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EMERGENCY DEPARTMENT · WALL POSTER

Blakemore Tube — Balloon Tamponade

NOT YET REVIEWED BY A CLINICIAN. Written for this site and cited, but nobody has read it line by line. Check it against your own practice before you use it.
STEPS  ·  ◆ KEY STEP — LOGGED WITH ITS TIME
AIRWAY FIRST — THEN THE TUBE
  1. Intubate first.
  2. Two tested suctions, rigid tips, both at the head of the bed. Bed up 45°.
  3. Leak-test both balloons underwater before insertion; lubricate the tube generously.
  4. Scissors taped within reach for the entire dwell time.
  5. Sudden airway obstruction or respiratory distress at any point = cut all lumens and remove the tube immediately.
INSERT AND SEAT THE GASTRIC BALLOON
  1. Insert to 50 cm at the lips. Confirm past the GE junction before full inflation.
  2. Confirm gastric position: inject air down the gastric port while auscultating the epigastrium; inflate the gastric balloon with an initial 50 mL of air, then a chest film before full inflation.
  3. Gastric balloon: 50 mL, then 50–100 mL steps to 250–300 mL. Stop inflating if the patient has pain. ◆ GASTRIC BALLOON INFLATED — 250–300 mL
  4. Those are Sengstaken-Blakemore volumes — the tube stocked here; a Minnesota tube takes 450–500 mL. Stop if the pressure rises more than 15 mmHg above the pre-insertion reading: suspect esophageal placement and deflate at once.
  5. Clamp the gastric port; withdraw gently until resistance — the balloon is seated against the GE junction.
  6. Traction ≈1 kg — a 1 L fluid bag over a pulley. Mark the tube at the lips. ◆ TRACTION ON — ≈1 kg
  7. Continuous suction on the gastric port; the separate NG/OG tube sits above the gastric balloon for proximal aspiration.
STILL BLEEDING — THE ESOPHAGEAL BALLOON
  1. Esophageal balloon only if still bleeding: 30 mmHg, 5 mmHg steps, max 45. Deflate q6–8 h. ◆ ESOPHAGEAL BALLOON INFLATED — ≤45 mmHg
  2. Balloon tamponade: a bridge when endoscopy is unavailable or failed. Max dwell 24 h.
  3. Call GI — variceal within 12 h, non-variceal within 24 h.
  4. If no endoscopy on site, start the transfer call.
EQUIPMENT
FIGURE
A temporary measure until endoscopy or TIPS; never definitive treatment. Intubate first.
EMERGENCY DEPARTMENT · WALL POSTER

Central Venous Catheter (CVC) — Triple Lumen Catheter

STEPS  ·  ◆ KEY STEP — LOGGED WITH ITS TIME
SITE, POSITION & PREP
  1. Right IJ or femoral as first choice. After a failed IJ attempt, make the next attempt on the same side.
  2. Supine, head neutral, Trendelenburg for IJ or subclavian. Pre-scan the vein.
  3. Full sterile prep and drape; sheath the probe; flush all lumens; anesthetize skin and track.
SELDINGER — STEP BY STEP
  1. Puncture under real-time ultrasound at ~45°, tracking the tip, until dark flash.
  2. Drop the angle, stabilize, occlude the hub, thread the J-wire to ~15 cm. Never force it.
  3. Never let go of the wire. Remove the needle over it.
  4. Confirm the wire in the vein in transverse and longitudinal planes before dilating.
  5. Nick the skin ~0.5 cm beside the wire, then dilate only the first third to half.
  6. Depth: right IJ ~13 cm · left IJ ~15 · right SC 13–15 · left SC 15–17 · femoral 20.
  7. Withdraw the wire out of the distal (brown) port — check the whole wire is out and on the tray. ◆ CATHETER IN — WIRE OUT
  8. Aspirate then flush every lumen; non-return cap on each.
  9. Secure: two sutures + Biopatch + Tegaderm.
  10. Confirm: CXR for IJ or subclavian — tip at the cavoatrial junction, no pneumothorax.
EQUIPMENT
IN THE KIT — 8 ITEMS · ROOM 7 (RESUS BAY) CABINET · VASCULAR ACCESS
ALSO NEEDED — NOT IN THE KIT
FIGURE
Right IJ preferred — anterolateral to the carotid, compressible, straight run to the SVC. Never advance the needle toward the carotid. Same two devices, same drawing, same colors as the Resuscitation Line, with a different emphasis. This card is the triple lumen: three ports for drugs and monitoring, each of them flow-limited. If the line is for volume, use the introducer, not a bigger CVC.
WIRE IN ~15 CM · SKIN NICK 0.5 CM
DEPTH: RIJ 13 · LIJ 15 · R-SC 13–15 · L-SC 15–17 · FEM 20 CM
FLOW: 7 FR TLC ~1.6–3.1 L/H BY LUMEN VS 8.5 FR SHEATH ~7.6 L/H
CAUTION: INR >3.0 OR PLATELETS <20
PITFALLS & PEARLS

Losing the guidewire intravascularly — one hand on the wire at all times, and count it out at the end.

Dilating before two-plane wire confirmation → arterial dilation, the injury that matters.

Threading the wire too deep → ventricular ectopy/arrhythmia — stop near 15 cm.

Relying on a triple-lumen for massive transfusion.

EMERGENCY DEPARTMENT · WALL POSTER

Chest Tube

DECIDEDrain air or fluid from the pleural cavity — pneumothorax, hemothorax, effusion/empyema. · Pleural lavage — active internal rewarming in severe hypothermia.
STEPS  ·  ◆ KEY STEP — LOGGED WITH ITS TIME
PREP — MD AND RN IN PARALLEL
  1. Open your kit onto the sterile field.
  2. Gown and gloves.
  3. Select the tube size — 28–32 Fr for blood, 24–28 Fr for air, 14 Fr pigtail. Sizes live loose on the shelf.
  4. Prep the skin — ChloraPrep.
  5. Drape. Fenestrated + regular ½ drape — both are in the kit.
  6. Draw up lidocaine 1%, 20 mL, with the 21 g and 25 g needles.
  7. Antibiotic prophylaxis.
  8. Prime the Pleur-evac (underwater-seal drain) and bring it to the bedside.
  9. Monitor and analgesia — continuous pulse oximetry and cardiac monitor; analgesia or sedation per order.
  10. Have ready: large Tegaderm from the kit, and the separate dressing kit.
TECHNIQUE — STEP BY STEP
  1. BOTHPosition: supine or head up 30–45°, arm on the affected side abducted or behind the head.
  2. MDLandmark the safe triangle: 4th–5th intercostal space, anterior-to-mid axillary line — anterior border of latissimus dorsi, lateral border of pectoralis major, above the 5th ICS (nipple line). Palpate and confirm before prepping.
  3. MDIncise 2–4 cm through skin, parallel to and directly over the rib below the target space.
  4. MDBlunt-dissect with the Kelly over the top of that rib — the neurovascular bundle runs under each rib's inferior edge.
  5. MDPunch through the parietal pleura with the closed clamp — expect a loss of resistance and a hiss of air or rush of blood — then spread to widen the track.
  6. MDFinger sweep: insert a full gloved finger, sweep 360° to confirm you are intrapleural and clear adherent lung. In arrest this is the whole procedure › ◆ FINGER THORACOSTOMY DONE
  7. MDTube: clamp the distal end; guide the tip through the track on curved forceps or your finger — apically for air, posterobasally for blood. Every fenestration must sit inside the pleura.
  8. BOTHConnect to the primed UWSD; confirm fogging, respiratory swing, drainage or bubbling.
  9. BOTHSecure: heavy suture (anchor stitch, wrap and tie to the tube), occlusive dressing; keep the drain ≥45 cm below the chest. CXR to confirm; document the depth marking at skin.
  10. RNDocument time of incision, tube size, depth at skin, and initial drainage volume. Obtain the confirmatory CXR.
  11. RNWatch the output and call the numbers out loud — >1500 mL immediately, or >200 mL/hr — consider thoracotomy.
  12. BOTHMassive hemothorax on insertion → activate the Massive Transfusion Protocol and prepare for possible transfer/operative management. ◆ MTP ACTIVATED
EQUIPMENT
IN THE KIT — 13 ITEMS · ROOM 7 (RESUS BAY) CABINET · CHEST DRAINAGE
NURSING DRESSING KIT — 8 ITEMS · ROOM 7 (RESUS BAY) CABINET · CHEST DRAINAGE
ALSO NEEDED — NOT IN THE KIT
FIGURE
Go in over the top of the rib, inside the triangle — never below the nipple line without imaging.
SITE 4–5TH ICS · ANT–MID AXILLARY · INCISION 2–4 CM
TUBE 28–32 FR HEMOTHORAX · 24–28 FR (14 FR PIGTAIL) PTX
UWSD PRIMED · KEPT ≥45 CM BELOW THE CHEST
>1500 ML OUT, OR >200 ML/HR × 2–4 H → THORACOTOMY CALL
PITFALLS & PEARLS

Below the 5th ICS without imaging → liver/spleen/diaphragm injury.

Dissecting under the rib → intercostal vessel hemorrhage.

Recurrent tension: re-examine and re-finger the track.

Prefer finger thoracostomy once they are on positive pressure or arrested.

EMERGENCY DEPARTMENT · WALL POSTER

Compartment Pressure — Stryker STIC

NOT YET REVIEWED BY A CLINICIAN. Written for this site and cited, but nobody has read it line by line. Check it against your own practice before you use it.
STEPS  ·  ◆ KEY STEP — LOGGED WITH ITS TIME
DECIDE — THE EXAM COMES FIRST
  1. Acute compartment syndrome is a clinical diagnosis. A number supports it and documents it; it does not overrule an exam that indicates fasciotomy.
  2. Reason to measure: the exam is unreliable — obtunded, intubated, regional block, distracting injury, or a child.
  3. Reason to measure: the exam is equivocal and you are deciding about transfer.
  4. A single normal pressure does not exclude an evolving compartment syndrome. Re-examine, and measure again if the limb changes.
  5. Say out loud which limb and which compartments you are about to measure.
SET UP — STRYKER STIC
  1. Get the kit — Room 6 · cabinet.
  2. Open the monitor, seat the diaphragm chamber, and attach the side-port needle.
  3. Attach the pre-filled saline syringe. Hold the assembly at about 45° and purge until fluid reaches the needle tip — no air in the line.
  4. Zero the monitor holding the needle at the same angle you will insert it, at the level of the compartment. ◆ STIC ZEROED
MEASURE — EVERY COMPARTMENT OF THE SEGMENT
  1. Prep the skin. Insert within 5 cm of the fracture — pressure is highest there and falls off with distance.
  2. Inject about 0.3 mL of saline, let the reading settle, then read it. Record the compartment by name with the value. ◆ COMPARTMENT MEASURED
  3. Leg — measure all four: anterior, lateral, superficial posterior, deep posterior. One normal compartment says nothing about its neighbour.
  4. Forearm: volar (superficial and deep) and dorsal. Thigh: anterior, posterior, adductor.
  5. Use the diastolic blood pressure at the same moment.
DECIDE — DELTA PRESSURE
  1. Delta pressure = diastolic BP − compartment pressure.
  2. Work out the delta for each compartment you measured and say the numbers out loud.
  3. The pressure meets the threshold, or the exam indicates fasciotomy regardless of the number → consider fasciotomy. Consult orthopedics or surgery. ◆ FASCIOTOMY DECISION MADE
  4. Below the threshold but the limb is evolving → keep the limb at the level of the heart (not elevated), remove circumferential dressings and casts, treat pain, and re-measure.
DOCUMENT & PITFALLS
  1. Record for every compartment: the time, the compartment by name, the pressure, the diastolic, and the delta.
  2. Zeroed at the wrong angle — the single commonest source of a wrong reading.
  3. Measured too far from the fracture — a falsely reassuring number.
  4. Only one compartment measured — the deep posterior compartment of the leg is the one most often missed.
  5. Too much saline injected — raises the number you are about to read.
  6. Elevating the limb lowers perfusion pressure. Keep it at heart level.
EQUIPMENT
Room 6 · Cabinet
FIGURE
Measure supports the diagnosis; it does not replace the exam.
Compartment pressure >30 mmHg, or delta pressure ≤30 mmHg → fasciotomy.
Pain out of proportion or on passive stretch is the earliest and most reliable sign.
EMERGENCY DEPARTMENT · WALL POSTER

Emergency Burr Hole (Craniotomy)

DECIDECandidate: CT clot + herniating despite max therapy, neurosurgery >2 h away. Consult neurosurgery for decompression planning. · Temporal: 2 finger-breadths forward and 2 up from the ear canal, above the zygoma. Use the side of the CT lesion; with CT, drill where the clot is thickest. · Frontal: ~10 cm above the orbital rim, mid-pupillary line. Stay off the midline. · This gains time for transport; it is not definitive care.
STEPS  ·  ◆ KEY STEP — LOGGED WITH ITS TIME
DRILL — STEP BY STEP
  1. Prepare: intubated and sedated, head up 30°, shave and prep wide, cefazolin 2 g IV.
  2. Incise 4 cm down to bone; insert the self-retaining retractor; scrape the periosteum off.
  3. Drill perpendicular, firm steady pressure, assistant irrigating with saline. ◆ BURR HOLE OPENED
  4. Codman: select the 3/8 inch bit.
  5. Drill three holes in a triangle, about 2 cm on a side.
  6. Rongeur or nippers: nip away the bridges, connecting the three holes into one triangular opening — an adequate drainage area.
  7. Let extradural clot extrude on its own — gentle irrigation and suction only; never suction on brain.
  8. Subdural on CT with dura intact: lift the dura on the hook and nick it.
  9. Transfer: head up 30°, no neck ties, PaCO₂ 35–40, MAP >90, deeply sedated. Re-deteriorates en route → PaCO₂ briefly to ~30, mannitol 0.5–1 g/kg or hypertonic saline.
EQUIPMENT
IN THE KIT — 9 ITEMS · TRAUMA CART · SHELF A
ALSO NEEDED — NOT IN THE KIT
FIGURE
Alfred STAR landmark set: temporal hole two finger-breadths anterior and two superior to the ear (external auditory meatus), above the zygomatic arch — directly over the middle meningeal artery. Frontal hole ~10 cm above the eye in the mid-pupillary line; parietal hole posterosuperior to the ear.
TEMPORAL: 2 FB ANTERIOR + 2 FB SUPERIOR TO THE EAR
FRONTAL: 3 CM OFF MIDLINE · CORONAL SUTURE · MID-PUPIL
INCISION 4 CM · LIDO+ADR ~10 ML · CEFAZOLIN 2 G IV
GATE: GCS <8 + PUPIL ASYMMETRY + >2 H TO NEUROSURGERY
TRANSFER: HEAD UP 30° · PACO₂ 35–40 · MAP >90
PITFALLS & PEARLS

Plunging through the inner table into brain.

Superficial temporal artery bleeding from the scalp incision obscuring the field — control it before drilling.

Hole too small to pass solid clot or see the middle meningeal bleeder — enlarge with the nibbler.

Doing it at all without a neurosurgical discussion or CT localization.

EMERGENCY DEPARTMENT · WALL POSTER

Escharotomy

DECIDEBurns only: limb hypoperfusion or restricted ventilation from inelastic eschar. · Limb: pulses fading, pressure >30 mmHg, deficit progressing. Torso: rising peak pressures. · No test decides this. Consult the burn service before cutting whenever time permits.
STEPS  ·  ◆ KEY STEP — LOGGED WITH ITS TIME
TECHNIQUE — STEP BY STEP
  1. Mark the incision lines with the limb in anatomical position.
  2. Incise the full thickness of eschar down to fat only — do not cut the fascia. Edges should spring apart. ◆ ESCHAROTOMY INCISED
  3. Extend each incision at least 1 cm into unburned skin at both ends.
  4. Limbs: mid-lateral and mid-medial lines, carried across joints.
  5. Avoid: ulnar nerve at the elbow, peroneal at the fibular neck, posterior tibial behind the malleolus.
  6. Hands: extend to the thenar and hypothenar eminences.
  7. Chest: bilateral anterior axillary lines, joined above and below.
  8. Endpoint: edges gape, Doppler returns, ventilation pressures fall.
  9. After: hemostasis, dress, elevate, neurovascular checks hourly, transfer to the burn center.
EQUIPMENT
IN THE KIT — 8 ITEMS · ROOM 7 (RESUS BAY) CABINET · PROCEDURE TRAYS
ALSO NEEDED — NOT IN THE KIT
FIGURE
Cut through eschar only, until it gapes and distal perfusion (or chest excursion) returns — avoid named nerves at the elbow/wrist/fibular head.
COMPARTMENT PRESSURE TRIGGER >30 MMHG
EXTEND ≥1 CM INTO UNBURNED SKIN, BOTH ENDS
DEPTH: THROUGH ESCHAR TO SUBCUT FAT — NOT FASCIA
RECHECK DISTAL PERFUSION AT LEAST HOURLY
PITFALLS & PEARLS

Too shallow (does not release) or too deep (fasciotomy-level structures, nerves).

Missing the second line.

Cutting over the ulnar or common peroneal nerves or the malleolar bundles — mark the lines first.

Underestimating the bleeding once perfusion returns.

EMERGENCY DEPARTMENT · WALL POSTER

Finger Thoracostomy

STEPS  ·  ◆ KEY STEP — LOGGED WITH ITS TIME
FINGER THORACOSTOMY — IN ARREST THIS IS THE WHOLE PROCEDURE
  1. Arm abducted. 5th intercostal space, anterior to the mid-axillary line, at nipple level.
  2. 4–5 cm transverse incision through skin and subcutaneous tissue.
  3. Blunt dissect over the top of the rib with a clamp, then push through the pleura.
  4. Sweep a full gloved finger 360° — lung, clot, diaphragm. Feel for a hole. ◆ FINGER IN — PLEURA SWEPT
  5. Do the other side in traumatic arrest.
  6. Re-finger if tension physiology recurs.
  7. Massive blood out on either side → consider thoracotomy.
FIGURE
Go in over the top of the rib, inside the triangle — never below the nipple line without imaging.
EMERGENCY DEPARTMENT · WALL POSTER

JADA System Insertion

DECIDEPPH persisting after massage and uterotonics. · Cervical dilation ≥3 cm, confirmed by direct visualization, before attempting insertion. · Contraindicated: ongoing pregnancy · untreated rupture · inversion · cervical cancer · cervix <3 cm. · Extra caution, involve OB: uterus under 34 weeks size, coagulopathy, accreta. · An adjunct to the rest of the PPH pathway.
STEPS  ·  ◆ KEY STEP — LOGGED WITH ITS TIME
TECHNIQUE — STEP BY STEP
  1. First rule out lacerations and retained products.
  2. Empty the bladder, then connect the canister and tubing to the vacuum source.
  3. Draw ALL air out of the Cervical Seal first. Never inflate it with any gas.
  4. Confirm ≥3 cm cervical dilation, compress the loop near its tip, insert loop-first. No force. ◆ JADA INSERTED
  5. Loop in the frontal plane, Seal Valve at 6 or 12 o'clock, seal at the external os.
  6. Fill the Cervical Seal with 60 mL sterile fluid; add up to an additional 60 mL as needed for full os coverage.
  7. Set the vacuum to 80 ± 10 mmHg while occluding the end of the tubing, then connect the tubing to the device.
  8. Watch for blood in the tubing and improving tone. Vacuum must never exceed 90 mmHg.
  9. Tape the tubing to the inner thigh without tension once flow/tone response is confirmed.
MONITORING & REMOVAL
  1. Leave in place until bleeding is controlled for at least 1 hour and the uterus is firm with a stable patient.
  2. Disconnect the vacuum, monitor ≥30 min with it still in place. Minimum indwell ~1.5 h. ◆ JADA VACUUM DISCONNECTED
  3. Maximum indwell 24 hours.
  4. Removal: DISCONNECT THE VACUUM FIRST. Then empty the seal, steady the fundus, withdraw.
  5. Consider prophylactic antibiotics for prolonged use, per local practice.
EQUIPMENT
IN THE KIT — 6 ITEMS · OB / NEONATAL CART · DRAWER 4 · POSTPARTUM HEMORRHAGE
ALSO NEEDED — NOT IN THE KIT
FIGURE
Set the vacuum to 80 mmHg (acceptable range 70–90); do not exceed 90. The seal is confirmed by fluid in the tubing, not by air — a column of air means the seal has failed and the device is not tamponading. Stored in PPH / drawer 4.
CERVICAL DILATION ≥3 CM REQUIRED TO INSERT
VACUUM 80 ± 10 MMHG STANDARD — NEVER EXCEED 90 MMHG
CERVICAL SEAL FILL 60 ML, +UP TO 60 ML MORE PRN
CONTROL ≥1 HR, THEN ≥30 MIN MONITORED OFF-VACUUM BEFORE REMOVAL
MAXIMUM INDWELL TIME 24 HOURS
PITFALLS & PEARLS

Filling the Cervical Seal with air instead of sterile fluid.

Removing the device while vacuum is still connected — disconnect first, every time.

Forcing insertion against resistance.

No flow or tone change: check for an air leak or incomplete seal coverage.

Losing track of insertion time — write it down; 24 hours is the maximum.

EMERGENCY DEPARTMENT · WALL POSTER

Junctional Hemorrhage Control

DECIDEJunctional = groin, axilla, neck base, perineum — no bone to compress against. · “Compressible with effort” — packing works here.
STEPS  ·  ◆ KEY STEP — LOGGED WITH ITS TIME
TECHNIQUE — STEP BY STEP
  1. Direct manual pressure first, anchored against an adjacent bony structure where possible.
  2. Pack INTO the cavity, layer by layer, until nothing more will go in.
  3. Hold uninterrupted pressure for at least 3 minutes. Do not release to check. ◆ PRESSURE HOLD STARTED
  4. Soaked through after the full hold → remove, repack fresh, hold again.
  5. iTClamp: head and neck wounds with apposable edges only. Never groin, axilla or perineum. Keep it ≥1 cm from the eye or eyelid; on the neck, watch for airway compromise.
EQUIPMENT
IN THE KIT — 5 ITEMS · TRAUMA CART · DRAWER 4 · HEMORRHAGE CONTROL 2
ALSO NEEDED — NOT IN THE KIT
FIGURE
PACK DIRECTLY INTO THE CAVITY, NOT OVER THE SURFACE
HOLD PRESSURE ≥3 MIN — DO NOT RELEASE TO CHECK.
2 FAILED PACKING ATTEMPTS → ESCALATE
PITFALLS & PEARLS

The “wicking effect” — packing that absorbs without tamponading.

Repeatedly checking/disturbing a packed wound before the hold time is complete.

Still unstable with correct technique → transfer.

EMERGENCY DEPARTMENT · WALL POSTER

Lateral Canthotomy & Cantholysis

DECIDETense proptotic eye + RAPD, acuity <6/18, IOP ≥40, or ophthalmoplegia → cut now. · Only contraindication: suspected globe rupture.
STEPS  ·  ◆ KEY STEP — LOGGED WITH ITS TIME
TECHNIQUE — STEP BY STEP
  1. Prepare: analgesia/sedation as needed; topical anesthetic drops; irrigate the area with saline.
  2. Infiltrate lidocaine with epinephrine at the lateral canthus, needle away from the globe.
  3. Crush: clamp the lateral canthus horizontally out to the rim for ~1 minute to devascularize the incision line.
  4. Canthotomy: 1–2 cm horizontal cut from the lateral canthal angle to the rim. ◆ LATERAL CANTHOTOMY CUT
  5. Cantholysis: pull the lower lid up and out, strum the inferior crus, cut toward the earlobe. ◆ INFERIOR CRUS RELEASED
  6. Endpoint: the lid swings free and everts easily, fat is visible, the globe softens.
  7. If the orbit is still tight, re-explore and finish the inferior release in stages.
  8. After: no eye pad. Ointment, serial pupil and IOP checks, CT, ophthalmology.
EQUIPMENT
IN THE KIT — 6 ITEMS, ZIP-LOCK
ALSO NEEDED — NOT IN THE KIT
FIGURE
The cantholysis — cutting the inferior crus of the canthal tendon — is the step that decompresses the orbit; the canthotomy alone is just the exposure.
TRIGGERS: IOP ≥40 MMHG · VA <6/18 · RAPD
WINDOW: 60–90 MIN CRITICAL ISCHEMIA (SOME CITE 90–120)
CLAMP ~1 MIN · INCISION 1–2 CM · CUT THE INFERIOR CRUS
PITFALLS & PEARLS

Cutting skin only.

Iatrogenic globe injury.

If IOP is still high, the inferior tendon may not be fully cut. Re-explore.

Padding the eye, or delaying for CT or ophthalmology.

EMERGENCY DEPARTMENT · WALL POSTER

Pelvic Binder Application

DECIDEUnstable blunt trauma with a suspected pelvic ring injury. · Assess pelvic stability once. · Apply empirically in the undifferentiated unstable patient. · Apply over an open pelvic fracture too. Give early antibiotics.
STEPS  ·  ◆ KEY STEP — LOGGED WITH ITS TIME
TECHNIQUE — STEP BY STEP
  1. Expose the pelvis/hips; bring the legs together.
  2. Slide it under at the GREATER TROCHANTERS — not the iliac crests.
  3. One clinician reduces the pelvis while a second tightens the device.
  4. Tighten until it clicks or the belt edges meet. Two fingers must still fit. ◆ BINDER APPLIED
  5. Bind ankles/knees together to maintain internal rotation. Document time of application.
  6. No device: folded bedsheet ~18 in wide at the trochanters, pulled tight, clipped.
EQUIPMENT
FIGURE
The commonest binder error is placing it on the iliac crests, where it looks correct but has no effect — the band has to sit over the greater trochanters, level with the hip joints, to reduce pelvic volume. Cut clothing away and apply to skin.
GREATER TROCHANTERS, NOT ILIAC CRESTS
ASSESS PELVIC STABILITY ONCE ONLY
SKIN CHECK BY ~4H · REMOVE BY 24H IF FEASIBLE
MOSTLY VENOUS BLEEDING — BINDER ≠ DEFINITIVE CONTROL
PITFALLS & PEARLS

Placing it over the iliac crests/abdomen — the single most common error, and it does not work there.

Overtightening — increases skin-injury risk without added hemostatic benefit.

Treating the binder as definitive control.

Leaving it on indefinitely — skin necrosis can start within 2–4 hours.

EMERGENCY DEPARTMENT · WALL POSTER

Penetrating Neck Trauma

DECIDEZone I: notch to cricoid · Zone II: cricoid to mandible · Zone III: mandible to skull base. · Triage by hard and soft signs, not by zone. Use the zone to choose the imaging. · Hard signs → OR now, no imaging. · Soft signs → CTA workup, not the OR.
STEPS  ·  ◆ KEY STEP — LOGGED WITH ITS TIME
IMMEDIATE PRIORITIES
  1. Airway: intubate early. No nasogastric or nasotracheal tubes.
  2. Direct manual pressure. Never circumferential, never bilateral.
  3. Do not probe, cannulate or clamp blindly. Leave an impaled object in place.
  4. Foley tamponade: 16 Fr along the tract, balloon up with ~20 mL saline, gentle traction. ◆ FOLEY TAMPONADE IN
  5. No collar in isolated penetrating neck trauma.
EQUIPMENT
IN THE KIT — 5 ITEMS · TRAUMA CART · DRAWER 3 · HEMORRHAGE CONTROL 1
ALSO NEEDED — NOT IN THE KIT
FIGURE
ZONE I: NOTCH→CRICOID · II: CRICOID→MANDIBLE · III: MANDIBLE→SKULL BASE
HARD SIGNS → OR · SOFT SIGNS → CTA
FOLEY TAMPONADE: 16 FR, ~20 ML BALLOON
PITFALLS & PEARLS

Blindly probing or clamping the wound — the most dangerous mistake on this card.

Removing an impaled object — leave it in place.

Circumferential or bilateral neck dressings.

Treating a "no hard signs" wound as trivial — it still needs CTA-based workup.

EMERGENCY DEPARTMENT · WALL POSTER

Pericardiocentesis

NOT YET REVIEWED BY A CLINICIAN. Written for this site and cited, but nobody has read it line by line. Check it against your own practice before you use it.
STEPS  ·  ◆ KEY STEP — LOGGED WITH ITS TIME
DECIDE — IS IT TAMPONADE, AND IS THIS THE RIGHT PROCEDURE
  1. Traumatic tamponade in arrest needs a thoracotomy, not a needle. If this is penetrating trauma or a traumatic arrest, leave this card and run Traumatic Cardiac Arrest.
  2. Tamponade is an echo diagnosis: effusion, right ventricular diastolic collapse, a plethoric IVC that does not vary — in a patient who is shocked.
  3. Beck’s triad is late and often absent.
  4. Say out loud what you are seeing on the screen and that you are draining it. ◆ TAMPONADE CONFIRMED ON ECHO
  5. Start the transfer conversation in parallel — draining is temporary; it does not treat the cause.
  6. A small effusion that has collected fast tamponades; a large chronic one may not.
SET UP — THE ULTRASOUND CHOOSES THE WINDOW
  1. There is no pericardiocentesis tray in this department. Two ways to do it with what is stocked — pick one before you scrub.
  2. Option A — the Central Line Kit (Room 7 · Vascular Access). Its introducer needle and wire let you rail a catheter into the sac, so you can leave a drain. Take this one if the effusion is likely to come back.
  3. Option B — an 18 G spinal needle on a 20 mL syringe with a three-way stopcock. One long needle, aspirate and withdraw, nothing left behind. Faster to set up; no drain at the end of it.
  4. Scan first, then decide. Find the largest pocket that is closest to the skin and free of lung and liver, and note its depth.
  5. Use the window where the fluid is — subxiphoid, parasternal or apical.
  6. Sit the patient up to about 30–45° if they will tolerate it; the effusion moves toward where you are going.
  7. Sedation and positive pressure can arrest a tamponade patient — both drop the preload this heart depends on. Drain first if you can.
  8. Prep the skin, sterile probe cover, local anesthetic if there is time.
DRAIN
  1. Advance under real-time ultrasound, aspirating and watching the needle tip the whole way in.
  2. Fluid returns — stop advancing. Hold the needle absolutely still and stabilize your hand on the patient. ◆ PERICARDIAL FLUID ASPIRATED
  3. If unsure whether you are in the pericardium or the ventricle, inject agitated saline — bubbles in the pericardium confirm the correct location.
  4. Blood that clots in the syringe is usually ventricular. Pericardial blood is defibrinated and does not clot.
  5. Withdraw fluid and reassess as you go — 20–50 mL is often enough to bring back a pulse and a pressure.
  6. If you used the Central Line Kit: pass a catheter over the wire and secure it. If you used the spinal needle: aspirate to effect and withdraw. Re-accumulation is expected — if a catheter is in, do not pull it out. ◆ DRAIN SECURED
AFTER
  1. Re-scan: is the right ventricle filling, is the IVC less plethoric, is the pressure up? Judge the result by the echo, not by the volume in the syringe.
  2. Send the fluid — cell count, cytology, culture, and hematocrit against the patient’s own.
  3. Look for what you may have caused: pneumothorax, myocardial or coronary injury, arrhythmia, liver injury. Chest film and a rhythm strip.
  4. Sudden decompensation afterwards is re-accumulation until proven otherwise. Re-scan before anything else.
  5. Hand over the depth you went to, the window you used, how much came out and what it looked like.
FIGURE
Buys minutes. It is a bridge to drainage, not the fix.
PITFALLS

Landmarks instead of ultrasound when an ultrasound is available.

Sedating or intubating first. Both reduce the preload this patient depends on.

Draining a big chronic effusion that is not tamponading. The indication is tamponade physiology, not effusion size.

Pulling the catheter once the pressure comes up. The effusion re-accumulates.

Treating a traumatic tamponade with a needle, traumatic pericardial tamponade requires a thoracotomy.

EMERGENCY DEPARTMENT · WALL POSTER

Pigtail Chest Tube (Seldinger)

DECIDEUse a pigtail, first-line for pneumothorax — spontaneous, iatrogenic or traumatic. · Use a pigtail for effusion and empyema — small-bore is commonly used for these. · Traumatic hemothorax needs a chest tube, not a pigtail — 28–32 Fr — see Chest Tube. · Large bore, not a pigtail: hemothorax, instability, theatre drainage, big air leak. · Relative contraindications: coagulopathy, overlying infection, adhesions or loculation.
STEPS  ·  ◆ KEY STEP — LOGGED WITH ITS TIME
SIZE AND SITE
  1. This site stocks one size: 14 Fr.
  2. Triangle of safety. Insert at the 4th–5th space, mid- to anterior-axillary line.
  3. Never below the nipple line.
  4. Always over the UPPER border of the rib below.
  5. Aim the catheter anterior and superior for air, posterior and inferior for fluid.
  6. An anterior 2nd-space midclavicular pigtail is deliberately not described here.
ULTRASOUND
  1. Scan at the bedside immediately before, in the position they will be in.
  2. Confirm the fluid, the depth to pleura, and where the diaphragm and organs are.
  3. Re-scan afterwards for sliding or for clearance of the fluid.
THE SELDINGER SEQUENCE
  1. 1. Consent, timeout, monitoring, analgesia. Head up 30–60°, arm behind the head.
  2. 2. Ultrasound mark. Chlorhexidine, full sterile drape, gown, mask, eye protection.
  3. 3. Lidocaine 1% — up to 3.0 mg/kg, never more than 250 mg (≈20 mL in an adult).
  4. 4. Introducer needle over the upper border of the rib, aspirating continuously. Air or fluid confirms entry.
  5. 5. Wire in 15–20 cm, or just past the needle. It must always slide freely, and never come back.
  6. 6. Number 11 blade, a skin nick of about 1 cm beside the wire.
  7. 7. Dilate sequentially with gentle twisting. Re-check free wire movement after EACH dilator.
  8. 8. Catheter and stiffener over the wire to 15–20 cm. Last side hole inside the pleura. ◆ PIGTAIL IN THE PLEURA
  9. 9. Confirm: aspirate air or fluid, look for respiratory swing and fogging, re-scan.
  10. 10. Suture with 0 or 1-0 silk or nylon, occlusive dressing, loop the tubing, underwater seal with the bottle ~100 cm BELOW the chest. CXR for every patient.
DRAINAGE, COMPLICATIONS, PITFALLS
  1. Underwater seal first. Suction only if the pneumothorax persists or the effusion is large — −20 cmH₂O. Swing means patent; bubbling on coughing means an air leak.
  2. Never clamp a bubbling drain.
  3. Re-expansion pulmonary edema: drain a maximum of 1.5 L, then clamp briefly.
  4. Guidewire loss into the pleural space.
  5. Malposition, intercostal artery injury, organ laceration, blockage, dislodgement, infection.
EQUIPMENT
IN THE KIT — PIGTAIL THORACOSTOMY
FIGURE
SITE: 4TH–5TH ICS, TRIANGLE OF SAFETY
ALWAYS OVER THE TOP OF THE RIB
14 FR — THE ONLY SIZE STOCKED HERE
LIDOCAINE 1% ≤20 ML · MAX 3 MG/KG, 250 MG
NICK 1 CM · CATHETER TO 15–20 CM
SUCTION −20 CMH₂O · DRAIN ≤1.5 L THEN CLAMP
CXR AFTER EVERY INSERTION
EMERGENCY DEPARTMENT · WALL POSTER

Resuscitation Line (Cordis / AVA 3Xi)

DECIDEMassive transfusion, anticipated or running (MTP). · Need big-bore volume → use the AVA 3Xi. · If only drug and monitoring access is needed, place a plain triple-lumen instead — Central Venous Catheter.
STEPS  ·  ◆ KEY STEP — LOGGED WITH ITS TIME
TECHNIQUE — STEP BY STEP
  1. Site, position and Seldinger steps are identical to a standard CVC.
  2. Nick the skin generously, then dilate deliberately.
  3. Advance the unit over the wire to depth, withdraw the wire, confirm it is fully out. ◆ INTRODUCER IN — WIRE OUT
  4. AVA 3Xi: the triple-lumen threads through the sheath valve in the same pass.
  5. Plain Cordis: cap the large-bore lumen if you are not using it right away.
  6. Secure: two sutures + Biopatch + Tegaderm, same as Central Venous Catheter. Confirm: CXR — tip position, no pneumothorax.
  7. PERIPHERAL 20G ~60 · 18G ~105 · 16G ~220 ML/MIN
  8. TRIPLE-LUMEN CVC — 18G PORTS ~26 ML/MIN EACH · 16G/BROWN PORT ~52 ML/MIN
  9. 8.5 FR CORDIS / AVA 3Xi BIG-BORE LUMEN — ~126 ML/MIN GRAVITY, ~333 ML/MIN PRESSURE-BAGGED @ 300 MMHG
  10. TEACHING POINT: A PERIPHERAL 16G OUTFLOWS A TRIPLE-LUMEN CVC'S BEST PORT
EQUIPMENT
IN THE KIT — 8 ITEMS · ROOM 7 (RESUS BAY) CABINET · VASCULAR ACCESS
ALSO NEEDED — NOT IN THE KIT
FIGURE
The AVA 3Xi combines a Cordis-style large-bore introducer lumen with an integrated triple-lumen catheter in one device, placed with one stick: drugs and monitoring through the standard ports, volume through the introducer.
PITFALLS & PEARLS

Placing a plain triple-lumen when MTP is already anticipated — slower than a 16 g peripheral.

Running products through gravity alone.

Confusing this with a plain triple-lumen on the shelf — check the label.

Same wire and dilation cautions as Central Venous Catheter, at a larger scale.

EMERGENCY DEPARTMENT · WALL POSTER

Resuscitative Hysterotomy

DECIDEGestation >20 weeks = If FUNDUS above UMBILICUS → PROCEED
STEPS  ·  ◆ KEY STEP — LOGGED WITH ITS TIME
1 · IMMEDIATE (WITH CPR)
  1. “Maternal arrest — resuscitative hysterotomy now.” Fundus at or above the umbilicus, not reversible.
  2. Manual left uterine displacement — continuous until delivery.
  3. Call “ED OB emergency.” Activate telehealth.
  4. Set up for the infant: bottom drawer of the cart, airway and monitor from the top. Activate the neonatal chemical heat pad now.
  5. No ROSC after one defibrillation or one round of trauma resuscitation → cut now.
2 · THE INCISION
  1. Splash prep with chlorhexidine or betadine — never delay the incision for it.
  2. Incise vertical midline, above the umbilicus to the symphysis, deep to fascia.
  3. Fingers separate the rectus muscles to expose the uterus; scissors on fascia only if needed.
  4. Vertical uterine incision; extend with fingers or bandage scissors.
3 · DELIVERY & MATERNAL CARE
  1. Extract the infant, note the time, hand to the neonatal team. ◆ BABY OUT
  2. Three cord clamps: two on the baby side, cut between; one toward the placenta.
  3. Manually remove the placenta, wipe the cavity with gauze.
  4. Close the uterus with running locked 0 chromic; staple the skin.
  5. Continue maternal ACLS. Recheck rhythm.
EQUIPMENT
FIGURE
EMERGENCY DEPARTMENT · WALL POSTER

Resuscitative Thoracotomy

DECIDEReserved for: in extremis, deteriorating, with proven tamponade on ultrasound. · No signs of life and PEA on arrival: do not start. · Ultrasound in the primary survey is what finds tamponade.
STEPS  ·  ◆ KEY STEP — LOGGED WITH ITS TIME
SEQUENCE — STEP BY STEP
  1. Splash prep with chlorhexidine or iodine — no delay for full asepsis.
  2. Extend the left thoracostomy along the 5th ICS, sternum to mid-axillary line.
  3. Clamshell only when needed — extend with heavy shears.
  4. Insert the Finochietto, open widely, sweep the left lung out of the way.
  5. Pericardium: tent with forceps, cut vertically in front of the phrenic. Deliver the heart. ◆ PERICARDIUM OPENED
  6. Cardiac wound: finger first, then staples, 3-0 suture, or a Foley balloon.
  7. Internal massage two-handed at ~100/min; internal defibrillation for VF starting ~10–20 J.
  8. Aorta: hand down the posterior chest wall, compress against the spine or cross-clamp. ◆ AORTA CROSS-CLAMPED
  9. ROSC: control the mammary bleeding, sedate, ventilate, move toward the OR.
CLAMSHELL EXTENSION — WHEN THE RIGHT CHEST IS BLEEDING
  1. Massive blood from the right thoracostomy is the reason to extend to a clamshell.
  2. 1. Mirror the incision on the right — same 5th ICS, sternum to the table.
  3. 2. Divide the sternum transversely — Gigli saw, Lebsche knife or heavy shears.
  4. 3. Lift the anterior chest wall up, hinging it open. Both pleural cavities are now open.
  5. 4. Find and clamp BOTH internal mammary arteries.
  6. 5. Pack, then find the source: hilum, great vessels, lung.
CLOSE THE HEART — USE THE FASTEST METHOD THAT HOLDS
  1. Finger first. Direct pressure on the hole while somebody sets up the repair.
  2. Foley 16 Fr through the wound, balloon up with 5–10 mL, gentle traction, clamp the port.
  3. Skin stapler — staples across the defect, perpendicular. Fastest in a bleeding field.
  4. Pledgeted suture 2-0 or 3-0 non-absorbable, horizontal mattress over pledgets.
  5. Near a coronary: pass the suture underneath the vessel.
  6. Atrium: a side-biting clamp or a purse string is usually quicker than pledgets.
HILAR TWIST — MASSIVE UNILATERAL LUNG BLEEDING
  1. For massive bleeding from one lung, or air embolism from a deep lung injury.
  2. 1. Divide the inferior pulmonary ligament first.
  3. 2. Rotate the lung 180° around the hilum — clockwise on the right, anticlockwise on the left.
  4. 3. Bleeding stops, and so does ventilation to that lung. Note the time.
  5. 4. Alternative: clamp the whole hilum, or simply compress it in your hand.
EQUIPMENT
IN THE KIT — 9 ITEMS · TRAUMA CART · SHELF A
ALSO NEEDED — NOT IN THE KIT
FIGURE
Follow the infra-mammary crease bilaterally and cut the sternum transversely — pericardium opened vertically, in front of the phrenic nerve.
INCISION 5TH ICS BILATERAL · AXILLA TO AXILLA
PERICARDIUM: LONG VERTICAL CUT · ANTERIOR TO PHRENIC
INTERNAL DEFIB 10–20 J · MASSAGE 2-HANDED ~100/MIN
WOUND: FINGER → STAPLES / 3-0 NYLON-PROLENE / FOLEY
ALFRED 2008–13: 9 SURVIVORS OF 27 EDT · 89% BLUNT
PITFALLS & PEARLS

A transverse pericardial cut severs the phrenic nerve — open vertically, in front of it.

Under-opening: a small anterolateral slit is not enough.

Forgetting the internal mammary arteries after ROSC → occult exsanguination.

Total hilar occlusion for prolonged periods → acute RV failure; use partial or intermittent occlusion.

EMERGENCY DEPARTMENT · WALL POSTER

SALAD — Suction-Assisted Laryngoscopy

DECIDEDecontaminate, THEN intubate. · Massive emesis, upper GI bleed (Massive Hematemesis), hemoptysis, drowning, cardiac arrest. · Lead with suction.
STEPS  ·  ◆ KEY STEP — LOGGED WITH ITS TIME
THE THREE TRAJECTORIES — WHICH WAY IS IT COMING FROM?
  1. The direction of flow decides the technique.
  2. 1 — UP from the GI tract. Park the catheter in the hypopharynx as a continuous drain.
  3. 2 — UP from the lungs. Aim the bougie at the froth and feel for tracheal rings or a firm stop when you pass into the bronchus.
  4. 3 — DOWN from above. Suction to navigate. Do NOT park deep.
SETUP — BEFORE YOU GIVE THE DRUGS
  1. IN THE KIT — SALAD SUCTION KIT Two suction units, both tested, both with a canister that has capacity.
  2. DuCanto rigid catheter x2 — DuCanto (about 0.26 inch / 6.6 mm bore, no thumb port, curve matched to hyperangulated blades) and/or HI-D Big Stick (thumb port, milder curve, suits direct laryngoscopy).
  3. Meconium aspirator and a spare 8.0 ETT.
  4. Bougie · airway-exchange catheter · NG/OG tube · ETCO₂ · cricothyrotomy kit open.
  5. The Yankauer is the backup, not the primary catheter.
  6. POSITION AND PRIME Head up at least 20°, or steep reverse Trendelenburg.
  7. Park one suction under the right shoulder or at the corner of the bed.
  8. Decompress the stomach before induction. Bag-mask pressures under 20 cmH₂O.
THE SEQUENCE
  1. 1. Suction in the right hand, overhand grip. Laryngoscope in the left. Lead with the suction.
  2. 2. Sweep from the right corner of the mouth to the midline, decontaminating along the tongue as you go.
  3. 3. Blade in along the tongue.
  4. 4. Suction the hypopharynx, then advance into the proximal esophagus as a drain.
  5. 5. The SALAD park: catheter to the LEFT corner, pinned by the blade, tip at the esophageal inlet.
  6. 6. Deliver the tube with the second suction ready in someone else’s hand. ◆ TUBE DELIVERED — SALAD
  7. 7. Cuff up, suction down the ETT, THEN ventilate and confirm ETCO₂.
  8. 8. Place an OG tube. ET tube blocked? Meconium aspirator on it and suck it through.
FIGURE
2 SUCTIONS · TESTED · LARGE-BORE RIGID
HEAD UP ≥20° · BMV <20 CMH₂O
TRAJECTORY 1 GUT → PARK IN ESOPHAGUS
TRAJECTORY 2 LUNG → BOUGIE TO THE FROTH, CUFF + PEEP
TRAJECTORY 3 ABOVE → NAVIGATE ONLY, DO NOT PARK DEEP
SUCTION THE TUBE BEFORE THE FIRST BREATH
PITFALLS

One suction unit. An untested suction unit. A Yankauer as the primary catheter.

Laryngoscoping before decontaminating — or suctioning endlessly without the blade in.

Trying to pass a bougie through a standard suction catheter.

Working the suction and the laryngoscope alone when there is a second pair of hands in the room.

Parking deep when the blood is coming down from the face.

Never let this delay a cricothyrotomy in a patient you cannot oxygenate.

EMERGENCY DEPARTMENT · WALL POSTER

Tourniquet Application

DECIDELimb bleeding not stopped by pressure, a traumatic amputation, or pressure not feasible. · Pediatric: adult windlass devices are validated down to about age 2, roughly 13 cm limb circumference. Below that, direct pressure with hemostatic gauze — there is no data.
STEPS  ·  ◆ KEY STEP — LOGGED WITH ITS TIME
TECHNIQUE — STEP BY STEP
  1. Cannot assess the wound: high and tight, as proximal as possible.
  2. Once time/safety allow: convert to direct skin application, 2–3 inches above the wound, not over a joint.
  3. Wrap the band around the limb, thread it through the buckle, remove all slack.
  4. Twist until bleeding stops AND the distal pulse is gone.
  5. Lock the rod with the clip, secure the strap over it, mark the time on the strap. ◆ TOURNIQUET APPLIED
  6. Still bleeding: a second tourniquet side by side, proximal if the anatomy allows.
EQUIPMENT
FIGURE
Limbs only. Place 2–3 inches proximal to the wound, directly on skin, clear of any joint. Tighten until the distal pulse is gone. Write the time on it.
2–3 IN ABOVE THE WOUND, ON SKIN, NOT OVER A JOINT
TIGHTEN UNTIL BLEEDING STOPS AND PULSE IS GONE
ATTEMPT CONVERSION <2H IF SAFE TO DO SO
CAUTION / MONITORING NEEDED BEYOND 6H
PITFALLS & PEARLS

“Venous tourniquet” — too loose, so bleeding gets worse.

Left over clothing once time/safety allow direct-skin application — convert as soon as feasible.

Improvised: use the widest material available.

Not documenting the time — this single number drives every downstream conversion and transfer decision.

EMERGENCY DEPARTMENT · WALL POSTER

Transvenous Pacing (TVP)

DECIDESymptomatic bradyarrhythmia unresponsive to drugs and pacing pads — Symptomatic Bradycardia first. · Access order: right IJ ≫ left subclavian ≫ left IJ ≫ right subclavian.
STEPS  ·  ◆ KEY STEP — LOGGED WITH ITS TIME
FLOAT, CAPTURE & SETTINGS — STEP BY STEP
  1. Test the balloon in saline (1.5 mL, no leak). Sleeve on before insertion. Distal = negative.
  2. Set before floating: rate 80/min, output maximal at 20 mA, asynchronous/non-sensing.
  3. Advance to 15–20 cm (just beyond the sheath tip), then inflate the balloon gently and lock it.
  4. Float watching for both captures — paced QRS and a real pulse. RV is ~30–40 cm from a right IJ.
  5. On capture: stop. Deflate the balloon passively — unlock and let it empty. ◆ CAPTURE — PACING
  6. Threshold: turn output down until capture is lost, then set at 2× that. Ask for a cough.
  7. Sensitivity: switch to demand (VVI), find the sensing threshold, set at about half.
  8. Secure: lock the sleeve, suture the sheath, loop and tape the wire, hang the generator.
  9. Confirm: CXR — tip at the RV apex, crossing the midline. 12-lead — paced LBBB, superior axis.
EQUIPMENT
IN THE KIT — 6 ITEMS · ROOM 7 (RESUS BAY) CABINET · TRANSVENOUS PACING
ALSO NEEDED — NOT IN THE KIT
FIGURE
Set rate and output before floating; confirm mechanical capture, then turn down to find threshold and set the final output.
OUTPUT 20 MA → THRESHOLD <1 MA → SET 2×
RATE 80 · ASYNC TO START
BALLOON 1.5 ML AIR · INFLATE ONLY BEYOND 15–20 CM
RIJ → RV ≈ 30–40 CM · NEVER ADVANCE PAST ~50 CM
PITFALLS & PEARLS

Advancing with the balloon down (perforation risk) or withdrawing with it up (valve injury).

Coiling in the RA/IVC — depth keeps rising without capture: deflate, pull back to 20 cm, re-float.

Calling capture from pacing spikes or artefact without a mechanical pulse check.

Output left at bare threshold → capture lost with a cough or movement — that is why it is set at 2× threshold.