Emergency Procedures Week 2 Spring 2025 PDF

ESM I Week 2 Spring 2025 Professor Formaneck Objectives ESM7 Describe the mechanism by which each of the following establishes and/or helps maintain asepsis or sterility and demonstrate appropriate aseptic technique. Disinfection & Sterilization Instrument/Surgical packs...

ESM I Week 2 Spring 2025 Professor Formaneck Objectives ESM7 Describe the mechanism by which each of the following establishes and/or helps maintain asepsis or sterility and demonstrate appropriate aseptic technique. Disinfection & Sterilization Instrument/Surgical packs Scrubbing and Gowning Skin preparation Rules of surgical asepsis ESM8 Describe the effect of surgical procedures on each of the following physiologic processes: Blood and hemostasis Wound healing ESM9 Discuss the risk factors, pathophysiologic processes, diagnostic studies, and initial management for post-op complications. ESM10 Recognize commonly encountered postoperative infections, including their microbial causes, typical time of onset, preventative measures, and initial treatment options. Surgical Patient Approach 1. Pre-op Management Discussed last week 2. OR Prep 3. Surgical Operation Perform the Procedure- throughout the course Wounds 4. Post-op Recovery Complications 5. Disposition Throughout the course 6. Documentation (multiple notes throughout the process) EENT Week 1 OR Prep ESM 7  Surgical Tools- Disinfection & Sterilization Items used during an operation are sterilized to destroy microorganisms on the surface of the instrument or in a fluid. An autoclave system uses saturated steam under pressure. This is the most widely used method due to its ability to rapidly sterilize devices while being relatively inexpensive and nontoxic. Can be prepackaged or made  Scrubbing and Gowning An essential element of perioperative practice Gowning and gloving will take place immediately after surgical hand antisepsis and the whole process is often referred to as scrubbing, gowning and gloving Scrubbing 101 Gowning and Gloving Self Gowning Technique Scrubbing and Gowning Key steps Keep nails short and pay attention to them when washing your hands – most microbes on hands come from beneath the fingernails. Do not wear artificial nails or nail polish. Remove all jewelry (rings, watches, bracelets) before entering the operating theatre. Wash hands and arms with a non-medicated soap before entering the operating theatre area or if hands are visibly soiled. Clean subungual areas with a nail file. Nailbrushes should not be used as they may damage the skin and encourage shedding of cells. If used, nailbrushes must be sterile, once only (single use). Scrubbing and Gowning Procedural steps - SCRUBBING Start timing. Scrub each side of each finger, between the fingers, and the back and front of the hand for 2 minutes. Proceed to scrub the arms, keeping the hand higher than the arm at all times. This helps to avoid recontamination of the hands by water from the elbows and prevents bacteria-laden soap and water from contaminating the hands. Wash each side of the arm from wrist to the elbow for 1 minute. Repeat the process on the other hand and arm, keeping hands above elbows at all times. If the hand touches anything at any time, the scrub must be lengthened by 1 minute for the area that has been contaminated. Scrubbing and Gowning Procedural steps - SCRUBBING Rinse hands and arms by passing them through the water in one direction only, from fingertips to elbow. Do not move the arm back and forth through the water. Proceed to the operating theatre holding hands above elbows. At all times during the scrub procedure, care should be taken not to splash water onto surgical attire. Once in the operating theatre, hands and arms should be dried using a sterile towel and aseptic technique before donning gown and gloves.  Skin Preparation of the Patient Cleaning the skin is done using sterile technique - meaning you are gowned and gloved Apply Betadine in circular motion, starting from center and work outwards https://www.youtube.com/watch?v=DbmDWQ0fCsU Drape the area  Rules of Surgical Asepsis Goal is maintaining the sterile field If you have contact with unsterile objects – discard or re-sterilize the objects If questionable sterility – assume it unsterile Never turn your back on sterile field Keep sterile gloved hands in view, above the waist and below neckline  Know how to scrub in WATCH the videos of gowning and gloving Sterility Conclusion Know the steps of skin prep Know how to maintain surgical asepsis Perform the Procedure Perform the Procedure- Analgesia Analgesia will allow for a humane and easier closure of the wound. Infiltration with a local anesthetic is the most common form of analgesia used. The maximum level of lidocaine is 3mg/kg and the addition of epinephrine allows for up to 7mg/kg (a 1% solution equates to 10mg/ml). Remember to not use adrenaline with local anesthetic if administering in or near appendages (e.g. a finger) Perform the Procedure Follow the Surgeon and OR Teams Instructions. Wound Closure ESM 8 Clinical Wound Management The basic principles for the management of a surgical wound or laceration are: Hemostasis Wound closure Wound dressing Hemostasis Process that’s causes bleeding to stop. In most wounds, hemostasis will be spontaneous. In cases of significant injury or lacerations of vessels, steps may need to be taken to reduce bleeding and aid hemostasis.  Wound Healing Primary healing occurs when tissue is cleanly incised and anatomically reapproximated AKA healing by primary intention Tissue repair usually proceeds without complication Secondary healing occurs in wounds left open through the formation of granulation tissue and eventual coverage of the defect by migration of epithelial cells. AKA healing by secondary intention Most infected wounds and burns heal in this manner. Tertiary healing occurs when a wound is left open to heal under a carefully maintained, moist wound healing environment for approximately 5 days and is then closed as if primarily Less likely to become infected than if closed immediately because bacterial balance is achieved, and oxygen requirements are optimized through capillary formation in the granulation tissue  Primary Wound Closure Most important means of achieve good healing is appropriate technique! Excessively tight closure will strangulate tissue Can lead to hernia formation or infection Steps of wound closure! Start deep – close the deep fascial layers with nonabsorbable or slowly absorbing monofilament sutures Then middle – subcutaneous tissues should be closed with braided absorbable sutures (Don’t put them in the fat!) Approximate skin edges to make it pretty and to aid in rapid wound healing Can do absorbable buried dermal sutures or use stainless steel staples or nonabsorbable monofilament sutures Can reinforce with skin tapes Dress the wound Sutures Sutures – Ideal suture material is flexible, strong, easily tied and securely knotted Want it to stimulate LITTLE tissue reaction and not serve as a nidus for infection Want to pick the smallest suture required to hold layers of wound in approximation Suture- Read the Packaging Type of Suture Absorbable vs non-absorbable Braided vs monofilament Size of Suture 3-0 smaller than 2-0 Type of Needle Tapered Cutting Suture Material 1.Nonabsorbable Sutures Not dissolved by the body and therefore must be removed. They are less scarring than absorbable sutures if removed in a timely manner and are primarily suited for use on the skin. 2.Absorbable Sutures Dissolved by the body’s tissues and therefore do not need to be removed. They are best suited for use under the skin as they produce a pronounced scar if used externally. They can also be used if there is concern a patient may not return for suture removal. If you suspect this is possible, you must warn the patient of the probability of increased scarring. 3.Braided Sutures Comprised of several small strands twisted together. They can be easier to tie than nonbraided sutures however the tiny gaps between suture strands can harbor bacteria increasing risk of infection. 4.Non-braided Sutures- Also known as monofilament, are made of single strand. These types of sutures are typically used in skin closure and in wounds where there is risk of infection. Suture Size Types of Needles 1. Cutting- preferred for skin 2. Tapered/round– delicate tissues inside body 3. Double armed- needles at both ends of suture Anastomoses of vessel/bowels  Wound Dressings Purpose – to provide ideal environment for wound healing Covering a wound mimics the barrier role of epithelium and prevents further damage Compression from dressings helps provide homeostasis and limit edema Controls level of hydration and oxygen tension in wound Allows transfer of gases and water vapor Helps in dermal collagen synthesis and epithelial cell migration and limits tissue desiccation Studies have shown that exposed wounds are more inflamed and developed more necrosis than covered wounds Dressing contraindicated in infected and/or highly exudative wounds  Wound Dressings Primary – placed directly on the wound Secondary – placed on the primary dressing for further protection Absorbent dressings – helps absorb excess moisture (from exudative wounds) to prevent maceration and bacterial overgrowth Ex. Cotton, wool and sponge Nonadherent dressings – impregnated with paraffin, petroleum jelly or water-soluble jelly Needs a secondary dressing on top to help prevent desiccation and infection (need to seal the edges) Occlusive and semiocclusive – provide a good environment for clean, minimally exudative wounds. Waterproof and impervious to microbes, but permeable to water vapor and oxygen  Wound Dressings Hydrophilic and Hydrophobic – components of composite dressing Hydrophilic – aids in absorption Hydrophobic – waterproof and prevents absorption Alginates – Derived from brown algae Swell and absorb a great deal of fluid Used where there is skin loss, open surgical wounds with medium exudation and on full- thickness chronic wounds Absorbable materials – used within wounds as hemostats Ex. Collagen, gelatin, oxidized cellulose Medicated dressings – used as a drug delivery system Disposition Wound care How often to change dressing When to shower Avoids baths Pat dry Protect for >12 months to minimize scarring Signs/Symptoms of infection Follow-up Routine and Urgent Work/School excuse Surgical Complications Postoperative fever Emboli: DVT, fat and air emboli ESM 9 Postoperative Fever What is a fever? Temperature greater than 38ºC or 100.4ºF This is COMMON in the first few days after surgery The MC cause of postoperative fever is a normal physiologic response Usually caused by inflammatory stimulus as a response to tissue damage and resolves spontaneously Differential: surgical site infection, other hospital related conditions (like PNA, UTI), drug fever, DVT, etc Timing of Fever One of the most important factors to consider to determine your differential Immediate – starts in the OR or within hours after surgery Acute – onset within first week after surgery Subacute – onset one to four weeks after surgery Delayed – onset more than one month after surgery Cause Related to Timing Immediate – ( 1 month) Infection, some SSIs, viral or parasitic infections Risk Factors Infectious origin of the fever include: Preoperative trauma ASA class above 2 Fever onset after the second postoperative day Initial temperature elevation above 38.6°C Postoperative white blood cell count greater than 10,000/μL Postoperative serum urea nitrogen of 15 mg/dL or greater If three or more of the above are present, the likelihood of associated bacterial infection is nearly 100% Timing and Causes of Postoperative Fever Postoperative Day Fever Sources 0-1 Acute MI 1-2 Atelectasis, PE, Aspiration 3-5 Urinary tract infection, pneumonia, phlebitis 5-7 Wound infection, anastomotic breakdown, intra- abdominal infection, deep vein thrombosis Anytime Drug reaction, transfusion reaction, bacteremia  Helpful W’s Mnemonic The 5+ Ws: Waves (POD 0) – acute MI (like EKG waves) Wind (POD 2)– Pneumonia, PE, aspiration, atelectasis Water (POD 3) – UTI Walking (POD 5+) – VTE Wound (POD 5-7)– SSI, infection Wonder drugs/What did we do? (anytime)– drug fever Postoperative Fever Approach Not every patient needs diagnostic testing Always start with a thorough chart review, history and physical Discontinue unnecessary medications and catheters Obtain diagnostics guided by your evaluation Postoperative Fever: Treatment Scheduled antipyretics (preferably acetaminophen) for 48 hours for patient comfort Antibiotics are generally not indicated early in the postoperative course If critically ill or hemodynamically unstable, broad spectrum antibiotics should be used and causes identified. If no cause found after 48 hours, stop antibiotics. Management Continued Evaluation should be tailored to the individual patient based on history, symptoms, and physical findings. All unnecessary treatments, including medications, nasogastric tubes, and intravascular and urinary catheters should be discontinued in the febrile patient Thromboembolism Virchow’s triad – Hypercoagulable state, stasis, and endothelial damage High incidence of DVT if untreated Risk factors: Trauma, cancer operations or dissections of the pelvis Nonmodifiable – ex. Thrombophilia, prior VTE, CHF, etc Modifiable – type of surgery, central venous lines, HRT, etc Thromboembolism Diagnosis US of Leg D-dimer Treatment Minor – oral anticoagulants Extensive DVT – can consider tPA infusion Prevention Limit surgical time, SCDs, early mobilization, anticoagulant therapy Thromboembolism Prevention Surgery carries an increased risk of DVT High risk in older patients, extensive surgery, longer duration of surgery, prior VTE, cancer, immobility, pregnancy, and hypercoagulability Low risk with minor procedures (even arthroscopy and laparoscopy), short duration surgery (