The Anatomy of Femoral Vascular Access

The Anatomy of Femoral Vascular Access

Prior to the widespread availability of point-of-care ultrasonography, invasive medical procedures were performed by the “landmark method”.  Landmark methods are based on surface anatomy, palpation, and sometimes trigonometry, and are fraught with the potential for error.  Complications, while unquantified in the misty past, were likely much more common than in the current era of readily available bedside imaging.  Vascular access procedures are inarguably safer and more successful when guided by sonography, but interpretation of ultrasound images still requires an understanding of both surface and deeper anatomy to relate the two-dimensional screen image to three-dimensional reality.  Further, there are circumstances where either the urgency of the resuscitation, or compromised access to the patient, requires that vascular access be obtained using landmarks rather than real-time imaging.  In such cases a detailed understanding of regional anatomy is critical to maximize procedural success and minimize complications.

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When the Easy LP Isn't Easy

When the Easy LP Isn't Easy

Lumbar punctures can be mercurial procedures.  There are certainly patients in whom it can be predicted that a lumbar puncture will be challenging.  Obesity, patients with known degenerative changes, and agitated patients all present unique challenges when it comes to successfully completing a lumbar puncture.  There are patients, however, who throw you a bit of a curveball.  Sometimes cooperative patients with good landmarks, in whom you had every expectation that you would find success, become seemingly impossible to successfully complete a lumbar puncture.  

For the provider, knowing how to troubleshoot the unexpectedly difficult lumbar puncture can be the difference between success and failure.

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Airways, like Martinis, are Best "Dry"

Airways, like Martinis, are Best "Dry"

Have you ever looked down the blade of a laryngoscope and said to yourself, “Damn!  This airway is just too dry!”  I thought not.  Rather, we often look down the blade into a mucky swamp of secretions that drip from the pharyngeal walls like drool from a big, sloppy dog, and often obscure familiar landmarks and goop-up our optical and video adjuncts.  Is there no solution?  There is!  Let us review an illustrative case...

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Thoracentesis

Thoracentesis

General Considerations

Both the diagnostic and therapeutic thoracenteses are performed using a similar technique. The major difference is the amount of fluid removed. The proceduralist may also choose to only use the needle technique as opposed to the needle-catheter unit when obtaining fluid for diagnostic purposes only.

It is generally recommended that needle size be limited to 18-gauge or smaller to minimize risk of pneumothorax and damage to nearby structures.

US-guided thoracentesis is associated with a significantly lower rate of complications and has become the standard of care. (1)  Real-time ultrasound (US) guidance is recommended for small or loculated effusions when there is concern that the diaphragm or lung tissue is <10mm from the pleural surface. It is also recommended in patients with relative contraindications such as coagulopathies and the mechanically ventilated patient.

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You've Been Blocked!

You've Been Blocked!

Case 1

CC:  Laceration to Upper Lip

HPI:  23 year old male presents to the ED with laceration to his upper lip.  Patient states he was “Minding his own business” when all of the sudden the ground came up and hit him in the face.   His friend alcohol might have been there.  Patient states he now has a cut on his lip and a bruise on his pride.

Physical Exam:  Physical exam demonstrates a 2 centimeter full thickness laceration of the left upper lip that crosses the vermillion border.

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Favorite Positions!

Favorite Positions!

Multiple casualties are brought to you from a house fire.  There are four victims:

  1. A 5’11” 70 kg woman with a GCS of 8
  2. A 5’9” 140 kg man with circumferential burns of the chest and neck
  3. A 20 month-old with a pedi-GCS of 10
  4. An elderly, 5’6” 65 kg man with no burns, but a history of severe CHF and complaining of chest pain and dyspnea

You determine that they all require intubation for various indications.  You choose RSI as the method for all except the morbidly obese patient, who you intend to intubate awake, with sedation and topical airway anesthesia.

Question:

How would you position each of these patients to optimize your chances of successful intubation on the first attempt?

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Field Amputation

Field Amputation

Hey, everybody! Today we are going to talk about field limb amputation.

I know what you are all thinking… No, I’m not crazy. Yes, you’ll probably never do one. No, this is not a common procedure. You just might, however, be in a situation on Air Care where knowing how to correctly perform this procedure can safe a life. 

First, let’s provide a little background on the pre-hospital limb amputation. The procedure itself has gained much more press in the FOAMed world and the emergency medicine and pre-hospital literature since the 2010 earthquake in Haiti during which early physician responders were faced with large numbers of patients trapped under debris and few responders with familiarity or basic working knowledge of the procedure (Lorich et al, 2010). A few of case reports and articles surfaced around this time and the field amp even made an appearance in an episode of the popular television show ‘Greys Anatomy’ in 2011. 

So I was told… 

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"Video Laryngoscopy" Needs to Die

"Video Laryngoscopy" Needs to Die

Let the record show, this is not a debate for or against the use of video cameras on laryngoscopes. It’s not really a debate at all. It’s a plea. An honest plea…

The “DL vs. VL” debate has been had. It will continue to be had as our research evolves and our tools evolve (and we will participate). But, I beg of us as a community to pause and collectively consider a point of order: our discussion and debate, and worse our education of novice critical care providers, and even worse our research, is becoming marred by the fact that we aren’t all speaking the same language. We often throw around terms without RIGOROUS attention to detail.

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LMA FOI - You Mean You Can Intubate through that Thing?

LMA FOI - You Mean You Can Intubate through that Thing?

Emergency airway management is being revolutionized. Think about it…those of us who are in training now are being exposed to some very different core skills. The big culprit is the recent advent of video laryngoscopy – not much argument there.

With that said, I will argue that almost as significant as the advent of video laryngoscopy from a general “airway management revolution” perspective is the philosophical change of many pre-hospital providers in that it is becoming the norm for extra-glottic devices to be placed primarily, or at least considerably more often than in the past.

It is likely that the rate of field placement of extra-glottic devices will become more common. Thus, we will probably see many more patients present to the ED in whom EMS has placed an extra-glottic. As we recognize the power of extra-glottic devices, I think that even the most advanced airway managers will use extra-glottic devices with more frequency to facilitate rescue oxygenation and ventilation.

This begs the obvious question: should we remove these devices after they are in and working?

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Rescue Me

Rescue Me

Extraglottic devices are often term "rescue devices."  And I can't decide whether this is a term that glorifies or degrades.  While yes they can often save your tail after a failed attempt at direct or video laryngoscopy, they can do so much more. Running a code in a resource limited setting with 2 providers? The gold standard of 2 person bag valve mask technique ain't going to be an option for you.  And you think you can hold C-E mask seal while bagging for 20 min?  If you can, you must have hands that rival the late great Andre Rene Roussimoff...

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Needle Cricothyrotomy

Needle Cricothyrotomy

Circumstances rarely are such where we must perform a surgical airway emergently. When we do, it is always for the same indication: you have a patient that you can’t intubate AND can’t oxygenate. In most cases where a surgical airway is required, a traditional open or Seldinger technique is preferred.

In children, however, these approaches are contraindicated (most authors describe age less than 10 or so as the cut-off). Thus, the needle cricothyrotomy is a procedure that we must be prepared to perform as emergency providers as this can be done in pediatric patients.

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Intubating (not in the SRU)

Intubating (not in the SRU)

Logistics are pretty much everything.  A focus on logistics is what helps UPS deliver 500,000,000 during the holiday season.  A focus on logistics is what helped the Allies win World War II.  But logistics doesn’t just happen on the global, macroscopic scale.  Logistics plays a role in every procedure we do in the ED and in the prehospital environment.  If you only focus on learning the mechanics of physically performing a procedure, you are neglecting crucial steps that will help ensure your success.  In this our latest podcast in the Air Care and Mobile Care Online Flight MD Orientation, Dr. Steuerwald and Dr Hill discuss some of the complicating factors for prehospital airways, focusing on both some of the logistical issues that come into play and some of the mechanical/physical considerations.

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So You Want to Tomahawk Somebody?

So You Want to Tomahawk Somebody?

If you took a listen to our last podcast or inferred from our most recent post, the "challenging airway" that was described was managed by way of a tomahawk intubation.  As we discussed in the podcast, there were a number of different ways we could have elected to manage that patient's airway including intubation from the back of the stretcher with the patient seated upright, awake fiberoptic intubation (both nasotracheal and oropharyngeal with the assistance of a Williams airway), tomahawk intubation, or, as was suggested by one of the residents (nice suggestion Dr. Cousar) after our simulation (on the same case), through a bronch adapter hooked to a LMA...

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What Makes an Airway Difficult

What Makes an Airway Difficult

What Makes an Airway Difficult? In short, a lot of different factors play into making an airway difficult.  In general, they can be broken down into anatomicphysiologic, and logistic.  We'll cover some of the logistical issues that can complicate intubations on a later post (mostly with regards to intubation in the HEMS and prehospital  setting).

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Oxygen is Good, Methods for Delivery Often are Not

Oxygen is Good, Methods for Delivery Often are Not

An elderly patient with steroid and oxygen dependent COPD, and NYHA Class IV CHF, presents with dyspnea.  The patient is alert but looks somewhat desperate, confused, and exhausted.  Exam reveals accessory muscle use, grunting expirations, poor air movement, and cool clammy skin.  The patient speaks in two-word phrases.  Attempts to improve the situation are made with Lasix, nebulizers, and non-invasive ventilatory support.  The patient cannot tolerate BiPAP due to anxiety.

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