Placing an arterial line can provide an accurate way for continuous blood pressure monitoring and arterial sampling when further acid-base determination is needed.

Most Common Indications: Blood gas sampling, continuous pressure monitoring, need for frequent blood sampling

Contraindications:
-Absolute: Inadequate circulation, Raynaud’s Syndrome, Buerger’s Disease, full-thickness burns
-Relative: Previous surgery in the area, anticoagulation/coagulopathy, skin infections at the site, atherosclerosis, inadequate collateral flow, partia-thickness burns

Complications: Hematoma formation, infection, bleeding, ischemia, thrombosis/embolism, arteriovenous fistula, pseudoaneurysm formation

Check this video out. Knee

Shoulder

Central venous access remains an important skill to perform when treating critically-ill patients.

Most common indications: Central venous pressure monitoring, high-volume/flow resuscitation, emergency venous access, inability to obtain peripheral venous access, repetitive blood sampling, administering certain medications/fluids, insertion of transvenous pacemakers, hemodialysis or plasmaphersis

Contraindications: Infection over the placement site, distortion of landmarks , coagulopathies (including anticoagulation and thrombolytic therapy), pathologic conditions (including superior vena cava syndrome), current venous thrombosis in the target vessel, prior vessel injury or procedures, morbid obesity, uncooperative patient

Complications: Arterial puncture hematoma, pneumothorax subclavian and IJ approach), hemothorax (subclavian and IJ approach), vessel injury, air embolism, cardiac dysrhythmia, nerve injury, infection, thrombosis, catheter misplacement

These should be placed under sterile conditions whenever practically possible.

Using ultrasound guidance to insert central lines is the standard of care. Review the following video to learn how to use ultrasound guidance when placing your central line.

Tube thoracostomy is a procedure used to evacuate an abnormal accumulation of fluid or air from the pleural space and can be performed on an elective, urgent, or emergent basis. Air or fluid can accumulate in the pleural space as a result of spontaneous or traumatic pneumothorax, pleural fluid accumulation of blood, malignancy, infection (empyema), or lymph (chylothorax). (Roberts and Hedges, 7th edition)

Most Common Indications: Spontaneous and traumatic pneumothorax, hemothorax, empyema, patients with penetrating chest trauma undergoing positive pressure ventilation or long distance transport

Contraindications:
-Absolute: None
-Relative: Presence of multiple pleural adhesions, presence of emphysematous blebs, coagulopathy

Complications: Infection, laceration of intercostal vessel, pulmonary injury, intra-abdominal or solid organ tube placement, failure of reexpansion of pneumothorax, reexpansion pulmonary edema

After you place a chest tube, you will need to connect it to a drainage and suction system. Here is a video about the Atrium waterseal system. They also go over how to troubleshoot problems that you may encounter.

You may choose to place a pigtail (Wayne) catheter.

Here is a how-to.

Here is another example using Melker Tray.

Here is another example

Be prepared

With bougie

Here are some videos

Here’s another video

You will be given a knot tying board to practice.

Two-Handed Square Knot

One-Handed Square Knot

Simple Interrupted

Horizontal and Vertical Mattress Suture

Please review the following website for general information about performing this procedure.

The following video goes over general indications and demonstrates the procedure.

The next video is a little longer in duration, but provides some meaningful discussion on how to find the canthal tendon.

Lumbar puncture is a medical procedure most commonly performed to collect cerebrospinal fluid (CSF) for diagnostic testing.

Most Common Indications: Suspected central nervous system infection, suspected spontaneous subarachnoid hemorrhage, suspected idiopathic intracranial hypertension

Contraindications:
-Absolute: Presence of infection near the puncture site
-Relative: Coagulopathy, presence of increased intracranial pressure caused by a space occupying lesion, thrombocytopenia

Complications: Brain herniation, cauda equina syndrome, cranial nerve VI palsy, epidermoid tumor, epidural and cerebrospinal fluid collection, epidural hematoma, intrathecal pump catheter, meningitis, minor backache, post dural puncture headache, retroperitoneal abscess, subarachnoid hemorrhage, subdural hematoma

It’s worth considering the anatomy when performing a lumbar puncture.

Here is a video going over the steps of the procedure.

Here is a video showing a real lumbar infant lumbar puncture.

Here’s another one.

“Immediate decompression of the chest must be considered in all injured patients with unexplained hypotension or tachypnea, particularly those with penetrating chest injuries. The goal is to open the pleural space quickly to allow any accumulated air to escape and decompress the chest cavity. This can be accomplished…with a large-bore needle/angiocatheter combination (minimum of 16 gauge). Place the catheter in the second intercostal space at the midclavicular line on the side with diminished breath sounds or on both sides if the diagnosis is unclear. If unable to obtain access to this landmark, or if unsuccessful in penetrating into the pleural space, an alternative site in the fourth or fifth intercostal space at the midaxillary line can be used. Remove the needle, but leave the angiocatheter in place to create a simple pneumothorax. Regardless of whether needle decompression is successful in improving the patient’s vital signs, a standard tube thoracostomy should be immediately performed following the decompression…Needle decompression causes an open pneumothorax and in most cases needs to be converted to an open thoracostomy.” (Roberts and Hedges, 7th edition)

Paracentesis is a procedure in which a needle or catheter is inserted into the peritoneal cavity to obtain ascitic fluid for diagnostic or therapeutic purposes.  A ascitic fluid may be used to help determine the etiology of ascites as well as to evaluate for infection or presence of cancer. (emedicine.medscape.com)

Most common indications: New onset ascites, suspected spontaneous bacterial peritonitis, to relieve the cardiorespiratory and gastrointestinal manifestations of tense ascites

Contraindications: Uncorrected coagulopathy and clinically evident fibrinolysis or disseminated intravascular coagulation, bowel dilation or obstruction, pregnancy, abdominal hematoma, engorged veins, or superficial infection at puncture site

Complications:
-Systemic: Hyponatremia, renal dysfunction, hepatic encephalopathy, hemodynamic compromise, significantly
-Local: Persistent eccentric fluid leak at the wound site, abdominal wall hematoma, localized infection
-Intraperitoneal: Perforation of vessels and viscera, generalized peritonitis, abdominal wall abscess

Ultrasound-guided

Being able to obtain access is

The first video will go over the instruments used to perform the procedure.

The next video demonstrates the procedure.

This video will review the procedure and the types of repairs that can be performed once you get inside the chest.

The next video shows an actual thoracotomy in the ED and eventual repair in the operating room.

Thoracentesis is a percutaneous procedure during which a needle is inserted into the pleural space to remove fluid for diagnostic or therapeutic purposes. (Roberts and Hedges, 7th edition)

Most common indications: Suspected pleural space infection, new effusion without a clear diagnosis, relief of dyspnea associated with large pleural effusion

Contraindications:
-Absolute: None
-Relative: Severe clotting abnormality, infection or herpes zoster at selected site

Complications: Pneumothorax, cough, infection, pneumothorax, Maria stanchion reexpansion pulmonary edema, embolism, catheter fragment in the pleural space, intra-abdominal hemorrhage

This is a slit lamp examination.