Don’t Forget Your Online Access to Mobile. Searchable. Expandable. ACCESS it on any Internet-ready device SEARCH all Expert Consult titles you own LINK to PubMed abstracts ALREADY REGISTERED? FIRST-TIME USER? 1. Log in at expertconsult.com 1. REGISTER 2. Scratch off your Activation Code below • Click “Register Now” at expertconsult.com 3. Enter it into the “Add a Title” box • Fill in your user information and click “Continue” 4. Click “Activate Now” 2. ACTIVATE YOUR BOOK 5. Click the title under “My Titles” • Scratch off your Activation Code below • Enter it into the “Enter Activation Code” box • Click “Activate Now” • Click the title under “My Titles” For technical assistance: Activation Code email [email protected] call 800-401-9962 (inside the US) call +1-314-995-3200 (outside the US) Roberts & Hedges’ Clinical Procedures Emergency Medicine in ASSOCIATE EDITORS Arjun S. Chanmugam, MD, MBA Associate Professor Department of Emergency Medicine The Johns Hopkins School of Medicine Baltimore, Maryland Carl R. Chudnofsky, MD Chairman Department of Emergency Medicine Albert Einstein Medical Center Professor Jefferson Medical College Philadelphia, Pennsylvania Peter M.C. DeBlieux, MD Professor of Clinical Medicine Louisiana State University Health Sciences Center New Orleans, Louisiana Amal Mattu, MD Professor and Vice Chair Department of Emergency Medicine University of Maryland School of Medicine Baltimore, Maryland Stuart P. Swadron, MD, FRCPC Associate Professor Department of Emergency Medicine Assistant Dean for Pre-Health Undergraduate Studies Keck School of Medicine of USC University of Southern California Los Angeles, California Roberts & Hedges’ Clinical Procedures Emergency Medicine in SIXTH EDITION EDITOR-IN-CHIEF James R. Roberts, MD, FACEP, FAAEM, FACMT Professor of Emergency Medicine Vice Chair, Department of Emergency Medicine Senior Consultant, Division of Toxicology The Drexel University College of Medicine Chairman, Department of Emergency Medicine Director, Division of Medical Toxicology Mercy Catholic Medical Center Philadelphia, Pennsylvania SENIOR EDITOR ILLUSTRATION EDITOR Catherine B. Custalow, Todd W. Thomsen, MD, PhD MD Associate Professor, Retired Department of Emergency Medicine Department of Emergency Medicine Mount Auburn Hospital University of Virginia School of Medicine Cambridge, Massachusetts Charlottesville, Virginia Instructor in Medicine Harvard Medical School Boston, Massachusetts EDITOR EMERITUS Jerris R. Hedges, MD, MS, MMM Professor and Dean John A. Burns School of Medicine University of Hawaii—Manoa Honolulu, Hawaii Professor and Vice-Dean, Emeritus Department of Emergency Medicine Oregon Health & Science University School of Medicine Portland, Oregon 1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899 ROBERTS AND HEDGES’ CLINICAL PROCEDURES ISBN: 978-1-4557-0606-8 IN EMERGENCY MEDICINE Copyright © 2014, 2010, 2004, 1998, 1991, 1985 by Saunders, an imprint of Elsevier Inc. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies, and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods, they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence, or otherwise or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Library of Congress Cataloging-in-Publication Data Clinical procedures in emergency medicine. Roberts and Hedges’ clinical procedures in emergency medicine / editor-in-chief, James R. Roberts ; senior editor, Catherine B. Custalow ; illustration editor, Todd W. Thomsen ; editor emeritus, Jerris R. Hedges.—Sixth edition. p. ; cm. Clinical procedures in emergency medicine Preceded by Clinical procedures in emergency medicine / editors, James R. Roberts, Jerris R. Hedges ; associate editors, Catherine B. Custalow … [et al.]. 5th ed. c2010. Includes bibliographical references and index. ISBN 978-1-4557-0606-8 (hardcover : alk. paper) I. Roberts, James R., 1946- editor of compilation. II. Custalow, Catherine B. editor of compilation. III. Thomsen, Todd W. editor. IV. Hedges, Jerris R. editor. V. Title. VI. Title: Clinical procedures in emergency medicine. [DNLM: 1. Emergencies. 2. Emergency Medicine—methods. 3. Emergency Treatment— methods. WB 105] RC86.7 616.02′5—dc23 2013017645 Senior Content Strategist: Stefanie Jewell-Thomas Senior Content Specialist: Dee Simpson Publishing Services Manager: Anne Altepeter Senior Project Manager: Doug Turner Designer: Lou Forgione Printed in the People’s Republic of China Last digit is the print number: 9 8 7 6 5 4 3 2 1 To Lydia, Matthew, Martha, and, of course, Jeanne. J.R.R. To my son, Nicholas, and to the memory of my daughter, Lauren. C.B.C. To my wonderful wife, Karen—thank you for your inspiration, support, and remarkable partnership; to Sydney, William, and Nathan, who will always be reminders of what is truly important; to my parents, who helped to foster the passion of medical education as a public service. To Cathy Custalow, MD, for her many, many hours and dedication to this book. And finally to those who practice and teach emergency medicine—may this book serve you well. A.S.C. To Marcy … my wife, my best friend, and my soul mate. C.R.C. To my wife, Karen, and my sons, Joshua and Zachary—thank you for your unlimited patience and encouragement while I pursued this educational passion. None of this could happen without your love. To our residents, peer faculty, nurses, and patients at LSU and Charity Hospital— your example and inspiration for patient care keep me focused on the mission of “care for all.” P.M.C.D. To my wife, Sejal, and my three children, Nikhil, Eleena, and Kamran, for giving me purpose and inspiration. To my colleagues and my mentors for all that they have taught me through the years. To Jim Roberts, for continuing to be a driving force behind this text. And to emergency physicians around the world, who continually care and advocate for their patients despite the toughest of times and circumstances. A.M. To my amazing wife, Joyce; my supportive parents; the students and residents of the Keck School of Medicine; and the gracious patients of Los Angeles County–USC Medical Center. S.P.S. To Jim Roberts and Cathy Custalow, for the opportunity to collaborate on this project. To Gary Setnik, for your mentorship throughout the years. To my parents, Alfred and Beverly Thomsen, for everything. And most importantly, to my beautiful wife, Cristine, and wonderful sons, Henry and Cole, for your love and patience during the many months that this book took me away from you. T.W.T. HOW THIS MEDICAL TEXTBOOK SHOULD BE that may confront clinicians who are experienced in emer- VIEWED BY THE PRACTICING CLINICIAN AND gency medicine practice. This text cannot replace physician THE JUDICIAL SYSTEM judgment; cannot describe every possible aberration, nuance, clinical scenario, or presentation; and cannot define rigid The editors and authors of this textbook strongly believe that standards for clinical actions or procedures. Every medical the complex practice of medicine, the vagaries of human dis- encounter must be individualized, and every patient must be eases, the unpredictability of pathologic conditions, and the approached on a case-by-case basis. No complex medical interac- functions, dysfunctions, and responses of the human body tion can possibly be reduced to the written word. The treat- cannot be defined, explained, or rigidly categorized by any ments, procedures, and medical conditions described in written document. Therefore it is neither the purpose nor the this textbook do not constitute the total expertise or knowl- intent of our textbook to serve as an authoritative source on any edge base expected to be possessed by all clinicians. Finally, medical condition, treatment plan, or clinical intervention; nor many of the described complications and adverse outcomes should our textbook be used to rigorously define a standard of care associated with implementing or withholding complex that should be practiced by all clinicians. medical and surgical interventions may occur, even when Our written word provides the physician with a literature- every aspect of the intervention has been performed correctly referenced database and a reasonable clinical guide that is and as per any textbook or currently accepted standards. combined with practical suggestions from individual experi- enced practitioners. We offer a general reference source and The editors and authors of Roberts and Hedges’ clinical roadmap on a variety of conditions and procedures Clinical Procedures in Emergency Medicine, Sixth Edition Contributors Benjamin S. Abella, MD, MPhil James T. Amsterdam, DMD, Jason P. Becker, MD Clinical Research Director MD, MMM, FACEP, FACPE Undergraduate Medical Education Department of Emergency Medicine Chair/Service Line Director Director Center for Resuscitation Science Department of Emergency Medicine Emergency Medicine Residency University of Pennsylvania York Hospital Program Artificial Perfusion during Cardiac Arrest York, Pennsylvania Albert Einstein Medical Center Professor of Clinical Emergency Philadelphia, Pennsylvania Bruce D. Adams, MD Medicine Treatment of Bursitis, Tendinitis, and Professor Department of Emergency Medicine Trigger Points Chief of Emergency Medicine Penn State University College of Center for Emergency Medicine Medicine Lance B. Becker, MD, FAHA University of Texas School of Medicine Hershey, Pennsylvania Director San Antonio, Texas Adjunct Professor of Emergency Center for Resuscitation Science Central Venous Catheterization and Medicine Professor Central Venous Pressure Monitoring Department of Emergency Medicine Department of Emergency Medicine Drexel University College of Medicine Perelman School of Medicine Erik H. Adler, MD Philadelphia, Pennsylvania University of Pennsylvania Health Senior Resident Regional Anesthesia of the Head and Neck System Department of Emergency Medicine Philadelphia, Pennsylvania Denver Health Jennifer Avegno, MD Artificial Perfusion during Cardiac Arrest Denver, Colorado Clinical Assistant Professor Thoracentesis Department of Medicine Kip R. Benko, MD, FACEP Section of Emergency Medicine Clinical Assistant Professor of Pablo F. Aguilera, MD Louisiana State University Health Emergency Medicine Instructor of Emergency Medicine Sciences Center University of Pittsburgh School of Department of Internal Medicine New Orleans, Louisiana Medicine Emergency Medicine Program Educational Aspects of Emergency Faculty, Presbyterian University Pontificia Universidad Católica de Department Procedures Hospital Chile University of Pittsburgh Medical Santiago, Chile David K. Barnes, MD, FACEP Center Emergency Medicine Program Assistant Professor Pittsburgh, Pennsylvania Coordinator Residency Program Director Emergency Dental Procedures Hospital Dr. Sótero del Río Department of Emergency Medicine Puente Alto, Región Metropolitana University of California Davis Health Edward S. Bessman, MD, MBA Puente Alto, Chile System Chairman and Clinical Director Venous Cutdown Sacramento, California Department of Emergency Medicine Extensor and Flexor Tendon Injuries in the Johns Hopkins Bayview Medical Hand, Wrist, and Foot Center Assistant Professor Steven J. Bauer, MD, MS Department of Emergency Medicine Staff Physician The Johns Hopkins School of Department of Emergency Medicine Medicine Meritus Medical Center Baltimore, Maryland Hagerstown, Maryland Emergency Cardiac Pacing Alternative Methods of Drug Administration vii viii CONTRIBUTORS Barbara K. Blok, MD G. Richard Braen, MD, FACEP Ilene Claudius, MD Associate Professor Professor and Chairman Assistant Professor Department of Emergency Medicine Department of Emergency Medicine Department of Emergency Medicine University of Colorado School of Assistant Dean of Graduate Medical Los Angeles County and University of Medicine Education Southern California Aurora, Colorado School of Medicine and Biomedical Los Angeles, California Associate Program Director Sciences Pediatric Vascular Access and Blood Denver Health Residency in University at Buffalo Sampling Techniques Emergency Medicine Buffalo, New York Denver, Colorado Culdocentesis Joseph E. Clinton, MD Thoracentesis Professor and Head Christine Butts, MD Department of Emergency Medicine Heather A. Borek, MD Clinical Assistant Professor of University of Minnesota Medical Attending Physician Emergency Medicine School Department of Emergency Medicine Director of Division of Emergency Chief of Service Division of Medical Toxicology Ultrasound Department of Emergency Medicine Albert Einstein Healthcare Network Louisiana State University Health Hennepin County Medical Center Philadelphia, Pennsylvania Sciences Center Minneapolis, Minnesota Decontamination of the Poisoned Patient New Orleans, Louisiana Basic Airway Management and Decision Ultrasound Making Eduardo Borquez, MD Tracheal Intubation Staff Physician Sharon K. Carney, MD Department of Emergency Medicine Clinical Assistant Professor of Wendy C. Coates, MD Kaiser Permanente San Diego Medical Emergency Medicine Professor of Clinical Medicine Center Drexel University College of Medicine David Geffen School of Medicine at San Diego, California Chief Medical Officer University of California, Los Angeles Noncardiac Implantable Devices Mercy Catholic Medical Center Los Angeles, California Philadelphia, Pennsylvania Director, Medical Education Sudip Bose, MD, FACEP, FAAEM Intravenous Regional Anesthesia Director, Fellowship in Medical Associate Clinical Professor Education Department of Emergency Medicine Merle A. Carter, MD Department of Emergency Medicine University of Illinois Residency Director Harbor-UCLA Medical Center Chicago, Illinois Department of Emergency Medicine Torrance, California Attending Emergency Medicine Albert Einstein Medical Center Anorectal Procedures Physician Philadelphia, Pennsylvania Partner, Basin Emergency Physicians, Compartment Syndrome Evaluation Jonathan E. Davis, MD LLC Associate Professor Department of Emergency Medicine Theodore C. Chan, MD Department of Emergency Medicine Medical Center Hospital Professor Georgetown University School of Odessa, Texas Department of Emergency Medicine Medicine Program Director Cricothyrotomy and Percutaneous University of California, San Diego Emergency Medicine Residency Translaryngeal Ventilation Health Sciences Program San Diego, California Georgetown University Hospital/ William J. Brady, MD Basic Electrocardiographic Techniques Washington Hospital Center Professor of Emergency Medicine and Washington, District of Columbia Medicine Carl R. Chudnofsky, MD Urologic Procedures Chair, Medical Emergency Response Professor (Formerly Resuscitation) Committee Department of Emergency Medicine Anthony J. Dean, MD Medical Director, Emergency Jefferson Medical College Associate Professor of Emergency Management Chair, Department of Emergency Medicine University of Virginia Medical Center Medicine Associate Professor of Emergency Charlottesville, Virginia Albert Einstein Healthcare Network Medicine in Radiology Medical Director Philadelphia, Pennsylvania Director, Division of Emergency Allianz Global Assistance Alternative Methods of Drug Ultrasonography United States and Canada Administration Department of Emergency Medicine Basic Electrocardiographic Techniques Splinting Techniques University of Pennsylvania Medical Center Philadelphia, Pennsylvania Bedside Laboratory and Microbiologic Procedures