Download Indications

University of sulaymany
college of medicine
for (forth, fifth, sixth ) stage medical
student
Prepared & collected by:
Dr .Soran Mohamad Gharib
2008
1
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 force
 Translational deceleration force
 Rotational force
 Direct, focal, sharp penetrating force
 Blunt 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.
*Consider the need for "advance trauma life support system protocol (ATLS)"
along with stabilization of airway, breathing, circulation, disability and exposure
(ABCD and E).
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*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;
Eye opening
Spontaneous
To speech
To pain
None
4
3
2
1
Verbal
response
Oriented
Confused
Inappropriate words
Incomprehensible sounds
None
5
4
3
2
1
Best motor
response
Obeys commands
Localize pain
Withdrawal from pain
Flexion to pain
Extension to pain
None
6
5
4
3
2
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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.
•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
responses
Scalp injuries;
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•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 fracture
Scalp 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
“Black Eye". Trauma
Ant. Cr. Fos s a #
Extravasated blood is not limited to the
orbital margin, it is diffuse
Limited to the orbital margin by the
attachment of Orbicularis Occuli m. it
tend to be circular
Discoloration is “Beefy Redness” after
trauma
Purplish from the start
The bleeding is in the conjunctiva and
moves with it
Always subconjunctival and does not
move with the movement of the
conjunctiva
On rotating the eye ball, a posterior limit
can be defined
No such posterior limit
In trauma, usually there is one black eye
Two black eyes is very suggestive
Middle Cranial Fossa Fracture;
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•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 amnesia
2. Cortical contusions and lacerations
3. Bone fragmentation injury
4. Diffuse axonal injury
5. Brain stem contusions.
Secondary;
1. Intracranial heamatoma
2. Cerebral edema
3. Hypoxemia
4. Ischemia
5. Infections
6. Epilepsy
7. 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.
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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.
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.
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Quick Cranial N examination;
 Olfactory (1st)
 Optic (2nd)
 Ocuolomotor (3rd)
 Trochlear (4th)
 Trigeminal (5th)
 Abducent (6th
 Facial (7th)
 Acoustic (8th)
 Glossopharangeal (9th)
 Vagus (10th)
 Accessory (11th)
 Hypoglossal (12th)
use non irritant smell.
test for visual fields.
lid and eye movements, pupillary reflex and laccommodation.
diplopia on looking downwards.
inability to clench teeth
affected eye does not follow an object laterally
facial m. paralysis.
hearing and caloric test.
loss of test in the posterior third of the tongue.
loss of soft palate movement. Uvula to the opposite side.
Failure to shrug the shoulder
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) Alcoholism
2) Severe concomitant brain injury.
3) Combination of extradural and intracerebral bleeding.
* In this case, you may suspect this by:
1) Presence of heamatoma of the temporalis muscle on the affected side.
2) The gradual onset of hemi paresis and hemiplagia.
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3) Deepening coma.
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;
•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 heamatoma
Hutchinson's pupil;
The pupil opposite to the
compression side
The pupil on the side of
compression
Normal
Slightly contracted and reacting
to light
Normal
Moderately dilated, sluggish
reaction to light
Moderately dilated, react to light
Widely dilated, does not react to
light
Widely dilated, insensitive
Widely dilated, insensitive, with
ptosis
Cerebral irritation;
Patient is found curled up in bed
avoiding light (Photophobia)
eye lids are closed
temperature is moderately raised
the patient is irritable
This indicates blood in the CSF.
Delayed effects of head injury;
Post traumatic epilepsy
Cerebrospinal fluid fistula
Post-concussion symptoms
Neurological and Neuro-psychological deficits
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Neuroendocrine and metabolic disturbances
Examination of the
Vascular System
Examination of the Arterial Circulation
Arteries accessible for clinical examination are:
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Common Carotid and bifurcation in the neck
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the facial and superficial temporal over the skull
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the subclavian artery behind the clavicle
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the axillary artery in the axilla
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the Brachial artery at the elbow
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the radial and ulnar arteries at the wrist
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the femoral artery below the mid inguinal point
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the popliteal artery in the popletial fossa
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the posterior tibial artery behind the medial malleolus
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the anterior tibial artery between the two malleoli
•
the dorsalis pedis artery between the first and second metatarsals just
medial to the flexor hallusis longus tendon
•
the abdominal aorta in thin subject when compressed against the
vertebral column
Clinical assessment of the arterial circulation
• Examine in warm environment
• Examine the heart
• Assess Blood pressure in both arms
Assessment of ischemic limb
Inspection
• Skin; white marble, redness or blueness.
• A purple blue cyanosis may be obvious.
• When cyanotic areas become fixed, the ischemia is irreversible.
• Gangrene turn skin permanent blue/black colour first seen
caudally in the toes
Clinical assessment of the arterial circulation
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•
•
The Vascular (Buerger's) angle
Capillary filling time and “Buerger’s positional test”
Inspect for venous filling-Guttering of veins
•
Inspect carefully pressure areas for Thickening of the skin, a
purple or blue discoloration, blistering, ulceration or patches of
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•
•
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black, red, dead gangrene. Pressure areas are:
bottom, back and lateral surface of the heal and ball of the foot
skin over the malleoli
skin over the head of the fifth metatarsal
tips of the toes and areas between the toes
Clinical assessment of the arterial circulation
Palpation
• Assess temperature
• Capillary refilling time
• Felling the pulse
Auscultation
• An audible bruite is caused by turbulent flow beyond a stenosis or
irregularity in the artery wall.
• Blood flow in the vessel is assessed by a hand-held Doppler probe
which can detect pulstile flow when the pulse pressure is
impalpable to the fingers.
Symptoms and signs of acute ischemia (remember
the letter “P”)
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Pain, severe, sudden onset as a result of ischemia of muscles and nerves
Parasthesia progressing to
Paralysis
Pallor of the limb
Pulselessness
Perishingly cold limb
Poor capillary circulation resulting in
Prolonged capillary refilling time
Perceptively empty veins
Poor power, sensation and limb reflexes
Pulse Doppler flowmetry confirm absent pulsation
Persistent ischemia lead to hardness of muscles, blistering of the skin and
development of gangrene starting in the toe and spreading proximally
Clinical manifestations of chronic ischemia
• Intermittent claudication (limping)
• Pre-gangrene
• Gangrene
• Ischemic ulcers
Ischemic ulcers
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Site tips of the toes and over pressure points
Size small to large flat
Shape often elliptical
Tenderness mild, moderate or sever
Temperature; surrounding tissue is usually cold due to ischemia
Edge punched-out or sloping
Floor grey-yellow slough covering flat pale granulation tissue
Depth; is often very deep and penetrating
Discharge clear fluid, serum or pus
•
•
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Base may be stuck or may be part of any underlying tissue
Lymph Nodes: not enlarged unless there is secondary infection
State of local tissue: surrounding tissue may show signs of
ischemia.
Distal pulses are invariably absent
Doppler pressure index is reduced
Neurological examination numbness, Parasthesia, and absent
sensation may indicate trophic ulcer
General examination may show evidence of vascular disease or
diabetes
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Ischemic ulcers
Examination of the venous circulation
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Veins are either superficial or deep.
In the upper limb flow is from peripheral to proximal veins.
In the lower limb, in addition, flow is also from superficial to deep veins
Valves are sited
• at any junction between superficial and deep veins
• in the perforating veins
• along the deep and superficial veins
limb veins have three principle functions
• pathway to return blood to the heart
• blood storage
• thermoregulation.
Thrombosis of superficial veins (superficial
thrombophlebitis)
Clinically, the vein become
• Firm,
• Palpable
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• Redness and stiffness in the overlying skin which
become warm and tender .
• It may be complicated by suppuration or
extension of the thrombus along a perforating
vein to the deep veins causing deep venous
thrombosis.
Examination of a case of deep vein thrombosis
• Observe for inequality of circumference and any prominent veins over the
dorsum of foot.
• Examine the ankle for pitting Oedema
• Dorsiflexion of the foot produce pain in the calf muscle (Homan's sign)
• Tender calf muscles
• Palpate the popliteal space for tenderness in full leg extension position
• Seek for tenderness in the thigh along the course of the femoral vein
• Comparative circumferential measurement at identical points
Examination of a case of varicose veins
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By inspection:
Inspect from back and front for varicosities of long,
short or both saphenous veins.
Inspect the site of perforators which produce discrete
venous bulges.
Inspect for the presence of swelling, skin pigmentation,
pre-ulcerative lesions, ulcer mainly just above the
medial malleolus and any scars due to healed ulcers.
Examination of a case of varicose veins
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By palpation:
Palpate over the course of long and short saphenous
veins
Perform the "cough impulse test"
Perform the percussion or "Tap" sign.
Perform Brodie-Trendelenburg test
Seek for the site of perforators (Fegan's method)
Test for the patency of deep vein (Perthe's test
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Examination of the arterial circulation of the
lower limbs
• -Examination should be in aworm room.
• -Exposure:
• -from goin to toes,preserving his dignity by keeping his
underwear on.
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Inspection:
-colour:white/red.
Vascular angle:”buerger’s angle”
Lift the leg above the bed,raises it above the heart level.
Normal leg can be raised to 90 degree and still remain perfused.
The angle between the horizontal and the leg when it become white is
vascular angle.
If the angle less than 20 it indicate sever ischemia
• Capillary filling time:
• After elevating the legs,ask the patient to sit up and dangle the foot over
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the site of the couch.
Anormal leg and foot remain healthy pink in colour.
Ischaemic leg slowly turns from white to pink and thentakes 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.
In sever ischaemia it may be as long as15-30 seconds
• -Venous filling:
• in an ischaemic foot the veins collapse and sink below the skin
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surface to look like pale-blue gutter.this is called guttering of the
veins.
-look at the-look at the pressure areas.
Trophic changes:
-loss of skin.
-loss of hair.
-Gangrene.
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• Ulcers:
• Arterial(ischaemic) ulcers are found typically in the least well perfused areas and over the
pressure points.
• The lesions are punched out because there is no attempt at healing,and well
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described,may be very tender and the surrounding skin is cold.
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 base ,otherwise the
base is flat and pale.
They may be very deep and penetrate surrounding tissue like bone..
Commenest differencial is with the neuropathic ulcer.
• Palpation
• -feel for skin temperature., use the back of hands ,comparing
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one side with other.
-examine the toes for capillary refill,use thmb to push hard over
the pulp of the big toe on both sides.,normally the toe blunches
but then return to the normal colour withn 2 seconds,.any
longer than this is abnormal.
Only after all had been completed should you move on to
examine the pulses
• Femoral pulse:
• -can be identified by the level of the groin skin crease .
• anatomically dscribed at the mid- inguinal point ,halfway
between
• Anterior superior iliac spine and the pubic symphysis.
• -compare one side with the other.
• Popliteal pulse:
• -the most convenien technique for feling the popliteal pulse is to extend the patient knee
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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 touching behind the knee,over the
lower part of the popliteal fossa.,the pulse demonstrated when the popliteal artery is
compressed against the posterior aspect of the tibia.
-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 difficult.
-sometime it can be feel by turning the patient in to the prone position and feeling along
the course of the artery.
-when it is easy to feel it may be aneurysmal.
-compare.
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• Foot pulses
• -the dorsalis pedis and the posterior tibial pulses can be palpated bilaterally
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and simultaneously.
-demonstrate the tendon of extensor hallucis longus.
-the DPA is immidately lateral to this tendon.
-swing your hand down to the medial malleolus and run your fingers
posteriorly ,posterior tibial artery lie1/3 of the way along aline between the
tip of the medial malleolus and the point of the hill.
• Auscultate:
• -check for bruit .
• -measure blood pressure.
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complete your examination by:
-examine the abdomen for an aneurysm.
-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 brachial artery using a
Doppler probe.
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 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.
The index is the ankle pressure dividedby the brachial pressure.
Normal index is 1.
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 rest pain have an index<0.5
Antibiotics in Surgical Practice
General Terms
Antimicrobials
Chemotherapeutics
Antibiotics
Bactericidal
Bacteriostatic
Broad spectrum
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Narrow spectrum
Principles of antimicrobial therapy
Antimicrobials are either used as
• Therapeutic
• Prophylactic
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•
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Therapeutically, only spreading infection or signs of systemic
infection justify the use of antibiotics.
Organism and its sensitivity should be determined prior to
commencement of active therapy.
Empirical antibiotic therapy may confuse the clinical picture
and affect the opportunity to make a precise diagnosis.
Approaches to antibiotic treatment
•
Narrow spectrum antibiotic is used to treat a known sensitive
infection
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Combination of broad spectrum antibiotics
can be used when the organism is not known
or when it is suspected that more than one organism may be
responsible for the infection.
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Alternatives for single drugs are always available
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Mono-therapy (single drug) as an alternative to triple therapy
Approaches to antibiotic treatment
• In the surgical units, in which commensal organisms have become
as "resident opportunists", it may be necessary to rotate
antibiotics between broad spectrums
• Alternatives of combinations of antibiotics should be monitored by
"Infection Control Team"
• New antibiotics should be used with caution and, whenever
possible, sensitivities should first be obtained
The concept of prophylactic antibiotic therapy
– 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
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The concept of prophylactic antibiotic therapy
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 prophylaxis of
surgical infections
Penicillins (Benzyl Pencillin)
• Broad spectrum
• Effective against G+ve Streptococci, Clostridia and non betalactamase Staphylococci. It is still effective against Actinomycosis
spp.
Flucloxacillin and Methicillin
• Narrow spectrum
• Beta-lactamase-resistant Penicillins
• Effective against Staphylococcal beta-lactamase producing
organisms
Antibiotics in current use for treatment and prophylaxis of
surgical infections
Ampicillin and Amoxicillin
• Broad spectrum beta-lactam penicillins.
• Effective against Enterobacteriaceae, Enterococcus faecalis and
the majority of group D Streptococci
Mezlocillin and Azlocillin
• Broad spectrum ureido-penicillins with good activity against
Enterobacter and Klebsiella and Pseudomonas.
• have some activity against Bactroids and Enterococci.
• usually combined with an Aminoglyciside for sever mixed
infections caused by G-ve organisms.
Antibiotics in current use for treatment and prophylaxis of
surgical infections
• Clavulanic acid is combined with amoxicillin (Amoxiclav) taken
orally, protect amoxicillin from being inactivated by betalactamase producing bacteria. It is effective against Klebsiella and
staphylococcus in animal and human bites
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Cephalosporins
Broad spectrum.
The types important in surgical practice are the beta-lactamasestable Cefuroxime, Cefotaxime and Ceftazidime.
The first two are effective against Staphylococcus aureus and
most Entrobacteria.
Ceftazidime is active against G-ve organisms but most effective
against Pseudomonous aeroginosa.
usually combined with Aminoglycoside or an Imidazole for perfect
anaerobic cover.
Antibiotics in current use for treatment and prophylaxis of
surgical infections
Aminoglycosides
• Broad spectrum Gentamicine and Tobramycin.
• Particularly effective against G-ve Enterobacteria, Pseudomonas,
Anaerobs and Streptococci. Ototoxicity and Nephrotoxicity may
follow sustained high toxic levels.
Vancomycin
• A narrow spectrum antibiotic of the glycopeptide type.
• most effective against G+ve and MRSA.
• It is the drug of choice orally against Clostridium Difficile which
cause Pseudomembranous enterocolitis
Antibiotics in current use for treatment and prophylaxis of
surgical infections
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Imidazoles
The most widly used is the Narrow spectrum Metranidazol
active against all anaerobic bacteria including anaerobic cocci,
Bactroids and Clostridia.
Carbapenems
Broad spectrum Meropenem, Ertapenem and Imipenem
Beta-lactamase resistant, anti-anaerobic and anti-G+ve
Expensive drugs.
Quinolones
Narrow spectrum Ciprofloxacin. It is potent bactericidal against
Pseudomonas spp.
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Dressings in Surgery
General indications for application of surgical
dressings
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To prevent contamination from external
environment. Example; dressing of surgical wounds.
•
To cover and absorb heavily exudating wounds.
Example; dressing of burns.
•
To eliminate dead space and prevent collections.
Example; packing deep wounds.
General indications for application of surgical
dressings
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To activate fibrinolysis and liquefy pus. Example
dressing of chronic skin ulcers.
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To debride necrotic skin. Example; dressing of
necrotic sloughing skin ulcers.
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To remove bacteria and excessive moisture.
Example; dressing of deep granulating wound.
General indications for application of surgical
dressings
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To absorb harmful materials. Example; pus of
infected wounds and discharges of different fistulae
and sinuses.
•
To maintain moist environment and to promote
epithelialization and formation of granulation tissue.
either with gaseous exchange; using semipermiable
dressings
or without gaseous exchange; using complete
occlusive dressings
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•
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General indications for application of surgical
dressings
• To cover the entry site of different surgical drains.
• To stop bleeding by the technique of Dry Pack Pressure
Dressing. Example; in lacerated heavily bleeding liver
injuries.
Types of dressings used in surgical practice I
Simple dressings:
• Dry plain Gauze; cotton mesh only.
• Dry packs; gauze and cotton with or without non-adherent
coating of Melolin.
• Tulles; cotton thread mesh impregnated with non-adherent
Paraffin.
• The addition of non-adherent coating facilitates removal.
• Charcoal is added to some act as an absorbent and reduce
swelling.
• Relatively cheap
Types of dressings used in surgical practice II
Hydrogel polymers (Geliperm and Intrasite)
• maintain a moist environment.
• semi-permeable and allow gas exchange.
Hydrocolloids (Comfeel and Granuflex)
• used for complete occlusion technique.
• promotes epithelialization of granulating tissue.
• maintain a moist environment but with out gas exchange across them.
Fibrous polymers (Kaltostat and Sorban)
absorptive alginate dressings that are derived from natural sources.
All are used to pack deep wounds in order to promote epithelization of newly
forming granulation tissue.
Types of dressings used in surgical practice III
Foams (Silastic, Lyofoam and allevyn)
• These are Elastomeric dressings
• can be shaped to fit deep cavities and granulating wounds.
• absorbent and non-adherent
Polymeric films (Opsite and Bioclusive)
• primary adhesive transparent dressings.
20
• used to cover sutured surgical wounds and donor sites
Bead dressings (Debrisan and Iodosorb)
• It removes bacteria and excessive moisture by 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
 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
21
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
 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)
22
Surgical drains
• Drains are inserted to:
– Evacuate establish collections of pus, blood or other fluids
(e.g. lymph)
– Drain potential collections
• 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:
–
–
–
–
Presence of a drain increases the risk of infection
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 drains
• Drains can be:
– Open or closed
– Active or passive
Drains are often made from inert silastic material
They induce minimal tissue reaction
Red rubber drains induce an intense tissue reaction allowing a
tract to form
• In some situations this may be useful (e.g. biliary t-tube)
•
•
•
Open drains
• Include corrugated rubber or plastic sheets
• Drain fluid collects in gauze pad or stoma bag
• They increase the risk of infection
Closed drains
• Consist of tubes draining into a bag or bottle
23
• They include chest and abdominal drains
• The risk of infection is reduced
• Active drains
• Active drains are maintained under suction
• They can be under low or high pressure
• Passive drains
• Passive drains have no suction
• Function by the differential pressure between body
cavities and the exterior
Gastric intubation
is a common )i.e. nasogastric route(Gastric intubation via the nasal passage
procedure that provides access to the stomach for diagnostic and
.tube is used for the procedure )NG( A nasogastric .therapeutic purposes
The placement of a NG tube can be uncomfortable for the patient if the
patient is not adequately prepared with anesthesia to the nasal passages
and specific instructions on how to cooperate with the operator during the
.procedure
INDICATIONS
Diagnostic:
- Evaluation of upper gastrointestinal (GI )b
)bleeding(i.e. presence, volume).
- Aspiration of gastric fluid content.
- Identification of the esophagus and stomach on a chest radiograph.
- Administration of radiographic contrast to the GI tract.
Therapeutic:
- Gastric decompression, including maintenance of a decompressed state after endotracheal intubation, often
via the oropharynx
bowel obstruction-- Relief of symptoms and bowel rest in the setting of small
24
- Aspiration of gastric content from recent ingestion of toxic material
- Administration of medication
- Feeding
- Bowel irrigation
CONTRAINDICATIONS
• Absolute contraindications:
– Severe midface trauma
– Recent nasal surgery
• Relative contraindications:
– Coagulation abnormality
– Esophageal varices or stricture
– Recent banding or cautery of esophageal varices
– Alkaline ingestion
•
EQUIPMENT
Nasogastric 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%
•
Oral analgesic spray (Benzocaine spray or other)
•
Oral syringe, 12 mL
•
Equi. Cont..
Glass of water with a straw
•
Water-based lubricant
•
Toomey syringe, 60 mL
•
Tape
•
Emesis basin or plastic bag
25
•
Wall suction, set to low intermittent suction
•
Suction tubing and container
POSITIONING
• Position the patient in the sitting upright position.
TECHNIQUE
• Explain the procedure, benefits, risks, complications, and
alternatives to the patient or the patient's representative.
• Examine the patient’s nostril for septal deviation .To determine
which nostril is more patent, ask the patient to occlude each
nostril and breathe through the other .
• Instill 10 mL of viscous lidocaine 2% (for oral use )down the
more patent nostril with the head tilted backwards, and ask the
patient to sniff and swallow to anesthetize the nasal and
oropharyngeal mucosa .In pediatric patients, do not exceed 4
mg/kg of lidocaine .Wait 5-10 minutes to ensure adequate
anesthetic effect.
• Estimate the length of insertion by measuring the distance from
the tip of the nose, around the ear, and down to just below the
left costal margin .This point can be marked with a piece of tape
on the tube .When using the Salem sump nasogastric tube
(Kendall, Mansfield, Mass) in adults, the estimated length
usually falls between the second and third preprinted black lines
on the tube.
• Position the patient sitting upright with the neck partially
flexed .Ask the patient to hold the cup of water in his or
her hand and put the straw in his or her mouth .
Lubricate the distal tip of the nasogastric tube.
26
• Gently insert the nasogastric tube along the floor of the nose and advance
it parallel to the nasal floor (ie, directly perpendicular to the patient's head,
not angled up into the nose )u
)until it reaches the back of the nasopharynx,
where resistance will be met (10-20 cm .)A
.)At this time, ask the patient to
sip on the water through the straw and start to swallow .C
.Continue to
advance the nasogastric tube until the distance of the previously estimated
length is reached.
• Stop advancing and completely withdraw the nasogastric tube if, at any time, the patient
experiences respiratory distress, is unable to speak, has significant nasal hemorrhage, or if
the tube meets significant resistance.
• 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 gastric content .T
.The authors
recommend always obtaining a chest radiograph in order to verify correct placement,
especially if the nasogastric tube is to be used for medication or food administration .
• Tape the nasogastric tube to the nose to secure it in
place .If clinically indicated, attach the nasogastric tube
to wall suction after verification of correct placement.
• During insertion, if concern exists that the tube is in the
incorrect place, ask the patient to speak. If the patient
is able to speak, then the nasogastric tube has not
passed through the vocal cords and/or lungs .
• The nasogastric tube may coil in the nasopharynx or oropharynx. If this
occurs, or if the tube is difficult to pass in general, one can try curling the
distal end and partially freezing it in a cup of ice in order to temporarily
hold its curled shape better. Insert the lubricated tube tip through the nose
with the curled end pointing downwards .O
.Once the distal tip passes into the
hypopharynx, the curved tip will be facing anteriorly .R
.Rotate the tube 180
degrees so that the curved end is pointing posteriorly toward the
esophagus .C
.Continue to insert in the usual manner by having the patient
swallow water.
27
• Another option (in paralyzed patients only )is to place 2-3
fingers through the patient’s mouth into the oropharynx .The
fingers are used to guide the nasogastric tube into the
hypopharynx.
• Lifting the thyroid cartilage anterior and upward might open the
esophagus and allow passage into the proximal esophagus .
COMPLICATIONS
•
Patient 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 generously lubricating the tube tip and using a gentle technique.
•
Respiratory tree intubation
Esophageal perforation
Urethral catheterization
Is a routine medical procedure that has both diagnostic
and therapeutic purposes.
INDICATIONS
1. Diagnostic:
- Collection of uncontaminated urine specimen.
- Monitoring of urine output.
- Imaging of the urinary tract.
2. Therapeutic:
28
- 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.
CONTRAINDICATIONS
Urethral catheterization is contraindicated in the presence of traumatic injury
to the lower urinary tract (e.g. urethral tear). This condition may be
suspected in male patients with a pelvic or straddle-type injury. Signs that
increase suspicion for injury are a high-riding prostate, perineal hematoma,
or blood at the meatus. When any of these findings are present in the
setting of concerning trauma, a retrograde urethrogram should be
performed to rule out a ureteral tear prior to placing a catheter into the
bladder.
EQUIPMENT
- 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 blunt
tip urethral applicator or a plastic syringe (5-10 mL).
POSITIONING
Place the patient supine, in the frog leg position, with
knees flexed.
TECHNIQUE
Explain the procedure, benefits, risks, complications, and alternatives to the
patient or the patient's representative.
Position the patient supine, in bed, and uncover the genitalia.
Open the iodine/chlorhexidine preparatory solution and pour it onto the sterile
cotton balls. Open a sterile lidocaine 2% lubricant with applicator or a 10-
29
mL syringe and sterile 2% lidocaine gel and place them on the sterile field.
Wear sterile gloves and use the nondominant hand to hold the penis and
retract the foreskin (if present). This hand is the nonsterile hand and holds
the penis throughout the procedure.
Use the sterile hand and sterile forceps to prep the urethra and glans 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 urethra. Place a
finger on the meatus to help prevent spillage of the anesthetic lubricant. Allow 2-3 minutes
before proceeding with the urethral catheterization.
While holding the penis at approximately 90 and stretching it upward to straighten out the
penile urethra, slowly and gently introduce the catheter into the urethra. Continue to
advance the catheter until the proximal Y-shaped ports are at the meatus.
Wait for urine to drain from the larger port to ensure that the distal end of
the catheter is in the bladder. The lubricant jelly–filled distal catheter
openings may delay urine return. If no spontaneous return of urine occurs,
try attaching a 60-mL syringe to aspirate urine. If urine return is still not
visible, withdraw the catheter and reattempt the procedure (preferably
after using ultrasonography to verify the presence of urine in the bladder).
After visualization of urine return (and while the proximal ports are
at the level of the meatus), inflate the distal balloon by injecting
5-10 mL of 0.9% NaCl (normal saline) through the cuff inflation
port. Inflation of the balloon inside the urethra results in severe
pain, gross hematuria, and, possibly, urethral tear.
30
Gently withdraw the catheter from the urethra until resistance is
met. Secure the catheter to the patient's thigh with a wide tape.
If the patient is uncircumcised, make sure to reduce the
foreskin, as failure to do so can cause paraphimosis.
COMPLICATIONS
1. Infections
- Urethritis
- Cystitis
- Pyelonephritis
- Transient bacteremia
2. Paraphimosis, caused by failure to reduce the foreskin after catheterization
3. Creation of false passages
4. Urethral strictures
5. Urethral perforation
6. Bleeding
Prophylactic antibiotics are recommended for patients with
prosthetic heart valves, artificial urethral sphincters, or penile
implants.
Catheter 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.
31
Bed-side Surgical procedures
General Principles
Definition
How to approach?
Observe…Practice….Pass on Experience
General principles
•
Confidence and competency
•
Equipments
•
Consent
•
Checking patient’s details
•
Reassure and explain
•
Additional arrangements
•
Sedation
•
Assistance
•
Expert opinion
•
Documentation
•
Dangers to the operator
•
Signing by name and rank
Vein puncture
•
•
•
•
•
•
•
Indications and procedure
Tips and problems
Poor veins
Agitated patient
Obese patient
Failed attempts
Obtaining blood for culture and sensitivity testing
Intravenous cannulation
•
•
•
•
•
•
•
•
Indications and procedure
Tips and complications
Poor veins
Agitated patient
Obese patient
Selection of the site
Failed attempts
Blood transfusion
32
Venous cut down (Vein section)
Indications and method
Tips and problems
• Freeing enough segment of vein
• Caution not to injure the posterior wall
• Securing the cannula
Central venous access I
Indications
• CVP
• TPN
• Special drugs
• Poor or failed peripheral access
Cautions
• Clotting disturbances
• Hypovolemia
Central venous access II
•
•
•
•
•
Preparation
Lie patient supine with head supported by one pillow. If
a patient is shocked, tilt the head of the bed down
Tilt the patient head away from the side of insertion
Ensure that each port of the cannula is "primed" with
heparinized saline
Identify the site of entry before scrubbing up
If possible, place the patient on cardiac monitor
Central venous access III
Approach
• the right side is used to avoid damaging the thoracic duct.
• If a chest tube is there, use the same side for cannulation.
For the subclavian vein
• identify the mid- point of right clavicle
• pass the needle under and closely applied to the lower border of
the clavicle aiming to supra-sternal notch.
For the internal jugular vein
• identify the carotid pulse at the level of the thyroid cartilage
insert the needle at the medial border of the sternomastoid
muscle 0.5-1 cm lateral to the artery and advanced at 450, aiming
for the ipsilateral nipple.
33
Central venous access IV
•
•
•
•
•
•
Tips and problems
Line in the neck on chest x-ray
Pnemothorax on x-ray
Infection
Cardiac arrhythmias
Blocked cannula
Measurement of the CVP
Arterial puncture (cannulation)
Cautions
•
Clotting disturbances
Approaches
•
Radial A ( apply Allan’s test)
•
Femoral A
Tips and problems
•
Poorly palpable artery
•
Venous sample
•
Bleeding from puncture site
Endotracheal intubation
Indications
•
Cardiac arrest
•
Serious head injury
•
Certain acute respiratory and trauma settings
•
Prior to surgical operations
Tips
•
The patient is pre oxygenated
•
Ensure that the laryngoscope and endotracheal tube cuff are
functioning
•
Remove any dentures from the mouth. Excess saliva or
secretions must be suctioned.
•
Assess the correct positioning
Nasogastric tube insertion
Indications
• Intestinal obstruction
• Paralytic ileus
34
• Peri operative gastric decompression
• Enteral feeding
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 problems
Patients has problem in swallowing: ask the patient to swallow
sips of water as the tube is passed
Constant coiling in to the mouth: the tube may be too soft; cool in
fridge
Resistance to passage: there may be an anatomical reason for
this, e.g. esophageal stricture. The tube may need to be passed
under X-ray control
Obtain an X-ray: prior to commencing Enteral feeding in order to
confirm the position of the tube and avoid iatrogenic aspiration.
Sengestaken-Blakmore tube
Method
• The tube is passed through the mouth, advanced in to the
esophagus
• inflate the gastric balloon slowly to a pressure of 60 mmHg
• Pull the tube back until resistance is met, as the balloon
reaches the cardia.
• Inflate the esophageal balloon to 40-50 mmHg and secure the
tube under mild tension.
• Aspirate the gastric and esophageal ports every 30 min.
• the esophageal balloon must be deflated every hour to prevent
mucosal ulceration or necrosis.
Urethral catheterization
•
•
•
•
•
Indications
Perioperative monitoring of urinary output
Acute urinary retention
Chronic urinary retention
Prior to abdominal or pelvic surgery
Incontinence
Tips and problems
35
•
•
•
•
•
•
No urine immediately
Inability to insert
Decompression of grossly distended bladder
Urine is bypassing the catheter
Catheter stops draining
Female catheterization
Suprapubic catheterization
•
•
•
•
•
Indications
Failed or contraindicated transurethral catheterization
Cautions
patient with known bladder tumor or previous bladder
surgery
Ensure clinically (and by US if available) that the bladder
is full and distended.
Tips and problems
Bypassing urine
No urine or faeculent matter in the catheter
Pleurocentesis
•
•
•
•
•
•
•
Indications
Drainage of pleural effusion
Drainage of early empyema
Tips and problems
Diagnostic tap
Dry tap
Pnemothorax
Very bloody tap
Marking the proposed site
Thoracostomy tube drainage
•
•
•
•
•
•
Indications
Pnemothorax
Haemothorax
Post-thoracotomy
Tips and problems
Agitated or anxious patient
Securing the drain
Do not clamp the drain
36
•
•
•
Blocked drain
Persistent bubbling
Removal of the drain
Paracentesis abdominis
•
•
•
•
•
•
•
Indications
Diagnostic evaluation of ascitis
Therapeutic drainage of ascitis
Tips and problems
Identify a suitable tap site
Amount aspirated
Unable to aspirate adequate amount of fluid
Blood or faeculent material
Considering Peritoneal catheter
Rigid sigmoidoscopy
•
•
•
•
•
•
Indications
Investigation of the lower GI symptoms
Visualization of the rectum and lower sigmoid colon
prior to barium enema
Tips and problems
Advancing slowly under direct vision
Recto-sigmoid junction
Biopsy
Withdrawal
Local anesthesia
Indications
• Minor procedure
• Postoperative infiltration
Cautions
• Allergy
• Infection at the proposed site for infiltration
• Increased risk of toxicity: heart block, low cardiac output,
epilepsy, myasthenia gravis, hepatic impairment, porphyria, betablockers, and cimitidien therapy all increase this risk.
• Adrenaline containing solution (decrease blood loss, prolong
duration of anesthesia and delay absorption of agent)
Agents
Lignocaine: for short procedures
• Concentrations: 0.5%, 1%, and 2% Plain or with adrenaline.
37
• Duration of action: rapid onset (2-3) minutes, effect last for 30-90 minutes
depending on the site and the dose.
• Maximum dose: plain solution 200 mg or 20 ml of 1% solution for an adult, 3
mg/kg for a child.
Bupivacaine: for longer procedures
• Concentrations: 0.25-0.75 % plain solutions, 0.25-0.5 % with adrenaline.
• Duration of action: slower onset of action than lignocaine. Its Effect last for 3-8
hours.
• Maximum dose: 150 mg or 30 ml 0.5% solution for an adult, 2 mg/kg for a
child.
•
•
•
•
•
•
•
•
•
Toxicity
Symptoms mainly neurological. Drowsiness, confusion, slurred speech, lightheadedness, tinnitus, and numbness of the tongue or mouth may all occur. If sever,
convulsion and coma may follow.
Signs may include early tachycardia and hypertension. Later bradycardia, hypotension,
cardiac arrhythmias and cardiac arrest may occur.
Treatment
Stop procedure
Maintain airway and provide oxygen
Ensure IV access
Perform an ECG
Give valium 5-10 mg IV, slowly for convulsions.
Raise the bed and initiate IV fluids for hypotension
Bradycardia: usually resolve, atropine is rarely needed.
Inadequate analgesia
Intercostals nerve block
Indications
• Painful fractured rib
• Post-thoracotomy pain relief
• Position the patient as for pleural aspiration
Tips
• For a broken rib: inject medial to the site of fracture on the
posterior aspect of the chest wall
• For post-thoracotomy pain relief: inject medial to the posterior
edge of the scar on the posterior chest wall
• Multiple blocks: ensure that you did not reach a toxic dose
• Air or blood is aspirated: withdraw needle slowly and re-aspirate.
Nasotrachieal intubation


Indication;
Contraindication;
 Pregnancy
 Coagulopathy
 Nasal occlusion
 Deviated septum
 C.S.F Rhinorrhea
Technique;
Awake patient , spontaneously breathing
Signs of correct advancement
38
Complications;
Esophageal intubation.
bleeding


Nasal packs
Indication;
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 cauterization
Complications and management;




1. Persistent or recurrent bleeding
2. Infection
3. hypoxima
Internal jugular venous access
Indications;
1. C.V.P monitoring
2. Total Paranteral nutrition
3. Long term drug infusion
4. Haemodialysis
Contraindications;
1. Previous ipsilateral neck surgery
2. Untreated sepsis
3. 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
39

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
pericardiocentesis
Indications;
 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.
40
 Laboratory test (cell count, amylase,
Protein, glucose, culture…)
6. Monitoring of the patient
7. 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
Anoscopy
Indication;
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- Fissure
2- bleeding
Diagnostic peritoneal lavage
Indication;
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.
Retroperitoneal injury
41
Prior to abdominal surgery.
Anaesthesia;
Positioning;
Supine.
Decompress stomach.
Decompress bladder.
Technique;
-Preparation and anaesthesia
-Indication for immediate laparotomy;
Gross blood(5ml or more)
Gross enteric contents
Dialysat in chest tube or foley catheter
-Positive finding;
•RBC>500/mm3
•Amylase>175
Complications and management;
•Bladder injury
•Injury to bowel or other abdominal organs.
•Haemorrhage.
•Peritonitis
•Wound infection.
Lumber puncture
Indications;
•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 syndrome
Anaesthesia;
Positioning;
Lateral (fetal position)
Sitting position
Technique;
42
-Space;
L4-L5
L3-L4
L5-S1
-Needle directed cranially and parallel to midline
-The stylet should always be in the needle..?
•If blood clears……….Traumatic
•Not clear+ clots………Reattempt
•Not clear+ not clots………Subarachnoid haemorrhage
-If the bone is encountered
-C.S.F
•flow;
•Measure C.S.F pressure;
•Normal<15cm H2O
•Borderline 15-20cm H2O
•Abnormal>20mmH2O
-Sample send to;
•Cell count.
•Protein and amylase
•Culture and sensitivity
•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.V
o Intubation……..PCO2=30mmHg
o Neurosurgical consultation.
2-Nerve root injury.
3-Spinal haedache
4-Aortic /arterial puncture
Culdocentesis
Indication;
Suspected pelvic abscess.
Suspected rupture ectopic pregnancy
Contraindications;

Obliterated cul-de-soc

Severely retroverted uterus
Anaesthesia;
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2%Lidocaine jelly
1%Lidocaine solution
Positioning;
Technique;
Complication and management; bleeding
Tourniquets
A/Finger tourniquet;
Indications
Contraindication
Anaesthesia
Positioning
Technique
Complications and management; Ischemia.
B/Arm tourniquet.
Measurement of compartment pressure
Indication
Sign of ischemia
1) Pain………….early sign
2) Pallor
3) Parasthesia
4) Paralysis……….late sign
5) Pulselessness…………late sign
Compartments of the leg;
a. Anterior compartment
b. Lateral compartment
c. Superficial posterior compartment
d. Deep posterior compartment
Indications;
Contraindications;
1. Coagulopathy
2. Infection
Anaesthesia; No need …………why?
Positioning;
Technique (white side's technique);
pressure>40mmHg--------fasciatomy.
Complications;
1) Error in reading
2) Infection
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Arthrocentesis , intraarticular and
periarticular injections
Indications;
A/Diagnostic;
1) Septic arthritis
2) Differentiate inflammatory and noninflammatory condition
3) Synovial biopsy
B/Therapeutic;
1. Intraarticular injection
2. Aspiration
3. lavage
Contraindication;

Local infection

Systemic infection

Coagulopathy

Allergy

Prosthetic joint

Distorted joint
Anaesthesia;
Positioning and approach;
I. Metacarpopharangeal joint
II. Wrist joint
III. carpel tunnel syndrome
IV. Elbow joint
V. 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 malignant
2. Follow benign condition
3. 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;
Indication
Contraindication
Anaesthesia
Positioning
Technique;
• 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
Prepared by :
Dr. Soran Mohamad Gharib
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