EMIG's Procedures & Workshop Blog

Fall 2008 IV Workshop

2009-02-05T14:04:00.000-08:00

Check out some of these pictures from our Fall 2008 IV workshop! Good thing we practiced on each other, first!

UWMC Procedures Page

2008-06-08T16:20:00.001-07:00

This excellent resource from the UWMC's Division of Emergency Medicine has multiple procedures all available from a central page based on FLASH. (needs flash player).

http://depts.washington.edu/emed/procedures/index.swf

Thoracentesis & Fluid Analysis (Loyola)

2008-05-08T16:32:00.000-07:00

Thoracentesis and Fluid Analysis
Arcot J. Chandrasekhar M.D and Edward Garrity M.D

Indications (See More)

Effusion without a secure clinical diagnosis (e.g., CHF) or small quantity
Thoracentesis is a diagnostic procedure done............

Examination of the Larynx and Pharynx (NEJM)

2008-05-08T16:29:00.001-07:00

View Video

Visualization of the larynx and pharynx is an essential part of a complete head and neck examination. Although the location of these structures often precludes direct visualization, simple techniques can be used to evaluate these anatomic structures in the clinical setting. Indirect laryngoscopy can be performed with either a simple dental mirror or with a flexible fiberoptic endoscope. These procedures can be performed on patients who are awake and cooperative, and are usually well tolerated. Patients with symptoms such as chronic cough, dysphonia, chronic throat pain, dysphagia, voice changes, and symptoms of aspiration should all undergo careful laryngoscopy. Patients who are at high risk . . . .

Chapters:

Overview
Indications
Equipment
Mirror Laryngoscopy
Flexible Nasolaryngoscopy
Limitations
Aftercare
Tips & Troubleshooting
Summary

Positive Pressure Bag Valve Mask (NEJM)

2008-05-08T16:26:00.000-07:00

View Video

Providing positive-pressure ventilation with a face mask and a bag-valve device can be a lifesaving maneuver. Although seemingly simple, the technique requires an understanding of the airway anatomy, the equipment, and the indications. Developing manual skills is necessary to provide adequate face-mask ventilation. While endotracheal intubation is frequently the definitive airway management approach for patients in respiratory failure, it is not always feasible. In these circumstances, ventilating a patient with a face mask can be an invaluable temporizing measure. The purpose of this video is to demonstrate the equipment and technique used to provide positive-pressure . . . .

Chapters:

Introduction
Overview
Indications
Contraindications
Equipment
Procedure
Complications
Summary

Male & Female Catheterization (NEJM)

2008-05-08T16:24:00.000-07:00

View Video

Male urethral catheterization may be performed as either a therapeutic or a diagnostic procedure. Therapeutically, catheters may be placed to decompress the bladder in patients with acute or chronic urinary retention. In addition, catheters may be placed to facilitate bladder irrigation in patients with gross hematuria. Diagnostically, urinary catheters may be placed to obtain an uncontaminated urine sample for microbiologic testing, to measure urinary output in critically ill patients or during surgical procedures, or to measure post-void residuals. The only absolute contraindication to urethral catheterization is known or suspected urethral injury, usually in the setting of a pelvic fracture. Trauma patients . . . . View Video

Chapters:

Introduction
Indications
Contraindications
Equipment
Anatomy
Preparation
Catheterization
Troubleshooting
Complications

View Video

Female urethral catheterization, the insertion of a catheter through the urethra into the urinary bladder to permit drainage of urine, is a fundamental skill for the practicing health care professional. This video discusses the indications for catheterization, the equipment available, the current methods of catheter insertion and maintenance, potential complications, and how to troubleshoot common problems. Indications Female urethral catheterization is indicated for both therapeutic and diagnostic purposes. Urinary catheterization is therapeutic in several circumstances. It permits effective bladder drainage in patients with acute or chronic urinary retention. A urinary catheter may be used to instill medication for local . . . .

Chapters:

Introduction
Indications
Contraindications
Equipment
Preparation
Anatomy
Procedure
Complications
Summary

Abscess Incision and Drainage (NEJM)

2008-05-08T16:21:00.000-07:00

View Video

Incision and drainage is the primary therapy for cutaneous abscess management, as antibiotic treatment alone is inadequate for treating many of these loculated collections of infectious material. Most localized skin abscesses without associated cellulitis can be managed with simple incision and drainage and do not require antibiotic treatment. Cutaneous abscesses have been described in all areas of the body, but are most commonly found in the axillae, buttocks, and extremities. This outpatient procedure is appropriate for many office settings, as well as for urgent care and emergency department practice environments. Diagnosis of a skin abscess is the first step . . . .

Chapters:

Overview
Indications
Contraindications
Equipment
Preparation
Abscess Incision and Drainage
Aftercare
Complications

Lumbar Puncture (eMedicine)

2008-05-08T16:19:00.001-07:00

Lumbar puncture is a procedure that is often performed in the emergency department to obtain information about the cerebrospinal fluid (CSF). Although usually used for diagnostic purposes to rule out potential life-threatening conditions such as bacterial meningitis or subarachnoid hemorrhage.... (read more)

Central Line Placement (ClinicalCases.org)

2008-05-08T16:15:00.000-07:00

Central Line Placement: A Step-by-Step Procedure Guide with Photos

Authors: V. Dimov, M.D., Clinical Assistant Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio; B. Altaqi, M.D., Assistant Clinical Professor of Medicine, University of Louisville, Kentucky

The Physical Exam (A Collection)

2008-05-08T16:08:00.000-07:00

Percussion of the spleen? If you need to brush up your physical exam skills, the websites below can be very useful.... (read more)

Nasogastric Intubation (NEJM)

2008-05-08T16:07:00.000-07:00

View Video

Common indications for nasogastric intubation include decompression of the GI tract in patients with bowel obstruction and gastric emptying in intubated patients to prevent aspiration. NG tubes may be placed as an adjunct for the delivery of oral agents, such as activated charcoal or oral radiographic contrast medium. NG tubes are often placed in patients with suspected upper GI hemorrhage. However, the sensitivity and negative predictive value of nasogastric aspirates for detecting active bleeding is suboptimal, and the absence of bloody return cannot be relied upon to rule out hemorrhage. Nonetheless, nasogastric intubation may be useful in selected patients. Evacuation . . . . View Video

Chapters:

Introduction
Indications
Contraindications
Equipment
Preparation
Tube Insertion
Confirmation
Securing the tube
Complications

Arthrocentesis of the Knee (NEJM)

2008-05-08T16:05:00.000-07:00

View Video

Diagnostically, arthrocentesis is indicated to rule out septic arthritis in individuals presenting with a single or several inflamed joints. Arthrocentesis can also be used to differentiate between crystal arthropathies, such as gout and pseudogout, inflammatory and noninflammatory effusions, and hemarthroses. It should be emphasized that a single inflamed joint should almost always undergo at least one diagnostic aspiration. Therapeutically, arthrocentesis may be performed to drain large effusions, hemarthroses, or to inject steroids or local anesthetic. Arthrocentesis should be avoided in patients with cellulitis overlying the site of needle entry, out of concern of seeding the joint cavity with bacteria. Known . . . . View Video

Chapters:

Introduction
Indications
Contraindications
Equipment
Anatomy & approach
Joint aspiration
Synovial-fluid analysis
Complications

Placement of an Arterial Line (NEJM)

2008-05-08T16:03:00.000-07:00

View Video

Arterial Line Placement (Introduction) This video will demonstrate arterial line placement in the radial artery using two of the many techniques available for arterial line placement, an over-the-wire technique and an over-the-needle technique. Placement of an arterial line is indicated for continuous monitoring of arterial pressure and direct arterial blood sampling. The radial pulse is palpated between the distal radius and the flexor carpi radialis tendon. Prior to line placement, perfusion of the extremity should be checked. For radial arterial catheters, an Allen test or a modified Allen test may be performed. While the value of the Allen test has . . . . View Video

Chapters:

Introduction & Overview
Landmarks
Preparation
Positioning
Over-the-Wire Technique
Over-the-Needle Technique
Secure with Suture
Troubleshooting

Scrubbing For the OR (Boston University)

2008-05-08T16:00:00.000-07:00

Scrubbing for the O.R.

A video created by
Ellen Lones, M.S.N., R.N., C.N.O.R. and Wayne W. LaMorte, M.D., Ph.D., M.P.H.

Pelvic Exams (NEJM)

2008-05-08T15:59:00.000-07:00

View Video

This video will demonstrate how to perform a comprehensive pelvic examination, which includes an examination of the external genitalia, a Papanicolaou test, a bimanual examination, as well as a rectovaginal examination. Indications Women should undergo a pelvic examination when they have vulvar and or vaginal complaints such as pain, discharge, abnormal bleeding, itching, and/or a mass. A pelvic examination is also indicated when pregnancy is suspected or proven, and in women who have been exposed to sexually transmitted infections. Pap testing is the main screening tool for detecting precancerous lesions of the cervix, we will now highlight the American Cancer Society . . . .

Overview
Indications
Preparation
Procedure
Troubleshooting
Contraindications

Basic Suturing (Boston University)

2008-05-08T15:56:00.000-07:00

Basic Knot Tying and Suturing
Wayne W. LaMorte, M.D., Ph.D., M.P.H.

The modules below consist of step-by-step instructions and streaming video demonstrations of basic knot tying and suturing techniques. (read more)

Basic Laceration Repair (NEJM)

2008-05-08T15:55:00.001-07:00

View Video

Lacerations are among the most common reasons for visits to emergency departments. Although most lacerations will heal without treatment, repair of these injuries reduces infection, scarring, and patient discomfort. Sutures, tissue adhesives, and wound tapes may all be used for laceration repair. Tissue adhesives and wound tapes are suitable for smaller lacerations that are not subject to substantial tension. In this video, however, we will demonstrate the use of simple interrupted sutures. Contraindications Not all lacerations are suitable for primary closure. Some should be allowed to heal by secondary intention (i.e., granulation and re-epithelialization). The interval between injury and . . . .

Chapters:

Overview
Indications
Contraindications
Equipment
Preparation
Laceration repair
Aftercare
Complications

Anchoring Central Lines (Boston University)

2008-05-08T15:52:00.000-07:00

This info may be specific to Boston University, but there may also be good stuff in general on central lines.... (read more) (video)

Basic Wound Closure (Boston University)

2008-05-08T15:50:00.000-07:00

Basics of Wound Closure and Healing

Wayne W. LaMorte, M.D., Ph.D., M.P.H.

There are many circumstances in which sutures are used to repair tissue and facilitate healing. The techniques that you use, the suture material you use, and the specific type of needle you use will vary depending on whether you are closing a simple laceration on the foot, a complex laceration on the face, a gastrointestinal anastomosis, a vascular anastomosis, or closing a median sternotomy. (read more)

Central Venous Catheterization via Subclavian (NEJM)

2008-05-08T15:47:00.000-07:00

View Video

Evidence suggests that the risk of major central venous line complications, particularly line-related bloodstream infections, is lower when the subclavian approach is used. This video will identify the landmarks and procedure for placement of a subclavian central line. Specific contraindications for the placement of a central venous line in the subclavian vein include infection of the area overlying the target vein and thrombosis of the target vein and fracture or suspected fracture of the clavicle or proximal ribs. Coagulopathy, while not an absolute contraindication, should be of greater concern with the subclavian approach because of the difficulty in applying . . . .

Chapters:

Overview
Preparation
Placing the Line
Troubleshooting

Orotracheal Intubation (NEJM Videos)

2008-05-08T15:46:00.000-07:00

View Video

Emergency orotracheal intubation is indicated in any situation in which definitive control of the airway is needed. Specific indications include cardiac or respiratory arrest, failure to protect the airway from aspiration, inadequate oxygenation or ventilation, and impending or existing airway obstruction. Orotracheal intubation is also commonly performed as part of the care of the critically ill patient with multisystem disease or injuries, and to facilitate control of the airway during surgical procedures requiring general anesthesia. Contraindications: In emergent cases, such as cardiac arrest, airway management is of paramount importance, and there are very few contraindications to orotracheal intubation. Unstable . . . . View Video

Chapters:

Overview
Indications
Contraindications
Equipment
Preparation
Orotracheal Intubation
Confirmation
Securing the Tube
Complications

Lumbar Punctures (NEJM Video)

2008-05-08T15:45:00.000-07:00

View Video

This video will demonstrate safe and successful methods of performing lumbar puncture. Lumbar puncture is indicated for both diagnostic and therapeutic purposes. Also, the administration of spinal and epidural anesthesia involves the use essentially of the same technique. Analysis of cerebrospinal fluid may be helpful in the diagnosis of infectious processes such as meningitis, inflammatory diseases such as multiple sclerosis, cancers such as leukemia, and metabolic processes. Therapeutically, lumbar puncture allows for the intrathecal administration of chemotherapeutic agents and antibiotics. There are specific contraindications to lumbar puncture. The condition of patients with cardiorespiratory compromise may worsen as a consequence of . . . .

Chapters:

Introduction
Overview
Gather the Equipment
Positioning
Preparation
Needle Insertion
Opening Pressure
Specimen Collection
Challenges
Complications

Chest Tubes (NEJM Video)

2008-05-08T15:44:00.000-07:00

View Video

The insertion of a pleural chest tube is often done in a setting where immediate action is required. Nonetheless, adherence to sterility, analgesia, sound technique, and safety are always warranted. Indications The most common indications for chest-tube drainage are: Pneumothorax that is recurrent, persistent, under tension, or bilateral; any pneumothorax in a patient on positive-pressure ventilation; hemothorax; recurrent or symptomatic large pleural effusion; empyema; and chylothorax. Contraindications There are relative contraindications, mainly based on hematologic abnormalities such as bleeding diatheses or coagulopathy. Blood products or coagulation factors may need to be transfused in order to reduce the . . . . View Video

Chapters:

Overview
Indications
Contraindications
Equipment
Landmarking
Anesthetizing Tissues
Incision and Dissection
Securing the Tube
Pleural Drainage Systems
Complications
Removing the Tube

Thoracentesis (NEJM Video)

2008-05-08T15:34:00.001-07:00

View Video

Thoracentesis is used diagnostically to establish the cause of a pleural effusion. It can also be performed to drain large effusions that lead to respiratory compromise. Contraindications Limited data exist regarding the safety of thoracentesis in patients with coagulation abnormalities. The procedure is probably safe in patients with mild or moderate elevations of the prothrombin time or partial-thromboplastin time. The decision to use fresh-frozen plasma or platelet concentrates in patients with clinically significant coagulopathy or thrombocytopenia must be made on an individual basis. The procedure should be used with care in patients who are receiving mechanical ventilation, since positive-pressure . . . .

Chapters:

Introduction
Indications
Contraindications
Equipment
Preparation
Pleural fluid aspiration
Pleural fluid analysis
Complications

EMIG's Suture Workshop Handout

2008-05-08T15:24:00.001-07:00

This is an excellent handout to accompany the UW EMIG Suture Workshop! Be sure to attend our annual suturing workshop in the fall, every fall!! Contact EMIG for more info!