Surgical Procedures

1. Surgical Procedures Devashish J. Anjaria Surgical Fundamentals August 11, 2006

2. 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. • What’s the plan????

4. ABC’s

5. Airway • Secure airway = cuffed tube in the trachea • Endotracheal • Orotracheal • Nasotracheal • Surgical airway • Cricothyroidotomy • Tracheostomy

6. Indications • Inability to oxygenate • PaO2/FiO2 < 200 • Inability to ventilate • Respiratory rate > 30 or < 5 • PCO2 > 60 • Inability to protect airway • GCS ≤ 8

7. Initial Maneuvers • Chin lift • Contraindicated in cervical spine injuries or cervical fusion • Jaw thrust

8. Initial Maneuvers • Bag valve mask • Nasal and/or oral airways • The goal is to ventilate and pre-oxygenate

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

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

11. And of course. . . The endotracheal tube

12. Nasotracheal Intubation • Prerequisites • Awake spontaneously breathing patient • Contraindications • Facial fractures • Basilar skull fracture • Apnea • Coagulopathy • Pregnancy

13. 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.

14. 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.

15. 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

16. Orotracheal Intubation - Technique

17. 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

18. 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

19. 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.

20. 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???

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

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

23. Cricothyroidotomy – Anatomy

24. Cricothyroidotomy – Anatomy

25. 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.

26. 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

27. Cricothyroidotomy

28. 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?

29. 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.

30. 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

31. 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.

32. 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.

34. 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.

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

38. Central Venous Access • Indications • CVP monitoring • TPN • Long-term infusion of drugs • Inotropic agents • Hemodialysis • Poor peripheral access

39. Contraindications Vein thrombosis Coagulopathy or thrombocytopenia Vein sites Femoral Subclavian Internal jugular Central Venous Access

40. 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

41. 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.

42. 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.

43. 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

44. Central Venous Access - Jugular • Position in Trendelenburg • Turn the patient’s 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

45. Central Venous Access - Jugular

46. 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.

47. 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.

48. 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 < 6 cm.

49. 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 > 2 attempts • Line sepsis – lowest with subclavian, highest with femoral, strict sterile technique lowers rates.