Common Procedures

In this section, we review the following procedures:

• Intubation

• Premedication, Sedation, and Paralysis for Intubation

• Suturing

• Procedural Sedation

• Focused Assessment with Sonography for Trauma (FAST)

Ventilation is discussed in the Critical Care rotation guide.

At the end of the page, we provide a list of links to videos of common procedures performed in the emergency department (ED):

Intubation

The decision to intubate a patient is based on clinical judgment; intubate in any situation where definitive control of the airway is indicated. In the ED, intubation is generally achieved through use of rapid sequence induction (RSI).

Indications

• Altered mental status with an inability to protect the airway/aspiration risk, for example:

  • Glasgow Coma Scale (GCS) <8

  • pooled oral secretions, suppressed gag reflex, vomiting

• Respiratory failure unlikely amenable to, or failed, noninvasive pressure-assisted ventilation, for example:

  • severe pulmonary edema/congestive heart failure (CHF)

  • pulmonary embolism

  • COVID-19 or other infectious etiology

  • COPD or asthma exacerbations

• Facilitate delivery of high-complexity critical care, for example:

  • status epilepticus

  • complex trauma patient

Contraindications

• Other airway/respiratory interventions initially indicated, for example:

  • noninvasive ventilatory support, such as bilevel or continuous positive airway pressure (BiPAP or CPAP)

  • nasal trumpet may resolve tongue prolapse without other intervention in toxicologic situation

• Severe anatomic distortion suggesting surgical airway should be attempted first (rare)

Equipment

• Protective:

  • gloves and face shield

• For preoxygenation:

  • bag-valve mask attached to an oxygen source

• For apneic oxygenation:

  • nasal cannula with maximum O2 flow

• Preventative:

  • suction system actively suctioning (Yankauer or other suction)

  • backup airway devices

    • gum-elastic bougie

    • laryngeal mask airway

    • fiberoptic intubating bronchoscope

    • scalpel and trach hook for surgical airway nearby

• At time of intubation:

  • endotracheal tube with stylet

  • video or standard laryngoscope

    • both tube and laryngoscope should be sized appropriately for the patient

• After intubation:

  • 10-mL syringe

  • endotracheal-tube holder or cloth tape

  • end-tidal carbon dioxide detector

  • stethoscope

Preparation

• All equipment is readily accessible and functioning, and personnel are properly prepared.

• The patient has intravenous (IV) access and is on a monitor.

• Written informed consent has been obtained from the patient or the patient’s health care proxy if the clinical situation permits.

  • You can justify no consent if the situation is emergent and there is no proxy or clear advanced directive.

• Position the patient.

  • Adjust the height of the bed so that the patient’s head is level with the lower portion of your sternum.

  • Move the patient into the “sniffing” position by placing a pillow or folded towel under the patient’s occiput. Ideally, the patient's tragus (or ear canal) should be about at the level of their suprasternal notch.

  • Remove the patient’s dentures, if present.

  • If the patient’s mental status is diminished or if the patient is pharmacologically sedated, an assistant should apply firm pressure to the cricoid cartilage (the Sellick maneuver).

• Pre-oxygenate the patient with a bag-valve mask to an adequate saturation. Only assist if needed.

• Pediatric considerations:

  • Children’s anatomy requires additional positioning and thorax alignment with the head by placing a rolled towel under the shoulders.

  • Tube size: General rule of thumb is 4 for patients age ≥16, or follow pediatric measuring tape (Broselow Pediatric Equipment).

• Apply strict in-line stabilization of the cervical spine if unstable injury is suspected. The anterior portion of the cervical collar is opened or removed to permit the patient’s mouth to be fully opened.

• If intubation by mouth is inappropriate, nasotracheal intubation may be attempted before a surgical airway.

Premedication, Sedation, and Paralysis for Intubation

The majority of intubations in the ED require the use of medications to sedate and paralyze the patient to optimize intubation conditions and increase the likelihood of a first-pass success. These agents will improve visualization of the vocal cords and prevent the patient from vomiting and aspirating gastric contents.

Pretreatment

Evidence is inconclusive on the benefit of using the following agents:

• Lidocaine was routinely used as a pretreatment agent for patients with elevated intracranial pressure (ICP) caused by intubation in patients with head trauma, but more recent data show no benefit from lidocaine in reducing ICP or improving neurologic outcomes.

• Atropine may decrease the incidence of bradycardia associated with direct laryngoscopy; use is considered generally only in young children.

Induction

Induction provides a rapid loss of consciousness and should be administered before paralyzing a conscious patient.

• Etomidate (Amidate) has a rapid onset, short duration, is cerebroprotective (reduces ICP and cerebral oxygen consumption while maintaining cerebral perfusion pressure). Etomidate is infrequently associated with a significant drop in blood pressure (BP) and may cause adrenal suppression.

  • consider in patient with head trauma; dose can be adjusted for hypotension

• Ketamine (Ketalar) results in a “dissociative” state, has analgesic properties, is a bronchodilator, and increases sympathetic tone (increasing both HR and BP). Ketamine may increase ICP.

  • consider in patient with asthma and hypotension

• Propofol (Diprivan) has rapid onset, short duration, is cerebroprotective, and decreases systemic vascular resistance and blood pressure.

  • consider for high blood pressure and seizures

Paralysis

Paralysis is used for intubation to provide neuromuscular blockade and is administered immediately after the induction agent. Paralytics do not provide sedation and analgesia and is not associated with amnesia. It is paramount to initiate continuous sedation immediately after intubation to avoid placing a patient in an awake state while paralyzed.

• Succinylcholine (Anectine) is a depolarizing neuromuscular blocker associated with rapid onset and the shortest duration of action (~10 min). However, there are many contraindications to succinylcholine; it should be used with caution in patients with known or suspected hyperkalemia or neuromuscular disease.

  • associated with muscle fasciculations after administration

• Rocuronium (Zemuron) is a nondepolarizing neuromuscular blocker with a slightly longer onset of action and duration of action (~30 min). It is not associated with muscle fasciculations after administration.

  • Sugammadex is a binding agent that can reverse the paralytic effects of rocuronium (and other nondepolarizing paralytics) within minutes.

Suturing

See the Color Atlas of Cutaneous Excisions and Repairs (Chapter 1) for instructions and illustrations of various suturing techniques.

General Suturing Guidelines

• Wear protective equipment. Suturing is not a sterile procedure; however, you should strive for a clean environment.

• Achieve homeostasis and grossly inspect the wound.

  • Never blind clamp.

  • Assess and document neurovascular and mechanical compromise in the form of pulse, capillary refill, sensation, and intact range of movement.

    • Whenever suspicion exists that a wound has injured a tendon, nerve, joint, or other important anatomic structure, or has been caused by a foreign body, the wound should be explored before repair.

    • Contact the appropriate specialists.

  • Wounds older than 6 hours (hands and feet) and 24 hours (on the face) or caused by animal/human bites usually should not be closed because of the high risk for infection. However, some clinicians choose to close animal bite wounds, particularly if the bite is on the face.

• Numb the local area or perform a nerve block. Choose between lidocaine strength (higher concentration reduces injected volume) and addition of epinephrine for the wound area.

  • Epinephrine is generally not recommended for distal areas where perfusion is of essence (fingers, ears, or nose).

  • Decrease pain of injection with one or more of these 5 steps:

    • warm anesthetic to near body temperature (axilla or a convenient blanket warmer)

    • inject through the exposed edge of laceration rather than through intact skin

    • use a small gauge needle (27 g if available)

    • inject slowly

    • buffer 9:1 with sodium bicarbonate (9 mL anesthetic and 1 mL sodium bicarbonate).

• Irrigate copiously with clean water.

  • Normal saline, clean tap water, or sterile water are all acceptable. Studies have not demonstrated a benefit of one irrigation fluid over another.

  • The volume of irrigation depends on the size and contamination of the wound. If grossly contaminated, irrigate until the wound is free from visible contamination (50-100 mL/cm wound length is a reasonable).

  • The ideal pressure of irrigation is up for debate; some evidence suggests that equivalent outcomes are achieved with tap water irrigation and higher-pressure forms. Multiple commercial irrigation tools have proven to provide adequate, continuous pressure; optimal pressure also depends on the degree of contamination. High pressures reduce bacterial count but come at the expense of tissue injury. Many experts suggest irrigating through a 19 g catheter attached to a 60 cc syringe.

  • Use of a shield is recommended to limit clinician exposure to bodily fluids.

• Select the type of wound closure and technique that best suits the area. (For an overview of wound closure materials see Cutaneous Wound Closure Materials: An Overview and Update.)

• Provide the patient with good care instructions and return precautions.

  • Advise good hygienic practice: Clean the wound at least two times per day.

  • Counsel about cosmetic results: Exposure of the wound to the sun leads to increased scarring.

  • Schedule suture removal: face, 3 to 4 days; scalp, 5 days; trunk, 7 days; arm or leg, 7 to 10 days; and foot, 10 to 14 days.

  • Systemic antibiotics have not been shown to provide protection against development of wound infection for uncomplicated wounds and lacerations. Consider antibiotics for:

    • animal bites (amoxicillin/clavulanate)

    • puncture wound through the sole of a shoe (fluoroquinolones)

    • immunocompromised patients with wounds to areas with poor vascularity (e.g., elderly diabetic with hand laceration)

• Immediate administration of IV antibiotics should be considered in the scenarios:

  • complex or mutilating wounds, especially of the hand or foot

  • grossly contaminated wounds with penetrating debris and foreign bodies

  • lacerations in areas of lymphatic obstruction and lymphedema

  • suspected penetration of bone (open fractures), joints, or tendons

  • animal bite wounds (only when there is exposed bone, an open fracture, or extensive injuries in a patient requiring hospital admission)

  • amputation injuries, especially where replantation is a consideration

  • significant lacerations in patients with preexisting valvular heart disease

  • presence of disease or drugs causing immunosuppression or altered host defenses

• A first-generation cephalosporin, such as cefazolin, is usually the initial IV antibiotic of choice.

  • For penicillin-allergic patients, ciprofloxacin and clindamycin are reasonable alternatives.

  • For bites, consider ampicillin/sulbactam, ceftriaxone plus metronidazole, or trimethoprim-sulfamethoxazole (TMP-SMX) plus clindamycin.

• Consider rabies exposure and follow CDC guidelines.

  • Ask about tetanus status: Tetanus should be administered if less than 48 hours from infliction of the wound (see CDC guidelines).

(Source: Immunization Program, Minnesota Department of Health.)

Procedural Sedation

As defined by the American College of Emergency Physicians (ACEP), “procedural sedation is a technique of administering sedatives or dissociative agents with or without analgesics to induce a state that allows the patient to tolerate unpleasant procedures.” The American Society of Anesthesiologists (ASA) developed Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists.. The guideline does not apply to patients receiving inhaled anesthetics, analgesia for pain control without sedation, sedation to manage behavioral emergencies, or to patients who are intubated.

• Educate and obtain patient consent before sedation.

• Place the patient on the monitor with telemetry, a reliable pulse oximetry reading, frequent blood pressure checks (q2-5min), and end-tidal CO2.

• Have suction, oxygenation, and an intubation cart near and ready. Some institutions require immediate availability of respiratory therapy. Check your departmental policy before performing a sedation.

• Frequently reevaluate level of sedation and modify dosing accordingly.

• Do not leave the room until the patient is conscious and has purposeful movement.

Focused Assessment with Sonography for Trauma (FAST)

The objective of the FAST exam is to detect free fluid that might indicate internal bleeding in the trauma setting. A phased-array or curvilinear probe is most commonly used. Visual demonstrations of the FAST exam can be seen here (skip to the second video) and here.

The FAST exam typically involves four views:

• hepatorenal recess or Morison pouch (right upper quadrant)

  • ultrasound reliably detects as little as 250 mL of free fluid in Morison pouch

• splenorenal or perisplenic view (left upper quadrant)

• pelvic view

• pericardial or subxiphoid view

Videos of Related Procedures

Peripheral Intravenous Cannulation
Central Venous Catheterization
Orotracheal Intubation
Chest-Tube Insertion
Cricothyroidotomy
Needle Aspiration of Primary Spontaneous Pneumothorax
Noninvasive Positive-Pressure Ventilation
Lumbar Puncture
Procedural Sedation and Analgesia in Children
Conscious Sedation for Minor Procedures in Adults
Point-of-Care Ultrasonography
FAST Examination (video 2)
Technique for Temporary Pelvic Stabilization after Trauma
Pelvic Examination
Clinical Examination of the Shoulder
Clinical Evaluation of the Knee
Basic Splinting Techniques
Reduction of Paraphimosis in Boys
Basic Laceration Repair
Examination of the Hand and Wrist