Con \201 rmation restoration of sinus rhythm for elective cases or a cardiac output in the emergency situation; perform 12-lead ECG. Complications life-threatening arrhythmias, thro mboembolism, aspiration, local burning to skin, risks to user and bystanders Safety users o f the manual defi brillator must have passed an ALS or ILS course; caution with electricity and wet/bloody environments. Alternatives automated external defi brillators (AEDs) are be coming widespread and require no rhythm recognition by the user. Two hands- free electrodes are applied to the patient and the AED determines if a shock is advisable or not; if a sho ck is advisable the operator just presses the \200\230shock \200\231 button when the AED t ells them to. AEDs should not be used for elective cardioversions. Hints and tips always de fi brillate safely; if in doubt contact your resus- citation offi cer for some extra traini ng. OHFP.indb 532 OHFP.indb 532 30/05/2014 16:18 30/05/2014 16:18 533 CARDIOVERSION AND DEFIBRILLATION Fig. 16.9 Position of manual defi brillator paddles. Make sure gel-pads are placed on the s kin underneath the paddles as these reduce the impedance and limit skin burns. Fig. 16.10 Position of hands-free adhesive defi brillation electrodes. The electrodes for m ost hands-free systems indicate where they should be placed: to the right of the upper ster num and over the 5th left intercostal space in the anterior axillary line. Fig. 16.11 Position of either manual paddles or hands-free electrodes in the AP position. T he anterior site is to the left of the lower sternal border and the posterior position is j ust inferior to the left scapula. _OHFP.indb 533 _OHFP.indb 533 30/05/2014 16:18 30/05/2014 16:18 534 CHAPTER 16 Procedures Central lines Consent verbal/written Level F2+ Diffi culty 3 \200\2235/5 Indications monitoring fl uid balance, temporary pacing wires, drug administration, parente ral feeding, permits blood sampling, pulmonary artery catheterisation (Swann \200\223Ganz c atheters). Contraindications absolute competent patient refusal; relative infection at site , abnormal clotting, shock. Site internal jugular, subclavian or femoral vein. j g Equipment 5ml/10ml syringes, blue (23G) and green (21G) needles, non- absorbable suture, Se ldinger central line kit (introducing needle, 5ml syringe, guidewire, dilator, small blade, central line with 2 \200\2235 lumens and bungs), 1% lidocaine, sterile gown, hat, mask and gloves, dressing pack, sterile drapes, portable ultrasound, continuous ECG monitoring on p atient. Patient position fl at on their back with their head down for internal jugular and subclavian cannulation; fl at on their back with head up for femoral cannulation \200\223 helps fi ll the vein. Procedure using aseptic technique, clean with 2% chlorhexidine and drape the area. Identify landmarks and using ultrasound identify the vein. Anesthetize the skin and deep layers wit h 10ml lidocaine. Whilst the anesthetic takes eff ect, fl ush all lumens of the central lin e with saline and cap all except the green one. Attach 5ml syringe fi lled with saline to t he central line needle and introduce through the skin, directing it towards the vein under ultrasound guidance, visualizing the needle tip at all times, aspi- rating whilst advancing . Once dark red blood is aspirated freely into the syringe, stop advancing. Remove syringe whilst holding the needle fi rmly in place. If blood spurts out in a pulsatile fashion it i s likely to be an arterial cannulation \200\223 STOP (see What to do if the artery is can nulated ). Once venous fl ashback obtained, advance the guidewire through the lumen of the needle (should advance without resistance), checking for ectopic beats on ECG. Once about h alf of the guidewire is inserted, remove the needle, but always holding onto the guidewire. Make a small incision in the skin adjacent to the guidewire with the blade; thread the dil ator over the guidewire and fi rmly advance the dilator through the skin and deep layers, r otating to ease its passage. Stop once half the dilator is through skin and remove it whils t holding on to the guidewire. Pass the central line over the guidewire and advance it thro ugh the skin, holding onto the guidewire at all times. Remove the guidewire once the centra l line is inserted and cap the open lumen. Check blood can be easily aspirated from each lu men and fl ush with saline. Suture the line to the skin, clean the skin and apply clear ste rile dressing. Con \201 rmation blood aspirated from all lumens, blood O2 sats <fi nger O2 sats (SvO2<SpO 2), CXR to locate the catheter tip and exclude pneu- mothorax. Always confi rm guidewire re moved. Complications arterial cannulation, bleeding, pneumothorax (subclavian >internal jug ular), failure to identify vein, air embolism, infection. Safety never perform this procedu re for the fi rst time on your own. Hints and tips make sure you and the patient are both c omfortable before you start. Use suffi cient LA. Ultrasound should be used routinely for in ternal jugular line placement. OHFP.indb 534 OHFP.indb 534 30/05/2014 16:18 30/05/2014 16:18 535 CENTRAL LINES SCM External jugular vein Internal jugular vein Carotid Larynx Clavicular head of SCM Clavicle Sternal head of SCM Subclavian artery Subclavian vein 1st rib Fig. 16.12 Anatomy of the major vessels in the neck. The internal jugular is the most commo n site and has fewer acute complications than subclavian cannulation; subclavian lines have lower rates of infection than internal jugular lines, femoral cannulation has the highest rate of infection. The internal jugular lies deep to sternocleidomastoid muscle (SCM). The needle should puncture the skin midway between the mastoid process and the sternoclavicular joint, lateral to the carotid pulse. The needle should then be directed towards the nipple on the same side to hit the vein. Accidental arterial cannulation Signs of arterial cannulation \200 Bright-red blood, rath er than dark-red \200 Pulsatile blood, rather than constant low fl ow \200 iO2 sats (>9 5%) of blood compared with fi nger O2 sats \200 If the left carotid artery is cannulated the central line will cross the midline on the CXR. What to do if the artery is cannulated \200 Identify arterial cannulation \200 Remove a ll needles, guidewires and lines; press fi rmly over site for 10min \200 Seek senior help . _OHFP.indb 535 _OHFP.indb 535 30/05/2014 16:18 30/05/2014 16:18 536 CHAPTER 16 Procedures Thrombolysisy Consent verbal/written Level F2 Diffi culty 3/5 Indications acute myocardial infarction which meets the following criteria: presentation wi thin 12h of onset of symptoms; typical chest pain lasting >30min; >2mm ST elevation in two or more chest leads (V1 \200\223V6) or >1mm in two or more limb leads (aVR, aVL, aVF, I, II , III) or >2mm ST segment depression in V1 to V3 (suggesting posterior infarct) or new LBBB . Contraindications absolute 3 PCI available within 2h, competent patient refusal, active b leeding, CNS trauma, neoplasms or arteriovenous malfor- mations, previous intracerebral hem orrhage, ischaemic stroke in previous 6mth, major trauma/surgery within previous 3wk, non-c ompressible punc- tures in the last 24 hours (eg liver biopsy, lumbar puncture) relative, T IA in previous 6mth, prolonged CPR, known bleeding disorder or current anti- coagulation th erapy, pregnancy, active dyspepsia or history of GI haemor- rhage, sustained hypertension ( systolic BP >180mmHg), advanced liver disease, infective endocarditis. Age is not a contrai ndication. Site peripheral IV cannulae. Agent check local policy for choice of thrombolytic agent. Streptokinase is a naturally occ urring thrombolytic derived from streptococcal bacteria and as such will cause an antibody response in the patient so repeat doses can be given within 4d of the fi rst dose but never again after that. The standard dose is 1.5 million units in 50ml 0.9% saline by IV infusio n over 1h but check the BNF/local guidelines. If streptokinase has been administered more t han 4d ago or systolic BP <110mmHg use a recombinant thrombolytic agent. Alteplase, retepla se, and tenecteplase are all recombinant tissue plasminogen activators; doses should be det ermined from the BNF/ local guidelines. Alteplase is given as a bolus followed by an infusi on. Reteplase is given as two boluses. Tenecteplase is given as a single bolus. Heparin is commenced following administration of all the recombinant thrombolytics (see b p198). Monit oring during treatment monitor cardiac rhythm continuously and BP every 5min. Reperfusion a rrhythmias (including VT) are common and usually self-limiting. Use ALS algorithm if persis tent or cause compromise. Desired outcome eventual normalization of ST segments and improve ment in chest pain. If symptoms and/or ST segment changes persist seek senior cardiology he lp; a second thrombolysis dose may sometimes be given. Complications bleeding (intracranial (1%), other major bleed (5%)), reperfusion arrhythmias , hypotension, anaphylaxis. If hypotension occurs during treatment with streptokinase, slow the infusion down. Safety never perform this procedure for the fi rst time on your own. Al ternatives primary coronary intervention (PCI) (see OHCM9 b p808). Hints and tips only unde rtake in a well-monitored environment (ED resus, CCU, HDU). Bleeding from cannula sites is common and patients should be warned not to worry about this. In the event of massive life- threatening hemorrhage, antifi brinolytics (eg tranexamic acid) and FFP can be used to rev erse the process. OHFP.indb 536 OHFP.indb 536 30/05/2014 16:18 30/05/2014 16:18 This page intentionally left blank 538 CHAPTER 16 Procedures Pleural tapp Consent verbal/written Level F2 Diffi culty 3/5 Indications diagnosis of eff usion, aspiration of small pneumothorax, symptomatic relief. C ontraindications absolute competent patient refusal; relative local infection, contralatera l pneumothorax/eff usion, abnormal clotting. Site simplest and safest sites are shown in Fi g. 16.13, directly below the inferior angle of the scapula or in the posterior-axillary lin e; choose an intercostal space two or three spaces below the top of the eff usion. See Fig. 16.14. g Equipment 5, 10, 20, 50ml syringes, orange (25G) and green (21G) needles, intravenous can nula (14 \200\22316G), 3-way tap, 3 specimen con- tainers and fl uoride oxalate blood tube (b p517), sterile jug/bowl, 1% lidocaine, sterile gloves, dressing pack, antiseptic swab. C hecks confi rm side of the eff usion clinically and on CXR; lay equipment out on clean trea tment trolley; recruit an assistant. Patient position see Fig. 16.13. Procedure wash hands and wear sterile gloves. Clean area thoroughly with Betadine or chlo rhexidine. Infi ltrate 5 \200\22310ml of LA with orange needle into subcutaneous and then d eeper layers towards pleura, avoiding neurovascular bundles (Fig. 16.15). Allow 2min to tak e eff ect. Using either a green needle on a 20ml syringe or a cannula, gently advance the n eedle through the anesthetized area over the rib directly towards the pleura. Once in the p leural space, fl uid is easily drawn into the syringe or a fl ashback will be seen in the c annula; if using the cannula then remove the needle, leaving the plastic component in place , and attach a syringe. Aspirate volume required and divide into specimen containers. If pe r- forming a therapeutic procedure use the cannula and attach a 3-way tap with a 50ml syrin ge; withdraw and dispose of fl uid into a jug. Once com- plete withdraw needle/cannula and apply plaster to skin. Con \201 rmation pleural fl uid aspirated, always get a CXR (?pneumothorax and reassess th e level of the eff usion if a therapeutic procedure). Complications pneumothorax, haemothor ax, pain, bleeding, damage to inter costal nerve, local or intrapleural infection, visceral puncture (liver, spleen, kidney). Safety do not perform this procedure without supervision ; take care not to allow air into the pleural space. If aspirating fl uid (ie not pneumotho rax) ultrasound guidance is strongly recommended. The use of ultrasound to mark a spot for subsequent drainage attempts is not recommended. Alternatives retry in a diff erent rib spa ce; radiology might perform a diagnostic tap under ultrasound guidance; chest drain for lar ge eff usions. Hints and tips make sure you and the patient are comfortable before you star t; try to anesthetize the skin fully and insert the local anesthetic needle at right angles to the skin when infi ltrating down to the pleura. Aspiration of pneumothorax tension pneu mothorax is a medical emergency and requires immediate treatment (b p279). A small spon- ta neous pneumothorax (<2cm) in a patient who is not breathless can be aspirated using this te chnique (b p279). OHFP.indb 538 OHFP.indb 538 30/05/2014 16:18 30/05/2014 16:18 539 PLEURAL TAP Lateral edge of latissimus dorsi Base of axilla Border of 5th intercostals space Lateral edge of pectoralis major Fig. 16.13 Position of the patient for aspiration of pleural fl uid. Get the patient to lea n forwards over a table or the back of a chair to open up the rib spaces and prevent excess ive movement. Heart Right lung Left lung Fig. 16.14 Position of the normal heart within the thorax at level of T6/T7 vertebra. The d iaphragm lies between T8/T12. Posterior and lateral approaches for pleural aspiration with standard green (21G) needle or IV cannula are highly unlikely to puncture the heart, even o n the left side of the chest. Thoracic cavity Rib External intercostal Costal groove Intercostal vein, artery and nerve Internal intercostal muscle Innermost intercostal muscle Costal groove Rib Fig. 16.15 Safe pleural aspiration to avoid neurovascular bundles. The main bundle sits jus t posterior to the inferior rib edge, though collateral branches are located adjacent to th e superior border. The safe approach is to advance the needle above a rib, but not right ag ainst its superior edge. _OHFP.indb 539 _OHFP.indb 539 30/05/2014 16:18 30/05/2014 16:18 540 CHAPTER 16 Procedures ) Chest drain (Seldinger method) Diffi culty 3-5/5 Consent verbal/written ( g Level F2+ Indications pneumo/haemothorax, pleural eff usion, empyema. Contraindications absolute comp etent patient refusal; relative local infection, abnormal clotting. Site mid-axillary line, 5th intercostal space for a pneumothorax or below fl uid level in an eff usion. Equipment 5, 10, 20ml syringes, orange (25G) and green (21G) needles, suture, Seldinger che st drain pack, bottle with underwater seal (400ml sterile water), 1% lidocaine, sterile glo ves, hat, mask and gown, dressing pack, antiseptic swab, sharps bin, portable ultrasound. C hecks confi rm side of the eff usion clinically and on CXR; lay equipment out on clean trea tment trolley; recruit an assistant. Patient position hunched forwards over a table (Fig. 1 6.16a) or reclining back with their arm behind the head (Fig. 16.16b); choose according to comfort. Procedure wash hands and wear sterile gloves. Clean area thoroughly with Betadine or chlo rhexidine. Infi ltrate 5 \200\22310ml of LA with orange then green needle into subcutaneous and then deeper layers towards pleura, avoiding neurovascular bundles (Fig. 16.15, b p539) . Allow 2min to take eff ect. Attach Seldinger needle onto the syringe and advance through the area of infi ltration as for a pleural tap (b p538). Once needle tip is inside the pleu ral space, remove the syringe and pass the guidewire through the needle. Never let go of th e guidewire. Withdraw the needle fully leaving half the guidewire in the chest. Make a smal l incision with the scalpel alongside the guidewire and pass the dilator along the guidewir e to make a tract to the pleural space. Withdraw dilator, but leave the guidewire in situ. Pass the chest drain over the guidewire to the required depth then remove the guidewire. At tach the 3-way tap to the end of the chest drain and turn \200\230off to chest \200\231. S uture the chest drain to the chest wall using more LA if needed. Connect the 3-way tap to t he tubing of the chest drain bottle and open the 3-way tap. Fluid drainage/bubbling will co mmence. Cover wound with clear dressings. Con \201 rmation fl uid or air draining from pleural cavity, CXR (confi rmation of positio n and reduction of eff usion/pneumothorax). Complications failure to site drain in pleural cavity, pneumothorax, haemothorax, pain, bleeding (local/internal), damage to intercostal n erve, local or intrapleural infection, pulmonary oedema, visceral puncture. Safety chest dr ains should only be inserted out of hours in an emergency or if patient has signifi cant re spiratory compromise. Do not attempt this procedure without direct senior supervision. If i nserting a drain for fl uid (ie not for pneumothorax) ultrasound guidance is strongly recom mended. Alternatives narrow-bore pigtail chest drains can be inserted under ultrasound guid ance by a radiologist, but these block easily if the fl uid drained is too viscous. Traditi onal wide-bore chest drains are predominantly used in trauma cases (see box). Hints and tip s make sure both you and the patient are comfortable before you start; use suffi cient LA. OHFP.indb 540 OHFP.indb 540 30/05/2014 16:18 30/05/2014 16:18 541 CHEST DRAIN (SELDINGER METHOD) (a) Base of axilla Lateral edge of pectoralis major Lateral edge of latissimus dorsi Border of 5th intercostal space (b) Base of axilla Lateral edge of pectoralis major Lateral edge of latissimus dorsi Border of 5th intercostal space Fig. 16.16 (a) Position of the patient for chest drain insertion. Ask the patient to lean f orwards over a table or the back of a chair, since this opens up the rib spaces and prevent s them from moving too much. Aim for the safe triangle (see Havelock, T. et al. Pleural pro cedures and thoracic ultrasound: British Thoracic Society pleural disease guideline 2010 Th orax 2010 65(Suppl 2):ii61 for further information, available at (cid:27)www.brit-thoracic. org.uk). (b) Alternative position of the patient for chest drain insertion. Position the pa tient at about 45 with their arm above and behind the head, exposing the axilla. Removing a chest drain \200 Leave the drain unclamped \200 Remove dressings from skin \200 Clean skin with Betadine or chlorhexidine \200 Remove all sutures \200 Gently b ut fi rmly remove drain as patient exhales; occlude wound \200 Re-suture mattress sutures around drain site (b p560) \200 Apply sterile dressing. Sutures should stay in for 5d \200 CXR to ensure no pneumothorax has developed during drain removal. p p g Surgical chest drain \200 Used in the management of trauma to drain haemothoraces and pne umothoraces. A wide-bore (32 or 36Ch) chest drain is used. These often come with a metal tr ochar, which should be discarded before drain insertion Landmarks, local anesthesia and aseptic technique as per Seldinger drains. Patient is normally lying in position (b) in Fig. 16.16 Skin is incised using a scalpel, followed by blunt dissection to the pleural space using a curved clamp and your fi nger. Never insert a chest drain into a pre- existing chest wound The tip of the drain is gripped with the curved clamp and advanced into the pleural space. The drain is then secured in place with a mattress suture and connected to the chest drain bottle Confi rmation of position as per Seldinger drains. Decompression of tension pneumothorax see b p279. _OHFP.indb 541 _OHFP.indb 541 30/05/2014 16:18 30/05/2014 16:18 542 CHAPTER 16 Procedures ) Endotracheal intubation (adult) Diffi culty 5/5 Consent assumed if unconscious ( Level F2 Emergency indications securing a defi nitive airway in the unconscious patient and protecti ng the lungs from gastric contaminants. Contraindications absolute a conscious or semi-cons cious patient, inex- perienced operator; relative upper airways obstruction from foreign bo dy, known or suspected cervical fractures, laryngeal oedema/trauma. y g Equipment endotracheal tube (ETT), 7 \200\2238mm internal diameter for a woman, 8 \200\2239 mm for a man; have smaller tubes available. 10ml syringe and water-based lubricant. Working laryngoscope (commonly size 3 and size 4 Macintosh) and spare laryngoscope in case batteri es fail. Bougie and Magill forceps. Stethoscope. Guedel, and nasopharyngeal airways. LMA si zes 3, 4, and 5. Bag and mask for pre-oxygenation. Tape to secure ETT and suction with yank er attached. CO2 monitor is essential. Gloves. Patient position laying fl at, with single p illow under neck to achieve \200\230sniffi ng morning air \200\231 position (neck fl exed, head extended). Procedure an IV induction agent and a muscle relaxant must be given in a non-arrest situati on, but this should only be undertaken by someone who is experienced and well rehearsed in intubating in an emergency and in the presence of a skilled assistant who can apply cricoid pressure. Check equipment and lubricate the ETT with aqueous gel. Pre-oxygenate the patien t for 3min with 15l/min O2 if time allows using the bag and mask, assisting their ventilati on if it is inadequate. Once induction agent and muscle relaxant have worked, remove mask, tilt head backwards (unless there is C-spine injury) and open the mouth. Holding the laryng oscope in your left hand, advance the tip of the laryngoscope blade between the teeth on th e right-hand side of the patient \200\231s mouth over the top of the tongue. Sweep the tong ue to the left of the patient \200\231s mouth. Advance the laryngoscope in the midline unti l the uvula can be seen, then advance further until the epiglottis is visualized (Fig. 16.1 8). Lift the laryngoscope away from you, do not lever as this will break the patient \200 \231s teeth. As you lift the laryngoscope, the epiglottis should also be lifted and the voc al cords and the opening into the trachea (the glottis) visualized. Take the ETT in your ri ght hand and pass it through the mouth and observe it passing between the vocal cords. When the ETT is at about 20cm at the lips the assistant should infl ate the cuff ; gently remov e the laryngoscope, holding the ETT securely in place. Attach the CO2 monitor and re-infl a ting bag to the ETT and gently squeeze. Once satisfi ed with the position of the ETT allow assistant to release cricoid pressure and secure ETT in place with tape and continue to ven tilate, giving sedatives/hypnotics as required. Con \201 rmation the chest should rise and fall, the ETT should mist up and the CO2 monito r should detect CO2 as the chest falls. Auscultate in both axillae for breath sounds and ov er the epigastrium to exclude air entering the stomach. Obtain a CXR to check the ETT is no t in too far, as it is often past the carina in the right main bronchus. See Fig. 16.18. OHFP.indb 542 OHFP.indb 542 30/05/2014 16:18 30/05/2014 16:18 543 ENDOTRACHEAL INTUBATION (ADULT) Endobronchial intubation can often be detected clinically prior to check X-ray, allowing ad justment of tube position and hopefully decreasing need for repeated imaging. Complications failure to visualize the vocal cords \200\223 revert to bag and mask ventila tion Guedel/nasopharyngeal airway, or attempt to put in an LMA until expert help arrives . Oesophageal intubation \200\223 no air entering chest, no CO2, gurgling in stomach; remo ve ETT immediately and revert to bag and mask ventilation Guedel/nasopharyngeal airway, or attempt to put in an LMA until expert help arrives. Endobronchial intubation \200\223 d iffi culty in ventilating the patient, only one side of the chest wall moves and breath sou nds only audible on that side; withdraw the ETT a centi- meter at a time and re-check. Safety never undertake this procedure on your own. If in doubt bag and mask ventilate a pat ient until expert help arrives or insert an LMA if appropriately trained to do so (see b p5 44). You will never be criticized for supporting an obtunded patient \200\231s breathing wi th bag and mask ven- tilation alone with a Guedel airway in situ, but you will be if you un suc- cessfully undertake a procedure you are unfamiliar with and untrained to perform. Hints and tips speak to a friendly anesthetist and ask to go to theater to watch and help a t intubations and other airway skills. Tongue Epiglottis Vocal cord Trachea Esophagus Fig. 16.17 Structures which should be visible at laryngoscopy. Laryngoscope ETT Epiglottis Nasopharynx Trachea Esophagus Fig. 16.18 Position of the laryngoscope and ETT once inserted. _OHFP.indb 543 _OHFP.indb 543 30/05/2014 16:18 30/05/2014 16:18 544 CHAPTER 16 Procedures Laryngeal mask airway (LMA) Contraindications, consent, equipment and positioning as for in tubation. Sizes: women 3 or 4, men 4 or 5. Procedure as for intubation. Check equipment and check that cuff on LMA works and there is no leak; apply a small amount of lubrication to the top of the LMA around the cuff . Once t he patient is adequately pre-oxygenated and sedated, remove mask, tilt head backwards (avoi d if C-spine injury), and open mouth. Standing at the patient \200\231s head, take the LMA in your right hand holding it like a pen with the black line on the LMA shaft facing you. S lide the LMA along the roof of the mouth fi rmly and smoothly. Keep advancing until the mas k of the LMA disappears from view and it reaches a natural stop. Infl ate the cuff with the required volume of air (documented on the LMA itself ). Attach the CO2 monitor and re-infl ating bag to the LMA and gently squeeze. Once satisfi ed with the position of the LMA, sec ure it in place with tape and continue to ventilate, giving sedatives/hypnotics as required . See Fig. 16.19. Con \201 rmation the chest should rise and the CO2 monitor should detect CO2 as the chest falls (exhalation). Auscultate in both axilla to listen for breath sounds. If unsure, remov e, re-oxygenate with a bag and mask and attempt once more. Complications failure to ventilate the patient revert to bag and mask ventilation Guedel /nasopharyngeal airway and reattempt once more. If still unsuccessful revert to bag and mas k ventilation Guedel/ naso-pharyngeal airway until expert help arrives. Safety never undertake this procedure on your own. If in doubt, bag and mask ventilate a pa tient until expert help arrives. You will never be criticized for supporting an obtunded pa tient \200\231s breathing with bag and mask ventilation alone, but you will be if you unsuc cessfully undertake a procedure you are unfamiliar with and untrained to perform. Hints and tips speak to a friendly anesthetist and ask to go to theater to watch and help a t inserting an LMA and other airway skills. LMA Epiglottis Nasopharynx Trachea Esophagus Fig. 16.19 Position of an LMA once inserted. OHFP.indb 544 OHFP.indb 544 30/05/2014 16:18 30/05/2014 16:18 This page intentionally left blank 546 CHAPTER 16 Procedures Urethral catheterisation Consent verbal Level F1 Diffi culty 2/5 Indications monitor urine output/fl uid balance, urinary retention, incapacitation (eg dGCS ), incontinence, urological investigations. Contraindications absolute competent patient re fusal; relative suspected urethral injury, urethral strictures/fi stulas, active UTI, prost atic tumor or hypertrophy. Site via urethra into bladder. Equipment catheter pack (kidney dish, bowl, cotton balls, sterile towel and gloves), Foley catheter (10 \200\22316F), antiseptic solution, gauze, 10ml 1% lidocaine/lubricant gel in p re-fi lled syringe, 10ml saline-fi lled syringe, catheter bag. Checks no latex allergy/UTIs , correct sex catheter. Patient position lying on back, genitalia exposed (legs apart in wo men). Procedure wash hands and wear sterile gloves. Prepare the equipment, using aseptic techniqu e. Ask an assistant to pour antiseptic solution into the sterile bowl. Male create a hole i n the center of the towel and drape it over the patient with the penis through the hole. Ho ld the penis with gauze in your non-dominant hand. Retract the foreskin and clean the penis with antiseptic. Hold the penis upright and instill 10ml lidocaine gel into the meatus. Oc clude the penile tip to help push the gel along the urethra. Allow 2min for the anesthetic to take eff ect, lubricate the tip of the catheter with lubricant. Put the kidney bowl betw een the patient \200\231s thighs and place the draining end of the catheter in it. Using yo ur clean hand insert the catheter tip into the urethra and advance. Continue to advance the catheter to the hilt once urine starts draining to make sure the catheter balloon is withi n the bladder. Once urine is seen to fl ow, infl ate the balloon with 10ml water via the si de port. Stop if there is pain or discomfort. Disconnect the syringe and pull back the cath eter until you feel resistance. Attach a draining tube and bag to the free end of the cathe ter. Clean and redress the patient. Always replace the foreskin. Female (Fig. 16.20) usuall y performed by nurses. Drape the sterile towel between the patient \200\231s thighs. Separa te labial folds with your non-dominant hand and clean with antiseptic solution. The urethra is between the vagina and clitoris. Continue as for a male patient. If the catheter is inc orrectly inserted into the vagina, do not reuse it to catheterise the urethra, leave it in situ and use a fresh, clean catheter to try again. Con \201 rmation urine drains freely, no pain on infl ating balloon. Complications pain, i nfection, local trauma, haematuria, strictures (long-term), retention on removing catheter. OHFP.indb 546 OHFP.indb 546 30/05/2014 16:18 30/05/2014 16:18 547 URETHRAL CATHETERISATION Safety never force the catheter or fi ll the balloon under force. Alternatives coude-tip ur ethral catheter (curved tip to aid insertion past an enlarged prostate), insertion using gu idewire fl exible cystoscopy, or suprapubic catheter \200\223 seek senior advice (see b p548). Hints and tips \200 Double glove on your dominant hand and remove the top glove once you have fi nished cleaning the genitalia so that you remain sterile when handling the catheter Avoid touching the lubricant gel with the hand holding the catheter as this makes the catheter slippery and diffi cult to grip and insert Try not to touch the catheter; it usually comes in a plastic cover which can be shuffl ed d own or torn away as you insert it into the urethra \200 If you feel resistance at the pro static urethra hold the penis vertically and try to advance the catheter The urethra is 4 \200\2237cm in women so urine should be seen after 8cm; the male urethra i s much longer (20cm) so the catheter must be inserted further If no urine appears check the catheter is in the correct place and advanced far enough; fl ush the catheter with saline to make sure it is not blocked with lu bricant gel \200\223 if you still do not get urine, do not infl ate the balloon, remove th e catheter and seek senior advice Urine samples can be taken from a catheter (CSU) \200 Start with a 14F silastic catheter if catheterising a patient for the fi rst time. Should urine leak around the catheter once inserted, it will need to be replaced with a wider catheter 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.