Transcript Trauma Procedures

Surgical Procedures
Devashish J. Anjaria
Surgical Fundamentals
July 16, 2010
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.
• What’s the plan????
ABC’s
Airway
• Secure airway = cuffed tube in the trachea
– Endotracheal
• Orotracheal
• Nasotracheal
– Surgical airway
• Cricothyroidotomy
• Tracheostomy
Indications
• Inability to oxygenate
– PaO2/FiO2 < 200
• Inability to ventilate
– Respiratory rate > 30 or < 5
– PCO2 > 60
• Inability to protect airway
– GCS ≤ 8
Initial Maneuvers
• Chin lift
– Contraindicated in
cervical spine injuries or
cervical fusion
• Jaw thrust
Initial Maneuvers
•Bag valve mask
•Nasal and/or oral airways
•The goal is to ventilate
and pre-oxygenate
What you need. . .
MAC or Miller
Blades
Laryngoscope
Capnograph
What you need. . .
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Working suction
10 cc syringe (to inflate the balloon)
Medications – to premedicate, if applicable
Tape or twill
Stylet
Pulse ox monitoring
And of course. . . The endotracheal
tube
Nasotracheal Intubation
• Prerequisites
– Awake spontaneously breathing patient
• Contraindications
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Facial fractures
Basilar skull fracture
Apnea
Coagulopathy
Pregnancy
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.
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.
Orotracheal Intubation - Technique
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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
Orotracheal Intubation - Technique
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
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
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.
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???
Cricothyroidotomy
• Indications
– Extensive orofacial trauma preventing
laryngoscopy
– Upper airway obstruction
• Hemorrhage
• Edema
• Foreign body
– Unsuccessful endotracheal intubation
• WHEN UNABLE TO VENTILATE!!!!!
Cricothyroidotomy
• Contraindications
– Children under age 12
• Needle cricothyroidotomy is preferred to prevent
damage to the cricoid cartilage.
Cricothyroidotomy – Anatomy
Cricothyroidotomy – Anatomy
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.
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
Cricothyroidotomy
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?
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.
Tube Thoracostomy
• What you need. . .
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Chest tube
Pleurevac
Sterile drapes, gloves and gown
Instruments – scalpel and kelly clamp
Heavy silk suture
Gauze and silk tape for dressing
Tube Thoracostomy
•Procedure:
− Prep and drape hemithorax
− Infiltrate skin, subcutaneous
tissue and pleura with 1%
lidocaine
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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.
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.
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.
Case Presentation
• Now that the chest tube is draining the
hemopneumothorax, the patient’s pressure
drops to 60/palp
• Help?
• The patient has bilateral track marks from his
history of IVDA.
Central Venous Access
• Indications
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CVP monitoring
TPN
Long-term infusion of drugs
Inotropic agents
Hemodialysis
Poor peripheral access
Central Venous Access
• Vein sites
– Femoral
– Subclavian
– Internal jugular
• Contraindications
– Vein thrombosis
– Coagulopathy or
thrombocytopenia
Central Venous Access
• What you need
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Central line kit/tray
Sterile gloves and gown
Mask and hat
Sterile drapes
Sterile flush – 10 cc
syringe per port
– Lidocaine
– Betadine
– Silk suture
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.
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.
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
Central Venous Access - Jugular
• Position in Trendelenburg
• Turn the patient’s 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
Central Venous Access - Jugular
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.
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.
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 < 6 cm.
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 > 2 attempts
• Line sepsis – lowest with subclavian, highest with
femoral, strict sterile technique lowers rates.
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?
Arterial Blood Gas (ABG)
• Indications
– Need to assess acid-base
status, oxygenation and
ventilation
– Need to assess
carboxyhemoglobin
• Sites
– Radial artery
– Femoral artery
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.
Case Presentation
• As the respiratory therapist is suctioning the
patient’s mouth, he starts vomiting rice and
beans mixed with beer.
• He does not appear to have aspirated, but his
stomach is not empty yet. . .
Nasogastric Tube
• Indications
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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)
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
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.
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.
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.