GEMC- EMedHome Board Review: Procedures- Resident Training

Project: Ghana Emergency Medicine Collaborative
Document Title: EMedHome Board Review: Procedures
Author(s): Joe Lex, MD, FACEP, FAAEM, MAAEM (Temple University)
2013
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2

EMedHome Board Review: Procedures
Joe Lex, MD, FACEP, FAAEM, MAAEM
Associate Professor, Emergency Medicine
Temple University School of Medicine
Philadelphia, PA USA
3

General Rules before Doing a Procedures
•Explain risks and benefits, including what will happen if you don’t do it
•Obtain written informed consent (when possible)
•Use appropriate monitoring equipment
•Position patient properly
5

General Rules before Doing a Procedures
•Clean / prep / drape appropriate body part
•Use aseptic / sterile technique
•Provide post-procedure instructions
6

For this talk…
•Not the everyday procedures
•No RSI
•No procedural sedation
•No laceration repair
•Things you MIGHT want to look at a reference before doing
7

For this talk…
Indications / Contraindications
Procedure Description
Procedure Pictorial (if available)
Complications
8

Indication Nasotracheal Intubation
•Spontaneously breathing patient requiring airway management
•Alternative to RSI when oral airway may be obstructed
18

Contraindication Nasotracheal Intubation
•Apnea
•Severe midface injuries
•Basilar skull fracture
•Closed head injury with  intracranial pressure
•Nasopharyngeal obstruction
•Coagulopathy (relative)
19

Procedure Nasotracheal Intubation
•Preoxygenate
•Apply vasoconstrictor / topical anesthetic
•Insert tube with bevel facing septum
•Slowly advance – listen for breath sounds OR use whistle
•Advance tube through vocal cords
20

Procedure Nasotracheal Intubation
Thomas H. Burford, Wikimedia Commons
21
See: “Procedure Nasotracheal Intubation” in Knoop KJ, Stack LB, Storrow AB, Thurman RJ: The Atlas of Emergency Medicine, 3rd Edition, http://accessmedicine.com.

Complications Nasotracheal Intubation
•Epistaxis
•Mucosa / turbinate avulsion
•Laryngeal / tracheal trauma
•Intracranial / esophageal placement
•Hypoxia
26

Indication / Contraindication Retrograde Intubation
Indication
•Patient requires airway
•Less invasive means have failed
Contraindication
•Ability to intubate / ventilate by less invasive means
•Trismus; inability to open mouth
27

Procedure Retrograde Intubation
•Stabilize patient’s larynx, identify cricothyroid membrane
•Connect 16- to 18-gauge catheter- over-needle to 10 ml syringe contained 3 mL sterile saline
•Puncture cricothyroid membrane at 20–30o angle to skin, pointed at head
•Aspirate – should see air bubbles
28

Source: Reichman EF, Simon RR: Emergency Medicine Procedures
29

•Advance catheter-over-needle until hub is against skin
•Remove syringe and needle
•Feed guidewire through catheter until it comes out patient’s mouth
•Advance guidewire until only ~5cm protruding from neck
•Stabilize wire at neck with hemostat
30

31

•If available, advance introducer sheath until meets obstruction
•Remove wire
•Advance endotracheal tube over introducer into trachea
•Confirm placement
•Secure tube
32
Recommended Reference: Reichman EF, Simon RR: Emergency Medicine Procedures

Complications Retrograde Intubation
•Damage to tracheal cartilage
•Inability to intubate
•Hypoxia
34

Indication / Contraindication Cricothyrotomy
Indications
•Unable to ventilate or intubate
Contraindications
•Child <8-10 years
•Significant trauma to tracheal / cricoid cartilages
•Ability to intubate / ventilate
35

Procedure Cricothyrotomy
•Stabilize larynx, identify cricothyroid membrane
•Make midline vertical incision
•Make horizontal stab incision through cricothyroid membrane
•Insert tracheal skin hook to elevate inferior border of tracheal cartilage
36

Procedure Cricothyrotomy
•Insert Trousseau dilator, remove skin hook, open membrane
•Insert tube: endotracheal (6.0 mm) or tracheostomy tube (4.0 Shiley)
37

Complications Cricothyrotomy
•Esophageal perforation
•Subcutaneous emphysema
•Subcutaneous tube placement
•Bleeding
•Unable to intubate
•Subglottic stenosis
•Cartilage damage: thyroid, cricoid
42

Indication / Contraindication Tube Thoracostomy
Indications
•Pneumothorax (24F – 28F tube)
•Hemothorax (32F – 40F tube)
Contraindications
43

Procedure Tube Thoracostomy
•Identify 4th-5th intercostal space, anterior axillary line
•Abduct ipsilateral arm
•Make incision parallel to ribs
•Bluntly dissect upwards with Kelly
•Enter pleura above rib with clamp  avoids neurovascular bundle
44

Procedure Tube Thoracostomy
•Digitally explore tract
•Insert chest tube, aiming toward apex for pneumothorax, base for hemothorax
•Connect tube to pleural drainage system
•Secure tube
•Obtain confirmatory x-ray
45

Complications Tube Thoracostomy
Complications
•Bleeding, hemothorax
•Visceral organ perforation / vascular structure injury
•Subcutaneous tube placement
•Pneumonia
•Empyema
50

Indication / Contraindication Needle Thoracostomy
Indications
•Tension pneumothorax
Contraindications
•None
51

Procedure Needle Thoracostomy
•Connect a 14- to 16-gauge catheter- over-the-needle to a 5- to 10-mL syringe without the plunger
•Insert needle into 2nd intercostal space, midclavicular line
•Advance needle to rush of air, then advance until hub against skin
•Place chest tube
52

Complications Needle Thoracostomy
•Lung injury
•Local hematoma
•Intercostal nerve / vessel injury
•Failure to decompress tension pneumothorax
54

Indications Resuscitative Thoracotomy
•Penetrating chest trauma patients who are hemodynamically unstable and those who demonstrated palpable pulse, blood pressure, pupil reactivity, any purposeful movement, organized cardiac rhythm, or any respiratory effort either in the field or ED, but subsequently deteriorated
55

Contraindications Resuscitative Thoracotomy
•Penetrating chest trauma victim with no vital signs in field
•Blunt trauma victim with or without field vitals
56

Procedure Resuscitative Thoracotomy
•Make incision through skin, subcutaneous tissue, superficial muscles
•Incise intercostal muscles with Mayo scissors
•Insert rib spreader with handles down and open
•Grasp and open pericardium
57

Complications Resuscitative Thoracotomy
•Injury of personnel
•Laceration of internal mammary or intercostal arteries
•Laceration of lung or myocardium
•Transection left phrenic nerve
•Laceration of myocardium or coronary artery
•Delayed cardiac compressions
65

Indication / Contraindication Paracentesis
Indications
•Diagnostic: new ascites, suspected spontaneous bacterial peritonitis
•Therapeutic: tense, large-volume
Contraindications
•Overlying cellulitis
•Pregnancy, organomegaly (relative)
66

Procedure Paracentesis
Potential sites:
•Midline: 2 cm inferior to umbilicus
•RLQ / LLQ: 2–4cm medial & cephalad to anterior superior iliac spine
67

Procedure Paracentesis
•Use ultrasound to be certain
•Apply skin traction: “Z-track”
•Advance needle / catheter
•Aspirate fluid
•Remove needle / catheter
•Send fluid for analysis
–SBP: PMN >250 WBC/mm3
68

Complication Paracentesis
•Hypotension after large volume removal
•Localized infection
•Abdominal wall hematoma
•Persistent fluid leak
•Injury to abdominal organ
70

Indication / Contraindication Thoracentesis
Indication
•Pleural fluid requiring fluid analysis or therapeutic drainage
Contraindication
•Positive pressure ventilation (caution)
71

Diagnostic Thoracentesis
•Use 18-g needle on 50mL syringe containing 1mL heparin (100U/ml)
•Insert needle 5–10 cm lateral to spine 1 or 2 intercostal spaces below upper level of pleural effusion
•Go over top of rib
•Stop when you get enough
•Post-procedure chest x-ray
72

Therapeutic Thoracentesis
•Make skin incision at insertion site
•Use 14- to 18-gauge catheter-over- needle attached to 10 mL syringe
•Insert needle 5–10 cm lateral to spine 1 or 2 intercostal spaces below upper level of pleural effusion
•When fluid reached, angle needle caudally until hub against skin
73

Therapeutic Thoracentesis
•Withdraw needle, leaving catheter
•Cover catheter with gloved finger (prevent air entry)
•Attach hub to 3-way stopcock attached to 50 mL syringe
•Aspirate and move fluid
•Terminate procedure when symptoms relieved or after 1000 mL
74

Complications Thoracentesis
•Pneumothorax
•Hemothorax
•Intercostal vessel / nerve injury
•Post-expansion pulmonary edema
79

Indications Lumbar Puncture
Indications
•Suspected meningitis
•Suspected subarachnoid hemorrhage (after negative head CT scan)
•Spinal fluid required for analysis
•Delivery of anesthetics, antibiotics, chemotherapy
80

Contraindications Lumbar Puncture
Contraindications
•Coagulopathy
•Cerebral herniation or increased intracranial pressure
81

Procedure Lumbar Puncture
•Position patient: lateral recumbent with hips & knees flexed
•Identify landmarks: L3-L4-L5 spinous processes, iliac crests
•Insert 20-gauge or smaller needle into interspinous space
•Align bevel parallel to dural fibers (facing “upward”)
82

•Advance needle to “pop”
•If you encounter bone, partially withdraw and redirect
•Remove stylet  free flow CSF
•Obtain opening pressure
•Collect 1 – 2mL in each tube
•Reinsert stylet and remove needle
83

Brainhell, Wikimedia Commons
84

BruceBlaus, Wikimedia Commons
85

Source: Waxman SG: Clinical Neuroanatomy, 26th Edition: http://www.accessmedicine.com
86

BruceBlaus, Wikimedia Commons
87

Complications Lumbar Puncture
•Post-dural headache: ~1/3
–Post-tap position does not matter
•Localized pain
•Cerebral herniation
•Subarachnoid epidermoid cyst
88

Indication / Contraindication Intraosseous Infusion
Indication
•Urgent vascular access when traditional methods have failed
Contraindication
•Diseased / osteoporotic bone
•Overlying cellulitis / deep burn (relative)
89

Procedure Intraosseous Infusion
•Identify landmarks: distal femur, proximal tibia, proximal humerus, sternum
•Stabilize extremity
•Insert needle perpendicular to long axis of bone
•In kids: direct needle away from growth plate
90
Recommended Source: Tintinalli JE, et al., Tintinall’s Eergency Medicine: A Comprehensive Study Guide, 7th Edition: http://www.accessmedicine.com

Procedure Intraosseous Infusion
Source Undetermined
91

Complications Intraosseous Infusion
•Subcutaneous / subperiosteal fluid extravasation
•Compartment syndrome
•Osteomyelitis
•Growth plate injury
97

Indication / Contraindication Diagnostic Peritoneal Lavage
Indication
•Patient with abdominal trauma without indication for emergent exploratory laporotomy
Contraindication
•Patient with abdominal trauma and with indication for emergent exploratory laporotomy
98

Procedure Diagnostic Peritoneal Lavage
•Introduce needle midline through abdominal wall 1 to 2cm below umbilicus at 45o angle to skin
•Apply negative pressure as you advance needle toward pelvis
•Feel for three distinct ‘pops’ – skin, fascia, peritoneum
•Advance 2 – 3 mm after 3rd ‘pop’
99

•If you find blood  end of procedure
•Insert guidewire through needle, then remove needle
•Make small skin incision adjacent to guidewire
•Place lavage catheter over guidewire and advance into peritoneal cavity
100

•Infuse 1L crystalloid solution, then place empty bag on floor
•Collect minimum 200 mL fluid, but as much as possible
•Remove catheter when finished
•Send fluid for cell count
–Threshold 100,000 RBCs/mm3
101

Complications Diagnostic Peritoneal Lavage
•Bleeding / hematoma formation
•Damage to intra-abdominal organs
106

Indication / Contraindication Lateral Canthotomy
Indication
•Acute orbital compartment syndrome
Contraindication
•None
107

Procedure Lateral Canthotomy
•Inject lateral canthal fold: lidocaine with epinephrine
•Insert straight hemostat in lateral canthal fold, clamp for 1 minute to devascularize
•Incise lateral canthus
•Identify and transect lateral canthal tendon
108

Procedure Lateral Canthotomy
Source Undetermined
109

Complications Lateral Canthotomy
•Bleeding
•Globe perforation
•Lacrimal gland injury
•Lateral rectus muscle injury
•Scleral laceration
110

Indication / Contraindication Pericardiocentesis
Indication
•Pericardial tamponade
•Analysis pericardial effusion
Contraindication
111

Procedure Pericardiocentesis
•Insert 18-gauge spinal needle between xiphoid process and left costal margin at 30 – 45o angle
•Aim tip toward patient’s left shoulder
•Aspirate fluid
•Use ULTRASOUND when possible
112

Source Undetermined
114

Source Undetermined
115

Complications Pericardiocentesis
•Pneumothorax
•Bleeding complication
•Damage to coronary artery
•Damage to intraabdominal organ(s)
•Death
116

Indication / Contraindication Venous Cutdown
Indication
•Immediate need for vascular access, no peripheral or central available
Contraindication
•Proximal extremity vascular injury / long bone fracture
•Overlying skin infection, coagulopathy (relative
117

Procedure Venous Cutdown
•Location of greater saphenous vein (GSV): 2.5 cm anterior and 2.5 cm superior to medial malleolus
•Make transverse skin incision from anterior tibial border to posterior tibial border
•Isolate GSV
118

•Insert curved hemostat tip down, scrape along periosteum starting on posterior border until the tip reaches the anterior border
•Rotate hemostat 180o so tip faces upward
•Open the jaws of the hemostat – the GSV should be visible
119

•Switch to straight hemostat, remove curved hemostat
•Insert 16- to 18-gauge IV catheter- over-needle into vein
120

Procedure Venous Cutdown: Groin
•Identify where scrotal / labial fold meets the thigh  ~2cm below site for femoral central venous line
•Make transverse incision medial to lateral beginning at fold
•Dissect subcutaneous tissue with curved hemostat
•Identify and isolate GSV
123

Procedure Venous Cutdown: Groin
•Identify and isolate GSV
•Cannulate either directly or using Seldinger technique
124

Complications Venous Cutdown
•Infection
•Vascular injury
•Nerve injury
•Phlebitis
•Tromboembolism
•Wound dehiscence
125

Indication / Contraindication Anterior / Posterior Nasal Pack
Indications
•Epistaxis
Contraindications
•None
126

Procedure Posterior Nasal Pack
•Prepare the pack: use 3 inch dental rolls, tonsil packs, or 4x4 gauze
•Form a tight cylindrical roll with gauze
•Tie two pieces of umbilical tape or 0- silk suture around pack to divide it into thirds (see picture)
131

132

•Insert red rubber catheters through nostril and pull out through mouth
•Attach pack to red rubber catheters
•Pull pack into place
–Use finger to pass pack around soft palate and uvula
•Place anterior nasal pack
•Secure ties of posterior pack
133
Recommended Source: Reichman EF, Simon RR: Emergency Medicine Procedures

Procedure Posterior Nasal Balloon
•Gather nasal speculum, light source, suction, anethetizing and packing materials
•Place patient in “sniffing position,” give emesis basin and some tissues
•Anesthetize nasal mucosa using cotton pledgets soaked in LET (or cocaine)
142

•Lubricate Foley catheter or posterior balloon with antibiotic ointment
•Insert transnasally until visible in posterior oropharynx
•Inflate balloon with 7 ml of water, gently retract catheter ~2 to 3 cm until lodged in posterior nasopharynx
143

•Inflate balloon with additional 5 to 7 ml of saline
•Secure pack by taping to patient's cheek
144

145

Complications Posterior Nasal Pack
•Nasal septal perforation
•Sinusitis / otitis media
•Toxic shock syndrome
•Aspiration
•Alar necrosis
•Hypoxia from intrapulmonary shunting due to stimulation of nasopulmonary reflex
147

Indication / Contraindication Peritonsillar Abscess I&D
Indication
•Peritonsillar abscess
Contraindication
148

Procedure Peritonsillar Abscess Aspiration
•Identify area of maximum fluctuance
•Cut needle cap so that needle projects only 1cm beyond distal cap
•Depress / distract tongue
•Insert needle, staying parallel to mouth floor
•Advance and aspirate
149

Procedure Peritonsillar Abscess Aspiration
150

Complications Peritonsillar Abscess I&D
•Aspiration
•Airway compromise
•Bleeding
•Vascular injury
153

Indication: Thrombosed External Hemorrhoid Excision
Indication
•Painful thrombosed external hemorrhoid
154

Contraindication: Thrombosed External Hemorrhoid Excision
Contraindication
•Grade IV internal hemorrhoids with thrombosed external hemorrhoids
•Very large hemorrhoids
•Inflammatory bowel disease anorectal fissure, perianal infection, portal hypertension, rectal prolapse, anorectal tumor, immunocompromise
155

Procedure: Thrombosed External Hemorrhoid Excision
•Identify area to be incised
•Use two radial incisions starting near center of anus
•Dissect skin and thrombosis with scissors
•DO NOT cut anal sphincter
•Control bleeding: AgNO3
156

Indication / Contraindication Nail Bed Repair
Indication
•Nail bed injury
Contraindication
•None
160

Procedure Nail Bed Repair
•After digital / regional block: insert closed tip of fine scissors between nail plate and nail bed
•Advance tip while opening / closing blades to separate plate from bed
•Stop scissors when blade tips at eponychium
161

Procedure Nail Bed Repair
•Grasp nail plate with hemostat, pull along long axis of finger
•Repair nailbed laceration with absorbable suture
•Replace nail plate onto nail bed. Suture in place for ~7 days
•If nail missing  petrolatum gauze
162

Complications Nail Bed Repair
•Complete nail loss (expected)
•Nail growth abnormalities
165

Indication / Contraindication Arthrocentesis
Indication
•Diagnosis: obtain synovial fluid
•Therapy: inject steroid, anesthetic
Contraindication
•Overlying infection, coagulopathy, prosthetic joint, septic / bacteremic patient (all relative)
166

Procedure Arthrocentesis
•Palpate bony anatomy, identify anatomic landmarks
•Insert needle into joint space
•If strike bone, withdraw slightly and redirect
•Aspirate synovial fluid
167

Procedure Arthrocentesis – Knee
Source Undetermined
168

Complications Arthrocentesis
•Bleeding / hematoma
171

Indication / Contraindication Felon Incision & Drainage
Indication
•Fluctuant felon
Contraindications
•Herpes whitlow
•Non-fluctuant felon
172

Procedure Felon Incision & Drainage
•If central pulp: central longitudinal finger pad incision with #11 scalpel
•Radial / ulnar fluctuance: medial / lateral pad incision
•Do not cross DIP
•Break up loculations
•Irrigate, pack with drain / dressing
173

Procedure Felon Incision & Drainage
Source Undetermined
174

Complications Felon Incision & Drainage
•Skin necrosis
•Osteomyelitis
•Extension of local infection
•Flexor tenosynovitis
•Neurovascular injury
•Finger pad damage
176

Indication Escharotomy
Indication
•Circumferential full / partial thickness extremity burns & impaired perfusion
•Chest wall burns impairing chest wall movement / ventilation
•Neck burns / impending tracheal obstruction
177

Contraindication Escharotomy
Contraindication (all relative)
•Overlying skin infection
•Coagulopathy
•Prosthetic joint
•Sepsis / bacteremia
178

Procedure Escharotomy
•Sedate patient / use local anesthesia
•Use scalpel / cautery  make incision along medial and lateral aspect of involved extremity
•Make incision from 1cm proximal to burn  1 cm distal to burn
•Extend only through full thickness of skin
179

•Chest: incise along anterior axillary line from clavicle to costal margin bilateral – may join with another
•Neck: incise posterior and lateral to vascular structures
180

Source: Tintinalli JE, et al., Tintinall’s Eergency Medicine: A Comprehensive Study Guide, 7th Edition: http://www.accessmedicine.com
181

Source: Tintinalli JE, et al., Tintinall’s Eergency Medicine: A Comprehensive Study Guide, 7th Edition: http://www.accessmedicine.com
182

Complications Escharotomy
•Bleeding
•Neurovascular damage
•Inadequate decompression
–Muscle damage, nerve injury
–Renal failure  hyperkalemia
–Metabolic acidosis
183

Indication Urethrogram & Cystogram
Indication
•Suspected traumatic injury to lower urinary tract
–Blood at urethral meatus
–High-riding prostate
–Gross hematuria
–Perianal / scrotal hematoma
184

Contraindication Urethrogram & Cystogram
Contraindication
•Hemodynamic instability
•Acute urethritis in patient with low risk
•Cystogram contraindicated if urethral injury identified on urethrogram
185

Procedure: Retrograde Urethrogram & Cystogram
•Use Cystographin, Renographin-60, or Hypaque® 50%
•Retract and secure penile foreskin
•Prime catheter tubing with contrast prior to inserting
•Insert catheter until retention balloon is within glans (fossa navicularis)
186

•Straighten penis across thigh to prevent urethral folding
•Inject 50-60mL over 5–10 seconds
•Can also use 60mL Toomey irrigating syringe
•Get KUB during injection final 10mL
•Extravasation outside urethral contour  disruption
187

•Contrast in bladder with extravasation  partial disruption
•No extravasation  proceed with retrograde cystogram
188

•No extravasation  proceed with retrograde cystogram
•Advance catheter into bladder
•Inflate balloon and gently pull back to lodge balloon at bladder neck
•Remove plunger from 60mL syringe
190

•Fill bladder by gravity with 300 - 350mL of contrast
•Clamp catheter with hemostat
•Obtain KUB  look for filling, extravasation
•Release clamp and drain contrast by gravity
191

•Obtain ‘washout’ KUB
–Extraperitoneal bladder injury  flame-like projection within pelvis  possible conservative management
–Intraperitoneal bladder injury  contrast outlines intraperitoneal organs  surgical management
192

Complications: Retrograde Urethrogram & Cystogram
•Relatively benign procedure – complications rare
194

Indications Perimortem C-Section
•To optimize maternal cardiopulmonary resuscitation
•Rescue of a viable fetus >24 weeks gestation is an important consideration, but such rescue is always secondary to the safety and life of the mother
195

Contraindications Perimortem C-Section
• Mother with serious brain injury but otherwise hemodynamically stable, fetus shows no signs of distress.
•Inability to adequately resuscitate infant after delivery
•Extreme fetal prematurity/immaturity
196

Procedure Perimortem C-Section
•Make a vertical midline skin incision with a #10 scalpel blade beginning 2 to 3 cm above pubic symphysis and extending to 1 cm below umbilicus
•Ignore any subcutaneous bleeding unless it is arterial
–Clamp bleeding artery or use electro- cautery unit to coagulate if available
197

•Extend incision through subcutaneous fat to rectus sheath.
•Grasp and elevate rectus sheath using a toothed forceps
•Make an incision in the rectus sheath with a Mayo scissors. Extend the rectus sheath incision superiorly and inferiorly with a Mayo scissors
199

•Expose the uterus – the underlying peritoneum should be visible
•Insert retractors to fully expose the peritoneal membrane
•Grasp and elevate the peritoneal membrane with a toothed forceps
•Incise the peritoneal membrane with a Mayo or Metzenbaum scissors
201

•Make reasonable attempts to protect the bowel and bladder from injury
•Elevate the bowel off the field and cover it with a saline soaked towel
•Place a bladder retractor over the pubic symphysis to retract the rectus sheath and bladder
202

•Identify the position of the fetal head by palpating the uterus
•Make a 2 to 4 cm midline vertical incision in the uterus
–The amniotic sac will bulge through the incision if the membranes are intact
•Place a finger into the uterine incision and aimed vertically
204

•Insert one blade of a bandage scissors between the finger and the uterine wall
–The other blade of the scissors should be outside the uterus
•Extend the vertical uterine incision fundally, superior and away from the bladder
205

•Rupture the amniotic membranes with a clamp or other blunt instrument
•Carefully transect the placenta if it is anterior to the fetus
•Insert a hand between the pubic symphysis and the fetal occiput
208

•Advance the hand to the base of the occiput
•Flex the fetal head and apply gentle anteriorly and superiorly directed traction to elevate and deliver the head
210

•Deliver the entire fetal head
212

•Suction the mouth and nose with a bulb syringe
214

•Deliver the shoulders in a manner similar to that of a vaginal delivery
•Apply gentle upward traction on the head while an assistant applies pressure on the uterine fundus
–First deliver the anterior shoulder
–Deliver the other shoulder followed by the torso and lower extremities
216

•Clamp umbilical cord with hemostat or umbilical cord clamp approximately 10 to 15 cm from fetus
•Attach second hemostat or clamp 2 to 3 cm distal to the first
•Cut umbilical cord between the clamps with a Mayo scissors
•Resuscitate the neonate
218

Complications Perimortem C-Section
•Maternal sepsis
•Maternal visceral injury
•Maternal hemorrhage
•Fetal injury secondary to delivery
•Possible benefits of maternal and / or fetal survival should far outweigh these considerations
219

Resources
•Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e Judith E. Tintinalli, J. Stephan Stapczynski, O. John Ma, David M. Cline, Rita K. Cydulka, and Garth D. Meckler
•Emergency Medicine Procedures Eric R. Reichman, Robert R. Simon
220

Resources
•Atlas of Emergency Medicine, 3e Kevin J. Knoop, Lawrence B. Stack, Alan B. Storrow, R. Jason Thurman
221

Summary
•Explain risks and benefits, including what will happen if you don’t do it
•Obtain written informed consent (when possible)
•Use appropriate monitoring equipment
•Position patient properly
222

Summary
•Clean / prep / drape appropriate body part
•Use aseptic / sterile technique
•Provide post-procedure instructions
•Many of these procedures available on YouTube
223

GEMC- EMedHome Board Review: Procedures- Resident Training

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GEMC- EMedHome Board Review: Procedures- Resident Training