GS

Acute Limb Ischemia

Anchoring Chest Tube

Burns -- Blisters

Seldinger Chest Drainage

Trauma Documentation

Trauma Documentation

A = C-collar in situ, talking with normal voice, no stridor,

B = SpO2 = 99%RA, RR 16, trachea midline, equal air entry, no SQ air

C = BP , pulse, no external bleeding

D = GCS, pupils, moves all 4 limbs

E =

F = Finger, Fast, Foley, Family, Fentanyl

Allergies

Meds

Past Medical

Last meal

LMP

Events

Family, Friends, Field Personnel

Secondary Survey

- thorough, every bone, every joint

- check mouth, check back

Acute Limb Ischemia (shortcut)

• sudden decrease in limb perfusion with threat to limb viability
• 3 main causes: Emboli, thrombus, trauma
  
• Embolism: of relatively healthy arterial tree
  - originates from heart (MS with Af, MI with mural thrombus) or dilated diseased artery (aortic aneurysm)
  - suddenly occludes
  - usually arrests at arterial bifurcation (Aortic/iliac/femoral/popliteal bifurcation)
  
  
• Thrombus: of previously diseased arterial tree
  - Atherosclerosis: causes progressive narrowing
  - stimulates collaterals
  
  
• Must differentiate Embolus from Thrombus since Management is different
  Embolus: PECS (normal Pulse contralateral, known Embolic source, no Claudication, Sudden)
  
  
• HISTORY:
  1. Acute or not: sudden, severe, severity over time, duration
  DDx for acute ischemia (acute DVT/phlegmasia), hypoperfusion state (HF, Sepsis)
  * partial relief over time may be thrombus with collaterals
  
  2. Severity: numbness, weakness
  
  3. Etiology: Claudication, Heart disease, previous arterial surgery (cardiac cath)
  Atherosclerosis risks: Smoking, HTN, DM, lipids, family hx of CAD
  
  5P's
  
  Pain: symptom
  Pallor: early
  Pulselessness
  Paraesthesia
  Paralysis
  
  
• Pallor/Color
  - Early: pale
  - Late: cyanosed -> mottling -> fixed mottlling and cyanosis
  
  
• Pulse
  - palpate peripheral pulses (femoral, popliteal, posterior tibial, dorsalis pedis) and compare
  - temperature: cold
  - capillary refill: slow
  
  
• Paraesthesia: numbness will progress to anesthesia
  - progress of sensory loss
  1. light touch, vibration sense, proprioception = early
  2. deep pain, pressure sense = late
  
  
• Paralysis: advanced limb threatening ischemia
  - muscle turgidity: irreversible
  - intrinsic foot muscles first, then leg muscles
  - detecting early muscle weakness is hard because toe movements are produced by leg movements
  
  
• Classes of Acute Ischemia (Viable, marginal threat, immediate threat, irreversible)

• Investigations
  1. Doppler: assess level of obstruction and severity of ischemia
  2. If pedal signals are present = there is time for conventional arteriography and patient prep
  3. ABI: no value for acute ischemia, if it can be measured then the limb is not threatened
  
  4. Arteriography
  - high clinical embolic ischemia = no need for angiography
  - Do angiography if: (1) condition permits (2) unclear if thrombus or embolus
  - value
  (1) localizes obstruction
  (2) visualize arterial tree and distal run-off
  (3) can diagnose embolus (sharp cut off, reversed meniscus or clot silhouette)
  
  
• Treatment
  1. Heparin to avoid propagation
  2. Supportive: analgesia, keep foot dependent, avoid extremes of temperature, avoid pressure over heal, O2, correct hypotension, treat HF/Af
  3. Catheter Directed Thrombolysis (CDT): uses strepto/urokinase, TPA
  i: (1) class I, IIa (2) recent acute thrombosis (not for emboli, not for old thrombi)
  c/i absolute
  (1) stroke within 2 months
  (2) active bleeding or recent GI bleed within 10 days
  (3) intracranial trauma or NS within 3 months
  c/i relative
  (1) CPR within 10 days
  (2) major surgery or trauma within 10 days
  (3) uncontrolled hypertension
  
  4. Surgery
  - acute embolism: catheter embolectomy under LA
  - immediate surgical revascularization: class IIb
  or Class I, IIa when thrombolysis is not possible or contraindicated
  
  5. Combination
  6. Amputation: irreversible ischemia with permanent tissue damage (turgid muscle, fixed cyanosis)
  palpable popliteal pulse = below knee
  absent = above knee
  
  
  
  
  --
  link
  

Seldinger Chest Drainage

Seldinger Technique (Catheter Over Guidewire) for Tube Thoracostomy has become very popular these days. It may very well be the procedure of choice for spontaneous pneumothorax.

Indications:

1. Pneumothorax, spontaneous or iatrogenic
2. Low protein effusions, benign or malignant
   
3. Low viscosity empyema

Checklist:

1. Indications
   Pneumothorax vs bullous lung disease
   Pleural effusion vs lung collapse (Seldinger is usually not done in effusion)
2. Side, Site, Triangle of Safety
3. Risk of hemorrhage: coagulopathy, thrombocytopenia
4. Lung densely adherent to chest wall is contraindicated
5. Consent (patient and family), cooperation/compliance
6. Anatomy: Skin, Subcutaneous adipose, Muscle, Intercostal neurovascular bundle,
   Parietal pleura, pleural space, lung tissue
7. Materials: Seldinger chest drain set, 1% lignocaine/syringe 10 mL/needle (skin and deeper tissue), underwater seal bottle, sterile adhesive wound dressing eg Primapore
   
8. Supervision, experience
   

Materials:

1. Skin knife (Scalpel size 11)
2. Tuohy introducer needle (hollow needle with curved tip)
   + 10 mL syringe to confirm (by aspirating) if pleural cavity has been entered
3. Guidewire (50 cm)
   
4. Dilator with safety stop (14F newer 10 cm vs traditional 20 cm)
5. Pleural catheter (12F, 30 cm; some brands have 18F)
   
   
6. Male connector to permit connection to a chest drain system
7. 4-way stopcock

Steps:

1. Position: semi-recumbent 30-45degrees, abduct the shoulder to open the ribs
   
2. Landmark: triangle of safety, identify angle of Louis, the interspace below is 2nd ICS (intercostal space), mark 4th ICS, anterior axillary line with the blunt back of the needle
3. Sterile technique: Gown, chlorhexidine, cover
   then anesthesize the skin, subcutaneous, periosteal surface of rib below the interspace, deeper tissue, pleura -- direction of the needle should be cephalad
   
   After the pleural cavity is entered, hold the level of the needle visible on the skin
   (1) to determine the actual depth the Tuohy introducer needle must traverse
   (2) to determine the actual depth the Dilator must traverse
   
   
   
   

   After the anesthesizing needle is withdrawn, lie it beside the Tuohy introducer needle and measure the depth. Tuohy introducer needle has alternating white and black shades -- each shade corresponds to 1 cm. Also lie it beside the dilator, add another 1cm and slide the safety stop onto that mark.
   
   
   
4. Blade 11: make a 0.5 cm decisive incision on the mark above and parallel to the rib.
   
   
5. Tuohy introducer needle: attach the 10 mL syringe to Tuohy introducer needle; for pneumothorax, the curved bevel should point cephalad on ipsilateral axilla; insert it gently directing to the lower rib at first, then slide it superiorly, this time pointing to contralateral axilla. Enter the pleural cavity gently with the expected depth. Confirmed by easy aspiration, remove the syringe, covering the base of the introducer needle with your thumb
   
6. Guidewire: introduce the guidewire until about 10 cm is visible, remove the Tuohy introducer needle while making sure the guidewire is secure
7. Dilator: Insert it gently directing to the lower rib at first, then, in a rotating fashion push it gently and superiorly pointing to contralateral axilla until the pleural cavity feels a give. The depth should not exceed the safety stop that you marked earlier. Remove the dilator still holding the guidewire in place
   
8. 12F Pleural Catheter: rotate it inward through guidewire until 12 cm level. Remove the guidewire, covering the opening of the Pleural Catheter with your thumb
   
   
9. Insert the male connector or the 4 way stopcock, aspirate and measure the air as if doing needle aspiration.
10. Connect the pleural catheter to underwater seal bottle. Oscillation of the fluid level/colum indicates:
    (1) tip of the pleural catheter is not adherent to soft tissues
    (2) the catheter is not clogged with any tissue
    (3) the catheter is not kinked
    Secure it with dressing. The pleural catheter is usually snugly fit and there is usually no need to anchor it with sutures.
11. Reorder Chest xray. Documentation.

Notes:

• Introducing the anesthesizing needle, Tuohy introducer needle, the dilator, and the pleural catheter should be directed cephalad

DOCUMENTATION
CLINICAL NOTES
right chest tube inserted by Seldinger technique
indication: failed pneumothorax needle aspiration x2
informed consent
Full asepsis
12 Fr pleural catheter, anchored at 12cm level
first pass, uneventful, tolerated well
(see procedure notes)
for repeat CXR

PROCEDURE NOTES
right chest tube inserted inside triangle of safety;
Seldinger technique;
indication: spontaneous pneumothorax, failed to expand adequately after needle aspiration x2;
informed consent, time-out;
Full asepsis;
- Sterile grown, gloves, mask, and face shield;
Positioned, prepped and draped;
local anesthesia, 5mm skin nick;
touhy introducer needle, first pass;
guidewire, then dilated;
12Fr pleural catheter inserted over guidewire, cephalad;
anchored at level 12;
guidewire removed;
connected to underwater seal bottle;
- oscillation of fluid level +;
secured to skin with 2-0 prolene;
dressing;
to re-order xray;

Anchoring Chest Tubes

Fig. 1

One annoying beef that ward doctors receive from EP's is poor anchoring of chest tube -- along with it are chest tube dislodgement, and additional stitches after removing the tube.

One author (M.A. Rashid) has used a simple technique without any such complication for many years. Let's call it the Rashid Technique. [PDF link here].

In the image above, 3 sutures are applied: one is horizontal mattress at the center (purse- string) and 2 simple interrupted at either side. I recommend size 0 Silk for the two anchoring simple interrupted sutures and a Prolene 2-0 for the purse-string.

Steps:

1. Adhere to sterile technique, anesthetize with 10-20mls of 1% Lignocaine, then 2-3 cm skin incision using blade 11 parallel and superior to the rib inside the triangle of safety, 3rd to 5th intercostals at anterior axillary line.
2. Apply the Rashid Technique about 0.5 cm from the wound edge. (you may also do this after inserting the chest tube)
3. Occlude midway of the tube with forceps or clamp and also clamp the tip for protected trochar technique
4. Bluntly dissect with Kelly clamp and confirm/clear with finger sweep, and insert the chest tube with the "protected" trocar  -- anteroapically for air or posterobasally if fluid.
   (Tip: Always point/touch the rib with Kelly, then slide superiorly and dissect; i.e, Rib-Dissect-Rib- Dissect)
5. Clamp the tube and secure the sutures [Fig. 2]
   
   Fig. 2
   
   
   
6. The 2 sutures at either side are first tied to close the wound and the free edges are tied around the tube to bilaterally anchor it. The purse-string is not tied, but wrapped around the tube, few times above the 2 sutures. Then the free edges are grasped by a mosquito clamp from underneath the mattress suture and turned up to be tied around the tube to anchor it. Apply surgical dressing.
   
   Removing the Chest Tube
   
7. Before tube is removed, just cut the 2 side sutures just above their knots. Cut the purse-string below the knot and apply tension on the free ends to close incision and prevent air entry. Ask patient to hold breath at end inspiration and perform Valsalva, remove the tube smoothly and quickly. [Fig 3]
   
   Fig. 3
   
   
8. Tie the sutures to approximate the wound edges. [Fig. 4]
   Fig. 4
   

Blisters in Burns

Q: What do you do to blisters that you see in skin burns?