chapter 26 Critical Procedures Brent R. King, MMM, MD, FAAP, FACEP, FAAEM Christopher King, MD, FACEP Wendy C. Coates, MD, FACEP Objectives Chapter Outline Demonstrate the Introduction Section 10: Emergent Intubation 1 maneuvers required Section 1: Pediatric Length-Based 10.1 Endotracheal Intubation for the basic treatment Resuscitation Tape 10.2 Rapid Sequence Intubation of ill and injured Section 2: Cervical Spine Section 11: Rescue Airway children, including Stabilization Techniques oxygen administration, Section 3: Monitoring 11.1 Supraglottic Devices monitoring, and basic 3.1 ECG Monitoring 11.1A Laryngeal Mask Airway airway maneuvers. 3.2 Impedance Pneumatography 11.1B Combitube Demonstrate 3.3 Blood Pressure Monitors 11.2 Specialized Laryngoscopes 2 orotracheal intubation 3.4 Pulse Oximetry 11.2A Fiberoptic Scopes using a manikin model. 3.5 Exhaled Carbon Dioxide 11.3 Laryngoscopes With Special Monitors Blades Demonstrate 11.3A Video Laryngoscopes Section 4: Oxygen Administration placement of an 11.3B Lighted Stylet 3 4.1 Nasal Cannula intraosseous needle 11.4 Tracheal Guides 4.2 Oxygen Masks in a manikin or other 4.3 Nonrebreathing Masks Section 12: Surgical Airway model and describe 4.4 Oxygen Hoods Techniques the landmarks for 12.1 Needle Cricothyrotomy Section 5: Suction intraosseous needle 12.2 Retrograde Intubation Section 6: Opening the Airway placement in a child. 12.3 Wire-Guided Cricothyrotomy 6.1 Chin-Lift Maneuver Describe the 12.4 Surgical Cricothyrotomy 6.2 Jaw-Thrust Maneuver indications and 12.5 Tracheostomy Management 4 Section 7: Airway Adjuncts technique for needle Section 13: Cardioversion and 7.1 Oropharyngeal Airways thoracostomy. Defibrillation 7.2 Nasopharyngeal Airways 13.1 Cardioversion and Describe indications Section 8: Bag-Mask Ventilation Defibrillation and technique for 5 Section 9: Management of Upper 13.2 Automated External pericardiocentesis. Airway Foreign Bodies With Defibrillator Magill Forceps Section 14: Vascular Access 14.1 Peripheral Venous Catheter Placement 14.2 External Jugular Vein Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians Chapter Outline (continued) Cannulation 17.2 Dislocations 14.3 Central Venous Catheter Placement 17.3 Shoulder Dislocation 14.4 Umbilical Vein Catheterization 17.4 Elbow Dislocation 14.5 Intraosseous Needle Placement 17.5 Knee Dislocation 14.6 Venous Cutdown 17.6 Hip Dislocation Section 15: Thoracic Procedures 17.7 Splinting 15.1 Needle Thoracostomy (Thoracentesis) 17.7A Volar Arm Splint 15.2 Tube Thoracostomy 17.7B Sugar-Tong Splint (Forearm) 15.3 Emergency Thoracotomy 17.7C Ulnar Gutter 15.4 Pericardiocentesis 17.7D Thumb Spica Section 16: Miscellaneous Procedures 17.7E Sugar-Tong Splint (Upper Extremity) 16.1 Nasogastric or Orogastric Intubation 17.7F Finger Splints 16.2 Catheterization of the Bladder 17.7G Posterior Splint (Lower Extremity) 17.7H Sugar-Tong Splint (Lower Extremity) Section 17: Orthopedic Procedures 17.8 Crutch Walking 17.1 Compartment Syndrome Introduction chapter addresses the performance of several key Competence in emergency care is, in part, based emergency procedures. The individual practitio- on the physician’s ability to perform potentially ner must determine the extent to which each of lifesaving procedures. In many cases, perfor- these procedures is likely to be required in his mance of the procedure takes precedence over or her practice, but all physicians who care for other aspects of treatment. When a child presents children with serious illnesses and/or injuries in impending respiratory failure or in the early must possess, in addition to cognitive skills, the phases of shock, urgent therapy is warranted requisite procedural skills. All procedures should even in the absence of a specific diagnosis. This be performed with universal precautions. 26-3 Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians Section 1: Pediatric Length- Based Resuscitation Tape 1.1 Pediatric Length-Based Resuscitation Tape Length-based resuscitation tape permits the rapid determination of size-dependent resus- citation parameters, such as drug doses, endo- tracheal tube (ETT) sizes, mask sizes, and vital Figure 26.1 Application of a length-based resuscitation tape. signs, which potentially speeds resuscitation efforts and reduces the likelihood of a medi- cal error. The tape is placed at one end of the 4. Verbalize the color or letter block (on patient, and the other end of the patient aligns the edge of the tape) and the weight with a color-coded block corresponding to the estimate determined by the tape so that patient’s length-based resuscitation parameters. this information can be recorded. There might be two sets of blocks, one of which 5. Use the appropriate color or letter block corresponds to tube sizes, vital signs, etc., and to identify appropriate drug doses and the other of which indicates drug dosing. Many equipment sizes (Figure 26.2). systems include books with color-coded pag- es that provide even more information. Some length-based resuscitation systems will have Section 2: Cervical Spine corresponding color-coded bags or carts that contain the actual resuscitation devices (eg, tra- Stabilization cheal tubes and laryngoscope) and drugs (pre- calculated unit doses). 2.1 Cervical Spine Stabilization Technique Indications 1. Align the end of the tape to the patient. Although cervical spine injuries are relatively Alternatively, if the tape is secured to the rare in children, patients who have sustained gurney, adjust the patient’s position to significant blunt trauma (eg, falls from heights, align with one end of the tape. automobile-pedestrian crashes, moderate to se- 2. Identify the inferior end of the patient vere motor vehicle crashes, diving injuries) and using the heels, not the toes (Figure 26.1). those who sustain direct injury to the neck (blunt 3. If the child is larger than the tape (>36 or penetrating) are at risk, and the cervical spine kg), proceed as in the case of an adult. should be protected before complete evaluation. Figure 26.2 The length-based resuscitation tape. 26-4 Critical Procedures Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians Likewise, children and adolescents with symp- a neutral position. A collar that is too tall toms of cervical cord dysfunction after trauma hyperextends the neck, whereas one that (eg, numbness and/or tingling or weakness in is too short allows for unwanted neck an extremity) should be appropriately stabilized flexion. Both hyperextension and flexion pending further evaluation, even if the symptoms can be disastrous in the face of a cervical are transient. Finally, patients who have signifi- spine injury and, therefore, should be cant alterations in mental status and who might avoided. have been injured should also be stabilized until 4. Some cervical collars require assembly they can be thoroughly evaluated. before use. If necessary, assemble the Equipment collar. • Appropriately sized rigid cervical collar 5. Open the cervical collar and carefully slide (Figure 26.3) the rear portion behind the neck while an • Long spine stabilization board assistant maintains inline stabilization of • Lateral spacing blocks or similar devicesa the patient’s head and neck. a • Straps or tape 6. Bring the front of the collar into position Required for Infants and Young Children: and then attach the front and back • Specially designed long spine stabiliza- portions together using the adhesive tion board with cutout or indentation to straps. The collar should fit snugly but accommodate the occiputa or not constrict the airway or restrict blood • Pad placed on the spine board and ex- flow to the skin (Figure 26.4B). tending from the child’s shoulders to his 7. Ensure that the head remains in a neutral a or her feet position. aThis equipment can be obtained as part of a kit specially 8. Secure the patient to a long spine board. designed for this purpose. If the patient is seated, a short spine board or extrication vest should be secured to the patient to stabilize the head and trunk as a unit. Then place a long spine board beside the patient and, keeping the knees and hips bent, pivot and lower the patient onto the long board. Lower the knees to the board. If the patient is supine, log-roll the patient onto his or her side, maintaining inline stabilization of the neck. Place the long board on edge behind the patient and roll the patient and the board as a unit back into a supine Figure 26.3 Rigid cervical collars in pediatric sizes. position (Figure 26.4C). 9. Secure the patient to the spine board. Technique Place soft lateral spacing devices on 1. Ensure that adequate personnel are either side of the patient’s head. Heavy available to assist. objects such as sandbags should be 2. Stabilize the patient’s head in place by avoided because they can place undue holding the head and keeping the neck lateral pressure on the spine if the board in a neutral position (Figure 26.4A). is inadvertently tilted (Figure 26.4D). 3. Determine the proper size for the cervical 10. Using tape or commercial straps, first collar. The ideally sized collar extends secure the forehead, then the chin, from the top of the shoulders to the shoulders, and pelvis to the board (Figure bottom of the chin, leaving the neck in 26.4E). Section 2: Cervical Spine Stabilization 26-5 Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians A D Figure 26.4A The head and neck should be aligned in a Figure 26.4D The cervical spine should be stabilized neutral cervical spine position. by using blanket rolls or blocks from a cervical immobilization device to block lateral head motion and rotation and to prevent upward motion of the shoulder. B E Figure 26.4B An appropriately sized, rigid cervical collar should be applied.