Basic Splinting Techniques

Basic Splinting Techniques Indications Patients frequently present to primary care offices, urgent care, and emergency departments with musculoskeletal injuries, such as fractures, sprains, and dislocations. Many distal-extremity injuries can be initially managed in an outpatient setting using basic splinting techniques. Splinting immobilizes injured extremities and prevents further injury, decreases pain and bleeding, and allows healing to begin. While there are many indications for splinting an extremity, three main types of injuries are commonly treated in outpatient settings: Fractures: Splinting is used to stabilize fractures of the upper and lower extremity, providing patient comfort and maintaining proper bone alignment. Dislocations

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Peripheral Intravenous Cannulation

Peripheral Intravenous Cannulation Introduction The ability to obtain peripheral intravenous access is an essential skill for all physicians. Although considered one of the simplest invasive procedures, mastering this potentially lifesaving intervention requires refined skills and experience. Cannulating a vein, particularly a small one, can be challenging. The purpose of this video is to demonstrate how to access peripheral veins using an intravenous catheter. Indications Peripheral intravenous catheterization is required in a broad range of clinical applications, including intravenous drug administration, for intravenous hydration, transfusions of blood or blood components

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Umbilical Vascular Catheterization

The placement of umbilical catheters is an essential technique for the treatment of many newborns in unstable condition. This video will demonstrate the placement of catheters in the umbilical vein and the umbilical artery. Careful preparation, sterile technique, and attention to detail are instrumental in successful catheter placement. We will demonstrate the regional anatomy of the umbilicus, indications and contraindications for the insertion of an umbilical catheter, the recommended technique for catheter placement in both the umbilical artery and vein, selected complications associated with the procedure and suggestions for how to avoid them, and appropriate aftercare of the catheter

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Placement of a Femoral Venous Catheter

Femoral venous catheterization is a rapid way to obtain intravenous access in hospitalized or emergency department patients. In this video, you will learn how to safely place a femoral line. Placement of a femoral line may be indicated in the following situations: to obtain vascular access when peripheral access cannot be accomplished, to administer hemodialysis when access at a preferable site is not an option, to perform cardiac catheterization, or to administer large or caustic infusions. The following situations are relative contraindications: an uncooporative patient; the presence of infection, trauma, or distorted anatomy at the insertion site

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Cricothyroidotomy

Cricothyroidotomy is an emergent procedure performed on patients experiencing severe respiratory distress in whom orotracheal or nasotracheal intubation has failed. The procedure involves making an incision in the cricothyroid membrane, which lies between the thyroid and cricoid cartilages, followed by inserting a tracheostomy tube, which allows ventilation. This video describes how to perform a cricothyroidotomy in an adult. The major indication for cricothyroidotomy is the inability to establish an airway by orotracheal or nasotracheal intubation. Failure to secure an orotracheal or nasotracheal airway may be due to factors such as difficult patient anatomy

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Female Urethral Catheterization

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

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Examination of the Larynx and Pharynx

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

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Central Venous Catheterization — Subclavian Vein

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

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Abscess Incision and Drainage

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

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Chest-Tube Insertion

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

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Positive-Pressure Ventilation with a Face Mask and a Bag-Valve Device

 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

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Pelvic Examination

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

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Central Venous Catheterization

The placement of a central venous line is an essential technique in the treatment of many hospitalized patients. This video will demonstrate the placement of a central venous catheter in the internal jugular vein with the use of one of several variations of the Seldinger technique. An additional video on subclavian line placement will be forthcoming. We will demonstrate and review the regional anatomy of the neck, indications for the insertion of a central line, the recommended site and technique for placement of a line in the internal jugular vein, selected complications associated with the procedure

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Orotracheal Intubation

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

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Paracentesis

Abdominal paracentesis is performed as a diagnostic procedure to establish the etiology of new-onset ascites or to rule out spontaneous bacterial peritonitis in patients with preexisting ascites. Large-volume paracentesis is performed in hemodynamically stable patients with tense or refractory ascites to alleviate discomfort or respiratory compromise. Contraindications Many patients undergoing paracentesis will have baseline coagulopathy or thrombocytopenia. However, the incidence of clinically significant bleeding during paracentesis is extremely low, and routine use of fresh-frozen plasma or platelet concentrates is not recommended. Paracentesis should be avoided in patients with disseminated intravascular coagulation

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Basic Laceration Repair

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)

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Thoracentesis

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

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Lumbar Puncture

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

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Male Urethral Catheterization

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

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Arthrocentesis of the Knee

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

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Nasogastric Intubation

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

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Placement of an Arterial Line

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

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