Surgical Procedures

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Surgical Procedures

• Devashish J. Anjaria
• Surgical Fundamentals
• August 11, 2006

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Case Presentation

• 25 year old male presents s/p single stab wound
  to the left chest. He clearly smells of alcohol
  and is lethargic responding only to painful
  stimuli. Field vitals are P 150, BP 80/palp,
  Resp 35.
• Whats the plan????

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ABCs
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Airway

• Secure airway cuffed tube in the trachea
• Endotracheal
• Orotracheal
• Nasotracheal
• Surgical airway
• Cricothyroidotomy
• Tracheostomy

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Indications

• Inability to oxygenate
• PaO2/FiO2 lt 200
• Inability to ventilate
• Respiratory rate gt 30 or lt 5
• PCO2 gt 60
• Inability to protect airway
• GCS 8

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Initial Maneuvers

• Chin lift
• Contraindicated in cervical spine injuries or
  cervical fusion
• Jaw thrust

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Initial Maneuvers

• Bag valve mask
• Nasal and/or oral airways

• The goal is to ventilate and pre-oxygenate

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What you need. . .
MAC or Miller Blades
Laryngoscope
Capnograph
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What you need. . .

• Working suction
• 10 cc syringe (to inflate the balloon)
• Medications to premedicate, if applicable
• Tape or twill
• Stylet
• Pulse ox monitoring

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And of course. . . The endotracheal tube
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Nasotracheal Intubation

• Prerequisites
• Awake spontaneously breathing patient
• Contraindications
• Facial fractures
• Basilar skull fracture
• Apnea
• Coagulopathy
• Pregnancy

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Nasotracheal Intubation - Technique

• Pick an endotracheal tube 1 size smaller than the
  largest nasal airway which fits.
• Thoroughly lubricate the endotracheal tube
• Anesthetize the nares (if possible) with
  lidocaine jelly or cetacaine spray
• Gently advance the tube until fogging is
  encountered and/or air moves through tube.

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Nasotracheal Intubation - Technique

• Ask the patient to take deep breaths and slowly
  advance the tube past the vocal cords with
  inspiration
• When phonation is lost, inflate cuff, confirm
  position (listen, ETCO2) and secure tube.

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Orotracheal Intubation - Technique

• Stabilize cervical spine if necessary
• Have somebody apply cricoid pressure
• Open mouth and separate teeth with right hand
• Hold laryngoscope in left hand and insert in
  right side of mouth, pushing the tongue to the
  left.
• Vertical traction is applied to lift the
  epiglottis and visualize the vocal cords

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Orotracheal Intubation - Technique
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Orotracheal Intubation - Technique

• The endotracheal tube is inserted through the
  cords and the cuff is inflated.
• Tube position is confirmed
• Auscultation/Chest excursion
• Capnography
• CXR
• Tube is secured

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Sedatives and Neuromuscular Blockers

• Induction agents
• Thiopental 4 6 mg/kg
• Etomidate 0.3 mg/kg
• Ketamine 1 3 mg/kg
• Neuromuscular blocking agents
• Succinylcholine 1.0 mg/kg
• Vecuronium 0.3 mg/kg for intubating
• Sedatives
• Midazolam 0.05 0.15 mg/kg
• Propofol

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Intubating Pearls

• If the patient is an elective or semi-elective
  intubation pre-oxygenate with 100 O2 for at
  least 5 minutes. This can allow up to 10 minutes
  to intubate without desaturation.
• If intubating without a pulse oximeter, hold your
  breath while attempting intubation, if you need
  to breath so does the patient bag ventilate.
• ETCO2 requires cardiac output and therefore may
  not be reliable if intubating during a cardiac
  arrest if none detected, confirm with physical
  exam.

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Case Presentation

• Neuromuscular blockade was administered however
  you are not able to intubate the patient.
• Despite bagging, the patient is desaturating and
  now becoming bradycardic.
• Now what???

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Cricothyroidotomy

• Indications
• Extensive orofacial trauma preventing
  laryngoscopy
• Upper airway obstruction
• Hemorrhage
• Edema
• Foreign body
• Unsuccessful endotracheal intubation
• WHEN UNABLE TO VENTILATE!!!!!

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Cricothyroidotomy

• Contraindications
• Children under age 12
• Needle cricothyroidotomy is preferred to prevent
  damage to the cricoid cartilage.

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Cricothyroidotomy Anatomy
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Cricothyroidotomy Anatomy
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Cricothyroidotomy

• Prep the neck
• Palpate the cricothyroid membrane below the
  thyroid cartilage in the midline
• Stabilize the thyroid cartilage frimly with one
  hand and make a transverse incision 2 cm in
  length down to and incising the cricothyroid
  membrane.

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Cricothyroidotomy

• Insert either a tracheal spreader or the back end
  of the scalpel handle and gently dialate
• Insert a tube (tracheostomy, endotrachial, BIC
  pen?)
• Confirm ventilation
• Suture tube to secure
• Obtain hemostasis if necessary

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Cricothyroidotomy
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Case Presentation

• As you are screaming a knife, a knife, my
  kingdom for a knife, your colleague successfully
  intubates with return of end-tidal CO2.
• The chest is auscultated with good breath sounds
  heard on the right, and no breath sounds on the
  left.
• Now what?

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Tube Thoracostomy

• Indications
• Hemothorax/Pleural effusion
• Pneumothorax
• Note for tension pneumothorax first tx should be
  14 or 16 gauge angiocath in 2nd intercostal space
  in midclavicular line.

• Anatomy
• 5th intercostal space in the anterior axillary
  line (at the level of the nipple).
• Measure tube from insertion site to apex of
  lung.

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Tube Thoracostomy

• What you need. . .
• Chest tube
• Pleuravac
• Sterile drapes, gloves and gown
• Instruments scalpel and Kelly clamp
• Heavy silk suture
• Gauze and silk tape for dressing

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Tube Thoracostomy

• Procedure
• Prep and drape hemothorax
• Infiltrate skin, subcutaneous tissue and pleura
  with 1 lidocaine

• 1.5-2 cm incision directly over the 6th rib down
  to the rib
• With a blunt clamp, dissect over the superior
  edge of the rib.
• Bluntly pierce the pleura with the clamp and
  spread the track.
• Be prepared for a rush of blood, fluid and/or
  air.

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Tube Thoracostomy

• Procedure (cont)
• Place finger in track to confirm intrapleural
  positioning and lyse any adhesions.
• Insert tube via track (with or without clamp)
  towards apex of lung.
• Attach tube to pleuravac.
• Secure tube to patient with heavy silk suture and
  tape all connections.

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Warning!

• History of chest tubes, thoracotomies or
  inflammatory pulmonary pathology.
• Assume adhesions between the lung and the chest
  wall.
• The chest tube insertion can cause a lung
  laceration.
• Be very careful how low you are, you can easily
  place an abdominal tube if you are not careful.

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Case Presentation

• Now that the chest tube is draining the
  hemopneumothorax, the patients pressure drops to
  60/palp
• Help?
• The patient has bilateral track marks from his
  history of IVDA.

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Central Venous Access

• Indications
• CVP monitoring
• TPN
• Long-term infusion of drugs
• Inotropic agents
• Hemodialysis
• Poor peripheral access

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Central Venous Access

• Contraindications
• Vein thrombosis
• Coagulopathy or thrombocytopenia

• Vein sites
• Femoral
• Subclavian
• Internal jugular

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Central Venous Access

• What you need
• Central line kit/tray
• Sterile gloves and gown
• Mask and hat
• Sterile drapes
• Sterile flush 10 cc syringe per port
• Lidocaine
• Betadine
• Silk suture

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Central Venous Access

• General procedure
• Prep the skin, sterile drape, sterile gown and
  glove
• Ensure proper position
• Infiltrate 1 lidocaine for adequate anesthesia
• Cannulate the vein with a finder needle (if
  applicable) and then the 18 gauge primary needle
  while aspirating back on a syringe.
• Once successful, hold the needle still and
  disconnect the syringe.

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Central Venous Access

• General procedure (cont.)
• Ensure that back bleeding from needle is venous
• Feed J wire into vein while holding needle still
• Remove needle, leaving wire in place
• Make a skin incision over the needle
• Use the dilator over the wire to dilate the skin
  and subcutaneous tissues
• Remove the dilator and feed the venous catheter
  over the wire.

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Central Venous Access

• General procedure (cont.)
• Place the catheter to the appropriate length and
  remove the wire.
• Aspirate and flush all ports to confirm placement
• Suture the line into place
• Apply sterile dressing
• CXR for jugular or subclavian attempts.
• During the entire procedure NEVER LOSE CONTROL
  OF THE WIRE

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Central Venous Access - Jugular

• Position in Trendelenburg
• Turn the patients head contralaterally
• Anterior approach
• Identify the apex of the triangle formed by the
  heads of the sternocleidomastoid muscle.
• Palpate the carotid and retract medially
• Insert syringe w/ needle at apex at an angle of
  45 to the skin pointing towards the ipsilateral
  nipple
• Vein should be within 3 cm in most people

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Central Venous Access - Jugular
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Central Venous Access - Jugular

• Posterior approach
• Identify the lateral border of the SCM where the
  ext. jugular crosses (about 4-5 cm above the
  clavicle)
• Insert a needle anteriorly and inferiorly
  pointing to the sternal notch
• The vein should be encountered within 3 cm in
  most individuals.

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Central Venous Access - Subclavian

• Place an index finger at the sternal notch and
  the thumb at the intersection of the clavicle and
  the first rib
• Insert the needle w/ syringe at the junction of
  the distal 1/3 and proximal 2/3 of the clavicle,
  1 cm inferior to the clavicle.
• Keeping the needle horizontal, advance towards
  the sternal notch, using the thumb to help the
  needle under the clavicle.
• Aspirate while advancing straight towards notch.
• If unsuccessful, consider reattempt 1 cm more
  lateral than initial trial.

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Central Venous Access - Femoral

• Palpate the femoral artery
• Midpoint between ant. sup. iliac spine and pubic
  symphysis
• Femoral vein is immediately medial to the artery.
• Insert needle medial and parallel to the pulse at
  45 to the skin.
• The vein should be encountered within lt 6 cm.

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Central Venous Access - Complications

• Arterial puncture remove needle/catheter and
  apply at least 5 minutes of direct pressure
• Dysrhythmias most often with wire, but if
  persists may require repositioning distal to RA
• Pneumothorax rates of 1 to 2 for subclavian
  and IJ, rates increase with gt 2 attempts
• Line sepsis lowest with subclavian, highest
  with femoral, strict sterile technique lowers
  rates.

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Case Presentation

• Now with a femoral cordis in place, the patient
  receives 2 liters of LR with an improvement in
  vitals. He has 800 cc of blood drained from his
  left chest.
• Is he adequately resuscitated? Over? Under?

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Arterial Blood Gas (ABG)

• Indications
• Need to assess acid-base status, oxygenation and
  ventilation
• Need to assess carboxyhemoglobin
• Sites
• Radial artery
• Femoral artery

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Arterial Blood Gas (ABG)

• Palpate the pulse of the desired artery.
• Have a bag of ice available
• Prep the skin
• Using a heparinized syringe and a 20 guage
  needle, aim at the pulse localized between 2
  fingers at a 45 angle to the skin
• Once blood return is seen, dedicated syringes
  will self fill
• Once complete, hold 5 minutes of direct pressure
  and confirm hemostasis.

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Case Presentation

• As the respiratory therapist is suctioning the
  patients mouth, he starts vomiting rice and
  beans mixed with beer.
• He does not appear to have aspirated, but his
  stomach is not empty yet. . .

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Nasogastric Tube

• Indications
• Acute gastric dilatation
• Gastric outlet obstruction
• Ileus
• Small bowel obstruction
• Upper GI hemorrhage
• Enteral feeding

• Contraindications
• Basilar skull fracture
• Absence of gag reflex
• Recent esophageal or gastric surgery (relative)

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Nasogastric Tube

• Measure tube from nose to earlobe to anterior
  abdomen so that proximal hole is distal to
  xiphoid.
• Lubricate the tube
• Have the patient flex their neck

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Nasogastric Tube

• Slowly insert the tube straight posteriorly from
  the nares.
• Advance the tube into the pharynx aiming
  posteriorly, asking the patient to swallow if
  possible.
• Once the tube has been inserted to desired
  length, inject air into the tube and auscultate
  over the stomach for placement.

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Nasogastric Tube

• Secure the tube with tape to the nose. Be sure
  not to secure it to the forehead/upward as this
  can cause alar necrosis.

• If the tube is to be used for feeding, placement
  should be confirmed by xray.

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Conclusions

• Knowledge about simple surgical procedures can be
  lifesaving however pure knowledge is not a
  substitute for repeated practice.
• Take every opportunity to practice these
  procedures with senior and/or attending
  supervision under controlled circumstances.

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