Manual of common bedside surgical procedures pdf

Suspected cervical spine injury b. Down's syndrome due to incomplete C1C2 ossification and cervical vertebral subluxation c. Previous cervical fusion d. Known cervical spine pathology ankylosing spondylitis, arthritis, rheumatoid arthritis 3.

Anesthesia: None 4. Equipment: None 5. Positioning: Supine 6. TechniqueHead Tilt: a. If any of the contraindications above apply, use jaw thrust only. Tilt head back on atlanto-occipital C1 joint while keeping mouth closed; head remains in neutral position. Lift chin to facilitate elevation and anterior movement of hyoid bone away from pharyngeal wall see Figure 1.

TechniqueJaw Thrust: a. Open mouth slightly; gently depress mentum with thumbs. Grip mandibular rami with fingers, and lift the mandibular teeth over and in front of maxillary teeth see Figure 1. A two-handed technique works best because the elasticity of the mandibular joint capsule and masseter muscle will pull the mandible back into the joint if the grip is relaxed.

Complications and Management: In children under age 5 years, the cervical spine can bow upward with manual maneuvers. Such maneuvers can worsen the obstruction by pushing the posterior pharyngeal wall upward against the tongue and epiglottis. In children, the airway is best maintained by leaving the head in a neutral position. Complete or partial obstructed upper airway b.

Bite block in the unconscious or intubated patient c. Adjunct for oropharyngeal suctioning 2. Contraindications: a. Dental or mandibular fracture b. History or acute episode of reactive airway disease 3. Equipment: a. Plastic or elastomeric flanged oral airway b. Tongue depressor c. Suction apparatus 5. Positioning: Supine or lateral 6.

Technique: a. Open mouth; place tongue blade at base of tongue; draw the tongue anteriorly to lift it off of the pharynx. Place airway in the mouth with the concave side facing the mentum so that the distal end is approximating but not touching the posterior wall of the oropharynx; flange and 12 cm of the shaft of the airway should protrude above the incisors.

Perform the jaw thrust maneuver to lift the tongue off of the pharyngeal wall. Tap the airway down the last 2 cm so that the curve lies beyond the base of the tongue. Alternatively, the airway may be inserted with concave side facing the palate. Insert in mouth until tip is past the uvula no tongue blade required ; rotate to sweep under the tongue from the side. This method of twisting the oral airway in the mouth is not recommended if the patient has poor dentition or oral trauma, because the teeth may be further dislodged or the bleeding increased.

Complications and Management: a. Exacerbation of reactive airway disease Maintain airway with maneuver described in Section A. Retching or vomiting Turn the head to the side and suction. Increased airway obstruction if not properly placed Remove the device and re-insert if needed.

Upper airway obstruction in awake or semicomatose patients b. Dental or oropharyngeal trauma c. Inadequate airway patency after placement of oral airway device 2. Nasal occlusion b. Nasal fractures or basal skull fractures c. Deviated septum d. Coagulopathy e. Cerebrospinal fluid CSF rhinorrhea f. Previous transsphenoidal hypophysectomy g. Previous posterior pharyngeal flap for repair of craniofacial defects h. Pregnancy due to vascular engorgement of the nasal passages after the first trimester 3.

Anesthesia: a. Gauge patency of nares by visual inspection relative size, presence of bleeding or polyps or by exhalation test. Have the patient exhale through nose onto small hand-held mirror or shiny bevel of laryngoscope blade. Relative size of condensation indicates which naris is more patent. Swab lidocaine jelly mixture just inside external edge of naris until local anesthesia occurs.

Gently place successive swabs deeper into naris until three swabs can comfortably be placed simultaneously to the level of the posterior nasal wall. If three cotton swabs can be accommodated, a 7. If swabs are not available, the lidocaine mixture may be syringed directly into the nose.

Cotton swabs b. Graduated sizes of nasal airways generally 6. Phenylephrine e. Positioning: Supine, lateral, or sitting 6. Pass the airway gently into the nose with the concave side facing the hard palate. The airway follows a path through the nose that is parallel to the palate and under the inferior turbinate.

If resistance is met in the posterior pharynx, bend the tube with gentle pressure to proceed down the pharynx; it also may be helpful to rotate the airway 90 counterclockwise and rotate it back to the original position as it makes the bend down the pharynx. If the airway will not pass with moderate pressure, a narrower airway should be used. If the airway still does not advance, withdraw it 2 cm and pass a small suction catheter through it, then push the airway forward, using the catheter as a guide.

If still unsuccessful, the naris can be re-dilated or the other naris can be prepped and used. Epistaxis Pack anterior superficial bleeders per Section H. Consult otolaryngology service for posterior bleeding. Submucosal tunneling Remove device. Patient may require plastic surgical repair.

Spontaneous ventilation absent or inadequate b. Preliminary preoxygenation when intubation is planned c. Short-term oxygenation when ventilation is temporarily compromised 2. Hiatal hernia b. Suspicion of active or passive regurgitation c. Need to avoid head and neck manipulation d. Tracheoesophageal fistula e. Tracheal fracture or laceration f. Facial fractures or trauma g.

Severe disruption of dermal surface h. Full stomach relative 3. None 4. Fitted face mask with collar b. Respiratory or resuscitator Ambu bag c. O2 supply d.

Positioning: Supine, head in anatomic sniffing position 6. Place an oral Section B or nasal Section C airway. Hold the mask in the left hand; the thumb and index finger grip the mask around the collar with the body of the mask fitting into the left palm.

Place the narrow end of the mask on the bridge of the nose, avoiding pressure on the eyes. Lower the body of the mask to the face so the chin section of the mask rests on the alveolar ridge. Seal the contact areas with the midsection of the face by pulling the mandible up into the mask with the curled fingers of the left hand and tilting the mask slightly to the right see Figure 1.

Deliver intermittent breaths with the right hand on the bag. In a spontaneously breathing patient, time the delivered breaths to coincide with the patient's inhalations. In the tachypneic patient, alternate the assisted breaths with spontaneous respirations. Buccal gauze sponges can be placed in the cheeks of an edentulous patient to improve fit to the face.

Care must be taken not to increase airway obstruction; if this occurs, remove sponges immediately. In very difficult mask airways, the mask may be fitted to the face with both hands as an assistant delivers breaths see Figure 1.

Acute gastric distension Requires placement of a nasogastric tube to decompress the stomach b. PO2 decreased from age-appropriate level b. PCO2 increased from baseline c. Change in mental status d.

In the adult patient, respiratory rate fewer than 7 breaths per minute or greater than 40 breaths per minute e. Inability to protect airway f. Anticipated cardiovascular or respiratory collapse sepsis, severe burn, etc. Anticipated bronchoscopic evaluation 2. Oral intubation Tracheal fracture or disruption b.

Nasal intubation Pregnancy due to vascular engorgement of the nasal passages after the first trimester Coagulopathy Nasal occlusion Nasal fracture Deviated septum CSF rhinorrhea Previous transsphenoidal hypophysectomy Previous posterior pharyngeal flap for repair of craniofacial defects 3.

Anesthesia: Frequently, an induction agent and a neuromuscular blocking agent are administered to facilitate intubation; a sedative is commonly given afterward to lessen agitation in the awake, intubated patient. Neuromuscular blocking agents Succinylcholine 1.

Sedatives Diazepam 0. Resuscitation drugs should be available at the bedside: atropine, phenylephrine, ephedrine, and epinephrine. Use topical lidocaine spray to anesthetize the airway when intubation of awake patient is planned.

Rigid laryngoscope blade and handle see Figure 1. Ambu bag and mask c. Suction apparatus e. Styletted endotracheal tubes ETT in varying sizes usually 6.

Positioning: a. Supine with head in sniffing position if patient is already horizontal or unconscious, or if oral intubation is planned b.

May remain sitting for blind nasal intubation if the patient cannot tolerate lying flat 6. TechniqueOral Intubation: a. Check the ETT cuff for leaks by inflating and deflating the balloon with 10 ml of air.

Check the blade and handle to ensure that the light is functioning. Preoxygenate with mask ventilation; have assistant apply cricoid pressure see Figure 1. Remove oral airway. Grasp laryngoscope blade and handle in left hand. Instruct the awake patient to open the mouth as widely as possible. In the unconscious patient, place the thumb and second fingers of the right hand on the right upper and lower molars and open the mouth with a scissor-like motion, subluxating the jaw out of the temporomandibular joint.

Gently place the laryngoscope blade in the right side of the mouth, taking care to avoid damaging the teeth see Figure 1. Move the tongue to one side of the oral cavity while advancing the blade toward the glottic opening see Figure 1.

Position the end of the blade under the epiglottis or in the vallecula, depending on the type of blade used see Figure 1. With the left wrist in an unbroken position, firmly lift the laryngoscope handle toward an imaginary point above the patient's left foot to expose the vocal cords.

It is extremely important to avoid cocking the left wrist backward and levering the blade on the teeth. Pass the styletted tube with the cuff deflated into the right side of the mouth and through the vocal cords; have an assistant remove the stylet as the cuff passes through the vocal cords to avoid damage to the trachea. Place the ETT so that the cuff is just distal to the cords cannot be seen between or above the cords ; inflate the balloon with ml of air and hold the tube firmly in place at the lips.

Place the portable end-tidal CO2 monitor in the breathing circuit between the tube adaptor and the ventilator bag; gently give several breaths. Watch the chest for expansion. Check a minimum of six breaths for measurement of CO2 on the CO2 monitor; this is to ensure that the C O2 returned to the breathing circuit has a pulmonary source and is not insufflated air from the stomach.

Listen for bilateral breath sounds over the chest and for an absence of sounds over the gastric area. If all clinical signs point to intubation of the trachea, the assistant may release the cricoid cartilage when instructed to do so. Tape the tube securely. Carefully place an oral airway, or in an awake patient, place a bite block to avoid obstruction of the tube by biting.

Obtain a chest radiograph to check ETT placement. If more than one intubation attempt is necessary, the patient should have a mask airway re-established between attempts. If the esophagus is intubated inadvertently in a case in which the vocal cords are difficult to visualize , it may be helpful to leave the ETT in place as a marker to avoid repeated esophageal placements. Inadequate mouth-opening is a common mistake and can make laryngoscopy unnecessarily difficult as well as greatly increase the risk of dental damage.

Exposure and visualization of the vocal cords is usually easier with a Miller blade; however, passing the ETT can be more difficult because the view of the cords is sometimes obstructed by the tube as it passes through the oral cavity and supraglottis. Retraction of the right cheek and placing the ETT from the lateral side of the right molars can be helpful.

TechniqueNasal Intubation: a. Check the function of the laryngoscope light source. Nasal intubation is generally done in the awake, spontaneously breathing patient when there is an advantage to avoiding laryngoscopy cervical neck fracture, etc.

Prepare the naris as for a nasal airway. Use nasal airways to dilate the naris; generally the ETT used will be one size smaller than the largest nasal airway that can be comfortably placed.

Coat the end and cuff of an unstyletted tube with viscous lidocaine jelly; if warm saline is available, the tube may first be soaked for 3 minutes and then preformed with a gentle curve about 3 cm from the end to facilitate passage under the epiglottis. Place gently in the nose; advance the tube using the technique described for placing the nasal airway; gently extend the neck if the tube is difficult to pass.

Watch the tube for signs of fogging as the tube approaches the vocal cords; quality of the voice may also change see Figure 1. Ask the patient to breathe deeply, and gently advance the tube through the cords while they are open during inspiration; the patient should immediately lose phonation.

Inflate the cuff, verify position, and secure as for an oral ETT. An oral airway is not necessary. Minor airway damage Inspect for lacerations to tongue, lips, and gums to ensure that any bleeding has stopped. Repair lacerations if necessary.

Dental damage Immediate retrieval of any dislodged teeth is mandatory. Consult the dental or ENT service for further management. Esophageal intubation Decompress the stomach. Major airway trauma Obtain chest radiograph. Perform emergent cricothyroidotomy if needed see Section H.

Consult the ENT service immediately. Airway is completely or partially obstructed b. Alternative to ventilation with bagmask or ETT c. Mask ventilation or endotracheal intubation is difficult 2. History or acute episode of reactive airway disease c. Pharyngeal abscess or obstruction d. Full stomach e. Need for mechanical positive pressure ventilation f. Foreign body in airway 3. Anesthesia: The laryngeal mask airway LMA can be used in the heavily sedated, spontaneously breathing patient or during general anesthesia with or without neuromuscular blockade.

Heavy sedation without neuromuscular blockade Midazolam 0. Resuscitation drugs should be readily availableatropine, phenylephrine, epinephrine. LMA, appropriately sized b. Gauze bite-block d. Tape f. O2 source g.

Fully deflate and smooth out wrinkles in cuff. Lubricate the back of the cuff. With the right hand, open mouth with thumb and second finger on lower and upper incisors, respectively, using a scissor-like motion. Grasp the LMA in left hand, and slide it over the tongue with lubricated back of LMA against the palate into the hypopharynx until resistance is met see Figure 1. Inflate the cuff with ml of air. Examine the patient for bilateral breath sounds, using either spontaneous or mechanical ventilation.

When assured of correct placement, secure LMA to face with tape. Insert gauze bite-block between upper and lower teeth to prevent obstruction of the tube by biting. Dental damage Immediately retrieve any dislodged teeth. Consult dental service for further management. Alternative to direct laryngoscopy b. Difficult conventional intubation 2.

Known anatomical abnormalities in oropharynx or upper airway b. Epiglottitis c. Foreign body in airway d. Upper airway trauma e. Morbid obesity 3. Anesthesia: Endotracheal intubation with a light wand requires general anesthesia with neuromuscular blockade as described in oral and nasal tracheal intubation.

Light wand b. ETT, appropriately sized. Water-soluble lubricant e. Suction apparatus f. Tape 5. Supine b. Head and neck in neutral position in contrast to anatomical sniffing position for direct laryngoscopy 6.

Test the ETT cuff with 10 ml of air, then deflate. Lubricate the length of the light wand with a water-soluble lubricant. Bend the ETT-light wand at the designated location on the proximal end of the light wand into a 90 angle. Standing behind the patient's head, use the nondominant hand to grasp the patient's mandible place the thumb inside the patient's mouth to secure the tongue against the mandible and lift away from the posterior pharynx.

With dominant hand, slide the concave angle of the ETT-light wand over the midline of the tongue into the posterior pharynx. Gently rock the ETT-light wand back and forth along the midline until a discreet glow appears on the neck slightly superior to the sternal notch indicating correct placement of the light source into the glottis.

Stabilize the ETT-light wand in position, retract the stiff internal stylet of the light wand, and advance the ETT-light wand into the trachea. Release the ETT from the light wand by unlocking the adaptor and removing the light wand while firmly holding the ETT in position. When assured of correct placement, secure the ETT to the face with tape. Carefully place an oral airway or bite block in an awake or nonparalyzed patient to avoid obstruction of the ETT by biting.

Obtain chest radiograph to confirm ETT placement. Dental damage As described above b. Disconnection of light source from light wand Ensure correct ETT placement. Consult otolaryngology service for removal of foreign body. Subluxation of cricoarytenoid cartilagerarely occurs if stiff stylet is correctly withdrawn before ETT-light wand is advanced into trachea. As above, ensure correct ETT placement.

Consult ENT service. Extensive orofacial trauma preventing laryngoscopy b. Upper airway obstruction secondary to edema, hemorrhage, or foreign body c.

Unsuccessful endotracheal intubation and need for emergent airway 2. Contraindications: Children under age 12 years. Needle cricothyroidotomy is preferred to avoid damage to cricoid cartilage see next section. Scalpel blade and handle b. Tracheal spreader c. Sterile prep solution, gloves, and towels e. Ambu bag and oxygen f. Hemostats 5. Positioning: Supine, with neck in neutral position. In trauma patients, a cervical spine injury must be assumed until radiological and clinical examination have excluded this diagnosis.

Sterile prep and drape the neck. Make a longitudinal 3- to 4-cm incision in the midline of the neck from the thyroid cartilage down past the cricothyroid membrane see Figure 1. Palpate the cricothyroid membrane below the thyroid cartilage in the midline. Stabilize the thyroid cartilage with the non-dominant hand and make a transverse incision approximately 2 cm through the cricothyroid membrane with a scalpel see Figure 1.

Insert tracheal spreader into the trachea and gently spread. If a tracheal spreader is not available, insert the handle of the scalpel into the trachea and turn the scalpel 90 to enlarge the opening in the cricothyroid membrane. Insert the tracheostomy tube and remove tracheal spreader. Auscultate the chest to confirm equal and clear breath sounds bilaterally. Control superficial bleeding either with direct pressure or with hemostats and 3-O silk ligatures if necessary.

Bleeding Usually superficial and self-limited Control with direct pressure or sutures. Esophageal injury Can occur if scalpel penetrates the posterior trachea. Keep incision superficial, stopping once cricothyroid membrane is incised. If esophageal injury is suspected, obtain surgical consultation. However, needle cricothyroidotomy can only provide adequate ventilation for only minutes. Unsuccessful endotracheal intubation d. Preferred method of obtaining emergent airway in children under age 12 years 2.

Contraindications: None 3. Y connector d. Oxygen supply with flow meter e. Oxygen tubing f. Sterile prep solution and gloves 5. In trauma patients a cervical spine injury must be assumed until radiological and clinical examination have excluded this diagnosis.

Sterile prep and drape the neck see Figure 1. Attach a 5-ml syringe to a to gauge angiographic catheter, and puncture the skin in the midline over the cricothyroid membrane. Direct catheter inferiorly at 45 to the skin see Figure 1. Advance the catheter while aspirating. Stop once air is aspirated, which confirms position within the tracheal lumen.

Advance the catheter over the needle down the distal trachea, and withdraw the needle. Attach a 3. Attach a Y connector to oxygen tubing and to pediatric ETT adaptor. Provide ventilation by intermittently placing thumb over open end of Y connector for 1 second and off for 4 seconds. Esophageal injury Can occur if angiographic catheter penetrates the posterior trachea.

Stop advancing catheter once air is aspirated. Indications: Persistent nasal bleeding despite simple first aid measures. Cocaine solution 2.

Headlight b. Forceps c. Suction catheter d. Silver nitrate sticks e. Lubricated ribbon gauze 0. Foley catheter g. Syringe, 10 ml 5. Positioning: Sitting 6. Assess patient's general condition to determine effect of blood loss already sustained. Any patient who appears to be in shock should have a baseline hemoglobin, platelet count, prothrombin time, partial thromboplastin time, and cross-matching of blood while resuscitation with crystalloid fluid is underway.

In contrast, if the patient is hypertensive, reassurance and antihypertensives should be administered to control the BP. Stable patients should then be assessed sitting in a wellilluminated area where suction is available. Initially have patient pinch nostrils between finger and thumb continuously for 10 minutes. Apply ice pack to bridge of nose. If bleeding persists, remove blood clots from nose either with forceps or suction catheter.

This will anesthetize the nasal mucosa and vasoconstrict blood vessels. Carefully inspect the nasal mucosa, searching for a bleeding point. If bleeding has stopped, the patient should be observed for 12 hours to ensure that no further treatment is required. If bleeding persists from a visible site, it should be chemically cauterized. If bleeding continues without an identifiable source, nasal packing will be required.

Insert one end of the lubricated ribbon gauze 0. Introduce folds lengthwise from floor to roof of the nasal cavity until it is firmly filled. Generally, cm of ribbon gauze can be inserted without difficulty see Figure 1. Pack may be left in place for 23 days with prophylactic oral antibiotics and ENT follow-up to remove pack.

If bleeding persists, a posterior nasal pack will be required. Remove anterior nasal pack and insert a Foley catheter along the floor of the nostril until the tip of the catheter reaches the nasopharynx see Figure 1. Inflate balloon with 10 ml of air, and withdraw catheter until balloon blocks posterior choana. Tape catheter firmly to nostril to prevent balloon from falling into oropharynx.

Patient with posterior nasal packs will require hospitalization and prophylactic antibiotics. Persistent or recurrent bleeding If anterior and posterior packs fail, surgical ligation of the maxillary and anterior ethmoidal arteries will be required.

Obtain ENT consultation. Infection Can occur with obstruction of the eustachian tube Prophylactic antibiotics should be administered to patients with nasal packs, along with instructions to seek medical care immediately if fever or discharge occur. If infection is suspected, remove pack immediately.

Hypoxemia May occur, because nasal packs compromise respiration Elderly patients or those with respiratory problems should be admitted for observation. Although this procedure is routine for most surgical house officers, central line insertion should be approached with caution and adequate preparation.

Patient positioning is crucial to success. Informed consent should be obtained prior to performing elective access procedures, and bleeding parameters i. Central venous pressure CVP monitoring b.

Total parenteral nutrition TPN c. Long-term infusion of drugs d. Inotropic agents e. Poor peripheral access 2. Venous thrombosis b.

Untreated sepsis d. For the standard infraclavicular approach: need for hemodialysis access, because there is an association with subclavian vein stenosis 3. Sterile prep solution b. Mask, sterile gown, gloves, towels, dressings c. Shoulder roll towel f. Appropriate catheters and dilator g. Intravenous IV tubing and flush h. Scalpel k. Positioning: Supine, in Trendelenburg. Place a towel roll between the scapulas underneath the thoracic vertebrae as shown. Allow the patient's shoulders to fall down and back or have an assistant apply gentle traction to the ipsilateral arm , and have the patient's head turned away from the side of the line placement see Figure 2.

TechniqueStandard Infraclavicular Approach: a. In a sterile fashion, dress with mask and gown and prep and drape the patient's left or right subclavian area. It is often useful to prep the ipsilateral neck into the sterile field in case it is necessary to attempt an internal jugular vein approach. Place an index finger at the sternal notch and the thumb at the intersection of the clavicle and first rib see Figure 2. Use a gauge needle to anesthetize the periosteum of the clavicle 23 cm lateral to the first rib intersection.

Alternative to ventilation with bag-mask or ETT c. Mask ventilation or endotracheal intubation is difficult P. Pharyngeal abscess or obstruction d.

Full stomach e. Need for mechanical positive pressure ventilation f. Foreign body in airway 3. Anesthesia: The laryngeal mask airway LMA can be used in the heavily sedated, spontaneously breathing patient or during general anesthesia with or without neuromuscular blockade. Heavy sedation without neuromuscular blockade Midazolam 0. LMA, appropriately sized b. Gauze bite-block d. Tape f. O 2 source g. Fully deflate and smooth out wrinkles in cuff. Lubricate the back of the cuff. With the right hand, open mouth with thumb and second finger on lower and upper incisors, respectively, using a scissor-like motion.

Grasp the LMA in left hand, and slide it over the tongue with lubricated back of LMA against the palate into the hypopharynx until resistance is met see Figure 1. Examine the patient for bilateral breath sounds, using either spontaneous or mechanical ventilation. When assured of correct placement, secure LMA to face with tape. Insert gauze bite-block between upper and lower teeth to prevent obstruction of the tube by biting.

Dental damage Immediately retrieve any dislodged teeth. Consult dental service for further management. Alternative to direct laryngoscopy b. Difficult conventional intubation 2. Known anatomical abnormalities in oropharynx or upper airway b. Epiglottitis c. Foreign body in airway d. Upper airway trauma e. Morbid obesity 3. Anesthesia: Endotracheal intubation with a light wand requires general anesthesia with neuromuscular blockade as described in oral and nasal tracheal intubation.

Light wand b. ETT, appropriately sized c. Water-soluble lubricant e. Suction apparatus f. Tape 5. Supine b. Test the ETT cuff with 10 ml of air, then deflate. Lubricate the length of the light wand with a water-soluble lubricant.

Standing behind the patient's head, use the nondominant hand to grasp the patient's mandible place the thumb inside the patient's mouth to secure the tongue against the mandible and lift away from the posterior pharynx. With dominant hand, slide the concave angle of the ETT-light wand over the midline of the tongue into the posterior pharynx.

Gently rock the ETT-light wand back and forth along the midline until a discreet glow appears on the neck slightly superior to the sternal notch indicating correct placement of the light source into the glottis. Stabilize the ETT-light wand in position, retract the stiff internal stylet of the light wand, and advance the ETT-light wand into the trachea.

Release the ETT from the light wand by unlocking the adaptor and removing the light wand while firmly holding the ETT in position. When assured of correct placement, secure the ETT to the P. Carefully place an oral airway or bite block in an awake or nonparalyzed patient to avoid obstruction of the ETT by biting. Obtain chest radiograph to confirm ETT placement.

Dental damage As described above P. Disconnection of light source from light wand Ensure correct ETT placement. Consult otolaryngology service for removal of foreign body. As above, ensure correct ETT placement. Consult ENT service. Extensive orofacial trauma preventing laryngoscopy b. Upper airway obstruction secondary to edema, hemorrhage, or foreign body c. Unsuccessful endotracheal intubation and need for emergent airway 2.

Contraindications: Children under age 12 years. Needle cricothyroidotomy is preferred to avoid damage to cricoid cartilage see next section. Scalpel blade and handle b. Tracheal spreader c. Sterile prep solution, gloves, and towels e. Ambu bag and oxygen f. Hemostats 5. Positioning: Supine, with neck in neutral position.

In trauma patients, a cervical spine injury must be assumed until radiological and clinical examination have excluded this diagnosis. Sterile prep and drape the neck. Make a longitudinal 3- to 4-cm incision in the midline of the neck from the thyroid cartilage down past the cricothyroid membrane see Figure 1. Palpate the cricothyroid membrane below the thyroid cartilage in the midline.

Stabilize the thyroid cartilage with the non- dominant hand and make a transverse incision approximately 2 cm through the cricothyroid membrane with a scalpel see Figure 1. Insert tracheal spreader into the trachea and gently spread. Insert the tracheostomy tube and remove tracheal spreader.

Auscultate the chest to confirm equal and clear breath sounds bilaterally. Control superficial bleeding either with direct pressure or with hemostats and 3-O silk ligatures if necessary. Esophageal injury Can occur if scalpel penetrates the posterior trachea.

Keep incision superficial, stopping once cricothyroid membrane is incised. If esophageal injury is suspected, obtain surgical consultation. Unsuccessful endotracheal intubation d. Preferred method of obtaining emergent airway in children under age 12 years 2. Contraindications: None 3. Y connector d. Oxygen supply with flow meter e.

Sterile prep solution and gloves 5. In trauma patients a cervical spine injury must be assumed until radiological and clinical examination have excluded this diagnosis. Sterile prep and drape the neck see Figure 1. Attach a 5-ml syringe to a to gauge angiographic P. Advance the catheter while aspirating. Stop once air is aspirated, which confirms position within the tracheal lumen.

Advance the catheter over the needle down the distal trachea, and withdraw the needle. Attach a 3. Attach a Y connector to oxygen tubing and to pediatric ETT adaptor. Provide ventilation by intermittently placing thumb over open end of Y connector for 1 second and off for 4 seconds. Bleeding Usually superficial and self-limited Control with direct pressure or sutures. Esophageal injury Can occur if angiographic catheter penetrates the posterior trachea.

Indications: Persistent nasal bleeding despite simple first aid measures. Cocaine solution 2. Headlight b. Forceps c. Suction catheter d. Silver nitrate sticks P. Lubricated ribbon gauze 0.

Foley catheter g. Syringe, 10 ml 5. Positioning: Sitting 6. Assess patient's general condition to determine effect of blood loss already sustained. Then you can start reading Kindle books on your smartphone, tablet, or computer no Kindle device required. Bedside Obstetrics Amp Gynaecology. This manual also for Gbhd Please, tick the box below to get your link For a book that conspicuously describes itself as a "pocket sized manual", the is curiously large.

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