ADZU-SOM COURSE IV OUTLINE

ADZU-SOM POTENTIA DOMUSCOURSE IV OUTLINEEmergency Medicine

1. Medical Emergencies

These are unwanted conditions in human beings which can lead to death or permanent disability if not managed adequately on time.2. Common Types of Medical Emergency seen in the Communitya. Types of medical emergencies will vary from community to communityb. People have varying interpretations of Medical Emergenciesc. As a consequence of the second factor, the list will be long enough if not infinite3. Physicians Responsibilities in the Management of Medical Emergencies Preparedness Competencies Self-directed Learning Materials Equipments Medicines4. Physicians Goals in the Management of Medical Emergencies Save life Prevent Disability Restore Health5. General Strategies in Managing Medical Emergencies Rapid, Accurate Diagnosis Adequate and Timely Treatment Airway Breathing Circulation Others Rehabilitation6. Diagnose Cardiopulmonary ArrestIt is the absence or inadequacy of ventricular contraction that immediately leads to systemic circulatory failure. Warning Signs Angina Pectoris Sudden onset of palpitation Sustained tachycardia Light-headedness Dyspnea Early Signs Loss of consciousness Rapid, shallow breathing, leading rapidly to apnea Non-palpable pulses over major vessels Absent heart sounds Late Signs Progressive cyanosis Loss of pupillary reflex (dilated pupils) Arterial hypoxemia7. Pathophysiology of Cardiopulmonary ArrestElectrical dysfunction is the most common mechanism of cardiac arrest (80%) with Ventricular fibrillation accounting for (70%) of those. In VF, loss of coordinated global contraction of the ventricular myocardium leads to immediate loss of effective cardiac output resulting to circulatory shock.Sustained Ventricular Tachycardia is a relative uncommon cause (10%) but has the best prognosis. Contributory factors include coronary artery disease, cardiomyopathy, hyperkalemia and digitalis poisoning.Asystole is the complete ECG absence of electrical activity with absent perfusion, BP and pulse. Causes include severe generalized myocardial ischemia and hyperpolarization of cardiac cell membrane seen in severe hyperkalemia, hypomagnesemia or ventricular rupture.Electrochemical Dissociation accounts for 20% of the cases. The primary mechanisms are cardiac rupture, acute tamponade, global ischemia, acute MI and chronic heart disease.Circulatory Shock has many aetiologies but diastolic arterial hypotension is the final common denominator leading to impairment of coronary artery blood flow, myocardial electric instability and cardiac respiratory arrest. Circulatory shock may be due to decreased circulatory blood volume or obstruction to ventricular filling or output. Respiratory arrest may be primary, caused by airway obstruction, and decreased respiratory drive or respiratory muscle weakness; or secondary as a result of cardiac arrest itself.

8. Steps in Cardiopulmonary Resuscitation (2010 AHA Standard)1) Gently shake the shoulders and ask loudly,Hey! Hey! Are you OK? (Done twice)2) If the victim is unresponsive, call for Help!Help! Call 911! Activate E.M.S.! And get the A.E.D!3) Check for signs of circulation (carotid pulse), If there is no pulse...4) Provide Chest Compressions. Place the heel of the palm, at the center of the chest between the nipples. Position shoulders over hands with elbows locked and arms straight. Arms should be perpendicular to the victims body. Compress the breastbone at least two inches with each compression. Provide 30 compressions and 2 ventilations. Push hard, push fast, allow chest recoil, minimize interruptions and avoid hyperventolations. Continue to provide 4 or more cycles of 30 chest compressions and 2 slow breaths. After 5 cycles of CPR, check the pulse.Note: If signs of circulation are detected, stop chest compression and continue to provide rescue breathing if needed. (1 breath every 5 seconds) If you dont detect signs of circulation, continue to provide 5 cycles of 30 chest compressions and 2 slow rescue breaths.8. Post-resuscitation Management of CPR When to terminate CPR? Remember STOPS.s- Spontaneous breathing and circulation are detected.T- Trained personnel have arrived. Endorse.O-Operator is exhausted.P-Physician has announced that the patient is dead.s- Scene is not safe.

Complications of CPR. Remember, FLPGB.F-Fractured ribL-Lacerated liverP-Punctured LungsG-Gastric distentionb-Bruises An atraumatic individual who recovers spontaneous respirations and circulation should be placed on their sidethe Recovery Position or Haines positon with high arm in endangered spine. Recovery from cardiac arrest depends on time to CPR and rhythm-specific intervention.9. Diagnose Acute Respiratory ObstructionIt is a condition wherein the patencies of the respiratory passages are compromised. The common culprits are: foreign bodies and the tongue. Normal breathing stops or breathing is reduced and that oxygen intake becomes insufficient to support life.CLINICAL MANIFESTATIONS: Weak, Ineffective cough Stridor Respiratory distress Cyanosis Inability to speak or breathe collapseTYPES:a) Complete airway obstruction Apnea Unable to speak, breathe or cough May clutch the neck with the thumb and fingers (The universal sign of choking)b) Partial airway obstruction Noisy breathing1) Good air exchange Can cough forcefully Wheezing present between cough2) Poor air exchange Weak, ineffective cough High pitched noise when inhaling Respiratory difficulty Possible cyanosis10. Pathophysiology of Acute Respiratory ObstructionIf the airways are obstructed, either foreign object or tongue, there occurs poor ventilation leading to decreased oxygenation of vital organs. This will eventually lead to unconsciousness and cardiopulmonary arrest. If no oxygen reaches the brain in 10-15 minutes, there will be irreversible brain damage and death will occur.

11. Procedures to Relieve Acute Respiratory ObstructionA. Back Blows Administer 5 blows with the heel of the hand over the spine, between the shoulder blades. While supporting the patient with the other hand on the sternum. Apply the back blows in rapid succession. They may be given in any position. If possible, position the patients head lower than the chest.B. Subdiaphragmatic Thrust/Heimlich Maneuver (2010 AHA Standard) Is often done to forcefully expel the blocking object. This is repetitively done until the object is expelled or the victim becomes unconscious. Steps:1. Ask the patient, are you choking? (If the patient nods, continue the following procedure. You dont need to act if the victim can forcefully cough and speak because coughing is the best way to remove the obstruction.2. Stand behind the victim.3. Insert one leg in between the victims leg. (Tripod Position)4. Make a fist with one hand placing the thumb side of the fist against the abdomen, in the midline slightly above the umbilicus and below the xyphoid process.5. Grasp your fist with the other hand.6. Deliver quick upward thrust into the victims abdomen.7. Continue until the object is expelled or the victim becomes unconscious.

C. Abdominal Thrust for lying patient1. Position the patient on the back.2. Sit and ride the patients hip facing his face with one of your hands on top of the other. Place the heel of the bottom hand on the patients abdomen between the waist and the rib cage.3. Deliver quick upward thrust into the victims abdomen.4. Continue until the object is expelled or the victim becomes unconscious.

D. Finger Sweep1. Open the patients mouth by grasping both the tongue and the lower jaw between your thumb and fingers then them both.2. Sweep your finger into the patients mouth using a hooking action to dislodge and remove the foreign body.3. If the patient is unconscious, attempt to ventilate with mouth to mouth ventilation.4. Repeat back blows, thrusts and finger sweep.12. Post-Procedure Management of Acute Respiratory Obstruction Place patient in recovery position. Maintain airway and promote rest. Continuously monitor vital signs. Assess for possible complications during initiation of life-saving measures to remove foreign body obstruction.13. General Principles in the Management of Trauma Patients The most important clinical sign in head injuries is the changing state of consciousness. Carefully document this and other neurologic signs at frequent intervals in any head-injured patient. Falling blood pressure is almost never caused by head injury. Look for a source of major hemorrhage elsewhere in the body if the head-injured patient becomes hypotensive. Seal open injuries in the neck immediately to prevent possible air embolism. If any patient whose mechanisms of injury suggest the possibility of spine injury, immobilize the spine. For practical purposes, this category every multiple-injured patient as well as any patient with serious head injury-irrespective of whether clinical signs or spinal injury are present. Palpate the chest for instability and stabilize any flail segments. Cover any eviscerated abdominal organs with bulky sterile saline dressings. Dont attempt to place any eviscerated organs back into the abdomen. Stabilize any impaled object in place. Always check all extremities for pulse. Dress all wounds before splinting fractures. Splint all fractures before moving the patient. Straighten angulated fractures. Fractures involving the joints should be splinted where they lie. Save amputated parts. These should be wrapped in sterile gauze that has been moistened with sterile saline and placed in a plastic bag. The bag should then be placed on ice. 14. Diagnose Acute Fractures A disruption of normal bone continuity, soft tissue injury often also occurs. The following are types of fractures:1. Closed fracture- does not involve a rupture of the skin and frequently is referred to as Simple fracture.2. Open fracture- implies skin is broken and is sometimes called Compound fracture.3. Complete Fracture- fracture line extends through the entire bone structure.4. Incomplete fracture (partial)-fracture line extends partway through the bone.5. Impacted fracture (telescoped)-one bone fragment is forcibly driven into another adjacent bone fragment.6. Comminuted fracture- more than one fracture line and bone fragments are crushed or broken into several pieces.7. Displaced fracture- bone fragments are at a fracture line8. Complicated fracture-The fracture is associated with injury to surrounding structures. Fracture Assessment Findings1. Deformity-alignment and contour changes Angulation, rotation and limb shortening Bone depression Altered curves2. Swelling3. Bruising-also called ecchymosis from subcutaneous bleeding4. Muscle Spasm-due to involuntary muscle contraction near the fracture5. Pain- accompanied by tenderness6. Impaired sensation or numbness7. Loss of normal function8. Abnormal immobility9. Crepitus10. Shock -which results from blood loss (hypovolemia) or other factors such as extensive soft tissue damage.11. Abnormal X-ray findings15. Pathophysiology of Acute FracturesFracture occurs when a force is applied to a bone which exceeds the strength of a bone. A fracture may also result when a pathologic process abnormally weakens a bone. This type of fracture is called a pathologic fracture.16. Splinting Procedures in the Management of Acute Fractures1. Check and mark pulses and sensations initially, following x-ray and/or manipulation and every 30-60 minutes until definitive emergency treatment.2. Splint extremities including the joint above and below the fracture site.3. Do not straighten out injured part.4. Do not relocate dislocated joints unless vascular compromise is evident.5. Apply ice bags all around the site, not on top alone; incorporate ice bags into the splint if necessary. Remove rings and other constrictive jewelry.17. Post-Splinting Management of Acute Fractures1. Closed Reduction- Bony fragments are brought into opposition by manipulation and manual traction. Restores alignment.a. May be done under anesthesia for pain relief and muscle relaxationb. Cast or splint applied to immobilize extremity and maintain reduction.2. Traction- Force applied to accomplish and maintain reduction and alignment.a. Used for fracture of long bonesb. Technique Skin Traction is a force applied to a bony skeleton directly under wires, pins, and tongs placed in a bone.3. ORIF (Open Reduction with Internal Fixation) Operative intervention to achieve reduction, alignment and stabilization.a. Bone fragments directly visualizedb. Internal fixation devices (metals, pins, wires, screws, plates, nails and rods) may be used to hold bone fragments in position until solid bone healing occurs. (Devices may be removed when bone is healed.)c. After closure of the wound, splints or casts may be used for additional stabilization and support.4. Endoprosthetic Replacements Replacement of fracture fragments with an implanted metal device, utilized when fracture disrupts nutrition of a bone or treatment of choice is bony replacement.5. External Fixation Device- Stabilization of complex and open fracture with use of a metal frame and pin system, permits active treatment of injuries to soft tissue.a. Wound may be left openb. Repair of damage to blood vessels, soft tissues, muscles, nerves and tendons as indicated.c. Reconstructive surgery may be necessary.18. Diagnose the Different Types of Surface Wounds1. Laceration- made by an object that tears tissues producing jagged, irregular edges.2. Contused- made by a blunt force which does not break through the skin but causes considerable soft tissue damage (e.g. Hematoma)3. Abrasion- Results from the scraping (abrading) of the skin and thereby damaging it.4. Avulsion- Involves the forcible separation or tearing of tissues from the victims body. 5. Bite- Injuries produced when an animal or person bites another person.6. Puncture- made by a pointed instrument such as ice picks, bullets, knife stab and nail.7. Crush- Injuries commonly occurring in vehicular or industrial accidents. It causes an area of cell death and vessel damage marked by inflammation and swelling of the affected tissues.19. Explain the Pathophysiology of the Different types of Surface WoundsA wound is trauma to any tissue in the body caused by physical means and with interruption of skin continuity. When this occurs, the body initiates a process of repair. The process involves a replacement of damage tissues to healing. If the area of damage is extensive the defect fills with granulation tissue. Contraction occurs and eventually the wound re-epitheliates.20. Treatment procedures for the Different Types of Surface Wounds1. Puncture Wounds- When dealing with any puncture wounds, (except in the eye and neck) assume that there is extensive internal injury. Always look for an exit wound realizing that exit wounds can be more serious than entrance wounds. If the wound contains an impaled object, expose the wound, control bleeding and stabilize the impaled object.2. Avulsions, Bites, Crush, Laceration, Contusions and Abrasionsa. Direct Pressure- In most cases of external bleeding, surface wounds can be controlled by applying direct pressure to the site of the wound. Ideally, sterile dressing should be used. However, if it is not available, and you have to waste time to get it, any clean cloth will do. Apply the dressing to the bleeding area and apply pressure.b. Elevation- This may be used in combination with direct pressure when dealing with bleeding with surface wounds from the arm or leg. The effects of gravity will help reduce blood pressure and slow bleeding.c. Pressure Points- These are sites where artery, close to the body surface, lies directly over a bone. The flow of blood through such an artery can be interrupted if pressure is applied to compress the artery.d. Tourniquets- A band or belt used to control bleeding. You must always consider that tourniquet is always regarded as the last resort used only when other methods of controlling life threatening bleeding fail.21. Post- Procedure Management for Different Types of Wounds1. Dressing- Any material used to cover a wound that will help control bleeding and help prevent contamination. There are two types of dressing:

a. Bulky- are complete covering of large woundsb. Occlusive- used when it is necessary to close n open wound that penetrates a body cavity.You can use a folded plastic wrapper or plastic bag to help seal the wound. 2. Bandaging- Dressings are more effective if they are hand in place. Usually, this is done by taping or tying. You can use adhesive bandage or available or tie a dressing in place using a gauze roller bandage, a handkerchief or any other material that will not cut into the patients skin. (Do not use elastic bandages as this may restrict circulation and will apply undesirable pressure to an injured tissue.)22. Diagnose SeizuresA seizure is a common manifestation of central nervous system dysfunction and represents a paroxysmal synchronous neuronal discharge. It indicates the presence of an underlying brain abnormality and not a disease per se. It may arise from a structurally normal or abnormal cortex and maybe a function of the anatomic or metabolic derangement.Clinical Findings: Localized twitching of muscles (jacksonian seizure) Localized numbness or tingling Chewing movements or smacking of lips Olfactory Hallucinations Visual Hallucinations ( from images and flashes of light ) Complex autonomic behaviourisms23. Pathophysiology of SeizuresSeizures are the result of excessive electrical activity within the brain, the site of initiation is referred to as epileptogenic focis, these need not to be structural lesions. Epileptic seizures can be induced in any normal human brain with a variety of different electrical or chemical stimuli. The ease and rapidity with which these seizures can occur and the stereotypal nature of the seizure produced suggest that the normal brain, particularly the cerebral cortex contains within its fine anatomic and physiologic structures, a mechanism which is inherently unstable and which can be influenced in many ways to produce a seizure.

24. Management of Seizures1. Place patient in a semi-prone position, head-down to avoid aspiration.2. Oxygen should be given via face mask.3. Patient should not be forcibly restrained and there should be no attempt made to insert a tongue blade or other object between the teeth.4. Reversible metabolic disorders such as hypoglycaemia, hyponatremia and drug or alcohol withdrawal should be promptly corrected.5. Patient should be rolled to his side to prevent aspiration.6. For generalized motor (grand mal) or partial motor (petit mal) seizures, Carbamazepine or Valproate is the drug of choice. Phenytoin- 300mg/day can de given in divided doses at bed time Carbamazepine- 200mg/day qid to 400mg/day tid can be given but should be started slowly Phenobarbital- 100mg/day at bedtime Primidone- up to 1500mg/day can be added to slowly minimize drowsiness.25. Protection from Further Injuries during Seizures1. During seizures, cushion patients head and place padding around the extremities.2. Do not leave the person unattended.3. Do not restrain the persons movements.4. Do not attempt to force anything between the teeth.26. Post-Seizure Management1. Encourage normal life.2. Moderate exercise is recommended.3. Alcoholic beverages are contraindicated.4. Family members are taught a common sense attitude towards the patient instead of overprotective or oversolicitous attitude. Sympathetic support should be directed against feelings of inferiority, self-consciousness and other emotional handicaps.5. Emphasis placed in preventing invalidism.6. Vocational rehabilitation may help.7. Institutional care is advised for those whose attacks are frequent, violent and uncontrolled by drugs.27. Allergic and Anaphylactic ReactionsAltered reaction capacity to a specific substance which causes no symptoms of hypersensitivity to the non-sensitive.

Clinical Manifestations:1. Environmental and other factorsa. runny, itchy eyesb. headachec. rashes and skin irritationsd. cough and sneezinge. wheezing2. Diet and Fooda. nausea and vomitingb. diarrhoeac. migrained. Celiacs diseaseAnaphylaxis is a systemic immeadiate hypersensitivity reaction of multiple organ systems to an antigen induced IgE mediated immunologic mediator released in previously sensitized patients.Signs & Symptoms:1. Mild manifestationsa. Urticariab. angioedema2. Life-Threatening manifestationsa. Respiratory Acute Upper Airway Obstruction with Stridor (most common cause of Death) Lower Airway manifestations of Bronchospasm with diffused Wheezing Cardiovascular presents in the form of: Syncope Hypotension Tachycardia Arrhythmia28. Pathophysiology of Anaphylactic ReactionsSystemic anaphylaxis occurs as a result of the release of bioactive substance after exposure to an antigenic agent. Generally, the inciting substance complexes with IgE, attaches to mast cells or Basophils, causing membrane alteration and consequent granulation.Physiologic sequelae are in large measure, related to increased or decreased smooth tone and increases permeability of small blood vessels. Anaphylaxis is frequently of sudden onset and if not promptly treated may be fatal.Etiologies:1. Environmenta. Grassb. Pollenc. Dust mitesd. Animal haire. Feathersf. Certain plantsg. Industrial and chemical pollutants2. Diet/Fooda. Milk and dairy productsb. Eggsc. Nutsd. Fish and shell fishe. Wheat and flourf. Chocolateg. Artificial colorants3. Other Factorsa. Soapb. Perfumesc. Detergentsd. Insect bites and stingse. Nickel in jewelryf. Antibioticsg. Cosmetics29. Management of Anaphylactic Reactions1. Upper Airway Obstruction with Edema and Stridor should be treated with:a. High flow nebulized oxygenb. Racemic epinephrinec. IV epinephrine2. If Airway Obstruction is severe or increases:a. Endotracheal Intubationb. Cricothyrotomy

A. Acute Bronchospasm Treated with epinephrineB. Mild to Moderate wheezing in patient with normal BP Treated with 0.1mg/kg of 1:1000 SC or IMC. Severe Respiratory Distress IV epinephrine with draft infusion 1mg Epinephrine in 250 D5W at an initial rate of 1 drop per minuteD. Cardiovascular Collapse with Hypotension Treated with constant infusion of epinephrine Titrating the rate to a systolic BP of 100mmHg or a mean arterial pressure of 80mmHgE. Full Cardiac Arrest Administer 0.1-1.2 mg/kg of 1:1000 epinephrine slow IV push or via endotracheal tube Immediate Endotracheal intubation or cricothyrotomy should be performed.30. Post-Anaphylactic ManagementImmunotherapyDisensitization or hyposensitization is a treatment in which patient is gradually vaccinatedwith progressively larger doses of allergen in question. This can either reduce the severity or eliminate hypersensitivity altogether.Intravenous injection of monoclonal anti-IgE antibodies binds to free and B-cell associated IgE, signalling their destruction. They do not bind to IgE already bound to the Fc receptor on basophils and mast cells, as this would stimulate the allergic inflammatory response.Sublingual immunotherapy is an orally administered therapy which takes advantage of oral immune tolerance to non-pathogenic antigens such as foods and resident bacteria.31. Diagnose Fainting and Loss of Consciousness1. Hyperventilation to ectopic tachycardia to hypoglycaemia2. Numbness and tingling in the hands and face3. Genuine convulsions occur during the attack with heart block, asystole or ventricular tachycardiaTypes of Fainting:1. Simple Faints (vasovagal syncope)2. Cardiopulmonary Syncopea. Cardiac Arrestb. Acute MIc. Cardiac arrhythmiasd. Cardiac inflow obstructione. Cardiac outflow obstruction3. Cardiovascular Syncopea. Basilar artery insufficiencyb. Carotid sinus syncope4. Orthostatic hypotension32. Pathophysiology of FaintingThe loss of consciousness in syncope is caused by reduction of oxygen to those parts of the brain which sub served consciousness. These are reduction in cerebral blood flow, cerebral oxygen utilization, and cerebrovascular resistance. Prolonged ischemia may result to necrosis of brain tissue in the boarder zones of perfusion between vascular territories of major cerebral arteries. In patient with syncope accompanied by bradycardia, one has to distinguish if that is due to failure of neurogenic reflexes or cardiogenic shock/attack. Cardiogenic shock can be recognized clinically by their longer duration, by greater constancy of the slow heart rate, by the presence of audible heart sounds synchronous with atrial contraction (a) waves in the jugular venous pulse and marked variation in intensity of the first sound despite the regular rhythm.33. Management of Fainting1. Place in a position which permits maximal cerebral blood flow (with head lowered between the knees) if in sitting position.2. Loosen all light clothes and other constrictions.3. Head turned to avoid falling back of tongue into the throat that cause blockage of airway. 4. Sprinkle or dash cold water on the face, neck and apply cold, moist towels.5. If temperature is subnormal, cover the body with a warm blanket.6. Head should be turned to the side and nothing given by mouth until the patient has regained consciousness.7. Patient should not be permitted to rise until sense of physical weakness has passed and should be watched carefully for a few minutes after rising.34. Indications for Nasogastric Intubation and its ComplicationsIndications:1. Diagnosis2. Lavage3. Decompression4. FeedingObjectives:1. To be able to diagnose bleeding or suspected poison ingestion2. To be able to do a lavage3. To be able to decompress as in obstructive states4. To use as means of feedingComplications:1. Tissue necrosis of the nostrils2. Gastric erosion3. Reflux esophagitis

35. Nasogastric Intubation Procedure:1. Estimate the length of the tube needed to reach the stomach. Add distance from the bridge of the nose to the earlobe, to the distance from the earlobe to the tip of the xyphoid process.2. Lubricate the distal 3-4 inches of the tube with a generous amount of water-soluble jelly.3. Insert the tube slowly through the nostril into the pharynx, into the esophagus and into the stomach.a) If an obstruction is met inside the nose through one nostril, rotate, manipulate, and gently push until the tube passes through the obstruction. If the obstruction persists, try the other nostril.b) When the tube is in the pharynx, ask the patient to swallow several times in succession. This may help proper the tube into the esophagus.c) When inserting the tube through the pharynx, the patient may gag, cough or retch. If those things happen, stop. Withdraw the tube back to the nasopharyngeal level, then slowly and gently, try to pass the tube through the pharynx again until it reaches the stomach.d) To check the proper placement of the tube in the stomach, aspirate the tube, the free return of gastric contents signifies gastric intubation. Another way of checking is the injection of 5-10cc of air into the tube and listening with a stethoscope in the epigastrium. A characteristic gurgle indicates stomach placement. Never inject fluids until proper placement is ensured.4. Anchor or secure the tube with adhesive tape at the entrance to the nostril.Equipment and Materials:1. Nasogastric tube2. Adhesive tape3. LubricantEvaluation Indicators: 1. Able to diagnose bleeding or poison ingestion2. Able to lavage3. Able to decompress4. Able to use as means of feeding

36. Indications and Complications of Urinary Bladder IntubationUrinary catheterization is the introduction of the catheter through the urethra into the bladder for the purpose of withdrawing urine. A catheter is a tube for injecting or removing fluids.Indications:1. Urine drainage2. Urine output monitoring3. For examination for diagnosisComplications:1. Infection2. Formation of fistula37. Bladder Intubation ProcedureA. Female Catheterization1. Open the sterile tray and don sterile gloves.2. Lubricate the catheter for about 3-7cm being careful not to fill the eyes.3. Place the thumb and one finger between the labia minora and identify the meatus.4. Maintain separation of the labia until urine is flowing.5. Clean thoroughly the area around the meatus. Move the cotton ball held in a forcep from above the meatus towards the rectum.6. With the uncontaminated hand, pick up a catheter and insert it into the meatus 5cm to 7.5 cm. Do not use excessive force.7. Ask the patient to breathe deeply and rotate the catheter gently if slight resistance is met. The sphincter relaxes and the catheter enters easily.8. Hold the catheter securely as the bladder empties.9. When the flow of urine decreases, withdraw the catheter slowly at 1cm at a time until urine barely drips and then withdraw it.10. Remove the equipment and make the patient comfortable.

B. Male Catheterization1. Open the sterile tray and don sterile gloves. Place tray directly on the patients thigh. If not restless.2. Place a drape under the penis and another above it over the pubic area. If a fenestrated drape is available, place it over the penis and the pubic area and exposing the penis only.3. Lubricate the insertion tip liberally for about 5-7cm. Place it aside on the sterile tray for insertion.4. Cleanse the meatus by grasping the penis firmly behind the glans and spreading the meatus between the thumb and forefinger. Retract the foreskin for an uncircumcised male. Cleanse meatus first then wipe the surrounding tissue in a circular fashion. Use forceps to hold the swab and discard after one use.5. Place the drainage end of the catheter into a urine receptacle then pick up the insertion end with the uncontaminated hand holding it about 8-10cm from insertion tip for an adult or about 2.5 cm for a small boy.6. To insert, lift the penis to a perpendicular body and exert slight traction. Insert steadily about 20cm. Or until urine flows. To bypass slight resistance at the sphincter, twist the catheter or wait until the sphincter relaxes. Have patient take a deep breath or try to void.7. While urine flows, lower the penis and transfer hand to hold the catheter in place at the meatus.8. Collect the urine specimen after the urine has flowed for a few seconds. Pinch the catheter before transferring the drainage and of the catheter into the specimen bottle.9. Empty the bladder and remove the catheter slowly. For adults experiencing urinary retention, it is recommended that no more than 750ml be removed at one time. Removing larger amounts of urine too quickly can induce engorgement of the pelvic blood vessels and hypovolemic shock.10. Dry the penis with a towel or drape.11. Remove the equipment. Assist the patient to a comfortable position.38. Indications and Complications for the Establishment of an Intravenous LineIndications Medication administration Nutrition Keeping a vein open in emergency casesComplications Infiltration Phlebitis Thrombus Speed shock

39. Establishing an Intravenous Line1. Prepare adhesive tape strips for stabilization of IV needle once it is inserted.2. Select a site starting at the distal end of the vein. Sclerosing of the veins can result from infusion or the needle and interfere with the venous flow. If that occurs, more proximal part of the veins can be used.3. Shave skin where tape will be applied, if necessary.4. Apply tourniquet 6-7 inches above the intended site. This must be tight enough to obstruct venous low but not to occlude arterial flow.5. Clean the skin with an antiseptic swab at the entry site.6. Use one thumb to pull skin taut below the entry site. This will stabilize the vein and make penetration less painful.7. Hold the needle at 30 degrees angle with bevel up and pierce the skin beside the vein about 1 cm. below the site planned for piercing the skin. 8. Once needle is through the skin, lower it so that it is almost parallel with the skin. Follow the course of the vein and pierce its side.9. When blood flows into the needle tubing, insert needle further up the vein. Sudden lack of resistance can be as the blood enters the needle.10. Release the tourniquet, attach the infusion and initiate the flow as quickly as possible.11. Dress the venipuncture.12. Loop the tubing and secure it to the dressing with tape.13. Apply a padded arm board to splint the elbow or wrist joints if needed.14. Adjust flow rate.15. Label.40. Indications and Complications of Blood ExtractionIndications For hepatitis, HIV tests Evaluation of blood electrolyte and acid base balance Cross-matching for blood transfusion.Complications Immediate Local Complicationsa. Hemoconcentrationb. Failure of blood to enter the syringec. Hematomad. Circulatory failuree. Syncopef. Continued bleeding

Late Local Complicationsa. Thrombosisb. Thrombophlebitis Late General Complicationsa. Serum Hepatitis41. Perform Blood Extraction1. Apply the tourniquet. Let the patient close his hand to distend the veins.2. Clean the skin with 70% alcohol, let dry.3. Fix the vein in position by supporting the patients forearm with your arm and compressing and pulling the soft tissue just below the intended site with your thumb.4. Hold the syringe between the thumb and the last three fingers resting on the patients arm. Rest the free index finger against the hub of the needle.5. Push the needle into the vein with a single direct puncture of the skin and vein.6. Entrance into the vein is followed immediately by the appearance of blood in the hub, if that doesnt occur, withdraw the plunger slightly and in any instant blood appears.7. Loosen the tourniquet if blood flows freely otherwise, leave it in a place until desired amount is collected.8. Have the patient open his fist, release the tourniquet and withdraw syringe and needle.9. Apply gentle pressure on the puncture site, instruct patient to hold the pad and to raise the arm for a few minutes.10. Before dismissing a patient, the operator must see that the patients condition is satisfactory. If there is a sign of continued discomfort, anxiety or shock, the patient must be kept lying.42. Indications of Parenteral Administration of DrugsTable 21 Some Characteristics of Common Routes of Drug Administration

ROUTEINDICATIONSCOMPLICATIONS

Intravenous Valuable for emergency useIncreased risk of adverse effects

Permits titration of dosageMust inject solutions slowly as a rule

Usually required for high-molecular-weight protein and peptide drugsNot suitable for oily solutions or poorly soluble substances

Subcutaneous Suitable for some poorly soluble suspensions and for instillation of slow-release implantsNot suitable for large volumesPossible pain or necrosis from irritating substances

Intramuscular Suitable for moderate volumes, oily vehicles, and some irritating substancesAppropriate for self-administration (e.g., insulin)Precluded during anticoagulant therapyMay interfere with interpretation of certain diagnostic tests (e.g., creatine kinase)

Oral ingestion Most convenient and economical; usually more safeRequires patient complianceBioavailability potentially erratic and incomplete

SOURCE: GOODMAN & GILLMANS43. Perform Intramuscular and Intravenous Administration of DrugsFor intramuscular (IM) injections:a) Use only drug preparations labelled or commonly used for IM injections. Check label instructions for mixing drugs in powder form.b) Use an 112-inch needle for most adults and a 58- to 112-inch needle for children, depending on the size of the client.c) Use the smallest-gauge needle that will accommodate the medication. A 22-gauge is satisfactory for most drugs; a 20-gauge may be used for viscous medications.d) Select an appropriate injection site, based on client preferences, drug characteristics, anatomic landmarks, and visual inspection of possible sites. Rotate sites if frequent injections are being given, and avoid areas with lumps, bruises, or other lesions.e) Cleanse the site with an alcohol sponge.f) Tighten the skin, hold the syringe like a pencil, and insert the needle quickly at a 90-degree angle. Use enough force to penetrate the skin and subcutaneous tissue into the muscle in one smooth motion.g) Aspirate. Pull back gently on the plunger (aspirate). If no blood enters the syringe, inject the drug. If blood is aspirated into the syringe, remove the needle, and re-prepare the medication.h) Remove the needle quickly and apply pressure for several seconds.

For intravenous (IV) injections:a) Use only drug preparations that are labelled for IV use.b) Check label instructions for the type and amount of fluid to use for dissolving or diluting the drug.c) Prepare drugs just before use, as a general rule. Also, add drugs to IV fluids just before use.d) For venipuncture and direct injection into a vein, apply a tourniquet, select a site in the arm, cleanse the skin with an antiseptic (eg, povidone-iodine or alcohol), insert the needle, and aspirate a small amount of blood into the syringe to be sure that the needle is in the vein. Remove the tourniquet, and inject the drug slowly. Remove the needle and apply pressure until there is no evidence of bleeding.

44. Indications and Complications of Thoracentesis

Indication:Thoracentesis can be safely done at the patient's bedside or in an outpatient setting. Presence and location of pleural fluid is verified by physical examination (chest percussion) or by imaging techniques. Ultrasonography, CT, or both may be useful if chest x-rays are equivocal, if prior thoracentesis attempts were unsuccessful, or if the fluid is loculated.

Complications: Pneumothorax Hemoptysis due to lung puncture Re-expansion pulmonary edema or hypotension after rapid removal of large volumes of fluid Hemothorax due to damage to intercostal vessels Puncture of the spleen or liver Vasovagal syncope

Bloody fluid that does not clot in a collecting tube indicates that blood in the pleural space was not iatrogenic, because free blood in the pleural space rapidly defibrinates.

45. Perform a Needle Thoracentesis

Thoracentesis is best done with the patient sitting upright and leaning slightly forward with arms supported. Recumbent or supine thoracentesis (eg, in a ventilated patient) is possible but best done with ultrasound or CT guidance. Only unstable patients and patients at high risk of decompensation due to complications require monitoring (eg, pulse oximetry, ECG).a) Under sterile conditions, 1 to 2% lidocaine is injected with a 25-gauge needle to anesthetize the skin. b) A larger (20- or 22-gauge) needle with anesthetic is then inserted at the upper border of the rib one intercostal space below the fluid level in the midscapular line. c) The needle is advanced with periodic aspiration (to avoid inadvertent insertion into a blood vessel and intravascular injection), and anesthetic is injected at progressively deeper levels. The most painful level after the skin is the parietal pleura, which should be infiltrated the most. d) The needle is then advanced beyond the parietal pleura until pleural fluid is aspirated, at which point the depth of the needle should be noted. e) A large-bore (16- to 19-gauge) thoracentesis needle-catheter device is then attached to a 3-way stopcock, which is connected to a 30- to 50-mL syringe and tubing that drains into a container. The thoracentesis needle is passed through the skin and subcutaneous tissue along the upper border of the rib into the effusion at about the same depth noted during anesthesia. f) The catheter is inserted through the needle, and the needle is withdrawn to decrease the risk of pneumothorax.g) Pleural fluid can then be aspirated and, with a turn of the stopcock, collected in tubes or bags for further evaluation. Fluid should be removed in stages not to exceed 1.5 L/day because hypotension and pulmonary edema may occur with removal of > 1.5 L of fluid at one sitting or with rapid evacuation of the pleural space using a vacuum or suction bottle. When large volumes of fluid must be removed, blood pressure should be monitored continuously.It has been standard practice to obtain a chest x-ray after thoracentesis to rule out pneumothorax, document the extent of fluid removal, and view lung fields previously obscured by fluid, but evidence suggests that routine chest x-ray is not necessary in asymptomatic patients.Coughing is common as the lung re-expands; it does not signify pneumothorax. If the pleural process is inflammatory, pleuritic pain, an audible pleural rub, or both may develop as fluid is removed because of approximation of inflamed visceral and parietal pleura. When substantial volumes of fluid are removed from the pleural space, the plunger on the syringe should be released periodically during aspiration. If the fluid in the syringe is drawn back into the pleural space when negative pressure on the syringe is decreased, pleural pressure may be too negative, and the lung may be restricted from re-expanding because of enveloping adhesions or tumor. May Kris Dimple T. Coros Adzu-Som Level I