Project: Ghana Emergency Medicine Collaborative Document Title: EMedHome Board Review: Procedures Author(s): Joe Lex, MD, FACEP, FAAEM, MAAEM (Temple University)

Project: Ghana Emergency Medicine Collaborative

Document Title: EMedHome Board Review: Procedures

Author(s): Joe Lex, MD, FACEP, FAAEM, MAAEM (Temple University) 2013

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EMedHome Board Review: EMedHome Board Review:

ProceduresProceduresEMedHome Board Review: EMedHome Board Review:

ProceduresProcedures

Joe Lex, MD, FACEP, FAAEM, MAAEMJoe Lex, MD, FACEP, FAAEM, MAAEMAssociate Professor, Emergency MedicineAssociate Professor, Emergency Medicine

Temple University School of MedicineTemple University School of MedicinePhiladelphia, PA USAPhiladelphia, PA USA

3

Commercial DisclaimersCommercial DisclaimersCommercial DisclaimersCommercial Disclaimers

NoneNone4

General Rules before Doing a General Rules before Doing a ProceduresProceduresGeneral Rules before Doing a General Rules before Doing a ProceduresProcedures• Explain risks and benefits, including Explain risks and benefits, including

what will happen if you donwhat will happen if you don’’t do itt do it

• Obtain written informed consent Obtain written informed consent (when possible)(when possible)

• Use appropriate monitoring Use appropriate monitoring equipmentequipment

• Position patient properlyPosition patient properly

5

General Rules before Doing a General Rules before Doing a ProceduresProceduresGeneral Rules before Doing a General Rules before Doing a ProceduresProcedures• Clean / prep / drape appropriate body Clean / prep / drape appropriate body

partpart

• Use aseptic / sterile techniqueUse aseptic / sterile technique

• Provide post-procedure instructionsProvide post-procedure instructions

6

For this talk…For this talk…For this talk…For this talk…• Not the everyday proceduresNot the everyday procedures

• No RSINo RSI

• No procedural sedationNo procedural sedation

• No laceration repairNo laceration repair

• Things you MIGHT want to look at a Things you MIGHT want to look at a reference before doingreference before doing

7

For this talk…For this talk…For this talk…For this talk…

Indications / Contraindications

Procedure Description

Procedure Pictorial (if available)

Complications8

IndicationIndicationNasotracheal IntubationNasotracheal IntubationIndicationIndicationNasotracheal IntubationNasotracheal Intubation• Spontaneously breathing patient Spontaneously breathing patient

requiring airway managementrequiring airway management

• Alternative to RSI when oral airway Alternative to RSI when oral airway may be obstructed may be obstructed

18

ContraindicationContraindicationNasotracheal IntubationNasotracheal IntubationContraindicationContraindicationNasotracheal IntubationNasotracheal Intubation• ApneaApnea

• Severe midface injuriesSevere midface injuries

• Basilar skull fractureBasilar skull fracture

• Closed head injury with Closed head injury with intracranial intracranial pressurepressure

• Nasopharyngeal obstructionNasopharyngeal obstruction

• Coagulopathy (relative)Coagulopathy (relative)

19

ProcedureProcedureNasotracheal IntubationNasotracheal IntubationProcedureProcedureNasotracheal IntubationNasotracheal Intubation• PreoxygenatePreoxygenate

• Apply vasoconstrictor / topical Apply vasoconstrictor / topical anestheticanesthetic

• Insert tube with bevel facing septumInsert tube with bevel facing septum

• Slowly advance – listen for breath Slowly advance – listen for breath sounds OR use whistlesounds OR use whistle

• Advance tube through vocal cordsAdvance tube through vocal cords

20

ProcedureProcedureNasotracheal Nasotracheal IntubationIntubation

ProcedureProcedureNasotracheal Nasotracheal IntubationIntubation

Thomas H. Burford, Wikimedia Commons21

See: “ProcedureProcedureNasotracheal Intubation” in Nasotracheal Intubation” in Knoop KJ, Stack LB, Storrow AB, Thurman RJ: The Atlas of Emergency Medicine, 3rd Edition, http://accessmedicine.com.

https://commons.wikimedia.org/wiki/File:Chapter5figure69b-nasotracheal_intubation.jpg

ComplicationsComplicationsNasotracheal IntubationNasotracheal IntubationComplicationsComplicationsNasotracheal IntubationNasotracheal Intubation• EpistaxisEpistaxis

• Mucosa / turbinate avulsionMucosa / turbinate avulsion

• Laryngeal / tracheal traumaLaryngeal / tracheal trauma

• Intracranial / esophageal placementIntracranial / esophageal placement

• HypoxiaHypoxia

26

Indication / Contraindication Indication / Contraindication Retrograde IntubationRetrograde IntubationIndication / Contraindication Indication / Contraindication Retrograde IntubationRetrograde IntubationIndicationIndication

• Patient requires airwayPatient requires airway

• Less invasive means have failedLess invasive means have failed

ContraindicationContraindication

• Ability to intubate / ventilate by less Ability to intubate / ventilate by less invasive meansinvasive means

• Trismus; inability to open mouthTrismus; inability to open mouth

27

ProcedureProcedureRetrograde IntubationRetrograde IntubationProcedureProcedureRetrograde IntubationRetrograde Intubation• Stabilize patientStabilize patient’’s larynx, identify s larynx, identify

cricothyroid membranecricothyroid membrane

• Connect 16- to 18-gauge catheter-Connect 16- to 18-gauge catheter-over-needle to 10 ml syringe over-needle to 10 ml syringe contained 3 mL sterile salinecontained 3 mL sterile saline

• Puncture cricothyroid membrane at Puncture cricothyroid membrane at 20–3020–30oo angle to skin, pointed at head angle to skin, pointed at head

• Aspirate – should see air bubblesAspirate – should see air bubbles28

ProcedureProcedureRetrograde IntubationRetrograde IntubationProcedureProcedureRetrograde IntubationRetrograde Intubation

Source: Reichman EF, Simon RR: Emergency Medicine Procedures 29

ProcedureProcedureRetrograde IntubationRetrograde IntubationProcedureProcedureRetrograde IntubationRetrograde Intubation• Advance catheter-over-needle until Advance catheter-over-needle until

hub is against skinhub is against skin

• Remove syringe and needleRemove syringe and needle

• Feed guidewire through catheter until Feed guidewire through catheter until it comes out patientit comes out patient’’s mouths mouth

• Advance guidewire until only ~5cm Advance guidewire until only ~5cm protruding from neckprotruding from neck

• Stabilize wire at neck with hemostat Stabilize wire at neck with hemostat 30

ProcedureProcedureRetrograde IntubationRetrograde IntubationProcedureProcedureRetrograde IntubationRetrograde Intubation


ProcedureProcedureRetrograde IntubationRetrograde IntubationProcedureProcedureRetrograde IntubationRetrograde Intubation• If available, advance introducer If available, advance introducer

sheath until meets obstructionsheath until meets obstruction

• Remove wireRemove wire

• Advance endotracheal tube over Advance endotracheal tube over introducer into tracheaintroducer into trachea

• Confirm placementConfirm placement

• Secure tube Secure tube

32Recommended Reference: Reichman EF, Simon RR: Emergency Medicine Procedures

ComplicationsComplicationsRetrograde IntubationRetrograde IntubationComplicationsComplicationsRetrograde IntubationRetrograde Intubation• Damage to tracheal cartilageDamage to tracheal cartilage

• Inability to intubateInability to intubate

• HypoxiaHypoxia

34

Indication / Contraindication Indication / Contraindication CricothyrotomyCricothyrotomyIndication / Contraindication Indication / Contraindication CricothyrotomyCricothyrotomyIndicationsIndications

• Unable to ventilate or intubateUnable to ventilate or intubate

ContraindicationsContraindications

• Child <8-10 yearsChild <8-10 years

• Significant trauma to tracheal / cricoid Significant trauma to tracheal / cricoid cartilagescartilages

• Ability to intubate / ventilateAbility to intubate / ventilate

35

Procedure Procedure CricothyrotomyCricothyrotomyProcedure Procedure CricothyrotomyCricothyrotomy• Stabilize larynx, identify cricothyroid Stabilize larynx, identify cricothyroid

membranemembrane

• Make midline vertical incisionMake midline vertical incision

• Make horizontal stab incision through Make horizontal stab incision through cricothyroid membranecricothyroid membrane

• Insert tracheal skin hook to elevate Insert tracheal skin hook to elevate inferior border of tracheal cartilageinferior border of tracheal cartilage

36

Procedure Procedure CricothyrotomyCricothyrotomyProcedure Procedure CricothyrotomyCricothyrotomy• Insert Trousseau dilator, remove skin Insert Trousseau dilator, remove skin

hook, open membranehook, open membrane

• Insert tube: endotracheal (6.0 mm) or Insert tube: endotracheal (6.0 mm) or tracheostomy tube (4.0 Shiley)tracheostomy tube (4.0 Shiley)


ComplicationsComplicationsCricothyrotomyCricothyrotomyComplicationsComplicationsCricothyrotomyCricothyrotomy• Esophageal perforationEsophageal perforation

• Subcutaneous emphysemaSubcutaneous emphysema

• Subcutaneous tube placementSubcutaneous tube placement

• BleedingBleeding

• Unable to intubateUnable to intubate

• Subglottic stenosisSubglottic stenosis

• Cartilage damage: thyroid, cricoidCartilage damage: thyroid, cricoid42

Indication / ContraindicationIndication / ContraindicationTube ThoracostomyTube ThoracostomyIndication / ContraindicationIndication / ContraindicationTube ThoracostomyTube ThoracostomyIndicationsIndications

• Pneumothorax (24F – 28F tube)Pneumothorax (24F – 28F tube)

• Hemothorax (32F – 40F tube)Hemothorax (32F – 40F tube)



43

ProcedureProcedureTube ThoracostomyTube ThoracostomyProcedureProcedureTube ThoracostomyTube Thoracostomy• Identify 4Identify 4thth-5-5thth intercostal space, intercostal space,

anterior axillary lineanterior axillary line

• Abduct ipsilateral armAbduct ipsilateral arm

• Make incision parallel to ribsMake incision parallel to ribs

• Bluntly dissect upwards with KellyBluntly dissect upwards with Kelly

• Enter pleura above rib with clamp Enter pleura above rib with clamp avoids neurovascular bundleavoids neurovascular bundle

44

ProcedureProcedureTube ThoracostomyTube ThoracostomyProcedureProcedureTube ThoracostomyTube Thoracostomy• Digitally explore tractDigitally explore tract

• Insert chest tube, aiming toward apex Insert chest tube, aiming toward apex for pneumothorax, base for for pneumothorax, base for hemothoraxhemothorax

• Connect tube to pleural drainage Connect tube to pleural drainage systemsystem

• Secure tubeSecure tube

• Obtain confirmatory x-rayObtain confirmatory x-ray45Recommended Reference: Reichman EF, Simon RR: Emergency Medicine Procedures

ComplicationsComplicationsTube ThoracostomyTube ThoracostomyComplicationsComplicationsTube ThoracostomyTube ThoracostomyComplicationsComplications

• Bleeding, hemothoraxBleeding, hemothorax

• Visceral organ perforation / vascular Visceral organ perforation / vascular structure injurystructure injury

• Subcutaneous tube placementSubcutaneous tube placement

• PneumoniaPneumonia

• EmpyemaEmpyema

50

Indication / ContraindicationIndication / ContraindicationNeedle ThoracostomyNeedle ThoracostomyIndication / ContraindicationIndication / ContraindicationNeedle ThoracostomyNeedle ThoracostomyIndicationsIndications

• Tension pneumothoraxTension pneumothorax


• None None

51

ProcedureProcedureNeedle ThoracostomyNeedle ThoracostomyProcedureProcedureNeedle ThoracostomyNeedle Thoracostomy• Connect a 14- to 16-gauge catheter-Connect a 14- to 16-gauge catheter-

over-the-needle to a 5- to 10-mL over-the-needle to a 5- to 10-mL syringe without the plungersyringe without the plunger

• Insert needle into 2Insert needle into 2ndnd intercostal intercostal space, midclavicular linespace, midclavicular line

• Advance needle to rush of air, then Advance needle to rush of air, then advance until hub against skinadvance until hub against skin

• Place chest tubePlace chest tube52Recommended Reference: Reichman EF, Simon RR: Emergency Medicine Procedures

Complications Complications Needle ThoracostomyNeedle ThoracostomyComplications Complications Needle ThoracostomyNeedle Thoracostomy• Lung injuryLung injury

• Local hematomaLocal hematoma

• Intercostal nerve / vessel injuryIntercostal nerve / vessel injury

• Failure to decompress tension Failure to decompress tension pneumothoraxpneumothorax

54

IndicationsIndicationsResuscitative ThoracotomyResuscitative ThoracotomyIndicationsIndicationsResuscitative ThoracotomyResuscitative Thoracotomy• Penetrating chest trauma patients Penetrating chest trauma patients

who are hemodynamically unstable who are hemodynamically unstable and those who demonstrated and those who demonstrated palpable pulse, blood pressure, pupil palpable pulse, blood pressure, pupil reactivity, any purposeful movement, reactivity, any purposeful movement, organized cardiac rhythm, or any organized cardiac rhythm, or any respiratory effort either in the field or respiratory effort either in the field or ED, but subsequently deteriorated ED, but subsequently deteriorated

55

ContraindicationsContraindicationsResuscitative ThoracotomyResuscitative ThoracotomyContraindicationsContraindicationsResuscitative ThoracotomyResuscitative Thoracotomy• Penetrating chest trauma victim with Penetrating chest trauma victim with

no vital signs in fieldno vital signs in field

• Blunt trauma victim with or without Blunt trauma victim with or without field vitalsfield vitals

56

ProcedureProcedureResuscitative ThoracotomyResuscitative ThoracotomyProcedureProcedureResuscitative ThoracotomyResuscitative Thoracotomy• Make incision through skin, Make incision through skin,

subcutaneous tissue, superficial subcutaneous tissue, superficial musclesmuscles

• Incise intercostal muscles with Mayo Incise intercostal muscles with Mayo scissorsscissors

• Insert rib spreader with handles down Insert rib spreader with handles down and openand open

• Grasp and open pericardiumGrasp and open pericardium57Recommended Reference: Reichman EF, Simon RR: Emergency Medicine Procedures

ComplicationsComplicationsResuscitative ThoracotomyResuscitative ThoracotomyComplicationsComplicationsResuscitative ThoracotomyResuscitative Thoracotomy• Injury of personnelInjury of personnel

• Laceration of internal mammary or Laceration of internal mammary or intercostal arteriesintercostal arteries

• Laceration of lung or myocardium Laceration of lung or myocardium

• Transection left phrenic nerve Transection left phrenic nerve

• Laceration of myocardium or coronary Laceration of myocardium or coronary artery artery

• Delayed cardiac compressionsDelayed cardiac compressions 65

Indication / ContraindicationIndication / ContraindicationParacentesisParacentesisIndication / ContraindicationIndication / ContraindicationParacentesisParacentesisIndicationsIndications

• Diagnostic: new ascites, suspected Diagnostic: new ascites, suspected spontaneous bacterial peritonitisspontaneous bacterial peritonitis

• Therapeutic: tense, large-volumeTherapeutic: tense, large-volume


• Overlying cellulitisOverlying cellulitis

• Pregnancy, organomegaly (relative)Pregnancy, organomegaly (relative)

66

ProcedureProcedureParacentesisParacentesisProcedureProcedureParacentesisParacentesisPotential sites:Potential sites:

• Midline: 2 cm inferior to umbilicusMidline: 2 cm inferior to umbilicus

• RLQ / LLQ: 2–4cm medial & cephalad RLQ / LLQ: 2–4cm medial & cephalad to anterior superior iliac spineto anterior superior iliac spine

67

ProcedureProcedureParacentesisParacentesisProcedureProcedureParacentesisParacentesis• Use ultrasound to be certainUse ultrasound to be certain

• Apply skin traction: Apply skin traction: ““Z-trackZ-track””

• Advance needle / catheterAdvance needle / catheter

• Aspirate fluidAspirate fluid

• Remove needle / catheterRemove needle / catheter

• Send fluid for analysisSend fluid for analysis– SBP: PMN >250 WBC/mmSBP: PMN >250 WBC/mm33


ComplicationComplicationParacentesisParacentesisComplicationComplicationParacentesisParacentesis• Hypotension after large volume Hypotension after large volume

removalremoval

• Localized infectionLocalized infection

• Abdominal wall hematomaAbdominal wall hematoma

• Persistent fluid leakPersistent fluid leak

• Injury to abdominal organInjury to abdominal organ

70

Indication / ContraindicationIndication / ContraindicationThoracentesisThoracentesisIndication / ContraindicationIndication / ContraindicationThoracentesisThoracentesisIndicationIndication

• Pleural fluid requiring fluid analysis or Pleural fluid requiring fluid analysis or therapeutic drainagetherapeutic drainage



• Positive pressure ventilation (caution)Positive pressure ventilation (caution)

• Coagulopathy (relative)Coagulopathy (relative)71

DiagnosticDiagnosticThoracentesisThoracentesisDiagnosticDiagnosticThoracentesisThoracentesis• Use 18-g needle on 50mL syringe Use 18-g needle on 50mL syringe

containing 1mL heparin (100U/ml)containing 1mL heparin (100U/ml)

• Insert needle 5–10 cm lateral to spine Insert needle 5–10 cm lateral to spine 1 or 2 intercostal spaces below upper 1 or 2 intercostal spaces below upper level of pleural effusionlevel of pleural effusion

• Go over top of ribGo over top of rib

• Stop when you get enoughStop when you get enough

• Post-procedure chest x-rayPost-procedure chest x-ray72

TherapeuticTherapeuticThoracentesisThoracentesisTherapeuticTherapeuticThoracentesisThoracentesis• Make skin incision at insertion siteMake skin incision at insertion site

• Use 14- to 18-gauge catheter-over-Use 14- to 18-gauge catheter-over-needle attached to 10 mL syringeneedle attached to 10 mL syringe

• Insert needle 5–10 cm lateral to spine Insert needle 5–10 cm lateral to spine 1 or 2 intercostal spaces below upper 1 or 2 intercostal spaces below upper level of pleural effusionlevel of pleural effusion

• When fluid reached, angle needle When fluid reached, angle needle caudally until hub against skin caudally until hub against skin

73

TherapeuticTherapeuticThoracentesisThoracentesisTherapeuticTherapeuticThoracentesisThoracentesis• Withdraw needle, leaving catheterWithdraw needle, leaving catheter

• Cover catheter with gloved finger Cover catheter with gloved finger (prevent air entry)(prevent air entry)

• Attach hub to 3-way stopcock Attach hub to 3-way stopcock attached to 50 mL syringeattached to 50 mL syringe

• Aspirate and move fluidAspirate and move fluid

• Terminate procedure when symptoms Terminate procedure when symptoms relieved or after 1000 mLrelieved or after 1000 mL


ComplicationsComplicationsThoracentesisThoracentesisComplicationsComplicationsThoracentesisThoracentesis• PneumothoraxPneumothorax

• HemothoraxHemothorax

• Intercostal vessel / nerve injuryIntercostal vessel / nerve injury

• Post-expansion pulmonary edemaPost-expansion pulmonary edema

79

IndicationsIndicationsLumbar PunctureLumbar PunctureIndicationsIndicationsLumbar PunctureLumbar PunctureIndicationsIndications

• Suspected meningitisSuspected meningitis

• Suspected subarachnoid hemorrhage Suspected subarachnoid hemorrhage (after negative head CT scan)(after negative head CT scan)

• Spinal fluid required for analysisSpinal fluid required for analysis

• Delivery of anesthetics, antibiotics, Delivery of anesthetics, antibiotics, chemotherapychemotherapy

80

ContraindicationsContraindicationsLumbar PunctureLumbar PunctureContraindicationsContraindicationsLumbar PunctureLumbar PunctureContraindicationsContraindications

• CoagulopathyCoagulopathy

• Cerebral herniation or increased Cerebral herniation or increased intracranial pressureintracranial pressure


81

ProcedureProcedureLumbar PunctureLumbar PunctureProcedureProcedureLumbar PunctureLumbar Puncture• Position patient: lateral recumbent Position patient: lateral recumbent

with hips & knees flexedwith hips & knees flexed

• Identify landmarks: LIdentify landmarks: L33-L-L44-L-L55 spinous spinous

processes, iliac crestsprocesses, iliac crests

• Insert 20-gauge or smaller needle Insert 20-gauge or smaller needle into interspinous spaceinto interspinous space

• Align bevel parallel to dural fibers Align bevel parallel to dural fibers (facing (facing ““upwardupward””))

82

ProcedureProcedureLumbar PunctureLumbar PunctureProcedureProcedureLumbar PunctureLumbar Puncture• Advance needle to Advance needle to ““poppop””

• If you encounter bone, partially If you encounter bone, partially withdraw and redirectwithdraw and redirect

• Remove stylet Remove stylet free flow CSF free flow CSF

• Obtain opening pressureObtain opening pressure

• Collect 1 – 2mL in each tubeCollect 1 – 2mL in each tube

• Reinsert stylet and remove needleReinsert stylet and remove needle

83

ProcedureProcedureLumbar PunctureLumbar PunctureProcedureProcedureLumbar PunctureLumbar Puncture

Brainhell, Wikimedia Commons

84

http://en.wikipedia.org/wiki/File:Wikipedian_getting_a_lumbar_puncture_(2006).jpg


BruceBlaus, Wikimedia Commons

85

http://en.wikipedia.org/wiki/File:Blausen_0617_LumbarPuncture.png


Source: Waxman SG: Clinical Neuroanatomy, 26th Edition: http://www.accessmedicine.com 86


BruceBlaus, Wikimedia Commons 87

http://en.wikipedia.org/wiki/File:Spinal_Tap.png

ComplicationsComplicationsLumbar PunctureLumbar PunctureComplicationsComplicationsLumbar PunctureLumbar Puncture• Post-dural headache: ~1/3Post-dural headache: ~1/3

– Post-tap position does not matterPost-tap position does not matter

• Localized painLocalized pain

• Cerebral herniationCerebral herniation

• Subarachnoid epidermoid cystSubarachnoid epidermoid cyst

88

Indication / ContraindicationIndication / ContraindicationIntraosseous InfusionIntraosseous InfusionIndication / ContraindicationIndication / ContraindicationIntraosseous InfusionIntraosseous InfusionIndicationIndication

• Urgent vascular access when Urgent vascular access when traditional methods have failedtraditional methods have failed


• Diseased / osteoporotic boneDiseased / osteoporotic bone

• Overlying cellulitis / deep burn Overlying cellulitis / deep burn (relative)(relative)

89

ProcedureProcedureIntraosseous InfusionIntraosseous InfusionProcedureProcedureIntraosseous InfusionIntraosseous Infusion• Identify landmarks: distal femur, Identify landmarks: distal femur,

proximal tibia, proximal humerus, proximal tibia, proximal humerus, sternumsternum

• Stabilize extremityStabilize extremity

• Insert needle perpendicular to long Insert needle perpendicular to long axis of boneaxis of bone

• In kids: direct needle away from In kids: direct needle away from growth plategrowth plate

90Recommended Source: Tintinalli JE, et al., Tintinall’s Eergency Medicine: A Comprehensive Study Guide, 7th Edition: http://www.accessmedicine.com

ProcedureProcedureIntraosseous InfusionIntraosseous InfusionProcedureProcedureIntraosseous InfusionIntraosseous Infusion

Source Undetermined 91

ComplicationsComplicationsIntraosseous InfusionIntraosseous InfusionComplicationsComplicationsIntraosseous InfusionIntraosseous Infusion• Subcutaneous / subperiosteal fluid Subcutaneous / subperiosteal fluid

extravasationextravasation

• Compartment syndromeCompartment syndrome


• OsteomyelitisOsteomyelitis

• Growth plate injuryGrowth plate injury

97

Indication / ContraindicationIndication / ContraindicationDiagnostic Peritoneal LavageDiagnostic Peritoneal LavageIndication / ContraindicationIndication / ContraindicationDiagnostic Peritoneal LavageDiagnostic Peritoneal LavageIndicationIndication

• Patient with abdominal trauma Patient with abdominal trauma without indication for emergent without indication for emergent exploratory laporotomyexploratory laporotomy


• Patient with abdominal trauma and Patient with abdominal trauma and with indication for emergent with indication for emergent exploratory laporotomyexploratory laporotomy

98

ProcedureProcedureDiagnostic Peritoneal LavageDiagnostic Peritoneal LavageProcedureProcedureDiagnostic Peritoneal LavageDiagnostic Peritoneal Lavage• Introduce needle midline through Introduce needle midline through

abdominal wall 1 to 2cm below abdominal wall 1 to 2cm below umbilicus at 45umbilicus at 45oo angle to skin angle to skin

• Apply negative pressure as you Apply negative pressure as you advance needle toward pelvisadvance needle toward pelvis

• Feel for three distinct Feel for three distinct ‘‘popspops’’ – skin, – skin, fascia, peritoneumfascia, peritoneum

• Advance 2 – 3 mm after 3Advance 2 – 3 mm after 3rdrd ‘‘poppop’’99

ProcedureProcedureDiagnostic Peritoneal LavageDiagnostic Peritoneal LavageProcedureProcedureDiagnostic Peritoneal LavageDiagnostic Peritoneal Lavage• If you find blood If you find blood end of procedure end of procedure

• Insert guidewire through needle, then Insert guidewire through needle, then remove needleremove needle

• Make small skin incision adjacent to Make small skin incision adjacent to guidewireguidewire

• Place lavage catheter over guidewire Place lavage catheter over guidewire and advance into peritoneal cavityand advance into peritoneal cavity

100

ProcedureProcedureDiagnostic Peritoneal LavageDiagnostic Peritoneal LavageProcedureProcedureDiagnostic Peritoneal LavageDiagnostic Peritoneal Lavage• Infuse 1L crystalloid solution, then Infuse 1L crystalloid solution, then

place empty bag on floorplace empty bag on floor

• Collect minimum 200 mL fluid, but as Collect minimum 200 mL fluid, but as much as possiblemuch as possible

• Remove catheter when finishedRemove catheter when finished

• Send fluid for cell countSend fluid for cell count– Threshold 100,000 RBCs/mmThreshold 100,000 RBCs/mm33

101

Recommended Source: Tintinalli JE, et al., Tintinall’s Eergency Medicine: A Comprehensive Study Guide, 7th Edition: http://www.accessmedicine.com

ComplicationsComplicationsDiagnostic Peritoneal LavageDiagnostic Peritoneal LavageComplicationsComplicationsDiagnostic Peritoneal LavageDiagnostic Peritoneal Lavage• Localized infectionLocalized infection

• Bleeding / hematoma formationBleeding / hematoma formation

• Damage to intra-abdominal organsDamage to intra-abdominal organs

106

Indication / ContraindicationIndication / ContraindicationLateral CanthotomyLateral CanthotomyIndication / ContraindicationIndication / ContraindicationLateral CanthotomyLateral CanthotomyIndicationIndication

• Acute orbital compartment syndromeAcute orbital compartment syndrome


• NoneNone

107

ProcedureProcedureLateral CanthotomyLateral CanthotomyProcedureProcedureLateral CanthotomyLateral Canthotomy• Inject lateral canthal fold: lidocaine Inject lateral canthal fold: lidocaine

with epinephrinewith epinephrine

• Insert straight hemostat in lateral Insert straight hemostat in lateral canthal fold, clamp for 1 minute to canthal fold, clamp for 1 minute to devascularizedevascularize

• Incise lateral canthusIncise lateral canthus

• Identify and transect lateral canthal Identify and transect lateral canthal tendontendon

108

ProcedureProcedureLateral CanthotomyLateral CanthotomyProcedureProcedureLateral CanthotomyLateral Canthotomy


ComplicationsComplicationsLateral CanthotomyLateral CanthotomyComplicationsComplicationsLateral CanthotomyLateral Canthotomy• BleedingBleeding

• Globe perforationGlobe perforation


• Lacrimal gland injuryLacrimal gland injury

• Lateral rectus muscle injuryLateral rectus muscle injury

• Scleral lacerationScleral laceration

110

Indication / ContraindicationIndication / ContraindicationPericardiocentesisPericardiocentesisIndication / ContraindicationIndication / ContraindicationPericardiocentesisPericardiocentesisIndicationIndication

• Pericardial tamponadePericardial tamponade

• Analysis pericardial effusionAnalysis pericardial effusion



111

ProcedureProcedurePericardiocentesisPericardiocentesisProcedureProcedurePericardiocentesisPericardiocentesis• Insert 18-gauge spinal needle Insert 18-gauge spinal needle

between xiphoid process and left between xiphoid process and left costal margin at 30 – 45costal margin at 30 – 45oo angle angle

• Aim tip toward patientAim tip toward patient’’s left shoulders left shoulder

• Aspirate fluidAspirate fluid

• Use ULTRASOUND when possibleUse ULTRASOUND when possible

112


ProcedureProcedurePericardiocentesisPericardiocentesisProcedureProcedurePericardiocentesisPericardiocentesis

Source Undetermined

114

ProcedureProcedurePericardiocentesisPericardiocentesisProcedureProcedurePericardiocentesisPericardiocentesis

Source Undetermined

115

ComplicationsComplicationsPericardiocentesisPericardiocentesisComplicationsComplicationsPericardiocentesisPericardiocentesis• PneumothoraxPneumothorax

• Bleeding complicationBleeding complication

• Damage to coronary arteryDamage to coronary artery

• Damage to intraabdominal organ(s)Damage to intraabdominal organ(s)

• DeathDeath

116

Indication / ContraindicationIndication / ContraindicationVenous CutdownVenous CutdownIndication / ContraindicationIndication / ContraindicationVenous CutdownVenous CutdownIndicationIndication

• Immediate need for vascular access, Immediate need for vascular access, no peripheral or central availableno peripheral or central available


• Proximal extremity vascular injury / Proximal extremity vascular injury / long bone fracturelong bone fracture

• Overlying skin infection, coagulopathy Overlying skin infection, coagulopathy (relative(relative

117

ProcedureProcedureVenous CutdownVenous CutdownProcedureProcedureVenous CutdownVenous Cutdown• Location of greater saphenous vein Location of greater saphenous vein

(GSV): 2.5 cm anterior and 2.5 cm (GSV): 2.5 cm anterior and 2.5 cm superior to medial malleolussuperior to medial malleolus

• Make transverse skin incision from Make transverse skin incision from anterior tibial border to posterior tibial anterior tibial border to posterior tibial borderborder

• Isolate GSVIsolate GSV

118

ProcedureProcedureVenous CutdownVenous CutdownProcedureProcedureVenous CutdownVenous Cutdown• Insert curved hemostat tip down, Insert curved hemostat tip down,

scrape along periosteum starting on scrape along periosteum starting on posterior border until the tip reaches posterior border until the tip reaches the anterior borderthe anterior border

• Rotate hemostat 180Rotate hemostat 180oo so tip faces so tip faces upwardupward

• Open the jaws of the hemostat – the Open the jaws of the hemostat – the GSV should be visibleGSV should be visible

119

ProcedureProcedureVenous CutdownVenous CutdownProcedureProcedureVenous CutdownVenous Cutdown• Switch to straight hemostat, remove Switch to straight hemostat, remove

curved hemostatcurved hemostat

• Insert 16- to 18-gauge IV catheter-Insert 16- to 18-gauge IV catheter-over-needle into veinover-needle into vein

120


ProcedureProcedureVenous Cutdown: GroinVenous Cutdown: GroinProcedureProcedureVenous Cutdown: GroinVenous Cutdown: Groin• Identify where scrotal / labial fold Identify where scrotal / labial fold

meets the thigh meets the thigh ~2cm below site ~2cm below site for femoral central venous linefor femoral central venous line

• Make transverse incision medial to Make transverse incision medial to lateral beginning at foldlateral beginning at fold

• Dissect subcutaneous tissue with Dissect subcutaneous tissue with curved hemostatcurved hemostat

• Identify and isolate GSVIdentify and isolate GSV123

ProcedureProcedureVenous Cutdown: GroinVenous Cutdown: GroinProcedureProcedureVenous Cutdown: GroinVenous Cutdown: Groin• Identify and isolate GSVIdentify and isolate GSV

• Cannulate either directly or using Cannulate either directly or using Seldinger techniqueSeldinger technique

124

ComplicationsComplicationsVenous CutdownVenous CutdownComplicationsComplicationsVenous CutdownVenous Cutdown• InfectionInfection

• Vascular injuryVascular injury

• Nerve injuryNerve injury

• PhlebitisPhlebitis

• TromboembolismTromboembolism

• Wound dehiscenceWound dehiscence

125

Indication / ContraindicationIndication / ContraindicationAnterior / Posterior Nasal PackAnterior / Posterior Nasal PackIndication / ContraindicationIndication / ContraindicationAnterior / Posterior Nasal PackAnterior / Posterior Nasal PackIndicationsIndications

• EpistaxisEpistaxis


• None None

126Recommended Source: Tintinalli JE, et al., Tintinall’s Eergency Medicine: A Comprehensive Study Guide, 7th Edition: http://www.accessmedicine.com

ProcedureProcedurePosterior Nasal PackPosterior Nasal PackProcedureProcedurePosterior Nasal PackPosterior Nasal Pack• Prepare the pack: use 3 inch dental Prepare the pack: use 3 inch dental

rolls, tonsil packs, or 4x4 gauzerolls, tonsil packs, or 4x4 gauze

• Form a tight cylindrical roll with gauzeForm a tight cylindrical roll with gauze

• Tie two pieces of umbilical tape or 0-Tie two pieces of umbilical tape or 0-silk suture around pack to divide it silk suture around pack to divide it into thirds (see picture)into thirds (see picture)

131

ProcedureProcedurePosterior Nasal PackPosterior Nasal PackProcedureProcedurePosterior Nasal PackPosterior Nasal Pack


ProcedureProcedurePosterior Nasal PackPosterior Nasal PackProcedureProcedurePosterior Nasal PackPosterior Nasal Pack• Insert red rubber catheters through Insert red rubber catheters through

nostril and pull out through mouthnostril and pull out through mouth

• Attach pack to red rubber cathetersAttach pack to red rubber catheters

• Pull pack into placePull pack into place– Use finger to pass pack around soft Use finger to pass pack around soft

palate and uvulapalate and uvula

• Place anterior nasal packPlace anterior nasal pack

• Secure ties of posterior packSecure ties of posterior pack133Recommended Source: Reichman EF, Simon RR: Emergency Medicine Procedures

ProcedureProcedurePosterior Nasal BalloonPosterior Nasal BalloonProcedureProcedurePosterior Nasal BalloonPosterior Nasal Balloon• Gather nasal speculum, light source, Gather nasal speculum, light source,

suction, anethetizing and packing suction, anethetizing and packing materialsmaterials

• Place patient in Place patient in ““sniffing position,sniffing position,”” give emesis basin and some tissuesgive emesis basin and some tissues

• Anesthetize nasal mucosa using Anesthetize nasal mucosa using cotton pledgets soaked in LET (or cotton pledgets soaked in LET (or cocaine)cocaine)

142

ProcedureProcedurePosterior Nasal BalloonPosterior Nasal BalloonProcedureProcedurePosterior Nasal BalloonPosterior Nasal Balloon• Lubricate Foley catheter or posterior Lubricate Foley catheter or posterior

balloon with antibiotic ointmentballoon with antibiotic ointment

• Insert transnasally until visible in Insert transnasally until visible in posterior oropharynxposterior oropharynx

• Inflate balloon with 7 ml of water, Inflate balloon with 7 ml of water, gently retract catheter ~2 to 3 cm until gently retract catheter ~2 to 3 cm until lodged in posterior nasopharynxlodged in posterior nasopharynx

143

ProcedureProcedurePosterior Nasal BalloonPosterior Nasal BalloonProcedureProcedurePosterior Nasal BalloonPosterior Nasal Balloon• Inflate balloon with additional 5 to 7 Inflate balloon with additional 5 to 7

ml of saline ml of saline

• Secure pack by taping to patient's Secure pack by taping to patient's cheekcheek

144

ProcedureProcedurePosteriorPosterior Nasal Balloon Nasal BalloonProcedureProcedurePosteriorPosterior Nasal Balloon Nasal Balloon


ComplicationsComplicationsPosterior Nasal PackPosterior Nasal PackComplicationsComplicationsPosterior Nasal PackPosterior Nasal Pack• Nasal septal perforationNasal septal perforation

• Sinusitis / otitis mediaSinusitis / otitis media

• Toxic shock syndromeToxic shock syndrome

• AspirationAspiration

• Alar necrosisAlar necrosis

• Hypoxia from intrapulmonary Hypoxia from intrapulmonary shunting due to stimulation of shunting due to stimulation of nasopulmonary reflexnasopulmonary reflex 147

Indication / ContraindicationIndication / ContraindicationPeritonsillar Abscess I&DPeritonsillar Abscess I&DIndication / ContraindicationIndication / ContraindicationPeritonsillar Abscess I&DPeritonsillar Abscess I&DIndicationIndication

• Peritonsillar abscessPeritonsillar abscess



148

ProcedureProcedurePeritonsillar Abscess AspirationPeritonsillar Abscess AspirationProcedureProcedurePeritonsillar Abscess AspirationPeritonsillar Abscess Aspiration• Identify area of maximum fluctuanceIdentify area of maximum fluctuance

• Cut needle cap so that needle Cut needle cap so that needle projects only 1cm beyond distal capprojects only 1cm beyond distal cap

• Depress / distract tongueDepress / distract tongue

• Insert needle, staying parallel to Insert needle, staying parallel to mouth floormouth floor

• Advance and aspirateAdvance and aspirate

149

ProcedureProcedurePeritonsillar Abscess AspirationPeritonsillar Abscess AspirationProcedureProcedurePeritonsillar Abscess AspirationPeritonsillar Abscess Aspiration

Source: Reichman EF, Simon RR: Emergency Medicine Procedures

150

ComplicationsComplicationsPeritonsillar Abscess I&DPeritonsillar Abscess I&DComplicationsComplicationsPeritonsillar Abscess I&DPeritonsillar Abscess I&D• AspirationAspiration

• Airway compromiseAirway compromise

• BleedingBleeding

• Vascular injuryVascular injury

153

Indication: Thrombosed Indication: Thrombosed External Hemorrhoid ExcisionExternal Hemorrhoid ExcisionIndication: Thrombosed Indication: Thrombosed External Hemorrhoid ExcisionExternal Hemorrhoid ExcisionIndicationIndication

• Painful thrombosed external Painful thrombosed external hemorrhoidhemorrhoid

154

Contraindication: Thrombosed Contraindication: Thrombosed External Hemorrhoid ExcisionExternal Hemorrhoid ExcisionContraindication: Thrombosed Contraindication: Thrombosed External Hemorrhoid ExcisionExternal Hemorrhoid ExcisionContraindicationContraindication

• Grade IV internal hemorrhoids with Grade IV internal hemorrhoids with thrombosed external hemorrhoidsthrombosed external hemorrhoids

• Very large hemorrhoidsVery large hemorrhoids

• Inflammatory bowel disease anorectal Inflammatory bowel disease anorectal fissure, perianal infection, portal fissure, perianal infection, portal hypertension, rectal prolapse, hypertension, rectal prolapse, anorectal tumor, immunocompromiseanorectal tumor, immunocompromise

155

Procedure: Thrombosed Procedure: Thrombosed External Hemorrhoid ExcisionExternal Hemorrhoid ExcisionProcedure: Thrombosed Procedure: Thrombosed External Hemorrhoid ExcisionExternal Hemorrhoid Excision• Identify area to be incisedIdentify area to be incised

• Use two radial incisions starting near Use two radial incisions starting near center of anuscenter of anus

• Dissect skin and thrombosis with Dissect skin and thrombosis with scissorsscissors

• DO NOT cut anal sphincterDO NOT cut anal sphincter

• Control bleeding: AgNOControl bleeding: AgNO33

156

Indication / ContraindicationIndication / ContraindicationNail Bed RepairNail Bed RepairIndication / ContraindicationIndication / ContraindicationNail Bed RepairNail Bed RepairIndicationIndication

• Nail bed injuryNail bed injury


• None None

160

ProcedureProcedureNail Bed RepairNail Bed RepairProcedureProcedureNail Bed RepairNail Bed Repair• After digital / regional block: insert After digital / regional block: insert

closed tip of fine scissors between closed tip of fine scissors between nail plate and nail bednail plate and nail bed

• Advance tip while opening / closing Advance tip while opening / closing blades to separate plate from bedblades to separate plate from bed

• Stop scissors when blade tips at Stop scissors when blade tips at eponychiumeponychium

161

ProcedureProcedureNail Bed RepairNail Bed RepairProcedureProcedureNail Bed RepairNail Bed Repair• Grasp nail plate with hemostat, pull Grasp nail plate with hemostat, pull

along long axis of fingeralong long axis of finger

• Repair nailbed laceration with Repair nailbed laceration with absorbable sutureabsorbable suture

• Replace nail plate onto nail bed. Replace nail plate onto nail bed. Suture in place for ~7 daysSuture in place for ~7 days

• If nail missing If nail missing petrolatum gauze petrolatum gauze

162Recommended Source: Reichman EF, Simon RR: Emergency Medicine Procedures

ComplicationsComplicationsNail Bed RepairNail Bed RepairComplicationsComplicationsNail Bed RepairNail Bed Repair• Complete nail loss (expected)Complete nail loss (expected)


• Nail growth abnormalitiesNail growth abnormalities

165

Indication / ContraindicationIndication / ContraindicationArthrocentesisArthrocentesisIndication / ContraindicationIndication / ContraindicationArthrocentesisArthrocentesisIndicationIndication

• Diagnosis: obtain synovial fluidDiagnosis: obtain synovial fluid

• Therapy: inject steroid, anestheticTherapy: inject steroid, anesthetic


• Overlying infection, coagulopathy, Overlying infection, coagulopathy, prosthetic joint, septic / bacteremic prosthetic joint, septic / bacteremic patient (all relative)patient (all relative)

166

ProcedureProcedureArthrocentesisArthrocentesisProcedureProcedureArthrocentesisArthrocentesis• Palpate bony anatomy, identify Palpate bony anatomy, identify

anatomic landmarksanatomic landmarks

• Insert needle into joint spaceInsert needle into joint space

• If strike bone, withdraw slightly and If strike bone, withdraw slightly and redirectredirect

• Aspirate synovial fluidAspirate synovial fluid

167

ProcedureProcedureArthrocentesis – Knee Arthrocentesis – Knee ProcedureProcedureArthrocentesis – Knee Arthrocentesis – Knee


ComplicationsComplicationsArthrocentesisArthrocentesisComplicationsComplicationsArthrocentesisArthrocentesis• Localized infectionLocalized infection

• Bleeding / hematomaBleeding / hematoma

171

Indication / ContraindicationIndication / ContraindicationFelon Incision & DrainageFelon Incision & DrainageIndication / ContraindicationIndication / ContraindicationFelon Incision & DrainageFelon Incision & DrainageIndicationIndication

• Fluctuant felonFluctuant felon


• Herpes whitlowHerpes whitlow

• Non-fluctuant felonNon-fluctuant felon

172

ProcedureProcedureFelon Incision & DrainageFelon Incision & DrainageProcedureProcedureFelon Incision & DrainageFelon Incision & Drainage• If central pulp: central longitudinal If central pulp: central longitudinal

finger pad incision with #11 scalpelfinger pad incision with #11 scalpel

• Radial / ulnar fluctuance: medial / Radial / ulnar fluctuance: medial / lateral pad incisionlateral pad incision

• Do not cross DIPDo not cross DIP

• Break up loculationsBreak up loculations

• Irrigate, pack with drain / dressingIrrigate, pack with drain / dressing

173

ProcedureProcedureFelon Incision & DrainageFelon Incision & DrainageProcedureProcedureFelon Incision & DrainageFelon Incision & Drainage


ComplicationsComplicationsFelon Incision & DrainageFelon Incision & DrainageComplicationsComplicationsFelon Incision & DrainageFelon Incision & Drainage• Skin necrosisSkin necrosis

• OsteomyelitisOsteomyelitis

• Extension of local infectionExtension of local infection

• Flexor tenosynovitisFlexor tenosynovitis

• Neurovascular injuryNeurovascular injury

• Finger pad damageFinger pad damage

176

IndicationIndicationEscharotomyEscharotomyIndicationIndicationEscharotomyEscharotomyIndicationIndication

• Circumferential full / partial thickness Circumferential full / partial thickness extremity burns & impaired perfusionextremity burns & impaired perfusion

• Chest wall burns impairing chest wall Chest wall burns impairing chest wall movement / ventilationmovement / ventilation

• Neck burns / impending tracheal Neck burns / impending tracheal obstructionobstruction

177

ContraindicationContraindicationEscharotomyEscharotomyContraindicationContraindicationEscharotomyEscharotomyContraindication (all relative)Contraindication (all relative)

• Overlying skin infectionOverlying skin infection

• CoagulopathyCoagulopathy

• Prosthetic jointProsthetic joint

• Sepsis / bacteremiaSepsis / bacteremia

178

ProcedureProcedureEscharotomyEscharotomyProcedureProcedureEscharotomyEscharotomy• Sedate patient / use local anesthesiaSedate patient / use local anesthesia

• Use scalpel / cautery Use scalpel / cautery make make incision along medial and lateral incision along medial and lateral aspect of involved extremityaspect of involved extremity

• Make incision from 1cm proximal to Make incision from 1cm proximal to burn burn 1 cm distal to burn 1 cm distal to burn

• Extend only through full thickness of Extend only through full thickness of skinskin

179

ProcedureProcedureEscharotomyEscharotomyProcedureProcedureEscharotomyEscharotomy• Chest: incise along anterior axillary Chest: incise along anterior axillary

line from clavicle to costal margin line from clavicle to costal margin bilateral – may join with anotherbilateral – may join with another

• Neck: incise posterior and lateral to Neck: incise posterior and lateral to vascular structuresvascular structures

180

ProcedureProcedureEscharotomyEscharotomyProcedureProcedureEscharotomyEscharotomy

Source: Tintinalli JE, et al., Tintinall’s Eergency Medicine: A Comprehensive Study Guide, 7th Edition: http://www.accessmedicine.com

181

ProcedureProcedureEscharotomyEscharotomyProcedureProcedureEscharotomyEscharotomy

Source: Tintinalli JE, et al., Tintinall’s Eergency Medicine: A Comprehensive Study Guide, 7th Edition: http://www.accessmedicine.com 182

ComplicationsComplicationsEscharotomyEscharotomyComplicationsComplicationsEscharotomyEscharotomy• BleedingBleeding


• Neurovascular damageNeurovascular damage

• Inadequate decompressionInadequate decompression– Muscle damage, nerve injuryMuscle damage, nerve injury

– Renal failure Renal failure hyperkalemia hyperkalemia

– Metabolic acidosisMetabolic acidosis

183

IndicationIndicationUrethrogram & CystogramUrethrogram & CystogramIndicationIndicationUrethrogram & CystogramUrethrogram & CystogramIndicationIndication

• Suspected traumatic injury to lower Suspected traumatic injury to lower urinary tracturinary tract– Blood at urethral meatusBlood at urethral meatus

– High-riding prostateHigh-riding prostate

– Gross hematuriaGross hematuria

– Perianal / scrotal hematomaPerianal / scrotal hematoma

184

ContraindicationContraindicationUrethrogram & CystogramUrethrogram & CystogramContraindicationContraindicationUrethrogram & CystogramUrethrogram & CystogramContraindicationContraindication

• Hemodynamic instabilityHemodynamic instability

• Acute urethritis in patient with low riskAcute urethritis in patient with low risk

• Cystogram contraindicated if urethral Cystogram contraindicated if urethral injury identified on urethrograminjury identified on urethrogram

185

Procedure: Retrograde Procedure: Retrograde UrethrogramUrethrogram & Cystogram & CystogramProcedure: Retrograde Procedure: Retrograde UrethrogramUrethrogram & Cystogram & Cystogram• Use Cystographin, Renographin-60, Use Cystographin, Renographin-60,

or Hypaque® 50%or Hypaque® 50%

• Retract and secure penile foreskinRetract and secure penile foreskin

• Prime catheter tubing with contrast Prime catheter tubing with contrast prior to insertingprior to inserting

• Insert catheter until retention balloon Insert catheter until retention balloon is within glans (fossa navicularis)is within glans (fossa navicularis)

186

Procedure: Retrograde Procedure: Retrograde UrethrogramUrethrogram & Cystogram & CystogramProcedure: Retrograde Procedure: Retrograde UrethrogramUrethrogram & Cystogram & Cystogram• Straighten penis across thigh to Straighten penis across thigh to

prevent urethral foldingprevent urethral folding

• Inject 50-60mL over 5–10 secondsInject 50-60mL over 5–10 seconds

• Can also use 60mL Toomey irrigating Can also use 60mL Toomey irrigating syringesyringe

• Get KUB during injection final 10mLGet KUB during injection final 10mL

• Extravasation outside urethral contour Extravasation outside urethral contour disruption disruption

187

Procedure: Retrograde Procedure: Retrograde UrethrogramUrethrogram & Cystogram & CystogramProcedure: Retrograde Procedure: Retrograde UrethrogramUrethrogram & Cystogram & Cystogram• Contrast in bladder with extravasation Contrast in bladder with extravasation

partial disruption partial disruption

• No extravasation No extravasation proceed with proceed with retrograde cystogramretrograde cystogram


Procedure: Retrograde Procedure: Retrograde Urethrogram & Urethrogram & CystogramCystogramProcedure: Retrograde Procedure: Retrograde Urethrogram & Urethrogram & CystogramCystogram• No extravasation No extravasation proceed with proceed with

retrograde cystogramretrograde cystogram

• Advance catheter into bladderAdvance catheter into bladder

• Inflate balloon and gently pull back to Inflate balloon and gently pull back to lodge balloon at bladder necklodge balloon at bladder neck

• Remove plunger from 60mL syringeRemove plunger from 60mL syringe

190

Procedure: Retrograde Procedure: Retrograde Urethrogram & Urethrogram & CystogramCystogramProcedure: Retrograde Procedure: Retrograde Urethrogram & Urethrogram & CystogramCystogram• Fill bladder by gravity with 300 -Fill bladder by gravity with 300 -

350mL of contrast350mL of contrast

• Clamp catheter with hemostatClamp catheter with hemostat

• Obtain KUB Obtain KUB look for filling, look for filling, extravasationextravasation

• Release clamp and drain contrast by Release clamp and drain contrast by gravitygravity

191

Procedure: Retrograde Procedure: Retrograde Urethrogram & Urethrogram & CystogramCystogramProcedure: Retrograde Procedure: Retrograde Urethrogram & Urethrogram & CystogramCystogram• Obtain Obtain ‘‘washoutwashout’’ KUB KUB

–Extraperitoneal bladder injury Extraperitoneal bladder injury flame-like projection within pelvis flame-like projection within pelvis possible conservative managementpossible conservative management

–Intraperitoneal bladder injury Intraperitoneal bladder injury contrast outlines intraperitoneal contrast outlines intraperitoneal organs organs surgical management surgical management


Complications: Retrograde Complications: Retrograde Urethrogram & CystogramUrethrogram & CystogramComplications: Retrograde Complications: Retrograde Urethrogram & CystogramUrethrogram & Cystogram• Relatively benign procedure – Relatively benign procedure –

complications rarecomplications rare

194

IndicationsIndicationsPerimortem C-SectionPerimortem C-SectionIndicationsIndicationsPerimortem C-SectionPerimortem C-Section• To optimize maternal To optimize maternal

cardiopulmonary resuscitationcardiopulmonary resuscitation

• Rescue of a viable fetus >24 weeks Rescue of a viable fetus >24 weeks gestation is an important gestation is an important consideration, but such rescue is consideration, but such rescue is always secondary to the safety and always secondary to the safety and life of the motherlife of the mother

195

ContraindicationsContraindicationsPerimortem C-SectionPerimortem C-SectionContraindicationsContraindicationsPerimortem C-SectionPerimortem C-Section• Mother with serious brain injury but Mother with serious brain injury but

otherwise hemodynamically stable, otherwise hemodynamically stable, fetus shows no signs of distress. fetus shows no signs of distress.

• Inability to adequately resuscitate Inability to adequately resuscitate infant after deliveryinfant after delivery

• Extreme fetal prematurity/immaturityExtreme fetal prematurity/immaturity

196

ProcedureProcedurePerimortem C-SectionPerimortem C-SectionProcedureProcedurePerimortem C-SectionPerimortem C-Section• Make a vertical midline skin incision Make a vertical midline skin incision

with a #10 scalpel blade beginning 2 with a #10 scalpel blade beginning 2 to 3 cm above pubic symphysis and to 3 cm above pubic symphysis and extending to 1 cm below umbilicusextending to 1 cm below umbilicus

• Ignore any subcutaneous bleeding Ignore any subcutaneous bleeding unless it is arterialunless it is arterial– Clamp \ bleeding artery or use electro-Clamp \ bleeding artery or use electro-

cautery unit to coagulate if availablecautery unit to coagulate if available


ProcedureProcedurePerimortem C-SectionPerimortem C-SectionProcedureProcedurePerimortem C-SectionPerimortem C-Section• Extend incision through Extend incision through

subcutaneous fat to rectus sheath.subcutaneous fat to rectus sheath.

• Grasp and elevate rectus sheath Grasp and elevate rectus sheath using a toothed forcepsusing a toothed forceps

• Make an incision in the rectus sheath Make an incision in the rectus sheath with a Mayo scissors. Extend the with a Mayo scissors. Extend the rectus sheath incision superiorly and rectus sheath incision superiorly and inferiorly with a Mayo scissorsinferiorly with a Mayo scissors

199

ProcedureProcedurePerimortem C-SectionPerimortem C-SectionProcedureProcedurePerimortem C-SectionPerimortem C-Section• Expose the uterus – the underlying Expose the uterus – the underlying

peritoneum should be visibleperitoneum should be visible

• Insert retractors to fully expose the Insert retractors to fully expose the peritoneal membraneperitoneal membrane

• Grasp and elevate the peritoneal Grasp and elevate the peritoneal membrane with a toothed forcepsmembrane with a toothed forceps

• Incise the peritoneal membrane with Incise the peritoneal membrane with a Mayo or Metzenbaum scissorsa Mayo or Metzenbaum scissors

201

ProcedureProcedurePerimortem C-SectionPerimortem C-SectionProcedureProcedurePerimortem C-SectionPerimortem C-Section• Make reasonable attempts to protect Make reasonable attempts to protect

the bowel and bladder from injurythe bowel and bladder from injury

• Elevate the bowel off the field and Elevate the bowel off the field and cover it with a saline soaked towelcover it with a saline soaked towel

• Place a bladder retractor over the Place a bladder retractor over the pubic symphysis to retract the rectus pubic symphysis to retract the rectus sheath and bladdersheath and bladder

202

ProcedureProcedurePerimortem C-SectionPerimortem C-SectionProcedureProcedurePerimortem C-SectionPerimortem C-Section• Identify the position of the fetal head Identify the position of the fetal head

by palpating the uterusby palpating the uterus

• Make a 2 to 4 cm midline vertical Make a 2 to 4 cm midline vertical incision in the uterusincision in the uterus– The amniotic sac will bulge through the The amniotic sac will bulge through the

incision if the membranes are intactincision if the membranes are intact

• Place a finger into the uterine incision Place a finger into the uterine incision and aimed verticallyand aimed vertically

204

ProcedureProcedurePerimortem C-SectionPerimortem C-SectionProcedureProcedurePerimortem C-SectionPerimortem C-Section• Insert one blade of a bandage Insert one blade of a bandage

scissors between the finger and the scissors between the finger and the uterine walluterine wall– The other blade of the scissors should The other blade of the scissors should

be outside the uterusbe outside the uterus

• Extend the vertical uterine incision Extend the vertical uterine incision fundally, superior and away from the fundally, superior and away from the bladderbladder

205

ProcedureProcedurePerimortem C-SectionPerimortem C-SectionProcedureProcedurePerimortem C-SectionPerimortem C-Section• Rupture the amniotic membranes with Rupture the amniotic membranes with

a clamp or other blunt instrumenta clamp or other blunt instrument

• Carefully transect the placenta if it is Carefully transect the placenta if it is anterior to the fetusanterior to the fetus

• Insert a hand between the pubic Insert a hand between the pubic symphysis and the fetal occiputsymphysis and the fetal occiput

208

ProcedureProcedurePerimortem C-SectionPerimortem C-SectionProcedureProcedurePerimortem C-SectionPerimortem C-Section• Advance the hand to the base of the Advance the hand to the base of the

occiputocciput

• Flex the fetal head and apply gentle Flex the fetal head and apply gentle anteriorly and superiorly directed anteriorly and superiorly directed traction to elevate and deliver the traction to elevate and deliver the headhead

210

ProcedureProcedurePerimortem C-SectionPerimortem C-SectionProcedureProcedurePerimortem C-SectionPerimortem C-Section• Deliver the entire fetal headDeliver the entire fetal head

212

ProcedureProcedurePerimortem C-SectionPerimortem C-SectionProcedureProcedurePerimortem C-SectionPerimortem C-Section• Suction the mouth and nose with a Suction the mouth and nose with a

bulb syringebulb syringe

214

ProcedureProcedurePerimortem C-SectionPerimortem C-SectionProcedureProcedurePerimortem C-SectionPerimortem C-Section• Deliver the shoulders in a manner Deliver the shoulders in a manner

similar to that of a vaginal delivery similar to that of a vaginal delivery

• Apply gentle upward traction on the Apply gentle upward traction on the head while an assistant applies head while an assistant applies pressure on the uterine funduspressure on the uterine fundus– First deliver the anterior shoulderFirst deliver the anterior shoulder

– Deliver the other shoulder followed by Deliver the other shoulder followed by the torso and lower extremitiesthe torso and lower extremities

216

ProcedureProcedurePerimortem C-SectionPerimortem C-SectionProcedureProcedurePerimortem C-SectionPerimortem C-Section• Clamp umbilical cord with hemostat Clamp umbilical cord with hemostat

or umbilical cord clamp approximately or umbilical cord clamp approximately 10 to 15 cm from fetus10 to 15 cm from fetus

• Attach second hemostat or clamp 2 to Attach second hemostat or clamp 2 to 3 cm distal to the first3 cm distal to the first

• Cut umbilical cord between the Cut umbilical cord between the clamps with a Mayo scissorsclamps with a Mayo scissors

• Resuscitate the neonateResuscitate the neonate218

ComplicationsComplicationsPerimortem C-SectionPerimortem C-SectionComplicationsComplicationsPerimortem C-SectionPerimortem C-Section• Maternal sepsisMaternal sepsis

• Maternal visceral injuryMaternal visceral injury

• Maternal hemorrhageMaternal hemorrhage

• Fetal injury secondary to deliveryFetal injury secondary to delivery

• Possible benefits of maternal and / or Possible benefits of maternal and / or fetal survival should far outweigh fetal survival should far outweigh these considerationsthese considerations

219

ResourcesResourcesResourcesResources• Tintinalli’

s Emergency Medicine: A Comprehensive Study Guide, 7e

Judith E. Tintinalli, J. Stephan Judith E. Tintinalli, J. Stephan Stapczynski, O. John Ma, David M. Stapczynski, O. John Ma, David M. Cline, Rita K. Cydulka, and Garth D. Cline, Rita K. Cydulka, and Garth D. MecklerMeckler

• Emergency Medicine ProceduresEric R. Reichman, Robert R. SimonEric R. Reichman, Robert R. Simon220

http://www.accessemergencymedicine.com/resourceToc.aspx?resourceID=40





ResourcesResourcesResourcesResources• Atlas of Emergency Medicine, 3e

Kevin J. Knoop, Lawrence B. Stack, Kevin J. Knoop, Lawrence B. Stack, Alan B. Storrow, R. Jason ThurmanAlan B. Storrow, R. Jason Thurman

221


SummarySummarySummarySummary• Explain risks and benefits, including Explain risks and benefits, including

what will happen if you donwhat will happen if you don’’t do itt do it

• Obtain written informed consent Obtain written informed consent (when possible)(when possible)

• Use appropriate monitoring Use appropriate monitoring equipmentequipment

• Position patient properlyPosition patient properly

222

SummarySummarySummarySummary• Clean / prep / drape appropriate body Clean / prep / drape appropriate body

partpart

• Use aseptic / sterile techniqueUse aseptic / sterile technique

• Provide post-procedure instructionsProvide post-procedure instructions

• Many of these procedures available Many of these procedures available on YouTubeon YouTube

223

Documents

Project: Ghana Emergency Medicine Collaborative Document Title: EMedHome Board Review: Procedures Author(s): Joe Lex, MD, FACEP, FAAEM, MAAEM (Temple University)