ESSENTIAL PROCEDURES
Medical students will be expected to be able to perform the following procedures. Follow all standard barrier precautions. Note that in most instances, these procedures should only be performed under supervision. Although steps to perform procedures are provided, by no means should students perform a procedure without requesting permission from a supervising physician.
1
List the usage, materials, and procedural steps of an intravenous (IV) catheter insertion
Use
For access to administer fluids, blood, or medication.
Materials
IV cannula (angiocatheter or intracatheter), tourniquet, alcohol swab, dressing (Tegaderm), tape.
Steps
- 1
Choose distal veins on the upper, nondominant extremity first. However, any peripheral vein, the external jugular vein, or even scalp veins may be used.
- 2
Place the tourniquet proximal to the access site. To help visualize the veins, it may help to lightly tap a finger over the veins. This can cause the vein to bulge slightly.
- 3
Clean the site with an alcohol swab.
- 4
Stabilize the vein with your free hand, being sure not to contaminate the sterilized area as displayed in Figure 12-1 . This can be done by providing steady traction distal to the puncture site.
Figure 12-1
Stabilizing the vein during an intravenous catheter insertion.
(From Roberts JR, Hedges JR: Clinical Procedures in Emergency Medicine, ed 4, Philadelphia, WB Saunders, 2004, with permission.)
- 5
Enter the vein at about a 20-degree angle. When a “flash” of blood is seen, decrease the angle a bit further and advance 2 mm more to ensure that the needle and the tip of the catheter are in the vein as displayed in Figure 12-2 .
Figure 12-2
Insertion of the needle and catheter into the vein during an intravenous catheter insertion.
(From Roberts JR, Hedges JR: Clinical Procedures in Emergency Medicine, ed 4, Philadelphia, WB Saunders, 2004, with permission.)
- 6
Advance the IV catheter, and then remove the needle.
- 7
Secure the IV catheter with dressing and tape.
2
List the usage, necessary materials, and procedural steps of a blood draw for an arterial blood gas (ABG) measurement
Use
For blood gas determination and analysis.
Materials
Heparinized syringe (a special syringe used for blood gases), 22- to 25-gauge needle (it may be easier to use a butterfly needle), alcohol swab.
Steps
- 1
The radial artery is used most frequently, and this approach is described here. Verify patency of the collateral circulation with the Allen test. Have the patient make a tight fist. Occlude both the radial and ulnar arteries at the wrist. Have the patient pump his or her fist until the hand is pale. While maintaining pressure on the radial artery, release the ulnar artery. Color should return to the hand within 10 seconds. If the result of this test is positive (color does not return), the radial artery should not be used.
- 2
It may help to have an assistant hyperextend the patient’s wrist and hold the patient’s hand in place.
- 3
Prepare the puncture site with an alcohol swab.
- 4
Enter the artery with the bevel up at a 60- to 90-degree angle as displayed in Figure 12-3 .
Figure 12-3
Insertion of the needle into the radial artery at a 60- to 90-degree angle during an arterial blood gas.
(From Roberts JR, Hedges JR: Clinical Procedures in Emergency Medicine, ed 4, Philadelphia, WB Saunders, 2004, with permission.)
- 5
When a “flash” of blood is seen, slowly withdraw blood. For a blood gas measurement, only 2 to 3 mL are typically needed.
- 6
Withdraw the needle quickly and apply firm pressure directly over the puncture site.
- 7
Place the collection tube on ice before taking the sample to the laboratory if required by the hospital.
3
List the usage, necessary materials, and procedural steps of an arterial line placement
Use
For frequent sampling of arterial blood and hemodynamic monitoring when continuous blood pressure readings are necessary.
Materials
20-gauge (or smaller) angiocatheter, arterial line setup per intensive care unit routine (transducer, tubing, and pressure bag with heparinized saline), armboard, dressing (Tegaderm), lidocaine.
Steps
- 1
The radial artery is used most frequently, and this approach is described here. Verify patency of the collateral circulation with the Allen test, as described earlier.
- 2
Place an armboard beneath the arm, with a roll of gauze behind the wrist to hyperextend the wrist. Prepare the wrist with an iodine solution, and drape with sterile towels, exposing only the puncture site.
- 3
Palpate the radial artery. Inject 1% lidocaine above where the pulse is felt.
- 4
Using a 30-degree angle with the bevel up, advance the angiocatheter into the artery. Once a “flash” of blood is seen in the hub, advance 1 to 2 mm further so that both the needle and catheter are in the artery. Advance the catheter over the needle into the artery.
- 5
Manually occlude the artery proximally, remove the needle, and connect pressure tubing.
- 6
Secure the catheter in place with 3-0 silk suture or with sterile dressing.
- 7
Adjust the transducer’s height until it is level with the patient’s left atrium. The line will then need to be calibrated on the basis of the respective institution’s method.
4
List the usage, necessary materials, and procedural steps of a nasogastric (NG) tube insertion
Use
For gastrointestinal decompression, stomach lavage, or feeding patients. Contraindicated in patients with nasal or basilar skull fractures.
Materials
NG tube, lubricant jelly, glass of water, straw, tape
Steps
- 1
Squirt anesthetic into the nose to numb the area if desired.
- 2
Approximate the amount of tube needed: measure from the xiphoid process, up to the patient’s nose, and around the ear, and then add 6 inches more. An example is displayed in Figure 12-4 .
Figure 12-4
A method for approximating the length of tubing necessary during a nasogastric tube insertion.
(From Roberts JR, Hedges JR: Clinical Procedures in Emergency Medicine, ed 4, Philadelphia, WB Saunders, 2004, with permission.)
- 3
Run the tube under warm water or wrap tubing around your finger to make it more pliable at the tip.
- 4
Lubricate the end of the tube.
- 5
Place the patient’s head in flexion, and insert the tube gently along the floor of the nasal passageway.
- 6
When the tube is in the back of the patient’s throat, ask the patient to drink water through the straw. Continue to pass the tube as the patient drinks water until the estimated point is reached.
- 7
Secure the tube by taping the tube to the patient’s nose or forehead.
- 8
If the patient can talk without difficulty and gastric fluid returns, the tube should be located in the stomach. Also verify placement by blowing air into the tube and listening for a stomach gurgle with your stethoscope. Obtain an x-ray if unsure and before starting any feedings.
5
List the usage, necessary materials, and procedural steps of a bladder catheterization
Use
For urinary retention, obtaining clean urine samples, and monitoring urine output. Do not perform if blood is seen at urethral meatus, pelvic injury is suspected, a high-riding prostate is present on pelvic examination, or if you are concerned about acute prostatitis.
Materials
Usually come in a prepackaged Foley catheter insertion tray.
Steps
- 1
Open the package and put on gloves using sterile procedure. Open the iodine preparation solution and soak cotton balls. Apply sterile drapes.
- 2
Inflate and deflate the balloon on the catheter to ensure proper functioning. Coat the end with sterile lubricant.
- 3
Use one hand to expose the urethral meatus if necessary (spreading the labia in females or retracting the foreskin in males). This hand is now considered unsterile.
- 4
Prepare the urethral meatus with iodine solution on cotton balls.
- 5
Place the catheter into the urethra and advance until urine returns. As soon as urine returns, advance a few more centimeters and then inflate the balloon with saline.
- 6
If catheter cannot be inserted, try a larger Foley catheter or a coude catheter (has a curved tip).
- 7
When removing the Foley catheter, remember to first deflate the balloon!
6
List the usage, necessary materials, and procedural steps of a laceration repair
Use
Most traumatic lacerations that will not stop bleeding on their own will require suture. In addition, suturing a laceration may help the wound heal faster.
Materials
For skin lacerations, use nylon 6-0 for the face, 5-0 for the hands and feet, and 4-0 for the body. For deep lacerations, use Vicryl 5-0 for the face, 4-0 for the hands and feet, and 3-0 for the body. Sterile saline, gauze, lidocaine 1% or LET (a topical anesthetic composed of lidocaine, epinephrine, and tetracaine), suture scissors.
Steps
- 1
Cleanse the wound with sterile saline and dry with gauze.
- 2
Inject 1% lidocaine around the wound, or apply LET for >20 minutes. Do not use LET if the laceration is on an extreme distal portion of the body such as a toe or tip of a finger.
- 3
Using interrupted stitches, close the wound, leaving 3 to 5 mm between each stitch. An example is displayed in Figure 12-5 . Because most traumatic lacerations are uneven, it is difficult to use running or subcuticular stitches to close these wounds.
