat the stitch
The simple interrupted stitch is the most commonly used suture so that it is equidistant from the wound edges. Make a loop in
technique and is useful in many situations (Figure 93-6). One major the suture with the two-handed tie or the instrument tie. Pull
advantage is that each stitch is placed independent of the oth- the suture to appose the wound edges and cinch down the knot
ers. Therefore tension on each stitch can be adjusted separately. (Figure 93-6E). The tissue at the base of the wound will come
Additionally, the entire repair is not compromised if one suture into apposition before the tissue at the skin surface and thus evert
should happen to come out. The other sutures will remain in place the wound edge. Complete the knot to one side of the laceration
to help assure proper wound healing. The needle must enter and (Figure 93-6F). Just prior to cinching the second throw onto
exit the skin at a 90° angle to help evert the wound edges. Take the first, pull the ends so that the knot is not directly over the
equal volumes of skin from each side of the area being sutured. wound and the edges of the wound remain in apposition. Apply
Drive the needle equidistantly into and out of the wound edges additional sutures equidistant from each other until the wound is
and incorporate the base of the wound. closed (Figure 93-6G).
FIGURE 93-6. The simple interrupted stitch.
OPEN-LOOP SIMPLE INTERRUPTED STITCH knot tightly to the second knot. This “locks” the third knot onto
the second knot.
The open-loop simple interrupted stitch is a variation of the sim- This knot is indicated when there is the possibility of edema form-
ple interrupted stitch (Figure 93-7). The same basic technique is ing at the suture site. If edema forms, the first knot will have room
used except that the knot is tied differently. The tie involves laying to open as it slides toward the second knot. This stitch avoids exces-
down the first knot with an instrument tie. However, the second sive tension on the wound and prevents the suture from cutting into
knot placed on the suture is not pulled all the way down. Pull the the skin. This stitch facilitates suture removal when numerous small
second knot only until it is just above the first knot (Figure 93-7A). stitches are placed next to a wound edge. Cutting the open loop
In other words, the second knot is loosely tied, leaving a loop unravels the knot and allows for easy removal of the suture. This
between the first and second knots. Place a third knot as a single stitch should not be used in areas where the skin is thin or if there
knot square to the second knot (Figure 93-7B). Cinch the third is little subcutaneous tissue (e.g., dorsal hand and foot). In these
areas, the wound edges often become unopposed while the knot is
being secured.
INTERLOCKING SLIP KNOT

This technique can be used in patients who will be traveling, camp-
ing, or otherwise away from their primary source of medical care
(Figure 93-8). The patient can easily remove the sutures without
having to find an unfamiliar or foreign healthcare provider for rou-
tine suture removal. The interlocking slip knot can be removed by
hand without the use of a scissors or a scalpel. This can be useful for
suture removal in pediatric patients, who may find it hard to sit still
for suture removal.
Place a suture through the skin on both sides of the laceration
(Figure 93-8A). Loop the tail end of the suture around the tip
of the needle driver (Figure 93-8A). Grasp the needle end of the
suture with the needle driver (Figure 93-8B). Pull the needle end
of the suture through the loop while simultaneously pulling on the
tail end of the suture with a second needle driver (Figure 93-8C).
Continue to pull both suture halves in opposite directions until a
knot is formed against the skin and the wound edges are apposed
(Figure 93-8D). Release the needle driver holding the now formed
loop. Insert the needle driver through the loop and grasp the tail
end of the suture (Figure 93-8E). Grasp the needle end of the
FIGURE 93-7. The open-loop simple interrupted stitch. suture with the second needle driver (Figure 93-8E). Pull the
FIGURE 93-8. The interlocking slip knot.
needle drivers in opposite directions to lock and secure the knot Place the initial stitch as a simple interrupted stitch (Figure
(Figure 93-8F). The knot is now complete (Figure 93-8G). To 93-9A). Do not cut the suture after the knots are securely tied.
remove the stitch, pull the free end of the suture to unlock the knot. Place a second stitch 3 to 5 mm from the first stitch as if placing
Continue to pull the suture until it is free from the skin. This stitch another simple interrupted stitch (Figures 93-9B & C). Place a
can easily become loose or open before the wound is healed. Thus, third stitch 3 to 5 mm from the second stitch (Figures 93-9D &
it is recommended to cover the wound and sutures with skin clo- E). Continue to place additional stitches until the end of the lacera-
sure tape (e.g., Steri-Strips). tion is reached. Use care to ensure that the sutures are all lined
up with each other and equidistant from the laceration. Do
CONTINUOUS OVER-AND-OVER not pull the last throw taut against the skin (Figure 93-9F). The
loop will act as the tail end of the suture for knot tying. Loop the
STITCH (SIMPLE RUNNING STITCH)
needle end of the suture twice around the tip of the needle driver
Continuous (simple running) sutures minimize the time required (Figure 93-9G). Grasp the last throw with the tips of the needle
for laceration repair. Stitches can be placed very quickly, since driver (Figure 93-9G). Pull the last throw through the loops until
each individual stitch does not have to be tied. This stitch provides the knot is against the skin (Figure 93-9H). Perform three to five
strength and applies equal tension on all sutures in the repair. This more instrument ties to secure the knot. Cut off the excess suture
stitch can be used to achieve hemostasis. The wound must be long (Figure 93-9I).
and straight. Simple running stitches can effectively be used in par-
tial-thickness lacerations and wounds under minimal tension. CONTINUOUS SINGLE-LOCKED STITCH
However, there are several disadvantages to this stitch. It can
(RUNNING-LOCKED CLOSURE)
be associated with significant epithelialization of the suture track.
This is especially true if the suture is not removed early and This stitch may promote less epithelialization of the suture track
remains for a prolonged period of time. Inclusion cysts may form than the continuous over-and-over stitch. It maintains the advan-
within a few weeks after removal of the sutures. Simple running tages of a continuous suture. This variation of the simple running
stitches should not be used on any wound under tension. If one closure locks each stitch after it is placed (Figure 93-10). It provides
suture breaks, the entire wound may open. This stitch should not a secure apposition of the wound edges while each subsequent stitch
be used when closing a wound where there is a risk of subse- is placed. The main disadvantage of this stitch is the time it takes
quent hematoma formation. Hematoma formation would require compared to a continuous over-and-over stitch.
the removal of all of the sutures in order to drain the hematoma. Place the initial stitch as a simple interrupted stitch (Figure
Although this suture is not commonly used in the Emergency 93-10A). Do not cut the suture after the knots are securely tied.
Department, it can be very helpful for closing bleeding scalp Loop the tail end of the suture over the nondominant fifth fin-
wounds, as the injury will be covered with hair and cosmesis is a ger (Figure 93-10B). Apply slight tension on the tail end of the
secondary concern. suture while placing the second stitch (Figures 93-10C & D).
FIGURE 93-9. The continuous over-and-over or simple running stitch.
As the needle exits the skin, move the nondominant hand to bring the loops until the knot is against the skin (Figure 93-10I). Perform
the suture loop down and over the needle (Figure 93-10E). Grasp three to five more instrument ties to secure the knot. Cut off the
the front of the needle with the needle driver. Simultaneously pull excess suture (Figure 93-10J).
the needle and suture through the laceration while releasing the
loop from the fifth finger (Figure 93-10F). Repeat this procedure
VERTICAL MATTRESS STITCH
until the laceration is closed (Figure 93-10G). Do not pull the last
throw taut against the skin. The loop will act as the tail end of The vertical mattress stitch is a double stitch that provides for excel-
the suture for knot tying. Loop the needle end of the suture twice lent wound eversion (Figure 93-11). It optimizes wound closure of
around the tip of the needle driver (Figure 93-10H). Grasp the last lacerations under tension. This stitch is useful in areas where the
throw with the tips of the needle driver. Pull the last throw through skin is very lax, such as the elbow and the dorsum of the hand. This
FIGURE 93-10. The continuous single-locked or running-locked stitch.

FIGURE 93-11. The vertical mattress stitch.
stitch provides for both superficial as well as deep closure of lacera- wound eversion in half the time as the traditional method. Place
tions. This stitch is contraindicated in lacerations involving the the first throw close to the lacerated wound edge to approximate
volar aspect of the hands and feet or the face, as it requires the the skin edges (Figures 93-12A & B). Grasp and pull the suture to
blind placement of a deep suture. The main disadvantage of elevate the wound edges (Figure 93-12C). This allows the needle to
the vertical mattress closure is the time it takes to place it. more easily take a large bite of tissue on the second throw. Place the
Place the first throw much like a simple interrupted stitch with second throw 1.0 to 1.5 cm from the wound edge (Figures 93-12C
a few noted differences. The needle should enter and exit the & D). Release the suture. Tie the suture to approximate the wound
skin 1.0 to 1.5 cm from the wound edge. The needle should tra- edges and evert the skin surface (Figure 93-12E). The final prod-
verse the base of the wound and grasp a large amount of tissue uct looks exactly the same as the traditional vertical mattress suture
(Figures 93-11A & B). Reverse the needle. The second throw (Figure 93-12F).
should enter and exit the skin approximately 2 to 3 mm from the
wound edge (Figures 93-11C & D). The first and second throws
LOCKED VERTICAL MATTRESS STITCH
must be directly over each other and parallel. Tie the suture to
approximate the wound edges (Figure 93-11E). The first throw will The locked vertical mattress stitch is useful in areas that are widely
close the wound base and relieve the tension at the skin surface. The separated and where deep sutures must be avoided (Figure 93-13).
second throw approximates and everts the skin edges. This stitch helps to reduce the amount of tension needed to close
The newer version of the classic vertical mattress is referred to as a wound. It helps to avoid the pain and scarring that can result
the “shorthand” vertical mattress stitch (Figure 93-12). It provides if too much tension is applied to a laceration. It does not put an
FIGURE 93-12. The “shortcut” vertical mattress stitch. An alternative method to place the vertical mattress stitch.
FIGURE 93-13. The locked vertical mattress stitch.
excessive amount of tension on the deep throw, as does the vertical to the wound edges because, theoretically, no suture is placed
mattress stitch. through the wound edges. This helps to avoid tension on the wound
This is a modification of the vertical mattress stitch (Figures edges from the suture and subsequent local necrosis. This stitch
93-11 & 93-12). Place the first two throws as if placing a vertical is placed more rapidly than the vertical mattress stitch. It requires
mattress stitch (Figure 93-13A). Leave the suture lax with a loop fewer stitches to close a wound with horizontal rather than verti-
above the wound surface. Pass the needle end of the suture through cal mattress stitches. The throws are side by side rather than on top
the open loop (Figure 93-13B). This step will form the locked por- of each other, as with the vertical mattress, and each stitch closes
tion of the stitch. Pull the needle end of the suture taut to appose more tissue. This closure may be used on the volar surfaces of the
the wound edges (Figure 93-13C). Tie and secure the suture in the hands and fingers, as these delicate skin areas may swell and be cut
standard manner. by simple interrupted sutures. The main disadvantage of the hori-
zontal mattress stitch is that it takes more experience to properly
place this stitch to achieve wound eversion than with the vertical
HORIZONTAL MATTRESS STITCH
mattress stitch.
The horizontal mattress stitch is placed along the axis of the wound Place the first throw much like a simple interrupted stitch with
and helps to eliminate tension on the wound (Figure 93-14). It is a a few noted differences. The needle should enter and exit the skin
good closure technique for wounds with relatively poor circulation 0.5 to 1.0 cm from the wound edge. The needle should traverse the
FIGURE 93-14. The horizontal mattress stitch.

FIGURE 93-15. The half-buried horizontal mattress stitch is

used to approximate a star-shaped (stellate) laceration (A) and
a Y-shaped laceration (B).
base of the wound (Figures 93-14A & B). Reverse the needle and placed rapidly. The running horizontal mattress stitch is contra-
make a second throw 0.5 cm from the first (Figure 93-14C). The indicated in wounds under tension if the goal of wound closure is
needle must enter and exit the skin and the wound edges so that optimal cosmesis.
the first and second throws are parallel to each other (Figures This stitch begins with a simple interrupted stitch at one end of a
93-14C & D). Pull the free ends of the suture taut to appose and laceration (Figure 93-16). The needle is then run along the length
evert the wound edges (Figures 93-14E & F). Tie and secure the of the wound while placing horizontal mattress stitches. The differ-
suture in the standard manner. ence between this and the standard horizontal mattress stitch is that
the suture is not tied and cut after each individual stitch. Rather, the
HALF-BURIED HORIZONTAL MATTRESS STITCH stitch is continued (running) the length of the laceration. At the end
of the laceration, the stitch is tied and secured in the same way as the
This is the stitch of choice to close complex wounds with mul- simple running stitch (Figure 93-9).
tiple flaps in a single-layer closure. This stitch is ideal to close stel-
late, Y-shaped, V-shaped, and T-shaped lacerations. The half-buried
CONTINUOUS SUBCUTICULAR STITCH
horizontal mattress stitch allows a tissue flap to be reapproximated
without tension on the edges of the flap. The vascular supply to a This closure is ideal for lacerations of the face and neck. It provides
flap is derived from its base. The flaps sometimes have a limited excellent cosmesis, leaves no suture marks on the skin, and causes
or poor vascular supply. This stitch may be used to approximate a minimal scarring. It requires more time and skill to place than other
flap-like laceration in which the corner has limited vascularity and/ types of stitches. It may be performed for the temporary pull-out
or viability. (Figure 93-17) or permanent placement (Figure 93-18) of subcuta-
The key to this stitch is that the needle and suture pass through neous sutures. Polypropylene or nylon sutures must be used for this
the dermis of the flap and not the epidermis (Figure 93-15). Begin stitch. Polypropylene is preferred as it is stiffer, stronger, and easier
by placing the first stitch percutaneously through the skin adjacent to remove than nylon.
to the tip of the flap (Figure 93-15A). Advance the needle through The use of this stitch is limited to lacerations that are clean,
the dermal layer of the flap, the dermal layer of the skin adjacent straight, have sharp edges, and are less than 6 cm in length. It may
to the tip of the flap, and out the skin adjacent to the tip of the flap be extremely difficult to remove the suture material for the pull-out
opposite to where the stitch began (Figure 93-15A). The needle technique if the laceration is greater than 6 cm in length. The lacera-
must traverse the dermis of the flap and adjacent tissue at the tion can be longer if the permanent placement of absorbable sutures
same level of the dermis to properly approximate the wound is being used. The dermis and subcutaneous tissue must be apposed
edges. Gently pull on the free ends of the suture to approximate the before proceeding with this stitch. If necessary, apply buried absorb-
flap against the adjacent skin edges. Tie and secure the suture in the able sutures to appose the dermis before applying this stitch. The
usual manner. Secure the edges of the flap with half-buried horizon- superficial wound surface must be tension-free, as this stitch is
tal mattress stitches (Figure 93-15A), simple interrupted stitches, for cosmesis and not strength. The wound may require undermin-
vertical mattress stitches, or horizontal mattress stitches. ing to release the tension from the wound edges. Refer to Chapter 92
Stellate lacerations are often seen in the Emergency Department. for details regarding wound undermining.
They occur due to bursting of the skin from crush injuries. These The pull-out technique allows the subcuticular stitch to be
lacerations are often encountered on the extremities, forehead, and removed after the laceration heals (Figure 93-17). The subcuticu-
scalp. Begin by inserting the needle through the skin of the largest lar suture should enter the intact skin 3 to 4 mm from one end of
flap. Advance the needle so that its tip exits the dermis. Continue
to advance the needle through the dermis of each flap. The half-
buried horizontal mattress stitch should encompass the tips of all
the flaps (Figure 93-15B). The remainder of the procedure is as
described above.
CONTINUOUS (RUNNING)
HORIZONTAL MATTRESS STITCH
The running horizontal mattress stitch is indicated in areas of the
body where there is loose skin that tends to overlap or invert, such
as the skin of the upper eyelids or the dorsum of the hand. This
stitch can also be used as the surface closure in a multiple-layer clo-
sure if there is a tendency for wound inversion. Like the traditional
horizontal mattress stitch, it provides good apposition and can be FIGURE 93-16. The continuous or running horizontal mattress stitch.
As an alternative, the continuous stitch may be placed using

absorbable suture material to provide longer-lasting strength to
the wound (Figure 93-18). Suture material of choice includes
Dexon, PDS, or Vicryl. The same indications, preparation, and
stitch are used as with the pull-out technique. The only difference
is in the starting and ending stitch. Place the first stitch into the
dermis, just inside the laceration edge, as a buried knot (Figures
93-18A to C). Place the continuous suture until the opposite end
of the laceration is reached (Figure 93-18D). The final throw
should be left lax with a trailing loop of suture (Figure 93-18E).
The loop should be used as the “tail end” to perform an instru-
ment tie (Figure 93-18F). Tie three or four knots in the suture.
Lift the free ends of the suture and cut them just above the knot.
FIGURE 93-17. The continuous subcuticular pull-out stitch. Apply wound tape across the laceration to help maintain the
apposition of the wound.
the laceration and burrow through the dermal-epidermal junc-

tion to emerge through the skin at the other end of the laceration
BURIED (SUBCUTANEOUS) KNOT STITCH
(Figure 93-17A). The suture will continuously pass through the This stitch helps to decrease potential dead space underneath a lac-
subcuticular layer on alternate sides of the laceration. The point eration and gives tensile support for up to 4 to 6 weeks, while the
of entry of each stitch should be directly across from or slightly wound is still weak. The loop is constructed so that the knot lies at
behind the exit point of the previous stitch. It is very important the bottom of the wound base (Figure 93-19). This helps to keep the
to keep the needle at the same level of depth throughout the skin surface smooth and flat. The buried knot stitch is most useful
wound. The tension on the suture should be adjusted to ensure in closing subcutaneous tissue just under the skin surface.
that there is no puckering of the skin. Tape the free suture at This stitch requires practice to master. Insert the needle into
both ends of the laceration to the skin (Figure 93-17B). Place one side of the base of the wound (Figure 93-19A). Drive the nee-
wound tape (e.g., Steri-strips) across the laceration to help main- dle from deep to superficial and exiting at the dermal-epidermal
tain the apposition of the epidermis. This stitch is easily removed. junction (Figure 93-19A). Insert the needle through the dermal-
Remove the wound tape and slowly pull one end of the suture epidermal junction on the opposite side of the wound and drive
with a needle driver. it through the base of the wound (Figure 93-19B). The suture
FIGURE 93-18. The continuous subcuticular permanent stitch.

FIGURE 93-19. The buried (subcutaneous) knot stitch.
should exit the base of the wound across from and level with avoid pulling potentially contaminated epithelial cells through the
the entrance site of the first throw. Pull both free ends of the wound. The stitch is placed like the horizontal mattress stitch and
suture up and out through the laceration (Figure 93-19C). Tie sterile buttons or rubber tubing is used to achieve approximation
a knot in the suture (Figure 93-19D). Pull both free ends of the to a point where the wound edges can be closed without signifi-
suture to lower the knot to the base of the wound and appose cant tension (Figures 93-20A & B). Do not attempt to appose the
the tissue (Figure 93-19E). Tie two additional knots to secure the wound edges when using retention sutures. Appose the remaining
suture. Cut off any excess suture. skin edges with simple interrupted, vertical mattress, or horizontal
mattress stitches. The reinforcing sutures should remain in place
REINFORCING (RETENTION) SUTURES after the skin sutures are removed. The reinforcing sutures should
FOR WOUNDS UNDER TENSION be removed after the wound has healed and gained significant ten-
sile strength.
Reinforcing or retention sutures are particularly useful for wounds
in which the edges are widely separated or where the skin is too SUTURE REMOVAL TECHNIQUES
atrophic to approximate without the suture cutting through the skin.
The reinforcing sutures help to decrease the tension on the wound Remove sutures as soon as possible to avoid the possibility of
by providing more support for the wound edges. Reinforcing sutures infection and prevent the formation of suture marks. However,
can be placed using sterile buttons or rubber tubing (Figure 93-20). if they are removed too early, wound dehiscence may occur. Simple
Heavy sizes of nonabsorbable suture materials are used for reinforc- interrupted sutures should be cut at the end away from the knot and
ing sutures. This is not for strength but to avoid the finer suture then pulled out (Figure 93-21A). This helps to prevent the outer
from cutting through the tissue. contaminated portion of the suture from passing back through the
Ideally, a double-swaged (needle) suture should be used to place wound. In order to remove a running simple or running-locked
suture from the inside of the wound toward the outside skin to stitch, grasp the knot at the end of the closure and cut each loop
FIGURE 93-20. Reinforcing sutures for wounds under tension. Sterile buttons (A) or pieces of sterile rubber tubing (B) can be used to secure the suture and prevent
injury to the soft tissues.
FIGURE 93-21. Suture removal techniques. A. Simple interrupted stitch. B. Simple running stitch. C. Running-locked stitch. D. Vertical mattress stitch. E. Horizontal
mattress stitch.
(Figures 93-21B & C). Pull out each individual suture piece. Tissue adhesives come in a variety of forms and applicator tips
Vertical and horizontal mattress sutures can be removed in much (Figure 93-22A). Approximate the wound edges with forceps.
the same way as the simple interrupted stitch (Figures 93-21D & E). Commercially available, disposable, single-patient-use tissue for-
ceps can be used (Bionix Development Corp., Toledo, OH). These
are specifically designed to approximate the wound edges prior to
TISSUE ADHESIVE CLOSURE
using cyanoacrylates (Figure 93-22B). Apply the adhesive in two or
(CYANOACRYLATES) three layers along the wound edge (Figure 93-22C). The adhesive
Tissue adhesives (skin glues) are best used to close low-tension, may also be applied in spots over the laceration (Figure 93-22D) or
small, straight-edged, and superficial wounds (Figure 93-22). They across the laceration, like wound tape (Figure 93-22E). Droplets or
should not be used for lacerations that are bleeding, lacerations lines should be placed 0.5 cm from each other. Support the wound
over joints, or lacerations under tension. There must be adequate for 30 to 60 seconds while the adhesive dries.
hemostasis and the tissue must be as dry as possible. The major
advantage to the use of tissue adhesives is speed. Wounds can be
SKIN CLOSURE TAPES
repaired quickly and without anesthesia. Other contraindications to
this type of closure are angled or beveled wounds. Petroleum-based Skin closure tapes (e.g., Steri-Strips) are used to close very low
ointments or similar products will dissolve the tissue adhesive and tension wounds that are tidy and small. They can be used as the
should be avoided on this type of closure. Refer to Chapter 94 for a primary closure technique for superficial wounds (Figure 93-23)
more complete discussion of tissue adhesives. or they can provide reinforcement after sutures have been placed
FIGURE 93-22. Laceration repair with cyanoacrylate tissue adhesive. A. Several examples of tissue adhesive. From left to right: Dermabond ProPen, SurgiSeal, Indermil
Loctite, Liquiband Flow Control. B. Commercially available wound forceps (Bionix Development Corp., Toledo, OH). C. Tissue adhesive applied continuously over the
laceration. D. Tissue adhesive applied in spots over the laceration. E. Tissue adhesive applied across the laceration.
(Figure 93-24). Skin tapes are easy to use and can be placed rel- Skin closure tapes may be placed over a sutured laceration
atively quickly. They do not leave suture marks and have no skin (Figure 93-24). The tapes will provide additional support to the
reactivity. wound edge and help to prevent dehiscence. This technique is espe-
Skin closure tapes should not be used in wounds where the edges cially useful in areas of cosmetic concern, such as the face.
are widely separated or on parts of the body where there is move- The skin closure tapes should remain in place for at least as long
ment or moisture. This technique does not work well on irregularly as the sutures. They must be kept dry to prevent them from coming
shaped wounds or wounds where there will be a propensity for off prematurely and the wound from dehiscing. The wound should
swelling of the wound edges. Care should be taken in using these be observed daily for signs of infection.
tapes in a child. If they are not secured properly, the child may Skin closure tapes may be placed across a wound when sutures or
remove them prematurely. staples are removed. The tapes will maintain the apposition of the
After the initial cleansing of the skin, clean the skin surface epidermis as the wound matures. Apply benzoin solution to the skin
with acetone or alcohol to remove any surface oils. Allow the skin before removing the sutures or staples. Remove several sutures or
to dry. Apply benzoin solution, or gum mastic (e.g., Mastisol), staples and apply the skin closure tapes. Continue this process until
to the skin on both sides of the wound (Figure 93-23A). Allow all the sutures or staples have been removed and the wound is cov-
60 to 90 seconds for the liquid benzoin to dry and become tacky. ered with skin closure tapes. Alternatively, remove all of the sutures
Cut the skin closure tapes to the proper length (Figure 93-23B). or staples and then apply the skin closure tapes.
Gently tear the end-tab off the back of the card to prevent the Suturing lacerations in a thin-skinned individual is often diffi-
strips from deforming (Figure 93-23C). Remove a strip from the cult. The skin frequently tears as the wound is approximated and
card (Figure 93-23D). Firmly secure the tape to one side of the the suture is tied. The use of skin closure tapes can facilitate wound
wound (Figure 93-23E). Use the nondominant hand to appose the closure, strengthening the skin edges, and allow for a more secure
wound edges as the tape is brought over and secured to the skin wound closure. Clean, prep, and anesthetize the skin. Apply benzoin
on the opposite wound edge (Figure 93-23F). Place additional solution to the skin adjacent to and on both sides of the laceration.
tapes at 2 to 3 mm intervals until the wound edges are apposed Allow the benzoin to sit and become tacky. Apply skin closure tapes
(Figures 93-23G & H). Place pieces of tape across the tape edges over the benzoin on both sides of the laceration. Suture the lacera-
to prevent premature removal and skin blistering from the tape tion, ensuring that the needle enters the skin on one side of the lac-
ends (Figure 93-23I). eration and exits the skin on the other side of the laceration through
FIGURE 93-23. Skin closure tapes to primarily close a laceration.
the skin closure tapes on each side. Remove the skin closure tapes at
the time of suture removal.
Two advanced skin closure tape-based systems are the ClozeX
(Clozex Medical LLC, Wellesly, MA) and the 3M Steri-Strip S
Surgical Skin Closure (3M Healthcare, St. Paul, MN). These are
nonlatex, disposable, single patient use, transparent, adhesive-based
wound closure devices for the primary closure of lacerations and
wounds not under tension. They align the wound edges and provide
good cosmetic results. They come in a variety of sizes, ranging from
10 to 100 mm.
STAPLE CLOSURE
Stapling is a rapid closure technique that is useful for superficial
scalp lacerations and linear lacerations of the trunk and extremi-
ties. Staples should not be used on the face, neck, hands, or feet.
These areas have little subcutaneous tissue and the staples can
damage underlying structures. Staples should also be avoided in
any area of the body that will be exposed to computed tomogra-
FIGURE 93-24. Skin closure tapes can provide reinforcement for sutures. phy (CT) or magnetic resonance imaging (MRI). The staples are
A B
FIGURE 93-25. Examples of two styles of skin staplers.
made of an inert material, which helps to decrease tissue reactiv- staple is inserted into the tissue. The stapler automatically loads the
ity. Staples should not be used for wounds that are crush wounds, next staple after one staple is discharged. Skin staplers typically have
infected, irregular, macerated, over bony prominences, or under 10 or 35 preloaded staples.
tension. Prepare the wound for stapling. Place deep sutures to close the
The skin stapler is a simple device (Figure 93-25). It is a single subcutaneous tissue and, if the wound is gaping, bring the wound
patient use, sterile, disposable unit that is preloaded with staples. It edges into apposition. Approximate the skin edges with the domi-
is grasped and held with one hand. When the handle is squeezed, a nant hand (Figure 93-26A). Evert the wound edges with a forceps
FIGURE 93-26. Laceration repair with staple closure. A. The wound edges are apposed and everted. B. The stapler is applied over the laceration. C. The stapler is applied
over the everted wound edges. D. The plunger advances the staple into the wound margins. E. The anvil bends the staple into shape. F. The final product.
held in the nondominant hand (Figure 93-26A). Grasp the sta-

pler with the dominant hand. Gently place the skin stapler over
the laceration (Figure 93-26B). Start at one end of the lacera-
tion and work toward the opposite end. Do not indent the skin
with the stapler, as this will cause the staples to be placed too
deep. Align the arrow on the front of the stapler over the lacera-
tion (Figure 93-26C). Squeeze the handle of the stapler. A plunger
will advance a staple into the wound margins (Figure 93-26D).
An anvil will bend the staple into a square or rectangular shape to
secure the staple (Figure 93-26E). Continue to evert the wound
edges and apply staples every 3 to 5 mm until the wound is approxi-
mated and without any gaps (Figure 93-26F). A small space will
be visible between the skin surface and the staple if it is properly
positioned. If the staple is against the skin, it has been placed too
deep. Remove the staple and replace it.
There are a few complications associated with staple use. Their
removal can be uncomfortable or difficult. Minor bleeding can
FIGURE 93-28. Staple removal. A. The lower jaw of the staple remover is placed
occur from the holes after the staples are removed. Staples placed
under the staple. B. The upper jaw compresses the center of the staple and allows
on the face, feet, hands, and neck can damage superficial subcutane-
the staple arms to exit the skin.
ous structures (e.g., blood vessels, muscles, nerves, and tendons).
Improper wound eversion can result in wound dehiscence upon
staple removal, larger scars, and poor wound healing. Staples can cause larger and more prominent skin marks and subsequent scar-
ring when compared to sutures.
STAPLE REMOVAL
Staples should remain in place for approximately 5 to 10 days, the
same amount of time as sutures. They can remain longer if placed
over a joint or in cases of slow wound healing. The staple remover
is a disposable, sterile, single-patient-use device (Figure 93-27A).
It is made of metal or plastic with metal tips. The lower jaw of the
stapler has two upwardly angled metal prongs (Figures 93-27B &
93-28). The upper jaw of the stapler is a flat piece of metal. Insert
the prongs of the lower jaw of the staple remover between the sta-
ple and the skin (Figure 93-28A). Close the handles of the staple
remover. This will cause the upper jaw to compress the center of
the staple and the arms of the staple to withdraw from the skin
(Figure 93-28B). Lift the staple remover and staple off of the skin.
Discard the staple and continue the process until all the staples
have been removed. A patient who plans to follow-up in a clinic
or office should be given a staple remover to take with them, as
A many clinics and offices do not routinely stock these devices.
HAIR APPOSITION
Scalp wounds can be closed using hair-tying, also known as the
hair apposition technique (HAT).11–15 This technique is relatively
painless, does not usually require anesthesia, results in a shorter
procedure time, eliminates the need for staple or suture removal,
is cost-effective, and the wound outcome is similar or superior to
sutures.11,12,15 This technique should not be used on wounds under
tension, wounds with ongoing hemorrhage, wounds that are grossly
contaminated, or if the hair is <3 cm in length.
Clean, prep, anesthetize, and dry the laceration and sur-
rounding skin. Start at one end of the laceration and grasp 5 to
15 hairs on each side of the laceration. Twist the hair strands on
each side of the laceration to form a single “rope.” Tie the two
“ropes” of hair together to close the wound and appose the edges.
Use a hemostat and an instrument tie to make the process sim-
pler and easier. Continue this process until the entire laceration
is closed with hair ties. As the laceration heals, the hair know
B will grow away from the wound edges. The hair knot can be cut
off by a family member, friend, or primary care provider in 2 to
FIGURE 93-27. The staple remover. A. Overview. B. The tip with the jaws open. 4 weeks.
An alternative HAT uses tissue adhesive instead of making a hair proximal end is the suture needle attached to an absorbable barbed
knot (Figure 94-5).15 Clean, prep, anesthetize, and dry the laceration suture. The distal end is a fixed loop of the suture material. This self-
and surrounding skin. Start at one end of the laceration and grasp anchoring loop and barb combination eliminates knot tying when
5 to 15 hairs on each side of the laceration. Twist the hair strands closing wounds. It is placed similar to a running subcuticular stitch.
on each side of the laceration to form a single “rope.” Twist the two The barbs are circumferentially distributed on the suture strand and
“ropes” of hair together to close the wound and appose the edges. spread tension evenly across the wound. This device is mostly used
Apply tissue adhesive to the twisted hair and apposed skin segment for postoperative skin wounds but may become more popular in the
of the laceration. Allow 30 seconds for the tissue adhesive to dry. Emergency Department.
Apply a second layer of tissue adhesive and allow it to dry. Continue
this process until the entire laceration is closed. This method does INSORB SUBCUTICULAR SKIN STAPLER
not require the later cutting away of the hair knot. Unfortunately,
this technique may not produce as much hemostasis or wound ever- The Insorb subcuticular skin stapler (Incisive Surgical, Plymouth,
sion as tying a hair knot.15 MN) combines absorbable sutures and a device similar to a skin sta-
pler (Figure 93-29). This is a sterile, single patient use device that
MISCELLANEOUS WOUND deploys up to 20 absorbable subcutaneous staples (Figure 93-29A).
CLOSURE DEVICES The subcutaneous staples are horse shoe-shaped (Figure 93-29B).
The device allows wound eversion with no external sutures or metal
staples that require later removal (Figures 93-29C & D). The final
V-LOC ABSORBABLE WOUND CLOSURE DEVICE
cosmetic results are similar to sutures or skin staples. The company
The V-Loc (Covidien, Norwalk, CT) is an absorbable, dispos- also sells a reusable three-arm proprietary forceps to make wound
able, single use, unidirectional barbed wound closure device. The approximation easier for one person.
A B
C D
FIGURE 93-29. The Insorb subcuticular skin stapler. A. The staple unit. B. The absorbable staple resting on a fingertip. C. Artist illustration of the unit in action. The inset
shows the relationship of the staple to the subcutaneous tissues. D. The unit closing a laceration. (Photos courtesy of John L. Shannon Jr., Incisive Surgical Inc.)
CHAPTER 94: Tissue Adhesives for Wound Repair 647
SUMMARY present.5,6 The cost to the patient is less for lacerations repaired
with tissue adhesives compared to suturing.7,18 This takes into
There are multiple techniques available for closing wounds. The account physician time, procedure time, materials, and repeat vis-
principles and techniques discussed will help to provide the most its for suture removal.7,24 There is less need for the painful injec-
appropriate closure for the various types of wounds that are seen in tion of local anesthetic solution. The risk of a needlestick injury
the Emergency Department. Care should be taken to provide the best is decreased when not suturing. An additional benefit of tissue
closure possible to provide good cosmesis and avoid complications. adhesives is that they provide an occlusive covering for wounds,
keeping them moist, water tight, and providing protection from
invading microbials.8 Wounds closed with tissue adhesive do not
require routine follow-up like those sutured closed do for suture
removal.
Tissue Adhesives
94 for Wound Repair
INDICATIONS
Tissue adhesives are best used to close low-tension, small, straight-
Hagop M. Afarian edged, and superficial wounds. Although not an absolute contra-
indication, specific precautions should be taken when using tissue
INTRODUCTION adhesives near the eye. The liquid adhesive has a tendency to run. If
the eyelid margins are not protected, the tissue adhesive can cause
The year 1942 marked the discovery of cyanoacrylate, the chemi- iatrogenic sealing of the eyelids.9 Tissue adhesive may be used for
™
cal found in adhesives such as Superglue .1 The use of cyano- wounds that are deep or under tension as a superficial closure layer
acrylates for wound closure has been described since the 1960s only after the subcutaneous layer has been repaired to bring the
when it was first assessed for military use. It was not until 1998 wound edges together and relieve tension. Most wounds on the
that N-2-octylcyanoacrylate (Dermabond) was approved by the head, neck, torso, and proximal extremities can be closed with tis-
FDA for use in the United States. Tissue adhesives have since sue adhesive. Flap type lacerations and lacerations of thin skin can
redefined the overall approach to laceration repair, especially in be closed where the use of sutures can compromise the skin. Long
the Emergency Department. Their ease of use, relative painless- lacerations can be divided into segments and each segment closed as
ness, and simplicity of aftercare make it an ideal tool for small if it were a small laceration.19
straight wounds and use in children.2
CONTRAINDICATIONS
Tissue adhesives should not be used on wounds which are
Cyanoacrylates are a monomer liquid. When activated by water, actively infected, heavily contaminated, greater than 6 to 12
they polymerize via an exothermic reaction to form a strong bond. hours old, a result of a crush injury, punctures, on the eyelids or
Heat is released by this polymerization reaction and may cause surrounding skin, or due to bites. Tissue adhesives can only be
some discomfort. Cyanoacrylates are classified as either butyl or used on the skin surface and not used within wounds, on mucous
octyl based on the length of their side chain.20,23 Butyl cyanoacry- membranes, or on mucocutaneous junctions (e.g., the mouth
lates have short and straight side chains. This allows them to form and lips). Do not use tissue adhesives on patients with a known
bonds that are strong, tight, and poorly flexible. Unfortunately, hypersensitivity to cyanoacetate and formaldehyde, as cyanoac-
these bonds can become brittle and fracture. Butyl cyanoacrylates rylates degrade into these byproducts. It is recommended that
are best suited for short lacerations under no tension. Examples of tissue adhesives not be used in areas of the body that are exposed
butyl cyanoacrylates include Histoacryl (B. Braun, Bethlehem, PA) to heavy moisture (e.g., the perineum and axilla) and parts of
and Indermil (Syneture, Norwalk, CT). Octyl cyanoacrylates have the body prone to frequent movement (e.g., hands, feet, and over
longer side chains. This allows them to form bonds that are strong, joints).10 Wounds must be dry. Do not use tissue adhesives on
flexible, and less likely to fracture. Octyl cyanoacrylates can be wounds that are actively bleeding or oozing. Tissue adhesive
used on lacerations of any length. Examples of octyl cyanoacrylates use in these areas may lead to wound dehiscence as the adhesive
include Dermabond (Ethicon Corp., Norwood, MA) and SurgiSeal cracks and/or peels.10 Stop the bleeding with direct pressure or
(Adhezion Biomedical, Wyomissing, PA). Newer agents are a com- the injection of local anesthetic solution with epinephrine prior
bination of the strong and fast-setting butyl cyanoacrylates with to the application of tissue adhesive. They may be difficult to use
the flexibility of the octyl cyanoacrylates. An example is LiquiBand in areas covered densely with hair (i.e., the scalp and axilla) since
(MedLogic Global Ltd., Plymouth, UK). the tissue adhesive will not bond adequately to the skin. They are
The nonmedical and medical adhesives contain similar ingredi- not recommended for stellate wounds because of the difficulty of
ents. The differences between these two types are sterile production, adequately approximating the many wound edges. Other contra-
sterile packaging, and the attached alcohol chain in medical grade indications to this type of closure are angled or beveled wounds,
tissue adhesives. Converting a methyl to an octyl group reduces unless deep sutures are first placed to approximate the wound
the heat produced by polymerization and decreases the amount of edges and relieve any tension.
direct tissue inflammation caused by the breakdown products of the
adhesive.1,3 EQUIPMENT
The major advantage to the use of tissue adhesives is speed.
Wounds can be repaired quickly and without anesthesia. Tissue • Povidone iodine or chlorhexidine solution
adhesives have been shown to offer similar wound closure and cos- • Gloves
metic results as sutures and adhesive strips (e.g., Steri-strips).4,18,19,24
• Wound adhesive (Figure 94-1)
The initial tensile strength of wounds repaired with tissue adhe-
sives are not equivalent to wounds closed with sutures.5,6 Within • Wound cleaning and irrigation supplies (Chapter 92)
7 days, however, any differences in tensile strength are no longer • Forceps
FIGURE 94-1. Several examples of tissue adhesive. From left to right: Dermabond FIGURE 94-2. Commercially available wound forceps (Bionix Development Corp.,
ProPen, SurgiSeal, Indermil Loctite, and Liquiband Flow Control. Toledo, OH).
• Petroleum jelly of tissue adhesive approximately 0.5 cm from each other. Hold
• Acetone or nail polish removal pads the wound edges together for 30 to 60 seconds following the
application of the first layer of tissue adhesive to allow for opti-
• Gauze squares
mum polymerization.
• Occlusive dressing (e.g., Tegaderm)
PATIENT PREPARATION
Explain the procedure, its risks, and benefits to the patient and/
or their representative. Obtain a signed consent for the procedure.
Anesthetize the wound. Cleanse the wound and surrounding skin
of any dirt and debris. Irrigate the wound with normal saline or tap
water. If the wound is dirty, consider the use of a wound irrigation
device as described in Chapter 92. Injuries which require substan-
tial cleaning may not be good candidates for tissue adhesive closure.
Inspect the wound for any retained foreign bodies or injuries to
deep structures. All bleeding must be controlled prior to the appli-
cation of the wound adhesive. Repair lacerations with continued or
heavy bleeding with sutures to achieve adequate hemostasis. Dry
the skin surrounding the laceration with gauze squares.
TECHNIQUES
GENERAL TISSUE ADHESIVE TECHNIQUE

The general technique will be described. There are some differences
in the type of applicator. Prepare the tissue adhesive. Some only
require the removal of a twist-off plastic cap. Others are supplied in
ampules that must be crushed and allowed to soak the foam tip of
the applicator. Use the tissue adhesive immediately after opening the
container as it dries within minutes and may not continue to flow
freely for very long.
Approximate the wound edges with forceps. Commercially
available, disposable, single-patient-use tissue forceps can be used
(Bionix Development Corp., Toledo, OH). These are specifically
designed to approximate the wound edges prior to using tissue
adhesives (Figure 94-2). Alternatives to these devices are Adson
forceps or using gloved fingers. Place a thin layer of tissue adhe-
sive over the wound and extending 5 to 10 mm beyond the wound
margins (Figure 94-3A). The tissue adhesive may also be applied FIGURE 94-3. Laceration repair with tissue adhesive. A. Tissue adhesive applied
in spots over the laceration (Figure 94-3B) or across the lacera- continuously over the laceration. B. Tissue adhesive applied in spots over the lac-
tion like wound tape (Figure 95-3C). Apply the droplets or lines eration. C. Tissue adhesive applied across the laceration.
CHAPTER 94: Tissue Adhesives for Wound Repair 649
Apply a total of three to four thin layers of tissue adhesive. Allow (Figure 94-4C). Unfold the dressing and center the cut-out ellipse
each layer to dry for approximately 30 to 60 seconds before apply- over the wound (Figure 94-4D). Make sure that the newly created
ing the next layer. Each successive layer will take longer to dry as hole in the center is large enough to include the entire laceration
the water available for the polymerization reaction has been cov- and some surrounding skin. If not, cut additional material from the
ered by the previous layer. Be careful to use only thin layers and dressing. Remove the protective tape from the back of the dressing
not large drops of adhesive to assist drying time and prevent and apply it to the skin. Approximate the wound edges and apply tis-
discomfort from any heat released by the exothermic polym- sue adhesive (Figure 94-4E). Cover the entire precut hole and some
erization reaction. Tissue adhesive should not be allowed to of the surrounding dressing with the tissue adhesive. Allow the lay-
flow into the wound. It can remain in the wound long after it has ers of tissue adhesive to completely dry. Carefully remove the dress-
healed leading to delayed healing, prolonged inflammation, and ing. The result is a well-demarcated, circular film of tissue adhesive
tattooing.20,21 overlying the closed laceration (Figure 94-4F).
Do not touch the layers of wound glue as they are drying to
prevent cracking and inadvertent adhesion of foreign bodies to HAIR APPOSITION TECHNIQUE
the wound. If gloved fingers or other foreign bodies have become
attached to the wound, gently peel them away from the most recent Scalp wounds can be closed using hair-tying, also known as the
layer before it dries. Tissue adhesive applied to an area where it does hair apposition technique (HAT).11–16 This technique is relatively
not belong should be wiped away within 10 seconds. painless, does not usually require anesthesia, results in a shorter
procedure time, eliminates the need for staple or suture removal,
is cost-effective, and the wound outcome is similar or superior to
PREVENTING THE TISSUE
sutures.12,13,16 This technique should not be used on wounds under
ADHESIVE FROM RUNNING tension, wounds with ongoing hemorrhage, wounds that are grossly
Techniques have been described for use when working around areas contaminated, or if the hair is <3 cm in length.
that must not come in contact with the tissue adhesive, such as the Clean, prep, anesthetize, and dry the laceration and surrounding
eye. The first and easiest precautionary technique is patient posi- skin. Start at one end of the laceration and grasp 5 to 15 hairs on
tioning. Position the patient so that the tissue adhesive will not run each side of the laceration (Figure 94-5A). Twist the hair strands
away from the wound. Ideally, the wound surface should be parallel on each side of the laceration to form a single “rope.” Tie the two
to the floor. Unfortunately, this is not always possible to accomplish. “ropes” of hair together to close the wound and appose the edges.
Alternatively, position the patient in a manner such that the wound Use a hemostat and an instrument tie to make the process simpler
rests below the sensitive area. Gravity allows any of the liquid tis- and easier. Tissue adhesive can be applied to the hair knot for added
sue adhesive to run away from the area of concern. Avoid squeez- security. Continue this process until the entire laceration is closed
ing the tissue adhesive container too much to control the amount with hair ties. As the laceration heals, the hair know will grow away
expressed. This can help to minimize any runoff. Consider placing from the wound edges. The hair knot can be cut off by a family
a piece of gauze or occlusive dressing over the area of concern to member, friend, or primary care provider in 2 to 4 weeks.
protect it from any runoff. An alternative HAT uses tissue adhesive instead of making a
A barrier can be created between the wound and the sensitive hair knot.16,22 Clean, prep, anesthetize, and dry the laceration and
area. Place a thin film of petroleum jelly between the wound and surrounding skin. Start at one end of the laceration and grasp
the sensitive area. This will ensure that if the tissue adhesive were 5 to 15 hairs on each side of the laceration with your gloved fin-
to run, it will not spread beyond the barrier. Alternatively, apply the gers or a hemostat (Figure 94-5A). Twist the hair strands on
petroleum jelly in a wide circle surrounding the wound, creating a each side of the laceration to form a single “rope.” Twist the two
valley for the tissue adhesive to fill if it runs. It may become difficult, “ropes” of hair together to close the wound and appose the edges
however, to hold the wound edges together in a small space cov- (Figures 94-5B & C). Apply tissue adhesive to the twisted hair
ered with petroleum jelly. The oil-based petroleum jelly, if it gets on and apposed skin segment of the laceration (Figure 94-5D). Do
the skin immediately adjacent to the wound, may prevent adequate not allow the tissue adhesive to run into the wound. Allow 60 to
binding of the tissue adhesive. 90 seconds for the tissue adhesive to dry. Apply a second layer of
A final technique to keep the wound adhesive from running tissue adhesive and allow it to dry. Continue this process until
is through the use of an occlusive dressing such as a Tegaderm the entire laceration is closed. This method does not require the
(Figure 94-4).11 Obtain an occlusive dressing large enough to later cutting away of the hair knot. Unfortunately, this technique
cover the area in question (Figure 94-4A). Fold the dressing may not produce as much hemostasis or wound eversion as tying
in half (Figure 94-4B). Cut a hemi-ellipse out of the dressing a hair knot.16
FIGURE 94-4. The use of an occlusive dressing for protection of nearby sensitive structures when using tissue adhesives. A. The occlusive dressing. B. The dressing is
folded in half. C. A hemi-ellipse is cut out of the dressing. D. The dressing is opened with the cut-out ellipse centered over the wound. The protective tape is removed
and the dressing adhered to the skin. E. The wound is approximated and tissue adhesive is applied. F. The result after the dressing has been removed reveals a well-
circumscribed area of tissue adhesive.
FIGURE 94-5. The hair apposition technique (HAT) to close a scalp laceration. A. Grasp 5 to 15 hairs on each side of the laceration. Twist the hair strands on each side of
the laceration to form a single “rope.” B. Cross the hair ropes to opposite sides of the laceration. C. Twist the two “ropes” of hair together to close the wound and appose
the wound edges. D. Apply tissue adhesive to the twisted hair and apposed skin segment of the laceration.
PEDIATRIC CONSIDERATIONS in a bathtub, spa, or pool. Instruct the patient to return immediately
to the Emergency Department or to their primary care provider for
Pediatric patient movement is the factor that causes the greatest any signs of a wound infection.
difficulties when working with wound adhesives. Although tissue
adhesives are most useful in the pediatric population, this specific COMPLICATIONS
population has the greatest risk of movement as well. Movement
will permit running of the adhesive and leakage onto uninvolved Many of the complications associated with the use of tissue adhe-
areas. Extra caution must be incorporated when working around sives are preventable. The Emergency Physician must choose the
sensitive areas. A high viscosity tissue adhesive may be used to limit proper patient, the proper wound, and the appropriate wound loca-
leakage when working around sensitive areas or on children who tion. These few things in association with the appropriate tissue
have trouble remaining still. adhesive application technique will avoid most complications. The
details of these have been described previously in the indications,
ASSESSMENT contraindications, and techniques sections.
A certain percentage of repaired wounds will become infected.
Assess the closed wound to ensure that the edges are approximated. Minimize any infections by properly preparing the wound
Tissue adhesive that has adhered and dried on uninvolved areas may (Chapter 92). This includes the use of anesthesia if appropriate,
be removed using petroleum jelly or topical antibiotic ointment. wound irrigation, wound debriding, wound undermining, wound
Apply the oil-based jelly or ointment to the dried tissue adhesive exploration for foreign bodies, and the use of deep sutures to release
and let it stand for 30 minutes. Gently peel away the tissue adhe- tension.
sive. Use acetone or nail polish remover pads to remove the tissue
adhesive more quickly instead of waiting the time for the oil-based SUMMARY
products to work.17 Be careful to not let acetone drip into the eye
or on mucous membranes. Tissue adhesives have changed the face of laceration repair. Wounds
Tissue adhesive occasionally does enter the eye or the eyelids are repaired more quickly with tissue adhesives and often at a lower
become glued shut. Tissue adhesives are not toxic to the globe cost compared to suturing. Patient satisfaction is increased. There
and will not cause damage to the conjunctiva or cornea. Do not are very few limitations to the use of tissue adhesives. Proper patient
attempt to pry open the eyelids or cut between the eyelid mar- selection, proper wound selection, and proper wound preparation
gins to separate the eyelids. Immediately wipe away any excessive will minimize any complications.
adhesive and flush the eye with saline or tap water. If the eyelids are
sealed shut, apply an ophthalmic antibiotic ointment to the eyelids.
Allow the ointment to sit for 30 minutes. Instruct the patient to
open their eyelids. If they can open their eyelids, gently wipe the
Advanced Wound
95
ointment and adhesive from the eyelids. If they cannot open their
eyelids, instruct them to apply the ointment five to six times a day
and gently attempt to open their eyelids. Within 2 to 3 days at most,
Closure Techniques
their eyelids will separate. Eric F. Reichman
AFTERCARE INTRODUCTION
Instruct the patient that oil-based substances should not be used Traumatic wounds or skin lacerations are among the most common
on any wound repaired with tissue adhesives.1 Tissue adhesive does injuries, occurring in people of all ages, that require evaluation and
not need to be removed. It will peel away within 5 to 10 days as new treatment in the Emergency Department. The result of many if not
epithelial layers are formed below it. Wounds repaired with tissue all wound closures is scar formation. Although most wounds heal
adhesive may briefly come in contact with water (e.g., showering), with a surprisingly pleasing cosmetic transformation from their ini-
but should not be scrubbed clean. Do not soak the wound, whether tial presentations, it is not uncommon for some wounds to present
CHAPTER 95: Advanced Wound Closure Techniques 651
complications during the healing period as well as to produce an more favorable cosmetic results from less complex wound closures.
undesirable scar. A systematic approach to wound management However, younger patients will benefit from more advanced wound
serves to help in deciding how to close complicated wounds, reduce closure techniques to properly close large or complicated wounds.
the risk for infection, and minimize less favorable outcomes. Rotational and advancement flaps are frequently performed to
Wound management in the Emergency Department includes an make scarring less obvious when suturing across lines of tension.3
assessment of the mechanism and conditions that were present at The type of skin, regardless of age, will affect scar formation.3,4
the time of injury. Initially, one must address the concerns of the Oily or hyperpigmented skin more frequently has poor scar tis-
patient, family members, or friends with a concise explanation of sue formation, resulting in scars that are hypertrophic, deep, and
how the wound will be treated and what can be anticipated for after- asymmetrical. Consideration of wound outcome should be given to
care. Many lawsuits and concerns of poor care evolve from poor areas of the skin that are rich in sebaceous glands or simply hyper-
cosmetic outcomes. It is recommended that verbal wound care pigmented (from environmental exposure or ethnicity). Patients
instructions be offered once wound closure is completed, in addi- with underlying connective disease disorders or conditions with
tion to giving the patient written discharge instructions.1 a high likelihood of concomitant vitamin deficiencies should also
Regardless of the severity of the wound or possible inherent com- be scrutinized, as wound closure and healing may be compromised
plications associated with the injury, many patients are primarily in such cases, resulting in highly variable and less predictable
concerned with the potential for scarring or disfigurement. Most outcomes.
patients expect cosmetic and functional perfection as an ultimate The mechanism of injury, including environmental exposure
result after their wounds are treated and the healing process is com- to underlying tissue, should not be overlooked, so that adequate
pleted. These expectations are often not clearly expressed during debridement and preparation may be done prior to a complex
the evaluation and treatment in the Emergency Department. The wound closure. This allows the Emergency Physician to better visu-
Emergency Physician must openly explain and discuss the fact alize the anatomic layers of the skin. It can be difficult to determine
that virtually no wound heals without a scar following wound a clear delineation between the anatomic layers of the skin when
closure.1,2 A clear understanding of this is not to be used as an the wound was a result of a crush injury, shredding mechanism, or
explanation for a poor outcome but to counter any misconcep- any circumstance resulting in uneven or macerated wound edges.
tion that a wound will heal to look exactly like the previously intact Delineate the pigmented epidermis from the thicker underlying
skin. Treatment is rendered to offer the best possible functional and dermis, especially when multilayer wound closures are required, as
esthetic outcome while reducing the risk of potential soft tissue suturing may then become unnecessarily complicated and affect the
infection. overall integrity of the wound closure.
An overall plan of wound site preparation and closure will be It should be noted that the literature supports a significant unde-
needed to provide the greatest likelihood of a pleasing cosmetic rutilization of multilayer closures, though these are often necessary.
result.1 The mechanism of injury, severity of the wound, location Single-layer closures and excessively large suture materials are the
of the wound, and the presence or risk of necrotic tissue can all greatest causes of residual scar tissue.1 It is recommended to prepare
influence the risk of infection. Additionally, the decision of how to the wound edges by creating a bevel or undercutting of the wound
approach wound closure will be affected by the patient’s skin type, margin to allow subtle epidermal eversion, thus augmenting the
age, gender, occupation, and hobbies. natural process of scar formation.1,2 This allows the natural flatten-
Wound healing ultimately takes place over at least 6 to 9 months. ing and depression of the forming scar to occur without excessive
Any wound presenting with concerns for a poor outcome or an obvi- depression from the wound margins.2 This will also help to reduce
ous likelihood of wound revision in the future should be evaluated the thickness of the scar tissue and decrease the refraction of light
and treated by a Plastic Surgeon when possible.1,2 All other wounds from the scar, making it less noticeable.
requiring complex closures should be properly assessed and treated Depending on the presentation of the tissue defect, more than
by the Emergency Physician. one wound closure technique may be used to adequately close a
wound. Utilizing more than one technique will help remove under-
ANATOMY AND PATHOPHYSIOLOGY lying tension and allow better approximation of the epidermis. With
the help of specific camouflage techniques used in closing the epi-
In order to have a better understanding of scar tissue formation
dermis, irregularly shaped wounds can heal with less obtrusive scar-
and the antecedent techniques of wound closure, the Emergency
ring. Familiarity with a few of these techniques and their application
Physician should have knowledge of specific physiologic condi-
will allow the Emergency Physician to comfortably close the more
tions and anatomic areas that may increase the chances of unfavor-
challenging wounds encountered, with expectantly more favorable
able scarring following wound repair.2,3 The age of the patient and
cosmetic prognoses.
appearance of the patient’s intact skin should be taken into consid-
eration. The younger patient tends to heal more rapidly, while the
INDICATIONS
older patient tends to have a more favorable cosmetic outcome with
wound closure. Older patients have less overall elastic and subcuta- Advanced wound closure techniques are indicated for closing
neous tissue and more wrinkling, thus decreasing the tension on the wounds with irregularly shaped defects or defects too large for pri-
healing wound and making scarring less noticeable.2,3 Wrinkling, mary closure. They can be used to close circular, square, elliptical,
or lines of minimal tension, makes wound repair more technically or asymmetrical skin defects. Advanced wound closure techniques
challenging. are beneficial when there is a need to reduce skin tension and con-
Suturing of asymmetrical, deep, or large wounds requires par- tracture, which are likely to result in hypertrophic scar formation.3,4
ticular attention to the preexisting lines of minimal tension or lines Rotational and advancement flap techniques are useful in areas
of facial expression. Without properly addressing such preexistent where tissue loss must be avoided and the undermining of wound
anomalies, the cosmesis of wound repair can be grossly affected.2,3 edges must be minimized. This is often encountered with facial
Scars from wounds closed perpendicular to preexisting function- wounds in proximity to the eyelids, eyebrows, canthi, nasolabial
ally anatomic lines undergo repetitive physical stress and may folds, or lip borders. These techniques allow the initial shape of the
result in hypertrophic scar tissue. With markedly less skin elas- wound to be altered such that there is reduced tension on the wound
ticity and subcutaneous fat, older patients will often experience edges, which may then be closed simply.
CONTRAINDICATIONS one-third of the way from the swag (distal) end with the tip of the
needle driver.
Specific wound closure techniques should take into account the The skin must be grasped and manipulated during wound repair
potential for scar formation to occur in an undesirable location. to allow for proper suture placement. Forceps are most commonly
This can happen when a wound must be elongated to create parallel used to grasp and manipulate the skin. Smooth (nontoothed) for-
lines and to decrease the tension on the wound edges. Elongation ceps should never be used to grasp skin. They require the applica-
of a wound may bring it into proximity of other anatomic position of a large amount of force to grasp the tissue. This can crush
tions or landmarks, thus further complicating the healing process. tissue very easily. An Adson forceps is the forceps of choice. It has
If not planned well, excessively large defects may result, making it fine teeth that grasp tissue securely with minimal force.
more likely that the scar will require later revision. More obvious A skin hook is a sharp, pointed instrument that is inserted into
conditions may exist that compromise complex wound closures. the wound edge and grasps the tissue from the undersurface. It pro-
Particular attention must be given to crush injuries with devi- duces a small puncture wound in the subcutaneous tissues and does
talized or contaminated tissues. Severely contaminated wounds, not penetrate the skin surface. Skin hooks are preferable to forceps,
including those with prolonged exposure, generally are at greater as they do not crush tissues. A skin hook is awkward to use at first.
risk of infection with multilayer closures. Do not perform these With proper instruction and experience, the Emergency Physician
techniques if the patient is at risk for poor wound healing (i.e., dia- will most certainly prefer a skin hook to forceps.
betes, poor vascular supply to the area, or prior radiation therapy Several types of scissors are required for proper wound closure.
to the area), keloid formation, or coagulopathic. Careful wound Iris scissors have sharp, delicate tips for making precise cuts in tis-
assessment may result in a decision to use simple approxima- sue. They should not be used to cut suture material, as this rapidly
tion of the wound edges with close follow-up for ongoing wound dulls and nicks the blades. Suture scissors have one blunt tip and one
care. Contraindications to complex wound closures will at times pointed tip. Both blades of the suture scissors are sharp. Suture scis-
be reliant on temporal factors, such as the need to close a wound sors are used to cut adhesive tape, gauze, rubber drains, and suture
prior to the patient receiving surgical intervention for more life- material. Metzenbaum scissors should be used to debride heavy tis-
threatening injuries. There must be a commonsense approach in sue, bluntly dissect tissue, and undermine tissue.
deciding how to close more challenging wounds in the Emergency Hemostats are used to clamp small vessels that are bleeding, to
Department. explore a wound, and to grasp fascia. Hemostats are available in a
variety of sizes and styles. A straight 6 in. hemostat is used for most
EQUIPMENT purposes during wound repair. A curved 5 in. mosquito hemostat
can be used for small wounds or delicate tissues.
Three different scalpel blades should be available when a wound
• Needle drivers, 4.5 and 6.0 in. is being repaired. A #11 blade is used to make stab incisions. It is
• Skin hooks often used for the incision and drainage of abscesses, cricothyroid-
• Scalpel blades (#10, #11, and #15) otomies, and the removal of small or tight sutures. A #10 blade is
used to make straight cuts in the skin and debride wound edges. It
• Scalpel handles is rarely used in laceration repair. A #15 blade is small and curved
• Iris scissors, straight 4 in. and curved 4 in. to allow precise incisions. It is used for excising foreign bodies and
• Suture scissors, 6 in. wound debridement.
• Forceps, toothed Adson
PATIENT PREPARATION
• Metzenbaum scissors, curved 6 in.
Explain the risks, benefits, and complications of the wound closure
• Hemostats, straight 6 in., and curved mosquitoes
to the patient and/or their representative. The risks include poor
• Suture material healing, wound dehiscence, bleeding, pain, a worse scar, infection,
• Skin closure tapes loss of the tissue, and further surgery. The benefits include improved
• Benzoin solution, swabs or spray cosmesis and wound healing. Alternatives to advanced wound clo-
sure include wet-to-dry dressings and allowing the wound to granu-
• Tissue adhesive late or follow-up with a Plastic Surgeon for closure or a skin graft.
• Tissue adhesive forceps Discuss the presence of a visible scar after the repair, which may
• Gauze, 4 × 4 squares require subsequent revision. Explain the aftercare and follow-up.
• Overhead light source or headlight Obtain a signed informed consent for the procedure.
Place the patient in a position of comfort that is equally comfort-
The above equipment can be purchased in single-use, sterile, able for the Emergency Physician. This should allow for appropri-
and disposable plastic surgery wound kits from several commercial ate stretcher or seat height, lighting, and maneuverability so that
manufacturers. These kits tend to be expensive and occasionally physical obstacles are not a complicating variable during the wound
have a limited amount of equipment. Many hospitals package and repair. Clean the wound and surrounding skin of any dirt and
sterilize their own wound repair kits. This decreases the cost, as the debris. Flush the wound with normal saline. Apply povidone iodine
equipment can be repeatedly sterilized and reused. It also allows the or chlorhexidine solution to the surrounding skin, not the wound,
kits to contain a wide variety of instruments for multiple situations and allow it to dry. Anesthetize the area using local or regional anes-
(e.g., minor laceration, large laceration, and plastics closure). thesia (refer to Chapters 123 through 127).
Needle drivers come in a variety of sizes. A 4.5 in. needle driver Examine the wound for obvious foreign bodies or contaminants.
can be used comfortably with most types of needles. A 6 in. needle Remove these with pressure irrigation using sterile saline. Apply
driver may be required if large needles are used to close a wound. sterile drapes to demarcate a sterile field. Apply the drapes so that
Hold the needle driver with the fingertips to provide greater flex- the wound may be approached easily from different angles and with-
ibility. The fingers can also be placed through the finger holes, out the risk of contaminating the site or any of the materials being
but this is not as efficient when closing a wound. Grasp the needle used. There can be a great degree of variability in sterile techniques;
therefore, it is important to note that the best way to avoid wound Clean, prep, and anesthetize the wound and surrounding skin.
infections is to employ and maintain consistency with sterile proce- If the wound edges are irregular, sharply debride them using a #15
dures throughout the wound repair. scalpel blade to form straight edges (Figure 95-1A). Measure and
draw 60° angles from the ends of the laceration (Figure 95-1B).
TECHNIQUES Draw the arms of the Z on the patient’s skin with a skin-mark-
ing pen. The arms must be the same length as the original
Z-PLASTY laceration. Incise the arms of the Z using a #15 scalpel blade
(Figure 95-1C). Undermine the flaps of the Z and the surround-
It can be challenging to change the axis of orientation of a wound. ing skin. Elevate the flaps of the Z (Figure 95-1D). Transpose
The reason for changing the orientation of a wound is to create the flaps so that the wound is reoriented (Figure 95-1E). Place
a more functionally and cosmetically pleasing scar. The Z-plasty simple interrupted sutures to approximate the wound edges
has been described as a basic technique for scar revision, though (Figure 95-1F).
its application also proves useful to lengthen and reorient wounds.5
Wound lengthening reduces the formation of contractures, which
APPROXIMATING THE EDGES OF A LACERATION
often occur when the wound crosses areas of flexion. The Z-plasty
should not be used for wounds from burn injuries where normal
WITH GROSSLY UNEQUAL LENGTHS
skin is not present. It also breaks up a linear scar into an accordion- Creating an equilateral triangle from the midpoint of the longest
like scar that has some degree of elasticity. wound edge allows wound edges of unequal length to be closed eas-
The Z-plasty is generally described to redirect a wound occurring ily (Figure 95-2).3–5 Determine the widest point between the two
across a flexion crease, over a joint, or on the face. It requires two wound edges. Determine which of the two wound edges is longer.
incisions that create two triangular flaps with approximately 60° of Mark the middle of the longest wound edge (Figure 95-2A). Draw an
separation between the flaps, though the angle may vary between equilateral triangle centered at this mark (Figure 95-2B). The sides
30° and 90° (Figure 95-1).5 The greater the angle, the greater the and base of the triangle must all be of equal length and the same
gain in wound length. Sharper angles increase the risk of necrosis length as the widest part of the original wound. Incise the arms
in the tip of the flap. Broader angles result in difficulty in rotating of the equilateral triangle with a #15 scalpel blade and remove
the flaps. Angles of 60° increase the wound length by 75%. Angles the tissue (Figure 95-2B). Undermine the wound edges. Close
of 45° increase the wound length by 50%. Angles of 30° increase the wound and the perpendicular incision from the triangle with
the wound length by 25%. The length of both arms of the inci- simple interrupted or running sutures (Figure 95-2C). Closure of
sion must be the same length as the wound. The undermining the two wounds results in a clean linear wound with a short per-
and separation of the two triangular flaps lengthens the wound and pendicular linear wound offsetting the previously unequal edges
allows it to be reoriented perpendicularly to the original location. (Figure 95-2C).
Additionally, small Z-plasties may be used in sequence to offset the
appearance of straight wounds crossing lines of flexion or where
CLOSING A SQUARE-SHAPED DEFECT
contractures are likely to occur, so that the wound site then becomes
parallel to the lines of flexion, further reducing the occurrence of Wounds are rarely square-shaped after an injury (Figure 95-3A).
contracture formation.3,4 Debride the wound to make a square-shaped defect (Figure 95-3B).
FIGURE 95-1. The Z-plasty. A. The original laceration. B. Draw the arms of the Z at a 60° angle from the ends of the lacerations. The arms must be the same length as
the laceration. C. The skin has been incised to form the Z. D. Undermine and elevate the flaps. E. Transpose the flaps to reorient the wound. F. Approximate the wound
edges with simple interrupted sutures.
FIGURE 95-2. Approximating edges of grossly unequal lengths in repairing a laceration. A. The laceration. B. Draw an equilateral triangle along the longest side and cen-
tered about the widest part of the laceration. The sides of the triangle must be equal to the length of the widest part of the original laceration. C. Approximate the wound
edges with simple interrupted sutures.
Square-shaped defects can be difficult to close and require a sin- defect. It requires the formation of two adjacent angles of the
gle pedicle advancement flap.3 Elongating two sides of the square rhomboid that must be 60° and 120° for an optimal flap.
allows small- and moderate-sized defects to be closed primar- Wounds are rarely diamond-shaped after an injury (Figure
ily (Figure 95-3C). Draw lines to extend two parallel edges of the 95-4A). Debride the wound to make a diamond-shaped defect
square by twice their length (Figure 95-3C). Draw Burow’s triangles (Figure 95-4A). Draw a line to extend the distance of the short
on the ends of the extended lines (Figure 95-3C). These triangles diagonal of the defect to double its total length (Figure 95-4B).
will be removed, allowing the flap to be transposed into the wound Draw a line from the extended line and parallel (back cut) to the
and creating a more symmetrical flap.3–5 Draw the Burow’s triangles adjacent wound edge that is equal to the length of the extended line
as equilateral triangles whose sides are half the length of the square (Figure 95-4B). Incise along the extended lines with a #15 scalpel
defect (Figure 95-3C). blade. Undermine the flap and adjacent skin. Rotate the flap into the
Incise along the extended lines and Burow’s triangles with a diamond-shaped defect (Figure 95-4C). Approximate the wound
#15 scalpel blade. Remove the tissue of the Burow’s triangles. edges with simple interrupted sutures along the linear edges and
Undermine the rectangular flap and the area surrounding the base half-buried horizontal mattress sutures at the intersection or angles
of the flap. Do not undermine the area lateral to the extended of the wound edges (Figure 95-4D).3–5 Depending on the location
lines. Advance the tissue flap to close the defect (Figure 95-3D). of loose tissue and adjacent structures, one of four Limberg flaps can
Place a simple interrupted suture in the center of the short edge be created to close the defect (Figure 95-4E).
of the flap to hold it in position. Place half-buried horizontal mat-
tress sutures to secure the corners of the flap. Approximate the CLOSURE OF AN ELLIPTICAL DEFECT
wound edges with simple interrupted sutures along the long arms.
Approximate the corner of the Burow’s triangles with half-buried Wounds are often irregular and elliptical (Figure 95-5A). Creating
horizontal mattress stitches and the rest of the triangle with simple an ellipse from a wound allows more even closure of asymmetri-
interrupted sutures.3–5 cal wounds. This is also referred to as an S-plasty. This technique
may be used when there is concern of significant scarring and con-
tracture formation from an associated thermal burn injury and
CLOSURE OF A DIAMOND-SHAPED DEFECT
Z-plasties are not recommended.4 The less acute and more rounded
Diamond- or rhomboid-shaped defects require the rotation of a flap edges of the ellipse tend to result in less tissue necrosis.3,4
referred to as a Limberg flap. The Limberg flap is a transposition Draw lines to debride the wound and form an S-shaped defect
flap suitable only for closing a diamond- or rhomboid-shaped (Figure 95-5A). Incise the extended lines with a #15 scalpel blade
FIGURE 95-3. Closure of a square-shaped defect. A. The

original tissue defect. Draw lines around the defect to form a
square. B. The skin has been incised and the original defect
removed to create a square-shaped defect. C. Draw lines to
extend two sides of the square into a rectangle. Draw Burow’s
triangles at the ends of the rectangular lines. D. Advance the
flap and approximate the wound edges.
FIGURE 95-4. Closure of a diamond- or rhomboid-shaped defect. A. The original tissue defect. Draw lines around the defect to form a diamond or rhomboid. B. The
skin has been incised to create a diamond-shaped defect. Draw lines to form the flap. Extend the short diagonal (BD) by one times its length to form line DE. Draw line
EF parallel to line CD and the same length as line CD. C. Transpose the flap to close the defect. D. Approximate the wound edges. E. The four available Limberg flaps that
can be created to fill the defect.
to form the S-shaped defect and excise the wound (Figure 95-5B). CLOSURE OF A V-Y ADVANCEMENT FLAP
Undermine the wound edges. Place buried sutures to close the
wound and prevent tension on the wound edges. Approximate The V-Y flap is not a rotational flap but rather a V-shaped flap
the wound edges by placing simple interrupted sutures alternat- created away from the wound site, which then allows the skin
ing at each end of the S-shaped defect and ending in the middle to be advanced into the defect (Figure 95-6).3–6 These advance-
(Figure 95-5C). Suturing from the ends and moving inward reduces ment flaps may be used to avoid defects from lacerations of the
the tension on the wound edges.3,4 fingertips, lips, or face.
FIGURE 95-5. Closure of an elliptical defect. A. The original tissue

defect. Draw lines around the defect to form an S-shaped defect.
B. The skin has been incised and the original defect removed to
create an S-shaped defect. C. Approximation of the wound edges
with simple interrupted sutures.
FIGURE 95-6. Closure of a V-Y advancement flap. A. The original tissue defect. Draw lines around the defect to form an oval. B. The skin has been incised and the original
defect removed to form an oval-shaped defect. C. Draw a V-shaped line adjacent to the oval defect. It should be positioned the maximum width of the oval defect from
the wound edge. D. Incise the V and undermine the skin edges. Approximate the oval-shaped defect with buried sutures and simple interrupted sutures. E. Draw and
incise a line perpendicular to the apex of the V and equal to the maximum width of the V-shaped defect. This forms the V into a Y. F. Approximation of the Y-shaped defect.
Wounds may be oval and elliptical (Figure 95-6A). Creating Approximate the oval-shaped defect with buried sutures, if neces-
an oval from a wound allows more even closure of asymmetri- sary, and simple interrupted sutures (Figure 95-6D). This will result
cal wounds. Draw lines to debride the wound and form an oval- in an opening of the V-shaped defect (Figure 95-6D). Draw and
shaped defect (Figure 95-6A). Incise along the lines with a #15 incise a line perpendicular to the apex of the V-shaped defect with a
scalpel blade to form the oval-shaped defect and excise the wound #15 scalpel blade (Figure 95-6E). The line should be as long as the
(Figure 95-6B). Draw a V-shaped line adjacent to the oval-shaped width of the V-shaped defect. Approximate the three arms of the
defect (Figure 95-6C). The line should be the length of the oval- defect with simple interrupted sutures to form a Y (Figure 95-6F).
shaped defect and approximately the width of the original wound An alternative V-Y advancement flap can be used to close the
away from the defect along its entire length. Although the two injury without making a second wound (Figure 95-7). Draw lines
sites do not directly communicate with each other, the V-shaped to debride the wound and form a V-shaped defect (Figure 95-7A).
incision allows the original wound to be closed primarily and with- Incise along the lines with a #15 scalpel blade to form the V-shaped
out tension. Undermine the wound and the V-shaped incision. defect and excise the wound (Figure 95-7B). Draw and incise a line
FIGURE 95-7. An alternative V-Y advancement flap closure. A. The original tissue defect. Draw lines around the defect to form a V. B. The skin has been incised and the
original defect removed to form a V-shaped defect. C. Draw and incise a line perpendicular to the apex of the V and equal to the maximum width of the V-shaped incision.
D. Approximate the center of the Y with a half-buried horizontal mattress suture. Approximate the arms of the Y with simple interrupted sutures.
FIGURE 95-8. Closure of a rectangular defect. A. The original defect. Draw lines around the defect to form a rectangle. B. The skin has been incised and the original defect
removed to form a rectangle. C. Draw triangles along the short sides of the rectangle. The length from the apex to the base of the triangle must be equal to the width of
the rectangle. D. The resulting defect after incising and removing the triangles. E. Approximation of the wound edges to form a linear scar.
perpendicular to the apex of the V-shaped defect with a #15 scalpel

blade (Figure 95-7C). The line should be as long as the width of the
V-shaped defect. Undermine the V-shaped defect and the perpen-
dicular line. Place a half-buried horizontal mattress suture to close
the center of the Y (Figure 95-7D). Approximate the edges of the
defect with simple interrupted stitches (Figure 95-7D).
CLOSURE OF A RECTANGULAR DEFECT

Wounds may be in the form of an ellipse or oblong (Figure 95-8A).
These can be converted into a rectangular defect to allow primary
closure.3 Draw lines to debride the wound and form a rectangular
defect (Figure 95-8A). Incise along the lines with a #15 scalpel blade
to form the rectangular defect and excise the wound (Figure 95-8B).
Draw lines to convert the short ends of the rectangle into triangles
(Figure 95-8C). The width of the rectangle should serve as the
measurement to create an equal distance between the base and
the apex of the triangle. Excising triangles from the ends of the
rectangular defect reconfigures the ends of the wound. Incise
along the lines with a #15 scalpel blade and remove the triangles
(Figure 95-8D). Undermine the skin surrounding the defect.
Approximate the wound edges with simple interrupted sutures to
form a straight line (Figure 95-8E).
CLOSURE OF A TRIANGULAR
DEFECT (ROTATION FLAP)
Closing of a triangular defect can be accomplished with the use of a
rotational flap (Figure 95-9). These flaps can be turned on a pivot
point. The flap must be planned carefully so that the direction of
rotation coincides with the geometry of the defect.3–5 Always plan
FIGURE 95-9. Closure of a triangular defect. A. The original defect. Draw lines
and draw the arch of the flap carefully to visualize the pivot point
around the defect to form a triangle. B. The skin has been incised and the origi-
and direction of rotation prior to making the incision. The cre-
nal defect removed to form a triangle. C. Draw a line to extend the base of the
ation of a rotation flap is a significant procedure. It can result in triangle in a wide arc that is three to four times the length of the base of the
a vascular disaster and leave a deformity greater than the original triangle. Make sure that the arc is drawn beyond the line from point a to point d.
defect it was supposed to correct. Do not create a rotation flap Draw a Burow’s triangle at the end of the arc. The base of the Burow’s triangle
unless you have experience with this technique and know that the should be half the length of the base of the triangular defect. Approximate the
flap has an adequate vascular supply. triangular defect and any corners with halfburied horizontal mattress sutures.
Wounds are often irregular and elliptical (Figure 95-9A). Draw D. An alternative technique. Draw a wide arc from the base of the triangle similar
lines to debride the wound and form an isosceles triangular defect. to that in (C) but which ends opposite the apex of the triangle (point a). Draw
Incise along the lines with a #15 scalpel blade to form the trian- a line to make a back-cut that is three-fourths the length of the base of the tri-
gular defect and excise the wound (Figure 95-9B). Draw the rota- angular defect. Approximate the entire wound edge with half-buried horizontal
tion flap very carefully. The edge of the flap is an arch from the mattress sutures.
FIGURE 95-10. Closure of an oval-shaped defect. A. The original defect. Draw lines around the defect to form a rectangle. B. The skin has been incised and the original
defect removed to form an oval. C. Draw a mirror image of the defect so that it is abutting the defect. D. The flap has been rotated and the wound margins approximated
with half-buried horizontal mattress sutures.
base of the triangle and three to four times longer than the actual Draw a mirror image of the defect abutting the original wound
base of the triangle (Figures 95-9C & D).3 Draw a second triangle (Figure 95-10C). Incise only along the lines noted with a #15
as a Burow’s triangle in the area next to the pivot point of the flap scalpel blade. Undermine the rotation flap and surrounding skin.
(Figure 95-9C).3–5 The base of the Burow’s triangle should be half Rotate the flap to close the defect (Figure 95-10D). Approximate
the length of the base of the triangular defect, with one corner of the edges of the flap with half-buried horizontal mattress sutures
the base formed by the end of the arch. Incise along the lines with (Figure 95-10D). Approximate the wound from where the flap
a #15 scalpel blade. Remove the Burow’s triangle. Undermine the originated with simple interrupted sutures, if it is not excessively
rotation flap and the surrounding skin. Rotate the flap to close the large or under tension, or with half-buried horizontal mattress
defect and approximate the wound edges with interrupted sutures sutures.
(Figure 95-9C). Place half-buried horizontal mattress sutures to
approximate the triangular defect and any corners. Place simple CLOSURE OF A CIRCULAR DEFECT
interrupted sutures to approximate the remaining wound edges.
A triangular defect may be closed with a modification to the Some defects can be closed primarily. Examples include circu-
above technique when there is minimal room to form and excise lar defects or triangular defects that are converted to ellipses
the Burow’s triangle or if lines of skin tension limit the location of (Figure 95-11). Excise the tissue defect to form a circle. Excise a sur-
the pivot point.3 This modified technique should be considered rounding ellipse of tissue centered about the circle (Figure 95-11A).
only when necessary, which may occur from poor planning of The ellipse must be 2½ to 3 times as long as its greatest width.
the initial flap or in areas where fascia can be separated from the Undermine the edges of the ellipse. Close the resulting defect with
subcutaneous layer (e.g., scalp wounds and areas involving the deep sutures if required and cutaneous sutures (Figure 95-11B).
trunk).3–5 Form the triangle to debride the wound and draw the arch
as described previously. Do not draw the area beyond the point
perpendicular to the apex of the triangle (Figure 95-9D). Rather
than drawing a Burow’s triangle for excision, draw a line to make a
back-cut from the pivot point (the end of the arc) and along the base
of the flap (Figure 95-9D).3,5 This line should be three-fourths the
length of the base of the triangular defect. Incise along the lines
with a #15 scalpel blade. Undermine the defect and the rotation flap.
Rotate the flap to close the defect and approximate the entire wound
edge with half-buried horizontal mattress sutures (Figure 95-9D).
Suture the back-cut prior to closing the triangular defect or the
arch.3 This alternative technique carries the risk of having a poor
blood supply to the flap due to its small base.
CLOSURE OF AN OVAL DEFECT

Oval defects can be closed by creating a rotational or interpolation
flap from the intact adjacent tissue (Figure 95-10).3 Wounds are
often irregular and elliptical (Figure 95-10A). Choose a side of the
oval defect to form the flap. The adjacent skin used to make the
flap must be vascularly intact to avoid the risk of tissue necrosis
once the flap is sutured into position. Draw lines to debride the FIGURE 95-11. Closure of a circular tissue defect. A. Draw lines around the defect
wound and form an oval defect (Figure 95-10A). Incise along the to form an ellipse. B. The skin has been incised and the original defect removed
lines with a #15 scalpel blade to form the oval defect and excise the to form an ellipse. The wound edges are approximated with deep and cutaneous
wound (Figure 95-10B). Draw the rotation flap very carefully. sutures.
CHAPTER 96: Management of Specific Soft Tissue Injuries 659
COMPLICATIONS
A brief discussion of the complications of wound closure is pre-
sented below. Refer to Chapter 92 for a more complete discussion.
The complications of any wound can be greatly affected by the prep-
aration of the wound prior to wound closure. The maintenance of
sterile technique throughout wound closure and adequate irrigation
of the wound will limit the risk of infection. It is unrealistic to expect
any wound site to be bacteria-free.
Wounds may show poor scar formation or delayed healing due
to several factors. Poor aftercare without adequate dressing changes
or neglect (including premature exposure to environmental irritants
such as dirty water, direct and excessive sun exposure, or chemicals)
will likely result in a less favorable and unpredictable healing pro-
cess. The wound site should be protected from excessive contact or
use during the initial healing period. Mechanical trauma or overuse
can increase the chance of edema or hematoma formation, leading
to wound dehiscence or atypical scar formation.
Proper follow-up should be arranged and stressed within the ini-
FIGURE 95-12. The double V-Y closure to repair a tissue defect. A. Create an tial 24 to 48 hours following the treatment and thereafter as may be
ellipse centered about the tissue defect. Remove the tissue defect and form straight warranted. Awareness that wound healing takes place in sequential
edges at the bases of the triangular flaps. B. Approximate the bases of the trian- physiologic steps is needed to properly direct patients, so that the
gular flaps, followed by the arms and bases of the “Y’s,” using simple interrupted risk of complications or the need for antibiotics will be minimal.
sutures.
SUMMARY
Patients present to the Emergency Department with a wide vari-
ety of wound types. The use of local flap techniques allows the
Larger defects require the use of a double V-Y closure
Emergency Physician to close difficult and complex wounds. If pri-
(Figure 95-12). Create two sliding pedicle flaps with a #15 scalpel
mary closure is not possible, these techniques decrease the tension
blade. Incise the skin and dermis but not the underlying subcu-
on a wound and allow for appropriate cosmesis. They require close
taneous tissue, to form an ellipse centered about the tissue defect
follow-up and appropriate patient selection if complications are to
(Figure 95-12A). Remove the tissue defect and debride the tissues
be prevented.
at the base of the flaps to form two straight edges (Figure 95-12A).
Gently undermine the edges of the ellipse. Do not undermine the
triangular tissue flaps, so that their vascular supply is preserved.
Slide (advance) the flaps on their subcutaneous pedicles until the
bases are touching. Approximate the base of one flap to the other
Management of Specific
using simple interrupted sutures (Figure 95-12B). Approximate the
arms and bases of the Y’s using simple interrupted sutures. 96 Soft Tissue Injuries
ASSESSMENT Christopher J. Russo and Ajay Desai
Inspect the wound edges carefully for adequate approximation.
Observe the wound for a period of time to make sure that it remains
INTRODUCTION
viable and is not compromised due to a poor blood supply or tight Blunt and penetrating trauma can lead to a myriad of soft tissue
sutures. A nonviable repair requires immediate removal of the injuries. The management of the majority of these injuries is dis-
sutures and consultation with a Plastic Surgeon. cussed elsewhere in this text. Some specific soft tissue injuries
require detailed explanations for their repair. These injuries are dis-
AFTERCARE cussed below.
Pull the suture knots lying directly over the wound margin to one
side so that all the knots lie on the same side. Wipe off any residual
MULTIPLE FOREHEAD LACERATIONS
povidone iodine or chlorhexidine solution with sterile saline. Apply a Forehead lacerations are common in all age groups, occurring most
topical antibiotic ointment to the wound, followed by a nonadherent frequently during early childhood. While most forehead lacerations
dressing. Arrange follow-up in 24 hours with the patient’s Primary are not associated with any other significant injuries, their loca-
Care Provider, a Plastic Surgeon, or the Emergency Department. tion demands a complete head and neck evaluation.1 Furthermore,
Consider the use of prophylactic antibiotics even though there is no their visibility requires meticulous attention to detail. Knowledge
evidence to support or refute this practice. of the principles regarding their repair allows for good cosmesis.
Instruct the patient and/or their representative regarding wound The repair of forehead lacerations differs from that of other soft
care and dressing changes. Provide clear instructions of what to look tissue injuries due to the role of skin tension lines, the lack of extra
for regarding possible signs of early infection, both localized around tissue, and scarring promoted by too many deep dermal sutures.2–4
the wound site as well as systemic symptoms. Any patient who Forehead injury repair is governed by three principles: (1) skin ten-
experiences excessive swelling, erythema, a purulent or foul smell- sion lines run parallel to the skin creases and play a major role in
ing discharge, significant pain from the wound site, or fever should the outcome of any forehead laceration; (2) lacerations running
return to the Emergency Department immediately. perpendicular to skin tension lines are more likely to result in a
noticeable scar2,3; and (3) there is little excess tissue on the forehead freely over the deeper tissues and is easily mobilized with forceps.
to allow later wound revisions. Resist the temptation to excise Surface landmarks include—from posterior (nearest the globe) to
ragged wounds.4 This leaves enough tissue for the Surgeon to work anterior (nearest the skin)—the mucocutaneous junction, the ori-
with if further revision is required. Place as few deep sutures as fices of the meibomian glands, the gray line, and the lash line. The
possible, as they tend to promote more tissue reaction and more gray line is a key landmark. It is located on the palpebral edge and
noticeable scar formation. consists of an isolated strip of pretarsal orbicularis oculi muscle just
Many forehead lacerations require repair in order to promote anterior to the tarsus (Riolan’s muscle). Lacerations through the
cosmesis and provide hemostasis. Perform primary repair at any gray line require diligent reapproximation and should be referred
time up to 24 hours after the initial insult. This allows referral to to an Ophthalmologist.10 There are three or four irregular rows con-
a consultant if there is any question about one’s ability to achieve taining approximately 100 lashes on the upper eyelid and two or
satisfactory cosmesis or if the wounds are so extensive as to take three rows of approximately 50 lashes on the lower eyelid.
the Emergency Physician away from their departmental respon- The levator palpebrae muscle arises from the roof of the orbit. It
sibilities for an unacceptably long time regardless of the level of inserts into the midtarsus and overlying skin, intimately associating
complexity. with the orbicularis oculi muscle. Suspect levator injuries with any
Laceration repair is dependent on the type of laceration. Small and horizontal laceration of the upper eyelid. Improper repair or fail-
uncomplicated lacerations can be closed with simple interrupted ure to repair a laceration may result in ptosis or a deformity of the
6-0 nonabsorbable sutures (e.g., nylon or Prolene).1 Flaps smaller supratarsal fold.
than 5 mm can be closed using simple interrupted 6-0 nonabsorb- Canthal injuries must be actively sought. Determine whether the
able sutures (e.g., nylon or Prolene). Larger flaps can be closed using medial or lateral canthal tendon is injured. Apply lateral traction on
the half-buried horizontal mattress stitch. Partial-thickness abra- the eyelid. Displacement of the punctum laterally may be due to a
sions and gouges less than 1 cm wide and 2 mm deep should be disruption of the medial canthal tendon. Such a disruption is likely
allowed to heal by secondary intention.2,5,6 Bunched-up, small flap to be associated with nasal fractures, orbital fractures, ethmoid frac-
lacerations can be excised together and the resulting defect repaired tures, and canalicular injuries.11 Apply medial traction on the eyelid.
primarily.6 This technique is described under “Multiple Small Skin Displacement of the lateral canthus medially is due to a disruption
Flaps” in this chapter. of the lateral canthal tendon. Inspection and/or probing through the
Deeper transverse lacerations that involve the deep fascia, the wound may confirm a canalicular interruption. Early repair is pre-
frontalis muscle, and the periosteum should be repaired in layers ferred, as the tissue becomes more difficult to identify and repair
using 5-0 absorbable suture (e.g., nylon or Prolene).1 The epidermal when swollen. However, the value of early repair of canalicular
layer can be closed with either simple interrupted 6-0 nonabsorb- lacerations is debated.12 Early repair may exacerbate the degree of
able sutures (e.g., nylon or Prolene), skin closure strips over adhe- canalicular damage, the risk of stenosis, and may result in damage to
sive adjuncts, or with tissue adhesive. The latter two are an especially other parts of the canalicular system.12 Consult an Ophthalmologist,
attractive alternative method of wound closure if the patient is at risk as meticulous repair is mandatory to avoid damaging the lacrimal
to develop keloids or hypertrophic scars. Skin folds, skin creases, apparatus.
and the hairline should be approximated with great precision. The orbicularis oculi muscle closes the eyelids tightly. Failure to
properly repair the levator muscle, the tarsal fascia, or the orbicu-
laris muscle in a deep upper eyelid laceration may result in ptosis.
EYELID LACERATIONS
Consult an Ophthalmologist for all deep upper eyelid lacerations.
The objective of eyelid repair is the restoration of normal align- There are at least six published variations on the techniques
ment and anatomic function. Eyelid lacerations are classified as described for repair of the eyelid margin with less than one-third
marginal if they cross the eyelid margin or extramarginal if they do of tissue loss measured horizontally, yet there is no literature com-
not cross the eyelid margin.7 A careful history and a thorough phys- paring outcomes.7,13–19 The experience and skill of the practitioner
ical examination looking for concealed injury or foreign bodies is are vital. Each minor variation aims for precise apposition to avoid
imperative. The examination must specifically address and exclude malalignment or notching of the eyelid margin. Each technique var-
canthal injuries, lacrimal apparatus (most commonly canalicular) ies the sequence, number, or type of margin sutures or the order of
injuries, and/or injuries to deep structures. Injuries medial to the margin sutures (final or temporary) versus tarsal suture placement
lacrimal punctum must prompt the Emergency Physician to explic- and closure (if required).
itly address the possibility of a lacrimal apparatus or canalicular A recently published edition of a major Emergency Medicine text
injury. Consult an Ophthalmologist for a probe evaluation of the maintains that only Ophthalmologists or Oculoplastic Surgeons
lacrimal apparatus. Failure to identify canalicular interruptions can should close marginal lacerations. Consult an Ophthalmologist
compromise outcome, as canalicular repair delayed beyond several prior to repairing any marginal lacerations. Repair requires consid-
days is less successful than primary repair. A delay of 2 to 3 days may erable experience, the use of magnification, and the placement of
be advantageous, as the cut medial ends may become edematous, deep sutures.
whitened, and easier to locate.8,9 Eyelid lacerations without marginal involvement are consid-
Recognition and management of injuries to deep structures— ered “superficial.” Approximate these lacerations with interrupted
including the lacrimal apparatus, orbicularis oculi muscle, levator 6-0 nonabsorbable sutures (e.g., nylon or Prolene), which should
palpebrae muscle, tarsal plates, and medial or lateral canthal ten- remain in place for 3 days.10 The skin and orbicularis muscle may
dons—is necessary to prevent dysfunctional tearing, lid malalign- be closed in one layer. Consult an Ophthalmologist or Oculoplastic
ment, ptosis, functional abnormalities, and cosmetic defects. Surgeon for lacerations involving the tarsal plates.
Awareness of the eyelid’s complex anatomy is essential to the proper Eyelid lacerations with tissue loss require individualization.13,20
recognition and repair of less-evident impairment due to injury. Wound edge loss of less than 25% of the horizontal length of the
Certain key features are reviewed here as they are necessary to pre- eyelid can often be closed primarily. Approximate the wound edges
vent overlooked injury and understand proper repair. with a toothed forceps to evaluate wound tension. Freshen ragged
The eyelid’s skin is the thinnest in the body, with that of the upper edges without loss of tissue. Avoid penetration to the conjunctival
eyelid being thinner than that of the lower eyelid. The skin moves surface to avoid contact with the cornea. Accurate repair of the
FIGURE 96-1. The wedge excision and repair technique for auricular lacerations. A. Excise a full-thickness triangle of tissue. B. Place interrupted nonabsorbable sutures
through the skin and perichondrium. C. Approximate the wound edges by tying the sutures.
tarsus is vital because it forms the skeleton of the eyelid. Remove exposed cartilage, splinting the ear appropriately after the repair,
sutures in 5 days. Tissue loss of greater than 25% may require a and recognizing the indications for consulting a Plastic Surgeon
canthotomy, cantholysis, or a tissue flap. Refer these injuries to an (cartilage defects > 5 mm, inability to cover exposed cartilage, and
Ophthalmologist or Oculoplastic Surgeon. Older patients with skin amputation injuries).
laxity may be able to tolerate a greater than 25% loss with adequate Examine the area for signs of an acute hematoma or other asso-
cosmesis.13,20 ciated traumatic injuries, (e.g., hemotympanum or Battle’s sign).10
Some eyelid lacerations without eyelid margin involvement may Clean, prepare, and anesthetize the auricle. Refer to Chapter 168
involve the levator muscle. Evaluate horizontal lacerations of the regarding the techniques of auricular anesthesia.24 Consider local
upper eyelid for levator interruption. Visible fat indicates orbital infiltration for small, isolated wounds without cartilage involvement
septum penetration and raises the suspicion of levator involvement. or an auricular block for complicated or extensive lesions. Use only
These lacerations should be repaired with fine absorbable suture to a local anesthetic agent without epinephrine to prevent potential
avoid ptosis.10,13 An eyelid crease and/or minimal levator function complications. Close simple lacerations primarily with interrupted
suggests an intact levator.13 6-0 nonabsorbable suture (e.g., nylon or Prolene).
The orbital septum lies deep to the orbicularis oculi muscle. The Wounds involving soft tissue and cartilage loss of less than
levator palpebrae muscle lies deep to the orbital septum. The septum 5 mm should be closed with a wedge excision and repair technique
is rigidly attached to the orbit and does not move on traction with (Figure 96-1). The auricular skin does not stretch to allow cover-
a forceps. Grasp the levator muscle with a forceps and instruct the age of defects. Thus, the wedge excision technique allows a primary
patient to look up. A brief pull will be felt as the muscle contracts. closure that would otherwise have been difficult to achieve with-
It is crucial to distinguish between the levator apparatus and the out distortion or buckling the anatomy of the auricle due to the
orbital septum. Injuries involving the orbital septum carry a higher underlying cartilage.
risk of globe injury, intraorbital foreign body, and orbital cellulitis. Excise a full-thickness triangle of tissue in the antihelix with a
The septum must not be included in a repair of the levator, as it #15 scalpel blade (Figure 96-1A). Approximate the skin on the
will restrict movement of the levator. Consult an Ophthalmologist anterolateral surface followed by the posterior surface with inter-
or Oculoplastic Surgeon for deep extramarginal lacerations with rupted 6-0 nonabsorbable sutures (e.g., nylon or Prolene). Carefully
suspected levator muscle involvement, in addition to a computed approximate the ridges and valleys to minimize the cosmetic
tomographic scan to evaluate for potential transorbital fascia/septal defect. Place the sutures through the skin and perichondrium,
involvement.21 not the cartilage. The skin and underlying cartilage are so adher-
Complications associated with eyelid repair include malalign- ent to each other that it is not necessary to close the cartilage sepa-
ment, missed canalicular lacerations with attendant tearing dysfunc- rately. A preferred technique by some, who believe that the cartilage
tion, missed foreign bodies, corneal abrasions, missed globe injury, fragments will be drawn together and heal much better, is to place
missed canthal interruption, and missed fractures with entrapment. numerous interrupted sutures through the skin and perichondrium
Unless an Emergency Physician has adequate familiarity with the on either side of the wound (Figure 96-1B) and then approximate
techniques, referral to an Ophthalmologist or Oculoplastic Surgeon the wound edges (Figure 96-1C).
is recommended. Auricular lacerations can involve one or all layers without any
loss of tissue. The cartilage may protrude into the wound further
than the overlying skin (Figure 96-2A). This type of wound is dif-
EAR LACERATIONS
ficult to close primarily without debridement as the skin does not
Ear lacerations can result from blunt or sharp trauma to the auricle. stretch to cover the cartilage. Use a #15 scalpel blade to carefully
The primary goals are to preserve the normal contours of the auri- trim the cartilage back to the level of the skin or so that the skin
cle, to prevent chondritis, and to prevent hematoma formation.22,23 overhangs the cartilage by 1 mm (Figure 96-2B). This allows the
The skin of the ear is extremely vascular. The underlying auricular skin edges to be everted when closed. Approximate the skin and
cartilage is avascular and receives its nourishment from the overly- perichondrium with interrupted 6-0 nonabsorbable sutures (e.g.,
ing skin. Minimize any debridement of the auricular soft tissues nylon or Prolene).
to ensure that the repair covers all exposed cartilage. Auricular Extensive lacerations of the auricle are managed in a similar man-
laceration repair follows the same principles as other laceration ner. Trim any protruding cartilage as described above. Place inter-
repair techniques. Differences to be appreciated include the impor- rupted 6-0 absorbable sutures (e.g., Vicryl or Dexon) through the
tance of debriding as little soft tissue as possible, always covering perichondrium to approximate the cartilage at important landmarks
solution without epinephrine. The nasal mucosa can be anesthe-

tized using cocaine-soaked pledgets (Chapter 170).
Lacerations limited to the outer aspect of the nose (i.e., skin lacer-
ations and not through-and-through lacerations) can be repaired as
simple lacerations. Minimize any debridement, as the lack of redun-
dancy of nasal skin can result in disfiguring scarring.26
Lacerations involving the nasal cartilages require a thorough
cleansing, minimal if any debridement, and a multilayered clo-
sure. Do not place stitches through the avascular nasal car-
tilages, as this increases the chances of a postrepair infection.
Approximation of the nasal mucosa, subcutaneous tissues, and
FIGURE 96-2. Repair of an auricular laceration. A. The skin has retracted and the skin will appose the cartilage edges. It is crucial to have proper
cartilage protrudes into the wound. B. Trim the cartilage so that it is level with the alignment of the alar rim and columella in order to achieve
skin or so that the skin overhangs the cartilage by 1 mm. good cosmetic results25 and to avoid the postrepair complication
known as “notching.” The repair proceeds from inside outward.
Approximate the nasal mucosa with interrupted 5-0 or 6-0 absorb-
able sutures (e.g., Vicryl, Dexon, or gut). Approximate the subcuta-
and remove tension from the wound edges. Approximate the skin neous tissues with interrupted 5-0 or 6-0 absorbable sutures (e.g.,
and perichondrium with interrupted 6-0 nonabsorbable sutures Vicryl or Dexon). Approximate the skin with 5-0 or 6-0 nonabsorb-
(e.g., nylon or Prolene). able sutures (e.g., nylon or Prolene).
Lacerations of the external auditory canal require repair only if
the underlying cartilage is exposed. This is done in an attempt to ORAL MUCOSAL LACERATIONS
prevent a chondritis. Otherwise, pack the external auditory canal
with a nonabsorbent wick (e.g., petrolatum gauze wrapped around a Lacerations of the oral mucosa generally heal without intervention.
cotton ball) to approximate the wound edges and speed the healing Wounds requiring repair are those large enough to trap food par-
process. ticles (greater than 2 to 3 cm) and wounds with a tissue flap that
Consult a Plastic Surgeon for wounds with tissue loss of greater falls between the occlusive surfaces of the teeth. Some physicians
than 5 mm, wounds with exposed cartilage that cannot be cov- prefer to place 4.0 silk sutures, as they are not irritating to the patient
ered without sacrificing greater than 5 mm of cartilage, complete and do not tempt the patient to “play” with them with their tongue
or almost complete ear avulsion injuries, and injuries with obvi- or bite through them. The disadvantage of silk sutures is that they
ous devitalization of the auricle. Care for the avulsed auricle as require a return visit for removal. Absorbable sutures (e.g., plain gut
an “amputated part” to preserve viability should the consultant or chromic gut) are thus preferable, especially in children to avoid
desire to pursue reimplantation. the task of suture removal.25 However, the choice of using absorb-
Uncomplicated wounds not involving the auricular cartilage able versus silk sutures remains physician-dependent. Tissue flaps
require local wound care and suture removal in 4 to 5 days. Larger that fall between the occlusal surfaces of the teeth may be approxi-
wounds and those involving the auricular cartilage require oral mated or excised. A diet of soft foods and liquids is recommended
antibiotics to cover skin flora and a dressing that conforms to the for the first 2 to 3 days after the repair. The mouth should be rinsed
anatomic configuration of the auricle. The dressing will provide gently two or three times a day and after meals with chlorhexidine
support and prevent an auricular hematoma from forming. Refer to solution. Some authors recommend the use of prophylactic antibi-
Chapter 168 regarding the details of placing this dressing. Sutures otics although this practice is controversial.27
should be removed in 3 to 5 days in children, 4 to 5 days in adults.22
The complications following ear laceration repair are similar to LIP LACERATIONS
those occurring after all wound repairs. Specific problems include
Attention to detail is essential for attaining a good cosmetic
the development of a chondritis, which is much more likely if the
result in repairing lip lacerations, as they can result in devastat-
auricular cartilage is left exposed. Deformities can be due to the
ing cosmetic defects if not repaired properly. Malalignment of
injury itself, poor repair techniques, or the development of an auric-
the vermilion border or the “white line” (the border between the
ular hematoma secondary to poor ear splinting. Antistaphylococcal
skin of the face and the red part of the lip), by as little as 0.5 to
antibiotic coverage is recommended in cases where cartilage has
1 mm will be easily noticeable.
been exposed or a hematoma has been drained. Hematomas that
Anesthetize the lip using a nerve block to avoid tissue distortion
have been drained should be rechecked in 24 hours to evaluate for
and allow proper tissue apposition (Chapters 126 and 176). Avoid
reaccumulation.22 Refer to Chapter 168 for a complete discussion of
using epinephrine with anesthesia, as this will blunt the vermilion
these complications.
border landmark.28 Close the vermilion border first, using 6-0 non-
NASAL LACERATIONS absorbable sutures (e.g., nylon or Prolene) (Figure 96-3A). Close
the orbicularis muscle layer next using 5-0 plain gut or chromic gut
Important points to note in dealing with nasal lacerations are suture (Figure 96-3B). Close the mucosal border with the same type
the extent of the laceration and the structures involved. Cartilage of suture. Close the skin with interrupted 6-0 nonabsorbable sutures
involvement increases the likelihood of developing a subsequent (e.g., nylon or Prolene) (Figure 96-3C).
infection. Lacerations are difficult to close because the skin is inflex- Adhering to this plan will allow the best cosmetic result pos-
ible and lacks redundancy. Associated injuries, such as nasal frac- sible. Other anatomic areas that require careful approximation to
tures and septal hematomas, must also be managed. Suturing back a attain good cosmesis include the mucosal border (separating the
totally avulsed nose is unnecessary as it will most often fail.25 intraoral and extraoral portions of the lip) and the orbicularis oris
The repair of nasal lacerations requires local anesthesia, which muscle. Through-and-through lip lacerations often violate all three
can be achieved using an infraorbital nerve block (Chapter 126), a of these structures. In these cases, consider debridement of irregular
nasal block (Chapter 170), or direct infiltration of local anesthetic borders.28
FIGURE 96-3. Lip laceration repair. A. Always approximate the vermillion border first. B. Approximation of the orbicularis oris muscle. C. Approximation of the mucosal
surface and the skin.
The aftercare for a sutured lip laceration is much the same as GINGIVAL LACERATIONS
for oral mucosal lacerations. Instruct the patient to avoid bring-
ing excessive pressure to bear on the suture line. Remove the skin Gingival lacerations differ from other lacerations in that there is
sutures in 4 to 5 days to avoid scarring. Parents should be instructed often no subcutaneous tissue available to anchor the flap. Small gin-
to distract their children from biting the sutures off while they are gival lacerations tend to heal well without intervention because of
still anesthesized.28 the extensive blood supply in this area. Repair wounds that are large,
actively bleeding, gaping open, or that fall onto the occlusive surface
TONGUE LACERATIONS of the teeth.
Flap lacerations exposing the alveolar ridge and tooth roots
The majority of tongue lacerations are the result of oral trauma and pose a special problem, as there is no subcutaneous support to
tongue biting, and heal well without intervention.29 Lacerations anchor the mucosa. The technique requires the placement of
that do not require repair are generally small, linear, and superficial a 4-0 or 5-0 absorbable suture that first runs circumferentially
lacerations located in the central tongue region or small flaps on around and then is tied posterior to the tooth.35 Place the suture
the edge of the tongue that can be excised. The tongue’s generous 2 to 3 mm proximal to the gingival margin (Figure 96-4A). Place
blood supply allows these wounds to heal well, yet can also cause the suture through the gingiva so that it passes circumferentially
serious hemorrhage and potential airway compromise.29 Therefore, around the tooth to secure the flap (Figure 96-4B). Loosely tie
patients who have tongue lacerations that require repair should the suture on the inner aspect of the tooth so that the knot does
also be evaluated for potential airway problems, and the need for not irritate the lip or strangulate the tissues (Figure 96-4B). The
procedural sedation or possibly general anesthesia (especially in aftercare is the same as described under “Tongue Lacerations” in
children).28 Some wounds require closure and can be very chal- this chapter.
lenging to repair.30–33 These may include large lacerations (>1 cm),
gaping wounds, actively bleeding lacerations, U-shaped lacerations,
wounds that bisect the tongue, and large flaps on the tongue edge.
SUTURING THROUGH HAIR
The main problem is not the repair itself but achieving control of the It is inadvisable to shave hair bordering the edges of a laceration, as
area to facilitate the repair. this only serves to increase the likelihood of a wound infection.36
Anesthetize the tongue via local wound infiltration or a lingual Instead of shaving the hair, brush it aside or mat it down using
nerve block for the anterior two-thirds of the tongue (Chapter 176). petroleum jelly or antibiotic ointment prior to wound repair. It is
These can be supplemented with procedural sedation techniques of particular importance never to shave eyebrows or eyelashes,
(Chapter 129). Instruct an assistant to gain control of the tongue. as they will take months to grow back if they grow back at all.
Grasp the anesthetized tip of the tongue with a towel clip, a suture Always debride an eyebrow laceration oblique to the hair follicles
through the tip of the tongue, or a gauze square. Consider insert-
ing a bite block to further protect the patient and the Emergency
Physician from injury during the repair process. Thoroughly irri-
gate the wound. Close the laceration using absorbable 4-0 plain gut
or chromic gut sutures. Take large bites that include the mucosal
and muscular layers of the tongue. Buried or deep sutures are not
required when taking large bites. Multiple well-secured sutures are
preferred to prevent the untying of suture material with tongue
motion.34
Extensive complex tongue lacerations are at a greater risk for
infection and should be treated with prophylactic antibiotics that
cover normal oropharyngeal flora.34 Children with tongue lacera-
tions may chew off the stitches, and so parents should be made
aware of this and be instructed to distract the child until the local FIGURE 96-4. Gingival laceration repair. A. Place the suture 2 to 3 mm proximal to
anesthesia wears off.28 Aftercare instructions are similar to those for the gingival margin. B. Place the suture through the gingiva and circumferentially
oral mucosal lacerations. around a tooth to secure the flap.
FIGURE 96-6. Closing a wound with edges of unequal thickness using half-buried
FIGURE 96-5. Repair of eyebrow lacerations. A. Debride the wound edges horizontal mattress sutures.
obliquely and parallel to the hair follicles and not perpendicular to the wound
edges. B. Approximate the wound edges.
INCOMPLETE LACERATIONS
and not perpendicular to the skin edge (Figure 96-5). This will Lacerations involving the epidermal and superficial papillary layers
reduce the loss of hair follicles. of the skin but sparing the deep papillary layer are referred to as
incomplete lacerations. Excise the loose epidermal pieces of skin.
MUSCLE LACERATIONS Cover the wound with petrolatum gauze and a pressure dressing.
The repair of muscle lacerations begins with a careful assessment of

the extent of injury and the level of contamination prior to repair.
WOUNDS OF UNEQUAL THICKNESS
Large and/or grossly contaminated muscle injuries require opera- Wounds of unequal thickness are not suited for repair with simple
tive management. All other muscle injuries may be managed in interrupted sutures. Unequal tissue loss on each edge of a wound
the Emergency Department. Treatment should focus on repair or creates a thick edge–thin edge wound. The depressed edge must be
reconstruction of a muscle using its long tendons of origin and elevated to the level of the nondepressed edge in order to attain
insertion to anchor the repair, as the muscle tissue alone is inad- proper wound apposition and cosmesis.
equate for suture repair.37 There are two techniques to repair wounds with edges of unequal
Lacerations of the fascia surrounding a muscle are common. thickness. The first technique utilizes a half-buried horizontal mat-
Thoroughly cleanse the area and debride any devitalized tissue. tress suture (Figure 96-6).38 Place the suture through the thick edge
Approximate small violations of the muscle fascia with interrupted of the wound, across the wound and buried into the subcutane-
3-0 or 4-0 absorbable sutures (e.g., Vicryl or Dexon). Closing small ous tissue of the thin edge, and back out the skin of the thick edge
rents will prevent symptomatic herniation of muscle tissue through (Figure 96-6A). Apply traction to the suture and tie it to approxi-
them in the future. Do not repair large violations of the muscle fas- mate the wound (Figure 96-6B). Apply an ointment-based com-
cia. Anecdotal reports of muscle compression and compartment pressive dressing.
syndromes after such repairs abound. The second technique requires undermining both wound edges
Lacerations through the muscle require a thorough cleansing at the same depth in the subcutaneous tissue plane (Figure 96-7).39
and debridement of any devitalized tissue. Repair the laceration Make an incision in the subcutaneous tissues of both wound
with 3-0 or 4-0 absorbable sutures (e.g., Vicryl or Dexon). Place edges and at the same level (Figure 96-7A). Undermine the area
horizontal mattress stitches to close the laceration. Interrupted to free the tissue flaps (Figure 96-7B). Grasp the subcutaneous tis-
sutures are not effective, as they tend to pull through the muscle sue flap from the thicker side and insert it under the thinner side
fibers and not hold. beneath the undermined area (Figures 96-7B & C). Place a buried
FIGURE 96-7. An alternative technique to close a wound with edges of unequal thickness. A. Make an incision in the subcutaneous tissue of both wound edges.
B. Undermine the edges. Transpose the subcutaneous tissue of the thicker side into the undermined area of the thinner side (arrow). C. Approximate the wound edges
using interrupted sutures.
FIGURE 96-8. Repair of a flap laceration. A. Sharply debride

the edges. B. The resultant defect. C. Approximation of the
wound edges. First place a half-buried horizontal mattress
suture to close the tip of the flap. Approximate the remain-
ing wound edges with interrupted sutures.
horizontal mattress suture to maintain the flaps in position. This (Figure 96-8C). Place a half-buried horizontal mattress suture to
“flap” elevates the depressed wound edge and facilitates appropriate close the tip of the flap. Approximate the base and arms of the Y
wound approximation (Figure 96-7).39 Place interrupted sutures to with interrupted sutures.
approximate the wound edges (Figure 96-7C). A flap laceration may present difficulties. It may not be pos-
Tangential flap lacerations over thin skin, such as the dorsum of sible to revise and repair it or it may be obviously nonviable. It is
the hand or the pretibial area, where there is very little subcutane- often possible to “ellipse” the flap (Figure 96-9). Excise the tissue
ous tissue can be approximated with a specially placed simple inter- defect to form a circle. Excise a surrounding ellipse of tissue cen-
rupted suture. Insert the needle through the tip of the thin edge, tered about the circle (Figure 96-9A). The ellipse must be 2½ to
across the wound, into the dermis of the thick edge, and out the skin 3 times as long as its greatest width. Undermine the edges of the
of the thick edge. Apply traction to the suture to pull the thick edge ellipse. Approximate the center of the resulting defect using a locked
up to meet the thin edge, producing good approximation rather vertical mattress stitch, which allows approximation of the remain-
than overlap of the edges. Apply an ointment-based compressive der of the wound with minimal extrinsic tension. Approximate the
dressing. remainder of the resulting defect with deep sutures, if required, and
cutaneous sutures (Figure 96-9B).
FLAP LACERATIONS In some cases, there is simply not enough tissue to cover the
defect, no matter what technique is attempted. These wounds may
Flap lacerations occur when shearing forces to the skin tear the be left to heal by secondary intention if small or referred to a Plastic
dermis from the underlying subcutaneous tissues. This type of lac- Surgeon for skin grafting. The only complication unique to the
eration is problematic. The flap is now separated from its blood repair of flap lacerations is the possibility that the flap may not sur-
supply except for the blood entering through the base. This makes vive, requiring referral and revision or skin grafting.
the flap susceptible to necrosis and infection. As a general rule,
a flap will remain viable if the base of the flap is three times its
length.40 Flaps with a ratio of less than 3:1 are less likely to sur-
vive intact; therefore, alternative methods of closure should be
entertained.
A flap can easily be repaired primarily if it has viable edges and
meets or exceeds the 3:1 ratio of base to length. Anesthetize, clean,
and prepare the area. Trim the excess fatty tissue from the under-
side of the flap. This will improve the chances of healing. Place a
half-buried horizontal mattress suture as the first stitch to close the
corner or the tip of the flap. Approximate the sides of the flap with
interrupted sutures or half-buried mattress sutures.
Some viable flaps have nonviable edges that must be debrided
prior to closure to ensure proper cosmesis and survival of the tis-
sue. Debride the nonviable edges sharply with a #15 scalpel blade
or an iris scissors (Figures 96-8A & B). Place a half-buried hori-
zontal mattress suture as the first stitch to close the corner. This is
necessary to close the flap, as the debridement has left the flap too
small to close the wound. Approximate the sides of the flap with
simple interrupted sutures, mattress sutures, or half-buried mat-
tress sutures.
Some flaps may be too small after debridement or be under
too much tension to stretch across the wound. These flaps can be FIGURE 96-9. Closure of a tissue defect. A. Excise the defect and a surrounding
closed by forming a Y-shaped closure instead of a v-shaped closure ellipse. B. Approximation of the wound edges with deep and cutaneous sutures.
FIGURE 96-10. The double V-Y closure to repair a tissue defect. A. Create an
ellipse centered about the tissue defect. Remove the tissue defect and form straight
edges at the bases of the triangular flaps. B. Approximate the bases of the trian- FIGURE 96-11. Repair of multiple small lacerations. Excise the lacerations as a
gular flaps followed by the arms and bases of the Y’s, using interrupted sutures. group to form a single wound that can be closed primarily.
AVULSION INJURIES in a manner similar to that described under “Multiple Forehead

Lacerations,” above.
The treatment of tissue avulsion injuries varies depending on the
amount of tissue lost and its depth. Allow full-thickness defects
less than 1 to 2 cm2 to heal by secondary intention after debride-
DISTAL FINGERTIP AMPUTATIONS
ment. Full-thickness defects greater than 2 cm2 require a different Injuries of the distal fingertip rank among the most frequently
approach utilizing skin grafts, flaps, or converting the wound to one injured parts of the hand.42 Amputations of the fingertip are
that can be closed primarily. Treat avulsed tissue as an “amputated defined as loss of the tissues distal to the insertions of the extrin-
part” that may be used in the repair process. Consider consulting a sic flexor and extensor tendons on the distal phalanx, distal to the
Plastic Surgeon for a large avulsion that cannot be closed primarily level of the lunula. These injuries may include skin, pulp, bone,
or to convert it into a wound that can be closed primarily. the nail matrix, or the nail plate.42 Treatment options have evolved
Some defects can be closed primarily. Examples include cir- remarkably over the past 30 years, though change in clinical prac-
cular defects or triangular defects that are converted to ellipses tice has lagged. Multiple treatment modalities exist and depend
(Figure 96-9).41 This technique is described above under “Flap on whether the amputated part was retrieved, its condition, the
Lacerations.” character of the injury, the patient’s preference and underlying
Larger defects require the use of a double V-Y closure, which health status, as well as the availability and sophistication of
converts the flap to a different shape prior to the repair and thus consultants.
increases the chances of successful primary closure (Figure 96-10).41 For amputations with pad loss of less than 1 cm, with and with-
Create two sliding pedicle flaps with a #15 scalpel blade. Incise the out bone exposure, conservative nonsurgical management with
skin and dermis, but not the underling subcutaneous tissue, to serial dressing changes of nonadherent gauze is appropriate.43,72
form an ellipse centered about the tissue defect (Figure 96-10A). Nonoperative open management has been shown to be at least as
Remove the tissue defect and debride the tissues at the base of the effective as primary closure, local and distant tissue-transfer flap
flaps to form two straight edges (Figure 96-10A). Gently under- procedures, and grafts.44–51,73 Conservative management is advo-
mine the edges of the ellipse. Do not undermine the triangular cated in children less than 12 years of age, as they have greater regen-
tissue flaps, so that their vascular supply is preserved. Slide erative potential than do adults.42 Anatomic classification schemes
(advance) the flaps on their subcutaneous pedicles until the bases for the level of injury are multiple and make literature comparisons
are touching. Approximate the base of one flap to the other using problematic. Therefore, it is best to describe injuries related to ana-
simple interrupted nonabsorbable sutures (e.g., nylon or Prolene) tomic landmarks.
(Figure 96-10B). Approximate the arms and bases of the Y using Amputations proximal to the lunula are less common. Those who
interrupted nonabsorbable suture (e.g., nylon or Prolene). address the issue specifically recommend shortening and primary
closure without discussion or data. These injuries require emer-
MULTIPLE SMALL SKIN FLAPS gent consultation for possible re-implantation. Injuries from the
flexor digitorum profundus insertion to approximately the level of
Numerous small skin flaps that are bunched up, as commonly the mid-nail can be replanted if the amputated part is available.52–54
seen when a patient’s forehead shatters a windshield, are difficult The purpose of replantation is the restoration of cosmesis and func-
to repair individually. Excise them as a group to form a single tion. The patient’s perception may be that replantation will restore
laceration that can be repaired primarily (Figure 96-11). Larger functional and cosmetic normality. Inform the patient that this is
and more “spread out” groups of flap lacerations can be repaired doubtful.
Conservative therapy usually provides acceptable preservation of be given to prevention or treatment of local bacterial infection, and
contour and better salvage of two-point discrimination than grafts, prevention, recognition, and management of subsequent systemic
is cheaper than replantation, is associated with a virtual absence of illness.57 Infections following a bite wound are polymicrobial. The
postsurgical infections, and limits joint stiffness. It is equivalent to most frequent bacteria isolated from infected dog and cat bites are
other techniques in terms of functional use, preservation of length, Pasteurella, staphylococci, streptococci, and anaerobes. Human
and time absent from work. Moreover, eventual patient satisfaction bites result in infections due mainly to anaerobes and less com-
may be even greater than with surgical techniques. Patients may monly staphylococci, streptococci, and Eikenella corrodens.58,59
have to be convinced that closure by secondary intention is both Any bites to the hand, especially clenched-fist injury human
rational and, in fact, optimal. A set of photographs demonstrating bites, are the most likely to be complicated by infection. Human
this is often helpful. bites in other locations do not have higher rates of infection than
Clean, prep, and anesthetize the finger. Fingertip amputations other types of lacerations. E. corrodens is isolated from a signifi-
tend to bleed profusely. Achieve hemostasis with direct pressure cant percent of clenched-fist injury human bites, may cause a
using a nonadherent dressing while the hand is raised above heart septic arthritis or osteomyelitis, and can be resistant to several
level for several minutes. Do not remove the dressing if this is suc- commonly prescribed antibiotics (e.g., clindamycin and penicil-
cessful. Consider the application of sterile compression sponge cov- linase-resistant penicillin).
ered with a nonadherent dressing and the application of pressure Severe infections occasionally develop after bite wounds.59
if the bleeding continues. Attempts at cauterizing bleeding vessels Consider the presence of Capnocytophaga canimorsus infection in
are usually unsuccessful because of the tissue’s vascularity. Apply a dog bites, E. corrodens in human bites, and Bartonella henselae in
sterile Penrose drain as a tourniquet, without excessive constriction, cat bites with persistent lymphadenopathy and/or drainage. There
to provide a dry field if debridement of devitalized tissue is required. are no prospective studies confirming the indications for repairing
The presence of protruding bone poses several treatment options. bite wounds. Primary closure with subsequent antibiotic therapy
Some physicians rongeur any significantly protruding bone until it of head and neck wounds from dogs, cats, and humans have low
is flush with the wound surface and thereafter continue open treat- infection rates in studies of small numbers of patients. Suturing
ment. There is no published evidence supporting rongeuring of head and neck lacerations within 6 hours of a dog bite, following
protruding bone in adults. Anecdotal statements supporting this a meticulous debridement and irrigation protocol, was successful
technique exist in texts.45,51 Published reports support not shorten- without subsequent antibiotic use.60 Therefore, some bite wounds
ing protruding bone in children under the age of 12.49,55 Consider can be safely closed primarily while others are left open for delayed
trimming the nail bed back to the bone margin if a remnant over- primary closure (Table 96-1). The issue of closure applies only to
hangs or is not supported by adequate bone. wounds of cosmetic significance. Allow wounds without notable
Dress the wound with either a bulky hand dressing or tube gauze cosmetic significance to be left open for delayed primary closure or
and a four-pronged disposable (metal or plastic) splint. There is no healing by secondary intention. Do not primarily close puncture
documented benefit for the use of topical or oral antibiotics. Refer all wounds, hand wounds, human bites, extremity wounds, wounds
patients to a Hand Surgeon or primary care provider in 24 to 48 hours. less than 2 cm in size, facial wounds more than 12 to 24 hours
Inform all patients of the 30% to 50% incidence of sensory impair- old, or nonfacial wounds more than 6 to 12 hours old. Limit the
ment (i.e., diminished sensation, cold intolerance, and dysesthesia), use of buried sutures, as they can increase the infection rate of a
impaired function, or cosmetic deformity.44,46,50,51,56 Document this repaired bite wound.
in the medical record. The possibility of a wound infection is very Preparation of the wound for closure is of the utmost impor-
small with conservative treatment.48,74 Healing may be prolonged if tance. Obtain radiographs of the bite wound if there is the possibil-
protruding bone is not debrided or if it is debrided at a later time. ity of a fracture, a retained tooth, or penetration of a joint. Debride
any devitalized tissue, compromised tissue, or dirty wounds. Gently
scrub the surrounding skin, and not the wound, with povidone
ANIMAL BITES
iodine, chlorhexidine solution, or soap and water. Copiously irri-
Animal bites must be carefully explored to rule out underly- gate the wound. Antibiotic coverage is no substitute for meticu-
ing fractures, retained teeth, penetrated joints, tendon injuries, lous wound cleansing. Refer to Chapter 92 for a complete discussion
nerve injuries, and/or vascular injuries. Consideration must also of wound irrigation principles and techniques. Some studies report
TABLE 96-1 The Repair of Laceration-Type Bite Wounds

Location Dog bites Cat bites Human bites
Face PC PC PC
Scalp PC PC PC
Neck PC PC PC
Trunk PC if >2 cm PC if >2 cm PC or DPC
DPC if <2 cm DPC if <2 cm
Arm PC if > 2 cm PC if >2 cm PC if >2 cm
DPC if <2 cm DPC if <2 cm DPC if <2 cm
Hand with foreign body, extensor Hand Surgeon consultation, Hand Surgeon consultation, Hand Surgeon consultation,
tendon injury, joint capsule injury, exploration, and intravenous exploration, and intravenous exploration, and intravenous
or bone involvement antibiotics antibiotics antibiotics
Hand with only soft tissues involved DPC or secondary closure DPC or secondary closure DPC or secondary closure
Leg PC if >2 cm PC if >2 cm PC if >2 cm
DPC if <2 cm DPC if <2 cm DPC if <2 cm
Foot DPC DPC DPC
Key: PC, primary closure; DPC, delayed primary closure.
lower infection rates when wounds have been irrigated with a topi- Consult the local public health department for guidelines and the
cal antibiotic.61 However, this cannot be recommended as standard incidence of rabies in your community.
practice. The discharge instructions are just as important as the
Bites to the hand require radiographs to rule out a fracture, Emergency Department management. Provide the patient with a
retained teeth, or air in the joint cavity. Bite wounds, especially written copy of a wound care sheet, regardless of whether the wound
human bite wounds, involving a joint cavity or tendon require was closed primarily. Instruct the patient to elevate any involved
operative debridement and parenteral antibiotics. Bite wounds extremity, even with antibiotic treatment.66 Arrange follow-up
not involving a joint or tendon can be cleaned, debrided, splinted, within 24 to 48 hours for a reevaluation of the wound. Physical ther-
watched expectantly on an outpatient basis, and treated with oral apy following a hand infection may be required and initiated 3 to
antibiotics.62 Instruct the patient to keep the hand elevated and 5 days after the infection resolves.59
return in 12 to 24 hours for a reevaluation.
The use of antibiotics for an infected bite wound is benefi- DEBRIDEMENT OF GUNSHOT WOUNDS
cial. However, there is little concurrence regarding the routine
use of prophylactic antibiotics. Data demonstrating effectiveness The lack of primary literature on this subject makes it a con-
are limited. Differences in wound care, antibiotic regimens, and troversial area. Wounds created by low-velocity bullets tend to
the severity of wounds make comparison of studies problem- cause damage only along the bullet track. Debridement is unnec-
atic. Prophylactic treatment should ideally allow infection rates essary for wounds created by bullets with muzzle energy of less
to be less than 5%.63 The only significant benefit that has been than 400 foot-pounds, as many consider bullets to be sterile.67
shown was for dog or cat bites of the hands.57 As a result there is Devitalized and contaminated tissue are more likely to result from
a trend toward benefit for the prophylactic antibiotic treatment shotgun wounds and high-velocity bullets.68 The shock wave cre-
of hand wounds and bites presenting more than 8 hours after the ated by the bullet damages tissue distant from the track of the bul-
injury.59,62,64 let.68 Consider these wounds for debridement.68 The debridement
High-risk wounds include puncture wounds (as opposed to of gunshot wounds requires exposure of the entire bullet track and
laceration-type wounds), cat bites, bites to the hands, severe treatment as a delayed closure, followed by referral for skin graft-
crush injuries, wounds in immunocompromised patients, and ing if needed.
bites requiring surgical repair. The relative risk of infection Clean, prep, and anesthetize the skin overlying the path of the bul-
can be reduced with prophylactic antibiotics (Table 96-2). Dog let (or shotgun blast). Incise the wound with a #11 scalpel blade to
bites have the lowest associated infection rate of all bite wounds expose the area. Sharply debride any devitalized and contaminated
(5%-6%) which is similar to the rate found with lacerations from tissue. Repeated staged exploration should be undertaken at 24 and
non-bite mechanisms.57,59,62,64 Higher rates of infection in cat bites 48 hours to remove necrotic or devitalized tissues.69 Treat with pro-
(60%-80%) may be due to the fact that a greater proportion of phylactic antibiotics; cefazolin, 1 g intravenously every 8 hours, is
cats have narrower, sharper teeth than dogs, and thus the abil- satisfactory.69 Treat the area with delayed closure techniques, giv-
ity to deliver infectious agents deep into a small-bore puncture ing priority to reestablishment of bony relationships, followed by
wound.57 It is unclear whether all cat bites require prophylactic soft tissue coverage.69 Consider skin grafting for large areas of tissue
antibiotic treatment. It may eventually be proven that superficial destruction for adequate closure.
laceration-type cat bites may not require treatment beyond irri-
gation and debridement.65 Recommended treatment regimens ABRASIONS
for prophylaxis are 5 to 7 days for all bites with a beta lactam–
An abrasion is a skin wound created by tangential trauma to the
beta lactamase inhibitor antibiotic (i.e., amoxicillin/clavulanate).
epidermis and dermis. The skin is forced against an abrasive surface
Penicillin or ampicillin provides adequate coverage for Pasteurella
in a rubbing fashion and the resultant injury resembles a thermal
multocida infections, and thus is a logical lower cost option for
burn. The goals of managing an abrasion include the prevention of
prophylaxis of cat bites. Penicillin-allergic patients can receive
infection, promotion of healing, and prevention of “tattooing” with
doxycycline or cefuroxime for cat bites, and clindamycin plus a
retained foreign bodies. Large and heavily contaminated abrasions
fluoroquinolone for dog bites. Cephalexin, dicloxacillin, eryth-
are best managed in the operating room, as the volume of local
romycin, and clindamycin do not cover Pasteurella species and
anesthetic required to achieve anesthesia would likely exceed toxic
therefore should not be used alone.57
limits.
Immunoprophylaxis may be required. Administer tetanus
Prepare the wound. Anesthesia may be required prior to wound
immune globulin and tetanus toxoid as indicated. With any animal
management. EMLA cream, which contains lidocaine and prilo-
bite, consider rabies postexposure prophylaxis. In North America,
caine, produces anesthesia of the intact skin but it must be in place for
bites from bats, raccoons, skunks, and foxes carry a special risk.
about 60 minutes in order to provide significant benefit.70 Perform
a field block or regional nerve block (Chapter 126) as appropriate.
Large abrasions may be anesthetized by applying 5% lidocaine gel
topically for 5 to 10 minutes. Remove any dirt or debris, using a ster-
TABLE 96-2 Indications for Prophylactic Antibiotic Therapy for Bite Wounds ile scrub brush and surgical soap (or saline). Consider imaging (i.e.,
Dog bites Cat bites Human bites plain radiographs) to evaluate for potential foreign bodies.28 Use the
Puncture wound Yes Yes Yes tip of a #11 scalpel blade to remove deeply embedded and larger
Hand bites Yes Yes Yes particles from the wound. Apply petroleum jelly or antibiotic oint-
Facial bites No Consider No ment to remove embedded tar.71 Apply an antibacterial ointment to
Non-hand-laceration-type bites No Consider No the wound.
Immunocompromised patients* Yes Yes Yes Instruct the patient to cleanse the wound three to four times a day.
Surgical closure Yes Yes Yes The wound may also be covered with petrolatum gauze and sterile
Severe crush Yes Yes Yes gauze. Instruct the patient on how to properly cleanse the wound
* Immunocompromised includes patients with age > 50, diabetes, alcoholism, asplenia, and and reapply the bandage. Provide the patient with wound care sup-
patients with any other illness associated with an impaired immune status. plies prior to discharge from the Emergency Department.
CHAPTER 97: Subcutaneous Foreign Body Identification and Removal 669
it may be impossible to eradicate the infection until the foreign

Subcutaneous Foreign body is removed.2,3,12 Metals that oxidize may cause mild to mod-
97 Body Identification erate inflammation. Some retained foreign bodies, like lead, have
the potential to produce systemic effects, especially when in contact
and Removal with pleural, peritoneal, cerebrospinal, or joint fluid.13 Inert objects
with smooth, nonporous surfaces like glass or plastic elicit minimal
Samuel J. Gutman and Michael B. Secter tissue reaction. Retained foreign bodies that are not dissolved or
extruded by the body’s defenses become encapsulated, after which
INTRODUCTION the inflammation will subside.13
Wounds with retained foreign bodies are a frequent presenting com-

plaint to Emergency Departments. Up to 38% of embedded objects
HISTORICAL AND PHYSICAL ASSESSMENT
are missed on the initial assessment.1 Identification and removal Patients presenting after an injury require a focused history includ-
of debris and foreign bodies promote optimal healing of traumatic ing the details of the incident, the wounding agent, and the mecha-
wounds. The presence of an unrecognized foreign body can lead nism of injury. This information may suggest the presence of a
to complications that include infection, pain, loss of function, retained foreign body and direct which imaging study is required.14,15
joint injury, tenosynovitis, tendon rupture, and osteomyelitis.2–5 Historical features that may signal unusual circumstances or diffi-
Patients presenting with chronic, recurrent, or delayed skin infec- cult wound healing and management include diabetes, renal failure,
tions should be assessed for the presence of an unrecognized for- immunosuppression, lymphedema, or peripheral vascular disease.16
eign body. Failure to diagnose and treat a foreign body is a common Past anesthetic history and the potential for aspiration should be
cause of litigation against Emergency Physicians. The presence of a assessed if procedural sedation is to be considered.17 Medications
foreign body may not be obvious. A high index of suspicion and and allergies should be queried. Assess the patient’s tetanus immu-
careful methodical examination, including appropriate imaging, nization status. Provide booster doses and tetanus immune globulin
must be undertaken to identify a foreign body. as needed (Table 92-2).
It is important to be familiar with the characteristics of different A directed physical examination should begin with a brief inspec-
types of foreign bodies and the interactions they may have with a tion and documentation of the distal neurovascular status and func-
host patient. This information is crucial in determining the urgency tion. An injured extremity must be carefully examined through a full
or necessity of removal (not all implanted objects require removal), range of motion to ensure the integrity of the tendons. Discoloration
the appropriate imaging techniques, the approach to removal, and of the skin may suggest a foreign body.8 Palpation may reveal super-
whether specialty referral is required. The removal of foreign bodies ficial foreign bodies. Sharp localized pain with palpation over a
from subcutaneous tissue can be a frustrating and time-consum- puncture wound may suggest a retained foreign body. Adequate
ing endeavor when it is ill conceived. The successful removal of a anesthesia, lighting, and good hemostasis are required to allow a
foreign body requires a directed history and physical examina- thorough examination of the wound. The examiner must avoid
tion, appropriate imaging, adequate light, anesthesia, exposure, probing only superficially since the subcutaneous tissue can
hemostasis, patient cooperation, an uninterrupted time period reapproximate and give the appearance of a superficial wound.
for attempted removal, appropriate wound care, and assured The wound edges should be extended with a scalpel to facilitate
postprocedural follow-up. inspection if there is concern regarding a retained foreign body and
direct visualization is difficult.
ANATOMY AND PATHOPHYSIOLOGY A retained foreign body can be ruled out with a negative predic-
tive value of 96% for wounds less than 5 mm deep if the bottom of
Only a small percentage of wounds actually contain concealed the wound is visible.6 Never insert a gloved finger to probe the
foreign bodies.6 The mechanism of injury may give some idea of wound cavity, as this can result in injury from sharp foreign bod-
the likelihood of a retained object.1 Crush wounds and puncture ies. Gentle blind probing with a hemostat is an acceptable and pre-
wounds, especially those involving the sole of the foot, as well as ferred alternative. A grating sensation that can be appreciated by
wounds deeper than 5 mm involving adipose tissue are associated the examiner is produced if the probe strikes a metallic or glass for-
with a higher incidence of foreign bodies that are often difficult to eign body. Avoid blind grasping within a wound with a hemostat.
find.6 Wounds caused by objects that shatter, splinter, or break in the Direct visualization is preferable when examining wounds of the
process of causing injury have a higher risk of having a retained for- face, feet, or hands.
eign body.7 Lip or facial lacerations associated with dental fractures
must be explored for pieces of teeth. Thorns, spines, or slivers tend
to penetrate deeply and break. Broken-off needles are common for- RADIOLOGIC ASSESSMENT
eign bodies in injection drug users. Objects greater than 4.5 mm in Imaging is indicated in most cases where a retained foreign body
diameter that penetrate the skin may push fragments of epidermis is suspected but not found during wound exploration, when thor-
deep into the wound producing an epidermal inclusion cyst, which ough exploration of the entire wound cavity is not possible, or if the
can act as a foreign body.8 patient feels that there is a retained foreign body.
Depending upon the type of material retained and the physical
form of the foreign object, excess inflammation may result. This
can delay healing or destroy surrounding soft tissues. Retained
PLAIN RADIOGRAPHY
organic foreign bodies trigger the most severe inflammatory reac- Most foreign bodies missed during the initial clinical examination can
tions and can lead to chronic granulomatous reactions, periosteal be seen on plain radiographs.14 Plain radiographs are readily available.
reactions, osteolytic lesions, or severe infections such as necrotiz- Some authors suggest radiographic evaluation of nearly any penetrat-
ing fasciitis.8–10 The presence of soil in wounds markedly lowers ing wound involving an extremity.1,4,18 Standard anteroposterior and
the concentration of bacteria required to cause an infection by its lateral radiographs should be performed using an underpenetrated
interaction and interference with white blood cells.11 Wounds tend “soft-tissue technique” to increase the contrast between the foreign
to be resistant to antibiotics when a foreign body is present2,3,12 and body and the surrounding tissue.3 Visibility of foreign material in
soft tissues is dependent upon its composition, relative density, con-

figuration, size, and orientation.19,20 Oblique and other views can be
added to avoid superimposition of the object over bony structures.
Radiopaque foreign bodies may be invisible if they are projected over
or impacted within bone.21 Metal, bone, teeth, pencil graphite, certain
plastics, gravel, sand, and aluminum are all visible on plain radio-
graphs.3,20,22 Glass fragments have been thought to require lead or
heavy metal content to be visible. However, glass fragments as small
as 0.5 mm appear on two-view plain radiographs if not obscured by
bone fragments; and glass fragments as small as 2 mm appear in the
presence of overlying bone regardless of lead content.23,24
Organic materials and plastics are not reliably detected on plain
radiographs. They may be indirectly shown as a radiolucent filling
defect when the object is less dense than the surrounding tissue,
making plain radiography worthwhile even in cases of suspected
nonradiopaque foreign bodies.25,26
It is important to examine the entire radiograph for the appear-
ance and location of an unexpected foreign body.27 The evaluation
can be terminated after adequate wound exploration and plain
radiographs for a known radiopaque foreign body, if nothing is FIGURE 97-1. A sonographic image of a subcutaneous thorn. The foreign body is
found. Other imaging modalities are required if there is a strong hyperechoic (white) with an acoustic shadow deep to it.
suspicion for a retained foreign body of the type that is not usually
demonstrated on plain radiographs.
The advantages of plain radiographs include their universal
availability, low cost, and familiarity to most Emergency Physicians. The procedure for locating a subcutaneous foreign body with
The disadvantages include the inability to resolve objects with ultrasound begins with selecting the highest available transducer
densities similar to body tissues. Plain films do not demonstrate frequency.40 Higher frequency transducers have better resolution for
anatomic structures that may be intervening between the skin and superficial structures. The use of a standoff pad or gel filled glove
foreign body along the planned surgical approach. It may be dif- (with the air and talc carefully removed) can act as a dead zone for
ficult to accurately judge the depth of a foreign body using two- objects that would normally be too superficial to fall within the focal
dimensional radiographs.8 Despite these drawbacks, standard zone of the transducer.41,42 Adjust the focus to the required depth
radiographs remain the most clinically practical means of screen- and proceed to scan the field in two orthogonal planes.40 The scan-
ing for foreign bodies.19 ning beam must be oriented parallel to the long axis of a hemostat,
which can be directed toward the long axis of the foreign body.31
ULTRASOUND Please refer to Chapter 98, Ultrasound-Guided Foreign Body
Identification and Removal, for more complete details.
Radiography alone is not sufficient to detect nonradiopaque for- The sonographic appearance of foreign bodies is related to
eign bodies. Bedside ultrasound has become available in many the surface characteristics and not its composition.43,44 Metals
Emergency Departments. The lack of radiation exposure or harm and needles are often hyperechoic with reverberation artifact or
to patients and its ease of use dictates an assessment with bedside comet tails. Gravel is usually hyperechoic and shows dense poste-
ultrasound by the Emergency Physician as a screening tool when rior acoustic shadowing. Organic materials such as wood have a
foreign bodies are suspected or not found on plain radiography.28 characteristic appearance and are ideal for ultrasonographic eval-
Many recent studies have shown ultrasonography to have a higher uation. Wood is most often hyperechoic with a posterior acous-
sensitivity for nonradiopaque foreign bodies than plain radiogra- tic shadow (Figure 97-1). Furthermore, the foreign body is often
phy.28,29 High-resolution real-time ultrasound using a 7.5 MHz or surrounded by a hypoechoic halo37,42,44 (Figure 97-2). This is
greater linear array probe or transducer, in the hands of a skilled
and experienced operator, can detect radiolucent superficial foreign
bodies with a similar radiographic density as the surrounding tis-
sue.8,30–34 This can include wood, small glass fragments, fish bones,
sea urchin spines, and other vegetative material.8,34–38 Wood foreign
bodies can act as a source for infection and should be evaluated
with ultrasound in patients where radiographs are negative.35 This is
especially important in the Emergency Department where wood for-
eign bodies make up as much as 34% of all foreign bodies and plain
radiographs have a sensitivity as low as 7.4% for organic material.36
Patient perception of a retained foreign body and the use of bedside
ultrasound can localize a retained object with a sensitivity of 88.9%
and a specificity of 76.5%.37 One study showed that the accuracy of
detection was above 80% for radiolucent objects by ultrasound tech-
nologists, Radiologists, and Emergency Physicians.38
Ultrasound has the ability to localize a foreign body within three
dimensions, thus helping to establish its relation to adjacent bone,
muscle, tendons, and tendon sheaths.32 Preoperative ultrasound FIGURE 97-2. A sonographic image of several shards of glass in the palm. Note
results in less damage to the surrounding tissues, reduced operative the hyperechoic (white) foreign bodies surrounded by an echo-poor (black) signal
time, and reduced postoperative morbidity.32,39 consistent with either a hematoma or edema.
frequently a zone of edema, granulation tissue, or abscess.40 While foreign bodies must also be sought prior to MRI scanning to pre-
this hypoechoic halo can represent an inflammatory response, it vent iatrogenic injury. This requires a thorough screening history
may not be visible within 24 hours of the wound.35 Doppler ultra- and plain radiographs prior to MRI scanning. Gravel and ferro-
sound shows a hypoechoic (black) ring around a hyperechoic magnetic substances produce significant artifact.14 Differentiating
(white) foreign body. Doppler also shows marked hyperemia scar tissue, tendons, and calcifications from an actual foreign body
around the periphery of a foreign body, something considered to can be challenging.60 MRI is better suited to evaluate the complica-
be a reliable secondary sign.45 tions of foreign bodies and is not used routinely in the Emergency
Once a foreign body has been located on ultrasound, both ends of Department.
the object should be marked.46 This is often done by inserting paper-
clips between the skin and the transducer and connecting both ends INDICATIONS
with a marked dotted line. Meticulously scan along the entire length
of the suspected object and also visualize the foreign body perpen- Every effort should be made to identify foreign bodies, even if
dicular to the transducer. they are not likely to be removed. It must be decided whether a
There are several disadvantages when using ultrasound, including foreign body needs to be removed immediately, electively, or at all
the level of skill required for its use in diagnosing musculoskeletal once identified. Factors that influence the decision to proceed with
foreign bodies.46–49 Studies assessing the accuracy of ultrasound have attempted removal include the size and reactivity of the foreign
shown a sensitivity of 30% to 100% and a specificity of 70% to 90%.49 body, its proximity to vital structures, and associated injuries. These
These values have been mostly demonstrated in referred patients must be weighed against the potential for further tissue damage and
studied by Radiologists and certified technicians.50,51 Ultrasound by contaminating the wound.
Emergency Physicians has a specificity of only 59% under conditions A foreign body requires immediate removal if it is likely to
that replicate a typical Emergency Department situation.51 Another provoke significant tissue inflammation or injury.3,61,62 Contam-
disadvantage is that false positives can occur with tendons, old scar inated objects such as teeth, soil, or foreign bodies located in
tissue, calcifications, fresh bleeding, sutures, air in wounds, sesamoid the presence of an established infection should be immediately
bones, ossified cartilage, or keratin plugs.8,35,42 Ultrasound localization removed.3,11 Allergenic foreign bodies, toxic foreign bodies, or those
may also be difficult if the object is close to bone or deep to subcuta- causing hemorrhage or ischemia should be immediately removed.3,62
neous gas.43 As such, Emergency Physicians with a high suspicion Foreign bodies interfering with sensory or motor function, or hav-
for a retained subcutaneous foreign body not identified by bedside ing the potential for migration, should be urgently removed.3
ultrasound should request a formal diagnostic imaging study. Foreign bodies in the hands and feet usually require removal as they
may cause persistent pain and can sever nerves or tendons much
COMPUTED TOMOGRAPHY (CT) SCAN later.5 The foreign body may require removal for cosmetic or psy-
chological reasons in some cases.1
CT imaging should be requested in cases where radiography and
ultrasonography have failed to demonstrate suspected foreign bod-
ies such as nonradiopaque material or those that cannot technically
CONTRAINDICATIONS
be located by ultrasound due things like overlying bone or gas.52 CT The foreign body should be urgently removed under ideal condi-
is valuable because it is more sensitive in differentiating densities tions by an appropriate Surgeon when it is associated with a neuro-
and thus is capable of detecting more types of foreign bodies.14,53–56 vascular injury or is located near tendons, nerves, or blood vessels.1,3
The modality can also be used in high-risk wounds when there is Deep exploration of the hands or feet should be avoided to prevent
potential for infection or joint involvement. CT images can be cre- injuring the intricate structures. Large, deep, and impaled foreign
ated in multiple planes and can demonstrate the relationship of a bodies are assumed to be tamponading hemorrhage, should initially
foreign body to important anatomic structures.53,57 CT-guided per- be left in place, and urgently removed in the Operating Room.27
cutaneous placement of a catheter or needle can guide surgical dis- Foreign bodies associated with fractures or located within a joint
section to a foreign body, aiding in the subsequent removal.53,57 The require prompt surgical debridement to prevent osteomyelitis or
disadvantages of CT scanning include its higher cost, radiation dos- septic arthritis.62 Urgent surgical intervention is required for all
age, the need for patient cooperation, and availability. Additionally, high-pressure injection injuries. These injuries may initially appear
organic foreign bodies become less visible over time due to absorp- innocuous but often cause extensive damage and carry a signifi-
tion of body fluids.28 cantly high risk of complications.62 Consider referral based on one’s
own experience, anticipated problems related to the foreign body’s
MRI location or depth of penetration, the duration of retention, or other
patient factors likely to complicate the procedure or follow-up.
MRI appears to be more accurate than any other modality for iden- A deeply embedded, inert object not near any vital structures can
tifying wood, glass, plastic, spines, and thorns.14,53 It is superior to be left in place. The difficulty of removal is usually not worth the
CT scanning in detecting the presence and extent of edema, hemor- potential tissue damage. These patients can be referred for elective
rhage, and infection surrounding foreign bodies.14,53 Wood foreign removal, if necessary.1,62 If the decision is made not to remove a for-
bodies often show linear hypointensity with an associated sur- eign body, the patient must be informed and the issues discussed
rounding inflammatory response.28 MRI’s other advantages include including the potential for migration and infection. Document
the high resolution and contrast between adjacent tissues. It allows this discussion in the medical record.
the precise localization of foreign bodies in three dimensions to aid
in surgical planning and assessment of the need for advanced explo-
ration, debridement, and irrigation. It does not expose the patient EQUIPMENT
to any radiation.58 • 18 gauge needles
The disadvantages of MRI include its lack of availability and • 27 gauge needles
high cost. Patients must be assessed to rule out a magnetic for-
eign body due to the risk of movement of the foreign body dur- • 10 mL syringes
ing MRI scanning.59 Prior history of an ocular or other metallic • Povidone iodine or chlorhexidine solution
• Lidocaine (1%) with and without epinephrine with the anesthetic to control localized capillary bleeding if no
• Topical 4% liposomal lidocaine contraindications exist. A 0.25 to 0.50 in. Penrose drain can be
wrapped tightly around a finger or toe and secured in place with
• Depilatory wax, rubber cement, or hardening facial gel a hemostat.
• #11 scalpel blade on a handle Adequate anesthesia is crucial to the procedure. A field block
• #15 scalpel blade on a handle or regional nerve block, depending upon the location of the foreign
body, best accomplishes anesthesia without distorting the wound
• Nylon suture, 1-0 or 2-0
further by local infiltration.64 Consider using topical anesthetics in
• Methylene blue the pediatric population. Liposomal lidocaine (4%), for example,
• Paper clips has a very fast onset and is associated with higher success rates,
• Wire grid reduced procedure time, and less pain.65,66 The techniques of topi-
cal and regional anesthesia are described in Chapters 124 through
• Eye magnet 127. Procedural sedation (Chapter 129) or general anesthesia may
• Hemoclips be required, especially in children where cooperation may not be
• Hemoclip applier otherwise possible.
• Fluoroscopy unit
• Hemostats, two sizes TECHNIQUES
• Forceps
SUPERFICIAL WOOD OR
• 22 gauge needles for foreign-body localization ORGANIC SPLINTER REMOVAL
• Magnification eye loupes
Very fine foreign bodies can be difficult to visualize. One method to
• Normal saline help localize them is to spread soft soap very lightly over the skin.67
• 19 gauge blunt-tip needle or angiocatheter Only superficial organic splinters and foreign bodies should be
• 35 mL syringe pulled out with forceps as they often come apart leaving a fragment
that is more difficult to remove.3,68 Occasionally, cactus spines or
• Blood pressure cuff or Penrose drains
wood splinters lie superficial and parallel to the skin surface. Make
• 4 × 4 gauze squares an incision parallel to the long axis of the foreign body and then lift
• Adhesive tape it out of the wound. Enlarge the skin entrance wound with a scal-
• Bedside ultrasound with high frequency transducer pel so that the foreign body can be grasped and withdrawn with a
hemostat under direct visualization if it is lodged in the subcutane-
• Standoff pad or gel filled glove ous tissue.
Small cactus spines may be difficult to locate and remove directly.
PATIENT PREPARATION Application of a depilatory wax, rubber cement, or a water-soluble
facial gel with a brush can successfully aid in the removal of small
Foreign body removal can be frustrating and time consuming, even
fine spines.61 Apply the wax, rubber cement, or facial gel over the
when performed under ideal conditions. It is appropriate to set a
skin containing the protruding spines. Apply a layer of gauze over
time limit that is reasonable based upon the staffing and volume
the wet substance. Allow the substance to dry onto the skin and the
of the Emergency Department. Approximately 10 to 30 minutes is
gauze. Remove the gauze to lift off the dried substance and attached
appropriate to find and remove an embedded foreign body. Inform
spines. Repeat this process as required to remove the remaining
the patient of the planned time limit at the outset. The search should
spines.
be discontinued and the patient referred to a Surgeon after expira-
tion of the predetermined time.
Apply povidone iodine or chlorhexidine to the skin site sur- PUNCTURE WOUNDS
rounding the wound. Avoid spilling the solution into the wound Puncture wounds of the foot are commonly seen in Emergency
cavity as both are toxic to wound defenses and may increase the Departments. Punctures frequently, drive pieces of clothing, shoes,
incidence of a subsequent wound infection.12 Obtain a bloodless or other debris deep into the wound resulting in an infection rate
field for the examination. Place a blood pressure cuff proximal of approximately 10%.69,70 Although technically difficult, punc-
to the injury. Elevate the extremity for at least 1 minute and then ture wounds in the distal foot may profit from debridement and
inflate the cuff to a pressure greater than the patient’s systolic irrigation.
blood pressure. Although it will cause some discomfort, this Puncture wounds can be trimmed or ellipsed to remove con-
is safe for up to 2 hours.63 A local vasoconstrictor can be used taminated and/or embedded foreign bodies (Figure 97-3).3 This
FIGURE 97-3. Creating an ellipse to remove a contaminated

or embedded foreign body. A. An ellipse is made in the skin
surrounding the foreign body. B. The epidermis is removed
to expose the foreign body. A block of subcutaneous tissue
(dotted line) can be removed if the foreign body is difficult to
visualize. C. The skin, the subcutaneous tissue, and the foreign
body can be removed en bloc.
FIGURE 97-4. Removal of a foreign body embedded perpen-

dicular to the skin. A. The embedded foreign body. The dotted
line represents the proposed incision line. B. A linear incision is
made 1 mm lateral to the foreign body. C. The incision is spread
open to visualize and remove the foreign body.
technique also works well for foreign bodies that are difficult to the foreign body (Figure 97-5B). Apply digital pressure over the
localize. Make an ellipse in the skin surrounding the foreign body undermined areas to displace the foreign body into the center of the
with a #15 scalpel blade (Figure 97-3A). Lift up the ellipse of skin wound and upward (Figure 97-5B). Grasp the foreign body with a
and separate it from the underlying dermis (Figure 97-3B). The for- hemostat and remove it.
eign body may be visible. Grasp it with a hemostat or forceps and
remove it from the tissue.
NYLON SUTURE LOCALIZATION
If unable to exactly localize the object, the foreign body and
the ellipsed puncture wound can both be extracted in a block of One technique described for use in fresh wounds involves the local-
tissue (Figure 97-3B, dotted line).64 First ensure that no nerves, ization of a foreign body by marking its entry tract with a nylon
blood vessels, or tendons will be injured. Alternatively, make the suture.71 Grasp a piece of 1-0 or 2-0 nylon suture between the
skin ellipse and extract the block of tissue containing the foreign thumb and index finger. Rotate the suture while pushing it into the
body without dissecting the skin from the subcutaneous tissue wound so that it follows the tract made by the foreign body. It is
(Figure 97-3C). Both techniques allow for the removal of foreign reported that the foreign body is easily felt when the nylon contacts
bodies and better cleaning of the wound. Puncture wounds of the the foreign body.71 Leave the suture in the wound tract. Open the
foot require careful follow-up due to the risk of infection. wound tract by cutting alongside the nylon suture until the foreign
There are several alternative techniques if removing an ellipse body is reached, at which time it is removed. A 92% success rate
of skin and/or tissue is contraindicated or if the Emergency up to 48 hours after the time of injury has been reported with this
Physician is not comfortable with this technique (Figures 97-4 & technique.71
97-5). A foreign body may be embedded perpendicular to the skin
(Figure 97-4A). Make a linear incision that passes 1 mm to the side
GEOMETRIC APPROACH
of the puncture wound with a #15 scalpel blade (Figures 97-4A &
B). Spread the incision open. Visualize the foreign body, grasp it
FOR A NEEDLE IN THE FOOT
with a hemostat, and remove it. A technique that is useful for the removal of a needle in the plan-
The final technique of removing a foreign body from a puncture tar surface of the foot involves the use of standard anterior, pos-
wound involves making a superficial skin incision and manually terior, and lateral radiographs to identify the cutaneous site
expressing the foreign body (Figure 97-5). Make an elliptical inci- corresponding to the location of the needle.72 The incision site
sion surrounding the foreign body or a linear incision over the for- is determined by bisecting the midpoint of the needle, as seen in
eign body (Figure 97-5A). Remove the ellipse of skin or spread the each projection, by a line drawn at right angles to the long axis of
linear incision. Undermine the subcutaneous tissues surrounding the needle. The ideal plane of dissection is perpendicular to the
needle’s midpoint, which is correlated with the surface anatomy of
the foot.
Prepare and anesthetize the skin after determining the dissection
plane. Make a 0.5 to 1.0 cm skin incision in the plane perpendicular
to the needle in its midpoint. Advance an iris scissors into the inci-
sion and along the dissection plane with the blades slightly open.
Advance the scissors 1 to 2 mm and close the blades. Withdraw
the scissors slightly. Open the blades of the scissors, advance them
1 to 2 mm, and close the blades. Care must be taken to avoid cut-
ting the flexor tendons, although they are located deep and in
close association to the bones of the foot. Continue this process of
advancing and closing the blades until the needle prevents closure of
the scissors. Advance a hemostat into the wound and over the blades
of the scissors. Grasp and secure the needle. Pull the hemostat out
of the wound to simply back the needle out of its entry tract. This
procedure is reported to have a 100% success rate and takes approxi-
mately 10 minutes.72
FIGURE 97-5. An alternative technique to remove a foreign body from a puncture DYE LOCALIZATION
wound. A. Incise and remove an ellipse of epidermis (1). Alternatively, make a
linear incision centered over the foreign body (2). B. Undermine the subcutaneous Methylene blue may be used to track the location of a foreign body.73
tissue surrounding the foreign body. Apply digital pressure (arrows) to visualize Identify the presence of a needle or foreign body on plain radio-
and express the foreign body. graphs. Clean and prepare the skin. Sterilely inject 0.1 to 0.2 mL
of methylene blue very gently through the entrance wound of the EYE MAGNET
foreign body. The dye will travel along the path of least resistance,
that is, the path of the foreign body. Make an A-, U-, V-, or Y-shaped Another technique reported to have a good success rate in removing
incision from the point of entry and raise a flap of tissue. The blue metallic foreign bodies utilizes a hand-held eye magnet.78 Confirm
dot of dye serves as a guide to the location of the foreign body. This the presence of a radiopaque foreign body with plain radiographs.
procedure is often complicated by seepage of dye and is therefore of Prepare, drape, and anesthetize the area. Slightly enlarge the entry
limited value. wound to permit entrance of the magnet tip. Apply a sterile ultra-
sound probe cover or glove over the magnet. Gently probe the
wound track with the magnet until a “click” is appreciated. Withdraw
PAPER CLIP X-RAY LOCALIZATION the magnet with the foreign body attached to the magnet. Perform
Simple paper clips may be used to locate a foreign body.74,75 Obtain further and more directed wound exploration with the magnet if
plain radiographs to demonstrate the presence of a radiopaque for- resistance is met. This technique is likely of limited value.
eign body. Bend two or more paperclips into different shapes. Place
the ends over the wound entry site. Secure the paper clips in posi- TAGGED HEMOCLIPS
tion with tape. Obtain two plain radiographs taken at right angles
It can be difficult to find foreign bodies once the dissection actu-
to each other. Examine the radiographs to determine the cutaneous
ally begins since the tissues may be distorted by retraction, edema,
location of the foreign body in relation to the paper clips and note
or local anesthesia; even with the most elaborate marking system
its depth from the skin surface. Mark the exact cutaneous location
using grids or needles. The tagged Hemoclip method was developed
of the foreign body on the patient’s skin with a permanent ink pen.
to address this problem.79 It requires a skin incision and dissection
Remove the paper clips.
down to where the physician believes the foreign body to be, based as
Clean, prepare, and anesthetize the skin. Make a stab incision at
observed on plain radiographs. Prepare two or three Hemoclips with
a 90° angle to the middle of the foreign body, taking the shortest
a long silk suture attached to each one. Place them into the Hemoclip
distance between the skin and the foreign body, and following the
applier. Dissect down to where the foreign body is believed to be
method discussed for the geometric approach for a needle in the
located. Place two or three Hemoclips into the depths of the wound.
foot. Insert a small hemostat into the incision. Advance the hemo-
Obtain repeat radiographs to show the relationship of the foreign
stat allowing localization of the object with minimal probing. Grasp
body to the Hemoclips. Remove all but the closest Hemoclip. Dissect
and remove the foreign body.
towards the Hemoclip and the foreign body. Identify and remove the
foreign body. Remove the Hemoclip. If the foreign body is not read-
WIRE GRID LOCALIZATION ily found, repeat the procedure after placing two or three additional
This technique follows a similar approach to the paper clip method.76 Hemoclips. Follow the trail of Hemoclips to the foreign body.
Place a wire grid over the skin. Obtain radiographs in two planes to
locate the object within the grid system. Mark the skin and remove ULTRASONOGRAPHIC REMOVAL
the grid. Remove the foreign body as discussed for the paper clip There are a multitude of different approaches to the ultrasound-
technique. guided removal of subcutaneous foreign bodies.37,40–42,46,80 A detailed
working knowledge of the pertinent anatomy is essential. Locate
NEEDLE GRID LOCALIZATION and mark the location of the foreign body. Clean, prep, and anes-
thetize the skin. Insert a needle under ultrasonographic guidance.
The grid principle may also be used to remove superficial and non-
The ultrasound monitor screen will display a hyperechoic linear
linear radiopaque foreign bodies after they have been identified on
object with posterior reverberation effect. Guide the needle under
plain radiographs. Clean, prep, and anesthetize the skin. Insert three
ultrasound until it touches the foreign body. Make a skin incision
25 gauge, 1.5 in. needles into the skin near the estimated location
down to the foreign body. The addition of a second needle in a
of the foreign body and at right angles to each other. Obtain two
perpendicular plane can enhance the objects localization.41 Inset a
orthogonal plain radiographs. This process can be repeated, each
closed hemostat to approach the foreign body.41,80 Ideally, the hemo-
time moving the needles slightly until one is superimposed on the
stat should be inserted along the plane of the foreign body. Open
foreign body. Determine the cutaneous position of the foreign body
the jaws of the hemostat under sonographic guidance to reveal two
by noting its position within the needle grid. Mark this position on
echogenic structures, the jaws of the hemostat, with posterior rever-
the skin. It must be remembered that this technique does not pro-
beration effect. Once the object is within the hemostat’s grasp, it can
vide a true three-dimensional image since divergence and parallax
be removed under sonographic guidance. Always rescan the area
distortion of images occur on the radiographs.3
after the foreign body is removed in order to ensure that no addi-
The Emergency Physician must recall that tendons and other
tional fragments remain. Patients should be instructed to return if
structures may block the planned path to the object.7 Make a 0.5 to
there are any signs of infection.46 A more detailed description of
1.0 cm incision in a plane perpendicular to the long axis of the for-
ultrasound-guided foreign body removal is available in Chapter 98.
eign body to an appropriate depth or dissect along the path of the
closest needle.27 Identify and remove the foreign body. A drawback
of this technique is the potential for dislodging of the needles with
FLUOROSCOPIC TECHNIQUES
attendant repeated trips to the Radiology Department. The use of a Fluoroscopy offers an excellent aid in the removal of radiopaque
portable fluoroscopy unit will prevent this problem. foreign bodies.81 Make an incision over the foreign body as judged
Another similar technique involves the placement of three to four from plain radiographs. Localize the foreign body under fluo-
needles of different gauges at 90° to each other in the anesthetized roscopy. Guide a curved hemostat to the foreign body with brief
subject.77 Obtain repeat radiographs to identify which needle is clos- intermittent exposures of the fluoroscopy unit.82 Grasp and remove
est to the object. Remove all but the closest needle. Make an inci- the foreign body. This procedure exposes the operator’s hands to
sion down to the estimated depth where the foreign body is located. radiation and may risk damaging structures in the wound by blind
Identify and remove the foreign body. manipulation of the hemostat.83
The grid and needle localization techniques described previously puncture wounds, avulsions, and wounds resulting from mis-
can be applied under fluoroscopy. Rotate the site of injury under the siles, crushing, burns, and frostbite are considered to be tetanus
fluoroscope to visualize the foreign body between the markers. This prone. Recent studies have found that up to 26% of those patients
may improve the ability to judge the location of the foreign body reporting they were up to date with tetanus vaccination were con-
in three dimensions and aid in its removal. Intermittent exposure firmed not to be, while a further 30.2% were indeterminate.91 In the
with a fluoroscope can allow repositioning of the needles until the Emergency Department, it is vital to investigate a patient’s tetanus
foreign body is localized between two needles or at the tip of a single status and vaccinate according to the accepted guidelines.40,92 For
needle. Make a small incision carried down to the foreign body and patients who have had three or more doses, those who received
remove it.83,84 their previous dose within 5 to 10 years presenting with a nonclean
Additional techniques using fluoroscopy and neurosurgical ste- and minor wound should receive the Tdap booster (preferred over
reotactic devices have been described.3 The cost, availability, and the Td booster). Those patients who have gone more than 10 years
practicality make these approaches unattractive in the Emergency since their last dose should also receive the booster regardless of
Department and are therefore not discussed further. wound type. All patients who have fewer than three doses or an
uncertain vaccination history should receive the vaccine booster.
AFTERCARE Of these patients, those with complicated or contaminated wounds
(such as those due to a puncture) should receive the tetanus immu-
It is often prudent to take postextraction radiographs to ensure noglobulin (TIG) in addition to the vaccine booster.92 Please
complete removal of the foreign body, especially if multiple objects refer to Chapter 92 for more complete details regarding tetanus
are involved or if there is concern about the object fragment- prophylaxis.
ing.77 Carefully irrigate and debride the wound of all epidermal
fragments.3 The most effective form of wound preparation and
cleansing is jet lavage irrigation with normal saline to decrease COMPLICATIONS
the bacterial load in the wound and the risk of developing infec-
The removal of embedded foreign bodies is relatively free of com-
tion.85 This can be performed with a commercially available device
plications if properly conceived. Care must be taken to docu-
or a 35 mL syringe armed with a 19 gauge angiocatheter or blunt
ment the functional and neurovascular status prior to and after
needle.12 Studies of simple pediatric wounds has found that using
any significant manipulations. Appropriate referral of compli-
drinkable tap water to irrigate wounds is a good alternative to
cated cases, including those with foreign bodies located deep in
saline, as it shows similarly low infection rates.86 The quality of
the hands, the feet, or near vital structures will lessen the risk of
mechanical cleaning is important to wound prognosis.1 Clean,
unfavorable outcomes. Infection remains the most common com-
thoroughly irrigated, and debrided wounds with a good blood
plication of a retained foreign body, even when the object itself is
supply do not require antibiotics and may be sutured closed after
not contaminated. Aseptic technique and avoidance of excessively
removal of the foreign body. Patients should be followed up in 5 to
prolonged manipulation and searching for embedded foreign bod-
7 days for suture removal.
ies are important to prevent introducing infection into a previously
If complete cleansing of the wound is not assured or if the wound
sterile area. In cases where the foreign body cannot be found, it may
is at significant risk for infection for other reasons, delayed primary
be necessary, although less than ideal, to wait for abscess formation
closure or healing by secondary intention should be considered.12,87
in order to pinpoint the location of an object at a later time.3 Referral
Delayed primary closure involves packing the wound open for 4 to
for additional imaging and removal may be appropriate. The patient
5 days, after which it is reassessed and closed primarily if the edema
must be advised in detail of the likely course, and follow-up must be
has resolved, no infection is present, and exudate has been removed.
assured and documented.
This technique results in minimal tissue damage. It is especially use-
ful in clean contaminated and contaminated wounds, achieving a
90% success rate in appropriate patients. SUMMARY
Antibiotic therapy may be considered in those with wounds
that are at significant risk for infection. But, antibiotics are not a Virtually all embedded subcutaneous foreign bodies should be
replacement for proper wound care. Infection rates for traumatic identified and located with rigorous assessment of each and every
wounds range from 4.5% to 6.3%. Those patients who are immu- traumatic wound and a high index of suspicion. The history and
nocompromised, have puncture wounds, crush injuries, open frac- physical examination should guide the search for retained foreign
tures, bites, burns, frostbite, or wounds that involve tendons and bodies and the approach to locating them. The majority of for-
cartilage as well as those wounds contaminated with feces, soil, eign bodies are visible on plain radiographs. Wounds for which a
saliva should be considered high risk and should be considered for radiopaque foreign body may be retained should be imaged with
antibiotic therapy.88,89 Close follow-up is especially important in standard radiographs utilizing a soft tissue technique. Bedside
these patients. Prophylaxis for endocarditis is not recommended ultrasound should be utilized to assist in the identification and
unless foreign body removal is undertaken through an area of an removal of subcutaneous foreign bodies. Additional diagnostic
established infection.90 Splint the involved extremity if the foreign imaging with CT, ultrasound, or MRI may be indicated if the sus-
body is near a joint, a highly mobile region, or a vital structure to pected foreign body is likely to be radiolucent or is not adequately
prevent injury and/or migration of the foreign body if the patient identified. Once identified and located, several techniques are avail-
is referred for delayed removal.8 A more complete discussion on able to aid in localization and removal. A decision must be made
wound cleansing, wound irrigation, and the general principles of regarding the necessity of immediate or urgent removal in the
wound management can be found in Chapter 92. Emergency Department or by referral to a specialist. Inert foreign
bodies that are unlikely to cause long-term complications may be
left in situ with information provided to the patient explaining the
TETANUS PROPHYLAXIS
reasoning behind this conservative approach. Appropriate wound
Tetanus prophylaxis must be considered for wounds involving care is crucial to satisfactory healing, and postprocedure follow-up
foreign bodies. Wounds contaminated with feces, soil, or saliva, must be assured.
Ultrasound-Guided
98 Foreign Body Identification
and Removal
Daniel S. Morrison
INTRODUCTION
Retained foreign bodies are associated with up to 1.9% of all
wounds.1 The presence of a foreign body in a wound increases the
incidence of a wound infection.2 Retained foreign bodies are also
a major cause of litigation against Emergency Physicians.3,4 A high
index of suspicion for a retained foreign body must be maintained
whenever there is the potential for a foreign body in a wound.5,6 This
chapter focuses on ultrasound-guided identification and removal of
subcutaneous foreign bodies.
Foreign bodies may be small, leave no skin entry marks, and con-
sist of many different types of material. Almost any object (solid,
liquid, or gas) can become a foreign body and present itself in a FIGURE 98-1. US image of a subcutaneous pebble. Notice the hyperechoic short
location where it should not reside. Standard radiographs and fluo- radius and tight curvature. The pebble casts a strong acoustic shadow as it blocks
roscopy are good at identifying radiopaque objects such as metal, transmission of the US beam.
gravel, and glass.7–13 The ability of these techniques to identify a
foreign body varies by the size and composition of the foreign
body.9 MRI and CT are useful to detect foreign bodies.12,14,15 These
are expensive imaging modalities and the images vary depend- INDICATIONS
ing upon the length of time the foreign body has been present.15
Certain foreign bodies may produce artifacts that diminish the Patients with a foreign body sensation or soft tissue mass should
MRI and CT image qualities.12 Plastic, hair, vegetative material, be considered to have a foreign body until ruled out.5,16 Foreign
and rubber are not radiopaque and are not routinely identified on bodies can migrate great distances from the original inser-
radiographs.6–8,10–13,16–18 Ultrasound (US) is able to identify radi- tion site requiring the Emergency Physician to maintain a high
opaque foreign bodies. US can also detect foreign bodies that are index of suspicion for a foreign body.39 Any patient in which the
not radiopaque due to their different echotextures in relation to Emergency Physician has any index of suspicion for a foreign body
surrounding structures.6,8,14–30 should have additional investigations. Wood, thorns, spines, veg-
etative foreign bodies, dirt, clothing, and heavily contaminated
foreign bodies should be removed immediately, as should those
ANATOMY AND PATHOPHYSIOLOGY with potential for migration or entrance into the systemic circula-
tion. It is generally believed that glass, metal, and plastic are inert
Foreign bodies can be present in almost any part of the body. Foreign and can be removed electively as they tend to be encysted by scar
bodies can be detected with US even when they are found in nontra- tissue. Their removal is dependent on the specific situation, phy-
ditional places. They have been identified in the eye,31 esophagus,29 sician preference, and patient characteristics. Patients who have
and tongue32 with US. Foreign bodies isolated to small spaces, such
as in the web spaces of the hand, may not be identified due to the
size of the US probe footprint and the difficult anatomic location
to scan.26
Not diagnosing foreign bodies can be dangerous for the patient
and lead to an increased risk of complications. Legislation to intro-
duce an aluminum penny into circulation in the United States in
1973 was defeated in part by Pediatricians and Pediatric Radiologists
concern that these new coins would not be easily identified on
radiographs.33 Patients with retained lead foreign bodies can have
statistically significant elevated blood lead levels as compared with
Hyperechoic
matched controls.34
upper surface
Foreign bodies have specific US characteristics. Smooth and flat
surfaces typically produce a dirty shadowing or reverberation arti-
fact.35,36 Irregular surfaces with a small radius or curvature produce
a more clean shadow (Figure 98-1). Glass and metal typically pro- Reverberation
duce a ring-down or reverberation artifact11,23,28,29,35,37 (Figure 98-2). artifact
A wood foreign body produces a bright echogenic reflection with a
strong acoustic shadow6,11,29,38 (Figure 98-3). Foreign bodies resid-
ing in soft tissue longer than 24 hours can cause an inflammatory
reaction, which creates a hypoechoic rim around the echogenic for- FIGURE 98-2. US image of a subcutaneous metallic BB. The BB is hyperechoic
eign body (Figure 98-4).35 and produces a reverberation artifact.
CHAPTER 98: Ultrasound-Guided Foreign Body Identification and Removal 677
A B
FIGURE 98-3. US image of a subcutaneous wood foreign body. The wood produces a strong hyperechoic reflection and a hypoechoic acoustic shadow. A. Long axis US
view. B. Short axis US view.
persistent pain, neuropraxia, impairment of function, limitation EQUIPMENT

of range of motion of a joint, or psychological distress should have
the foreign body removed. Foreign bodies adjacent to bone can • US machine
cause osteomyelitis and should be removed within 96 hours.40 Any • High frequency linear US probe
patient in whom a foreign body, especially wood, was removed • Sterile US probe cover or glove
should have a further investigation to ensure there are no addi-
tional foreign bodies or a fragment of the removed foreign body • Skin cleansing solution (chlorhexidine or povidone iodine)
present.18 • Sterile US gel (or other type of sterile gel, i.e., Surgilube)
CONTRAINDICATIONS • Suture kit or individual components (sterile drape, gauze pads,
US is a safe imaging modality without any known ionizing radia- hemostat, and forceps)
tion. There are no known contraindications to using US to identify • Local anesthetic solution, usually lidocaine
and remove a foreign body. • 5 mL syringes
• 18 gauge needle to draw up local anesthetic solution
• Skin marking pen
• Paperclips
• Stand-off pad (or a 50 mL or 100 mL saline bag)
PATIENT PREPARATION
Obtain informed consent in which the risks, benefits, and any alter-
native treatment modalities are discussed. Cleanse the skin of any
dirt and debris. Apply a liberal amount of US gel over the area in
which the foreign body is suspected. Use a high frequency linear
US probe to search for the foreign body. Look for signs of the for-
eign body such as reverberation artifact, comet-tail artifact, acoustic
shadowing, a hypoechoic rim surrounding an echogenic structure,
or any other signs associated with foreign bodies.
Foreign bodies may be very superficial. It may be necessary to
change the focal zone on the US machine. An acoustic interface
may assist in locating a superficial foreign body. Apply a stand-off
pad over the site of the foreign body. This can be either a commer-
FIGURE 98-4. US image of a subcutaneous wood foreign body that has been in cially available stand-off pad, a small saline bag in which the air is
place for over 24 hours. The inflammatory reaction forms an anechoic rim around removed, or a glove filled with saline or US gel.17,41 The water bath
the foreign body (Courtesy of James W. Tsung, MD, MPH). technique works well for the hands and feet. Place the body part
A B
FIGURE 98-5. Paper clip localization of a foreign body. The wood foreign body has a bright echogenic reflection and casts an acoustic shadow. The paper clip casts a ring-
down or reverberation artifact that is lined up over the leading edge or most superficial aspect of the foreign body. A. Long axis US view. B. Short axis US view.
in a water-filled container. Place the US probe in the water-filled approximately 3 to 4 mm proximal to the skin markings. Aim the
container without actually contacting the patient’s skin. Identify the syringe containing the local anesthetic solution downward and in
presence of a foreign body. Once identified, it must be localized to the direction of the foreign body. Slowly insert and advance the nee-
make removal easier for the patient and the Emergency Physician. dle through the skin mark under US guidance while slowly injecting
a small volume of local anesthetic solution. The injection of local
anesthetic solution around the foreign body creates a hypoechoic
TECHNIQUE halo that helps with the identification of the foreign body. Stop
advancing the needle when the tip reaches the foreign body. Remove
PAPER CLIP LOCALIZATION AND REMOVAL the needle without moving the US probe.
Since the foreign body is located under the skin, its location Use a #11 scalpel blade to make a small skin incision just proximal
should be marked on the patient’s skin. It is helpful to use a metal to the skin mark and in an area that has been previously anesthe-
foreign body, such as a paper clip, to create a shadow to locate the tized. Insert the jaws of a closed hemostat or the arms of a closed
foreign body. The metal paper clip will cast a distinct shadow. alligator forceps into the skin incision. Advance the instrument
Identify the foreign body on US. Place the US probe on the under US guidance and bluntly dissect down to the foreign body.
patient’s skin above the foreign body. Turn the US probe so its long Align the tip of the instrument with the leading edge of the foreign
axis is aligned with the long axis of the foreign body. Insert the tip body (Figure 98-6). Open the instrument, grasp the foreign body,
of an unfolded paper clip between the US probe and the skin sur- and remove it.
face. Slowly advance the paper clip until the shadow it casts aligns
with the leading edge (the most superficial aspect) of the foreign
body (Figure 98-5). Use a skin marker to mark this location on the
patient’s skin. Rotate the US probe 90° to visualize the short axis
or cross-sectional view of the foreign body. Insert the tip of the
unfolded paper clip between the US probe and the patient’s skin.
Mark the location on the patient’s skin where the shadow cast by
the paper clip aligns with the leading edge of the foreign body. The
intersection of these two lines is where the leading edge of the for-
eign body resides under the skin.
Prepare to remove the foreign body. Prepare a 5 mL syringe with
a 27 gauge needle and local anesthetic solution. Cleanse the patient’s
skin with chlorhexidine or povidone iodine solution and allow it to
dry. Apply sterile drapes to form a sterile field. Inject local anesthetic
solution subcutaneously around the skin markings over the leading
edge of the foreign body.
Prepare the US probe. Apply US gel to the footprint of the US
probe. Apply a sterile probe cover or a sterile glove over the US probe.
Squeeze any air out of the space between the US probe and the cover.
Apply sterile US gel on the probe cover.
The Emergency Physician should don sterile gloves. The use of a
hat, face mask, and sterile gown is not necessary for this procedure. FIGURE 98-6. Retrieval of the foreign body. US image of the forceps approaching
Grasp the US probe with the nondominant hand. Align the long a wood foreign body. Note that the arms of the forceps are open and in line with
axis of the US probe along the long axis of the foreign body, and the foreign body.
CHAPTER 99: Tick Removal 679
NEEDLE LOCALIZATION AND REMOVAL

Tick Removal
Identify the foreign body using US. Cleanse the skin, apply sterile
drapes, prepare the syringe, and prepare the US probe as described
above. Infiltrate local anesthetic solution subcutaneously in the area
99 Zach Kassutto
overlying the foreign body. Align the long axis of the US probe with
the long axis of the foreign body. Insert a 27 gauge needle in front of INTRODUCTION
the US probe. Slowly advance the needle under US guidance until its
tip is against the foreign body. Release the needle with the dominant Ticks are blood-feeding external parasites (Figure 99-1). Ticks are
hand and grasp a #11 scalpel. Insert the #11 scalpel blade along the a significant infectious disease problem in the United States as well
needle until the tip of the blade is at the tip of the needle. Remove as worldwide. They have been implicated as vectors in the transmis-
the scalpel blade and needle without moving the US probe. Insert sion of many diseases including Lyme disease, ehrlichiosis, babe-
a forceps, hemostat, or alligator forceps along the incision track siosis, Rocky Mountain spotted fever, tularemia, tick paralysis, and
under US guidance. Open the instrument, grasp the foreign body, tick-borne relapsing fever. Disease transmission is postulated to
and remove it. occur when stomach contents and saliva from the tick are intro-
duced into the host during the blood-feeding process. There is sig-
ASSESSMENT nificance in how long a tick has been attached and how quickly a
feeding tick can be removed to the transmission of tick-borne dis-
It is important to rescan the area after removal of the foreign eases. Early removal is felt to limit the transmission of disease. For
body to ensure there is no additional foreign body or a retained example, current entomological thinking suggests that the tick must
piece of the original foreign body which needs to be retrieved. be attached for at least 24 hours in order to transmit B. burgdorferi,
Foreign bodies may not be removed in their entirety. A second for- the spirochete responsible for Lyme disease.1
eign body may be present in an injury and not visible on the initial
US scans.
AFTERCARE There are two main families of ticks.2 Hard body ticks belong to
the Ixodidae family. Soft body ticks belong to the Argasidae family.
Ensure that the foreign body is completely removed. There are
Hard body ticks are responsible for the transmission of the majority
many different thoughts on the care of wounds. Copiously irri-
of human diseases and will be the focus of this chapter. Hard ticks
gate the area. A review of the Cochrane Database indicates that
pass through four life cycle stages from birth (egg, larva, nymph,
there is no evidence that using tap water to cleanse acute wounds
and adult). They require a blood meal in order to progress into the
in adults increases infection; while some evidence suggests that it
next stage of their development.
reduces infection rates.42 There is no strong evidence that cleansing
The bite of a tick is painless and often goes unnoticed unless the
wounds per se increases healing or reduces infection.42 Close any
tick is found attached to the skin. Ticks are often encountered in the
lacerations from the wound itself or from the procedure to remove
late spring, summer, and early fall. Ticks are more prevalent in rural
the foreign body. There is no strong evidence to support the use
and wooded areas. They like to feed in dark (covered) and moist
of antibiotics in simple non-bite wounds.43 Wounds associated with
areas of the body such as the axilla, groin, or scalp.
foreign bodies are at an increased risk for infection. Instruct the
Ticks have specialized mouthparts that make their removal dif-
patient to be aware of the signs and symptoms of an infection. In one
ficult (Figure 99-2).2 They screw their mouthparts into the skin
review, 44.4% of all subjects with a foreign body removed were pre-
in a clockwise direction. Mouthparts include the palps, the chelic-
scribed antibiotics.44 However, when consultants were utilized in the
erae, and the hypostome. The chelicerae are used to cut through the
care of these patients, this number rose to 84.4%.44 A short course
host’s epidermis and allow passage of the tick’s hypostome, through
of antibiotics may be appropriate to prevent iatrogenic septic com-
which the feeding takes place. Ticks attach themselves to their host
plications or sequelae caused by mobilization of the foreign body.45
by inserting the rod-like hypostome into the skin. The hypostome
COMPLICATIONS
Foreign bodies, as well as the procedures to remove them, have
been associated with infections (e.g., flexor synovitis, cellulitis,
gas gangrene, abscesses, osteomyelitis, fungal infections, and lym-
phangitis), laceration of adjacent structures (e.g., nerves and ten-
dons), neuropraxia, inclusion cysts, fractures, arthritis, and even an
angiosarcoma.13,23,40,46,47 Even though attempts are made to identify
and remove all foreign bodies, some of them may be missed. A
retained foreign body can lead to similar symptoms at a later time.48
Therefore, it is important to investigate and remove foreign bod-
ies in a timely manner.
SUMMARY
Foreign bodies are a major source of physician litigation. They are
often not detected on standard radiographs and can be associated
with complications. A high index of suspicion must be maintained
when the patient has a laceration, soft tissue mass, or foreign body
sensation. US can be used to identify and guide the removal of
foreign bodies in the Emergency Department. FIGURE 99-1. The tick.
Optional Equipment
Hypostome • Magnifying headlamp
Palp
Cement • 18 gauge needle
• 3 mL syringe with a 27 gauge needle
Epidermis • Skin biopsy punches
• #15 surgical scalpel blade on a handle
Dermis
• 5-0 nylon suture
• Specimen container with isopropyl alcohol
• Commercial tick removal device10
PATIENT PREPARATION
Explain the risks and benefits of the procedure to the patient and/or
their representative. Risks include failure to remove all tick parts and
infection. Obtain an informed consent for the procedure. Clean any
FIGURE 99-2. The specialized mouthparts of the tick.
dirt and debris from the skin. Apply povidone iodine or chlorhexi-
dine solution to the skin surrounding the tick and allow it to dry. An
alcohol swab can be used as a substitute.
has many backward pointing sharp barb-like projections that pre-
vent it from being pulled out. Additionally, some ticks secrete a TECHNIQUE
cement-like material around the hypostome to secure its attach-
ment to the host while it feeds. The longer the tick is attached, the Direct mechanical removal of the tick is the only recommended
more difficult it becomes to remove it intact. The tick releases its technique.4 Grasp the tick tightly with a fine forceps or mosquito
mouthparts from the host after the meal is complete. It can take hemostat at the tick’s head or mouthparts, as close to the patient’s
anywhere from hours to days for an adult tick to finish its blood skin as possible (Figure 99-3A). Do not crush, puncture, squeeze,
meal and detach from its host.4 or tear the ticks’ abdomen. Apply firm and upward pressure to
remove the tick (Figure 99-3B). Carefully examine the skin for
any remaining portions of the tick’s mouthparts. Gently grasp
INDICATIONS and remove any retained parts of the tick with a fine forceps or tease
Any tick found attached to the skin should be removed. Transmission them out with the tip of a sterile needle.
of bacteria, spirochetes, viruses, or other infectious agents is directly Direct traction is the preferred method, although some have sug-
related to length of time of attachment. Ticks attached less than gested that a rotary counterclockwise movement combined with the
24 hours are very low risk for transmission of disease.3 firm pull may be more effective.4 Another technique that has been
described suggests first rotating the tick two complete revolutions
around its axis to loosen its attachment prior to pulling it away from
CONTRAINDICATIONS the skin.5 The premise is that the twisting action will disengage the
There are no absolute or relative contraindications to the removal tick’s mouthparts. There is not enough information to recommend
of a tick. or refute these methods.
EQUIPMENT ALTERNATIVE TECHNIQUES

Required Equipment Some Emergency Physicians prefer a surgical technique to remove
the tick and its attachment to the skin to ensure that no fragments of
• Povidone iodine solution, chlorhexidine solution, or isopropyl
the tick mouthparts remain within the patient. Clean and prep the
alcohol swabs
skin. Inject 0.25 to 0.50 mL of local anesthetic solution subcutane-
• Gloves ously immediately underneath the tick’s mouthparts. Apply povi-
• Fine forceps or mosquito hemostat done iodine or chlorhexidine solution to the skin and allow it to
FIGURE 99-3. Removal of the tick. A. The tick is grasped

as close to the skin as possible. B. Firm upward pressure is
applied to remove the tick.
CHAPTER 100: Fishhook Removal 681
dry. Stretch the skin on each side of the tick with the nondominant outdoors, patients should be advised to wear clothes to cover their
hand. Apply the skin biopsy punch perpendicular to the skin. Make arms, legs, and torso; tuck the cuffs of pants into boots; apply a repel-
sure that the tick is centered within the skin biopsy punch. Advance lent (chemical or botanical in origin) or an insecticide to clothes and
the skin biopsy punch downward using a twisting (clockwise– exposed skin; and physically check for the presence of ticks at the
counterclockwise) motion until a loss of resistance is felt. The loss end of the activity or the end of the day.
of resistance indicates that the skin biopsy punch is through the
epidermis and at the level of the dermis. Remove the skin biopsy COMPLICATIONS
punch. Grasp and lift the punched skin plug with a forceps. Cut
the plug at the dermal-epidermal junction with an iris scissors or The major complication of the direct removal technique is the sepa-
a #15 scalpel blade. Alternatively, remove the tick and skin with a ration of the tick body from the embedded head. Leaving foreign
#15 surgical scalpel blade. At the Emergency Physician’s discretion, material in the wound can serve as a site for subsequent infec-
close the skin site with a single 5-0 nylon suture or leave it open to tion.5 Any remaining pieces of the tick should be removed using an
granulate and heal. 18 gauge needle, a skin biopsy punch, or sharp dissection with a #15
Patients or their family members may use variety of folk/home scalpel blade.
therapies in their efforts to either passively or actively remove ticks. Inadvertent crushing of the tick may allow stomach contents or
Techniques that involve coating the tick with noxious materials such saliva from the tick to enter the wound. It is theorized that grasp-
as kerosene, lidocaine, or nail polish to cause the tick to voluntarily ing the tick too distal to its head, across its thorax/abdomen, could
withdraw its attachment have not been shown to be successful.4,6 induce regurgitation of stomach contents into the wound and
Techniques that attempt to suffocate the tick with petroleum jelly increases the risk of disease transmission.5
are also not felt to be useful due to the low respiratory rate of 3 to Local complications include bleeding and infection. The appli-
10 breaths per hour in a feeding tick.5 The use of a heated object, cation of direct pressure will control any bleeding. A cellulitis
e.g., a match tip or piece of metal, applied to the abdominal surface presents a few days after the bite and is often due to the ticks feed-
of the tick has not been shown to effect rapid tick detachment and ing process, skin contamination entering the bite site, or retained
presents a risk of burning the patient. Subcutaneous injection of mouthparts. Carefully inspect the bite site to ensure there are no
local anesthetic solution at the attachment site was studied and was retained mouthparts. If unsure, use a skin biopsy punch to remove
found to be ineffective in stimulating tick detachment.7 There are the bite site. Treat the cellulitis with oral antibiotics that cover typi-
specific devices that are commercially available and advertised to cal skin flora.
aid in manual tick removal. Some of these devices have been tested
and are not felt to offer any advantage over forceps removal.8–10 SUMMARY
Ticks are a vector for numerous serious diseases and should be
ASSESSMENT removed from the skin as soon as they are identified. Disease
After removing the tick, carefully inspect the bite site to ensure no transmission is felt unlikely if the tick has been attached less than
foreign material has been retained. Ticks can usually be discarded 24 hours. The only recommended technique for tick removal is
as testing of the tick is usually not indicated. If testing is desired, manual detachment using forceps.
place the tick in a specimen container with isopropyl alcohol until
testing can be performed by a laboratory or the local public health
department.
AFTERCARE Fishhook Removal

Cleanse the area with a mild disinfectant or soap and water.
Administer tetanus prophylaxis if the patient’s immunization his-
100 Eric F. Reichman and Renee C. Hamilton
tory is not up-to-date. The appearance of any rash or the occurrence
of any febrile illness 2 to 12 days after a documented tick exposure
should prompt further medical follow-up. Provide the patient infor- INTRODUCTION
mation regarding the signs and symptoms of Lyme disease and/or Depending on practice location and season of the year, the presen-
other tick-borne diseases seen in your specific geographical area. tation of a fishhook embedded in the subcutaneous tissue can be
The patient should inspect the site twice a day for signs of an infec- common. The patient or a well-meaning bystander will often have
tion. They should return to the Emergency Department or their already attempted removal that was prevented by the hook’s barb.
Primary Care Physician if they develop redness, tenderness, swell- The ensuing tissue trauma and patient anxiety can complicate the
ing, a discharge, or a rash at the bite site. task for the Emergency Physician. Removal can be difficult as a fish-
A detailed discussion identifying the types of ticks or the indi- hook is designed not to pull out of a fish’s mouth. Several methods
cations for prophylactic antibiotic therapy is beyond the scope of of removal have been described.1–9 The method chosen depends on
this chapter. Consult the current medical literature or an Infectious the type and size of the hook, the depth of penetration, and the ana-
Disease Specialist regarding these questions. The use of prophy- tomical location of injury.
lactic oral antibiotics to cover typical skin flora or Lyme disease is
not routinely recommended. If antibiotics are prescribed, options
include 5 to 7 days of: doxycycline (100 mg bid), tetracycline
(500 mg qid), amoxicillin-clavulanate (400 to 875 mg bid), levo- Most fishhooks become embedded in the skin and subcutaneous
floxacin (500 mg qd), or erythromycin (125 to 500 mg qid). Do not soft tissue. The anatomy of a fishhook is simple (Figure 100-1). The
prescribe doxycycline, tetracycline, or levofloxacin in children and long, straight section is known as the shaft. The proximal end of the
pregnant women to avoid associated complications. shaft has a closed circle, the eyelet, where the fishing wire attaches.
Patients should be educated about ticks and preventative mea- The distal end of the shaft curves in a semicircle known as the belly
sures to avoid tick bites. Prevention is the best protection. When of the fishhook. The belly tapers into a sharp point with a barb. The
• Wire cutter
• Needle driver
• Hemostat
• 18 gauge needle
• #11 scalpel blade on a handle
• String, fishing line, or a strong silk tie, at least 50 cm in length
• Tongue depressors
• Safety glasses/goggles or a face mask with an eye shield
PATIENT PREPARATION
FIGURE 100-1. Anatomy of a fishhook. Explain the risks and benefits of the procedure to the patient and/
or their representative. Ask the patient to describe the type of fish-
hook embedded, especially in regards to the number and location
of the barbs. Ask the patient to draw a picture of the fishhook or
barb is usually located on the inner surface of the hook, pointing provide you with a similar one to examine. The number and loca-
away from the tip. The barb, once pierced through the skin, becomes tion of the barbs will help in determining the appropriate removal
embedded within the tissue and prevents removal of the fishhook. technique. Obtain a signed consent form prior to beginning the
Additional barbs may be located along the shaft of the fishhook. procedure. Cleanse the skin of any dirt and debris. Apply povi-
done iodine or chlorhexidine solution to the skin surrounding the
INDICATIONS embedded fishhook and allow it to dry. The Emergency Physician
should wear eye protection when removing a fishhook to prevent
Any embedded fishhook must be removed from the body. There injuring themself. At minimum, wear safety glasses or goggles. If
is no reason a fishhook should not be removed by the Emergency available, a face mask with an eye shield is preferred.
Physician if no contraindication exists.
TECHNIQUES
CONTRAINDICATIONS
There are no absolute contraindications to fishhook removal. PULL-THROUGH TECHNIQUE
Occasionally, the procedure should be referred to a consultant.
This is the traditional method that is used for larger sized hooks
Globe perforation or laceration requires emergent consultation
embedded in the soft tissue with the barb near the skin surface. This
with an Ophthalmologist. Place the patient supine with a shield,
is the preferred technique for fishhooks embedded in the ear, a joint,
not a patch, over the eye. Please see Chapter 161 for the complete
or in the nasal cartilages. Experienced fishermen often perform this
details regarding eye patching and eye shields. Penetration of, or
technique in the field, as they would hate to lose prime fishing time
near, vital structures (e.g., the neck, groin, or major neurovascu-
to go to the Emergency Department.
lar structures) should be given consideration for the appropriate
Identify the barbed end of the fishhook, located under the skin
surgical consultation prior to removal of the fishhook.
surface. Inject 0.5 to 1.0 mL of local anesthetic solution into the
subcutaneous tissue overlying the barbed end of the fishhook to
EQUIPMENT raise a skin wheal (Figure 100-2A). Allow 3 to 4 minutes for the
local anesthetic solution to take effect. Grasp the shaft of the fish-
hook with a needle driver (Figure 100-2B). Advance the fishhook
• Local anesthetic solution without epinephrine until the barbed end protrudes through the anesthetized skin
• 3 mL syringe armed with a 25 gauge needle (Figure 100-2B). Securely clamp a hemostat over the barb. This
FIGURE 100-2. The pull-through technique for fishhook removal. A. Subcutaneous anesthetic is placed over the barb. B. The fishhook is advanced until the barb protrudes
from the skin. C. A hemostat is placed over the barb before it is cut off with wire cutters. D. The fishhook is removed.
CHAPTER 100: Fishhook Removal 683
FIGURE 100-3. An alternative pull-through technique for the removal of a multibarbed fishhook. A. Subcutaneous anesthetic is placed over the barb. B. The fishhook is
advanced until all of the proximal barbs are under the skin. C. The shaft is cut. D. The fishhook is removed.
will prevent it from becoming a projectile when cut and injuring An alternative method is to insert a #11 scalpel blade parallel to
someone. Cut the belly of the fishhook just proximal to the barbed the shaft of the fishhook at the site it enters the skin. Advance the
end with a wire cutter (Figure 100-2C). Grasp the shaft of the fish- scalpel blade until it is adjacent to the barb. Withdraw the fishhook
hook with the needle driver and withdraw it along its direction of and scalpel through the tract. The barb will be resting against the
entry (Figure 100-2D). scalpel blade and not get embedded in the subcutaneous tissues.
Occasionally, fishhooks may have additional barbs on the shaft This method is not recommended due to the blind insertion of a
or the belly (Figure 100-3). Inject 0.5 to 1.0 mL of local anes- scalpel blade into the soft tissues and the potential for secondary
thetic solution into the subcutaneous tissue overlying the barbed injury.
end of the fishhook (Figure 100-3A). Allow 3 to 4 minutes for
the local anesthetic solution to take effect. Grasp the shaft of the STRING-YANK TECHNIQUE
fishhook with a needle driver (Figure 100-3B). Advance the fish-
hook until the barbed end protrudes through the anesthetized This method has been extensively described and is often performed
skin (Figure 100-3B). Continue to advance the fishhook until by experienced fishermen in the field. It is rapid, effective, easy to
all the barbs on the belly and shaft are below the skin surface perform, and relatively painless. This technique should not be used
(Figure 100-3B). Securely clamp a hemostat over the proximal for fishhooks in the ear, nose, or a joint cavity. The Emergency
shaft of the fishhook (Figure 100-3C). Cut the shaft of the fish- Physician should take caution for themselves, the patient, and
hook at the level of the skin with a wire cutter (Figure 100-3C). bystanders. The hook often forcibly flies out of the patient.
Grasp the fishhook just proximal to the barbed end with the nee- Ensure the suspected path of the fishhook is clear. Eye protec-
dle driver and pull the remainder of the fishhook out of the tissues tion is recommended with this technique for both the Emergency
(Figure 100-3D). Physician and the patient.
Place the body part that the fishhook entered firmly on a flat sur-
face. Local anesthetic solution can be infiltrated, at the Emergency
BARB-SHEATH TECHNIQUE
Physicians discretion, into the area where the fishhook enters the
This method is reserved for small fishhooks embedded near the skin. Wrap the midpoint of a long string around the belly of the
skin surface. This technique should not be used for fishhooks in fishhook at the site it enters the skin (Figure 100-5A). The string
the ear, nose, or a joint cavity. Inject 0.5 to 1.0 mL of local anes- ends should be firmly wrapped around and secured to the index and
thetic solution to form a wheal subcutaneously around the area middle fingers of the Emergency Physician’s dominant hand. Use
where the fishhook enters the skin. Insert an 18 gauge needle along the gloved nondominant thumb or index finger to firmly depress
the entrance wound and aimed toward the barb (Figure 100-4A). the shaft of the fishhook against the skin, until slight resistance is
The bevel of the needle should face the barb with the goal being to met (Figure 100-5B). The shaft should be parallel to the skin and
engage and cover the barb. Advance the needle and engage the barb touching the skin. This will disengage the barb from the soft tissues.
in the core of the needle (Figure 100-4B). Gently twist and pull the Quickly and firmly jerk the string (Figure 100-5C). This maneuver
hook back through the entrance wound while the needle covers the will release the fishhook from the subcutaneous tissues and pull it
barb (Figure 100-4C). out through the entry wound.
FIGURE 100-4. The barb-sheath technique for fishhook removal. A. Insert the needle through the entrance wound and aimed toward the barb. B. Advance the needle
through the entry site to catch the barb in the core of the needle. C. The needle and fishhook are removed as a unit.
FIGURE 100-5. The string-yank technique for fishhook removal. A. A string is wrapped around the belly of the fishhook. B. The shaft of the fishhook is depressed until
resistance is encountered. The shaft should be parallel to the skin and touching the skin. C. A quick tug on the string will remove the fishhook.
Alternatively, the Emergency Physician may use two tongue SUMMARY

depressors to provide secure traction to the string. Wrap each end of
the string around one tongue depressor. Instruct an assistant to gen- Fishhook removal can be accomplished by one of several simple
tly depress the fishhook shaft against the skin while the Emergency techniques. It can be performed in the Emergency Department, the
Physician jerks the string.6 office, or the field with minimal supplies. Almost painless removal
is possible in most cases. This procedure is gratifying both for the
AFTERCARE patient and the Emergency Physician.
The wound should be cleaned of any blood and a dry dressing

applied. Administer tetanus prophylaxis if the immunization his-
tory is not up-to-date. A radiograph is indicated if there is any
suspicion of a retained foreign body. Acetaminophen or nonsteroi-
dal anti-inflammatory drugs will provide any required analgesia.
Ring Removal
Instruct the patient to clean the area with warm soapy water three
times a day and to keep the wound covered until healed. Instruct
the patient as to the signs of infection. They should return to the
101 Steven H. Bowman
Emergency Department, or their physician, if signs of an infection
develop. Routine follow-up is often not required unless the fishhook
penetrated the ear, nose, or a joint.
INTRODUCTION
Antibiotic prophylaxis remains controversial.1,2 The use of The need to remove a ring is not uncommon in the Emergency
antibiotics is left to the discretion of the Emergency Physician Department. Patients may present with an initial primary com-
and should include consideration for the anatomic site of injury, plaint that they can no longer remove a ring or that a ring has
depth of penetration, evidence of gross contamination, and fac- become painful. A variety of conditions may necessitate the
tors that may compromise the patient’s immunity (e.g., diabetes urgent removal of a ring, including swelling from extremity
mellitus, HIV infection, steroid use, or malignancy). If antibiotic trauma, infections or burns, increases in total volume status,
prophylaxis is chosen, prescribe a broad spectrum antibiotic such and allergic reactions. Swelling of the digit can rapidly progress,
as trimethoprim-sulfamethoxazole or doxycycline. These will causing the ring to become a constricting band and compromise
provide good coverage against gram-negative organisms typically blood flow to the digit. Critically ill patients undergoing admis-
associated with water recreation injuries, as well as some coverage sion to intensive care settings or emergency surgery may need to
against MRSA and other community acquired infections.7 Adding have rings removed urgently. The Emergency Physician’s goal is
ciprofloxacin for pseudomonas coverage may also be considered, to remove the ring in a timely manner and not cause additional
as pseudomonas and its subtypes are commonly found in soil and injury. The information in this chapter applies to rings on the
freshwater.6 fingers and toes.
COMPLICATIONS ANATOMY AND PATHOPHYSIOLOGY

Complications include infection or damage to the surrounding tis- The second through fourth digits receive their blood supply
sue. Infection is often due to either the contaminated fishhook inoc- through four vessels: the palmar radial digital arteries, the palmar
ulating the tissues or the fishhook penetrating contaminated skin. ulnar digital arteries, the dorsal radial digital arteries, and the dor-
Using proper removal techniques will minimize, but not eliminate, sal ulnar digital arteries. The thumb receives its blood supply from
any damage to the soft tissues. the dorsalis pollicis and princeps pollicis arteries. Blood returns
Use caution when extracting fishhooks to avoid secondary injury from the digits via the dorsal digital veins. When the digit is com-
to bystanders, the patient, or the Emergency Physician. Protective pressed for prolonged periods by a tight-fitting ring, which acts as
eyewear should be worn with all three techniques of fishhook a tourniquet, venous return is impeded and swelling ensues. The
extraction. Ocular injury has been reported to occur during this swelling results in greater compression and further propagation of
procedure.2 Fishhooks have been surgically extracted from the this cycle. In theory, the increased swelling will eventually impede
hypopharynx and the intestine.8,9 A surgical face mask with a face the arterial supply to the digit.
shield is another mode of protection that we recommend. When The greatest circumference of the finger is at the proximal inter-
using the pull-through technique, clamping a hemostat to the phalangeal (PIP) joint. Rings usually become entrapped proximal
exposed portion of the fishhook that is to be cut off will prevent to the PIP joint. Skin breakdown and tissue necrosis occur if the
flying shrapnel. constricting ring is not removed. Left untreated, the digit is at risk
CHAPTER 101: Ring Removal 685
for infections such as cellulitis, tenosynovitis, and osteomyelitis. In Glove Technique

severe cases, the digit’s viability may be threatened. There are several • Rubber gloves
case reports of rings that have become embedded in the soft tissue
• Lubricant (K-Y jelly, Surgilube, petrolatum, mineral oil, or liquid
of the digits.1–5
soap)
Most patients will experience pain and seek medical attention
prior to the development of severe complications. Patients with an • Mosquito hemostat
altered mental status, psychiatric illness, peripheral neuropathies, • Scissors
peripheral vascular disease, or other chronic disability may present
later with complications.1,2,4,5 Ring Cutter Technique
• Ring cutter, manually operated or battery-powered
• Steinman pin cutter if a ring cutter is not available
INDICATIONS
• Two large hemostats or needle drivers
Rings are usually removed to prevent ischemia of a digit. Remove
• Pliers (optional)
a ring if the digit shows any signs of neurovascular compromise
such as decreased capillary refill, decreased pulse wave on pulse Vice-grips Pliers Technique
oximetry, mottling, paleness, paresthesias, or diminished sensa- • Medium size vice-grip pliers
tion. Rings should be removed whenever patients complain that
a ring is causing pain. Generally, even a tight-fitting ring will not Miscellaneous Supplies
be painful. Rings must be removed from any injured digit where • Ice water
edema is a possible consequence. Examples include sprains, con- • Penrose drain or IV tourniquet
tusions, fractures, lacerations, crush injuries, and burns. Rings
should be removed from all digits on the involved side for any • Basin or zip-lock bag for ice water
extremity injury above the digits and where edema of the distal
extremity is a possible consequence. Other nontraumatic condi-
tions that may necessitate emergent ring removal include infec- PATIENT PREPARATION
tions of the upper or lower extremity, acute increases in volume Place the patient sitting upright or in a semi-recumbent posi-
status, and allergic reactions. A patient may present and request tion. Position their hand on a bedside procedure table. Explain
a ring be removed that is tight and can no longer be taken off. the procedure to the patient and/or their representative. A signed
Consider the need for urgent ring removal with markedly informed consent is not required for the removal of a ring.
decreased levels of consciousness and in all critically ill patients, Analgesia should be provided in the form of a metacarpal block
particularly those being admitted to intensive care settings or for patients who are complaining of pain. Refer to Chapter 126 for
undergoing emergent surgery. the complete details regarding a metacarpal block.
The removal of a tight ring should be considered a two-step
process: first reduce the edema in the finger, then remove the
CONTRAINDICATIONS
ring.6 Instruct the patient to elevate the affected hand or foot to
There are no absolute contraindications to removing a ring. It is reduce edema prior to any attempts at ring removal. Use a fin-
important to note that certain techniques may be more applicable ger trap to elevate the affected extremity if the patient has dif-
than others, depending on the individual patient. ficulty or cannot keep the extremity elevated. Consider soaking
the hand or foot in ice water for 5 to 10 minutes to reduce edema.
A Penrose drain, piece of tape, gauze, or elastic bandage can be
EQUIPMENT wrapped around the finger, from distal to proximal, to further
reduce swelling.
Metacarpal Block
The simplest and most effective way to remove a ring from a
• Povidone iodine or chlorhexidine solution, or an isopropyl alco- finger is simply to cut the ring using a ring cutter. Reassure the
hol swab patient that cut rings can be repaired by a jeweler. However,
• 3 mL syringe patients may still be reluctant to have expensive rings or rings
• 25 or 27 gauge needle, 1 in. long with sentimental value removed in such a way. The practitioner
must consider time, the individual circumstances regarding the
• 3 to 5 mL local anesthetic solution without epinephrine entrapment, and which alternative techniques may be effective.
Lubricant and Caterpillar Techniques
• Lubricant (K-Y jelly, Surgilube, petrolatum, mineral oil, or liquid
soap) TECHNIQUES
String Technique LUBRICANT TECHNIQUE
• String (1-0 silk suture, cotton umbilical string, tracheal tape,
This technique works for mild cases of ring entrapment with
Penrose drain, or intravenous tourniquet)
minimal swelling and without significant trauma. Many patients
• Mosquito hemostat will attempt to remove the ring using some type of lubricant at
Rubber Band Technique home prior to presenting to the Emergency Department. Despite
this, the same technique may also be tried in the Emergency
• 3 to 4 mm wide rubber band
Department prior to attempting other techniques. Liberally apply
• Lubricant (K-Y jelly, Surgilube, petrolatum, mineral oil, or liquid a lubricant (e.g., K-Y jelly, Surgilube, petrolatum, mineral oil, or
soap) liquid soap) to the digit and beneath the ring. Attempt to advance
• Mosquito hemostat the ring over the PIP joint with steady traction.
FIGURE 101-2. The string technique. A. A string is passed between the ring and
the finger. B. The string distal to the ring is wound tightly around the finger and
continued distally to the level just below the PIP joint. C. The string proximal to the
ring is slowly unwound and moves the ring distally. D. When the ring passes the
PIP joint, it usually comes off without effort.
FIGURE 101-1. The caterpillar technique. A. The entire finger is lubricated. B. The
ring has been pushed down the proximal phalanx until it reaches the PIP joint.
Push the bottom of the ring up firmly while maintaining pressure. C. Swing the Pass a length of 1-0 silk suture or a piece of string underneath
top portion of the ring distally over the joint while maintaining upward pressure. the ring (Figure 101-2A). Avoid monofilament sutures and
D. Push down firmly while maintaining downward pressure. E. Swing the bottom smaller-size sutures as they may break or inadvertently cut the
portion of the ring proximally over the joint and remove the ring. patient if wound too tightly. Passage of the string or suture may
be facilitated with the use of a mosquito hemostat.8–10 Wind the
distal portion of the suture tightly around the digit in a closed
spiral (Figure 101-2B). There should be no interposition of skin
between the turns of the suture material so as to ensure even
CATERPILLAR TECHNIQUE compression of the skin and soft tissue. Continue the spiral dis-
tally to just beyond the PIP joint. Grasp the proximal end of the
This recently described technique is useful in that it requires
suture. Unwind the suture while maintaining traction in the distal
no additional materials other than lubricant (Figure 101-1).7
direction (Figure 101-2C). The ring will be pushed distally as the
Liberally apply a lubricant to the finger (Figure 101-1A). Slide
suture unwinds. The ring is easily removed once it clears the PIP
the ring down the proximal phalanx and just proximal to the PIP
joint (Figure 101-2D).
joint. Apply and maintain upward pressure on the bottom of the
Other materials—such as umbilical tape, cotton gauze, rub-
ring (Figure 101-1B). Simultaneously swing the upper portion of
ber intravenous tourniquets, or Penrose drains—have also been
the ring distally (Figure 101-1C). Pull the top of the ring over the
used.6,11,12 These materials have certain practical advantages. Since
PIP joint. Apply and maintain downward pressure on the top of the
they are wider than sutures, shorter lengths and fewer turns are
ring (Figure 101-1D). Simultaneously swing the lower portion of
required to encircle the finger. It is easier to wind these materials
the ring distally to free it (Figure 101-1E). Remove the ring from
around the digit without interposition of the skin between the turns
the finger. This “caterpillar motion” allows the ring to be slowly
(Figure 101-3).
advanced distally and ultimately removed.
Insert the umbilical tape under the ring, from distal to proximal,
with the aid of a mosquito hemostat (Figure 101-3A). Pull 6 to 7 cm
STRING TECHNIQUE of the umbilical tape proximal to the ring (Figure 101-3B). Wind
Several authors have extensively described the string technique and the distal portion of the umbilical tape tightly around the digit in
its modifications5,6,8,17 (Figure 101-2). This technique consists of a closed spiral (Figure 101-3C). There should be no interposition
using a “string” to compress the edematous tissue, exsanguinate the of skin between the turns of the umbilical tape. Continue to spi-
digit, and then facilitate the passage of the ring over the PIP joint. ral distally to just beyond the PIP joint (Figure 101-3C). Grasp the
This technique should be avoided if the patient has an associated proximal end of the umbilical tape. Unwind the proximal end of
finger laceration, finger fracture, or an embedded ring.8,9 the umbilical tape while maintaining traction in a distal direction
FIGURE 101-3. The string technique with umbilical tape. A. The umbilical tape is inserted under the ring with a mosquito hemostat. B. The umbilical tape is pulled through
to the other side of the ring. C. The umbilical tape distal to the ring is wound tightly around the finger to the level just below the PIP joint. D. The umbilical tape proximal
to the ring is slowly unwound and moves the ring distally. E. The ring passes the PIP joint. F. The ring is free and usually comes off without effort.
(Figure 101-3D). Continue to unwind the umbilical tape until the Choose a glove that fits the patient snugly. Use the patient’s other
ring passes the PIP joint (Figure 101-3E). The ring is easily removed hand to aid in choosing the right size glove. Cut the finger from a
once it clears the PIP joint (Figure 101-3F). glove to match the finger of the patient (Figure 101-5A). Cut off the
tip of the finger of the glove to create a cylinder (Figure 101-5A).
RUBBER BAND TECHNIQUE Slide the cylinder onto the patient’s finger. Advance the proximal
portion of the cylinder beneath the ring using a mosquito hemostat
This technique utilizes a 3 to 4 mm wide rubber band, which is (Figure 101-5B). Lubricate the cylinder and the ring with K-Y jelly,
used to apply traction on the ring to facilitate its passage over the Surgilube, petrolatum, mineral oil, or liquid soap. Pull the proximal
PIP joint10 (Figure 101-4). Though success has been reported using edges of the latex cylinder distally, with your fingers or mosquito
rubber bands, this technique should be reserved for less severe ring hemostats, to advance the ring distally (Figure 101-5C). Continue
entrapments. Avoid this technique if the patient has a laceration, a to pull on the proximal cylinder until the ring moves past the PIP
fracture, or an embedded ring. joint and falls off the finger.
Lubricate the finger liberally, as described above. Pass the rubber
band beneath the ring using a mosquito hemostat (Figures 101-4A RING CUTTER TECHNIQUE
& B). Position the rubber band so that equal lengths are on each
side of the ring (Figure 101-4C). Insert a finger through both loops The definitive method for ring removal is cutting the ring. The
of the rubber band (Figure 101-4D). Pull the loops of the rubber ring should be cut if the patient presents with an underlying injury,
band distally while simultaneously moving them circumferentially severe swelling, an embedded ring, or entrapment with nonjewelry
between the ring and the finger (Figure 101-4D). Continue the items. Cutting a ring is generally rapid and safe. A ring cutter can
motion until the ring is removed (Figure 101-4E). be used to cut rings made of gold, plastic, platinum, silver, stainless
steel, and titanium.
Many devices will cut rings. The standard rotary ring cut-
GLOVE TECHNIQUE
ter should be available in every Emergency Department
This technique has been advocated for use in patients with underly- (Figure 101-6). The ring cutter’s blade should be periodically
ing soft tissue injury to the finger.13,14 Its success is anecdotal. The inspected and it should be sharp. Battery-powered ring cutters are
glove technique uses a finger cut from an appropriately sized rubber also available (Figure 101-7) (Mooney & Co., Ashland, OR). The
glove (Figure 101-5). The glove finger provides mild compression, advantage of the powered ring cutters is that they are easy to use,
acts as a barrier to protect damaged soft tissue, and provides a “lead- lightweight, fast, powerful, can easily cut nonjewelry items, and do
ing edge” to guide the ring over the damaged tissues. Despite these not rely on the strength of the healthcare provider to use them. In
theoretical advantages, the glove technique may be no more effec- the absence of a ring cutter, another medical device that has been
tive than any other in cases of severe finger edema. used successfully to cut rings is the Steinman pin cutter.15 Our
FIGURE 101-4. The rubber band technique. A. A mosquito hemostat is passed below the ring and grasps the rubber band. B. The rubber band is pulled beneath the
ring and out the other side. C. The rubber band is positioned with equal lengths of loop on each side of the ring. D. Both loops of the rubber band are grasped and pulled
distally while it is simultaneously rotated circumferentially. E. When the ring passes the PIP joint, it usually comes off without effort.
Emergency Department also maintains a sharp pair of diagonal

pliers that can be effective at cutting small rings.
Pass the finger guard of the ring cutter between the ring and the
digit at the thinnest part of the ring (Figure 101-8). Care should be
taken to place the ring cutter correctly and avoid additional injury.
The ring may be squeezed using a heavy needle driver, hemostat,
or pliers to change its shape from round to oval to facilitate pas-
sage of the finger guard (Figure 101-9). This additional distortion
of the ring will not further exacerbate the entrapment.15 Lower the
cutting blade onto the ring. Turn the turn key to rotate the blade
while maintaining pressure on the ring. Continue turning the turn
key until the blade completely cuts through the ring. Pry the ring
open with two hemostats or needle drivers once it is completely cut
through and remove the ring. An alternative to one cut and prying
the ring open is to make two cuts on opposite sides of the ring so
that it falls apart in two pieces.
If an open wound is present, it should be irrigated with normal
saline to remove any small metal fragments that may result from the
cutting process. There has been a case report of a foreign body gran-
uloma caused by metal particles left in a finger wound in a patient
following ring removal.16
VICE-GRIP PLIERS TECHNIQUE

Many rings cannot be removed with the previously described tech-
niques. These rings can be of a material that also cannot be cut with
a carbide, diamond, or metal cutting disk on a ring cutter. This
FIGURE 101-5. The latex glove technique. A. The finger matching the one on includes rings made of ceramics, natural stone (e.g., jade or onyx),
which the ring is lodged is cut from an examination glove. B. The latex cylinder is and tungsten carbide. These rings can be removed by cracking them
put on the finger. The proximal edges of the cylinder are pulled under and proximal into pieces in a controlled fashion using a vice-grip pliers.
to the ring using a mosquito hemostat. C. The proximal edges of the latex cylinder A medium-sized vice-grip pliers is usually appropriate for
are slowly pulled distally to roll the ring off the finger. most ring sizes. Open the jaws of the vice-grip pliers. Adjust the
A B
FIGURE 101-6. Manually operated ring cutters. A. Examples of manually operated ring cutters. B. The anatomy of a ring cutter.
tightening screw so that the closed jaws of the vice-grips fit over tools such as heavy-duty saws and bolt cutters may be needed to
the ring (Figure 101-10). Close and clamp the vice grip so that the remove these objects. Battery-powered ring cutters may be ideal in
jaws close lightly on the ring. Release the jaws, turn the tighten- these situations. Power saws and Dremel tools with carbon blades
ing screw one-quarter of a turn, and reclamp the jaws on the ring. have been used to successfully remove hardened steel rings from a
Continue this process of releasing the jaws, turning the tightening patient’s fingers.5 If it becomes necessary to use a powered metal
screw one-quarter of a turn, and reclamping the jaws on different cutting device, additional care should be taken to protect the
places of the ring each time until a crack is heard. Keep continuing patient from secondary injury from the cutting element and the
this process of tightening the jaws and reclamping different areas heat these powered devices may generate.
of the ring until the ring breaks into pieces and falls off.
ASSESSMENT
ALTERNATIVE TECHNIQUES Thoroughly examine the finger for any injuries after the ring is
Patients may rarely present with other heavy circular objects on removed. Reassess perfusion to the digit by noting the capillary refill
their digits such as steel rings, nuts, or washers that cannot be time, the color, and the pulse oximeter reading on the affected digit
removed using a manually operated ring cutter. Powered cutting compared to adjacent fingers.
FIGURE 101-7. The GEM Ring Cutting System (Mooney & Co., Ashland, OR).
A battery-powered and motorized ring cutter. FIGURE 101-8. Ring removal using a manual ring cutter.
Check that the proper cutting disk is on the ring cutter and that it
is not dull or worn. Install fresh batteries or recharge them to maxi-
mize the power of the electric ring cutter. The ring, and the patient’s
finger, can become quite hot and burn the patient. Periodically
check the progress and make sure that the ring has not been cut
and you are now cutting the finger guard. Using a cutting disk that
is dull, worn, or incorrect can generate significant heat. Correct
these issues. Submerge the finger in ice water for a few minutes then
resume cutting the ring.
SUMMARY
Ring removal is a relatively straightforward and simple procedure.
In situations in which the ring is extremely difficult to remove, a
variety of potential approaches may assure success. Use of the ring
cutter is the most reliable and quickest technique. The decision to
use a ring cutter should be based upon the urgency with which the
ring must be removed and not upon the monetary or sentimental
value of the ring.
FIGURE 101-9. A pair of pliers is used to make the ring “oval” in shape. This may
facilitate the use of a ring cutter.
Subungual Hematoma
AFTERCARE
No specific aftercare is required following the ring removal process.
Elevation, nonsteroidal anti-inflammatory agents, and local wound
102 Evacuation
Steven H. Bowman
care are all that is necessary. Consultation with a Hand Surgeon,
Orthopedic Surgeon, Plastic Surgeon, or Podiatrist is recommended
in severe cases that include embedded rings, infections, vascular INTRODUCTION
compromise, and/or neurologic compromise. The aftercare is based The fingertips are sensitive, mobile, and prone to injury. Blunt
on any lacerations and/or fractures of the digit. The patient’s tetanus trauma to the tip of the finger or toe may result in a variety of inju-
immune status should be ascertained and, if the skin is broken, the ries including fractures, avulsions to the nail and nail apparatus,
appropriate tetanus prophylaxis administered. Instruct the patient contusions, lacerations, and amputations. The most common inju-
not to place any rings on the digit until the edema has completely ries to the distal fingers and toes are crush injuries. The most com-
resolved. Place the ring, and any pieces, in a specimen container and mon mechanisms of injury are closure of some type of door (car,
return it to the patient. house, etc.) on the finger, dropped objects on the fingers or toes,
hand tools, and power tools.
COMPLICATIONS Subungual hematomas often develop following blunt trauma
The direct complications of ring removal are minor compared to the to the distal finger or toe.1–3 They result from the accumulation of
complications that may occur from failure to remove a ring. Direct blood between the nail and the nail bed. Treatment of a subungual
complications include secondary injury to soft tissues, vascular hematoma is relatively straightforward, yet in some cases it is still
structures, and nerves and granuloma formation. This can be due controversial. It is important to understand the structure of the dis-
to passing objects and instruments under an extremely tight ring or tal finger or toe, to determine whether simple drainage will be suf-
from improperly used instruments to remove the ring. ficient management, and to consider how initial management may
Ring cutters have their own specific issues. It may cut too slowly. affect outcome.
Ensure that you are using the proper cutting technique. The cutting
disk may be worn, dull, or the wrong cutting disk for the material. ANATOMY AND PATHOPHYSIOLOGY
The distal digits of the fingers and toes and the nail apparatus are
complex structures (Figure 102-1). The perionychium is composed
of the nail bed and the surrounding soft tissue. The hyponychium
is the junction of the nail bed at the sterile matrix and the fingertip
skin beneath the distal margin of the nail. The eponychium is the
distal portion of the nail fold where it attaches to the proximal sur-
face of the nail. The lunule is the white arc seen in the proximal por-
tion of the nail. The nail bed consists of the germinal matrix on the
proximal ventral floor of the nail fold and the sterile matrix, which
extends from the lunule to the hyponychium. The germinal matrix
is primarily responsible for the growth of the nail, with a significant
contribution from the sterile matrix.4,5 The nail bed must be smooth
for normal nail growth. A nail matrix that has not been well approx-
imated to minimize scar formation may develop a deformed nail.1,3–8
The nail bed receives its blood supply from the two terminal
FIGURE 101-10. A vice-grip pliers can be used to remove hard or brittle rings. branches of the volar digital artery, which communicate to form
CHAPTER 102: Subungual Hematoma Evacuation 691
A Lunule Lateral nail fold to the injury itself and the increased pressure from the hematoma.
The hematoma appears as a black-and-blue or black-and-purple
Distal Body of nail area under the nail that is extremely tender to palpation.
interphalangeal Eponychium (nail plate) Nail bed injuries may be classified as simple lacerations, stellate
joint lacerations, severe crush injuries, and avulsions.1 It is important to
understand that each of these types of nail bed injuries may result in
a subungual hematoma.
The management of subungual hematomas is still somewhat con-
troversial. The approach to management was initially very aggres-
sive, since subungual hematomas are often seen with fractures of
the distal phalanx, damage to the nail, and damage to the nail appa-
ratus.1,2,4–8 The surgical literature generally recommends removal
of the nail, inspection of the nail bed, and repair of any nail bed
injury if the subungual hematoma involves 25% or more of the nail
surface.1,2,4–9 This practice has been questioned recently by newer
controlled studies that demonstrated excellent outcomes in patients
with large (greater than 25%) subungual hematomas treated by
B Root of nail trephination alone, regardless of the presence of fractures.11,12 Larger
Body of nail
Proximal (nail plate) hematomas involving over 50% of the nail surface may be treated
nail fold Eponychium successfully with trephination. Many authors, primarily Hand
Surgeons, still advocate the removal of the nail plate to thoroughly
Lunule Nail bed inspect the nail bed and effect repair in all patients who present with
Nail a subungual hematoma. Although this approach is time-honored,
matrix more recent studies have demonstrated that it is not necessary if the
patient’s nail is still attached to the matrix, even in the presence of a
Extensor distal phalanx fracture.11,12
digitorum
insertion INDICATIONS
Patients who present to the Emergency Department after sustain-
ing an injury with a resultant subungual hematoma will generally
complain of severe pain. Trephination, the process of making a
Epidermis
small hole in the nail to allow the collected blood to escape, will
Flexor digitorum Distal phalanx provide significant relief for most patients.2,9 The trephination
profundus insertion procedures described below should be utilized when patients
present with a subungual hematoma and an intact (not frac-
FIGURE 102-1. The anatomy of the distal fingertip and nail bed. A. Surface anat- tured or avulsed) nail plate that is still attached to the matrix.
omy. B. Midsagittal view. If the nail plate is partially or completely avulsed from the
matrix, simple evacuation of the hematoma may not constitute
adequate therapy.9,10,11,13
blood sinuses. Venous drainage begins at the proximal portion of CONTRAINDICATIONS

the nail bed and the skin proximal to the nail fold.4
Force applied to the tip of the finger or toe disrupts the vascu- Simple trephination is reserved for patients with intact nails.
lar structures in the nail bed. Trauma causes the capillaries of the Patients who present with nail plate fractures, avulsions of the
nail bed to be compressed between the nail and the distal phalanx. nail plate, disruption of the nail margin, or partial amputa-
Blood collects between the nail bed and the nail, forming a subun- tions may require more extensive therapy with removal of the
gual hematoma (Figure 102-2). The patient’s pain is directly related nail plate and repair of the nail bed. A description of these tech-
niques is provided in Chapters 96 and 104. Trephination using
heat-based methods should be avoided in patients wearing arti-
ficial nails due to the potential for igniting the nail or nail adhe-
sive.13 Subungual hematomas that extend proximal to the nail
bed often represent proximal nail plate avulsions or injuries
that require nail plate removal, nail plate repair or reinsertion,
and nail bed repair.
EQUIPMENT
Digital/Metacarpal Block
• Povidone iodine or chlorhexidine solution, or an isopropyl alco-
hol pad
• 3 mL syringe
• 25 or 27 gauge needle, 1 in. long
FIGURE 102-2. The subungual hematoma. A. Surface view. B. Sagittal view. • Local anesthetic solution without epinephrine
Electrocautery
hol pad
• Battery-powered electrocautery device
Paper Clip Technique
hol pad
• Heat source (open flame)
• Paper clip
• Hemostat
Drill Technique
hol pad
• 18 gauge needle
• Cotton-tipped applicators
FIGURE 102-3. The battery-operated electrocautery device.
The PathFormer (Path Scientific, Carlisle, MA) is an FDA
approved device for nail plate trephination. It allows for the pre-
cise control of the depth of penetration while making a 400 µm
diameter hole in the nail plate. The device is a battery-powered drill cool for 1 to 2 seconds. This may prevent penetrating the nail plate
that automatically retracts the drill bit after the nail plate is pen- too quickly and damaging the underlying nail bed. Place the hot
etrated. Thus, the sensitive and vascular nail bed is not contacted or tip on the nail plate, centered over the hematoma (Figure 102-4).
injured. Unfortunately, the PathFormer device is not often available Tap the nail plate several times with the cautery pen tip. Do not
in Emergency Departments. constantly hold the hot tip against the nail plate. The cautery
tip will easily penetrate the nail plate. Do not plunge as the nail
PATIENT PREPARATION bed can be injured in addition to causing additional pain to the
Explain the procedure to the patient and emphasize that pain relief patient.
rapidly follows nail trephination. Obtain a consent to perform the Darkened blood will flow out of the hole when the hematoma is
procedure. Consider obtaining radiographs for significant trau- entered. The nail will regain its normal color after the hematoma
matic injuries, suspected associated fractures, or any injury where is drained. Apply slight digital pressure to the nail plate to ensure
the nail plate is damaged or avulsed. Place the patient in a sit- complete drainage of the hematoma. The patient will usually begin
ting or semi-recumbent position on a gurney or multipositional to feel pain relief at this point.
procedure chair. Sit facing the patient. Place the hand with the The tips of some microcautery devices are shaped in such a way
injured digit palm side down on a flat surface such as a proce- that they will not make a hole that is wide enough to allow ade-
dure table. Cleanse the injured digit of any dirt and debris. Apply quate drainage. Slightly rotate the cautery unit as it traverses the nail
povidone iodine or chlorhexidine solution over the nail plate and plate to ensure an adequate sized drainage hole of 3 to 4 mm. Some
allow it to dry. An alcohol swab is an alternative to these solu- Emergency Physicians prefer to make an additional hole in the nail
tions. Always allow the alcohol to dry before touching the nail plate to ensure drainage if the first hole should become occluded.
plate with a hot object so that the alcohol does not ignite. A
digital block is generally not needed if using heat-based methods
to penetrate the nail plate.2,5,9,13 The nail plate is not innervated
and the hematoma prevents contact with the nail bed. A digital
block may be required if the patient is excessively anxious, if addi-
tional injury is present, or if a drill technique is to be performed.
Refer to Chapter 126 for the complete details regarding digital
and metacarpal blocks. An alternative to the digital block is to
soak the affected finger in ice water for a few minutes prior to
the procedure. The techniques described below may be used on
fingernails and toenails.
TECHNIQUES
ELECTROCAUTERY TECHNIQUE
Electrocautery is the preferred technique to drain a subungual
hematoma. Battery-operated microcautery devices are generally
available in the Emergency Department (Figure 102-3). Assure
the patient that they will not be burned. Stabilize the injured digit
proximally with the nondominant hand. Grasp the cautery unit
like a pencil with the dominant hand. Press the button on the cau- FIGURE 102-4. The electrocautery technique. The hot tip of the unit is centered
tery unit to heat the tip. Release the button and allow the tip to over the subungual hematoma and allowed to penetrate the nail plate.
CHAPTER 102: Subungual Hematoma Evacuation 693
FIGURE 102-5. The paper clip technique. The hot tip of the paper clip is centered
over the subungual hematoma and allowed to penetrate the nail plate.
As an alternative to the single large hole, place three to four smaller

drainage holes in the nail plate.
PAPER CLIP TECHNIQUE

This technique is similar to that using the electrocautery unit.
Unfold and heat the tip of a paper clip with a flame from a lighter or
alcohol lamp. Place the heated tip of the paper clip against the nail
plate, centered over the subungual hematoma (Figure 102-5). Apply
slight downward pressure to allow the paper clip to perforate the FIGURE 102-6. Drill techniques. A. A twisting motion of the 18 gauge needle is
nail plate. Do not plunge as the nail bed can be injured in addition used to penetrate the nail plate. B. A cotton-tipped applicator has been inserted
to causing additional pain to the patient. A drop of blood will be into the hub of the needle. A twisting motion is used to penetrate the nail plate.
seen as the paper clip enters the hematoma. Place at least one addi-
tional hole in the nail plate to ensure drainage if the first hole should
become occluded.
The paper clip will not get as hot as a cautery device. More than ASSESSMENT
one attempt may be necessary to penetrate a thick nail. Another Gently compress the nail plate to evacuate the hematoma. Any
disadvantage of this technique is the possibility of introducing car- underlying injury should be evaluated and managed.
bonaceous material into the hole. The use of an open flame may be
potentially dangerous or prohibited in the Emergency Department. AFTERCARE
DRILL TECHNIQUE The patient should keep the wound clean and monitor drainage.
The nail plate may be covered with a nonadherent dressing. The
This technique uses a needle as a small drill to penetrate the nail hematoma may continue to drain for several hours or up to 1 to
plate (Figure 102-6). Small electric nail drills are available that 2 days. If there is a reaccumulation, denoted by the reappear-
greatly simplify this procedure, though they may not be readily ance of darkened blood beneath the nail, the nail can be soaked
available in the Emergency Department. Drilling through the nail in warm water and pressure applied to express the hematoma.
plate may require a digital block. This is particularly true if there is Inform the patient that the discoloration under the nail plate can
a fracture, another associated injury, or the nail plate is very thick. persist for several weeks. Also inform them that the nail plate may
Grasp an 18-gauge needle by its hub with the dominant thumb and fall off and it can take up to 3 months for another nail plate to
forefinger (Figure 102-6A). Place the tip of the needle over the nail completely form. A splint should be applied if a distal phalanx
plate, centered over the subungual hematoma. Spin the needle back fracture is present. No studies have demonstrated that prophy-
and forth while applying gentle downward pressure. Small shavings lactic antibiotics are beneficial in the management of a subun-
will appear as the needle begins to drill through the nail plate. A loss gual hematoma.9,14 The patient should immediately return to
of resistance will be felt as the hematoma is entered and darkened the Emergency Department or their primary physician for fever,
blood will flow from the hole. Do not plunge as the nail bed can increased pain, purulent drainage from the nail, or any redness or
be injured in addition to causing additional pain to the patient. swelling of the digit.
Place at least one additional hole in the nail plate to ensure drainage
if the first hole should become occluded. COMPLICATIONS
The editor uses a modified version of this technique (Reichman,
personal communication). A cotton-tipped applicator may be Direct complications from nail trephination are rare.11–13
wedged into the needle hub to facilitate the drilling (Figure 102-6B). Complications will more likely result from the original injury and
This method makes the drilling more efficient, as the cotton-tipped include nail loss, nail deformity, cosmetic changes, and infection.
applicator is easier to hold and offers a mechanical advantage when Patients should be warned that as the nail grows out, loss of the nail
it is twisted. The drill technique is very useful in the absence of a is a possibility. The hematoma may reaccumulate if the hole in the
heat-generating device. nail is too small and becomes occluded. Reaccumulation can be
prevented by making a large hole or multiple holes in the nail plate. A Lunule Lateral nail fold
Plunging through the nail plate with a cautery unit or needle will
cause the patient pain and injury to the nail bed that may be perma- Distal Body of nail
nent and result in a deformed nail plate. interphalangeal Eponychium (nail plate)
joint
SUMMARY
Fingertip injuries are common. Patients will often present to the
Emergency Department with a subungual hematoma and a com-
plaint of pain. Rapid relief of pain and good outcomes can be
obtained in the majority of cases by simply performing a nail trephi-
nation. It is important to distinguish when trephination alone will
not be adequate therapy. Patients presenting with nail plate frac-
tures, avulsions of the nail plate, or partial finger amputations will
require removal of the nail plate and repair of the nail bed.
B Root of nail Body of nail

Proximal (nail plate)
Subungual Foreign nail fold Eponychium
103 Body Removal Nail

Lunule Nail bed
Steven H. Bowman matrix
INTRODUCTION Extensor
digitorum
Subungual foreign bodies are often difficult to treat. Foreign bodies
insertion
such as wood or metal splinters, pencil lead, thorns, spines, or hair
may become lodged beneath the fingernail.1–3 Tradesmen such as
carpenters, landscapers, auto mechanics, and individuals who work
without hand protection with materials that produce small splinters
Epidermis
are at risk for this type of injury. Subungual foreign bodies may also
present less commonly under the toenails. Flexor digitorum Distal phalanx
Patients generally present for medical intervention with pain profundus insertion
after unsuccessfully attempting to remove the foreign body. Prior
removal attempts often result in breakage of the foreign body or FIGURE 103-1. The anatomy of the distal fingertip and nail bed. A. Surface anat-
pushing it further beneath the nail; both of which complicate the omy. B. Midsagittal view.
next extraction attempt. Left untreated, retained subungual foreign
bodies often become infected or cause tissue reactions and granu-
loma formation. These injuries may be treated rapidly with com-
plete removal of the foreign body and without causing additional INDICATIONS
patient discomfort. Subungual foreign bodies should be removed to prevent the com-
plications of infection, foreign body reaction, and possible nail
ANATOMY AND PATHOPHYSIOLOGY deformity. Deeply embedded foreign bodies, splintered foreign
bodies, those that traverse the nail plate, or contaminated foreign
The distal fingertip and nail apparatus are complex structures bodies may require the removal of the nail plate to extract the for-
(Figure 103-1). The perionychium is composed of the nail bed and eign body. Refer to Chapter 104 regarding the details of removing
the surrounding soft tissue. The hyponychium is the junction of the the nail plate. Consult a Hand Surgeon if the foreign body cannot
nail bed at the sterile matrix and the fingertip skin beneath the distal be removed, if the site is infected, if the foreign body is “chronic”
margin of the nail plate. The eponychium is the distal portion of the
nail fold where it attaches to the proximal surface of the nail plate.
The lunule is the white arc seen on the proximal portion of the nail
plate. The nail bed consists of the germinal matrix on the proximal
ventral floor of the nail fold and the sterile matrix that extends from
the lunule to the hyponychium. The germinal matrix is primarily
responsible for the growth of the nail. The subungual space is the
area immediately beneath the nail plate.
Foreign bodies may enter the subungual space at the distal fin-
gertip beneath the nail, or may penetrate the nail plate directly
(Figure 103-2). In either event, separation of the nail from the nail
bed results in severe pain. Patients frequently attempt to remove the
foreign body immediately because of this intense pain. An infection
or foreign body reaction will often ensue if the foreign body is not FIGURE 103-2. Subungual foreign bodies can enter from under the distal nail
removed in its entirety. plate or through the nail plate.
CHAPTER 103: Subungual Foreign Body Removal 695
and an osteomyelitis is present on radiographs, or if significant breaking or fragmenting the foreign body, and complete removal.
injury to the digit is present. Superficially located subungual foreign bodies may be removed by
one of the following techniques.
CONTRAINDICATIONS
SCRAPE TECHNIQUE
There are no absolute contraindications to the removal of a subun-
gual foreign body. This technique has been described anecdotally.4,5 It appears promis-
ing as it does not require the administration of a digital block and
EQUIPMENT causes less trauma to the nail and the nail bed compared to other
techniques. This technique works well for subungual foreign bodies
General Supplies that either traverse the nail plate or are lodged beneath the distal or
• Povidone iodine or chlorhexidine solution middle portion of the nail.
Support the patient’s hand on a procedure table. Sit on a chair
• Alcohol swabs facing the patient. Place a #11 or #15 scalpel blade on the nail plate
• Sterile saline solution and directly over the foreign body (Figure 103-3A). Hold the blade
• Topical antibiotic ointment perpendicular to the surface of the nail plate. Draw the scalpel blade
• Nonadherent dressing (e.g., petrolatum gauze) from proximal to distal using short strokes and gentle pressure over
the foreign body (Figure 103-3A). A small shaving of the nail plate
• 4 × 4 gauze squares is removed with each stroke of the scalpel blade. The finger may be
• Adhesive tape soaked in lukewarm water for 15 to 20 minutes to soften the nail
plate if it is thick and difficult to shave. Continue to remove succes-
Digital/Metacarpal Block
sive slivers of the nail plate to eventually create a U-shaped defect
• 3 mL syringe and expose the foreign body (Figure 103-3B). Grasp the foreign
• 25 or 27 gauge needle, 1 in. long body with a splinter forceps and remove it once a significant portion
• 3 to 5 mL local anesthetic solution without epinephrine protrudes. The defect created in the nail plate will move distally and
eventually be replaced as the nail plate continues to grow.
Scrape Technique
• Splinter forceps WEDGE TECHNIQUE
• #11 or #15 scalpel blade on a handle The wedge technique works well for subungual foreign bodies
Wedge Technique lodged beneath the distal portion of the nail plate.1,6 Patients will
require a digital or metacarpal block prior to attempting this tech-
• Splinter forceps
nique since it involves manipulation of the nail bed.
• Tissue scissors or nail clippers Sit on a chair facing the patient. Cut a triangular wedge from
Needle Technique the distal portion of the nail plate overlying the foreign body with
a small pair of tissue scissors or nail clippers (Figure 103-4A).
• Needles, 19 and 25 or 27 gauges
• Splinter forceps
• Hemostat
PATIENT PREPARATION
Explain the risks and benefits of the procedure to the patient and/or
their representative. Obtain an informed consent for the procedure.
Ascertain the patient’s tetanus immune status and administer the
appropriate tetanus prophylaxis. The Emergency Physician should
attempt to gain the patient’s cooperation. Place the patient sitting or
in a semi-recumbent position with their hand on a bedside proce-
dure table. Clean any dirt and debris from the affected finger. Apply
povidone iodine or chlorhexidine solution and allow it to dry. Any
manipulation of the nail bed will result in additional patient discom-
fort. Determine the need for a digital or metacarpal block depending
on the type and extent of the foreign body and the removal tech-
nique. Please refer to Chapter 126 for the complete details regarding
anesthesia of the finger or toe. Radiographs are not required unless
a metallic foreign body cannot be visually located or the clinical sus-
picion exists for an osteomyelitis or a gas forming finger infection.
TECHNIQUES
Foreign bodies protruding through or from underneath the nail
plate may be grasped with a forceps and removed. A scalpel blade or
18 gauge needle may be used to entrap a small protruding tip of the FIGURE 103-3. The scrape technique. A. With the scalpel blade held 90° to the
foreign body against the nail plate and draw it out. Do not attempt nail bed, strokes are made in a proximal to distal direction. A U-shaped defect
to remove the foreign body through a puncture wound or small will be created to expose the foreign body. B. The foreign body is grasped and
incision. Enlarging the access site allows for easier removal, not removed with a forceps.
FIGURE 103-4. The wedge technique. A. A triangular incision is made in the

nail plate overlying the foreign body. B. The cut section of the nail plate has been
removed. The foreign body is grasped with a forceps and removed.
Prevent iatrogenic injury to the nail bed by ensuring that the tip FIGURE 103-5. Needle techniques. A. A 19 gauge needle is inserted along the
of the scissors under the nail plate is aimed upward and against tract of the foreign body. The tip is used to tease the foreign body out of the tissues.
the nail plate. Remove the wedge of nail. This will provide enough B. The tip of a 25 or 27 gauge needle has been formed into a hook with the aid
exposure to grasp and remove the foreign body with splinter forceps of a hemostat. The needle is inserted along the tract of the foreign body. The tip is
(Figure 103-4B). used to grasp the foreign body and pull it out of the tissues.
NEEDLE TECHNIQUES
The needle technique works well for subungual foreign bodies
located beneath the distal portion of the nail plate.1 Patients will AFTERCARE
require a digital or metacarpal block prior to attempting this tech- In most cases, local wound care and the application of a topical anti-
nique. Insertion of a needle into the nail bed is extremely painful. biotic are all that is required. Irrigate the foreign body tract and exci-
The major drawback of this technique is the potential for leaving sion site with sterile saline. Apply topical antibiotic ointment to the
fragments of the foreign body beneath the nail plate. area. Apply a nonadherent dressing over the nail. Follow-up with a
Sit in a chair facing the patient. Introduce a 19-gauge needle Hand Surgeon and systemic antibiotics may be necessary in severe
beneath the nail plate and along the track of the foreign body cases, such as the presence of a nail deformity or chronic foreign
(Figure 103-5A).7 Use the tip of the needle to touch the foreign bodies with an infection. Postprocedural pain can be managed with
body. Lower the hub of the needle to raise its tip and trap the foreign acetaminophen or nonsteroidal anti-inflammatory drugs. The use
body between it and the nail plate. Withdraw the needle while drag- of prophylactic antibiotics is not recommended unless the foreign
ging the foreign body out along the nail plate. Alternatively, tease body was contaminated or had deeply penetrated into the soft tis-
out and move the foreign body distally until it can be grasped with sue of the digit. Instruct the patient to return immediately to the
a splinter forceps. Emergency Department if they develop any signs of an infection
Two alternate techniques have also been described for the needle (i.e., purulent drainage, increased tenderness, redness or swelling of
extraction of a subungual foreign body.7,8 The first is a modification the digit, or fever).
of the needle technique.7 Place a hook in the distal end of a 25 or
27 gauge needle with a hemostat or needle driver (Figure 103-5B).
Pass the bent needle along the foreign body tract. Grasp the foreign
COMPLICATIONS
body with the tip of the bent needle. Withdraw the needle to move There are a few potential complications from subungual foreign
the foreign body distally so that it may be grasped with a splinter body removal. Damage to the nail bed can result in a residual nail
forceps. A third technique involves the excision of a small portion deformity. Failure to completely remove a subungual foreign body
of the nail plate overlying the foreign body with an 18 gauge nee- may result in a nail deformity, an infection, or a foreign body reac-
dle.8 This is similar to the shave technique with the exception of an tion with granuloma formation. An infection can result from a con-
18 gauge needle being used instead of a scalpel blade. taminated foreign body, flora on the nail plate or skin driven into
the soft tissues by the foreign body, or if aseptic technique is not
ASSESSMENT followed.
The subungual area should be inspected for any remaining frag-

SUMMARY
ments of the foreign body that may have broken off in the nail bed.
Any remaining fragments of the foreign body must be removed. Patients with subungual foreign bodies often present in severe pain
Refer the patient to a Hand Surgeon if the foreign body fragments after prior unsuccessful attempts at removal or after complications
cannot be removed. develop. Though sometimes challenging, it is important that the
CHAPTER 104: Nail Bed Repair 697
Emergency Physician completely remove the foreign material in A Dorsal roof

the subungual space to prevent further complications. Providing Ventral floor
adequate anesthesia and using the appropriate instruments and Eponychium
(germinal matrix)
techniques allows the successful removal of most subungual for-
eign bodies in the Emergency Department. Nail plate
Hyponychium
Nail Bed Repair

104 Raemma Paredes Luck and Eric F. Reichman
Nail bed
(sterile matrix &
INTRODUCTION germinal matrix) Distal phalanx
The fingertip, the most sensitive area of the hand, is often our first
contact with the environment. It has important functional roles in
grasping and pinching, in addition to its sensory and cosmetic func- B
tions.1,2 The fingernail protects the fingertip and provides increased
sensation to the volar pulp.3 However, it also conceals the true extent
of fingertip injuries. Hand injuries, with the fingertips most fre-
quently involved, are second only to back injuries as the most com- Lateral nail fold
mon occupational injuries resulting in loss of work days.4 Hence, it (perionychium)
is important for the Emergency Physician to evaluate the full extent
Lunule
of the injury, to assess potential disabilities, and to recognize the
need for prompt referral to a Hand Surgeon.
The fingernails are frequently injured due to their anatomic loca- Proximal nail fold
tion and their functional role. Immediate primary repair is the (eponychium)
ideal management when these injuries involve the nail bed and sur-
rounding skin fold structures.3,5 Careful repair is necessary to avoid
functional impairment and cosmetic derangement of the nail plate.6 FIGURE 104-1. Anatomy of the fingernail. A. Lateral view. B. Top view. The col-
The following discussion will refer primarily to the fingernail. The ored area represents the perionychium.
toenail has less importance, both cosmetically and functionally, as
grasp and pinch are not needed. However, all the principles and rec-
ommendations made also apply to the toenail.7
Skin overlies the nail plate proximally and laterally
ANATOMY AND PATHOPHYSIOLOGY (Figure 104-1B).9 The proximal skin fold is referred to as the
Knowledge of the anatomy of the nail unit enables the Emergency eponychium. The eponychium protects the germinal matrix located
Physician to recognize the types of injuries and provide anticipa- in the proximal nail bed and is the home of the dorsal roof matrix.
tory guidance of the consequences of these injuries to the patients. The skin immediately over the dorsal roof is called the nail wall.8
The “perionychium” or the nail unit consists of the nail fold, the nail The lateral skin folds, the adjacent cutaneous areas, and the adja-
plate, nail bed, and the hyponychium (Figure 104-1).1,2 cent nail bed (germinal matrix and sterile matrix) are collectively
The nail plate enhances the sensibility of the fingertip by apply- referred to as the perionychium (Figure 104-1B).6,8,9 The lunule is
ing a counterforce to the pulp space nerve endings.3 The digital tip the pale arc just distal to the eponychium and roughly corresponds
and the nail plate also function in unison to smoothly coordinate to the location of the germinal matrix.1,2,8,9
normal pinch and grasp, which are important for picking up fine The nail bed is comprised of the germinal matrix proximally and
objects such as coins and pins.3,8 the sterile matrix distally. The borders of the nail bed are the proxi-
The nail plate is comprised of compacted, flattened, and mal nail fold, the lateral nail folds, and the hyponychium distally.
elongated anucleated cells that originate from cornified epithe- The hyponychium is the thick layer of cells at the junction of the
lial cells.9 There are three atomic sites where these cells exist.5,8 distal nail bed (sterile matrix) and the fingertip skin.8 It is located
The nail bed contains two of the sites: the sterile matrix and the just under the distal free margin of the nail plate (Figure 104-1A).
germinal matrix.8 The other location is the dorsal roof matrix The hyponychium serves as a barrier preventing the delicate nail
(Figure 104-1A). Of these, the germinal matrix is the most bed from exposure to bacteria and fungi.8
important for normal nail growth.5 The germinal matrix is The rate of nail growth varies from finger to finger, from indi-
responsible for approximately 90% of the nail plate by volume.8 vidual to individual, and varies with age.3,8 Nail growth is fastest
The sterile matrix is responsible for a small percent of the nail between 4 and 30 years of age and after 80 years of age. Fingernails
plate by volume and varies from individual to individual. This cell grow four times faster than the toenails.1 A new nail takes a min-
production accounts for the nail plate being thicker at its distal tip imum of 4 months to grow, and even longer following an injury.
compared to its proximal origin.8 The nail cells from the dorsal Progression of the distal nail occurs at a rate of 0.1 mm/day or 0.5 to
roof matrix are small in number and form a very thin layer on the 1 mm/week.3,9 This rate varies and is usually faster in fingers than in
surface of the nail plate. These cells are responsible for the shine toes, and faster in the summer months.3 The pressure of new cells
of the nail. If the dorsal roof is destroyed, the nail will lose its being formed leads to the flattening and elongation of the older cells
shine and become dull. as well as their progression distally.8
important to note that significant force is required to break, pen-

etrate, or avulse the nail plate.6 Therefore, the fragile nail bed is most
likely disrupted if the nail plate is disrupted.
INDICATIONS
Injuries to the fingertip and nail, if not initially managed cor-
rectly, have long lasting functional as well as cosmetic conse-
quences. The most important consideration is functional.9 Normal
nail growth after injury requires a smooth nail bed. Therefore, nail
bed injuries must be meticulously repaired to prevent cosmetic
deformities and functional impairment.9–11 Scar tissue may form
between the wound edges if the nail bed is not accurately approxi-
mated. This scar tissue will not form the intermediate nail cells
responsible for nail adherence.8 Furthermore, loss of the germinal
matrix alone will result in permanent loss of the nail plate.5,12 The
skin folds surrounding the nail margins must also be preserved.5,11
Failure to do so will result in the painful complication of adhesion
formation between the skin fold and the nail bed.5,11 Secondary
repair of these spaces, or of the nail bed, requires more complex
procedures and are usually associated with a poor outcome.4,10
Therefore, every effort should be made to primarily repair all
significant nail bed injuries.
FIGURE 104-2. A crush injury to the distal fingertip. A. Proximal nail bed avul-
sion. B. A more severe crush injury can result in a proximal nail bed avulsion and CONTRAINDICATION
fracture of the distal phalanx. Note that the distal nail plate remains attached to the
sterile matrix in both of these injuries. No absolute contraindications exist for primary nail bed repair. Any
life-threatening injuries, limb-threatening injuries, and/or uncon-
trolled hemorrhage must be addressed prior to nail bed repair.
The sterile matrix is more adherent to the nail plate than to the
adjacent germinal matrix. Therefore, avulsions involving nail bed EQUIPMENT
tissue are more likely to occur at the sterile matrix.8,10,11 Conversely, • Povidone iodine or chlorhexidine solution
the nail plate is loosely held to the germinal matrix. This accounts
• Restraining device(s), as necessary
for the peculiar injury of avulsions of the proximal nail plate from
the proximal nail fold while the distal nail plate remains attached • 10 mL syringe armed with a 27 gauge needle
(Figure 104-2). • Local anesthetic solution without epinephrine, 1% lidocaine or
The digital artery supplies the volar radial and ulnar sides of the 0.25% bupivacaine
finger and consistently sends even smaller branches to the proximal • Digital tourniquet
nail fold and to the nail bed producing a rich capillary network.1
The small veins of the nail bed, pulp, and lateral nail folds coalesce • #15 scalpel blade on a handle
proximally to form a larger commissural vein that runs lateral to • Magnification device
the distal phalanx and a terminal vein that runs dorsal to the dis- • Sterile prefabricated nail, if available
tal phalanx. The digital nerve accompanies the digital artery and
• Nonadherent petrolatum gauze
sends branches beyond the distal interphalangeal joint and into the
nail fold, nail bed, and the finger pulp. The extensor tendon attaches • 5-0, 6-0, and 7-0 chromic gut (or polyglactin 910 or irradiated
itself to the distal phalanx just proximal to the germinal matrix.8,11 polyglactin 910) on a p-3 cutting needle
The periosteum of the distal phalanx, in turn, closely adheres to the • 6-0 monofilament nylon sutures
sterile matrix.8 • Needle driver
With these anatomic considerations in mind, certain patterns
• Curved hemostat
emerge as a result of injury. Avulsions of the nail bed tend to occur
in the sterile matrix rather than the less adherent germinal matrix. • Fine scissors or periosteal elevator
Another pattern of injury seen is the avulsion of the proximal nail • Forceps
plate from the proximal nail fold while the distal part remains • Sterile towels or drapes
attached to the nail bed (Figure 104-2). Because the sterile matrix
closely adheres to the periosteum of the distal phalanx, fractures of • Sterile gloves
the distal phalanx might injure the nail bed producing a subungual • Dry gauze/tube gauze
hematoma.6 Due to the close proximity of the germinal matrix and • Splinting material
the attachment of the extensor tendon, injuries to or repair of these
• Battery-powered electrocautery device
structures might involve the other. A subungual hematoma is a col-
lection of blood between the nail bed and the nail plate. Although The use of a digital tourniquet is essential to properly repair a
a large subungual hematoma may require repair of the underlying nail bed. Its use provides a bloodless field, which allows for a more
nail bed, this is controversial. meticulous and precise wound approximation. Numerous options
Emergency Physicians must consider in each case whether are available to use as a tourniquet in the Emergency Department.
there exists enough damage to require surgical nail bed repair. It is Home-grown options include the use of a sterile Penrose drain,
FIGURE 104-3. A sterile Penrose drain or IV tourniquet used as a digital

tourniquet. FIGURE 104-5. The Tourni-cot digital tourniquet.
rubber IV tourniquet, or sterile glove. A sterile Penrose drain or IV PATIENT PREPARATION

tourniquet secured with a hemostat is often used as these items are
readily available (Figure 104-3). A sterile glove may be used as a The first step in the evaluation of fingertip injuries is obtaining a
tourniquet (Figure 104-4). Apply a sterile glove onto the patient’s thorough history. The mechanism of injury can provide some clues
hand that is snug or a size one-half smaller than their actual glove to the type and extent of injuries as well as amount of contamina-
size. Cut just the tip off of the glove over the affected finger(s). Roll tion to be expected. Other pertinent information includes age, hand
the cut finger back and onto the proximal phalanx to form the tour- dominance, occupation or hobbies, comorbidities, and tetanus vac-
niquet (Figure 104-4). cination status. All significant injuries to the fingertip should be
Several commercially produced digital tourniquets are often evaluated radiographically for fractures. The management of fin-
available in the Emergency Department. The Tourni-cot (Mar gertip injuries may differ in the presence of a fracture. Thoroughly
Med Co., Grand Rapids, MI) is a sterile, single use, disposable, evaluate and document a complete neurovascular examination, ten-
rubber ring that slides over the fingertip and rolled backward until don function and intactness, and ligamentous stability of the joints.
it rests over the proximal phalanx (Figure 104-5). These come in Ascertain the patient’s tetanus immune status and administer pro-
several sizes to fit the appropriate finger size. The advantage of the phylaxis if required.
Tourni-cot is that it exsanguinates the digit as it is applied. The It is important to explain both the risks of doing the procedure
T-Ring (Precision Medical Devices LLC, San Clemente, CA) is a and of not doing the procedure. Document this conversation and
“one size fits all” digital tourniquet (Figure 104-6). It is a sterile, obtain an informed consent. Place the patient on a gurney with the
single use, disposable, rubber diaphragm with a central hole. It hand on a bedside procedure table in a well-lit area. Be prepared to
slides over the fingertip and is pushed backward until it rests over use age-appropriate sedation or to apply appropriate restraints for
the proximal phalanx. The T-Ring also exsanguinates the digit as children.11 Procedural sedation may be necessary in patients who
it is applied. are agitated, uncooperative, or require extensive repair. Apply a type
FIGURE 104-4. A sterile glove used as a digital tourniquet. FIGURE 104-6. The T-Ring digital tourniquet.
of magnification device if available. This may consist of a head-strap

device, a swing arm device, magnification glasses, or loupe magni-
fication glasses.
Anesthetize the injured digit(s). Anesthesia may be achieved
with a digital block or a metacarpal block when only a single digit
is involved.6 Lidocaine (1% or 2%) can provide pain relief of up to
3 hours. For longer analgesia, use 0.5% bupivacaine. Although recent
studies have shown that the practice of using lidocaine with epi-
nephrine for digital blocks is safe, this is still controversial and many
do not advocate its use.13–15 Multiple metacarpal blocks or an axillary
nerve block may be performed if multiple digits are involved.6 Please
refer to Chapter 126 for the details regarding regional nerve blocks.
Thoroughly clean the hand of any dirt and debris. Apply povi-
done iodine or chlorhexidine solution and allow it to dry.16 Irrigate
the wound with sterile saline. If the nail plate has been avulsed, irri-
gate it with a dilute povidone iodine or chlorhexidine solution fol-
lowed by a gentle rinse with sterile saline. It is important not to
scrub the undersurface of the avulsed nail plate because adherent
squamous tissue may be destroyed.6
A bloodless field is desired and, in many cases, necessary. Apply a
digital tourniquet as described in the “Equipment” section above.6 If
available, a pneumatic tourniquet may be placed on the arm instead
of using the digital tourniquet. The pneumatic tourniquet is espe-
cially helpful when the patient has fractures or lacerations of the FIGURE 104-7. Removal of the nail plate. Dissect along the plane between the nail
proximal digit that preclude the use of a digital tourniquet. Avoid plate and the nail bed using a pair of fine scissors or periosteal elevator.
using a blood pressure cuff, as these tend to deflate during use. As
with all tourniquets, limit the amount of time in which the tour-
niquet is in place. Create a sterile field by applying sterile towels.
scissors parallel to the long axis of the finger. Slightly angle the tips
of the scissors toward the nail plate to prevent any damage to the nail
TECHNIQUES bed.11 Advance the tips of the scissors 1 to 2 mm. Open the blades
Adhering to certain principles will improve the outcome when of the scissors to separate the nail bed from the nail plate. Close the
repairing nail beds. A smooth and flat nail bed is necessary to the blades of the scissors. Continue to advance the tips of the scissors in
normal growth of the nail and should be the primary goal in any 1 to 2 mm increments and separate the nail bed from the nail plate.
repair. Avoid or severely limit the amount of debridement.5 The Stop advancing the scissors when the tips of the blades are at the
germinal matrix must be meticulously repaired and the proxi- level of the eponychium. Firmly grasp the nail plate with a hemostat.
mal nail fold, the eponychium, preserved or that space is obliter- Pull the nail plate parallel to the long axis of the finger to completely
ated within a few days and result in adhesions or abnormal nail remove it from the finger.
growth.5 Thoroughly clean and replace the nail plate whenever Making two linear incisions with a scalpel at 90° from the
possible. This will preserve the nail folds surrounding the nail eponychial edge will allow greater exposure to the germinal matrix
bed, allow the nail plate to serve as a splint for fractures, and act for repair (Figure 104-8).7 This allows the eponychium to be folded
as a protective cover for the healing nail bed.6 Treatment goals or sutured back and therefore increase exposure of the germinal
also include preservation of length and sensation of the fingertip, matrix.2,17
early mobilization, prevention of joint contractures, and atten-
tion to cosmesis.4,17 SIMPLE LACERATIONS
The technique of nail bed repair depends upon the type of injury
as well as which structures are involved. Various classification Simple lacerations are caused by localized blows to the nail plate.
schemes, such as the nature of injury or anatomic location, have After removing the nail plate and exposing the nail bed, repair the
been developed to categorize fingertip injuries and guide treatment. laceration meticulously using 6-0 or 7-0 chromic gut or irradiated
Nail bed injuries are classified as simple lacerations, crushing lac- polyglactin 910 sutures.2,6,17 Minimize debridement as much as
erations, avulsion-lacerations, lacerations with associated fractures, possible to avoid scarring that will result in nonadherence or
lacerations with loss of skin and pulp, and fingertip amputations.2,12
NAIL PLATE REMOVAL

A significant force is required to break the nail plate. The nail plate
should be removed to visualize the underlying nail bed if the nail
plate is damaged or avulsed, or the lateral skin folds lacerated as
an associated nail bed injury is highly likely. Removal of the nail
plate is unnecessary in minor injuries where the nail plate is not
damaged and still attached to the nail folds.
Remove the nail plate to repair nail bed injuries or to inspect the
nail bed for potential injuries (Figure 104-7). Insert the closed tips
of a fine scissors between the nail bed and the nail plate. A periosteal FIGURE 104-8. Incisions can be made at 90° to the corners of the eponychium
elevator, if available, can be substituted for the scissors. Hold the for better exposure of the germinal matrix.
previously described injuries. Distal nail bed avulsions simply

require petrolatum gauze to be placed over the injury followed by
sterile gauze. Suture the petrolatum gauze and sterile gauze in place
using 5-0 or 6-0 nylon suture for 10 days to allow the wound to heal
by second intention (Figure 104-10B).5,17 Avulsion-laceration inju-
ries may require consultation with a Hand Surgeon depending on
the amount of tissue involved and whether the germinal matrix is
involved.6,11,12 More severely damaged nail beds with a large amount
of avulsed tissue usually require dermal grafts or split-thickness
matrix grafts.6
Small fragments of avulsed nail bed may remain attached to the
nail plate. These may be simply treated by carefully replacing the
nail plate in its anatomic position.18 Larger segments of avulsed
FIGURE 104-9. Crushing lacerations to the nail bed. A. Stellate or complex lacera-
nail bed that remain attached to the nail plate should be repaired
tions of the nail bed can occur after a crush injury. B. Approximation of the nail bed
with fine absorbable sutures.
(Figures 104-11A & B). Gently shave away the nail bed from the
nail plate with a #15 scalpel blade (Figure 104-11C). Replace the
avulsed nail bed and suture it in place with 5-0 or 6-0 chromic gut
or irradiated polyglactin 910 sutures (Figure 104-11D).10,18 Apply a
splitting of the nail plate. Repair any skin lacerations adjacent to petrolatum gauze dressing and replace the nail plate.
the nail bed using 6-0 or 5-0 monofilament nylon sutures.5 Nail A special type of avulsion injury occurs when there is a crush
fold lacerations may require repair in layers in order to preserve injury to the distal fingernail. This results in an avulsion of the proxi-
these spaces.9 mal nail plate with or without involvement of the germinal matrix
(Figure 104-2). The proximal nail plate is less adherent to the nail bed
CRUSHING LACERATIONS and can be pulled out from under the eponychium (Figure 104-2).
Remove the nail plate if the proximal nail plate is avulsed without
The second type of injury is a crush injury with resultant lacera-
involvement of the germinal matrix. Clean the nail plate and nail bed
tions. Crushing injuries may produce stellate lacerations and frag-
with sterile saline. Replace and secure the nail plate.
mentation of the nail bed (Figure 104-9A). Attempt to meticulously
repair the fragmented nail bed using 6-0 or 7-0 chromic gut or irra-
diated polyglactin 910 sutures to achieve precise approximation and
the smoothest result possible (Figure 104-9B).6
AVULSION-LACERATIONS
The third type of nail bed injury is the avulsion-laceration
(Figure 104-10A). These injuries are more complex than the
FIGURE 104-10. Avulsion-laceration of the nail bed. A. The dorsal aspect of the FIGURE 104-11. Large avulsion of the nail bed that is adherent to the nail plate.
fingertip is avulsed with the nail plate. B. Petrolatum gauze is placed over the injury. A. Lateral view of injury. B. Top view of injury. C. Gently shave away the avulsed
This is subsequently covered with sterile gauze and sutured into place for 10 days. segment. D. Repair the nail bed using the avulsed segment.
FIGURE 104-13. Classification of fingertip injuries. Zone I is distal to the bony pha-
lanx. Zone II is distal to the lunule and over the bony phalanx. Zone III is proximal
to the distal end of the lunule.
FIGURE 104-12. Repair of the germinal matrix after an avulsion. A. A series of bony phalanx. These injuries often have exposed bone. Zone III
horizontal mattress sutures are placed. B. The nail bed is returned to its proper injuries occur proximal to the distal end of the lunule. Zone II and
location and the sutures tied. C. Lateral view of the repair. Zone III injuries should be managed in consultation with a Hand
Surgeon. Either type of injury may require reconstruction with a
pedicle flap and/or skin grafting.3
More often with these crush injuries the germinal matrix is TREPHINATION FOR A SUBUNGUAL HEMATOMA
avulsed as well. In these cases, the germinal matrix should be
replaced with a series, usually three, of 6-0 nylon simple inter- A subungual hematoma is a collection of blood under the nail plate
rupted or horizontal mattress sutures (Figure 104-12).5,6,10 Place caused by blunt trauma to the fingertip. The nail bed is usually
all three sutures before returning the nail bed to its proper loca- crushed or lacerated with resultant extravasation of blood into the
tion. Making two linear incisions with a scalpel at 90° from the plane between the nail plate and the nail bed.11 As pressure builds up,
eponychial edge will allow exposure to the germinal matrix for compression of nail bed nerves occurs and often causes significant
repair (Figure 104-8).7 This allows the eponychium to be folded pain. Usually this pain is what causes the patient to seek medical
or sutured back and therefore increase exposure of the germinal attention. The management of subungual hematomas is discussed
matrix. Place a piece of petrolatum gauze between the eponych- separately because these injuries are typically minor and treated by
ium and the germinal matrix after the repair (Figure 104-12B). simple trephination. A complete discussion of the management of
Larger germinal matrix avulsions require consultation with a Hand subungual hematomas can be found in Chapter 102.
Surgeon for grafting.2,6,11,17 It is generally accepted that subungual hematomas <50% of the
nail plate may be managed conservatively by simple trephination
(puncture) of the nail plate.2,5,6,11,17,20,21 This allows for drainage of
LACERATIONS WITH ASSOCIATED FRACTURES
blood and immediate pain relief. No anesthesia is usually neces-
The fourth type of nail bed injury is lacerations associated with sary for this procedure. Ideally, this is accomplished with the use of
fracture(s). Approximately 50% of nail bed injuries have an asso- an electrocautery device creating a 3 to 4 mm hole in the nail plate
ciated phalangeal tuft fracture.19 The nail bed laceration should be overlying the hematoma. The nail plate should be clean and dry for
repaired as previously described and the fracture addressed as a this procedure. If an electrocautery device is not available, a heated
separate entity.5 It is important to remember that the sterile matrix paperclip may be used.5 Refer to Chapter 102 for more complete
is closely adherent to the dorsal periosteum of the distal phalanx. details of the procedure.
Therefore, fractures require precise anatomic reduction in order Some controversy exists over the management of subungual
for normal nail bed healing and nail plate growth to take place.6,10,12 hematomas >50% of the nail plate. The concern is that a larger
Replacing the nail plate and splinting the finger after repairing hematoma may hide an occult laceration that requires repair in
the nail bed laceration is often enough to reduce these fractures. order to avoid the complication of step-off with subsequent ridging
Occasionally, fixation may be employed by a Hand Surgeon using as the new nail grows back. Some authors feel that it is impossible to
Kirschner wires to prevent rotation of the bony fragments.2,6 accurately assess the amount of damage beneath a subungual hema-
toma unless the nail plate is removed to directly inspect the nail
LACERATIONS WITH SKIN LOSS bed.6,21 These authors noted that subungual hematomas that have
separated greater than 50% usually have lacerations that require
AND FINGERTIP AMPUTATIONS
repair. Another study found that a subungual hematoma with more
The final two types of injury are lacerations with loss of skin and than 50% separation had a 60% incidence of having a nail bed lac-
pulp, and fingertip amputations. They can be further classified eration that required repair and up to a 95% incidence when there
according to zones based upon the anatomic level of amputation was an associated phalanx fracture.21 In contrast to these studies,
(Figure 104-13).3 Zone I injuries occur distal to the bony phalanx. a prospective study found no complications at 6 months follow-up
These do not result in the loss of function and rarely result in a cos- for subungual hematomas treated by electrocautery trephination
metic deformity. Management consists of cleansing, placing topical alone.2,20 This was regardless of the size of the subungual hematoma
antibiotic ointment over the injured area, and then applying a layer or the presence of a fracture. These authors feel that removing the
of petrolatum gauze. This should be followed by a sterile dressing nail plate and attempting repair may actually cause further trauma
and a splint. Zone II injuries occur distal to the lunule and over the to the nail bed.20
fold structures when the original nail plate is not available or sig-
nificantly damaged (Figure 104-15).
After repair of the nail bed, the digit(s) involved will need to
be bandaged in order to protect it from infection, moisture, and
trauma. The application of becaplermin, recombinant human plate-
let-derived growth factor, has shown to improve outcomes.22 This
substance is not routinely used in the Emergency Department and
should be applied after consultation with a Hand Surgeon. Place pet-
rolatum gauze over the nail bed to avoid adherence from secretions.
Apply a tube gauze dressing followed by a digital aluminum splint.3
Movement of the distal interphalangeal joint should be restricted for
7 to 10 days with a splint.6 For infants and young children, the entire
FIGURE 104-14. A hole is placed in the nail plate before it is sutured in place. hand should be dressed. If petrolatum gauze was used to keep the
proximal nail fold (eponychium) open, it should be removed in 5 to
10 days.6 Petrolatum gauze used to keep open the lateral nail folds
It was previously recommended that radiographs be obtained to (perionychium) should remain in place for 10 days.5 Any sutures
rule out a fracture for all hematomas larger than 50% of the nail placed in the skin structures or nail folds should be removed in 7 to
plate. A newer study found no correlation between the size of the 10 days.5
hematoma and the presence of fractures.20 If a fracture is suspected, Prophylactic antibiotics are not routinely required. They are rec-
have a low threshold to obtain plain radiographs prior to evacuating ommended for large avulsions, amputations, and associated frac-
the hematoma. tures when there is contamination with organic material.6 Topical
In summary, most subungual hematomas may be treated by antibiotics may be applied to Zone I fingertip amputations. All inju-
simple nail trephination using an electrocautery device. This ries require a wound check in 24 to 72 hours.3,5,6 The patient’s tetanus
procedure will lead to beneficial drainage only if done before 36 to immune status should be determined and prophylaxis adminis-
48 hours from the time of the injury.11 The clinical benefit of nail tered if required. The hand should be elevated whenever possible.
bed repair with larger subungual hematomas is controversial. It may Narcotic analgesics may be prescribed as needed for pain control.
be prudent to maintain a lower threshold for nail bed repair with It is important to explain to the patient that regeneration of a new
a larger subungual hematoma, particularly if an ideal cosmetic nail may take up to 6 to 12 months.6 Warn the patient that as the new
outcome is desired. nail forms, it may look irregular and snag on cloth or string objects.6
The patient should trim and file the leading edge of the new nail
AFTERCARE once it extends past the hyponychium in order to avoid snagging.
Whenever possible, the nail plate should be replaced after repair- COMPLICATIONS
ing any of the above-mentioned injuries. The nail plate covers the
sensitive nail bed and protects it from injury, maintains the proxi- The complications associated with failure to repair or improper
mal nail fold (eponychium) to allow for growth of a new nail, and repair of a nail bed can be either functional, cosmetic, or both. The
splints the nail bed. In order to accomplish the best outcome, place more serious complications are those which impair function or
a hole in the center of the nail plate to allow for fluid drainage.11 cause pain. There are basically seven complications that may arise.
Make one or two holes in the lateral aspects of the nail plate. Suture These exclude the infectious complications (abscess formation, cel-
the nail plate in place using 5-0 nylon sutures through the lateral lulitis, and lymphangitis) that are inherent to all wounds. The occur-
skin folds (Figure 104-14).6,10,11 These sutures should remain in rence of osteomyelitis from these injuries is rare, even with open
place for 7 days. An alternative to suturing the nail plate in position fractures. The seven complications are loss of the nail, a split nail,
is to use tissue adhesive. After replacing the nail plate, apply tissue a nonadherent nail, an ingrown nail, a malaligned nail, wide nails,
adhesive along the eponychium and lateral nail folds at the area and narrow nails.12
where they overlap the nail plate. An artificial nail may be used if The complete loss of a nail could result in significant functional
the original nail plate is not available. The potential problem with impairment to the fingertip as well as an abnormal looking finger-
sterile prefabricated nails is that there exists an increased risk for tip. Complete nail loss occurs when there is complete disruption of
infection and a risk of erosion into the nail bed or nail folds.6 The the germinal matrix, either by significant avulsion of the matrix or
editor recommends petrolatum gauze be used to maintain the nail amputation. Remember that if the germinal or roof matrices are not
FIGURE 104-15. Petrolatum gauze may be placed between the dorsal roof and germinal matrix (A) or between the lateral skin fold and nail bed (B) to preserve the skin
fold spaces.
repaired, the pouch deep to the proximal skin fold (eponychium) is often give a history of repetitive motion at the site. The mass usually
obliterated within a few days.20 increases in size progressively over time or, occasionally, may grow
A split nail occurs when the germinal matrix is improperly rapidly over a short period. Patients presenting to the Emergency
approximated.5,6,12 A wide scar will result that will not form a new Department with ganglia may have already attempted one of sev-
nail. Subsequently, a split nail develops. This can be avoided by the eral popular home remedies, including homeopathic medications or
careful approximation of the nail bed with sutures. striking the cyst firmly with a large book or hammer.
A nonadherent nail occurs when the nail bed is not repaired and Ganglion cyst aspiration is a relatively simple procedure that may
granulation tissue forms secondarily. The nail plate will not adhere be performed by the Emergency Physician. The practice of cyst
at the site of the granulation tissue as well as distal to the granulation aspiration has been challenged because of the high recurrence rate
tissue.12 The nail can snag and be exposed to repeated tears once the after the procedure.2,3 Recurrence rates of up to and even greater
nail plate loses adhesion to the nail bed. than 50% have been described.4,5 However, the procedure usually
The nail plate may ingrow if the lateral skin folds or sulci are not alleviates presenting symptoms, is occasionally curative, and is more
maintained and kept open.12 Adhesions that form between the skin cost-effective than referring all patients for surgical treatment.6
and nail bed can be very painful when the new nail tries to grow
through that space.5 Ingrown nails also have the long-term prob- ANATOMY AND PATHOPHYSIOLOGY
lem of a higher rate of infections (paronychia). This can be avoided
Ganglia are synovial cysts that originate from a joint capsule or ten-
by the replacement of the nail plate or the placement of petrolatum
don sheath. They have no malignant potential. It is unclear whether
gauze to elevate the lateral nail fold from the nail bed.
ganglia are formed by herniation of the tendon sheath, myxoma-
The nail plate will grow in a malaligned direction if the matrix is
tous degeneration of connective tissue, or some other mechanism.
displaced or repaired in such a manner that it is improperly aligned.12
Contained within the cyst is a viscous, jelly-like fluid. Ganglia often
Functional impairment and cosmetic deformity may ensue depend-
connect with the underlying synovial cavity or tendon sheath by a
ing upon the degree of this misdirected growth.
stalk. Hyaluronic acid makes up all or part of the mucoid fluid.7
Wide nails often result from a crush injury with a tuft frac-
Ganglia are usually encountered on the dorsum of the wrist, in
ture.12 Separated bony fragments leave the nail bed flatter and
particular over the scapholunate ligament (Figure 105-1). They may
wider. Narrow nails occur when a central avulsion-laceration is not
also be found on the palmar surface of the wrist, the lateral sur-
repaired. Scar tissue forms in the center and allows the intact lateral
face of the wrist, or on the hand itself. Ganglia of the foot and ankle
portions to contract toward each other.12 The new nail subsequently
are less commonly seen.8 Ganglia are less commonly encountered
becomes narrow and thick.
in other areas such as the shoulder, hip, elbow, knee (including the
Tubular gauze dressings are commonly applied after the repair
anterior cruciate ligament), the lumbar spine, temporomandibular
of a nail bed. When improperly placed, tubular gauze dressings can
joint, and even the odontoid process of the cervical spine.9–11
result in significant injury.23,24 This includes digital ischemia that
Ganglia present as fixed or slightly movable masses that are usu-
may be permanent and require an amputation. Tubular gauze dress-
ally solitary. Frequently characterized as smooth and “rubbery,”
ings should not be placed by healthcare personnel not trained in
cysts may become more noticeable with wrist flexion. They vary in
their proper application.
size from barely palpable to 3 cm in diameter (smaller than 1.5 cm
SUMMARY being the norm). Tenderness is sometimes but not invariably pres-
ent. Ganglion cysts will transilluminate, as they are fluid-filled.
Nail bed injuries are common and may result in a cosmetically They may “disappear” over time by spontaneously rupturing or
deformed or functionally impaired fingertip. Complications may resorption.
occur even with precise repair. The treatment of choice is imme- Diagnosing a ganglion cyst is usually not difficult. However,
diate primary repair of the nail bed and surrounding structures. ganglia of the foot and those occurring in other uncommon loca-
Remember to minimize any debridement and to replace the nail tions may be difficult to palpate despite causing significant discom-
plate whenever possible. Injuries with associated fractures and sim- fort. The differential diagnosis of ganglia includes joint capsulitis,
ple subungual hematomas are managed separately from the nail bed neuromas, and other soft tissue neoplasms such as sarcomas and
injury. Always be thorough and meticulous when repairing nail bed chondrosarcomas. Ultrasonography can be employed to aid in the
injuries to provide the best possible outcome. Finally, know when to diagnosis, particularly of occult ganglia or ganglia presenting atypi-
consult with a Hand Surgeon. cally.12 MRI is frequently used to confirm the diagnosis and plan its
Ganglion Cyst Aspiration

105 and Injection
Thomas P. Graham
INTRODUCTION
Ganglion cysts, also known as synovial cysts or ganglia, are the most
common soft tissue tumors of the wrist and hand.1 They are a com-
mon reason for patients to present to the Emergency Department.
The chief complaint is usually a mild pain or ache, exacerbated by
movement, and localized to a 1 to 2 cm mass on the wrist or hand.
Patients may also present with concerns about a painless “lump.” FIGURE 105-1. Oblique view of the wrist demonstrating a ganglion cyst overlying
Acute trauma prior to presentation is uncommon, though patients the scapholunate joint.
CHAPTER 105: Ganglion Cyst Aspiration and Injection 705
operative removal. Plain radiographs and laboratory tests are not

helpful in the work-up.
INDICATIONS
The most common indication for ganglion aspiration is worsening
pain and swelling, in particular when normal range of motion is
restricted or occupational disability is present. Failure of conser-
vative measures such as rest, splinting, and the use of nonsteroi-
dal anti-inflammatory medications to resolve symptoms may also
prompt ganglion aspiration in the Emergency Department.
CONTRAINDICATIONS
There are few contraindications to ganglion cyst aspiration.
Introducing a needle through an area of cellulitis should be avoided.
However, cellulitis overlying a ganglion is uncommon and should
raise suspicion for an alternate diagnosis such as a skin abscess. The
procedure can be safely deferred, with the patient being given a refer-
ral to a Hand Surgeon, if the diagnosis of a ganglion is uncertain. FIGURE 105-2. Cross section through the scapholunate joint demonstrating a
The location of a ganglion is generally not a contraindication to ganglion cyst. The needle is inserted into the cyst cavity to aspirate its contents.
aspiration. However, the procedure should be deferred if there is a
concern that the aspirating needle could damage an adjacent struc-
ture and cause neurologic or vascular injury. Aspiration of lower
pressure to the syringe to aspirate the cyst contents once the tip of
extremity ganglia may be performed in a similar fashion to hand
the needle is within the cyst cavity. The contents may be difficult
and wrist lesions, with similar results.8,13 Some literature suggests
to aspirate, as the mucinous contents of the cyst are quite viscous.
that volar wrist ganglion cysts recur at an even higher rate than
The cyst can be manipulated and compressed to express more of
those of the dorsal wrist and lower extremity; leading some authors
the contents into the syringe once the very viscous, clear or yellow
to recommend surgical excision, and not aspiration, as the primary
material begins to flow into the syringe. Generally, 1 to 2 mL of fluid
therapy for this subset of ganglia.14
can be aspirated from a typical ganglion. Withdraw the needle when
fluid can no longer be aspirated. Apply a simple dressing. A pressure
EQUIPMENT dressing may also be temporarily applied, taking care not to com-
• Sterile gloves promise neurologic or vascular function.
• Povidone iodine solution or chlorhexidine solution
GLUCOCORTICOID INJECTION
• 25 or 27 gauge needle on a 3 mL syringe for local anesthesia The injection of glucocorticoids into a ganglion cyst immediately
after aspiration is commonly recommended. One small study
• 16 or 18 gauge needle on a 5 or 10 mL syringe for aspiration
showed glucocorticoid injections decreased recurrence rates com-
• 10 to 15 mg methylprednisolone acetate (20 mg/mL) or predniso- pared to aspiration alone.16 The literature has not yet shown a clear
lone tebutate (20 mg/mL) benefit.17 If a steroid injection is desired, securely hold the aspirating
needle in place after the cyst contents have been aspirated into the
PATIENT PREPARATION syringe. Remove the syringe. Without moving the needle, attach a
Explain the risks and benefits of the procedure to the patient and/or second syringe containing 10 to 15 mg of the glucocorticoid solu-
their representative. Obtain an informed consent, either signed or tion onto the needle. Aspirate to confirm the tip of the needle is not
verbal, with adequate documentation to support the latter method. within a vascular structure. Inject the glucocorticoid solution into
If available, ultrasonography can be used to confirm the diagnosis the cyst cavity. Withdraw the needle and apply a simple dressing.
and to facilitate needle entry into the cyst. When ganglia are located
near neurovascular structures, ultrasound can help to avoid these ALTERNATIVE TECHNIQUES
structures.15 Place the patient on a gurney with the hand on a bed- Other variations of ganglion cyst aspiration and injection have been
side procedure table. Clean the skin of any dirt and debris. Apply described in the literature. The injection of hyaluronidase into the
povidone iodine or chlorhexidine solution and allow it to dry. It cyst, with or without corticosteroids, has shown favorable results.18,19
is recommended to provide local anesthesia for patient comfort, Puncturing the ganglion wall at multiple separate locations has not
although the cyst can be aspirated and/or injected without anesthe- been proven to decrease the recurrence rate when compared to
sia. Place a subcutaneous wheal of local anesthetic solution immedi- aspiration at a single point alone.20 Injection of hypertonic saline
ately over or adjacent to the periphery of the ganglion. and other sclerosants (e.g., 1 mL of 3% sodium tetradecyl sulfate)
has been suggested. Further study is necessary before these tech-
TECHNIQUE niques can be recommended for widespread use in the Emergency
Department.
GANGLION ASPIRATION
ASSESSMENT
Manipulate the wrist (or other affected extremity) to expose more of
the cyst and facilitate needle entry into the cavity. Insert a 16 or 18 Patients usually report total or near-total relief of their symp-
gauge needle on a 5 or 10 mL syringe through the anesthetized tis- toms immediately after aspiration. Obtaining highly viscous, clear
sue and into the ganglion cyst cavity (Figure 105-2). Apply negative or yellow fluid from the cyst virtually confirms the diagnosis.
Obtaining purulent fluid suggests a skin abscess and not a gan-

glion cyst. Failure to obtain fluid does not rule out the diagno- Subcutaneous Abscess
sis of a ganglion, but should prompt an evaluation for alternative
diagnoses. 106 Incision and Drainage
Samuel J. Gutman and Michael B. Secter
AFTERCARE
INTRODUCTION
Patients should be reassured that ganglia are not malignant tumors.
Immobilization of the affected limb may be performed temporarily Subcutaneous abscesses are commonly seen in the Emergency
for patient comfort. However, splinting limits the ability of patients Department. Approximately 1% to 2.5% of patients present with
to function normally and does not appear to affect recurrence this chief complaint.1–3 Abscesses occur in numerous anatomical
rates.21 Aftercare instructions should direct patients to return to the areas with varied etiology and bacteriology. An abscess is a tender
Emergency Department for any significant increase in pain, ery- and fluctuant mass located in the dermal or subdermal tissue. It
thema at the site or up the extremity, swelling beyond the ganglion’s usually demonstrates the classic inflammatory responses of rubor,
original size, purulent discharge, continued bleeding, or the devel- tumor, dolor, and calor. Although the abscess is usually tender, the
opment of a fever. Patients should also be directed to elevate the surrounding and underlying tissue should not be tender.4,5 There is
extremity, avoid strenuous activity of the affected limb, and rewrap usually minimal surrounding erythema in a mature abscess.
the pressure dressing (if one is applied) to make it snug but not Incision and drainage is the definitive treatment of a soft tis-
uncomfortable. Acetaminophen or nonsteroidal anti-inflammatory sue abscess.6 This procedure results in significant improvement
medications may be recommended for relief of mild postprocedure in symptoms and a rapid resolution of the infection in uncompli-
pain. Narcotic analgesics are not required nor recommended. Oral cated cases.7 However, premature incision before localization of pus
corticosteroids have not been demonstrated to play a role in gan- will not be curative and may be deleterious. In cases of immature
glion therapy. abscesses or cellulitis, oral antibiotics and warm compresses may be
All patients with ganglion cysts aspirated in the Emergency of value in helping the infection to coalesce. These methods are not
Department should be informed of the potential for recurrence a substitute for incision and drainage and should not be continued
and the possibility of definitive ganglion treatment by surgi- for more than 24 to 36 hours without a reassessment of the patient.
cal excision. Referral to a Hand Surgeon should be provided, if With the emergence of methicillin-resistant Staphylococcus aureus
desired by the patient. Although reports of postsurgical recur- (MRSA), the role for ancillary antibiotic use has come into question.
rence rates vary widely, currently the most effective therapy for
ganglion cysts is believed to be open excision. During this proce- ANATOMY AND PATHOPHYSIOLOGY
dure, a Hand Surgeon removes the cyst and, if possible, the stalk
or pedicle that connects it to the normal synovium. Arthroscopic PATHOGENESIS
removal of wrist ganglia has also been described and performed
successfully.22 An abscess is a localized collection of pus caused by suppuration
buried in a tissue, organ, or confined space.8 Intact skin is very resis-
tant to bacterial invasion. Localized pyogenic infections are usually
COMPLICATIONS initiated by a breakdown in the normal epithelial defense mecha-
Complications of ganglion cyst aspiration are uncommon. They nisms in the normal host. Plugging of the ducts of a superficial
include bleeding and infection. Bleeding is self-limited and eas- exocrine gland, such as apocrine and sebaceous glands or a con-
ily controlled with manual pressure. The use of sterile technique genital cyst or sinus, may initiate the process. Occlusion prevents
will minimize any infectious complications (abscess, cellulitis, or desquamation and provides a moist environment for organisms to
septic arthritis). Rare complications of corticosteroid injection proliferate. The combination of a high concentration of organisms,
include localized depigmentation that is due to injection outside the presence of nutrients, and sufficient damage to the corneal skin
of the cyst capsule or leakage out of the cyst capsule through the layer to allow organisms to penetrate the skin defenses results in
needle tract.23 Subcutaneous infiltration of glucocorticoids can abscess formation.1,9
also result in fat atrophy, skin atrophy, and skin dimpling from fat Subcutaneous abscesses typically begin as a cellulitis with organ-
atrophy. isms that cause necrosis, liquefaction, and accumulation of leuko-
cytes and debris. Early stages appear as an area of hyperemia and
tender inflammation that later becomes fluctuant as an exudate of
SUMMARY leukocytes, necrotic material, and cellular debris accumulates. This
is followed by loculation and walling off of the pus. This progresses
Ganglion cysts are common growths of the wrist and hand. They
and the area of liquefaction increases until it “points” and eventually
frequently enlarge to cause pain, sometimes to the point of dis-
ruptures through the area of least resistance.5
ability. Contraindications to the aspiration of a ganglion cyst in the
The body area involved depends upon host factors such as drug
Emergency Department are few. The procedure is often warranted
use, employment-related exposures, or minor trauma.9,10 Areas with
due to debilitating pain, deformity, or inability on the patient’s part
a compromised blood supply are more prone to infection as nor-
to promptly seek the care of a surgical specialist. The procedure is
mal host cell-mediated immunity is not as available.9 The frequency
simple, quick, and only slightly uncomfortable if performed cor-
of abscess occurrence in different body areas includes the buttocks
rectly. Although the injection of steroids into the cyst is commonly
and perirectal area in 25% of cases, the head and neck in 20%, the
advocated to prevent recurrence, the efficacy of this procedure has
extremities in 18%, the axilla in 16%, and the inguinal area in 15%.1
not been conclusively demonstrated. Ganglia recurrence is very
common after aspiration and may occur even after surgical excision.
BACTERIOLOGY
This fact must be clearly relayed to the patient. All patients should
be offered referral to a Hand Surgeon on a nonemergent basis to The majority of abscesses are polymicrobial with the isolated organ-
discuss further intervention. isms usually representing the normal resident flora associated with
CHAPTER 106: Subcutaneous Abscess Incision and Drainage 707
the body area on which the abscess is found.1,11 Nonresident bacte- axilla, the inguinal region, or both.26 Initially, this process will
ria are found in abscesses that occur as a result of direct inocula- appear like a typical abscess and is only identifiable in its chronic
tion of extraneous organisms such as those following human bite scarring phase when there are multiple lesions with tender areas
wounds, intravenous drug use, or bacterial seeding of embedded of induration and inflammation in various stages of healing. The
foreign bodies.12 In normal hosts, aerobic Staphylococcus and group chronic process leads to draining fistulous tracts that require
A Streptococcus are the most common organisms isolated from ongoing surgical management. Emergency Department manage-
abscesses of the head, neck, extremities, and trunk.11,13 Anaerobes ment involves the usual incision and drainage procedure of any
are found in all areas of the body but predominate in abscesses of area of fluctuance. Patients should be informed that the interven-
the buttocks and perirectal regions.11,13 tion is not curative and that the problem is chronic. Arrange a
Staphylococcus aureus occurs in 24% to 60% of abscesses and in referral to a General Surgeon, Dermatologist, or Plastic Surgeon
pure cultures is the only organism in 21% to 72% of cases.1,13–16 for long-term follow-up.
Community-acquired MRSA (CA-MRSA) is presently considered Up to 80% of breast abscesses occur in nonlactating women.4
to be the most common identifiable pathogen causing abscess at Peripheral and superficial lesions are similar to abscesses elsewhere
major centers.17 CA-MRSA is defined as infection with MRSA on the body and respond to conservative incision and drainage
acquired in the community lacking the traditional risk factors of with an incision that radiates out (centripetally) from the nipple.27
hospital-acquired MRSA including a recent stay in a long-term Deeper and periareolar abscesses are often complex and require sur-
care facility or in a day care setting, recent healthcare contacts gical referral and general anesthesia to properly treat. Postpartum
or surgery, an indwelling device, dialysis, immunosuppression, mastitis is common and precipitated by milk stasis and bacterial
chronic illness, or recent antibiotic use.18,19 Many cohorts of invasion through a cracked nipple. The offending organism is com-
patients who are at a higher risk of acquiring MRSA infections monly Staphylococcus aureus or Streptococcus species. Treatment
include those with recent household or daycare contacts, children, includes the application of heat, oral antibiotics, and continued
men who have sex with men, those in the military, incarcerated breast emptying with a breast pump or feeding of the baby. The mas-
patients, athletes (especially those in contact sports or who share titis may evolve into an abscess and is often associated with systemic
equipment), Native Americans, Pacific Islanders, patients with symptoms. Appropriate antibiotic therapy and follow-up in 24 to
previous MRSA infections, and intravenous drug users.18–21 While 48 hours is required.
it is important to consider MRSA in patients with aforementioned Sebaceous cysts are a common cause of a subcutaneous abscess.
risk factors it is essential not to exclude MRSA in the absence of They can persist for long periods as nontender subcutaneous
them.17 Patients presenting with a complaint of a “spider bite” swellings before becoming infected. They appear like most other
should be investigated for MRSA.18,19,22 In a recent observational abscesses. Sebaceous cysts can be identified by a small punctate
study of urban patients, MRSA was isolated from abscesses in 51% sinus tract near the center of the fluctuant area. The initial treat-
of patients.23 An American study of 11 academic centers found ment is incision and drainage. The contents are usually thick cheesy
MRSA incidence rates as high as 74% in patients presenting with material that needs to be manually expressed. A sebaceous cyst has
abscesses.17 As much as 77% of MRSA-related illness, especially a definite shiny white capsule that must be excised, preferably at
presenting in the Emergency Department, are skin and soft tissue the time of incision and drainage or at the first follow-up visit, to
infections (SSTI).24 prevent recurrence. The area is then treated as any other healing
CA-MRSA carries the mecA gene, which is thought to impart abscess cavity.
the antimicrobial resistance. This is carried on the Staphylococcal The recurrence of an abscess that has been previously drained
Cassette Chromosome Type-IV, which is distinct from other forms should suggest the possibility of underlying osteomyelitis, a
of MRSA.18,19 CA-MRSA also produces an exotoxin called Panton- retained foreign body, or the presence of unusual organisms such
Valentine Leukocidin (PVL) that predisposes patients to cutaneous as mycobacteria or fungi. Recurrent abscesses should prompt fur-
infections.18,19 PVL has been identified in up to 98% of CA-MRSA ther investigation including an assessment of the patient’s immune
cases.17 status.
Up to 17% of abscesses are sterile.1,7,13 Nearly 40% of these are
secondary to intravenous drug use and most likely result from injec- SPECIAL CONSIDERATIONS
tion of necrotizing chemical irritants.3 Viruses (e.g., herpes), auto-
The precise risk for endocarditis associated with subcutaneous
immune mechanisms, or systemic illnesses including metastatic
abscesses is unknown. Up to 5% of patients with abscesses have
tumors, benign tumors, and granulomatous disease may also cause
bacteremia at the time of presentation.4,16 Incision and drainage
sterile abscesses.4,25 These atypical etiologies may present with the
of cutaneous abscesses can result in transient bacteremia with the
absence of local inflammatory signs and symptoms and only with
organism causing the abscess.7,14,28 More recently, the clinical rel-
an exacerbation of the underlying disease process.
evance of this bacteremia has become controversial.16 At this time,
only patients considered to be at high risk for endocarditis are
SPECIFIC CLINICAL ENTITIES
recommended to receive antimicrobial prophylaxis before inci-
Furuncles, or boils, are acute circumscribed abscesses of the skin sion and drainage (Table 106-1).29 Bacterial endocarditis prophy-
and subcutaneous tissue that most commonly occur on the face, laxis should be directed at the most likely pathogen causing the
neck, buttocks, thigh, perineum, breast, or axilla. Carbuncles are infection. An antistaphylococcal penicillin or a first-generation
aggregates of interconnected furuncles that frequently occur on cephalosporin is an appropriate choice for most soft tissue infec-
the back of the neck where the thick skin causes lateral exten- tions (Table 106-2). Clindamycin is an acceptable alternative for
sion of the infection rather than pointing toward the skin sur- patients allergic to penicillin. Patients with immunodeficiency and
face. These occur with a higher frequency in diabetics. They can localized soft tissue abscesses may be at higher risk for developing
be large and cause systemic signs, symptoms, and complications. septicemia secondary to bacteremia induced by incision and drain-
Carbuncles often require surgical consultation and treatment in age, but it is unclear if they are at higher risk of complications and
the Operating Room. death.30,31 These patients may benefit from prophylactic antibiotics
Hidradenitis suppurativa is a chronic relapsing inflammatory prior to incision and drainage, but only indirect evidence and no
disease process affecting the apocrine glands primarily in the controlled studies are available.32 High-risk patients with known
TABLE 106-1 Cardiac Conditions at Risk for Endocarditis that Require evolve into extensive necrotizing soft tissue infections.34 General
Antibiotic Prophylaxis for Incision and Drainage29 assessment of the airway and cardiopulmonary system, vital
Prosthetic cardiac valves—including bioprosthetic and homograft valves signs, and mental status is indicated if procedural sedation is to
Previous bacterial endocarditis be employed.33
Unrepaired cyanotic congenital heart disease (CHD)—including palliative shunts Routine laboratory studies are not indicated in otherwise healthy
and conduits individuals. In immunocompromised patients, a CBC looking for
Repaired CHD with prosthetic material or device—within 6 months after the leukopenia or toxic granulations should be considered. Diabetics
procedure (regardless of method of placement) should have electrolytes, BUN, creatinine, and glucose assessed.
Repaired CHD with residual defects at or adjacent to site of prosthetic patch or Elevated potassium in diabetics may indicate myonecrosis.35
device Consider a urinalysis for myoglobinuria.
Cardiac transplant with cardiac valvulopathy Culturing the purulent material from a drained abscess was pre-
Except for the conditions listed above antibiotic prophylaxis is no longer viously considered to be of little value. Controversy exists today
recommended for any other form of CHD as to the value of culture in abscess management. While many
experts suggest that it is of little value because it has no bearing
on acute management (curative I & D), others suggest that it is
vital to help determine antimicrobial susceptibility and outbreak
patterns.22 Cultures should be obtained as they may alter later
or suspected MRSA infection should receive IV Vancomycin or management in cases with recurrent or refractory infections,
Clindamycin when undergoing incision and drainage.29 those patients who are seriously ill or immunocompromised,
patients on an antimicrobial with variable activity, those who
have failed surgical treatment, and any patient being admit-
PATIENT ASSESSMENT ted to the hospital.22,36 Gram stain and cultures for both aerobic
Prior to the treatment of an abscess, a focused history should be and anaerobic bacteria may be helpful in those patients who are
taken assessing for trauma, intravenous drug use, history of fever, febrile, systemically unwell, immunocompromised, or who present
and past medical history. Specifically inquire about diabetes, renal atypically. Consider obtaining radiographs of the affected areas if
failure, steroid use or other immune suppression, peripheral vascu- there is a history of trauma, drug use, or concern regarding deep
lar disease, and valvular heart disease. It is important to note any infection. Foreign bodies and fractures may not be easily identifi-
of the aforementioned risk factors for CA-MRSA as this may alter able because of the edema and tenderness caused by the infection.
management of certain patient populations. Past anesthetic history Gas or osteolytic lesions on plain radiographs may indicate severe
and the potential for aspiration should be assessed if procedural deeper infection, the need for urgent surgical consultation, and
sedation is to be considered.33 Medications and allergies should be prompt antibiotic therapy.37
queried. The patient’s tetanus status must be confirmed and booster
doses provided as required.
A brief physical examination documenting function and intact
ULTRASONOGRAPHIC EVALUATION
distal neurovascular status of extremities involved is required. Bedside ultrasound use in the Emergency Department is of great
Evidence of pain on passive or active movement of fingers may value to the Emergency Physician in evaluating skin and soft tis-
suggest a deep space infection.4 A high index of suspicion is sue infections. This modality can be used to differentiate a cel-
required, especially in injection drug users (IDU), to identify lulitis from an abscess in difficult cases. Ultrasound is portable,
those seemingly simple cutaneous infections that unpredictably inexpensive, comfortable for patients, and provides no radiation
TABLE 106-2 Prophylactic Antibiotic Regimens for Procedures29

Clinical situation Agent Dose* Timing
Standard general prophylaxis Amoxicillin Adults: 2.0 g PO, 30–60 min prior to the procedure
Child: 50 mg/kg
Unable to take oral medications Ampicillin Adults: 2.0 g IV or IM, 30 min prior to the procedure
Child: 50 mg/kg
Unable to take oral medications Cefazolin or Ceftriaxone** Adults: 1.0 g IV or IM, 30–60 min before procedure
Child 50 mg/kg
Allergic to penicillin or ampicillin Cephalexin** Adults: 2.0 g PO, 30–60 min prior to procedure
Child: 50 mg/kg
Allergic to penicillin or ampicillin Clindamycin Adults: 600 mg PO, 30–60 min prior to procedure
Child: 20 mg/kg
Allergic to penicillin or ampicillin Azithromycin or Clarithromycin Adults: 500 mg PO, 30–60 min prior to procedure
Child: 15 mg/kg
Allergic to penicillin and unable Cefazolin or Ceftriaxone** Adults: 1.0 g IV or IM, 30–60 min prior to procedure
to take oral medications Child: 25 mg/kg
Allergic to penicillin and unable Clindamycin Adults: 600 mg IV or IM, 30-60 min prior to procedure
to take oral medications Child: 20 mg/kg
Known or suspected MRSA Vancomycin Adults: 1 g IV, 30 min prior to procedure
Child 20 mg/kg
* Total child dose should not exceed adult dose.
** Cephalosporins should not be used in patients with immediate-type hypersensitivity reactions (urticaria, angioedema, or anaphylaxis) to penicillin.
exposure. It is fast and easy to gain proficiency for specific appli-

cations.38 Ultrasound is indicated for ambiguous physical findings
such as widespread cellulitis, localizing an incision site, and for
ruling out dangerous masses such as a pseudoaneurysm that mas-
querade as an abscess.39 Ultrasonography is helpful in identifying
small or early abscesses, deep abscesses, abscesses under previ-
ous scars, and for localizing adjacent major vessels or nerves.39
Recent studies have found that ultrasound has a sensitivity of 98%
and specificity of 88% in detecting an abscess.38 One study of pre-
sumed cellulitis in the Emergency Department found that ultra-
sound changed the case management in 71 of 126 patients (56%),
as swelling thought to be due to cellulitis can hide an abscess.40 In
the pediatric population, ultrasound is useful in evaluating a cel-
lulitis and determining if an incision and drainage is necessary.41
Finally, ultrasound can be used to guide an aspiration to confirm
the presence of an abscess and to obtain material for culture and
gram stain.42 FIGURE 106-2. Ultrasound image showing a large hypoechoic area representing
Before ultrasonographic examination, it is important that the a large superficial abscess.
Emergency Physician has an appreciation of the anatomical struc-
tures of the area. The location and sonographic appearance of arter-
ies, veins, nerves, and tendons should be known before the incision
and drainage procedure. Generally, a 5 to 7.5 MHz linear array or elliptical shaped anechoic or echo-poor region with sharper echo-
transducer is used. Some find a standoff pad or gel-filled glove to genic borders.39,43 (Figure 106-2). Within the echo-poor area there
be useful for superficial structures.39 Once the probe has been elec- may be gas, lobulations, septations, and echogenic debris. There
tronically focused to an ideal depth, scan the area of infection in are some cases where the abscess can appear to be isoechoic and
two orthogonal planes.39,40 Lower frequency transducers are useful even hyperechoic. In these cases, there may be a role for ultrasound-
for deeper abscesses, while higher frequency probes are more effec- guided aspiration.43 If unsure if an abscess is present on ultrasound,
tive for superficial abscesses. It is important to use probe covers gentle digital palpation or pressure may induce motion of the puru-
as well as proper cleaning and disinfecting supplies in order to lent material within the abscess.43 Posterior acoustic enhancement
avoid cross contamination. can be seen in the presence of an abscess.39 This technique can help
Differentiation between a cellulitis and an abscess on ultrasound rule out similarly presenting hematomas, necrotic tumors, vascular
is based on several findings. Cellulitis shows diffuse hyperecho- lesions, or schwannomas.42 There is an emerging role for Doppler
genicity and thickening of the skin and subcutaneous fat. The pres- ultrasound in abscess evaluation. The findings of increased vascula-
ence of echo-poor strands between hyperechoic fatty lobules in the ture, peripheral blushing and hyperemia, and increased large vessel
subcutaneous tissue is known as cobblestoning and is indicative of flow around the abscess are common (Figure 106-3).44
cellulitis.38,39,42 (Figure 106-1). An abscess has a wider array of pre-
sentations on ultrasound. Most frequently, an abscess is a spherical INDICATIONS
The presence of a fluctuant mass in an area of induration, erythema,
and tenderness is clinical evidence that an abscess requires inci-
sion and drainage. Antimicrobial treatment without incision and
FIGURE 106-1. Ultrasound image of a breast showing cobblestoning of the sub-

cutaneous tissue indicative of edema secondary to cellulitis with echogenic mate- FIGURE 106-3. Color Doppler ultrasound image showing peripheral hyperemia
rial surrounded by echo-poor areas consistent with early abscess formation. around a large abscess cavity.
drainage can lead to treatment failures in patients with abscesses.45 • 4 × 4 gauze squares
Examination alone may not definitively indicate an abscess, espe- • Iodoform gauze packing
cially if it is deep. This can be further confirmed by bedside ultra-
• Adhesive tape
sound, with or without needle aspiration.4 Obtaining purulent
material on aspiration identifies an abscess and is an indication • Culture swabs and vials
for incision and drainage.4 If no pus is aspirated, oral antibiotics, • Ultrasound machine with a 5 to 7.5 MHz probe
warm compresses, and follow-up in 24 hours must be arranged for • Ultrasound probe covers
a reassessment.
• Ultrasound gel
• Standoff pad
CONTRAINDICATIONS
• Ultrasound probe cleaning and disinfecting solutions
The only absolute contraindication to the incision and drainage
of an abscess in the Emergency Department is the possible asso- PATIENT PREPARATION
ciation with a mycotic aneurysm.10,35 Commonly, abscesses overlie
large vessels including those in the anterior triangle of the neck, Explain the procedure, its risks, and benefits to the patient and/
the supraclavicular fossa, the deep space of the axilla, the antecu- or their representative. Patients should be warned of potential
bital fossa, the groin, and the popliteal space.46 In these locations, cosmetic complications prior to proceeding. Obtain an informed
or if the abscess is pulsatile, fine needle aspiration for blood, diag- consent to perform the procedure. If endocarditis prophylaxis is
nostic imaging, and/or angiography is indicated prior to incision indicated, oral regimens should be given 1 hour prior to the pro-
and drainage. cedure and parenteral regimens within 30 minutes of the proce-
Relative contraindications to incision and drainage include dure (Table 106-1). Clean the skin of any dirt and debris. Apply
an inability to achieve adequate anesthesia. An abscess associ- povidone iodine or chlorhexidine solution to the skin and allow it
ated with a deep foreign body that requires additional real-time to dry. Apply drapes to delineate a sterile field. Many Emergency
imaging such as a fluoroscopy or ultrasound may require surgical Physicians regard this last step optional. The procedure of cut-
referral.47 Proximity of an abscess to important neurologic, tenting into a contaminated abscess is considered to be clean and
dinous, or vascular structures may require specialty consultation not sterile.
and magnification in the operating room. Deep space infections
or involvement of any joint requires admission for parenteral ANESTHESIA
antibiotic therapy and possible operative debridement. Patients It is usually possible to achieve adequate anesthesia for the skin inci-
presenting with soft tissue infections exhibiting pain out of pro- sion but any additional manipulation may be painful. Local anes-
portion to physical examination findings or deep anesthesia of thetic infiltration is often less effective than in other procedures.
the involved or distal area should raise the possibility of deeper The pH of infected tissue is often low and retards the diffusion of
infections such as necrotizing fasciitis or myonecrosis.37 Perirectal the local anesthetic solution into nerve axons.48 A regional field
and periurethral abscesses are often larger and deeper than they block can be instituted by injecting a ring of 1% lidocaine or 0.5%
appear and may be complicated by sinus tracts that require explo- bupivacaine subcutaneously approximately 1 cm away from the
ration under general anesthesia. Manipulation of abscesses in the perimeter of the erythematous border of the abscess. The onset of
“danger triangle” of the face (corners of the mouth to glabella) anesthesia occurs after about 5 minutes. A small amount of local
can lead to septic thrombosis of the cavernous sinus. Periorbital anesthetic solution can be injected intradermally into the roof of
or orbital abscesses require ophthalmologic assessment and the abscess in a linear fashion along the line of the planned incision
treatment. (Figure 106-4A).4 Be careful during this portion of the procedure
as the abscess may be under pressure. The inadvertent injection of
EQUIPMENT local anesthetic solution into the abscess cavity may cause fluid to
be forcibly ejected toward the Emergency Physician. Appropriate
Anesthesia universal precautions should be employed including a face mask
• 18 and 27 gauge needles, 1½ in. long and eye protection.
In superficial abscesses or furuncles, which are unlikely to
• 10 mL syringes
require significant exploration, topical ethyl chloride spray can
• Povidone iodine or chlorhexidine solution be used to provide anesthesia. Invert the bottle and compress the
• Local anesthetic solution with epinephrine spray nozzle to begin the flow of fluid. Direct the spray toward the
• Local anesthetic solution without epinephrine if abscess is near planned site of incision. The pain relief from ethyl chloride is vari-
an end arteriolar system able and fleeting. It is also highly flammable.5 The application of
an ice pack over the planned incision site secured with an elastic
• Ethyl chloride spray
bandage for 15 minutes can also be effective. This may be especially
• Ice pack useful for children, those with severe needle phobias, or in cases of
Procedure a true anesthetic allergy.
Nitrous oxide is safe and was previously thought to be effective as
• #11 and #15 scalpel blades on a handle an adjunct to the incision and drainage of abscesses.49 More recently,
• Two hemostats, in two sizes for breaking up loculations and prob- it has been shown to cause no significant reduction in pain and to
ing the cavity only be marginally effective as an anxiolytic.50 Procedural sedation
• Scissors with agents such as ketofol (ketamine and propofol in a 50:50 mix-
ture in a dose of approximately 1 mL/kg IV in adults) can be use-
• Normal saline
ful in deep abscesses that require extensive probing.51 It is difficult
• 10 or 20 mL syringe with a 20 or 22 gauge angiocatheter to obtain adequate pain control in these cases, even with a well-
• Suction source, tubing, and catheter for larger abscesses performed field block.
FIGURE 106-4. Incision and drainage of a subcutaneous abscess. A. Infiltration of local anesthetic solution over the abscess. B. A straight incision to drain the abscess.
C. An elliptical incision to drain the abscess. D. The wound is irrigated with sterile saline. Any pockets of pus are opened by blunt dissection with the hemostat. E. The
wound is packed open.
TECHNIQUES straight incision with a #11 scalpel blade is usually performed

(Figure 106-4B). An elliptical incision with a #15 scalpel blade is
ASPIRATION an alternative and often results in a similar appearing final scar
(Figure 106-4C). The purpose of the elliptical incision is to remove
Aspiration is performed as a diagnostic procedure in cases of soft a full thickness wedge of tissue so that the wound will remain open.
tissue infections where the presence of an abscess is unclear, a This type of incision should not be made in cosmetically sensitive
mycotic aneurysm must be ruled out, or samples for Gram stain and areas (e.g., face, neck, or breasts) or in areas with minimal subcuta-
culture are required. Aspiration is not a therapeutic procedure in neous tissue (e.g., hands and feet). It is important to ensure a large
and of itself. Anesthetize the skin. If ultrasound is available, locate enough incision to promote adequate drainage with the excep-
the abscess cavity and try to determine the shortest needle path. tion of cosmetically sensitive areas where a stab incision may be
Insert an 18 gauge needle attached to a 10 mL syringe into the skin. initially attempted to limit scar formation.5
On ultrasound, the needle should appear as a bright, hyperechoic Debride any necrotic or devitalized tissue. Probe the cavity by
line with posterior reverberation artifact.42 As the needle penetrates inserting a hemostat. Gently spread the jaws open to break up any
deeper, it should become increasingly oblique. Apply negative pres- loculations and to release any further pockets of purulent material
sure to the syringe. Advance the needle into the area where pus or (Figure 106-4D).6 Rotate the hemostat around the entire abscess
blood is presumed to be loculated. The procedure should be ter- to break any loculations. A scalpel should not be used for the
minated and incision and drainage should be performed immedi- blunt dissection of an abscess cavity as it may cause additional tis-
ately if pus is obtained on aspiration. Anaerobic and aerobic culture sue damage and bacteremia.14 Remove the tough shiny capsule by
bottles should be inoculated directly from the syringe if cultures are grasping the edges with a hemostat and applying firm traction if the
indicated. Simple swabbing of the purulent material after incision abscess is due to an infected sebaceous cyst. The capsule can often
and drainage is inadequate for growth of anaerobic organisms. If be removed intact.
blood is aspirated, terminate the procedure and apply firm pressure Irrigate the abscess cavity with an 18 gauge angiocatheter
to the area to prevent a hematoma from forming. Angiography with attached to a 10 mL syringe containing sterile saline (Figure 106-
surgical consultation should immediately follow. If no pus or blood 4D). This will flush away all loosened purulent and necrotic
is aspirated, redirect the needle in several directions to confirm the material. Loosely pack iodoform gauze into the abscess cavity
absence of an abscess. Discharge the patient with oral antibiotics, (Figure 106-4E). Leave 1 to 2 cm of gauze exiting from the cavity
warm compresses, and follow-up in 24 hours for a reassessment. to prevent the incision from sealing over and ensure an adequate
drainage tract for the cavity. The value of antiseptic impregnated
gauze over plain gauze is uncertain. Do not over pack the abscess
INCISION AND DRAINAGE cavity as this may interfere with the inflammatory hyperemia nec-
Make an incision spanning the entire area of fluctuance and par- essary for healing or retard drainage and reproduce “abscess-like”
allel to the relaxed skin tension lines to reduce scarring.35 A conditions.6 Apply an absorbent dressing of 4 × 4 gauze over the
wound. Splinting and elevation of the affected area may be benefi- occurs in 5 to 9 days in most cases.4,6,15 The patient may be dis-
cial in select patients (e.g., young patients and confused patients). charged from medical care when all signs of infection (i.e., ery-
thema, drainage, pain, and induration) have resolved.
AFTERCARE
The majority of available evidence suggests that incision and FUTURE ADVANCES IN
drainage of subcutaneous abscesses alone is adequate treat- ABSCESS MANAGEMENT
ment and additional antimicrobial therapy is unnecessary in
It is currently standard practice to pack an abscess cavity after an
healthy patients with no major comorbidities. Many recent
incision and drainage. Packing is used for hemostasis, to keep the
studies involving abscesses, including those caused by MRSA,
abscess cavity from closing prematurely, and to debride the abscess
have demonstrated that patients have similar outcomes regard-
cavity. Packing an abscess cavity can be painful and requires multiple
less of whether or not appropriate antibiotics were used after an
follow-up visits. These visits are at an additional cost to the patient.
abscess incision and drainage.17,24,52–54 A pediatric study demon-
A small, prospective study of noncomplicated abscesses found not
strated 94% resolution with incision and drainage alone in patients
packing an abscess cavity resulted in less pain, less analgesic use,
with abscesses smaller than 5 cm in diameter.52 Some conflicting
and no increased morbidity.62 Further studies are required before
evidence from a retrospective cohort found ancillary antimicro-
any definitive recommendation can be made regarding to pack or
bial treatment active against MRSA had a resolution of 95% while
not to pack an abscess cavity.
those patients not receiving antimicrobial treatment had a resolu-
Abscesses are currently allowed to heal by granulation. This pro-
tion of only 87%.55
cess can take weeks and results in large scars. Primary suture clo-
Consider empiric antimicrobial therapy active against MRSA in
sure after incision and drainage has been used around the world
cases involving multiple lesions, cutaneous gangrene, immunocom-
except in the United States.63,64 This treatment can reduce scarring,
promised patients, extensive surrounding cellulitis, systemic toxic-
reduce pain, and promote faster healing. Most of the studies involve
ity, unusual pathogens, and in patients requiring hospitalization.36,56
a small number of patients, administered preprocedural antibiot-
Further, recommendations from the Center for Disease Control
ics, and were performed in the Operating Room. Further studies are
suggest antibiotics after incision and drainage in those with rapid
required before this change in practice can be recommended for the
progression, comorbidities such as diabetes mellitus, HIV, neoplas-
Emergency Department management of abscesses.
tic disease, those patients at extremes of age, abscesses in locations
that are difficult to drain or have a risk of septic phlebitis associ-
ated with it, and lack of response to incision and drainage alone.19 DECOLONIZATION AND PREVENTION
Pediatric patients with abscesses greater than 5 cm should also The role of decolonization regimes after incision and drainage
receive empiric antimicrobial therapy.52 does not have established effectiveness.19 However, a decoloni-
An oral antibiotic such as cephalexin can be a good first choice zation regimen may play a role in those patients with recurrent
for healthy individuals in areas where the prevalence of MRSA is infections, those not responding to therapy, or in patients with a
extremely low.19 Knowledge of local MRSA prevalence and anti- closely associated cohort at risk (e.g., infirmed family, sports teams,
microbial susceptibility patterns are paramount when selecting or the institutionalized).36 A recent randomized controlled trial of
the appropriate antibiotic.19,36 If more than 10% to 15% of com- 2% chlorhexidine gluconate wash, 2% mupirocin intranasal oint-
munity Staphylococcus aureus isolates are MRSA, empiric treatment ment and oral rifampin, and doxycycline for 7 days found that after
with agents that show activity against MRSA is warranted.57 Current 3 months, 74% of patients were free of MRSA colonization.61 This
guidelines for outpatient therapy suggest using trimethoprim- number dropped to 54% at 8 months post-treatment.61 Colonization
sulfamethoxazole, Clindamycin, Doxycycline, Minocycline, or rates vary by geography and colonization is considered a risk factor
Linezolid. Rifampin can be added to many of these antimicrobials, for MRSA infection. However, decolonization is not routinely rec-
but should not be used alone. IV therapy for patients with signifi- ommended due to limited supporting evidence, poor patient com-
cant comorbidities and signs of systemic infection should include pliance, and the risk of increasing antibiotic resistance.22
either Vancomycin, Daptomycin, Linezolid, or Tigecycline.22,56 Patient education is the most effective way to reduce the spread
Trimethoprim-sulfamethoxazole, Clindamycin, and Doxycycline of infection and recurrent infections from MRSA.19,22 Maintaining a
(if over the age of 7 years) are recommended in healthy children.58 clean and dry wound, frequent handwashing and bathing, avoiding
More serious infections should be approached with IV Vancomycin sharing any personal items at all (athletic or otherwise), laundering
or Clindamycin, with the addition of nafcillin or gentamicin, and clothing that has come into contact with the wound, avoiding skin
admission to the hospital.58 The addition of an agent active against to skin contact and disinfecting equipment and other surfaces are
Group A Streptococcus is also recommended in cases with a severe essential recommendations that should be made to outpatients with
surrounding cellulitis.19 Current literature and consideration of MRSA skin and soft tissue infections.19
the local antibiotic resistance patterns should guide antimicrobial
selection.19,56,59
COMPLICATIONS
Follow-up in 24 to 48 hours to remove the packing and assess
the response to therapy should be arranged. Pain can be ade- Complications resulting from the incision and drainage of an
quately controlled with the use of acetaminophen or nonsteroidal abscess are uncommon. In most cases, some scarring will result
anti-inflammatory drugs. Narcotic analgesics are rarely required. from deliberate open packing and secondary intention granulation
Instruct the patient to immediately return to the Emergency of the wound. Infectious complications, including inciting bacterial
Department if they develop fever, chills, increased pain, increased endocarditis as discussed earlier, are possible. Endocarditis can be
swelling, or increased redness to the surrounding skin. Repack avoided with appropriate screening of patients and the admin-
the cavity approximately every 48 hours until granulation tissue is istration of prophylactic antibiotic therapy in patients at risk.
developing throughout the wound and the drainage tract is well Precipitation of septicemia because of transient bacteremia in an
established if a large amount of drainage continues.15,60 At that time, immunodeficient patient must be considered prior to the procedure.
the remaining packing is removed and the patient is instructed to Incision and drainage of a mycotic aneurysm should not occur if an
soak the area in warm water three to four times per day.3 Healing appropriate assessment is completed prior to making the incision.
CHAPTER 107: Paronychia or Eponychia Incision and Drainage 713
SUMMARY the use of artificial nails, hangnails or ingrown nails, or nail biting.2
A disruption of the seal between the nail plate and nail fold allows
Simple incision and drainage under local or regional anesthesia in bacteria to enter, leading to pus formation in the eponychial space
the Emergency Department can effectively treat most subcutane- (Figure 107-1). It begins as a swelling and erythema in the dor-
ous abscesses. Adjunctive procedural sedation may be required solateral corner of the nail fold that can progress to an abscess. A
to adequately probe a deep cavity. A directed history and physical paronychia can grow and spread to adjacent structures and result in
examination will identify those who may require additional lab a felon, an osteomyelitis, or a tenosynovitis. Many paronychias are
work, imaging, specialty consultation, and follow-up. The majority polymicrobial, containing both aerobic and anaerobic organisms.14
of patients will not require antibiotics, although there may be a role The most common organism to cause a paronychia is Staphylococcus
for ancillary treatment in selected patients with MRSA infections. aureus.3 In children and nail biters, paronychias are often caused
Attention must be paid to requirements for endocarditis prophy- by anaerobes secondary to finger sucking or nail biting.4 Gram-
laxis and consideration given to the possibility of inducing bactere- negative organisms should be considered in immunocompromised
mia in any given patient. hosts. Chronic paronychias are the result of separation of the nail
from the nail plate, which leaves a space for bacteria and fungi to
collect.12 These infections are usually caused by Candida albicans.5
INDICATIONS
Paronychia or Eponychia
107 Incision and Drainage
An early paronychia with signs of cellulitis may be treated nonsur-
gically. This requires frequent warm soaks (e.g., water, vinegar, or
Burow’s solution), immobilization, elevation, topical antibiotics (e.g.,
Lisa R. Palivos
bacitracin or Mupirocin) with or without topical corticosteroids, and
follow-up in 24 hours.2,6,11,12 Paronychia resistant to these measures
INTRODUCTION should be treated with oral antibiotics to cover Staphylococcus, plus
A paronychia is an infection or abscess of the tissues around the anaerobic coverage if nail biting or finger sucking were causative
base and along the sides of the nail plate. It is the most common agents.12 Amoxicillin/clavulanate, clindamycin, and trimethoprim-
infection in the hand.1 A paronychia can be located on the fingers or sulfamethoxazole are commonly used antibiotics. Take into account
the toes. It occurs in all age groups. It can cause significant pain and the prevalence of methicillin-resistant Staphylococcus aureus in your
discomfort leading to a visit to the Emergency Department. community when deciding upon the choice of antibiotic.
A paronychia initially presents with redness, swelling, and ten- A progression of the infection results in fluctuance and the forma-
derness along the edges of the nail plate. This can progress to an tion of an abscess. The digital pressure test may be used to diagnose
abscess that requires drainage. An infection that extends to the the presence of an abscess when the exam is otherwise equivocal.
overlying proximal cuticle is termed an eponychia. This chapter dis- Instruct the patient to oppose the thumb and affected finger and
cusses the treatments, which vary with the extent and the location apply light pressure to the distal volar aspect of the affected digit.
of the infection. If an abscess is present, the skin under the nail plate will blanch.10
The presence of an abscess, fluctuance, or pus beneath the nail plate
ANATOMY AND PATHOPHYSIOLOGY requires an incision and drainage procedure. This procedure will
relieve the patient’s pain, promote healing, and prevent complica-
The dorsal aspect of the distal digit consists of the nail plate, the nail tions from local extension into surrounding bone and soft tissues.
bed (matrix), and the perionychium (Figure 107-1). The nail bed is
situated beneath the nail plate and is responsible for growth of the CONTRAINDICATIONS
nail. The perionychium consists of the soft tissue surrounding the
nail plate (eponychium and lateral nail folds). A herpetic whitlow is a herpes simplex virus infection of the distal
A paronychia is usually the result of frequent trauma, tight fitting phalanx that can be confused with an early paronychia or felon. The
apparel (e.g., gloves, pantyhose, and shoes), aggressive manicures, presence of multiple clear vesicles that coalesce suggests a herpetic
whitlow. The herpetic whitlow is a nonsurgical and self-limited
infection. Treatment consists of a dry dressing to the affected finger
in order to prevent autoinoculation and transmission of the infec-
Distal tion, oral antiviral agents, and analgesics. Incision and drainage is
interphalangeal not recommended, will prolong the recovery, and lead to secondary
joint bacterial infection.7 A chronic paronychia should be referred to a
Hand Surgeon or Dermatologist for treatment.
Eponychium
(proximal EQUIPMENT
nail fold) Perionychium
Lateral
nail fold • Sterile gloves
• #11 scalpel blade or an 18 gauge needle
Nail plate
• 18 and 27gauge needles
Paronychia
• 5 to 10 mL syringe
Hyponychium
• Ethyl chloride spray
FIGURE 107-1. The distal finger illustrating a paronychia and the surface anatomy. • Forceps
• Mosquito hemostat
• Ribbon-gauze packing, ½ in. wide
• Petrolatum gauze, ½ in. wide
• Scissors
• 20 mL syringe
A Portion of nail
• Sterile saline to be removed
• Adhesive tape Small incision
may be necessary
PATIENT PREPARATION
Assess and update the patient’s tetanus immune status if indicated.
Place the patient on a gurney with the extremity on a bedside pro- B
cedure table in a well-lit room. Soak the digit in warm water for
5 minutes to soften the skin. Perform a digital nerve block if the
patient is apprehensive, has significant tenderness, or if it is not a Petrolatum gauze
simple paronychia or eponychia. Refer to Chapter 126 for the com-
plete details regarding digital anesthesia techniques. Alternatively, FIGURE 107-3. Removal of the lateral nail plate is required when pus extends
apply ethyl chloride spray to the area until the skin turns frosty and laterally below the nail plate. A. The dotted line over the nail represents the inci-
pale. Apply povidone iodine or chlorhexidine solution circumferen- sion required to remove the nail plate. An additional incision may be required on
tially to the distal digit and allow it to dry. The digit can be secured the eponychium. B. The lateral portion of the nail plate has been removed and
to a sterile tongue depressor for better control, especially in unco- petrolatum-gauze packing has been inserted to keep the nail fold elevated from
operative children. the nail bed.
TECHNIQUES
the elevated soft tissue followed by a simple dressing. If packing is
SIMPLE PARONYCHIA OR EPONYCHIA not performed, apply an antibiotic ointment followed by a simple
dressing or bandage. Oral antibiotics are not recommended for an
There is no need for a skin incision in an uncomplicated paro- uncomplicated paronychia or eponychia.
nychia or eponychia. Simply lifting the eponychium off the nail
plate at the point of maximal tenderness and/or fluctuance is usually PARONYCHIA WITH EXTENSION
curative. Slide the tip of a #11 scalpel blade (or an 18 gauge needle) UNDER THE LATERAL NAIL PLATE
under the paronychia, or eponychia, at the site of maximal fluctu-
ance (Figure 107-2). Advance the scalpel blade to lift the soft tissue A more extensive incision and drainage is required when pus accu-
from the nail plate until there is an efflux of purulent fluid. Apply mulates laterally and beneath the nail plate. Remove the lateral nail
digital pressure to the area to express the pus. Gently place a hemo- plate to allow adequate drainage (Figure 107-3A). Use scissors
stat under the soft tissue to break any loculations. Irrigate the pocket to cut the nail plate longitudinally. Aim the point of the scissors
with an angiocatheter on a syringe containing sterile saline. upward and against the undersurface of the nail plate to prevent
Packing a paronychia is controversial and physician-dependent. injuring the nail bed. Remove the lateral nail plate with a hemostat.
Place a small piece of ribbon gauze or petrolatum gauze under A small (2 to 3 mm) incision may be required in the corner of the
nail fold to remove the nail plate (Figure 107-3A). This will result
in the egress of pus. Irrigate the area with saline. Insert a small piece
of petrolatum gauze under the nail fold (Figure 107-3B). This will
prevent the nail fold from fusing to the nail bed.
PARONYCHIA WITH EXTENSION

UNDER THE PROXIMAL NAIL PLATE
A paronychia with extension under the proximal nail plate also
requires the removal of a portion of the nail plate (Figure 107-4).
Make two 3 to 4 mm long incisions at the corners of the nail folds
(Figure 107-4A). Cut the proximal one-third of the nail plate with
scissors (Figure 107-4B). Aim the point of the scissors upward and
against the undersurface of the nail plate to prevent injuring the nail
bed. Grasp and remove the proximal segment of the nail plate with
a hemostat. This will result in the egress of pus. Irrigate the area
FIGURE 107-2. Drainage of a simple paronychia or eponychia. The eponychial with saline. Insert a piece of petrolatum gauze under the nail fold to
fold is elevated from the nail plate with a #11 scalpel blade. Note that the blade is prevent it from fusing to the nail bed (Figure 107-4C).
parallel to the nail plate, thereby avoiding injury to the nail matrix and not incising Removal of the entire nail is rarely necessary except in the case
the skin. of an extensive subungual abscess. An alternative to nail removal
CHAPTER 107: Paronychia or Eponychia Incision and Drainage 715
coexists with S. aureus.5,6 Initial treatment typically includes avoid-

ing the noxious exposure, topical emollients, and antifungals.13
Definitive treatment for a chronic paronychia is eponychial marsu-
pialization. This involves removal of a crescent-shaped piece of skin
proximal to the nail fold and parallel to the eponychium, extending
from the radial to ulnar borders. In addition to marsupialization,
complete or partial nail removal may be necessary if nail ridging is
present.9 A chronic paronychia may be confused with another con-
dition that looks similar and mimics a chronic paronychia such as
cysts, foreign body reactions, malignancies, psoriasis, and verrucae.
Refer all chronic paronychia to a Hand Surgeon due to the higher
rate of recurrence, the complexity in management, and where
follow-up care can be more consistent.
AFTERCARE
Immobilize and elevate the digit. Instruct the patient to avoid nail
biting or sucking. Any discomfort can be treated with acetamino-
phen or nonsteroidal anti-inflammatory medications. Follow-up
care in 24 hours is important as complications can occur despite
proper Emergency Department management. Packing of a simple
paronychia should be removed in 24 hours. Warm soaks can begin
immediately if packing is not placed. Otherwise, warm soaks should
be delayed until the packing is removed in 24 hours. There is no evi-
dence that oral antibiotics improve outcome after the incision and
drainage of a simple and uncomplicated paronychia. Oral antibiot-
ics are not necessary unless the nail bed is involved, there is apparent
cellulitis of the surrounding tissue, or if there are systemic signs of
infections such as lymphangitis and fever.6 Patients should return
to the Emergency Department if they develop a fever, reaccumula-
tion of pus, redness extending up the finger and hand, or increased
tenderness to the digit.
Most simple paronychias resolve within a few days. If they per-
sist longer or recur, consult a Hand Surgeon for more aggressive
management, such as eponychial marsupialization and nail plate
removal.
Paronychia or eponychia that extend under the nail plate require
follow-up in 24 hours. The packing must be maintained between the
nail fold and the nail bed for at least 5 to 7 days. The nail fold will
FIGURE 107-4. Removal of the proximal nail plate is required when pus extends fuse to the nail bed if the packing is removed too soon and a new
proximally below the nail plate. A. Two incisions are required through the eponych- nail plate will not form. These infections require a 5 to 7 day course
ium, represented by dotted lines. B. The dotted line over the nail plate represents of oral antistaphylococcal antibiotics. Nonsteroidal anti-inflamma-
the incision required to remove the nail plate. C. The proximal portion of the nail tory medications supplemented with occasional narcotic analgesics
plate has been removed and petrolatum-gauze packing has been inserted to keep will provide adequate pain control for these patients.
the nail fold elevated from the nail bed.
COMPLICATIONS
Complications, even in a properly drained paronychia, include
is trephination with a heated paper clip or a microcautery unit.8 A a felon, osteomyelitis of the distal phalanx, and a tenosynovitis.
large opening or multiple holes are required with this technique in Superinfection with C. albicans or other fungi can also occur. These
order to eliminate the pus. Refer to Chapter 102 for the complete complications can be due to the paronychia itself or from an inad-
details regarding trephination. equate incision and drainage procedure.
Complications from the incision and drainage procedure are rare
CHRONIC PARONYCHIA if it is properly performed. Care must be taken if the lateral or proxi-
A chronic paronychia occurs from recurrent episodes of inflamma- mal nail plate is removed to avoid damaging the underlying matrix
tion or from neglected infections. It is much more difficult to treat so that a nail deformity does not result. Fusion of the nail fold to
and eradicate than an acute infection. A chronic paronychia is seen the nail bed will result in a new nail not being formed. Inadequate
frequently in immunosuppressed patients, such as those with dia- drainage can result in the infection spreading to adjacent bone and
betes or cancer. These effects are due to the disease process, such as soft tissues. Incision of the skin instead of elevating it off the nail
in diabetes, or due to effects of treatment, as seen with certain HIV plate can result in prolonged healing.
drugs and chemotherapeutic agents.12 A chronic paronychia is also
common in people who wash their hands often, such as dishwash-
SUMMARY
ers and healthcare providers. It can also be due to frequent contact A paronychia is one of the most common hand infections. The treat-
with chemicals, finger biting or sucking, and cuticle trimming. The ment depends on the extent and location of the infection. The inci-
most frequently isolated organism is C. albicans, which commonly sion and drainage procedure is quick, simple, and easy to perform.
Simple paronychias require elevation of the nail fold with no inci- septa extend from the volar surface of the fat pad to the periosteum of
sion. A more extensive incision and drainage is required along with the distal phalanx. They divide and compartmentalize the pulp area.
nail excision when pus accumulates below the nail plate. Follow-up When an abscess occurs, it is confined by the septa. They also limit
is critical as complications may occur, even when the Emergency the proximal spread of an infection. Unfortunately, they also inhibit
Department treatment is optimal. the abscess from reaching the surface and inhibit drainage after the
incision and drainage procedure. Blood is supplied by branches of the
digital arteries that run parallel and lateral to the phalanx and termi-
nate in the pulp region. The terminal branches of the digital nerves lie
palmer and superficial to the arteries. The flexor digitorum profun-
Felon Incision dus tendon inserts on the volar surface of the proximal distal phalanx.
108 and Drainage INDICATIONS

Lisa R. Palivos All felons that are fluctuant should be incised and drained. Volar
digital pads that are tense, tender, painful, and suspected of contain-
INTRODUCTION ing a felon should be incised and drained regardless if fluctuance is
palpated or not.
A felon is a subcutaneous infection or abscess in the pulp space
on the volar surface of the distal phalanx. It is usually caused by CONTRAINDICATIONS
penetrating trauma, an abrasion, spread from adjacent tissues (e.g.,
eponychium, osteomyelitis, or paronychia), or a minor cut with Felons that are not yet fluctuant, as in an early infection, may be
invasion of bacteria. A felon can also develop in the presence of a treated with warm soaks, elevation, oral antibiotics, and follow-up
foreign body, such as a wood splinter or a thorn.1 It can be iatrogenic in 24 hours.6,7 A herpetic whitlow can sometimes be confused with
from multiple fingersticks for glucose determination.2 The offend- a felon.5,9 A herpetic whitlow can be clinically distinguished by the
ing organism is usually Staphylococcus aureus. Mixed infections and presence of multiple vesicles and a history of recurrence or simul-
gram-negative infections may occur in the immunocompromised taneous genital or oral lesions. Treatment of a herpetic whitlow is
patient. A felon can less commonly occur on the toes. The informa- nonsurgical and consists of a protective dry dressing, oral antiviral
tion in this chapter can be applied to a felon of the finger or the toe. agents, and analgesics. Incision and drainage of a herpetic whitlow
may spread the virus and predispose the patient to secondary bacte-
rial infection.9
ANATOMY AND PATHOPHYSIOLOGY Consult a Hand Surgeon for complicated felons. This includes a
Felons initially present with a gradual onset of pain and erythema of felon that is associated with lymphangitis, osteomyelitis, a tenosyno-
the distal volar finger. Intense throbbing pain, warmth, and swelling vitis, an infection that has spread proximal to the distal interphalan-
develop with the formation of an abscess as the infection progresses. geal joint, or if the patient is immunocompromised. These patients
The proper treatment for a felon is incision and drainage. There require hospital admission, intravenous antibiotics, and possible
are multiple techniques to incise and drain a felon. The patient incision and drainage in the Operating Room.
requires digital elevation, immobilization, oral antistaphylococcal
antibiotics, oral analgesics, and close follow-up to prevent compli- EQUIPMENT
cations following the incision and drainage.3–7
The distal finger consists of a closed compartment that is bound • Povidone iodine or chlorhexidine solution
by the nail plate dorsally, by the skin ventrally and distally, and by • Sterile gloves
the flexion crease proximally (Figure 108-1). This pulp region is • #11 scalpel blade on a handle
divided by multiple (up to 15 or 20) vertical fibrous septa.8 These
• 18 and 27 gauge needles
• 5 or 10 mL syringe
Nail Extensor digitorum
plate Cuticle tendon • 20 mL syringe
(eponychium) • Ethyl chloride spray
Nail bed Middle
matrix phalanx • Sterile saline
• Mosquito hemostat
• Ribbon gauze, ½ in. wide
• Bandage material
Distal • Digital splint (plaster, preformed, or tongue depressor)
phalanx • Sling
• Digital tourniquet, optional
Nerves • Aerobic and anaerobic culture bottles, optional
Septa
Arteries
PATIENT PREPARATION
Distal anterior Flexor digitorum
closed space (pulp) profundus tendon Explain the procedure, its risks, and benefits to the patient and/or
FIGURE 108-1. Midsagittal section demonstrating the anatomy of the distal finger. Assess and update the patient’s tetanus immune status if indicated.
CHAPTER 108: Felon Incision and Drainage 717
Gently probe the loculations with a mosquito hemostat. Irrigate the

A B wound with an 18 gauge angiocatheter on a 5 or 10 mL syringe con-
taining sterile saline. Place a piece of ribbon gauze into the wound.
Apply a dry bulky dressing.
Alternative incisions have been advocated but are not recom-
Avoid distal mended because they have higher complication rates (Figure
digital nerves 108-3). These incisions can result in neurovascular injury, pain-
ful scars, and altered fingertip sensation. The hockey stick inci-
sion can result in digital nerve injury and produce numbness to the
FIGURE 108-2. Recommended incisions for the incision and drainage of a felon. fingertip (Figure 108-3A).5 The through-and-through or bilateral
A felon should be incised and drained in the area of maximal fluctuance. A. The longitudinal incision can result in bilateral digital nerve injury and
longitudinal fat pad incision over the area of maximum fluctuance. B. The unilat- complete anesthesia of the fingertip (Figure 108-3B).6 The trans-
eral longitudinal incision is high, lateral, and just below the level of the nail. verse palmar incision may transect the digital neurovascular bun-
dles (Figure 108-3C). The fishmouth or horseshoe incision is very
extensive, can take a long time to heal, produces a large scar, and an
unstable pulp (Figure 108-3D).5
Some physicians prefer to obtain anteroposterior and lateral radio-
graphs of the digit to rule out an osteomyelitis or foreign body prior AFTERCARE
to performing the procedure. A positive radiograph for osteomy-
elitis will alter the time course for antibiotic therapy and require Splint the involved digit. Provide the patient a sling to keep the hand
follow-up with a Hand Surgeon. elevated. Since the incidence of community-acquired methicillin-
Place the patient on a gurney with the extremity on a bedside resistant Staphylococcus aureus (CA-MRSA) skin and soft tissue
procedure table in a well-lit room. Soak the digit in warm water for infections presenting to the Emergency Department are increasing,
5 minutes to soften the skin. Perform a digital nerve block if the an oral antibiotic effective against CA-MRSA is recommended.10,11
patient is apprehensive, has significant tenderness, or if it is not a Depending on local resistance patterns, sulfamethoxazole-trime-
simple felon. Refer to Chapter 126 for the complete details regard- thoprim, doxycycline, or clindamycin are appropriate choices for a 7
ing digital anesthesia techniques. Alternatively, apply ethyl chloride to 10 day course. Nonsteroidal anti-inflammatory medications sup-
spray to the area until the skin turns frosty and pale. Apply povidone plemented with narcotic analgesics will control any postprocedural
iodine or chlorhexidine solution circumferentially to the distal digit pain. Instruct the patient to soak the digit in warm water several
and allow it to dry. Apply sterile drapes to delineate a sterile field. times a day to speed healing. Patients should immediately return to
The digit can be secured to a sterile tongue depressor for better con- the Emergency Department if they experience fever, increased pain,
trol, especially in uncooperative children. The application of a digi- difficulty using the finger, redness of the finger or hand or arm, or a
tal tourniquet to create a bloodless field is optional. discharge from the wound.
The patient should be reevaluated in 24 to 48 hours for removal
TECHNIQUES of the gauze and inspection of the digit. Remove the gauze during
the follow-up visit. Perform a digital or metacarpal block for patient
Multiple incisions can be employed. Make an incision in the area of comfort. Irrigate the wound with sterile saline and break up any
greatest fluctuance or tenderness with a #11 scalpel blade.3–6 Make further loculations, if needed. Replace the gauze for another 24 to
a longitudinal incision if the maximal tenderness is in the center 48 hours if there is continued drainage.
of the pulp of the distal fingertip (Figure 108-2A). The incision
should not come within 4 mm of or cross the crease of the dis- COMPLICATIONS
tal interphalangeal joint as this can lead to injury of the flexor
digitorum longus tendon or the joint, flexor tenosynovitis, and Untreated or mistreated felons may cause skin necrosis, osteitis or
flexion contractures.7 Make the incision along the lateral surface osteomyelitis of the distal phalanx, septic arthritis of the distal inter-
of the finger if the felon has maximal tenderness on the radial or phalangeal joint, extension of the infection into the palm and adja-
ulnar aspect of the finger (Figure 108-2B). Purulent and/or bloody cent fingers, suppurative tenosynovitis, and lymphangitis.12 Flexor
pink fluid will exit from the incision. While not required, consider tenosynovitis can occur if the incision is extended too far proxi-
obtaining aerobic and anaerobic cultures of the purulent material. mally and too deep. Improperly placed incisions can result in injury
A B C D
FIGURE 108-3. Incisions not recommended for the drainage

of a felon. A. The hockey stick incision. B. The through-and-
through or bilateral longitudinal incision. C. The transverse
palmar incision. D. The fishmouth incision.
to the flexor digitorum profundus tendon or the distal interphalan-

geal joint, mobility of the pad of the finger, neurologic compromise,
and/or vascular compromise. The lack of improvement within 24 to
48 hours requires consultation with a Hand Surgeon.
SUMMARY
Felons require incision and drainage. The procedure is quick, sim-
ple, and easy to perform. The incision should be made at the point
of maximal fluctuance while avoiding injury to the digital arteries,
digital nerves, the flexor digitorum profundus tendon, and the distal
interphalangeal joint. Close follow-up is mandatory to prevent any
complications. Consult a Hand Surgeon for any complications asso-
ciated with the felon.
Pilonidal Abscess or Cyst

109 Incision and Drainage FIGURE 109-1. Pilonidal sinuses occur in the midline, approximately 4 to 5 cm
Lauren M. Smith above the anus and in the natal cleft.
INTRODUCTION
Controversy surrounds pilonidal disease, from who first described appreciated. The sinuses may be quite extensive depending upon the
it, to the etiology, and how to manage it surgically. Some believe that chronicity of the disease process prior to presentation.
pilonidal disease was first described in 1880 by Hodges.1 However,
others say it was first described in 1833 by Mayo.2 Hodges used the ANATOMY AND PATHOPHYSIOLOGY
term “pilonidal sinus” to describe a chronic infection that contained
hair and was usually found between the buttocks. The word “piloni- A pilonidal sinus consists of a characteristic midline opening,
dal” comes from “pilus” or hair and “nidus” or nest. It literally means or series of openings, in the upper aspect of the gluteal cleft and
“nest of hair.” The condition did not receive much attention until it approximately 4 to 5 cm from the anus (Figure 109-1). The skin
became a significant problem in the armed services around the time enters the sinus giving the opening a smooth edge. This primary
of World War II. In 1940, in the United States Navy, the number of tract leads into a subcutaneous cavity that contains granulation tis-
sick days caused by pilonidal disease and its complications exceeded sue and often a nest of hairs (Figure 109-2). The hairs may be seen
those of either syphilis or hernias.3 This condition was coined as projecting through the skin opening. Many sinuses have lateral or
“jeep disease” by Buie in 1944 because of the high occurrence rate secondary openings (fistulas) extending from the pilonidal abscess
in those that drove or were frequent passengers in military vehicles.4 (Figure 109-2).
Pilonidal sinus disease primarily affects Caucasian males. Blacks There have been various opinions as to the etiology of the con-
are infrequently affected and the condition is rare in Asians and dition since the first description of the disease. In the first half of
Indians. Males are affected three to four times more frequently than the twentieth century, it was generally attributed to a congenital
females. The affected females tend to be younger than males.19 The lesion. Some authors believed that the pilonidal sinus originated
condition is prevalent from the onset of puberty to young adulthood from a remnant of the medullary canal that subsequently became
and is rare after the age of 40. The peak age of incidence is 21 years. infected. However, pilonidal disease can form in other areas of the
The increased incidence in adolescents and young adults is attrib- body that lack hair, as some barbers have experienced in interdigi-
uted to hormonal effects of increased hair on the torso, increased tal spaces.10,11 Currently, it is widely accepted that pilonidal disease
activity of sebaceous and sweat glands, fat deposition on the but- is acquired.5 Some of the contributing factors to this belief are the
tocks, and deepening of the gluteal cleft. Other risk factors may
include hirsutism, obesity, and poor personal hygiene. Repeated
trauma to the area may also contribute to the formation of pilonidal
disease. There is an increased prevalence in drivers and others with
occupations requiring long periods of sitting.6,7
Patients with pilonidal sinus disease may present with three dif-
ferent clinical pictures: asymptomatic disease, an acute abscess,
or chronic disease. Asymptomatic disease patients have a painless
sinus pit at the top of the natal cleft. Patients with chronic disease
may have mild discomfort and a chronically draining sinus in the
upper gluteal region. Approximately 50% of patients with symp-
tomatic pilonidal disease will present acutely with severe pain and
frequently swelling that is indicative of a pilonidal abscess that
necessitates incision and drainage.8,9 Inspection will reveal one or
more midline sinus tract openings, often with protruding tufts of FIGURE 109-2. Cross section through a pilonidal abscess and sinus. A primary
hair. The area will be tender, erythematous, and indurated when tract and skin pit leads to the subcutaneous abscess. There may be secondary or
an abscess is present. Fluctuance and swelling may not be readily lateral openings (fistulas).
CHAPTER 109: Pilonidal Abscess or Cyst Incision and Drainage 719
rate of recurrence after excision, occurrence at other sites than the • Skin razor
gluteal cleft, and the frequency seen among certain populations (i.e., • 10 mL syringe
barbers, armed forces, etc.).10,11
• 25 or 27 gauge needle, 2 in. long
Loose hairs from the adjacent gluteal region are thought to form
a bristly tuft and penetrate into the skin, perhaps in an area of skin • Local anesthetic solution with epinephrine, lidocaine, or bupiva-
irregularity. This process may be aided by pressure on the region in caine
persons with occupations that require long hours of driving or sit- • #11 scalpel blade on a handle
ting. The hairs may also be pulled in by a suction effect between the • #15 scalpel blade on a handle
moving buttocks. The hair penetrates the skin and causes a foreign
body reaction and secondary inflammation with the potential for • Curved hemostat
infection and abscess formation. The sinuses spread cranially and • 4 × 4 gauze squares
laterally. They rarely approach the anus and generally remain super- • Ribbon gauze, plain or iodoform
ficial to the presacral fascia.9,10,12
• Adhesive tape
INDICATIONS PATIENT PREPARATION
Incision and drainage is indicated whenever a patient presents with Explain the risks, benefits, and potential complications of the proce-
a pilonidal abscess. Antibiotics alone are ineffective in treating a dure to the patient and/or their representative. The postprocedure
pilonidal abscess. Rarely, systemic signs and symptoms may ensue. care should be explained as well. Document the discussion of the
There are reported cases of necrotizing fasciitis from neglected pilo- risks and benefits of the procedure. Obtain a signed informed con-
nidal sinus disease. Thus, it is preferable to treat pilonidal abscesses sent for the procedure.
expeditiously with an incision and drainage procedure. The best visualization of the sacral region, particularly in obese
patients, occurs with the use of a proctoscopic examination table, if
CONTRAINDICATIONS available (Figure 109-3A). Place the patient prone on a gurney or on
The great majority of pilonidal abscesses may be drained in the the proctoscopy table. Alternatively, place the patient in the lateral
Emergency Department. Patients occasionally present with fever, knee-chest position to expose the affected area (Figure 109-3B).
systemic signs and symptoms, and/or toxicity. They should be Apply benzoin solution to the buttocks and allow it to dry. Apply
admitted to the hospital for parenteral antibiotics, incision and adhesive tape to the buttocks and tape them open (Figure 109-4).
drainage, and observation. This is particularly true if the patient has Clean any dirt and debris from the skin overlying the abscess or
diabetes or is immunocompromised. Consult a Surgeon to manage cyst. Apply povidone iodine or chlorhexidine solution and allow
these patients. Extensive abscesses should be incised and drained it to dry. Shave the surrounding area, if the patient is hirsute, to
in the Operating Room under general anesthesia. Patients who are aid in the application of the dressing after the procedure. Some
asymptomatic do not require an incision and drainage and can be authors advocate shaving the sacral region to prevent recurrence
referred to a Surgeon for removal. The procedure should be con- as well, although this has not been proven to be effective. A gown,
ducted under general anesthesia in the Operating Room if adequate face mask, and gloves (nonsterile) are recommended to be worn for
anesthesia cannot be obtained and pain limits the procedure. this procedure.
EQUIPMENT ANESTHESIA
Local anesthesia should be administered, recognizing that it is
• Gown, face mask, and gloves
often difficult to obtain complete anesthesia by direct infiltration
• Benzoin solution of an abscess. Local anesthetics are weak acids and are less effective
• Povidone iodine or chlorhexidine solution in the acidic environment of an abscess. The skin over the abscess
FIGURE 109-3. Patient placement. A. Prone on a proctoscopy table. The patient may also be placed prone on a gurney. B. The lateral knee-chest position.
FIGURE 109-4. Exposure of the abscess. FIGURE 109-6. Field block anesthesia for a pilonidal abscess. A. Local anesthetic
solution is infiltrated subcutaneously on all four sides of the abscess. B. The local
anesthetic solution is infiltrated deep to the abscess cavity in a fan-like pattern.
cavity usually becomes insensate, but anesthesia of the abscess cav-

ity itself is not possible. The pain caused by injection of the local
anesthetic solution is related to the rate that it is injected and the
sedation. Patient-administered nitrous oxide, with or without
force necessary to inject it. Inject the local anesthetic solution
supplemental narcotic analgesics, is an alternative to procedural
slowly through a small-bore needle (25 or 27 gauge) as the needle
sedation. Refer to Chapter 128 for the complete details of nitrous
is withdrawn through the dermis. The needle bore will create a
oxide anesthesia. Obtain an additional signed informed consent for
passage through the subcutaneous tissue as it is inserted that enables
the procedural sedation or the nitrous oxide administration. The
the local anesthetic solution to be infiltrated slowly and with less
procedure should be conducted under general anesthesia in the
discomfort.
Operating Room if adequate anesthesia cannot be obtained and
Hold the syringe horizontal in reference to the skin surface. Inject
pain limits the procedure.
3 to 4 mL of local anesthetic solution intradermally over the dome
of the abscess (Figure 109-5). The skin will blanch if the injection is
given properly. Do not inject the local anesthetic solution into the TECHNIQUE
abscess cavity. The increased pressure within the cavity will cause Incise the skin over the area of maximum fluctuance with a scal-
more discomfort to the patient and may cause the local anesthetic pel blade. A 10% recurrence rate after drainage of chronic abscesses
solution or the abscess contents to be forcefully expelled if there is through a vertical incision lateral to the midline has been reported.14
an opening in the skin. This may be due to better healing of wounds that are off the mid-
Additional anesthesia is accomplished by performing a field line. Thus, some authors and Colorectal Surgeons recommend that
block (Figure 109-6).13 Inject local anesthetic solution subcutane- the incision for an acute abscess be off the midline if the abscess
ously around the periphery of the abscess (Figure 109-6A). Inject can be drained adequately through the incision (Figure 109-7A).
local anesthetic solution deep to the abscess in a fan-like pattern Extend the incision the length of the abscess to allow for proper
(Figure 109-6B). drainage. A full-thickness, thin ellipse of skin can be removed to
Systemic analgesia (i.e., procedural sedation) is usually required prevent premature closure of the skin edges. Approximately 40% of
since it is quite difficult to obtain adequate anesthesia of an abscess pilonidal abscesses will be cured from simple incision and drainage
locally. Refer to Chapter 129 for the complete details of procedural alone.15 It is not necessary to perform more radical excision proce-
dures in the Emergency Department.
It is important that loculations be lysed and the area thor-
oughly drained to minimize recurrence. Several methods can be
used to lyse adhesions within the cavity. A gloved finger may be used
to bluntly break up the adhesions. Hemostats can be inserted and
spread within the abscess cavity. A useful technique employs a 4 × 4
gauze square clamped in a hemostat and swirled inside the abscess
cavity to break adhesions and remove debris (Figure 109-7B). This
technique aids in removing hair and the infected lining of the cyst.
Irrigate the abscess cavity with normal saline.
Loosely pack the cavity with ribbon gauze. Packing the cavity too
tightly may cause ischemia to the surrounding tissue, delays heal-
ing, and is uncomfortable for the patient. The purpose of the pack-
FIGURE 109-5. Subcutaneous infiltration of local anesthetic solution. The needle ing is to keep the skin edges from adhering before the cavity closes.
and syringe are held parallel to the skin. The needle is inserted into the subcutane- Cover the incision with a simple bandage composed of gauze and
ous tissue overlying the pilonidal abscess. Infiltrate the local anesthetic solution as adhesive tape. A thick layer of absorbent gauze will soak up any
the needle is withdrawn. The skin should blanch (shaded area) if injected properly. continued drainage.
CHAPTER 109: Pilonidal Abscess or Cyst Incision and Drainage 721
FIGURE 109-7. Incision and drainage of a pilonidal abscess.

A. An incision is made lateral to the midline and overlying the
abscess cavity. B. A hemostat with gauze clamped in the jaws is
inserted into the abscess cavity and rotated to break loculations
and remove debris.
AFTERCARE skin surrounding the abscess. Patients often have pain in the first
2 to 3 days after the incision and drainage. This can be controlled
Antibiotics are generally unnecessary to treat a simple abscess when with nonsteroidal anti-inflammatory drugs and supplemented with
there is no cellulitis surrounding the wound.16 No data could be occasional narcotic analgesics.
found on the optimal duration of antibiotic treatment if the overly- Inform the patient that incision and drainage in the acute
ing skin is cellulitic. The conventional 7 to 10 day course of anti- care setting is not definitive treatment and that the condition
biotics is probably adequate. Likewise, no studies could be found may recur. Arrange for follow-up with a Surgeon who can pro-
regarding treating patients with diabetes, cardiac valve disease, vide wound care as well as definitive therapy if surgery is required.
those who have hardware in their body, or those who are immuno- Definitive treatment of a chronic pilonidal abscess or sinus still
compromised and have a pilonidal abscess. These patients are at risk remains controversial among Colorectal Surgeons. Options include
for infectious complications and it is advised that they be treated wide excision with primary closure, wide excision with secondary
with oral antibiotics. closure, or marsupialization.2
There is a disparity in the literature regarding the bacteriology Educate the patient about their role in the prevention of a recur-
of pilonidal abscesses. Staphylococcus aureus is the most commonly rence. Recurrence may be prevented with meticulous hygiene
found bacteria and, surprisingly, Escherichia coli is rarely found.17 and periodic shaving of the area.10,13 Instruct the patient on the
A report in children recovered primarily anaerobes from piloni- methods for meticulous hygiene in the area, even after the wound
dal cysts.18 Escherichia coli was the most common aerobe cultured has healed. Repeated trauma to the area should be avoided. This
from this series. In light of these conflicting results, and in the includes exercises such as sit-ups and leg lifts, and prolonged peri-
event that antibiotics are deemed necessary, coverage for skin ods of sitting.
flora as well as aerobes and gram-negative organisms would be
advised. A combination of a first-generation cephalosporin or pen-
icillinase-resistant penicillin along with metronidazole or clindamy- COMPLICATIONS
cin is recommended. Keep in mind the ever increasing rates of Pilonidal disease may return, even with radical and extensive surgi-
community-acquired methicillin-resistant Staphylococcus aureus cal excision procedures. Thus, recurrence is to be expected and the
(CA-MRSA) infections. Consider prescribing clindamycin, doxy- patient alerted of this possibility. Rarely, pilonidal lesions prog-
cycline, or trimethoprim-sulfamethoxazole if CA-MRSA is a poten- ress to necrotizing fasciitis. Proceed cautiously with patients who
tial pathogen.19 are diabetic or otherwise immunocompromised as they are at risk
Instruct the patient to change the gauze dressing as often as nec- for widespread infections. Those with systemic signs and symptoms
essary to keep the outside of the dressing dry. The patient should are best admitted for treatment. Necrotizing fasciitis is a surgical
return for follow-up in 48 hours for a wound check and removal emergency and requires extensive operative debridement, systemic
of the packing. If the wound is large, or there is not a clear open antibiotics, and intensive supportive care.
tract for continued drainage, reinsert new packing upon follow-up. Rarely, a nonhealing pilonidal infection may be a pilonidal sinus
Incisions that remain open do not require repacking. Advise the malignancy.20 Squamous cell carcinoma has been described to arise
patient to have the packing changed every 24 to 48 hours, depend- from chronic sinus tracts. This emphasizes the importance of fol-
ing upon the amount of drainage. Decrease the amount of packing low-up for all patients with pilonidal sinus disease.
each time to allow the wound to heal from the base outward. The Other complications include infection and tissue injury. The inci-
patient should thoroughly wash the wound with soap and water in sion and drainage procedure can result in a subsequent cellulitis,
the shower or take a sitz bath each time the packing is removed. It endocarditis, fasciitis, meningitis, myositis, sacrococcygeal osteo-
is helpful to let the stream of shower water run inside the wound to myelitis, or septicemia. The sharp and blunt dissection can injure
aid in wound irrigation. After showering, the patient should dry the underlying or adjacent structures including blood vessels, the coc-
area thoroughly. Discontinue the packing once the wound is well cyx, muscles, nerves, and tendons.
granulated and there is no concern that the skin edges will adhere
to each other. The patient must continue to clean the wound thor-
oughly every day until it is fully healed. Healing may take several
SUMMARY
weeks depending upon the size of the abscess cavity. Instruct the Pilonidal disease is common in the young adult population and more
patient that they must return to the Emergency Department if prevalent in males. It is now widely accepted as being an acquired
they develop a fever, increased pain, or increased redness of the condition caused by hair that penetrates an irregular area of skin in
the sacral area. Pits occur in the skin that in turn lead to cysts in the epithelialized tract or fistula-in-ano. Abscesses and fistulas are dif-
subcutaneous tissue. Patients may present with asymptomatic pits ferent sequelae of the same process.5
noted incidentally, as chronically draining sinuses, or an acute pain-
ful abscess. No treatment is necessary for asymptomatic patients.
Nontender sinuses may be referred for surgical treatment. Abscesses ANATOMY AND PATHOPHYSIOLOGY
should be drained expeditiously under adequate analgesia and anes- Knowledge of the anatomy of the region is important to under-
thesia. Antibiotics are not indicated unless the patient has surround- stand the pathophysiology of anorectal infections (Figures 110-1 &
ing cellulitis or is immunocompromised. Recurrences are common 110-2). Columnar epithelium transitions to squamous epithelium at
and patients must be referred for follow-up with a Surgeon who can the columns of Morgagni at the level of the dentate line. Semilunar
provide wound care as well as surgical treatment for chronic cases. folds of epithelium called anal valves connect the inferior borders of
the anal columns. At the base of each anal valve is an anal crypt, into
which opens the ducts of the anal glands. The anal glands secrete
mucous to aid in the evacuation of feces. The anal glands are located
in the space between the internal and external anal sphincter mus-
Perianal Abscess cles. Most anorectal infections begin in this intersphincteric space
110 Incision and Drainage due to blockage and resultant infection of the anal glands.6
The spread of an infection is determined by the anatomy of
Maggie Ferng and Ryan C. Headley the anorectal region. There are five anatomic spaces into which
an infection can spread (Figure 110-3).5 The perianal space is
located at the area of the anal verge. The ischiorectal space, which
INTRODUCTION is continuous with the perianal space, extends from the levator ani
Anorectal infections are common problems presenting to the muscle to the perineum. The intersphincteric space lies between
Emergency Department. Understanding anorectal anatomy is the internal and external anal sphincter muscles. It connects infe-
essential to make a diagnosis, institute proper treatment, and riorly with the perianal space and superiorly with the rectal wall.
anticipate complications. Failure to diagnose and treat an extensive The supralevator (or pelvirectal) space is located superior to the
abscess may be life threatening. It is imperative to obtain a surgical levator ani muscle and is bounded superiorly by the peritoneum.
consultation if one is unsure of the extent of an abscess. The rectum forms its medial border and the pelvic wall forms the
Anorectal infections occur mostly in the third or fourth decade lateral boundary. The deep postanal space is located between the
of life. Perianal abscesses are two to three times more common in tip of the coccyx and the anus. It courses through the superficial
men than women.1 Male predominance is even more pronounced in external anal sphincter and the levator ani. The superficial post-
the pediatric population.2 In one series, all patients under 2 years of anal space lies posterior to the anal verge and is subcutaneous. The
age were males, while 60% of the children greater than 2 years were retrorectal space is high in the pelvis. It occupies the area between
males.2 The increased incidence of perianal infection in males may the distal rectum and the sacrum.
be related to androgen conversion in the anal glands.3 In infants, Most anorectal infections begin in the intersphincteric space.
deep anal crypts are associated with perianal abscesses.4 Natural barriers are broken down by formation of an abscess and
Abscesses may completely resolve after a proper incision and the infection can spread to contiguous spaces. Abscesses are clas-
drainage procedure. However, 50% recur or develop a chronic sified according to their location. Perianal abscesses are common,
Column
of Morgagni
Dentate line Transitional Anal

zone canal
Anal gland
Anal crypt
Anoderm
FIGURE 110-1. The anatomy of the anal canal.

CHAPTER 110: Perianal Abscess Incision and Drainage 723
Longitudinal
muscle
Levator ani muscle

Valve of Houston
Circular muscle
Puborectalis muscle
Conjoined
longitudinal muscle
Internal anal sphincter muscle
Column of Morgagni Deep

External anal
Anal gland
sphincter muscles
Superficial
Subcutaneous
Corrugator cutis External

ani muscle hemorrhoidal plexus
FIGURE 110-2. The major supporting structures of the anal canal.
ischiorectal abscesses occur less frequently, and supralevator

abscesses are least common.7 Bilateral involvement may occur when
an infection spreads circumferentially via the deep postanal space,
resulting in a horseshoe abscess.
Patients with anorectal abscesses present with buttock pain and
swelling. There is, occasionally, spontaneous drainage from the
abscess site. Symptoms depend upon the location of the abscess.
Patients with perianal infections have anal pain that increases with
defecation or sitting. Pain associated with deeper infections may be
atypical. Patients with supralevator abscesses may have deep rectal
pain, gluteal pain, dysuria, or other urinary symptoms.
Erythema, swelling, and fluctuance are often present at the
abscess site. The location of the swelling and fluctuance of a perianal
abscess is at the anal verge. Ischiorectal space infections track farther
from the anus onto the buttock. Supralevator and intersphincteric
abscesses may have minimal or no external signs.8 The diagnosis of
perianal cellulitis is highly suspect. These patients have either an
anorectal abscess or Fournier’s Gangrene until proven otherwise.
Patients with gluteal pain and a small amount of erythema in the
perianal area have a deep-seated abscess until proven otherwise.
A digital rectal examination is necessary as intersphincteric, deep
postanal, and submucosal abscesses may be palpated but often can-
not be appreciated on external examination. A superficial digital
examination of the anal canal alone is inadequate for detection
of some abscesses. The gloved finger must extend into the rectum
seeking tenderness and a mass. Unfortunately, digital rectal exam
may fail to detect some deep abscesses due to patient discomfort. If
unable to obtain an adequate exam due to pain or if a deep abscess is
suspected, obtain a CT scan of the pelvis with rectal and intravenous
contrast.
A fistula-in-ano represents the chronic phase of an unhealed peri-
anal abscess. Fistulas may form due to persistent obstruction of the
FIGURE 110-3. The anorectal spaces. A. Coronal section through the pelvis. anal gland or inadequate drainage of an abscess. The tract eventually
B. Sagittal section through the pelvis. becomes epithelialized with glandular tissue. Fistulas may also form
may safely undergo standard surgical drainage. Small perianal

abscesses may be drained in the Emergency Department. Consult
Posterior a General or Colorectal Surgeon for those patients with late-stage
(curvilinear tract) HIV disease. Infections are more likely to be extensive and ano-
rectal sepsis is more common because these patients have poor
wound healing.10
Transverse CONTRAINDICATIONS
anal line
Most small, uncomplicated perianal and submucosal abscesses can
be drained in the Emergency Department. A General or Colorectal
Surgeon should drain all other types of anorectal abscesses.
Caution is urged when an abscess is on the buttock for it may
Anterior
manifest an ischiorectal abscess. Patients with bleeding disorders,
(straight tract)
taking anticoagulants, or thrombocytopenia should be managed by
FIGURE 110-4. Goodsall’s rule. a Surgeon. Consult a Surgeon if the infection is extensive or if the
extent of the abscess cannot be determined. Surgical consultation
is also necessary for patients with purulent drainage from inside
the anus. Internal findings may indicate that the patient has an
as a result of epithelialization by cells derived from the transitional intersphincteric or a supralevator abscess; the full extent of which
zone of the anal canal and thus may be unrelated to persistent anal can be determined only under general anesthesia. The procedure
gland disease.9 Patients with a fistula-in-ano will often give a history should be conducted by a surgeon under general anesthesia in the
of a previous abscess in the same area that was either drained surgi- Operating Room if adequate anesthesia cannot be obtained and
cally or spontaneously. Patients may complain of chronic drainage pain limits the procedure.
from the site or subacute pain. Patients with fever or toxicity should be admitted to the hospital
Physical examination of a fistula-in-ano reveals an external for parenteral antibiotics, incision and drainage in the Operating
opening with scant drainage and visible surrounding granulation Room, and observation. Anorectal infections occasionally progress
tissue. Digital rectal examination may reveal an indurated cord- to necrotizing fasciitis, a true surgical emergency. Physical examina-
like structure beneath the skin within the anal canal. The inter- tion findings in such cases may initially be minimal except for sys-
nal opening may be palpable along the dentate line. Pus may be temic signs or symptoms. Patients who are immunocompromised
expressed externally or from within the anus upon palpation of the or with late-stage HIV infection should be referred to an experi-
fistulous tract. enced Surgeon due to the higher complication rate and increased
The greater the distance from the anus that the external opening risk of extensive infection.
is located, the more complex is the fistulous tract. Goodsall’s rule Chronically draining fistulas without an acute infection should be
describes the likelihood of the location of fistulous tracts and the referred to a General or Colorectal Surgeon for care. Patients with
internal opening based upon the location of the external opening purulent drainage from the anus, even if there is no significant ten-
(Figure 110-4). Anterior external openings tend to communicate in derness, should be examined under general anesthesia as they may
a linear fashion with the internal opening in the anal canal. Fistulas still have an internal abscess along with a fistulous tract.
with posterior external openings tend to communicate in a curvilin-
ear fashion with the internal opening. EQUIPMENT
Patients with multiple or recurrent fistulas require evaluation of
the bowel for Crohn’s disease. This is particularly true if associated • Gown, face mask, and gloves
with chronic diarrhea or cramping, both of which suggests inflam- • Povidone iodine or chlorhexidine solution
matory bowel disease. Recurrent fistulas may be indicative of tuber-
• 10 mL syringe
culosis or a sexually transmitted disease such as lymphogranuloma
venereum. It is imperative that these patients be referred to a • 25 or 27 gauge needle, 2 in. long
Surgeon who is experienced in managing anorectal disease. • Local anesthetic solution with epinephrine, lidocaine, or bupiva-
caine
INDICATIONS • #11 scalpel blade on a handle
Incision and drainage is the treatment for an anorectal abscess. • #15 scalpel blade on a handle
Uncomplicated perianal abscesses and submucosal abscesses may • Curved hemostat
be drained in the Emergency Department. Management of deeper
or more extensive abscesses should be in consultation with a • 4 × 4 gauze squares
Surgeon. Use caution in draining abscesses. The ischiorectal space • 10 to 16 French mushroom (de Pezzer) catheter, optional
is quite large, particularly in the obese patient, and adequacy of • Adhesive tape
drainage is not assured except under general anesthesia. It is not • Feminine napkin, optional
uncommon for an abscess to have a small erythematous and swol-
len area on the buttock overlying an extensive and deep abscess. • Normal saline
Attempts at drainage in the Emergency Department may be • 18 gauge angiocatheter
inadequate. • 20 mL syringe
Perianal disease is commonly encountered in the HIV-infected
• 2-0 nylon suture
patient. Complication rates were noted to be high in the past and a
hands-off approach was espoused. However, more recent data sug- • Needle driver
gest that those patients with a relatively preserved immune system • Scissors
FIGURE 110-5. Patient placement. A. Prone on a proctoscopy table. The patient may also be placed prone on a gurney. B. The lateral knee-chest position.
PATIENT PREPARATION the surrounding area, if the patient is hirsute, to aid in the applica-
tion of the dressing after the procedure.
Explain the risks, benefits, and potential complications of the proce-
dure to the patient and/or their representative. The postprocedure ANESTHESIA
care should be explained as well. Document the discussion of the
risks and benefits of the procedure. Obtain an informed consent for Local anesthesia should be administered, recognizing that it is
the procedure. Wear a face mask, gown, and gloves for the entire often difficult to obtain complete anesthesia by direct infiltra-
procedure. The injection of local anesthetic solution can force tion of an abscess. Local anesthetics are weak acids and are less
abscess contents to shoot out. Incision of a tense abscess can also effective in the acidic environment of an abscess. The skin over
result in contamination. the abscess cavity usually becomes insensate, but anesthesia of the
The best visualization of the sacral region, particularly in obese abscess cavity itself is not possible. The pain caused by injection
patients, occurs with the use of a proctoscopic examination table, of the local anesthetic solution is related to the rate that the anes-
if available (Figure 110-5A). Place the patient prone on a gurney thetic is injected and the force necessary to inject it. Inject the local
or on the proctoscopy table. Alternatively, place the patient in the anesthetic solution slowly through a small-bore needle (25 or
prone or lateral knee-chest position on a gurney or examination 27 gauge) as the needle is withdrawn through the dermis. The
table to expose the affected area (Figure 110-5B). Apply benzoin needle bore will create a passage through the subcutaneous tissue
solution to the buttocks and allow it to dry. Apply adhesive tape to as it is inserted that enables the local anesthetic solution to be infil-
the buttocks and tape them open (Figure 110-6). Clean any dirt trated slowly and with less discomfort.
and debris from the skin overlying the abscess or cyst. Apply povi- Hold the syringe horizontal in reference to the skin surface. Inject
done iodine or chlorhexidine solution and allow it to dry. Shave 3 to 4 mL of local anesthetic solution intradermally over the dome
of the abscess (Figure 110-7). The skin will blanch if the injection is
given properly. Do not inject the local anesthetic solution into the
abscess cavity. The increased pressure within the cavity will cause
more discomfort to the patient and may cause the solution to be
forcefully expelled if there is an opening in the skin.
FIGURE 110-7. Subcutaneous infiltration of local anesthetic solution. The needle

and syringe are held parallel to the skin. The needle is inserted into the subcuta-
neous tissue overlying the abscess. Infiltrate the local anesthetic solution as the
FIGURE 110-6. Exposing the abscess. needle is withdrawn. The skin should blanch (shaded area) if injected properly.
A B
Sebaceous FIGURE 110-9. Drainage of a perianal abscess. A. An elliptical incision is made

cyst in the skin. B. The ellipse of skin is removed to prevent premature closure of the
skin edges.
of skin (Figure 110-9B). A full-thickness ellipse of skin is excised

to prevent premature closure of the skin edges. Some prefer to
make a cruciate incision over the abscess and excise the edges
FIGURE 110-8. Field block anesthesia. A. Local anesthetic solution is infiltrated (Figure 110-10).5 Both of these techniques delay cutaneous heal-
subcutaneously on all four sides of the abscess. B. The local anesthetic solution is ing while the abscess is decompressing and allow it to drain freely
infiltrated deep to the abscess cavity in a fan-like pattern. without the need for packing.
A linear incision is acceptable instead of the above incisions, but
is not recommended for a perianal abscess. The body location and
Additional anesthesia is accomplished by performing a field excessive skin often result in premature closure before the cavity has
block (Figure 110-8). Inject local anesthetic solution subcutane- healed. A linear incision requires repeated packing at 24 to 48 hour
ously around the periphery of the abscess (Figure 110-8A).11 Inject intervals to prevent premature closure. The area is difficult to access
local anesthetic solution deep to the abscess in a fan-like pattern by the patient to pack the cavity. The pain of repeated packing often
(Figure 110-8B). results in noncompliance. It is also difficult for the patient to wash
Systemic analgesia (i.e., procedural sedation) is usually required out the cavity in the shower or bathtub.
since it is difficult to obtain adequate anesthesia of an abscess locally. It is important that loculations be lysed and the area thor-
Refer to Chapter 129 regarding the details of procedural sedation. oughly drained to minimize recurrence. Several methods can be
Self-administered nitrous oxide, with or without opioid supplemen- used to lyse adhesions within the abscess cavity. A gloved finger
tation, is an alternative. Refer to Chapter 128 regarding the details of may be used to bluntly break up the adhesions. Hemostats can be
nitrous oxide anesthesia. Obtain an additional informed consent for inserted and spread within the cavity. A useful technique employs
the procedural sedation or nitrous oxide procedure. The procedure a gauze 4 × 4 square clamped in a hemostat and swirled inside the
should be conducted by a surgeon under general anesthesia in the abscess cavity to break adhesions and remove debris. Irrigate the
Operating Room if adequate anesthesia cannot be obtained and cavity with normal saline.
pain limits the procedure. It is not necessary to pack an incised and drained perianal abscess
that has been incised by removing a full-thickness skin ellipse or a
TECHNIQUES cruciate incision. Consider temporarily packing the abscess cavity
in the Emergency Department to control any hemorrhage. Remove
INCISION AND DRAINAGE OF PERIANAL ABSCESSES the packing before discharging the patient to reassess the need for
further hemorrhage control. Cover the wound with a thick layer of
Make a stab incision with a #11 scalpel blade in the skin overlying absorbent gauze to soak up continued drainage. A feminine napkin
the area of fluctuance to decompress the abscess. Make the inci- may also be used to absorb drainage and obviates the need for taping
sion as close to the anus as possible so that if a fistula forms, the dressing in place.
its size will be limited. This maneuver will minimize the length
of a fistulotomy, should it become necessary, in the future. Extend
the incision with the #11 scalpel blade or a #15 scalpel blade in a
CATHETER DRAINAGE OF PERIANAL ABSCESSES
full-thickness elliptical pattern along the length of the abscess cav- Another method used to drain perianal abscesses, and preferred by
ity or the area of fluctuance (Figure 110-9A). Remove the ellipse some Colorectal Surgeons, is catheter drainage. The mushroom or
FIGURE 110-10. Drainage of perianal abscess employing

a cruciate incision. A. The cruciate incision is made over
the abscess. B. Excision of the skin flap edges. C. The final
appearance.
FIGURE 110-11. Catheter drainage of an abscess. A. The

mushroom (de Pezzer) catheter. B. A stab incision is made over
the area of maximal fluctuance. C. Place the tip of the hemostat
through the side hole to stretch the tip of the catheter. Insert
the stretched catheter through the stab incision. D. Remove the
hemostat to expand the head of the catheter so that it remains
within the abscess cavity. E. The catheter is cut so that it pro-
trudes 2 to 3 cm from the skin incision.
de Pezzer catheter has a tunnel through a solid mushroom-shaped SUBMUCOSAL ABSCESSES

tip (Figure 110-11A).12 Make a stab incision with a #11 scalpel
blade over the anal side of the area of fluctuance (Figure 110-11B). The majority of submucosal abscesses may be drained in the
Insert a hemostat into the abscess cavity. Open and close the jaws of Emergency Department. The procedure requires the use of an
the hemostat to lyse any adhesions and express the pus. Flush the anoscope to visualize the abscess. Refer to Chapter 70 for the com-
abscess cavity with normal saline using an 18 gauge angiocatheter plete details regarding the use of an anoscope. Make a superficial
on a 20 mL syringe. stab incision in the abscess with a #11 scalpel blade. Gently insert
Insert a 10 to 16 French latex mushroom catheter using a hemo- a hemostat and lyse any adhesions. Remove a small ellipse of the
stat to stretch the tip so that it will fit through the incision. Place mucosa to allow the abscess to drain. Arrange follow-up with a
the tip of the hemostat through the hole in the mushroom catheter. Colorectal Surgeon within 24 hours.
With one hand holding the hemostat, use the other hand to pull on
the tubing to stretch the mushroom tip and enable it to fit into the
AFTERCARE
abscess cavity (Figure 110-11C). Insert the stretched mushroom tip
into the abscess cavity (Figure 110-11C). Release the traction on the Antibiotics are generally unnecessary to treat a simple abscess when
hemostat once the catheter tip is within the abscess cavity and there is no cellulitis surrounding the wound.13 No data could be
the mushroom shape will be restored (Figure 110-11D). Remove found on the optimal duration of antibiotic treatment if the overlying
the hemostat from the abscess cavity. skin is cellulitic. The conventional 7 to 10 day course of antibiotics is
Suture the catheter in place. Place a single simple interrupted likely adequate. Likewise, there is no data in the literature regarding
stitch using 2-0 nylon adjacent to the stab incision. Leave both ends the treatment of patients with diabetes, cardiac valve disease, those
long, tie the suture knots, and do not cut the suture. Pass the needle who have hardware in their body, or those who are immunocom-
through the catheter as it exits the skin incision. Tie the needle end promised with antibiotics for a perianal abscess. These patients are
of the suture to the tail end of the suture to secure the catheter. Cut at risk for infectious complications. It is advised that they be treated
off the excess suture. Cut the catheter so that it protrudes only 2 to with antibiotics. Bacteriology of anorectal abscesses is polymicro-
3 cm from the incision (Figure 110-11E). Apply a dressing of gauze bial, with coliforms and anaerobes predominating.14 Recommended
squares or a feminine napkin. antibiotics include an extended spectrum β-lactams, a second- or
Many Colorectal Surgeons prefer the catheter method. On subse- third-generation cephalosporin with metronidazole or clindamycin,
quent visits they can assess the wound for the presence of a fistula or a newer fluoroquinolone with metronidazole or clindamycin.
without removing the catheter. Hydrogen peroxide can be infused The patient may change the gauze dressing as often as necessary
through the catheter. Bubbles seen escaping from an opening within to keep the outside of the dressing dry. Instruct the patient to return
the anal canal are diagnostic for a fistula. Hydrogen peroxide is also for follow-up in 48 hours for removal of packing if placed and a
used to produce an ultrasound interface that facilitates the definition wound check. The patient may begin sitz baths or showers 24 hours
of a fistulous tract and the internal opening.5 The smaller stab incision after the procedure. They should thoroughly clean the wound with
takes less time to heal than the larger incision and drainage wound. soap and water at least once a day until the wound is fully healed. It
is helpful to let the stream of shower water run inside the wound to ANATOMY AND PATHOPHYSIOLOGY
aid in irrigation. Healing may take several weeks depending upon
the size of the abscess. Additional measures to aid in healing and Sebaceous cysts are the result of obstruction of sebaceous gland
comfort include stool bulking agents and stool softeners. Pain can ducts. They are freely mobile, slow growing, round shaped, pain-
be controlled with nonsteroidal anti-inflammatory drugs supple- less, and located in the subcutaneous tissues. The cysts are made
mented with occasional narcotics analgesics. of a thin white capsule filled with a thick, cheesy, and keratinous
Advise the patient that the condition is likely to recur. They material. Their size is variable and ranges from less than a quarter
must be referred to a General or Colorectal Surgeon who is expe- of an inch to more than 2 inches. These keratin-containing lesions
rienced in the management of anorectal infections. Inform the are usually seen in young and middle-aged adults in relation to a
patient that they may require an operation to prevent future recur- pilosebaceous follicle.1 Sebaceous cysts may be present for many
rences. Instruct the patient to immediately return to the Emergency years before infection occurs. Physical examination often reveals a
Department if they develop a fever, increased pain or redness to the subcutaneous mass that is fluctuant and tender. The overlying skin
area, or a foul-smelling discharge. may appear normal or erythematous.
The initial treatment of choice of an infected sebaceous cyst is
COMPLICATIONS incision and drainage. The sebaceous material is too thick to allow
for spontaneous drainage and it must be expressed. The sebaceous
Perianal abscesses may recur or a fistula may form. Recurrence is cyst will likely recur, however, unless the capsule of the cyst is
more likely if the patient has had abscesses in the same location in removed. Patients may have the initial incision and drainage per-
the past. Occasionally, anorectal infections progress to necrotizing formed in the Emergency Department with follow-up at some later
fasciitis. Patients with any systemic signs and symptoms require sur- date to remove the cyst capsule. Alternatively, the cyst capsule may
gical consultation, hospital admission, parenteral antibiotics, and a be removed at the time of the initial incision and drainage.
drainage procedure.
Complications associated with the incision and drainage pro-
cedure are rare. A linear incision or too small of an incision can INDICATIONS
result in premature skin closure, incomplete healing of the cavity, Incision and drainage in the Emergency Department is indicated
and recurrence. Too large of an incision can result in delayed heal- whenever a patient presents with a tender sebaceous cyst consis-
ing. An overly aggressive incision can damage adjacent structures. tent with an abscess. The procedure will relieve the patient’s pain.
Postprocedural bleeding is rare. Antibiotics without drainage are ineffective in treating abscesses.2
The vast majority of infected sebaceous cysts may be drained in
SUMMARY the Emergency Department, clinic, or office setting. A noninfected
sebaceous cyst may be removed electively and for cosmetic pur-
Anorectal infections are commonly seen in the Emergency
poses in the clinic or office setting by a Primary Care Provider or
Department. They are thought to be due to obstruction and sub-
a Surgeon.
sequent infection of the anal glands that in turn form an abscess.
Small perianal abscesses and submucosal abscesses can safely be
drained in the Emergency Department. A digital rectal examina- CONTRAINDICATIONS
tion may aid in determining the extent of an abscess. A General or
There are no absolute contraindications to the incision and drain-
Colorectal Surgeon should manage patients with fever, signs of tox-
age or removal of an infected sebaceous cyst. Caution is advised
icity, evidence of a deep or extensive infection beyond the perianal
in those patients with bleeding disorders, taking anticoagulants, or
area, or who are immunocompromised. Be alert that abscesses with
with thrombocytopenia. Incision and drainage is preferred if the
maximum fluctuance on the buttock are more likely to have ischio-
overlying skin is cellulitic. The capsule can be removed at a later
rectal extension, are more complex, and greater in size. Perianal
time. Extremely large abscesses or those in which adequate anes-
abscesses must be drained expeditiously to prevent their spread.
thesia is not possible should be managed in the Operating Room
Approximately 50% of anorectal abscesses will develop a fistu-
by a General Surgeon or Plastic Surgeon. The procedure should
lous tract. Patients require referral for follow-up with a General or
be conducted under general anesthesia in the Operating Room if
Colorectal Surgeon who can provide wound care as well as manage
adequate anesthesia cannot be obtained and pain limits the pro-
chronic cases.
cedure. Refer patients with noninfected sebaceous cysts to their
Primary Care Physician, a General Surgeon, or a Plastic Surgeon
for removal.
Sebaceous Cyst Incision EQUIPMENT

111 and Drainage •
•
Gown, face mask, and gloves
Povidone iodine or chlorhexidine solution
Carlos J. Roldan
• 10 mL syringe
INTRODUCTION • 25 or 27 gauge needle, 2 in. long
Sebaceous cysts are common, present with a very benign evolu- • Local anesthetic solution, with or without epinephrine
tion, may be located anywhere on the body, and frequently become • #11 scalpel blade on a handle
infected. They are most commonly found on the face, neck, and • #15 scalpel blade on a handle
trunk. Sebaceous cysts are usually asymptomatic unless they become • Curved hemostat
infected. The Emergency Physician must be acquainted with the
principles involved in treating infected sebaceous cysts, particularly • Iris scissors
if they are located on cosmetically important areas such as the face. • Ribbon gauze, plain or iodinated
CHAPTER 111: Sebaceous Cyst Incision and Drainage 729
• Adhesive tape
• Sterile saline A B
• Nylon sutures for skin closure, various sizes
• 3-0 Vicryl suture
• Needle driver
PATIENT PREPARATION
Explain and document the risks, benefits, and potential complica-
tions of the procedure to the patient and/or their representative.
The postprocedure care should be explained as well. Obtain an Sebaceous
informed consent for the procedure. Obtain an additional informed cyst
consent for the procedural sedation or nitrous oxide procedure if
it applies. Wear a face mask, gown, and gloves for the entire pro-
cedure. The injection of local anesthetic solution can force abscess
contents to shoot out. Incision of a tense abscess can also result in
contamination.
Antibiotic resistance is a growing concern. The incision and
drainage of a simple and noncomplicated skin abscess does not FIGURE 111-1. Field block anesthesia. A. Local anesthetic solution is infiltrated
require antibiotic therapy.3,4 The incision and drainage procedure subcutaneously on all four sides of the infected sebaceous cyst. B. Local anesthetic
may release bacteria into the circulation. Consider the use of pre- solution is infiltrated deep to the infected sebaceous cyst in a fan-like pattern.
procedural intravenous antibiotics in those patients suspected or
known to be immunocompromised, a history of prosthetic heart
valve replacement, a history of artificial joint replacement, or signs
Hold the syringe horizontally in reference to the skin surface.
of systemic toxicity.
Inject 3 to 4 mL of local anesthetic solution intradermally over the
Clean any dirt and debris from the skin overlying the abscess or
dome of the abscess (Figure 111-2). The skin will blanch if the injec-
cyst. Apply povidone iodine or chlorhexidine solution and allow it
tion is given properly. The increased pressure within the cavity will
to dry. Apply drapes to delineate a procedural field and absorb any
cause more discomfort to the patient and may cause the solution
material or blood that escapes from the abscess cavity.
to be forcefully expelled if there is an opening in the skin therefore
some practitioners prefer to skip this step. Alternative anesthesia
ANESTHESIA could be accomplished with regional or individual nerve blocks
Recognizing that it is often difficult to obtain, local anesthesia when the abscess is located in an anatomical area of innervation.
should be considered the first choice. Direct infiltration of the Systemic analgesia (i.e., procedural sedation) is strongly recom-
skin and soft tissues in a fan-like pattern surrounding an abscess mended in the pediatric population, it may occasionally be required
or “field block” provides sufficient anesthesia to tolerate the proce- as well in adults when a field anesthesia has suboptimal results. In
dure (Figures 111-1A & B).5 Local anesthetics are weak acids and rare occasions, the procedure should be conducted under general
less effective in the acidic environment of an abscess and should not anesthesia in the Operating Room if adequate anesthesia cannot be
be directly injected in the abscess cavity. The pain caused by injec- obtained and pain limits the procedure.
tion of the local anesthetic solution is related to the rate that the
anesthetic is injected and the force necessary to inject it. Inject the TECHNIQUES
local anesthetic solution slowly through a small-bore needle (25 to
30 gauge) as the needle is withdrawn through the dermis. The nee-
dle bore will create a passage through the subcutaneous tissue as it
INCISION AND DRAINAGE
is inserted that enables the local anesthetic solution to be infiltrated Make a stab incision with a #11 scalpel blade in the skin overlying
slowly and with less discomfort. the area of fluctuance (Figure 111-3A). The incision should be
FIGURE 111-2. Subcutaneous infiltration of local anesthetic solution. The needle and syringe are held parallel to the skin. The needle is inserted into the subcutaneous
tissue overlying the infected sebaceous cyst. Infiltrate the local anesthetic solution as the needle is withdrawn. The skin should blanch (shaded area) if injected properly.
A. Superior view. B. Lateral view.
FIGURE 111-3. Incision and drainage of an infected seba-

ceous cyst. A. A straight incision to drain the abscess. B. An
elliptical incision to drain the abscess. C. The wound is irri-
gated with sterile saline. Pockets of purulent material are
opened with the hemostat. D. The wound is packed open.
parallel to any lines of tension to produce the least conspicuous subcutaneous tissues with an iris scissors. The delineation between
scar, particularly in cosmetically important areas such as the face. the thin, shiny, white capsule and the surrounding tissues is very
Extend the incision the length of the fluctuant area with a #11 or obvious. Do not puncture the capsule of the sebaceous cyst. Doing
#15 scalpel blade unless the abscess is in a cosmetically impor- so and spilling some of the contents sets up a nidus for subsequent
tant area. A linear incision is adequate, although some advocate infection or reformation of the sebaceous cyst. Start at both ends of
a cruciate incision (Figure 110-10). The cruciate incision results the incision and free the cyst circumferentially. Once the sides of
in greater scarring, however, and probably is not necessary. An the cyst are free from the surrounding adipose tissue, gently grasp
elliptical incision can be performed in noncosmetically important the top of the cyst with a hemostat or forceps and gently elevate it.
areas (Figure 111-3B). The purpose of the elliptical incision is Dissect the inferior border of the cyst free until it can be removed.
to remove a full thickness wedge of tissue so that the wound will Irrigate the wound with at least 200 mL of normal saline solution.
remain open. Limit the length of the incision on cosmetically Allow the cavity to heal by granulation. Alternatively, close the
important areas to 3 to 4 mm. This is just large enough to drain pocket with 3-0 Vicryl deep sutures and approximate the skin edges
the abscess. with nylon sutures.
Express the pus and the sebaceous material. It is too thick to drain The cyst capsule can often rupture when attempting to remove
spontaneously. It is important that loculations be lysed and the area it intact. If this occurs, express the contents as if incising and
be thoroughly drained to minimize recurrence. Insert a hemostat draining an abscess. Gently flush the cyst cavity with normal
and spread the jaws within the cavity (Figure 111-3C). Useful tech- saline. Grasp the shiny, cut edges of the capsule with a hemostat.
nique employs gauze clamped in the jaws of a hemostat and swirled Gently elevate the cyst capsule edges and dissect the complete
inside the abscess cavity to break adhesions and remove debris. cyst capsule free from the surrounding adipose tissue. Irrigate
Irrigate the cavity with normal saline (Figure 111-3C). the wound with at least 200 mL of normal saline solution. Allow
Loosely pack the wound cavity with ribbon gauze or gauze squares the cavity to heal by granulation. Alternatively, close the pocket
to prevent the skin edges from closing prematurely if a linear inci- with 3-0 Vicryl deep sutures and approximate the skin edges with
sion was made (Figure 111-3D). Cruciate and elliptical incisions do nylon sutures.
not require packing of the wound. Cover the wound with a bulky Submit the complete cyst and capsule or the ruptured capsule
gauze dressing to soak up continued drainage. for pathologic diagnosis in a sterile container. Several patho-
logic conditions can mimic a sebaceous cyst. This includes adeno-
INCISION AND DRAINAGE WITH mas, adenocarcinomas, dermoids in children, and melanomas.
Preauricular tender masses can be parotid gland tumors.
PRIMARY CYST REMOVAL This technique results in fewer days to heal, less pain for the
The entire sebaceous cyst, including the capsule, can be removed at patient, and less scarring than with incision and drainage alone.6
the time of the incision and drainage with a simplified technique.6 This was not a blinded study and no other studies could be found
Make an incision in the skin overlying the center of the sebaceous to verify their results. The researchers noted that primary resection
cyst. Extend the incision to be slightly longer than the diameter of (average of 50 minutes) takes longer than simple incision and drain-
the sebaceous cyst. Do not cut into the dermis or subcutaneous age (average of 10 minutes). This may limit its use in the Emergency
tissues. Sharply dissect the sebaceous cyst free of the surrounding Department.
CHAPTER 112: Hemorrhage Control 731
AFTERCARE abscess. Most cutaneous abscesses can be drained in the Emergency

Department. Consult a Surgeon for those patients with large
Antibiotics are generally unnecessary to treat a simple abscess abscesses who require drainage in the Operating Room. Patients
unless there is cellulitis of the skin surrounding the wound.2 No data with signs of fever or toxicity should be admitted for parenteral anti-
could be found regarding patients with an abscess who are diabetic, biotics, incision and drainage, and observation. Refer patients to a
have cardiac valve disease, who have hardware in their body, or who physician who can provide wound care as well as definitive excision
are immunocompromised. These patients are at risk for infectious of the sebaceous cyst.
complications. It is advised to cover these patients with antibiotics.
Likewise, there is no data on the optimal duration of antibiotic treat-
ment. The conventional 7 to 10 day course of antibiotic coverage is
probably adequate.
Bacteriology of cutaneous abscesses remote from the rectum usu-
Hemorrhage Control
ally show aerobic skin flora, with Staphylococcus and Streptococcus
being the most common etiologies.4 Antibiotics recommended are
a first-generation cephalosporin, a penicillinase-resistant penicillin,
112 Christopher Freeman and Eric F. Reichman
or a newer fluoroquinolone. Prescribe clindamycin, doxycycline,
or trimethoprim-sulfamethoxazole if methicillin-resistant Staph-
ylococcus aureus is suspected as the etiology.7 INTRODUCTION
Instruct the patient to change the gauze dressing as often as nec- Control of external hemorrhage from an injury is a priority of basic
essary to keep the outside of the dressing dry. Patients should have first aid, beginning with the first responder in the prehospital set-
scheduled follow-up in 48 hours for a wound check and removal ting and continuing with Emergency and Trauma Physicians in the
of the packing. The packing should be removed in 24 hours if the resuscitation suite. Bleeding from extremity wounds is common.
wound is on the face. If the wound is large, reinsert the packing Most extremity bleeding is a minor inconvenience for the busy
upon follow-up. Incisions that remain open or that have an elliptical Emergency Physician in the crowded Emergency Department, pro-
or cruciate incision do not require packing. Advise the patient to longing wound closure and complicating wound healing. However,
change the packing every 24 to 48 hours, depending on the amount major exsanguinating extremity hemorrhage can be a life threat.
of drainage. Decrease the amount of packing each time to allow Hemorrhage from extremity injuries was a leading cause of death
the wound to heal from the base outward. The patient should thor- in the Vietnam War and Operation Desert Storm.1,2 Hemorrhage
oughly wash the wound with soap and water in the shower each remained the leading cause of death in Operation Iraqi Freedom
time the packing is removed. It is helpful to let the stream of shower and Operation Enduring Freedom; however, torso hemorrhage was
water run inside the wound to aid in wound irrigation. Discontinue the leading cause of death.3 Methods for rapid and effective con-
the packing once the wound is well granulated and there is no control of bleeding are essential in managing traumatic injuries and
cern that the skin edges will adhere to each other. The patient must optimizing wound management.
continue to clean the wound thoroughly every day until it is fully
healed. ANATOMY AND PATHOPHYSIOLOGY
Healing may take one to several weeks depending upon the size of
the abscess cavity, the patient’s age, and any comorbidities. Instruct Hemostasis is the first biological response to injury.4–6 Hemostatic
the patient to return to the Emergency Department immediately if platelet plugs form at the ends of transected vessels within seconds
they develop a fever, increased pain, or worsening redness of the of traumatic disruption of the skin. Fibrin fibers gather about the
skin surrounding the abscess. Pain relief can be provided with non- platelet plug within minutes. This fibrin mesh becomes part of an
steroidal anti-inflammatory drugs. Occasionally, narcotic analgesics early matrix that initiates wound healing.4
may be required in the first 24 hours after the procedure. Hemostasis is also the first priority in wound management for
Inform the patient that incision and drainage in the acute care the Emergency Physician caring for traumatic wounds. Control of
setting is not definitive treatment and that the condition is likely bleeding is necessary to establish hemodynamic stability and pre-
to recur unless the cyst is removed. Refer the patient to a physician vent further blood loss. Hemostasis is the first step in preparing for
who can provide wound care as well as remove the cyst capsule. wound closure. Inadequate hemostasis with hematoma formation
impairs wound healing, increases the risk of wound infection, leads
COMPLICATIONS to tissue ischemia, and results in hypertrophic scars.7,8 Large hema-
tomas may cause delayed wound dehiscence.
Sebaceous cyst infections may spread if the wound is inadequately Bleeding from wounds may be superficial or deep. Superficial
drained. Attention must be paid to underlying anatomical struc- wounds, such as abrasions, avulsions, or simple lacerations involve
tures, such as cranial nerve VII, when draining facial abscesses to damage to the epidermis, dermis, and subcutaneous tissue. Bleeding
avoid complications caused by inadvertently incising these struc- from most superficial wounds is predominantly from capillaries,
tures. Incomplete removal of the cyst wall or spillage of the cyst small veins, or arterioles. Wounds deep to the fascia involve larger
contents sets up a nidus for future infection and/or recurrence of vessels and are typical of deep puncture or stab wounds, gunshot
the sebaceous cyst. A linear incision or too small of an incision can wounds, or major crush injuries. The approach to the bleeding
result in premature skin closure, incomplete healing of the cavity, wound will depend upon the nature of bleeding (e.g., large vessel vs.
and recurrence. Too large of an incision can result in delayed heal- small, discrete source vs. diffuse), the site of injury, and its associa-
ing and significant scarring. Postprocedural bleeding is rare. tion with other major organ injury.
SUMMARY INDICATIONS
Infected sebaceous cysts are commonly seen in the Emergency The immediate control of excessive bleeding is always a prior-
Department. They are thought to be due to blockage of the ducts ity and should occur during the first contact with the patient. All
of sebaceous glands that subsequently become infected and form an bleeding must be controlled. Exsanguinating hemorrhage must be
immediately controlled. All other bleeding can wait until the ABC’s • Dry gelatin
and life-threats are addressed. The timing and selection of specific • Thrombin
measures to isolate and treat the bleeding source will depend upon
• Microfibrillar collagen
the management priorities of each patient. A simple compressive
dressing or tourniquet may be used as a first-line measure to con- • Cyanoacrylate
trol bleeding in a multiple trauma patient. Measures that are more • Various agents as listed in the techniques section
definitive may be taken early to identify and treat the specific injury
if it is isolated. Miscellaneous Supplies
CONTRAINDICATIONS • Penrose drain
• Finger tourniquet
There are no absolute contraindications to any particular tech-
nique to control bleeding. The Emergency Physician should choose • Hemoclips
the technique best suited to the individual situation. An impressive • Hemoclip applicator
wound should not distract or divert attention away from other inju- • Bone wax
ries that may be less dramatic but more immediate life threats. The
simplest and most effective techniques should be used to control • Raney scalp clips and applier
hemorrhage when faced with multiple injuries.
PATIENT PREPARATION
EQUIPMENT Control of hemorrhage is the priority. Attention to wound prep-
aration should not delay definitive action to control bleeding.
Pressure Control Obtain intravenous access and a type and crossmatch for blood
• Blood pressure cuff products in any patient with active bleeding and hemodynamic
• Sterile 4 × 4 gauze pads compromise while applying direct pressure to the bleeding site.
Explain the procedures to the patient while preparing for and per-
• Elastic bandage
forming the procedures. A local anesthetic can be administered
Wound Manipulation prior to significant wound manipulation if the injury is minor and
• Hemostats the patient is stable. Contaminated wounds should be irrigated free
of foreign bodies and debris and the surrounding area cleaned with
• Needle driver an antiseptic solution (i.e., povidone iodine or chlorhexidine).
• Assorted suture Refer to Chapter 92 for the complete details of wound cleansing
• Scissors and preparation.
• Sterile saline
• 20 mL syringes TECHNIQUES
• 10 mL syringes
DIRECT PRESSURE
The quickest and easiest method to stop bleeding is the application
of direct pressure to the bleeding site.9–11 Poor lighting may prevent
Anesthetics the exposure and visualization necessary to identify discrete bleed-
• Lidocaine, with and without epinephrine ing sites in the prehospital setting. A compressive dressing may be
the best option to control bleeding. Unfortunately, most compres-
• Bupivacaine, with and without epinephrine sive bandages apply too little pressure over too wide an area and act
• 18 gauge needles more like a sponge than a pressure dressing. Significant blood loss
• 27 gauge needles can be hidden within a bulky dressing.
• 10 mL syringes Explore a bleeding wound as soon as lighting is sufficient and cir-
cumstances allow. Even brisk bleeding frequently has a few discrete
Wound Cautery sources that can be easily managed once identified. Direct pressure
• Silver nitrate (AgNO3) over bleeding vessels allows time for a platelet plug to form and
gives a chance for the body’s natural mechanisms of hemostasis to
• Electrocautery unit
take place. Apply pressure over arterial wounds for 10 to 15 min-
• Monsel’s solution (20% ferric subsulfate solution) utes to control most bleeding. Apply pressure to a proximal artery
• Drysol (30% aluminum chloride solution) to impede arterial inflow and control, or slow, the bleeding when
wound exploration is not practical.12,13
Vasoconstrictors
• Epinephrine, 1:1000 TOURNIQUETS
• Cocaine, 1% to 4%
The use of tourniquets for extremity hemorrhage has received a
• Tetracaine, epinephrine, and cocaine (TEC) solution great deal of attention throughout history. In reality, tourniquets
Topical Hemostatic Agents are seldom necessary to control hemorrhage, even in major crush
wounds, amputations, and in wilderness settings.14 Direct pres-
• Gelfoam
sure is more effective and causes less tissue ischemia. Tourniquets
• Surgicel may be required to control bleeding and free rescue personnel to
• Cellulose attend to other concerns if there is significant bleeding in a mass
FIGURE 112-1. Control of the bleeding vessel that is visualized. A. Clamp the cut end of the vessel with a hemostat. B. Wrap a suture ligature about the base of the vessel.
C. Tie and secure the suture around the base of the bleeding vessel.
casualty disaster. Tourniquets should be used as a last resort when Familiarity with the vascular supply to the extremities will help the
other methods fail and the patient’s life is in jeopardy.12,14 Some of Emergency Physician anticipate major arterial injuries and look for
the currently available tourniquets include the Combat Application likely bleeding sources. Whenever a transected vessel is seen, the
Tourniquet (Composite Resources, Rock Hill, SC), the Special other end should be searched for. A retracted artery in spasm will
Operations Forces Tactical Tourniquet (Tactical Medical Solutions, likely bleed later and should be actively sought and ligated.
Anderson, SC), and the Emergency and Military Tourniquet (Delfi Bleeding vessels that can be visualized should be ligated with
Medical, Vancouver, Canada). suture (Figure 112-1). Grasp the cut end of the bleeding vessel
There is no definitive time period to safely apply a tourniquet. with a hemostat (Figure 112-1A). Pass an appropriate sized suture
There is a risk of limb ischemia and eventual limb loss any time around the vessel (Figure 112-1B). Use absorbable sutures that
a tourniquet is used. It is generally accepted that 2 hours is a safe do not lose their tensile strength too soon (e.g., Vicryl, Monocryl,
time period.38–40 Beyond this time, it is believed that permanent and PDS). Tie and secure the suture around the base of the bleed-
muscular or neurologic injury may occur. However, a tourniquet ing vessel (Figure 112-1C). Gently release the hemostat from the
has been safely applied for up to 6 hours without permanent com- blood vessel.
plications.40–42 Use the minimal tourniquet pressure necessary to Cut blood vessels, especially arteries and arterioles, often retract
maintain hemostasis. Release the tourniquet periodically and reas- into the tissue and are difficult to visualize. A suture can be used
sess the extremity. It is best to limit the use of a tourniquet for the to control the bleeding (Figure 112-2). Place a figure-of-eight
minimum time required to temporarily be lifesaving and until stitch (Figure 112-2A) or a pursestring stitch (Figure 112-2B) to
definitive care can be received. encompass the blood vessel. These sutures are simple, quick, and
easy to place.
BALLOON CATHETERS
Physicians have been using balloon catheters to tamponade exsan-
guinating bleeding from deep wounds or wound tracks. These
devices were not specifically designed for this purpose, but used
as an improvised technique to temporarily tamponade the hemor-
rhage. Devices used have included Fogarty catheters, Foley cath-
eters, and Sengstaken–Blakemore tubes. These devices are blindly
placed in the wound and inflated to tamponade bleeding from vas-
cular and solid organ injuries.
Tourniquets specific for deep wound hemorrhage are being
developed. These devices may be used when conventional external
methods (e.g., clotting agents, direct pressure, and tourniquets) do
not control the hemorrhage. This group of devices are inserted into
the wound or wound track and inflated to tamponade the bleeding.
One of these devices is the Tournicath (CardioCommand, Tampa,
FL). These devices have not yet been fully evaluated for use in the
prehospital setting or in the Emergency Department.
SUTURE LIGATION
Thoroughly inspect briskly bleeding wounds. Place a blood pres-
sure cuff proximally and inflate it until a dry bloodless field is FIGURE 112-2. Control of a bleeding vessel deep or embedded in tissue. A. The
obtained. Large vessel bleeding will first become apparent as the figure-of-eight stitch. B. The pursestring stitch. Note that both of these stitches are
cuff pressure is slowly dropped. Large and intermediate-sized not tied tightly for the sake of clarity. In real use, both of these stitches will be tied
vessels will need to be ligated or oversewn for effective control. tightly to seal the bleeding vessel.
It forms an insoluble precipitate with tissue protein to form an arti-

ficial clot or an eschar that occludes the vessel lumen. Silver nitrate
cannot be used on briskly bleeding vessels as it will coagulate the
blood and not the vessel. The cut vessel must not be bleeding or just
oozing for silver nitrate to coagulate the tissue.
The reduced silver nitrate salts stain the tissue it contacts black.
Most of the black silver salts are resorbed by the body over several
weeks. There is the possibility of permanent staining or tattooing of
the skin. Thus, do not use silver nitrate on light skin individuals or
close to the skin surface in cosmetically sensitive areas. Minimize
tissue contact with silver nitrate to prevent damage to the underly-
ing tissue.
Two topical solutions can be used for chemical cauterization.
Monsel’s solution is a 20% ferric subsulfate solution that is thick and
dark brown to black in color. Like silver nitrate, it can permanently
stain or tattoo the skin. Drysol solution is a 30% aluminum chloride
solution that is colorless. It will not stain or tattoo the skin. Drysol
solution may not be as effective as Monsol’s solution for cauteriza-
FIGURE 112-3. The battery-powered electrocautery device. tion. Both of these solutions are applied to a relatively dry or slightly
moist area with a cotton-tipped applicator.
Briefly apply the electrocautery or chemical cautery directly to the
bleeding source. Neither technique will work well unless the field
CAUTERY is dry. This can be achieved with the use of suction, the wound can
be dabbed dry with gauze or cotton-tipped applicators, or exter-
Place a blood pressure cuff proximally and inflate it until a dry
nal pressure. More liberal use to the surrounding tissue will leave
bloodless field is obtained. Small bleeding vessels will be identified
unnecessary damage and impair wound healing. Overzealous use
as the inflated blood pressure cuff pressure is gradually reduced.
of electrocautery and chemical cautery can cause unnecessary tissue
The most likely source of significant bleeding from small vessels
necrosis and increase the risk of infection.
are from veins and dermal arterioles. Venous bleeding usually stops
with direct pressure alone. Dermal arterioles tend to resist direct
pressure and cause persistent oozing from the wound edges. Blood VASOCONSTRICTORS
vessels are best identified by picking up the wound edge and inspect-
Smaller bleeding vessels will usually constrict and eventually stop
ing the dermis. These bleeding vessels can be effectively treated with
on their own once major vessels have been treated. If not, the use of
electrocautery or chemical cauterization.
local vasoconstrictors and topical hemostatic agents is effective.16
Electrocautery is surprisingly easy and effective against aggres-
Epinephrine is a convenient and effective vasoconstrictor.17 It can
sive bleeding from small vessels less than 2 mm in diameter.9
be injected into the wound edges with local anesthetic or placed
Handheld battery-driven electrocautery units use a heated electrode
directly into the wound. Epinephrine and other vasoconstric-
to deliver a thermal burn to the tissue and char the ends of vessels
tors should not be used in a finger, toe, ear, nose, or penis where
(Figure 112-3). They are simple to use, inexpensive, and stocked
ischemia may cause tissue loss. Topical vasoconstrictors should
in most Emergency Departments. More versatile electrosurgical
be used with diligent attention to the total dose administered
units, such as the Bovie and Hyfrecator, are extremely effective
to avoid systemic side effects such as hypertension, tachycardia,
coagulators.15 Unfortunately, they are not routinely available in most
and seizures.
Emergency Departments.
Commonly available local anesthetic solutions containing epi-
Chemical cauterization with silver nitrate (AgNO3) is an effective
nephrine that are available in the Emergency Department include
alternative. The silver nitrate is a dark material that is provided on
lidocaine and bupivacaine. Inject 1 to 2 mL of local anesthetic solu-
the end of a wooden applicator stick, resembling a large matchstick
tion containing epinephrine into the tissue surrounding the bleed-
(Figure 112-4). Rub the silver nitrate over the cut end of the vessel.
ing vessel, cover the wound with saline-moistened gauze, and apply
external pressure for 2 to 4 minutes. Use caution and aspirate prior
to the injection to ensure that the solution is not being injected
intravascularly. Alternatively, spray 1 to 2 mL of 1:1000 epineph-
rine or epinephrine containing local anesthetic solution over the
wound surface with a 25 gauge needle, cover the wound with a
sterile saline-moistened gauze, and apply external pressure for 2 to
4 minutes.18
A more dilute epinephrine solution can be used in larger wounds
to minimize potential side effects. Solutions as dilute as 1:100,000
to 1:1,000,000 are used to control the brisk bleeding that accom-
panies tangential burn wound excision and graft donor sites.19
Topical cocaine (1% to 4%) is a potent vasoconstrictor commonly
used on mucous membranes. Combinations of 0.5% tetracaine,
1:2000 epinephrine (adrenalin), and 11.8% cocaine (TEC) are used
for topical anesthesia and hemostasis in pediatric wounds.20 Apply
1 to 2 mL of these solutions directly into the wound followed by an
FIGURE 112-4. The silver nitrate (AgNO3) applicator. occlusive dressing.
TOPICAL HEMOSTATIC AGENTS Quickclot is a zeolite powder that adsorbs water and produces an
exothermic reaction, releasing heat into the surrounding tissue.23
This group of agents has seen most of the recent innovation in hem- The exact composition is proprietary, but the company states that
orrhage control. Most of these agents were originally developed for it contains no biological or botanical substances. It is available as a
operative hemostasis. There use has expanded into the Emergency loose powder and granular beads in a meshwork fabric. While zeo-
Department. More and more hemostatic agents are being devel- lite provided hemostasis in some animal models, there were mixed
oped for hemorrhage control outside the operating room or for life- outcomes and the exothermic reaction can cause temperatures in
threatening hemorrhage when other standard agents have failed. excess of 212°F or 100°C, leading to thermal tissue injury.24,25 A new
Topical hemostatic agents used in the Emergency Department formulation now produces heat of approximately 105°F or 40.5°C to
include cellulose, dry gelatin, thrombin, microfibrillar colla- reduce the potential for thermal injury. This may limit Quickclot’s
gen, cyanoacrylate, inorganic, and polysaccharide-based agents. clinical use. Woundstat is a smectite nonmetallic mineral that is
Injudicious reliance on hemostatic agents should not replace a composed of sodium, calcium, and aluminum silicates. It adsorbs
methodical approach to wound care and a meticulous search for water without producing an exothermic reaction, concentrates
bleeding vessels. blood products, and promotes hemostasis. It is available as granular
Oxidized cellulose (i.e., Surgicel) or dry gelatin (e.g., Gelfoam, powder that is packed into wounds. Woundstat use demonstrated
Surgifoam) based agents can be used to provide hemostasis in decreased blood loss and improved survival compared to Quickclot
wounds when there is diffuse oozing, especially where a small in animal studies.26,27
amount of blood impedes wound closure and jeopardizes a cosmetic The polysaccharide-based agents are classified as N-acetyl-
outcome. These agents provide a matrix for platelet deposition and glucosamines containing glycosaminoglycans and microporous
aid hemostasis.7,16 Troublesome wounds can be treated with these polysaccharide hemispheres. The data supporting the use of these
agents and covered with a pressure dressing. After a few minutes, agents are limited, mostly derived from animal studies with multiple
the dry field can be approximated with sutures. Another option is differing models making direct comparison between the products
to simply leave the hemostatic agent in the wound, close the wound, difficult. N-Acetylglucosamine glycosaminoglycans are a complex
and apply a pressure dressing. These techniques will be effective polysaccharide derived from marine microalgae or crustacean
for many wounds. These substances are not free of complications. shells in the form of chitin or chitosan.24 These agents are thought to
Absorbable gelatin in a wound can produce excessive granulation provide hemostasis through multiple mechanisms including tissue
tissue and fibrosis. Cellulose can cause a foreign body reaction. adhesion, attraction of circulating red blood cells, and vasospasm.28
In cases where the bleeding persists, topical thrombin or N-Acetylglucosamine-based agents include Hemcon and ChitoFlex
microfibrillar collagen (e.g., Avitene, Instat, Helistat) may be use- (Hemcon Medical Technologies, Portland OR), Celox (SAM
ful hemostatic agents in these problematic cases.16 Apply topical Medical Products, Portland OR), and Modified Rapid deployment
thrombin in powder form, or diluted with saline and sprayed on Hemostat (Marine Polymer Technologies, Danvers, MA). Hemcon
the wound. Concentrations of 100 units/mL are usually effective. is available as a coated bandage. Celox is available as granules, gran-
Concentrations of 1000 to 2000 units/mL can be used if the bleeding ules in a disposable bag, coated flexible gauze, and in a plunger for
is severe. Alternatively, microfibrillar collagen can be used to encour- deep application. Modified Rapid deployment Hemostat is available
age platelet aggregation. Both thrombin and microfibrillar collagen as a coated gauze. Hemcon, one of the best studied agents, has dem-
are expensive and are not usually supplied outside the Operating onstrated mixed results in animal studies but has favorable reports
Room. Their use should be restricted to the unusual patient with a from its limited use with the United States military.29 A limited
coagulopathy or severe bleeding unresponsive to other measures. study of 10 trauma patients with intraabdominal injuries achieved
Cyanoacrylate tissue adhesives are commonly used in the hemostasis in 90% of the patients with Modified Rapid deployment
Emergency Department for wound closure. It is also a helpful adju- Hemostat.30
vant for hemostasis. In simple wounds where cyanoacrylate is used Microporous polysaccharide hemispheres are derived from
for wound closure, it forms an occlusive dressing that provides potato starch. The agent in this class is Traumadex (Medafor,
hemostasis. There is little human data demonstrating the hemostatic Minneapolis, MN). Traumadex functions as a sponge, dehydrat-
activity of cyanoacrylate. It has been shown to promote clot forma- ing the blood, concentrating the blood constituents, and promot-
tion, decrease bleeding time, and decrease rebleeding in porcine ing clot formation.24 It is available as a powder and an impregnated
models for epistaxis and femoral arterial injury.21,22 It is important bandage. Similar products are available as a spray and plunger for
to note that cyanoacrylate works best in a dry, bloodless field that deep application. It performed better than a standard dressing in
can be obtained by a combination of direct pressure, irrigation, and a swine model of lethal hemorrhage, but worse than both Hemcon
temporary tourniquet use. Hemostasis was achieved in a porcine and Quickclot.31
arterial hemorrhage model in 90% of the animals after temporary Dry Fibrin Sealant Dressing (DFSD) is composed of clotting
tourniquet placement, irrigation, and cyanoacrylate application via proteins purified from donated blood and plasma. The DFSD is a
spray.22 Given the occlusive nature of cyanoacrylate, the wound can multilayered dressing composed of fibrin, calcium chloride, throm-
remain uncovered after its application, allowing for easier recogni- bin, and an absorbable mesh. The dressing combines with blood to
tion of rebleeding if it occurs. become activated and adhere to the tissues. These DFSD’s require
A relatively new area in topical hemostasis is the management special handling and are very expensive, both of which will limit its
of life-threatening bleeding in the nonoperative setting. This has use in the Emergency Department.
focused on hemostatic dressing and agents, which when applied, The limited human evidence, case reports, and small studies make
lead to rapid hemorrhage control. These products are placed in comparison of the various hemostatic agents difficult. The applica-
the wound, covered with gauze, and pressure is then applied. tion of these agents is simple. Determining which of these agents
More definitive management can be planned after hemostasis is to use is difficult. It is likely that one or more of these products will
achieved. These agents fit into two broad categories, inorganic and become a useful adjunct in topical hemostasis in the early phase of
polysaccharide-based hemostatic agents. trauma management in the Emergency Department.
The inorganic hemostatic agents include Quickclot (Z-Medica, The Defense Advance Research Projects Agency (DARPA) is look-
Wallingford, CT) and Woundstat (TraumaCure, Bethesda, MD). ing into novel methods of hemorrhage control for the battlefield.
They are in the process of developing a wound dressing with an

embedded ultrasound device that would be tuned at the resonant
frequency of blood. The ultrasound would emit and focus high-
power energy toward the bleeding site and stimulate coagulation.
If practical and effective, its use can be expanded to the prehospital
environment and the Emergency Department.
WOUND CLOSURE VERSUS PACKING

The wound can be approximated, a pressure dressing applied, and
the limb elevated when oozing cannot be controlled by any other
method. Alternatively, the wound can be packed with saline-
moistened gauze until better hemostasis is achieved. Obtain a
coagulation profile in anyone with persistent diffuse bleeding. If a
correctable coagulopathy is identified, the wound can be approxi-
mated after the coagulopathy is corrected.
The general techniques discussed above apply to bleeding from
most sites. There are a number of techniques applicable to specific
anatomic sites.
THE HAND
Hand injuries pose special problems. Strict hemostasis is neces-
sary to examine the wound and identify any associated damage to
tendons, nerves, and joint capsules. A tourniquet can be placed to
FIGURE 112-5. Finger tourniquets. A. A Penrose drain wrapped about the base
exsanguinate the extremity and facilitate wound inspection. Elevate of the finger provides effective hemostasis. B. A finger of a surgical glove has been
the limb and wrap it with an elastic bandage to “milk” the venous cut and rolled down the finger. C. A commercial finger tourniquet.
return toward the heart. Apply a blood pressure cuff to the forearm
or arm and inflate it above the systolic blood pressure. This pre-
vents arterial inflow while minimizing the backflow from venous
engorgement to reliably provide a bloodless field. trauma patient, although continued brisk bleeding from the scalp
A digital tourniquet may expedite the examination if the injury can contribute to hemorrhagic shock.35 Techniques for vascular
is confined to a single digit.32,33 A number of methods are effec- control of the damaged scalp should be simple, fast, and not inter-
tive. A Penrose drain can be wrapped about the base of the finger fere with the ongoing assessment and treatment of other injuries.
and secured with a hemostat (Figures 104-3 & 112-5A). Mark a A few techniques can help gain rapid control of scalp bleeding
0.25 in. Penrose drain with two lines placed 26 mm apart. Stretch with a minimal investment of time or personnel (Figure 112-6).
the Penrose drain about the base of an average adult finger until the The fastest and most effective method is the application of Raney
lines meet. Clamp the Penrose drain with a hemostat to generate a scalp clips (Figure 112-6A). These have been used for years by
sufficient but safe pressure.32 An alternative is to use a surgical glove Neurosurgeons performing craniotomies.36 Scalp clips should only
with the fingertip cut off and rolled down to leave a tight band at the be used on the thick skin of the scalp. Use elsewhere can crush
base of the digit (Figures 104-4 & 112-5B). Use a glove size larger and devitalize thin skin or damage subcutaneous structures. If
than what would typically fit the patient for general use to avoid these are not available, apply hemostats at the wound edges where
generating excessive pressure.32 Disposable, preformed, rubber digi- the bleeding is brisk (Figure 112-6B). Inject local anesthetic solu-
tal tourniquets are commercially available (Figures 104-5, 104-6, tion with epinephrine into the wound edges to constrict smaller ves-
and 112-5C).34 Refer to Chapter 104 for a more complete discussion sels. A Penrose drain can be wrapped about the head as a temporary
of digital tourniquets. These tourniquets exsanguinate the digit and tourniquet (Figure 112-6C).12 A last method is to place a figure-of-
prevent arterial inflow. Tourniquets should be applied for no more eight suture, simple running sutures, mattress sutures, or surgical
than 20 to 30 minutes to avoid injury to the digital nerves. staples to temporarily close the wounds and achieve hemostasis. A
Hemostasis is important but should not be pursued without more definitive closure can be performed after the patient has been
regard to the surrounding tissues. Hand wounds should not be stabilized.
explored or probed deep to surface structures. Blind exploration The use of Raney clips can be cumbersome. This is especially
or clamping is never advised. Probing and clamping can dam- true if the Emergency Physician has little or no experience with
age small nerves and other structures. Vasoconstrictors, such as the system. It requires a special applier, individually loading the
epinephrine, should not be used on the digits. Consult a Hand clips on the applier, and manipulating the clips. A much sim-
Surgeon if wounds require deep exploration, a digital artery is pler system is a Raney clip gun (Figure 112-7). The clips are
injured, or hemostasis is difficult to achieve. preloaded in a magazine that snaps into the clip gun. A clip
is applied by touching the tip of the gun to the scalp edge and
squeezing the handle. The clip gun then ejects and applies a clip,
THE SCALP loads the next clip, and is set to apply the next clip. The process
Scalp wounds frequently occur in association with other major and technique of applying a clip is similar to using a skin stapler.
intracranial, spinal, thoracic, and intraabdominal injuries. Control The clip gun is much easier, quicker, and simpler to use than the
of scalp bleeding is frequently not the first priority in the multiple traditional method.
FIGURE 112-6. Hemorrhage from scalp wounds can easily

be controlled. A. Hemostatic Raney scalp clips seal the wound
edge. B. Hemostats applied about the edge of the wound.
C. A Penrose drain wrapped about the head.
MAJOR EXTREMITY INJURY tamponade active bleeding.37 Consider the application of a topi-
cal hemostatic agent such as Hemcon, QuickClot, or Traumadex.
Amputations, major crush wounds, soft tissue avulsions, and frac- These conservative and simple measures can dramatically reduce
tures of the extremity may present with active bleeding. Diffuse ongoing blood loss.
bleeding from muscle and soft tissue may be difficult to local-
ize and treat. Immobilize the extremity and apply direct pressure EXPOSED BONE
if discrete bleeding sites cannot be identified. Reduction of long
bone fractures and immobilization of soft tissue injuries can sta- Exposed bone will tend to ooze. This can be especially trouble-
bilize the damaged tissue and minimize blood loss. The applica- some in amputations and crush wounds. Bone wax can tamponade
tion of a MAST suit or air splint may stabilize bony fragments and these sites and temporarily halt the bleeding until more definitive
action can be taken. Open a sterile package of bone wax and hold
it in a sterile-gloved hand to warm it up and make it more pli-
able. Remove a piece of the bone wax and mold it over the end of
the broken bone. Firmly push the bone wax into the bone to seal
the edges. Use care to prevent lacerating your glove and finger,
resulting in a potentially significant bloodborne pathogen expo-
sure. Possible complications associated with the use of bone wax
include granulomatous reactions, infection, and interference with
osteogenesis. An alternative to bone wax is Ostene (Ceremed Inc.,
Los Angeles, CA), a water-soluble alkylene oxide copolymer that
dissolves within 24 hours.
ARTERIAL INJURIES
Puncture wounds, open fractures, amputations, and deep lacera-
tions may be complicated by arterial injuries. These may be obvi-
ous if they present with dramatic pulsatile bleeding. However, the
elastic recoil of arteries frequently causes the damaged vessel to
retract deep within the wound, only to rebleed after wound closure.
Recurrent pulsatile bleeding and deep hematoma formation are
characteristics of unrecognized arterial injuries. This is particularly
true of puncture wounds where the damage may be deep and not
FIGURE 112-7. The Medtronic Clip Gun Kit (Medtronic Neurosurgery, Goleta, visible to the examiner’s eye. These wounds may require angiogra-
CA). It contains the clip gun, three magazines preloaded with Raney-type clips, a phy, embolization, or wound exploration to identify the source if
clip remover tool, and an instruction manual. they rebleed despite local measures.
ASSESSMENT that the Emergency Physician perform a thorough history and phys-
ical examination, with an emphasis on the neurological and ortho-
The ideal goal in wound care is to achieve a dry bloodless field pedic examination to exclude other causes of musculoskeletal pain.3
without compromising the vitality of the tissue. Simply control-
ling the hemorrhage and preserving life is the goal in major trauma
victims. Expediting wound closure and preventing hematoma for- ANATOMY AND PATHOPHYSIOLOGY
mation is a more modest goal for minor injuries. The etiology and pathogenesis of MTrPs have yet to be elucidated.
Likewise, the precise mechanism by which MTrP injections inac-
AFTERCARE tivate the trigger point is unknown. Researchers do agree that
acute trauma or repetitive microtrauma appears to lead to the
A healthy wound is proof of adequate hemostasis. Routine wound development of a MTrP.6 The risk for a MTrP is increased when
care should verify a healthy incision line and the absence of a hema- other factors are present, including poor physical conditioning,
toma or an infection. Refer to Chapters 92 through 96 regarding the poor posture, and prolonged bending.7 MTrPs mostly affect the
details of wound care and repair. muscle groups used to maintain posture (i.e., muscles of the neck,
shoulders, and back). When the head and neck region is affected,
COMPLICATIONS the patient may present with a tension headache or temporoman-
dibular joint pain.6
The techniques in this chapter are all safe and effective when used as MTrPs are hyperirritable points located within a taut band of skel-
described. Complications occur when the described techniques are etal muscle or fascia.2 When these points are compressed, they may
used in excess or in the wrong setting. The specific complications cause referred pain, local tenderness, and autonomic changes.2 Pain
of each technique are discussed under each specific section in this may be localized or diffuse. It can be described as burning, dull,
chapter. sharp, or some combination of these. Autonomic changes associ-
ated with a MTrP include dizziness, edema at the site, lacrimation,
SUMMARY piloerection, salivation, and tinnitus. The compression of a MTrP
can further lead to muscle spasm, stiffness, shortening, and fatigue.1
There are a number of techniques available for the control of hemor-
This may progress to impaired muscle coordination, reduced mus-
rhage. A methodical approach to the bleeding wound will optimize
cle strength, and decreased range of motion.1
the outcome. Simple measures should be used first and progressive
systematic steps taken until hemostasis is achieved. All bleeding
eventually stops! The goal is to halt the bleeding before irreparable DIAGNOSIS OF MTrPs
harm occurs. The diagnosis of a MTrP relies on the following criteria: a tender
spot with an underlying taught band, pain on palpation of the ten-
der spot, and a local twitch response (i.e., a transient local contrac-
tion of skeletal muscle fibers in response to palpation or needling).3
While the data on clinical outcomes provide no definitive answer,
Trigger Point Injections the best outcomes appear to occur in patients who exhibit a local
113 Danielle Campagne

twitch response with palpation.4 The current literature provides no
pathophysiologic explanation for this result. There are no labora-
tory, pathology, or radiology studies to identify or verify a MTrP.
Identifying the palpable, taut band is critical in locating the MTrP.
The MTrP can be identified by flat palpation, snapping palpation,
INTRODUCTION pincer palpation, and/or deep palpation. Flat palpation uses a fin-
Musculoskeletal pain is a significant health problem for the North gertip to slide across the skin over the affected muscle to find the
American population.1–9 Such pain affects between 10% and 20% of MTrP (Figure 113-1). The taut band may be felt under the slid-
the population and is a major cause of morbidity.1 It is estimated that ing fingertip. Snapping palpation uses the tip of the index finger to
approximately half of the chronic pain complaints result from a mus- pluck the skin in an attempt to feel the underlying taut band. This
culoskeletal origin.2 It is hypothesized that myofascial trigger point motion is similar to plucking a guitar string. Pincer palpation uses
(MTrP) injections may alleviate much of this pain. It is imperative the dominant thumb and index finger to firmly grasp the skin and
FIGURE 113-1. Flat palpation to identify a MTrP or taut band. A. The index finger pushes down over the MTrP or taut band. B. The index finger rolls off the tender spot
and pushes the skin to one side. C. The index finger pushes the skin back to the tender spot to feel the taut band. D. The index finger rolls off the tender spot and pushes
the skin to the opposite side.
CHAPTER 113: Trigger Point Injections 739
TABLE 113-1 Determining Isolated MTrPs Versus MTrPs Associated with

Fibromyalgia
Characteristic Isolated MTrPs Fibromyalgia
Sexual predilection None Female
Pain and tenderness Local or regional Generalized and
widespread
Muscle tissue Taut bands palpable Soft, no taut bands
palpable
Muscle range of motion Stiff and decreased Normal
MTrPs Few, discrete, and Many and widespread
localized
FIGURE 113-2. Pincer palpation to identify a MTrP or taut band. A. The skin, Immediate response to Resolution of symptoms Poor or none
subcutaneous tissue, and muscle are grasped between the thumb and index finger. injection therapy
B. The fingers are moved back and forth (arrows) to feel the taut band as it is Source: Data from Simmons et al.2
rolled between the fingertips.
CONTRAINDICATIONS
muscle as a unit and roll it to identify the taut band (Figure 113-2). Contraindications to MTrP injections are similar to other injection
Deep palpation can be used to identify a deep MTrP or a superficial procedures. This includes the presence of a local or systemic infec-
MTrP in an obese patient. Use the tip of the index finger to press tion, malignancy, anticoagulation therapy, a bleeding disorder, or a
slowly and deeply to reproduce the patient’s symptoms and identify dermatologic condition over the injection site.5 Relative contrain-
the MTrP. dications include allergies to local anesthetic agents, patients with
Studies have utilized a variety of injectant fluids and solutions needle phobias, and uncooperative patients.
during injections of MTrPs including sterile water, sterile saline, It is important to differentiate between a patient with one or more
local anesthetic solutions, corticosteroid suspensions, ketorolac, isolated MTrPs and fibromyalgia (Table 113-1). A patient with
and botulinum toxin.1 No specific fluid or solution has demon- fibromyalgia can have multiple MTrPs. Do not perform MTrP
strated a clearly superior clinical outcome. Rather, it appears that injections in a patient with fibromyalgia. The injection may
the optimal injectant fluid or solution varies by Physician prefer- worsen their pain.
ence. The duration of pain relief has been found to last longer than
the duration of action of the injectant. A recent meta-analysis of
eight randomized and controlled clinical trials examined the type EQUIPMENT
of injectant used and the resulting effect on symptom relief.1 The
• Sterile gloves
authors concluded that the injection of either lidocaine or botu-
linum toxin provided greater symptom relief than placebo (i.e., • Povidone iodine or chlorhexidine solution
dry needling alone). No particular injectant was more efficacious • Alcohol swabs
than any other injectant. This finding is consistent with the general • Sterile gloves
medical literature on the topic, which is still in its infancy, and pro-
vides no clear indication of effectiveness. More research is required • Gauze 4 × 4 squares
in this area. • 25 or 27 gauge, 1.5 in. needle for superficial trigger points
• 25 or 27 gauge, 2 in. needle for deeper trigger points
NONINVASIVE MTrP MANAGEMENT • 3 or 5 mL syringe
Numerous noninvasive techniques have been used to treat a • Injection solutions:
MTrP.2,5,8 One of the more common techniques uses spray vapo- ▶ Lidocaine without epinephrine
coolant (e.g., ethyl chloride) in combination with passive muscle ▶ Bupivacaine without epinephrine
stretch to relax the taut band. Ischemic compression therapy is the
▶ Sterile water
application of pressure to the MTrP to produce ischemia and ablate
the MTrP. Digital pressure is applied and increased until the taut ▶ Sterile normal saline
band relaxes. A deep pressure or stroking massage can be used to ▶ Botulinum toxin A, 20 units or 0.4 mL (50 U/mL) (Botox,
stretch the affected muscle and relax the taut band. Physical therapy Allergan, Irvine, CA) diluted to 1 mL with normal saline
can stretch and relax the affected muscles. Transcutaneous electrical
stimulation units with the electrodes placed over the MTrP can be • Ultrasound machine with a 5 to 7.5 MHz probe
used to stimulate and relax the underlying muscle. Ultrasound can • Ultrasound gel
transmit heat and vibration to a superficial MTrP with the goal of
muscle relaxation. PATIENT PREPARATION
INDICATIONS Explain the risks and benefits of the procedure to the patient and/or
their representative. Obtain an informed consent, either signed or
MTrP injections have been advocated for points of muscle pain that verbal, with adequate documentation to support the latter method.
are not assisted by noninvasive therapy such as ischemic compres- Place the patient in a comfortable position on a gurney with the
sion therapy, massage, physical therapy, spray vapocoolant, trans- MTrP(s) exposed. Ideally, the muscle with the MTrP(s) positioned
cutaneous electrical stimulation (TENS), and ultrasound.8 There so that it is relaxed. Identify the MTrP site(s). Clean the skin of any
is no emergent indication for a MTrP injection in the Emergency dirt and debris. Use ultrasound to ensure there are no neurologic,
Department. tendinous, or vascular structures in the area that can be injured
FIGURE 113-3. Identifying and securing the MTrP or taut band. A. Push with the index finger and middle finger, alternating between the fingers, to identify and isolate the
MTrP or taut band. B. Compress the skin with both fingers to secure the MTrP or taut band and inject it.
by the MTrP injection. Mark the MTrP skin site with a pen. Apply longer palpable.7 Completely withdraw the needle. Apply pressure
povidone iodine or chlorhexidine solution over the injection site(s) over the injection site to prevent bleeding and hematoma forma-
and surrounding skin and allow it to dry. Follow aseptic technique tion. Instruct the patient to slowly and fully stretch the affected
for the injection procedure. muscle group.8
Prepare multiple 3 or 5 mL syringes armed with a 25 or 27 gauge
needle and containing the injection solution. The editor recom- ASSESSMENT
mends local anesthetic solution as the injectant in the Emergency
Department. The number of syringes to prepare depends upon the The patient should experience relief of their symptoms after the
number of MTrP sites to be injected and the volume injected at injection. Passively and actively stretch the affected muscle in a
each site. slow manner to stretch it out. Apply digital compression to the
injection site, the MTrP, and the taut band. If symptoms are still
TECHNIQUES
INJECTION TECHNIQUE
Reidentify the MTrP site. Use the nondominant index and
middle fingers to locate and isolate the MTrP or taught band
(Figures 113-3A & B). Insert the needle into the skin approximately
1 cm away from the MTrP or taught band, at a 30° angle to the skin,
and aimed at the MTrP or taut band. Advance the needle into the
MTrP or taut band. Insert the needle briskly, but also in a con-
trolled manner. Use a “fast in, fast out” approach to elicit a local
twitch response when the tip of the needle hits the MTrP or taut
band.8 Aspirate to ensure that the tip of the needle is not within a
blood vessel. Inject the solution within the syringe.
Common practice is to inject between 0.5 and 2.0 mL total per
MTrP.5 This volume can be injected into the one location of max-
imal tenderness or numerous sites in a fanlike pattern within the
MTrP (Figure 113-4).9 Once the injection is completed, withdraw
the needle to the skin surface but do not completely remove it from
the skin. Allow the injection solution to work for up to a minute.
Reinsert the needle into the MTrP in a fanlike pattern until the local
twitch response is no longer elicited or resisting muscle tautness is
no longer palpable.7 Completely withdraw the needle. Apply pres-
sure over the injection site to prevent bleeding and hematoma for-
mation. Instruct the patient to slowly and fully stretch the affected
muscle group.8
DRY NEEDLING
The technique of dry needling involves inserting a needle into
multiple sites within the MTrP or taut band without injecting
any fluid or solution. This is similar to acupuncture. Insert the
needle as described above. Withdraw the needle until the tip is
just below the skin surface. Redirect and reinsert the needle in a
fanlike pattern into a different location within the MTrP or taut FIGURE 113-4. Injection of the MTrP or taut band. The needle is inserted through
band. Continue this process several times until the local twitch a single skin puncture and into multiple places within the MTrP or taut band in a
response is no longer elicited or resisting muscle tautness is no fanlike pattern.
CHAPTER 114: Escharotomy 741
present, repeat the procedure with local anesthetic solution or by injury deaths in the United States.1 Conversely, less than 6% of
dry needling. Observe the injection site and apply pressure to con- the above patients who were admitted to a recognized burn cen-
trol any bleeding. ter subsequently died as a result of their injuries.2–4 These data
underscore the need for rapid and effective emergency care
AFTERCARE focused on facilitating the successful transfer of these patients
to specialized burn centers. The initial management of these
Apply a simple adhesive bandage over the injection site. Postin- patients invariably falls upon the Emergency Department. The
jection soreness is expected and can be managed with acet- Emergency Physician needs to be well versed in the recognition of
aminophen or nonsteroidal anti-inflammatory drugs. Encourage acute thermal injuries, their associated complications, and their
the patient to use the affected muscle through its full range of appropriate treatment.
motion, but avoid strenuous activity for 1 to 3 days after the injec- Thermal injuries have the potential to affect any body surface,
tion. Instruct the patient to return to the Emergency Department both internally and externally, that a heated medium comes into
immediately if they develop fever, chills, swelling at the injec- contact. The overall depth and degree of injury is multifactorial.
tion site, redness at the injection site, or any drainage from the It is also typically proportional to the temperature of the source
injection site. medium, its unique specific heat, the actual rate of energy transfer,
and the overall duration of tissue exposure. This chapter focuses on
COMPLICATIONS the skin and its response to burn injuries.
The complications are the same as any injection procedure, includ- ANATOMY AND PATHOPHYSIOLOGY
ing infections and needle breakage. An allergic reaction to the
injection fluid or solution is possible. Treat this as any other aller- Skin exposure to any significant heat source results in a spectrum of
gic reaction. A thorough history may prevent an allergic reaction pathophysiological responses. An initial coagulation necrosis occurs
to the injectate. Never aim the needle at an intercostal space to as thermal energy is transmitted directly into living tissue. These
prevent an iatrogenic pneumothorax.7 Hematoma formation fol- cells subsequently die and lyse, spilling their intracellular contents
lowing injection can be minimized with proper technique and the and increasing the surrounding interstitial oncotic pressure. These
application of pressure over the soft tissue after the needle is with- processes serve to trigger a secondary edematous reaction in the
drawn.2 Never inject the patient when they are standing or sitting surrounding tissues. Cellular breakdown releases a host of gener-
in a chair. Ensure that the patient is always on a gurney and the alized inflammatory markers including histamines, prostaglandins,
side rails are upright to prevent injury if the patient becomes vaso- cytokines, and interleukins. These agents further exacerbate the
vagal or experiences syncope. Injury and inadvertent injection to localized edematous reaction via vasodilation and increased capil-
adjacent structures can be avoided by knowing the local anatomy lary permeability.5
and using ultrasonography before the injection to identify adjacent Burns involving over 20% of a patient’s total body surface area
structures. (TBSA) can result in secondary injury extending beyond the locally
involved tissues. The previously described inflammatory outburst
SUMMARY can become significantly large enough to produce a systemic
pathophysiologic response of internal fluid shifts and external fluid
MTrP injections can be performed in the Emergency Department. losses. Inadequate fluid resuscitation can result in tissue hypoper-
They are simple, quick, and effective to manage a patient’s pain. The fusion and multisystem organ dysfunction. Moreover, a secondary
efficacy of MTrP injections has not yet been established. However, systemic inflammatory response syndrome (SIRS) can further com-
MTrP injections may serve as part of a treatment plan to offer quick plicate the clinical course of patients whose burns involve greater
relief of myofascial pain when other noninvasive therapies have than 30% TBSA. This frequently results in widespread intravascu-
been unsuccessful. lar hemolysis, acute renal failure, and acute lung injury.6,7 A global
hypermetabolic state tends to accompany these injures. When
greater than 30% to 40% of a patient’s TBSA is involved, secondary
catecholamine release can raise the resting metabolic rate approxi-
mately two to three times above baseline. The consequent catabolic
Escharotomy tissue breakdown further exacerbates the emerging multisystem
114 Michael A. Schindlbeck

organ dysfunction.5,8 These burns are associated with significant
morbidity and mortality. Survivability rates are indirectly propor-
tional to the TBSA involved. Of special note is the loss of a protec-
tive functioning epidermis as severe and overwhelming infection
becomes a significant potential complication in those who survive
INTRODUCTION
beyond the initial resuscitative period.9 Systemic organ failure from
Few injuries have the same capacity for physical destruction the “burn sepsis” continues to be a leading cause of death in these
and emotional devastation as do thermal burns. They are rela- individuals.
tively common presentations that often require resource-intensive Burns are classified based upon the overall depth of injury sus-
management. The preceding decade saw nearly 500,000 burn tained. First-degree burns are limited solely to the epidermal layer.
injuries per year receiving medical care in the United States. Over They typically present as a tender erythematous region of skin. This
40,000 of these patients required inpatient treatment for their redness arises as the underlying dermal capillaries dilate in response
injuries, and up to 25% of these injuries were work related. The to the overlying injury. Deeper tissues are not directly involved
associated expenses are staggering. The mean hospital stay was and the capillary walls remain intact. This explains the blanchable
in excess of 1 week and at an average cost over 50,000 dollars per nature of these burns on physical examination. Blistering of the
admission. Over this same 10-year period, an average of over 4000 skin, indicating involvement of the underlying dermis, is not seen
individuals per year died as a result of burn-related injuries. Fires with first-degree burns. Classic examples include flash burns and
and burns now represent the fifth leading cause of unintentional sunburns. Despite extensive surface area involvement, these burns
do not generally illicit the systemic pathophysiologic response Any signs and symptoms of limb hypoperfusion should be
described above. Do not include first-degree burns when calculat- taken seriously. A restrictive etiology should be considered only
ing the overall TBSA affected. if hypoperfusion persists despite adequate volume resuscita-
Second-degree burns are the partial thickness injuries. These tion as hypovolemia is the most likely etiology of impaired tis-
burns extend into but not through the dermis. They are subdivided sue perfusion immediately after the burn injury. Perform and
into superficial second-degree and deep second-degree burns. document frequent and repeat physical examinations including
Superficial second-degree burns are typically moist to the touch, an assessment of overall skin appearance, distal capillary refill,
pink to reddish in color, blanchable with gentle pressure, and cov- peripheral pulse checks, any motor deficits, and any sensory defi-
ered with tensely distended blisters. Cutaneous nerves, located in the cits. Depending upon the presence of palpable pulses as the sole
uninvolved underlying deeper dermal layer, remain viable bestow- means to approximate compartmental pressures will grossly
ing an exquisitely painful character to these burns. Conversely, deep underestimate the need for decompression.15 Several methods
second-degree burns involve the deeper reticular dermis and differ are available to aid the Emergency Physician in frequently assess-
noticeably in appearance. They tend to be drier in texture and have ing for tissue hypoperfusion. Bedside arterial Doppler provides an
a more blanched whitish complexion. These injuries tend to be less easy means to gauge peripheral perfusion. It is concerning if any
painful than their superficial counterparts due to destruction of the signs of a progressive reduction in arterial flow occurs. The absence
cutaneous nerves. of arterial flow on a bedside Doppler is an indication for emer-
Full thickness burns involve the destruction of the entire epi- gent escharotomy. Keep in mind that the presence of Doppler
dermal and dermal tissues and are classified as third-degree burns. pulses does not necessarily indicate adequate perfusion. Pulse
Coagulation necrosis imparts a dry leathery appearance to these oximetry provides another useful adjunct. A distal oxygen satu-
burns. The overlying tissue is insensate secondary to the oblitera- ration of less than 95% in a circumferentially burned extremity
tion of the cutaneous nerves. The dermal proteins in third-degree has been shown to be an indicator for an emergent escharotomy.16
burns are heated and tend to contract, facilitating the formation of Compartmental pressures can usually be measured quickly at
a constrictive eschar of scar tissue. Rare scenarios where the tissue the bedside. An intracompartmental pressure of ≥40 mmHg is
destruction extends through the dermis and into the underlying tis- an indication for an escharotomy. Consider an escharotomy for
sues (e.g., muscle, bone, and fascia) are categorized as fourth-degree intracompartmental pressures between 25 and 40 mmHg. Refer to
burns. These injuries are catastrophic in appearance and tend to Chapter 74 regarding the complete details of compartment pres-
result in extensive tissue loss.10 sure measurement.
Burn injuries can generate an extensive redistribution of flu- Significant burns to both the chest and abdomen can result in
ids into the interstitial spaces. Aggressive fluid resuscitation will restricting ventilation. Respiratory distress is generally multifacto-
help to limit the consequent invariable hypoperfusion but does rial in burn patients. A concurrent inhalation injury or secondary
nothing to limit further leakage of fluids into the interstitium. ARDS should be entertained in the differential diagnosis. Early
This third spacing can lead to significant elevations in the local- intubation and mechanical ventilation is essential in any burn
ized hydrostatic pressures in tissues already constricted by an patient exhibiting respiratory distress. Mechanically ventilated
extensive overlying eschar. Impairment in regional lymphatic and patients with severe truncal burns, persistent arterial hypercapnia,
venous drainage further exacerbates this adulteration of the local and elevated peak inspiratory pressures (although often confounded
pressure gradient. Eventually, the normal arteriolar perfusion by concurrent airway edema and secondary bronchospasm) are
pressure will be overwhelmed and result in distal tissue hypoper- objective signs suggesting a significant restrictive respiratory physi-
fusion. Distal tissue necrosis can progress to limb loss if the burn ology. An emergent escharotomy in these patients could be a life-
occurs on an extremity. Swelling and scarring can result in the saving procedure.
loss of a functional airway if the burn occurs over the neck. Burns Facial burns can result in eschar formation around the eyes and
occurring across the torso can produce an abdominal compart- mouth. Measure intraocular pressure if an eschar surrounds the eye.
ment syndrome, progressing to intra-abdominal organ ischemia, Elevated intraocular pressure should be decompressed with a lateral
impaired diaphragmatic excursion, and reduced cardiac output canthotomy. Refer to Chapters 156 and 162 regarding the complete
secondary to diminished venous return.11–13 Significant thoracic details of intraocular pressure measurement and a lateral canthot-
burns can also impede the dynamic chest wall motions of respira- omy, respectively.
tion producing a further restrictive ventilation that can progress
to respiratory failure.14 CONTRAINDICATIONS
INDICATIONS No specific contraindications exist for performing an escharotomy
provided the above indications are satisfied. Concern for possible
The general indication to perform an escharotomy is to limit the medical futility should arise in those patients with no chance of sal-
circulatory or respiratory insult caused by an overlying circum- vageability, although this is very difficult to determine within the
ferential burn. These indications can also be present with a sig- Emergency Department.
nificant noncircumferential burn. The development of a significant
restrictive physiology often requires several hours after the initial
burn. Most patients could be successfully transported to a special-
EQUIPMENT
ized burn center within this time span. Invasive means to assess • Glove, gown, and face mask
compartmental pressures (Chapter 74) should not be undertaken
at the expense of proper fluid resuscitation and preparation for • Povidone iodine or chlorhexidine solution
transport. The Emergency Physician must maintain a high index • #10 scalpel blade on a handle
of suspicion to limit any further injury to viable tissues. Once the • Electrocautery unit, optional
decision to perform an escharotomy is made, it should be per-
formed without delay. If possible and time permits, perform the
escharotomy in consultation with the accepting burn center and/or • Local anesthetic solution
Burn Surgeon. • Needles and syringes
PATIENT PREPARATION FACE ESCHAROTOMY

This procedure is considered life and/or limb sparing. Inform the The face is commonly involved in burn injuries. Eschars can form
patient for the need to perform an escharotomy, its risks and bene- on the face just as they can form on other areas of the body. A
fits, and the outcome if not performed. Document the discussion in patient complaint of any visual disturbance or burns around the eye
the medical record. The patient’s medical condition often precludes requires a thorough investigation. This includes measuring visual
them from signing a consent form. Despite the fact that escharoto- acuity, a topical fluorescein examination, a fundoscopic examina-
mies are performed upon tissues previously destroyed by full thick- tion, and measurement of intraocular pressure. Refer to Chapters
ness burns, some intermittent nerve function can persist. This may 153 and 156 regarding the complete details of these examinations.
necessitate the use of local anesthesia and/or procedural sedation. If Elevated intraocular pressure may require a decompressive lateral
not contraindicated, administer some form of procedural sedation canthotomy and cantholysis. Refer to Chapter 162 regarding the
(Chapter 129) in the conscious patient for pain control as well as to complete details of this procedure.
limit the profound anxiety elicited by this procedure. Strict aseptic Perioral burns can form eschars. These eschars may limit or
technique should be followed. Clean the skin of any dirt or debris. prevent mouth opening. An escharotomy may be required to aid
Apply dilute povidone iodine or chlorhexidine solution to the skin in oropharyngeal suctioning and orotracheal intubation. Make the
and allow it to dry. This procedure has the potential to introduce a escharotomy incisions at the bilateral corners of the mouth and
devastating infection. extending directly posterior (in the supine patient) and approxi-
mately 4 to 5 cm long (Figure 114-1A). Make the incisions very
TECHNIQUES superficial to prevent injury to the underlying facial artery, cra-
nial nerves, superficial facial structures, and the parotid gland.
Make the skin incisions along the proper plane with a #10 scalpel
blade or an electrocautery unit. Electrocautery has the added abil-
ity to coagulate the potential bleeding encountered from inadver- NECK ESCHAROTOMY
tently incised superficial subcutaneous vessels. Limit the depth Significant burns to the neck can result in the formation of a con-
of the incision to the dermis. Use extreme caution to avoid over- strictive eschar that can compromise the airway. Make paired ver-
aggressively extending these incisions too deeply and injuring the tical incisions on the posterolateral surfaces of the neck from the
underlying deep investing fascia, muscles, and/or tendons. There mastoid process to the clavicle (Figure 114-1A). Meticulous care
is a pressure buildup underlying the constricting tissue. A prop- and attention should be given to always remain posterior to
erly placed incision should elicit a rapid separation of the eschar the clavicular border of the sternocleidomastoid muscle. This
exposing the underlying subcutaneous fat. Carefully run a gloved will avoid injury to the internal jugular vein, carotid artery, thyroid
fingertip along the incision lines to detect any residual connecting gland, trachea, and vagus nerve.
bands of tissue requiring further incision. To ensure an adequate
release, continue the incision across the entire eschar and extending
1 to 2 cm into the unscarred tissue on either end. Cosmetic concerns
TORSO ESCHAROTOMY
are not a concern as the incised tissue will often require eventual Perform a thoracic escharotomy by extending bilateral verti-
skin grafting, provided the patient survives. cal incisions from the lateral clavicle to the costal margins along
FIGURE 114-1. The location of incisions for escharotomies.

A. The head and neck. B. The extremities and torso. C. The hand
and fingers.
the anterior axillary lines (Figure 114-1B). Use caution in female the perfusion pressures of affected tissues. Infants and younger chil-
patients to avoid incising directly through the breast tissue. Instruct dren depend to a greater extent upon diaphragmatic excursion and
an assistant to grasp the breast and move it medially to avoid the abdominal wall mobility for normal respiratory function. They are
escharotomy incision line. In those patients whose burns also therefore more susceptible to significant respiratory compromise
involve a significant portion of the abdominal wall, extend the tho- from extensive truncal burns. This necessitates that the treating
racic incision inferiorly beyond the costal margins and across the Emergency Physician possesses both a high index of suspicion and
entire eschar to ensure adequate decompression (Figure 114-1B). the technical ability to intervene surgically. The patient preparation
Make a horizontal bridging incision along the inferior costal and escharotomy techniques are the same as in an adult.
margin in those patients whose burns extend from the thorax
and onto the abdomen to support proper respiratory mechanics ASSESSMENT
(Figure 114-1B).
Circumferential burns of the penis require an escharotomy to The response to an escharotomy should be almost immediate
decompress the area and prevent ischemia. Distal ischemia can rap- with the signs of improving distal perfusion of the extremities or
idly progress and produce significant tissue loss. Make bilateral inci- improved ventilation. The distal extremity should demonstrate
sions along the lateral margins of the body of the penis. Meticulous decreased pallor and return of a natural skin color, return of sen-
care and attention should be given to avoid injuring the dorsally sation, appropriate Doppler arterial flow, and appropriate pulse
located neurovascular structures that lie between the 10 o’clock oximetry. Provided adequate respiratory mechanics, distal pulse
and the 2 o’clock position. oximetry readings should rapidly climb into a normal range.18 Lack
of improvement in distal perfusion should alert the Emergency
Physician to either an inadequate surgical decompression or an
UPPER EXTREMITY ESCHAROTOMY
insufficient fluid resuscitation. If there is no improvement in per-
Perform an upper extremity escharotomy on the medial and lat- fusion despite appropriately addressing these two concerns, con-
eral aspects of the involved limb, extended along the line dividing sider an underlying intrafascial compartment syndrome that would
the flexor and extensor surfaces (Figure 114-1B). Place the upper require an emergent fasciotomy. Please refer to Chapter 74 regard-
extremity supine to ensure adequate landmark identification. ing compartment pressure measurements and Chapter 75 for the
The areas surrounding joints are sites of severe potential restric- details of performing a fasciotomy.
tion due to relatively tight tissue adherence. Use caution when
extending the incisions across these locations. Meticulous care AFTERCARE
and attention should be given to avoid the ulnar nerve along the
medial surface of the elbow as it courses posterior to the median Continue routine burn care and fluid resuscitation as necessary.
epicondyle and the superficial branch of the radial nerve along Manage any continued bleeding from the escharotomy incisions
the lateral surface of the wrist as it courses superficially above with the application of pressure or electrocautery. Cover the escha-
the radius. If the hand is involved, extend the forearm incisions rotomy incisions with sterile saline-soaked gauze and an outer
to include the thenar and hypothenar eminences (Figure 114-1C). dressing. Frequently reassess the patient to rule out the development
Further hand decompression can be accomplished by making verti- of additional tissue ischemia or respiratory compromise that would
cal incisions down the four intermetacarpal grooves on the dorsum indicate the need for further extension of the initial escharotomy
of the hand (Figure 114-1C). The fingers can be decompressed incisions. Transfer the patient to a specialized burn center or an
with linear incisions along the middle of the radial and ulnar sur- intensive care unit to continuously monitor and manage the patient.
faces, between the flexor and extensor surfaces (Figure 114-1C).
In an attempt to limit the potential damage to a patient’s grasp- COMPLICATIONS
ing surfaces, incise the ulnar finger surfaces (radial surface on the
thumb) and assess if this unilateral incision is sufficiently adequate As with any invasive procedure, bleeding can be a significant
to restore perfusion prior to automatically incising the correspond- complication. This is rare when the escharotomy incisions are
ing opposing surface.17 properly limited to the dermis. Bleeding can be extensive when
an underlying subcutaneous vessel is incised. This is often com-
plicated by the consumptive coagulopathy that frequently accom-
LOWER EXTREMITY ESCHAROTOMY panies these burns. Electrocautery is an attractive option to limit
The lower extremity should be approached in a similar manner, such bleeding if encountered. Otherwise, direct pressure should
with incisions extending along the groove between the flexor and generally suffice. Some blood vessels may require ligature for
extensor surfaces (Figure 114-1B). Meticulous care and attention definitive hemostasis.
should be given to avoid damaging the common peroneal nerve The burn-damaged epidermis can no longer function to protect
along the lateral knee as it courses superficial to the fibular head deeper tissues from the external environment. Furthermore, the
and the posterior tibial artery along the medial ankle as it courses overlying eschar of necrotic tissue provides an ideal environment
posterior to the medial malleolus. If the foot is involved, extend the for uncontrolled bacterial colonization. Escharotomy incisions pro-
incisions along the medial and lateral borders of the foot to the great vide a direct route for bacterial penetration into susceptible subcu-
toe and the fifth toe, respectively (Figure 114-1B). Decompress the taneous tissues if sterile precautions are not properly maintained.
toes in a manner similar to the fingers. This can result in catastrophic infection and burn sepsis.
Inadvertent injury of deeper structures such as blood vessels,
TECHNIQUE FOR PEDIATRIC PATIENTS nerves, and tendons can occur. This is preventable by controlling
the depth of the incisions and not extending into and through the
Pediatric patients have a higher surface area to volume ratio than subcutaneous tissues. This is especially true when incising over
does an adult. Consequently, burns pose a greater risk for significant high-risk areas as previously described.
external fluid losses and the rate of fluid resuscitation needs to be Making an escharotomy incision on the fingers is controversial.
adjusted accordingly. More aggressive fluid resuscitation, however, There is little to no muscle at risk of ischemia in the fingers. The
increases the likelihood for pathologically significant elevations in fingers primarily consist of bone, ligaments, subcutaneous fat, and
tendons. These structures are quite resistant to ischemia. A finger SUMMARY

escharotomy can expose the metacarpophalangeal and interphalan-
geal joints, make them prone to infection, and require a subsequent Thermal burns are frequently encountered injuries prompting
fusion or amputation. patients to seek medical care. Their associated morbidity, mor-
A final complication is the inadequate release of the overlying tality, and costs of treatment can be astronomical. Emergency
restrictive eschar. Ongoing tissue ischemia can lead to permanent Physicians often provide an essential role in the acute resuscita-
disability from disfiguring muscle contractures, irreparable neu- tion and stabilization of these patients prior to their ideal transfer
rologic damage, or limb loss. Rhabdomyolysis can lead to life- to a specialized burn center. Severe burns can destroy the natu-
threatening electrolyte abnormalities and acute renal failure. Several ral elastic properties of skin and result in the formation of con-
authors advocate extending the escharotomy incisions 1 to 2 cm strictive overlying eschars. If not recognized and treated, these
beyond the eschar border into viable tissue. A secondary reperfu- eschars can result in catastrophic limb loss, airway compromise,
sion injury can follow the primary decompression as blood once or respiratory failure. When performed properly, an escharotomy
again streams into previously hypoperfused tissue. The consequent can be a limb and life-saving procedure that, at the least, grants
swelling can cause the formation of a secondary underlying intrafas- the patient a significant chance to undergo more specialized and
cial compartment syndrome. definitive burn care.
SECTION
Neurologic and Neurosurgical Procedures 8

Lumbar Puncture
115 Eric F. Reichman, Kevin Polglaze, and Brian Euerle
While the entire cavity of the brain and spinal cord has a volume
of approximately 1650 mL, CSF occupies approximately 150 mL
of this volume. The brain literally floats in the CSF because the
specific gravity of the CSF and brain are approximately the same.
Approximately 500 mL (0.35 mL/min) of CSF is produced each
INTRODUCTION
day. Most (over two-thirds) of the CSF is produced by the choroid
Meningitis and subarachnoid hemorrhage (SAH) are serious plexus within the lateral ventricles. Small amounts of choroid plexus
life-threatening conditions. They require prompt and accurate can also be found in the third and fourth ventricles. Small amounts
diagnosis in the Emergency Department due to their significant of CSF are secreted by the ependymal surfaces of the ventricles. A
morbidity and mortality. There are many diagnostic modalities minimal volume of CSF is produced by the brain through the small
available to the Emergency Physician to assist in the diagnosis. perivascular spaces that surround the blood vessels entering the
However, the lumbar puncture (LP) is still considered the gold brain substance.
standard. The LP is a procedure that is often performed in the The flow of CSF through the ventricular system is rather sim-
Emergency Department to obtain information about the cerebro- ple (Figure 115-1). CSF produced in the lateral ventricles flows
spinal fluid (CSF) to aid in the diagnosis of a variety of medical through the foramina of Monro into the midline third ventricle. It
conditions. Knowledge about the proper indications, contrain- then passes through the Aqueduct of Sylvius into the fourth ven-
dications, various techniques, equipment, and recognition and tricle. From the fourth ventricle, the CSF flows into the cisterna
treatment of its complications is vital to any Emergency Physician magna via two lateral openings (foramina of Luschka) and one
who performs this procedure. An LP should be performed after midline opening (foramen of Magendie). The cisterna magna is
a thorough neurological exam. Significant morbidity and mor- located beneath the medulla and cerebellum and is continuous
tality can result if the procedure is performed on the wrong with the subarachnoid space that surrounds the brain and spi-
patient. nal cord. The CSF then flows through the subarachnoid space to
Arachnoid villi
Dura
Sagittal sinus Arachnoid
Choroid plexus
Lateral ventricle
Tentorium
cerebelli
Foramen of Monro
Third ventricle
Aqueduct of Sylvius
Foramen of Luschka
Fourth ventricle
Foramen of Magendie FIGURE 115-1. CSF circulation around the brain and
upper spinal cord.
747
748 SECTION 8: Neurologic and Neurosurgical Procedures
bathe the brain and spinal cord. The CSF is absorbed back into the
venous system by way of arachnoid villi.
CSF pressure should average 130 mmH2O when measured in
the lateral decubitus position. It can range from 70 to 180 mmH2O
in a normal person. Since the CSF production rate is constant, the
pressure is regulated by the rate of CSF absorption by the arachnoid
villi that act as one-way valves into the venous blood of the dural
sinuses. Certain disease states may impede reabsorption and lead to
increased intracranial pressure (ICP).1
Familiarity with the anatomy of the spinal column is important
when performing an LP. The anatomy will be briefly reviewed
from superficial to deep as the spinal needle traverses the midline
structures. The skin and subcutaneous tissue are the first layers
encountered. These are followed by the supraspinous and intraspi-
nous ligaments, located between the spinous processes of adjacent
vertebrae. Deep to these ligaments is the thick ligamentum flavum
that accounts for the characteristic “pop” that is described when
performing an LP. The next layers encountered are the epidural fat,
in the epidural space, followed by the dura mater, and finally the
subarachnoid space.
When considering the lateral approach, there are subtle anatomic
differences. The layers include skin and subcutaneous tissue fol- FIGURE 115-2. Physical examination of meningeal signs. A. Brudzinski’s sign.
lowed by the paraspinal ligaments. The intraspinous ligament is less Upon passive elevation of the head by the examiner, the patient complains of
likely to be encountered with an extreme lateral approach, as this neck and low back pain, and may have involuntary flexion of the knees and hips
is a midline structure. The ligamentum flavum and deeper struc- suggesting meningeal irritation. B. Kernig’s sign. Begin with the patient starting in a
tures should be encountered in the same fashion regardless of the supine position with their hips and knees flexed 90°. Gradually extending the knee
approach. causes the patient to complain of neck or lower back pain.
INDICATIONS
There are many indications for performing an LP. The primary SUSPICION OF MENINGITIS IN CHILDREN
indications to perform an LP are the suspicion for a central nervous
system infection, such as meningitis, or for a SAH. It may also be When evaluating the febrile infant, the decision of whether to per-
performed for the evaluation of new-onset seizures, to obtain CSF form an LP will be based on the clinical suspicion of meningitis,
biomarkers, to relieve CSF pressure, and confirm the diagnosis of the age and appearance of the child, and whether an identifiable
pseudotumor cerebri. Other indications include CSF evaluation for source of fever is present. The Emergency Physician will often be
central nervous system diseases (e.g., Guillain–Barré, multiple sclero- faced with a well-appearing febrile infant with no obvious source of
sis, and systemic lupus erythematosus), to confirm demyelinating or fever. Until recently, many institutions managed all febrile infants
inflammatory diseases, to administer antibiotics or chemotherapeu- less than 3 months old with a full sepsis workup (including LP) and
tic agents, to aid in radiologic imaging procedures (e.g., cysternog- admission to the hospital.
raphy or myelography), and to diagnose meningeal carcinomatosis. Guidelines based on an extensive literature review and a meta-
analysis by an expert panel identify patients at low risk for serious
SUSPICION OF MENINGITIS IN ADULTS bacterial infection (SBI), where LP and hospitalization may or may
not be indicated.3 Examples of serious bacterial infections include
An LP should be performed in adults when there is a clinical sus- meningitis, sepsis, osteomyelitis, septic arthritis, urinary tract infec-
picion of a central nervous system (CNS) infection. While a fever tions, pneumonia, and enteritis. Since clinical evaluation alone is
is often present (most sources consider a fever >100.4°F or >38°C), inadequate to exclude serious bacterial infections in infants, it must
it is not a dependable sign. Meningeal signs include nuchal rigid- be combined with laboratory studies that can define low-risk cri-
ity, Kernig’s sign, and Brudzinski’s sign. Other signs of a possible teria. These criteria apply to nontoxic-appearing infants with reli-
CNS infection include a severe headache, photophobia, or a pete- able parents and prearranged follow-up. A more detailed discussion
chial rash. Unfortunately, these signs may or may not be present. regarding the evaluation of the child with a fever is beyond the scope
This is especially true in the elderly, the young, or the immunocom- of this chapter.
promised patient. An LP should be a routine procedure in febrile It should be noted that any febrile child, regardless of age, who
adults with an altered mental status and no source of fever. appears “toxic” should have an LP as an integral part of the sep-
The most commonly looked-for signs of meningitis include the sis workup. Certain bacterial infections have a high propensity for
Kernig’s sign and the Brudzinski’s sign (Figure 115-2). Place the dissemination and systemic bacteremia. Examples include epiglot-
patient supine to test for these physical examination signs. Passively titis, buccal cellulitis, periorbital cellulitis, and septic arthritis. These
flex the patient’s head until their chin touches the sternum. Flexion children should also be considered for a LP in their evaluation and
of the patient’s hips and knees in response to the head flexion is work-up.
known as the Brudzinski’s sign (Figure 115-2A). The patient may
also experience neck pain and resistance to flexion if meningitis is IS AN LP INDICATED FOR THE
present. Passively flex one of the patient’s legs to 90° at the hip and FIRST FEBRILE SEIZURE?
to 90° at the knee (Figure 115-2B). Passively extend the knee. Pain
in the lower back or resistance to knee extension is known as the The Emergency Physician will be faced with the decision of whether
Kernig’s sign.2 to perform an LP when evaluating infants and children with a first
CHAPTER 115: Lumbar Puncture 749
febrile seizure. The American Academy of Pediatrics recommends An LP must be performed if the CT scan is negative and a
that a LP be “strongly considered in infants less than 12 months of SAH is still suspected.10 The presence of xanthochromia or red
age” and “considered in children 12 to 18 months of age.”4 This is blood cells in the CSF will confirm the presence of bleeding. While
based on the lack of clinical signs and symptoms often associated the CSF will usually confirm a SAH, it is possible that the LP may
with meningitis in this age group. For children over 18 months of be negative despite a recent SAH if there has not been sufficient
age, an LP should only be performed if there is a clinical suggestion time for the red blood cells to migrate to the lumbar spine area.
of meningitis. Clinical signs and symptoms that have been shown to In this case, despite a negative head CT scan or a negative LP, a
correlate with the presence of meningitis include petechiae, nuchal cerebral angiogram or follow-up LP in 12 to 18 hours should be
rigidity, coma, persistent drowsiness, Kernig’s or Brudzinski’s sign, performed.
status epilepticus, and paralysis.5
Benign febrile seizures are those that occur in children 3 months CONTRAINDICATIONS
to 5 years of age, are associated with a fever at the onset of an ill-
ness, have a single generalized seizure lasting less than 15 minutes in Knowledge of the contraindications to performing an LP is impor-
a child with normal psychomotor development, have no history of tant. The Emergency Physician will often have to weigh the poten-
prior febrile seizures with this current illness, and have no evidence tial risks of performing the procedure with the benefits of obtaining
of an intracranial infection or acute neurological illness. These chil- the CSF. The decision must be made whether the procedure should
dren generally appear well except for the fever and generally do not be performed immediately or can be delayed until further stud-
require a LP. This is based upon the level of Emergency Physician ies are completed. Absolute contraindications to performing an
comfort in a nontoxic-appearing child. LP include a cellulitis or abscess at the skin puncture site or signs
Complex febrile seizures are those that do not meet the criteria and symptoms of increased ICP except for idiopathic intracranial
of a benign febrile seizure. These children require a complete sep- hypertension (IIH, previously known as pseudotumor cerebri).
tic work-up including an LP. Criteria include seizures that begin The LP should be delayed in patients with an unstable airway,
focally, seizures lasting over 15 minutes, children with a prolonged hypotension, shock, or status epilepticus until the patient has been
postictal period, suspicious findings on physical examination, stabilized. Hypoxemia, clinical deterioration, apnea, and cardiopul-
children less than 12 months of age, children already receiving monary arrest are reported complications of LP in unstable patients.
antibiotics, children who have seen a Physician for an illness in the Relative contraindications to performing an LP include the pres-
preceding 24 hours, or those who have had multiple seizures dur- ence of a brain abscess, epidural or subdural fluid collection, brain
ing a single period of illness. Seizures not associated with the onset tumors, and spinal cord tumors.
of an illness have an increased risk of being due to meningitis or Note that antibiotics should not be delayed if meningitis is sus-
bacteremia. Children seizing upon presentation to the Emergency pected and the LP must be delayed. If meningitis is highly sus-
Department are considered to be seizing over 15 minutes or to pected but the patient is unstable, treatment should be initiated
have recurrent seizures. Suspicious findings on physical exami- with parenteral antibiotics and the LP delayed until the patient’s
nation that suggest a complex seizure include rashes, petechiae, condition is stabilized.
cyanosis, hypotension, abnormal respirations, increased or floppy
tone, stiff neck, difficult to console, deviated eyes, doll’s eyes, nys- INCREASED ICP
tagmus, ataxia, photophobia, bulging or tense fontanelles, unable
to fix and follow, or children that do not respond to voice or pain- An LP is relatively contraindicated in the presence of increased
ful stimuli. ICP.13–15 This includes patients with space-occupying lesions (e.g.,
tumor or abscess), lateralizing signs such as hemiparesis on the
SUBARACHNOID HEMORRHAGE physical examination, or when signs of uncal herniation are present
(unilateral third-nerve palsy). Brain herniation or coning has also
A suspected SAH is the other common indication for an LP. The been reported in patients with meningitis and increased ICP. The
classic description of a SAH is the sudden onset of an excruciat- sudden drop in ICP induced by an LP may precipitate a pressure
ing headache (“thunderclap”) during exertion that may or may cone or herniation.
not be associated with syncope, nausea, vomiting, diaphoresis, or Pseudotumor cerebri, now known as IIH, has been treated with
meningeal signs. Physical examination findings may include nuchal a combination of medicines and repeated LPs to decrease ICP.
rigidity, an altered level of consciousness, papilledema, retinal hem- Removal of CSF for IIH is a common diagnostic and therapeutic
orrhage, third-nerve palsy, sixth-nerve palsy, bilateral lower leg procedure in the Emergency Department. The use of LP in IIH is
weakness, nystagmus, ataxia, aphasia, or hemiparesis. Additional sometimes questioned. Many of these patients are obese, making
risk factors for a SAH include cigarette smoking, hypertension, an LP more difficult to perform, often requiring multiple attempts,
alcohol abuse, a family history of SAH, polycystic kidney disease, and painful for the patient. The CSF removed reforms within a few
connective tissue disorders, or sickle cell anemia. hours, thus the LP provides only temporary relief of the patient’s
It is estimated that 20% to 50% of patients with a SAH may have symptoms. Consult a Neurologist before performing an LP in the
sentinel bleeds or small leaks that precede the major bleeding event. patient with IIH. An LP may be required to make the initial diagno-
It is important to diagnose a sentinel bleed because early man- sis of IIH, but may be unnecessary in the patient when the diagnosis
agement and intervention can improve the overall outcome for has been made previously.
the patient. A sentinel bleed may precede a major SAH by hours,
days, weeks, or months.6,7
BRAIN ABSCESS
A CT scan of the head is often the first study used to investigate
a patient complaining of the sudden-onset headache. The sensi- Patients with brain abscesses are at high risk for herniation.16,17 Brain
tivity of CT scan for SAH can range from 92% to 98% when per- abscesses may present with a progressively worsening headache,
formed within 24 hours of the onset of symptoms.8–10 The sensitivity low-grade fever, and the development of focal neurological signs
decreases markedly (about 76%) when performed 48 to 72 hours (e.g., hemiparesis, papilledema, visual field deficits, and mild obtun-
after onset of symptoms.11–12 The head CT scan can be negative in dation). Suspect a brain abscess in patients with a history of otic
the patient with a sentinel bleed. or paranasal sinus infection, orbital cellulitis, chronic pulmonary or
abdominal infection, endocarditis, congenital heart disease, recent

dental procedures, dental abscesses, recent neurosurgery, craniofa-
cial trauma, open skull fractures, or recent meningitis.
WHEN IS A CT SCAN INDICATED BEFORE AN LP?

It should be emphasized that increased ICP by itself is not neces-
sarily a contraindication to an LP. ICP is usually mildly elevated in
patients with IIH or meningitis.18–20 A CT scan does not need to be
routinely performed in straightforward cases of suspected meningi-
tis in the patient with a normal neurological examination.21–25 The
inability to visualize the optic discs does not constitute a focal find-
ing and, by itself, is not an indication for a head CT scan prior to an
LP.23 Despite this, there are occasional cases of herniation in patients
with a normal CT scan.13,14,19
Most literature suggests that CT scans be performed prior to LP
when patients are comatose or altered, have focal neurological signs,
are HIV positive, have a progressively worsening headache, or have FIGURE 115-3. A commercially available LP kit.
papilledema.23–25 The lack of papilledema is not always a reliable
sign of normal ICP, as it often takes greater than 48 hours to
develop papilledema.21 Papilledema may be absent in up to 15% of
EQUIPMENT
adults and up to 50% of children with early increased ICP.
The CT scan should be evaluated for mass lesions, shift of mid- • Sterile gloves and gown
line structures, or hydrocephalus due to obstructing masses, cister- • Face mask and cap
nal obstruction, and cerebral edema.25 There are three findings that
• 1% lidocaine solution
may predispose a patient to herniation if an LP is performed.26 The
first finding is midline shift. This suggests unequal pressures across • Povidone iodine or chlorhexidine solution
the midline. The second finding is a loss of the suprachiasmatic • LP needles, various gauges and lengths
and basilar cisterns. This suggests unequal pressures between the • Topical anesthetic agent (e.g., EMLA), optional
supratentorial and infratentorial compartments. The third finding
is any evidence of a posterior fossa mass, obliteration of the superior • LP kit
cerebellar cistern, or obliteration of the quadrigeminal plate cistern Most of the equipment necessary for performing an LP is avail-
caudal to the midbrain. These findings all suggest the presence of able in prepackaged, sterile, disposable, and single-patient use com-
increased infratentorial pressure. mercial kits (Figure 115-3). These kits usually contain a 20 gauge
Do not delay the initiation of antibiotics if meningitis is sus- Quincke spinal needle, syringes, needles (25 gauge and 22 gauge)
pected and a CT scan is indicated before performing an LP. for local anesthesia, a manometer with a stopcock, sterile drapes,
Administer the antibiotics before the patient undergoes CT scan- specimen tubes, 1% lidocaine, gauze, brushes for prepping the skin,
ning. Several studies have shown that delays in the initiation of anti- and bandages. Some kits provide povidone iodine or chlorhexidine
biotics are common in the Emergency Department. These delays are swab sticks whereas other kits have a small basin that needs to be
often Emergency Physician generated and result from the need for filled. The Emergency Physician should become familiar with the
a CT scan prior to LP, waiting for LP results before administering kit used at their institution.
antibiotics, and not giving antibiotics before a patient is transferred Additional supplies may be needed to perform the procedure
to the ward.27–30 without interruption. For example, some Emergency Physicians
prefer a smaller gauge Quincke needle or a nontraumatic needle
COAGULATION DEFECTS such as a Sprotte or Whitacre that are not often provided in the com-
mercial kits (Figure 115-4). The use of a 25 gauge spinal needle is
An LP is relatively contraindicated in patients with a coagulopathy.
This includes hemophiliacs, those on anticoagulants, and patients
with thrombocytopenia. An LP can result in a spinal epidural or
subdural hematoma with subsequent spinal cord compression.
Appropriate replacement of platelets and/or clotting factors should
be undertaken prior to attempting an LP if the procedure can be
delayed.31 The most experienced Emergency Physician should
perform the procedure with a small gauge needle when an imme-
diate LP is indicated in these patients.
BACTEREMIA
Some sources list bacteremia as a contraindication to an LP, espe-
cially in children. While there is some suggestion that there may be
an association between performing an LP in a bacteremic patient
and the later development of meningitis, the risk of this is low. An
LP should not be withheld for fear of inducing meningitis. The FIGURE 115-4. The three types of spinal needle tips. The standard Quincke nee-
risk of delaying the diagnosis of meningitis clearly outweighs the dle has a sharp, beveled end. The Whitacre and Sprotte needles are designed to
small chance of causing meningitis with an LP.32 spread atraumatically, rather than cut dural fibers.
recommended as it causes a smaller puncture hole and less postpro- parents or caregivers whether or not they would like to be present
cedural headaches.33–37 It has been suggested that atraumatic needles for the LP.
should be the standard when performing an LP.38,39 In general, it is There are a variety of different patient positions that can be
a good idea to have extra spinal needles, lidocaine, gauze, and skin used to perform the LP (Figure 115-5).33,42,43 Knowledge and profi-
antiseptic (e.g., povidone iodine or chlorhexidine solution) when ciency in more than one approach will be useful for the Emergency
performing an LP. There are numerous formulae to determine the Physician, especially when encountering a difficult tap. The position
LP depth and the length of the spinal needle required.40,41 A reli- of the patient will be chosen based upon the patient’s body habitus,
able formula for estimating the required LP needle length is LP their ability to assume a position, their level of cooperativeness, and
depth (cm) = 1 + [17 × (weight (kg)/height (cm))].41 Emergency Physician preference.
There are subtle differences among the spinal needles commonly The sitting position is more commonly used in adults than the
available (Figure 115-4). The standard Quincke needle has a sharp lateral decubitus position. It is easier to identify the midline and pal-
tip with a broad bevel at the end. The Whitaker and Sprotte needles pate the spinous processes with the patient sitting (Figure 115-5A).
have smaller tips with smaller diameter bevels. The bevel of the The sitting position is particularly useful when patients are obese.
Sprotte needle is broader with a rounded tip so as to separate fibers While the LP can still be performed in the lateral decubitus position
of the dura as opposed to cutting through them. Always remember for obese patients, palpating the spinous processes and identifying
to keep the bevel oriented parallel to the fibers of the dura when the midline can be difficult. The measurement of hydrostatic pres-
performing an LP regardless of needle style. sure in the CSF is not accurate with the patient sitting. It gives a
falsely elevated pressure reading.
The lateral decubitus position is often the most comfortable posi-
PATIENT PREPARATION
tion for the patient (Figure 115-5B). Place the patient with their
Explain the risks, benefits, and complications of the procedure to knees flexed, the upper back arched to spread the interlaminar
the patient and/or their representative. Obtain a signed informed spaces, and the neck slightly flexed. Ensure that the patient’s shoul-
consent for the procedure. If the patient is a child or minor, ask the ders, back, and hips are exactly perpendicular to the stretcher and
FIGURE 115-5. Patient positioning for an LP. A. An adult in the sitting position. B. An adult in the lateral decubitus position. C. An infant restrained in the sitting position.
D. A child restrained in the sitting position. E. A child restrained in the lateral decubitus position.
floor. This will increase the chances of keeping the needle in the intersect the midline at approximately the L4 spinous process or the
midline as it is introduced parallel to the surface of the stretcher. L3-L4 interspace. One can select any of the spaces between L2-L3
This is particularly important in infants and children where an and L5-S1 to perform an LP. Palpate the intended interspace before
assistant may be called upon to hold the patient in position. Severe prepping the area. Some Emergency Physicians mark the site lightly
neck flexion is not necessary and can lead to airway obstruction or with a pen or make a small indentation with the hub of a needle.
lack of CSF flow. Adjust the bed height so that you can sit in a comfortable position
Children can be placed in the sitting or lateral decubitus position. while performing the procedure.
An assistant can easily maintain neonates and infants in the sitting Prepare the LP kit. Open the kit using sterile technique and
position (Figure 115-5C). Toddlers and school-aged children can place it on a bedside table. Place povidone iodine or chlorhexidine
also often be maintained in the sitting position (Figure 115-5D). The solution into the basin provided with the kit. Place any additional
lateral decubitus position can be used for any child (Figure 115-5E). needles or supplies onto the sterile field. This procedure requires
It is important to assess the child visually and with pulse oxim- strict aseptic technique. The Emergency Physician should don
etry during the procedure. These positions may cause improper full sterile and personal protective equipment at this point.50–52
neck flexion that can result in respiratory compromise, oxygen This should include sterile gloves, a sterile gown, a face mask, and a
desaturation, hypoxemia, and anoxic encephalopathy.44,45 The cap. Prepare the stopcock and manometer. The manometer is usu-
largest interspinous space is achieved with the patient sitting ally in two pieces that slide together. Insert the manometer into the
upright with their hips flexed, leaning forward, and with slight vertical port of the stopcock. Turn the handle toward the outflow
neck flexion based on ultrasonographic studies.45–48 side of the stopcock. In general, the stopcock handle will occlude
The subarachnoid space must be entered below the termina- the port that it points to.
tion of the spinal cord that is situated at the lower level of L1 or Prepare the patient’s back. Clean the skin of any dirt and debris.
the body of L2 (Figure 115-6). Identify by palpation the vertebral Apply povidone iodine or chlorhexidine solution using a cir-
spinous processes in the midline and the posterior superior iliac cular motion from the intended site of entry outward. Allow the
spines. The patient can help to determine the midline.179,180 Just ask solution to completely dry prior to inserting the spinal needle.53
them if the needle is in the midline. Another option is to draw a Chlorhexidine solution introduced into the spinal canal can result
line between the spinous process of C7 and the gluteal cleft.49 An in arachnoiditis and neurotoxicity. Prepare an area of at least 10 cm
imaginary line connecting the posterior superior iliac spines should in diameter. Most kits include a solid drape and a fenestrated drape.
Place the solid drape between the patient’s hips and the bed. Place
the fenestrated drape with the adhesive side toward the patient’s
back and the opening centered at the desired level for the procedure.
Spinal cord Reidentify the anatomic landmarks. Place a finger over the
L1 desired interspace to use for the procedure. Place a skin wheal of
Vertebral local anesthetic solution subcutaneously over the desired interspace
spine using a 25 gauge needle. Infiltrate and anesthetize the deeper tissue
Interspinous of the interspace along the projected needle track using the 22 gauge
L2
ligament needle. The infiltration of local anesthetic solution, unless con-
traindicated, should be used in all patients, including neonates
Supraspinous and young children. Local anesthetic makes it more likely the LP
ligament L3 will be successful.46,47,54
Alternatively, a field block can easily be performed to produce
Filum anesthesia of the skin, interspinous ligaments and muscles, and the
Needle in terminale periosteum. The interspinous ligament and the periosteum are sup-
L4
subarachnoid plied by the recurrent spinal nerves branching off the nerve roots
space exiting the spinal canal at the same level. Inject local anesthetic solu-
tion into the interspinous ligaments, between the spinous processes
Ligamentum L5 superior and inferior to the intended puncture site, and on either side
flavum Vertebral of the interspinous space (Figure 115-7).33 A topical anesthetic (e.g.,
body EMLA cream) may be applied over the interspace for 30 to 60 min-
S1 utes prior to performing the LP if the patient is awaiting a CT scan
of the head and antibiotics have been administered. Unfortunately,
this only anesthetizes the skin and superficial subcutaneous struc-
tures. The patient will still require a local anesthetic injection.
It may occasionally be difficult for some patients to remain still
and cooperative with the procedure. This can include anxious
patients, those with an altered mental status, and small children.
These patients may require an intravenous anxiolytic, nitrous oxide
administration, or procedural sedation.
Sacrococcygeal TECHNIQUES
ligament
LATERAL DECUBITUS POSITION
FIGURE 115-6. Midsagittal section of the lumbosacral region with a spinal AND MIDLINE APPROACH
needle in the L3-L4 interspace. The needle has penetrated the supraspinal liga-
ment, the interspinous ligament, the ligamentum flavum, the dura mater, and the Palpate the intended interspace. Introduce the needle in the mid-
arachnoid mater. dle of the interspace and parallel to the bed. Orient the bevel of
FIGURE 115-7. Field block for LP anesthesia.
the spinal needle parallel to the longitudinal dural fibers to

increase the chances that the fibers will be separated rather than
cut by the tip of the needle.55 This has been shown to decrease the
incidence of postdural puncture headache.56–58 The bevel should
point up or down with the patient in the lateral decubitus posi-
tion. Angle the needle 10° cephalad, or toward the umbilicus, and
advance it slowly. The needle can be held between both index fin-
gers and advanced with the thumbs (Figure 115-8A). Alternatively,
it can be guided with a thumb and forefinger near the puncture site
FIGURE 115-8. Two-handed techniques for spinal needle insertion. A. The index
while the other hand holds the hub of the needle and advances it
fingers guide the tip while the thumbs advance the needle. B. An alternative
(Figure 115-8B).
technique. One hand is placed at the needle tip and the other is at the base of
Resistance will usually be felt as the needle penetrates the inter-
the needle.
spinous ligaments. Stop advancing the needle and remove the sty-
let frequently to check for the presence of CSF.59 Many describe a
characteristic “pop” that is felt when the needle enters the subarach-
noid space. The commonly used Quincke needles often decrease or Ensure that the manometer hub remains at the level of the
eliminate this sensation. It may also not be felt using atraumatic nee- needle in order to get an accurate reading if using the exten-
dles.59 If bone is encountered, withdraw the needle to the subcuta- sion tubing. Phasic changes with respirations should be noted as
neous tissue, confirm your landmarks, and readvance the needle in the manometer fills. Instruct the patient, or an assistant, to gently
the midline. If bone is still encountered, redirect the needle slightly extend the patient’s legs to decrease intraabdominal pressure and
more cephalad and readvance it. Perform the procedure at a differ- lower the reading. Normal opening pressure is 70 to 180 mmH2O.
ent level if still unsuccessful. Obtain the pressure reading once the CSF flow stops. Turn the stop-
CSF should flow freely once the subarachnoid space is entered. cock handle toward the needle hub (or patient) to empty the con-
The rate of CSF flow from the hub of the spinal needle may be tents of the manometer into the first tube for collection. To continue
slow. The flow rate can be increased by one of the following: ask collection, remove the stopcock or simply remove the manometer
the patient to Valsalva by gently coughing or bearing down, rotate and continue collection through the stopcock by pointing the han-
the spinal needle 90°, or repeat the procedure with a larger bore dle toward the manometer port.
spinal needle. Attach the stopcock and manometer directly to In general, 1.0 mL of CSF in each of the four tubes should be
the needle. Alternatively, use the short extension tubing provided in adequate to perform the CSF analysis. Collect 2 mL in each tube if
most kits to connect the needle to the manometer. Hold the hub of cytology or antigen testing is necessary. When the samples have
the needle firmly between the thumb and index finger and brace been collected, carefully replace the stylet and remove the needle.
your hand against the patient’s back when attaching or removing There is disagreement regarding the use of the spinal needle sty-
anything from the spinal needle. This will prevent the needle from let.181 The literature notes an increased incidence of intraspinal epi-
advancing or withdrawing. The stopcock handle should point pos- dermoid tumors after an LP if a stylet is not used. This led to the
teriorly and CSF will begin to fill the manometer. habit of leaving the stylet in place while inserting the spinal needle
A B Supraspinous ligament
Interspinous ligament Ligamentum

20º
flavum
Erector spinae
Subarachnoid space Articular

containing cauda equina process
Body of
L3
Epidural space Dura/arachnoid
FIGURE 115-9. The lateral approach. A. If the patient is in the lateral decubitus position, insert the spinal needle approximately 2 cm below the midline and directed
approximately 20° toward the midline, and 10° cephalad. B. Cross section of the spinal column showing the path of the spinal needle during the lateral approach. Notice
that it avoids the calcified supraspinal and interspinal ligaments.
to prevent transferring epidermal cells into the spinal canal. Some Position the patient and select an appropriate interspace.
now recommend removing the stylet after the tip of the spinal nee- Cleanse, drape, and anesthetize the area as previously described.
dle has been inserted past the epidermis.46,60 This method has shown Insert the spinal needle 1.5 to 2.0 cm lateral to the midline. The
to result in a greater success rate when performing an LP. needle can approach from either side (left or right) if the proce-
Reinserting the stylet into the spinal needle is potentially prob- dure is being performed in the sitting position. Approach from the
lematic. Many will hold and stabilize the spinal needle with one hand inferior side if performing the LP in the lateral decubitus position
and reinsert the stylet with the other hand. This risks a potential (Figure 115-9A). Direct the needle 10° cephalad and approximately
needlestick injury. The author inserts the stylet with one hand with- 20° to the midline. This angle will direct the needle through the
out using the other hand to stabilize the spinal needle. Reinserting erector spinae muscles and lateral to the supraspinous and inter-
the stylet prior to removal of the spinal needle has been shown to spinous ligaments. The needle will penetrate the ligamentum fla-
decrease the incidence of the post-LP symptoms of dizziness, head- vum, the dura, and then the subarachnoid space (Figure 115-9B).
ache, nausea, and tinnitus.61 The method of using the stylet is left to If bone is encountered, partially withdraw the needle and redirect
Emergency Physician preference. it at the same angle toward the midline but slightly more cephalad.
The remainder of the procedure is as described previously.
SITTING POSITION AND MIDLINE APPROACH
LP IN INFANTS AND CHILDREN
Place the patient sitting on the edge of the bed. Ask the patient to
flex their lower back and lean forward onto some support, such Performing an LP in an infant or child is similar to that of an adult.
as an assistant or bedside stand, in order to open the interlaminar Place the patient in the lateral decubitus position or the sitting posi-
spaces in the lumbar area. Orient the bevel of the needle laterally tion. Place the neck in midflexion in the lateral decubitus position.
(to the left or right). The remainder of the procedure is the same as Severe flexion of the neck does not facilitate the procedure and
previously described. can result in the lack of CSF flow or airway obstruction.
Hypoxemia has been reported during LP in infants. The
increased intraabdominal pressure caused by flexing the knees into
LATERAL APPROACH
the abdomen may lead to compression of the diaphragm, ventila-
The lateral approach may be useful in avoiding the calcified supra- tion-perfusion mismatch, and hypoxemia.62 For this reason, the
spinous and interspinous ligaments often encountered in elderly sitting position or modified lateral decubitus position (hips only
patients. This approach may be performed with the patient in the flexed to 90°) is preferred.63 Preoxygenation with 100% oxygen via
lateral decubitus position or the sitting position. Though it is less face mask for 2 to 5 minutes may prevent hypoxemia.64 Consider
commonly used than the midline approach, it is a good idea for the the use of continuous pulse oximetry in infants and young chil-
Emergency Physician to become familiar with this technique as an dren undergoing an LP.
alternate approach if the midline approach has failed. This may prove Some authors advocate the use of a butterfly needle and using the
easier in the patient who has had multiple previous midline LPs. tubing as a manometer to get a general idea of the opening pressure.
The use of nonstyletted needles, however, may occasionally result of overweight (BMI = 25 to 29.9) and obese (BMI ≥ 30) patients.71
in the implantation of cells and a subsequent epidermoid tumor. In Under this approach, patients in whom an LP is not predicted to be
some low ICP syndromes, CSF may fail to flow during the proce- difficult would have it attempted initially with the landmark palpa-
dure and gentle suction with a 1 mL syringe can be used. tion method, reserving US guidance for failures. The final approach
Local anesthesia should be used in all patients, even in neonates. uses US guidance initially for all patients, regardless of their BMI or
There is evidence that pain perception is present even in prema- the predicted ease of an LP.
ture neonates.65 The use of local anesthetic is often omitted in the US can be used to visualize structures and mark the point of
neonate and young infant, possibly in fear of obscuring anatomical needle insertion. It can also be used to visualize the deep soft tis-
landmarks. Pinheiro et al. studied the success rate of LP in neonates sue structures, allowing the Emergency Physician to estimate the
given local anesthetic, the amount of struggling during lidocaine depth that the needle needs to be inserted to enter the subarach-
injection, and the amount of struggling during spinal needle inser- noid space.79
tion.66 They found that local anesthesia did not alter the success rate A high-frequency linear US probe is the transducer of choice. In
of the procedure and led to a decreased amount of struggling during patients with a higher BMI, the linear probe may not allow visual-
spinal needle insertion. ization to the depth required. In these cases, use a lower-frequency
The use of a eutectic mixture of local anesthetics (EMLA) cream US probe, generally a curvilinear array. A pen or surgical skin
or similar topical anesthetic is common and effective for venipunc- marker is needed to mark the skin at the point of needle insertion.
ture in children. It also can be used successfully before LP in children Surgical skin markers have the advantage of using scrub-resistant,
and adults.67,68 EMLA has been shown in some studies on adults to non-smearing ink.
be more effective than lidocaine infiltration.69,70 The major disad- Both transverse and longitudinal midline images centered over
vantage of EMLA cream is that it requires application for a mini- the lumbar spine are utilized.71,72 Ferre and Sweeney indicated a
mum of 30 minutes before the procedure is performed. In general, it preference for the paramedian longitudinal view.72 This view was
is more effective if it stays on longer. It also does not anesthetize the felt to allow better visualization of deep soft tissue structures such as
deeper tissues and local infiltration is still required. the ligamentum flavum and dura mater. In the transverse view, the
Procedural sedation is usually reserved for those children getting spinous process causes a shadow that extends from near the top to
routine LPs for intrathecal chemotherapy. If absolutely necessary, the bottom on the monitor screen (Figure 115-10).73,77 In the lon-
procedural sedation can be used while performing a diagnostic gitudinal view, the distal tips of the spinous processes are seen as a
LP. Procedural sedation should not be used unless the child has a series of echogenic convexities (Figure 115-11).
normal mental status and is hemodynamically stable. The decision
regarding procedural sedation must be considered on a case-by-
case basis.
ULTRASOUND-GUIDED LP
For the past several decades, Anesthesiologists have been using
ultrasound (US) to assist in various spinal procedures. More recently,
Emergency Physicians have reported on the use of US to assist in per-
forming an LP or to evaluate spinal anatomy.71–75 Peterson and Abele
described two patients in whom multiple attempts at landmark-
guided LP were unsuccessful. US-guided LP was performed easily
and was successful in each patient. The authors concluded that the
technique has great potential as a time-saving tool.73 Nomura and
colleagues performed a randomized, double-blind study comparing
LP using landmarks identified by palpation versus those identified
by US.75 The use of US significantly reduced the number of failures
in all patients and improved the perceived ease of the procedure in
obese patients. A group of Radiologists studied US guidance for LPs
in children.76 They found US superior to fluoroscopy as it allows
three-dimensional guidance in real time and provides visualization
of soft-tissue structures.
With the increasing availability of US machines in Emergency
Departments, ultrasonography is more readily available to assist
the Emergency Physician in performing many procedures includ-
ing an LP.71,72 US can visualize both superficial and deep tissue
structures. Emergency Physicians who consider using US in assist-
ing with an LP should be properly trained in the use and theory
behind US before attempting to use it in the clinical setting.
There are three possible approaches to establishing the indica-
tions for the use of US to guide an LP. US guidance can be used
for an LP when the traditional landmark-guided approach has
failed. This approach may result in more patients having multiple
attempts at an LP. US guidance can be used as the initial method
in patients predicted to have a higher failure rate with landmark-
guided LP. This includes patients with spinal landmarks that are FIGURE 115-10. US image of the lumbar spine in the transverse view. The spi-
difficult or impossible to palpate.72,77,78 The landmarks are increas- nous process (arrow) causes a shadow that extends from the top to the bottom
ingly difficult to palpate in the body mass index (BMI) categories of the monitor screen.
FIGURE 115-12. The US probe is oriented transversely across the lumbar spine.
A mark is placed on each side of the US probe’s midpoint.
FIGURE 115-11. US image of the lumbar spine in the longitudinal view. The
distal tips of the spinous processes are seen as a series of echogenic convexities
(arrows).
Place the patient into the position they will be in during the LP,
whether the lateral decubitus position or sitting upright. It is impor-
tant that the patient be in the exact position, such as with spinal
flexion and their knees drawn up, that will be used during the LP. FIGURE 115-13. The US probe is oriented longitudinally along lumbar spine.
Any change in patient position between the time of the US and A mark is placed on each side of the US probe’s midpoint.
the LP could change the location of the landmarks and decrease
the likelihood of success.
Use US to locate the entry site of the spinal needle. Using the trans-
verse view at the level of the iliac crests, move the US probe until
the shadow caused by the spinous process is centered on the moni-
tor screen (Figure 115-10). Use the skin marker to place a mark on
each side of the US probe, exactly at its midpoint (Figure 115-12).
When these two lines are connected, they will form a single line that
marks the midline of the spine. Rotate the US probe 90° to a midline
longitudinal view. Move the US probe until the tops of two adjacent
spinous processes are seen, with the gap between them located in
the center of the screen (Figure 115-11). Again, make two marks
on the patient’s skin, one on each side of the US probe at its mid-
point (Figure 115-13). These two marks, when connected, will form
a single transverse line that indicates the center of the gap between
adjacent spinous processes.
Set aside the US probe. Connect the two pairs of skin marks
to form two lines that intersect at a right angle (Figure 115-14).
Their intersection marks the site of needle entry (Figure 115-14).
Clean and prep the patient’s skin and perform the LP as described FIGURE 115-14. Two pairs of marks are obtained. Their intersection (purple dot)
previously. marks the spot for the spinal needle entry.
RISK FACTORS FOR TRAUMATIC across the tentorial incisura or foramen magnum may occur after
OR UNSUCCESSFUL LP removal of CSF from the lumbar area. Patients with increased ICP
secondary to intracranial mass lesions, cerebral edema, and acute
There are numerous risk factors for obtaining a traumatic or unsuc- hydrocephalus are at greater risk for cerebral herniation or coning.
cessful LP.60,80 It is important to recognize these, as traumatic or Herniation has also been known to occur in patients with meningi-
unsuccessful attempts may cause diagnostic ambiguity and lead to tis. For many years, the role of LP in precipitating brain herniation
unnecessary antibiotic use, hospitalization, and patient discomfort. has been the subject of debate. Several studies suggest that an LP is
In the setting of a high likelihood of a difficult LP, steps may be relatively safe in the patient with increased ICP.82–84 However, each
taken to minimize patient discomfort and maximize the chance of individual patient’s risks and benefits must be considered before
a successful LP. Have the most experienced Emergency Physician proceeding.
perform the procedure. If there is a high likelihood of a traumatic Herniation has resulted from an LP in patients with meningi-
LP and there is a high suspicion of a SAH, consider the use of US or tis and SAH.85–87 The actual role that an LP has in precipitating or
fluoroscopic guidance. Emergency Physicians should never delay facilitating the process of herniation is not known.85 Patients with
administering antibiotics, or other potentially lifesaving treat- decorticate or decerebrate posture, focal neurologic signs, or no
ment, because an LP may appear difficult. response to pain should receive antibiotics but not a LP; this is
In adults, the inability to either visualize or palpate the spinous true even in the face of a normal CT in suspected cases of men-
processes is predictive of a difficult LP. The inability to visualize the ingitis.85,87 Deterioration after an LP has been reported in patients
spinous processes is associated with an increased risk of a traumatic with a SAH. Fortunately, it is a rare outcome as a result of an LP. A
LP.80 As described previously, the use of bedside US can assist in the CT scan should be obtained before performing an LP if there is a
identification of the spinous processes. suspicion for a SAH.88,89
There are several risk factors in children associated with an
unsuccessful or traumatic LP.60 These include patient-related factors POSTDURAL PUNCTURE HEADACHE
such as young age and inability to visualize the spinous processes,
physician factors such as less experience performing LP, and proce- The PDPH is the most common complication of an LP. It is thought
dural factors such as no local anesthetic use, patient movement, and to be the result of continued CSF leakage at the puncture site. The
advancement of the spinal needle with the stylet in place.60 reason why this causes a headache is unclear.90 It is thought that the
Physicians have traditionally been taught to keep the stylet in lower CSF pressure induced by the leakage causes the brain to “sag.”
place as the spinal needle is advanced into the subarachnoid space This leads to traction on pain-sensitive structures in the brain such
as this will avoid the introduction of epidermal cells into the sub- as the dura, nerves, and bridging veins. Intracranial venous dilation
arachnoid space and the subsequent development of an epidermoid and increased brain volume may lead to a neurohumoral response
spinal canal tumor. However, the stylet-out technique has not been identified as pain.
linked to this complication as long as the stylet is used as the needle The headache begins within 24 hours of the procedure in 65%
penetrates the skin.60 The greatest benefit of stylet removal appears of cases and within 48 hours in 90% of cases.91 Delayed develop-
to occur in young infants when the Emergency Physician is less ment of a PDPH 5 to 14 days after the procedure has been reported.
likely to feel the spinal needle penetrate the dura. The stylet-out The headache typically resolves within 7 days. It has been reported
technique allows for continuous monitoring of penetration into the to last several months in rare individuals. The headache is usually
subarachnoid space by direct visualization for CSF return. located in the frontal or occipital area. It may vary in intensity. The
PDPH is usually described as bilateral pressure that is throbbing or
achy and improves with supine positioning. Associated symptoms
AFTERCARE may include nausea, vomiting, neck stiffness, auditory symptoms,
Clean the excess povidone iodine or chlorhexidine from the and vestibular symptoms.91
patient’s back and apply a dressing or bandage to the puncture site. The incidence of PDPH has been reported to be anywhere from
Immediately place the patient supine to decrease the potential for 1% to 70%. The wide range is most likely due to the fact there are
a postdural puncture headache (PDPH) and decrease the risk of several identifiable risk factors that influence its development. Age
local bleeding. Recumbent positioning will decrease the postural and gender play a significant role.91–93 The highest incidence occurs
headache that sometimes follows LP, but it has not been shown to in 18 to 30 year olds. There seems to be a decreased incidence after
decrease the incidence of PDPH. the age of 60, the reason for which is unknown.
The type of needle and its diameter also influence the develop-
ment of a PDPH.34–38 This is based upon the amount of trauma and
COMPLICATIONS the size of the rent it makes in the dura. Smaller diameter needles
The use of proper technique is essential when performing an LP. It and atraumatic needles lower the incidence of PDPH. However, a
is also important that the Emergency Physician is aware of poten- 22 or larger gauge needle must be used to determine the opening
tial complications, how to recognize them, and how to manage pressure and to collect samples in a timely fashion when perform-
the complications that can result from an LP. Refer to the article ing a diagnostic LP.94 The bevel orientation should be parallel to
by Evans for a complete review of LP complications.81 The PDPH the longitudinal dural fibers when using a Quincke needle. This
is the most common complication and cerebral herniation is the significantly reduces the incidence of PDPH.58,95–97 The use of an
most immediately life-threatening complication. Localized celluli- atraumatic needle may also decrease the incidence of PDPH.98,99
tis, dural abscesses, discitis, and localized bleeding are also potential These needles are designed to separate rather than shear the dural
complications. fibers. Replacement of the stylet before removing the spinal needle
has been shown to decrease the incidence of PDPH.100 Repeated
CEREBRAL HERNIATION dural punctures have been associated with an increase in the inci-
dence of PDPH.101
The most serious complication that may result from an LP is brain Other nonproven risk factors for a PDPH include psychogenic
herniation or coning.14 Theoretically, if a large pressure gradient factors, the rapidity of CSF withdrawal, race, patient position-
exists between the cranial and lumbar compartments, herniation ing, and hydration status. Bed rest for 24 hours was often widely
recommended. However, it has not been shown to decrease the inci- complication is the spinal subdural hematoma.122 Other modali-
dence of PDPH.102–104 Other studies have shown bed rest to increase ties for PDPH relief that have been used but not widely studied are
the risk of PDPH.105,106 Early ambulation does not increase the inci- epidural saline injections, dextrose injections, gelatin injections,
dence of PDPH.107 Dehydration was once felt to impair the patient’s and epidural morphine.
ability to produce CSF to compensate for the leaking CSF. Dieterich
and Brandt found that the incidence of PDPH was independent of
INFECTIONS
daily fluid intake.108 They postulated that it is the closure of the dural
defect and not the CSF loss that is the critical factor in the termina- Local infections including cellulitis, abscesses (lumbar epidural
tion of the PDPH. or spinal cord), and discitis can result from an LP. Performing an
Supine positioning can provide some symptomatic relief for LP through an area with a local infection, such as a cellulitis or an
initial or mild PDPHs. A single 300 mg dose of oral caffeine may abscess, can introduce bacteria into the CSF and lead to meningitis.
provide transient relief.109 While offering no advantage over caf- Contamination of the needle by airborne pathogens can also occur.
feine, an oral dose of theophylline can also be given. Administer Always wear a sterile gown and gloves, a mask, and a cap while
500 mg of intravenous caffeine, or 5 to 6 mg/kg of intravenous performing an LP.50 It is possible for the Physician’s oral flora to
aminophylline, for more severe headaches. In the only study contaminate the field and equipment, resulting in an iatrogenic
to date describing the use of intravenous caffeine, Sechzer and meningitis.50–52
Abel reported an approximately 70% success rate in treating It was once thought that an LP could induce meningitis in a
PDPH.110 A more recent study suggests that intravenous caffeine bacteremic patient. Further studies have shown this idea to be
administered prophylactically may minimize the incidence of unfounded.123–125 Bacteremia is not a contraindication to perform-
PDPH.111 There is some promise in the use of triptans.112,113 The ing an LP. Proper cleaning and disinfecting of the skin, avoiding
use of cosyntropin, an ACTH analog, has shown promise in the infected areas with the spinal needle, and using aseptic technique
treatment of PDPH.114,115 An occipital nerve block may resolve a will minimize but not eliminate any risk of infection.
PDPH.116,117
A more definitive but invasive treatment for the PDPH is the
HEMORRHAGE
epidural blood patch.118 This procedure is to be performed by
an Anesthesiologist. It involves injecting 10 to 20 mL of autolo- A traumatic LP is a common occurrence. Up to 72% of LPs have
gous blood into the epidural space at the level of the previous LP. anywhere from 1 to over 50 red blood cells.126 This is a common
The blood acts to tamponade any further CSF leakage and allows and usually uncomplicated occurrence in patients with a normal
healing of the dural rent. Epidural blood patching is successful coagulation profile. Traumatic LPs can result in a spinal epidural or
in 85% of patients after one injection and about 98% of patients spinal subdural hematoma in patients with or without coagulation
if a second blood patch is required.119–121 Epidural blood patch- abnormalities.127–131 Epidural hematomas most likely result from
ing should be performed no sooner than 24 hours after the LP. needle trauma to the internal vertebral plexus or radicular vessels
Complications of the blood patch include back pain, paresthesias, (Figure 115-15).126 The radicular vessels course down the length of
radiculopathies, and weakness; all of which are transient. A rare each nerve root. It has been suggested that the bevel of the spinal
External vertebral venous plexus
Nerve roots forming Internal vertebral

cauda equina venous plexus
Rediculomedullary
vein
Dura
L4
Spinal Arachnoid
needle
Lumbar
vein
Internal vertebral
L5
venous plexus
FIGURE 115-15. Illustration of the spinal cord and the potential
sources of spinal needle-induced bleeding. Note, however, that
the correct path of the spinal needle should usually avoid the
internal vertebral venous plexus.
needle can induce trauma and bleeding to these vessels much like Prevent secondary injury by always inserting the stylet into the
they produce paresthesias when touching the nerve roots. Spinal spinal needle before removing it.61 Withdrawing the spinal needle
epidural hematomas, if large enough, can result in a cauda equina without the stylet can result in the aspiration of a lumbar nerve
syndrome.132 root or arachnoid tissue into the epidural space. If this occurs, the
Subdural or SAH is a rare but catastrophic complication in patient may require a laminectomy to replace the nerve root or
patients with or without a coagulopathy.130 Edelson et al. recom- arachnoid tissue. The reinsertion of the stylet will also decrease
mend that the procedure be performed only if absolutely neces- the incidence of post-LP symptoms (e.g., dizziness, headache, nau-
sary in patients with a thrombocytopenia.133 Platelets should be sea, and tinnitus).61
transfused prior to an LP in patients with platelet counts less than It is now common for adolescents and adults to have tattoos on
20,000 or if platelet counts are dropping rapidly. The most skilled their lower back. It is recommended to perform an LP in an area
Emergency Physician should perform the LP using a 22 gauge (or void of tattoo ink, at a higher or lower interspace, or nicking the skin
smaller) needle.133 Patients should be observed after the procedure with a needle or scalpel prior to inserting the spinal needle.144,145 All
for the development of neurological signs suggesting a hematoma. these techniques avoid the spinal needle penetrating through the
Such signs include paraplegia, lower extremity weakness, sensory tattoo ink. The tattoo ink may contain substances that can be irritat-
deficits, or incontinence. ing or toxic if introduced into the spinal canal.
Another rare bleeding complication is an intracranial subdural
hematoma.134,135 This may result from the same mechanism caus- CSF INTERPRETATION
ing a PDPH, namely the downward displacement of the brain from
decreased CSF volume and persistent leakage after an LP. This Proper interpretation of the CSF is an important skill for the
may occasionally cause tearing of the bridging veins and lead to Emergency Physician who performs the LP. Tables 115-1 and 115-2
a unilateral or bilateral subdural hematoma. Suspect this diagno- list the normal CSF values and the CSF values in a variety of differ-
sis when a headache sounding like a PDPH lasts for more than ent medical conditions.146,147
a week, is no longer postural in nature, or returns after initially
improving.136 CSF PRESSURE
MISCELLANEOUS COMPLICATIONS Normal CSF pressure ranges from 70 to 180 mmH2O in adults and
from 50 to 80 mmH2O in infants and children. Note that many
Neuropathies involving cranial nerves III, IV, V, VI, VII, and VIII manometer kits use cmH2O on the demarcations whereas results
have been reported. They most likely result from traction on the are commonly interpreted in mmH2O. Elevated CSF pressure may
nerves caused by low ICP after the LP. Typical complaints may be seen in bacterial meningitis, viral meningitis, brain abscesses,
include visual and auditory symptoms. Epidural fluid collections of tuberculous meningitis, fungal meningitis, encephalitis, meningeal
CSF after an LP can be significant.137 They usually resolve spontane- carcinomatosis, SAH, pseudotumor cerebri, and Guillain–Barré
ously with time but can compromise the thecal sac if large enough. syndrome. It may be falsely elevated when the patient is tense or
Mild low back pain is a common complaint that results from the creating a lot of intraabdominal pressure by flexing their knees
local trauma of the needle tract. Transient dysesthesias are fairly into the abdomen. The pressure will also be falsely elevated if the
common, resulting from spinal needle contact with the nerve roots. patient is in a sitting position. Although CSF pressure is not rou-
A spinal needle that passes beyond the subarachnoid space into the tinely recorded in infants and children (most likely because they are
annulus fibrosis can cause disc herniation. This can also result in a often crying, struggling, or difficult to hold), it should be recorded
discitis and vertebral collapse.138 whenever possible. Low CSF pressure may be the result of a spinal
Intraspinal epidermoid tumors are composed of well- root obstructing the flow of CSF into the needle or obstruction of
differentiated stratified squamous epithelium surrounding a mass flow from a spinal mass.
of caseous substance formed by the desquamation of epidermal tis- A novel device to measure pressure is the Compass LP (Mirador
sue. They are often congenital but may result from the introduction Biomed, Seattle, WA). This device is a single patient use and dis-
of epidermal fragments into the spinal canal. This may occur if the posable unit that attaches to the spinal needle. It provides a digital
stylet of the needle is not used. Spinal epidermoid tumors may pres- readout of the CSF pressure. Further research is required before this
ent months to years after an LP.139–142 device replaces the standard manometer.
A dry tap is often the result of lateral displacement of the spinal
needle. Maintain the spinal needle in the midline while it is being
CELL COUNTS AND DIFFERENTIAL
advanced. Not penetrating deep enough with the spinal needle can
also result in a dry tap. This is especially true in obese patients that A variable amount of white blood cells (WBCs) may be normally
may require long, 7 to 10 in., spinal needles to gain access to the present in the CSF depending upon the age of the patient.148
subarachnoid space. It has been suggested that the standard 3.5 in. Neonates may have up to 32 WBCs/mm3 with 60% polymor-
spinal needle is adequate for 97% of patients.143 phonuclear leukocytes (PMNs). Infants 4 to 8 weeks of age may
TABLE 115-1 Normal CSF Values

Preterm infant Term infant Child Adult
White blood cell count 9 (range 0–32) 8 (range 0–22) 0–7 0–5
(WBC/mm3) 57% PMNs 61% PMNs 0% PMNs 0% PMNs
Glucose (mg/dL) 24–63 (mean 50) 34–119 (mean 52) 40–80 50–80
CSF/blood glucose ratio
Normal ratio 55%–105% 44%–128% 50% 60%–70%
Abnormal ratio <0.5–0.6 <0.5–0.6 <0.4–0.5 <0.4–0.5
Protein (mg/dL) 65–150 (mean 115) 20–170 (mean 90) 5–40 15–45
TABLE 115-2 CSF Values in Various Neurological Conditions

Condition Appearance Pressure Cell count (mm3) Glucose (mg/dL) Protein (mg/dL)
Bacterial meningitis Clear, cloudy, Elevated 500–10,000 + cells with 0–40 >50
or purulent 90%–95% PMNs
Partially treated Possibly cloudy Normal or elevated 1–500 cells, lymphs, or monos Low or normal >50 and <500
bacterial meningitis may predominate
Brain abscess Clear, cloudy, Elevated Possibly >100,000 cells if abscess Normal <200
or purulent ruptures. PMNs predominate
Tuberculous meningitis Clear, opalescent, Elevated 25–500 WBCs, PMNs early but 10–40 50–500
or ground glass usually lymphs predominate
Fungal meningitis Clear or cloudy Elevated 10–500 WBCs, lymphs <40 <600
predominate. PMNs early
Viral meningitis Clear, may have Normal or elevated 6–1000 cells, predominance Normal but may be <200
or encephalitis faint opalescence of lymphs. PMNs early low with herpes
or mumps
Acute syphilitic meningitis Clear or turbid Elevated 100–500 WBCs, usually lymphs Normal or decreased <200
Meningeal carcinomatosis Clear or mucinous Elevated 10–500 WBCs, lymphs <40 <500
predominate
Subarachnoid Bloody, xanthochromia, Elevated 1000–3.5 × 106 RBCs Normal, but can Increased
hemorrhage clear be decreased in
10%–15% of cases
Multiple sclerosis Clear Normal 0–20 lymphocytes, >50 rare Normal 45–75
Progressive multifocal Clear Normal <10 monos Normal Normal
leukoencephalopathy
Guillain–Barré syndrome Clear or xanthochromic Normal or elevated Normal, but 10–200 WBCs, Normal May be as high as 1000
predominantly lymphs
Pseudotumor cerebri Clear Elevated Normal Normal Normal
Subacute sclerosing Clear Normal Usually normal Normal Increased, check CSF
panencephalitis measles titers and
CSF gamma-globulin
Neuro-Behçet’s syndrome Clear Normal or elevated Up to 3000 WBCs, Normal Increased
PMNs predominate
have up to 22 WBCs/mm3. However, most sources consider blood is compared to the ratio in the CSF. This is based upon the
anything greater than 8 to 10 WBCs/mm3 to be abnormal.149,150 assumption that when blood is introduced into the CSF, the ratio of
Normal adult CSF should contain no more than 5 WBCs/mm3 RBCs to WBCs should stay the same. Some use a set RBC to WBC
with a differential of mononuclear cells or lymphocytes. The pres- ratio of 750:1 or 500:1. This is not always accurate as a periph-
ence of more than one PMN should be considered abnormal. eral leukocytosis may often be present. By comparing the ratios,
In cases of bacterial meningitis, cell counts are usually greater a predicted WBC count for the CSF can be obtained (predicted
than 500 WBCs/mm3 with a predominance of PMNs; though lym- CSF WBC = CSF RBC × blood WBC ÷ blood RBC). The actual
phocytosis can uncommonly occur.151 The CSF will usually con- WBC count will then be the predicted WBC subtracted from the
tain less than 1000 WBCs/mm3 in patients with viral meningitis observed or measured WBC (actual CSF WBC = observed CSF
and have a differential of 100% lymphocytes. Early in the course WBC − predicted CSF WBC).
of viral meningitis (the first 48 hours), 20% to 75% of patients will Most studies on patients with traumatic taps that did not have
have a predominance of PMNs in the CSF, making it difficult to meningitis have shown that these formulae are often inaccurate.156
distinguish it from bacterial meningitis.152,153 Within 8 to 12 hours, Oftentimes, the observed CSF WBC count is less than the pre-
approximately 90% of patients will show a switch to a mononu- dicted CSF WBC count.157 This raises concerns that in the pres-
clear pleocytosis on repeat LP.154 ence of meningitis, the diagnosis could be missed. Mayefsky and
Normal cell counts and differentials do not always exclude Roghmann studied the use of the formula in patients that had men-
meningitis. Approximately 95% of the population does not nor- ingitis and found that it led to many false-positive and false-negative
mally have any PMNs in their CSF. The presence of one PMN could results.158 They investigated the value of an O:P ratio (observed CSF
represent an abnormality. One PMN may be seen in approximately WBC/predicted CSF WBC) in predicting the presence of menin-
5% of normal children. Bonadio and colleagues reviewed 424 LPs gitis. They found that a ratio greater than 10 had a sensitivity of
of which 106 had PMNs but no pleocytosis.155 All 106 patients had 88% and a specificity of 90% in predicting culture positive meningi-
negative Gram’s stains and cultures. The authors concluded that the tis. They concluded, along with others, that pleocytosis in bacterial
older child without pleocytosis or abnormal CSF chemistries can meningitis is rarely masked by a traumatic tap.158,159 The O:P ratio of
be considered at very low risk for meningitis. If meningitis is sus- ≤0.01 can be used to identify patients with traumatic LPs that do not
pected and the CSF is normal or has PMNs, close clinical obser- have meningitis.160
vation and hospitalization for treatment and repeat LP should be
considered until CSF culture results are negative.
GLUCOSE
A traumatic LP can often make the interpretation of the CSF
difficult as peripheral WBCs can be introduced into the CSF. Normal values for CSF glucose are listed in Table 115-1. Compare
Clearing of the red hue of the CSF from the first to last tube sug- the ratio of CSF glucose to a simultaneously determined blood glu-
gests that the tap was traumatic. However, this is not always a reli- cose level to determine if low CSF glucose (hypoglycorrhachia)
able sign. Traditionally, the ratio of the RBCs to the WBCs in the exists. The ratio is abnormal in preterm infants if it is lower than
CHAPTER 116: Burr Holes 761
0.5 to 0.6. A ratio of less than 0.4 to 0.5 in children and adults is of intracranial bleeding.172,173 Xanthochromia, when measured by
abnormal. Approximately 58% of patients with bacterial meningi- spectrophotometry, has a sensitivity that approaches 100% when
tis will have a glucose of <40 mg/dL. The sensitivity for detecting performed between 12 hours and 2 weeks from the initial SAH. Do
bacterial meningitis increases to about 70% if a CSF-to-serum glu- not accept gross xanthochromia as a positive finding.174–176 Gross
cose ratio of <0.31 is used.161 The normal steady state of 0.6 tends to xanthochromia can be a false positive. Always rely on a spectro-
decrease as serum glucose increases. Ratios of less than 0.3 should photometric determination of xanthochromia. Xanthochromia can
be considered abnormal in cases of severe hyperglycemia. The CSF- develop in specimens within a few hours if the tap was traumatic.177
to-serum glucose ratio is less accurate when there are rapid changes One cannot rely on the finding of xanthochromia if the WBC count
in the serum glucose. A low CSF-to-serum glucose ratio should is >10,000 or if the analysis of CSF samples is delayed.177
always raise the concern of bacterial or fungal meningitis. Other So how should patients that present within 12 hours of their
conditions such as tuberculous or syphilitic meningitis, meningeal symptom onset be managed? Delaying a LP for 12 hours would
carcinomatosis, or SAH can also be the etiology. Approximately 15% require holding patients in the Emergency Department or admit-
to 20% of patients with a SAH will have hypoglycorrhachia.162,163 ting everyone who required an LP for evaluation. This presents a
Normal CSF-to-serum glucose ratios are usually seen with aseptic legitimate logistical problem. Edlow et al. suggest that patients that
meningitis, encephalitis, brain abscesses, and subdural empyemas. have a negative CT should undergo immediate LP.178 If the CSF is
persistently bloody without xanthochromia, and clinical suspicion
PROTEIN is high, vascular imaging should be the next step.
The normal CSF protein levels are listed in Table 115-1. Elevated SUMMARY
CSF protein levels, often greater than 150 mg/dL, are seen in acute
bacterial meningitis. Others causes of increased CSF protein include Most LPs will be performed in suspected cases of meningitis or SAH
any type of meningitis, encephalitis, CNS tumors, SAH, demyelinat- after a negative head CT. The risks of performing an LP need to
ing syndromes, and a traumatic LP.164 Correct the CSF protein by be weighed against the potential benefits of diagnosing these two
subtracting 1 mg/dL of protein for each 1000 RBCs in traumatic LPs. potentially life-threatening illnesses promptly. Knowledge of the
proper indications, contraindications, technique, and interpretation
of the CSF findings will undoubtedly help the Emergency Physician
GRAM’S STAIN to minimize the complications that can be associated with the pro-
The Gram’s stain is a very reliable test when performed by properly cedure. Although most complications are rare, awareness of their
trained individuals. In general, it is positive in identifying approxi- existence, presentation, and proper treatment is imperative.
mately 80% of bacterial CNS infections.165 The probability of detect-
ing bacteria on a Gram’s stain depends upon the number of bacteria
present in the CSF.166 Approximately 25% of smears are positive with
≤103 colony-forming units (CFU)/mL, 60% with 103 to 105 CFU/
mL, and 97% with >105 CFU/mL. False negatives can result from Burr Holes
partially treated meningitis where the sensitivity decreases to about
60%.167 False positives can result from the use of contaminated LP
116 Eric F. Reichman
trays or reagents, or the use of an unoccluded spinal needle.168
INTRODUCTION
CSF CULTURES
Burr holes in the Emergency Department setting are uncommonly
CSF cultures should be obtained in all patients suspected of having
performed for diagnostic and therapeutic purposes. Diagnosis and
meningitis. Positive cultures are assumed to be 100% specific but
treatment of increased intracranial pressure (ICP) in a timely fash-
may only occur in 80% of patients thought to have bacterial menin-
ion can be a lifesaving measure. Increased ICP can be the result of
gitis.169 Transport the CSF specimens to the laboratory promptly, as congenital anomalies, hemorrhage, infection, trauma, and tumors.
H. influenza and meningococcus will not survive storage or varia-
There has been less need to make exploratory burr holes in head-
tions in temperature. In general, antibiotics given prior to LP can
injured patients since CT scanning has become widely available.
sterilize the CSF. However, depending upon the amount of bacteria Burr holes can be lifesaving on rare occasions when the patient
in the CSF and the elapsed time from initiation of antibiotics, there is worsening neurologically or has blown a pupil and CT scan is
is probably a window of about 2 to 3 hours where antibiotics do not unavailable. Suspect a space-occupying lesion when there is clinical
affect the culture results. The percentage of positive CSF cultures evidence of tentorial herniation or upper brain stem dysfunction.
decreases from 33% to 4% and Gram’s stains from 41% to 7% when This includes pupillary dilation with a decreased or absent light
antibiotics are given prior to LP.170 Blazer et al. studied the effect of reflex, progressive deterioration in the patient’s level of conscious-
full intravenous antibiotic treatment on CSF cultures by perform-
ness, and/or hemiparesis including posturing (decerebrate/decorti-
ing an initial LP and then a repeat LP in 44 to 66 hours.171 All but
cate) or flaccidity. The placement of a temporal burr hole on the side
one of the cultures became negative whereas the cytology and bio-
of the mydriatic pupil to decompress an epidural or subdural hema-
chemistry were not affected. They concluded that partial treatment
toma can be lifesaving. Up to 70% of patients with evidence of brain
with antibiotics may alter the culture results but does not distort the
stem dysfunction soon after head trauma have significant intracra-
other characteristics of a “bacterial” CSF.
nial mass lesions, most of which are extra-axial blood collections.1
SUBARACHNOID HEMORRHAGE ANATOMY AND PATHOPHYSIOLOGY

It is imperative to interpret the CSF results correctly when an LP A significant proportion of patients with fatal head injuries die
is performed after a negative head CT to rule out the possibility before reaching the hospital. The cause of death is usually a result
of a SAH. Most sources agree that the presence of xanthochromia, of an expanding intracranial hemorrhage, extensive basilar skull
which results from lysis of red blood cells, confirms the presence fractures with associated injury to the venous sinuses, intracranial
carotid artery lacerations, and/or major cortical blood vessel lacera- cranium. This location makes them vulnerable to injury, especially
tions. Skull fractures are present in up to 90% of adults who develop from fractures of the temporal bone. The bony vault of the skull is
a traumatic intracranial hematoma. Children are less likely to suffer fairly thick, approximately 5 mm in thickness, and shows consider-
a skull fracture after head trauma than adults. able individual and regional variation. The temporal bone, in par-
The middle meningeal artery is a branch of the maxillary artery ticular the squamous temporal bone, is much thinner than other
and enters the cranium via the foramen spinosum. It is usually areas of the skull. This makes it more vulnerable to a fracture with
located between the periosteal and meningeal layers of the dura an associated injury to the underlying middle meningeal vessels.
mater. Shortly after entering the skull, it divides into anterior and Posttraumatic epidural hematomas usually develop in the tempo-
posterior branches. The larger branches of the middle meningeal ral or temporoparietal location as a result of an injury to the mid-
artery lie within the dura and are accompanied by veins. Their super- dle meningeal vessels (Figures 116-1A & B). More than 50% of all
ficial location in the dura produces grooves on the interior of the epidural hematomas result from an injury to the middle meningeal
B D
FIGURE 116-1. Hematomas requiring drainage through a burr hole. A. Illustration of an epidural hematoma. B. CT scan of an epidural hematoma. C. Illustration of a
subdural hematoma. D. CT scan of a subdural hematoma.
Consider reversing these conditions by the administration of fresh

frozen plasma and/or platelets prior to performing a burr hole. A
mild elevation in the international normalized ratio (INR) up to
1.6 may be acceptable to place a burr hole.3
EQUIPMENT
• Sterile prep kit
• Face mask with an eye shield or goggles
• Cap
• Sterile drapes
• 1% or 2% lidocaine containing epinephrine
• 5 mL syringe
• #10 scalpel blades
• #11 scalpel blades
FIGURE 116-2. Percentages of epidural hematomas by anatomic location. • #3 scalpel handle
• Bipolar cautery, optional
• Self-retaining mastoid retractors
artery itself. Epidural hematomas occur laterally over the cerebral
• Hudson brace drill
hemispheres with the epicenter at the pterion in approximately 70%
of patients (Figure 116-2). The remaining epidural hematomas are • Skull perforator bits
distributed in the frontal area, occipitoparietal area, and the pos- • Conical burr bits
terior fossa. Other sources of epidural hematomas include a torn • Small hook
venous sinus or an injury to the carotid artery before it enters the
intracranial dural mater. • Bone wax
Subdural hematomas are collections of blood between the dura • Thrombin-soaked Gelfoam
mater and the brain (Figures 116-1C & D). They usually are the • Periosteal elevator
result of blunt head trauma.1 These result from the tearing of a
• Suction catheter kit
bridging vein as the brain forcefully moves within the skull. The
patient will present with an abnormal neurological examination • Head covers, masks, and sterile gowns
minutes to hours after the acute injury. • Ventriculostomy catheter (optional)
Pupillary changes are not an early sign of an intracranial hema- • Bone rongeur
toma. However, when they do occur, they signify cerebral compres-
• Mayo scissors
sion and transtentorial herniation. Other causes of acute pupillary
changes need to be ruled out. Hematomas are usually found ipsilat- • 4-0 nylon suture
eral to the pupillary change in up to 85% of cases. • Potts scissors
The required equipment is all contained within a prepared ster-
INDICATIONS ile tray that can be obtained from the Operating Room or hospital
There are a few indications to emergently place a burr hole in the central supply (Figure 116-3). A completely disposable, sterile, and
Emergency Department. These include monitoring of intracranial single patient use instrument set is also available (Spectrum Surgical
pressure, the emergent drainage of an intracranial hematoma, and Instruments Corp., Stow, Ohio). The Hudson brace drill is a hand-
the emergent cannulation of the ventricular system (Chapter 118). held device (Figure 116-4). It has a stabilizing handle in series with
This procedure may be performed by trained Emergency Physicians a handle that rotates in circles. The distal end has a snap lock chuck
if a Neurosurgeon has been consulted and is not immediately that slides to allow easy insertion and removal of the bits. The bits
available. come in a variety of shapes and sizes (Figure 116-5). The perforator
bits have a sharp point. The tip of the perforator bit is designed to
CONTRAINDICATIONS penetrate the inner table of the skull and lock without allowing it to
puncture the dura or the brain (Figure 116-6). However, exercise
The only absolute contraindication is a patient who is coagulo- extreme caution as the bit may occasionally not lock when it pen-
pathic. Otherwise, the available Emergency Physician with the most etrates the inner table of the skull. The burr bits are rounded. They
skill and experience in performing this technique should be the one are used to enlarge the hole in the skull made by the perforator bit
to place the burr hole. Other contraindications include localized (Figure 116-6).
infections of the scalp and patients who are thrombocytopenic. This
procedure should not be performed by those unfamiliar with the
technique and its complications.
PATIENT PREPARATION
A coagulopathy or thrombocytopenia makes a burr hole danger- The patient should be fully monitored with a noninvasive blood
ous to perform. The use of anticoagulants and antiplatelet agents pressure cuff, pulse oximetry, cardiac monitor, and end-tidal car-
by the patient increases their risk of hemorrhagic complications. bon dioxide monitor (if available). Obtain a CT scan of the head
FIGURE 116-3. The contents of the hospital-prepared burr hole tray. FIGURE 116-5. Examples of perforator bits (left) and burr bits (right).
to determine the presence of an acute subdural or epidural hema- the patient is not thrombocytopenic or coagulopathic. These may
toma, the location and extent of the hematoma, to rule out the pres- require reversal with the administration of fresh frozen plasma
ence of a mass, and to determine if there is any herniation. Obtain and/or platelets.
a complete blood count (hemoglobin, hematocrit, and platelet Explain the risks, benefits, and complications of the procedure
count) and a coagulation profile (PT, PTT, and INR) to ensure that to the patient and/or their representative. Obtain an informed con-
sent. However, in the patient who is deteriorating neurologically
with tentorial herniation, consciousness is usually lost and time is
of the essence.
Determine the site for the skin incision and the burr hole
(Figure 116-7). A frontal or anterior burr hole is made just anterior
to the coronal suture and 3 cm lateral to the midline, approximately
along the midpupillary line (Figure 116-7A). The coronal suture is
often palpable. If not, draw a perpendicular line midway between
the lateral canthus of the orbit and the external auditory meatus. The
frontal burr hole can be used to drain an intracranial hematoma or
to perform a ventriculostomy. The temporal burr hole is made two
FIGURE 116-6. The perforator bit is used to make a hole through the skull and
FIGURE 116-4. The Hudson brace drill. just penetrate the inner table of bone. The burr bit is used to enlarge the hole.
A Midpupillary B Position of Frontal

line motor strip burr hole
Parietal
Frontal Position
burr hole
burr hole of middle
meningeal
artery
Temporal
3 cm
burr hole
External occipital
Coronal
protuberance
suture
Sigmoid sinus
Sagittal
suture External auditory meatus
Mastoid process
Zygomatic arch
FIGURE 116-7. Typical locations for burr holes. A. Superior view of the skull. B. Lateral view of the skull.
finger breadths above the zygomatic arch and two finger breadths it difficult to turn. Insert a small self-retaining retractor into the
anterior to the external auditory meatus (Figure 116-7B). The pari- wound (Figure 116-8A). Hemostasis can often be obtained with
etal or posterior burr hole is made two finger breadths behind the the use of the retractor. However, having cautery available can be
external auditory meatus and three finger breadths above the mas- helpful. Small bleeding vessels may be tied off with absorbable
toid process (Figure 116-7B). suture (Figure 116-8A).
Prepare the patient. Orotracheally intubate the patient to pro- Fit the Hudson brace drill with a perforator bit. Grasp the stabiliz-
tect and secure the airway. Insert a nasogastric tube to decom- ing handle of the Hudson brace with the nondominant hand. Grasp
press the stomach. Shave the scalp at least 5 cm in all directions the rotating handle with the dominant hand. Place the tip of the
from the proposed skin incision. This procedure requires strict perforator bit against the skull (Figure 116-8B). Turn the rotating
aseptic technique. Clean the skin of any dirt or debris. Cleanse handle clockwise with the dominant hand using a smooth and slow
the skin first using 70% alcohol followed by povidone iodine or motion. Always maintain the drill perpendicular to the skull.
chlorhexidine solution. Allow the povidone iodine or chlorhexi- Maintain controlled pressure on the Hudson brace drill. Watch
dine solution to dry. The Emergency Physician should don full as the perforator bit cuts through the skull. Frequently remove the
sterile and personal protective equipment at this point. This perforator bit to examine the hole. Irrigate the area. Use suction to
should include sterile gloves, a sterile gown, a face mask with an remove the bone fragments and the irrigation fluid. Gently probe the
eye shield or goggles, and a cap. Isolate the surgical field by using hole to determine if the inner table has been penetrated. Continue
sterile drapes. Prophylactic intravenous antibiotic coverage is rec- to drill until the inner table has been penetrated or the perfora-
ommended if time permits. Administer a broad-spectrum anti- tor bit locks (Figure 116-8C). Do not apply too much downward
biotic that covers gram-positive skin flora. Position the patient pressure on the brace to prevent it from plunging into the brain.
so that the proposed incision site is visible and easily accessible. Exercise extreme caution as the bit does not always lock when the
Place the patient supine with a folded blanket or towel under the inner table is perforated.
ipsilateral shoulder. Turn the head to the contralateral side if the Remove the perforator bit from the Hudson brace drill. Place the
cervical spine has been cleared. Instruct an assistant to hold and burr bit on the Hudson brace drill. Place the burr bit into the hole in
steady the patient’s head. the skull. Hold the Hudson brace drill as described above. Rotate the
handle clockwise to enlarge the hole in the skull (Figure 116-8D).
TECHNIQUES Frequently remove the burr bit to examine the hole. Irrigate the
area. Use suction to remove the bone fragments and the irrigation
fluid. Continue to drill until the hole in the inner table is enlarged
BURR HOLES
enough to accept the tip of the bone rongeur. Do not apply too
Identify the site to make the burr hole. Infiltrate 5 mL of lido- much downward pressure on the Hudson brace drill to prevent it
caine containing epinephrine along the proposed incision site from plunging into the brain.
and down to the level of the periosteum on the skull. This will Control bleeding from the bone with bone wax and from the
result in analgesia and vasoconstriction that may aid in hemo- epidural space with Gelfoam. The clot of an epidural hematoma
stasis. Make a 2 cm long skin incision centered about the site to will be obvious as it separates the inner table of the skull from
make the burr hole. Carry the incision down to the bone of the the dura. This clot will be gelatinous in consistency and drainage
skull. The incision must traverse all layers of the scalp includ- through a single burr hole can be difficult. Free the underlying
ing the skin, the subcutaneous tissue, the temporalis muscle (if dura from the bone edge with a Penfield elevator. Gently insert
present), and the periosteum. Remove the periosteum overlying the elevator between the inner table of the skull and the dura.
the skull by scraping it away with a periosteal elevator. The peri- Gently separate the dura from the skull. Enlarge the burr hole
osteum will otherwise get caught in the perforator bit and make in order to facilitate aspiration of the blood clot. Insert a bone
FIGURE 116-8. Drainage of an epidural hematoma. A. An incision is made through the skin, subcutaneous tissue, temporalis muscle, and galea aponeurotica. The incision
is held open with a self-retaining retractor. B. A Hudson brace drill fitted with a perforator bit is used to penetrate the skull to the inner table. C. A hole has been made
with the perforator bit. D. The hole is enlarged with a burr bit on the Hudson brace drill. E. The bone edges have been removed with a rongeur to expose the epidural
hematoma. The hematoma is gently removed by suction.
rongeur into the hole. Take small bites of the skull to enlarge the VENTRICULOSTOMY
hole (Figure 116-8E). Do not concern yourself with making the
hole smooth or symmetric. The Neurosurgeon will later trim and The burr hole can be made in order to place a ventriculostomy cath-
repair the bony defect. eter. Make a nick in the dural with an 18 gauge needle or a #11 scalpel
blade. Perform a ventriculostomy using an appropriate ventricular
HEMATOMA DRAINAGE catheter. Anatomical landmarks suggestive for placement of the
catheter within the ventricular system are to insert the catheter
An epidural hematoma is aspirated by gentle suction and irri-
gation with normal saline through an adequate bone opening
(Figure 116-8E). Pay close attention to the temperature of the
irrigation solution. It should ideally be body temperature. Use
wall suction with a #9 or #11 French aspirator.
Epidural and subdural hemorrhages are usually clotted in the
acute stages. In the event that an epidural hematoma is not iden-
tified after placement of the burr hole, inspect the underlying
dura for a possible subdural hematoma. The presence of a sub-
dural hematoma causes the dura to have a bluish hue or tinge
(Figure 116-9A). Carefully place a traction suture in the middle
of the exposed dura using 4-0 nylon (Figure 116-9B). Apply trac-
tion on the suture to elevate the dura. Incise the dura with a fine
Mayo scissors or a #11 scalpel blade (Figure 116-9B). Exercising
extreme caution during the maneuver is mandatory to prevent
lacerating the brain. Open the dura in a cruciate fashion. Drain
the subdural clot using suction and gentle irrigation. At no time FIGURE 116-9. Drainage of a subdural hematoma. A. The dura is exposed and a
should any pressure be placed on the brain. Care should be hematoma is visible below it. B. Traction is placed on a suture that has been placed
taken not to irrigate with any force directly against the brain through the center of the exposed dura. The tented dura is carefully opened with
surface. a scissors or scalpel to expose the underlying hematoma.
CHAPTER 117: Lateral Cervical Puncture 767
perpendicular to the skull and directed toward the ipsilateral inner technique. Other complications include plunging with the perfora-
canthus.2 Advance the catheter to a depth of approximately 5 to tor bit or the burr bit resulting in a penetrating injury to the brain,
6 cm. If unsuccessful after three attempts, place the parenchymal cortical lacerations, cortical contusions, and seizures. Blunt or pen-
monitor or a subarachnoid bolt. Refer to Chapter 118 for the com- etrating brain injuries can result in delayed stroke and hemorrhage.
plete details of performing a ventriculostomy. At times, this can be produced by a post-traumatic aneurysm or
arteriovenous fistula. In the severely head-injured patient, a multi-
ASSESSMENT tude of coagulopathic abnormalities can occur including hyperco-
agulable and fibrinolytic states as well as disseminated intravascular
Assessment and stabilization of the head injury victim prior to coagulation (DIC).
placement of the burr hole, during the procedure, and postproce- Significant bleeding complications can occur from this pro-
durally requires attention to securing the patient’s airway, adequate cedure.3 Penetration of the sagittal sinus can result in significant
and aggressive treatment of hemodynamic instability and shock, hemorrhage and possible exsanguination. Prevent this by staying at
stabilization of the cervical and thoracolumbar spine, and con- least 2 cm from the midline and properly identifying the landmarks
comitant treatment of any extracranial injuries. Aggressive man- before drilling into the skull. Avoid lacerating the middle menin-
agement of hypoxia and hypotension cannot be overemphasized. geal artery or its branches. Prevent injuries to these arteries by not
Hyperventilation in the first 24 hours after severe head injury drilling beyond the inner table and carefully separating the dura
should be avoided as it can reduce cerebral blood flow. The from the skull before using the bone rongeur. Another option is to
assessment should include hemodynamic parameters, Glasgow obtain a lateral plain radiograph of the skull. Note the position of
Coma Score, and frequent neurological examinations. The neu- the grooves in relation to the external auditory meatus. Avoid these
rological examination should include pupillary size and reaction, grooves, and thus the branches of the middle meningeal artery,
extraocular muscle function, and motor movements of the extremi- when determining the exact site to place the burr hole.
ties. Intubation utilizing the rapid sequence technique often pre-
cedes burr hole placement in the patient with severe head injury. SUMMARY
This precludes a detailed neurological examination as most patients
will have received neuromuscular blockade. The prognosis for the severely head-injured patient with clinical
Reduction in pupillary size can be appreciated postevacuation of evidence of tentorial herniation and brainstem compression is poor.
the hematoma in patients who have had pupillary changes preced- Rapid evacuation of an intracranial hematoma may help to improve
ing the burr hole placement. Repeat the hemodynamic and neuro- the outcome. Ideally, these patients are resuscitated and a CT scan
logical assessments often, every 5 minutes, and document these in of the head is completed in order to determine the presence of an
the patient’s record. Obtain a postprocedural CT scan of the head as intracranial hematoma. Patients may at times undergo rapid neuro-
early as possible to check the status of the hematoma. CT scanning logical deterioration prior to CT scanning or CT scanning may not
also verifies catheter location and reduction in ventricular size in be readily available. Diagnostic burr hole exploration and evacua-
patients in which trephination has been completed for ventricular tion of an extra-axial hematoma can be a lifesaving measure. The
catheter placement. author does not wish to suggest that exploratory surgery should
replace CT scanning in the management of patients with a severe
AFTERCARE head injury. The CT scan is invaluable in assessing and identify-
ing accurately the location of any mass lesion intracranially. Burr
Patients who have had burr hole placement because of neuro- hole evacuation in a trauma setting should be considered only in
logical deterioration require further definitive management by the presence of rapid neurological deterioration with evidence of
a Neurosurgeon. A craniotomy is indicated for a more thorough herniation and brainstem compression and the unavailability of a
evaluation, irrigation of the epidural or subdural space, and for Neurosurgeon to perform the procedure.
hemostasis. Postprocedural CT scanning should not be performed
if definitive management by a Neurosurgeon is available. It is an
unnecessary waste of time and the patient should proceed directly
to the Operating Room. Cranioplasty is often not completed ini-
tially after burr hole placement in order to minimize the infectious Lateral Cervical Puncture
risk. Postprocedural treatment often requires airway protection with
continued endotracheal intubation, adequate fluid resuscitation,
management of hypoxia, management of hypotension, manage-
ment of seizures, and management of any coagulopathy. Secondary

injuries can evolve, even after adequate hematoma evacuation. They INTRODUCTION
need to be anticipated, recognized, and treated aggressively.
A two-layer closure is recommended in the event a craniotomy The safest procedure to obtain cerebrospinal fluid (CSF) is lum-
is not to follow or will be delayed. The dura is usually not closed. bar puncture. However, there are situations where lumbar puncture
Cover the dura with a small piece of thrombin-soaked Gelfoam. is either contraindicated or technically not feasible. This includes
Close the galea with 3-0 absorbable suture. Close the scalp/skin infections in the lumbar area, obesity, previous spinal surgery,
with 3-0 nylon suture. Apply a dry dressing to the scalp wound. previous spinal fusion, a history of arachnoiditis, and the previ-
Alternatively, apply sterile saline-soaked gauze over the wound and ous injection of chemotherapeutics. The usual and safe alternative
cover this with a dry dressing. method is a lateral cervical puncture under such circumstances.
Cisternal puncture describes the suboccipital access to cisterna
magna, a CSF containing space. It is a less frequently used proce-
COMPLICATIONS
dure due to the high incidence of complications. As a result, cister-
Wound infections, abscesses, hemorrhage, and postoperative nal puncture should be performed by a Neurosurgeon for patients
hematomas are major complications.3 These can be avoided by whose CSF cannot be accessed by lumbar puncture or lateral cervi-
using sterile precautions, antibiotic prophylaxis, and fine surgical cal puncture.1
FIGURE 117-1. The course of the vertebral artery at the level of C1-C2. A. Posterior view. B. Lateral view.
Dr. Mullan introduced a method for performing a percutane- approximately 23 mm at C1 and 20 mm at C2. The cross-sectional
ous cordotomy using a lateral cervical puncture in the early 1960s.2 area of the cervical spinal canal is greatest at C2 and progressively
He introduced a strontium-90 needle through the C1-C2 inter- decreases. It is smallest at the level of C7. The vertebral canal is
space and into the subarachnoid space under fluoroscopic guid- narrower in women than in men. The spinal canal at the level
ance. He then directed the needle anteriorly toward the anterior of C1-C2 can be divided into three parts. The anterior third is
dura mater to interrupt the spinal thalamic fibers in an attempt to occupied by the odontoid process. The middle third is occupied
control intractable pain. The lateral cervical puncture is a direct by the spinal cord itself. The posterior third is occupied by the
derivative of this technique. subarachnoid space. The spinal cord is suspended and cushioned
within the subarachnoid space by cerebral spinal fluid. The ante-
ANATOMY AND PATHOPHYSIOLOGY rior boundary of the spinal canal is formed by the posterior aspect
of the vertebral bodies and the intervertebral disks. The lateral
Lateral cervical puncture involves the placement of a spinal needle wall of the spinal canal is formed by the pedicles and the interver-
into the C1-C2 interspace, posterior and inferior to the vertebral tebral foramen. The posterior wall of the spinal canal is formed
artery. The vertebral artery ascends through the foramina in the by the lamina, the ligamentum flavum, and the lateral masses or
transverse processes of the cervical vertebrae beginning at the sixth articular processes.
cervical vertebra. It winds behind the lateral mass of the atlas (C1) The morphology of the spinal cord demonstrates considerable
to enter the skull through the foramen magnum (Figure 117-1). individual variation in size and shape. The spinal cord changes in
Inserting the needle 1 cm inferior to the tip of the mastoid process morphology throughout the entire spinal canal. It is cylindrical in
and 1 cm posterior from that point will avoid puncturing the verte- shape and larger in transverse diameter than anteroposterior diam-
bral artery (Figure 117-2). eter. The spinal cord is largest from C3 to C6, obtaining approxi-
The spinal canal is formed by sequential vertebral foramina mately 13 to 14 mm in maximal transverse diameter. The average
and is triangular in shape. Its lateral width is greater than the sagittal diameter of the cervical spinal cord is approximately 11 mm
anteroposterior width. The spinal canal is more spacious in the at C1 and 10 mm at C2.
upper cervical spine allowing for safe placement of a needle into The cervical nerve roots usually occupy the inferior one-third of
the C1-C2 interspace. The sagittal diameter of the spinal canal is the neural foramen. The first cervical spinal nerve root exits between
the occiput and C1. The C2 through C7 spinal nerves exit above
their corresponding numbered vertebra. Each nerve root innervates
a specific dermatome and myotome, with considerable anatomical
variation and overlap. The C1-C2 interspace is guarded laterally by
the ligamentum flavum. The ligamentum flavum is composed of a
yellow elastic tissue, the fibers of which are almost perpendicular in
direction. It is attached to the lower part of the anterior surface of
the lamina above and the posterior surface of the upper margin of
the lamina below.
INDICATIONS
The lateral cervical puncture is an alternative method for obtaining
CSF when lumbar puncture is not feasible or successful. Conditions
that make lumbar puncture difficult are considered contraindica-
tions such as lumbar arachnoiditis, marked obesity, infections in
the lumbar area, prior lumbar spine surgery, prior administration
of lumbar intrathecal chemotherapeutics, and known congenital
FIGURE 117-2. Anatomic landmarks for the lateral cervical puncture. The site for anomalies of the lumbar area (e.g., meningocele and myelomenin-
insertion of the needle is represented by an ⊗. gocele). The lateral cervical puncture is performed, like the lumbar
CHAPTER 117: Lateral Cervical Puncture 769
puncture, in order to obtain CSF for analysis. CSF analysis is indi- Explain the procedure, its risks, and benefits to the patient and/
cated in patients suspected of having a central nervous system infec- or their representative. Explain the postprocedural care. Obtain an
tion or a subarachnoid hemorrhage. Other indications for lateral informed consent for the procedure. Place the patient supine on the
cervical puncture include the installation of antineoplastic or anti- gurney, without a pillow, and the neck as straight as possible. Limit
microbial agents. Lateral cervical puncture may also be necessary any head rotation from the true supine position. The landmark for
for the introduction of dye for radiographic studies. needle insertion is 1 cm caudal and 1 cm posterior to the tip of the
mastoid process (Figure 117-2).
This procedure requires strict aseptic technique. Clean the
CONTRAINDICATIONS
skin of any dirt and debris. Swab the area with alcohol pads. Shave
Contraindications for a lateral cervical puncture include brain the area so that the mastoid tip is contained within the sterile field.
abscesses, brain tumors, cervical spine anomalies and deformities, The Emergency Physician should don full sterile and personal pro-
coagulopathy, increased intracranial pressure, inflammatory adhe- tective equipment at this point. This should include sterile gloves, a
sions, local infections, posterior fossa abscesses, posterior fossa sterile gown, a face mask with an eye shield or goggles, and a cap.
tumors, thrombocytopenia, and vertebral artery anomalies (course Apply povidone iodine or chlorhexidine solution to the skin and
or location). Arnold-Chiari malformations and other congenital allow it to dry. Apply sterile towels and drapes to delineate a sterile
abnormalities in the region of the foramen magnum are also a rela- field. Inject local anesthetic solution subcutaneously at the above
tive contraindication. These include achondroplasia, basilar impres- identified landmark. Consider the administration of intravenous
sion, Dandy-Walker malformation, Klippel–Feil syndrome, and diazepam or midazolam, if not contraindicated, to relax the patient.
syringomyelia. Some patients may require the administration of procedural seda-
tion. The aid of an assistant to hold the patient’s head straight and
upright is recommended.
EQUIPMENT
• Sterile gloves and gown TECHNIQUE
Maintain the patient in the supine position with absolutely no
• Cap head movement. An assistant should stabilize the patient’s head.
• 20 gauge spinal needle with a stylet Introduce a 21 or 22 gauge spinal needle perfectly horizontal, parallel
• 23 gauge spinal needle with a stylet to the plane of the bed, and perpendicular to the neck (Figure 117-3).
The needle will cross a number of tissue planes including the skin,
• 3 mL syringe
subcutaneous tissue, trapezius muscle, suboccipital muscles, and the
• 20 gauge needles meninges. Advance the needle slowly and in 2 to 3 mm increments.
• 22 gauge needles Remove the stylette frequently to check for CSF. The subarachnoid
• Three-way stopcock space is approximately 6 cm from the skin surface in most adults.
Puncture of the dura is often felt as a “pop” or loss of resistance.
• Manometer
Frequent checks for CSF prevent excessive penetration of the needle
• Extension tubing, optional
• Four specimen vials with caps
• Gauze pads
• Sterile towels
• Fenestrated sterile drape
• Lidocaine hydrochloride, 1%
• Sterile gloves
• Fluoroscopy unit, optional
All of the basic equipment can be found in commercially avail-
able lumbar puncture kits. The kit needs to be supplemented with
personal protective equipment and skin antiseptic.
PATIENT PREPARATION
The patient should be fully monitored with a noninvasive blood
pressure cuff, pulse oximetry, cardiac monitor, and end-tidal carbon
dioxide monitor (if available). Obtain a CT scan of the head if a
complete neurological examination cannot be performed or if it is
abnormal in any way, the patient has a history of malignancy, of the
patient may have a potential mass occupying lesion (e.g., the HIV
patient). Obtain a complete blood count (hemoglobin, hematocrit,
and platelet count) and a coagulation profile (PT, PTT, and INR) to
ensure that the patient is not thrombocytopenic or coagulopathic.
Do not delay the administration of intravenous antibiotics pending
these studies if meningitis is in the differential diagnosis and the
reason for the lateral cervical puncture. FIGURE 117-3. Proper needle trajectory for a lateral cervical puncture.
through subarachnoid space, overshooting the spinal canal, or inad- incidence of postdural puncture headache is less with the lateral cer-
vertent puncture of the spinal cord or vertebral artery. Immediately vical puncture than with a lumbar puncture. Refer to Chapter 115
remove the spinal needle if the patient develops any neurological for the complete details regarding the complications associated with
symptoms. a lumbar puncture.
CSF flow through the needle signifies that the tip is within the
subarachnoid space. If CSF is not draining after puncture of the dura SUMMARY
and removal of the stylet, rotate the needle 30°. The use of a portable
fluoroscopic unit can confirm the needle’s trajectory and exact posi- A lumbar puncture is still the preferred technique to obtain cerebro-
tion. Carefully apply the three-way stopcock and manometer to the spinal fluid for analysis as well as for injection of contrast material.
spinal needle to measure the pressure of the CSF. Carefully remove The lateral cervical puncture is a safe alternative method. One can
the stopcock and the manometer from the spinal needle. Do not avoid the complications of puncturing the vertebral artery or the
allow the spinal needle to move while applying and removing the spinal cord by observing maximum attention to detail. The lat-
stopcock and manometer. Keep in mind that the needle is not eral cervical puncture can be performed at the bedside. However,
very well supported by the soft tissue as in the lumbar puncture. the availability of a portable fluoroscopy unit can facilitate the
Hence, the needle must be supported more carefully. Collect 1 to procedure.
2 mL of CSF in each specimen tube. Insert the stylet into the spinal
needle. Remove the spinal needle and stylet as a unit. Apply a ban-
dage to the skin puncture site.
Encountering arterial blood from the spinal needle usually indi-
cates that it was pointing too far anteriorly and that the vertebral Ventriculostomy
artery was penetrated. The venous plexus surrounding the vertebral
artery may also be penetrated. Remove the spinal needle and apply
manual pressure if the vertebral artery is inadvertently entered.
Reattempt the procedure with the tip of the spinal needle directed
slightly more posteriorly. Directing the spinal needle too far poste- INTRODUCTION
riorly causes it to enter the spinal musculature and miss the spinal
canal. In the event that bone is encountered, meaning that either the Performing an emergent ventriculostomy may be lifesaving when
lateral arch of C1 or C2 is encountered, redirect the spinal needle faced with a patient who is deteriorating rapidly from a neurologic
slightly rostrally or caudally and advance it into the subarachnoid perspective and all other therapeutic options have been employed.1
space. This chapter will discuss some of the situations when this procedure
may be considered, other therapeutic options, and an explanation of
how to perform an emergent ventriculostomy.
AFTERCARE
Maintain the patient in a supine position after the procedure. A ANATOMY AND PATHOPHYSIOLOGY
small bandage is usually sufficient to control any soft tissue bleed-
ing or continued CSF leakage. Postdural puncture headaches can The cranium is a fixed space after infancy that has little capacity
be minimized by utilizing a small-gauged spinal needle inserted for added volume or mass. Pathologic conditions such as tumors,
with the bevel parallel to the fibers of the dura. Resting in the intracranial hemorrhage, infection, massive cerebral infarctions,
supine position for 24 hours also reduces the incidence of postdural and edema can exert direct pressure on the brain or interrupt flow of
puncture headaches. Monitor the patient’s neurological status. Any the cerebrospinal fluid (CSF). These processes can all result in fluid
change in patient’s baseline neurological examination requires a CT accumulation and increased intracranial pressure (ICP).
scan of the brain, posterior fossa, and occipital-cervical junction in The patient with increased ICP may display the classic clinical
order to rule out a herniation, epidural hematoma, or intradural signs of headache, vomiting, and papilledema.1 Vomiting is partic-
hemorrhage. ularly associated with acute increases in ICP. Other signs include
Send the aspirated fluid for the appropriate laboratory analysis if an abducens nerve palsy (cranial nerve VI) that causes diplopia,
an etiology other than an acute traumatic hemorrhage is suspected.3 decreased consciousness, and an elevated blood pressure with bra-
This can include a biochemistry analysis (glucose and protein level), dycardia (Cushing’s phenomenon). An increase in ICP may eventu-
cell count and differential, culture (bacterial, fungal, viral, etc.), ally progress to brain herniation.
cytology, and gram stain. Herniation occurs when there exists a force in part of the brain
great enough to push other parts of the brain into different com-
partments. The cranial contents are divided into compartments by
COMPLICATIONS
invaginations of the dura mater (Figure 118-1).2 The supratentorial
The complications associated with lumbar puncture are also pos- space is separated from the infratentorial space by the tentorium
sible during the lateral cervical puncture. Specific complications cerebelli. The right and left hemispheres are separated by the falx
from lateral cervical puncture include penetration of the vertebral cerebri.
artery with subsequent hematoma formation and puncture of the When a unilateral supratentorial mass exerts enough force, the
spinal cord with resultant neurological deficits.3–8 Minimize compli- ipsilateral cerebral hemisphere is pushed medially toward the oppo-
cations by utilizing a small gauge spinal needle. These complications site hemisphere (Figure 118-2A). The medial aspect of the tempo-
should result in no serious consequences if unilateral and recog- ral lobe is pushed down toward the brainstem and over the edge
nized.3 Approximately 0.4% of the population has an anomalously of the tentorium cerebelli (Figure 118-2B). This process is known
positioned vertebral artery. There has been a single case report of as tentorial herniation. Symptoms of tentorial herniation include a
a death from a subdural hematoma due to puncture of this vessel.4 worsening of any headache with vomiting, progressively decreasing
A nerve root may be irritated with passage of the needle resulting consciousness, anisocoria, hemiparesis, and Parinaud’s syndrome
in local pain or possibly a headache. Other complications include (an upward gaze paresis). Compression of the oculomotor nerve
infection, herniation syndromes, neck pain, and headache. The results in a sluggish and dilated pupil, usually on the same side as
CHAPTER 118: Ventriculostomy 771
FIGURE 118-1. The falx cerebri and tentorium

cerebelli divide the skull into compartments.
A. Sagittal view. B. Coronal view. C. Top of the
skull removed with a section of tentorium cer-
ebelli also removed.
the mass lesion. A progression to a fixed and dilated pupil, with of tonsillar herniation include profuse vomiting, irregular respira-
decerebrate rigidity (extensor posturing), is an ominous sign of tions (ataxic breathing), neck pain, and neck stiffness. The patient
increased ICP. may not necessarily lose consciousness or have pupillary changes
Mass effect in the infratentorial compartment of the skull may prior to the terminal events of tonsillar herniation. Upward hernia-
produce downward pressure of the cerebellum into the foramen tion forces the cerebellum and upper brainstem through the ten-
magnum (Figure 118-3A) or upward pressure of the midbrain into torial notch (Figure 118-3B). The patient is usually obtunded or
the supratentorial compartment (Figure 118-3B), the former being comatose with small or anisocoric pupils that may, at first, be reac-
more common. The downward pressure is known as tonsillar or tive. There may be an associated paresis of the extremities that pro-
cerebellar herniation (Figure 118-3A) and the terminal events sur- gresses to decorticate posturing.
rounding this condition may occur more urgently and fatally than Any patient with these potentially life-threatening neurologic
a supratentorial herniation. For example, an acute respiratory arrest findings should be considered unstable and worked up accord-
may occur from compression of the medulla. Other important signs ingly. An emergent head CT scan, if available, is the diagnostic test
FIGURE 118-3. Infratentorial herniation of the brain. A. Downward tonsillar her-

FIGURE 118-2. Supratentorial herniation of the brain. A. Tentorial herniation. niation through the foramen magnum. B. Upward herniation into the supratento-
B. Subfalcial herniation. rial compartment.
of choice after the patient’s airway, breathing, and circulation have CONTRAINDICATIONS
been stabilized. Signs of herniation on the head CT include an ante-
rior midline shift with brain tissue from one side pushed under the Performing a ventriculostomy could precipitate or worsen hernia-
falx and into the opposite side of the brain (subfalcial herniation; tion and hasten the patient’s mortality if an infratentorial mass has
Figure 118-2A). Other signs include generalized cerebral edema been identified and it appears to be inducing upward pressure into
with effacement of the sulci, the ventricles, the basilar cisterns, and the supratentorial compartment. A coagulopathy or thrombocyto-
the fourth ventricle. penia makes a ventriculostomy dangerous to perform. The use of
There are several clinical interventions that should be imple- anticoagulants and antiplatelet agents by the patient increases their
mented immediately once increased ICP, hydrocephalus, or hernia- risk of hemorrhagic complications. Consider reversing these con-
tion is suspected and the patient’s condition is declining. The airway ditions by the administration of fresh frozen plasma and/or plate-
must be stabilized and rapid-sequence intubation is the procedure lets prior to performing a ventriculostomy. A mild elevation in the
of choice. Pretreatment with lidocaine is useful in diminishing the international normalized ratio (INR) up to 1.6 may be acceptable to
elevation in ICP that occurs during direct laryngoscopy. Thiopental, place a ventriculostomy.5
etomidate, and propofol are the induction agents of choice as they
decrease the ICP. EQUIPMENT
Neuromuscular blockade is accomplished with succinylcholine
after administering a defasciculating dose of a nondepolarizing • Skin razor
neuromuscular blocking agent. Paralytics may only be neces- • Skin prep kit
sary for a brief period during intubation. It is preferable to avoid • Sterile gloves and gown
paralysis for any length of time when the patient’s neurologic
status needs to be followed closely and any changes readily iden- • Face mask with an eye shield or goggles
tified. However, the need to follow the patient’s neurologic course • Cap
should be balanced by the need to reduce elevated ICP that may • Povidone iodine or chlorhexidine solution
be accomplished, in part, with sedatives and paralytics. The poten- • Skin marker
tial for succinylcholine increasing ICP is most prevalent in patients
with neoplasms of the central nervous system and may not be sig- • Ventricular catheter with stylet
nificant for acute trauma or bleeds.3 Maintain the patient’s oxygen • Drainage tubing and collection system
saturation at 100%. Elevate the head of the bed to 30°. Place the • Measuring implement
patient in the reverse Trendelenburg position if a cervical spine
• Scalpel handle
injury is suspected.
It is desirable for the mean arterial pressure to be 90 mmHg or • #15 scalpel blade
higher in order to maintain an adequate cerebral perfusion pressure • 10 mL syringe
and diminish the risk of cerebral ischemia. The commonly employed • 25 gauge needle
modalities of hyperventilation and osmotic diuresis are still used in
the acutely deteriorating patient but their value is limited because • Lidocaine with epinephrine, 1%
of the ischemic and metabolic complications related to their use. • Self-retaining retractor
Reducing the pCO2 to 25 mmHg via hyperventilation can reduce • Twist drill with a ¼ in. bit
the ICP in the acute resuscitation phase. The pCO2 should not be • Sterile towels
maintained below 35 mmHg during the immediate postresuscita-
tion period. The use of osmotic diuretics, such as mannitol, can • Bipolar cautery
also reduce ICP quickly. Unfortunately, any extended duration of • Needle driver
use of osmotic diuretics places the patient at an increased risk for • 3-0 nylon suture
cerebral ischemia. Other methods to consider include the use of
• Suction source
dexamethasone in patients with edema surrounding a neoplastic
mass or abscess. Pentobarbital can be used to induce a coma and • Suction tubing
reduce the ICP, but it can also cause hypotension. An ICP monitor- • Suction catheters
ing device must be put into place since the ability to do sequential • Headlight, optional
neurological checks is lost.
• Curette, optional
INDICATIONS • Three-way stopcock, optional
It is preferable to treat an identifiable pathologic process as soon It is most useful to have either a commercially available ventricu-
as possible. This usually requires intervention by a Neurosurgeon. lostomy kit or assemble one to have available in the resuscitation
The Neurosurgeon may be able to take the patient to the Operating area. Complete, disposable, and single-patient use kits are conve-
Room to place an indwelling ventricular shunt system in an expe- nient and cost-effective (Figure 118-4).
dited fashion. The ICP can be monitored and reduced by draining
CSF via a ventriculostomy in the Emergency Department if the PATIENT PREPARATION
patient continues to deteriorate and a definitive procedure cannot
be immediately arranged. The patient should be fully monitored with a noninvasive blood
The primary indication for a ventriculostomy is cerebral her- pressure cuff, pulse oximetry, cardiac monitor, and end-tidal car-
niation unresponsive to less invasive management methods. A bon dioxide monitor (if available). Obtain a CT scan of the head to
ventriculostomy can also be performed to drain CSF to treat determine the presence of an acute subdural or epidural hematoma,
hydrocephalus, decrease ICP from any cause, measure ICP, intro- the location and extent of the hematoma, to rule out the presence of
duce contrast for radiographic studies, or to collect CSF from the a mass, and to determine if there is any herniation. Obtain a com-
ventricular system.4 plete blood count (hemoglobin, hematocrit, and platelet count) and
CHAPTER 118: Ventriculostomy 773
povidone iodine or chlorhexidine solution and allow it to dry. The

Emergency Physician should don full sterile and personal protec-
tive equipment at this point. This should include sterile gloves, a
sterile gown, a face mask with an eye shield or goggles, and a cap.
Denote the landmark on the skin with a sterile skin marker. Apply
sterile drapes to the head so that the medial canthus of the right eye
can be visualized. Note the premade markings on the ventricular
catheter or mark 4, 5, and 7 cm on the catheter prior to its insertion.
Consider the administration of prophylactic intravenous broad
spectrum antibiotics immediately prior to the procedure. The usual
infecting organisms are Staphylococcus epidermidis and Staphy-
lococcus aureus. Appropriate antibiotic coverage includes third-
generation cephalosporins and penicillinase-resistant penicillins.
TECHNIQUE
Infiltrate the marked area with 3 to 5 mL of lidocaine with epineph-
rine. Make a 1 to 2 cm incision with a #15 scalpel blade. Carry the
FIGURE 118-4. An example of the contents of a commercially available ventricu- incision from the skin surface down to and through the periosteum
lostomy kit. of the skull. Tie off or cauterize any bleeding vessels. Insert the self-
retaining retractor into the incision to provide adequate exposure.
Prepare the hand drill. Choose the appropriate drill bit and insert
it into the drill. Adjust the safety stop on the drill bit to the estimated
a coagulation profile (PT, PTT, and INR) to ensure that the patient is skull thickness. Secure the safety stop on the drill bit firmly with
not thrombocytopenic or coagulopathic. These may require reversal an Allen wrench. Carefully and slowly drill through the outer and
with the administration of fresh frozen plasma and/or platelets. inner tables of the skull. Take care not to penetrate the dura. Do
This procedure is often performed emergently. Explain the proce- not apply too much force against the drill to prevent plunging
dure, its risks, and benefits to the patient and/or their representative. the drill bit into the brain. Stop drilling when a loss of resistance
If it will not unduly delay the treatment, obtain an informed consent is felt. Flush the hole with warm sterile saline to remove any debris.
to perform the procedure. Carefully make an opening in the dura with an 18 gauge needle or
This procedure requires strict aseptic technique. Place the a #11 scalpel blade.
patient supine on a gurney with the head elevated 30°. Identify the A simple ventricular catheter or a fiberoptic catheter with a
burr hole entry site. This is located 3 cm to the right of midline and screw-in mechanism should be available. Apply gentle pressure
10 cm behind the glabella in the midpupillary line or 1 cm anterior while inserting the catheter into the brain matter and aiming for
to the coronal suture in the midpupillary line (Figure 118-5). Shave the medial canthus of the ipsilateral eye (Figure 118-5A). A loss
the right side of the head, the nondominant side in most people, for of resistance or a “give” will often be felt as the catheter enters the
4 to 5 cm surrounding the burr hole entry point. The hair from the ventricle. There should be a return of CSF at a depth of 4 to 5 cm
entire frontal area back to the ear may be shaved, but it is probably of catheter penetration. Withdraw the stylet and advance the cath-
unnecessary to do so. Clean the scalp of any dirt and debris. Apply eter 1 cm farther. Do not insert the catheter more than 7 cm deep.
FIGURE 118-5. Placement of a ventriculostomy catheter. A. Insertion of the ventricular catheter. B. The catheter is tunneled and the skin closed.
FIGURE 118-6. Transorbital ventricular decompression. A. The upper eyelid is retracted and the globe is displaced downward. B. Insertion of the needle.
If no CSF is obtained, withdraw the catheter and reinsert it while remains in place (Figure 118-5B). Close the skin around the ven-
aiming slightly more medially and posteriorly, as the position of the tricular catheter. If a pressure transducer is being utilized, obtain a
ventricles may be distorted by the underlying pathologic process. measurement prior to allowing any quantity of CSF to drain. Attach
Attach the pressure transducer to measure ICP. the sterile fluid collection system. If a simple drainage bag is being
used, ensure that it is kept at the level of the ventricle to avoid over-
ALTERNATIVE TECHNIQUE drainage. Frequently recheck and document the patient’s neuro-
logic status. It is useful to send a baseline sample of CSF for culture,
The gathering of equipment, making the burr hole, and the inser- cell count, chemistry, and cytology (if applicable) after ventriculos-
tion of the ventriculostomy catheter can take significant time and tomy placement.
experience. The required equipment may not be readily avail-
able. An easier, quicker, and simpler technique is to perform a PEDIATRIC CONSIDERATIONS
transorbital decompression.9,10 This technique is adapted from
the old frontal lobotomy of years ago. Clean and prep the skin of Young children have an open anterior fontanelle. This large area
the eyelids and periorbital area. Moisten sterile gauze with ster- devoid of bone is ideal for the introduction of a needle to drain CSF
ile saline. Instruct an assistant to grasp the upper eyelid with a from the ventricular system. This procedure may be required in
piece of saline-moistened gauze. Instruct the assistant to retract cases of acute patient decompensation due to an acute nonobstruct-
the upper eyelid outward then upward and maintain this posi- ing hydrocephalus (e.g., meningitis), an acute obstructing hydro-
tion (Figure 118-6A). Grasp a piece of saline-moistened gauze in cephalus (e.g., brain abscess, brain tumor, epidural hematoma,
the nondominant hand. Apply this to the sclera at the 12 o’clock intracranial hemorrhage, or subdural hematoma), or the acute
position and displace the globe downward (Figures 118-6A & decompensation of a chronic hydrocephalus (e.g., aqueductal ste-
B). Be sure to not place the gauze on the cornea as this can nosis, posterior fossa tumors, or other congenital malformations).4
cause a significant corneal abrasion. Apply an 18 gauge, 1.5 to The ventriculostomy procedure in a young child is similar to that
2.5 in. angiocatheter or spinal needle on a syringe. Insert the nee- in an older child, adolescent, and adult with a few exceptions. A burr
dle through the orbital roof, 1 cm posterior to the superciliary arch hole is not required as the anterior fontanelle allows an easy access
(Figure 118-6B). Aim the needle toward the coronal suture at the point. Use an 18 or 20 gauge, 1.5 in. long angiocatheter instead of
midline or vertex of the skull. Advance the needle approximately the spinal needle. The procedure is similar to inserting an intra-
3 cm so that its tip enters the anterior horn of the lateral ventricle. venous catheter. Insert the angiocatheter perpendicular to the skin
Gently aspirate after the needle is inserted to a depth of 3 cm and and at the most lateral aspect of the anterior fontanelle or the coro-
CSF is aspirated. If using an angiocatheter, the soft plastic catheter nal suture to avoid the midline sagittal sinus. Stop advancing the
can be secured to the orbital roof with a suture and the ICP moni- angiocatheter when CSF flows from the hub of the needle. Slightly
tored through the pressure transducer. advance the plastic catheter while withdrawing the needle. Apply
the pressure transducer to the hub of the catheter to measure ICP.
Remove enough CSF to decrease the ICP to an appropriate level or
AFTERCARE
until the signs and symptoms of herniation are reversed.6,7 Remove
It is desirable to tunnel the drainage tubing subcutaneously for sev- the catheter or secure it to the scalp with suture. The secured cath-
eral centimeters to reduce the risk of infection (Figure 118-5B).1,6 eter can be capped or left attached to transducer to continue to
Suture the ventricular catheter and tubing to the skin so that it monitor ICP.
CHAPTER 119: Ventricular Shunt Evaluation and Aspiration 775
COMPLICATIONS as infants will require two shunt revisions secondary to obstruction

within their first 10 years.1 The overall shunt infection rate is 10% to
The most common complication of placement of an emergent ven- 20%.1,3,4 Approximately 90% of these infections will present within
triculostomy is a CSF infection. The risk of infection increases the 3 months of the shunt placement.1 These statistics apply to the pop-
longer the drain is left in place. Fortunately, infections are rare for ulation with conventionally treated hydrocephalus using indwelling
those in place for fewer than 4 days. Tunneling the drainage tubing, ventricular shunt devices. It is significant to note that with the wide
adhering to strict aseptic technique, and administering prophylactic application and development of neuroendoscopic techniques, many
antibiotics can reduce the incidence of infection. of the complications discussed in this chapter may be significantly
Ventricular puncture can result in an acute bleed in the subdu- reduced or possibly eliminated.
ral, intraparenchymal, or ventricular spaces. This can occur from Complications resulting from ventricular shunts take many
direct trauma to the vascular system or excessive CSF drainage forms.5 These include proximal obstruction (most common), distal
that shrinks the brain and tears the bridging vessels to the subdural obstruction, disconnection, wound and cerebrospinal fluid (CSF)
space. It is estimated that the risk of hemorrhage associated with a infections, seizures, epidural hygromas, subdural hematomas, low
ventriculostomy is 5.7%, with 1% of ventriculostomy patients having (overdrainage) and high pressure (slit ventricle) syndromes, and
a clinical significant hemorrhage.8 An emergent head CT is indi- cranial deformities. There are other unique complications experi-
cated if the patient’s condition deteriorates further after ventric- enced by the smaller number of patients who have ventriculoatrial
ulostomy placement. Patients should always be tested for normal (V-A) and ventriculopleural shunt systems and these will be dis-
blood clotting function prior to performing a ventriculostomy. cussed separately. Unless stated otherwise, the reader should assume
The most feared complication of this procedure is plunging with that reference is being made to the more common ventriculoperito-
the drill bit uncontrollably into the brain substance. This procedure neal (V-P) shunt device.
should not be performed by those unfamiliar and untrained in the Patients with shunts may present with clinical entities as benign
technique. Apply the minimal amount of pressure to the drill so that as a viral upper respiratory infection or with a life threat like
the bit penetrates the bone. Never use a hand twist drill without hydrocephalus. The wide range of possibilities is a challenge to the
the safety stop. Emergency Physician’s diligence and clinical acumen. Common
presenting symptoms include headache, fever, vomiting, decreased
SUMMARY alertness, neck stiffness, visual changes, malaise, abdominal pain,
abdominal distension, and surgical site problems.
The traumatically head-injured patient or the patient with chronic
hydrocephalus who presents with a rapidly deteriorating neuro-
logic status may have increased ICP or be in the process of brain ANATOMY AND PATHOPHYSIOLOGY
herniation. There are several tools, in addition to emergent ven- Hydrocephalus, a condition defined by an excessive quantity of CSF,
triculostomy placement, that can temporarily stabilize the patient’s is the condition most frequently associated with the initial need for a
changing neurological status. This includes intubation, hyperven- ventricular shunt or a shunt revision if it malfunctions. Most abnor-
tilation, osmotic diuresis, maintenance of cerebral perfusion pres- mal accumulations of CSF are identified in the ventricles, although
sure, dexamethasone administration, and barbiturate coma. While it may also occur in the subarachnoid or subdural spaces.
the ultimate goal is to treat the primary pathologic condition, Several types of hydrocephalus are cited in the literature.
this chapter was designed to describe the use of CSF drainage via Communicating hydrocephalus occurs when there is unobstructed
a ventriculostomy and its use in the context of the other methods flow of CSF between the ventricular system of the brain and the
commonly used to reverse the life-threatening complications of an spinal cord. It frequently occurs in patients who have had a hem-
acutely increasing ICP. orrhage or infectious process whereby particulate matter interferes
with the normal circulation and absorption of CSF. A congenital
problem such as aqueductal stenosis or a mass lesion in the pos-
terior fossa may obstruct the flow of CSF between the brain and
spinal cord causing obstructive hydrocephalus or noncommuni-
Ventricular Shunt cating hydrocephalus. Normal pressure hydrocephalus is usually a
119 Evaluation and

diagnosis made in older people who present with the clinical triad
of dementia, ataxic gait, and urinary incontinence. The CSF is found
to flow within a normal pressure range, but the patient accumulates
Aspiration excess CSF due to decreased absorption. Hydrocephalus ex vacuo is
Eric F. Reichman the result of excessive CSF and ventricular enlargement due to brain
atrophy. It presents a challenge to the acute care practitioner who
may need to decide if a patient with large ventricles on head CT has
INTRODUCTION a pathologic condition or has so much brain atrophy that the fluid-
Pediatric and adult patients with ventricular shunts frequently seek filled spaces appear excessively large.6
medical attention in acute care settings with complaints that may The clinical presentation of hydrocephalus will vary depending
or may not be caused by a malfunction and/or infection of these upon its acuity and the age of the patient. The individual who expe-
indwelling devices. The challenge for the Emergency Physician is riences shunt failure may present in the same way as one who is pre-
to determine if the shunt system is functioning properly and if it is senting with hydrocephalus initially. Infants may have an enlarged
a direct cause of the patient’s acute problem. This chapter will dis- head circumference, a bulging anterior fontanel, separation of the
cuss the complications of ventricular shunt malfunction including cranial sutures, bilateral or unilateral palsy of the abducens nerve
infection. (medial eye deviation), or Parinaud’s syndrome.7 Parinaud’s syn-
Complications in children with ventricular shunts are common drome is a paralysis of upward gaze (also known as “sunset eyes” or
whereas those in adults occur less frequently. Approximately 30% to the setting sun sign), unequal pupils, and the loss of convergence.7
40% of infants will experience shunt complications during their first Within hours of an acute cause of hydrocephalus, the patient
year following shunt placement.1,2 Children who had shunts placed (past infancy) will commonly experience a headache with nausea
FIGURE 119-1. The components of a ventricular shunt.
and vomiting secondary to the quick increase in intracranial pres-

sure (ICP). The patient may less commonly have a focal neuro-
logical deficit due to the pressure exerted by the brainstem from
a dilated third ventricle. There may also be visual changes that
include Parinaud’s syndrome. A change in mental status may
occur as the increase in ICP persists. Finally, the signs of hernia-
tion signify a terminal event. It will be observed with, for example,
decorticate or decerebrate posturing, a third cranial nerve palsy,
and the Cushing reflex (elevated blood pressure accompanied
by bradycardia). The process of herniation is nearly completely
reversible with immediate ventricular drainage through emergent
revision of a malfunctioning shunt or the de novo placement of a
ventricular drain.
Chronic hydrocephalus can present with a variety of signs and
symptoms. The patient may complain of an isolated bifrontal
headache, a generalized headache, vomiting, a change in behav-
ior, a change in mentation, or a change in cognition. Ocular find-
ings include papilledema, unilateral or bilateral abducens nerve
palsy, Parinaud’s syndrome, or even a bitemporal hemianopsia.
The extremities may be involved with spasticity in the legs that is
more pronounced than that found in the arms. FIGURE 119-2. The anatomical pathway of a ventriculoperitoneal shunt.
Once the diagnosis of hydrocephalus is made, the Neurosurgeon
will be responsible for treating the primary causes (e.g., tumor,
bleed, congenital abnormality) along with placement of an indwell- a specified level. A variable resistance constant flow valve keeps CSF
ing ventricular shunt. The components of a standard shunt sys- rates constant and, therefore, provides a more physiologic system by
tem include a ventricular catheter, a one-way valve, and distal varying the resistance in the valve as the individual changes posi-
tubing that enters the cavity into which the fluid is being shunted tion. Some of these valves, although palpable on physical examina-
(Figure 119-1). It is standard practice to enter the right lateral vention, do not allow access to the CSF for aspiration nor do they allow
tricle and tunnel the valve system and distal tubing subcutaneously for any noninvasive assessment of CSF flow. A bubble-like reser-
along the right temporoparietal region of the skull, the lateral neck, voir (may be single or two bubbles in tandem) for the draining of
the anterolateral chest wall, and finally into the peritoneal space CSF is a common addition to the standard three-part shunt system.
just superior or lateral (right side) to the umbilicus (Figure 119-2). While they can be inserted anywhere in the system, they are most
The shunt system may occasionally be found on the left side in frequently located adjacent to the valve mechanism on the lateral
some patients. aspect of the skull (Figure 119-2).
Much of the shunt pathway is palpable on physical examination The distal tubing is made of a flexible and soft synthetic rubber
(Figure 119-2). The entire system may be visualized on plain radio- material that is attached to the reservoir or valve system and tun-
graphs. The system is impregnated with radiopaque material either neled subcutaneously through the lateral neck, chest, and abdomi-
entirely or with intermittent markings. nal wall. A small incision is made in the skin and the peritoneum
The ventricular catheter is inserted through a burr hole and into where the tubing is brought from the subcutaneous tissue into the
the lateral ventricle. The distal end of the ventricular catheter is con- peritoneal cavity. After securing the tubing to the peritoneum, a
nected to one of many different types of valves currently available. generous portion of tubing is left free floating inside the peritoneal
Functionally, there are two main types. The differential pressure cavity. This allows for the distal end to lengthen as the patient grows
valve allows the Neurosurgeon to select a low, medium, or high pres- and lends further stability to its place within the abdominal cavity.
sure system whereby the CSF will flow out of the ventricle through The distal tubing in ventriculoatrial and ventriculopleural shunt
a one-way system when the CSF pressure or CSF flow rate builds to systems will terminate in the right atria and right pleural cavity,
CHAPTER 119: Ventricular Shunt Evaluation and Aspiration 777
respectively. However, these configurations are not used frequently. A double bubble (reservoir system) may be occasionally palpated.
One may also come across a patient with a lumboperitoneal shunt Compress the proximal reservoir to empty it and fill the distal res-
that avoids any invasive procedures to the brain directly. This sys- ervoir. While still compressing the proximal reservoir, compress
tem is inserted into the lumbar subarachnoid space with the valve/ the distal reservoir. Any resistance to compression indicates a distal
reservoir system located above the iliac crest and the distal tub- malfunction. With both reservoirs compressed, release the proxi-
ing tunneled subcutaneously in the abdominal wall and into the mal reservoir. It should refill very quickly. Any delay in filling of the
abdominal cavity. proximal reservoir indicates a proximal malfunction.
The patient is subject to a host of complications due to mechani- Move down and palpate the temporal region of the scalp and
cal malfunctioning that can occur anywhere along the path of the the neck. Note any gaps in the system that could indicate a discon-
system. There is the risk of infection, as is the case with any indwell- nection. The individual components of the shunt system are com-
ing medical device. The remainder of this chapter will guide the monly joined by small connectors that may come apart. Continue
Emergency Physician through the process of identifying the various to palpate the tubing along the neck and chest until you reach the
types of shunt problems. abdomen. Perform a thorough abdominal examination, specifically
noting the presence of any tenderness, masses, distension, or ery-
INDICATIONS thema of the abdominal wall.
The distal end of the shunt may not function for several reasons.
The Emergency Physician is obliged to assess the patency, place- The tip may have withdrawn out of the peritoneal cavity and into
ment, and integrity of the shunt system when a patient presents the preperitoneal fat or subcutaneous tissue of the abdominal wall
with any symptoms even remotely related to hydrocephalus. The where the CSF cannot be resorbed. This may have occurred sim-
presence of systemic signs (e.g., fever, tachycardia, or hypotension) ply because the patient had grown and used up the extra length
or local signs of infection (e.g., warmth, tenderness, bogginess, or of catheter that was originally left in the peritoneal cavity just for
redness along the shunt tract) is a reason to consider aspirating this reason. Intraperitoneal infections, particularly those caused by
CSF from the system. This is not to say that every child with an anaerobic organisms, may cause loculations around the catheter
upper respiratory infection requires that the shunt be tapped. It is tip forming a pseudocyst. It is important to note that these patients
not uncommon to have overlapping findings in that an infection may not have any signs of a systemic infection. Additional causes of
may obstruct the system and therefore require both mechanical and distal catheter obstruction include kinking of the intraabdominal
infectious complications to be addressed. The withdrawal of CSF tubing, debris collection around the tube openings, and compres-
from the shunt can be lifesaving and sustain the patient who is sion secondary to pregnancy or other processes that increase the
herniating, in extremis, or deteriorating neurologically until a intraabdominal pressure.
Neurosurgeon can repair the shunt. After completing the history and physical examination, including
an assessment of the shunt system, the differential diagnoses will
CONTRAINDICATIONS help initiate an appropriate work-up. One or more of the follow-
There are no contraindications to performing a thorough physical ing studies may be indicated: plain radiograph shunt series, com-
examination of the shunt system, obtaining a head CT, and obtain- puterized tomography (CT) of the head, shunt aspiration of CSF,
ing plain radiographs to assess its integrity. There is some contro- or a radioisotope shunt scan. Stabilize the patient and arrange for
versy, however, that surrounds the tapping of a shunt by personnel an emergent head CT if any life-threatening signs of neurologic
other than a Neurosurgeon.8–10 It is possible to disrupt the pres- dysfunction appear.
sure and valve mechanism by the manipulation of the needle that There are several important points to note. Findings consistent
is required to perform the tap. The reservoir may develop a leak with hydrocephalus include enlargement or effacement of the ven-
if the correct technique is not employed or if the shunt is tapped tricles, particularly looking for fullness of the temporal horns of the
too frequently. There is the risk that bacteria will be introduced into lateral ventricles (Figure 119-3). It can be difficult to determine if
the system. Many patients have had multiple complications related there is a change in the ventricular system because congenital or
to both a primary disease and the shunt, with some already having chronic abnormalities can give the CT scan an abnormal appear-
undergone a number of shunt revisions. It is prudent to assume ance. The best way to approach this situation is to compare the cur-
a conservative approach with each of these patients and consult rent scan to a previous one, preferably by comparing the two scans
a Neurosurgeon prior to tapping the shunt. side by side. Brain atrophy causes the ventricles to appear abnor-
mally full when, in fact, they appear large because of the relative loss
of brain tissue.
SHUNT ASSESSMENT Impending herniation may be a concern if the brain appears to be
The technique of shunt evaluation begins with taking a com- under increased pressure with a loss of the sulcal markings, loss of
plete history and performing a thorough physical examination. the differentiation between the gray and white matter, or an inability
Palpate the entire system starting with the cranium. Examine the to visualize the fourth ventricle. The ventricles can appear unusually
surrounding scalp carefully for any bogginess (indicating that small which may be an indication of a shunt system that is draining
CSF may have extravasated from the system), redness, tender- CSF too vigorously. Overdrainage may be the problem if the patient
ness, or warmth. The suture line should be examined as well if complains of a positional headache that is worse in the upright posi-
the shunt has been placed recently. Examine the scalp on the right tion and less severe when supine. If this is the case, it is important
side for a burr hole. This is where you may palpate a shunt reser- to carefully examine the CT scan for any subdural hematomas
voir that is placed subcutaneously. The reservoir feels like a firm that can result from the brain shrinking away from the dura
fluid-filled bubble. Compress the bubble gently to assess if there and tearing a bridging vein secondary to overdrainage of CSF.
is brisk refilling of the CSF. Quick filling of the reservoir is an The patient’s scan may reveal small ventricles accompanied by
indication that the proximal portion of the system may be pat- signs of increased ICP in the slit ventricle syndrome.11,12 While the
ent, but this is by no means a perfect test. Resistance to compres- slit ventricle syndrome is poorly understood, it is theorized that
sion indicates a distal malfunction. Avoid pumping the reservoir ventricles with poor compliance (common in those with chronic
repeatedly. hydrocephalus) will respond to small increases in CSF pressure with
A B
FIGURE 119-3. Head CT of a patient with hydrocephalus. A. The ventricles are enlarged with effacement. B. Pronounced temporal horns.
large increases in ICP. The management of the slit ventricle system responsible for any shunt revisions and follow-up. Patients with
can be medical, replacement of the valve with one of a higher resis- ventriculoatrial shunts are a particular concern when there are any
tance to flow, or the placement of a new shunt.12,13 signs of an infection. The distal catheter sits at the intersection of
Obtain a plain radiograph shunt series if there is the slightest the right atrium and the superior vena cava. This puts the patient
suspicion of a shunt malfunction or infection. This study consists at risk for life threats such as endocarditis and septic emboli. It may
of anteroposterior and lateral plain radiographs of the skull, neck, be possible to evaluate the majority of shunt malfunctions without
chest, and abdomen. These films are useful for assessing placement tapping the device.8
and integrity of the connections within the shunt system.14 Shunt Tapping a ventricular shunt is a quick and simple procedure.
materials are impregnated with a radiopaque substance either com- Palpate the lateral aspect of the skull (usually the right side of the
pletely or in regularly placed markings so that the entire device can patient) for the reservoir. Plain radiographs may be helpful if it is
be visualized on plain radiographs. It is important to obtain and difficult to identify upon palpation. Prepare for the procedure by
review the lateral abdominal film as this view is frequently over- having the following equipment available: four sterile fluid speci-
looked. It is impossible to determine if the shunt tubing lies within men tubes with tight fitting tops (those supplied in the standard
the peritoneal cavity or not if the lateral abdominal film is excluded. lumbar puncture kit are ideal), a 23 to 25 gauge butterfly needle,
The entire path of the shunt system should be visualized. Particular a 5 to 10 mL syringe, a shave-prep set, an antibacterial cleansing
findings to note on this study include placement of the ventricu- preparation (povidone iodine or chlorhexidine solution), a fenes-
lar catheter inside of the ventricle, the integrity of the connections trated drape, and personal protective equipment.
around the valve and/or reservoir, and the identification of the distal Local anesthetic is not required for this procedure. Place the
catheter within the peritoneal cavity. Examine the chest radiographs patient in whatever position is mutually comfortable. Shave a small
closely for a pleural effusion or a pneumothorax in a patient with a patch of hair overlying the reservoir. Clean the skin of any dirt and
ventriculopleural shunt.15 debris. Apply povidone iodine or chlorhexidine solution and allow
it to dry. This procedure requires strict aseptic technique. The
Emergency Physician should don full sterile and personal protec-
SHUNT ASPIRATION
tive equipment at this point. This should include sterile gloves, a
Tapping the ventricular shunt should be considered whenever sterile gown, a face mask with an eye shield or goggles, and a cap.
there are signs of localized infection, systemic infection, or in some Place the drape over the patient’s head so that the fenestration over-
cases of suspected obstruction without an identifiable cause. It lies the reservoir and prepped skin. Set up a bedside table with a
should also be performed if the patient is in extremis, deteriorat- sterile drape and all the supplies. A lumbar puncture tray supple-
ing neurologically, or has signs of herniation on the CT scan. This mented with a butterfly needle is all that is required.
can temporarily restore cerebral perfusion and sustain the patient Insert the needle at approximately 45° from the vertex of the res-
until a Neurosurgeon can repair the shunt. It is recommended ervoir bubble with the tip pointed toward the center of the reservoir
that a Neurosurgeon be consulted and given the first option (Figure 119-4). This is where the greatest amount of CSF is located.
to perform the procedure. The Neurosurgeon may have already Avoid inserting the needle into any of the connections or internal
manipulated the hardware multiple times and will ultimately be pressure mechanisms that may be at either end of the reservoir.
CHAPTER 120: Subdural Hematoma Aspiration in the Infant 779
current management of shunt-related infections has been reviewed

by Stenehjem and Armstring.19 Empiric therapy includes vancomy-
cin with either cefotaxime or ceftriaxone for children and vanco-
mycin with rifampin for adults.20 Consider additional coverage for
methicillin-resistant Staphylococcus aureus if indicated.
FUTURE CONSIDERATIONS
The ShuntCheckT (NeuroDx Development, Bensalem, PA) is a new
device that allows the noninvasive detection of CSF flow through a
shunt.21 The procedure requires placing an ice cube over the shunt.
A single patient use and disposable sensor is placed on the skin of
the neck overlying the shunt tubing. The sensor is attached to the
ShuntCheckT device with a cable. The ShuntCheckT analyzes the
temperature readings from the sensor and determines if CSF flow
is present or not.
FIGURE 119-4. Tapping the shunt reservoir.
COMPLICATIONS
There are a few complications associated with the aspiration of a
Allow the CSF to passively drain from the butterfly tubing into ster- ventricular shunt. The introduction of bacteria into the reservoir
ile tubes. It may be necessary to very gently aspirate 4 to 5 mL of can result in meningitis, peritonitis, brain abscesses, shunt occlu-
CSF with a sterile syringe. The ventricular end of the shunt is usually sion, or infection anywhere along the course of the shunt tubing.
obstructed if CSF cannot be aspirated.10 Withdraw the needle from It is of the utmost importance to maintain strict aseptic technique.
the shunt reservoir. The needle can damage the reservoir and result in a permanent hole
Label the tubes of CSF and have them transported to the labora- necessitating its removal and replacement. A misplaced needle can
tory for a cell count and differential, Gram’s stain, culture (bacte- damage the connections or valves of the shunt system.
rial, viral and fungal), and chemistry (protein and glucose). Obtain
a sample of the patient’s serum glucose at the same time so as to SUMMARY
more accurately determine what level of glucose in the CSF to call
Patients with indwelling ventricular shunt devices are subject to
abnormal. A normal level of CSF glucose should not be any lower
many complications throughout their lives. This most commonly
than 50% to 66% of the serum level.
includes obstruction, infection, and malfunction secondary to loss
It is possible to attach the end of the butterfly tubing to a manom-
of placement or connection. Emergency Physicians will see patients
eter so that an opening pressure can be measured. This must be
of all ages with shunts and who present with headache, fever, nau-
done, however, with the patient in the lateral decubitus position,
sea, vomiting, seizures, irritability, or a change in mental status.
reservoir side up, and the head level with the heart.
The challenge, frequently a formidable one, will be to determine
Obtain a nuclear medicine scan (“shunt-o-gram”) if CSF can-
whether or not the patient’s complaint is related to the shunt. This
not be aspirated to determine proximal patency of the system. A
chapter discussed some of the common shunt complications and an
radioactive isotope (e.g., technetium) is injected into the reservoir
approach to their diagnosis. The head CT, the plain film shunt series,
after manually occluding the distal shunt tubing. The flow, or lack
and the shunt tap will prove most useful. Of course, a careful history
thereof, of the radioactive isotope is then imaged.4 The addition of a
and a skilled physical examination will set the Emergency Physician
nuclear medicine scan to the CT scan can increase the sensitivity of
on a path toward a good outcome for the patient. A Neurosurgeon
diagnosing a shunt malfunction.16
should be consulted if available. A conservative approach to diagno-
A lumbar puncture should never be performed in lieu of tap-
sis, management, and patient disposition is strongly recommended
ping the shunt. Obstruction of the shunt system can result in
due to the life-threatening nature of shunt complications.
obstructive hydrocephalus. Lumbar puncture in a patient with
obstructive hydrocephalus can cause a significant pressure dif-
ferential and precipitate brain herniation.
CSF ASSESSMENT
Subdural Hematoma
The CSF obtained from the shunt is interpreted in the same way
as CSF from a lumbar puncture. A high white cell count with a
120 Aspiration in the Infant
large number of polymorphonuclear leukocytes, low glucose, and Eric F. Reichman
a high protein level indicates a high likelihood of bacterial infec-
tion. However, the positive Gram stain and culture make the defini-
tive diagnosis. Unfortunately, there is no standard for the number
INTRODUCTION
of white cells that definitively indicates an infection. Some patients Extra-axial fluid collections in children are classified as symptom-
with indwelling shunts may have a chronically elevated CSF white atic and asymptomatic. Symptomatic, chronic extra-axial fluid col-
blood cell count, albeit with more lymphocytes or eosinophils than lections have been variously classified as hematomas, effusions, or
polymorphonuclear leukocytes.3 Refer to Chapter 115 for a more hygromas with differing definitions associated with each. It has been
detailed discussion regarding the evaluation of CSF. Antibiotic cov- proposed that they all be classified together as extra-axial fluid col-
erage should be initiated if a shunt is being tapped. Staphylococcus lections because their appearance on CT scan and the treatment is
epidermidis causes the vast majority of infections with Staphylococcus identical.1 Symptomatic, chronic extra-axial fluid collections usually
aureus and gram-negative bacilli following in frequency.17,18 The show ventricular compression and flattening or obliteration of the
TABLE 120-1 The Etiologies for Intracranial and Extra-Axial

Fluid Collections
Brain atrophy
Child abuse
Coagulopathy
Hydrocephalus
Infection
Masqueraders
Craniocerebral disproportion
Extracerebral space is enlarged and filled with CSF-like fluid as a result
of the head being too large for the enclosed brain
External hydrocephalus in a child with ventriculomegaly and
extracerebral fluid
Neoplastic
Metastatic FIGURE 120-1. Surface anatomy of the infant skull. The shaded area represents
Primary the underlying superior sagittal sinus.
Prior surgery
Spontaneous
Trauma
Vascular ANATOMY AND PATHOPHYSIOLOGY
Aneurysm
Vascular malformation A subdural aspiration (or tap) is usually performed by puncturing
Ventriculoperitoneal shunt malfunction the anterior fontanel. However, it can also be approached through
the coronal suture as well as through the soft cranium. The dia-
mond-shaped anterior fontanel is formed by the junction of the
sagittal, coronal, and frontal sutures (Figure 120-1). It measures
cerebral sulci on CT scans. Benign subdural fluid collections usu- approximately 4 cm in the anteroposterior plane and 2.5 cm in the
ally appear as a hypodensity over the frontal lobes with dilatation of transverse plane. The bones of the infant calvarium are separated
the interhemispheric fissure, cortical sulci, and Sylvian fissure. The by connective tissue bands referred to as sutures. The fontanels are
ventricles are usually normal or slightly enlarged with no evidence readily palpable at the junctions of the sutures. Six of the fontanels
of transependymal flow. are located at the corners of the two parietal bones. Two of these, the
Seizures, a large head, vomiting, irritability, depressed level of anterior and posterior fontanels, are in the midline.
consciousness, and lethargy are common presenting symptoms of a The anterior fontanel, the largest of the neonatal fontanels, is uti-
symptomatic extra-axial fluid collection. The physical examination lized for percutaneous subdural aspiration. The diamond-shaped
reveals a full fontanel, macrocephaly, fever, lethargy, hemiparesis, anterior fontanel is formed by the junction of the sagittal, coronal,
retinal hemorrhages, generalized increased tone, or gaze paresis. and frontal sutures (Figure 120-1). It measures approximately 4 cm
Markwalder has done an excellent review of the pathophysiology in the anteroposterior plane and 2.5 cm in the transverse plane.
and experimental studies of chronic subdural hematomas.2 The posterior fontanel is at the junction of the lamboidal and sagit-
The majority of extra-axial fluid collections result from head tal sutures. In general, the anterior fontanel has usually closed by
trauma. Other causes include bacterial meningitis (postinfectious) 18 months of age but can be patent up to the age of 2 years. The pos-
and the placement of a ventriculoperitoneal shunt. The etiology terior fontanel usually closes earlier in life and is usually complete
of intracranial hemorrhage and extra-axial fluid collections are by 6 weeks of age.
quite varied (Table 120-1). Acute and chronic subdural fluid col- The anterior fontanel is composed of connective tissue and eas-
lections are common problems during infancy. Males are affected ily perforated with a spinal needle. Continued advancement of the
more commonly than females. A clear history of injury or trauma needle would then perforate the underlying dura, allowing the tip
should be sought in the presence of an acute or chronic subdu- of the needle to rest within the subdural space. Traversing the dura
ral hematoma. Consider the possible etiology of child abuse if is usually associated with a definite change in resistance as the sub-
a history of injury is not forthcoming or if the history does not dural space is entered. Successful entry of the tip of the needle into
make sense. It is incumbent upon the medical team to rule out the subdural fluid collection can be confirmed by removal of the
abuse. This may require a period of inpatient observation, social stylet and observing spontaneous drainage from the needle hub.
services consultation, a radiographic skeletal survey, a bone scan, The anterior fontanel is readily palpable and bulging in cases of
and possibly an ophthalmological assessment. The presence of reti- symptomatic chronic extra-axial fluid collections. The lateral
nal hemorrhages in association with a subdural fluid collection extent of the anterior fontanel is continuous with the coronal suture
is highly suspicious for child abuse. Admission to the hospital for (Figure 120-1).
further observation is warranted if child abuse cannot be ruled out.
The presence of congenital anomalies may predispose the child to INDICATIONS
subdural hematoma formation.
Percutaneous removal of the subdural fluid is useful in diagnos- A subdural aspiration is performed for diagnostic purposes as well
ing an active infection and rapidly lowering the intracranial pressure as for rapid decompression of subdural fluid collections, whether
in the symptomatic patient. Repeated removal of the fluid by per- acute or chronic. Perform a subdural aspiration in the young child
cutaneous aspirations has been advocated by some Neurosurgeons with a subdural fluid collection and radiographic signs of elevated
for definitive treatment of chronic extra-axial fluid collections.3,4 intracranial pressure, a depressed level of consciousness, and/or a
Subdural fluid collections in infants have a tendency to increase in changing level of consciousness.5 Other indications to perform a
size, are often bilateral, can be difficult to diagnose, and are most subdural aspiration include the clinical signs and symptoms associ-
often seen in children under the age of 2 years. The combination of ated with elevated intracranial pressure: bulging fontanelles, coma,
CT and MRI is usually diagnostic. cranial nerve palsies, hemiparesis, hypotonia, irritability, lethargy,
CHAPTER 120: Subdural Hematoma Aspiration in the Infant 781
posturing, seizures, somnolence, and vomiting (repeated or intrac- edge of the bed facilitate aspiration. An alternative is to use a com-
table). Aspiration of extra-axial fluid collections can reduce intra- mercially available immobilization device (e.g., Papoose board).
cranial pressure dramatically. Subdural aspiration of fluid allows for The aid of an assistant to hold the child’s body with the head
culture and sensitivity, identification of microorganisms, and aids straight and upright is recommended if the child is restless. Some
in the selection of bacterial specific antimicrobial agents if an infec- children may require the administration of parenteral sedatives or
tious etiology is considered to be the cause of the extra-axial fluid procedural sedation.
collection. This procedure requires strict aseptic technique. Shave the
frontal and parietal regions of the child’s head. Clean any dirt and
CONTRAINDICATIONS debris from the scalp. Identify by palpation the anterior fontanel,
the coronal suture, and the lateral margin of the coronal suture. The
The main contraindications to performing a subdural aspiration Emergency Physician should don full sterile and personal protec-
include localized infections of the scalp, patients who are coagulo- tive equipment at this point. This should include sterile gloves, a
pathic or thrombocytopenic, children over the age of two, children sterile gown, a face mask with an eye shield or goggles, and a cap.
who have an absence of the anterior fontanel as a result of premature Apply povidone iodine or chlorhexidine solution to the skin over
closure, a solid clot that is not liquefied, and children with congeni- the entire scalp and allow it to dry. Ensure that the solution is not
tal anomalies of the skull or brain. This procedure should not be allowed to drain onto the baby’s face or eyes. Apply sterile drapes
performed by those unfamiliar with the technique and its compli- leaving the frontal and parietal regions of the skull exposed. A local
cations. Consult a Neurosurgeon, if available, prior to performing anesthetic agent is usually not required but may be used at the
this procedure. Repeated aspirations are rarely indicated as blood Emergency Physician’s discretion. If used, place a skin wheal using
or fluid reaccumulation often requires the placement of a drain or a 0.25 to 0.50 mL of 1% or 2% lidocaine at the site the needle will enter
surgical procedure by a Neurosurgeon. the scalp.
EQUIPMENT TECHNIQUE
• Sterile skin prep kit Form a Z-tract by gently sliding the scalp skin laterally
• Povidone iodine or chlorhexidine solution (Figure 120-2). Insert a 22 gauge spinal needle into the lateral
margin of the anterior fontanel, about 2.5 to 3 cm off the midline
• Sterile gloves and gown (Figure 120-2). Advance the spinal needle beneath the frontal
• Face mask with an eye shield or goggles bone until the subdural space is penetrated. This is usually within
• Sterile drapes 5 to 8 mm from the skin surface. A loss of resistance is usually
appreciated as the dura is penetrated and the subdural space is
• 1% or 2% lidocaine, with or without epinephrine
entered. Do not advance the needle any further. Securely hold
• 18 to 22 gauge, 1.5 in. spinal needle or angiocatheter the spinal needle so that it does not move (Figure 120-3). An
• Tincture of benzoin alternative is to insert the needle at a 45° angle to the skin sur-
• Cotton swab face, tunnelling it under the scalp and into the subdural space
(Figure 120-4). Remove the stylet. Spontaneous drainage is often
• Bandage appreciated. This fluid may appear hemorrhagic. However, it is
• Bundling blanket not uncommon, especially in patients who require multiple aspi-
• Commercially available immobilization device rations, to drain xanthochromic fluid.
• Syringe for aspirating fluid The initial subdural aspiration usually results in spontane-
ous drainage through the spinal needle. The spontaneous cessa-
• Sterile specimen containers tion of flow through the needle suggests that the extracranial and
• Culture bottles or swabs intracranial pressures are equalized, not that the fluid has been
• IV extension tubing, optional completely evacuated. If the fluid does not spontaneously drain,
carefully and gently apply a syringe to the spinal needle and gently
All of the basic equipment can be found in commercially available aspirate the fluid. Use minimal negative pressure to just aspirate
pediatric lumbar puncture kits. The kit needs to be supplemented
with personal protective equipment and skin antiseptic.
PATIENT PREPARATION
The patient should be fully monitored with a noninvasive blood
pressure cuff, pulse oximetry, cardiac monitor, and end-tidal car-
bon dioxide monitor (if available). Obtain a CT scan of the head to
determine the presence of an extra-axial fluid collection, the loca-
tion and extent of the fluid collection, the type of fluid (e.g., blood,
pus, etc.), and to rule out the presence of a mass. Obtain a complete
blood count (hemoglobin, hematocrit, and platelet count) and a
coagulation profile (PT, PTT, and INR) to ensure that the patient is
not thrombocytopenic or coagulopathic.
Explain the procedure to the parents and/or guardian of the
child if time permits. Obtain an informed consent to perform the
procedure. Place the patient supine on a stretcher. The child may
need to be restrained to prevent movement during the procedure. FIGURE 120-2. Subdural fluid aspiration. The needle is inserted at the lateral
Bundling an infant in a blanket and placing their head close to the border of the coronal suture and at 90° to the skull.
FIGURE 120-4. An alternative method for subdural fluid aspiration. The inset
shows the oblique trajectory of the needle into the subdural space.
FIGURE 120-3. Coronal section through the skull at the level of the coronal
suture. The needle is visible along its trajectory.
bandage placed over the puncture site is usually sufficient and can
be removed 48 to 72 hours after the procedure. Continued sponta-
neous drainage through the puncture site should be monitored care-
the fluid collection and prevent pulling the brain or any bridg- fully as it poses an infectious risk.
ing veins into the needle. Alternatively, apply digital pressure
to the anterior fontanelle to increase the flow through the spinal
needle. Some Physicians may choose to apply intravenous exten- AFTERCARE
sion tubing to the spinal needle to allow the subdural fluid to drain Perform an ultrasound or CT scan of the head to determine if the
away from the patient and directly into the specimen tubes. This fluid collection has been adequately drained. Bedside ultrasonogra-
is left to the Emergency Physician’s preference. Observe the grad- phy is an effective tool in neonates and young children. Any change
ual flattening of the anterior fontanel to determine the endpoint in the child’s neurological examination requires an emergent head
for the procedure.6 Generally, on any one occasion, no more than CT scan or ultrasonography to determine if the subdural fluid col-
25 to 30 mL of subdural fluid should be aspirated. Larger volumes, lection has reaccumulated. Send the aspirated fluid for the appropri-
up to 80 mL, have been safely aspirated.7 Remove the spinal needle ate laboratory analysis if an etiology other than an acute traumatic
and apply a bandage. hemorrhage is suspected. This can include a biochemistry analysis
(glucose and protein level), cell count and differential, culture (bac-
ALTERNATIVE TECHNIQUES terial, fungal, viral, etc.), cytology, and gram stain. Admit the child
to the Intensive Care Unit where they can be appropriately moni-
Consult a Neurosurgeon to evaluate and manage the patient. There tored and observed.
are numerous alternatives to the aspiration of the fluid collection.
These include observation, burr hole drainage, drainage through an
external collecting system, placement of a subdural-to-peritoneal COMPLICATIONS
shunt, and a craniotomy. A craniotomy should be performed in Injury to the superior sagittal sinus or draining veins is best avoided
patients with a symptomatic nonliquefied clot or extensive mem- by inserting the spinal needle 2.5 to 3 cm lateral to the midline. At
brane development precluding aspiration. no time should the trajectory of the needle be in the midline or
Some Physicians prefer to use an intravenous catheter rather than parasagittal in location. Overpenetration of the spinal needle can
the spinal needle. Removal of the metal needle leaves a soft Teflon result in intracerebral hemorrhage. Have an assistant immobilize the
catheter in place that minimizes the risk of injury to the brain or child to prevent them from moving and the needle lacerating the
intracranial vascular structures. The use of an intravenous cath- brain or a blood vessel. Persistent leakage of subdural fluid from
eter set rather than a spinal needle is left to the discretion of the the puncture site can be the result of insufficient fluid aspiration or
Emergency Physician. failure to use a Z-tract. This complication can also be prevented by
tunneling the needle under the scalp prior to penetrating the lat-
ASSESSMENT eral margin of the anterior fontanel (Figure 120-4). This leakage
can usually be controlled with local pressure, head elevation, and
Monitor the child for a change in their level of functioning after rarely by using cotton soaked with tincture of benzoin. Placement
subdural aspiration. Comparison to the child’s baseline neuro- of a single suture at the puncture site will usually control continued
logical examination is essential. It is mandatory to document leakage if less invasive methods fail. Introducing infection into the
timed serial neurological examinations in the patient’s chart. The subdural space has also been reported following a subdural aspira-
clinical examination is age-related. It is often prudent to observe the tion.8 This is best avoided by maintaining strict aseptic technique.
infant in the arms of a parent or healthcare worker while monitor-
ing their level of alertness, facial expression, extraocular movement,
SUMMARY
pupillary response, and limb movement. Obtain daily head cir-
cumference measurements and plot them on a head circumference Acute and chronic subdural fluid collections are common prob-
chart. Note the size and feel of the anterior fontanel. Infection can lems during infancy. They are regarded as posttraumatic lesions in
be prevented with careful attention to aseptic technique. A simple the great majority of cases. Birth trauma is sometimes implicated
CHAPTER 121: Skeletal Traction (Gardner-Wells Tongs) for Cervical Spine Dislocations and Fractures 783
but uncommon. It appears that minor injuries during infancy or Clinical stability of the cervical spine is determined by the ability
even more violent injuries such as infant shaking and/or cranial of the spine under physiological loads to maintain its normal ana-
impact are the inciting events. It is incumbent upon the Emergency tomical relationship so that there is no damage to the spinal cord or
Physician to rule out any possibility of child abuse! Report actual or nerve roots. It has been proposed that spinal instability be separated
suspected abuse to the appropriate state agency as required by law. into mechanical, neurologic, and combined types. Mechanical insta-
Aspiration of extra-axial fluid collections in the symptomatic child bility implies that the injured spine could collapse or distort under
can be completed safely with very little risk to the child. Admission normal physiological stresses. Neurological instability implies a risk
and continued observation are mandatory. of neural injury (spinal cord and/or nerve root) subsequent to the
initial injury.
It is exigent that a thorough clinical and radiological evalu-
ation be completed to determine if the patient has suffered an
unstable cervical spine injury. This begins with a thorough history
Skeletal Traction and physical examination, including a complete neurological exam-
121 (Gardner-Wells Tongs)

ination with particular attention to spinal cord function. Cervical
spine radiography (including possibly CT, MRI, and myelography)
is indicated to evaluate fracture patterns, disk disruption, verte-
for Cervical Spine bral subluxation, vertebral dislocation, vertebral angulation, and
Dislocations and Fractures ligamentous injury. Ligamentous injury evaluation should look for
disruption of each of the major spinal ligaments including the ante-
Eric F. Reichman rior longitudinal ligament, the posterior longitudinal ligament, the
apophyseal ligamentous complex, and the posterior ligamentous
INTRODUCTION complex. Radiological findings that indicate instability include ver-
tebral displacement, interspinous process widening, diastasis of the
Traumatic injuries to the cervical spine result from forces acting on apophyseal joints, widening of the spinal canal, and disruption of
the head and neck. The incidence of spinal cord injury in the United the posterior vertebral body line.
States is approximately 5 per 100,000 population.1 Approximately White and Panjabi proposed a checklist point value system
60% to 80% of spinal cord injuries involve the cervical spine. Motor (Table 121-1).6 A point value is assigned to each of the injuries
vehicle collisions are the most common cause and account for appreciated on the cervical spine radiographs. A specific point
almost half of the cervical spine injuries.2 The remaining cervical value is allotted to the location of injuries, sagittal plane trans-
spine injuries result from falls, sports injuries, violence, penetrating lation or rotation, spinal cord injury, nerve root injury, and the
wounds, and miscellaneous causes. presence of intervertebral widening, rotation, or angulation. The
The primary aims of therapy in the treatment of the patient total point values are then summated. A score of five or more is
with an acute spinal cord injury are to minimize secondary injury suggestive of clinical instability. A discussion of the indications for
to the spinal cord, to realign the spine, to improve neurological the application of the Gardner-Wells tongs includes evidence of
recovery, to maintain spinal stability, and to obtain an early func- cervical spine instability.
tional recovery. This is achieved by decompression of the spinal Crutchfield is credited for introducing skeletal tongs in the man-
cord by restoring the normal sagittal diameter of the spinal canal agement of cervical spinal injuries.3 Gardner-Wells tongs were intro-
or by removing a compressive lesion surgically. This is particu- duced in the early 1970s and utilize the principle of a spring-loaded
larly important in patients who have sustained an incomplete spi- point for cervical traction.4 The spring-loaded pin design and tilt-
nal cord lesion and are found to have a progressing neurological ing of the pins in the direction of pull ensure a firm and prolonged
deficit. Restoring the normal anatomic position also provides for grasp of the skull. These tongs have the capacity to tolerate at least
pain relief. 65 pounds or more of traction. The amount of weight necessary to
Early operative intervention can be performed for the treatment accomplish reduction varies considerably. As a rule, 5 pounds of
of acute cervical fractures to achieve decompression and restore weight should be applied for each vertebral level above the level of
normal alignment. The use of skeletal traction in the acute spi- the fracture or the dislocation. Most authors have recommended
nal cord injury patient remains a very safe and straightforward the use of up to 50 to 60 pounds of weight.7 Others have, on occa-
method of reducing fractures and maintaining the spinal canal in sion, applied weights in excess of 100 pounds to reduce a cervical
anatomical alignment. subluxation.8
Fabricius Hildanus utilized forceps in treating fractures or dislo-
cations of the cervical spine as early as 1646. Crutchfield developed
a pair of self-tightening tongs in 1933 that allowed him to apply
traction to the cranium in a patient with a cervical spine fracture.3 TABLE 121-1 Checklist for the Diagnosis of Clinical Instability in the
These tongs were subsequently modified and have essentially been Lower Cervical Spine6
replaced by the Gardner-Wells tongs.4 Element Point value*
Anterior element destroyed or unable to function 2
ANATOMY AND PATHOPHYSIOLOGY Posterior element destroyed or unable to function 2
Relative sagittal plane translation > 3.5 mm 2
Cervical spinal cord injuries can be divided into upper (occiput to Relative sagittal plane rotation > 11° 2
C3) and lower (C3 to C7) injuries. Numerous classification systems Positive stretch test 2
exist. These are based upon the morphology and the mechanism Spinal cord damage 2
of injury.5 No classification is ideal. However, critical to all cervi- Root damage 1
cal classifications is the determination of stability of a fracture or Abnormal disk narrowing 1
dislocation. Stability of the vertebral column is dependent upon the Dangerous loading anticipated 1
integrity of the vertebra, the intervertebral disk, the facet joints, and Developmentally narrow spinal canal 1
most importantly the ligamentous structures. * Summate the points. A total of five or more points is considered clinically unstable.
The concern for using an excessive amount of traction weight

is overdistraction that can result in a traction type of spinal cord
injury. Begin by applying 5 to 10 pounds of weights.2 Add addi-
tional weight in 3 to 5 pound increments if the initial application
of weights fails to achieve spinal alignment. Obtain lateral cervical
spine radiographs 10 to 15 minutes after each addition of weight
until the cervical spine is realigned. This time is needed after the
application of weight to allow the soft tissues to accommodate. It is
of paramount importance to monitor the patient’s neurological
status during the entire procedure to prevent iatrogenic injury
from overdistraction of an unstable motion segment.
INDICATIONS
Definitive management of the cervical spine injury would include
skeletal traction with Gardner-Wells tongs if clinical instability is
demonstrated or suspected. Other indications for the application of
Gardner-Wells tongs in a neurosurgical setting are cervical spon-
dylosis, anterior cervical diskectomy with graft fusion, and certain FIGURE 121-1. The Gardner-Wells tongs.
cervical infections or neoplasms. Gardner-Wells tongs should only
be applied if the patient requires temporary longitudinal traction.9
Their use requires the patient to remain bedridden, as compared to
halo vest traction. S-shaped hook is permanently attached to the top of the Gardner-
Wells tongs. The string and traction weights are attached to this
hook. Permanently attached to the S-hook is a metal plate that is
CONTRAINDICATIONS engraved with the instructions (Figure 121-3). The instruction
Cervical traction is contraindicated in someone who has sustained plate faces upward and is readable when the Gardner-Wells tongs
posttraumatic disc herniation with spinal cord compression. Hence, are properly applied (Figure 121-4).
a good neurological evaluation and an MRI scan should be per-
formed prior to applying cervical traction. Fractures of the skull PATIENT PREPARATION
and infections overlying the potential pin sites are contraindications
Explain the procedure, its risks, and benefits to the patient and/
to the use of skeletal traction. Other contraindications are diseased
or their representative. Obtain an informed consent to apply the
bone, children less than 3 years of age, atlantooccipital dislocations,
Gardner-Wells tongs. Signed consent may be omitted in cases
and C1-C2 dislocations. Applying Gardner-Wells tongs to some-
where the patient is immobilized or has an altered mental status.
one who survives an atlantooccipital type injury could worsen the
Document the reason for the lack of a signed consent in the medical
patient’s condition and/or neurological deficit.
record. Intravenous sedation may be required in certain cases, at the
discretion of the treating Emergency Physician.
EQUIPMENT Consider the use of some form of deep venous thrombosis pro-
phylaxis since the application of Gardner-Wells tongs requires
• Prep kit
the patient to remain bedridden. The use of sequential compres-
• Povidone iodine or chlorhexidine solution sive devices (SCDs) is simple, easily applied in the Emergency
• 1% or 2% lidocaine with epinephrine Department, and will not cause complications. Consult a Spine
• 5 mL syringe Surgeon or Neurosurgeon before prescribing intravenous, oral, or
subcutaneous anticoagulants.
Identify the anatomic landmarks required to place the Gardner-
• 22 gauge needles Wells tongs. The pins are introduced in the temporal region,
• Gardner-Wells traction tongs 2 to 3 finger-breadths (3 to 4 cm) above the pinna of the ear
• Pulley traction system (Figure 121-5). Place them directly above the external auditory
meatus for neutral distraction, 2 to 3 cm posterior to the external
• Traction weights, 3 to 5 pound increments auditory meatus for flexion distraction, and 2 to 3 cm anterior to
Gardner-Wells tongs are a simple device (Figure 121-1). It con- the external auditory meatus for extension distraction. A helpful
sists of a contoured and rigid stainless steel rod that follows the coro- landmark is the squamosal line where the temporalis muscle inserts
nal contour of the calvarium. Gardner-Wells tongs are also available into the skull. Tong placement should be below this line to allow
in versions composed of graphite or titanium alloy. These versions
are compatible with and facilitate subsequent CT and MRI scans
without producing artifacts. It has a threaded hole on each end that
accommodates the pins. The spring-loaded pins are threaded screws
with sharp cone-shaped points. One of the pins is the calibration pin
(Figure 121-2). It contains an indicator pin that extends and retracts
as the tip penetrates the skull. The pins screw into the rigid rod so
that the points are tilted in the direction of the pull. This results in
the pins pressing into the skull when traction is applied and ensur-
ing that they do not pull out. A squeezing pressure of 30 pounds
is applied to the skull when the pins are properly positioned.3 An FIGURE 121-2. The calibration pin of the Gardner-Wells tongs.
CHAPTER 121: Skeletal Traction (Gardner-Wells Tongs) for Cervical Spine Dislocations and Fractures 785
FIGURE 121-3. Instructions for the use of the Gardner-Wells tongs. FIGURE 121-4. Application of the Gardner-Wells tongs to a human skull.
adequate traction. Another useful landmark is to observe for the pin is observed on one side of the tongs when adequate tension
widest biparietal diameter of the patient’s skull. This usually corre- is applied (Figures 121-2 & 6). Recommendations by the manu-
sponds to the landmark just inferior to the squamosal line. facturer suggest that the pins should be tightened simultaneously
The use of Gardner-Wells tongs does not require shaving the until there is a 1 mm protrusion of the indicator pin beyond the
patient’s hair at the proposed pin sites. Clean the skin and hair of flat surface (Figure 121-6). Tighten the securing nuts to prevent
any dirt and debris. Apply povidone iodine or chlorhexidine solu- the tongs from loosening.
tion to the skin and hair at the proposed pin sites and allow it to dry. The points of the pins will not pull out when properly applied.
Infiltrate 1 mL of lidocaine with epinephrine into each of the two The depth of penetration of the pins is self-limited by a gradual
proposed pin sites. Infiltrate subcutaneously and down to the level lessening of the spring tension and an increase in the surface area
of the periosteum of the skull. of contact between the tips of the pins and the skull. The pressure
exerted by each pin is exactly the same, regardless if one pin has
TECHNIQUE been advanced farther than the other. The curve of the rigid rod
allows the traction loop to find its proper position.
The Gardner-Wells tongs are fast and easy to apply by one person.
The patient should already be supine on the gurney. Stand above
the patient’s head. Assemble the Gardner-Wells tongs by inserting
ASSESSMENT
the pins into the threaded holes. Place the pins of the Gardner- Gently rock the Gardner-Wells tongs to assure that the pins are prop-
Wells tongs over the proposed pin insertion sites. The instruc- erly seated within the outer table of the skull (Figure 121-7). Place
tions on the S-hook must be facing upward and readable. If the patient in the reverse Trendelenburg position (Figure 121-8).
not, the tongs are upside down. Apply the Gardner-Wells tongs Tie a rope to the S-shaped hook. Feed the other end of the rope
so the pins are symmetrically located on each side of the head. through a pulley at the head of the bed and apply weights. Proper
Screw in the pins equally and symmetrically on both sides of the attention to the head position and the axis of distraction are
tongs (Figure 121-5B). Note that a small spring-loaded indicator important elements in achieving closed reduction. Initially apply
FIGURE 121-5. Application of the Gardner-Wells tongs. A. It

can be positioned and applied without shaving the patient’s
entire head. B. Schematic demonstrating the pin position into
the skull.
FIGURE 121-8. The patient is placed in reverse Trendelenburg and traction is

applied.
FIGURE 121-6. The calibration pin indicator is at 1 mm when the pins are prop-
erly seated in the skull.
COMPLICATIONS
a 10-pound weight for the head.6 Obtain a lateral cervical spine
Skull penetration from placing the pins too low in the temporal
radiograph 10 to 15 minutes after the application of the weight. Add
region where the skull is thinnest can lead to dural tears, epidural
5 pound weights, one at a time, for each vertebral segment above
hematomas, and possibly intracranial injury. Pins located in the
the level of the injury. Obtain a lateral cervical spine radiograph
temporal fossa pierce the temporalis muscle and can cause pain-
10 to 15 minutes after each 5 pound weight is added. Continue to
ful mastication. Overdistraction can lead to iatrogenic injury. This
increase the traction weight in 3 to 5 pound increments. Obtain
is best prevented by the initial use of a minimal amount of weight
repeat lateral cervical spine radiographs 10 to 15 minutes after each
necessary to distract or reduce the cervical spine injury. Pin site
additional weight is added. Stop adding weights when the radio-
infections are prevented by close attention to surgical technique and
graphs demonstrate appropriate alignment of the cervical spine.
daily hygiene. Other complications reported include intracranial
Careful assessment and documentation of the patient’s neuro-
aneurysms, CSF leaks, and osteomyelitis of the skull.
logical function is mandatory throughout the application of
weights and skeletal traction.
SUMMARY
AFTERCARE The application of skeletal traction in the form of Gardner-Wells
Clean the pin sites every shift with povidone iodine or hydrogen tongs is a safe, simple, and quick procedure when there is evidence
peroxide solution followed by iodine ointment. Obtain daily cer- of clinical or radiological cervical spine instability. It requires only
vical spine radiographs to follow the spinal alignment. Reduce the local anesthesia and antiseptic preparation of the skin. Careful atten-
weight by 50% to maintain the alignment if spinal realignment is tion to the application technique utilizing the suggested anatomical
obtained with traction. landmarks will reduce the chances of complications. Monitoring
The points of the pins tend to penetrate the outer table of the realignment and/or reduction procedures with frequent cervical
skull due to the continuous pressure exerted by the springs on a very spine radiographs is prudent. Gardner-Wells tongs are not recom-
small area. Readjust the pins in 24 hours, again setting the indicator mended as a long-term immobilization technique. Definitive man-
pin so that it protrudes approximately 1 mm from the flat surface. agement of cervical spine instability requires surgical stabilization
Further adjustment of the Gardner-Wells tongs is not necessary and/or halo bracing.
and is not recommended as it can result in erosion of the pin point
through the skull.
Edrophonium
122 (Tensilon) Testing
Eric F. Reichman
INTRODUCTION
Myasthenia gravis is an autoimmune disorder that occurs when
polyclonal antibodies bind to a significant number of postsynap-
tic acetylcholine receptors at the neuromuscular junction leading
to inadequate neuromuscular transmission.1–3 It most commonly
affects 10- to 30-year-old females and 70- to 90-year-old males.
Multiple tests are available to diagnose myasthenia gravis.3–7
These include the use of muscle biopsies, curare, edrophonium
chloride (Tensilon), electromyography, ice packs, neostigmine,
nerve stimulation, and serologic testing. The edrophonium test
FIGURE 121-7. The Gardner-Wells tongs have been applied. The arms are is the most commonly used diagnostic test for myasthenia gra-
grasped and gently twisted to confirm proper seating of the pins. vis.8–10 Many of these techniques are seldom used and not feasible
CHAPTER 122: Edrophonium (Tensilon) Testing 787
to perform in the Emergency Department. For these reasons, only equipment, Advanced Cardiac Life Support medications, and
the edrophonium test and the ice pack test will be described in additional support personnel are not immediately available.
this chapter. Edrophonium should not be administered if the Physician is not
properly trained in airway management and rescue techniques.
ANATOMY AND PATHOPHYSIOLOGY Use caution when administering edrophonium if the patient’s
medications can cause atrioventricular node blocking or slowing
Acetylcholine is a neurotransmitter of the neuromuscular junction of transmission (e.g., beta-blockers, calcium channel blockers,
that is released by the presynaptic nerve terminals when stimu- and digoxin). These can make the edrophonium associated dys-
lated.4,11 An electrical potential is produced at the myoneural end rhythmias more pronounced.
plate when sufficient numbers of the postsynaptic receptors at the Edrophonium testing is relatively contraindicated in patients
neuromuscular junction are bound by the released acetylcholine. with known myasthenia gravis that are taking oral pyridostigmine
This electric potential then propagates and ultimately leads to mus- (Mestinon) and present with increasing weakness. The weakness
cle contraction. Simultaneously, acetylcholinesterase rapidly termi- may be due to insufficient drug treatment (myasthenic crisis) or too
nates the neurotransmission by metabolizing the acetylcholine in much drug treatment (cholinergic crisis).3 The terminology regard-
the synaptic cleft of the neuromuscular junction. ing these types of crises is controversial and beyond the scope of
Myasthenia gravis is an autoimmune disorder that occurs when this chapter.19,20 The patient will improve with edrophonium testing
polyclonal antibodies bind to postsynaptic acetylcholine receptors if the etiology of the weakness is a myasthenic crisis. The symptoms
at the neuromuscular junction.2–4,11 This leads to inactivation of the will worsen with edrophonium testing if the etiology of the weak-
receptors and inadequate neuromuscular transmission. Myasthenia ness is a cholinergic crisis. Consult a Neurologist, for these reasons,
gravis is characterized clinically by muscle weakness that develops prior to performing an edrophonium test on a patient with myas-
after repetitive muscle contraction. thenia gravis who is already taking oral anticholinergic medications.
Patients are divided into two clinical groups. The first includes A patient with known myasthenia gravis complaining of respi-
patients who present with ocular complaints. Patients most com- ratory distress should be assessed and managed similar to any
monly present with some degree of ocular muscle involvement. other patient with respiratory compromise. An edrophonium test
Diplopia is the most common patient complaint. Ptosis is the most is contraindicated if it is being used to improve a patient’s respira-
visible sign noted on the physical examination. Diplopia with dis- tory distress. A cholinergic crisis treated with edrophonium can fur-
conjugate gaze can be elicited by having the patient maintain a ver- ther compromise the patient’s respiratory status, possible leading to
tical gaze for approximately 3 minutes. Ptosis can also be made to a respiratory arrest.
worsen by having the patient maintain an upward gaze for the same The use of edrophonium is contraindicated in pregnancy. It may
duration of time. These patients may or may not have associated induce the patient into preterm labor. A neostigmine test is safer if
weakness of the pharyngeal and facial muscles that present with the testing is required. Testing should be performed only after consulta-
complaints of dysarthria and dysphagia. These symptoms can often tion with an Obstetrician and a Neurologist.
be elicited by having the patient count backward from 100. Edrophonium testing is relatively contraindicated in patients with
The second group includes patients with proximal muscle weak- asthma, bronchospastic disease, cardiac dysrhythmias, or if a group
ness. Weakness of the limbs usually involves the proximal muscles of muscles that are weak are not easily observable. Edrophonium
and may be asymmetric. Weakness of the muscles can be elicited by testing should be deferred in favor of neurological consultation and
having the patient perform repetitive exercises involving the muscle consideration of other testing methods.
groups in question. Involvement of respiratory and pharyngeal
muscles should be taken very seriously as it may lead to respira-
tory failure or aspiration.2,3,12–15
EQUIPMENT
Edrophonium chloride is a short-acting acetylcholinesterase • 10 mg edrophonium chloride (Tensilon)
inhibitor (anticholinesterase) used in the diagnosis of myasthenia • Tuberculin syringe
gravis.3,11 Its onset of action is rapid (within 1 to 2 minutes) and the
duration of action is brief (2 to 5 minutes). These characteristics • 10 mL syringe containing 9 mL of sterile normal saline
make it ideal to use in the Emergency Department. Edrophonium • Intravenous access with normal saline solution attached to the
given intravenously to patients with myasthenia gravis briefly inhib- IV catheter
its the actions of the acetylcholinesterase, thus prolonging the inter- • Cardiac monitor
action between the acetylcholine and the postsynaptic receptors. • Pulse oximeter
This results in a temporary but noticeable improvement in muscle
contraction.1,14 Edrophonium can rapidly, and temporarily, reverse • Noninvasive blood pressure monitor
the signs and symptoms of myasthenia gravis. • Supplemental nasal oxygen
• Resuscitative equipment and medications
INDICATIONS • Digital camera
Testing is indicated when the patient’s condition is suggestive of • Ice pack, ice cubes, or instant cold packs
myasthenia gravis.4,5 Edrophonium chloride can be used for patients
presenting with diplopia, facial muscle weakness, appendicular PATIENT PREPARATION
muscle weakness, or ptosis suggestive of myasthenia gravis. The ice
pack test is reserved to evaluate patients presenting with ptosis.16–18 Explain the risks, benefits, and potential complications to the patient
and/or their representative. Obtain a signed consent for the proce-
dure. Place the patient sitting upright or supine in a bed. Obtain
CONTRAINDICATIONS
intravenous access. Apply supplemental oxygen, pulse oximetry,
There is the possibility of worsening the patient’s symp- cardiac monitoring, and noninvasive blood pressure monitoring.
toms, causing respiratory distress or arrest, and cardiac dys- Resuscitative equipment and medication must be immediately
rhythmias. Do not administer edrophonium if resuscitative available if required.
Identify a group of muscles that can easily be observed and moni- patients with ptosis actually relieved the symptoms and signs of
tored for improvement of function. If possible, the muscle group ocular myasthenia gravis.16,17 This test is quick, simple, inexpensive,
to be tested should be fatigued. For example, have the patient look and easy to perform in the Emergency Department. It has none of
upward for 3 minutes to accentuate ptosis. Muscle groups of the the potential complications associated with the intravenous admin-
extremities can be exercised for several minutes until the patient istration of edrophonium chloride. There are no contraindications
experiences fatigue. Take a picture, if a camera is available, of the to performing in this test.
muscle group to be observed after it has been fatigued. This is the Place a bag of ice directly over the eye with ptosis and/or diplopia
“before” photograph. for 2 minutes or until the patient is no longer able to tolerate the
Prepare the edrophonium chloride. It is essential that the edro- cold. An alternative to an ice pack is ice cubes placed in a glove or
phonium concentration be accurate regardless of who (i.e., instant cold packs that are activated by compression. Remove the ice
Emergency Physician, Nurse, or Pharmacist) prepares the solu- pack from the eye and observe the patient for any improvement in
tion. It is supplied in a concentration of 10 mg/mL. Using sterile the ptosis or diplopia. A clear improvement of the ptosis indicates
technique, transfer 10 mg (1 mL of 10 mg/mL) of edrophonium into a positive test. This test may be limited by the patient’s intolerance
a syringe containing 9 mL of sterile normal saline. The resulting to the ice pack.
solution will contain 1 mg of edrophonium chloride per mL of fluid.
Verify the concentration of the edrophonium solution prior to ASSESSMENT
use, especially if it was made by someone else.
These tests can be positive and confirm the diagnosis of myasthe-
nia gravis. Objective findings of improved muscle function must
TECHNIQUE be observed to identify the test as positive. It is very common
Administer the edrophonium soon after the weakened muscle to observe fasciculations of the facial muscles or tongue after the
is identified, carefully noted, and fatigued. Ideally, one person intravenous administration of edrophonium chloride. Muscle fas-
should administer the medication while another person observes ciculations are not considered a positive test. The patient having
the patient for the effects of the edrophonium chloride. It may be the subjective feeling of “feeling better” without objective evidence
administered in increasing doses up to a total of 10 mg. Inject of improved muscle function is also not considered a positive test.
1 mg (1 mL) of edrophonium chloride intravenously followed by a Document improvement by taking a photograph. This is the “after”
saline flush. Physical improvement in the observed muscle group photograph. Place both the “before” and “after” photographs in the
should be seen within 30 seconds to 2 minutes if the edrophonium patient’s medical record.
is effective. Muscle improvements will revert to their original state
after 2 to 3 minutes. The test is concluded if there is a positive AFTERCARE
response to the edrophonium in the observed muscle group.
Inject 3 mg (3 mL) of edrophonium chloride intravenously fol- The patient may be safely discharged if they are ambulatory
lowed by a saline flush if there is no improvement after the first and without respiratory distress. All patients with suspected or
dose. The test is concluded if improvement is seen in the muscle proven myasthenia gravis should be referred to their Primary
group. Inject the remaining 6 mg (6 mL) of the edrophonium chlo- Care Physician and a Neurologist for further evaluation and
ride intravenously followed by a saline flush if there is no response management.
within 2 to 3 minutes after the second dose. The test is consid-
ered negative and concluded if there is no response to the third COMPLICATIONS
dose of edrophonium (total of 10 mg). A negative test argues Muscarinic side effects can be seen due to the prolonged choliner-
against myasthenia gravis, but does not completely exclude the gic stimulation in patients hypersensitive to edrophonium chloride.
diagnosis.13,15 These effects include increased salivation, increased lacrimation,
Some Neurologists prefer to give the entire 10 mg (10 mL) dose and miosis. Some patients may experience bradycardia, junctional
of edrophonium chloride as a single intravenous bolus and observe rhythms, and ventricular dysrhythmias due to the increased vagal
the muscle group for improvement. This has the potential to cause effects of the prolonged acetylcholine stimulation of the heart.11
significant bradycardia and is not recommended. Older patients may experience a resultant postural syncope. These
The total dose of edrophonium to administer to children is effects are usually transient and self-limited. Intravenous atro-
0.15 mg/kg, not to exceed 10 mg of edrophonium.5 An initial dose pine in low doses (0.5 mg) is effective to counteract any of the
of 1 mg is appropriate for children. Administer subsequent doses of above symptomatology.
1 to 2 mg to a maximum of 0.15 mg/kg or 10 mg of edrophonium. There are no complications associated with the proper use of the
ice pack test. Leaving the ice pack on the eyelids too long can result
ALTERNATIVE TECHNIQUE in a frostbite injury.
ICE PACK TEST FOR OCULAR MYASTHENIA GRAVIS SUMMARY

The ice pack test can be used to diagnose patients with ocular signs Myasthenia gravis is an autoimmune disease that results in muscle
of myasthenia gravis.16–18 This test is reserved for the patient present- weakness. The edrophonium test allows for a rapid, simple, and safe
ing with ptosis and/or diplopia suggestive of myasthenia gravis. The way to diagnose myasthenia gravis in the Emergency Department.
basis of this test is the finding that patients with myasthenia gravis The ice pack test for ocular myasthenia gravis offers a simple alter-
have symptoms that worsen in warm weather and that improve in native to diagnose myasthenia gravis. Obtain prompt Neurological
cold weather. Based on this clinical observation, studies have shown consultation for all patients presenting with signs and symptoms
that placement of a bag of ice directly over the eyes of myasthenia suggestive of myasthenia gravis.
SECTION
Anesthesia and Analgesia 9

Local anesthetic agents function by reversibly binding to
Local Anesthesia membrane-based sodium channels, thereby inhibiting the initial
123 Michael A. Schindlbeck
sodium influx that results upon the stimulation of an idle neu-
ron.4–9 If a significant number of these channels are blocked, the
critical threshold of sodium influx required for the voltage-gated
sodium channel opening cannot be met, widespread membrane
INTRODUCTION depolarization cannot occur and nerve impulses will not be trans-
mitted. Careful examination of neuronal cells reveals that the
Modern medicine can trace the use of local anesthetics back to the actual binding sites for local anesthetic agents are located on the
year 1884, when the Austrian Physician Karl Koller first used topical internal surfaces of their cellular membranes. Therefore, in order
cocaine to assist with an ophthalmological operation.1 The follow- to function, the local anesthetic agent must first diffuse across the
ing year, the premier Surgeon William Halstead first used injected bi-lipid cellular membrane as an uncharged lipophilic compound.
cocaine to generate the intentional blockade of nerve transmission.2 Once intracellular, the local anesthetic agent is converted to its
Unfortunately for Halsted, his experiments with cocaine soon led to active cationic state, terminating signal transduction and subse-
a concurrent dependency.3 The emerging illicit market for this com- quently producing tissue anesthesia.13
pound soon prompted the search for a less toxic agent.3 Procaine, All local anesthetic agents generally share the same molecular
more commonly known by its trade name Novocain, was the first framework. They contain a lipophilic aromatic group linked to an
synthetic local anesthetic. It is a benzoic acid ester derivative devel- ionizable group, usually a tertiary amine, via an intermediate link-
oped by the German chemist Alfred Einhorn in 1904. Although it age.4,7 This intermediate linkage comes in two types, namely an
had less drawbacks than its cocaine predecessor, it was far from the amino-amide or an amino-ester bond. This property is used to clas-
ideal agent. Lidocaine was the first amide local anesthetic agent and sify the local anesthetics as either “amides” or “esters.” Beyond this
was first produced in 1945. The market for more effective agents basic dichotomy, further variations on this generalized structure
continued to blossom. Over the following decades, no less than generate the altered pharmacokinetics that impart the unique quali-
20 additional agents were developed for use as a local anesthetic ties to the individual local anesthetic agents.7
agent, each possessing unique pharmacokinetic properties to tai- The potency of a given local anesthetic agent is directly propor-
lor its utility to specific clinical applications. They are all synthetic tional to its lipid solubility.9,10 More lipophilic agents tend to be more
derivatives of cocaine. potent, as the more soluble agent will readily diffuse across the cel-
Parallel to this proliferation in pharmacologic development, lular membrane despite a lower concentration of the extraneuronal
the clinical utilization of these agents has become widespread anesthetic. Therefore, a lower quantity of local anesthetic is needed
throughout all medical specialties. The daily practice of Emergency to elicit the same endpoint response.11 However, variable potencies
Medicine presents multiple scenarios that necessitate their use. The are rarely of significance to the Emergency Physician. The available
Emergency Physician must maintain a familiarity with the local preparations utilize concentrations of the local anesthetic specifi-
anesthetic agents available and their unique characteristics, have an cally formulated to correct for this variable potency.
expertise in their delivery, be knowledgeable of the potential side The primary determinant of a local anesthetic’s onset of action is
effects, and know how to avoid and treat adverse reactions to ensure its pKa.12 The pKa is the pH at which a given drug exists in equal
the safest and most optimal pain relief. proportions as ionized and unionized molecules. The unionized
molecules more readily cross the nerve cell membrane. A por-
PHARMACOLOGY AND PATHOPHYSIOLOGY tion of the molecule becomes charged once inside the neuron. It
At a cellular level, nerve cell function and signal conduction are is this ionized portion that binds most completely to receptor pro-
dependent upon a resting negative intracellular electrical potential teins within the sodium channels.4,10 Commercially available local
(approximately −70 mV) as compared to the surrounding extra- anesthetic agents are weak bases with pKa’s of 7.6 to 8.9.4 Agents
cellular environment. This polarity results from the abundance with a lower pKa at physiologic pH (7.4) will have relatively more
of sodium (Na+) cations found within the extracellular space. uncharged molecules free to cross the nerve cell membrane (i.e.,
Membrane-based sodium–potassium (Na+/K+) pumps establish this faster onset) than agents with a higher pKa.6,10 Low tissue pH, such
sodium gradient. Adjacent voltage-gated sodium channels maintain as seen in abscess cavities, results in so little local anesthetic in the
the gradient by inhibiting the concentration mediated and electri- uncharged form that the agent is ineffective.6 This phenomenon
cally driven sodium influx that would invariably result. Upon the explains why local anesthetics function poorly in acidic environ-
stimulation of an idle neuron, a small intracellular sodium influx ments (e.g., abscess cavities) as a greater percentage of the agent
ensues. This sodium influx results in a slight depolarization of the is secondarily converted to its ionized state within the extracellu-
resting membrane potential. When a critical threshold of sodium lar environment. It also explains why the addition of a buffering
influx is met, the voltage-gated sodium channels reflexively open. agent such as sodium bicarbonate increases the pH of the injected
This results in a massive sodium ion influx and widespread mem- local anesthetic solution, increasing the ratio of nonionized local
brane depolarization.4–6 Impulse transmission proceeds as this anesthetic agent present, and enhancing the rapidity of anesthe-
membrane depolarization is propagated down the entire length of sia onset. Increasing the total quantity of local anesthetic injected,
the nerve fiber.7 whether by manipulating its concentration or increasing the overall
789
790 SECTION 9: Anesthesia and Analgesia
volume, will hasten the onset of activity by augmenting the diffu- CONTRAINDICATIONS
sion gradient and more aggressively driving the local anesthetic
agent intracellularly.7,8 Conversely, once successfully intracellular, The primary and most important contraindication to the use of
local anesthetic agents with higher intrinsic pKa’s generate more a local anesthetic agent is a history of an allergic reaction. Less
effective sodium channel blockade via their tendency to persist in than 1% of all adverse reactions from local anesthetic agents are
an ionized and functionally active state.8,13 The rate at which a local due to true IgE-mediated allergic phenomena.18 Ester agents are
anesthetic agent diffuses through surrounding non-neuronal tis- responsible for the majority of such cases, whereas allergic reactions
sues also appears to be an important variable.5,8 to amide anesthetics are exceptionally rare.7,15,19–21 The physiology
A local anesthetic agent’s duration of activity is typically pro- behind this finding is rooted in the divergent metabolism of the two
portional to the overall degree of protein binding.6–8,10 Those that classes of local anesthetic agents.
possess a higher affinity for the target receptor are less likely to be The ester-type local anesthetic agents are rapidly metabolized
dislodged and thus exhibit a longer duration of action.7,10 All of the within the bloodstream by serum pseudocholinesterase, explain-
available local anesthetic agents produce a degree of localized vaso- ing their very short plasma half-lives. The secondary metabolites
dilation. This serves to increase regional blood flow, promote sys- are derivatives of the organic compound PABA. They exhibit aller-
temic absorption of extracellular fluid, and thusly decrease the total genic properties and are the agents responsible for the allergic
duration of activity.5,7,10 Therefore, counteracting this phenomenon response. This property makes ester-type local anesthetic agents
by compounding a vasoconstrictor with the local anesthetic agent (e.g., cocaine, procaine, and tetracaine) a less commonly used
represents another practical way to increase the duration of action option in daily practice. Amide-type local anesthetic agents, how-
of a particular agent.4,14 This is accomplished clinically via the addi- ever, are metabolized in the liver into nonallergenic byproducts
tion of small doses of epinephrine. via cytochrome P-450 mediated pathways. Allergic reactions to
The two classes of local anesthetic agents undergo metabolism the amide-type local anesthetic agents are very rare but do occur.
via different mechanisms.5,7,15–17 Esters are metabolized rapidly Methylparaben is a close analog of PABA and a preservative com-
by plasma pseudocholinesterase to the major metabolite para- monly used in multidose preparations of amide agents. It may
aminobenzoic acid or PABA.5,7,15 PABA is allergenic and likely account for the rare occurrence of an apparent allergic reaction to
responsible for the infrequent allergic reactions to ester agents.5,7,16 the amide class of local anesthetic agents.7,15,16,21–24
Patients with atypical pseudocholinesterase are at increased risk An agent from the opposite class may be chosen if a history of
for systemic toxicity from ester anesthetic agents.16,17 Amide anes- a prior allergic reaction to a particular agent is obtained from a
thetic agents are metabolized more slowly by the liver to a variety patient requiring local anesthesia. There is no true cross reactivity
of metabolites that are unrelated to PABA. Patients with impaired between the esters and the amides.7 A preservative-free prepara-
liver function are at increased risk for systemic toxicity from amide tion should be chosen, however, to avoid possible reaction from
anesthetic agents.16,17 this source.22 Solutions intended for single use or intravenous
use tend to be free of preservatives. Intravenous formulations of
INDICATIONS lidocaine can be found in any standard Emergency Department
“crash cart.”
Local anesthetic agents are used in the Emergency Department for The size of the anesthetic field required for a given procedure can
local infiltration, regional nerve blockade (Chapter 126), periph- further dictate the utility of infiltrative anesthesia. Larger fields, by
eral nerve blockade, and topical application (Chapter 124). General default, will require the injection of larger quantities of local anes-
principles concerning their use and local infiltration will be dis- thetic solution. Do not exceed the maximum safe dose of a local
cussed in this chapter. A complete review of specific techniques and anesthetic agent (Table 123-1). Consider an alternative anesthetic
procedures are available elsewhere in this text. technique (e.g., regional nerve blockade, procedural sedation) if
Localized injected anesthesia, or infiltrative anesthesia, repre- infiltrative anesthesia requires potentially toxic local anesthetic
sents the most common use of local anesthetic agents within the doses. An alternative is to dilute the local anesthetic solution in half
Emergency Department. It is generally a safe procedure that is using sterile normal saline. This diluted local anesthetic solution
technically easy to perform and well tolerated by the patient. It may not provide adequate anesthesia.
can be readily used for the majority of surgical procedures that are Certain procedures necessitate meticulous tissue reapproxima-
routinely performed by the Emergency Physician. This includes tion (e.g., facial lacerations). The injection of local anesthetic solu-
wound repair, foreign body removal, cutaneous abscess drainage, tion, especially in higher volumes, can distort the surrounding tissue
intravascular catheter placement, and hematoma blocks to name and diminish the probability for an optimal outcome. Consider an
a few. alternative anesthetic technique in these situations.
TABLE 123-1 Properties and Dosages for Injectable Local Anesthetic Agents
Local Relative Duration
anesthetic Relative onset of of action Maximum dose with epinephrine Maximum dose without epinephrine
class Anesthetic agent potency action (min)* (mg/kg) (mg) (mg/kg) (mg)
Ester Procaine (Novocaine) 1 Slow 60–90 9.0 500 7.0 600
Ester Chloroprocaine 3 Rapid 15–90 11.0 800 14.0 1000
(Nesacaine)
Ester Tetracaine (Pontocaine) 8 Slow 120–480 1.5 100 2.5 200
Amide Lidocaine (Xylocaine) 2 Rapid 90–200 7.0 300 4.5 500
Amide Mepivacaine (Carbocaine) 2 Rapid 120–240 8.0 300 7.0 500
Amide Bupivacaine (Marcaine) 8 Moderate 180–600 3.0 175 2.0 225
Amide Etidocaine (Duranest) 8 Fast 120–240 0.4 300 8.0 400
* Longer times represent the addition of epinephrine to the local anesthetic solution.
CHAPTER 123: Local Anesthesia 791
Topical anesthetic agents are contraindicated on mucous mem- PATIENT PREPARATION

branes, the eye, denuded skin, or burned skin as they are rapidly
absorbed through these tissues. Such absorption can produce severe Discuss the procedure with the patient and/or their representa-
systemic toxicity and death. Eye contact can produce corneal injury. tive. The most common adverse reaction to a local anesthetic
Topical agents containing cocaine and epinephrine are contraindi- agent is a vasovagal reaction.12 This complication is more likely
cated in regions of end artery flow because they can result in intense when patients are anesthetized while sitting in an upright posi-
vasoconstriction.25 tion (e.g., dental procedures). The Emergency Physician must
Infiltration of a wound with 1% diphenhydramine is clini- take precautions to alleviate secondary injury to the patient.
cally effective as an alternative agent in the rare circumstance that Whenever possible, place the patient lying in a bed with side
a patient has a true IgE-mediated allergy to the local anesthetic rails up to prevent injury no matter how minor the proce-
agents.26 Diphenhydramine is more painful to inject than the local dure. Friends and family members have been reported to syn-
anesthetic agents. It was less effective at attaining adequate anesthe- copize upon witnessing injections. Therefore, they should either
sia when compared to local anesthetic agents. Reserve the use of be asked to leave the room prior to starting or kept in a sitting
diphenhydramine for the rare instance of a patient with an actual position throughout the duration of the procedure. Sedation can
local anesthetic allergy.26 Dilute the 5% parenteral formulation of minimize the response to treatment while maintaining stable vital
diphenhydramine to 1% (add 1 mL of diphenhydramine to 4 mL of signs and spontaneous respirations when the patient exhibits con-
normal saline) to make a solution for local infiltration. siderable anxiety. Refer to Chapter 129 regarding the details of
procedural sedation.
EQUIPMENT Prepare the area prior to injecting local anesthetic solution. Clean
the skin of any dirt and debris. Apply an alcohol swab, povidone
• Syringes, 1 mL to 20 mL sizes iodine, or chlorhexidine to the skin over the injection site and the
• Needles, various sizes and lengths surrounding area and allow it to dry. Apply sterile drapes, if appli-
cable, to delineate a sterile field.
• Local anesthetic solution, with and without epinephrine
• Alcohol swabs, povidone iodine, or chlorhexidine
• Gauze squares LOCAL INFILTRATION AND
• 8.4% sodium bicarbonate solution (1 meq/mL) PERIPHERAL NERVE BLOCKADE
• Gloves
LOCAL ANESTHETIC DOSING
Infiltration anesthesia refers to the injection of a local anesthetic
• 5% parenteral diphenhydramine solution
solution directly into the subcutaneous tissues about to be manipu-
Universal precautions are of utmost importance in perform- lated. The first step to be considered is the selection of the proper
ing any procedure using a local anesthetic agent. It is vital to anesthetic. Barring a history of an allergic reaction to a given class of
wear gloves when administering topical anesthetic agents to local anesthetic agents, the amide anesthetics lidocaine (Xylocaine)
protect the fingers, to prevent absorption of the local anesthetic and bupivacaine (Marcaine) are the most common agents employed
agent through the fingers of the healthcare worker, and to prevent within the Emergency Department. The choice between these
introduction of bacteria into the wound. Wear a mask with a face agents should be tailored to the individual patient and situation.
shield or goggles to prevent accidental mucous membrane expo- Lidocaine exhibits a quicker onset of activity, whereas bupivacaine
sure if the injectable local anesthetic solution shoots out of the exhibits a longer duration of action (Table 123-1). Lidocaine pos-
wound margins. sesses a wider margin of safety, with larger doses required to illicit
One of the most important determinants of pain response dur- a toxic response. In amide allergic patients, the ester agent procaine
ing administration of a local anesthetic agent is needle size. Use (Novocain) is a reasonable alternative.
a 25 or 27 gauge needle for infiltration to minimize pain. A long It is important to keep in mind the maximal recommended
needle allows for the infiltration of a larger region with a single doses for the chosen local anesthetic agent to avoid systemic tox-
needle pass and decreases the number of times tissues must be icity (Table 123-1). The disadvantage of local infiltration is that
punctured. A 2.0 inch, 27 gauge needle is typically an optimal a large amount of local anesthetic must be used for a small area.
choice. The needle should not be inserted more than two-thirds Extensive wounds may require toxic doses of local anesthetic agents.
of its length to prevent inadvertent breakage within the tissues.12 A lower concentration or the addition of epinephrine will allow a
Another important factor is the rate of infiltration. A slow steady larger volume of local anesthetic to be used. Local infiltration may
method minimizes the pain response. distort the wound edges and complicate the repair.
Many Emergency Departments have a small local anesthesia The maximal recommended dose of a local anesthetic agent is the
tray or basket containing the necessary equipment for provid- same for local infiltration or regional nerve blockade. It is impor-
ing local anesthesia. Such a kit may include the following items. tant to properly calculate the amount of local anesthetic agent
Needles in sizes from 18 to 30 gauge, 1 to 2 cm long and 4 cm administered to a patient. Local anesthetic solutions are supplied
long. Syringes ranging from 1 mL (tuberculin) through 10 mL. with the concentration denoted as a percentage (e.g., 1% lidocaine,
Cotton-tipped applicators for the application of topical agents. 0.25% bupivacaine, 4% cocaine). This percentage must be converted
Local anesthetic agents such as 1% and 2% lidocaine, 0.25% and to mg/mL. A 1% local anesthetic solution is prepared by dissolving
0.5% mepivacaine and bupivacaine, and the same agents com- 1 g of the local anesthetic agent in 100 mL of diluent. This results
bined with 1:200,000 epinephrine. Sodium bicarbonate may be in a concentration of 10 mg/mL (1 g/100 mL = 1000 mg/100 mL =
used for buffering the local anesthetic agent. Alcohol swabs, povi- 10 mg/mL). A simple method to calculate the strength of a local
done iodine swabs or solution, or chlorhexidine are required for anesthetic solution is to move the decimal point one place to the
cleansing the skin. Nonsterile and sterile examination gloves are right to convert from a percentage to a concentration in mg/mL
required for the infiltration of the local anesthetic agent and per- (e.g., 0.25% = 2.5 mg/mL, 2% = 20 mg/mL, 4% = 40 mg/mL).
forming the procedure. This value must be multiplied by the volume to be administered
to determine the total amount (in mg) of local anesthetic agent

administered. This value must be compared to the maximal
allowable dose (Table 123-1) to ensure it is not a toxic dose.
EPINEPHRINE CONTAINING AGENTS

Epinephrine can be added to a local anesthetic solution to prolong
its duration of action, to assist with hemostasis by local vasocon-
striction, and to slow the absorption of the local anesthetic agent.
This allows for larger quantities of local anesthetic solution to be
injected without the concern for systemic toxicity. Local anesthetic
agents are generally compounded with epinephrine in a 1:100,000
or 1:200,000 solution and usually come packaged as such by the
manufacturer.
If a compounded solution is not available, one can be readily
formulated. Begin by obtaining 1:1000 epinephrine that is usu-
ally administered to patients for severe allergic reactions or bron-
chospasm. This solution of 1:1000 contains 1 g of epinephrine per
1000 mL or 1 mg/mL of epinephrine. Diluting this solution by a FIGURE 123-1. The needle is inserted through the wound edge to inject local
factor of 100 will result in the desired 1:100,000 concentration. Place anesthetic solution.
0.1 mL of 1:1000 epinephrine into 10 mL of local anesthetic solution
to make a dilution of 1:100,000 (or 0.010 mg/mL). Place 0.1 mL of
1:1000 epinephrine into 20 mL (or 0.05 mL in 10 mL) of local anes- the patient from the inadvertent injection into an intravascular
thetic solution to make a dilution of 1:200,000 (or 0.005 mg/mL). space. When anesthetizing an open wound, make every attempt to
infiltrate through the exposed wound edges rather than puncturing
REDUCING THE PAIN OF INFILTRATION through the adjacent intact skin (Figure 123-1).34 This will provide
a much less painful experience for the patient. Infiltrate grossly con-
Local anesthetic agents are weak bases. They are packaged, however, taminated wounds percutaneously through clean and intact skin to
as hydrochloride salts with a pH of 4 to 6 to increase their solubil- decrease the risk of spreading the contamination and to decrease the
ity and shelf life. This acid pH causes much of the pain associated risk of an infection related to the infiltration. Also limit the num-
with the injection of local anesthetic agents.4,6 Because epinephrine ber of needle punctures through uninjured skin in contaminated
is unstable at a physiologic pH, commercial solutions contain- wounds. The application of gentle pressure to the injection site prior
ing epinephrine are generally formulated with similarly acidic pH to the injection, such as pressing a sterile cotton-tipped applicator
values. Buffering lidocaine, mepivacaine, or bupivacaine with against the skin, limits the pain associated with childhood vaccina-
sodium bicarbonate has been shown to reduce the pain of injections.35 Dentists have been using similar techniques for many years
tion significantly.25,27,28 Raising the pH of the local anesthetic agent to perform dental blocks. The use of this technique in the Emergency
increases the percentage of local anesthetic molecules in the non- Department is limited by the fact that infiltrations into previously
ionized diffusible state.27 This may allow nearly instantaneous pen- inflamed tissue, and thus any kind of additional stimulation, may
etration of the nerve cell membrane by the anesthetic molecules and simply expose the patient to unwarranted additional pain. A slower
block or reduce the pain of infiltration.27,29,30 Raising the pH also rate of local anesthetic solution injection is associated with less pain.
contributes to decreasing the pain of the injection. Buffering local Insert the needle into an open wound at its apex (Figure 123-2).
anesthetic agents does not appear to affect the duration or degree of Tunnel the needle its entire length down the wound margin. Inject
anesthesia. There does not appear to be an increase in the degree of the local anesthetic solution while slowly withdrawing the needle.
anesthesia, the serum levels of the local anesthetic agent, or in toxic-
ity of buffered anesthetic agents.
Caution must be exercised when buffering highly lipophilic
and less soluble anesthetic agents, like bupivacaine, because pre-
cipitation can occur.4 To buffer a local anesthetic agent, use the pre-
packaged 50 mL ampules of 8.4% (1 meq/mL) sodium bicarbonate
found in any “crash cart.” Add 1 mL of 8.4% (1 meq/mL) sodium
bicarbonate to 10 mL of 1% lidocaine or 1% mepivacaine, with or
without epinephrine, to achieve buffering.27 Add 0.05 to 0.10 mL
of 8.4% (1 meq/mL) sodium bicarbonate to each 10 mL of 0.5%
bupivacaine.28
The use of warm lidocaine [37°C (98.6°F) to 42°C (107.6°F)]
decreases the pain of infiltration.31,32 The exact etiology of this is
unknown. It is hypothesized that warm lidocaine does not stimulate
cold receptors and it diffuses into tissues faster. Warm the local anes-
thetic agent by placing it in a blanket warmer or a water bath. The
combination of both warming and buffering a compound results in
an even less painful procedure.32,33
Other simple measures can help to limit the pain of the local anes-
thetic injection. Limit the infiltration of a local anesthetic solution
to the subdermal space. This practice helps to limit the overall pain FIGURE 123-2. The needle is inserted through the intact skin below the wound to
of injection, minimize the degree of tissue distortion, and protect inject local anesthetic solution.
CHAPTER 123: Local Anesthesia 793
Do not completely withdraw the needle from the skin. Redirect is suitable for injection.41,42 Diphenhydramine should be considered
it along the opposing wound margin and repeat the technique. a viable alternative to the more commonly used local anesthetic
This can be performed down the entire length of the wound as agents when they are contraindicated.
necessary. Minimizing the number of skin punctures will help to
minimize pain. ASSESSMENT
The pain upon injection of local anesthetic agents can be
reduced by following a few simple suggestions. Warm and/or It is important to wait long enough after the local anesthetic agent
buffer the local anesthetic agent as discussed previously. Inject is administered to allow the onset of adequate anesthesia before the
the local anesthetic agent slowly. Inject open wounds through the planned procedure is started. A period of 5 to 10 minutes is adequate
wound edges and not through intact skin. An exception to this for subcutaneous local infiltration. A period of 15 to 30 minutes may
is grossly contaminated wounds. Infiltrate subdermally to mini- be required for peripheral nerve blocks. A simple examination of
mize pain and tissue distention. Insert and advance the needle to the area being anesthetized with fine touch and pinprick is impor-
create a tract and inject as the needle is withdrawn to minimize tant to insure adequate anesthesia prior to the procedure. It may
tissue distention. Do not totally withdraw the needle after infil- be necessary to inject additional local anesthetic solution in areas
tration. Leave the tip of the needle within the skin and redirect of continued sensitivity, keeping in mind the total dose injected to
the needle to prevent excessive skin punctures. avoid toxicity.
COMBINING LOCAL ANESTHETIC AGENTS AFTERCARE

Physicians have for some time combined various local anesthetic The Emergency Physician should observe the patient for a minimum
agents in an attempt to exploit the unique properties of each indi- of 15 minutes following the use of local anesthesia to insure no evi-
vidual local anesthetic agent and achieve both a rapid onset of dence of an adverse reaction. The length of time analgesia is main-
action and a prolonged duration of action.36,37 Lidocaine, with its tained depends upon the agent used for the procedure (Table 123-1).
rapid onset, can be safely mixed in a 1:1 ratio with longer acting The patient need not wait in the Emergency Department for normal
bupivacaine or mepivacaine. Employing this mixture may be no sensation to return prior to discharge. They should be instructed to
more dangerous than sequentially administering equal doses of return to the Emergency Department if normal sensation has not
either parent compound. The value of such an approach is ques- returned within 12 to 24 hours.
tionable. Enough concern still persists regarding the potential tox-
icity of this mixture to often preclude its use within the Emergency COMPLICATIONS
Department. The combined benefits might not be as relevant within
the Emergency Department, as the majority of the studies refer- Toxic reactions to local anesthetics agents are far more common
enced come from the anesthesia and surgical literature. than allergic sequelae.12,17,43 The propensity for toxicity is directly
It is important to realize that the toxic effects in an overdose sit- proportional to the potency of the drug.7,9,10 Table 123-1 lists the
uation are additive, even if an amide and ester are combined.38,39 recommended maximal doses for commonly used local anesthetic
Mixing two local anesthetic agents can complicate the overall agents. These are only estimates and in certain circumstances the
dosage calculations and enhance the potential for a toxic injec- toxic dose might be considerably less.7,20 Infiltration into highly
tion. It is also difficult to determine the maximum dose if two vascular areas, inadvertent intravascular injection, or applica-
local anesthetic agents are mixed together. If the patient devel- tion to mucous membranes may cause toxicity at accepted stan-
ops an allergic reaction, it will be impossible to determine which dard doses.7
local anesthetic agent is the causative agent. The combination It is unlikely that toxic serum concentrations of local anesthetic
of local anesthetic agents can therefore not be currently recom- agents will be reached in most clinical situations in the Emergency
mended. Use lidocaine containing epinephrine to prolong the Department. For example, the maximum dose of 1% lidocaine
anesthetic effect rather than combining it with a second local without epinephrine in a 70 kg patient would be approximately
anesthetic agent. 31.5 mL, a volume more than adequate for most wounds. It is
important to be vigilant of the total dose administered, espe-
cially in patients with large or multiple lacerations in whom
higher doses of local anesthetics may be required. A less con-
It has been known since the 1940s that injected antihistamines centrated form of the local anesthetic agent (e.g., 0.5% lidocaine
exhibit anesthetic properties. A 1956 study comparing the infiltra- as opposed to 1%) may be used when the maximum dose could
tion of diphenhydramine to procaine demonstrated equal anes- be exceeded. General anesthesia in the Operating Room may be
thetic properties. Subsequent Emergency Medicine based studies required to repair larger wounds.
have shown equal anesthetic results when comparing the injection The major manifestations of local anesthetic toxicity occur in the
of 1% solutions of either lidocaine or diphenhydramine, although central nervous system (CNS) and the cardiovascular system.6,9,12,15
the latter was associated with a more painful infiltration. A further Initial signs and symptoms are of CNS excitation. This occurs as
study comparing 0.5% diphenhydramine to 1% lidocaine demon- a result of the suppression of inhibitory cortical neurons that per-
strated a resolution in the disparity regarding the pain of injection, mits unopposed functioning of facilitatory pathways. Signs and
although at the expense of a decreased anesthetic effect.40 The over- symptoms include lightheadedness, dizziness, nystagmus, sen-
all duration of anesthesia produced by infiltrated diphenhydramine sory disturbances (e.g., visual difficulties, tinnitus, perioral tin-
is shorter than that of lidocaine. A concern has arisen regarding the gling, metallic taste in the mouth), restlessness, disorientation, and
possible destruction of local tissue and subsequent skin necrosis psychosis. Slurred speech, muscle twitching, and/or tremors may
associated with diphenhydramine infiltration. Multiple early expe- immediately precede seizures. There may also be augmentation
riences had reported this complication. However, an appropriate of medullary and sympathetic activity with resultant tachypnea,
dilution prior to injection should eliminate this potential complica- hyperpnea, hypertension, and tachycardia. Generalized depression
tion. Dilute 1 mL of standard parenteral 5% diphenhydramine solu- of the entire CNS can occur and is manifested as drowsiness, coma,
tion with 4 mL of sterile normal saline to achieve a 1% solution that and respiratory arrest.9,15
Management of CNS toxicity should begin with an assessment Of note, although often readily available, the drug propofol is com-
of the patient’s airway, breathing, and circulation. Treatment is pounded in a 10% lipid solution and therefore not applicable for
primarily supportive. Hypoxia and acidosis enhance CNS and similar use. The volume of propofol solution needed to reverse
myocardial absorption of local anesthetic agents and must be bupivacaine toxicity would require the administration of a toxic
addressed aggressively. Hypocapnia raises the seizure threshold dose of propofol.48–50
(to prevent convulsions) by inducing cerebral vasoconstriction Adding epinephrine to a local anesthetic agent increases both
and by decreasing the delivery of the local anesthetic agent to the amount of drug that can be administered and the duration of
the CNS.7,44 An alert and cooperative patient may be instructed action.4,14 It also decreases bleeding into the surgical field. There
to hyperventilate if early signs of toxicity are present.6,20,45 Manage are, however, significant drawbacks to the use of epinephrine.
seizures with intravenous benzodiazepines as they raise the CNS This includes increased pain of infiltration, increased wound
threshold to local anesthesia-induced convulsions. The metabo- inflammation, increased wound infection rates, uncomfortable
lism of local anesthetics is short enough that loading patients with side effects in susceptible patients (e.g., palpitations, tremors,
long-acting antiseizure agents, such as phenytoin, is generally not syncope), and the potential for severe tissue ischemia if used in
required. The effect of phenytoin upon sodium channel conduc- regions of end arterial circulation such as the digits, the tip of the
tion can potentiate the arrhythmogenic property of local anesthet- nose, the pinna, or the penis.12 Emergency Medicine dogma cau-
ics. Administer short-acting neuromuscular blocking agents, such tions against the use of an epinephrine containing local anesthetic
as succinylcholine or vecuronium, until serum levels of the local agent in these regions in order to avoid potential distal tissue
anesthetic agent decline if the seizures fail to respond to benzo- infarction and necrosis. However, the clinical evidence supporting
diazepines.7 Succinylcholine, however, is metabolized by pseudo- this concern is questionable, and the little that does exist is over
cholinesterase. This is the same plasma enzyme that metabolizes 50 years old. A study of elective hand procedures demonstrated
ester anesthetic agents. Therefore, avoid succinylcholine in ester- no adverse consequences following over 3000 digital injections of
induced seizures.7,6,20 epinephrine containing local anesthetic solutions.51,52 Literature
The cardiovascular system is relatively resistant to local anes- focused on the inadvertent infiltration of epinephrine into fin-
thetic toxicity in comparison with the CNS.17,24 The cardiovascular gers via improperly used autoinjectors has failed to demonstrate
system does not exhibit toxicity until much higher blood levels are a single significant case of tissue necrosis. The majority of these
reached.17,24 Cardiovascular toxicity results from the direct effects cases demonstrate a spontaneous return of perfusion with only
upon cardiac and vascular smooth muscle and the indirect effects conservative treatments (i.e., warm soaks and digital massage).
upon autonomic tone. Complications are the result of negative inot- Prolonged vasospasm and ischemia in these areas can be reversed
ropism, peripheral vasodilatation, and slowing of the myocardial with the subcutaneous infiltration of 1.0 mL of 1:1000 phentol-
conduction system.9,15 Arterial dilation combined with decreased amine (i.e., 1 mg) diluted with saline in a 1:1 mixture at the local
cardiac contractility leads to progressive hypotension and even- anesthetic injection site.53–57 A less invasive alternative is to apply
tual cardiovascular collapse. Additionally, the sodium and calcium topical nitroglycerine paste to the affected area. Caution must be
channel blockade exhibited at more toxic doses of local anesthetic used when administering epinephrine to patients who are elderly,
agents predisposes the patient to fatal arrhythmias. The end results taking beta-blockers, or with a history of coronary artery dis-
are hypotension, bradycardia, prolonged electrocardiographic inter- ease, hypertension, hyperthyroidism, or pheochromocytoma.6,12
vals, and cardiac arrest.9,10,15 Treatment is supportive with intrave- Inadvertent intravascular injection of epinephrine can have fatal
nous fluids, vasopressors, and inotropes as the mainstays of therapy. consequences.58,59
Avoid class IB antidysrhythmics due to their potential to accentuate The potential systemic complications unique to epinephrine are
cardiac sodium channel blockade. Vasopressors with positive ino- not often an issue. Using 1:100,000 preparations, one must infiltrate
tropic effects, such as dopamine, will treat profound cardiovascular 30 mL of local anesthetic solution to attain a cumulative dose of
depression.7 0.3 mg, a quantity commonly used subcutaneously in the practice
Bupivacaine is more cardiotoxic than other local anesthetic of Emergency Medicine. Such a large volume is rarely encountered
agents. Treatment of bupivacaine cardiotoxicity has shown a poten- with infiltrative anesthesia. Consider an alternative anesthetic tech-
tial benefit with the use of high dose intravenous insulin (2 IU/kg) nique if such a large volume of local anesthetic solution containing
in concert with supplemental intravenous glucose and intravenous epinephrine is required. Rare reports of patient mortality second-
potassium boluses.46 The infusion of a lipid emulsion (i.e., Intralipid) ary to an inadvertent intravenous injection have been reported.
has been proposed for use in bupivacaine-associated cardiac arrests. Extreme care should be taken when using such preparations in any
Several recent case reports have substantiated the use of Intralipid. patient with suspected cardiovascular disease.
The actual mechanism of action is unclear, but proposals include True allergic reactions are rare adverse events to the local anes-
the extraction of lipophilic anesthetics from their target tissues via thetic class of medications. Effective management of an allergic
the fatty emulsion and/or the direct antagonization of anesthetic reaction depends upon its severity and may include the use of epi-
mediated suppression of cardiac fatty acid metabolism.47 nephrine, antihistamines, steroids, and vasopressors. A complete
There is no accepted standard protocol for the administration of review of the management of allergic reactions and anaphylaxis can
Intralipid. A proposed dosing regimen is described here. Of note, be found in standard Emergency Medicine textbooks.
these rescue interventions should be attempted only in patients Methemoglobinemia has been reported to occur following the
failing to respond to standard ongoing ACLS protocols. Administer use of both classes of local anesthetic agents. It is most commonly
an initial bolus of 1.5 mL/kg of a 20% Intralipid solution. This is the seen after the use of the topical agent benzocaine.60 The use of this
standard used for adult total parenteral nutrition (TPN). Repeat medication is discussed elsewhere in this book. The Emergency
this dose up to two additional times over a 5 minute period for Physician must be aware of this potential complication and inter-
patients in refractive asystole. If the return of spontaneous cir- vene appropriately.
culation ensues, initiate a maintenance intravenous infusion of Injection of local anesthetic agents can cause complications in
0.25 mL/kg/min for 30 to 60 minutes. This allows the toxic effects the area of the infiltration. These agents have not been shown to
of the local anesthetic agent to dissipate. The Intralipid infusion increase the incidence of wound infections. Do not inject local
can be easily titrated to maintain a stable perfusing blood pressure. anesthetic agents into a joint prior to obtaining synovial fluid. They
CHAPTER 124: Topical Anesthesia 795
can result in false-negative culture results, false-negative crystal

analysis, and false-positive (anesthetic crystals) crystal analysis. Topical Anesthesia
Needle punctures of arteries, nerves, and veins are usually a tempo-
rary inconvenience with no long-lasting consequences. Intraneural
injection can result in temporary or permanent nerve injury. Never
124 Erika D. Schroeder and Peter Taillac
inject local anesthetic agents if the patient experiences paresthesias

(indicating intraneural needle placement). Withdraw the needle INTRODUCTION
1 to 2 mm and allow the paresthesias to resolve before infiltrating
with the local anesthetic solution. Never redirect the needle when Invasive procedures can cause significant anxiety in patients both
more than the tip is subcutaneous to prevent needle breakage. young and old, much of which is related to fear of the associated
pain. Topical anesthesia has been shown to decrease pain and anxi-
ety surrounding procedures such as lumbar puncture, intravenous
SUMMARY access, and laceration repair.1 This chapter will discuss topical anes-
Local anesthetic agents have become an indispensible tool in the thetic agents and the range of techniques that are available for deliv-
practice of Emergency Medicine. Emergency Physicians often rely ery of these agents.
on local anesthetic agents to relieve patient discomfort and provide
wound care. Infiltrative anesthesia represents one of the most prev-
alent uses for these agents. It is relatively quick, easy to perform, Mechanical, thermal, and chemical stimuli are detected by nerve
well tolerated, and when performed correctly, has a large margin of endings called nociceptors. These pain receptors are located in the
safety. Complications can and do arise. The Emergency Physician skin, specifically in the dermis and the epidermis, below the stratum
must be ready to recognize the warning signs of local anesthetic tox- corneum (Figure 124-1). Nociceptors are free nerve endings that
icity and intervene appropriately. An expertise in the use of these have their cell bodies outside the spinal column in the dorsal root
agents plays an important role in the practice of the art of medicine. ganglia. The intact stratum corneum, the outer layer of cornified
For hundreds of years physicians have sought to relive the pain and epithelial cells of the skin, is an effective barrier to the outside envi-
suffering of our patients. These agents allow us to come closer to ronment. Local anesthetics must transverse the stratum corneum
attaining that goal. to be delivered to the terminals of cutaneous sensory nerve fibers.
Free nerve endings
Sweat pore Dermal papilla
Stratum corneum Hair shaft

lucidum
granulosum
Epidermis
spinosum
germinativum
Meissner's
corpuscle
Sebaceous gland
Hair follicle
Dermis
Arrector pili muscle
Sweat Pacinian corpuscle

gland
Papilla of hair
Nerve
Subcutaneous fiber
fatty tissue
(hypodermis)
Artery
Vein
Blood and lymph

vessels
FIGURE 124-1. Cross section of skin with underlying sensory nerve endings.
The three methods by which the stratum corneum can be bypassed Iontophoresis
to deliver a local anesthetic are direct injection, passive diffusion, • 2% lidocaine hydrochloride containing 1:100,000 epinephrine
and needle-free drug delivery strategies. Refer to Chapter 123 for
• Device to administer iontophoresis (e.g., Phoresor II or Dupel)
the complete details regarding the direct injection of local anesthetic
solution. This chapter will discuss techniques for enhancing passive • Iontophoresis System
diffusion and needle-free administration of local anesthetic agents, Ultrasound-assisted Local Anesthetic Delivery
collectively known as topical anesthesia.
• Ultrasound device (e.g., SonoPrep)
INDICATIONS • Topical local anesthetic agent
Topical anesthesia is commonly utilized in the Emergency Depart- Powdered Anesthetics

ment in two situations. The first is the patient experiencing pain • Needle-free powder lidocaine delivery system
from an injury such as a laceration, abrasion, or contusion. The sec- Lidocaine Needle-free Injection
ond is in the patient who will undergo a painful procedure such as
venipuncture, lumbar puncture, abscess incision and drainage, or • Needle-free injection system, prefilled or fillable
laceration repair. • 1% or 2% lidocaine
Topical anesthetic agents offer several potential advantages over Heat-enhanced Diffusion
local infiltration anesthesia. They are less painful to apply, do not
distort the wound margins, and decrease the need for sedation.2 The • Lidocaine–tetracaine thermal patch
major limitations of topical anesthesia have been the extended time Laser-assisted Transdermal Passage
required to achieve anesthesia and the lack of sufficient analgesia • Cutaneous resurfacing laser
in many clinical situations that often requires supplemental infil-
tration anesthesia. These constraints have limited the use of topical • Topical anesthetic agent
anesthesia in the Emergency Department. Several new agents and Topical Vapocoolant Sprays
delivery techniques have addressed these limitations with some suc- • Topical vapocoolant spray
cess, offering the Emergency Physician more options for providing
anesthesia.
PATIENT PREPARATION
CONTRAINDICATIONS Discuss the procedure, its risks, benefits, complications, and alter-
There are very few contraindications to the use of topical anes- natives with the patient and/or their representative. Take precau-
thetics. The topical anesthetic agent is typically not systemically tions to prevent further injury or pain to the patient. Cleanse the
absorbed to any significant degree. However, they can cause local skin of any dirt and debris. Apply povidone iodine or chlorhexidine
adverse reactions and should not be used in patients who are solution to the skin and allow it to dry. Consider administering a
allergic to the medication or its components (such as preserva- supplemental anxiolytic or procedural sedation if required.
tives). Use care when applying topical anesthetics to mucous
membranes, as absorption is typically more rapid and efficient PASSIVE DIFFUSION OF LOCAL
than through skin and more substantial systemic absorption ANESTHETIC AGENTS
can occur. A relative contraindication to using topical anesthetic
Topical local anesthetic agents are often applied in the form of a gel
agents are patients taking Class 1 antiarrhythmics such as mexi-
or cream. There are numerous combinations of anesthetic agents to
letine and tocainide, as they can produce additive and possibly
use topically on wounds. TAC (tetracaine, adrenaline, and cocaine),
toxic effects. Many of the topical anesthetics are contraindicated
LET (lidocaine, epinephrine, and tetracaine), and EMLA (eutectic
or require special ophthalmic formulations for use in the eye.
mixtures of lidocaine and prilocaine) are three commonly applied
When using topical anesthetics in neonatal patients, special care
combinations (Table 124-1). Other topical local anesthetic agents
and attention to dosing is imperative to avoid toxicity. Specific
include lidocaine gel and liposomal lidocaine.
contraindications and concerns for each topical agent and appli-
cation technique are addressed later in this chapter as well as in
Chapter 123. TAC
Many Emergency Departments use TAC for topical anesthesia. It is
EQUIPMENT a combination of 0.5% tetracaine, 1:2000 or 0.05% adrenalin (epi-
nephrine), and 11.8% cocaine. TAC can be purchased or Hospital
General Supplies Pharmacists can compound these agents into a gel or liquid. It can
• Alcohol swabs be partitioned into individual use vials for easy application. The
degree of anesthesia achieved with TAC is comparable to that of
local infiltration with lidocaine for wounds on the face and scalp.3
• Gauze squares, 2 × 2 and 4 × 4 The effects are less profound, however, for wounds on the trunk and
• Gloves extremities.
The cocaine component in TAC is a powerful and effective local
Topical Cream, Gel, or Liquid anesthetic agent as well as a vasoconstrictive agent. Unfortunately,
• TAC (0.5% tetracaine, 1:2,000 epinephrine, and 11.8% cocaine) TAC is a controlled substance. This makes it’s storage, utilization,
• LET (0.5% tetracaine, 1:2,000 epinephrine, and 4% lidocaine) and monitoring subject to stringent regulation and documenta-
tion requirements. This may limit the availability and use of TAC
• EMLA (2.5% lidocaine and 2.5% prilocaine)
in some institutions.
• LMX-4 or LMX-5 (4% or 5% liposomal lidocaine) Dose recommendations generally call for 5 mL of TAC for lacera-
• Topicaine (4% lidocaine gel) tions smaller than 3 cm in length and 10 mL for lacerations greater
CHAPTER 124: Topical Anesthesia 797
TABLE 124-1 Characteristics of Topical Anesthetic Agents by weight. Each gram of EMLA contains 25 mg of lidocaine and
25 mg of prilocaine. Apply EMLA only onto intact skin and not
Time to
into open wounds. It is nonsterile and preservative free. It is also
anesthesia
commercially available in prepackaged transdermal disks.
Medication or method (min) Side effects
EMLA is indicated prior to performing venipuncture, arterial
Liposomal lidocaine 15–30 Skin erythema punctures, accessing indwelling ports and reservoirs, lumbar punc-
(LMX-4 and LMX-5) ture, minor skin procedures, or regional nerve blockade. Apply
Lidocaine, epinephrine, 15–30 None
EMLA cream to intact skin and cover it with an occlusive dressing
and tetracaine (LET)
(e.g., Tegaderm) or apply a transdermal disk. Allow at least 1 hour
Tetracaine, adrenaline, 20–30 Seizures, cardiac arrest (rare)
and cocaine (TAC)
for the EMLA to take effect. Analgesia is usually satisfactory after
Lidocaine gel (Topicaine) 30 Local skin reactions 1 hour, peaks at 2 hours, and persists for about 1 hour after it is
Eutectic mixture of lidocaine 60 Local skin reactions removed from the skin. The prolonged time required for anesthesia
and prilocaine (EMLA) to take effect limits its practical use in the Emergency Department.
Iontophoresis with lidocaine 10–20 Burns, local skin reactions EMLA should not be applied to infants less than 3 months of age
with epinephrine due to the risk of methemoglobinemia.7
Ultrasound-assisted delivery 5 Local skin reactions
Powdered lidocaine injector 1–3 Contusions, minor bleeding, LIPOSOMAL AGENTS
cellulitis
Jet lidocaine injection 1–3 Contusions, minor bleeding, Liposomal Lidocaine (LMX-4 or LMX-5) is a 4% or 5% lidocaine
cellulitis, administration pain cream that is a liposome-encapsulated formulation. The encapsu-
Heat-enhanced diffusion 10 Local skin reactions lation of lidocaine keeps it from being rapidly metabolized. The
Laser-assisted transdermal 5 Local skin reactions, lipid content of the liposomes allows for better drug penetration
administration pain of the stratum corneum. The LMX-4 cream has several advantages
Vapocoolant sprays 0.1–0.2 Frostbite, skin erythema over other topical anesthetic agents. This includes a more rapid
onset of action and not requiring an occlusive dressing.1 The most
frequent adverse reaction is local erythema. Although no serious
than 3 cm in length.3 Apply the chosen volume of TAC liquid or gel side effects have been reported with the use of LMX-4, it is recom-
onto a 2 × 2 gauze square or a cotton ball. Invert the gauze square or mended that it be applied to an area less than 100 cm2 in patients
cotton ball to apply TAC within the wound margins. Allow TAC to who weigh less than 20 kg.8 When compared to a placebo, intrave-
remain for up to 15 minutes or until visible skin blanching occurs. nous cannulation after the application of LMX-4 showed improved
Blanching indicates the presence of vasoconstriction and ade- success rates on the first attempt.9 LMX-4 is as effective as EMLA.10
quate analgesia. The gauze pad can be held in place by the patient’s However, buffered lidocaine injection decreased the pain associ-
gloved hand, the patient’s representatives gloved hand, or with tape. ated with intravenous catheter insertion to a greater extent than
TAC is not free of complications. Always wear gloves when han- lidocaine cream.1
dling TAC to prevent percutaneous absorption. Do not apply TAC
to tissues with an end-arteriole supply. This includes the fingers, TOPICAINE
toes, nose, ear, and penis. There is the possibility of vasoconstrictive
ischemic injury to these tissues. The systemic absorption of cocaine Topicaine is a 4% lidocaine gel that is used for a number of proce-
as a result of TAC administration has been implicated in rare epi- dures in the Emergency Department including placement of Foley
sodes of respiratory arrest, seizures, and death.4,5 catheters and nasogastric tubes. It is readily available and easy to use.
Patients can develop a contact dermatitis, particularly if they have
an allergy to amide-type local anesthetic agents. Apply Topicaine for
LET 30 minutes prior to a procedure for maximum efficacy.
LET is an alternative to TAC. It is a combination of 4% lidocaine,
0.1% (1:1000) adrenaline (epinephrine), and 0.5% tetracaine. It is ACTIVE NEEDLE-FREE LOCAL
considered safer, similarly effective, more practical, and more cost ANESTHETIC DELIVERY
effective to use than TAC. LET does not contain a controlled sub-
stance and has no potential for abuse. The resultant security and An alternative to either the injection of local anesthetic solution
documentation requirements are therefore much less complicated or the use of topical creams and gels are needle-free drug delivery
than those required for TAC. Hospital Pharmacists can compound systems. These techniques utilize various strategies designed to
this agent. speed the delivery of the local anesthetic agent across the stratum
Apply liquid LET by dripping it into the wound or taping a LET corneum.
soaked cotton ball or 2 × 2 gauze square over the wound. The addi-
tion of methylcellulose to liquid LET makes a gel that is more adher- IONTOPHORESIS
ent and can be painted on wounds. The gel form will not drip or
run. Similar to TAC, it should not be placed on the digits, ear, nose, Iontophoresis is a process by which direct electrical current facili-
penis, or other areas that are supplied by end arteries due to the tates dermal penetration of positively charged lidocaine molecules
strong vasoconstrictive effect and risk of ischemia. This dogma is when placed under a positive electrode. The dose is calculated by
currently being challenged.6 multiplying the duration of delivery with the current used to deliver
the local anesthetic agent. Studies evaluating this method typically
use 20 to 30 mA and 2% lidocaine hydrochloride with 1:100,000
EMLA CREAM
epinephrine.11,12 It takes approximately 10 to 20 minutes to obtain
The use of EMLA (eutectic mixture of local anesthetics) cream has adequate analgesia for intravenous catheter placement. The side
gained significant popularity, particularly in pediatric patients. It is effects of iontophoresis include skin blanching, erythema, tingling,
an emulsion of 2.5% lidocaine and 2.5% prilocaine in a 1:1 ratio itching, and burning sensations. Burns have been reported to rarely
occur during iontophoresis with an incidence of 1 per 15,000 to heating system incorporated into an adhesive patch. It is specifically
20,000 treatments.13 Iontophoresis has been successfully used prior designed to warm the skin which, in turn, accelerates the absorp-
to intravenous catheter placement and lumbar puncture.14 tion of the local anesthetic agents. The heating component of the
patch is automatically activated when the patch is removed from its
ULTRASOUND-ASSISTED packaging. The lidocaine–tetracaine patch can be used for minor
LOCAL ANESTHETIC DELIVERY invasive procedures such as lumbar puncture, intravenous catheter
placement, and arterial puncture. The lidocaine–tetracaine patch
Ultrasound has been utilized to accelerate the delivery of topical can provide effective anesthesia after 10 minutes. It was more effec-
anesthetic agents. Ultrasound disrupts the layers of the stratum tive than EMLA or a placebo at all application times shorter than
corneum forming temporary pores that facilitate the distribution 60 minutes.29,30 Common side effects include skin erythema, blanch-
of topical anesthetic agents below the epidermis.15 Focal ultrasound ing, and edema.
followed by a 5 minute application of 4% liposomal lidocaine pro-
vided more effective anesthesia when compared with a placebo or LASER-ASSISTED TRANSDERMAL PASSAGE
standard care.16,17 Ultrasound reduces the time to achieve anesthe-
sia with EMLA cream from 60 minutes to 5 minutes.18 The use of Another technique to break down the stratum corneum skin barrier
ultrasound prior to a 5 minute application of liposomal lidocaine involves the use of a laser.31 A cutaneous resurfacing laser is used
produced the same amount of pain relief as the typical 30 minute to ablate the outer layer of skin, generally an area about 6 mm in
application of liposomal lidocaine.19 Ultrasound-assisted delivery is diameter. Topical anesthetic is then applied to this area and is able to
effective for intravenous catheter placement and phlebotomy.20 rapidly penetrate through the ablated skin to the subcutaneous pain
receptors. The ablation procedure is typically painless. Anesthesia
occurs approximately 5 minutes after the local anesthetic applica-
POWDERED ANESTHETICS tion. The amount of energy used for the ablation varies but typically
Another alternative to the injection of lidocaine solution is the is in the range of 2.0 to 3.5 J/cm2. Side effects may include mild pain,
transepithelial injection of powdered lidocaine using a special- erythema, and itching at the ablation site. In addition, patients may
ized delivery system. The delivery system is a prefilled, disposable, experience temporary hyperpigmentation or hypopigmentation at
single use device that is designed to produce rapid analgesia for the treatment site. The biggest drawback to this technique is the cost
venipuncture and intravenous catheter placement. The system is of the handheld laser.
applied 3 minutes prior to venipuncture or intravenous cannula-
tion. The device works by releasing pressurized helium, which VAPOCOOLANT SPRAYS
in turn ruptures a cassette of lidocaine powder. The particles of
lidocaine powder are accelerated to a velocity that is sufficient Vapocoolant sprays, also known as vapocoolants and refriger-
to penetrate the stratum corneum and become deposited in the ant sprays, are an alternative to topical local anesthetic agents.
subepithelial layer. The onset of anesthesia is approximately 1 to Vapocoolant sprays are a good choice for patients requiring brief
3 minutes after the injection.21 When compared with a placebo, procedures or with allergies to the medications used in topical
this delivery system results in a significant reduction in pain.22 anesthetics. Vapocoolant sprays work immediately, are easy to use,
The potential adverse effects of powdered lidocaine administra- cost-effective, and may be repeatedly applied without the risk of
tion include local skin contusion, application site bleeding, and a methemoglobinemia or systemic toxicity. Vapocoolant sprays are
subsequent cellulitis. sterile liquids that vaporize upon contact with the skin. As the liq-
uid vaporizes, it cools the skin surface and provides brief topical
anesthesia. Commonly used vapocoolants include ethyl chloride,
JET LIDOCAINE fluorohydrocarbons, and alkane mixtures.
Another form of needle-free lidocaine injection is commonly They are commercially available in containers with a tip that
referred to as jet lidocaine. The device uses pressurized CO2 to directs a precise stream of liquid to the desired area. The vaporiza-
inject up to 0.5 mL of aqueous lidocaine into the subcutaneous tis- tion of the liquid lowers the skin temperature in the area of contact
sue. To use the device, the lidocaine is drawn up into the reser- to approximately −20°C (−4°F) as it vaporizes. The skin becomes
voir and it is then held firmly against the skin where the proposed temporarily cold then frozen. Vapocoolant sprays are convenient,
procedure is to occur. The CO2 cartridge is activated, forcing the effective, “needle-less”, and provide immediate anesthesia.32 Their
microaerosolized lidocaine thru the stratum corneum, depositing it use is limited by a very brief duration of action of approximately
the subcutaneous tissues. The onset of anesthesia is approximately 30 seconds. These sprays only provide superficial anesthesia.
1 to 3 minutes after the injection. Approximately 19.5% of patients Vapocoolant sprays can be used prior to accessing indwelling ports
in a randomized trial experienced pain from administration of and reservoirs, arterial puncture, venipuncture, intravenous cath-
the system.23 Other complications include device failure 10% of the eter placement, intramuscular injections, local anesthetic injection,
time and minor local bleeding. In studies comparing jet lidocaine lumbar puncture, and minor skin procedures.33
to EMLA or liposomal lidocaine, jet lidocaine was found to pro- Using the vapocoolant spray is very simple. Assemble and gather
vide more effective anesthesia.24,25 Jet lidocaine has been found to all the equipment required for the procedure to be performed.
be more effective than placebo.26,27 Interestingly, a study compared Clean and prep the skin. Apply sterile drapes if applicable. Hold the
jet lidocaine to jet placebo (saline).28 It found jet lidocaine to be inverted container of refrigerant spray 10 to 15 cm above the skin
no more effective at providing local anesthesia, suggesting that the surface. Spray the liquid onto the skin until a white frost appears and
injection itself may play a role in providing anesthesia. the skin turns white. This usually takes 7 to 12 seconds. Immediately
perform the procedure to ensure an adequate anesthetic effect.
Avoid spraying the liquid onto the skin for prolonged periods as
HEAT-ENHANCED DIFFUSION
it may result in frostbite. Do not use vapocoolant sprays on mucous
The application of heat improves the dermal absorption of topi- membranes. The vapocoolants are significantly absorbed through
cal anesthetics. The lidocaine–tetracaine topical patch consists of mucous membranes and can result in adverse reactions and toxicity.
70 mg of each local anesthesia agent, combined with an air-activated These agents are highly volatile and must be used in well-ventilated
CHAPTER 125: Hematoma Blocks 799
areas. Never spray around open flames or an electrocautery unit as These techniques all have the potential to decrease the pain due to
some vapocoolant sprays are highly flammable. Do not use vapo- procedures. More information and trials are required before these
coolant spray on open wounds as it may delay wound healing. The can be used in the Emergency Department.
application of ice packs work just as well but takes longer to achieve
anesthesia. ASSESSMENT
It is important to wait long enough after the topical agent is admin-
MUCOUS MEMBRANE ANESTHESIA istered to allow the onset of adequate anesthesia before the planned
Mucous membranes warrant a special note as the systemic procedure is started. The period of time necessary for the onset of
absorption from mucous membranes is much more rapid and anesthesia is highly variable and dependent on the topical anesthetic
effective than absorption through the skin and results in higher used and the delivery technique utilized. A simple examination of
blood levels of the anesthetic agent. Numerous agents may be the area being anesthetized with fine touch and pinprick is impor-
used to provide anesthesia to mucous membranes. This commonly tant to insure adequate anesthesia prior to the procedure. It may be
includes benzocaine, cocaine, lidocaine, and tetracaine. These necessary to apply additional anesthetic or use an alternative anes-
local anesthetic agents produce only superficial anesthesia. They thetic technique in areas of continued sensitivity, keeping in mind
do not provide for any pain relief that originates submucosally or the total dose applied to avoid toxicity.
deeper. The total dose applied should be one-third to one-half the
dose used for infiltration. Use these agents cautiously on the oral AFTERCARE
mucosa as they can suppress the gag reflex and increase the risk
for aspiration. The Emergency Physician should observe the patient for a mini-
Benzocaine is a commonly used mucous membrane anesthetic. mum of 15 minutes following the use of topical anesthesia to ensure
It is available in spray, liquid, and gel form in a concentration of no evidence of an adverse reaction. The patient need not wait in
14% to 20% (e.g., Cetacaine, Hurricaine, Americaine). It is nontoxic the Emergency Department for normal sensation to return prior to
when applied to intact mucous membranes due to its poor water discharge.
solubility. It provides brief analgesia. Overuse of benzocaine has the
potential to produce methemoglobinemia.34,35 COMPLICATIONS
Cocaine is supplied in solution at concentrations of 4% and There are case reports of patients developing CNS toxicity after the
10%. It is an extremely effective mucous membrane anesthetic application of topical anesthetics.43 There have been cases of met-
with significant vasoconstrictive properties. Systemic absorption hemoglobinemia reported in patients, particularly with the use of
is enhanced when it is applied to inflamed mucous membranes. benzocaine.34 Topical anesthetics in patients taking Class 1 antiar-
The maximum dose is 3 mg/kg. This dose still has the potential to rhythmics such as mexiletine and tocainide can produce additive
result in toxicity and serious complications. Do not use cocaine and possibly toxic effects. EMLA has been reported to cause ulcer-
in patients with hypertension, cardiomyopathy, known or sus- ation of the gingival mucosa and thus should not be used for muco-
pected coronary artery disease, or patients sensitive to exog- sal anesthesia.44 Many of the topical anesthetics are contraindicated
enous catecholamines. or require special ophthalmic formulations for use in the eye. When
Lidocaine is available in jelly and liquid form with a concentra- using topical anesthetics in neonatal patients, special care and atten-
tion of 2% to 10%. The 2% and 4% viscous solutions are often used tion to dosing are imperative to avoid toxicity.
in the Emergency Department. Instruct the patient to swish the
solution in their mouth for 30 to 60 seconds then spit it out. It can
SUMMARY
result in significant systemic absorption if swallowed. The maximal
dose is 300 mg in adults (15 mL of 2% or 7.5 mL of 4%) and 3 mg/kg There are a number of effective techniques available to decrease
in children. Use extreme caution when sending patients home the pain and anxiety associated with invasive procedures. Topical
with viscous lidocaine for intraoral use. Frequent use and swal- anesthetic agents, particularly those with fast acting properties, are
lowing can both result in elevated blood levels of the parent drug excellent adjuncts for use in the Emergency Department. Topical
and its metabolites, both of which can result in potential adverse anesthetic creams, active medication delivery, or alternative tech-
and toxic effects.36,37 niques should be considered prior to performing a painful invasive
Tetracaine is available in liquid and aerosol form with a con- procedure.
centration of 0.25% to 1.0%. It has significant cardiotoxic effects.
It is therefore not often used for mucous membrane anesthesia.
Tetracaine should not be used for mucous membrane anesthesia in
the Emergency Department.
Hematoma Blocks
MISCELLANEOUS AGENTS
Several alternative topical anesthetic techniques have been used to
125 Thomas P. Graham
provide analgesia. S-Caine Peel (Zars Pharma) has been developed

as a local anesthetic peel. It is applied to an area for 20 to 30 min-
INTRODUCTION
utes. It dries into a flexible membrane that can be peeled off after
the application period. This agent is easily applied to non-flat body Distal extremity fractures are commonly seen in the Emergency
surfaces. Its primary use has been for laser vein treatments and laser Department. These fractures often require closed reduction by
tattoo removal.38–40 Acupressure has been used for hundreds of years manipulation, which can be a painful and frightening experience
to relieve pain. It has been recently used in acute painful condi- for the patient. Achieving adequate analgesia is important to facili-
tions.41 The ShotBlocker (Bionix, Toledo, Ohio) is a plastic device tate reduction and to minimize patient discomfort. However, stud-
that is pressed against the skin just before and during an injection.42 ies suggest that Physicians frequently provide inadequate analgesia
It may be used to decrease the pain of local anesthetic injections. to patients, and particularly children, with extremity fractures.1,2
ANATOMY AND PATHOPHYSIOLOGY due to an uncooperative patient. Relative contraindications include

patients with bleeding disorders and those taking anticoagulants.
The hematoma block is a technique to inject a local anesthetic solu- The potential additional hemorrhage from the injection of local
tion into the hematoma between the fractured bone fragments. anesthetic solution into a closed space may result in a compartment
Fracture manipulation can then often be undertaken painlessly syndrome.
or with significantly reduced pain. Hematoma blocks of the dis-
tal forearm are considered safe in children and adults.3–8 Another
advantage is the relative ease of the procedure. A hematoma block EQUIPMENT
may be superior to intravenous sedation in alleviating discomfort • Sterile gloves and gown
during fracture reduction.9 The hematoma block, unlike procedural • Face mask and cap
sedation, avoids the side effects of sedating drugs, does not require
intravenous access and cardiac monitoring, and is not associated • Povidone iodine or chlorhexidine solution
with a prolonged recovery phase. One Physician can safely perform • Sterile drapes
a hematoma block, whereas the presence of two Physicians is gen- • Local anesthetic solution without epinephrine, usually 1%
erally recommended for procedural sedation. The disadvantages lidocaine
of the hematoma block include the discomfort and anxiety result-
• Syringes, various sizes
ing from injecting into the fracture site, and the potential for a rare
complication. • 22 or 23 gauge, 2-inch long needles
Extremity fractures, when displaced or angulated, generally result • Spinal needles for obese patients
in the formation of a hematoma between the fracture fragments.
The hematoma is easily accessible with a needle and the injection of Optional Equipment
local anesthetic solution can significantly alleviate pain. The major- • Ultrasound machine
ity of important neurovascular structures in the upper extremity • 7.5 to 10 MHz ultrasound probe
are contained in the volar soft tissue, making the dorsal or lateral • Sterile ultrasound gel
approach preferred. The majority of important neurovascular struc-
tures in the lower extremity are contained in the proximal anterior • Sterile ultrasound probe cover
thigh or posteriorly in the leg, making the lateral approach preferred
in the proximal thigh and the anterior or lateral approach from the PATIENT PREPARATION
mid-thigh distally.
Explain the risks, benefits, complications, and alternatives to the
Other techniques are available to provide analgesia and anesthe-
patient and/or their representative. The technique for adult and
sia. Some authors have concluded that a Bier block (intravenous
pediatric patients is identical. An adult usually tolerates the hema-
regional anesthesia, Chapter 127) may lead to more effective anes-
toma block injection without any supplemental analgesia or seda-
thesia and require fewer re-manipulations for the reduction of fore-
tion. Some adults and children may require supplemental nitrous
arm fractures when compared to the hematoma block.10–12 However,
oxide, intravenous sedation, or an intravenous anxiolytic agent to
the Bier block is a technique that most Emergency Physicians are
facilitate the hematoma block.
not familiar and have not developed proficiency, requires equip-
Prepare for the procedure. The hematoma block must be per-
ment not commonly available in the Emergency Department, and
formed using strict aseptic technique. Cleanse the skin of any
can be associated with adverse outcomes. Intraarticular injection of
dirt and debris over the fracture site and surrounding skin. Apply
local anesthetic solution for the reduction of intraarticular fracture-
povidone iodine or chlorhexidine solution onto the skin and allow
dislocations, though not as well studied or widely utilized as a hema-
it to dry. Apply sterile drapes to form a sterile field. The Emergency
toma block, have also been advocated as safe and effective.13,14 The
Physician should be wearing sterile gloves and a sterile gown during
joints of the extremities are easily entered by performing an arthro-
the procedure. The use of a face mask and cap is also recommended.
centesis (Chapter 77). Local anesthetic solution injected intraar-
Using aseptic technique, draw up sterile 1% lidocaine without epi-
ticularly diffuses throughout the joint cavity and exits through the
nephrine into a syringe armed with a 22 or 23 gauge, 2-inch long
fracture site to alleviate pain.
needle. A longer spinal needle may be required in the obese patient.
Fill the syringe with 0.3 mL/kg to a maximum of 10 mL of lidocaine,
INDICATIONS the volume to be injected. Larger volumes maybe required in adults
A hematoma block is indicated in adult and pediatric patients with and larger fractures. Always be aware of the maximum safe dose of
closed fractures of the extremity that require manipulation or closed 4.5 mg/kg when using lidocaine without epinephrine.
reduction. Consider performing a hematoma block when medical
resources are limited or scarce. It is an alternative when procedural TECHNIQUES
sedation is impossible or impractical. A hematoma block may be
performed purely for analgesia when fracture manipulation is HEMATOMA BLOCK FOR DISTAL RADIUS FRACTURES
unnecessary and/or other methods of analgesia are ineffective or
contraindicated. Follow strict aseptic technique throughout the procedure.
Inform the patient of the early signs of local anesthetic toxic-
ity. These include circumoral and tongue numbness, dizziness,
CONTRAINDICATIONS lightheadedness, mental status decline, tinnitus, and visual dis-
Hematoma blocks are contraindicated when there is a history of turbances. Instruct the patient to inform you immediately if they
allergic reactions to local anesthetic agents. The procedure is also experience any of these symptoms.
contraindicated in the setting of an open fracture, cellulitis overly- Place a wheal of 1% lidocaine subcutaneously over the fracture
ing the fracture site, or the presence of a neurovascular deficit. A site. Allow 1 to 2 minutes for the anesthetic to take effect. Slowly
hematoma block should not be performed if a sterile field cannot insert and advance the 23 gauge needle attached to the lidocaine-
be maintained or the safety of the medical staff cannot be assured filled syringe through the skin wheal and aimed at the fracture site.
CHAPTER 125: Hematoma Blocks 801
solution. Remove the needle and apply a bandage to the skin punc-
ture site.
Several adjuncts to the hematoma block may aid in increasing its
efficacy. The addition of hyaluronidase to the local anesthetic solu-
tion has been advocated and become routine at some centers as a
means of increasing the speed and efficiency of the hematoma
block. The hyaluronidase breaks down the connective tissue and
allows better penetration of the local anesthetic solution into the
area. The evidence for the efficacy of hyaluronidase is currently
lacking.15 Based on available data, it is not currently recommend
to add hyaluronidase to the local anesthetic solution. The use of
ultrasound can facilitate the injection into the correct site.16,17 Some
authors recommend the use of other agents, such as anxiolytics, in
FIGURE 125-1. The hematoma block. The needle is inserted into the hema- combination with the hematoma block for fracture manipulation.
toma near the fracture fragments. Local anesthetic solution is injected into the
Combining the hematoma block with nitrous oxide has shown posi-
hematoma.
tive results.18
ASSESSMENT
Continue to slowly advance the needle toward and into the expected Reassess and document a thorough neurologic and vascular
location of the gap between the fracture fragments (Figure 125-1). examination distal to the fracture site immediately after the injec-
Aspirate with the syringe. A flash of blood indicates entry into tion. Assess the patient’s level of pain with gentle range of motion in
the hematoma. If the needle strikes bone or if no flash of blood 10 minutes. A second injection of local anesthetic solution may be
is returned, withdraw the needle and re-direct it in an attempt to performed if required for analgesia if the patient is not experienc-
enter the hematoma. Slowly inject the contents of the syringe into ing any side effects or toxicity and the total combined doses do not
the hematoma. Withdraw the needle. Apply a bandage to the skin exceed the maximum allowable limit of 4.5 mg/kg.
puncture site.
Some physicians reposition the needle to different areas within AFTERCARE
the hematoma and inject small amounts of the local anesthetic solu-
tion into each area. This technique distributes the local anesthetic The extremity can be manipulated to reduce the fracture once ade-
solution to increase the efficacy of the hematoma block. Injection quate analgesia has been obtained. Splint the extremity. Perform
into multiple areas also minimizes the risk of intravascular injection and document another neurologic and vascular examination of
of the entire dose of local anesthetic solution. the extremity after any manipulation and splinting. Instruct the
patient to immediately return to the Emergency Department for
severe pain, significant swelling, numbness, paresthesias, or pallor
HEMATOMA BLOCK FOR INTRAARTICULAR of the extremity. Arrange appropriate follow-up with an Orthopedic
FRACTURE-DISLOCATIONS Surgeon. Prescribe analgesics as appropriate.
The procedure is identical to that described above except for
the anatomic landmarks and the volume of local anesthetic solu- COMPLICATIONS
tion injected. Refer to Chapter 77 for the complete details of The complications associated with a hematoma block are rare.
arthrocentesis. These include a compartment syndrome, local anesthetic toxicity,
and osteomyelitis.19–25 The early signs of local anesthetic toxicity
ULTRASOUND-GUIDED HEMATOMA BLOCK include circumoral and tongue numbness, dizziness, lighthead-
edness, mental status decline, tinnitus, and visual disturbances.
Identify the fracture site and hematoma using ultrasound (US). The cardiovascular toxic effects include asystole, atrioventricular
Place the US probe on the patient’s skin above the fracture site. Turn blocks, bradycardia, cardiac depression, dysrhythmias, and hypo-
the US probe so its long axis is aligned with the long axis of the bone. tension. The neurologic toxic effects include agitation, coma, con-
Identify the fracture site and hematoma. Rotate the US probe 90° to fusion, headaches, seizures, and possibly death. Seizures associated
visualize the short axis or cross-sectional view of the fracture site with local anesthetic toxicity are usually short lasting and respond
and hematoma. to barbiturates, benzodiazepines, and propofol. Please refer to
Clean, prep, and sterilely drape the patient as described previ- Chapters 123 and 127 for the complete details regarding local anes-
ously. Prepare the US probe. Apply US gel to the footprint of the thetic complications and toxicity. Introducing bacteria into a pre-
US probe. Apply a sterile probe cover or a sterile glove over the US viously closed fracture and injury to vascular structures are also
probe. Squeeze any air out of the space between the US probe and potential complications. These can be minimized or eliminated
the cover. Apply sterile US gel on the probe cover. by using strict aseptic technique and carefully identifying the ana-
Grasp the sterile US probe with the nondominant hand. Align tomic landmarks.
the long axis of the US probe along the long axis of the bone and
approximately 8 to 10 mm proximal to the fracture site. Aim the
syringe containing the local anesthetic solution downward and
SUMMARY
in the direction of the fracture site. Slowly insert and advance the A hematoma block is an effective technique to facilitate manipula-
needle through the skin under US guidance. Advance the needle tion of extremity fractures and intraarticular fracture-dislocations
into the hematoma at the fracture site. Inject the local anesthetic in adults and children. It may also be performed purely for
analgesia when no manipulation is required. Complications are its use is required. Nerve stimulators are rarely available in the
rare if proper techniques are used. The procedure requires fewer Emergency Department. US can be used to locate nerves.
Emergency Department resources than procedural sedation or The traditional method used by Anesthesiologists to perform
a Bier block. Consider performing a hematoma block when pro- regional anesthesia involves a combination of surface landmarks
cedural sedation is impractical or contraindicated. Patient prefer- and nerve stimulation. Over the past 10 to 15 years, ultrasound (US)
ence should also be considered. Many patients would likely prefer has gained a prominent role in guiding nerve blocks. It offers the
a shorter Emergency Department stay with a hematoma block advantages of visualizing the nerve and the needle, as well as directly
rather than a much longer one involving procedural sedation and visualizing the deposition of local anesthetic solution around the
the associated risks. nerve. Several small studies have shown that Emergency Physicians
can safely perform US-guided nerve blocks.1–4
It is common to encounter children complaining of pain in the
Emergency Department. Regional anesthesia is frequently over-
looked in children. Its use is increasing and serves as an excel-
Regional Nerve Blocks lent opportunity to minimize pain in the pediatric population.5
126 (Regional Anesthesia)

It can be administered safely and effectively in these patients. A
child may require intravenous or intramuscular sedation in con-
junction with nerve blockade in more complicated cases. The
Eric F. Reichman, Jehangir Meer, and Nikesh Seth use of nitrous oxide with pediatric patients in the Emergency
Department has been found to be successful when used for fore-
INTRODUCTION arm fracture manipulation.6 It can also be used for other proce-
dures. Refer to Chapter 128 regarding the use of nitrous oxide as a
Regional anesthesia or regional nerve blocks are defined as infil-
supplement or to perform the regional nerve block. The disadvan-
tration of a peripheral nerve with local anesthetic agents to attenu-
tages of regional nerve blocks in children include the extra time
ate motor output and sensory input. It provides anesthesia to allow
required to perform the block, mandatory technical dexterity, and
conditions to be treated efficiently and with minimal discomfort.
assistant support because the child may not remain still for the
Patients typically tolerate nerve blocks better than direct wound
procedure.
infiltration. Nerve blocks often require less local anesthetic solution
This chapter covers regional anesthetic blocks of the head, neck,
than does infiltration of large wounds.
upper extremity, lower extremity, and two of the many torso blocks
Regional anesthesia provides sensory blockade of a region with-
(Table 126-1). Dental blocks are discussed in Chapter 176. Refer to
out altering the normal anatomic features of the area to be repaired.
Chapter 123 for a more complete discussion on the properties of
It may be considered for use in the repair of extensive wounds, inci-
local anesthetic agents.
sion and drainage of abscesses, foreign body removal, wound explo-
ration, burn care, fracture reduction, or pain control. Once familiar
with the body’s sensory innervation, the Emergency Physician can
easily employ regional anesthesia techniques within the Emergency There is a topographic arrangement of axons within peripheral
Department. nerves (Figure 126-1A).7,8 Axons located in the outer or mantle
Locating and anesthetizing a peripheral nerve is accomplished layer innervate proximal structures. Axons in the center of the nerve
in one of four ways. First is to identify the general location of the or core layer innervate distal structures. Local anesthetic solution
nerve using anatomy and landmarks. Infiltrate local anesthetic injected near a nerve diffuses from the mantle layer to the core lay-
solution at that site and allow it to diffuse over the area. The sec- ers. This explains why anesthesia slowly spreads along the nerve
ond is to locate a nerve by using the injecting needle to elicit par- distribution in a proximal to distal direction.
esthesias. Once paresthesias are elicited, withdraw the needle 1 to Avoid intraneural injection when performing peripheral nerve
2 mm and allow the paresthesias to resolve before injecting the blocks. The nerve has a tough, fibrous outer sheath that acts as a
local anesthetic solution. A nerve stimulator can be used to accu- physical barrier to trap intraneural fluid (Figure 126-1B). Injection
rately locate peripheral nerves with motor fiber components. Use of local anesthetic agents into the nerve bundle will compress the
of a nerve stimulator does not require cooperation on the part of fragile axons and their capillary blood supply.9,10 This can result in
the patient. However, due to its complexity, a physician skilled in axonal necrosis and permanent nerve damage. Paresthesias elicited
TABLE 126-1 Nerves and Anatomical Areas That Can Be Anesthetized in the Emergency Department Using a Regional Block
Head and neck Lower extremity Upper extremity Torso
Supraorbital nerve block Femoral nerve block Brachial plexus block Intercostal block
Supratrochlear nerve block Saphenous nerve block Median nerve block Penile nerve block
Infraorbital nerve block Lateral femoral cutaneous nerve block Ulnar nerve block
Mental nerve block Obturator nerve block Radial nerve block
Greater occipital nerve block Sciatic nerve block Wrist block
Lesser occipital nerve block Popliteal fossa block Digital nerve block
Greater auricular nerve block Common peroneal nerve block
Scalp block Superficial peroneal nerve block
External ear block Deep peroneal nerve block
External auditory canal block Sural nerve block
Cervical plexus block Posterior tibial nerve block
Ankle block
Digital nerve block
CHAPTER 126: Regional Nerve Blocks (Regional Anesthesia) 803
A Nerve trunk
Mantle bundle Spinal cord Dorsal root

Axon of
Core bundle sensory neuron
Proximal:
early block
Axon of
motor neuron
Epineurium
Perineurium
Distal:
Endoneurium
delayed block
Myelin
Schwann cell
From skin
To muscle
FIGURE 126-1. The anatomy and topographic arrangement of axons in a peripheral nerve. A. The gross anatomy of a peripheral nerve. B. The microscopic anatomy of
a peripheral nerve.
upon needle insertion indicate that the tip of the needle is within removal, incision and drainage of abscesses, pain control, wound
the nerve bundle. Withdraw the needle 1 to 2 mm and allow the exploration, and wound care.
paresthesias to resolve, usually within 15 to 30 seconds. The anes- US-guided regional anesthesia offers a number of advantages
thetic agent can be safely injected when the paresthesias resolve. when compared with the anatomic landmark. It is safer and results
Cutaneous innervation is referenced to a segment known as in fewer complications (e.g., vascular puncture, pneumothorax, and
a dermatome.7 This is defined as an area of skin supplied by a intravascular injection of local anesthetic).13 US achieves higher
single spinal or segmental nerve. This type of innervation is best rates of successful block (over 95%) and delivers a more rapid onset
represented in worms, where each body segment has its own ner- of anesthesia. In addition, a smaller volume of local anesthetic solu-
vous supply. The pattern of segmental innervation still holds true tion is required for the block.13 US can eliminate the need for proce-
with some minor modifications as one moves up the phylogenetic dural sedation and analgesia (PSA) and its potential complications
tree. The truncal dermatomes in humans are represented as simple (e.g., apnea, hypoxia, and hypotension). Preprocedural fasting is not
bands while the extremity dermatomes are serpiginous and fol- required as it is a potential requirement in PSA. US-guided nerve
low the embryonic rotation of the limb buds. The most commonly blocks reduce Emergency Department lengths of stay compared
used dermatomal chart is that developed by Keegan and Garrett with patients receiving PSA.1 It facilitates procedures in patients
(Figure 126-2).8 Their model of the extremity dermatomes is in with higher American Society of Anesthesiology (ASA) classifica-
strips of innervation, all originating from the limb base and extend- tion scores, who would otherwise be put at higher risk for complica-
ing distally. This system is used in clinical medicine today. tions by the administration of PSA.
INDICATIONS CONTRAINDICATIONS
Regional anesthesia produces profound analgesia with minimal There are few contraindications to regional anesthesia.7,14 Absolute
physiologic or anatomic alteration. These techniques are espe- contraindications include injection through infected tissue, his-
cially useful in large or extensive lacerations that would other- tory of a bleeding disorder or a coagulopathy, or an allergy to the
wise require infiltration of a large and potentially toxic volume of anesthetic agent. Relative contraindications include preexisting
local anesthetic solution. Nerve blocks can avoid a patient being neurologic damage prior to the procedure. This should carefully be
taken to the Operating Room because the volume of local anes- documented before any anesthetic injection. Additionally, patient
thetic required for extensive wound repair may require toxic doses. uncooperativeness can make the procedure technically more diffi-
These techniques are also useful in cosmetic repairs where local cult. Therefore, procedural sedation may be a necessary adjunct.5,15
infiltration may cause distortion of tissues or loss of anatomic This is particularly true of the pediatric population and those with
landmarks making approximation and repair difficult. The neces- an altered mental status.16
sity to palpate deep tissue for excision is also an indication for There are no patient contraindications to the use of US to guide
regional anesthesia.11,12 Regional nerve blocks can be performed nerve blocks. Emergency Physician contraindications include the
prior to burn care, dislocation or fracture reduction, foreign body lack of familiarity and training with the procedure. Psychomotor
C2
C2
C3
C4
C3 C5
C4 C6
C7
C5 C8
T1 T1
T2 T2
Ventral axial T4 T3
T3 T5
line of arm
T4 T6
T7
T5 T8
T6 T9
T10
T7 T11
T8 T12
L1
T9 L2
T10 L3
L4
T11 L5
S1
T12
L1 C6 S2
L2
L3 C7
C8
L4
Ventral
axial line
of leg
L5 S1
S2
S1
S1 L5
L4
FIGURE 126-2. The dermatomal chart of the human body.
coordination and experience with US are required. Caution is • 20 to 27 gauge noncutting or Quincke needles for injection,
advised for the novice ultrasonographer. 2 inches long
• 22 to 24 gauge noncutting or Quincke spinal needles
EQUIPMENT • 1, 3, 5, 10, and 60 mL syringes
Anatomic Landmark-Guided Nerve Blocks • Intravenous extension tubing
• Sterile gloves US-Guided Nerve Blocks
• Sterile drapes • Above listed supplies
• Povidone iodine or chlorhexidine solution • US machine
• Alcohol swabs • High frequency, linear-array, US probe
• Local anesthetic solution (Table 126-2 and Chapter 123) • Sterile US probe cover
• 18 gauge needle to draw up local anesthetic solution • Sterile US gel
TABLE 126-2 Maximum Doses of Local Anesthetic Agents bubbles away from the footprint of the US probe to prevent imag-
ing artifacts. Secure the cover with rubber bands to prevent it from
Maximum Duration of
sliding off the US probe (Figure 50-6C). Place the US probe on the
Anesthetic agent dose (mg/kg) action (min)
sterile field (Figure 50-6D). Apply sterile US gel onto the cover over
Procaine (2%) 6 15–30 the US probe footprint just before scanning.
Procaine (2%) with epinephrine 8 30–90
Tetracaine (0.25%) 1 120–140
Tetracaine (0.25%) with epinephrine 2 240–280 TECHNIQUE
Chloroprocaine (2%) 8 15–30 The general procedure will first be described and specifics will be
Chloroprocaine (2%) with epinephrine 10 30–90
addressed with each individual nerve block.
Lidocaine (1%) 3 30–120
Lidocaine (1%) with epinephrine 5 60–400
Etidocaine (0.5%) 3 30–120 ANATOMIC LANDMARK TECHNIQUE
Etidocaine (0.5%) with epinephrine 4 60–200
Position the patient. Identify the nerve or nerves to be blocked and
Mepivacaine (1%) 3 30–120
their associated anatomic landmarks. Carefully clean and prepare
Mepivacaine (1%) with epinephrine 5 60–400
Bupivacaine (0.25%) 1.75 120–240 the skin over the injection site in a sterile fashion. Draw up the
Bupivacaine (0.25%) with epinephrine 2.25 240–480 local anesthetic solution to be injected. The amount will vary based
Prilocaine (4%) 5 30–60 upon the specific block. Always keep in mind the maximum allow-
Prilocaine (4%) with epinephrine 6 120–300 able dose of local anesthetic (Table 126-2). Reidentify the anatomic
landmarks. Insert the needle into the site. Withdraw the plunger to
ensure that the tip of the needle is not within a blood vessel, thus
avoiding intravascular injection. If paresthesias are elicited, with-
All of the required equipment is readily available in any Emergency draw the needle 1 to 2 mm and allow them to resolve. Inject the
Department. Some have a pre-prepared tray or tackle box contain- local anesthetic solution. Apply an appropriate bandage to the site.
ing all the required equipment. Allow 5 to 15 minutes for the block to take effect. Confirm that
anesthesia has been achieved with pinprick prior to performing the
PATIENT PREPARATION procedure for which regional anesthesia was performed. Document
the regional anesthesia procedure, the procedure for which regional
Explain the procedure, its risks, and benefits to the patient and/or anesthesia was performed, and any complications in the medical
their representative. Emphasize that there are few complications record. A sample regional anesthesia procedure note is described
with this procedure. However, all possible complications should in Table 126-3.
be discussed beforehand. Inform the patient of the possibility of
paresthesias during the procedure and of the expected duration US-GUIDED TECHNIQUE
of action of the local anesthetic agent (Table 126-2). Obtain an
informed consent for the regional nerve block in addition to the Position and prepare the patient as described above for the ana-
procedure for which it is performed. Ideally, the consent should tomic landmark technique. Find the general location of the nerve
be documented in the medical record and signed by the patient. using anatomic landmarks. Use US to identify the targeted nerve.
Some Emergency Physicians prefer to note on the patient’s chart Use a longitudinal needle approach for all US-guided nerve blocks.
“Indications, risks, and benefits were discussed with the patient” The US probe should image the nerve bundle in the short axis,
rather than having the patient sign a consent form. This decision allowing the entire length of the needle to be visualized as it
is specific to each Emergency Physician, their institution, and state approaches the nerve. Use a noncutting needle, such as a Quincke
requirements. spinal needle, to reduce the risk of intraneural injection or nerve
Perform and document a neurological examination of the injury. Place the US machine on the patient’s opposite side to
area to be anesthetized before performing regional anesthesia. allow the Emergency Physician to glance easily and quickly from
Include a description of any neurological deficit in the document the field to the US monitor. It is recommended to use an assistant
of informed consent for the procedure. Have the patient sign an to inject the local anesthetic solution. This allows the Emergency
agreement that the defect was present prior to the administration Physician to use their hands to hold the US probe with one hand
of the local anesthetic solution. and manipulate the needle with the other hand. Center the target
Position the patient based upon the specific regional block to be nerve on the screen.
performed. Place the patient supine on a gurney or procedure table An important concept regarding the injection of local anesthetic
prior to the procedure in most cases. If the patient must sit upright, solution around the nerve bundle is the “donut sign.” This is the
place the patient on an adjustable bed. The patient’s comfort should circumferential spread of local anesthetic solution around the nerve.
be optimized to prevent unexpected complications such as vasova- This is the desired location of the local anesthetic solution around
gal syncope.7,17,18 Expose the area of the injection and identify the the nerve and it is usually associated with a successful block.
anatomic landmarks required for proper needle placement. Clean
all dirt and debris from the skin. Scrub the needle insertion site with
povidone iodine or chlorhexidine solution and allow it to dry. Apply TABLE 126-3 A Sample Regional Anesthesia Procedure Note
sterile drapes to delineate a sterile field. After informed consent and identification of the necessary landmarks, the
If using US-guidance, prepare the US probe. Always use a sterile skin overlying (location) was cleaned and prepped with
US probe cover and sterile US gel when performing nerve blocks povidone iodine or chlorhexidine solution. Using sterile technique, a skin
to prevent deep infections. Set up a sterile field on a bedside table.
wheal of local anesthetic solution was placed. A gauge needle was used
Open the US probe cover set onto the sterile field. Instruct an assis-
to anesthetize the nerve with mL of %
tant to hold the US probe upright and place standard or sterile US
gel on the footprint of the US probe (Figure 50-6A). Apply the ster- (lidocaine, marcaine, procaine, etc.). Anesthesia was
ile probe cover over the US probe (Figure 50-6B). Smooth all the air confirmed with needle pinprick testing. No complications were noted.
Needle Insertion and Direction Place a skin wheal of local anesthetic

solution over the midline of the forehead at the level of the eyebrow.
Insert a 25 or 27 gauge needle through the skin wheal and aimed
laterally (Figure 126-4B). Advance the needle while infiltrating
subcutaneously with 3 to 5 mL of local anesthetic solution. Always
maintain the needle just above the supraorbital ridge while advanc-
ing it (Figure 126-4B). Stop infiltrating when the needle passes the
midline of the bony orbit.
Remarks This technique will anesthetize both the supraorbital and
supratrochlear nerves. Infiltrate 2 mL of local anesthetic solution
directly over the supraorbital foramen, or notch, if it is palpable
rather than subcutaneously infiltrating above the supraorbital ridge.
SUPRATROCHLEAR NERVE BLOCK

Anatomy The supratrochlear nerve is a branch of the ophthalmic
division of the trigeminal nerve. It emerges through the trochlea at
FIGURE 126-3. The supraorbital foramen, the infraorbital foramen, and the men- the supermedial aspect of the bony orbit (Figure 126-4A). It pro-
tal foramen all lie along a straight line drawn through the pupil in the midposition. vides innervation to the middle of the forehead beginning at the
superior orbital ridge and extending superiorly to the vertex of the
scalp. It is often blocked simultaneously with the supraorbital nerve,
because there is considerable overlap in their areas of innervation.
REGIONAL ANESTHESIA TECHNIQUES Patient Positioning Place the patient supine, or sitting, and facing the
FOR THE HEAD AND NECK Emergency Physician.
Landmarks Identify, under the eyebrow, the superior orbital rim by
SUPRAORBITAL NERVE BLOCK palpation.
Anatomy The supraorbital foramen lies on the supraorbital Needle Insertion and Direction Place a skin wheal of local anesthetic
ridge along a line drawn through the pupil in the midposition solution over the midline of the forehead at the level of the eye-
(Figures 126-3 & 126-4). The supraorbital foramen may be pal- brows. Insert a 25 or 27 gauge needle through the skin wheal, aimed
pable as an indentation. The supraorbital nerve is a branch of the laterally (Figure 126-4B). Advance the needle while infiltrating
ophthalmic division of the trigeminal nerve. It emerges through subcutaneously with 2 to 3 mL of local anesthetic solution. Always
the supraorbital foramen, or notch, at the midline of the superior maintain the needle just above the supraorbital ridge while advanc-
orbital ridge (Figure 126-4A). Its area of innervation includes the ing it (Figure 126-4B). Stop infiltrating when the needle passes the
forehead, beginning at the superior orbital ridge and extending midline of the bony orbit.
superiorly to the vertex of the scalp. It is blocked simultaneously Remarks Stop infiltrating 1.5 cm from the skin wheal so as to block
with the supratrochlear nerve, as there is considerable overlap in only the supratrochlear nerve.
their areas of innervation.
Patient Positioning Place the patient supine, or sitting, and facing the INFRAORBITAL NERVE BLOCK,
Emergency Physician. EXTRAORAL APPROACH
Landmarks Identify, under the eyebrow, the superior orbital rim and
Anatomy The infraorbital nerve is a branch of the maxillary division
the supraorbital foramen by palpation.
of the trigeminal nerve. It emerges through the infraorbital foramen,
1 cm below the middle to medial third of the inferior orbital ridge
(Figure 126-5A). It lies in the same plane as the supraorbital fora-
men and pupil that is in the midposition (Figures 126-3 & 126-5).
FIGURE 126-4. The supraorbital and supratrochlear nerve block. A. The location FIGURE 126-5. The extraoral approach to the infraorbital nerve block. A. Location
of the nerves. B. Insertion of the needle. of the nerve. B. Insertion of the needle.
The nerve exits the infraorbital foramen and travels inferiorly and
medially. It provides sensory innervation to the medial cheek, nasal
ala, upper lip, and the skin between the upper lip and nose. The
infraorbital nerve terminates as the anterior and middle superior
alveolar nerves. They provide sensory innervation to the maxillary
incisors, canine, and premolar teeth, as well as their bony support
and surrounding soft tissues.
Patient Positioning Place the patient supine, or sitting, and facing the
Landmarks Identify the infraorbital foramen by palpation. Signifi-
cant tenderness will be elicited when the infraorbital nerve is pal-
pated as it exits the infraorbital foramen.
Needle Insertion and Direction Insert a 25 or 27 gauge needle just
above the infraorbital foramen (Figure 126-5B). Advance the nee-
dle until the maxilla is contacted. Inject 1 to 2 mL of local anesthetic FIGURE 126-7. The extraoral approach to the mental nerve block. A. Location of
solution. the nerve. B. Insertion of the needle.
Remarks The infraorbital nerve can be blocked intraorally. The
intraoral route results in the patient experiencing less pain than the
extraoral route. (Figures 126-3 & 126-7). The nerve travels inferiorly and ante-
riorly to provide sensory innervation to the skin of the lower lip
INFRAORBITAL NERVE BLOCK, INTRAORAL APPROACH and chin.
Anatomy The anatomy and innervation of the infraorbital nerve is Patient Positioning Place the patient supine, or sitting, and facing the
described in the previous section. Emergency Physician.
Patient Positioning Place the patient supine, or sitting, and facing the Landmarks Identify the vertical plane consisting of the supraor-
Emergency Physician. bital foramen, the infraorbital foramen, and the midposition pupil.
Landmarks Identify the infraorbital foramen by palpation. It lies in Identify the point where the vertical plane crosses the middle of the
a plane with the supraorbital foramen and the pupil in the midposi- body of the mandible (Figure 126-7A). This is where the mental
tion (Figures 126-3 & 126-6A). nerve exits the mental foramen.
Needle Insertion and Direction Place the index finger of the nondomi- Needle Insertion and Direction Insert a 25 or 27 gauge needle at the
nant hand over the infraorbital foramen (Figure 126-6B). Use the above identified landmark (Figure 126-7B). Place a skin wheal of
nondominant thumb to retract the upper lip. Insert a 2.5 to 4.0 cm, 25 local anesthetic solution at this intersection. Advance the needle
or 27 gauge needle through the mucous membranes, directed at the through the skin wheal until the mandible is contacted. Inject 1 to
index finger. Advance the needle until its tip is palpable at the infra- 2 mL of local anesthetic solution.
orbital foramen by the index finger. The estimated depth of needle Remarks This nerve can also be blocked intraorally.
penetration is 1.0 to 1.5 cm. Inject 2 mL of local anesthetic solution.
Remarks This is the preferred route to block the infraorbital nerve. MENTAL NERVE BLOCK, INTRAORAL APPROACH
It can also be blocked extraorally.
Anatomy The anatomy and innervation of the mental nerve is
MENTAL NERVE BLOCK, EXTRAORAL APPROACH described in the previous section.
Patient Positioning Place the patient supine, or sitting, and facing the
Anatomy The mental nerve is a branch of the mandibular divi- Emergency Physician.
sion of the trigeminal nerve. It emerges from the mental foramen.
Landmarks Retract the lower lip and identify the junction of the first
The foramen lies in a vertical plane with the supraorbital fora-
men, the infraorbital foramen, and the pupil that is midposition and second premolars. The patient’s mouth may be open or closed.
Needle Insertion and Direction Insert a 25 or 27 gauge needle directed
inferiorly and posteriorly through the gingival mucosa at the junc-
tion of the first and second premolars (Figure 126-8). Advance the
needle one-third the depth of the mandibular body and contact the
mandible. Inject 1 to 2 mL of local anesthetic solution.
Remarks This is the preferred approach to block the mental nerve.
The intraoral route results in the patient experiencing less pain than
the extraoral route.
GREATER OCCIPITAL NERVE BLOCK

Anatomy The greater occipital nerve is a branch of the dorsal ramus
of the second cervical nerve. It provides sensory innervation to
the posterior neck, extending superiorly to the vertex of the scalp
(Figure 126-9). It emerges on the posterosuperior neck, just below
the line connecting the external occipital protuberance and the mas-
FIGURE 126-6. The intraoral approach to the infraorbital nerve block. A. Location toid process (Figure 126-10). The posterior occipital artery accom-
of the nerve. B. Insertion of the needle. panies the greater occipital nerve.
FIGURE 126-8. The intraoral approach to the mental nerve block.
FIGURE 126-9. The cutaneous nerve supply to the face, scalp, and upper neck.
A B
Posterior occipital Occipital
artery artery
External occipital
protuberance
Superior
nuchal line
Area of
infiltration
Mastoid
process
Great
auricular
Lesser nerve
occipital nerve
Greater
occipital nerve
Lesser occipital
nerve
FIGURE 126-10. Regional anesthesia of the posterolateral scalp. A. The greater occipital nerve block. B. The lesser occipital and great auricular nerve blocks.
Patient Positioning Place the patient prone. nerve. The great auricular nerve can be blocked at the level of the
Landmarks Identify the external occipital protuberance and mas- cervical plexus. Refer to the section on cervical plexus blockade
toid process by palpation (Figure 126-10A). Connect these land- below.
marks with a line. Identify the occipital artery by its palpable pulse,
approximately one-third the distance from the external occipital SCALP BLOCK
protuberance.
Needle Insertion and Direction Place a skin wheal of local anesthetic Anatomy The scalp receives its sensory innervation from branches
solution over the pulse of the occipital artery. Insert a 25 gauge nee- of the trigeminal nerve anteriorly and the cervical plexus posteriorly
dle 1 to 2 mm to the left of the occipital artery pulse. Inject 1 mL of (Figure 126-11). The scalp may be anesthetized anywhere along the
local anesthetic solution. Redirect the needle 1 to 2 mm to the right anterior midline to the posterior midline. This involves blocking
of the pulse and inject 1 mL of local anesthetic solution. the supratrochlear, supraorbital, auriculotemporal, lesser occipital,
great auricular, and greater occipital nerves.
Remarks This block is useful for laceration repair as well as relief
of occipital muscular or tension headaches. If the pulse of the Patient Positioning Place the patient supine with their head turned
posterior occipital artery is not palpable, divide the line between toward the side opposite that being anesthetized.
the external occipital protuberance and the mastoid process into Landmarks Identify the glabella and the external occipital protuber-
thirds. Infiltrate the middle third subcutaneously with 5 to 8 mL ance by palpation.
of local anesthetic solution (Figure 126-10A). This technique will Needle Insertion and Direction Place a skin wheal of local anesthetic
also anesthetize the lesser occipital nerve. solution over the glabella. Insert a 25 gauge needle through the skin
wheal. Infiltrate a continuous line of local anesthetic solution subcu-
LESSER OCCIPITAL NERVE BLOCK taneously between the glabella and the external occipital protuber-
ance (Figure 126-11B). This requires 15 to 20 mL of local anesthetic
Anatomy The lesser occipital nerve is a branch of the cervical plexus. solution.
It provides sensory innervation to the skin and scalp between the Remarks Infiltrate the local anesthetic solution subcutaneously
ear and the mastoid process (Figure 126-9). It emerges at the mid- along the scalp base inferior to the area in which the procedures
dle third of the posterior border of the sternocleidomastoid muscle will be performed to block only a portion of the scalp. It is use-
and travels superiorly toward the mastoid process (Figure 126-10). ful to add epinephrine (1:200,000) to the local anesthetic solu-
Patient Positioning Place the patient supine or sitting with their head tion to cause vasoconstriction and prevent excessive blood loss.
turned toward the side opposite that being anesthetized. Significant systemic absorption of the local anesthetic agent does
Landmarks Identify the mastoid process by palpation. not occur despite the extensive vascularity of the scalp. Scalp
blocks provide anesthesia for laceration repair, drainage of superfi-
cial abscesses, and the exploration of scalp wounds. Complications
solution just posterior to the mastoid process. Insert a 25 gauge nee-
are fairly rare. There is a case report of a temporary facial nerve
dle directed anteriorly through the skin wheal. Advance the needle
palsy after a scalp block.19
while infiltrating local anesthetic solution subcutaneously until the
posterior ear is contacted (Figure 126-10B). This requires 3 to 7 mL
of local anesthetic solution. EXTERNAL EAR BLOCK
Remarks The lesser occipital nerve can be blocked at the level of Anatomy The ear is a difficult structure to anesthetize. It is inner-
the cervical plexus. Refer to the section on cervical plexus blockade vated by a large number of sensory fibers that originate from the
below. cervical plexus, the trigeminal nerve, and the vagus nerve. The
external ear, or pinna, is innervated by the cervical plexus and the
GREAT AURICULAR NERVE BLOCK auriculotemporal branch of the trigeminal nerve (Figures 126-9 &
126-11).
Anatomy The great auricular nerve is a branch of the cervical Patient Positioning Place the patient supine or sitting upright with
plexus. It emerges at the middle third of the posterior border of the their head turned toward the side opposite that being anesthetized.
sternocleidomastoid muscle and travels superiorly with the external
Landmarks Identify the angle of the mandible by palpation.
jugular vein (Figure 126-10B). This nerve provides sensory inner-
vation to the skin and scalp behind the ear, the posterior ear, and the Needle Insertion and Direction Place a skin wheal of local anesthetic
lobule (Figure 126-9). solution over the angle of the mandible. Insert a 25 gauge needle
Patient Positioning Place the patient supine with their head turned
through the skin wheal. Infiltrate local anesthetic solution subcu-
toward the side opposite that being anesthetized. taneously in an anterior and superior direction, from the angle of
the mandible to the superior surface of the ear, to block the auricu-
Landmarks Identify the lobule of the ear, the mastoid process, and lotemporal nerve (Figure 126-12A). Infiltrate local anesthetic solu-
the sulcus behind the ear. tion subcutaneously in a posterior and superior direction, from the
Needle Insertion and Direction Place a skin wheal of local anesthetic angle of the mandible to the superior surface of the ear, to block the
solution just posterior to the mastoid process. Insert a 25 gauge nee- great auricular and lesser occipital nerves (Figure 126-12A). This
dle directed anteriorly through the skin wheal. Advance the needle requires a total of 8 to 10 mL of local anesthetic solution.
while infiltrating local anesthetic solution subcutaneously until the Remarks Some may prefer to anesthetize the auriculotempo-
posterior ear is contacted (Figure 126-10B). This requires 3 to 7 mL ral nerve trunk by injecting local anesthetic solution just above
of local anesthetic solution. Complete and successful anesthesia the posterior aspect of the zygomatic arch (Figure 126-12B). It
occurs within 10 minutes. requires less local anesthetic solution and hurts less than subcuta-
Remarks The great auricular nerve block is indicated for lacerations neous infiltration. An alternative technique is to circumferentially
of the auricle, debridement, and hematoma evacuations. It is rarely infiltrate local anesthetic solution subcutaneously around the ear
performed without simultaneous blockade of the auriculotemporal (Figure 126-12C).
Zygomaticotemporal
A B
Supratrochlear nerve Supraorbital
nerve nerve
Supraorbital
nerve Supratrochlear
nerve
Zygomaticotemporal
nerve
Auriculotemporal
nerve
Lesser
occipital nerve External occipital
protuberance
Greater occipital
nerve
Lesser occipital
nerve
Greater Auriculotemporal
occipital nerve nerve
FIGURE 126-11. The scalp block. A. The sensory innervation of the scalp. B. Local anesthetic solution is injected subcutaneously along the base of the scalp.
EXTERNAL AUDITORY CANAL BLOCK Landmarks Identify the helix, the tragus, and the lobule of the ear to
be anesthetized (Figure 126-13).
Anatomy The external auditory canal (and the tympanic mem- Needle Insertion and Direction Anesthetize the external audi-
brane) receives its innervation from the auriculotemporal nerve and tory canal using a four-quadrant block (Figure 126-13). Insert
the vagus nerve. a 25 gauge needle, advance it 0.5 to 0.75 cm, and inject 1 mL of
Patient Positioning Place the patient sitting upright or supine with local anesthetic solution at each of the four landmarks identified
their head turned toward the side opposite that being anesthetized. in Figure 126-13.
FIGURE 126-12. The external ear block. A. Infiltration of local anesthetic solution from the angle of the mandible to the anterior (1) and posterior (2) superior surfaces of
the ear. B. The site for anesthetizing the trunk of the auriculotemporal nerve. C. An alternative method.
(Figure 126-14A). The cervical plexus provides motor innervation

to the strap muscles of the neck.
The four superficial nerves of the cervical plexus are the lesser
occipital nerve, the great auricular nerve, the anterior (or transverse)
cervical nerve, and the supraclavicular nerve (Figure 126-14A).
The lesser occipital nerve travels superiorly and posteriorly to
provide sensory innervation to part of the posterior surface of the
upper ear and the postauricular skin. The great auricular nerve
travels superiorly and anteriorly to provide sensory innervation to
the skin over the posterior surface of the ear, the anterior lower
half of the ear, and over the angle of the mandible. The anterior,
or transverse, cervical nerve of the neck travels anteriorly to pro-
vide sensory innervation to the skin of the neck, from the inferior
border of the mandible to the sternum. The supraclavicular nerves
travel from the clavicle down to the second rib.
Patient Positioning Place the patient supine with their head turned
toward the side opposite of that being anesthetized.
Landmarks Identify the posterior border of the sternocleidomastoid
FIGURE 126-13. External auditory canal block. Inject local anesthetic solution at muscle by palpation. Divide this border into thirds.
each of the four landmarks. This block also anesthetizes the tympanic membrane. Needle Insertion and Direction Place a skin wheal of local anesthetic
solution over the middle third of the posterior border of the ster-
nocleidomastoid muscle. Insert a needle through the skin wheal.
Infiltrate 5 to 10 mL of local anesthetic solution subcutaneously over
Remarks This block can be quite painful for the patient. The the middle third of the posterior border of the sternocleidomastoid
authors recommend to first anesthetize the external ear before muscle (Figure 126-14B).
anesthetizing the external auditory canal. This block also anesthe-
tizes the tympanic membrane. Remarks This block is useful when managing burns or suturing lac-
erations on the anterolateral neck.
CERVICAL PLEXUS BLOCK

REGIONAL ANESTHESIA TECHNIQUES
Anatomy The cervical plexus originates from the anterior rami of FOR THE UPPER EXTREMITY
cervical nerves two through four. These rami form numerous loops
that anastomose to form nerves that provide sensory innervation
BRACHIAL PLEXUS BLOCK
to the anterolateral neck, the scalp, the ear, and the infraclavicular
area. The four nerves of the cervical plexus become superficial at The brachial plexus innervates the entire upper extremity. Blockade
the midportion of the posterior border of the sternocleidomas- of the brachial plexus can be performed to repair tendons or exten-
toid muscle and then distribute to their respective sensory areas sive lacerations, to reduce fractures and dislocations, or to provide
A B
Lesser
occipital nerve
Great auricular nerve
Sternocleidomastoid Spinal accessory nerve

muscle
Trapezius muscle
Anterior cervical
nerve
Supraclavicular nerve Sternocleidomastoid muscle
FIGURE 126-14. The cervical plexus block. A. The cutaneous nerves of the cervical plexus. B. Injection of local anesthetic solution posterior to the middle third of the
sternocleidomastoid muscle.
A Roots B
C4
C5 Trunks
C6
Su Divisions
per
C7 ior
Mid
dle
C8
Cords
Infe
rior
T1
Lat
era
l Branches
Po
sterio
r
Med
ial
FIGURE 126-15. The brachial plexus. A. The anatomy of the brachial plexus. B. The brachial plexus is contained within a sheath. The subclavian artery and vein enter the
sheath at the level of the clavicle.
anesthesia for burn care, to name a few uses. Protect the arm from Aspirate to ensure that the tip of the needle is not within a blood
injury if this procedure is to be performed by properly support- vessel. Inject 40 mL of local anesthetic solution. Reduce the volume
ing the arm, padding the ulnar nerve and pressure points, and not based upon the patient’s body size and the maximal allowable dose
extending or displacing the arm posteriorly. to prevent toxicity.
The brachial plexus arises from the C5 to T1 nerve roots US-Guided Block Place the US probe in an oblique coronal plane
(Figure 126-15). The nerve roots fuse to form three trunks. Each above the clavicle and lateral to the sternocleidomastoid muscle
trunk divides into an anterior and posterior division that then (Figure 126-16D). Locate the subclavian artery. It is a pulsatile,
redistributes to form the lateral, medial, and posterior cords. These round, and hypoechoic structure in cross section. The trunks of
cords divide in the region of the axilla to form the musculocutane- the brachial plexus are located adjacent to the subclavian artery
ous nerve, the median nerve, the ulnar nerve, the axillary nerve, (Figure 126-16E). Posterior to the subclavian artery lies the
the radial nerve, and several cutaneous nerves. The brachial plexus first rib, and the pleural line can be seen sliding in real time. Use
crosses the midclavicle to enter the axilla (Figure 126-16A). color/power Doppler to confirm the location of the subclavian
The brachial plexus may be blocked from the supraclavicular, artery and any branches or take-offs, all of which must be avoided
interscalene, infraclavicular, or axillary approach. The preferred (Figure 126-16F). Anesthetize the skin. Position the spinal needle
method for the Emergency Physician is the axillary block. lateral to the US probe and parallel to its long axis. Slowly insert and
advance the needle. Visualize the entire length of the needle as it
is introduced through the subcutaneous tissue toward the brachial
BRACHIAL PLEXUS BLOCK, plexus. Advance the needle through the nerve sheath. Aspirate to
SUPRACLAVICULAR APPROACH ensure the needle tip is not in a blood vessel. Inject a test dose of
1 to 2 mL of local anesthetic solution. Watch the spread of anes-
Anatomy The anatomy of the brachial plexus is described above.
thetic around the nerves. If it is satisfactory, inject the remain-
This approach blocks the brachial plexus at the level of the trunks,
der of the local anesthetic solution to achieve the “donut sign”
where it is most compactly arranged.
(Figure 126-16G). If the test dose is not satisfactory, reposition the
Patient Positioning Place the patient supine with their head turned needle and inject another test dose.
45° from the midline and toward the side opposite that being anes-
Remarks This block is characterized by a quick onset of anesthe-
thetized (Figure 126-16A). Place the ipsilateral arm in any position
sia and a complete block. A high volume of anesthetic is required
of comfort for the patient.
with a quick onset of anesthesia. There is no chance of missing
Landmarks The subclavian artery is the main landmark. Palpate the peripheral or proximal nerve branches because of failure of the
subclavian artery immediately lateral to the clavicular head of the local anesthetic solution to spread along the sheath of the brachial
sternocleidomastoid muscle in the interscalene groove. Identify plexus. Unfortunately, this technique is difficult to teach and to
the midpoint of the clavicle. master without considerable experience. This technique has a high
Needle Insertion and Direction Place a skin wheal of local anes- incidence of an iatrogenic pneumothorax, reportedly up to 6%.
thetic solution 2 cm above the midclavicle. Insert a 25 gauge needle Other complications include blockade of the phrenic nerve, sub-
directed caudally through the skin wheal (Figures 126-16B & C). clavian artery puncture, and Horner’s syndrome. Unintentional
Advance the needle until the patient experiences paresthesias. intravascular injection can result in high blood levels of the local
Withdraw the needle 1 mm and allow the paresthesias to resolve. anesthetic agent.
A B
External jugular
Sternocleidomastoid muscle vein
Middle scalene muscle

2 cm
Anterior scalene muscle
External jugular vein
Subclavian
artery
Subclavian
vein
Subclavian
artery
C Sternocleidomastoid
Anterior scalene
muscle
muscle
Clavicle Brachial plexus
Subclavian
Subclavian vein artery
First rib Lung
D E
FIGURE 126-16. The supraclavicular approach to the brachial plexus block. A. The course of the brachial plexus. B. The needle is inserted perpendicular to the skin and
2 cm superior to the middle of the clavicle. C. Sagittal section demonstrating the trajectory of the needle (dotted line). D. US probe and needle placement. E. The supra-
clavicular brachial plexus (arrowheads) is adjacent to the subclavian artery (SA). The first rib is denoted by the arrows.
BRACHIAL PLEXUS BLOCK, Patient Positioning Place the patient supine with their head turned
INTERSCALENE APPROACH 45° from midline and toward the side opposite that being anesthe-
tized (Figure 126-17A). Place the ipsilateral arm in any position of
Anatomy The anatomy of the brachial plexus is described above. comfort for the patient.
This approach blocks the brachial plexus at the level of the trunks Landmarks Identify the posterior border of the clavicular head of
(Figure 126-17A). the sternocleidomastoid muscle by palpation. Move the palpating
F G
FIGURE 126-16. (continued ) F. Color Doppler of the supraclavicular brachial plexus (arrowheads). The subclavian artery and a branch are visible in color. G. The “donut
sign.” Local anesthetic solution (*) surrounds the nerve bundles.
A B
Sternocleidomastoid External
muscle jugular vein
Middle scalene
muscle
Interscalene
groove Cricoid
Anterior scalene Cricoid
muscle cartilage cartilage
C D
FIGURE 126-17. The interscalene approach to the brachial plexus block. A. The anatomy of the region. B. The needle is inserted into the interscalene groove at the level of
the cricoid cartilage. C. US probe placement. D. The brachial plexus (between the arrows) is located between the anterior scalene (AS) and the middle scalene (MS) muscles.
finger laterally until it rolls into the interscalene groove between the assistant to deliver a test dose of 1 to 2 mL of local anesthetic solu-
anterior and middle scalene muscles, at the level of the cricoid car- tion. If the anesthetic spreads around the nerves, slowly deliver
tilage (Figure 126-17B). the remainder of the local anesthetic solution to obtain the “donut
Needle Insertion and Direction Place a skin wheal of local anesthetic sign.” If the test dose is not satisfactory, reposition the needle and
solution in the interscalene groove, at the level of the cricoid car- inject another test dose.
tilage. Slowly insert a 25 gauge needle through the skin wheal in Remarks The advantages and disadvantages are similar to those
a dorsal, medial, and caudal direction (Figure 126-17B). Advance of the supraclavicular approach with the exception of possibly not
the needle until the patient experiences paresthesias. Withdraw achieving anesthesia of the lower trunk. This may require supple-
the needle 1 mm and allow the paresthesias to resolve. Aspirate to mentary blockade of the median and ulnar nerves. The intersca-
ensure that the tip of the needle is not within a blood vessel. Inject lene brachial plexus block, although ideal for regional anesthesia
30 to 40 mL of local anesthetic solution. Reduce the volume based of the shoulder, has been associated with recurrent laryngeal
upon the patient’s body size and the maximal allowable dose to pre- nerve paralysis and an almost 100% incidence of phrenic nerve
vent toxicity. paralysis.20 This can be significant in patients with respira-
US-Guided Block This block is performed at the level of the inter- tory comorbidities (e.g., COPD, obesity).21 The supraclavicu-
nal jugular vein and carotid artery in the neck. Place the US probe lar brachial plexus block is associated with lower rates of these
on the neck, less than a third of the way up from the clavicle complications.2
(Figure 126-17C). Identify the carotid artery and internal jugular
vein. Move the US probe laterally to find the muscle bellies of the BRACHIAL PLEXUS BLOCK, AXILLARY APPROACH
anterior and middle scalene muscles (Figure 126-17D). Between
the muscles lie the nerve roots of the brachial plexus in cross sec- Anatomy The anatomy of the axillary brachial plexus nerve block
tion. It is represented by hypoechoic circles within the hyperechoic is rather simple. The neurovascular bundle is easily found at the
rings of the nerve sheaths (Figure 126-17D). Use color Doppler anterior axillary fold by palpating for the pulsations of the axillary
to identify any blood vessels in the field, and note their loca- artery. The neurovascular bundle is surrounded by the fibrous axil-
tion so as to avoid them. Anesthetize the skin. Using a posterior lary sheath (Figure 126-18A). The axillary sheath is bound medially
approach, insert the spinal needle connected by extension tubing by skin and connective tissue, anteriorly by the biceps and coraco-
to a 20 mL syringe filled with local anesthetic solution. Advance brachialis muscles, inferiorly by the triceps muscle, and laterally
the needle and visualize it approaching the brachial plexus. The by the neck of the humerus. The axillary artery is the central refer-
needle path will usually go through the middle scalene muscle. ence structure within the neurovascular bundle. Within the axillary
Once the brachial plexus is close to the needle tip, use a short sheath, the median nerve is anterior, the radial nerve is posterolat-
and controlled jab to penetrate through the nerve sheath. Aspirate eral, and the ulnar nerve is posterior to the axillary artery. The axil-
to verify that the needle tip is not in a blood vessel. Instruct an lary vein is medial to the artery. The medial antebrachial cutaneous
A B
Median nerve
Deltoid
Pectoral
muscle Biceps
muscle
Musculocutaneous muscle
nerve
Axillary Radial nerve

vein
Axillary sheath of
brachial plexus
Ulnar nerve Axillary artery
Coracobrachialis
C
muscle
Median nerve
Musculocutaneous
nerve
Axillary vein Radial nerve
Axillary artery
Ulnar nerve
FIGURE 126-18. The axillary approach to the brachial plexus block. A. The topographical arrangement of the contents of the axillary sheath at the level of the blockade.
B. The patient is positioned and the axillary artery pulse is palpated with one finger. The needle is inserted above the pulse and along the course of the axillary sheath.
C. The needle may travel above the sheath and enter it at a higher level.
D E
F G
FIGURE 126-18. (continued ) D. US image of the axillary brachial plexus. E. Same image as (D) with labels (A—axillary artery, B—biceps muscle, V—axillary vein, red
oval—median nerve, green oval—ulnar nerve, blue oval—radial nerve). F. US probe and needle placement. G. Color Doppler of the axillary artery (red) and vein (blue).
nerve and the medial brachial cutaneous nerve are medial to the pulse (Figure 126-18C). Instruct an assistant to attach the distal
artery (Figure 126-18A). The only sensory nerve outside the neu- end of intravenous extension tubing to the hub of the needle, and
rovascular bundle is the musculocutaneous nerve. This nerve exits the proximal end to a 60 mL syringe containing local anesthetic
the axillary sheath as it crosses the clavicle. solution. The Emergency Physician must always maintain pres-
Patient Positioning Place the patient supine with their head turned sure against the neurovascular bundle with the nondominant hand
toward the side opposite that being anesthetized (Figure 126-18B). while stabilizing the needle with the dominant hand. Instruct the
Abduct the arm 90°. Flex the elbow 90° so that the forearm is paral- assistant to aspirate to ensure that the tip of the needle is not within
lel to the long axis of the body and the palm is facing upward. a blood vessel. Withdraw the needle 2 mm if blood flow or pares-
thesias are elicited.
Landmarks Identify the brachial artery by its palpable pulse. Trace Apply digital pressure to the neurovascular bundle just dis-
it proximally to the anterior axillary fold, formed by the pectoralis tal to the tip of the needle with the nondominant fingers. This
major muscle. Use the index and middle fingers of the nondominant prevents the local anesthetic solution from flowing distally. Inject
hand to secure the neurovascular bundle (identified by the pulse) the local anesthetic solution into the axillary sheath after the pares-
against the humerus (Figure 126-18B). thesias have resolved and a negative aspiration has been achieved.
Needle Insertion and Direction Place the skin wheal of local anes- Instruct the assistant to inject a volume of approximately 40 mL
thetic solution overlying the axillary artery pulse, just posterior in the adult patient. This volume has been shown to consistently
to the anterior axillary fold. Insert a 22 gauge spinal needle just block the entire brachial plexus. Reduce the volume based upon
above the fingertip on the axillary pulse, directed toward the the patient’s body size and the maximal allowable dose to prevent
apex of the axilla and in the direction of the neurovascular bun- toxicity. Continue to apply digital pressure to the neurovascular
dle (Figure 126-18B). Advance the needle. A “pop” will be felt bundle just distal to the needle during and after injection of the
as the axillary sheath is penetrated. The correct needle position local anesthetic solution.
is confirmed by eliciting paresthesias, observing blood flow in Withdraw the needle while the assistant simultaneously injects
the needle, or observing pulsations of the needle that match the 3 to 5 mL of local anesthetic solution into the subcutaneous tissue.
This blocks the medial brachial cutaneous nerve and the intercosto- BRACHIAL PLEXUS BLOCK,
brachial nerve. Abduct the patient’s arm 30° to 45° after the needle INFRACLAVICULAR APPROACH
is withdrawn. Maintain this position, while continuing to apply
digital pressure to the neurovascular bundle just distal to the needle This approach to the brachial plexus has many advantages and few
insertion site, for 2 to 3 minutes. serious complications. Unfortunately, this technique requires con-
US-Guided Block This block is performed at the level of the terminal siderable experience on the part of the Emergency Physician and
branches of the brachial plexus within the axillary sheath. These a nerve stimulator to locate the brachial plexus (Figures 126-19A
branches are visualized as hyperechoic nodules around the pulsa- & B). For these reasons, the anatomic landmark approach will not
tile and hypoechoic axillary artery (Figures 126-18D & E). Place be described. The US-guided technique is described below.
the US probe with the marker pointing cephalad at the superior Anatomy The anatomy of the brachial plexus is described above.
axillary crease (Figure 126-18F). Locate the axillary artery and This approach blocks the brachial plexus at the level of the cords
vein in cross section (Figure 126-18G). The musculocutaneous (Figure 126-15A).
nerve can be seen between the biceps muscle and the coracobrachi- Patient Positioning Place the patient supine with their head turned
alis muscle. Use color Doppler to confirm the location of the axil- 45° from midline and toward the side opposite that being anesthe-
lary artery, vein, and any branches or take-offs (Figure 126-18G). tized (Figure 126-19A). Place the ipsilateral arm extended 90°.
Anesthetize the skin. Position the spinal needle inferior or superior
to the long axis of the US probe (Figure 126-18F). Slowly insert Landmarks Identify the middle third of the clavicle.
and advance the needle. Visualize the entire length of the needle as Infraclavicular Block This block is performed below the clavicle. The
it is advanced. Aim the needle between the axillary artery and vein. cords of the brachial plexus lie below the pectoralis major and minor
Advance through the nerve sheath. Aspirate to ensure the needle muscles. They appear as distinct hyperechoic nodules positioned
tip is not in a blood vessel. Inject a test dose of 1 to 2 mL of local laterally, medially, and posteriorly around the subclavian artery
anesthetic solution. Watch the spread of local anesthetic solution (Figures 126-19C & D). Prep and drape the infraclavicular region.
around the subclavian artery. If it is satisfactory, inject the remain- Place the US probe with the marker pointing cephalad below the
der of the local anesthetic solution to produce the “donut sign.” If clavicle, medial to the coracoid process (Figure 126-19E). Locate
the test dose is not satisfactory, reposition the needle and inject the subclavian artery (which is pulsatile) and vein in cross section.
another test dose. Use color Doppler to confirm the location of the subclavian artery,
Remarks The axillary approach to the brachial plexus is the most vein, and any branches or take-offs (Figure 126-19F). Anesthetize
commonly used and preferred technique. The procedure is easily the skin. Position the spinal needle inferior or superior to the long
mastered, has no major complications, and is easily performed in axis of the US probe (Figure 126-19E). Insert and advance the
the obese patient. The disadvantages of this technique include insuf- needle. Visualize the entire length of the needle as it is advanced.
ficient anesthesia of the shoulder and upper arm. The musculocu- Aim the needle between the subclavian artery and vein. Advance the
taneous nerve provides sensory innervation to the radial aspect of needle. Continue to advance the needle through the nerve sheath.
the forearm and may be missed by the local anesthetic agent. The Aspirate to ensure that the needle tip is not in a blood vessel. Inject a
subcutaneous infiltration of local anesthetic solution usually blocks test dose of 1 to 2 mL of local anesthetic solution. Watch the spread
the musculocutaneous nerve. Proximal flow of the local anesthetic of local anesthetic solution around the subclavian artery. If satisfac-
solution is required to ensure adequate anesthesia. Abduction of tory, inject the remainder of the local anesthetic solution to produce
the arm while maintaining pressure on the neurovascular bundle the “donut sign.” If the test dose is not satisfactory, reposition the
allows proximal flow of the local anesthetic solution. It also prevents needle and inject another test dose.
the humeral head from limiting proximal spread due to compres- Remarks This block can result in an iatrogenic pneumothorax due
sion of the brachial plexus. to the proximity of the needle to the lung apex.
A B
Chassaignac's
tubercle (C6)
Axillary sheath of
brachial plexus
2.5 cm
Brachial
artery Clavicle
2.5 cm
Pectoralis
major muscle
FIGURE 126-19. The infraclavicular approach to the brachial plexus block A. Needle insertion and direction. B. Sagittal section demonstrating needle insertion into the
neurovascular bundle. The alligator clip is attached to a nerve stimulator.
C D
FIGURE 126-19. (continued ) C. US image of the infraclavicular brachial plexus.

D. Same image as (C) with labels (A—subclavian artery, V—subclavian vein, red
oval—lateral cord, green oval—medial cord, blue oval—posterior cord). E. US probe
and needle placement. The clavicle is located between the two red lines. F. Color F
Doppler of the subclavian artery (red) and vein (blue).
Landmarks Identify the medial and lateral epicondyle of the

humerus by palpation. Connect the epicondyles with a straight line
(Figure 126-21A). Identify the brachial artery by palpating for its
pulse just medial to the biceps tendon and over the line just drawn.
Mark the site of the palpable pulse with a marker.
solution just medial to the pulse, at the level of the intercondylar
line. Insert a 25 gauge needle perpendicular to the skin and slowly
advance it. If paresthesias are elicited, withdraw the needle 1 to
2 mm and allow the paresthesias to resolve. Inject 3 to 5 mL of local
anesthetic solution. If paresthesias are not elicited, slowly move the
needle in a fan-like pattern to elicit paresthesias. Withdraw the nee-
dle 1 to 2 mm, allow the paresthesias to resolve, and inject 3 to 5 mL
of local anesthetic solution.
US-Guided Block Place the US probe in the crease of the antecubi-
tal fossa. Locate the pulsatile brachial artery in the middle of the
antecubital fossa (Figure 126-21B). Anesthetize the skin medial
to the brachial artery. Place the spinal needle inferior to the short
axis of the US probe directly over the median nerve, which should
be medial to the brachial artery. Only the tip of the needle will
be visualized in this view. Insert and advance the needle until its
tip is at the median nerve. Aspirate to ensure that the needle tip
is not in a blood vessel. Inject a test dose of 1 to 2 mL of local
anesthetic solution. Watch the spread of the local anesthetic solu-
tion around the median nerve. If satisfactory, inject the remain-
der of the local anesthetic solution to produce the “donut sign.” If
the test dose is not satisfactory, reposition the needle and inject
another test dose.
Remarks The median nerve has no sensory branches in the forearm.
Therefore, there is no advantage to blocking the median nerve at the
elbow. Inserting the needle to elicit paresthesias can be quite painful
for the patient. Blockade at the wrist is usually easier to perform,
especially in obese patients.9
MEDIAN NERVE BLOCK AT THE WRIST

Anatomy The median nerve lies in the carpal tunnel on the volar
aspect of the wrist. It is located between the tendons of the flexor
carpi radialis and palmaris longus muscles (Figure 126-21C). The
innervation of the median nerve is described in the previous section.
Patient Positioning Place the patient supine with their arm abducted
FIGURE 126-20. The sensory innervation of the hand. A. The median nerve. 45°, the elbow in full extension, and the hand fully supinated
B. The ulnar nerve. C. The radial nerve. (Figure 126-21A).
Landmarks Identify the palmaris longus tendon by flexing the
patient’s clenched hand against resistance. Mark the radial border of
the palmaris longus tendon. Note the position of the proximal and
distal wrist creases.
MEDIAN NERVE BLOCK AT THE ELBOW
Anatomy The median nerve innervates all the muscles of the ante- solution along the radial border of the palmaris longus tendon,
rior forearm except the flexor digitorum profundus to the ring and between the proximal and distal wrist creases. Insert a 25 gauge
little fingers and the flexor carpi ulnaris.12,22,23 It innervates the the- needle perpendicular to the skin wheal and advance it slowly
nar muscles and the lumbrical muscles to the index and middle (Figure 126-21C). If paresthesias are elicited, withdraw the needle
fingers in the hand. It provides sensory innervation to the palmar 1 to 2 mm and allow them to resolve. Inject 3 to 5 mL of local anes-
aspect of the thumb, index finger, middle finger, radial portion thetic solution. If paresthesias are not elicited, inject 5 to 10 mL of
of the ring finger, and the lateral half of the palm (Figure 126- local anesthetic solution. Injection of the local anesthetic solution
20A). The median nerve provides a variable amount of sensory should not raise a skin wheal and should flow effortlessly if the
innervation to the dorsal distal surfaces of the lateral three and needle is within the carpal tunnel.12
one-half fingers.12 US-Guided Block Place the US probe over the middle of the
Patient Positioning Place the patient supine with their arm wrist with the marker pointing laterally (Figure 126-21D). The
abducted 45°, the elbow in full extension, and the hand supinated Palmaris longus tendon should be visible in the middle of the
(Figure 126-21A). wrist. The median nerve is hyperechoic and directly lateral to
FIGURE 126-21. The median nerve block. A. Blockade at the level of the elbow.
B. US image of the median nerve at the antecubital fossa. C. Blockade at the level
of the wrist. D. US probe and needle placement. E. US image of the volar wrist. E
The median nerve is the round, hyperechoic structure in the center of the image.
this tendon (Figure 126-21E). The radial artery is lateral to the radialis tendon by the same method as identifying the palmaris
median nerve (Figure 126-21C). Anesthetize the skin lateral to longus tendon. Inject the local anesthetic solution 1 cm medial
the palmaris longus tendon. Place the needle inferior to the short to the ulnar edge of the flexor carpi radialis tendon, between the
axis of the US probe and directly over the median nerve (Figure proximal and distal wrist creases. The technique is otherwise as
126-21D). Insert and advance the needle until its tip is at the noted above.
median nerve. Aspirate to ensure that the needle tip is not in a
blood vessel. Inject a test dose of 1 to 2 mL of local anesthetic ULNAR NERVE BLOCK AT THE ELBOW
solution. Watch the spread of the local anesthetic solution around
the median nerve. If satisfactory, inject the remainder of the local Anatomy The ulnar nerve lies in the ulnar groove of the humerus
anesthetic solution to produce the “donut sign.” If the test dose at the elbow, between the olecranon process and medial condyle
is not satisfactory, reposition the needle and inject another test of the humerus (Figure 126-22A). It provides motor innerva-
dose. tion to the flexor carpi ulnaris, the ring and little finger portion
Remarks A small percentage of the population (10% to 15%) does of the flexor digitorum profundus, the palmaris brevis, the hypo-
not have a palmaris longus tendon. Identify the flexor carpi thenar muscles, the third and fourth lumbricals, the interossei,
Olecranon
A process of ulna B
Ulnar nerve
90°
Medial
epicondyle
Distal skin
of humerus Ulnar nerve crease
Flexor carpi Proximal skin
ulnaris tendon crease
Flexor carpi
radialis tendon
Ulnar artery
Radius Ulna Median nerve
Palmaris
longus tendon
FIGURE 126-22. The ulnar nerve block. A. Blockade at the level of the elbow.
B. Blockade at the level of the wrist. C. US probe and needle placement. D. US
image of the volar wrist. The ulnar artery (arrow) is lateral to the hyperechoic ulnar D
nerve (in the crosshairs).
and the adductor pollicis muscles. It provides sensory innervation Landmarks Identify the olecranon process and the medial epicon-
to the medial one-third to one-half of the palm, the palmar aspect dyle of the humerus by palpation. Palpate the groove between the
of the ulnar half of the ring finger, and the entire little finger olecranon process and the medial epicondyle. The ulnar nerve is
(Figure 126-20B). The ulnar nerve provides sensory innervation located within this groove.
to the dorsomedial half of the hand, the little finger, and the ulnar Needle Insertion and Direction Place a skin wheal of local anesthetic
half of the ring finger on the dorsal surface of the hand.24 solution 1 to 2 cm proximal to the ulnar groove. Insert a 25 gauge
Patient Positioning Place the patient supine with their elbow flexed needle through the skin wheal and directed toward the ulnar
90° and the shoulder flexed 45° (Figure 126-22A). groove. Aim the needle parallel to the ulnar groove and the course
of the nerve (Figure 126-22A). Advance the needle into the ulnar the needle tip is not in a blood vessel. Inject a test dose of 1 to 2 mL
groove and inject 5 to 7 mL of local anesthetic solution. If pares- of local anesthetic solution. Watch the spread of local anesthetic
thesias are elicited, withdraw the needle 1 mm and allow them to solution around the ulnar nerve. If satisfactory, inject the remain-
resolve before injecting the local anesthetic solution. der of the local anesthetic solution to produce the “donut sign.” If
US-Guided Block Place the US probe in the crease between the the test dose is not satisfactory, reposition the needle and inject
olecranon process and the medial epicondyle, with the marker another test dose.
pointing laterally. Two hyperlucent structures should be seen, the Remarks This is the preferred approach to block the ulnar nerve.
medial epicondyle medially and the olecranon process closer to Blockade of the ulnar nerve at the wrist is very reliable and does not
the marker. The ulnar nerve is hyperechoic and courses between have the associated complications as at the elbow.25
these two hyperlucent structures. Anesthetize the skin. Place the
needle inferior to the short axis of the US probe and directly over RADIAL NERVE BLOCK AT THE ELBOW
the ulnar nerve. Only the tip of the needle will be visualized in this
view. Insert and advance the needle until its tip is at the ulnar nerve. Anatomy The radial nerve and the sensory branch of the musculo-
Aspirate to ensure that the needle tip is not in a blood vessel. Inject a cutaneous nerve run together in the sulcus between the biceps and
test dose of 1 to 2 mL of local anesthetic solution. Watch the spread the brachioradialis muscle on the anterolateral aspect of the elbow.
of local anesthetic solution around the ulnar nerve. If satisfactory, The radial nerve provides sensory innervation to portions of the
inject the remainder of the local anesthetic solution to produce the dorsal arm and forearm, the dorsolateral half of the hand, and the
“donut sign.” If the test dose is not satisfactory, reposition the needle dorsal proximal aspects of the thumb, index, middle, and radial half
and inject another test dose. of the ring fingers (Figure 126-20).12 It provides motor innervation
Remarks The ulnar nerve has no sensory branches in the forearm to the muscles on the posterior aspect of the arm, forearm, and hand.
and thus may be blocked at the wrist or at the elbow. Blockade of Patient Positioning Place the patient supine with their elbow flexed
the ulnar nerve at the elbow is not recommended. A fibrous sheath 15° to 30°.
surrounds the ulnar nerve at the elbow requiring intraneural injec- Landmarks Palpate the tendon of the biceps muscle in the antecubi-
tion for a successful blockade. This can lead to residual neuritis and tal fossa. Identify the flexion skin crease of the elbow. Palpation of
nerve dysfunction. Blocking the ulnar nerve several centimeters the biceps tendon is greatly facilitated by having the patient flex their
above the elbow may prevent these complications. Blockade at the elbow 90° then contract and relax their biceps muscle. Identify the
wrist is very reliable and does not have the associated complications medial and lateral condyles of the humerus. Draw a line between
as at the elbow. the humeral condyles (Figure 126-23A). This line should be located
at the level of the antecubital crease.
ULNAR NERVE BLOCK AT THE WRIST Needle Insertion and Direction Place a skin wheal of local anes-
thetic solution 2 cm lateral to the biceps tendon and 1 cm proxi-
Anatomy The ulnar nerve lies between the distal and proximal mal to the antecubital crease (Figure 126-23A). Insert a 25 gauge
flexor skin creases of the wrist, lateral (or radial) to the flexor carpi needle through the skin wheal and perpendicular to the skin
ulnaris tendon and medial (or ulnar) to the ulnar artery (Figure (Figure 126-23A). Advance the needle 1 to 2 cm. Probe in a fan-
126-22B). The innervation of the ulnar nerve is described in the like pattern until paresthesias are elicited. Withdraw the needle 1 to
previous section. 2 mm and allow the paresthesias to resolve. Inject 5 to 7 mL of local
Patient Positioning Place the patient supine with their arm abducted anesthetic solution.
45° to 90°, the elbow fully extended, and the hand supinated US-Guided Block Position the patient with their arm abducted 45°,
(Figure 126-22B). the elbow in full extension, and the hand supinated. Place the US
Landmarks Identify the flexor carpi ulnaris tendon by flexing the probe on the lateral aspect of the crease of the antecubital fossa.
patient’s clenched hand against resistance. Mark the medial aspect The radial nerve is lateral to the biceps tendon and the brachial
of the flexor carpi ulnaris tendon. Identify the ulnar artery by its pal- artery (Figure 126-23A). Anesthetize the skin over the radial
pable pulsations between the proximal and distal wrist crease. Note nerve. Place the needle inferior to the short axis of the US probe
the position of the proximal and distal wrist creases. and directly over the radial nerve. Only the tip of the needle will
Needle Insertion and Direction Place a skin wheal of local anes- be visualized in this view. Insert and advance the needle until its
thetic solution in the quadrangle defined by the proximal flexor tip is at the radial nerve. Aspirate to ensure that the needle tip
skin crease, the distal flexor skin crease, the lateral aspect of the is not in a blood vessel. Inject a test dose of 1 to 2 mL of local
flexor carpi ulnaris tendon, and medial to the ulnar artery. Insert a anesthetic solution. Watch the spread of local anesthetic solution
25 gauge needle perpendicular to the skin wheal and slowly advance around the radial nerve. If satisfactory, inject the remainder of the
it 0.5 cm (Figure 126-22B). If paresthesias are elicited, withdraw the local anesthetic solution to produce the “donut sign.” If the test
needle 2 mm and allow them to resolve. Inject 2 mL of local anes- dose is not satisfactory, reposition the needle and inject another
thetic solution once the paresthesias resolve. If paresthesias are not test dose.
elicited, inject 3 to 5 mL of local anesthetic solution. Remarks Blockade of the radial nerve at the elbow is difficult, has
US-Guided Block Place the US probe over the middle of the wrist limited applications, is painful for the patient, and often results in
with the marker pointing laterally (Figure 126-22C). The Palmaris a large antecubital hematoma. The preferred technique is blockade
longus tendon should be visible in the middle of the wrist. Move at the wrist.
the US probe medially until the ulnar artery is visible. The ulnar
nerve is hyperechoic and directly medial to the ulnar artery RADIAL NERVE BLOCK AT THE WRIST
(Figure 126-22D). Anesthetize the skin medial to the ulnar artery.
Position the needle inferior to the short axis of the US probe and Anatomy The radial nerve at the wrist consists of a trunk and termi-
directly over the ulnar nerve (Figure 126-22C). Insert and advance nal branches that arise in the forearm (Figure 126-23C). The inner-
the needle until its tip is at the ulnar nerve. Aspirate to ensure that vation of the radial nerve is described in the previous section.
FIGURE 126-23. The radial nerve block. A. Blockade at the level of the elbow. B. US image of the radial nerve at the elbow. C. Blockade at the level of the wrist. The
numbers represent the three injections required to anesthetize the branches of the radial nerve. D. US image of the wrist. The radial artery (arrow) is adjacent and medial
to the radial nerve (in the crosshairs).
Patient Positioning Place the patient supine with their arm abducted If paresthesias are not elicited, inject 3 to 5 mL of local anesthetic
45°, the elbow fully extended, and the hand midway between supi- solution. This will anesthetize the terminal trunk of the radial
nation and pronation (Figure 126-23C). nerve. Infiltrate 5 to 7 mL of local anesthetic solution at the level
Landmarks Identify the radial artery by its pulsation at the level of of the extensor wrist crease, from the lateral aspect of the radius
the proximal wrist crease. to the base of the fourth metacarpal (Figure 126-23C). This will
anesthetize the terminal branches that arise in the forearm.
solution 1 mm lateral to the radial pulse. Insert a 25 gauge nee- US-Guided Block Place the US probe over the middle of the wrist
dle 1 mm lateral to the radial pulse, through the skin wheal, and with the marker pointing laterally. The palmaris longus tendon
perpendicular to the skin (Figure 126-23C). Advance the needle should be visible in the middle of the wrist. Move the US probe lat-
0.5 cm. If paresthesias are elicited, withdraw the needle 1 to 2 mm erally until the radial artery is visualized. The radial nerve is hyper-
and allow them to resolve. Inject 2 mL of local anesthetic solution. echoic and directly lateral to the radial artery (Figures 126-23D).
Anesthetize the skin lateral to the radial artery and directly over the Remarks This block produces less swelling than does the ring block.
radial nerve. Place the needle inferior to the short axis of the US Subsequently, there is less risk of vascular compromise. This is a less
probe and directly over the radial nerve. Insert and advance the nee- painful technique than the ring block.
dle until its tip is at the radial nerve. Aspirate to ensure that the nee-
dle tip is not in a blood vessel. Inject a test dose of 1 to 2 mL of local DIGITAL NERVE BLOCK
anesthetic solution. Watch the spread of local anesthetic solution
around the radial nerve. If satisfactory, inject the remainder of the
(RING BLOCK) OF THE FINGER
local anesthetic solution to produce the “donut sign.” If the test dose Anatomy The anatomy and innervation of the digital nerves are
is not satisfactory, reposition the needle and inject another test dose. described in the previous section.
Remarks This is the preferred technique for blockade of the radial Patient Positioning Place the patient sitting upright or supine with
nerve. their hand pronated on a bedside examination table.
Landmarks Locate the dorsum of the proximal phalanx to be
WRIST BLOCK anesthetized.
Perform the wrist block by blocking the radial, ulnar, and median Needle Insertion and Direction Insert a 25 gauge needle on the dorsal
nerves at the wrist. The technique for each specific nerve block surface of the base of the proximal phalanx (Figure 126-24D(1)).
was discussed previously. The wrist block provides complete Inject 1 mL of local anesthetic solution along the dorsal surface of
anesthesia to the hand and is commonly used in hand surgery. the finger. Remove the needle and reinsert it downward, perpendic-
It can be performed in the Emergency Department to provide ular to the phalanx and to a depth just past the base of the phalanx
anesthesia for burn management, foreign body removal, wound (Figure 126-24D(2)). Inject 1.0 to 1.5 mL of local anesthetic along
exploration, or extensive laceration repair. Wrist blockade is reli- the lateral aspect of the finger. Withdraw the needle, reinsert it on
able but slow, as it requires extended time to block all three nerves the other side of the finger to be blocked, and inject 1.0 to 1.5 mL of
at the wrist.12 local anesthetic solution (Figure 126-24D(3)).
An alternative is the half-ring block (Figure 126-24E). It is a vari-
ant of the ring block (Figure 126-24D). Inject 1.0 to 1.5 mL of local
INTERMETACARPAL NERVE BLOCK anesthetic solution on one side of the base of the proximal phalanx
to be anesthetized. Repeat this procedure on the other side of the
Anatomy The principal nerves supplying the finger are the palmar finger. The injection of local anesthetic on one side of the finger is
digital nerves, which originate from the deep volar branches of the termed the half-ring block. It takes two half-ring blocks to anesthe-
ulnar and median nerves in the region of the wrist. These nerves tize a finger.
follow the artery along the lateral aspects of the bone and supply
sensation to the volar skin, the interphalangeal joints, the distal fin- Remarks The indications for a digital block include repair of finger
ger, and the fingertip of all five digits. lacerations and amputations, reductions of fractures and disloca-
Two dorsal and two palmar nerves supply each finger. These tions, incision and drainage of infections, removal of fingernails,
nerves run along the phalanxes in the 2, 4, 8, and 10 o’clock posi- and relief of pain from burns. Do not inject more than 5 mL of local
tions.26 These nerves also supply the dorsal, distal aspect of the fin- anesthetic solution into a digit. Using local anesthetic agents that
ger, including the fingertip and nail bed. The dorsal digital nerves contain epinephrine is not recommended because the finger con-
originate from the radial and ulnar nerves that wrap around the tains end arteries and may experience ischemia from the vasocon-
dorsum of the hand. They supply the nail bed of the thumb and strictive effects of epinephrine.
small finger and the dorsal aspect of all five digits up to the dis-
tal interphalangeal joints. The palmar and dorsal nerves need to be
blocked in the case of the thumb and fifth finger.
REGIONAL ANESTHESIA
TECHNIQUES FOR THE TORSO
Patient Positioning Place the patient sitting upright or supine with
their hand pronated on a bedside examination table.
INTERCOSTAL NERVE BLOCK
Landmarks Locate the web spaces and the metacarpal heads on each
side of the finger to be blocked. Anatomy The intercostal nerves originate from the thoracic spinal
Needle Insertion and Direction Insert a 25 gauge needle into the cord and have four major branches (Figure 126-25). The first is the
dorsal aspect of the web space on one side of the digit to be anes- gray rami communicans to the sympathetic ganglion. The second
thetized (Figure 126-24A). Advance the needle approximately branch is the posterior cutaneous nerve that supplies the paraverte-
0.5 cm. Inject 1 mL of local anesthetic solution. Repeat the proce- bral muscles and overlying skin. The third branch is the lateral cuta-
dure on the other side of the digit to be blocked. When blocking neous nerve that arises about the midaxillary line. It divides into an
the second and fifth digits, a half-ring block is required on the anterior and posterior division to supply most of the chest and the
ulnar aspect of the fifth digit and radial aspect of the second digit. abdominal wall. The final branch is the terminal anterior cutaneous
When blocking the thumb, infiltrate the dorsum and sides in a nerve. It supplies the anterior chest and abdominal wall adjacent
half-ring manner. to the midline. Each intercostal nerve travels within a neurovascu-
An alternative is the metacarpal head block. This technique can be lar bundle behind the inferior border of each rib (Figure 126-25B).
used to anesthetize any of the fingers. Insert a 25 gauge needle per- The intercostal nerve lies inferior to the intercostal vein and artery.
pendicular to the dorsum of the hand and adjacent to the metacar- The intercostal nerve may be blocked at several sites along its
pal head on one side of the finger to be blocked (Figure 126-24B). course. The most common site is at the angle of the rib. The tech-
Advance the needle 0.5 cm and inject 1 mL of local anesthetic solu- nique described will be the blockade of the intercostal nerves at the
tion. Repeat the procedure on the other side of the finger to be angle of the rib.
blocked. Some physicians prefer to perform this block on the volar Patient Positioning Place the patient prone with a pillow under the
aspect of the hand (Figure 126-24C). This technique is extremely midabdomen to straighten the lumbar curve and increase the size of
painful and should be avoided. the intercostal spaces posteriorly.
FIGURE 126-24. Techniques to anesthetize the digital nerves of the fingers. A. Intermetacarpal nerve block through the web space. B. Intermetacarpal nerve block on the
dorsal surface of the hand, between the metacarpal heads. C. Intermetacarpal nerve block on the ventral surface of the hand, between the metacarpal heads. D. The ring
block. E. The half-ring block.
Landmarks The most important step is to correctly identify the Use the index finger of the nondominant hand to pull the skin
anatomy of the patient. Draw a line along the vertebral spines cor- at the lower edge of the rib up onto the rib (Figure 126-26B).
responding to the levels to be anesthetized. Palpate laterally from Grasp the syringe in the dominant hand. Insert the 25-gauge
the vertebral spines to the edge of the paraspinal muscles. This needle at a 60° angle along the tip of the nondominant index
is the location where the ribs are most superficial. This distance finger while the dominant hand is resting on the patient’s back
can vary from 6 to 8 cm from the midline in the average adult. (Figure 126-26C). Advance the needle until the rib is contacted
Draw vertical lines parallel to the first line and along the edge of (Figure 126-26C, inset).
the paraspinal muscles (Figure 126-26A). These lines must angle Reposition the nondominant hand so that it is resting against the
slightly medially over the upper ribs to avoid the scapula. Palpate patient’s back and holding the needle between the thumb, index,
and mark the inferior edge of each rib along these two vertical and middle fingers (Figure 126-26D). Use the nondominant hand
lines (Figure 126-26A). to slowly and carefully “walk” the needle off the inferior rib margin
Needle Insertion and Direction This procedure requires the (Figure 126-26E). Advance the needle 3 mm with the nondomi-
utmost of care to prevent inducing a pneumothorax. Inject nant hand (Figure 126-26F). It is imperative that the needle not
local anesthetic solution to make a skin wheal at the intersection be advanced more than 3 mm after it is “walked” off the infe-
of the horizontal lines with the vertical paraspinal muscle lines. rior border of the rib to prevent an iatrogenic pneumothorax.
A Posterior cutaneous nerve Spinal nerve

(posterior ramus) Dorsal root B
Rib
Muscular branch Vein
Artery
Nerve
Branches to
parietal pleura External
intercostal
Sympathetic muscle
ganglion
Internal
Lateral intercostal
Ventral (anterior) ramus Spinal cord
cutaneous muscle
forming intercostal nerve
nerve
Intercostalis
intimus muscle
Branches to
parietal pleura
Muscular branch Parietal pleura
Visceral pleura
Anterior
cutaneous nerve
FIGURE 126-25. The intercostal nerve. A. The anatomy of a typical thoracic spinal nerve. B. Cross section through the chest wall. The intercostal nerves are contained
within a neurovascular bundle that lies behind the inferior border of each rib.
Aspirate to ensure that the tip of the needle is not within a blood between the anterior superior iliac spine and the pubic tubercle
vessel or the lung. Inject 1 to 2 mL of local anesthetic solution (Figure 126-28A). The femoral nerve lies anterior to the iliopsoas
(Figure 126-26G). Remove the needle and repeat the procedure at muscle and lateral to the femoral artery in the proximal thigh
the other desired interspaces. (Figure 126-28B). The femoral nerve has both sensory and motor
Remarks Local anesthetic solution for intercostal blocks should components. It provides motor innervation to the anterior thigh
contain 1:200,000 or less of epinephrine. Obtain a postprocedural muscles. It provides sensory innervation for the anterior thigh,
upright chest radiograph to ensure that the patient does not have anteromedial thigh, medial thigh, medial leg, and the medial border
an iatrogenic pneumothorax.27 of the foot (Figure 126-27).
Patient Positioning Place the patient supine with their hip and knee
extended and the leg slightly externally rotated.
PENILE BLOCK
Landmarks Identify the anterior superior iliac spine and the pubic
The penis may be anesthetized for the purposes of circumcision, tubercle by palpation. Connect these landmarks with a straight
laceration repair, foreign body removal, zipper entrapment, or line to roughly approximate the position of the inguinal ligament.
to perform the release of a phimosis or paraphimosis. The dor- Identify the femoral artery by its palpable pulse 1 to 2 cm below the
sal nerves of the penis provide sensory innervation to the penis. midpoint of the inguinal ligament.
They emerge from under the pubis, just lateral to the symphysis,
Needle Insertion and Direction Place a skin wheal of local anes-
and course along the dorsal surface of the penis. These nerves are
thetic solution just lateral to the femoral artery pulse. Insert a
located approximately 0.5 cm from the dorsal penile midline. These
25 gauge needle through the skin wheal and perpendicular to the
nerves are blocked at the base of the penis. Refer to Chapter 146 for
skin (Figure 126-28B). Slowly advance the needle while remain-
the complete details of the penile block.
ing perpendicular to the skin. The femoral nerve is identified
once paresthesias are elicited. Withdraw the needle 2 mm and
REGIONAL ANESTHESIA TECHNIQUES allow the paresthesias to resolve. Inject 15 to 20 mL of local anes-
thetic solution.
FOR THE LOWER EXTREMITY
US-Guided Block Place the US probe along the inguinal crease, mid-
The sensory innervation of the lower extremity is illustrated in way between the anterior superior iliac spine and the pubic tubercle
Figure 126-27. Note that the nerves provide patches of innervation (Figure 126-28C). Identify the femoral artery and femoral vein. The
rather than stripes of innervation beginning at the torso and extend- femoral nerve is hyperechoic and located 0.5 to 1 cm lateral and
ing to the foot. posterior to the common femoral artery (Figure 126-28D). Apply
pressure with the US probe to distinguish the compressible femo-
FEMORAL NERVE BLOCK ral vein from the incompressible femoral artery. Use color Doppler
to confirm the location of the femoral artery and any branches or
Anatomy The femoral nerve is formed from the lumbar plexus. take-offs. Place the needle lateral to the long axis of the US probe
It travels in the pelvis between the iliacus and psoas major mus- (Figure 126-28C). Slowly insert and advance the needle. Visualize
cles. It enters the thigh below the inguinal ligament, midway the entire length of the needle as it is inserted and approaches the
FIGURE 126-26. The intercostal nerve block. A. The patient is placed prone. A line is drawn along the lateral border of the paraspinal muscles. Note that the upper end
is angled medially to avoid the scapula. Cross-marks are drawn to denote the inferior border of the rib and the location to perform the block. B. The index finger of the
nondominant hand pulls the skin over-lying the inferior border of the rib upward. C. The dominant hand is resting against the patient. The needle is inserted at a 60° angle
to the skin and advanced until the rib is contacted. D. The fingers of the nondominant hand grasp and stabilize the needle. E. The needle is “walked” off the inferior border
of the rib. F. The needle is advanced 3 mm so that the tip is within the neurovascular bundle. G. Inject 1 to 2 mL of local anesthetic solution while maintaining the needle
in a stable position with the nondominant hand.
Posterior femoral
cutaneous nerve
Lateral femoral
Lateral femoral cutaneous nerve
cutaneous nerve
Femoral nerve
Femoral nerve
Obturator nerve
Obturator nerve
Sural nerve
Sural nerve
Saphenous nerve Saphenous nerve
Posterior tibial nerve
Sural nerve
Sural
Saphenous nerve nerve
Superficial
Lateral
peroneal nerve
plantar nerve
Sural
nerve
Deep
peroneal
nerve Medial
Superficial
plantar nerve
peroneal nerve
FIGURE 126-27. The sensory distribution of the cutaneous nerves of the lower extremity.
femoral nerve. Continue to advance the needle and penetrate the before injecting the local anesthetic solution. Deposition of the
fascia lata and fascia iliaca so that the tip of the needle is adjacent to local anesthetic solution outside of the fibrous sheath will not result
the femoral nerve. Aspirate to ensure that the needle tip is not in a in any anesthesia except in the area of the injection.
blood vessel. Inject a test dose of 1 to 2 mL of local anesthetic solu-
tion. Watch the spread of local anesthetic solution around the femo-
SAPHENOUS NERVE BLOCK AT THE KNEE
ral nerve. If satisfactory, inject the remainder of the local anesthetic
solution to produce the “donut sign.” If the test dose is not satisfac- Anatomy The saphenous nerve is the terminal branch of the femoral
tory, reposition the needle and inject another test dose. nerve. It travels across the anterior thigh in a medial direction to
Remarks The femoral nerve is contained within a fibrous sheath become superficial at the medial knee after emerging between the
that is separate from the other contents (femoral artery and vein) tendons of the gracilis and sartorius muscles (Figure 126-29A). It
of the femoral triangle (Figure 126-28B). Paresthesias must be follows the great saphenous vein from above the knee to below the
elicited to confirm the proper position of the tip of the needle medial malleolus (Figure 126-29B). It provides sensory innervation
A Anterior superior
iliac spine B
Femoral nerve
Fascia
lata Inguinal
ligament Femoral artery
Femoral vein
Femoral
Pectineus nerve
muscle
Fascia
lata
Fascia
iliaca
Iliopsoas Pectineus
muscle Femoral Femoral muscle
artery vein
Femoral
sheath
C D
FIGURE 126-28. The femoral nerve block. A. The anatomy of the inguinal region. B. Blockade of the femoral nerve. C. US probe and needle placement. D. US image of
the femoral neurovascular bundle. The femoral nerve is located within the crosshairs. (A—femoral artery, V—femoral vein)
to the anteromedial leg, medial leg, posteromedial leg, and medial Needle Insertion and Direction Place a skin wheal of local anesthetic
border of the foot to the ball of the great toe (Figure 126-27). It has solution over the posteromedial aspect of either condyle (femoral
no motor component. or tibial). Insert a 25 gauge needle through the skin wheal. Infiltrate
Patient Positioning Place the patient supine with their ankle sup- 7 to 10 mL of local anesthetic solution subcutaneously in a trans-
ported on a pillow or blanket, the knee extended, and the leg exter- verse line from the posteromedial to the anteromedial aspect of
nally rotated. either condyle (Figure 126-29C).
Landmarks Identify the femoral condyle above the knee or the tibial US-Guided Block Identify the femoral artery and femoral nerve at
condyle below the knee by palpation. the inguinal crease (see femoral nerve block). Move the US probe
896 SECTION 10: Obstetrical and Gynecologic Procedures
can be prevented by using appropriate techniques and care when beliefs have been challenged. There is a growing body of evidence
delivering the infant. demonstrating increased injury to the pelvic floor with the routine
use of an episiotomy.3–6 A recent Cochrane database review of eight
SUMMARY randomized controlled trials concluded that there is less posterior
perineal trauma, less suturing, and fewer complications with a
The Emergency Physician will occasionally be required to perform restrictive use versus the liberal use of an episiotomy.7 Currently, the
a delivery of a baby when the Obstetrician or Family Physician is evidence does not support a liberal or routine use of an episiotomy.8
not available or when delivery is imminent. Fortunately, births in These practice patterns are reflected in a steady decline in the use of
the Emergency Department are rare and most proceed with good an episiotomy from 1.6 million in 1992 to 716,000 in 2003.9,10
outcomes. Knowledge of the normal labor and delivery mechan- Nonetheless, there is a place for the episiotomy in modern obstet-
ics aids in a safe delivery and helps to identify complications. The rics. The indications for an episiotomy today are based primarily on
Emergency Physician must develop strategies to treat potential the clinical situation at the time of delivery. Another important rea-
complications and must be prepared to intervene. son to make an episiotomy is the prevention of a long and irregular
spontaneous perineal laceration. The repair of a controlled surgical
incision might be easier to repair, and the anatomical planes easier
to recognize. Good clinical judgment is still the best guide to pro-
ceed or not with an episiotomy.11
Episiotomy
132 Francisco Orejuela
ANATOMY OF THE PERINEUM

The most critical area of the perineum is the distance from the ves-
INTRODUCTION
tibular fossa to the anus. This area is known as the pudenda, or more
An episiotomy is a surgical incision of the female perineum per- commonly as the perineal body. It is usually 3 to 4 cm in length in
formed at the time of delivery to increase the diameter of the soft the nonpregnant woman.10,11 The perineal body is a complex fibro-
tissue pelvic outlet and facilitate a vaginal delivery. It is one of the muscular mass into which many structures insert. It is bordered
most commonly performed surgical procedures in women in the cephalad by the rectovaginal septum (Denonvilliers’ fascia), caudad
United States, yet it is controversial. by the perineal skin, anteriorly by the posterior wall of the vagina,
For many decades the episiotomy was thought to provide protec- posteriorly by the anterior wall of the anorectum, and laterally by
tion to the female genital tract.1,2 It is thought to prevent perineal the ischial rami.12
tearing by substituting a straight surgical incision for a ragged spon- The perineal body is the center of the hub of a wheel that
taneous laceration that may have a worse outcome after repair. It was includes the transverse perineal muscles, the capsule of the
also believed that an episiotomy resulted in decreased postoperative external anal sphincter muscle, and the bulbospongiosus mus-
pain and improved healing when compared to a tear. These original cle (Figure 132-1). The perineal body attaches to the ischial
Ischiocavernosus muscle
Clitoris
Urethra
Internal
pudendal Bulbospongiosus muscle
artery
Opening of vagina
Central tendon of perineum
Superficial transverse
perineal muscle
Levator ani muscle

External anal sphincter muscle
Anus
Anococcygeal ligament
Ischiorectal Coccyx
FIGURE 132-1. The anatomy of the fossa Gluteus maximus
perineum. The skin and subcutaneous
tissues have been removed.
CHAPTER 132: Episiotomy 897
tuberosities and to the inferior pubic rami through the perineal MIDLINE EPISIOTOMY
membrane and superficial transverse perineal muscles. The bul-
bospongiosus muscles are located laterally to the introitus and The midline episiotomy is a surgical incision made in the midline
deep to the labia majora. They insert into the inferior limit of of the perineal body, starting from the vaginal orifice toward the
the perineal body with the superficial transverse muscles and the anus (Figure 132-2B). The incision transects the central tendi-
subcutaneous portion of the external anal sphincter. Laterally, the nous portion of the perineal body and usually extends to the level
bulbospongiosus muscle is attached to the muscles of the pelvic of the transverse perineal muscle (Figure 132-1). This is the most
diaphragm. It is anchored posteriorly to the coccyx by the anal common type of episiotomy performed in the United States. The
sphincter and anococcygeal ligament. The mediolateral episiot- midline episiotomy is easy to perform and to repair. It is associated
omy transects the superficial muscles of the perineum whereas with quicker healing, less pain and postpartum discomfort since no
the midline episiotomy does not. muscle belly is transected, and less blood loss than the other types
The pudendal nerve supplies most of the innervation to the peri- of episiotomies. Compared to mediolateral episiotomies, there is an
neal body. This nerve is formed from the ventral rami of sacral spi- increased risk of third-degree and fourth-degree extensions with the
nal nerves two through four. The arterial supply is primarily derived midline episiotomy.
from the internal pudendal artery, one of the branches of the ante-
rior trunk of the internal iliac artery.11 MEDIOLATERAL EPISIOTOMY
The mediolateral episiotomy is preferred outside the United States.20
TYPES OF EPISIOTOMY The mediolateral episiotomy is a surgical incision made from the
midline of the posterior vaginal orifice obliquely toward the ischial
An episiotomy may be performed in the midline or mediolater-
tuberosity (Figure 132-2C). The anatomic structures transected
ally (Figure 132-2).13–16 The choice between the two types of episi-
from superficial to deep are the skin, the subcutaneous tissues, the
otomy is largely dependent upon the experience of the practitioner.
bulbospongiosus muscle, the superficial transverse perineal muscle,
Factors that influence type of episiotomy include, but are not lim-
and a portion of the levator ani muscle and fascia.
ited to, the site of prior episiotomies, position of the presenting fetal
The mediolateral episiotomy is the preferred technique as it is
part, the thickness or rigidity of the patient’s perineum, and the
associated with a decreased risk of extension to the anal sphincter
obstetric perception of an impending severe laceration that risks a
(third-degree laceration) and the rectum (fourth-degree laceration),
fourth-degree extension. A mediolateral incision may be prudent
especially when combined with an operative vaginal delivery.21 The
when an extended episiotomy is required or when the risk of a
disadvantages of the mediolateral episiotomy are the increased
fourth-degree laceration is significant.17–19 Never perform a lateral
blood loss, higher degree of difficulty to repair, and increased post-
(Figure 132-2A) or a Schuchardt (Figure 132-2D) episiotomy in
partum discomfort.6,17,22,23 It may also result in faulty healing, ana-
the Emergency Department. These are associated with significant
tomical deformities, and dyspareunia. The adequate surgical repair
complications.13
of these structures requires a good understanding of the anatomy of
the perineum, and is technically more challenging.
EXTENSION OF AN EPISIOTOMY
The classification of perineal lacerations most often used in the
United States is quite simple.24 A first-degree laceration is a super-
ficial laceration of the vaginal mucosa or perineal body not requir-
ing suturing. A second-degree laceration or episiotomy involves
the vaginal mucosa and/or perineal skin and subcutaneous tissue.
It requires suture closure. The third-degree laceration or episi-
otomy is an extension of the laceration to involve any part of the
capsule or anal sphincter muscle. Finally, the fourth-degree lacera-
tion or episiotomy is an extension to include involvement of the
rectal mucosa.
INDICATIONS
The rate of episiotomy decreases as one travels the continuum from
Obstetrician to Family Practitioner to Certified Nurse Midwife
to lay Midwife. The indications for episiotomy are more largely
based on expert consensus than in evidence-based criteria. The
indications depend on the clinical picture at the time of delivery.
Most practitioners consider the performance of an episiotomy to
be appropriate in situations of fetal distress or maternal disease
requiring urgent delivery.8 Deliveries necessitating greater space
accommodation for effective delivery are also indications for an
episiotomy. These situations include shoulder dystocia, breech
delivery, forceps or vacuum extractions, occiput posterior posi-
tions, and cases of imminent perineal rupture.25 Other indications
include too small of a perineal body with a high likelihood of a large
FIGURE 132-2. The types of episiotomies. A. Lateral. B. Midline. C. Mediolateral. spontaneous laceration, contracted outlet syndrome, face presenta-
D. Schuchardt. tions, and extensive fetal head extension. It is commonly believed
that an episiotomy safely aids in shortening the second stage of • Sterile gown and gloves
labor and reduces trauma to the pelvic floor musculature.4 More • Chromic or polyglycolic acid suture, 2-0 or 3-0
perineal and pelvic tissue injury is noted with a precipitous labor;
• Vicryl suture, 4-0 and 5-0
thus a timely episiotomy is critical.1
• Needle driver
CONTRAINDICATIONS • 23 gauge spinal needle
Contraindications to performing an episiotomy include rectal or

perineal lesions, prior or concurrent fistulae, inflammatory bowel
PATIENT PREPARATION
disease, prior rectal surgery, or prior anal surgery.26 Maternal dis- Explain the procedure, its risks, and benefits to the patient. Clean
eases that impair healing such as autoimmune disorders (e.g., SLE, the perineum of any dirt, debris, stool, and urine. Apply povidone
rheumatoid arthritis), HIV, pregestational diabetes mellitus, and iodine or chlorhexidine solution and allow it to dry. Place sterile
immunosuppression are relative contraindications to an episi- drapes beneath the buttocks, over the legs, and on the abdomen to
otomy. Some authors suggest that coagulation disorders may be prevent contamination from nonsterile areas.
contraindications.13 However, a vaginal delivery with an episi- Anesthetize the perineal body (Figure 132-3). Infiltrate 10 to
otomy is preferable to a cesarean delivery.13 Relative contraindi- 20 mL of local anesthetic solution directly into the perineal body,
cations specific to the midline episiotomy are a short perineum, from the posterior base of the vaginal fourchette to the anus
fetal macrosomia, vaginal operative deliveries, and abnormal fetal (Figure 132-3A). This provides safe and effective anesthesia. It
presentation. may be carefully performed if the baby’s head is within the vagina
or crowning.
EQUIPMENT A bilateral pudendal nerve block will also provide excellent pain
control (Figure 132-3B). It requires more time to perform and can-
• Local anesthetic solution, lidocaine or bupivacaine not be done if the baby’s head is in the vagina. Arm a 10 mL syringe
• Alcohol wipes with a 23 gauge spinal needle and filled with local anesthetic solu-
• 16 to 18 gauge needle tion. Place the nondominant index finger in the vagina and palpate
the ischial spine. The ischial spines are identified as the bony pro-
• 10 mL syringe trusions located in the posterolateral region of the vaginal side wall.
• 22 to 25 gauge needle The sacrospinous ligament is a firm band that runs from the ischial
• Straight Mayo scissors spine to the sacrum. The pudendal nerve and artery lie between the
ischial spine and ischial tuberosity. Palpate the ischial tuberosity
• #10 scalpel blade on a handle
with the nondominant thumb.
• Povidone iodine solution To perform the block on the maternal right side, use the right
• Sterile drapes index and middle fingers to palpate the right ischial spine and guide
FIGURE 132-3. Anesthesia of the perineum. A. Local anesthetic infiltration subcutaneously from the posterior fourchette to the anus. B. The pudendal nerve block.
FIGURE 132-4. Performing a midline episiotomy. A. Place the nondominant index and middle fingers inside the introitus with the palm facing outward. B. Pull the perineal
body away from the fetus and insert the straight Mayo scissors. Note that the blades of the Mayo scissors are positioned between the fingers. C. The introitus readily opens
after making the episiotomy.
the spinal needle. Use the left hand to introduce the needle. Insert part without compromising the anal sphincter. The incision must
the tip of the needle 1 cm medial and 1 cm posterior to the ischial include the tendinous central portion of the perineal body. This
spine. Advance the needle through the sacrospinous ligament. involves (in order of progression from anterior to posterior) the
Aspirate to ensure that the injection will not be intravascular. Inject muscular attachments of the bulbospongiosus muscle, the superfi-
3 to 4 mL of local anesthetic solution. Advance the needle a few mil- cial transverse perineal muscle, a portion of the levator ani muscle,
limeters and inject another 3 to 5 mL of local anesthetic solution. and the capsule of the anal sphincter muscle.8 The most impor-
Repeat the procedure on the contralateral side. tant aspect of the midline episiotomy is extension of the incision
Occasionally, a cutaneous branch of the inferior anal nerve can upward into the vaginal mucosal and past the hymenal ring. This
innervate the area surrounding the anus. The infiltration of a local releases any constriction and allows maximal room for the present-
anesthetic solution will be required.11 ing part of the fetus.
TECHNIQUES MEDIOLATERAL EPISIOTOMY

Place the index and middle fingers of the nondominant hand into Make an incision at a 45° angle to the midline of the posterior vagi-
the patient’s introitus, with the palm of the hand facing outward nal orifice, from the inferior portion of the hymenal ring toward
(Figure 132-4A). Pull the perineal body away from the fetal pre- the ischial tuberosity (Figure 132-2C). The length of the incision
senting part to protect the fetus from injury (Figure 132-4B). Use is less critical than that for a median episiotomy. Longer incisions
a #10 scalpel blade, a #15 scalpel blade, or a straight Mayo scissors require a more extensive repair. The side to which the episiotomy
to make the incision. The editor recommend using only the Mayo is performed is generally the same as the handedness of the opera-
scissors. A scalpel can cause significant injury to the fetus, the tor.1 Make the incision at approximately 5 o’clock for left-handed
mother, and/or the Emergency Physician. dominants or at 7 o’clock for right-handed dominants. If the incision
Insert the Mayo scissors so that one blade lies along the skin is not deep enough, there will be too little tissue relaxation and a
and the other is inside the introitus, between the index and second incision will be necessary. This second incision increases the
middle fingers, and against the vaginal mucosa (Figure 132-4B). risk of a zigzag line after healing.11 The anatomic structures incised
Allow the maximum descent of the fetal presenting part and mod- and requiring repair (in progression from superficial to deep) are
erate distension of the perineum before making the incision to the skin and subcutaneous tissues, the bulbospongiosus muscle, the
avoid a third-degree or fourth-degree laceration. Make the inci- superficial transverse perinei muscle, and a portion of the levator
sion when the perineum is bulging and when approximately 4 cm ani muscle and its fascia.
of fetal scalp is visible during a contraction unless early delivery is
indicated.1,22 Extend the incision 2 to 3 cm vertically up the vaginal ASSESSMENT
mucosa. The introitus will readily open after making the episiotomy
(Figure 132-4C). Carefully examine the vagina, cervix, and lower uterine segment
for any signs of injury or laceration immediately following deliv-
ery of the infant and placenta. Do not begin repairing the episi-
MIDLINE EPISIOTOMY
otomy until after the delivery of the placenta. The repair may be
Make the incision vertically in the midline of the perineal body, compromised if manual removal of the placenta or intravaginal pro-
from the midpoint of the posterior vaginal orifice to the capsule cedures must be performed after the episiotomy is reconstructed.
of the anal sphincter (Figure 132-4). The incision length depends Assess the incision for extension (third-degree or fourth-degree).
upon the perineal length. Make it of sufficient length to increase Identify any site of excessive bleeding and immediately control it
the area of the introitus for successful delivery of the presenting with a Vicryl ligature. Perform a digital rectal examination to rule
out a fourth-degree extension or button-holing (a laceration through Place each stitch to bring together the mucous membrane of
to the rectal mucosa which is not contiguous with the episiotomy). the vagina and the tissue between the vagina and rectum. This
method of suturing provides for hemostasis, eliminates dead space,
and decreases the risk of subsequent infection. Extend the continu-
MIDLINE EPISIOTOMY ous suture by one to two stitches past the hymenal ring and to the
REPAIR TECHNIQUES edge of the skin. Place the final suture to incorporate the subcutane-
The midline episiotomy repair is an easier approximation than ous tissue but not the skin. Finish reapproximating the skin incision
the mediolateral episiotomy as the incision is symmetrically situ- with a buried knot.
ated in the perineal tissue.21,27,28 The choice of suture is physician- The second suture is the so-called “crown suture.” It is placed at
dependent.28 There are several options for episiotomy closure with the base of the sutured vaginal wound. Insert the needle into the
limited data to suggest the superiority of one single type of material. immediate subcutaneous tissue, perpendicular to the skin, and
The principal disadvantage of chromic is the rapid loss of tensile angled deeply to approximate the edges of the bulbospongiosus
strength, increased wound breakdown, and increased initial pain.24 muscle and its fascia. It is important to evaluate the perineal body
The derivatives of polyglycolic acid, Vicryl and Dexon, have about at this time. If there is a big defect, close it with interrupted sutures
a 20% reduction in short-term pain but causes perineal irritation. to prevent leaving any open dead space. Close the remainder of the
They frequently require removal during the puerperium. There are incision with the one-suture (Figure 132-6) or the two-suture tech-
now monofilament absorbable sutures or more rapidly absorbable nique (Figure 132-7).
polyglactin derivates that combine both desirable characteristics of
strength and rapid disappearance.8 Use a round needle to close all ONE-SUTURE TECHNIQUE
layers except the capsule and skin to minimize the risk of a subcu-
taneous hematoma. The one-suture technique utilizes one strand of suture to close
the entire episiotomy (Figure 132-6). Close the vaginal mucosa,
as described previously, with a running stitch (Figure 132-6A).
VAGINAL MUCOSA REPAIR Approximate the hymeneal ring. Continue the running stitch to
Repair the vaginal mucosa first (Figure 132-5). Use 3-0 suture on approximate the perineal body (Figure 132-6B). Continue the run-
a noncutting needle. Place the initial suture superior to the apex ning stitch until the bottom of the episiotomy is reached. Place a
of the vaginal incision to incorporate any retracted vessels. Tie running subcuticular stitch from the bottom of the episiotomy
the suture at the apex of the incision securely. Approximate the upward to the hymenal ring (Figure 132-6C). Finish approximating
wound edges with a running subcuticular stitch (Figure 132-5A) the skin incision with a buried knot at the hymenal ring.
or a running simple stitch (Figure 132-5B). Place a running locked
stitch (Figure 132-5C) if there are any concerns about hemostasis.
TWO-SUTURE TECHNIQUE
Continue the suture to the hymenal ring. Do not allow the needle
to enter through the rectal mucosa as this can result in the forma- This technique utilizes two strands of suture to close the episi-
tion of a rectovaginal fistula. otomy (Figure 132-7). Close the vaginal mucosa, as described
FIGURE 132-5. Methods of closing the vaginal mucosa. A. The running subcuticular stitch. B. The running simple stitch. C. The running locked stitch.
FIGURE 132-6. The one-suture technique to close an episiotomy. A. Approximate the vaginal mucosa with a running stitch. B. Approximate the hymenal ring followed by
a running stitch to approximate the perineal body. C. Reverse the suture direction with a running subcuticular stitch to approximate the skin.
previously, with a running stitch (Figure 132-7A). Approximate After the perineal body is closed, use the first strand of suture
the hymenal ring with this first strand of suture (Figure 132-7B). to place a subcuticular running stitch to approximate the skin
Close the perineal body using a second strand of suture mate- (Figure 132-7C). Finish approximating the skin incision with a
rial. Place running or interrupted stitches (Figure 132-7B). buried knot.
FIGURE 132-7. The two-suture technique to close an episiotomy. A. Approximate the vaginal mucosa with a running stitch. B. The hymenal ring is approximated with the
first suture. The perineal body is approximated with a second suture utilizing an interrupted stitch. C. The first suture is continued subcutaneously to approximate the skin.
close the subcutaneous tissues and perineal body along with the
overlying vaginal mucosa and skin.
THIRD-DEGREE LACERATION REPAIR

A third-degree laceration involves the anal sphincter muscle and
spares the anal mucosa. Visually inspect the anal sphincter muscle
for partial lacerations. A patient can have normal anal sphincter
tone and a partial anal sphincter muscle laceration. Repair any
anal sphincter muscle lacerations as described in the following sec-
tion on fourth-degree laceration repair.
FOURTH-DEGREE LACERATION REPAIR

Fourth-degree lacerations may occur as a result of a tearing of the
tissues with or without an episiotomy. These lacerations involve
the anal sphincter muscle and the anal mucosa. They must
be repaired to restore the normal anatomy and decrease the
chance of fecal incontinence.
A suture is placed 1 cm above the apex of the laceration, and
extended through the submucosal tissue, but not through the
mucosa. The mucosa is closed in a continuous running or subcutic-
ular fashion. The suture should not penetrate the rectal mucosa, and
the suture carried down to the perineal body (Figure 132-8A). 4-0 or
5-0 chromic gut sutures are usually used for this step, but synthetic
FIGURE 132-8. An alternative technique to close an episiotomy. Place simple material can also be used. A second layer over the rectal mucosa
interrupted stitches to approximate the mucosa, skin, and perineal body. is placed, in order to reinforce the initial suture. Additionally, this
suture will close the dead space between the vaginal mucosa and
the rectum.
ALTERNATIVE TECHNIQUE Identify both ends of the anal sphincter. They are usually
retracted laterally. Use Allis clamps to grasp the edges and pull
Approximation of an episiotomy with one or two sutures can be them together in the midline (Figure 132-9A). It is very important
time consuming and difficult. An alternative is to close the epi- to incorporate the capsule of the anal sphincter in the repair and
siotomy using a simple interrupted stitch (Figure 132-8). Take not just the muscle fibers (Figure 132-9B). We recommend the
deep bites of tissue with the needle to ensure that the stitches use of the pneumonic “PISA” when repairing the anal sphincter.
FIGURE 132-9. Repair of a fourth-degree laceration or episi-

otomy. A. Approximate the rectal submucosa and muscularis
with simple interrupted sutures. Grasp the cut edges of the anal
sphincter muscle with Allis clamps. B. Approximate the ends of
the anal sphincter muscle with transfixion stitches.
FIGURE 132-10. Repair of a mediolateral episiotomy. A. Find and approximate the ends of the transected bulbospongiosus muscle. B. Approximate the vagina and deep
peroneal tissues using the one-suture or two-suture technique. C. Approximate the skin with running subcuticular stitches.
The use of a 2-0 polygalactic acid suture (e.g., Vicryl) on a taper especially important in patients with third-degree or fourth-
needle is recommended. Initiate the repair with the Posterior degree lacerations.
aspect of the sphincter, which has the structure of a cylinder, at
the 9 o’clock position. Next, place the most Inferior suture at the COMPLICATIONS
6 o’clock position. Follow this with a stitch in the Superior aspect
at the 12 o’clock position. Finish the repair with a suture at the The most common complications are hemorrhage, infection, and
3 o’clock position on the Anterior aspect of the sphincter. dehiscence. Most hemorrhage can be controlled by the application
of direct pressure with a sterile gauze. Place a figure-of-eight stitch
in the tissues if direct pressure fails. The mediolateral episiotomy
MEDIOLATERAL EPISIOTOMY has an increased risk of hemorrhage compared to the midline epi-
REPAIR TECHNIQUE siotomy. Therefore, adequate hemostasis must be assured during
It is extremely important to locate and repair the transected bul- the repair. Vaginal hematomas can easily form. Large or expanding
bospongiosus muscle. Find and grasp the transected ends of the vaginal hematomas usually require the incision to be opened, the
bulbospongiosus muscle with Allis clamps. Approximate it using hematoma drained, and the hemorrhage controlled. Small hemato-
4-0 and 5-0 Vicryl sutures (Figure 132-10A). Approximate the mas can be managed with analgesics and ice packs.
vagina and deep perineal tissues using the one-suture or the two- Infection usually presents 6 to 8 days after delivery. The patient
suture technique (Figure 132-10B). Approximate the skin of the usually complains of a fever, perineal pain, and a purulent dis-
perineum using a running subcuticular stitch (Figure 132-10C). charge that may be foul smelling. Management includes local
perineal care and exploration with debridement under adequate
anesthesia to drain a potential abscess. Carefully examine the
AFTERCARE
patient and explore the area to rule out necrotizing fasciitis.25
The aftercare for a perineal incision involves perineal hygiene Unless the patient is septic, begin intravenous antibiotics after
and adequate analgesia. The use of warm sitz baths three to four consulting with the Obstetrician–Gynecologist and obtaining
times a day in concert with the use of ice packs to the perineum wound cultures.
will decrease inflammation and the risk of infection. Routine Pain at the episiotomy site is common. It usually resolves in 3 to
use of prophylactic antibiotics has never been proven effective 5 days. The pain usually responds to acetaminophen and non-
to prevent infections after an episiotomy. Prescribe stool soften- steroidal anti-inflammatory drugs. If the patient is complaining
ers to decrease the pain of defecation and the risk of episiotomy of intense pain, a hematoma or an infection must be ruled out.
disruption, especially if it was associated with a third-degree or Dyspareunia is more common with a mediolateral episiotomy.11
fourth-degree extension. Nonsteroidal anti-inflammatory drugs Prospective studies have not found differences in the resumption
or acetaminophen provide adequate analgesia in most patients. of intercourse at 3 months when compared to patients without an
Narcotic analgesics may be required for 24 to 72 hours, espe- episiotomy.8
cially in cases of mediolateral episiotomies. Many Obstetricians Dehiscence is reported in 0.1% to 2% of episiotomies. Early closure
prefer oxycodone or acetaminophen with codeine as they are within 1 week is preferable to the delayed closure at 2 to 3 months.
not as constipating as the other narcotic analgesics. This is It is necessary to remove all necrotic tissue and copiously irrigate
the area with a diluted povidone iodine solution. This should be fol- of shoulder dystocia make designing prospective studies difficult,
lowed by twice daily scrubbings of the wound with a scrub brush both in describing the incidence and in evaluating the efficacy of
and povidone iodine. The wound can be repaired once it is free of various release maneuvers.8
exudates and begins to show granulation tissue. Intravenous antibi- Shoulder dystocia may not be anticipated in advance. Many
otics might be necessary in the presence of infection.29 The repair risk factors are associated with shoulder dystocia. However, many
procedure should be performed by a Gynecologist or a Colorectal patients with shoulder dystocia have none of these risk factors.
Surgeon if the dehiscence involves the anal sphincter. Emergency Physicians usually do not have knowledge of the
The use of a midline episiotomy may increase the risk of third- patient’s prenatal history, ultrasound reports, or previous deliveries.
degree and fourth-degree lacerations.30–33 A third-degree laceration This makes it difficult to predict shoulder dystocia. It is imperative
is diagnosed when the capsule and/or the muscle of the anal sphinc- for the Emergency Physician to be knowledgeable and comfortable
ter is interrupted. A fourth-degree laceration involves the anal with the various release maneuvers in the event that shoulder dys-
sphincter and the mucosa of the anus or rectum. Third-degree and tocia is encountered during a precipitous delivery. When the baby is
fourth-degree lacerations may result in incontinence of feces, incon- being delivered, there is not time to look up references.
tinence of flatus, and/or rectovaginal fistula formation if not prop-
erly repaired. Complications include increased blood loss, especially ANATOMY AND PATHOPHYSIOLOGY
if the incision is made too early.
The midline episiotomy has been shown to be associated with an Shoulder dystocia is usually diagnosed after delivery of the fetal
increased risk of third-degree and fourth-degree perineal lacera- head, when the fetal shoulders fail to deliver despite standard gentle
tions in operative vaginal deliveries. Perineal and pelvic floor mor- traction on the fetal head. It results from impingement of the biacro-
bidity was greatest among women receiving a median episiotomy mial diameter of the fetus against the maternal pubic symphysis
versus those remaining intact or sustaining spontaneous perineal anteriorly and the maternal sacral promontory posteriorly.9
tears in a study of the relationship between episiotomy and maternal Shoulder dystocia is a rare and potentially catastrophic obstetri-
morbidity. Severe lacerations were nearly 50 times more likely in cal emergency. The Emergency Physician must deliver the fetus
parturients with midline episiotomies and over 8 times more likely quickly and without applying excessive forces that may result
in women with mediolateral episiotomies than in women who did in fetal injury. Always be prepared for the possibility of shoulder
not undergo an episiotomy. dystocia. Recognize the possible associated risk factors that include
fetal macrosomia, maternal diabetes, a prior history of shoulder
dystocia or macrosomia, prolonged second stage of labor, post-term
SUMMARY pregnancy, multiparity, obesity, and operative vaginal delivery from
Episiotomies are not performed routinely but should be utilized the midpelvis.9
on a selective basis for the appropriate indication. Surgical judg- Fetal macrosomia is defined as fetal growth beyond a specific
ment, patient assessment, acknowledgment of surgical expertise weight, usually 4000 to 4500 g, regardless of the fetal gestational
level, and common sense should be employed. The midline episi- age. The risk of shoulder dystocia is 9.2% to 24% in nondiabetic
otomy is the preferred technique for non-Obstetricians. It is easier pregnant women, and 19.9% to 50% in diabetic women when birth
to perform and easier to repair when compared to the mediolateral weight is greater than 4500 g.10 The ability to predict fetal macroso-
episiotomy. mia is limited. Shoulder dystocia can occur unexpectedly in infants
of normal birth weights.10 A simple algorithm to help determine if
shoulder dystocia or fetal macrosomia may be present is shown in
Figure 133-1.
Shoulder Dystocia INDICATIONS

133 Management The presence of shoulder dystocia is the unique indication for the
procedures described in this chapter. They should be utilized in the
Eric F. Reichman and Camaran E. Roberts approximate order described, from the least invasive and easiest to
perform to the most invasive and difficult to perform.
INTRODUCTION A symphysiotomy is indicated for shoulder dystocia unrespon-
sive to less invasive techniques and for fetal head entrapment
Shoulder dystocia is a rare obstetric emergency that immediately by presumed cephalopelvic disproportion. It is an alternative to
places the mother and the fetus at risk for significant morbidity the cesarean section when a qualified Obstetrician or Surgeon is
and mortality. It is diagnosed when, after delivery of the fetal head, unavailable.10 Refer to Chapter 137 for the complete details regard-
further expulsion of the fetus is prevented by impaction of the fetal ing a symphysiotomy.
shoulders within the maternal pelvis.1 Shoulder dystocia is con-
sidered an emergent situation that the Emergency Physician
CONTRAINDICATIONS
must recognize and quickly respond to by promptly delivering
the fetus. There are few contraindications to the release maneuvers in an
The incidence of shoulder dystocia varies and is seen in up to emergent situation of shoulder dystocia and imminent fetal demise.
4% of cephalic spontaneous vaginal deliveries depending upon the The only absolute contraindication is if the procedure might endan-
source.2–7 Differing definitions of shoulder dystocia may account for ger the mother.
some of this variability. Some reports require that maneuvers for The indications to perform a cesarean delivery are relative con-
shoulder release be documented on the chart whereas others accept traindications for release maneuvers. Fetal macrosomia has been
the Physician’s clinical diagnosis of shoulder dystocia. Other defini- associated with shoulder dystocia.10 The American College of
tions look at the timing of the delivery of the head, the delivery of Obstetricians and Gynecologists (ACOG) supported the recom-
the shoulders, or the completion of the birth. The rare occurrences mendation that planned cesarean delivery may be a reasonable
CHAPTER 133: Shoulder Dystocia Management 905
FIGURE 133-1. An algorithm providing a sequence of decisions for evaluation and anticipation of shoulder dystocia.10
strategy for diabetic pregnant women with estimated fetal weights • Clock or timer watch
exceeding 4250 to 4500 g.8 ACOG issued guidelines on fetal mac- • Sterile perineal drapes
rosomia in 2001. The guidelines were based upon limited or incon-
• Sterile gloves
sistent scientific evidence. ACOG recommended that an estimated
fetal weight of more than 4500 g, a prolonged second stage of labor, • Chromic suture, 2-0 and 4-0
or arrest of descent in the second stage of labor are indications for • Vicryl suture, 2-0 and 3-0
cesarean delivery.10 ACOG noted that the diagnosis of fetal macro- • Bulb syringe
somia is imprecise and recommended prophylactic cesarean deliv-
ery be considered with estimated fetal weights of more than 5000 g • Clean towels/blanket for baby
in nondiabetic pregnant women and more than 4500 g in diabetic • Umbilical cord clamp
pregnant women.10 • Sterile scissors to trim umbilical cord
• Infant warmer
EQUIPMENT Delivery Instrument Pack
General Supplies • Bandage scissors
• Electronic fetal monitor • Towel clips
• Sterile towels • Two Allis forceps
• Four ring forceps

• Six straight Kocher clamps
• Straight Mayo scissors
• Two suture scissors
• Adson forceps, or other forceps with teeth
• Russian forceps, 5½ inches and 8 inches
• Gelpi retractor
• Richardson retractors, small and medium
• Army/Navy retractors
• 6 inch needle driver
Symphysiotomy
• #10 or #15 scalpel blade on a handle
• Finger guard
• Foley catheter
PATIENT PREPARATION FIGURE 133-2. The head may retract toward the perineum (turtle sign) when
delivery of the fetal head is not followed by delivery of the shoulders.
Pain associated with the first stage of labor can be relieved with a
paracervical block (Chapter 131). Inject 5 mL of local anesthetic
solution into the submucosa of the lateral vaginal fornix. Repeat
the injection in the contralateral lateral vaginal fornix. Pain trans-
mission is interrupted for all visceral sensory nerve fibers from
the uterus, cervix, and upper vagina. The somatosensory fibers
from the perineum are not blocked. This technique is effective
only during the first stage of labor and before shoulder dystocia
occurs.11,12
A pudendal nerve block and local perineal infiltration anesthesia
are usually administered just before delivery (Chapter 131).12 Refer
to Chapters 131 and 132 regarding the complete details of these
anesthetic techniques. Unfortunately, these techniques must also be
performed prior to the occurrence of shoulder dystocia.
The patient should already be in the lithotomy position on a
bed with stirrups. Preparation begins with suspicion of fetal mac-
rosomia by clinical examination and/or fetal ultrasonography.
Retraction of the fetal head immediately after its delivery and the
fetal chin against the maternal thigh (turtle sign) with difficulty
FIGURE 133-3. Restitution (external rotation) of the fetal head normally results in
suctioning the mouth may signal impending shoulder dystocia
a natural perpendicular relationship of the head to the shoulders.
(Figure 133-2).
The fetal sagittal suture generally lies oblique to the mater-
nal anteroposterior diameter with the fetal shoulders occupy-
ing the opposite oblique diameter after delivery of the fetal head
(Figure 133-3). The shoulder may become impacted behind the
pubic symphysis and impede delivery if the anterior shoulder
descends in the anteroposterior diameter. Apply gentle and down-
ward pressure on the fetal head to move the posterior shoulder
into the hollow of the sacrum and deliver the anterior shoulder
(Figure 133-4). Resist applying excessive downward or lateral
traction on the fetal head and neck.
TECHNIQUES
Perform attempts at gentle traction coordinated with maternal
expulsive efforts before attempting maneuvers to relieve shoul-
der dystocia. Initiate a planned sequence of events if delivery is
impeded. Avoid applying fundal pressure and discontinue mater-
nal pushing efforts until disimpaction has occurred. Fundal pres-
sure and maternal pushing may further impact the fetal shoulders.
Contact an Anesthesiologist for pain control. Summon extra per- FIGURE 133-4. Apply gentle and downward pressure on the fetal head (1) to
sonnel for help, with one person designated as a timekeeper. Notify move the posterior shoulder into the hollow of the sacrum (2) and deliver the
a Neonatologist of the impending delivery. Maneuvers for shoulder anterior shoulder (3).
MCROBERTS MANEUVER
The McRoberts maneuver is easy to perform (Figure 133-6). Place
an assistant on each side of the patient. Hyperflex the mother’s
thighs onto her abdomen (Figure 133-6A). Instruct the assistants to
maintain support of the hyperflexion while simultaneously applying
suprapubic pressure (Figure 133-6B). This results in a flattening of
the maternal lumbosacral curve and a rotation of the pubic sym-
physis cephalad (Figure 133-6C). Rotation of the maternal pelvis
may free the impacted anterior fetal shoulder.7,13 This maneuver
has the advantages of reducing shoulder extraction forces, brachial
plexus stretching, and the incidence of clavicular fractures.7,13 The
McRoberts maneuver is effective in disimpacting the fetal shoulders
in 50% to 90% of cases of shoulder dystocia.7,13
RUBIN MANEUVER
The Rubin maneuver is simple and may lead to the descent and
FIGURE 133-5. Moderate suprapubic pressure is applied to disimpact the fetal delivery of the anterior fetal shoulder (Figure 133-7). Insert the
shoulder while gentle downward traction is applied to the fetal head. dominant hand into the vagina. Place the fingers of the hand against
the posterior aspect of the anterior fetal shoulder. Rotate the fetal
shoulder counterclockwise in a small arc to approximately the
dystocia disimpaction will be described in order of ease of imple- 10 o’clock position. The Rubin maneuver compresses and dimin-
mentation and from least invasive to more invasive. ishes the size of the fetal shoulder girdle to disimpact the anterior
shoulder. Rotation of the anterior fetal shoulder in the opposite
SUPRAPUBIC PRESSURE direction (i.e., clockwise) will open the shoulder girdle, increase the
size of the shoulder girdle, and further impact the fetus.
This maneuver can be used alone or in combination with the
McRoberts maneuver. Apply gentle downward traction to the fetal
head while an assistant simultaneously applies moderate suprapubic
WOOD’S CORKSCREW MANEUVER
pressure (Figure 133-5). Do not apply heavy pressure to prevent The Wood’s corkscrew maneuver (Figure 133-8) is an alternative
injury to the fetus’s brachial plexus, neck, and spinal cord. to the Rubin maneuver. Insert the dominant hand into the vagina.
FIGURE 133-6. The McRoberts maneuver. A. Hyperflex the maternal thighs upon the abdomen. B. An assistant applies suprapubic pressure while maintaining flexion of
the legs. C. This maneuver results in cephalad rotation of the maternal pelvis and an increase in the size of the pelvic outlet.
FIGURE 133-7. The Rubin maneuver. Rotation of the anterior shoulder counter- FIGURE 133-8. The Wood’s corkscrew maneuver. Rotation of the posterior shoul-
clockwise through a small arc to the oblique position. der through a 180° arc.
Place the fingers of the hand against the posterior aspect of the labor. Manually rotate the fetal head into the prerestitution posi-
posterior fetal shoulder. Gently rotate the posterior shoulder 180° tion (Figure 133-10A). This is usually the direct occiput anterior
clockwise (Figure 133-8).15 This maneuver, like the Rubin maneu- position with full extension of the neck (Figure 133-10B). The
ver, compresses and diminishes the size of the fetal shoulder girdle second maneuver is flexion of the fetal head followed by gentle
to disimpact the anterior shoulder. Rotation in the opposite direc- upward pressure on the head to replace it into the maternal vagina
tion (i.e., counterclockwise) will open the shoulder girdle, increase (Figure 133-10B). The Emergency Physician must maintain their
the size of the shoulder girdle, and further impact the fetus. hand in the vagina and maintain gentle pressure on the fetal head
to prevent re-expulsion. The Emergency Physician, or an assistant,
DELIVERY OF THE POSTERIOR ARM must keep their hand in the vagina and holding the fetal head dur-
ing the entire transport to the Operating Room and until a cesarean
Attempt to deliver the posterior arm if the previous maneu- section is performed.
vers are unsuccessful (Figure 133-9). Insert the dominant hand This series of maneuvers decompresses the fetus. Immediately
into the vagina. Place the fingers of the hand against the poste- transport the mother to the Operating Room for a cesarean section.
rior fetal humerus (Figure 133-9A). Sweep the fetal arm across The Zavanelli maneuver was found to be successful in 84% of initial
the chest (Figure 133-9B). Palpate for and grasp the fetal hand attempts and 91% of attempts when uterine relaxing anesthesia or
(Figure 133-9C). Gently pull the hand along the side of the face. uterine relaxing medication (usually 0.25 mg terbutaline subcutane-
Continue to gently pull the hand to deliver the posterior arm and ously) was administered.16,17 More importantly, it was successful on
shoulder (Figure 133-9D). Apply gentle downward traction on the first attempt by untrained practitioners in 69% of the cases.
the fetal head and arm while an assistant simultaneously applies
suprapubic pressure to release and deliver the anterior shoulder
(Figure 133-9E). Rotate the shoulder girdle into the oblique diam- SYMPHYSIOTOMY
eter if traction on the fetal head and arm does not deliver the ante- A symphysiotomy is an uncommon procedure utilized primarily in
rior shoulder.9 This will usually disimpact the anterior shoulder and two situations. The first is shoulder dystocia unresponsive to less
allow it to be delivered. The major disadvantage of this maneuver invasive techniques. The second is when the head of a breech deliv-
is that it may result in a clavicle fracture or a humerus fracture. ery is trapped by presumed cephalopelvic disproportion. It serves as
an alternative to the more invasive cesarean section. It is especially
DELIBERATE FRACTURE OF THE CLAVICLE useful in situations where an Obstetrician or Surgeon is unavail-
Fracture the fetal clavicle by pressing the anterior clavicle against able.17,18 Refer to Chapter 137 for the complete details regarding a
the maternal pubic symphysis. This will decrease the rigidity and symphysiotomy.
the size of the fetal shoulder girdle. Exert the pressure in a direction
away from the lungs to avoid a pneumothorax. Never use an instru- AFTERCARE
ment to fracture the clavicle. It may penetrate into the thoracic
cavity, cause a pneumothorax, or result in subsequent osteomyelitis Disimpaction of the shoulder girdle is usually followed by deliv-
if the skin is punctured.14 The fracture will heal quickly and is much ery of the infant. Clamp and cut the umbilical cord. Immediately
less serious than a brachial plexus injury, asphyxia, or death. This assess and implement any resuscitative measures for the infant with-
maneuver is difficult to perform.15 It is physically and mentally dif- out delay. Deliver the placenta. Repair any lacerations, Dührssen’s
ficult to deliberately fracture the clavicle of a large infant. incisions, episiotomy incisions, perineal lacerations, and vaginal
lacerations. Refer to Chapter 132 for the complete details regard-
ing episiotomy repair. Refer to Chapter 135 for the complete details
ZAVANELLI MANEUVER
regarding postpartum hemorrhage management. Initiate uterine
The Zavanelli maneuver involves replacement of the fetal head massage and administer intramuscular pitocin following delivery of
followed by a cesarean section (Figure 133-10). The expulsed the placenta to prevent postpartum hemorrhage. Clearly and com-
head must undergo two maneuvers to reverse the mechanisms of pletely document the series of events in the medical record.
FIGURE 133-9. Delivery of the posterior arm. A. Insert a hand into the vagina and along the posterior fetal humerus. B. Sweep the fetal arm across the chest. C. Grasp
the hand and extend the arm along the side of the face. D. Deliver the posterior arm and shoulder from the vagina

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Emergency Medicine

Eric F. Reichman, PhD, MD, FAAEM, FACEP

Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii 18 Supraglottic Airway Devices . . . . . . . . . . . . . . . . . . . 106

38 Needle Thoracostomy . . . . . . . . . . . . . . . . . . . . . . 238 61 Whole Bowel Irrigation. . . . . . . . . . . . . . . . . . . . . . 398

129 Procedural Sedation and 149 Phimosis Reduction . . . . . . . . . . . . . . . . . . . . . . . . 995

170 Nasal Fracture Reduction . . . . . . . . . . . . . . . . . . . 1092 SECTION 15 Podiatric Procedures . . . . . . . . . . . . . 1169

Hagop M. Afarian, MD [94, 129] Bashar M. Attar, MD, PhD,

Gary An, MD [189] Joseph Bledsoe, MD [21]

Sobia Ansari, MD, MPH [75] Heather H. Bohn, DO [78]

David W. Boldt, MD, MS [8] Steven Charous, MD, FACS [173]

Michael Bublewicz, MD [84] Joseph Cornett, MD [11]

David D. Caldarelli, MD [172] Eileen F. Couture, DO [190]

Shoma Desai, MD [9] Steven Go, MD [147, 151]

Pratik Doshi, MD [53] Thomas P. Graham, MD, FACEP [105, 125]

Tamara Espinoza, MD [187] David D. Gummin, MD [61]

Christopher Freeman, MD, FACEP [112, 127] Renee C. Hamilton, MD [100]

Jaime Harper, MD [76] Nabil Issa, MBChB, FRCS, FACS [189]

Eric Isaacs, MD [1] Stephen M. Kelanic, MD, FACS [172]

Charlie C. Kilpatrick, MD [138] M. Scott Linscott, MD [21]

Jehangir Meer, MD, RDMS, Ned F. Nasr, MD [6, 8, 10, 22]

Amit Mehta, MD [191] Mike Nelson, MD, MS [188]

Olga Pawelek, MD [14, 15] Raed Rahman, DO [22]

Fred A. Severyn, MD, FACEP [18] Susan Stroud, MD [57]

Scott C. Sherman, MD, FAAEM [79] Peter Taillac, MD [124]

Michelle M. Verplanck, DO [156] Meghan Wilson, MD [171]

Joseph Weber, MD [20]

Therapeutic privilege may be applied when direct disclosure to a INFORMED REFUSAL

quently limited by time and consultant availability. Consultations in

provides much longer antimicrobial activity (up to 48 hours) and is

REMOVAL OF PROTECTIVE CLOTHING COMPLICATIONS

The list of indications for present-day emergency US is long and

FREQUENCY AND PERIOD

AMPLITUDE, OUTPUT, AND BIOEFFECTS

TABLE 3-2 Common Types of US Probes Used in the ED

any warranty and maintenance considerations. Many US manufac- TRANSDUCER TYPES

FREQUENCY AND TISSUE HARMONIC IMAGING

FIGURE 3-9. Components of a typical US machine.

COUPLING MEDIUM GAIN

FIGURE 3-11. Time gain compensation (TGC) controls on an US machine consist

(“overmagnification”), the organ of interest will appear too large and

PATIENT DATA ENTRY

FREEZE AND CINE

PRINCIPLES OF GENERAL US IMAGING

FIGURE 3-15. Echogenic gallstones are present in the gallbladder. Shadowing is

echoes deep to a structure that is hyperechoic as the lack of reflec-

MIRROR IMAGE MISCELLANEOUS ARTIFACTS

PULSED WAVE DOPPLER MODE

COLOR DOPPLER MODE

ONE-PERSON VERSUS ORIENTATION OF THE NEEDLE

(Figure 4-1). The transverse or short-axis approach refers to plac-

MECHANICAL NEEDLE GUIDES

BLUNT THORACOABDOMINAL TRAUMA

A complete discussion of US equipment is beyond the scope of

FIGURE 5-12. Imaging a pneumothorax. A. Rib shadowing is seen on both sides

Vestibule of nose Nasopharynx

Larynx Thyroid cartilage

Cricoid cartilage Esophagus

Entry point of internal branch

Anterior view Posterior view

Vallecula (location of Epiglottis Tubercle of