new emergency procedure

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EmergencyProcedures



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PREFACE

The Emergency Procedures is written by the fourth year medical students of

University Malaya .The book has been prepared during our A&E posting .Procedures that

are usually done in A&E department has been focused and are written in a simple and

understandable way .With the advent of the internet, a direct link to the video has been

added to help the reader to get a better understanding of the procedures. We hope that

this book will be a useful guide for our juniors going through Emergency Medicine posting in

future.

We wish to thank Dr Rishya Manikam (Head of Department of A&E at UMMC) who

has helped in many ways for guiding the preparation of this book. Despite his tight and busy

schedule, he has taken the initiative to come up with a simple and targeted guide for 4th

year medical student to grasp the important knowledge throughout the limited 2 weeks

posting. His understanding and personal experience as a medical student during his younger

days inspired him to come out with his own module that hopefully will benefit the students

fruitfully during the short course of posting. In the near future, he plans to make this book

available electronically so that students can assess the knowledge anywhere, anytime

whether on the Iphone, Ipad or laptop. Medical students worked as a group; sacrificing their

scarce leisure time to compile this book. During the course of completing this book, we

faced many difficulties owing to the fact that we are busy with our classes and also on-calls

in A&E up to the wee hours of the morning. However, with the help of Dr. Rishya Manikam

and the rest of his team, we managed to overcome the obstacles and finally came up with

this book.

On behalf of the 2008/2013 batch, we hope the incoming juniors in future will

continue to improve and add-on to this book for the benefits and betterment of the

emergency medicine practice amongst students. We also sincerely hope that our juniors will

take the trouble to regularly update and review on the best emergency managementoptions available during their time of posting.

Thank you very much.

Editor

NOV 2011 TOK ERN LAI



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CONTENTS

1. Oxygen mask by Tok Ern Lai…………………………………………………………………………………………………………………………………4

2. Blood taking by Leong Ya Shan………………………………………………………………………………………………………………………….….6

3. Taking vital signs by Chiew Ai Wen………………………………………………………………………………………………………………..….8

4. AED by Mohd Luqman bin Sahar………………………………………………………………………………………………………………………..………11

5. Cervical collar by Yvonne Ling…………………………………………………………………………………………………………………………....13

6. Nebulizers by Tan Chen Long…………………………………………………………………………………………………………………………….....15

7. Urinary Catheter by Alfred Tan…………………………………………………………………………………………………………………….…..16

8. Helmet removal by Taye Zhi Ling……………………………………………………………………………………………………………………….18

9. Immobilisation by Taye Zhi Ling………………………………………………………………………………………………………………………..…19

10. Suturing by Raechell ………………………………………………………………………………………………………………………………………………...21

11. Arterial blood gas Maleenawati Letchumanan……………………………………………………………………………………………….….23

12. Paracentesis by Fidraus Hariri…………………………………………………………………………………………………………………………….….25

13. Chest tube insertion by Muhammad Syafiq…………………………………………………………………………………………………..…28

14. Nasogastric tube by Zuliyasmin binti Zulkifli……………………………………………………………………………………………………..…31

15. CPR by Koh Wei Jun……………………………………………………………………………………………………………………………………………………….33

16. Intubation by Nur Syazwani Jamhuri…………………………………………………………………………………………………………………….…35

17. IV line by Al Malek Hussien………………………………………………………………………………………………………………………………………….39

18. ECG by Hidayat Shariff…………………………………………………………………………………………………………………………………………………41



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Oxygen Mask

Purpose

Deliver low to moderate levels of oxygen to relieve hypoxia.

Indication

Cardiac and respiratory arrest

Hypoxaemia with PaCO2<5.3 kPa

Hypotension (systolic blood pressure <100 mm Hg)

Low cardiac output and metabolic acidosis (bicarbonate<18 mmol/l)

Respiratory distress (respiratory rate >24/min)

Types

Types O2

concentrations(%)

O2 flow rates(L/min)

1. Nasal prong

24-44 1-6

2. Simple oxygenmask 40-60 10

3. Partial

rebreather

mask50-70 5-15

4. Nonrebreather

mask 80-90 10-15

5. Venturi mask

24-50 4-10



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Precedures

1. Explain procedure to patient and review safety precautions necessary when

oxygen is in use. (Don’t smoke)

2. Perform hand hygiene.

3. Attach face mask to oxygen setup with humidification. Start flow of oxygen to fill bag

before placing mask over patient’s nose and mouth.

4. Position face mask over patient’s nose and mouth. Adjust it with the elastic strap so

mask fits snugly but comfortable on face.

5. Use gauze pads to reduce irrigation on patient’s ears and scalp.

6.

Perform hand hygiene.

7. Remove mask and dry skin every 2 to 3 hours if oxygen is running continuously.

8. Assess and chart patient’s response to therapy.

Complication

Discomfort

Dryness of the skin cause by O2

Reference

http://www.youtube.com/watch?v=UXCckItO7ys



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EQUIPMENT REQUIRED USING THE VACUTAINER SYSTEM

A Tourniquet which should be applied at a pressure which is high enough to impede venousdistension but not restrict arterial. This allows blood to flow into the arm but stops it from leaving,causing the veins to fill with blood and become prominent.

A sterile alcohol swab to clean the puncture site. The area must be allowed to dry first otherwise thealcohol base may seep into the puncture site causing the patient discomfort. Research has shownthat although cleansing of the skin reduces the number of bacteria present on its surface, it is notnecessary to prevent infection prior to parenteral procedures

A vacutainer system sample bottle holder

An appropriately sized needle designed for use with the vacuum system

Cotton wool to apply to the puncture site following the procedure

A sterile plaster or hypoallergenic tape to secure the cotton wool

Specimen bottles and requisition form correctly filled in with the patients details, Diagnosis, G.Ps /Consultants details and signed.

Sharps disposal bin for the safe disposal of the specimen tube holder and needle

PREPARATIONS PRIOR TO CARRYING OUT THE PROCEDURE

It is important that patient distress and inconvenience is minimised, and it mustalways be remembered that painful venepuncture and unsightly bruising can leavea lasting impression. Careful and unhurried preparation will all help to alley the

patients fears/anxieties

With the patient seated, begin by explaining the procedure to him/her, answeringany questions they may have and ensuring that the patient has given their verbalconsent for you to carry out the procedure.

The patient should be asked whether or not they have had any blood taken in thepast, and when (as any recent sites should be avoided). Whether they are awareof any particular problems encountered and of the best sites available.

After checking that the light is adequate and all the written information has beenobtained, the procedure can be carried out.

CARRYING OUT THE PROCEDURE

After washing her hands, the practitioner should apply the tourniquet to thepatients upper arm. If the arm is placed in a dependent position and the patientasked to clench and release their fist this will help to increase the prominence ofthe veins.

we should then palpate the area with our index and middle finger to select a veinand also to allow us to distinguish such structures as arteries, tendons etc. Theselected vein should be firm and bouncy.

The needle should be inserted along the length of the vein at an angle of



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approximately 30 degrees. The tip of the needle should be inserted through theskin into the vein in one continuous movement with the bevel of the needle facingupwards.Check for back flow of blood into needle. Once the needle is in thecorrect position, the required vacuumed bottles are then attached will each thendraw up the required amount of blood for each test.

Once the required amount of blood has been collected into the bottles, and the lastbottle detached from the needle, the tourniquet should then be released and acotton wool ball placed over the point of entry. At the point the needle should thenbe removed and discarded. DO NOT recap needle. pressure should be appliedover the entry site for approximately 2 minutes to stop any further bleeding. Thearm should be kept straight and not bent, as the latter enlarges the entry holecausing more bleeding and bruising. A sticking plaster or hypo-allergenic dressingmay then be a applied to the site once the bleeding has stopped.

NB. Care should be taken with patients who have a history of bleedingdisorders or who have been taking warfarin or other anti-coagulants, as thismay increase the time it takes for the bleeding to stop.

IMPORTANT POINTS TO REMEMBER

If the tourniquet has been on for longer that 2 minutes prior to insertionof the needle, then it should be released to allow blood to return to thehand before reapplying, and attempting the procedure again.

If a venous valve is entered during the procedure the patient willexperience sudden, acute pain. The procedure should be thendiscontinued immediately.

If after 2 attempts the procedure has been unsuccessful, thenassistance should be sought from a colleague.

The Patient should be observed throughout the procedure for signs ofdizziness or fainting.

BE AWARE, the Brachial Artery is sited near the sites mostcommonly used for venepuncture.Procedure is the same by using a syringe.

http://www.youtube.com/watch?v=_8ZsqXFqvQM&feature=related

http://www.youtube.com/watch?v=9pIWn6i1VZs









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Taking Vital Signs

Measurement of Temperature (Digital Thermometer, Mercury Thermometer )

For Oral Temperature

1. Turn on the thermometer and wait for the display to flash indicating that it is ready.Shake the thermometer using a vigorous wrist movement until the mercury reading is

below 35 degree celcius.

2. Do not hold the thermometer at the measurement portion

3. Put the thermometer in the thermometer sheath.

4. Check patient has not taken any warm/hot drinks/food at least 15 mins prior to themeasurement. (if yes, give water or measure axillary temperature or wait)

5. Instruct the patient to open his/her mouth and lift his/her tongue and insert thethermometer as far back as possible under the tongue

6. The patient is to close his/her lips tightly.

7. Wait for completion beeps. Leave the thermometer in place for at least 1min but no longer than 2mins.

8. Remove the sheath, hold the thermometer horizontally at your eye level.

9. Read the display and record the temperature reading and switch off the

thermometer.

Read and record the temperature reading.10. Clean the thermometer with soapy water or alcohol swab.

For Axillary Temperature

1. Start with steps 1-3 above.

2. Ensure the axilla is dry.

3. Place the measurement end of the thermometer high in the axilla, against the torso and

perpendicular to the length of the body.

4. Use the patient’s arm to hold the thermometer in place.

5. Leave the thermometer and wait for completion beeps.

Leave the thermometer completely covered for 3mins, but not longer then 5mins.

6. Read and record the temperature reading.

For Rectal Temperature

1. Start with steps 1-3 above.

2. Ensure privacy and keep patient comfortable.

3. Position the patient in the left lateral position. 4. Apply lubricant to sheathed thermometer and insert into anus.

5. Leave the thermometer and wait for completion beeps. Leave the thermometer for 2-3mins then record the reading.

Normal Temperature Range Armpit: 34.7 – 37.3 C (94.5 – 99.1 F)

Mouth: 35.5 – 37.5 C (95.9 – 99.5 F)

Ear: 35.8 –

38 C (96.4 –

100.4 F) Rectum: 36.6 – 38 C (97.9 – 100.4 F)



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Measurement of Pulse Rate

1. Place your index and middle fingers over the radial artery at the wrist, or the brachial

artery at the ante-cubital fossa or the carotid artery in the neck.2. Count the number of beats over 60 seconds.

3. Describe the rate, rhythm, strength and characteristic of the pulse.

4. Consider comparing pulses on the right with those on the left (radi0-radial delay).

5. Compare radial pulse and femoral pulse for radio-femoral delay.

Normal Heart Rates by Age Group at Rest

Newborns 100-160 bpm

Infants 80-150 bpm

Preschool children 80-130 bpm

Older children 70 – 100 bpm

Adults 60 –

100 bpm

Measurement of Respiratory Rate

1. Place 2 fingers on the patient’s radial artery.

2. While still palpating the patient’s pulse, observe the patient’s breathing (by observingthe patient’s chest wall movement) (if can’t see chest wall movement, put your hand

at the back of patient).

3. Ensure that the patient is unaware of the actual observation.

4. Count respirations for one minute.5. Record the result.

Normal Respiratory Rate Newborns 30-50 breaths per minute

Infants 20-40 breaths per minute

Preschool children 20-30 breaths per minute

Older children 16-25 breaths per minute

Adults 12- 20 breaths per minute

Measurement of Blood Pressure

1. The patient should be seated with their arm resting on a table so the brachial srtery is

level with the heart (4th

intercostals space at the sternum).

2. Ensure no tight clothing is constricting the arm.3. Select the blood pressure cuff which is long enough to nearly encircle the arm.

4. Select the blood pressure cuff of appropriate width (2/3 of the length of the upper

arm).

5. Place the centre of the cuff’s bladder medially over the brachial artery (don’t use

thumb the locate the brachial artery).

6. The cuff should be positioned so that the lower edge is about 2cm above the

elbow.

7. Wrap the cuff snugly around the patient’s upper arm.

8. Check that the mercury column of the manometer is vertical.

9. Close the valve on the pump tubing.



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10. Palpate the brachial artery or the radial artery.

11. Inflate the cuff until the pulse disappear and inflate to a further 20mmHg.

12. Deflate the cuff at a rate of 1-2mmHg per second and the pressure at which the pulse

is palpable is the estimated systolic blood pressure.

13. Deflate till 0mmHg immediately.14. The bell of the stethoscope is placed medially in the ante-cubital fossa, over the

brachial artery. The stethoscope should not be placed under the cuff.

15. Inflate the cuff to 20mmHg above the estimated systolic blood pressure reading that

you made.

16. The valve on the pump is loosened slowly to allow the pressure of the

sphygmomanometer cuff to decrease slowly at about 1-2mmHg/sec.

17. The scale should be read at eye level.

18. Record the level at which you first hear the pulse (first Korotkoff sound = systolic) to

the nearest 2mmHg.

19. Continue allowing the pressure to decrease and record the disappearance of sound

(fifth Korotkoff sound = diastolic) to the nearest 2mmHg.

20. Record whether patient was standing, sitting or lying during BP measurement and

which limb is used.

http://www.youtube.com/watch?v=q4A1uLNzNOc&feature=related

By Chiew Ai Wen






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AUTOMATED EXTERNAL DEFIBRILLATOR

Portable electronic device that can audibly prompt and deliver an electric shock that

will disrupt or stop the heart's dysarhythmic electrical activity.

Treat sudden cardiac arrest (SCA).

PURPOSE

To analyze a heart rhythm

Identify shockable or nonshockable heart rhythms

Guide an AED operator to initiate defibrillation

Delivers an electric shock which is will discharge all electrical

activity of cardiac to stop the useless quivering of the heart.

INDICATION

Adult and children 1 year old and above that are:

Unresponsive

Non breathing

Pulseless

* AED not recommended for infant less under 1 year old.

CONTRAINDICATION

Present of pulse

Conscious patient Touching patient

Wet patient

Implanted defibrillator

SAFETY CONSIDERATION

No metal

No water

Remove medication patches

At least 1 inch away from pacemaker and implanted defibrillator

Remove excessive chest hair Remove electrical device

LANDMARKS FOR ELECTRODE PLACEMENT

Adults :

Upper : right sternal border directly below the clavicle

Lower : left midaxillary line 5th

-6th

intercostal space with top

margin below the axilla.

SCA

Condition in which the heart

suddenly and unexpectedly

stops beating.

Most common cause is

ventricular fibrillation and

ventricular tachycardia.

Sign and Symptoms

Fainting

No pulse*Palpitation

*SOB

*Chest pain

*Dizziness

*within 1 hour before fainting

Shockable rhythm

Ventricular fibrillation

Ventricular tachycardia

Nonshockable rhythm

Normal sinus

Pulseless electrical activity(PEA)

Asystole

Sign of shock has been

delivered

Arching of the back

Brief straightening of arm

*muscular contractions reduce

with each shock

*no contractions noted in

patient that already arrest for

prolonged period.



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Small child :

Anterior : one pad over sternum between nipples Posterior : one pad between shoulders blade

Large child :

Anterior and posterior as above

Anterior and anterior- pads must not toucha. Right pad – wrap over child’s shoulder

b. Left pad – left anterior to cover midclavicular and

midaxillary line

PROGNOSIS AFTER SHOCK DELIVERED

Pulse present + breathing- place patient in recovery room

Pulse present w/o breathing- ventilate patient

No pulse + AED indicates “no shock”- continue CPR

No pulse + AED indicates “shock”- clear and follow voice prompt

EQUIPMENT

Following supplies are maintained in each AED unit :

1. One AED

2. One user’s guide

3. Two sets of electrodes4. One installed battery and one spare

5. One installed PC data card

6. One carrying case

7. One mouth barrier device

8. One pair of scissors

9. Two sets of gloves

10. One razor

11. 4×4 gauze

Normal sinus

Ventricular fibrillation

Ventricular tachycardia

PEA (electrical activity normal

but patient cardiac muscle

problem or severe

hypovolemia)

Asystole

Artifact (loose leads or patient

move)



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CERVICAL COLLAR

CERVICAL COLLAR

A cervical collar (also neck brace) is an orthopaedic medical device used to support a patient's neck and head.

It is also used by emergency personnel for victims of traumatic head or neck injuries, and can be used to treatchronic medical conditions.

INDICATIONS

Neck Extension Injuries (Whiplash)

Cervical Spondylitis

Cervical Spondylosis

R/A & O/A Cervical Spine

Herniated Cervical Disc

INSTRUCTION

1. Size the collar

-Use your fingers to size by putting your hand as shown with the small finger on the

trapezium and count your fingers to jaw line.

2. Put your hand on the side of the collar, your small finger to the bottom edge, and the

correct number of fingers to the marker pin.

3. Get some one to support the head so there is no movement while it is fitted. Always

explain to the patient what you are doing.

4. Immobilisation can be constructed from several different materials. It needs head blocks and

sufficient straps to make it effective

TYPES

There are four types of cervical collar :

1. Aspen Collar

2. Miami-J Collar3. Soft Foam Collar

4. Philadelphia Collar

1 2 3 4



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ALL CERVICAL COLLARS:

1. Must be worn moderately snug to limit motion.

2. Must be worn according to specifics outlined above based on type of collar used.

3. May be washed and/or liners may be changed.

4. Must be kept clean and dry to protect skin integrity.

5. Duration of time wearing the collar and amount of time during the day

wearing the collar are always patient specific and will be determined by your physician.

COMPLICATIONS

Development of skin pressure points and ulcer formation

Possible delay in weaning from ventilator

Potential to exposure for blood borne disease

REFERENCES:

1.http://www.med.umich.edu/op/Patient%20Education%20Forms/5A/Cervical%20Collars.pdf

2.video:

http://www.youtube.com/watch?v=rkDTnFOic9w&feature=autoplay&list=ULknAMhmmg5gU&lf=mf

u_in_order&playnext=1 (with immobilisation)

3.video: http://www.youtube.com/watch?v=knAMhmmg5gU&feature=mfu_in_order&list=UL

http://www.med.umich.edu/op/Patient%20Education%20Forms/5A/Cervical%20Collars.pdf



http://www.youtube.com/watch?v=rkDTnFOic9w&feature=autoplay&list=ULknAMhmmg5gU&lf=mfu_in_order&playnext=1



http://www.youtube.com/watch?v=knAMhmmg5gU&feature=mfu_in_order&list=UL









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Nebulizers

Tan Chen Long

Aim

- deliver a therapeutic dose

of desired drug as an aerosol

in the form of respirable

particles within a fairly short

period of time, usually 5-10

minutes.

Types

1) Jet nebulizers (most common): a nebulizing chamber 2) Ultrasonic nebulizers: self-contained electrical

in which an aerosol is generated with a flow of gas devices in which an aerosol is generated by vibrating

provided either by an electrical compressor or fluid placed within them; nebulize larger volumes of

compressed gas (air or oxygen). fluid& are quiet.

Indications

1) Most common: emergency treatment of

asthma and exacerbations of COPD.

2) Less frequently:

-long term treatment of chronic air flow

obstruction with bronchodilators.-prophylactic drug tx- e.g. corticosteroids in

asthma.

-antimicrobial tx in cystic fibrosis,

bronchiectasis, AIDS.

-symptom relief in palliative care

Drugs for nebulization

1) Bronchodilators: β agonists (salbutamol,

terbutaline); anticholinergics ( ipratropium

bromide).

2) Steroids: budesonide

3) Antibiotics: colistin& gentamicin for cystic fibrosis4) Pentamidine: prophylaxis for Pneumocustis carinii

pneumonia in HIV positive patients.

5) Lignocaine: in terminal care to relieve cough.

N.B. Water should not be used as it may cause

bronchoconstriction when nebulized.

Method of inhalation

-Patient should sit upright or in a

chair

-Take normal steady breaths (tidal

breathing)

-Not to talk during nebulization

-Keep the nebulizer upright

Demonstration of nebulizer use:

http://www.youtube.com/watch?v=svG5S2wn4xQ






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Urinary catheterization

Introduction

Urinary catheterization or Foley catheterization as it is commonly referred to be an invasive

procedure. It involves introducing a plastic or rubber tube into the urethra then advancing thetube into the bladder. Once in the bladder the catheter provides for a continuous flow of urine.

Indications for urinary catheterizations are:

Collection of sterile urine sample.

Provide relief of discomfort from bladder distention.

Decompression of the bladder.

Measure residual urine.

Management of patients with spinal cord injury, neuromuscular degeneration, or

incompetent bladders.

Contraindications are:

Blood at urethral opening.

Injury to genitalia or urethra

Pelvic injuries

Risks associated with catheterization include:

Urethral trauma and bleeding from inappropriate catheter size or use of force.

Urinary tract infections related to poor sterile technique or long-term catheterization.

Bladder spasms and pain

Equipment:

Sterile gloves, Cleansing solution, Cotton swabs, Forceps, Sterile water, Foley catheter, Syringe,Lubricant Collection bag and tubing

Sizes of catheters:

Diameters:

5Fr, 6fr, 8fr 10fr, 12fr, 14fr, 16fr, 18fr, 20fr, 22fr, 24fr, 26fr.

The higher the number the larger the diameter of the catheter.

1Fr. = 3mm (i.e. a 24fr. catheter is 8mm in diameter)

Pediatric catheterization:

Size- 5, 6, 8, 10Fr. or smaller depending on the size of the urethra and age of child.

Male catheterization:

16Fr. or 18Fr. catheter is typically used for most men, as they are more rigid and often easier

to insert past the prostate.



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Female Catheterization:

12fr., 14Fr.or 16Fr. catheter is typically used.

Steps in Catheterization:

Male*:

In non-circumcised men, retract the foreskin slightly

Cleanse the glans penis

Hold the penis upright and extended with your non-dominant hand

Instil anaesthetic gel into the urethral meatus

Wait for the anaesthetic gel to take effect (3-4mins)

Hold the catheter in your dominant hand

Place the catheter tip in the urethral meatus and advance it slowly until the base of penis, then

bend the penis down and continue insertion slowly

On completing the procedure, reposition the foreskin

*http://www.youtube.com/watch?v=DIImiBjjuKQ

Female`:

Place the catheter tip in the urethral meatus and advance it slowly

If there is resistance at the bladder sphincter ask the patient to cough while you continue to

advance the catheter

Continue to advance the catheter until urine drains

Advance the catheter another 10cm

Inflate the balloon with sterile water

Withdraw the catheter until the balloon gently abuts the bladder neck

Connect the urine bag to the catheter

Unclamp the urine bag

Stray the catheter to the patient’s thigh ensuring that it is not pulling on the urethra

`http://www.youtube.com/watch?v=d8WxqIs9vUw

Confirmation:

Urine will be drained out.

Complication:

Urethristis

Cystitis

Pyelonephritis

Transient bacteremia



18

Name: Helmet removal

Indication:

- Gives providers access to a patient's airway and allows them to stabilize the patient's head

and neck

Contraindication:

- Paresthesia or neck pain during the removal procedure. Paresthesia suggests worsening

stretch or pressure on nerve endings as they exit the spinal column.

Technique:

1) First rescuer maintains inline immobilization by placing his hands on each side of the helmet with the

fingers on the victim’s mandible. This position prevents slippage if the strap is loose.

2) The second rescuer cuts or loosens the strap at the D-rings.

3) The second rescuer places one hand on the mandible at the angle (the thumb on one

side, other fingers on the other) and the other hand apply pressure from the occipital

region. This manoeuvre transfer inline immobilisation responsibility to the second

rescuer.

4) The rescuer at the top moves the helmet. Three factors should be kept in mind:

The helmet is egg shaped and therefore must be expanded laterally to clear the

ears

If the helmet provides full facial coverage, glasses must be removed first.

If the helmet provides full facial coverage, the nose may impede removal. To clear the

nose, the helmet must be tilted backward and raised over it.

5) Throughout the removal process, the second rescuer maintains inline immobilization from

below to prevent unnecessary neck motion.

6) After the helmet has been removed, the rescuer at the top replaces his hands on either side

of the victim’s head with his palms over the ears.

7) Inline immobilization is maintained from above until a backboard is in place and a cervical

immobilization device (collar) is applied.

Complications: Worsen an extant cervical spine injury.

References: http://www.facs.org/trauma/publications/helmet.pdf

http://emedicine.medscape.com/article/1413407-overview

http://www.facs.org/trauma/publications/helmet.pdf









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Name: Immobilisation

Indications:

- Prevent an injured area from moving and reduce the chances of further injury by

holding a joint or limb in place with a splint or sling.

Equipments:

Splints - Used to immobilise an injured arm or leg immediately after an

injury.

Slings - Used to support the arm after a fracture or other injury. They are

generally used along with a splint, but sometimes are used alone as a

means of immobilisation.

Traction - Applies tension to correct the alignment of two structures (such

as two bones) and hold them in the correct position as well as reduces the

pain.

Cervical Collar - Used to support the neck when there has been a

suspected fracture in one of the bones of the neck.

Spinal Board - Used in conjunction with a collar for the treatment of a

suspected cervical or back injury to maintain inline immobilisation.

Vacuum Mattress - Used for the immobilisation of patients, especially in

case of a neck, back, pelvis or limb trauma as it moulds to their contours

and makes the journey far more comfortable than a spinal board.

Kendrick Extrication Device or KED - A device that is used in vehicle

extrication to remove a casualty.



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General Principles:

− Always assume a fracture− Treat fractures before moving unless safety of yourself or the patient prevents this

− Support and immobilise the affected area to prevent further movement

− Immobilise fractures using padding, blankets, bandages or splints (Vacuum or box).

− Put patient in a comfortable position with affected part elevated to reduce swelling.

− Do not put pressure on the site of an injury. Gently pad an open wounds

− Use the body's natural hollows to pass bandages to opposite side of injury. (Under

knees, ankles and small of back. etc)

− Always check that bandages are not reducing circulation to affected part if the limb

starts to swell. (capillary refill and distal pulse check)

− Immobilise the fracture above and below point of injury and never over the top.

References: http://www.ambulancetechnicianstudy.co.uk/immobilisation.html

http://www.ambulancetechnicianstudy.co.uk/immobilisation.html






21

SUTURING

I. Definition

This procedure will take place when a percutaneous tube requires securing, or when a

wound requires skin closure for proper healing.

II. Indications

1. Percutaneous tube that is insecure;

2. Significant tenderness, erythema or irritation at current securing suture site;

3. Evidence of weeping, such as in ascites;

4. Accidental dislodgement of a suture.

III. Precautions

1. The patient may need wound culture & antibiotics2. Cellulitis should be determined

3. Effectiveness of the drain should be established

4. Appropriateness of wound condition for closure

IV. Contraindications

1. If there is reddening and edema of the wound margins

2. Infection manifested by discharge or pus

3. Persistent fever or toxemia

4. Puncture wounds or animal bite

5. Tendon, verve, or vessel involvement

6. Any wound more than 12 hours old. With the exception of the face and hands

V. Materials

1. Lidocaine 1%, 24g needle, 1cc syringe

2. Betadine swabs

3. Needle holder

4. Nonabsorbable/absorbable suture material (sizes range from 00 to 10-0)

5. Needle (curved needles; tapered or cutting )

6. Forceps

7. Scissors

8. Gauze sponges

VI. Suturing Procedure

Procedure:

1. clean area with betadine or similar appropriate solution

2. inject local anesthetic agent, allowing time for effectiveness

3. pierce the epidermis and the dermis at 90 degree angle

4. curve the needle and suture through the tissues, technique should allow

for proper wound eversion

5. tie knot in a manner that minimizes wound tension

6. ensure the involved tube is secure and optimally positioned for comfort

7. dress the site as a ro riate



22

VII. Complications

Immediate complications include the formation of hematoma secondary to improperhemostasis technique and the development of a wound infection. Prophylactic

antibiotics have a role in protecting against wound infection.

Late complications include scar formation, which may be due to either improper

suturing with excess tension or lack of eversion of the edges.

Additionally,hypertrophic scarring and keloid formation are unfortunate later

complications of wound closure in some individuals. Other complications include

stitch marks and wound necrosis.

VIII. Special features

Suture techniques Figure

Knot tying (Square knot)The long end of the suture is wrapped around the tip of the closed needle

holder twice before grasping the short end of the suture with the needle

holder. The first double knot is then pulled gently tight. Two (or three)

further single throws are then added in a similar fashion to secure the

knot. Each throw is pulled in the opposite direction across the woundedge.

Simple interrupted sutureThe wound edge should be gently stabilised with either toothed forceps

or a skin hook. The needle should enter perpendicular to the skin 3-5mm

from the wound edge. Entering perpendicular causes a wider bite of

deeper tissue to be included in the suture than at the surface andconsequently causes more wound edge eversion and ultimately a

superior cosmetic result with a thinner scar. The knot is then tied as seen

in above figure.

Continuous sutureUsing a continuous suture rather than multiple interrupted sutures offers

a significant time saving. However,it is not as strong as interrupted

sutures, and can strangulate the blood supply in wounds under more than

minimal tension. An interrupted suture is performed, but only the free

suture end is cut before the needle is reintroduced and directed

diagonally across the wound to exit the skin on the other side.

Horizontal mattress sutureThis suture is especially good for distributing wound tension acrosslarger wounds particularly for the initial sutures. The disadvantage of

this suture is the risk of strangulation of the dermal blood supply and

subsequent edge necrosis.

Suture Removal

If the sutures are taken out within 7 – 10 days, suture removal is usually easy and should not

cause more than a pinching sensation to the patient. Cut the suture where it is exposed,

crossing the wound edges, then remove the entire stitch by grabbing the knot with a clamp or

forceps and pulling gently.

IX. Reference

http://emedicine.medscape.com/article/1836438-overview#showall

practicalplasticsurgery.org/docs/ Practical_01.pdf










23

http://dermnetnz.org/procedures/suturing.html

Arterial Blood Gas (ABG)

Procedure : Arterial Blood Gas

An arterial blood gas (ABG) test measures the acidity (pH) and the levels of oxygen and carbon

dioxide in the blood from an artery. An ABG test uses blood drawn from an artery, where the oxygen

and carbon dioxide levels can be measured before they enter body tissues.

What is measured by an ABG?

An ABG measures:

Partial pressure of oxygen (PaO2). This measure the pressure of oxygen dissolved in the

blood and how well oxygen is able to move from the airspace of the lungs into the blood. Partial pressure of carbon dioxide (PaCO2). This measures how much carbon dioxide is

dissolved in the blood and how well carbon dioxide is able to move out of the body.

pH. The pH measures hydrogen ions (H+) in blood. The pH of blood is usually between 7.35

and 7.45. A pH of less than 7.0 is called acid and a pH greater than 7.0 is called basic

(alkaline). So blood is slightly basic.

Bicarbonate (HCO3). Bicarbonate is a chemical (buffer) that keeps the pH of blood

from becoming too acidic or too basic.

Oxygen content (O2CT) and oxygen saturation (O2Sat) values. O2 content measures

the amount of oxygen in the blood. Oxygen saturation measures how much of the

haemoglobin in the red blood cells is carrying oxygen (O2).

Indications

An arterial blood gas (ABG) test is done to:

Check for severe breathing problems and lung diseases, such as asthma, cystic fibrosis, or

chronic obstructive pulmonary disease (COPD).

See how well treatment for lung diseases is working.

Find out if the patients need extra oxygen or help with breathing (mechanical ventilation).

Find out if the patients are receiving the right amount of oxygen when they are using oxygen

in the hospital.

Measure the acid-base level in the blood of people who have heart failure, kidney failure, uncontrolled diabetes, sleep disorders, severe infections, or after a drug overdose.

Procedure

A sample of blood from an artery is usually taken from the inside of the wrist (radial artery),

but it can also be taken from an artery in the groin (femoral artery) or on the inside of the arm above

the elbow crease (brachial artery). A procedure called the Allen test may be done to ensure that

blood flow to the hand is normal. An arterial blood gas (ABG) test will not be done on an arm used

for dialysis or if there is an infection or inflammation in the area of the puncture site.

The health professional taking a sample of the blood will:

http://www.webmd.com/hw-popup/ph

http://www.webmd.com/hw-popup/hemoglobin-7998

http://www.webmd.com/hw-popup/asthma

http://www.webmd.com/hw-popup/cystic-fibrosis

http://www.webmd.com/hw-popup/chronic-obstructive-pulmonary-disease-copd

http://www.webmd.com/hw-popup/heart-failure-8021

http://www.webmd.com/hw-popup/kidney-failure

http://www.webmd.com/hw-popup/diabetes

http://www.webmd.com/a-to-z-guides/allen-test-topic-overview

http://www.webmd.com/hw-popup/dialysis

http://www.webmd.com/hw-popup/dialysis

http://www.webmd.com/a-to-z-guides/allen-test-topic-overview

http://www.webmd.com/hw-popup/diabetes

http://www.webmd.com/hw-popup/kidney-failure

http://www.webmd.com/hw-popup/heart-failure-8021

http://www.webmd.com/hw-popup/chronic-obstructive-pulmonary-disease-copd

http://www.webmd.com/hw-popup/cystic-fibrosis

http://www.webmd.com/hw-popup/asthma

http://www.webmd.com/hw-popup/hemoglobin-7998

http://www.webmd.com/hw-popup/ph



24

Clean the needle site with alcohol. You may give an injection of local anaesthetic to numb

that area.

Put the needle into the artery.

Allow the blood to fill the syringe. Ensure your patient to breathe easily and be relax

throughout the procedure.

Put a gauze pad or cotton ball over the needle site as the needle is removed. Put a bandage over the puncture site and apply firm pressure for 5 to 10 minutes (possibly

longer if the patient is on blood-thinning medicine or have bleeding problems).

What is an Allen Test?

The blood supply to the hand normally comes from 2 arteries, the radial artery and the ulnar artery.

Before drawing blood for an arterial blood gas test, the doctor will make sure that both arteries are

open and working correctly. A procedure called the Allen test may be used to find out if the blood

flow to the hand is normal.

For the Allen test, the doctor drawing the blood will apply pressure to the arteries in the wrist for

several seconds. This will stop the blood flow to the hand; and the hand will become cool and pale.

Blood is then allowed to flow through the artery that will not be used to collect the blood sample.

This is usually the ulnar artery, which is found on the outer (little finger side) of the wrist. Arterial

blood gases are usually taken from the radial artery.

Normal

(positive)

Hands quickly become warm and return to its normal colour. This means that

one artery alone will be enough to supply blood to the hand and finger.

Abnormal

(negative)

Hand remains pale and cold. This means that one artery is not enough to supply

blood to the hand and fingers. Blood will not be collected from an artery in this

hand.

If the hand remains pale and cold, the Allen test will then be performed on the other hand. If the

other hand also remains pale, the blood often will be collected from another artery, usually in the

groin or elbow crease.

Complications

1) Pain

2) Hematoma

3) Haemorrhage

4) Compression neuropathy

5) Aneurysm

6) Infection of site of puncture

7) Thrombus formation

8) Improper anticoagulant

References:

http://www.webmd.com/hw-popup/local-anesthesia

http://www.webmd.com/hw-popup/local-anesthesia



25

1) Pagana KD, Pagana TJ (2010). Mosby’s Manual of Diagnostic and Laboratory Tests, 4th ed. St.

Louis: Mosby Elsevier.

2) http://www.youtube.com/watch?v=6ko6YbpO4AE&feature=related

PARACENTESIS

Paracentesis or peritoneal tap provides is important procedure in the management of peritonitis. It

was first performed and described by Solomon in 1906.

Indications

1. New onset ascites or ascites of unknown origin

2. Patient with a known ascites who has fever, abdominal pain, hypotension or encephalopathy

3. Symptomatic treatment of large ascites

Contraindications

1. Uncooperative patient

2. Uncorrected bleeding diathesis

3. Acute abdomen that requires surgery

4. Intra-abdominal adhesions

5. Distended bowel

6. Abdominal wall cellulitis at the site of puncture

7. Pregnancy

Equipment

1. 16 G Angiocath (or a spinal needle) x 1

2. 10 cc syringe x 13. One-liter vacuum bottle x 5

4. Thoracentesis kit tubing x 2

5. Sterile gloves x 2

6. Betadine swab x 3

7. Sterile drape x 2

8. 4x4 sterile gauze x 4

9. Band-aid x 1

Procedure

A) Patient preparation 1. Explain the risks, benefits and alternatives to the patient.

2. If patient is not able to provide consent, it can be taken from the relative of the next of kin.

3. Ask the patient to urinate before the procedure or use a Foley to empty the bladder.

4. Position the patient with the head elevated at 45-60O

to allow fluid to accumulate in lower abdomen.

B) Preparation for the procedure

1. Get all the things ready at the bedside. Take note that the procedure is a sterile procedure

2. The patient should lie on his back in a slightly recumbent position toward the site of

paracentesis.

http://www.youtube.com/watch?v=6ko6YbpO4AE&feature=related


http://note3.blogspot.com/2004/02/paracentesis-procedure-guide.html






26

3. Insertion site is inferior to umbilicus at the level of percussed dullness (2-3 fingerbreadths below umbilicus)

4. Clean the area with Betadine in a circular fashion from the center out.

5. Apply the sterile drapes.

6. Open the 16 G angiocath and syringe, and place them on the sterile drapes.

7. Place the 1-L vacuum bottles nearby.

8. Ensure that the angiocath fits the tubing.

C) Procedure technique

1. Pull the skin down and go in with the Angiocath at the marked point. Then release the skin.#

2. Aspirate as you go in.

3. Once the fluid is in the needle, advance the needle slightly.

4. Then thread in the plastic part while withdrawing the needle.

5. Aspirate again to make sure that the plastic catheter is still inside the fluid collection.

6. Unscrew the syringe and connect the tubing to the 1-L vacuum bottle.#this is called Z-technique which creates a skin track to stop ascitic fluid from leaking out post-operatively.

If no fluid can be withdrawn:

1. Try to reposition the catheter.

2. If still no fluid, pull out and reintroduce the needle (if kept sterile).

3. Do not push hard or deeper than the midpoint of the collection.

4. Alternatively, the procedure can be performed with ultrasound-guided.

After the procedure:

1. Ask the patient to lie in bed and monitor vital signs Q1H for 4 hours to avoid hypotension.

2. It is recommended to give 25cc of albumin (25% solution) for every 2L of ascitic fluid removed.*

3. Write a procedure note which includes all the steps described above.

4. Record the amount and character of fluid obtained, estimated blood loss, complications(if any) and

test requested.

*eg. If the patient had a 4L paracentesis, he should receive 50 cc of albumin IV (25% solution) over 2 hours).The rationale for

giving albumin is to avoid intravascular fluid shift and renal failure after a large-volume paracentesis.

D) Laboratory tests

1. Usually, only one of the 1L bottle is sent.



27

2. General test includes ammonia, CBC, CMP, albumin, amylase, lipase, INR/PTT.

3. Test for paracentesis ascitic fluid includes protein, albumin, specific gravity, glucose, bilirubin,

amylase, lipase, triglyceride, LDH, cell count and differential, C&S, Gram stain, AFB, fungal, cytology

and pH.

4. Ensure that test results are followed up and reviewed.

Possible complications

1. Persistent leak from the puncture site

2. Abdominal wall hematoma

3. Perforation of bowel

4. Introduction of infection

5. Hypotension after a large-volume paracentesis

6. Dilutional hyponatremia

7. Hepatorenal syndrome

8. Major blood vessel laceration

9. Catheter fragment left in the abdominal wall or cavity

Additional feature

By having an ultrasound scan performed prior to the procedure, a precise puncture point can be

marked. The distance from the skin to the fluid is usually 1 cm. It gives you an idea how deep you

have to go with the needle before getting fluid in the syringe. The distance to the midpoint of the

collection is usually 3 cm. It gives you an idea how deep you can go with the needle in relative safety.

References

1. Dimov V. Paracentasis: A Step by step procedure guide. Clinical Notes.(http://note3.blogspot.com/2004/02/paracentesis-procedure-guide.html)

2. Garcia-Tiso G. Cirrhosis and its sequellae. In: Goldman L, Ausiello D, eds. Cecil Medicine . 23rd ed.

Philadelphia, Pa: Saunders Elsevier; 2007: chapter 157.

3. Procedure can be viewed at: http://www.youtube.com/watch?v=TTFNgIzgKTw


http://www.youtube.com/watch?v=TTFNgIzgKTw

http://www.youtube.com/watch?v=TTFNgIzgKTw




28

Chest tube insertion

Definition

Procedure to place a flexible, hollow drainage tube into the chest in order toremove an abnormal collection of air or fluid from the pleural space (located

between the inner and outer lining of the lung). usually performed as an emergency procedure.

Used to treat conditions that can cause the lung to collapse, which occurs becauseblood or air in the pleural space can hamper the ability of a patient to breath.

4 common conditions than can require surgical chest tube insertion, including:

pneumothorax (air leak from the lung into the chest)

hemothorax (bleeding into the chest)

empyema (lung abscess or pus in the chest) pneumothorax or hemothorax after surgery or from trauma to the chest

Description



29

1. The point of insertion in the chest most commonly occurs on the side (lateral

thorax), at a line drawn from the armpit (anterior axillary line) to the side

(lateral) of the nipple in males, or to the side (about 2 in [5 cm]) above thesternoxiphoid junction (lower junction of the sternum, or chest bone) in

females.

2. The skin is sterilized with antiseptic solution covering a wide area, and localanesthesia is administered to minimize discomfort.

3. At the rib chosen for insertion, the skin over the rib is anesthetized with

lidocaine (a local chemical anesthetic agent) using a 10-cc syringe and 25-gauge

needle.

4. At the rib below the rib chosen for pleural insertion, the tissues, muscles, bone, and

lining covering the lung are also anesthetized using a 22-gauge needle.

5. All health-care providers will take precautions to keep the procedure sterile, includingthe usage of sterile gown, facemask, and eye protection.

6. All equipment must be sterile as well and universal precautions are followed forblood and body fluids.

7. Chest tube size is selected depending on the problem; an 18 – 20 F(rench) catheter isused for pneumothorax, a 32 – 26 F catheter for hemothorax, and trauma patients

usually require a 38 – 40 F catheter size; children generally require smaller tube sizes.

8. The patient's arm is placed over the head with a restraint on the affected side. For an

insertion line down the armpit (axillary line insertion), the patient's head is elevated

from the bed 30 – 60°.

9. Using the anesthetic needle and syringe, the physician will insert a needle (aspirate)into the pleural cavity to check for the presence of air or fluid. Then, an incision is

made and a clamp is used to open the pleural cavity. At this stage, either air or fluid

will rush out when the pleural cavity is opened.

10. The chest tube is positioned for insertion with a clamp and attached to the suction-

drain system.

11. A silk suture is used to hold the tube firmly in place.

12. The area is wrapped and an x ray is taken to visualize the status of the tube placement

Risks

A. Risks from any anesthesia are:

Problems breathing

Reactions to medications

B. Risks from any surgery are:

Bleeding

Infection

C. Risks from the procedure itself:

Accidental movement of the tube

Buildup of pus (empyema)

Improper placement of the tube--into the tissues, abdomen, or too far in the chest

Injury to the lung or heart



30

Injury to the spleen, liver, stomach, or diaphragm

Aftercare

1. Remains secure and in place until imaging studies such as x rays show that air

or fluid has been removed from the pleural cavity.2. This removal of air or fluid will allow the affected lung to fully re-expand,

allowing for adequate or improved breathing.3. Patient will stay in the hospital until the tube is removed.

4. During the stay, the medical and nursing staff will carefully and periodically monitorthe chest tube for air leaks or if the patient is having breathing difficulties.

5. Deep breathing and coughing after insertion can help with drainage and lung re-

expansion.

6. Also include chest tube removal and follow-up care.

7. The patient is placed in the same position in which the tube was inserted.

8. Using precautions to maintain a sterile field, the suture holding the tube in place is

loosened and the chest is prepared for tying the insertion-point wound.

9. The chest tube is then clamped to disconnect the suction system.10. At this point, the patient will be asked to hold his or her breath, and the clinician will

remove the tube with a swift motion.11. After the suture is tied, dressing (gauze with antibiotic ointment) and tape is securely

applied to close the wound.12. A chest x ray should be repeated soon after tube removal and, within 48 hours, a

routine wound care clinic follow-up is advised to remove the dressing and to further

assess the patient's medical status and condition.

Normal results

Commonly used procedure, and it is typical for patients to recover fully from insertion and

removal. If no complications develop, the procedure can relieve air or fluid accumulation in

the pleural cavity that caused breathing impairment. Breathing is usually improved, and

follow-up within the immediate 48 hours after hospital discharge is advised so that the patient

can be further assessed with x rays and in the wound care clinic.

Alternative NamesChest drainage tube insertion; Insertion of tube into chest; Tube thoracostomy

http://www.surgeryencyclopedia.com/St-Wr/Wound-Care.html





31

NASOGASTRIC TUBES (By Zuliyasmin)

These tubes are passed into the stomach via the nose-orogastric if via the mouth-

and drain externally.

INDICATIONS

To empty the stomach

For gastric lavage following overdose.

Intra-operatively

For irreversible dysphagia

For feeding ill patients

CONTRAI NDICATIONS

Absolute contraindications :a) Severe midface trauma

b) Recent nasal surgery

Relative contraindications :

a) Coagulation abnormality

b) Esophageal varices/ stricture

c) Recent banding/ cautery of esophageal varices

d) Alkaline ingestion

EQUIPMENT

Nasogastric tube size

a) Adult 16-18F

b) Pediatric Tubes size dependent with age

2% Viscous lidocaine

Glass of water with a straw

Water-based lubricant

60 ml Toomey syringe Tape

Emesis basin or plastic bag

Wall suction, set to low intermittent suction

Suction tubing and container

Figure 1 : Equipment for

nasogastric intubation

Figure 2: Estimation of NGT

length from nostril to stomach



32

PASSING THE TUBE

1. Wear non-sterile gloves.

2. Explain procedure to patient.

3. Take a new tube and lubricate well with aqueous gel.

4. Use the tube, by holding it against the patient’s head, to estimate the length

required to get from the nostril to back of throat.

5. Examine the patient's nostril for septal deviation.

6. To determine which nostril is more patent, ask the patient to occlude each

nostril and breathe through the other.

7. Place lubricated tube in the nostril with its natural curve promoting passage

down. The right nostril is often easier than the left. Advance directly backward.

8. When the tip is estimated to be entering the throat, rotate the tube by ~180°to

discourage passage into the mouth.

9. Advance the tube into the esophagus during a swallow and hence to thestomach. Take a sip of water helps to enhance swallowing similarly with

rotating the tube. If this fails: Try the other nostril, then oral insertion.

10. Tape securely to the nose.

CHECK PLACEMENT

Use pH paper

‘Woosh test’

Chest X-ray used to check positioning

Figure 3: Auscultation over the

stomach

Figure 4: Secured NGT



33

COMPLICATIONS:

Pain

Or rarely: loss of electrolytes, esophagitis, tracheal or duodenal intubation,

necrosis (retro- or nasopharyngeal), stomach perforation.

WEANING

Weaning is preferable for decompression/ relief of obstruction when removing

of NGT in situ allow patients to manage well without it.

a) First it should be on free drainage with eg 4hrly aspiration

b) Then spigot with 4hrly aspirations

c) Then spigot only. If this is tolerated along with oral intake it is probably

safe to remove the tube; if not, then take a step backwards.

VIDEO

http://www.youtube.com/watch?v=en5ctZInOyA

REFERENCES

Longmore M., Wilkinson I. B., et al (2010), Oxford Handbook of Clinical

Medicine, 8th Edition, Practical Procedures, 19: 773

Retrieved from http://emedicine.medscape.com/article/80925-

overview#showall












34

Cardio-Pulmonary Resuscitation (CPR)By: Koh Weijun

Checking The Pulse

The pulse check is no longer taught or expected of laypersons. Instead, if there is no response after

two mouth-to-mouth breaths, begin to pump on the chest. Please note that the pulse check is still

expected of health care providers.

Complications of CPRVomiting is the most frequently encountered complication of CPR. If the victim starts to vomit, turn

the head to the side and try to sweep out or wipe off the vomit. Continue with CPR.

The spread of infection from the victim to the rescuer is exceedingly rare. Most cardiac arrests occur

in people's homes - relatives or friends will be the ones needing to do CPR. Even CPR performed on

strangers has an exceedingly rare risk of infection. There is NO documentation of HIV or AIDS ever

being transmitted via CPR.

http://www.youtube.com/watch?v=O9T25SMyz3A



35

INTUBATION

( Nur Syazwani Jamhuri)

Intubation is a procedure that is done by inserting an endotracheal tube (ETT)

through the mouth and into the trachea.

Usually done under sedation however in emergency setting, it is usually involving an

unconscious patient.

Indications for intubation

1. Unable to protect airway ( e.g. Glasgow Coma Scale (GCS) below 8, individual with

airway trauma, deeply comatose from a head injury or drug overdose ) .Absence of the

gag reflex is a reliable method of assessing whether or not the airway is protected.

2. Inadequate oxygenation with spontaneous respiration. SPO2 < 90% despite 100% O2

given or rising PCO2 (eg: asthma, COPD or pulmonary edema)

3. Anticipatory scenarios: trauma, respiratory failure, overdose, congestive heart failure,

asthma, chronic obstructive pulmonary disease, and inhalation injury.

4. Shock

5. Anticipatory transfer of critically ill patients

INTUBATION TOOLS

O2 source and self-inflating bag

Face mask

ETT

Tracheal stylet

Syringe for ETT cuff inflation

Suction

Laryngoscope

Medications that can be

delivered via ETT

NAVEL

N= Naloxone

A=Atropine

V=Ventolin (Salbutamol)

E= Epinephrine



36

Approach to ETT intubation in trauma patient

C-spine x-ray

No Immediate NeedImmediate Need

Apneic Breathing

Oral ETT

Rescue devices or

cricothyroidectomy

Oral ETT

(no RSI)

Nasal / Ora

ETT (+,- RSI

Rescue devices or

cricothyroidectomy

Unable

Unable

+ve -ve

Fiberoptic / Nasal ETT

or RSI Nasal / OralETT (+,- RSI)

Rescue devices or

cricothyroidectomy

Unable

Trauma Requiring Intubation



37

Steps of Intubation

1. Perform basic airway management

Protect the C-spine with cervical collar

Head-tilt ( if C-spine injury is not expected) or

jaw thrust to open airway

Suction to clear mouth from foreign materials

2. Assess for potential difficulties

3. Ensure all equipments are present and working well

4. RSI if required to be performed

5. If not, proper laryngoscope to visualize the glottis

6. Insert ETT, and inflate cuff

7. Ensure proper positioning of ETT ( 20-23cm mark at the right corner of the mouth if

men and 19-21cm for women)

Visualization of ETT passing through cords

Auscultate for equal bilateral breath sounds

Chest movement and not abdominal distension

8. Ventilate when ETT is in place

Complications of Intubation

Mechanical

Laceration (lips, gum, pharynx,esophagus)

Dental damage

Laryngeal trauma

Esophageal or endobronchial intubation

Accidental extubation

Systemic

Laryngospasm

Bronchospasm

Signs of Esophageal Intubation

No chest wall movement

Abdominal distension

Hypoxia/cyanosis

Presence of gastric

content in ETT

Abnormal sounds during

assisted ventilation

End tidal CO2 zero or

near zero on capnograph

Signs of Endobronchial

Intubation

If too deep, usually result in

right endobronchial intubation

Unilateral breath sound

Right sided tension

pneumothorax

Left sided atelectasis



38

Complications: Prevention and Management

Complication: Prevention: Management:

Missing/broken teeth: Remove loose teeth prior;

avoid using upper teeth as

fulcrum for laryngoscopeblade.

Check chest x-ray to rule out

aspiration.

Clenched teeth: Paralytic medication.

Air leak: Check cuff prior to beginning

procedure. Inject more air or change tube

over guide wire.

Inability to visualize vocal

cords:

Proper patient positioning,

proper laryngoscope bladesize, proper suctioning.

Reposition, choose a different

blade, adequate suction, cricoidpressure by assistant.

Esophageal intubation: Visualize cords. Remove tube, re-oxygenate and

reinsert.

Right lung intubation: Avoid excessive tube

advancement. Deflate cuff, re-position and re-

inflate.

Laryngospasm: Spray vocal cords with 2%

Lidocaine. Benzodiazepine or paralytic

medication.

Failure to intubate: None. Have alternative plan prepared:

e.g., BVM, another type of tube,

cricothyrotomy.

Advantages and disadvantages of ETT

Advantages

“5 P’s”

1. Ensure airway PATENCY

2. PROTECTS against aspiration

3. Allow POSITIVE PRESSURE ventilation

4. PULMONARY toileting “suctioning”

5. PHARMACOLOGICAL administration

Disadvantages

1. Difficult insertion

2. Endobronchial intubation or esophageal intubation

3. Laryngospasm on intubation or extubation later

Links

1. http://www.youtube.com/watch?v=IO_eUC9ph6o ( Nasal ETT)

2. http://www.youtube.com/watch?v=mKrl3I3Z28s (Oral ETT)

http://www.youtube.com/watch?v=IO_eUC9ph6o


http://www.youtube.com/watch?v=mKrl3I3Z28s






39

3. http://www.youtube.com/watch?v=kahoOfAndDc (Cricothyroidotomy)

4. http://apps.med.buffalo.edu/procedures/basicairway.asp?p=4 (Basic airway management)

Name of procedure: Intravenous lines by mrmalekahmad

Indication: 1. IV access is usually needed for anesthesia care, laboring patients, trauma patients,hospital inpatients, and patient care requiring any of the following:

Emergency administration of medications

Fluid resuscitation

Administration of blood products

Elective administration of intravenous antibiotics, chemotherapeutic agents,

or other treatments

Administration of diagnostic substances, such as methylene blue,

indocyanine green, indigo carmine, or intravenous contrast agents

2. Patients donating blood products

Contraindication: 1. Patients with anatomy that poses a risk for fluid extravasation orinadequate

flow (extremities with massive edema, burns or injury), in these cases other

IV sites need to be accessed

2. For the patient with severe abdominal trauma, it is preferable to start the

IV in an upper extremity because of the potential for injury to vessels

between the lower extremities and the heart

3. For the patient with cellulitis of an extremity, the area of infection should

be avoided when starting an IV because of the risk of inoculating the

circulation with bacteria

*there is no absolute contraindication

Equipment: 1. Gloves and protective equipment

2. Appropriate size catheter 14-25 G IV catheters

3. Non-latex tourniquet

4. Alcohol swab/other cleaning instrument

5. 2x2 gauze

6. 6x7cm Transparent Dressing

7. 3 pieces of 2.5 cm tape approximately 10 cm in length

8. IV bag with solution set (tubing) (flushed and ready) or saline lock

9. Sharps container

Procedure: 1. Explain procedure to patient/parent and prepare the equipment2. Wash hands with antiseptic soap and wear gloves

3. Apply the tourniquet above insertion site

(For pediatric patient, an assistant’s hand used both as a tourniquet and restraint, is

often more acceptable to a child than a tourniquet)

4. Disinfect the selected site with skin prep and allow to dry

(Do not touch the skin with the fingers after preparation solution has been applied)

5. If infiltration of local analgesia is required, inject lignocaine 1% at the proposed

site of entry of cannula

6. Inspect the cannula before insertion to ensure that the needle is fully inserted

into the plastic cannula and that the cannula tip is not damaged (Do not touch the

shaft or tip of the cannula)

http://www.youtube.com/watch?v=kahoOfAndDc


http://apps.med.buffalo.edu/procedures/basicairway.asp?p=4


http://www.google.com/cse?cx=partner-pub-9411161529365210%3A2gwkutv8u3i&ie=ISO-8859-1&q=lignocaine&sa=Search&siteurl=nursing-resource.com%2Fforums%2F








40

7. Ensure that the bevel of the cannula is facing upwards (Rationale: Facilitates the

piercing of the skin by the bevel)

8. Insert the needle and the cannula into the vein (Gentle traction on skin may

stabilize the vein under the skin)

9. Partially withdraw the needle and advance the cannula

10. Release the tourniquet11. Secure the hub of the cannula with clean adhesive tape (Do not cover the

puncture site, cut tape immediately prior to use only)

12. Flush the cannula with normal saline (Rationale: Ensures the line is patent and

accessible)

13. Cover the intravenous and surrounding area with a sterile transparent dressing

(Ensure that the insertion site and the area proximal to the site are visible for

inspection purposes)

14. If infusion is ordered, prime the line and connect the intravenous giving set to

the cannula (If the site needs to be immobilized, use a well padded splint and

strapping if necessary)

For infants <12 months, a transparent tape must be usedIf a bandage is used, apply it at each end of splint so that the central area is lightly

covered for easy inspection

Conform bandages to secure the splint are available for pediatric patients if required.

15. Dispose of equipment safely

*To remove the IV

1. Shut off the IV by closing the roller camp

2. Remove the tape and plaster from the tubing and catheter

3. Place a non-sterile 2x2 gauze over the IV site and remove the catheter from

the arm and secure it in place with a piece of tape

Complication: 1. Infection and infiltration

2. Tissue damage

3. Superficial thrombophlebitis

4. Catheter embolism or air embolism

Reference: 1. http://nursing-resource.com/iv-insertion/#proc

2. http://www.med.uottawa.ca/procedures/iv/



41

Electrocardiogram (ECG) in Emergency

Clinical Indications:

Known or Suspected Cardiac Patient

Known or Suspected Tricyclic Overdose Electrical Injuries Syncope

Procedure:

1. Assess patient and monitor cardiac status.2. Administer oxygen per patient condition as tolerated.3. If patient is unstable, definitive treatment is the priority. If the patient is stable

or stabilized after treatment, perform a 12-lead ECG.4. Prepare ECG monitor and pre-cordial lead cables.5. Enter patient demographic data.

6. Expose the chest and prep as necessary. Modesty should be considered.7. Apply chest leads and limb leads as follows:

RA----right arm LA----left arm N ----right leg F ----left leg V1----4th intercostal space at right sternal border V2----4th intercostal space at left sternal border V3----between V2 and V4 V4----5th intercostal space at midclavicular line V5----Level with V4 at the left anterior axillary line V6----Level with V5 at the left midaxillary line

8. Instruct patient to remain still.9. Press the 12 lead acquisition button on the monitor.10. Once acquired, transmit to the appropriate receiving facility.11. Contact the receiving facility to notify them of the patient and the incoming 12-

lead.12. Monitor and reassess the patient enroute and continue treatment protocol.13. Attach a copy of the 12-lead with the patient’s record at the hospital.

Resources

http://www.iredellems.com/protocols/employees/ICEMS%20Protocol%20Web/Procedure%2

0Pages/12%20Lead%20ECG.htm

http://www.iredellems.com/protocols/employees/ICEMS%20Protocol%20Web/Procedure%20Pages/12%20Lead%20ECG.htm





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