performing-emergency-procedures

name	performing-emergency-procedures
description	Documents procedural indications, consent, technique, and complications for ED procedures. Use when performing emergency procedures, documenting procedural notes, or recording bedside procedures.
tags	["process","emergency-medicine"]
metadata	{"author":"casemark","practice_areas":["Emergency Medicine"],"document_types":["Procedure Note"],"skill_modes":["Execution"]}

Performing Emergency Procedures

Documents procedural indications, informed consent, technical execution, and complication management for critical emergency department procedures including chest tube insertion, central venous access, endotracheal intubation, procedural sedation, and bedside ultrasonography.

Why This Skill Exists

Emergency procedures are performed under time pressure on undifferentiated patients with limited history, often without the controlled conditions of an operating room or interventional suite. The procedural complication rate in the ED is directly correlated with documentation quality, pre-procedure planning, and structured post-procedure assessment. A chest tube placed without confirming the indication can cause organ injury. A central line inserted without ultrasound guidance doubles the mechanical complication rate. An intubation without a backup airway plan converts a manageable situation into a fatal one.

This skill structures the pre-procedure assessment, procedural technique documentation, and post-procedure verification for the highest-stakes ED procedures, ensuring that every critical step is performed and recorded even under time pressure.

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Checkpoint A: Pre-Procedure Intake (Mandatory)

1. What is the specific procedure indicated, and what is the clinical indication?
2. What are the contraindications — absolute and relative — for this patient?
3. Has informed consent been obtained (or is the situation an emergency exception)?
4. What is the patient's coagulation status (INR, platelets, anticoagulant use)?
5. What is the patient's airway assessment (Mallampati, neck mobility, prior difficult airway history)?
6. What equipment has been assembled at the bedside, including backup equipment?
7. Is ultrasound guidance available and indicated for this procedure?
8. Who is the supervising physician (if a trainee is performing), and what is the level of supervision?

Documents to Request

• Most recent vital signs and continuous monitoring readout
• Current lab values (CBC, coagulation studies, ABG/VBG, lactate, type and screen)
• Relevant imaging (chest X-ray, CT, FAST exam)
• Medication list with focus on anticoagulants and antiplatelets
• Allergy documentation (especially latex, chlorhexidine, local anesthetics, iodine)
• Prior procedure notes if re-access or revision
• Advanced directive / code status documentation

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Step 1: Endotracheal Intubation

Pre-Intubation Checklist (Structured Approach)

Component	Action
S — Suction	Yankauer suction at head of bed, tested and functioning
O — Oxygen	Pre-oxygenation ≥ 3 minutes or 8 vital-capacity breaths with 100% O₂; nasal cannula at 15 LPM during apneic period
A — Airway equipment	Laryngoscope (video AND direct available), ETT (primary size + 0.5 smaller), stylet, bougie, supraglottic airway (LMA), cricothyrotomy kit
P — Pharmacy	RSI medications drawn up and labeled: induction agent + paralytic; push-dose pressor; post-intubation sedation/analgesia
M — Monitors	Continuous SpO₂, waveform capnography, cardiac monitor, NIBP
E — End-tidal CO₂	Waveform capnography MUST be available for confirmation of tube placement

RSI Drug Selection

Induction Agent	Dose	Onset	Duration	Best For	Avoid When
Etomidate	0.3 mg/kg IV	30–60 sec	3–5 min	Hemodynamically unstable patients	Sepsis (theoretical adrenal suppression; debated)
Ketamine	1.5–2 mg/kg IV	30–60 sec	10–15 min	Asthma, hypotension, head injury (no longer contraindicated)	Schizophrenia (relative)
Propofol	1–2 mg/kg IV	15–45 sec	5–10 min	Status epilepticus, controlled hemodynamics	Hypotension, shock
Midazolam	0.1–0.3 mg/kg IV	60–90 sec	15–30 min	Availability when others unavailable	Hemodynamically unstable

Paralytic	Dose	Onset	Duration	Notes
Succinylcholine	1.5 mg/kg IV	45–60 sec	6–10 min	Fastest onset; contraindicated in hyperkalemia, burns > 48h, denervation injury, malignant hyperthermia
Rocuronium	1.2 mg/kg IV	60–90 sec	40–60 min	Reversible with sugammadex 16 mg/kg; preferred when succinylcholine contraindicated

Post-Intubation Confirmation

1. Waveform capnography: Gold standard — persistent CO₂ waveform for 6+ breaths confirms tracheal placement
2. Direct visualization: ETT seen passing through vocal cords
3. Bilateral breath sounds: Auscultate axillae bilaterally
4. Chest rise: Symmetric chest expansion
5. Chest X-ray: Confirm tip position 3–5 cm above carina
6. SpO₂: Maintained or improving

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Step 2: Central Venous Access

Site Selection

Site	Advantages	Disadvantages	Preferred When
Internal jugular (IJ)	Compressible, ultrasound-guided; lower PTX risk than subclavian	Difficult in cervical collar; risk of carotid puncture	Default first choice; coagulopathic patients
Subclavian	Lower infection rate; comfortable for patient; good flow rates	Non-compressible; highest PTX risk; difficult to ultrasound	Expected prolonged access; non-coagulopathic
Femoral	No PTX risk; easy landmark access	Higher infection rate; DVT risk; limits ambulation	Cardiac arrest; coagulopathy; when IJ/SC impossible

Ultrasound-Guided IJ Central Line Procedure

1. Position: Trendelenburg 15°, head turned slightly contralateral
2. Sterile prep: Chlorhexidine > 30 seconds dry time; full barrier drape, cap, mask, gown, gloves
3. Ultrasound: Linear probe in sterile sheath; identify IJ (compressible, lateral) vs. carotid (non-compressible, medial, pulsatile)
4. Access: Enter skin at 45° under real-time ultrasound guidance; advance needle into IJ with continuous aspiration
5. Confirm venous blood (dark, non-pulsatile); transduce pressure if uncertain
6. Seldinger technique: Guidewire through needle; remove needle; nick skin; dilator over wire; catheter over wire
7. Confirm wire position with ultrasound in IJ and check for wire in the right atrium (subcostal cardiac view)
8. Secure catheter; sterile dressing
9. Post-procedure chest X-ray: Confirm catheter tip at cavoatrial junction; rule out pneumothorax
10. Document: Indication, consent, sterile technique, ultrasound use, number of attempts, complications, confirmation method

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Step 3: Tube Thoracostomy (Chest Tube)

Indications

Indication	Urgency	Tube Size (Adult)
Tension pneumothorax (after needle decompression)	Emergent	28–32 Fr
Traumatic hemothorax	Urgent	32–36 Fr
Large spontaneous pneumothorax (> 2 cm apex, symptomatic)	Urgent	20–28 Fr (small-bore pigtail acceptable for simple PTX)
Empyema/complicated parapneumonic effusion	Semi-urgent	28–32 Fr
Massive pleural effusion with respiratory compromise	Semi-urgent	28–32 Fr

Procedure Steps

1. Position: Supine with arm abducted 90° and externally rotated (or arm above head)
2. Identify insertion site: 4th–5th intercostal space, anterior to mid-axillary line (safe triangle: lateral border of pectoralis major, anterior border of latissimus dorsi, line of nipple/inframammary fold)
3. Sterile prep and drape; local anesthesia (lidocaine 1% with epinephrine) — anesthetize skin, subcutaneous tissue, periosteum of rib, and parietal pleura
4. Incision: 2–3 cm transverse incision at the level of the intercostal space
5. Blunt dissection: Kelly clamp through subcutaneous tissue over the TOP of the lower rib (avoid neurovascular bundle on inferior rib border)
6. Puncture parietal pleura with clamp; spread to create opening; finger sweep to confirm intrapleural space (rule out adhesions, diaphragm)
7. Insert tube directed posteriorly and superiorly for pneumothorax, posteriorly and inferiorly for effusion/hemothorax
8. Connect to underwater seal drainage system (e.g., Pleur-evac at −20 cmH₂O suction)
9. Secure with suture (0-silk); occlusive dressing
10. Post-procedure CXR: Confirm tube position and lung re-expansion

Chest Tube Output Monitoring

Finding	Significance	Action
> 1500 mL blood immediate output	Massive hemothorax	Consult surgery for thoracotomy
> 200 mL/hr blood for 2–4 hours	Ongoing hemorrhage	Consult surgery
Continuous air leak	Persistent air leak / bronchopleural fistula	Consult surgery if no resolution in 48–72 hours
Abrupt cessation of output	Tube clot, kink, or malposition	Strip tube, check position on CXR

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Step 4: Procedural Sedation and Analgesia

Pre-Sedation Assessment

1. ASA Physical Status classification
2. Airway assessment (Mallampati, predictors of difficult BVM ventilation: MOANS — Mask seal, Obesity, Age > 55, No teeth, Stiffness)
3. NPO status assessment (ASA guidelines apply; for emergencies, weigh aspiration risk against procedure urgency)
4. Consent for sedation (separate from procedure consent when possible)
5. Monitoring setup: SpO₂, capnography, cardiac monitor, NIBP, supplemental O₂ ready

Common ED Procedural Sedation Agents

Agent	Dose	Onset	Recovery	Best For	Avoid
Ketamine	1–2 mg/kg IV; 4–5 mg/kg IM	IV: 1 min; IM: 5 min	15–30 min (IV); 60–90 min (IM)	Children, fracture reduction, painful procedures	Age < 3 months; psychosis
Propofol	0.5–1 mg/kg IV, titrate 0.5 mg/kg q30sec	30 sec	5–10 min	Short procedures, cardioversion, joint reduction	Hypotension, hemodynamic instability
Etomidate	0.1–0.15 mg/kg IV	30–60 sec	5–15 min	Brief procedures, hemodynamically unstable	Myoclonus may complicate procedure
Ketofol	Ketamine 0.5 mg/kg + Propofol 0.5 mg/kg	30–60 sec	10–15 min	Balanced hemodynamics and analgesia	Same as individual agents

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Step 5: Cricothyrotomy (Surgical Airway)

Indications

• Cannot intubate, cannot oxygenate (CICO) — the ultimate airway rescue
• Massive facial trauma precluding oral/nasal intubation
• Complete upper airway obstruction unrelieved by supraglottic airway
• Angioedema with progressive airway compromise

Contraindications

• Age < 8–10 years (relative — needle cricothyrotomy preferred in young children; anatomy unfavorable for surgical approach)
• Tracheal transection with retraction (requires surgical exploration)
• Laryngeal fracture through the cricothyroid membrane (perform tracheotomy instead if time permits)

Surgical Cricothyrotomy Technique

1. Position: Neck extended (if no C-spine concern); identify cricothyroid membrane between thyroid and cricoid cartilages
2. Stabilize larynx with non-dominant hand
3. Vertical skin incision (3–4 cm) over cricothyroid membrane — reduces vessel injury compared to horizontal
4. Horizontal stab incision through cricothyroid membrane — aim inferiorly to avoid vocal cords
5. Insert tracheal hook or rotate scalpel handle 90° to open the membrane
6. Insert appropriately sized cuffed tracheostomy tube (6.0 Shiley) or ETT (6.0 cuffed)
7. Inflate cuff; ventilate; confirm with capnography and bilateral breath sounds
8. Secure tube; obtain CXR

Needle Cricothyrotomy (Temporizing in Pediatric Patients)

1. Insert 14-gauge or 12-gauge angiocath through cricothyroid membrane at 45° caudally
2. Aspirate air to confirm tracheal placement
3. Connect to jet ventilation system (if available) or BVM with a 3.0 ETT adapter
4. This is a TEMPORIZING measure only — provides oxygenation but cannot adequately ventilate; definitive airway still needed

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Checkpoint B: Post-Procedure Alignment (Mandatory)

1. Was the indication documented with supporting clinical evidence (vitals, imaging, labs)?
2. Was consent obtained and documented (or emergency exception documented)?
3. Was the procedure technique documented including patient position, sterile preparation, equipment used, and number of attempts?
4. Were complications assessed and documented (or "no immediate complications" noted)?
5. Was post-procedure imaging obtained when indicated (CXR for central line and chest tube; waveform capnography for ETT)?

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Quality Audit

#	Criterion	Pass / Fail
1	Indication for procedure clearly documented with supporting evidence
2	Informed consent obtained or emergency exception documented
3	Time-out / procedural pause performed before invasive procedure
4	Sterile technique used and documented for central lines and chest tubes
5	Ultrasound guidance used for central venous access (IJ and femoral)
6	Waveform capnography used to confirm ETT placement
7	RSI medications, doses, and times documented
8	Post-intubation sedation/analgesia initiated and documented
9	Post-procedure imaging obtained and interpreted
10	Complications documented or explicitly stated as absent
11	Number of attempts documented for all access procedures
12	Procedure note completed within 1 hour of procedure
13	Supervising physician documented for trainee-performed procedures
14	Chest tube output monitored with surgical consultation thresholds applied

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Guidelines

• Waveform capnography is the gold standard for ETT confirmation — esophageal detector devices and colorimetric CO₂ detectors are adjuncts, not replacements
• Ultrasound guidance for central venous access is standard of care, not optional — it reduces mechanical complications by 50%+ compared to landmark technique
• Always have a backup airway plan articulated BEFORE the first intubation attempt: if direct/video laryngoscopy fails → bougie → supraglottic airway → surgical airway
• Never place a chest tube without confirming the side and level — wrong-side chest tubes occur and are never defensible
• The safe triangle for chest tube insertion is bounded by the anterior border of latissimus dorsi, lateral border of pectoralis major, and a horizontal line at the level of the nipple — avoid inserting too low (liver/spleen risk) or too medial (internal mammary artery)
• Document every procedure note using a structured template: indication, consent, timeout, technique, findings, specimens, complications, post-procedure orders
• For procedural sedation, the provider managing sedation should be separate from the provider performing the procedure when patient volume and staffing allow
• Debrief after every failed procedure or complication — not as blame, but as system improvement; document the debrief outcome