Emergency Procedure

Aka: Emergency Procedure, Emergency Department Procedure, Emergency Procedure Skills, High Acuity Low Opportunity Procedure, HALO Procedure, HALO Event

advertisement

II. Definitions

  1. High Acuity Low Opportunity Procedure (HALO Procedure, HALO Event)
    1. Risky, rare procedures (e.g. Cricothyrotomy) in life threatening events

III. Approach

  1. Maintaining procedural competence and proficiency
    1. We lose skills over time in procedures we perform infrequently
    2. Skills start waning as early as 2 months after the last time performed
    3. Practice procedural skills frequently (e.g. visualization, procedure courses)
    4. Schedule procedure self-study and practice frequently (e.g. one procedure per month for 30 minutes)
    5. Watch online procedure videos
    6. Improvise practice tools (e.g. toilet paper roll for Cricothyrotomy practice)
    7. Coordinate group procedure practice
  2. Use visualization to learn or prepare for a procedure
    1. Picture the scenario, the environment and the patient
    2. Visualize the step-by-step approach to performing the procedure
    3. Move your hands as if performing the procedure, and vocalize orders
    4. Orman, Herbert and Cloyd in Herbert (2017) EM:Rap 17(4):14

IV. Precautions: Bleeding Risk for Emergency Bedside Procedures

  1. See Perioperative Anticoagulation
  2. Indications: Patients at Increased Risk of Procedure-Related Bleeding Complications
    1. See Bleeding Diathesis
    2. Thrombocytopenia (<20-50k)
    3. Cirrhosis
      1. INR, PTT and Bleeding Time cannot accurately predict bleeding risk
      2. Thromboelastogram (TEG) or Thromboelastometry (ROTEM) are preferred to estimate bleeding risk
      3. In Cirrhosis, Emergency Procedures have Fibrinogen levels thresholds
        1. Low risk Emergency Procedures in Cirrhosis should have a Fibrinogen Level >100-120
        2. High risk Emergency Procedures in Cirrhosis should have a Fibrinogen Level >150
        3. Fibrinogen may be increased with 1 pack of Cryoprecipitate (2 packs if weight >80 kg)
    4. Anticoagulation or antiplatelet use (including Dual Antiplatelet Therapy)
      1. Low risk, emergent procedures may be performed without reversal
        1. Assumes adequate Platelet Count and function
        2. Ideally, in non-emergent circumstances, agents are held or bridged
      2. High risk procedures should be reversed, held or bridged depending on patient Thrombophilia risk
        1. See Perioperative Anticoagulation
        2. See Emergent Reversal of Anticoagulation
  3. Low Bleeding Risk Procedures (most emergency bedside procedures)
    1. Criteria to perform
      1. INR <3.0 for patients on Warfarin
      2. Platelet Count >20,000
      3. Fibrinogen >100-120 (in Cirrhosis patients)
    2. Image guided vessel cannulation
      1. Central Line Placement in compressible vessel (Internal Jugular or Femoral Line)
        1. May be performed safely in compressible vessels regardless of INR/PTT or Platelet Count
        2. Very low risk of significant bleeding (0.01 to 0.1%) even in high risk patients
      2. Arterial Line placement (<=6F, >=14 guage)
      3. Dialysis Catheter placement
    3. Other image guided procedures (typically Ultrasound-guided)
      1. Thoracentesis
      2. Paracentesis
      3. Small-bore Chest Tube placement (<20 F)
      4. Soft-tissue abscess Incision and Drainage
  4. High Bleeding Risk Procedures
    1. Criteria to perform
      1. INR <1.5 for patients on Warfarin
      2. Platelet Count >50,000
      3. Fibrinogen >150 (in Cirrhosis patients)
    2. Emergency Procedures
      1. Pericardiocentesis
      2. Central Line Placement in NON-compressible vessel (e.g. Subclavian Line)
      3. Lumbar Puncture
        1. Minimum safe Platelet Count varies (20-50k)
        2. Low serious bleeding rates (i.e. Epidural Hematoma) with Platelet Counts >20,000
        3. van Veen (2010) Br J Haematol 148(1):15-25 +PMID: 19775301 [PubMed]
    3. Other specialty procedures
      1. Gastrostomy Tube placement
      2. Solid organ biopsy
      3. Nephrostomy Tube Placement
      4. Deep abscess drainage
  5. References
    1. (2025) Bleeding Risk Bedside Procedures, Hospital Procedures Course
    2. Patel (2019) J Vasc Interv Radiol 30(8):1168-84 +PMID: 31229333 [PubMed]

V. Procedure: Airway

  1. Airway Adjuncts
    1. Nasopharyngeal Airway
    2. Oropharyngeal Airway
    3. Laryngeal Mask Airway (LMA) and other Extraglottic Devices
    4. Elastic Bougie
  2. Definitive Airway
    1. Advanced Airway
    2. Rapid Sequence Intubation
    3. Endotracheal Intubation
    4. Endotracheal Tube
    5. Awake Nasotracheal Intubation
  3. Failed Airway
    1. Cricothyrotomy
    2. Needle Cricothyrotomy
    3. Tracheostomy

VI. Procedure: Breathing

  1. Ventilation
    1. Positive Pressure Ventilation (e.g. Bag Valve Mask)
    2. Non-Invasive Positive Pressure Ventilation (NIPPV, CPAP, BiPap)
    3. Mechanical Ventilation
    4. Ventilator Troubleshooting
  2. Pneumothorax
    1. Needle Thoracentesis
    2. Small Caliber Chest Tube
    3. Chest Tube
  3. Monitoring
    1. Lung Ultrasound
    2. ABG Interpretation

VII. Procedure: Circulation

  1. Access: Child and Adult
    1. Intravenous Access
    2. Intraosseous Access
    3. Peripheral IV Access
    4. Central IV Access
    5. Ultrasound Guided Vascular Access
  2. Access: Newborns
    1. Umbilical Artery Catheter
    2. Umbilical Vein Catheter
  3. Monitoring
    1. Arterial Cannulation
    2. Central Venous Pressure
    3. Emergency Echocardiography
  4. Pericardium
    1. Pericardiocentesis
  5. Arrhythmia
    1. Synchronized Cardioversion and Defibrillation
    2. Emergency Transvenous Pacing
  6. Resuscitation
    1. ABC Management
    2. Trauma Primary Survey
    3. Trauma Secondary Survey
  7. Trauma
    1. Emergency Thoracotomy

VIII. Procedure: Head and Neck

  1. Eye
    1. Corneal Foreign Body
    2. Lateral Canthotomy for Retrobulbar Hematoma
    3. Intraocular Pressure
    4. Eye Ultrasound
  2. Nose
    1. Nasolaryngoscopy
    2. Anterior Nasal Hemorrhage Management
    3. Posterior Nasal Hemorrhage Management
  3. Throat
    1. Control of Hemorrhage after Tonsillectomy

IX. Procedure: Abdomen

  1. Gastrointestinal Tract
    1. Nasogastric Tube
    2. Esophageal Balloon Tamponade
  2. Trauma
    1. FAST Exam
    2. Diagnostic Peritoneal Lavage (rare use in U.S.)
  3. Bladder
    1. Urethral Catheterization
    2. Suprapubic Catheter
  4. Obstetrics
    1. Perimortem Cesarean Section
  5. Ultrasound
    1. Abdominal Aorta Ultrasound
    2. Obstetric Ultrasound
    3. RUQ Ultrasound

X. Procedure: Musculoskeletal

  1. Trauma
    1. Fracture Splinting and Fracture Casting
    2. Intracompartmental Pressure Monitor
  2. Injection
    1. Joint Injection and Soft Tissue Injections
  3. Dislocations
    1. Shoulder Relocation Maneuvers
  4. Ultrasound
    1. See Bedside Ultrasound

XI. Procedure: Neurologic

  1. Diagnostics
    1. Lumbar Puncture
    2. Epidural Blood Patch
  2. Trauma
    1. Skull Trephination (Skull Burr Hole)
  3. Headache
    1. Greater Occipital Nerve Block
    2. Transnasal Sphenopalatine Ganglion Block
  4. Anesthesia
    1. Regional Anesthesia

XII. Procedure: Dental

  1. See Dental Emergency
  2. Infection
    1. Dental Incision and Drainage
  3. Trauma
    1. Dental Splint
  4. Anesthesia
    1. Inferior Alveolar Block
    2. Periapical Block

XIII. Procedure: Skin

  1. Trauma
    1. Tick Removal
    2. Fingertip Amputation Repair
    3. Laceration Repair
    4. Fishhook Removal
  2. Infection
    1. Incision and Drainage
  3. Nails
    1. Toenail Removal
  4. Diagnostics
    1. Skin Biopsy

Images: Related links to external sites (from Bing)

These images are a random sampling from a Bing search on the term "Emergency Procedure." Click on the image (or right click) to open the source website in a new browser window. Search Bing for all related images

Related Topics in Procedure

advertisement