Hemostasis & Emergency Situations
ST230Concorde Career College
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Clotting Process Phase I – Vascular Phase
Constriction of the blood vessel to decrease blood flowFollows injury
Phase II – Platelet PhasePlatelets clump together and adhere to injured vessels to
form a plug and inhibit bleeding Phase III – Coagulation
Coagulation factors are released and a blood clot is formed to seal off damaged areas
Phase IV – Clot Retraction PhaseBleeding stops and clot retracts to bring torn edges of
vessel together Phase V – Fibrinolysis
Final repair of injured vesselClot breaks upCells carry out further repair
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Factors Affecting HemostasisPreexisting Hemostatic Defects
May be congenitalHemophilia most common
Acquired Hemostatic DisordersLiver diseaseAnticoagulant therapy
Heparin, Warfarin sodiumAplastic anemiaAlcoholic liver failureDrug-therapy-induced platelet dysfunctions
aspirin
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Methods of HemostasisMechanicalThermalPharmacologic
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Mechanical HemostasisClampsLigatures
Ties, Stick ties, reels, etc.ClipsSponges
Direct pressurePledgetsBone wax
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Mechanical HemostasisHow do the following facilitate hemostasis?
Suction?Drains?Tourniquets?
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Thermal HemostasisDefinition and Usage
Electric current used to cut and/or coagulate tissue
Used to cut fat, fascia, muscle, and internal organs
Part of surgeon’s routine armamentariumOften referred to as the “Bovie”
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Electrosurgery
© 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
8
Thermal DevicesThermal Devices
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Monopolar vs BipolarMonopolar vs Bipolar
© 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
9
What’s the difference?
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Monopolar CurrentMonopolar Current
© 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
10
Most frequently used type of cauteryRequires a grounding padPencil-style handpiece is usedMay be activated with a foot control or
hand switch
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Bipolar CurrentBipolar Current
© 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
11
Used for minor procedures; plastic procedures; delicate procedures such as ophthalmic and neurosurgery
Does not require a grounding padVarious types of forceps are used (one
tip is the active electrode and the opposing tip is inactive)
Foot pedal is used to activate
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Flow of CurrentFlow of Current
© 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
12
Monopolar current flows from the… 1. Generator or electrosurgical unit (ESU)
to the2. Active electrode (cautery tip) through
the3. Patient’s tissue to the4. Dispersive electrode (grounding pad)
and back to the5. ESU
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Flow of CurrentFlow of Current
© 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
13
Bipolar current flows from the… 1. Generator or electrosurgical unit (ESU)
to the2. Active tip of the forceps through the3. Patient’s tissue to the4. Opposing forceps tip and back to the 5. ESU
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Types of Monopolar Types of Monopolar CurrentCurrent
© 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
14
CoagulateCoagulate capillary and other small
bleeding vesselsCutCut adipose tissue, fascia, internal organsBlendCombination of cutting and coagulating
currentNot a strong coagulating currentEffective on capillary bleeding
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Monopolar HandpieceMonopolar Handpiece
© 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
15
Handpiece (with cord attached) and tip are single-use disposable items
Distal end of cord is passed to the circulator to be connected to the generator
Coagulating current is activated with the distal handpiece button
Cutting current is activated with the proximal handpiece button
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Monopolar HandpieceMonopolar Handpiece
© 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
16
Tip of handpiece isRemovable to facilitate use of various
styles (blade, needle, loop, etc)Considered a “sharp” and must be handled
and disposed as suchA countable item in some facilities
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Monopolar HandpieceMonopolar Handpiece
© 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
17
Types of tipsBlade - most frequently used;
available in regular and long (for use in deep body cavities) lengths
Ball - ball shape on end of tip; frequently used in throat procedures such as T&A
Needle - ends in a sharp point; used in minor procedures, plastic, and delicate procedures
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Monopolar Monopolar HandpieceHandpiece
© 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
18
Cleaning of TipTo keep charred tissue from building
up on cautery tip preventing effective flow of current
Clean the tip using moist sponge or cautery scrapperCautery scrapper: small square abrasive
pad with adhesive backing placed on sterile field
Knife blade NOT recommended, but is often used
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Grounding Pad and Grounding Pad and PlacementPlacement
© 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
19
Technical names - inactive or dispersive electrode
Single-use disposable itemAvailable in various sizes ranging from
adult to infantPrelubricated with conducting gelPosition patient; then place the pad
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Grounding Pad and Grounding Pad and PlacementPlacement
© 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
20
Place pad as close as possible to the operative site
Do not remove and reposition pad Loss of conducting gelNew pad must be placed
Pad should cover as large of area as possible
Extremity - place on area of largest circumference
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Grounding Pad and Grounding Pad and PlacementPlacement
© 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
21
Do not place on area with excessive scar tissue
Do not place over area with excessive hairMay have to shave the area
Do not place over bony prominencesDo not place over or near metal
implants
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Grounding Pad and Grounding Pad and PlacementPlacement
© 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
22
Do not allow skin prep fluids to pool around or under the pad
Place on clean, dry skinPad must uniformly adhere to patient’s skin
No tunneling effect or air pocketsEdges cannot curl up
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Grounding Pad and Grounding Pad and PlacementPlacement
© 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
23
No part of the patient’s body can touch a metal surface such as OR tableElectric current is attracted to metalCurrent will seek the path of least resistance
to complete the circuitBody part touching metal will be severely
burned
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Grounding Pad and Grounding Pad and PlacementPlacement
© 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
24
Awake patientWarn patient of placement due to cold and sticky nature of conducting gel so that the patient is not startled
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Principles Associated with Principles Associated with Cauterizing TissueCauterizing Tissue
© 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
25
ESU produces “buzzing” sound when activated Surgeon may ask the assistant to “buzz” a
clamp or forceps to coagulate tissue withinSurgeon holds tissue or vessel with forceps
or clampAssistant touches instrument with
electrocautery (“Bovie”) tipCurrent travels down instrument to cauterize
tissue or vessel
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Principles Associated with Principles Associated with Cauterizing TissueCauterizing Tissue
© 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
26
Precautions when “buzzing” Do not activate cautery prior to
application to instrument to avoid “arcing” of current
Place cautery tip below fingers of surgeonCurrent can penetrate surgical gloves
and cause pin point 3rd degree burn Be sure that the instrument grasping the
tissue is not touching other tissue Be sure that the instrument grasping the
tissue is not touching other metal instruments such as a retractor
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
DocumentationDocumentation
© 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
27
Circulator records all information on patient’s intraoperative record
Location of grounding padCondition of patient’s skin pre- and
postoperativelyPower settings for cutting and
coagulating currentsESU hospital identification number
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Safety PrinciplesSafety Principles
© 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
28
Initial skin incision is be made with the scalpelBovie will char and scar the skin
Keep handpiece protected when not in use to prevent accidental activationPlace in plastic protective holster
that can be attached to the drapesKeep out of team member’s way to
avoid leaning on it
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Safety PrinciplesSafety Principles
© 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
29
General safety ruleStart with lowest power settings of
current that accomplish the jobAdjust the current at the surgeon’s
request
Clue to equipment malfunctionSurgeon has repeated request for more
power
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Safety PrinciplesSafety Principles
© 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
30
Avoid inhaling plume (smoke)
Not yet proven; could be harmfulCould contain bits of vaporized
tissue that could be mutagenic and/or carcinogenic
Plume is irritating to the respiratory tract
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Safety PrinciplesSafety Principles
© 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
31
Oxygen and Nitrous Oxide UsedDo not use cautery in the mouth, around the
head, or in pleural cavity in the presence of oxygen and nitrous oxide
Nitrous oxide supports combustionMetal jewelry removed from patientOnly moist sponges used in presence of ESU
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Safety PrinciplesSafety Principles
© 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
32
ECG ElectrodesPlace electrodes as far away from operative
site as possiblePlace grounding pad as far away from ECG
electrodes as possibleElectrical current can be attracted to ECG
electrodes and cause severe burns
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Safety PrinciplesSafety Principles
© 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
33
ESU can disrupt the operation of implanted cardiac pacemaker
Alcohol used for skin prepAlcohol must be allowed to dry before
draping the patientIf not allowed to dry, fumes can build up
under the drapes and possibly ignite when cautery is used
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Reasons for Malfunction Reasons for Malfunction of ESUof ESU
© 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
34
Improper placement of grounding padLess that full contact of grounding pad with
skin surfaceESU machine malfunctionFrayed cord
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Chemical Hemostasis – Pharmacologic AgentsMore developed each yearManufacture’s recommendations for usage
and handling must be followed
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Absorbable GelatinAbsorbable Gelatin
© 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
36
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
CollagenCollagen
© 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
37
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Oxidized CelluloseOxidized Cellulose
© 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
38
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Silver Nitrate, Epinephrine, Silver Nitrate, Epinephrine, ThrombinThrombin
© 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
39
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Blood ReplacementBlood ReplacementBlood types &
Groups
HemologousAutologous
© 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
40
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Blood ReplacementBlood Replacement
© 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
41
Handling of blood componentsAutotransfusionHemolytic Transfer Reactions
Emergencies
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Indications of Emergency Indications of Emergency SituationsSituations
© 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
43
List indications of emergency situationsObjective & priorities in Emergency SituationsSyncope?Convulsions/Seizures
TypesManagement
Anaphylactic ReactionClinical manifestations of Cardiac Arrest
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Cardiac Arrest/Malignant Cardiac Arrest/Malignant HyperthermiaHyperthermia
© 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
44
CPRCardiac Arrest: What happens in the
surgical setting?Define Malignant Hyperthermia
PreventionTreatmentEmergency services
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Terms Anaphylaxis
An unusual or exaggerated allergic reaction of an organism to foreign protein or other substances
Asystole Cardiac standstill or arrest; absence of heartbeat
Bolus A concentrated amount of medication
administered rapidly intravenously Bradycardia
Slow heart beat, less than 60 bpm Bronchospasm
Involuntary contraction of the smooth muscle of the bronchi, causing impaired breathing
Capnography Measurement of inspired and expired
carbon dioxide concentrations
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Terms Cyanosis
A bluish discoloration of the skin and mucous membranes due to inadequate oxygen in the blood
Desaturation Reduction of oxygen saturation in the blood
Diaphoresis Perspiration, especially profuse perspiration
Hemoglobinuria Presence of free hemoglobin in the urine
Hypermetabolic Increased metabolism
Pyrexia A fever, or febrile condition
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Terms Tachycardia
Abnormally rapid heart rate, greater than 100 beats per minute
Tachypnea Very rapid respirations, greater
than 30 per minute
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Purpose/Uses Dantrolene sodium (Dantrium)
Malignant hyperthermia
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Purpose/UsesDopamine (Intropin)
AnaphylaxisLidocaine (Xylocaine)
PVCs, ventricular tachycardia, ventricular arrhythmias
Not as a local anesthetic
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Purpose/UsesSodium bicarbonate
Metabolic acidosisEpinephrine
Cardiac stimulantArrest due to anaphylaxisNote: vasoconstriction is NOT emergency use
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
ScenariosCover ST duties in all 3 basic roles:
First scrubSecond scrubCirculator
Other team members and their basic duties
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
EquipmentCardiac defibrillator
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Malignant hyperthermia
Background on MH:RARE, inherited muscle conditionWhen triggered by some drugs:
Causes hypermetabolic state (huge Ca+ release)Sudden; life-threatening
Trigger agents:SuccinylcholineAll inhalation agents except nitrous oxideSome antipsychotics
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
Malignant hyperthermiaMust have defect AND exposure to trigger50% of offspring have itDefect in sarcoplasmic reticulum
Stores and releases Ca+
Ca+ released in massive amountsCauses very sustained contractionCell metabolism continues at even rateDepletes O2, CO2 which causes acidosisMuscle cells break down fast from
contraction and release myoglobin into blood; clog kidneys
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
MHList clinical signs of MH
Increase in end-tidal CO2
TachycardiaTachypneaMasseter muscle rigidity (MMR)Unstable blood pressureArrhythmiasCyanosisDiaphoresisPyrexia
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
MH in end-tidal CO2
Expired levels of CO2Many reasons, assess
TachycardiaRapid heart rateMany reasons, assess
TachypneaRapid breathingEven over ventilator settingEffort to blow off CO2Classic for MH
Masseter muscle rigidityNoted at intubationClassic for MH but could be normal for patient
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
MHUnstable blood pressure
Many reasons, assessArrhythmias
Absence of normal rhythmMany reasons, assess
CyanosisAbnormal condition; “blue”Check ventilator
DiaphoresisSweating Due to heat build up
PyrexiaHigh feverLate signTemperatures can rise to 109°
Patient can die in 15 minutes
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
MH Treatment
Use pneumonic if helpfulHow Do Surg Techs Do It?H D S T D
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
MH Treatment Hyperventilate with O2
Why? Blow off CO2
Dantrolene Why?
Skeletal muscle relaxant Sodium bicarbonate
Counteract metabolic acidosis Due to CO2 = acidosis
Temperature management Ice packs at pulse points on patient Attempt to cool patient rapidly
Diuretics Mannitol is mixed in with Dantrium Keeps kidneys from getting clogged with myoglobin
Insulin Treat hyperkalemia
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
STSR RoleFirst, if you aren’t paying attention to what is going on with
the patient, you are not much help early in the crisis. Be aware of anesthesia signs Rapid response increases survival rate When declared, drop what you are doing! Anesthesia/Operation is stopped STAT First scrub role; stay sterile if procedure going
Help close PRNHand iced NaCl irrigation
Second scrub roleBreak scrubGet or send people for iceMay help reconstitute Dantrium
If no other personnel available e.g., on call
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
STSR Role Circulating role
Treat like code blueGet MH cartCall for helpChange anesthesia machine when provider is
readySet up iced lavage
Bladder, rectum, abdomenReconstitute Dantrium
Remember, all of these things are happening simultaneously.
Knowing the procedure makes you more valuable in the crisis.
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
MH
Keep in mindIf the patient is identified as MH susceptible,
there will be no crisis, as trigger agents are NOT administered to patient.
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
In summaryThe more you know, the more effective you are
in assisting the anesthesia provider in an emergency.