Anatomical Review of Jugular Central Line Placement

Image Source: Wikipedia

This post was peer reviewed.
Click to learn more.

Authors:
Benjamin Mogni, MS-IV
Medical Student
University of Kentucky College of Medicine

Terren Trott, MD
Critical Care Fellow
Cooper Hospital University

Jugular venous catheters allow for central administration of medications, frequent blood draws and central venous sampling. While standard of care for placement of central venous catheters (CVCs) involves ultrasound guidance, physicians should be aware of the traditional landmark approach to line placement. This means having a detailed knowledge of the anterior and posterior triangles of the neck, specifically the division of the sternocleidomastoid into the clavicular and sternal heads, as shown in Figure 1 and Figure 2. This review will summarize the anatomy involved in the placement of a jugular venous catheter and possible complications.

Pre-intubation Optimization of the Neurocritical Care Patient

This post was peer reviewed.
Click to learn more.

Image Credit: Wikimedia

Author: Tim Montrief, MD MPH
Jackson Memorial Health System/University of Miami
AAEM/RSA Publications and Social Media Committee Member

The catastrophic neurologic emergency remains one of the most challenging presentations managed by emergency physicians. Stress, diagnostic uncertainty, and time-sensitive nature lead to challenging management decisions. Likewise, the intubation of the neurocritical care patient provides many challenges, and requires a modified technique to avoid the harmful consequences of intubation, including an exaggerated reflex sympathetic response to laryngoscopy, hypotension due to induction agents, and exacerbation of elevated intracranial pressure (ICP). Additionally, maximizing first past success and minimizing hypoxia is especially important in patients with central nervous system (CNS) pathology, in particular, unsecured aneurysmal subarachnoid hemorrhage (SAH), traumatic brain injury (TBI), and stroke. Optimization of the neurocritical care patient is of upmost importance, and many of the techniques are familiar to the emergency physician. For instance, apneic oxygenation via a nasal cannula on the patient at 15 L/min maximizes oxygenation prior to intubation. Additionally, one may raise the head of the bed, which decreases ICP and has a ben­eficial effect on oxygenation. While ninety degrees is the ideal angle, elevation of the head of bed to thirty degrees is also an option. Finally, if faced with an agitated, combative patient, delayed sequence intubation (read more about it here) may be an option to optimize preoxygenation.

ECMO in the Adult ED

Image Source: Joint Base San Antonio

This post was peer reviewed.
Click to learn more.

Author: Tim Montrief, MD, MPH
Emergency Medicine Resident, PGY-2
Jackson Memorial Hospital

Extra Corporeal Membrane Oxygenation (ECMO), more accurately known as Extracorporeal Life Support (ECLS) is a type of prolonged mechanical cardiopulmonary support that began in the 1970s. Its technology, indications, and usage have rapidly evolved over the last two decades; it has now become an essential tool in the care of critically ill adults and children refractory to conventional management who have potentially reversible causes of respiratory/cardiac failure. With the development of ECMO programs across the nation, this technology is making its way to an emergency department (ED) near you.

Critical Care Pearl: Metabolic Acidosis: Bicarbonate Drips and Alternative Options

Image Credit: Pixabay

Authors: Victoria Weston, MD; Kevin Bajer, PharmD; and Randy Orr, MD
Northwestern University
Originally Published: Modern Resident, June/July 2013

The focus of this critical care pearl is to discuss the use of bicarbonate drips for severe metabolic acidosis, as well as alternative options, which are available. Given the current nature of medication shortages, it is valuable to learn about the alternative options available for use in some of our most critically ill patients.

When approaching a patient with metabolic acidosis, it is important to consider the cause of their acidosis (e.g., increased generation of acids as in lactic acidosis, ketoacidosis and ingestions vs. loss of bicarbonate or decreased acid excretion). As this is a relatively broad topic, this critical care pearl will focus on the treatment of lactic acidosis, as treatment of ingestions may vary with the substance ingested.

End of Life Care in the Emergency Department

Image Credit: Flickr

Author: Andrew W Phillips, MD MEd

Clinical Fellow, Division of Critical Care

Stanford University

 

We’ve all been there too many times: A terminally ill patient is rushed to the emergency department (ED) by ambulance in distress, either missing the Physician Orders for Life Sustaining Treatment (POLST) or the family instructs EMS to “do everything.” The ED staff begins to stabilize the patient: inotropes and pressors, central line, intubation, arterial line, pressure bagging, fluids — and then they are told to stop.

Now what? How do you allow the acutely ill patient to pass comfortably with dignity after you just did so many invasive, painful procedures? If there is no other place for the patient but the ED, here are some recommendations, based on literature and my personal experience, to make the patient’s final moments as comfortable as possible.

Preparation [1]

• Put the patient in a private room. The resuscitation bay is not the place to transition a patient to comfort care.

• Get social work, the chaplain, and/or palliative care involved to help with the “small” things that are meaningful (water, chairs for the family, calling family members, etc.) so you can focus on the patient.

• Determine what the most life-threatening physiology is for that patient – it is usually hypotension versus hypoxemia.