A physician’s diagnostic and therapeutic tool kit must include a variety of basic procedures that can be performed in the outpatient setting. These procedures include emergency intervention of the airway; drainage of fluid from the abdomen, joints, and spinal canal; and incision and drainage of abscesses. Although these procedures may be of reduced complexity, there are still inherent risks associated with invasive procedures, and these risks must be reduced through consistent aseptic and procedural techniques.
Last updated: 29 Mar, 2022
Achievement of a secure airway Airway ABCDE Assessment:
Cricothyroidotomy (critical care):
Tracheostomy Tracheostomy Surgical formation of an opening into the trachea through the neck, or the opening so created. Laryngomalacia and Tracheomalacia:
Absolute:
Relative:
Both procedures can be performed at the bedside; however, it is preferable for tracheotomies to be performed in the OR.
Preoperative preparation:
Cricothyroidotomy:
Tracheostomy Tracheostomy Surgical formation of an opening into the trachea through the neck, or the opening so created. Laryngomalacia and Tracheomalacia (Seldinger-type technique):
Right after the airway Airway ABCDE Assessment is secured:
Steps for a cricothyroidotomy
Image by Lecturio.Insertion of tracheostomy Tracheostomy Surgical formation of an opening into the trachea through the neck, or the opening so created. Laryngomalacia and Tracheomalacia tube into a cricothyroidotomy incision
Image by Lecturio.Types of tracheotomy incisions:
Absolute:
Relative:
Owing to its simplicity, the procedure can be performed at the bedside.
Surface anatomy landmarks:
Preoperative preparation:
Technique:
After the procedure:
Paracentesis Paracentesis A procedure in which fluid is withdrawn from a body cavity or organ via a trocar and cannula, needle, or other hollow instrument. Portal Hypertension technique:
The skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions is held under tension while the needle is advanced into the peritoneal cavity Peritoneal Cavity The space enclosed by the peritoneum. It is divided into two portions, the greater sac and the lesser sac or omental bursa, which lies behind the stomach. The two sacs are connected by the foramen of winslow, or epiploic foramen. Peritoneum: Anatomy at a 90- or 45-degree angle.
Image by Lecturio.Ascites Ascites Ascites is the pathologic accumulation of fluid within the peritoneal cavity that occurs due to an osmotic and/or hydrostatic pressure imbalance secondary to portal hypertension (cirrhosis, heart failure) or non-portal hypertension (hypoalbuminemia, malignancy, infection). Ascites being drained by paracentesis Paracentesis A procedure in which fluid is withdrawn from a body cavity or organ via a trocar and cannula, needle, or other hollow instrument. Portal Hypertension
Image: “Draining ascites Ascites Ascites is the pathologic accumulation of fluid within the peritoneal cavity that occurs due to an osmotic and/or hydrostatic pressure imbalance secondary to portal hypertension (cirrhosis, heart failure) or non-portal hypertension (hypoalbuminemia, malignancy, infection). Ascites, secondary to hepatic cirrhosis Cirrhosis Cirrhosis is a late stage of hepatic parenchymal necrosis and scarring (fibrosis) most commonly due to hepatitis C infection and alcoholic liver disease. Patients may present with jaundice, ascites, and hepatosplenomegaly. Cirrhosis can also cause complications such as hepatic encephalopathy, portal hypertension, portal vein thrombosis, and hepatorenal syndrome. Cirrhosis” by John Campbell. License: Public DomainOwing to its simplicity, the procedure can be performed at the bedside or in an outpatient setting.
Preoperative preparation:
Technique:
Postoperative care Postoperative care After any procedure performed in the operating room, all patients must undergo close observation at least in the recovery room. After larger procedures and for patients who require hospitalization, observation must continue on the surgical ward. The primary intent of this practice is the early detection of postoperative complications. Postoperative Care:
Schematic depiction of the basic steps of incision and drainage Incision And Drainage Chalazion
Image by Lecturio.Drained abscess Abscess Accumulation of purulent material in tissues, organs, or circumscribed spaces, usually associated with signs of infection. Chronic Granulomatous Disease in a diabetic foot Foot The foot is the terminal portion of the lower limb, whose primary function is to bear weight and facilitate locomotion. The foot comprises 26 bones, including the tarsal bones, metatarsal bones, and phalanges. The bones of the foot form longitudinal and transverse arches and are supported by various muscles, ligaments, and tendons. Foot: Anatomy
Image: “ Diabetic Foot Infection Diabetic foot infection Bacteroides Status post incision and drainage Incision And Drainage Chalazion with insertion and antibiotic beads” by Mark A. Dreyer. License: CC BY 4.0Absolute:
Preoperative preparation:
Technique:
Postprocedure care:
Identification of puncture site for spinal tap by drawing an imaginary line between the superior aspect of the iliac crests:
Note how the imaginary line intercepts the spinous process of L4.Sagittal Sagittal Computed Tomography (CT) cut of the spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy and spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy showing the spinal needle entering the spinal canal Spinal Canal The cavity within the spinal column through which the spinal cord passes. Spinal Cord Injuries
Image by Lecturio.Preoperative preparation:
Technique:
Arthrocentesis Arthrocentesis Puncture and aspiration of fluid (e.g., synovial fluid) from a joint cavity. It is used sometimes to irrigate or administer drugs into a joint cavity. Septic Arthritis of the right knee using the lateral infrapatellar approach
Image: “Introduction of the Needle from the Anteriolateral Portal” by Chavez-Chiang CE, Sibbitt WL, Band PA, Chavez-Chiang NR, Delea SL, Bankhurst AD AD The term advance directive (AD) refers to treatment preferences and/or the designation of a surrogate decision-maker in the event that a person becomes unable to make medical decisions on their own behalf. Advance directives represent the ethical principle of autonomy and may take the form of a living will, health care proxy, durable power of attorney for health care, and/or a physician’s order for life-sustaining treatment. Advance Directives. License: CC BY 2.0Postoperative care Postoperative care After any procedure performed in the operating room, all patients must undergo close observation at least in the recovery room. After larger procedures and for patients who require hospitalization, observation must continue on the surgical ward. The primary intent of this practice is the early detection of postoperative complications. Postoperative Care:
The following are complications of cricothyroidotomy/tracheotomy:
The following are complications of paracentesis Paracentesis A procedure in which fluid is withdrawn from a body cavity or organ via a trocar and cannula, needle, or other hollow instrument. Portal Hypertension:
The following are complications of incision and drainage Incision And Drainage Chalazion of superficial abscesses:
The following are complications of lumbar puncture Lumbar Puncture Febrile Infant: