Liver enlargement is detected by downward percussion in the chest, and upward percussion and palpation in the abdomen (figure 61a–e): ascites is detected by shifting abdominal dullness (figure 62 a,b). Pitting edema is best sought below the knee and in the sacral area (figure 63a). When extensive, it may involve the thighs and creep up the anterior abdominal wall. The critical sign is pitting, which occurs when applying light pressure to the skin. This can be demonstrated by pressure in front of the tendo Achilles or over the shins (figure 63b–d). The latter may cause discomfort so watch the patient’s face.

Emergency management of cardiac arrest includes cardiac massage and defibrillation. Another important technique, used usually in hospital, is inserting a needle into the pericardium and the heart, to drain pericardial effusion (pericardiocentesis) and insert drugs (usually adrenalin) into the heart in asystole.

The needle is inserted in the angle between the xiphisternum and the left costal margin, and directed at the inferior angle of the left scapula. This direction is at approximately 45 degrees to the sagittal, coronal and transverse planes (figure 66).  64