Minor Surgical Procedures. Thomas W. White, MD, FACS, CNSC. Mark R. Michael, ANCP

Transcription

1 Minor Surgical Procedures Thomas W. White, MD, FACS, CNSC Trauma Surgery/Critical Care, Medical Director Nutrition Support Service, Shock Trauma ICU Attending, Intermountain Medical Center; Clinical Professor of Surgery, University of Utah Surgery Residency Program; Salt Lake City, Utah Mark R. Michael, ANCP Trauma Nurse Practitioner, Department of Surgery, Flagstaff Memorial Center, Flagstaff, Arizona Objectives: Identify the common indications for intraocular pressure evaluation and canthotomy intramuscular compartment pressure evaluation and decompressive fasciotomy Discuss the most common complications of and pitfalls associated with minor surgical procedures Discuss the role of informal consent in the setting of minor emergency procedures

2 INTRAOSSEUS ACCESS Case: Physiology: Takes advantage of non-collapsible sinusoids in bone with then enter the central circulation. Indications: Any patient who needs rapid vascular access (pre-hospital, ED, trauma patients) Contraindications: Fracture distal to site Previous surgery on extremity Suspected underlying vascular injury Overlying burns Infection / Cellulitis in extremity Anatomy / Locations: Theoretically any bone with substantial marrow cavity can be accessed Realistically, extremities, sternum, ileum, clavicle are most ideal Best to have palpable landmarks, thin cortex, without proximity to vital structures Tibia: Flat surface of anterioriomedial proximal tibia Types of devices: Manual devices (Cook) EZ IO (Vidacare Corp) Technique: (See video) 1. Prepare site 2. Locally infiltrate with 1-2% lidocaine without epi 3. Support and stabilize leg with nondominant hand 4. Direct IO Drill at point perpendicular to bone 5. Press trigger and insert 2cm inferior (distal) to tibial tuberosity to 6. Use steady pressure letting hollow needle to the work

3 7. Do not start and stop drill (can twist skin) 8. Once cortex is penetrated, there will be a decrease in resistance 9. Attach LuerLock hub and pigtail, aspirate, then flush 10. Secure site well. Infused Products / Notes: Medications: Any medication (paralytics, anticonvulsants, analgesic, vasoactive Blood products: Fluids: Isotonic crystalloid Note Time to effect can be delayed Rate of infusion may be slowed, depending on situation to around 30cc/minute Resistance is determined by the medullary cavity itself Actually may run faster in younger people Complications: Incidence is Low, ~1% Pain during insertion Cellulitis Osteomylitis Iatrogenic fracture Fat embolus (rare) Videos: 1. NEJM video (protected, but I think we can get it through your log in) 2. (Larry Melnick) 3. (Arrow EZ IO official) Demonstration / Hands-On: Conclusion / Pearls / Questions: -Use 1-2ml 2% lidocaine (presertive free, without epi) infusion with NS flush for local anesthesia -In general, do not attempt more than once in any one bony site -Caution with certain medications that may cause sclerosis if they extravasate (Calcium Chloride, Dopamine) -Labs: Can draw labs off IOs -Use pressure bags of infusion pumps

4 ELEVATED INTRA-OCCULAR PRESSURE: The TONOPEN Case: Pathophysiology of Increased Ocular Pressure Anatomic Considerations Indications All cases of vision loss Eye pain Suspected glaucoma Acute or remote trauma Contraindications If globe rupture from remote or penetrating trauma is suspected TonoPen -- Steps 1. Self test (Blue button) display should show Green light (double dashes) in 3. Pen is ready...15 seconds to start the test (to save 4. Gently applinate the cornea. 5. Use light / quick touches (see video) 6. Two clicks indicate that inward and outward applination has occurred 7. After 10 reading have occurred, the averages are taken and the IOP is displayed 8. Smaller number in the display is the statistical confidence percentage. Next Steps / Surgical Considerations

5 LOWER EXTREMITY COMPARTMENT SYNDROME: (STRIKER COMPARTMENT PRESSURE DEVICE) Case: 33 y/o male PTD #2 from MCC, tx to surgical floor POD #1 R tib/fib fx Call from bedside nurse of increasing pain and burning in R leg. VS: 36.7, 118, 145/87, 22 PE: Pt in distress, A&O x3, tachypnic, cc LE burning DDX what s most likely going on?: Differential includes a non healing fracture, undiscovered vascular injury, expanding hematoma, infection, or compartment syndrome Compartment Syndrome: History: First described in 1881 by Richard Van Volkmann who observed that paralysis and contractures were a late sequella of an interruption of blood supply to the muscles in the foreman. In 1924, shown that prompt surgical decompression of the compartment could prevent this result. Develops when the pressure within an osteofacial compartment of muscle causes ischemia and subsequent necrosis Results from swelling of muscle in a confined space (bound by inflexible structures such as fascia or bone) A potentially devastating early complication of extremity vascular injury All muscle compartments are vulnerable to intracomparmental hypertension Which can lead to muscle necrosis May occur, more commonly, from, and the setting of: 1. Direct Trauma: Decreased perfusion and ischemia secondary to intracompartmental hemorrhage 2. After successful revascularization with reperfusion edema Once started, the swelling leads to increased in tissue pressure within the confined compartment This compresses both venous and lymphatic outflow As well as arteriolar inflow to a lesser extent. A venous tourniquet is created

6 If unrecognized and/or untreated can result in ischemic neurolysis or myonecrosis Common Sites Lower leg (most common), forearm, foot hand, gluteus, thigh Skin can also act as a restricting membrane at certain times Can occur at any site theoretically Assessment / Symptoms and Signs: Any injury to the lower extremity can precipitate a compartment syndrome. Risk factors / scenarios where a high index of suspicion should be maintained Tibial / forearm fractures Injuries immobilized in tight dressings or casts Severe crush injury to muscle Localized, prolonged external pressure on an extremity Burns Excessive exercise The Classic Signs: Five Ps Pain Parenthesis Pallor Poikilothermia Pulseless Not all may be present to make diagnosis. Classic = 15% Notes on assessment / signs: All signs may not be present. Index of suspicion is important. Pulselessness is an uncommon or very late sign and should not be relied upon. Changes in capillary refill are not reliable in diagnosing compartment syndrome Asymmetric pulses can indicate a proximal vascular injury The lower the systolic blood pressure, the lower the compartment pressure that causes compartment syndrome. Caution in patients whose conditions may mask clinical findings: i.e. those who are sedated, unresponsive and/or hypovolemic Complications: Rhabdomyolysis myoglobin-induced renal failure, Hyperkalemia

7 Compartment syndrome is a clinical diagnosis and is not one that is solely determined by pressure measurements. Compartment measurements are only intended to aid the physician in the diagnosis of compartment syndrome. (ATLS) Anatomy: Four Compartments of the Lower Extremity Anterior, Lateral, Superficial Posterior, Deep Posterior Inside the Numbers: Normal compartment pressure is less than 10 mm Hg Pressures up to 20mmHg can be tolerated without significant damage. Tissue pressures greater than 20-45mm Hg suggested decreased capillary blow flow Delta P method of calculating tissue pressures Compartment pressure subtracted from the DBP If this is less than 30 mm Hg suggest s compartment syndrome The Striker Device: Measuring Compartment Pressures: Calibrating Checking each compartment in lower extremity Surgical Considerations Once diagnosis is made, treatment is surgical 4 compartment fasciotomy