Anesthesiologist's Manual of Surgical Procedures, 4th ed.

Chapter 15

Emergency Procedures for the Anesthesiologist

Frederick G. Mihm MD

Anesthesiologist

Myer H. Rosenthal MD, FACCP

Anesthesiologist

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Emergency Cricothyrotomy

Clinical situation: Typically, this is a hypoxic patient with obstructed airway (not involving direct tracheal trauma), who cannot be mask ventilated or intubated.

Emergency “Stab” Cricothyrotomy5

Equipment

·         Scalpel with #11 blade

·         Tracheal hook

·         Tracheostomy tubes: #6, #7

·         ETTs: #6, #7

·         Umbilical or twill tape for securing tube

·         10-mL syringe for inflating cuff

·         Prep solution

·         2% lidocaine

·         Suction device (Yankauer or Tonsil Tip)

·         Lubricant (lidocaine jelly or KY jelly)

Procedure

1.     Prep skin.

2.     Palpate cricothyroid membrane.

3.     Make transverse incision through skin and cricothyroid membrane with single stab5 (Fig. 15-1).

4.     Reverse scalpel, place handle into wound, and turn 90° to expand incision.

5.     Pass tracheostomy tube (or standard ETT) into trachea.

6.     Inflate cuff on tracheostomy/ETT.

7.     Ventilate patient.

8.     Secure tube.

Emergency “Guidewire” Cricothyrotomy

Equipment

·         Melker Emergency Cricothyrotomy Set (Cook Critical Care), or equivalent

·         Scalpel with #15 blade

·         6-mL syringe half-filled with NS

·         18-ga introducer needle

·         18-ga iv catheter/needle

·         Amplatz extra-stiff guidewire 0.038”

·         Curved dilator

·         Airway catheter

·         Umbilical or twill tape

Procedure

1.     Identify cricothyroid membrane between cricoid and thyroid cartilages (Fig. 15-2).

2.     Stabilize cricothyroid membrane and make a vertical midline incision with #15 blade (Fig. 15-3).

3.     Attach syringe to iv catheter and needle, and advance at a 45° caudad angle through incision until air bubbles can be aspirated (tracheal lumen). (See Fig. 15-4).

4.     Remove syringe and needle, leaving catheter in place.

5.     Advance soft end of guidewire into catheter several cm past end of catheter.

6.     Remove catheter.

7.     Assemble emergency airway device (Fig. 15-5) by inserting the dilator through the airway catheter until the handle stops against the connector of the airway catheter.

8.     Advance the dilator/airway catheter assembly over the guidewire into the trachea, keeping proximal end of guidewire visible at all times (Fig. 15-6).

9.     Remove guidewire and dilator, leaving airway catheter in place.

10.   Ventilate patient.

11.   Secure airway with umbilical or twill tape around the neck.

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Figure 15-1. Reproduced with permission from Shackford S: Tracheostomy and cricothyrotomy. In Clinical Procedures in Anesthesia and Intensive Care. Benumof JL, ed. JB Lippincott, Philadelphia: 1992, 391–403.

 

Figure 15-2.

 

Figure 15-3.

 

Figure 15-4.

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Figure 15-6.

 

Figure 15-5.

Pericardiocentesis

Clinical situation: The patient typically has severe ↓ BP unexplained by any other causes (e.g., anesthetic drugs, autoPEEP, tension pneumothorax) and consistent with acute cardiac tamponade (↓ BP, ↑ HR, ↓ pulse pressure, ↑ CVP) ± equalization of pressures (RAP ~RVEDP ~PAD ~PAOP) ± confirmation by TEE. Because of the high intrapericardial pressures all “filling pressures” of both right and left heart appear high when preload is actually very low. In severe cases, patients will experience cardiac arrest with pulseless electrical activity (PEA).

Equipment

·         10-mL syringe

·         18-ga spinal needle

Procedure2

1.     Identify xiphoid process and point 1″ below and 1″ left of midline (Fig. 15-7).

2.     Prep skin below xiphoid.

3.     Attach needle to syringe and direct needle under rib toward left shoulder (Fig. 15-8).

4.     If pericardial fluid is withdrawn, BP will ↑ immediately.

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Figure 15-7. Reproduced with permission from Danforth J: Pericardiocentesis. In Clinical Procedures in Anesthesia and Intensive Care. Benumof JL, ed. JB Lippincott, Philadelphia: 1992.

 

Figure 15-8. Reproduced with permission from Danforth J: Pericardiocentesis. In Clinical Procedures in Anesthesia and Intensive Care. Benumof JL, ed. JB Lippincott, Philadelphia: 1992.

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Arterial Cutdown

Clinical situation: A patient requires arterial catheterization for BP/blood gas monitoring, following failed percutaneous attempts, or with coagulopathy.

Equipment

·         Prep solution

·         Wrist board

·         2% lidocaine

·         Curved hemostat

·         Curved pickups

·         Scalpel with #10 and #11 blades

·         Gauze

·         2–0 suture

·         Needle driver

Radial artery cutdown procedure3,4

1.     Position wrist in extension on arm board.

2.     Prep and drape wrist.

3.     Infiltrate skin and deep tissues down to the bone on either side of the vessel with lidocaine (1–2%, 2–3 mL).

4.     Make 1 cm transverse incision ~2 cm proximal to wrist crease and just lateral to flexor carpi radialis tendon (Fig. 15-9).

5.     Using blunt dissection with the hemostat (in the direction of the vessel), identify the artery.

6.     Blunt dissect just under artery and pass sutures around the vessel both distally and proximally (do not ligate vessel) (Fig. 15-10).

7.     Use traction on the distal suture to stabilize artery for cannulation.1

8.     After cannulation, remove sutures and close incision. (For cleaner wound closure, pass catheter through skin rather than directly into wound.)

9.     Suture catheter to skin.

 

Figure 15-9. Reproduced with permission from Hirschl RB, Heiss K: Cardiopulmonary critical care and shock. In Surgery of Infants and Children. Oldham KT, Colombani PM, Foglia RP, eds. Lippincott-Raven, Philadelphia: 1997.

P.1525

 

Figure 15-10. Reproduced with permission from Hirschl RB, Heiss K: Cardiopulmonary critical care and shock. In Surgery of Infants and Children. Oldham KT, Colombani PM, Foglia RP, eds. Lippincott-Raven, Philadelphia: 1997.

Emergent Needle/Catheter Thoracostomy

Clinical situation: A patient is experiencing severe hypotension and hypoxemia unexplained by any other cause (e.g., autoPEEP, cardiac tamponade) and consistent with acute tension pneumothorax (↑ Paw ↓ movement of involved chest, ↓ breath sounds, ↑ resonance to percussion, compared to uninvolved side), and cardiovascular Sx related to ↑ thoracic pressures → ↓ preload (↓ BP, ↑ HR, ↓ pulse pressure, ↑ CVP). The CVP is artifactually elevated, reflecting the high intrathoracic pressures. Actual (transmural) CVP is very low. In severe cases, patients may experience cardiac arrest with pulseless electrical activity (PEA) because high intrathoracic pressures effectively stop venous return to the heart.

*NB: AutoPEEP MUST be ruled out first, particularly when the diagnosis is bilateral tension PTX. AutoPEEP is effectively ruled out (except with a ball valve airway lesion) by disconnecting the ETT from ventilator/ambu bag and allowing patient to exhale. If the patient's condition immediately improves, you have made the diagnosis of autoPEEP.

*NB: Release of the pressure that has built up in the chest is a life-saving maneuver. A large-bore chest tube does not need to be placed emergently. The much simpler needle/catheter thoracostomy is effective and less demanding for the nonsurgeon.

Equipment

One of the following:

·         16-ga needle

·         16-ga iv catheter/needle

·         16-ga single-lumen CVP kit

Procedure

1.     Identify the 2nd intercostal space by first identifying the Angle of Louis (union of manubrium and sternum); then move laterally to find the insertion of the 2nd rib. The interspace directly below this rib is the 2nd intercostal space. (See Fig. 15-11.)

2.     Wipe skin with alcohol.

3.     Use needle to enter the interspace anteriorly in line with a line drawn down from the clavicle at the junction of the middle and medial one-third sections. (This should be ~3 cm from the sternal margin.)

4.     With entry into the pleural space, there should be an audible rush of air and immediate hemodynamic improvement in the patient.

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Figure 15-11. Adapted with permission from Baker RJ, Fischer JE: Mastery of Surgery, 4th edition. Lippincott Williams & Wilkins, Philadelphia: 2001.

(Note: A more permanent chest tube will still need to be placed [i.e., the patient no longer has a tension pneumothorax, but still has a pneumothorax.] This can be done in a more controlled situation by someone skilled in that procedure.)

Suggested Readings

  1. Barftlett R, Munster A: An improved technique for prolonged arterial cannulation. N Engl J Med1968; 279:92–3.
  2. Danforth J: Pericardiocentesis. In Clinical Procedures in Anesthesia and Intensive Care.Benumof JL, ed. JB Lippincott, Philadelphia: 1992, 561–75.
  3. Durbin CG Jr: Techniques for performing tracheostomy. Respir Care2005; 50(4):488–96.
  4. Grassmick B: Venous and arterial access. In Manual of Critical Care Procedures.Victor L, ed. Aspen Publishers, Rockville MD: 1989, 47.
  5. Mackersie R: Venous and arterial cutdown. In Clinical Procedures in Anesthesia and Intensive Care.Benumof JL, ed. JB Lippincott, Philadelphia: 1992, 391–403.
  6. Shackford S: Tracheostomy and cricothyrotomy. In Clinical Procedures in Anesthesia and Intensive Care.Benumof JL, ed. JB Lippincott, Philadelphia: 1992, 215–26.