List of Procedures

Index


1.CHEST TUBE AND FUHRMAN CATHETER INSERTION
2.ABSCESS INCISION AND DRAINAGE
3.Arterial Blood Sampling (ABG)
4.ARTHROCENTESIS
5.Foley (Urethral) Catheterization
6.TRANSCUTANEOUS PACING
7.THORACENTESIS
8.REPAIR OF LACERATIONS: SUTURES, STAPLES, AND DERMABOND GLUE
9.Peripheral Intravenous Access
10.PARACENTESIS
11.Nasogastric Intubation
12.LUMBAR PUNCTURE
13.VASCULAR ACCESS: PLACEMENT OF AN INTRAOSSEOUS NEEDLE
14.External Jugular Venous Catheter
15.DEFIBRILLATION
16.PROCEDURAL SEDATION
17.Basic Airway Management & Endotracheal Intubation
18.ELECTRICAL CARDIOVERSION
19.SPLINTING
20.Central Venous Line Placement
21.Dilatation & Currettage:
22.Fibroid or uterine artery embolization
23.Episiotomy Repair by Suturing
24.Obstetric Forceps Use During Birth
24a.TYPES OF FORCEPS
25.Bronchoalveolar Lavage
26.Intramuscular (IM) Injection in Neonate:
27.Barium Enema(Barium X-ray, Lower GI Series)
28.Upper Gastrointestinal (GI) Series(Barium Swallow, Barium Meal)
29.Debridement of a Wound, Infection, or Burn
30.Dialysis
31.Measurement of Intraocular Pressure
32,How Visual Acuity Is Measured
33.Lymph Node Biopsy
34.Intrauterine Devices-Insertion technique
35.Ear wax removal-Syringing technique
36.Gram-staining Procedure
37.Ziehl-Neelsen Staining Procedure
38.Digital Nerve Block
39.Injection Techniques
40.Injection Technique in Older and Emaciated

END OF INDEX

CHEST TUBE AND FUHRMAN CATHETER INSERTION

Indications

1.Drainage of hemothorax, or large pleural effusion of any cause

2.Drainage of large pneumothorax (greater than 25%)

3.Prophylactic placement of chest tubes in a patient with suspected chest trauma before transport to specialized trauma center

4.Flail chest segment requiring ventilator support, severe pulmonary contusion with effusion


Contraindications

1.Infection over insertion site

2.Uncontrolled bleeding diathesis


Materials

1.Chest tube with or without trocar; OR Fuhrman catheter

2.Chest tube suction unit (PleurevacR or SaharaR), tubing, wall suction hookup

3.Chest tube tray to include scalpel blade and handle, large Kelly clamps, needle driver, scissors

4.Packet of 0 or 1.0 silk suture on a curved needle

5.Tape, gauze

6. 2% lidocaine with epinephrine, 20 cc syringe, 23-gauge needle for infiltration

7. Sterile prep solution; mask, gown and glove



Preprocedure patient education



1.Obtain informed consent

2.Inform the patient of the possibility of major complications and their treatment

3. Explain the major steps of the procedure, and necessity for repeated chest radiographs



Procedure

NOTE: Conscious sedation during this procedure is an option for those patients who are clinically stable.



1. Examine the patient and assess need for placement of a thoracostomy tube. Obtain pre-procedure chest Xray

2.Select site for insertion: mid-axillary line, between 4th and 5th ribs…this is usually on a line lateral to the nipple

3.Don mask, gown and gloves; prep and drape area of insertion. Have patient place ipsilateral arm over head to “open up” ribs

4. Widely anesthetize area of insertion with the 2% lidocaine. Infiltrate skin, muscle tissues, and right down to pleura


Fuhrman catheter insertion:


-remove catheter, dilator, introducer wire, and introducer needle from bag

-insert introducer needle into the thoracic cavity. Withdraw air with a syringe to confirm placement

-Thread introducer wire through needle into chest. Remove needle leaving introducer wire running into chest

-Thread dilator over introducer wire, and advance into chest, dilating a tract for catheter. Remove dilator

-Thread Fuhrman catheter over the wire fully into chest. Remove wire. Tape or suture catheter in place

-Attach catheter to suction unit

-Obtain post procedure chest Xray



Chest tube insertion



-After infiltrating insertion site with local anesthetic, make a 3-4 cm incision through skin and subcutaneous tissues between the 4th and 5th ribs, parallel to the rib margins (Figure 1)


Figure 1: Incising the chest wall



-Continue incision through the intercostal muscles, and right down to the pleura

-Insert Kelly clamp through the pleura and open the jaws widely, again parallel to the direction of the ribs (this “creates” a pneumothorax, and allows the lung to fall away from the chest wall somewhat, See Figure 2)




Figure 2: Opening the incision with a Kelly clamp


-Insert finger through your incision and into the thoracic cavity. Make sure you are feeling lung (or empty space) and not liver or spleen

-Grasp end of chest tube with the Kelly forcep (convex angle towards ribs), and insert chest tube through the hole you have made in the pleura. After tube has entered thoracic cavity, remove Kelly, and manually advance the tube in (Figure 3).


Figure 3: Using a Kelly clamp to guide insertion of the chest tube



If the tube is of the trocar variety, grasp tube with one hand close to the sharp trocar end and guide the tube slowly and gently through the hole in the pleura into the chest cavity (Figure 4). Remove trocar once tube has just entered the cavity, and feed tube in approximately 1/2 to 2/3 of its length, until all the fenestrations of the tube are within the chest.


Figure 4: Inserting a trocar chest tube


-Clamp outer tube end with Kelly

-Suture and tape tube in place

-Attach tube to suction unit

-Obtain post procedure chest Xray for placement; tube may need to be advanced or withdrawn slightly





Complications, Prevention, and Management



1.Puncture of liver or spleen. This is entirely preventable; insertion site is in the nipple line, between 4th and 5th ribs!

2.Bleeding; this usually ceases

3.Cardiac puncture. Again preventable, carefully control the tube going in, and remove the trocar early!

4.Passage of tube along chest wall instead of into chest cavity. In this case, widen and deepen the dissection between the ribs, and make sure the insertion of the tube follows this path



Documentation in the Medical Record

1.Consent if obtained

2.Indications and contraindications for the procedure on this patient

3. Procedure used (trocar vs. non-trocar)

4.Any complications, or “none”

5. Who was notified of any complication (family, attending physician)



Items for evaluation of person learning this procedure



1.Anatomy of the chest, lungs, pleura

2.Indications, and contraindications of this procedure

3. Use of sterile technique and Universal Precautions

4. Technical ability

5. Appropriate documentation

6. Understanding of potential complications and their correction

__________________

ABSCESS INCISION AND DRAINAGE



Abscesses are localized infections of tissue marked by a collection of pus surrounded by inflamed tissue. Abscesses may be found in any area of the body, but most abscesses presenting for urgent attention are found on the extremities, buttocks, breast, perianal area, or from a hair follicle. Abscesses begin when the normal skin barrier is breached, and microorganisms invade the underlying tissues. Causative organisms commonly include Streptococcus, Staphylococcus, enteric bacteria (perianal abscesses), or a combination of anaerobic and gram-negative organisms.

Abscess resolve by drainage. Smaller (<5mm in diameter) abscesses may resolve to conservative measures (warm soaks) to promote drainage. Larger abscesses will require incision to drain them, as the increased inflammation, pus collection, and walling off of the abscess cavity diminish the effectiveness of conservative measures.


Indications

1.Abscess on the skin which is palpable


Contraindications


1.Extremely large abscesses which require extensive incision, debridement, or irrigation (best done in OR)

2.Deep abscesses in very sensitive areas (supralevator, ischiorectal, perirectal) which require a general anesthetic to obtain proper exposure

3.Palmar space abscesses, or abscesses in the deep plantar spaces

4.Abscesses in the nasolabial folds (may drain to sphenoid sinus, causing a septic phlebitis)


Materials


1.Universal precautions materials

2.1% or 2% lidocaine WITH epinephrine for local anesthesia, 10 cc syringe and 25 gauge needle for infiltration

3. Skin prep solution

4. #11 scalpel blade with handle

5.Draping

6.Gauze

7.Hemostat, scissors, packing (plain or iodoform, 1/2”)

8.Tape

9.Culture swab

Preprocedure education


1.Obtain informed consent

2.Inform the patient of potential severe complications and their treatment

3. Explain the steps of the procedure, including the not insignificant pain associated with anesthetic infiltration

4.Explain necessity for follow-up, including packing change or removal



Procedure


1.Use universal precautions

2. Cleanse site over abscess with skin prep

3.Drape to create a sterile field

4.Infiltrate local anesthetic, allow 2-3 minutes for anesthetic to take effect

5. Incise widely over abscess with the #11 blade, cutting through the skin (Figure 1) into the abscess cavity. Follow skin fold lines whenever able while making the incision




Figure 1: Making the incision


6. Allow the pus to drain, using the gauzes to soak up drainage and blood. Use culture swab to take culture of abscess contents, swabbing inside the abscess cavity

7.Use the hemostat to gently explore the abscess cavity to break up any loculations within the abscess

8.Using the packing strip, pack the abscess cavity (Figure 2 )





Figure 2: Packing the abscess


9. Place gauze dressing over wound, and tape in place


Documentation on the medical record


1.Consent

2. Procedure used, prep, anesthetic (and quantity), success of drainage, culture if made

3. Any complications (or “none)

4. Who was notified of any complication (family, attending MD)

5.Follow-up arrangements


Items for evaluation of person learning this procedure


1. Anatomy of skin and subcutaneous tissues

2. Indications and contraindications for this procedure

3.Interaction between MD, patient, and family

4.Use of sterile technique and Universal Precautions

5.Technical ability

6.Appropriate documentation

7.Understanding of potential complications and their correction

Arterial Blood Sampling (ABG)

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

Indications:

·To access PH, PO2, PCO2 (note: PO2 may often be obtained by pulse ox).

·Inability to obtain venous sample.

Contraindications:

·Skin infection

·Relative Bleeding diathesis

Equipment:

1.ABG kit

2.Ice

Procedure:

Choose site for arterial puncture:


1.Radial- No adjacent nerve or vessels (Figure 1)

Assess for adequate ulnar artery circulation:

Position wrist in extension

Palpate arterial pulse

Clean skin

Consider subcutaneous Lidocaine

Insert needle at 30º - 40º angle (See Figure 2)




In adults with adequate blood pressure, the syringe will “fill itself”; in hypotensive patients or children, the sample will need to be aspirated.

Remove needle, apply pressure for 5 mins. or until bleeding is controlled.



2.Brachial arterial puncture:

Position elbow in extension

Same technique



3. Femoral arterial puncture:

Position patient supine with hip extended and slightly, externally rotated

Same technique

ARTHROCENTESIS


INDICATIONS:


* Diagnosis of septic joint or crystal-induced arthritis
* Differentiation of traumatic effusion (blood in the joint) from inflammatory process
* Diagnosis of intra-articular fracture (blood with fat globules in the joint)
* Pain relief from acute hemarthrosis or tense effusion
* Local instillation of medications (anti-inflammatory or local anesthetics)


ABSOLUTE CONTRAINDICATIONS:


* Infection in tissue overlying puncture site


RELATIVE CONTRAINDICAIONS:


* Bacteremia
* Bleeding diatheses
* Joint prosthesis


MATERIALS:


* Skin preparation solution (povidone-iodine and alcohol)

* Sterile gloves and drapes

* Local anesthetic

* Syringes (2mL, 10mL, and 20mL)

* Needles (18, 20, 22 and 25ga)

* Sterile saline

* Sterile gauze dressings

* Hemostat

* 3-way stopcock

* sterile basin, cup, and/or test tubes

* green-top tube with liquid anticoagulant (to evaluate for crystals)

* microscope slides and coverslips

* culture media (if looking for infection)



PRE-PROCEDURE PATIENT EDUCATION:

Explain indications for procedure, technique, and possible complications. Obtain written consent when appropriate. Answer any questions the patient may have.


PROCEDURE/TECHNIQUE:


* Carefully palpate joint to be aspirated to identify all landmarks

* Select puncture site and approach to joint, taking care to avoid tendons, major vessels and nerves

* Use only sterile equipment and ensure proper sterile technique

* Thoroughly scrub the skin with a surgical scrub and then apply/paint on an antiseptic solution (Betadine) several times, allowing it to dry between applications

* Remove betadine with alcohol to prevent transference of betadine into the joint space

* Change gloves after skin prep.

* Apply sterile towels/drape

* Infiltrate skin with local anesthetic using 22 or 25 ga needle


* Identify landmarks

* Attach needle (18-22ga) to syringe and insert at desired landmark through the skin and subcutaneous tissue into the joint space.


Try not to bounce the needle off of the bony structures as a means of locating the joint to avoid damaging articular cartilage.

* Use a larger syringe for larger joints and larger effusions

* Consider using a 3-way stopcock to help to drain large effusions. This will help you to avoid having to change the syringe, which can cause the needle to move or become dislodged after you have already entered the joint space.

* If the syringe must be changed during the procedure, grasp the needle hub with a hemostat and hold it tightly while the syringe is changed.

* Intra-articular placement is confirmed by easy aspiration of synovial fluid (and/or blood, joint space contents)

* Try to remove all joint space contents/fluid


If the fluid stops flowing, the joint space has been drained, or the needle tip has moved/become dislodged, or there is debris or clot obstructing the tip.

If you suspect the needle has moved, slightly advance or retract the needle, rotate the bevel, or try using less pressure to aspirate.

* Remove the needle and apply a sterile dressing to the puncture site once aspiration is complete

* Send synovial fluid for analysis in proper containers (check with lab) as indicated by clinical scenario.


COMPLICATIONS, Prevention & Management:

· Infection can occur from introduction of skin bacteria into the joint space during the needle puncture. This complication can be limited by maintaining sterile technique and avoiding needle insertion through obviously infected skin.

· Bleeding is rarely a significant complication, but can occur in patients with bleeding disorders (such as hemophilia) or in patients who are taking anticoagulants. Arthrocentesis should be delayed until the clotting disorder has been reversed or enhanced with administration of specific clotting factors.

· Rarely, a local allergic reaction may occur from hypersensitivity to the local anesthetic. If it does occur, it is usually minor and can be treated with oral antihistamines. Monitor the patient for any signs of systemic allergic reaction or anaphylaxis. If there are signs of system reaction, this is an emergency and will require IV therapy, cardiac monitoring, and other treatments depending on the severity of the reaction.



DOCUMENTATION FOR THE MEDICAL RECORD:

Write a procedure note describing the indications for the procedure, skin preparation, sterile technique used, equipment and needle size used, amount and type of local anesthetic, number of attempts required, appearance and quantity of joint contents aspirated, type of dressing/splinting applied, lab studies ordered, and patient tolerance of procedure as well as complications.



ITEMS FOR EVALUATION:

· Understands indications/contraindications

· Educates/prepares patient

· Identifies proper landmarks

· Uses sterile technique

· Performs procedure correctly

· Understands potential complications and their management

· Adequate documentation performed

Foley (Urethral) Catheterization

Assess indications. Note that catheter insertion carries a risk of infection. A specific surgical consent is not generally obtained. Explain urethral catheterization (may be intermittent or indwelling).

Indications:

· Diagnostic

To collect uncontaminated urine specimen

Study anatomy of the urinary tract

Urine output monitoring

· Therapeutic

Acute urinary retention

Chronic obstruction causing hydronephrosis

Intermittent bladder decompression for neurogenic bladder

Chronically bed-ridden patients for hygiene

Contraindications:

1. Urethral injury

Trauma patients with blood at meatus or abnormal prostate location on rectal exam.

Equipment:

1. Catheter tray.

2. Foley Catheter:

18 F Adults

18 F Coudé if obstruction at prostrate

5 – 12 F Children

5 F feeding tube with tape – infants < 6 months

3. Drainage bag.

4. Transurethral topical Lidocaine jelly (Uro-jet). [OPTIONAL]

Procedure:

1. Consider prophylactic antibiotics: valvular heart disease or acute prostatitis.

2. Consider intraurethral anesthetic (Uro-jet).

3. Position: supine, frogleg or knees flexed.

4. Locate meatus. (Fig. A)

5. Apply antiseptic.

6. Gently insert lubricated tube until urine is obtained. (Fig. B)

7. Inflate retention balloon slowly with 5cc saline.

8. Connect to drainage system.

9. Secure tube with tape.


Removal:

· Deflate retention balloon by aspirating contents with 10cc syringe from side port.

. Withdraw catheter gently, taking care not to splash from tip.


Complication:


1.Inability to locate urethra:
Proper position.Compress foreskin edema. Use lubricated pediatric vaginal speculum with edematous foreskin.

2.Vaginal catheterization:
Position.Discard catheter.Re-attempt with fresh catheter.

3.Paraphimosis: Properly replace foreskin.Urology consult.

4.Urethral stricture:Trial of smaller tube.

5.Inability to deflate:
Remove syringe adaptor.Insert guidewire into inflating channel – balloon water should flow out.

__________________

TRANSCUTANEOUS PACING


INDICATIONS:

· Hemodynamically significant bradydysrhythmias unresponsive to atropine treatment

· (Hypotension, chest pain, pulmonary edema, altered mental status)

· temporary cardiac pacing until the more permanent transvenous pacing can be initiated or until the underlying cause of the bradydysrhythmia can be corrected (i.e. electrolyte disturbance, drug OD)

· asystolic cardiac arrest

· more likely to be successful when initiated early after a witnessed arrest (must be attempted within 10 minutes)



CONTRAINDICATIONS:

· Active pacing may not be necessary for hemodynamically stable awake patients. Instead, attach the pacing pads and turn the pacer on to “standby” mode due to the potential for deterioration (i.e. heart block resulting from cardiac ischemia). Then the pacer can be quickly activated in the event the patient becomes “unstable” due to the bradyarrhythmia.



· Non-intact skin at the site of the electrode placement


MATERIALS:

· ACLS equipment and medications (“code box” and “code cart”)

· Airway equipment (Oxygen, suction, BVM, intubation supplies, etc.)

· Pacemaker/monitor (and defibrillator)

· 2 sets of electrodes

· ECG electrodes for rhythm monitoring

· Pacing electrode pads



PRE-PROCEDURE PATIENT EDUCATION:

For awake patients, explain the procedure, advise them of the benefit of pacing, potential risks of further deterioration if pacing is not attempted, and of the potential complications (listed below).



PROCEDURE/TECHNIQUE:

· If time permits and the patient is hemodynamically stable, correct metabolic and electrolyte abnormalities, or reverse unwanted drug effects which may be the cause of the bradycardic rhythm.

· 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 monitor on to “pacing” mode

* Apply monitor cable leads 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

· pacing pad placement:

· 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)

· attach pads to the instrument cable and attach cable to pacer, carefully check all connections

· select a pacing rate (target heart rate)

· usually range of 60-70 beats per minute, target rate is chosen to maintain cardiac output, improve BP and improve pre-pacing symptoms

· select power/output

· for hemodynamically compromising bradycardia without cardiac arrest, start at 0 mA and slowly increase the output until capture is achieved

· in cardiac arrest setting, start at max power setting and decrease the output after capture is achieved

· assessment of capture: look at the ECG tracing on the monitor for pacer spikes that are each followed by a QRS complex

· SEE DIAGRAMS of CAPTURE AND NON-CAPTURE TRACINGS

· Assess patient hemodynamic stability (measure blood pressure, assess tissue perfusion) and tolerance to pacing. Provide sedation/analgesia PRN.


DOCUMENTATION FOR THE MEDICAL RECORD:

· A brief progress note should be written in the chart to include the indications for pacing, pre-paced rhythm and 12-lead ECG findings, medications given, energy level/settings required, any complications that occurred, patient assessment and outcome, disposition, and the notification of attending physician and family members.



COMPLICATIONS, Prevention & Management:

· Failure to recognize VF (which is treatable with defibrillation) due to the size of pacing artifact on the ECG screen. You should frequently re-assess the patient and the rhythm, defibrillation is indicated immediately if VF occurs.

· Induction of other dysrhythmias. Follow ACLS guidelines for arrhythmia management.

· Soft tissue discomfort may result from pacing. Ensure adequate analgesia and sedation.

· There is a potential for local cutaneous injury with prolonged TCP. Remember TCP is temporary, correct possible underlying causes for bradydysrhythmia, and/or arrange for transvenous pacemaker placement.

THORACENTESIS


Indications

1. Removal of fluid from the pleural space for diagnostic or therapeutic purposes


Contraindications

1. Local skin infection over proposed site of thoracentesis

2. Uncontrolled bleeding or clotting abnormality

Materials

1. 1% or 2% lidocaine with epinephrine for local anesthesia

2. 3 ml syringe with 1 1/2” 25-gauge needle for anesthetic infiltration

3. 1 1/2 “ 18-gauge needle

4. Skin prep solution, sterile drapes

5. 2- 1-litre evacuated bottles for fluid collection

6. Thoracentesis or blood set tubing (these are short IV tubings with a midpoint clamp, a fastened needle at one end, and a port for a second needle at the other end) NOTE: A secondary IV tubing set may also be used

7. Occlusive dressing

8. Universal precautions materials


Optional: 60-ml syringe with 3-way stopcock


Preprocedure patient education


1. Obtain informed consent

2. Inform patient of the possibility of major complications and their treatment

3. Explain the major steps of the procedure

4. Explain the necessity of positioning, and follow-up chest radiograph


Procedure

1. Assess indications for procedure and obtain informed consent as appropriate. Use universal precautions and sterile technique.

2. Obtain a chest radiograph to document and localize effusion. Perform a physical examination to define the place where you will enter the thorax. Clinical findings associated with an effusion include diminished breath sounds at the base(s) of the affected lung(s), and a decreased percussion note.

3. Position patient upright and sitting with arms up and forward (draping arms over a bedside table is perfect). See Figure 1.



Figure 1: Positioning the patient

4. Select site for needle puncture. This should be done clinically, by percussion of the chest wall, to locate the upper end of the effusion. Measure down two rib interspaces from this upper end of the effusion in the mid-scapular line. Mark this space with a pen or fingernail; this will be the needle puncture site.

5. Cleanse skin over puncture site with skin prep and drape to create a sterile field.

6. Anesthetize the skin and deeper layers with the lidocaine. Be sure to anesthetize the pleura, which is quite pain-sensitive. If lidocaine enters the pleural space, it will simply mix with the effusion and be of little concern.

7. Remove thoracentesis or blood tubing from its packaging, and close the midpoint clamp securely. Attach the 18-gauge needle to the free end of the tubing.

8. Remove the protective covering from the evacuated bottle stopper. Insert the tubing with the fixed needle through the stopper.

9. With the free 18-gauge needle, puncture the skin at the marked intercostal space. Advance the needle until you feel a slight give (entering the pleural space).

10. Open the clamp. This will provide negative pressure from the evacuated bottle. If you are in the right location, fluid will drain spontaneously into the bottle. If no fluid flows, you may advance the needle cautiously until the fluid flow begins.


11. If frank blood returns, you may have punctured the lung. Withdraw needle slowly until fluid flows. If no fluid flows at all, with draw the needle until it is just under the skin. Clamp the tubing, and with draw the needle completely from the patient. Re-examine the patient to correlate the location of the effusion, and repeat steps 5-10.


To change collection bottle:

12. Close clamp on collection tubing. Leave intercostal needle in place. Remove needle from the full collection bottle, and replace it into the new empty collection bottle. Then, re-open clamp.

When procedure is done:

13. Leave tubing clamp OPEN. Remove intercostal needle slowly and completely from patient. Dress puncture site with an occlusive dressing. Leaving the collection tubing clamp open maintains a negative pressure throughout the system and in the pleural space, minimizing the chance of an iatrogenic pneumothorax.

14. Obtain a post-procedure radiograph to check for iatrogenic pneumothorax.

Alternate technique using a 3-way stopcock:

1. Follow Steps 1-6 above. Attach the free end of the collection tubing to the 3-way stopcock, and attach the collection syringe and the 18-gauge needle to the other stopcock ports. Familiarize yourself with the operation of the stopcock. Make sure the stopcock is in the OFF position in the direction of the collection tubing.

2. Puncture the collection bottle with the 18-gauge needle, and CLOSE the stopcock connection to the collection bottle.

3. Now puncture the skin over the selected intercostal space and advance into the pleural space.

4. Withdraw the syringe plunger to fill the syringe with pleural fluid.

5. Turn stopcock OFF in the direction of the collection tubing. This will open up the connection between the syringe and the collection bottle. Empty the syringe into the collection bottle, then CLOSE the connection to the collection bottle.

6. Repeat Steps 4 and 5 until desired amount of fluid is withdrawn.

7. Remove intercostal needle while maintaining slight negative pressure on the syringe.

8. Obtain post-procedure radiograph to check for iatrogenic pneumothorax.


Complications, Prevention, and Management


Fluid doesn’t flow: Reposition needle by either advancing or withdrawing slightly

May have to chose another interspace.

Check tubing connections and collection bottle for vacuum


2.Fluid is bloody:

May have punctured lung...withdraw or reposition needle

Could this be an underlying hemothorax?

3.Patient is coughing during procedure

Needle may be touching pleura of lung…withdraw slightly so that cough stops yet fluid still flows

Have patient only take shallow breaths during procedure

4.Decreased breath sounds in hemithorax after procedure

Possible pneumothorax. Obtain chest radiograph. If greater than 10% pneumothorax, will need to insert a chest tube

REPAIR OF LACERATIONS: SUTURES, STAPLES, AND DERMABOND GLUE


Indications:


Most lacerations are minor, and repairable by primary wound closure. Primary closure technique attempt to bring the wound edges together neatly and evenly, stop any bleeding, preserve function of the tissue, prevent infection, restore cosmetic appearance, and promote rapid healing. Techniques to obtain primary closure may involve steri-strip dressings, sutures, glue, or staples.

As a general rule, lacerations on any part of the body may be closed primarily for up to 12 hours following the injury. Facial wounds may be closed primarily up to 72 hours following the injury. Wounds that have been grossly contaminated, infected, or have come to medical attention late may be allowed to heal by granulation (secondary intention) after appropriate cleansing.


Contraindications

Lacerations that should be managed in an operating room under general anesthesia with a surgical consultant include wounds with:

1. Excessive length or depth, potentially requiring a toxic dose of local anesthesia to obtain adequate analgesia

2. Severe contamination requiring extensive cleansing or debridement

3. Open fractures, tendon, nerve, or major blood vessel injury

4. Complex structures requiring meticulous repair (eyelid)


Materials


1. Universal precautions materials

2. Suture set to include: needle driver, toothed forceps, suture scissors

3. Lidocaine 1% or 2% with and without epinephrine for local anesthesia

4. 10 cc syringe, and 25 gauge needle for infiltrating anesthetic

5. Sutures: absorbable or non-absorbable of appropriate size and needle type; OR Dermabond® glue OR surgical steel staples and stapler

6. Wound preparation materials: prep solution, gauze, scrub brushes

7. Wound dressings, tape

8. Tetanus immunization serum and syringe


Preprocedure patient education


1. Obtain informed consent

2. Inform patient of the major steps of the procedure, including the transient discomfort associated with local anesthesia


Procedure:

Laceration repair involves four steps:

1. Wound assessment

2. Wound preparation

3. Wound closure

4. Tetanus prophylaxis

Assessment

1. Brief history and PE

2. Potential for foreign body in wound, or fracture

3. Examine and document vascular and neurologic status

4. Radiographs, if appropriate

Preparation

1. Mechanical cleansing: surgical scrub brush, soap and water

2. Mechanical Cleansing: normal saline irrigation using a 30- or 60-cc syringe with an 18- or 20-gauge needle to develop pressure. Use 100 cc of saline for each cm of wound

3. Chemical cleansing: Betadine, Savlon, or Hibiclens

4. Freshen wound edges if necessary with scalpel or scissors

NOTE: The maximum dose of lidocaine in 4 mg/kg


Wound Closure


1. Glue: approximate edges of wound, apply glue in thin layers along wound‘s length, allow to dry between applications

2. Suturing:



Face: 1% lidocaine with epinephrine

4.0 or 5.0 nonabsorbable monofilament,

or 5.0 absorbable monofilament on cutting needle

Use interrupted or intracuticular technique, layered closure if deep

Sutures out in 3-5 days



Scalp: 1% lidocaine with epinephrine

2.0 or 3.0 nonabsorbable monofilament on cutting needle

Use interrupted or mattress technique

Sutures out in 10 days



Figure 1: A simple interrupted suture. Note the broad, even bite, and the knot tied to one side.


Ear: 1% or 2% PLAIN lidocaine, or field block

1.0 synthetic absorbable on taper needle for perichondrium, interrupted sutures

1.0 synthetic nonabsorbable monofilament on cutting needle for skin, interrupted sutures

sutures out in 5 days

Lip: 1% or 2% lidocaine with epinephrine; consider regional block

4.0 or 5.0 synthetic absorbable on taper needle for deeper layers, interrupted sutures

1.0 synthetic monofilament on cutting needle for skin, interrupted sutures

sutures out in 3-5 days


Oral cavity: lidocaine 1% with epinephrine; consider regional block if extensive laceration

4.0 absorbable gut, or synthetic absorbable on taper needle, mattress technique

allow sutures to dissolve; remove any remaining after 7 days





Neck, chest, back, abdomen:

1% lidocaine with epinephrine

4.0 or 5.0 nonabsorbable synthetic monofilament on cutting needle, interrupted or running sutures

sutures out in 10 days



Figure 2: The basic interrupted suture used to close dead space. Notice that the knot is buried in the deeper tissues.


Extremity: 1% or 2% lidocaine with epinephrine

1.0 or 4.0 absorbable synthetic on taper needle for muscle or fascia; interrupted sutures or 5.0 nonabsorbable monofilament on cutting needle for skin; interrupted or running sutures

sutures out in 10 days

Hands, feet: 1% PLAIN lidocaine, or consider regional block with bupivicaine

1.0 or 5.0 nonabsorbable synthetic monofilament on cutting needle; interrupted or running sutures

sutures out in 10-14 days


Nail beds: 2% PLAIN lidocaine, or consider regional block with bupivicaine

5.0 plain gut on taper needle; interrupted sutures

use a stent for the nail fold

allow to absorb


Figure 3: A horizontal mattress suture


Stapling

Many surgical staplers are on the market. The staple is inserted into the skin in the shape of an upside-down “U” which elevates, everts, and approximates the skin edges. Stapling is appropriate for wounds on the scalp, trunk, or extremities. They should be removed in 10 days.


Tetanus prophylaxis



Currently, a basic course of minimally three doses of tetanus vaccine with a booster dose every 10 years is current standard of care for everyone. However, patients may be deficient in one or more doses, and require tetanus prophylaxis in the ER,



1. Patients who have a clean wound, with last booster > 5 years require Td or Tetanus toxoid

2. Patients with a clean wound who have had a tetanus booster < 5 years require no vaccination

3. Patients who have not had at least three doses of tetanus vaccine as a primary course should receive Tetanus Immune Globulin, AND Td or Tetanus toxoid, and a schedule to complete their primary vaccinations

4. Patients with grossly contaminated wounds whose last tetanus booster was > 5 years ago require Tetanus Immune Globulin AND Td or Tetanus toxoid.

Peripheral Intravenous Access

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

Indications:

· Access to the peripheral circulation for blood sampling.

· Administration of medication, fluids or nutrition.

Contraindications:

1. Absolute thrombosis

2. Phlebitis or cutaneous infection

3. Relative ipsilateral to mastectomy, dialysis shunts, or distal to an area or trauma

Equipment:

1. Alcohol swab

2. Tourniquet

3. Appropriate size catheter

4. Tape or occlusive dressing

5. Filled IV bag and tubing or Heparin trap

6. Anesthetic and topical (EMLA cream) or local (1% Lidocaine, 1cc SQ) [OPTIONAL]

Procedure:

1. Site selection will depend on many factors including: Patient comfort, accessibility, urgency of IV access, intended use and patient age. In general, more distal sites should be selected first. This allows use of a more proximal site if initial attempt is unsuccessful. Acceptable sites include: dorsal hand, forearm, antecubital (higher likelihood of position related flow obstruction), foot, lower leg and scalp in children.

2. Apply a tourniquet proximal under tension.

3. Consider venous dilation; active or passive pumping of an extremity, warm compress or gravity. Some advocate a small amount of nitroglycerin ointment.

4. Clean skin with alcohol swab.

5. Apply anesthetic.

6. Stabilize skin by taught traction distally with the non-dominant hand.

7. Puncture skin at a 30º angle, bevel up, just over or parallel to the vein. Once blood is seen in the flash chamber, the catheter is advanced over the needle.

8. Remove needle, connect IV tubing or Heparin trap.

9. Apply tape or dressing. Additional dressing or tape may be used to prevent removal.

PARACENTESIS


Removal of abdominal fluid is of value in evaluating patients with ascites of new onset or unknown etiology, and provides symptomatic relief in patients with known disease or in the setting of a