AVOIDING COMMON ERRORS IN THE

EMERGENCY DEPARTMENT
Ch. X, XI, XII
CH X : FINDING THE SITE: SITE SELECTION AND MINIMIZING COMPLICATIONS
FOR CENTRAL LINE PLACEMENT

• AVOID ARTERIAL INJURY

• Arterial puncture and hematoma formation are the most common complications of
central line placement
• Two techniques, ultrasound guidance and pressure measurement, have been shown
to decrease the rates of arterial catheter insertion.
• Ultrasound Guidance : It has been widely demonstrated that 2D dynamic ultrasound
imaging, in which the tip of the needle is visualized in real time entering the intended
vein, significantly decreases rates of arterial puncture In order to minimize arterial
cannulation, ultrasound can be used to confirm guidewire placement in the vein prior
to dilation of the vessel.
• Pressure Measurement : central line placements with mandatory use of pressure
measurement resulted in zero arterial catheter insertions. The first method of pressure
measurement is to attach sterile tubing to the needle or short plastic catheter and hold it
vertically while watching for the rise of blood. There are also commercially available sterile
manometers that can be used to confirm venous pressure.
• SUBCLAVIAN APPROACH
• Site selection is critical in avoiding complications and optimizing success rates. The
subclavian approach is useful for patients with cervical collars or patients with severe
orthopnea who must remain in a sitting position. However, the subclavian vein in not
in a compressible site, which limits the ability to apply compression in response to an
arterial puncture should one occur. Further, the clavicle can decrease the ability to
visualize the vein with ultrasound. The subclavian vein can be cannulated from a
supraclavicular or infraclavicular approach.
• INTERNAL JUGULAR APPROACH
• The internal jugular approach allows superior ultrasound visualization compared to
the other sites, both in locating the target vein and in demarcating adjacent arteries.
Further, should arterial puncture be a complication, this site allows easy compression
and visualization of any expanding hematoma. However, access to the internal
jugular may be difficult in situations of chest compressions, complicated airway
management, or trauma patients with cervical collars or neck injuries.
• FEMORAL APPROACH
• The femoral approach is useful in a patient undergoing chest compressions, since
the insertion site is located away from the moving chest wall. In addition, there is no
risk of iatrogenic pneumothorax and the artery is in a compressible site. However,
the long-term risk of catheter-associated deep venous thrombosis is significantly
higher in femoral lines, and the rate of catheter-associated blood infections may also
be higher in femoral lines, although the data surrounding this issue have provided
mixed results.
CH. XI : MANAGING CARDIAC ARREST
• Cardiac arrest (CA) can be defined as the acute loss of heart function, either
instantaneously or following a range of symptoms, ultimately leading to an arrest of
circulation.
• Clinically, the three classic characterizing features of CA are pulselessness,
unresponsiveness, and abnormal breathing—either agonal or absent.
• There is a multitude of underlying etiologies with ischemic heart disease being the most
common. There are four main conduction rhythms of CA. The first two are ventricular
fibrillation and pulseless ventricular tachycardia (VF/pVT)—these are shockable with a
more favorable outcome. The other two are nonshockable and they include pulseless
electrical activity (PEA) and asystole.
• Even in those patients managed in the prehospital setting by emergency medical service
(EMS) personnel, the rate of survival to hospital discharge with meaningful neurologic
outcome is roughly 8%.
• In some settings, however, survival rates have been shown to approach nearly 50%
suggesting that there is still significant room for improvement in CA care. This disparity
seems to lie not in what new or advanced technologies are being used, but rather, in how
quickly and effectively the basic CA efforts are being performed
• Whether occurring at home, in the public setting, or in the hospital, prompt recognition of
CA is key. Early activation of emergency response systems, initiation of high-quality
cardiopulmonary resuscitation (CPR), and expedient use of automated external
defibrillators (AEDs) are absolutely paramount. Swift deliverance of high-quality CPR can
prevent progression of shockable rhythms to nonshockable rhythms and increase
successful defibrillation rates, chances for survival, and neurologic integrity.
• Unfortunately, less than half of patients with out-of-hospital CA will receive bystander
CPR, and AEDs are used <10% of the time. Even with recent technologic advances, these
basic components, especially early defibrillation and high-quality CPR, remain the
mainstay of CA resuscitation.
• In most cases, delivering a shock comes in a standardized, devicedependent fashion with
the push of a button; the same cannot be said about CPR. There is much more to high-
quality CPR than simply pushing on a patient’s chest. This is critical because even though
high-quality CPR is one of the few interventions that has been shown to improve CA
outcomes, it is still performed ineffectively in many cases.
• The most frequent deficits in high-quality CPR are inadequate rate and depth of chest
compressions. With hands positioned on the lower half of the patient’s sternum,
compressions should be performed at a rate of 100 to 120 per minute at a minimum depth
of 2 inches (5 cm) and no >2.5 inches (6 cm). Compressors should allow for full chest wall
recoil in between compressions and avoid leaning on the chest.
• Appropriate ventilation rates are also important. A single resuscitator should follow a 30:2
compressions-to-rescue breath ratio. When additional personnel are available, one breath
every 6 seconds (10 per minute) should be given.
• Any pause in chest compressions should be limited to no longer than 10 seconds. This
means that at no point in a CA resuscitation, for example, for rescue breaths, pulse
checks, rhythm analysis, charging for defibrillation, etc., should compressions be held for
longer than this. Compressions should be resumed immediately after shock administration
and should constitute at least 60% of the total resuscitation time.
• When high-quality CPR with minimal disruptions is effectively provided, observational studies
have demonstrated more successful defibrillation rates, return of spontaneous circulation
(ROSC), and survival to hospital discharge. There are additional therapies and other adjuncts
that can be considered for CA care as well. Nevertheless, effective high-quality CPR and early
defibrillation continue to remain two of the most beneficial and critical interventions.
• In the emergency department or other appropriately equipped environments, more advanced
treatments may be considered. Airway management adjuncts, physiologic monitoring, and
ultrasonography are just a few of these. Medications in CA also have a role but will be
discussed elsewhere. Use of these therapies should never take precedence over, nor cause
prolonged breaks in, high-quality CPR.
• Decision to place advanced airways, for example, an endotracheal tube (ETT), versus use of
bag-mask ventilation is frequently encountered in CA. As of 2015, no studies had demonstrated
definitive evidence to advise routine placement of advanced airways according to the AHA.
Effective bagmask ventilation, albeit less invasive, still requires considerable skill; therefore,
advanced airway placement may still be considered depending on the expertise of the provider.
If an ETT is placed, continuous waveform capnography, or end-tidal CO2 (ETCO2) monitoring,
is the preferred, most reliable modality for confirmation and ongoing assessment of correct
placement.
• Waveform capnography is also one of several parameters that may be reasonable to utilize
during CA care for ongoing physiologic monitoring. These can provide real-time feedback about
the patient’s condition and aid in assessing both CPR quality and in early detection of ROSC. At
the time of this publication, no studies had definitively demonstrated improved survival or
neurologic outcomes by using these, however. The 2015 Advanced Cardiovascular Life Support
(ACLS) guidelines still do include cutoff values for ETCO2 (<10 mm Hg) and diastolic relaxation
phase on arterial waveform (<20 mm Hg) as values at which to encourage better CPR. They
also note abrupt increase in ETCO2 measurement over 40 mm Hg or spontaneous arterial
pressure waves as indicative of ROSC.
• Lastly, ultrasonography is slowly being incorporated into CA management. When an
experienced ultrasonographer is present, this modality may be considered for both confirmation
of ETT placement as well as evaluating for reversible causes of CA, for example, tamponade,
pneumothorax, and hypovolemia in the presence of a PEA CA. Overall, data are still limited at
this time to show any long-term benefits.
• In general, CA resuscitations should always have one designated leader coordinating all efforts,
paying close attention to ensuring proper administration of high-quality CPR. Also, family
members should be allowed to be present if desired. Finally, a debriefing period after
completion of the resuscitation should be considered to assess overall performance and
recognize areas for future improvement.
CH. XII : MEDICATIONS IN CARDIAC
ARREST: TIME FOR A REQUIEM?
• In 1968, Redding and Pearson showed that resuscitation of dogs in cardiac arrest due to
ventricular fibrillation (VF) was more successful while using epinephrine; since then, the
American Heart Association (AHA) has recommended the use of many drugs in its
advanced cardiovascular life support (ACLS) and emergency cardiovascular care (ECC)
algorithms. These drugs, however, have not withstood the test of time.
• Due to a lack of evidence showing any benefit, many of them have been omitted as the
algorithms have been updated. Procainamide and buffers that were recommended in the
2000 ACLS guidelines were removed from the 2005 guidelines, and in the most recent
ACLS guidelines, the use of atropine and lidocaine is no longer routinely recommended
for pulseless rhythms
• There are however medications, including some of the abovementioned, that are still
recommended in special situations. The current medications recommended by the AHA
for cardiac arrest will be discussed below.
• EPINEPHRINE
• Epinephrine has been persistently recommended in the ACLS guidelines, despite the
weak evidence supporting its use. In 2014, a large systematic review of the literature
was able to identify only one randomized controlled trial (RCT) comparing
epinephrine to placebo that showed higher rates of return of spontaneous circulation
(ROSC) and survival to admission after out-of-hospital cardiac arrest, in favor of
epinephrine. However, the trial showed no difference in long-term neurologic
outcome and survival to discharge
• Currently, the AHA still recommends administering a 1-mg dose of epinephrine
(1:10,000 concentration) via the intravenous (IV) or intraosseous (IO) route, or 2
to 2.5 mg endotracheally, every 3 to 5 minutes during cardiac arrest.
• VASOPRESSIN
• In 2005, a meta-analysis of three RCTs that compared vasopressin with epinephrine as a
first-line vasopressor in cardiac arrest did not show any difference in ROSC, survival to
discharge, or neurologic outcome. In 2010, the AHA recommended that 40 units of
vasopressin, either IV or IO, may replace the first or second dose of epinephrine. This has
very recently changed in the new 2015 updates; due to its equivalence to epinephrine, the
AHA has simplified its algorithms and no longer recommends the use of vasopressin.
• AMIODARONE
• Amiodarone is a class 1, 2, and 4 antiarrhythmic, and its use is currently recommended for
refractory shockable rhythms, namely, ventricular tachycardia (VT) and VF. A systematic
review in 2013 showed no benefit of amiodarone compared to placebo with respect to
survival to hospital discharge, but showed higher rates of ROSC and survival to
admission. The 2010 ACLS guidelines recommend an initial dose of 300 mg amiodarone
IV/IO followed by one dose of 150 mg for refractory ventricular fibrillation or pulseless VT.
• LIDOCAINE
• In the 2010 ACLS guidelines, the AHA removed the use of lidocaine as a standard
antiarrhythmic for shockable rhythms that were refractory to CPR and defibrillation.
However, the guidelines still recommended the consideration of lidocaine if
amiodarone was unavailable. Most recently in the 2015 AHA updates, the initiation or
continuation of lidocaine may be considered immediately after ROSC, if the arrest
was due to either VT or VF
• MAGNESIUM SULFATE
• Magnesium sulfate may be used for special situations in cardiac arrest. For torsades
de pointes (polymorphic VT associated with prolonged QT interval), magnesium
sulfate can be administered as an IV/IO bolus at a dose of 1 to 2g diluted in 10 mL
D5W..
• SODIUM BICARBONATE
• In previous ACLS guidelines, the routine administration of sodium bicarbonate during
cardiac arrest was recommended. However, this recommendation has long been
removed for multiple reasons. By reducing systemic vascular resistance, sodium
bicarbonate can compromise cerebral perfusion pressure. It may also create
extracellular alkalosis, shifting the oxyhemoglobin saturation curve to the left,
thereby inhibiting oxygen release to the tissues. Additionally, by producing excess
carbon dioxide, it can paradoxically contribute to intracellular acidosis.
• In certain special situations, however, sodium bicarbonate does offer benefit.
For example, in patients who have end-stage renal disease with preexisting
metabolic acidosis or suspected hyperkalemia, or in tricyclic antidepressant
(TCA) overdose, sodium bicarbonate may be beneficial by increasing serum pH
and increasing sodium levels. In these cases, sodium bicarbonate (8.4%
solution, 1 mEq/mL) can be administered in boluses of 1 mL/kg.
• In conclusion, while the evidence behind the use of various medications in cardiac arrest
is very weak, many of these drugs are still recommended to be used per the AHA
guidelines. The clinician has to be vigilant in considering the potential benefit versus harm
in administering these drugs during resuscitation.
THANK YOU