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Algorithms for Emergency Medicine
ii
Algorithms for
Emergency Medicine

Edited by

Mark Harrison
Consultant in Emergency Medicine,
Northumbria Specialist Emergency Care Hospital,
UK

and

Ala Mohammed
Consultant in Emergency Medicine,
Sunderland Royal Hospital,
UK
iv

Great Clarendon Street, Oxford, OX2 6DP,

United Kingdom
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First Edition published in 2023
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Published in the United States of America by Oxford University Press
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Printed and bound by
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Oxford University Press makes no representation, express or implied, that the
drug dosages in this book are correct. Readers must therefore always check
the product information and clinical procedures with the most up-​to-​date
published product information and data sheets provided by the manufacturers
and the most recent codes of conduct and safety regulations. The authors and
the publishers do not accept responsibility or legal liability for any errors in the
text or for the misuse or misapplication of material in this work. Except where
otherwise stated, drug dosages and recommendations are for the non-​pregnant
adult who is not breast-​feeding
Links to third party websites are provided by Oxford in good faith and
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contained in any third party website referenced in this work.
 P R E FAC E

Delivering Emergency Medicine involves constant challenges to the emergency clinician, re-
flected by the wide breadth of conditions that are encountered, the necessity for the frequent
need to deal with multiple severely unwell patients, the time constraints of acute illnesses, and
the urgency needed in diagnosis and treatment.
Algorithms for Emergency Medicine is designed to be a ‘straight to the point’ reference to help
face these challenges and allow the busy emergency clinician to respond and deliver appropriate
care in a timely fashion.
The book is divided into ten sections (e.g. Practical procedures, Airway and breathing,
Cardiovascular) and each section is comprised of a number of topics. Each topic is divided into
an information section, which provides essential knowledge, tips, and salient points on the topic,
and an algorithm, which is aimed to guide the clinician in a step-​by-​step manner in managing
these conditions. These are based on the Royal College of Emergency Medicine curriculum for
those who would like to train or obtain experience in delivering Emergency Medicine which
contains up-​to-​date evidence and knowledge.
This book would have not been possible without the dedication and commitment by the au-
thors and the willingness to share their experience in delivering emergency care.
We hope that this book will be useful for Emergency Nurse Practitioners, new doctors
starting their placement in the Emergency Department, and trainee doctors working towards
specializing in Emergency Medicine.

Ala Mohammed
Mark Harrison
vi
 CO N T E N T S

Detailed Contents ix
Contributors xiii
Abbreviations xv

 Practical procedures 1
2 Airway and breathing 47
3 Cardiovascular 65
4 Abdominal 79
5 Neurological 99
6 Trauma 123
7 Environmental emergencies 157
8 Other medical 169
9 Other surgical 209
0 Miscellaneous 231

Index 239
vii
D E TA I L E D CO N T E N T S

Contributors xiii
Abbreviations xv

S E C T I O N   Practical procedures 1
 Basic life support 2
2 Airway protection 4
3 Rapid sequence induction 6
4 Cricothyroidotomy 8
5 Needle thoracocentesis 10
6 Pleural aspiration—pneumothorax 12
7 Intercostal drain—​seldinger 14
8 Intercostal drain—​open 16
9 Arterial blood gas sampling 18
0 Peripheral venous cannulation 20
 Central venous cannulation 22
2 Intraosseous access 24
3 Urinary catheterization 26
4 Nasogastric tube insertion 28
5 Arterial cannulation and arterial pressure monitoring 30
6 Lumbar puncture 32
7 Abdominal paracentesis/​ascetic tap 34
8 DC cardioversion 36
9 Temporary pacing (external) 38
20 Knee aspiration 40
2 Fracture manipulation 42
22 Procedural sedation 44

S E C T I O N 2  Airway and breathing 47

 Anaphylaxis 48
2 Apnoea, stridor and airway obstruction 50
3 Pneumothorax/​haemothorax 52
4 Asthma and chronic obstructive pulmonary disease (COPD) 54
5 Pulmonary embolism 56
6 Acute heart failure 58
7 Cough 60
8 Cyanosis 62

S E C T I O N 3  Cardiovascular 65
 Cardiorespiratory arrest—​adult life support (ALS) 66
2 Cardiorespiratory arrest—​advanced paediatric life support (APLS) 68
 3 Chest pain 70
x 4 Palpitations 72
5 Tachyarrhythmias 74
6 Bradyarrhythmias 76

S E C T I O N 4  Abdominal 79
Detailed Contents

 Acute abdominal pain 80

2 Rectal bleeding 82
3 Dehydration in children 84
4 Diarrhoea 86
5 Dysuria 88
6 Ectopic pregnancy 90
7 Haematemesis and melaena 92
8 Jaundice 94
9 Nausea and vomiting 96

S E C T I O N 5  Neurological 99
 The unconscious patient 100
2 Aggressive/​disturbed behaviour 102
3 Alcohol and substance abuse 104
4 Acute confusion/​delirium 106
5 Dizziness and vertigo 108
6 Fits/​seizures 110
7 Headache 112
8 Syncope and pre-​syncope 114
9 Weakness and paralysis 116
0 Stroke 118
 Subarachnoid haemorrhage 120

S E C T I O N 6  Trauma 123
 Primary survey 124
2 Secondary survey 126
3 Head injury 128
4 Major trauma—​chest injuries 130
5 Major trauma—​abdominal trauma 132
6 Major trauma—​spinal injuries 134
7 Major trauma—​maxillofacial 136
8 Major trauma—​burns 138
9 Traumatic limb and joint injuries 140
0 Wound assessment and management 142
 Shoulder examination 144
2 Elbow examination 146
3 Hand examination 148
4 Hip examination 150
5 Knee examination 152
6 Ankle examination 154
S E C T I O N 7  Environmental emergencies 157
xi
 Heat stroke and heat exhaustion 158
2 Drug-​related hyperthermias 160
3 Hypothermia and frostbite 162
4 Electrical burns/​electrocution 164
5 Drowning 166

Detailed Contents
S E C T I O N 8  Other medical 169
 The septic patient 170
2 The shocked patient 172
3 Abnormal blood glucose—​diabetic ketoacidosis (DKA) 174
4 Abnormal blood glucose—​hyperosmolar hyperglycaemic state (HHS) 176
5 Sickle cell crisis 178
6 Anaemia 180
7 Purpura and bruising in children 182
8 Leukaemia/​lymphoma in children 184
9 Bruising and spontaneous bleeding 186
0 Fever 188
 The oliguric patient 190
2 Oncology emergencies 192
3 Poisoning/​self-​harm 194
4 Rashes 196
5 Acute red eye 198
6 Acute visual loss 200
7 Hyperkalaemia 202
8 Rhabdomyolysis 204
9 High INR 206

S E C T I O N 9  Other surgical 209

 Acute back pain 210
2 Epistaxis 212
3 Falls 214
4 Non-​traumatic limb pain and swelling 216
5 Acute neck pain 218
6 Painful ear (otalgia) 220
7 Sore throat 222
8 Scrotal pain 224
9 Acute urinary retention 226
0 Per-​vaginal bleeding 228

S E C T I O N  0  Miscellaneous 231
 Suicidal ideation 232
2 Needlestick injury 234
3 Pain management 236

Index 239
xii
 CO N T R I B U TO R S

Charlotte Bates Mark Harrison

Consultant in Emergency Medicine Consultant in Emergency Medicine
Northumbria Specialist Emergency Care Hospital Northumbria Specialist Emergency Care Hospital
UK UK

Dave Bramley Ala Mohammed

Chief Medical Officer Consultant in Emergency Medicine
Great North Air Ambulance Service Sunderland Royal Hospital
UK UK

Laurence Chuter Alister T. Oliver

Consultant in Emergency Medicine Consultant in Emergency Medicine
Musgrove Park Hospital Northumbria Specialist Emergency Care Hospital
UK UK

Damian Garwell
Consultant in Emergency Medicine
Northumbria Specialist Emergency Care Hospital
UK
xvi
 A B B R E V I AT I O N S

6-​CIT six-​item Cognitive Impairment Test AXR abdominal X-​ray

AAA abdominal aortic aneurysm BASHH British Association for Sexual Health
and HIV
AAGBI Association of Anaesthetists of Great
Britain and Ireland BBV blood-​borne virus
ABCDE airway, breathing, circulation, disability, BE base excess
exposure
BiPAP bilevel positive airway pressure
ABG arterial blood gas
BLS basic life support
ABPI ankle-​brachial pressure index
BM Boehringer Mannheim (fingerprick
AC alternating current glucose)
ACE angiotensin-​converting enzyme BNF British National Formulary
ACJ acromioclavicular joint BP blood pressure
ACL anterior cruciate ligament BPH benign prostatic hyperplasia
ACS acute coronary syndrome BSA body surface area
AE air entry BTS British Thoracic Society
AED automated external defibrillator BVM bag-​valve-​mask
AF atrial fibrillation C spine cervical spine
AKI acute kidney injury C&S culture and sensitivity
AKIN Acute Kidney Injury Network CAM Confusion Assessment Method
ALL acute lymphoblastic leukaemia CCF congestive cardiac failure
ALS advanced life support CCU coronary care unit
ALT alanine transaminase CIWA-​Ar clinical institute withdrawal assessment
for alcohol (revised)
AP antero-​posterior
CK creatinine kinase
APLS advanced paediatric life support
CNS central nervous system
APTT activated partial thromboplastin time
COPD chronic obstructive pulmonary disease
ARDS acute respiratory distress syndrome
CPAP continuous positive airway pressure
ASIA American Spinal Injury Association
Cr creatinine
AST aspartate transaminase
CRP C-​reactive protein
ATLS advanced trauma life support
CRT capillary refill time
ATN acute tubular necrosis
CSF cerebrospinal fluid
AUR acute urinary retention
CSU catheter specimen urine
AVM arteriovenous malformation
CT computed tomography
AVPU alert, to voice, to pain, unconscious
 CTPA computed tomography pulmonary FH family history
xvi angiography
Fr French
CURB confusion, urea, respiratory rate, blood
FU follow-​up
pressure
FVC forced vital capacity
CXR chest X-​ray
G&S group and save
D&V diarrhoea and vomiting
GABHS group A beta-​haemolytic
DBP diastolic blood pressure
Abbreviations

streptococcus
DIC disseminated intravascular coagulation
GCA giant cell arteritis
DIPJ distal interphalangeal joint
GCS Glasgow Coma Scale
DKA diabetic ketoacidosis
GGT γ-​glutamyltransferase
DM diabetes mellitus
GI gastrointestinal
DMARD disease-​modifying antirheumatic drug
GRACE global registry of acute
DNACPR do not attempt cardiopulmonary coronary events
resuscitation
GTN glyceryl trinitrate
DTs delirium tremens
GUM genito-​urinary medicine
DVT deep vein thrombosis
h/​o history of
EBV Epstein–​Barr virus
Hb haemoglobin
ECG electrocardiogram
HB hepatitis B
ECHO echocardiogram
HBIg hepatitis B immunoglobulin
ED Emergency Department
HCG human chorionic gonadotropin
eFAST extended focused assessment with
HCO3 bicarbonate
sonography
HCV hepatitis C virus
EGSYS Evaluation of Guidelines in
Syncope Study HDU high dependency unit
EHS exertional heat stroke HHS hyperosmolar hyperglycaemic state

ENT ear, nose, and throat HIV human immunodeficiency virus

ESR erythrocyte sedimentation rate HR heart rate

ET endotracheal tube HTX haemothorax

ETCO2 end-​tidal carbon dioxide ICD intercostal chest drain

FAST face, arm, speech, time ICP intracranial pressure

FAST focused assessment with sonography IDA iron deficiency anaemia

FB foreign body Ig immunoglobulin

FBC full blood count IHD ischaemic heart disease

FDP flexor digitorum profundus IM intramuscular

FDS flexor digitorum superficialis INR internalized normalized ratio

FEV forced expiratory volume IO intraosseous

FFP fresh frozen plasma ITU intensive therapy unit

IV intravenous NEB nebulizer
xvii
IVF in vitro fertilization NEHS non-​exertional heat stroke
IVU intravenous urogram NG nasogastric
JVP jugular venous pressure NHL non-​Hodgkin lymphoma
K potassium NIBP non-​invasive blood pressure
KUB kidney, ureter, and bladder NIBP non-​invasive blood pressure

Abbreviations
LA local anaesthesia NICE National Institute for Health and Care
Excellence
LBBB left bundle branch block
NIV non-​invasive ventilation
LCL lateral collateral ligament
NP nasopharyngeal
LFT liver function test
NPIS National Poisons Information Service
LGIB lower gastrointestinal bleeding
NPV negative predictive value
LMA laryngeal mask airway
NSAIDs non-​steroidal anti-​inflammatory drugs
LMWH low molecular weight heparin
NSTEMI non-​ST elevation myocardial infarction
LOC loss of consciousness
NT-​pro BNP N-​terminal pro B-​type natriuretic
LP lumbar puncture
peptide
LRTI lower respiratory tract infection
O&G obstetrics and gynaecology
LSD lysergic acid diethylamide
O/​P outpatient
LVF left ventricular failure
OD overdose
MAP mean arterial pressure
OP oropharyngeal
MC&S microscopy, culture, and sensitivity
ORT oral rehydration therapy
MCA Mental Capacity Act
OT occupational therapy
MCHb mean corpuscular haemoglobin
PaCO2 partial pressure of carbon dioxide
MCL medial collateral ligament
PaO2 partial pressure of oxygen
MCPJ metacarpophalangeal joint
PBF peripheral blood film
MCV mean corpuscular volume
PCI percutaneous coronary intervention
MDMA 3,4-​methyl-​enedioxy-​
PCL posterior cruciate ligament
methamphetamine
PE pulmonary embolus
MHA Mental Health Act
PEA pulseless electrical activity
MI myocardial infarction
PEEP positive end-​expiratory pressure
MILS manual in-​line stabilization
PEFR peak expiratory flow rate
MOI mechanism of injury
PEP post-​exposure prophylaxis
MRI magnetic resonance imaging
PICU paediatric intensive care unit
MSU mid-​stream urine
PID pelvic inflammatory disease
MTS Mental Test Score
PIPJ proximal interphalangeal joint
NAI non-​accidental injury
PMH past medical history
NBM nil by mouth
 PN percussion note SOB shortness of breath
xviii
PO per os (by mouth) SOFA Sequential Organ Failure Assessment
PPE personal protective equipment SOL space occupying lesion
PPI proton pump inhibitor SP suprapubic
PR per rectum SpO2 peripheral oxygen saturations
PT prothrombin time SSRI selective serotonin reuptake inhibitor
Abbreviations

PTX pneumothorax STAT statim (immediately)

PU passed urine STEMI ST-​elevation myocardial infarction
PV per vagina SVC superior vena cava
PVD peripheral vascular disease SVT supraventricular tachycardia
qSOFA Quick Sequential Organ Failure TB tuberculosis
Assessment
TIA transient ischaemic attack
RBC red blood cell
TIMI thrombolysis in myocardial infarction
RIDDOR Reporting of Injuries, Diseases and
TMJ temporomandibular joint
Dangerous Occurrences Regulations
TSH thyroid stimulating hormone
RIFLE Risk, Injury, Failure, Loss of kidney
function, and End-​s tage kidney U&E urea and electrolytes
disease UGIB upper gastrointestinal bleeding
ROSIER recognition of stroke in the UO urine output
emergency room
URTI upper respiratory tract infection
RR relative risk
US ultrasound
RR respiratory rate
USS ultrasound scan
RSI rapid sequence induction
UTI urinary tract infection
RWS Revised Wells score
V/​Q ventilation/​perfusion
SAD supraglottic airway device
VBG venous blood gas
SAH subarachnoid haemorrhage
VF ventricular fibrillation
SaO2 oxygen saturations
VT ventricular tachycardia
SBP systolic blood pressure
WBC white blood cell
SIGN Scottish Intercollegiate Guidance
Network WFNS World Federation of Neurological
Surgeons
SIRS systemic inflammatory response
syndrome WHO World Health Organization
SECTION  1

Practical procedures
 Basic life support 2
2 Airway protection 4
3 Rapid sequence induction 6
4 Cricothyroidotomy 8
5 Needle thoracocentesis 10
6 Pleural aspiration—​pneumothorax 12
7 Intercostal drain—​seldinger 14
8 Intercostal drain—​open 16
9 Arterial blood gas sampling 18
0 Peripheral venous cannulation 20
 Central venous cannulation 22
2 Intraosseous access 24
3 Urinary catheterization 26
4 Nasogastric tube insertion 28
5 Arterial cannulation and arterial pressure monitoring 30
6 Lumbar puncture 32
7 Abdominal paracentesis/​ascetic tap 34
8 DC cardioversion 36
9 Temporary pacing (external) 38
20 Knee aspiration 40
2 Fracture manipulation 42
22 Procedural sedation 44
2

2 . Basic life support

Personal safety
Algorithms for Emergency

● Check for your personal safety and that patient surroundings are safe
● Wear gloves and other protective equipment, e.g. apron, eye protection

Call for help

Check for signs of life: Loudly ask ‘Are you OK?’ and gently shake shoulders.
If response:
Medicine

● Call for urgent medical help—​use hospital protocol to contact resus/​medical team
● Assess using airway, breathing, circulation, disability, exposure (ABCDE) approach
● Give O2 as guided by pulse oximetry
● Attach monitoring equipment and take vital signs
● Obtain intravenous (IV) access and take bloods as appropriate (e.g. full blood count (FBC), urea and
electrolytes (U&E), C-​reactive protein (CRP), glucose, liver function test (LFT), coagulation test, group and
save (G&S), lactate)—​consider venous/​arterial blood gas (ABG)
If no response:
● Lie patient on back
● Open airway: Head tilt, chin lift if no trauma/Jaw thrust is suspicion of trauma
● Look, listen, and feel for breathing and assess carotid pulse at same time (<0 s)
If pulse present/​other signs of life: ABCDE approach, O2, monitoring, IV access, await medical team
If no pulse/​no sign of life:
● Ask colleague to call the resuscitation team and to collect the resuscitation trolley
● Start CPR
● Place heel of one hand in the middle of the lower half of sternum and place the other hand on top

● Depth of compressions should be 5–​6 cm at rate of 00–​20 compressions per minute

● Allow complete recoil of chest between compressions

● Give 30 compressions followed by 2 ventilations (minimize any interruptions in CPR)

● Ventilation
● Use whatever equipment is available, e.g. bag mask, pocket mask, or supraglottic airway device (SAD)

(e.g. laryngeal mask airway (LMA)) and self-​inflating bag. Consider mouth to mouth ventilation if nothing
else available. Minimize air leak by forming good seal if using bag mask
● Use inspiratory time of  s and ensure visible chest rise

● Give supplementary O when possible

2
● Defibrillation
● When available, apply pads to chest (one beneath right clavicle and one in left mid-​axillary line)

● Assess rhythm: if indicated (i.e. ventricular fibrillation (VF)/​pulseless ventricular tachycardia (VT)) charge

machine, stand clear, remove O2, and deliver shock, minimizing gaps in CPR. (Note: If using automated
external defibrillator (AED), follow audio-​visual prompts)
● When resuscitation team arrives, progress to advanced life support (ALS)

If respiratory arrest (i.e. has a pulse but not breathing):

● Ventilate lungs, checking for pulse and response every 0 breaths
● If any doubt about presence of pulse, start CPR

Further reading
Soar J, Deakin CD, Nolan JP, Perkins GD, Yeung J, Couper K, . . . Hampshire S. Adult advanced life support guidelines.
Retrieved from https://​www.resus.org.uk/​libr​ary/​202-​resusc​itat​ion-​gui​deli​nes/​adult-​advan​ced-​life-​supp​ort-​gui​deli​
nes, 202.
 Algorithm for basic life support

Collapsed patient

Ensure personal safety

Call for help and assess patient

Signs of life?

No Yes

Assess
Airway
Breathing
Call resus team
Circulation
Disability
Exposure

Commence CPR
Give oxygen Treat patient if obvious
Use airway adjuncts cause found
Obtain IV/IO access

Apply pads and cardiac

monitor as soon as Give oxygen
available Obtain IV access
If appropriate, Place on monitor
defibrillate

Continue and progress

Call resus
to ALS when
Team/medical
resuscitation team
emergency team
arrive
4

4 2. Airway protection

Introduction
Algorithms for Emergency

The gold standard in airway protection is the passage of a cuffed tube into the trachea. However, even in cases
where this is clearly indicated, and the appropriate staff and equipment are available, it cannot happen instantly. It is
essential that all practitioners who are expected to deal with emergency presentations are capable of emergency
airway assessment and management. Table . lists methods of optimizing an airway.

Table . Methods of optimizing an airway

Medicine

Method Information
Patient position Unconscious patients with no suspicion of spinal injury should be placed in the recovery position
with close monitoring.
Ideally the trolley should be capable of being tipped head-​down in case of vomiting.
In some cases of facial trauma or foreign body obstruction, for example, patients may present
sitting forwards, sometimes even holding their own tongue/​mandible to maintain their airway.
Invariably they do this better than you can: let them, and request additional help.
Supine patients who it is not appropriate to place in the recovery position should be managed on
a trolley which can be tipped head-​down, and if spinal injury is not suspected, then the ‘sniffing
the morning air’ position should be achieved; alternatively a jaw thrust can be used.
Suction Suction should be performed using a Yankauer-​type suction catheter under direct vision.
Consider using a tongue depressor to facilitate this.
Airway adjuncts Oropharyngeal (OP) airway should be used in the absence of a gag reflex.
Nasopharyngeal (NP) airway is very useful where trismus is present or there is a risk of
precipitating vomiting with an OP airway. This should preferentially be avoided in cases of serious
head injury; however, if the patient is hypoxic and other methods of airway maintenance have
failed, then the risk of worsening secondary brain injury because of hypoxia is likely to outweigh
the small risk of inadvertently introducing the NP airway through a base of skull fracture. After
placement, position may be confirmed by intraoral palpation or inspection.
SADs are useful in cardiac arrest cases and failed intubation scenarios during RSI as they can
be inserted rapidly and offer some degree of (but not complete) airway protection. However,
they may precipitate vomiting or laryngospasm and as such are not recommended in the non-​
anaesthetized patient where other methods are effective.
Rapid sequence induction of The gold standard in airway protection in the passage of a cuffed tube into the trachea. This
anaesthesia requires appropriate staff, monitoring, and equipment, and it is essential that an airway is
maintained during the preparation time involved.
Surgical airway In the apnoeic peri-​arrest or actual cardiac arrest patient with an airway that is unmanageable by
any other means, this must be performed immediately.

Further reading
Lloyd G. ‘Basic airway management’, RCEM Learning, 2020; https://​www.rceml​earn​ing.co.uk/​ref​eren​ces/​basic-​air​way-​
man​agem​ent/​ (accessed March 22).
Brady MP, Becker JU. ‘Best Practices: Emergency Airway Management’, Medscape, 206; https://​refere​nce.medsc​ape.
com/​featu​res/​slides​how/​air​way-​man​agem​ent#page=​ (accessed March 22).
 Algorithm for airway protection

Assessment reveals
actual or anticipated
airway problem

Able to maintain own airway and ventilation?

No Yes

Airway open and

self-ventilating

Yes No

Bag/valve/mask
ventilation

Follow cardiac arrest

protocols
Effective No Cardiac arrest Yes Attempt intubation or
SAD—immediate
surgical airway if
ineffective

Yes No

Maintain oxygenation
if possible.
Optimize airway If peri-arrest due to
(see Table 1.1) airway obstruction
attempt intubation or
Continue until help arrives
SAD—immediate
Team to prepare for RSI surgical airway if
ineffective
6

6 3. Rapid sequence induction

Introduction
Algorithms for Emergency

In all cases of RSI, the benefits and risks must be evaluated. This must include consideration of who (patient and
clinician), when, and where to perform this.
However, in time-​critical airway or ventilation problems, transferring a patient to another part of the hospital is
not possible. As such, the Emergency Department should be able to facilitate a safe and effective RSI of anaesthesia
and manage predictable complications.
Medicine

Checklist
In order to do this, a checklist should always be used (Table .2) and the ‘6 Ps’ approach followed:
● Pre-​oxygenation—​should be delivered using tight-​fitting mask and circuit with reservoir bag (e.g. bag-​valve-​
mask (BVM) or Mapleson C)
● Preparation—​all the items listed in the checklist, along with optimizing the patient’s current condition. This
may include using fluids, sedation, chest decompression, pelvic splintage, etc.
● Premedication—​if required, e.g. fentanyl in isolated head injuries
● Paralysis and sedation—​appropriate agents include thiopentone (3–​5 mg/​kg) or ketamine (2 mg/​kg) with
suxamethonium (.5 mg/​kg) or rocuronium (.2 mg/​kg)
● Passage of the tube—​routine use of a bougie is recommended, but this should be passed carefully to avoid
airway trauma
● Post-​intubation care—​appropriate monitoring (minimum of SPO2, end-​tidal carbon dioxide (ETCO2), non-​
invasive blood pressure (NIBP), 3-​lead electrocardiogram (ECG)), ongoing sedation, and paralysis. Consider
head-​up position in raised intracranial pressure
Table .2 RSI checklist
Checked
Pre-​oxygenation taking place
Baseline observations (ECG, SpO2, BP)
2× IV access
One connected to fluid and runs easily
Suction working
Airway adjuncts (OP/​NP)
Endotracheal tube (ET) size chosen, cuff tested
Syringe 0 mL for cuff
Tape or tie
Elastic bougie
Laryngoscopes: two working
Alternative laryngoscope blades available
Heat and moisture exchange filter
Catheter mount
SAD and emergency cricothyroidotomy kit available
Induction agent and paralysis agent prepared
Maintenance of paralysis and sedation agents prepared
Drug giver briefed
Ventilator and BVM connected to O2
Monitoring, including ECG, NIBP, SpO2, ETCO2
Stethoscope
Premedication if required
Inline immobilizer briefed
Cricoid pressure person briefed

Further reading
Difficult Airway Society, 2022; https://​www.das.uk.com.
 Algorithm for rapid sequence induction

Decision made to perform

ED Rapid Sequence Induction

Pre-oxygenation
tolerated

No Yes

Team to prepare equipment as per checklist

Optimise patient condition (consider fluids,
chest decompression, pelvic splintage, etc.)
Request additional Administer premedication if required
help if required
Request everyone is quiet where possible
Titrate appropriate
Assistant to read out checklist. Confirm each
sedation in order to
item present
allow pre-oxygenation
Unfasten C-collar if present: apply MILS. Give
drugs, cricoid pressure on. At onset of
paralysis attempt to view cords Remove laryngoscope,
adjust head position if
able, consider different
size laryngoscope blade.
Consider external
Cords clearly seen No Pass bougie laryngeal manipulation.

Yes Carina +/– tracheal

rings felt

Pass tube (over

bougie if used) Yes
Inflate cuff

Breath sounds on ventilation Release cricoid

Chest moving symmetrically pressure and insert
SAD
ETCO2 trace seen

Yes
Request additional
help
Remove tube

Release cricoid pressure

Maintain paralysis and
sedation
Manage underlying condition
Allow to wake up if appropriate
Attempt bag/mask
Able to ventilate Yes Bag/mask ventilation until
ventilation
additional help available

Immediate surgical
No
cricoidotomy
8

8 4. Cricothyroidotomy

Introduction
Algorithms for Emergency

● Accounts for ~% of all secured airways in the Emergency Department

● Needle cricothyroidotomy (success rate 40%) should only be used for 30–​45 minutes
● Surgical cricothyroidotomy has a success rate of around 84%
Indications
To save life—​a situation where you ‘can’t intubate and can’t ventilate’
Medicine

● Other airway techniques should have been attempted first

● Consider use of bougie if difficult placement

● Likely aetiology:
● Severe upper airway haemorrhage

● Maxillofacial injuries or abnormal facial anatomy

● Airway trauma

o Inhalational or thermal
o Foreign body in the upper airway
o Laryngeal disruption
● Airway oedema

● Mass (tumour, haematoma, abscess)

● Supraglottitis

Contraindications
There are no absolute contraindications, only relative due to being a life-​saving measure:
● Age under 0 years undesirable; under 5 years should be avoided
● Pre-​existing laryngeal pathology (epiglottitis, cancer)
● Anatomic barriers (stab wounds, haematoma)
● Coagulopathy
Complications
● Substantial complication rate (0–​40%) for emergency cricothyroidotomy
● Damage to the thyroid cartilage and vocal chords

● Subcutaneous emphysema

● Haemorrhage

● Extra-​tracheal tube placement (false-​passage)

● Pneumothorax

● Supraglottic or tracheal stenosis

● Oesophageal perforation and fistulae

● Infection

Anatomy
● Vocal chords short distance above thyroid notch (avoid this area)
● Cricoid is a complete cartilaginous ring
● Cricothyroid membrane located between thyroid and cricoid cartilages
● 30% of population have veins lateral to the midline
Further reading
Cook TM, Woodall N, Frerk C. Fourth National Audit Project. Major complications of airway management in the
UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway
Society. Part : anaesthesia. Br J Anaesth 20;06:67–​63.
Hubble MW, Wilfong DA, Brown LH, Hertelendy A, Benner RW. A meta-​analysis of prehospital airway control tech-
niques part II: alternative airway devices and cricothyrotomy success rates. Prehosp Emerg Care 200;4(4):55–​530.
Spiegel JE, Shah V. Surgical management of the failed airway: a guide to percutaneous cricothyrotomy. Anesthesiology
News 202;38(8):57–​6.
 Algorithm for cricothyroidotomy

Indication for cricothyroidotomy

Time to prepare equipment for surgical cricothyroidotomy

No Yes

Needle cricothyroidotomy Surgical cricothyroidotomy

Connect a large bore (12–14 G) cannula to a 10-mL syringe, and

Place patient supine and stablise the cricothyroid membrane
oxygen tubing to a 3-way valve (or Y-connector) and an
with one hand
oxygen supply. Ensure that all ports are open on 3-way valve.

Palpate thyroid cartilage, cricoid cartilage (caudal to the thyroid Anaesthetize skin with local anaesthetic (if patient conscious
cartilage), and cricothyroid membrane between them. and time allows)

Place patient supine and stablize the cricothyroid membrane Make a small vertical skin incision in the midline over the
with one hand cricothyroid membrane

Pierce skin with cannula aiming at 45° caudally Spread the wound edges lateral and identify membrane

Aspirate as needle advanced, until correct position confirmed by

Make a horizontal incision through membrane's lower half
withdrawal of air

Dilate the opening with curved forceps (or rotation of an

Slide cannula over needle and remove needle
inverted scalpel handle)

Connect cannula to 3-way valve (or Y-connector), and set

Insert a small cuffed ET or tracheotomy tube aiming caudally
oxygen at 15 L/minute for adults (or age of child in years)

Oxygenate via insufflation by occluding ‘empty’ port of 3-way valve

Inflate the cuff, confirm correct position, and secure in place
with thumb for 1 second, then remove thumb for 4 seconds

Prepare for surgical cricothroidotomy Ventilate as per ET tube

10

10 5. Needle thoracocentesis

Definition
Algorithms for Emergency

● A procedure where a needle and catheter are inserted through the chest wall into the pleural space
● The catheter provides a pathway for the release of accumulated pressure within the pleural space

Indications
● Primary spontaneous pneumothorax
Tension pneumothorax
Medicine

● Any patient with thoracic injury at risk for developing tension pneumothorax

o Increased risk with penetrating wound or signs of rib fracture

● A needle decompression should also be considered if any of the following indications are present in the
trauma patient:
● Patients with decreased or absent breath sounds, and examination consistent with pneumothorax, or

tension pneumothorax
● Patients with shortness of breath and/​or respiratory distress

● Subcutaneous emphysema

● Tracheal deviation

Contraindications
There are no significant contraindications if a penetrating chest trauma. Relative contraindications include:
● Secondary spontaneous pneumothorax (underlying lung disease)
● Traumatic pneumothorax without tension

Clinical decision making

● Based on mechanism of injury (MOI) and a noted increase in difficulty breathing
● Inspection—​unequal rise and fall of the chest during respirations
● Auscultation—​decreased breath sounds
● Percussion—​hyper-​resonant to percussion
● Palpation—​flail segments or crepitus

Complications
● Local cellulitis
● Local haematoma (2%)
● Pleural infection, empyema
● Pneumothorax
● % chance of causing a pneumothorax if one not present initially

● Haemothorax (0.8%)
● Subcutaneous emphysema
● Cannula needle may not be long enough in up to /​3 adult males, so prepare for immediate thoracostomy in
peri-​arrest situation

Further reading
Celik B, Sahin E, Nadir A, Kaptanoglu M. Iatrogenic pneumothorax: etiology, incidence and risk factors. Thorac Cardiovasc
Surg 2009;57(5):286–​290.
Algorithm for needle thoracocentesis

Indication to perform needle thoracocentesis

Consent patient, place on monitoring, and obtain IV access

Administer oxygen and ventilate as necessary

Confirmation of site of insertion clinically (and on radiology if time

allows)

Position the patient (upright if spinal injury has been excluded)

Identify landmarks—2nd intercostal space mid-clavicular line on the

affected side

Clean the area with betadine

Using aseptic technique infiltrate local anaesthetic (if time allows)

Pass a 14-G cannula just above the superior surface of the 3rd
rib at 90° angle to the skin

Puncture the parietal pleura

Remove the needle and listen for rush of air

Occlude cannula and secure in place

Reassess patient

Prepare for intercostal drain insertion

12

12 6. Pleural aspiration—​pneumothorax

Introduction
Algorithms for Emergency

A pneumothorax can be spontaneous or traumatic. Spontaneous pneumothorax can be subdivided into pri-
mary and secondary pneumothorax. Primary pneumothorax occurs in the absence of underlying lung disease.
Secondary pneumothorax occurs when there is underlying chest disease (e.g. chronic obstructive pulmonary
disease (COPD), asthma, malignancy, tuberculosis (TB)) or evidence of underlying lung disease on examination or
chest X-​ray (CXR).
Medicine

Indications
British Thoracic Society (BTS) guidelines suggest that a pneumothorax should be aspirated in the following
circumstances:
● Primary spontaneous pneumothorax with difficulty in breathing and/​or a rim of pneumothorax on CXR
>2 cm (measured at the level of the hilum). A >2-​cm pneumothorax is by definition a large pneumothorax
and a 2-​cm radiographic pneumothorax approximates to a 50% pneumothorax by volume
● Secondary spontaneous pneumothorax with no difficulty in breathing and a -​to 2-​cm rim of pneumothorax
on CXR

Contraindications
● Tension pneumothorax should undergo immediate needle decompression
● Traumatic pneumothorax requires intervention
● Bilateral pneumothoraces
● Previous pneumothorax within last 2 weeks
● Haemodynamically unstable patient
● Anticoagulated patient (await internalized normalized ratio (INR) prior to attempted aspiration)
● Spontaneous pneumothoraces suitable for conservative management
● Secondary spontaneous pneumothorax with difficulty in breathing or >2-​cm rim of air on CXR should be
treated with Seldinger chest drain

Patient positioning and the triangle of safety

Whilst performing aspiration of a pneumothorax, the patient should be positioned sitting upright, with the hand
of the affected side behind the head. The triangle of safety for aspiration of the pneumothorax lies between the
lateral edges of the pectoralis major and latissimus dorsi, above the 5th intercostal space and below the base of
the axilla.

Patient discharge advice

Patients who are suitable for discharge should be referred for follow-​up in the chest clinic, and information should
be sent to their GP to confirm their diagnosis. Patients should be given the following information:
● Return to the ED immediately if they experience breathlessness or chest pain
● They should avoid diving for life
● They should avoid air travel until given further advice at chest clinic review

Further reading
Maskell N. British Thoracic Society Pleural Disease Guidelines—​200 update. Thorax 200;65:667–​669.
Ramrakha P, Moore K, Sam, A. Oxford Handbook of Acute Medicine. Oxford, UK: Oxford University Press. Retrieved
2 May, 2022, from https://​oxf​ordm​edic​ine.com/​view/​0.093/​med/​97809​8797​425.00.000/​med-​97809​8797​425,
209–​.
Wyatt J, Taylor R, de Wit K, Hotton E. Oxford Handbook of Emergency Medicine. Oxford, UK: Oxford University
Press. Retrieved 2 May, 2022, from https://​oxf​ordm​edic​ine.com/​view/​0.093/​med/​97809​8784​97.00.000/​med-​
97809​8784​97, 2020–​08.
Algorithm for pleural aspiration—pneumothorax
14

14 7. Intercostal drain—​seldinger

Indications
Algorithms for Emergency

● Pneumothorax
● Malignant pleural effusion

Predrainage
● Correct coagulopathy or platelet defect if possible
Explain procedure to patient and record informed consent
Medicine

● Place patient on monitoring for pulse oximetry, ECG, and blood pressure (BP)
● Premedication (benzodiazepine or opioid) to reduce patient distress unless contraindicated
● Position patient slightly recumbent, with ipsilateral hand behind patient’s head to expose axillary area and
‘triangle of safety’ (Figure .)
● Lateral edge of latissimus dorsi (posteriorly)

● Lateral border of pectoralis major (anteriorly)

● Line superior to horizontal level of the nipple or 5th IC space (inferiorly)

● Base of the axilla (superiorly)

● Alternatively: patient sat upright leaning forwards over adjacent table with a pillow
● Confirm site of drain insertion by reviewing clinical signs and chest radiograph
● Prophylactic antibiotics not routinely indicated

Drainage
● Common position for insertion is in the mid-​axillary line through the ‘safe triangle’
● For apical pneumothoraces, 2nd intercostal space in mid-​clavicular line

● Aseptic technique with skin cleansing using iodine or chlorhexidine

● Local anaesthetic (LA) prior to insertion of drain (up to 3 mg/​kg of lidocaine)
● Insertion of a small-​bore (8–​4 French (Fr)) drain with aid of a guidewire by Seldinger technique does not
require blunt dissection
● Position of tube tip should be apically for pneumothorax or basally for pleural effusion
● However, any tube position can be effective, and a functioning drain should not be repositioned because of

its radiographic position

● Secure drain with stay suture to prevent it falling out—​such as -​0 silk
● Connect chest tube to a single flow drainage system (e.g. underwater seal bottle)
● Position confirmed with swinging and bubbling

Figure . Safe triangle for intercostal drain insertion.

Reproduced with permission from Murray et al. Oxford Handbook of Clinical Medicine 7e, 2007, Oxford University Press.

Further reading
Laws D, Neville E, Duffy J. BTS guidelines for the insertion of a chest drain. Thorax 2003;58(Suppl II):ii52–​ii59.
Algorithm for intercostal drain—seldinger

Indication to insert seldinger chest drain

Consent patient and place on monitoring. Give premedication if

required (capnography if sedated).

Confirmation of site of insertion clinically and on radiology

Position the patient

Clean the area with betadine and apply sterile drapes

Using aseptic technique infiltrate local anaesthetic

To localize position for insertion, pass a needle just above the

superior surface of a rib, whilst aspirating to identify air or pleural fluid

Pass a guidewire down the hub of the needle, and maintain a hold on
wire so that it is not pushed fully into the pleural cavity

Remove the needle

Make a small incision parallel to the ribs through skin

Enlarge tract with a dilator

Pass small-bore tube into thoracic cavity along the wire

Remove the guidewire

Secure drain and suture

Underwater seal

Confirm position
16

16 8. Intercostal drain—​open

Indications
Algorithms for Emergency

● Traumatic haemothorax
● Traumatic pneumothorax
● Open pneumothorax
● Selected patients with suspected severe lung injury (e.g. multiple rib fractures or pulmonary contusions) who
need positive-​pressure ventilation or transport via road or air
Medicine

● Traumatic cardiac arrest (either insert bilateral intercostal drains (ICDs) or perform bilateral finger
thorocostomies)
● Empyema and complicated parapneumonic effusion
● Postsurgical (e.g. thoracotomy, oesophagectomy, cardiac surgery)

Contraindications
● Patient unstable: no contraindications
● Patient stable: consider coagulopathy/​multiple pleural adhesions

Equipment
● Personal protective equipment (sterile gloves and gown, consider face shield)
● Skin antiseptic solution (use hospital policy, e.g. iodine/​chlorhexidine in alcohol)
● Sterile drapes and swabs
● A selection of syringes and needles
● LA (e.g. % lignocaine +​/​–​adrenaline)
● Scalpel and blade
● Instrument for blunt dissection (e.g. curved clamp)
● A chest tube (size 28–​32 Fr in adults) with the trocar discarded
● Connecting tubing
● Underwater seal drain
● Suture (e.g. 0 or -​0 silk)
● Dressing and tape

Complications
● Damage to intercostal nerve, artery, or vein
● Infection, e.g. thoracic empyema
● Creation of false track
● Persistent pneumothorax
● Subcutaneous emphysema
● Organ damage, e.g. liver, spleen, lung, heart, diaphragm
● Chronic pain

Other considerations
● Antibiotics should be considered in trauma patients having an ICD inserted, especially with penetrating trauma
● Patients should be referred to a thoracic surgeon if the ICD yields >.5 L of blood immediately OR if there is
persistent blood loss via the ICD (e.g. >200 mL/​hour for 2 hours)
● A ruptured bronchus is suggested by persistent air through the ICD, especially if the lung fails to expand; this
needs urgent discussion with a thoracic surgeon
● Consider Seldinger drain in non-​traumatic pneumothorax
● Consider conservative management for small isolated traumatic pneumothoraces with no haemothorax

Further reading
Maskell N. British Thoracic Society Pleural Disease Guidelines—​200 update. Thorax 200;65:667–​669.
American College of Surgeons. ATLS: advanced trauma life support for doctors: student course manual. Chicago,
IL: American College of Surgeons, 2008.
 Algorithm for intercostal drain—open

Identify need for open ICD

Preparation:
• Obtain consent: ideally written, but in emergency setting verbal is adequate.
If patient is unable to give consent, perform procedure if deemed in the best
interests of the patient
• Ensure assistant is present
• Monitoring: ensure patient is attached to full monitoring and has 100%
oxygen (unless any contraindications to high flow oxygen)
• Consider parenteral analgesia e.g. IV morphine

Procedure
1. Position patient appropriately—classically supine or at 45°
(depending on other injuries) with arm fully abducted or held
behind patient’s head.
2. Determine insertion site: commonly 5th intercostal space, just
anterior to the mid-axillary line on the affected side

3. Don full personal protective equipment

4. Prepare equipment on procedure trolley
5. Maintain asepsis
6. Clean skin with appropriate antiseptic solution
7. Surgically drape the chest
8. Insert local anaesthetic to skin and down to rib periosteum
9. Make 2- to 3-cm transverse incision on upper border of the rib and
bluntly dissect down through tissues

10. Puncture the parietal pleura and insert a gloved finger into the
pleural cavity to release adhesions and to ensure that you are in the
pleural space
11. Insert the chest tube into the pleural cavity with the aid of a clamp,
and look for fogging of air or passage of blood in the drain tube

12. Connect the end of the tube with the underwater seal
13. Suture tube in place and apply a dressing
14. Ensure tube is secure

Post procedure
Re-evaluate patient
Obtain CXR
18

18 9. Arterial blood gas sampling

Indications
Algorithms for Emergency

Arterial blood gas (ABG) sampling is useful:

● In patients with respiratory disease who are at risk of inadequate ventilation and tissue oxygenation.
● In critically ill patients
● In those with metabolic disease (e.g. diabetic ketoacidosis)
● In poisoning and drug overdose.
Medicine

Contraindications
Contraindications are relative and patient risk should be weighed against the importance of sampling.
● Areas of infected skin/​cellulitis overlying the sample site (due to the risk of inoculation with bacteria)
● Patients with coagulopathy or who are anticoagulated.
● Consideration should also be given to the presence of collateral circulation (see section ‘Selection of a suitable
artery’) due to the risk of thrombus formation.
Complications
● The commonest complication is local haematoma at the site of sampling.
● Other complications include intra-​arterial thrombus and infection at the sampling site.
Selection of a suitable artery
ABG sampling can be performed using the radial, brachial, or femoral arteries. If the radial artery is to be used, a
modified Allen test should ideally be performed to assess and confirm good collateral circulation. To do this, ask
the patient to make a fist and apply occlusive pressure to both radial and ulnar arteries with your thumbs. Ask the
patient to clench their fist until the palmar skin is blanched. Release the pressure over the ulnar artery only and
watch to ensure the palm becomes pink. Repeat the process again, this time releasing pressure on the radial artery
only to ensure the palm becomes pink. If pressure release over either artery fails to allow blood flow to the palm
and colour to return within 5 seconds, consider a different site for ABG sampling.
To access the radial artery the patient should be positioned supine, with the forearm supinated and the wrist
dorsiflexed to approx. 40° if possible.
To access the brachial artery the patient is positioned supine, with the shoulder in slight abduction, the elbow
extended, and the forearm fully supinated.
To access the femoral artery the patient is positioned supine, with the legs in the anatomical position.
Use of local anaesthetic
LA does not tend to be used routinely as the insertion of LA is itself painful. If LA is to be utilized 0.5–​.0 mL of
% lignocaine can be injected subcutaneously using an orange needle over the intended site of arterial puncture.
Care should be taken to aspirate prior to instilling the anaesthetic agent to ensure that the artery has not been
punctured and so avoid intra-​arterial administration of the LA.
ABG normal values
pH 7.35–​7.45
PaO2 0.0–​3.0 kPa on room air
PaCO2 4.7–​6.0 kPa
HCO3 22–​26 mmol/​L
BE –​2 to +​2
SaO2 >95%
(As a rule of thumb, PaO2 should usually be around 0 kPa less than inspired partial pressure. Practically, this
means PaO2 should be numerically around 0 less than the inspired O2 concentration (%).)
Further reading
Danckers M. Arterial Blood Gas Sampling. https://​emedic​ine.medsc​ape.com/​arti​cle/​902​703-​overv​iew, 2020.
Wyatt JP, Illingworth RN, Graham CA, Hogg K, Robertson C, Clancy M. Oxford Handbook of Emergency Medicine, 4th
edn. Oxford: Oxford University Press, 202.
 Algorithm for arterial blood gas sampling

ABG sampling indicated

• Prepare equipment
• Position patient
• Put on gloves

Palpate artery to be sampled

Artery palpable?
Consider
attempting
Yes No sample from
another
site/artery

• Clean skin with alcohol swab and allow drying

Seek help
• Continue to palpate artery with non-dominant hand
from senior
• Hold ABG syringe between 2 fingers of dominant
or
hand
anaesthetist
• Insert needle under skin with bevel facing up
• Advance needle at 45° angle in direction of artery

Arterial blood flow into syringe?

Yes No

• Collect 2–3 mL of blood • Withdraw needle

• Withdraw needle • Apply pressure
• Apply pressure and dressing to puncture site and dressing to
• Ask assistant to continue to apply pressure puncture site until
until haemostasis achieved haemostasis
• Push needle carefully into bung or apply achieved
protective sleeve
• Remove needle and place in sharps bin
• Expel excess air from syringe and apply Multiple previous
syringe cap if needed attempts at ABG
• Insert sample into ABG analyser or place on sampling from this
ice and send to laboratory site?

Obtain and interpret ABG result No Yes

20

20 0. Peripheral venous cannulation

Indications
Algorithms for Emergency

Peripheral venous cannulas are used for:

● The administration of IV fluids, blood and blood products, drugs, and parenteral nutrition.
● They are also inserted prophylactically in unstable patients and before certain procedures are commenced.

Contraindications
Medicine

Peripheral venous cannulation is contraindicated:

● Where there is evidence of infection over the site of insertion.
● Relative contraindications include avoiding forearm veins in patients with renal failure (who may require
arteriovenous fistulae) and small veins with low flow rates, especially when irritant drugs are to be used
● Established arteriovenous fistulas should not be cannulated.

Complications
Complications include:
● Infection, phlebitis and thrombophlebitis
● Emboli
● Pain
● Haematoma or haemorrhage
● Extravasation
● Arterial cannulation.

Selection of a suitable vein

In general, peripheral veins in the upper limb are used in preference to those in the lower limb, as they cause less
interference with a patient’s mobility and are less prone to thrombophlebitis and thrombosis. In the upper limb the
dorsal hand veins, cephalic veins, and basilic veins are all commonly used. If a limb is affected by lymphoedema, is
infected, or has sustained injuries or burns, then another limb should be cannulated in preference.
If a suitable vein is difficult to identify, a number of techniques may be useful. These include:
● Try a different limb to see if veins are more readily visible
● Ask the patient to open and close their fist when the tourniquet is in situ
● Gently tap or stroke the site
● Enlist the help of gravity, by holding the limb down
● Place the limb in warm water or apply heat pack/​warm towel to the site

Ultrasound-​guided peripheral cannulation

If peripheral veins are not readily visible and the above techniques do not help, US-​guided cannulation is a useful
technique. The linear/​vascular probe can be used to visualize veins and a cannula can then be inserted using the
standard technique.

Topical anaesthetic
In non-​emergent situations, topical anaesthetic creams and gels may be applied to the skin to decrease the pain
associated with cannulation. This is particularly useful in paediatric patients, but can also be valuable in adults who
are very anxious or have a fear of needles.

Further reading
Campbell J. Intravenous cannulation: potential complications. Prof Nurse 997;2(8 Suppl):S0–​S3.
Clutton-​Brock TH. Vascular access. How to set up a drip and keep it going. Br J Hosp Med 984;32:62, 64, 66–​67.
Shlamovitz GZ. Intravenous Cannulation. https://​emedic​ine.medsc​ape.com/​arti​cle/​998​77-​overv​iew, 202.
Waitt C, Waitt P, Piromohamed M. Intravenous therapy. Postgrad Med J 2004;80:–​6.
 Algorithm for peripheral venous cannulation

Peripheral IV cannula insertion indicated

• Prepare equipment
• Put on gloves
• Apply tourniquet proximal to insertion site
• Identify vein for cannula insertion
• Clean skin with alcohol swab and allow to dry
• Stabilize vein with non-dominant hand
• Hold cannula in dominant hand, with bevel facing up
• Puncture skin and advance needle at 10–25°angle

Consider:
• US-guided
cannulation Flashback seen?
• IO access
• Withdraw to just below skin
• Central access
• Adjust angle/direction and
• Senior help re-advance
Yes No

• Slide hub of cannula over needle and into vein

Yes No • Apply pressure proximal to cannula
• Remove needle and discard in sharps bin

Blood samples required? • Attach vacuum tube adaptor

or use syringe to collect blood
• Send for relevant tests
No Yes
Multiple previous • Discard adaptor in sharps bin
attempts at peripheral
cannulation?

• Remove tourniquet
• Insert bung or attach IV fluids as
appropriate
• Secure cannula with adhesive
dressing
• Flush cannula with normal saline to
ensure it is correctly sited

Cannula flushes without

extravasation?

• Remove cannula
• Apply pressure and
dressing to puncture No Yes Cannula correctly sited
site
22

22 . Central venous cannulation

Indications
Algorithms for Emergency

● If the patient requires medications that need central access to allow administration such as inotropes or
amiodarone
● If a patient has very poor peripheral venous access and needs a more definitive line
● As part of fluid balance monitoring in the critically ill patient
● If a patient requires a rapid infusion of fluid or blood, such as in haemorrhagic shock secondary to trauma
Medicine

Contraindications
There are no absolute contraindications for central line insertion, but a risk versus benefit approach should be
considered in the following circumstances:
● If the patient has a coagulopathy that hasn’t been addressed
● Infection in the tissues around the insertion site
● If there is local thrombosis causing venous obstruction
● Raised intracranial pressure. A femoral line should be considered in this situation
● Local damage such as a burn or a contaminated wound

Consent
Consent for this procedure should cover the following risks:
● Bleeding—​local or from arterial puncture
● Infection
● Failure of procedure
● Pneumothorax and damage to other local structures
● Pain
● Thrombus formation
● Uncooperative patient

Ultrasound identification of the internal jugular vein

The following features will help differentiate between the carotid artery and the internal jugular vein:
● It usually lies lateral to the carotid artery within the carotid sheath
● The internal jugular vein should be compressible, whereas the carotid artery will not be
● Valsalva manoeuvre will increase the diameter of the vein
● Doppler flow will show blood flowing away from the probe

Further reading
Hatfield A, Bodenham A. Ultrasound for central venous access. Continuing Education in Anaesthesia, Critical Care & Pain
2005;5(6):87–​90.
 Algorithm for central venous cannulation

Ensure the patient is consented for the procedure

Choose the site of the line. Ideally this should be the internal jugular vein, but it could be th e
femoral vein.

Wash hands, apply sterile gloves and gown. Clean the area and apply sterile drapes. Ensure
the ultrasound probe has a sterile sheath on

Use ultrasound to identify the internal jugular vein

Infiltrate lignocaine under ultrasound guidance

Prepare the central line by flushing all lumens. Ensure all lumens are clamped, except for the
seldinger port

Take a seldinger needle and syringe, and under ultrasound guidance insert into the internal
jugular vein. Ensure that you can easily aspirate blood

Remove the syringe and insert the guidewire through the needle. Ensure you hold the wire
whilst removing the needle

Using a scalpel, make a small incision by cutting away from the guidewire to allow passage of
the dilator. This should be 2–3 mm

Pass the dilator over the guide wire, whilst applying firm pressure to create a tract for the
line. Remove the dilator and pass the central line over the guidewire, ensuring the guidewire
is held at all times

Remove the guidewire. Aspirate and flush all lumens

Suture the central line to the skin and apply a clear dressing
24

24 2. Intraosseous access

Important points
Algorithms for Emergency

● Any medication or fluid that you would give peripherally can go intraosseous (IO) at the same dose
● Any age patient can have an IO needle inserted
● Each medication given needs to be flushed with 5 mL of normal saline

Indications
Any situation where IV access is proving difficult/​impossible, e.g. burns, circulatory collapse, cardiac arrest
Medicine

Contraindications
● Vascular damage or fracture proximal to the intended site of insertion
● Infection in the skin overlying the intended site of insertion
● Osteogenesis imperfecta

Equipment
● Manual IO needle or IO needle with mechanical driver (drill)
● Select the correct IO needle:
● 5 mm: 3–​39 kg

● 25 mm: >40 kg

● 45 mm: proximal humeral site, or excessive subcutaneous tissue

● Three-​way tap with primed extension set with 0.9% saline

Complications
● Epiphyseal injury
● Bleeding
● Skin necrosis
● Infection
● Through and through bone penetration
● Subcutaneous infiltration
● Iatrogenic fracture

Possible sites for insertion

● Proximal tibia: approx. 2.5 cm distal to the tibial tuberosity on the antero-​medial aspect of the tibia
● Distal tibia: 2.5 cm proximal to the medial malleolus
● Distal femur: 2.5 cm proximal to the lateral femoral condyle on the antero-​lateral surface
● Proximal humerus: at the greater trochanter on the antero-​lateral aspect

Notes
● Bone marrow can be tested for BM, cultures, or group and save
● Any fluid inserted through the IO will need to be manually syringed
● Continually assess to ensure patency of IO placement
● Remove IO needle as soon as two IV accesses have been obtained and within 24 hours of insertion

Further reading
American College of Surgeons. ATLS: advanced trauma life support for doctors: student course manual. Chicago,
IL: American College of Surgeons, 2008.
Advanced LifeAdvanced Life Support Group. Advanced Paediatric Life Support: A Practical Approach to Emergencies
(APLS), 6th edn. Wiley-​Blackwell, 206.
 Algorithm for intraosseous access

Preparation
• Explain the procedure to patient/relative and obtain consent if appropriate.
• Identify the insertion site
• Sterilize the skin
• Support the limb on a blanket

Manual IO insertion Mechanical IO insertion (with drill)

1. Insert local anaesthetic (e.g. 1% 1. Local anaesthetic to the skin is

lignocaine) subcutaneously if
needed
2. Firmly grasp the handle and use
a twisting motion to insert the
needle at a 90°angle to the
bone. Stop when you feel the
give of breaching the medullary
cavity
3. Remove stylet and confirm
placement by aspiration of
bone marrow (Note: failure to
aspirate bone marrow does not
necessarily signify incorrect IO
placement)
not needed
2. Select correct IO needle size and
place needle into drill
3. Insert the needle at 90° to the
skin up to the 5-mm black line on
the shaft of the needle
4. Remove the drill and the stylet of
the IO needle, leaving the needle
itself in the medullary cavity
5. Confirm placement by aspiration
of bone marrow
6. Note: failure to aspirate bone
marrow does not necessarily
signify incorrect IO placement

Attach the 3-way tap and extension set, and flush the IO with 0.9% saline
Look for soft tissue swelling around the IO site—this may suggest incorrect IO
positioning
Secure IO needle to leg with tape or consider a plaster of Paris back slab to ensure
leg immobilization
26

26 3. Urinary catheterization

Important safety notes

Algorithms for Emergency

● Adult urinary catheters are manufactured in two lengths: female length (20–​26 cm) and standard length (40–​
45 cm). The use of standard-​length catheters in females poses no safety issues. However, if a female-​length
catheter is accidentally used for a male, the ‘balloon’ inflated with sterile water to retain the catheter will be
within the urethra, rather than the bladder, and can then cause severe trauma
● Most widely used types of catheter contain latex. If the patient is allergic to latex, an all-​silicone catheter must
Medicine

be used

Technique for insertion

. Obtain an assistant/​chaperon
2. Choose an appropriate size catheter (e.g. 2–​4 Fr) and appropriate length (see above) and prepare your
equipment
3. Position the patient in supine with legs slightly apart
4. Wash and dry your hands, then put on sterile gloves
5. Clean thoroughly around the urethral meatus (retract the foreskin if applicable) using an antiseptic
solution like chlorhexidine
6. Insert LA gel and hold the meatus close; wait for 5 minutes for it to work
7. a) Hold the penis vertically with one hand and gently advance the catheter with the other hand, until all is
inserted
b) Part the labia with one hand and gently advance the catheter with the other hand, until all is inserted
8. Wait until urine starts flowing through the catheter
9. Inflate the balloon using 0 mL of sterile water, ensuring that it does not cause any pain, and attach a
catheter bag
0. Gently pull on the catheter until resistance is felt
. Reposition the foreskin if applicable

Useful tips
● Instruct the patient to try to void when you feel resistance passing the catheter. This will sometimes open the
sphincter, allowing the catheter to pass
● Use forceps to aid advancing and applying gentle pressure to the catheter as it advances; this will provide
better grip to the catheter and stops slipping

Further reading
NPSA alert (NPSA/​2009/​RRR02): Female urinary catheters causing trauma to adult males. Nurs Times 30 April 200.
Another random document with
no related content on Scribd:
"I saw one Thing this morning," said Wentworth grimly. "I don't like to
think about it. If they're bringing it over to snap us up when this can
is lifted off us, we're up against plenty of trouble. You keep your
finger on the flight-button! That Thing was bigger than the Galloping
Cow! I'll try to tip McRae off as to what's happened."
He settled down by the communicator. Every ten minutes he tried to
call the expedition's ship. Every time there came a monstrous roar of
static as the set came on, and no other sound at all. Aside from that,
nothing happened. Absolutely nothing.
The flier lay on the ground with an unnatural assortment of reflected
and re-reflected light-beams from the twin landing-lamps. There
were four clumps of skit-trees sharing the prison with the flier and the
men.
Silence. Stillness. Nothing. Every ten minutes Wentworth called the
Galloping Cow. It was an hour and a half before there came an
answer to Wentworth's call.
"—llo!" came McRae's voice through the crackling static. "Down in—
gain—no sign—sort anywhere—"
"Get a directional on me!" snapped Wentworth. "Can you hear me
above the static?"
"What sta—voice perfectly clear—" came McRae's booming. "Keep
—talking...."
Wentworth blinked. No static at the Galloping Cow? When his ears
were practically deafened? Then it made sense. All of it!
"I'll keep talking!" he said fervently. "Use the directional and locate
me! But don't try to help me direct! Take a bearing from where you
find me to where a fifty-foot dirt embankment sticks out from a
mountain-spur to the north. Get on that line and you'll hear the static,
all right.
"It's in a beam coming right here at me. Follow that static back to the
mountains, and when you find where it's being projected from, you'll
find some skit-tree planters with all the artifacts your little heart
desires. Only maybe you'll have to blast them."
He swallowed.
"It works out to sense," he went on more calmly. "They built up a
civilization based on generating instead of building the things they
wanted to use. Our force-fields are globular, because the generator's
inside. If you want a force-field to have a definite shape, you have to
generate it differently. Their cities and their machines weren't
substance, though they were solid enough. They were force-fields!
"The generators were off at a distance, throwing the force-field they
wanted where they needed it. They projected solidities like we
projected pictures on a screen. They projected their cities. Their
tools. Probably their spaceships too! That's why we never found
artifacts. We looked where installations had been, instead of where
they were generated and flung to the spot where they were wanted.
There's a beam full of static coming from those mountains."
Light! With all the blinding suddenness of an atomic explosion, there
was light. Wentworth had a moment's awareness of sunshine on the
brittle stalks of skit-trees, and then of upward acceleration so fierce
that it was like a blow. The atmosphere-flier hurtled skyward with all
its lift-jets firing full blast, and there was the Galloping Cow lumbering
ungracefully through atmosphere at ten thousand feet, some twelve
or more miles away.

McRae's voice came out of a communicator which now picked up no

static whatever.
"What the devil?" he boomed. "We saw something that looked like a
big metal tank, and it vanished and you went skyward from where it'd
been like a bat out of a cave."
"Suppose you follow me," said Wentworth grimly. "The skit-tree
planters on this planet, anyhow, don't want us around. By pure
accident, I got a line on where they were. They lured me away from
their place by projecting a city.
"I went to look, and it vanished. I played hide and seek with it until
they changed tactics and let it stay in existence. Maybe they thought
we'd land on it, high up, and get out of the flier to explore.
"Then the city would have vanished and we'd have dropped a mile or
two, hard. But we landed on the ground instead, and they clapped a
jail around us.
"I don't know what they intended, but you came along and they let
the jail vanish to keep you from examining it. And now we'll go talk to
them!"
The flier was streaking vengefully back to the embankment to where
only that morning, before sunrise, Wentworth had seen something
he still didn't like to think about.
The Galloping Cow veered around to follow, with all the elephantine
grace of the animal for which she had been unofficially christened.
She'd been an Earth-Pluto freighter before conversion for the
expedition, and she was a staunch vessel, but not a handy one.
The flier dived for the hills. Wentworth's jaws were hard and angry.
The Galloping Cow trailed, wallowing. The flier quartered back and
forth across the hills, examining every square inch of ground.
Nothing. Absolutely nothing. The search went on. The communicator
boomed.
"They're playing 'possum," McRae's voice said. "We'll land and make
a camp and prepare to hunt on foot."
Wentworth growled angrily. He continued to search. Deeper and
deeper the flier went into the hills, going over and over every bit of
terrain. Then, quite suddenly, the communicator emitted babbling
sounds. Shoutings. Incoherent outcries. From the ship, of course.
There were sudden, whining crashes, electronic cannon going off at
a panic-stricken rate. Then a ghastly crashing sound, and silence.
The flier zoomed until Haynes and Wentworth could see. They
paled. Wentworth uttered a raging cry.
The Galloping Cow had landed. Her ports were open and men had
emerged. But now a Thing had attacked the ship with a ruthless,
irresistible ferocity. It was bigger than the Galloping Cow. It stood a
hundred feet high at the shoulder. It was armored and possessed of
prodigious jaws and gigantic teeth. It was all the nightmares of
mechanistic minds rolled into one.
It must have materialized from nothingness, because nothing so
huge could have escaped Wentworth's search. But as Wentworth
first looked at it, the incredible jaws closed on the ship's frame and
bit through the tough plates of beryllium steel as if they had been
paper. It tore them away and flung them aside.
A mainframe girder offered resistance. With an irresistible jerk, the
Thing tore it free. And then it put its claws into the very vitals of the
Galloping Cow and began to tear the old spaceship apart.
The crewmen spilled out and fled. The Thing snapped at one as he
went but returned to its unbelievable destruction. Someone heaved a
bomb into its very jaws, and it exploded, and the Thing seemed not
to notice.
Wentworth seized the controls of the flier from Haynes. He dived, not
for the ship, but for the space between the ship and the mountains.
He flung the small craft into crazy, careening gyrations in that space.
And then the communicator shrieked with clacking static. The flier
passed through the beam, but Wentworth flung it back in. He
plunged toward the mountains. He lost the beam, and found it again,
and lost it and found it.
"There!" he said, choking with rage. "Down from the top of that cliff.
There's a hole—a cave-mouth. The beam's coming from there!"
He plunged the flier for the opening, and braked with monstrous
jetting that sent rocket-fumes blindingly and chokingly into the tunnel.
The flier hit, and Wentworth scrambled to the forepart of the little
ship and leaped to the cliff-opening against which it bumped. Then
he ran into the opening, his flame-pistol flaring before him.
There was a blinding flash inside. The blue-white flame of a short-
circuit created a gigantic arc. It died. The place was full of smoke,
and something small ran feebly across the small space that
Wentworth could see, and fell, and kicked feebly, and was still.
Wentworth could hear a machine come to a jolting stop. And
crouching there fiercely, he waited for more antagonists.
None came. The fumes drifted out the cave-mouth. Then he could
see the Thing on the floor. Clad in a weirdly constructed space-suit,
the creature he had knocked over was not human and looked very
tired. It was dead. Next he saw an almost typical tight-beam
projector, linked with heavy cables to a scanning device.
He saw a model—all of five feet high—of the city he and Haynes had
tried to reach. The model was of unbelievable delicacy and
perfection. But the scanning system now was focused on a metal
object which was a miniature Thing with claws and jaws and armor.
It was two feet long, and there was a cable control by which its
movements could be directed. A solidity which was controlled by that
ingenious mechanical toy could dig canals, or gather the crop from
the tops of skit-trees—when enlarged in the projection to stand a
hundred feet high at the shoulder—or it could tear apart a spaceship
as a terrier rends a rat.
There was more. Much more. But there had been only the one small
Inhabitant, who wore a space-suit on his own planet. And he was
dead. Haynes' voice came from the flier at the cave-mouth.
"Wentworth! What's happened? Are you alive? What's up?"
Wentworth went out, still in a savage mood. He wanted to see how
the Galloping Cow had withstood the attack. What he had seen last
looked bad.
It was bad. The Galloping Cow was a carcass. Her engines were not
too badly smashed, but her outer shell was scrap-iron, her frame
was twisted wreckage, and there was no faintest hope that they
could repair her.
"And—I'm engaged to be married when we get back," said Haynes,
white-faced. "We'll never get back in that."
Less than a month later, though, the Galloping Cow did head for
home. Haynes, unwittingly, had made it possible. Examination of the
solidity-projector revealed its principles, and Haynes—trying forlornly
to make a joke—suggested that he model a statuette of the last
Inhabitant to be projected a mile or two high above the skit-tree
plantations now forever useless.
But he was commissioned to model something else entirely, and in
his exuberance his fancy wandered afar. But McRea dourly
permitted the model to stand, because he was in a hurry to start.
So that, some six weeks from the morning when Wentworth had
seen an impossible Thing moving in the gray dawnlight on an
unnamed planet, the Galloping Cow was almost back in touch with
humanity. Two weeks more, and the outposts of civilization on Rigel
would be reached.
A long, skeleton tower had been built out from the old ship's battered
remnant. A scanner scanned, and a beam-type projector projected
the image of Haynes' modeling to form a solid envelope of force-field
about the ship. It was much larger than the original hull had been.
There would be room and to spare on the voyage home. And
Haynes was utterly happy.
"Think!" he said blissfully, in the scanning-room where the force-field
envelope was maintained about the ship. "Two weeks and Rigel!
Two months and home! Two months and one day and I'm a married
man!"
Wentworth looked at the small moving object on which the scanners
focused.
"You're a queer egg, Haynes," he said. "I don't believe you ever had
a solemn thought in your head. Do you know what wiped out those
people?"
"A boojum?" asked Haynes mildly. "Tell me!"
"The biologists figured it out," said Haynes. "A plague. The last poor
devil wore a space-suit to keep the germs out. It seems that some
wrecked Earth-ship drifted out to where one of their explorers found
it. And they hauled it to ground. They learned a lot, but there were
germs on board they weren't used to. Coryzia, for instance.
"In their bodies it had an incubation period of about six months, and
was highly contagious all the time. Then it turned lethal. They didn't
know about it in time to establish quarantines. No wonder the poor
devil wanted to kill us! We'd wiped out his race!"
"Too bad!" said Haynes. He looked down at the small moving thing
he had modeled for a new hull for the Galloping Cow.
"You know," he said blithely, "I like this model! I may not be the best
sculptor in the world—as an amateur I wouldn't expect it. But for a
while after we land on earth, I'm going to be the most famous man
alive."
And he beamed at the jerkily moving object which was the model for
the hull of the Galloping Cow. It was twelve hundred feet long, as it
was projected about the old ship's engine-room and remaining
portions. It had a stiffly extended tail and an outstretched neck and
curved horns. Its legs extended and kicked, and extended and
kicked.
The Galloping Cow, in fact, exactly fitted her name by her outward
appearance, as she galloped Earthward through emptiness.
 *** END OF THE PROJECT GUTENBERG EBOOK SKIT-TREE
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