List of procedures

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

Central Venous Line Placement

Subclavian Venipuncture, Infraclavicular Approach

Large veins such as the subclavian have relatively constant relationships to easily identifiable anatomic landmarks. This makes the subclavian a good site for central line placement.

Indications:

* Placement of 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 (the flow rate is determined by the caliber and length of the catheter, shorter and greater caliber catheters delivering greater volumes over equivalent amounts of time)
* Central venous pressure measurement
* Administration of sclerosing agents such as chemotherapeutic agents, hyperalimentation fluids, etc.
* As an alternative to repetitive venous cannulations
* For placement of pulmonary wedge catheters
* For placement of trans venous pacemakers
* For performance of hemodialysis or plasmapheresis

Contraindications:

* Infection over the insertion site
* Distortion of landmarks from any reason
* Suspected injury to the superior vena cava (eg., SVC syndrome)
* Coagulopathies including anticoagulation therapy
* Pneumothorax or hemothorax on the contralateral side
* Inability to tolerate pneumothorax on the ipsilateral side
* Uncooperative patients
* Patients unable to tolerate a Trendelenberg position
* Prior injury to that vein (choose the one on the other side)
* Morbid obesity
* Recently discontinued subclavian catheter at the same location
* Planned mastectomy on the side of subclavian insertion
* Patients receiving ventilatory support with high end expiratory pressures (temporarily reduce the pressures)
* Patients with vigorous, ongoing cardiopulmonary resuscitation
* Children less than 2 years (higher complication rates)
* Fracture or suspected fracture of ipsilateral upper ribs or clavicle

Materials:

* Universal precautions material
* Tape and dressings
* IV tubing
* IV fluid
* Central line kit
* Bath towel or rolled up sheet
* Availability of STAT chest radiography

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 (Infraclavicular Approach):

* Use Universal Precautions and sterile technique
* Attach the IV tubing to the IV vluids 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 to the side contralateral to the site chosen
* Place a rolled towel or sheet between the shoulder blades to make the clavicles more prominent but do not overaccentuate this position since it might move the clavicle closer to the first rib, making cannulation of the subclavian vein more difficult
* Place the arms to the sides of the patient (restrain if necessary)
* Locate landmarks

1. The subclavian vein is a continuation of the axillary vein

2. Subclavian vein is located just deep to the middle third of the clavical, and runs parallel to it (this is the only area where there is a close anatomic relationship between the subclavian vein and the clavicle)

3. The subclavian vein is valveless and has a diameter of 1 to 2 cm.

4. The subclavian artery is superior and posterior to the vein and is separated from the vein behind the anterior scalene muscle.

5. The costoclavicular ligament connects the first rib to the clavicle

6. The costoclavicular ligament lies at the junction of the medial third and middle third of the clavicle at the point where the clavicle bends slightly posteriorly

7. The subclavian vein traverses an imaginary line connecting two points established by placing ones thumb over the costoclavicular ligament and index finger in the suprasternal notch

8. Contiguous structures include the phrenic nerve, the thoracic duct on the left side and the lymphatic duct on the right side.

9. The left subclavian approach has a sweeping curve to the apex of the right ventricle and is the preferred approach for temporary transvenous pacing

10. The right subclavian vein approach is generally preferred because the dome of the pleura of the right lung is usually lower than the left, and the left-sided large thoracic duct is less likely to be lacerated

11. By premeasuring the catheter length against the patient’s chest size, one can determine a catheter length that will place the catheter tip about 2 to 3 cm below the manubrial-sternal junction (in the superior vena cava, just above the right atrium)

* Before gloving, mark a spot 1 cm caudad to the clavicle at the junction of the middle and medial thirds of the clavicle
* Prep and dress the area
* U sing a 25 gauge needle and 1 cc of lidocaine, anesthetize the spot that you have marked
* U sing a 22 gauge needle and more lidocaine, anesthetize the structures deeper to the spot marked
* Use the 22 gauge needle (seeker needle) on a 3 cc syringe to locate the vein, aspirating as the needle is advanced until a flush of blood returns
* Note the angle and depth of the seeker needle and remove it
* Use an 18 gauge needle on a 5 cc syringe to follow the path of the seeker needle, aspirating as the needle is advanced. Entry into the vein is marked by a flush of blood.
* Stabilizing the needle with the thumb and forefinger, remove the syringe and immediately occlude the hub of the needle (maintaining a “closed system”)
* Thread the J wire into the 18 gauge needle leaving about half of the wire extruding from the needle
* Secure the J wire with a fmgertip and remove the 18 gauge needle over the exposed, remaining portion of the J wire
* Make a small cut in the skin adjacent to the entry site of the J wire using a scalpel
* Thread the silastic dilator over the wire
* Advance the dilator fully into the chest
* Remove the dilator while still leaving the J wire in place
* Remove the hub from the long central catheter
* Thread the long central catheter over the wire into the vein

· Leave 5 to 10 cm of the catheter outside the skin

* Carefully remove the J wire
* Attach IV tubing to the catheter
* Lower the IV bag below the level of the patient to observe for blood return
* Discontinue the Trendelenberg position
* Secure the catheter in place using sutures and ties
* Place an occlusive dressing over the catheter
* Obtain a STAT post-procedure chest x-ray looking for a pneumothorax or hemothorax, and looking for the catheter position. The STAT chest x-ray should be obtained whether the procedure is successful or not.

Complications, Prevention and Management:

· Pneumothroax

o Prevention: Remove patient from ventilator before advancing the needle, choose the right side rather than left, avoid multiple attempts when possible

o Management: Check postprocedure x-ray, if pneumothorax arrange for thorcostomy depending on the size of the pneumothorax

* Hemothorax – as above
* Bilateral Iatrogenic complications

o Prevention: If attempted catheterization is unsuccessful, try the ipsilateral internal jugular or subclavicular approach before trying contralateral subclavian catheterization

* Catheter embolization

o Prevention: Never withdraw a catheter past a needle bevel which might shear off the catheter

o Management: x-ray the patient and contact specialist who can remove the embolized catheter

* Infection

o Prevention: Never choose an insertion site that goes through infected tissue; use antimicrobial-impregnated catheters; avoid the use of antibiotic ointments (increase of fungal contamination and antibiotic resistant bacteria)

* Cardiac dysrhythmia

o Prevention: if available, have someone watch monitor for dysrhythmia while the catheter is advanced (this comes from direct contact of the catheter tip with the myocardium of the right atrium)

o Management: reposition the catheter; treat dysrhythmia according to ACLS protocols.

* Air embolism

o Prevention: Maintain a Trendelenberg position, ask the patient to exhale while you are advancing the catheter, 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.

Dilatation & Currettage:

Indications:

Uterine scraping (D & C) may be done to:

Diagnose conditions by collecting tissue samples for biopsy.

To treat irregular or heavy bleeding.

Evacuation of retained products of conception (ERPOC) – removes any leftover tissue after a spontaneous abortion .

The other indications for D & C include:

Treat intermenstrual bleeding.

To investigate the causes of infertility.

To remove polyps in the endometrial or inner lining of the uterus.

To diagnose endometrial cancer.

To remove an embedded intrauterine device (IUD) used for contraception.

To perform abortion in the early stages of pregnancy.

To evacuate spontaneous abortion products.

To investigate the cause of abnormal bleeding in postmenopausal women taking hormone replacement therapy.

Contraindications:

There are very few contraindications to D&C. They are:

If a patient is too ill to undergo surgery.

If the patient is unable
to move her legs apart, such as with severe arthritis in the hips.

If the patient has problem with clotting mechanism of the body.

Anesthesia:

The different types of anesthesias given to a patient prior to the procedure depend on both the choice of the anesthetist and the patient. It is best to discuss it with him or her when they visit you before surgery.

a. General Anesthesia

General anesthesia is a state of total unconsciousness resulting from anesthetic medicines. The medicines can be administered as an inhaled gas or as an injected liquid. Most D&Cs are done under general anesthesia. The procedure is normally very short and the general anesthetic can be quickly reversed, with the patient going home soon afterwards.

b. Spinal Anesthesia

Spinal anesthesia is induced by injecting small amounts of local anesthetic into the back of the spine in the middle section. The drug is injected using a very fine needle that is almost similar to the thickness of hair. The patient is put on the side in a crouching position to get the right space between the vertebrae. Once the injection pierces the tough fascia, the anaesthetic drug is injected into the cerebro-spinal fluid (CSF).

The advantage of spinal anesthesia is that the patient is awake but at the same time does not have any sensation below the waist. It avoids all the complications of general anesthesia. Another popular anesthesia is called Epidural anesthesia Here the injection is given in a slightly different space in the spinal region and this takes away the sensationof pain keeping intact the power in the lower limbs.

c. Local Anesthesia

Local anesthesia involves numbing a small area by injecting a local anesthetic medicine under the skin just where an incision is to be made. The medicine can be injected locally. Occasionally, in a very motivated patient, the D&C procedure can be done under a local anesthetic with or without intravenous pain medication.

Procedure:

The actual procedure is done in a sterile environment such as an operating room, either in a hospital, a surgical center, or in a specially designated room in a physician’s office.

After adequate anesthesia has been administered, the patient’s legs are parted and flexed and comfortably put up on a stirrup in a position that is called the ‘lithotomy’ position. This ensures a good view of the genital area for the surgeon or gynecologist to operate.

The vagina and cervix are scrubbed with an antibacterial solution that maybe iodine or alcohol based.

The cervix is visualized using an instrument that is located in the vagina called the speculum. Lights are so adjusted to visualize the cervix so that its upper lip can be grasped with a special curved forceps called the ‘Vulsellum’. This helps both in stabilizing and bringing the cervix down towards the vaginal opening to ease with rest of the procedure.

Dilatation is next done using sequential metal round tapered dilators and the opening to the uterus is gradually widened to about the size of a large pencil.

Once this dilatation has been completed, the spoon like curette is inserted into the uterine cavity and is used to gently scrape the lining of the uterus.

When the surgeon feels the gritty layer of cells just above the muscle of the uterus, then he/she knows that the scraping has gone deep enough to sample the tissue adequately.

This scraping is done throughout the uterus and the tissue that is removed is then sent to a pathologist for microscopic examination.

Depending on the indication for the procedure the surgeon terminates the procedure once he feels that enough tissue has been obtained, or that the entire cavity has been sampled or scrapped.

Complications

Complications are usually rare.
Complications due to Anesthesia include:

Reactions to Anesthetic medications

Breathing difficulties

Complications of Surgery include:

Bleeding

Infection

Puncture (perforation) of the uterus

Laceration (tear) of the cervix

Scarring of the uterine lining (endometrium)

Fibroid or uterine artery embolization

Uterine artery embolization (UAE) is a favorable treatment alternative for women with fibroids who want to preserve their uterus and avoid surgery.

UAE is a minimally invasive procedure performed by an interventional radiologist through a tiny nick in the skin while the patient is conscious but sedated.

The interventional radiologist inserts a catheter (hollow tube) into an artery located in the groin. Under fluoroscopic (X-ray) guidance, the catheter is advanced into the vessels (uterine arteries) supplying blood flow to the uterine fibroids (Figure 1).

Figure 1

Once the catheter is positioned in the uterine arteries, small particles (Figure 2) are injected to block blood flow to the uterine fibroids.

Figure 2

Following embolization of the uterine arteries, the catheter is removed and compression of the catheter insertion site is performed for approximately 15 minutes. The patient is required to lie flat for 6 hours following the procedure. A majority of patients are discharged the same day as the procedure or the following morning.

What are the complications associated with uterine artery embolization?

Although UAE is considered a very safe treatment, there are a few complications associated with the procedure. Infection occurs in a small number of patients and is usually treated with a course of oral antibiotics. Injury to the uterus potentially leading to hysterectomy is fortunately rare. Women following the procedure may develop fever, pain and nausea, which are managed with pain medications, anti-nausea medications and Tylenol.
Premature menopause is another potential procedural risk. However this is unusual (3%) in younger patients (under 40 years old), but much more common in patients in their late forties and early fifties.

Despite the complications mentioned above, complications associated with UAE are lower than those related to the available surgical alternatives; myomectomy and hysterectomy.

How successful is uterine artery embolization?

Fibroids typically shrink in size approximately 40% by 3 months. As far as symptom relief, success rates are 90% or greater for heavy bleeding and 85% or greater for bulk-related symptoms (i.e. urinary frequency).

Episiotomy Repair by Suturing

USING ANESTHESIA

Injecting anesthesia for a hospital-based episiotomy. In a home birth episiotomy (which is rare), we find this is not necessary since we use the episiotomy as a last resort and the perineal tissue is usually stretched to a very thin maximum already and not requiring anesthesia. Anything given to the mother will cross the placenta and have effect on the baby.

Types of episiOtomy incisions

VARIOUS TYPES OF EPISIOTOMY INCISIONS

# Medio-lateral (posterio-lateral) – Is a favorite of birth practitioners and does not require careful control of the baby’s head which may damage or tear through the anal sphincter. Often it is used to help with forceps and vacuum extraction types of deliveries. The incision is begun at the center of the fourchette and directed posterio-laterally, usually to the woman’s right. It should be not more than 3 cm long and is directed diagonally in a straight line which runs 2-5 cm distant from the anus. If the anus is considered to be 6 on the clock, the incision would be directed to 7 o’clock.

# Median - The incision, begun at the center of the fourchette, is directed posteriorly for approximately 2-5 cm in the midline of the perineum. It is a favored by experienced birth practitioners that have careful control of the baby’s head as it passes through the vaginal opening. There is a great risk that the incision will be extended during delivery and can go directly into the anal sphincter resulting in a third degree tear. When vaginal manipulation is necessary or the baby is large, the median incision does not provide as much space as the medio-lateral incision. The advantages are (a) less bleeding, (b) more easily and successfully repaired, (c) greater subsequent comfort for the woman.

# J-Shaped – The incision is begun at the center of the fourchette and directed posteriorly to the mid-line for about 2 cm and then directed outwards toward 7 on the clock to avoid the anus. The suturing of this incision is difficult. Shearing of the tissues occurs. The repaired wound tends to be puckered.

# Lateral – The incision is begun one or more cm distant from the center of the fourchette and is not a favored incision. Bartholin’s duct may be severed. The levator ani muscle is weakened. Bleeding is more profuse. Suturing is more difficult and the women experiences subsequent discomfort.

lateral tear/incision

performing mediolateral episiotomy

A mediolateral episiotomy is cut. This is a standard procedure in a hospital birth and is supposed to help facilitate descent of the baby’s presenting part (head or buttocks) and the common use of forceps to aid in the delivery of the fetal head.

Care must be taken to prevent injury to the fetal presenting part. A blunt-ended side of the scissors should be used on the inside of the perineum and the presenting part protected by the practitioner doing the episiotomy.

Inspection of the episotomy

Inspection of the episiotomy is done and the extent of the wound is assessed. Careful inspection includes matching up of land marks (such as the hymenal tags).

first degree tear/incision

Assessment includes determination of damage. With a first degree tear or incision, only the fourchette is damaged.

second degree tear/incision

A second degree tear or incision has damage beyond the fourchette, into the muscle tissue but not involving the rectum or anal sphincter.

third degree tear/incision

A third degree tear or incision has damage into or through the anal sphincter.

Locating and finding the apex of the incision and the matching sides. Repair of the episiotomy is achieved by closure of the vaginal wall, interrupted sutures into the levatores ani, and interrupted sutures to the skin.

Care is taken to expose the apex of the incision in the vaginal wall and a continuous absorbable suture is used to close the vaginal wall.

Closure of the episiotomy

The wound is closed to the introitus.

Care is take to ensure that the introitus is not constricted. Interrupted absorbable sutures are inserted into the levatores ani.

Interrupted mattress sutures are used to close the skin.

Obstetric Forceps Use During Birth

Forceps should not used in a homebirth setting and by individuals that are not fully trained in the proper use of and dangers of these obstetric tools.

DESCRIPTION

The obstetric forceps is designed to grasp the fetal head when it is in the vagina and bring about delivery by traction and guidance without causing injury to the mother or baby. The forceps consists of two arms which are movable.

The blades have two curves.

The cephalic curve is adapted to provide a good application to the fetal head. The pelvic curve allows the blades to fit in with the curve of the birth canal.

There are several kinds of locks:

The pelvic axis necessitates traction “round a corner”, so some forceps have detachable handles, rods or tapes which allow traction in the pelvic axis. This technique of “axis traction” should be unnecessary in present day practice. Difficult forceps delivery is avoided by cesarean section.

The traction rods can make the forceps a very powerful and therefore dangerous instrument.

Forceps operations are of two kinds:

Low Forceps

The fetal head has reached the perineal floor and is visible at the vulva. Mid Forceps

Engagement has taken place and the leading part of the head is below the level of the ischial spines.

Application of the forceps when the head is not “engaged” is known as “high forceps”. Some suggest that only low forceps should be used and that mid forceps should be replaced by cesarean section.

cont……

TYPES OF FORCEPS

There are very many different patterns. The forceps shown here are all well known and are identified with the three main operations – the low forceps, the mid forceps, and the rotation-extraction forceps delivery.

Wrigley’s Forceps: Wrigley’s Forceps is designed for use when the head is on the perineum and local anesthesia is being used. It is a short light instrument with pelvic and cephalic curves and an English lock.

Milne Murray’s Axis Traction Forceps: In theory the axis traction rods which were designed to apply traction to a head high in the pelvis are now obsolete; but in practice they are often of considerable help and the action of the rods allows the forceps blades to move more naturally along the pelvic curve without hindrance from the operator’s hands. The forceps has an English lock and an additional screw lock to maintain a firm application, and the traction rods are connected in such a way as to give the best mechanical advantage. This instrument is a little awkward for the beginner, and the traction rods if used may damage the perineum unless a large episiotomy is made. This instrument can be very powerful and therefore very dangerous if not used with caution.

Kielland’s Forceps: This forceps was originally designed to deliver the fetal head at or above the pelvic brim, lying in the transverse axis of the pelvis and rotating it when it had reached the pelvic cavity. The forceps is used today for rotation and extraction of the head which is arrested in the deep transverse or occipito-posterior position.

The blades have very little pelvic curve and are virtually an axis traction forceps. A large episiotomy is needed. The shallowness of the curve allows safe rotation in the vagina. Downward traction encourages rotation of the head.

The Claw Lock allows the blades to slide on each other and correct or encourage synclitism of the fetal head as required.

The range of movement allowed by the lock makes it possible to apply lethal compression to the fetal head if the instrument is used improperly.
forceps compression

INDICATIONS FOR THE USE OF FORCEPS

1. Second stage delay. When progress is absent or slow and the laboring woman is tiring, whatever the position of the baby’s occiput. This covers a wide variety of attitudes to the second stage; but in general, in the current medical practice it may be said that the second stage should not last over an hour in a primigravida and half-an-hour in a multigravida.

2. Fetal Distress.

3. Maternal Distress. When the mother is exhausted by a long labor or is emotionally unequal to the demands of a second stage labor; or when some condition such as cardiac failure or hypertension makes the effort of the second stage undesirable.

CONDITIONS & PREPARATIONS FOR FORCEPS DELIVERY

1. The cervix must be fully dilated. If the forceps is applied before this stage is reached the operator may produce severe lacerations and hemorrhage.

2. Except when the head is on the perineum, the bladder should be emptied by catheter.

3. The laboring woman should be in the lithotomy position, although some practitioners find delivery easier with the laboring woman in the left lateral position. She must be cleaned and draped and aseptic precautions must be observed. Negligence in this respect will almost certainly lead to genital infection.

4. For low forceps operations local anesthesia may be used provided it is acceptable to the mother. It avoids the risks of general anesthesia and allows the mother to assist in the delivery by bearing down when asked.

5. Epidural anesthesia may be used for pain relief, and this is adequate for low forceps or when little manipulation is required.

6. If general anesthesia is used, it should be given by an experienced anesthesiologist. The stomach must be emptied by gastric suction, the laboring woman should receive pre-medication, and endotracheal intubation is probably the safest technique.

7. Mechanical suction should be available for mother and child, and the head end of the bed or table used for the operation should be capable of being lowered rapidly if vomiting should occur when the mother is under anesthetic.

USE OF ANESTHESIA FOR FORCEPS DELIVERY

LOCAL ANESTHESIA

Local anesthesia for forceps delivery is usually a combination of local infiltration and pudendal nerve block. Lidocaine or xylocaine in 1% without adrenaline solution is satisfactory and up to 50 mls may be used with safety.

Local infiltration is usually all that is needed for low forceps operation.

PUDENDAL NERVE BLOCK

The forefinger is placed on the ischial spine (behind which runs the pudendal nerve) and a long needle is passed via the ishiorectal fossa. When needle point, spine and finger are in conjunction, 5 ml of anesthetic is injected. It is advisable to withdraw the plunger before injecting to make sure that the needle is not in a blood vessel. The needle, preferably a guarded one can be passed per vagina if the practitioner finds it easier.

COMPLICATIONS OF FORCEPS DELIVERY

LACERATIONS

1. Perineal tears are inevitable unless episiotomy is done at the right time.

2. Vaginal wall may be split especially if compressed between ischial spine and fetal head or forceps inserted carelessly.

3. Cervical and vaginal tears may be caused during a Kielland’s rotation. After delivery the vagina and cervix should be carefully palpated and all damage repaired.

HEMORRHAGE

Except from lacerations, hemorrhage is no more likely than after spontaneous delivery. If the uterus is “atonic” (i.e., if contractions have ceased for some time before delivery) intravenous oxytocin should be given.

INJURIES TO BABY

If the blades have been properly applied, the fetal head should be protected by the rigid case of the forceps blades. Where excessive traction force has been applied, there may be bruising, facial nerve palsy, or depression fracture of the skull.

FAILED FORCEPS

This is an old term which means that an attempt to deliver with forceps has been unsuccessful. The causes are:

1. Unsuspected disproportion.
2. Misdiagnosis of the position of the head.
3. Incomplete dilation of the cervix.
4. Outlet contraction (very rare in an otherwise normal pelvis).

TREATMENT

1. If the mother is in good condition and the cause is undiagnosed malposition, an attempt at correction may be made by an experienced practitioner. Antibiotic cover should be started and general anesthesia should be used.

2. If the cause is incomplete dilation of the cervix and mother and child are in good condition, the woman should be given sedatives and given intravenous fluids and antibiotic cover. Contractions should be stimulated with oxytocin to see if labor advances.

3. If disproportion is present, or if the woman is exhausted and lacerated, cesarean section should be carried out. In such circumstances there is a good argument for the classical operation which avoids the edematous and easily torn lower segment.

Bronchoalveolar Lavage

General indications:

* Non-resolving pneumonia
* Diffuse lung infiltrates (interstitial and/or alveolar)
* Suspected alveolar hemorrhage
* Quantitative cultures for ventilator associated pneumonia
* Infiltrates in an immunocompromised host
* Exclusion of diagnosable conditions by BAL, usually infection
* Research

BAL can be diagnostic in the appropriate clinical setting for:

* Alveolar hemorrhage

* Malignancies

o Lymphangitic carcinomatosis
o Bronchoalveolar carcinoma
o Other malignancies

* Infections

o PCP
o Mycobacterial
o Bacterial
o Fungal
o Viral

Equipment

* Flexible bronchoscope
* Sterile collection trap
* Suction tubing
* Sterile saline
* Vacuum source
* Syringe
* Optional 3 way stop-cock
* Lidocaine 1-2%

Preparation and Anesthesia

1. Obtain informed consent.
2. If an outpatient procedure, the patient should be accompanied by a person designated to drive the patient.
3. BAL should be planned to be performed prior to any other bronchoscopic procedure.
4. Review radiographs to determine ideal site of alveolar lavage.

* In diffuse infiltrates, the right middle lobe (RML) or the lingula in the supine patient is preferred.

5. Prepare bronchoscope, collection trap, and tubing. ( Click for image)
6. Prepare supplemental oxygen and monitoring equipment.
* ECG, pulse-oximetry, BP cuff.
7. Premedicate with bronchodilators and/or warm the saline solution for those at risk for bronchospasm.
8. Position patient, preferably in supine position when approaching RML or lingula.
9. Apply monitors and supplemental oxygen.

10. Sedation with a benzodiazepine and a narcotic will allow patient comfort and minimize cough reflex.

* Example: midazolam (adult dose 1 to 2.5 mg IV) and fentanyl (adult dose 25-100 mcg IV).

* Topical anesthesia with lidocaine should be minimized.
o Up to 8.2 mg/kg was found to be safe in a single study (endorsed as the maximum safe limit by the British Thoracic Society), but this amount is rarely necessary.
o Conventional proposed maximum limits vary from 4-5 mg/kg. At our institution, we generally use the limit of 5 mg/kg of 2% lidocaine. Reduced limits are advised in those with liver or cardiac disease.

Technique

1. Perform preparatory steps and obtain adequate sedation. (See Preparation and Anesthesia)

2. Plan to perform the BAL preceding any other planned bronchoscopic procedure to avoid specimen contamination.

* Avoid suctioning prior to obtaining BAL specimen.
* If needed however, the suction channel should be thoroughly rinsed with saline prior to the BAL.

3. Minimize use of topical anesthesia as there may be bacteriostatic effects of lidocaine.
* Typically, we use the minimum amount of 2% lidocaine topically that is necessary to minimize coughing with a typical upper limit of 4-5 mg/kg.
4. Advance bronchoscope until wedged in a desired subsegmental bronchus at the desired location.
* Avoidance of bronchial trauma is particularly important in the patient with suspected alveolar hemorrhage.
5. Infuse 20mL of saline with a syringe, observing the flow of saline at the distal tip of the bronchoscope.
6. Maintaining wedge position, apply gentle suction (50-80mmHg), collecting the lavage specimen in the collection trap.

7. Repeat steps 5 and 6, up to 5 times as needed (total 100-120 mL), to obtain an adequate specimen (40-60 mL – usually 40-70% recovery of total instillate).

* Observe for flow of bubbles returning from the alveolar space.

* Gentle re-orientation of bronchoscope tip may allow better return of fluid.
* Distal airways may collapse at higher negative suction pressures.
* Reduction in pressure or intermittent suctioning may help with distal airway collapse.
* Instructing the patient to inhale and exhale deeply may also help improve return of specimen.
* Higher aliquots and higher total volume can occasionally be used (up to 300 mL).

8. BAL specimen should be processed as soon as possible with desired tests ordered.
9. Patient should be observed for a minimum of 1 hour after the procedure, with continued monitoring.

Common tests/Analysis

Gross observation

* Pulmonary alveolar proteinosis

o Opaque or translucent brownish or sandy colored fluid, sediments out into two layers if left to sit

* Alveolar hemorrhage

o Sequentially more hemorrhagic with each aliquot

Cell count and differential

* Alveolar macrophages (Normal >80%)

* Neutrophils (Normal <3%)
o Nonspecific, but suggests active alveolitis
o IPF, ARDS, infection, connective tissue disorders, Wegener’s granulomatosis, pneumoconiosis

* Eosinophilia (Normal <1-2%)

o Low to moderate eosinophilia (5-20%): Drug induced lung disease (e.g. minocycline, nitrofurantoin, penicillin), infections (parasitic, mycobacterial, fungal), asthma, malignancies (infrequently), other interstitial pneumonias occasionally (BOOP or COP, IPF/UIP, ILD associated with Connective tissue disorders)

o Moderate to marked eosinophilia (>20%): ABPA, Churg-Strauss syndrome, Acute eosinophilic pneumonia, chronic eosinophilic pneumonia, idiopathic hypereosinophilic syndrome

* Lymphocytosis (Normal <15%)

o Lymphocytosis can be found in a variety of conditions as listed below, but is not sufficiently sensitive and specific to recommend for routine clinical practice? Commonly noted associations are listed below.

+ Elevated CD4/CD8: Active sarcoidosis, berylliosis, asbestosis, Crohns disease, connective tissue disorders

+ Normal CD4/CD8: Tuberculosis, malignancies

+ Low CD4/CD8: Hypersensitivity pneumonitis, silicosis, drug-induced lung disease, HIV infection, BOOP (COP)

+ Others: Lymphoma, viral pneumonia, alveolar proteinosis

* Erythrocytes

o Elevated erythrocyte count – early sign of alveolar hemorrhage (first several hours)

o Phagocytosed erythrocytes – alveolar hemorrhage within 48 hours

o Hemosiderin laden macrophages – alveolar hemorrhage > 48hours

Microbiology

* Cultures

* Stains and Immunohistochemistry

o Gram stain: Bacterial
o KOH preparation: Fungal
o Periodic acid-Schiff (PAS): Pulmonary alveolar proteinosis
o Auramine-rhodamine, Auramine-O, or Ziehl-Neelson: Mycobacterial
o Modified acid fast stain (Kinyoun): Nocardia
o Silver methenamine: Pneumocystis carinii pneumonia, fungal
o Direct fluorescent antibody testing (DFA) for Legionella

* Polymerase chain reaction (PCR)

o Mycobacteria tuberculosis
o Possible for numerous pathogens but clinical utility still unclear

* Quantitative or semiquantitative cultures

o Particularly for ventilator associate pneumonia
+ Diagnostic of infection if organism identified:
- Pneumocystis carinii
- Toxoplasma gondii
- Strongyloides stercoralis
- Legionella pneumophila
- Cryptococcus neoformans
- Histoplasma capsulatum
- Mycobacterium tuberculosis
- Mycoplasma pneumoniae
- Influenza A and B viruses
- Respiratory syncytial virus
+ Colonization by organism possible:
- Bacteria
- Herpes, cytomegalovirus
- Aspergillus
- Candida
- Atypical mycobacteria

Cytology

* Foamy macrophages
o Nonspecific finding but can be seen in patients using amiodarone

* Malignancies
o Lymphangitic carcinomatosis
o Lymphoma
o Bronchoalveolar carcinoma and other primary lung malignancies
o Extrapulmonary malignancies

* Sulfur granules
o Actinomycetes

* Hemosiderin Laden Macrophages

o 20% is highly specific and sensitivie for alveolar hemorrhage, although a spectrum of findings can be seen depending on the timing and severity of the hemorrhage. Subclinical hemorrhage is thought to be possible at a level as low as 5%.

* Langerhans cells
o >5% suggestive of Pulmonary Langerhans cell histiocytosis
o Also CD1a (OKT6) or S100

* Cytomegalic cells
o Viral pneumonias (cytomegalovirus, herpes)

* Oil red O stain
o Indicates neutral fat droplets that can be seen in fat embolism

* Fat and Lipid stain (e.g. Sudan III)
o Lipoid pneumonia (aspiration)
o Lipid-laden alveolar macrophage index > 100 (Sensitivity of 100%, Specificity 57%)

Other

* Dust particle inclusions
o Pneumoconioses, asbestos exposure

* Electron microscopy (Rarely indicated if ever for clinical purposes)
o Birbeck granules or “X” bodies (pentilaminar cytoplasmic inclusions) – indicates Langerhans cells
o Myelin like ultrastructure with lamellar bodies and myelin – alveolar proteinosis

Complications/Adverse events

* No complications in up to 95%
* Cough
* Transient fever (2.5%)
* Transient chills and myalgias
* Transient infiltrates in most (resolves in 24 hours)
* Bronchospasm (<1%)
* Transient fall of lung function
* Transient decrease in baseline PaO2
* In patients with already severely compromised respiratory status, the loss of lung function may necessitate the need for mechanical ventilation. Ideally, BAL in these patients should be avoided, but could be done after intubation if the patient progresses to this point.

To be continued

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