Surgical Procedures - PowerPoint PPT Presentation

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Surgical Procedures

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ETCO2 requires cardiac output and therefore may not be reliable if intubating during a cardiac arrest if none detected, confirm with physical exam. – PowerPoint PPT presentation

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Title: Surgical Procedures


1
Surgical Procedures
  • Devashish J. Anjaria
  • Surgical Fundamentals
  • July 16, 2010

2
Case Presentation
  • 25 year old male presents s/p single stab wound
    to the left chest. He clearly smells of alcohol
    and is lethargic responding only to painful
    stimuli. Field vitals are P 150, BP 80/palp,
    Resp 35.
  • Whats the plan????

3
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4
ABCs
5
Airway
  • Secure airway cuffed tube in the trachea
  • Endotracheal
  • Orotracheal
  • Nasotracheal
  • Surgical airway
  • Cricothyroidotomy
  • Tracheostomy

6
Indications
  • Inability to oxygenate
  • PaO2/FiO2 lt 200
  • Inability to ventilate
  • Respiratory rate gt 30 or lt 5
  • PCO2 gt 60
  • Inability to protect airway
  • GCS 8

7
Initial Maneuvers
  • Chin lift
  • Contraindicated in cervical spine injuries or
    cervical fusion
  • Jaw thrust

8
Initial Maneuvers
  • Bag valve mask
  • Nasal and/or oral airways
  • The goal is to ventilate and pre-oxygenate

9
What you need. . .
MAC or Miller Blades
Laryngoscope
Capnograph
10
What you need. . .
  • Working suction
  • 10 cc syringe (to inflate the balloon)
  • Medications to premedicate, if applicable
  • Tape or twill
  • Stylet
  • Pulse ox monitoring

11
And of course. . . The endotracheal tube
12
Nasotracheal Intubation
  • Prerequisites
  • Awake spontaneously breathing patient
  • Contraindications
  • Facial fractures
  • Basilar skull fracture
  • Apnea
  • Coagulopathy
  • Pregnancy

13
Nasotracheal Intubation - Technique
  • Pick an endotracheal tube 1 size smaller than the
    largest nasal airway which fits.
  • Thoroughly lubricate the endotracheal tube
  • Anesthetize the nares (if possible) with
    lidocaine jelly or cetacaine spray
  • Gently advance the tube until fogging is
    encountered and/or air moves through tube.

14
Nasotracheal Intubation - Technique
  • Ask the patient to take deep breaths and slowly
    advance the tube past the vocal cords with
    inspiration
  • When phonation is lost, inflate cuff, confirm
    position (listen, ETCO2) and secure tube.

15
Orotracheal Intubation - Technique
  • Stabilize cervical spine if necessary
  • Have somebody apply cricoid pressure
  • Open mouth and separate teeth with right hand
  • Hold laryngoscope in left hand and insert in
    right side of mouth, pushing the tongue to the
    left.
  • Vertical traction is applied to lift the
    epiglottis and visualize the vocal cords

16
Orotracheal Intubation - Technique
17
Orotracheal Intubation - Technique
  • The endotracheal tube is inserted through the
    cords and the cuff is inflated.
  • Tube position is confirmed
  • Ausculation/Chest excursion
  • Capnography
  • CXR
  • Tube is secured

18
Sedatives and Neuromuscular Blockers
  • Induction agents
  • Thiopental 4 6 mg/kg
  • Etomidate 0.3 mg/kg
  • Ketamine 1 3 mg/kg
  • Neuromuscular blocking agents
  • Succinylcholine 1.0 mg/kg
  • Vecuronium 0.3 mg/kg for intubating
  • Sedatives
  • Midazolam 0.05 0.15 mg/kg
  • Propofol

19
Intubating Pearls
  • If the patient is an elective or semi-elective
    intubation pre-oxygenate with 100 O2 for at
    least 5 minutes. This can allow up to 10 minutes
    to intubate without desaturation.
  • If intubating without a pulse oximeter, hold your
    breath while attempting intubation, if you need
    to breath so does the patient bag ventilate.
  • ETCO2 requires cardiac output and therefore may
    not be reliable if intubating during a cardiac
    arrest if none detected, confirm with physical
    exam.

20
Case Presentation
  • Neuromuscular blockade was administered however
    you are not able to intubate the patient.
  • Despite bagging, the patient is desaturating and
    now becoming bradycardic.
  • Now what???

21
Cricothyroidotomy
  • Indications
  • Extensive orofacial trauma preventing
    laryngoscopy
  • Upper airway obstruction
  • Hemorrhage
  • Edema
  • Foreign body
  • Unsuccessful endotracheal intubation
  • WHEN UNABLE TO VENTILATE!!!!!

22
Cricothyroidotomy
  • Contraindications
  • Children under age 12
  • Needle cricothyroidotomy is preferred to prevent
    damage to the cricoid cartilage.

23
Cricothyroidotomy Anatomy
24
Cricothyroidotomy Anatomy
25
Cricothyroidotomy
  • Prep the neck
  • Palpate the cricothyroid membrane below the
    thyroid cartilage in the midline
  • Stabilize the thyroid cartilage frimly with one
    hand and make a transverse incision 2 cm in
    length down to and incising the cricothyroid
    membrane.

26
Cricothyroidotomy
  • Insert either a tracheal spreader or the back end
    of the scalpel handle and gently dialate
  • Insert a tube (tracheostomy, endotrachial, BIC
    pen?)
  • Confirm ventilation
  • Suture tube to secure
  • Obtain hemostasis if necessary

27
Cricothyroidotomy
28
Case Presentation
  • As you are screaming a knife, a knife, my
    kingdom for a knife, your colleague successfully
    intubates with return of end-tidal CO2.
  • The chest is auscultated with good breath sounds
    heard on the right, and no breath sounds on the
    left.
  • Now what?

29
Tube Thoracostomy
  • Indications
  • Hemothorax/Pleural effusion
  • Pneumothorax
  • Note for tension pneumothorax first tx should be
    14 or 16 guage angiocath in 2nd intercostal space
    in midclavicular line.
  • Anatomy
  • 5th intercostal space in the anterior axillary
    line (at the level of the nipple).
  • Measure tube from insertion site to apex of
    lung.

30
Tube Thoracostomy
  • What you need. . .
  • Chest tube
  • Pleurevac
  • Sterile drapes, gloves and gown
  • Instruments scalpel and kelly clamp
  • Heavy silk suture
  • Gauze and silk tape for dressing

31
Tube Thoracostomy
  • Procedure
  • Prep and drape hemithorax
  • Infiltrate skin, subcutaneous tissue and pleura
    with 1 lidocaine
  • 1.5-2 cm incision directly over the 6th rib down
    to the rib
  • With a blunt clamp, dissect over the superior
    edge of the rib.
  • Bluntly pierce the pleura with the clamp and
    spread the track.
  • Be prepared for a rush of blood, fluid and/or
    air.

32
Tube Thoracostomy
  • Procedure (cont)
  • Place finger in track to confirm intrapleural
    positioning and lyse any adhesions.
  • Insert tube via track (with or without clamp)
    towards apex of lung.
  • Attach tube to pleuravac.
  • Secure tube to patient with heavy silk suture and
    tape all conections.

33
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34
Warning!
  • History of chest tubes, thoracotomies or
    inflammatory pulmonary pathology.
  • Assume adhesions between the lung and the chest
    wall.
  • The chest tube insertion can cause a lung
    laceration.
  • Be very careful how low you are, you can easily
    place an abdominal tube if you are not careful.

35
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37
Case Presentation
  • Now that the chest tube is draining the
    hemopneumothorax, the patients pressure drops to
    60/palp
  • Help?
  • The patient has bilateral track marks from his
    history of IVDA.

38
Central Venous Access
  • Indications
  • CVP monitoring
  • TPN
  • Long-term infusion of drugs
  • Inotropic agents
  • Hemodialysis
  • Poor peripheral access

39
Central Venous Access
  • Contraindications
  • Vein thrombosis
  • Coagulopathy or thrombocytopenia
  • Vein sites
  • Femoral
  • Subclavian
  • Internal jugular

40
Central Venous Access
  • What you need
  • Central line kit/tray
  • Sterile gloves and gown
  • Mask and hat
  • Sterile drapes
  • Sterile flush 10 cc syringe per port
  • Lidocaine
  • Betadine
  • Silk suture

41
Central Venous Access
  • General procedure
  • Prep the skin, sterile drape, sterile gown and
    glove
  • Ensure proper position
  • Infiltrate 1 lidocaine for adequate anesthesia
  • Cannulate the vein with a finder needle (if
    applicable) and then the 18 guage primary needle
    while aspirating back on a syringe.
  • Once successful, hold the needle still and
    disconnect the syringe.

42
Central Venous Access
  • General procedure (cont.)
  • Ensure that backbleeding from needle is venous
  • Feed J wire into vein while holding needle still
  • Remove needle, leaving wire in place
  • Make a skin incision over the needle
  • Use the dilator over the wire to dilate the skin
    and subcutaneous tissues
  • Remove the dilator and feed the venous catheter
    over the wire.

43
Central Venous Access
  • General procedure (cont.)
  • Place the catheter to the appropriate length and
    remove the wire.
  • Aspirate and flush all ports to confirm placement
  • Suture the line into place
  • Apply sterile dressing
  • CXR for jugular or subclavian attempts.
  • During the entire procedure NEVER LOSE CONTROL
    OF THE WIRE

44
Central Venous Access - Jugular
  • Position in Trendelenburg
  • Turn the patients head contralaterally
  • Anterior approach
  • Identify the apex of the triangle formed by the
    heads of the sternocleidomastoid muscle.
  • Palpate the carotid and retract medially
  • Insert syringe w/ needle at apex at an angle of
    45 to the skin pointing towards the ipsilateral
    nipple
  • Vein should be within 3 cm in most people

45
Central Venous Access - Jugular
46
Central Venous Access - Jugular
  • Posterior approach
  • Identify the lateral border of the SCM where the
    ext. jugular crosses (about 4-5 cm above the
    clavicle)
  • Insert a needle anteriorly and inferiorly
    pointing to the sternal notch
  • The vein should be encountered within 3 cm in
    most individuals.

47
Central Venous Access - Subclavian
  • Place an index finger at the sternal notch and
    the thumb at the intersection of the clavicle and
    the first rib
  • Insert the needle w/ syringe at the junction of
    the distal 1/3 and proximal 2/3 of the clavicle,
    1 cm inferior to the clavicle.
  • Keeping the needle horizontal, advance towards
    the sternal notch, using the thumb to help the
    needle under the clavicle.
  • Aspirate while advancing straight towards notch.
  • If unsuccessful, consider reattempt 1 cm more
    lateral than initial trial.

48
Central Venous Access - Femoral
  • Palpate the femoral artery
  • Midpoint between ant. sup. iliac spine and pubic
    symphysis
  • Femoral vein is immediately medial to the artery.
  • Insert needle medial and parallel to the pulse at
    45 to the skin.
  • The vein should be encountered within lt 6 cm.

49
Central Venous Access - Complications
  • Arterial puncture remove needle/catheter and
    apply at least 5 minutes of direct pressure
  • Dysrhythmias most often with wire, but if
    persists may require repositioning distal to RA
  • Pneumothorax rates of 1 to 2 for subclavian
    and IJ, rates incease with gt 2 attempts
  • Line sepsis lowest with subclavian, highest
    with femoral, strict sterile technique lowers
    rates.

50
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51
Case Presentation
  • Now with a femoral cordis in place, the patient
    receives 2 liters of LR with an improvement in
    vitals. He has 800 cc of blood drained from his
    left chest.
  • Is he adequately resuscitated? Over? Under?

52
Arterial Blood Gas (ABG)
  • Indications
  • Need to assess acid-base status, oxygenation and
    ventilation
  • Need to assess carboxyhemoglobin
  • Sites
  • Radial artery
  • Femoral artery

53
Arterial Blood Gas (ABG)
  • Palpate the pulse of the desired artery.
  • Have a bag of ice available
  • Prep the skin
  • Using a heparinized syringe and a 20 guage
    needle, aim at the pulse localized between 2
    fingers at a 45 angle to the skin
  • Once blood return is seen, dedicated syringes
    will self fill
  • Once complete, hold 5 minutes of direct pressure
    and confirm hemostasis.

54
Case Presentation
  • As the respiratory therapist is suctioning the
    patients mouth, he starts vomiting rice and
    beans mixed with beer.
  • He does not appear to have aspirated, but his
    stomach is not empty yet. . .

55
Nasogastric Tube
  • Indications
  • Acute gastric dilatation
  • Gastric outlet obstruction
  • Ileus
  • Small bowel obstruction
  • Upper GI hemorrhage
  • Enteral feeding
  • Contraindications
  • Basilar skull fracture
  • Absence of gag reflex
  • Recent esophageal or gastric surgery (relative)

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57
Nasogastric Tube
  • Measure tube from nose to earlobe to anterior
    abdomen so that proximal hole is distal to
    xiphoid.
  • Lubricate the tube
  • Have the patient flex their neck

58
Nasogastric Tube
  • Slowly insert the tube straight posteriorly from
    the nares.
  • Advance the tube into the pharynx aiming
    posteriorly, asking the patient to swallow if
    possible.
  • Once the tube has been inserted to desired
    length, inject air into the tube and auscultate
    over the stomach for placement.

59
Nasogastric Tube
  • Secure the tube with tape to the nose. Be sure
    not to secure it to the forehead/upward as this
    can cause alar necrosis.
  • If the tube is to be used for feeding, placement
    should be confirmed by xray.

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61
Conclusions
  • Knowledge about simple surgical procedures can be
    lifesaving however pure knowledge is not a
    substitute for repeated practice.
  • Take every opportunity to practice these
    procedures with senior and/or attending
    supervision under controlled circumstances.

62
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