ORALS - PROCEDURES Flashcards
PROCEDURE
CCPS
Consent
Contraindications
PPE
Sterile
How to consent
VIC
Voluntary - Ensure consent is voluntary + specific to the treatment plan
Informed - Ensure patient is informed / understands risks, benefits + options of treatment
Assess capacity (KAC – knowledge of options, awareness of consequences/personal cost benefit, consistency of choice)
CHEST TUBE INSERTION
Position – supine
Landmark – arm above head and expose lateral chest
- Anterior axillary line, Intercostal space, 4th / 5th rib
- (pregnancy) – 3rd rib space
Analgesia – infiltrate skin + pleura with lidocaine
Procedure
- #10 scalpel
- 3cm incision to skin and subcutaneous tissue over the rib
- Blunt dissection with Kelly clamp => to pleura over superior portion of rib to avoid NV bundle
- @ pleura – penetrate pleura with Kelly clamp
- Spread clamp to increase pleural defect diameter
- Insert finger and check for adhesions
- Insert chest tube along my finger => posterior + superior (pneumothorax) / posterior + inferior (hemothorax)
- Connect to underwater seal device, secure using 1.0 silk and cover with occlusive dressing
CXR, RA vitals
follow up questions
- indications for tube thoracostomy
- traumatic pneumothorax (except asymptomatic apical)
- Mod (15%-60%) to large PTX (remember small at cupola=3cm)
- Resp symptoms regardless of size
- Increasing size after conservative treatment
- Recurrence following removal of CT
- Mechanical vent
- Requires GA
- Bilateral
- Tension PTX
- Empyema
- HTX - Complications of a tube thoracostomy
infection
intercostal vessel laceration
lung parenchymal injury
solid organ injury
re-expansion pulm edema
bronchopleural fistula - Indications for a thoracotomy post chest tube placement
>1500cc initial (>20cc/kg => 15cc/kg peds)
>200cc/hr / 3hrs (7cc/kg/hr x3 => 2cc/kg peds)
incr HTX on rpt CXR
continued hypotension despite blood
ED THORACOTOMY
Assign an additional ERP to concurrently perform:
- a R mainstem intubation to deflate the L lung
- Insert NG to identify the aorta
Position – supine + secured above head
Procedure –
- #10 blade, incision through skin + SQ tissue
- Cut through pec + serratus muscle along 4th rib along the inframammary line and extend from sternum past posterior axillary line
- Blunt scissors – cut intercostal muscles over superior rib to avoid the NV bundle
- Cut parietal pleura with same scissors => Enter chest cavity => increase visual field with rib spreader and ensure cross bar
- Address fatal injuries by
1. Pericardiotomy => forceps, lift pericardium + cut anterior + parallel to phrenic nerve (avoid nerve + coronary artery injury)
2. Direct hemorrhagic control => inspect heart, close defects using a foley or 3.0 non absorbable sutures
3. Cross clamp aorta with debakey clamp => run hand along posterior rib cage towards vertebral column + aorta
Use NG in esophagus to identify
aorta
4. Hilar twist / clamping the hilum
5. Cardiac arrest – use internal defibrillators (20-50J) for shockable rhythms
follow up questions
1. indications for ED thoracotomy
Blunt, SOL, 10min CPR (WEST)
penetrate, SOL, 15min CPR (WEST)
Refractory shock, SBP 60 (WEST)
Suspected air embolus (ROSENS)
Penetrate, SOL (EAST, strong)
Pentetrate, noSOL (EAST, conditional)
Penetrate, extrathoracic +/- SOL (EAST, conditional)
Blunt, SOL (EAST, conditional)
BLUNT, no SOL (EAST, NOT recommended)
- Signs of traumatic aortic dissection on CXR
wide mediastinum
NG displacement
trachea displaced
L mainstem depressed
L pleural apical cap
loss of aortic knob
loss of PA window
wide paratracheal stripe
L HTX - Signs of esophageal rupture on CXR
mediastinal air
L pleural effusion
PTX
wide mediastinum
pulmonary infiltrates
THORACOTOMY / AIR EMBOLISM
Position – trandelenburg position
Procedure –
- Perform left thoracotomy.
- Flood thorax with saline
- Look for bubbling under PPV
No source
Extend thoracotomy to opposite side
Source found
Control broncho-venous fistula
Needle aspirate air from R + L ventricle
PULSUS PARADOXUS
Procedure –
- Inflate BP until no sound
- decrease pressure until systolic sound during expiration (record this number)
- continue to decrease until sounds are throughout respiratory cycle (record this number)
- difference >10mmHg = pulsus paradoxus
PERICARDIOCENTESIS
Position – semi-fowlers position (20-30deg)
Procedure –
- ultrasound guidance for landmarking
- 16 gauge, 15cm angio catheter with 35cc syringe, 1-2cm left of xiphochondral junction or where the largest pocket of fluid is visualized
- Insert needle at 45 degree angle, direct towards left shoulder under negative pressure
- When fluid flash – advance catheter and withdraw needle
- Connect 3 way stopcock and withdraw as much blood as possible
- Secure catheter
TRANSVENOUS PM
Ensure adequate sedation and analgesia and that the patient is on cardiac-respiratory monitors
Prepare equipment: Check pulse generator for new batteries
Position – supine with neck exposed
Procedure –
- ultrasound guidance for landmarking
- use seldinger to insert cordis into right IJ
- check for balloon leaks
thread pacing wire through sterile sleeve
connect pacing wire to pulse generator
settings: asynchronous mode, rate 80, output of 5mA
- insert pacing wire through the cordis
- @15cm – inflate balloon and float wire into the RV
- Watch for widening QRS – associated with pacer spike to ensure you’ve obtained capture
- Deflate the balloon
- Turn down output until capture is lost and increase output to 2x this
- Confirm mechanical capture
- Secure wire at this level, ensure generator is secured, and secure the cordis with a suture + place a dressing overtop of the site
Obtain a post procedure CXR
PROCEDURAL SEDATION
Obtain consent
Obtain history – previous anesthetics, respiratory history. PMDHX [ if ASA 3-4 would consider anesthesia]
Examine airway using my LEMONS, MOANS, RODS + SMART mnemonic
Gather supplies including
- Suction, NP, BVM
- Airway cart and intubation tray
Gather team including = RN, RTs and fellow ERP to perform procedure
Place patient on cardiac-respiratory monitoring
- Cycle BP Q3min
- Supply O2 for comfort + monitor ETCO2
- Ensure functional IV
I will ask for 20mg ketamine and propofol in 20mg aliquots until sedation is achieved
SHOULDER REDUCTION
Ensure adequate sedation and analgesia
Document neurovascular status
ANTERIOR REDUCTION
External rotation - supine with arm fully adducted + elbow flexed 90deg
- Holding wrist => externally rotate until reduced
Milch Technique – abduct arm to overhead position + longitudinal traction with ER
- Apply pressure to humeral head towards GH joint
Traction/counter traction – wrap sheet around affected axilla + across chest
- Require assistance to provide counter traction + I will pull patient’s arm + adducted
Cunningham – sitting, adducted arm + flexed elbow. My arm btwn their forearm + body and apply downward traction
- Massage delt, trap + bicep
- Ask patient to shrug / move shoulder superiorly
Stimson – prone with 5kg weight attached to arm hangs over edge
- 20-30min
POSTERIOR REDUCTION – TRACTION / COUNTERTRACTION
- Sheet around affected axilla + across chest
- Assistant use sheet to provide counter traction
- I’ll grab arm and lean back
- Apply internal rotation + anteriorly directed pressure on humeral head
Post reduction
- Sling
- Post reduction XR
- Post reduction NV exam
- Arrange ortho follow up
RADIAL HEAD SUBLUXATION
Ensure adequate sedation + analgesia
Document neurovascular status
Hold elbow with non dominant hand
hold forearm while hyperpronating forearm while elbow is flexed
I will then supinate and flex elbow until I feel a click
Post reduction
- 30min obs
- Not using arm? => XR +/- ortho f/u
POSTERIOR HIP REDUCTION
Whistler
- Supine, Flex knee 130deg
- Stand next to limb, arm under knee + hold unaffected knee
- Other hand grabs affected ankle
- Elevated leg using arm as lever as shoulder is raised
- Assistant to stabilize pelvis
Stimson
- Prone with pelvis off edge of bed, hips + knees flexed 90deg
1 person => apply downward traction over posterior prox tibia
2nd person - push greater trochanter towards acetabulum
internal and external rotation of hip
Captain Morgan
- Supine
- Flex hip. Knee to 90deg
- Place knee under affected limbs knee, hold ankle
- Upward force by plantar flexing my food
- Post reduction – affected limb in extension
ANTERIOR HIP REDUCTION
Modified Allis
- Supine
- Assistant to place pressure over ASIS + stabilize
- Flex affected knee + hip
- Apply in line traction
- ADDUCT + internally rotate
Anterior => FABER (ABduct, Externally rotated)
ABI/API
Procedure – ABI (Ankle / Brachial Index)
- BP cuff on upper, non injured limb
- Doppler placed over brachial artery over identify the arterial pulse
- Inflate cuff until brachial pulse goes away
- Deflate until sound (systolic pressure)
- Repeat same procedure on lower leg using posterior tibial / dorsalis pedis pulse (using doppler)
- Calculate ABI (ankle SYSTOLICS / arm SYSTOLICS)
- 0.9 – abnormal
Procedure – API (Arterial Pressure Index)
- BP cuff => upper non injured limb
- Doppler on uninjured limb => listen for arterial pulse (posterior tibial / dorsalis pedis pulse)
- Inflate cuff until arterial pulse is gone
- Deflate until sound (Systolic pressure)
X2 on injured limb
- Calculate API (injured SYSTOLIC / uninjured SYSTOLIC)
0.9 abnormal = OR/angio (1 = obs x12-24h)
follow up questions
1. Hard signs of popliteal injury (MARD)
Mottled / cool
Arterial popliteal hemorrhage
Rapid expanding popliteal hematoma
Distal pulse deficit
IO INSERTION
C/I: # bone, prior use of bone for an IO
- Overlying burn / infection
- Osteogenesis imperfecta, osteoporosis
Landmark:
PROX TIBIA: 2 fingerbreadths below tibial tuberosity + 1 fingerbreadths medial
DISTAL TIBIA: medial surface of tibia @ junction of medial malleolus + shaft of tibia
DISTAL FEMUR: 2-3cm above femoral condyles midline, direct 10degrees cephalad (use in peds)
HUMERUS: internally rotate, 1cm superior to surgical neck on greater tubercle (use large, 4.5cm needle)
Procedure –
- Prime IO line + select needle
- Stabilize distal limb with non-dominant hand + insert needle perpendicular to skin
- Penetrate bone cortex – remove stylet, connect tubing
- Confirm placement – aspirating marrow + secure IO with tape
- Conscious patient – infuse 1-2cc of 1% lidocaine for analgesia
