The Ten Surgical Procedures

8/7/2019 The Ten Surgical Procedures

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The Ten Surgical Procedures

Submitted By:

Jayzel & Marjay

Submitted To:

The Nutty Professor

Submitted On:

May 19, 2010

Year & Section:

III-B BSN

Central Venous Pressure Monitoring


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Central venous pressure is considered a direct measurement of the blood pressure in

the right atrium and vena cava. It is acquired by threading a central venous catheter

(subclavian double lumen central line shown) into any of several large veins. It is

threaded so that the tip of the catheter rests in the lower third of the superior vena cava.

The pressure monitoring assembly is attached to the distal port of a multilumen central

vein catheter.

Assisting with CVP placement

y Adhere to institutional Policy and Procedure.y Obtain history and assess the patient.y Explain the procedure to the patient, include:

o local anesthetico trendelenberg positioningo drapingo limit movemento need to maintain sterile field.o post procedure chest X-ray

y Obtain a sterile, flushed and pressurized transducer assemblyy Obtain the catheter size, style and length ordered.y Obtain supplies:

o Maskso Sterile gloveso Line insertion kito Heparin flush per policy

y Position patient supine on bed capable of trendelenberg positiony Prepare for post procedure chest X-ray

The CVP catheter is an important tool used to assess right ventricular function andsystemic fluid status.

y Normal CVP is 2-6 mm Hg.y CVP is elevated by :

o overhydration which increases venous returno heart failure or PA stenosis which limit venous outflow and lead to venous

congestiono positive pressure breathing, straining,

y CVP decreases with:o hypovolemic shock from hemorrhage, fluid shift, dehydrationo negative pressure breathing which occurs when the patient demonstrates

retractions or mechanical negative pressure which is sometimes used forhigh spinal cord injuries.

The CVP catheter is also an important treatment tool which allows for:


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y Rapid infusiony Infusion of hypertonic solutions and medications that could damage veinsy Serial venous blood assessment

Venous Cutdown and Intraosseous Infusion

Gaining intravenous access is a common procedure but may be difficult inhypovolaemic patients or those with difficult veins. When direct cannulation of a veincannot be performed or is taking too long, a venous cutdown or intraosseous infusionare alternative methods of access to the circulation. These two techniques aredescribed below. In this article "proximal" means the part of the vein or bone closer tothe chest, and the word "distal" the part of the vein or bone furthest from the chest.

Venous cutdown

This procedure exposes the vein surgically and then a cannula is inserted into the veinunder direct vision. If no cannulae are available the sterile end of the drip tubing may beused in adults after cutting off the Luer (cannula) connection. The procedure must beperformed under sterile conditions to avoid sepsis developing which will not onlyshorten the life of the infusion but may have serious consequences for the patient.

During the procedure 2 ligatures (sutures) are placed around the vein. The distalligature is used to tie off the vein distally and the proximal ligature holds the cannula inthe vein While the vein is incised the ligatures help to hold it.

Equipment

1. Sterile gloves2. Swabs and sterile drapes3. Skin disinfectant4. Local anaesthetic (5ml of 0.5% lignocaine is sufficient)5. Scalpel6. Two small curved artery forceps7. Sharp pointed scissors (use scalpel if scissors blunt/unavailable)8. Ligatures (2/0 catgut / vicryl are best, but silk is adequate)

9. Skin closing sutures10. Cannula

Sites. In adults use the upper limb at the medial aspect of the antecubital fossa. Try toavoid the leg veins as they are thicker and more prone to thrombosis, phlebitis andinfection. In children a cutdown may be performed using either the brachial or longsaphenous veins.


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Technique. Clean the skin and use the drapes to create a sterile area around thechosen vein.

(1) Infiltrate the skin with local anaesthetic.

(2) Make a 1.5 - 2cm transverse incision over the vein(a).

(3) Bluntly dissect out the vein by opening the forcepsin the line of the vein (b).

(4) Make a small stab skin incision 1cm distal to the incisionin the line of the vein. Pass two ligatures around the vein.Tie the distal one, but leave the ends uncut. Hold the endsof the ligatures with the artery forceps (c).

(5) Whilst holding the ligatures tight, make a "V" shapedincision in the anterior surface of the vein with the scissorsor scalpel (d).

(6) Pass the cannula through the inferior stab incision andthe through the "V" shaped incision into the vein. Tie the

proximal ligature tightly over the cannulated vein and, ifthere is no bleeding, now cut the ends of the ligatures. Ifbleeding occurs place a further ligature around the vein.Connect the cannula to the giving set and commence theinfusion.


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(7) Close the skin with sutures (f).

After the infusion is finished the cannula can be removed by a

firm steady pull followed by direct pressure over the site ofthe incision for 5 minutes.

Placement of an internal jugular dialysis catheter into the superior intercostal

vein

(Section Editor: G.H. Neild)

Mark J. Sarnak and Andrew S. Levey

Division of Nephrology, New England Medical Center, Boston, MA, USA

Correspondence and offprint requests to: Mark J. Sarnak, MD, Division of Nephrology,New England Medical Center, Box 391, 750 Washington Street, Boston, MA 02111,USA.

Keywords: catheter; chest radiograph; haemodialysis; internal jugular vein

The value of a routine radiograph following an uneventful placement of an internaljugular haemodialysis catheter has been questioned.The argument is that unsuspectedfindings occur in less than1.5% of routine chest radiographs after uneventful placement

of internal jugular catheters [1]. We describe an unusual venous anomaly that wasrevealed by a routine post-procedure chest radiograph and review the potentialcomplications that may haveresulted if dialysis had been initiated.

Case

A 79-year-old woman with a history of chronic renal insufficiency was admitted to thehospital after suffering a myocardial infarction. She became progressively fluidoverloaded and required ventilatorysupport. A 16-cm dialysis catheter was placed in theleft internal jugular vein for haemodialysis access. Non-pulsatile dark blood wasaspirated and the haemodialysis catheter was placed without difficulty using theSeldinger technique. No complications weresuspected. A subsequent chest radiograph(Figure 1 ) revealed the tip of the catheter projecting on the lateral aspect of theproximal descending thoracic aorta. An angiogram (Figure 2 ) was performed whichshowed an occluded left brachiocephalicvein. Drainage of the left internal jugular and


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subclavian systemswas through a superior intercostal vein that communicated withanaccessory hemiazygos vein and subsequently drained into the azygos vein. Theabsence of any relevant medical history suggested that the anomaly was most likelycongenital in origin. The catheterwas removed due to the concern that the caliber of theblood vessel would not be sufficient to tolerate haemodialysis blood flows or cause

complications.

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Fig. 1. Anteroposterior supine chest radiograph after

placement of left internal jugular temporary venous

haemodialysis catheter. The tip of the catheter

projects upon the lateral aspect of the proximal

descending aorta.

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Fig. 2. Angiogram after injection of contrast through

the tip of the haemodialysis catheter. The left

brachiocephalic vein is occluded. The distal tip of the

catheter (white arrowhead) is located within a large

superior intercostal vein (long white arrow). The

superior intercostal vein communicates with the

accessory hemiazygos vein (thin black arrow) which

drains into the azygos system (short white arrow).

The thick black arrow is the SwanGanz catheter.


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Discussion

Hypoplasia or absence of the brachiocephalic vein necessitates alternate pathwayswhereby blood from the left upper extremityand left internal jugular vein may reach the

right atrium. Possibilities

include a persistent left sided superior vena cava which drains

into the coronary sinus, as well as several variations through which blood drains viasuperior intercostal veins into the accessoryhemiazygos vein and subsequently into theazygos system [2].

The left paramedian location of the catheter on the anteroposteriorradiograph raised thepossibility of placement in a remnant left-sided superior vena cava, or internal thoracic(mammary) vein which runs anteriorly [36], or superior intercostal vein which runsposteriorly [710] (Figure 3 ). Placement in the pericardiophrenic vein was possiblealthough less likelyas it usually runs laterally along the cardiac border [1114].A lateralfilm would have been helpful in distinguishing thesepossibilities but was difficult given

the requirement for ventilatory

support. Placement of a central venous catheter in thepericardiophrenic vessel has resulted in pericardial tamponade [13] while placement inthe internal thoracic vein has resulted in pleural effusions, chest wall abscess,pulmonary oedema, dyspnea and chest pain [5,6]. Placement in the superiorintercostal/hemiazygos or azygos systems has resulted in back pain [8,15]. Theangiogram confirmed the posterior location of the catheter and probable drainage

through the superior intercostal vein to the accessory hemiazygosvein and finally to theazygos system. The vertical flow of contrast was inconsistent with that followed by apersistent left-sided superior vena cava. The angiogram also confirmed an occludedbrachiocephalic vein which therefore precluded realignment of the catheter in the leftbrachiocephalic vein, a procedurethat is often recommended [11,12,14].

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Fig. 3. Tributaries of the left brachiocephalic vein.

Reprinted with permission from the Journal of

Parenteral and Enteral Nutrition (1983; 7: 291).


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What Is a Tracheostomy

A tracheostomy (TRA-ke-OS-to-me) is a surgically made hole that goes through thefront of your neck and into your trachea (TRA-ke-ah), or windpipe. The hole is made tohelp you breathe.

A tracheostomy usually is temporary, although you may have one long term or evenpermanently. How long you have a tracheostomy depends on the condition thatrequired you to get it and your overall health.

Overview

To understand how a tracheostomy works, it helps to understand how your airwayswork. The airways are pipes that carry oxygen-rich air to your lungs. They also carrycarbon dioxide, a waste gas, out of your lungs.

The airways include your:

y Nose and linked air passages (called nasal cavities)y Mouthy Larynx (LAR-ingks), or voice boxy Trachea, or windpipey Tubes called bronchial tubes or bronchi, and their branches

Air first enters your body through your nose or mouth. The air then travels through yourvoice box and down your windpipe. The windpipe splits into two bronchi that enter yourlungs. (For more information, see the Diseases and Conditions Index How the LungsWork article.)

A tracheostomy provides another way for oxygen-rich air to reach your lungs, besidesgoing through your nose or mouth. A breathing tube, also called a trach (trake) tube, isplaced through the tracheostomy and directly into the windpipe to help you breathe.

Tracheostomy is done for a number of reasons. Usually, it's done because a personneeds to be on a ventilator (VEN-til-a-tor) for more than 1 to 2 weeks. A ventilator is amachine that helps you breathe. With a tracheostomy, the trach tube connects you tothe ventilator.


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You also may need a tracheostomy if you have a condition that interferes with coughingor blocks your upper airways. Coughing is a natural reflex that protects your lungs. Ithelps clear mucus (a slimy substance) and bacteria from your airways. A trach tube canbe used to help remove, or suction, mucus from your airways.

Less often, people who have swallowing problems due to strokes or other conditionsmay have tracheostomies.

Outlook

Creating a tracheostomy is a fairly common, simple procedure. It's one of the mostcommon procedures for critical care patients in hospitals.

Because the windpipe is located almost directly under the skin of the neck, a surgeonoften can create a tracheostomy fairly quickly and easily.

While the procedure to create a tracheostomy usually is done in a hospital operatingroom, it also can be safely done at a patient's bedside. Less often, a doctor oremergency medical technician may create a tracheostomy in a life-threatening situation,such as at the scene of an accident or other emergency.

The procedure generally is very safe, but it can lead to various complications, includingbleeding, infection, and other, more serious problems. The risk of complications oftencan be reduced with proper care and handling of the tracheostomy and the tubes andother related supplies.

Some people continue to need tracheostomies even after they leave the hospital.

Hospital staff will teach the patients and their families or caregivers how to properly carefor their tracheostomies at home.

What Is Thoracentesis

Thoracentesis (THOR-a-sen-TE-sis) is a procedure to remove excess fluid in the spacebetween the lungs and the chest wall. This space is called the pleural space.

Normally, the pleural space is filled with a small amount of fluidabout 4 teaspoons full.Some conditions, such as heart failure, lung infections, and tumors, can cause more

fluid to build up. When this happens, its called a pleural effusion (PLUR-al e-FU-shun).A lot of extra fluid can press on the lungs, making it hard to breathe.

Overview

Thoracentesis is done to find the cause of a pleural effusion. It also may be done to helpyou breathe easier.


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During the procedure, your doctor inserts a thin needle or plastic tube into the pleuralspace. He or she draws out the excess fluid. Usually, doctors take only the amount offluid needed to find the cause of the pleural effusion. However, if there's a lot of fluid,they may take more. This helps the lungs expand and take in more air, which allows youto breathe easier.

After the fluid is removed from your chest, it's sent for testing. Once the cause of thepleural effusion is known, your doctor will plan treatment. For example, if an infection iscausing the excess fluid, your doctor may prescribe antibiotics. If the cause is heartfailure, you'll be treated for that condition.

Thoracentesis usually takes 10 to 15 minutes. It may take longer if there's a lot of fluid inthe pleural space. You'll be watched for up to a few hours after the procedure forcomplications.

Outlook

The procedure usually doesn't cause serious problems, but some risks are involved.These include pneumothorax (noo-mo-THOR-aks), or collapsed lung; pain, bleeding,bruising, or infection where the needle or tube was inserted; and liver or spleen injury(very rare).

Most of these complications get better on their own, or they're easily treated.

Who Needs Thoracentesis?

Your doctor may recommend thoracentesis if you have a pleural effusion. A pleuraleffusion is the buildup of excess fluid in the pleural space (the space between the lungs

and the chest wall).

Thoracentesis helps find the cause of the pleural effusion. It also may be done to helpyou breathe easier if there's a lot of fluid in the pleural space.

The most common cause of a pleural effusion is heart failure. This is a condition inwhich the heart can't pump enough blood to the body.

Other causes include lung cancer, tumors, pneumonia, tuberculosis, pulmonary

embolism, and other lung infections. Asbestosis, sarcoidosis, and reactions to somedrugs also can lead to a pleural effusion.

Diagnosing a Pleural Effusion

A pleural effusion is diagnosed based on your medical history, a physical exam, andtest results.


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Medical History

Your doctor will ask about your symptoms, such as trouble breathing, coughing, andhiccups. Other things your doctor may ask about include whether you've ever:

y Had heart diseasey Smokedy Traveled to places where you may have been exposed to tuberculosisy Had a job that exposed you to asbestos

Physical Exam

Your doctor will listen to your breathing with a stethoscope and tap lightly on your chest.If you have a pleural effusion, your breathing may sound muffled. There also may be adull sound when your doctor taps on your chest.

Diagnostic Tests

Your doctor may use one or more of the following tests to diagnose a pleural effusion.

y Chest x ray. This test takes pictures of the structures inside your chest, such asyour heart and lungs. The test may show air or fluid in the pleural space. It alsomay show the cause of the pleural effusion, such as pneumonia or a lung tumor.To get more detailed pictures, the x ray may be done while you're in variouspositions.

y Ultrasound. This test uses sound waves to create pictures of the structures inyour body, such as your lungs. Ultrasound may show where fluid is in your chest.

Sometimes the test is used to find the right place to insert the needle or tube forthoracentesis.

y Chest computed tomography (to-MOG-ra-fee) scan, or chest CT scan. This testprovides a computer-generated picture of the lungs that can show pockets offluid. It may show fluid when a chest x ray doesn't. It also may show signs ofpneumonia or a tumor.

What To Expect Before Thoracentesis

Before thoracentesis, your doctor will talk to you about the procedure and how to

prepare for it. Tell your doctor what medicines you're taking, about any previousbleeding problems youve had, and whether you have allergies to medicines or latex.

No special preparations are needed before thoracentesis.


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Lumbar Puncture

A lumbar puncture (also called a spinal tap) is a procedure to collect and look at the

fluid (cerebrospinal fluid, or CSF) surrounding the brain and spinal cord.

During a lumbar puncture, a needle is carefully inserted into the spinal canal low in theback (lumbar area). Samples of CSF are collected. The samples are studied for color,blood cell counts, protein, glucose, and other substances. Some of the sample may beput into a special culture cup to see if any infection, such as bacteria or fungi, grows.The pressure of the CSF also is measured during the procedure.

Why It Is Done

A lumbar puncture is done to:

y Find a cause for symptoms possibly caused by an infection (such as meningitis),inflammation, cancer, or bleeding in the area around the brain or spinal cord(such as subarachnoid hemorrhage).

y Diagnose certain diseases of the brain and spinal cord, such as multiple sclerosisorGuillain-Barr syndrome.

y Measure the pressure of cerebrospinal fluid (CSF) in the space surrounding thespinal cord. If the pressure is high, it may be causing certain symptoms.

A lumbar puncture may also be done to:

y Put anesthetics or medicines into the CSF. Medicines may be injected to treatleukemia and other types of cancer of the central nervous system.

y Put a dye in the CSF that makes the spinal cord and fluid clearer on X-raypictures (myelogram). This may be done to see whether a disc or a cancer isbulging into the spinal canal.

In rare cases, a lumbar puncture may be used to lower the pressure in the brain causedby too much CSF.

How To Prepare

Before you have a lumbar puncture, tell your doctor if you:

y Are taking any medicines. If you take medicines every day, ask your doctorwhether you should take these medicines on the day of the lumbar puncture.

y Are allergic to any medicines, such as those used to numb the skin (anesthetics).y Have had bleeding problems or take blood-thinners, such as aspirin or warfarin

(Coumadin).y Are or might be pregnant.


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y Take any herbal remedies. Some of these remedies may thin the blood.

You will empty your bladder before the procedure.

For a lumbar puncture, you will be asked to sign a consent form. Talk to your doctor

about any concerns you have regarding the need for the procedure, its risks, how it willbe done, or what the results will mean. This procedure is often done in an emergencysituation. If you are scheduled to have this procedure, you can understand theimportance of it by filling out the medical test information form (What is a PDFdocument?).

How It Is Done

A lumbar puncture may be done in your doctor's office, in an emergency room, or atyour bedside in the hospital. It may also be done in the radiology department iffluoroscopy is used.

How It Is Done continued...

You will lie on a bed on your side with your knees drawn up toward your chest. Or youmay sit on the edge of a chair or bed and lean forward over a table with your head andchest bent toward your knees. These positions help widen the spaces between thebones of the lower spine so that the needle can be inserted more easily. If fluoroscopyis used, you will lie on your stomach so the fluoroscopy machine can take pictures ofyour spine during the procedure. See a picture of a lumbar puncture .

Your doctor marks your lower back (lumbar area) with a pen where the puncture will

occur. The area is cleaned with a special soap and draped with sterile towels. Anumbing medicine (local anesthetic) is put in the skin.

Then a long, thin needle is put in the spinal canal. When the needle is in place, the solidcentral core of the needle (stylet) is removed. If the needle is in the right spot in thespinal canal, a small amount of cerebrospinal fluid (CSF) will drip from the end of theneedle. If not, the stylet will be put back in and the needle will be moved in a little fartheror at a different angle to get to the fluid. Your doctor may need to move to another areaof your spine if it is hard to get to the spinal fluid.

When the needle is in the spinal canal, a device called a manometer is hooked to the

needle to measure the pressure of the CSF. You may be asked to straighten your legswhile you are lying down. Your doctor takes the pressure reading, called the openingpressure, and checks whether the fluid is clear, cloudy, or bloody. Several smallsamples of fluid are collected and sent to the lab for study.

A final pressure reading, called the closing pressure, may be taken after the fluidsamples are done. The needle is taken out and the puncture site is cleaned andbandaged.


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The entire procedure takes about 30 minutes.

To lower your chance of getting a headache following a lumbar puncture, you may betold to lie flat in bed or with your head slightly raised for 1 to 4 hours. Since your brainmakes new CSF all the time and replaces it 2 to 3 times a day, the small amount of fluid

that is removed will be quickly replaced.Y

ou may be told to drink extra fluids after theprocedure to help prevent or to reduce the severity of a headache.

How It Feels

Some people find it uncomfortable to lie curled up on their side. The soap may feel coldon your back. You will probably feel a brief pinch or sting when the numbing medicine isgiven. You may feel a brief pain when the spinal needle is inserted or repositioned.

Defibrillation

Defibrillation is a process in which an electrical device called a defibrillator sends anelectric shock to the heart to stop an arrhythmia resulting in the return of a productiveheart rhythm.

Purpose:

Defibrillation is performed to correct life-threatening arrhythmias of the heart includingventricular fibrillation and cardiac arrest. In cardiac emergencies it should be performedimmediately after identifying that the patient is experiencing an arrhythmia, indicated bylack of pulse and unresponsiveness. If an electrocardiogram is available, the arrhythmiacan be displayed visually for additional confirmation. For medical treatment by aphysician, in non-life threatening situations, atrial defibrillation can be used to treat atrialfibrillation or flutter.

Precautions

Defibrillation should not be performed on a patient who has a pulse or is alert, as thiscould cause a lethal heart rhythm disturbance or cardiac arrest. The paddles used in theprocedure should not be placed on a woman's breasts or over an internal pacemaker.

A portable defibrillator is used in an attempt to revive a man who had a heart

attack before he is transported to an emergency room. (

Photograph by Adam Hart-Davis. Science Source/Photo Researchers. Reproduced by

permission.)


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Cardiac arrhythmias that prevent the heart from pumping blood to the body can causeirreversible damage to the major organs including the brain and heart. Thesearrhythmias include ventricular tachycardia, fibrillation, and cardiac arrest. About 10% ofthe ability to restart the heart is lost with every minute that the heart fibrillates. Deathcan occur in minutes unless a productive heart rhythm, able to generate a pulse, is

restored through defibrillation. Because immediate defibrillation is crucial to the patient'ssurvival, the American Heart Association has called for the integration of defibrillationinto an effective emergency cardiac care system. The system should include earlyaccess, early cardiopulmonary resuscitation , early defibrillation, and early advancedcardiac care.

Defibrillators deliver a brief electric shock to the heart, which enables the heart's naturalpacemaker to regain control and establish a productive heart rhythm. The defibrillator isan electronic device that includes defibrillator paddles and electrocardiogrammonitoring.

During external defibrillation, the paddles are placed on the patient's chest with aconducting gel ensuring good contact with the skin. When the heart can be visualizeddirectly, during thoracic surgery , sterile internal paddles are applied directly to theheart. Direct contact with the patient is discontinued by all caregivers. If additionaldefibrillation is required the paddles should be repositioned exactly to increase thelikelihood of further shocks being effective in stopping the arrhythmia. The patient'spulse and/or electrocardiogram are continually monitored when defibrillation is not inprogress. Medications to treat possible causes of the abnormal heart rhythm may beadministered. Defibrillation continues until the patient's condition stabilizes or theprocedure is ordered to be discontinued.

Early defibrillators, about the size and weight of a car battery, were used primarily inambulances and hospitals. The American Heart Association now advocates publicaccess defibrillation; this calls for placing automated external defibrillators (AEDS) inpolice vehicles, airplanes, and at public events, etc. The AEDS are smaller, lighter, lessexpensive, and easier to use than the early defibrillators. They are computerized toprovide simple, verbal instructions to the operator and to make it impossible to deliver ashock to a patient whose heart is not fibrillating. The placement of AEDs is likely toexpand to many public locations.

Preparation

Once a patient is found in cardiac distress, without a pulse and non-responsive, andhelp is summoned, cardiopulmonary resuscitation (CPR) is begun and continued untilthe caregivers arrive and are able to provide defibrillation. Electrocardiogram leads areattached to the patient chest. Gel or paste is applied to the defibrillator paddles, or twogel pads are placed on the patient's chest. The caregivers verify lack of a pulse whilevisualizing the electrocardiogram, assure contact with the patient is discontinued, anddeliver the electrical charge.


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Atrial defibrillation is a treatment option that will be ordered for treatment of atrialfibrillation or flutter. The electrocardiogram will be monitored throughout the procedure.The paddles are placed on the patients chest with conducting gel to ensure goodcontact between the paddles and skin. If the heart can be visualized directly duringthoracic surgery, the paddles will be applied directly to the heart. The defibrillator is

programmed to recognize distinct components of the electrocardiogram and will only firethe electrical shock at the correct time. Again, all direct contact with the patient isdiscontinued prior to defibrillation.

Aftercare

After defibrillation, the patient's cardiac status, breathing, and vital signs are monitoredwith a cardiac monitor. Additional tests to measure cardiac damage will be performed,which can include a 12 lead electrocardiogram, a chest x-ray, and cardiac

catheterization . Treatment options will be determined from the outcome of theseprocedures. The patient's skin is cleansed to remove gel and, if necessary, electricalburns are treated.

Risks

Skin burns from the defibrillator paddles are the most common complication ofdefibrillation. Other risks include injury to the heart muscle, abnormal heart rhythms, andblood clots.

Normal results

Defibrillation performed to treat life-threatening ventricular arrhythmias is most likely tobe effective within the first five minutes, preventing brain injury and death by returningthe heart to a productive rhythm able to produce a pulse. Patients will be transferred toa hospital critical care unit for additional monitoring, diagnosis, and treatment of thearrhythmia. Intubation may be required for respiratory distress. Medications to improvecardiac function and prevent additional arrhythmias, are frequently administered. Somecardiac function may be lost due to the actual defibrillation, but is also associated withthe underlying disease.

Atrial defibrillation is successful at restoring cardiac output, alleviating shortness of

breath, and decreasing the occurrence of clot formation in the atria.

2D- ECHO

Echocardiography is a unique noninvasive method for imaging the living heart. It isbased on detection of echoes produced by a beam of ultrasound (very high frequencysound) pulses transmitted into the heart.


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From its introduction in 1954 to the mid 1970's, most echocardiographic studiesemployed a technique called M-mode, in which the ultrasound beam is aimed manuallyat selected cardiac structures to give a graphic recording of their positions andmovements. M-mode recordings permit measurement of cardiac dimensions anddetailed analysis of complex motion patterns depending on transducer angulation. They

also facilitate analysis of time relationships with other physiological variables such asECG, heart sounds, and pulse tracings, which can be recorded simultaneously.

A more recent development uses electromechanical or electronic techniques to scanthe ultrasound beam rapidly across the heart to produce two-dimensional tomographicimages of selected cardiac sections. This gives more information than M-mode aboutthe shape of the heart and also shows the spatial relationships of its structures duringthe cardiac cycle.

A comprehensive echocardiographic examination, utilizing both M-mode and twodimensional recordings, therefore provides a great deal of information about cardiac

anatomy and physiology, the clinical value of which has established echocardiographyas a major diagnostic tool.

This unit covers the principles of two-dimensional echocardiography in more detail; itexplains the normal two-dimensional recordings in terms of the anatomy of the cardiacsections scanned by the ultrasound beam. Some supplementary M-mode recordingsare included. Subsequent units will discuss applications of both M-mode and two-dimensional echocardiography in acquired and congenital disease.

In the M-mode technique, all the ultrasonic pulses are propagated along the same axisand different parts of the heart are studied by changing the direction of the beam

manually. An M- mode echocardiogram is not a "picture" of the heart, but rather adiagram that shows how the positions of its structures change during the course of thecardiac cycle. It is an admirable method for studying a structure like a heart valve, but itdoes not provide information about the spatial relationships of different parts of the heartto each other. However, this can be accomplished by scanning the ultrasound beamrapidly back and forth across a section of the heart.

Because access to the heart afforded by the ribs and lungs is very limited, almostall cardiac scanners are of the sector type. A mechanical sector scanner can useeither an oscillating or rotating scan head. In the rotating type (Click here to enlargeFigure 1), several transducers spin inside a small dome filled with liquid. As each onepasses over the heart, it transmits pulses and receives echoes. The next element thentakes over, like a succession of beams from a lighthouse scanning over the sea. Theecho signals are displayed in B-mode form. Signals from the scan head are used tosteer the oscilloscope beam in the same manner as the ultrasound beam. The result isa tomographic image of the heart, showing the structures in the selected scan planeand their motion patterns.

Electrocardiography

Fig. 1


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Definition

Electrocardiography is a commonly used, noninvasive procedure for recording electrical

changes in the heart. The record, which is called an electrocardiogram (ECG or EKG),

shows the series of waves that relate to the electrical impulses which occur during each

beat of the heart. The results are printed on paper or displayed on a monitor. The waves

in a normal record are named P, Q, R, S, and T and follow in alphabetical order. The

number of waves may vary, and other waves may be present.

Purpose

Electrocardiography is a starting point for detecting many cardiac problems. It is used

routinely in physical examinations and for monitoring the patient's condition during and

after surgery, as well as during intensive care. It is the basic measurement used for

tests such as exercise tolerance. It is used to evaluate causes of symptoms such as

chest pain, shortness of breath, and palpitations.

PrecautionsNo special precautions are required.

Description

The patient disrobes from the waist up, and electrodes (tiny wires in adhesive pads) are

applied to specific sites on the arms, legs, and chest. When attached, the electrodes are

called leads; three to 12 leads may be employed.

Muscle movement may interfere with the recording, which lasts for several beats of the

heart. In cases where rhythm disturbances are suspected to be infrequent, the patient

may wear a small Holter monitor in order to record continuously over a 24-hour period;this is known as ambulatory monitoring.

Preparation

The skin is cleaned to obtain good electrical contact at the electrode positions.

Aftercare

To avoid skin irritation from the salty gel used to obtain good electrical contact, the skin

should be thoroughly cleaned after removal of the electrodes.

Risks

No complications from this procedure have been observed.

Normal results

When the heart is operating normally, each part contracts in a specific order.

Contraction of the muscle is triggered by an electrical impulse. These electrical

impulses travel through specialized cells that form a conduction system. Following this

pathway ensures that contractions will occur in a coordinated manner.


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When the presence of all waves is observed in the electrocardiogram and these waves

follow the order defined alphabetically, the heart is said to show a normal sinus rhythm,

and impulses may be assumed to be following the regular conduction pathway.

The heart is described as showing arrhythmia or dysrhythmia when time intervals

between waves, the order, or the number of waves do not fit this pattern. Other featuresthat may be altered include the direction of wave deflection and wave widths.

In the normal heart, electrical impulsesat a rate of 60-100 times per minuteoriginate

in the sinus node. The sinus node is located in the first chamber, known as the right

atrium, where blood re-enters the heart. After traveling down to the junction between the

upper and lower chambers, the signal stimulates the atrioventricular node. From here,

after a delay, it passes by specialized routes through the lower chambers or ventricles.

In many disease states, the passage of the electrical impulse can be interrupted in a

variety of ways, causing the heart to perform less efficiently.

Abnormal results

Special training is required for interpretation of the electrocardiogram. To summarize the

features used in interpretations in the simplest manner, the P wave of the

electrocardiogram is associated with the contraction of the atria. The QRS series of

waves, or QRS complex, is associated with ventricular contraction, with the T wave

coming after the contraction. Finally, the P-Q or P-R interval gives a value for the time

taken for the electrical impulse to travel from the atria to the ventricle (normally less than

0.2 sec).

The cause of dysrhythmia is ectopic beats. Ectopic beats are premature heart beats thatarise from a site other than the sinus node-commonly from the atria, atrioventricular

node, or the ventricle. When these dysrhythmias are only occasional, they may produce

no symptoms, or a feeling of the heart turning over or "flip-flopping" may be

experienced. These occasional dysrhythmias are common in healthy people, but they

also can be an indication of heart disease.

The varied sources of dysrhythmias provide a wide range of alterations in the form of

the electrocardiogram. Ectopic beats that start in the ventricle display an abnormal QRS

complex. This can indicate disease associated with insufficient blood supply to the

muscle (myocardial ischemia). Multiple ectopic sites lead to rapid and uncoordinatedcontractions of the atria or ventricles. This condition is known as fibrillation. In atrial

fibrillation, P waves are absent, and the QRS complex appears at erratic intervals, or

"irregularly irregular."

When the atrial impulse fails to reach the ventricle, a condition known as heart block

results. If this is partial, the P-R interval (the time for the impulse to reach the ventricle)


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is prolonged. If complete, the ventricles beat independently of the atria at about 40

beats per minute, and the QRS complex is mostly dissociated from the P wave.

Suctioning

The upper airway warms, cleans and moistens the air we breathe. The trach tubebypasses these mechanisms, so that the air moving through the tube is cooler, dryerand not as clean. In response to these changes, the body produces more mucus.Suctioning clears mucus from the tracheostomy tube and is essential for proper

breathing. Also, secretions left in the tube could become contaminated and a chestinfection could develop. Avoid suctioning too frequently as this could lead to moresecretion buildup.

Removing mucus from trach tube without suctioning

1. Bend forward and cough. Catch the mucus from the tube, not from the nose andmouth.

2. Squirt sterile normal saline solutions (approximately 5cc) into the trach tube tohelp clear the mucus and cough again.

3. Remove the inner tube (cannula).4. Suction.5. Call 911 if breathing is still not normal after doing all of the above steps.6. Remove the entire trach tube and try to place the spare tube.7. Continue trying to cough, instill saline, and suction until breathing is normal or

help arrives.

When to suction

Suctioning is important to prevent a mucus plug from blocking the tube and stopping thepatient's breathing. Suctioning should be considered

y Any time the patient feels or hears mucus rattling in the tube or airwayy In the morning when the patient first wakes upy When there is an increased respiratory rate (working hard to breathe)y Before mealsy Before going outdoorsy Before going to sleep

The secretions should be white or clear. If they start to change color, (e.g. yellow, brownor green) this may be a sign of infection. If the changed color persists for more thanthree days or if it is difficult to keep the tracheostomy tube intact, call your surgeon'soffice. If there is blood in the secretions (it may look more pink than red), you shouldinitially increase humidity and suction more gently. A Swedish or artificial nose (HME),which is a cap that can be attached to the tracheostomy tube, may help to maintainhumidity. The cap contains a filter to prevent particles from entering the airway and


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maintains the patient's own humidity. Putting the patient in the bathroom with the doorclosed and shower on will increase the humidity immediately. If the patient coughs up orhas bright red blood mucus suctioned, or if the patient develops a fever, call yoursurgeon's office immediately.

How to suction

EquipmentClean suction catheter (Make sure you have the correct size)Distilled or sterile waterNormal salineSuction machine in working orderSuction connection tubingJar to soak inner cannula (if applicable)Tracheostomy brushes (to clean tracheostomy tube)Extra tracheostomy tube

1. Wash your hands.2. Turn on the suction machine and connect the suction connection tubing to the

machine.3. Use a clean suction catheter when suctioning the patient. Whenever the suction

catheter is to be reused, place the catheter in a container of distilled/sterile waterand apply suction for approximately 30 seconds to clear secretions from theinside. Next, rinse the catheter with running water for a few minutes then soak ina solution of one part vinegar and one part distilled/sterile water for 15 minutes.Stir the solution frequently. Rinse the catheters in cool water and air-dry. Allowthe catheters to dry in a clear container. Do not reuse catheters if they become

stiff or cracked.4. Connect the catheter to the suction connection tubing.5. Lay the patient flat on his/her back with a small towel/blanket rolled under the

shoulders. Some patients may prefer a sitting position which can also be tried.6. Wet the catheter with sterile/distilled water for lubrication and to test the suction

machine and circuit.7. Remove the inner cannula from the tracheostomy tube (if applicable). The patient

may not have an inner cannula. If that is the case, skip this step and go tonumber 8.

a. There are different types of inner cannulas, so caregivers will need to learn the

specific manner to remove their patient's. Usually rotating the inner cannula in aspecific direction will remove it.

b. Be careful not to accidentally remove the entire tracheostomy tube while

removing the inner cannula. Often by securing one hand on the tracheostomytube?s flange (neck plate) one can/ will prevent?accidental removal.


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c. Place the inner cannula in a jar for soaking (if it is disposable, then throw itout).

8. Carefully insert the catheter into the tracheostomy tube. Allow the catheter tofollow the natural curvature of the tracheostomy tube. The distance to thelocation of catheter becomes easier to determine with experience. The least

traumatic technique is to pre-measure the length of the tracheostomy tube thenintroduce the catheter only to that length. For example if the patient?stracheostomy tube is 4 cm long, place the catheter 4 cm into the tracheostomytube. Often, there will be instances when this technique of suctioning (called tipsuctioning) will not clear the patient?s secretions. For those situations, thecatheter may need to be inserted several mm beyond the end of thetracheostomy tube (called deep suctioning). With experience, caregivers will beable to judge the distance to insert the tracheostomy tube without measuring.

9. Place your thumb over the suction vent (side of the catheter) intermittently whileyou remove the catheter. Do not leave the catheter in the tracheostomy tube formore than 5-10 seconds since the patient will not be able to breathe well with the

catheter in place.10. Allow the patient to recover from the suctioning and to catch his/her breath. Waitfor at least 10 seconds.

11. Suction a small amount of distilled/sterile water with the suction catheter to clearany residual debris/secretions.

12. Insert the inner cannula from extra tracheostomy tube (if applicable).13. Turn off suction machine and discard catheter (clean according to step 3 if to be

reused).14. Clean inner cannula (if applicable).

References:

Wikipedia.com

Medscape.com

http://www.surgeryencyclopedia.com/Ce-Fi/Defibrillation.html

http://www.americanheart.org/presenter.jhtml?identifier=3005172

http://medical-dictionary.thefreedictionary.com/electrocardiography

http://www.hopkinsmedicine.org/tracheostomy/living/suctioning.html

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