---
name: performing-emergency-procedures
language: en
description: Documents procedural indications, consent, technique, and complications for ED procedures. Use when performing emergency procedures, documenting procedural notes, or recording bedside procedures.
tags:
  - process
  - emergency-medicine
metadata:
  author: casemark
  practice_areas:
    - Emergency Medicine
  document_types:
    - Procedure Note
  skill_modes:
    - Execution
---

# Performing Emergency Procedures

Documents procedural indications, informed consent, technical execution, and complication management for critical emergency department procedures including chest tube insertion, central venous access, endotracheal intubation, procedural sedation, and bedside ultrasonography.

## Why This Skill Exists

Emergency procedures are performed under time pressure on undifferentiated patients with limited history, often without the controlled conditions of an operating room or interventional suite. The procedural complication rate in the ED is directly correlated with documentation quality, pre-procedure planning, and structured post-procedure assessment. A chest tube placed without confirming the indication can cause organ injury. A central line inserted without ultrasound guidance doubles the mechanical complication rate. An intubation without a backup airway plan converts a manageable situation into a fatal one.

This skill structures the pre-procedure assessment, procedural technique documentation, and post-procedure verification for the highest-stakes ED procedures, ensuring that every critical step is performed and recorded even under time pressure.

---

## Checkpoint A: Pre-Procedure Intake (Mandatory)

1. What is the specific procedure indicated, and what is the clinical indication?
2. What are the contraindications — absolute and relative — for this patient?
3. Has informed consent been obtained (or is the situation an emergency exception)?
4. What is the patient's coagulation status (INR, platelets, anticoagulant use)?
5. What is the patient's airway assessment (Mallampati, neck mobility, prior difficult airway history)?
6. What equipment has been assembled at the bedside, including backup equipment?
7. Is ultrasound guidance available and indicated for this procedure?
8. Who is the supervising physician (if a trainee is performing), and what is the level of supervision?

### Documents to Request

- Most recent vital signs and continuous monitoring readout
- Current lab values (CBC, coagulation studies, ABG/VBG, lactate, type and screen)
- Relevant imaging (chest X-ray, CT, FAST exam)
- Medication list with focus on anticoagulants and antiplatelets
- Allergy documentation (especially latex, chlorhexidine, local anesthetics, iodine)
- Prior procedure notes if re-access or revision
- Advanced directive / code status documentation

---

## Step 1: Endotracheal Intubation

### Pre-Intubation Checklist (Structured Approach)

| Component | Action |
|-----------|--------|
| **S** — Suction | Yankauer suction at head of bed, tested and functioning |
| **O** — Oxygen | Pre-oxygenation ≥ 3 minutes or 8 vital-capacity breaths with 100% O₂; nasal cannula at 15 LPM during apneic period |
| **A** — Airway equipment | Laryngoscope (video AND direct available), ETT (primary size + 0.5 smaller), stylet, bougie, supraglottic airway (LMA), cricothyrotomy kit |
| **P** — Pharmacy | RSI medications drawn up and labeled: induction agent + paralytic; push-dose pressor; post-intubation sedation/analgesia |
| **M** — Monitors | Continuous SpO₂, waveform capnography, cardiac monitor, NIBP |
| **E** — End-tidal CO₂ | Waveform capnography MUST be available for confirmation of tube placement |

### RSI Drug Selection

| Induction Agent | Dose | Onset | Duration | Best For | Avoid When |
|----------------|------|-------|----------|----------|------------|
| Etomidate | 0.3 mg/kg IV | 30–60 sec | 3–5 min | Hemodynamically unstable patients | Sepsis (theoretical adrenal suppression; debated) |
| Ketamine | 1.5–2 mg/kg IV | 30–60 sec | 10–15 min | Asthma, hypotension, head injury (no longer contraindicated) | Schizophrenia (relative) |
| Propofol | 1–2 mg/kg IV | 15–45 sec | 5–10 min | Status epilepticus, controlled hemodynamics | Hypotension, shock |
| Midazolam | 0.1–0.3 mg/kg IV | 60–90 sec | 15–30 min | Availability when others unavailable | Hemodynamically unstable |

| Paralytic | Dose | Onset | Duration | Notes |
|-----------|------|-------|----------|-------|
| Succinylcholine | 1.5 mg/kg IV | 45–60 sec | 6–10 min | Fastest onset; contraindicated in hyperkalemia, burns > 48h, denervation injury, malignant hyperthermia |
| Rocuronium | 1.2 mg/kg IV | 60–90 sec | 40–60 min | Reversible with sugammadex 16 mg/kg; preferred when succinylcholine contraindicated |

### Post-Intubation Confirmation

1. **Waveform capnography**: Gold standard — persistent CO₂ waveform for 6+ breaths confirms tracheal placement
2. **Direct visualization**: ETT seen passing through vocal cords
3. **Bilateral breath sounds**: Auscultate axillae bilaterally
4. **Chest rise**: Symmetric chest expansion
5. **Chest X-ray**: Confirm tip position 3–5 cm above carina
6. **SpO₂**: Maintained or improving

---

## Step 2: Central Venous Access

### Site Selection

| Site | Advantages | Disadvantages | Preferred When |
|------|-----------|---------------|---------------|
| Internal jugular (IJ) | Compressible, ultrasound-guided; lower PTX risk than subclavian | Difficult in cervical collar; risk of carotid puncture | Default first choice; coagulopathic patients |
| Subclavian | Lower infection rate; comfortable for patient; good flow rates | Non-compressible; highest PTX risk; difficult to ultrasound | Expected prolonged access; non-coagulopathic |
| Femoral | No PTX risk; easy landmark access | Higher infection rate; DVT risk; limits ambulation | Cardiac arrest; coagulopathy; when IJ/SC impossible |

### Ultrasound-Guided IJ Central Line Procedure

1. Position: Trendelenburg 15°, head turned slightly contralateral
2. Sterile prep: Chlorhexidine > 30 seconds dry time; full barrier drape, cap, mask, gown, gloves
3. Ultrasound: Linear probe in sterile sheath; identify IJ (compressible, lateral) vs. carotid (non-compressible, medial, pulsatile)
4. Access: Enter skin at 45° under real-time ultrasound guidance; advance needle into IJ with continuous aspiration
5. Confirm venous blood (dark, non-pulsatile); transduce pressure if uncertain
6. Seldinger technique: Guidewire through needle; remove needle; nick skin; dilator over wire; catheter over wire
7. Confirm wire position with ultrasound in IJ and check for wire in the right atrium (subcostal cardiac view)
8. Secure catheter; sterile dressing
9. Post-procedure chest X-ray: Confirm catheter tip at cavoatrial junction; rule out pneumothorax
10. Document: Indication, consent, sterile technique, ultrasound use, number of attempts, complications, confirmation method

---

## Step 3: Tube Thoracostomy (Chest Tube)

### Indications

| Indication | Urgency | Tube Size (Adult) |
|-----------|---------|------------------|
| Tension pneumothorax (after needle decompression) | Emergent | 28–32 Fr |
| Traumatic hemothorax | Urgent | 32–36 Fr |
| Large spontaneous pneumothorax (> 2 cm apex, symptomatic) | Urgent | 20–28 Fr (small-bore pigtail acceptable for simple PTX) |
| Empyema/complicated parapneumonic effusion | Semi-urgent | 28–32 Fr |
| Massive pleural effusion with respiratory compromise | Semi-urgent | 28–32 Fr |

### Procedure Steps

1. Position: Supine with arm abducted 90° and externally rotated (or arm above head)
2. Identify insertion site: 4th–5th intercostal space, anterior to mid-axillary line (safe triangle: lateral border of pectoralis major, anterior border of latissimus dorsi, line of nipple/inframammary fold)
3. Sterile prep and drape; local anesthesia (lidocaine 1% with epinephrine) — anesthetize skin, subcutaneous tissue, periosteum of rib, and parietal pleura
4. Incision: 2–3 cm transverse incision at the level of the intercostal space
5. Blunt dissection: Kelly clamp through subcutaneous tissue over the TOP of the lower rib (avoid neurovascular bundle on inferior rib border)
6. Puncture parietal pleura with clamp; spread to create opening; finger sweep to confirm intrapleural space (rule out adhesions, diaphragm)
7. Insert tube directed posteriorly and superiorly for pneumothorax, posteriorly and inferiorly for effusion/hemothorax
8. Connect to underwater seal drainage system (e.g., Pleur-evac at −20 cmH₂O suction)
9. Secure with suture (0-silk); occlusive dressing
10. Post-procedure CXR: Confirm tube position and lung re-expansion

### Chest Tube Output Monitoring

| Finding | Significance | Action |
|---------|------------|--------|
| > 1500 mL blood immediate output | Massive hemothorax | Consult surgery for thoracotomy |
| > 200 mL/hr blood for 2–4 hours | Ongoing hemorrhage | Consult surgery |
| Continuous air leak | Persistent air leak / bronchopleural fistula | Consult surgery if no resolution in 48–72 hours |
| Abrupt cessation of output | Tube clot, kink, or malposition | Strip tube, check position on CXR |

---

## Step 4: Procedural Sedation and Analgesia

### Pre-Sedation Assessment

1. ASA Physical Status classification
2. Airway assessment (Mallampati, predictors of difficult BVM ventilation: MOANS — Mask seal, Obesity, Age > 55, No teeth, Stiffness)
3. NPO status assessment (ASA guidelines apply; for emergencies, weigh aspiration risk against procedure urgency)
4. Consent for sedation (separate from procedure consent when possible)
5. Monitoring setup: SpO₂, capnography, cardiac monitor, NIBP, supplemental O₂ ready

### Common ED Procedural Sedation Agents

| Agent | Dose | Onset | Recovery | Best For | Avoid |
|-------|------|-------|----------|----------|-------|
| Ketamine | 1–2 mg/kg IV; 4–5 mg/kg IM | IV: 1 min; IM: 5 min | 15–30 min (IV); 60–90 min (IM) | Children, fracture reduction, painful procedures | Age < 3 months; psychosis |
| Propofol | 0.5–1 mg/kg IV, titrate 0.5 mg/kg q30sec | 30 sec | 5–10 min | Short procedures, cardioversion, joint reduction | Hypotension, hemodynamic instability |
| Etomidate | 0.1–0.15 mg/kg IV | 30–60 sec | 5–15 min | Brief procedures, hemodynamically unstable | Myoclonus may complicate procedure |
| Ketofol | Ketamine 0.5 mg/kg + Propofol 0.5 mg/kg | 30–60 sec | 10–15 min | Balanced hemodynamics and analgesia | Same as individual agents |

---

## Step 5: Cricothyrotomy (Surgical Airway)

### Indications

- Cannot intubate, cannot oxygenate (CICO) — the ultimate airway rescue
- Massive facial trauma precluding oral/nasal intubation
- Complete upper airway obstruction unrelieved by supraglottic airway
- Angioedema with progressive airway compromise

### Contraindications

- Age < 8–10 years (relative — needle cricothyrotomy preferred in young children; anatomy unfavorable for surgical approach)
- Tracheal transection with retraction (requires surgical exploration)
- Laryngeal fracture through the cricothyroid membrane (perform tracheotomy instead if time permits)

### Surgical Cricothyrotomy Technique

1. Position: Neck extended (if no C-spine concern); identify cricothyroid membrane between thyroid and cricoid cartilages
2. Stabilize larynx with non-dominant hand
3. Vertical skin incision (3–4 cm) over cricothyroid membrane — reduces vessel injury compared to horizontal
4. Horizontal stab incision through cricothyroid membrane — aim inferiorly to avoid vocal cords
5. Insert tracheal hook or rotate scalpel handle 90° to open the membrane
6. Insert appropriately sized cuffed tracheostomy tube (6.0 Shiley) or ETT (6.0 cuffed)
7. Inflate cuff; ventilate; confirm with capnography and bilateral breath sounds
8. Secure tube; obtain CXR

### Needle Cricothyrotomy (Temporizing in Pediatric Patients)

1. Insert 14-gauge or 12-gauge angiocath through cricothyroid membrane at 45° caudally
2. Aspirate air to confirm tracheal placement
3. Connect to jet ventilation system (if available) or BVM with a 3.0 ETT adapter
4. This is a TEMPORIZING measure only — provides oxygenation but cannot adequately ventilate; definitive airway still needed

---

## Checkpoint B: Post-Procedure Alignment (Mandatory)

1. Was the indication documented with supporting clinical evidence (vitals, imaging, labs)?
2. Was consent obtained and documented (or emergency exception documented)?
3. Was the procedure technique documented including patient position, sterile preparation, equipment used, and number of attempts?
4. Were complications assessed and documented (or "no immediate complications" noted)?
5. Was post-procedure imaging obtained when indicated (CXR for central line and chest tube; waveform capnography for ETT)?

---

## Quality Audit

| # | Criterion | Pass / Fail |
|---|-----------|-------------|
| 1 | Indication for procedure clearly documented with supporting evidence | |
| 2 | Informed consent obtained or emergency exception documented | |
| 3 | Time-out / procedural pause performed before invasive procedure | |
| 4 | Sterile technique used and documented for central lines and chest tubes | |
| 5 | Ultrasound guidance used for central venous access (IJ and femoral) | |
| 6 | Waveform capnography used to confirm ETT placement | |
| 7 | RSI medications, doses, and times documented | |
| 8 | Post-intubation sedation/analgesia initiated and documented | |
| 9 | Post-procedure imaging obtained and interpreted | |
| 10 | Complications documented or explicitly stated as absent | |
| 11 | Number of attempts documented for all access procedures | |
| 12 | Procedure note completed within 1 hour of procedure | |
| 13 | Supervising physician documented for trainee-performed procedures | |
| 14 | Chest tube output monitored with surgical consultation thresholds applied | |

---

## Guidelines

- Waveform capnography is the gold standard for ETT confirmation — esophageal detector devices and colorimetric CO₂ detectors are adjuncts, not replacements
- Ultrasound guidance for central venous access is standard of care, not optional — it reduces mechanical complications by 50%+ compared to landmark technique
- Always have a backup airway plan articulated BEFORE the first intubation attempt: if direct/video laryngoscopy fails → bougie → supraglottic airway → surgical airway
- Never place a chest tube without confirming the side and level — wrong-side chest tubes occur and are never defensible
- The safe triangle for chest tube insertion is bounded by the anterior border of latissimus dorsi, lateral border of pectoralis major, and a horizontal line at the level of the nipple — avoid inserting too low (liver/spleen risk) or too medial (internal mammary artery)
- Document every procedure note using a structured template: indication, consent, timeout, technique, findings, specimens, complications, post-procedure orders
- For procedural sedation, the provider managing sedation should be separate from the provider performing the procedure when patient volume and staffing allow
- Debrief after every failed procedure or complication — not as blame, but as system improvement; document the debrief outcome