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Hemostasis & Emergency Situations
Concorde Career College
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Clotting Process Phase I – Vascular Phase Phase II – Platelet Phase
Constriction of the blood vessel to decrease blood flow Follows injury Phase II – Platelet Phase Platelets 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 Phase Bleeding stops and clot retracts to bring torn edges of vessel together Phase V – Fibrinolysis Final repair of injured vessel Clot breaks up Cells carry out further repair
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Factors Affecting Hemostasis
Preexisting Hemostatic Defects May be congenital Hemophilia most common Acquired Hemostatic Disorders Liver disease Anticoagulant therapy Heparin, Warfarin sodium Aplastic anemia Alcoholic liver failure Drug-therapy-induced platelet dysfunctions aspirin Click links to open additional content
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Methods of Hemostasis Mechanical Thermal Pharmacologic Define each
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Mechanical Hemostasis
Clamps Ligatures Ties, Stick ties, reels, etc. Clips Sponges Direct pressure Pledgets Bone wax
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Mechanical Hemostasis
How do the following facilitate hemostasis? Suction? Drains? Tourniquets?
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Thermal Hemostasis Definition 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 armamentarium Often referred to as the “Bovie”
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Thermal Devices Electrosurgery
© 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
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Monopolar vs Bipolar What’s the difference?
© 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
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Monopolar Current Most frequently used type of cautery
Requires a grounding pad Pencil-style handpiece is used May be activated with a foot control or hand switch © 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
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Bipolar Current Used for minor procedures; plastic procedures; delicate procedures such as ophthalmic and neurosurgery Does not require a grounding pad Various types of forceps are used (one tip is the active electrode and the opposing tip is inactive) Foot pedal is used to activate © 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
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Flow of Current Monopolar current flows from the… 1. Generator or electrosurgical unit (ESU) to the 2. Active electrode (cautery tip) through the 3. Patient’s tissue to the 4. Dispersive electrode (grounding pad) and back to the 5. ESU © 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
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Flow of Current Bipolar current flows from the… 1. Generator or electrosurgical unit (ESU) to the 2. Active tip of the forceps through the 3. Patient’s tissue to the 4. Opposing forceps tip and back to the 5. ESU © 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
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Types of Monopolar Current
Coagulate Coagulate capillary and other small bleeding vessels Cut Cut adipose tissue, fascia, internal organs Blend Combination of cutting and coagulating current Not a strong coagulating current Effective on capillary bleeding © 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
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Monopolar Handpiece 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 © 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
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Monopolar Handpiece Tip of handpiece is
Removable to facilitate use of various styles (blade, needle, loop, etc) Considered a “sharp” and must be handled and disposed as such A countable item in some facilities © 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
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Monopolar Handpiece Types of tips
Blade - 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 © 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
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Monopolar Handpiece Cleaning of Tip To keep charred tissue from building up on cautery tip preventing effective flow of current Clean the tip using moist sponge or cautery scrapper Cautery scrapper: small square abrasive pad with adhesive backing placed on sterile field Knife blade NOT recommended, but is often used © 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
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Grounding Pad and Placement
Technical names - inactive or dispersive electrode Single-use disposable item Available in various sizes ranging from adult to infant Prelubricated with conducting gel Position patient; then place the pad © 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
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Grounding Pad and Placement
Place pad as close as possible to the operative site Do not remove and reposition pad Loss of conducting gel New pad must be placed Pad should cover as large of area as possible Extremity - place on area of largest circumference © 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
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Grounding Pad and Placement
Do not place on area with excessive scar tissue Do not place over area with excessive hair May have to shave the area Do not place over bony prominences Do not place over or near metal implants © 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
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Grounding Pad and Placement
Do not allow skin prep fluids to pool around or under the pad Place on clean, dry skin Pad must uniformly adhere to patient’s skin No tunneling effect or air pockets Edges cannot curl up © 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
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Grounding Pad and Placement
No part of the patient’s body can touch a metal surface such as OR table Electric current is attracted to metal Current will seek the path of least resistance to complete the circuit Body part touching metal will be severely burned © 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
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Grounding Pad and Placement
Awake patient Warn patient of placement due to cold and sticky nature of conducting gel so that the patient is not startled © 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
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Principles Associated with Cauterizing Tissue
ESU produces “buzzing” sound when activated Surgeon may ask the assistant to “buzz” a clamp or forceps to coagulate tissue within Surgeon holds tissue or vessel with forceps or clamp Assistant touches instrument with electrocautery (“Bovie”) tip Current travels down instrument to cauterize tissue or vessel © 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
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Principles Associated with Cauterizing Tissue
Precautions when “buzzing” Do not activate cautery prior to application to instrument to avoid “arcing” of current Place cautery tip below fingers of surgeon Current 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 © 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
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Documentation Circulator records all information on patient’s intraoperative record Location of grounding pad Condition of patient’s skin pre- and postoperatively Power settings for cutting and coagulating currents ESU hospital identification number © 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
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Safety Principles Initial skin incision is be made with the scalpel
Bovie will char and scar the skin Keep handpiece protected when not in use to prevent accidental activation Place in plastic protective holster that can be attached to the drapes Keep out of team member’s way to avoid leaning on it © 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
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Safety Principles General safety rule
Start with lowest power settings of current that accomplish the job Adjust the current at the surgeon’s request Clue to equipment malfunction Surgeon has repeated request for more power © 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
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Safety Principles Avoid inhaling plume (smoke)
Not yet proven; could be harmful Could contain bits of vaporized tissue that could be mutagenic and/or carcinogenic Plume is irritating to the respiratory tract © 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
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Safety Principles Oxygen and Nitrous Oxide Used
Do not use cautery in the mouth, around the head, or in pleural cavity in the presence of oxygen and nitrous oxide Nitrous oxide supports combustion Metal jewelry removed from patient Only moist sponges used in presence of ESU © 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
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Safety Principles ECG Electrodes
Place electrodes as far away from operative site as possible Place grounding pad as far away from ECG electrodes as possible Electrical current can be attracted to ECG electrodes and cause severe burns © 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
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Safety Principles ESU can disrupt the operation of implanted cardiac pacemaker Alcohol used for skin prep Alcohol must be allowed to dry before draping the patient If not allowed to dry, fumes can build up under the drapes and possibly ignite when cautery is used © 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
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Reasons for Malfunction of ESU
Improper placement of grounding pad Less that full contact of grounding pad with skin surface ESU machine malfunction Frayed cord © 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
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Chemical Hemostasis – Pharmacologic Agents
More developed each year Manufacture’s recommendations for usage and handling must be followed
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Absorbable Gelatin © 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
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Collagen © 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
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Oxidized Cellulose © 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
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Silver Nitrate, Epinephrine, Thrombin
© 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
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Blood Replacement Blood types & Groups Hemologous Autologous
© 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
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Blood Replacement Handling of blood components Autotransfusion
Hemolytic Transfer Reactions © 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
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Emergencies
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Indications of Emergency Situations
List indications of emergency situations Objective & priorities in Emergency Situations Syncope? Convulsions/Seizures Types Management Anaphylactic Reaction Clinical manifestations of Cardiac Arrest © 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
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Cardiac Arrest/Malignant Hyperthermia
CPR Cardiac Arrest: What happens in the surgical setting? Define Malignant Hyperthermia Prevention Treatment Emergency services © 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.
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Terms Anaphylaxis Asystole Bolus Bradycardia Bronchospasm Capnography
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
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Terms Cyanosis Desaturation Diaphoresis Hemoglobinuria Hypermetabolic
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
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Terms Tachycardia Tachypnea
Abnormally rapid heart rate, greater than 100 beats per minute Tachypnea Very rapid respirations, greater than 30 per minute
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Purpose/Uses Dantrolene sodium (Dantrium) Malignant hyperthermia
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Purpose/Uses Dopamine (Intropin) Lidocaine (Xylocaine) Anaphylaxis
PVCs, ventricular tachycardia, ventricular arrhythmias Not as a local anesthetic
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Purpose/Uses Sodium bicarbonate Epinephrine Metabolic acidosis
Cardiac stimulant Arrest due to anaphylaxis Note: vasoconstriction is NOT emergency use
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Scenarios Cover ST duties in all 3 basic roles:
First scrub Second scrub Circulator Other team members and their basic duties
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Equipment Cardiac defibrillator
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Malignant hyperthermia
Background on MH: RARE, inherited muscle condition When triggered by some drugs: Causes hypermetabolic state (huge Ca+ release) Sudden; life-threatening Trigger agents: Succinylcholine All inhalation agents except nitrous oxide Some antipsychotics
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Malignant hyperthermia
Must have defect AND exposure to trigger 50% of offspring have it Defect in sarcoplasmic reticulum Stores and releases Ca+ Ca+ released in massive amounts Causes very sustained contraction Cell metabolism continues at even rate Depletes O2, CO2 which causes acidosis Muscle cells break down fast from contraction and release myoglobin into blood; clog kidneys
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MH List clinical signs of MH Increase in end-tidal CO2 Tachycardia
Tachypnea Masseter muscle rigidity (MMR) Unstable blood pressure Arrhythmias Cyanosis Diaphoresis Pyrexia
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MH in end-tidal CO2 Tachycardia Tachypnea Masseter muscle rigidity
Expired levels of CO2 Many reasons, assess Tachycardia Rapid heart rate Tachypnea Rapid breathing Even over ventilator setting Effort to blow off CO2 Classic for MH Masseter muscle rigidity Noted at intubation Classic for MH but could be normal for patient
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MH Unstable blood pressure Arrhythmias Cyanosis Diaphoresis Pyrexia
Many reasons, assess Arrhythmias Absence of normal rhythm Cyanosis Abnormal condition; “blue” Check ventilator Diaphoresis Sweating Due to heat build up Pyrexia High fever Late sign Temperatures can rise to 109° Patient can die in 15 minutes
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MH Treatment Use pneumonic if helpful How Do Surg Techs Do It?
H D S T D
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MH Treatment Hyperventilate with O2 Dantrolene Sodium bicarbonate
Why? Blow off CO2 Dantrolene 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
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STSR Role First, 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 PRN Hand iced NaCl irrigation Second scrub role Break scrub Get or send people for ice May help reconstitute Dantrium If no other personnel available e.g., on call
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STSR Role Circulating role
Treat like code blue Get MH cart Call for help Change anesthesia machine when provider is ready Set up iced lavage Bladder, rectum, abdomen Reconstitute Dantrium Remember, all of these things are happening simultaneously. Knowing the procedure makes you more valuable in the crisis.
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MH Keep in mind If the patient is identified as MH susceptible, there will be no crisis, as trigger agents are NOT administered to patient.
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In summary The more you know, the more effective you are in assisting the anesthesia provider in an emergency.
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