# Clinical Cases: Emergency Procedures

## Case 1: Emergent Intubation - The Crashing Patient

### Patient Demographics
- **Age:** 56 years
- **Sex:** Male
- **Occupation:** Restaurant manager

### Chief Complaint
"He can't breathe!"

### History of Present Illness
A 56-year-old male with history of COPD presents in severe respiratory distress. Wife reports progressive shortness of breath over 3 days with increasing sputum production (green/yellow). He ran out of his inhalers last week. Over the past hour he has become increasingly lethargic and "can't catch his breath." He uses home oxygen at 2L/min.

### Initial Assessment

**ESI Level:** 1 - Respiratory failure requiring immediate intervention

**First Impression:**
- Appearance: Severely distressed, tripod positioning, diaphoretic, cyanotic
- Work of breathing: Severe - accessory muscle use, paradoxical breathing
- Circulation: Pale, diaphoretic

**Vital Signs:**
- Heart rate: 128 bpm
- Blood pressure: 168/96 mmHg
- Respiratory rate: 36 breaths/min (labored)
- SpO2: 78% on 2L NC
- Temperature: 38.2C
- GCS: 11 (E3V3M5) - Decreasing

### Indications for Intubation

**Classic Indications (3 F's and an A):**
1. **Failure to oxygenate** - SpO2 78% despite supplemental O2 ✓
2. **Failure to ventilate** - Hypercarbic, tiring ✓
3. **Failure to protect airway** - Decreasing mental status ✓
4. **Anticipated clinical course** - Will only worsen without intervention ✓

**Decision:** Emergent endotracheal intubation indicated

### Pre-Intubation Assessment

**Difficult Airway Predictors (LEMON):**
- **L**ook externally: Obese, short neck, beard
- **E**valuate 3-3-2: Mouth opening adequate, thyromental distance short
- **M**allampati: Unable to assess (distress)
- **O**bstruction: No obvious obstruction
- **N**eck mobility: Adequate

**Anticipated Difficulty:** MODERATE (obese, short neck)

**Preparation (7 P's of RSI):**
1. **Preparation** - Equipment, personnel, monitoring
2. **Preoxygenation** - Critical before paralysis
3. **Pretreatment** - Consider for specific indications
4. **Paralysis/Induction** - RSI medications
5. **Positioning** - Optimize for success
6. **Placement** - Laryngoscopy and tube insertion
7. **Post-intubation** - Confirm, secure, ventilate

### Equipment Setup

**Airway Equipment:**
- Laryngoscope (direct AND video available)
- ETT sizes 7.0, 7.5, 8.0 (cuffed)
- Stylet
- Bougie (gum elastic)
- BVM with PEEP valve
- Suction (Yankauer)
- End-tidal CO2 detector
- Backup: LMA, surgical airway tray

**Medications:**
- Induction: Ketamine 2 mg/kg (bronchodilator, preserves BP)
- Paralytic: Succinylcholine 1.5 mg/kg (rapid onset)
- Push-dose epinephrine available

**Personnel:**
- Provider for intubation
- Respiratory therapy (BVM, ventilator)
- Nurse (medications, monitoring)
- Second physician (backup, cricothyrotomy if needed)

### Preoxygenation

**Critical in COPD/Hypoxic Patient:**
- High-flow nasal cannula at 15L/min + non-rebreather mask
- Apneic oxygenation: Maintain nasal cannula during laryngoscopy
- Goal: SpO2 >93% before paralysis
- Patient preoxygenated 3 minutes; SpO2 improved to 88% (best achievable)

### Procedure - Rapid Sequence Intubation

**Positioning:**
- Ramped position (elevation of head/shoulders) - optimizes obese airway
- External ear canal aligned with sternal notch

**Induction:**
- Ketamine 150mg IV push (2 mg/kg)
- Patient sedated within 30 seconds

**Paralysis:**
- Succinylcholine 120mg IV push (1.5 mg/kg)
- Fasciculations noted
- Paralysis achieved at 45 seconds

**Laryngoscopy:**
- Video laryngoscopy used (Glidescope)
- Grade II view (arytenoids visible)
- Bougie passed through cords
- ETT 7.5 passed over bougie
- Cuff inflated
- ETT secured at 23cm at lip

### Confirmation of Tube Placement

**Multiple Methods Required:**
1. **End-tidal CO2 (ETCO2):** Waveform present - MOST RELIABLE
2. **Bilateral breath sounds:** Present and equal
3. **Chest rise:** Symmetric
4. **Misting in ETT:** Present
5. **SpO2 improvement:** 88% → 94%
6. **Chest X-ray:** ETT tip 3-5cm above carina (confirms position, not placement)

### Post-Intubation Management

**Immediate Actions:**
- Secure tube with commercial holder
- Ventilator settings:
  - Mode: Volume control
  - Tidal volume: 6-8 mL/kg IBW
  - Rate: 12-14 (allow for prolonged expiration in COPD)
  - PEEP: 5 cmH2O
  - FiO2: 100% initially, wean to target SpO2 >92%
- Sedation: Propofol infusion + fentanyl PRN
- Gastric decompression: OG tube
- Arterial line for monitoring

**Post-Intubation Vitals:**
- HR: 98 bpm
- BP: 128/78 mmHg (improved with positive pressure)
- SpO2: 96%
- ETCO2: 58 mmHg (will need to improve with ventilation)

### Secondary Survey

**SAMPLE History (from wife):**
- Symptoms: Progressive dyspnea, cough, sputum
- Allergies: Sulfa
- Medications: Albuterol, tiotropium (ran out), prednisone PRN
- PMH: COPD (severe), CAD, HTN
- Last Meal: Last night
- Events: COPD exacerbation

### Diagnosis

**COPD Exacerbation with Acute Hypercarbic Respiratory Failure** requiring emergent intubation

### Diagnostic Testing

**ABG Post-Intubation:**
- pH: 7.22
- pCO2: 72 mmHg
- pO2: 118 mmHg
- HCO3: 28 mEq/L

**Interpretation:** Acute on chronic respiratory acidosis

**Chest X-ray:**
- ETT in good position
- Hyperinflation
- Right lower lobe infiltrate (possible pneumonia trigger)

### Management

**COPD Exacerbation Treatment:**
- Albuterol/ipratropium nebulizers via ETT
- Methylprednisolone 125mg IV
- Antibiotics: Azithromycin + ceftriaxone (CAP coverage)
- Optimize ventilator for COPD (longer expiratory time)

### Disposition
- Medical ICU admission
- Weaning protocol initiated day 2
- Extubated day 3
- Step-down unit day 4
- Discharged day 7 with inhaler teaching and pulmonology follow-up

### Teaching Points

1. **Recognize indications early:** Don't wait until crash to decide on intubation
2. **Preparation prevents disaster:** Equipment, personnel, backup plans ready
3. **Preoxygenation is critical:** Maximizes safe apnea time
4. **Ketamine for bronchospasm:** Bronchodilator and maintains hemodynamics
5. **Video laryngoscopy improves first-pass success:** Especially in difficult airways
6. **Confirm placement multiple ways:** ETCO2 waveform is gold standard
7. **Anticipate post-intubation hypotension:** Especially in hypovolemia, sedation
8. **Ramped positioning:** Critical for obese patients - ear to sternal notch alignment

### Clinical Image
![Laryngoscopy View - Cormack-Lehane Classification](case_01_image.jpg)

**Image Description:** Illustration of Cormack-Lehane laryngoscopic view classification from Grade I (full glottic opening visible) to Grade IV (no glottic structures visible), used to describe the view during direct or video laryngoscopy.

**Attribution:** Image from Wikimedia Commons, Cormack Lehane classification. Licensed under CC BY-SA 4.0. Source: https://commons.wikimedia.org/wiki/File:Cormack-Lehane_classification_system.svg

---

## Case 2: Chest Tube Insertion - The Traumatic Hemothorax

### Patient Demographics
- **Age:** 34 years
- **Sex:** Female
- **Occupation:** Motorcycle enthusiast

### Chief Complaint
"Motorcycle crash - she's having trouble breathing."

### History of Present Illness
A 34-year-old female is brought by EMS after a motorcycle crash. She was traveling approximately 40 mph when she lost control and struck a guardrail. She was wearing a helmet but landed on her left side. She is complaining of severe left chest pain and difficulty breathing.

### Initial Assessment (Trauma Primary Survey)

**ESI Level:** 1 - Trauma activation

**First Impression:**
- Appearance: Distressed, splinting left chest
- Work of breathing: Labored, asymmetric chest rise
- Circulation: Pale, tachycardic

**Vital Signs:**
- Heart rate: 122 bpm
- Blood pressure: 94/62 mmHg
- Respiratory rate: 28 breaths/min
- SpO2: 88% on NRB
- Temperature: Not obtained
- GCS: 15

### Primary Survey (ATLS)

**A - Airway:** Patent, speaking in short sentences
**B - Breathing:**
- Decreased breath sounds LEFT chest
- Dullness to percussion LEFT chest
- Asymmetric chest rise (left decreased)
- Paradoxical movement left chest wall (flail segment)
**C - Circulation:**
- Tachycardic, hypotensive
- Weak peripheral pulses
- JVD: Absent (hypovolemia vs. tension physiology would have JVD)
**D - Disability:** GCS 15, moving all extremities
**E - Exposure:** Multiple abrasions, left chest wall deformity

### Life-Threatening Thoracic Injuries Identified

1. **Hemothorax** - Decreased breath sounds, dullness, hypotension
2. **Flail chest** - Paradoxical chest wall movement (3+ ribs fractured in 2+ places)
3. **Possible tension physiology** - Decreasing BP, desaturation

### Immediate Intervention Required

**Indication for Chest Tube:**
- Hemothorax in unstable patient
- Respiratory compromise
- Will need evacuation and monitoring of blood loss

**Needle Decompression First?**
- No tracheal deviation, no JVD
- Dull to percussion (blood, not air)
- Proceed directly to chest tube (hemothorax)

### Chest Tube Insertion - Procedure

**Equipment:**
- 36 French chest tube (large bore for hemothorax)
- Chest tube tray (scalpel, clamps, suture, sterile drapes)
- Chest drainage system (Pleur-evac)
- Sterile gloves, gown
- Local anesthetic (lidocaine 1%)

**Landmarks:**
- **Safe triangle:** Anterior border of latissimus dorsi, lateral border of pectoralis major, horizontal line at nipple level, apex below axilla
- **Insertion point:** 5th intercostal space, anterior axillary line (left side)

**Procedure Steps:**
1. **Preparation:** Sterile prep, drape, position patient (arm above head if possible)
2. **Anesthesia:** Infiltrate skin, subcutaneous tissue, periosteum of rib, pleura
3. **Incision:** 3-4cm horizontal incision over rib below intended interspace
4. **Dissection:** Blunt dissection with Kelly clamp over superior aspect of lower rib (avoid neurovascular bundle)
5. **Pleural entry:** Puncture pleura with clamp; expect rush of blood (hemothorax)
6. **Finger sweep:** Confirm intrathoracic location, assess for adhesions
7. **Tube insertion:** Guide tube posteriorly and superiorly using clamp
8. **Connection:** Connect to drainage system
9. **Secure:** Suture in place, apply occlusive dressing
10. **Confirm:** Chest X-ray

### Immediate Results

**Initial Output:**
- 1200mL blood immediately drained (significant hemothorax)
- Continued drainage: ~200mL/hour

**Clinical Response:**
- Breath sounds improved on left
- SpO2: 94% on NRB
- BP: 102/68 after 1L crystalloid
- Respiratory distress improved

### Massive Hemothorax Criteria

**Definition:** Initial output >1500mL OR ongoing >200mL/hour for 2-4 hours

**This Patient:**
- Initial output: 1200mL (significant but <1500mL threshold)
- Ongoing: 200mL/hour - close monitoring needed

**If criteria met:** Surgical thoracotomy indicated

### Resuscitation

**Transfusion:**
- Type O negative blood initiated (2 units)
- Type-specific blood when available
- Massive transfusion protocol on standby

**Assessment:**
- Hemoglobin: 8.2 g/dL on arrival
- After transfusion: 10.1 g/dL

### Secondary Survey

**SAMPLE History:**
- Symptoms: Left chest pain, dyspnea
- Allergies: None
- Medications: None
- PMH: Healthy
- Last Meal: 2 hours ago
- Events: MCC, 40 mph, impact to left side

**Physical Exam (Secondary):**
- Head: Abrasion on helmet contact points
- C-spine: Cleared clinically (no tenderness, full ROM, no neuro deficit)
- Chest: Flail segment (ribs 4-7 left), chest tube in place
- Abdomen: Soft, non-tender (FAST negative)
- Pelvis: Stable
- Extremities: Abrasions, no deformity

### Imaging

**Chest X-ray Post-Tube:**
- Chest tube in good position
- Residual small hemothorax (improving)
- Multiple left rib fractures (4-7) with flail segment
- Small left pulmonary contusion
- No pneumothorax

**CT Chest:**
- Left pulmonary contusion
- No aortic injury
- Rib fractures confirmed
- Residual hemothorax draining

### Management

**Flail Chest:**
- Pain control essential (prevents splinting, atelectasis)
- Epidural analgesia (placed by anesthesia)
- Incentive spirometry when able
- Pulmonary toilet
- Consider surgical rib fixation if severe

**Chest Tube Management:**
- Monitor output hourly
- Keep on suction (-20 cmH2O)
- Output decreased to <50mL/hour by hour 6

**Continued Resuscitation:**
- Total transfusion: 3 units PRBC
- Hemoglobin stabilized at 10.4 g/dL

### Disposition
- Trauma ICU admission
- Epidural for pain control
- Chest tube to water seal day 3
- Removed day 5 (output <100mL/24hr, no pneumothorax on clamping)
- Transferred to floor day 6
- Discharged day 10 with pulmonary follow-up

### Teaching Points

1. **Large-bore tube for hemothorax:** 28-36 French; blood is viscous
2. **Safe triangle:** Know the landmarks; avoid neurovascular bundle
3. **Finger sweep is critical:** Confirm intrathoracic location, assess for adhesions
4. **Massive hemothorax criteria:** >1500mL initial OR >200mL/hour = surgery
5. **Autotransfusion:** Blood from hemothorax can be autotransfused if available
6. **Flail chest = pulmonary contusion:** Treat the underlying lung injury
7. **Pain control prevents complications:** Epidural or regional anesthesia for rib fractures
8. **CXR confirms position:** But procedure success is clinical (drainage, improved breath sounds)

### Clinical Image
![Chest Tube Insertion Landmarks](case_02_image.jpg)

**Image Description:** Anatomical illustration demonstrating the safe triangle for chest tube insertion, bounded by the anterior border of latissimus dorsi, lateral border of pectoralis major, and a horizontal line at the level of the nipple, with the apex below the axilla.

**Attribution:** Image from Wikimedia Commons, Chest tube insertion site. Licensed under CC BY-SA 3.0. Source: https://commons.wikimedia.org/wiki/File:Chest_tube_insertion.svg

---

## Case 3: Central Venous Access - The Hypotensive Patient

### Patient Demographics
- **Age:** 62 years
- **Sex:** Female
- **Occupation:** Retired teacher

### Chief Complaint
"She's been vomiting blood all day."

### History of Present Illness
A 62-year-old female presents with hematemesis. She reports multiple episodes of vomiting "coffee ground" material since this morning, followed by bright red blood in the last hour. She feels weak and lightheaded. She has a history of alcohol use disorder and was told she has liver problems. She appears acutely ill and has poor peripheral venous access.

### Initial Assessment

**ESI Level:** 1 - GI hemorrhage with hemodynamic instability

**First Impression:**
- Appearance: Ill-appearing, pale, lethargic
- Work of breathing: Tachypneic
- Circulation: Pale, delayed cap refill

**Vital Signs:**
- Heart rate: 128 bpm
- Blood pressure: 78/48 mmHg
- Respiratory rate: 24 breaths/min
- SpO2: 94% on room air
- Temperature: 36.2C
- GCS: 14 (E3V5M6)

### Immediate Need for Vascular Access

**Peripheral IV Attempts:**
- Two failed peripheral IV attempts (poor veins, edema)
- Patient unstable, needs immediate access

**Options:**
1. **Intraosseous (IO):** Fast, effective for resuscitation
2. **Central Venous Catheter (CVC):** Multiple lumens, can give large volumes
3. **Ultrasound-guided peripheral:** May be successful

**Decision:** Need CVC for resuscitation AND vasopressors likely needed → Place central line

### Central Line Site Selection

| Site | Advantages | Disadvantages |
|------|------------|---------------|
| Internal jugular | Compressible, low pneumothorax risk | Interferes with airway, neck positioning |
| Subclavian | Comfortable for patient, low infection | Non-compressible, pneumothorax risk, contraindicated in coagulopathy |
| **Femoral** | **No pneumothorax risk, can compress, fast** | **Higher infection risk, limits mobility** |

**This Patient:**
- Coagulopathic (liver disease) → Avoid subclavian
- Possible airway intervention needed → Avoid IJ initially
- **Femoral CVC selected** - Appropriate for emergent access in coagulopathy

### While Preparing for CVC

**Intraosseous Access Placed:**
- Proximal tibia
- Resuscitation started via IO
- Buys time for CVC placement

### Central Venous Catheter Insertion - Femoral

**Equipment:**
- CVC kit (triple lumen catheter)
- Ultrasound with linear probe (vascular access)
- Sterile gown, gloves, mask, cap
- Full sterile drape
- Sterile saline for flushing
- Lidocaine 1%

**Ultrasound-Guided Femoral Vein Access:**

**Landmarks:**
- Below inguinal ligament
- Medial to femoral artery (use ultrasound to confirm)
- NAVL: Nerve-Artery-Vein-Lymphatics (lateral to medial)

**Procedure (Seldinger Technique):**
1. **Position:** Patient supine, leg slightly abducted and externally rotated
2. **Sterile prep and drape:** Maximum barrier precautions
3. **Ultrasound:** Identify femoral vein (compressible, medial to artery)
4. **Anesthesia:** Lidocaine to skin and subcutaneous tissue
5. **Access:** 18g needle with syringe, ultrasound-guided, advance into vein
6. **Confirm venous blood:** Dark, non-pulsatile flow
7. **Guidewire:** Pass J-wire through needle, maintain ultrasound visualization
8. **Nick skin:** Small incision at wire entry site
9. **Dilator:** Pass dilator over wire, remove
10. **Catheter:** Pass triple-lumen catheter over wire, remove wire
11. **Confirm placement:** Aspirate and flush all ports
12. **Secure:** Suture in place, sterile dressing

### Confirmation

**Methods:**
- Blood aspirated from all 3 lumens
- Transduced waveform confirms venous (not arterial) access
- Chest X-ray not required for femoral line (no pneumothorax risk)

### Resuscitation Via Central Line

**Administered:**
- 2L crystalloid (pressure bag)
- 4 units PRBC
- 2 units FFP
- Norepinephrine initiated (patient required vasopressors)

**Response:**
- BP improved: 92/58 mmHg on norepinephrine 0.1 mcg/kg/min
- HR: 108 bpm

### Secondary Survey

**SAMPLE History:**
- Symptoms: Hematemesis (coffee ground → bright red), weakness, lightheadedness
- Allergies: None
- Medications: Spironolactone, lactulose, propranolol (non-compliant)
- PMH: Alcohol cirrhosis, known esophageal varices, prior variceal bleed
- Last Meal: Yesterday
- Events: Vomiting blood since morning

**Physical Exam:**
- General: Ill-appearing, jaundiced
- Abdomen: Distended (ascites), no tenderness, splenomegaly
- Rectal: Melena
- Stigmata of liver disease: Spider angiomata, palmar erythema, gynecomastia

### Diagnosis

**Upper GI hemorrhage - presumed variceal bleed** in patient with known cirrhosis

### Additional Management

**Variceal Bleed Protocol:**
- Octreotide 50mcg bolus, then 50mcg/hour infusion
- Ceftriaxone 1g IV (SBP prophylaxis in cirrhosis with GI bleed)
- PPI 80mg IV bolus, then 8mg/hour
- Emergent GI consultation for EGD
- Consider intubation for airway protection before EGD

**Labs:**
- Hemoglobin: 6.8 g/dL
- Platelets: 68,000
- INR: 2.1
- Total bilirubin: 4.2

**EGD Findings:**
- Large esophageal varices with active bleeding
- Band ligation performed
- Hemostasis achieved

### Disposition
- ICU admission
- Continued octreotide x 5 days
- Transfusion to Hgb >7 (cirrhotics)
- Hepatology consultation
- Liver transplant evaluation discussion
- TIPS evaluation if rebleeds
- Discharged day 6 with propranolol, close follow-up

### Central Line Complications to Know

**Immediate:**
- Arterial puncture
- Pneumothorax (IJ, subclavian)
- Hematoma
- Air embolism
- Arrhythmia (wire in heart)

**Delayed:**
- Infection (CLABSI)
- Thrombosis
- Catheter malposition

### Teaching Points

1. **Don't delay resuscitation for CVC:** IO is fast and effective bridge
2. **Site selection matters:** Coagulopathy → avoid subclavian; pneumothorax risk assessment
3. **Ultrasound guidance is standard:** Reduces complications, improves success
4. **Maximum barrier precautions:** Reduces infection; full sterile field
5. **Confirm venous access:** Non-pulsatile blood, transduced waveform, ultrasound visualization
6. **Femoral for emergencies:** Fast, compressible, no pneumothorax; higher infection risk acceptable short-term
7. **CVC allows vasopressors:** Peripheral vasopressors only appropriate temporarily
8. **Remove as soon as possible:** Daily assessment of CVC necessity

### Clinical Image
![Ultrasound-Guided Central Venous Access](case_03_image.jpg)

**Image Description:** Ultrasound image demonstrating femoral vein access with the needle visible entering the femoral vein (medial, compressible) with the femoral artery (lateral, pulsatile, non-compressible) visible for reference.

**Attribution:** Image from Wikimedia Commons, Ultrasound guided central line. Licensed under CC BY-SA 4.0. Source: https://commons.wikimedia.org/wiki/File:Ultrasound_guided_central_venous_catheterization.jpg