Wider catheters are also advised for patients passing bloody urine, clots, sediment, or par ticularly thick urine. However, in general, the smallest catheter possible should be used a s wide catheters are more likely to cause urethral damage Catheters come in 2 lengths, designed for the male and female urethra. The longer male catheters can be used in female catheterisation should shorter cat heters be unavailable. Prepuce Mons pubis Clitoris Labia majora Urethral orifice Opening of Skene \200\231s gland Labia minora Vagina Opening of Bartholin \200\231s gland Anus Perineum Fig. 16.20 Anatomy of the female genitalia for catheterisation. _OHFP.indb 547 _OHFP.indb 547 30/05/2014 16:18 30/05/2014 16:18 548 CHAPTER 16 Procedures p p Replacing a suprapubic catheter g Consent verbal p Level F1 Diffi culty 1/5 Indications long-term catheter due for change (every 8 \200\22310wk) or problem with cathet er (blocked, leaking, UTI). Contraindications absolute competent patient refusal; relative suprapubic stoma only recently created (<3d), abnormal clotting. y Site suprapubic catheter site, usually midline about 10cm below umbilicus. Equipment sterile dressing pack, sterile gloves, new long-term catheter (usually 16F) and a ppropriate syringe with water for infl ating balloon, sterile lubricating anesthetic gel, c leaning solution, new drainage bag, 20ml syringe, disposable gloves and waste bag. Patient position lying supine, exposing suprapubic catheter site. Procedure wearing gloves empty current catheter bag. Defl ate existing balloon with 20ml sy ringe, emptying syringe if there is more than 20ml in the balloon. Gently, but fi rmly, rem ove the old catheter and put in a waste bag. Clean hands, put on sterile gloves, prepare st erile trolley with dressing pack, and remove perforated end of new catheter. Place sterile drape over insertion site, making a hole in the drape if necessary fi rst. Clean insertion site, then apply some anesthetic gel over the site and a small amount into the site; wait f or 2min for anesthetic to work. Take the catheter in its plastic cover and pass the tip int o catheter site, avoiding touching the rubber directly. Gently feed catheter in all the way . Connect to new drainage bag. Wait for urine to fl ow out of the catheter before infl atin g the balloon; volume of water to infl ate balloon is stipu- lated on catheter and its pack aging. Withdraw catheter to ensure balloon is working and catheter cannot fall out. Documen t in patient \200\231s records the date and the sizes and types of catheter taken out and t hen put in. Con \201 rmation urine fl owing freely. Complications bleeding at catheter site or blood-s tained urine after new catheter sited (common and if minor not a concern), patient discomfo rt, catheter site closes up after removal of old catheter (uncommon with mature catheter si tes, but can occur with freshly formed stomas (<3d). Safety only undertake catheter changes on mature, established stomas as newly created ones (<3d) may close immediately after remo ving catheter. Hints and tips if in doubt, speak to a urology nurse or the urology speciali st. Sometimes the old balloon won \200\231t defl ate, or the old catheter won \200\231t pul l out \200\223 there are numerous reasons for this; speak to your senior or the urology nu rse specialist/urology StR on-call. Replacing a PEG feeding tube Although placing a defi nitive replacement is usually performe d by a gastroenterologist or an endoscopist, if the PEG has just fallen out it is important to attempt to prevent the hole closing up. With the patient lying down, apply gentle press ure to introduce a well lubricated urinary catheter into the hole. This may prevent the nee d for a repeat endos- copy and hence should always be attempted urgently. OHFP.indb 548 OHFP.indb 548 30/05/2014 16:18 30/05/2014 16:18 549 NASOGASTRIC (NG) TUBES ( Nasogastric (NG) tubes g Level F1 Consent verbal ) Diffi culty 2/5 Indications stomach emptying, eg bowel obstruction (wide-bore or Ryle \200\231s tube), nutr ition (fi ne bore). Contraindications absolute basal skull fracture, facial trauma, compe- tent patient refusal. Site inserted into the stomach via a nostril. Equipment non-sterile gloves, NG tube, lubricant jelly, glass of water, adhesive tape, drai nage bag and bowl (or spigot). Checks make sure patient is alert, with no history of head i njury. Use an appropriate sized tube. Gauge the length of tube to insert by meas- uring the distance from the nostril to angle of the jaw and from angle of the jaw to the xiphisternu m. Warn the patient about initial discomfort (which does improve). Patient position sit the patient upright with head against a pillow Procedure wash hands and wear non-sterile gloves. Ask the patient to take a sip of water an d hold it in their mouth. Cover the tip of the NG tube with lubricant gel and insert into t he patient \200\231s nostril. Aim the tube directly backwards. Once the patient feels the t ube at the back of the throat ask them to swallow so you can advance the tube. Continue adv ancing until you reach the length measured earlier (usually 750cm). Tape the tube to the no stril. Attach a drainage bag to the free end of the NG tube. Con \201 rmation see Table 16.4. Complications pain/irritation, aspiration, oesophagitis, tracheal/duodenal intubation, electrolyte depletion, local tissue necrosis, gastric perfora tion, tube may curl in mouth or pharynx. Safety check the tube is in the correct position w ith a CXR, essential before the tube is used for feeding Alternatives if you cannot insert the tube, try the other nostril or consider passing it orally (only if patient unconscious) ; see b p548 for other options Hints and tips use a chilled NG tube as these are less fl ex ible. Table 16.4 Methods of con \201 rming NG tube placement CXR Essential before a fi ne-bore feeding tube is used and recommended for a wide-bore tube. Ch eck tip of NG is visible below diaphragm and not in bronchial tree (check local policy if F 1s are allowed to check NG position) NG aspiration Aspirate fl uid and test pH (stomach fl uid usually acidic, pH <4, can be raised in those on PPIs, hence may still need CXR to confi rm) Listening for air over th e stomach as air is injected is not a valid way to confi rm position prior to using the tub e and should not be performed Air injection _OHFP.indb 549 _OHFP.indb 549 30/05/2014 16:18 30/05/2014 16:18 550 CHAPTER 16 Procedures ) Ascitic tap (abdominal paracentesis) Consent verbal p ( p Level F1 Diffi culty 3/5 Indications diagnosis from ascitic fl uid (Table 16.5). Contraindications absolute competen t patient refusal; relative abnormal clotting, local infection. Consent verbal; explain why a tap is required. Site left/right iliac fossa, at the level of the umbilicus and lateral to the mid-inguinal point (see Fig. 16.21). Avoid the suprapubic area with the bladder and inferior epigastric vessels. g Equipment sterile gloves, antiseptic solution in a bowl, 10ml 1% lidocaine, swabs, green (2 1G) needle, 20ml syringe, sterile adhesive dressing, sharps bin. Checks PT/INR/APTT, seek a dvice if abnormal, empty bladder. Patient position lying on their bed, tilted slightly to o ne side. Procedure percuss the abdomen to assess the location and extent of the ascites. Wash hands and wear sterile gloves. Using aseptic technique clean the target area. Infi ltrate around the area with 1% lidocaine initially into subcutaneous, then deeper layers towards the peri toneum. Allow 2min, then insert a green needle with a 20ml syringe vertically into the skin . Advance whilst aspirating until fl uid fl ashback is seen (usually straw- colored; may be bloodstained). Obtain 20ml fl uid, then remove the needle and apply a sterile adhesive dre ssing. \200 Send \202 uid for FBC, bacteriology (M, -C+S, ZN stain/TB culture), biochemistry (protein, glucose, LDH, amylase/lipase), cytology. Con \201 rmation fl uid aspirated from abdominal cavity. Complications pain, bleeding (loc al or perforated viscus), perforated bowel/bladder, infection (skin or peritonitis), fl uid leakage from wound. Safety do not have repeated attempts, if unsuccessful contact a senior and consider performing under ultrasound guidance. Alternatives therapeutic paracentesis ( see box). Hints and tips avoid sites close to old surgical scars to avoid going through adh esions; in obese patients use a longer needle. Afterwards lie the patient with the puncture site upwards to minimize fl uid leakage. Table 16.5 Classi \201 cation of ascites Transudate ascites Exudate ascites Total protein <30g/l Etiology >30g/l \200 Infection (>250 white cells/mm3) \200 Pancreatic cause \200 Malignancy \200 Budd \200\223Chiari syndrome Cirrhosis \200 Nephrotic syndrome \200 CCF OHFP.indb 550 OHFP.indb 550 30/05/2014 16:18 30/05/2014 16:18 551 ASCITIC TAP (ABDOMINAL PARACENTESIS) Therapeutic paracentesis Ascites may need to be drained for symptomatic relief, to reduce i nfection risk and prevent respiratory compromise. Up to 6l of ascitic fl uid can be drained . In order to prevent hypotension from removal of this fl uid, 100ml salt-poor albumin IV s hould be given for every 1.5l ascitic fl uid drained. The patient \200\231s FBC, U+E, LFT, and PT and APTT should be checked before the procedure. A Seldinger paracentesis set or a dedicated pigtail drain insertion kit may be used. The pr ocedure is similar to an ascitic tap except that a drain is introduced, either over a guide wire or directly from an introducer needle. Unless tunneled (eg for malignant eff usions) t he drain should be removed within 6h due to the risk of introducing infection. Target areas Fig. 16.21 Target areas for ascitic tap at the level of the umbilicus, 3 \200\2234cm latera l to the mid-inguinal line. _OHFP.indb 551 _OHFP.indb 551 30/05/2014 16:18 30/05/2014 16:18 552 CHAPTER 16 Procedures ) ( p Lumbar puncture (LP) Level F2 Consent verbal Diffi culty 3 \200\2234/5 Indications suspected meningitis, encephalitis, subarachnoid hemorrhage (SAH), investigatio n of other neurological conditions. Contraindications absolute competent patient refusal, i intracranial pressure (see b p360, check CT), infection at the site, cardiorespiratory comp romise (treat fi rst, including antibiotics); relative abnormal clotting, spinal deformity, spinal metalwork. Consent verbal; explain why the lumbar puncture is required. Site draw a line between the iliac crests and feel for a gap in the spine where the line crosses it, t his is about L3/L4. The cord ends at L1/L2, so never do LPs above the L2/L3 interspace; mar k the spaces using arrows away from the spine (Fig. 16.22b). Equipment 2ml syringe, orange (25G) needle, 1% lidocaine, antispetic swab, gauze, lumbar pu ncture pack, sterile gloves, 3 specimen pots labeled 1/2/3 (or 4 pots if you suspect SAH), fl uoride oxalate blood tube (b p517). Checks check pots are numbered and the assistant kno ws this. Patient position lying on their side on the edge of the bed with their back expose d, legs curled up, and neck fl exed (fetal position). Their body should be parallel to the fl oor. Procedure wash hands and wear sterile gloves, gown, hat and mask. Clean area thoroughly wit h antiseptic. Infi ltrate subcutaneously with 5 \200\22310ml of 1% lidocaine and 25G needle . Allow 2min to take eff ect during which you should assemble the manometer (thin tube, che ck the numbers match up). Insert spinal needle between the spinous processes with the bevel facing up and aim for the umbilicus (Fig. 16.22a). You should feel resistance from the sup raspinous ligaments then the ligamentum fl avum and dura followed by a lack of resistance a s you enter the subarachnoid space (Fig. 16.22c). Withdraw the stylet and look for clear fl uid (do not panic if you see blood, this is probably a spinal vessel \200\223 withdraw an d use a lower space), if there is no CSF pull back 2 \200\2233cm and realign. If the patien t feels pain shooting down their leg you are hitting a nerve root so withdraw, then next ti me head more towards the midline. Once CSF is seen attach the manometer and measure opening pressure (normal opening pressure is 7 \200\22320cm CSF). Use the 3-way tap to drain the m anometer fl uid into the 3 specimen pots (10 drops in each) and the fl uoride tube (6 drops ). Withdraw the entire needle and cover the wound with a sterile plaster. Take a blood samp le in a fl uoride oxalate (b p517) tube and send for glucose levels. Advise the patient to lie fl at for 1h. Ask the nurses to check neurological obs and BP. OHFP.indb 552 OHFP.indb 552 30/05/2014 16:18 30/05/2014 16:18 553 LUMBAR PUNCTURE (LP) Con \201 rmation CSF fl uid seen. Complications headache post-procedure (worse sitting up, occurs within a week and lasts 3 \200\2234d, b p361), infection, trauma to nerve roots. Sa fety never do this procedure for the fi rst time on your own. Alternatives can be performed under X-ray guidance though this is rare. Hints and tips position is everything; explain e xactly what you want the patient to do, lie the patient on their side, make sure their back is straight in the vertical plane and their legs are tightly curled up. If you are having diffi culty fi nding the midline, ask the patient if it feels to the left, right or middle. Make sure the needle is horizontal. CSF samples send sample 2 and the fl uoride tube for b iochemistry (protein, glucose, pH), samples 1 and 3 to microbiology for M, -C+S (consider r equesting viral culture/PCR) and the fourth in a brown envelope (away from light) to bioche mistry for xanthochromia if SAH suspected. Spinal cord L2 Cauda equina Subarachnoid space (contains CSF) Dura Epidural space Ligamentum flavum 2 L3 3 Lumbar spine Supraspinous ligament L4 Skin 4 L5 5 Spinous process Fat Sacrum (a) Spinous process Subarachnoid space Iliac crest Sacrum Cauda equina L2 L3 L4 L5 X Spinal nerve L4 Lumbar spine (b) Fig. 16.22 (a) Anatomy of a lumbar puncture. (b) Position and surface anatomy for a lum bar puncture. (c) Cross-section of the spine during a lumbar puncture. (c) _OHFP.indb 553 _OHFP.indb 553 30/05/2014 16:18 30/05/2014 16:18 554 CHAPTER 16 Procedures y g Normal vaginal delivery Level F1 Consent verbal Diffi culty 2/5 The fi rst stage of labor often takes many hours. Monitor maternal HR, BP, temp, contractio ns, and fetal HR every 15min. Second stage begins once the cervix is fully dilated \200 \223 see box. y Equipment sterile gloves, cord clamp x 2, cord scissors, swabs, Syntometrine injection (e rgometrine 0.5mg and oxytocin 5units given IM into the thigh as the baby \200\231s anterior shoulder is delivered), neonatal resuscitaire, name tags for baby. Patient position usuall y on her back with legs open and supported. Procedure wash hands and wear sterile gloves. Stand between the woman \200\231s legs slight ly to one side with sterile swabs to hand. When the head becomes visible (crowning) it shou ld be facing towards the moth- er \200\231s back with its occiput anterior (Fig. 16.23a). T he head will continue to descend and the mother \200\231s perineum will stretch; press the skin between the anus and vagina with a swab to protect it and place your other hand on the baby \200\231s head to control the descent (Fig. 16.23b). As the top of the head passes th e vagina instruct the mother to stop pushing and to pant; meanwhile allow the head to slowl y emerge (Fig. 16.23c). Support the head once it has been delivered; the head will turn to one side, this is called restitution (Fig. 16.23d). Ask a midwife to get the Syntometrine injection ready and to give to the mother as the anterior shoulder is delivered. Hold the head fi rmly at the base of the skull with two hands (Fig. 16.23e). On the next contraction pull the head down- wards so the anterior shoulder can be delivered then upwards for the p osterior shoulder; the whole body will follow quickly (Fig. 16.23f ). Place the baby on the mother \200\231s chest and apply two clamps to the cord 15 \200\22330cm from the baby and cut in between. If the baby is not well crash-call the neonatal team; see b p236 for resusc itation. The uterus will now contract and the placenta will separate. Keep gentle traction on the cord; after about 2 \200\2235min it will give slightly as a small amount of blood co mes out of the vagina. Gently pull the cord whilst pressing on the lower abdomen and the pl acenta should come out. Check the placenta is complete and the cord has two arteries and on e vein. Complications failure to progress, hemorrhage, perineal tears, fetal distress, fetal hypoxi a, shoulder dystocia. Safety always have midwives to hand and call a senior if you are at a ll unsure at any stage. Alternatives ventouse, forceps, Cesarean if failing to progress. Hi nts and tips encourage good pushes (deep inspiration, no noise, pushing for at least 20s wi th movement of head), maintain a suitable position with legs wide, give clear instructions of when to push and when to stop. Analgesia TENS machines, breathing exercises, paracetamol , Entonox (nitrous oxide and air), pethidine or diamorphine (early \200\223mid 1st stage only), epidural. OHFP.indb 554 OHFP.indb 554 30/05/2014 16:18 30/05/2014 16:18 555 NORMAL VAGINAL DELIVERY (a) (d) (b) (e) (c) (f ) Fig. 16.23 (a \200\223f ) Birth from the perspective of the junior doctor. Posterior Lambdoidal suture Posterior fontanelle Sagittal suture Anterior fontanelle Coronal suture Frontal suture Anterior Fig. 16.24 Palpable anatomy of the fetal skull. _OHFP.indb 555 _OHFP.indb 555 30/05/2014 16:18 30/05/2014 16:18 556 CHAPTER 16 Procedures Joint aspiration and injection Consent verbal/written Level F2 Diffi culty 4/5 Indications diagnostic look for blood/crystals/pus; therapeutic steroid injection, drain te nse/septic eff usion or haemarthrosis. Contraindications absolute competent patient refusal ; relative abnormal clotting, local infection, prosthetic joint. Site any synovial joint (e g wrist, elbow, shoulder, knee, ankle). Con \201 rmation fl uid aspirated, tension relieve d. Equipment 2, 10, 20ml syringes, orange (25G) and green (21G) needles IV cannula (16 \200 \22318G), 3 specimen containers and fl uoride oxalate blood tube (b p517), 1% lidocaine, st erile gloves, dressing pack, antiseptic cleaning solution, sharps bin. Checks recruit an as sistant to pass you things, make sure aspiration/ injection is required. Patient position d epends on joint; easier if larger joints are slightly fl exed such as the knee and elbow as this opens up the joint. Position larger joints over a few pillows to make the patient mor e comfortable. Procedure for aspirating knee identify lateral border of patella and the depression lateral to it over the joint line (see Fig. 16.25). Wash hands and wear sterile gloves. Clean area thoroughly with Betadine or chlorhexidine. Infi ltrate 2 \200\2235ml of LA with 25G need le into sub- cutaneous tissue and then deeper towards joint space. Allow 2min to take eff e ct. Either attach 21G needle to a 10ml syringe or a 16G cannula; advance the needle through the area of LA infi ltration directly towards the joint space. A slight \200\230pop \200 \231 might be felt as the synovium is punctured. Once in the joint space fl uid will be eas ily drawn into the syringe, or a fl ashback in the cannula will be seen; if using a cannula then remove the needle, leave the plastic component in place, and attach a syringe. Aspira te as much as needed and divide into specimen pots. Once complete withdraw needle/cannula a nd apply plaster to skin. Medial approaches are also described (OHCS8 b p708). Complications failure to tap synovial fl uid, pain, bleeding, subsequent infection of subcu taneous tissues or within joint. Safety never perform this for the fi rst time on your own; always perform aspiration aseptically, as an iatrogenically infected joint is disastrous; avoid advancing needle through infected skin. Alternatives seek help from orthopedic surgeo n/rheumatologist; some radiologists perform this under ultrasound guidance. Hints and tips thick viscous eff usions are diffi cult to draw up through small needles, so use a larger n eedle or cannula. Always speak to the relevant laboratory beforehand and enquire what volum e and in which container they need their sample. OHFP.indb 556 OHFP.indb 556 30/05/2014 16:18 30/05/2014 16:18 557 JOINT ASPIRATION AND INJECTION Joint injection Steroid injections are used for a number of infl ammatory disorders, but sh ould be performed by an expert. If there is doubt whether a joint is infected or not, then steroids must not be injected into that joint (OHCS8 b p708). Table 16.6 Synovial \202 uid in health and disease Aspiration of synovial fl uid is used primarily to look for infectious or crystal (gout and pseudogout) arthropathies. Appearance Viscosity WBC/mm3 N \230 Normal Non-infl ammatory1 Haemorrhagic2 Clear, colorless High High Clear, straw Variable <10,000 Bloody, xanthochromic Turbid, yell ow <200 <5000 <25% <25% <50% Acute infl ammatory3 \200 Acute gout \200 Rheumatoid arthritis Septic \200 TB \200 Gonorrhoeal \200 Septic (other)4 Reduced 780% 765% 2,000 \200\2235,000 5,000 \200\22310,000 Turbid, purulent Reduced 770% 760% 795% 10,000 \200\22330,000 10,000 \200\22330,000 10,000 \200\223100,000 1 eg degenerative joint disease, trauma. 2 eg tumor, hemophilia, trauma. 3 Includes eg Reit er \200\231s, pseudogout, SLE etc. 4 Includes staphs, streps, Lyme disease, and pseudomonas (eg post-op). Fig. 16.25 Aspirating a left knee joint using a lateral approach; rest the fl exed knee on a pillow. _OHFP.indb 557 _OHFP.indb 557 30/05/2014 16:18 30/05/2014 16:18 558 CHAPTER 16 Procedures ) ( Local anesthetic (LA) Level F1 Consent verbal Diffi culty 2/5 Local anesthetics (LAs) should not be used without knowledge of their side eff ects, toxic doses, and properties. A basic understanding about this drug class is essential as it will improve the patient \200\231s outcome. Indications suturing, wound cleaning, FB removal, ca nnulation, cardiac arrhythmias, minor and major surgery (cataracts/hip replacement); topica l preparations for cannulation, catheterisation, corneal anesthesia. Which LA to use most wards will stock lidocaine (formerly lignocaine); 1% lidocaine solutio ns are usually suffi cient. Other LAs are more likely to be used in the operating theater o r the ED. Diff erent LAs vary in their speed of onset and duration of action. Table 16.7 sh ows properties of commonly used LAs. See also Tables 16.8. and 16.9. LAs with adrenaline (e pinephrine) the vasoconstricting action of adrenaline prevents the LA from being rapidly re distributed by the circulation, prolonging its action at the injection site and allowing a larger dose to be administered. It is especially useful for scalp and facial anesthesia. Th ere is debate as to whether one should avoid using LAs with adrenaline near end arteries, ( fi ngers, toes, penis, nose, ears) as this may lead to ischaemia/gangrene. Types of block a fi eld block is infi ltration of LA into the tissue around a wound; this n umbs small cutaneous nerves. In a peripheral nerve block a specifi c nerve is anesthetized (eg digital, median) with subse- quent anesthesia in the region supplied by that nerve. A s pinal anaes- thetic blocks motor and sensory nerves below the level at which it is injected (often L3/L4). For full descriptions see OHCS8 b p634. Bier \200\231s block an IV injectio n of LA distal to a double-cuff ed tourniquet, often used to manipulate a fractured wrist i n an awake patient (OHCS8 b p744). IV use of LA requires specialist training with close sup ervision. Haematoma LA injection into the haematoma formed around a long bone fracture, eg before closed distal radius fracture manipulation in the conscious patient. The needle is a dvanced into the \200\230step \200\231 felt at the fracture site whilst pulling back on th e plunger. A fl ashback is seen when the haematoma is reached, after which the anesthetic s hould be injected slowly, looking for signs of toxicity. LA toxicity Always observe for the symptoms and signs of toxicity shown in Table 16.10. Thi s usually occurs when serum concentrations peak (usually 45 \200\22360min after use). The t oxic dose of LAs represents the maximum dose that should be injected into the tissues. Mana gement of LA toxicity if suspected, stop any further injection or infusion of LA, check ABC and give 15l/min O2; call for senior help; midazolam 1 \200\2234mg/STAT IV increases the c onvulsion threshold and may prevent seizures; consider: \200 Intubation if conscious leve l falls or seizures are resistant to therapy (b p542). CPR if there is no palpable pulse or signs of life (b p228). \200 IV lipid emulsion will create a sink for lipophilic drugs. OHFP.indb 558 OHFP.indb 558 30/05/2014 16:18 30/05/2014 16:18 559 LOCAL anesthetic (LA) Allergy to LAs this is rare but more likely with the ester group of LAs (cocaine, tetracain e (formerly amethocaine)) than the amide group of LAs (lidocaine, bupivacaine, prilocaine); treat as for anaphylaxis (b p470). Alternatives Entonox , sedation LA, general anesthe sia LA. Hints and tips LAs sting as they are injected; lidocaine is less painful if it is warmed an d injected slowly. LAs are \200\230activated \200\231 by alkaline conditions and so are mu ch less eff ective when injected into infl amed/infected tissues which have a lower (acidic ) pH. Table 16.7 Commonly used local anesthetics and their properties Local anesthetic Bupivacaine (Marcain ) Medium Levobupivicaine (Chirocaine ) Medium Lidoc aine Lidocaine (with adrenaline) Prilocaine (Citanest ) Ropivacaine (Naropin ) Onset Duration Maximum dose Long Long Medium Medium 2mg/kg 2mg/kg (data lacking) 3mg/kg 7mg/kg Fast Fast Fast Medium Medium Long 6mg/kg 3 \200\2234mg/kg Table 16.8 Calculating LA concentrations Multiply the percentage solution by 10 to give the concentration in mg/ml mg/ml % solution mg/ml % solution 0.25% 0.5% 0.75% 2.5mg/ml 5mg/ml 7.5mg/ml 1% 2% 4% 10mg/ml 20mg/ml 40mg/ml Table 16.9 Maximum doses of lidocaine without adrenaline /kg Volume in brackets represents ml of 1% lidocaine solution Weight (kg) Maximum dose Weight (kg) Maximum dose 50 60 70 150mg (15ml) 180mg (18ml) 210mg (21ml) 80 90 100 240mg (24ml) 270mg (27ml) 300mg (30ml) Table 16.10 Symptoms and signs of systemic local anesthetic toxicity Tingling around the mouth \200 Metallic taste \200 Tinnitus \200 Altered consciousnes s \200 Convulsions \200 Respiratory arrest \200 Cardiac arrhythmias Visual disturbance \200 Slurred speech Mild toxicity Coma Moderate toxicity Cardiovascular collapse 3 Potentially fatal toxicity _OHFP.indb 559 _OHFP.indb 559 30/05/2014 16:18 30/05/2014 16:18 560 CHAPTER 16 Procedures Suturing Consent verbal (in the ED), written (elective surgery), common law Level F2 (emergency surg ery) Diffi culty 3/5 Indications the two main indications for skin suturing are: \200 Wound closure \200 Kee ping drains and lines in place. Contraindications absolute competent patient refusal, forei gn body in wound, dirty or infected wound, old wound (>12h except on face), bite. Site appr opriate to wound/drain/line site. Equipment sterile drape, sterile gloves, sterile water, 10ml syringe, green (21G) needle, o range (25G) needle, LA, appropriate suture material, suture pack (toothed forceps, needle-h older, scissors, gauze), assistant to hold the local anesthetic, sharps bin. Checks tetanus status (b p436), no infection or foreign bodies, no neuro vascular defi cit requiring refe rral, no damage to the underlying structures (eg tendons); if in doubt ask for senior opini on. Patient position patient lying comfortably with wound site exposed. Anesthetic perform a fi eld block as follows. Prepare the sterile pack on the trolley with sterile gloves open and antiseptic solution in the receiver. Wash hands and put on sterile gloves. Draw up LA using a green needle and a 10ml syringe. Change to an orange needle for infi ltration. Clean the skin with antiseptic solution and use the sterile drape to cover t he area except for the wound. Warn the patient and insert the LA needle (it is less painful to go through the walls of the wound than through the skin). Draw back to check you are no t in a blood vessel then infi ltrate superfi cially. Allow 2 \200\2235min for the LA to wor k. Use this time to prepare your suture material and hold it with the needle facing upwards in the needle-holder. Before starting to suture, ensure the skin is numb. Suturing startin g at the middle of the wound, pick up the skin edge with the toothed forceps and pass the n eedle perpendicularly through the skin 5mm from the wound edge and into the wound just unde r the dermis. Grasp the needle point with the needle holder and pull it through gently. Hol d the other skin edge with toothed forceps and again pass the needle through the skin, this time through the dermis fi rst, up to the surface about 5mm from the wound edge. Pull most of the suture through then grasp both ends of the suture, tighten and oppose the skin edge so the edges are slightly everted but without tension. Hold the free end of the suture wit h the needle-holding forceps and make 3 knots around the forceps (anticlockwise, clockwise, anticlockwise). Make sure you \200\230lock \200\231 each knot by pulling the knot initial ly in the direction of the wound and then perpendicular to it. Cut the ends of the knot abo ut 1cm long. The knots should lie to the side of the wound not on top of it. Repeat the pro - cedure with sutures 5 \200\22310mm apart, depending on the area being sutured. When you h ave fi nished, clean the wound, apply a dry dressing, and tell them when the sutures will n eed to be removed (Tables 16.11 and 16.12). OHFP.indb 560 OHFP.indb 560 30/05/2014 16:18 30/05/2014 16:18 561 SUTURING Con \201 rmation stitches apposing wound edges but not under tension. Complications infect ion, poor healing, hypertrophic/keloid scarring, wound breakdown. Safety avoid touching the needle by using the needle-holder; when you do not need the needle keep it back to front i n the needle-holder, with the point covered by the needle holder. Alternatives steristrips \204 and glue (b p436); staples have a lower infec- tion rate, but can cause prominent hyp ertrophic scarring and require staple removers to take them out (may need to attend ward). Hints and tips \200 Make sure you and the patient are in comfortable position with good lighting before you start Use toothed forceps on skin as blunt forceps crush the tissue \200 LA can be dangerous, s ee b p558; adrenaline helps haemostasis, but should be used with caution on extremities Avoid nylon sutures for drains as this is often uncomfortable \200 Consult a senior if th e edges need a lot of tension to meet; you may need to use deep or subcutaneous sutures See b p436 for treatment of wounds \200 Get senior help early; if the sutures do not look right the patient will have the scar for life and it is often better to start again Operations are judged by the scars; take time to make them look good. Table 16.11 Suture size and suggested dates for removal of sutures (ROS) Location Absorbable? Suture size ROS at day Face and neck Lips/mouth/tongue Chest/abdomen Limbs No Yes No No 6/0 6/0 vicryl 3/0 4/0 3 \200\2234 N/A 7 \200\22310 5 \200\2237 Table 16.12 Types of suture material Non-absorbable sutures Absorbable sutures Nylon (ethylon) Prolene Silk Vicryl PDS Monocryl Wound care advice for patients \200 Keep the wound area clean and dry for at least 48h \200 Seek medical help if the wound looks infected, ie redness, swelling, tenderness Avoid heavy lifting for at least 6wk (except for scalp or face wounds) \200 Drive when yo u can perform an emergency stop and check the view over your shoulder (see b p605). _OHFP.indb 561 _OHFP.indb 561 30/05/2014 16:18 30/05/2014 16:18 562 CHAPTER 16 Procedures Reduction of fractures and dislocations Consent verbal Level F1 Diffi culty 3/5 Indication traumatic injury resulting in a fracture or dislocation. Contraindications relat ive neurological or vascular defi cit (get senior help immediately), open fracture. Closed Colles \200\231 fracture reduction Equipment three personnel (two to manipulate the fracture, one to apply backslab plaster), plaster, crepe bandage, tube stocking, water, sling and equipment for Bier \200\231s block or haematoma block (b p558). Checks X-rays of fracture from two views showing displacement; no neuro vascular defi cit; adequate analgesia. Patient position: sitting up with upper limb held at side at roughly 90 . Procedure: Your assistant applies traction backwards distal to the elbow whilst you apply f orward traction gently to unlock the two bone fragments. You may also apply downwards press ure to the bone fragments in order to help them come into alignment. When aligned, fl ex an d deviate the wrist towards the ulna. In this position, the plaster is applied. Only once t he cast has set can traction on the limb be released. Neurovascular status should be re-che cked and a check X-ray performed. If position is not satisfactory on X-ray, a further attem pt at closed reduction can be made. If this fails surgery may be required. Slings, crutches and analgesia should be provided as appropriate for patients being dischar ged home. All fractures require orthopedic follow-up to ensure adequate union of bone, eith er as an in-patient or via out-patient fracture clinics. Shoulder dislocations Around 96% of shoulder dislocations are anterior dislocations and the re are many methods that can be used to reduce them. The technique employed should reduce t he dislocation without causing additional trauma. The method used depends on patient condit ion, deepness of sedation, and your competence at the technique. Two of the most commonly u sed methods are outlined here. Posterior and inferior dislocations frequently require reduc tion under general anesthetic, so techniques to reduce these are not covered here. OHFP.indb 562 OHFP.indb 562 30/05/2014 16:18 30/05/2014 16:18 563 REDUCTION OF FRACTURES AND DISLOCATIONS Never attempt a technique you are not fully familiar with. Dislocations of the shoulder are diagnosed clinically and on X-ray. Anterior dislocations are normally obvious on AP should er views, and confi rmed on scapular \200\230Y \200\231-view (the humeral head sits anteri or to the glenoid). Posterior dislocations can look normal or show the \200\230lightbulb s ign \200\231 (due to internal rotation of the humerus) on AP view. They are confi rmed on \200\230Y \200\231-view (the humeral head sits posterior to the glenoid). Equipment 2 \200\2233 personnel, one to perform and monitor sedation if used (eg midazolam) and 1 or 2 to perform the reduction, sling. Checks X-rays (2 views minimum) to diagnose dislocation and check for associated fractures, except in patients with a history of recurrent atraumatic dislocation, no neurovascular de fi cit, and specifi cally axillary nerve function (see \200\230Complications \200\231), ad equate analgesia/sedation. Patient position lying fl at on their back. External rotation technique (single-person technique). The arm is slightly abducted and ben t at the elbow to 90 . Support the elbow with one hand and the patient \200\231s wrist wit h the other. Slowly ask the patient to allow their forearm to rotate away from their body ( externally rotate), stopping whenever pain or muscle spasm is felt. Support their arm in th at position until pain/spasm resolves and then ask them to allow their hand to fall to the side again. Repeat as many times as required, with the hand moving further each time. When externally rotated to between 70 and 110 , the shoulder should click back into position. Traction-countertraction technique (two-person technique). With the patient relaxed, abduc t the arm and apply traction at the distal forearm through the length of the arm whilst you r assistant applies counter-traction using a sheet wrapped around the patient \200\231s axi lla. Apply traction steadily until rotator cuff muscles relax enough to allow the shoulder to click back into position. For any reduction method, neurovascular status should be docu- mented before and after the procedure and a shoulder X-ray must be performed after reducti on. The patient should have a broad arm sling applied, be given adequate analgesia and have orthopedic follow-up. Complications axillary nerve and blood vessel injury (ensure the \200\230badge-patch \200 \231 area on the lateral side of the upper arm over the deltoid muscle, is checked for sens ation and this is documented pre- and post- procedure); Bankart lesions and Hill \200\223Sa chs deformities in recurrent dislocations, requiring elective surgery; failure of reduction leading to emergency reduction in theater. Alternatives other techniques exist for anterior dislocation reduction. These include the S paso, modifi ed-Milch, chairback and scapular manipula- tion techniques (single operator te chniques that are relatively atraumatic). Older techniques include Kocher \200\231s method and the Hippocratic method; however these techniques have higher levels of associated injur y and are not generally used in the UK. _OHFP.indb 563 _OHFP.indb 563 30/05/2014 16:18 30/05/2014 16:18 This page intentionally left blank Chapter 17 Interpreting results 565 Blood tests Full blood count (FBC) 566 Clotting 567 Cardiac markers 567 Infl ammatory respo nse 567 Urea and electrolytes (U+E) 568 Liver function tests (LFT) and amylase 569 Calcium and phosphate 570 Endocrine tests 571 Cardiology Electrocardiogram (ECG) 572 Respiratory Chest X-ray (CXR) 582 Arterial blood gasses (ABGs) 584 Respiratory function tes ts 586 Gastrointestinal Abdomen X-ray (AXR) 588 Urine tests 590 Neurological CSF 592 Musculoskeletal Autoantibodies and associated diseases 593 Cervical spine radiographs 594 S keletal radiographs 596 _OHFP.indb 565 _OHFP.indb 565 30/05/2014 16:18 30/05/2014 16:18 566 CHAPTER 17 Interpreting results Full blood count (FBC) There are three main components: red cells (measured by hemoglobin o r Hb), white cells (leucocytes or WCC), and platelets (plts). Remember these components rep resent the three cell lines from bone marrow. Main FBC abnormalities b p392 d Hb b p478 FBC often initially normal b p482 i WCC, i plts ii WCC b p396 Persistent change in \211 1 cell line b p396 Anemia Acute blood loss Infection/infl ammation Hematological malignancies Bone marrow diso rders Hb \200\223 red bloods cells (male: 130 \200\223180g/L: female: 115 \200\223160g/L) \200 dHb Anemia, classifi ed according to MCV, see b p392 for causes, investigations, and management iHb Dehydration (b p378), secondary polycythaemia, eg heart/ lung disease, polycythaemia ve ra (b p396). Consider prophylactic LMWH (b p406) due to the increased thrombosis risk. Reticulocytes (50 \200\223100 \227 109/l or 0.5 \200\2232.5%) these are immature red cells released from bone marrow in response to haemolysis or blood loss (response detectable aft er a few hours, not hyperacutely). They are also raised secondary to infl ammation and infe ction. WCC \200\223 white blood cells (4 \200\22311 \227 109/l; Table 17.1) Table 17.1 Causes of abnormal white cell diff erentials Cell Neutrophils (2.0 \200\2237.5 \227 109/l) Causes i Bacterial infection, infl ammation, acute illness, myeloid leukemia, steroid therapy