Nasogastric Intubation

Assess indications and explain procedure to patient/family. A specific surgical consent is not generally obtained.

Indications:

1. Removing stomach contents

A. Diagnostic

GI bleeding

Penetrating or blunt trauma

B. Therapeutic

Paralytic ileus

Gastric dilatation

Intestinal obstruction Persistent vomiting

Removal of toxins and pill fragments

Heating or cooling for temperature abnormalities

C. Prophylactic

Decompression prior to abdominal surgery or peritoneal lavage

Prevention of aspiration in multiple trauma

2. Instillation of materials

Medications, feedings, contrast, charcoal

Contraindications:

* Loss of integrity of cribriform plate (midface fracture)

* Esophageal stricture

* Comatose patients without airway protection

* Penetrating neck trauma

(Note: varices are not a contraindication)


Equipment:

1. Salem sump tube of appropriate size

2. Suction apparatus

3. Cup of water with straw (for cooperative patients)

4. 2% Lidocaine gel, small syringe

5. Lubricant

6. Tape, benzoin

7. Nasal decongestant (optional)

Procedure:

1. Position patient: fully sitting if awake; supine wlneck flexion if comatose

2. Inspect nares for obstruction; apply nasal decongestant and anesthetic to nasal mucosa, pharynx

3. Estimate tube insertion length: ear-nose-xiphoid, mark wltape (Fig. 1)

4. Pass lubricated tube along floor of nose (Fig. 2)

5. Ask patient to sip water, advance tube quickly with swallowing

6. Confirm placement by auscultation over stomach, aspiration of gastric contents,

or by x-ray in comatose patients.

7. Secure with tape (Fig. 3)

Complications, Prevention and Management


1.Coiling of the tube in the oral cavity:

Mild neck flexion; stiffening of the tube tip by cooling in ice.

Partially withdraw, and again encourage patient to swallow.

2.Tracheal intubation:

Withdraw and re-advance with slight neck flexion.

3.Reflux of gastric contents into the vent lumen:

Do not clamp vent lumen.

Flush vent lumen with a syringe filled with air.

4.Bronchial placement:

Radiologic exam is mandatory in comatose patients.

Remove and replace.

5.Obstruction of tubes used for instillation:

Only liquids should be administered, followed by 30 -50cc water flush.

Attempt to flush with 50cc water.

LUMBAR PUNCTURE


Indications

1. Suspected CNS infection

2. Suspected subarachnoid hemorrhage

3. Therapeutic reduction of cerebrospinal fluid (CSF) pressure

4. Sampling of CSF for any other reason

Contraindications

1. Local skin infections over proposed puncture site (absolute contraindication)

2. Raised intracranial pressure (ICP); exception is pseudotumor cerebri

3. Suspected spinal cord mass or intracranial mass lesion (based on lateralizing neurological findings or papilledema)

4. Uncontrolled bleeding diathesis

5. Spinal column deformities (may require fluoroscopic assistance)

6. Lack of patient cooperation


Materials

1. Lumbar puncture tray (to include 20 or 22 gauge Quinke needle with stylet, prep solution, manometer, drapes, tubes, and local anesthetic)

2. Universal precautions materials

Preprocedure patient education

1. Obtain informed consent

2. Inform patient of possibility of complications (bleeding, persistent headache, infection) and their treatment

3. Explain the major steps of the procedure, positioning, and postpocedure care


Procedure

1. Assess indications for procedure and obtain informed consent as appropriate

2. Provide necessary analgesia and/or sedation as required

3. Position patient: lateral decubitus position with “fetal ball” curling up, or seated and leaning over a table top; both these positions will open up the interspinous spaces (see Figure 1)



Figure 1: Positioning patient for lumbar puncture

4. Locate landmarks: between spinous processes at L4-5, L3-4, or L2-3 levels (see Figure 2). On obese patients, find the sacral promontory; the end of this structure marks the L5-S1 interspace. Use this reference to locate L4-5 for the entry point. You will aim the needle towards the navel.



Figure 2. Anatomy of lumbar spine

5. Prep and drape the area after identifying landmarks. Use lidocaine 1% with or without epinephrine to anesthetize the skin and the deeper tissues under the insertion site

6. Assemble needle and manometer. Attach the 3-way stopcock to manometer

7. Insert Quinke needle bevel-up through the skin and advance through the deeper tissues. A slight pop or give is felt when the dura is punctured. Angle of insertion is on a slightly cephalad angle, between the vertebra (Figure 3). If you hit bone, partially withdraw the needle, reposition, and re-advance



Figure 3

8. When CSF flows, attach the 3-way stopcock and manometer. Measure ICP…this should be 20 cm or less. Note that the pressure reading is not reliable if the patient is in the sitting position

9. If CSF does not flow, or you hit bone, withdraw needle partially, recheck landmarks, and re-advance

10. Once the ICP has been recorded, remove the 3-way stopcock, and begin filling collection tubes 1-4 with 1-2 ml of CSF each



Tube 1: glucose, protein, protein electrophoresis

Tube 2: Gram’s stain, bacterial and viral cultures

Tube 3: cell count and differential

Tube 4: reserve tube for any special tests



11. After tap, remove needle, and place a bandage over the puncture site. Instruct patient to remain lying down for 1-2 hours before getting up

NOTES:

1. Insertion of the needle bevel-up minimizes dural trauma

2. A traumatic “bloody tap” occurs when a spinal venous plexus is penetrated. Often the fluid will clear as succeeding tubes are filled. Spin down the first tube: if red blood cells have been in the spinal fluid for some time (for example, subarachnoid hemorrhage), xanthochromia will be present in the supernatant fluid. If the fluid is clear after it is spun down, the tap was only traumatic

3. In some cases, conscious sedation is helpful in reducing patient anxiety and allowing maximal spinal flexion

Items for evaluation of person learning this procedure

1. Anatomy of lumbar spine

2. Indications of procedure

3. Contraindications for procedure

4. Interaction between physician, staff, patient, and/or family

5. Sterile technique, universal precautions

6. Technical ability

7. Appropriate documentation

8. Understanding of potential complications and their correction

VASCULAR ACCESS: PLACEMENT OF AN INTRAOSSEOUS NEEDLE


Indications


1. Immediate venous access for delivery of fluids, drugs or blood products in children, ages 0-7 years of age including neonates

2. Reliable access site for emergent or resuscitative situations where peripheral venous access is unobtainable


Contraindications

1. Open fracture at proposed insertion site

2. Skin infection at proposed insertion site

NOTES

a. The preferred site for intraosseous access is in the center of the tibia, just distal to the tibial tubercle in neonates; in 6-12 month olds, insert 1 cm distal to tibial tuberosity, and in children > 1 year of age, insert 2 cm distal to the tibial tuberosity

b. Intraosseous access may be maintained at the same site for 96 hours

Materials

1. Sterile gloves, mask

2. Prep solution

3. IV solution and tubing

4. Disposable 16- or 18- gauge intraosseous needle OR 16- or 18 gauge spinal needle with stylet

5. Optional: lidocaine 1% for local anesthesia, with 25-or 27-gauge needle on a 3 cc syringe

6. Gauze, tape


Preprocedure patient education

1. Obtain informed consent

2. Inform patient (or parent/guardian) of the possibility of major complications and their treatment

3. Explain the major steps of the procedure


Procedure

1. Assess need for placement of an intraosseous line, and obtain consent if appropriate.

2. Identify landmarks: tibial tubercle; don mask and sterile gloves; prepare IV tubing and fluid

3. Use prep solution to cleanse the skin over the insertion site

4. If appropriate, infiltrate skin and periosteum over insertion site with 1 cc of the lidocaine 1% solution, using the 25- or 27-gauge needle with the 3 cc syringe

5. Open the intraosseous needle, hold the stylet ball in the palm of your hand, and place the tip of your index finger 1- 1.5 cm from the tip of the needle

6. Insert the needle through the skin at the selected insertion site, and advance until you reach the periosteum of the tibia. You should be in the MIDLINE of the tibia, with the needle at a 300 angle from vertical (Figure 1)

7. Advance the needle through the periosteum into the bone with a screwing motion. A sudden “give” is felt when you enter the marrow cavity

8. Withdraw needle stylet, and attach IV tubing; open up IV flow



Figure 1: Inserting the intraosseous needle


NOTE

If IV fluid is seen extravasating from around the needle, it is not in the marrow cavity. Remove the needle and reposition it in the marrow cavity.

9. Secure the needle with gauze and tape

Complications, Prevention, and Management

1. Local hematoma or cellulitis. Apply pressure dressing for bleeding.

2. RARELY osteomyelitis; requires IV antibiotics.

External Jugular Venous Catheter


The external jugular vein is a peripheral vein that generally is neither collapsed (with a patient in a Trendelenberg position) nor thrombosed. This site is often difficult for the patient because the catheter entrance and the dressing are on the patient's neck. The external jugular vein may be the site of last resort when a patient needs peripheral access but other veins are not usable. The external jugular vein may be used for non-sclerosing fluid administration. Note that, as with other IV sites, shorter catheters of a given caliber can deliver more fluid than a longer catheter, and shorter catheters may be preferred in the situation where large amounts of fluid are being given emergently.



Indications:

* Placement of a venous access line when other peripheral sites are unavailable. Placement of a large-bore venous catheter in an emergent situation to deliver a high flow of fluid or blood products
* Rarely, for central venous pressure measurement or other CVP catheter uses
* (transvenous pacemaker, pulmonary wedge catheter, etc.)



Contraindications:

* Infection over the insertion site
* Lack of anatomic landmarks due to neck size, shape or deformities
* Suspected or proven fracture of the cervical spine
* With coagulopathies, other more easily compressible sites should be considered.
* Patients unable to tolerate a Trendelenberg position
* Unsuccessful contralateral attempt at insertion with resultant hematoma

Materials:

* Universal precaution material
* Tape and dressings
* Lidocaine (1 % lidocaine mixed 50:50 with sodium bicarbonate will lessen the sting of the lidocaine)
* Syringe (5 cc) and 25 gauge needle
* IV tubing
* IV fluid
* Prep wipes for the neck
* Large bore IV catheter over needle (for adults, 14 to 18 gauge)


Preprocedure patient education:

* Obtain informed consent
* Inform the patient of the possibility of major complications and their treatment . Explain the major steps of the procedure
* Explain the necessity of a prolonged Trendelenberg position


Procedure:

* Use Universal Precautions and sterile technique
* Attach the IV tubing to the IV fluids and place at the bedside on an IV pole
* Place the patient in a Trendelenberg position (15 to 30 degrees head down) to reduce the chance of an air embolism
* Turn the patient's head away from the side chosen for insertion
* Prep and drape the entire side of the neck chosen
* Identify the vein
o Patient Valsalva may help engorge the vein
o The vein runs from the angle of the mandible infero-Iaterally to the clavicle, crossing the sternomcleidomastoid muscle 5 cm above the clavicle
* Choose a site at about the midpoint of the vein
* Make a skin wheal with the lidocaine and a 25 gauge needle at the chosen site
* Stretch the skin over the external jugular vein cephalad with your free hand
* Using the other hand, insert the catheter over needle aiming along the axis of the vein toward the clavicle (the vein is generally shallower than one might think)
* When a flash of blood returns, advance the catheter over the needle and remove the needle
* Attach the IV tubing to the catheter and secure the catheter to the neck with tape . Turn on the IV fluids to ascertain that there is good flow.

· For an additional check to ascertain good flow into the vein, remove the IV solution from the pole and lower the bag below the level of the patient to establish that there is blood return from the vein.

· Return the solution bag to the IV pole and regulate the flow of the fluid as necessary.



Complications, Prevention and Management:

· Local hematoma

o Prevention: going too deep might lacerate the deep wall of the vein or too superficially the superficial wall of the vein. To prevent this, take care to strictly follow the axis of the vein during insertion.

o Management: Local pressure (but never circumferentially applied)

· Laceration of the deeper internal jugular vein

o Prevention: Do not insert the needle deeply for this procedure

o Management: Local pressure as above

· Infection:

o Prevention: Sterile procedure, and never through infected skin

o Management: Appropriate antibiotics

· Air embolism

o Prevention: Maintain a Trendelenberg position, have the patient exhale while advancing the catheter, and maintain a "closed" system
o Management: Place the patient in a left lateral decubitis, head down position to minimize the chances of an air embolism to the brain


Helpful hints:

* Before removing the needle, slightly bend the IV catheter upwards in its sterile sheath. This "prebending" of the needle allows you to enter the vein in a more shallow fashion, reducing the chances of going too deeply (the external jugular vein, in average sized people is surprisingly shallow)

DEFIBRILLATION


INDICATIONS:

· ventricular arrhythmia (ventricular tachycardia or ventricular fibrillation) and associated cardiac arrest (unresponsive patient without a pulse)


CONTRAINDICATIONS:

· awake, responsive patients

· any arrhythmias in a patient with a pulse

MATERIALS:

· defibrillator

· many different machines/models

· become familiar with equipment where you are practicing

· paddles

· adult size (8-9cm diameter) for patient weight > 10 kg.

· pediatric size ( 2.2 cm diameter) for patient weight < 10 kg.

· Electrode pads

· Self – adhesive

· Conductive material

· Gel, paste or pads


PRE-PROCEDURE PATIENT EDUCATION:

· Not necessary (or possible) for an emergent, potentially life-saving procedure in an unresponsive patient


PROCEDURE/TECHNIQUE:

· Sudden death/cardiac arrest patients in VF or VT without a pulse should be defibrillated as soon as possible (even before CPR, medications or advanced airway procedures)

· Initiate CPR/ACLS protocols until defibrillator available

· Power on the defibrillator and select “unsynchronized/defibrillation” mode

· turn monitor selector to “paddles”

· Apply conductive materials (depends on what is available) before paddle placement

· Apply defibrillator monitor cables, pads, or “quick-look” paddles to patient in cardiac arrest to determine rhythm

· Paddle placement:

· First (“sternum”) paddle: to the right of the upper sternum and below the clavicle

· Second (“apex”) paddle: to the left of the nipple in the midaxillary line, centered in the 5th intercostal space

· Avoid placing both paddles next to one another on the anterior chest wall

· Lead placement:

· “White-on-the-right” will help you to remember the white electrode is placed on the right side of the chest just below the right clavicle

· “smoke over fire” will help you to remember that the black lead is placed on the left chest just below the left clavicle, and the red lead is placed in the left midaxillary line below the expected PMI of the heart

· electrode pad placement:

· can be placed as described above for paddles, or

· anterior pad just to the left of the sternum, and posterior pad on the patient’s back to the left of the spine. (This technique “sandwiches” the heart between the pads)

· assess rhythm to confirm VF/VT:

· if you see a flatline, turn up the gain to rule out fine VF, if flatline remains (and you have checked monitor, connections, and the patient) rotate paddles 90 degrees and re-assess rhythm to assure VF or (pulseless) VT remains

· choose energy level and charge defibrillator (“charge” buttons may be located on the paddles or on the machine itself)

· deliver shock(s) by simultaneously pressing the discharge buttons located on the paddles (or on the monitor for electrode pads) after ensuring “all clear” from the patient for equipment and providers

· re-assess patient, consider recommended medications, further management


COMPLICATIONS, Prevention & Management:

· Soft tissue injury can occur after repeated shocks. The presence of liquid (body fluids, medications, or IV fluids) may cause electrical arching thermal burns to the skin and soft tissue and produce ineffective defibrillation by allowing the current to pass across the trunk rather than transthoracic. To minimize this potential complication, ensure that any body fluids or liquids are wiped away from the skin before defibrillation attempts.

· Myocardial and epicardial injury may result from the electrical current (not direct thermal injury)applied in defibrillation. Use the minimal recommended energy levels to minimize injury

· Post-defibrillation cardiac dysrhythmias are more common following prolonged VF and higher energy level countershocks. Early defibrillation at the recommended energy levels minimizes this complication. Follow ACLS protocols to manage resulting dysrhythmias.

· Electrical injuries to health care providers can result if participants remain in contact with the patient during delivery of a countershock, because they can serve as a ground for the current discharged. Fires which can result from sparks in the presence of nitroglycerin patches or ointment, flammable gasses, or an oxygen-rich environment can also be a source of injury to the patient or healthcare providers. Ensure “all clear” from the patient prior to delivery of shock to avoid these complications.

PROCEDURAL SEDATION


Indications

Procedural sedation is a clinical technique that creates a decreased level of awareness for a patient yet maintains protective airway reflexes and adequate spontaneous ventilation. The goals of procedural sedation are to provide analgesia, amnesia, and anxiolysis during a potentially painful or frightening procedure.

Pharmacologic agents used in procedural sedation are of three general classes: sedatives, analgesics, and systemic agents. Using a combination of a sedative/analgesic provides a synergistic combination that generally gives consistent clinical results; using systemic agents provides very rapid sedation and relaxation with some analgesia. Patients should be NPO for at least 4-6 hours prior to procedure if at all possible.

Patients should be triaged to the appropriate Physical Status Classification before conscious sedation is performed:



Class I: Normally healthy

Class II: Patient with mild systemic disease (e.g. hypertension)

Class III: Patient with severe systemic disease (e.g. CHF), non-decompensated

Class IV: Patient with severe systemic disease, decompensated

Class V: Moribund patient, survival unlikely



Procedural sedation is appropriate for patients in Classes I, II and III. Patients in classes IV and higher are better suited for the OR.


Procedures appropriate for procedural sedation include ANYTHING painful: debridement of wounds, placement of central lines, chest tube placement, abscess drainage, reduction of fractures and dislocations.


Contraindications

1. Recent (<2 hr) ingestion of large food or fluid volumes

2. Physical class IV or greater

3. Lack of support staff or monitoring equipment

4. Lack of experience/credentialing on part of clinician


Materials

1. Monitoring equipment: BP cuff, pulse oximeter, cardiac monitor

2. IV access

3. Oxygen delivery by nasal prongs or mask

4. Resuscitation equipment: Endotracheal tubes, Ambu bag and mask, defibrillator, emergency cardiac drugs, naloxone, flumazenil

5. Personnel trained in airway management, and recovery of sedated patients

6. Informed consent as appropriate


Medication combinations for conscious sedation:


1. Ketamine, atropine (or glycopyrrolate), and benzodiazepine

2. Benzodiazepine and analgesic

3. Systemic agents (propofol or etomidate) and analgesic


Preprocedure patient education


1. Discuss with the patient/parent(s)/guardian the need for sedation in light of the presenting clinical situation

2. Obtain informed consent

3. Explain the major steps of procedural sedation

4. Inform the patient of the possibility of transient unpleasant sensations of pain, nausea, dizziness; stress benefits of improved comfort, relaxation, and analgesia

NOTE: Procedural sedation should be appropriate to the procedure being performed. A laceration on a child may require only ketamine, whereas a hip dislocation on an obese adult probably requires a systemic agent and analgesic for proper sedation and relaxation.


Procedure


Using Ketamine, atropine and a benzodiazepine

-this is an excellent combination for children under 11 years of age. Older children and adults do not require the addition of atropine.

-emergence reactions are more common in adults, and combination treatment with a benzodiazepine may alleviate this

-ketamine is an excellent sedation agent for asthmatics, as it does not cause airway hyperreactivity


Time 0 Attach monitoring equipment and obtain baseline readings

+1 minute Ketamine 1-2 mg/kg IV OR 3-5 mg IM, PLUS atropine 0.01 mg/kg IV/IM, OR gylcopyrrolate 0.005 mg/kg IM/IV

PLUS midazolam 0.05 mg/kg IV/IM

+5-10 min Begin procedure

+30-120 min Recover patient


Using Analgesic and a benzodiazepine



Time 0 Attach monitoring equipment and obtain baseline readings

+1 minute fentanyl 0.001-0.002 mg/kg IV OR morphine 0.1-0.2 mg IV, PLUS midazolam OR lorazepam 0.05 mg/kg IV

+3-5 min Begin procedure

+10-120 min Recover patient


Using a systemic agent and an analgesic

Time 0 Attach monitoring equipment and obtain baseline readings

+1 minute Propofol 1-2 mg/kg IV OR etomidate 0.3 mg/kg IV, PLUS morphine 0.05 mg/kg IV (NOTE THE LOWER DOSE OF ANALGESIA…this is due to the synergistic effect of the anesthetic)

+3-5 min Begin procedure

+10-120 min Recover patient

Reversal of Sedation

Rarely should reversal of agents used in procedural sedation be necessary if they are titrated appropriately.

Naloxone is a competitive antagonist of the opioid receptors; it is used for reversal of narcotic analgesics. Use 0.001 mg/kg IM/IV titrated to effect. Be aware that the duration of naloxone is less than the duration of action for most opiates. Be prepared to re-bolus the naloxone, or use a naloxone drip at .01-.05 mg/min.

Flumazenil is a pure benzodiazepine antagonist, and can be used for reversal of benzodiazepine sedation. Like naloxone, it has a shorter duration of action than the benzodiazepine agents it reverses. Prepare to re-bolus with flumazenil, or run a flumazenil drip at 0.1 mg/min. Use 0.2 mg IV every 2-5 minutes titrated to effect, or up to 2-3 mg in total if needed.


Complication, Prevention, and Management


1. Inadequate amnesia or analgesia:

a. Dosage of amnesic or analgesic agents are based upon patient weight. Make sure weights are accurate, and dosages are adequate. As a general rule, the elderly need less, muscular young men need more, and agitated children may also require slightly more medication.

b. Allow sufficient time for the agents to work. It is tempting to start the procedure(s) immediately upon drug administration, but do allow time to titrate the effect of the sedation medications.

2. Decreasing oxygen saturation: apply nasal cannula or a non-rebreather mask for increased oxygenation. Occasionally, a bag-valve-mask with positive pressure ventilation may be required transiently.

3. Prolonged recovery: prolonged offset of sedation is dependent on several factors of which the most important are drug distribution in the patient, and the patient’s own clearance of the sedation agents. Be prepared to recover the patient for a prolonged period, with adequate oxygenation and clearance of any airway secretions.

Basic Airway Management & Endotracheal Intubation

(Note: Rapid sequence and use of pharmacologic adjuncts for intubation are not specifically covered in this section)

Indications:

1. Treatment of symptomatic hypercapnia.

2. Treatment of symptomatic hypoxemia.

3. Airway protection against aspiration.

4. Pulmonary toilet.

Contraindications:

1. Awake patient.

2. Airway can be managed less invasively.

Equipment:

1. IV access, EKG, pulse ox monitors.

2. Suction apparatus.

3. Oropharyngeal, nasopharyngeal airways.

4. Non- rebreather mask.

5. Oxygen.

6. Bag valve mask.

7. Appropriate size endotracheal tube (7.5 mm – adult, child = diameter of little finger); with stylet and 10cc syringe.

8. Laryngoscope blade and handle (appropriate size).

9. Tape.

Procedure:

* Assess airway – note landmarks, swelling, deformities. Remove dentures. – Assess tongue size, dental obstruction, visibility of oropharynx, degree of neck mobility. - Maintain cervical spine stability as necessary.
* Open airway: suction or manually extract foreign material. – Chin lift, jaw thrust.
* Heimlich maneuver as needed.
* Use artificial airways if needed: oropharyngeal, nasopharyngeal. (See Figure 1)


* Preoxygenate with 100% non-rebreather or bag-valve-mask. Keep pulse ox greater than 95% at all times.
* Position patient into “sniffing position” if possible; restrain as necessary.
* Standing at the supine patient’s head, gentle insert laryngoscope blade with left hand. Use suction as necessary with right hand. (See Figure 2)



* Visualize glottic opening/vocal cords.
* Advance ETT with right hand through cords. (See Figure 3)



* Remove stylet.
* Inflate ETT cuff with 5 – 10 cc air via syringe.
* Ventilate with bag and oxygen.
* Confirm tube placement with chest auscultation, CO2 monitor and chest x-ray.
* Secure tube with tape.

Complications: Prevention and Management

Missing/broken teeth:

Remove loose teeth prior; avoid using upper teeth as fulcrum for laryngoscope blade.
Check chest x-ray to rule out aspiration.

Esophageal intubation:

Visualize cords.
Remove tube, re-oxygenate and reinsert.

Right lung intubation:

Avoid excessive tube advancement.
Deflate cuff, re-position and re-inflate.

Laryngospasm:

Spray vocal cords with 2% Lidocaine.
Benzodiazepine or paralytic medication.

ELECTRICAL CARDIOVERSION


INDICATIONS:

· URGENT/EMERGENT

· conversion of tachycardias with associated serious signs / symptoms (chest pain, pulmonary edema, hypotension, mental status changes)

· ELECTIVE

· Conversion of stable atrial fibrillation or flutter of greater than 48 hours duration

· Consider anticoagulation for at least 3 weeks prior to elective cardioversion to decrease risk of embolization of atrial thrombi

· Early cardioversion can be attempted if TEE negative for atrial clot, and patient started on IV Heparin, then continue anticoagulation for 4 weeks post-procedure



(RELATIVE) CONTRAINDICATIONS:

· Cardioversion is unlikely to be successful and may be harmful in dysrhythmias due to enhanced automaticity (i.e. digoxin toxicity) because a homogenous depolarization state already exists

· cardioversion is usually not only ineffective but is associated with a higher incidence of post-shock VT/VF. Medications are usually more effective than cardioversion to control the rate/convert the rhythm.



MATERIALS:

· defibrillator

· many different machines/models

· you should become familiar with equipment where you are practicing

· paddles

· adult size (8-9cm diameter) for patient weight > 10 kg.

· pediatric size ( 2.2 cm diameter) for patient weight < 10 kg.

· Electrode pads

· Self – adhesive

· Conductive material

· Gel, paste or pads


PRE-PROCEDURE PATIENT EDUCATION:

· Explain procedure indications, expected outcome and possible complications, as well as any alternatives (possible medications without cardioversion) to the patient.

· Answer any questions the patient may have.

· Obtain written consent for the procedure.



PROCEDURE/TECHNIQUE:

· If time permits and the patient is hemodynamically stable, correct metabolic and electrolyte abnormalities which may be the cause of the arrhythmia.

· Provide supplemental O2 and obtain IV access.

· Ensure airway management equipment is readily available (suction, BVM, O2, laryngoscope, ETT, pulse ox, etc.)

· Bring “code box” to bedside due to potential urgent need for ACLS meds.

· Strongly consider sedation

· Turn on defibrillator/monitor

Apply defibrillator monitor cable leads, or pads to patient to determine rhythm

· Lead placement: Attach monitor leads (“white on right”, “smoke over fire”) to patient to confirm rhythm

· “White-on-the-right” will help you to remember the white electrode is placed on the right side of the chest just below the right clavicle

· “smoke over fire” will help you to remember that the black lead is placed on the left chest just below the left clavicle, and the red lead is placed in the left midaxillary line below the expected PMI of the heart

· electrode pad placement:

· can be placed as described above for paddles, or

· anterior pad just to the left of the sternum, and posterior pad on the patient’s back to the left of the spine. (This technique “sandwiches” the heart between the pads)

· Engage synchronization mode (press the “sync” button)

· Look for markers on “R” wave to indicate sync mode activated

· If necessary adjust monitor gain or change leads to select large enough R waves for sync mode recognition

· Select appropriate recommended energy level (Initial/subsequent)

· Atrial fibrillation (100/200)

· Atrial flutter (20/50/100)

· Atrial tachycardia – other (50/100/200)

· Ventricular tachycardia (50/100/200)

· Position conductor pads on patient (or apply conductive gel to paddles)

· Position paddles on the patient (sternum/apex)

· First (“sternum”) paddle: to the right of the upper sternum and below the clavicle

· Second (“apex”) paddle: to the left of the nipple in the midaxillary line, centered in the 5th intercostal space

· Avoid placing both paddles next to one another on the anterior chest wall to prevent arching current

· Ensure “all clear”

· Press “charge” button on paddle (usually located on “apex” paddle in right hand)

· Apply firm downward pressure on paddles and press discharge buttons simultaneously after ensuring everyone and equipment is “all clear” from the patient

· Check monitor, analyze rhythm, and reassess patient

· If subsequent cardioversions are required, recheck the sync mode, as some defibrillators default back to unsynchronized mode after each shock



COMPLICATIONS, Prevention & Management:

· Soft tissue injury can occur after repeated shocks. The presence of liquid (body fluids, medications, or IV fluids) may cause electrical arching thermal burns to the skin and soft tissue and produce ineffective defibrillation by allowing the current to pass across the trunk rather than transthoracic. To minimize this potential complication, ensure that any body fluids or liquids are wiped away from the skin before defibrillation attempts.

· Myocardial and epicardial injury may result from the electrical current (not direct thermal injury)applied. Use the minimal recommended energy levels to minimize injury

· Post-cardioversion cardiac dysrhythmias are possible. Follow ACLS protocols to manage resulting dysrhythmias.

· Electrical injuries to health care providers can result if participants remain in contact with the patient during delivery of a shock, because they can serve as a ground for the current discharged. Fires which can result from sparks in the presence of nitroglycerin patches or ointment, flammable gasses, or an oxygen-rich environment can also be a source of injury to the patient or healthcare providers. Ensure “all clear” from the patient prior to delivery of shock to avoid these complications.

SPLINTING



INDICATIONS:

Temporary immobilization to improve pain and discomfort, decrease blood loss, reduce the risk for fat emboli and minimize the potential for further neurovascular injury associated with:

· Fractures

· Sprains

· reduced dislocations

· tendon lacerations

· deep lacerations across joints

· painful joints associated with imflammatory disorders


MATERIALS:

* Plaster Rolls or sheets
o Strips or rolls of various width made from crinoline-type material impregnated with plaster which crystallizes or “sets” when water is added
* Prefabricated Splint Rolls (Ortho-Glass)
o Layers of fiberglass between polypropylene padding
* Stockinette
* Cast padding
* Elastic bandages
* Adhesive tape
* Heavy scissors
* Bucket
* Protective sheets or pads to protect patient clothing
* gloves


PATIENT EDUCATION:

* Instructions should be both verbal and written
* Explain and demonstrate the importance of elevation to minimize swelling and decrease pain
* Apply ice bags or cold packs (bags of frozen vegetables also work well) for at least 30 minutes at a time during the first 24-48 hours after injury to decrease swelling and pain
* Avoid getting the splint wet – some splints may be removable for bathing purposes, otherwise plastic bags may be placed over the splint to keep it dry while bathing
* Explain signs of infection and vascular compromise, instruct patient to seek help for any concerns
* Instruct patient to return for evaluation of damaged/broken or wet splint
* Discuss follow-up guidelines


PROCEDURE/TECHNIQUE:

* Prepare the patient

o Cover patient with sheet or gown to protect clothing
o Inspect skin for wounds and soft tissue injuries
o Clean, repair and dress wounds as usual prior to splint application

* Padding

o Apply stockinette to extremity to extend several cm beyond edges of plaster, so that it may be folded back over the edges of the splint after plaster is applied to create a smooth edge
o Roll on two to three layers of cast padding evenly and smoothly (but not too tight) over the area to be splinted.
o Extend the padding out beyond the planned area to be splinted so that it can be folded back with the stockinette over the edges of plaster to create smooth edges.
o Each turn of the webril/cast padding should overlap the previous by 25-50 % of its width.
o Place extra padding over bony prominences to decrease chance of creating pressure sores
o An alternative to circumferential stockinette and cast padding is to place 2-3 layers of padding directly over wet plaster, and then apply this webril-lined splint over the area to be immobilized and secure it with an elastic bandage

* Prepare the plaster splint material

o Ideal length and width of plaster depends on body part to be immobilized in the splint
o Estimate the length by laying the dry splint next to the area to be splinted
o Be generous in estimating length, the ends can always be trimmed or folded back
o Width should be slightly greater than the diameter of the limb to be immobilized
o Cut or tear the splint material to the desired length
o Choose thickness based on body part to be immobilized, patient body habitus, and desired strength of splint
+ Average of 8-12 layers
+ Less layers (8-10) for upper extremities
+ More layers (12-15) for lower extremities
+ More layers may be needed for large patients
o Fill a bucket with cool water, deep enough to immerse the splint material into
+ Using cool water decreases the chances of thermal burns, but takes longer for the splint to dry

* Application of the splint

o Submerge the dry splint material in the bucket of water until bubbling stops
o Remove splint material and gently squeeze out the excess water until plaster is wet and sloppy
o Smooth out the splint to remove any wrinkles and laminate all layers
o Place the splint over the webril cast padding and smooth it onto the extremity
o An assistant (or a cooperative and willing patient) may be required to hold the splint in place while you adjust the splint
o Fold back the edges of the stockinette and cast padding over the ends of the splint
o Secure the splint with an elastic bandage
o Place the extremity in the desired position and mold the splint to the contour of the extremity using the palms of your hand. (Avoid using your fingers to mold in order to decrease indentations in the plaster which can lead to pressure sores)
o Hold the splint in the desired position until it hardens

* Check and finish the splint

o Check for vascular compromise
o Check for discomfort or pressure points
o Apply tape along the sides of the splint to prevent elastic bandages from rolling or slipping, (avoid circumferential tape to allow for swelling)
o Provide sling or crutches as needed

COMPLICATIONS, Prevention & Management:

Compartment Syndrome

* Usually less common in splints than with circumferential casts
* may occur associated with splints from constricting webril (cast padding) or elastic bandages that cause increased pressure within a closed space on an extremity
* increased pressure leads to inadequate tissue perfusion and loss of tissue (muscle, vascular and nerve) function within the compartment.
* Presenting signs and symptoms: (The “5 P’s” are pathognomonic for ischemia: pain, pallor, paresthesias, paralysis, and pulselessness, but seldom all occur simultaneously, and when they do – indicate a late finding associated with poor prognosis).

· pain in the extremity

· tenderness over the involved compartment

· significant pain with passive stretching of ischemic muscle tissue

· diminished distal pulses and sensation

· delayed capillary refill, and pale cool skin.



Prevention

· avoid wrapping bandages too tightly or making circumferential splints

· elevate the extremity to decrease swelling

· apply topical cold packs

· no weight bearing

· early (24-48 hour) follow-up for high-risk injuries


Management

· remove all constricting bandages and splint materials

· consider compartment pressure monitoring

· early consultation with orthopedist and/or vascular surgeon for possible fasciotomy


Pressure Sores

* Uncommon with short term splinting
* Can result from stockinette wrinkles, irregular wadding of padding, insufficient padding over bony prominences or indentions in plaster form using fingers to mold splint
* If suspected, remove the splint materials and check the skin carefully, care for wounds and revise the splint if necessary


Heat Injury

* can result from drying plaster which produces heat and may cause burns to underlying skin
* To reduce risk for thermal injury, use cool water to wet the splint material and keep splint thickness less than 12 sheets of plaster

Infection

* More common with open wounds, but may occur with intact skin
* Clean and debride wounds well prior to splint application
* Consider using a removable splint for periodic wound checks

Joint Stiffness

* Expected to some extent after any immobilization of a joint
* Avoid prolonged immobilization if possible