EMERGENCY

PROCEDURES
MASTERCLASS
HANDBOOK

Siamak Moayedi, MD
Table of contents
Rapid sequence intubation 3
Cardioversion and defibrillation 5
Transcutaneous pacing 7
Transvenous pacing 8
Vertigo maneuvers 10
Central venous access 13
Chest tubes 15
Lumbar puncture 17
Peripheral IV access 19
Reading list 21
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Chapter 1

RAPID SEQUENCE INTUBATION

Indications Contraindications
• Failure to oxygenate • If oxygenation or ventilation can be
• Failure to ventilate accomplished using less invasive means
• Failure to protect airway (e.g., high flow oxygen or BiPAP)
• Relative contraindications
- limited mouth opening
- upper airway trauma / mass / swelling
- excessive blood or secretions

Tools

Laryngoscope Endotracheal tube and stylet Suction Bag-valve-mask (BVM)

Medications
• Sedatives
- ketamine (2 mg / kg ideal body weight)
- etomidate (0.3 mg / kg total body weight)
• Paralytics
- succinylcholine (1 mg / kg total body weight)
- rocuronium (1 mg / kg ideal body weight)

Identify important airway anatomy

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Prepare
• Prepare your equipment
• Preoxygenate the patient
• Place the patient in the sniffing position
• Sedate and paralyze the patient

Sniffing position

Procedure
1. Sweep tongue to the left
2. Visualize arytenoids or vocal cords
3. Place tube in the trachea
4. Inflate the balloon

Always hold laryngoscope in left hand

Post-procedure
• Secure the tube
• Confirm proper tube placement with auscultation and end-tidal capnometry
• Elevate head of bed 45 degrees to avoid aspiration
• Obtain a chest x-ray
• Consider more sedation for the patient

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Chapter 2
Procedure
1.
2.
3.
CARDIOVERSION AND
Guide needle tip into vein at shallow angle
Once blood enters, push catheter over needle until back is flush with skin
Apply pressure to kink tube
4.
5.
6.
Retract needle
Attach connector DEFIBRILLATION
Draw blood (if necessary)
7. Flush IV and clamp connector
8. Secure IV using biofilm
Defibrillation versus cardioversion
• Defibrillation
Pearls
- electricity delivered as soon as shock button is pushed
• Cardioversion
- shock delivered during • QRS complex
To relieve anxiety in children, show catheter beforehand
- turn on sync mode • To steady vein in elderly, pin vein and push up towards tourniquet above
placement site

Indications Contraindications
• Defibrillation • No absolute contraindications
- non-perfusing ventricular tachycardia and • Patients with coronary artery disease may
ventricular fibrillation develop a post-shock bradycardia that may
• Cardioversion (sync mode) require transient pacing.
- non-sinus tachydysrythmias (e.g.,
atrial fibrillation / flutter, re-entrant
supraventricular tachycardia, ventricular
tachycardia with pulse)

Obtaining consent
• No time to consent for defibrillation
• Inform patient of risks, benefits and alternatives
• Cardioversion is painful and requires procedural sedation
• Risk of stroke very low (< 0.1%) if patient is in atrial fibrillation < 48 hrs

Complications
• Pain / burn at site of paddles / pads
• Muscle soreness in the chest

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Tools

The device Paddles Pads

Sedative
• Etomidate 0.1 mg / kg

Procedure (atrial fibrillation)

1. Place IV
2. Attach pads
3. Turn on SYNC mode to switch to cardioversion
4. Select energy level (100-200 joules biphasic)
5. Administer sedative
6. Charge
7. Shock

Pad placement

Pearls
• Prolonged atrial fibrillation may be refractory to cardioversion
• Obese patients usually require higher energy
• With defibrillation—no time for sedation
• Don’t be fooled by a wide complex hyperkalemia rhythm—do not shock!

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Chapter 3

TRANSCUTANEOUS PACING
Indications Contraindications
• Sinus node dysfunction • No absolute contraindications
• Unstable atrioventricular (A–V) nodal block

Complications
• Pain / burn at site of paddles / pads
• Discomfort during pacing

Tools

The device (set to pacer mode) Pads

Sedative
• Benzodiazepines / opiates (midazolam / fentanyl)

Procedure (atrial fibrillation)

1. Attach pads
2. Attach monitor leads
3. Turn on pacer mode
4. Select rate (> 80 bpm) and output (at least 1 mA / kg)
5. Increase rate until mechanical capture
6. Administer sedative / pain medication
7. Prepare for transvenous pacing
Attach pads and monitor leads

Pearls
• Hyperkalemia cannot be paced
• Transcutaneous pacing is a temporary solution, while setting up for
transvenous pacing
• Obese patients usually require higher output
• Monitor leads must be attached for pacing

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Chapter 4

TRANSVENOUS PACING
Indications Contraindications
• Sinus node dysfunction • Any central line contraindication
• Unstable atrioventricular (A–V) nodal block (e.g., thrombocytopenia, coagulopathy)
• Hyperkalemia
• Prosthetic tricuspid valve
• Hypothermia

Tools

Wire Pacerbox Adapter Introducer catheter

Procedure
1. Place introducer in right internal jugular vein
2. Turn on pacer
3. Connect to adapter, then connect to wire
(positive to proximal)
4. Test balloon, feed wire through sheath, then introducer Rate 80, sensitivity turned down,
5. Advance wire to 20 cm output > 10 mA
6. Inflate balloon and advance until you see electrical capture
7. Deflate balloon and lock wire
8. Confirm mechanical capture
(with pulse oximeter, or by measuring pulse)
9. Decrease output to minimal needed to pace and increase
sensitivity to 3 mV
Electrical capture

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Troubleshooting

Failure to capture

Potential problems Potential solutions

Wire not touching ventricle wall Reposition wire

Output too low Increase output

Hyperkalemia Fix electrolytes

Failure to sense

Potential problems Potential solutions

Sensitivity too low Increase sensitivity

Failure to pace

Potential problems Potential solutions

Oversensing Decrease sensitivity

Low battery Replace battery

Loose connection Replace lead

or fix connection

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Chapter 5

VERTIGO MANEUVERS
Vertigo

Constant Episodic

Vestibular Posterior Triggered Spontaneous

neuritis stroke
BPPV Orthostatic
hypotension
Migraines TIA
Ménière’s disease

Benign paroxysmal positional vertigo (BPPV)

• Brief episodes, triggered by head movement
• Commonly caused by obstruction of fluid flow in semicircular canal
• Diagnose with Dix-Hallpike
• Treat with Epley maneuver

Vestibular neuritis
• Constant, prolonged episodes
• Viral etiology
• Transient 8th cranial nerve palsy
• Diagnose with HINTS exam

Stroke
• Generally abrupt onset, gait impairments, vomiting
• Consider risk factors (e.g., smoking, hypertension, diabetes)
• Physical exam (motor / sensory impairments, gaze palsy, cerebellar deficits)
• Perform HINTS exam

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Dix-Hallpike maneuver
1. Seat patient on bed such that, when they lay down, their head extends beyond the head of the bed

2. Start with the side that makes patient dizzy

3. Quickly lay patient supine, with head turned 45 degrees to side you’re testing, and neck extended
30 degrees off bed

4. Look for nystagmus

5. If no nystagmus or vertigo, repeat in opposite direction

Epley maneuver
1. Perform the Dix-Hallpike
2. Wait 30 seconds after nystagmus resolves
3. Turn patient’s head 90 degrees in opposite direction

4. Wait 1 minute
5. Have patient roll onto shoulder and face down to ground

6. Help patient sit up looking forward, maintain position for at least 3 minutes

7. Confirm resolution with a negative Dix-Hallpike, and repeat Epley if necessary

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HINTS exam
• Helps differentiate between peripheral and central causes of vertigo
• Head impulse test (HIT)
- tests vestibulo-ocular reflex
- corrective saccade indicates vestibular neuritis
- no corrective saccade (reflex intact) indicates central cause
• Nystagmus
- vertical or direction changing nystagmus indicates central cause
• Test of skew
- vertical or diagonal eye movement indicates central cause

Pearls
• Never perform Dix-Hallpike on a patient who has persistent vertigo
• Never perform HINTS on an asymptomatic patient
• All forms of vertigo are worsened with head movement

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Chapter 6

CENTRAL VENOUS ACCESS

Indications Contraindications
• Inability to access peripheral veins • Infection at placement site
• Infusion of • Coagulopathy
- vasopressor(s) • Thrombocytopenia
- concentrated solutions • Other devices at site of placement
(e.g., calcium chloride) (e.g., pacemaker)
- multiple medications • Thrombosis of target vein
• Rapid fluid / blood administration • Abnormality of overlying skin (e.g., cellulitis)
• Transvenous pacemaker placement • Non-cooperative patient
• Less invasive alternative access available

Tools

Lidocaine 18 gauge needle Wire Dilator Scalpel Suture Catheter

and syringe

Patient positioning

Femoral vein Internal jugular vein Subclavian vein

• Externally rotate hip • Keep head in neutral position • Head turned 30 degrees toward
the side of insertion

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Procedure
1. Anesthetize skin over placement site
2. Insert needle and syringe
3. Apply negative pressure
4. When blood flows freely, secure needle and remove syringe
5. Feed wire to 20 cm
6. Remove needle and make incision along wire
7. Thread dilator over wire until fully in vein
8. Remove dilator
9. Place catheter over wire
10. Remove wire and clamp ports

Always use sterile technique

Post-procedure
1. Flush all ports
2. Suture central line in place and apply bio-occlusive dressing
3. Obtain chest x-ray
- check catheter position
- rule out pneumothorax

Pearls
• Consider using ultrasound guidance
• If possible, use wire through catheter technique
• Avoid femoral approach in patients with inferior vena cava filter
• Wire misplacement
- sensation of water running—misplacement into internal jugular vein
- shoulder and arm pain—misplacement in opposite subclavian vein

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Chapter 7

CHEST TUBES
Indications Contraindications
• Pneumothorax • No absolute contraindications
• Hemothorax • Relative contraindications
• Empyema - coagulopathy
- thrombocytopenia
- transudative effusion

Complications
• Infection
• Bleeding
• Lung injury
• Misplacement
• Pain

Tools

Sterilizing Anesthesia Scalpel Kelly clamps Chest tube Needle driver Zero suture
solution

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Insertion sites

fourth intercostal space

fifth intercostal space

Procedure
1. Apply local anesthetic (e.g., lidocaine)
2. Make incision 1.5 times diameter of tube
3. Place large Kelly clamp into pleural space
4. Spread clamp slightly to approximate size of chest tube
5. Withdraw clamp
6. Place finger into cavity and confirm you’re in pleural space
7. Pass tube into pleural cavity using Kelly clamp
8. For a pneumothorax, guide the tube anteriorly and superiorly toward lung apex

Always use sterile technique

Post-procedure
1. Connect to suction
2. Suture tube in place
3. Place dressing
4. Obtain chest x-ray

Pearls
• Use needle or finger decompression to rapidly treat tension pneumothorax in
unstable patient
• Consider using Seldinger technique (pigtail catheter) in non-trauma
situations (e.g., spontaneous pneumothorax or pleural effusion)
- less painful
- smaller incision

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Chapter 8

LUMBAR PUNCTURE
Indications Contraindications
• Meningitis • Skin infection near puncture site
• Subarachnoid hemorrhage • Coagulopathy
• Multiple sclerosis • Thrombocytopenia
• Idiopathic intracranial hypertension • Increased intracranial pressure
• Measurement of opening pressure • Agitation
• Prior lumbar fusion or laminectomy

Complications
• Infection
• Bleeding
• Nerve injury
• Post-lumbar puncture headache

Tools

22 gauge spinal needle Lumbar puncture kit Sterile gloves

(with stylet)

Patient position

Lateral decubitus position Sitting position

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Procedure
1. Sterilize skin and apply dressing
2. Apply local anesthesia
3. Insert needle and advance through ligamentum flavum (confirmed by pop)
4. Remove stylet and measure opening pressure
5. Collect four tubes of fluid
6. Replace stylet and remove needle
7. Apply dressing

Pearls
• Upright position is easier to tap, but complicated if opening pressure is
needed
• If traumatic tap, allow gross blood and cerebral spinal fluid (CSF) to clear
prior to collection
• No need for remaining supine after procedure
• To decrease chance of post-lumbar puncture headache
- insert stylet before removing needle
- use 22 gauge needle
- place bevel parallel to long axis of spine
- use blunt-tipped needle

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Chapter 9

PERIPHERAL IVACCESS
PERIPHAL IV ACCESS
Indications
• Rapidly administer medications and fluids

Tools

Tourniquet IV Connector Gauze Alcohol wipe

Biofilm adhesive Tape Saline flush

Tourniquet placement

Wrap around arm Cross ends Push one end into Tighten
center of cross

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Procedure
1. Guide needle tip into vein at shallow angle
2. Once blood enters, push catheter over needle until back is flush with skin
3. Apply pressure to kink tube
4. Retract needle
5. Attach connector
6. Draw blood (if necessary)
7. Flush IV and clamp connector
8. Secure IV using biofilm

Pearls
• To relieve anxiety in children, show catheter beforehand
• To steady vein in elderly, pin vein and push up towards tourniquet above
placement site

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Emergency Procedures
Procedure

READING LIST
1. Guide needle tip into vein at shallow angle
2. Once blood enters, push catheter over needle until back is flush with skin
3. Apply pressure to kink tube
4. Retract needle
5. Attach connector
Chapter
6. Draw1.blood
Rapid(ifsequence
necessary)intubation
7. Flush IV and clamp connector
8. Secure
Roberts, IV using
J. 2018. biofilm
Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care. 7th
edition. New York: Elsevier. (Roberts 2018, 39–111)

Tintinalli, JE. 2016. Tintinalli‘s Emergency Medicine. 8th edition. New York: McGraw-Hill. (Tintinalli 2016,
183–191) Pearls
Chapter 2. Cardioversion and• defibrillation
To relieve anxiety in children, show catheter beforehand
• To steady vein in elderly, pin vein and push up towards tourniquet above
placement
Roberts, J. 2018. Roberts and Hedges’ siteProcedures in Emergency Medicine and Acute Care. 7th
Clinical
edition. New York: Elsevier. (Roberts 2018, 238–257)

Roberts, J. 2018. Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care. 7th
edition. New York: Elsevier. (Roberts 2018, 594–620)

Tintinalli, JE. 2016. Tintinalli‘s Emergency Medicine. 8th edition. New York: McGraw-Hill. (Tintinalli 2016,
157–159)

Tintinalli, JE. 2016. Tintinalli‘s Emergency Medicine. 8th edition. New York: McGraw-Hill. (Tintinalli 2016,
249–255)

Chapter 3. Transcutaneous pacing

Roberts, J. 2018. Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care. 7th
edition. New York: Elsevier. (Roberts 2018, 288–308)

Tintinalli, JE. 2016. Tintinalli‘s Emergency Medicine. 8th edition. New York: McGraw-Hill. (Tintinalli 2016,
216–222)

Chapter 4. Transvenous pacing

Roberts, J. 2018. Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care. 7th
edition. New York: Elsevier. (Roberts 2018, 288–308)

Tintinalli, JE. 2016. Tintinalli‘s Emergency Medicine. 8th edition. New York: McGraw-Hill. (Tintinalli 2016,
216–222)

Harrigan, RA, Chan, TC, Moonblatt, S, et al. 2007. Temporary transvenous pacemaker placement in the
Emergency Department. J Emerg Med. 32: 105–111.

Chapter 5. Vertigo maneuvers

Roberts, J. 2018. Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care. 7th
edition. New York: Elsevier. (Roberts 2018, 1281–1294)

Tarnutzer, AA, Berkowitz, AL, Robinson, KA, et al. 2011. Does my dizzy patient have a stroke? A systematic
review of bedside diagnosis in acute vestibular syndrome. CMAJ. 183: E571–E592.

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Kattah, JC, Talkad, AV, Wang, DZ, et al. 2009. HINTS to diagnose stroke in the acute vestibular syndrome:
three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging.
Procedure
Stroke. 40: 3504–3510.

1. GuideJE.
Tintinalli, needle
2016.tipTintinalli‘s
into vein at shallow angle
Emergency Medicine. 8th edition. New York: McGraw-Hill. (Tintinalli 2016,
2. Once blood enters, push catheter over needle until back is flush with skin
1164–1172)
3. Apply pressure to kink tube
4. Retract
Edlow, Diagnosing dizziness: we are teaching the wrong paradigm!. Acad Emerg Med. 20: 1064–
needle
JA. 2013.
5. Attach connector
1066.
6. Draw blood (if necessary)
Chapter
7. Flush6.IVCentral venous
and clamp access
connector
8. Secure IV using biofilm
Roberts, J. 2018. Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care. 7th
edition. New York: Elsevier. (Roberts 2018, 405–438)

Pearls
Tintinalli, JE. 2016. Tintinalli‘s Emergency Medicine. 8th edition. New York: McGraw-Hill. (Tintinalli 2016,
198–208)
• To relieve anxiety in children, show catheter beforehand
Roldan, CJ and Paniagua, L, •et al.To2015.
steady vein in
Central elderly,catheter
venous pin veinintravascular
and push up malpositioning:
towards tourniquet above
causes,
placement
prevention, diagnosis, and correction. J Emerg Med. 16: 658–664.
West site

Taylor, RW and Palagiri, AV. 2007. Central venous catheterization. Crit Care Med. 35: 1390–1396.

Marik, PE, Flemmer, M, and Harrison, W. 2012. The risk of catheter-related bloodstream infection with femoral
venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of
the literature and meta-analysis. Crit Care Med. 40: 2479–2485.

Moayedi, S, Witting, M, and Pirotte, M. 2016. Safety and efficacy of the „easy internal jugular (IJ)“: an
approach to difficult intravenous access. J Emerg Med. 51: 636–642.

Chapter 7. Chest tubes

Roberts, J. 2018. Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care. 7th
edition. New York: Elsevier. (Roberts 2018, 196–220)

Tintinalli, JE. 2016. Tintinalli‘s Emergency Medicine. 8th edition. New York: McGraw-Hill. (Tintinalli 2016,
249–255)

Tintinalli, JE. 2016. Tintinalli‘s Emergency Medicine. 8th edition. New York: McGraw-Hill. (Tintinalli 2016,
464–467)

Chapter 8. Lumbar puncture

Roberts, J. 2018. Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care. 7th
edition. New York: Elsevier. (Roberts 2018, 1258–1280)

Tintinalli, JE. 2016. Tintinalli‘s Emergency Medicine. 8th edition. New York: McGraw-Hill. (Tintinalli 2016,
1199–1206)

Lavi, R, Yarnitsky, D, Rowe, JM, et al. 2006. Standard vs atraumatic Whitacre needle for diagnostic lumbar
puncture: a randomized trial. Neurology. 67: 1492–1494.

Chapter 9. Peripheral IV access

Roberts, J. 2018. Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care. 7th
edition. New York: Elsevier. (Roberts 2018, 394–404)

Tintinalli, JE. 2016. Tintinalli‘s Emergency Medicine. 8th edition. New York: McGraw-Hill. (Tintinalli 2016,
198–208)
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 COURSE
TITLE

Teacher name
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