Erin Klein, DPM, MS

D A R R E L R . L A T V A , D . P. M .

GOALS + OBJECTIVES

Goals and Indications

Standards of Care
The EKG
Pulse Oximetry, BP, Temperature
Capnography and Airway Gas Analyses
N/M Monitoring
Positioning

GOALS AND INDICATIONS

Collect data that

reflects
Vigilance

STANDARDS OF CARE
Observe patient

Use instrumentation and electronic monitors

Interpret monitors
Initiate corrective therapy as needed

Goal:
Enhance patient safety during anesthesia by
identifying trends and instituting corrective
therapy

PULSE OXIMETRY
Monitors oxygenation by measuring pulse rate
and oxygen saturation of arterial hemoglobin
Uses wavelengths of light that are reflected off
oxygenated hemoglobin
Placed on digit, earlobe, buccal mucosa
Effected by movement, color, contrast dye, UV
lights, non-invasive blood pressure monitors

KOROTKOFF METHOD
Korotkoff actually described five types of sounds

The first Korotkoff sound is the snapping sound first heard at the systolic
pressure. Clear tapping, repetitive sounds for at least two consecutive beats
is considered the systolic pressure.

The second sounds are the murmurs heard for most of the area between the
systolic and diastolic pressures.

The third sound was described as a loud, crisp tapping sound.

The fourth sound, at pressures within 10 mmHg above the diastolic blood
pressure, was described as "thumping" and "muting".

The fifth Korotkoff sound is silence as the cuff pressure drops below the
diastolic blood pressure. The disappearance of sound is considered
diastolic blood pressure -- 2 mmHg above the last sound heard.

The second and third Korotkoff sounds have no known clinical significance.

KOROTKOFF METHOD
Elevate blood pressure cuff obstruct the artery in
question
Release the blood pressure cuff
Hear the first b.p. sound blood rushing through the
minimally open artery
Continue to release the blood pressure cuff
Sounds get louder and then softer
Continue to release the blood pressure cuff
Sounds disappear all together

BLOOD PRESSURE

Placed on upper extremity

Monitored at 5 minute intervals
MAP = 1/3 (SP DP)
Quick deflations underestimate blood pressures
Bladder needs to be 40% circumference of extremity
Bladder needs to encircle 60% of the extremity

POTENTIAL COMPLICATIONS
Ulnar neuropathy
May interfere with drug administration
Compartment syndrome

TEMPERATURE MONITORING
Placed on skin, in esophagus, tympanic membrane
Axillary
Rectal
Bladder fluid
Hypothermia
Temp in room is too low
Med may cause decrease in core temp
Hypothermia is not benign

TEMPERATURE MONITORING
Malignant Hyperthermia
Increase in core body temperature that can be life
threatening if not recognized and treated
Genetic predisposition
More common with general anesthesia
Anticholinergics block sweating
Increased metabolic rate
IT CAN KILL YOU!

TEMPERATURE MONITORING
What do you do?
Call for Dantrolene & malignant hyperthermia kit
2.5 mg/kg IV push q5-10 minutes until
symptoms subside
10 mg/kg IV push maximum dose
STOP THE ANESTHESIA
Cavity lavage with cold water
Listen to what the anesthesiologist is saying
Administer IV dantrolene

CAPNOGRAPHY
Measurement of CO2 concentration
Continuous concentration-time display of CO2 concentration
Shows relative measure of ventilation
Increase in CO2
Malignant hyperthermia
Re-breathing
Decrease in CO2
Malposition of endotracheal tube
Airway obstruction
Cardiac arrest
Embolism

NEUROMUSCULAR MONITORING
Assessing inter-op relaxation and time of anesthesia reversal
Measure with nerve stimulator at motor nerve
Usually at facial nerve
Response is proportional to the # of muscle fibers activated by
pulse and blocked by NM blocking agents

OTHER MONITORS ARTERIAL LINE

Usual radial artery
Done when NIBP monitors do not work
Multiple arterial blood gasses need to be measured

OTHER MONITORS SWAN-GANZ CATHETER

4 port catheter fed into the right side of the heart
good for infusion, cardiac pressure monitoring and cardiac
output measurements

OTHER MONITORS CENTRAL VENOUS

PRESSURE
Enters right external jugular vein into the right side of the
heart
Status indicator
Infuse drugs
Remove air bubbles
Index the circulating blood volume and preload to the right
ventricle

THE EKG

Quick EKG Interpretation

Dude and date

Ischemia

Rate and rhythm

Injury

P and QRS

Infarction

QRS and T

Cardiac Conduction and Rhythm

Primary AV block

Sick Sinus Syndrome

Secondary AV block
I
II

Premature Atrial Contractions

Left bundle branch block

Right bundle branch block

Premature ventricular
contractions

Complete AV block

Ventricular tachycardia

Sinus tachycardia

Ventricular fibrillation

Sinus bradycardia

Atrial flutter
Atrial fibrillation

DRUGS THAT CAN AFFECT ELECTRICAL ACTIVITY

Ca channel blockers
Digitalis
Quinidine
Anti-arrhythmic
Anything that affects potassium
Anything that affects calcium

ISCHEMIA
Inverted t-waves
This can be new
ischemia
This can be old ischemia

INJURY ST SEGMENT ELEVATION

ST segment elevation denotes injury

Injury denotes the acuteness of the infarct

Therefore ST segment elevation acute infarct

INJURY ST SEGMENT ELEVATION

Acute infarct ST segment elevation
May return to baseline later
Other conditions that may raise the ST segment
Pericarditis
Ventricular aneurysm

ST SEGMENT DEPRESSION
Subendocardial Infarction
Digitalis
Positive Masters test

INFARCTION Q WAVES
Q waves make the diagnosis of infarction
1 mm (1 small box) wide
1/3rd size of the QRS complex
Leads I, II, V5, V6 commonly contain
insignificant Q-waves

POSITIONING

PATIENT SAFTEY
Patient has little to no ability to protect
him/herself
Attention must be directed to patients position
Access to surgical site

PRESSURE POINTS
Prevent pressure points
Patient could potentially lay there for hours
Most common injuries
Ulnar nerve palsy
Peroneal nerve palsy
Brachial plexus injury
Pressure sores

PRINCIPLES OF SAFE POSITIONING

Protect patient
Provide access to the surgical site that doesnt
compromise the patient
Prevent pressure necrosis
Prevent nerve injuries

SURGICAL POSITIONING
Supine

Prone
Lateral Decubitus (right and left)
Lithotomy
Sitting/Lawnchair

Jacknike
Lateral
Prone

SUPINE POSITION
Normal position
TQ immediately proximal
to the malleoli
Heels at the edge of the
bed
Bump hips as necessary
Arms straight out on arm
boards
Safety strap intact
Pillow behind the head

PRONE POSITION
Pt is prone
Pressure points:
Forehead/face
Chest
Genitals
Knees
Nerve Concerns:
Brachial plexus
Toes off the edge of the bed
PROTCET THE AIRWAY!!!!!

LATERAL DECUBITUS POSITION

Pt laying on side
Knees bent
Beanbag
Pressure points:
Any point along the side of their
body
Shoulders
Knees
Nerve issues:
Brachial plexus
Lateral femoral cutaneous nerve
Common peroneal nerve

LITHOTOMY POSITION
Pt on back
Feet/legs in stirrups
Pressure points:
Sacrum
Back
Stirrups
Nerve damage:
Sciatic

SITTING or LAWNCHAIR POSITION

Pt is sitting
Legs at heart level
Pressure points:
Head
Sacrum
Heels

LATERAL JACKKNIFE POSITION

Lateral decubitus + table
bend
Pressure points:
Ear, head
Shoulder
Hip
Knee
Ankle

PRONE JACKKNIFE POSITION

Prone position + table bend
Pressure points:
Head
Chest
Genitals
Knees
Dorsal foot

PRONE ANDREWS TABLE

Kneeling frame
Pressure points:
Face
Elbows
Arms
Knees
Feet/Heels

So lets apply this RIVETING information.

(This is the part of the lecture why you are supposed to realize
why you care about positioning)

The medical resident in the ER gives you a call.

The conversation goes like this.

Hi Dr. Are you from orthopedics?
Well, no, you paged ortho/trauma & Im covering ortho/trauma tonight. How
can I help you?
I have a patient with a fracture.
Okay. Is the patient stable?
She just has a fracture.

What is fractured?
Her bones. That is why I called you. You are supposed to do bones.
..
Sigh.

The real story

Doc, I am drunk. I think I broke myself.
25 y/o male patient
Fell off a porch while minding his own biznezz.
Could not walk
PMH: unremarkable; PSH: unremarkable
No medications or allergies
ROS: negative except for pain in the left leg and
ankle

The OR Game Plan

Make sure you have lead & eyeball

protection available!

Patient Positioning
Supine

Bump under ispilateral hip

Allows easier access to lateral incision
Allows easier positioning of the mortise film
Thigh TQ
C-arm on side contralateral to the fracture
The sterile football bump

Stepwise Technique
Incision dependant on fracture

Open laterally & reduce fibular fracture first

Open medially & reduce medial malleolus second
Deal with posterior malleolus if necessary

Test/fix syndesmosis
Close & Splint

Lateral Incision

The Cotton Test

The Cotton Test

So the ER gives you a call at 2 am..

The Presentation.
Fell 5 feet off a ladder
Cant walk
Pain in the heel

Relatively healthy 55 y/o male

Smoker

Unclassifiable intraarticular calcaneal

disaster

Yep this is kinda

disastrous.

Notes:

Thigh TQ
Well strapped in proximally
The non-injured extremity is
straight and OUT OF THE
WAY of the C-arm shots
of the fractured side
Pillows and sheets are
between the legs to pad
all potential pressure
areas and to give the
surgeon a place to work.

Its 6:30 pm on a Friday at the VA.

And the ER calls with something stinky.
A 62 y/o male with fever, chills, nausea, vomitting
and 10/10 pain in the perinum.

PLEASE NOTE THAT THE

FOLLOWING PICTURES ARE
GRAPHIC & OF SENSITIVE

How do you position the patient for the I&D?

Presentation I felt a pop in the back of my leg

and I couldnt walk anymore

What position do you use for this procedure?