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Emergency Procedures

PREFACE

The Emergency Procedures is written by the fourth year medical students of University Malaya .The book has been prepared during our A&E posting .Procedures that are usually done in A&E department has been focused and are written in a simple and understandable way .With the advent of the internet, a direct link to the video has been added to help the reader to get a better understanding of the procedures. We hope that this book will be a useful guide for our juniors going through Emergency Medicine posting in future. We wish to thank Dr Rishya Manikam (Head of Department of A&E at UMMC) who has helped in many ways for guiding the preparation of this book. Despite his tight and busy schedule, he has taken the initiative to come up with a simple and targeted guide for 4th year medical student to grasp the important knowledge throughout the limited 2 weeks posting. His understanding and personal experience as a medical student during his younger days inspired him to come out with his own module that hopefully will benefit the students fruitfully during the short course of posting. In the near future, he plans to make this book available electronically so that students can assess the knowledge anywhere, anytime whether on the Iphone, Ipad or laptop. Medical students worked as a group; sacrificing their scarce leisure time to compile this book. During the course of completing this book, we faced many difficulties owing to the fact that we are busy with our classes and also on-calls in A&E up to the wee hours of the morning. However, with the help of Dr. Rishya Manikam and the rest of his team, we managed to overcome the obstacles and finally came up with this book. On behalf of the 2008/2013 batch, we hope the incoming juniors in future will continue to improve and add-on to this book for the benefits and betterment of the emergency medicine practice amongst students. We also sincerely hope that our juniors will take the trouble to regularly update and review on the best emergency management options available during their time of posting. Thank you very much.

Editor NOV 2011 TOK ERN LAI

CONTENTS
1. Oxygen mask by Tok Ern Lai 4 2. Blood taking by Leong Ya Shan..6 3. Taking vital signs by Chiew Ai Wen...8 4. AED by Mohd Luqman bin Sahar..11 5. Cervical collar by Yvonne Ling....13 6. Nebulizers by Tan Chen Long.....15 7. Urinary Catheter by Alfred Tan...16 8. Helmet removal by Taye Zhi Ling. 18 9. Immobilisation by Taye Zhi Ling.. 19 10. Suturing by Raechell ...21 11. Arterial blood gas Maleenawati Letchumanan..23 12. Paracentesis by Fidraus Hariri..25 13. Chest tube insertion by Muhammad Syafiq..28 14. Nasogastric tube by Zuliyasmin binti Zulkifli..31 15. CPR by Koh Wei Jun.33 16. Intubation by Nur Syazwani Jamhuri.35 17. IV line by Al Malek Hussien. 39 18. ECG by Hidayat Shariff 41

Oxygen Mask Purpose Deliver low to moderate levels of oxygen to relieve hypoxia. Indication Types
Types O2 concentrations(%) O2 flow rates(L/min)

Cardiac and respiratory arrest Hypoxaemia with PaCO2<5.3 kPa Hypotension (systolic blood pressure <100 mm Hg) Low cardiac output and metabolic acidosis (bicarbonate<18 mmol/l) Respiratory distress (respiratory rate >24/min)

1. Nasal prong 24-44 1-6

2. Simple oxygen mask

40-60

10

3. Partial rebreather mask 4. Nonrebreather mask

50-70

5-15

80-90

10-15

5. Venturi mask 24-50 4-10

Precedures 1. Explain procedure to patient and review safety precautions necessary when oxygen is in use. (Dont smoke) 2. Perform hand hygiene. 3. Attach face mask to oxygen setup with humidification. Start flow of oxygen to fill bag before placing mask over patients nose and mouth. 4. Position face mask over patients nose and mouth. Adjust it with the elastic strap so mask fits snugly but comfortable on face. 5. Use gauze pads to reduce irrigation on patients ears and scalp. 6. Perform hand hygiene. 7. Remove mask and dry skin every 2 to 3 hours if oxygen is running continuously. 8. Assess and chart patients response to therapy.

Complication Discomfort Dryness of the skin cause by O2

Reference http://www.youtube.com/watch?v=UXCckItO7ys

EQUIPMENT REQUIRED USING THE VACUTAINER SYSTEM

A Tourniquet which should be applied at a pressure which is high enough to impede venous distension but not restrict arterial. This allows blood to flow into the arm but stops it from leaving, causing the veins to fill with blood and become prominent. A sterile alcohol swab to clean the puncture site. The area must be allowed to dry first otherwise the alcohol base may seep into the puncture site causing the patient discomfort. Research has shown that although cleansing of the skin reduces the number of bacteria present on its surface, it is not necessary to prevent infection prior to parenteral procedures A vacutainer system sample bottle holder An appropriately sized needle designed for use with the vacuum system Cotton wool to apply to the puncture site following the procedure A sterile plaster or hypoallergenic tape to secure the cotton wool Specimen bottles and requisition form correctly filled in with the patients details, Diagnosis, G.Ps /Consultants details and signed. Sharps disposal bin for the safe disposal of the specimen tube holder and needle

PREPARATIONS PRIOR TO CARRYING OUT THE PROCEDURE

It is important that patient distress and inconvenience is minimised, and it must always be remembered that painful venepuncture and unsightly bruising can leave a lasting impression. Careful and unhurried preparation will all help to alley the patients fears/anxieties With the patient seated, begin by explaining the procedure to him/her, answering any questions they may have and ensuring that the patient has given their verbal consent for you to carry out the procedure. The patient should be asked whether or not they have had any blood taken in the past, and when (as any recent sites should be avoided). Whether they are aware of any particular problems encountered and of the best sites available. After checking that the light is adequate and all the written information has been obtained, the procedure can be carried out.

CARRYING OUT THE PROCEDURE

After washing her hands, the practitioner should apply the tourniquet to the patients upper arm. If the arm is placed in a dependent position and the patient asked to clench and release their fist this will help to increase the prominence of the veins. we should then palpate the area with our index and middle finger to select a vein and also to allow us to distinguish such structures as arteries, tendons etc. The selected vein should be firm and bouncy. The needle should be inserted along the length of the vein at an angle of

approximately 30 degrees. The tip of the needle should be inserted through the skin into the vein in one continuous movement with the bevel of the needle facing upwards.Check for back flow of blood into needle. Once the needle is in the correct position, the required vacuumed bottles are then attached will each then draw up the required amount of blood for each test. Once the required amount of blood has been collected into the bottles, and the last bottle detached from the needle, the tourniquet should then be released and a cotton wool ball placed over the point of entry. At the point the needle should then be removed and discarded. DO NOT recap needle. pressure should be applied over the entry site for approximately 2 minutes to stop any further bleeding. The arm should be kept straight and not bent, as the latter enlarges the entry hole causing more bleeding and bruising. A sticking plaster or hypo-allergenic dressing may then be a applied to the site once the bleeding has stopped. NB. Care should be taken with patients who have a history of bleeding disorders or who have been taking warfarin or other anti-coagulants, as this may increase the time it takes for the bleeding to stop.

IMPORTANT POINTS TO REMEMBER

If the tourniquet has been on for longer that 2 minutes prior to insertion of the needle, then it should be released to allow blood to return to the hand before reapplying, and attempting the procedure again. If a venous valve is entered during the procedure the patient will experience sudden, acute pain. The procedure should be then discontinued immediately. If after 2 attempts the procedure has been unsuccessful, then assistance should be sought from a colleague. The Patient should be observed throughout the procedure for signs of dizziness or fainting. BE AWARE, the Brachial Artery is sited near the sites most commonly used for venepuncture. Procedure is the same by using a syringe.

http://www.youtube.com/watch?v=_8ZsqXFqvQM&feature=related http://www.youtube.com/watch?v=9pIWn6i1VZs

Taking Vital Signs Measurement of Temperature (Digital Thermometer, Mercury Thermometer) For Oral Temperature 1. Turn on the thermometer and wait for the display to flash indicating that it is ready. Shake the thermometer using a vigorous wrist movement until the mercury reading is below 35 degree celcius. 2. Do not hold the thermometer at the measurement portion 3. Put the thermometer in the thermometer sheath. 4. Check patient has not taken any warm/hot drinks/food at least 15 mins prior to the measurement. (if yes, give water or measure axillary temperature or wait) 5. Instruct the patient to open his/her mouth and lift his/her tongue and insert the thermometer as far back as possible under the tongue 6. The patient is to close his/her lips tightly. 7. Wait for completion beeps. Leave the thermometer in place for at least 1min but no longer than 2mins. 8. Remove the sheath, hold the thermometer horizontally at your eye level. 9. Read the display and record the temperature reading and switch off the thermometer. Read and record the temperature reading. 10. Clean the thermometer with soapy water or alcohol swab. For Axillary Temperature 1. Start with steps 1-3 above. 2. Ensure the axilla is dry. 3. Place the measurement end of the thermometer high in the axilla, against the torso and perpendicular to the length of the body. 4. Use the patients arm to hold the thermometer in place. 5. Leave the thermometer and wait for completion beeps. Leave the thermometer completely covered for 3mins, but not longer then 5mins. 6. Read and record the temperature reading. For Rectal Temperature 1. Start with steps 1-3 above. 2. Ensure privacy and keep patient comfortable. 3. Position the patient in the left lateral position. 4. Apply lubricant to sheathed thermometer and insert into anus. 5. Leave the thermometer and wait for completion beeps. Leave the thermometer for 2-3mins then record the reading.

Normal Temperature Range Armpit: 34.737.3 C (94.599.1 F) Mouth: 35.537.5 C (95.999.5 F) Ear: 35.838 C (96.4100.4 F) Rectum: 36.638 C (97.9100.4 F)

Measurement of Pulse Rate 1. Place your index and middle fingers over the radial artery at the wrist, or the brachial artery at the ante-cubital fossa or the carotid artery in the neck. 2. Count the number of beats over 60 seconds. 3. Describe the rate, rhythm, strength and characteristic of the pulse. 4. Consider comparing pulses on the right with those on the left (radi0-radial delay). 5. Compare radial pulse and femoral pulse for radio-femoral delay. Normal Heart Rates by Age Group at Rest Newborns 100-160 bpm Infants 80-150 bpm Preschool children 80-130 bpm Older children 70 100 bpm Adults 60 100 bpm Measurement of Respiratory Rate 1. Place 2 fingers on the patients radial artery. 2. While still palpating the patients pulse, observe the patients breathing (by observing the patients chest wall movement) (if cant see chest wall movement, put your hand at the back of patient). 3. Ensure that the patient is unaware of the actual observation. 4. Count respirations for one minute. 5. Record the result. Normal Respiratory Rate Newborns 30-50 breaths per minute Infants 20-40 breaths per minute Preschool children 20-30 breaths per minute Older children 16-25 breaths per minute Adults 12- 20 breaths per minute Measurement of Blood Pressure 1. The patient should be seated with their arm resting on a table so the brachial srtery is level with the heart (4th intercostals space at the sternum). 2. Ensure no tight clothing is constricting the arm. 3. Select the blood pressure cuff which is long enough to nearly encircle the arm. 4. Select the blood pressure cuff of appropriate width (2/3 of the length of the upper arm). 5. Place the centre of the cuffs bladder medially over the brachial artery (dont use thumb the locate the brachial artery). 6. The cuff should be positioned so that the lower edge is about 2cm above the elbow. 7. Wrap the cuff snugly around the patients upper arm. 8. Check that the mercury column of the manometer is vertical. 9. Close the valve on the pump tubing.

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10. Palpate the brachial artery or the radial artery. 11. Inflate the cuff until the pulse disappear and inflate to a further 20mmHg. 12. Deflate the cuff at a rate of 1-2mmHg per second and the pressure at which the pulse is palpable is the estimated systolic blood pressure. 13. Deflate till 0mmHg immediately. 14. The bell of the stethoscope is placed medially in the ante-cubital fossa, over the brachial artery. The stethoscope should not be placed under the cuff. 15. Inflate the cuff to 20mmHg above the estimated systolic blood pressure reading that you made. 16. The valve on the pump is loosened slowly to allow the pressure of the sphygmomanometer cuff to decrease slowly at about 1-2mmHg/sec. 17. The scale should be read at eye level. 18. Record the level at which you first hear the pulse (first Korotkoff sound = systolic) to the nearest 2mmHg. 19. Continue allowing the pressure to decrease and record the disappearance of sound (fifth Korotkoff sound = diastolic) to the nearest 2mmHg. 20. Record whether patient was standing, sitting or lying during BP measurement and which limb is used. http://www.youtube.com/watch?v=q4A1uLNzNOc&feature=related

By Chiew Ai Wen

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AUTOMATED EXTERNAL DEFIBRILLATOR

Portable electronic device that can audibly prompt and deliver an electric shock that will disrupt or stop the heart's dysarhythmic electrical activity.

Treat sudden cardiac arrest (SCA).

SCA Condition in which the heart suddenly and unexpectedly stops beating. Most common cause is ventricular fibrillation and ventricular tachycardia. Sign and Symptoms Fainting No pulse *Palpitation *SOB *Chest pain *Dizziness *within 1 hour before fainting

PURPOSE
To analyze a heart rhythm Identify shockable or nonshockable heart rhythms Guide an AED operator to initiate defibrillation Delivers an electric shock which is will discharge all electrical activity of cardiac to stop the useless quivering of the heart.

INDICATION Adult and children 1 year old and above that are: Unresponsive Non breathing Pulseless * AED not recommended for infant less under 1 year old. CONTRAINDICATION
Present of pulse Conscious patient Touching patient Wet patient Implanted defibrillator

Shockable rhythm Ventricular fibrillation Ventricular tachycardia Nonshockable rhythm Normal sinus Pulseless electrical activity(PEA) Asystole

SAFETY CONSIDERATION
No metal No water Remove medication patches At least 1 inch away from pacemaker and implanted defibrillator Remove excessive chest hair Remove electrical device

Sign of shock has been delivered Arching of the back Brief straightening of arm *muscular contractions reduce with each shock *no contractions noted in patient that already arrest for prolonged period.

LANDMARKS FOR ELECTRODE PLACEMENT

Adults : Upper : right sternal border directly below the clavicle Lower : left midaxillary line 5th-6th intercostal space with top margin below the axilla.

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Small child : Anterior : one pad over sternum between nipples Posterior : one pad between shoulders blade

Normal sinus

Ventricular fibrillation Large child : Anterior and posterior as above Anterior and anterior- pads must not touch a. Right pad wrap over childs shoulder b. Left pad left anterior to cover midclavicular and midaxillary line

Ventricular tachycardia

PROGNOSIS AFTER SHOCK DELIVERED

Pulse present + breathing- place patient in recovery room Pulse present w/o breathing- ventilate patient No pulse + AED indicates no shock- continue CPR No pulse + AED indicates shock- clear and follow voice prompt

PEA (electrical activity normal but patient cardiac muscle problem or severe hypovolemia)

EQUIPMENT
Following supplies are maintained in each AED unit : 1. One AED 2. One users guide 3. Two sets of electrodes 4. One installed battery and one spare 5. One installed PC data card 6. One carrying case 7. One mouth barrier device 8. One pair of scissors 9. Two sets of gloves 10. One razor 11. 44 gauze

Asystole

Artifact (loose leads or patient move)

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CERVICAL COLLAR
CERVICAL COLLAR
A cervical collar (also neck brace) is an orthopaedic medical device used to support a patient's neck and head. It is also used by emergency personnel for victims of traumatic head or neck injuries, and can be used to treat chronic medical conditions.

INDICATIONS

Neck Extension Injuries (Whiplash) Cervical Spondylitis Cervical Spondylosis R/A & O/A Cervical Spine Herniated Cervical Disc

INSTRUCTION
1. Size the collar -Use your fingers to size by putting your hand as shown with the small finger on the trapezium and count your fingers to jaw line. 2. Put your hand on the side of the collar, your small finger to the bottom edge, and the correct number of fingers to the marker pin. 3. Get some one to support the head so there is no movement while it is fitted. Always explain to the patient what you are doing. 4. Immobilisation can be constructed from several different materials. It needs head blocks and sufficient straps to make it effective

TYPES
There are four types of cervical collar : 1. 2. 3. 4. Aspen Collar Miami-J Collar Soft Foam Collar Philadelphia Collar

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ALL CERVICAL COLLARS: 1. Must be worn moderately snug to limit motion. 2. Must be worn according to specifics outlined above based on type of collar used. 3. May be washed and/or liners may be changed. 4. Must be kept clean and dry to protect skin integrity. 5. Duration of time wearing the collar and amount of time during the day wearing the collar are always patient specific and will be determined by your physician.

COMPLICATIONS
Development of skin pressure points and ulcer formation Possible delay in weaning from ventilator Potential to exposure for blood borne disease

REFERENCES:
1.http://www.med.umich.edu/op/Patient%20Education%20Forms/5A/Cervical%20Collars.pdf 2.video: http://www.youtube.com/watch?v=rkDTnFOic9w&feature=autoplay&list=ULknAMhmmg5gU&lf=mf u_in_order&playnext=1 (with immobilisation) 3.video: http://www.youtube.com/watch?v=knAMhmmg5gU&feature=mfu_in_order&list=UL

15 Types
1) Jet nebulizers (most common): a nebulizing chamber in which an aerosol is generated with a flow of gas provided either by an electrical compressor or compressed gas (air or oxygen). 2) Ultrasonic nebulizers: self-contained electrical devices in which an aerosol is generated by vibrating fluid placed within them; nebulize larger volumes of fluid& are quiet.

Aim
- deliver a therapeutic dose of desired drug as an aerosol in the form of respirable particles within a fairly short period of time, usually 5-10 minutes.

Method of inhalation
-Patient should sit upright or in a chair -Take normal steady breaths (tidal breathing) -Not to talk during nebulization -Keep the nebulizer upright

Nebulizers
Tan Chen Long

Indications
1) Most common: emergency treatment of asthma and exacerbations of COPD. 2) Less frequently: -long term treatment of chronic air flow obstruction with bronchodilators. -prophylactic drug tx- e.g. corticosteroids in asthma. -antimicrobial tx in cystic fibrosis, bronchiectasis, AIDS. -symptom relief in palliative care

Drugs for nebulization

1) Bronchodilators: agonists (salbutamol, terbutaline); anticholinergics ( ipratropium bromide). 2) Steroids: budesonide 3) Antibiotics: colistin& gentamicin for cystic fibrosis 4) Pentamidine: prophylaxis for Pneumocustis carinii pneumonia in HIV positive patients. 5) Lignocaine: in terminal care to relieve cough.

N.B. Water should not be used as it may cause bronchoconstriction when nebulized.

Demonstration of nebulizer use: http://www.youtube.com/watch?v=svG5S2wn4xQ

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Urinary catheterization
Introduction Urinary catheterization or Foley catheterization as it is commonly referred to be an invasive procedure. It involves introducing a plastic or rubber tube into the urethra then advancing the tube into the bladder. Once in the bladder the catheter provides for a continuous flow of urine. Indications for urinary catheterizations are: Collection of sterile urine sample. Provide relief of discomfort from bladder distention. Decompression of the bladder. Measure residual urine. Management of patients with spinal cord injury, neuromuscular degeneration, or incompetent bladders. Contraindications are: Blood at urethral opening. Injury to genitalia or urethra Pelvic injuries

Risks associated with catheterization include: Urethral trauma and bleeding from inappropriate catheter size or use of force. Urinary tract infections related to poor sterile technique or long-term catheterization. Bladder spasms and pain

Equipment: Sterile gloves, Cleansing solution, Cotton swabs, Forceps, Sterile water, Foley catheter, Syringe, Lubricant Collection bag and tubing

Sizes of catheters: Diameters: 5Fr, 6fr, 8fr 10fr, 12fr, 14fr, 16fr, 18fr, 20fr, 22fr, 24fr, 26fr. The higher the number the larger the diameter of the catheter. 1Fr. = 3mm (i.e. a 24fr. catheter is 8mm in diameter)

Pediatric catheterization: Size- 5, 6, 8, 10Fr. or smaller depending on the size of the urethra and age of child.

Male catheterization: 16Fr. or 18Fr. catheter is typically used for most men, as they are more rigid and often easier to insert past the prostate.

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Female Catheterization: 12fr., 14Fr.or 16Fr. catheter is typically used.

Steps in Catheterization: Male*: In non-circumcised men, retract the foreskin slightly Cleanse the glans penis Hold the penis upright and extended with your non-dominant hand Instil anaesthetic gel into the urethral meatus Wait for the anaesthetic gel to take effect (3-4mins) Hold the catheter in your dominant hand Place the catheter tip in the urethral meatus and advance it slowly until the base of penis, then bend the penis down and continue insertion slowly On completing the procedure, reposition the foreskin

*http://www.youtube.com/watch?v=DIImiBjjuKQ Female`: Place the catheter tip in the urethral meatus and advance it slowly If there is resistance at the bladder sphincter ask the patient to cough while you continue to advance the catheter Continue to advance the catheter until urine drains Advance the catheter another 10cm Inflate the balloon with sterile water Withdraw the catheter until the balloon gently abuts the bladder neck Connect the urine bag to the catheter Unclamp the urine bag Stray the catheter to the patients thigh ensuring that it is not pulling on the urethra

`http://www.youtube.com/watch?v=d8WxqIs9vUw Confirmation: Urine will be drained out. Complication: Urethristis Cystitis Pyelonephritis Transient bacteremia

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Name: Helmet removal

Indication: - Gives providers access to a patient's airway and allows them to stabilize the patient's head and neck Contraindication: - Paresthesia or neck pain during the removal procedure. Paresthesia suggests worsening stretch or pressure on nerve endings as they exit the spinal column. Technique:

1)

First rescuer maintains inline immobilization by placing his hands on each side of the helmet with the fingers on the victims mandible. This position prevents slippage if the strap is loose.

2) The second rescuer cuts or loosens the strap at the D-rings. 3) The second rescuer places one hand on the mandible at the angle (the thumb on one side, other fingers on the other) and the other hand apply pressure from the occipital region. This manoeuvre transfer inline immobilisation responsibility to the second rescuer. 4) The rescuer at the top moves the helmet. Three factors should be kept in mind: The helmet is egg shaped and therefore must be expanded laterally to clear the ears If the helmet provides full facial coverage, glasses must be removed first. If the helmet provides full facial coverage, the nose may impede removal. To clear the nose, the helmet must be tilted backward and raised over it. 5) Throughout the removal process, the second rescuer maintains inline immobilization from below to prevent unnecessary neck motion. 6) After the helmet has been removed, the rescuer at the top replaces his hands on either side of the victims head with his palms over the ears. 7) Inline immobilization is maintained from above until a backboard is in place and a cervical immobilization device (collar) is applied. Complications: Worsen an extant cervical spine injury. References: http://www.facs.org/trauma/publications/helmet.pdf

http://emedicine.medscape.com/article/1413407-overview

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Name: Immobilisation Indications: - Prevent an injured area from moving and reduce the chances of further injury by holding a joint or limb in place with a splint or sling. Equipments: Splints - Used to immobilise an injured arm or leg immediately after an injury. Slings - Used to support the arm after a fracture or other injury. They are generally used along with a splint, but sometimes are used alone as a means of immobilisation. Traction - Applies tension to correct the alignment of two structures (such as two bones) and hold them in the correct position as well as reduces the pain. Cervical Collar - Used to support the neck when there has been a suspected fracture in one of the bones of the neck. Spinal Board - Used in conjunction with a collar for the treatment of a suspected cervical or back injury to maintain inline immobilisation. Vacuum Mattress - Used for the immobilisation of patients, especially in case of a neck, back, pelvis or limb trauma as it moulds to their contours and makes the journey far more comfortable than a spinal board. Kendrick Extrication Device or KED - A device that is used in vehicle extrication to remove a casualty.

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General Principles: Always assume a fracture Treat fractures before moving unless safety of yourself or the patient prevents this Support and immobilise the affected area to prevent further movement Immobilise fractures using padding, blankets, bandages or splints (Vacuum or box). Put patient in a comfortable position with affected part elevated to reduce swelling. Do not put pressure on the site of an injury. Gently pad an open wounds Use the body's natural hollows to pass bandages to opposite side of injury. (Under knees, ankles and small of back. etc) Always check that bandages are not reducing circulation to affected part if the limb starts to swell. (capillary refill and distal pulse check) Immobilise the fracture above and below point of injury and never over the top. References: http://www.ambulancetechnicianstudy.co.uk/immobilisation.html

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SUTURING I. Definition This procedure will take place when a percutaneous tube requires securing, or when a wound requires skin closure for proper healing. II. Indications 1. Percutaneous tube that is insecure; 2. Significant tenderness, erythema or irritation at current securing suture site; 3. Evidence of weeping, such as in ascites; 4. Accidental dislodgement of a suture. III. Precautions 1. The patient may need wound culture & antibiotics 2. Cellulitis should be determined 3. Effectiveness of the drain should be established 4. Appropriateness of wound condition for closure IV. Contraindications 1. If there is reddening and edema of the wound margins 2. Infection manifested by discharge or pus 3. Persistent fever or toxemia 4. Puncture wounds or animal bite 5. Tendon, verve, or vessel involvement 6. Any wound more than 12 hours old. With the exception of the face and hands V. Materials 1. Lidocaine 1%, 24g needle, 1cc syringe 2. Betadine swabs 3. Needle holder 4. Nonabsorbable/absorbable suture material (sizes range from 00 to 10-0) 5. Needle (curved needles; tapered or cutting ) 6. Forceps 7. Scissors 8. Gauze sponges VI. Suturing Procedure
Procedure: 1. clean area with betadine or similar appropriate solution 2. inject local anesthetic agent, allowing time for effectiveness 3. pierce the epidermis and the dermis at 90 degree angle 4. curve the needle and suture through the tissues, technique should allow for proper wound eversion 5. tie knot in a manner that minimizes wound tension 6. ensure the involved tube is secure and optimally positioned for comfort 7. dress the site as appropriate

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VII. Complications Immediate complications include the formation of hematoma secondary to improper hemostasis technique and the development of a wound infection. Prophylactic antibiotics have a role in protecting against wound infection. Late complications include scar formation, which may be due to either improper suturing with excess tension or lack of eversion of the edges. Additionally,hypertrophic scarring and keloid formation are unfortunate later complications of wound closure in some individuals. Other complications include stitch marks and wound necrosis. VIII. Special features Suture techniques Figure Knot tying (Square knot)
The long end of the suture is wrapped around the tip of the closed needle holder twice before grasping the short end of the suture with the needle holder. The first double knot is then pulled gently tight. Two (or three) further single throws are then added in a similar fashion to secure the knot. Each throw is pulled in the opposite direction across the wound edge.

Simple interrupted suture

The wound edge should be gently stabilised with either toothed forceps or a skin hook. The needle should enter perpendicular to the skin 3-5mm from the wound edge. Entering perpendicular causes a wider bite of deeper tissue to be included in the suture than at the surface and consequently causes more wound edge eversion and ultimately a superior cosmetic result with a thinner scar. The knot is then tied as seen in above figure.

Continuous suture
Using a continuous suture rather than multiple interrupted sutures offers a significant time saving. However,it is not as strong as interrupted sutures, and can strangulate the blood supply in wounds under more than minimal tension. An interrupted suture is performed, but only the free suture end is cut before the needle is reintroduced and directed diagonally across the wound to exit the skin on the other side.

Horizontal mattress suture

This suture is especially good for distributing wound tension across larger wounds particularly for the initial sutures. The disadvantage of this suture is the risk of strangulation of the dermal blood supply and subsequent edge necrosis.

Suture Removal If the sutures are taken out within 710 days, suture removal is usually easy and should not cause more than a pinching sensation to the patient. Cut the suture where it is exposed, crossing the wound edges, then remove the entire stitch by grabbing the knot with a clamp or forceps and pulling gently. IX. Reference
http://emedicine.medscape.com/article/1836438-overview#showall practicalplasticsurgery.org/docs/Practical_01.pdf

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http://dermnetnz.org/procedures/suturing.html

Arterial Blood Gas (ABG) Procedure : Arterial Blood Gas An arterial blood gas (ABG) test measures the acidity (pH) and the levels of oxygen and carbon dioxide in the blood from an artery. An ABG test uses blood drawn from an artery, where the oxygen and carbon dioxide levels can be measured before they enter body tissues. What is measured by an ABG? An ABG measures:

Partial pressure of oxygen (PaO2). This measure the pressure of oxygen dissolved in the blood and how well oxygen is able to move from the airspace of the lungs into the blood. Partial pressure of carbon dioxide (PaCO2). This measures how much carbon dioxide is dissolved in the blood and how well carbon dioxide is able to move out of the body. pH. The pH measures hydrogen ions (H+) in blood. The pH of blood is usually between 7.35 and 7.45. A pH of less than 7.0 is called acid and a pH greater than 7.0 is called basic (alkaline). So blood is slightly basic. Bicarbonate (HCO3). Bicarbonate is a chemical (buffer) that keeps the pH of blood from becoming too acidic or too basic. Oxygen content (O2CT) and oxygen saturation (O2Sat) values. O2 content measures the amount of oxygen in the blood. Oxygen saturation measures how much of the haemoglobin in the red blood cells is carrying oxygen (O2).

Indications An arterial blood gas (ABG) test is done to:

Check for severe breathing problems and lung diseases, such as asthma, cystic fibrosis, or chronic obstructive pulmonary disease (COPD). See how well treatment for lung diseases is working. Find out if the patients need extra oxygen or help with breathing (mechanical ventilation). Find out if the patients are receiving the right amount of oxygen when they are using oxygen in the hospital. Measure the acid-base level in the blood of people who have heart failure, kidney failure, uncontrolled diabetes, sleep disorders, severe infections, or after a drug overdose.

Procedure A sample of blood from an artery is usually taken from the inside of the wrist (radial artery), but it can also be taken from an artery in the groin (femoral artery) or on the inside of the arm above the elbow crease (brachial artery). A procedure called the Allen test may be done to ensure that blood flow to the hand is normal. An arterial blood gas (ABG) test will not be done on an arm used for dialysis or if there is an infection or inflammation in the area of the puncture site. The health professional taking a sample of the blood will:

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Clean the needle site with alcohol. You may give an injection of local anaesthetic to numb that area. Put the needle into the artery. Allow the blood to fill the syringe. Ensure your patient to breathe easily and be relax throughout the procedure. Put a gauze pad or cotton ball over the needle site as the needle is removed. Put a bandage over the puncture site and apply firm pressure for 5 to 10 minutes (possibly longer if the patient is on blood-thinning medicine or have bleeding problems).

What is an Allen Test? The blood supply to the hand normally comes from 2 arteries, the radial artery and the ulnar artery. Before drawing blood for an arterial blood gas test, the doctor will make sure that both arteries are open and working correctly. A procedure called the Allen test may be used to find out if the blood flow to the hand is normal.

For the Allen test, the doctor drawing the blood will apply pressure to the arteries in the wrist for several seconds. This will stop the blood flow to the hand; and the hand will become cool and pale. Blood is then allowed to flow through the artery that will not be used to collect the blood sample. This is usually the ulnar artery, which is found on the outer (little finger side) of the wrist. Arterial blood gases are usually taken from the radial artery. Normal (positive) Abnormal (negative) Hands quickly become warm and return to its normal colour. This means that one artery alone will be enough to supply blood to the hand and finger. Hand remains pale and cold. This means that one artery is not enough to supply blood to the hand and fingers. Blood will not be collected from an artery in this hand.

If the hand remains pale and cold, the Allen test will then be performed on the other hand. If the other hand also remains pale, the blood often will be collected from another artery, usually in the groin or elbow crease. Complications 1) 2) 3) 4) 5) 6) 7) 8) Pain Hematoma Haemorrhage Compression neuropathy Aneurysm Infection of site of puncture Thrombus formation Improper anticoagulant

References:

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1) Pagana KD, Pagana TJ (2010). Mosbys Manual of Diagnostic and Laboratory Tests, 4th ed. St. Louis: Mosby Elsevier. 2) http://www.youtube.com/watch?v=6ko6YbpO4AE&feature=related

PARACENTESIS Paracentesis or peritoneal tap provides is important procedure in the management of peritonitis. It was first performed and described by Solomon in 1906.

Indications 1. New onset ascites or ascites of unknown origin 2. Patient with a known ascites who has fever, abdominal pain, hypotension or encephalopathy 3. Symptomatic treatment of large ascites Contraindications 1. Uncooperative patient 2. Uncorrected bleeding diathesis 3. Acute abdomen that requires surgery 4. Intra-abdominal adhesions 5. Distended bowel 6. Abdominal wall cellulitis at the site of puncture 7. Pregnancy Equipment 1. 16 G Angiocath (or a spinal needle) x 1 2. 10 cc syringe x 1 3. One-liter vacuum bottle x 5 4. Thoracentesis kit tubing x 2 5. Sterile gloves x 2 6. Betadine swab x 3 7. Sterile drape x 2 8. 4x4 sterile gauze x 4 9. Band-aid x 1

Procedure A) Patient preparation 1. Explain the risks, benefits and alternatives to the patient. 2. If patient is not able to provide consent, it can be taken from the relative of the next of kin. 3. Ask the patient to urinate before the procedure or use a Foley to empty the bladder. 4. Position the patient with the head elevated at 45-60O to allow fluid to accumulate in lower abdomen. B) Preparation for the procedure 1. Get all the things ready at the bedside. Take note that the procedure is a sterile procedure 2. The patient should lie on his back in a slightly recumbent position toward the site of paracentesis.

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3. Insertion site is inferior to umbilicus at the level of percussed dullness (2-3 fingerbreadths below umbilicus ) 4. Clean the area with Betadine in a circular fashion from the center out. 5. Apply the sterile drapes. 6. Open the 16 G angiocath and syringe, and place them on the sterile drapes. 7. Place the 1-L vacuum bottles nearby. 8. Ensure that the angiocath fits the tubing. C) Procedure technique # 1. Pull the skin down and go in with the Angiocath at the marked point. Then release the skin. 2. Aspirate as you go in. 3. Once the fluid is in the needle, advance the needle slightly. 4. Then thread in the plastic part while withdrawing the needle. 5. Aspirate again to make sure that the plastic catheter is still inside the fluid collection. 6. Unscrew the syringe and connect the tubing to the 1-L vacuum bottle.
#

this is called Z-technique which creates a skin track to stop ascitic fluid from leaking out post-operatively.

If no fluid can be withdrawn: 1. Try to reposition the catheter. 2. If still no fluid, pull out and reintroduce the needle (if kept sterile). 3. Do not push hard or deeper than the midpoint of the collection. 4. Alternatively, the procedure can be performed with ultrasound-guided.

After the procedure: 1. Ask the patient to lie in bed and monitor vital signs Q1H for 4 hours to avoid hypotension. 2. It is recommended to give 25cc of albumin (25% solution) for every 2L of ascitic fluid removed.* 3. Write a procedure note which includes all the steps described above. 4. Record the amount and character of fluid obtained, estimated blood loss, complications(if any) and test requested.

eg. If the patient had a 4L paracentesis, he should receive 50 cc of albumin IV (25% solution) over 2 hours).The rationale for

giving albumin is to avoid intravascular fluid shift and renal failure after a large-volume

paracentesis.

D) Laboratory tests 1. Usually, only one of the 1L bottle is sent.

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2. General test includes ammonia, CBC, CMP, albumin, amylase, lipase, INR/PTT. 3. Test for paracentesis ascitic fluid includes protein, albumin, specific gravity, glucose, bilirubin, amylase, lipase, triglyceride, LDH, cell count and differential, C&S, Gram stain, AFB, fungal, cytology and pH. 4. Ensure that test results are followed up and reviewed.

Possible complications 1. Persistent leak from the puncture site 2. Abdominal wall hematoma 3. Perforation of bowel 4. Introduction of infection 5. Hypotension after a large-volume paracentesis 6. Dilutional hyponatremia 7. Hepatorenal syndrome 8. Major blood vessel laceration 9. Catheter fragment left in the abdominal wall or cavity Additional feature By having an ultrasound scan performed prior to the procedure, a precise puncture point can be marked. The distance from the skin to the fluid is usually 1 cm. It gives you an idea how deep you have to go with the needle before getting fluid in the syringe. The distance to the midpoint of the collection is usually 3 cm. It gives you an idea how deep you can go with the needle in relative safety.

References

1. Dimov V. Paracentasis: A Step by step procedure guide. Clinical Notes.

(http://note3.blogspot.com/2004/02/paracentesis-procedure-guide.html)

2. Garcia-Tiso G. Cirrhosis and its sequellae. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007: chapter 157. 3. Procedure can be viewed at: http://www.youtube.com/watch?v=TTFNgIzgKTw

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Chest tube insertion

Definition

Procedure to place a flexible, hollow drainage tube into the chest in order to remove an abnormal collection of air or fluid from the pleural space (located between the inner and outer lining of the lung). usually performed as an emergency procedure. Used to treat conditions that can cause the lung to collapse, which occurs because blood or air in the pleural space can hamper the ability of a patient to breath. 4 common conditions than can require surgical chest tube insertion, including:

pneumothorax (air leak from the lung into the chest) hemothorax (bleeding into the chest) empyema (lung abscess or pus in the chest) pneumothorax or hemothorax after surgery or from trauma to the chest

Description

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1. The point of insertion in the chest most commonly occurs on the side (lateral thorax), at a line drawn from the armpit (anterior axillary line) to the side (lateral) of the nipple in males, or to the side (about 2 in [5 cm]) above the sternoxiphoid junction (lower junction of the sternum, or chest bone) in females. 2. The skin is sterilized with antiseptic solution covering a wide area, and local anesthesia is administered to minimize discomfort. 3. At the rib chosen for insertion, the skin over the rib is anesthetized with lidocaine (a local chemical anesthetic agent) using a 10-cc syringe and 25-gauge needle. 4. At the rib below the rib chosen for pleural insertion, the tissues, muscles, bone, and lining covering the lung are also anesthetized using a 22-gauge needle. 5. All health-care providers will take precautions to keep the procedure sterile, including the usage of sterile gown, facemask, and eye protection. 6. All equipment must be sterile as well and universal precautions are followed for blood and body fluids. 7. Chest tube size is selected depending on the problem; an 1820 F(rench) catheter is used for pneumothorax, a 3226 F catheter for hemothorax, and trauma patients usually require a 3840 F catheter size; children generally require smaller tube sizes. 8. The patient's arm is placed over the head with a restraint on the affected side. For an insertion line down the armpit (axillary line insertion), the patient's head is elevated from the bed 3060 . 9. Using the anesthetic needle and syringe, the physician will insert a needle (aspirate) into the pleural cavity to check for the presence of air or fluid. Then, an incision is made and a clamp is used to open the pleural cavity. At this stage, either air or fluid will rush out when the pleural cavity is opened. 10. The chest tube is positioned for insertion with a clamp and attached to the suctiondrain system. 11. A silk suture is used to hold the tube firmly in place. 12. The area is wrapped and an x ray is taken to visualize the status of the tube placement

Risks
A. Risks from any anesthesia are:

Problems breathing Reactions to medications

B. Risks from any surgery are:

Bleeding Infection

C. Risks from the procedure itself:

Accidental movement of the tube Buildup of pus (empyema) Improper placement of the tube--into the tissues, abdomen, or too far in the chest Injury to the lung or heart

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Injury to the spleen, liver, stomach, or diaphragm

Aftercare
1. Remains secure and in place until imaging studies such as x rays show that air or fluid has been removed from the pleural cavity. 2. This removal of air or fluid will allow the affected lung to fully re-expand, allowing for adequate or improved breathing. 3. Patient will stay in the hospital until the tube is removed. 4. During the stay, the medical and nursing staff will carefully and periodically monitor the chest tube for air leaks or if the patient is having breathing difficulties. 5. Deep breathing and coughing after insertion can help with drainage and lung reexpansion. 6. Also include chest tube removal and follow-up care. 7. The patient is placed in the same position in which the tube was inserted. 8. Using precautions to maintain a sterile field, the suture holding the tube in place is loosened and the chest is prepared for tying the insertion-point wound. 9. The chest tube is then clamped to disconnect the suction system. 10. At this point, the patient will be asked to hold his or her breath, and the clinician will remove the tube with a swift motion. 11. After the suture is tied, dressing (gauze with antibiotic ointment) and tape is securely applied to close the wound. 12. A chest x ray should be repeated soon after tube removal and, within 48 hours, a routine wound care clinic follow-up is advised to remove the dressing and to further assess the patient's medical status and condition.

Normal results
Commonly used procedure, and it is typical for patients to recover fully from insertion and removal. If no complications develop, the procedure can relieve air or fluid accumulation in the pleural cavity that caused breathing impairment. Breathing is usually improved, and follow-up within the immediate 48 hours after hospital discharge is advised so that the patient can be further assessed with x rays and in the wound care clinic.

Alternative Names
Chest drainage tube insertion; Insertion of tube into chest; Tube thoracostomy

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NASOGASTRIC TUBES (By Zuliyasmin) These tubes are passed into the stomach via the nose-orogastric if via the mouthand drain externally. INDICATIONS To empty the stomach For gastric lavage following overdose. Intra-operatively For irreversible dysphagia For feeding ill patients
Figure 1 : Equipment for nasogastric intubation

CONTRAI NDICATIONS Absolute contraindications : a) Severe midface trauma b) Recent nasal surgery Relative contraindications : a) Coagulation abnormality b) Esophageal varices/ stricture c) Recent banding/ cautery of esophageal varices d) Alkaline ingestion

EQUIPMENT Nasogastric tube size a) Adult 16-18F b) Pediatric Tubes size dependent with age 2% Viscous lidocaine Glass of water with a straw Water-based lubricant 60 ml Toomey syringe Tape Emesis basin or plastic bag Wall suction, set to low intermittent suction Suction tubing and container

Figure 2: Estimation of NGT length from nostril to stomach

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PASSING THE TUBE 1. 2. 3. 4. Wear non-sterile gloves. Explain procedure to patient. Take a new tube and lubricate well with aqueous gel. Use the tube, by holding it against the patients head, to estimate the length required to get from the nostril to back of throat. 5. Examine the patient's nostril for septal deviation. 6. To determine which nostril is more patent, ask the patient to occlude each nostril and breathe through the other. 7. Place lubricated tube in the nostril with its natural curve promoting passage down. The right nostril is often easier than the left. Advance directly backward. 8. When the tip is estimated to be entering the throat, rotate the tube by ~180to discourage passage into the mouth. 9. Advance the tube into the esophagus during a swallow and hence to the stomach. Take a sip of water helps to enhance swallowing similarly with rotating the tube. If this fails: Try the other nostril, then oral insertion. 10. Tape securely to the nose.

Figure 4: Secured NGT

Figure 3: Auscultation over the stomach

CHECK PLACEMENT Use pH paper Woosh test Chest X-ray used to check positioning

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COMPLICATIONS: Pain Or rarely: loss of electrolytes, esophagitis, tracheal or duodenal intubation, necrosis (retro- or nasopharyngeal), stomach perforation.

WEANING Weaning is preferable for decompression/ relief of obstruction when removing of NGT in situ allow patients to manage well without it. a) First it should be on free drainage with eg 4hrly aspiration b) Then spigot with 4hrly aspirations c) Then spigot only. If this is tolerated along with oral intake it is probably safe to remove the tube; if not, then take a step backwards. VIDEO http://www.youtube.com/watch?v=en5ctZInOyA

REFERENCES Longmore M., Wilkinson I. B., et al (2010), Oxford Handbook of Clinical Medicine, 8th Edition, Practical Procedures, 19: 773 Retrieved from http://emedicine.medscape.com/article/80925overview#showall

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Cardio-Pulmonary Resuscitation (CPR)

By: Koh Weijun

Checking The Pulse

The pulse check is no longer taught or expected of laypersons. Instead, if there is no response after two mouth-to-mouth breaths, begin to pump on the chest. Please note that the pulse check is still expected of health care providers.

Complications of CPR
Vomiting is the most frequently encountered complication of CPR. If the victim starts to vomit, turn the head to the side and try to sweep out or wipe off the vomit. Continue with CPR. The spread of infection from the victim to the rescuer is exceedingly rare. Most cardiac arrests occur in people's homes - relatives or friends will be the ones needing to do CPR. Even CPR performed on strangers has an exceedingly rare risk of infection. There is NO documentation of HIV or AIDS ever being transmitted via CPR. http://www.youtube.com/watch?v=O9T25SMyz3A

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INTUBATION ( Nur Syazwani Jamhuri)

Intubation is a procedure that is done by inserting an endotracheal tube (ETT) through the mouth and into the trachea. Usually done under sedation however in emergency setting, it is usually involving an unconscious patient.

Indications for intubation 1. Unable to protect airway ( e.g. Glasgow Coma Scale (GCS) below 8, individual with airway trauma, deeply comatose from a head injury or drug overdose ) .Absence of the gag reflex is a reliable method of assessing whether or not the airway is protected. 2. Inadequate oxygenation with spontaneous respiration. SPO2 < 90% despite 100% O2 given or rising PCO2 (eg: asthma, COPD or pulmonary edema) 3. Anticipatory scenarios: trauma, respiratory failure, overdose, congestive heart failure, asthma, chronic obstructive pulmonary disease, and inhalation injury. 4. Shock 5. Anticipatory transfer of critically ill patients

INTUBATION TOOLS O2 source and self-inflating bag Face mask ETT Tracheal stylet Syringe for ETT cuff inflation Suction Laryngoscope

Medications that can be delivered via ETT NAVEL N= Naloxone A=Atropine V=Ventolin (Salbutamol) E= Epinephrine L= Lidocaine

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Approach to ETT intubation in trauma patient

Trauma Requiring Intubation

No Immediate Need

Immediate Need

C-spine x-ray

Apneic

Breathing

+ve = Fiberoptic / Nasal ETT or RSI Unable

-ve = Nasal / Oral ETT (+,- RSI)

Oral ETT Oral ETT Unable Rescue devices or cricothyroidectomy (no RSI) Unable Rescue devices or cricothyroidectomy

Nasal / Ora ETT (+,- RSI

Rescue devices or cricothyroidectomy

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Signs of Esophageal Intubation Steps of Intubation No chest wall movement Abdominal distension Hypoxia/cyanosis Presence of gastric content in ETT

Abnormal sounds during 1. Perform basic airway management assisted ventilation Protect the C-spine with cervical collar Head-tilt ( if C-spine injury is not expected) or End tidal CO2 zero or jaw thrust to open airway near zero on capnograph Suction to clear mouth from foreign materials 2. Assess for potential difficulties 3. Ensure all equipments are present and working well 4. RSI if required to be performed 5. If not, proper laryngoscope to visualize the glottis 6. Insert ETT, and inflate cuff 7. Ensure proper positioning of ETT ( 20-23cm mark at the right corner of the mouth if men and 19-21cm for women) Visualization of ETT passing through cords Auscultate for equal bilateral breath sounds Chest movement and not abdominal distension 8. Ventilate when ETT is in place Complications of Intubation Mechanical Laceration (lips, gum, pharynx,esophagus) Dental damage Laryngeal trauma Esophageal or endobronchial intubation Accidental extubation Systemic Laryngospasm Bronchospasm Signs of Endobronchial Intubation If too deep, usually result in right endobronchial intubation Unilateral breath sound Right sided tension pneumothorax Left sided atelectasis

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Complications: Prevention and Management

Complication: Missing/broken teeth:

Prevention: Remove loose teeth prior; avoid using upper teeth as fulcrum for laryngoscope blade.

Management: Check chest x-ray to rule out aspiration.

Clenched teeth: Air leak: Inability to visualize vocal cords: Esophageal intubation: Right lung intubation: Laryngospasm: Failure to intubate: Check cuff prior to beginning procedure. Proper patient positioning, proper laryngoscope blade size, proper suctioning. Visualize cords. Avoid excessive tube advancement. Spray vocal cords with 2% Lidocaine. None.

Paralytic medication. Inject more air or change tube over guide wire. Reposition, choose a different blade, adequate suction, cricoid pressure by assistant. Remove tube, re-oxygenate and reinsert. Deflate cuff, re-position and reinflate. Benzodiazepine or paralytic medication. Have alternative plan prepared: e.g., BVM, another type of tube, cricothyrotomy.

Advantages and disadvantages of ETT Advantages 5 Ps 1. 2. 3. 4. 5. Ensure airway PATENCY PROTECTS against aspiration Allow POSITIVE PRESSURE ventilation PULMONARY toileting suctioning PHARMACOLOGICAL administration

Disadvantages 1. Difficult insertion 2. Endobronchial intubation or esophageal intubation 3. Laryngospasm on intubation or extubation later Links 1. http://www.youtube.com/watch?v=IO_eUC9ph6o ( Nasal ETT) 2. http://www.youtube.com/watch?v=mKrl3I3Z28s (Oral ETT)

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3. http://www.youtube.com/watch?v=kahoOfAndDc (Cricothyroidotomy) 4. http://apps.med.buffalo.edu/procedures/basicairway.asp?p=4 (Basic airway management)

Name of procedure: Intravenous lines by mrmalekahmad Indication: 1. IV access is usually needed for anesthesia care, laboring patients, trauma patients, hospital inpatients, and patient care requiring any of the following: Emergency administration of medications Fluid resuscitation Administration of blood products Elective administration of intravenous antibiotics, chemotherapeutic agents, or other treatments Administration of diagnostic substances, such as methylene blue, indocyanine green, indigo carmine, or intravenous contrast agents 2. Patients donating blood products 1. Patients with anatomy that poses a risk for fluid extravasation or flow (extremities with massive edema, burns or injury), in these cases other IV sites need to be accessed 2. For the patient with severe abdominal trauma, it is preferable to start the IV in an upper extremity because of the potential for injury to vessels between the lower extremities and the heart 3. For the patient with cellulitis of an extremity, the area of infection should be avoided when starting an IV because of the risk of inoculating the circulation with bacteria *there is no absolute contraindication Equipment: 1. Gloves and protective equipment 2. Appropriate size catheter 14-25 G IV catheters 3. Non-latex tourniquet 4. Alcohol swab/other cleaning instrument 5. 2x2 gauze 6. 6x7cm Transparent Dressing 7. 3 pieces of 2.5 cm tape approximately 10 cm in length 8. IV bag with solution set (tubing) (flushed and ready) or saline lock 9. Sharps container 1. Explain procedure to patient/parent and prepare the equipment 2. Wash hands with antiseptic soap and wear gloves 3. Apply the tourniquet above insertion site (For pediatric patient, an assistants hand used both as a tourniquet and restraint, is often more acceptable to a child than a tourniquet) 4. Disinfect the selected site with skin prep and allow to dry (Do not touch the skin with the fingers after preparation solution has been applied) 5. If infiltration of local analgesia is required, inject lignocaine 1% at the proposed site of entry of cannula 6. Inspect the cannula before insertion to ensure that the needle is fully inserted into the plastic cannula and that the cannula tip is not damaged (Do not touch the shaft or tip of the cannula)

Contraindication: inadequate

Procedure:

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7. Ensure that the bevel of the cannula is facing upwards (Rationale: Facilitates the piercing of the skin by the bevel) 8. Insert the needle and the cannula into the vein (Gentle traction on skin may stabilize the vein under the skin) 9. Partially withdraw the needle and advance the cannula 10. Release the tourniquet 11. Secure the hub of the cannula with clean adhesive tape (Do not cover the puncture site, cut tape immediately prior to use only) 12. Flush the cannula with normal saline (Rationale: Ensures the line is patent and accessible) 13. Cover the intravenous and surrounding area with a sterile transparent dressing (Ensure that the insertion site and the area proximal to the site are visible for inspection purposes) 14. If infusion is ordered, prime the line and connect the intravenous giving set to the cannula (If the site needs to be immobilized, use a well padded splint and strapping if necessary) For infants <12 months, a transparent tape must be used If a bandage is used, apply it at each end of splint so that the central area is lightly covered for easy inspection Conform bandages to secure the splint are available for pediatric patients if required. 15. Dispose of equipment safely *To remove the IV 1. Shut off the IV by closing the roller camp 2. Remove the tape and plaster from the tubing and catheter 3. Place a non-sterile 2x2 gauze over the IV site and remove the catheter from the arm and secure it in place with a piece of tape Complication: 1. Infection and infiltration 2. Tissue damage 3. Superficial thrombophlebitis 4. Catheter embolism or air embolism Reference: 1. http://nursing-resource.com/iv-insertion/#proc 2. http://www.med.uottawa.ca/procedures/iv/

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Electrocardiogram (ECG) in Emergency Clinical Indications:

Known or Suspected Cardiac Patient Known or Suspected Tricyclic Overdose Electrical Injuries Syncope

Procedure: 1. Assess patient and monitor cardiac status. 2. Administer oxygen per patient condition as tolerated. 3. If patient is unstable, definitive treatment is the priority. If the patient is stable or stabilized after treatment, perform a 12-lead ECG. 4. Prepare ECG monitor and pre-cordial lead cables. 5. Enter patient demographic data. 6. Expose the chest and prep as necessary. Modesty should be considered. 7. Apply chest leads and limb leads as follows: RA----right arm LA----left arm N ----right leg F ----left leg V1----4th intercostal space at right sternal border V2----4th intercostal space at left sternal border V3----between V2 and V4 V4----5th intercostal space at midclavicular line V5----Level with V4 at the left anterior axillary line V6----Level with V5 at the left midaxillary line 8. Instruct patient to remain still. 9. Press the 12 lead acquisition button on the monitor. 10. Once acquired, transmit to the appropriate receiving facility. 11. Contact the receiving facility to notify them of the patient and the incoming 12lead. 12. Monitor and reassess the patient enroute and continue treatment protocol. 13. Attach a copy of the 12-lead with the patients record at the hospital. Resources http://www.iredellems.com/protocols/employees/ICEMS%20Protocol%20Web/Procedure%2 0Pages/12%20Lead%20ECG.htm