List of Surgical Procedures

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List of Surgical 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
1
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
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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
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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
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-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.
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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)
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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
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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)
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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
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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
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
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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
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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)
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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
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
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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
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.
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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:
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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.
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
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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)
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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
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
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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
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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
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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
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
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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.
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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.
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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 decompensating clinical state. Abdominal paracentesis is a
simple procedure that may be performed rapidly and with a minimum of equipment.
Indications
1. New onset ascites or ascites of unknown origin
2. Patients with ascites of known etiology who may have a decompensation clinical
state as indicated by fever, painful abdominal distention, peritoneal irritation,
hypotension, encephalopathy or sepsis
3. Suspected malignant ascites
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4. Peritoneal dialysis patients with fever, abdominal pain or other signs of sepsis
(usually the paracentesis fluid may be removed directly from the patient’s dialysis
catheter)
Contraindications
1. Uncorrected bleeding diathesis
2. Previous abdominal surgeries with suspected adhesions
3. Severe bowel distention
4. Abdominal wall cellulitis at the proposed site of puncture
Materials
2. 1-liter vacuum bottles
3. Blood collection tubing, or a secondary IV tubing set
4. 18 gauge needle
5. Skin prep solution
6. Sterile draping
7. 1% or 2% lidocaine with epinephrine for local anesthesia
8. 5 cc syringe with 25 gauge needle for anesthesia infiltration
If available, a bedside ultrasound machine is an asset.
2. Inform the patient of potential complications (infection, hypotension) and their

treatment
Procedure
1. Obtain relevant patient history, and perform a physical exam to document and
localize ascitic fluid.
2. If ultrasound machine is available, scan patient to localize fluid collections, and

perform the procedure under real-time ultrasound guidance.
3. Place patient in supine position, with head elevated 20-300. Select and mark a
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position on the abdominal wall for puncture (Figure 1)
Figure 1.
4. Don sterile gown, gloves, and mask
5. Use skin prep solution to cleanse skin over the proposed puncture site, and drape
to define a sterile field
6. Anesthetize the skin over the proposed puncture site with the lidocaine drawn up in
the 5 cc syringe with the attached 25 gauge needle. Anesthetize down to the
peritoneum. Aspirate periodically; if ascitic fluid returns, withdraw the needle slightly
to re-enter tissue before further anesthetic is infiltrated
7. Attach 18 gauge needle to free end of blood collection tubing or the secondary IV
tubing. Leave capped. Close valve tightly on the tubing. Puncture the rubber stopper
of the vacuum bottle with the other end of the tubing
8. Insert the 18 gauge needle perpendicularly through the anesthetized abdominal

wall, and advance until hub of needle is 5mm-1cm from the skin surface. Open up the
tubing clamp. Ascitic fluid should begin to flow into the bottle
9. To change vacuum bottles as they become full, close the clamp on the tubing.
Then, remove needle of collection tubing from the full bottle, and re-insert into empty
bottle. Reopen clamp to start fluid flowing again
10. When paracentesis is done, simply remove needle from abdominal wall. Place a
small pressure dressing on puncture site. Have patient remain supine for 2-4 hours
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1.Fluid is feculent
Insert needle into area of known fluid collection
Withdraw needle and choose another site. Observe clinically over next 24 hours for
signs or symptoms of peritonitis
2.Fluid is bloody
Avoid insertion over veins; usually no preventative step
Check coagulation time prior to paracentesis; withdraw needle
3.Hypotension after procedure
Often no warning; limit paracentesis to maximum of 4-5 liters
Judicious IV saline bolus, Trendelenberg position, 1-2 units of salt-free albumin after
removal of 4-5 liters of fluid
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
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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.
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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
28
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
29
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. 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)
30
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.
31
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
32
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
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
33
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
34
2. Inform patient (or parent/guardian) of the possibility of major complications and
their treatment
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.
35
9. Secure the needle with gauze and tape
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.
36
* 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.
37
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)
38
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
39
· 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
40
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.
41
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
42
Medication combinations for conscious sedation:
1. Ketamine, atropine (or glycopyrrolate), and benzodiazepine
2. Benzodiazepine and analgesic
3. Systemic agents (propofol or etomidate) and analgesic
1. Discuss with the patient/parent(s)/guardian the need for sedation in light of the
presenting clinical situation
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
43
+30-120 min Recover patient
Using Analgesic and a benzodiazepine
+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
Using a systemic agent and an analgesic
+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)
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
44
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:
45
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)
46
* 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.
47
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
48
· 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.
· 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
49
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
50
· 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
51
· 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
* 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)
52
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
53
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
54
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
Last edited by a4assasins; 02-03-2008 at 08:03 PM.
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
55
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
56
* 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
57
* 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
58
* 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.
59
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
60
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
61
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).
62
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
63
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).
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#23
02-09-2008, 04:32 PM
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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.
64
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
65
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.
66
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.
67
Interrupted mattress sutures are used to close the skin.
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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:
68
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
69
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.
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#25
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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.
70
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.
71
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.
72
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
73
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:
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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.
__________________
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#26
02-10-2008, 12:00 AM
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Location: Chennai
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Intramuscular (IM) Injection in Neonate:
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Introduction
The anterolateral thigh is the preferred site for IM injection in infants under 12 months
of age.
Medications are injected into the bulkiest part of the vastus lateralis thigh muscle,
which is the junction of the upper and middle thirds of this muscle.
Equipment
• IM medication ampoule
• Large bore needle for withdrawing medication from ampoule
• 1 ml or 2 ml syringe
• 23 gauge 25 mm needle or 25 gauge 16 mm needle for preterm babies 2
months or younger
• Cotton wool swab
• Gloves for standard precaution
Procedure
There must be a written medication order on the medication chart.
Check the correct drug/dose/time/route/infant.
Draw the medication up into the syringe using the large bore needle.
Change to the 23 g 25 mm needle or 25 g 16 mm needle.
A second staff member to help position the infant on his/her back on a table or bed
may be required.
Undo the infant’s nappy to locate the junction of the upper and middle thirds of the
vastus lateralis thigh muscle.
The clinician performing the injection places their forearm across the infant’s pelvis
and secures the thigh between their thumb and forefinger.
Bunch up the thigh muscle to increase the muscle mass.
Administer the IM injection at a 45-60° angle to the skin. The needle must be angled
toward the knee. At this angle, the needle can be safely inserted to a depth of
between 16-25 mm skin-to-needle-tip depth. Inserting the needle at this angle results
in less tissue resistance as the needle penetrates the muscle. The following figures of
the thigh show the recommended injection site.
Diagram of the muscles of the thigh showing the recommended injection site
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Diagramtic cross section of the thigh showing recommended injection site
Withdraw the plunger to ensure that the medication does not go directly into a blood
vessel.
Slowly inject the medication for even distribution and to minimise the infant's
discomfort.
Remove the needle.
Check the injection site for bleeding and apply cotton wool ball if necessary. Observe
the site for local inflammation.
Dispose of the needles and syringe into a labeled puncture proof container to prevent
needle stick injury & reuse.
Document the administration of the IM injection on the medication chart and/or child
health record (where appropriate).
Practice Points
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• Avoid subcutaneous and intramuscular injections when intravenous
administration is a suitable alternative option. Note that VitaminK is preferably
given intramuscularly as soon as possible after birth and endogenous
endorphins are present at high levels at the time of birth.
• Alcohol and other disinfecting agents must be allowed to evaporate before
injection of medication.
• Never give an IM injection in the buttocks. Using the vastus lateralis muscle
avoids the risk of sciatic nerve damage from gluteal injection. Also the vastus
lateralis muscle has a larger muscle mass than the gluteal region and therefore
has reduced risk of severe local reactions. The deltoid in infants is not
sufficiently bulky to absorb IM medications adequately. The vastus lateralis
muscle avoids the thicker layer of subcutaneous fat on the anterior thigh.
• It is important that infants do not move during the IM injection. However
excessive restraint can increase the infant’s fear and can result in increased
muscle tension
• The infant can be held in the ‘cuddle’ or semi-recumbent position on the lap of
the parent/caregiver/health professional.
• Oral sucrose may be given for relief of distress (link to section).
• The volume of the IM injection should not be more than 1ml.
• When two IM injections are being administered, give one medication into the
right thigh and the other into the left thigh.
__________________
Barium Enema
(Barium X-ray, Lower GI Series)
Definition
A barium enema is a rectal injection of barium given to coat the lining of the colon
and rectum. It is done before x-rays, in order to create better image of the lower
intestine. Barium is a milky fluid that absorbs x-rays.
Parts of the Body Involved
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A barium enema is used to highlight the colon and rectum.
Reasons for Procedure
A barium enema is done to enhance x-ray images. X-rays are taken of the colon
and/or rectum to look for the following:
• Abnormal growths, such as polyps or cancers

• Ulcers
• Diverticula (small pouches protruding through the wall of the colon)
• Thickening of the lining of the colon or rectum
Risk Factors for Complications During the Procedure
Allergy to the latex balloon on the tip of enema tube (rare)

Severe rectal inflammation (patients with active colitis should not have procedure)
Pregnancy (x-rays of the abdomen and pelvis are only done in extreme cases)
Prior to Procedure
Your intestines must be empty before this test. The day before your test, you may be
asked to take some of the following steps to empty the colon as directed by your
doctor:
• Eat a clear liquid diet

• Take laxatives
• Take warm water or over-the-counter enemas
• Do not eat or drink anything after midnight
Description of the Procedure
A well-lubricated enema tube is gently inserted into the rectum. Barium is injected
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through this tube into the colon and rectum. A small balloon at the end of the tube is
inflated to keep the barium inside. You are repositioned several times to insure that
the barium coats the walls of the colon and rectum. A small amount of air is then
injected into the colon. A series of X-rays are taken. After x-ray images are
completed, the enema tube is removed, and you are shown to the bathroom to expel
the barium and air.
Possible Complications
• Inflammation of the lining of the rectum due to an allergic reaction to latex

balloon
• Perforated rectum or colon (serious, but rare)
• Fetal malformation, if done during pregnancy
Upper Gastrointestinal (GI) Series

(Barium Swallow, Barium Meal)
Definition
A series of x-rays of the esophagus, stomach, and duodenum during and after
drinking a barium solution. The duodenum is the first part of the small intestine. The
esophagus, stomach, and duodenum are collectively called the upper gastrointestinal
(GI) tract or upper digestive system.
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The upper GI tract, the esophagus, stomach, and duodenum are viewed in this
procedure.
Indications
An upper GI series may be ordered if you have:
• Diarrhea
• Weight loss
• Abdominal pain
• Difficulty swallowing
• Regurgitation
• Rectal bleeding
• Bloody stools or black, tarry stools
• Bloody vomit or "coffee-ground" vomit
An upper GI series can help detect:
• An ulcer
• A blockage
• An abnormal growth or tumor
• Diverticula—an abnormal pouch or sac opening from a hollow organ, such as
the intestine
• Gastroesophageal reflux disease (GERD)
• A hiatal hernia
• Crohn's disease
• Pulmonary aspiration—inhalation of fluid, food, or other foreign matter into the
lungs
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• Inflammation of the stomach or small intestine
Risk Factors for Complications during the Procedure
• Presence of food in the stomach

• Presence of barium in the colon
• Perforated or obstructed bowel
Due to the risks of radiation exposure, you should not have an upper GI series if you
are pregnant.
Prior to Procedure
• Review your medications with your doctor. There are some that you may need
to stop taking before this procedure.
• Do not eat, drink, or smoke for at least eight hours before the procedure.
• You may be given a medication called glucagon to slow down the activity of the
stomach and small intestine.
• You may be asked to swallow baking soda crystals, which will bubble and
produce gas in your stomach, allowing for more detailed x-rays.
• If you are going to have a small bowel follow-through, you may be asked to
take a laxative medication the day before your exam, in order to clean out the
small intestine.
Remove all jewelry and wear a hospital gown. You will drink barium, which is a thick,
white, chalky milkshake-like liquid that coats the inside lining of the esophagus,
stomach, and duodenum. As you drink the barium, the radiologist takes x-rays of the
upper GI area, using a machine called a fluoroscope. If your doctor wants to examine
the esophagus, you may have pictures taken as you actually swallow the liquid or
small bits of food that are covered with barium. You will be asked to change positions
frequently in order to coat the entire surface of the GI tract with barium.
If the radiologist wants to examine more of the small intestine, a small bowel follow-
through may be done. For this exam, x-ray pictures are taken every 15 to 30 minutes
while the barium travels through the intestine.
• Constipation for a few days after the procedure

• White stool
• Bowel obstruction, rare
• Aspiration of the barium into your lungs, which can lead to pneumonia
Drink lots of fluids to eliminate the barium from your system.
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Debridement of a Wound, Infection, or Burn
Definition
Surgical, chemical, mechanical, or autolytic (using the body's own processes) removal
of wound or burn tissue to promote healing.
Debridement is used to clean dead and contaminated material from a wound to aid in
healing, increase the tissue's ability to resist infection, and decrease inflammation. It
can also be performed to get a tissue sample for testing and diagnosis. The procedure
is most often performed for the following reasons:
• To remove tissue contaminated by bacteria, foreign tissue, dead cells, or a

crust
• To create a neat wound edge to decrease scarring
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• To aid in healing very severe burns or pressure sores (decubitus ulcers)
• Bleeding
• Infection
• Pre-existing medical conditions
• Smoking
• Diabetes
• Use of steroid or other immunosuppressive medications
• Poor nutrition
• Poor circulation
• Immune disorders
Anesthesia
Local or general anesthesia may be used when surgically debriding deep pressure
ulcers or other wounds. Anesthesia usually is not given for other methods.
The following four methods are frequently used in conjunction with one another:
Surgical Debridement
If your wound is characterized by large, deep tissue damage and/or is especially

painful, or if debriding your wound is urgent, surgical debridement will be done using
scalpels, forceps, scissors, and other instruments. The skin surrounding the wound is
cleaned and disinfected, and the wound is probed with a metal instrument to
determine its depth and locate any foreign matter. The doctor cuts away dead tissue,
then washes out any remaining, free tissue. The resulting edge is smooth and usually
runs from one end of the wound to the other. In some cases, transplanted skin may
be grafted into place. Sometimes, cutting away the entire contaminated wound may
be the most effective treatment.
Chemical Debridement
The healthcare provider applies debriding medication to the wound and covers with a
dressing. The enzymes dissolve the necrotic tissue of the wound.
Mechanical Debridement
Methods include whirlpool baths, use of syringe and catheter, or wet to dry dressings
to remove dead or infected tissue. The wet to dry procedure involves applying a wet
dressing to the wound. As this dressing dries, it absorbs wound material. When the
dressing is remoistened and removed, some of the tissue comes with it.
Autolytic Debridement
If quickly debriding your wound is not essential, if your wound is not infected, and/or
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if your body cannot tolerate the more forceful treatments, autolytic debridement may
be done. Dressings that retain wound fluids (hydrocolloid, hydrogel, and transparent
film) can facilitate the body's natural abilities to clean the wound. This type of
dressing is often used to treat pressure sores.
Biodebridement
One example is maggot therapyThe medical benefits are acknowledged by the US

Food and Drug Administration (FDA) and other scientific organizations. The procedure
involved using sterile fly maggots to break down or ingest infected or necrotic tissue.
The maggots do not damage healthy tissue. The bacteria in the wound is eliminated,
which reduces odor and allows the wound to heal more quickly.
• Pain
• Bleeding
• Infection
• Delayed healing
• Removal of healthy tissue with mechanical debridement
Dialysis
Definition
Dialysis is a treatment that performs the functions of natural kidneys when the they
fail (kidney failure). Most patients begin dialysis when their kidneys have lost 85%-
90% of their ability to function, and will continue dialysis for the rest of their lives (or
until they receive a kidney transplant); this is called end-stage renal disease (ESRD).
ESRD may be caused by a variety of conditions that can impair kidney function,
including diabetes, kidney cancer, drug use, high blood pressure, or other kidney
problems. Dialysis is not a cure for ESRD, but helps you feel better and live longer.
There are two types of dialysis: hemodialysis and peritoneal dialysis.
Hemodialysis—veins in the arm, leg, or neck
Peritoneal dialysis—abdomen
The purpose of dialysis is to help keep the body's chemicals in balance, which the
kidneys do when they are healthy. The main functions of dialysis are:
• Removing waste and excess fluid from the blood to prevent build-up
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• Controlling blood pressure
• Keeping a safe level of chemicals in the body, such as potassium, sodium,
and chloride
Dialysis may also be done to quickly remove toxins from the bloodstream, in cases of
poisoning or drug overdose.
Hemodialysis
Heart problems
Peritoneal dialysis
• Adhesions or significant abdominal scar tissue

• Infection of the peritoneum (lining of the abdominal cavity)
• Abdominal hernia
• Diverticulitis
• Abdominal defects
Prior to Procedure
Hemodialysis
• Weight, blood pressure, and temperature are taken

• Topical anesthetic (a pain numbing medicine) is applied to the arm for needle
insertion
• Heparin (a medication that prevents blood clotting) is given
Peritoneal dialysis
Before the first treatment, the physician places a small, soft tube (approximately 24
inches long) in the abdomen, which remains there permanently. A portion of the
tube remains outside the body for use in the peritoneal dialysis process. It is
important to keep this access clean and dry to prevent infection.
Anesthesia
For hemodialysis, topical anesthetic
Hemodialysis
An artificial kidney machine, called a dialyzer, filters the blood, and returns the
cleaned blood to your body. You are connected to the dialyzer via tubes that are
inserted into a vein in your arm, leg, or occasionally, neck. If hemodialysis is being
performed as a temporary measure, then the catheter is likely to be inserted through
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the neck vein. If hemodialysis is going to be done regularly, then an access site
called a fistula or shunt may be surgically created in one of your veins.
Fistulas may need as long as 2 to 3 months to fully heal or “mature” before they can
be used on a regular basis. Occasionally a surgically created fistula may fail to heal
properly, requiring either a revision or in some cases a completely new fistula to be
created. For this reason, fistulas are never used in circumstances where the
indications for dialysis are either emergent or temporary. Rather, they are typically
created electively many months before dialysis is begun in cases of chronic renal
failure where the need for dialysis is felt to be inevitable.
Hemodialysis is usually done at a dialysis center or hospital, by trained technicians or

nurses, or may be done at home with assistance. Hemodialysis is usually done three
times a week and each treatment lasts from two to four hours.
Peritoneal dialysis
Instead of using a machine, this type of dialysis uses the abdominal lining, called the
peritoneal membrane, to filter blood. A cleansing solution, called a dialysate, is
infused through a tube inserted into your abdomen. Long-term peritoneal dialysis
may require the surgical creation of a port in the abdomen through which this
dialysate can be infused. Fluid, wastes, and chemicals pass from the tiny blood
vessels in the peritoneal membrane into the dialysate, which is then drained after
several hours. New dialysate can then be added to repeat the process.
There are three types of peritoneal dialysis:
1. Continuous ambulatory peritoneal dialysis (CAPD)—This is the most common type

of peritoneal dialysis. A bag of dialysate is infused into the abdomen through a
catheter, remains there for 3-6 hours, and is then drained. You then refill your
abdomen with fresh solution through the catheter. This way your blood is always
being cleaned. No machine is required, and the empty plastic bag may be hidden
under clothing.
2. Continuous cyclical peritoneal dialysis (CCPD)—Fluid exchanges in this procedure
are done by machine, usually at night while sleeping.
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3. Intermittent peritoneal dialysis (IPD)—Uses the same type of machine as CCPD,
but requires assistance and is usually done at a hospital or center. It often takes
longer than CCPD.
• Anemia
• Drop in blood pressure during dialysis
• Muscle cramps
• Nausea, vomiting
• Headaches
• Infection
• Feeling hot, sweaty, weak, and/or dizzy
• Peritonitis (infection of the peritoneum), which causes fever and stomach pain
(peritoneal dialysis only)
• Growth problems in children
• Inflammation of the heart sac (pericarditis)
• Neurologic problems
• Disruption of calcium and phosphorus balance, resulting in weakened bones
88
Measurement of Intraocular Pressure
Physiologic basis:
• significance of raised intraocular pressure, normal range etc.

• general principles of tonometry
• indentation tonometry: increased pressure, firmer eye, less readily indented
with Schiotz plunger, low Schiotz reading = high pressure
• applanation tonometry: increased pressure, firmer eye, more pressure required
to flatten a small area of the cornea, high reading = high pressure
Test techniques
Schiotz:
Use of instrument:
• When lifting out from the box, pick it up by the handles

• The 5.5 weight is preset, make sure that the plunger moves freely
• The Schiotz can be autoclaved if necessary, but usually the base is wiped clean
with an alcohol wipe.
• Zero the instrument by placing it on the steel plate within the box, and ensure
that the arm reads "0", that is, no indentation is occurring
Examination technique
• Place topical anaesthesia on the cornea and lie the patient flat. Gently lower the
plunger onto cornea and keep the instrument steady by holding the handles; do
not push the instrument into the cornea.
• Take the reading off the scale and convert to mm Hg by table. If the reading is
at the low end of the scale (high pressure) add a second weight (7.5g or 10g)
to the plunger and retake the pressure.
• If the scale reading is 4, the IOP is 22.3 mm Hg with the 5.5g weight, 33.0 mm
Hg with the 7.5g weight, and 50.4 mm Hg with the 10 g weight.
Goldman:
• To perform Goldman applanation tonometry requires a slit lamp. The patient

must be given topical anaesthetic with fluorescein staining of the tear film.
Sterile filter paper impregnated with fluorescein is recommended for occasional
use, as premixed solutions can become contaminated if left unused for too
long.
89
• The cobalt blue filter is used to produce a blue light, and the tonometer prism is
advanced until close to the cornea, then observed through the oculars of the slit
lamp.
• When the prism is in contact with the cornea, two green hemi circular mires are
seen. The position of these is adjusted with the knob on the prism box until the
inner aspects of the circles are just in contact. The intraocular pressure is read
off the side of the box, multiplying the number shown by 10.
• Applanation tonometry works by measuring the force required to flatten a

known area (3.06 mm) of a sphere (the Imbert-Fick Law). The cornea is not an
exact, perfect, sphere, but the average corneal thickness is balanced by the
attractive force of the tear film. Corneas that are much thicker or thinner than
average will also affect the reading, but applanation remains the best estimate
of the intraocular pressure in clinical practice
Tonopen:
• The Tonopen is also an applanation device with a very small “footprint” on the
cornea, which makes it easier to use with corneal abnormalities. Since the
patient can be done lying or sitting, it is also useful when the patient cannot sit
positioned properly at the slit lamp.
• To use the Tonopen, a sterile cover must be over the tip.
• The Tonopen must be calibrated by pressing the activation button until “CAL”
appears in the window. Hold the Tonopen with the tip straight down toward the
floor. When the instrument beeps and “UP” appears in the window, rotate the
instrument so the tip is straight up. If “GOOD” appears, press the button again
until a double line ==== appears.
• Ensure that the patient has anaesthetic, and gently tap the Tonopen against the
cornea. It should beep with every contact and show the pressure reading. When
enough readings have been obtained (usually 4 – 6) it will beep again and
display the final averaged reading, with an indicator against the 5%, 10% 20%
90
or >20% level, indicating the confidence of the reading.
How Visual Acuity Is Measured
Testing techniques:
• An occluder is used to cover one of the patient's eyes for monocular testing, ie:
to facilitate testing one eye at a time. Do not allow patients to use their own
hand (they may peek through fingers.)
• One may slide a tissue between the eye to be occluded and the patient's
glasses as well.
• Test "with distance correction if available" (ie: if the patient uses their glasses
91
for distance viewing, have them use their glasses for the examination)
• "In myopia (or 'near-sightedness'), a sharp image is formed in front of the
retina. A myopic eye can be thought of as having a refractive power that is too
strong for the eye's axial length (either the eye is too long or the refraction
power of the eye is too strong.) In hyperopia (or 'far-sightedness'), a sharp
image is formed behind the retina. The unaccommodated hyperopic eye's
refractive power is too weak for the eye's axial length" (either eye is too short
or the refractive power is not strong enough..)
(Note: emmetropia = no refractive error; ametropia = refractive error)
SNELLEN CHART
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Lymph Node Biopsy
Definition
A lymph node biopsy is the removal and examination of all, or part, of a lymph node.
Lymph nodes are found throughout the body, and are part of the body’s immune
system. These nodes help fight infection by producing special white blood cells called
lymphocytes. They also work by trapping bacteria, viruses, and cancer cells.
Normally, lymph nodes cannot be felt unless they become swollen. Infection, usually
by a virus, is the most common cause of lymph node swelling. Other causes include
inflammatory disease, abscess, and cancer.
Common areas for biopsy include:
• Groin
• Armpit
• Neck
• Under the jaw and chin
• Behind the ears
• On the back of the head
Lymph node biopsies are performed to find out why a node is swollen. This procedure
is also used to see if there are cancer cells in the lymph node(s).
Anesthesia
Most biopsies are performed using a local anesthetic.
General anesthesia is sometimes used for open biopsies.
Description of the Procedure .
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Needle Biopsy
There are two types of needle biopsies, fine needle biopsy, and core needle biopsy.
A fine needle biopsy uses a thin, hollow needle to obtain fluid and tissue samples.
A core needle biopsy uses a larger needle to cut a piece of tissue from the sample.
Sometimes an ultrasound or computed tomography (CT) scan is used to help locate
the biopsy site.
Lymph Node Biopsy
Open Biopsy
An open biopsy means removing the lymph node(s) through an incision, or surgery.
For this type of biopsy, a surgeon will cut into the skin and remove either the whole
lymph node or part. More than one lymph node may be sampled. After removal, the
incision is closed with stitches and bandaged. Either local or general anesthesia may be
used, depending upon where the sample is taken.
Sentinel Lymph Node Biopsy
This type of biopsy is used to detect cancer. A sentinel lymph node is the first node or
nodes, that cancer is expected to spread to from the primary tumor. For this biopsy, a
special dye and a radioisotope tracer are placed near the tumor. The doctor then
traces where the dye and isotopes go, and removes the lymph nodes the dye reaches
first. These nodes are then checked for cancer. The benefit to this type of testing is
that fewer lymph nodes may need to be removed.
• There is a small risk of bleeding or infection.

• Nerve damage including numbness at the biopsy site may occur.
• If you received dye during a sentinel biopsy, you may experience discolored
95
skin or urine.
• There is also a rare risk of allergic reaction to the dye.
Intrauterine Devices-Insertion technique
Equipment for IUD Insertion
• Cervical tenaculum
• Cotton balls moistened with antiseptic solution or povidone-iodine (Betadine)
swabs
• Long suture scissors
• Ring forceps
• Sterile and nonsterile examination gloves
• Sterile IUD package with IUD
• Sterile tray for the procedure
• Sterile vaginal speculum
• Uterine sound
Contraindications to IUD Insertion
• Acute liver disease or liver carcinoma*

• Breast carcinoma*
• Confirmed or suspected pregnancy
• Copper allergy†
• Genital actinomycosis
• History of ectopic pregnancy
• History of pelvic inflammatory disease unless subsequent intrauterine
pregnancy occurred
• Immunodeficiency disorders
• Immunosuppressive therapy
• Jaundice*
• Known or suspected pelvic malignancy
• Multiple sexual partners for patient or her partner
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• Postpartum endometritis or septic abortion in previous three months
• Undiagnosed vaginal bleeding
• Uterine abnormality
• Wilson's disease†
*-Specific for hormone-releasing IUD (Mirena).

†-Specific for copper-releasing IUD (ParaGard).
Patient Preparation
The physician should discuss with the patient the risks and benefits of the IUD and, if
necessary, other forms of contraception. The patient should review the manufacturer's
patient information materials and have the opportunity to discuss with her physician
any concerns. Informed consent may be obtained after these steps are completed.
Administration of a nonsteroidal anti-inflammatory drug (e.g., 600 to 800 mg of

ibuprofen [Motrin]) one hour before insertion may alleviate discomfort. The physician
should instruct the patient about how to locate the IUD threads.
It is necessary for the woman to locate the threads to verify the position of the IUD
after each menstruation. The patient should be told to call her physician's office if she
is ever unable to locate the IUD threads.
Insertion
The proper equipment should be assembled before the procedure. Then, a bimanual
examination with nonsterile gloves should be performed to determine the position of
the uterus.
Fig.1
The arms of the IUD are to be folded into the insertion tube far enough to retain
them. This can be done before the start of the procedure, working through the sterile
package.
97
Sterile technique, including sterile gloves, is necessary during the procedure to
minimize the risk of contamination or infection. The cervix and adjacent vaginal
fornices should be cleansed liberally with an antiseptic solution. Chlorhexidine
gluconate (Hibiclens) may be used if the patient is allergic to iodine.
The physician should stabilize the cervix during the insertion of the IUD with a
tenaculum. Local anesthesia, such as 5 percent lidocaine gel (Xylocaine) placed in the
cervical canal, or a paracervical block may be used to minimize discomfort.
A sterile uterine sound should be used to determine the depth of the uterine cavity.
Contact with the vagina or speculum blades should be avoided. The uterine sound has
a bulbous tip to help prevent perforation. An alternative to the uterine sound is an
endometrial aspirator such as those used for endometrial biopsy sampling. An
adequate uterine depth is between 6 and 9 cm and should be documented in the
patient's record. An IUD should not be inserted if the depth of the uterus is less than 6
cm.
The physician should use sterile gloves to remove the IUD from the sterile package.
The blue flange should be aligned with the IUD arms and set at the distance the
uterus was sounded. The white inserter rod should then be placed into the insertion
tube at the end opposite the arms of the IUD and approximated against the ball at the
base of the IUD.
Fig.2
Fig.3
The physician should then insert the IUD into the uterus until the flange is against the
cervical os. The clear inserter tube should be pulled back on the insertion rod
approximately 2 cm so that the arms can spread to the "T” position (Figure 2). The
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tube should be advanced slowly to ensure a correct positioning of the IUD (Figure 3).
Fig.4
The physician should remove the insertion rod by holding the insertion tube in place
(Figure 4) and then remove the insertion tube and the tenaculum.
Finally, the threads emerging from the cervical os should be cut to a length of 3 cm.
The length of the threads in the vagina should be noted in the patient's record for
further reference.
Adverse Effects or Complications from IUDs
• Cramping
• Displaced threads
• Ectopic pregnancy
• Embedment or fragmentation of IUD
• Expulsion
• Infertility
• Pelvic infections
• Septicemia during pregnancy
• Tubo-ovarian damage
• Uterine or cervical perforation
• Vaginal bleeding, with or without anemia
• Vasovagal reaction (on insertion)
99
Ear wax removal-Syringing technique
Syringing a patient’s ears is usually performed to remove the cerumen (wax), but can
also be performed to remove exudates, pus or, in some cases, foreign bodies. It is the
irrigation of the external auditory canal of the ear with water at body temperature
using an ear syringe or electronic pulsed water unit.
The Ear Canal
• Use a good auroscope (a white halogen fibre-optic light is best)

• Choose the largest speculum that will fit comfortably into the ear canal
• Tip the patient’s head away from you
• Gently apply traction to the pinna in an up and backward direction.
Do not irrigate if:
• 1) the patient has a history of tympanic membrane perforation

• 2) Grommets are in place
• 3) Recent history of middle ear infection
• 4) If you suspect otitis externa
• 5) If the patient scuba dives (may indicate the problem is caused
• by pressure)
Before you make an appointment.
• Use plain and simple Olive Oil which can be bought from your local chemist or
supermarket. This helps to soften the wax and makes the whole procedure
much easier and more successful.
•
• Warm the oil (dip a teaspoon in boiling water, pour a little oil onto the
teaspoon and then into a small container e.g. Eggcup)
•
• Draw the oil up into a pipette, (obtainable from your chemist) or pour off a
spoon.
•
• Lay on your bed or settee, if possible and insert as much oil as you can into
the affected ear or ears, preferably twice a day for 2 -6 days.
•
• Try to remain lying down for at least 15 minutes, after inserting the oil, on
each side, to ensure it reaches the wax and softens it.
•
• Sometimes using the oil in this way clears the wax without the need to syringe.
If it doesn’t then do make an appointment to see the GP or Practice Nurse.
•
• NEVER use cotton buds to try and clear wax – you could damage your
100
eardrum.
This should ensure more comfort for you and the effective removal of the wax.
THE PROCEDURE:
Patients should be advised not to swallow during the procedure unless they feel they must, as if the patient
swallows during the procedure they may have a perforation.
• Fill the syringe with warm water (at body temperature 37c), not hot water
• Check to ensure nozzle is secured tightly
• If using propulse, expel air from tubing
• Ask patient (if able) to hold water reservoir under ear – if patient unable, seek
assistance to hold reservoir
• Straighten ear canal while controlling jet. Aim jet upwards and backwards
directing the water stream along the roof of the meatus aiming at the posterior
wall (the five to five past clock position
• Periodically inspect the meatus with the auroscope and inspect the water in the
reservoir
• Increase the water pressure as determined by the aural condition - check this
is not causing undue discomfort to the patient
• It is advised that no more than two tanks of water should be used in any one
procedure/ or the procedure should not last for more than two minutes
• After removal of wax or debris, dry mop excess water using a Jobson Horne
probe and cotton wool: static water can contain the pathogen Pseudomonas
aeruginosa
• After removal of wax inspect the tympanic membrane checking for any old
healed perforations. Examine the canal for any signs of otitis externa.
• Stop at any stage if patient complains of pain, dizziness or nausea
• Check the patients other ear and repeat procedure on this ear if necessary
Last edited by a4assasins; 02-18-2008 at 12:13 PM.
101
Gram-staining Procedure
Gram-staining is a four part procedure which uses certain dyes to make a bacterial cell
stand out against against its background. The specimen should be mounted and fixed
on a slide before you procede to stain it.
The reagents you will need to successfully perform this operation are:
• Crystal Violet (the Primary Stain)

• Iodine Solution (the Mordant)
• Decolorizer (ethanol is a good choice)
• Safranin (the Counterstain)
• Water (preferably in a squirt bottle)
Before starting, make sure that all reagents, as well as the squirt-bottle of water, are
easily accessible because you won't have time to go get them during the staining
procedure. Also, make sure you are doing this near a sink because it can get really
messy. Wear a lab coat.
STEP 1:
Place your slide on a slide holder or a rack. Flood (cover completely) the entire slide
with crystal violet. Let the crystal violet stand for about 60 seconds. When the time
102
has elapsed, wash your slide for 5 seconds with water. The specimen should appear
blue-violet when observed with the naked eye.
STEP 2:
Now, flood your slide with the iodine solution. Let it stand about a minute as well.
When time has expired, rinse the slide with water for 5 seconds and immediately
procede to step three. At this point, the specimen should still be blue-violet.
STEP 3:
This step involves addition of the decolorizer, ethanol. Step 3 is somewhat subjective
because using too much decolorizer could result in a false Gram (-) result. Likewise,
not using enough decolorizer may yield a false Gram (+) results. To be safe, add the
ethanol dropwise until the blue-violet color is no longer emitted from your specimen.
As in the previous steps, rinse with the water for 5 seconds.
STEP 4:
The final step involves applying the counterstain, safranin. Flood the slide with the dye
as you did in steps 1 and 2. Let this stand for about a minute to allow the bacteria to
incorporate the saffranin. Gram positive cells will incorporate little or no counterstain
and will remain blue-violet in appearance. Gram negative bacteria, however, take on a
pink color and are easily distinguishable from the Gram positives. Again, rinse with
water for 5 seconds to remove any excess of dye.
After you have completed steps 1 through 4, you should blot the slide gently with
bibulous paper or allow it to air dry before viewing it under the microscope. DO NOT
RUB THE SMEAR!
Ziehl-Neelsen Staining Procedure
STEP 1:
Flame slides to heat fix
STEP 2:
103
• Flood the entire slide with Carbol Fuchsin
• Ensure enough stain is added to keep the slides covered throughout the entire
staining step.
STEP 3:
• Using a Bunsen burner, heat the slides slowly until they are steaming. Maintain
steaming for 5 minutes by using low or intermittent heat (i.e. by occasionally
passing the flame from the Bunsen burner over the slides)
• Caution: Using too much flame or heat can cause the slide to break.
STEP 4:
Rinse the slide with water.
STEP 5:
104
• Flood the slide with 3% acid-alcohol and allow to decolorize for 5 minutes.
• Throughout the 5 minutes, continue to flood the slides with 3% acid-alcohol
until the slides are clear of stain visible to the naked eye.
• To the right are examples of slides insufficiently and sufficiently flooded with
3% acid-alcohol.
STEP 6:
Rinse the slide thoroughly with water and then drain any excess from the slides.
STEP 7:
Flood the slide with the counterstain, Methylene Blue. Keep the counterstain on the
slides for 1 minute.
STEP 8:
Rinse the slide thoroughly with water.
If all steps are performed correctly you should have a slide that looks like this.
105
Digital Nerve Block
Digital Nerve Block
Overview
• Indications: Surgery on the fingers

• Nerves: Digital nerves
• Local anesthetic: 2-3 mL per side
• Never use an epinephrine-containing local anesthetic
• Complexity level: Basic
Regional anesthesia anatomy
The common digital nerves are derived from the median and ulnar nerves and divide
in the distal palm into the volar aspect, tip, and nail bed area.
106
The main digital nerves, accompanied by digital vessels, run on the ventrolateral
aspect of the finger immediately lateral to the flexor tendon sheath. Small dorsal
digital nerves run on the dorsolateral aspect of the finger and supply innervation to
the back of the fingers as far as the proximal joint.
Patient positioning
The hand is pronated and rested on a flat surface or supported by an attendant.
Equipment
A standard regional anesthesia tray is prepared with the following

equipment:
107
• Sterile towels and 4"x4" gauze packs
• A controlled, 10-mL syringe with local anesthetic
• One 1½" 25-gauge needle
Technique
Block of Volar and Dorsal Digital Nerves at the Base of the Finger
A 25-gauge 1½" needle is inserted at a point on the dorsolateral aspect of the base of
the finger and a small skin wheel is raised. The needle is then directed anteriorly
toward the base of the phalanx. The needle is advanced until the it contacts the
phalanx, while the anesthesiologist observes for any protrusion from the palmar
dermis directly opposite the needle path. One mL of solution is injected as the needle
is withdrawn 1 to 2 mm from the bone contact. An additional 1 mL is injected
continuously as the needle is withdrawn back to the skin. The same procedure is
repeated on each side of the base of the finger to achieve anesthesia of the entire
finger.
108
Transthecal Digital Block
The transthecal digital block is placed by using the flexor tendon sheath for local
anesthetic infusion. In this technique, with the patient's hand supinated, the flexor
tendon is located. Using a 25 to 27 gauge 1-inch needle, 2 mL of local anesthetic is
injected into the flexor tendon sheath at the level of the distal palmar crease. The
needle should puncture the skin at a 45-degree angle. Resistance to the injection
suggests that the needle tip is against the flexor tendon. Careful withdrawal of the
needle results in the free flow of medication as the potential space between tendon
and sheath is entered. Proximal pressure is then applied to the volar surface for the
duration of the injection for the diffusion of the medication throughout the synovial
sheath.
TIPS:
• The advantage of this approach is the provision of anesthesia to the entire digit
with a single injection and a reportedly a higher success rate.
• For more extensive surgery on the finger, it may be advantageous to combine
both approaches discussed in this chapter for a greater success rate and more
extensive distribution of anesthesia.
Complications and How to Avoid Them
109
Injection Techniques
Injection Techniques
Intradermal route
110
The intradermal route provides a local, rather than systemic, effect and is used
primarily for diagnostic purposes such as allergy or tuberculin testing, or for local
anaesthetics.
To give an ID injection a 25-gauge needle is inserted at a 10-15° angle, bevel up, just
under the epidermis, and up to 0.5ml is injected until a wheal appears on the skin
surface (Fig. 1). If it is being used for allergen testing, the area should be labelled
indicating the antigen so that an allergic response can be monitored after a specified
time lapse.
The sites suitable for intradermal testing are similar to those for subcutaneous
injections (Fig. 2) but also include the inner forearm and shoulder blades
(Springhouse Corporation 1993).
111
When testing for allergies, it is essential to ensure that an anaphylactic shock kit is
easily accessible in case the patient develops a hypersensitive reaction
(Campbell 1995).
Subcutaneous route
The subcutaneous route is used for a slow, sustained absorbtion of medication, up to

1-2ml being injected into the subcutaneous tissue.
Figure 2 shows suitable locations for SC injections. Traditionally, SC injections have

been given at a 45° angle into a raised skin fold (Thow and Home 1990).
However, with the introduction of shorter insulin needles (5, 6 or 8mm), the
recommendation for insulin injections is now an angle of 90° (Burden 1994). The skin
should be pinched up to lift the adipose tissue away from the underlying muscle,
especially in thin patients (Fig. 3).
Insulin that is injected into muscle is absorbed more rapidly and can lead to glucose
instability and potential hypoglycaemia. Hypoglycaemic episodes may also occur if the
anatomical location of the injection is
changed, as insulin is absorbed at varying rates from different anatomical sites
(Peragallo-Dittko 1997).
Therefore insulin injections should be systematically rotated within an anatomical site
– for example, using the upper arms or abdomen for several months, before there is a
planned move elsewhere in the body
(Burden 1994).
It is no longer necessary to aspirate after needle insertion before injecting

subcutaneously.
It has also been noted that aspiration before administration of heparin increases the
112
risk of haematoma formation (Springhouse Corporation 1993).
Intramuscular route
Intramuscular injections deliver medication into well perfused muscle, providing rapid
systemic action and absorbing relatively large doses; from 1ml in the deltoid site to
5ml elsewhere in adults (these values should be halved for children). The choice of
site should take into consideration the patient’s general physical status and age, and
the amount of drug to be given. The proposed site for injection should be inspected
for signs of inflammation, swelling, and infection, and any skin lesions should be
avoided. Similarly, two to four hours after the injection, the site should be checked to
ensure there has been no adverse reaction.
If injections are repeated frequently, the sites should be documented to ensure an

even rotation. This reduces patient discomfort from overuse
of any one area and lessens the likelihood of the development of complications, such
as muscle atrophy or sterile abscesses resulting from poor absorbtion(Springhouse
Corporation 1993).
Cont...
Z-Technique
The Z track technique was initially introduced for drugs that stained the skin or were
particularly irritant. It is now recommended for use with the full range of IM
113
medications (Beyea and Nicholl 1995) and is believed
to reduce pain, as well as the incidence of leakage (Keen 1986).
It involves pulling the skin downwards or to one side at the intended site (Fig. 7).
This moves the cutaneous and subcutaneous tissues by approximately 1-
2cm. When identifying the site for injection, it is important to remember that moving
the skin may distract you from the intended needle destination.
Therefore, once the surface location has been identified, you need to be able to
visualise the underlying muscle that is to receive the injection, and aim
for that location, rather than a distinguishing mark on the skin. The needle is
inserted and the injection given. Allow ten seconds before removing the needle to
allow the medication to diffuse into the muscle. On removal, the retracted skin is
released. The tissues then close over the deposit of medication and prevent it from
leaking from the site. Exercising the
limb afterwards is believed to assist absorbtion of the drug by increasing blood flow
to the area (Beyea and Nicholl 1995).
Air bubble Technique
This is a technique that was popular in the US. It arose historically from the use of
glass syringes which required an added air bubble to ensure an accurate dose was
given. It is no longer considered necessary
to allow for the dead space in the syringe and needle, as plastic syringes are
calibrated more accurately than glass ones, and it is no longer recommended
by manufacturers (Beyea and Nicholl 1995).
However, two recent studies into depot (oil-based, slow release) injections in the UK
(MacGabhann 1998, Quartermaine and Taylor 1995) compared the Z track with the
air bubble technique, which is also intended to seal the medication in after injection.
Quartermaine and Taylor (1995) suggested that the air bubble technique is more
successful at preventing
leakage than the Z track technique, but
MacGabhann’s (1998) findings were inconclusive.
There are issues related to the accuracy of the dose when using this technique – it
may significantly increase the dose (Chaplin et al 1985). Further research on this
technique needs to be undertaken as it is relatively new to the UK. However, if it is
used, the nurse should ensure that patients’ dosages are adjusted to accommodate
the addition of the air bubble, and that the technique is used consistently to ensure
an accurate dose.
Aspiration
Although aspiration is no longer recommended for SC injections, it should be

practised in IM injections. If a needle is mistakenly placed in a blood vessel, the drug
may be given intravenously by mistake and could cause an embolus as a result of
the chemical components of
114
the drug.
Massage of the site should be discouraged because it may cause the drug to leak
from the needle entry site and irritate
local tissues (Beyea and Nicholl 1995).
12 Points for Painless Injection
THE END
a4assasins
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115
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04-20-2008, 12:47 AM
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Location: Chennai
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Z-Technique
The Z track technique was initially introduced for drugs that stained the skin or were
particularly irritant. It is now recommended for use with the full range of IM
medications (Beyea and Nicholl 1995) and is believed
to reduce pain, as well as the incidence of leakage (Keen 1986).
It involves pulling the skin downwards or to one side at the intended site (Fig. 7). This
moves the cutaneous and subcutaneous tissues by approximately 1-
2cm. When identifying the site for injection, it is important to remember that moving
the skin may distract you from the intended needle destination.
Therefore, once the surface location has been identified, you need to be able to
visualise the underlying muscle that is to receive the injection, and aim
for that location, rather than a distinguishing mark on the skin. The needle is inserted
and the injection given. Allow ten seconds before removing the needle to allow the
116
medication to diffuse into the muscle. On removal, the retracted skin is released. The
tissues then close over the deposit of medication and prevent it from leaking from the
site. Exercising the
limb afterwards is believed to assist absorbtion of the drug by increasing blood flow to
the area (Beyea and Nicholl 1995).
Air bubble Technique
This is a technique that was popular in the US. It arose historically from the use of
glass syringes which required an added air bubble to ensure an accurate dose was
given. It is no longer considered necessary
to allow for the dead space in the syringe and needle, as plastic syringes are
calibrated more accurately than glass ones, and it is no longer recommended
by manufacturers (Beyea and Nicholl 1995).
However, two recent studies into depot (oil-based, slow release) injections in the UK
(MacGabhann 1998, Quartermaine and Taylor 1995) compared the Z track with the
air bubble technique, which is also intended to seal the medication in after injection.
Quartermaine and Taylor (1995) suggested that the air bubble technique is more
successful at preventing
leakage than the Z track technique, but
MacGabhann’s (1998) findings were inconclusive.
There are issues related to the accuracy of the dose when using this technique – it
may significantly increase the dose (Chaplin et al 1985). Further research on this
technique needs to be undertaken as it is relatively new to the UK. However, if it is
used, the nurse should ensure that patients’ dosages are adjusted to accommodate
the addition of the air bubble, and that the technique is used consistently to ensure an
accurate dose.
Aspiration
Although aspiration is no longer recommended for SC injections, it should be practised

in IM injections. If a needle is mistakenly placed in a blood vessel, the drug may be
given intravenously by mistake and could cause an embolus as a result of the
chemical components of
the drug.
Massage of the site should be discouraged because it may cause the drug to leak
from the needle entry site and irritate
local tissues (Beyea and Nicholl 1995).
12 Points for Painless Injection
117
THE END
118

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List of Surgical Procedures

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

1.Infection over insertion site

2.Uncontrolled bleeding diathesis

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

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

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

Fuhrman catheter insertion:

-Attach catheter to suction unit

-Obtain post procedure chest Xray

Figure 1: Incising the chest wall

Figure 2: Opening the incision with a Kelly clamp

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

-Clamp outer tube end with Kelly

-Suture and tape tube in place

-Attach tube to suction unit

Complications, Prevention, and Management

1.Puncture of liver or spleen. This is entirely preventable; insertion site is in the

2.Bleeding; this usually ceases

Documentation in the Medical Record

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)

1.Anatomy of the chest, lungs, pleura

2.Indications, and contraindications of this procedure

3. Use of sterile technique and Universal Precautions

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

Abscess resolve by drainage. Smaller (<5mm in diameter) abscesses may resolve to

1.Abscess on the skin which is palpable

1.Extremely large abscesses which require extensive incision, debridement, or

2.Deep abscesses in very sensitive areas (supralevator, ischiorectal, perirectal)

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

1.Universal precautions materials

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

3. Skin prep solution

4. #11 scalpel blade with handle

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

1.Obtain informed consent

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

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

1.Use universal precautions

2. Cleanse site over abscess with skin prep

3.Drape to create a sterile field

Figure 1: Making the incision

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

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

3. Any complications (or “none)

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

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