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
RETROGRADE CYSTOGRAM
Ensure no urethral injury – insert foley catheter under sterile technique
Position – supine
PRE-contrast KUB
Remove plunger from 60cc catheter tip syringe + attach to foley
Hold syringe uprignt + above level of bladder
400cc of 10% water soluble contrast
End points:
- Full 400cc administered
- Extravasation visualized
- If bladder contracts => wait for contraction to pass and instill an additional 50cc of contrast
Once bladder is full:
- Clamp foley - Take additional XR / CT to look for extrav
- Unclamp foley + take additional XR
RETROGRADE URETHROGRAM
Position – supine + STRETCH PENIS over the thigh to unfold urethra
PRE-contrast KUB
Insert 60cc syringe with Christmas tree adapter/Toomey inserted into distal urethra
60cc of contrast injection over 30-60seconds
Take XR over last 10seconds of contrast injection
End points
- Full 60cc administered
- Extravasation visualized
SUPRAPUBIC CATHETER
Position – supine
Landmark – using US, I would identify the bladder
Analgesia – infiltrate skin + dipper tissues with lidocaine
Procedure
- Seldinger technique – place guide wire into bladder
- Incise small stab along the guide wire
- Pass dilator and sheath over the wire
- Remove dilator + wire, keep sheath in bladder
- Pass foley through the sheath and NFLATE catheter
- Withdraw sheath – leave suprapubic catheter in place
INTRACORPEAL ASPIRATION
Position – supine
Analgesia – ensure adequate analgesia + treat underlying causes
- Perform a penile nerve block
- Inject 1% lidocaine at base of penis (2 + 10 oclock)
- Aspirate before injection to ensure no vein / artery
Procedure
- Use butterfly needle attached to syringe – insert needle into the corpus cavernosum at lateral aspect of penis
- Aspirate blood from one or both sides of the corpus cavernosum
- If still no detumescence – inject 100mcg-500mcg of phenylephrine
- Bandage to prevent re-accumulation
Consult urology for FU if successful
If unsuccessful – urology in ED, consider terbutine
BARTHOLIN ABSCESS DRAINAGE
Ensure chaperone in procedure room
Position – lithotomy position with appropriate draping
Analgesia – stabilize abscess with non dominant thumb and index
- 2cc of lidocaine into mucosa of abscess
Procedure
- 10 blade scapel – stab incision into anesthetized mucosa of abscess
- Hemostat – widen entry into the abscess
- Place sterile word catheter into abscess cavity + inflate balloon with 3cc of saline
- Ensure catheter is draining + secure device in place
Arrange gyne follow up.
Discharge instructions – including catheter removal 2-6wks
LATERAL CANTHOTOMY
Indications => DIPACONE (decr visual acuity, IOP >40, proptosis, AFD, cherry red macula, ophthalmoplegia, nerve head pallor, eye pain)
C/I => globe rupture
Position – sitting
Assistant to help stabilize the head
Analgesia – area of lateral canthus – needle away from globe, 2% lidocaine with epi
Procedure
- Crush lateral canthus with small hemostat (establish hemostasis / minimize bleeding)
- Cut 1cm from rim of orbit using iris scissors
- Pull lower lid down + away from lateral orbital rim with forceps
- Identify inferior crus of lateral canthus tendon and cut using my iris scissors
- Recheck IOP
>40 = cut superior crus
BLAKEMORE TUBE INSERTION
Indications: temporize persistent variceal bleeding (pending endoscopy, TIPS)
C/I: recent gastric / esophageal surgery, hx of strictures
Intubate patient prior to start of procedure
Assign second ERP for intubation / ongoing resuscitation
Prepare equipment
- Minnesota tube
- Traction device
- Manometer
- Suction
- ice bath
Position – semi fowler position (HOB @45deg)
Procedure
- Test equipment of Minnesota tube, inflate, deflate balloons + lubricate (ice bath - stiffen tube)
- Insert tube to 50cm (@ gum line) + suction gastric port
- Insufflate gastric balloon w 50cc of air
- Confirm balloon in stomach (CXR)
- Position confirmed – continue to inflate balloon (50cc at a time => max 500cc)
- Pull balloon back against gastric fundus – note measurements at lips
- Apply 1kg traction + secure tube to traction device
- 2nd CXR (confirm placement – ensure still in stomach)
- Suction the ports
- ?ongoing bleeding – inflate esophageal balloon (until 30mmHg => MAZ 45mmHg)
- Reassess
PERIMORTEM C SECTION
ROSC NOT obtained = perform perimortem C-section
Have nurse insert foley catheter to decompress the bladder
Position – supine
Procedure
- 10blade – make large vertical incision from subxiphoid to symphysis pubis down to the uterus
- Assistant to retract tissue + bladder
- Use scalpel to make 5cm vertical incision on lower uterus until amniotic fluid
- Use fingers to lift uterine wall + cut uterus using scissors to the fundus
- Deliver infant + clamp and cut cord
- deliver placenta
- Hand baby to NICU team and continue maternal resuscitation
SHOULDER DYSTOCIA
Pre-procedure –to prepare for the procedure, I would ask:
- Gestational age
- Prenatal care
- Multiples
- Meconium present
- History of vaginal bleeding
- SAMPLE history
Procedure
- Approach using step wise approach using HELPER mnemonic
- Help – call for obstetrical help
- Episiotomy – consider performing episiotomy
- Legs flexed – 2 assistants to help mom flex knees + hips up to her chest (McRoberts maneuver)
- Pressure – ask assistant to apply suprapubic pressure over impacted anterior shoulder
- Enter – enter vagina
Ruben’s maneuver – hand in vag behind shoulder and rotate towards baby face
Wood corkscrew – pressure over anterior, posterior shoulder + free anterior shoulder
- Remove – posterior arm if maneuvers not successful
hand into vagina + sweep posterior arm across chest, deliver posterior arm
- SOS
Try algorithm again (from mcroberts)
Deliver on all 4s (attempt to deliver)
Fracture clavicle + push baby back into vag
BREECH
Position – mother’s pelvis at very end of the bed to allow for breech delivery
- Lithotomy position
Procedure
1. Hands off
2. Umbilicus expulsion
3. support hip + pelvis (no traction)
4. wrap baby in towel
5. mom push scapula
6. scapular appears => L arm across chest for delivery
7. Rotate baby to occiput-anterior-posterior + sweep out R arm
8. Deliver head (baby body on forearm), index + middle fingers over maxilla) = FLEXION
9. Mariceau maneuver (elevate body after delivery)
9. Clamp + cut the cord (delay cord clamp 1min)
10. Give baby to NICU / 2nd ERP + deliver placenta
Medical mgmt
- 10U oxytocin IM
NORMAL DELIVERY
Position – lithotomy position
Procedure – deliver in stepwise approach
- HEAD – deliver head – downwards
Towel + hand on perineum
Check for nuchal cord + release if present
- SHOULDER – deliver spontaneously
Downward pressure until anterior shoulder
Upward pressure for posterior shoulder
- Give 10mg oxytocin IM to prevent PPH
- BODY – spontaneously delivers
Clamp cord w 2 clamps + cut btwn
Give baby to NICU
- PLACENTA – deliver placenta
Usually within 5min
Marked with
1) gush of blood
2) umbilical cord lengthening
3) globular + firmer uterus
find 2 arteries / 1 vein in placenta
CORD PROLAPSE
Time critical emergency
Cord prolapse can = cord compression + fetal death
Optimal mgmt = C section via OBS (STAT OBS to ED)
Position – knee to chest position +/- trendelenberg OR all 4s
(goal – have mother’s pelvis elevated above the level of her head)
Procedure:
- elevate presenting part of the cord + don’t move hand from this position
- don’t manipulate the cord
- cover exposed cord in moist sterile gauze
- place foley catheter + bladder filled to also elevate the presenting part
- 2g amp
UMBILICAL VEIN CATHETER
Position – supine
Equipment
- Umbilical catheter
- UVC insertion tray
- Sterile NS syringes
Procedure
- Hold umbilical stump @ base
- Clean cord, base + surrounding area with antiseptic solution
- Use umbilical cord tape to anchor line + provide hemostasis
- Using 10 scalpel – cut cord 1-2cm from skin
- Identify 2 arteries + 1 vein
Vein @ 1) 12 o’clock position, 2) larger diameter
Arteries – 2 of them @ 5 + 7oclock position, thicker walled
- Attach stop cock + saline flush to end of 5Fr umbilical line catheter (premies – 3.5Fr)
- Flush catheter (remove air)
- Advance catheter down the vein 1-2cm beyond initial point of flash back (~4-5cm)
- Secure into place + reassess for hemostasis
CONTRAINDICATIONS:
ophalmocele
gastroschisis
omphalitis
peritonitis
COMPLICATIONS
bleeding
Infection
vessel perforation
air embolism
catheter tip embolism
hepatic necrosis (injection of sclerosing agent into the liver)
SURGICAL AIRWAY
First would call for help – ENT + anesthesia
Using the bougie, scalpel, ETT technique:
I will landmark the cricoid thyroid membrane (4 fingerbreadths above the sternal notch), prep + drape neck
Stabilize the thyroid cartilage (non dominant hand) and make a 3cm vertical incision with a scalpel (dominant hand) through the skin overlying the cricothyroid membrane
Will make a 1-2cm incision through the cricothyroid membrane + dilate with scalpel handle
Pass bougie along handle of scalpel – towards carina, Pass 6.0 ETT over tube + intubate the trachea and inflate balloon
NEEDLE CRIC
Call for help – ENT + anesthesia
Landmark cricothyroid membrane
I will then attach a 10cc syringe (filled with 5cc NS) to a 16 gauge angiocath
- Puncture membrane with needle aimed at 45deg towards the feet w negative pressure
- stop once bubbles appear
- Advance angiocath and remove the needle
- Attach barrel of 3 cc syringe into angiocath with a 7.0 ETT connector on top of the syringe (remove plunger) and attach BVM and oxygen
Turn up O2 to 15LPM (40psi)
Attempt to ventilate through angiocath
PTA
Consent
PPE
Sterile
Position - upright
Landmark - superior poll of tonsil, under US guidance
Analgesia - lidocaine spray
Procedure
- patient to hold laryngoscope in mouth to hold tongue out of the way
=> other hand to use suction prn
- for aspiration => 20g
- identify superior poll of tonsil => use US to ID the abscess + carotid
- negative aspiration as i advance needle
Post procedure
- RA
- ENT for +/- ABX
FOLLOW UP QUESTIONS
1. ddx for sialadenitis
adenitis
cellulitis
tularemia
goiter
thyroglossal duct cyst
scrofula
lymphoma
EPISTAXIS
- MOVID, BW
- AC reversal if required
- initial treatment
=> blow clots
=> spray nares with otraven, lido with epi, TXA (?no pack)
=> direct pressure - If anterior:
=> cautery if you can visualize source
=> anterior pack
=> surgifoam
=> pack contralateral area - if posterior
=>EPISTAT:
1) insert with lubrication
2) inflate posterior balloon then anterior balloon w 30cc of air
=> FOLEY
1) insert w lubrication
2) partially fill balloon
3) retract until lodges against choana
4) fill balloon fully (pain = overfilled)
5) clamp catheter in place w umbilical clamp
CALL ENT
MODIFIED VAGAL MANEUVERS
children
blow into a occluded straw / syringe
baby:
assuming head down position (15-20sec)
Bag containing a slurry crushed ice + water to face
rectal stimulation using a thermometer
place bag of ice water over the upper half of infants face
adults
IV fluid
Bearing down (Valsalva maneuver)
blow into 10cc syringe sitting => supine with legs up
10cc syringe, blow against negative pressure
trandelenberg then upright
DESCRIBE WEBER + RINNE EXAM
Weber
tuning fork - center of forehead
lateralization = ABNORMAL
conductive = lateralizes (louder) to affected ear
sensorineural = lateralizes to good ear
RINNE
tuning fork - mastoid until no sound
normal = can still hear AC>BC
conductive = BC>AC
Describe how to do a thoracic lavage
consent, PPE, sterile technique
Position - supine with arm above their head, expose lateral chest
Landmark - intercostal space btwn 4-5th rib at posterior axillary line
procedure
=> infiltrate skin + pleura with lidocaine
=> #10 scalpel, 3cm incision in skin + subcutaneous tissues over rib
=> kelly clamp (bluntly dissect down to pleura over superior portion of the rib)
=>clamp to penetrate the pleura
=> tip of clamp in the pleura, spread to increase the diameter of the pleural defect
=> insert finger direct posterior + superior
=> rpt process btwn ribs 3+2 anteriorly
attach caudal chest tub to pleural vac drainage
attach cephalad chest tube to warmed irrigated fluid
