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St. Luke’s College of Medicine-William H. Quasha Memorial
Batch 2012
ER
Block III
Lecture Trans
Common Emergency Department Procedures
Gloria, MD
22 September 2009
Emergency Medicine Procedures for Clerks
 Intravenous Cannulation
 Urinary Catheterization
 Nasogastric Intubation
 Bag-Valve Mask Ventilations
Intravenous Cannulation
Indications
 Access to venous circulation
 Administer blood products, fluids or drugs
 Obtain samples of blood for laboratory evaluation
Preparation:
 Apply universal precautions (BSI on!)
 Catheter gauge depends on clinical scenario
o G22 – routine maintenance fluids (ateneo blue)
o G18 or G20 – blood product administration (la salle
green)
o G16 – suggested for resuscitation (pink)
Site Selection
Depends on:
 Intended use of the catheter
 Accessibility of the vein given the position of the
patient
 Patient’s age & comfort (esp px’s handedness)
 Urgency of the situation
Best starting place is the hand (most accessible).
 In s/p MRM patients, AVOID arm on the same side
Circulation may be impaired
You want to avoid the arm of the same side for the
simple reason that in MRM there is dissection of the
lymph nodes. Possibleng natamaan ‘yung mga blood
vessels. You are unsure of the drainage of that area.
Your circulation might be impaired.
Equipment Needed
 Gloves
 Eye Protection
 Non-latex Tourniquet
 Antiseptic Solution
 Sterile Gauze
 Saline Flush
 Tape
 Transparent Occlusive dressing
 Catheter of appropriate size
 IV Fluid bag with tubing
 Sharps container
 Topical Anesthetic
Procedure:
1. Insert spiked end of IV tubing into IV bag
2. Pinch drip chamber to fill bulb halfway before
infusing fluid
Krista & Doms
Steps 1 and 2
3. Flush IV tubing
4. Flush saline lock
5. Apply tourniquet 3-4 cm proximal to the insertion
site
6. Cross tourniquet ends & apply tension
7. Tuck middle portion or one end snugly under
opposite end to make a loop
8. Distal portion of tucked end is left free for one-hand
release of tourniquet
9. Prep the insertion site with alcohol
10. Grasp skin & pull taut to apply traction
11. Take catheter between thumb & forefinger in
dominant hand
 Bevel up, Angled 5-30°, aligned parallel to the
vein
12. Puncture vein
13. Once flash is seen, advance catheter several mm
more to ensure it has entered the vein & not just
the wall
14. Occlude vein using the fingers anchoring the vein at
the tip of the catheter
15. Remove needle & connect
 Syringe for phlebotomy
 Saline lock/IV line
ER: Common Emergency Department Procedures
page 1 of 6
St. Luke’s College of Medicine-William H. Quasha Memorial
Batch 2012
16. Release the tourniquet
17. Anchor the device
 Use adhesive tape (1/2 in dia), adhesive up under
the hub of the catheter
 Fold it over like a bow
18. Clear polyurethane dressing can be used with or
instead of tape
19. Secure loose saline lock or IV tubing with tape to
prevent accidental dislodgement
20. Sign & date dressing to assure timely changes
Complications
 Pain
 Bruising
 Bacterial Infection
 Phlebitis
 Extravasation
 Thrombosis
 Nerve Injury
 Air embolism
CDC Recommendations for IV Care:
 Record and date the time of the catheter insertion in
an obvious location near the insertion site
 Do NOT palpate insertion site after skin has been
cleansed with antiseptic
 Palpate insertion site for tenderness daily through an
intact dressing
 Visually inspect the site if the patient reports
tenderness
 Wash hands before and after palpating, inserting,
replacing or dressing any intravascular access site
 Replace dressing when they are damp, loose, or soiled
Urethral Catheterization
Indications
 Bladder drainage in urinary retention
 Instill local intravesical therapy or irrigation to remove
clots from urinary bladder
 Obtain sterile urine samples
 Instill contrast media for imaging procedures
 Measuring residual volumes after voiding
 Urine output monitoring in any critically ill or injured
patient
Absolute Contraindication
 Trauma patient with suspected urethral injury
o Blood at urethral meatus
o Abnormal-feeling or high-riding prostate on rectal
examination
o Penile, scrotal or perineal hematoma
Equipment:
 Povidone iodine
 Sterile cotton balls
 Water-soluble lubrication gel
 Sterile drapes
 Sterile gloves
Krista & Doms
Lecture Trans
 Urethral catheter
 Prefilled 10-mL saline syringe
 Urinometer connected to a collection bag
Female Urethra
 Short (≈4cm) straight tube
 Wide caliber
 Lying on top of the vagina
 Occasionally hidden
Male Urethra
 Approximately 20 cm long
o From external meatus to the bladder neck
 Posterior prostatic urethra is approximately 3.5 cm
long
Procedure: Females
 Non-dominant thumb & index finger are used to
separate the labia & expose the urethral meatus
 Urethra is approached between the double labia
 Clean exposed meatus with antiseptic solution
 Lubricate catheter
 Slowly & gently pass the catheter
 Only half the total length of the catheter has to be
inserted before it is safe to inflate the balloon
 Slowly withdraw catheter until approximation of the
bladder neck precludes further withdrawal
 Secure the catheter using tape
Procedure: Males
 Foreskin should be retracted to its fullest extent
proximal to the glans penis
 Establish sterile field
 Secure penis between the long & ring fingers of the
non-dominant hand
 The non-dominant index finger & thumb will then
manipulate the catheter
 Procedure: Males
 The penis should be held taut & upright
o Downward traction kinks the penis & promotes
urethral folding at the level of the penile suspensory
ligament
 Catheter must be fully inserted to the ballooninflating side arm before it is safe to inflate the
balloon
Nasogastric Intubation
Indications
 Decompression of the gastrointestinal tract
o Small bowel obstruction
o Gastric emptying in intubated pxs to prevent
aspiration
 Administration of oral agents
o activated charcoal, oral radioactive contrast media
 Gastrointestinal hemorrhage
Contraindications
 Maxillofacial trauma
ER: Common Emergency Department Procedures
page 2 of 6
St. Luke’s College of Medicine-William H. Quasha Memorial
Batch 2012
 Esophageal abnormalities
-eg strictures, diverticula  perforation
 Altered mental status and impaired airway defenses
Equipment
 Nasogastric tube
o Adult - 16-18F
o 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
 Glass of water with a straw
 Water-based lubricant
 Toomey syringe, 60 mL
 Tape
 Emesis basin or plastic bag
 Wall suction, set to low intermittent suction
 Suction tubing and container
Procedure
1. Position the patient seated upright.
2. 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.
3. 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.
4. 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
Lecture Trans
8. At this time, ask the patient to sip on the water
through the straw and start to swallow
9. Continue to advance the nasogastric tube until the
distance of the previously estimated length is
reached.
10. 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
11. Ideally, obtain a chest radiograph in order to verify
correct placement, especially if the nasogastric tube
is to be used for medication or food administration
12. 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
Complications
 Patient discomfort
o Generous lubrication, the use of topical anesthetic,
and a gentle technique may reduce the patient’s
level of discomfort
o Throat irritation may be reduced with
administration of anesthetic lozenges (eg,
benzocaine lozenges [Cepacol]) prior to the
procedure
 Epistaxis
o May be prevented by generously lubricating the
tube tip and using a gentle technique
 Respiratory tree intubation
 Esophageal perforation
Bag-Valve Mask Ventilation
Indications
 Respiratory failure (but breathing)
 Complete apnea
 General anesthesia, neuromuscular blocking agents,
narcotic overdose, cerebrovascular accidents,
cardiopulmonary resuscitation
 Other situations in wc spontaneous breathing fails
Contraindications
 RARELY contraindicated
 Caution is advised in:
o Severe facial trauma
o Eye injuries
5. Position the patient sitting upright with the neck
partially flexed
6. Lubricate the distal tip of the nasogastric tube
7. 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) until it reaches the back of
the nasopharynx, where resistance will be met (1020 cm)
Krista & Doms
Equipment
 Face mask
 Bag-valve
 Suction
 Oxygen
Rescue Breathing Using Bag Mask:
Single Rescuer
 Position yourself directly above the patient’s head
 Place mask on victim’s face, using bridge of nose as
guide for correct position
 E-C Clamp Technique
ER: Common Emergency Department Procedures
page 3 of 6
St. Luke’s College of Medicine-William H. Quasha Memorial
Batch 2012
Lecture Trans
 Use thumb & index finger of one hand to make a “C”,
pressing edges of mask to the face
NPA insertion
 Remaining 3 fingers form an “E”
E-C Clamp Technique
 Remaining fingers (forming an “E”) lift angles of the
jaw & open airway
 Squeeze bag to give breaths (1 sec each)
Rescue Breathing Using Bag Mask:
Two Rescuers
 Provides more effective ventilation
 1 rescuer opens airway with head tilt & jaw lift &
opens mask to the face
 2nd rescuer squeezes the bag
1.
2.
3.
4.
Oropharyngeal Airway
 If patient is unconscious & has no gag reflex, oral
airway may be used
Cricoid Pressure (Sellick Maneuver)
 May be applied if 3rd rescuer is present
 Done ONLY in the unconscious patient
 Minimizes gastric inflation
OPA Insertion
1.
Sellick Maneuver:
1. Locate thyroid cartilage with the index finger
2. Move down neck to first cartilage ring (cricoid
cartilage)
3. Apply modest pressure (5-10 lbs) using thumb &
index finger
4. Nasopharyngeal Airway
5. Nasopharyngeal airway may initially establish &
maintain airway patency in the conscious patient
Krista & Doms
2.
ER: Common Emergency Department Procedures
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St. Luke’s College of Medicine-William H. Quasha Memorial
Batch 2012
Lecture Trans
3.
Alternative Methods: OPA procedure
 Insert the airway sideways and rotate it 90O
Oral Pharyngeal Airway
 Definitive airway should be established if there is any
doubt about the patient’s ability to maintain integrity
Advantages of tracheal intubations:
Airway patency
 Protects the airway
 Maintains patency during positioning
 Insertion of OPA using a tongue depressor
Complications
 Corneal abrasions and blindness in the presence of
eye injury
 Soft-tissue injuries, including injuries to the nose and
lips, may result when excessive pressure is applied
Airway Procedures
A. Nasopharyngeal Airway
Control of ventilation
 Ventilation over a long period of time without
intubation can lead to gastric distention and
regurgitation
Advantages of tracheal intubations:
Route for inhalation anesthesia and emergency
medications :
N – Narcan
A – Atropine
V – Valium
E – Epinephrine
L – Lidocaine
Complications of tracheal intubation:
Trauma to the lips, teeth, and soft tissues of the airway.
 Awareness
 Meticulous technique
Bronchial intubation
 Frequent complication
 Auscultation of the chest bilaterally
Airway
 If patient is unconscious & has no gag reflex, oral
airway may be used
Complications of tracheal intubations:
 Laryngospasm
o common when extubation is done when the patient
is in a semiconscious state
o extubation should be done in a relatively deep
anesthesia or when the protective laryngeal reflex
has returned
 Post-intubation hoarseness and sore throat
o Due to mechanical presence of the tracheal tube
Oral Pharyngeal Airway
 Measure
 Confirm patient is unconscious
 Insert, rotate 180 degrees as inserting
Preparation of Equipment
 Assemble pharyngeal airways in assorted sizes
 Inspect laryngoscope for serviceability
o Batteries
1.
2.
3.
4.
5.
Lubricate !
Insert along floor of nasal cavity
If resistance met, use back-and forth motion
Don’t Force – Use other nostril
If patient gags, withdraw slightly
Krista & Doms
ER: Common Emergency Department Procedures
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St. Luke’s College of Medicine-William H. Quasha Memorial
Batch 2012
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o Light bulb
o Blades; curved/straight (Macintosh or Miller)
Selection of laryngoscope blade (preference)
Macintosh is a curved blade whose tip is inserted into
the vallecula (the space between the base of the
tongue and the pharyngeal surface of the epiglottis).
Selection of laryngoscope blade (preference)
Miller is a straight blade that is passed so that the tip
of the blade lies beneath the laryngeal surface of the
epiglottis
o The epiglottis is then lifted to expose the vocal
cords
Tube size
o adult male 8 mm to 9 mm tube
o adult female 7 mm to 8 mm tube
Preparation of Equipment -Inspect endotracheal
tubes
Tube length – extend from the lower incisor to a point
midway between the cricoid cartilage and Louis's
angle (the sternal angle) on the patient
Endotracheal tube cuff
Malleable stylet (should not extend past Murphy's
eye)
Lubrication
Laryngeal sprays
Inspect resuscitator (AMBU bag) for serviceability
 Bag
 Mask
 Intake valve
 Valve body with relief valve
Intubation Technique
 Ventilate with 100 percent oxygen for approximately
1 min
 Position bed height to bring the patient's head to a
mid-abdominal height
 Flex the cervical spine and extend the head at the
atlanto-occipital joint
 Long axis of the oral cavity, pharynx, and trachea lie
almost in a straight line
 Introduce the blade into the right side of the patient's
mouth
 Move the blade posteriorly and toward the midline,
sweeping the tongue to the left and keeping it away
from the visual path with the flange of the blade
 Ensure the lower lip is not being pinched by the lower
incisors and laryngoscope blade
 Advance the laryngoscope until the epiglottis is in
view
 Lift the laryngoscope upward and forward
 Insert the endotracheal tube from the right with its
concave curve facing downward and to the right side
of the patient
 Maneuver the endotracheal tube into the larynx,
midway between the cricoid cartilage and the sternal
angle
Krista & Doms
Lecture Trans
 Inflate the cuff and apply positive pressure ventilation
while the assistant auscultates
 Secure the endotracheal tube in position
 Confirmation of tracheal intubation:
Direct visualization of the ET tube passing through
the vocal cords
CO2 in exhaled gases
Confirmation of tracheal intubation:
 Bilateral breath sounds
 Absence of air movement during epigastric
auscultation
 Confirmation of tracheal intubation: Others
 Condensation (fogging) of water vapor in the tube on
exhalation
 Refilling of reservoir bag during exhalation
 Maintenance of arterial oxygenation
Chest X-ray: the tip of the ET tube should be between
the carina and thoracic arc or approximately at the level
of the aortic arch
Additional notes:
(recall lang. alam nyo na ‘to.)
CPR with Advanced Airway
 Compression rate is about 100 bpm
 1 breath every 6-8 sec
 Avoid hyperventilation
 Do no pause compressions to provide breaths
If the adult patient is not intubated, you would want to
give him how many breaths? 10 to 12 breaths per
minute.
Pag pedia, ilan? How many per minute? 12 to 20.
ER: Common Emergency Department Procedures
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