Procedures

Intubate first.

Two tested suctions, rigid tips, both at the head of the bed. Bed up 45°.

Leak-test both balloons underwater before insertion; lubricate the tube generously.

Scissors taped within reach for the entire dwell time.

Sudden airway obstruction or respiratory distress at any point = cut all lumens and remove the tube immediately.

Insert to 50 cm at the lips. Confirm past the GE junction before full inflation.

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.

Gastric balloon: 50 mL, then 50–100 mL steps to 250–300 mL. Stop inflating if the patient has pain.

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.

Clamp the gastric port; withdraw gently until resistance — the balloon is seated against the GE junction.

Traction ≈1 kg — a 1 L fluid bag over a pulley. Mark the tube at the lips.

Continuous suction on the gastric port; the separate NG/OG tube sits above the gastric balloon for proximal aspiration.

Esophageal balloon only if still bleeding: 30 mmHg, 5 mmHg steps, max 45. Deflate q6–8 h.

Balloon tamponade: a bridge when endoscopy is unavailable or failed. Max dwell 24 h.

Call GI — variceal within 12 h, non-variceal within 24 h.

If no endoscopy on site, start the transfer call.

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.

EQUIPMENT — GATHER / CHECK

The right catheter: triple-lumen 7 Fr, 15–20 cm for drugs/monitoring; 8.5 Fr introducer sheath (Cordis/MAC) for volume resuscitation — or the combination AVA 3Xi device, see the Resuscitation Line; 12 Fr dialysis catheter where needed. The set includes 18 g introducer needle + syringe, J-tip guidewire, dilator.

Ultrasound + high-frequency linear probe, sterile probe cover and gel.

Full barrier: gown, gloves, cap, mask, large drape. Dressing tray, 600 mL bowl, 150 mL gallipot.

Skin prep: chlorhexidine 2% in 70% alcohol, or povidone-iodine.

Sharps and syringes: disposable 10/11 scalpel; 2× 10 mL + 1× 5 mL Luer-lock syringes; 18 g blunt, 21 g, and 25 g needles; lidocaine 1%.

To finish: lay it all out and count before draping.

IN THE KIT — 8 ITEMS · ROOM 7 (RESUS BAY) CABINET · VASCULAR ACCESS

Triple-lumen catheter 7 Fr, 15–20 cm ×1

Sterile probe cover + gel ×1

Scalpel No. 11 blade ×1

Luer-lock syringes — 2 x 10 mL, 1 x 5 mL ×3

Needles — 18 g blunt, 21 g, 25 g ×3

Suture 3-0 non-absorbable + needle driver ×1

Biopatch + Tegaderm 10x12 and 6x7 ×1

Non-return valve caps ×1

ALSO NEEDED — NOT IN THE KIT

Full barrier kit and chlorhexidine 2% in 70% alcohol from the shelf. Ultrasound from the bay.

DRAFT — not yet assembled or signed off. If the line is for volume rather than drugs and ports, use the Resuscitation Line.

SITE, POSITION & PREP

Right IJ or femoral as first choice. After a failed IJ attempt, make the next attempt on the same side.

Supine, head neutral, Trendelenburg for IJ or subclavian. Pre-scan the vein.

Full sterile prep and drape; sheath the probe; flush all lumens; anesthetize skin and track.

SELDINGER — STEP BY STEP

Puncture under real-time ultrasound at ~45°, tracking the tip, until dark flash.

Drop the angle, stabilize, occlude the hub, thread the J-wire to ~15 cm. Never force it.

Never let go of the wire. Remove the needle over it.

Confirm the wire in the vein in transverse and longitudinal planes before dilating.

Nick the skin ~0.5 cm beside the wire, then dilate only the first third to half.

Depth: right IJ ~13 cm · left IJ ~15 · right SC 13–15 · left SC 15–17 · femoral 20.

Withdraw the wire out of the distal (brown) port — check the whole wire is out and on the tray.

Aspirate then flush every lumen; non-return cap on each.

Secure: two sutures + Biopatch + Tegaderm.

Confirm: CXR for IJ or subclavian — tip at the cavoatrial junction, no pneumothorax.

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.

Sources

Go in over the top of the rib, inside the triangle — never below the nipple line without imaging.

EQUIPMENT — GATHER / CHECK

Chest tube: 28–32 Fr for trauma/hemothorax; 24–28 Fr — or a 14 Fr pigtail — for simple pneumothorax.

Underwater-seal drain (UWSD) — the RN primes it in parallel with MD prep.

Scalpel (No. 10 or 11 blade) + two Kelly clamps / curved artery forceps.

Sterile field: ChloraPrep, drapes, gown/gloves/mask.

Lidocaine 1%, 20 mL, syringe + needle — if the patient is awake.

To secure: heavy suture (0 or 2-0) + needle driver, gauze, occlusive dressing, tape.

IN THE KIT — 13 ITEMS · ROOM 7 (RESUS BAY) CABINET · CHEST DRAINAGE

ChloraPrep 10.5 mL swab ×1

Povidone-iodine swab — the alternative prep; both are in the bag ×1

Silk 0 sutures ×2

Scalpel No. 10 ×1

Blunt needle — to draw; lidocaine comes from the Omnicell, not the bag ×1

10 mL syringe ×1

25 gauge 1½ needle — to inject ×1

Long curved blunt scissors ×1

Large needle driver ×1

Large Kelly clamp — to dissect ×1

Medium Kelly clamp — on the tube ×1

Fenestrated drape ×1

Half drape ×1

NURSING DRESSING KIT — 8 ITEMS · ROOM 7 (RESUS BAY) CABINET · CHEST DRAINAGE

A second bag in the same section. The provider takes the insertion kit; the nurse takes this one.

Large Op-Site 6x8 ×2

4x4 drain sponge ×2

2x2 gauze ×2

Xeroform (or petroleum) dressing 5x9 ×2

Safety pin ×2

3 inch tape ×1 roll

Chest tube clamp ×2

Chest tube troubleshooting resource ×1

ALSO NEEDED — NOT IN THE KIT

Chest tube 28–32 Fr and 24–28 Fr, 14 Fr pigtail, and the primed underwater-seal drain — all stocked loose on the Chest Drainage shelf, not inside the bag. Gown, gloves, mask and eye protection — Trauma Cart · Drawer 5 · PPE. The nursing Chest Tube Dressing Kit is a separate bag: Op-Site, drain sponges, gauze, Xeroform, safety pins, tape, chest tube clamps and the troubleshooting sheet. Not in this bag: Foley catheter 16 Fr, toothed tissue forceps, curved Mayo scissors and the large Tegaderm. Lidocaine 1% from the Omnicell.

INDICATIONS

Drain air or fluid from the pleural cavity — pneumothorax, hemothorax, effusion/empyema.

Pleural lavage — active internal rewarming in severe hypothermia.

FINGER THORACOSTOMY — IN ARREST THIS IS THE WHOLE PROCEDURE

A scalpel, a clamp and your finger.

PREP — MD AND RN IN PARALLEL

Open your kit onto the sterile field.

Gown and gloves.

Select the tube size — 28–32 Fr for blood, 24–28 Fr for air, 14 Fr pigtail. Sizes live loose on the shelf.

Prep the skin — ChloraPrep.

Drape. Fenestrated + regular ½ drape — both are in the kit.

Draw up lidocaine 1%, 20 mL, with the blunt draw needle and the 25 g injection needle.

Antibiotic prophylaxis.

Prime the Pleur-evac (underwater-seal drain) and bring it to the bedside.

Monitor and analgesia — continuous pulse oximetry and cardiac monitor; analgesia or sedation per order.

Have ready: large Tegaderm from the kit, and the separate dressing kit.

TECHNIQUE — STEP BY STEP

Position: supine or head up 30–45°, arm on the affected side abducted or behind the head.

Landmark 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.

Incise 4–5 cm through skin, parallel to and directly over the rib below the target space.

Blunt-dissect with the Kelly over the top of that rib — the neurovascular bundle runs under each rib's inferior edge.

Punch 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.

Finger sweep: insert a full gloved finger, sweep 360° to confirm you are intrapleural and clear adherent lung. In arrest this is the whole procedure ›

Tube: 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.

Connect to the primed UWSD; confirm fogging, respiratory swing, drainage or bubbling.

Secure: 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.

Document time of incision, tube size, depth at skin, and initial drainage volume. Obtain the confirmatory CXR.

Watch the output and call the numbers out loud — >1500 mL out, or >200 mL/hr — consider thoracotomy.

Massive hemothorax on insertion → activate the Massive Transfusion Protocol and prepare for possible transfer/operative management.

SITE 4–5TH ICS · ANT–MID AXILLARY · INCISION 4–5 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 → CONSIDER THORACOTOMY

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.

Sources

Acute compartment syndrome is a clinical diagnosis. A number supports it and documents it; it does not overrule an exam that indicates fasciotomy.

Reason to measure: the exam is unreliable — obtunded, intubated, regional block, distracting injury, or a child.

Reason to measure: the exam is equivocal and you are deciding about transfer.

A single normal pressure does not exclude an evolving compartment syndrome. Re-examine, and measure again if the limb changes.

Say out loud which limb and which compartments you are about to measure.

Get the kit — Room 6 · cabinet.

Open the monitor, seat the diaphragm chamber, and attach the side-port needle.

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.

Zero the monitor holding the needle at the same angle you will insert it, at the level of the compartment.

Prep the skin. Insert within 5 cm of the fracture — pressure is highest there and falls off with distance.

Inject about 0.3 mL of saline, let the reading settle, then read it. Record the compartment by name with the value.

Leg — measure all four: anterior, lateral, superficial posterior, deep posterior. One normal compartment says nothing about its neighbour.

Forearm: volar (superficial and deep) and dorsal. Thigh: anterior, posterior, adductor.

Use the diastolic blood pressure at the same moment.

Delta pressure = diastolic BP − compartment pressure.

Work out the delta for each compartment you measured and say the numbers out loud.

The pressure meets the threshold, or the exam indicates fasciotomy regardless of the number → consider fasciotomy. Consult orthopedics or surgery.

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.

Record for every compartment: the time, the compartment by name, the pressure, the diastolic, and the delta.

Zeroed at the wrong angle — the single commonest source of a wrong reading.

Measured too far from the fracture — a falsely reassuring number.

Only one compartment measured — the deep posterior compartment of the leg is the one most often missed.

Too much saline injected — raises the number you are about to read.

Elevating the limb lowers perfusion pressure. Keep it at heart level.

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.

EQUIPMENT — GATHER / CHECK

Drill: Codman disposable perforator, clutched and self-stopping.

Bit: clutched perforator. Otherwise non-clutched for the outer table, blunt burr for the inner.

Scalpel (4 cm incision), self-retaining retractor, suction, sterile saline for irrigation.

Lidocaine 1% with epinephrine (~10 mL); razor or clippers to shave widely.

Sharp dural hook or fine artery forceps; bone nibbler in case the hole must be enlarged.

Cefazolin 2 g IV before drilling.

IN THE KIT — 9 ITEMS · TRAUMA CART · SHELF A

Codman disposable perforator — clutched / self-stopping ×1

Hudson brace or driver — whichever your perforator fits ×1

Scalpel No. 10 blade — 4 cm incision ×1

Self-retaining retractor ×1

Sharp dural hook ×1

Bone nibbler — in case the hole must be enlarged ×1

Lidocaine 1% with epinephrine 10 mL + syringe ×1

Clippers — shave widely ×1

Sterile saline 500 mL for irrigation ×1

ALSO NEEDED — NOT IN THE KIT

Cefazolin 2 g IV comes from the Omnicell, not the tray. Suction is set up separately.

DRAFT — not yet assembled or signed off. Confirm the perforator is the clutched, self-stopping type before it is stocked.

DECISION & SITE

Candidate: 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.

DRILL — STEP BY STEP

Prepare: intubated and sedated, head up 30°, shave and prep wide, cefazolin 2 g IV.

Incise 4 cm down to bone; insert the self-retaining retractor; scrape the periosteum off.

Drill perpendicular, firm steady pressure, assistant irrigating with saline.

Let extradural clot extrude on its own — gentle irrigation and suction only; never suction on brain.

Subdural on CT with dura intact: lift the dura on the hook and nick it.

No clot: try frontal, then parietal, same side. Only then the other side.

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.

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.

Sources

Cut through eschar only, until it gapes and distal perfusion (or chest excursion) returns — avoid named nerves at the elbow/wrist/fibular head.

EQUIPMENT — GATHER / CHECK

Scalpel (No. 10/20 blade) and/or electrocautery with cutting + coag — cautery preferred for hemostasis.

Antiseptic prep, sterile drapes, marking pen — draw the lines before you cut.

Artery forceps, gauze, topical hemostatics.

Analgesia/sedation: full-thickness eschar itself is insensate, but the margins are not.

Aftercare: petroleum gauze, topical antimicrobial, burn dressings.

IN THE KIT — 8 ITEMS · ROOM 7 (RESUS BAY) CABINET · PROCEDURE TRAYS

Scalpel No. 10 blade ×1

Scalpel No. 20 blade ×1

Marking pen — draw the lines first ×1

Artery forceps ×2

Topical hemostatic gauze ×1

Gauze packs ×6

Antiseptic prep + sterile drapes ×1

Petroleum gauze + burn dressing — aftercare ×1

ALSO NEEDED — NOT IN THE KIT

Electrocautery with cutting and coag is preferred over the scalpel for hemostasis and lives on the unit, not in the bag. Analgesia and sedation from the Omnicell.

DRAFT — not yet assembled or signed off. Draw the lines before you cut. Have the hemostatics open first.

DECISION

Burns 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.

TECHNIQUE — STEP BY STEP

Mark the incision lines with the limb in anatomical position.

Incise the full thickness of eschar down to fat only — do not cut the fascia. Edges should spring apart.

Extend each incision at least 1 cm into unburned skin at both ends.

Limbs: mid-lateral and mid-medial lines, carried across joints.

Avoid: ulnar nerve at the elbow, peroneal at the fibular neck, posterior tibial behind the malleolus.

Hands: extend to the thenar and hypothenar eminences.

Chest: bilateral anterior axillary lines, joined above and below.

Endpoint: edges gape, Doppler returns, ventilation pressures fall.

After: hemostasis, dress, elevate, neurovascular checks hourly, transfer to the burn center.

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.

Sources

Arm abducted. 4th–5th intercostal space, anterior to the mid-axillary line.

4–5 cm transverse incision through skin and subcutaneous tissue.

Blunt dissect over the top of the rib with a clamp, then push through the pleura.

Sweep a full gloved finger 360° — lung, clot, diaphragm. Feel for a hole.

Do the other side in traumatic arrest.

Re-finger if tension physiology recurs.

Massive blood out on either side → consider thoracotomy.

EQUIPMENT — GATHER / CHECK

JADA System single-use kit, plus the collection canister.

Regulated vacuum source able to hold a gauge-visible 80 ± 10 mmHg.

Two sterile syringes: one to draw air out of the seal, one 60 mL of sterile fluid.

Straight catheter or Foley kit — empty the bladder before insertion.

Speculum, sterile gloves, antiseptic prep — to visualize and confirm cervical dilation before inserting.

Tape — secures the tubing to the inner thigh without tension once running.

IN THE KIT — 6 ITEMS · OB / NEONATAL CART · DRAWER 4 · POSTPARTUM HEMORRHAGE

JADA System single-use kit ×1

Sterile syringes — one to draw air from the cervical seal, one 60 mL of sterile fluid ×2

Straight catheter or Foley kit — empty the bladder before insertion ×1

Speculum ×1

Antiseptic prep + sterile gloves ×1

Tape — secures the tubing to the inner thigh, no tension ×1

ALSO NEEDED — NOT IN THE KIT

Regulated vacuum source — wall regulator or portable pump — able to hold a controlled, gauge-visible 80 mmHg. Not in the bag.

DRAFT — not yet assembled or signed off. Empty the bladder first. The vacuum source has to hold a gauge-visible 80 mmHg — check the regulator on the monthly check.

DECISION

PPH 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.

TECHNIQUE — STEP BY STEP

First rule out lacerations and retained products.

Empty the bladder, then connect the canister and tubing to the vacuum source.

Draw ALL air out of the Cervical Seal first. Never inflate it with any gas.

Confirm ≥3 cm dilation, compress the loop near its tip, insert loop-first. No force.

Loop in the frontal plane, Seal Valve at 6 or 12 o'clock, seal at the external os.

Fill the Cervical Seal with 60 mL sterile fluid; add up to an additional 60 mL as needed for full os coverage.

Set the vacuum to 80 ± 10 mmHg while occluding the end of the tubing, then connect the tubing to the device.

Watch for blood in the tubing and improving tone. Vacuum must never exceed 90 mmHg.

Tape the tubing to the inner thigh without tension once flow/tone response is confirmed.

MONITORING & REMOVAL

Leave in place until bleeding is controlled for at least 1 hour and the uterus is firm with a stable patient.

Disconnect the vacuum, monitor ≥30 min with it still in place. Minimum indwell ~1.5 h.

Maximum indwell 24 hours.

Removal: DISCONNECT THE VACUUM FIRST. Then empty the seal, steady the fundus, withdraw.

Consider prophylactic antibiotics for prolonged use, per local practice.

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.

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.

Sources

EQUIPMENT — GATHER / CHECK

Gloves, hemostatic gauze (or plain Kerlix), and enough people to hold pressure.

IN THE KIT — 5 ITEMS · TRAUMA CART · DRAWER 4 · HEMORRHAGE CONTROL 2

Hemostatic gauze — Combat Gauze / Celox, if stocked ×2

Plain roller gauze / Kerlix — if hemostatic gauze is not stocked ×4

Pressure dressing ×1

Permanent marker — time of application ×1

Trauma shears ×1

ALSO NEEDED — NOT IN THE KIT

A dedicated junctional tourniquet (SAM Junctional, CRoC, JETT) if your department stocks one — most rural EDs do not.

DRAFT — not yet assembled or signed off. Pack with two hands and your full body weight. Stock enough gauze for packing.

DECISION

Junctional = groin, axilla, neck base, perineum — no bone to compress against.

“Compressible with effort” — packing works here.

TECHNIQUE — STEP BY STEP

Direct manual pressure first, anchored against an adjacent bony structure where possible.

Pack INTO the cavity, layer by layer, until nothing more will go in.

Hold uninterrupted pressure for at least 3 minutes. Do not release to check.

Soaked through after the full hold → remove, repack fresh, hold again.

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.

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.

Sources

The cantholysis — cutting the inferior crus of the canthal tendon — is the step that decompresses the orbit; the canthotomy alone is just the exposure.

EQUIPMENT — GATHER / CHECK

IN THE KIT — 6 ITEMS, ZIP-LOCK

3 mL syringe — for the lidocaine.

Needle to draw (blunt or 18 g).

Needle to inject (25–27 g).

Mosquito clamp — the 1-minute crush.

Toothed forceps.

Blunt-tipped iris scissors.

ALSO NEEDED — NOT IN THE KIT

Lidocaine with epinephrine — not in the kit; from the medication drawer.

Sterile saline for irrigation — never chlorhexidine or alcohol near the eye.

Topical anesthetic drops.

Tonometer (iCare/Tono-Pen) if available — trigger and endpoint checks.

Aftercare: antibiotic ointment (e.g. chloramphenicol); a clean polystyrene cup trimmed as a transport cover.

DECISION

Tense proptotic eye + RAPD, acuity <6/18, IOP ≥40, or ophthalmoplegia → cut now.

Only contraindication: suspected globe rupture.

TECHNIQUE — STEP BY STEP

Prepare: analgesia/sedation as needed; topical anesthetic drops; irrigate the area with saline.

Infiltrate lidocaine with epinephrine at the lateral canthus, needle away from the globe.

Crush: clamp the lateral canthus horizontally out to the rim for ~1 minute to devascularize the incision line.

Canthotomy: 1–2 cm horizontal cut from the lateral canthal angle to the rim.

Cantholysis: pull the lower lid up and out, strum the inferior crus, cut toward the earlobe.

Endpoint: the lid swings free and everts easily, fat is visible, the globe softens.

If the orbit is still tight, re-explore and finish the inferior release in stages.

After: no eye pad. Ointment, serial pupil and IOP checks, CT, ophthalmology.

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.

Sources

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.

EQUIPMENT — GATHER / CHECK

Commercial pelvic binder (e.g. SAM Pelvic Sling II or T-POD) — primary device.

Backup: a folded bedsheet plus 2 towel clips.

Trauma shears to expose the pelvis and hips · tape or bandage to bind ankles/knees together.

DECISION

Unstable 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.

TECHNIQUE — STEP BY STEP

Expose the pelvis/hips; bring the legs together.

Slide it under at the GREATER TROCHANTERS — not the iliac crests.

One clinician reduces the pelvis while a second tightens the device.

Tighten until it clicks or the belt edges meet. Two fingers must still fit.

Bind ankles/knees together to maintain internal rotation. Document time of application.

No device: folded bedsheet ~18 in wide at the trochanters, pulled tight, clipped.

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.

Sources

EQUIPMENT — GATHER / CHECK

Surgical airway kit open and ready at the bedside before any intubation attempt.

16 Fr Foley + syringe. CTA-capable imaging, or a transfer arrangement.

IN THE KIT — 5 ITEMS · TRAUMA CART · DRAWER 3 · HEMORRHAGE CONTROL 1

Foley catheter 16 Fr — one to place, one spare ×2

20 mL syringe ×1

Umbilical tape or clamp — to secure the catheter under tension ×1

Gauze packs ×4

Occlusive dressing ×1

ALSO NEEDED — NOT IN THE KIT

Surgical airway kit — open and ready at the bedside, from drawer 2 of the code cart. CTA-capable imaging and the transfer call run in parallel.

DRAFT — not yet assembled or signed off. This is temporary control, not a repair. The surgical airway kit is open at the bedside before any intubation attempt in a penetrating neck injury.

DECISION — ZONES & SIGNS

Zone 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.

IMMEDIATE PRIORITIES

Airway: intubate early. No nasogastric or nasotracheal tubes.

Direct manual pressure. Never circumferential, never bilateral.

Do not probe, cannulate or clamp blindly. Leave an impaled object in place.

Foley tamponade: 16 Fr along the tract, balloon up with ~20 mL saline, gentle traction.

No collar in isolated penetrating neck trauma.

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.

Sources

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.

Tamponade is an echo diagnosis: effusion, right ventricular diastolic collapse, a plethoric IVC that does not vary — in a patient who is shocked.

Beck’s triad is late and often absent.

Say out loud what you are seeing on the screen and that you are draining it.

Start the transfer conversation in parallel — draining is temporary; it does not treat the cause.

A small effusion that has collected fast tamponades; a large chronic one may not.

There is no pericardiocentesis tray in this department. Two ways to do it with what is stocked — pick one before you scrub.

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.

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.

Scan first, then decide. Find the largest pocket that is closest to the skin and free of lung and liver, and note its depth.

Use the window where the fluid is — subxiphoid, parasternal or apical.

Sit the patient up to about 30–45° if they will tolerate it; the effusion moves toward where you are going.

Sedation and positive pressure can arrest a tamponade patient — both drop the preload this heart depends on. Drain first if you can.

Prep the skin, sterile probe cover, local anesthetic if there is time.

Advance under real-time ultrasound, aspirating and watching the needle tip the whole way in.

Fluid returns — stop advancing. Hold the needle absolutely still and stabilize your hand on the patient.

If unsure whether you are in the pericardium or the ventricle, inject agitated saline — bubbles in the pericardium confirm the correct location.

Blood that clots in the syringe is usually ventricular. Pericardial blood is defibrinated and does not clot.

Withdraw fluid and reassess as you go — 20–50 mL is often enough to bring back a pulse and a pressure.

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.

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.

Send the fluid — cell count, cytology, culture, and hematocrit against the patient’s own.

Look for what you may have caused: pneumothorax, myocardial or coronary injury, arrhythmia, liver injury. Chest film and a rhythm strip.

Sudden decompensation afterwards is re-accumulation until proven otherwise. Re-scan before anything else.

Hand over the depth you went to, the window you used, how much came out and what it looked like.

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.

IS A PIGTAIL THE RIGHT TUBE?

Use 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.

SIZE AND SITE

This site stocks one size: 14 Fr.

Triangle of safety. Insert at the 4th–5th space, mid- to anterior-axillary line.

Never below the nipple line.

Always over the UPPER border of the rib below.

Aim the catheter anterior and superior for air, posterior and inferior for fluid.

An anterior 2nd-space midclavicular pigtail is deliberately not described here.

ULTRASOUND

Scan at the bedside immediately before, in the position they will be in.

Confirm the fluid, the depth to pleura, and where the diaphragm and organs are.

Re-scan afterwards for sliding or for clearance of the fluid.

THE SELDINGER SEQUENCE

1. Consent, timeout, monitoring, analgesia. Head up 30–60°, arm behind the head.

2. Ultrasound mark. Chlorhexidine, full sterile drape, gown, mask, eye protection.

3. Lidocaine 1% — up to 3.0 mg/kg, never more than 250 mg (≈20 mL in an adult).

4. Introducer needle over the upper border of the rib, aspirating continuously. Air or fluid confirms entry.

5. Wire in 15–20 cm, or just past the needle. It must always slide freely, and never come back.

6. Number 11 blade, a skin nick of about 1 cm beside the wire.

7. Dilate sequentially with gentle twisting. Re-check free wire movement after EACH dilator.

8. Catheter and stiffener over the wire to 15–20 cm. Last side hole inside the pleura.

9. Confirm: aspirate air or fluid, look for respiratory swing and fogging, re-scan.

10. Suture with 0 or 1-0 silk or nylon, occlusive dressing, loop the tubing, underwater seal with the bottle ≥45 cm below the chest. CXR for every patient.

DRAINAGE, COMPLICATIONS, PITFALLS

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.

Never clamp a bubbling drain.

Re-expansion pulmonary edema: drain a maximum of 1.5 L, then clamp briefly.

Guidewire loss into the pleural space.

Malposition, intercostal artery injury, organ laceration, blockage, dislodgement, infection.

THE KIT

IN THE KIT — PIGTAIL THORACOSTOMY

Sterile gown, mask, eye protection, gloves, drapes · chlorhexidine · skin marker

Ultrasound with a sterile probe cover and gel

25 G and 21 G needles · 10 mL and 20 mL syringes · Lidocaine 1%

Number 11 scalpel · Introducer needle · Marked guidewire · Sequential dilators

Pigtail catheter with stiffener — 14 Fr · Kelly clamps

0 or 1-0 silk or nylon suture with needle driver · gauze · occlusive dressing · tape

Connecting tubing · Underwater-seal drain with sterile water, or a Heimlich valve

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

Sources

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.

EQUIPMENT — GATHER / CHECK

Pick the device: plain Cordis 8–9 Fr, or AVA 3Xi 8.5 Fr. Check the kit before opening it.

Kit contents: 18 g introducer needle + syringe, J-tip guidewire, dilator (larger than a standard CVC dilator — expect more resistance), sheath/catheter unit, integral sterile catheter sleeve.

Ultrasound + high-frequency linear probe, sterile probe cover and gel.

Full barrier and prep, same as Central Venous Catheter. Dressing tray, 600 mL bowl, 150 mL gallipot.

Pressure bag or rapid infuser if this line is for massive transfusion.

IN THE KIT — 8 ITEMS · ROOM 7 (RESUS BAY) CABINET · VASCULAR ACCESS

Introducer sheath 8–9 Fr — Cordis-type, or AVA 3Xi if a second lumen is needed ×1

18 g introducer needle + syringe ×1

J-tip guidewire ×1

Dilator — larger than a standard CVC dilator ×1

Sterile probe cover + gel ×1

Suture 3-0 non-absorbable + needle driver ×1

Non-return valve caps ×1

Biopatch + Tegaderm ×1

ALSO NEEDED — NOT IN THE KIT

Full barrier kit (gown, gloves, cap, mask, large drape) from the shelf. Use a pressure bag or rapid infuser if this line exists for massive transfusion.

DRAFT — not yet assembled or signed off. The dilator is larger than a standard CVC dilator.

DECISION — WHEN TO PLACE THIS INSTEAD OF A PLAIN TRIPLE-LUMEN

Massive 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.

TECHNIQUE — STEP BY STEP

Site, position and Seldinger steps are identical to a standard CVC.

Nick the skin generously, then dilate deliberately.

Advance the unit over the wire to depth, withdraw the wire, confirm it is fully out.

AVA 3Xi: the triple-lumen threads through the sheath valve in the same pass.

Plain Cordis: cap the large-bore lumen if you are not using it right away.

Secure: two sutures + Biopatch + Tegaderm, same as Central Venous Catheter. Confirm: CXR — tip position, no pneumothorax.

PERIPHERAL 20G ~60 · 18G ~105 · 16G ~220 ML/MIN

TRIPLE-LUMEN CVC — 18G PORTS ~26 ML/MIN EACH · 16G/BROWN PORT ~52 ML/MIN

8.5 FR CORDIS / AVA 3Xi BIG-BORE LUMEN — ~126 ML/MIN GRAVITY, ~333 ML/MIN PRESSURE-BAGGED @ 300 MMHG

TEACHING POINT: A PERIPHERAL 16G OUTFLOWS A TRIPLE-LUMEN CVC'S BEST PORT

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.

Sources

Follow the infra-mammary crease bilaterally and cut the sternum transversely — pericardium opened vertically, in front of the phrenic nerve.

EQUIPMENT — GATHER / CHECK

PPE first: gown, double gloves, eye protection.

Scalpel with a large blade (No. 10/20); chlorhexidine or iodine for a splash prep.

Heavy Mayo scissors / tough-cut shears for intercostal muscle and pleura.

Finochietto rib spreader + Gigli saw (or heavy scissors) for the sternum — the clamshell kit.

Artery forceps (to tent the pericardium) + long forceps.

For the cardiac wound: 3-0 nylon or prolene on a large needle, skin stapler, Foley.

Vascular (aortic) cross-clamp if available; internal defibrillation paddles.

Rib spreader — Finochietto. Crank handle down, toward the axilla.

Lebsche knife, Gigli saw, or heavy trauma shears for the sternum.

Teflon pledgets, and a side-biting clamp for an atrial wound.

Vascular clamp for the hilum, and a second one for the aorta.

Running in parallel: ETT in place, large-bore access (14 g / RIC / MAC sheath), blood products at the bedside.

IN THE KIT — 9 ITEMS · TRAUMA CART · SHELF A

Finochietto rib spreader ×1

Gigli saw with handles — or heavy shears for the sternum ×1

Mayo scissors, heavy ×1

Scalpel No. 20 blade ×1

Long artery forceps — to tent the pericardium ×2

Vascular (aortic) cross-clamp — if stocked ×1

3-0 monofilament on a large needle — nylon or prolene, for the cardiac wound ×3

Skin stapler — the fast option for a ventricular wound ×1

Foley 16 Fr + 20 mL syringe — balloon tamponade of a cardiac wound ×1

Lebsche knife or heavy trauma shears — the sternum, if no Gigli saw ×1

Teflon pledgets ×1 pack

Side-biting (Satinsky) clamp — for an atrial wound ×1

Vascular clamp for the hilum — a second clamp ×1

ALSO NEEDED — NOT IN THE KIT

PPE (gown, double gloves, eye protection) and splash prep are on the cart. Internal paddles live with the defibrillator.

DRAFT — not yet assembled or signed off. The decision is the procedure. Do not open this to browse it — resealing needs a full re-check.

PATIENT SELECTION — THE DECISION IS THE PROCEDURE

Reserved 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.

SEQUENCE — STEP BY STEP

In parallel: secure the airway (RSI), bilateral finger thoracostomies, activate MTP.

Splash prep with chlorhexidine or iodine — no delay for full asepsis.

Extend the left thoracostomy along the 5th ICS, sternum to mid-axillary line.

Clamshell only when needed — extend with heavy shears.

Insert the Finochietto, open widely, sweep the left lung out of the way.

Pericardium: tent with forceps, cut vertically in front of the phrenic. Deliver the heart.

Cardiac wound: finger first, then staples, 3-0 suture, or a Foley balloon.

Internal massage two-handed at ~100/min; internal defibrillation for VF starting ~10–20 J.

Aorta: hand down the posterior chest wall, compress against the spine or cross-clamp.

ROSC: control the mammary bleeding, sedate, ventilate, move toward the OR.

CLAMSHELL EXTENSION — WHEN THE RIGHT CHEST IS BLEEDING

Massive blood from the right thoracostomy is the reason to extend to a clamshell.

1. Mirror the incision on the right — same 5th ICS, sternum to the table.

2. Divide the sternum transversely — Gigli saw, Lebsche knife or heavy shears.

3. Lift the anterior chest wall up, hinging it open. Both pleural cavities are now open.

4. Find and clamp BOTH internal mammary arteries.

5. Pack, then find the source: hilum, great vessels, lung.

CLOSE THE HEART — USE THE FASTEST METHOD THAT HOLDS

Finger first. Direct pressure on the hole while somebody sets up the repair.

Foley 16 Fr through the wound, balloon up with 5–10 mL, gentle traction, clamp the port.

Skin stapler — staples across the defect, perpendicular. Fastest in a bleeding field.

Pledgeted suture 2-0 or 3-0 non-absorbable, horizontal mattress over pledgets.

Near a coronary: pass the suture underneath the vessel.

Atrium: a side-biting clamp or a purse string is usually quicker than pledgets.

HILAR TWIST — MASSIVE UNILATERAL LUNG BLEEDING

For massive bleeding from one lung, or air embolism from a deep lung injury.

1. Divide the inferior pulmonary ligament first.

2. Rotate the lung 180° around the hilum — clockwise on the right, anticlockwise on the left.

3. Bleeding stops, and so does ventilation to that lung. Note the time.

4. Alternative: clamp the whole hilum, or simply compress it in your hand.

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.

Sources

WHEN — AND THE ONE IDEA THAT MAKES IT WORK

Decontaminate, THEN intubate.

Massive emesis, upper GI bleed (Massive Hematemesis), hemoptysis, drowning, cardiac arrest.

Lead with suction.

THE THREE TRAJECTORIES — WHICH WAY IS IT COMING FROM?

The direction of flow decides the technique.

1 — UP from the GI tract. Park the catheter in the hypopharynx as a continuous drain.

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.

3 — DOWN from above. Suction to navigate. Do NOT park deep.

SETUP — BEFORE YOU GIVE THE DRUGS

IN THE KIT — SALAD SUCTION KIT

Two suction units, both tested, both with a canister that has capacity.

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).

Meconium aspirator and a spare 8.0 ETT.

Bougie · airway-exchange catheter · NG/OG tube · ETCO₂ · cricothyrotomy kit open.

The Yankauer is the backup, not the primary catheter.

POSITION AND PRIME

Head up at least 20°, or steep reverse Trendelenburg.

Park one suction under the right shoulder or at the corner of the bed.

Decompress the stomach before induction. Bag-mask pressures under 20 cmH₂O.

THE SEQUENCE

1. Suction in the right hand, overhand grip. Laryngoscope in the left. Lead with the suction.

2. Sweep from the right corner of the mouth to the midline, decontaminating along the tongue as you go.

3. Blade in along the tongue.

4. Suction the hypopharynx, then advance into the proximal esophagus as a drain.

5. The SALAD park: catheter to the LEFT corner, pinned by the blade, tip at the esophageal inlet.

6. Deliver the tube with the second suction ready in someone else’s hand.

7. Cuff up, suction down the ETT, THEN ventilate and confirm ETCO₂.

8. Place an OG tube. ET tube blocked? Meconium aspirator on it and suck it through.

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.

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

Sources

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.

EQUIPMENT — GATHER / CHECK

Windlass tourniquet (e.g. CAT Gen7) — trauma/code cart.

Permanent marker for time documentation · a second tourniquet within reach in case bleeding continues.

DECISION

Limb 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.

TECHNIQUE — STEP BY STEP

Cannot assess the wound: high and tight, as proximal as possible.

Once time/safety allow: convert to direct skin application, 2–3 inches above the wound, not over a joint.

Wrap the band around the limb, thread it through the buckle, remove all slack.

Twist until bleeding stops AND the distal pulse is gone.

Lock the rod with the clip, secure the strap over it, mark the time on the strap.

Still bleeding: a second tourniquet side by side, proximal if the anatomy allows.

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.

Sources

EQUIPMENT — GATHER / CHECK

Introducer sheath kit (Cordis-type) 6–7 Fr, with its integral sterile sleeve.

Balloon-tipped bipolar pacing catheter, 5 Fr, marked every 10 cm. Syringe capped at 1.5 mL air.

External generator with a fresh battery, plus its connecting cable.

Ultrasound at the bedside. Pads on and push-dose epinephrine drawn up as backup.

Standard central-access sterile bundle (as per the CVC card) + suture.

IN THE KIT — 6 ITEMS · ROOM 7 (RESUS BAY) CABINET · TRANSVENOUS PACING

Introducer sheath 6–7 Fr with sterile sleeve — Cordis-type, its own sheath ×1

Balloon-tipped bipolar pacing catheter 5 Fr — depth-marked every 10 cm ×1

Balloon syringe capped at 1.5 mL ×1

Connecting cable ×1

Suture 2-0 + needle driver ×1

Sterile probe cover + gel — mechanical-capture confirmation ×1

ALSO NEEDED — NOT IN THE KIT

External generator with a fresh battery, stored beside the bag. Standard central-access sterile bundle from the CVC shelf. Transcutaneous pads on and push-dose epinephrine drawn up before you start.

DRAFT — not yet assembled or signed off. Find the generator and check its battery on the monthly check.

DECISION & ACCESS

Symptomatic bradyarrhythmia unresponsive to drugs and pacing pads — Symptomatic Bradycardia first.

Access order: right IJ ≫ left subclavian ≫ left IJ ≫ right subclavian.

FLOAT, CAPTURE & SETTINGS — STEP BY STEP

Test the balloon in saline (1.5 mL, no leak). Sleeve on before insertion. Distal = negative.

Set before floating: rate 80/min, output maximal at 20 mA, asynchronous/non-sensing.

Advance to 15–20 cm (just beyond the sheath tip), then inflate the balloon gently and lock it.

Float watching for both captures — paced QRS and a real pulse. RV is ~30–40 cm from a right IJ.

On capture: stop. Deflate the balloon passively — unlock and let it empty.

Threshold: turn output down until capture is lost, then set at 2× that. Ask for a cough.

Sensitivity: switch to demand (VVI), find the sensing threshold, set at about half.

Secure: lock the sleeve, suture the sheath, loop and tape the wire, hang the generator.

Confirm: CXR — tip at the RV apex, crossing the midline. 12-lead — paced LBBB, superior axis.

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.

Set rate and output before floating; confirm mechanical capture, then turn down to find threshold and set the final output.

Sources