University of sulaymany

college of medicine

for (forth, fifth, sixth ) stage medical student

Prepared & collected by:Dr .Soran Mohamad Gharib

2008

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Clinical Assessment of a case Of head injury

Head injuries;"No head injury is so slight that it should be neglected, or so sever that life should be despaired of"Trauma imparted to the cranium can take the form of:

Translational acceleration forceTranslational deceleration forceRotational forceDirect, focal, sharp penetrating forceBlunt force

• Why most cerebral contusions occurs with out skull fractures and why patients with skull fractures are often awake with only a minor neurological dysfunction? What is Coups and Countercoups injury?

Things to remember…..*Letters in the word "scalp" can define different layers of the scalp that may be injured;• S stands for Skin• C stands for subcutaneous tissue• A stands for Aponeurosis• L stands for loose areolar tissue• P stands for Pericranium*identify the severity of the primary brain injury and record a base line of neurological disability. *Get initial information from the witnesses and ambulance crew about the nature and the velocity of the trauma, initial state of consciousness, post-traumatic amnesia, headache, vomiting or fits. Things to remember…..*consider the possibility of other life threatening injuries *record initially any history of drug intake or concomitant medical illness.*Decide, as early as possible, when to refer to a specialist neurosurgical care, and, to the same degree, not to refer without a good indication.*Patient must be reexamined many times at frequent intervals.*Understand the standard "Evaluation score" so called Glasgow Coma Scale.

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*Consider the need for "advance trauma life support system protocol (ATLS)" along with stabilization of airway, breathing, circulation, disability and exposure (ABCD and E).*You may need to immobilize the cervical spine, as there is a high possibility of associated cervical spine injury.Things to remember…..*Perform a correct, informative and reliable detailed neurological examination to pick up, as early as possible, signs of focal neurological damage and that of rise in intracranial pressure.*Not to aim always at referring the victim without recording the result of your observations.*Use your armamentariums, a "narrow spot" torch light, a hammer, gloves, little of neuroanatomy and neurophysiology, and a real will to be helpful.*Keep on looking to a copy of "Glasgow Coma Scale", repeat applying it for all head injury cases.

Glasgow Coma Scale;

654321

Obeys commandsLocalize painWithdrawal from painFlexion to painExtension to painNone

Best motor response

54321

OrientedConfusedInappropriate wordsIncomprehensible soundsNone

Verbal response

4321

SpontaneousTo speechTo painNone

Eye opening

654321

Obeys commandsLocalize painWithdrawal from painFlexion to painExtension to painNone

Best motor response

54321

OrientedConfusedInappropriate wordsIncomprehensible soundsNone

Verbal response

4321

SpontaneousTo speechTo painNone

Eye opening

Factors affecting Glasgow coma scale other than cerebral injury;• Limitation of eye opening may occur in facial trauma and periorbital Edema affecting assessment of eye opening.

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• Upper limb is more representative of the motor reflex than the lower limb. Presence of fracture, that may be missed, can affect interpretation of motor response.• Language and endotracheal intubations may affect assessment of verbal responsesScalp injuries;• Scalp never gapes unless the galea aponeurotica has been divided.• Collection of blood beneath the Aponeurosis tends to involve the whole area between the occipitofrontalis muscles. • Effusions beneath the Pericranium are limited to the suture lines• Subpericranial heamatoma may feels exactly like a depressed fractureScalp injuries• Proper examination need complete shaving of the scalp hair.• Bleeders from the scalp injury can be controlled by pressure application, hemostat application or by eversion of the galea. • Depressed skull fractures may underlie a scalp injury.• Scalp heamatoma always overlie a skull fracture in infants.• Scalp lacerations tend to bleed very heavily

Common types of skull fracture;Simple linear; It may be confused with suture lines. Those that cross the middle meningeal artery can cause extradural hemorrhage.Depressed; It needs suturing of overlying scalp wound before referral for debridement and elevation. Base of the skull fractures; may present with "Raccoon eyes“, Mastoid bruises or CSF leak.Orbital blow-out fractures; Cause diplopia and require repair.

Fracture base of the skull;Anterior Cranial fossa #....danger of CSF Rhinorrhoea

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Two black eyes is very suggestiveIn trauma, usually there is one black eye

No such posterior limitOn rotating the eye ball, a posterior limit can be defined

Always subconjunctival and does not move with the movement of the conjunctiva

The bleeding is in the conjunctiva and moves with it

Purplish from the startDiscoloration is “Beefy Redness” after trauma

Limited to the orbital margin by the attachment of Orbicularis Occuli m. it tend to be circular

Extravasated blood is not limited to the orbital margin, it is diffuse

Ant. Cr. Fossa #“Black Eye". Trauma

Two black eyes is very suggestiveIn trauma, usually there is one black eye

No such posterior limitOn rotating the eye ball, a posterior limit can be defined

Always subconjunctival and does not move with the movement of the conjunctiva

The bleeding is in the conjunctiva and moves with it

Purplish from the startDiscoloration is “Beefy Redness” after trauma

Limited to the orbital margin by the attachment of Orbicularis Occuli m. it tend to be circular

Extravasated blood is not limited to the orbital margin, it is diffuse

Ant. Cr. Fossa #“Black Eye". Trauma

Middle Cranial Fossa Fracture;• Suspected when there is blood or blood diluted with CSF escaping from the external auditory meatus.• In tympanic membrane rupture, blood will clot, but will not in case of blood mixed with CSF• There may be an associated facial palsy, deafness or nystagmus in cases of fracture middle cr. Fossa.• Bruises over the mastoid process (Battle's sign) appearing one or two days after trauma confirm the diagnosis of middle cr. Fossa fracture

Fracture Posterior Cranial Fossa;• The main danger is the torn of a venous sinus.• Deep coma may be present. Pupils become dilated and inactive.• Periodic "Chyne-Stockes" respirations are present.• Irregular pulse indicate brain stem lesion and the case is fatal.• If a slowly developing heamatoma accumulate, nystagmus and ataxia is present.

Brain injuries;Primary; 1. Concussion; defined by a period of amnesia2. Cortical contusions and lacerations3. Bone fragmentation injury4. Diffuse axonal injury5. Brain stem contusions.

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Secondary;1. Intracranial heamatoma2. Cerebral edema3. Hypoxemia4. Ischemia5. Infections6. Epilepsy7. metabolic-endocrine disturbances.

Types of intra cranial heamatoma;Intracerebral; Hyper dense on CT-scan, small ones may enlarge. Large ones may need evacuation.Extradural; Result From bleeding middle meningeal artery. Trauma may be trivial. Lucid interval is characteristic. Surgery without delay is essential.

Acute subdural; It is the most common. Develop from torn bridging veins or from cortical lacerations. It May be sub acute.Chronic subdural; It is most common in children and elderly, and present with progressive neurological deficit. They should be drained if continue to enlarge.

Indications for CT scan;• The patient is persistently drowsy or has a more seriously depressed consciousness level• There are lateralizing neurological signs• There is neurological deterioration• There is clinical evidence of fracture base of skull

Category of head injury;Category I: The patient is unconscious;• Examine the scalp.• Inspect the nostril and back of the throat.• Examine the external auditory meatus.• Compare the size of the pupils and reaction to light.• Make a general survey of the body for other injuries.• Assess how deep the patient is unconscious.Coma is a state of absolute unconsciousness in which the patient dose not respond to any stimuli and reflexes (including the corneal and swallowing reflexes) are absent.

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Semi coma means that the patient responds only to painful stimuli and reflexes are present.• Search for paralysis. Pinch the soles of the feet; only one leg may be drawn up.• Palpate and Percuss the lower abdomen for evidence of over filled bladder.• Set half- hourly Chart for pulse rate, respiratory rate, and temperature. Make a behaviors chart • Place and have the patient kept on his side with a clear air way (remove blood and mucus from mouth and nose).• Consider at any time the need for endotracheal intubations• Arrange for safe referral with an informative preliminary report.

Category II: The patient is conscious or semiconscious;• Record the degree of mental confusion• Assess for; Stupor; No sensible answers can be obtained but the patient obeys simple commands.Delirium; Appear out of touch from his surroundings, relevant answers to obvious questions are possible, but irritable when disturbed, may be aggressive, noisy and try to get out of bed.Confusion; Overall, some degree of coherent conversation is possible.

**Any impairment of consciousness, when combined with radiological evidence of skull fracture, is associated with high incidence of intracranial bleeding and heamatoma.

Quick Cranial N examination;Olfactory (1st) use non irritant smell. Optic (2nd) test for visual fields.Ocuolomotor (3rd) lid and eye movements, pupillary reflex and laccommodation. Trochlear (4th) diplopia on looking downwards. Trigeminal (5th) inability to clench teethAbducent (6th affected eye does not follow an object laterally Facial (7th) facial m. paralysis.Acoustic (8th) hearing and caloric test.Glossopharangeal (9th) loss of test in the posterior third of the tongue.Vagus (10th) loss of soft palate movement. Uvula to the opposite side.

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Accessory (11th) Failure to shrug the shoulderHypoglossal (12th) Deviation of the protruded tongue to the affected side.

Significant Signs occurring during the period of observation of a case of Head;

"To wait until the clinical diagnosis is certain is to wait until the patient is near death"Monitor the followings during observation period:• Pulse rate• Temperature• Respiration• Fits• Neck rigidity• Lucid interval• Lateralizing Neurological signs• Signs of Cerebral irritation Lucid Interval;* Classical sign of middle meningeal bleeding and formation of extradural heamatoma.* Very variable, occurring for few minuets up to several days.* Completely absent in cases of:

1)1) Alcoholism2)2) Severe concomitant brain injury.3)3) Combination of extradural and intracerebral bleeding.

* In this case, you may suspect this by:1)1) Presence of heamatoma of the temporalis muscle on the affected side.2)2) The gradual onset of hemi paresis and hemiplagia.3)3) Deepening coma.4)4) Presence of "Hutchinson's pupil".

Differential Diagnosis of Lucid interval;• In cases of subdural hemorrhage, its occurrence is more common, and it is not associated with lucid interval, however, lateralizing neurological signs may be present.• Sub arachnoids hemorrhage can be suspected from signs of cerebral irritation and positive tap of blood with CSF.• Intracerebral bleeding may be associated with extra or sub dural heamatoma or may occur alone. Lateralizing signs are usually absent.

Lateralizing neurological signs;

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• Contra lateral hemiplagia of extradural heamatoma associated with absent abdominal reflexes, increased triceps jerks, and positive "Babaniski's" sign.• Difficulty in speech (Aphasia), which may be the first lateralizing sign if the lesion is left sided in a right handed patient because "Broca's" speech area is left sided in right handed.• Inequality of the pupils, The so called "Hutchinson's pupil, occurring in extradural heamatomaHutchinson's pupil;

Widely dilated, insensitive, with

ptosisWidely dilated, insensitive

Widely dilated, does not react to light

Moderately dilated, react to light

Moderately dilated, sluggish reaction to light

Normal

Slightly contracted and reacting to light

Normal

The pupil on the side of compression

The pupil opposite to the compression side

Widely dilated, insensitive, with ptosis

Widely dilated, insensitive

Widely dilated, does not react to light

Moderately dilated, react to light

Moderately dilated, sluggish reaction to light

Normal

Slightly contracted and reacting to light

Normal

The pupil on the side of compression

The pupil opposite to the compression side

Cerebral irritation;Patient is found curled up in bedavoiding light (Photophobia)eye lids are closedtemperature is moderately raisedthe patient is irritableThis indicates blood in the CSF.

Delayed effects of head injury;Post traumatic epilepsyCerebrospinal fluid fistulaPost-concussion symptomsNeurological and Neuro-psychological deficitsNeuroendocrine and metabolic disturbances

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Examination of theExamination of the Vascular SystemVascular System

Examination of the Arterial CirculationExamination of the Arterial CirculationArteries accessible for clinical examination are:Arteries accessible for clinical examination are:•• Common Carotid and bifurcation in the neckCommon Carotid and bifurcation in the neck•• the facial and superficial temporal over the skullthe facial and superficial temporal over the skull•• the subclavian artery behind the claviclethe subclavian artery behind the clavicle•• the axillary artery in the axillathe axillary artery in the axilla•• the Brachial artery at the elbowthe Brachial artery at the elbow•• the radial and ulnar arteries at the wristthe radial and ulnar arteries at the wrist•• the femoral artery below the mid inguinal pointthe femoral artery below the mid inguinal point•• the popliteal artery in the popletial fossathe popliteal artery in the popletial fossa•• the posterior tibial artery behind the medial malleolusthe posterior tibial artery behind the medial malleolus•• the anterior tibial artery between the two malleolithe anterior tibial artery between the two malleoli•• the dorsalis pedis artery between the first and second the dorsalis pedis artery between the first and second

metatarsals just medial to the flexor hallusis longus tendonmetatarsals just medial to the flexor hallusis longus tendon•• the abdominal aorta in thin subject when compressed against the the abdominal aorta in thin subject when compressed against the

vertebral columnvertebral column

Clinical assessment of the arterial Clinical assessment of the arterial circulationcirculation•• Examine in warm environmentExamine in warm environment•• Examine the heartExamine the heart•• Assess Blood pressure in both armsAssess Blood pressure in both armsAssessment of ischemic limbAssessment of ischemic limbInspectionInspection•• Skin; white marble, redness or blueness.Skin; white marble, redness or blueness.•• A purple blue cyanosis may be obvious. A purple blue cyanosis may be obvious. •• When cyanotic areas become fixed, the ischemia is When cyanotic areas become fixed, the ischemia is irreversible. irreversible. •• Gangrene turn skin permanentGangrene turn skin permanent blue/black colour first blue/black colour first seen caudally in the toesseen caudally in the toesClinical assessment of the arterial Clinical assessment of the arterial circulationcirculation•• The Vascular (Buerger's) angleThe Vascular (Buerger's) angle•• Capillary filling time and “Buerger’s positional test”Capillary filling time and “Buerger’s positional test”•• Inspect for venous filling-Guttering of veinsInspect for venous filling-Guttering of veins

•• Inspect carefully pressure areas for Thickening of the Inspect carefully pressure areas for Thickening of the skin, a purple or blue discoloration, blistering, skin, a purple or blue discoloration, blistering, ulceration or patches of black, red, dead gangrene. ulceration or patches of black, red, dead gangrene. Pressure areas are:Pressure areas are:

•• bottom, back and lateral surface of the heal and ball of bottom, back and lateral surface of the heal and ball of the footthe foot

•• skin over the malleoliskin over the malleoli•• skin over the head of the fifth metatarsalskin over the head of the fifth metatarsal

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•• tips of the toes and areas between the toestips of the toes and areas between the toes

Clinical assessment of the arterial Clinical assessment of the arterial circulationcirculationPalpation Palpation •• Assess temperatureAssess temperature•• Capillary refilling timeCapillary refilling time•• Felling the pulseFelling the pulse

AuscultationAuscultation•• An audible bruite is caused by turbulent flow beyond An audible bruite is caused by turbulent flow beyond a stenosis or irregularity in the artery wall.a stenosis or irregularity in the artery wall.•• Blood flow in the vessel is assessed by a hand-held Blood flow in the vessel is assessed by a hand-held Doppler probe which can detect pulstile flow when the Doppler probe which can detect pulstile flow when the pulse pressure is impalpable to the fingers.pulse pressure is impalpable to the fingers.

Symptoms and signs of acute ischemia Symptoms and signs of acute ischemia (remember the letter “P”)(remember the letter “P”)•• Pain, severe, sudden onset as a result of ischemia of muscles Pain, severe, sudden onset as a result of ischemia of muscles and nervesand nerves•• Parasthesia progressing toParasthesia progressing to•• ParalysisParalysis•• Pallor of the limbPallor of the limb•• PulselessnessPulselessness•• Perishingly cold limbPerishingly cold limb•• Poor capillary circulation resulting inPoor capillary circulation resulting in•• Prolonged capillary refilling timeProlonged capillary refilling time•• Perceptively empty veinsPerceptively empty veins•• Poor power, sensation and limb reflexesPoor power, sensation and limb reflexes•• Pulse Doppler flowmetry confirm absent pulsationPulse Doppler flowmetry confirm absent pulsation•• Persistent ischemia lead to hardness of muscles, blistering of Persistent ischemia lead to hardness of muscles, blistering of the skin and development of gangrene starting in the toe and the skin and development of gangrene starting in the toe and spreading proximallyspreading proximally

Clinical manifestations of chronic Clinical manifestations of chronic ischemiaischemia•• Intermittent claudication (limping)Intermittent claudication (limping)

•• Pre-gangrenePre-gangrene

•• GangreneGangrene

•• Ischemic ulcersIschemic ulcersIschemic ulcersIschemic ulcers•• SiteSite tips of the toes and over pressure points tips of the toes and over pressure points

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•• Size Size small to large flatsmall to large flat•• ShapeShape often elliptical often elliptical•• Tenderness Tenderness mild, moderate or severmild, moderate or sever•• TemperatureTemperature ; surrounding tissue is usually cold due ; surrounding tissue is usually cold due to ischemiato ischemia•• EdgeEdge punched-out or sloping punched-out or sloping •• FloorFloor grey-yellow slough covering flat pale grey-yellow slough covering flat pale granulation tissuegranulation tissue•• DepthDepth ; is often very deep and penetrating; is often very deep and penetrating•• DischargeDischarge clear fluid, serum or pus clear fluid, serum or pus

Ischemic ulcersIschemic ulcers

•• BaseBase may be stuck or may be part of any underlying may be stuck or may be part of any underlying tissuetissue•• Lymph NodesLymph Nodes : not enlarged unless there is secondary: not enlarged unless there is secondary infectioninfection•• State of local tissueState of local tissue : surrounding tissue may show : surrounding tissue may show signs of ischemia.signs of ischemia.•• Distal pulsesDistal pulses are invariably absent are invariably absent•• Doppler pressure indexDoppler pressure index is reduced is reduced•• Neurological examinationNeurological examination numbness, Parasthesia, numbness, Parasthesia, and absent sensation may indicate trophic ulcerand absent sensation may indicate trophic ulcer•• General examinationGeneral examination may show evidence of vascular may show evidence of vascular disease or diabetesdisease or diabetes

Examination of the venous circulationExamination of the venous circulation•• Veins are either superficial or deep. Veins are either superficial or deep. •• In the upper limb flow is from peripheral to proximal veins. In the upper limb flow is from peripheral to proximal veins. •• In the lower limb, in addition, flow is also from superficial to deep In the lower limb, in addition, flow is also from superficial to deep

veinsveins Valves are sitedValves are sited •• at any junction between superficial and deep veins at any junction between superficial and deep veins •• in the perforating veins in the perforating veins •• along the deep and superficial veinsalong the deep and superficial veins

limb veins have three principle functionslimb veins have three principle functions •• pathway to return blood to the heart pathway to return blood to the heart •• blood storage blood storage •• thermoregulation.thermoregulation.

Thrombosis of superficial veinsThrombosis of superficial veins (superficial thrombophlebitis)(superficial thrombophlebitis)

Clinically, the vein becomeClinically, the vein become •• Firm, Firm,

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•• PalpablePalpable•• Redness and stiffness in the overlying Redness and stiffness in the overlying skin which become warm and tender . skin which become warm and tender . •• It may be complicated by suppuration It may be complicated by suppuration or extension of the thrombus along a or extension of the thrombus along a perforating vein to the deep veins causing perforating vein to the deep veins causing deep venous thrombosis.deep venous thrombosis.Examination of a case of deep vein Examination of a case of deep vein thrombosisthrombosis•• Observe for inequality of circumference and any prominent Observe for inequality of circumference and any prominent veins over the dorsum of foot.veins over the dorsum of foot.

•• Examine the ankle for pitting OedemaExamine the ankle for pitting Oedema

•• Dorsiflexion of the foot produce pain in the calf muscle Dorsiflexion of the foot produce pain in the calf muscle (Homan's sign)(Homan's sign)

•• Tender calf musclesTender calf muscles •• Palpate the popliteal space for tenderness in full leg extension Palpate the popliteal space for tenderness in full leg extension positionposition

•• Seek for tenderness in the thigh along the course of the femoralSeek for tenderness in the thigh along the course of the femoral veinvein

•• Comparative circumferential measurement at identical pointsComparative circumferential measurement at identical points

Examination of a case of varicose veinsExamination of a case of varicose veinsBy inspection:By inspection:•• Inspect from back and front for varicosities ofInspect from back and front for varicosities of long, short or both saphenous veins.long, short or both saphenous veins.•• Inspect the site of perforators which produce Inspect the site of perforators which produce discrete venous bulges.discrete venous bulges.•• Inspect for the presence of swelling, skin Inspect for the presence of swelling, skin pigmentation, pre-ulcerative lesions, ulcer mainly pigmentation, pre-ulcerative lesions, ulcer mainly just above the medial malleolus and any scars duejust above the medial malleolus and any scars due to healed ulcers.to healed ulcers.Examination of a case of varicose veinsExamination of a case of varicose veinsBy palpation:By palpation:•• Palpate over the course of long and short Palpate over the course of long and short saphenous veinssaphenous veins•• Perform the "cough impulse test" Perform the "cough impulse test" •• Perform the percussion or "Tap" sign. Perform the percussion or "Tap" sign. •• Perform Brodie-Trendelenburg testPerform Brodie-Trendelenburg test

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•• Seek for the site of perforators (Fegan's Seek for the site of perforators (Fegan's method)method)•• Test for the patency of deep vein (Perthe's Test for the patency of deep vein (Perthe's testtest

Examination of the arterial circulation ofExamination of the arterial circulation of the lower limbsthe lower limbs

•• -Examination should be in aworm room.-Examination should be in aworm room.•• -Exposure:-Exposure: •• --from goin to toes,preserving his dignity by from goin to toes,preserving his dignity by keeping his underwear on.keeping his underwear on.

•• InspectionInspection ::•• -- colourcolour :white/red.:white/red.•• Vascular angle:Vascular angle: ”” buergerbuerger ’’ s angles angle ””•• Lift the leg above the bed,raises it above the heart level.Lift the leg above the bed,raises it above the heart level.•• Normal leg can be raised to 90 degree and still remain Normal leg can be raised to 90 degree and still remain perfused.perfused.•• The angle between the horizontal and the leg when it become The angle between the horizontal and the leg when it become white is vascular angle.white is vascular angle.•• If the angle less than 20 it indicate sever ischemia If the angle less than 20 it indicate sever ischemia

•• Capillary filling timeCapillary filling time ::•• After elevating the legs,ask the patient to sit up and dangle After elevating the legs,ask the patient to sit up and dangle the foot over the site of the couch.the foot over the site of the couch.•• Anormal leg and foot remain healthy pink in colour.Anormal leg and foot remain healthy pink in colour.•• Ischaemic leg slowly turns from white to pink and thentakes Ischaemic leg slowly turns from white to pink and thentakes on a suffused purple-red colour.the time taken for the colour of the on a suffused purple-red colour.the time taken for the colour of the foot to change from white to pink is the capillary filling time.foot to change from white to pink is the capillary filling time.•• In sever ischaemia it may be as long as15-30 seconds In sever ischaemia it may be as long as15-30 seconds

•• --Venous filling:Venous filling:•• in an ischaemic foot the veins collapse and sink in an ischaemic foot the veins collapse and sink below the skin surface to look like pale-blue gutter.this is below the skin surface to look like pale-blue gutter.this is called guttering of the veins.called guttering of the veins.•• -look at the-look at the pressure areas.-look at the-look at the pressure areas.

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•• Trophic changes:Trophic changes:•• -loss of skin.-loss of skin.•• -loss of hair.-loss of hair.•• -Gangrene.-Gangrene.

•• Ulcers:Ulcers: •• Arterial(ischaemic) ulcers are found typically in the least well perfused Arterial(ischaemic) ulcers are found typically in the least well perfused areas and over the pressure points.areas and over the pressure points.•• The lesions are punched out because there is no attempt at healing,and The lesions are punched out because there is no attempt at healing,and well described,may be very tender and the surrounding skin is cold.well described,may be very tender and the surrounding skin is cold.•• They may vary in size but are usually smaller than venous ulcer.They may vary in size but are usually smaller than venous ulcer.•• There is no granulation tissue but may be a thin layer of slough at the baseThere is no granulation tissue but may be a thin layer of slough at the base ,otherwise the base is flat and pale.,otherwise the base is flat and pale.•• They may be very deep and penetrate surrounding tissue like bone..They may be very deep and penetrate surrounding tissue like bone..•• Commenest differencial is with the neuropathic ulcer.Commenest differencial is with the neuropathic ulcer.

•• PalpationPalpation •• -- feel for skin temperature., use the back of feel for skin temperature., use the back of hands ,comparing one side with other.hands ,comparing one side with other.•• -examine the toes for capillary refill,use thmb to -examine the toes for capillary refill,use thmb to push hard over the pulp of the big toe on both push hard over the pulp of the big toe on both sides.,normally the toe blunches but then return to the sides.,normally the toe blunches but then return to the normal colour withn 2 seconds,.any longer than this is normal colour withn 2 seconds,.any longer than this is abnormal.abnormal.•• Only after all had been completed should you Only after all had been completed should you move on to examine the pulsesmove on to examine the pulses

•• Femoral pulse:Femoral pulse: •• -can be identified by the level of the groin skin-can be identified by the level of the groin skin crease .crease .•• anatomically dscribed at the mid- inguinal anatomically dscribed at the mid- inguinal point ,halfway between point ,halfway between •• Anterior superior iliac spine and the pubic Anterior superior iliac spine and the pubic symphysis.symphysis.•• -compare one side with the other.-compare one side with the other.

•• Popliteal pulse:Popliteal pulse: •• -- the most convenien technique for feling the popliteal pulse is to extend the most convenien technique for feling the popliteal pulse is to extend the patient knee fully and place both haqnds around the top of the calf with the the patient knee fully and place both haqnds around the top of the calf with the thumbs placed on the tibial tuberosity and the tips of the fingers of each hand thumbs placed on the tibial tuberosity and the tips of the fingers of each hand touching behind the knee,over the lower part of the popliteal fossa.,the pulse touching behind the knee,over the lower part of the popliteal fossa.,the pulse

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demonstrated when the popliteal artery is compressed against the posterior demonstrated when the popliteal artery is compressed against the posterior aspect of the tibia.aspect of the tibia.•• -flexing the knee to 135 degree may make the lower half of the artery -flexing the knee to 135 degree may make the lower half of the artery easier to feel but may make palpation of the upper half of the artery more easier to feel but may make palpation of the upper half of the artery more difficult.difficult.•• -sometime it can be feel by turning the patient in to the prone position and-sometime it can be feel by turning the patient in to the prone position and feeling along the course of the artery.feeling along the course of the artery.•• -when it is easy to feel it may be aneurysmal.-when it is easy to feel it may be aneurysmal.•• -compare.-compare.

•• Foot pulsesFoot pulses •• -the dorsalis pedis and the posterior tibial pulses can be -the dorsalis pedis and the posterior tibial pulses can be palpated bilaterally and simultaneously.palpated bilaterally and simultaneously.•• -demonstrate the tendon of extensor hallucis longus.-demonstrate the tendon of extensor hallucis longus.•• -the DPA is immidately lateral to this tendon.-the DPA is immidately lateral to this tendon.•• -swing your hand down to the medial malleolus and run your -swing your hand down to the medial malleolus and run your fingers posteriorly ,posterior tibial artery lie1/3 of the way along fingers posteriorly ,posterior tibial artery lie1/3 of the way along aline between the tip of the medial malleolus and the point of the aline between the tip of the medial malleolus and the point of the hill.hill.

•• Auscultate:Auscultate: •• --check for bruit .check for bruit .•• -measure blood pressure.-measure blood pressure.

•• complete your examination by:complete your examination by: •• --examine the abdomen for an aneurysm.examine the abdomen for an aneurysm.•• -measure the ankle brachial pressure indicies on each side.-measure the ankle brachial pressure indicies on each side.•• The pressure cuff is inflated over the upper arm and the systolic pressure measured at the The pressure cuff is inflated over the upper arm and the systolic pressure measured at the brachial artery using a Doppler probe.brachial artery using a Doppler probe.•• The cuff is then placed over the calf.The cuff is then placed over the calf.•• When the dorsalis pedis pulse has been located with the Doppler,the cuff is inflated until the When the dorsalis pedis pulse has been located with the Doppler,the cuff is inflated until the pressure is high enough to occlude the artery and thus the Doppler sound disappear.pressure is high enough to occlude the artery and thus the Doppler sound disappear.•• Slowly lower the cuff pressure until the Doppler sound restart,this is the ankle pressure.Slowly lower the cuff pressure until the Doppler sound restart,this is the ankle pressure.•• The index is the ankle pressure dividedby the brachial pressure.The index is the ankle pressure dividedby the brachial pressure.•• Normal index is 1.Normal index is 1.•• In patient with the peripheral vascular disease the ratio begin to fall.In patient with the peripheral vascular disease the ratio begin to fall.•• Patient with the intermittent claudication have an index of 0.5-0.8,.Patient with the intermittent claudication have an index of 0.5-0.8,.•• Patient with the rest pain have an index<0.5Patient with the rest pain have an index<0.5

Antibiotics in Surgical PracticeAntibiotics in Surgical Practice

General TermsGeneral TermsAntimicrobialsAntimicrobialsChemotherapeuticsChemotherapeutics

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Antibiotics Antibiotics Bactericidal Bactericidal Bacteriostatic Bacteriostatic Broad spectrum Broad spectrum Narrow spectrumNarrow spectrumPrinciples of antimicrobial therapyPrinciples of antimicrobial therapyAntimicrobials are either used asAntimicrobials are either used as•• TherapeuticTherapeutic•• Prophylactic Prophylactic

•• Therapeutically, only spreading infection or signs of Therapeutically, only spreading infection or signs of systemic infection justify the use of antibiotics.systemic infection justify the use of antibiotics.

•• Organism and its sensitivity should be determined priorOrganism and its sensitivity should be determined prior to commencement of active therapy. to commencement of active therapy.

•• Empirical antibiotic therapy may confuse the clinical Empirical antibiotic therapy may confuse the clinical picture and affect the opportunity to make a precise picture and affect the opportunity to make a precise diagnosis.diagnosis.

Approaches to antibiotic treatmentApproaches to antibiotic treatment •• Narrow spectrum antibiotic is used to treat a known Narrow spectrum antibiotic is used to treat a known

sensitive infectionsensitive infection •• Combination of broad spectrum antibiotics Combination of broad spectrum antibiotics •• can be used when the organism is not known can be used when the organism is not known •• or when it is suspected that more than one organism or when it is suspected that more than one organism

may be responsible for the infection.may be responsible for the infection.

•• Alternatives for single drugs are always availableAlternatives for single drugs are always available

•• Mono-therapy (single drug) as an alternative to triple Mono-therapy (single drug) as an alternative to triple therapytherapy

Approaches to antibiotic treatmentApproaches to antibiotic treatment•• In the surgical units, in which commensal organisms In the surgical units, in which commensal organisms have become as "resident opportunists", it may be have become as "resident opportunists", it may be necessary to rotate antibiotics between broad spectrumsnecessary to rotate antibiotics between broad spectrums •• Alternatives of combinations of antibiotics should be Alternatives of combinations of antibiotics should be monitored by "Infection Control Team"monitored by "Infection Control Team" •• New antibiotics should be used with caution and, New antibiotics should be used with caution and, whenever possible, sensitivities should first be obtainedwhenever possible, sensitivities should first be obtained

The concept of prophylactic antibiotic The concept of prophylactic antibiotic therapytherapy

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– used when local wound defenses are not yet activated so called "decisive period“

– maximum blood and tissue levels should be present at the time that the first incision is made

– Intra-venous administration at induction of anesthesia is optimal, the so called per-operative administration

– pre- and peri-operative administration can also be used

The concept of prophylactic antibiotic The concept of prophylactic antibiotic therapytherapy

5. when contamination is expected, the dose of antibiotic that has started preoperatively may be continued postoperatively repeated 6 or 8 hourly

6. The choice of antibiotics for prophylaxis depend on– the expected spectrum of organism– the cost of treatment– local hospital policies based on experience of local

resistance trends

7. The use of newer, wide spectrum antibiotics should be avoided

Antibiotics in current use for treatment and Antibiotics in current use for treatment and prophylaxis of surgical infectionsprophylaxis of surgical infectionsPenicillins (Benzyl Pencillin)Penicillins (Benzyl Pencillin)•• Broad spectrum Broad spectrum •• Effective against G+ve Streptococci, Clostridia and Effective against G+ve Streptococci, Clostridia and non beta-lactamase Staphylococci. It is still effective non beta-lactamase Staphylococci. It is still effective against Actinomycosis spp.against Actinomycosis spp. Flucloxacillin and MethicillinFlucloxacillin and Methicillin•• Narrow spectrumNarrow spectrum•• Beta-lactamase-resistant PenicillinsBeta-lactamase-resistant Penicillins•• Effective against Staphylococcal beta-lactamase Effective against Staphylococcal beta-lactamase producing organismsproducing organismsAntibiotics in current use for treatment and Antibiotics in current use for treatment and prophylaxis of surgical infectionsprophylaxis of surgical infectionsAmpicillin and AmoxicillinAmpicillin and Amoxicillin•• Broad spectrum beta-lactam penicillins.Broad spectrum beta-lactam penicillins.•• Effective against Enterobacteriaceae, Enterococcus Effective against Enterobacteriaceae, Enterococcus faecalis and the majority of group D Streptococcifaecalis and the majority of group D Streptococci

Mezlocillin and AzlocillinMezlocillin and Azlocillin•• Broad spectrum ureido-penicillins with good activity Broad spectrum ureido-penicillins with good activity against Enterobacter and Klebsiella and Pseudomonas.against Enterobacter and Klebsiella and Pseudomonas.•• have some activity against Bactroids and have some activity against Bactroids and Enterococci.Enterococci.

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•• usually combined with an Aminoglyciside for sever usually combined with an Aminoglyciside for sever mixed infections caused by G-ve organisms.mixed infections caused by G-ve organisms.Antibiotics in current use for treatment and Antibiotics in current use for treatment and prophylaxis of surgical infectionsprophylaxis of surgical infections•• Clavulanic acid is combined with amoxicillin Clavulanic acid is combined with amoxicillin (Amoxiclav) taken orally, protect amoxicillin from being (Amoxiclav) taken orally, protect amoxicillin from being inactivated by beta-lactamase producing bacteria. It is inactivated by beta-lactamase producing bacteria. It is effective against Klebsiella and staphylococcus in animal effective against Klebsiella and staphylococcus in animal and human bitesand human bitesCephalosporinsCephalosporins•• Broad spectrum.Broad spectrum.•• The types important in surgical practice are the beta-The types important in surgical practice are the beta-lactamase-stable Cefuroxime, Cefotaxime and Ceftazidime.lactamase-stable Cefuroxime, Cefotaxime and Ceftazidime. •• The first two are effective against Staphylococcus The first two are effective against Staphylococcus aureus and most Entrobacteria. aureus and most Entrobacteria. •• Ceftazidime is active against G-ve organisms but Ceftazidime is active against G-ve organisms but most effective against Pseudomonous aeroginosa.most effective against Pseudomonous aeroginosa.•• usually combined with Aminoglycoside or an usually combined with Aminoglycoside or an Imidazole for perfect anaerobic cover.Imidazole for perfect anaerobic cover.

Antibiotics in current use for treatment and Antibiotics in current use for treatment and prophylaxis of surgical infectionsprophylaxis of surgical infectionsAminoglycosidesAminoglycosides•• Broad spectrum Gentamicine and Tobramycin. Broad spectrum Gentamicine and Tobramycin. •• Particularly effective against G-ve Enterobacteria, Particularly effective against G-ve Enterobacteria, Pseudomonas, Anaerobs and Streptococci. Ototoxicity andPseudomonas, Anaerobs and Streptococci. Ototoxicity and Nephrotoxicity may follow sustained high toxic levels.Nephrotoxicity may follow sustained high toxic levels.

VancomycinVancomycin•• A narrow spectrum antibiotic of the glycopeptide A narrow spectrum antibiotic of the glycopeptide type. type. •• most effective against G+ve and MRSA. most effective against G+ve and MRSA. •• It is the drug of choice orally against Clostridium It is the drug of choice orally against Clostridium Difficile which cause Pseudomembranous enterocolitisDifficile which cause Pseudomembranous enterocolitisAntibiotics in current use for treatment and Antibiotics in current use for treatment and prophylaxis of surgical infectionsprophylaxis of surgical infectionsImidazolesImidazoles•• The most widly used is the Narrow spectrum The most widly used is the Narrow spectrum MetranidazolMetranidazol•• active against all anaerobic bacteria including active against all anaerobic bacteria including anaerobic cocci, Bactroids and Clostridia.anaerobic cocci, Bactroids and Clostridia.CarbapenemsCarbapenems•• Broad spectrum Meropenem, Ertapenem and Broad spectrum Meropenem, Ertapenem and Imipenem Imipenem

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•• Beta-lactamase resistant, anti-anaerobic and anti-Beta-lactamase resistant, anti-anaerobic and anti-G+veG+ve•• Expensive drugs.Expensive drugs.QuinolonesQuinolones•• Narrow spectrum Ciprofloxacin. It is potent Narrow spectrum Ciprofloxacin. It is potent bactericidal against Pseudomonas spp.bactericidal against Pseudomonas spp.

Dressings in SurgeryDressings in Surgery

General indications for application of General indications for application of surgical dressingssurgical dressings•• To prevent contamination from external To prevent contamination from external

environment. Example; dressing of surgical environment. Example; dressing of surgical wounds.wounds.

•• To cover and absorb heavily exudating To cover and absorb heavily exudating wounds. Example; dressing of burns.wounds. Example; dressing of burns.

•• To eliminate dead space and prevent To eliminate dead space and prevent collections. Example; packing deep wounds.collections. Example; packing deep wounds.

General indications for application of General indications for application of surgical dressingssurgical dressings•• To activate fibrinolysis and liquefy pus. To activate fibrinolysis and liquefy pus.

Example dressing of chronic skin ulcers.Example dressing of chronic skin ulcers.

•• To debride necrotic skin. Example; dressing of To debride necrotic skin. Example; dressing of necrotic sloughing skin ulcers.necrotic sloughing skin ulcers.

•• To remove bacteria and excessive moisture. To remove bacteria and excessive moisture. Example; dressing of deep granulating wound.Example; dressing of deep granulating wound.

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General indications for application of General indications for application of surgical dressingssurgical dressings•• To absorb harmful materials. Example; pus of To absorb harmful materials. Example; pus of

infected wounds and discharges of different infected wounds and discharges of different fistulae and sinuses.fistulae and sinuses.

•• To maintain moist environment and to promoteTo maintain moist environment and to promote epithelialization and formation of granulation epithelialization and formation of granulation tissue.tissue.

•• either with gaseous exchange; using either with gaseous exchange; using semipermiable dressings semipermiable dressings

•• or without gaseous exchange; using complete or without gaseous exchange; using complete occlusive dressingsocclusive dressings

General indications for application of General indications for application of surgical dressingssurgical dressings•• To cover the entry site of different surgical To cover the entry site of different surgical drains.drains.

•• To stop bleeding by the technique of Dry To stop bleeding by the technique of Dry Pack Pressure Dressing. Example; in lacerated Pack Pressure Dressing. Example; in lacerated heavily bleeding liver injuries.heavily bleeding liver injuries.

Types of dressings used in surgicalTypes of dressings used in surgical practice Ipractice I

Simple dressings:Simple dressings:•• Dry plain Gauze; cotton mesh only.Dry plain Gauze; cotton mesh only.•• Dry packs; gauze and cotton with or without non-Dry packs; gauze and cotton with or without non-

adherent coating of Melolin.adherent coating of Melolin.•• Tulles; cotton thread mesh impregnated with non-Tulles; cotton thread mesh impregnated with non-

adherent Paraffin.adherent Paraffin. •• The addition of non-adherent coating facilitates The addition of non-adherent coating facilitates

removal. removal.

•• Charcoal is added to some act as an absorbent and Charcoal is added to some act as an absorbent and reduce swelling.reduce swelling.

•• Relatively cheapRelatively cheapTypes of dressings used in surgicalTypes of dressings used in surgical

practice IIpractice II

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Hydrogel polymers (Geliperm and Intrasite)Hydrogel polymers (Geliperm and Intrasite)•• maintain a moist environment. maintain a moist environment. •• semi-permeable and allow gas exchange.semi-permeable and allow gas exchange.

Hydrocolloids (Comfeel and Granuflex)Hydrocolloids (Comfeel and Granuflex) •• used for complete occlusion technique.used for complete occlusion technique.•• promotes epithelialization of granulating tissue.promotes epithelialization of granulating tissue.•• maintain a moist environment but with out gas exchange acrossmaintain a moist environment but with out gas exchange across them.them.

Fibrous polymers (Kaltostat and Sorban)Fibrous polymers (Kaltostat and Sorban)absorptive alginate dressings that are derived from natural sourcesabsorptive alginate dressings that are derived from natural sources..

All are used to pack deep wounds in order to promote epithelization of All are used to pack deep wounds in order to promote epithelization of newly forming granulation tissuenewly forming granulation tissue..

Types of dressings used in surgicalTypes of dressings used in surgical practice IIIpractice III

Foams (Silastic, Lyofoam and allevyn)Foams (Silastic, Lyofoam and allevyn)•• These are Elastomeric dressingsThese are Elastomeric dressings•• can be shaped to fit deep cavities and granulating can be shaped to fit deep cavities and granulating wounds.wounds.•• absorbent and non-adherentabsorbent and non-adherent

Polymeric films (Opsite and Bioclusive)Polymeric films (Opsite and Bioclusive)•• primary adhesive transparent dressings.primary adhesive transparent dressings.•• used to cover sutured surgical wounds and donor used to cover sutured surgical wounds and donor sitessites

Bead dressings (Debrisan and Iodosorb)Bead dressings (Debrisan and Iodosorb)•• It removes bacteria and excessive moisture by It removes bacteria and excessive moisture by capillary action in deep granulating wounds.capillary action in deep granulating wounds.

Diathermy(Cautery) Diathermy is the use of high frequency electric current to produce

heat Used to either cut or destroy tissue or to produce coagulation Mains electricity is 50 Hz and produces intense muscle and nerve

activation Electrical frequency used by diathermy is in the range of 300 kHz

to 3 MHz Patients body forms part of the electrical circuit

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Current has no effect on muscles

Monopolar diathermy

Electrical plate is placed on patient and acts as indifferent electrode Current passes between instrument and indifferent electrode As surface area of instrument is an order of magnitude less than

that of the plate Localised heating is produced at tip of instrument Minimal heating effect produced at indifferent electrode

Bipolar diathermy

Two electrodes are combined in the instrument (e.g. forceps) Current passes between tips and not through patient

Effects of diathermy The effects of diathermy depends on the current intensity and

wave-form used Coagulation

o Produced by interrupted pulses of current (50-100 per second)

o Square wave-form

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Cutting o Produced by continuous current o Sinus wave-form

Risk and complications Can interfere with pacemaker function Arcing can occur with metal instruments and implants Superficial burns if use spirit based skin preparation Diathermy burns under indifferent electrode if plate improperly

applied

Channeling effects if used on viscus with narrow pedicle (e.g. penis or testis)

Surgical drainsSurgical drains•• Drains are inserted to: Drains are inserted to:

– Evacuate establish collections of pus, blood or other fluids (e.g. lymph)

– Drain potential collections

•• Indications for their use include: Indications for their use include: – Drainage of fluid removes potential sources of infection – Drains guard against further fluid collections – May allow the early detection of anastomotic leaks or

haemorrhage – Leave a tract for potential collections to drain following

removal

•• Arguments against their use include: Arguments against their use include: – Presence of a drain increases the risk of infection

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– Damage may be caused by mechanical pressure or suction – Drains may induce an anastomotic leak – Most drains abdominal drains infective within 24 hours

Types of drainsTypes of drains•• Drains can be: Drains can be:

– Open or closed – Active or passive

•• Drains are often made from inert silastic material Drains are often made from inert silastic material •• They induce minimal tissue reaction They induce minimal tissue reaction •• Red rubber drains induce an intense tissue reaction Red rubber drains induce an intense tissue reaction allowing a tract to form allowing a tract to form •• In some situations this may be useful (e.g. biliary t-In some situations this may be useful (e.g. biliary t-tube) tube) Open drainsOpen drains•• Include corrugated rubber or plastic sheets Include corrugated rubber or plastic sheets •• Drain fluid collects in gauze pad or stoma bag Drain fluid collects in gauze pad or stoma bag •• They increase the risk of infection They increase the risk of infection Closed drainsClosed drains•• Consist of tubes draining into a bag or bottle Consist of tubes draining into a bag or bottle •• They include chest and abdominal drains They include chest and abdominal drains •• The risk of infection is reduced The risk of infection is reduced

•• Active drainsActive drains•• Active drains are maintained under suction Active drains are maintained under suction •• They can be under low or high pressure They can be under low or high pressure

•• Passive drainsPassive drains•• Passive drains have no suction Passive drains have no suction •• Function by the differential pressure between Function by the differential pressure between body cavities and the exterior body cavities and the exterior

GastricGastric  intubationintubationGastricGastric  intubation via the nasal passage intubation via the nasal passage ((i.e. nasogastric routei.e. nasogastric route) ) is a is a

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common procedure that provides access to the stomach for common procedure that provides access to the stomach for diagnostic and therapeutic purposesdiagnostic and therapeutic purposes..  A nasogastric A nasogastric ((NGNG) ) tube is tube is used for the procedureused for the procedure. . The placement of a NG tube can The placement of a NG tube can bebe  uncomfortable for the patient if the patient is not adequately uncomfortable for the patient if the patient is not adequately preparedprepared  with anesthesia to the nasal passages and specific with anesthesia to the nasal passages and specific instructions on how to cooperate with the operator during the instructions on how to cooperate with the operator during the procedureprocedure..  

INDICATIONSINDICATIONS Diagnostic:Diagnostic:- Evaluation of upper gastrointestinal - Evaluation of upper gastrointestinal ((GIGI) ) bleedingbleeding((i.e. presence, volume).i.e. presence, volume).

- Aspiration of gastric fluid content.- Aspiration of gastric fluid content.

- -Identification of the esophagus and stomach on a chest radiographIdentification of the esophagus and stomach on a chest radiograph..

- Administration of radiographic contrast to the GI tract.- Administration of radiographic contrast to the GI tract.

TherapeuticTherapeutic::

- -Gastric decompression, including maintenance of a decompressed state after endotracheal Gastric decompression, including maintenance of a decompressed state after endotracheal intubation, often viaintubation, often via  the oropharynxthe oropharynx  

- -Relief of symptoms and bowel rest in the setting of smallRelief of symptoms and bowel rest in the setting of small--bowel obstructionbowel obstruction

- -Aspiration of gastric content from recent ingestion of toxic materialAspiration of gastric content from recent ingestion of toxic material

- -Administration of medicationAdministration of medication

- -FeedingFeeding

- Bowel irrigation- Bowel irrigation

CONTRAINDICATIONSCONTRAINDICATIONS •• Absolute contraindications:Absolute contraindications:

– Severe midface trauma

– Recent nasal surgery •• Relative contraindications:Relative contraindications:

– Coagulation abnormality

– Esophageal varices or stricture

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– Recent banding or cautery of esophageal varices

– Alkaline ingestion

EQUIPMENTEQUIPMENT •• Nasogastric tubeNasogastric tube

– Adult - 16-18F

– Pediatric - In pediatric patients, the correct tube size varies with the patient’s age. To find the correct size, add 16 to the patient’s age in years and then divide by 2 (eg, [8 y + 16]/2 = 12F) •• Viscous lidocaine 2%Viscous lidocaine 2%

•• Oral analgesic spray Oral analgesic spray ((Benzocaine spray or otherBenzocaine spray or other))

•• Oral syringe, 12 mLOral syringe, 12 mL

Equi. Cont..Equi. Cont..•• Glass of water with a strawGlass of water with a straw

•• WaterWater--based lubricantbased lubricant

•• Toomey syringe, 60 mLToomey syringe, 60 mL

•• TapeTape

•• Emesis basin or plastic bagEmesis basin or plastic bag

•• Wall suction, set to low intermittent suctionWall suction, set to low intermittent suction

•• Suction tubing and containerSuction tubing and container

POSITIONINGPOSITIONING •• Position the patient in the sitting upright Position the patient in the sitting upright positionposition..

TECHNIQUETECHNIQUE

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•• Explain the procedure, benefits, risks, Explain the procedure, benefits, risks, complications, and alternatives to the patient or the complications, and alternatives to the patient or the patient's representativepatient's representative..

•• Examine the patientExamine the patient’’s nostril for septal deviations nostril for septal deviation. . To determine which nostril is more patent, ask the To determine which nostril is more patent, ask the patient to occlude each nostril and breathe through the patient to occlude each nostril and breathe through the otherother. .

•• Instill 10 mL of viscous lidocaine 2% Instill 10 mL of viscous lidocaine 2% ((for oral usefor oral use) ) down the more patent nostril with the head tilted down the more patent nostril with the head tilted backwards, and ask the patient to sniff and swallow to backwards, and ask the patient to sniff and swallow to anesthetize the nasal and oropharyngeal mucosaanesthetize the nasal and oropharyngeal mucosa. . In In pediatric patients, do not exceed 4 mgpediatric patients, do not exceed 4 mg//kg of lidocainekg of lidocaine. . Wait 5-10 minutes to ensure adequate anesthetic effectWait 5-10 minutes to ensure adequate anesthetic effect..

•• Estimate the length of insertion by measuring the Estimate the length of insertion by measuring the distance from the tip of the nose, around the ear, and distance from the tip of the nose, around the ear, and down to just below the left costal margindown to just below the left costal margin. . This point can This point can be marked with a piece of tape on the tubebe marked with a piece of tape on the tube. . When using When using the Salem sump nasogastric tube the Salem sump nasogastric tube ((Kendall, Mansfield, Kendall, Mansfield, MassMass))  in adults, the estimated length usually falls in adults, the estimated length usually falls between the second and third preprinted black lines on between the second and third preprinted black lines on the tubethe tube..

•• Position the patient sitting upright with the Position the patient sitting upright with the neck partially flexedneck partially flexed. . Ask the patient to hold the Ask the patient to hold the cup of water in his or her hand and put the straw cup of water in his or her hand and put the straw in his or her mouthin his or her mouth. . Lubricate the distalLubricate the distal  tip of the tip of the nasogastric tubenasogastric tube..

•• Gently insert the nasogastric tube along the floor of the Gently insert the nasogastric tube along the floor of the nose and advance it parallel to the nasal floor nose and advance it parallel to the nasal floor ((ie, directly ie, directly perpendicular to the patient's head, not angled up into the noseperpendicular to the patient's head, not angled up into the nose) ) until it reaches the back of the nasopharynx, where resistance willuntil it reaches the back of the nasopharynx, where resistance will be met be met ((10-20 cm10-20 cm). ). At this time, ask the patient to sip on the At this time, ask the patient to sip on the water through the straw and start to swallowwater through the straw and start to swallow. . Continue to Continue to

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advance the nasogastric tube until the distance of the previously advance the nasogastric tube until the distance of the previously estimated length is reachedestimated length is reached..

•• Stop advancing and completely withdraw the nasogastric tube if, at any Stop advancing and completely withdraw the nasogastric tube if, at any time, the patient experiences respiratory distress, is unable to speak,time, the patient experiences respiratory distress, is unable to speak,  has has significant nasal hemorrhage, or if the tube meets significant resistancesignificant nasal hemorrhage, or if the tube meets significant resistance..

•• Verify proper placement of the nasogastric tube by auscultating a rush Verify proper placement of the nasogastric tube by auscultating a rush of air over the stomach using the 60 mL Toomey syringe or by aspirating of air over the stomach using the 60 mL Toomey syringe or by aspirating gastric contentgastric content. . The authors recommend always obtaining a chest radiograph The authors recommend always obtaining a chest radiograph in order to verify correct placement, especially if the nasogastric tube is to be in order to verify correct placement, especially if the nasogastric tube is to be used for medication or food administrationused for medication or food administration. .

•• Tape the nasogastric tube to the nose to Tape the nasogastric tube to the nose to secure it in placesecure it in place. . If clinically indicated, attach If clinically indicated, attach the nasogastric tube to wall suction after the nasogastric tube to wall suction after verification of correct placementverification of correct placement..

•• During insertion, ifDuring insertion, if  concern exists thatconcern exists that  the the tube is in the incorrect place, ask the patient to tube is in the incorrect place, ask the patient to speakspeak..  IfIf  the patient isthe patient is  able to speak, then the able to speak, then the nasogastric tube has not passed through the nasogastric tube has not passed through the vocal cords andvocal cords and//or lungsor lungs. .

•• The nasogastric tube may coil in the nasopharynx or The nasogastric tube may coil in the nasopharynx or oropharynxoropharynx..  If this occurs, or if the tube is difficultIf this occurs, or if the tube is difficult  to pass in to pass in general, one can trygeneral, one can try  curling the distal end and partially freezing it curling the distal end and partially freezing it in a cup of ice in order to temporarily hold its curled shape in a cup of ice in order to temporarily hold its curled shape betterbetter..  Insert the lubricated tube tip through the nose with the Insert the lubricated tube tip through the nose with the curled end pointing downwardscurled end pointing downwards. . Once the distal tipOnce the distal tip  passes into passes into the hypopharynx, the curved tip will be facing anteriorlythe hypopharynx, the curved tip will be facing anteriorly. . Rotate Rotate the tube 180 degrees so that the curved end is pointing the tube 180 degrees so that the curved end is pointing posteriorly toward the esophagusposteriorly toward the esophagus. . Continue to insert in the usual Continue to insert in the usual manner by having the patient swallow watermanner by having the patient swallow water..

•• Another option Another option ((in paralyzed patients onlyin paralyzed patients only) ) is to is to place 2-3 fingers through the patientplace 2-3 fingers through the patient’’s mouth into the s mouth into the oropharynxoropharynx. . The fingers are used to guide the The fingers are used to guide the nasogastric tube into the hypopharynxnasogastric tube into the hypopharynx..

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•• Lifting the thyroid cartilage anterior and upward Lifting the thyroid cartilage anterior and upward might open the esophagus and allow passage into the might open the esophagus and allow passage into the proximal esophagusproximal esophagus. . COMPLICATIONSCOMPLICATIONS

•• Patient discomfortPatient discomfort

– Generous lubrication, the use of topical anesthetic, and a gentle technique may reduce the patient’s level of discomfort.

– Throat irritation may be reduced with administration of anesthetic lozenges (eg, benzocaine lozenges [Cepacol]) prior to the procedure. •• Epistaxis may be prevented by generouslyEpistaxis may be prevented by generously  lubricating the tube tip andlubricating the tube tip and  using a using a gentle techniquegentle technique..

•• Respiratory tree intubationRespiratory tree intubation

•• Esophageal perforationEsophageal perforation

Urethral catheterizationUrethral catheterizationIs a routine medical procedureIs a routine medical procedure  that hasthat has  both both diagnostic and therapeutic purposesdiagnostic and therapeutic purposes..

INDICATIONSINDICATIONS11 . .DiagnosticDiagnostic : :

-Collection of uncontaminated urine specimen .

-Monitoring of urine output .

-Imaging of the urinary tract.

22 . .TherapeuticTherapeutic : : -Acute urinary retention (e.g., benign prostatic hypertrophy, blood clots) .

-Chronic obstruction that causes hydronephrosis.

-Initiation of continuous bladder irrigation .

-Intermittent decompression for neurogenic bladder.

-Hygienic care of bedridden patients.

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CONTRAINDICATIONSCONTRAINDICATIONSUrethral catheterization is contraindicated in the presence of Urethral catheterization is contraindicated in the presence of traumatic injury to the lower urinary tracttraumatic injury to the lower urinary tract (e.g. urethral tear). This (e.g. urethral tear). This condition may be suspected in male patients with a pelvic or condition may be suspected in male patients with a pelvic or straddle-type injury. Signs that increase suspicion for injury are a straddle-type injury. Signs that increase suspicion for injury are a high-riding prostate, perineal hematoma, or blood at the meatus. high-riding prostate, perineal hematoma, or blood at the meatus. When any of these findings are present in the setting of When any of these findings are present in the setting of concerning trauma, a retrograde urethrogram should be concerning trauma, a retrograde urethrogram should be performed to rule out a ureteral tear prior to placing a catheter performed to rule out a ureteral tear prior to placing a catheter into the bladderinto the bladder..EQUIPMENTEQUIPMENT

-Povidone iodine .

-Sterile cotton balls .

-Water-soluble lubrication gel .

-Sterile drapes.

-Sterile gloves .

-Urethral catheter .

-Prefilled 10-mL saline syringe .

-Urinometer connected to a collection bag. - -Sterile anesthetic lubricant (e.g. lidocaine gel 2%) with a Sterile anesthetic lubricant (e.g. lidocaine gel 2%) with a

blunt tip urethral applicator or a plastic syringe (5-10 blunt tip urethral applicator or a plastic syringe (5-10 mL)mL)..

POSITIONINGPOSITIONINGPlace the patient supine, in the frog leg position, Place the patient supine, in the frog leg position, with knees flexedwith knees flexed..

TECHNIQUETECHNIQUEExplain the procedure, benefits, risks, complications, and Explain the procedure, benefits, risks, complications, and

alternatives to the patient or the patient's representativealternatives to the patient or the patient's representative . .Position the patient supine, in bed, and uncover the genitaliaPosition the patient supine, in bed, and uncover the genitalia . .

Open the iodine/chlorhexidine preparatory solution and pour it onto Open the iodine/chlorhexidine preparatory solution and pour it onto the sterile cotton balls. Open a sterile lidocaine 2% lubricant with the sterile cotton balls. Open a sterile lidocaine 2% lubricant with applicator or a 10-mL syringe and sterile 2% lidocaine gel and applicator or a 10-mL syringe and sterile 2% lidocaine gel and place them on the sterile fieldplace them on the sterile field..

Wear sterile gloves and use the nondominant hand to hold the penisWear sterile gloves and use the nondominant hand to hold the penis and retract the foreskin (if present). This handand retract the foreskin (if present). This hand  is the nonsterile is the nonsterile

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hand and holds the penis throughout the procedurehand and holds the penis throughout the procedure..

Use the sterile hand and sterile forceps to prep the urethra and Use the sterile hand and sterile forceps to prep the urethra and glans in circular motions with at least 3 different cotton ballsglans in circular motions with at least 3 different cotton balls..

Using a syringe with no needle, instill 5-10 mL of lidocaine gel 2% into the Using a syringe with no needle, instill 5-10 mL of lidocaine gel 2% into the urethra. Place a finger on the meatus to help prevent spillage of the anesthetic urethra. Place a finger on the meatus to help prevent spillage of the anesthetic lubricant.lubricant.  Allow 2-3 minutes before proceeding with the urethral Allow 2-3 minutes before proceeding with the urethral catheterizationcatheterization..

While holding the penis at approximately 90 and stretching it upward to While holding the penis at approximately 90 and stretching it upward to straighten out the penile urethra, slowly and gently introduce the catheter into straighten out the penile urethra, slowly and gently introduce the catheter into the urethra. Continue to advance the catheter until the proximal Y-shaped the urethra. Continue to advance the catheter until the proximal Y-shaped ports are at the meatusports are at the meatus..

Wait for urine to drain from the larger port to ensure that the distal Wait for urine to drain from the larger port to ensure that the distal end of the catheter is in the bladder. The lubricant jellyend of the catheter is in the bladder. The lubricant jelly––filled filled distal catheter openings may delay urine return. If no distal catheter openings may delay urine return. If no spontaneous return of urine occurs, try attaching a 60-mL syringe spontaneous return of urine occurs, try attaching a 60-mL syringe to aspirate urine. If urine return is still not visible, withdraw the to aspirate urine. If urine return is still not visible, withdraw the catheter and reattempt the procedure (preferably after using catheter and reattempt the procedure (preferably after using ultrasonography to verify the presence of urine in the bladder)ultrasonography to verify the presence of urine in the bladder)..

After visualization of urine return (and while the proximal After visualization of urine return (and while the proximal ports are at the level of the meatus), inflate the distal ports are at the level of the meatus), inflate the distal balloon by injecting 5-10 mL of 0.9% NaCl (normal balloon by injecting 5-10 mL of 0.9% NaCl (normal saline) through the cuff inflation port. Inflation of the saline) through the cuff inflation port. Inflation of the balloon inside the urethra results in severe pain, gross balloon inside the urethra results in severe pain, gross hematuria, and, possibly, urethral tearhematuria, and, possibly, urethral tear..

Gently withdraw the catheter from the urethra until Gently withdraw the catheter from the urethra until resistance is met. Secure the catheter to the patient's resistance is met. Secure the catheter to the patient's thigh with a wide tape. If the patient is uncircumcised, thigh with a wide tape. If the patient is uncircumcised, makemake  sure to reduce the foreskin, as failure to do so can sure to reduce the foreskin, as failure to do so can

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cause paraphimosiscause paraphimosis..

COMPLICATIONSCOMPLICATIONS11 . .InfectionsInfections

-Urethritis

-Cystitis

-Pyelonephritis

-Transient bacteremia

22 . .ParaphimosisParaphimosis, caused by failure to reduce the foreskin after , caused by failure to reduce the foreskin after catheterizationcatheterization

33 . .Creation of false passagesCreation of false passages

44 . .Urethral stricturesUrethral strictures 55 . .Urethral perforationUrethral perforation

66 . .BleedingBleeding

Prophylactic antibiotics are recommended for patients Prophylactic antibiotics are recommended for patients with prosthetic heart valves, artificial urethral with prosthetic heart valves, artificial urethral

sphincters, or penile implantssphincters, or penile implants . .

Catheter types and sizesCatheter types and sizes::Adults: Foley (16-18 F)

Adults with obstruction at the prostate: Coudé (18 F)

Children: Foley (5-12 F)

Infants younger than 6 months: Feeding tube (5 F) with tape.

Bed-side SurgicalBed-side Surgical proceduresprocedures

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General PrinciplesGeneral PrinciplesDefinitionDefinitionHow to approach?How to approach?Observe…Practice….Pass on ExperienceObserve…Practice….Pass on ExperienceGeneral principlesGeneral principles•• Confidence and competencyConfidence and competency•• EquipmentsEquipments•• ConsentConsent•• Checking patient’s detailsChecking patient’s details•• Reassure and explainReassure and explain•• Additional arrangementsAdditional arrangements•• SedationSedation•• AssistanceAssistance•• Expert opinionExpert opinion•• DocumentationDocumentation•• Dangers to the operatorDangers to the operator•• Signing by name and rank Signing by name and rank

Vein punctureVein puncture•• Indications and procedureIndications and procedure•• Tips and problemsTips and problems •• Poor veinsPoor veins•• Agitated patientAgitated patient•• Obese patientObese patient•• Failed attemptsFailed attempts•• Obtaining blood for culture and Obtaining blood for culture and sensitivity testingsensitivity testing

Intravenous cannulationIntravenous cannulation•• Indications and procedureIndications and procedure•• Tips and complicationsTips and complications •• Poor veinsPoor veins•• Agitated patientAgitated patient•• Obese patientObese patient•• Selection of the siteSelection of the site•• Failed attempts Failed attempts •• Blood transfusionBlood transfusion

Venous cut down (Vein section)Venous cut down (Vein section)Indications and methodIndications and methodTips and problemsTips and problems

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•• Freeing enough segment of veinFreeing enough segment of vein•• Caution not to injure the posterior wallCaution not to injure the posterior wall•• Securing the cannulaSecuring the cannula

Central venous access ICentral venous access IIndicationsIndications•• CVPCVP•• TPNTPN•• Special drugsSpecial drugs•• Poor or failed peripheral accessPoor or failed peripheral accessCautionsCautions•• Clotting disturbancesClotting disturbances•• Hypovolemia Hypovolemia

Central venous accessCentral venous access II IIPreparationPreparation•• Lie patient supine with head supported by Lie patient supine with head supported by one pillow. If a patient is shocked, tilt the head of one pillow. If a patient is shocked, tilt the head of the bed down the bed down •• Tilt the patient head away from the side of Tilt the patient head away from the side of insertioninsertion•• Ensure that each port of the cannula is Ensure that each port of the cannula is "primed" with heparinized saline"primed" with heparinized saline•• Identify the site of entry before scrubbing upIdentify the site of entry before scrubbing up•• If possible, place the patient on cardiac If possible, place the patient on cardiac monitormonitor

Central venous access IIICentral venous access IIIApproachApproach•• the right side is used to avoid damaging the thoracic the right side is used to avoid damaging the thoracic duct. duct. •• If a chest tube is there, use the same side for If a chest tube is there, use the same side for cannulation.cannulation.For the subclavian vein For the subclavian vein •• identify the mid- point of right clavicleidentify the mid- point of right clavicle•• pass the needle under and closely applied to the pass the needle under and closely applied to the lower border of the clavicle aiming to supra-sternal notch.lower border of the clavicle aiming to supra-sternal notch.For the internal jugular veinFor the internal jugular vein •• identify the carotid pulse at the level of the thyroid identify the carotid pulse at the level of the thyroid cartilage insert the needle at the medial border of the cartilage insert the needle at the medial border of the sternomastoid muscle 0.5-1 cm lateral to the artery and sternomastoid muscle 0.5-1 cm lateral to the artery and advanced at 45advanced at 4500, aiming for the ipsilateral nipple., aiming for the ipsilateral nipple.

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Central venous access IVCentral venous access IVTips and problemsTips and problems•• Line in the neck on chest x-rayLine in the neck on chest x-ray•• Pnemothorax on x-rayPnemothorax on x-ray•• InfectionInfection•• Cardiac arrhythmiasCardiac arrhythmias•• Blocked cannulaBlocked cannula•• Measurement of the CVPMeasurement of the CVP

Arterial puncture (cannulation)Arterial puncture (cannulation)CautionsCautions•• Clotting disturbancesClotting disturbancesApproachesApproaches•• Radial A ( apply Allan’s test)Radial A ( apply Allan’s test)•• Femoral AFemoral ATips and problemsTips and problems•• Poorly palpable arteryPoorly palpable artery

•• Venous sampleVenous sample

•• Bleeding from puncture siteBleeding from puncture site

Endotracheal intubationEndotracheal intubationIndicationsIndications•• Cardiac arrestCardiac arrest•• Serious head injurySerious head injury•• Certain acute respiratory and trauma settingsCertain acute respiratory and trauma settings•• Prior to surgical operationsPrior to surgical operationsTips Tips •• The patient is pre oxygenatedThe patient is pre oxygenated•• Ensure that the laryngoscope and endotracheal tube Ensure that the laryngoscope and endotracheal tube

cuff are functioningcuff are functioning•• Remove any dentures from the mouth. Excess saliva orRemove any dentures from the mouth. Excess saliva or

secretions must be suctioned.secretions must be suctioned.•• Assess the correct positioningAssess the correct positioning

Nasogastric tube insertionNasogastric tube insertionIndicationsIndications•• Intestinal obstructionIntestinal obstruction•• Paralytic ileusParalytic ileus•• Peri operative gastric decompressionPeri operative gastric decompression•• Enteral feedingEnteral feeding

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Check the position of the tube by:Check the position of the tube by:– Aspirating gastric contents that turn the blue litmus in to red– Blow air down the tube and auscultate for the bubbling over the stomach

and problemsand problems •• Patients has problem in swallowing: ask the patient Patients has problem in swallowing: ask the patient to swallow sips of water as the tube is passedto swallow sips of water as the tube is passed•• Constant coiling in to the mouth: the tube may be tooConstant coiling in to the mouth: the tube may be too soft; cool in fridgesoft; cool in fridge•• Resistance to passage: there may be an anatomical Resistance to passage: there may be an anatomical reason for this, e.g. esophageal stricture. The tube may reason for this, e.g. esophageal stricture. The tube may need to be passed under X-ray controlneed to be passed under X-ray control•• Obtain an X-ray: prior to commencing Enteral feedingObtain an X-ray: prior to commencing Enteral feeding in order to confirm the position of the tube and avoid in order to confirm the position of the tube and avoid iatrogenic aspiration.iatrogenic aspiration.

Sengestaken-Blakmore tubeSengestaken-Blakmore tubeMethodMethod•• The tube is passed through the mouth, advanced in to The tube is passed through the mouth, advanced in to

the esophagusthe esophagus•• inflate the gastric balloon slowly to a pressure of 60 inflate the gastric balloon slowly to a pressure of 60

mmHgmmHg•• Pull the tube back until resistance is met, as the Pull the tube back until resistance is met, as the

balloon reaches the cardia.balloon reaches the cardia.•• Inflate the esophageal balloon to 40-50 mmHg and Inflate the esophageal balloon to 40-50 mmHg and

secure the tube under mild tension.secure the tube under mild tension.•• Aspirate the gastric and esophageal ports every 30 min.Aspirate the gastric and esophageal ports every 30 min.•• the esophageal balloon must be deflated every hour to the esophageal balloon must be deflated every hour to

prevent mucosal ulceration or necrosis.prevent mucosal ulceration or necrosis.

Urethral catheterizationUrethral catheterizationIndicationsIndications•• Perioperative monitoring of urinary Perioperative monitoring of urinary outputoutput•• Acute urinary retentionAcute urinary retention•• Chronic urinary retentionChronic urinary retention•• Prior to abdominal or pelvic surgeryPrior to abdominal or pelvic surgery•• IncontinenceIncontinenceTips and problemsTips and problems

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•• No urine immediatelyNo urine immediately•• Inability to insertInability to insert•• Decompression of grossly distended Decompression of grossly distended bladderbladder•• Urine is bypassing the catheterUrine is bypassing the catheter•• Catheter stops drainingCatheter stops draining•• Female catheterizationFemale catheterization

Suprapubic catheterizationSuprapubic catheterizationIndicationsIndications•• Failed or contraindicated transurethral Failed or contraindicated transurethral catheterizationcatheterizationCautionsCautions•• patient with known bladder tumor or patient with known bladder tumor or previous bladder surgeryprevious bladder surgery•• Ensure clinically (and by US if available) that Ensure clinically (and by US if available) that the bladder is full and distended.the bladder is full and distended.Tips and problemsTips and problems•• Bypassing urineBypassing urine•• No urine or faeculent matter in the catheterNo urine or faeculent matter in the catheter

PleurocentesisPleurocentesisIndicationsIndications•• Drainage of pleural effusionDrainage of pleural effusion•• Drainage of early empyemaDrainage of early empyemaTips and problemsTips and problems•• Diagnostic tapDiagnostic tap•• Dry tapDry tap•• PnemothoraxPnemothorax•• Very bloody tapVery bloody tap•• Marking the proposed siteMarking the proposed site

Thoracostomy tube drainageThoracostomy tube drainageIndicationsIndications•• PnemothoraxPnemothorax•• HaemothoraxHaemothorax•• Post-thoracotomyPost-thoracotomyTips and problemsTips and problems•• Agitated or anxious patientAgitated or anxious patient•• Securing the drainSecuring the drain•• Do not clamp the drainDo not clamp the drain

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•• Blocked drainBlocked drain•• Persistent bubblingPersistent bubbling•• Removal of the drainRemoval of the drain

Paracentesis abdominisParacentesis abdominisIndicationsIndications•• Diagnostic evaluation of ascitisDiagnostic evaluation of ascitis•• Therapeutic drainage of ascitisTherapeutic drainage of ascitisTips and problemsTips and problems•• Identify a suitable tap siteIdentify a suitable tap site•• Amount aspiratedAmount aspirated•• Unable to aspirate adequate amount of fluidUnable to aspirate adequate amount of fluid•• Blood or faeculent materialBlood or faeculent material•• Considering Peritoneal catheterConsidering Peritoneal catheter

Rigid sigmoidoscopyRigid sigmoidoscopyIndicationsIndications•• Investigation of the lower GI symptomsInvestigation of the lower GI symptoms•• Visualization of the rectum and lower sigmoidVisualization of the rectum and lower sigmoid colon prior to barium enemacolon prior to barium enemaTips and problemsTips and problems•• Advancing slowly under direct visionAdvancing slowly under direct vision•• Recto-sigmoid junctionRecto-sigmoid junction•• BiopsyBiopsy•• Withdrawal Withdrawal

Local anesthesiaLocal anesthesiaIndicationsIndications•• Minor procedure Minor procedure •• Postoperative infiltrationPostoperative infiltrationCautionsCautions•• AllergyAllergy•• Infection at the proposed site for infiltration Infection at the proposed site for infiltration •• Increased risk of toxicity: heart block, low cardiac Increased risk of toxicity: heart block, low cardiac output, epilepsy, myasthenia gravis, hepatic impairment, output, epilepsy, myasthenia gravis, hepatic impairment, porphyria, beta-blockers, and cimitidien therapy all porphyria, beta-blockers, and cimitidien therapy all increase this risk.increase this risk.•• Adrenaline containing solution (decrease blood loss, Adrenaline containing solution (decrease blood loss, prolong duration of anesthesia and delay absorption of prolong duration of anesthesia and delay absorption of agent)agent)AgentsAgentsLignocaine: for short proceduresLignocaine: for short procedures•• ConcentrationsConcentrations : 0.5%, 1%, and 2% Plain or with adrenaline.: 0.5%, 1%, and 2% Plain or with adrenaline.

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•• Duration of actionDuration of action : rapid onset (2-3) minutes, effect last for 30-: rapid onset (2-3) minutes, effect last for 30-90 minutes depending on the site and the dose.90 minutes depending on the site and the dose.•• Maximum doseMaximum dose : plain solution 200 mg or 20 ml of 1% solution : plain solution 200 mg or 20 ml of 1% solution for an adult, 3 mg/kg for a child.for an adult, 3 mg/kg for a child.

Bupivacaine: for longer proceduresBupivacaine: for longer procedures•• ConcentrationsConcentrations : 0.25-0.75 % plain solutions, 0.25-0.5 % with : 0.25-0.75 % plain solutions, 0.25-0.5 % with adrenaline.adrenaline.•• Duration of actionDuration of action : slower onset of action than lignocaine. Its : slower onset of action than lignocaine. Its Effect last for 3-8 hours.Effect last for 3-8 hours.•• Maximum doseMaximum dose : 150 mg or 30 ml 0.5% solution for an adult, 2 : 150 mg or 30 ml 0.5% solution for an adult, 2 mg/kg for a child.mg/kg for a child.ToxicityToxicity•• Symptoms mainly neurological. Drowsiness, confusion, slurred speech, Symptoms mainly neurological. Drowsiness, confusion, slurred speech, light-headedness, tinnitus, and numbness of the tongue or mouth may all light-headedness, tinnitus, and numbness of the tongue or mouth may all occur. If sever, convulsion and coma may follow.occur. If sever, convulsion and coma may follow.•• Signs may include early tachycardia and hypertension. Later Signs may include early tachycardia and hypertension. Later bradycardia, hypotension, cardiac arrhythmias and cardiac arrest may occur.bradycardia, hypotension, cardiac arrhythmias and cardiac arrest may occur.TreatmentTreatment•• Stop procedureStop procedure•• Maintain airway and provide oxygenMaintain airway and provide oxygen•• Ensure IV accessEnsure IV access•• Perform an ECGPerform an ECG•• Give valium 5-10 mg IV, slowly for convulsions.Give valium 5-10 mg IV, slowly for convulsions.•• Raise the bed and initiate IV fluids for hypotensionRaise the bed and initiate IV fluids for hypotension•• Bradycardia: usually resolve, atropine is rarely needed.Bradycardia: usually resolve, atropine is rarely needed.Inadequate analgesiaInadequate analgesia

Intercostals nerve blockIntercostals nerve blockIndicationsIndications•• Painful fractured ribPainful fractured rib•• Post-thoracotomy pain reliefPost-thoracotomy pain relief•• Position the patient as for pleural aspirationPosition the patient as for pleural aspirationTips Tips •• For a broken rib: inject medial to the site of fracture For a broken rib: inject medial to the site of fracture on the posterior aspect of the chest wallon the posterior aspect of the chest wall•• For post-thoracotomy pain relief: inject medial to theFor post-thoracotomy pain relief: inject medial to the posterior edge of the scar on the posterior chest wallposterior edge of the scar on the posterior chest wall•• Multiple blocks: ensure that you did not reach a toxicMultiple blocks: ensure that you did not reach a toxic dosedose•• Air or blood is aspirated: withdraw needle slowly andAir or blood is aspirated: withdraw needle slowly and re-aspirate.re-aspirate.

Nasotrachieal intubationIndication;Contraindication;

Pregnancy Coagulopathy Nasal occlusion Deviated septum C.S.F Rhinorrhea

Technique; Awake patient , spontaneously breathing Signs of correct advancement

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Complications; Esophageal intubation. bleeding

Nasal packsIndication ; Anaesthesia;Position;Technique;-Assessment of the patient; Pinch the nostrils….10 minutes. Apply ice pack. Cotton swabs soaked with 2% Lidocaine +1:1000 epinephrine Chemical cauterizationComplications and management;

1. Persistent or recurrent bleeding2. Infection3. hypoxima

Internal jugular venous accessIndications;1. C.V.P monitoring2. Total Paranteral nutrition3. Long term drug infusion4. Haemodialysis

Contraindications;1. Previous ipsilateral neck surgery2. Untreated sepsis3. Venous thrombosis

Positioning;Technique (central approach); Localization. If there is no venous blood return? If air or arterial blood is encountered.

Complications and management; Carotid puncture Air embolus Pneumothorax Malpositioning Horner's syndrome

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Dysrhythmias

Femoral venous access

Indications; Emergent central access. Haemodialysis. Unable to obtain other venous access

Contraindications; Prior groin surgery (relative) Patient must maintain bed rest.

Technique; Position and anaesthesia Surface anatomy and localization; If no venous return If arterial blood aspirated.

Complications and management;Femoral artery puncture/haematoma

pericardiocentesisIndications;

To prevent further cardiac compression For diagnosis

Contraindications; Coagulopathy Post coronary bypass surgery Acute traumatic haemopericardium Small pericardial effusion<200ml Absence of anterior effusion or loculated effusion.

Positioning;

Technique; Site of the needle introduction. Advance the needle toward the left shoulder Contact with epicardium negative deflection of the QRS. Contact with the myocardium ST-segment elevation.

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Laboratory test (cell count, amylase, Protein, glucose, culture…)6. Monitoring of the patient7. Success in reducing tamponade;

Decrease right atrial pressure Increase cardiac output Disappearance of pulsus paradoxus.

Complications and management; Cardiac puncture or laceration. Air embolism. Cardiac arrhythmia Haemothorax or Pneumothorax infection

AnoscopyIndication; Anal lesion diagnosis. Rectal bleeding Rectal pain Banding or injection of haemorrhoids

Contraindication; Anal stricture Acute perianal conditions Acutely thrombosed haemorrhoid.

Positioning;

Technique;-Digital examination first.

Complications and management;1- Fissure2- bleeding

Diagnostic peritoneal lavageIndication;

Blunt abdominal trauma with equivocal or unreliable abdominal examination.

Unexplained hypotension or blood loss.Unstable patient.

Absolute contraindication;Indication for laparotomy.Pregnancy.

Relative contraindication; Cirrhosis Morbid obesity.

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Retroperitoneal injury Prior to abdominal surgery.

Anaesthesia;

Positioning;1. Supine.2. Decompress stomach.3. Decompress bladder.

Technique;-Preparation and anaesthesia-Indication for immediate laparotomy;

1. Gross blood(5ml or more)2. Gross enteric contents3. Dialysat in chest tube or foley catheter

-Positive finding;1. RBC>500/mm32. Amylase>175

Complications and management;• Bladder injury• Injury to bowel or other abdominal organs.• Haemorrhage.• Peritonitis• Wound infection.

Lumber punctureIndications;• C.S.F evaluation• C.S.F drainage• Intracranial pressure measurement• Intra thecal drug administration

Contraindication; Non communicating hydrocephalus. Intracranial mass Coagulopathy Cellulitis Complete spinal block Tethered cord syndromeAnaesthesia;

Positioning; Lateral (fetal position) Sitting positionTechnique;

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-Space;1. L4-L52. L3-L43. L5-S1

-Needle directed cranially and parallel to midline-The stylet should always be in the needle..?

1. If blood clears……….Traumatic2. Not clear+ clots………Reattempt3. Not clear+ not clots………Subarachnoid haemorrhage

-If the bone is encountered-C.S.F

1. flow;2. Measure C.S.F pressure;

1. Normal<15cm H2O2. Borderline 15-20cm H2O3. Abnormal>20mmH2O

-Sample send to;1. Cell count.2. Protein and amylase3. Culture and sensitivity4. Cell count (comparison)

Complications and management;1-Tonsillar herniation• Altered mental state• Cranial nerve abnormality (third nerve+ respiratory difficulty)• Cushing response (increase B.P +decrease P.R+ respiratory depress)Management;

o Position of the patient.o Manitol 1gm/Kg I.Vo Intubation……..PCO2=30mmHgo Neurosurgical consultation.

2 -Nerve root injury. 3-Spinal haedache4-Aortic /arterial puncture

Culdocentesis

Indication;Suspected pelvic abscess.Suspected rupture ectopic pregnancy

Contraindications; Obliterated cul-de-soc Severely retroverted uterus

Anaesthesia;2%Lidocaine jelly

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1%Lidocaine solutionPositioning;Technique;Complication and management; bleeding

TourniquetsA/Finger tourniquet;IndicationsContraindicationAnaesthesiaPositioningTechniqueComplications and management; Ischemia.

B/Arm tourniquet.

Measurement of compartment pressureIndicationSign of ischemia1)1) Pain………….early sign2)2) Pallor3)3) Parasthesia4)4) Paralysis……….late sign5)5) Pulselessness…………late signCompartments of the leg;a. Anterior compartmentb. Lateral compartmentc. Superficial posterior compartmentd. Deep posterior compartmentIndications;Contraindications;1. Coagulopathy2. InfectionAnaesthesia; No need …………why?Positioning;

Technique (white side's technique);pressure>40mmHg--------fasciatomy.

Complications;1)1) Error in reading2)2) Infection

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Arthrocentesis , intraarticular and periarticular injections

Indications;A/Diagnostic;1)1) Septic arthritis2)2) Differentiate inflammatory and noninflammatory condition3)3) Synovial biopsy

B/Therapeutic;1. Intraarticular injection2. Aspiration3. lavageContraindication; Local infection Systemic infection Coagulopathy Allergy Prosthetic joint Distorted joint

Anaesthesia;Positioning and approach;

I. Metacarpopharangeal jointII. Wrist joint

III. carpel tunnel syndromeIV. Elbow jointV. Shoulder joint

VI. Knee and ankle joint

Technique;

Complications;• Infection• Bleeding• Allergy• Post injection flare• cutaneous atrophy• Tendon rupture• Weakness of extremity• Vasovagal syncope• Steroid arthropathy• Avascular necrosis• Steroid induced osteoporosis

Steroid available;• Hydrocortisone--------25-100mg• Prednisolone-------------5-40mg• Methyl prednisolone acetate-----4-40mg• Triamcinolone acetomide--------5-40mg

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Needle biopsies

Advantage;1. Diff. benign and malignant2. Follow benign condition3. Biopsy(+/- ultrasound)4. Sensitive ,inexpensive, noninvasive.

Types of needle biopsy;• Fine needle aspiration (FNA)• Large needle cutting biopsy (LNCB)

Fine needle aspiration of thyroid nodule;

IndicationContraindicationAnaesthesiaPositioningTechnique;

• Non suction technique• Suction technique

Complications and management;• Bleeding and haematoma• Tracheal puncture• Infection

NB; FNA of the breast , soft tissue and lymph nodes.

Note: These information has been taken from the lectures of (Dr.Ibtisam K. Salih ) and (Dr. Mohamad Kamil) and some other sources

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Prepared by :Dr. Soran Mohamad Gharib

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