Transcript ppt - Open.Michigan

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:
Procedures
Joe Lex, MD, FACEP, FAAEM, MAAEM
Associate Professor, Emergency Medicine
Temple University School of Medicine
Philadelphia, PA USA
3
Commercial Disclaimers
4
General Rules before Doing a
Procedures
• Explain risks and benefits, including
what will happen if you don’t do it
• Obtain written informed consent
(when possible)
• Use appropriate monitoring
equipment
• Position patient properly
5
General Rules before Doing a
Procedures
• Clean / prep / drape appropriate body
part
• Use aseptic / sterile technique
• Provide post-procedure instructions
6
For this talk…
•
•
•
•
•
Not the everyday procedures
No RSI
No procedural sedation
No laceration repair
Things you MIGHT want to look at a
reference before doing
7
For this talk…
Indications / Contraindications
Procedure Description
Procedure Pictorial (if available)
Complications
8
Indication
Nasotracheal Intubation
• Spontaneously breathing patient
requiring airway management
• Alternative to RSI when oral airway
may be obstructed
1
Contraindication
Nasotracheal Intubation
•
•
•
•
Apnea
Severe midface injuries
Basilar skull fracture
Closed head injury with  intracranial
pressure
• Nasopharyngeal obstruction
• Coagulopathy (relative)
19
Procedure
Nasotracheal Intubation
• Preoxygenate
• Apply vasoconstrictor / topical
anesthetic
• Insert tube with bevel facing septum
• Slowly advance – listen for breath
sounds OR use whistle
• Advance tube through vocal cords
20
Procedure
Nasotracheal
Intubation
See: “Procedure
Nasotracheal Intubation” in Knoop KJ,
Stack LB, Storrow AB, Thurman RJ: The
Atlas of Emergency Medicine, 3rd Edition,
http://accessmedicine.com.
Thomas H. Burford, Wikimedia Commons
21
Complications
Nasotracheal Intubation
•
•
•
•
•
Epistaxis
Mucosa / turbinate avulsion
Laryngeal / tracheal trauma
Intracranial / esophageal placement
Hypoxia
26
Indication / Contraindication
Retrograde Intubation
Indication
• Patient requires airway
• Less invasive means have failed
Contraindication
• Ability to intubate / ventilate by less
invasive means
• Trismus; inability to open mouth
27
Procedure
Retrograde Intubation
• Stabilize patient’s larynx, identify
cricothyroid membrane
• Connect 16- to 18-gauge catheterover-needle to 10 ml syringe
contained 3 mL sterile saline
• Puncture cricothyroid membrane at
20–30o angle to skin, pointed at head
• Aspirate – should see air bubbles
28
Procedure
Retrograde Intubation
Source: Reichman EF, Simon RR: Emergency Medicine Procedures
29
Procedure
Retrograde Intubation
• Advance catheter-over-needle until
hub is against skin
• Remove syringe and needle
• Feed guidewire through catheter until
it comes out patient’s mouth
• Advance guidewire until only ~5cm
protruding from neck
• Stabilize wire at neck with hemostat
30
Procedure
Retrograde Intubation
Source: Reichman EF, Simon RR: Emergency Medicine Procedures
31
Procedure
Retrograde Intubation
• If available, advance introducer
sheath until meets obstruction
• Remove wire
• Advance endotracheal tube over
introducer into trachea
• Confirm placement
• Secure tube
Recommended Reference: Reichman EF, Simon RR: Emergency Medicine Procedures
32
Complications
Retrograde Intubation
• Damage to tracheal cartilage
• Inability to intubate
• Hypoxia
34
Indication / Contraindication
Cricothyrotomy
Indications
• Unable to ventilate or intubate
Contraindications
• Child <8-10 years
• Significant trauma to tracheal / cricoid
cartilages
• Ability to intubate / ventilate
35
Procedure
Cricothyrotomy
• Stabilize larynx, identify cricothyroid
membrane
• Make midline vertical incision
• Make horizontal stab incision through
cricothyroid membrane
• Insert tracheal skin hook to elevate
inferior border of tracheal cartilage
36
Procedure
Cricothyrotomy
• Insert Trousseau dilator, remove skin
hook, open membrane
• Insert tube: endotracheal (6.0 mm) or
tracheostomy tube (4.0 Shiley)
Recommended Reference: Reichman EF, Simon RR: Emergency Medicine Procedures
37
Complications
Cricothyrotomy
•
•
•
•
•
•
•
Esophageal perforation
Subcutaneous emphysema
Subcutaneous tube placement
Bleeding
Unable to intubate
Subglottic stenosis
Cartilage damage: thyroid, cricoid
42
Indication / Contraindication
Tube Thoracostomy
Indications
• Pneumothorax (24F – 28F tube)
• Hemothorax (32F – 40F tube)
Contraindications
• Coagulopathy (relative)
43
Procedure
Tube Thoracostomy
• Identify 4th-5th intercostal space,
anterior axillary line
• Abduct ipsilateral arm
• Make incision parallel to ribs
• Bluntly dissect upwards with Kelly
• Enter pleura above rib with clamp 
avoids neurovascular bundle
44
Procedure
Tube Thoracostomy
• Digitally explore tract
• Insert chest tube, aiming toward apex
for pneumothorax, base for
hemothorax
• Connect tube to pleural drainage
system
• Secure tube
• Obtain confirmatory x-ray
Recommended Reference: Reichman EF, Simon RR: Emergency Medicine Procedures
45
Complications
Tube Thoracostomy
Complications
• Bleeding, hemothorax
• Visceral organ perforation / vascular
structure injury
• Subcutaneous tube placement
• Pneumonia
• Empyema
50
Indication / Contraindication
Needle Thoracostomy
Indications
• Tension pneumothorax
Contraindications
• None
51
Procedure
Needle Thoracostomy
• Connect a 14- to 16-gauge catheterover-the-needle to a 5- to 10-mL
syringe without the plunger
• Insert needle into 2nd intercostal
space, midclavicular line
• Advance needle to rush of air, then
advance until hub against skin
• Place chest tube
Recommended Reference: Reichman EF, Simon RR: Emergency Medicine Procedures
52
Complications
Needle Thoracostomy
•
•
•
•
Lung injury
Local hematoma
Intercostal nerve / vessel injury
Failure to decompress tension
pneumothorax
54
Indications
Resuscitative Thoracotomy
• Penetrating chest trauma patients
who are hemodynamically unstable
and those who demonstrated
palpable pulse, blood pressure, pupil
reactivity, any purposeful movement,
organized cardiac rhythm, or any
respiratory effort either in the field or
ED, but subsequently deteriorated
55
Contraindications
Resuscitative Thoracotomy
• Penetrating chest trauma victim with
no vital signs in field
• Blunt trauma victim with or without
field vitals
56
Procedure
Resuscitative Thoracotomy
• Make incision through skin,
subcutaneous tissue, superficial
muscles
• Incise intercostal muscles with Mayo
scissors
• Insert rib spreader with handles down
and open
• Grasp and open pericardium
Recommended Reference: Reichman EF, Simon RR: Emergency Medicine Procedures
57
Complications
Resuscitative Thoracotomy
• Injury of personnel
• Laceration of internal mammary or
intercostal arteries
• Laceration of lung or myocardium
• Transection left phrenic nerve
• Laceration of myocardium or coronary
artery
• Delayed cardiac compressions
65
Indication / Contraindication
Paracentesis
Indications
• Diagnostic: new ascites, suspected
spontaneous bacterial peritonitis
• Therapeutic: tense, large-volume
Contraindications
• Overlying cellulitis
• Pregnancy, organomegaly (relative)
66
Procedure
Paracentesis
Potential sites:
• Midline: 2 cm inferior to umbilicus
• RLQ / LLQ: 2–4cm medial & cephalad
to anterior superior iliac spine
67
Procedure
Paracentesis
•
•
•
•
•
•
Use ultrasound to be certain
Apply skin traction: “Z-track”
Advance needle / catheter
Aspirate fluid
Remove needle / catheter
Send fluid for analysis
– SBP: PMN >250 WBC/mm3
Recommended Reference: Reichman EF, Simon RR: Emergency Medicine Procedures
68
Complication
Paracentesis
• Hypotension after large volume
removal
• Localized infection
• Abdominal wall hematoma
• Persistent fluid leak
• Injury to abdominal organ
70
Indication / Contraindication
Thoracentesis
Indication
• Pleural fluid requiring fluid analysis or
therapeutic drainage
Contraindication
• Overlying cellulitis
• Positive pressure ventilation (caution)
• Coagulopathy (relative)
71
Diagnostic
Thoracentesis
• Use 18-g needle on 50mL syringe
containing 1mL heparin (100U/ml)
• Insert needle 5–10 cm lateral to spine
1 or 2 intercostal spaces below upper
level of pleural effusion
• Go over top of rib
• Stop when you get enough
• Post-procedure chest x-ray
72
Therapeutic
Thoracentesis
• Make skin incision at insertion site
• Use 14- to 18-gauge catheter-overneedle attached to 10 mL syringe
• Insert needle 5–10 cm lateral to spine
1 or 2 intercostal spaces below upper
level of pleural effusion
• When fluid reached, angle needle
caudally until hub against skin
73
Therapeutic
Thoracentesis
• Withdraw needle, leaving catheter
• Cover catheter with gloved finger
(prevent air entry)
• Attach hub to 3-way stopcock
attached to 50 mL syringe
• Aspirate and move fluid
• Terminate procedure when symptoms
relieved or after 1000 mL
Recommended Reference: Reichman EF, Simon RR: Emergency Medicine Procedures
74
Complications
Thoracentesis
•
•
•
•
Pneumothorax
Hemothorax
Intercostal vessel / nerve injury
Post-expansion pulmonary edema
79
Indications
Lumbar Puncture
Indications
• Suspected meningitis
• Suspected subarachnoid hemorrhage
(after negative head CT scan)
• Spinal fluid required for analysis
• Delivery of anesthetics, antibiotics,
chemotherapy
80
Contraindications
Lumbar Puncture
Contraindications
• Coagulopathy
• Cerebral herniation or increased
intracranial pressure
• Overlying cellulitis
81
Procedure
Lumbar Puncture
• Position patient: lateral recumbent
with hips & knees flexed
• Identify landmarks: L3-L4-L5 spinous
processes, iliac crests
• Insert 20-gauge or smaller needle into
interspinous space
• Align bevel parallel to dural fibers
(facing “upward”)
82
Procedure
Lumbar Puncture
• Advance needle to “pop”
• If you encounter bone, partially
withdraw and redirect
• Remove stylet  free flow CSF
• Obtain opening pressure
• Collect 1 – 2mL in each tube
• Reinsert stylet and remove needle
83
Procedure
Lumbar Puncture
Brainhell, Wikimedia Commons
84
Procedure
Lumbar Puncture
BruceBlaus, Wikimedia Commons
85
Procedure
Lumbar Puncture
Source: Waxman SG: Clinical Neuroanatomy, 26th Edition: http://www.accessmedicine.com
86
Procedure
Lumbar Puncture
BruceBlaus, Wikimedia Commons
87
Complications
Lumbar Puncture
• Post-dural headache: ~1/3
– Post-tap position does not matter
• Localized pain
• Cerebral herniation
• Subarachnoid epidermoid cyst
88
Indication / Contraindication
Intraosseous Infusion
Indication
• Urgent vascular access when
traditional methods have failed
Contraindication
• Diseased / osteoporotic bone
• Overlying cellulitis / deep burn
(relative)
89
Procedure
Intraosseous Infusion
• Identify landmarks: distal femur,
proximal tibia, proximal humerus,
sternum
• Stabilize extremity
• Insert needle perpendicular to long
axis of bone
• In kids: direct needle away from
growth plate
Recommended Source: Tintinalli JE, et al., Tintinall’s Eergency Medicine: A Comprehensive Study Guide, 7th Edition:
http://www.accessmedicine.com
90
Procedure
Intraosseous Infusion
Source Undetermined
91
Complications
Intraosseous Infusion
• Subcutaneous / subperiosteal fluid
extravasation
• Compartment syndrome
• Localized infection
• Osteomyelitis
• Growth plate injury
97
Indication / Contraindication
Diagnostic Peritoneal Lavage
Indication
• Patient with abdominal trauma
without indication for emergent
exploratory laporotomy
Contraindication
• Patient with abdominal trauma and
with indication for emergent
exploratory laporotomy
98
Procedure
Diagnostic Peritoneal Lavage
• Introduce needle midline through
abdominal wall 1 to 2cm below
umbilicus at 45o angle to skin
• Apply negative pressure as you
advance needle toward pelvis
• Feel for three distinct ‘pops’ – skin,
fascia, peritoneum
• Advance 2 – 3 mm after 3rd ‘pop’
99
Procedure
Diagnostic Peritoneal Lavage
• If you find blood  end of procedure
• Insert guidewire through needle, then
remove needle
• Make small skin incision adjacent to
guidewire
• Place lavage catheter over guidewire
and advance into peritoneal cavity
100
Procedure
Diagnostic Peritoneal Lavage
• Infuse 1L crystalloid solution, then
place empty bag on floor
• Collect minimum 200 mL fluid, but as
much as possible
• Remove catheter when finished
• Send fluid for cell count
– Threshold 100,000 RBCs/mm3
Recommended Source: Tintinalli JE, et al., Tintinall’s Eergency Medicine: A Comprehensive Study
Guide, 7th Edition: http://www.accessmedicine.com
101
Complications
Diagnostic Peritoneal Lavage
• Localized infection
• Bleeding / hematoma formation
• Damage to intra-abdominal organs
106
Indication / Contraindication
Lateral Canthotomy
Indication
• Acute orbital compartment syndrome
Contraindication
• None
107
Procedure
Lateral Canthotomy
• Inject lateral canthal fold: lidocaine
with epinephrine
• Insert straight hemostat in lateral
canthal fold, clamp for 1 minute to
devascularize
• Incise lateral canthus
• Identify and transect lateral canthal
tendon
108
Procedure
Lateral Canthotomy
Source Undetermined
109
Complications
Lateral Canthotomy
•
•
•
•
•
•
Bleeding
Globe perforation
Localized infection
Lacrimal gland injury
Lateral rectus muscle injury
Scleral laceration
110
Indication / Contraindication
Pericardiocentesis
Indication
• Pericardial tamponade
• Analysis pericardial effusion
Contraindication
• Coagulopathy (relative)
111
Procedure
Pericardiocentesis
• Insert 18-gauge spinal needle
between xiphoid process and left
costal margin at 30 – 45o angle
• Aim tip toward patient’s left shoulder
• Aspirate fluid
• Use ULTRASOUND when possible
Recommended Source: Tintinalli JE, et al., Tintinall’s Eergency Medicine: A Comprehensive Study
Guide, 7th Edition: http://www.accessmedicine.com
112
Procedure
Pericardiocentesis
Source Undetermined
114
Procedure
Pericardiocentesis
Source Undetermined
115
Complications
Pericardiocentesis
•
•
•
•
•
Pneumothorax
Bleeding complication
Damage to coronary artery
Damage to intraabdominal organ(s)
Death
116
Indication / Contraindication
Venous Cutdown
Indication
• Immediate need for vascular access,
no peripheral or central available
Contraindication
• Proximal extremity vascular injury /
long bone fracture
• Overlying skin infection, coagulopathy
(relative
117
Procedure
Venous Cutdown
• Location of greater saphenous vein
(GSV): 2.5 cm anterior and 2.5 cm
superior to medial malleolus
• Make transverse skin incision from
anterior tibial border to posterior tibial
border
• Isolate GSV
118
Procedure
Venous Cutdown
• Insert curved hemostat tip down,
scrape along periosteum starting on
posterior border until the tip reaches
the anterior border
• Rotate hemostat 180o so tip faces
upward
• Open the jaws of the hemostat – the
GSV should be visible
119
Procedure
Venous Cutdown
• Switch to straight hemostat, remove
curved hemostat
• Insert 16- to 18-gauge IV catheterover-needle into vein
Recommended Source: Tintinalli JE, et al., Tintinall’s Eergency Medicine: A Comprehensive Study
Guide, 7th Edition: http://www.accessmedicine.com
120
Procedure
Venous Cutdown: Groin
• Identify where scrotal / labial fold
meets the thigh  ~2cm below site
for femoral central venous line
• Make transverse incision medial to
lateral beginning at fold
• Dissect subcutaneous tissue with
curved hemostat
• Identify and isolate GSV
123
Procedure
Venous Cutdown: Groin
• Identify and isolate GSV
• Cannulate either directly or using
Seldinger technique
124
Complications
Venous Cutdown
•
•
•
•
•
•
Infection
Vascular injury
Nerve injury
Phlebitis
Tromboembolism
Wound dehiscence
125
Indication / Contraindication
Anterior / Posterior Nasal Pack
Indications
• Epistaxis
Contraindications
• None
Recommended Source: Tintinalli JE, et al., Tintinall’s Eergency Medicine: A Comprehensive Study
126
Guide, 7th Edition: http://www.accessmedicine.com
Procedure
Posterior Nasal Pack
• Prepare the pack: use 3 inch dental
rolls, tonsil packs, or 4x4 gauze
• Form a tight cylindrical roll with gauze
• Tie two pieces of umbilical tape or 0silk suture around pack to divide it
into thirds (see picture)
131
Procedure
Posterior Nasal Pack
Source: Reichman EF, Simon RR: Emergency Medicine Procedures
132
Procedure
Posterior Nasal Pack
• Insert red rubber catheters through
nostril and pull out through mouth
• Attach pack to red rubber catheters
• Pull pack into place
– Use finger to pass pack around soft
palate and uvula
• Place anterior nasal pack
• Secure ties of posterior pack
Recommended Source: Reichman EF, Simon RR: Emergency Medicine Procedures
133
Procedure
Posterior Nasal Balloon
• Gather nasal speculum, light source,
suction, anethetizing and packing
materials
• Place patient in “sniffing position,”
give emesis basin and some tissues
• Anesthetize nasal mucosa using
cotton pledgets soaked in LET (or
cocaine)
142
Procedure
Posterior Nasal Balloon
• Lubricate Foley catheter or posterior
balloon with antibiotic ointment
• Insert transnasally until visible in
posterior oropharynx
• Inflate balloon with 7 ml of water,
gently retract catheter ~2 to 3 cm until
lodged in posterior nasopharynx
143
Procedure
Posterior Nasal Balloon
• Inflate balloon with additional 5 to 7
ml of saline
• Secure pack by taping to patient's
cheek
144
Procedure
Posterior Nasal Balloon
Source: Reichman EF, Simon RR: Emergency Medicine Procedures
145
Complications
Posterior Nasal Pack
•
•
•
•
•
•
Nasal septal perforation
Sinusitis / otitis media
Toxic shock syndrome
Aspiration
Alar necrosis
Hypoxia from intrapulmonary shunting
due to stimulation of nasopulmonary
reflex
147
Indication / Contraindication
Peritonsillar Abscess I&D
Indication
• Peritonsillar abscess
Contraindication
• Coagulopathy (relative)
148
Procedure
Peritonsillar Abscess Aspiration
• Identify area of maximum fluctuance
• Cut needle cap so that needle
projects only 1cm beyond distal cap
• Depress / distract tongue
• Insert needle, staying parallel to
mouth floor
• Advance and aspirate
149
Procedure
Peritonsillar Abscess Aspiration
Source: Reichman EF, Simon RR: Emergency Medicine Procedures
150
Complications
Peritonsillar Abscess I&D
•
•
•
•
Aspiration
Airway compromise
Bleeding
Vascular injury
153
Indication: Thrombosed
External Hemorrhoid Excision
Indication
• Painful thrombosed external
hemorrhoid
154
Contraindication: Thrombosed
External Hemorrhoid Excision
Contraindication
• Grade IV internal hemorrhoids with
thrombosed external hemorrhoids
• Very large hemorrhoids
• Inflammatory bowel disease anorectal
fissure, perianal infection, portal
hypertension, rectal prolapse,
anorectal tumor, immunocompromise
155
Procedure: Thrombosed
External Hemorrhoid Excision
• Identify area to be incised
• Use two radial incisions starting near
center of anus
• Dissect skin and thrombosis with
scissors
• DO NOT cut anal sphincter
• Control bleeding: AgNO3
156
Indication / Contraindication
Nail Bed Repair
Indication
• Nail bed injury
Contraindication
• None
160
Procedure
Nail Bed Repair
• After digital / regional block: insert
closed tip of fine scissors between
nail plate and nail bed
• Advance tip while opening / closing
blades to separate plate from bed
• Stop scissors when blade tips at
eponychium
161
Procedure
Nail Bed Repair
• Grasp nail plate with hemostat, pull
along long axis of finger
• Repair nailbed laceration with
absorbable suture
• Replace nail plate onto nail bed.
Suture in place for ~7 days
• If nail missing  petrolatum gauze
Recommended Source: Reichman EF, Simon RR: Emergency Medicine Procedures
162
Complications
Nail Bed Repair
• Complete nail loss (expected)
• Localized infection
• Nail growth abnormalities
165
Indication / Contraindication
Arthrocentesis
Indication
• Diagnosis: obtain synovial fluid
• Therapy: inject steroid, anesthetic
Contraindication
• Overlying infection, coagulopathy,
prosthetic joint, septic / bacteremic
patient (all relative)
166
Procedure
Arthrocentesis
• Palpate bony anatomy, identify
anatomic landmarks
• Insert needle into joint space
• If strike bone, withdraw slightly and
redirect
• Aspirate synovial fluid
167
Procedure
Arthrocentesis – Knee
Source Undetermined
168
Complications
Arthrocentesis
• Localized infection
• Bleeding / hematoma
171
Indication / Contraindication
Felon Incision & Drainage
Indication
• Fluctuant felon
Contraindications
• Herpes whitlow
• Non-fluctuant felon
172
Procedure
Felon Incision & Drainage
• If central pulp: central longitudinal
finger pad incision with #11 scalpel
• Radial / ulnar fluctuance: medial /
lateral pad incision
• Do not cross DIP
• Break up loculations
• Irrigate, pack with drain / dressing
173
Procedure
Felon Incision & Drainage
Source Undetermined
174
Complications
Felon Incision & Drainage
•
•
•
•
•
•
Skin necrosis
Osteomyelitis
Extension of local infection
Flexor tenosynovitis
Neurovascular injury
Finger pad damage
176
Indication
Escharotomy
Indication
• Circumferential full / partial thickness
extremity burns & impaired perfusion
• Chest wall burns impairing chest wall
movement / ventilation
• Neck burns / impending tracheal
obstruction
177
Contraindication
Escharotomy
Contraindication (all relative)
• Overlying skin infection
• Coagulopathy
• Prosthetic joint
• Sepsis / bacteremia
178
Procedure
Escharotomy
• Sedate patient / use local anesthesia
• Use scalpel / cautery  make
incision along medial and lateral
aspect of involved extremity
• Make incision from 1cm proximal to
burn  1 cm distal to burn
• Extend only through full thickness of
skin
179
Procedure
Escharotomy
• Chest: incise along anterior axillary
line from clavicle to costal margin
bilateral – may join with another
• Neck: incise posterior and lateral to
vascular structures
180
Procedure
Escharotomy
Source: Tintinalli JE, et al., Tintinall’s Eergency Medicine: A Comprehensive Study Guide, 7th Edition:
http://www.accessmedicine.com
181
Procedure
Escharotomy
Source: Tintinalli JE, et al., Tintinall’s Eergency Medicine: A Comprehensive Study Guide, 7th Edition:
http://www.accessmedicine.com
182
Complications
Escharotomy
•
•
•
•
Bleeding
Localized infection
Neurovascular damage
Inadequate decompression
– Muscle damage, nerve injury
– Renal failure  hyperkalemia
– Metabolic acidosis
183
Indication
Urethrogram & Cystogram
Indication
• Suspected traumatic injury to lower
urinary tract
– Blood at urethral meatus
– High-riding prostate
– Gross hematuria
– Perianal / scrotal hematoma
184
Contraindication
Urethrogram & Cystogram
Contraindication
• Hemodynamic instability
• Acute urethritis in patient with low risk
• Cystogram contraindicated if urethral
injury identified on urethrogram
185
Procedure: Retrograde
Urethrogram & Cystogram
• Use Cystographin, Renographin-60,
or Hypaque® 50%
• Retract and secure penile foreskin
• Prime catheter tubing with contrast
prior to inserting
• Insert catheter until retention balloon
is within glans (fossa navicularis)
186
Procedure: Retrograde
Urethrogram & Cystogram
• Straighten penis across thigh to
prevent urethral folding
• Inject 50-60mL over 5–10 seconds
• Can also use 60mL Toomey irrigating
syringe
• Get KUB during injection final 10mL
• Extravasation outside urethral contour
 disruption
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Procedure: Retrograde
Urethrogram & Cystogram
• Contrast in bladder with extravasation
 partial disruption
• No extravasation  proceed with
retrograde cystogram
Recommended Source: Reichman EF, Simon RR: Emergency Medicine Procedures
188
Procedure: Retrograde
Urethrogram & Cystogram
• No extravasation  proceed with
retrograde cystogram
• Advance catheter into bladder
• Inflate balloon and gently pull back to
lodge balloon at bladder neck
• Remove plunger from 60mL syringe
190
Procedure: Retrograde
Urethrogram & Cystogram
• Fill bladder by gravity with 300 350mL of contrast
• Clamp catheter with hemostat
• Obtain KUB  look for filling,
extravasation
• Release clamp and drain contrast by
gravity
191
Procedure: Retrograde
Urethrogram & Cystogram
• Obtain ‘washout’ KUB
–Extraperitoneal bladder injury 
flame-like projection within pelvis 
possible conservative management
–Intraperitoneal bladder injury 
contrast outlines intraperitoneal
organs  surgical management
Recommended Source: Reichman EF, Simon RR: Emergency Medicine Procedures
192
Complications: Retrograde
Urethrogram & Cystogram
• Relatively benign procedure –
complications rare
194
Indications
Perimortem C-Section
• To optimize maternal
cardiopulmonary resuscitation
• Rescue of a viable fetus >24 weeks
gestation is an important
consideration, but such rescue is
always secondary to the safety and
life of the mother
195
Contraindications
Perimortem C-Section
• Mother with serious brain injury but
otherwise hemodynamically stable,
fetus shows no signs of distress.
• Inability to adequately resuscitate
infant after delivery
• Extreme fetal prematurity/immaturity
196
Procedure
Perimortem C-Section
• Make a vertical midline skin incision
with a #10 scalpel blade beginning 2
to 3 cm above pubic symphysis and
extending to 1 cm below umbilicus
• Ignore any subcutaneous bleeding
unless it is arterial
– Clamp \ bleeding artery or use electrocautery unit to coagulate if available
Recommended Source: Reichman EF, Simon RR: Emergency Medicine Procedures
197
Procedure
Perimortem C-Section
• Extend incision through
subcutaneous fat to rectus sheath.
• Grasp and elevate rectus sheath
using a toothed forceps
• Make an incision in the rectus sheath
with a Mayo scissors. Extend the
rectus sheath incision superiorly and
inferiorly with a Mayo scissors
199
Procedure
Perimortem C-Section
• Expose the uterus – the underlying
peritoneum should be visible
• Insert retractors to fully expose the
peritoneal membrane
• Grasp and elevate the peritoneal
membrane with a toothed forceps
• Incise the peritoneal membrane with
a Mayo or Metzenbaum scissors
201
Procedure
Perimortem C-Section
• Make reasonable attempts to protect
the bowel and bladder from injury
• Elevate the bowel off the field and
cover it with a saline soaked towel
• Place a bladder retractor over the
pubic symphysis to retract the rectus
sheath and bladder
202
Procedure
Perimortem C-Section
• Identify the position of the fetal head
by palpating the uterus
• Make a 2 to 4 cm midline vertical
incision in the uterus
– The amniotic sac will bulge through the
incision if the membranes are intact
• Place a finger into the uterine incision
and aimed vertically
204
Procedure
Perimortem C-Section
• Insert one blade of a bandage
scissors between the finger and the
uterine wall
– The other blade of the scissors should
be outside the uterus
• Extend the vertical uterine incision
fundally, superior and away from the
bladder
205
Procedure
Perimortem C-Section
• Rupture the amniotic membranes with
a clamp or other blunt instrument
• Carefully transect the placenta if it is
anterior to the fetus
• Insert a hand between the pubic
symphysis and the fetal occiput
208
Procedure
Perimortem C-Section
• Advance the hand to the base of the
occiput
• Flex the fetal head and apply gentle
anteriorly and superiorly directed
traction to elevate and deliver the
head
210
Procedure
Perimortem C-Section
• Deliver the entire fetal head
212
Procedure
Perimortem C-Section
• Suction the mouth and nose with a
bulb syringe
214
Procedure
Perimortem C-Section
• Deliver the shoulders in a manner
similar to that of a vaginal delivery
• Apply gentle upward traction on the
head while an assistant applies
pressure on the uterine fundus
– First deliver the anterior shoulder
– Deliver the other shoulder followed by
the torso and lower extremities
216
Procedure
Perimortem C-Section
• Clamp umbilical cord with hemostat
or umbilical cord clamp approximately
10 to 15 cm from fetus
• Attach second hemostat or clamp 2 to
3 cm distal to the first
• Cut umbilical cord between the
clamps with a Mayo scissors
• Resuscitate the neonate
218
Complications
Perimortem C-Section
•
•
•
•
•
Maternal sepsis
Maternal visceral injury
Maternal hemorrhage
Fetal injury secondary to delivery
Possible benefits of maternal and / or
fetal survival should far outweigh
these considerations
219
Resources
• Tintinalli’s Emergency Medicine: A
Comprehensive Study Guide, 7e
Judith E. Tintinalli, J. Stephan
Stapczynski, O. John Ma, David M.
Cline, Rita K. Cydulka, and Garth D.
Meckler
• Emergency Medicine Procedures
Eric R. Reichman, Robert R. Simon
220
Resources
• Atlas of Emergency Medicine, 3e
Kevin J. Knoop, Lawrence B. Stack,
Alan B. Storrow, R. Jason Thurman
221
Summary
• Explain risks and benefits, including
what will happen if you don’t do it
• Obtain written informed consent
(when possible)
• Use appropriate monitoring
equipment
• Position patient properly
222
Summary
• Clean / prep / drape appropriate body
part
• Use aseptic / sterile technique
• Provide post-procedure instructions
• Many of these procedures available
on YouTube
223