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دانلود کتاب Roberts and Hedges' Clinical Procedures in Emergency Medicine: Expert Consult - Online and Print, 6e
دانلود کتاب رویه های بالینی رابرتز و هجز در طب اورژانس: مشاوره متخصص - آنلاین و چاپی، 6e
مشخصات کتاب
Roberts and Hedges' Clinical Procedures in Emergency Medicine: Expert Consult - Online and Print, 6e
ویرایش: [6 ed.]
نویسندگان: James R. Roberts MD FACEP FAAEM FACMT
سری: Roberts, Clinical Procedures in Emergency Medicine
ISBN (شابک) : 145570606X, 9781455706068
ناشر: Saunders
سال نشر: 2013
تعداد صفحات: 1560
[1713]
زبان: English
فرمت فایل : PDF (درصورت درخواست کاربر به PDF، EPUB یا AZW3 تبدیل می شود)
حجم فایل: 153 Mb
قیمت کتاب (تومان) : 46,000
در صورت تبدیل فایل کتاب Roberts and Hedges' Clinical Procedures in Emergency Medicine: Expert Consult - Online and Print, 6e به فرمت های PDF، EPUB، AZW3، MOBI و یا DJVU می توانید به پشتیبان اطلاع دهید تا فایل مورد نظر را تبدیل نمایند.
توجه داشته باشید کتاب رویه های بالینی رابرتز و هجز در طب اورژانس: مشاوره متخصص - آنلاین و چاپی، 6e نسخه زبان اصلی می باشد و کتاب ترجمه شده به فارسی نمی باشد. وبسایت اینترنشنال لایبرری ارائه دهنده کتاب های زبان اصلی می باشد و هیچ گونه کتاب ترجمه شده یا نوشته شده به فارسی را ارائه نمی دهد.
توضیحاتی در مورد کتاب رویه های بالینی رابرتز و هجز در طب اورژانس: مشاوره متخصص - آنلاین و چاپی، 6e
خرید شما به شما این حق را می‌دهد که تا زمانی که نسخه بعدی منتشر شود، یا تا زمانی که نسخه فعلی دیگر برای فروش توسط Elsevier عرضه نشود، به وبسایت دسترسی داشته باشید. الزویر این حق را برای خود محفوظ می دارد که در صورت قطع دسترسی به وب سایت، یک محصول جایگزین مناسب (مانند نسخه الکترونیکی قابل دانلود یا مبتنی بر CD-ROM) ارائه دهد.
روشهای بالینی رابرتز و هجز در پزشکی اورژانس همچنان به سنت دیرینه خود که شناخته‌شده‌ترین و قابل اعتمادترین کتابچه راهنمای روش‌ها در پزشکی اورژانس است، ادامه می‌دهد. ویرایش 6امین جدید این مرجع پزشکی کلاسیک با بررسی گام به گام، روش کار و جعبه های اولتراسوند که جدیدترین تجهیزات، دستگاه ها، درمان های دارویی، و تکنیک‌هایی که باید برای تمرین مؤثر طب اورژانس بدانید. شما به راهنمایی کامل و دقیق در مورد زمان، چگونه و چرا برای انجام همه های رایج و روشهای غیرمعمول و بهترین نتایج را دریافت کنید.
- درباره هر روشی که احتمالاً در نظر دارید بدانید از جمله چگونه، چرا، چه موقع و چه موقع نآنها را انجام دهید، علاوه بر سایر روش های اضطراری که ممکن است یک گزینه باشد.
- کل مطالب را به صورت آنلاین به سرعت مرور کنید، از جمله ویدیوهای کاملاً جدید از رویه‌های رایج و پیچیده، در مشاوره متخصص.
- کل مراحل را در یک نگاه ببینید با افزودن جعبه‌های روش جدید، که آموزش تصویری گام به گام را در مورد بیش از 250 تکنیک اضطراری ارائه می‌دهد. ایده‌آل برای مرجع در نقطه مراقبت، این جعبه‌های روش به عنوان یک اطلس کوچک جامع نیز عمل می‌کنند و مخصوصاً برای رویه‌هایی که کمتر دیده می‌شوند یا مواردی که به تجهیزات پیچیده نیاز دارند، مفید هستند.< /li>
- به‌آسانی جدیدترین تکنیک‌های اولتراسوند اضطراری را از طریق جعبه‌های اولتراسوند جدید، که همگی به طرز ماهرانه‌ای نوشته شده‌اند و با عکس‌های این تکنیک و همچنین عکس‌برداری از صفحه نمایش تصاویر ایالات متحده به تصویر کشیده شده‌اند، اعمال کنید.< /li>
- تسلط بر داغترین روشهای جدید امروزی از جمله سونوگرافی برای تشخیص پنوموتوراکس. زهکشی آبسه حلقه؛ احیاء مایعات کودکان؛ و لوله گذاری به کمک ویدئو.
- تمام مراحل اضطراری را به وضوح و کارآمد تجسم کنید با بازنگری کامل ارقام، اکنون تقریباً همه به رنگ کامل. تصاویر تشخیصی جدید نشان دهنده چندین روش. و ویدئوهای رویه ای فقط آنلاین که تکنیک های کلیدی را نشان می دهد.
خرید شما به شما این حق را می‌دهد که تا زمانی که نسخه بعدی منتشر شود، یا تا زمانی که نسخه فعلی دیگر برای فروش توسط Elsevier عرضه نشود، به وبسایت دسترسی داشته باشید. الزویر این حق را برای خود محفوظ می دارد که در صورت قطع دسترسی به وب سایت، یک محصول جایگزین مناسب (مانند نسخه الکترونیکی قابل دانلود یا مبتنی بر CD-ROM) ارائه دهد.
توضیحاتی درمورد کتاب به خارجی
Roberts and Hedges' Clinical Procedures in Emergency Medicine continues its long tradition of being the most well-known and trusted procedures manual in emergency medicine. The newly revised 6th edition of this classic medical reference has been thoroughly updated with step-by-step Review, Procedure, and Ultrasound Boxes covering the latest equipment, devices, drug therapies, and techniques you need to know for effective practice of emergency medicine. You'll access complete and detailed guidance on exactly when, how, and why to perform all of today's common and uncommon procedures and get the best results.
- Understand the ins and outs of every procedure you're likely to consider, such as how, why, when to, and when not to perform them, in addition to other emergency procedures that may be an option.
- Rapidly review the entire contents online, including brand-new videos of common and complex procedures, at Expert Consult.
- See entire procedures at a glance with the addition of new Procedure Boxes, which offer step-by-step visual instruction on over 250 emergency techniques. Ideal for point-of-care reference, these Procedure Boxes also serve as a comprehensive mini atlas and are especially useful for less-encountered procedures or those that require complex equipment.
- Easily apply the latest emergency ultrasound techniques through new Ultrasound Boxes, all of which are expertly written and richly illustrated with photographs of the technique as well as screen captures of the US images.
- Master today's hottest new procedures including ultrasound for diagnosis of pneumothorax; loop abscess drainage; pediatric fluid resuscitation; and video-assisted intubation.
- Clearly and efficiently visualize all emergency procedures with a complete overhaul of figures, now nearly all in full color; new diagnostic images representing multiple modalities; and online-only procedural videos demonstrating key techniques.
Your purchase entitles you to access the web site until the next edition is published, or until the current edition is no longer offered for sale by Elsevier, whichever occurs first. Elsevier reserves the right to offer a suitable replacement product (such as a downloadable or CD-ROM-based electronic version) should access to the web site be discontinued.
فهرست مطالب
Front cover Expert Consult Page Half-title page Associate Editors Roberts and Hedges - Clinical Procedures in Emergency Medicine Copyright page Dedication How this Medical Textbook Should be Viewed by the Practicing Clinician and the Judicial System Contributors Video Contributors Preface Foreword Acknowledgments Instructions for online access Table of Contents Video Contents Special Features Procedure Boxes Ultrasound Boxes I Vital Signs and Patient Monitoring Techniques 1 Vital Signs Measurement Background Normal Values Respiration Indications and Contraindications Procedure Interpretation Respiratory Rate Respiratory Pattern and Amplitude Pulse Physiology Indications and Contraindications Procedure Interpretation Pulse Rate Heart Rhythm Pulse Amplitude and Contour Pulses during Cardiopulmonary Resuscitation Arterial Blood Pressure Physiology Indications and Contraindications Equipment Cuff Type Procedure Complications Interpretation Hypertension Measurement Errors Pulse Pressure Differential Brachial Artery Pressure Pulsus Paradoxus Shock Index Doppler Ultrasound for Evaluation of Pulse and Blood Pressure Principles of Doppler Ultrasound Indications and Contraindications Equipment Procedure Interpretation Vital Sign Determination of Volume Status Orthostatic Vital Signs Measurement Physiologic Response to Hypovolemia Physiologic Response to Changes in Posture Variables Affecting Orthostatic Vital Signs Indications and Contraindications Technique Interpretation Capillary Refill Indications and Contraindications Procedure Interpretation Temperature Physiology Indications and Contraindications Measurement Sites Core Body Temperature Peripheral Body Sites Approximating Core Temperature Procedure Interpretation Pain as a Vital Sign Background Procedure/Interpretation Overview of Visual Analog Pain Scales Overall Goal of Pain Relief References 2 Devices for Assessing Oxygenation and Ventilation Spirometry Indications Evaluation of Acute Asthma Attacks Evaluation of Exacerbations of COPD Differentiating Causes of Dyspnea Evaluation of Neuromuscular and Chest Wall Disease Contraindications Need for Immediate Intervention Conditions That May Be Worsened by Increased Intrathoracic Pressure Equipment Procedure Interpretation Noninvasive Oxygenation Monitoring: Pulse Oximetry Technology Physiology Clinical Utility Indications Procedure Interpretation Sources of Interference Effects of Dyshemoglobinemias Fetal Hemoglobin Low Perfusion Intravenous Dyes Bilirubin Skin Pigmentation Nail Polish High Saturation Venous Pulsations Anemia Ambient Light Motion Probe Site Electrocautery Conclusions CO2 Monitoring Terminology Technology Physiology Indications for Intubated Patients Verification of ET Tube Placement Monitoring Tube Position during Transport Gauging the Effectiveness of Cardiopulmonary Resuscitation Indicator of ROSC Assessing Prognosis after Initiation of Cardiac Arrest Resuscitation Identifying the Cause of Cardiac Arrest Titrating ETco2 in Patients with Suspected Increased Intracranial Pressure Indications for Capnography in Spontaneously Breathing Patients Assessment of Critically Ill, Injured, or Seizing Patients Assessment and Triage of Victims of Chemical Terrorism and Mass Casualty Gauging Severity and Response to Treatment of Patients in Acute Respiratory Distress Procedural Sedation and Analgesia Determining the Adequacy of Ventilation in Patients with Altered Mental Status Detection of Metabolic Acidosis Limitations Conclusion References Suggested Readings Pulse Oximetry CO2 Monitoring II Respiratory Procedures 3 Basic Airway Management and Decision Making The Challenge of Emergency Airway Management Basic Airway Management Techniques Opening the Airway Manual Airway Maneuvers The Head-Tilt/Chin-Lift Maneuver The Jaw-Thrust Maneuver The Triple Airway Maneuver Patient Positioning Foreign Body Airway Obstruction Abdominal Thrusts (Heimlich Maneuver), Chest Thrusts, and Back Blows (Slaps) Suctioning Oropharyngeal and Nasopharyngeal Artificial Airways Indications and Contraindications Artificial Airway Placement Complications Oxygen Therapy Indications and Contraindications Oxygen Administration during Cardiac Arrest and Neonatal Resuscitation Oxygen Delivery Devices Procedure Preoxygenation for Rapid-Sequence Intubation Oxygen Therapy during Apnea Nasal High-Flow Oxygen Complications of Oxygen Therapy Bag-Mask Ventilation Indications and Contraindications Bag-Mask Ventilation Technique Complications Cricoid Pressure: Sellick’s Maneuver Extraglottic Airway Devices LMAs Background Anatomy and Physiology Pathophysiology Indications Contraindications Procedure LMA Fastrach LMA Classic (or Single-Use LMA Unique) Aftercare Complications Retroglottic Airway Devices King LT Indications and Contraindications Placement of the King LT Complications Combitube and EasyTube Indications and Contraindications Placement of the Combitube Complications Decision Making in Emergency Airway Management Rapid-Sequence Intubation Difficult Airways, Failed Intubation, and When to Avoid Rapid-Sequence Intubation Emergency Airway Management Algorithm Conclusion Acknowledgment References 4 Tracheal Intubation General Approach to Emergency Intubation Airway Anatomy Preparation Preoxygenation Assessing for a Difficult Airway Direct Laryngoscopy Indications and Contraindications Equipment Laryngoscope Tracheal Tubes Optimal Patient Positioning for Direct Laryngoscopy Procedure and Technique of Direct Laryngoscopy Adults Infants and Children Sellick’s Maneuver, External Laryngeal Manipulation, Bimanual Laryngoscopy, and BURP Sellick’s Maneuver External Laryngeal Manipulation, Bimanual Laryngoscopy, and BURP Passing the Tube Tracheal Tube Introducer (Bougie) Laryngospasm Positioning and Securing the Tube Confirmation of Tracheal Tube Placement Clinical Assessment Esophageal Detector Device End-Tidal CO2 Detector Devices Ultrasound Detection of Tracheal Tube Location Comparison of Detector Devices Complications of Intubation Conclusion Video and Optical Laryngoscopes Video Laryngoscopes with Standard Macintosh Blades Background Anatomy and Physiology Pathophysiology Indications Contraindications Procedure Complications Video Laryngoscopes with Angulated Blades Background Indications Contraindications Procedure and Technique Complications Summary Video and Optical Laryngoscopes with a Tube Channel Background Anatomy and Physiology Indications Contraindications Procedure Aftercare Complications Intubating Laryngeal Mask Airways Indications Contraindications Intubation through the LMA Fastrach Procedure and Technique Using a Standard ET Tube Fiberoptic Intubation through the LMA Fastrach LMA Fastrach Removal Intubation through the LMA Classic Fiberoptic Intubation through the LMA Classic Complications When Intubating through LMAs Summary Flexible Fiberoptic Intubation Indications and Contraindications Procedure and Technique Nasal Approach Oral Approach Complications Summary Optical Stylets Indications and Contraindications Procedure and Technique Summary Lighted Stylet Intubation Indications and Contraindications Procedure and Technique Complications Summary Blind Nasotracheal Intubation General Indications and Contraindications Blind Placement Indications and Contraindications Procedure and Technique Technical Difficulties Anterior to the Epiglottis Arytenoid Cartilage and Vocal Cord Piriform Sinus Esophageal Placement Laryngospasm Complications Summary Digital Intubation Indications and Contraindications Procedure and Technique Complications Summary Retrograde Intubation Indications and Contraindications Equipment Procedure and Technique Complications Summary TRACHEAL INTUBATION WITH A LARYNGEAL TUBE OR COMBITUBE IN PLACE Changing Tracheal Tubes Procedure and Technique Preventing Unplanned Extubation Conclusion Acknowledgment References 5 Pharmacologic Adjuncts to Intubation Overview of Rapid-Sequence Intubation Pretreatment: preventing the Complications of Intubation The Pressor Response Intracranial Hypertension Induction Agents Barbiturates: Thiopental and Methohexital Etomidate Ketamine Propofol Benzodiazepines (Midazolam) Opioids (Fentanyl) Neuromuscular Blocking Agents Succinylcholine Nondepolarizing Agents Long-Acting Agents: Pancuronium Intermediate-Acting Agents: Vecuronium, Atracurium, Mivacurium, and Rocuronium The “Sedated Look” Evaluation of the Airway before Rapid-Sequence Intubation Awake Intubation Direct Application Cricothyroid Membrane Puncture Nebulized Anesthesia Sedation for Awake Intubation Acknowledgment References 6 Cricothyrotomy and Percutaneous Translaryngeal Ventilation Anatomy Surgical Cricothyrotomy Indications and Contraindications Equipment Procedure Traditional Technique Rapid Four-Step Technique (Brofeldt) Melker Percutaneous Cricothyrotomy Technique Complications Success Rates Percutaneous Translaryngeal Ventilation Indications and Contraindication Equipment Procedure Complications Conclusion References 7 Tracheostomy Care Introduction Background Tracheal Anatomy and Physiology Evaluation of Tracheostomy Patients General Equipment for Tracheostomy Patients Routine Tracheostomy Maintenance Ventilating Tracheostomy Patients Tracheal Suctioning Indications Equipment Procedure and Technique Complications of Suctioning Minitracheostomy Suctioning Procedure Changing a Tracheostomy Tube Indications Equipment Sizing Components Procedure Complications of Tracheostomy Obstruction and Complications from Tube Changes Preparation Interventions Dislodgment Preparation Interventions False Passage Equipment Failure Fracture Tracheal Cuff Complications Infection Tracheal Stenosis and Tracheomalacia Interventions Tracheoesophageal Fistula Interventions Bleeding Major Bleeding Preparation Interventions Minor Bleeding Preparation Interventions Transesophageal Puncture for Voice Restoration Complications Transtracheal Oxygen Delivery Systems Interventions Stents Transtracheal Needle Aspiration Special Populations Obese Patients Preparation Interventions Pediatrics Equipment Sizing Cuff Humidifiers Suctioning Complications Summary References 8 Mechanical Ventilation Introduction Basic Physiology Minute Volume and Alveolar Ventilation Volume-Pressure Relationship Airway Pressures Plateau Pressure Peak Airway Pressure Positive End-Expiratory Pressure Extrinsic PEEP Intrinsic PEEP Indications for Mechanical Ventilation Equipment—standard Options Set Respiratory Rate Fraction of Inspired Oxygen Positive End-Expiratory Pressure Flow Rate Waveform Decelerating (Ramp) Square I/E Time Ratio Trigger Sensitivity Modes of Ventilation Spontaneous Breathing Volume-Cycled Ventilation Pressure-Cycled Ventilation Modes of Ventilation Commonly Used in the ED Assist/Control Ventilation Synchronized Intermittent Mechanical Ventilation Advanced Modes of Mechanical Ventilation Dual Control Modes Other Modes High-Frequency Ventilation Airway Pressure Release Ventilation and Bi-Level Ventilation Noninvasive Positive Pressure Ventilation Definitions Rationale for Using NPPV Pathophysiologic Effects of NPPV Acute Exacerbation of Chronic Obstructive Pulmonary Disease Acute Cardiogenic Pulmonary Edema Hypoxemic Respiratory Failure Immunosuppressed Patients “Do-Not-Intubate/Do-Not-Resuscitate” Patients Initiation of NPPV Cautions with the Use of NPPV High-Flow Nasal Cannula Conclusions Neuromuscular Blockade/Paralyzing Agent for Mechanically Ventilated Patients Sedation Specific Disease Processes Asthma and COPD (Fig. 8-15) ALI and ARDS Complications of MV Pneumothorax Ventilator-Induced Lung Injury Hemodynamic Compromise Intrinsic PEEP Difficulty Triggering the Ventilator Auto-Cycling Rapid Breathing Outstripping the Ventilator and Double Cycling Straining over the Ventilator Coughing Equipment Failure Troubleshooting Determine Hemodynamic Stability Cardiac Arrest and Near Arrest Patients Step 1: Disconnect the Patient from the Ventilator Step 2: Breathing—Hand-Ventilate with 100% Oxygen Step 3: Airway—Determine That the ET Tube Is Functioning and in the Proper Position Step 4: Special Procedures Stable and Nearly Stable Patients Step 1: Obtain a Focused History Step 2: Perform a Focused Physical Examination Airway Breathing Circulation Step 3: Assess Gas Exchange Step 4: Check Respiratory Mechanics Step 5: Observe Ventilator Waveforms Step 6: Imaging Studies—Chest Radiograph and Bedside Ultrasound Step 7: Evaluate Sedation Special Scenarios Liberation from the Ventilator Conclusion References 9 Thoracentesis Anatomy and Physiology of the Pleural Space Etiology of Pleural Effusions Transudates: Overwhelming the System Exudates: Pathology of Tissues, Destroying the System Traumatic Effusions: Acute and Catastrophic Destruction of the System Diagnosis of Pleural Effusion Clinical Diagnosis Radiologic Diagnosis Chest Radiograph CT Ultrasound Indications Diagnostic Thoracentesis Therapeutic Thoracentesis Contraindications Procedure Choosing a Technique Equipment and Patient Preparation Termination of the Procedure Insertion Site and Patient Position Anesthesia and Pleural Fluid Localization Over-the-Needle-Catheter Insertion Technique Pediatric Patients Postprocedure Radiograph Pleural Fluid Analysis Visual Inspection Distinguishing Transudate from Exudate: Light’s Criteria Evaluation of Exudates Cell Count with Differential Culture Glucose Adenosine Deaminase Cytology Parapneumonic Effusions Complications Pneumothorax Cough Infection Uncommon Serious Complications References 10 Tube Thoracostomy Pathophysiology Pneumothorax Spontaneous (Closed) Pneumothorax Traumatic Closed Pneumothorax Traumatic Open Pneumothorax Tension Pneumothorax Hemothorax Empyema and Effusions Chylothorax Diagnosis Symptoms Physical Examination Unstable Patients Stable Patients Radiography Plain Radiographs Thoracic CT Ultrasound Indications for Tube Thoracostomy Pneumothorax Hemothorax Empyema Contraindications Treatment Treatment of a Possible Tension Pneumothorax in an Unstable Patient Prehospital Treatment Emergency Department Treatment Equipment Procedure Tube Insertion Site Patient Preparation Anesthesia Insertion Confirmation of Tube Placement Securing the Tube Drainage and Suction Systems Prophylactic Antibiotics Tube Removal Other Techniques Small-Bore Tube Thoracostomy Guidewire Technique for Catheter Aspiration Tube Thoracostomy in Pediatric Patients Complications References III Cardiac Procedures 11 Techniques for Supraventricular Tachycardias Introduction Overview and Significance: Anatomy and Physiology of Supraventricular Tachycardia Vagal Maneuvers Background Anatomy and Physiology Indications for Vagal Maneuvers Equipment and Setup Carotid Sinus Massage Contraindications Technique Complications Valsalva Maneuver Contraindications Technique Apneic Facial Exposure to Cold (“Diving Response,” Diving Bradycardia): Technique Selected Pharmacologic Agents Adenosine Indications and Contraindications Dosage Calcium Channel Blockers Diltiazem Indications and Contraindications Dosage Verapamil Indications and Contraindications Dosage β-Adrenergic Blockade Propranolol Esmolol Indications and Contraindications Dosage Procainamide Indications and Contraindications Digoxin Indications and Contraindications Dosage Amiodarone Indications and Contraindications Dosage Electrical Cardioversion Conclusion References 12 Defibrillation and Cardioversion Introduction Principles of Resuscitation Anatomy, Physiology, and Pathophysiology Mechanisms of Cardiac Dysrhythmias Defibrillation and Sudden Cardiac Arrest Cardiopulmonary Resuscitation: Ventricular Fibrillation and Pulseless Ventricular Tachycardia Indications for and Contraindications to Defibrillation Conductive Material Procedure Witnessed Sudden Cardiac Arrest (Figs. 12-10 and 12-11) Cardiopulmonary Resuscitation Rhythm Assessment Energy Selection Mode Selection Defibrillate Resume Cardiopulmonary Resuscitation Reassess the Patient: Management of the Airway and Intravenous Access Changes in Cardiopulmonary Resuscitation Energy and Mode Selection for the Second Shock Second Defibrillation Unwitnessed Arrest Automated External Defibrillator Application Medication Complications Pediatric Defibrillation Ventricular Fibrillation in Children Procedure and Technique Pediatric Sudden Cardiac Arrest Equipment. Paddle and Pad Application and Use of Conductive Material. Procedure in an Unresponsive Child Rhythm Assessment. Energy Selection. Mode Selection. Defibrillate. Resume Cardiopulmonary Resuscitation. Reassess the Patient, Manage the Airway, and Gain Intravenous Access. Change in Cardiopulmonary Resuscitation. Second Shock: Energy Selection and Mode. Medications. Automatic External Defibrillators in Children Cardioversion Introduction and Physiology Indications and Contraindications Treatment Equipment and Setup Technique Sedation Cardioverter Use Electrode Position: Same As for Defibrillation Energy Requirements Complications Conclusion Pediatric Cardioversion Acknowledgment References 13 Assessment of Implantable Devices Pacemaker Characteristics Characteristics of AICDs Indications for Placement of Implantable Pacemakers and Aicds Pacemaker and AICD Response to Magnet Placement Clinical Evaluation of Patients with Implanted Pacemakers and Aicds History Physical Examination Radiography Electrocardiography Cardiopulmonary Resuscitation, ACLS Interventions, and External Cardiac Defibrillation in Patients with Implanted Pacemakers or AICDs Complications and Malfunction of Implanted Pacemakers Pacemaker Output Failure Failure to Capture Failure to Sense Runaway Pacemaker Syndrome Pacemaker-Mediated Tachycardia Diagnosis of Acute Myocardial Infarction in the Presence of a Paced Cardiac Rhythm Automatic Implantable Cardioverter-Defibrillators—Unique Malfunctions Use of a Magnet for AICD Technique “Twiddler’s Syndrome” Mental Health Issues Related to Implanted Pacemakers and AICDs Implantable Pacemaker and AICD Recalls Electromagnetic Interference and Implantable Devices Out-of-Hospital Discharge of AICD Disposition Criteria References 14 Basic Electrocardiographic Techniques Background Indications Basic Equipment The 12-Lead ECG Standard 12 Leads Electrode Placement Pediatric Electrode Placement Features of the ECG Information Provided by the Computer Adjustable Features Additional Leads 15-Lead ECG Posterior Leads Right-Sided Leads Invasive Procedural Leads Body Surface Mapping Alternative Techniques for Assessment of Rhythm Alteration in Amplitude and Paper Speed Alternative Leads Lewis Leads Vertical Sternal “Barker” Leads Limb-Precordium Leads Modified Bipolar Chest Leads Esophageal Leads Central Venous Catheter Intracardiac Leads Electrode Misplacement and Misconnection Limb Electrode Reversal Easily Recognizable without an Old ECG Not Easily Recognizable without an Old ECG Precordial Electrode Misplacement and Misconnection Artifact References 15 Emergency Cardiac Pacing Emergency Transvenous Cardiac Pacing Background Indications Bradycardias Sinus Node Dysfunction Asystolic Arrest AV Block Trauma Bundle Branch Block and Ischemia Tachycardias Cardiac Pacing for Drug-Induced Dysrhythmias Contraindications Equipment Pacing Generator Pacing Catheters and Electrodes ECG Machine Introducer Sheath Procedure Patient Preparation Site Selection Skin Preparation and Venous Access Pacemaker Placement ECG Guidance Catheter Placement in Low-Flow States US Guidance Testing Threshold Testing Sensing Securing and Final Assessment Complications Problems Related to Central Venous Catheterization Complications of Right-Sided Heart Catheterization Complications of the Pacing Electrode Emergency Transcutaneous Cardiac Pacing Indications and Contraindications Equipment Technique Pad Placement Pacing Bradycardiac Rhythms Overdrive Pacing Complications References 16 Pericardiocentesis Definition Anatomy and Physiology Pericardium and Pericardial Space Pathophysiology of Pericardial Tamponade Compensatory Mechanisms and Pericardiocentesis Special Considerations in Patients with Pericardial Effusion and Tamponade Epidemiology Causes of Pericardial Effusion (Box 16-1) Acute Hemopericardium Traumatic Hemopericardium Penetrating Trauma Blunt Trauma Miscellaneous Trauma Atraumatic Hemopericardium Nonhemorrhagic Effusions Idiopathic Effusions Neoplastic Effusion Congestive Heart Failure Radiation HIV-Associated Effusions Renal Failure and Uremia Hypothyroidism Special Considerations in Pericardial Disease Diagnosing Cardiac Tamponade History: Patient Profile and Symptoms Physical Examination Vital Sign Abnormalities Pulsus Paradoxus Neck Vein Distention and Elevated CVP Diagnostic Testing Chest Radiography Electrocardiography Echocardiography Diagnosing Pericardial Effusions and Tamponade Limitations of Ultrasound CT Scan Treating Pericardial Effusions and Tamponade Indications for Pericardiocentesis Diagnostic Pericardiocentesis Therapeutic Pericardiocentesis Tamponade of Uncertain Cause: Pulseless Electrical Activity Tamponade Caused by Nonhemorrhagic Effusions Pericardiocentesis in Patients with Hemorrhagic Tamponade Contraindications Overview of Techniques and Equipment Procedure Temporizing Measures Preparation ECG Monitoring Ultrasound-Guided Pericardiocentesis Subxiphoid/Subcostal Approach Apical Approach Parasternal Approach Procedure and Technique Fluid Aspiration and Evaluation Complications Acknowledgment References 17 Artificial Perfusion during Cardiac Arrest Conventional CPR Compressions Ventilations Pulse Checks Leadership and Teamwork New Directions: CC-CPR Adjuncts to Improve the Quality of CPR ACD-CPR ITD Monitoring and Feedback Devices Mechanical CPR Devices Emergency Cardiac Bypass Monitoring during CPR Overview of CPR Capnography Ultrasound Monitoring Conclusion References 18 Resuscitative Thoracotomy Indications and Contraindications Cardiac Injuries—Penetrating Cardiac Injuries—Blunt Pulmonary Injuries Air Embolism Blunt and Penetrating Abdominal Injury Open-Chest Resuscitation for Nontraumatic Arrest Nontraumatic Hypothermic Cardiac Arrest Equipment Procedure Preliminary Considerations Airway Control Anesthesia and Amnesia Anterolateral Thoracotomy Incision Pericardiotomy Internal Cardiac Defibrillation Direct Cardiac Compressions Control of Hemorrhagic Cardiac Wounds Control of Hemorrhagic Great-Vessel Wounds Aortic Cross-Clamping Management of Air Embolism Interpretation and Hemodynamic Monitoring EDT in Children Complications Acknowledgment References IV Vascular Techniques and Volume Support 19 Pediatric Vascular Access and Blood Sampling Techniques Patient Preparation and Restraint Anesthesia Blood Sampling Techniques Capillary Blood Sampling Indications and Contraindications Equipment and Setup (Box 19-1) Technique Complications Interpretation Venipuncture Indications and Contraindications Equipment and Setup (Box 19-2) Technique Complications Arterial Blood Sampling Indications and Contraindications Equipment and Setup (Box 19-3) Technique Complications Vascular Line Placement: Venous and Arterial Peripheral Venous Catheterization: Percutaneous Indications and Contraindications Equipment and Setup (Box 19-4) Vein Imaging Devices Technique External Jugular Venous Catheterization Technique. Complications Peripheral Venous Catheterization: Venous Cutdown Indications and Contraindications Equipment and Setup (Box 19-5) Technique Mini-Cutdown Complications Central Venous Catheterization: Percutaneous Indications and Contraindications Equipment and Setup (Box 19-6) Techniques Femoral Catheterization Technique. Internal Jugular Venous Catheterization Technique. Subclavian Venous Catheterization Technique. Complications Emergency Vascular Access Umbilical Vein Catheterization Indications and Contraindications Equipment and Setup Technique Complications Umbilical Artery Catheterization Indications and Contraindications Equipment and Setup Technique Complications Percutaneous Arterial Catheterization Indications and Contraindications Equipment and Setup Technique Complications Arterial Cutdown Catheterization Indications and Contraindications Equipment and Setup (Box 19-8) Technique Complications Rehydration Techniques in Infants and Children Approach to Dehydration Oral Rehydration Laboratory Tests Parenteral Rehydration Nasogastric Tube Rehydration Subcutaneous Rehydration Discharge References 20 Arterial Puncture and Cannulation Historical Perspective Indications and Contraindications Arterial versus Venous Analysis Equipment: Arterial Puncture Arterial Puncture with a Needle/Syringe Continuous Monitoring via Arterial Catheter Preparation for Arterial Cannulation Site Selection Techniques Arterial Puncture Percutaneous Technique for Arterial Cannulation Direct Over-the-Needle Catheter Cannulation Guidewire Techniques for Arterial Cannulation Seldinger Technique Cutdown Technique for Arterial Cannulation Local Puncture Site and Catheter Care Fluid-Pressurized Systems Selection of Arteries for Cannulation Radial and Ulnar Brachial Dorsalis Pedis Femoral Umbilical and Temporal Complications of Arterial Cannulation Interpretation Conclusion Acknowledgment References 21 Peripheral Intravenous Access Introduction Historical Perspective Indications and Contraindications Ultrasound Guidance and Transillumination Anatomy Preparation Safety Choosing the Catheter Gauge Appropriate Site Adjuncts for Finding a Vein Anesthesia IV Assembly Inspection and Positioning Cannulation Anchoring the Device Maintaining Patency Dressing Percutaneous Brachial Vein Cannulation Complications Extravasation of Medications and Vasopressors References 22 Central Venous Catheterization and Central Venous Pressure Monitoring Historical Perspective Anatomy SV System IJ Vein Femoral Vein Indications CVP Monitoring and Oximetry Delivery of High-Flow Fluid Boluses and Blood Products Emergency Venous Access and Inability to Achieve Peripheral Access Routine Serial Blood Drawing Infusion of Hyperalimentation and Other Concentrated Solutions Other Indications Contraindications Subclavian Approach IJ Approach Femoral Approach Procedure Equipment Ultrasound Needle Guidewire Catheters Technique Preprocedure Preparation Guidewire Placement with the Seldinger Technique Sheath Unit and Catheter Placement Replacement of Existing Catheters Over-the-Needle Technique Site Selection Subclavian Approaches IJ Approach Femoral Approach Specific Vessel Access Techniques Infraclavicular Subclavian Approach Positioning Venipuncture Site Needle Orientation Unsuccessful Attempts Supraclavicular Subclavian Approach Positioning Needle Orientation Subclavian Ultrasound Technique IJ Approach Positioning Venipuncture Site Central Route Posterior and Anterior Routes IJ Ultrasound Technique Femoral Approach Positioning and Needle Orientation Venipuncture Femoral, Ultrasound Technique Aftercare Anchoring the Central Line Dressing Assessing Line Placement Radiographs Redirection of Misplaced Catheters Special Considerations for Other Vessels External Jugular Vein Approach Basilic and Cephalic Approaches Vascular Access in Cardiac Arrest CVP Monitoring CVP Measurement Physiology Indications for and Contraindications to CVP Measurement Procedure Errors in CVP Measurement Interpretation of CVP Measurement Fluid Challenge Cardiac Tamponade Complications Mechanical Complications Infectious Complications Thrombotic Complications Subclavian Approaches IJ Approach Femoral Approach Training and Simulation References 23 Venous Cutdown Indications Children Hypovolemic Shock Contraindications Anatomy and Selection of the Site The Great Saphenous Vein The Basilic Vein The Cephalic Vein Equipment Technique Mini-Cutdown Modified Cutdown Technique Complications Acknowledgment References 24 Indwelling Vascular Devices: Historical Perspective Indwelling VADs Cuffed, Tunneled RA Catheters (Broviac, Hickman, Hemocath, Leonard, Raaf) Groshong Catheter TIVADs/Ports (Port-A-Cath, Proport, Infuse-A-Port, Mediport) PICC (Nontunneled, Noncuffed) Midline Peripheral Catheters HD VADs Temporary Dialysis Catheters (Quinton, Mahurkar, Tessio, Vascath, Uldall) Chronic HD Vascular Access AV Fistulas AV Grafts Accessing Vads in the ED Accessing Long-Term Venous Access Catheters Accessing TIVADs Accessing AV Fistulas, Shunts, and HD Catheters Complications of VADs Infection Antimicrobial Therapy Prophylactic Measures Antibiotic Prophylaxis during Initial Line Insertion Impregnated Catheters Routine Line Changing Thrombus Formation Catheter Occlusion Embolization Hemorrhagic Complications Mechanical Approach to Bleeding Complications Direct Pressure Dialysis Clamps Suture Thrombogenic Agents Vasoconstrictive Agents Chemical Cautery Coagulopathy Uremic Platelet Dysfunction Heparin-Associated Coagulopathy Warfarin-Associated Coagulopathy Catheter Displacement, Migration, or Malposition Catheter Fracture Steal Syndrome Aftercare Instructions Acknowledgment References 25 Intraosseous Infusion Historical Perspective Anatomy and Physiology Indications Contraindications Equipment and Setup IO Needles (Fig. 25-3) Bone Marrow Aspiration Needle Illinois Sternal/Iliac Aspiration Needle Jamshidi Disposable Sternal/Iliac Aspiration Needle Cook IO Needle Sur-Fast Needle IO Devices FAST-1 Intraosseous Infusion System (Fig. 25-4) Bone Injection Gun—BIG (Fig. 25-5) EZ-IO Device (Fig. 25-6) TIAX Reusable IO Infusion Device (Fig. 25-7) Procedure Sites for IO Needle Placement Proximal Tibia Distal Tibia Sternum Humerus Other Sites Site Preparation Manual Needle Insertion (Fig. 25-9) Use of Specific IO Devices FAST-1 (Fig. 25-10) BIG (Fig. 25-11) EZ-IO Needle (Figs. 25-12 and 25-13) Complications Technical Difficulties Soft Tissue and Bony Complications Infection Skin Sloughing Compartment Syndrome Epiphyseal Injuries Fat Embolism Pain with Infusion Training Acknowledgment References 26 Alternative Methods of Drug Administration ET Administration of Medication Historical Perspective Recommendations For ET Drug Delivery Appropriate Dose Volume for a Single Dose Appropriate Diluent Technique for ET Drug Delivery Effects of Hypoxia, Hypotension, and Cardiopulmonary Arrest Indications Contraindications Equipment Procedure Direct Instillation into the ET Tube Use of a Catheter Use of ET Tubes with Irrigation and Drug Delivery Lumens Injection through the Wall of the ET Tube Use of the ET Atomizer Complications Intranasal Administration of Medication Anatomy and Physiology Indications and Contraindications Narcotic Overdose Seizures Sedation Pain Management Contraindications Notes on Medication Dosing Equipment Procedure Nasal Drops Nasal Atomization Complications Nebulized Naloxone Rectal Administration of Medication Anatomy and Physiology Indications and Contraindications Equipment Procedure Suppositories Liquids and Gels Medications Analgesics and Antipyretics Sedative-Hypnotic Agents Anticonvulsants Antiemetics Cation Exchange Resin Complications References 27 Autotransfusion Introduction Background Anatomy Pathophysiology Advantages Indications Contraindications Equipment and Material Blood Filters Vacuum Suction Anticoagulation Historical Techniques Using Standard ED Equipment Autotransfusion Units Procedure for Autotransfusion Atrium Chest Drainage Devices In-Line Autotransfusion Blood Collection and Infusion Procedure (Fig. 27-8) Self-Filling Autotransfusion Blood Collection and Infusion Procedure Continuous Autotransfusion (Fig. 27-11) Pleur-evac Chest Drainage Devices In-Line Blood Collection and Autotransfusion Procedure Continuous Infusion Complications Hematologic Complications Nonhematologic Complications Resources References 28 Transfusion Therapy: Background RBC Antigens and Antibodies Crossmatching Types of RBC Preparations Whole Blood PRBCs Washed RBCs Leukocyte-Reduced RBCs Irradiated RBCs Infectious Complications of Transfusions Transfusion Reactions Acute Reactions Allergic Anaphylactic Febrile (Nonhemolytic) Acute Hemolytic Drug-Induced Hemolysis TRALI Delayed Delayed Hemolytic GVHD Posttransfusion Purpura Miscellaneous Transfusion Issues Transfusion Thresholds Massive Transfusion Transfusion Coagulopathy Severe Trauma and Coagulopathy Emergency Transfusions Metabolic Disturbances Directed and Autologous Donations RBC Substitutes Other Blood Products Platelet Concentrates FFP Cryoprecipitate Specific Factor Therapy Factor VII ICH Trauma Factor VIII Concentrate Human Antihemophilic Factor Recombinant Antihemophilic Factor Factor VIII Concentrate FEIBA DDAVP Factor VII in the Hemophiliac Population Factor IX Concentrate PCC, FFP, and Reversal of Warfarin Reversal of Other Agents Collection and Storage of Blood Products Ordering of Blood Blood Request Forms Blood Products for Jehovah’s Witnesses Administration of Blood Products IV Transfusions IO Transfusions Filters Rate of Infusion Rewarming Monitoring Conclusion References V Anesthetic and Analgesic Techniques 29 Local and Topical Anesthesia Background Pharmacology and Physiology Chemical Structure and Physiochemical Properties Nerve Structure and Impulse Transmission Functional and Structural Components of a Peripheral Nerve The Nerve Impulse and Transmission Mechanism of Action The Active Form The Physiologic and Cellular Basis for Neuronal Blockade Activity Profile during Neuronal Blockade Onset of Action Potency Duration Topical Anesthesia Mucous Membranes Agents and Uses Technique and Precautions Intact Skin Agents and Uses Lidocaine Cream EMLA Cream, ELA-Max, and Tetracaine Base Patch Ethyl Chloride and Trichloromonofluoromethane and Dichlorodifluoromethane (Fluori-Methane) Sprays Technique Lidocaine Cream Tetracaine Base Patch and EMLA Cream Ethyl Chloride and Fluori-Methane Sprays Iontophoresis Microneedle Pretreatment Jet Injection Complications Lacerations Background Indications and Contraindications Agents and Effectiveness TAC and Related Mixtures LET and Related Solutions Technique and Dosage Complications Infiltration Anesthesia Background Indications and Contraindications Choice of Agent Equipment Technique Buffering Temperature Manipulation Injection Special Considerations Hematoma Block Intraarticular Anesthesia and Analgesia Intrapleural Anesthesia Indications Technique Complications Local Anesthetic Effect on Wounds Wound Healing Wound Infection Local Injuries Use of Epinephrine with Local Anesthetics Systemic Toxic Reactions High Blood Levels Site and Mode of Administration Rate Dose and Concentration Addition of Epinephrine Specific Drug. Clearance Maximum Safe Dosage Inadvertent Intravascular Injection Host Factors Hypoxia Acid-Base Status Protein Binding Concomitant Drugs. Recognition of CNS Toxicity Recognition of Cardiovascular Toxicity Prevention of Toxicity Treatment of Systemic Toxicity Intravenous Lipid Emulsion Allergic Reactions Allergenic Agents Diphenhydramine and Benzyl Alcohol Skin Testing Summary of Anesthetic “Allergy” Management Catecholamine Reactions Vasovagal Reactions Summary References 30 Regional Anesthesia of the Head and Neck Anatomy of the Fifth Cranial (Trigeminal) Nerve Ophthalmic Nerve Maxillary Nerve Mandibular Nerve Equipment for Dental and Cranial Nerve Blocks General Recommendations Technique Topical Anesthesia Supraperiosteal Infiltration Posterior or Superior Alveolar Nerve Block Anatomy Intraoral Approach Complications MSA Nerve Block Anatomy Intraoral Approach ASA Nerve Block Anatomy Intraoral Approach Infraorbital Nerve Block Anatomy Intraoral Approach Extraoral Approach Inferior Alveolar Nerve Block Anatomy Approach Complications Gow-Gates Block Anatomy Approach Complications Mental Nerve Block Anatomy Approaches Scalp Block Anatomy Approaches Greater and Lesser Occipital Nerve Block Anatomy Approach Ophthalmic (V1) Nerve Block Anatomy Approach Complications Conclusion References 31 Nerve Blocks of the Thorax and Extremities General Concepts Indications Preparation Instructions Equipment Choice of Anesthetic Positioning the Patient Preparation of the Area to Be Blocked Choosing the Nerves to Block Locating the Nerve Nerve Stimulator Ultrasound Paresthesia Injecting the Anesthetic Complications and Precautions Nerve Injury Intravascular Injection Hematoma Infection Systemic Toxicity Limb Injury Specific Nerve Blocks Intercostal Nerve Block Anatomy Technique Precautions Nerve Blocks of the Upper Extremity Nerve Blocks at the Elbow Ulnar Nerve: Anatomy and Technique (Fig. 31-4A) Radial Nerve: Anatomy and Technique (Fig. 31-4B) Median Nerve: Anatomy and Technique (Fig. 31-4C) Nerve Blocks at the Wrist Median Nerve: Anatomy and Technique (Fig. 31-6A) Radial Nerve: Anatomy and Technique (Fig. 31-6B) Ulnar Nerve: Anatomy and Technique (Fig. 31-6C) Nerve Blocks of the Digits Anatomy Technique Alternative Techniques Jet Injection Technique Transthecal Digital Block Technique Complications and Precautions Nerve Blocks of the Lower Extremity Femoral Nerve Block (Three-In-One Block) Anatomy (Fig. 31-14A) Technique (Fig. 31-14B) Nerve Blocks of the Ankle Anatomy Technique Posterior Tibial Nerve (Fig. 31-17A) Sural Nerve (Fig. 31-17B) Superficial Peroneal Nerves (Fig. 31-17C) Deep Peroneal Nerve (Fig. 31-17D) Saphenous Nerve (Fig. 31-17E) Nerve Blocks of the Metatarsals and Toes Anatomy Technique Complications and Precautions References 32 Intravenous Regional Anesthesia* Indications and Contraindications Equipment Procedure Mechanism of Action Procedural Points Anesthetic Agent Exsanguination Site of Injection Complications Anesthetic Agent Additional Complications References 33 Systemic Analgesia and Sedation for Procedures Terminology PSA Guidelines Evaluation before PSA General Airway Cardiovascular Respiratory Gastrointestinal Hepatic and Renal Personnel and Interactive Monitoring Equipment and Mechanical Monitoring Pulse Oximetry Capnography ECG Monitoring BIS Monitoring Resuscitation Equipment and Supplies Vital Signs Supplemental Oxygen Discharge Criteria General Principles Routes of Administration Drug Selection Strategies Insufficient Analgesia. Insufficient Anxiolysis. Insufficient Immobilization. General Considerations. minor procedures in cooperative adults and older children. more complex procedures of longer duration in cooperative adults and older children. procedures in uncooperative adults or the mentally challenged. minor procedures in uncooperative older children and in young children. major procedures in uncooperative children. Pharmacopeia Sedative-Hypnotic Agents Chloral Hydrate Pharmacology. Adult Use. Pediatric Use. Adverse Effects. Midazolam Pharmacology. Adult Use. Pediatric Use. Adverse Effects. Pentobarbital Pharmacology. Adult Use. Pediatric Use. Adverse Effects. Ultrashort-Acting Sedative-Hypnotic Agents Propofol Pharmacology. Adult and Pediatric Use. Adverse Effects. Etomidate Pharmacology. Adult Use. Pediatric Use. Adverse Effects. Thiopental and Methohexital Pharmacology. Adult Use. Pediatric Use. Adverse Effects. Analgesic Agents Fentanyl Pharmacology. Adult Use. Pediatric Use. Adverse Effects. Diamorphine Other Short-Acting Opioids Ketamine Pharmacology. Adult Use. Pediatric Use. Adverse Effects. Ketamine-Propofol Combination (Ketofol) for Procedural Sedation and Analgesia in the ED Nitrous Oxide Pharmacology. Adult and Cooperative Child Use. Uncooperative Child Use. Adverse Effects and Precautions. Antagonists Naloxone Nalmefene Flumazenil References VI Soft Tissue Procedures 34 Principles of Wound Management Background: Wound Healing Initial Evaluation History Wound Age Other Historical Factors Physical Examination Mechanism of Injury and Classification of Wounds Contaminants (Bacteria and Foreign Material) Devitalized Tissue Wound Location Underlying Structures Cleaning Patient Preparation Mechanical Scrubbing Antiseptics during Cleaning Irrigation Antibiotic Solutions for Irrigation Recommendations for Cleaning the Wound Preparation for Wound Closure Débridement Excision Selective Débridement Control of Hemorrhage Tourniquets Closure Open versus Closed Wound Management Delayed Primary or Secondary Closure Protection Dressings Function of Dressings Contact Layer: Dry, Semiocclusive, and Occlusive Dressings Absorbent Layer Outer Layer Splinting and Elevation Ointments Wound Cultures Systemic Antibiotics Immunoprophylaxis Patient Instructions Secondary Wound Care Reexamination Suture Removal Complications Miscellaneous Aspects of Wound Care The ED Approach to Puncture Wounds Gunshot Wounds Animal Bites Human Bites Serious Wound Infections Digital Nerves Accidental Soft Tissue Injection with an EpiPen References 35 Methods of Wound Closure Wound Tape Background and Tape Comparisons Indications Contraindications Equipment Procedure Complications Summary Tissue Adhesive (Tissue Glue) Procedure Complications Wound Staples Background Indications and Contraindications Equipment Procedure Complications Sutures Equipment Instruments Suture Material Composition Handling and Performance Absorption and Reactivity Size and Strength Needles Suturing Techniques (Figs. 35-16 and 35-17) Skin Preparation Closure Principles Minimizing Tissue Trauma Relieving Tension Undermining. Layered Closure. Suture Placement SQ Layer Closure Surface Closure Complications Eversion Techniques Interrupted Stitch Continuous Stitch Continuous Subcuticular Stitch Mattress Stitch Figure-of-Eight Stitch Correction of Dog-Ears Stellate Lacerations Repair of Special Structures Facial Wounds (General Features) Forehead Eyebrow and Eyelid Lacerations Ear Lacerations Nose Lacerations Lip and Intraoral Lacerations Tongue Lacerations Scalp Lacerations Nail Bed Lacerations Subungual Hematomas Partial Nail Avulsions Nail Bed Repair Complete Nail Avulsions Complicated Nail Bed Injuries Removal of a Nail Tuft Fractures Drains in Sutured Wounds Lacerations over Joints Fingertip Amputations Distally and Proximally Based Flap Lacerations References 36 Foreign Body Removal Evaluation and Diagnosis Augmenting the Physical Examination: Imaging Techniques Plain Radiography US CT MRI Fluoroscopy FB Removal Removal Decisions Equipment and Preparation Operative Technique Special Scenarios and Techniques Puncture Wounds in the Sole of the Foot Subungual FBs Metallic Fragments and Bullets FBs in Fatty Tissue Pencil Lead/Graphite Fishhooks Advance and Cut Technique String-Yank Technique Needle Cover Technique Retrograde Technique Wooden Splinters Traumatic Tattooing Marine FBs Coelenterates Coral Sponges Sea Urchins and Starfish Catfish Stingrays Tetanus and Antibiotic Therapy Cactus Spines Ring Removal String-Wrap Method Ring Cutter Body Piercing and Removal Postoperative Suture Removal Tick Removal Zipper Entrapment Infiltration of Radiographic Contrast Material TASER Darts Human and Animal Bite FBs Pyogenic Granuloma (Lobar Capillary Hemangioma) Hair-Thread Tourniquet Disposition Management Tetanus Antibiotics FB Reactions Discharge Instructions Acknowledgment References 37 Incision and Drainage Abscess Etiology and Pathogenesis Bacteriology of Cutaneous Abscesses Special Considerations MRSA Manifestations of Cutaneous Abscesses Imaging Ultrasound-Guided Needle Aspiration Laboratory Findings Indications for and Contraindications to I&D Prophylactic and Therapeutic Antibiotic Therapy Therapeutic Antibiotics Prophylactic Antibiotics Prophylaxis for Endocarditis Prophylaxis for Bacteremia in Other Conditions Recurrent Infections I&d Procedure Procedure Setting Equipment and Anesthesia Incision Wound Dissection Wound Irrigation Packing and Dressing Follow-Up Examination Specific Abscess Therapy Folliculitis, Furuncles, and Carbuncles Hidradenitis Suppurativa Breast Abscess Bartholin Gland Abscess Pilonidal Abscess Perirectal Abscesses Pathophysiology Physical and Laboratory Findings Treatment Infected Sebaceous Cyst Paronychia Herpetic Whitlow Felon Seroma and Hematoma Drainage Subungual Hematoma Methods of Trephination Outcome Conditions with a Similar Appearance Mucocele Acknowledgments References 38 Burn Care Procedures Wound Evaluation Estimating Burn Depth Estimating Burn Size Histopathology of Burns Outpatient Versus Inpatient Care Procedure Emergency Treatment Initial Care of Major Burns Initial Care of Minor Burns Outpatient Care of Minor Burns Open Burn Care Burn Dressings Biologic Dressings Synthetic Dressings Specific Clinical Issues in Minor Burn Care Analgesia Pruritus Edema Use of Topical Preparations and Antimicrobials Specific Topical Agents Silver Sulfadiazine (Silvadene). Other Topical Preparations. broad-spectrum antibiotic ointments. aloe vera cream. honey. corticosteroids. Follow-Up Care of Minor Burns Outpatient Physical Therapy for Burn Care Burn Wound Healing Special Minor Burn Care Circumstances Blisters Minor Burn Infections Foot Burns Hand Burns Facial Burns Abuse of Children and Elderly Individuals Burns in Pregnancy Specific Burning Agents Hot Tar Burns Chemical Burns Acid and Alkali Burns Contact Burns from Wet Cement Air Bag Keratitis and Thermal Burns Hydrocarbon Burns Phenol Injury Hydrofluoric Acid Injury Chromic Acid Injury Phosphorus Burns Elemental Alkali Metal Burns Electrical Burns TEN and SJS Clinical Features Management Frostbite Radiation Burns Emergency Escharotomy Indications Technique of Escharotomy Limbs Chest Neck Penis Complications Conclusion Acknowledgment References VII Gastrointestinal Procedures 39 Esophageal Foreign Bodies General Features Anatomy Epidemiology Complications Clinical Findings Evaluation Radiology of Esophageal FBs Background Indications Plain Radiographs Contrast-Enhanced Esophagograms Background Procedure CT Conclusions Visualization of Esophageal and Pharyngeal FBs Esophagoscopy Esophageal Pharmacologic Maneuvers Background Indications and Contraindications Glucagon Pharmacology Indications and Contraindications Administration of Glucagon Complications Further Evaluation and Therapy Nitroglycerin and Nifedipine Pharmacology Indications and Contraindications Use and Complications Further Evaluation and Therapy Gas-Forming Agents Pharmacology Indications and Contraindications Use and Complications Further Evaluation and Therapy Papain Removal of Esophageal FBs in the ED Magill Forceps Removal of Esophageal FBs Background Procedure (Fig. 39-11) Aftercare Foley Catheter Removal of Esophageal FBs Background Indications Contraindications Procedure (Fig. 39-12) Complications Aftercare Esophageal Bougienage Background Indications and Contraindications Procedure (Fig. 39-13) Complications Aftercare Special Situations Childhood Coin Ingestion Fish or Chicken Bones in the Throat Sharp Objects in the Esophagus Nonradiopaque Objects in the Esophagus Impacted Food Bolus Button Battery Ingestion Magnets The Patient in Distress ED Evaluation of FB Sensation in the Throat References 40 Nasogastric and Feeding Tube Placement Properties of NG and Feeding Tubes NG Tube Placement Indications and Contraindications Equipment Procedure Relief of Discomfort Confirmation of Tube Placement Securing the Tube Placement Issues Complications Replacement of Nasoenteric Feeding Tubes Indications and Contraindications Feeding Tube Site Procedure Confirmation of Placement Complications Patient or Nursing Instructions Pharyngostomy and Esophagostomy Feeding Tubes Gastroenterostomy and Jejunostomy Tubes Equipment for Replacing a Dislodged Tube Removal of a Transabdominal Feeding Tube Securing a Transabdominal Feeding Tube Verification of Placement Complications Clogged Feeding Tubes References 41 Balloon Tamponade of Gastroesophageal Varices Introduction Background Indications Contraindications Procedure Aftercare Complications Conclusion References 42 Decontamination of the Poisoned Patient Gastric Decontamination Gastric Lavage Background Indications Contraindications Equipment and Preparation Technique Complications Activated Charcoal Background Indications Contraindications Technique Complications Multiple Doses of Activated Charcoal Indications Contraindications Technique Complications Cathartics Background Indications Contraindications Technique Complications Whole Bowel Irrigation Background Indications Contraindications Technique Complications Dermal Decontamination Background Technique References 43 Peritoneal Procedures DPL Indications Blunt Trauma Penetrating Trauma Stab Wounds Gunshot Wounds Contraindications Procedure Placement of the Catheter Semi-open Technique Closed Technique Site Aspiration and Lavage Complications Local and Systemic Intraperitoneal Technical Failure Interpretation Gross Blood RBC Count WBC Count Enzymes Miscellaneous Conclusion Paracentesis Clinical Features Determination of Ascites Differential Diagnosis Indications and Contraindications Systemic Anatomic Technique Preliminary Actions Site of Entry Procedure Ultrasound Guidance Volume of Fluid Removed Complications Systemic Local Intraperitoneal Interpretation Inspection Cell Count Albumin Culture and Gram Stain Miscellaneous Medical Therapy and Disposition Chronic Ambulatory Peritoneal Dialysis Acknowledgment References 44 Abdominal Hernia Reduction Background Classification Indirect Inguinal Hernia Direct Inguinal Hernia Pantaloon Hernia Femoral Hernia Incisional Hernia Umbilical Hernia Epigastric Hernia Spigelian Hernia Diagnosis History and Physical Examination Radiologic Imaging Diagnosis of Incarcerated Versus Strangulated Hernias Differential Diagnosis Reduction Indications and Contraindications Procedure Potential Complications Interpretation References 45 Anorectal Procedures Anatomy DRE Indications and Contraindications Procedure Complications Anoscopy Indications and Contraindications Equipment and Setup Positioning Procedure Complications Management of Hemorrhoids Conservative Treatment Surgical Excision of Thrombosed External Hemorrhoids Indications and Contraindications Procedure Complications Management of Anorectal Abscess and Pilonidal Cyst and Abscess Management of Rectal FBs Indications and Contraindications Equipment Procedure Complications Management of Rectal Prolapse Indications for Reduction Procedure Complications Anal Fissure References VIII Musculoskeletal Procedures 46 Prehospital Immobilization Spine Immobilization Background Epidemiology Pathophysiology Indications Contraindications Equipment Cervical Collars Cervical Extrication Splints Full-Body Spine Immobilizers Full-Body Spine Boards (Backboards) Scoop Stretchers Full-Body Splints Lateral Neck Stabilizers Foam Padding Procedure Cervical Spine Immobilization Thoracolumbar Spine Immobilization Sitting Position Recumbent Position Scoop Stretcher. Full-Body Spine Boards (Backboards). Standing Position Pediatric Patients Complications Cervical Immobilization Thoracolumbar Immobilization Conclusion Extremity Immobilization Upper Extremity Background Indications and Contraindications Equipment Rigid Splints Soft Splints Procedures Rigid Splints Soft Splints Complications Conclusion Lower Extremity Background Indications Contraindications Equipment Procedure Special Considerations Complications Conclusion Pelvic Immobilization Background Indications and Contraindications Procedure Complications Conclusion Removal of Helmets and Protective Equipment Background Indications Contraindications Procedure Sport Helmet Removal Motorcycle Helmet Removal Complications Conclusion Special Circumstances Clinical Clearance of Immobilized Patients in the ED Gunshot Wounds to the Head Seizure Patients References 47 Management of Amputations Background Indications Contraindications General Considerations Mechanism of Injury Ischemia Time Assessment of the Patient Care of the Stump and Amputated Part Special Considerations Hand Function Lower Extremity Amputations Fingertip Amputations and Dermal “Slice” Wounds Conservative Management of Fingertip Amputations Penis, Ear, and Nose Amputations Complications Field Amputations Acknowledgment References 48 Extensor and Flexor Tendon Injuries in the Hand, Wrist, and Foot Extensor Tendons Functional Anatomy General Approach to Extensor Tendon Injuries Use of Antibiotics Preparation for Repair Patterns of Injury and Management Zone 7 and 8 Injuries Zone 6 Injuries Zone 5 Injuries Zone 4 Injuries Zone 3 Injuries Zone 1 and 2 Injuries Complications Postrepair Care and Rehabilitation Extensor Tendon Injuries of the Foot Flexor Tendon Injuries Achilles Tendon Rupture Knee Extensor Tendon Rupture References 49 Management of Common Dislocations Preparation of the Patient General Principles Timing of Reduction Shoulder Dislocations Anterior Shoulder Dislocations Clinical Assessment Radiologic Examination Reduction Techniques Stimson Maneuver (Fig. 49-12A) Scapular Manipulation Technique (see Fig 49-12B) BOB Technique (see Fig. 49-12C) External Rotation Method (see Fig. 49-12D) Milch Technique (see Fig. 49-12E) Traction-Countertraction (see Fig. 49-12F) Spaso Technique (see Fig. 49-12G) Other Methods Postreduction Care Posterior Shoulder Dislocations Clinical Assessment Radiologic Examination Reduction Technique (Fig. 49-18A) Postreduction Care Unusual Shoulder Dislocations Luxatio Erecta AC Joint Subluxation and Dislocation First Degree (Type I) Second Degree (Type II) Third Degree (Type III) Fourth, Fifth, and Sixth Degrees (Types IV to VI) Radiographic Examination Sternoclavicular Dislocations Elbow Dislocations Posterior Dislocations Radiologic Examination Reduction Techniques and Postreduction Care Traditional Traction Method Alternatives Recommended Initial Approach Postreduction Care Anterior Dislocations Radial Head Subluxation (Nursemaid’s Elbow) Clinical Assessment Radiographic Examination Reduction Techniques Supination Method Pronation Method After Attempted Reduction Hand Injuries Thumb Dislocations IP Joint Dislocation of the Thumb MCP Joint Injury of the Thumb Dorsal Dislocation Volar Dislocation Ulnar Collateral Ligament Rupture CMC Dislocations of the Thumb Finger Dislocations PIP Joint Dislocations Dorsal PIP Dislocations Volar PIP Dislocations Lateral PIP Dislocations DIP Dislocations MCP Dislocations CMC Dislocations Carpal Dislocation/Dissociation Hip Dislocations Radiographic Examination Analgesia and Anesthesia Posterior Hip Dislocation Reduction Techniques Stimson Technique (Fig. 49-51A) Allis Technique (see Fig. 49-51B) Whistler Technique (see Fig. 49-51C) Captain Morgan Technique (see Fig. 49-51D) Dislocations of Hip Prostheses Anterior Hip Dislocation Reduction Techniques (Fig. 49-55) Knee (Femur, Tibia) Dislocations Clinical Assessment Vascular Injury Reduction Technique (Fig. 49-60) Postreduction Care Dislocations of the Fibular Head Reduction Technique Patellar Dislocation Clinical Assessment Radiographs Reduction Technique and Postreduction Care (Fig. 49-64) Ankle Dislocations Radiographic Examination Reduction Techniques (Fig. 49-67) Postreduction Care Dislocations of the Foot Hindfoot Injuries Subtalar Dislocation Dislocation of the Talus Forefoot Dislocations MTP Dislocations IP Dislocations Conclusion References 50 Splinting Techniques Indications and Contraindications Equipment (see Review Box 50-1) Support Materials Plaster of Paris Prefabricated Splint Rolls Protective and Miscellaneous Equipment Stockinette Padding Elastic Bandages Adhesive Tape Utility Knife, Scalpel, and Plaster or Trauma Scissors Bucket Protective Gear General Procedure of Custom Splint Application Patient Preparation Padding Plaster Preparation Splint Application (see Fig. 50-3) Patient Instructions Upper Extremity Splints Long Arm Splints Long Arm Posterior Splint Indications. Construction. Application. Long Arm Anterior Splint Indications. Construction. Application. Double Sugar-Tong Splint Indications. Construction. Application. Forearm and Hand Splints Volar Splint Indications. Construction. Application. Sugar-Tong Splint Indications. Construction and Application. Thumb Spica Splint Indications. Construction. Application. Ulnar Collateral Ligament Injury (Gamekeeper’s or Skier’s Thumb) Ulnar Gutter Splint Indications. Construction. Application. Radial Gutter Splint Indications. Construction. Application. Finger Splints Pitfalls of Hand Dressings and Splints Sling, Swathe and Sling, and Shoulder Immobilizer Sling Swathe and Sling Shoulder Immobilizer Figure-of-Eight Clavicle Strap Lower Extremity Splints Knee Splints Knee Immobilizer Indications. Application. Posterior Knee Splint Indications. Construction. Application. Jones Compression Dressing Indications. Construction. Application. Ankle Splints Posterior Splint Indications. Construction. Application. Anterior-Posterior Splint Indications. Construction. Application. U-Splint (Stirrup Splint) Indications. Construction. Application. Walking Boots Indications. Application. Semirigid Orthosis Indications. Application. Hard Shoe (Cast or Reese Shoe) Indications. Application. Ankle Wraps and Bandages Soft Cast Indications. Construction. Application. Complications of Splints Ischemia Heat Injury Pressure Sores Infection Dermatitis Pruritus Joint Stiffness Cast Pain Conclusion References 51 Podiatric Procedures Common Nontraumatic Conditions of the Foot Footpad Use Heel Pain Syndromes Retrocalcaneal Bursitis, Achilles Tendinopathy, and Calcaneal Apophysitis Painful Conditions of the Plantar Surface of the Foot Plantar Fasciitis Forefoot Neuroma Ganglion Cyst of the Foot Traumatic Conditions of the Foot Toe Fractures and Fractures of the Sesamoid Bones Stress Fractures Plantar Puncture Wounds Evaluation Treatment Ingrown Toenail Evaluation Treatment Removal of the Nail Spicule and Débridement of Hyperkeratosis for Minor Ingrown Toenails Toenail Removal for Complex or Extensive Ingrown Toenails Nail-Splinting Technique References 52 Treatment of Bursitis, Tendinitis, and Trigger Points General Anatomic Considerations Bursae and Tendon Sheaths Trigger Points Rationale for Injection Therapy Bursitis and Tendinopathies Trigger Points Indications and Contraindications Bursae and Tendon Sheaths Trigger Points Hazards and Complications Corticosteroid Preparations Dosage and Administration Bursae and Tendon Sheaths Trigger Points Preparation of the Site Techniques General Considerations Bursae and Tendon Sheaths Trigger Points Noninvasive Techniques Spray and Stretch Massage Therapy Ischemic Compression Therapy Invasive Techniques Injection Therapy Specific Regions and Clinical Entities Bursitis and Tendinitis Shoulder Region Bicipital Tendinitis (Tenosynovitis) (Fig. 52-6). approach. Calcareous Tendinitis, Supraspinatus Tendinitis, and Subacromial Bursitis. anterior approach. posterolateral appproach. AC Joint Inflammation. approach. Elbow Region Radiohumeral Bursitis, Lateral Epicondylitis, and Medial Epicondylitis. approach. Olecranon Bursitis (Aseptic). Septic Bursitis. approach. Wrist and Hand Region Ganglion Cysts of the Wrist or Hand. approach. de Quervain’s Disease and Intersection Syndrome. approach. Carpal Tunnel Syndrome. approach. Digital Flexor Tenosynovitis (“Trigger Finger”). approach. Carpal/Metacarpal Inflammation. Hip Region Trochanteric Bursitis. approach. Ischiogluteal Bursitis. approach. Knee Region Prepatellar Bursitis. approach. Suprapatellar Bursitis. approach. Anserine Bursitis. approach. Medial Collateral Ligament Bursa. Popliteal Cyst. Ankle, Foot, and Heel Region Ankle Tendinitis. approach. Bunion Bursitis. approach. Heel Pain. approach. Trigger Points Myofascial Headache Syndromes Torticollis. Levator Scapulae Muscle Syndrome. Splenius Capitis and Semispinalis Capitis Muscle Syndrome. Trapezius Muscle Syndrome. Sternocleidomastoid Muscle Syndrome. Myofascial Shoulder Disorders Scapula Muscles. Infraspinatus Muscle Syndrome. Somatic Visceral Reflex Phenomenon Rectus Abdominis Muscle Syndrome. Pectoralis Major/Pectoralis Minor Muscle Syndrome. Intercostal Muscle Syndrome. Knee Region Tensor Fasciae Latae Muscle Syndrome. Ankle, Foot, and Heel Region Anterior Tibialis Muscle Syndrome. Gastrocnemius/Soleus Muscle Syndrome. Myofascial Back Pain Quadratus Lumborum Muscle Syndrome. Gluteus Medius Muscle Syndrome. Acknowledgment References 53 Arthrocentesis Background Indications and Contraindications Articular versus Periarticular Disease Septic Arthritis Hemarthrosis Intraarticular Corticosteroid Injections Equipment General Arthrocentesis Technique Complications Specific Arthrocentesis Techniques First Carpometacarpal Joint (Fig. 53-7) Landmarks. Position. Needle Insertion. Comments. Interphalangeal and Metacarpophalangeal Joints (Fig. 53-8) Landmarks. Position. Needle Insertion. Comments. Radiocarpal Joint (Wrist) (Fig. 53-9) Landmarks. Position. Needle Insertion. Radiohumeral Joint (Elbow) (Fig. 53-10) Landmarks. Position. Needle Insertion. Comments. Glenohumeral Joint (Shoulder), Anterior Approach (Fig. 53-11) Landmarks. Position. Needle Insertion. Comments. Knee Joint, Anteromedial Approach (Fig. 53-12) Landmarks. Position. Needle Insertion. Comments. Tibiotalar Joint (Ankle) (Fig. 53-13) Landmarks. Position. Needle Insertion. Comments. Metatarsophalangeal and Interphalangeal Joints (Fig. 53-14) Landmarks. Position. Needle Insertion. Synovial Fluid Interpretation String Sign Mucin Clot Test Cell Count Glucose and Protein Serology Fluid Processing Polarizing Microscope Polarization Physics Microscopic Analysis Joint Arthrography Background Indications and Contraindications Equipment and Procedure Complications Conclusion Acknowledgment References 54 Compartment Syndrome Evaluation Background Pathophysiology Clinical Features Diagnosis Ancillary Studies Invasive Compartment Pressure Monitoring Indications and Contraindications Patient Preparation and Positioning Equipment Pressure Measurement Systems Mercury Manometer System (Fig. 54-4) Equipment Setup and Procedure Procedural Caveats Arterial Line System (Fig. 54-5) Equipment Setup and Procedure Stryker Intracompartmental Pressure Measurement (Fig. 54-6) Equipment Setup and Procedure (see Fig. 54-6) Needle Placement Techniques for Specific Compartments General Principles Lower Extremity Anterior Compartment (Fig. 54-8A) Deep Posterior Compartment (see Fig. 54-8B) Lateral Compartment (see Fig. 54-8C) Superficial Posterior Compartment (see Fig. 54-8D) Forearm Volar Compartment (Fig. 54–9A) Dorsal Compartment (see Fig. 54–9B) Mobile Wad (see Fig. 54–9C) Gluteal Musculature Gluteal Compartments Foot Medial Compartment (see Fig. 54-11B) Central (Calcaneal) Compartment (see Fig. 54-11B) Lateral Compartment (see Fig. 54-11B) Intrinsic (Interosseous) Compartment (see Fig. 54-11B) Interpretation of Compartment Pressure Measurements Complications Acknowledgment References IX Genitourinary, Obstetric, and Gynecologic Procedures 55 Urologic Procedures Introduction Testicular Torsion Background Anatomy and Physiology Pathophysiology Indications Contraindications Procedure Manual Detorsion and Spermatic Cord Anesthesia Spermatic Cord Anesthesia Manual Detorsion Aftercare Complications Conclusion Priapism Background Anatomy and Physiology Pathophysiology Indications Contraindications Procedure Minimally Invasive Technique—Simple Injection Aspiration/Irrigation Technique Aftercare Complications Conclusion Paraphimosis Background Anatomy and Physiology Pathophysiology Indications Contraindications Procedure Manual Reduction Technique Adjunctive Techniques to Assist in Manual Reduction Aftercare Complications Conclusion Phimosis Anatomy and Physiology Pathophysiology Indications Contraindications Procedure Aftercare Complications Conclusion Urethral Catheterization Background Anatomy and Physiology Female Catheterization Male Catheterization Indications Contraindications Procedure Equipment General Procedure (Figs. 55-21 and 55-22) Bladder Irrigation DUC Aftercare Complications Mechanical Bleeding Infection Long-Term Catheter Use Undesirable Catheter Retention Removal of a Nondeflating Catheter Traumatic Foley Catheter Removal Conclusion Suprapubic Aspiration Introduction Indications Contraindications Procedure Aftercare Complications Conclusion Suprapubic Cystostomy Introduction Indications Contraindications Procedure Aftercare Complications Conclusion Lower GU Tract Imaging Background Anatomy and Physiology Pathophysiology Indications Contraindications Procedure RUG Retrograde Cystography Aftercare Complications Conclusion Upper GU Tract Imaging Acknowledgment References 56 Emergency Childbirth Background Anatomy and Physiology Identification of Labor Evaluation of Labor Labor Movements: Vertex Labor Movements: Breech Types Vaginal Examination Fetal Well-Being Auscultation Management of Fetal Distress Tocolytic Therapy β2-Receptor Agonists Magnesium Sulfate Calcium Channel Blockers Prostaglandin Inhibitors Steroids Vaginal Bleeding during the Third Trimester Procedure Technique for Uncomplicated Delivery Spontaneous Vertex Delivery Delivery of the Head Delivery of the Shoulders Clearing the Airway Clamping the Cord Delivery of the Placenta Complications Complex Deliveries Shoulder Dystocia Management Breech Delivery Technique Delivery of the Presenting Part and Body. Delivery of the Head. Episiotomy Technique Immediate Postpartum Hemorrhage Management Oxytocics PCS Indications Technique The Newborn Evaluation Respiration Heart Rate Color Stabilization Technique References Selected Readings 57 Culdocentesis Anatomy Indications Ectopic Pregnancy Blunt Abdominal Trauma Contraindications Equipment Technique Preparation Exposure Aspiration Interpretation of Results Complications References 58 Examination of the Sexual Assault Victim Definitions Evaluation and Treatment of Patients Suffering From Sexual Assault Preparation Consent History Physical Examination Collection of Clothing General Body Examination Imaging Oral Evaluation Genital Examination Pubic Hair Samples Colposcopy Forensic Evidence Collection Genital Testing for STDs Perineal Toluidine Blue Dye Staining Anal Evaluation Reference Samples Blood Tests Urine Tests Spermatozoa, Semen, and DNA Testing Chain of Custody Treatment STD Prophylaxis Prevention of Hepatitis B Prevention of HIV Infection Pregnancy Prophylaxis Psychological Support Postexamination Follow-Up Specific Populations Male Evidentiary Examinations Child Sexual Assault Examinations Suspect Examinations The Unconscious Victim and “Drug-Facilitated Sexual Assault” Legal Issues Sexual Assault Response Teams Acknowledgment References X Neurologic Procedures 59 Management of Increased Intracranial Pressure and Intracranial Shunts Pathophysiology of ICP Brain CSF Blood Signs and Symptoms Medical Treatment of Increased ICP Oxygenation Sedation and Paralytics Oxygenation and Hyperventilation Head Position Fluid Management Diuresis Seizure Prophylaxis Steroids Glucose Control Hypothermia Skull Trephination Operative Management Intracranial Shunts Shunt Assessment Shunt Tapping Special Considerations—Postoperative Shunt Complications Hemorrhage Shunt Malfunction Seizures Shunt Infection—Treatment and Prevention Acknowledgment References 60 Spinal Puncture and Cerebrospinal Fluid Examination Historical Perspective Anatomy and Physiology Indications for Spinal Puncture General Indications IIH (Pseudotumor Cerebri) Contraindications to Spinal Puncture Equipment Procedure Lateral Approach for Lumbar Puncture Lumbar Puncture in Infants The Difficult Lumbar Puncture Complications Headache after Lumbar Puncture Infection Herniation Syndromes after Lumbar Puncture Epidermoid Tumor Backache and Radicular Symptoms Spinal Epidural Hemorrhage Interpretation Pressure Appearance Cells Glucose Protein The Traumatic Tap Absolute Number of RBCs RBC Clearance from First to Last Tubes Xanthochromia CSF Analysis with Infections Bacterial Infections Microbial Antigens and PCR Empirical Antibiotic Use before Lumbar Puncture Dexamethasone Therapy for Bacterial Meningitis Neurosyphilis Viral Meningitis CSF Analysis in Immunocompromised Patients Neurosyphilis in Patients Infected with HIV Cryptococcal Meningitis Toxoplasmosis Mycobacterial Tuberculosis Primary CNS Lymphoma Progressive Multifocal Leukoencephalopathy Cytomegalovirus Infection Acknowledgment References 61 Special Neurologic Tests and Procedures Caloric Testing Historical Perspective Physiology and Functional Anatomy Indications and Contraindications Equipment Procedure Complications Interpretation First Phase of Interpretation Second Phase of Interpretation Summary DIX-Hallpike Test For The Diagnosis of Positional Vertigo Background Indications and Contraindications Procedure Interpretation Complications Summary Canalith-Repositioning Maneuvers Background Indications and Contraindications Procedure Complications Summary Tests to Distinguish Central From Peripheral Lesions in Patients with AVS Background Indications and Contraindications Procedure Interpretation Complications Summary Brain Death Testing Background Indications and Contraindications Procedure Establishment of Coma and Cortical Assessment Brainstem Reflex Testing Pupillary Response Auditory Reflex Caloric Testing Corneal Reflex Cough Reflex Apneic Oxygenation Test Declaration of Death Complications Summary MG Testing Background Edrophonium (Tensilon) Test Background Indications and Contraindications Equipment Procedure Complications Interpretation Ice Pack Test Background Indications Procedure Complications Interpretation Summary References XI Ophthalmologic, Otolaryngologic, and Dental Procedures 62 Ophthalmologic Procedures Assessment of Visual Acuity Indications Distant Visual Acuity Procedure Near Visual Acuity Procedure Dilating the Eye Indications and Contraindications Agents Procedure Complications The Fluorescein Examination Indications and Contraindications Procedure Interpretation Summary Eye Irrigation Indications and Contraindications Equipment Procedure Basic Technique Duration of Irrigation Prolonged Irrigation Complications Summary Ocular FB Removal Indications and Contraindications Globe Protection Equipment Consideration of an Intraocular FB Procedure FB Location FB Removal Rust Rings Multiple FBs Aftercare Use of Ophthalmic Anesthetic Agents Use of Ophthalmic NSAIDs Complications Summary Eye Patching Contact Lens Procedures Mechanism of Corneal Injury from Contact Lens Wear Hard Contact Lenses Soft Contact Lenses Indications for Removal Contraindication to Removal Procedure Hard Contact Lens Removal Soft Contact Lens Removal Lens Storage Evaluation of a “Lost” Contact Lens Complications of Lens Removal Summary Bandage Contect Lenses for Treatment of Corneal Abrasions Indications and Contraindications Equipment Procedure Complications Summary Infectious Keratitis Tonometry Tonometric Techniques Contraindications to Tonometry Procedure Palpation Technique Impression (Schiøtz) Technique Errors with Impression Tonometry Impression (Tono-Pen XL) Technique (Fig. 62-23) Complications Slit Lamp Examination Indications and Contraindications Equipment Procedure Unilateral Loss of Vision Central Renal Artery Occlusion Therapy Complications Orbital Compartment Syndrome Technique: Lateral Canthotomy and Cantholysis (Fig. 62-33) Complications Reduction of Globe Luxation Indications and Contraindications Technique Complications Aftercare Stye APD or Marcus Gunn Pupil Subconjunctival Hemorrhage Acknowledgment References 63 Otolaryngologic Procedures Pharynx and Larynx Examination of the Larynx Anatomy Indications and Contraindications Equipment Procedure Flexible Laryngoscopy Mirror Laryngoscopy Complications Tonsil: PTA Anatomy Pathophysiology and Clinical Findings Indications and Contraindications Equipment Procedure Needle Aspiration Incision and Drainage Complications of Surgical Drainage Antibiotic Therapy Glucocorticoid Therapy Ear Anatomy Anesthesia of the External Ear Auricle Procedure EAC and TM Procedure Examination Removal of Impacted Cerumen Indications and Contraindications Procedure Ceruminolytics Irrigation (Ear Syringing) Manual Instrumentation Complications Ear Canal Débridement and Wick Placement Indications and Contraindications Procedure Complications FBs in the Ear Canal Indications and Contraindications Procedures Suction-Tipped Catheters Manual Instrumentation Fogarty Catheters Cyanoacrylate (Superglue) Removal of Insects Complications Drainage of Auricular Hematomas Indications and Contraindications Procedure Needle Aspiration Incision (see Fig. 63-23) Complications Nose Anatomy Anesthesia of the Nose Examination Management of Epistaxis Anticoagulated Patients with Epistaxis Additional Testing for Epistaxis Indications and for Contraindications to Treatment of Epistaxis Equipment Procedure Cautery Anterior Nasal Packing Complications Posterior Nasal Packing Posterior Gauze Pack Inflatable Balloon Packs Other Techniques Complications Antibiotics Following Nasal Packing Patient Disposition following Nasal Packing Septal Hematoma Indications and Contraindications Equipment Procedure Complications Reduction of Nasal Fractures Indications and Contraindications Equipment Procedure Complications Nasal FB Removal Indications and Contraindications Equipment Procedure Manual Instrumentation Balloon Catheter Positive Pressure Complications Mandible Dislocation of the Mandible Indications and Contraindications Equipment Procedure Classic Technique (see Fig 63-45B) Recumbent Approach (see Fig 63-45C) Posterior Approach Ipsilateral Approach (see Fig 63-45C) Alternative Manual Method Wrist Pivot Method (see Fig. 63-45C) Gag Reflex Method Complications Uvulitis/Angioedema of the Uvula Posttonsillectomy Bleeding References 64 Emergency Dental Procedures Teeth The Periodontium Acute Toothache in the ED Dentoalveolar Trauma Dental Fractures Ellis Class I Fractures Ellis Class II Fractures Ellis Class III Fractures Luxation, Subluxation, Intrusion, and Avulsion Luxation and Subluxation Intrusion and Avulsion Prognosis Alveolar Bone Fractures Lacerations and Dentoalveolar Soft Tissue Trauma Buccal Mucosa Gingiva Frenulum The Tongue Oral Hemorrhage Direct Pressure Alveolar Osteitis (Dry Socket) Dentoalveolar Infections Disease of the Pulp Disease of the Periodontium Drainage of Dentoalveolar Infections Intraoral Technique Extraoral Technique Deep Space Infections of the Head and Neck Dental Material Intraoral Piercing Acknowledgments References XII Special Procedures 65 Procedures Pertaining to Hypothermia and Hyperthermia Procedures Pertaining to Hypothermia Definitions Measurement of Core Temperature Pathophysiology Initial Evaluation and Stabilization of Hypothermic Patients Prehospital Care ED Management Management Guidelines Passive External Rewarming Active External Rewarming Indications Equipment Technique Arteriovenous Anastomoses Rewarming Complications Active Core Rewarming Emergency Warming of Saline in a Microwave Inhalation of Heated Humidified Oxygen or Air Indications and Contraindications. Technique. Summary. Peritoneal Dialysis (Lavage) Indications and Contraindications. Equipment. Technique. Complications. Summary. Gastrointestinal and Bladder Rewarming Indications and Contraindications. Equipment. Technique. Complications. Summary. Thoracic Cavity Lavage Indications and Contraindications. Closed Thoracic Lavage. Open Thoracic Lavage. Summary. Cardiac Bypass Hemodialysis Experimental Techniques Special Situations Cardiac Arrest Airway Management Acid-Base Disturbances Coagulopathies Trauma and Hypothermia Pharmacotherapy and Monitoring Frostbite Cold Water Immersion and Submersion Conclusion Procedures Pertaining to Hyperthermia Normal Thermoregulation Types of Hyperthermia Mild Heat Illness Heatstroke MH NMS Hyperthermia and Psychostimulant Overdose Hemorrhagic Shock and Encephalopathy Syndrome Cooling Techniques General Considerations Indications for Rapid Cooling Contraindications to Rapid Cooling Evaporative Cooling Procedure Complications Immersion Cooling Procedure Complications Whole-Body Ice Packing Procedure Strategic Ice Packs Procedure Complications External versus Core Cooling Cold Gastric Lavage Procedure Complications Cold Peritoneal Lavage Procedure Complications Other Cooling Techniques Conclusion Acknowledgments References 66 Ultrasound Physics Indications and Contraindications Equipment General Approach Complications References 67 Bedside Laboratory and Microbiologic Procedures Assessment of Urine Obtaining a Urine Specimen General Considerations regarding Urine Collection Bladder Percussion and the Midstream Specimen in Infants Bag Collection in Non–Toilet-Trained Children Urine Specimens from Patients with Chronic Urinary Drainage Systems Catheterization and SPA Urine Dipstick Method Interpretation Glucose Ketones Leukocyte Esterase Nitrites Protein “Blood” Urine Bilirubin Urobilinogen pH Specific Gravity Microscopic UA Summary of Tests Used in the Diagnosis of UTI Urine Dipstick Microscopic UA Urine Culture The Bottom Line Testing for Pregnancy Blood Cultures in the ED Indications The Controversy Regarding “Outpatient Blood Cultures” Technique for Obtaining Blood for Culture Special Considerations in Obtaining Blood for Culture “Changing the Needle” after Phlebotomy Special Access Sites Heel Stick in Neonates Intraosseous Specimens Timing of Blood Cultures Blood Culture Volumes Volumes in Adults Volumes in Children How Many Sets of Blood Cultures Are Needed? Aerobic versus Anaerobic (versus Other) Bottles Identifying Contaminants Fungal Cultures Principles and Pitfalls in Phlebotomy for Blood Testing Bedside Tests for GI Hemorrhage Detection of Blood in Stool Method Testing for Gastric Blood Method Blood Glucose Meters Diagnostic and Therapeutic Toxicologic Bedside Procedures Noninvasive Diagnostic Procedures Amatoxin: Meixner Test Mothball Identification Body Secretion Analysis Bedside Toxicologic Tests on Urine Ethylene Glycol Salicylates Bedside Toxicologic Tests on Oral Secretions and Breath: Ethyl Alcohol Bedside Toxicologic Tests on Blood: Methemoglobinemia Invasive Diagnostic Procedures Naloxone Flumazenil Physostigmine Deferoxamine Invasive Therapeutic Procedures Alkalinization of Urine and Blood Ethanol Infusion References 68 Standard Precautions and Infectious Exposure Management Guidelines for Standard Precautions Barrier Precautions Sharps Precautions Respiratory Precautions Hand Washing Occupational Disease Exposure HBV Transmission Postexposure Management HCV Transmission Postexposure Management HIV Transmission Postexposure Management Evidence Supporting PEP Selecting Patients for PEP Choice of PEP Medications Timing, Duration, and Side Effects of PEP TB Transmission Postexposure Management References 69 Educational Aspects of Emergency Department Procedures Concepts in Procedural Skill Training Formal Education Procedural Training at the Bedside Educational Alternatives for Practicing Procedures Volunteers Simulation Task Trainers High-Fidelity Simulation Cadaver Laboratories Long-Term Skill Retention and Uncommon Procedures Training for Uncommon Procedures Teaching Key ED Procedures Airway Management Lumbar Puncture Cricothyroidotomy Ultrasound-Guided Procedures Chest Tubes Central Lines Suturing Incision and Drainage Assessing Procedural Competency Online Resources for Procedural Education Conclusion References 70 Physical and Chemical Restraint EXDS Medicolegal Concerns Patient Assessment Deescalation Techniques Types of Patient Restraint Seclusion Physical Restraint Restraint Devices Limb Holders (Restraints) Belts/Fifth-Point Restraint Jackets and Vests Hobble Leg Restraints Indications Contraindications Procedure Complications Increased Agitation Local Skin Complications Vascular Compromise Respiratory Compromise Positional Asphyxia Cocaine-Associated Agitated Delirium Metabolic Acidosis Chemical Restraint Other Methods of Drug Delivery Indications Contraindications and Adverse Effects Neuroleptic Agents Contraindications Adverse Effects Haloperidol Dosage and Administration. Droperidol Dosage and Administration. Benzodiazepines Contraindications Adverse Effects Lorazepam Dosage and Administration. Midazolam Dosage and Administration. Diazepam Atypical Antipsychotic Agents Contraindications Adverse Effects Ziprasidone Dosage and Administration. Olanzapine Dosage and Administration. Aripiprazole Dosage and Administration. Dissociative Agents Ketamine Dosage and Administration. Choosing the Best Agent Undifferentiated Agitation Agitation Caused by Alcohol and Drugs of Abuse Agitation Caused by Medical Illness Agitation Caused by an Underlying Psychiatric Disorder Agitation in Children Agitation in Pregnancy Agitation in Older Patients Conducted Electrical Weapons Electronic Control Devices Removal Techniques Complications TASER Use in the ED Acknowledgment References 71 Noncardiac Implantable Devices Insulin Infusion Devices Background Anatomy Device Complications Procedure Intrathecal Drug Delivery Systems Background Anatomy Device Complications Procedure VNS Background Anatomy Device Complications Procedure Additional Implantable Devices MRI and Implantable Devices References 72 Radiation in Pregnancy and Clinical Issues of Radiocontrast Agents Types of Radiation Ionizing Radiation Units of Radiation Timing of Radiation during Pregnancy and Its Effects Stages of Fetal Development Preimplantation and Implantation Phase Organogenesis Fetal Period Mental Impairment Growth Retardation Carcinogenesis Mutagenesis Radiation Exposure from Diagnostic Radiographs Radiation Exposure from CT Scans Nuclear Medicine Studies Diagnosis of PE Diagnosis of Appendicitis Diagnosis of Pregnancy and Consent Patient Counseling Nonionizing Radiation: MRI and US MRI US Summary Clinical Use of Radiocontrast Material References Appendix Commonly Used Formulas and Calculations Introduction English-to-Metric Conversions Calculation of MAP QT and QTc Intervals Predicted PEFR Endotracheal Intubation and Mechanical Ventilation Selecting the ETT Adults. Pediatrics. Determining Initial Ventilator Settings Renal Function Acid-Base, Fluid, and Electrolyte Balance Calculating the Osmolal Gap Hyponatremia Hypernatremia Potassium Calcium Maintenance IV Fluid Rate Fluid Resuscitation of Burned Patients Acid-Base Balance Winter’s Formula Glasgow Coma Scale NIH Stroke Score Diagnostic Probability Acknowledgment Index A B C D E F G H I J K L M N O P Q R S T U V W X Y Z Clinical Key Appendix 2
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