hemostasis & emergency situations st230 concorde career college

Hemostasis & Emergency Situations

ST230Concorde Career College

Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.

Clotting Process Phase I – Vascular Phase

Constriction of the blood vessel to decrease blood flowFollows injury

Phase II – Platelet PhasePlatelets clump together and adhere to injured vessels to

form a plug and inhibit bleeding Phase III – Coagulation

Coagulation factors are released and a blood clot is formed to seal off damaged areas

Phase IV – Clot Retraction PhaseBleeding stops and clot retracts to bring torn edges of

vessel together Phase V – Fibrinolysis

Final repair of injured vesselClot breaks upCells carry out further repair


Factors Affecting HemostasisPreexisting Hemostatic Defects

May be congenitalHemophilia most common

Acquired Hemostatic DisordersLiver diseaseAnticoagulant therapy

Heparin, Warfarin sodiumAplastic anemiaAlcoholic liver failureDrug-therapy-induced platelet dysfunctions

aspirin


Methods of HemostasisMechanicalThermalPharmacologic


Mechanical HemostasisClampsLigatures

Ties, Stick ties, reels, etc.ClipsSponges

Direct pressurePledgetsBone wax


Mechanical HemostasisHow do the following facilitate hemostasis?

Suction?Drains?Tourniquets?


Thermal HemostasisDefinition and Usage

Electric current used to cut and/or coagulate tissue

Used to cut fat, fascia, muscle, and internal organs

Part of surgeon’s routine armamentariumOften referred to as the “Bovie”


Electrosurgery

© 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.

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Thermal DevicesThermal Devices


Monopolar vs BipolarMonopolar vs Bipolar


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What’s the difference?


Monopolar CurrentMonopolar Current


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Most frequently used type of cauteryRequires a grounding padPencil-style handpiece is usedMay be activated with a foot control or

hand switch


Bipolar CurrentBipolar Current


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Used for minor procedures; plastic procedures; delicate procedures such as ophthalmic and neurosurgery

Does not require a grounding padVarious types of forceps are used (one

tip is the active electrode and the opposing tip is inactive)

Foot pedal is used to activate


Flow of CurrentFlow of Current


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Monopolar current flows from the… 1. Generator or electrosurgical unit (ESU)

to the2. Active electrode (cautery tip) through

the3. Patient’s tissue to the4. Dispersive electrode (grounding pad)

and back to the5. ESU


Flow of CurrentFlow of Current


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Bipolar current flows from the… 1. Generator or electrosurgical unit (ESU)

to the2. Active tip of the forceps through the3. Patient’s tissue to the4. Opposing forceps tip and back to the 5. ESU


Types of Monopolar Types of Monopolar CurrentCurrent


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CoagulateCoagulate capillary and other small

bleeding vesselsCutCut adipose tissue, fascia, internal organsBlendCombination of cutting and coagulating

currentNot a strong coagulating currentEffective on capillary bleeding


Monopolar HandpieceMonopolar Handpiece


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Handpiece (with cord attached) and tip are single-use disposable items

Distal end of cord is passed to the circulator to be connected to the generator

Coagulating current is activated with the distal handpiece button

Cutting current is activated with the proximal handpiece button




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Tip of handpiece isRemovable to facilitate use of various

styles (blade, needle, loop, etc)Considered a “sharp” and must be handled

and disposed as suchA countable item in some facilities




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Types of tipsBlade - most frequently used;

available in regular and long (for use in deep body cavities) lengths

Ball - ball shape on end of tip; frequently used in throat procedures such as T&A

Needle - ends in a sharp point; used in minor procedures, plastic, and delicate procedures


Monopolar Monopolar HandpieceHandpiece


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Cleaning of TipTo keep charred tissue from building

up on cautery tip preventing effective flow of current

Clean the tip using moist sponge or cautery scrapperCautery scrapper: small square abrasive

pad with adhesive backing placed on sterile field

Knife blade NOT recommended, but is often used


Grounding Pad and Grounding Pad and PlacementPlacement


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Technical names - inactive or dispersive electrode

Single-use disposable itemAvailable in various sizes ranging from

adult to infantPrelubricated with conducting gelPosition patient; then place the pad




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Place pad as close as possible to the operative site

Do not remove and reposition pad Loss of conducting gelNew pad must be placed

Pad should cover as large of area as possible

Extremity - place on area of largest circumference




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Do not place on area with excessive scar tissue

Do not place over area with excessive hairMay have to shave the area

Do not place over bony prominencesDo not place over or near metal

implants




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Do not allow skin prep fluids to pool around or under the pad

Place on clean, dry skinPad must uniformly adhere to patient’s skin

No tunneling effect or air pocketsEdges cannot curl up




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No part of the patient’s body can touch a metal surface such as OR tableElectric current is attracted to metalCurrent will seek the path of least resistance

to complete the circuitBody part touching metal will be severely

burned




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Awake patientWarn patient of placement due to cold and sticky nature of conducting gel so that the patient is not startled


Principles Associated with Principles Associated with Cauterizing TissueCauterizing Tissue


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ESU produces “buzzing” sound when activated Surgeon may ask the assistant to “buzz” a

clamp or forceps to coagulate tissue withinSurgeon holds tissue or vessel with forceps

or clampAssistant touches instrument with

electrocautery (“Bovie”) tipCurrent travels down instrument to cauterize

tissue or vessel


Principles Associated with Principles Associated with Cauterizing TissueCauterizing Tissue


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Precautions when “buzzing” Do not activate cautery prior to

application to instrument to avoid “arcing” of current

Place cautery tip below fingers of surgeonCurrent can penetrate surgical gloves

and cause pin point 3rd degree burn Be sure that the instrument grasping the

tissue is not touching other tissue Be sure that the instrument grasping the

tissue is not touching other metal instruments such as a retractor


DocumentationDocumentation


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Circulator records all information on patient’s intraoperative record

Location of grounding padCondition of patient’s skin pre- and

postoperativelyPower settings for cutting and

coagulating currentsESU hospital identification number


Safety PrinciplesSafety Principles


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Initial skin incision is be made with the scalpelBovie will char and scar the skin

Keep handpiece protected when not in use to prevent accidental activationPlace in plastic protective holster

that can be attached to the drapesKeep out of team member’s way to

avoid leaning on it




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General safety ruleStart with lowest power settings of

current that accomplish the jobAdjust the current at the surgeon’s

request

Clue to equipment malfunctionSurgeon has repeated request for more

power




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Avoid inhaling plume (smoke)

Not yet proven; could be harmfulCould contain bits of vaporized

tissue that could be mutagenic and/or carcinogenic

Plume is irritating to the respiratory tract




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Oxygen and Nitrous Oxide UsedDo not use cautery in the mouth, around the

head, or in pleural cavity in the presence of oxygen and nitrous oxide

Nitrous oxide supports combustionMetal jewelry removed from patientOnly moist sponges used in presence of ESU




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ECG ElectrodesPlace electrodes as far away from operative

site as possiblePlace grounding pad as far away from ECG

electrodes as possibleElectrical current can be attracted to ECG

electrodes and cause severe burns




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ESU can disrupt the operation of implanted cardiac pacemaker

Alcohol used for skin prepAlcohol must be allowed to dry before

draping the patientIf not allowed to dry, fumes can build up

under the drapes and possibly ignite when cautery is used


Reasons for Malfunction Reasons for Malfunction of ESUof ESU


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Improper placement of grounding padLess that full contact of grounding pad with

skin surfaceESU machine malfunctionFrayed cord


Chemical Hemostasis – Pharmacologic AgentsMore developed each yearManufacture’s recommendations for usage

and handling must be followed


Absorbable GelatinAbsorbable Gelatin


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CollagenCollagen


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Oxidized CelluloseOxidized Cellulose


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Silver Nitrate, Epinephrine, Silver Nitrate, Epinephrine, ThrombinThrombin


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Blood ReplacementBlood ReplacementBlood types &

Groups

HemologousAutologous


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Blood ReplacementBlood Replacement


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Handling of blood componentsAutotransfusionHemolytic Transfer Reactions

Emergencies


Indications of Emergency Indications of Emergency SituationsSituations


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List indications of emergency situationsObjective & priorities in Emergency SituationsSyncope?Convulsions/Seizures

TypesManagement

Anaphylactic ReactionClinical manifestations of Cardiac Arrest


Cardiac Arrest/Malignant Cardiac Arrest/Malignant HyperthermiaHyperthermia


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CPRCardiac Arrest: What happens in the

surgical setting?Define Malignant Hyperthermia

PreventionTreatmentEmergency services


Terms Anaphylaxis

An unusual or exaggerated allergic reaction of an organism to foreign protein or other substances

Asystole Cardiac standstill or arrest; absence of heartbeat

Bolus A concentrated amount of medication

administered rapidly intravenously Bradycardia

Slow heart beat, less than 60 bpm Bronchospasm

Involuntary contraction of the smooth muscle of the bronchi, causing impaired breathing

Capnography Measurement of inspired and expired

carbon dioxide concentrations


Terms Cyanosis

A bluish discoloration of the skin and mucous membranes due to inadequate oxygen in the blood

Desaturation Reduction of oxygen saturation in the blood

Diaphoresis Perspiration, especially profuse perspiration

Hemoglobinuria Presence of free hemoglobin in the urine

Hypermetabolic Increased metabolism

Pyrexia A fever, or febrile condition


Terms Tachycardia

Abnormally rapid heart rate, greater than 100 beats per minute

Tachypnea Very rapid respirations, greater

than 30 per minute


Purpose/Uses Dantrolene sodium (Dantrium)

Malignant hyperthermia


Purpose/UsesDopamine (Intropin)

AnaphylaxisLidocaine (Xylocaine)

PVCs, ventricular tachycardia, ventricular arrhythmias

Not as a local anesthetic


Purpose/UsesSodium bicarbonate

Metabolic acidosisEpinephrine

Cardiac stimulantArrest due to anaphylaxisNote: vasoconstriction is NOT emergency use


ScenariosCover ST duties in all 3 basic roles:

First scrubSecond scrubCirculator

Other team members and their basic duties


EquipmentCardiac defibrillator


Malignant hyperthermia

Background on MH:RARE, inherited muscle conditionWhen triggered by some drugs:

Causes hypermetabolic state (huge Ca+ release)Sudden; life-threatening

Trigger agents:SuccinylcholineAll inhalation agents except nitrous oxideSome antipsychotics


Malignant hyperthermiaMust have defect AND exposure to trigger50% of offspring have itDefect in sarcoplasmic reticulum

Stores and releases Ca+

Ca+ released in massive amountsCauses very sustained contractionCell metabolism continues at even rateDepletes O2, CO2 which causes acidosisMuscle cells break down fast from

contraction and release myoglobin into blood; clog kidneys


MHList clinical signs of MH

Increase in end-tidal CO2

TachycardiaTachypneaMasseter muscle rigidity (MMR)Unstable blood pressureArrhythmiasCyanosisDiaphoresisPyrexia


MH in end-tidal CO2

Expired levels of CO2Many reasons, assess

TachycardiaRapid heart rateMany reasons, assess

TachypneaRapid breathingEven over ventilator settingEffort to blow off CO2Classic for MH

Masseter muscle rigidityNoted at intubationClassic for MH but could be normal for patient


MHUnstable blood pressure

Many reasons, assessArrhythmias

Absence of normal rhythmMany reasons, assess

CyanosisAbnormal condition; “blue”Check ventilator

DiaphoresisSweating Due to heat build up

PyrexiaHigh feverLate signTemperatures can rise to 109°

Patient can die in 15 minutes


MH Treatment

Use pneumonic if helpfulHow Do Surg Techs Do It?H D S T D


MH Treatment Hyperventilate with O2

Why? Blow off CO2

Dantrolene Why?

Skeletal muscle relaxant Sodium bicarbonate

Counteract metabolic acidosis Due to CO2 = acidosis

Temperature management Ice packs at pulse points on patient Attempt to cool patient rapidly

Diuretics Mannitol is mixed in with Dantrium Keeps kidneys from getting clogged with myoglobin

Insulin Treat hyperkalemia


STSR RoleFirst, if you aren’t paying attention to what is going on with

the patient, you are not much help early in the crisis. Be aware of anesthesia signs Rapid response increases survival rate When declared, drop what you are doing! Anesthesia/Operation is stopped STAT First scrub role; stay sterile if procedure going

Help close PRNHand iced NaCl irrigation

Second scrub roleBreak scrubGet or send people for iceMay help reconstitute Dantrium

If no other personnel available e.g., on call


STSR Role Circulating role

Treat like code blueGet MH cartCall for helpChange anesthesia machine when provider is

readySet up iced lavage

Bladder, rectum, abdomenReconstitute Dantrium

Remember, all of these things are happening simultaneously.

Knowing the procedure makes you more valuable in the crisis.


MH

Keep in mindIf the patient is identified as MH susceptible,

there will be no crisis, as trigger agents are NOT administered to patient.


In summaryThe more you know, the more effective you are

in assisting the anesthesia provider in an emergency.

hemostasis & emergency situations st230 concorde career college

Documents

elsevier items

derived items

imprint of elsevier

repair slide

bovie slide

delmar learning

division of thomson

bleeding phase