Miscellaneous Procedures

Glen Tinkoff

Frederick Giberson

Introduction

Many procedures are performed as adjuncts to the resuscitation of the trauma patient in the emergency department or at the bedside in the ICU. We describe approaches and where available, the internet URL addresses of images and video clips of these procedures in the public domain have also been cited.

I. Adjunctive Procedures to Resuscitaton

Naso/orogastric tube intubation
- Indications
  - Gastric decompression
  - Gastric lavage
- Contraindications
  - Mid-face or basilar skull fracture (use an orogastric route)
  - Obstruction of the naso/oropharynx, or esophagus
- Technique
  - In the conscious patient, nasal insertion is preferred if not contraindicated; in patients who are unconscious or have been intubated, the oral route is preferred.
  - Lubricate tube with a water soluble lubricant.
  - Elevate head of bed, if possible.
  - If inserting nasally, introduce the tube gently into the nostril; slowly direct the tube posteriorly and caudad into the posterior oropharynx by inserting short increments (do not advance upward—a common error, usually done when external nasal slope is followed instead of passage directly posterior). If inserting orally, advance tube to the posterior oropharynx over the tongue in a similar fashion.
  - Do not advance the tube while the patient is talking or inhaling.
  - If possible, the tube should be inserted by gently advancing as the patient swallows.
  - Once in the esophagus, the tube should advance easily into the stomach. Gagging is common during insertion; if the patient loses their voice, becomes hoarse, or has violent coughing, withdraw the tube as it is likely to be in the trachea.
  - Inject air into the tube via a large syringe and auscultate over the left upper quadrant of the abdomen for a “rush” of air.
  - If gastric location is confirmed with air injection, irrigate the tube with normal saline and aspirate to remove particulate gastric contents.
  - Secure the tube with adhesive tape.
  - Attach to low continuous suction (if a sump tube).
- Complications
  - Epistaxis (nasal placement)
  - Sinusitis (nasal placement greater than 24 hours)
  - Pneumothorax
  - Aspiration
  - Intracranial insertion (nasal placement)
- Available internet video
  - http://emedicine.medscape.com/article/80925-overview#a15
  - http://www.nejm.org.easyaccess1.lib.cuhk.edu.hk/doi/full/10.1056/NEJMvcm050183#figure=preview.gif
Optical tonometry/lateral canthotomy
- Indications
  - Traumatic retrobulbar hematoma with intraocular pressure (IOP) >30 mm Hg
  - Proptosis
  - Decreased visual acuity
  - Presence of retrobulbar hematoma
- Contraindications
  - Globe rupture
- Technique of optical tonometry (e.g., Tono-Pen®)
  - Clear debris, cleanse and prep affected periorbital area
  - Apply topical ocular anesthetic (e.g., tetracaine, proparacaine) to cornea
  - Place cover over probe tip
  - Activate and calibrate device
  - Take measurement of affected eye by lightly touching the cornea and listening for the “click”; take at least four separate readings or until instrument signals and provides an average reading
  - If IOP >30 mm Hg, perform a lateral canthotomy
- Technique of lateral canthotomy
  - Infiltrate dermis above lateral canthus with 1 to 2 cc of 1% to 2% lidocaine with epinephrine
  - Apply straight hemostat from lateral canthus toward bony orbit for 30 to 90 seconds
  - Incise demarcated area 1 to 2 cm
  - With forceps, pull caudad on lower led to visualize inferior lateral canthal tendon
  - Incise inferior canthal tendon with iris scissors
  - Reassess IOP—if increased, lift upper eyelid and incise superior lateral canthal tendon
- Complications
  - Infection
  - Hemorrhage
  - Injury to globe
- Available internet video
  - Optical tonometry
    - http://www.youtube.com/watch?v=-l2fS4ykYsc…feature=related
    - http://www.youtube.com/watch?v=-Y3KtAnbuFo…feature=related
  - Lateral canthotomy
    - http://emedicine.medscape.com/article/82812-overview#a15
Reduction of common dislocations
- General considerations
  - Manage life-threatening injuries first.
  - Perform a thorough neurovascular examination of the affected extremity.
  - Confirm clinical findings with appropriate radiologic assessment.
  - Know the joint anatomy well.
  - If an associated fracture is evident, consult an orthopedic surgeon early.
  - Administer adequate IV analgesia and sedation with appropriate hemodynamic monitoring before proceeding.
  - If unable to reduce the dislocation or reduction is lost, splint the extremity in position and obtain orthopedic consultation.
- Reduction of a shoulder dislocation
  - Anterior dislocation (most common)
    - Place patient supine with the affected arm adducted with elbow flexed at 90 degrees.
    - Hold the patient’s wrist and slowly externally rotate.
    - Continue the external rotation until the forearm is near the coronal plane.
    - If this maneuver is unsuccessful, lift the arm perpendicular to the patient’s torso while applying axial traction and rotate the arm externally.
    - If the shoulder still remains dislocated, consider utilizing traction–countertraction.
    - Flex the patient’s elbow on the affected side to 90 degrees and wrap a sheet or strap around the proximal forearm.
    - Wrap a sheet or strap around the upper chest under the axilla of the affected shoulder to provide countertraction.
    - Apply traction to the arm while an assistant applies countertraction.
    - Also gently rotate the arm externally to facilitate reduction.
  - Posterior dislocation
    - Posterior dislocation is usually amenable to closed reduction only if there is minimal displacement and recent onset.
    - Use traction–countertraction method as described previously.
    - Abduct and internally rotate the affected arm.
    - Apply anteriorly directed pressure on the humeral head.
  - Post-procedure care
    - Reassess neurovascular status (notably sensation on shoulder area).
    - Confirm reduction of the dislocation with post-reduction radiographs that include a lateral view.
    - Immobilize the reduced shoulder with sling.
  - Complications
    - Displacement of fractures of the humeral neck
    - Avascular necrosis of the humeral head
    - Neurovascular injury
    - Joint instability leading to recurrent dislocation
- Reduction of a hip dislocation
  - Posterior dislocation (most common)
    - Confirm diagnosis based on the presence of a shortened, internally rotated lower extremity on physical examination and on radiologic examination, the femoral head located posterior to the acetabulum.
    - Have an assistant apply countertraction by pushing on the anterior superior iliac spines
    - Hold affected leg in adduction with the knee flexed.
    - Apply axial traction, in line with the deformity while gently flexing the hip to 90 degrees or until reduction is achieved.
  - Anterior dislocation
    - In anterior hip dislocations, the femoral head is displaced anterior to the acetabulum causing the lower extremity to be shortened and externally rotated. On radiologic assessment, the femoral head should lie over the obturator foramen.
    - Have an assistant apply countertraction by pushing on the anterior superior iliac spines.
    - Hold affected leg in abduction, with the knee slightly flexed.
    - Apply axial traction, in line with the deformity, and gently adduct and internally rotate until reduction is achieved.
  - Post-reduction care
    - Reexamine the hip range of motion to assess stability.
    - Repeat the neurovascular examination.
    - Immobilize; use a knee immobilizer for posterior and an abduction pillow for anterior dislocations.
    - Obtain appropriate post-reduction imaging studies.
    - If the hip is unstable, a traction pin may be needed.
  - Complications
    - Nerve or vascular injury
    - Avascular necrosis of the femoral head
    - Osteoarthritis
    - Heterotopic ossification
- Reduction of an ankle dislocation
  - Posterior dislocation (most common)
    - Grasp the foot by the heel and forefoot while an assistant holds the leg at the knee in flexion.
    - Plantar flex the foot slightly and apply axial traction.
    - Slowly push the heel anteriorly against downward countertraction on the tibia until reduction is achieved.
    - Keep the foot in dorsiflexion until splinted.
  - Anterior dislocation
    - Grasp the foot by the heel and forefoot while an assistant holds the leg at the knee in flexion.
    - Dorsiflex the foot and apply axial traction.
    - Slowly push the forefoot posteriorly against upward countertraction on the tibia until reduction is achieved.
    - Keep the foot in plantar flexion until splinted.
  - Lateral dislocation
    - Associated with malleoli fractures often managed with open reduction and internal fixation.
    - Closed reduction achieved in a similar manner to posterior dislocation except foot should be manipulated medially or laterally as needed to achieve reduction.
  - Post-procedure care
    - Splint the ankle at 90 degrees with a posterior short leg splint.
    - Reassess neurovascular status.
    - Repeat radiologic assessment to confirm reduction.
  - Complications
    - Neurovascular injury, uncommon
    - Loss of range of motion
    - Joint instability
    - Chronic pain
- Available internet video
  - Shoulder (anterior)—http://emedicine.medscape.com/article/109130-overview #a15
  - http://www.youtube.com/watch?v=CGvy6sA2OD4…feature=youtube gdataplayer
  - Hip (posterior)—http://www.medicalvideos.us/videos/1598/
  - Ankle (posterior)—http://emedicine.medscape.com/article/109244-overview #a15
Ring removal from a compromised digit
- Indications
  - Removal of ring or other constricting object from a compromised or potentially compromised digit.
  - If neurovascular compromise, ring cutter or other metal cutting instrument should be employed.
- Technique
  - Elevate finger relative to others above head and/or torso and compress it manually.
  - Pass tape/suture under ring (may be facilitated with a hemostat) then wrap proximal to distal with umbilical tape or heavy silk in spiral fashion from tip to base.
  - Lubricate ring generously.
  - Apply gentle pull traction on ring and toward tip and unwrap the tape/suture from under ring while pushing ring toward tip of the finger.
  - The finger portion from a powder-free latex glove can be used in similar manner with cut edge pulled under the ring.
  - If this fails, the ring must be cut to relieve neurovascular compromise.
- Complications
  - Injury to underlying skin and soft tissue structures
  - Fracture/dislocation of the proximal phalanx
- Available internet images
  - http://www.knowabouthealth.com/quick-tips-to-remove-stuck-ring-from-swollen-finger/3510/
Skeletal traction pin insertion
- Indications
  - Femur fracture which cannot undergo early definitive treatment (i.e., severe TBI)
- Contraindications
  - Unstable knee injury
  - Open distal femur or proximal fibula fracture
- Technique
  - For short duration (i.e., 2 to 3 days), insert 1 cm distal to anterior tibial tubercle.
  - For more prolonged traction (i.e., ≈1 week) insert into distal femur.
  - Align leg from the great toe, through the patella to the anterior iliac spine.
  - Elevate the leg to allow the drill handle to turn without striking the bed.
  - Prepare and drape the knee and proximal tibia.
  - Infiltrate entry and exit sites with local anesthetic.
  - Use a non-threaded Steinman pin or Kirschner wire for tibial insertion (a threaded pin should be used with femoral insertion).
  - Make a small skin incision laterally, 2 cm distal and posterior to the anterior tibial tubercle or 2 cm above the femoral condyles.
  - Engage the pin/wire against the bone and stay parallel to the ground.
  - Drill through both cornices. When the pin pushes against the medial skin, the skin is incised with the scalpel. The pin/wire should extend beyond the skin 1 to 2 in.
  - Cut the pin/wire to length and cap the ends with corks or rubber stoppers.
  - Attach the pin/wire into the appropriate bow and traction.
  - Dress the pin sites with povidone-iodine and 2 × 2 gauze.
- Complications
  - Failure to obtain purchase into bone
  - Bleeding
  - Pin site infection
- Available internet video
  - http://www.youtube.com/watch?v=WXN9RMjyn4M…feature=email