This card covers the standard triple-lumen catheter — drugs, monitoring, everyday central access. Need large-bore volume for massive transfusion instead? See card 14 — Resuscitation Line (Cordis / AVA 3Xi).
FIG 1 · RIGHT IJ ACCESS UNDER ULTRASOUND
Right IJ preferred — anterolateral to the carotid, compressible, straight run to the SVC. Never advance the needle toward the carotid.
FIG 2 · TRIPLE LUMEN vs INTRODUCER — SAME DRAWING AS CARD 14
THREE PORTS, NOT MORE FLOW
~1.6–3.1 L/h per lumen
Drugs and monitoring — not volume
Same two devices, same drawing, same colors as card 14 — only the emphasis changes. This card is the triple lumen: three ports for drugs and monitoring, each of them flow-limited. If the reason for the line is volume, the device you want is the introducer, not a bigger CVC.
EQUIPMENT — GATHER / CHECK
IN THE KIT — 8 ITEMS · ROOM 7 (RESUS BAY) CABINET · VASCULAR ACCESS
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 this is for volume rather than drugs, you want the resuscitation line instead — see card 14. Build sheet and expiry card.
SITE, POSITION & PREP
SELDINGER — STEP BY STEP
KEY NUMBERS
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
Sources: The Procedures Course — CVC Reference, Alfred STAR Program (Alfred Health, Melbourne): the equipment panel is the Alfred kit (bowls/gallipot/dressing tray; chlorhexidine 2% in 70% alcohol or povidone prep with 15 cm foam applicators; suture kit with 3/0 non-absorbable; disposable 10/11 scalpel; syringes and needles by gauge; gauze; Biopatch; Tegaderm 10×12 + 6×7; non-return caps ×4) and positioning (supine, head neutral, cervical collar applied in trauma). Site selection, Seldinger steps, depths, and coagulopathy numbers paraphrased from StatPearls — Central Venous Catheterization, wikem.org — Central venous catheterization, and litfl.com — Central Venous Catheters. Depth formulas are approximations (±2 cm) — confirm tip position on CXR. Flow rates are gravity max-flow figures (18 g lumen ~26 mL/min, 16 g/brown lumen ~52 mL/min, 8.5 Fr sheath ~126 mL/min) from emupdates.com — Flow Rates of Various Vascular Catheters (citing the ETM Course large-bore IV showdown and Traylor 2016 ACEP abstract) — real flow will be lower and device-dependent.
— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.
A second bag in the same section. The provider takes the insertion kit; the nurse takes this one. Two bags rather than one long list, because they are opened by different people at different moments.
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 — all four were on an earlier version of this list and are not in the current build. Lidocaine 1% from the Omnicell.
Contents are the department’s own typed kit sheet, supplied 2026-08-14 — it supersedes both earlier reconstructions. Still worth checking against the physical bag on the next cart walk. Instruments are peel-packed singly: thirteen packs, thirteen expiries, so the check card is per pack. The drain never gates the incision — finger thoracostomy decompresses on its own and needs no drain at all. The RN primes the UWSD in parallel, ready before the TUBE is connected. Sizes live loose on the shelf, not in the bag. Build sheet and expiry card.
INDICATIONS
FINGER THORACOSTOMY — IN ARREST THIS IS THE WHOLE PROCEDURE
A drain is a separate decision, made later. If the patient survives to need one, the kit, prep and technique for it are the rest of this card.
PREP — MD AND RN IN PARALLEL
Two columns because these run at the same time, not in order. Neither list waits for the other, and nothing here delays decompression.
MDMD PREP
RNRN PREP
TECHNIQUE — STEP BY STEP
PREVIEW — roles on this card only. RN steps run in parallel, not after.
KEY NUMBERS
SITE 4–5TH ICS · ANT–MID AXILLARY · INCISION 2–4 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 → THORACOTOMY CALL
PITFALLS & PEARLS
Sources: The Procedures Course — Chest Tube Reference, Alfred STAR Program (Alfred Health, Melbourne): indications (drainage of pleural air/fluid; pleural lavage in severe hypothermia) and thoracic-trauma epidemiology (thoracic injuries primarily responsible for ~25% of trauma deaths and contributing to a further 25%; >85% of thoracic trauma needs no thoracic surgery; tube thoracostomy in ~25% of Alfred major trauma). Equipment, steps, and numbers paraphrased from litfl.com — Finger Thoracostomy, litfl.com — Intercostal Catheter Insertion, litfl.com — Own the Chest Tube, and wikem.org — Finger thoracostomy. Hemothorax tube size is disputed (modern 28–32 Fr vs older 32–36 Fr teaching) — follow local practice.
— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.
04Emergency Burr Hole (Craniotomy)
HERNIATING + NEUROSURGERY FAR AWAY
See Isolated Head Trauma for the surrounding triage and herniation-treatment ladder.
⚠ LOCALIZE THIS CARD: a last-resort temporizing procedure for a herniating patient with a CT-proven extra-axial hematoma when neurosurgical care is hours away. Agree in advance with your referral neurosurgeons whether, when, and how this would ever be done here — ideally with them on the phone in the moment.
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
IN THE KIT — 9 ITEMS · TRAUMA CART · SHELF A
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. A non-clutched bit in this tray is a hazard, not a spare. Build sheet and expiry card.
DECISION & SITE
DRILL — STEP BY STEP
KEY NUMBERS
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
Sources: The Procedures Course — Craniotomy Reference, Alfred STAR Program (Alfred Health, Melbourne): burr-hole landmark diagram (temporal hole above the zygomatic arch, anterior/superior to the ear (external auditory meatus), over the middle meningeal artery; parietal hole posterosuperior; external landmarks — ear, mastoid, zygomatic arch, coronal/sagittal sutures, sigmoid sinus) — the figure above is a redrawn schematic of that diagram. Frontal-site landmark (~10 cm above the eye in the mid-pupillary line) and prophylactic antibiotic (cefazolin 2 g IV) follow litfl.com — Procedure: Craniostomy Instructions, an Alfred Health emergency-procedure card — this supersedes an older internal reference that gave the frontal site as "3 cm off midline at the coronal suture" (same general neighborhood, different landmark convention). Additional gate, equipment, drill steps, and neuroprotection numbers paraphrased from wikem.org — Burr hole and emcrit.org — Burr Holes / Craniotomy (IO-drill discussion). Verify with your neurosurgeon. Drill device (Codman disposable perforator) reflects this site's actual stocked equipment — relabel this line if your site stocks a different brand.
— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.
08Escharotomy
BURNS · PERFUSION OR VENTILATION FAILING
See Burn for TBSA estimation, fluid resuscitation, and transfer criteria.
FIG 1 · ESCHAROTOMY LINES
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
IN THE KIT — 8 ITEMS · ROOM 7 (RESUS BAY) CABINET · PROCEDURE TRAYS
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 — the eschar is insensate, the margins are not.
DRAFT — not yet assembled or signed off. Draw the lines before you cut. Released eschar edges bleed — have the hemostatics open first. Build sheet and expiry card.
DECISION
TECHNIQUE — STEP BY STEP
KEY NUMBERS
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
Sources: The Procedures Course — Escharotomy Reference, Alfred STAR Program (Alfred Health, Melbourne): definition (incision of inelastic eschar impairing extremity perfusion or restricting chest-wall movement/ventilation), the two indications, limb hypoperfusion occurring with circumferential AND non-circumferential burns, and the explicit note that there is insufficient evidence for any specific standard or test to decide the need for escharotomy. Consult-before-cutting guidance from vicburns.org.au — Escharotomy (Victorian Adult Burns Service at The Alfred). Incision lines, depth, triggers, and structures-at-risk paraphrased from wikem.org — Escharotomy and emcurious.com — The Escharotomy (2015); nerve specifics are standard burns teaching — verify with your burn center.
— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.
The cantholysis — cutting the inferior crus of the canthal tendon — is the step that decompresses the orbit; the canthotomy alone is just the exposure.
TRAUMA CART · DRAWER 6 — CANTHOTOMY KIT zip-lock bag, wrapped in the poster, behind the drawer label
EQUIPMENT — GATHER / CHECK
IN THE KIT — 6 ITEMS, ZIP-LOCK
ALSO NEEDED — NOT IN THE KIT
DECISION
TECHNIQUE — STEP BY STEP
KEY NUMBERS
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
Sources: The Procedures Course — Quick Reference (lateral canthotomy), Alfred STAR Program (Alfred Health, Melbourne): decompression endpoint (tendon firmness lost, lower lid freely evertable, yellow orbital fat visible; re-assess the eye), post-procedure care (eye left exposed, trimmed polystyrene cup for transport, antibiotic ointment, urgent ophthalmology), pitfalls (failure to expose/cut the inferior canthal tendon as the commonest pitfall; iatrogenic globe injury as the most serious complication; 60–90 min critical ischemia time). Triggers, crush-cut-strum steps, and equipment paraphrased from alfredemergency.org — Orbital Decompression / Lateral Canthotomy (Alfred Emergency Academic Centre) and eyewiki.org — Retrobulbar Hemorrhage. The ischemia window is disputed (Alfred 60–90 min; others cite irreversible retinal ischemia by ~90–120 min) — treat it as “minutes matter”.
— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.
02Resuscitative Thoracotomy
TAMPONADE ON ULTRASOUND · IN EXTREMIS
⚠ LOCALIZE THIS CARD: confirm whether ED thoracotomy is within your facility's scope, who is credentialed, and your surgical-backup/transfer reality before an event — a rural ED without immediate surgical backup must decide this in advance, not at the bedside.
FIG 1 · CLAMSHELL INCISION
Follow the infra-mammary crease bilaterally and cut the sternum transversely — pericardium opened vertically, in front of the phrenic nerve.
EQUIPMENT — GATHER / CHECK
IN THE KIT — 9 ITEMS · TRAUMA CART · SHELF A
ALSO NEEDED — NOT IN THE KIT
PPE (gown, DOUBLE gloves, eye protection) and splash prep are on the cart, not in the tray — you put them on before you open it. 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. Build sheet and expiry card.
PATIENT SELECTION — THE DECISION IS THE PROCEDURE
SEQUENCE — STEP BY STEP
CLAMSHELL EXTENSION — WHEN THE RIGHT CHEST IS BLEEDING
CLOSE THE HEART — PICK THE FASTEST THING THAT HOLDS
HILAR TWIST — MASSIVE UNILATERAL LUNG BLEEDING
KEY NUMBERS
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
Sources: The Procedures Course — Thoracotomy Reference, Alfred STAR Program (Alfred Health, Melbourne): reversible-pathology framing (tamponade from a low-pressure chamber laceration, occult without external signs/ECG changes), ultrasound-driven selection, poor outcome with no signs of life + PEA at arrival, reserve for in-extremis patients with proven tamponade on ultrasound; Alfred data 2008–2013: 9 survivors of 27 ED thoracotomies, 89% performed for blunt trauma. Clamshell steps and numbers paraphrased from litfl.com — Resuscitative Thoracotomy and emcrit.org — Procedure of Thoracotomy. Cardiac-wound suture (3-0 nonabsorbable monofilament — nylon or prolene) follows the Western Trauma Association — Resuscitative Thoracotomy algorithm (Note D). Published downtime cutoffs are disputed (≈10 min penetrating / 5 min blunt in LITFL; some services extend penetrating to 15 min) — agree on your gate in advance.
Clamshell extension, cardiac repair and hilar twist (added 2026-08-20): the clamshell sequence, internal-mammary control and the hilar-twist steps follow litfl.com — Resuscitative Thoracotomy and emcrit.org — Procedure of Thoracotomy. Cardiac-wound options (finger occlusion, Foley balloon, skin staples, pledgeted horizontal-mattress repair, passing a suture beneath a coronary, side-biting clamp or purse string on the atrium) follow the Western Trauma Association Resuscitative Thoracotomy algorithm. The Lebsche knife is listed as an alternative to the Gigli saw because both appear in these sources; stock whichever your tray carries.
— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.
07Transvenous Pacing (TVP)
AFTER DRUGS + TRANSCUTANEOUS FAIL
EQUIPMENT — GATHER / CHECK
IN THE KIT — 6 ITEMS · ROOM 7 (RESUS BAY) CABINET · TRANSVENOUS PACING
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 — those are the backup, not the kit.
DRAFT — not yet assembled or signed off. Find the generator and check its battery on the monthly check — the night you need this is the wrong time to discover a flat one. Build sheet and expiry card.
DECISION & ACCESS
FLOAT, CAPTURE & SETTINGS — STEP BY STEP
KEY NUMBERS
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
FIG 1 · GENERATOR SETTINGS TO FLOAT
Set rate and output before floating; confirm mechanical capture, then turn down to find threshold and set the final output.
Sources: The Procedures Course — TVP Reference, Alfred STAR Program (Alfred Health, Melbourne): definition (pacing-wire electrode into the right ventricle for electrical stimulation), place in the escalation ladder (after pharmacotherapy and transcutaneous pacing fail), bradyarrhythmia indication list. Equipment and floating sequence paraphrased from emcrit.org — Transvenous Pacemakers (EMCrit 310). Pacing rate (80/min) and output setting (2× threshold) follow wikem.org — Transvenous pacing — EMCrit's alternative of 2× intrinsic rate / 2.5–3× threshold is also reasonable; pick one convention and use it consistently. Femoral access is intentionally omitted here — right IJ/subclavian only. Generator models and default behaviors vary — know your own device before the night you need it.
— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.
The commonest binder error is placing it on the iliac crests, where it looks right and does nothing — the band has to sit over the greater trochanters, level with the hip joints, to actually reduce pelvic volume. Cut clothing away and apply to skin.
EQUIPMENT — GATHER / CHECK
DECISION
TECHNIQUE — STEP BY STEP
KEY NUMBERS
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
Sources: Joint Trauma System CPG, Pelvic Fracture Care, ID 34, 17 Feb 2026. StatPearls, "EMS Pelvic Binders" (NBK598968) and "Pelvic Trauma" (NBK556070). LITFL, "Pelvic Binders" and "Pelvic Binders Instructions." Wohlford L, "Unstable Pelvic Trauma Patient," emDocs, Jun 2023. Emergency Medicine Cases, Episode 119 (Helman, Bosman, Hicks, Petrosoniak), Jan 2019. Biffl WL, "Control of pelvic fracture-related hemorrhage," Surgery Open Science 2022;8:23-26. Shackelford S, et al., "The Use of Pelvic Binders in TCCC: Guidelines Change 1602," J Spec Oper Med 2017 (sheet-vs-device equivalence and a real-world mortality disparity attributed to technique variability, not device choice).
— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.
10Tourniquet Application
LIFE-THREATENING EXTREMITY HEMORRHAGE
For groin/axilla/neck-base bleeding, see Junctional Hemorrhage Control instead — a limb tourniquet doesn't work there.
FIG 1 · LIMBS ONLY — WHERE THE TOURNIQUET GOES
2–3 IN ABOVE THE WOUND
On skin · not over a joint
Tighten until the pulse is gone
Limbs only. Place 2–3 inches proximal to the wound, directly on skin, clear of any joint — over a joint it cannot compress the vessel. Tighten until the distal pulse is gone; a tourniquet that still allows a pulse is a venous tourniquet and will increase bleeding. Write the time on it.
EQUIPMENT — GATHER / CHECK
DECISION
TECHNIQUE — STEP BY STEP
KEY NUMBERS
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
Sources: Tactical Combat Casualty Care (TCCC) Guidelines, current edition, Committee on TCCC. American College of Surgeons, Stop the Bleed, "Bleeding Control for the Injured," 2017. Faculty of Pre-Hospital Care (Royal College of Surgeons Edinburgh), Position Statement on the Application of Tourniquets, Jul 2017. Pons PT, "Stop the Bleed: 8 Pitfalls to Avoid in Hemorrhage Control," Trauma System News, 2017/2021. American Red Cross Scientific Advisory Council, pediatric tourniquet use review. Note: a 2025–2026 CoTCCC proposed change (Koch et al., J Spec Oper Med 2026) would formalize mandatory 2-hour reassessment — check for a newer numbered TCCC release before treating that as adopted.
— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.
IN THE KIT — 5 ITEMS · TRAUMA CART · DRAWER 3 · HEMORRHAGE CONTROL
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 a bridge, not a repair. The surgical airway kit is open at the bedside BEFORE any intubation attempt in a penetrating neck injury. Build sheet and expiry card.
DECISION — ZONES & SIGNS
IMMEDIATE PRIORITIES
KEY NUMBERS
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
Sources: StatPearls, "Neck Trauma" (Alao & Waseem, NBK470422). EAST Practice Management Guideline, Penetrating Neck Injuries (Tisherman et al., J Trauma 2008;64(5):1392-1405). Western Trauma Association, Critical Decisions — Penetrating Neck Trauma algorithm. Sperry JL, et al., J Trauma Acute Care Surg 2013; Chandrananth J, et al., systematic review, ANZ J Surg 2021 (no-zone approach). J Trauma Acute Care Surg 2024 diagnostic review, PMID 38523116. Navsaria PH, et al., "Foley Catheter Balloon Tamponade," World J Surg 2006; Scriba MF, et al., World J Surg 2020 (technique update).
— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.
12Junctional Hemorrhage Control
GROIN · AXILLA · NECK BASE
Where a standard limb tourniquet doesn't work — for a limb wound, see Tourniquet Application.
FIG 1 · AXILLA / GROIN — WHERE PACKING GOES
EQUIPMENT — GATHER / CHECK
IN THE KIT — 5 ITEMS · TRAUMA CART · DRAWER 3 · HEMORRHAGE CONTROL
ALSO NEEDED — NOT IN THE KIT
A dedicated junctional tourniquet (SAM Junctional, CRoC, JETT) if your department stocks one — most rural EDs do not, and the card says so rather than pretending otherwise.
DRAFT — not yet assembled or signed off. Packing is a two-hand job with your whole weight behind it. Stock enough gauze that nobody has to stop and go looking mid-pack. Build sheet and expiry card.
DECISION
TECHNIQUE — STEP BY STEP
KEY NUMBERS
PACK DIRECTLY INTO THE CAVITY, NOT OVER THE SURFACE HOLD PRESSURE ≥3 MIN — DON'T PEEK 2 FAILED PACKING ATTEMPTS → ESCALATE
PITFALLS & PEARLS
Sources: StatPearls, "EMS Junctional Hemorrhage Control" (NBK597371). Tactical Combat Casualty Care (TCCC) Guidelines, current edition, Committee on TCCC (hold time, hierarchy, iTClamp adoption). JEMS, "Wound Packing Essentials for EMTs and Paramedics." J Spec Oper Med, TCCC Proposed Change 19-04 (iTClamp), Jun 2019. Joint Trauma System CPG, "REBOA for Hemorrhagic Shock," ID 38, rev. 2025–2026 (brief cross-reference only).
— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.
13JADA System Insertion
PPH · VACUUM-INDUCED UTERINE TAMPONADE
Second-line device, after uterotonics — see Postpartum Hemorrhage engine for the full pathway. Stocked in the PPH drawer (Drawer 4).
EQUIPMENT — GATHER / CHECK
IN THE KIT — 6 ITEMS · OB / NEONATAL CART · DRAWER 4 · POSTPARTUM HEMORRHAGE
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; confirm it exists and works.
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, not at the bedside. Build sheet and expiry card.
DECISION
TECHNIQUE — STEP BY STEP
MONITORING & REMOVAL
KEY NUMBERS
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
FIG 1 · JADA SYSTEM — VACUUM SETTING
80 ± 10 mmHg
Vacuum · never exceed 90
Seal: fluid, never air
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. Lives in PPH / drawer 4.
Sources: Organon (Alydia Health), JADA System Instructions for Use ("white seal" variant), organon.com — indications, contraindications, device description, insertion/vacuum-connection steps, removal technique, and warnings (air-embolism, perforation/inversion risk). Cross-checked against Canada's Drug Agency (CADTH) Horizon Scan, "Vacuum-Induced Uterine Tamponade for Postpartum Hemorrhage," NCBI Bookshelf NBK596675, which independently confirms the 80±10 mmHg standard vacuum and 24-hour maximum dwell, and additionally notes the device has not been evaluated for uteri <34 weeks gestational size, coagulopathy, or placenta accreta — added here as a caution, not a manufacturer contraindication. If the two sources are ever superseded by a newer IFU revision, defer to the label in the box.
— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.
14Resuscitation Line (Cordis / AVA 3Xi)
LARGE-BORE ACCESS · MASSIVE TRANSFUSION
Also called: cordis, code line, big line, MTP line. Not the same device as a standard triple-lumen CVC (card 06) — see the DECISION section for when to choose this instead.
FIG 1 · RIGHT IJ ACCESS — LARGE-BORE INTRODUCER
FIG 2 · INTRODUCER / AVA 3XI — VOLUME LINE
FLOW, NOT LUMENS
~7.6 L/h vs ~1.6–3.1 L/h per lumen
Massive transfusion goes here
Three lumens do not mean three times the flow — a triple-lumen CVC is flow-limited on every port, including its biggest. 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. Distinct from a plain triple-lumen CVC (card 06), which has no large-bore lumen at all.
EQUIPMENT — GATHER / CHECK
IN THE KIT — 8 ITEMS · ROOM 7 (RESUS BAY) CABINET · VASCULAR ACCESS
ALSO NEEDED — NOT IN THE KIT
Full barrier kit (gown, gloves, cap, mask, large drape) from the shelf. Pressure bag or rapid infuser if this line exists for massive transfusion — gravity alone wastes the bore you just paid for.
DRAFT — not yet assembled or signed off. The dilator is larger than a standard CVC dilator. Do not mix this tray with the triple-lumen trays on the same shelf — that swap is the one that wastes minutes in a transfusion. Build sheet and expiry card.
DECISION — WHEN TO PLACE THIS INSTEAD OF A PLAIN TRIPLE-LUMEN
TECHNIQUE — STEP BY STEP
KEY NUMBERS — FLOW RATE BY ACCESS (GRAVITY, THEN PRESSURE-BAGGED)
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
Sources: Site selection, Seldinger steps, depths, and coagulopathy cautions are shared with card 06 — see that card's sources (The Procedures Course/Alfred STAR Program, StatPearls NBK557798, wikem.org, litfl.com). AVA 3Xi device description (large-bore introducer + integrated triple-lumen infusion catheter, single-stick placement) per Edwards Lifesciences product literature, cross-referenced via graylinemedical.com kit-contents listings. General Cordis/MAC-type introducer sizing (8–11 Fr, 11 cm IJ / 23 cm femoral lengths) and comparison framing per eddyjoemd.com. Flow-rate figures (peripheral IV, triple-lumen CVC ports, 8.5 Fr introducer gravity/pressure-bagged) from emupdates.com — Flow Rates of Various Vascular Catheters (citing the ETM Course large-bore IV showdown and Traylor 2016 ACEP abstract) — real flow will be lower and device-dependent; pressure-bagged figures assume ~300 mmHg.
— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.
15SALAD — Suction-Assisted Laryngoscopy
CONTAMINATED AIRWAY · DECONTAMINATE THEN INTUBATE
FIG 1 · THE THREE TRAJECTORIES — ONE CATHETER, THREE TIP POSITIONS
1FROM THE GUT— haematemesis, obstruction, intoxication, GLP-1 agonists Park the tip in the proximal esophagus as a continuous drain. Decompress the stomach first if you can.
2FROM THE LUNG— hemoptysis, pulmonary edema, drowning Take the tip to the laryngeal inlet and follow the froth. Cuffed tube, positive pressure and PEEP, urgently.
3FROM ABOVE— maxillofacial hemorrhage, epistaxis, post-tonsillectomy bleed Navigate with it and stop high. Do NOT park deep — the source is above you. Control the bleeding itself.
CODE CART · DRAWER 4 — SUCTION · ROOM 7 CABINET — AIRWAY two rigid large-bore catheters, tubing and a meconium aspirator live with the suction · cart label · door label
WHEN — AND THE ONE IDEA THAT MAKES IT WORK
THE THREE TRAJECTORIES — WHICH WAY IS IT COMING FROM?
SETUP — BEFORE YOU GIVE THE DRUGS
IN THE KIT — SALAD SUCTION KIT
POSITION AND PRIME
THE SEQUENCE
PITFALLS
HOW GOOD IS THE EVIDENCE? — THIN, AND WORTH SAYING SO
KEY NUMBERS
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
— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.
16Pigtail Chest Tube (Seldinger)
SMALL-BORE THORACOSTOMY · TRIANGLE OF SAFETY
FIG 1 · WHERE THE NEEDLE GOES IN — AND OVER THE TOP OF THE RIB
The green check is where you go in Middle of the triangle, 4th–5th intercostal space, mid- to anterior-axillary line. The same mark appears in the rib view, so the two panels are one place seen two ways.
The triangle of safety Anterior border pectoralis major, posterior border latissimus dorsi, floor the 5th intercostal space at nipple level, apex the base of the axilla. Never below the nipple line — that is diaphragm, and under it liver, spleen and stomach.
Red is the artery, and it lives under the rib The neurovascular bundle runs along the lower border of each rib. Hug the upper border of the rib below and you pass under it. This is the one rule on this card with a vessel behind it.
FIG 2 · SELDINGER — THE TAIL COILS IN THE PLEURA
ROOM 7 (RESUS BAY) CABINET · CHEST DRAINAGE pigtail catheters, chest tubes, primed drain and suture · door label
IS A PIGTAIL THE RIGHT TUBE?
SIZE AND SITE
ULTRASOUND
THE SELDINGER SEQUENCE
DRAINAGE, COMPLICATIONS, PITFALLS
THE KIT
IN THE KIT — PIGTAIL THORACOSTOMY
KEY NUMBERS
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: Pneumothorax meta-analysis and the P-CAT hemothorax trial — REBEL EM, Pigtail vs large-bore and Traumatic hemothorax; emDocs on P-CAT (early termination, stable-patients-only caveat). Triangle of safety, above-rib rule, lidocaine limits, wire and catheter depths, suction setting and the 1.5 L rule — reviseMRCEM chest drain insertion. Sizes by indication, mandatory bedside ultrasound, guidewire loss and large-bore escalation criteria — NHS Scotland adult chest drain protocol. Positioning, equipment list and the underwater-seal height — Merck Manual. Wire-depth alternative, the dilator “give” and the kink check — EP Monthly. Complications — StatPearls Chest tube; re-expansion edema after <1 L — CHEST. Two questions are printed as options with the source on each: pigtail versus large bore for traumatic hemothorax, and how far to advance the guidewire.
— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.