Nina Holland PhD

• Adjunct Professor, Emerita, Environmental Health Sciences

https://publichealth.berkeley.edu/people/ernest-hook/

Historically blood pressure medication used for sleep hyzaar 50 mg low price, operator skill and experience have reliably predicted complication or success rates hypertension journal impact factor generic hyzaar 12.5 mg buy on line. Inadvertent arterial puncture and hematoma formation are usually easily recognized and controlled with simple compression blood pressure zolpidem order discount hyzaar online. In cardiac arrest heart attack types order hyzaar 50 mg line, low-flow arteria znaczenie buy cheapest hyzaar, or shock states, arterial puncture may not be obvious, and arterial cannulation and intraarterial infusions have occurred. This can lead to the development of ischemia or thrombosis of the artery and limb. In critically ill patients, however, this complication may escape detection for some time. Mumtaz and coworkers cited a 3% bleeding rate in coagulopathic patients who experienced only minor bleeding that could be controlled with digital pressure. Initially, the importance of this complication was minimized, but reports of fatalities caused by tension pneumothorax, bilateral pneumothorax, and combined hemopneumothorax followed. A small pneumothorax can quickly become a life-threatening tension pneumothorax with positive pressure ventilation. Treatment of a catheter-induced pneumothorax is controversial, but not all patients will require formal tube thoracostomy. Air embolism is a very rare, but potentially life-threatening complication of central venous cannulation. A chest radiograph should be taken routinely to assess the position of a central venous catheter introduced via the subclavian or internal jugular route. The catheter is still in place (large arrow), and the absence of lung markings on the right and the pleural reflection (small arrows) are readily apparent. B, Left hydropneumothorax after left subclavian venipuncture (the catheter was removed before this radiograph). Note the straight line of fluid (air-fluid level, black arrows) and no meniscus, indicating that a pneumothorax must also be present. No clinician can place central venous catheters and fail to have at least some complications that are inherent to the procedure, regardless of even flawless technique. A 14-gauge needle can transmit 100 mL of air per second with a 5­cm H2O pressure difference across the needle. The recommended treatment is to place the patient in the left lateral decubitus position to relieve air bubble occlusion of the right ventricular outflow tract. Catheter or wire embolization resulting from shearing of a through-the-needle catheter by the tip of the needle is a serious and generally avoidable complication. Embolization can occur when the catheter or wire is withdrawn through the needle or if the guard is not properly secured. Adverse events after embolization include arrhythmias, venous thrombosis, endocarditis, myocardial perforation, and pulmonary embolism. Initiatives by national safety bodies such as the National quality Forum in the United States have focused on reducing the incidence of retained wires by classifying them as "never" events that require mandatory reporting in many states. Delayed perforation of the myocardium is a rare, but generally fatal complication of central venous catheterization by any route. Emergency echocardiography, pericardiocentesis, and operative intervention by a thoracic surgeon may all be required for salvage of the patient. Catheter knotting or kinking may occur if the catheter is forced or repositioned or if an excessively long catheter is used. Neurologic complications are extremely rare and presumably caused by direct trauma from the needle during venipuncture. Brachial plexus palsy and phrenic nerve injury with paralysis of the hemidiaphragm have been reported. Femoral venous catheterization carries a greater risk for infection than subclavian catheterization. Merrer and associates reported the overall infectious complication rate from femoral and subclavian catheters to be 19. Organisms most commonly recovered from colonized femoral catheters are coagulase-negative staphylococci, Enterobacteriaceae, Enterococcus species, and Pseudomonas aeruginosa. The risk for catheter-related thrombosis is directly related to the site of access. The relatively superficial location of the vein when approached from above the clavicle (1. Infectious Complications Infectious complications include local cellulitis, thrombophlebitis, generalized septicemia, osteomyelitis, and septic arthritis. Extra care should be taken in anticoagulated patients or after the administration of thrombolytic agents. In extreme cases when hemostasis cannot be achieved through direct pressure, a vascular surgeon should be consulted. Injury to the bowel is usually minimal and unlikely to require specific treatment. Nonetheless, the potential bacterial contamination of the femoral puncture site can pose a significant problem. Aspiration of air during placement of a femoral line necessitates removal of the catheter and reinsertion at another site. Other complications include muscular abscesses, infection of the hip joint, damage to the femoral nerve, and puncture of the bladder. Strict attention to sterile technique and limiting use to a few days will negate most of the negatives of this approach. A, Significant hemorrhage can occur after puncture of the femoral artery, but this area is readily compressed. The femoral route may be the approach of choice in a patient with an inadvertently placed arterial catheter who requires a central line. B, Bleeding from an inadvertently placed arterial catheter that was removed without adequate pressure in an anticoagulated patient. Duffy B: the clinical use of polyethylene tubing for intravenous therapy: a report on 72 cases. Keeri-Szanto M: the subclavian vein, a constant and convenient intravenous injection site. Karakitsos D, Labropoulos N, De Groot E, et al: real-time ultrasoundguided catheterization on the internal jugular vein: a prospective comparison with the landmark technique in critical care patients. Biffi r, Orsi F, Pozzi S, et al: Best choice of central venous insertion site for the prevention of catheter-related complications in adult patients who need cancer therapy: a randomized trial. Barton Br, Hermann G, Weil r, 3rd: Cardiothoracic emergencies associated with subclavian hemodialysis catheters. Andel H, rab M, Felfernig M, et al: the axillary vein central venous catheter in severely burned patients. Franceschi D, Gerding rL, Phillips G, et al: risk factors associated with intravascular catheter infections in burned patients: a prospective, randomized study. Mey U, Glasmacher A, Hahn C, et al: Evaluation of an ultrasound-guided technique for central venous access via the internal jugular vein in 493 patients. Leung J, Duffy M, Finckh A: real-time ultrasonographically-guided internal jugular vein catheterization in the emergency department increases success rates and reduces complications: a randomized, prospective study. Finck C, Smith S, Jackson r, et al: Percutaneous subclavian central venous catheterization in children younger than one year of age. Feller-Kopman D: Ultrasound-guided central venous catheter placement: the new standard of care Boyd r, Saxe A, Phillips E: Effect of patient position upon success in placing central venous catheters. Kitagawa N, Oda M, Totoki T, et al: Proper shoulder position for subclavian venipuncture: a prospective randomized clinical trial and anatomical perspectives using multislice computed tomography. Galloway S, Bodenham A: Ultrasound imaging of the axillary vein- anatomical basis for central venous access. Sharma A, Bodenham Ar, Mallick A: Ultrasound-guided infraclavicular axillary vein cannulation for central venous access. Slama M, Novara A, Safavian A, et al: Improvement of internal jugular vein cannulation using an ultrasound-guided technique. Cajozzo M, quintini G, Cocchiera G, et al: Comparison of central venous catheterization with and without ultrasound guide. Agency for Healthcare research and quality: Making health care safer: a critical analysis of patient safety practices, Publication No. Bacuzzi A, Cecchin A, Del Bosco A, et al: recommendations and reports about central venous catheter­related infection. In Spath P, editor: Error reduction in health care: a systems approach to improving patient safety, San Francisco, 2000, Jossey-Bass. Lichtenstein D, Saifi r, Augarde r, et al: the internal jugular veins are asymmetric. Baumann U, Marquis C, Stoupis C, et al: Estimation of central venous pressure by ultrasound. Kumar A, Anel r, Bunnell E, et al: Pulmonary artery occlusion pressure and central venous pressure fail to predict ventricular filling volume, cardiac performance, or the response to volume infusion in normal subjects. Nagdev A, Stone M: Point-of-care ultrasound evaluation of pericardial effusions: Does this patient have cardiac tamponade Giacomini M, Iapichino G, Armani S, et al: How to avoid and manage a pneumothorax. Pikwer A, Baath L, Davidson B, et al: the incidence and risk of central venous catheter malpositioning: a prospective cohort study in 1619 patients. Depierraz B, Essinger A, Morin D, et al: Isolated phrenic nerve injury after apparently atraumatic puncture of the internal jugular vein. Porzionato A, Montisci M, Manani G, et al: Brachial plexus injury following subclavian vein catheterization: a case report. Wu X, Studer W, Erb T, et al: Competence of the internal jugular vein valve is damaged by cannulation and catheterization of the internal jugular vein. Patients with severe shock, asystole, or pulseless electrical activity will lack palpable femoral pulses, thus making percutaneous femoral vein catheterization more difficult. Attempts at percutaneous venous cannulation may be complicated or even impossible in such patients. Venous cutdown, a time-honored surgical technique, has largely been replaced by alternative methods of obtaining venous access, including intraosseous lines, the Seldinger technique, and ultrasound-guided central and peripheral venous cannulation. First described by Keeley in 1940 and Kirkham in 1945,2,3 venous cutdown offered an alternative to venipuncture in patients with shock. Though no longer taught as a mandatory procedure in the Advanced Trauma Life Support course, venous cutdown is considered optional and continues to be taught at the discretion of the instructor. With a thorough understanding of ill or patients requires Managementand critically vascularinjuredcrystalloid orduring immediate adequate access, especially trauma resuscitation, when rapid infusion of blood Children Venipuncture in small children poses a challenge in even the healthiest of patients, let alone those in extremis whose veins may be poorly visualized. Central vein catheterization, intraosseous line placement, or venous cutdown should be considered as an alternative means of emergency vascular access when other peripheral sites have been exhausted. The distal saphenous vein at the ankle is often recommended for venous cutdown in children given its large diameter and anatomic predictability at this location. Consequently, large-bore lines placed by venous cutdown are an excellent mechanism for the treatment of severe hypovolemia. Use of the modified Seldinger technique described both by Shockley and Butzier, and by Klofas, has been shown to decrease that time by 22%. Absolute contraindications include major blunt or penetrating trauma involving the extremity on which the procedure is to be performed. Other considerations include any previous saphenous vein harvest for coronary artery bypass or other vascular surgery proximal to the anticipated cutdown site. There are four primary locations at which venous cutdown is performed: the great saphenous vein distally at the ankle and proximally at the thigh, the basilic vein above the elbow, and the cephalic vein below it. Brachial vein cutdown is no longer recommended as an emergency venous access route because of its time-consuming dissection and risk for neurovascular injury. The anatomy of individual vessels and their relative merits as cutdown sites are described in the following sections. It is most easily accessible at the ankle but may also be cannulated below the knee and below the femoral triangle. The great saphenous vein begins just anterior to the medial malleolus where it is a continuation of the medial marginal vein of the foot. The vein crosses 1 cm anterior to the medial malleolus and, together with the saphenous nerve, ascends along the anteromedial aspect of the leg. A cutdown performed 1 to 4 cm below the knee and immediately posterior to the tibia has been described in the pediatric literature. The saphenous vein is easily distinguished from surrounding fat with blunt dissection. Also lying anteromedially in the thigh is the lateral femoral cutaneous vein, which has a smaller diameter and lies lateral to the great saphenous vein. The Basilic Vein the basilic vein is a preferred site for venous cutdown in the upper extremity because of its predictable anatomic location. The size of this vein enables it to be located easily, even in hypotensive or hypovolemic patients. Superficially at this level there are no important associated structures, but the brachial artery and the median nerve are found deep to the basilic vein. At the midforearm level, the basilic vein crosses anterolaterally and then courses ventrally at the medial epicondyle. The medial cubital vein crosses over from the radial side of the arm to join the basilic vein just above the medial epicondyle. The basilic vein then continues proximally, where it occupies a superficial position between the biceps and pronator teres muscle. In this segment it lies in close proximity to the medial cutaneous nerve, which supplies sensation to the ulnar side of the forearm.

If unsuccessful arrhythmia hyperkalemia buy hyzaar us, reduce the paraphimosis surgically by dorsal slit or definitive circumcision heart attack 80s song hyzaar 12.5 mg purchase mastercard. Procedure Manual Reduction Technique Description Background Paraphimosis is a urologic emergency that must be treated promptly to prevent glans necrosis blood pressure record order 12.5 mg hyzaar with amex. The most commonly employed initial maneuver involves manual compression of the distal penis to decrease edema heart attack xanax 12.5 mg hyzaar buy visa, followed by reduction of the glans penis back through the proximal constricting band of foreskin (phimotic ring) blood pressure medication make you gain weight purchase hyzaar 12.5 mg mastercard. The corpora cavernosa and the corpus spongiosum are wrapped by a thin connective tissue layer, the tunica albuginea. The foreskin, or prepuce, in uncircumcised males lies over the glans and can be retracted proximally to expose the glans. Pathophysiology Patients will present with a red, painful, and swollen glans penis associated with an edematous, proximally retracted foreskin that forms a circumferential constricting band. Compression inhibits venous drainage of the glans and results in a cycle of progressive glans edema. Glans edema may become so severe that arterial flow is compromised, which can result in necrosis and gangrene of the glans penis. This can be accomplished by using a nonirritating topical anesthetic lubricant applied to the inner surface of the foreskin (not to the shaft of the penis) and the glans to reduce friction and decrease the discomfort of the procedure. If there is significant discomfort or patient apprehension, systemic analgesia or procedural sedation may be useful adjuncts. Alternatively, place the index and long fingers of both hands in apposition just proximal to the phimotic ring. The key to success in both these maneuvers is the application of slow, steady pressure. Several alternative methods for reducing the edema have been described in the literature. These methods can be used before attempting manual reduction, or if simple manual reduction fails. Apply six to eight babcock clamps spaced evenly around the foreskin, straddling the phimotic ring (one edge just proximal and the other edge just distal to the phimotic ring). Grasp all clamps and apply simultaneous distal traction to pull the phimotic ring over the glans. Other techniques focus on reduction of glans or foreskin edema (or both), followed by reduction of the paraphimosis. Half fill a large glove with crushed ice and water, and tie the cuff end securely. Invaginate the thumb of the glove and then draw it over the lubricated paraphimotic penis. The combination of cooling and compression usually decreases the edema sufficiently to permit manual reduction of the foreskin. Compress the foreskin and glans by grasping it with the palm of your hand and applying pressure for several minutes. Foreskin 7 Grasp the shaft of the penis with one hand and apply force onto the urethral meatus with the thumb of your other hand. Note that the glans has retracted into its normal position and only the edematous foreskin is visible. Draw the invagination over the lubricated paraphimotic penis and hold it in place for 5 to 10 minutes. The combination of cooling and compression decreases edema and facilitates foreskin reduction. The Dundee technique involves creating multiple micropunctures of the edematous foreskin and then expressing edema fluid. This enzyme, when injected into the swollen retracted foreskin, causes hydrolysis of hyaluronic acid that, in turn, increases tissue permeability so the edema in the foreskin is diffused out into the surrounding penile tissue. Sugar forms an osmotic gradient that draws out edema fluid, but this may take several hours. To date, there have not been any large studies of comparative effectiveness; as such it is difficult to recommend any one method as superior. Aftercare Observe the patient to ensure adequate local hemostasis, ability to void spontaneously, and recovery from analgesia or sedation, if utilized. Replacing the foreskin to its native position following examination, catheter placement, sexual activity, or any other manipulation is essential to preventing recurrent episodes. Patients should be referred to a urologist for evaluation of possible surgical options, including circumcision. Complications Penile shaft laceration or simple tearing of edematous and taut penile skin may occur during manual or surgical paraphimotic reduction. If reduction of a paraphimosis cannot be achieved by other means, surgical interventions should be considered. Conclusions Emergency manual or surgical reduction of the edematous foreskin is mandatory to restore proper circulation, relieve discomfort, and permit resolution of potential serious sequelae: skin ulceration and gangrene. Once the foreskin is successfully reduced, urgent referral for dorsal slit or definitive circumcision is necessary. However, circumcision rates vary with religious affiliation, racial and ethnic group, as well as socioeconomic status. An alternative strategy is to crush a portion of the foreskin followed by an incision (dorsal slit), using local anesthesia with or without parenteral analgesia or sedation to allow access to the urethral meatus. Procedure Overview Indications: (1) phimosis and the inability to void or perform urethral catheterization; (2) as definitive treatment following successful foreskin reduction in a patient with paraphimosis; or (3) phimotic ring incision and foreskin reduction in a patient with an otherwise irreducible paraphimosis. Complications: injury to the urethral meatus or glans penis, bleeding at site of tissue injury (when tissue is crushed and then cut). Uncircumcised infants and young children often have a physiologic phimosis due to adhesions between the prepuce and glans. This is in contrast to a pathologic phimosis, where failure to retract results from distal scarring of the prepuce. Circumcision (removal of the foreskin), rendering phimosis and paraphimosis anatomically impossible, is commonplace in Key Procedure Sequence 1. If anesthesia is inadequate, consider dorsal nerve block or "ring block" at the base of the penis. Advance both jaws of a hemostat proximally between the inner layer of the foreskin and glans. Remove the hemostat, reinsert one jaw, and use the hemostat to crush interposed foreskin tissue. Use absorbable sutures to reapproximate leaves of foreskin resulting from the cut (if necessary). With success, the prepuce is easily retracted for exposure of the glans penis and urethral meatus. Description Background Phimosis is constriction of the foreskin that limits retraction of the foreskin over the glans. Ordinarily, treatment is not required; however, dilation of the phimotic opening may be required if the patient is unable to void or if urethral catheterization must be performed. Pathologic phimosis is caused by local trauma, infection, chemical irritation, complications of circumcision (insufficient tissue removal), or poor hygiene. On examination, the physician will discover a tender foreskin that is not easily retracted. Although the prepuce may be gently manipulated to allow a better exam, do not attempt forced retraction. Indications Dorsal slit of the foreskin is performed in any emergency situation to gain access to the urethral meatus for urethral catheterization. In the setting of paraphimosis, a dorsal slit may be used as a definitive treatment following simple foreskin reduction, or for phimotic ring incision and reduction in a patient with an otherwise irreducible paraphimosis. Elective circumcision rather than dorsal slit of the foreskin is the definitive procedure of choice in nonemergency situations. With the patient in the supine position, clean and drape the penis with sterile towels. After several minutes, grasp the foreskin with toothed forceps to test for anesthesia. The operator must be certain that the inner surface of the foreskin is also anesthetized. Take care that the meatus and urethra are visualized or palpated at all times to avoid inadvertent injury during this maneuver. Once release of adhesions is complete, open the hemostat, and place one jaw of the hemostat in the recently developed plane between the glans penis, opened to tent the skin to ensure proper placement, and the superior overlying inner layer of foreskin. Advance the hemostat to the level of the coronal sulcus and then close it, effectively crushing the interposed anesthetized foreskin. Leave the closed hemostat in place for 3 to 5 minutes, then remove it and cut the resultant serrated crushed foreskin longitudinally with straight scissors throughout the extent of the crushed tissue. Standard antibiotic ointment may be used to lubricate the suture material and facilitate passage of the suture through the delicate foreskin tissue. After successful dorsal slit of the foreskin, the prepuce is easily retracted for cleansing of the glans penis or exposure of the urethral meatus. Postprocedural conscientious foreskin reduction to its normal anatomic position must be ensured after any distal penile manipulation to avoid paraphimosis. If reduction of a paraphimosis cannot be achieved with other means, then surgical interventions should be considered. Aftercare Ideally, a definitive elective circumcision is recommended after a dorsal slit. Complications Injury to the urethral meatus, urethra, and the glans penis may occur if the hemostat or straight scissors are blindly and unknowingly introduced into the urethra. The latter two problems are easily resolved with the previously described running hemostatic suture. Conclusions Dorsal slit of the foreskin is performed in any emergency situation either to gain access to the urethral meatus for urethral catheterization or as definitive treatment after simple foreskin reduction, or phimotic ring incision and foreskin reduction in a patient with an otherwise irreducible paraphimosis. This minor operative procedure can be readily performed in the acute care setting when necessary. Infiltrate plain lidocaine without epinephrine into the dorsal midline of the foreskin just beneath the superficial fascia throughout the course of the planned incision. Insert both jaws of the hemostat proximally to the level of the coronal sulcus and carefully separate any adhesions. Remove the hemostat, then reinsert only one jaw, and advance again to the coronal sulcus. A formal, complete circumcision can be performed after the inflammation has resolved, if desired. If hemostasis is required, first suture a1 to a and then sew the remainder of the cut edges together. C, the ventral transposed foreskin will assume a beagle-ear deformity after the dorsal slit procedure has been completed. Urethral catheterization is definitive and routinely used to collect urine for analysis and culture in infants and young children who are not yet potty-trained. The penis has two dorsal penile arteries and two nerves running together and one dorsal penile vein in the midline. A dorsal nerve block at the base of the penis will provide anesthesia of only the dorsum of the penis. Ring Block Base of the penis infiltrated with anesthetic Alternatively, infiltrate subcutaneous lidocaine (without epinephrine) in a circumferential fashion for a (ring) field block at the base of the penis. Consider the use of supplemental intravenous analgesia or procedural sedation, or both, based on the clinical scenario. In adult men without anatomic lesions, first-voided midstream specimens can define the presence or absence of culture-proven bacteriuria. In adult women, properly collected clean-catch midstream specimens have been found to be as bacteriologically reliable as catheterized specimens. Ideally, patients must sit backward on the toilet when collecting the specimen. Of more concern is the fact that such studies excluded patients with vaginitis, urologic abnormalities, pregnancy, and vaginal bleeding. However, this needs to be balanced with the reality that catheterization may introduce unnecessary patient discomfort and resource utilization, as well as the risk of introducing bacteria into the bladder. Infiltrate local anesthetic from the constricting band of the paraphimosis proximally along the dorsal aspect of the penis. Approximate the two apices of the dorsal slit (a and b) after the foreskin is reduced. Urethral Catheterization Indications Acute urinary retention Obstructive uropathy Urine output monitoring in any critically ill or injured patient Collection of a sterile urine specimen for diagnostic purposes Intermittent bladder catheterization in patients with neurogenic bladder dysfunction Urologic study of the lower urinary tract Equipment Urethral catheter Sterile drapes Lubricant Sterile water Sterile gloves Contraindications Situations in which a less invasive procedure is sufficient Trauma patient with suspected urethral injury Complications Urethral trauma and hemorrhage Paraphimosis (if the foreskin is not reduced after the procedure) Infection Undesirable catheter retention (nondeflating balloon) Cotton balls Betadine solution and applicator forceps Collection bag Review Box 55. Procedure Overview Indications: bladder access for urinary drainage or evaluation of bladder urine. Complications: mechanical (false passage, iatrogenic paraphimosis following foreskin retraction for urethral access), infection, bleeding, undesired catheter retention, complications of long-term catheter use. With the dominant hand, cleanse the area in a circular motion, from the meatus outward. Lubricate the catheter (sterile), and pass it through the meatus towards the bladder. For males: consider instilling 5 mL of 2% viscous lidocaine (or similar) into the urethra prior to passing the catheter. Pass the catheter fully into the bladder, confirm its placement by the flow of urine. If resistance or obvious discomfort is felt, deflate the balloon and attempt repositioning.

Harrison M: A 4-year review of human bite injuries presenting to emergency medicine and proposed evidence-based guidelines prehypertension youtube cheap 12.5 mg hyzaar free shipping. Pronchik D blood pressure of 9060 hyzaar 12.5 mg order otc, Barber C pulse pressure young adults generic hyzaar 50 mg mastercard, Rittenhouse S: Low- versus high-pressure irrigation techniques in Staphylococcus aureus­inoculated wounds blood pressure xanax purchase hyzaar with american express. Moscati R arrhythmia and stroke discount hyzaar online mastercard, Mayrose J, Fincher L, et al: Comparison of normal saline with tap water for wound irrigation. Erdur B, Ersoy G, Yilmaz O, et al: A comparison of the prophylactic uses of topical mupirocin and nitrofurazone in murine crush contaminated wounds. Human rabies prevention- united States, 2008: recommendations from the Advisory Committee on Immunization Practices. Broder J, Jerrard D, Witting M: Low risk of infection in selected human bites treated without antibiotics. Velissarious I: Management of adrenaline (epinephrine)-induced digital ischemia in children after accidental injection from an EpiPen. Zehtabchi S: the role of antibiotic prophylaxis for prevention of infection in patients with simple hand lacerations. Cummings P: Antibiotics to prevent infection in patients with dog bite wounds: a meta-analysis of randomized trials. Advantages include ease of application, reduced need for local anesthesia, evenly distributed wound tension, no need for suture removal, no residual suture marks, minimal skin reaction, superiority for some grafts and flaps, and suitability for use under plaster casts. One main advantage of wound tape over standard sutures and wound staples is its greater resistance to wound infection. Of these three wound tapes, the investigators considered Shur-Strips to be superior for wound closure. One comprehensive study of wound tapes compared CuriStrip, Steri-Strip, Nichi-Strip, Cicagraf, Suture Strip, and Suture Strip Plus. Each tape was compared for breaking strength, elongation under stress, air porosity, and adhesiveness. However, when wet (a condition that can occur in the clinical setting), Cicagraf outperformed all tapes. All the tapes tested had similar elongation-under-stress profiles with the exception of Suture Strip Plus. Nichi-Strip was the most porous to air, and Cicagraf was almost vapor impermeable. When the skin was treated with tincture of benzoin, however, Steri-Strip dramatically outperformed all other products. When all study parameters were considered, Nichi-Strip, Curi-Strip, and Steri-Strip achieved the highest overall performance rankings. Indications the primary indication for tape closure is a superficial straight laceration under little tension. Areas particularly suited for tape closure are the forehead, chin, malar eminence, thorax, and non­joint-related areas of the extremities. Tape may also be preferred for wounds in anxious children when suture placement is not essential. In young children who are likely to remove the tape, tape closure must be protected with an overlying gauze bandage. In experimental wounds inoculated with Staphylococcus aureus, tape-closed wounds resisted infection better than wounds closed with nylon sutures. Finally, because of the minimal skin tension created by tape, it can be used on skin that has been compromised by vascular insufficiency, altered by prolonged use of steroids, and in the fragile skin of the aged. For example, wounds on the pretibial area are difficult to close, especially so in the elderly because of tissue atrophy. Wound tape provides an alternative or adjunct to suture closure in this situation. Background and Tape Comparisons Currently, several brands of tape with different porosity, flexibility, strength, and configuration are available. They allow not only air and water but also wound exudates to pass through the tape. An iodoform-impregnated Steri-Strip (3M Corporation) is intended to further retard infection without sensitization to iodine. Steri-Strip S (formerly marketed as ClozeX) is a novel method of tape application which has shown benefit in surgical wounds. Koehn15 showed that Steri-Strip tape maintains adhesiveness approximately 50% longer than Clearon tape does. Rodeheaver and coworkers16 compared Shur-Strip, Steri-Strip, and Clearon tape in terms of breaking strength, elongation, shear adhesion, and air porosity. Steri-Strip tape had approximately twice the breaking strength of the other two tapes in both conditions; there was minimal loss of strength in all tapes when wetted. Shur-Strip tape showed approximately two to three times the elongation of the other tapes at the breaking point, whether dry or wet. Shear adhesion (amount of force required to dislodge the tape when a load is applied Contraindications Tape closure has disadvantages as well. Tape does not work well on wounds under significant tension or on wounds that are irregular, on concave surfaces, or in areas of marked tissue laxity. In many cases, tape does not provide satisfactory apposition of the wound edges without concurrent underlying deep closure. Naturally moist areas, such as the axilla, the palms of the hands, the soles of the feet, and the perineum prevent tape from sticking well. It is of little value on lax and intertriginous skin, on the scalp, and on other areas with a high concentration of hair follicles. If placed circumferentially, the natural wound edema of an injured digit can make the tape act like a constricting band, which can lead to ischemia and possible necrosis of the digit. Tissue movement and fluid buildup are some reasons why flaps and avulsed skin fail to heal. Tape should be placed in a semicircular or spiral pattern on digits to avoid constriction. A skin avulsion in the elderly following minor trauma is an ideal wound to repair with closure tape because such injuries cannot be closed with sutures. The goal is to provide approximation of the avulsed skin and apply pressure to avoid movement of the skin flap or accumulation of fluid under the avulsion. A, An elderly woman who was taking steroids had extremely thin skin and suffered a skin avulsion that could not be repaired with sutures. F, A compression dressing, such as an elastic bandage or a Dome paste (unna boot) dressing, can be applied to minimize movement of the flap and decrease buildup of fluid under the flap. For wounds larger than 4 cm, however, 1/2-inch­wide strips provide greater strength. Procedure Proper wound preparation, irrigation, débridement, and hemostasis must precede tape closure. Do not attempt to apply tape to a wet area or over a wound that is slowly oozing blood because it will usually result in failure of the tape to stick to the skin. With the backing still attached, cut the tape to the desired length or long enough to allow approximately 2 to 3 cm of overlap on each side of the wound. After the end tab is removed, gently peel off the tape from its backing using forceps by pulling straight back. Do not pull to the side because the tape will curl and be difficult to apply to the wound. Hold the wound edges as close together as possible and at equal height to prevent the development of a linear, pitted scar. Place a sufficient number of tape strips so that the wound is completely apposed without totally covering the entire length of the wound. An arrangement of tape strips parallel to each other and perpendicular to the wound provides good tape adherence over time. An adhesive bandage may also adhere to the tapes and pull them off the skin during dressing changes. Instruct the patient to clean the taped laceration gently with a slightly moist, soft cloth after 24 to 48 hours. However, emphasize that if excessive wetting or mechanical force is used, premature tape separation may result. Instruct patients to gently trim the curled edges of the closure tape with fine scissors to avoid premature loss of the tape. Pretibial lacerations, particularly in the aged and in those with thin skin, may be challenging to manage. For flap-type lacerations, an immobilizing suture placed in the middle of the flap would act much like a button, lessening the tension along the wound margins. Bain and coworkers advocate using tissue glue rather than tissue tape to support suture placement. The wound infection rate in clean wounds closed with tape compares favorably with rates for other standard closures. When tincture of benzoin is used, apply it carefully to the surrounding, uninjured skin. Two types of tissue adhesive are available: 2-octylcyanoacrylate (Dermabond, Ethicon, Inc. LiquiBand (Advanced Medical Solutions, Winsford, united Kingdom) is a blend of an octylcyanoacrylate and butylcyanoacrylate. Animal studies have shown octylcyanoacrylate-based adhesive to have significantly greater strength and flexibility than butylcyanoacrylate-based adhesive, and Dermabond Advanced has better viscosity, as well as strength and flexibility, among the products in this catagory. These bonding agents can be used on superficial wounds, even in hair-bearing areas. After wound preparation (and placement of deep closures, if needed), dry the skin thoroughly at least 2 inches around the wound. Failure to dry the skin and failure to obtain perfect hemostasis are common causes of failure of tape to stick to the skin. Apply a thin coating of tincture of benzoin around the wound to enhance tape adhesiveness. Place half of the first tape at the midportion of the wound; secure firmly in place. Gently but firmly appose the opposite side of the wound with the free hand or forceps. The tape should be applied by bisecting the wound until the wound is closed satisfactorily. Only if using woven tape strips, additional supporting strips of tape are placed approximately 2. Taping in this manner prevents the skin blistering that may occur at the ends of the tape. These strips will support the stitches and prevent them from tearing through the fragile tissue. B, A stitch is placed through the center strip of tape, tacking the flap to the base of the wound and reducing the tension along the wound margins. C, the needle is passed through the two strips that are parallel to the wound, and the knot is tied with minimal tension. D, Additional strips of tape are placed around the other two sides of the flap, which is sutured in place. Squeeze the small, cylindrical plastic container to expel droplets of tissue adhesive through the cotton-tipped applicator at the end of the container. Support and hold the edges of the wound together for at least 1 minute while the adhesive dries. Low-viscosity tissue adhesives may seep into the wound or trickle off rounded surfaces during application. This tendency toward migration or "runoff" can be minimized by using high-viscosity adhesives33. Squeeze the container to expel the adhesive through the cotton-tipped applicator at the end of the container. If the adhesive enters the eye or lids, wipe it off with the gauze and flush with saline. If unsuccessful, tell the patient to shower normally and the eye will open in a few days as the glue sloughs off the lid. For pediatric patients, same-day ophthalmology referral is recommended due to the risk of occlusive amblyopia and corneal abrasion. Note: glue that touches a latex glove, gauze, or a plastic instrument (but not vinyl gloves or metal instruments) will cause them to stick to the patient. Wound closures with tissue adhesive can be reinforced by pulling the edges of the wound into apposition with a few strips of porous surgical tape before application of the adhesive. Tissue adhesive can be placed on top of surgical tape, but tape should not be placed on top of dried tissue adhesive. Once the adhesive has dried completely, further protect the closure with a nonocclusive bandage. Tissue adhesives can also be used to treat superficial skin tears that do not extend past the dermis. After the wound and skin flap are cleaned, lay the flap over the base of the wound and approximate the edges of the wound. Express any remaining blood and serum from under the flap, and ensure the entire area is dry. Apply a thin layer of adhesive over the wound margins and 1 to 2 cm beyond the margin. A dressing is not required unless there is a reason to protect the wound from repeated injury. Wounds can be closed in as little as one-sixth the time required for repair with sutures. Wounds closed with tissue adhesive have less tensile strength in the first 4 days than do sutured wounds,36,37 but 1 week after closure, the tensile strength and overall degree of inflammation in wounds closed with tissue adhesive are equivalent to those closed with sutures. Do not apply ointments or occlusive bandages on wounds closed with tissue adhesive. Complications Although tissue adhesive is classified as nontoxic, some authors warn against placing it within the wound cavity.

J tubes that enter the small bowel directly are inserted surgically under general anesthesia blood pressure medication starting with x 12.5 mg hyzaar order fast delivery, require a surgical incision blood pressure chart child purchase hyzaar 12.5 mg with mastercard, and result in a surgical scar at the insertion site 5 hypertension discount 50 mg hyzaar amex. Replacement of a nasoenteric feeding tube requires greater time and effort if the patient is uncooperative or has a physically obstructing lesion blood pressure chart canada hyzaar 12.5 mg order on-line. It is generally advisable to restrain the hands of demented blood pressure chart for infants order 50 mg hyzaar with amex, impaired, or otherwise uncooperative patients. If a feeding tube stylet is used, lubricate and insert it into the feeding tube before introducing it into the naris. Never allow the stylet to protrude beyond the end of the feeding tube because these stiff, small-diameter wires have the capacity to scratch the esophagus and allow the creation of a false passage. The stylet may lock into position on the tube at the proximal end and should be properly secured. When the patient is uncooperative or cannot drink, introduce 5 to 15 mL of water into the mouth or into the proximal end of the feeding tube with a syringe; this may induce swallowing and facilitate passage of the tube. Although the patient may not swallow for several minutes, wait for swallowing because this may mean the difference between a coiled or pulmonary tube placement and successful passage. Although some of these tubes had fallen out or had been coughed out, more than half were pulled out by the patient. Management of a clogged or nonirrigating feeding tube is discussed in the later section on clogged feeding tubes. Confirmation of Placement Auscultatory confirmation of tube placement can be misleading, so confirm proper placement of the tube with a radiograph before feeding. B, An axial image from the neck reveals that the nasogastric tube is coiled multiple times in the pharynx (arrows) and thus never reached the stomach. It then coiled again, turned downward, and ultimately came to rest in the trachea (large red arrow) anterior to the endotracheal tube (yellow arrow). In viewing the radiograph, it is particularly important to study the area around the carina. An esophageal tube shows at most a mild change in course, whereas a tracheally placed tube usually deviates significantly as it travels into the right or left main stem bronchus. The stylets of most tubes are designed to allow insufflation and aspiration while in place. Even when stomach entry is certain, the intestinal location may be misleading on a radiograph. A nasoenteric tube may lie completely to the left of midline and yet have its tip in the duodenum, or it may occupy a position overlying the right side of the abdomen yet not have entered the duodenum. A contrast-enhanced study is necessary to ascertain duodenal position when pulmonary placement has been ruled out. An esophageal puncture should be evaluated with endoscopy and may require surgery, depending on the size of the rent. The end-bulb of many nasoduodenal tubes will pass into the duodenum after positioning the patient in the right decubitus position for an hour. Some researchers recommend pretreatment with metoclopramide to enhance gastric emptying. In addition, 3 mg/kg of erythromycin lactobionate given intravenously over a 1-hour period works similarly and may be effective even if metoclopramide fails. Indent the skin with a finger to determine the optimal puncture site where the stomach and abdominal wall are closest, with no bowel between. B, Fill a syringe with saline and advance it percutaneously to the selected entry point until the tip of the needle is seen entering from the gastric lumen through the endoscope. If air is aspirated and no needle tip is seen, the needle is in the bowel, not the stomach. C, Push and pull the scope/snare/feeding tube combination into position (arrows show direction of travel). E, Use an external bolster or crossbar to keep the tube snug against the skin and gastric wall, but not so tight that it causes ischemia of the intervening tissue. Fluoroscopy may allow careful insertion of a guidewire or stylet into an in situ tube to facilitate removal. Fluoroscopy may also identify the mechanical problem interfering with removal of the tube. A, Using forceps, grasp the tube in the pharynx and pull it out through the mouth (arrow shows direction of travel). Insert the guidewire with care because it must not protrude from the inserted end. Leave the loop long enough so that it does not apply continuous pressure to the nose or palate while at rest. This anchor is simpler to construct and more comfortable than anchors that pass through the opposite nostril. Aspiration of tubes to check for residuals is not recommended with tubes 9 Fr in size or smaller. Aspiration is likely to clog the tubes because they collapse under pressure and relatively small particles can occlude the tube. The tube should be anchored to the nose and face in such a way that it is not in contact with the skin at the nasal opening. This reduces tube discomfort and prevents necrosis of the alae, nares, and distal septum. Patients receiving tube feedings should have their head elevated to at least 30 degrees above the horizontal. Cervical esophagostomies are generally performed at the time of cervical or maxillofacial operations. Malignant growths in the proximal part of the esophagus, head, or neck are the primary indications for esophagostomy. Cervical esophagostomies may eventually evolve into a permanent sinus, thereby allowing the feeding tube to be removed between meals. Complications of pharyngostomy and esophagostomy include local soft tissue irritation, accidental extubation because of excessive length of the external tube, pulmonary aspiration from vomiting, arterial erosion with exsanguination, and esophagitis or stricture of the esophagus from reflux. Tubes are kept in place by either a modified end (such as a mushroom tip) or an inflatable balloon. Some tubes have two lumens, one terminating in the stomach for decompression and the other in the small bowel for feeding. These can be confused with tubes that have two entrances to one lumen (one for continuous feeding and the other for medications) and tubes that have a second lumen leading to an inflatable balloon. Note that on cross section this original long tube has no balloon or port to inflate a balloon but has a mushroom end that is removed by traction. A call from a nursing home indicating that a tube has been pulled out should be answered with the advice that a Foley catheter be used immediately to keep the stoma open. Always inflate the balloon with saline and use a bolster to prevent migration of the tube. The clinician has a few options when faced with the task of replacing a feeding tube. Unfortunately, old records or nursing home personnel rarely give specific information that is helpful to the emergency clinician. When in doubt, pass a Foley catheter without balloon inflation, tape it to the skin, and refer the patient to a consultant or the original referring clinician. Some type of tube must be placed to stent the stoma, or the stoma will quickly close (in a matter of hours) and the patient might require a more complicated procedure to regain access. The only real concern of placing a gastric tube into the jejunum is that the balloon will produce intestinal obstruction if it is fully inflated. If the tube is nonfunctioning yet still in place, the clinician must make a judgment regarding the risk versus benefit of removal and replacement, versus an attempt at unclogging the tube (see the subsequent discussion on unclogging). If it appears that a skin incision was used to place the tube, it is unlikely that the patient has an easily removable tube. Note that a migrated tube, with the balloon or tube obstructing the gastric outlet, is a common cause of gastric distention, persistent vomiting, or signs of intestinal obstruction. Adhesions, however, usually keep the stomach appropriately positioned, but only after the tract has matured. Nonoperative tube replacement techniques are safe only through an established tract between the skin and the bowel. Catheter replacement should not be attempted in the immediate postoperative period. Poor nutrition is the most common element compromising wound healing in patients requiring a feeding tube. The operative scar on the abdominal wall suggests an implanted tube, not a simple gastric tube. B, Injection of contrast material before removal of the tube demonstrates the tip of the tube ending in the small bowel, not the stomach. C, If the tube has been removed and questions remain about the type of tube and circumstances of placement, a new tube is best placed under fluoroscopy with guidewire assistance. Equipment for Replacing a Dislodged Tube Equipment for replacing a feeding tube through a matured site includes gloves, a stethoscope, a feeding tube, an external bolster, lubricant, a basin, and a syringe that fits the tube. Tincture of benzoin, tape, and absorbent dressing material may be used to dress the wound, although many are better left undressed. Gently probe the stoma site with a cotton-tipped applicator to determine patency and direction of the tract. In selected cases, a hemostat can gently dilate the opening to accept a replacement tube. Note that the retention bolster is designed to prevent inward migration of the tube and not to be an anchoring device sutured to the skin. C, A gastric balloon jejunal feeding tube enters the stomach and delivers feedings into the jejunum. After the tube is passed, restrain the hands to avoid removal of the tube by uncooperative patients. Removal of a Transabdominal Feeding Tube A feeding tube may need to be removed because it is irreversibly clogged, leaking, or broken; persistently develops kinks; is too large or too small; causes a hypersensitivity reaction; is associated with an abscess; or is not the appropriate length for feeding into the desired viscus. Before attempting to remove the tube in place, it is imperative to know whether it is safe to remove. Standard de Pezzer or mushroom catheters that have been modified with bolsters or rings at the time of endoscopic or surgical insertion may no longer be safe to remove with traction. It is rare, however, to encounter a tube that cannot be removed with traction/ countertraction. This causes the tube and end mushroom to narrow, and the tube should come out easily. The inner crossbar, if present, may remain in the stomach when the rest of the feeding tube complex is removed by traction. The crossbar will pass in stool, and obstruction from it has yet to be reported in adults. In small children, obstruction is a possibility, and the crossbar should be removed by endoscopy. If the Foley balloon cannot be deflated, cut the tube to allow the balloon to deflate. Do not cut the catheter so close to the abdomen that it will be impossible to maintain a grip on it for removal by traction if the balloon still does not deflate. Using the taut feeding tube as a guide, pass a small-gauge needle along the tube to puncture the balloon. It may be necessary to try again on the other side of the catheter because the balloon may be inflated asymmetrically and contact with the needle may be established on one side and not the other. B, When replaced, a balloon-type tube (upper tube) is used in place of the original mushroom tip tube (lower tube). C, this original tube is leaking because the mushroom tip has been pulled out of the stomach lumen and is lodged in the soft tissue of the abdominal wall. D, If the tube tract has matured (at least 2 weeks after placement), it may be removed by traction/countertraction. Significant force may be required; be prepared for a pop and splattering of gastric contents. Simply cut the tube, and if there is no additional port or channel to inflate the balloon, then F, it must be the type of tube that can be removed by traction. Allow a minute for the balloon to deflate before making another attempt at removal by traction. Large, nondeflating balloons should probably be punctured, whereas small balloons may be removed with traction. If it is not possible to pull the inner bolster or mushroom out through the ostomy, cut the tube at the skin, push the remaining short stump into the stomach, and rely on later rectal passage. Although obstruction or impaction is infrequent, it can occur, and this alternative has the potential to be problematic in children or patients who have had previous impaction, potential for bowel obstruction, or stool-passing problems. Rigid or large internal mushrooms and bolsters, the very kind that cause the most difficulty with percutaneous removal, are also more likely to cause difficulty with rectal passage. In no case should a device be released into the gut with a long length of tubing attached. Remember that doublepart tubes may have an additional length of tubing for duodenal or jejunal feeding that extends far past the inner bolster. A bolster will prevent migration of the tube, which can cause gastric obstruction. Insert a hemostat through the holes in the new bolster and grasp the feeding tube. Surrounding scars may suggest that the tube is in fact an implanted jejunal tube, not a simple G tube. Foley catheters are not ideal feeding tubes but can be useful temporarily to maintain stoma patency. If the tape is replaced at home, it may be placed under too much tension and cause thinning of the abdominal wall at the stoma.

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