GEMC- EMedHome Board Review: Procedures- Resident Training

Project: Ghana Emergency Medicine Collaborative

Document Title: EMedHome Board Review: Procedures

Author(s): Joe Lex, MD, FACEP, FAAEM, MAAEM (Temple University)

2013

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2

EMedHome Board Review:

Procedures

Joe Lex, MD, FACEP, FAAEM, MAAEM

Associate Professor, Emergency Medicine

Temple University School of Medicine

Philadelphia, PA USA

3

Commercial Disclaimers

4

General Rules before Doing a

Procedures

• Explain risks and benefits, including

what will happen if you don’t do it

• Obtain written informed consent

(when possible)

• Use appropriate monitoring

equipment

• Position patient properly

5

General Rules before Doing a

Procedures

• Clean / prep / drape appropriate body

part

• Use aseptic / sterile technique

• Provide post-procedure instructions

6

For this talk…

• Not the everyday procedures

• No RSI

• No procedural sedation

• No laceration repair

• Things you MIGHT want to look at a

reference before doing

7

For this talk…

Indications / Contraindications

Procedure Description

Procedure Pictorial (if available)

Complications 8

Indication

Nasotracheal Intubation

• Spontaneously breathing patient

requiring airway management

• Alternative to RSI when oral airway

may be obstructed

1

8

Contraindication


• Apnea

• Severe midface injuries

• Basilar skull fracture

• Closed head injury with intracranial

pressure

• Nasopharyngeal obstruction

• Coagulopathy (relative)

19

Procedure


• Preoxygenate

• Apply vasoconstrictor / topical

anesthetic

• Insert tube with bevel facing septum

• Slowly advance – listen for breath

sounds OR use whistle

• Advance tube through vocal cords

20

Procedure

Nasotracheal

Intubation

Thomas H. Burford, Wikimedia Commons 21

See: “Procedure

Nasotracheal Intubation” in Knoop KJ,

Stack LB, Storrow AB, Thurman RJ: The

Atlas of Emergency Medicine, 3rd Edition,

http://accessmedicine.com.

https://commons.wikimedia.org/wiki/File:Chapter5figure69b-nasotracheal_intubation.jpg

Complications


• Epistaxis

• Mucosa / turbinate avulsion

• Laryngeal / tracheal trauma

• Intracranial / esophageal placement

• Hypoxia

26

Indication / Contraindication

Retrograde Intubation

Indication

• Patient requires airway

• Less invasive means have failed

Contraindication

• Ability to intubate / ventilate by less

invasive means

• Trismus; inability to open mouth

27

Procedure


• Stabilize patient’s larynx, identify

cricothyroid membrane

• Connect 16- to 18-gauge catheter-

over-needle to 10 ml syringe

contained 3 mL sterile saline

• Puncture cricothyroid membrane at

20–30o angle to skin, pointed at head

• Aspirate – should see air bubbles 28

Procedure


Source: Reichman EF, Simon RR: Emergency Medicine Procedures 29

Procedure


• Advance catheter-over-needle until

hub is against skin

• Remove syringe and needle

• Feed guidewire through catheter until

it comes out patient’s mouth

• Advance guidewire until only ~5cm

protruding from neck

• Stabilize wire at neck with hemostat 30

Procedure



Procedure


• If available, advance introducer

sheath until meets obstruction

• Remove wire

• Advance endotracheal tube over

introducer into trachea

• Confirm placement

• Secure tube

32

Recommended Reference: Reichman EF, Simon RR: Emergency Medicine Procedures

Complications


• Damage to tracheal cartilage

• Inability to intubate

• Hypoxia

34


Cricothyrotomy

Indications

• Unable to ventilate or intubate

Contraindications

• Child <8-10 years

• Significant trauma to tracheal / cricoid

cartilages

• Ability to intubate / ventilate

35

Procedure

Cricothyrotomy

• Stabilize larynx, identify cricothyroid

membrane

• Make midline vertical incision

• Make horizontal stab incision through

cricothyroid membrane

• Insert tracheal skin hook to elevate

inferior border of tracheal cartilage

36

Procedure

Cricothyrotomy

• Insert Trousseau dilator, remove skin

hook, open membrane

• Insert tube: endotracheal (6.0 mm) or

tracheostomy tube (4.0 Shiley)

37


Complications

Cricothyrotomy

• Esophageal perforation

• Subcutaneous emphysema

• Subcutaneous tube placement

• Bleeding

• Unable to intubate

• Subglottic stenosis

• Cartilage damage: thyroid, cricoid

42


Tube Thoracostomy

Indications

• Pneumothorax (24F – 28F tube)

• Hemothorax (32F – 40F tube)

Contraindications


43

Procedure

Tube Thoracostomy

• Identify 4th-5th intercostal space,

anterior axillary line

• Abduct ipsilateral arm

• Make incision parallel to ribs

• Bluntly dissect upwards with Kelly

• Enter pleura above rib with clamp

avoids neurovascular bundle

44

Procedure

Tube Thoracostomy

• Digitally explore tract

• Insert chest tube, aiming toward apex

for pneumothorax, base for

hemothorax

• Connect tube to pleural drainage

system

• Secure tube

• Obtain confirmatory x-ray 45 Recommended Reference: Reichman EF, Simon RR: Emergency Medicine Procedures

Complications

Tube Thoracostomy

Complications

• Bleeding, hemothorax

• Visceral organ perforation / vascular

structure injury

• Subcutaneous tube placement

• Pneumonia

• Empyema

50


Needle Thoracostomy

Indications

• Tension pneumothorax

Contraindications

• None

51

Procedure

Needle Thoracostomy

• Connect a 14- to 16-gauge catheter-

over-the-needle to a 5- to 10-mL

syringe without the plunger

• Insert needle into 2nd intercostal

space, midclavicular line

• Advance needle to rush of air, then

advance until hub against skin

• Place chest tube 52


Complications

Needle Thoracostomy

• Lung injury

• Local hematoma

• Intercostal nerve / vessel injury

• Failure to decompress tension

pneumothorax

54

Indications

Resuscitative Thoracotomy

• Penetrating chest trauma patients

who are hemodynamically unstable

and those who demonstrated

palpable pulse, blood pressure, pupil

reactivity, any purposeful movement,

organized cardiac rhythm, or any

respiratory effort either in the field or

ED, but subsequently deteriorated

55

Contraindications


• Penetrating chest trauma victim with

no vital signs in field

• Blunt trauma victim with or without

field vitals

56

Procedure


• Make incision through skin,

subcutaneous tissue, superficial

muscles

• Incise intercostal muscles with Mayo

scissors

• Insert rib spreader with handles down

and open

• Grasp and open pericardium

57 Recommended Reference: Reichman EF, Simon RR: Emergency Medicine Procedures

Complications


• Injury of personnel

• Laceration of internal mammary or

intercostal arteries

• Laceration of lung or myocardium

• Transection left phrenic nerve

• Laceration of myocardium or coronary

artery

• Delayed cardiac compressions 65


Paracentesis

Indications

• Diagnostic: new ascites, suspected

spontaneous bacterial peritonitis

• Therapeutic: tense, large-volume

Contraindications

• Overlying cellulitis

• Pregnancy, organomegaly (relative)

66

Procedure

Paracentesis

Potential sites:

• Midline: 2 cm inferior to umbilicus

• RLQ / LLQ: 2–4cm medial & cephalad

to anterior superior iliac spine

67

Procedure

Paracentesis

• Use ultrasound to be certain

• Apply skin traction: “Z-track”

• Advance needle / catheter

• Aspirate fluid

• Remove needle / catheter

• Send fluid for analysis

– SBP: PMN >250 WBC/mm3

68 Recommended Reference: Reichman EF, Simon RR: Emergency Medicine Procedures

Complication

Paracentesis

• Hypotension after large volume

removal

• Localized infection

• Abdominal wall hematoma

• Persistent fluid leak

• Injury to abdominal organ

70


Thoracentesis

Indication

• Pleural fluid requiring fluid analysis or

therapeutic drainage

Contraindication


• Positive pressure ventilation (caution)


71

Diagnostic

Thoracentesis

• Use 18-g needle on 50mL syringe

containing 1mL heparin (100U/ml)

• Insert needle 5–10 cm lateral to spine

1 or 2 intercostal spaces below upper

level of pleural effusion

• Go over top of rib

• Stop when you get enough

• Post-procedure chest x-ray 72

Therapeutic

Thoracentesis

• Make skin incision at insertion site

• Use 14- to 18-gauge catheter-over-

needle attached to 10 mL syringe

• Insert needle 5–10 cm lateral to spine

1 or 2 intercostal spaces below upper

level of pleural effusion

• When fluid reached, angle needle

caudally until hub against skin 73

Therapeutic

Thoracentesis

• Withdraw needle, leaving catheter

• Cover catheter with gloved finger

(prevent air entry)

• Attach hub to 3-way stopcock

attached to 50 mL syringe

• Aspirate and move fluid

• Terminate procedure when symptoms

relieved or after 1000 mL 74 Recommended Reference: Reichman EF, Simon RR: Emergency Medicine Procedures

Complications

Thoracentesis

• Pneumothorax

• Hemothorax

• Intercostal vessel / nerve injury

• Post-expansion pulmonary edema

79

Indications

Lumbar Puncture

Indications

• Suspected meningitis

• Suspected subarachnoid hemorrhage

(after negative head CT scan)

• Spinal fluid required for analysis

• Delivery of anesthetics, antibiotics,

chemotherapy

80

Contraindications

Lumbar Puncture

Contraindications

• Coagulopathy

• Cerebral herniation or increased

intracranial pressure


81

Procedure

Lumbar Puncture

• Position patient: lateral recumbent

with hips & knees flexed

• Identify landmarks: L3-L4-L5 spinous

processes, iliac crests

• Insert 20-gauge or smaller needle into

interspinous space

• Align bevel parallel to dural fibers

(facing “upward”) 82

Procedure

Lumbar Puncture

• Advance needle to “pop”

• If you encounter bone, partially

withdraw and redirect

• Remove stylet free flow CSF

• Obtain opening pressure

• Collect 1 – 2mL in each tube

• Reinsert stylet and remove needle

83

Procedure

Lumbar Puncture

Brainhell, Wikimedia Commons

84

http://en.wikipedia.org/wiki/File:Wikipedian_getting_a_lumbar_puncture_(2006).jpg

Procedure

Lumbar Puncture

BruceBlaus, Wikimedia Commons

85

http://en.wikipedia.org/wiki/File:Blausen_0617_LumbarPuncture.png

Procedure

Lumbar Puncture

Source: Waxman SG: Clinical Neuroanatomy, 26th Edition: http://www.accessmedicine.com 86

Procedure

Lumbar Puncture

BruceBlaus, Wikimedia Commons 87

http://en.wikipedia.org/wiki/File:Spinal_Tap.png

Complications

Lumbar Puncture

• Post-dural headache: ~1/3

– Post-tap position does not matter

• Localized pain

• Cerebral herniation

• Subarachnoid epidermoid cyst

88


Intraosseous Infusion

Indication

• Urgent vascular access when

traditional methods have failed

Contraindication

• Diseased / osteoporotic bone

• Overlying cellulitis / deep burn

(relative)

89

Procedure


• Identify landmarks: distal femur,

proximal tibia, proximal humerus,

sternum

• Stabilize extremity

• Insert needle perpendicular to long

axis of bone

• In kids: direct needle away from

growth plate 90

Recommended Source: Tintinalli JE, et al., Tintinall’s Eergency Medicine: A Comprehensive Study Guide, 7th Edition:

http://www.accessmedicine.com

Procedure


Source Undetermined 91

Complications


• Subcutaneous / subperiosteal fluid

extravasation

• Compartment syndrome


• Osteomyelitis

• Growth plate injury

97


Diagnostic Peritoneal Lavage

Indication

• Patient with abdominal trauma

without indication for emergent

exploratory laporotomy

Contraindication

• Patient with abdominal trauma and

with indication for emergent

exploratory laporotomy 98

Procedure


• Introduce needle midline through

abdominal wall 1 to 2cm below

umbilicus at 45o angle to skin

• Apply negative pressure as you

advance needle toward pelvis

• Feel for three distinct ‘pops’ – skin,

fascia, peritoneum

• Advance 2 – 3 mm after 3rd ‘pop’ 99

Procedure


• If you find blood end of procedure

• Insert guidewire through needle, then

remove needle

• Make small skin incision adjacent to

guidewire

• Place lavage catheter over guidewire

and advance into peritoneal cavity

100

Procedure


• Infuse 1L crystalloid solution, then

place empty bag on floor

• Collect minimum 200 mL fluid, but as

much as possible

• Remove catheter when finished

• Send fluid for cell count

– Threshold 100,000 RBCs/mm3

101

Recommended Source: Tintinalli JE, et al., Tintinall’s Eergency Medicine: A Comprehensive Study

Guide, 7th Edition: http://www.accessmedicine.com

Complications



• Bleeding / hematoma formation

• Damage to intra-abdominal organs

106


Lateral Canthotomy

Indication

• Acute orbital compartment syndrome

Contraindication

• None

107

Procedure

Lateral Canthotomy

• Inject lateral canthal fold: lidocaine

with epinephrine

• Insert straight hemostat in lateral

canthal fold, clamp for 1 minute to

devascularize

• Incise lateral canthus

• Identify and transect lateral canthal

tendon

108

Procedure

Lateral Canthotomy


Complications

Lateral Canthotomy

• Bleeding

• Globe perforation


• Lacrimal gland injury

• Lateral rectus muscle injury

• Scleral laceration

110


Pericardiocentesis

Indication

• Pericardial tamponade

• Analysis pericardial effusion

Contraindication


111

Procedure

Pericardiocentesis

• Insert 18-gauge spinal needle

between xiphoid process and left

costal margin at 30 – 45o angle

• Aim tip toward patient’s left shoulder

• Aspirate fluid

• Use ULTRASOUND when possible

112



Procedure

Pericardiocentesis

Source Undetermined

114

Procedure

Pericardiocentesis

Source Undetermined

115

Complications

Pericardiocentesis

• Pneumothorax

• Bleeding complication

• Damage to coronary artery

• Damage to intraabdominal organ(s)

• Death

116


Venous Cutdown

Indication

• Immediate need for vascular access,

no peripheral or central available

Contraindication

• Proximal extremity vascular injury /

long bone fracture

• Overlying skin infection, coagulopathy

(relative 117

Procedure

Venous Cutdown

• Location of greater saphenous vein

(GSV): 2.5 cm anterior and 2.5 cm

superior to medial malleolus

• Make transverse skin incision from

anterior tibial border to posterior tibial

border

• Isolate GSV

118

Procedure

Venous Cutdown

• Insert curved hemostat tip down,

scrape along periosteum starting on

posterior border until the tip reaches

the anterior border

• Rotate hemostat 180o so tip faces

upward

• Open the jaws of the hemostat – the

GSV should be visible 119

Procedure

Venous Cutdown

• Switch to straight hemostat, remove

curved hemostat

• Insert 16- to 18-gauge IV catheter-

over-needle into vein

120



Procedure

Venous Cutdown: Groin

• Identify where scrotal / labial fold

meets the thigh ~2cm below site

for femoral central venous line

• Make transverse incision medial to

lateral beginning at fold

• Dissect subcutaneous tissue with

curved hemostat

• Identify and isolate GSV 123

Procedure

Venous Cutdown: Groin

• Identify and isolate GSV

• Cannulate either directly or using

Seldinger technique

124

Complications

Venous Cutdown

• Infection

• Vascular injury

• Nerve injury

• Phlebitis

• Tromboembolism

• Wound dehiscence

125


Anterior / Posterior Nasal Pack

Indications

• Epistaxis

Contraindications

• None

126 Recommended Source: Tintinalli JE, et al., Tintinall’s Eergency Medicine: A Comprehensive Study


Procedure

Posterior Nasal Pack

• Prepare the pack: use 3 inch dental

rolls, tonsil packs, or 4x4 gauze

• Form a tight cylindrical roll with gauze

• Tie two pieces of umbilical tape or 0-

silk suture around pack to divide it

into thirds (see picture)

131

Procedure



Procedure


• Insert red rubber catheters through

nostril and pull out through mouth

• Attach pack to red rubber catheters

• Pull pack into place

– Use finger to pass pack around soft

palate and uvula

• Place anterior nasal pack

• Secure ties of posterior pack 133 Recommended Source: Reichman EF, Simon RR: Emergency Medicine Procedures

Procedure

Posterior Nasal Balloon

• Gather nasal speculum, light source,

suction, anethetizing and packing

materials

• Place patient in “sniffing position,”

give emesis basin and some tissues

• Anesthetize nasal mucosa using

cotton pledgets soaked in LET (or

cocaine)

142

Procedure


• Lubricate Foley catheter or posterior

balloon with antibiotic ointment

• Insert transnasally until visible in

posterior oropharynx

• Inflate balloon with 7 ml of water,

gently retract catheter ~2 to 3 cm until

lodged in posterior nasopharynx

143

Procedure


• Inflate balloon with additional 5 to 7

ml of saline

• Secure pack by taping to patient's

cheek

144

Procedure



Complications


• Nasal septal perforation

• Sinusitis / otitis media

• Toxic shock syndrome

• Aspiration

• Alar necrosis

• Hypoxia from intrapulmonary shunting

due to stimulation of nasopulmonary

reflex 147


Peritonsillar Abscess I&D

Indication

• Peritonsillar abscess

Contraindication


148

Procedure

Peritonsillar Abscess Aspiration

• Identify area of maximum fluctuance

• Cut needle cap so that needle

projects only 1cm beyond distal cap

• Depress / distract tongue

• Insert needle, staying parallel to

mouth floor

• Advance and aspirate

149

Procedure

Peritonsillar Abscess Aspiration

Source: Reichman EF, Simon RR: Emergency Medicine Procedures

150

Complications

Peritonsillar Abscess I&D

• Aspiration

• Airway compromise

• Bleeding

• Vascular injury

153

Indication: Thrombosed

External Hemorrhoid Excision

Indication

• Painful thrombosed external

hemorrhoid

154

Contraindication: Thrombosed


Contraindication

• Grade IV internal hemorrhoids with

thrombosed external hemorrhoids

• Very large hemorrhoids

• Inflammatory bowel disease anorectal

fissure, perianal infection, portal

hypertension, rectal prolapse,

anorectal tumor, immunocompromise 155

Procedure: Thrombosed


• Identify area to be incised

• Use two radial incisions starting near

center of anus

• Dissect skin and thrombosis with

scissors

• DO NOT cut anal sphincter

• Control bleeding: AgNO3

156


Nail Bed Repair

Indication

• Nail bed injury

Contraindication

• None

160

Procedure

Nail Bed Repair

• After digital / regional block: insert

closed tip of fine scissors between

nail plate and nail bed

• Advance tip while opening / closing

blades to separate plate from bed

• Stop scissors when blade tips at

eponychium

161

Procedure

Nail Bed Repair

• Grasp nail plate with hemostat, pull

along long axis of finger

• Repair nailbed laceration with

absorbable suture

• Replace nail plate onto nail bed.

Suture in place for ~7 days

• If nail missing petrolatum gauze

162 Recommended Source: Reichman EF, Simon RR: Emergency Medicine Procedures

Complications

Nail Bed Repair

• Complete nail loss (expected)


• Nail growth abnormalities

165


Arthrocentesis

Indication

• Diagnosis: obtain synovial fluid

• Therapy: inject steroid, anesthetic

Contraindication

• Overlying infection, coagulopathy,

prosthetic joint, septic / bacteremic

patient (all relative)

166

Procedure

Arthrocentesis

• Palpate bony anatomy, identify

anatomic landmarks

• Insert needle into joint space

• If strike bone, withdraw slightly and

redirect

• Aspirate synovial fluid

167

Procedure

Arthrocentesis – Knee


Complications

Arthrocentesis


• Bleeding / hematoma

171


Felon Incision & Drainage

Indication

• Fluctuant felon

Contraindications

• Herpes whitlow

• Non-fluctuant felon

172

Procedure


• If central pulp: central longitudinal

finger pad incision with #11 scalpel

• Radial / ulnar fluctuance: medial /

lateral pad incision

• Do not cross DIP

• Break up loculations

• Irrigate, pack with drain / dressing

173

Procedure



Complications


• Skin necrosis

• Osteomyelitis

• Extension of local infection

• Flexor tenosynovitis

• Neurovascular injury

• Finger pad damage

176

Indication

Escharotomy

Indication

• Circumferential full / partial thickness

extremity burns & impaired perfusion

• Chest wall burns impairing chest wall

movement / ventilation

• Neck burns / impending tracheal

obstruction

177

Contraindication

Escharotomy

Contraindication (all relative)

• Overlying skin infection

• Coagulopathy

• Prosthetic joint

• Sepsis / bacteremia

178

Procedure

Escharotomy

• Sedate patient / use local anesthesia

• Use scalpel / cautery make

incision along medial and lateral

aspect of involved extremity

• Make incision from 1cm proximal to

burn 1 cm distal to burn

• Extend only through full thickness of

skin 179

Procedure

Escharotomy

• Chest: incise along anterior axillary

line from clavicle to costal margin

bilateral – may join with another

• Neck: incise posterior and lateral to

vascular structures

180

Procedure

Escharotomy

Source: Tintinalli JE, et al., Tintinall’s Eergency Medicine: A Comprehensive Study Guide, 7th Edition:

http://www.accessmedicine.com 181

Procedure

Escharotomy

Source: Tintinalli JE, et al., Tintinall’s Eergency Medicine: A Comprehensive Study Guide, 7th Edition:

http://www.accessmedicine.com 182

Complications

Escharotomy

• Bleeding


• Neurovascular damage

• Inadequate decompression

– Muscle damage, nerve injury

– Renal failure hyperkalemia

– Metabolic acidosis

183

Indication

Urethrogram & Cystogram

Indication

• Suspected traumatic injury to lower

urinary tract

– Blood at urethral meatus

– High-riding prostate

– Gross hematuria

– Perianal / scrotal hematoma

184

Contraindication


Contraindication

• Hemodynamic instability

• Acute urethritis in patient with low risk

• Cystogram contraindicated if urethral

injury identified on urethrogram

185

Procedure: Retrograde


• Use Cystographin, Renographin-60,

or Hypaque® 50%

• Retract and secure penile foreskin

• Prime catheter tubing with contrast

prior to inserting

• Insert catheter until retention balloon

is within glans (fossa navicularis)

186



• Straighten penis across thigh to

prevent urethral folding

• Inject 50-60mL over 5–10 seconds

• Can also use 60mL Toomey irrigating

syringe

• Get KUB during injection final 10mL

• Extravasation outside urethral contour

disruption 187



• Contrast in bladder with extravasation

partial disruption

• No extravasation proceed with

retrograde cystogram




• No extravasation proceed with

retrograde cystogram

• Advance catheter into bladder

• Inflate balloon and gently pull back to

lodge balloon at bladder neck

• Remove plunger from 60mL syringe

190



• Fill bladder by gravity with 300 -

350mL of contrast

• Clamp catheter with hemostat

• Obtain KUB look for filling,

extravasation

• Release clamp and drain contrast by

gravity

191



• Obtain ‘washout’ KUB

–Extraperitoneal bladder injury

flame-like projection within pelvis

possible conservative management

–Intraperitoneal bladder injury

contrast outlines intraperitoneal

organs surgical management


Complications: Retrograde


• Relatively benign procedure –

complications rare

194

Indications

Perimortem C-Section

• To optimize maternal

cardiopulmonary resuscitation

• Rescue of a viable fetus >24 weeks

gestation is an important

consideration, but such rescue is

always secondary to the safety and

life of the mother

195

Contraindications


• Mother with serious brain injury but

otherwise hemodynamically stable,

fetus shows no signs of distress.

• Inability to adequately resuscitate

infant after delivery

• Extreme fetal prematurity/immaturity

196

Procedure


• Make a vertical midline skin incision

with a #10 scalpel blade beginning 2

to 3 cm above pubic symphysis and

extending to 1 cm below umbilicus

• Ignore any subcutaneous bleeding

unless it is arterial

– Clamp \ bleeding artery or use electro-

cautery unit to coagulate if available


Procedure


• Extend incision through

subcutaneous fat to rectus sheath.

• Grasp and elevate rectus sheath

using a toothed forceps

• Make an incision in the rectus sheath

with a Mayo scissors. Extend the

rectus sheath incision superiorly and

inferiorly with a Mayo scissors 199

Procedure


• Expose the uterus – the underlying

peritoneum should be visible

• Insert retractors to fully expose the

peritoneal membrane

• Grasp and elevate the peritoneal

membrane with a toothed forceps

• Incise the peritoneal membrane with

a Mayo or Metzenbaum scissors 201

Procedure


• Make reasonable attempts to protect

the bowel and bladder from injury

• Elevate the bowel off the field and

cover it with a saline soaked towel

• Place a bladder retractor over the

pubic symphysis to retract the rectus

sheath and bladder

202

Procedure


• Identify the position of the fetal head

by palpating the uterus

• Make a 2 to 4 cm midline vertical

incision in the uterus

– The amniotic sac will bulge through the

incision if the membranes are intact

• Place a finger into the uterine incision

and aimed vertically 204

Procedure


• Insert one blade of a bandage

scissors between the finger and the

uterine wall

– The other blade of the scissors should

be outside the uterus

• Extend the vertical uterine incision

fundally, superior and away from the

bladder

205

Procedure


• Rupture the amniotic membranes with

a clamp or other blunt instrument

• Carefully transect the placenta if it is

anterior to the fetus

• Insert a hand between the pubic

symphysis and the fetal occiput

208

Procedure


• Advance the hand to the base of the

occiput

• Flex the fetal head and apply gentle

anteriorly and superiorly directed

traction to elevate and deliver the

head

210

Procedure


• Deliver the entire fetal head

212

Procedure


• Suction the mouth and nose with a

bulb syringe

214

Procedure


• Deliver the shoulders in a manner

similar to that of a vaginal delivery

• Apply gentle upward traction on the

head while an assistant applies

pressure on the uterine fundus

– First deliver the anterior shoulder

– Deliver the other shoulder followed by

the torso and lower extremities

216

Procedure


• Clamp umbilical cord with hemostat

or umbilical cord clamp approximately

10 to 15 cm from fetus

• Attach second hemostat or clamp 2 to

3 cm distal to the first

• Cut umbilical cord between the

clamps with a Mayo scissors

• Resuscitate the neonate 218

Complications


• Maternal sepsis

• Maternal visceral injury

• Maternal hemorrhage

• Fetal injury secondary to delivery

• Possible benefits of maternal and / or

fetal survival should far outweigh

these considerations

219

Resources

• Tintinalli’s Emergency Medicine: A

Comprehensive Study Guide, 7e

Judith E. Tintinalli, J. Stephan

Stapczynski, O. John Ma, David M.

Cline, Rita K. Cydulka, and Garth D.

Meckler

• Emergency Medicine Procedures

Eric R. Reichman, Robert R. Simon

220

http://www.accessemergencymedicine.com/resourceToc.aspx?resourceID=40





Resources

• Atlas of Emergency Medicine, 3e

Kevin J. Knoop, Lawrence B. Stack,

Alan B. Storrow, R. Jason Thurman

221


Summary

• Explain risks and benefits, including

what will happen if you don’t do it

• Obtain written informed consent

(when possible)

• Use appropriate monitoring

equipment

• Position patient properly

222

Summary

• Clean / prep / drape appropriate body

part

• Use aseptic / sterile technique

• Provide post-procedure instructions

• Many of these procedures available

on YouTube

223

Education

GEMC- EMedHome Board Review: Procedures- Resident Training