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(BQ) Part 1 book “ABC of practical procedures” has contents: Introduction, consent and documentation, universal precautions and infection control, local anaesthesia and safe sedation, pleural aspiration, intravenous cannulation, central venous, lumbar puncture,… and other contents.
Practical Procedures Practical Procedures E D I TE D B Y Tim Nutbeam Specialist Trainee in Emergency Medicine West Midlands School of Emergency Medicine Birmingham, UK Ron Daniels Consultant in Anaesthesia and Critical Care Heart of England NHS Foundation Trust Birmingham, UK This edition first published 2010, © 2010 by Blackwell Publishing Ltd BMJ Books is an imprint of BMJ Publishing Group Limited, used under licence by Blackwell Publishing which was acquired by John Wiley & Sons in February 2007 Blackwell’s publishing programme has been merged with Wiley’s global Scientific, Technical and Medical business to form Wiley-Blackwell Registered office: John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Editorial offices: 9600 Garsington Road, Oxford, OX4 2DQ, UK The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK 111 River Street, Hoboken, NJ 07030-5774, USA For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell The right of the author to be identified as the author of this work has been asserted in accordance with the Copyright, Designs and Patents Act 1988 All rights reserved No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher Wiley also publishes its books in a variety of electronic formats Some content that appears in print may not be available in electronic books Designations used by companies to distinguish their products are often claimed as trademarks All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners The publisher is not associated with any product or vendor mentioned in this book This publication is designed to provide accurate and authoritative information in regard to the subject matter covered It is sold on the understanding that the publisher is not engaged in rendering professional services If professional advice or other expert assistance is required, the services of a competent professional should be sought The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by physicians for any particular patient The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions Readers should consult with a specialist where appropriate The fact that an organization or Website is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or Website may provide or recommendations it may make Further, readers should be aware that Internet Websites listed in this work may have changed or disappeared between when this work was written and when it is read No warranty may be created or extended by any promotional statements for this work Neither the publisher nor the author shall be liable for any damages arising herefrom Library of Congress Cataloging-in-Publication Data ABC of practical procedures / edited by Tim Nutbeam, Ron Daniels p ; cm (ABC series) Includes bibliographical references and index ISBN 978-1-4051-8595-0 Clinical medicine Handbooks, manuals, etc I Nutbeam, Tim II Daniels, Ron, MD III Series: ABC series (Malden, Mass.) [DNLM: Therapeutics methods Clinical Competence Diagnostic Techniques and Procedures Inservice Training WB 300 A134 2010] RC55.A23 2010 616 dc22 2009021675 ISBN: 978-1-4051-8595-0 A catalogue record for this book is available from the British Library Set in 9.25/12 pt Minion by Newgen Imaging Systems (P) Ltd, Chennai, India Printed and bound in Malaysia 2010 Contents Contributors, vii Preface, ix Introduction, Tim Nutbeam and Ron Daniels Consent and Documentation, Tim Nutbeam Universal Precautions and Infection Control, Anne Mutlow Local Anaesthesia and Safe Sedation, 11 Ron Daniels Sampling: Blood-Taking and Cultures, 18 Helen Parry and Lynn Lambert Sampling: Arterial Blood Gases, 23 Kathryn Laver and Julian Hull Sampling: Lumbar Puncture, 29 Mike Byrne Sampling: Ascitic Tap, 35 Andrew King Sampling: Pleural Aspiration, 39 Nicola Sinden 10 Access: Intravenous Cannulation, 44 Anna Fergusson and Oliver Masters 11 Access: Central Venous, 50 Ronan O’Leary and Andrew Quinn 12 Access: Emergency – Intraosseous Access and Venous Cutdown, 57 Matt Boylan 13 Therapeutic: Airway – Basic Airway Manoeuvres and Adjuncts, 65 Tim Nutbeam 14 Therapeutic: Airway – Insertion of Laryngeal Mask Airway, 70 Tim Nutbeam 15 Therapeutic: Endotracheal Intubation, 73 Randeep Mullhi 16 Therapeutic: Ascitic Drain, 80 Sharat Putta 17 Therapeutic: Chest Drain, 84 Nicola Sinden v vi Contents 18 Monitoring: Urinary Catheterisation, 91 Adam Low and Michael Foster 19 Monitoring: Central Line, 97 Ronan O’Leary and Andrew Quinn 20 Monitoring: Arterial Line, 101 Rob Moss 21 Specials: Suturing and Joint Aspiration, 107 Simon Laing and Chris Hetherington 22 Specials: Paediatric Procedures, 114 Kate McCann and Amy Walker 23 Specials: Obstetrics and Gynaecology, 120 Caroline Fox and Lucy Higgins Index, 125 Contributors Matt Boylan Julian Hull Emergency Medicine Registrar HEMS Doctor Midlands Air Ambulance DCAE Cosford, UK Consultant Anaesthetist and Critical Care Clinical Lead Heart of England NHS Foundation Trust Good Hope Hospital Birmingham, UK Mike Byrne Andrew King Anaesthetic Registrar Birmingham Heartlands Hospital Bordesley Green East Birmingham, UK Clinical Research Fellow Centre for Liver Research University of Birmingham Birmingham, UK Ron Daniels Simon Laing Consultant in Anaesthesia and Critical Care Heart of England NHS Foundation Trust Birmingham, UK ST2 Emergency Medicine City Hospital Birmingham, UK Anna Fergusson Lynn Lambert CT2 Anaesthetics Russells Hall Hospital Dudley, UK Consultant in Acute Medicine University Hospital Birmingham Birmingham, UK Michael Foster Kathryn Laver Consultant Urologist Heart of England NHS Foundation Trust Good Hope Hospital Birmingham, UK CT2 Anaesthetics Birmingham City Hospital Birmingham, UK Caroline Fox CT2 Anaesthetics University Hospital Birmingham Birmingham, UK Lecturer Birmingham Women’s Hospital Birmingham, UK Chris Hetherington Consultant in Emergency Medicine Worcestershire Acute Hospitals NHS Trust Alexandra Hospital Redditch, UK Lucy Higgins Academic Clinical Fellow Maternal and Fetal Health Research Centre University of Manchester St Mary’s Hospital Manchester, UK Adam Low Kate McCann Paediatric Registrar New Cross Hospital Wolverhampton, UK Oliver Masters Specialist Registrar in Anaesthesia Queen Elizabeth Hospital Birmingham, UK Rob Moss ST3 Anaesthetics Mersey Rotation Liverpool, UK vii viii Contributors Randeep Mullhi Sharat Putta Specialist Registrar in Anaesthesia Department of Anaesthesia Queen Elizabeth Hospital Birmingham, UK Specialist Registrar, Liver Queen Elizabeth Hospital Birmingham, UK Andrew Quinn Anne Mutlow Matron for Critical Care Critical Care Unit Heart of England NHS Foundation Trust Good Hope Hospital Birmingham, UK Tim Nutbeam Specialist Trainee in Emergency Medicine West Midlands School of Emergency Medicine Birmingham, UK Ronan O’Leary Specialist Registrar in Anaesthesia Yorkshire Deanery York, UK Helen Parry ST2 Doctor University Hospital Birmingham Birmingham, UK Consultant in Anaesthesia and Intensive Care Department of Anaesthesia Bradford Royal Infirmary Bradford, UK Nicola Sinden Specialist Registrar in Respiratory Medicine West Midlands Rotation Birmingham, UK Amy Walker Specialist Registrar in Paediatrics Department of Neonatology Birmingham Women’s Hospital Birmingham, UK 42 ABC of Practical Procedures Complications following pleural aspiration Complications include the following Pneumothorax—Intercostal drain insertion may be necessary Bleeding—Apply direct pressure Spleen or liver puncture—Request an ultrasound of the chest with marking of the site for aspiration if fluid is difficult to detect Malignant seeding along track—If mesothelioma is suspected then mark the site of aspiration indelibly to guide radiotherapy Pleural effusions – clinical assessment A pleural effusion can be defined as fluid in the pleural space There are many causes of pleural effusions and they are commonly classified into transudates and exudates In patients with a normal serum protein, a transudate is where the pleural fluid protein is less than 30 g/L and an exudate is where the pleural fluid protein level is greater than 30 g/L In borderline cases (pleural fluid protein 25–35 g/L) or where the patient has an abnormal serum protein, Light’s criteria can be applied The effusion is an exudate if it meets any of the following criteria: • pleural fluid protein : serum protein ratio >0.5 • pleural fluid LDH : serum LDH ratio >0.6 • pleural fluid LDH more than two-thirds the upper limit of normal serum LDH Management Management of a patient with a pleural effusion should involve the following • History, examination and chest X-ray • Treat heart failure if present with diuretics • Perform pleural aspiration which may be diagnostic or therapeutic depending on the volume of fluid drained • Determine whether the pleural effusion is an exudate or a transudate Further investigations may be necessary if the diagnosis remains unclear (e.g CT of the thorax, pleural biopsy) Transudative pleural effusions These are caused by either increased hydrostatic pressure or decreased osmotic pressure in the microvascular circulation Treatment is directed at the underlying cause Causes of transudative plural effusions can be found in Box 9.2 Exudative pleural effusions These are caused by an increase in capillary permeability and impaired pleural fluid reabsorption Treatment is directed at the underlying cause as well as measures to improve symptoms and remove pleural fluid such as pleural aspiration or intercostal drain insertion Causes of exudative pleural effusions can be found in Box 9.3 Box 9.2 Causes of transudative pleural effusions • • • • • • • • Left ventricular failure Liver cirrhosis Hypoalbuminaemia Peritoneal dialysis Hypothyroidism Nephrotic syndrome Constrictive pericarditis Meig’s syndrome (associated with ovarian tumours) Box 9.3 Causes of exudative pleural effusions • • • • • • • • • • • Malignancy Mesothelioma Parapneumonic effusions Empyema Pulmonary infarction Rheumatoid arthritis Autoimmune diseases Pancreatitis Chylothorax Benign asbestos effusion Drugs Aspiration of a pneumothorax A pneumothorax is defined as air in the pleural space A primary pneumothorax can occur in healthy people with no pre-existing lung disease, whereas a secondary pneumothorax may occur in a patient with underlying lung disease (e.g chronic obstructive pulmonary disease) Indications for aspiration • Primary pneumothorax if patient is symptomatic and/or a rim of air greater than cm is seen on the CXR • Secondary pneumothorax if patient is minimally breathless, aged under 50 years of age and with a small pneumothorax (