Procedural Sedation

Pediatrics: Ketamine (3.5mg/kg) + Atropine (0.01mg/kg)

[自行整理] Chap. 10: Tube Thoracostomy [Clinical Procedures in Emergency Medicine]

1. Chest tube insertion最常用的位置: Anterior Axillary line with 4th~5th ICS

2. Patient preparation:

(a) 床頭搖高 30~60 degrees & Abduction of ipsilateral arm (i.e. over head)

(b) 置放前先測量預訂深度: Insertion site至到clavicle (?Mid or distal)

3. 一定要把所有的side-holes放進pleural cavity; 只要管子在pleural cavity內, 任何的位置都可以引流blood, fluid以及air (air & fluid that is not loculated will follow the path of least resistance & enter a functioning drainage tube as the lung expands and the pleural space becomes smaller)

4. Anesthesia: GENEROUS local anesthesia (max: 4(7)mg/kg) should be given along the entire anticipated track of the tube's passage; (參考NEJM video)

5. Skin incision要夠長 (at least 4 cm, 用No. 10 blade scaplel)且通常在1~2根肋骨低於預進入的ICS

6. Pleural penetration通常是最痛的 (故居部麻醉時要麻到); Opening in the parietal pleura should be wide enough to comfortably insert a finger AND the tube; however an extensive pleural opening should be avoided to prevent subcutaneous emphysema

7. 永遠要確認pathway的patency! (不管是用手指或器械); 故把Kelly移除之前一定要留一根手指在pleura的洞口, 該根手指也可作為放置tube時的導引 (避免subcutaneous dissection with tube)

8. 用Kelly夾chest tube時要確保Kelly的金屬段不會跑出來(以免傷到lung)

[自行整理] Chap. 35: Methods of Wound Closure [Clinical Procedures in Emergency Medicine]

4種常見的wound closure方法：Tape, Tissue Adhesive(Glue), Metal Staples, Sutures

TAPE
1. Indication
(a) Superficial straight lacerations under little tension (forehead, chin, malar eminence, thorax, non-joint extremities)
(b) Delayed suture removal (e.g. under plaster casts)
(c) Flaps and grafts in place, particularly over fingers, flat areas of extremities, and trunk
(d) Pretibial area
(e) After early suture removal (i.e. on the face)
(f) Areas due to vascular insufficiency or altered by prolonged steroid use
2. Contraindication
(a) Naturally moist areas (axilla, palm, sole & perineum)
(b) Secretions, copious exudates, or persistent bleeding
(c) High concentration of hair follicles (scalp)
3. Pearls & Pitfalls
(a) 傷口周圍一定要乾，止血要做好
(b) 先從傷口的中間開始貼， 要覆蓋傷口以外的2.5公分
(c) 不要整條傷口都被覆蓋 (?原因)
(d) 結束時要在貼紙的末端再貼上和傷口平行的貼紙 (避免tape ends blistering of skin)

Staples 最大的優點 -- Speed of closure
1. Indication: Linear lacerations with straight, sharp edges (superficial scalp lacerations)
2. Contraindication: Face, neck, hands or feet
3. Pearls & Pitfalls
(a) 傷口在approximation時要維持eversion (因為stapling會造成inversion)
(b) 不要用力往傷口壓 (以免造成ischemia within staple loop; 理想是離皮膚約2~3mm)

[自行整理] Chap. 50: Splinting Techniques [Clinical Procedures in Emergency Medicine]

Caveats for Proper Emergency Department Splinting

1. Smooth and mold the splint without squeezing. Use the palms, not the fingers to mold the splint to fit the contour of the body part.

2. Simply roll elastic bandages over an extremity without undue tension.

3. Post-check includes function, arterial pulse, capillary refills, temperature of skin, and sensation (FACTS).

4. Tape over metal clips used to fasten the elastic bandages to keep in place and avoid ingestion by child.

Padding

1. The stockinete should extend at least 10~15 cm beyond the area to be splinted at both ends of the extremities. It can be folded back over the ends of the splint to create smooth, padded rims

2. Wrinkling over flexion creases should also be avoided by slitting and overlapping the stockinette at bony prominences.

3. Padding should be at least 2~3 layers thick and each turn should overlap the previous turn by 25~50% of its width. If significant swelling is anticipated, 3 or 4 layers of padding should be added. It should also extend 2.5~5 cm beyond the ends of the splint so that it, too, can be folded back over areas of bony prominence.

4. Care should be taken to avoid wrinkling, because significant skin pressure might occur.

5. Rare complication of circumferential padding is ischemic injury due to unanticipated swelling. This can be prevented by cutting throught the padding along the side of the extremitiy opposite to the plaster splint.

6. Areas that Require Additional Padding

a. Upper extremities: Olecranon, Radial styloid, Ulnar styloid

b. Lower extremities: Upper portion of inner thigh, Patella, Fibular head, Achilles tendon, Medial & lateral malleoli

Plaster Preparation

1. For an average-sized adult, upper extermities should be splinted with 8 sheets of plaster, whereas lower extremities injuries generally requires 12~15 sheets.

Splint Application

1. Molding the wet splint to conform to the body's anatomy is probably the most important, yet the most frequently overlooked step to ensure adequate immobilization. 

2. A single layer of padding or roll gauze can be wrapped around the wet plaster loosely before application of the elastic bandage, to prevent incorporation of elastic bandage into the drying plaster. Only one layer of padding should be use to prevent high drying temperature.

3. Most patients feel better immediately after the splint has been applied. Never release a patient who complains of increased pain after splinting

Patient instructions

1. Cold packs should be applied for at least 30 mins at a time, which is in contrast to the popular recommendation of "ice 20 minutes on, 20 minutes off" which does nothing more than cool the skin.

2. Cold packs should not be applied for more than the first 24~48 hours because cold can interfere with long term healing.