Emergency Medicine and Critical Care

Source: Julianna Jung, MD, FACEP, Associate Professor of Emergency Medicine, The Johns Hopkins University School of Medicine, Maryland, USA High-quality cardiopulmonary resuscitation (CPR) is the single most important determinant of intact survival in cardiac arrest, and it is critical that all healthcare workers are able to perform this lifesaving technique effectively. Despite the conceptual simplicity of CPR, the reality is that many providers perform it incorrectly, resulting in suboptimal...

Source: Julianna Jung, MD, FACEP, Associate Professor of Emergency Medicine, The Johns Hopkins University School of Medicine, Maryland, USA High-quality cardiopulmonary resuscitation (CPR) and defibrillation are the most important interventions for patients with cardiac arrest, and should be the first steps that rescuers perform. This is reflected in the American Heart Association's new "CAB" mnemonic. While rescuers were once taught the "ABCs" of cardiac arrest, they now learn "CAB" -...

Source: Rachel Liu, BAO, MBBCh, Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA The heart lies within the pericardium, a relatively inelastic fibrous sac. The pericardium has some compliance to stretch when fluid is slowly introduced into the pericardial space. However, rapid accumulation overwhelms pericardial ability to accommodate extra fluid. Once a critical volume is reached, intrapericardial pressure increases dramatically, compressing the right ventricle and...

Source: James W Bonz, MD, Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA Lateral canthotomy is a potentially eyesight-saving procedure when performed emergently for an orbital compartment syndrome. An orbital compartment syndrome results from a buildup of pressure behind the eye; as pressure mounts, both the optic nerve and its vascular supply are compressed, rapidly leading to nerve damage and blindness if the pressure is not quickly relieved. The medial and lateral...

Source: James W Bonz, MD, Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA A surgical airway procedure is indicated when other forms of endotracheal intubation have failed and ventilation is worsening or not possible. This is the feared "can't intubate, can't ventilate" scenario, and in the emergency setting, cricothyrotomy is the surgical procedure of choice. Cricothyrotomy is preferred over tracheotomy because of the lower risk of complications, the predictable anatomy...

Source: James W Bonz, MD, Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA Open cricothyrotomy is an emergent surgical procedure. It is performed to establish an airway access by passage of a tube through an incision in the cricothyroid membrane. This is a procedure of choice in the feared "can't intubate, can't ventilate" scenario - when all other forms of endotracheal intubation have failed and the spontaneous ventilation is worsening or has become impossible. The...

Source: Rachel Liu, BAO, MBBCh, Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA A tension pneumothorax is a life-threatening situation in which excess air is introduced into the pleural space surrounding the lung, either through trauma to the chest cavity or as a spontaneous leak of air from the lung itself. Air trapped within the pleural space causes separation of the lung from the chest wall, disrupting normal breathing mechanisms. Pneumothorax may be small without...

Source: Rachel Liu, BAO, MBBCh, Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA Tube thoracostomy (chest tube placement) is a procedure during which a hollow tube is inserted into the thoracic cavity for drainage of fluid or air. Emergency chest tube insertion is performed for definitive treatment of tension pneumothorax, traumatic hemothorax, large-volume pleural effusions, and empyemas. Irrespective of the cause of air and fluid accumulation in the pleural space, the...

Source: Rachel Liu, BAO, MBBCh, Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA The anterior shoulder dislocation is one of the most common joint dislocations seen in emergency settings. In anterior shoulder dislocation, the humeral head is displaced out of the glenohumeral joint in front of the scapular glenoid, resulting in a loss of the articulation between the arm and the rest of the shoulder. This can be caused by a fall onto an abducted, extended, and externally...

Source: Sharon Bord, MD, Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Maryland, USA When monitoring patients, it is important to obtain values that are accurate and reliable. Blood pressure monitoring is one of the essential vital signs, and for a majority of patients, measuring it utilizing non-invasive techniques provides accurate values. However, there are situations in which the blood pressure requires more exact, specific, and reliable measurements.

Source: Julianna Jung, MD, FACEP, Associate Professor of Emergency Medicine, The Johns Hopkins University School of Medicine, Maryland, USA For unstable patients requiring urgent administration of medications, fluids, or blood products, establishing vascular access quickly is essential. However, there are many factors that can complicate placement of a peripheral intravenous cannula (PIV), and it is extremely common for PIV attempts to fail. PIV placement may be technically challenging in small...

Source: Sharon Bord, MD, Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Maryland, USA Placement of an intravenous (IV) catheter is one of the key procedures in medicine. The IV catheter allows patients to receive critical medications, including pain medicine, insulin, antibiotics, blood products, and fluids for rehydration. Additionally, placing an IV catheter allows for blood samples to be obtained, which can be sent to the laboratory for testing and...

Source: James W Bonz, MD, Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA Central venous access is necessary in a multitude of clinical situations, including vascular access, vasopressor and caustic medication delivery, central venous pressure monitoring, intravascular device delivery (pacing wires, Swann-Ganz catheters), volume resuscitation, total parental nutrition, hemodialysis, and frequent phlebotomy. Safe reliable placement of a central venous catheter (CVC) in...

Source: James W Bonz, MD, Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA Central venous access is necessary in a multitude of clinical situations, including vascular access, vasopressor and caustic medication delivery, central venous pressure monitoring, volume resuscitation, total parental nutrition, hemodialysis, and frequent phlebotomy. There are three veins in the body that are accessed for central venous cannulation: the internal jugular, the subclavian, and the...

Source: James W Bonz, MD, Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA Central venous access is necessary in a multitude of clinical situations for hemodynamic monitoring, medication delivery, and blood sampling. There are three veins in the body that are accessed for central venous cannulation: the internal jugular, the subclavian, and the femoral vein. Central venous access via the subclavian vein has several advantages over other possible locations. The subclavian...