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Project: Ghana Emergency Medicine Collaborative Document Title: EMedHome Board Review: Procedures Author(s): Joe Lex, MD, FACEP, FAAEM, MAAEM (Temple University) 2013 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact [email protected] with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. 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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 Contraindication Nasotracheal Intubation • • • • Apnea Severe midface injuries Basilar skull fracture Closed head injury with intracranial pressure • Nasopharyngeal obstruction • Coagulopathy (relative) 19 Procedure Nasotracheal Intubation • 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 See: “Procedure Nasotracheal Intubation” in Knoop KJ, Stack LB, Storrow AB, Thurman RJ: The Atlas of Emergency Medicine, 3rd Edition, http://accessmedicine.com. Thomas H. Burford, Wikimedia Commons 21 Complications Nasotracheal Intubation • • • • • 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 Retrograde Intubation • Stabilize patient’s larynx, identify cricothyroid membrane • Connect 16- to 18-gauge catheterover-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 Retrograde Intubation Source: Reichman EF, Simon RR: Emergency Medicine Procedures 29 Procedure Retrograde Intubation • 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 Retrograde Intubation Source: Reichman EF, Simon RR: Emergency Medicine Procedures 31 Procedure Retrograde Intubation • If available, advance introducer sheath until meets obstruction • Remove wire • Advance endotracheal tube over introducer into trachea • Confirm placement • Secure tube Recommended Reference: Reichman EF, Simon RR: Emergency Medicine Procedures 32 Complications Retrograde Intubation • Damage to tracheal cartilage • Inability to intubate • Hypoxia 34 Indication / Contraindication 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) Recommended Reference: Reichman EF, Simon RR: Emergency Medicine Procedures 37 Complications Cricothyrotomy • • • • • • • Esophageal perforation Subcutaneous emphysema Subcutaneous tube placement Bleeding Unable to intubate Subglottic stenosis Cartilage damage: thyroid, cricoid 42 Indication / Contraindication Tube Thoracostomy Indications • Pneumothorax (24F – 28F tube) • Hemothorax (32F – 40F tube) Contraindications • Coagulopathy (relative) 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 Recommended Reference: Reichman EF, Simon RR: Emergency Medicine Procedures 45 Complications Tube Thoracostomy Complications • Bleeding, hemothorax • Visceral organ perforation / vascular structure injury • Subcutaneous tube placement • Pneumonia • Empyema 50 Indication / Contraindication Needle Thoracostomy Indications • Tension pneumothorax Contraindications • None 51 Procedure Needle Thoracostomy • Connect a 14- to 16-gauge catheterover-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 Recommended Reference: Reichman EF, Simon RR: Emergency Medicine Procedures 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 Resuscitative Thoracotomy • Penetrating chest trauma victim with no vital signs in field • Blunt trauma victim with or without field vitals 56 Procedure Resuscitative Thoracotomy • 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 Recommended Reference: Reichman EF, Simon RR: Emergency Medicine Procedures 57 Complications Resuscitative Thoracotomy • 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 Indication / Contraindication 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 Recommended Reference: Reichman EF, Simon RR: Emergency Medicine Procedures 68 Complication Paracentesis • Hypotension after large volume removal • Localized infection • Abdominal wall hematoma • Persistent fluid leak • Injury to abdominal organ 70 Indication / Contraindication Thoracentesis Indication • Pleural fluid requiring fluid analysis or therapeutic drainage Contraindication • Overlying cellulitis • Positive pressure ventilation (caution) • Coagulopathy (relative) 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-overneedle 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 Recommended Reference: Reichman EF, Simon RR: Emergency Medicine Procedures 74 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 • Overlying cellulitis 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 Procedure Lumbar Puncture BruceBlaus, Wikimedia Commons 85 Procedure Lumbar Puncture Source: Waxman SG: Clinical Neuroanatomy, 26th Edition: http://www.accessmedicine.com 86 Procedure Lumbar Puncture BruceBlaus, Wikimedia Commons 87 Complications Lumbar Puncture • Post-dural headache: ~1/3 – Post-tap position does not matter • Localized pain • Cerebral herniation • Subarachnoid epidermoid cyst 88 Indication / Contraindication Intraosseous Infusion Indication • Urgent vascular access when traditional methods have failed Contraindication • Diseased / osteoporotic bone • Overlying cellulitis / deep burn (relative) 89 Procedure Intraosseous Infusion • 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 Recommended Source: Tintinalli JE, et al., Tintinall’s Eergency Medicine: A Comprehensive Study Guide, 7th Edition: http://www.accessmedicine.com 90 Procedure Intraosseous Infusion Source Undetermined 91 Complications Intraosseous Infusion • Subcutaneous / subperiosteal fluid extravasation • Compartment syndrome • Localized infection • Osteomyelitis • Growth plate injury 97 Indication / Contraindication 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 Diagnostic Peritoneal Lavage • 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 Diagnostic Peritoneal Lavage • 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 Diagnostic Peritoneal Lavage • 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 Recommended Source: Tintinalli JE, et al., Tintinall’s Eergency Medicine: A Comprehensive Study Guide, 7th Edition: http://www.accessmedicine.com 101 Complications Diagnostic Peritoneal Lavage • Localized infection • Bleeding / hematoma formation • Damage to intra-abdominal organs 106 Indication / Contraindication 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 Source Undetermined 109 Complications Lateral Canthotomy • • • • • • Bleeding Globe perforation Localized infection Lacrimal gland injury Lateral rectus muscle injury Scleral laceration 110 Indication / Contraindication Pericardiocentesis Indication • Pericardial tamponade • Analysis pericardial effusion Contraindication • Coagulopathy (relative) 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 Recommended Source: Tintinalli JE, et al., Tintinall’s Eergency Medicine: A Comprehensive Study Guide, 7th Edition: http://www.accessmedicine.com 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 Indication / Contraindication 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 catheterover-needle into vein Recommended Source: Tintinalli JE, et al., Tintinall’s Eergency Medicine: A Comprehensive Study Guide, 7th Edition: http://www.accessmedicine.com 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 Indication / Contraindication Anterior / Posterior Nasal Pack Indications • Epistaxis Contraindications • None Recommended Source: Tintinalli JE, et al., Tintinall’s Eergency Medicine: A Comprehensive Study 126 Guide, 7th Edition: http://www.accessmedicine.com 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 0silk suture around pack to divide it into thirds (see picture) 131 Procedure Posterior Nasal Pack Source: Reichman EF, Simon RR: Emergency Medicine Procedures 132 Procedure Posterior Nasal Pack • 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 Recommended Source: Reichman EF, Simon RR: Emergency Medicine Procedures 133 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 Posterior Nasal Balloon • 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 Posterior Nasal Balloon • Inflate balloon with additional 5 to 7 ml of saline • Secure pack by taping to patient's cheek 144 Procedure Posterior Nasal Balloon Source: Reichman EF, Simon RR: Emergency Medicine Procedures 145 Complications Posterior Nasal Pack • • • • • • Nasal septal perforation Sinusitis / otitis media Toxic shock syndrome Aspiration Alar necrosis Hypoxia from intrapulmonary shunting due to stimulation of nasopulmonary reflex 147 Indication / Contraindication Peritonsillar Abscess I&D Indication • Peritonsillar abscess Contraindication • Coagulopathy (relative) 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 External Hemorrhoid Excision 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 External Hemorrhoid Excision • 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 Indication / Contraindication 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 Recommended Source: Reichman EF, Simon RR: Emergency Medicine Procedures 162 Complications Nail Bed Repair • Complete nail loss (expected) • Localized infection • Nail growth abnormalities 165 Indication / Contraindication 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 Source Undetermined 168 Complications Arthrocentesis • Localized infection • Bleeding / hematoma 171 Indication / Contraindication Felon Incision & Drainage Indication • Fluctuant felon Contraindications • Herpes whitlow • Non-fluctuant felon 172 Procedure Felon Incision & Drainage • 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 Felon Incision & Drainage Source Undetermined 174 Complications Felon Incision & Drainage • • • • • • 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 Localized infection 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 Urethrogram & Cystogram Contraindication • Hemodynamic instability • Acute urethritis in patient with low risk • Cystogram contraindicated if urethral injury identified on urethrogram 185 Procedure: Retrograde Urethrogram & Cystogram • 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 Procedure: Retrograde Urethrogram & Cystogram • 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 Procedure: Retrograde Urethrogram & Cystogram • Contrast in bladder with extravasation partial disruption • No extravasation proceed with retrograde cystogram Recommended Source: Reichman EF, Simon RR: Emergency Medicine Procedures 188 Procedure: Retrograde Urethrogram & 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 Procedure: Retrograde Urethrogram & Cystogram • 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 Procedure: Retrograde Urethrogram & Cystogram • Obtain ‘washout’ KUB –Extraperitoneal bladder injury flame-like projection within pelvis possible conservative management –Intraperitoneal bladder injury contrast outlines intraperitoneal organs surgical management Recommended Source: Reichman EF, Simon RR: Emergency Medicine Procedures 192 Complications: Retrograde Urethrogram & Cystogram • 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 Perimortem C-Section • 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 Perimortem C-Section • 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 electrocautery unit to coagulate if available Recommended Source: Reichman EF, Simon RR: Emergency Medicine Procedures 197 Procedure Perimortem C-Section • 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 Perimortem C-Section • 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 Perimortem C-Section • 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 Perimortem C-Section • 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 Perimortem C-Section • 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 Perimortem C-Section • 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 Perimortem C-Section • 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 Perimortem C-Section • Deliver the entire fetal head 212 Procedure Perimortem C-Section • Suction the mouth and nose with a bulb syringe 214 Procedure Perimortem C-Section • 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 Perimortem C-Section • 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 Perimortem C-Section • • • • • 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 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